IR 05000220/1990002
| ML17056A701 | |
| Person / Time | |
|---|---|
| Site: | Nine Mile Point  |
| Issue date: | 03/14/1990 |
| From: | Meyer G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17056A700 | List: |
| References | |
| 50-220-90-02, 50-220-90-2, 50-410-90-02, 50-410-90-2, NUDOCS 9003260557 | |
| Download: ML17056A701 (32) | |
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NUCLEAR REGULATORY COMMISSION
REGION I
Report Nos.:
Docket Nos.:
50-220/90-02 50-410/90-02 50-220 SO-410 DPR-63 License Nos.:
NPF-69 Licensee:
Facility:
Location:
Dates:
Approved by:
Niagara Mohawk Power Corporation 301 Plainfield Road Syracuse, New York 13212 Nine Mile Point, Units 1 and
Scriba, New York February 1,
1990 through February 28, 1990 W. A. Cook, Senior Resident Inspector R.
R.
Temps, Resident Inspector
. A. Laura, R sid Inspector enn W. Meyer, Chief Reactor Projects Section
.
o Date Ins ection Summar
This inspection report documents routine and reactive inspections during day and backshift hours of station activities including:
plant operations; radio-logical protection; surveillance and maintenance; emergency preparedness; security; engineering and technical support; and safety assessment/quality verification.
Results:
Three NON-CITED VIOLATIONs were identified during this inspection period invol-ving energized equipment tagging practises, licensed operator required physical examinations and use of overtime.
An Executive Summary follows.
9003260557 900315 PDR ADOCK 05000220
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EXECUTIVE SUMMARY Plant 0 erations:
Inspector followup of the incomplete licensed operator physical examinations concluded Niagara Mohawk oversight of this activity was poor.
Followup of an unresolved item involving the improper use and authoriza-tion of station employee overtime concluded appropriate corrective actions had been taken.
Numerous unresolved items from the Unit 2 IATI were reviewed and closed during this inspection period.
Inspector review of the Unit 2 scram on February
concluded that it was the result of maintenance personnel error.
Several maintenance personnel errors in recent months indicated a poor perform-ance trend.
Radiolo ical Protection:
Cleanup activities on the 225 foot elevation of the Unit 1 Radwaste Building were well planned and well executed.
Inspector obser-vations of General Employee Training and Radiation Protection Training indi" cated more emphasis has been placed on improving employee radiation protection practices.
Surveillance and Maintenance:
Followup of the maintenance staff involvement in the Unit
SRM problem identified a non-cited violation of the station markup procedures.
The Unit 1 special core spray testing was well planned and con-ducted.
Unit 2 inspector tours identified some obvious equipment discrepancies which should be more promptly identified and resolved by the station staff.
Inspector followup of a Temporary Inspection Instruction on EOG air start sys-tems identified a weakness in the vendor manual revision process.
Emer enc Pre aredness:
No noteworthy findings.
~gecurit:
inspector review of security an'd safeguards training during General Employee Training indicated satisfactory coverage of the area.
En ineerin and Technical Su ort:
Inspector assessment of the Unit
emet g-ency ventilation deluge system modification package presented to SORC concluded that the proposed modification was poorly researched and designed and that there was limited communication or input from the station in developing this proposal.
Safet Assessment/
ualit Verification:
Observations of a HPES presentation on the Unit
SRM problem to SORC indicated some fundamental weaknesses in the overall HPES process as used for this event analysis.
The Unit 2 cotenants'nitiative for having MATS assess Unit 2 operations appeared to be a
sound decision with evidence of thorough and detailed assessments.
Overall assess-ment of Niagara Mohawk performance in improving in the areas of the Restart Action Plan underlying root causes 2 and 4 was mixed this inspection perio }w
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DETAILS Plant 0 erations (Modules 71707, 71710, 93702)
On February 1, station management informed the resident staff that they had identified a deficiency in the medical examinations administered to the licensed operators at both units.
Based upon discussions with a
medical doctor, recently contracted by Niagara Mohawk to perform the physical examinations, and the previously contracted physician, they con-cluded that laboratory work (various blood tests)
was not previously per'-
formed dur ing the examinations.
Niagara Mohawk took the position that their licensed operators satisfied the minimum health and physical fitness requirements to continue routine watchstanding.
However, all license holders would be expeditiously reexamined to the physical examination standards published in ANSI/ANI-3.4-1983, Medical Certification and Monitoring of Personnel Requiring Operator Licenses for Nuclear Power Plants.
The inspector identified that Niagara Mohawk's previously contracted physician had not used the guidance of ANSI/ANI-3.4 for performing routine physical examinations and Niagara Mohawk had not provided the physician with a
specific checklist.
Also, Niagara Mohawk had not verified the specific physical attributes checked during the medical examinations.
Niagara Mohawk was fortunate 'in that the newly contracted physician ques-tioned the minimum physical examination requirements and sought clarifica-tion prior to certifying the licensed operators'edical status on NRC Form 396.
By letter dated February 21, 1990, Niagara Mohawk provided the NRC with a summary of this event and a commitment to complete all medical reexamina-tions by February 23, 1990.
A subsequent letter will be submitted by Niagara Mohawk documenting the results of these reexaminations after the laboratory tests have been reviewed.
The NRC Region I staff concluded that no enforcement action will be taken against Niagara Mohawk or the individual license holders for this failure to completely adhere to
CFR Part 55 operator licensing requirements.
This concern was brought to the attention of the NRC by Niagara Mohawk, promptly addressed by the expeditious reexamination of all license holders and was of minimal safety consequence.
The actions to prevent recurrence appeared to be adequate.
These actions were being formalized in a proced-ure by the Niagara Mohawk Employee Relations Department with the assist-ance of the station staff.
In accordance with the discretionary enforce-ment guidance of 10 CFR 2, Appendix C,Section V.A.,
no Notice of Viola-tion has been issued for this event.
NON-CITED VIOLATION 50-220/90-02-01 and 50-410/90-02-0 T 1'
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1.1 Unit 1 During this inspection period the unit remained in cold shutdown with the core reloaded and the reactor vessel head in place.
The vessel head studs had not been tensioned.
Preparations continued for unit restart.
an b.
The inspector monitored various aspects of the reactor cavity drain down and reactor vessel reassembly.
In accordance with the Niagara Mohawk Nuclear Improvement Plan, the station staff closely monitored the reactor cavity shelf drain leakage while draining down the reactor cavity in preparation for vessel reassembly.
At approximately 12 feet down from the top of the cavity, shelf drain system leakage significantly decreased.
Subsequent visual inspection of the reactor cavity stainless steel liner identified a puncture type hole in the liner between 100 and 110 degrees from North.
The inspector determined that Niagara Mohawk plans to repair the liner prior to unit startup.
The inspector judged this approach to be acceptable.
During a
routine review of the Unit 1 control room operator logs, the inspector noted that the reactor building R21 sump pump had failed and a temporary.pump was installed to pump the sump to the adjacent floor drain.
Upon further investigation, the inspector determined that the practice was not uncommon/ of operators connecting a temporary air-operated pump to the sump discharge piping and pumping the contents to the floor drain system, given the frequent failures of the non-safety related sump pump.
After further discussion with the Unit
radwaste supervisor, the inspector determined that the sump discharge piping had been modified several years ago to provide a connection for the tem-porary pump.
The radwaste supervisor identified that the con-trol drawings for this piping system had not been updated to reflect this change.
Secondly, the radwaste supervisor indi-cated his staff had typically not been made directly aware of the R21 sump pump failures and alternate pumping to the floor drain system initiated by the operations staff.
No procedural guidance or instructions were documented for either the opera-tions or radwaste staff for this evolution.
The inspector concluded that better controls and communication were needed for this type of temporary evolution/activity.
The poor communications and poor drawing controls indicated a poten-tial for an adverse impact on safety related systems and worker safety.
The inspector discussed his concerns with station man-agement, and after further consideration they stated that their controls would be broadened for this and similar activities involving temporary system M
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Review of 0'en Items (Closed)
Unresolved Item (50-220/89-81-01):
This item was opened based on a finding during the Integrated Assessment Team Inspection (IATI).
The team found that the Unit I Operations Department method for tracking overtime was not in compliance with the unit's Technical Specifications (TS).
Specifically, overtime was being tracked on a
calendar week basis, rather than by the TS required seven day rolling basis.
Additionally, overtime in excess of the limits was being routinely approved by blanket authorization.
2.
The inspector reviewed Niagara Mohawk's actions to correct this concern.
These actions included:
the identification of Nuclear
. Generation personnel affected by the overtime requirements (primarily those involved in safety related functions);
rescindment of the blanket authorization for overtime in excess of the TS limits; and changeover to a
rolling seven day method of tracking overtime as required by TS 6.2.2.
Further, NMPC plans to extract the rules governing use of over time from AP-4.0 (Administration of Operations)
and issue them, together with more comprehen-sive administrative and management review controls, in a
new procedure, AP-4.3, Control of Overtime.
Based on review of the final draft of AP-4.3 and of the corrective actions, this item is closed.
Although the failure to properly track and control overtime per the Unit 1 Technical Specifications is, a violation, a
Notice of Violation is not being cited in accordance with the discretionary enforcement guidance in
CFR 2,
Appendi x C,
Section V.A.
NON-CITED VIOLATION (50-220/
90"02-02).
(Closed)
Unresolved Item (50-220/89-81-02):
This item was opened during the IATI based on deficiencies noted in the reload system walkdowns.
To address this item, Niagara Mohawk conducted several meetings to review performance deficiencies and to develop lessons learned for incorpora-tion into the restart systems walkdown procedure.
The inspector reviewed Temporary Procedure N1-88-7.6,
"System and Area Walkdown for Res<art Procedure".
Review of this procedure indicated that numerous enhancements had been made as a result of the review.
Some of the important
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changes included criteria for more effective, comprehensive walkdowns of systems by multi-disciplinary inspection teams, a better method for assigning follow-up action for identified deficiencies, use of a deficiency tagging sys-tem, and independent verification to assess the results of the walkdowns.
Based on review of this procedure and its satisfactory implementation, this item is closed.
(Closed)
Unresolved Item (50-220/89-81-04):
This item was opened during the IATI and was based on the inspectors'oncern about the timeliness of the scheduled review of non-channel functional test surveillances.
Based on the procedure inadequacies identified during the channel func-tional test review, which ultimately resulted in a
1005 review of these procedures, the team was concerned about the adequacy of the remaining surveillance procedures.
Additionally, they were concerned that under Niagara Mohawk's schedule for review, not all of these procedures would be reviewed prior to restart.
Since the IATI, Niagara Mohawk has completed a 100K review of channel and non-channel functional tests.
Niagara Mohawk was in the process of reviewing and assessing the findings from these reviews during this inspection.
Sepa-rate reports, one for channel functional tests and one for non-channel functional tests, were to be issued in March.
Items identified during these reviews which involve failure to meet TS requirements are to be documented in Occurrence Reports and will subsequently be incorporated into supple-ments for Licensee Event Reports (LERs)
89-03 or 89-07.
Based on the actions taken and the adequacy of the reviews in progress, this item is closed.
(Closed)
Unresolved Item (50-220/89-81-05):
This item was opened during the IATI based on a Niagara Mohawk commitment to complete implementation of preventive maintenance for electrical area inspections for motors designated as'mpor-tant to safety.
Following the IATI,.Niagara Mohawk -resumed the performance of all portions of electrical preventive maintenance procedure Nl-EMP-GEN-M178, Monthly Rounds.
The inspector reviewed the completed data sheets from this pro-.
cedure for three months (November 89 - January 90)
and verified the appropriate inspections were being satisfac-torilyy performed.
This item is close.
(Closed)
Unresolved Item (50-220/89-81-10):
Niagara Mohawk was to clarify the procedural guidance for analyzing root causes and reporting problems.
The IATI report stated a
concern that the root cause evaluation did not provide guidance in the areas of trigger criteria (for the initia-tion of root cause evaluations)
and that the mechanism for requesting and initiating evaluations was not defined.
The inspector reviewed a draft copy of procedure DP"16.01, Revision 00, Root Cause Evaluations, and confirmed that the above concerns had been appropriately addressed in the draft procedure.
Another aspect of this unresolved item concerned the Prob-lem Report (PR) system.
The. inspectors noted what appeared to be two different programs within the.Nuclear'ivision as evidenced by two different procedures, S-SUP-2 and NEL-018, dealing with PRs.
The IATI inspectors were concerned about:
numbering, tracking and prioritizing of PRs; responsibility for reportability review of PRs; and three different PR forms in use.
Following the IATI, NEL-018 was replaced by NEL-900, Problem Report Program.
Review of this procedure and S-SUP-2, Revision 4,
by the inspector indicated that the above concerns have been adequately addressed and that the PR program was consis'tently outlined and implemented by these two procedures.
This item is closed.
1.2 Unit 2 Repairs to the reactor feedwater pumps were completed, and the reactor was taken critical on February 4.
The unit operated at power during the remainder of this inspection period.
a 0 While shutdown 'n February 1,
an automatic reactor scram occurred when I&C technicians were backfilling the reference column of a
reactor water level transmitter.
Station staff investigation determined the cause of the scram was the tech-nician failed to follow the procedure and inadvertently left a plastic tube connected to the transmitter test port with its isolation valve open.
This condition resulted in a drop in the
'variable leg pressure, which falsely indicated a
decrease in reactor water leve,E l ~
The inspector was concerned that this event was another of several maintenance personnel errors in recent months due to inattention to detail and failure to follow procedures.
The inspector addressed this concern with station management and planned to review their corrective actions and associated LER 90-04 in a subsequent report.
b.
Safety System Operability Verification:
The inspectors directly examined portions of selected safety system trains to verify that the systems were properly aligned in the standby mode.
The following systems were examined:
High Pressure Core Spray Low Pressure Core Spray The
. inspector found the systems to be properly aligned and fully operational.
2.
Radiolo ical. Protection (Modules 71707, 83723)
a.
Review of Radwaste Buildin 225 Foot Elevation Cleanu The inspectors reviewed the cleanup activities on the 225 foot eleva-tion of the Unit 1 radwaste building.
At the time of this review the radwaste staff was conducting manual decontamination of the operating aisle.
The inspectors were accompanied by.a radwaste supervisor who was involved with the cleanup efforts and who explained the cleanup processes and progress made via the aid of remote monitoring equip-ment.
The monitoring equipment consists of several remotely con-trolled cameras complete with continuously monitored remote displays and video recording equipment.
Video surveillance is maintained to support the work crews and to ensure ALARA practices are being fol-lowed, to allow additional supervisory oversight without unnecessary exposure, and to provide historical records for future ALARA planning.
Cleanup activities appeared to be progressing smoothly.
Decontamina-tion of the storage aisles is dependent upon delivery of the tethered remote operating device (TROD).
Niagara Mohawk representatives have been working extensively with the vendor to improve the capabilities and precision of the robotic arm at the vendor's facility.
This effort is expected to reduce the potential number and severity of difficulties encountered when the TROD is placed in operation on the 225 foot elevation.
Overall, the inspectors considered the cleanup activities to be well planned, implemented and supervise 'Vl
b.
Radiation Protection Trainin During this inspection period the inspectors attended the annual employee radiation protection (RP) training course given in conjunc-tion with General Employee Training (GET).
The inspector considered the course to be well structured and presented.
The inspectors noted that no station employees are allowed to validate or test out of RP training this year because of a demonstrated need to improve employee knowledge and RP practices at the station.
Testing out will be reconsidered next year pending improved performance.
The inspector also noted a significant change in the RP practical portion of the course.
RP workers are now required to take a
graded (pass/fail)
practical exam at the conclusion of training.
This is considered a
positive training attribute.
3.
Surveillance and Maintenance (Modules 71707, 61726, 62703)
The inspectors observed portions of the surveillance testing and mainten-ance activities listed below to verify that the test instrumentation was properly calibrated, approved procedures were used, the work was performed by qualified personnel, limiting conditions for operations were met, appropriate system or component isolation was provided and the system was correctly restored following the testing or maintenance activity.
3.1 Unit 1 a.
Maintenance activities observed included:
As part of the inspector's investigation into the source range monitor (SRM) bypass incident (reference IR 50-220/89-33),
the inspector determined that Niagara Mohawk administrative rules
'or equipment markups were violated when repairs to the SRM were made.
Specifically, during replacement of the faulty coil in the SRM, electrical isolation was provided by pulling a relay module; however, a component markup (tagout)
was not used for this isolation.
Rather, the isolation was controlled by an individual at the job site maintaining control over the pulled relay until the coil replacement was completed.
Use of "human markups" was contrary to station administrative procedures and the Niagara Mohawk safety manual.
After a week of maintenance staff review and frequent discuss-ions with the inspector following the inspector's initial pre-sentation of their concerns, the station maintenance staff developed a clear and accurate summary of this maintenance activity.
They concluded that while a markup was not used when isolation was provided, via the pulled relay, the individual replacing the faulty coil worked as if the electrical equipment was still energized.
This lessened the personnel safety concern over this maintenance activit Further review by the maintenance staff concluded that the prac-tice of providing isolation using
"human markups" has occurred routinely in the past.
The site maintenance manager informed the inspector that this practice would not be allowed to con-tinue, that a
lessons learned transmittal would be issued and trained on, and that a
soon to be issued administrative pro-cedure would clarify the demarcation between troubleshooting and maintenance activities.
b.
The failure to provide appropriate SRM electrical isolation to repair a faulty coil was contrary to station Adminstrative Pro-cedure 4.2., Control of Equipment Markups.
In that this viola-tion was of minor safety significance, low severity level, not a concern previously identified by the NRC, and Niagara Mohawk corrective actions to prevent recurrence appear to be adequate, no Notice of Violation is being issued in accordance with the guidance of
CFR 2,
Appendix C,
Section V.A.
NON-CITED VIOLATION (50"220/90-02"03).
The inspector concluded that when the concerns were initially identified to maintenance management, the responses were slow and tended to confuse the issue rather than clarifying it.
After a
week, the correct facts were finally determined and presented to the inspectors.
In summary, this event was another example of poor problem identification, slow resolution of an identified problem and inadequate self"assessment.
Surveillance testing observed included a review of the special core spray system testing conducted in accordance with Nl-88-7. 12, Core Spray System Injection Test, performed on February 22 for loop No.
11.
This test assessed pump perform-ance and potential system water hammer.
Results of the test were within the acceptance criteria, and the inspector con" sidered the test to have been properly performed.
3.2 Unft 2 The inspector observed the performance of N2-OSP-EGF"f001, Emergency Diesel Generator (EDG) fuel oil pump quarterly sur-veillance test, on the Division II EDG.
In order to obtain pro-per vibration data, the fuel oil pump motor top guard had to be removed.
The inspector observed that this aspect of the sur-veillancee test was recognized by the. operations surveillance procedure, but not the Inservice Testing (IST) vibration proced-ure (GENE-28).
Also, the inspector noted that the vibration test points were identified by stickers on the top cover vice the motor casing.
This was an incorrect IST test location.
These two concerns were discussed with operations management and adequately resolve b.
The reactor core i so 1 ati on cool ing system (RCIC)
operabi 1 ity test performed during plant startup was observed by the inspec-tor.
This procedure was recently rewritten as part of the pro-cedure upgrade process.
During the performance of the test, test methodology problems were identified by the reactor oper-ator responsible for the test.
The inspector noted that the operator stopped, sought clarification from inservice inspection personnel, and processed a
procedure change to correct the problems.
Overall, the inspector concluded that the test was well controlled by the reactor operator and that the test changes represented good problem identification and resolution.
c.
Various aspects of the Niagara Mohawk and General Electric staffs inspection, and transfer of new fuel to dry storage were observed.
No noteworthy findings were identified.
d.
During tours of the reactor building and emergency diesel gener-ator (EDG)
spaces, the inspector identified two deficiencies:
A conduit for leads going to the Division II EDG control circuits was broken.
The wires inside the conduit were not damaged.
The reactor building component cooling system (CCP)
head tank water supply totalizer was leaking a drop per second onto a
CCP pump terminal box.
In Doth cases, the inspector subsequently determined that no work request had been initiated by station personnel to address these two obvious discrepancies.
The inspector considered this a weakness that maintenance, operations and management personnel had not identified and initiated corrective actions.
This was discussed with the station superintendent who agreed with the concern and reemphasized the importance of plant equipment deficiency identification to station personnel.
e.
During a tour of the Division II EDG space, the inspector noted a large cloth towel left laying against the base of the diesel cylinder head.
Closer inspection revealed the towel was draped ta catch oil leakage from an improperly installed cylinder cover gasket.
This oil leak was previously identified as evidenced by a deficiency tag.
The inspector was concerned that the oil soaked towel was a potential fire hazard.
This concern was brought to the attention of the operating staff, and the towel was promptly removed from the upper cylinder are l t
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3.3 Units 1 and 2 a 0 Re ion I Tem orar Instruction 86-03:
In October 1986, while designing a circuit modification for mechanical vacuum pumps, Susquehanna station identified four GE HGA relays (part
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which should have been replaced in 1981.
These particular GE HGA relays were found to be susceptible to contact chatter during seismic testing.
The inspector requested that Niagara Mohawk determine if this type relay was used for any applications at Units 1 and 2.
The Niagara Mohawk staff concluded that there was an extremely low probability of any application of these relays at Unit 1 or 2.
The warehouse inventory was checked, computerized purchase orders were reviewed, the Unit 2 Master Equipment List (MEL) was reviewed, and a spot check of HGA relays in the Unit 1 auxiliary control room was conducted, and no evidence was found of these specific type HGA relays.
Further, the GE site representative conducted a
GE Purchase Part Drawings/Category Number search and found none procured by Niagara Mohawk.
The GE site representa" tive also
- identified that the subject relay was categorized
"inactive for new design" prior to 1983.
The inspector con-cluded that a reasonable search to locate this type GE HGA relay was performed by Niagara Mohawk and that Temporary Instruction 86-03 is closed.
b.
Re ion I Tem orar Instruction 87-06: Diesel Generator Air Start Motor Lubrication Followup.
On July 13, 1987, the Electric Motor Division (EMD)
of General Motors issued an owner's advisory (Power Products Pointer)
identifying an error in the EMD Engine Maintenance Manual.
The advisory stated that the air motor starting system in-line lubricator needle valve should be adjusted to provide one to two drops per second, vice three to four drops per minute as stated in the maintenance manual.
The inspector determined from the maintenance staff that, at Unit 2, the applicable diesel generator maintenance procedure (N2-MSP-EGS-R002)
for the Division III diesel was revised to reflect this lubrication adjustment.
At Unit 1, although docu-mented evidence of either a vendor manual revision or completed maintenance record of the lubrication adjustment could not be provided, the maintenance supervisor was knowledgeable of the Power Products Pointer and was confident that the in-line lubri-cator was adjusted to provide ample lubrication during the last diesel generator overhaul.
In support of his statement, no history of air start motor failures due to insufficient lubrica-tion were known to have occurred at Unit FQope Iwcesseesse~~~s'essesu Le%~
s ewwc. rsssroee~sw e ';eieer rsssser The inspector was satisfied that the maintenance performed on the air-start systems at Units I and 2 were in accordance with the July 13, 1987 owner's advisory.
However, the inspector was concerned that the Unit I vendor manual was not properly revised to reflect the EMD Power, Products Pointer correction.
Further discussion with station management indicated that there is a
problem with the prompt reviews and approval of all vendor manual revisions such as this.
Management indicated that cor-rective actions were being taken to improve this process.
The inspector will followup on this concern in a subsequent report and review this item in conjunction with Unresolved Item 50-220/
89-81-03.
Temporary Instruction 87-06 is closed.
4.,
Emer enc Pre aredness (Module 71707)
No noteworthy findings or observations were identified this inspection period.
5.
~Securlt (Modules 71707, 83723)
During this inspection period the inspectors attended the General Employee Training course.
The inspectors considered the training to be well struc-tured and presented.
No noteworthy security of safeguards findings were identified this inspec-tion period.
6.
En ineerin and Technical Su ort (Module 93702)
Unit 1 (Update)
Unresolved Item (50-220/89-08-04):
This open item deals with the deficiencies identified by the NRC with the deluge system modification installed in the emergency ventilation (EV)
system.
The inspector attended -'a SORC meeting where the proposed modification package for modifying the'resent'eluge system was presented to SORC by corporate engineering.
Due to numerous deficiencies and oversights in the proposed modification, SORC rejected the package and requested a reevaluation and resubmittal.
The inspector concluded that SgRC acted properly in rejecting the proposed modi'fication.
The proposed design modification indicated poor conceptual design review, weak station technical staff review, and a lack of communi-cation between engineering and the station for proper, effective resolu" tion to the problem.
The design engineer appeared unfamiliar with the system, and it was apparent that not all alternatives for location of the remote deluge supply and drain valves had been adequately pursued or even considere I
7.
Safet Assessment/
ual it Verification (Module 40500)
a ~
The 1988 SALP report identified a safety concern regarding a large number (50 to 60) of normally lit control room annunciators.
The large number of lit annunciators desensitizes operators'nnunciator response and contributes to a
poor control room environment which could potentially mask an operational event.
The numerous lit annun'
ciators were a contributing factor in the September 9,
1989 problem concerning Division III EOG unit cooler operability.
Progress in lit annunciator reduction has been slow.
The inspectors attribute this to inadequate management oversight.
In January 1990, Niagara Mohawk formed a task force to address and eliminate nuisance lit annunciators.
There are still approximately 50 lit annunciators on the front panels in the control room while the reactor is at rated power.
Niagara Mohawk has recently developed a
method to provide status of annunciator reduction on a monthly basis to senior manage-ment.
However, as stated above, progress in annunciator reduction has been slow and management involvement has been lacking relative to this concern.
b.
In July 1989 the cotenants of Unit 2 contracted a private consulting firm, Management, Analytical and Technical Services, Inc. (MATS),. to monitor, assess and assist Niagara Mohawk in improving the overall operation of Unit 2.
HATS conducts detailed assessments in a wide variety of functional areas.
To date, MATS has completed major assessments in the areas of outage management, operations and main-tenance, all of which the inspector reviewed during this inspection period.
The assessments were structured to review various aspects of the functional area from management oversight and program adequacy to field activities and worker training.
The inspector considered these assessments to be quite comprehensive and sufficiently detailed.
The inspector discussed recent MATS activities with the President and Chief Executive Officer, Joseph Firlit.
Mr. Firlit indicated that his organization had made a slight shift in their overall objective, focusing more on assistance to the Niagara Mohawk staff and less on pure assessments.
Discussions with station management indicated this approach has been better received by the Unit 2 staff.
Hr. Firlit stated that feedback from the cotenant-Management Committee (com-prised of senior executives from all four cotenant utilities)
was favorable for the information provided by the MATS assessments and their Unit 2 performance monitoring data.
This type of information and performance indicators were not previously available to the cotenants.
In summary, the utilization of the HATS organization appeared to be a
good initiative by the Unit 2 cotenants to not only monitor their financial interest in the unit, but to improve Unit'
performanc El
The inspector attended the SORC meeting at which the Human Perform-ance Evaluation System (HPES) group's findings concerning the Unit
SRM bypass event were discussed.
The SORC members had requested that the HPES group perform an independent root-cause analysis of the SRM bypass incident.
The inspector was concerned about assessments made by representatives of the HPES group.
Their assessments seemed to indicate that they did not understand the application of Administra" tive Procedure 4.0, Conduct of Operations, with respect to the use of hold out tags, nor did they have a full understanding of the manner in which maintenance on the SRM was conducted, despite interviewing the individuals who did the work.
At a
routine weekly meeting with the unit superintendents, the inspector discussed this concern.
The superintendents responded that the technical review (i.e.,
SORC review) of the material presented by the HPES personnel had corrected the misunderstandings.
While the inspectors agreed that the technical (SORC) review of presented mate-rial can ensure identification of conceptual errors in that material, it cannot ensure review of omitted material.
The inspector's funda-mental concern was that if personnel performing root-cause analyses are not fully familiar with how things are supposed to be done, or if they fail to maintain a fully questioning attitude, then important root-causes or causal factors may be overlooked.
Consequently, unless the technical review identifies an omission, identified root" causes may be deficient and therefore inadequate corrective actions may be taken.
The unit superintendents acknowledged this concern and indicated it would be promptly addressed with the HPES staff.
Underl in Root Causes 2 and 4 Performance The IATI, conducted in October 1989, concluded that Niagara Mohawk progress in the Restart Action Plan underlying root cause areas of problem solving and standards of performance/self-assessment was weak.
Accordingly, increased inspection emphasis has been placed in these areas to monitor Niagara Mohawk progress in support of Unit 1 restart and overall performance improvement.
Overall, performance in these two areas was observed to be mixed during this inspection period.
In this report period, the following activities were viewed as exampl'es of improvement in problem identification and resolution and standards of performance/self-assessment:
cleanup efforts on the 225 foot elevation radwaste building; enhancements in the GET/RP annual
.refresher training programs; contracting of MATS, Inc.
by the Unit 2 cotenants to assess Unit 2 operations; and the operator control of RCIC testing at Unit 'f aa At
In contrast, the following examples indicated marginal or no improve-ment in these same underlying root cause areas:
progress in reducing lit/nuisance annunciators at Unit 2; poor assessments by the mainten-ance and HPES staffs of the SRM incident at Unit 1; an. unsatisfactory proposal by engineering of an emergency ventilation deluge system modification at Unit 1, although, to Niagara Mohawk's credit, it was rejected by the SORC; and the apparent informal control of temporary systems potentially impacting safety related systems as demonstrated by the temporary R21 sump pump at Unit 1.
8.
LER Review (Module 92700)
The following LERs were reviewed and found satisfactory:
Unkt.2 LER 89-31, 10/13/89, Reactor water cleanup system isolation caused by equipment malfunction.
LER 89-32, 10/11/89, Inoperable reactor water cleanup flow trans-mitter due to operator error.
LER 89-33, 9/25/89, Reactor water cleanup isolation caused by valves left out of their normal positions.
This operational event was caused by operator error and resulted in an uncontrolled intersystem discharge of reactor coolant.
The corrective actions taken wer e satisfactory.
.LER 89-34, 10/12/89, Inoperable radiation monitor that resulted from personnel error.
LER 89-36, 10/18/89, Reactor scram from high neutron flux caused by operator error.
LER 89-37,-
10/18/89, Appendix R valve not properly controlled while the unit was in Hot Shutdown.
9.
LER 89-38, 10/20/89, An operator inadvertently started the wrong emergency diesel generator.
~3"
1 (3 3
333333 At'eriod intervals and at the'onclusion of the inspection, meetings were held with senior station management to discuss the scope and findings of this inspection.
Based on the NRC Region I review of this report and discussions held with Niagara Mohawk representatives, it was determined that this report does not contain Safeguards or
CFR 2.790 informatio l