IR 05000237/1988012

Insp Repts 50-237/88-12 & 50-249/88-14 on 880531-0608. Violations Noted.Major Areas Inspected:Dresden Emergency Operating Procedures (Deops),Including Comparison of Deops W/Bwr Owners Group Emergency Procedures Guidelines

ML17201J411
Person / Time
Site:	Dresden
Issue date:	08/17/1988
From:	Florek D, Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML17201J409	List: IR 05000237/1988012 ML17201J408 ML17201J410
References
50-237-88-12, 50-249-88-14, NUDOCS 8808290031
Download: ML17201J411 (43)

Text

U.S. NUCLEAR REGULATORY COMMISSION REGION I I I Reports No. 50-237/88012(DRS); 50-249/88014(DRS)

Docket Nos. 50-237; 50-249 Licenses No. DPR-19; DPR-25 Licensee:

Commonwealth Edison Company Post Office Box 767 Chicago, IL 60690 Facility Name:

Dresden Nuclear Power Station, Units 2 and 3 Inspection At:

Dresden Site, Morris, Illinois Inspection Conducted:~ May 31 through June 8, 1988 Team Leader:. ~

(,,.)~/~.

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~~J. F~enior Operations Engineer, Operations Branch Divis1on of Reactor Safety

• Region I

Inspectors:

R. Evans, Reactor Engineer, Region IV P. Kaufman, Dresden Resident Inspector C. Sisco, Operations Engineer, Region I*

A. Sutthoff, Human Factors Specialist Approved By:~~;_

Robert M. Gall)ci1lef Operations Branch, Division of Reactor Safety, Region I Inspection Summary

&-/17(f/

Date Ins ection on Ma 31 throu h June 8, 1988 Re arts No. 50-237/88012(DRS);*

50-249/88014*DRS Areas Inspected:

Special announced team inspection of Dresden Emergency Operating.Procedures (DEOPs) to include a comparison of the DEOPs with the BWR Owners Group Emergency Procedure Guidelines (EPGs) for technical adequacy, review of the DEOPs by control room and plant walkdowns, evaluation of the DEOPs on the plant simulator, human factor analysis, review of the validation verification

program, review of the ongoing evaluation program of DEOPs, QA measures in the DEOP program, and an assessment of the containment venting provision Results:

One violation was identified against 10 CFR 50, Appendix B, Criterion XVIII - Failure to perform planned and periodic audits of the Dresden Emergency Operatin9 Procedures between October 31, 1985 and June 8, 1988 (Paragraph 10). Also see Executive Summary (Paragraph 1).

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050002:37 PDC

DETAILS Executive Summary Background Following the Three Mile Island (TMI) accident, the office of Nuclear Reactor Regulation developed the 11 TMI Action Plan

(NUREG-0660 and NUREG-0737) which required licensees of operating reactors to reanalyze transients and accidents and to upgrade emergency operating procedures (EOPs) (Item I.C.1).

The plan also required the NRC staff to develop a long-term plan that*

integrated and expanded efforts in the writing, reviewing, and monitoring the plant procedures (Item I.C.9).

NUREG-0899,

"Guidelines for the Preparation of Emergency Operating Procedures,"

represents the NRC staff's* long term program for upgrading EOPs,

. and describes. the use *of a 11 Procedures Generation Package

( PGP)

to prepare EOP The licensees formed four vendor type owner groups corresponding to the four major reactor types iri the United States; Westinghouse, General Electric, Babcock & Wilcox, and Combustion Engineerin Working with the vendor company and the NRC, these owner groups developed Generic Technical Guidelines (GTGs) whith are generic procedures that set forth the desired accident mitigation strateg These GTGs were to be used.by the licensee in developing their PGP Submittal of the PGP was required by Generic Letter 82-33, 11 Supplement 1 to NUREG-0737 - Requirements for Emergency Response Capability 11 which includes:

(1) *Plant specific t~chnical guidelines with justification for differences from the GT *

(2)

A Writer's guid (3)

A description of the program to be used for the validation of EOP (4)

A description of the training program for the upgraded EOP From this PGP, plant specific EOPs were to have been developed that would provide the operator with directions to mitigate the consequences of a broad range of accidents and multiple equipment failure Due to various circumstances, there have been long delays in achieving NRC approval of many of the PGP Nevertheless, the licensees have all implemented their EOP To determine the success of the implementation, a series of NRC inspections are being performed to examine the final product of the program, the EOP..

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On May 31 through June 8, 1988, an NRC team of inspectors consisting of two reactor inspectors, a reactor system consultant, an operator licensing examiner/inspector, a human factors specialist, and the resident inspector conducted an inspection of the Emergency Operating Procedures at Dresden Units 2 and Dresden is a BWR-3 with a Mark I containmen The objectives of the team were to determine if:

the EOPs are technically correct, the EOPs can be physically carried~out in the plant, and the EOPs can be performed by the plant staf The objectives would be considered to be met if review of the following areas were found to be adequate:

comparison of the Em.ergency Operating Procedures (EOP) with the Plant Specific Technical Guidelines (PSTG) and the BWR Owners Group Emergency Procedures Guidelines (EPG), review of the technical adequacy of the deviations from the EPG, control room and plant walkdowns of the EOPs, real time evaluation of EOP usage by running EOP exercise scenarios on the plant simulator, evaluation of the 1icensee prog~am on continuing improvement of the EOPs and performance of human factor analysis of the EOP The inspection was to be focused on the adequacy of the end product and did not depend on review of the process to develop EOP However, because of the type of inspection findings on the end product, the inspection did review the facility development proces In addition, containment venting prov1s1ons were reviewed.. Containment venting provisions for all BWRs with Mark I containments are being reviewed across the country as an NRC inspection initiativ Conclusions The technical adequacy review (Section 4) identified that the facility DEOPs had deviated from the BWR Owner Group Emergency Procedure Guidelines and the Dresden Plant Specific Technical Guidelines~ These deviations included different logic, setpoint values and different system usag The documentation to justify many of these differences was not availabl The inspection also identified that the documentation was also not available to support some of the assumptions used in the calculations for the Drywell Spray initiation pressure limit, primary containment entry condition on high temperature and net positive suction hea Th~ inspection identified over thirty items for which the facility must develop the supporting documentation to justify the technical adequacy of the DEOP High level facility review of the documentation being developed is neede This item is included as part of the short terms actions of the license Associated with this item is the need for more awareness of the importance of maintaining the technical basis document (Plant Specific Technical Guidelines)

curren The walkdowns of the DEOPs in the plant concluded that the DEOPs are generally able to be performed (See Section 5).

There were areas identified that must be corrected by the license Thes *

include:

inconsistent use of magenta labels on OEOP equipment, some missing labels, some inconsistent terminology, referencing the wrong procedure section when transitioning from one procedure to another, precision of the instrument reading was not consistent with the DEOP values, completeness of procedure to transfer water from one torus to the other, inaccessibility of some equipment and boron in the warehouse, lack of control room space for use of DEOPs, and use of multi forms of DEOPs (text and flowchart).

The simulator portion of *the inspection (Section 6) noted differences between the simulator and control room which can affect the DEOP useability in the control roo This concerns include the different form of the DEOPs used for training and the physical differences between the simulator and control roo The facility is progressing to minimize the differences between the control room and simulato The simulator session also identified a concern regarding reactor depressurization when high pressure feed is los The team concluded that the DEOPs can be utilized by the plant staff and that the DEOPs will get th~ plant to a known safe stable conditio The human factor analysis (Section 7) characterized the concerns identified in the DEOPs to those with ~ strong relationship to potential human error (Areas 1-5) and those less directly related to potent i a 1 human error but which a 1 so affect useabil ity and understandability of the DEOPs (Areas 6-8). Oeci&ion steps/logic statements Caution~ and Note~

. Transitions Overall consistency Writers Guide Graphics Contra 1 Room DEOP-500 series The verification and validation of DEOPs was reviewed due to the number and type of items identified during the technical adequacy evaluation (see Section 8).

The principle concern was lack of a multi~disci~line team approach in the verification and validation~

proces Other observations include lack of detail on the checklists utilized, poor quality of documentation, lack of verification and validation on DEOP-500 series prior to implementation and not conducting plant walkthroughs on flowchart procedure steps not exercised on the simulato The ongoing evaluation of DEOPs (Section 9) concludes that the overall program is adequate, but due to lack of high quality basis documents (PSTG and Writer's Guide) and lack of multi-discipline review, the evaluation does not assure that the basis documents requirements are still me *

An evaluation of the QA measures in the DEOP program (Section 10)

concluded that management control system oversite activities were lacking in the DEOP progra No QA organization review of the DEOP program was conducte Management control oversite of DEOPs needs additional licensee attentio A violation was issued in this area due to lack of QA audits of the DEOP The containment venting section (Section 11) concludes that venting at Dresden meets the intent of the Plant Specific Technical Guideline Containment venting can be accomplished from the control roo If it cannot be performed from the control room, the accident environment around the valves to be operated would preclude local operatio The inspection concluded that the facility awareness of the EOP process which includes the development phase, validation and verification phase, implementing phase and maintenance phase needed improvemen The facility Plant Specific Technical Guideline, Writer's Guid~, use of a multi discipline team concept and management oversite controls need additional management attentio Even though the procedures can be physically carried out in the plant, some deficiencies were noted, including physical differences between the control room and simulator which must be eliminated to provide additional assurance that th~ DEOPs can be used when called upo Finally the procedures need to be modified to minimize the potential for operator error.

Persons Contacted Commonwealth Edison Company and Contractors * * * * * * * * * * * * *. * Alfred, Reactor Operator Armstron, Regulatory Assurance Supervisor Christensen, Operating Engineer Ciutinni, Reactor Operator Blackmon, Performance Improvement Assistant Eenigenburg, Station Manager

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Gerner, Superintendent of Performance Improvement Klika, EOP Coordinator LaSalle Kotowski, Assistant Superintendent Operations Langford, Shift Foreman Mohr, DEOP Coordinator Rodts, EOP Coordinator; Quad Cities Rogers, Consultant OEI Schilder, Consultant OEI Schroeder, Services Superintendent Scott, Senior Administration Engineer Silady, Nuclear Licensing Administrator Smith, BWR Licensing Supervisor Stiles, Training Supervisor Stobert, Director of Quality Assurance Tapella, BWR Site Engineer Wujeiga, Production Superintendent

U.S. Nuclear Regulatory Commission S. DuPont, Dresden Senior Resident Inspector

• G. Lapinsky, Senior Human Factor Specialist, NRR

• H. Miller, Director, Division of Reactor Safety, RIII The inspectors also contacted other licensee employees including members of the technical and engineering staffs and reactor and senior reactor operator *Denotes those present at the exit interview conducted on June 8, 198.

Basic EOP/BWR Owners Group Emergency Procedure Guideline Comparison A comparison of the facility EOPs and the BWR Owners Group Emergency Procedures Guidelines (EPGs), Revision 3, was conducted to ensure that the licensee had procedures as indicated in the EPG The EOPs reviewed are listed in Attachment A of this teport..

The facility EOPs are in agreement with the EPGs on the type of procedures required to respond to symptoms which result in entry into these procedure However, differences with the EPGs were noted and further discussed in the following section.

Independent Technical. Adequacy Review of the EOPs The EOPs in Attachment A were. reviewed to assure that the procedures are technically adequate and accurately incorporate the BWR Owners group EP A comparison of the plant specific technical guidelines (PSTG) to the EPGs and the EOPs was also performe Differences between the EPGs and PSTG were assessed for adequate technical justificatio Selected specific values from the procedures were reviewed to determine that the values were correc Specific findings are discussed in.the following section Plant Specific Values The inspector reviewed several values found in the DEOPs to verify their bases and adequac ( 1) The 1 i censee has deve 1 oped a p 1 ant speci. f i c drywe 11 spray initiation pressure limit curve based on calculational methods prepared by the General Electric Company under the auspices of the BWR owner's grou These calculations are interpreted by the licensee to allow full spray flow (two loops) to the drywell at drywell pressures greater than 5 psig and temperatures less that 350 deg. This interpretation is allowed when the *

drywell-to-wetwell differential pressure is five or more pound The key to this calculation is an assumption that the drywell torus vent pipe is the weak lin The licensee was unable to provide the inspector with calculations to validate this assumption. (Dresden No. X5)

Note: Items in parenthesis (Dresden No. X5) refer to the licenses tracking numbers for the ite Pending a review of these calculations, this item is open (50-237/88012-01; 50-249/88014-01).

(2)

The licensee has selected 200 deg. F. as the entry condition for Primary Containment high temperatur The PSTG states that this entry should be the 11 drywell maximum normal operating temperature.

A year 1 s worth of plant data was used to determine the plant average drywell temperatur This curve indicates the drywell maximum normal operating temperature to be less that 180 Deg. F. (Dresden No, X2).

Pending a review of the justification for using 200 deg. F. or changing the entry condition to meet the PSTG, this item is open (50-237/88012-02; 50-249/88014-02).

(3)

The licensee provided the inspector with calculations performed to create a nomograph showing allowable pump NPS These calculations were actually performed to validate the use of LPCI and core spray pumps for shutdown coolin These base calculations were modified to provide the operator with a tool to determine allowable pump flows with given torus temperature, torus level and drYwell pressur This nomograph is published on Page 1 of the DEOP However, the original data was calculated using torus pressure which is measured only within a restricted pressure range (+5 to -2.45 psig).

The licensee was unabl~ to provide the inspector with calculations showing the transition from torus pressure to drywell pressur Without this information, the validity of the nomograph could not be confirmed (Dresden No. X2).

Pending a review of these calculations, this item is open (50~237/88012-03; 50-249/88014-03). Technical Adequacy Differences (1). PSTG Caution 14, Flow Chart Procedure Caution 14, (Dresden No. 43) The PSTG states that the RPV should not be depressurized below a given value unless motor driven pumps sufficient to 11assure adequate core cooling 11 are running and available for injection whereas the DEOP caution states that unless motor driven pumps sufficient to 11 maintain RPV water level 11 are running and available for injectio (2)

PSTG Step SPIT, (Dresden No. 46) - This step has missing informatio (3)

PSTG Caution 21, (Dresden No. 48) - Caution 21 does not appear to apply to HPC (4)

DEOP Flow Chart 200-4, (Dresden No. 49) - The Flow Chart Procedure executes RVC at step C4A The PSTG does not execute this step until after emergency depressurizatio (5)

DEOP Flow Chart 200-4, Caution 9, (Dresden No. 51) - The caution says the condensate storage tank low level is 1.5 ft or 10000 gal The control room label indicates that 1.5 ft equals 12000 gal..

(6)

DEOP 200-1, (Dresden No. 52) - Step C2B calls for the operation of drywell coolers which is not in the PST (7)

DEOP 200-2, (Dresden No. 53 and No. 57) - Step C2 bypassing interlocks prior to starting drywell cooler is not in the PSTG, nor is the drywell pressure requirement of less than 5 psig for operation of these cooler (8)

DEOP 200-1, (Dr.esden No. 56) - First override differs from the associated override in the PSTG Torus 11cooling 11 is not contained in the PSTG Drywell spray is not contained in PSTG (9)

DEOP 200-1, (Dresden No. 58) - Drywell pressure value of 14 psig in the Flow Chart at Step 3 is different from the step in the PSTG which calls for 13.4 psig in the toru.

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(10} DEOP 200-1,. (Dresden No. 59) - The PSTG Step PC/P-7, 11 or if s~ppression chamber cannot b~ vented 11 has not been incorporated in the DEOP Flow Char *

(11) DEOP 300, (Dresden No. 61) - the integrated radiation release control actions and secondary containment control actions are differ~nt than the PSTG.*

(12) DEOP 100, (Dresden No. X4) - Step 4, last item not contained in the PST (13) DEOP 100, (Dresden No. 1) - Logic of control rod insertion differs from the PSTG Steps RC/Q-5.l ~ RC/Q- (14) DEOP 200, (Dresden No. 9) *- RC/L-2 step reversed in sequence relative to the PST (15) DEOP 100, (Dresden No. 10) - The word 11 AND CONTROL 11 omitted from RC/L, P, (16) DEOP 100, (Dresden No. 13) - Cautions identified as applicable to RC/P-5 differ from the PST (17) DEOP 100, (Dresden No. 15) - RC/PC2B, 2C are functionally different from the PST (18) DEOP 400-1, (Dresden No. 16) - Procedural override immediately before Step 1 does not appear in the PST (19) DEOP 400-1, (Dresden No. 17) - LPCI subsystem identifiers in PSTG and DEOPs are differen (20) DEOP 400-1, (Dresden No. 18) - Logic of step Cl2C is not consistent with the intent of PST (21) DEOP 400-2, (Dresden No. 19) - Logic of Steam Cooling differs from the PST *

(22) DEOP 400-2, (Dresden No. 21) - Step CG and the proceeding decision are not contained in the PST (23) DEOP 400-2, (Dresden No. 22) - Head vent as a method of RPV depressurization is contained in the PSTG, Step C2-l.3, but not contained in the DEO (24) DEOP 400-3, (Dresden No. 26) - Logic of step C4 does not meet the intent of the PST (25) DEOP 400-3, (Dresden No. 28) - References to Primary Containment Design Pressure, PSTG references suppression chamber pressur (26) DEOP 400-3, (Dresden No. 27) - Step 12 misreferences Step 1 PSTG references Step 1 (27) DEOP 400-4, (Dresden No. 35) - Step 8 is not con~ained in the PST (28) Procedures that may have to be executed concurrently with the DEOPs were reviewed by the tea As a r~sult of this review, the team concluded that Alarm Response and Abnormal Operating Procedures contain instructional steps that differ f~om the DEOPs. *(Dresden No. 5) Pending review of the resolutions of the technical deficiencies identified in Items (1) through (28) above, this item is open (50-237/88012-04; 50-249/88014-04).. Control Room and "Plant Walkdowns The inspectors walked down the DEOPs and procedures referenced therein to confirm that the procedures can be accomplishe The purpose of the walkdowns was to verify instruments and controls designated in the procedures are consistent with the installed plant equipment, ensure that the indicators, controls, annunciators referenced in the procedures are available to the operator; and ensure that the tasks can be accomplishe Detailed comments identified are noted in Attachment General comments and observations are noted belo Ability to Read the Meters to the Precision Stated in the DEOPs The values specified in the flow chart DEOPs frequently require a level of accuracy which is not obtainable from the instrument~

used by the operator The values used were often obtained from the technical specifications which are precisely calculated value The values were not all consistent with the capability of the installed instrumentatio If changes in values in the PSTG are required, and these result in changes from the vendor guidelines (EPG), then the differences between the EPG and PSTG should be documented and justified.

-. Inconsistencies and Omissions in Observed Marking and Labeling During the walkdowns frequent instances where the names of valves and meters did not agree with what they were called in the procedures were note The labels on valves, meters, recorders, etc., were sometimes missing or mislabele It is understood that many of these items will be corrected during the DCRD An in-depth comparison between the items planned to be accomplished during the DCRDR and the inconsistencies found between the DEOPs and the plant instrumentation and controls was not done by the tea Items Indicative of a Lack of Attention to Detail Many specific examples of items discovered during the walkdowns questioned the adequacy of the process to develop and implement the DEOP These were also illustrated by the technical adequacy concerns, human factor concerns., quality measures concerns and verification and validation concerns as are discussed in other sections of this repor Specific items are contained in Attachment In addition to the labeling problems mentioned in Paragraph 5.b above, referenced procedures which do not carry out the functiori intended by the DEOPs, the problems associated with obtaining boron from the warehouse, valves which are out of reach and references to the wrong*procedure step when transitioning to another procedure, are the most significan Most items, taken individually, have minimal impact on the ability of the DEOPs to be performed in the desired manne However, in the aggregate they might cause problems dOring an emergenc The walkdowns indicated*.

to the inspectors that improvements in quality of the DEOPs are necessar Pending a review of the deficiencies identified in Paragraph 5 above and in Attachment B to this report, this item is open (50-237/88012-05; 50-249/88014-05).

• Simulator Scenarios Five scenarios were run on the plant specific simulato The simulator scenarios provided information on real time activitie The purpose was to deter.mine that the procedures provide operators with sufficient guidance such that their responsibilities and required actions during the emergencies both individually and as a team are clearly outlined, verify that the procedures do not cause operators to physically interfere with each other while performing the DEOPs, verify that the procedures did not duplicate operator actions unless required (i.e., independent verification), when a transition from one DEOP to another DEOP or other procedures is required precautions are taken to ensure that a 11 necessary steps, prerequisites, and initial conditions are met or completed and that the operators are knowledgeable about where to enter and exit the procedure.

In addition, the simulator training lesson plans were reviewe The simulator scenarios utilized during training provided sufficient usage of all DEOPs and multiple malfunctions were include Through observations during the scenario the team concluded that the DEOPs do not cause operators to physically interfere with each other and operator actions are not duplicate When a transition from one DEOP to another DEOP or other procedure is required, the team concluded except for the one item listed below, the operator crew entered and exited the procedures at the correct point The team observed during the execution of DEOP-400-1 11 Level Restoration,

Step 70 an Emergency Depressurization was performed prior to the Reactor *

Level decreasing to (-143 inches) as would be required in the PSTG logi From discussions held with the operating crew and training staff, the team concluded that either the procedural step required revision to state the requirement to depressurize after the l~vel decreases to -143 inches or additional training on the specific step is neede The team concl~ded the EOPs did mitigate the plant upset condition The team noted that there were many physical differences in the simulator and control room that affected the determination of the useability of the procedure In the simulator, the DEOP flow charts were individually mounted on hard foam boards whereas in the control room paper copies of the flow charts are inserted in cellophane sleeves and kept in a si~ ring oversized binde The table in the simulator to use the DEOPs is an approximately 4 1/2 foot high panel in the control room with very little space to.use concurrent procedure The team attempted tb reproduce the binderization of the DEOPs flowcharts in the simulator by removing the flowcharts from the hard foam boards and clamping the flowcharts togethe The operators removed the clamps and individually used the DEOP flowcharts on the table as they were previously traine The inspectors concluded that, the flowchart form used in the control room is not as readily useable as the simulator versio The physical differences between the control room and simulator procedures and where the procedures are used require action to assure that the DEOPs are in fact useable in the control roo.

Human Fact~rs Analysis As a result of the human factors analysis of the Dresden Station DEOPs, a list of concerns has been generated (see Attachment C).

An initial desktop review of the DEOPs was conducted prior to the onsite inspectio Observation of simulator exercises, interviews with Dresden Station staff, and plant walkthroughs were used to both corroborate those problems noted during the desktop review and to identify additional concern The technical concerns identified in the Dresden Station DEOPs can generally be divided into two categories:

(a) those with a strong relationship to potential human error (Areas 1 through 5) and (b) those less directly related to potential human error but which also affect

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useability and understandability of the procedures (Areas 6 through 8).

A summary of concerns in each of these areas follow Attachment C contains the detailed concern Decision Steps/Logic Statements When individuals are subjected to emotional or environmental stressors, such as those which may be present during the use of DEOPs, difficulties may be experienced in a number of cognitive area For example, information drawn from long term memory may be incomplete or inaccurate, short term memory capacity may be reduced, and the ability to accurately assess the importance of details may be.degrade Any or all of these problems will lead to difficulty in decision-makin Because decisions play an important role in the execution of DEOPs, it i~ critical that decision and logic steps be clearly, consistently and appropriately use In the Dresden Station EOPs, numerous types of decisions are require *Because these many decisioni are inconsistently structuted, they may be difficult for tiperators to use in emergency situations and hold ~

potential for erro Cautions and. Notes Cautions are used to describe hazardous conditions that can cause injury or equipment damage and should describe the consequence of the hazar Notes are intended to provide supplemental information to the operato Neither.cautions rior notes should c6ntain directives to the operato~. Because of the critical nature of the information tontained in cautions, it is important that cautions be emphasized in a way that distinguishes them from notes and they be located where operators will not overlook the The human factors analysis revealed a number of problems related to format, structure, location, and labeling of cautions and notes in the Dresden Station EOP These deficiencies in the treatment of both critical and supplemental information coul.d lead to delayed operator action or operator erro Transitions Movement within and between procedures, (transitions), are often required of an operator during the execution of the DEOP An operator may be directed to concurrently perform more than one flow path, or more than one procedure, or to completely exit the procedure being executed and move to a different DEO An operator may also be required to reference tables, charts, supplemental information, or non-DEOP procedure Movement within and between DEOPs can be disruptive, confusing, and cause unnecessary delays and erro..

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Therefore, it is particularly important that these transitions be minimize When movement cannot be avoided, it is important that the transition directions to the operator be clearly and consistently structure Throughout the Dresden Station DEOPs, many transitions are required of the operato Transition directions to the operator are indicated in multiple, inconsistent, and sometimes unclear methods, making the procedures difficult to use and holding potential for erro Overall Consistency Because of the many performance variables that can increase the potential for error during execution of emergency operating procedures, it is particularly important that information be presented to the user using straightforward and clear method Training on the methods used to present different types of information can ensure that all users

• have common expectations about how the procedures ~re structured, and will therefore understand and execute the procedures in the same manne Thus, consistency of structure and content in emergency operating procedures is critical to both operator understanding of the actions required and conformity of performance across*

operating personne The Dresden Station EOPs contain numerous iriconsistencies in the presentation of every type of action step, as we 11 as in *a 11 types of information found in the procedure The extent of these inconsistencies is so widespread through critical steps, as well as in more supplemental information, that.the related potential fof error must be considered ~ubstantia Writer 1 s Guide In order to pr~pare clear, consistent DEOPs that will aid the operator and help minimize errors that can occur when operators execute procedures during emergencies, a complete and clear writer 1 s guide is necessar A number of inadequacies were identified in the Dresden Station Writer 1 s Guid These deficiencies result in a writer 1 s guide that does not provide the guidance necessary for consistent production and revision of high quality procedure Due to the types and numbers of problems related to writer 1 s guide deficiencies, the relationship of this item to potential error must be considered stron Graphics In emergency operating procedures formatted as flowcharts, the type and quality of graphics methods can greatly.affect useability and readability of the procedure In the Dresden Station EO.P flowcharts, there are a number of aspects of graphics methods that reduce the readability of the procedures and could lead to difficulty in their execution during an emergenc *

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Control Room The environment in which procedures are to be exercised plays an important part in procedure useabilit The Dresden Station control room layout and policies include a number of elements that can lead to difficulty in the execution of the DEOP DEOP 500 Series In the Dresden Station DEOP system, the 100 through 400 series constitute the main focus of all format control and maintenance activitie Outside the DEOP system, a procedure upgrade system is currently working to ensure consistency and quality among all non-DEOP procedure The DEOP 500 series, although a part of the emergency operating procedures, is subjected to minimal control of structure and qualit ~

Verification and V~lidation of DEOPs Verification of the dual-column format DEOPs was conducted between February and August 198 Verification activities included desktop review and control room/plant walkthrough These activities were conducted using the Emergency Procedure Verification Checklist, which was intended to assure that the procedures were consistent with the Dresden Emergency Procedure Guidelin The verification was conducted individually by a senior.licensed operator training program instructor and a senior licensed shift forema Their findings were ~valuated by the Assistant Technical Staff Supervisor - DEOP Coordinator, and*

integrated into the procedures according to his.judgeme~ Validation of the dual-column.format DEOPs was conducted on the Morris, Illinois, GE BWR simulator during February 18-22,-198 The validation consisted of using the procedures in 15 simulator scenarios that were designed to exercise as much of the prQcedures as possibl All steps in the dual-column procedures that were not exercised on the simulator were validated through plant and control room walkthrough Staff participating in the validation were the Assistant Technical Staff Supervisor - DEOP Coordinator, a senior licensed shift foreman, a licensed operator training program instructor, and a senior BWR certified simulator instructo The dual-column format DEOPs were implemented as Revision 0 on October 31, 198 Verification of the DEOP flowcharts and 500 series procedures was conducted between August and December 198 The verification was based on the same objectives as the verification of the dual-column DEOPs, using a combination of desktop review and control room walkthrough The effort was documented through the use of the Emergency Procedure Verification Checklist (for the 500 series) procedures and the newly developed DEOP Flowchart Verification Checklis The verification was conducted by two GE simulator instructors from the Morris, Illinois BWR Training Cente Their findings were evaluated by the Dresden DEOP Coordinator and the procedures were revised based on his conclusion *

Validation 6f the DEOP flowcharts was conducted during the week of July 14, 1986, at the Morris, Illinois, GE BWR simulato Two Dresden Station NSOs, the Assistant Superintendent of Operations, the Technical Staff Supervisor, and the DEOP Coordinator conducted the simulator validatio The DEOP 500 series was validated through plant walkthroughs conducted by the DEOP Coordinator, a senior licensed shift foreman, a senior licensed shift control room engineer, and a senior licensed shift engineer during June through September 198 Revision 0 of the 500 series DEOPs was implemented on October 31, 198 The flowchart version of the DEOP 100-400 series was implemented in January 198 Decisions regarding reverification and revalidation of the procedures are the responsibility of the DEOP Coordinato When changes to the technical specifications, the plant, or the procedures themselves are made, the procedures will be reverified or revalidated based on his judgemen Several concerns have been generated by a review of the Dresden Station EOP verification and validation proces The verifications and validation process at Dresden Station did not meet the objectives defined in the Dresden Station Procedures Generation Package, based on the following: The DEOP 500 series procedures were implemented prior to validation and verificatio The checklists used for both dual-column and flowchart verification are not sufficiently detailed to ensure that the procedures are consistent with the writer 1 s guid Verification documentation for the dual-column and flowchart versions of the DEOPs was completed in all cases by the DEOP Coordinator, not the individuals conducting the verificatio Because of this, it is not possible to assess to what extent th~ procedures were verified against the principles (limited as they were) reflected in the checklist The verification and validation processes did not utilize staffing from all the disciplines necessary to ensure a complete and adequate verification and validatio As conducted, the process lack~d human factors and technical writing suppor Steps in the flowcharts that could not be exercised on the simulator were not validated through walkthrough.

Ongoing Evaluation of EOPs Ongoing evaluation of Dresden Station EOPs. consists of three different types of activities.

First, a biennial review of all DEOPs is conducted in accordance with Dresden Administrative Procedure (OAP) 9-1, Station Procedures, and OAP 9-2, Procedures Preparation, OAP 9-3, Writer 1 s Review of Procedures,

and OAP 9-4, Control of Dresden Emergency Operating Procedure Prior to May 1988, these procedures called for a complete review of any procedure at the time of any revisio Due to this requirement, the DEOPs have already been reviewed several times and are not scheduled for their next biennial review until May 199 The scheduling of biennial reviews is controlled by the Dresden Station*

Procedure Coordinator, who notifies the DEOP Coordinator as reviews of DEOPs are du The DEOPs reviews have always been conducted by the DEOP Coordinator, though delegation is possible, and are documented using Checklist A, OAP 9-3, and Form 9-4A, Verification and Validation Checklis These forms are signed off by the DEOP Coordinato An explanation of the resolution of the comment is provided to the comment initiato The third method used for ongoing review of DEOPs is informal communication used by operators to relay their comments to the DEOP Coordinator when they are not undergoing tfainin The DEOP Coordinator reports that this* is the

~ost common method for him to receive operator inp~t about the DEOP The methods use~ fa; ongoing evaluat{~n of DEOPs at Dresden Station have several weaknesse They are: The actual review m~thods used for the biennial review are not indicated on the required documentatio Ii is therefore not possible to track by what methods or against what principles the procedures ar~ evaluate.

Although it. is ~ossible for the DEOP Coordinator to delegate the actual procedure review, the review would still be conducted by one individua Limiting staffing to a representative or representatives of one discipline prevents review of the procedures from multi-disciplinary perspective In addition, review by one individual (as opposed to a team) does not allow for adequate oversight and backup of one individual's evaluatio.

QA Involvement in the EOP Program The NRC team inspected the QA organizational involvement in the programmatic approach of the EOP progra The inspection focused on those policies, procedures and instructions necessary to provide a planned and periodic audit of the EOP development and implementation proces Discussions were held with the QA Directo From these discussions, it was determined that the QA organization did not perform auditing functions of the EOP progra A person from the QA organization was asked by the DEOP Coordinator to do an informal review, during the initial EOP development phase, of selected EOP The comments generated were not considered as formal QA comments and not formally tracke Many of the comments generated during this review were not incorporated in the subsequent implemented EOP Many of the comments generated by this review were similar in type to those found by the NRC team.. As discussed in Paragraph 8 above, the DEOPs were impleme.nted as Revision 0 on October 31, 198 All evidence obtained

from review of documents and personnel interviews confirmed that the DEOPs were not audits by QA from October 31, 1985 through June 8, 198 The licensee was informed that failure to perform planned and periodic audits of the Dresden EOPs is a violation of 10 CFR 50, Appendix B, Criterion XVIII (50-237/88012-06; 50~249/88014-06).

1 Containment Venting Dresden Nuclear Power Station is a three unit facility, with Units 2 and 3 utilizing GE Mark I primary containment configuration The Mark I containment design consists of a light bulb shaped drywell and a doughnut shaped toru The drywell is interconnected to the suppression pool by downcomers which submerge into the suppression pool wate Vacuum breakers are provided in the interconnections between the drywell, torus and Reactor Building~ The containment atmosphere is inerted with nitrogen during normal plant operatio Both the drywell and suppression pool chamber are designed to withstand a maximum of 62 psig internal pressur.

.

Containment venting is accomplished using components of the Pressure Suppression system, Reactor Building Ventilation system, and the Standby Gas Treatment (SBGT) syste Venting the drywell or torus can be perfonned in one of two way The fir~t path utilizes two 18 inch lines which are generally used for containment atmosphere purging and startup inertin The second path uses two 2 inch bypass lines which are used to vent excess

. pressure during plant heatup and normal operatio The volume vented from the drywell or torus is routed to the Reactor Building Ventilation system or SBGT, depending on the airborne activity levels in the drywell or

• torus. The Reactor Building Ventilation system discharges to the atmosphere through the 160 foot tall Reactor Building vent stac The SBGT system discharges to the 310 foot tall plant chimne The stack assures elevated vent gas releases to the environmen The containment venting configuration is generally identical in both Units 2 and In each unit, each of the two 18 inch lines (one line is connected to the torus and one line is connected to the drywell) have one butterfly air operated valve (AOV) that perfonns an inboard containment isolation functio Each of the two 2 inch bypass lines (the bypass lines bypass flow around the 18 inch AOV's) have a gate or globe AOV that also performs inboard containment isolation function The 2 inch drywell vent line uses globe valves while the 2 inch torus vent line uses-gate valve The two 18 inch lines for each unit merge into one line. The discharge

• flow is then routed in one of two direction One path is through a 6 inch line (with a 6 inch outboard containment isolation butterfly AOV)

to the suction of the Reactor Building Ventilation exhaust fan The containment vent piping and valves have a design pressure of 150 psi The SBuT filter trains have a design rating of 1 psi All AOV's can be remotely operated from the control room and receive air supplies from non safety-related source The butterfly valves also are connected to a fail safe accumulator syste All valve solenoids received

a safety related AC power suppl The valves can be operated manually by connecting portable air or nitrogen bottles to the valves locall However, most of the valves are located in high radiation or contaminated areas of the plan None of the AOV's are environmentally qualifie Operator access to the valves could be limited during certain accident conditions, due to potentially high radiation levels present in the vicinity of the valve For emergency venting of containments, the BWR owner's group recommended the following in Revision 3 of the EPG (guidance step PC/P-7):

11 If suppression chamber pressure exceeds the Primary Containment Pressure Limit, vent the containment in accordance with the (procedures for containment venting) to reduce and maintain pressure below Primary Containment Pressure Limit.

At Dresden, the instructions on when or how to vent the*containment during an emergency are provided in Procedure DEOP 500-4, Containment Ventin Entry into DEOP 500~4 is from DEOP 200-1, Primary Containment Pressu Control.. Operator actions necessary to vent the containment is based on contai~ment pressur During low pressure conditions (less than 2 psig),

the containment is vented in accordance with the normal venting or post accident venting procedure During high pressure conditions (greater that the Primary Containment Pressure. Limit curve), either the torus or drywell 2 inch vent relief valves are opened, depending on the torus water leve The discharge flow is then routed to SBG Venting through the torus should be the preferred method, since the primary containment

atmosphere will be scrubbed in the suppression pool prior to venting to the environmen In this way, the offsite exposure would be generally restricted to noble gases only. *

If the vent fl ow through the 2 inch 1 ine is not enough to maintain drywe 11 pressure below the Primary Containment Pressure Limit Curve, the 18 inch vent lines are use The flow is routed to the Reactor Building Ventilation system, because the SBGT is not designed to handle the vent pressure The licensee is aware that venting through the 18 inch line*

will probably overpressurize and rupture the piping downstr~am of the vent lin Based on the pressure ratings of the lines, the rupture of the line would be outside of the secondary containment but inside the Turbine Buildin This path is preferred by the licensee so as to allow operator access to essential equipment located in secondary containmen In conclusion, the procedure for containment venting at Dresden meets the intent of EPG Step PC/P-It should be noted the valves used to vent the containment are operated from the control room onl Failure of the valves, due to loss of air or power, could prevent the operators from venting the containmen Radiation levels in the vicinity of the valves could preclude operator access to the valve ;

1 Open Items Open items are matters which have been discussed with the licensee which will be reviewed further by the inspectors and which involves some action on the part of the NRC or licensee or bot Open items disclosed during this inspection are discussed in Paragraphs 4.a(l), 4.a(2), 4.a(3), 4.b, and 5, and Attachment B of this repor.

Exit At the conclusion of the inspection on June 9, 1988, an exit meeting was conducted with those persons indicated in Paragraph The inspection scope and findings were summarize The licensee did not identify as proprietary any material provided or reviewed by the inspectors during the inspectio At the exit meeting the licensee was requested to discuss the corrective action to be taken as a result of the inspection finding The licensee indicated that short term items would include addressing the technical issues identified, correct the procedure err6rs, address the DEOP procedures in the control room as far as useability and simulator differences and location, eliminate dual column format and fix label The longer term actions would include updating to EPG Revision 4, but first improve the DEOP development and maintenance process to effectively implement Revision *

Letter DJS 85-1152 Miscellaneous DAP 9-1 DAP 9-2 DAP 9-3 DAP 9-4

OAP 9-6 DAP 9-8

• DEOP-010 DEOP-100 DEOP-100-1 DEOP-100-2 DEOP-100-3 DEOP-200 DEOP-200-1 DEOP-200-2

DEOP-200-3 ATTACHMENT A Documents Reviewed Dresden Emergency Operating Procedures - Revised Procedure Generation Package dated December 12, 1985 Dresden Station Emergency Procedures Writer's Guideline dated February 11, 1987 Dresden Verification and Validation Records for both test and flowchart DEOPs Station Procedures Procedure Preparation Writer's Review of Procedures, Revision 3, dated April 1988 Control of Dresden Emergency Operating Procedµres, Revision 2, dated June 1987 Temporary Changes to Procedures, Revision 0, dated April 1988 Onsite Review of Procedures, Revision 0, dated April 1988 General Precautions, Revision 2, dated May 1988 Reactor Control, Revision 2, dated May 1988 Reactor Level Control, Revision 2, dated May 1988 RPV Pressure Control, Revision 2, dated May 1988 Reactor Power Control, Revision 2, dated May 1988 Primary Containment Control, Revision 1, dated May 1988 Primary Containment Pressure Control, Revision 3, dated May 1988 Drywell Temperature Control, Revision 3, dated May 1988 Torus Water Temperature Control, Revision 3, dated May 1988

• Attachment A DEOP-200-4 DEOP-300 DEOP-300-1 DEOP-400-1 DEOP-400-2 DEOP-400-3 DEOP-400-4 DEOP-500-1 DEOP-500-2 DEOP-500-3 DEOP-500-4 DOA 902(3)-3 B-3 DOA 902(3)-3 B-12 DOA 902(3)-3 B-16 DOA 902(3)-3 C-13 DOA 902(3)-3 G-16 DOA 902(3)-3 H-10 DGB 2-3 DOA 040-1 DOA 250-1

Torus Level Control, Revision 2, dated May 1988 Secondary Containment/Radioactive Release Control, Revision 2, dated May 1988 Secondary Containment Temperature/Radiation and Offsite Release Control, Revision 2, dated May 1988 Level Restoration, Revision 2, dated May* 1988 Emergency RPV Depressurization, Revision 2, dated May 1988 RPV Flooding, Revision 3, dated May 198 Level/Power Control, Revision 2, dated May 1988 Alternate Standby Liquid Control Injection, Revision 2, dated May 1988

.Bypassing Interlocks and Isolations; Revision 3, dated May 1988 Alternate Water Injection Systems; Revision 2, dated May 1988 Containment Venting, Revision 2, dated May 198 Isolation Condenser Vent High Radiation dated April 15, 1985 Suppression Chamber High Level, dated October 30, 1979 Reactor Building Ventilation System High Radiation Channel A or Channel B, dated October 30, 1983 Electromatic Relief Valve 3B Open, dated June 2, 1986 Reactor Low-Low Water Level, dated December 7, 1984 HPCI Floor Drain Sump High Level, dated February 26, 1985 Unit 2/3 Reactor Scram, Revision. 4, dated October 1985 Slow Leak, Revision 6, dated April 1988 Relief Valve Failure, Revision 6, dated August 1986

..

Attachment A

DOA 902(3)-5 B-4 DOP 1600-2 DOP 1700-10 Appendix C Documents Scram Air Header Dump Trip, Revision 0, dated June 1981 Torus Water Level Control, Revision 3 Obtaining and Calculating a Gaseous Release Rate from the U-2/3 Chimney, U-1 Chimney and U-2/3 Combined Reactor Vent Using the Eberline Control Terminal, Revision 1 Table Cl-T4, Plant Data, Part I Containment Data Section Max. D/W Spray Flow Rate Section Drywell Spray Initiation Pressure General Electric Letter G-EB0-5-401 of July 30, 198 Subject Dresden/Quad Cities Drywell Spray Initiation Limit General. Electric Letter G-EB0:-5-436 of August 14, 198 Subject Dresden/Quad Cities Drywell Spray Limit Improvement CEC Letter Boxer to Scott of September 6, 198 Subject Drywell Spray Limit Curve

,,

,,

ATTACHMENT B Walkdowns General Comments Many of the valves denoted in the DEOPs are not identified with permanent labels in the fiel These valves should be effectively tagged and readily identified in the plant to support the operators during emergency condition The licensee has initiated a formal labeling program following an August 1986 INPO evaluatio There are an estimated 29,000 valves in both unit Of these approximately 34%

have been tagg~d to dat The completion date established for valve labeling is January 198 Priority attention needs to be placed on those valves required to be operated for DEOP consideration Detailed Walkdown Comments DEOP 200, *Primary Containment Control; DEOP 200 Revision 1, DEOP 200-1 Revision 3, DEOP 200-2 Revision 3, DEOP 200-3 Revision 3, DEOP 200-4 Revision 2 The medium range Drywell pressure gage, 8540-001, used to detect an entry condition into Containment Pressure Control, has dymo label markings for the proper scale on the cover of a O to 100 gage scal.

The 11cooling valves 11 in Procedure Section 200-1, in the block between location Points 2 and 3 are actually labeled 11 Flow Test 11 (2... 1051-388 and 2-1501-208) on the pane.

The medium range drywell pressure strip chart indicator is covered with ink to the point of illegibility and the position indications on the panel drywell spray valve operating switch are also illegibl.

The nomenclature 11 Suppression Pool 11 and 11Torus 11 are used in panel labels, sometimes on the same instruments, such Recorders 2-1640-200A and B for torus water temperatur procedure seems to consistently use 11Torus.

interchangeably as back panel The fl ow chart 5. -

In the step following Block 4A of the torus temperature (200-3) procedure, torus water temperature is to be maintained below 156 degree The temperature indicator is calibrated in 5 degree increments and therefore can not be read to this 1eve1 of precision. *A 1 so, in the torus 1 eve l portion of the procedure (200-4), step 2, which refers to the tec.

spec. for minimum level l.imits, requires the use of a curve (Curve 4) with increments of 0.25 inche The meter from which the readings are obtained is graduated in 1 inch increment There are instances of inconsistency in the application of magenta DEOP indicator tags on instruments referenced in the DEOP Examples where tags are missing tags are, torus cooling and the acoustic monitors (which are also not labeled as to functio **

Attachment B 2 In the cautions and notes, No. 21 cautions that elevated torus pressure may trip the HPCI turbine on high turbine exhaust pressur The gage, PI 2340-5, is not marked for this trip point (100 psig).

No. 28 notes that only drywell pressure wide range indicators should be utilized for containment pressures above 5 psig, and specifies that indicators PI-2(3)1640-llA/B on Panel 902(3)-3 be used.* These indicators are marked LT-1641-5A and B (which are believed to be the pressure transmitters).

DEOP 100, Reactor Control, Revision 2 The inconsistent use of magenta labeling was noted during the walkdown of DEOP 10 For example, two of the four entry conditions (RPV pressure and power) had meters that were not identified with magenta labels in the *

contro.l roo Also, the DEOP equipment cabinets were identified with white label The use of colored labels is described in Procedure OAP 9-4, Control of Dresden Emergency Operating Procedure.

The meter~ 1602-1, Torus Pressure, was observed not to have any engineering units on the meter scal.

The scram test switches (Step 6C3) _do not have the switch positions labelled on Panel 902-1.

Step 100-1.4 states, 11Maintain RVP (typo, should be RPV) level greater than -143 inches.

The meter that is us~d to measure -143 inches has a range of +60 to -340 inches in increments of 10 inche A value of -143 inches can only be.estimate.

Step 3 states, 11Verify Aux Power has transferred.

The operators know how to perform this step using common knowledge, but the control room panel~

and breaker switches are not labelled "Aux Power." Caution 9 refers to a Condensate Storage Tank Level of "1.5 ft. or 10,000 gals." The meter is located in Unit 2 only (not in Unit 3, as implied by the wording of the caution) and has increments in feet of water leve A label next to the meter stated each foot of water level was equal to 8,000 gallon Therefore, 1.5 feet is equal to 12,000 gallons, not 10,000 gallon In the same caution, HPCI is incorrectly called HPIC, and the word "torus" is used when the control room labels call the torus a "suppression pool." Caution 19 stated, "Manually trip SLC pumps at 0% level in the SLC tank."

Since the pumps do not automatically trip on low level in the tank, waiting to stop the pumps at 0% can result in pump damage due to loss of pump suctio...

Attachment B

DEOP 300 Secondary Containment and Radioactive Release Control DEOP 300 Revision 2, DEOP 300-1 Revision 2 The Reactor Building Exhaust entry condition (greater than 4 mr/hr) is actually called a "Vent" on the mete It has no magenta EOP tag, and no indication of the alarm point (on either Unit 2 or Unit 3). The determination as to whether an area temperature entry condition has been reache.d (greater than 11 max norma 1

) is somewhat comple A front panel alarm is received which directs the operator to a back panel on which the individual locations which feed the front panel are indicate Those which are DEOP entry conditions are marked with the magenta DEOP label on this back pane In all but 4 cases this would immediately alert the operator that an entry condition had been reache To determine if an entry condition had been reached in the X-Area or Shutdown Cooling Area, the operator must press a button and read a mete DEOP 400~1. Level Restoration, Revision 2 The ADS system is called 11Automatic Slowdown System" (ABS) on the control.

panel name plat.

The table located under Step 3 of the flow chart procedure directs actions based on whether the RPV is a

• 1Low Pressure," "Intermediate Pressure 11 or 11 High Pressure.

The Low Pressure and the Intermediate Pressure regimes are separated by a bar labeled 80 psig and the Intermediate Pressure and High Pressure regimes by a bar labeled 330 psig." If the RPV pressure were exactly at 80 or 330 psig, the

'operator would be uncertain as to the correct action to take in accordance with this tabl In the center section (Intermediate Pressure section)

the entry question is 11 is HPCI available.

In the steps that.follow this question, there *is no step which directs the use of HPC.

Several steps in this procedure require that RPV level be read at -143 i The gage has gradations in 10 11 increments and so can not be read to this level of accurac Similarly, RPV pressure is to be read to 1101 psi This gage has increments of 20 psi.

This flow chart procedure has the same problems as previously noted regarding values which can not be read to the accuracy it specifie.

In Block 1, the word 11 opening 11 should be changed to 11 cycling.

DEOP 400-2, Emergency RPV Depressurization, Revision 2 In Block 1 the word 11 expect 11 should be changed to 11 except.

'*

Attachment B 4 This procedure, in several places, calls for "torus pressure" to be read and compared with RPV pressur The torus pressure gage can only be read from +5 to -2.45 in. and so can not be used in all cases to make this compariso It is believed that the operators actually use Drywell Pressure when making these comparison The narrow range of this pressure gage also makes it impossible for the torus pressure to be compared with primary containment design pressure as called for in Note 29 of the procedur.

The torus pressure gage on Unit 3 does not indicate the units of measuremen It should read PSI The scale also consists of dymo labels applied over a scale which is graduated 0 to 10 DEOP 400-3, RPV Flooding, Revision 3 This flow chart procedure has the same problems as previously noted regarding values which can not be read to the accuracy it specifie.

Caution 25 is repeated in the block which directs the operator to the cautio DEOP 500-1, Alternate Standby Liquid Control Injection, Revision 2 The inspector checked the access to and availability of boron to the plant in the event alternate boron injection is require Security was asked to provide a key to the storeroom where the chemicals are store The security personnel on duty could not identify the proper key which*

was ultimately obtained from storeroom per5onne Adequate boric acid (10, 325# barrels) and borax (8, 320# barrels) were lo~ated. However, these were found to be surro~nded by heavy pallets of absorbent granul~s which would need to be move out of the way before the boron could be taken to the Turbine Buildin There was no equipment in the store~oom which could be used to move either the boron or the blocking pallet Storeroom personnel stated that it is planned to bring fork lifts from the main storeroo Qualification and availability of personnel to

.perform this function on the back shifts and weekends should be verified by the license.

Steps 4.b.(l), (2), and (3) call for the manipulation of valves in the RWCU Demineralizer Valve Galler This is a high radiation are The valves are located high in the gallery and there is no ladder or other equipment provided to facilitate their operation in an emergenc.

Several problems were noted in carrying out Steps 5.a.(12)(a) through (c)

which are the steps in which alternative sources of water are obtained to prepare a boron solutio_n in the CATEX tan Step (a):

Neither of the clean demin. water source valves or supply' fittings were marke The supply located on the east end of U2 TBCCW Heat Exchanger has two stop

,.

Attachment B

valve The upstream valve is missing a valve handle. and it is unknown if the valve is open or shu Step (b):

There are several Condensate Demineralizer Post Strainer Drains, so the items should be made plural in the procedur Step (c):

The proper source of Service Water for this evaluation was not easily determine After some searching, it was determined that a pressure test connection which now has a gage attached would be the most likely candidate sourc These sources of water should be magenta tag and should also clearly indicate from which system the water is ~eing obtaine.

In Step 9.b.(l)(a) and (d) the Cleanup Controller and the Drain Flow Regulator were without numbers in the* Control Room (this is one example of many).

In Step (e), RWCU system temperature is obtained from a six position temperature instrumen The procedure does not specify which position should* be used (probably Position 2).

In Step (i), the operator is to observe Regentative Hx Inlet Pressure and Reactor Pressure and note when the difference is less than 100 psi The procedure does not direct the operator to the nearest Reactor Pressure gage to minimize the difficulty of making this calculation (probably the HPCI pressure gage}.

In Step (n), the operator is to 11mai ntai n suction pressure on RWCU Reci'rculation Pumps 11 however no values are give DEOP 500-2, Bypassing Interlocks and Isolations, Revision 3 In Procedure DEOP 500-2, some minor inconsistencies were noted between switch labe1ling in the control room and valve deicriptions in the procedur.

In Step A.8, Step C.1 should be E.1. * In Step C.1.c(7), Valve MO 3-3005 was noted not to be numbered on the control room label, only the name of the valve was give.

Three valves, MO 3-220-1, 220-3 and 220-4 were observed to have control switch positions (open-closed) that could not be read, because the labelling had worn of.

Step C.1.c(l8) instructs operators to 11 Return the MSL drain vales (typo, should be valves) to their normal position.

The step should clearly list which valves are to be returned to their normal positio.

In Step C.2.b, the words 11 to 11 are indicated as 11and 11 in the control room*

label.

In Step C.3.a(l)(f), the operator is supposed to perform an action based on reactor water level being below 2/3 core heigh This level in inches is more appropriate in the procedure and should be consistent with the ability to read the Fuel Zone range meter *

Attachment B 6 Step C.3.a(l)(k) references a dP indicating controller that the operator has to monito The *scale on the meter was noted to be incorrec The correct scale was superimposed onto the incorrect scale with a piece of tap.

Step C.4.a(2) directs operators to ensure the Fuel Pool radiation leve1 is below 100 mr/h The control room meter was labelled with an alarm setpoint of 90 mr/h The difference between the 90 and 100 mr/hr setpoint.was not clea.

Step C.4.a(4) should include the value needed for the operator to determine if Reactor Building differential pressure is being maintaine.

Steps C.4.b(3)(a) and (b) direct the operator to start faris without clearly identifying which.fans are to be starte.

Step C.6 incorrectly lists 11 RFP 11 as 11 RVP 11 *

Also, the last two steps, 0 and E,. are incorrectly labelled as G and OEOP 500-3, Alternate Water Injection Systems, Revision 2 *Step 0.1.b.(6). requires the operator to pump alternate units Torus to unit in distress Hotwells per OOP 1600-2 (Torus Water Level Control).

OOP 1600-2 does not contain a section or other direction to accompli*sh the required actio.

Step 2.a.(3)(a) _and (b). These two steps should be reverse Presently the*control room Valves are opened first and then the remotely operated valve.

Step 3.b.(7). CRO cooling water flow is not numbered in Unit.

Step 3.d.(8). This step requires the comparison of Pump*A and B discharge header pressures at the local control station, and throttle the lower pressure pump until the pumps are at approximately the same pressur These gages are widely separated and can not be used in the required manne.

Step 9.b.(12)(b). The breaker for MO 205-2-4 is labeled incorrectly on the breaker (now reads MO 205-24).

OEOP 500-4, Containment Venting, Revision 2 In Procedure Step A.l, the licensee should change Step 2.a to 2 and change Step C.l to In procedure Step A.2, change Step 8 to 8A or 88 and ch~nge Step C.2 to In Procedure Step 8.2, change Step C.1 to 0.1 and change C.2 to In all cases, the wrong step numbers were noted to be used in Procedure 500- *

Attachment B 7 Step D.l.a(6) instructs the operator to reset the drywell isolatio The step should instruct the operator to place the switch in both the left and right positions, to agree with instructions given in Step 0.2.c(l). Step D.l.b(3) tells the operator to monitor SBGT area radiation monitor The SBGT area radiation monitor is displayed only on Unit 3, and is not identified with a maroon colored DEOP labe.

Step 0.2.b instructs operators to verify SBGT is operatin The step implies SBGT is already in servic Instructions for starting SBGT should be added to the ste.

Steps 0.. 2.c(l) and (2) instruct operators to reset the drywell isolatio A review of the electrical schematic diagrams indicates the drywell isolation reset is not required to open the 211 vent relief valve.

Step 0.2.e provides directions to install jumpers utilizing open ended connections that require additional nut Th~ use of alligator clips would allow jumpers to be installed quicker and easier, but is not administratively allowed at Dresde * Step D.2.g(5) incorrectly underlines the word CLOS.

Valves used in the performance of DEOP 500-4 were inspected in the fiel Some valves were not clearly identifie Additionally, most valves are located in high radiation or contaminated area This could hinder operator actions if portable air or nitrogen bottles were required to be connected to certain valves on lOss of normal air supplie DEOP Equipment Storage Cabinets The contents of the two equipment storage cabinets were inspecte The cabinet located in the control room contained:

two sound powered headphone; miscellaneous jumpers of different lengths; tools to install jumpers, lift leads or pull fuses; insulated gloves; and fire hose fittings to connect fire protection water to the feed pump suction (alternate water injection). The cabinet located in the Turbine Building contained:

several sound powered headphones; hoses for alternate SLC injection (DEOP 500-1) and venting the over piston area of the CRD 1 s (DEOP 100, Step 6E); tools for connecting the hoses and venting the over piston area; hose fittings; and copies of.Procedure 500- The contents of the cabinets are supposed to be inspected on a quarterly basis, per Procedure DOS-10-15, which is currently in the draft proces Attachment B

DOP 1600-2, Torus Water Level Control Procedure, Revision 3 (a reference.procedure in DEOP 200) In Step F.2.c.(1) procedure specified Torus Transfer Isolation Val>>es are labeled Torus/Hotwell Iso Valve on the Panel (2(3)-1599-61 and -62). In Step F.2.h. the procedure calls for hotwell water level to be read on LI 1602-3 on Panel 902(3)- The specified indicator is actually the torus level indicato The proper indicator is 2-3340-06 on Panel 902(3)-.

In Step F.3.c., the HPCI Flow Bypass Valve M0-2301-14 is actually lab~led Minimum Flow Valve on the panel and is not a th~ottle valve as the procedur~ indicates. * In Attachment A to this procedure, the vertical axis is not labeled other than at the top with 11 PSIG.

The vertical axis should be labeled 11Torus/Drywel l Differential Pressure, PSI DOA 250-1, Reli~f Valve Failur~. Re~ision 6 (a referenced procedure in DEOP 200)

In Step D.2.d. the Motor Suction P~mp is actually labeled Turbine Main Shaft Suction Pump on the pane *

ATTACHMENT C Human Factors Review Examples The following examples are provided to clarify the types of problems identified in the human factors concerns described in Section 7 of this repor These examples are not intended to be viewed as an inclusive list of all such problems found,in the Dresden Station EOPs, but rather as limited examples of the types of inadequacies identified through the human factors analysi.

Decision Steps/Logic Statements Within the Dresden Station EOPs, required decisions are indicated by de~ision symbols, specific exit statements, and logic statement The d~cision directives within these steps and symbols are written in inconsistent and incorrect format Logic terms IF, WHEN, and THEN, are used in the flowch~rts in a manner inconsistent with that defined for use in the DEOPs (e.g., 100-2, Step C3; 100-2, Step 4; 300, Step 9).

Not only is this use of logic statements within action steps on the flowcharts inconsistent with that defined for DEOPs in the writer 1 s guide, but it fails to utilize the decision symbols provided for use in the flowchart,,

In addition, numerous non-logic terms ar~ used as if they were logic terms.. For example, 11 but only if, 11 (100-2, Step C3);

11 until 11 (400-3, Step 7);

11 but 11 (100-2, Step 4);

11 before 11 (300, Step 9).

Decisions are embedded. within action steps (100-2, Step C3, 100-2, Step 4; 300, Step 4).

11And 11 and 11 or 11 are used as logic terms when actually functioning as conjunction In addition, 11and 11 and 11or 11 are used within the same decision step, giving multiple meanings to the statement (100~2, Step 1 specific exit statements; 100-2, Step 4). Cautions and Notes Because of the critical nature of information contained in cautions, it is particularly important that they be (1) properly emphasized to catch the operator 1 s attention, and (2) distinguished from the non~critical information contained in note In the Dresden Station DEOP flowcharts, no distinction is made between cautions and note Both are placed along the perimeter of the flowchart and are referenced by number at the steps to which they appl This lack of any special emphasis and location out of the flowpath could cause operators ~o overlook critical informatio Cautions were also found embedded within action steps, lacking any special emphasis, and sometimes located after the action to which the.y app 1 i e Cautions are intended to contain critical information relating to potential injury or equipment damag Notes are intended to contain supplemental information that may be of use to the operato Neither should contain operator action Throughout the Dresden Station EOPs, cautions and

,l

Attachment C 2.

notes are found to (1) contain operator actions (e.g., 10, 11, 19);

(2) embedded logic statements (e.g., 10, 12, 14); and (3) transitions (e.g., 16).

Most cautions or notes containing cautionary information did not identify the potential hazard, and some information included in notes and cautions was so basic that it appeared unnecessary to include in the procedur Trans it i ans In the Dresden Station EOPs, users are required to move within and between flowcharts, to move to the cautions and notes placed along the side of each flowcharts, to move to reference tables and curves, and to move backward in flowlines to recheck specific exit statement Thes~ transitions are indicated in numerous, inconsistent and unclear method For example, some transitions are indicated through the use of both an action statement

~ directing the transition and a transition symbol containing the referenced procedure number (100~1, Step 1 specific exit statement).

In some cases, the step number indicated in the action step differs from that contained in the adjoining transition symbol (100-3, Step 7; 400-4, Step 3; 400-2, Step 6).

Some transition directives are incomplete (100-2, s~veral unnumbered steps).

In some cases, the transition is directed in the action step, but lacks a transition symbol (400-3, Step 12; 400-3, Step 14).

Numerous types of transition statements are used, for example:

11 return to 11 (100-2);

11 see 11 (300, Step 5);

11 go to 11 (400-1, Step Cl2C);

11 execute

(300, Step C9);

11 using 11 (100:...3, Step C5A);

11proceed directly to 11 (400-4, Step 5);

11per 11 (100-3, Step C6Dl); and 11 from 11 (400-1, Step Cl2A).

In some cases, the procedure number is included in a step within parentheses, rather than in an adjoining symbol (400-2, Caution 29).

In some cases, the transition is directed by use of the symbol alone (100-3, Step C6Dl).

No distinction is made between symbols used for 11within 11 procedure transitions and 11 between 11 procedure transition Important to easy movement within and between procedures is a clear and consistent step numbering syste In an attempt to correlate step numbers in the text DEOPs and flowchart DEOPs, the flowcharts have been left with inconsistent and incomplete step numberin This can lead to difficulty or errors when making transition In addition, an effective method for placekeeping is critical to efficient use of procedure The placekeeping squares used in the Dresden DEOP flowcharts are reported to be of no use to operators during execution of the procedure Overall Consistency Of special concern in the Dresden Station EOPs is the widespread lack of consistency in format and conten Inconsistencies have been identified in the use of decision steps, cautions and notes, and transitions

Attachment C 3.

throughout the procedure In addition, action steps are structured inconsistently and in conflict with the writer 1 s guid Action steps have been identified that use passive voice (200-2, Step C4); and that include multiple steps (100-1, Step 1 specific exit statement; 100-2, Step 6).

Steps within the flowcharts sometimes used terminology in an inconsistent manner (

11execute 11 vs. perform;

11 kept 11 v maintained;

11operate 11 v initiate 11 or 11 start 11 ); or used vague or ambiguous terminology (

11 rapidly 11 or 11 slowly 11 ).

In addition, steps were identified that included excess clauses or informatio Abbreviations and acronyms were used inconsistently throughout the procedures, conflicting with those listed in the writer 1 s guide or in other places within the procedure Periods and apostrophes were used with abbreviation and acronyms in an inconsistent manne Writer 1 s Guide The Dresden Station Writer 1 s Guide does not provide sufficient nor adequat~ly restrictive guidance to result ih consistently prepared and revised, high-quality DEOP For example, Section 3.0 for structure of the text version *DEOPs contains guidance on general writing technique However, Section 5.0, Structure of DEOP Flowcharts, does not include specific guidance on the writing of individual steps, but rather states that 11every effort has been made to adhere to DSEPWG Section 3.0.

The problems identified within the structure of flowchart steps couJd have been reduced if the writerJs guide had more specifi~ally defined the manner in which steps within the flowcharts were to be written, Also, the guidance that is provided in the writer 1 s guide is in some places vague and non-restrictiv For example, writers are told in Section 2. 7 that the 11 format for referencing or branching to other procedures should be as follows....

In Section 3.4, 11 should

is defined as 11 nonmandatory.

This lack of restrictiveness has led to inconsistent use of indications to the operator that a transition is to be mad Graphics Graphics methods employed in the production of the Dres~en Station flowcharts have contributed a number of problem For example, print size and quality vary between flowchart The smaller print size used on several of the flowcharts is estimated to be below the minimum standards required by human factors engineering principle Methods of production and reproduction used result in variable print quality and darkness that results in procedures that are in places very difficult to rea Use of all capital letters* not only is more difficult to read, but eliminates the use of all caps for emphasi While the directional arrow used on flowlines is helpful to the user, connections of lines do not include

Attachment C

any directions on which way the user is to mov The plastic sleeves in which the flowcharts are placed in the control room cause glare, making the flowcharts even more difficult to rea In addition, a high number of typographical errors, extra or missing spaces, inconsistent line spacing, and inconsistent use of periods were found throughout the procedure.

Control Room The current Dresden Station EOPs are designed for use in both Unit 2 and Unit In this form, a number of problems exis Because a number of differences exist between the units, some parts of the procedures apply to only one uni In addition, valve numbers differ between units and the attempt to accommodate the different numbering systems has led to references in the DEOPs that are not correct for either uni Further, should concurrent multi-unit events occur, the SRO in charge could have great difficulty in directing the use of procedures in the current for Current phy~ical structure of the Dresden Station control room ~oes not provide adequate desktop space for use of the flowchart~. Most users indicated that they would use the flowcharts on top of the offgas panel, rather than at the center des The height of the.panel would make it difficult for users of average height to read the flowchart In addition, no dedicated storage space for the flowcharts currently exists in the*

• Dresden Station control roo The control room at Dresden Station differs substantially from the simulator used for operator trainin The differences reduce the effectiveness of training and*could lead to operator difficulty in using the DEOPs during an actual plant even In addition, the physical form of the flowcharts in the control room differs from that of the flowcharts used in the simulato This further reduces the effectiveness of trainin DEOP 500 Series The DEOP 500 series is the only type of DEOP not formatted as a flowchart or double column text procedur The writer's guide states that a number of different types of single column format will be used with this series, as "best fit the intent of the procedures.

This disclafmer put the 500 series in a category that is not controlled by the Writer's Guid Current Dresden Station procedure focus includes a procedu~es upgrade program that addresses all non-DEOPs, and a strong focus within the DEOP program on flowchart DEOP Series 500 procedures have been overlooked for different aspects of validation and verification, and also contain numerous inconsistencies and problems as a result of these oversight These include numerous inconsistencies in sentence structure, incorrect grammar, inconsistent use of emphasis, and excessive verbiage and detai..

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TYPE CODE A(O

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TYPE CODE AfO

ABNORH. CNVIR. OC ALG

ALLCGAT ION 8UL

BULLCT IN CAL

CONFIR. ACTION LT CIR -

CIRCULAR Ol:V

DCVIATION

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