IR 05000237/1992001
| ML20133G884 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 10/08/1992 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20133G876 | List: |
| References | |
| 50-237-92-01-01, 50-237-92-1-1, 50-249-92-01, 50-249-92-1, NUDOCS 9701160202 | |
| Download: ML20133G884 (18) | |
Text
.
.
-.-
....- -... _... -... -. - = _ -..
. - - -.
_. - ~
. -....
. - -.
- ~.
.
e i
'
,
I SALP 11
!
,
t
{
INITIAL SALP REPORT i
i
)
(
t
.
U.S. NUCLEAR REGULATORY COMMISSION
REGION III
'
!
!
,
!
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE
!
Inspection Report No. 50-237/92001; 50-249/92001
!
Commonwealth Edison Company
-
,
Dresden Nuclear Power Station i
August 1, 1991, through July 31, 1992 j
.
e
I
!
9701160202 921008 PDR ADOCK 05000237 G
SUMMARY OF RESULTS A.
Overview This assessment period was from August 1, 1991, through July 31, 1992.
'
The overall station performance indicated cause for concern.
The last SALP report discussed a decline in station performance that was identified late in that assessment period.
This decline continued into the current period.
To accurately assess this decline, NRC conducted a number of intensive
+
inspections to provide better insight into your performance.
Based on these intensive inspections it is now apparent that this decline was a result of significant weaknesses in your management systems and controls and that, in some areas the ratings assigned last period were too high.
Poor personnel performance and material condition at Dresden station also contributed to the overall decline.
In the Plant Operations area, the decline in performance was attributed to a lack of management effectiveness in controlling day-to-day operations as well as ineffectiveness in reducing personnel errors.
Radiological Controls performance declined owing largely to ineffective management oversight of radiation workers, poor resolution of concerns from the previous assessment period, and lack of support for radiation protection i
practices and policies by line organizations outside the radiation protection i
department.
In the area of Engineering,' Technical Support, although increased onsite
)
corporate engineering support was recognized, the delayed resolution of technical concerns and weaknesses in management oversight of the technical staff were strong contributors to the decline in its rating.
.
Although the area of Safety Assessment / Quality Verification.also declined, an improving trend was assigned to it.
The decline was due to problems within the corrective actions program and delays in management resolution of concerns.
The improving trend reflects management improvement programs initiated this assessment period.
Performance in Maintenance / Surveillance remained steady, although concerns with post-maintenance testing were expressed.
The Security and Emergency Preparedness functional areas remained at the Category I level.
The performance ratings during the previous assessment period and this assessment period according to functional areas are given below:
Rating Last Rating This Functional Area Period Period Trend Plant Operations
3 Radiological Controls
3 Improving Maintenance / Surveillance
1 Security
1 Engineering / Technical
3 Support Safety Assessment / Quality
3 Improving Verification
-
B.
Other Areas of Interest During this assessment period, the decline in performance resulted in NRC senior management determining that Dresden required closer NRC attention.
In response to this, Dresden was placed on the NRC watch list, the assessment period was shortened to a twelve month cycle, and NRC inspection effort was
.
increased. Additionally, the Dresden Overview Team, comprised of Region III and headquarters managers, was formed to provide closer management attention
to Dresden activities.
III.
Performance Analysis A.
Plant Operations 1.
Analysis Evaluation of this functional area was based on the results of 10 routine and 2 special inspections and 3 operator licensing examinations conducted by resident, regional-and headquarters inspectors.
Enforcement history was poor. A Severity Level III violation and a civil penalty were issued midway through the assessment period for a breakdown in the control of licensed activities associated with fuel handling, routine operations, and outage activities. Other less significant violations reflected weaknesses in the quality anc implementation of equipment control
)
procedures.
..
-
-
.
--
l l
Management effectiveness in ensuring quality during routine operations was
!
occasionally poor. Operators failed to properly respond to alarms which l
resulted in heating the torus beyond technical specification (TS) limits and
'
extending the duration of the emergency diesel generator (EDG) daytank oil l
Unclear direction to onshift management, tolerance for malfunctioning l
operating or alarming equipment and incomplete log-keeping contributed to the poor operator performance.
Proper equipment control was not always maintained as exemplified by leaving a standby liquid control air sparging valve open following tank sampling, inserting the wrong control rod during routine l
testing and opening the circuit breaker to an isolation condenser valve for the wrong unit.
Contributing to the equipment control problem was lack of attention to detail, failing to follow procedures and inadequate procedures.
Though operator decorum and professionalism in the control room was generally good, non-licensed operators occasionally performed their rounds improperly.
Management effectiveness showed some improvement in the latter part of the assessment period. Confirmatory Action Letter corrective actions to the
'
October 1991 damaged fuel bundle event resulted in suspension of fuel movement and operator retraining. Subsequently, fuel handling activities were well performed. After being notified of NRC concerns at another Commonwealth Edison Company (Ceco) site, strong, appropriate action was taken to ensure non-licensed operators performed their rounds properly. A number of corrective actions were implemented to improve overall operator performance including one-on-one expectation meetings with each operator by the assistant superintendent of operations, log-keeping training, issuance of more stringent procedure implementation policies, and more frequent management presence in the control room.
Performance deficiencies continued, as exemplified by the 500 gallon diesel fuel spill late in the assessment period, but they occurred less frequently.
.
Good, prudent operational decisions were made throughout the assessment period. This was exemplified by not operating above 75 percent power unless all feedwater pumps were operational and establishing good shutdown, risk policies for the Unit 3 refueling outage.
Housekeeping and material condition were inconsistent. They were adequate during the first half of the assessment period, but deteriorated during the latter half.
This deterioration was exemplified by numerous negative observations in the crib house and numerous oil leaks on rotating equipment.
Though improving, mater'.al storage (radioactive and non-radioactive), outside the plant but within the protected area, was weak.
Operational. events reflected mixed performance. None of the three reactor scrams were attributable to operator error. However, lack of operator attentiveness resulted in a 2800 gallon spill of reactor coolant water and airborne contamination of both reactor buildings during a resin transfer.
Operator response to abnormal events was good, except when an operator continued moving fuel, after damaging fuel bundles, instead of stopping operations.
!
'
l
.
,
1
_ _.
-
_
_
-
.
-
.
- -
-
Staffing and experience levels were acceptable with a six-shift rotation used.
!
However, late in the assessment period, the loss of licensed operators s
l resulted in occasional forced overtime, mixing shift teams. Control room
)
personnel responsibilities and authorities were well defined except for
,
,
!
establishment of maintenance work priorities during the first half of the
'
!
assessment period.
An additional senior reactor operator (SR0).was placed in the control room during the Unit 3 refueling outage, enhancing supervisory coordination of outage activities. Operator overtime guidelines were adhered to, but no such guidelines were established for fuel-handlers.
For example,
'
some of the fuel handlers involved in the damaged fuel bundles event had worked 45 days consecutively.
Training and qualification effectiveness was generally good. Three
,
examinations -- one requalification, one initial retake, and one initial license -- were administered. The pass rate for the requalification examination improved from the previous assessment period with 19 of 20 candidates passing.
Eleven of twelve initial licensing candidates passed, and
,
the one retake candidate passed. Actual operator performance reflected
occasional weaknesses in knowledge of TS and administrative controls requirements. Also, a lack of fuel handler training in responding to unusual incidents contributed to the significance of the damaged fuel bundles event.
2.
Performance Ratina Performance is rated Category 3 in this area.
Performance was rated Category 2 during the previous assessment period.
3.
Recommendation Continued management involvement in established improvement programs, continued reinforcement of management expectations, and re-emphasis on attention to detail during day-to-day operations is needed in the Operations area.
.
B.
Radioloaical Controls 1.
Analysis Evaluations of this functional area was based on the results of three routine and three special inspections conducted by resident and regional inspectors.
Enforcement history was poor. One Severity Level III violation with a civil penalty was issued early during the Unit 3 refueling outage for a programmatic breakjown in radiological controls resulting in the unplanned exposure of two i
workers; it was caused, in part, by ineffective corrective actions for
'
previously identified problems.
Six Severity Level IV violations also were identified, with four having multiple examples. Most of the violations represented failures to follow procedures. One violation, identified late in the assessment period, was a failure to conduct procedurally required prejob briefings -- a causal factor identified in the earlier escalated enforcement i
action.
)
Managenent effectiveness in ensuring quality was poor overall.
Poor radi<> logical control practices persisted with considerable indication that v rious work groups, particularly those other than radiation protection, were still neither fully cognizant of nor fully subscribed to as-low-as-reasonably-
'
achievable (ALARA) principles and other radiation control program requirements and policies.
Examples included lack of ALARA consideration on incore probe work and on a fuel pool system modification, two liquid radwaste problems, failure to notify the RP department of damaged fuel bundles in the fuel pool, problems with control of high radiation area doors, and problems with worker use of electronic dosimeters (EDs).
Lax contamination control practices resulted in liquid spills which spread contamination, contaminated equipment or material found outside of or straddling control boundaries, improper remcval of potentially contaminated equipment from contaminated areas, and in the poorly planned use of a portable drywell ventilation system.
Management weaknesses were particularly evident in the frequent failure to maintain radwaste building doors closed and in the failure to clean and restore proper barricades and postings on radwaste building roof areas
'
following work completion. To address these problems, station management recently began emphasizing specific area responsibilities for individual managers and workers at all levels; however, this effort was not initiated early enough in the period to determine its effectiveness.
Conversely, progress was made by use of job history files, which improved ALARA dose estimates; extensive preoutage planning for the Unit 3 refueling outage; use of a radiation protection (RP) drywell coordinator during the outage; hydrolazing and other source term reduction efforts; and use of models and a surrogate tour system for worker training. ALARA efforts were effective in work on control rod drives, reactor vessel stud removal, reactor cavity bulkhead draioline removal, and in the positive initiatives pursued (after
'
some initial delay) in the liquid and solid radioactive waste (radwaste)
program.
Performance in the radwaste transportation program continued to be excellent.
In chemistry, management commitment to industry guidelines continued to maintain good quality reactor water. Also, agreement was reached
'
on 37 out of 38 non-radiological chemistry comparisons.
The approach to identifying and resolving technical issues from a safety standpoint was good.
The total station dose in 1991, a year that included 72 days of Unit 3 refueling outage and several months of forced outage for Unit
.
2, was the lowest since 1973, although still somewhat high at 1005 person-rem.
Although the Unit 3 outage continued into the first half of 1992, total station dose remained low. The number of personnel contamination events during 1991 was low at 118 and was low in the first half of 1992. Although the amount of the radiologically-controlled contaminated areas was high, operators were usually not hampered during routine rounds.
Radiological effluents remained well below regulatory limits.
However, a problem of high backgrou'nd radiation levels affecting the service water radiation monitors and
.
the inability of the radwaste building ventilation systems to meet design specifications have existed for several years without resolution.
l
,
-~ -
-
-
--
_ -.--
-
-
- _
i l
i Staffing and experience levels were acceptable.
The level of personnel
'
experience in the RP and chemistry departments continued to increase as a result of inw turnover, and several experienced and knowledgeable consultants and corporate health physicists were added to the RP staff as part of a general improvement plan.
The experience level of radwaste personnel and nuclear quality programs (NQP) RP auditors was also good.
The good performance of the ALARA group and the radioactive waste shipping group continued from last assessment period.
Training and qualification effectiveness was minimally acceptable.
For example, limited use of instructors with recent plant experience hampered the effectiveness of the nuclear general employee training (NGET) program. NGET discussions were weak concerning recent Dresden radiological problems, and there continued to be no audio demonstration of E0 alarms in the radiation workers' training, although personnel not responding to ED alarms was part of the escalated enforcement action.
Planned improvements to incorporate advanced radiation worker concepts into NGET and the continuing training program for experienced plant workers were delayed during the assessment period, although they were committed to in response to previous NRC violations. The need for their implementation was highlighted this assessment period by several identified radiological control weaknesses.
In contrast, the training program for chemistry technicians remained a strength.
2.
Performance Rating
'
Performance is rated Category 3 with an improving trend in this area.
Performance was rated Category 2 in the previous assessment period.
3.
Recommendations Continued management attention is warranted regarding station dose, procedural controls over system operational evolutions to prevent radiological consequences, and procedure and policy adherence by radiation workers'.
Additionally, corrective actions for identified weaknesses need to be pursued to completion.
C.
Maintenance / Surveillance 1.
Analysis Evaluation of this functional area was based on the results of 12 routine and 6 special inspections conducted by resident, regional and headquarters inspectors.
,
Enforcement history remained poor. Another Severity Level III violation with a civil penalty, the second in less than 2 years, was issued for inadequate post-maintenance testing of primary-containment isolation valves. Other violations reflected weaknesses in the quality and implementation of i
surveillance and maintenance procedures, and continued post-maintenance testing inadequacies.
)
,
l 7.
Management effectiveness in ensuring quality was mixed.
Strong, effective
management decisions significantly increased the integrity of the Unit 3 primary containment including proactive repair activities of minor penetration bellows cracks.
Emergent work was properly managed during the Unit 3 refueling outage so that it did not compromise the quality of maintenance performance, as it did during the previous assessment period. The inservice
'
inspection (ISI) and erosion / corrosion (E/C) programs were well implemented.
Surveillance activities were accomplished within TS requirements except for instances of missed chemistry samples.
Conversely, testing procedures were occasionally inadequate with some personnel errors during their implementation as demonstrated by instrument mechanics improperly calibrating steam line radiation monitors and not reconnecting the high-voltage supply to a neutron monitoring channel after completing calibration activities. Maintenance work packages, although generally adequate, were weak with respect to post-maintenance testing.
Policies for reviewing motor operated valve test results and the establishment of appropriate process test parameters for integrated tests were weak.
Planning, scheduling, and implementation of maintenance activities on important-to-safety equipment were occasionally untimely as in the case of the repairs on the diesel fire pump and the containment atmosphere dilution system.
There was limited use of a reliability-centered maintenance program.
The approach to identifying and resolving technical issues from a safety standpoint was good in most cases. Comprehensive corrective actions were taken to improve primary containment integrity and to resolve weaknesses in the motor operated valve test program.
Continuation of the integrated electrical contact review effort coupled with meeting procedural upgrade milestones was improving the content of test procedures.
Changes to the planning and scheduling process resulted in identification and correction of weaknesses which had prevented accomplishing routine maintenance activities in a timely manner.
The use of computer programs for E/C inspections was good.
In response to aging concerns, a systematic program to upgrade planti instrumentation with modern, more reliable equipment effected replacement of 51 recorders during the Unit 3 refueling outage.
Establishment of divisional
'
testing has been slow, although it was considered a significant deterrent to the potential for a common mode failure -- such as rendering inoperable all four main steam line radiation monitors.
Conservative management decisions resulted in outage extensions to correct latent design weaknesses or to perform extensive valve repairs reducing previous as-lef t valve leakages.
However, when the outages were through, poor balance of plant pump performance prevented consistent full-power operation.
'
Numerous reportable events were attributed to procedural or implementation errors during testing such as not performing source range and intermediate range nuclear instrument calibration at the appropriate TS frequency and discarding of reactor building ventilation exhaust charcoal cartridges required for TS iodine analysis.
-
.
.
.
.-
.
.
.
-_.
-.
..-
.
.
.
I l
Staffing and experience levels were acceptable.
Resources within the maintenance, ISI, and E/C areas also were adequate.
Key positions, such as the-assistant superintendent of maintenance and the instrument mechanic master, were filled on a priority basis with well qualified individuals.
Additionally, a new position, material control manager, was designated and filled during this assessment period.
However, personnel filling the " Lead
,
!
Leak Rate Test Engineer" position changed frequently, providing little continuity of experience.
Training and qualification effectiveness was good. Training to perform local leakrate tests was sufficient for routine test implementation.
ISI and E/C inspectors were appropriately certified and applicable engineering staff members were knowledgeable of their responsibilities and procedures.
Maintenance personnel appeared skilled and knowledgeable. However, weaknesses
'
in personnel knowledge of administrative controls were evident.
2.
Performance Ratino P
Performance is rated Category 2 in this area.
Performance was rated Category 2 during the previous assessment period.
3.
Recommendation None.
D.
Emeroency Preparedness 1.
Analysis Evaluation of this functional area was based on the results of one routine and two emergency preparedness (EP) exercise evaluations by regional inspectors.
Enforcement history remained excellent with no violations identifieds Management effectiveness in ensuring quality was excellent. The EP program was well maintained, as evidenced by excellent maintenance of the emergency response facilities, excellent training provided to members of the emergency response organization (ERO), and excellent exercise performance. Management devoted the resources needed to the EP program to maintain a high level of performance and to improve the program, such as the total revision of emergency plan implementing procedures (EPIPs).
The approach to identifying and resolving technical issues from a safety standpoint was excellent. The EPIPs were being completely rewritten to make them c.oncise and easy to use. During the 1991 annual exercise, problems were identified relating to the wording and subsequent interpretation of some security-related emergency action levels (EALs). Thorough corrective actions were taken to clarify these EAls.
I I
.
_ _ -.
_ _ _
.
The EP-related response to the seven operational events when EAls were entered was excellent.
Four Unusual Events and three Alerts were correctly and conservatively declared in accordance with the emergency plan. Timely,
.
accurate notifications of the events were made to State, local and NRC l
officials.
Activation of the technical support center and the operational support center following the Alert classifications was timely. Members of the ERO in these facilities provided good support to the control room staff.
i
\\
Exercise performance was excellent during both the 1991 and 1992 annual exercises with one exercise weakness assessed during the 1991 exercise and one
'
minor performance problem identified during the 1992 exercise. Both exercises were very challenging and included unrelated equipment failures that affected both operating reactors, activation of the security plan, use of the control i
room simulator, off-hours activation of the emergency response facilities, and the use of role players to portray the NRC.
The onsite EP planning group staffing was excellent with two full-time EP coordinators, a full-time EP trainer and a part-time EP trainer. The ER0 had
,
ample staff with at least three qualified individuals assigned to each key i
position, and most key positions had four qualified individuals to add depth
'
to the ERO. Support positions were also amply staffed.
The EP training program was excellent. All personnel assigned to the ERO were properly trained with accurate, indepth lesson plans and relevant findings from drill and exercise critiques.
2.
Performance Ratina Performance is rated Category 1 in this area.
Performance was rated Category 1 in the previous assessment period.
3.
Recommendations
,
None.
E.
Security 1.
Analysis Evaluation of this functional area was based on the results of two inspections conducted by regional inspectors.
,
Enforcement history improved and was excellent with no violations identified.
Management effectiveness in ensuring quality was excellent.
Plant and corporate management demonstrated excellent involvement in site security activities. Management strongly supported security initiatives involving improvements in staffing, training and equipment. Security management's overview of day-to-day operations was consistent and improved from the previous assessment period as demonstrated by effective monitoring of routine security activities. However, several isolated vulnerabilities were
,}
.
. - -
-
-
. -..
.
-
..
_
-_-
-
-
-,
i
.
identified regarding the monitoring of personnel, package and vehicle searches, and an unsecured protected information container.
Security
'
management immediately implemented effective corrective measures.
The approach to identifying and resolving technical issues from a safety
standpoint was excellent.
Significant improvement was noted in hardware system effectiveness and reduction in personnel errors through effective engineering, maintenance support, and management awareness.
Equipment enhancements included upgrades to the vital area access control key card
'
program and closed circuit television system.
Redundant intrusion alarm equipment continued to be effectively used when the effectiveness of primary
,
equipment was reduced.
-
,
Response to security events was excellent. Management actively developed and
,
monitored tracking and trending programs, identified actual and potential
~
problems, and implemented effective corrective actions resulting in a decreased number of security events.
Event reviews were thorough and complete. Resultant records were complete, well maintained and readily
.;
available.
Communication with the NRC was excellent.
Security staffing continued to be ample and was effectively used to implement
,
day-to-day operational activities.
A close and effective working relationship existed between security contractor site personnel and licensee security
personnel.
The security training and qualification effectiveness was excellent. Security
training was excellent in the area of armed contingency response as demonstrated through a program of frequent, complex, and demanding tactical i
drills.
To support this effort, a professional security consultant conducted periodic independent physical exercises and evaluations of the tactical training program.
In additi'on, curriculum changes were implemented to develop and improve managerial skills.
.
.
!
Overall implementation of the fitness-for-duty program continued to receive excellent management attention and support.
2.
Performance Ratina Performance is rated Category 1 in this area.
Performance was rated Category
'
1 in the previous assessment period.
i
,
i 3.
Recommendation i
l'
None.
,
F.
Enaineerina/ Technical Sucoort 1.
Analysis
.
Evaluation of this functional area was based on the results of 13 inspections and 3 operator licensing examinations conducted by resident, regional and
'
headquarters inspectors.
,
I
.
- _ -
Enforcement history was excellent with one Severity Level IV violation involving post-modification testing.
,
I Management effectiveness in ensuring quality was mixed.
As in the past, i
management failed, in a number of situations, to provide appropriate planning and prioritization of significant issues.
This, coupled with weak oversight
,
of technical staff, contributed to slow resolution of long-standing equipment problems such as pump seal reliability problems, spurious reactor water cleanup isolations, sticking control rod drives, and drywell liner sand pocket leakage. Management was occasionally ineffective in ensuring that specific plant equipment problem root causes were identified, resulting in recurring
'
failures. Also continuing from the previous assessment period was the lack of effective contractor oversight which occasionally resulted in inadequate
.
documents or information being provided to the NRC.
Examples included the incorrect Unit 2 TS reactor vessel pressure / temperature curve and a.
'
nonconservative feedwater regulating valve transient analysis.
Conversely, corporate engineering modification packages and station temporary alterations were good. Management initiatives to improve post-modification testing were effective as evidenced by detailed reviews performed on
]
electrical system modifications late in the assessment period. Communications between onsite engineering and the technical staff were good. Also, late in the assessment period, a system was implemented which prioritized modifications with safety significance heavily weighted.
Management effectiveness in operator licensing and requalification was good with some exceptions. The exceptions included incomplete and inaccurate examination material, an occasional lack of discrimination in job performance measure questions, and marginal simulator fidelity partly as a result of important temperature and radiation monitoring equipment being either not installed or out of service. The emergency operating procedures (E0P) program was sufficient to ensure the quality of the E0Ps was maintained.
From a human factors standpoint, the E0Ps were improved significantly from those reviewed in the 1988 NRC E0P inspection.
The approach to identifying and resolving technical issues from a safety standpoint was poor and led to some operational difficulties. Numerous technical issues were not appropriately addressed, a weakness from the previous assessment period.
Resolution of the EDG cooling water pump flooding concerns was untimely. Weak initial resolution of an annunciator common ground concern resulted in two emergency plan activations. Other examples included not considering coincident loading in the 250-Vdc battery load profile, inappropriate resolution of EDG day tank capacity concerns -- which left an annunciator constantly illuminated -- and a lack of understanding of j
the safety significance of abnormal reactor coolant system leakage into the drywell during the performance of the integrated leak rate test. Good engineering approach to technical issues was noted in the addition of a new alternate Unit 3125-Vdc battery and the thorough resolution of cable separation problems.
I
1
. _ _ _ _.
. __
_
__
_
_ _... _ _ _
_ __ _
.
+
The number of the engineering and technical support staff was adequate.
However, the low technical staff experience level, coupled with weaknesses in management oversight, contributed to the high work-activity backlog.
The experience level of corporate engineers, including those located onsite, was
!
good. Training department staffing was adequate to meet the training
!
department and NRC operator licensing examination administrative requirements.
The initial and requalification training program.s were excellent based on passing rates. However, weaknesses in candidate-performance were observed
including a lack of knowledge as to how to obtain required equipment during
'
simulated emergencies and inadequate use of the new E0P cabinet.
2.
Performance Ratina Performance is rated Category 3 in this area.
Performance was rated Category 2 in the previous assessment period.
3.
Recommendation Provide increased management oversight of technical staff engineers and emphasis on improving planning and prioritization skills, particularly when the technical staff is inexperienced.
Focus additional attention as necessary to resolve long-standing technical issues.
G.
Safety Assessment /0uality Verification
.l.
Anal ysi s Evaluation of this functional area was based on the results of 12 routine and 5 special inspections conducted by resident, regional and headquarters inspectors.
Enforcement history showed a significant decline this assessment per.iod and was weak. A civil penalty was issued for a Severity Level III problem, discussed in the Operations functional area, for five violations indicative of ineffective handling of personnel performance problems.
A second Severity Level.III violation, discussed in the Maintenance functional area, represents a continuation of a trend from the previous assessment period and is evidence
,
of a programmatic breakdown in the condition-adverse-to-quality (CAQ) system.
A third Severity Level III violation was issued after the assessment period for a reactor recirculation valve failure which occurred during the assessment period. Numerous Severity Level IV violations provided further examples of the breakdown in the CAQ system.
.
Management. effectiveness in ensuring quality was lacking during the first part of the assessment period but improved towards the end of the assessment period. At the beginning of the assessment period, there was little evidence
'
I of prior planning and assignment of priorities. Numerous violations and licensee event reports documented problems with management controls, procedural quality and adherence, communications, and corrective actions.
l
}
.
!
.
,
,
,,
.
.
There was a lack of reinforcement of management expectations at the worker g
level.
The cumbersome procedure change process deterred workers from identifying poor or inaccurate procedures for revision. Workers did not always use procedures or worked around procedure problems, did not understand the quality standards by which they would be judged, and did not properly complete their assigned tasks.
Situations requiring increased management attention were slow to be recognized and resolution of the numerous management weaknesses were ineffective.
The use of augmented station tailgate sessions, the preparation for the Unit 3 refueling outage, and other corrective actions were insufficient to preclude operational errors during the fall of 1991.
Midway through the assessment period, positive corrective actions began to be taken with improvements noticed by the end of the assessment period. A new plant manager was appointed and the Dresden situational review team (DSRT) was formed to evaluate problem root causes and overall station performance. The DSRT recommendations subsequently resulted in numerous short-and long-term corrective actions that were comprehensive in addressing station performance weaknesses.
Progress was made in the procedure change process, reducing the number of outstanding temparary procedure changes as well as the time needed to process a permanent procedure change. Milestones were met for completing
!
the overall procedure rewrite effort.
Management also began establishing a worker-level understanding of the need for procedural compliance and an accurate w6rk activities schedule.
Some progress was made in establishing more positive worker attitudes.
l The CAQ system had significant programmatic and implementation deficiencies throughout the assessment period. Management did not always acknowledge their CAQ responsibilities as exemplified by weak root cause analysis, numerous missed commitments, and untimely corrective actions.
For example, administrative-procedure training, a corrective action to an escalated enforcement violation from the previous assessment period, was not adequately provided to plant personnel. Midway through the assessment period, the CAQ system was supplemented by the Dresden improvement program.
Although the overall performance decline subsided, the new program was not effective in some areas, such as the prioritization and timeliness of corrective actions and worker adherence to radiation protection policies. By the end of the assessment period, improvement items were reprioritized and accelerated, commensurate with their importance.
In other areas, management effectiveness was good. The safety evaluation process (10 CFR 50.59 reviews) improved after more written guidance was provided. Nevertheless, the reviews were impaired by the quality of the final safety analysis report, inaccessibility of systematic evaluation program documents, and the minimal guidance provided on calculation assumptions. The 10 CFR Part 21 review and corrective action program functioned well as exemplified by the replacement of defective Yokagawa controllers and the inspection of degraded diesel generator rotor bolts.
However, the Part 21 screening process for non-hardware defects, such as engineering services, was poor.
l
)
'
,
.
e
,
i The self-assessment aspect of management's involvement in ensuring quality was mixed. The broad based self-assessment capability was unsuccessful in recognizing and rectifying performance degradations until NRC staff intervened. Conversely, limited scope evaluations were good. The use of SRO-qualified individuals to periodically observe control room activities, comparison of critical functions among the six CECO nuclear stations, and a shutdown risk assessment were excellent methods to identify weak areas. The l
I onsite nuclear safety group (0NSG) was a positive contributor to safety as exemplified by the prompt distribution of lessons-learned notifications from other Ceco sites. Both NQP and ONSG have good communications with corporate l
and counterpart organizations at other sites.
The licensee's corporate
'
engineering assurance organization provided a good technical review of engineering efforts by auditing corporate engineering, onsite engineering, and various contractors.
The approach to identifying and resolving technical issues from a safety standpoint was mixed.
There were a number of technical issues that required management involvement, such as degraded voltage setpoints, 250-Vdc battery testing, alternate 125-Vdc battery use, and the TS upgrade program. Although the importance or safety significance of some of these issues had to be brought to management's attention, once they focused on an issue, sufficient resources and effort were applied to obtain acceptable resolution and implementation of modifications in a timely manner, although numerous iterations were occasionally required.
Additionally, no assessment was made to determine the safety significance of performing the 5-year overhaul of the swing EDG with both units in power operation versus with both units shut down.
In contrast, the voluntary decision to remain shut down until corrective
'
actions associated with the cable separation issue were completed demonstrated a good commitment to safety. Due to numerous events occurring this assessment period that resulted in degraded or inoperable equipment, the vulnerability i
assess,ent team was formed to identify and prioritize equipment problems using risk-assessment as a basis.
'
,
Staffing of quality assurance and quality control groups was good.
Resources were available to implement the audit schedule to witness work activities.
Traini.g and qualification effectiveness of the quality oversight groups was good v th a broad experience base maintained. However, training on administrative procedures was minimal.
I 2.
Performance Ratina Performance is rated Category 3 with an improving trend in this area.
.
Performance was rated Category 2 with an improving trend during the previous assessment period.
3.
Re' commendation.
l l
..
l Although an improving trend was assigned, in recognition of the management improvement plans in progress, increased management involvement is needed to
,
j ensure management expectations are embraced by all levels of the organization.
t i
Additionally, senior management expectations of the CAQ program need to be i
reinforced to lower management tiers such that the weaknesses identified in the system are eliminated.
,
,
t
_
.
IV.
SUPPORTING DATA AND EllMMARIES t..
Maior Licensee Activities Significant outages and other major events are listed below.
1.
On August 17, 1991, an unplanned Unit 3 reactor scram occurred while performing routine surveillance testing of the turbine main stop valves.
2.
On August 26, 1991, an unplanned Unit 2 main turbine trip occurred with a reactor scram.
3.
On August 30, 1991, the Unit 2 main turbine was tripped while at low power to obtain data related to the August 26 scram. The reactor tripped on low pressure during this evolution.
4.
On September 8,1991, Unit 3 entered its 12th refueling outage.
5.
On October 21, 1991, Unit 2 was manually taken off line when the station 250-Vdc battery system was declared inoperable.
6.
On November 13, 1991, during Unit 2 reactor heatup, spurious intermediate range monitor spiking caused a reactor scram. While the unit was off line concerns were raised regarding Division I and Division 11 cable separation.
7.
On February 6,1992, Unit 2 was brought critical following completion of corrective action with respect to cable separation concerns.
8.
On April 25, 1992, Unit 3 was synchronized to the grid following the refueling outage.
B.
Ma.ior inspection Activities
The inspection reports discussed in the SALP are listed below:
Unit 2, Docket Number 50-237, Inspection Report Numbers:
91022-91027, 91029, 91031-91033, 91035-91041, 92002, and 92004-92020.
l Unit 3, Docket Number 50-249, inspection Report Numbers:
91022-91023, 91025-91029, 91031-91036, 91038, 91040-91045, 92002, and 92004-92020.
Three meetings of the Dresden oversight team have taken place during the assessment period.
,
.
.
16