IR 05000247/2002009
| ML021510228 | |
| Person / Time | |
|---|---|
| Site: | Indian Point  |
| Issue date: | 05/31/2002 |
| From: | Lanning W Division of Reactor Safety I |
| To: | Dacimo F Entergy Nuclear Operations |
| References | |
| IR-02-009 | |
| Download: ML021510228 (18) | |
Text
SUBJECT:
INDIAN POINT 2 NUCLEAR POWER PLANT - NRC SUPPLEMENTAL INSPECTION REPORT 50-247/02-09
Dear Mr. Dacimo:
On April 18, 2002, the NRC completed a supplemental inspection at your Indian Point 2 Nuclear Power Plant. During this inspection the NRC reviewed evaluations and corrective actions that your staff has completed or initiated in response to a finding of substantial safety significance (Yellow). The finding was associated with crew high failure rate during facility-administered annual licensed operator requalification examinations conducted last fall (NRC Inspection Report 50-247/01-013). The enclosed report documents the inspection findings which were discussed with you and other members of your staff during an exit meeting on April 18, 2002.
This supplemental inspection was conducted to provide assurance that the root causes and contributing causes of the Yellow finding were understood, to independently assess the extent of the condition, and to provide assurance that the corrective actions to risk significant performance issues were sufficient to address the causes, and to prevent recurrence. To accomplish these objectives, the inspectors reviewed your root cause analysis and evaluation of extent of condition, and conducted an independent assessment of the extent of condition and generic implications.
Based on our inspection, we determined you identified reasonable causes for the Yellow finding. The corrective actions described in your Training Improvement Plan (TIP) are appropriately focused on the identified causes. These actions were appropriately prioritized, and were either complete or scheduled for completion. We noted that you took immediate steps following the requalification examination failures to provide extensive retraining to each shift, and continue to provide this high intensity training. Your extent of condition reviews found, consistent with our independent assessment, that underlying problems in the operator training programs were long standing. Although many of these problems had been identified, previous corrective actions were either incomplete or had not been fully effective. Your success in fully resolving the issues that led to the crew high failure rate will rely heavily on your staffs continued rigorous implementation of the corrective actions.
Your facility remains under the Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix due to other inspection findings. Although your actions to date are considered
Mr. Fred Dacimo -2-appropriate, further demonstration of improved performance is needed for us to have confidence that your corrective actions will be effective in addressing the underlying causes of this Yellow finding. Consequently, this finding will remain open until after completion of your licensed operator requalification examinations, scheduled for later this year. The NRC will continue to monitor the mitigating systems cornerstone through normal baseline inspections and oversight of your TIP.
Your letter of January 18, 2002, indicated an intent to rescind your commitment to NRC to not use for watchstanding purposes restricted operators (as defined in your letter of December 13, 2001) who had not been observed by NRC in a plant operational setting. As noted in our Final Determination Letter of February 18, 2002, we requested that you maintain this commitment until the completion of this supplemental inspection, which has just concluded. Based on NRCs previous observations of retesting of operations staff and on the results of this inspection, we have determined that it is appropriate to release you from the commitment.
In accordance with 10 CFR 2.790 of the NRCs Rules of Practice, a copy of this letter and its enclosures will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRCs document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Wayne D. Lanning, Director Division of Reactor Safety Docket No. 50-247 License No. DPR-26
Enclosure:
NRC Inspection Report No. 50-247/02-09
REGION I==
Docket No: 50-247 License No: DPR-26 Report No: 50-247/02-09 Licensee: Entergy Nuclear Generation Company Facility: Indian Point 2 Nuclear Power Plant Dates: April 8 - 12, 2002 April 15 - 18, 2002 Inspectors: T. Fish, Operations Engineer, DRS, RI (Detailed - Team Leader)
A. Blamey, Sr. Operations Engineer, DRS, RI J. DAntonio, Operations Engineer, DRS, RI R. Pelton, Human Factors Specialist, NRR Approved by: Richard J. Conte, Chief Operational Safety Branch Division of Reactor Safety
SUMMARY OF FINDINGS IR 05000247/02-09; on 4/8-18/02; Entergy Nuclear Generation Co.; Indian Point 2 Nuclear Power Plant; Supplemental inspection for one degraded cornerstone in a strategic performance area (mitigating systems).
The inspection was performed by three regional inspectors and one headquarters inspector.
The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 3, dated July 2000.
Cornerstone: Mitigating Systems Supplemental Inspection Findings This supplemental inspection was performed by the NRC to assess the licensees evaluation associated with crew high failure rate (four of seven crews failed) during facility-administered annual licensed operator requalification examinations conducted last fall. The finding was previously characterized as having substantial safety significance (Yellow) in NRC Inspection Report 50-247/01-13.
The inspectors noted that the licensees evaluation identified a fundamental underlying weakness: The station has yet to overcome cultural weaknesses that include an unwillingness to confront poor performance, an over reliance on procedures to change behavior, and compartmentalization. More specifically, the licensee identified three root causes: 1) Operations training had not focused on the basic building blocks that ensure a healthy program; 2) The station had not maintained a core of career oriented, plant knowledgeable instructors and operators; and 3) Operations department involvement with Operations Training had often been ineffective. The inspectors concluded that the methodology and level of detail of the licensees root cause evaluation were reasonable.
The licensee implemented a number of corrective actions to address the identified causes. The corrective actions are described in the stations Training Improvement Plan. The more significant corrective actions included initiatives that aimed to 1)
improve the quality of training and training materials; 2) increase the number of instructors who have Unit 2 plant experience; and 3) provide additional management support and oversight of training. The inspectors determined that the corrective actions are appropriately focused on the identified causes. These actions were appropriately prioritized, and either complete or scheduled for completion. Notably, the licensee took strong immediate corrective actions following the requalification examination failures to provide extensive retraining to each shift, and continue to provide this high intensity training.
The inspectors independently assessed the extent of the underlying conditions that led to the Yellow finding and found that performance issues had also existed in other Operations Training programs, such as initial licensed operator and non-licensed operator training programs. These problems existed for at least three years, both prior to and following the steam generator tube failure event in 2001. Although licensee audits and assessments had identified most of the performance problems prior to the crew high failure rate, they did not identify long-term operator performance as a concern. The inspectors concluded that the licensees extent of condition review ii
appropriately bounded the underlying conditions that led to the Yellow finding as evidenced by the fact that the licensee had also identified the duration and extent of the problems, and the failure to recognize the long standing issues.
iii
Report Details 01 Inspection Scope (95002)
The NRC performed this supplemental inspection to assess the licensees evaluation associated with crew high failure rate during facility-administered annual licensed operator requalification examinations. This performance issue was previously characterized as Yellow in NRC Inspection Report 50-247/01-13 and is related to the mitigating systems cornerstone in the reactor safety strategic performance area.
02 Evaluation of Inspection Requirements 02.01 Problem Identification a. Issue Identification The issue, crew high failure rate, was self-revealing and was the final result of the facility-administered annual 2001 requalification operating examinations. During the root cause evaluation, the licensee identified numerous factors leading up to and contributing to the issue.
b. Duration and Prior Opportunities for Identification Crew high failure rate existed during and after the administration of the 2001 annual exams, essentially September through October, 2001. However, the licensees root cause evaluation showed that the genesis of the issue, including prior opportunities for identification, dated back several years. Their staff reviewed quality assurance audits, industry peer assessments, self assessments, plant events, and operator performance records dating back to 1998. Those documents, especially the facilitys own quality assurance audits, previously identified many of same performance issues that were again exposed by the 2001 examinations. As discussed in section 02.04 of this report, the inspectors agreed with the licensees evaluation that prior opportunities to identify this issue existed.
c. Risk Significance and Regulatory Compliance Crew performance on the simulator provides a measure of how operators could be expected to perform during actual plant events. The NRC Operator Requalification Human Performance Significance Determination Process provides a guide to the perceived risk associated with crew failure rate. NRC staff considered the significance of this event to warrant a Yellow finding, based, in part, on important performance deficiencies operators exhibited both in the plant and during simulator evaluations.
The licensees evaluation of the crew high failure rate was assigned the highest importance level (Level 1). Further, the results of personnel interviews and docketed correspondence to the NRC indicated Entergy staff recognized the substantial safety significance of the issue.
No compliance concerns were associated with the issue, because the operators that failed requalification examinations were removed from shift following the failures and
were retrained as required. In addition, NRC inspections of portions of the operator requalification program itself did not reveal violations of regulatory requirements.
02.02 Root Cause and Extent of Condition Evaluation a. Root Cause Methodology The inspectors reviewed Entergys condition report (CR) 200110995 and supporting analysis. The licensee utilized Events and Causal Factors Charting together with a Hazard-Barrier-Target Analysis to obtain an understanding of the training deficiencies and develop corrective actions. The worksheets detailing the methodologies used were available for inspection. The methods used by the licensee were reasonable.
b. Level of Detail The inspectors noted that the licensees evaluation identified a fundamental underlying weakness: The station has yet to overcome cultural weaknesses that include an unwillingness to confront poor performance, an over reliance on procedures to change behavior, and compartmentalization. More specifically, the licensee identified three root causes: 1) Operations training had not focused on the basic building blocks that ensure a healthy, accreditable program; 2) The station had not maintained a core of career oriented, plant knowledgeable instructors and operators; and 3) Operations department involvement with Operations Training often had been ineffective. The licensee performed an appropriate evaluation of the issues associated with the Yellow finding.
c. Prior Occurrences The analysis considered training issues, plant events, self-assessments, audits, and evaluations dating back to May 1998. Entergy staff, as well as consultants and personnel external to Indian Point 2, performed these reviews. The inspectors determined that this thorough review was evidence that the licensee considered prior occurrences and operating experience.
d. Common Cause and Extent of Condition Reviews The licensees evaluation considered the potential for common cause and extent of condition associated with the Yellow finding. They expanded the scope of the evaluation beyond issues within licensed operator requalification to include a broader spectrum of programmatic issues within Operations Training. The inspectors agreed with the licensees evaluation of common causes and extent of condition.
02.03 Corrective Actions a. Appropriateness The licensees corrective actions were appropriately linked to the identified causes.
Representative corrective actions for each of the root causes included initiatives to:
improve the quality of training and training materials; increase the number of instructors who have Unit 2 plant experience; and provide additional management support and oversight of training. The causal factors identified in the licensees January 18, 2002 letter to the NRC were also addressed by the corrective actions. The inspectors determined the completed and proposed corrective actions were appropriate.
b. Prioritization The licensees actions related to the root and contributing causes of the issue were appropriately prioritized. The licensee took immediate corrective actions such as improving instruction quality and providing extensive retraining to each shift. Following completion of the root cause evaluation, the licensee identified additional corrective actions and established a schedule for completion of the actions.
c. Implementation and Completion The inspectors determined that the licensee had either completed, or was tracking the completion of corrective actions identified within the Training Improvement Plan (TIP).
The inspectors noted each corrective action had a responsible individual assigned and an identified due date. As of the end of April, approximately 60% of the TIP was completed. The remainder of the programmatic improvements were scheduled for completion by the end of the year.
d. Effectiveness Measures The licensees evaluation includes a section for corrective action effectiveness measurement. Effectiveness reviews are scheduled for 2002 and 2003, with the specifics detailed in the TIP. The TIP also contains the process for evaluation and closure of corrective actions.
02.04 Independent Assessment of Extent of Condition and Generic Implications The inspectors made their independent assessment of the extent of condition and generic implications using NRC Inspection Procedure 41500, Training and Qualification Effectiveness and NUREG-1220, Training Review Criteria and Procedures. Using an interview protocol, as outlined in Attachment 1, Interview Protocol, the inspectors interviewed personnel from the Operations Department, Training Department, and management ranks.
Results of these interviews indicated deficiencies within the operator requalification program, such as poor instructors and inaccurate lesson plans, had existed in other Operations Training programs including initial licensed operator and non-licensed operator training programs. Interviews also indicated that operators supported the
changes made as a result of the crew high failure rate. The changes most frequently stated involved those associated with the conduct of operations in the classroom, simulator, and control room. All personnel interviewed indicated there was substantial improvement in the quality of training as well as a sharp increase in management involvement in the training processes.
Audits of operations training were conducted annually by Nuclear Quality Assurance.
Additionally, since 1998, assessments of operations training have been conducted following operational events. For example, an assessment of operations training was conducted following the tube rupture event in February 2000 and training areas for improvement (AFI) were identified. The AFIs identified in the assessment had the potential to improve operations training and operator knowledge.
Implementation of the AFIs was in progress, and a plan to determine effectiveness of the completed actions was in place when the technical training program was placed on probation by the Institute of Nuclear Power Operations (INPO) in the fall of 2000. This focused management attention and limited resources on the technical training programs rather than on operations training. While corrective actions were underway for improvements to the technical training programs, failures on the licensed operator biennial written examinations focused management attention on new operations training problems, further derailing actions being taken as a result of the tube failure event. Both the technical training program probation and the written examination failures were evaluated using the condition reporting process. Problems similar to those found in the technical training programs were found in operations training programs. As a result, a plan was developed and implemented to improve many aspects of operations training.
In early 2001, the corrective actions and the plan were evaluated by the NRC (Inspection Report 50-247/2001-002). The NRC determined that the plan appeared to identify appropriate causes, corrective actions appeared to appropriately address the causes of the training deficiencies, the corrective actions were being taken in a timely manner, long-term corrective actions were budgeted for completion in subsequent years, and corrective action effectiveness evaluations were scheduled starting in the summer of 2001. The crew high failure rate occurred during the annual licensed operator requalification examinations in September 2001 indicating that actions up to this point had not been fully effective.
The team determined that the performance issues associated with the crew high failure rate in fall 2001 had existed in other areas of operator training for at least three years.
However, continued ineffective, and in many cases incomplete, response to the corrective actions associated with the assessments and evaluations prevented any significant improvement in operations training. Audits and self-assessments of operations training were conducted by station personnel, contractors, and industry peers at least annually since 1998. The audits and assessments were critical of all aspects and areas of operations training, including plant specific knowledge of the instructors, the lack of instructors with IP2 experience, the quality of lesson materials, and the fundamental knowledge weaknesses of the licensed operators. However, the inspectors noted that none of the audits or self-assessments identified long-term operator performance, either in the simulator or control room, as an area of concern.
The licensees recent evaluation of the crew high failure rate identified poor performance of operators as a fundamental underlying operations training program weakness. As noted in 02.02.d above, the licensee had appropriately considered extent of condition beyond licensed operator requalification training and had substantiated it during the course of their evaluation. Consistent with the teams conclusions, the licensees evaluation also determined that assessments of long term licensed operator performance and response to internal audits and self-assessments had not been effective.
03 Management Meetings Exit Meeting Summary The inspectors presented the inspection results to Mr. and other licensee personnel at the conclusion of the inspection on April 18, 2002. The licensee acknowledged the observations presented.
During the meeting, the team stated that there was continued confidence in the ability of IP2 training and operations department staff to effectively and objectively evaluate licensed operator performance. This confidence is based, in part, on independent NRC assessment of crew performance; observation of high intensity training in both the simulator and classroom; interviews with operators, trainers, and managers; and the NRC evaluations of operator performance conducted since November 5, 2001.
However, the team also expressed its reservation regarding the run time for the corrective actions. Most of the licensees initiatives had been in place for just a few months. Consequently, the team did not make any determinations as to whether the corrective actions had effected or would effect positive, long term improvement in operator performance and behavior.
The team also discussed the licensees letter of January 18, 2002, in which Entergy indicated their intent to rescind a commitment to NRC to not use for watchstanding purposes restricted operators (as defined in Entergy letter of December 13, 2001) who had not been observed by NRC in a plant operational setting. As noted in NRC Final Determination Letter of February 18, 2002, NRC requested the licensee maintain the commitment until the completion of this inspection. The inspection team completed its activities and found the following, which serves as the basis to release the licensee from the commitment:
1) To date, operators have achieved a 100% pass rate on all operational evaluations conducted by the NRC staff.
2) The inspection team gained additional confidence in the licensee's ability to retrain and reevaluate subsequent to the high intensity training (HIT) initiated in January 2002. NRC independent review of the HIT material and its determinations made while observing its administration also indicated that licensee staff is providing higher standards of performance in operator training.
3) Finally, NRC independent observation of control room conduct indicated that operator performance was consistent, for the most part, with the higher standards introduced in the classroom and simulator environment.
KEY POINTS OF CONTACT Licensee Vice President, Operations, IP2 L. Temple - General Manager, Plant Operation J. Comiotes - Director Nuclear Safety Assurance J. McCann - Manager, Nuclear Safety and Licensing D. Morris - Problem Identification & Resolution Program J. Goebel - Acting General Manager Quality Assurance J. Wheeler - Site Training Manager W. Durr - Assistant Operations Manager, IP2 G. Dean - Training Supervisor, IP2 R. Allen - Manager, Regulatory Affairs B. Woomer - Non-Licensed Operator (NLO) Supervisor H. Howe - Lead Training Auditor S. Davis - Supervisor, IP2 Licensed Operator Requalification Training L. Cortopassi - IP3 Training Manager F. Wilson (via telephone) - Manager of Operations Training.
NRC P. Habighorst, Senior Resident Inspector T. Fish, Team Leader J. DAntonio, Operations Engineer A. Blamey, Sr. Operations Engineer R. Pelton, Human Factors Specialist, NRR R. Conte, Chief, Operational Safety Branch, DRS LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED Opened None Closed None Discussed None
DOCUMENTS REVIEWED Training Procedures Training Administrative Directive (TRAD) 501, Licensed Operator Requalification Examinations TRAD 104, Implementation Training Program Description 406, Continuing Training for Licensed Personnel Other Licensee Procedures Operations Administrative Directive (OAD) 15, Policy For Conduct of Operations Miscellaneous Documents Level 1 Analysis of Condition Report, CR200110995 Events & Causal Factors Chart Hazard-Barrier-Target Analysis November 5, 2001, Entergy letter documenting October 29, 2001, telephone conference between Entergy Nuclear Operations, Inc., and NRC December 5, 2001, NRC inspection report, 50-247/01-013, documenting Preliminary Yellow Finding January 18, 2002, Entergy letter documenting response to significance determination related to a Yellow finding for annual requalification exam failures February 28, 2002, NRC report EA-01-294, documenting final significance determination for a Yellow finding at Indian Point 2 Lessen Plan DIAGN-022, Problem Diagnosis, Situation Appraisal and Correcting Plant Problems for LOR Cycle 2002-2 Enhanced Training.
Unit 2 Operations Training Improvement Plan, Rev. 8, April 8, 2002.
Lesson Plan 624, Operations Standards and Expectations Lesson Plan TAA022001, Transient and Accident Analysis Introduction Lesson Plan, SYS-C-30, Chemical Volume Control System Lesson Plan SYS-C-161 Rod Control System 2000 Licensed Operator Annual JPM summary 2001 Licensed Operator Annual JPM summary Failure writeups for the 2001 simulator exams, performance improvement plans, retake scenarios for the critical task failures High Intensity Training schedule Human performance evaluation worksheets.
Training self assessments Training Administrative Directives, Desktop Guides FSAR accident analysis section IPE risk significant actions
ATTACHMENT 1 INTERVIEW PROTOCOL REFERENCE QUESTION M T O Management Questions 1 Page 4 What is the underlying root cause of the problems encountered in Ops X X Training?
2 Root cause #1 What is being done about the lack of management oversight and involvement X X in Ops training?
3 Root Cause What is being done about the lack of management support? X
- 2 4 Root Cause What is being done about the lack of understanding of what ownership X
- 3 means, for both Ops training and Technical training. What is being done about the lack of management oversight and involvement in Ops training?
5 Overall What is being done relative to accountability and Conduct of Operations? X X X What is being done relative to accountability and procedural compliance?
6 Overall How does accountability factor into the corrective actions? X 7 Page 14, Where does the Training Department fit into the current organization? How X items 3, 4, 5 does this compare to other Entergy facilities.
8 Page 16, $250,000 was allocated for simulator scenario guides. The instructor X X items 4 and 5 responsible for developing the guides did not have contractor assistance.
Where happened to the money that was allocated for training improvements?
9 Page 16, item How is the money split between Technical Training and Operations Training? X X 7a and 7b Is this money for Unit 2 or is Unit 3 included in this number?
10 Page 18, item The Business Plan proposed a training attendance performance indicator. X X 17 How is training attendance determined? Is this indicator for Ops training or all of training?
11 Page 30, What aspects of training performance will you use as an element when X X Corrective measuring operations crew performance?
Action 1-3 12 Page 18, item Regardless of where the two items in question were ranked, did their X X 18 placement make sense?
13 Page 21, item Following the appropriate TRAD, how often are instructor observations to be X X 46 conducted? Are the appropriate number of observations being conducted?
14 Page 27, What did the Training Improvement Plan discover regarding the relationship X X Extent of between Operations and Operations Training? How are any relationship Condition problems being handled?
15 Page 31, root How will continued management support and involvement be maintained after X X cause #3, implementation of the Training Improvement Plan?
statement #1 Training improvement/change questions 16 What improvements have you seen in training? How have they helped to X X X improve you life?
REFERENCE QUESTION M T O 17 What is done if you exhibit performance, either in the simulator or the control X X room, that is NOT up to management expectations?
18 What is done if you (or an operator) have to be remediated? X X 19 What has changed in training that is having a negative impact on you? X X 20 What needs to be done to improve training? X X X 21 What type of feedback do you provide to training? What is done with the X feedback after submission? How do you find out the status of your feedback?
22 Why is it so difficult to retain people in Training? X X 23 What is Indian Point 2s training get well plan and how do you fit into the plan? X X X 24 How do you know that the licensed operators remain proficient at performing X X risk significant tasks?
Level 1 Analysis of Condition Report 25 Problem Does the level 1 (L1) analysis cover the actions to be taken for the staff crews X statement or just the Ops crews?
26 Page 12, item What type of follow up is conducted after the Curriculum Review Committee X 15 makes a request of Training?
27 Page 12, item What actions were taken as result of Operations request? How was the X X 16 frequency modified? Who condoned/requested these actions?
28 Page 12, item If still held, who attends the Operations Manager morning meetings? X
29 Page 13, item What is the policy for procedural compliance relative to TRADs? X X
30 Page 13, item If licensed operators are required to follow procedures or modify them as X 26 appropriate, why is the training department allowed to not follow procedural requirements?
31 What is the perception of operators regarding verbatim compliance versus X X doing the right thing? What are the personal consequences of not following procedures?
32 Page 25, item What does the TRAD require when preparing remediation plans? X X
33 Section V, The Ops crews and one staff crew are mentioned in the SL-1 report. What X X page 2 type of remediation, if any, did the other staff crew receive?
34 Page 34 What is the status of the Corrective Action Effectiveness Measurement and X X how will these actions improve the effectiveness of the training corrective action program? Is the training corrective action program the same as the Training Action Request system?
Condition Reporting System 35 Page 6, items Why is the Training Action Request system still separate from the Condition X 7and 8 Report system?
36 Page 21 - 22, What is the status of the findings, for Operations training, from the October X X items 49 - 53 2001 sitewide self-assessment?
REFERENCE QUESTION M T O 37 Page 26 - 27, What is being done for all of these statements? X X items 16, 17, 18, 21, 22, 24, 25, 26, 27, 28 38 Page 28 - 29 What is the status of these condition reports? For those corrective actions X X Condition that have been completed, how will the effectiveness of the actions be Reports determined?
39 Page 30 What is the status of the corrective actions for the Level 1 Analysis? X 40 Page 30, What will you use as a template for an organization that supports excellent X Corrective training? How will you establish this organization?
Action 1-1 41 How was the material to be included in the high intensity training identified and X X prioritized?
M = Managers including Plant managers, training managers, Operations managers, Shift Managers T = Training Department personnel including lead instructors and instructors O = Operators