Text

Forwards Emergency Operating Procedures Team Safety Insp Rept 50-255/89-19 on 890724-0804 & Notice of Violation
	ML18054B054
Person / Time
Site:	Palisades
Issue date:	10/18/1989
From:	Miller H; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:	Hoffman D; CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
Shared Package
ML18054B055	List: IR 05000255/1989019; ML19327B222;
References
	NUDOCS 8910270164
	Download: ML18054B054 (57)
	v • d • e

Docket No. 50-255 Consumers Power Company ATTN:

David P. Hoffman, Vice President Nuclear Operations 1945 West Parnall Road Jackson, MI 49201 Gentlemen:

SUBJECT: EMERGENCY OPERATING PROCEDURES TEAM INSPECTION This refers to the special safety; inspection conducted by an* NRC EOP Inspection Team l~d by Mr. James E. Gagliardo on July 24 through Aug~st 4, 1989, of activities authorized by NRC Operating License No. DRP-20 for Palisades Nuclear Power Plant, and to the discussion of our findin~s with the members of your staff at the conclusion of the inspectio The purposes of the inspection were to verify that your eme"rgency operating procedures were technically accurate; that their specified actions could be meaningfully* accomplished using existing equipment, controls and instrumentation; and that ~vailab1e procedures had the usability necessary to provide the operator with an effective operating tool~ The areas examined during the*

inspection are identified within this report.. Within these areas, the in~pecti6n consisted of a selective examination of procedures and representative records, plant walkthroughs, interviews with personnel, and observation of acti~ities in progres.

.

The resalts of this in~pection indicated that the licensee's EOPs co~ld be:

effectively carried out in the plant and could be correctly performed by the Palisades staff. However, a number of significant deficiencies were identified as follow Although none were determined to pose a significant safety concern, they may pose potential probl~ms for operators.acting under stres.

The EOP verification and validation (V&V) program was not sufficiently comprehensive and needs to be better defined. For example~* the verification and validation effort did not utilize a multidisciplinary team that was independent of the staff involved in writing the EOPs, failed to walkdown EOP actions that were to be performed outside of the control room, and failed to walkdown the other procedures referred to by the EOP.

Quality Assurance involvement and oversight of the EOP development, V&V, training, and feedback efforts was weak in that QA oversight was. limited to a single review of one procedure and an ongoing two-year surveillance of the EOPs which did not include the aspects of training effectiveness 8910270164 891018 PDR ADOCK 05000255 G

PNU

Consumers Power Company

OCT l 8 1989 or verification and validation effort No technical audits had been conducte As a result, several of the findings identified by this inspection had not been identified by your QA activitie.

There was insufficient training of auxiliary operators on certain actions they were required to implement under the EOP It was apparent to the inspectors that essentially none* of the in-plant actions required to be implemented *by the Auxiliary Operators had been previously walked down by the.

A number of human factors and technical concerns were identified involving cautions and notes, operator aids, insufficient material presented, and use of a procedure to overcome a plant operating deficienc On a number*

of occasions, operators could not perform actions in the EOPs without first racking in a circuit breaker, unlocking a valve, or operating a key *

switch; however, none of these prerequi~ite actions were identified as steps or cautions in the EOP There were also examples in which room keys, a step ladder, or fuse pullers were required to perform local equipment operations without the EOPs noting suc The step in EOP to secure main feed pumps was being utilized to overcome an equipment problem where the automatic ramp down function did not perform as designed, rather than correcting the equipment proble Some of the above concerns appear to be in violation of NRC requirements, as*

specified in the enclosed Notic A written response is require In addition, your response should. also_address the following:

(1) the results of your determination as to why the main feedwater automatic runback on reactor or tutbine trip does not pefform as des~gned and a 10 CFR 50.59 evaluation determining whether or not this condition represents an unreviewed safety question; (2) a description of the actions you have taken to provide for a comprehensive verification and validation process that would identify and correct the types of deficiercies documented in this report; and (3) a description of your planned ictions for resolving each of the specific items identified in Appendices II (technical deficiencies) and III (human factors deficiencies) of this report including the dates by which those actions will be complete The response directed by this letter and the accompa~ying Notice is not subject *

to the clearance procedur~s of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-51 In accordance with 10 CFR 2.790 of the Commission's regulations, a copy of this letter, the enclosures, and your response to this letter will be placed in the NRC Public Document Roo *

Consumers Power Company

OCT 8 1989 Hubert J~ Miller, Director Division of Reactor Safety

Enclosures:

Appendix A - Notice.of Violation

,

. Appendix B ~ NRC R~gion III Inspection Report... /89019 Attachment I - List of Procedures Reviewed Attachment II - Technical Deficiencies Attachment III - Human Factors/Deficiencies Attachm~nt IV - Verification/Validation Deficiencies Attachment V - List of Persons Contacted

REGION III==

Report N /89019(DRS)

Docket N Operating License:

DRP-20 Licensee:

Consumers Power Company 212 West Michigan Avenue Jackson, MI 49201 Inspection At:

Palisades Nuclear Power Plant Inspection Conducted:

July 24 through August 4~ 1989

-. Q

,,/.~~/ /

Team Leader: /"/"~f-'/;.. J. E. Gagliardo, Chief Operational Programs Section, Division of Reactor Safety, Region IV 10A/P1 Date Team Members:

J~ Cummins, Inspector, Operational Programs Section, Division of Reactor Safety, Region IV J. Heller, Palisades Resident Inspector D. Damon, Licensing Examiner, Divisi~n of Reactor Safety, Region II I G. Bryan, Reactor Systems Specialist (Consultant)

I. Kingsley, License Examiner Specialist, (Consultant)

M. McWilliams, Human Factors Specialist, (Con~ultant)

Approved a

~fAf /

By:?'~~-~-

.

J. E. Gagliardo, Chief Operational Programs Section, Division of Reactor Safety, Region IV Inspection Summary 10/b/?1 Date Inspection Conducted July 24 - August 41 1989 (Report 50-255/89019(DRS)

Scope:

This special, announced inspection was conducted in the area of emergency operating procedures (EOPs),- including the implementation of vendor generic technical.guidelines (GTG), overall technical adequacy of the procedures, validation and verification (V&V) _progr~m, the performance 8910270166 891018 PDR ADOCK 05000255 Q

PNU

of training on the EOPs, and the ongoing ev~luation of the EOP Results:

No unsafe operational conditions were identified. The overall determination was that the EOPs could be effectively carried out in the plant and could be correctly performed by the staff. Training was adequate overall, but several areas needed improvemen Two viol~tions were identified (inadequate training of auxiliary operators, paragraph 5~c; and insufficient ov~rsight of EOP activities by QA, paragraph 6). The EOPs were generally capable of performing their intended function, but several discrepancies were noted and are documented as EOP technical review items and human factors element review item A major concern was identified regarding the licensee's V&V process, which was not independent of the EOP writers, was not multidisciplinary in nature, and had not reviewed proGedures referred to by

.the EOPs or attachments with actions performed outside the control roo These discrepancies will require further review by the licensee and will be the subject of followup inspection effort One unresolved item (paragraph 3) was also identified regarding the tripping of the main feed water pumps following a reactor tri I r,,

{: '

TABLE.OF CONTENTS Page Persons Contacted *

.....

..

. 4 Executive Summary

....................

4 EOP/CEOG Co~parison.

6 echnical Adequacy.****.,*.******** ~ *.**** ~.7 EOP Training..................... ~..... *... 9 Ongoing Evaluation of EOPs * ~ *. _ *.******* *.****.* 14 Human Factors Analysis of EOP.

Validation and Verification Unresolved Items *.....*

1 Open Itelils 1 Exit Intervie1*1 ATTACHMENT I ATTACHMEtff I I ATTACHMENT III ATTACHMENT IV ATTACHMENT V List of Procedure$ Reviewed Tec~nical Deficiencies Human Factors/Deficiericies Verification/Validation Deficiencies Persons Contacted *

... 15

.20

..22

.. 22

. 22

DETAILS. Persons Contacted The individuals contacted during the course of the-inspection and those in attendance at the exit interview on August 4, 1989, are listed in Attachment.

Executive Summary Following the TMI-2 accident, the nuclear power industry embarked upon an upgraded £OP program to provide operators with direction to mitigate the consequences of a broad range of accidents and equipment failure Supplement 1 to NUREG-0737 and NUREG-0899 were issued to establish,

- respectively, the requirement for the upgrade program and the process for development and implementatio Palisades responded to these requirements with an EOP development program consisting of the following significant elements:

0

0 Adoption 9f combustion engineering owners group (CEOG) CEN-152 as the GT Definition of the plant specific technical guidelines (PSTG) as the sum of four administrative procedures, the,GTG, the Palisade Fun~tion and Task Analysis (F&TA) report, Technical Specifications, existing EOPs, the final safety analysis report (FSAR), EDP-related licehs~ng commitment letters, and as-built plant drawing *

Development of EOP basis documents to justify GTG/PSTG deviation Incorporation of operator action setpoints into the EOP basis document Promulgation of an EOP Writer's Guid Development of plant specific EOP Performance of a V&V program for the EOP Plant Review Committee (PRC) review and promulgation of the EOP The Palisades EOPs listed in Attachment I were reviewed to ensure that the procedures were technically adequate and accurately i nco.rporated the guidelines of the Combustion Engineering Emergency Procedure Guidelines CEN-152, Revision 3..

The inspection was designed to verify that the

I {;

'

,

vendor step sequence was followed, the exit/entry points were correct, transfer between procedures was well defined*and appropriate for procedures performed concurrently, the procedures could be implemented with the minimum staff required onshift, and notes and cautions were used correctl Deviations from the CEN-152 guidelines were reviewed to ensure that they had been justified and that safety significant deviations were evaluated in accordance with 10 CFR 50.59 and reported to the NRC_as require The inspection team also verified that deviations warranted by the specific plant design were incorporated into the EOPs, prioritization of accident mitigation strategies were correct, and adverse containment values were also considered in the parameter measured/observed in the procedure The licensee had based their EOPs on Revision 3 (Submittal 2) to CEN-152 as approved by NRC letter to the CEOG dated November 5, 1986. *Revision 3 (fin~l) to CEN-152 had been subsequently issu~d and was reviewed and approved by NRC letter to th~ CEOG dated August 2, 198 It was noted that the licensee had prepared Revision 1 to their EOPs to the guidance of Revision 3, Submittal 2, but as the revisions were about to be finalized, Revision 3 (final) was issued and some additional changes were made in the EOPs based on the final revision.. The licensee indicated that Revision 3 (final) would be fully incorporated during the next biennial revie~ of all of the EOP The NRC team conducted inplant and control room walkdowns of the EOP Where the EOPs transferred to supporting procedure~, the inspectors verified that the transfers were correct and walked down the applica~le sections of the.supporting proced~res. With a few exceptions, nomenclat~re was found to be consistent between the control boards and the procedures. _

Those exceptions, which were evaluated as potential problems for operators acting under stress, are identified in Attachments II and II The inspection team's overall determination-was that the licensee's' EOPs could be effectively carried out in the plint and could be corre~tly performed by the Palisades staf Although a number of human factors concerns we~e identified, none were determined to pose a significant safety concer Training on the EOPs was adequate overall, but several areas needing improvement were note The most significant concerns identified during the inspection invoJved the inspector's-observations that (1) the EOP V&V program was not sufficiently comprehensive and needed to be better documented, (2) QA involvement and oversight of the EOP development, V&V, training, and feedback efforts were weak, _and (3) the training of the auxiliary operators (AOs) on actions they were required to implement from the EOPs was very poor..

5 Palisades EOP/CEOG CEN-152 Procedure Comparison (25592)

3.1 Scope of. Comparison A comparison of the Palisades EOPs and the CEOG Emergency Procedure Guidelines (EPGs) CEN-152, Revision 3, was conducted for each of the EOPs

. identified in Attachment. The objective of this review was to ensure that the -ljcensee had developed sufficient procedures in the appropriate area to cover the broad spectrum of accidents and equipment failures that must be considere The inspectrirs 1 review of the licensee's EOPs disclosed that the procedures had been developed in accordance with the CEOG recommendation The inspectors reviewed the licensee's documentation and interviewed licensee personnel to verify that any identified deviations from CEN-152 were justifie Discrepancies, identified by the team, between the EOPs and CEN-152, are discussed in Attachments II and II.2 Findings The team determined that, in general, the EOPs incorporated th~ procedure guidelines of CEN-152, Revision 3, and were technically adequat This determination was based on the following findings obser~~d during the review of the Palisades procedures:

0 The EOPs generally followed the CEN-152, Revision 3, step sequence,

-with detai~ed instructions fo~-operator actjons required to cooldown the plant or place the plant in a stable conditio Entry or exit points in the EOPs were clearly stated and could be followed by trained reactor operator *

The plant specific values were consistent with the plant desig The CEN-152 prioritization of the accident safety function hierarchy was maintained in the EOPs..

The licensee's standard p*ost-trip action diagnostic flowchart for reactivity control was expanded from that of CEN-152 to more adequately address the attributes of reactivity control that must be addressed in*

the analysi The inspection team determined that a potential equipment problem pertaining to the main feedwater pumps existe The basis for EOP discussed securing the main feedwater pumps because past experience had shown that prolonged operation after a trip had caused over cooiing and primary coolant depressurizatio However, Section 7.5.1.3 of the FSAR stated that in the event of a reactor or turbine trip while control is in auto, the feedwater pumps are automatically ramped down at a rate of 1.58%

per second to a speed corresponding to the flow required for decay heat The licensee normally operates the system in aut Since operating.

experience indicated that the system w6uld not perform as designed, but instead has ca~~ed overcooling or PCS depressu(ization, the ljcensee had incorporated a step in EOP 1.0 to trip the feedwater pumps after a reactor tri This step was a deviation from the guidelines of CEN-15 For the small break LOCA, three of the five success paths depend upon stea~

generator heat removal, and the licensee's step prematurely securing an operating feed system to shift to an off-line system would decrease the probability of success by reducing success probability for three of the

. five success path The NRC team concluded that the EDP 1.0 deviation to secure main feed would not be required if the system was performing per the FSAR descriptio Either.the original system design failed to conform with the FSAR description, or modifications to the syste~ have caused the system not

to perform as designe In the latter case, the 10 CFR 50.59 safety evaluation may have failed to appropriately consider the effects of this system in the determination of *whether an unreviewed safety question existe This issue is an unresolved item (255/89019-01) pending a determination of why the system does not perform as designe. * Technical Adequacy *Review of the Emergency'Operating Procedures (25592)

The Palisades EOPs listed in Attachment I were reviewed to ensure that*

the procedures were technically accurate and could be meaningfully accompli-shed* using existing--equipment, controls, and instrumentatio (I'

The inspection team i~entified a number of technical deficiencies, which were addressed to the license These deficiencies along with the licensee's.responses, are listed in Attachment II, and will be,identified as Open Item 255/89019-0 A summary of the technical deficiencies.is presented below:*

The technical deficiencies were found in the follo~ing key areas:

o

0

0 Referral to other procedures not adequat Special requirementi to perfor~ a step not being specifie Failure to hav~ piefabri~ated piping/cables/procedures for identifi~d EOP task Preferred instrumentation for parameter monitoring not specifie Degraded containment effects on instrumentation not considere. The. team noted that most EOPs could be improved in the 11 refer to 11 and 11 go to 11 step In* many instances only the procedure number *was referenced and the applicable section number and/or step number of the referenced procedure was not specifie Operator response time and effectiveness would be improved with more detailed p~ocedure referral It was noted, during plant and con~rol room walkdowhs, that the EOPs lacked information about special requirements needed to perform a particular ste On a number of occasions, operators could not perform actions in the EOPs without first racking in a circuit breaker, unlocking a valve, or operating a key switc There were also examples in which room keys, a step ladder, or fuse pullers were required to perform local equipment.operation As in the previous paragraph, more effort in detailing special requirements would ensure timely completion of operator actions in the high stress environment of implementing the EOP During control room walkdown of the EOPs, the team identified several EOP steps_ that required parameter verification without clear direction as to which instrument to monito In several cases where core exit temperature or Tave was being monitored, the EOPs needed to be more specific as to which instrumentation should be used and the limitations for the use of eac The team determined that an extensive effort had been made to incorporate the effects of degraded containment on instrumentation used by the EOP However, in at least one instance, instrumentation accuracy was as~~med to be adequate during degraded containment condition A pressurizer level of 20 percent was one of the conditions required to throttle safety injectio At 20 percent indicated level, with degraded containment, Palisades environ~ental equipment ~ualification (EEQ) analysis shows that actual pressurizer level may be as low as 1 percent (e.g. uncovering most pressuri~er h~~ters). It is possibl~ that a sustain~d lo~s of press~rizer

Cl'

function may result from premature throttling of safety injection.. The Ji censee agreed to.review the fi ndi.ngs of the study of instrument errors..

in a harsh environment, which was in progress under CEN Task 536, and to incorporate appropriate information obtain~d from the review in the EOPs to ensure they wouJd function under harsh environment condition The team identified several tasks in the EOPs that required the use of mechanical or eJectrical jumper However, the licensee did not have procedures for installing the jumpers, and it appeared to the team that, based on the complexity of the tasks, procedures would be appropriat It appeared to the team that the licensee should develop procedures to install these jumper *

The inspectors found the following instances where the procedures required performance of an action step that was not prestage The first involved Step 6.~ of EOP 3.0, which required installation

of a temporary modification to provide temporary air to the steam *

generator atmospheric dump * The second involved Steps 2.a and 2.b of Attachment 8 of EDP 5.0, which required a ~pecial lineup to transfer a waste holdup tank to a filter waste monitor tank or to a clean w~ste receiving tan The third i~volved Attachment 3, Step 2:c of EOP 2.0, which discussed gravity feed from T-90 to T-The au~iliary operators would use Section 7.5 of SOP 12, 11 Feedwater System, 11 Revision 14, which discussed in general terms the lineup required, but did not identify all of the valves reqaired to be operated, nor was the SOP referenced in the EO The fourth involved the lotation of the attachments-to various EOPs (e.g. status sheets).

Prior to the inspection, the licensee had.

moved the attachments to a file cabinet in the control room and did not inform the operator The operators required some effort to locate the attachment The licensee was encouraged to document all cases that were similar to the a~ove ~xamples and formulate a plan to resolve these deficiencie.

EOP Training (25592)

The inspectors assessed the adequacy of the EDP training by reviewing three area The first dealt with observing an unrehearsed operating crew performing the EOPs on the site-specific simulator with scenarios designed to exercise selected areas of the EOP The operating crew was made up of two licensed operators and two simulator instructor The second. effort was to review lesson plans and training records for the hot licensed and requalification operator training programs as they pertained to EDP trainin Finally, interviews were conducted with selected members of the operations and training staffs_

9 Simulator Scenarios The inspection team developed scenarios*similar to those used for licensed operator exams and the facility's EOP training. These scenarios included:

(1)

A reactor trip with two control rods stuc~ out of the core,

l2)

A loss of all AC power, including the diesel generators (D/G),

(3)

A small break loss of coolant accident, (4)

A steam generator feedwater line break inside containment~

(5) *A loss of all feedwater with se~vice water backup available, (6)

A loss of all feedwater with no service water backup (feed and bleed), and (7)

A steam generator tube ruptur~ with concurrent faulted steam generator (radiation release).

buring the performance of these scenarios with the unrehearsed operating crew, the inspection team had th~ opportunity to: assess human factors elements associat~d with the performance cf the procedure~ in a real time" atmosphere; observe how the operators *

diagnose* accident conditions and transition from one EOP to another; assess ~he licensee's operating philosophy; and observe operator performanc The team made the following observations:

0

The operators exhibited good knowledge of the EOPs and the CEN-152 guidanc *

The procedu~es generally provided operators with suffitient guidance concernin~ their responsibilities during the emergenci~ *

. The procedur~s appeared to be *organized in su~h i manner as to minimize physical interference between operators when carrying out the actions outlined in the procedure Duplicate operator attions in the procedures appeared to have been mlnimize There appeared to be no formal method used to track continuous action" or "non-sequential steps in the procedures. This presented a potential for overlooking some actions as the operator became involved with a lengthy procedure or when transitioning between procedure *

10 Formal Training Program Lesson plans and simulator scenarios us~d for EOP t~afning were reviewed to verify that the training covered the technical basis for the procedures as well as the structure and forma The following observations were made:

0

There was no formal classroom l~sson plan to cover EOP 3.0,

"Electrical Emergency Recovery," which was issued on August 11, *

198 This EOP had been covered only in a lesson given during simulator training se~slon There ~ere no lesson pl~ns for the individual success path procedures of EOP 9.0, either in the simulator or the classroom phases of instructio *

There was no lesson plan covering "rules of usage" for the EOP Examples of items that should have been included in such a iesson plan are:

definition of common terms such as "available" or "operable"; the meaning and use of "non-sequential" or

"continuous action" steps;-the difference between "referencing" and "branching" to other procedures; and the difference between a "note, 11 "caution," and "warning." There were inconsistencies exhibited by operators in their undetstanding of these areas during the EDP walkdowns and during the simulator demonstration Operations ahd Training Staff Interviews Operators were interviewed to determine their understanding of the EOPs and their responsibilities and required actions, both individually and as* a tea The operators were also questioned to determine if they were knowledgeable of the requirements for tr~nsitioning fro *one procedure to another, and if training was conducted on revised EOPs before-they were implemente The first.training con~ern identified was that there did nqt appear to be adequate training on the actions in the EOPs which were to be implemented by AO The AOs seemed to be unfamiliar with sections of the EOPs that required action on their par Most of the Abs were able to simulate the actions required by the EOPs; however, an inordinate amount of time was require The AOs were unsure of the aim of the procedures and were using a simple "cookbook" approach to the procedure AOs should be able to perform actions in the EOPs in a timely manner to ensure plant safety during the high stress period associated with an emergenc Int~rviews with members of the training staff revealed that there was a formal training program in place for AOs; however, no formal connection was made between the training items in AO lesson plans and action items AOs would be expected to perform as specified in

)

the EOP Many bf the actions AOs would implement which were required by the EDPs were covered by on-the-job training (OJT) item in the initial training journal which new AOs must complete prior to be fully qualified.-

However, not all of the EDP action items to be*

performed by AOs were covered in the initial training program; and not all of the AOs had completed the fqrmal initial training jburna For the AOs who had not formally completed the initial training *

journal, particularly the AOs who had been qualified *before the current program was implemented (more than three years as an AO), an individual evaluation was made by the training staff as to which items in the journal were to be compl~ted by the AO to maintain his proficienc During the-.wa 1 kdowns of the EDP act i ans that were to be performed outside of the control room, the inspectors found that none of the AOs involved or interviewed had been previously trained on the i n-p 1 ant 'actions re qui red by the EDP It was apparent that the AO training program was not being fully implemented to* _

familiarize the AOs with the actions they would be expected to perform under the EOPs,.

The training staff committed to perform a comparison between tr~ining journal OJT items and the EDP action items, and upgrade the training journal to include all AO action items included in the EOP The li~ensee representatives st~ted that particular care ~ould be taken to compare items with~subtle differences between the training jou~nal and the EOP, and these items would be stressed in trainin Action had been taken by the training staff to include AOs in the training sessions to be attended by reactor-operators (RO), so that a more integrated approach to the training would be affecte The training staff also agreed to upgrade the existi~g items in the training journal to state more clearly the relationship between the OJT ite and any applicable EOP action ite The license~'s failure to provide adequate training on the act~ons the EDPs require the AOs to perform is an apparent violation 255/89019-03 of the requirements of Criterion II t6 10 CFR 50, Appendix B, which requires that indoctrination and training of personnel performing activities affecting quality shall be provided as necessary to achieve and maintain suitable proficienc The second training concern was in the area of feedback of changes for the EOPs from the operation's staf A number of operators indicated that they were not aware of the resolution to changes that they had requested" Inefficiencies existed in the current system in that several operators could request the same change over a long period of time, not knowing that the requested change had already been resolve Changes made to an EOP procedure or other procedures should be addressed in the training curri'culum.* Conversely, reasons for not changing a procedure after such a suggestion has been made should be formally provided to the requeste )

l The third training concern was in.the area of training for licensed operators on the EDP base A 11 1 i censed operators_ interviewed

.

indicated that they had received very little training on the basis behind the EDP steps, and the overall strategy employed by the EDP Senior operators further stated that they.saw a need to include ROs in classes that explained the "bi-g picture" in the EDP They stated that most ROs did not know the ~easoning behind the actions in the EDPs, and used a simple "cookbook" approach to the procedure The expressed an interest in increased training in this are A fourth area of concern was simulator trainin The licensed operators stated that most simulator scenarios rarely were carried out to completio They particularly stated that s~ccess path procedures in EOP 9.0 were almost never completed while performing simulator scenarios designed to exercise these procedure In addition, nearly all of the operators stated that they desired more simulator training contact time during the -course of the training yea A third common theme* discussed *with the senior operators was

"board time" at the simulato All senior operators interviewed stated a desire to have more time to enhance their control board skills, as opposed to their supervisory skill They 11oted. that one of the responsibilities of a licensed senior operato~ was the ability to.operate all facility controls, if require A fifth concern was that personnel outside the operations department, receJved little or no training in their assigned ta~ks under the EOP For example, instrument and control (I&C) technicians may need to install a jumper to enable equipment operability or mechanical maintenance may need to install a spool piece to enable the transfer of liquid from tank to tan Training on these items would assure proficiency of plant personnel, but also assure that proper equipment was staged for the activit *.The inspectors also found that the operators were weak on the definition of certain key words used in the EDP The words "available, 11 "check,"

11 supplied,

11warning,

11 iritegrated decay he'at removal,

11 and 11 operating

were not consistently understood by the operators~

The inspection team was concerned w-i th the overall qua 1 i ty of training on the EOPs, especially training received by the AO The team concluded that the licensee needs to review the quality of training because of its impact on the ability of the operators to cope with conditions that could exist during an emergenc Resolution of these training related issues will be identified as Open Item 255/89019-0 J On-Going Evaluation of EOPs (25592)

Section 6.2.3. of NUREG-0899 states that 1icensee 1 s *should conside establishing a program for the ongoing evalua~ion of ~DP NUREG-0899 further states that the program should evaluate the technical adequacy of the EOPs in light of operational experience and use, training experience, and any simulator exercises and contra~ room walkthrough Section 6.9.6 of licensee Administrative Procedure 4.06, 11 Emergency Operating Procedure Deve fopment anp Implementation, 11 Revision 1, stated *

that the EOPs shall be periodica.lly reviewed (every 2 years) and listed for review considerations the criteria that were identified in NUREG-089 Section 5.0 of the licensee 1s Administrative Procedure 10.41, 11 Procedures on Procedu~es, 11 Revision 12, delineated the process for initiating a procedure revisio In addition to the formal proc~ss delineated in Procedure 10.41, an informal (not proceduralized) form was use This was ca 11 ed a 11 FORM 40 11 and was used by licensee personnel to identify a potential problem (e.g. a procedure change).

Based on discussions with

. licensee' personnel in the plant, this was the most frequently used method of identifying potential EDP procedure problems. *Form 40 was a three-part memorandum with carbon copies tha~ enabled the individual initiating the

form to retain a copy of i There was also a reply section on the form so that the recipient could document his or her response and return a copy to the originator for feedback of the action taken to disposition the concer The inspectors also found that feedback from the training center was being provided to the staff by a l~tter which compiled all of the comments from the operators in a given training class:

These letters and recent Form 40s were reviewed by the inspectors and provided adequate evidence that feedback was being provide The inspectors were concerned, however, with the disposition of the feedback comment After t~e comments w~re di~positioned, th~ comments were ~estroyed and not retaine Several of the operators interviewed were also concerned that they had not received feedback on their comment The licensee 1 s ongoing review and feedback process needs to be mor~ effectively controlled, and feedback comments need to be returned to the indivi~uals submitting the comment The existing system provided disincentives to the evaluation and feedback proces The inspection team reviewed the involvement and oversight provided by QA in the development, i~plementation, and training on the EOP The inspector found that the QA organization had reviewed EDP 1.0 durihg the de_ve 1 opment stage, and the comments provided by the review were generally editorial in natur The QA review had not included a walkdown of the procedures in the control room or in the plan J The inspectors also revi~wed the audits and surveillances performed by QA for activiti~s related to the_ EOP A QA survej_ll_anc~ was _begun_ i September 1987.arid had a checklist that compared the EOPs to CEN-152, Revision The chetklist included four activities including verification of PGP commitments, compliance ~ith the Writer's Guide, the adequacy of the V&V of the EOPs, and the adequacy of the training*

on the EOP The surveillance was not completed. until July 1989, over two months after the licensee was notified when this NRC inspection

would be ~onducted. At this point in time, the EOPs had been revised to conform with Revision 3 (Submittal 2) of CEN-15 The last two items on the surveillance checklist, v.erification of V&V and training, had been deleted from the checklis There was no evidence that any specific audits had been implemented since the initial review of EDP 1.0 in June 198 Audits of training activities at the simulator in 1988 and of operating procedures in 1989 did include some aspects of the EOP However, the training audit involved a review of training reccirds without any observation of the cictual training performed; and the audit of

operating procedures did not include a walkdow~ of the EOPs i~ the control room or in the plant to determine if the EOPs ~ere useable.. As noted elsewhere in this report, the two most significant deficiencies ih the EOP program related to V&V and training, the two areas deleted from the QA surveillanc There was no evi.dence that QA had ever conducted an au~it of the EOPs since the 1986 comments were develope The Ji~ensee's failure to perform ~lanne~ and periodic audits of the Palisades EOPs is an apparent violation (255/89019-05) of 10 CFR Part 50, Appendix B, Criterion XVIIIi which requir~s that a comprehensive syste of planned ~nd periodic audits shall be carried out to determine the effectiveness of the progra.

Human Factors_ (25592)

As a result of the evaluation of the Palisades EOPs, a number of human factors deficiencies were identifie Many of these appeared to be the result of a Jack of specific guidance provided in the EOP Writer's Guide (Administrative Procedure 4.06) or the licensee's failure to tonsistently

. apply the guidance provided therei These deficiencies were also indicative rif the general programmatic fail~re to utilize a multidisciplinary-team in procedure development and revision*, and the* - *

lack of an effective V&V progra Human factors deficiencies are summarized in the following paragraphs, with specific examples provided in Attach~ent 3, and their resolution will be tracked as Open Item 255/89019-0 EOP Structure and Format EDP structure ~nd format should provide for clear presentation of information in a consistent manne Procedure AP 4.06, however, permitted the use of two widely differing formats for EOPs - a

two column format to be used for EOP 1.0 and a single column format to be used for all other EOP This format was reportedly adopted

in emulation of the format used in CEN-152, Revision 3 (although the final submittal of CEN-152, Re-vision 3, adopted the two column format for all gehefic guideltnes).

Because bf the predominance of contingency action step*s throughout the Pali sades EOPs, the two col um_n format appears to be the more sui tab 1 e of the two formats currently in us Transitions Transitions are directives to the operator to move within and.between procedure These steps may instruct the operator to concurrently

use more than one procedure, or to completely exJt the procedure being used and move into a different procedur An operator may

~lso be required to reference tables, charts, attachments, or non EOP procedure To avoid confusion and unnecessary delays, transitions should be ~inimized. When they cannot be avoided, it is important that the transition directions be clearly and consistently presente * NUREG-0899 states that when transitions are necessary, a method should be used that is quick and creates the least amount of

disruptio Section 6.4.2.g of Procedure AP.4.06 provided direction on referencing and branching to other procedures or step There was no direction provided, however, which indicated when it was required to reference a procedure or ste Consequently, references were not provided for steps or conditions that the EOP writer determined to be generally known or understood by the operator Such information should be provided for use by the operator if necessar Proc~dure AP 4.06 stated that it was acceptable to reference or branch to a procedure giving only the procedure number without including the procedure title, page number, or the section bf the procedure to be execute Most references were found to not contain this informatio At a minimum, references.should direct the operator to.the specific section applicable to the steps called for in the EOP in order to ~liminate any confusion and delays in locating the approptiate step Several Control Operators (COs) and AOs indicated that they would have preferred having this additional information provide Use of Logic Terms Section 6.4.2.b of AP 4.06 stated that logic terms, including AND, OR, NOT, IF, IF NOT, WHEN, and THEN *should be capitalized.and underline In practice', however, all instances of these words were highlighted in this manner even though the contextual use was not as a logic ter For example, the word 11 AND 11 when used as a simple conjunction in a sentence was consistently underlined and capitalize Highlighting of the terms AND and.OR should have peen r~~erve~ for describing 11 necessary 11 (AND) or "sufficient" (OR) conditions of a

logic statemen The term NOT, unless included as part of an IF NOT statement.or condition, also sh-Ould not have been highlighted a~ a logic ter This practice detracted from the effectiveness of the highlighting used to call the operators attention to actual logic statements that required operator decision Paragraph 1 of Section 6.4.2.b of AP 4.06 stated that when four or more conditions need to be joined, a list format shall be use.

While no instances were found where more than three conditions were*

joined by AND in the same sentence, numerous instances were identified where list formats were used which als~ included AND between each conditio By prefacing the list of conditions with a statement indicating that all of the following conditions must be met, in~lusion of these ANDs was extraneous and should have been avoide *It was noted that in other instances where such lists were used, the AND terms were not use *

The terms IF and THEN should have been used to indicate actions to be taken by the operator IF a certain condition existed (as described in paragraph 3 of AP 4.06 6.4.2.b).

In some cases, however, IF/THEN statements were incorrectly used in the procedure to indicate expected plant response IF a c~rtain conditiQn exist Use of IF/THEN as logic terms ~hould have been reserved to those instances where operator actions were require Component Identification Section 6.~.2.h of AP 4.06 described the requirements for identifying components referenced in the EOP Paragraph 2 stated that when engraved names and numbers on panel placards and alarm windows were referred to in the procedure, the engraving s~ould be quoted verbati There were a number of instances where this requirement was not applied in the control roo There were also inconsistencies found between the format of component labels in the plant, and the referenced component ID numbers in the EOPs (e.g., MV779CA vs MV-CA779).

Paragraph 4 of AP 4.0.6 stated that when components were seldom used, or if the component may be diffi~ult to find, location information *

should be provided in the procedure. While location of co~ponents within the control room presented no general problems, significant difficulties were encountered in locating components in the plant.*

On several occasions, AOs experienced difficulties or delays in locating valves and other components referenced in the EOPs, attachments to the EOPs, and SOPs referenced by the EOP In addition to addressing equipment location in AO training, this information should have been indicated in the procedure There were numerous inconsistencies found in the way that component identification was accomplished within the EOP In some cases, only the name of the component was provid.ed. *In other cases;' on*ly the

component ID number was provide When both the name and ID number were provided, there were ir:iconsisten~i.es in th_e order of presentatio and in the use of parenthese The Writer 1s Guide needs to provide more specific guidance 6n the use of component ID numbers and describe a consistent format for presentation of identifying informatio Cautions and Notes Section 6.4.2.c of AP 4.06 described use of cautionary information*

and notes.. No discussion was provided, however, regarding the type of information that should be included in a c~ution statement, and very limited discussion was provided regarding information to be presented in note Instances were found where cautions contained incomplete information (especially regarding the consequences of actions).

Instances were a 1 so found where information was pTesented as a caution that was more appropriate to present as ~not~ and vice vers There were also cases in which information in the form of a note should have been added to the EOP, there were also instances where information that was presented was not actually needed or appropriate to the asso_ci ated step, Sentence Structure and Vocabulary Language used in EOPs should be as concise and direct as possible to min1m1ze potential for operator confusio Sectioh ~.4.3.c of AP 4.06

_stated that words used in the procedures should convey precise understa~ding to the trained ~erson.. In contradictioh to thi~

requirement, however, instances of vagLle, subjective, or indeterminant language were enco~ntered that ~ould require interpretation oh the part of the operato There were also instances of commonly used terms (some of which wer.e defined in the Writer 1s Guide) being interpreted inconsistently by. different operators on different crew There were several instances found of redundant instructions or steps, or inclusion of steps that would never be performed if the operator were to strictly follow the.branching instruction provided in previous contingencj st~p Such steps should have been eliminated as they provided unnecessary clutter and posed a potential source of confusio In-plant Component Labeling and Accessibility To ensure that AOs and other p 1 ant personne 1 could e*ffi ci ent ly carry out their responsibilities in implementing the EOPs, it was-important that components were correctly labeled and easily accessibl In performing in-plant walkdowns of the EOPs and the interfacing procedures, ~number of deficiencies were found.. In several cases,

.components were not labeled, requiring the AO to refer to plant drawings to positively identify the componen A number of instances were found where components were located at heights beyond easy reach of the AO and no ladder was located nearb In one instance, accessibility of the -nearest ladder was also hindered due.to its placement behind a beam with a hose and communications cable hanging in front of the ladder rac Another hindrance to cqmponent accessibility that was observed during in-plant walkdowns was the requirement for AOs to obtain keys from the. control room for operation df certain valves and electrical breaker Although the rationale for such requirements was well

founded, there was no i ndi c_at ion in the procedures that a* key was require This information should have been provided (including specific key numbers where applicable) so that AOs could be provided with the needed keys prior to being dispatched to perform local action Operators agreed that in stressful situations, it may be easy to overlook the need for_keys witho~t such a reminde This could result in significant delays in performing local actions, especially if protective clothing was required to enter the are Clarity of Instructional Steps Instructional steps should hav~ b~en more concise and as simple as possibl For equally acceptable steps, the operator should have been directed to carry out one of.the alternatives with the other alternatives provided in the event that the designated step could not be accomplishe There were instances observed ~here the EOPs did not follow thi_s guidance and provided directions for th~ operator to perform one of two or more alternative There were also a number of instances where EOP steps could have been reworded to reduce the number of steps or improve the overall clarit There were some EOP steps that were redundant or unnecessary (for examp_l e, directing.the

operator to continue with the next step when following the logic of previous steps would have lead him there anyw~y).-

Operator Aids Overall, the flowcharts incorporated into the EOPs (EOP 1, Attachment 1 and EOP 9.0, Attachment 1) were found to be consistent with approved flowchartin~.practic~s and served as useful operator aid Isolated -*

problems ~nvolving improper use of a note and an overly complex statement within a decision box were foun No guidance was provided, however, in AP 4.06 regarding requirements for EOP flowchart To ensure consistency in new.flow charts and.revisions to current flow charts, flow chart requirements should be specified.

. The general format of tables and graphs included as attachments to the EOPs was also found to be in acco~dance with accepted human factors principle No problems with legibility or appearance were observe Isolated problems with labeling of graph axis were observed and are discussed in Attachment II.

Validation and Verific~tion Program (25592)

The inspection team reviewed the licensee's V&V program and the V&V efforts applied to the EOPs and subsequent revisions t6 the EOP The reiults of this review are documented in Attachment IV of this report, and resolution of the deficiencies identified will be tracked as Open Item 255/89019-0 The findings are summarized in the paragraphs below..

As noted in the-previous sections, the walkdowns of the EOPs were generally positive, but deficiencies were noted in the technical adeq~acy of the EOPs and the app l i cat i ans of human f a.ctor Paragraph 3.3.5 of NUREG-0899 states thatL after development, the.EOPs were to undergo a process of V&V to determine that the procedures were technically adequate, addressed both technical and human factors issues, and could be accurately and efficiently carried out. *

~he licensee's V&V program was based upon INPO Guidelines83-004 and 83-006 and was described in the Palisades PGP submission The current program was defined in Administrative Procedure 4.0 The licensee provided documentation to show that the purpose of the verification program was to confirm the written correctness of the EOP procedures~ ensure that GTG and PSTG guidance was properly incarporated into the EOPs, and to verify that application of human factors aspects had been addresse *

The Palisades EOP verification program contained the following elements:

0

.o Quality assurance review for conformance to the Write.r's Guid Technical review to ensure:

Accuracy of the EOP steps, EOP compatibility with operator experience, training and plant hardware, and Identification of EEQ list requirements imposed by EOP equipment usag Control room walkthroughs of the EOPs The licensee also provided documentation to show that the purpose of the validation program was to determine if the control room operators could effectively manage emergency conditions using the EOP Program emphasis was on usability and operational correctnes Validation methodology consisted of the following elements:

0

Simulator validation Tabl~top validation WalkthrouQh validation The inspection* team reviewed administrative procedures to ensure that adequate controls existed to incorporat~ changes to the EOPs, that the latest revisions.were available to the operators, and that they were easily accessibl Verification and val.idation supporting documentation was reviewed on a sampling basi C.ontrol room, simulator, and plant EOP walkdowns were conducted to ensure that the procedures were validated and verified by the license The inspection team found that the defined V&V proces~ limi.ted QA

involvement in the EOP process to a check for Writer 1s Guide conformanc It did not extend to other potential areas of QA involvement such as confirmation of V&V feedback into the EDPs, GTG/PSTG audit and review of deviations, verification that operator action setpoints were available and incorporated into the EOPs, definition of EOP training requirements, verificatitin that preferfed V&V methods were chosen from the available options, confirmation that independent technical reviews were conducted by individuals other than the procedure writer, and EEQ applicabilit The NRC concluded that QA involvement in the EOP process should be extended beyond its present bounds of EOP Writer 1s Guide conformanc This is anothet example of the apparent violation (255/89Dl9-D5) against the requirements of Criterion XVIII of lD CFR 5D, Appendix B, which was cited in paragraph 6 of this repor The Palisades plant specific technical guidelines (PSTG) included four.

administrative procedures, the GTG, the F&TA report, Technical Specifications, existing EOPs, FSAR, EDP related licensing letters, and as-built plant drawing This body of documents is very voluminous and portions of the PSTG are neither plant specific (e.g. _CEN-152) nor technical (e.g. four administrative procedures, the ~riter's Guide, FT&A).

As a result, the PSTG was an unweildy document, which was difficult to verify or validat The inspection team noted some references in the EOPs were incorrectly identified and that the specific training requirements in support of the EOPs were occasionally undefined (e.g. the meaning of "qualified CETs" in the subcooling margin check).

During previous simulator V&V runs of the EOPs, records were made to flag EOP training support requirement However,.

these EDP training support requirements were apparently not communicated to the training organizatio The deficiencies identified in these areas indicated an inadequate V&V program or an inadequately implemented V&V progra The licensee's failure to perform a V&V of the supporting procedures, attachments, and documents to which the EDPs direct or refer the operators, and their failure to

perform the V&V (that which was completed) independent of the procedure writers was a major contributor to the fact that the deficiencies i~entified in this ieport had not been previously identifie A comprehensive V&V process would have enabled the licensee to identify and correct the problems before the inspection team arrive.

Unresolved Items Unresolved ~terns are matters about which more information is required in order to ascertain whether they are acceptable items, violations, or deviation~.

An unresolved item disclosed during the inspection is discussed in paragraph.

Open Items Open items are matters which.have been dis~ussed with the licehs~e. which will be reviewed furth~r by the inspectors, and which involve some action on the pait of th~ NRC or licensee or bot Open items disclosed during the inspection are discussed in paragraphs 4,. 5, 7, and.

Exit Interview (30703)

The inspectors met with licensee representatives (denoted in Par~graph 1)

on August 4, 1989, to discuss the scope and findings of the inspectio In addition, the inspectors also discussed the likely informational

content of the inspection report with regard to documents or processes reviewed by the inspector during the inspectio The licensee did not identify any such documents or processes as proprietar.)

ATTACHMENT I UST OF.PROCEDURES REVIEWED EOPs Reviewed.... EOP 1. 0 EOP 2. 0 EOP 3. 0 EOP 4. 0 EOP EOP6.Q.*

EOP 7. 0 EOP 8. 0 EOP 9. 0 Stand~rd Post Trip Actions Reactor Trip Recovery *

Electrical Emergency Recovery

. Lo.ss of Coo 1 ant Accident Recovery Steam Generator Tube Rupture Excess Steam Demand Event Loss of All Feedwater (LOF)

Loss of Forced Circulation Recovery FunCtional Recovery Procedure Procedures Reviewed Which Were Referenced* in EOPs Administrative Procedure 9.31 (Revision 4), "Temporary Modification Control

2.. ARP 3 (Revision 4'6), "Electrical Auxiliaries and Diesel Generator" EI-1 (Revision 15),

11 Activation of the Site Emergency Plan/Emergency Classification" EI-6.3. (Revision 4), i 1Release Rate Determination From High""Range Effluent Monitors EI-7.0 (ReviSion 3),

11 Emergency Post Accident Sampling Decision Process 11..

EM-04-08 EM-04-23

. EPS-E-7 EPS-E-8 and (Revision (Revision (Revision (Revision kV Bus lD 20),

11 Shutdown Margin Requirements

0), ~Shutdown Margin For Emergency Cooldown" 2) !

11 Lo ca 1 Tending of 2.4 kV Bus 1 C Switchgear

2) ! "Local Tending of Diesel-Generator 1-2 (K-6B)

Swi tchgear

1 GOP 9 (Revision 9),

11 Plan~ Cooldown From Hot Standby/Shutdown" 1 GOP 10 (Revision 6), "Emergency Shutdown From Power"

\\

'

1 M0-27c (Revision 2),

11 Functional Check of PCS Overpressure Protection system Setpoint 310 PSIA During Cooldown

.I

-

1 M0-270 (Revision 1),

11 Functional Check of PCS Overpressure Protection System Setpoi nt 575 PSIA. - Pl ant Ope rat i ng

1 PFM-E-1 (Revision 0) i 1Emergency Post-Fire Maintenance Guideline Repair Procedure For G6ing To Col~ shutdown In A Safe And Expedient Manner" 1 ONP 2.1 (Revis.ion 2) "Loss of AC Power

1 ONP 2.2 (Revision 1) "Loss of All Immediately Available AC Power" 1 ONP 6.1 (Revision 3),

11 Loss of Service Water

1 ONP 20 (Revision 13),

11 Diesel Generator Manual Control

1 ONP 24.1(Revision13),

11 Loss of Preferred AC Bus Yl0

2 ONP 24.2 (Revision 13),

11 Loss of Preferred AC Bus Y20

2 ONP 24.3 (Revision 12),

11 Loss of Preferred AC Bus Y30

2 ONP. 24.4 (Revision 12),

11 loss of Preferred AC Bus Y40

2 ONP 24.5 (Revision 13),

11 Loss of Instrument AC Bus YOl

2 ONP 25,.l (Revision 1),

11 Fire Which Threatens Safety Related Equipment

2 ONP 25.2 (Revision 3),

11 Alternate Safe Shutdown Procedure

2 SOP 2A (Revision 16), "Chemical and-Volume Control System Charging And Letdown:

Concentrated Boric Acid

2 SOP 3 (Revision 9),

11Safety Injection and. Shutdown Cooling System

2 SOP 4 (Revision 5),

11 Containment Spray and Iodine Remo.val *System

-

2 SOP 5 (Revision 5),

11 Containment Air Cooling and Hydrogen Recombining System

3 SOP 8 (Revision 22),

11Main Turbine and Generating Systems

/

-3 SOP 12 (Revision 14),

11 Feedwater System

3 SOP 24 (Revision 8),

11Ventilation and Air Conditioning System

2.

SOP 30 (Revision 10),, "Station Power" 3 SOP 38 (Revision 5), Gaseo~s Proceis Monitoring Syst~m Administrative Procedures Reviewed Administrative Pr6cedure 4.02, "Control of Equipment Status" Administrative Procedure 4.06; "Emergency Operating Procedure Development and Implementation"

ATTACHMENT II

. TECHNICAL DEFICIENCIES The following are specific defitiencies that were discussed with the license~.

The licensee representatives agreed to either correct the deficiency or to further review the issue for resolution EOP Standard Post Trip Actions

0

0 Step 5.d addressed AC power transfer to station power, but did not address DC powe DC power was addressed in CEN-152, Revision 3, paragraph The licensee's representative stated that DC.power availability was addressed in a bracketed step in CEN-152, Revisjon The basis of the step was to Reflect the automatic disconnect of the Main Turbine Generator and the transfer of power to offsite...

_

He stated that loss of DC would affect the ability of the AC buses to compl~te their transfe Therefore, AC bus availability was the primary operator actio The licensee's rep~esentative stated that they will-consider documenfing the abov as a deviation from CEN-15 Step 6.c required loop Th to be. at least 25° F subcooled and then the operator was referenced to a footnote at the bottom of the pag The

.inspector not~d that if the footnote was vital to the step, then why was it included as a footnote to the procedur The licensee's representative stated that they will evaluate this commen P~ragraphs 7 and 8 did not include a requirement to trend the specified parameter This was included in paragraphs 5 and 6 of CEN~l52, Revision The licensee's representative stated that the EOPs were written to Revision 3 (Supplement 2), which did not requir~

trendin He stated that the comment will be incorporated when the EOPs are revised to Revision 3 (final) as a result of the biennial revi_e The contingency o( Step 8 described natural circ~lation: The inspector questioned the necessity o.f this s_tep-since natural cjrculation cannot be verified for approximately 10 t6 15 minute Since EOP 1.0 is a prerequisite to the other EOPs, the time delay in waiting for indication of natural circulation, could delay getting into the other EOP The licensee's representative stated they will consider deleting the unnecessary steps and document this as a deviation from CEN-15 Paragraph 9 did not address minimum flow to the steam generators, however, CEN-152, Revision 3 di The licensee's representative stated that they will evaluate this comment. -

0

The contingency steps of paragraph fl did not address the flow of one pump to a single header or the flow of one pump to both header These options are discussed in CEN-152, Revision The licensee 1 s representative stated that he believed 'the contingency step, as *

written, identified the desired pump configuratio He stated that if the configuration was not adequate, the diagnostic flowchart would address the optional or recovery procedur The licensee agreed to document the change in the basis documen *

Steps 10.c and 10.e had nci contingency action CEN-152, Revision 3, had a contingency statement to consider steam generator tube ruptur The licensee agreed to evaluate this commen Step 12.b required operator verificatibn that two CCW pumps were runnin All of the operators interviewed stated that the plant

currently operated with only one CCW pump in-service and that the operator~ were trained to start the second CCW pump and consider the instructional step as being me The licensee 1 s representative stated that they will evaluate this commen *

The note on page 8 of 8 to the diagnostic flowchart appeared to be a logic flowpath action statement and should be included in the tre The licens~e agreed to review the diagnostic flowchart and revise it as necessar The inspectors noted that if the first diamond of page 8 of 8 of the diagnostic flowchart was answered with 11yes 11 the op_erator was directed to consider the appropriate functional recovery procedure.. The 1 ogi c path of the flowchart had provided a 11cons i der 11 block for all EDPs except EDP The licensee agreed to review the diagnostic flowchart and revise it as necessary.. EDP Reactor Trip Recovery

Section Jn.Step 2.a, the term 11 uncomplicated Reactor Trip 11 had not been defined but was discussed in the basis documen The team was told that it i~volved a reactor trip for which all the left hand column steps (conditions bf EDP 1.0) had been satisfie Using this definition, the operator would never get to this point, and Step 2.a could be eliminated by adding to Step 1, 11 and directs implementation of EDP 2.0.

The licensee 1s representative stated that they will evaluate this issue for possible chang Section General Comment - Many of the -steps_ in Section 4.0 are contingency _action This procedure was idally suited for two column forma Ste~ 2 was redundant and could ~e eliminate The licensee's representative stated that they will evaluate this issue for possible-chang In Step 4, if the definition of an uncomplicated reattor trip, was consistent with that of CEN-152, Revision 3 (e.g., all Safety function Status Check acceptance criteria satisfied), then the conditions of this step could not be met and it should be eliminate The licensee's representative stated that they would evaluate combining this step with St~p Step 5 should address 11vital AC buses 11 and the contingency action should direi:t action such as, 11 THEN attempt to restore power to the buses by implementing the following procedures.

The licensee's rep~eseritative stated that thi~ step would be corrected as note In Step 6, the statement "(refer to EM-04-08)

11 implied that EM-04-08 provided instruttions on how to emer~ency borate, in lieu of calculati~g the shutdown margin EM-04-08 specified the RO (CO)

as one of the persons with minimum skills to do the calculation During the walkdowns, the team found that the ROs wer~ trained annually on doing this calculatio During the walkdown, some of the ROs interviewed stated that they could not reliably perform the calculatio More training is needed for the CDs in performing the calculation Qr they should be removed from the list of people with'

the skill levels to perform the calculation The licensee's representativ~ stated-that they would evaluate this issue for possible chang Step 9 did not specify how the operators were to know that a spray with excessive delta-Thad occurre The licensee's representative stated that this was a training issue and they would eval~ate the need for possible changes in the training on this poin In Step 10 the preferred method to be used should be specifie The 1icensee 1 s representative stated that they would evaluate the need --

for a possible change in this ste The 11 Note 11 after Step 11 should be moved to follow Step 1 The licensee's representative stated that this note may be more appropriately loc~ted just before Step 1 He agreed that they would evaluate the possible chang Step 12 appeared to be redundant and should be eliminate The licensee's representative stated that they would evaluate this fssue for possible chang A new ste~ should be considered following Step 20, to refer the operators to the appropriate startup procedure The licensee's representative stated that they would provide a new ~tep as noted..

Attachment 3

.. Step 2.c provided for a gravity feed from Tank T-90 to Tank T-2, provided 11the spool piece is installed.

. SOP 12, Section 7.5 discussed in general terms the lineup required for this mode of inventory makeup; but the instructions did not include all of the valves to be operate Furthermore, SOP 12 *was not referenced by this step of the EO The licensee'.s representative stated that they would clarify this ste Attachment 4

0

In Step La the words 11at least" were not necessar The licensee's representative stated that they would correct this ste Step l.g directed the operator to determine if CCW had been i~terrupted for more than 10 minutes, but it did not indicate how the oper~tor was to make this determinatio The licensee's representative stated that this was a training issue and would be evaluated to determine if the chan~e was neede Step 4 clearly stated that it is the oil lift pump to be started and not the PC Words such as 11 start AC or DC Oi 1 Lift Pump for applicable PCP 11 would clarify this steP, The licensee's representative stated that they would correct the step as note.

EOP 3.0 "Electrical Emergency Recovery" General Comments It appeared that the basic strategy of CEN-152 was not followed for Procedure EOP 3..0 in two case Th~ two cases noted were:

0 Step 5 of Section 10.0 in CEN-152, deals with restoring power to a vital and nonvital bus from a diesel generato This step was covered, but only in part, by Procedure EOP 3.0, Steps 9, 16, 19, 25, 29, 30, and 3 Step 6 of Section 10.0 in CEN-152; deals with stripping DC busses to

.minimize battery discharge curren This step was covered, but only in part, by Procedure EOP 3.0, Steps 14, 20, 21, 22, and 2 Specific Comments Purpose Section 2.b 9id not specify which busses were considered "vital 480V AC.

Some of the operators interviewed were confused on this issu The licensee's representative stated that "Vital 480V AC busses 11 were defined in Technical Specification Operator Actions

0

0 In Step 6.c if Tave is less than 515° F_, the display would lockup and be useless for maint~ining the limits of Attachment If Tave were less than 515° F, another temperature must be tise *The temperature indication tp be used (hot or cold) should be specified. *The licensee agreed to evaluate this issue to determine the best temperature

indication'to be used for this cas For step 8b, none of the operators questioned know of any reason to*

_wait 60 seconds before going to cutout before stopping the D/G from the contra 1 roo The 1 i censee stated that this switch wi 11 be *

removed in the fall outage, and the step in the EOP will be delete *There was confusion on the part of the.AO asked to walkdown Step 4 There were no designations for the breakers to be operated, and it was not clear to the AO what actions were desired.. The AO stated that he would refer to SOP 30 to perform the task desired, as the SOP was written in a much clearer manne The licensee agreed to evaluate this step for revisio The breaker specified normally in Step 59.b.3.e was normally left in the racked-out positio The procedure did not explicitly.state to

rack the breaker in before attempting to close the breake The licensee agreed to evaluate adding a sub~tep to instruct the AO to rack in the breaker before attempting to close i There was a difference of opinion among the ope~ators interviewed as to what the term "operating" means in Attachment 1, Step Some operators thought it meant that the diesel was simply running unloaded, while others thought that it meant that the diesel was loade The licensee agreed to evaluate the use of the term

-"operating."

Step l.a of Attachment 13 needs a key to opetate these valves~ but there was no "note" explaining thi The licensee's representative stated that having key numbers on placards located under the keyswitch was adequate to inform operators of the need for a specific ke.i

..

0 The inspector could find no definition of the term 11 throttle open

used in Steps l.c and*l.d of Attachment 1 The procedure did not specify how far open 11throttled open 11 i The licensee will evaluate the need to mak_e the p~otedure clearer on this matte Step 9 referred to Procedure ONP-20 to l~cally start and load available diesel generators (D/Gs).

The following comments relate

to ONP-20, 11 Diesel Generato.r Manual Control 11 :

'*

Step 4. 2. b - the II note 11 stated that a ladder may be. require A ladder was necessary and fuse pullers should al so have been r_equire The ladders outside of Switchgear Room IC were too large for this applicatio The lic~nsee agreed to evaluate a rewrite of the not Step 4.3.b resets the lockout relay by placing the D/G 1 s output breaker control switch to the 11 tripped 11 conditio Step 4. implied that the above action starts the.DI If it does, 4. should so.stat The licensee agreed to rephrase the steps as necessar Step 4.3.c - the last line in this step was redundant and should have been delete The licensee stated that no change was contemplated at this tim Step 4. 6.1. d - the 11 n.ote 11 should have been at the end of the ste The licensee agreed to evaluate moving the not Step 4.6.l - a small ladder would be required to perform the substeps in this ste The licensee agreed to evaiuate adding a note to this ste The 11 notes 11 in ONP-20 did not appear to meet the* guidelines for notes in the EOP The licensee agreed to evaluate the 11 notes

an caut i ans

-

1 in accordance with the EDP Writer 1 s Gui de and Aqministrative Procedure 10.51.. EDP 4. 0 11 Los*s OF COOLANT ACCIDENT RECOVERY

Palisades EDP 1.0 required that the operator secure both main feed pumps after a reacto~trip, which was in deviation. from the guidelines of CEN 15 The FSAR stated that main feed should ramp down in auto at 1.5%/sec. to. the decay heat removal leve However, the basis document stated that operating experience indicated the system will not perform as designed, but instead has caused over cooling or primary coolant systems (PCS) depressurizatio Because of this

..

0

deviation, entry into the LOCA procedure would always be made with main feed secured and S/G heat removal dependent upon establishing auxiliary fee For the small breqk loss of coolant accident (LOCA),

3 of the 5 success paths ~epended upon S/G heat removal, (e.g., upon feed flow).

Only HPCI feed and bleed and shutdown cooling remai*ned as options and the latter was n6t available until temperature and pressure entry requirements for OHR had been me The NRC team concluded that the EDP 1.0 deviation to. secure main feed would not be required if the system were performing as designe Further,. the team noted that the question was academic for the LOCA inside containment since containment high pressure wduld shut the main steam isolation valves (MSIVs) and thus eliminate the main feed pump However, for the LOCA outside containment, prematurely securing an operating feed system to shift to an off-line system would decrease the probability of success by reducing success probability for 3 of the 5 success path *

The licensee.acknowledged:

that the auto ramp down did not ~erform in accordance with. the FSAR description, that past experience indicated the EDP 1.0 immediate action main feed pump trip was required as a deviation to the CEN~l52, that restoration to design conditions could not be economically justified and stated that the deviation would be retaine Supporting rational was based upon the fact that uhder LOCA conditions, main feed could only be expected to survive for* the small LOCA outside containment and even then it would have to be secured relatively early in EDP 4.0 because of inadequate throttling control or pump steam demand Contribution to coolin CEN-152, Step 4, stated to ensure maximum SI and charging flow, however, this statement was not included in the ED The licensee agreed to add the caution or emphasize the issue in EDP support

. trainin Steps 4 and 5 were incorrectly sequence Step 5 should have appeared f-irs That was the only way the direct transfer could be made to EDP As written, the operator who had misdiagnosed the LOCA..

would be delayed in a loop from EDP 1.0 to EDP 4.0, Step 4 back to EDP 1.0 until he was directed to EDP 9.0 by the status check The licensee stated that correction was planne Step 13.d should have been referred to PCP CCW flow or specific valves, not to 11 any CCW valve isolation valve closed

It was possible to have many CCW isolation valves closed without loss of flow to the PCS pump The licensee agreed to clarify the ste *o

Step 2 checked 11 open MD-2D8 The Writer's Guide indicated that 11 chec k 11 is to comp a re with a procedural requ iremeri During the walk down, the operator was ubable to define check and could not find procedural authority to close a valve he knew had to be close The licensee agreed to add this to the t~aining progra In Step 48, th~ recirculation actuation signal (RAS) shift to the sump was correctly identifi.ed as 2% safety injection refueling water tank (SIRWT) leve However, ARP-8 incorrectly listed RAS shift as

_9.7 percent SIRW When this was pointed out to the licensee, a TCN was issued the same da Step 49.e incorrectly stated to transfer valves to an alternate controlle This should have read transfer valves to an alternate suppl the licensee agreed to revise the ste CEN-152, Supplementary Instructfon 6, required that the operator should be cautioned against premature manual RAS initiation which

_could lead to insufficient sump inventor No caution was cont~ined in the EDP, no deviation existed, and the item was not specHically addressed in EDP support trainin The licensee agreed to resolve the issue either by procedure change or training and to document it as a d~viation if applicabl Step 6D.h should have referred to the required section in HR-3 since the operators were not famili~r with the procedure, no index was available, and the required section was 31 pages into the procedur The licensee agreed to revise the step to facilitate entr The portion of Step 68.a which addressed the hydrogen monitor was not required; the hydrogen monitor was placed in service at the first run -

of the containment atmosphere safety function status chec The licensee agreed to revise this step to have the operator verify the hydorgen monitor was in servic Steps 68 and 7D should have been reworded to eliminate any attempt to close an already closed power relief valve (PRV).

To do so runs the risk of the operator going to reset, then to close via ope The momentary opening of the valve runs the risk of a stuck open open head ven The licensee agreed to either revise the procedure or facto~ the item into trainin Step 77.c required at least ~ne SIG available for PCS heat removal as a prerequisite for LDCA shift to OH Although the step was consistent with the CEN-152 requirements earlier in the LDCA sequence, at this point in the EDP, the NRC team was unable to justify that requiremen For.example,_given that OHR was otherwise availablei but

. o

0

o no SIG was available as a heat sink, 'it made no sense to abort the shift to OHR; in fact.the shift to OHR *became more imperativ The licensee agreed that SIG ava*ilability was not a OHR prerequisite and indicated that it was in the procedure only because it was 1n the CEN-152 equivalent ste Deletion of this prer~quisite will be evaluated, and if it is deleted, a deviation will be issue Step 79 should have offered the alternative of a_ return to Step 77 to attempt to. establish OHR. a second tim the licensee agreed to incorpoiate this into the procedure.

In Step 81, the operator was free to choose from many options in any sequence (e.g. throttle SI, secure SI pumps, secure charging pumps etc).

Although this flexability was acceptable, a note or caution

should ha~e been added to remind the oper~tor of boration requirement The 1 i censee agreed to modify th_e procedure to incorporate the boron consideratio *

Step 83 appeared to be incomplete; no consideration was given to radiation level, PCS activity, and normal vs post-accident sampling system (PASS) sampl The licen~ee agreed to evaluate this ite In Attachment 1, page 5, Step 6.a.ii the note indicated that decalibtation could occur under adverse containment conditions and inferred that attachments 6 and 8 should be used in that cas Therefore, substeps a and b should have been labled actual leve The licensee will revise the procedur Based upon walk down comments from one auxiliary operator (AO) and three COs, the operation required in Step 2.c of Attachment 9 was infrequent enough such that a procedure reference was.required, * * * feed to T-2 in accordance with Section 7. 5 of SOP 1 The 1 i censee agreed to rey i se the ~rocedur In Step 50.c, the second 11 go to 11 transfer should have been to Step 50 The licensee agreed to revise the ste Step 62.b, the sentence was poorly worde Since PCS pressure was a OHR entry condition, this portion of the statement could be delete The licensee agreed to revise the ste Step 73 used the word 11 check 11 as it was defined in the Writer 1s Guid Since the.operators had not received training in the guide, they were unaware of its meanin The licensee agreed to incorporate this in EOP trainin In St~p 77.f, the ~ord acceptable was used without definitio Walkdown operators were not certain what was acce-ptabl The licensee will clarify the ste In Attachment 8, the graph on page 1, was contrary to the standard convention which was followed for all other graphs in this procedure (e.g. input variable on th~ X axi& and qutput on the Y axis).

The licensee will evaluate this ite * EOP 5. 0, 11 Steam Generator Tube Rupture"

0

0 Step 20.c stated that the operator was to perform steam line radiation surveys upstream ~f the main steam isolation valve~

(MSIVs).

A note should have be added to alert the health physics technician to.take a radiation monitoring instrument with a long extension on the detector, since the steam lines were approximately 10 feet above the floor level. *

The licensee agreed with this observation and agreed to incorporate information in the procedure identifying the need for a radiation monitoring instrument with an extension on it..

Step 53. a stated, "Block MSIV closure by pushing the BLOCK ISOLATION pushbutton on panel C-0 However, the label plate for the switch

.on Panel C-01 did not clearly describe this functio The licensee agreed to m~ke the label information on the panel and the EOP

'identification matc *

Step 2 of Attachment 5 stated 11Transfer Main Turbine Gland Sealing Steam to Plant Heating System per SOP 13, Section 7.6.1.

The AO, walking down this procedure, did*not think it was the correct procedure because of the wording in SOP 13, Section 7.6.l, which discussed putting the Steam Superheater M-911 in operatio The licensee agreed to review the wording in SOP-13 and EOP 5.0 and

clarify it, if necessar Steps 2.a and 2.b of Attachment 8 stated, "Commence Special Valve Lineup.

The required valve lineups were not delineated and the operators were required to go to the drawings and determine the required valve lineup The licensee ~greed to develop a procedure to delineate the special valve lineup Step 62.a referred to SOP-5, Step 7.2.l.b referred to Hydrogen Recombiner M-65A instead of M-69 The licensee agreed to co~rect this erro CEN-152 entry conditions included high activity and conductivity in the steam generator liquid sample and qn increasing steam generator leve EOP 5.0 did not include these two parameters as entry condition The licensee had not identified this as a deviation.

. The licensee gave as justification for not using these two parameters

0

0 that enough parameters (e.g. high radioactivity alarms, volume control tank level decreasing, standby charging pumps started, pressurizer level decfeasing, and pressurizer pressure low) were a 1 ready used. *

Step 6.b of Attachment 1, "Safety Function Status Check Sheet, 11 gave the* acceptahce criteria as Tave less than 545° F whereas CEN~l52 gav~

RCS Th less than [525° F].. The licensee justification for thi~

difference was that the RCS Th temperature had been changed from RCS Tav~ in Supplement 2 of Re~ision 3 to Th in the final Revision 3 of CEN-15 The licensee 1s representative stated that they were waiting for NRC approval of Revision 3 to the Combustion Engineering Emergency Procedures Guidelines before incorporating this chang As noted in paragraph 2 of this report, NRC approval has already been issued and the licensee 1 s ~epresentative committed to revi~e the EOPs to this revision during the next biennial review of the EOP Step _4. 0. 7 stated that the operator was to commence emergency boration to establish cold shutdown boron concentratio There was

no comparable step for this action in CEN-152 and it was not discussed by the licensee as a deviatio The licensee's basis d9cument only discussed increasing the shutdown margi This observation was discussed with licensee personnel and appeared to be a conservative action which would not negatively impact safe operation of the plan * EOP 5.0 provided instructions. (Steps 15 through 19) for primary coolant pressure control prior to determining which steam generator had a tube rupture rather than following the sequence in CEN-15 The licensee did not identify and justify this deviatio The licensee's representative stated that identifying the steam generator

- with the leaking tube would take time and in the interim the leak rate could.be reduced by reducing primary coolant pressur The licensee was evaluating the addition of justification for this step sequence deviation to the basis documen '

Step 12 of CEN-15~ stated that the operator was to control p~essurizer pressure at less than 1000 psia and approximately equal to the isolated steam generator pressure (+/- 50 psia).

The EOP comparable step specified to restore or maintain the pressurizer pressure as low as possible within the limits of the pressure-temperat~re curv This deviation was not discu~sed in the deviation document, however, the licensee's represe~tative stated that to reduce the pressure to less than 1000 psia could result in violating the pressure-temperature curve restriction The licensee agreed to consider including a discussion of this deviation in the basis documen.

'*,

0

The wording of Steps 5 and 6 in Attachment 8 was such that the inlet valve to one miscellaneous waste filt~r cbuld be opened and the outlet valve to the other filter could mistakenly be opene These steps should be rewritten to ensure the inlet and outlet valves for the same filter are opene The licensee agreed to clarify the wording in these step The caution after Step 6 in Attachment 8 warns of potential high radiation levels, but did not suggest.health physics coverage or the use of a radiation monitoring instrumen The licensee agreed with this observation and will correct the ste *

The AO and the I&C technician that walked down Attachment 8 with the inspectors had not received training on the procedure and had some difficulty finding specified valves and electrical terminal They were bbth well qualified, appeared to know the plant well, and found all the designated components; however, it was apparent that training on the EOPs would have ensured the. required actions being taken in a timely manne It appeared that component location information, if added to some of the procedures, would have been of benefit in helping locate components in a timely manne The licensee agreed to evaluate thfs observatio In Step 2.c it was not clear whether one or two standby charging pumps starting constituted the entry conditio According to the operator, one pump starting could be an indicatio Incbnsistent component references also contributed to lack of clarity in this instanc The previous step indicated component ID numbers using an 11 or 11 between number The licensee agreed to evaluate this observation;

In Step 10, no reference was given for the PCP operating limit The licensee's position on this observation was that operating the PCPs was within the skills of the operator using existing indications and alarm response procedure Step 17 refers to the use of the core exit thermocouples (CETs),

different operators used different methods in tising the CET The lic~nsee agreed to evaluat~ the need for guidance in obtaining and using CET informatio *

In Step 35 the operato~ was referenced to Attachment 4, 11 if additional PCPs are desired, 11 however, no criteria was provided for operating additional PCP The licensee agreed to evaluate this observatio The caution prior to Step 52 should have informed the operator of the-consequences of exceeding the speci fi"ed 1 imi ts (i.e., "exceeding a PZR cooldown rate of 150 degrees F/hr or a PZR spray delta T of 350 degrees F could cause.. ~.

11 ).

The li~ensee agreed to evaluate this observatio.

EOP 6 "Excess Steam Demand Event"

0

-

.

Step 2 directed sampling for SIG activity, but sample results were not used to determine corrective action The licensee agreed to evaluate and consider expanding the step and/or directing an exit to EOP 9. Procedure EM-04-08, Steps 5.5.L and T request Xenon reactivity at the

"desired" time after shutdow However, there was no place to record the desired tim An operator reviewing the calculations or verifying the proper boron concentration would not know the date and/or time upon which the calculations were base The licensee agreed with the comment and will evaluate _this concer Step 26.b referred the operator to-Attachment Attachment 5 did not reflect the pump parameters of FSAR Table 6-2 for the LPSI pumps and Table 6-3 for the HPSI pump For example, Table 6-2 stated that the maximum pump flow was 4500 gpm for a two ~ump total of 9000 gp The appropriate chart to Attachment 7 did not go to 9000 gp Also,*

the installed flow meters would provide a total flow of only 8000 gp Similar comments were applicable to Table 6-The licensee *agreed to evaluate this concer The Step 29 CAUTION statement did not include concerns with PTS that *

were addressed in CEN-152, Revision 3, Submission 2 (and final).

The licensee agreed to rephrase the CAUTION.to include PTS concern The Step.37 basis included a condition of imminent loss of suction to require shifting charging pump suctjon. _This condition did not appear in the ste The licensee agreed to evaluate and change either the step or the basi Step 40.d required th~ use of qualified CETs (number not specified);

however, CEN-152, Revision 3, stated the "average of the CETs".

This deviation was not addresse The licensee stated that the term

"qualified CETs" will be defined in_ future training along with other EOP terminology~ The licensee agreed to further evaluate this concer Step 55 directed the operator to block safety injection actuation signal* (SIAS), but allowed the operator to wait until 1605 psia,

which was the SIAS setpoin Thus, SIAS might.actuate before the operator had a chance to block it. The licensee agreetj to evaluate this conc~rn but stated that this had not been a performance proble.

EDP 7.0 "Loss of All Feedwater (LOF)

0

6 Step 7.b. directed the operator to exit the procedure and go to EDP 9. 0, 11 Funct i ona l Recovery Procedure

CEN-152, Revision 03 *.

required the operator to consider "Excess Steam Demand Event Optional Recovery Guideline."

The licensee 1 s representative believed that the appropriate action was to enter EOP 9.0, and then if appropriate, go to th~ excess steam demand event optional. recovery procedur *

Prior t~ Step 49, the operator~ ~hould have established Jake water feed to the steam generators via the auxiliary feedwater pump Step 49 directed the operators to EDP 9.0 "Function Recovery Proc~dure, 11 instead of using a TSC/PRC approved procedur It did not appear that EOP 9.0 addressed the situation and it may have been more appropriate to prepare a procedure that addresses the situatio The licensee agreed to review this commen Paragraph 11 had a caution note that implied that feed to *a.dry SIG could happen; however, the previous steps sent the operator to EOP The inspector questioned if the caution was appropriat The licensee agreed to review this co~men.

EDP 8. 0 11 Loss of Forced Ci rcul at ion Recovery

Section The 11 THEN 11 statement in Step 2 was confusin The licensee 1s repr~sentative stated that they will correct the step as note The term "Uncomplicated Loss of Forced Circulation 11 in Step 3 was not define The licensee 1s representative stated that they will evaluate the possible need for changing this ste Sectibn Step 4 woul~ never be entered because Step 3 seht the operators out of the procedur If the concern of the basis document occurs, thi~

could best be handled by the use of a 11 Note.

The licensee 1s representative stated that they will evaluate the possible need for combining this step and Step 3. to resolve this concer Step 5 was similar to Step 6 in Section 4.0 of EOP The licensee's representative stated that they will evaluate the need for revising this step and the step in EOP In Step 7, a 11 Note 11 should be added to have the auxiliary operator start the 11 8 11 air compresso The licensee 1 s representative stated that they will evaluate the possible need for adding the not Step 14 needed to specify if the step was referring to the main feed line, the auxiliary feed line, or any feed lin The operators were confused on thi The basis document stated main feed line, but it appeared that the step should be applicable to a~y feed lin The licensee 1s representative stated that they will evaluate the need to clarify this poin The inspectors questi~ned if EOP 8.0 would still be applicable if in Step 16.a.i a PCP is operatin This could have been clarified by adding the word 11 verify 11 after the word 11THEN 11, or replace 11 THEN

with 11 AND.

The licensee 1s representative stated that the first part of this statement will be retained because it ii their standardized SI throttling statemen The second part of the step will be corrected as note *

Acceptance criteria* for degraded pump or a break in an injection l~rie needs to be defined and addressed in Step 18~ The licensee 1 s representative stated that they will evaluate the possible need for re~olving this issue:

The logic of Step 24 should have been reverse to eliminate the 11 go to 11 statement, which transferred the operator to the next ste The licensee 1s representative stated that they will evaluate the need to

. revise this ste Step 32.a was redundant and should have been eliminate The licensee 1s representativ~ stated that they will evaluate the need to eliminate this ste The meaning of the 11 refer to 11 in Step 45 was different from that in Step 47. *This needed to be clarified at this point and t~roughout the procedure The licensee 1s representative stated th~t they wtl~

evaluate the need for revising the step and/or providing additional training on the meaning of the 11 refer to 11 statemen Step 51.j was not needed~* The licensee 1s representative stated that they would evaluate the need for eliminating this ste Palisades.did ~ot have an EOP operator action setpoint document, single*

source approved document from which EOP writers.and reviewers extract operator action parameter values (e.g., under adverse containment conditions, the pressurizer should be_ considered solid when board instrumentation reads X).

Instead, operator action ~etpoints and

supporting calculations had been merged into the individual EOP basis documents which serve primarily to document deviations between the GTG and the PST The license~ needed to create a single ~ource EOP operator action setpoint ~ocumen *

The licensee was unwilling to commit to resolution of this recommendatio Paragraph 6.4.1.3.2 defined the *Palisades safety functions.* The radioactive control safety function was not included in the definition nor was the safety function included in the EOP Supporting documentation noted the deviation is based upon installed radiation monitoring equipment and implementation of the Palisades Emergency Pla These items addressed accident assessment and dose red.uct io The licensee correctly stated that the direct radiation component of this safety function was addresse The indirect radiation component of the function was not treated because the GTG did not treat i The item was discussed in the PGP submission to NR The licensee did not commit to treat indirect radiation in the EOP ' -

.

,

ATTACHMENT III HUMAN FACTORS DEFICIENCIES The following human factors deficiencies were observed in the Palisades EOPs.-

These items are provided as specific examples of the general human factors concerns discussed in Section 8 of the repor.

Structure

.Ih EOP 1.0, Step 8 the format ~f contingency actions was inconsistent with the format used in previous step In previous steps, contingency substeps directly paralleled the instructional substep by the same

. alphanumeric designation, in Step 8, this convention was not use ~In EOP 4.0, pages 14 and 21, large blank spaces were left at the end of the page, which appeared to indicate the end of a section even thou~h related steps continued on the next page*.

EOP 5.0.contained 40 contingency actio~ steps and provided an example of how the procedures were heavily dominated by IF/THEN conditional statement.

Trans it ions

..

.

EOP 2.0, Step 15 required the operator tb dete~mine if PCP operating limits were satisfied, however, no reference was provided for these limit EDP 2.rr, Attachment 3, Step 2.c indicated the need for a special valve lineup *as a source of available feedwater.inventory;* however, no reference was provided for the valve lineup required for this mode of inventory

makeu *

During walkdown of EOP 3.0, the AO stated that he would refer to SOP 30 for guidance in performing the task required by Step 45; however, no r~ference to SOP 30 was provide The reference to EOP 4.o; Step 50.c identified substep (a) only, and did not identify the higher level step (50).

Since the reference immediately preceding this step (Step 50.b) was to Step 51, thi~ could have been misleadin In EDP 5.0, Attachment 5, Step 3, the reference to Section 7.6.1 of SOP 12 appeared to be incorrec Section 7.3.3 of SOP 12 appeared to be the*

correct referenc In EDP 5.0, Step 33, several interfacing procedures were referenced; however, the step did not identify the purpose of the reference (e.g.,

to energize a bus or regain power).

The applicable sections of the referenced procedures were not specified, ~or the order in which th~y should be implemente The reference to the Technical Data Book in EDP 5.D, Step 7 did not identify the applicable figure that was required for this ste EDP 6.0, Steps 20.c, 2D.d, and 25.c referred the operator to Attachment l, but did not specify the applicable section(s).

No reference was provided in EOP 8.0, Step 49.b.i to the applicable SOP that defined shutdown cooling entry conditions.* Component Identification The reference tb the ITC switch in EOP 3.0, Step 8.b was inconsistent with the actual labeling of the switch in the control room (labeled Backfeed).

Also, the position referred to in the procedure as 11cutout 11 was not consistent with the labeled position (transfer cutQut).

EOP 3.0, Step 13 was illustrative of instances where the format of the procedural references to comprin~nts was ndt consistent with the labeling

.conventions used in the plan EOP

Plant EOP PLANT

MV-WE008 MV-008WE MV-CD133 MV-133CD MV-WE050 MV-050WE MV-CD136 MV-136CD MV-WE007 MV-007WE MV-CD138 MV-138CD MV-WE026 MV-026WE MV-FP119 MV-119FP MV-SW124 MV-124SW MV-120 MV-120FP MV-FP180 MV-180FP The feference to the block isolation pushbutton in EOP 5.0, Step 5 was inconsistent with the actual labeling of the switch in the control roo EOP 5.0, Attachment 5, Step 8 directed the operator to check closed the blowdown tank vent valves (MV-MW158 and MV-M5160); however, MV-MW158 was the flash tank vent valv During the walkdown of EOP 5.0, Step 2.a.3, the RO had difficulty

locating Stack Gas Monitors RIA-2318 and RIA-231 Since these monitors were backups that were infrequently used and located on a back panel

separate from*primary monitors, a notation should have been made as to their locati.o *The numerous component references on containm~nt isolation checklist in EOP 6.0, Attachment 7 were inconsistent with labels in the control roo Th~ bus number in ONP 2.1, Step 1.2.a should have been added behind the br~ake~ number (e.~., 152-305 at Bus IE) to aid the AO in locating the breake.

Clarity of Instructional-Steps EOP 2.0, Step 2 was unnecessary in that the operator would not be directed to this procedure unless safety function criteria had been me If the operator observes the logic of EOP 2.0, Step 3, he will never get to Step If these steps ~ere considered simultaneously, they become contradictory. *

The seq~ence in EOP 3.0, Attachment 6, Steps 2, 3, and 4 needs rewordin If Step 2 instructioh (to open PCV-0632) was followed, then the Step 4-condition (IF PCV-0632 is closed)* would never be applicabl Step 3 was unnecessar fOP 4.0. was illustrative of the extensive use of continuous and nonsequential steps (17 and 54 respectively) in the Palisades EOP The designation of such stepi did not always appear to be consisten Operators expressed differing opinions on when these steps should or could be performed. Although sequential steps have a marginal line for use in place keeping, no effective means existed to track unaccomplished nonsequential actions nor was there a single page display to use as a reminder of continuous action step The placement of Step 12 in EOP 4.0. interrupted the flow of the related step.

Use of Logic Terms The conditional phrase 11 IF at least one PCP operating 11 in EOP 1.0)

Step 8.c, was improperly provided as a footnote and was also used improperly to indicate a plant condition when no operator action was require EOP 2.0, Steps 7~ 8, 10; and 11 were illustrative of incorrect highlighting of terms when they were not used in a conditional logi~

statemen This was a general problem found in all EOP EOP 2.~, Step 19, implied a desired plant condition IF certain conditions were met rather than instructing the operator to perform specific action

(e.g.,

11 THEN go to GOP 9, Section __ to initiate plant cooldown 11 ).

WHEN/THEN logic terms were us~d in EOP 3.0, Attachment 1, Step 7.. c.ii to~indicate plant conditions for acceptance criteria rather than contingent operator action EOP 4.0, Step 11 this step used layered logic statement The condition stipulated in Substep C was repetitive of ~he condition stipulated in the higher level ste EOP 4.0, Step ~7 was an example of an inappropriate use of IF/THEN logic terms since this was not an action statemen EOP 4.0, Steps 28/29 and 30/31 used inconsiitent format in presenting IF/THEN and IF/NOT statement Steps 28 and 29 presented IF/NOT conditions as a separate step, while Steps 30 and 31 pres~nted IF/THEN and IF/NOT conditions. as part of the same ste.

In-Plant Labeling and Accessibility EO~ 5.0, Attachment 8, Step 3, required the AO to operate Valve MV-DRW809; which was located at a height ~equiring a ladder for some AO~ to reac No ladder was, provided in the are EOP 5.0, Attachment 5 referred to SOPs 12 and 1 Valve MV-VAS915 and Temperature Indicator TI-8929 called out in the SOPs were not labeled:

Also, the TI located near TI-8929 was not labele ONP-20, Step 4.2.c re~uired the use of a ladder, however, the ladder that was provided outside of Swithchgear Room lC was too long for this applicatio ONP~20, Step 4.6.l required the use of a small ladder, which was not available in the immediate are.

Caut i ans and Notes The caution in EOP 3.0, Step 21 related only to Substep b, but was not so indicate A note should have been added to EOP 5.0, Step 20.c which would alert the health physics technician to the requirement for using a monitoring instrument with a long handle or extension, because the steam lines to be monitored were approximately 10 feet above floor leve The note in ONP 20, Step 4.5.was provided on the page prior to the associated step, and the note and caution provided for this step implied operator instruction The note in EOP 5.0, Step 47 contained instructions for plant restart that were not necessary or appropriate for the operator while in this EO.

Vocabulary Operators differed in their interpretation of the statement "Verify qualified CHs" in EOP 1.0,- Step The number of qualified CETs they would check varied from as few as one to as many-as five, and some said they would printout all of the *value The location of the core matrix from which they were to be selected (some from center or near center, some from perim~ter) was also a source of confusio Some operators.interpreted the statem~nt "Auxi 1 i ary feedwater fl o available" as meaning that flow must be present to meet this condition, and some interpreted it as meaning that power to the auxiliary feed pump breaker was sufficien Some operators defined "Uncomplicated reactor trip" as a trip for which all left hand column steps (conditions of EOP 1.0) had been satisfie Some operators interpreted the statement "Service water available" in EOP 3.0, Step 8, to mean being supplied, while others interpreted it to mean 11 ca*n be supplied if necessary."

The "Warning" in EOP 3. 0, Step 12, was not defined in the Writer 1 s Guide, nor was it addressed in lesson plans for operator trainin Many operators indicated that they did not know the meaning of the term

"integrated" in the caution step of EOP 3.0, Step 1 The term "Delta T" in EOP 4.0, Step 42, should be defined for clarity since it does not refer to the usual Th minus Tc.

. Operator Aids The first decision block (PCS SUBCOOLING RISING OR EITHER S/G PRESSURE

< 700 psia?) on page 6 of EOP 1.0, Attachment 1, was identified by operators as being confusing because of the 11 0R 11 and that 11 <

11 had recently been changed from 11>

11 *

This block would be clearer if split into 2 blocks, which would avoid the OR conditio *

,,

The conditional statement on page 8 of EDP 1.0, Attachment 1, included as a note should have been included as a decision block(s) in the -

flowchart structur The pre~entation of the graph in EDP 4.0, Attachment 8, page 1, was not consistent with the convention followed on_ other graphs in this attachment (e.g., input variable on the X axis and output variable on the Y axis).

When questioned, there was a discrepan~y among o~erators on how to use 11 non-sequential 11 step Some operators stated that these *steps could be performed at any time, while others stated that the procedure must be completed up to that step before the step could be completed in a 11 non-sequential manner.

Several operators were confused as to the difference between a 11 non-sequential 11 step and a 11continuous 11 ste The licensee stated that 11 non-sequential 11 and 11 continuous 11 *steps may be performed at any tim The licensee will evaluate the need for such a large number of 11 non-sequential 11 step Alarm panels were indexed in different manne~s on different parts of the control board One set of *panels was indexed from the top left, left to right, and top to botto Other panels were indexed from the

~op left, top to bottom, and left to righ The licensee' representative stated that the alarm resp6nse manuals were written in such a manner as to preclude any performance problems associated with al ternctte indexing method The 1 i censee did not pl an to modify the alarm indexing schem *

ATTACHMENT IV VERIFICATION/VALIDATION DEFICIENCIES Sp~cific detici~hcies regarding of the V&V prbgram are provided belo The licensee committed to evaluate the identified programmatic weaknesse Some examples of V&V weaknesses as evidenced in the EOP procedures are included as illustration It should be _noted' that the deficiericies i.n Attachment II ahd III were not identified during the Pali.sades V&V and, therefore, generally constitute V&V weaknesses as well as technical or human factors item It is also noted that NUREG-1358 was iss~ed shortly before this inspection and the licensee did not have time to review and incorporate its guidance into the EOP upgrade progra Programmatic weaknesses: V&V was not required and had not been accomplished on the EOP ~upporting procedures to which the EOPs refer or transfe * _The V&V process instructions did not require an independent revie Admiriistrative Procedure 4.06, Sections 6.6 and 6.7 described technical reviewer and validation team staffing requirements, but did not include a requirement that these personnel be inde~endent of the EOP procedure

writer *

3. * Administrative Procedure 4.06 contained reference to technical notebook(s).

The notebooks were no longe~ being use *

Administrative Procedure, Section 6.6 verification requirements did not extend into the plant; only control room walkthroughs were require.

Validation requirements could be met with only simulator validation and without a control room walkthroug To the extent that the simulator differed from the main control room, such a validation may have been 1naccurat.

Paragraph 6.7.2 listed validation methods in the order of simulator, tabletop, and walkthroug This order inferred that the table-top would be preferred to walkthroug.

Paragra~h 6.7.3~a.2 indicated the operations superintendent was responsible for determining if validation was require A minimum requirement for validation should have been stated (e.g., all EOP numbered revisions will be validated).

Specific V&V comments:

EOP * Steps 13 and 24:

Nomenclature differences between plant labels and the EOP were found in the case of 7 valve EOP labeling was MV-WExxx; plant labeling is"MV-xxxWE in Step 13 and MV-CDxxx vs MV-xxxCD in Step 2.

Step 59 b.3.e:

The breaker was normally racked ou The procedure.did not require rack i EOP 4. 0 Steps 4 and 5 were incorrectly sequenced; Step 5 should have appeared first, which was the only way the direct transfer could be made to EOP As written, the operator who had misdiagnosed the LOCA would be delayed in a loop until he was directed to EOP 9.0 by the status check.

Step 13d:

This step should have been related tci PCP CCW flow or particular valves, not to 11 any CCW v.alve isolation valve closed.

It was possible

to have many CCW isolation valves closed without loss of flow to the PCS pump.

Step 49.e:

Valves were transferred to an ~lternate controlle~, not an alternate suppl.. PSTG DEV:

GTG Supplementary Inst~uction 6 required that the operator should be-cautione*d against premature manual RAS initiation, which could lead to insufficient sump inventor No caution was contained in the EOP, no deviation existed, and the item-was not specifically addressed in EOP support trainin.

Attachment 2 pump curves:

Step 29.b labeled the curves as minimum flow requirement The curves *did not indicate minimu In addition, since the four individual meteis upper li~it was 250 gpm, the curves for two pump operation should have stopped at 1000 gp.

Step 12 was interspersed between St~ps 11. c and 13, which evaluate and maintain CCW to the PCS pump.

Step. 50. c:

The second 11 go to 11 transfer should have been to Step 50..

Step 77.f:

The word acceptable was used without definitio Walkdown

_operators were not certain what was acceptabl.

Attachment 8, graph on page 1:

This presentation was contrary to the standard convention, which was followed for all other graphs in this procedure (e.g., input variable on the X axis and output on the Y axis).

The licensee agreed to evaluate this ite EOP 5. 0 SOPs 12 and 13 were rarely used; equipment location was not specifie *

c Some plant components were unlabeled; lack of labeling contributed to delays during AO walkdowns (e.g., MV-VAS 915 and TI-8929.were missing labels; an ID number marker near MV-VAS 915 appeared to read 913) A ladder was required to evaporator boiler roo searching for the ladder delay EOP respons reach Steam Traps ST-8641 and 8928 in the The nearest ladder was two rooms away and contributed to walkdown delay~ and would also Component referencing was sometimes inconsistent (e.g.; MV-118FW was referenced in the procedure as MV-F118; MV-RWS120* as MV-RW 120) Attachment A referred to Step 7.6.1 in SOP 12; the proper step was 7..

Steps 5 and 6 of Attachment 8 identified inlet ~nd outlet valves for Tanks F59 and F6 However, the identification was not uni~ue to particular tan Administrative Procedure 4.06 Paragraphs 6.2.1 and 6.2.2 defined the Palisades PSTG, which consisted of four administrrative procedures, the GTG, the F&TA report, Technical Specifications, existing EOPs, the FSAR, EOP related licensing letters, and as-build plant drawing This was about 30 seperate publications which would stack over 5 feet hig Portions of the PSTG were neither plant specific (e.g., CEN-152)

nor technical (e.g., four administrative procedures, the Writer 1 s Guide, FT&A)~

As a result, the PSTG was an unweildy dotument which was extremely cumbersome to use effectivel *

The NRt team ~oted that this deficiency had little impact on success of the program, principly because the entire development program was accomplished by a few well qualified individuals whose span of control extended to all facets of the progra However, in the event of a significant proces~ or staffing change, the lack of a consolidated PSTG could inhibit the progra '"

...

ATTACHMENT V *

Persons Contacted Consumers Power Company G. Slade, Plant General Manager J. Lewis, Technical Director

R. Orosz, Engineering and Maintenance Manager

R. Rice, Operations Manager

W. Beckman, Radiological Services Manager -

J. Hanson, Operations Superintendent H. Tawney, Mechanical Maintenance Superintendent K. Osborne, Projects Superintendent

R. Brzezinski, I&C Superintendent K~naga, Radiation Protection Manager

C. Kozup, Licensing Engineer J. Brunet, Licensing Analyst

D. Malone, Licensing Analyst L. Dicks, General Simulator Instructor R. Massa, Shift S0per~isor 8. Dusterhoft, Operations Support Coordinator L. Schmi edeknec-ht, Supervisory Instructo C. Oberlinei Senior In~tructor D: Armstrong, General Simulator Instructor D. Rogers, Training Administrator P. Schmidt, Senior Nuclear Instructor J. Lewis, Auxiliary Operator G. Beechan, Control Operator J. Sherman, Auxiliary Operator S. Cogswell, Control Operator R. Stanton, Control Operator G. Perkins, Control Operator D. Peterson, Operations Support Coordinator (Training)

T. Watson, Senior Nuclear Operations Analyst G. Alkire, Senior Reactor Operator S. Cogswell, Reactor Operator

J. Schwanekamp, Auxiliary Operator R. Shaffer, Auxiliary Operator..

8. Kubacki, Senior Reactor Operator D. Retton, Auxiliary Operator M. Holbein, Shift Supervisor M. Kane, Shi ft Supervisor J. Ford, Control Operator 1 J. Waskiewicz, Control Operator 8. Bensen, Shift Supervisor

G.. Groff, Reactor Operator T. Bauer, Auxiliary Operator

t.

Nuclear Regulatory Commission (NRC)

'

E. Swanson, S~nior Resident Inspector G.. Wright, Chief, Operations Branch, Region III

Denotes some of those present at the Management Interview on August 4, 198

v t e Inspection Report - Palisades - 1989019
80 \| 81 \| 82 \| 83 \| 84 \| 85 \| 86 \| 87 \| 88 \| 89 \| 90 \| 91 \| 92 \| 93 \| 94 \| 95 \| 96 \| 97 \| 98 \| 99 00 \| 01 \| 02 \| 03 \| 04 \| 05 \| 06 \| 07 \| 08 \| 09 \| 10 \| 11 \| 12 \| 13 \| 14 \| 15 \| 16 \| 17 \| 18 \| 19 \| 20 \| 21 \| 22 \| 23 \| 24 \| 25 \|
1989 Quarterly Integrated 1Q (0) 2Q (0) 3Q (0) 4Q (0) Assessments Mid Cycle End of Cycle 7(0) 9(0) 10(0) 11(0) 12(0) 13(0) 14(0) 16(0) 17(0) 18(0) 19(0) 21(0) 22(0) 23(0) 24(0) 25(0) 26(0) 27(0) 28(0) 29(0) 30(0) 31(0) 32(0) 33(0) 34(0) Security Operator Exams Emergency Planning Other

IR 05000255/1989019

Text

Enclosures:

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