IR 05000255/1993001
| ML20058G082 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 12/01/1993 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20058G079 | List: |
| References | |
| 50-255-93-01, 50-255-93-1, NUDOCS 9312090094 | |
| Download: ML20058G082 (7) | |
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PALISADES SALP 12 REPORT NO. 50-255/93001 1.
INTRODUCTION The SALP process is used to develop the NRC's conclusions regarding a licensee's safety performance. The SALP report documents the NRC's observations and insights on a licensee's performance and communicates the results to the licensee and the public.
It provides a vehicle for clear communication with licensee management that focuse: on plant performance relative to safety risk perspectives. The NRC utilizes SALP results when allocating NRC inspection resources at licensee facilities.
This report is the NRC's assessment of the safety performance at Palisades for the period April 1, 1992, through October 30, 1993.
An NRC SALP Board, composed of the individuals listed below, met on November 12, 1993, to review the observations and data on performance and to assess performance in accordance with the guidance in NRC Management Directive 8.6, " Systematic Assessment of Licensee Performance."
Board Chairperson T. O. Martin, Deputy Director, Division of Reactor Projects, RIII Board Members W. L. Axelson, Director, Division of Radiation Safety and Safeguards, RIII W. Dean, Acting Director, Project Directorate III-1, NRR W. L. forney, Deputy Director, Division of Reactor Safety, RIII II.
Performance Ratings The current SALP process will assess performance in four functional areas instead of the previous seven. The four areas are Operations, Maintenance, Engineering, and Plant Support.
Safety Assessment / Quality Verification will be considered for each of the four functional areas rather than as a separate functional area. The Plant Support functional area will assess radiological controls, emergency preparedness, security, chemistry, and fire protection.
Three category ratings (1, 2, and 3) will continue to be used in the assessment of performance in each functional area.
Performance trends, improving or declining, have been eliminated as a part of the ratings.
9312o90094 931201 PDR ADOCK 05000255 G
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Current Functional Areas and Ratings:
Functional Area Rating This' Period
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Plant Operations
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Maintenance
l Engineering
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Plant Support
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Previous functional Areas and Ratings:
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Functional Area Rating Last Period Plant Operations
l Maintenance / Surveillance
l Engineering / Technical l
Support
Radiological Controls
Security
Safety Assessment / Quality
Verification III.
Performance Analysis A.
Plant Operations Performance in plant operations was adequate but declined significantly from the previous SALP period. The assessment period began while the plant was in the Cycle 9 refueling outage and ended with the plant in startup activities following the extended Cycle 10 refueling outage.
In general, the plant ran smoothly during routine power operations. However, the 1993 refueling outage revealed weaknesses in several areas that are discussed below.
Plant management involvement in operational activities was mixed. Shift supervision regularly toured the plant to _ check system lineups, work progress and plant status. The planning and practice runs for the loading of the dry cask storage were we?1 executed which contributed to the successful loading of two dry casks in May 1993.
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L Licensee management exhibited adequate safety focus on Palisades' operations
as evidenced by good equipment / system status control during power operations as well as shutdown conditions. The outages were well planned with an i
effective shutdown risk management program.
Pre-job briefings were j
strengthened during the refueling outage in response to earlier problems.
i However, the fuel failure discovered in July 1993 revealed that conservative
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decisions were not made concerning earlier chemistry data indicating possible
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I fuel failure in the core.
Management expectations were not always clearly conveyed to the working levels and work controls for plant staff were not always effective. These were contributing factors in the lifting of a control rod with the reactor vessel
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head and in the excessive cooldown rate from hot shutdown conditions after a
steam leak from the pressurizer was detected. Management expectations were j
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l likewise not effectively implemented to carefully control the refueling
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contractor's performance while moving the upper guide structure during the
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recent outage. The refueling contractor did not follow procedural j
requirements for use of the load cell and the associated readout devices during this evolution.
Problems with control of contractors were noted in the
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previous outage, and the corrective actions instituted by management were not i
fully effective in preventing re:urrence.
The plant operated smoothly during most of the routine power generation period; however, operator performance was weak during infrequently conducted activities.
In early 1993, there was an increase in the number of errors due to inattention to detail. Operators also occasionally failed to follow procedures.
Examples included the inappropriate use of the " Override Key Switch" to bypass the limit switches and programmed operating zones of the spent fuel handling machine without prior shift supervisor approval, and failure to follow a procedure for emergency diesel generator output breaker operation.
In general, communications between the operations staff and other departments were good, as demonstrated by the control of plant evolutions in response to equipment problems.
However, ineffective internal communications within the operations staff appeared to be a contributing cause to events such as undesirable exercising of control rods, failure to uncouple all control rods befece lifting the vessel head, and violation of the primary system cooldown rate limit.
Initiatives undertaken in the latter part of_the period to ctvrect operator performance problems appeared to be-positive but it was too early to assess the results. Additionally, the Nuclear Performance Assessment Department (NPAD) was not a significant contributor in identification and resolution of problems in the operations area.
The majority of the plant programs and procedures for the operations area were good.
Recent examples included the detailed procedures fnr loading the spent -
l fuel assemblies in the dry casks and placing the loaded casks onto the storage pads which contributed to the successful evolution.
Some weaknesses were
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noted in the primary system cooldown procedures, the procedures to evaluate fuel performance, and the control rod uncoupling procedure. The operators-demonstrated good knowledge of Palisades plant design erJ had a high pass rate on the initial and requalification license examinations.
However, the -
licensed operator training program had not generated a scenario, as previously committed, to evaluate the operator's response to a faulted steam generator (SG) with concurrent failure of the intact SG main steam isolation valve and resultant blowdown of both SGs.
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The performance rating is Category 3 in the area of operations.
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Maintenance
i Performance in the maintenance area at Palisades was good but declined from
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the last SALP period primarily due to inconsistencies in implementation of
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management expectations and continued problems with the control of
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-contractcrs. Many activities reflected high quality planning, scheduling, l
coordination and execution. Work prioritization was accurat and effectively j
implemented.
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.l Management support and oversight of maintenance functions were good.
'j Effective daily coordination meetings helped assure that adequate resources,
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proper direct oversight, and appropriate considerations for safety were typically applied. Management monitoring and control of outage maintenance j
activities involved dedicated containment and other outage managers.
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outage testing was well controlled and did not result in any inadvertent
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safety equipment actuations. This was an improvement from the two previous l
outages. The work backlog was well managed and worker overtime, though j
increased due to the extended refuelir.g outage, was kept within NRC
guidelines. Work was appropriately prioritized; however, there were cases l
when full advantage was not taken of equipment outages, therefore, some minor
deficiencies were long-standing.
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For the most part, effective maintenance resulted in excellent equipment
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reliability and in improved equipment performance. Material condition of the
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plant was good. However, there were a few notable long-standing equipment
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deficiencies, such as reactor head vent system valve leakage, and faulty nuclear power computer indication.
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Programs and procedures were in place to properly control and direct j
maintenance activities throughout the plant.
Improvements were made in the
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Inservice Inspection Program.
However, there were a few examples of
maintenance procedures that lacked necessary detail, breadth of coverage, or
quality verification aspects.
Also, some test procedures lacked necessary j
detail or did not fully implement programmatic requirements. These were
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promptly corrected when identified. Overall, the new " peer" inspection
process for quality verification was adequate. There were a few problems j
transitioning to the new program and there were some omissions due to non-
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conservative interpretation of applicable regulatory requirements. There was
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a good focus on preventive maintenance (PM), including a commitment to avoid
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deferral of PM.
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I The skill level of maintenance personnel was good and rework was infrequent.
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However, whm adverse conditions developed gradually, or were judged minor,
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they were not always identified in a timely manner.
Problems such as failure-l to follow procedures and poor work practices persisted with contractors and
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licensee workers not directly assigned to the station, a weakness noted in the l
last SALP period.
NPAD had not contributed effectively to resolving this
issue.
Inservice Inspection (ISI) program weaknesses identified during the
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previous appraisal period were addressed and resolved, but ISI results this SALP period were not conservatively evaluated in the case of a pressurizer relief valve piping weld indication.
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The performance rating is Category 2 in the area of maintenance.
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Engineering Performance in the engineering area was acceptable but declined from the i
previous SALP period. The unavailability of some design information and an i
incomplete understanding of plant design continued to have a negat#ve impact
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in resolving identified problems. Significant weaknesses were not ?d in
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several plant modifications.
However, your system engineers werr observed to
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be involved and responsive to the day to day operational and maintenance
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issues.
There were a number of weaknesses in management involvement and oversight of
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engineering activities. Management did not ensure that engineering activities
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were proactive and that all relevant information was evaluated before solutions to problems were proposed. An example of this was management's lack l
of oversight of failed fuel.
Some fuel vendor information indicated the
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potential for failed fuel, but it was not given proper consideration.
Management subsequently chose to perform limited inspections of fuel, which was insufficient to identify fuel cladding failures. Another example was the lack of management involvement in the initial stages of dry cask construction activities which was indicative of an over reliance on contractors without an
adequate review to provide confidence that activities would be accomplished in
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accordance with requirements.
The lack of control over contractors was a concern in the last SALP period. Continued problems in the equipment qualification (EQ) program were also attributed to weak management oversight.
l A lack of available design information and an incomplete understanding of plant design contributed to difficulties in resolving identified problems.
This was evident in the recurrence of problems in the Digital Electro--
l Hydraulic (DEH) control system and heavy reliance on contractors during system troubleshooting activities.
It was also evident in its impact on the modification program.
Examples include the inappropriate changeout of thermal i
overloads for engineered safeguards fans and the modification of an apparent
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"like for like" replacement of a spare 2400 volts-ac feeder breaker, performed l
through the use of a work order instead of through a formal design review.
Differences in the wiring of the replacement breaker resulted in an unplanned engineered safety features (ESF) actuation and an autostart of both Emergency Diesels.
However, the system engineering program exhibited good command of system operation and provided good support of maintenance, system testing, and
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other system support activities.
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Performance in the area of identification and resolution of technical issues was mixed. Weaknesses were noted in the initial evaluations associated with the pressurizer nozzle crack issue. However, once the existence of a through-wall crack was discovered during plant heat-up, the corrective actions were j
intentionally slow and measured and were considered to be thorough and comprehensive.
Similarly, previous corrective actions associated with stuck
fuel assemblies were ineffective, and a stuck assembly event occurred for the
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third time this SALP period.
System engineering involvement with emergent
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issues and support to other organizations was good, including responding to industry events and providing the necessary engineering support to resolve problems with motor operated valves, containment high pressure relays, and dry
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cask storage issues.
j Self-assessment activities were not effective in identification of problems i
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associated with refueling activities, and there was a lack of proactive Nuclear Engineering and Construction Organization (NECO) involvement in i
emergent issues. Also, self-assessments did not identify problems associated
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with the heavy reliance on contractors.
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The performance ratinn is Category 3 in the area of engineering.
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Plant Support i
Performance in the plant support area was considered to be good.
Efforts
related to dry cask storage, interdepartment communications and support to l
other organizations were strengths.
Self-assessments and resolution of technical issues, although adequate, were considered weak areas in plant
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support.
l There was a good focus on safety issues as evident by emphasis on auxiliary building housekeeping, the security program, the fitness-for-duty program, i
early implementation of new 10 CFR Part 20 radiation protection requirements,
-l dose trending, plant source term reduction, and actual emergency
classifications of plant events.
Efforts on overall dose reduction were good; i
however, an increase in personnel contaminations was noted due to some poor
worker practices. The security search program was noted to be weak regarding package and personnel searches.
Emergency exercise performance was good, but.
the use of small and non-dedicated office space reduced the effectiveness of i
the emergency response facility.
l Management involvement was very good. However, a significant weakness was noted in the nonconservative management decisions involving the chemistry analyses and the radiation survey indications of failed fuel. Ttere was strong support for the security program evident by the attention provided to the dry cask storage program. However, the results of Operational Safeguards
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Readiness Exercise (0SRE) drills indicated that contingency and tactical l
response was poor. The radiological protection, chemistry, and emergency
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preparedness programs also received strong management support, as evidenced by
broad based procedure and equipment upgrades. A reorganization of the
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Radiation Safety Department had a very positivt effect.
Self-assessments performed during the assessment period were adequate.
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emergency preparedness exercise critiques were very good and the assessments of the implementation of the new security access authorization program were i
good.
However, NPAD's change from an independent assessment organization to
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one that participates in correcting problems created a potential conflict of interest situation for the assessors in the radiation protection area.
i Observed deficiencies bat were corrected in the field were not documented.in
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audit reports.
The ineftScient tracking of assessment findings by both the radiation protection department and NPAD led to ineffective corrective
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actions. A weakly implement.ed security self-assessment program led to
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ineffective access controls and inconsistent operation of some alarm zones.
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Identification and resolution of technical issues was adequate. Assurance of habitability of emergency response facilities through ventilation system modifications was effectively completed. Controls to limit the amount of contaminated areas, with the exceptions of the spent fuel pool heat exchanger, and engineered safeguards rooms, were good. However, resolution of some-emergency preparedness issues lagged, and reliability of'the emergency plant radio system continued to be an ongoing problem.
Proactive actions were not always evident in the radwaste, chemistry, and transportation areas.
Identification of a major technical issue was lacking concerning a weak chemistry review of data indicating the possibility of failed fuel.
Support to other organizations was excellent.
Security and radiological support for the dry cask storage project and outage-radiological protection was excellent.
Interfaces with State and county officials on emergency planning issues were also excellent as evidenced by audit results and comments received at a recent meeting with State and county representatives.
Training in the plant support. area was generally good. The training of-radworkers and the emergency response organization were excellent while training of security force personnel was adequate.
The performance rating is Category 2 in the area of plant support.
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