IR 05000269/1993011
| ML15239A077 | |
| Person / Time | |
|---|---|
| Site: | Oconee  |
| Issue date: | 09/10/1993 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML15239A076 | List: |
| References | |
| 50-269-93-11-01, 50-269-93-11-1, 50-270-93-11, 50-287-93-11, 72-0004-93-01, 72-0004-93-11, 72-4-93-1, 72-4-93-11, NUDOCS 9310120376 | |
| Download: ML15239A077 (32) | |
Text
ENCLOSURE 5 ENCLOSURE FINAL SALP REPORT U. S. NUCLEAR REGULATORY COMMISSION
REGION II
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE INSPECTION REPORT NUMBERS 50-269/93-11, 50-270/93-11, 50-287/93-11 AND.72-4/93-11 DUKE POWER COMPANY OCONEE UNITS 1, 2 AND 3 AND INDEPENDENT SPENT FUEL STORAGE INSTALLATION FEBRUARY 2, 1992 THROUGH MAY 1, 1993 9310120376 930910 PDR ADOCK 05000289 GPDR
was also determined to be applicable to Units 1 and BASIS:
This change is for clarit occurred.... loss of occurred....loss of one of the the Keowee Hydro Keowee Hydro unit Statio BASIS:
During this event only one of the two hydro units was los In... two initial and In...
one initial (which included three requalification two retakes) and one requalification examinations.......
BASIS:
This change provides the correct number of initial and requalification examinations administered during this assessment period. Two retake examinations were administered during the initial examinatio licensing....
the Station Blackout and Keowee issues, licensing activities.............
BASIS:
This change is to capture an additional meetin ENCLOSURE INITIAL SALP REPORT S. NUCLEAR REGULATORY COMMISSION
REGION II
SYSTEMATIC AS SSMENT OF LICENSEE PERFORMANCE INSPEC ON REPORT NUMBERS 50-269/93-11, 50-2 /93-11 AND 50-287/93-11 DUKE POWER COMPANY OCONEE UNITS 1, AND 3 FEBRUARY 2, 1992 THROUGH Y 1, 1993
actively participated in the resolution of problems. Component engineering provided good support to maintenanc Engineering support for the resolution of other emerging issues, not identified as requiring immediate corrective action, was sometimes deficien Examples of problems noted included: (1) the failure to perform a safety evaluation for a temporary modification (installation of an electrical jumper on radiation monitor interlock to Valve 2LWD-2);
(2)
the use of incorrect design drawings in the completion of a plant odification (resulting in a reactor trip); (3)
an inadequate gineering evaluation of the operability of a letdown storage tank ch ck valve; (4) failure to take prompt and adequate corrective actions for low indicated service water flow through the 3B Low Pressure Inje ion (LPI) Coolers; and (5)
failure to correct the MG-6 testing defici cy after identification during Keowee Unit 2 testin An Elect 'cal Distribution System Functfial Inspection revealed problems i testing, design analyses; and design basis documentatio Similar pro ems were also found in the Oconee emergency AC power source. Thes problems resulted in part from the lack of a thorough understanding the design basis of the site's electrical distribution syste Operator training s effective. Improvements were noted in the initial training of license operator This good performance was indicated by the successful comple on of all seven candidates nominated for licenses in January 199 The c ndidates exhibited good communications and interactions during thei simulator examinations, but had a generic weakness in radiation pro ctio The previously noted problems with simulator fidelity to the p nt have been rectifie The performance of requalification was satisfac ry. During the June 1992 requalification examination, five of six crews and 22 of 24 operators passe Weaknesses noted included the c tent and construction of the written test and poor or improper cuing ring the job performance measure This was in contrast to the strong erformance of facility evaluators during the previous assessment peri.
Two Severity Level 4 Violations were i ntifie.
Performance Rating Category: 2 Board Recommendations None
actively participated in the resolution of problems. Component engineering provided good support to maintenanc Engineering support for the resolution of other emerging issues, not identified as requiring immediate corrective action, was sometimes deficient. Examples of problems noted included: (1) the failure to perform a safety evaluation for a temporary modification (installation of an electrical jumper on radiation monitor interlock to Valve 2LWD-2);
(2) the use of incorrect design drawings in the completion of a plant modification (resulting in a reactor trip); (3) an inadequate engineering evaluation of the operability of a letdown storage tank check valve; (4) failure to take prompt and adequate corrective actions for low indicated service water flow through the 3B Low Pressure Injection (LPI) Coolers; and (5) failure to adequately test the MG-6 relays to verify operability. After the development of an appropriate test procedure for testing the MG-6 relays, a long standing operability problem was identifie Although the Electrical Distribution System Functional Inspection revealed no inoperable systems and provided adequate assurance that the electrical system will perform as intended, it also revealed problems in testing, design analyses, and design basis documentation. Similar problems were also found in the Oconee emergency AC power source. These problems resulted in part from the lack of a thorough understanding of the design basis of the site's electrical distribution syste Operator training was effective. Improvements were noted in the initial training of licensed operators. This good performance was indicated by the successful completion of all seven candidates nominated for licenses in January 1993. The candidates exhibited good communications and interactions during their simulator examinations, but had a generic weakness in radiation protection. The previously noted problems with simulator fidelity to the plant have been rectified. The performance of requalification was satisfactory. During the June 1992 requalification examination, five of six crews and 22 of 24 operators passe Weaknesses noted included the content and consteuction of the written test and poor or improper cuing during the job performance measure This was in contrast to the strong performance of facility evaluators during the previous assessment perio Two Severity Level 4 Violations were identifie.
Performance Rating Category:
2 Board Recommendations None
Superintendent Operations, to Superintendent Work Control and Mr. G. '.
Rothenberger, former Superintendent Work Control, to Superintendent fperatio There were three refueling outages during this assessment period. Refueling outages were completed in March 1992 for Unit 2, September 1992 for Unit 3, and January 1993 for Unit 1.- These outages were satisfactorily completed with o major problems. However, the Unit 3 refueling outage required extensive d ontamination activities due to the contamination which occurred inside Uni 3 Containment following the November 23, 1991, break of a 3/4-inch tubing conn tor on the Reactor Coolant System. During the Unit 1 refueling outage, a larg r than normal number of degraded steam generator tubes were identified which w e required to be plugged. This was attributed primarily to revised tube plug ing criteri In September 1992, the licensee determined that both trains of the Units' 1 and 2 LPI sys m were inoperable. The cooling water flow of the LPSU system through the LP heat exchangers were found to exceed the manufacturer's specification he power level for both units was reduced to approximately 10 percent and mo fications were made to reduce the flow through the heat exchangers to meet e manufacturer's specification On October 19, 1992, d ing maintenance activities, a loss of off site power occurred for Unit 2 whi was followed by a subsequent loss of the Keowee Hydro Statio Since t Is event, the licensee has placed the Keowee Hydro Station under the Oconee m agement and has implemented a number of procedure changes to improve the relia ility of the emergency power supply for the Oconee Statio Direct Inspection and Review ctivities In addition to the 36 routine NRC ins ctions and two initial and three requalification examinations performed t the Oconee facility, the following three special inspections were conducte December 9, 1991 February 21, 1992 Shutdown isk Inspection October 20 - 28, 1992 Augmented I pection Team (AIT) Loss of Off-site AC P er Supply January 25 - March 5, 1993 Electrical Distr ution System Functional Inspection (EDSFI Escalated Enforcement Activities Orders None Civil Penalties (CP)
Two Severity Level III problem violations (IR 91-32/EA 91-167 were issued on February 3, 1992, involving ten specific violations lated to the degradation of the decay heat removal event of September 7, 91 and
Superintendent Operations, to Superintendent Work Control and Mr. G. Rothenberger, former Superintendent Work Control, to Superintendent Operatio There were three refueling outages during this assessment period. Refueling outages were completed in March 1992 for Unit 2, September 1992 for Unit 3, and January 1993 for Unit 1. These outages were satisfactorily completed with no major problems. However, the Unit 3 refueling outage required extensive decontamination activities due to the contamination which occurred inside Unit 3 Containment following the November 23, 1991, break of a 3/4-inch tubing connector on the Reactor Coolant System. During the Unit 1 refueling outage, a larger than normal number of degraded steam generator tubes were identified which were required to be plugged. This was attributed primarily to revised tube plugging criteri In September 1992, the licensee determined that both trains of the Units' 1 and 2 LPI system were inoperable. The cooling water flow of the LPSW system through the LPI heat exchangers, during a postulated design basis accident, could have potentially exceeded the manufacturer's specifications. This was discovered on a test performed on Unit 3 and was also determined to be applicable to Units 1 and 2. The power level for both units was reduced to approximately 10 percent and modifications were made to reduce the flow through the heat exchangers to meet the manufacturer's specification On October 19, 1992, during maintenance activities, a loss of off site power occurred for Unit 2 which was followed by a subsequent loss of one of the Keowee Hydro units. Since this event, the licensee has placed the Keowee Hydro Station under the Oconee management and has implemented a number of procedure changes to improve the reliability of the emergency power supply for the Oconee Statio Direct Inspection and Review Activities In addition to the 36 routine NRC inspections and one initial (which included two retakes) and one requalification examination performed at the Oconee facility, the following three special inspections were conducted:
December 9, 1991 February 21, 1992 Shutdown Risk Inspection October 20 - 28, 1992 Augmented Inspection Team (AIT) Loss of Off-site AC Power Supply January 25 - March 5, 1993 Electrical Distribution System Functional Inspection (EDSFI) Escalated Enforcement Activities Orders None
the over-pressurization of the LPI system piping on September 19-20, 1991. ($125,000) Although both of these events occurred during the previous assessment period, the violations were issued-during this assessment period on February 3, 199 A Severity Level III violation (EA 92-211) was issued on December 28, 1992, and involved the failure to take adequate corrective action to esolve a reduced Low Pressure Service Water System flow condition t ough the Unit 3B Low Pressure Injection system cooler. ($100,000)
The licensee requested mitigation of the civil penalty. Subsequent to this ssessment period, an order to pay was issued which the licensee compli wit Managemen Conferences February 5, 92: A meeting was held in Region II for Duke to discuss the items iden fied during the Design Basis Documentation Program evaluation of th Oconee electrical systems and the corrective actions initiated on the i entified problem June 24, 1992: A mee ng was held in Region II for Duke to discuss the shutdown risk procedure to be implemented for future Oconee refueling outages. Also, discusse were Duke's Problem Investigation Program, procedure adherence and co iguration control programs at Ocone July 17, 1992:
An enforceme conference was held in Region II to discuss the circumstances assoc ted with the May 8, 1992, Unit 1 reactor trip in which one of the o required Emergency Feedwater System flow paths was not operable and the operation of Unit 1 from May 11 through 24, 1992, with only one of t two Emergency Feedwater System flow paths operabl September 17, 1992: A meeting was held a the Oconee facility to discuss the operation, management and maint ance of the Keowee Hydro Statio November 24, 1992: An open enforcement conferen was held in Region II to discuss the circumstances associated with the mspositioned valve in the Unit 3 Low Pressure Service Water Syste March 29, 1993: A meeting was held at NRC Headquarters to discuss electrical issues at Ocone Several additional meetings were held with Duke Power throu out the assessment period to discuss a variety of other subjects i ing licensing activities, safety initiatives, Oconee's--self-assess nt, the Emergency Data System and the development status of a Babcox an ilcox digital module for use in the reactor protection syste Confirmation of Action Letters (CAL)
Following the October 19, 1992,.Unit 2 reactor trip and loss of power event, a CAL was issued to address the cause of the event. On October 26, 1992, a conference call was held and the licensee discussed enhancements to be made to the Keowee Hydro Station and Keowee
19 Civil Penalties (CP)
Two Severity Level III problem violations (IR 91-32/EA 91-167) were issued on February 3, 1992, involving ten specific violations related to the degradation of the decay heat removal event of September 7, 1991 and the over-pressurization of the LPI system piping on September 19-20, 1991. ($125,000) Although both of these events occurred during the previous assessment period, the violations were issued during this assessment period on February 3, 199 A Severity Level III violation (EA 92-211) was issued on December 28, 1992, and involved the failure to take adequate corrective action to resolve a reduced Low Pressure Service Water System flow condition through the Unit 38 Low Pressure Injection system cooler. ($100,000)
The licensee requested mitigation of the civil penalty. Subsequent to this assessment period, an order to pay was issued which the licensee complied wit Management Conferences February 5, 1992: A meeting was held in Region II for Duke to discuss the items identified during the Design Basis Documentation Program evaluation of the Oconee electrical systems and the corrective actions initiated on the identified problem June 24, 1992: A meeting was held in Region II for Duke to discuss the shutdown risk procedures to be implemented for future Oconee refueling outages. Also, discussed were Duke's Problem Investigation Program, procedure adherence and configuration control programs at Ocone July 17, 1992:
An enforcement conference was held in Region II to discuss the circumstances associated with the MAy 8, 1992, Unit 1 reactor trip in which one of the two required Emergency Feedwater System flow paths was not operable and the operation of Unit 1 from May 11 through 24, 1992, with only one of the two Emergency Feedwater System flow paths operabl September 17, 1992: A meeting was held at the Oconee facility to discuss the operation, management and maintenance of the Keowee Hydro Statio November 24, 1992: An open enforcement conference was held in Region II to discuss the circumstances associated with the mispositioned valve in the Unit 3 Low Pressure Service Water Syste March 29, 1993: A meeting was held at NRC Headquarters to discuss electrical issues at Ocone Several additional meetings were held with Duke Power throughout the assessment period to discuss a variety of other subjects including Station Blackout and Keowee issues, licensing activities, safety initiatives, Oconee's self-assessment, the Emergency Data System and the development status of a Babcox and Wilcox digital module for use in the reactor protection syste ENCLOSURE 5 ENCLOSURE FINAL SALP REPORT U. S. NUCLEAR REGULATORY COMMISSION
REGION II
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE INSPECTION REPORT NUMBERS 50-269/93-11, 50-270/93-11, 50-287/93-11 AND 72-4/93-11 DUKE POWER COMPANY OCONEE UNITS 1, 2 AND 3 AND INDEPENDENT SPENT FUEL STORAGE INSTALLATION FEBRUARY 2, 1992 THROUGH MAY 1, 1993
SUMMARY OF RESULTS Oconee was operated safely during the assessment period. This included improvement in shutdown operations. Effective command and control over plant evolutions was exercised. Weaknesses remained in configuration control and procedural usage. The previously established organizational structure impaired effective oversight of Keowee by nuclear operations. Following the loss of offsite power event of October 1992, Keowee was reorganized, and programs for operator standards and training were develope Performance in the radiological protection area was superior. The ALARA program remained strong. The water chemistry and the environmental and effluent monitoring programs were effectively implemented. The organization was stable, and the radiological training program was good. Deficiencies were identified with radioactive material labeling, area posting and adherence to radiological control area access procedure Preventive and predictive maintenance programs were effectively developed and implemented. These, along with management efforts to reduce existing backlogs of work requests and temporary modifications, improved plant equipment performance. Inadequate controls over maintenance and surveillance activities contributed to several operational events which included reactor trips and the October 1992 Loss of Offsite Power even Management commitment to the emergency response organization was evident as the program remained strong. The response team was aggressively exercised with numerous drills and challenging scenarios. Emergency facility equipment was well maintained, and a siren system upgrade was fully implemente The security program was well managed and supported. Personnel were effectively trained and knowledgeable of duties and responsibilitie Initiatives were taken to review fully all operability aspects of a support facility in order to provide appropriate security measures. Discrepancies were conservatively documented and addressed. Improvement was noted late in the assessment period with closed circuit television reliabilit Engineering provided good support for plant modifications, outages and maintenance. Engineering personnel were knowledgeable and demonstrated a high degree of ownership over their respective systems. Weaknesses existed in resolving emergent issues and with system flow model calculation Performance in the operator requalification program declined from the previous assessment period due to weaknesses in examination content and evaluator technique In the area of Safety Assessment/Quality Verification, performance was inconsistent. Management was thorough and conservative when addressing issues recognized as clearly safety significant and licensing submittal Corrective actions to improve shutdown risk and command and control of operating evolutions were effective. A questioning attitude towards suspect test results was not always evident, and management was slow to recognize the need for increased oversight of Keowee operation Overview Performance ratings assigned for the last rating period and the current period are shown belo Rating Last PeriodRating This Period Functional Area 8/01/90- 2/01/92 2/02/92 - 5/01/93 Plant Operations
2 Radiological Controls
1 Maintenance/Surveillance
1 Security
1 Engineering/Technical Support
2 Safety Assessment/
Quality Verification
2 II CRITERIA The evaluation criteria which were used to assess each functional area are described in detail in NRC Manual Chapter MC-0516, which can be found in the Public Document Room files. Therefore, these criteria are not repeated here, but will be presented in detail at the public meeting to be held with licensee management on July 28, 199 IV. PERFORMANCE ANALYSIS Plant Operations Analysis This functional area addresses the control and performance of activities directly related to operation of the facilit During the previous SALP assessment, weak or deficient operator attention and control of evolutions during outage conditions was identified. During this assessment period, command and control of operations activities improved particularly during shutdown condition Configuration control errors and mispositioned equipment events continued to occur. Procedural inadequacies, usage weakness and inattention to detail contributed to several operational event Although improvement was achieved in the area of command and control over licensed activities, there were occasions which demonstrated that continued efforts are needed. In one case a procedure review was inadequate when the task was inappropriately delegated. On another occasion, operators permitted maintenance activities during low power physics testing, which resulted in an inadvertent cooldow Operator response to transients and upset conditions was goo Prompt action by operators prevented over-pressurization of the quench tank during a system misalignment. Several transients requiring operator action were handled effectively. Operators generally demonstrated excellent knowledge of plant systems and processes. Fundamental watchstanding practices improved from last assessment period. Shift turnovers were thorough. Preshift meetings and mid-shift Operations Department update meetings provided effective communications to both operations personnel and other plant support groups. Log keeping was adequate, but amplifying details regarding evolutions were inconsisten Shift staffing exceeded Technical Specification requirements without the need of excessive overtime. Operators properly used Abnormal Procedures and Emergency Operating Procedures when require Operators were not required to have extensive knowledge of Keowee operations. This became evident during the loss of offsite power event in October 1992. The operators' response to and recovery from this event was complicated by the lack of appropriate procedural guidance and overall complexity of the various electrical power system interaction Adequate standards had not been established for Keowee operator performance, duties, responsibilities and knowledge levels. Keowee operations and management structure was subsequently reorganized to report to Oconee Nuclear Operations Departmen Performance standards for Keowee operations were established and implemented towards the end of this assessment period. Also, some limited training of Oconee operators on Keowee systems was initiated late in this assessment perio Configuration control and procedural adherence exhibited weaknesses that represented a continuation of problems identified during the last SALP period. Mispositioned equipment incidents continued to occur during this evaluation period. Failure to follow approved procedures occurred in several instances. In some cases procedural requirements and policies were not clearly understood by personne Procedural steps were inappropriately marked "Not Applicable" (NA) without a thorough review and resulted in a violation of Low Temperature Over-pressure Protection requirements and an inadvertent draining of a portion of the main feedwater system. Guidance on marking steps NA was implemented midway in the period and some improvements were note Other examples included the use of the wrong unit's procedure to calculate an estimated critical position and a failure to follow a procedure that resulted in misplaced fuel assemblies during refueling. In one instance, an Abnormal Procedure for restoring offsite power was considered inadequat Both operators and supervisory personnel exhibited a conservative approach to technical issues. The Operations Support Group was instrumental throughout the period in providing both technical and administrative support to the control room. Work control screening, outage scheduling and review, and procedure review and revision were also effectively performed by this group. The Operations Support Group was staffed primarily with licensed senior reactor operators (SROs) and reactor operators (ROs). The experience level of both control room personnel and the Operations Support Group were considered very hig Management continued to work toward the "black board" concept and improvement was noted by a reduction in the number of lit annunciators and nuisance alarms. Plant equipment labeling efforts have reduced the instances of wrong unit or wrong equipment events. Control room drawings were maintained legible, however, changes resulting from minor modifications were not always promptly reflecte Operator attention and control of evolutions during shutdown conditions improved from the previous assessment period. Management implemented changes to control room supervisory functions, and defined operator duties during shutdown conditions. These changes were in response to several significant events in the previous evaluation period. Control room decorum and professionalism improved. More formal communications resulted in a decrease in the number of events. The duties and responsibilities of the Operator at the Controls were revised to allow concentration on plant status and evolutions in progres Administrative duties and support activities were assigned to other personne These changes were effective and contributed to improved performance during shutdown -activitie One Severity Level 3 Violation and nine Severity Level 4 Violations were identifie.
Performance Rating Category: 2 Recommendations The Board noted that problems associated with inadequate procedures and failure to follow procedures continued from the previous SALP perio Management corrective actions to address this weakness have not been fully effective. A broad review of procedural usage should be undertaken to identify the underlying cause Radiological Controls Analysis This functional area addresses those activities related to radiation safety, radiological effluent control and monitoring and primary/secondary chemistry contro The licensee continued to maintain a stable and well-qualified radiation protection staff with no significant changes made to the licensee's radiological controls organization. The licensee's training program remained sufficient during the period with program enhancements that included instructions to plant workers and the revisions to 10 CFR Part 20, as well as the implementation of an Electronic Dose Capture System and its interface with digital alarming dosimeters (DADs). Early in the assessment period, continuing training was not being provided for contract health physics (HP) technicians. The licensee corrected this by adding training modules focusing on refresher HP theory and practices and providing additional training to the contract HP technician The licensee's program to maintain overall occupational external exposure as low as reasonably achievable (ALARA) remained very goo The collective dose for 1992 was 217 person-rem per unit. The collective dose in 1993 to the end of the SALP period was 24 person-rem per unit. During the assessment period, the licensee initiated and completed replacement of the letdown piping and "J" leg drains from the steam generators in Units 1 and 3. Replacing this highly radioactive piping with new piping, thereby reducing high dose rates in the containment basement areas, was a significant ALARA initiativ The internal exposure controls, i.e., contamination control, the respiratory protection, and the bioassay program, were effectively implemented to control exposure. No exposures exceeded regulatory limit Licensee performance in the contamination control area continued to be effective in ensuring that contaminated floor space and personnel contamination events were maintained below established goals and were trending down. Contaminated space was typically controlled to less than seven percent of the radiologically controlled area (RCA).
Personnel contamination events did not result in any skin doses or intakes greater than regulatory limit During the assessment period, repetitive problems were identified with radioactive material control practices. Specifically, the NRC identified:
(1) recurring instances of radioactive material in the RCA not being properly labeled as such, and (2) recurring instances of areas in the RCA containing radioactive material not being properly poste As a result of the licensee's investigation of a possible skin dose overexposure to a radwaste operator, the licensee found that the worker rarely used the Electronic Dose Capture System to log into the RCA of the plant. Further investigation revealed that approximately 20 percent of personnel working in the RCA were not logged in any radiation work permit (RWP). This indicated less than fully effective adherence to procedures and control of work being conducted in the RC During the assessment period, the licensee's audit program was effective in identifying radiological control program deficiencies. However, the effectiveness of the audit program was reduced because corrective actions to findings were not properly implemented. Specifically, of 23 problem identification reports reviewed, 17 had no corrective actions assigned for deficiencies identified, including several which were nearly a year old. Furthermore, out of 47 radiological deficiencies reviewed, all but one were assigned the lowest priority for correctio Typical issues not resolved included procedural inadequacies, non-ALARA work practices, and miscellaneous dosimetry problem The licensee's performance with regard to maintaining low levels of radiation doses from effluents was good. The whole body doses were less than one millirem/year each from the liquid effluents and from the gaseous effluents released during 1992. Those doses were a small percentage of their respective limits. Compared to 1991, larger volumes of liquid radwaste, with higher radionuclide concentrations, were processed through the liquid radwaste treatment systems during 199 Although the amount of activity released increased slightly, a small decrease in the total body dose from liquid effluents for 1992 was achieved by a reduction of the Cs-137 concentration in the effluent. By processing laundry waste water through powdered resin before release, the Cs-137 concentration in the effluent was significantly reduce There was one unplanned release during 1992 which occurred when approximately 2000 gallons of slightly contaminated water from the Low Pressure Service Water System were inadvertently discharged from the Unit 2 Low Pressure Injection Cooler to Lake Keowee. No release limits were exceeded during that even Effluent radiation monitor performance was mixed. A longstanding problem with the Low Pressure Service Water (LPSW) monitors was corrected and the monitors for Units 1 and 2 were returned to service during the assessment period. System modifications were required to correct insufficient sample flow from all portions of the LPSW syste The modification for the Unit 3 system was completed during the previous assessment period. Late in the assessment period there were two monitors that were inoperable for several days before the licensee detected that they were not functioning properly. Weaknesses were identified with the licensee's corrective actions for restoring the monitors to an operable statu The licensee's environmental monitoring program was effectively implemented. The program results for 1992 indicated that there was no significant radiological impact on the health and safety of the general public resulting from plant operations. Dose estimates calculated from environmental monitoring program data were in reasonable agreement with dose estimates calculated from effluent release data and were well within 40 CFR 190 dose limits. The licensee's performance in the Environmental Protection Agency's interlaboratory crosscheck program indicated that an effective quality assurance program had been maintained for analysis of environmental sample The parameters required to be monitored as part of the water chemistry control program were maintained well below their technical specification (TS) limits. The program also included provisions for implementing, with few exceptions, industry guidelines for PWR primary and secondary water chemistry. The activity of reactor coolant was also maintained well within the TS limits. The activity was slightly higher in the Unit 3 coolant than in Units 1 and 2 coolant due to residual contamination from leaking fuel in previous fuel cycles. The licensee has since implemented a policy of reloading fuel with zero defects with regard to leaking fue There were no transportation incidents involving the licensee's shipments of radioactive material during the assessment period. The program was effectively implemented and provided for preparation and shipment of radioactive material pursuant to the Department of Transportation's regulation Five Severity Level 4 Violations were identifie.
Performance Rating Category: 1 Recommendations None Maintenance/Surveillance Analysis This functional area addresses those activities related to equipment condition, maintenance, and surveillance testing. In addition to the routine inspections in this area, an Electrical Distribution System Functional Inspection (EDSFI) was conducted during this assessment perio The licensee's performance in the maintenance/surveillance functional area was inconsistent throughout the assessment period. Predictive maintenance and equipment monitoring was aggressively pursued and was effective whereas weaknesses were noted in areas such as procedural adherence, documentation of problems during troubleshooting and repairs, and maintenance/surveillance induced reactor trips and transient The licensee continued to focus efforts on preventative maintenanc The thermography program introduced during the previous SALP period was effective in identifying potentially significant maintenance problems prior to failure and was effective in identifying leaking valve Management efforts were effective in significantly reducing the maintenance work request backlog. The backlog was maintained at levels which were better than management expectations. This contributed to improved equipment reliability as only one reactor trip from power was caused directly by equipment failure. Improved controls and efforts to reduce temporary modifications have also been successfu The maintenance department was well staffed with experienced and knowledgeable personne The use of vendors and contractors was controlled with most maintenance support performed by Duke Power individuals. Plant material condition and routine housekeeping was adequat During this period, significant operational problems were attributable to poor maintenance controls. A loss of offsite power event and reactor trip occurred in October 1992 due to maintenance activities conducted in the 230 kilovolt switching station control power system. Three other reactor trips from power occurred during maintenance activities. These were due to problems during troubleshooting or repair activities and use of a wrong wiring diagram. Although three refueling outages were conducted and adequately managed, three unit shutdowns were required during the period due to inadequately performed maintenanc Problems with independent verification, undocumented work activities and other poor maintenance practices continued to occur during the perio Examples include an inadvertent reactor protection system channel actuation due to performing a surveillance on the wrong unit, improper wire terminations that were "verified" by two technicians and a Quality Control inspector, an undocumented activity involving lifting leads and an Emergency Feedwater Actuation due to poor scaffolding control Surveillance activities caused a unit runback and testing on the wrong unit caused a plant tri The test program for the Keowee Hydrostation did not adequately demonstrate the ability of the system to perform its design function. A periodic test had not been performed on the Keowee units to supply power through the overhead path. Additionally relays required to isolate portions of the switchyard and to transfer Keowee auxiliary power to an alternate source were not fully tested. Also, as discussed Section IV.F. (Engineering/Technical Support), LPSW testing had not been adequately performed to validate flow model calculations until the NRC pointed out errors in the mode In other areas, several inadequate surveillance procedures were identified during the period including one missed surveillanc The licensee's inservice inspection (ISI) program was effectively implemented during this inspection period. ISI non-destructive examinations were conservatively performed. The procedures, examination techniques, and documentation of results were good. Personnel were knowledgeable in their areas of responsibility. Some problems were identified involving the failure to document and resolve welding discrepancies identified by the vendor on ASME Code relief valves and an untimely and inadequate relief request from postmodification hydrostatic testin Seven Severity Level 4 Violations were identifie.
Performance Rating Category: 2 Recommendations A significant number of plant transients were attributed to inadequate maintenance or surveillance activities. Some of these were related to procedural problems and work controls. A broad review of procedures, similar to that mentioned in the Operations functional area is recommende Emergency Preparedness Analysis This functional area addresses activities related to the execution of the Emergency Plan and its implementing procedures, including licensee performance during emergency exercises and actual events, interactions between onsite and offsite emergency response organizations during emergency exercises and actual events, and support and training of onsite and offsite emergency response personne Management support and involvement in the emergency preparedness (EP)
program was evidenced by the numerous drills conducted and the emergency facility and equipment improvements made during the assessment perio The licensee continued to administer an aggressive schedule of EP training drills, creating challenges for the emergency response organization (ERO) that exceeded the training requirements of the Emergency Plan. These drills (two of which were conducted during off hours) included annual participation by each of the five Operations shifts in simulator-driven exercises involving the full ERO. This approach, combined with formal classroom training, appeared to be an effective way of maintaining organizational readiness for responding to an emergenc The onsite emergency preparedness staff was qualified and continued to provide comprehensive emergency preparedness training. Offsite support agency training for fire, ambulance, rescue, hospital, and local law enforcement agencies was conducted in accordance with commitments in the Emergency Plan and agreement letters with assisting agencie During the annual exercise in August 1992, the licensee demonstrated its capability to provide for the health and safety of the public by effectively implementing the Emergency Plan in response to the simulated accident scenario. The scenario appropriately challenged the licensee's ERO, and included full participation by the NRC. The licensee demonstrated the ability to identify emergency conditions, to make correct classifications in accordance with Emergency Plan implementing procedures, to take appropriate measures to mitigate the adverse consequences of degrading plant conditions, and to recommended appropriate protective actions for the public. The emergency response facilities were activated fully within the required time periods. The timely activation and capable functioning of the Emergency Operations Facility constituted an exercise strength. An exercise weakness was identified for failure of the Joint Information Center to quantify or put into perspective, for the general public, a radiological release which occurred as a component of the scenari The licensee maintained emergency facilities, equipment, instrumentation and supplies in a state of readiness with thorough equipment inventories, surveillances, and functional tests. Just prior to the beginning of the assessment period, the licensee fully implemented an upgrade of the offsite siren system through the addition of a computerized feedback capability for monitoring each siren's operation during any mode of testing or actual activation. This resulted in very
high siren availability (approximately 99 percent) during 1992, with the feedback system successfully identifying siren operability problems for prompt corrective actio The 1991 corporate reorganization necessitated major EP program changes which were implemented during the assessment period. Most of the EP program responsibilities previously held by the corporate staff were transferred to the site. Concurrent with this transfer of responsibility was the relocation of many emergency response personnel to the site. Some organizational functions were also shifted from the Emergency Operations Facility to the Technical Support Center. However, the totality of the functions performed did not change with the reorganization, and adequate emergency response capabilities were maintaine During this assessment period, the licensee's Emergency Plan was activated twice at the Notification of Unusual Event leve Each of the events was properly classified, and notifications to State and local governments and the NRC were made in accordance with applicable requirement One Severity Level 5 Violation was identifie.
Performance Rating Category: 1 Recommendations None Security Analysis This functional area addresses those safeguards activities related to the protection provided to the station's safety related vital equipment, and the assurance that individuals authorized station access are fit for dut The licensee's safeguards program was well managed at the site level as evidenced by the professionalism and effectiveness of its proprietary security force. Officers were well trained, knowledgeable of their duties and responsibilities, well versed in their procedures, and adequately equipped. Shifts were appropriately.staffe The licensee conducted effective quality assurance audits which were thorough and complete. Corrective actions for the audit findings were timely and appropriat As noted in previous SALP assessments, the licensee's closed circuit television system, used to assess protected area barrier alarms, continued to be non-operational in several zones. Several television
monitors located inside the alarm stations were frequently out of service. Thus, the licensee continued to use compensatory measures to meet its Plan commitments during the period. Toward the end of the SALP period, camera assessment system reliability had greatly improve The licensee completed an engineering evaluation of certain non-vital piping which, given various operational modes and valve lineups, could be important to safety and therefore should be protected. This licensee's initiative in conducting this review was well coordinated with the NRC and adequate compensatory measures have been implemented where necessar With respect to other elements of the safeguards program, access controls and alarm station operations were appropriate, barriers and alarms were maintained as required, lighting was sufficient, and (except as noted earlier regarding cameras) maintenance and compensatory measures were adequat During this SALP period, the licensee identified several security events involving inadequate communications. A failure by the Control Room operators to notify the security shift that a facility important to safety was not operable resulted in the failure to institute timely compensatory actions. A failure by Human Resources personnel to notify the security shift of a positive drug test resulted in an unauthorized access to the Station. Also identified by the licensee was its failure to conduct daily communications tests as committed to in its Security Plan. These were appropriately documented in the Safeguards Event Lo In addition, the NRC identified several Plan inaccuracies relative to the Turbine Building security barrier. The licensee took appropriate corrective actions for the aforementioned event The licensee has clarified its generic Corporate Procedure for Reporting Safeguards Events to ensure that NRC reporting criteria is met. This has resulted in an overall increase in reporting events in the Safeguards Log No violations were identifie.
Performance Rating Category:
1 Recommendations None
14 Engineering/Technical Support Analysis This functional area addresses activities associated with the design of plant modifications and of technical support for operations, outages, maintenance, licensed operator training and requalificatio Engineering support was strongest in support of plant operations and planned outages. Weaknesses were evident in the response to emergent issues not directly related to operability and in corrective action Licensed operator training improved, but some weakening of the requalification program was evident. The staffing of the engineering organizations was satisfactor Engineering support for plant modifications was adequate. The quality and technical content of temporary and minor modifications was generally good. Examples included the addition of Vent Valve ICCW-422, relocation of IC-850 and IC-852, and snubber additions on main feedwater and emergency feedwater piping. There were also instances found of inadequate design calculations and reviews, although some of the inadequacies occurred before this assessment period. Examples included previous and current Low Pressure Service Water (LPSW) flow model calculations used to justify operability of the system. After the NRC identified the errors, the licensee corrected them and then tested the LPSW to verify operability. The tests demonstrated that the LPSW systems were degraded in that excessive flow through the low pressure injection coolers could be achieved under certain design basis conditions and that LPSW flow through the reactor building cooling units could be significantly below the assumed accident condition flow rat The flow testing conducted on Unit 3 also identified that the system was degraded due to a mispositioned valve. Single failure vulnerabilities were also identified in the design basis documentation previously conducte The licensee's engineering and technical support have been responsive to station needs. Examples include identification and prompt communication to the NRC of the need to change a prior commitment relating to post accident boron dilution flow monitoring, modifications to correct degraded control voltage to the "S" and "E" breakers, corrective action for inadequate Keowee auxiliary breaker closing power, and modifications to the Standby Shutdown Facility makeup pump accumulators. Engineering has generally provided prompt and well-founded solutions to short-term, operational problems. The response to other issues in which immediate operability was not an issue has not been quick or as thoroug Examples include problems with Keowee X-relays, numerous LPSW issues (raised by the NRC), and a revised response to NRC Bulletin 88-04 concerning the deadheading of LPSW pumps. Also, the planning for the replacement of switchboard batteries did not identify potential problems with operating a battery charger without a connected battery. This resulted in a loss of offsite power and a reactor trip to Unit System engineers assumed "ownership" of their assigned systems and
actively participated in the resolution of problems. Component engineering provided good support to maintenanc Engineering support for the resolution of other emerging issues, not identified as requiring immediate corrective action, was sometimes deficient. Examples of problems noted included: (1) the failure to perform a safety evaluation for a temporary modification (installation of an electrical jumper on radiation monitor interlock to Valve 2LWD-2);
(2) the use of incorrect design drawings in the completion of a plant modification (resulting in a reactor trip); (3) an inadequate engineering evaluation of the operability of a letdown storage tank check valve; (4) failure to take prompt and adequate corrective actions for low indicated service water flow through the 3B Low Pressure Injection (LPI) Coolers; and (5) failure to adequately test the MG-6 relays to verify operability. After the development of an appropriate test procedure for testing the MG-6 relays, a long standing operability problem was identifie Although the Electrical Distribution System Functional Inspection revealed no inoperable systems and provided adequate assurance that the electrical system will perform as intended, it also revealed problems in testing, design analyses, and design basis documentation. Similar problems were also found in the Oconee emergency AC power source. These problems resulted in part from the lack of a thorough understanding of the design basis of the site's electrical distribution syste Operator training was effective. Improvements were noted in the initial training of licensed operators. This good performance was indicated by the successful completion of all seven candidates nominated for licenses in January 1993. The candidates exhibited good communications and interactions during their simulator examinations, but had a generic weakness in radiation protection. The previously noted problems with simulator fidelity to the plant have been rectified. The performance of requalification was satisfactory. During the June 1992 requalification examination, five of six crews and 22 of 24 operators passe Weaknesses noted included the content and construction of the written test and poor or improper cuing during the job performance measure This was in contrast to the strong performance of facility evaluators during the previous assessment perio Two Severity Level 4 Violations were identifie.
Performance Rating Category: 2 Board Recommendations None
16 Safety Assessment/Quality Verification Analysis This functional area addresses those activities related to the licensee's implementation of safety policies related to license amendments, exemptions and relief requests; responses to Generic Letters, Bulletins and Information Notices; resolution of safety issues; reviews of plant modifications performed under 10 CFR 50.59; safety review committee activities; and the use of feedback from self assessment programs and activitie Management performance in the area of safety assessment and quality assurance was inconsistent. Efforts to correct weaknesses in command and control were effective, however many repetitive problems continued in the area of procedural compliance by personne Prompt followup to deficiencies was not always evident. Licensing documentation and submittals were generally very goo Management implemented several corrective actions to improve the operation of the station in areas previously identified by the NRC as weak or deficient. Improved performance was noted in shutdown risk and control room command and control. Initiatives to improve the conduct of outage activities and the reduction in shutdown risk vulnerability were noteworthy. Of particular note was the reduction in control room distractions, efforts to more fully inform employees of outage activities, and an independent safety assessment of the outage schedul The Nuclear Safety Review Board was objective and thorough in its review of operations and problems at Oconee. Management was responsive to the comments and recommendations from the Boar In the area of Keowee operations and design, management was slow to recognize the need for corrective action to address previously identified NRC concerns and weak areas. In September 1992 a management meeting was held at NRC request to discuss these issues. The licensee indicated that while some changes to procedures were appropriate, major operational, organizational and procedural changes were not necessar However, in October 1992, a loss of off site power event occurred and followup inspections identified significant weaknesses in these area It should be noted that the licensee's Significant Event Investigation Team, dispatched to site to review the event, was effective in determining root causes, safety implications and provided recommendations for corrective actio Following these inspections, a comprehensive Emergency Power Management Plan was developed. This plan was intended to substantially improve the overall operation and maintenance of the Keowee facility. An organizational change was also made to incorporate the Keowee station under Oconee station line managemen At the conclusion of this assessment period the effectiveness of these changes remained under evaluatio Issues which the licensee recognized as clearly safety significant were normally resolved aggressively. Actions were conservative and thorough, and involved early interaction with the staff. Examples included 100 per cent steam generator tube inspection, corrective action for degraded
control voltage for "E" and "S" breakers and corrective actions related to the emergency electrical system after the Unit 2 Loss of Power even At times, the failure to further probe into questionable indications led to untimely identification of adverse conditions. Examples included the failure to investigate abnormal LPSW flow during valve testing and failure to promptly investigate abnormal position indication on a Keowee breaker. Management efforts to address the large number of operator errors and procedure violations have not been fully effective as they continued to occur in a number of areas in the plan A significant improvement was noted in the quality and timeliness of Inservice Inspection and Testing relief requests since the last evaluation period. Most amendments and relief requests were processed without the need for additional clarifying information or supplements to the original submitta When additional information was required, the licensee was very responsive in providing the requested information promptl The licensee provided responses to NRC requests within the time frame requested or provided written notification if circumstances prevented meeting the requested schedule. These responses were generally clear, precise, and sufficient. Examples include responses to Generic Letter 91-11, Vital Instrument Busses and Tie Breakers, Generic Letter 88-20, Independent Plant Examinations, and Generic Letter 87-02, Seismic Qualification of Mechanical and Electrical Equipment in Operating Plants. However, in one instance, an inadequate response to Bulletin 88-04, Safety Related Pump Loss, was not corrected until NRC requested a revised respons Licensee Event Reports (LERs) in most cases were timely and well written. One report, LER 269/92-12, concerning various problems with the Unit 1/2 LPSW system, was submitted lat Two Severity Level 3 Violations and two Severity Level 4 Violations were identifie.
Performance Rating Category:
2 Recommendations None SUPPORTING DATA AND SUMMARIES Licensee Activities A major reorganization was announced in November 1991, including relocating Design Engineering to the site. Implementation of the reorganization was completed in July 1992. Additional management changes during this assessment period included the April 1, 1993, reassignment of Mr. R. L. Sweigart, former
Superintendent Operations, to Superintendent Work Control and Mr. G. Rothenberger, former Superintendent Work Control, to Superintendent Operatio There were three refueling outages during this assessment period.. Refueling outages were completed in March 1992 for Unit 2, September 1992 for Unit 3, and January 1993 for Unit 1. These outages were satisfactorily completed with no major problems. However, the Unit 3 refueling outage required extensive decontamination activities due to the contamination which occurred inside Unit 3 Containment following the November 23, 1991, break of a 3/4-inch tubing connector on the Reactor Coolant System. During the Unit 1 refueling outage, a larger than normal number of degraded steam generator tubes were identified which were required to be plugged. This was attributed primarily to revised tube plugging criteri In September 1992, the licensee determined that both trains of the Units' 1 and 2 LPI system were inoperable. The cooling water flow of the LPSW system through the LPI heat exchangers, during a postulated design basis accident, could have potentially exceeded the manufacturer's specifications. This was discovered on a test performed on-Unit 3 and was also determined to be applicable to Units 1 and 2. The power level for both units was reduced to approximately 10 percent and modifications were made to reduce the flow through the heat exchangers to meet the manufacturer's specification On October 19, 1992, during maintenance activities, a loss of off site power occurred for Unit 2 which was followed by a subsequent loss of one of the Keowee Hydro units. Since this event, the licensee has placed the Keowee Hydro Station under the Oconee management and has implemented a number of procedure changes to improve the reliability of the emergency power supply for the Oconee Statio Direct Inspection and Review Activities In addition to the 36 routine NRC inspections and one initial (which included two retakes) and one requalification examination performed at the Oconee facility, the following three special inspections were conducted:
December 9, 1991 February 21, 1992 Shutdown Risk Inspection October 20 - 28, 1992 Augmented Inspection Team (AIT) Loss of Off-site AC Power Supply January 25 - March 5, 1993 Electrical Distribution System Functional Inspection (EDSFI) Escalated Enforcement Activities Orders None
19 Civil Penalties (CP)
Two Severity Level III problem violations (IR 91-32/EA 91-167) were issued on February 3, 1992, involving ten specific violations related to the degradation of the decay heat removal event of September 7, 1991 and the over-pressurization of the LPI system piping on September 19-20, 1991. ($125,000) Although both of these events occurred during the previous assessment period, the violations were issued during this assessment period on February 3, 199 A Severity Level III violation (EA 92-211) was issued on December 28, 1992, and involved the failure to take adequate corrective action to resolve a reduced Low Pressure Service Water System flow condition through the Unit 3B Low Pressure Injection system cooler. ($100,000)
The licensee requested mitigation of the civil penalty. Subsequent to this assessment period, an order to pay was issued which the licensee complied wit Management Conferences February 5, 1992: A meeting was held in Region II for Duke to discuss the items identified during the Design Basis Documentation Program evaluation of the Oconee electrical systems and the corrective actions initiated on the identified problem June 24, 1992: A meeting was held in Region II for Duke to discuss the shutdown risk procedures to be implemented for future Oconee refueling outages. Also, discussed were Duke's Problem Investigation Program, procedure adherence and configuration control programs at Ocone July 17, 1992:
An enforcement conference was held in Region II to discuss the circumstances associated with the May 8, 1992, Unit 1 reactor trip in which one of the two required Emergency Feedwater System flow paths was not operable and the operation of Unit 1 from May 11 through 24, 1992, with only one of the two Emergency Feedwater System flow paths operabl September 17, 1992: A meeting was held at the Oconee facility to discuss the operation, management and maintenance of the Keowee Hydro Statio November 24, 1992:
An open enforcement conference was held in Region II to discuss the circumstances associated with the mispositioned valve in the Unit 3 Low Pressure Service Water Syste March 29, 1993: A meeting was held at NRC Headquarters to discuss electrical issues at Ocone Several additional meetings were held with Duke Power throughout the assessment period to discuss a variety of other subjects including Station Blackout and Keowee issues, licensing activities, safety initiatives, Oconee's self-assessment, the Emergency Data System and the development status of a Babcox and Wilcox digital module for use in the reactor protection syste Confirmation of Action Letters (CAL)
Following the October 19, 1992, Unit 2 reactor trip and loss of power event, a CAL was issued to address the cause of the event. On October 26, 1992, a conference call was held and the licensee discussed enhancements to be made to the Keowee Hydro Station and Keowee operations. These commitments were documented in a letter to the NRC dated October 27, 199 Reactor Trips/Unplanned Shutdowns Seven automatic reactor trips occurred. Five of these were attributed to maintenance/surveillance activities, one to equipment failure and one to operator error. These trips are as follows:
Unit 1 May 7, 1992:
The unit experienced a reactor/turbine trip from 100 percent power due to a connector coming loose on the generator exciter field. (Maintenance/Surveillance)
May 8, 1992: The unit tripped from 14 percent following a turbine trip due to the loss of suction to the "lA" main feedwater pump which was caused by pressure swings while lowering hotwell leve (Operations)
Unit 2 October 19, 1992: The unit tripped from 100 percent power on the loss of off-site power which occurred during switchyard battery modification work when a battery charger was placed in service without a connected battery. (Maintenance/Surveillance)
Unit 3 February 27, 1992: The unit tripped from 100 percent power following a turbine trip due to human error. A technician was testing the loss of generator stator cooling on Unit 2 which was shutdown in a refueling outage but inadvertently performed the test on Unit (Maintenance/Surveillance)
June 24, 1992: A turbine/reactor trip occurred from 100 percent power while technicians were replacing low pressure service water instrumentation. A fuse blew in the Integrated Control System when an incorrectly wired card was installed. This caused a momentary loss of power to the steam generator water level instrumentation which resulted in a turbine/reactor tri (Maintenance/Surveillance)
September 29, 1992: The unit tripped from 73 percent power due to low reactor coolant system pressure from a defective Group 5 control rod drive programmer. (Equipment Failure)
January 26, 1993: A turbine/reactor trip from 100 percent power occurred due to low main feedwater pump discharge pressure which was
inadvertently caused by a technician during trouble shooting activitie (Maintenance/Surveillance) Review of Licensee Event Reports (LERs)
During the assessment period, 30 LERs were analyzed. The distribution of these events by cause as determined by the NRC staff was as follows:
Cause Total Unit 1 Common Unit 2 Unit 3 Component Failure
2
Design
8
Construction/Fabrication
1 Installation Other
1
Personnel
- Operating Activity
4
1
- Maintenance Activity
1
- Test/Calibration Activity
1
- Other
1
TOTALS
8
2
Notes: With regard to the area of personnel, the NRC considers lack of procedures, inadequate procedures, and erroneous procedures to be classified as personnel erro.
The other category is comprised of LERs where there was a spurious signal or a totally unknown caus.
One Special Report was submitted. Also, two LERs were submitted but were later rescinded. These reports are not included in the above tabulatio.
The above information was derived from a review of LERs performed by the NRC staff and may not completely coincide with the licensee's cause assignment Licensing Activities During the rating period, approximately 175 active licensing actions were submitted for the three Oconee units of whch 97 were complete There were 33 licensing amendment requests of which 24 were complete Enforcement Activity No. of Deviations and Violations in Each Functional Area:
V IV III II I Plant Operations
-
1 Radiological Controls
-
Maintenance/Surveillance
-
Emergency Preparedness Security Engineering/Technical
-
Support Safety Assessment/Quality
-
2 Verification TOTALS
25
-
NOTE:
Two of the Severity Level 3 violations and the Severity Level 5 violation were identified during the previous assessment period, but reports were not issued until this assessment period.