IR 05000275/1998011

Insp Repts 50-275/98-11 & 50-323/98-11 on 980526-28.No Violations Noted.Major Areas Inspected:Circumstances, Potential Safety Consequences & Licensee Response & Actions Taken Re Authorization of Tagout W/O Written Procedure

ML20236T380
Person / Time
Site:	Diablo Canyon
Issue date:	07/22/1998
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20236T345	List: IR 05000275/1998011 ML20236T343
References
50-275-98-11, 50-323-98-11, NUDOCS 9807280145
Download: ML20236T380 (18)

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ENCLOSURE 1 l

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U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket Nos.: 50-275 l

50-323 License Nos.: DPR-80 l DPR-82 I

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Report No.: 50-275/98-11 50-323/98-11 Licensee: Pacific Gas and Electric Company J

Facility: Diablo Canyon Nuclear Power Plant, Units 1 and 2 Location: 7 % miles NW of Avila Beach Avila Beach, California i

Dates: May 26-28,1998 Inspectors: Dyle G. Acker, Resident inspector Ryan Lantz, Reactor Inspector Approved By: Howard J. Wong, Chief, Reactor Projects Branch E Attachment: Supplemental Information 9807280145 980722 I PDR ADOCK 05000275 G PDR ,

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l EXECUTIVE SUMMARY i

Diablo Canyon Nuclear Power Plant, Units 1 and 2 NRC Inspection Report 50-275/98-11; 50-323/98-11 This special, announced inspection addressed the circumstances, potential safety consequences, and licensee response and corrective actions associated with actions taken on December 15,1997, by a Unit 2 Shift Foreman, with concurrence of the Shift Supervisor, to authorize a tagout without a written procedur Ooerations )

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The inspectors concluded that Quality Evaluation (OE) Q0011991 determined that the Shift Foreman and Shift Supervisor deviated from program documents (despite knowing that they had no authority to do so) (Section 2.4).

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The inspectors concluded that the actions and decisions of the Shift Foreman, Shift Supervisor, Senior Reactor Operator, and maintenance personnelin Unit 2 on {

December 15,1997, to perform the work using personnel standing by equipment, plus a j caution tag, instead of the clearance package described by the work order, without I modifying the work order, were contrary to the requirements of licensee procedures IDAP AD2.lD1, OP2.lD2, and AD7.lD1, and Technical Specification (TS) 6. (eel 50-323/98011-01) (Section 2.4).

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The inspectors concluded that there was little safety difference between the required '

work and the performed work in that both methods used single valve isolation (Section 2.4).

• The inspectors concluded that there was no measurable savings of person-rem or time at elevated temperatures between the method of work actually used and the method of 1 l

work allowed by licensee procedures (Section 2.4).

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The inspectors concluded that the formal root cause analysis, provided in QE 00011991 on February 25,1998, was self-critical and effectively identified the primary causes. The inspectors also concluded that the licensee's subsequent corrective actions to date have been extensive (Section 2.6).

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The inspectors concluded that the corrective actions for this December 15,1997, event were not prompt in that: (1) while the need for a QE was immediately identified, a QE was not formalized until December 30,1997, and no action was initiated to reso!ve the

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, OE until February 13,1998; and (2) written communication to operations personnel of l management's expectations with regard to this event was not accomplished until February 17,1998, in addition, failure to take corrective action to add to existing instructions of the man-on-line (MOL) tag resolution of Action Request (AR) A0411400, may have contributed to the event. These are three examples of an apparent violation of 10 CFR Part 50, Appendix B, Criterion XVI (eel 50-275;323/98011-02) (Section 2.6). )

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The delays in communicating the intentional nature of the event to operations personnel i was not consistent with licensee management's stated significant concern over the event (Section 2.6). l

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Report Details 1 Introduction 1.1 Puroose and Scooe of insoection (71707)

A special inspection team was initiated to review the circumstances surrounding the i actions taken on December 15,1997, by a Unit 2 Shift Foreman, with concurrence of the

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Shift Supervisor, to authorize a tagout without a written procedure. The issue was identified as an unresolved item (50-275;323/98008-01) in NRC inspection Report 50-275;323/98-0 The special inspection team consisted of two NRC personnel, including the team leader and a specialist in operations. The team's objectives included the following:

• Develop a sequence of events, including the licensee's corrective action * Determine which, if any, licensee procedures were not followe e Assess the safety significance of the even * Evaluate past actions taken in response to repair similar equipmen * Determine if the licensee's corrective actions were appropriate and timel * Review operations and nuclear quality services (NQS) assessments and trending for procedure adherence in operation In keeping with the NRC's emphasis on encouraging licensee self-assessment and corrective actions, the team utilized the licensee's sequence of events and investigations to the maximum extent possible. In addition, interviews between the NRC Office of Investigation and licensee personnel involved in the event were utilize Event Description (71707,92901)

2.1 Seauence of Events Date Description 12/11/97 AR A0449092 initiated to repair a steam leak on an instrument line for Steam Generator 2-4 level indication downstream of Valve MS-2-400 /15/97 Work Order (WO) C0155758 and associated Clearance 00057155 brought to control room (day shift) for review and approval to commence steam leak repair downstream of Valve MS-2-400 Operations and Maintenance personnel on shift agree to deviate from WO C0155758.

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-2-Shift Foreman initiates AR A0449239, " Intentional Procedure Deviation."

Repair is complete /16/97 Operations management leams of AR A0449239. Operations Director verbally informs Shift Supervisor and Shift Foreman that their actions were unacceptable. Operations services manager requests a QE be issue /16-22/97 Operations Director discusses events with remaining shift supervisor /23/97 Licensee AR review team determined that a QE should be issue /30/97 QE Q0011991 initiated and assigned to Operation /01/-

02/01/98 Operations Manager discussed event in requalification training sessions.

t 01/29/98 NRC Senior Resident inspector reviews QE 00011991 and requests from Operations information on corrective action /13/98 Root cause analysis assigned for action to NOS personne I 02'il/98 Operations shift order issued with an incident summary on this even l 02/20/98 Draft root cause given to Operations Services Manage /21-23/98 Positive discipline given to Shift Supervisor and Shift Foreman. Both are l removed from licensed dutie /25/98 Root cause analysis issue /26/98 Operations Services Manager sends written expectations regarding intentional procedure deviations to all Operations personne l 03/04/98 Remedial training plans issued for the Shift Supervisor and the Shift l Foreman.

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2.3. Discussion of Licensee Actions on December 15.1997 The Shift Foreman discussed WO C0155758 and Clearance 00057155 with the shift crew, maintenance technicians, and the maintenance foreman. The WO and clearance required that Valve MS-2-4008 be closed, independently verified, and tagged by Operations personnel, using the licensee normal clearance procedure. During the prejob l

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-3-discussion (tailboard) in the control room, shift personnel decided that performing the work as directed by the WO would result in unnecessary radiation exposure and time working in an elevated temperature, believed to be between 105'F and 130*F. This was because Valve MS-2-4008 and the actualleak were inside containment, high alongside the steam generator, and required climbing a 26-foot ladder, which traversed through a 165 mr per hour radiation field. Shift personnel stated that they believed that the WO required too many trips up and down the ladde As noted in AR A0449239, the Shift Foreman considered that seven trips up and down the ladder would be required to perform the work as written. However, statements made by the on shift personnel present at the talboard indicated that these personnel considered that 13 trips up the ladder would be required because a radiation protection (RP) technician was required to accompany personnel on every trip. The following is representative of the trips they believed to be required:

An operator to close Valve MS-2-4008 and hang a MOL tag Second operator to independently verify valve and tag j Two maintenance personnel to perform the repair l An operator to remove tag, open Valve MS-2-4008, and report complete Second operator to independently verify the valve position A maintenance person to verify leak repair was adequate i After discussions with on shift personnel, the Shift Foreman decided not to use the prepared clearance. The Shift Foreman decided to have the work isolated by having an operator close Valve MS-2-4008 and stand by the valve during the repair to ensure the valve remained closed. Maintenance personnel would perform independent verification of valve position, install a maintenance caution tag, perform the repair, and then remove I the caution tag. The operator would then open Valve MS-2-4008 and maintenance personnel would verify satisfactory retest. The operator, two maintenance technicians, ;

and an RP technician would all go up the ladder together, remain at the job site until the i work was completed, and then all exit togethe The Shift Foreman called the Shift Supervisor to join the tailboard near the end of the l discussion. The Shift Supervisor concurred with the plan as discussed in the tai! boar i The Shift Foreman, with input from other personnel attending the tailboard, decided to write an AR to describe why the clearance was not used and document the method of ,

system isolation actually use l l The Shift Foreman wrote AR A0449239 while two maintenance technicians, a senior reactor operator, and an RP technician entered containment, ascended the ladder, and performed the agreed upon work. The leak was successfully repaired using this metho ,

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-4- Review of Licensee Actions on December 15.1997 Insoection Scooe i

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The inspector reviewed licensee documentation associated with the December 15,1997, event, discussed the event with licensee management and quality assurance personnel, reviewed records of statements made by cognizant licensee personnel related to the event, and reviewed licensee procedures related to isolation of systems and components in support of maintenance wor Observations and Findinos Root Cause i

The licensee's cause analysis summary, Nuclear Safety Engineer Log 98-03, associated with QE Q0011991, concluded that the Shift Foreman knew that the plan used to insolate the work for WO C0155758 deviated from the requirements of Interdepartmental l Administrative Procedure (IDAP) OP2.lD1, " Clearances and Administrative Tagouts,"

Revision 8, and IDAP OP2.lD2, *DCPP Tagging Requirements," Revision 6. The cause analysis also determined that crew management circumvented the requirements of IDAP 1 AD2.lD1, " Procedure Use and Adherence," Revision 5, that did not allow intentional I deviations. The cause analysis summary also concluded that the Shift Foreman knew that he did not have authority to deviate from the procedures and that the Shift Supervisor acknowledged the procedure deviations and concurred with the proposed d pla WO Requirements I TS 6.8.1.a states, in part, that written procedures shall be established, implemented, and maintained coverin0 the applicable procedures recommended in Regulatory Guide 1.33, Revision 2, February 1978, Appendix A. Regulatory Guide 1.33, Appendix Section 9.e, requires procedures for the control of maintenance that include methods for obtaining permission and clearance for operation personnel to work and for logging such wor IDAP AD7.lD1, "Use of PIMS WO Module," Revision 2, Step 4.7.2, stated that work shall be performed in accordance with the instructions provided by the WO. Step 4.7.9 stated that WO steps shall be signed off, initialed, and dated as soon as practicable after completion, but not to delay signing off a completed activity beyond the end of the work shift in which the activity was complete Taooino Requirements IDAP OP2.lD2, Step 2.1, stated that red and MOL tags were used to mark working area boundaries, defined through a clearance process, prior to performing work on installed equipment. Step 5.3.2 further stated that MOL tags shall only be used to identify devices i

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5-that are positioned to prevent the flow of liquids, steam, or electrical power in order to place equipment in a safe condition for maintenance, repair, or testing. Step 2.2 stated that caution tags were used to identity or administratively control the operating status, position, or condition ofinstalled equipment. Step 5.5.3 stated that caution tags shall be used to identify plant equipment that shall not be operated for reasons other than those requiring use of a MOL ta Instructions on the licensee's MOL tags read "A MOL tag must be attached to the control i or operating mechanism of all switches or valves that control the supply of electricity, gas, steam, or water to the line or apparatus before men are permitted to work . . . "

instructions on the licensee's cautions tags read " . . This tag is not to be used in place of MOL NONTEST tags where men are working on lines or equipment." The inspectors observed that the clearance process was the only method authorized by licensee procedures for tagging of Operation's controlled equipment, for the purpose of personnel safet As discussed in Section 2.6 below, the licensee, in early 1997, had determined that personnel standing by equipment were not to be used as a substitute for required MOL tag Work Performance The inspectors observed that repair of the steam leak on December 15,1997, was being performed in accordance with WO C0155758. Steps 6,7, and 9 of this WO required that: operators initiate a clearance and hang a MOL tag; maintenance verify the clearance and hang a red tag; and personnel remove the tags and report off (verify work complete) when the job was finished. The clearance required isolation was to shut Valve MS-2-4008, which provided single valve isolation from steam generator pressur Steps 6,7, and 9 were not initialed and dated until December 17,1997, with a reference provided to AR A0449239, which indicated that these steps were not performed as required. Operations and Maintenance personnel failed to initiate the clearance, including hanging the required MOL and red tags specified in licensee tagging procedures to ensure personnel safety, which was required by WO C015575 j During discussions with licensee personnel, these personnel indicated that RP requirements would not have required an RP technician to accompany individuals up the l 26-foot ladder for each evolution. In addition, Administrative Procedure OP1.DC2, i " Verification of Operating Activities," Revision 7, allowed the Shift Foreman to waive

! independent verification of Valve MS-2-4008 for reasons that included person-rem l exposure and elevated temperatures or to assign the independent verification to maintenance personnel, as was actually done. The inspectors considered that, with only one trip by the RP technician and independent verification by a maintenance technician for valve position and tagging, only six trips up the ladder would have been necessar The inspectors considered that there would have been little or no person-rem savings, or time in the high temperature area, if the specified clearance had been used. The ,

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-6-inspectors observed that a similar steam leak on an instrument line off of a steam generator had been repaired at power in 1996, using the normal clearance procedure proces The inspectors also reviewed the actual method used by the licensee to ensure the safety of personnel working on a steam leak downstream of Valve MS-2-4008. Although this was a single valve isolation from a steam generator at full power, with the leak as the only vent, the inspectors considered that the methods actually used by licensee personnel on December 15,1997, provided essentially the same personnel protection as indicated in WO C0155758. There was no difference in the safety of plant equipmen Therefore, the inspectors considered that there was little safety difference between the required and the performed wor Taoaina and Clearance Procedures During review oilicensee procedures, the inspectors identified an apparent inconsistency in licensee procedures for control of work. Administrative Procedure OP1.DC18, Revision 3, " Authorization for Equipment Operation and Maintenance," Step 5.3, provides guidelines for removal of equipment from service. One method for approval was Shift Foreman signature approval on a clearance. Another method was Shift Foreman signature approval on a WO. During discussions with licensee personnel, some personnel told the inspectors that they believed that the Shift Foreman approval authority to remove equipment from service per OP1.DC18, Step 5.3, also constituted approval to perform work. Thus, the Shift Foreman, by signing WO C0155758, which was done on December 15,1997, had complied with licensee procedures for authorizing work. The inspectors did not agree. The inspectors noted that approval of removing equipment from service did not constitute authority to allow work on equipment outside the licensee's procedures for ensuring personnel safety. As noted above, the clearance procedure is the licensee's only defined process where protection of personnel is required. Since some licensee personnel appeared to believe that shift foremen had the authority to waive the clearance process, the inspectors considered that Procedure OP1.DC18 was inconsistent with the licensee tagging program contained in Program Directive OP2, " Tagging Programs," Revision 1, which stated that the clearance process defines and controls a safe working boundary using appropriate tag During their review, the inspectors noted that Procedure OP1.DC2 provided no clear guidance or training requirements for assignment of personnel to perform independent verifications. The inspectors discussed Procedure OP1.DC2 with licensee managemen Licensee management noted that they were considering developing a formal training program for qualification of site personnel who could perform independent verifications

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c. .Cnoclusions The inspectors concluded that QE 00011991 determined that the Shift Foreman and Shift Supervisor deviated from program documents (despite knowing that they had no authority to do so).

The inspectors concluded that the actions and decisions of the Shift Foreman, Shift Supervisor, Senior Reactor Operator, and maintenance personnelin Unit 2 on December 15,1997, to perform the work using personnel standing by equipment, plus a caution tag, instead of the clearance package described by the work order, without modifying the work order, was contrary to the requirements of licensee Procedures IDAP AD2.lD1, OP2.lD2, and AD7.lD1, as described above. This was an apparent violation of TS 6.8.1 (eel 50-323/98011-01).

The inspectors concluded that there was little safety difference between the required work and the performed work in that both methods used single valve isolatio The inspectors concluded that there were weaknesses in the licensee's program documents for control of work and independent verificatio The inspectors concluded that there was no measurable savings of person-rem or time at elevated temperatures between the method of work actually used and the method of work allowed by licensee procedure .5 Licensee Corrective Actions On December 16,1997, site management reviewed AR A0449239. The Operations Services Manager stated that he directed that a OE be initiated. The Acting Operations Director stated that he informed the involved Shift Supervisor and the Shift Foreman that the procedural deviation was unacceptable. The Acting Operations Director stated that he discussed the event with the remaining Shift Supervisors between December 16-22, 199 On December 23,1997, the licensee committee that reviews ARs determined that

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AR A0449239 met the criteria for a OE. The licensee defined a QE as a mechanism for processing a quality problem that did not rise to the level of a nonconformance report.

The QE process contained provisions for documenting a problem, specifying immediate

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corrective actions, determining the cause of the problem, and determining corrective actions to prevent recurrence. On December 30,1997, OE Q0011991, " Intentional Procedural Deviation," was initiated to investigate AR A0449239.

( During January 1998, the Operations Services Manager stated that he reviewed the event with his staff during Friday requalification training session On February 13,1998, OE Q0011991 was assigned to an individual in the NOS organization for action. On February 17,1998, the operations day shift supervisor

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-8-issued an incident Summary as part of the operations shift orders which discussed the December 15,1997, occurrence and discussed the need to follow procedures. On February 20,1998, NQS personnel briefed the Operations Services Manager on their preliminary cause analysis. Based on this information, management initiated positive discipline for the Shift Supervisor and the Shift Foreman, and both were temporarily removed from licensed activities for remediation. On February 25,1997, NQS formally issued the cause analysis. This analysis concluded that the primary cause of the event was an intentional violation of administrative procedures in that both the Shift Foreman and Shift Supervisor knew that they did not have the authority to take the actions they took. The analysis determined that a contributing cause was the belief of the Shift Foreman involved that the clearance process was complex and cumbersom Recommended actions included positive discipline at the formal written reminder level for selected individuals, reinforced management expectations with regard to the use of clearances for WOs, and measuring crew and management understanding of expectations with regard to procedure adherence in self-assessment activitie On February 26,1998, the Operations Services Manager issued a memorandum to all operations personnel concerning intentional deviations. Remedial training requirements were issued to the Shift Supervisor and Shift Foreman on March 4,199 In addition, the licensee stated that they had issued a nonconformance report to review past human performance to identify previous intentional procedure deviations. The licensee reported that their review did not identify any previous intentional deviations.

The licensee also noted that a separate nonconformance report, previously issued to

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resolve problems with procedure compliance errors, was updated to include the issues associated with compliance with the clearance proces The licensee stated that they planned to perform the self-assessment recommended in QE Q0011991 by NOS and to have NOS perform a followup assessment. During presentations to the inspectors at the beginning of this inspection, the licensee stated that the event was significant because of the intentional nature of the deviation and the lack of timely followup, including root cause analysis. In addition, the licensee provided the inspectors with trending information on operations procedure aoherence errors, l which indicated that there was no increasing trend in this are .6 Review of Licensee Corrective Actions

! Inscection Scoce The inspectors discussed the corrective actions taken with licensee personnel, reviewed related licensee procedure requirements and records, reviewed past procedure compliance records, and reviewed previous statements made by licensee personnel associated with corrective actions.

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, Observations and Findinos Licensee Corrective Actions for December 15.1997. Event As noted in Section 2.5 above, licensee operations management stated that they had verbally informed the operations staff in various briefings by February 1,1997, that failure to follow written requirements was unacceptable. However, a review of the statements made by members of the operations staff present in the control room on December 15,1997, conceming the verbal briefings provided by management personnel after the event, indicated these personnel had not completely understood management's concern with the difference between the subject event and previous procedure violations, which were the results of errors. The inspectors, therefore, considered that these

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briefings were not entirely effectiv As noted in Section 2.1 above, the licensee did not initiate formal action to investigate the event until December 30,1997, or over two weeks after the event occurre Although licensee procedures indicate that QEs should normally be resolved in 30 days, the assigned organization (operations) took almost 45 days to assign an investigator, in this case a member of the NOS staff. Members of the NOS staffinformed the inspectors that, after a 30-day period, unresolved QEs were marked and discussed daily by NOS personnel with the assigned organization. NQS personnel stated that they reminded operations personnel of the need to resolve QE Q0011991 after the 30-day period expired at the end of January 1998. In addition, on January 29,1998, the NRC senior resident inspector, during routine review of active QEs, reviewed QE Q0011991 and j requested information on licensee planned corrective action After February 20,1998, when NOS informally briefed operations management on their root cause analysis for AR A0449239, the inspectors noted that the licensee began to address the issue formally. The inspectors observed that licensee actions based on this root cause analysis were prompt and focused, including temporarily removing the Shift Supervisor and Shift Foreman from licensed duties. The memorandum ser:t by the Operations Services Manager to the staff on February 26,1998, clearly defined the need to follow procedures and that the actions taken on December 15,1997, were i unacceptable. However, the inspectors noted that the memorandum did not specifically address the inappropriate use of an operator and caution tag in place of a MOL tag. The inspectors reviewed the remediation plans for the Shift Supervisor and Shift Foreman and considered that they were adequate. The plans clearly reinforced to these individuals the consequences of willful violations of requirements contained in 10 CFR ;

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! Part 50.5 and 10 CFR Part 55.61. During the inspection period, both individuals had not been returned to shift dutie )

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The inspectors observed that the licensee's definitions for QE's and nonconformance reports were similar. Although the licensee used nonconformance reports to document the most significant problems, both document types required formal root cause analysis l l

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-10-and corrective actions. The inspectors considered that use of a QE for documenting resolution of AR A0449239, in lieu of a nonconformance report, was within the licensee's guideline Previous Procedure Comoliance Records and Corrective Actions The inspectors observed that, during 1993 and 1994, the licensee had experienced a number of problems with procedure compliance. Based on NRC violations and self-assessments, the licensee issued Nonconformance Report DCO-93-PG-N048,

" Procedural Adherence / Noncompliance," with corrective actions dated October 2,199 The licensee concluded that a contributing cause was a programmatic weakness in conveying management expectations for procedure compliance to the workforc Licensee corrective actions included administrative changes to more aggressively emphasize procedural adherence expectations, lowering of the threshold for problems receiving management attention, enhanced personal accountability, and improved trending to assure corrective actions were effectiv In October 1995, operators attempted to energize a 4160 volt load center with a grounding buggy still installed, resulting in the immediate transformer failure and fire. As noted in NRC Inspection Report 50-275;323/95-17, one of the major contributing causes of this event was widespread failure of operations and maintenance personnel to follow clearance procedural requirements for installation and removal of ground buggie Licensee self-assessments determined that the failure to follow procedures was not limited to the event. Licensee corrective actions included a series of Town Hall Meetings with all site personnel concerning procedure compliance, a meeting of all site supervisors with senior management concerning procedure compliance, selection of procedure error reduction as an area of focus for all site directors, supervisory workshops on procedure adherence, and improvements in the trending of procedure noncomplianc The inspectors reviewed the recent data provided by the licensee on procedure compliance errors and agreed with the licensee that there was not an increasing tren In addition, the inspectors reviewed recent operations self-assessments and NOS assessments. These assessments did not identify any potentialissues with intentionally not following procedures and did not identify any significant or widespread problems with procedure compliance within the operations organization. However, the inspectors noted that the licensee had identified a number of errors associated with the clearance and tagging process. The licensee was addressing clearance errors in an active i nonconformance report.

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l The inspectors noted that AR A0449239 stated that, in place of a MOL tag, the Shift Foreman, with concurrence of the Shift Supervisor, decided to use an operator standing by Valve MS-2-4008. The inspectors observed that AR A0411400, issued on August 16, 1996, indicated that NOS had identified several occasions where operators standing by l

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-11-circuit breakers and valves had previously been used in place of the required MOL tag NOS requested the management eva!uate and formally document this practice. On February 7,1997, management resolved AR A0411400 by directing that the practice of using operators as MOL tags be stopped until procedures were revised to allow for this practice. The inspectors reviewed current licensee clearance and tagging procedures and determined that they had not been modified to either allow or prohibit the practice of using operators standing by equipment in place of MOL tag The inspectors considered that failure to update tagging and clearance procedures, as indicated in AR A0411400, required operations personnel to remember the AR resolution and was a potential contributing cause to the event. Hao the tagging and/or clearance procedures clearly indicated management's expectations with regard to human observation replacing MOL tags, the onshift staff may not heve chosen the course of action they decided upo c. Conclusions The inspectors concluded that the formal root cause analysis, provided in QE Q0011991 on February 25,1998, was self-critical and effectively identified the primary causes. The inspectors also concluded that the licensee's subsequent corrective actions to date have been extensiv However, the inspectors concluded that these corrective actions for this December 15, 1997, event were not prompt in that: (1) while the need for a QE was immediately identified, a QE was not formalized until December 30,1997, and no action was initiated to resolve the QE until February 13,1998; and (2) written communication to operations personnel of management's expectations with regard to this event was not accomplished until February 17,1998. In addition, failure to take corrective action to add to existing instructions the MOL tag resolution of AR A0411400, may have contributed to the even These are three examples of an apparent violation of 10 CFR Part 50, Appendix B, Criterion XVI, which states, in part, that measures shall be established to assure that conditions adverse to quality, such as deficiencies and deviations, are promptly identified and corrected (eel 50-275;323/98011-02).

The delays in communicating the intentional nature of the event to operations personnel was not consistent with licensee management's stated significant concern over the event. In addition, the inspectors considered that the licensee missed an opportunity to have initiated corrective actions immediately after January 30,1998, due to: (1) failure of personnel who observed that QE Q0011991 had not been resolved within the 30-day target to elevate the problem to higher management; and (2) the licensee's

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-12-2.7 (Closed) Unresolved item 50-275:323/98009-01: review of licensee's determination that personnel failed to comply with the clearance procedure while being fully knowledgeable of the requirements, This item is closed by the apparent violations discussed above in this repor Management Meetings 3.1 Exit Meetino summarv The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection on July 2. The licensee acknowledged the findings presente The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identifie l

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AlTACHMENT SUPPLEMENTAL INFORMATION PARTIAL LIST OF PERSONS CONTACTED Licensee B. Blunt, Nuclear Quality Services J. Dye, Shift Supervisor, Operations Scheduling B. Garrett, Director Learning Services S. Heitt, Acting Director, Operations J. Molden, Manager, Operations Services R. Powers, Vice President and Plant Manager

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INSPECTION PROCEDURES (IP) USED IP 71707 Plant Operations IP 92901 Followup - Operations l

ITEMS OPENED AND CLOSED Opened 50-323/98011-01 eel Intentional failure to follow WO and clearance procedures 50-275;323/98011- eel Untimely corrective actions for intentional failure to follow 02 procedures l l

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l Closed 50-275;323/98009- URI Review of licensee's determination that personnel failed to 01 comply with procedures l

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t LIST OF ACRONYMS USED

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IDAP Interdepartmental Administrative Procedure IP inspection procedure MOL man-on-line NOS Nuclear Quality Services QE Quality Evaluation t- RP' radiation protection TS Technical Specification WO work order

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Enclosure 2

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SYNOPSIS This investigation was initiated'on February 10. 1998, by the Nuclear-Regulatory Commission (NRC). Office of Investigations (01). Region IV to determine if a shift foreman at Pacific Gas and Electric Company's (PG&E)

Diablo Canyon Nuclear Power Plant (Diablo), willfully violated a clearance procedure.

I Based on the evidence developed during this investigation, including a review of PG&E documents and interviews of PG&E personnel, the allegation that a l shift foreman willfully violated a clearance procedure was substantiated. '

l Additionally, it was determined a PG&E shift supervisor willfully approved the violation of a clearance procedure and a senior reactor operator willfully participated in the violation of a procedure.

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