IR 05000285/1990023
| ML20043C123 | |
| Person / Time | |
|---|---|
| Site: | Fort Calhoun  |
| Issue date: | 05/15/1990 |
| From: | Constable G, Westerman T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20043C118 | List: |
| References | |
| 50-285-90-23, NUDOCS 9006040080 | |
| Download: ML20043C123 (24) | |
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j APPENDIX U.S. NUCLEAR REGULATORY COMMISSION
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REGION IV
i NRC Assessment Report:
50-285/90-23 Licensee:
DPR-40 Docket:
50-285 Licensee: Omaha Public Power District (OPPD)
444 South 16th Street Mall Omaha, Nebraska 68102-2247 Facility Name:
Fort Calhoun Station (FCS)
Inspection At:
FCS, Blair, Nebraska Inspection Conducted: April 2-6,1990 Inspectors:
T. F. Westerman, Chief, Project Section A, Division of Reactor Projects (DRP)
G. L. Constable, Chief, Project Section C, DRP
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J. E. Gagliardo, Chief, Operations Section, Division of Reactor
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Safety P. H. Harrell, Senior Resident Inspector, FCS R. P. Mullikin, Project Engineer i
J. E. Bess, Reactor Inspector
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R. B. Vickrey, Reactor Inspector
,y m Approved:
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GTL. Constable, Chief ~7roject Section C, DRP Da'te
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0. 0-Y&).bbw 5ll4ko a
T.' F. Westerman,'Chtsf, Project Section ATOW Fate
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Assessment Summary
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Assessment Conducted April 2-6, 1990 (Report 50-2p5/90-23)
Results:
It appeared, based on the results of this assesment, that tt.e licensee has demonstrated positive steps toward improving their overall i
performance by the implementation of the iten;5 contained in the Safety
Enhancement Program (SEP).
The licensee has made substantial progress toward the completion of all SEP items.
It is expected that continued improvement in the overall operation and management of the Fort Calhoun Station will be realized as remaining items are completed.
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The assessment team identified the following observations:
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Institutionalization of the SEP items was not addressed completely in all cases.
The SEP items were not in some cases referenced in the affected
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procedures.
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Alarms were installed on very high radiation area doors (SEP Item 55), but hatches were not included in the program.
The licensee stated that a
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letter would be sent, by May 4, 1990, to the NRC to describe more fully I
the scope of this SEP item, i
Performance indicator data was not available for some items. The licensee indicated that the development of performance indicators would be given further consideration.
- During the approximately 2 years of the existence of the SEP, five.
individuals have been assigned at various times to oversee the completion
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of the items contained in the SEP. Due to the number of individuals involved, a lack of continuity has become apparent as indicated by the l
licensee's failure to address some followup of items identified during
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previous assessments of the SEP. The licensee has indicated their intent to provide continuity for the oversight function and a full-time OPPD employee has been assigned until the oversight function is no longer t
required.
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i DETAILS-
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Persons Contacted
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R. Acker, Quality Assurance (QA) Auditor J. Albers, Superintendent, Document Control, Production Engineering._
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R. Andrews, Division Manager, Nuclear Services N. Bateman, Supervisor, Procurement QA J. Bobba, Supervisor, Radiation Protection
J. Chase, Manager, Nuclear Licensing and Industry Affairs i
G. Cook, Safety Enhancement Program Coordinator
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M. Core, Supervisor, Maintenance S. Gambhir, Division Manager, Production Engineering J. Gasper, Manager, Training W. Gates, Division Manager, Nuclear Operations
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C. Huang, Supervisor, Human Performance Evaluation i
R. Jaworski, Manager, Station Engineering F. Kenney, Supervisor, Access Authorization
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L. Kusek, Manager, Nuclear Safety Review Group T. Matthews, Station Licensing Engineer K. Miller, Lead Mechanical Design Engineer G. Morris, Security W. Orr, Manager, QA/QC
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G. Petersen, Manager, FCS
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R. Phelps, Manager, Design Engineering D. Ritter, Supervisor, Security Support Services
J. Sefick, Manager, Security Services C. Simmons, Station Licensing Engineer
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T. Therkildsen, Supervisor, Nuclear Licensing J. Tills, Assistant Manager, FCS The above personnel attended the exit interview.
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The inspectors also contacted other plant personnel, 2.
Safety Enhancement Program (SEP)
The history of the SEP began in September 1988, when OPPD identified the intent to develop a plan that would integrate tasks as identified from a broad spectrum of areas, such as recommendations from the systematic assessment of licensee performance (SALP) and findings from other sources such as those made by the Institute of Nuclear Power Operations (INPO).
The first issue of the SEP (Revision 0) was sent to the NRC in December 1988.
In April 1989, the NRC conducted an assessment of the status of all SEP items.
This assessment identified the need for the licensee to verify and validate the completion of the items. The verification and validation (V&V) process was incorporated as part of the SEP and, in October 1989, the NRC reviewed the V&V process. This review found a weakness in that there was no formalized procedure for the SEP. The
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licensee issued Nuclear Operations Division Quality Procedure NOD-QP-28 in November 1989, which is the controlling procedure for the SEP. This procedure provides for verification, validation, revalidation, institutional 1 ration, tracking, and control of OPPD's SEP.
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Review of Items Included in the Safety Enhancement Program (SEP) (92702)
The NRC assessment team performed an evaluation of selected SEP items.
This is the third assessment conducted of the SEP process.
The team reviewed the licensee actions and commitments, the verification and validation close out, and the effectiveness and results being achieved.
3.1 SEP Item 1 - Imarove Communications Via Training, Team Building, Eliminate Organizational 3arriers, Monthly Managers Meetings, Newsletter The inspector observed the following licensee actions to improve communications:
Communications and team building modules have been incorporated into OPPD's management development program series (MDPS) as was indicated by the training records for OPPD's MDPS for 1988 and 1989.
The licensee has also integrated communication training into operations and entry-level training programs.
The Nuclear Management Development Steering Committee (NMDSC) has functioned under their charter to monitor and review the MDPS's curriculum and scheduling of training.
The second nuclear organ.'zation climate survey has been completed.
- The senior vice president conducts special meetings with the three nuclear division managers, department managers, and appropriate supervisors, as evidenced by meeting minutes which are maintained, The licensee publishes a biweekly newspaper, " Nuclear Notes," to
communicate issues of significance and interest to all personnel.
The inspector reviewed the V&V package provided by the licensee.
In the case of this package, the original validation records were found to be missing. The validation was repeated-by the licensee on March 31, 1990.
l The licensee has indicated that there are plans to complete a future revalidation of this package.
The inspector found that the V&V package did not include reference to the monitoring function of the NMDSC.
Consequently, the inspector found that the charter for the NMDSC did not i
contain reference to the SEP item as required by licensee Administrative i
Procedure N0D-QP-28, Step 6.2.6.
This requirement to reference the
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appropriate SEP item was initiated by the licensee to assure that proper i
consideration was given to an SEP commitment prior to making a procedure or program change. The inspector also found that the OPPD Nuclear Policy Manual 1.06, " Internal Communications," does not reference the SEP item.
This policy procedure implements a significant part of this SEP item.
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The inspector's review of this item indicated that the elements of this SEP item are being effectively implemented and have been procedurally ingrained (institutional 1 red) into the licensee's programs. Managers and
personnel are being trained in communications and team building. Meetings with management and supervisory personnel appear effective..The biweekly
" Nuclear News" has kept personnel informed of significant items of interest.
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The licensee's program for V&V was incomplete in the identification of the MDSC charter and in the verification of the appropriate reference to the
SEP item in the licensee's procedures.
The licensee has committed to reva11date this SEP item.
The licensee is establishing a process for final closure and for retiring each package when all actions are completed.
The licensee was encouraged, for purposes of continuity, to
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maintain one individual in charge of this final closure process.
3.2 SEP Item 2 - Initiate Training to Encourage Problem Reporting
The licensee has instituted a broad range of initiatives to encourage employees to identify and report problems.
Systems for reporting problems are in place. The licensee issued Standing Order (50) R-4, " Station r
Incident Reports", Revision 20, as the principle vehicle for identifying any sign 1ficant condition or event that could have safety implications with respect to plant operations. Other methods of identifying problems include " Deficiency Reports," " Quality Reports," and " Surveillance Items" as described in QA/QC Department Procedure No. 17.
Also, individuals may identify problems through maintenance work requests or engineering assistance requests described in 50 M-101 and G-82, respectively.
Individuals interviewed were aware of the reporting methods and reported that the systems were workable and that they were generally satisfied with the results.
Feedback to individuals who identify potential problems is a part of the formalized program.
To encourage an atmosphere where reporting problems is viewed as positive
.and helpful, the licensee has instituted visible and well thought out programs.
For example, all supervisors conduct weekly tours, referred to as " management by walking around," to improve face-to-face communications.
A strong industrial safety program is evident.
Training in team building and other psychological techniques were taught to operations, maintenance,
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l chemistry, and radiation protection personnel to improve communications i
among the station staff.
Regularly scheduled meetings are held at all
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levels to encourage communications.
Self-assessments are conducted in all areas important to safety.
Each of these techniques encourages better
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l understanding of safety issues and foster an atmosphere where problems are identified.
The licensee also encourages problem reporting by publicizing examples l
where individuals have identified problems. This is done in a variety of ways, but most notably in a widely circulated publication called " Nuclear l
Notes," which is published biweekly under the direction of the senior vice I
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president for nuclear operations.
It contains articles that encourage a positive attitude about safety and problem reporting. Good performance by individuals is recognized along with articles on management expectations for performance excellence.
Selected NRC enforcement actions and operational problems at other plants are also highlighted.
In conclusion, the licensee has a workable problem reporting system that
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appears to be well understood and used by the plant staff, Management has gone to great lengths to make performance expectations clear and to recognize and reward good performance.
3.3 SEP Item 4 - Develop Plant and System level Design Basis Documents As of the date of this assessment, the licensee had issued all of the planned 48 design basis document (DBD) packages.
Previous references mentioned a total of 50 DBD packages, which included a package for welding and the reactor vessel.
It was later determined that the existing welding manual adequately covered that area. The reactor vessel DBD will be included with the reactor coolant system DBD when the Combustion Engineering Owner's Group completes the development of a design basis reference manual for the reactor vessel.
The 48 packages include 33
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packages for safety-related systems and two systems (instrument air and
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feedwater systems) viewed as important to safe operation.
Fifteen other DBD packages, referred to as " plant level" issues, were developed to cover the design requirements for such broad areas as accident analysis, seismic
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criteria, and site meteorology.
The collecting and sorting of DBDs has been an enormous task involving sorting through over 10,000 boxes of documents in a variety of storage locations. At the time FCS was designed, vendors were not obligated to mainte % all design records.
Fortunately, essentially all design documen.s were stored and have been retrieved..The engineers who were-terviewed thought this was a good program but expressed reservations WJt the number of open items and the eventual ease of use of the
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Engineers who have reviewed the information that has been collected reported that the detailed information available is almost overwhelming.
It is sometimes difficult to find desired information.
I Although the DBD packages have been issued, they have not been verified or validated.
It is not clear, at this time, whether the design information is in a useful form for routine use. The inspector selected the high
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pressure injection system DBD and asked questions about the mechanical and electrical design of the third high pressure injection pump to determine the extent that the design basis allows that pump to substitute for the
"A" or "B" pump.
The information could not be found in a short period of time. A key-word computer search was also unsuccessful, i
The licensee has collected, sorted, and indexed design records and created DBD packages to identify the original design requirements for use in evaluating plant modifications.
Subsequent system modifications were
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included to ensure that the present as-built system status is within the design basis. Althcugh much work has been done, it is not yet clear whether the DBDs are in a form that will allow effective use.
3.4 SEP Item 8 - Establish and Train Safety Review Group OPPD has established a nuclear safety review group (NSRG) to provide independent technical reviews of issues important to safety at the FCS.
These reviews may be self-initiated or at the request of the safety audit and review committee (SARC).
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Initial training of NSRG members is essentially complete.
Individual members of the NSRG received about 5 months of systems engineer training.
In addition, MORT and Kepner-Trego problem solving and decisionmaking techniques were taught.
The licensee plans to provide additional training, including simulator training in the near future. Training policies and procedures have been institutionalized to assure formal management control and continuity.
The NSRG appeared to be fully integrated into site activities. A member of the group noted that problems were being identified and appropriately resolved.
He commented that he had personally used the incident reporting system and was satisfied with the results.
A strength of the NSRG is the variety of technical backgrounds.
Five individuals had worked as licensed operators or engineers at other nuclear facilities.
NSRG activities appear to have been successfully initiated. Training is adequate, and programs needed to assess facility performance are in place and effective.
3.5 SEP Item 10 - Complete the Implementation of Trending and Root Cause Analysis Program by Completing Policies, Procedures, and Training The actions of this SEP item consisted of issuance of a root cause analysis procedure, station engineering instructions on trending, and training of appropriate personnel in root cause analysis.
During review of this item, the inspector established the following:
Procedure N00-QP-19, " Root Cause Analysis Guidelines," was issued to address incident investigation and root cause analysis.
- Procedure QAM-21, " Deficiency Tracking, Trending, and Reporting," was issued to establish the requirements for deficiency tracking, trending, and reportin.
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L Procedure NOD-QP-20, " Human Performance Evaluation System Program,"
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provided instructions for implementation of the human performance evaluation system program.
Review of the documentation produced, as a result of the procedural
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Training had been provided to the appropriate personnel involved in
the activities addressed by this SEP item.
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The V&V process implemented for this SEP item was reviewed and determined to be adequate.
The adequacy was established by the inspector during review of the program implementing procedures.
Based on the results of the review performed by the inspector, it appeared
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that the licensee had fully completed this SEP item and had properly institutionalized their commitments.
The effectiveness of the programs
was evident based on the quality of the trending and root cause analysis reports being produced by the licensee.
3.6 SEP Item 18 - Develop an Overall Mission Statement and Implement Tunctional Position Descriptions This SEP item involved a licensee commitment to develop overall mission
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statements for each organizational division. Subsequently, position descriptions were developed for each individual that prescribe the function, qualifications, and interface responsibilities for their position.
The inspector reviewed the following:
Nuclear Policy Manual Section 1.05, " Functional Position
Descriptions," established the requirements for preparation, issuance, and maintaining position descriptions up to date.
- Position descriptions for 18 individuals to verify that the description fully documented the responsibilities of each position and that all individuals (both licensee and contract employees) had a description for their current position.
The inspector noted that the licensee had verified and validated that this SEP item had been fully institutionalized and implemented.
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Based on the review performed by the inspector, it appeared that this SEP item was fully implemented and that the results of establishing the position description program have resulted in enhanced individual performance.
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3.7 _SEP Item 17 - Develop and Implement succession Program The lietensee has developed a formal succession planing policy, which includes a requirement for a semiannual adjustment to the program by a management development steering committee.
Fifty-four key positions have presently been identified for succession planing. These positions range from shift supervisor to the senior vice president level.
Individuals are identified who have the potential _to fill a specific position.
This selection of candidates is based on observed performance and skills. The number of people identified vary depending on availability of qualified candidates and on the pool needed to fill the identified positions. The targeted individuals are told of their selection and a training program is developed to complete their qr lifications for the targeted positions.
Four such designated individuals have been selected to fill targeted positions to date.
In some other instances, the designated individuals
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were viewed as needing further development and outside candidates were selected.
The licensee has implemented a well' thought out succession plan. This plan has been institutionalized and appears to be functioning to provide a pool of well qualified candidates to fill important positions as they come open.
3.8 SEP Item 20 - Evaluate, Improve, and Strengthen the QA Audit and Surveillance Program This SEP item involved upgrading the audit and surveillance program by changing the emnhasis from a compliance-oriented to a performance-oriented program.
This effort was to be accomplished by revising procedural requirements for the audit and surveillance programs to include INPO good practices and the items identified during review of the licensee's program by an independent consultant.
The inspector found the following:
Procedure QAM-11. " Conduct of QA Surveillances," was issued to provide directions to QA personnel on the philosophy of conducting
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performance-oriented surveillances.
- Procedure QAM-10. " Conduct of Internal Audits," provided instructions in the method for conducting audits to evaluate the adequacy and effective implementation of the QA program requirements.
- The surveillance master list / schedule had been revised to incorporate surveillances based on identified problem areas rather than regularly scheduled audits of the various areas reviewed by QA.
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QA surveillance plans for audits of maintenance observations and i
quality control provided the appropriate instructions for conducting a performance-bar,ed audit.
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Based on review of the SEP item, it appeared that the licensee had adequately verified and validated the appropriate actions to ensure continued performance of the elements in this SEP item.
Institutionalization had been eporopriately completed.
3.9 SEP Item 22 - Initiate Periodic Observations of Work in Progress and Provide Timely Feedback to Craf tpersons and Supervisors This item concerned periodic direct observation of craft and technical personnel by first-line supervisors during normal work activities.
The licensee has developed a lesson plan for observation training.
That lesson plan has been administered to supervisors and foremen as part of the 1988 training curriculum.
In addition, a newly developed standing order (50 G-78, " Observation Program") for providing guidance for field observations was approved by the plant review committee in July 1989.
The inspector reviewed the licensee's training attendance sheets and 50 G-78.
The licensee's training attendance was satisfactory.
The review of SO G-78 found that it provided observation guidelines that were applicable to maintenance, operations, chemistry, and radiation protection.
These guidelines provided for observations by supervisors, foremen, and lead craftpersons. The implementation and frequency of formal observations were left to the discretion of the individual department heads. The inspector's review in this area of implementation and frequency found that the electrical maintenance department was under direction to have the supervisor conduct two observations each month.
The licensee's SO G-78 appears to be a good tool that has the capability of providing effective improvements when used properly. The effectiveness of this tool will be dependent upon how well department heads use it in areas requiring improvement and/or recognizing. excellence.
3.10 SEP Item 24 - Complete Staffing Study The licensee completed their staffing studies in 1988. The staffing study l
indicated a need for 136 new positions.
As of this inspection, there are 818 authorized permanent OPPD employees. Hiring is essentially complete
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except for newly authorized positions and replacements. The licensee has
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experienced an overall turnover rate of about 4 percent per year. An
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annual growth in staffing levels of 1 percent per year is anticipated over
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The licensee has completed a highly successful staffing study and hiring program. OPPD staffing now appears to be on par with other nuclear facilitie e p
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3.11 SEP Item 33 - Develop an On-line Maintenance and Mou "ication Schedule This SEP item was generated to address the actions to be instituted for the development of an on-line maintenance and modification schedule.
Only a limited review of this item was performed by the inspector since the licensee's document package for closure was incomplete.
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on this item was provided late on the last day of the inspection.
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on the documentation reviewed, the inspector noted the following:
No documentation was provided to indicate that institutionalization of this item had been completed.
- No documentation was provided to indicate that the issuance of performance indicators had been considered for this item.
Based on the above discussion, the inspector could not provide a conclusion as to the status of this item.
The licensee has completed V&V
of the item.
3.12 SEP Item 35 - Establish Criteria for Identifying Postmaintenance lesting Requirements, and Track Completion and Retesting Activities This SEP item involves actions to be taken by the licensee to establish a postmaintenance testing program. The elements contained in the program include items such as established criteria to identify the appropriate postmaintenance activities following the performance of scheduled or corrective maintenance, the implementation of a system for tracking corrective actions, and the retesting of equipment and components that fail the postmaintenance test.
This SEP item was first reviewed during the performance of the maintenance i
l team inspection (NRC Inspection Report 50-285/89-01) in March and April l
1989.
This area was subsequently reviewed in March 1990 (NRC Inspection Report 50-285/90-04) as part of a team inspection. The inspector concluded I
during this inspection that six of the seven elements in the " scope of work" for this SEP item had been satisfactorily completed.
The element that was not inspected (establish criteria for identifying postmaintenance testing requirements following troubleshooting) and the implementation and effectiveness of the completed elements will be reviewed during subsequent inspections.
3.13 SEP Item 36 - Reduce Corrective Nonoutage Maintenance Backlog This item addressed the need for the licensee to establish controls to reduce the large number of nonoutage corrective maintenance work order packages that were open.
The licensee has established controls and reduced the backlog from approximately 1500 to less than 600, which was their goa r.
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The inspector found, for example, that the electrical maintenance supervisor had been allotted additional manpower and overtime to reduce the backlog.
The supervisor was aware of the backlog status and satisfied with the planning support efforts in this area.
The licensee appears to have effectively reduced the backlog and has established performance indicators for corrective nonoutage maintenance backlog in the station performance indicator report.
3.14 SEP Item 38 - Major Technical Issues Monitoring /Statusing The licensee has established a monitoring and statusing program for seven major technical issues. This includes a quarterly report to the NRC to update the status. The status at the time of the inspection is as follows:
Probabilistic risk assessment - The overall project is 27 percent complete.
The fault trees are 74 percent complete. The current schedule indicates project completion to be December 30, 1992, unless the effort is expanded as a result of additional regulatory requirements.
- Install and make operational a third auxiliary feed water pump - This effort is on schedule for completion by July 30, 1990.
The diesel-driven pump, which is not designated as safety-related, was in place and mechanical connections were being made at the time of the inspection.
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Reduce flux on reactor vessel - The study is complete and the core configuration has been altered to reduce neutron flux at critical locations on the vessel wall.
- ATWS modification installation - This item is complete.
- Complete definition of seismically qualified equipment and complete equipment walkdowns - Although seismic concerns appear to be bounded and, for the time, acceptable for operation, the complexity of this effort has resulted in a schedule shift to December 1992 for completion.
- Related to Item 5 with a similar schedule.
- Complete and submit station blackout analysis - This item was completed on schedule.
The licensee's program for monitoring and statusing major technical issues appears to be functioning acceptably.
Schedule changes are routinely discussed with the NR p
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3.15 SEP Item 41 - Develop and Implement Preventive Maintenance Program The licensee committed to upgrade the preventive maintenance program to include deficiency criteria on major / safety equipment and develop and implement a planned and preventive maintenance program by the end of 1989.
The inspector revitwed the licensee's actions and verified that a preventive maintenance upgrade program, which resulted in the identification and basis for preventive maintenance (PM) tasks, had been completed.
The methodology used was applied to 53 major safety systems and resulting PM tasks were written on a new preventive maintenance order (PMO) form.
The remaining systems had their existing PM tasks converted to the new PMO form. The new PM0 forms provide more information to the instrumentation and control (I&C) technicians performing these activities.
To complete the preventive maintenance upgrade program, the licensee instituted a five phase program.
With the implementation of the five-phase program, the licensee has l
produced a comprehensive methodology and analytical tool.
The program
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provides for the identification and basis for PM tasks.
The FMEA allows for the identification of equipment for PM activities and provides the recommended PM task.
In conclusion, a PM program has been developed and
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1mplemented.
The inspector reviewed the licensee's verification and validation process.
Verification and validation for this item has been completed by the licensee.
During the validation of this item, the inspector noted that the licensee identified what was considered a significant weakness with respect to the lube oil and vibration analysis PM program. According to personnel interviewed, the lube oil and vibration analysis concerns were addressed by the other programs. However, no documented evidence of the program was reviewed during the validation effort.
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To address this concern, the licensee issued Corrective Action l
The inspector reviewed the licensee's response to the concern and concluded that the lube oil and vibration program is being l
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maintained by the predictive maintenance program which is governed by
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Station Engineering Instruction (SEI) 12.
The predictive maintenance activities are tasked by the PM program.
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SEI 13, and both programs are administered by 50 M-2, " Preventive
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Maintenance Program." Therefore, the two programs as outlined by SEI-12 l
and SEI-13 are matrixed together by S0 M-2.
A review of the referenced documents by the inspector veritied that a lube oil and vibration program has been completed, i
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The new PMO has been phased in since February 1990. Trending of this data is ongoing to determine the effectiveness of the program. The effectiveness of the PM program will be measured with information on the PM feedback forms, ongoing reviews of trend reporting, and component failure analysis reports.
Performance measurements incorporated in the performance indicator report will address maintenance ratio and overdue PM items.
To further ensure the effectiveness of the program, a PM
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administrator and PM engineer have been incorporated to maintain the program. Training has been completed on the PM process and 50 M-2 provides reference to SEP Item 41 and controls the program.
3.16 SEP Item 42 - Evaluate the Need for a Reliability-Centered Maintenance Program This SEP item addresses an evaluation to be performed by the licensee to determine the need for a reliability-centered maintenance (RCM) program.
The inspector discussed the status of this item with the licensee
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representatives who were involved in the development of the PM program.
The status of the PM program is discussed in SEP Item 41.
The inspector inquired regarding the prospects for actually developing the RCM program.
The licensee representatives were optimistic that this effort would be supported and completed. They noted that licensee management had committed additional resources (staff positions) to the development of the PM program.
They believed that, if these additional resources were not withdrawn upon completion of the PM program initiative, the resources would be applied to the RCM effort.
The licensee representatives noted that difficulty had been encountered in the development of the sophisticated maintenance history program needed to support effective RCM and PM efforts. They believed that this problem, which was caused by the difficulty in retrieving maintenance history data, would delay full implementation of the RCM program for 3-5 years.
The progress of this effort will be periodically reviewed in subsequent
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inspections.
3.17 SEP Item 44 - Compliance With and Use of Procedures The actions of this SEP item provide enhancements to the adherence and procedure compliance programs.
The inspector found the following:
Meetings have been held with the maintenance department on a quarterly or more frequent basis.
Enhancements have recently been made to this program to provide an agenda, scheduling, and attendance records.
- Maintenance personnel have been advised that one element of their performance appraisals will be their compliance with procedures.
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new performance appraisal format requires addressing this topic under
" Additional Nuclear Accountabilities."
- Maintenance supervisory personnel and lead foremen have received training in QC inspection techniques.
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SO M-100, " Conduct of Maintenance," and 50 M-101, " Maintenance Work Control," have been revised to require prejob briefings.
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A training program entitled " Guidelines for the Conduct of Maintenance" has been developed. A handbook entitled " Maintenance Crafts Administrative Handbook" has been developed.
- Performance indicators are available to monitor procedural compliance.
The verification and validation process implemented for this SEP item was reviewed and determined to be adequate.
However, the validation process indicated a few weak points, but the licensee stated that none appeared to detract from the item's overall effectiveness. One weak point was that not all sources of procedure noncomplianco information are used to identify and evaluate trends. Specifically, information from the QA department deficiency reports and quality rtports may not be getting the same level of review and analysis as are given to the incident reports used for performance indicators.
The second weak point concerned prejob briefing responsibilities.
The lead craf t supervisor is responsible conducting the briefing.
However, if other crafts are also involved in the job then there is a possibility of some aspect of the job being overlooked in the briefing.
The third weakness identified was that proceduress lesson plans, and plant performance indicator reports did not reference this SEP item.
Based upon the inspector's review of this SEP item, it appeared that that
the licensee has generally completed this item.
However, the inspector found that the performance indicator data for maintenance procedural l
noncompliance incidents was incomplete. The performance indicator chart, beginning in September 1989, only shows the number of incident reports involving procedural noncompliance that were closed each month.
This does not give an indication of the number of incidents that occurred each month.
The inspector brought this to the licensee's attention, and it was l
stated that they were aware of the situation and that the chart would be
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changed.
The effectiveness of this program was not readily apparent since the performance indicator data were not complete.
However, the actions taken by the licensee appear to have adequately resolved this SEP item.
The licensee needs to address the self-identified weaknesses, i
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3.18 SEP Item 55 - Procure Hardware and Replace _Locksets on Very High Radiation f
Area (VHRA) D.t. ors and Barriers and Implement an Improved Key Control
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Program The item involved actions to be taken by the licensee to ensure positive control of doors and barriers that control entry into VHRAs. The actions included alarming (locally and remotely) doors and barriers that provida i
entrance into VHRAs.
The inspector reviewed the following:
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Procedure GM-PM-MX-0501, " Inspection and Repetitive Maintenance for Alarmed RCA Doors," provided instructions for inspection and adjustment of all alarmed doors in the radiologically controlled area (RCA) on a monthly basis.
This procedure is intended to provide assurance that the doors remain operable.
- The installation of alarms on VHRA entrances during a tour of the plant.
During review of this SEP item, the following items were identified:
Alarms had been installed on doors for VHRAs, but alarms were not installed on two hatches (Rooms 62 and 11) that provided access to VHRAs.
- The licensee, in a letter dated January 19, 1990, provided a status to the NRC that stated that this item was completed.
In discussions with the licensee, the following items were established:
The scope of this SEP item was not intended to include installation of alarms on hatches.
- The licensee had not informed the NRC of the exclusion of hatches from the scope of this item.
- The hatches were under a lock and key program that was controlled by health physics personnel.
This program had been previously reviewed by Region IV health physics personnel for adequacy and was determined to be satisfactory.
Based on the discussions, the licensee stated that a letter would be sent, by May 4, 1990, to the NRC to more fully describe the scope of this SEP item.
In addition, the licensee, in the letter, will clarify the scope of any other SEP items, as appropriate.
The inspector concluded that the licensee had implemented this SEP item, except as described above.
Institutionalization had also been adequately addressed, i
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3.19 SEP Item 60 - Improve Controls Over Surveillance Test Procram The licensee has taken steps to improve the surveillance test (ST) program controls and ensure personnel compliance with ST program procedures.
The inspector reviewed the following licensee actions:
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SO G-23, " Surveillance Test Program," has been revised to assure that STs are reviewed and approved by the immediate supervisor or system engineer.
- Procedure N00-G-2 gives responsibility to the assistant plant manager to assure reviews and procedure revisions are completed to fulfill
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requirements of amendments to the Technical Specifications.
- ST results are reviewed and trended.
- Facility License Change (FLC) 88-19 was approved by the NRC which granted a 25 percent grace period for Technical Specifications surveillance due dates.
In addition, this change provides clear definitions of test-to-test frequencies.
- SO G-7, " Operating Manual," has been revised to require verbatim compliance from every individual performing activities at the FCS.
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The operations and maintenance departments have incorporated verb aim compliance requirements into their procedures.
- The ST tasking data has been loaded onto the Computerized History and Maintenance Planning System (CHAMPS).
- Station Engineering Instruction SEI-14, " Surveillance Testing," has been written.
This procedure provd. des guidelines for program administration, data management, scheduling, precedure preparation, performance, trending, and analysis and maintenance of records.
The licensee has completed the V&V process for this item.
In a memo dated August 8, 1989, the licensee identified two weaknesses.
One weakness was that FLC 88-19 had not been approved by the NRC at that tiee.
The second weakness was that the trending analysis had not been effective due to cotputer software problems.
Results showed a pattern rather than a trend.
The FLC 88 M has subsequently been approved and computer software problems have been resolved.
One of the major reasons that STs were late was that some STs did not have a grace period on due dates, previously, if an ST frequency was
" annually" and the ST was not performed by 1 year from the date of the last ST, then the test was late. The FLC 88-19 has corrected this problem and the reduction in late surveillance tests has shown this to be effective.
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The missed surveillance tests resulting in LERs will be incorporated into the plant performance indicator data beginning in April 1990.
The licensee's corre tive actions on this SEP item appear to adequately address this concern.
The number of LERs submitted for missed surveillance tests has been greatly reduced. The addition of missed surveillances into the performance indicators will be of benefit.
The licensee has done an adequate job of institutionalizing this SEP item.
3.20 SEP Item 61 - Modify Computer Program to Correctly Schedule Surveillance Tests The actions identified in this SEP item are to improve controls over the surveillance test program by implementing surveillance testing using the CHAMPS.
The inspector verified that the licensee has implemented the use of CHAMPS to schedule surveillance tests.
The licensee has completed verification and validation of this SEP item.
The validation efforts identified three weaknesses. The first one was that automatic scheduling of tasks when old ones are closed was not possible on the CHAMPS system. The second weak point was that CHAMPS has only a 30-day tasking window.
The third weak point was that the performance of group tasks by procedure instead of by component was contrary to the design of the CHAMPS sof tware.
The licensee responded to these identified weaknesses by stating that the enlargement of the tasking window beyond 30 days is possible but automatic tasking and the change from component to procedure level group tasking are not.
The licensee has completed SEI-14, " Surveillance Testing." This procedure provides guidelines for program administration, data management, i
scheduling, procedure preparation, performance, trending, and analysis and maintenance of records.
The effect of this procedure is too soon to tell since it was approved on March 30, 1990. The overall reduction in missed surveillances is evident as mentioned in SEP Item 60.
The last LER was written in May 1989 for a missed surveillance test.
I It appears that the licensae's actions to improve controls over
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surveillance test scheduling has been effective.
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3.21 SEP Item 62 - Establish Interim System Engineers The licensee established a system engineering department in July 1988 and a program plan for development and implementation of a staffing plan.
The establishment of this engineering function was to ensure better engineering support for the plan.
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The inspector found that all system engineering positions are filled.
There are 23 new hires and 18 who were selected from existing OPPD staff.
The final certification is to be completed in July 1990.
Four lead engineers have been assigned. There is a lead engineer each for primary systems, for secondary systems, for electrical /I&C systems, and
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for systems support. System and/or support. engineers are in turn assigned
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to each lead engineer, and they have, in turn, been assigned systems and/or support functions by the lead engineers.
The inspector found that key plant procedures have been revised to-incorporate the system engineering functions into maintenance work orders, temporary modifications, surveillance testing, and design changes.
The inspector found that system engineering department instruction had been established.
These instructions are considered to be interim and are to be incorporated into the production engineering procedures. There was some confusion on the part of system engineers interviewed on the status of these procedures. The licensee is encouraged to ensure that the duties and responsibilities of the system engineers is made clear to all involved individuals.
V&V have been completed for this item by the licensee.
The validation indicated three weaknesses. The first weakness was that thefullimplementationofthesystemengineerprogramwouldnotbe complete until July 1990.
The inspector s review of this weakness
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indicated that the title of this SEP item was interim system engineers and that the target date provided to the NRC of January 15, 1989, was based on having interim system engineers in place.
The words of the SEP item are based on implementation of a system engineering function and not an interim function. This appears to have resulted in some confusion.
There have, for example, been no performance indicators established since there l
are no interim system engineers.
Reference to this SEP item in the l
applicable procedures has also not occurred as required by N00-QP-28.
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The failure to establish performance indicators and to complete the l
institutionalization was also identified as one of the three weaknesses.
The remaining weakness indicated that specific number of personnel assigned to the system and/or support engineering functions was in minor variance to the number stated in the SEP commitment made to the NRC.
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licensee indicated that consideration would be given to clarify this item in a future revision to the SEP.
The inspector found that the system engineering function is being effectively implemented and has been incorporated in the day-to-day plant l
activities.
Results are evident in the control of work orders, temporary modifications, surveillance testing, and design changes.
System deficiencies are being identified and resolved in a timely fashion.
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Weekly walkdowns are also identifying system deficiencies and needed improvements.
Performance indicators have not been developed.
Such indicators would further highlight the effectiveness and results being achieved by the system engineering function.
The licensee has indicated that the development of performance indicators will be given further consideration.
- The reference of the SEP item in the appropriate procedures remains incomplete.
The completion of the incorporation of the system engineering instructions into the production engineering procedures also remains incomplete.
3.22 SEP Item 63 - Complete Safety-Related Vendor Manual Upgrade Project The licensee's Vendor Manuals Program Upgrade Project was responsible for establishing, upgrading, implementing, and maintaining a continuing program to ensure that vendor technical information is complete, current, and controlled. This project was created to address the intent of NRC Generic Letter 83-28, " Required Actions Based in Generic Implications of the Salem ATWS Events."
The licensee divided this project into two phases.
The first phase addressed the safety-related vendor manuals received prior to November 1, 1996. This work, which included 740 vendor manuals, has been completed.
The second phase was the identif'- ' ion and collection of programmatic deficiencies necessary to implemer.
.aaintain an ongoing vendor manual review program for manuals received +- i-November 1, 1986.
This phase has not been completed as yet.
The V&V process identified three weak points. The first weakness was that the upgrade project procedures, which came from Stone & Webster Technical Services, needed to be incorporated into plant procedures.
The second weakness was that the continuation of the program was not guaranteed.
The third weakness was in the annual review program.
If a document was revised by the vendor after the annual review, the licensee would not receive the revision until the following year when the annual review occurred.
These weaknesses described cannot be closed until the program is completed and turned over to the licensee from the contractor.
This is scheduled to be completed by the end of 1990.
l Based upon the inspector's review of this SEP item, it appeared that the
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licensee is satisfying the intent of the item.
The licensee should continue their efforts and assure institutionalization.
3.23 SEP Item 65 - Revise _the FCS Modification Control Procedures This item involved the need to incorporate the control of modifications into the FCS modification control procedures, j
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The inspector reviewed the following:
The controlled modification list for the 1990 outage
Section 4.0, " Approval Process-Project and Modifications," of the Nuclear Program Plan Manual The licensee had performed a V&V of this item, as well as institutional 1 ration of the program into the nuclear program plan.
Based on the review performed by the inspector, it appeared that the licensee had taken timely actions to implement the requirements of this item. As a result, a controlled modification list was generated for the 1990 refueling outage that provided a prioritized list of modifications to be completed.
The prioritization was based on the safety significance of the modification.
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3.24 SEP ltem 67 - Develop and Implement a Plan to Assign Licensed Operators as Instructors Authorization for two additional operators was authorized for 1988 to enhance OPPD's ability to reassign licensed operators.
One senior reactor operator was transferred to the training department and requisitions were approved to hire additional operations training instructors.
A plan was to be developed and implemented for transfer of operators to training to serve as instructors.
Additional nonlicensed operator personnel have been hired.
Two complete sessions of nonlicensed operator training were completed in 1989 to qualify personnel.
A plan to determine assignment of operations personnel to other departments was presented in a June 26, 1989, OPPD memorandum to the Division Manager, Nuclear Operations. The plan will result in the increase of three, six, and six additional licensed operators to the staff operating shift in May 1990, November 1990, and April 1991, respectively.
The plan is on schedule except for the last six additional licensed operators.
The licensee is delaying the next operator licensing class
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I until a minimum number of six are available. The licensee was notified by NRC that the minimum acceptable class size for examination is six.
l The training department, as part of its " Objective Work Plan Milestones,"
I is establishing plans in 1990 for increasing licensed operators in the l
operations and training organizations. Appropriate reference to this SEP l
item has been included in the milestones reviewed by the inspector.
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V&V for this SEP item has been completed.
The V&V process pointed out that the plan was contingent on some very tight expectations.
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inspector's review indicates that schedules are being met.
The delay in the last group of six is generally beyond the licensee's control and, at present, only represents a delay of 6 months.
Institutionalization appears to be occurring and the commitment to the SEP item is appropriately referenced in such documents as the training i
department 1990 milestones.
i The performance measurements are identified as TSP-09 and TSP-12, which are indicators of the total number of licensed and nonlicensed operators.
They do not, for example, directly relate to the increase of licensed operators in the training department.
f The inspector's observation is that the licensee is making a significant increase in licensed operators as committed to in this SEP.
The training manager indicated that it is the goal of the training department to have
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an organization composed of all licensed or equivalently certified j
personnel.
The elements of this SEP item appear to have been appropriately institutionalized into the licensee's programs.
Although there are performance indicators established for this SEP item, the licensee's training managers indicated that consideration would be given to establishing an indicator related more directly to the increase of licensed personnel in the training organization.
3.25 SEP ltem 71 - Improve Controls Over the Review and Documentation of Temporary Modifications
The actions of this SEP item consisted of determining how some other licensees control temporary modifications and incorporate any good practices into the FCS temporary modification program.
The licensee contacted INPO on how other plants control temporary modifications.
INPO subsequently provided the licensee with some sample industry procedures that describe the control of temporcry modifications.
The licensee, based on the review of the INPO-supplied prcy dures, revised i
SO 0-25, " Temporary Modification Control," S0 M-100, " Conduct of
Maintenance," and S0 M-101, " Maintenance Work Control." Training was
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completed on these procedures.
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The licensee's V&V efforts have been completed. Three weaknesses were discovered during the validation efforts. The first weakness noted the perception that the entire program for temporary modifications, initiated in response to the SEP, was ineffective due to the fact that a deficiency
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report was issued to document some administrative inadequacies found I
during an audit.
The licensee's response to this finding was that a new procedure and program in the initial implementations stage 15 an easy
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target for auditable discrepancies, but they do not render the program tntally ineffective.
The second weakness addressed an inspection report which was issued due to a temporary modification not reviewed by the plant review committee within the 14-day limit.
SO 0-25 was revised to require that all temporary
modifications be approved by the PRC before installation, except for emergency situations when 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> is granted.
- The last weakness involved the timing of plant review committee approval of temporary modifications as it relates to the Technical Specifications.
This was also resolved with the revision to SO 0-25.
The licensee has completed this SEP item.
Institutionalization appears complete and adequate. The licensee's performance indicator data for temporary modifications references SEP Item 71.
The performance indicator data has shown that the total number of temporary modifications has been fairly stable since March 1989, 3.26 SEp Item 72 - Surveillance Test Performance Needs Improvement The actions specified in this item include a review of existing surveillance procedures. Also, the actions included the verification of whether pump and valve procedures can be performed as written and the reevaluation of inservice inspection pump and valve acceptance criteria.
The licensee's specific actions included the following:
The safety-related procedures upgrade project has completed drafting all identified inservice inspection surveillance test procedures.
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The pump and valve surveillance test procedures were reviewed for
compliance to ASME Section XI and proper " ceptance criteria per Subsections IWP and IWV.
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The verification that the pump and valve procedures can be performed as written is being done as part of the safety-related procedures upgrade project.
- A review of existing pump and valve surveillance test procedures has been done to ensure that a complete list of pumps and valves exists
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to comply with the requirements of ASME Section XI.
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New procedures were developed for position indication verification to meet the requirements of IWV-3300.
- A checklist was developed to be attached to surveillance test procedures.
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This SEP item is essentially complete.
Some of the actions are connected to SEP Item 48, which is the safety-related procedures upgrade project.
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-4.0 Overall Conclusions
During the approximately 2 years of the existence of the SEP, five i
individuals have been assigned at various times to oversee the completion
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of the items contained in the SEP. -Due to the number of. individuals
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involved, a lack of continuity has become apparent as indicated by the
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licensee not addressing concerns identified during previous SEP reviews performed by NRC personnel.
The licensee has indicated that their intent
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is to continue with the assignment of the present full-time OPPD individual
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Overall, it appeared that the licensee was adequately addressing the issues identified in the SEP.
Based on the reviews performed, the NRC
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determined that licensee initiatives will complete and implement the various SEP issues.
Further, the completion of the SEP should enhance the
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licensee's capabilities to operate FCS in a safe and efficient manner.
t 5.0 Exit Interview
The inspectors summarized the scope and findings of_the assessment during the exit interview on April 6, 1990, with the personnel identified in paragraph 1.
No proprietary information is contained in this report.
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