IR 05000289/1988005

Insp Rept 50-289/88-05 on 880515-06-11 & 17.No Violations Noted.Major Areas Inspected:Loss of Main Feedwater Regulating Valve Differential Pressure Transmitter & Resulting Transient

ML20151E686
Person / Time
Site:	Three Mile Island
Issue date:	07/13/1988
From:	Cowgill C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20151E663	List: IR 05000289/1988005 ML20151E660
References
50-289-88-05, 50-289-88-5, NUDOCS 8807260170
Download: ML20151E686 (59)

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.U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Docket / Report No. 50-289/88-05 License: OPR-50 Licensee: GPU Nuclear Corporation P. O. Box 480 .

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Middletown, Pennsylvania 17057  ;

Facility: Three Mile Island Nuclear Station, Unit 1 Location: Middletown, Pennsylvania

Dates: May 15 - June 11 and 17, 1988 Inspectors: R. Conte, Senior Resident Inspector D. Johnson, Resident Inspector (Reporting Inspector) ,

T. Moslak, Resident Inspector A. Sidpara, Resident Inspector S. Peleschak, Reactor Engineer, RI R. Hernan, T -

Project Manager, NRR  !

Approved by:

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C. Cowgill, Chief,(Rejetor Projects Section 1A Date !

Inspection Summary: The NRC staff conducted routine safety inspections during nor-mal operations at power. Plant operations items reviewed were: the loss of a main feedwater regulating valve differential pressure transmitter and resulting transi-ent and planning for plant operations on decay heat removal with lowered reactor vessel water level (GL 87-12). Equipment operability items included: reactor trip breaker maintenance; RC-V-28 environmental qualificattor and NR-P-1C maintenanc .

Safety Issues Management System (SIMS) items reviewed included: MPA-A-15, diesel :

generator fuel oil; MPA-B-03, pressurized water reactor moderator dilution; and, '

! 75(B-90), Salem ATWS Generic Letter items 4.3 and 4.4, Other items included: a

, licensee /NRC staff meeting on the technical support self-assessment and licensee i action on previous inspection findings.

' Inspection Results: Operations activities continued to be accomplished safely with operator attention and response to the feedwater (FW) transient being espec. ally timely. No major plant transient resulted from the instrument failur Licensee action in response to the RTB undervoltage (UV) device problem was adequate, but it appears that finalization of adequate preventi ce maintenance (PM) activities

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was still to be determined. Also, new PM activities initiated by the site person-nel resulted in another different breaker problem (failure to shut). Licensee

, action in resolving the RC-V-28 EQ problem was adequate, although the response time to finally resolve the item after initial identification was excessive.

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i Licensee action on previous unresolved items and SIMS items was adequate. No ad-ditional concerns resulted from these reviews. The technical support assessment l

meeting was informative, but root causes.and specific corrective action for pre-

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vious problems were yet to be identified.

e i No violations of regulatory requirements were identified.

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8807260170 000714 PDR ADOCK 0500g 9 G -

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. SUMMARY RANKING l

Summary Functional Activity , Ranking

XVI STA 51 *

l Ill Surveillance Test Program 47 *

Xll SU&T 46 l l

XIV Maintenance Support 40 '

IVb IST Program 38 *

XV Fuels 32 *

i IVa iSI Rmram 32 * l Vil Technica Reviews 30 XVil Technical Programs 29 Xill Chemistry 23 *

IX Computer Software Maintenance 23 i Technical Support 22 X Pf ar.t Performance Mo Vill Rcactor Engineering 19 *

VI Set Point Control 18 XI Configuration Control 15 ll Engineering Assist. Requests 14 V Modification Control 13

• Limited Data Areas . .- . . -. .. -. ..

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COMMON 0BSERVATIONS

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Study structure would tend (and did) solicit comments that focus on weak or negative performance characteristics. TMI tended to be most critical, Parsippa leastcriticaland 00inbetwee Some areas examined had very little data surface. Therefore simpje quantitative !

results shouldn't lead to conclusions. Comments must be considered in combinationwith simpledat I Sufficient data had to be available to select areas for indepth evaluatio '

Frequency of comments and consistency of comments weighed heavily in the

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selection of areas for further study area '

Three issues selected are consistent with issues raised by NRC and INP0 and because of their perceptions, in addition to our results, should be examined furthe '

Broad functional areas with interdivisional ties tended to have more frequen diverse comments. Narrowly focused areas tended to have fewer comments and were perceived as better performing area '

Interviewers met with TSSA team and agreed on selection criterion and issues chosen.

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CONFIGURAT10N 00NTR0 Observations ~

o An area thatneedsattention

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o Many comments, could have anticipated most o Comment fairly evenly divided between - quality, timeliness,' p cooperationconcerns o Expectations of requirements differ between users, data originators, overseers, custodians o There are holes in our data base e.g., calculation records, setpoint backu l

SDDs, drawings  !

o New PolicyStatement o GPUNs current practice different than INP0 concept (87-006)

Hypotheses o GPUN Iacks a common corporate understanding of current configuratio '

management system requirements and future development plan nedad, o GPUN has an incomplete, inconsistent, overlapping process of configu ;

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00NFIGURATl0N 00NTROLLCont'd)

Follow-on Analysis o Limit analysis to Engineering Configuration Control i.e., excluded 0&M configuration management o Validate and/or modify and document the above hypotheses '

o identify changes to integrate existing elements of configuration management. Identify restructured controls needs, o Draft a development and implementation plan to supplement and strengthe existing systems / capabilities o Engineering Services lead the effort. Initial report Due 2nd Qarter 198 I

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'. MODIFICATl0NS CONTROL OBSERVATIONS GPUN Poor up front definitionlunderstanding of pro,ect scop ' BlAapprovalprocessuntimel ' Inadequatewalkdown ' Timing of PEDR and reviewer support inappropriate in many case ' Excessive rework of some mods as evidenced by large number of FOR's, FQ's etc

' Lateprocurementof equipmentandsparepart ' Modifications take excessive amount of time and cost too muc ' Startup and Test not considered part of design process and not included earl desig AE'S

' PoorPerformanceReflectedininterviews--395-3's 17-1's

' Poor definition of pro ect scope and direction given to ale on front end is heavy contributor to poor ale performanc ' ale's have inadequate overall plant knowledg ' Lack of Adequate Engineering Standards for ale Performanc ' Inadequate control of ale - not held accountable to schedule dates, et ' Inadequate in-house review of Alli design package prior to issuanc .. __- _ . .. . - . _ _

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MODIFICATIONS (Cont'd?

Hypothesis

' GPUN front end direction to the AE and subsequent control of the AE contributes to poor AE performanc l

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' Weaknesses in the modification control process such as lack of control of desig !

incomplete engineering documents, improperly designed or installed modification unclear procedures, etc. have been identified and require corrective actio ' Deficiencies tend to surface more frequently on the larger, multi-disciplinary pr than on the smaller, narrow scope pro;ect Follow-On Analysis Assigned 7 individuals to an analysis group devoted to review the modificat

' Analysis group met with Technical Self Assessment Analysis Team for clear d of workdone todat ' Reviewing findings and status of follow-up implementation of previous task l forces / studies in the modification are !

' Will compare results of above review with weaknesses defined as result of this self assessmen ' Review includes two multi-discipline type, modification packages at TMI a

Creekdonewithinthelast twoyear ' Will identify specific problems and correspondir.3 root caus ' Willidentifyrecommendcorrectiveaction ' Will examine type of concerns raised and resolved by EQlFOR proces ' Mod Group team initial report due June 1988

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l ENGINEERING ASSISTANCE REQUESTS l

OBSERVATIONS

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Work requests do not clearly identify problem to be solve work request prioritizations are not well controlle Reporting of backlog task status to originators is not consisten '

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Lackof timelinessincompletionof taskrequests.

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Five separate tasking systems Llack of commonality?.

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Threshold for work requests generation not commonly agreed upo HYP0 THESIS

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Inconsistent Technical Support results from inadequate resources being ap task due to poorlinconsistent prioritizatio Feedback systems are not in place to permit effective reprioritization of tasks to communicate changing status to originators,

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The goals of task prioritization are not clear (safety, capacity factor, operal convenience) and are not integrate FOLLOW-0N ANALYSIS l

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Each site location examined their role in the Engineering Assistance Req

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Taken location specific actions to improve timeliness and improve feedback originator Began meeting with Originators to review statuslthreshold for origination, etc

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Review performance in six to twelve month . -

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CONCLUSIONS o Technical Support Far Broader /More Complex than NR0llNP0 Focus o NRC Observation of Inconsistent Performance Supported by TSSA -

buton Different Basis o Location to Location Differences (Organization, Culture, .

Experience, Policy, Procedures, Stability, Accountability?

Complicate the Technical Support Environment

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o Site Perceptions / Expectations of Technical Functions Communicated to INP0lNR0 vs. First-Hand Knowledge of Performance o Problems identified in TSSA are Persistent; Human Behavior Oriented o For Sustaining Changes in Staff Performance, Management Accountabilities Must Be Accepted which Demonstrate Sustaining Interest in Routine and Non-Routine Activity Performance o Too Much Paper Reporting vs. Predictable, Face-To-Face,

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Functional Activity Reviews at Various Management Levels o No Silver Bullet. Solutions Must Be Actively Managed Over Long Time Frames to Achieve Changes in Corporate Culture

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SUMMARY OF RECOMMENDATIONS 1. Completing the Phase Ill follow-on effort as soon as practicable for the threefunctionalareasidentified, 2. ISSA Team will develop a specific set of guidelines in Phase IV for future monitoring of technical support performance, including when the first reassessment should be conducted, by whom and what scope is ,

appropriat , Comments obtained during the TSSA data collection effort are being grouped by functional areas and provided to the responsible functional managers. The managers are expected to take action, as appropriat . Copies of this final Phase I & li report are being sent to all interview team members and technical support functional managers, The report will be reviewed with the technical support staffs and feedback comments required by the functional managers to TSSA management sponsors regarding their staff's agreement with this final report and correctiveactionsidentifie . Technical support functional managers are expected to review the methods and the results of those methods used to hold their staffs and vendors accountable for performance. Changes should be discussed and concurred in by the respective Division Directors, 6. GPUN's Operational Analysis Section conducted an independent review of the TSSA effort. The methods were found acceptable for the intended purpose Comments were taken into account subsequentl _ _ _ - _ _ . - - . - - - -

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SUMMARY OF RECOMMENDATIONS (Continued)

l 7. To improve the knowledge and wareness of each sites' people, accountabilities and methods, there will be an increased rotation of staff

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and management members between functional organizations and between all staff locations. This should be done in a fashion which avoids losing i or degrading the positive morale and 'esprite de corps' that exist in the !

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individualorganization . Becoming more aggressive in the management of technical support l backlogsby: Identifying and quantifying backlogs by work category and setting !

targets to bring the total in each category to an acceptable level at each site, Reviewing each backlog category with originators and adjusting priorities ateachsit . At least annually we will conduct review meetings with the management !

of each ma,or AE to address accountabilities, expectations and performance over the period. The review should include performance evaluations on key core ale individuals. The reviews should contain strong and weak performance factor . _ .__ _- .__ . - -

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SUMMARY OF RECOMMENDATIONS (Continued)

10. Department management interface meetings are intended to be held on a sustaining basis between the following departments: Technical Functions - Plant Engineering

- Plant Engineering - OPSlMaintenance TechnicalFunctions-MC&F Plant Engineering-MC&F TechnicalFunctions-0A 11. GPUN Technical Support Management (Department Managers and above?

have agreed to adopt a policy and practice of regular business review meetings to provide forums for regular subordinate reporting, face-to-face, of successes, failures and forecasts of their performance on their functional accountabilitie l l

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CONFIGUR ATION M AN AGEMENT i PH ASE Ill ACTION PL AN o PHASEI AND ll--MANAGEMENT REVIEW

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- PresentedNovember1987 0 00NFIGURATION MANAGEMENT TASK FORCE FORMED

- ReportOutlinedJanuary1988 o CM MODEL DEVELOPED

- DraftSection Completed March 1988 o REVIEW GPUN ECM SYSTEM

- NearCompletion o TEST GPUN PERFORMANCE AGAINST MODEL

- AE Visits By Task Force-May11 &12

- OtherUtilityVisits-June 1988 ,

- Assessment of Existing GPUN Programs 0 00MPLETE CM REPORI-JUNE 1988

- Including Short/Long Range Recommendations

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o PHASE Ill MANAGEMENT REVIEW - JULY 1988 o TECHNICAL SUPP0RT GROUP TRAINING - SEPTEMBER 1988

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MODlfl0ATION CONTROL PHASEIll ACTION PLAN l

0 MODIFICATION ASSESSMENT TASK FORCE FORMED MARCH 1988

- 4 Modifications Selected for Review

- 2 from each site: 1 relativelyfreeof problems ,

l 1 with some problems o ASSESSMENT TEAM ESTABUSHED FOR EACH SITE

- Project Engineer

- Plant Engineer

- Plant Analysis Manager - M,0.R.T. Trained Nanagement Oversight & Risk TreeAnalysis?

- Engineering Services Engineer (common to both teams)

o INVESTIGATIONS CONDUCTED APR'L1988

- Evaluation of Modification Procestes and Prior Studies

- Evaluation of Implementation on Selectedects Pro o FA0Tl0BSERVATION-CONCLUSION-RECOMMENDATION

- TheTechnique Applied for theStudy

- Several Recommendations Being Evaluated o PREUMINARY REPORT

- June 1988

- Wili ce Reviewed by TSSA Team vs Phase I & ll Results

- Results will be Presented to GPUN Management l

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FUTURE o GPUN EXPECTATIONS

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o SHARING OBSERVATIONS WITH SITE RESIDENTS o SHARING OBSERVATIONS WITH REGIONAL MANAGEMENT o FEEDBACK FROM NRC

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, TECHNICALSUPP0RT ORGANIZATl0N o INP0 focus on organization, procedures, accountability, resources o High number of comments (800) but balanced strengths and weaknesses o TMl-1 comments skewed towards critical of others o Differences between sites in expectations evident

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o Nospecificfollow-on II. ENGINEERING ASSISTANCE PQUESTS o INP0 focus on service request, workload management, closecut 0 Fivedifferent systemsinuse o Significant supplierluser differences in expectations o Backloglfeedback major hard points o TSSA follow-on and additional management attention recommended Ill. SURVEILLANCE TEST PROGRAM o INP0 focus on technical specifications of test limits, results l

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0 Limited data (32 comments), mostly adequatelstrong o Nospecific follow-on I ISIPROGRAMllST PROGRAM l

o INP0 treats both together, GPUN separates programs 0 Quality Assurance Department has lead on ISI, Plant Eng, on IST o Both rated well, however ISI users commented on Technical Support o ISillST management should review all comments

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FUNCTIONAL ACTIVITIES SUMMARY (Continued? ,

I PLANT. MODIFICATION CONTROL

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o INP0 focus on design, procurement, quality and schedule o Ma or source of commeni: and frustrations o Ranked weakest overall, but not clear consensus

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o AlEPerformanceamaorissue o TSSA fallow-on and additional management attention recommended V SETP0lNT CONTROL o INP0 focus on controlled documentation vs. design basis o Not a centralized function or process for control o Considerable missingdata o TSSA follow-on as part of Configuration Management work recommended

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Vl TECHNICAL REVIEWS o INP0 focus on process of reviewing, confirming change adequacy o GPUN process for review umbrella's safety and technical o Safety review process and implementation inconsistent l

o Technical reviews procedures and implementation adequate o No specific TSSA follow on, but additional management attention recomme Vil REA0 TOR ENGINEERING  ;

o INP0 focus is on onsite core engineering functions o Limiteddatacollected i

o Communications between Systems Engineering and Oyster Creek a weak o No specific follow-on recommended due to recent organization change

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FUNCTIONAL ACTMTIES SUMMARY (Continued?

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I COMPUTER SOFTWARE CHANGE CONTROL

, o INP0 focus on process computer hardware / software o GPUN includes simulators and other real time systems o Comments focus on needs for personal computer hardware and

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applications controls of Technical Support functions o No specific follow-on identified but additional management attention mayberequired PLANT PERFORMANCE MONITORING o INP0 focus on plant / systems thermal performance; reliability o Limited data collected. Generally adequate, o No specific follow-on recommende X NFIGURATl0N 00NTROL o Not addressed by INP0 in Technical Support model o Organizationally disbursed accountability but not fully appreciatedas partof alllobs o importance is new issue in the industry LINP0lNRC?

o Follow-on work and managemont attention recommended XI START UP AND TEST

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o NotaddressedbyINP0 o Viewedgenerallyasastrength o Strengths based on small group, well focused, clear accountabilities and on si

o No specificfollow-onrecommended

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FUNCTIONAL ACTIVITIES SUMMARY LContinue(

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XIll. CHEMISTRY o No!coveredbyINP0 model  !

l o Limiteddatacollected 0 Communicationslinterface weakness apparent in comments o No specific follow-on, but management attention to communications weaknes recommended I

XI MAINTENANCESUPPORT o NotcoveredbyINP0 model o GPUN focus is different between sites but site users seem generally satisfiedI o Communications / feedback issues cited in comments I o No specific follow-on recommendations X FUELS l

0 Not covered by INP0 model. Technical Functions Division supports all off-sit fuel,fuelcyclework o Limited data collected, but generally seen as strong o No specific follow-on recommendations XV SHIFTTECHNICAL ADVISORS o Not covered by INP0 model, included for GPUN model completeness o Ranked strongest of all functional activities o Minorinterfaceproblems noted o No specific follow-on recommendations

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FUNCTIONAL ACTMTIES SUMMARY LContinued)

XVi TECHNICALPROGRAMS o NotcoveredbyINP0 model 1 o GPUN model includes Fire Protection, Environmental Qualification, Vendor Do Engineering Data Basel0uality Classification List

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o Programs neitherstrongnoweak o No specific follow-on recommendations f