IR 05000295/1990004
| ML20042E168 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 04/04/1990 |
| From: | Hasse R, Leemon R, Shepard D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20042E167 | List: |
| References | |
| 50-295-90-04, 50-295-90-4, 50-304-90-04, 50-304-90-4, NUDOCS 9004200319 | |
| Download: ML20042E168 (22) | |
Text
.
v
- r
. -
?se
E
.,
.
U.S. NUCLEAR REGULATORY COMMISSION REGION 111 Reports No. 50-295/90004(DRS);50-304/90004(DRS)
Docket Nos. 50-295; 50-304 Licenses No. DPR-39;'DPR-48 Licensee: Commonwealth Edison Company Post Office Box 767 Chicago, IL 60090 Facility Name:
Zion Nuclear Power Station - Units 1 and 2 Inspection At: Zion, IL 60099 j
~
Inspection Conoucted:
February 26 through March 9,1990 Inspectors: kOM N l4 l30-R. A. Hasse, Rill Date
'
Team Leader Yb VdN'lO D. L. ShApard, RIII Date d ? W-4/4/10
. Leemo W Date
.
J. R. Sears, Consultant (COMEX)
M. R. McWilliams, Consultant (SAIC)
Approved By:
88(dt
[C
'//2/ 70
/ Monte P. /Phillips, Chief Date Operational Programs Section Inspection Summary inspection Conducted on February 26 through March 9, 1990-(Report No. 50-295/90004(DRS); 50-304/9004(DRS))
Areas Inspected:
Special announced safety inspection.to verify that the Zion Emergency Operating Procedures (E0Ps) were technically correct and usable.
The inspection was conducted in accordance with TI 2515/92(SIMSNo.HF4.1).
Results:
No violations were identified. The licensee showed strength in-program control and basis documentation. Weaknesses were identified in the areas of licensed and non-licensed operator training, plant equipment labelling and lighting, and quality oversight, l
9004200319 900404 I
PDR ADOCK 05000295 l
.
.*
'
,.
..
.
i
i
l REPORT DETAILS l-1.
Persons Contacted L
l.
Commonwealth Edison Co. (Ceco)
l K. Graesser, General Manager, PWR Operations
'
T. Joyce, Zion Station Manager
.
P. LeBlond, Assistant Superintendent, Operations
N. Valos, Operations G. Trzyna, Training Supervisor R. Chrzanowski, Nuclear Licensing
>
,
!
R. Budowle, Services Director l
W. Kurth, Production Superintendent l
T. Saksefski, Regulatory Assurance l
R. Adams, (R&E). Operations-D. Kaley, Operating Procedures Coordinator T. Van De Voort, Quality Programs R. Landrum, Simulator Training Supervisor D. Selph, Simulator Senior Instructor L. Bunner, Training' (Byron)
H. Lagaros, Zion Training J. Madden, Technical Staff U.S. NRC l
G. Wright, Chief, Operations Branch, RIII l
M. Phillips, Chief, Operational Programs Section, RIII (
B. Clayton, Chief, Projects Section 1A,.RIII All personnel listed above attended the exit interview conducted on March 9, 1990.
Other licensee personnel were contacted / interviewed during the inspection.
2.
Emergency Operating Procedures l
a.
Background Emergency Operating Procedures (E0Ps) have undergone significant changes due to the 1979 accident at the Three Mile Island (TMI)
facility.
The post-THI procedures are sympton-oriented rather than event-oriented. Symptom oriented E0Ps provide the operator guidance on how to verify the adequacy of critical safety functions and how to restore and maintain these functions when they are degraded.
.
't
.G
.
'
..;
Symptom-oriented E0Ps are written in a manner that the operator need.
not diagnose an event to maintain the plant.in a safe shutdown condition for all accidents that are within.the scope of the E0Ps.
The purpose of this inspection was-to verify that the. Zion E0Ps are technically correct; prepared in accordance with the' writer'.s guide;
.
that their specified actions can be accomplished using existing equipment controls, and instrumentation; and that the available procedures have the usability necessary.to provide the operator with an effective operating' tool.
'
.
b.
Inspection Methodology
'
The inspection consisted of.a-desk top' review of 25 Optimal-Recovery
Procedures and 18 Function. Restoration Procedures; an in-plant.
walkdown of local actions specified in 9 Recovery Procedures and one-Abnormal Procedure; exercising six scenarios on the plant. simulator which tested the use of 17 procedures; and a human factors. review of'
'
the procedures, plant walkdowns, and-simulator exercises.. In addition, users and developers of the E0Ps were interviewed. A detailed listing of these activities is.givenlin Appendix A.
I c.
Inspection Results The inspectors concluded that the-Zion E0Ps were adequate to mitigate accidents within the scope ofJthe ERGS and could be implemented by the plant staff. A few concerns were. identified with the E0P with the primary concerns involving the performance of-activities outside the control room.
These and other concerns are discussed in the following paragraphs.
Detailed comments'are given in Appendix B.
(1) Desktop Review The desktop review consisted of a detailed comparison of the E0Ps to the Owners group (WOG) Emergency Response Guidelines (ERGS). Where deviations from the ERGS occurred, the documented justification was assessed. The documentation for the setpoints used in the E0Ps was also reviewed.
Most of the inspectors' concerns with the E0Ps were relatively minor and were resolved during the inspection (see.
Appendix B).
Concerns requiring further' assessment and resolution are discussed below.
The Zion Critical Safety Function-(CSF) status Tree F.0.1,
"Subcriticality" contains a caution stating that if the reactor cavity fans are lost, the nuclear instrumentation may be unreliable and an assessment of' reactor status should be
'
_
,
r
,
'u
.
-.
,
.
performed before continuing with the procedure. No guidance is given on how the' assessment should be performed. This status'
-
tree transitions to the ATWS procedure on an orange or red path
and the timeliness of this transition is important.; The
,
licensee agreed to assess the need for including assessment criteria or delete the~ caution.
.;
Tripping the Reactor Coolant pumps is a contingency. action in
,
the ERG for E-0, " Reactor Trip or Safety Injection" if.
containment spray is required.
In the ERG this is an immediate action step (which the operator is to comit to l
memory).
This is not an immediate action-step in the corresponding Zion E0P. The licensee stated that-this' action is identified on the E0P foldout page and would be performed if required. The inspector's concern was that the foldout page:is not committed to memory and some delay. in execution could occur. The licensee needs-to reassess their: position-on this
,
issue.
i
?
E0P ES-0.1, " Reactor Trip Response" provides no plant specific -
means for restoring power to the service buses as required by
,
the ERGS. The licensee agreed to assess this issue for an.
appropriate E0P change;lhowever, the licensee was waiting for I
a response to the station-blachout analysis which could impact this step.
Step 4 of the ERG for FR-S.1, " Response to Nuclear _ Power Generation /ATWS", initiates emergency' boration and11s an immediate action stop.. A substep of. step 4 in the ERG requires that the pressurizer pressure be ver_ified less than the PORV-pressure setpoint. This assures adequate injection = flow.
The corresponding Zion E0P incorporated this substep as a high~
level step not designated as an immediate action. The
..
inspector's concern was that an adequate.boration rate must be established quickly and the' pressurizer pressure can impact-this rate.. The licensee agreed to assess.this issue.
- In step 11.d of EOP E-1, " Loss of Reactor or Secondary Coolant",
Zion stops all but one containment spray pump. The equivalent:
ERG step specifies stopping all pumps. The deviation document stated that the reason for this was that the Standard Review Plan required running the containment spray _ pumps-for at least two hours.
The. licensee stated that this practice _at Zion
'
predated the implementation of the' ERGS. The inspector's concern was that unnecessary operation of the spray.-pumps could result in instrumentation' problems and unnecessary drawdown of the RWST. The licensee agreed to reassess this issue.
.
l
.a
.
.
?
,
-During the initial injection phase of core cooling, suction is taken from the RWST. When the RWST: low level is reached, the suction source is switched to the containment sump in the recirculation mode, in two cases (loss of recirculation capability and~ LOCA outside of-containment), the RWST is the only source of water for injection. Since the drawdown rate on the RWST may be considerably higher than the rate at which it can be refilled, makeup should be initiated as quickly as possible to maximize the length of time it is available as a suction source. The only Zion E0P explicitly directing the-refill of the RWST is ECA-1.1, " loss of Emergency Coolant Recirculation". The other E0Ps in the E-1 series:(loss of reactor or secondary coolant) in most cases contain steps directing the technical support center.to asses the need to refill the RWST; however, in some cases.these steps may not be reached due to transitions to other procedures. The licensee agreed to review this-issue for potential procedure changes.
Resolution of these issues will be tracked as an open item (295/90004-01; 304/90004-01).
,
Several strengths were identified during-th'e desktop review.
The setpoint documentation was very complete and well presented.
Also, the basis for each E0P step, caution or note was documented
!
on a " Bases identifier Sheet". This is a valuable resource for i
not only a reviewer but more importantly for anyone planning a
revision to a procedure.
The process for generating or revising E0Ps was well-documented and controlled including the writers guide and verification and
validation program.-
!
(2) Walkdowns
,
Walkdowns of selecte'd procedures were: conducted with' licensed and non-licensed operators who would normally-perform these l
tasks. The objective of these walkdowns was to verify that all
operator actions called for in the procedures could be
!
performed in a timely manner with minimum potential for error.-
!
Walkdowns were performed in the control ' room and.in the plant.
The results of these walkdowns are summarized below and examples of specific findings are provided in Appendix B.
i In general, control room indication and controls called for-in the E0Ps were available and labelling of the control panels was
,
consistent with the terminology used in the procedures.
No problems were observed with regard to operators being able to locate and use control room instrumentation..There were'some
,
!
l
<[
.-
..
.
.,
isolated instances of procedures failing to provide identification numbers for radiation monitors located on back'
panels, and some steps that could be reordered to prevent operator backtracking across the panels.
During the walkdown of in-plant tasks, there were some problems'
encountered by o pipe chase (VPC)perators in locating valves in the vertical. Valve locati
.
to be incorrect, providing line penetration levels instead of correct levels for valve access.
Locating valves was further
hampered by poor lighting, limited access, and valve labelling that was sometimes difficult'to read.
.
the VPC appeared to be inadequate to perform-actions during a
!
loss of AC power event, and no emergency lighting was available in the Spent Fuel Pit Heat Exchanger Room:or the pump rooms for CS, RHR, SI, and charging.
Problems with in-plant communications were observed, including poor. radio. transmission in some. areas and nonoperational telephones in the VPC. There were some
&
instances where valve labels were missing or'had become detached in the turbine building.
During the walkdowns, it was also determined that effective methods were not in place for providing equipment operators with a written list of local tasks to be-performed during I
I implementation of the E0Ps. Typically, control room operators
,
reported that they would make a photocopy of pertinent pages _to
,
send with the equipment operator, or communicate each step over
'
the phone or radio. This does not take into account situations where the copy machine may be unavailable, or communications may be poor as noted above.
The licensee needs to improve the efficiency:with which field activities can be performed. The elements: involved in this effort are discussed below:
t.
- Equipment Labelling - The licensee has a labelling upgrade program in progress. This has apparently been pursued on a relatively low priority basis.
The priority for labelling-equipment that may need to be operated locally-during
casualty situations should be increased.
I
Lighting - The licensee needs to improve normal and emergency lighting for local operations.
Some emphasis should be placed on emergency lighting in areas containing equipment that must be operated locally during the loss of all AC power (ECA-0.0, ECA-0.1, and ECA-0.2).
.
+
.
...
.
,
.
.
Communications - The_ licensee should evaluate the adequacy-
of communications between the control room and: personnel
performing actions-in the field during casualt This includes not only verbal' communications (y events. telephone
,
L
+
and radio) but the availability of written instructions to.
L the local operators.
'
The resolution of these' concerns will be tracked as an.
openitem(295/90004-02;304/90004-02).
\\
\\
l Equipment operator training which also impacts the
..
j efficiency of local--operation = is. discussed in; Paragraph 3.
l (3) Simulator Exercises Six scenarios exercising 17 E0Ps were conducted ~on the Zion simulator to verify that the procedures provided the operator
.j with an effective _ operating tool to place the plant in a safe shutdown condition for accidents and transients within the
-
scope-of the ERG's, The scenarios were run utilizing two different operating crews consisting of a Shift Engineer (SE),.
i Shift Foreman (SF), two licensed reactor operators-(NS0), and aShiftControlRoomEngineer(SCRE).
In general, the specified actions detailed in the selected l
E0P's were technically correct and could_be accomplished using l
the existing equipment, controls, and instrumentation._
Some concerns were identified:
There appeared to be no strict protocol for the reading of-steps, cautions and notes which was inconsistent with reported station policy requiring-verbatim reading of all I
substeps. notes and cautions during the performance of the E0P's. This was not evident-in many of the scenarios.in that notes or cautions were:not always read and at times substeps were not read.
In addition, steps, notes or cautions were sometimes paraphrased vice being read-verbatim. The station policy of repeat-backs was inconsistently applied, ranging from excellent to no feedback at all. At times, the procedure reader did not maintain eye contact with the operator: directed to perform-
.
'i actions which lead to operators crossing paths to perform tasks not clearly assigned..
The transitions were generally correct, however, one crew had confusion on whether to transition to FR-H.1 " Loss of
i
,
-
,.
'
m
.,-
.
,
,
q
~
l
.
.
l Heat Sink".when the capacity to feed the-steam' generators-
.
was lost with sufficient level only in a ruptured steam I
generator.. Another instance was-a transition to E-2
" Faulted Steam Generator Isolation,"- performance of steps in E-2,_and then a transition back to E-0 " Reactor
,
Trip or Safety Injection" without completion of E-2 or l
'
using ES-0.0 "Rediagnosis".
-At the' simulator, three copies of the E0P's.were available-
l for the crew's use.: The facility must ensure that the-i same availability of E0P's is used during training as is-
.
l available in the control: room. At times during the -
l simulator scenarios all the operators were reading the procedures and no one was monitoring plant parameters.
- During a Steam Generator Tube Rupture scenario,_the
,
accumulators were allowed to inject.into the. Reactor Coolant System. The cause of this appears to be the loo during the steps for securing -the Safety injection' (SI) ping
,
!
pumps. The ERG's only check for sufficient subcooling-and
,
not " pressure stable or increasing" as in the Zion E0P's.
During one scenario, the crew was concerned about the steam generators depressurizing. The cause was due to_an operator continuing the cooldown of the plant.
Some-confusion was generated until the Shift Engineer diagnosed
~
the problem.
Step 4c of E-3 " Steam Generator Tube Rupture" requires securing the Turbine Driven Auxiliary Feedwater Pump if
'
either steam generator B;or C are ruptured. This logic is'
not the desired action; this RNO should only apply if the steam supply from either A or D steam generator can not be closed.
The licensee agreed to: address these-issues through-training and/or procedure revisions..
(4) Verification and Validation
.
l The verification and validation programs were documented in ZAP-5-51-4A, "E0P verification", and ZAP-5-51-4B, " Procedure
'
Validation.
One strength identified in this area was the inclusion of all operating procedures in the validation program (a weakness found at many other facilities). At the same time, a weakness l
l
'
.
- '
.
.
.
"
p
,
'
l-
'
l was identified in the validation program in that it did not
~i
~
l emphasize'the walkdown methodology for.. field activities. Most
.
I of the inspector concerns-identified in Paragraph 2.c.(2) could
,
.have been identified by the licensee if the walkdown methodology.
t
,
l had been used more extensively.-
l The Safety Evaluation for'the Zion Procedures Generation Package
!
l was' issued subsequent to this inspection'(Chandu P. Patel, NRR-
.
to Thomas J. Kovach, CECO dated March 13,1990). This Safety Evaluation noted some concerns with.the verification and validation program.
It appeared'that at least some of-these concerns had been-addressed by' the licensee; however, the
.
licensee ~should carefully review these concerns.to assure that
,
,
L they all have been addressed.-
,
d.
Human Factors Review The E0Ps were reviewed for-consistency with guidance provided in l
Zion's E0P Writer's Manual (ZAP 5-51-5A) and accepted human' factors
?
l principals as described in NUREGs 0899-and 1358. The review
L identified a number of areas where human factors related I
improvements could be made; however, none were determined to pose l-significant safety concerns.
In many cases, where specified -
discrepancies were identified, corrections were implemented during
!
i l-the course of the inspection. Areas where concerns were identified l
are discussed below. Specific examples are provided in Appendix C'.
t j
(1) General'EOP Comments
.;
Cautions and Notes - Cautions should be used to alert operators to hazardous conditions that may cause-injury or equipment damage, and should describe the consequence of the hazard. Notes should be used to^present supplemental information to the operator.. Neither cautions.or notes should contain action statements.
In many cases, however, Zion's E0Ps contain cautions and notes that,are actually.
-
recurrent or contingent action steps. For example, If
-
CST level is less than 0.5 feet, SW must be. suppl.ied to-
-
the AFW pumps..."
Hazards or potential consequences of
-
actions (or inactions) are presented infrequently.
Cautions were also found that. contained non-critical information which serves to dilute <the.importance given
!
to them by the operators.
'
Use of Logic % rms - Logic statements are used to describe
,
a set of conditions that must be assessed by the operator or a sequence of actions that must be performed. Because-
'
decisions can be difficult to make dur.ing emergency
n
.-.
-
-.
,
~ ~
,p.;.
'h b
',
,
q-y a
'
.
situations, it is critical that logic statements be clearly -consistently and appropriately used. When action-
,
steps-are contingent upon certain conditions, the step
should begin with the description of the condition.
In
!
many cases, however, Zion procedures began the statement with the action term followed by'the condition.
For example, "Stop depressurization IF any of the following occur.."
In most instances, this structure was used in cases where the action could only be performed if the conditional statement was met, (for example " Reset SI,-
'
IF actuated"). Therefore, this practice did not' pose a
'
serious potential for causing actions to be performed
inadvertently by the operators. -It does', however, l
establish a poor. precedent for structuring: conditional i
statements that' could result in misleading instructional steps. There were'also some cases where conditional statements contained more than one condition which makes
~
"
it difficult to determine whether the contingent action should be performed.
Step Structure - Zion's E0Ps follow-the Westinghouse ERG format of providing high level _ steps followed-by lower-
level substeps that describe the specific actions that must be performed to accomplish each high' level step.
In-many cases, the. generic guidelines provideLsubsteps.that must actually be performed prior to the specific' action
,
describedinthehighlevelstep(i.everificationofpump
'
start criteria before actually starting the pump)..In
other cases, substeps. describe actions which are not-totally consistent with-the-high level step wording.
In many cases, Zion has reworded. steps to prevent possible-confusion; however, there are still a_ number of steps that contain this flaw.
j Equally Acceptable Steps - In a number of cases, steps are identified in the procedures as equally acceptable steps'.
For example, " Start RCP B AND/0R'D.
In reality, however, many of these alternatives are preferable for a given set i
of conditions. Zion procedures need to reflect when-a L
specific path is preferred and under what, conditions.
l L
Place Keeping - Procedures should provide methods for the
'
L operators to keep track of the current step while performing designated activities. -Although Zion's E0P notebooks have
,
ribbons for marking pages when the operator must leave and L
re-enter a procedure, no means of tracking steps is
'
provided. Aids such as check-off boxes should be provided to assist operators in tracking steps that have-been
,
'
,.
.
A-
'
.
performed or parameters that have been-verified..- Such aids are especially important in tracking performance.
of non-sequential steps.
Zion's prescribed method of-
'
using " yellow stickers" is not-viewed as an optimum.
placekeeping method.
-
l (2) Review of Writer's Guide
.
-
.
Guidance for the development of E0Ps at Zion is provided as
'
ZAP 5-51 5A, " Emergency Operating Procedure Content and
';
,
Format."
In general, this document provides adequate-direction.
'
l.
to writers and is' consistent with accepted human factors principals and guidance provided in NUREG-0899..There are a few areas however where inconsistencies were noted.or where l
guidance could use additional. detail. There-areas are
'
identified below:
i Section 3.5 Procedure-Access and: Identification - Needs-
toclarifyhowprocedureswillbe. tabbed (i.e. number?
!
title? color?).
Section 4.3.4 Recurrent-Steps - There<is no direction provided as to how the operator should be reminded to perform concurrent steps.-
Section 4.3.6 Non-Sequential: Steps - Directions on how to write these steps is' very' vague.
,
Section 5.2 Operator Actions - For steps that require l
completion before going on, give specific language to be
'
used.
Section 5.2.4 Use of Logic Terms - Writer's guide gives--
permission for conditional term to. follow the required
.
action for " simple" conditions. Conditional terms should.
always precede the action.
Section 5.2.7 Placekeeping Aids - Provides no mechanism.
r for placekeeping within a procedure, such as check-off
boxes.
t Section 5.2.8 Component Identification
.Does not require that abbreviations be from the-list of standard-abbreviations provided in table 3.
This.should be an all inclusive list, not '! examples" of abbreviations.
Section 7.4 Vocabulary - Instead of providing a list of
" frequently used" verbs, the list should identify and define all. action words that are acceptable for use in the E0Ps.
r
l l
!
.
q
-
.
The licensee should-also review the comments on the Writers Guide presented in the Safety Evaluation for the procedures Generation Package for pertinence to the current issue of the Writers Guide.
,
(3) Operator Interviews
"
Operators (R0s and SR0s) were interviewed to determine their understanding of the E0Ps and their responsibilities in executing the procedures as part of the control room team.-
Additionally, operator opinions were solicited regarding i
adequacy of training on the E0Ps, opportunities.for operator; input in revising-the E0Ps, and overall satisfaction with the technical accuracy and useability of:the procedures.- Interviews.
were also conducted with non-licensed operations staff regarding-their roles in supporting the. implementation of the:E0Ps.
In general, licensed operators demonstrated a-good.un'derstanding-
~i of the E0Ps and expressed no significantl concerns with the accuracy or usability of the procedures. There were a few steps where operators said that additional clarification or-guidance might be helpful, but none were viewed as serious problems. There were:some misunderstandings identified =
regarding conventions used in the procedures, (such as use of boxes around steps'to indicate non-corresponding-contingency actions),
There were some cinconsistencies reported initerms of ' control.
room protocol -(i.e. reading steas and substeps verbatim and
,
requirements for repeatbacks) witch were also observed in the s:mulator exercises. -This raises a' question'as:to the.
't effectiveness of crew training to instill-a cohesive. station policy regarding. procedure use. Operators indicated that crew 5}
,
l training is currently provided shortly before annual crew rurganization. Although most operators. felt that their-l training was adequate, there were some. concerns raised:about.
'
i the minimal _ time devoted to-some of the more remote E0Ps (such i
asFRs). Operators also felt that additional-training.in the ERG basis documents would.be helpful. Lack of. training in use
.
of the SPDS was mentioned as a training weakness.
Interviews were also conducted with equipment operators.:.It was determined that non-licensed operator training does not-specifically address.the A and:B operator functions during execution of the E0Ps. This area was also identified by the-
-
licensee as a weakeness and is being addressed (see paragraph 3).
's
,
i
.
'
.
< -
- ,_
.
,
.
'
'
.
3.
Trainir.g and Qualification Effectiveness
,
Training issues identified during this' inspection are discussed in Paragraphs 2.c.(2),2.c.(3),'and2.d.(3). These concerns are summarized below:
'
Licensed Operator Training - The operators expressed a need_for
more training in the E0P basis documents and the contingency and function restoration procedures.
Inspector observations during:the
,
simulator exercises confirmed this need as well as a.need for more training in_ procedure transitions and control room protocol.
,
Non-licensed operator training - During the walkdowns of local.
- operations, a need was identified for more equipment operator-training on the _ location of equipment:that may need to be operated locally during a' casualty event.
Because the list of equipment is extensive,-this training should also-include the~use of-available.
-
resources for quickly locating ' equipment if its location is not immediately known to the operator.
The resolution of these training) concerns will be tracked as an open
'
item (295/90004-03; 304/90004-03.
4.
Quality Verification Effectiveness The licensees efforts in this area was considered to be weak. No independent in-depth technical audit of the E0Ps had:been conducted
,
until February 1990. The limited scope of this audit precluded the-
'
identification of some concerns. identified by the inspection team.
Specifically, the audit did not cover field activities or training
'
adequacy.
Where the audit did cover areas-inspected by this inspection team,.it did not identify similar concerns. Specificall E-0, E-1, and FR-S.1-(see paragraph 2.c.(1)y, those. concerns relating to-and Appendix B).- The audit did identify several concerns which were resolved.
Licensee efforts'to strengthen this area will be tracked as an open item (295/90004-04; 304/90004-04).
5.
Open Items
'
Open items are matters which.: ave been discussed with the-licensee which will be reviewed further by the inspectors or which involve some actions on the part of the NRC or licensee or both. Open items disclosed during thisinspectionaredescribedinparagraphs2.c.(1),2.c.(2),3,and4.
6.
Exit interview The inspectors met with licensee representatives (denoted in Paragraph 1)
On March 9, 1990. The inspectors summarized the purpose, scope,'and findings of the inspection and the likely informational content of the inspection report. The licensee acknowledged this information and did not identify any information as proprietary.
a
,
'
,.
'.
'.
' Appendix A-
-
Description of Inspection Activities E0P(1)
TITLE (3)(2)E-0-Reactor. Trip Or Safety Injection-ES-0.0 Rediagnosis ES-0.1 Reactor Trip Response
ES-0.2 Natural Circulation Cooldown
'
ES-0.3 Natural Circulation Cooldown With
,
SteamVoidinVessel(WithRVLIS)
ES-0.4 Natural Circulation Cooldown With Steam Void In Vessel (Without RVLIS)
(2)(3)E-1 Loss Of Reactor Or Secondary Coolant (3)-
.SI Termination.
_
_
.
ES-1,2 Post-LOCA Cooldown And Depressurization (2)(3)
ES-1.3 Transfer to Cold Leg Recirculation (3)
ES-1.4-Transfer to Simultaneous Hot and Cold Leg Recirculation (3)
E-2 Faulted Steam Generator Isolation (2)(3)E-3'
Steam Generator Tube Rupture (3) ES-3.1 Post-SGTR Cooldown Using Backfill ES-3.2 Post-SGTR Cooldown_Using Blowdown ES-3.3 Post-SGTR Cooldown Using Steam Dump
-
L (2)(3)ECA-0.0 Loss Of All AC Power-ECA 4.1 Loss Of All AC Power Recovery Without S1 Required l-ECA-J.2 Loss Of All AC Power ~ Recovery With SI Required (2)(3)ECA.1.1 Loss Of Emergency Coolant Recirculation ECA-1.2 LOCA Outside Containment ECA-2.1 Uncontrolled Depressurization Of All Steam Generators l
I (3)ECA-3.1 SGTR With Loss Of Reactor Coolant-Subcooled Recovery ECA-3.2 SGTR With Loss Of Reactor Coolant-Saturated Recovery (3)ECA-3.3 SGTR Without Pressurizer Pressure Control F-0.1 Subcriticality F-0.2 Core Cooling F-0.3 Heat Sink F-0.4 Integrity
.
F-0.5 Containment F-0.6 Inventory (2)(3)FR-S.1 Response to Nuclear Power Generation /ATWS FR-S.2-Response to Loss of Core Shutdown (2)
FR-C.1 Response to Inadequate Core Cooling
'
FR-C.2 Response _to Degraded Core Cooling FR-C.3 Response to Saturated Core Cooling (3)FR-H.1 Response to Loss of Secondary ' Heat Sink FR-H.2 Response to Steam Generator Overpressure FR-H.3 Response to Steam Generator High Level FR-H.4 Response to Loss of Normal Steam Release Capabilities
.
.
..l *[
. ;,.
..
i
,
FR-H.S Response to Steam Generator Low Level:
'
FR-P.1 Response to Imminent Pressurized Thermal Shock Condition
.
!
FR-P.2 Response to Anticipated-Pressurized Thermal
!
Shock Condition
'
FR-Z.1 Response to High Containment Pressure (3)FR-Z.2 Response to Containment Flooding i
FR-Z.3 Response to'lligh Containment Radiation l
FR-1.1 Response to High Pressurizer Level
~
FR-1.2 Response to Low Pressurizer Level
-
FR-1.3 Response'to Voids in Reactor Vessel j
l
?
I
.i l.
I.
f
^
l l
>
-.
l i
!
-.
.
'
.
..
$
$
+- -
,
..
.
j
.
- -
-
.
'
.
AOP T11LE
.[
!
(2)
A0P-7.4 Control Room Inaccessibility
!
. i Notes:
.
t
.(1) All E0Ps were reviewed during theidesktop review described in i
Paragraph 2.c.(1).
l s
(2) Theseprocedureswerewalkeddownasdescribed.inParagraph2.c.(2).
[
t (3) These procedures were exercised during'the simulator scenario's
.i describedinparagraph2.c.(3).
[
!
t
.I
,
e
!
,
4 f i
~
.
t
- f
.
.
I
!
<
' !
'
.
.
..
.
Appendix B Detailed Connents on The Zion E0Ps Procedure Connents E-0
Step 5 - Verifying MSIV bypass valve closure should be included as an immediate action.
~
~
'
Determining the need to trip the RCPs should be an immediate action.
- Figure 1 - It should be made clear that " Containment Pressure is or has been greater than 23 psig.
- The E0P Basis identifier Sheet does not include the caution preceding step 20.
Step 9 - The direction to open the MSIV bypass valves when they may have been closed in step 1 RNO may cause confusion. Also, step 9.6 does not address Tavg with no RCPs running.
- Appendix A, Step 4d
"Significant duration" should be defined.
The sequence of steps 3, 4 and 6 should be reassessed.
RCS boration may be started and stopped many times before the required boron concentration is obtained.
Step 23.b RNO does not have a transition back to step 15.c.
ECA-0J
'
Step 4 - Contingency actions require use of an "R" key to obtain access to steam supply valves that must be locally operated. This requirement is not identified in the procedure.
Steps 4.b,13.a - Contingency actions and Table 3 provide incorrect-location information for a number of valves in the vertical pipe chase
'_
'-.
'
-
..
i
.
(VPC). The procedure provides the penetration level for the associated pipe instead of the access level for the valves themselves - (MOV MS0006, MOV-FW0052,53,56&57).
'
A number of equipment tags on valves in VPC were difficult to locate or
read (small metal tags, often facing away from line of sight).
- Step 6 - Directs operator to set equipment switches in Pull-To-Lock.
List of equipment is ordered such that the operator must walk back and forth several times.
Should follow normal operator path down the control
,
board from starting position at DGs.
!
Step 15 - Calls for checking CST level. Meter is labeled SEC WTR STOP TK
LEVEL.
Step 20.e - RNO action reference to containment spray / isolation phase B
,
reset pushbuttons inconsistent with new panel labeling..
Step 25.c - This step calls for check of radiation monitors on back panel but does not provide monitor number (ORE-0005 and ORT-AR03).
I
Step 25.c - This step calls for check of radiation monitors on back panel but does not provide monitor number (0RE-0005 and ORT-AR03).
,
Step 30.b RNO - Directs the operator to locally close boric acid evaporator inlet isolation valves.
Entry to this area requires a
l respirator.
Since the evaporator has not been in service for several years, these valves could be taken out of service or aligned closed so
'
that this step could be removed from the procedure.
l Step 30 e - Directs the operator to throttle open a CC water.HX discharge
valve while maintaining greater than 80 PSIG on local gauge.
Pressure gauge cannot be read at the valve locations. Also, this step should be identified in the step as a local action.
- Step 30.e.2 - Should be identified as a local action.
ES-1.3 l
l Steps 6a RNO and 9a RNO should define actions for the cases in which attempts to start RHR train B is or is not successful.
- Appendix A is not referenced in the procedure.
- Step 13
"If required" should be defined.
E_S.d
Step Ac RNO - This step should be reworded to clarify that MOV-MS0006 should be closed only if SG A and/or B is ruptured, a MD feedwater pump
.
' ',
'e
.
,
.
-
.
is available, and the associated AFW pump steam supply valve.cannot be l
closed.-
ECA-3.1
ERG note preceding E0P step 16 should be re-inserted.
There are cases j
where it would be applicable to Zion (e.g., loss of bus 147 with 1A ccp
andIBSIsecured)
,
Steps 16 and 17 - The subcooling valves based on-the number of SI. pumps
-
running should be re-inserted. The SI pumps could be inoperable.
FR-S.1 i
Step 6 --This should be an inmediate action step.
FR-S.2
!
Step lb RNO - If IR current is increasing, the operator should be in I
FR-S.I.
t
FR-C.1
The second caution before step 1-in the ERGS was~ deleted in the Zion E0Ps. The deviation documentation does not address this deletion.
+
f FR-1,1 Step 5 RN0(2) - The rationale for stopping the charging pumps is
acceptable; however, this should be addressed in the deviation document.
-i
.
!
t
?
I
>
i
- -.
--
.
,*
'
I
.
,
.
Appendix C Examples of Human Factors Findings ECA 0.0
The caution about establishing cooling to the DGs prior to step 5 is
)
worded as an action step. This caution should be reworded and_ include
!
information regarding time limit to establish cooling.
{
Step Sa.1 directs the operator to verify " Normal" DG voltage and
frequency. As no normal range is indicated on gauges, " normal" band!
l should be provided in procedure.
'
Step 13a. RNO should be reworded to indicate requirement for a
communication with Control Room to perform this task.
- Step 14a directs the operator to refer to ZED-3 to evaluate other i
non-essential DC loads. This should be pre-evaluated before event-and
,
included as appendix to procedure or elsewhere.
- Step 15.b RNO calls for arranging for offsite _ supply of water. Procedure for such arrangements should be pre-established and available in control room (perhapsincludedinA0P-4.3).
Step 16 directs the operator to " Initiate depressurization of Intact l
SGs."
Following steps provide criteria to be met before depressurization-
,
is really to begin.
- Step 24.b RNO should specify the valves that may need to he realigned to l
clear alarm or make reference to step 21 RNO.
I
!
Step 25.c directs operator to check level in spent fuel pit - Greater
'
than 610 feet.
Since low alarm set point is 614'4" this action would only be necessary if an alarm were present.
- Step 26 ends with the initiating logic condition.
Step 27 directs operator to energize 480V ESF Bus (es). Reference to
procedure (501-63) or appendix should be provided, t
Step 30.f directs the operator to " operate additional CC water pumps as
,
necessary" followed by step directing him not to exceed 2 pumps per HX.
This information should be provided prior to direction to operate pumps, t
Appendix A, steps 4 and 5.b should refer operator to Table 1.
i
_
.
^
.
-
,
,
,
'
I
'
.
f E-3 l
!
Step 2.a.2 RNO directs operator to stop all RCPs within 5 minutes.
'
Should indicate *within 5 minutes of loosing component cooling."
,
Step 8.a - Reorder substeps to prevent possible confusion due to negative i
in first statement, i
Step)8.a RNO - Clarify the condition to which the IF NOT epplies.
IF
(SGs NOT isolated or IF (SGs) NOT needed for cooldown.
I Step 14.c Use of AND/0R in listing alternatives for dumping steam makes
it difficult to determine preferred action. This statement needs
clarification as to the preferred method.
l l
Step 14.c RNO directs operator to either use faulted SG for dumping steam
.
OR go to ECA-3.1. Clarification should be provided as to conditions for
!
choosing either alternative.
,
!
Caution preceding Step 15 should indicate consequence of not completing
cooldown rather than simply directing operator to perform the action.
P
Step 18.a - Using AND/OR to connect two alternative ections makes _it difficult to determine preferred path.
.
Step 22 directs operator to stop ECCS pumps; however substep clarified to
"stop all but one charging pum)." Confusion could be prevented by rewording upper level step suc1 as "Stop the following ECCS pumps...'
Caution preceding step 31 refers to uncertainties of instrumentation, connotating unreliability.
Better wording would refer to differences in i
precision or calibration of instruments.
Step 37.c directs operator to start one or two RCPs at discretion of.
l
Shift Supervisor.
Based on reported differences in operator philosophies on prioritization, either additional guidance is needed in the procedure, or training in consistent station philosophy.
,
ECA-3.3
-
Step 4.b - Additional guidance needed on preference of starting RCP.
Use
of AND/0R does not define preferred path.
- Step 6.c - Conditional clause in a logic statement is presented after the
i contingent action is stated.
l Step 8.a needs to clarify if level greater than 4% is required in all SGs
[
or at least one SG to satisfy expected response.
e
,
.
-
,,, -
'.!'
.
,-
-
.,.
,
Q
,
.
.-
.
.
Step 11 should be reworded to indicate "stop the following ECCS pumps..."
Step 19.b should be reworded to clarify awkward sentence structure.
t
'
Caution preceding step 28 should be reworded as per comment.
l
.
Step 31 provides three alternative methods for depressurization, with no i
guidance for preferred method or conditions that would lead to selecting a particular method.
,
Note preceding step 10 allows operator to delete step "if desired".
[
Guidance should be provided regarding conditions that would warrant
performance or deletion of step.
'
ES-1.1 j
Step 4 directs operator to "stop all charging pumps but one centrifugal."
!
Step should be reworded to remove exception (but one) from end of
.
sentence.
.;
!
'
Appendix A. Step 12 needs to be reworded to ~ direct operator to return to.
j procedural step from which Appendix was entered.
$
!
-
!
q
i
'I f
I i
!
[
)
I t
i t
I
-l
-
.