IR 05000295/1997027
| ML20199G545 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 01/30/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20199G477 | List: |
| References | |
| 50-295-97-27, 50-304-97-27, NUDOCS 9802040295 | |
| Download: ML20199G545 (17) | |
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U. S. NUCLEAR REGULATORY COMMISSION REGION lil
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Docket Nos:
50 295;50 304
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License Nos:
DPR 39; DPR48 Report Nos:
50 295/97027; 50 304/97027 Licensee:
Commonwealth Edison Company (Comed)
Facility:
Zion Generating Station, Units 1 & 2 Location:
101 Shiloh Boulevard Zion,IL 60099 Dates:
November 17 25,1997 Inspectors:
M. Bic.oy, Examiner / Inspector Rlli H. Peterson, Examiner / Inspector Rlli Approved by:
M. Leach, Chief, Operator Licensing Branch Division of Reactor Safety 9002040295 900130 PDR ADOCK 05000295 G
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EXECUTIVE SUMMARY Zion Generating Station, Units 1 & 2
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NRC Examination Reports 50 295/97027; 50 304/97027
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This inspection report contains the findings and conclusions from the inspection of the licensed i
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reactor operator (RO) and senior reactor operator (SRO) requalification training programs. The
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Inspection included a review of training administrative procedures; operating examination
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material; observation and evaluation of operator performance and licensee evaluators during a requalification operating examination; an assessment of simulator fidelity; an evaluation of
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program controls to ensure a systems approach to training; and a review of requalification training records. Additionally, the inspectors observed a period of routine control room
operations. The inspectors used guidance contained in inspection procedures (IP) 71001 and
71707.
The li:enced operator requalification programs were implemented in accordance with 10 CFR Part 55 requirements:
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Control room conduct of operations and decorum were effective at maintaining
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appropriate focus on plant status. (Section 01.1)
In general, the annual requalification operating examination met the minimum criteria in
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accordance with the guldance given in NUREG 1021, * Operator Licensing Examination Standards for Power Reactors," Interim Revision 8. (Sections 05.2,05.3)
i Overall crew and individual performance during training and evaluations was satisfactory e
with instances of weak performance identified by the licensee evaluators.
(Section 05.3).
The remediation program contained adequate measures to ensure individual and crew
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performance weaknesses were addressed prior to resumption of licensed duties.
(Section 05.5)
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However, concerns were identified with regard to the following:
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Allotted turnover time for crews returning from an extended time-off may be insufficient
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for accurate understanding of system configuration. (Section 01.1)
Training programs have provided some improvement in operator performance in the
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areas of communications, self checking, conservative decision making and reactivity control; however, operator simulator performance continues to be cyclic. (Section 05.1)
Simulator scenarios identified a minimum number of critical tasks which could result in
ineffective evaluation of operator performance. (Section 05.2.1)
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The licensee's understanding and incorporation of examination security measures into a
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site specific examination security procedure were poor and required attention. (Section 05.3.1)
The analysis of training program self assessment data was not rigorous. (Section 05.4)
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The plant restart simulator demonstrations indicated that programs designed to address
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operator purformance issues were not entirely effective. (Section 08.1)
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Repeti.htalla 1. Doortilena
Conduct of Operations 01,1 Control Room Observations (717DI)
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insoection Scone The inspectors observed routine control room activities with both units shutdown, and Unit 1 defueled. The inspectors performed a dual unit panel walk-down, questioned operators about plant status, reviewed control toom logs and observed the oncoming shift briefing, bl Observations and Findinas Control room operators conducted themselves in a professional manner and were attentive to their respective panel indications. The Nuclear Shift Operator (NSO) and Unit Supervisor (US) used formal three way communications to address annunciator alarms. No annunciators were left unattended or in a prolonged state of alarm. Upon questioning by the inspectors, the operators demonstrated satisfactory knowledge of plant conditions and equipment status.
Control room decorum was professional with personnel access controlled and noise level maintained at a minimum. The work control supervisor did a good job of initially challenging personnel about their business prior to entering the main control room. The front office arrangement maintained a majority of the paperwork outside the main control room.
The sh!ft turnover was timely and informative; however, during the shift briefing the inspectors observed instances of poor tumover of system configuration and equipment status by watchstanders assigned outside the control room. The oncoming crew was on their first night shift after an extended time-off. Individual control room turnovers lasted
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During the briefing, individual watchstanders provided a status summary of their respective equipment and systems. The inspectors observed the follow!ng mistakes:
Instrunnent and station air systems were incorrectly identified as being cross-
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connected.
The incorrect train of closed cooling water was identified as protected (no train
was identified on the protected train board).
The wrong operating air comprer,sor was identified.
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In all cases the Shift Manager (SM) and US quickly corrected the misunderstandings and took appropriate action to verify proper plant configuration. The oncoming crew returned to the control room for a final turnover from their counterparts and assumed the shift.
The inspectors also observed a lack of coordination for performance of a test between the SM and System Engineer (SE). Subsequent to the shift briefing, the inspectors individually questioned the SM in the control room, and the SE at the test site, Rhout the start time and status of a scheduled Battery 211 Load Test. After the SE identified a significantly different start time, the inspectors asked the SM for clarification. The SM then stated he was not sure what time the test was to be performed, c.
Conclusions l
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The inspectors concluded that observed conduct of operations and decorum in the l
control room were effective at maintaining appropriate focus on plant status. Control l
room operators demonstrated good communication skills and satisfactory knowledge of l
plant conditions and equipment status. Conversely, communication between the SM
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and SE of a test performance was not well coordinated. Additionally, the inspectors were concemed that although allotted turnover time may be sufficient for crews involved in consecutive day to day operations, it may not be adequate for a crew returning from an extended time-off as evidenced by the system configuration misunderstand;ngs observed during the shift brief.
Operator Training and Qualification 05.1 Ooerating Historv (71001)
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Insoection Scone
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The inspectors reviewed the following to assess the licensed operator requalification program's effectiveness regarding operator performance:
Licensed Operator Requalification Training report 50 295/304 95013
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SALP report 50-295/304 96001
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Augmented Team Inspection of improper Control Rod Manipulations report 50-
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295/304 97006 Phoenix Operator Training Inspection report 50 295/304 97021
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Resident inspector observations and reports covering the 1997 time frame to
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present
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Observations and Findingg The inspectors noted that poor operator performance as documented in the above reports was attributable, in part, to lack of procedural adherence, lapses in self checking, lack of command and control, poor safety focus, and poor communications.
In early 1997, the licensee implemented an operator performance improvement training program to address concerns of previous fundamental operator errors. After the February 21,1997, control rod reactivity mis management event, the licensee conducted a self assessment and concluded the trahing program could not adequately address emerging issues of operator comnetency and training effectiveness in a timely manner. The Phoenix Training program was subsequently developed as part of the hconsee's restart plan to address the operator and training confidence issues with the goal of significantly improving operator performance. The licensee's specialized training programs resulted in some improved operator performance in the area of communications, self checking, conservative dec:sion making and reactivity control.
However, based on subsequent inspector observations of crews during Phoenix simulator evaluations, plant restart simulator dernonstrations, and annual licensed operator requalification operating examinations, operator performance was still at times
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poor with regard to command and control, reading and directing Emergency Operating Procedure (EOP) actions, failure to take expected unilateral a::tions for a faulted or l
ruptured steam generator, and failure to recognize parameters requiring EOP transition from a leaking to ruptured steam generator.
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Conclusions The inspectors concluded the licensed operator requalification training programs have provided operators with the necessary skills to safely operate the Zion Generating Station. However, based on subsequent inspector observations of cyclic poor operator performance in the simulator, further improvement in operator performance can only be sustained by continued reinforcement of the operational standards set by station j
management and staff.
05.2 Reaualification Examinations 05.2.1 Examination Material a.
Insoection Scoce (71001)
The inspectors reviewed the operating examination material based on guidance in NUREG 1021 " Operator Licensing Examination Standards for Power Reactors,"
Interim Revision 8, January 1997, and in Appendix A checklists in Inspection Procedure 71001," Licensed Operator Requalification Program Evaluation." This review included a comparison of dynamic scenarios and job performance measures (JPMs) with previously administered examinations.
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Observations and Findings
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The job performance measures (JPM) were safety significant tasks. They contained clearly stated critical steps, cues, and failure and termination criteria required for satisfactory completion.
The inspectors noted the dynarnic simulator scenario objectives incorporated probabilistic risk assessment significant events, but generally, they were straight forward and lacked significant challenge. Some of the scenarios were lacking in complexity; even though they provided minimum quantitative attributes to evaluate the crew and individual members on safety significant tasks and competencies. A majority of the scenarios only identified a minimum number of critical tasks that is an indication of a minimal level of scenario difficulty which could result in an ineffective evaluation of crew or individual performance. Of the five scenarios observed, three only had two crew critical tasks each.
The licensee only identified critical tasks based on the Westinghouse Owner's Group Emergency Response Guideline (ERG). In one scenario, the inspectors identified the ERG based guideline failed to identify one of the critical tasks. The scenario critical tasks listed for an accident involving total loss of AC power (station blackout) were as follows:
Manually close the open pressurizer power operated relief valve before
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completing the immediate action steps of ECA 0.0, station blackout procedure.
Establish the minimum required auxiliary feedwater flow rate to the steam
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generators before steam generator dryout occurs.
Manually start the essential service water pump such that the emergency diesel
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generator does not fall because of damage caused by engine overheating.
Deprcssurize the intact steam generator at the maximum rate.
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lsolate reactor coolant pump sealinjection before a charging pump starts or is
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started.
The inspectors identified that the ERG Based critical tasks did not list the specific action or actions required to restore at least one vital bus with AC power. Potential methods for restoring AC power included the restoration of an emergency diesel generator, the
'estoration of offsite power, or cross connect electrical buses for 9 dual unit station. In addition, the licensee did not list a success path to restore AC power as a crew significant task.
The licensee used additional evaluation criteria which they identified as crew significant tasks. However, if missed, these items would not in themselves result in a failure. The licensee indicated that evaluation of operator performance could include assessment of competencies and expectations outside of critical or significant tasks and niay
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subsequently result in an individual and/or crew failure based on overall performance.
This statement was verified after observing the licensee fall one crew based on inadequate fulfillment of management expectations. The crew and Individuals had successfully performed the critical tasks; however, an individual displayed weak command and control and the licensee evaluators failed the crew. The crew was subsequently remediated and re-evaluated on the simulator tne following day.
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Conclusions in general, the Inspectors concluded the operating examination material met the m!nimum quantitative attributes to provide an adequate evaluation of operator skills based on the guidance detailed in NUREG 1021 and Appendix A of Inspection procedure 71001, inspectors concluded the licensee's over reliance on the identification of all scenario critical tasks by the ERG-Based document could rcsult in some critical tasks being overlooked.
05.3 Reaualification Examination Administration Practices a.
Insoection Scoce (71001)
The inspectors observed the licensee evaluate crew and individual performance of two operating crews during the annual requalification operating examination The examination consisted of two dynamic scenarios and a set of five JPMs. The crews consisted of five licensed operators evaluated in the positions of US, SM, Primary NSO, Secondary NSO,3nd Shift Technical Advisor (STA' The inspectors attended the crew evaluation and evaluator critiques, b,
Observations and Findinas The licensee's evaluation team, one of whom was a member of Operation's management, identified unsatisfactory performance of one crew during the simulator scenarios. Although the crew satisfauorily performed the critical tasks, one individual displayed poor command and control, and the crew was evaluated as unsatisfactory based on inadequate fulfillment of management expectations. The crew was subsequently remediated, and evaluated as satisfactory in another dynamic scenario the following day.
Licensee evaluators performed the examination administration in a professional manner and properly documented operator performance deficiencies. After completion of each scenario, the evaluators met and discussed any required follow up questions for crew members to clarify observations. All evaluators were candid in their observations. After completion of both scenarios, evaluators held a final meeting to discuss weaknesses; perform final grading of the crew and individuals based on performance of critical tasks, significant tasks and competencies; and to formulate any required remedial training.
The inspectors agreed with grading of the crew and Individual critical tasks and competencies. No new simulator fidelity issues were identified by the inspectors during the operating examination observation.
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e The inspectors observed administration of five JPMs to each crew member. No evaluator miscuing or prompting was identified. The inspectors agreed with licensee grading of JPM critical tasks.
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Conclusions The inspectors concluded the licensee satisfactorily administered and evaluated the annual Licensed Oper 4 tor Requalification Training (LORT) examination in accordance with their program guidance and regulatory requirements as stated in 10 CFR Part 55.59.
05.3.1 Exaalnation security a.
Insection Scope The inspectors reviewed the licensee's examination security measures to ensure compliance with 10 CFR 55.49, * Integrity of Examinations and Tests." A problem identification form (PlF) No. Z1997 02496, " Breach of Exam Security Boundaries," wa; also reviewed.
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Qbiervations and Findings The inspectors identified the licensee's policy required operators taking the requalification examination to sign a security agreement described in NUREG 1021, Form ES-601 1, * Examination Security Agreement." Although NUREG 1021 does not specifically require such action, the licensee's intention was to add another level of security by having examinees sign the security agreement to proclude them from discussing examination content. However, the inspectors informed the licensee that such action does not alleviate them from taking additional measures to preclude inadvertent examination compromise. Such actions included separation and I
sequestering of exam groups, and minimizing examination material repetition.
During examination administration of JPMs, the licensee had armnged examinees into two groups, with four operators in each group. The inspectors observed that one group of operators was scheduled to perform JPMs concurrent with onother group attending significant operating events report (SOER) training. However, the licensee was going to release both groups to lunch, un-escorted, for approximately one hour. This was to be done after one group had finished a various combination of JPMs, while the other group had not seen any of the JPM material. Examinee integrity not withstanding, the inspectors identified this as poor examination security control that depicted a perception of, or potential for, inadvertent examination compromise, even though the operators that performed the JPMs were required to sign the security agreement. The inspectors discussed this practice with the licensee, who acknowledged the concerns, and escorted the individuals that had completed JPMs.
Another security concern was identified by the inspectors during examination administration when the schedule required changing due to inability of an operator to
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participate in simulator dynamic scenarlos because of a personal emergency. The licensee rescheduled the affected group that was schedul9d to perform the same set of JPMs in the afternoon as the moming group, to take the simulator scenario evaluation instead. As a result, the licensee planned to administer the same JPMs and simuictor
scenarios the following day. The inspectors questioned this practice noting the adequacy of sufficient exam mcterhi and the perception of, or potential for, inadvertent examination compromise. Subsequently, the licensee organized a new set of JPMs and simulator i,cenarios.
Prior to administration of the annuallicensed operator requalification examination, the t
licensee had identified a breach of simulator examination development security boundaries. On October 30,1997, an unauthorized Instructor failed to heed the posted
"Stop - Do Not Enter Requalification Examination Development in Progress * sign on
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commence development of a dynamic scenario examination. The licensee immediately noted the intrusion, and escorted the Instructor out of the simulator before any examination material was exposed. The licensee determined the unauthorized instructor was looking for a reference document in preparation for teaching a class and did not pay attention to the door sign. During a licensee interview, the instructor indicated that he felt there would be no problem with examination compromise if he did not see any examination material. The inspectors reviewed the licensee's PlF concerning the incident, the subsequent root cause, and corrective actions. The license did not perform a root cause analysis, but Implemented a corrective action by placing a
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rope barrier in front of the simulator room doors. The inspectors determined the overall root cause for such a breech of security as inadequate understanding of examination
security and lack of an approved procedure specifically describing security requirements
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and expectations.
The licensee Informed the inspectors they had setup a secure examination development room on August 22,1997, based on guidance from a corporate procedure entitled,
" Nuclear Operations Division Exam Security." The licenses was in the process of incorporating this guidance into a plant procedure NSP-TQ 3001," Examination Security Nuclear Division," Revision 00, July 31,1997. The inspectors noted the procedure currently did not completely detall site specific licensed operator requalification examination development and the administration of security measures, c.
Conclusions in general, the inspectors concluded the licensee met minimum requirements for maintaining exam security and no actual exam materla! compromise occurred.
However, based on the observed security issues, the licensee's understanding and implementation of examination security was weak.
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05.4 Ritqualification Training Program Feedback Syctem a.
lasnitction Scope (710011 The inspectors reviewed the following documents to assess the licensee's training program feedback system effectiveness:
Zion Station Training, Qualification and Staffing Audit Report, QAA 22 9612
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Training Requests and Individual Feedbacks
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Operations Department Self Assessment Readiness Report
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Zion Operations Department Phoenix Training Program Simulator Performance
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Review Licensed Operator Continuing Training and Requalification Program, Training
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Department Instruction, TDI 302, Revisitn 13 b.
Observations and Findings The licensee's training organization performed a variety of self assessments by assessing operator training requests, Individual operator and crew weaknesses in the classroom and simulator, and plant and industry events. Additional self assessments included the Phoenix Training simulator performance review, Operations Department self assessment readiness report, course evaluations, training staff skills and qualifications, instructor evaluations, classroom feedback, simulator evaluations and critiques, and on the job training evaluations. The licensee's Site Quality Verification (SOV) group also performed periodic audits of the Operations Training programs. A common theme identified throughout the licensee's own evaluations and audits, and outside organization audits, was that analysis of the data was weak.
The inspectors observed the licensee's feedback process was maintained up to date, and flexible enough to incorporate emerging training issues. However, they also found the licensee's self assessments contained a lot of data that identified problems and recommended quick resolutions while the root cause analysis was generally not rigorous. This was evidenced by the licensee repetitively identifying the same problem.
Examples of identified deficiencies extended into all operational categories including, adherence to standards, professionalism, technical performance, and operator knowledge and skill. Subsequently, the licensee acknowledged this weakness in their self assessment program and were actively pursuing actions to improve root cause analysis.
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Conclusioqs in general, the inspectors determined the training program feedback process was satisfactorily implemented although root cause analysis of the self assessment data was
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not rigorous.
05.5 % medial Tralnina Pr02 Cam a.
Insoection Scoce (71001)
The inspectors reviewed the licensee's remedial train!ng program and selected records to assess corrective actions for identified weaknesses in operator and crew performance l
during the annuallicensed operator requalification examination. This review also included an interview with selected personnelinvolved with the remedial training process, b.
Obtervations and Findings Remediation plans for three individuals with unsatisfactory performance during the annuallicensed operator requalification examination dynamic scenarios consisted of a description of Identified weaknesses and a scenario critique led by the Shift Operations Supervisor (SOS) with specific coaching on the identified weak areas. Additional coaching and counseling was provided by the crew's shift supervisor. The individuals participated in a simulator training exercise that addressed the individuals' identified weak areas. Individucts were then evaluated in a final scenario. The licensee required successful completion of the remediation training prior to individuals resuming licensed duties, c.
Conclusions The inspectors concluded the remediation program contained adequate measures to ensure individual and crew performance weaknesses were addressed prior to resumption of licensed duties.
05.6 Conformance with Ooerator License Conditions a.
Insoection Scoce (71001)
The inspectors reviewed the licensed operator medical and active license qualification programs to assess licensed operator compliance with regulatory requirements, b.
Observations and Findings Medical records are normally maintained offsite at the corporate office; however, a sample (ten percent) of the records were requested by the inspectors and delivered to the site for review. The inspectors observed the records contained appropriate documentation to validate operator medical qualifications to perform licensed duties. No
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required physicals exceeded the program allowed dates and no violation of regulatory requ# Jments were identified.
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The inspectors reviewed the licensee's guidance for maintaining oos..ator liconses
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active, ZAP 200 9A, " Control of 10 CFR 55 Requirements for Licensed Individuals." The
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procedure clearly identified the appropriate control room licensed operator positions and
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required on shift time to maintain an active license. Further review of the licensee's active licenses Indicated they were properly crediting active license duty watch standing hours, c.
Conclushqs The inspectors concluded operator license conditions were in conformance with program guidance and regulatory requirements stated in 10 CFR Part 55.53 and 10 CFR Part 55.21.
Miscellaneous Operations issues 00.1 Simulator Demonstrat[ons (MC 350)
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Insoection Ss; ope The inspectors observed licensee evaluated simulator demonstrations run on three of five operating crews on November 5,7, and 10,1997, as part of the plant restart plan.
The object was to verify operator performance cased on the licensee's standards and policies for communications, conservative dec!slon making, self checking, and reactivity control.
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Observations and Findinas Each crew attended a planned briefing lo;,ung approximately an hour and a half for the
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licensed and non-licensed crew members, and the Operations Manager. The briefing was conducted by the qualified nuclear engineer (QNE) for a scheduled surveillance involving a reactivity manipulation. During the briefing, the crew reviewed related industry events, discussed procedural steps and cautions, test and reactor trip criteria, and actions they would take for unexpected events during the surveillance. The
- Operations Manager thoroughly questioned each operator about their understanding of various procedural steps and Individual roles and responsibilities. Furthermore, the Operations Manager emphasized expected standards for communications, conservative decision making, self checkirig and reactivity control.
The simulator demonstrations started after the briefing and lasted approximately an hour and a half. They were designed to include an administrative control room distraction, minor instrument or system failure, performance of a normal surveillance test which involved a reactivity change and non catastrophic transient event. As a result of the transient event, the crew was expected to stop testing, stabilize the reactor, address the event, and make a conservative decision of whether to continue the test or shutdown
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the reactor.- The licensee evaluated two of the crews as satisfactory with minor comments on performance errors, communications, and self checking. One crew and
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two individuals were evaluated as unsatisfactory. The crew failed to identify and enter a Technical Specification Limiting Condition for Operation for the Auxillaq r eed Pump turbine trip valve being inoperaNe. During & rod swap surveillance the raw identified an unexplained reactivity addition (dilution event) but failed to stop the surveillance and investigate despite the rigorous prebriefing of actions with the Operations Manager they would take during perij. nance of the surveillance with respect to unexpected events.
The inspectors were in agreement with the licensee's evaluations
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The individuals demonstrating unsatisfactory performance were subsequently scheduled to be remed!ated prior to retuming to shift. Remediation included review of performance in the demonstration, counseling by the SOS and re-evaluation in another scenario by the SOS.
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Conclusions
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The inspectors concluded the scenarios were not overly challenging; however, they were adequate for the licensee to evaluate operator performance based on their standards and expectations for communications, self checking, reactivity management, command and control and conservative decision making. The inspectors observed that licensee evaluators continued to identify some of the same unsatisfactory operator performance issues as previously identified in earlier operator training programs and concluded that programs were not entirely effective.
nJanagement Meetings
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X1 Exit Meeting Summary The inspectors presented these observatione and findings to members of the licensee's mantgement on Novern'y d.1997. The licensee acknowledged the findings presented. The licensee also acknowledge <! tr. A nroprietary information given to the inspectors during the inspection was returned.
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PARTIAL LIST OF PERSONS CONTACTED
Licensee R. Harrsch, Operations Training Liaison F. Jones, Regulatory Assurance R. Landrurn, SOS / Operations A. Lucky, Training T, O'Connor, Operations Manager L. Schmeling, Training Manager G. Smith, Training R. Zyduck, Q&SA Director NBC E. Cobey, Resident inspector INSPECTION PROCEDURES USED IP 71001, " Licensed Operator Requalification Program Evaluation" IP 71707, " Plant Operations"
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ITEMS OPENED, CLOSED, AND DISCUSSED
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LIST OF ACRONYMS USED AC Alternating Current CFR Code of Federal Regulations DRS Division of Reactor Safety EOP Emergency Operating Procedures ERG Emergency Response Guideline ES Examination Standards IP inspection Procedure JPM Job Performance Measure LORT Licensed Operator Requalification Training NRC Nuclear Regulator Commission NRR NRC Office of Nuclear Reactor Regulation NSO Nuclear Shift Operator PDR Public Document Room PIF Problem Identification Form QNE Oualified Nuclear Engineer
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RO Reactor Operator SALP Systematic Assessment of Licensee Performance SE System Engineer SM Shift Manager r
l SOER Significant Operating Event Report
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SOS Shift Operating Supervisor
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SOV Site Quality Verification
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SRO Senior Reactor Operator STA Shift Technical Advisor US Unit Supervisor
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Attachment 1 SIMULATION FACILITY REPORT Facility Licensee: Zion Facility Licensee Docket Nos: 50-295/304-Operating Tests Administered: November 18 - 20,1997 This form is to be used only to report observations. These observations do not constitute audit or inspection findings and are not, without further verification and review, indicative of noncompliance with 10 CFR 55,45(b). These observations do not affect NRC certification or approval of the simulation facility other than to provide information that may be used in future
' evaluations. No licensee action is required in response to these observations.
While conducting the simulator portion of the operating tests, the following items were observed (if none, so state):
JIEM DESCRIPTION l
None identified.
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