IR 05000313/1993020
| ML20045C124 | |
| Person / Time | |
|---|---|
| Site: | Arkansas Nuclear  |
| Issue date: | 06/14/1993 |
| From: | Constable G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20045C123 | List: |
| References | |
| 50-313-93-20, 50-368-93-20, NUDOCS 9306220105 | |
| Download: ML20045C124 (10) | |
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APPENDIX U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Inspection Report:
50--313/93-20 50-368/93-20
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Operating Licenses: DRP-51 NPF-6 Licensee:
Entergy Operations, Inc.
Route 3, Box 137G
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Russellville, Arkansas 72801 Facility Name: Arkansas Nuclear One, Units 1 and 2 (AN0)
Inspection At: ANO, Russellville, Arkansas Inspection Conducted:
May 17-21, 1993 Inspector:
M. E. Murphy, Reactor Inspector, Plant Support Section Division of Reactor Safety Approved:
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6-1(4-93 4 G. L. Constable, Chief, Plant Support Date g
Section, Division of Reactor Safety Inspection Summary Areas Inspected (Units 1 and 2): Routine, announced inspection of the licensee's implementation of a corrective action process that identifies, follows, and corrects conditions adverse to quality, especially with regard to
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determination of the cause of the problem and elimination of both problem recurrence and occurrence of similar problems.
Results (Units 1 and 2):
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The licensee has implemented a very strong program for identifying,
following, and implementing corrective actions for. conditions adverse to
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quality (Section 1.4).
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The. administrative program establishes internal and external reporting
requirements, requires assessment'of the safety significance of the reported condition, and provides for assigning priorities (Section 1.2).
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Generic concerns, root causes, and human performance considerations were
effectively considered (Section 1.1).
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9306220105 930615 PDR ADOCK 0500
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-2-The licensee's human performance evaluation system was considered a
strength (Section 1.2).
Corrective action items were effectively developed, evaluated, approved,
documented, assigned, tracked, and closed out (Section 1.3).
The licensee's quality assurance audit program was considered a strength
(Section 1.3).
The use of prior events in the development of corrective actions could
be improved (Section 1.3).
Summary of Inspection Findinas:
There were no violations or deviations identified during this
inspection.
Attachments:
Attachment 1 - Persons Contacted and Exit Meeting
Attachment 2 - Documents Reviewed
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-3-DETAILS 1 CORRECTIVE ACTION (92720)
This inspection was conducted to determine that the licensee was effectively implementing a corrective action program that identified, followed, and corrected conditions adverse to quality. This evaluation was focussed on determining that the licensee's process identified events or problems that were adverse to quality, determined causes for in-house events or problems, and developed effective corrective actions. The inspection also ascertained if the licensee's corrective actions addressed elimination of both problem recurrence and occurrence of similar problems.
1.1 CONDITION IDENTIFICATION The licensee had several sources for identifying conditions adverse to quality.
These sources were plant operations, maintenance activities, engineering, radiological programs, security, quality assurance, employee concerns and NRC inspection reports for in house problems.
External sources were from industry operating experience, vendor and supplier alerts, prime contractors, and NRC generic correspondence.
Problems identified from these sources were documented in what the-licensee called a " Condition Report" (CR). These CRs were administratively handled under the licensee's Procedure 1000.104, " Condition Reporting and Corrective Actions." This procedure established responsibilities and authority for the initiation, processing, and review of CRs. The first level of assessment was performed by the condition review group (CRG). This group was staffed by various staff, supervisors, and managers that represented both units and common site functions. These meetings typically classified the CR as significant or not and made assignment to the responsible department manager.
The inspector attended a CRG meeting on the morning of May 20, 1993. The agenda for this meeting included three CRs for Unit 1, one CR for Unit 2, and -
two common CRs, all six conditions originated in-house.
Each CR was briefly presented by a representative from the initiating organization. The senior manager for the affected unit or common area assigned responsibility and determined if the CR was significant or not. This meeting resulted in one CR being administratively closed, four being declared non-significant, and one significant. The inspector considered the CRG to be an effective first level assessment activity for CRs and had no questions or comments.concerning the dispositions observed during the meeting. The CR for Unit I that was declared
significant was 1-93-0143 and resulted from an occurrence during the monthly inspection of self-contained breathing apparatus. One of.the containers was accidentally knocked off the walkway, through the handrail and hit a transmitter causing'a steam leak from the transmitter. This event, having been declared significant, will require a root cause analysis and a human performance evaluation. These reports, along with the recommended corrective actions will be reviewed by a corrective action review board within 30 days.
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-4-This board will evaluate the reports and assign the accepted corrective actions to the responsible departments.
During this SALP cycle, which started on March 1, 1992, the licensee had generated 1228 CRs.
Of these,152 were classified as significant and resulted in 19 licensee event reports, 4 50.72 reports and 1 Part 21 report. Two of the significant CRs originated from the licensing department as the result of a NRC inspection and a NRC bulletin. The remaining were classified as in-house events. The inspector selected a sample of 8 Unit 1, 7 Unit 2, and 5 common CRs, which had been initiated during this SALP cycle, for review.
This review confirmed that these were all licensee identified problems that originated from operational events, surveillance testing, engineering studies, and evaluations, maintenance activities, or quality assurance / quality control surveillances and audits.
Priority was assigned for the corrective action items by establishing a due date and assessing the safety significance.
Generic concerns and root causes were established for the CRs classified as significant.
1.2 CAUSE DETERMINATION The licensee's administrative program required that when a CR was classified as significant by the CRG then an evaluator was designated by the responsibic manager to determine the root cause and develop a proposed corrective action plan for resolution of the condition.
If the CRG found that human performance problems were present, then a human performance enhancement system (HPES)
evaluation was required to be performed as part of the root cause determination. These evaluations were performed by personnel specifically trained in root cause analysis and HPES evaluations. The composite packages, consisting of the root cause analysis, HPES evaluation (if required), and proposed corrective action plan, were then presented to the corrective action review board (CARB). The purpose of the CARB was to review and approve the packages prior to the implementation of the corrective action plan.
The inspector attended two CARB meetings, one on May 18 and one on May 20.
The first meeting was to review and approve actions taken for CR-C-93-0045.
This CR concerned the lack of compliance with the requirements of the " Hold and Caution Card" Procedure, 1000.027.
In preparation for the performance of maintenance on a Unit 2 instrument air valve, improper isolation boundaries and system alignment was established.
As a result, a portion of the Unit I shared system was isolated,-without the knowledge or approval of the Unit 1 supervision, which caused overheating of a Unit 1 instrument air dryer. The CRG had previously determined that this was a significant event and involved human performance problems, therefore, a root cause analysis and HPES evaluation had been performed. The CARB meeting was very professionally conducted with brief but thorough presentations.
Present at the meeting were individuals actually involved in the event to provide first hand accounts of individual actions taken.
Presentations and discussions of the root cause analysis, HPES evaluation, and proposed corrective action plan were provided by the responsible individuals. The inspector was particularly impressed by the depth and detail provided by the HPES evaluation along with the crisp
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specificity of the causes.
The CARB approved the package with only minor editorial comments and the responsible manager was directed to implement the l
i corrective action plan.
The inspector had no comments or questions concerning the root cause analysis, HPES evaluation, or corrective action plan.
However, the timeliness of initiating and processing this CR was of concern to the inspector.
The CR was not written until two weeks after the event, and the CARB meeting was held two months after the event. The inspector interviewed
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the Unit I shift supervisor involved in the event and the supervisor of l
in-house events analysis to determine what had caused the apparent delay.
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was explained to the inspector that there was a delay in agreeing that the event was in fact a CR item. When it was finally determined that it was, the involved shift crew had gone off-shift and the item was temporarily forgotten and the CR was two weeks late being initiated. Subsequent, approved delays in the CARB meeting were experienced due to the unavailability of the involved individuals. The inspector reviewed the immediate corrective actions and determined that they were timely and effective and the delay did not affect the equipment or system involved.
The second CARB meeting concerned CR-1-93-0126, which involved an incorrect treated waste monitor tank radioactive release. The waste control operator lined up the wrong tank for a planned release and the interlock between the radiation monitor and the radwaste to the flume control valve was not verified operable as required by the procedure. The CARB meeting for this CR was also-professionally conducted and had appropriate attendance. The required package was presented and reviewed by the CARB.
The inspector was also impressed with the quality of the HPES evaluation provided in this package. The CARB approved the package and directed the responsible manager to implement the corrective action plan.
The inspector had no comments or questions concerning the root cause analysis, HPES evaluation, or corrective action plan. The inspector observed that the root cause analysis identified no previous occurrences and the HPES stipulated that this was a " repeat event." The difference in conclusions was determined to be a difference in the definition
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of what constitutes a recurrent event. This will be discussed in more detail in the following section.
1.3 CORRECTIVE ACTION DEVELOPMENT AND IMPLEMENTATION l
Corrective action items originated from several sources within the licensee's organization. The most common source was the CR program, however, corrective actions also resulted from quality assurance audits /surveillances and the (
industry events analysis group's reviews of external operating and information I
sources.
Each source required formal assignment of action item responsibility, maintained at action item tracking system and was responsible
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for review and approval of completed actions.
The industry events analysis group was responsible for reviewing various sources of information concerning events in the industry, concerns or information from the NSSS supplier and other vendors, and NRC information notices. They also reviewed NRC inspection reports from other utilities for helpful hints.
Information that concerned any known safety-related equipment
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installed at ANO resulted in a CR, thus, insuring the development of formal corrective action as required. Other potential concerns resulted in the performance of a plant impact evaluation (PIE) as required.
The inspector's review of selected PIES determined that a CR could be required, but generally the action items were assigned directly to the responsible manager.
The industry events analysis group had the capability to research past activities for recurring events and used this capability as a routine to provide input to the corrective action item development.
The quality assurance department initiated CRs, as required, from the results of the audits and surveillance reviews they conducted.
These activities also produced action items that were assigned directly to the responsible manager.
Quality assurance also had an extensive data base that was used for trending purposes and provided an excellent source of information concerning recurring events.
This information was used in the development of recommended corrective action items. The inspector reviewed a summary of 17 program and 18 Technical Specification audits conducted during this SALP cycle.
These audits had resulted in the initiation of several significant CRs with the resulting corrective action plans, and numerous action items assigned directly to a responsible manager.
For example, Technical Specification Audit QAP-17K-92, " Radioactive Materials Sources," resulted in one finding that produced a CR and a licensee event report which concerned the movement of an excore detector without a leak test being conducted prior to the. detector being subjected to core flux. A second finding concerned the lack of calibration records for two sealed source leak test counters which produced a CR. This audit also resulted in the issuance of a request to licensing that subsequently caused the initiation of a Technical Specification change request.
Although the two CRs remained open pending completion of the corrective action plan, the inspector concluded that the immediate corrective actions were effective and timely and along with the remaining action items addressed the specific issues, and that sufficient effort had been taken to preclude recurrence.
The inspector noted that the scope, detail and results
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of the quality assurance audit program were impressive. This audit program along with the sense of respect and cooperation from the rest of ANO management is considered a strength in the quality assurance area.
The licensee's CR program produced the most significant contribution to the corrective action item population. All events classified as significant required a root cause determination, which could also involve a HPES evaluation. A root cause determination always. included a recommended corrective action plan and a HPES evaluation added to-the number of proposed corrective action items. The licensee's basic policy for the development of a proposed corrective action plan was that it should correct the condition and-prevent recurrence. The inspector determined, through the review of the selected CR packages, that this-policy was enforced.
Corrective actions addressed both units and/or multiple systems when the evaluation identified an impact on more than one system and/or the other Unit.
If a CR declared equipment operable based on engineering judgement in the initial assessment,-
then a corrective action item was assigned to verify the operability.. A'
determination for prior occurrences was always made.
As discussed in
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-7-Section 1.2 above, however, it appeared to the inspector that a very limited definition was used for prior occurrences, in that the same function and specific equipment or component had to be involved.
The inspector interviewed a trained and qualified root cause evaluator and HPES evaluator and discussed this observation with them. The root cause evaluator did feel that there was, by policy, a narrow focus on systems and components when determining prior occurrences. However, the individual did not feel restricted in the review of the data base, but did indicate a focus was maintained in accordance with the understanding of the policy.
The HPES evaluator did not feel that past event reviews were restricted since the HPES prior event evaluation is action based not event based.
The inspector discussed this with the supervisor of in house events assessment, and observed that this apparent limitation on identifying past events could impose a restriction on the availability of useful past experience in the development of recommended corrective action items. The supervisor of in house events assessment agreed that a potential limitation existed and said that the item would be evaluated and corrected as needed.
For the reviewed CRs the inspector determined that corrective action items were closed out, documented, and reviewed by in house events assessment as they were completed. The CR package was formally reviewed, closed and sent to records by In House Events Assessment when all corrective action items were complete.
1.4 CONCLUSIONS The licensee had active internal and external sources for problem identification and had implemented a very strong program for identifying, following, and implementing corrective actions for conditions adverse to quality. The administrative program provided for problem assessment and a distinct reportability chain that included required NRC reporting.
The identified problems were classified and assigned a priority following an assessment of the safety significance.
Generic concerns, root causes, and human performance considerations were effectively considered, with a particular strength in the quality of the HPES. Corrective action items were effectively developed, evaluated, approved, documented, assigned, tracked, and closed out.
The use of prior events in the development of corrective actions could be improved. The quality assurance audit program was considered a strengt *
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ATTACHMENT 1 1 PERSONS CONTACTED 1.1 Licensee Personnel
- S. Boncheff, Nuclear Safety and Licensing Specialist
- H. Cooper, Licensing Specialist
- B. Eaton, Director. Design Engineering
- R. Edington, Plant Manager, Unit 2
- J. Fisicaro, Director, Licensing
- C. Fite, Supervisor, In House Events Assessment
- C. Gaines, Supervisor, Industry Events Analysis Group
- R. Gillespie, Manager, Central Maintenance
- B. Gordon, Supervisor, Central Maintenance Engineering
- J. Haley, Licensing Specialist
- G. Hines, Design Engineering
- G. Holt, Unit 2 Electrical Maintenance
- L. Humphrey, Director, Quality Assurance R. King, Licensing Supervisor
- R. Lane, Manager, Engineering D. Hims, Manager, Unit 2 Systems Engineering J. Montgomery, Human Performance Enhancement System Coordinator
- S. Pohl, Central Maintenance Engineer
- J. Powell, Superintendent, Central Maintenance G. Provencher, Quality Assurance Supervisor
- E. Rogers, Central Maintenance Engineer
- B. Rogers, Design Engineering
- H. Ruder, Technical Specialist, In House Events Assessment
- T. Rush, Design Engineering
- H. Sellman, General Manager D. Smith, Senior Engineer
- B. Thweatt, Engineering Programs Technician
- J. Vandergrift, Plant Manager, Unit I
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0. Wagner, Quality Assurance Engineer
- W. White, Design Engineering C. Zimmerman, Operations Manager, Unit 1 1.2 NRC Personnel
- A. Gaines, Resident Inspector i
- H. Runyan, Reactor Inspector
- L. Smith, Senior Resident Inspector
- R. Vickery, Reactor Inspector In addition to the personnel listed above, the inspector contacted other personnel during this inspection.
- Denotes personnel that attended the exit meeting.
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-2-2 EXIT. MEETING An exit meeting was conducted on May 21, 1993. During this meeting, the inspector reviewed the scope and findings of the report. The licensee did not identify as proprietary any information provided to, or reviewed by, the inspector.
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ATTACHMENT 2
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DOCUMENTS
' Quality Program Audit & Finding Summary, dated 5/17/93 PIE-93-0016-B,. dated 1/26/93
PIE-93-0023-B,' dated 1/27/93 PIE-93-0024-B, dated 1/28/93 PIE-93-0046-B, dated'2/23/93 PIE-93-0048-B, dated 2/25/93 PIE-93-0074-B, dated 3/31/93
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PIE-93-0086-B, dated 3/31/93 PIE-93-0077-8, dated 4/23/93 CONDITION REPORTS
C-92-0022 C-92-0024 C-92-0025
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C-92-0042 C-92-0020
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C-93-0045 l-92-0068 1-92-0079
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1-92-0123
'l-92-0251 1-92-0280
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1-92-0534 1-92-0325-1-92-0559
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l-93-0126 2-92-0078 2-92-0089-2-92-0107 2-92-0143 2-92-0236
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2-92-0237 2-93-0118
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