IR 05000315/1995015
| ML17333A297 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 01/29/1996 |
| From: | Caldwell J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17333A296 | List: |
| References | |
| 50-315-95-15, 50-316-95-15, NUDOCS 9602150183 | |
| Download: ML17333A297 (28) | |
Text
U.S.
NUCLEAR REGULATORY COMMISSION REGION.III REPORT NO.
50-315/95015'0-316/95015 FACILITY Donald C.
Cook Nuclear Generating Plant-LICENSEE Indiana Michigan Power Company 1 Riverside Plaza Columbus, OH 43216 DATES January 8 22, 1996 INSPECTORS S. Stasek, Senior Resident Inspector Davis-Besse NPS J.
Gadzala, Resident Inspector Kewaunee NPS R. Lerch, Reactor Inspector, RIII E.
Cobey, Reactor Inspector, RIII S. Orth, Radiation Specialist, RIII M. Shannon, Reactor Operations Engineer, NRR APPROVED BY Jam s L. Caldwe 1, eputy Director Di ision of Rea tor Projects Date AREAS INSPECTED A preliminary (Phase I) assessment of plant performance was conducted using NRC Inspection Procedure 93808,
"Integrated Performance Assessment Process (IPAP)."
The In-office review assessed the written record for'erformance elements relating to Safety Assessment/Corrective Action, Operations, Engineering, Maintenance, and Plant Support.
9602i50i83 50003i5 PDR ADOCK 0 PDR
Preliminary (Phase I) Integrated Performance Assessment Donald C.
Cook Nuclear Plant, Units 1 and
OVERALL ASSESSMENT SCOPE AND OBJECTIVES An Integrated Performance Assessment of the Donald C.
Cook Nuclear Plant, is being performed in 'accordance with NRC Inspection Procedure 93808 "Integrated Performance Assessment Process."
The assessment is divided into two phases; a
preliminary assessment performed in the NRC Region III office, and a final assessment which will be performed onsite.
The assessment is being conducted by NRC Region III with assistance from the Office of Nuclear Reactor Regulation.
The preliminary assessment was performed during January 8-22, 1996.
The final assessment is scheduled to be performed during a two-week period beginning February 5,
1996.
The overall objectives are to identify programmatic and performance strengths and weaknesses in the areas of Safety Assessment/Corrective Action, Operations, Engineering, Maintenance, and Plant Support.
The preliminary assessment was based on an in-office review of NRC inspection reports, licensee event reports, NRC and licensee performance indicators, enforcement history, regional assessments, and licensee internal and external assessments.
The results from the first phase of the assessment are contained in this report.
During the second phase of the assessment, the team will attempt to determine current performance and compare and contrast those observations and assessments with observations outlined in the preliminary assessment report via a performance based, onsite assessment.
The results of the onsite assessment will be integrated with those of the preliminary assessment and be documented in a Final Assessment Report.
Included in the Final Assessment Report will, be the final recommendations on where to focus future NRC inspection effort.
These recommendations will be depicted on a Final Performance Assessment/Inspection Planning Tree.
ASSESSMENT METHODOLOGY During the preliminary assessment, the team evaluated the D.
C.
Cook inspection record and performance history for a two-year period spanning January 1994 - January 1996.
Observations drawn from this review were then compared with those contained in licensee internal and external assessment
, reports and associated documentation.
Where the observations were relatively consistent, a performance rating of either decreased, normal, or increased inspection was considered for the individual performance elements.
Where the observations obtained from the team's review of inspection and performance data differed significantly from those described in the licensee's internal and external assessments, or where sufficient information was not available to come to a meaningful conclusion, individual elements were rated as being indeterminate.
Ratings for the overall performance areas of Safety Assessment/Corrective Action, Operations,,
Engineering, Haintenance, and Plant Support were not addressed during the preliminary assessment phas t f
.D
SAFETY ASSESSNENT/CORRECTIVE ACTION From a programmatic standpoint, the licensee appeared to have appropriate mechanisms in place to identify and track plant problems.
The condition reporting system was widely used, and a substantial amount of effort was evident in the implementation of the gA audit and surveillance programs.
Numerous self assessments were also conducted during the assessment period.
However, it appeared evident that the recommendations identified during the self-assessments were not well tracked to assure their appropriate resolution.
In addition, it also appeared that plant problems were not always effectively corrected as early or as well as they could have been in that some problems recurred.
Insufficient information was available to adequately assess several elements within this area.
Because of this, the onsite assessment phase will focus on trending, tracking and'resolution of condition reports relating to gA audit and surveillance findings, as well as industry issues and events.
Additionally, resolution of self assessment recommendations and functioning of the plant nuclear safety review committee and the nuclear safety and design review committee will also be further reviewed.
I'.I Problem Identification Programmatically, the licensee maintained a good capability for problem identification.
The condition reporting (CR) system appeared to be well established and formalized, encompassed problem reporting site wide, and appeared to be well utilized by plant personnel to document problems in a variety of areas.
The CR process also included a sufficiently low initiation threshold level to allow identification of relatively minor deficiencies.
Numerous gA audits and surveillances were conducted during the two'ear assessment period and targeted most of the in-line functional units onsite with many findings being identified.
However, many of the findings were not directly performance oriented.
In addition, many self assessments were performed.
Those reviewed by the team encompassed primarily the operations, maintenance, and engineering areas with numerous recommendations noted.
However, the reviews themselves appeared to be generally programmatic in nature versus performance based.
The recommendations appeared to largely focus on programmatic aspects as well.
Although some assessment of the plant nuclear safety review committee and the nuclear safety and design review committee (onsite and offsite review committees)
were documented, no overall determination of their functionin'g or effectiveness could be made based
'on the limited amount of information available.
It was documented that two alternate members of the safety review committee did not meet technical specification requirements.
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1.2 1.3 Problem Anal sis and Evaluation The licensee had established a formal trending program for CRs.
A CR
'rend Report was issued twice per year, and included numerous computer sorts.
However, it was unclear if the Trend Report was the plant's sole trending vehicle or how the trends ide'ntified in the report were to be used.
There appeared to be almost a six month lag time between the evaluation period and issuance of the reports themselves.
Also, the CRs were primarily sorted on causal codes.
The licensee utilized a large number of causal codes (i.e.,
193 General/Administrative,,
161 Equipment Failure related, and 39 Human Behavioral related) to obtain trends within very small groupings.
However, it remained unclear as to whether adverse trends in more general areas were available or utilized.
For instance,
"Personnel Error" was not a causal code category, but it appeared that data and trends could possibly be extra'cted by summing several other more specific causal codes.
Finally, based on information in the Trend Report, the team noted that since 1993 about 4,500 CRs were written and a substantial number of CR causal codes were categorized as
"Indeterminate" (906), or "Other" (374).
Again, it was not clear the specific numbers involved were themselves significant, but by assigning large numbers of CRs to such generic categories, little trend value was gained.
Limited information was available to assess how well issues and recommendations identified in gA audits, surveillances, and self assessments were evaluated.
As such, the team was not able to perform a
detailed review of this area based on the available documentation.
However, it was noted that some assessment reports were not issued in a timely manner.
The report on equipment mispositionings during the first half of 1994 was not issued until April 1995.
The assessment of procedure inaccuracies for this same period was not issued until July 1995.
Problem Resolution Corrective actions taken in response to identified plant problems were not always effective.
These included but were not limited to personnel performance issues within the operations area, as well as recurring plant equipment problems (reference Sections 1.2, 2.2, and 3.2 of this report).
Apparent contributors to this sometimes ineffectiveness was the failure to adequately identify the root cause of problems and/or to implement corrective action in a timely manner.
Responsiveness to gA audit and surveillance findings as well as recommendations identified in licensee self assessments was indeterminate.
Albeit, by procedure, gA audit and surveillance findings were documented as CRs, insufficient information was available relating to their resolution to make an adequate assessment.
Although it appeared that, in the aggregate many recommendations were made as a result of self assessments, no discernable tracking mechanism
was in place to assure they were appropriately addressed with the information available in a readily retrievable form.
The CR system was utilized to document industry issues and operational events.
However, again, the adequacy of their resolution was not able to be assessed during the preliminary assessment.
2.0 OPERATIONS Operations performance over the last two years alternated between periods of good performance and weaker performance.
Recent performance appeared to have declined with several plant trips and other transients caused by operator error.
Inadequate self-checking also appeared to notably influence performance in this area.
Overall, performance deficiencies were appropriately identified, pre-jobs briefings were comprehensive, and shutdown risk formally evaluated.
However, although problems involving weak work practices and procedural deficiencies were properly identified by internal assessments, they were not effectively resolved.
Poor coordination and communication between operations and other departments appeared to contribute to a weakness in clearance control.
NRC onsite assessment efforts will concentrate in the areas of problem resolution, quality of operations, and programs and procedures.
The programs and procedures review will focus on equipment configuration control, operator workarounds, and procedure complexity and usefulness.
Inspectors plan to observe control room and inplant activities of licensed and non-licensed operators.
Observations of operations procedure usage, communications, control and coordination of activities from the control room, and clearance activities were also planned.
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'Senior management promoted a conservative operating philosophy in the operations area.
However, it appeared that there was some discontinuity between these expectations and operator performance.
Examples were noted where:
operators attempted to maintain power operation while trying to correct a loss of condenser vacuum; operators did not respond to an annunciator alarm signalling impending damage to a main transformer; and operators paid inadequate attention to plant conditions as discussed in Section 2.3 below.
Management involvement in the operations area appeared mixed.
However, indications were that it was least effective during and shortly= before outages.
The significance of several events was not recognized by plant management, resulting in failures to report these events to the NRC as required.
Events not reported included loss. of four loop injection capability, partial containment isolation, unexpected start of a Turbine Driven Auxiliary Feedwater (TDAFW) pump, and entry into conditions prohibited by Technical Specifications (TS).
Online maintenance of safety systems and time spent in Limiting Conditions for Operation (LCOs) appeared to be controlled overal.2 However, although allowed by the TSs, a few instances were noted where work control convenience was not balanced with a conservative risk, perspective, such as the unnecessary simultaneous removal of both trains of containment hydrogen monitors for maintenance and simultaneous removal of the two normal boron, injection flow paths to repair a leak.
Prejob briefings were normally comprehensive.
Shutdown risk was formally evaluated and appropriately factored into planning and conducting outage activities.
Recent improvements were also noted in the effectiveness of daily planning meetings.
Overall performance in this area was satisfactory.
Problem Identification and Resolution Overall, performance deficiencies were appropriately identified, although somewhat narrow in scope.
The condition reporting (CR) system included a low initiation threshold which resulted in the capture of a large number of concerns.
Although several of the gA audits and surveillances appeared to be thorough, others were not.
An April 1995 assessment of equipment mispositionings concluded that there was no decrease in performance and made no recommendations.
This was contradicted in a December 1995 assessment which was much more critical of performance.
Several licensee assessments performed since November 1995 appeared to be more thorough and candid than earlier assessments.
Correction of some, longstanding deficiencies was ineffective.
Corrective actions often focused on specific symptoms rather than the broader underlying cause.
Problems related to poor work practices and procedural deficiencies continued to occur despite repeated efforts to correct them.
Examples included:
Inadequate control of Reactor Coolant System (RCS) draining was noted during August 1993, with a repeat event during February 1994.
Despite procedure changes, performance problems in this area continued to recur.
Repeated instances of foreign material being found in the primary system, containment, and around the spent fuel pool were identified.
Overall, identification of problems in the operations area was satisfactory; however, resolution of many of those problems was not effective.
2.3 ualit of 0 erations Operations performance over the last two years appeared cyclic.
While
periods'of good operator performance continued to be observed (especially in, response to plant transients),
recent performance appeared to have declined with several plant trips and other transients caused by operator error.
Personnel errors also resulted in serious damage to a main transformer, two occurrences of damage to new 'fuel assemblies, partial loss of vacuum to 'a feedwater pump condenser, seal water transient on a reactor coolant pump, and brief loss of all Unit I control room annunciators.
Much of the cause for this poor performance was attributed to inadequate self checking by operators, inattention to the job at hand, failing to follow procedures, and weak communications.
Failure to follow procedures resulted in improper draindown of the RCS, failure to have at least 'one boric acid transfer pump in operation, failure to reduce power on loss of vacuum, failure to place the main generator core monitor in operation, brief loss of the automatic capability of safety injection, and improper, removal of a charging pump from service resulting in inadvertent entry into an LCO.
Operator inattention or lack of,self checking resulted in Component Cooling water (CCW) temperature being allowed to exceed operating limits, failure to drain a cleared system prior to commencing work, mispositioning the Unit 2 reactor trip switch which caused a reactor trip, and lack of awareness of low CCW flow on multiple occasions.
Also, equipment clearance problems appeared
'rimarily due to operator inattention and poor communications between work groups.
Miscommunication also resulted in a procedure step being missed during testing of an Emergency Diesel Generator (EDG)
and was the principal contribut'or to misadjustment of the control rod drive motor generators which caused a Unit 2 trip.
Inadequate communications between operations and I8C were also responsible for a reactor trip while
. shutdown.
Equipment knowledge weaknesses contributed to operators= experiencing problems in paralleling the main generator, inadvertent draining of 1500 gallons from the RCS, and inappropriate adjustment of the control rod drive motor generators.
Operator performance during simulator evaluation was very good.
Training staff support was a strength and operations management assigned training a high priority.
However, during operator examinations, a few instances of weak self checking caused operators to miss procedure steps and miss equipment irregularities.
Operator formality in the simulator was noted to be at higher levels than those observed in the control room.
Pro rams and Procedures Deficient procedures contributed to poor operator performance.
This was identified in gA reviews, plant trend reports, and numerous NRC inspections during the assessment period.
Inadequate procedures resulted in, or contributed to, improper RCS draindown, a resin spill,
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improper AFW pump operation following a reactor trip, and unexpected auto start of a diesel fire pump.
Related to this area were several weaknesses noted with performing temporary procedure changes.
Several condition reports also indicated that procedures were difficult to use, such as the wrong attachment to a procedure being used.
Although procedural problems appeared to exist, the cause of those problems could not be fully assessed during the preliminary assessment and is considered indeterminate.
The program for maintaining plant housekeeping and cleanliness appeared to be effectively implemented.
'F An aggressive program for identification of operator workarounds was initiated.
This program identified a significant number of items classified as workarounds, but many of these conditions appear to only be material deficiencies that do not necessarily impact operator performance.
The information available in inspection reports on equipment configuration control, operator workarounds, and procedure complexity and usefulness was limited or inconclusive.
Therefore overall performance in this area was indeterminate.
3.0 'NGINEERING Engineering performance was acceptable; however, failure to resolve technical issues contributed to reactor trips and could potentially lead to challenges-to regulatory requirements.
There'ere several repetitive'equipment problems and auxiliary feedwater (AFW) system operability was jeopardized by questionable settings for valve torque switches and motor over-current relays.
Assessments by the quality assurance organization were consistent with NRC observations and provided valuable additional reviews in some areas such as controls for leak sealing and AFW system performance.
Onsite inspection will focus on the resolution of identified technical issues primarily through the system engineers.
1. 1 ~fF Generally, the safety focus of engineering activities appeared good.
Several examples of a conservative safety focus were identified including eddy current inspection of the control rod drive mechanism (CRDH) nozzles and compensatory actions for critical control loops that contained circuit cards suspected to be susceptible to failures.
Other management decisions appeared to be less conservat'ive.
Management was not committed to weld restraint of all CRDM funnels, some of which had been found loose.
This occurred in late 1994, and further information of final disposition was needed to assess the resolution of this issue.
Another early issue, the disposition of potential fuel leaks (up to 5 pins), also warrants further revie k A more recent issue indicating a lack of safety focus was the lifting of Hain Steam Stop Valves (HSSVs) without readjusting the setpoints of those which were outside of Technical Specifications requirements.
Another was failing to resolve the adjustment of chattering relays on the CRDH motor generator (HG) sets by operations staff which resulted in a reactor trip.
Additionally, failure to adequately consider spurious AFW pump trips for operability brings into question the safety focus of system engineering.
3.2 Identification and Resolution of Issues
}i The identification of issues appeared fairly well assured by the low threshold applied by the licensee for'initiating condition reports.
However, programmatically, the threshold was increased for two issues, drawing deficiencies and pipe support ISI evaluations.
It was not apparent how accurate problem trends were identified with these changes.
Org'anizational self-assessments examined program performance and produced recommendations to strengthen them; however, other assessment approaches could have been used to identify performance challenges.
There were only a few examples identified where the identification of an issue was not adequate:
Boric acid transfer pump performance not meeting the Updated Safety Analysis Report (UFSAR) description was identified by inspectors
.=
Auxiliary feedwater pump overcurrent relays required resetting after pump trips were questioned by inspectors Component cooling water east pump discharge check valve slamming continued after first being identified in October 1994 In many other instances, where an. issue was evident, a cause could not be identified.
This led to several issues continuing for long periods.
Therefore, the resolution of issues does not appear to be strong.
Examples of these issues included:
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HSSV*setpoints repeatedly out of specification as reported in numerous LERs
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Hoisture separator/reheater (HSR) high level turbine/reactor trips
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Continuing failures in the Foxboro N-2AO-V2H modules Weak control of vender leakage sealing processes Repeated pressurizer safety valve setpoints being out of tolerance as identified in LERs CRDH relays which periodically chattered
3.3 ualit of En ineerin Work The quality of engineering appeared to be good with scattered exceptions.
This is also reflected in engineering programs which performed well.
One significant area of questionable performance was in engineering evaluations.
Examples of poor evaluations included:
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Lack of evaluation for additional sealant injections on an AFW steam supply valve
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The single failure analysis for the Essential Service Water (ESW)
system did not include electrical/I&C equipment
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The safety evaluation for the temporary modification removing the HSR high level trip was incomplete by not addressing moisture impact on turbine
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The operability evaluation for a sticking and slamming CCW check valve was confusing and disjointed Weak documentation for modifications involving an EDG starting relay and large bore pipe reconstitution program 3.4 Pro rams and Procedures Engineering programs and procedures were generally good as described in inspection reports.
Specifically,.the in-service testing, steam generator'eddy current. testing, and modifications programs were recognized as good.
An oil analysis"program was being implemented and a
heat exchanger performance review program was under consideration.
Some problems were identified from 1994 with unplanned modifications which increased CCW system temperature and a blocked CCW containment penetration cooling line; however, subsequent modification findings appear isolated.
In addition, program changes were initiated in 1995.
Some program deficiencies identified which had significance included:
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Weak controls of the leak sealant process
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An apparent lack of involvement by system engineers
"in post
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maintenance testing
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. The HOV program had poor justification of valve factors, poor documentation to demonstrate design basis capability, degraded voltage calculations based on historic values rather than system parameters, and AFW discharge valves had wrong torque switch settings Additional concerns were recently raised with pre-conditioning of emergency diesel generator testing and control of vendor initiated equipment modifications.
4.0 MAINTENANCE During this assessment period, the maintenance department's performance has been consistent.
The maintenance department's safety focus, problem identification, prog'rams and procedures, and quality of work were considered satisfactory.
However, the resolution of identified problems was not considered effective.
In addition, the material condition of the facility was not effectively maintained and resulted in numerous plant trips and transients.
In general, the NRC and licensee assessments in the area of maintenance have identified similar performance.
The onsite assessment will focus on the areas of material condition, preventative maintenance, rework, work backlog, and the resolution of identified problems.
The licensee generally demonstrated a conservative philosophy with emphasis on safety when handling maintenance issues.
For example, the licensee expanded the scope of their investigation into improperly installed environmentally qualified (Eg) seal assemblies of electrical connections which resulted in the shutdown of Unit 2 to conduct repairs of deficient Eg connections.
However, Hain Steam Safety Valve (HSSV)
testing conducted to exercise HSSVs did not demonstrate a conservative approach to TS surveillance requirements when MSSVs were not reset to the nominal lift setpoint when found outside of the acceptance criteria.
Management of TS Limiting Conditions for Operation action statements was generally good; however, a few examples of less than optimal entries into LCOs for maintenance were identified.
Specific examples included:
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A Hain Steam Stop Valve Dump Valve Test Selector, 2-HH0-240, was repacked six times from July 1992 through September 1994.
Four of these repairs were conducted during four hour LCO entries.
However, the probable cause for the repeated packing failures, a
damaged valve stem identified in July 1992, was not scheduled for completion until September 1994.
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An unplanned extension of 21 hours2.430556e-4 days <br />0.00583 hours <br />3.472222e-5 weeks <br />7.9905e-6 months <br /> to an LCO entry resulted from the addition of a work activity which was not required to be performed during an LCO, replacement of filter 2-(C-12, to a
previously approved LCO work plan.
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On several occasions both trains of the Post Accident Containment Hydrogen Monitoring system were simultaneously removed from service which resulted in unnecessary entries into 72-hour LCOs to perform preventative maintenance.
Overall, the safety focus exhibited by the maintenance department during the time frame covered by this assessment was satisfactor.2 Problem Identification Problem Resolution 4.3 The licensee's identification of maintenance deficiencies was considered satisfactory.
However, there were a few examples of fail'ure to identify material deficiencies and identify rework for repeat maintenance activities in a timely manner.
Specifically:
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The Unit 2 East Component Cooling Water Pump Discharge Check'alve had exhibited indications 'of sticking from October 1994 through September 1995, prior to the check valve being found stuck open.
The repeated valve maintenance of Hain'team Stop Valve Dump Valve Test Selector, 2-HH0-240, was not identified as rework.
In addition, a condition report was not initiated.
Identification of maintenance deficiencies during the performance of guality Assurance Audits and Surveillances were effective.
For example, during the surveillance of maintenance activities, the"licensee identified the over torquing of studs on the Unit 2 pressurizer safety valves and the addition of an excessive amount of leak sealant to a pressurizer spray valve by a contractor.
In addition, procedural adherence, inadequate procedures, foreign material exclusion practices, and inadequate post maintenance testing were repeatedly identified as maintenance weaknesses by both the NRC and the licensee's quality assurance department.
Although,the licensee's identification of maintenance deficiencies was effective, the maintenance department was not effective at resolving and preventing the recurrence of these weaknesses.
Also, there were indications of an adverse trends developing in the maintenance work backlog and rework of maintenance activities during the second half of 1995.
Maintenance department self-evaluations were programmatic and were not in-depth or critical.
On several occasions, these evaluations made recommendations; however, these recommendations tended to be vague and programmatic in nature.
Also, the reports for self-evaluations were not always timely.
For example, the self-evaluation on preventative maintenance was not issued until nine months following the completion of the evaluation.
I Overall, the problem identification exhibited by the maintenance department during the time frame covered by this assessment was satisfactory; however, the maintenance department's resolution of problems was not effective.
E ui ment Performance Material Condition Material condition problems have repeatedly been the cause of reactor trips, forced shutdowns, and plant transients throughout this assessment period.
On at least ten occasions a unit experienced a trip or was forced to shutdown as a result of equipment failures.
During at least
three of these instances, the plant recovery was further complicated by additional equipment failures.
In addition, at least nine plant transients could'irectly be attributed to failed or degraded equipment; and, at least two outages were significantly extended in order that necessary equipment repairs could be completed.
The majority of material condition problems involved balance of plant equipment.
However, there are some equipment problems that have been noted with the safety significant systems.
Some specific examples identified included:
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Auxiliary feedwater pump deficiencies including packing leaks, oil leaks, oil level, bearing over temperature, turbine governor overspeed trips, trip and throttle valve malfunctions, and start failures
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Control rod drive motor generator set output breaker overcurrent-relay cycling
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Low reactor coolant pump oil level As a result of the material condition of the facility, the plant's operators and protection systems were unnecessarily challenged to respond to these events.
ualit of Maintenance Work The quality of maintenance work activities was considered satisfactory.
However, there were several instances where inadequate maintenance directly contributed to equipment failure.
Specific examples included:
Improper assembly and installation of the Unit I east motor driven auxiliary feedwater pump resulted in excessive thrust on the outboard pump bearings which subsequently resulted in damage to the pump.
Incorrectly landed leads associated with the main generator voltage potentiometer replacement resulted in overexcitation of the main generator and damage to the main transformer.
The licensee previously experienced a similar event in March 1993, when an emergency diesel generator load conservation relay was improperly wired.
Improper setting of the overcurrent relay associated with the west centrifugal charging pump resulted in the pump being inoperable.
In addition, both'the NRC and the licensee's quality assurance department have identified foreign material exclusion practices and post maintenance testing as being recurring weaknesses.
Also, there were several examples of recurring material deficiencies and indications of increasing rework which could be attributed to the quality of work being performed by the maintenance department.
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4.5 Pro rams and Procedures Overall, the programs and procedures associated with maintenance were considered satisfactory.
However, procedural adherence and inadequate maintenance procedures were repeatedly identified as weaknesses by both the NRC and the licensee's quality assurance department.
Procedural issues noted included failure to follow procedures, incomplete or conflicting guidance in procedures, and not incorporating vendor information.
Specific examples included:
Maintenance: activities performed on main steam stop valve dump valve, 2-MRV-241, were not performed in accordance with the approved maintenance procedure and subsequently resulted in a reactor trip.
The maintenance procedure for removal and installation of pressurizer safety valves was inadequate; and as a result, pressurizer safety valve studs were overtorqued by up to 160 percent of yield stress.
Deficiencies in the installation of Eg seal assemblies of electrical connections resulted from a failure to incorporate vendor torque requirements in the appropriate maintenance procedure.
Also, based on the facility's equipment performance and reliability, the effectiveness of the preventative maintenance program was considered a
weakness.
5.0 PLANT SUPPORT NRC and licensee assessments of the areas in plant support identified similar results.
Overall, the licensee's identification of problems was excellent; however, the resolution did not appear as effective.
Program performance was generally excellent in radiation protection (RP)
and emergency preparedness (EP);
however, security, especially concerning fire watch duties, appeared to warrant additional attention'.
Although currently pl,armed, the chemistry program was not inspected by the NRC during the current assessment period and was indeterminate; however, recurring problems were identified in licensee CRs, indicating the need for additional review.
The focus of the NRC site inspection phase of this review is planned to include a routine review of a variety of plant support activities.
In particular, the team plans to review licensee performance concerning radiological postings and boundary control,, operability of area and process radiation monitors and the post accident sampling system, security access control'easures, fire protection compensatory measures, and emergency battery lighting.
5. 1 ~fF NRC and licensee assessments of safety focus in plant support were
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5.2 consistent.
However, performance among the plant support areas was mixed and, in chemistry, was indeterminate.
Assessments of RP and EP indicated excellent performance.
The licensee's safety focus in security was acceptable, with the exception of implementation of the fire protection responsibilities.
,RP,performance in this area was excellent.
Performance in refueling outages demonstrated the licensee's coordination, control, and planning of outage activities to maintain doses as-low-as-reasonably-achievable (ALARA).
The licensee conducted effective shutdowns which removed large quantities of corrosion products and,reduced radiation source term.
The RP department maintained effective implementation of the radiological environmental monitoring program (RENP)
and was very stable and experienced.
Although some improvement in chemistry performance was identified in late 1994, previous problems in sample collections and analyses were documented in NRC inspection reports and in licensee observations.
Licensee CRs continued to indicate problems concerning missed chemistry samples and post accident sampling system (PASS)
operability in 1995.
As chemistry inspections were not performed during 1995, performance in chemistry was not assessed and was indeterminate.
I Safety focus in security and fire protection was generally acceptable.
Satisfactory performance in security and fire drills demonstrated management's support and commitment to the program.
The access control computer system was upgraded and improved.
However, NRC inspection reports and licensee 4th quarter 1995 CRs indicated that unauthorized personnel entered areas including the central alarm station and the control room, which challenged the effectiveness of management's communication of expectations.
The number of impairments in the fire protection program was low.
However, weaknesses in emergency'lighting, fire watch activities, and plant personnel understanding of compensatory measures in fire protection were documented throughout 1994 and 1995 in licensee surveillances, LERs, and CRs.
Excellent performance in EP was documented in this area:
Hanagement support was evident through excellent performance in drills and exercises.
Actual plant events were classified correctly, and notifications were complete and timely.
Problem Identification and Resolution Identification of problems appeared effective throughout the program areas.
The licensee appeared to appropriately use CRs and self assessments to identify weaknesses.
However, the resolution of problems in several program areas did not appear as effective.
Audits and self assessments in RP improved performance in the 1994 Unit 2 and 1995 Unit 1 outages through lessons learned from weaknesses in the 1994 Unit 1 outage.
However, the NRC identified that the RP staff's evaluation of operators accessing Unit 1 containment during incore detector movements in September 1995 failed to identify some weaknesses.
Additionally, the apparent recurrence of problems as
documented in NRC inspection reports and 1995 licensee CRs concerning RP postings and boundaries; radiation monitor and PASS operability; and chemistry sampling, analyses, and quality control indicated challenges in the licensee's ability to resolve identified weaknesses.
In the security and fire protection areas, the resolution of problems also appeared weak.
NRC inspection reports and numerous licensee CRs documented personnel entering unauthorized areas (tailgating) throughout the fourth quarter of 1995.
Additionally, licensee problem identification systems were effective in identifying problems in compensatory fire watches and emergency battery lights throughout 1994 and 1995.
However, the licensee's actions appeared ineffective in changing performance.
Plant personnel's understanding of requirements for compensatory fire measures continued to be weak as evidenced by repeated identification of problems in 1994 and 1995 LERs, CRs, NRC inspection reports, and licensee audits.
I.I In the EP program, identification and resolution of problems was excellent.
As documented in NRC inspection reports, audits were very probing and thorough and satisfied the requirements of 10 CFR 50.54(t)
and the licensee's Emergency Plan.
The 1994 EP audit identified weaknesses in communication of data with the NRC and communications within the emergency operations facility (EOF).
These weaknesses app'eared to be effectively corrected, as demonstrated in the 1995 exercise.
ualit of Plant Su ort The quality of plant support programs appeared very good, with some exceptions in the implementation of the fire protection program.
The chemistry program was indeterminate, as discussed above,
'as a result of the lack of NRC inspection results.
Performance in the RP program appeared excellent.
Collective dose and effluents were low.
NRC inspections indicated that the licensee's implementation of ALARA, shutdown chemistry, and effective outage planning were effective in improving outage performance and decreasing dose.
NRC inspectors observed that station personnel had a very good knowledge of RP practices and ALARA.
Inspection results and licensee 1995 CRs indicated some minor weaknesses concerning radiological housekeeping and control of radiological postings and boundaries.
The licensee also documented some minor problems in procedural adherence in CRs.
NRC and licensee documentation of chemistry performance was indeterminate.
In late 1994, NRC and licensee, observations indicated improvements from prior performance problems.
However, licensee identified weaknesses in missed chemistry samples and laboratory quality control continued to be recorded in 1995 quality assurance audits and CRs.
Performance in security and fire protection programs appeared sound, with an apparent decline in performance.
NRC inspection reports indicated that performance in security and fire brigade drills was
'L ll 1
'J
satisfactory; however, security responses were somewhat burdened by fire watch duties.
Hanagement support for these program areas was observed to be very good, e.g., condition of security facilities and low number of fire protection impairments.
As described in Section 5.2, audits of these programs were thorough, but corrective actions were not always effective.
Continuing problems were noted by the NRC and licensee concerning security access control, emergency lighting, and implementation of compensatory fire protection measures.
Problems in the security staff's attention to detail and lack of a questioning attitude were identified by the NRC and licensee, which resulted in the approval of access to individuals having positive chemical tests and derogatory information in their security questionnaires.
,Overall, licensee identified observations contained in surveillances and audits appeared to indicate a lack of understanding of fire protection requirements and those actions that required compensatory actions.
Weaknesses in fire protection. training of security personnel were observed by the licensee and NRC.
Overall, the EP program was excellent.
Assessment, classification, and response to accident conditions was excellent in both actual and drill events.
- With the exception of an NRC identified problem with the communication of the protective action recommendation, the 1995 exercise performance was excellent.
Emergency facilities were in an excellent state of operational readiness.
The emergency response organization training appeared to be very good as indicated by very good exercise performance.
Pro rams and Procedures Programs and procedures in the plant support area were generally assessed as very good.
The procedures implementing the conduct of radiation protection activities were effective, as described in Section 5.3.
The EP and security plans appeared excellent.
The EP plan was revised (1994) to incorporate industry sponsored, improved emergency action levels.
Additionally, improvements were implemented in the chemistry sampling procedures and the security access control procedures
'to correct self-identified problems in those areas.
However, some problems were noted by the NRC concerning the security training procedures for fire watch activities.
Overall, the state of the chemistry program and procedures was indeterminate.
4 y
PERFORiMANCE ASSESSMENT/INSPECTION PLANNINGTREE PRELIMINARYASSESSMENT OF LICENSEE PERFORMANCE Donald C. Cook NIIclear plant
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