IR 05000315/1996001
| ML17333A527 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 07/08/1996 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17333A526 | List: |
| References | |
| 50-315-96-01, 50-315-96-1, 50-316-96-01, 50-316-96-1, NUDOCS 9607310176 | |
| Download: ML17333A527 (10) | |
Text
Donald C. Cook Nuclear Plant SALP 13 Report No. 50-315; 50-316/96001 I.
C
The Systematic Assessment of Licensee Performance (SALP) process is used to develop the Nuclear Regulatory Commission's (NRC) conclusions regarding a
licensee's safety performance.
The SALP report documents the NRC's observations and insights on a licensee's performance and communicates the results to the licensee and the public.
It provides a vehicle fot clear communication with licensee management that focuses on plant performance relative to safety risk perspectives.
The NRC utilizes SALP results when allocating NRC inspection resources at licensee facilities.
This report is the NRC's assessment of the safety performance at Donald C.
Cook Nuclear Plant for the period October 30, 1994, through May 25, 1996.
An NRC SALP Board, composed of the individuals listed below, met on June 5,
1996, to review the observations and data on performance and to assess performance in accordance with the guidance in NRC Management Directive 8.6,
"Systematic Assessment of Licensee Performance."
~d W. L. Axelson, Director, Division of Reactor Projects, RIII
~Bd ll B
G.
E. Grant, Director, Division of Reactor Safety, RIII F.
M. Reinhart, Acting Director, Project Directorate III-1, NRR II.
P RFORMANCE ANALYSIS A.
P nt0e at'o s
Overall performance in the area of operations was good and generally reflected a conservative, safety-oriented operating philosophy.
However, several initiatives in the operations area to improve performance which appeared to be underway near the end of the last SALP period were not sustained.
Throughout most of this period, there were examples of ineffective management oversight that contributed to a decline in performance.
Recognition of declining performance and implementation of corrective actions to arrest the trend were observed at the end of this SALP period.
The plant was operated in a conservative and safe manner.
During a unit shutdown, when unexpected main turbine high vibrations were encountered, the operators conservatively tripped the reactor.
However, there were some non-conservative operability determinations, such as exiting a technical specification action statement for an inoperable ice condenser intermediate-deck door, while plant conditions did not meet the limiting condition for operation requirement.
Early in the SALP period, several operator errors led to reactor trips and other plant transients.
The 96073iOi76 960708 PDR ADOCK 050003i5
number and significance of these errors generally declined during the latter part of the SALP period due to an increase in management oversight and corrective actions.
However, some operator errors continued such as operating a charging pump without a discharge flow path, and a plant transient during feedwater heater level alarm testing.
Examples of problems with procedure quality and adherence were observed throughout the period.
In one instance, operators did not reduce power during a loss of vacuum transient as required by procedure.
Instances of poor quality of normal operating, surveillance, and administrative procedures also contributed to performance problems, such as a reactor trip during main turbine overspeed testing, and a brief loss of all control room annunciators.
Efforts were initiated to improve the quality of these procedures and reduce the backlog of procedure changes such as allowing senior reactor operators to process certain procedure changes on-shift.
This has resulted in a reduction of the backlog of procedure changes.
Poor communications between operations and other departments were demonstrated when operations was not aware of the status of main steam safety valve setpoint testing.
This contributed to an unexpected Engineered Safety Features actuation during an instrumentation and control (IEC) maintenance activity. 'owever, the licensee took action to improve communication among the departments by instituting new standards and expectations for communications and requiring that the shift supervisor actively participate in the daily planning meeting.
These actions have shown some positive results but it's too early to assess the overall effects.
Hanagement efforts to identify and resolve issues in the operations area were not always effective or timely throughout this period.
Some longstanding deficiencies involving the procedure issues discussed above, poor work practices, and equipment clearance errors were not effectively addressed.
New problems, such as degrading secondary plant material condition were not always recognized in a timely manner, nor aggressively pursued.
On several occasions these deficiencies resulted in challenges to the operators, including reactor trips and several plant transients.
Nore self-critical assessments of performance within the department, or by the quality assurance organization, could have led to earlier identification and assessment of these performance problems.
Management oversight in operations appeared to have improved late in the assessment period when extensive actions were taken to evaluate and correct the performance of an entire operating crew.
The performance rating is Category 2 in this are I NAC Overall performance in the area of maintenance was good.
Most maintenance and surveillance activities were conducted in a conservative manner with an emphasis on safety and quality, but challenges remain.
Personnel errors caused some plant transients and operability problems, procedural inadequacies or noncompliance continued to be an issue, and declining material condition of balance-of-plant equipment contributed to several reactor trips, forced shutdowns, and plant transients.
The quality of most maintenance work was good, but some personnel errors occurred which caused plant transients and operability problems.
The frequency of these maintenance errors did not increase, but they became more significant and increasingly challenged operational safety.
For example, the miscalibration of a safety-related overcurrent relay resulted in prolonged, undetected inoperability of the Unit I Mest centrifugal charging pump.
Also the potentiometer on the Unit I main generator voltage regulator circuit was replaced improperly, directly contributing to significant damage to the Unit I main transformer.
Maintenance procedures were typically of good quality, and workers accomplished the specified maintenance activities successfully.
However, both the NRC and the licensee's quality assurance department identified examples of procedural deficiencies, including failure to follow procedures, incomplete or conflicting guidance in procedures, and not incorporating vendor information into procedures.
In addition, in instances where maintenance activities resulted in subsequent equipment failures, procedural noncompliance or inadequate procedures were identified as a contributing cause by both the NRC and the licensee.
guality Assurance audits and surveillances were limited in identifying issues in this area, and there appeared to be a high threshold for identification of material condition problems.
As a result, numerous material condition deficiencies were identified by the NRC during recent inspections.
Maintenance department self-evaluations were programmatic and were not in-depth or critical, and the resolution of some identified deficiencies was weak.
The maintenance department was not effective at preventing the recurrence of deficiencies and in some cases responded in a narrowly focused manner.
Although foreign material exclusion improved significantly during the recent Unit 2 refueling outage, a lack of effective management oversight of the foreign material exclusion program resulted in program implementation being less effective during the period.
Many condition reports for potential rework were narrow in scope, were not effective at determining the root cause, or did not identify appropriate actions to prevent recurrence.
In addition, if an action request was not originally initiated as a rework item, the priority system could delay subsequent rework for up to a year.
The preventive maintenance program was adequately implemented overall and the number of preventive maintenance activities being'erformed increased.
Equipment performance and material condition of safety related systems was considered very good.
Notably, the facility achieved a high degree of safety system performance for 1995 on the high pressure safety injection system, the auxiliary feedwater system, and the emergency AC distribution system.
However, there were at least two
equipment failures which could have been identified prior to the failure by a strong and proactive lube oil analysis program; the 2CD emergency
'iesel generator governor failure, and the Unit I east motor driven auxiliary feedwater pump outboard motor bearing failure.
Management of maintenance activities conducted during voluntary LCO action statements was also generally good; however, the estimated time for the system to be returned to service was frequently exceeded.
Despite significant online maintenance, the corrective maintenance backlog increased twofold after March 1995, partly due to instances of ineffective implementation of work planning and scheduling.
The licensee appeared to be making progress on improving post-maintenance testing (PHT), but there were instances of pre-conditioning equipment prior to surveillances.
Examples included rolling the diesel generators prior to fast star ts (which exercised several valves in the air start system),
and operating the turbine-driven auxiliary feedwater pump (TDAFWP) for one surveillance test just prior to being tested for another, TS required surveillance.
In addition, operators were instructed to check the operability of the TDAFWP steam traps just prior to the surveillance which had the potential to pre-condition the steam traps.
The performance rating is Category 2 in this area.
SJBKBUILG Throughout the SALP period, the licensee exhibited an overall conservative and technically sound approach to engineering issues; however, some weaknesses were demonstrated in certain engineering areas.
Engineering support in improving the material condition of plant secondary systems and in identifying and resolving issues was considered weak due to the many problems encountered.
Examples of inadequate awareness, understanding, and use of the plant design and licensing bases also occurred.
Once clearly focused on a problem, however, engineering efforts to resolve issues and support operation of the plant were good.
In addition, engineering performance was solid in most of the programmatic areas, such as modifications and ASME code inspections.
Engineering support to secondary plant material condition was not effective in the case of a steam generator chemistry excursion caused by numerous equipment deficiencies.
These included three of four turbine room sump pumps being degraded or out-of-service, a check valve and a
manual valve that leaked, and a level control valve that was not properly controlling level.
In addition, erratic actuation of a moisture separator reheater level switch resulted in turbine/reactor trips on two occasions.
Investigation of the fir'st trip was hindered because two level alarms did not work.
These and other secondary equipment malfunctions indicated that engineering was not taking a
proactive role in improving the material condition of the secondary plant.
Engineering was not aggressive in addressing other plant deficiencies, exhibiting a lack of questioning of conditions and a reluctance to generate condition reports by engineers.
For example, the boric acid system heat tracing had numerous high temperature alarms which went
unquestioned by operators and engineers.
The operations staff had also identified to engineering that the boric acid system heat trace temperature instruments were not in a calibration program, but no condition report was initiated.
Additionally, engineers were not always timely in generating condition reports, sometimes taking up to two days.
Corrective actions were also sometimes untimely and too narrowly focused.
For example, a sticking air start quick exhaust valve caused a
slow emergency diesel generator (EDG) start, but resolution of the root cause was not promptly pursued even though other exhaust valves and EDGs were potentially affected.
In another example, it was known for months that operators were performing voltage adjustments to stop relay chattering on control rod drive motor (CRDN) generator sets, but the problem was not resolved until after it caused a reactor trip.
In some cases, such as the'epetition of the instantaneous over-current trip of an auxiliary feedwater pump, prompting, by the NRC was necessary to initiate an evaluation by engineering.
Once engineering effort was focused on an issue, results were very good, such as, in the resolution of the CRDN chattering relays arid failing V2H circuit cards, which were difficult issues.
In several instances, weaknesses in the use and retrievability of licensing and design information were evident.
When ice condenser bypass flow design limits were questioned, for example, initial responses were that 50 square feet of flow area was allowable.
The actual design limit of 5 square feet was subsequently retrieved, but with some difficulty. Similarly, the plant staff had lost awareness of the requirements for having a criticality monitor for new fuel.
In another example, requirements for component cooling water system flows to sample coolers specified in the Updated Final Safety Analysis Report were not verified by the flow balance surveillance procedure.
Although there were examples of weak performance as noted above, fundamentally the licensee's programs and procedures were good.
The NRC inspections of programs for inservice-testing, steam generator eddy current inspection, and planned modifications were positive, and, although the motor operated valve program had some open issues, the program was making progress',towards closure.
The performance rating is Category 2 in this are N U
Overall performance in the plant support functional area was excellent.
Strengths in the'adiation protection, emergency preparedness, and security programs were evidenced by continued low collective station personnel exposures, very good radworker practices, excellent emergency drill performance, and effective maintenance of security systems.
'Although reactor water quality was maintained within aggressive goals, problems with procedural adherence, evaluation of quality control (gC)
data',
and post accident sampling system (PASS)
program implementation were identified in the chemistry area.
The radiological controls program continued to perform at an excellent level.
Although some outage planning and work-scope identification problems were encountered, collective personnel radiation exposure was minimized due to the extensive use of shielding, source term reduction efforts, and close oversight of work activities.
Also, station radworker practices continued to be very good as demonstrated by a low number of personnel contaminations and personnel errors.
Effective control of plant contamination provided uninhibited access to safety related equipment.
The radiological environmental monitoring program continued to be effectively implemented.
Chemistry program performance continued to improve as evidenced by the effective control of reactor water quality within aggressive goals.
However, procedural adherence problems and sampling errors, similar to those identified early in the previous assessment period, occurred in the PASS gC program.
Although laboratory instrument gC was good, the chemistry technicians and supervisors did not consistently evaluate gC data for performance trends and biases.
The PASS system was in poor material condition which contributed to occasional problems in obtaining PASS samples.
The chemistry staff's efforts and quality assurance support in initiating chemistry self assessments was a strength.
<!curity performance remained excellent and security systems were maintained in excellent condition.
Security and maintenance support staff were effective in identifying and resolving problems.
Security program enhancements during this assessment period included the replacement of the security computer, the central alarm station, and the uninterruptible power supply and the implementation of a hand geometry access control system and a'atchman program.
Two isolated personnel errors in the area of access authorization were identified.
Performance in the emergency preparedness (EP) program was also excellent.
Strengths included facility maintenance and the stable and experienced staff.
There was a comprehensive schedule of drills and exercises.
The 1994 and 1995 exercise performance was very good.
The 1995 and 1996 annual audits of the EP program were very good.
Actual event classifications and notifications were properly made.
The performance rating is Category 1 in this are I