IR 05000315/1997003
| ML17334B636 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 05/30/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17334B634 | List: |
| References | |
| 50-315-97-03, 50-315-97-3, 50-316-97-03, 50-316-97-3, NUDOCS 9706060031 | |
| Download: ML17334B636 (28) | |
Text
U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Docket Nos:
Licenses No:
50-315; 50-31 6 DPR-58; DPR-74 Reports.No:..
50-31 5/97003(DRS); 50-31 6/97003(DRS)
Licensee:
Indiana Michigan Power Company
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Facility:
II Donald C. Cook Nuclear Generating Plant Location:
1 Cook Place Bridgman, MI 49106 Dates:
February 10 - 14, 1997 March 11 -14, 1997
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Inspectors:
E. Plettner, Reactor Engineer M. Bielby, Reactor Engineer P. Cataldo, Reactor Engineer Approved by:
M. Leach, Chief, Operator Licensing Branch Division of Reactor Safety 970606003 1 970530 PDR ADQCK 05000315
. EXECUTIVE SUMlNARY D. C. Cook Units 1 and 2 NRC-inspection Reports 50-315/97003; 50-316/97003 This inspection report contains the findings and.conclusions from the inspection of the licensed reactor operator (RO) and senior reactor operator (SRO) requalification training programs.
The inspection included a review of training administrative procedures and operating examination material; observation and evaluation of operator. performance and.
licensee evaluators during.a requalification operating examination; an assessment of simulator fidelity; an evaluation of program controls to assure a systems approach to training; and a review of requalification training records.
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I The inspectors used the guidance in inspection procedure (IP) 71001.
Qgt~ri~in The inspectors identified two procedures involving.complex jobs where reliance on memory cannot be. trusted and the sequences;cannot be altered were not designated as "In-Hand" procedures with the """". This failed to meet licensee procedure requirements of PMI 2011: This was considered a violation of Technical Specification 6.8.1 (Section 03.1).
The. inspectors identified additional examples of a violation cited in inspection report 50-315/316/97002 involving procedural inadequacies.
This was considered a
violatiort'of Technical Specification 6.8.1.
However, since the examples had minor safety significance they are being issued as a non-cited violation (Section 03.1)
During review of the annual operating requalification examination, the inspectors'r identified several weaknesses in the scenario development process, for example the lack of clear. identification of the critical tasks and the failure criteria; weaknesses in the job performance measure (JPM) development process, for example critical steps not being identified; and a weakness in questions used in the written examination, for example reference questions that were "direct lookup" questions (Section 05.2).
During review of licensee evaluators'ocumentation from the annual operating requalification examination the inspectors identified inconsistencies in individual grading of JPM critical tasks between licensee evaluators'or the same JPM. This was considered a weakness (Section 05.2).
During observation of the annual operating requalification examination, the inspectors identified inconsistencies regarding the individual evaluation process utilized by the licensee which was to pass the individual based solely on the crew being able to perform the critical tasks.
This was considered a weakness (Section 05.3).
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The returning of operators to licensed duties without remediation and reevaluation after failing the written or JPMs examination was considered a weakness (Section 05.3)..
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'he failure to conduct a comprehensive annual operating examination was considered a violation of 10 CFR 50.54(k) and 10 CFR 55.59(a)(2) (Section 05.3).
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Operations Procedures and Documentation 03.1 D ficien ie Id n ifi in r
ion Pr d re a.
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During the operator requalification inspection conducted from February 10 to March 14; 1997, the inspectors-also evaluated, procedure usage and the adequacy of those procedures.
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While observing the annual operating examinations, the inspectors identified" problems. with procedure usage.
Technical Specification Section 6.8.1 requires that written procedures shall be established, implemented and maintained covering the activities referenced in Appendix "A" of Regulatory Guide 1.33, Revision 2, February 1978.
The licensee utilizes Plant Manager Instructions (PMI) to implement the Technical Specification requirements.
Plant Manager Instructions (PMI)
PMI 2011, "Procedure Use and Adherence," Section 3.1
~ 1 designates that -"In-Hand" procedures are indicated. by a """"in the procedure number.
The facility's Quality Assurance Program document dated July 1995, Section 1.7.5.2.5 states, in part, "Examples of "In-Hand" procedures are those developed for extensive or complex jobs where reliance on memory cannot be trusted.
Further, those procedures which describe a sequence which cannot be altered, or require the documentation of data during the course of the procedure, are considered."
Procedure 1'2 OHP 4021.018.002,
"Placing In Service and Operating the Spent Fuel Pit Cooling and Cleanup System," Revision 11, dated August 12, 1996, Section 4.1 contains instructions that require valve lineups on Lineup Sheet No.
1 (which contains 29 valves) be performed prior,to spent fuel pool pump operation, component cooling water system operation, and essential service water operation.
Similar circumstances are contained in Sections 4.3 and 4.5. This procedure was not designated as "In Hand" per Section 3.1.1 of PMI 2011.
Procedure 12 OHP 4021.018.013,
"Filling, Emptying and Refilling Fuel Transfer Canal," Revision 7, dated January 7, 1997, Data Sheet No. 1, contains instructions in Section 4.1 that require valve lineups on Lineup Sheet No.
1 (which contains
valv'es) be performed prior to doing equipment lineups involving the nitrogen system, and the starting and stopping of chemical volume control system (CVCS)
HUT recirculation pump.
Similar circumstances are contained in Data Sheets No. 2, 3, 4, and 5. This procedure was not designated as "In Hand" per Section 3.1.1 of PMI 2011.
Procedures 12 OHP 4021.018.002 and 12 OHP 4021.018.013 were not in accordance with PMI 2011 and represent a violation of Technical Specification Section'6.8.1 (50-315/97003-01(DRS);
50-316/97003-01(DRS)).
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While observing the. annual operating examinations, the inspectors identified problems with procedure adequacy.
"Operations Department Procedure Revision Manual," OPM.001, Revision 1, dated September 14, 1995, details the process for revising the Operations Department controlled procedures and instructions.
The following procedures failed to meet the OPM.001 requirements for component identification and for having "Initials" blank columns:
01 and 02 OHP 4021.012.001,
"Operation of the Control Rod Drive System," Revision 7, Unit 1, dated October 3, 1995, and Revision 7, Unit 2, dated June 21, 1996.
12 OHP 4021.018.002,
"Placing In Service and Operating the Spent Fuel Pit Cooling and Cleanup. System," Revision-11;-.dated August 12, 1996.
12 OHP 4021.018.013,
"Filling, Emptying and-Refilling -Fuel Transfer Canal,"
Revision 7, dated January 7, 1997.-
~i 01 and 02 OHP 4030.STP.017T,
"Turbine. Driven Auxiliary Feedwater System Test," Revision 13, dated October 16, 1996.
01 and 02 OHP 4030.STP.017TV, "Turbine Driven Auxiliary Feedpump Trip and Throttle Valve Operability Test," Revision 8, dated July 17, 1996.
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ni in These findings represent additional examples of a violation cited in Inspection-Reports 50-315/316/97002.
The examples are of a minor nature and are included here to further identify the scope of the procedural inadequacies described in Inspection Report 97002.
In accordance with Section 6.3.1.1 of the Enforcement:
Manual these examples due to their minor safety significance are being issued as a non-cited violation (50-315/97003-02(DRS);
50-316/97003-02(DRS)).
Operator Training and Qualification 05.1 0 cretin Histor a.
In ec i n S 71001 The inspectors reviewed the following to assess the licensed operator requalification training program's effectiveness regarding operator performance:
SALP Reports No. 50-315/96001; 50-316/96001.
Resident inspector observations and reports covering the time frame of December 1995 to present.
Licensee event reports covering the time frame of January 1996 to present.
Initial license examination'Reports No. 50-315/96-01(OL); 50-316/96-01(OL), and 50-315/96-02(OL); 50-316/96-02(OL).
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Licensed operator requalification training Reports No. 50-315/95002(DRS);
50-31 6/95002(DR S) ~
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Fin in The inspectors noted that poor operator performance as documented in the above reports was attributable in part to incorrect and inadequate procedures, and ineffective training for operators concerning usage of procedures.
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nl in The inspectors concluded that the licensed operator requalification program had not been effective in reenforcing proper procedural usage.
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1 The inspectors reviewed the following using IP 71001, Appendix A check-lists titled "Simulator Scenario Review Checklist," "Job Performance Measure (JPM) Quality Checklist," and the "NRC Checklist for Written Examination Questions" to assess the licensee's examination materials'uality and content:
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Sample plans.
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Written requalification exams administered in February 1996.
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Operating requalification exams administered during the inspection week.
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in The inspectors reviewed a scenario administered during the inspection week, as well as two additional scenarios administered in previous weeks using the
=Appendix A checklist titled "Simulator Scenario Review Checklist." The Training Program Management Plan (TAM) 3.03, Revision 11, Section 4.5.1.B.1 states, in part, that "Simulator evaluation scenarios should reflect applicable guidelines for content and standards established in the current revision of NUREG-1021 Revision 7." The following weaknesses were identified in two of the three scenarios:
Events were not related to each other.
Expected operator actions were not listed by shift position.
Formatting was not consistent regarding the identification of critical tasks, initial conditions, and failure criteria.
Events did not require the SRO to identify Technical Specifications requirement I
Transition into additional EOPs was minimal.
Few malfunctions occurred after the initial EOP entry.
Same individual conducted the review and approval.
The inspectors. reviewed the observed job performance measure (JPM) set and two additional JPM sets administered in previous weeks using the Appendix A checklist titled "Job Performance Measure (JPM) Quality Checklist." The following weaknesses were identified in the JPM sets:
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JPM (AE-.O-N230)."Reset the TDAFP for Remote Operation After it has Tripped Due to Mechanical Overspeed,"
Revision 5, dated 11/18/93, had 2-OHP 4030.STP.017T
"Turbine Driven Auxiliary Feedwater System Test,"
(Revision 9, CS-9) Steps 8.43 and 8.45 listed as a reference.
The inspectors reviewed the stated reference and noted that the JPM could not be performed using the stated reference.
The correct reference should have
- ': "been 02 OHP 4030.STP.017TV, "Turbine Driven Auxiliary Feedpump Trip and Throttle Valve Operability Test," Revision 8, dated July 17, 1996.
This condition occurred due to a lack of detailed review prior to performing the JPM.
Critical steps were identified within the JPMs when they did not meet the
~ = - definition of "critical step".
For example JPM (AE-0-E250) "Shift TDAFP" Suction To ESW," Revision 9, dated 2/10/97, had Step 7 which had the candidate "Locates Emergency ESW Supply Shutoff Valve:- 1-WMO-753 or 2-WMO-753" designated as critical. Step 8 had the candidate simulate the operation of manually opening the motor operated "Emergency ESW Supply Shutoff Valve" which was also designated as a critical ste.,<<:There were also.steps within the JPMs that did meet the definition of
"critical step" but were not identified.
For example in JPM (RO-0-E008)
"Perform Immediate Actions of E-0 Without SI," Revision 4, dated January 31, 1997, Step 8 requires the candidate to "Controls charging flow to maintain PZR level." This should have been critical as failure to control PZR level within the band required in E-0 would further degrade plant conditions.
JPM (AE-0-E231) "LocallyTrip the Reactor," Revision 10, dated January 24, 1997, contained a single performance step in order to complete the JPM.
This is not the preferred method of determining satisfactory performance during the evaluation process.
The inspectors reviewed the licensee's evaluators'ocumentation of the individuals'erformance on the JPMs administered during the annual operating exam.
The inspectors noted an additional weakness which contributed to the problems identified above.
In reviewing the individual's performance, the inspectors noted that different evaluators graded the individuals differently for the same JPM performance.
Follow up discussions with the evaluators and licensee management revealed that some regrading was necessary.
Regrading was performed without
changes in the final outcome for the individuals involved, which resulted in an overall pass for the JPM portion of the annual exam.
This weakness was a concern to the inspectors because the licensee's post administrative review process did not identify these inconsistencies.
The inspectors reviewed the written examination given in 1996 using the Appendix A checklist titled "NRC Checklist for Written Examination Questions."
The following weakness was identified in the written examination questions:
The written examination questions contained several instances where open reference questions were classified by the inspectors as a "direct look up" question.
A "direct.look-up".question is defined as a-question that immediately directs an operator to a particular reference where the answer is readily available.
This type of question should be avoided and the licensee agreed to reduce the number of direct look-up questions during the next
~ written exam.
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nl in Several weaknesses were identified in the scenario development process, for example the lack of clear identification of the critical tasks and the failure criteria.
Weaknesses were identified in the job performance measure (JPM) development process, for example critical steps not being identified. Weaknesses were identified in the questions used in the written examination for example reference questions that were "direct lookup" questions.
The majority of the weaknesses were due to poor reviews of the material.
05.3 R
ualifi i n Examin i n Admini r
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1 The inspectors performed the following to assess the licensee's policies and practices regarding requalification examination administration, and simulator fidelity:
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Observed and evaluated the performance of one operating crew during dynamic simulator scenarios and the JPM examinations.
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Reviewed Training Administrative Procedures.
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Reviewed the simulator fidelity log.
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Fin in 10 CFR 50.54(k), "Conditions of licenses" states "An operator or senior operator licensed pursuant to Part 55 of this chapter shall be present at the controls at all times during the operation of the facility." 10 CFR 55.59(a)(2), "Requalification requirements," states that "each licensee (individual licensed operator or senior operator) shall pass a comprehensive requalification written exam and an annual operating test." Additional clarification/guidance regarding 10 CFR 55.59 (a)(2)
was noted in the following NUREGs:
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NUREG-1262, published in 1987, documented the following question and answer in regards to the annual operating test.
Question 354:
Must the annual operating exam for requalification be given in one time'frame'or can that also be broken up into various pieces throughout the year?
It's very difficultto get everybody done in one year by the training staff.
A Answer:
'or a candidate, it needs to be done at one time, but if what you are asking is that you have 30 people that need to have
" an operating test, and you want to spread out the 30 tests over the period of a year, the answer is yes, But, you can'
take an individual and give him a walk-through today and some simulator evaluation tomorrow and then some six months from now add those three pieces up. That would not meet the intent of an annual operating test.
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NUREG-1021 ES 604 Section B "Dynamic Simulator Requalification Examination Scope" states "The dynamic simulator test consists of two scenarios."
During the inspection; the inspectors'.noted-that the licensee performed only one scenario on the crew participating in the annual operating test during the week.
The licensee identified that individuals in the observed crew had either participated in at least one other scenario earlier in the requalification cycle, or would participate in one during the following weeks.
As a result, the individual evaluations for
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operators from each scenario were not performed in the aggregate.
This concerned the inspectors, because based on the program change which occurred in March 1995, an individual could perform at an unsatisfactory level in different, individual competencies during each of the annual dynamic scenario exam evaluations but never fail the examination, or subsequently, be removed from licensed duties for remediation and reexamination.
The failure to conduct a comprehensive annual operating examination is a violation of 10 CFR 50.54(k) (50-315/97003-03(DRS);
50-31 6/97003-03(DRS)).
The inspectors reviewed records regarding the licensee's administered requalification exams from previous requalification cycles.
The inspectors noted that on February 5 through March 21, 1996, the licensee returned seven of nine operators to licensed duties without remediation and reevaluation after failure of the written requalification exam.
In addition, the inspectors noted that on February 3 and 4, 1997, the licensee returned two of four operators to licensed duties without remediation and reevaluation after failure of the job performance measure (JPM)
portion of the annual operating requalification exam.
This was considered a
weaknes The licensee's evaluators identified operator performance errors during the operating examinations.
The licensee evaluated the crew and all individuals as satisfactory if all crew critical tasks were accomplished.
The inspectors agreed
'ith the licensee's evaluation results for the crew critical tasks.
However, the inspectors were concerned with the evaluation process utilized by the licensee in passing all individuals before executing the individual evaluation process.
The licensee's decision to pass all individuals was based solely on the accomplishment of all crew critical tasks and competencies.
This was considered a weakness.
The inspectors noted that the licensee had a crew failure due to a missed crew critical task during performance of scenario RQ-E-2001 on July 15, 1996.
However, the licensee documented that all individuals had passed.
The Training
...,Program Management Plan (TAM) 3.03, Revision 11, Section 4.5.1.B.1 states, in
.part, that "Simulator evaluation scenarios should reflect applicable guidelines for
'ontent and standards established'in the current revision of NUREG-1021 Revision 7." NUREG-1021 ES 604 Section E.2 "Dynamic Simulator Requalification Examination Individual Operating Evaluations" states "The facilityevaluators are expected to, at a minimum, identify any operator on the crew who was directly responsible for the omission or incorrect performance of validated CTs" [Critical Task(s)].
This concerned the inspectors because one of the six licensed individuals was ultimately responsible for, the crew. failing to perform the critical task; however, none of, the three evaluators identified such an individual. This was considered a
weakness.
The licensee's simulator deficiency and condition reports were prioritized and addressed in a timely'manner."ln-addition, a continuous review and upgrade program was in place to address immediate and long range simulator improvement initiatives.
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i n The failure to conduct a comprehensive annual operating examination and the returning of operators to licensed duties without remediation and reevaluation after failing the written or JPMs examination had a minimal impact on safety because crewfindividuai performance errors have not been a contributing cause or have not caused any plant events.
The licensee's decision to pass all individuals based solely on the accomplishment of all crew critical tasks and competencies was considered a program weakness.
The reluctance of facility evaluators to identify any operator on the crew who was directly responsible for the omission or incorrect performance of validated CTs was considered a program weakness.
No simulator performance or fidelity deficiencies were observed during the examination process.
See the attached simulation facility report.
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lifi i n Tr inin Pr ram F edb k
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1 The inspectors performed the following to assess the licensee's training program feedback system effectiveness:
Reviewed the Safety Assessment and Quality Verification (SAQV) audit QA-95-10/NSDRC ¹226 and QA 96-13/NSDRC ¹237 for requalification training.
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Reviewed recorded changes to the requalification program.
Reviewed operator feedback.
i n 'n The inspectors reviewed training procedures and records associated with the feedback system.
In addition the inspectors interviewed a number training instructors.
The instructors were knowledgeable about the feedback system.
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nl in The inspectors determined that the feedback process was effectively implemented.
The licensee had an effective tracking program to incorporate changes resulting from identified weaknesses, operator training requests, and plant and industry events.
The program was current and up to date.
05.5 f mn wi r
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1 The inspectors reviewed the following documents to assess the licensee's compliance with 10 CFR 55.53, "License conditi'on requirements," and 10 CFR 55.21, "Medical examination."
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Systems approach to training program records.
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Requalification training records.
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Licensed operator medical records.
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rv i n n F'n The facility licensee's records for both active and inactive licenses covering the current two year requalification period were requested and reviewed.
The'records were easily retrieved by the licensee and contained sufficient documented details to compare facility licensee's activities to the requirements of 10 CFR 55.53 and 10 CFR 55.21.
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The inspectors did not identify any non-compliance items associated with the requirements of 10 CFR 55.53 and 10 CFR 55.21.
V. Ni na m n N e in s X1 Exi i
'mm r The inspectors presented thegreliminary inspection results to members of licensee management on February 14 and March 14, 1997.
On March 31, 1997, a telephone exit was conducted to inform the licensee that an unresolved item discussed in the exit
.:.. conducted on March 14, 1997, would become a potential violation. The licensee acknowledged the findings presented.
The inspectors asked the licensee whether any materials examined during. the inspection could be considered proprietary.
No proprietary information was identified.
Attachment 'imulation Facility Report
PARTIALLIST OF PERSONS CONTACTED
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"M. Ackerman, Nuclear Licensing
"R. Anderson, Operations Training Specialist G. Arent, Operations Procedure Supervisor P. Barrett, Director Performance Assurance
"A. Blind, Site Vice President
"B. Gillespie, Operations Supervisor
"D. Loope, Training Manager
"J. Sampson, Plant Manager
"L. Smart,.Nuclear Licensing
".D. Seipel, Operations Training
"G. Tollas, Operations Supervisor (Acting)
J..Wiebe, Manager Engineering, arid Analysis S. Wolf, Performance Assurance
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"B. Bartlett, D. C. Cook Senior Resident Inspector P. Cataldo, Reactor Engineer B. Fuller, D. C. Cook Resident Inspector J. Lennartz, Acting Chief, Operator Licensing. Branch:
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Denotes those present at the exit on February 14 and. the re-exit on March 14, 1997.
INSPECTION.PROCEDURES USED IP=7.1 001:
IP 71707:
Licensed Operator Requalification Program Evaluation Plant Operations ITEMS OPENED, CLOSED, AND DISCUSSED
~Oened 50-315/316/97003-01 NOV Failure to follow procedure PMI 2011.
50-31 5/31 6/97003-02 50-31 5/31 6/97003-03 NCV Failure to follow procedure OPM.001.
NOV Failure to conduct comprehensive operator licensing examinations.
Attachment SIIVIULATIONFACILITYREPORT Facility Licensee:
D. C. Cook Units 1 and 2 Facility Licensee Dockets No: 50-315, 50-316 Operating Tests Administered:
February 10 - 14, 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 facilityother 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):
DE IP NONE OBSERVED
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