IR 05000315/2004014
| ML050310286 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 01/31/2005 |
| From: | Eric Duncan NRC/RGN-III/DRP/RPB6 |
| To: | Nazar M American Electric Power Co |
| References | |
| IR-04-014 | |
| Download: ML050310286 (17) | |
Text
ary 31, 2005
SUBJECT:
D. C. COOK NUCLEAR POWER PLANT, UNITS 1 AND 2 NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000315/2004014; 05000316/2004014
Dear Mr. Nazar:
On December 17, 2004, the U.S. Nuclear Regulatory Commission completed an inspection at your D. C. Cook Nuclear Power Plant, Units 1 and 2. The enclosed report documents the inspection findings which were discussed on December 17, 2004, with you and other members of your staff.
This inspection was an examination of activities conducted under your license as they relate to the identification and resolution of problems, compliance with the Commissions rules and regulations, and with the conditions of your operating license. Within these areas, the inspection involved a selected examination of procedures and representative records, observations of activities, and interviews with personnel. Although this inspection was a scheduled biennial review, because a problem identification and resolution inspection was performed in December of 2003, this inspection reviewed the activities since the completion of that inspection.
The team concluded that in general, problems were being properly identified, evaluated, and corrected. The specific conclusions, also reflected in the feedback received from your staff, was that the identification of issues was generally satisfactory, but that problem resolution, although improved, warranted additional attention. Nonetheless, your implementation of the D.C. Cook Recovery Plan appears to have improved the effectiveness of your corrective action program as evidenced by the issues identified by the inspectors which, with one exception, were of only minor significance. The inspectors also concluded that there was no evidence that management did not foster an environment where workers felt free to raise safety concerns.
Based on the results from this inspection, one NRC-identified finding of very low safety significance (Green) which involved a violation of NRC requirements was identified. However, because the violation was of very low safety significance and because the issue was entered into your corrective action program, the NRC is treating this issue as a Non-Cited Violation in accordance with Section VI.A.1 of the NRCs enforcement policy. If you contest the subject or severity of a Non-Cited Violation, you should provide a response with a basis for your denial, within 30 days of the date of this inspection report, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission -
Region III, 2443 Warrenville Road, Suite 10, Lisle, IL 60532-4352; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at the D.C. Cook facility.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Eric R. Duncan, Chief Branch 6 Division of Reactor Projects Docket Nos. 50-315; 50-316 License Nos. DPR-58; DPR-74
Enclosure:
Inspection Report 05000315/2004014; 05000316/2004014 w/Attachment: Supplemental Information
REGION III==
Docket Nos: 50-315; 50-316 License Nos: DPR-58; DPR-74 Report No: 05000315/2004014; 05000316/2004014 Licensee: American Electric Power Company Facility: D. C. Cook Nuclear Power Plant, Units 1 and 2 Location: 1 Cook Place Bridgman, MI 49106 Dates: November 29 through December 17, 2004 Inspectors: R. Lerch, Project Engineer, DRP M. Garza, Resident Inspector, Palisades L. Haeg, Reactor Engineer, DRP I. Netzel, Resident Inspector, D.C. Cook R. Ng, Reactor Engineer, DRP R. Winter, Reactor Engineer, DRS Approved by: E. Duncan, Chief Branch 6 Division of Reactor Projects Enclosure
SUMMARY OF FINDINGS
IR 05000315/2004014; 05000316/2004014; 11/29/2004-12/17/2004; D. C. Cook Nuclear Power
Plant, Units 1 and 2; Problem Identification and Resolution.
The inspection was conducted by region-based inspectors and resident inspectors. One Green finding of very low safety significance with an associated Non-Cited Violation was identified.
The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter 0609, "Significance Determination Process (SDP)." Findings for which the SDP does not apply may be "Green" or be assigned a severity level after NRC management review. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 3, dated July 2000.
Identification and Resolution of Problems The team concluded that overall, problems were being properly identified, evaluated, and corrected. The specific conclusions, also reflected in the feedback received from the licensees staff, was that the identification of issues was generally satisfactory, but that problem resolution, although improved, warranted additional attention. Nonetheless, the implementation of the D.C. Cook Recovery Plan appeared to have improved the effectiveness of the licensees corrective action program as evidenced by the issues identified by the inspectors which, with one exception, were of only minor significance. The inspectors also concluded that there was no evidence that management did not foster an environment where workers felt free to raise safety concerns.
Cornerstone: Occupational Radiation Safety
- Green.
A finding of very low safety significance was identified by the inspectors when licensee personnel failed to adequately address repetitive radiological posting errors. The issue was more than minor since it was associated with the Program and Process attribute of the Occupational Radiation Safety cornerstone and adversely affected the cornerstone objective of ensuring the adequate protection of worker health and safety from exposure to radiation.
The finding was of very low safety significance since the issue did not directly impact As Low As Reasonably Achievable (ALARA) planning or work controls, was not associated with an overexposure or a substantial potential for an overexposure, or compromise the licensees ability to assess dose. As part of the licensees immediate corrective actions, areas with survey maps which were outdated were immediately updated to reflect the most recent survey results.
One Non-Cited Violation of Technical Specification 6.8.1 was identified. (Section 4OA2.3)
REPORT DETAILS
OTHER ACTIVITIES (OA)
4OA2 Problem Identification and Resolution
.1 Effectiveness of Problem Identification
a. Inspection Scope
The inspectors reviewed documentation from over the last year including NRC inspection report findings, selected corrective action documents, Recovery Plan actions, operating experience reports, and trend assessments, to determine if problems were being entered into the corrective action program (CAP) at the proper threshold.
Corrective action program implementation, metrics, and status such as corrective action generation rates and departmental performance indicators were reviewed and discussed with licensee personnel.
b. Assessment In general, licensee personnel identified issues and entered them into the corrective action program at an appropriate level. However, when the D.C. Cook Recovery Plan was developed and actions to be taken were identified, these actions were not tracked using the corrective action program. When this was identified by the NRC, the actions were entered into the corrective action program. The inspectors had several additional observations about the program, although no significant problems were identified. For example, the green card, intended for identifying issues when a computer was not available, was difficult to understand, especially by individuals such as contractors, who would not be familiar with plant CAP input codes. The green card itself was not well defined or controlled by procedures.
Since departmental self-assessments of CAP implementation were not performed, this area was not reviewed by the inspectors. The licensee established the Performance Observation Program (POP) to conduct narrowly focused self-assessments. This program had its own procedure and documentation forms separate from the corrective action program. Although a valuable tool, the inspectors identified a vulnerability for a problem to be identified through a POP observation and not tracked to resolution. While most departments diligently reviewed POP results, not all departments ensured that each problem identified during a POP observation was captured in a condition report (CR) in the CAP. A review of a sample of POP reports by the inspectors did not identify an example where a significant issue was not adequately resolved as a direct result of the failure to identify a POP observation in a condition report. The inspectors also identified that licensee personnel had an earlier opportunity to address this vulnerability.
The evaluation of CR 03363023, which identified that POP findings in the radiation protection department were inadequately reviewed because CRs were not generated, erroneously concluded that this problem was limited to the radiation protection department.
Cause codes were being used and trend thresholds were established and being used to identify trends in condition reports. Also, the handling of operating experience reports was improved with this improvement confirmed by licensee audits, the most recent of which identified only minor issues. Interviews of plant staff also indicated that problem identification was viewed as a strength.
.2 Prioritization and Evaluation of Issues
a. Inspection Scope
The inspectors reviewed procedures, inspection reports, and corrective action documents to verify that identified issues were appropriately characterized and prioritized in the CAP. Evaluations documented in CRs were reviewed to verify an appropriate depth and thoroughness of the review relative to the actual or potential significance of each issue. The inspectors attended management meetings to observe the assignment of CR categories for current issues and to observe the review of root cause, apparent cause, and common cause analyses, and corrective actions for existing CRs. The inspectors also assessed the corrective actions implemented to address Non-Cited Violations (NCVs).
b. Assessment Although several minor performance issues with individual condition reports were identified as discussed below, evaluations in general were acceptable.
- During the CR screening process, plant management assessed the significance of each CR and the appropriate evaluation. The inspectors identified two examples where these reviews prescribed inadequate corrective actions. The inspectors determined that during the review of CR 0448040, the concern was mis-interpreted in a non-conservative manner. Also, in CR 04330018, immediate corrective actions to post up-to-date radiation surveys clearly indicated that some surveys were not updated; but screening reviewers did not identify that the immediate corrective actions were inadequate (Section 4OA2.3). The licensee entered these issues into the corrective action program as CRs 04351051 and 04351038, respectively.
- The inspectors identified that the review of an audit finding lacked an appropriate extent of condition review. A finding in Audit PA 04-08 identified that a specified equipment performance criteria had not been measured. Although the specific issue, documented on CR 04043039, was of only minor significance, since the criteria was subsequently deleted, the licensees evaluation failed to address whether other criteria in the document might not have been tested appropriately. The licensee generated CR 04350007 to enter this issue into the corrective action program.
- The inspectors identified one example of improper closure of a condition report (CR 0400604) where corrective actions were not complete. This was due to a revision in the planned corrective actions that was not documented in the CR. Throughout the assessment period, licensee personnel also identified CRs that were not properly closed and issued followup CRs to identify those instances. In the examples reviewed by the inspectors, there were no issues which were of more than minor significance.
.3 Effectiveness of Corrective Actions
a. Inspection Scope
The inspectors reviewed corrective action documents including root cause reports and apparent cause evaluations and verified that corrective actions were identified and implemented in a timely manner, commensurate with the safety significance of the issues, and were effective. The inspectors also reviewed the licensees corrective actions for NCVs documented in NRC inspection reports in the past year.
b. Assessment In general, the licensees corrective actions for the samples reviewed were appropriate.
The inspectors identified one finding of very low safety significance (Green) and an associated Non-Cited Violation of Technical Specification 6.8.1, Procedures and Programs, when licensee personnel failed to adequately address repetitive radiological posting errors. The inspectors identified some additional issues that were repetitive in nature, however the significance of those issues was minor.
b.1 Failure to Promptly Correct Outdated Radiological Survey Maps Introduction The inspectors identified a Green finding and an associated Non-Cited Violation of Technical Specification 6.8.1, Procedures and Programs, when licensee personnel failed to adequately address repetitive radiological posting errors.
Description In January 2004, Performance Assurance Audit PA-04-07 identified that Radiological Area Status Sheets (Radiation Protection (RP) Survey Maps) posted in the access control hallway had not been updated as required by 12-THP-6010-RPP-401, Performance of Radiation and Contamination Surveys. Condition Report (CR) 04016049 was generated on January 16, 2004 to document the issue. The condition report also stated that this problem had been previously identified following a Performance Assurance (PA) field observation on February 9, 2002.
CR 040019014 was generated on January 19, 2004 by the radiation protection (RP)department personnel to document recurring deficiencies identified by the PA organization, including outdated surveys.
On February 16, 2004, radiation protection personnel performed a Performance Observation Program (POP) observation to verify that radiological survey maps posted at the turbine building side restricted access control area had been properly updated.
Licensee personnel discovered that 20 routine radiological surveys were not properly posted and CR 04047061 was generated to document the issue.
Due to the recurring instances of outdated survey maps in the access control area, an apparent cause evaluation (ACE) was performed to review this issue. Licensee personnel determined that the apparent cause for the issue was the failure of radiation protection personnel to ensure that the radiological surveys they performed were posted as prescribed by radiation protection procedures and in accordance with management expectations. Procedures and processes for conducting radiological surveys were evaluated and the need to revise the process to enhance the ownership and provide a second verification was identified. As a result, radiation protection management issued a letter dated April 15, 2004, to all radiation protection technicians which outlined the process change and accountability requirements for conducting and posting surveys.
On November 25, 2004, another POP observation was performed and again identified numerous deficiencies in the posting of survey maps. CR 04330018 was generated to identify this problem. As part of the licensees immediate corrective actions, all missing or outdated survey maps were properly posted. An ACE was scheduled to be performed by December 22, 2004 to evaluate this issue, however no additional corrective actions were planned in the interim.
On December 15, 2004, the inspectors performed a walkdown of the turbine building side restricted access control area to verify that posted survey maps reflected the most recent survey information. The inspectors discovered that the licensees corrective actions in response to the November 15, 2004, event were not effective and that 10 survey maps posted at the access control area were still outdated. Upon questioning by the inspectors, the licensee updated these survey maps and generated CR 04351038 to identify this issue.
Analysis The inspectors determined that the failure to update survey postings to reflect the most recent survey information was a performance deficiency warranting a significance evaluation. The inspectors concluded that the issue was more than minor in accordance with Inspection Manual Chapter (IMC) 0612, Power Reactor Inspection Reports, Appendix B, Issue Disposition Screening, since the finding was associated with the Program and Process attribute of the Occupational Radiation Safety cornerstone and adversely affected the cornerstone objective of ensuring the adequate protection of the worker health and safety from exposure to radiation. Specially, the failure to post survey data using the most recent survey information could result in an unintended exposure of workers to radiation in the event that radiological conditions had changed and workers were not aware of those conditions.
Using IMC 0609, Appendix C, "Occupational Radiation Safety Significance Determination Process, the inspectors determined that because the radiological survey maps posted at the entrance to restricted areas were for informational use and workers were required to contact radiation protection technicians before they enter the radiological restricted area, the issue did not directly impact As Low As Reasonably Achievable (ALARA) planning or work controls, was not associated with an overexposure or a substantial potential for an overexposure, or compromise the licensees ability to assess dose. Consequently, the finding screened as Green and was considered to be of very low safety significance.
Enforcement:
Technical Specification 6.8.1 requires, in part, that procedures shall be established implemented and maintained for the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2. Appendix A, Section 7.e, Radiation Protection Procedures, of Regulatory Guide 1.33 specifies procedures for radiation surveys and contamination control. Radiation protection procedure 12-THP-6010-RPP-401, Performance of Radiation and Contamination Surveys, required that up-to-date survey maps be posted in the access control hallway. Contrary to the above, licensee personnel failed to post up-to-date survey maps in the access control hallway as required by radiation protection procedure 12-THP-6010-RPP-401. In particular, licensee personnel failed to recognize that only those missing or outdated maps that originals could be located for were updated when this condition were identified on November 25, 2004. As a result, 10 radiological survey maps were still outdated when the inspectors inspected the postings on December 15, 2004.
However, because this violation was associated with a finding of very low safety significance and because the finding was entered into the licensees corrective action program, this violation is being treated as a Non-Cited Violation, consistent with Section VI.A.1 of the NRC Enforcement Policy (NCV 05000315/2004014-01; 050000316/2004014-01). This issue was entered into the licensees corrective action program as CAP059216. As part of the licensees immediate corrective actions, areas with survey maps which were outdated were immediately updated to reflect the most recent survey results.
b.2 Observations on the Effectiveness of Corrective Actions The inspectors had several observations regarding corrective actions that were not sufficiently effective in correcting the identified issue or to prevent recurrence. The examples identified were of only minor significance and are described below.
Foreign Material Exclusion On August 5, 2004, a vacuum hose was inadvertently dropped into the screen house forebay and could not be located for retrieval. Although no adverse impact on plant equipment occurred as a result of this event, the event revealed a potential vulnerability in the licensees Foreign Material Exclusion (FME) program. A root cause evaluation was performed for CR 04218086. Subsequently, other failures of FME controls occurred and on October 26, 2004 the Performance Assurance organization generated CR 0429044 to document an FME programmatic concern. The inspectors noted that even before the August 5, 2004 event, FME program implementation had been a repetitive and long-term issue, and corrective actions were not sufficiently effective. At the end of this inspection, a root cause evaluation for CRs 04296044 and 4298002 was in progress.
Procedural Adherence The inspectors identified through a review of CRs that failures by licensee personnel to adhere to procedures was a persistent and repetitive issue. Although the examples were of only minor significance, these issues demonstrated the potential for a significant issue to occur. Some examples included the following:
- CR 04313006 identified that workers were signed out of a work clearance regarding a primary relief tank maintenance activity before they had exited the area which was not permitted by procedures.
- CR 04337070 identified that workers verified that a nonsafety-related cavity sump was inspected for debris, although inspectors identified foreign material in the sump shortly afterward.
- CR 04335009 identified that operations staff had met power escalation prerequisites, but they were not signed off before performing the procedure.
- CR 04243140 identified that reactor coolant sample valves were left open by chemists on two occasions, contrary to procedures.
The licensee was addressing this area of performance through the D.C. Cook Recovery Plan and was tracking and trending procedure performance issues.
.4 Assessment of Safety-Conscious Work Environment
a. Inspection Scope
The inspectors conducted more than 100 interviews of licensee personnel to assess whether there were impediments to the establishment of a safety conscious wok environment and whether workers felt free to raise safety concerns. During these interviews, the inspectors utilized Appendix 1,Suggested Questions for Use in Discussions with Licensee Individuals Concerning PI&R Issues, to Inspection Procedure 71152, as a guide to gather information and develop insights. The team also discussed the implementation of the Employee Concerns Program (ECP) with the licensees ECP Coordinator.
b. Assessment In general, licensee personnel did not express any safety conscious work environment concerns. A few individuals expressed some hesitation to raise a concern, but they did not have any specific safety or regulatory issue to report. Licensee personnel were aware of and generally familiar with the corrective action program and other problem-reporting programs, including the ECP, through which concerns could be raised. A review of the issues entered in the ECP indicated that site personnel were appropriately using the corrective action program and the ECP to address their concerns. The ECP Coordinators were appropriately reviewing individual concerns and appropriately using the ECP and CAP programs to resolve issues. Plant communications in newsletters and posters informing workers of the CAP and ECP programs and how to access them were widely available.
The inspectors made the following observations:
- The inspectors identified that security force personnel was not well trained at generating CRs for issues they identified although these issues were entered into the corrective action program by their supervisors.
- The corrective action program provided a notification and feedback form for CR initiators to review the resolution of CRs they had written. Some initiators were frustrated by the time required to correct relatively minor issues and the number of CRs that were closed to the trending process without a corrective action to address the specific concern.
- The inspectors noted that the corrective action program did not require that the initiator be contacted during the CR evaluation process.
4OA6 Management Meetings
Exit Meeting Summary
The inspectors presented the inspection results to Mr. M. Nazar and other members of licensee management at the conclusion of the inspection on December 17, 2004. The licensee acknowledged the findings presented. The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary.
The licensee indicated that no proprietary information was provided to the inspectors.
ATTACHMENT:
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee
- M. Finissi, Plant Manager
- J. Jensen, Senior Vice President
- J. Labis, Employee Concerns Manager
- M. Nazar, Chief Nuclear Officer
- A. Rodriguez, Security Manager
- S. Simpson, Manager, Learning Organization Department
- R. Serocke, Radiation Protection Manager
- L. Weber, Performance Assurance Director
- T. Wood, Manager, Regulatory Assurance
- J. Zwolinski, Safety Assurance Director
Nuclear Regulatory Commission
- E. Duncan, Chief, Branch 6, Division of Reactor Projects
- B. Kemker, Senior Resident Inspector
ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
- 050000316/2004014-01 NCV Failure to Promptly Correct Radiological Survey Maps
Closed
- 050000316/2004014-01 NCV Failure to Promptly Correct Radiological Survey Maps
Discussed
None Attachment