IR 05000317/1989081
| ML20006C682 | |
| Person / Time | |
|---|---|
| Site: | Calvert Cliffs  |
| Issue date: | 01/23/1990 |
| From: | Blough A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20006C675 | List: |
| References | |
| 50-317-89-81, NUDOCS 9002080378 | |
| Download: ML20006C682 (65) | |
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U. S. NUCLEAR' REGULATORY COMMISSION Region _I'
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' Docket No.:
50-317-l
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l Report'No.~:
'50-317/89-81-Licensee:
Baltimore Gas and Electric Company
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Post Office' Box 1475'
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Baltimore,iMaryland 21203
. Facility:
'Calvert Cliffs Nuclear Power Plant, Unit 1-
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Inspection at: Lusby, Maryland
' - Inspection Conducted:
November 7-20, 1989 w-Team Manager: James T. Wiggins, Chief l
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Reactor Projects Branch No. 1 S
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Division of Reactor Projects-
Inspectors:
David F. Limroth, Acting SRI - Calvert Cliffs l
Elmo E. Collins,. SRI - Oyster Creek
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_ Wayne L. Schmidt,' SRI - FitzPat' rick
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Lawrence W; Rossbach, SRI - Indian Point 3
Tae J. ' Kim, RI - Pilgrim Allen G.' Howe, Senior Operations Engineer Henry K. Lathrop,, Reactor -Engineer
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Bruce Deist, NRC Contractor-
Approved By:
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A. Randy SleDgh, Chief- (Team i.eader)'
date
't Reactor Projects Section No. 3A
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Oivision of Reactor Projects-
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SUMMARY 0F.RESULTS........................................
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3.1 Operations...........................................
- 3.2~;Meintenance/ Surveillance.............................
3.3 Safety Assessment and Quality Verification...........
3.4~ Overall Results..................................'....
3.5 Summa ry of Li cen see Commi tments......................
3.6 Other Open Issues for Restart........................
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DETAILS OF INSPECTION.....................................
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k 4 4.1 ' Operations...........................................
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4.2 Maintenance / Surveillance.............................
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4'3' Safety Assessment and Quality Verification...........
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- 5.0L UNRESOLVED ITEMS..........................................
6.0 MANAGEMENT MEETINGS.......................................
51-t Appendices
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1.0' EXECUTIVE SUMMARY'
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A Readiness Assessment Team Inspection (RATI) was conducted to. determine
!whether licensee corrective actions had been effective at generally rais-l'
ing the level of performance in the areas targeted for improvement by
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Confirmatory Action Letter (CAL) 89-08 and related documents and whether performance was currently at a level that would provide assurance of
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safety _in support of plant operation. In order to appropriately cover the areas of interest, the Team was organized into three inspection groups:
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operations, maintenance / surveillance, and safety assessment and quality
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verification.
The groups were led by NRC Senior Resident Inspectors (SRIs) all from different Region I sites. Particular emphasis was placed on-evaluating the effectiveness of recent program changes and on deter-mining the level of licensee staff understanding of the changes. A repre-sentative of the State of Maryland observed the inspection.
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'In -the areas of Maintenance and Surveillance, the. Team found that the
level of performance had been raised and would support safe plant opera-tion of the plant.
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In the.rea of Safety Assessment and Quality Verification, the Team found
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that performance for the most part had been raised and would support safe plant operation. However, many programs were in transition and management initiative -was being relied upon to compensate for formal process weak-nesses.
For example, the generally successful identification of issues necessary-to be resolved before restart primarily had been the result of the licensee's major site-wide communications effort to encourage staff to bring issues forward.
Whereas the-Team developed a general ' confidence through checking a sampling of issues that restart issues had been pro-perly identified, the Team was concerned regarding the processes for tracking and resolution of routine corrective actions.
These concerns were based on the multiplicity of systems, the size of the backlogs, and inconsistencies in methods for prioritization, tracking and management review. Since the restart list is a specialized mechanism and these other multiple systems will be relied upon for corrective action management after restart, the Team considered it important that the licensee provide additional measures of assurance that deficiencies identified during oper-ation would be properly classified, prioritized, reviewed and tracked to assure effective corrective actions on appropriate schedules. The 11cen-see made an acceptable commitment to address this concern.
In the area of operations, the inspection covered three main areas:
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procedure usage; 2.
control of plant status and activities; and, 3.
safety tagging and equipment control.
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.s The Team found general improvement in the use of procedures and adminis-tration of change processes. During -the course of this review, the Team found examples of inadequate procedures for the current plant mode. These
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are being corrected by the licensee. The issue of adequacy of procedures for-other operational modes is being addressed outside the scope of this inspection.
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The Team also found a ' satisfactory level of control of plant status and
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adequate shift knowledge of plant status and activities.
In the area of safety tagging and equipment control, the Team found that the licensee was not ready for an NRC inspection.
Although tagouts were being properly researched, devised, approved and installed, the licensee lacked a meticulous approach to administration of the -program.
Further,
there was a lack 'of sensitivity to the need for application of-formal corrective action processes to deficiencies found in tagging program implementation.
Finally, management review of improvements and ongoing overview of this area had not been sufficient to identify that this area was not ready for the NRC RATI review. Because of the weaknesses identi-fied, the Team concluded that improvements would be necessary to assure that a satisfactory level of performance can be sustained to support safe operation of the facility.
The licensee is expected to re-evaluate this area and to provide a com-prehensive written response.
.The Team made the following general observations:
' There was a markedly increased awareness of the importance of, and
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requirements for, adherence to procedures.
The organization appeared to have become more sensitive to problem
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identification.
The mechanisms used to communicate current management goals, policies
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and objectives were effective-in making all levels of the plant staff aware of these expectations.
The-organization appeared weak in communicating with the NRC.
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The results of this inspection and related followup activities will be considered, along with below listed items, by NRC during deliberations regarding plant restart:
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results of NRC inspection activities to review individual open items needed to be resolved before restart; (2) results of BG&E efforts to achieve, and to internally verify, plant physical readiness for operation; and, (3) results of NRC evaluation of BG&E corrective actions relative to:
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,(1):. equipment and procedures for? shutdown from outside the control c. ;
room; and,
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(ii) assurance of adequacy of normal operating procedures.
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.These items were known"by NRC 'and BG&Esto be' pending when ths inspection
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'2.0 INTRODUCTION;
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-2.1 Background
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Baltimore Gas and Electric (BG&E or the licensee) has'an ongoing Per-
formance Improvement Plan (PIP), a long-term plan designed to raise i
the safety. performance at their-Calvert Cliffs' Nuclear Power Plant
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(CCNPP, the plant, the station,- or the - site).
In addition,. on
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May.23, 1989, BG&E indicated in a letter to the NRC, that it' intended
to keep both Calvert Cliffs units shut down while it took action to
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- address certain hardware and programmatic issues.
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The' hardware-problem involved' leakage from the Unit 2 pressurizer
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via heater element welds. - The. programmatic issues involved proced-ural adherence, work controls, and system._ status controls.
These commitments, along with BG&E's -intent not to restart Unit I without obtaining the NRC Regional Administrator's agreement, were formalized j
in NRC Confirmatory Action Letter (CAL) 89-08 on May 25,1989.
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r Subsequently, NRC issued a report of a Special. Team-Inspection (STI)-
50-317/89-80 and 50-318/89-80 conducted in February and March 1989.
In its June 21, 1989 letter, BG&E-also committed to address certain issues from this STI prior to restart.
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In an October 27, 1989 letter to NRC and at a meeting in NRC Region I on November 1,1989, BG&E described the specific corrective actions taken to resolve the programmatic actions associated with the CAL and-
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the STI report. The hardware issue had been previously resolved for
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-Unit 1.
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NRC review of BG&E's programmatic corrective actions includes a
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detailed technical review of each of over 40 specific issues which is being managed by the NRC Resident Inspector office and an overall
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assessment of licensee performance which was the function of this team inspection.
Although important to NRC deliberations regarding restart, the
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results of this inspection would not solely lead to NRC Region I concurrence with restart of either uni Region I management expects to review the results of this inspection along with the following:
(1) the results of inspection activities, still ongoing, to review individual open items needed to be resolved before restart.
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These include the detailed review of individual CAL /STI closeout packages; this review is still ongoing, as coordinated by the NRC resident staff;
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(2) the results.of BG&E efforts to make the plant physically ready W
for startup and to verify completion of those items internally evaluated by BG&E as restart items;:and,
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'(3) NRC evaluation of BG&E corrective actions relative to:
,t (a) equipment and procedures for-plant shutdown from outside
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the control room (commonly referred to as AOP-9 issues)-
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-4 (b) assurance of adequacy of' normal operating procedures'.
These items were known by BG&E and NRC to be incomplete when the
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inspection was scheduled.
2.2 Purpose and Scope of Inspection i
This RATI is part of the NRC staff process for determining restart
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readiness. -Its specific purpose was to determine whether corrective actions' have been ef fective at generally raising the -level of per-
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formance in the areas targeted for improvement by the CAL and related
documents and whether performance is now at a level that would pro-'
vide assurance of safety in support of plant operations.
The Team was designed to look very broadly at results and to assess the level of performance in the areas of previous concern. Tbc Team was not designed to look deeply and in detail at individual issue closeout packages prepared by BG&E, Detailed review of individual items is being coordinated by the resident staff during normal NRC inspections.
2.3 Methodology In order to appropriately cover the areas of interest, the Team was
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Operations;
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Maintenance / Surveillance; and,
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Safety Assessment and Quality Verification.
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The inspection consisted of interviews with licensee personnel, plant tours, observations of plant activities, and selective examinations of procedures, records, and documents.
Particular emphasis' was y
placed on evaluating the effectiveness of recent program changes and on determining the level of licensee staff understanding of the changes.
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e An important feature of the-Team was the extensive interaction among
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the Team members to arrive at a collective,. supportable assessment i
of the: level of performance and of areas.of strength and-weakness.-
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-The inspection focused on Unit.1 programs and_ activities, since the licensee's plans are to restart Unit-1= substantially in advance of Unit 2.
However, the Team noted that licensee programmatic controls are essentially identical for both units. - (An exception is the use
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Paragraph 4.1.)
Also, inspectors toured Unit 2 and observed Unit 2 conditions in cases where these observations could help provide an assessment of' licensee programs common to both units.
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3.0: SUMMARY OF RESULTS u
This section of the report provides a-summary of significant inspection findings in each area.
Within each area, the Team identified specific strengths, substantial imprcvements, and weaknesses. -These are summarized below.
Additionally, significant observations of the Team are, listed.
These observations may reflect positive or negative program and perform-ance attributes, but are not sufficiently noteworthy to be characterized as strengths, substantial improvements, or weaknesses.
For. each func-
tional area, more detailed findings are provided in paragraph 4.
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Paragraph 3.4 describes Team findings, that are applicable 'to all func-
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tional areas. Because of their broad applicability, these findings should i
be of special interest to senior licensee management. These findings are not repeated in paragraph 4.
Paragraph 3.5 summarizes formal licensee commitments made to the NRC Team during the inspection.
3.1 Operations c
The operations results are summarized-for each of the following areas:
safety-tagging and equipment control, use and control _ of procedures, and control of plant status and activities.
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3,1,1 Safety Tagging and Equipment Control Substantial Improvements
- The following substantial improvements were noted:
(1) additional licensed operator-review of-safety tagouts to-increase confidence in tagout adequacy; (2) strengthened programmatic requirements as described in the procedure for safety tagging;
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(3) use of color coding to better identify tagouts by unit
and area; (4) use of an equipment status board in the tagging office; (5) tagging representation in planning / scheduling meetings and shift turnover briefings; and, (6) elevation of the tag supervisor position to a shift
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supervisor level.
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Weaknesses - Three major weaknesses were noted:
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y-(1)- the tagout system is not being meticulously adminis-
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(2) the tagout system is not receiving sufficient perfo.rm =
-l ance monitoring and management oversight;;and,-
1 (3).tagout system implementation deficiencies. do' not
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always receive. adequate documentation ~, and are not always entered into _the appropriate - formal corrective -
action systems.
The following are examples of the above weaknesses:
(1) the required 30-day audits of-tagouts greater than 90
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days old were not completed for September and~
r October 1989; licensee management was unaware of the missed audits and no formal corrective action had been initiated;
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(2)- identification, documentation and management reviews
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of audit' discrepancies were' informal and often not fully followed up;
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(3) NRC identified a red danger tag attached to Unit I temporary refuel water leve1~. panel that had been moved from another panel without proper documentation; (4) recent tagout violations were followed up informally; responsible personnel were _ uncertain as to-which for-mal corrective action processes were appropriate; (5) in a November 12, 1989 audit conducted by the licensee in response to the identification of missed audits, o
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two electrical breakers were found with tags removed-and breakers repositioned.
Although corrective actions were initiated immediately, there was' a 3-day delay in initiating an NCR; and, (6) Use of laminated drawings to display tagout_ boundaries was found to be cumbersome, inefficient and only mar-ginally useful.
Of four sets of-drawings checked by
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NRC, each set contained errors or inconsistencies.
The licensee is considering discontinuing this aspect of its program due to its marginal usefulness.
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j42 Observations
(1) Staffing levels in the tagging area appear question-o able to support the outage workload.
(2) The licensee has recognized, and is' addressing, a need for additional electrical and I&C expertise in the tagging group.
3 '.1'. 2 Control and Use of Procedures
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Substantial Improvements
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t (1) There is increased awareness of the importance of pro-cedure use, i
(2) There is increased attention to evaluating procedure changes for change o.f intent.
(3) The licensee has improved the process for implementing-
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minor (i.e., pen and ink) procedure change:,,
(4) Operators are stopping work activities when appropri-
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ate to resolve procedure problems.
Weaknesses
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(1), Several examples of inadequate procedures for.the cur-rent plant mode were noted.
These involve operation and verification of the boration flow path for the.
existing plant condition.
These examples reinforce
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the need for procedure verification and. upgrades.
J Adequacy of pro'cedures for the operational modes will be evaluated by NRC outside the scope of this inspection.
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(2) GS-NO Standing Instruction which provide operating instruction that could affect nuclear safety were not deleted when replaced by approved procedures-as com-mitted by the licensee.
Although the specific cases were corrected during the inspection, the continued existence of this concern implies that current licen-see corrective action may not be effective at preven-ting recurrence of this program weakness.
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Observation
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-The. individual sections-of Operating Instructions are not l
organized in a well-thought out order.
l 3.1.3 Control'of Plant Status and Activities
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Substantial Improvements (1) Shift briefings are effective a t -- transferring
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(2)' Effective steps have been taken to increase plant status information to operators, including ' equipment status sheets, daily tagout. listings, and planning.and
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scheduling group representation at shift briefings =,
(3) -There is expanded use of cut-of-service (005) tags to display equipment status to operators.
(4) Safety review of temporary modifications (TMs) under procedure CCI-117 has been strengthened.
Weakness For TMs implemented outside procedure CCI-117, such _ as those under Engineering Test Procedures, there is no formal screening of status and acceptability prior to mode change.
Observation There is an unusually extensive use of temporary notes and other operator information aids on control panels.
If not reduced prior to restart, the sheer volume of this infor-mation could present a human factors concern.
However, based on a detailed review of those items by -the Team, it appeared that those notes could be largely removed before startup.
3.2 Maintenance / Surveillance
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Strength l
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The maintenance job supervisory observation program is a strength.
Supervisors are making meaningful observations and critical comments.
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Substantial Improvements (1) - The administrative procedure for control of Maintenance (CCI-200) is a good procedure that should provide strong control over-maintenance.- This includes improved planning, more detailed packages, better post-maintenance testing and improved documen-tation of completed work.
(2) Controls and accountability for ' surveillance scheduling have been improved; in the areas assigned, functional test coordina.
tors assure proper scheduling.
Weakness The decision.to exclude certain surveillances from program consolida-tion under the STP managers was not fully thought out. For example, Technical Specification required surveillances outside the consoli-dated program did not.have a completion certification signature required on mode change checklists. (OP-6),
(See paragraph 3.5.2 - for licensee corrective action commitments).
Observations (1) The scheduling function is developing rapidly.
(2) Control of vendor technical information is now adequate.
(3) The licensee is still' working out implementation and coordina-tion difficulties with respect to the new maintenance controls.
This results primarily in efficiency problems.
Although this is not a safety concern to NRC, the NRC could become concerned during power operations, if equipment important to plant safety undergoes unnecessarily long out-of-service times due to unrea-sonable delays in starting or coordinating work.
(4) The Team noted that licensee controls over MOV torque switches are behind industry general practice.
(See paragraph 4.2.3.2).
(5) The Team questioned the reportability of shutdown cooling heat exchangers flow information identified by BG&E in June 1988.
(See paragraph 4.2.3.2).
3.3 Safety Assessment and Quality Verification (SA/QV)
Substantial Improvements The following long-term programs have been substantially improved and, if implemented effectively, have the potential for significant safety benefits:
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(1) _ Procedures Upgrade Program;
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(2)' Supervisory Training Program; and,
'(3) System Engineer Program.
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y Weaknesses (1)' The Team ~1dentified weaknesses in the structure and relationship to line management of the Plant Operations-Safety Review Com-g o
mittee (POSRC):
(a) Authority to approve POSRC recommendations was delegated by the. Plant Manager to three alternate POSRC ~ Chairman.
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This indicates a lack of full appreciation of the POSRC function of advising the Plant Manager in that the Plant Manager's review function w3uld not be fulfilled; (b) The GS-QA was delegated both authority as POSRC Altern' ate -
Chairman and, more importantly, Plant Manager signature
. authority, without provisions to remove him from concurrent'
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QA duties. While the individual is well qualified for the functions, the assignment represents an undesirable cross-
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connect between-the operating and QA organizations; and, (c) The Team was concerned that the licensee's occasional practice of_ ' accepting a POSRC quorum which included an Alternate - Chairman along with two alternate members may impair the effectiveness of POSRC' reviews.
The licensee has taken immediate actions _to correct-the specific j
deficiencies; however, continued monitoring is appropriate to ensure the underlying root causes for-these deficiencies are E
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defined and understood.
I (2) There is a large number of POSRC open items, many of which are overdue.
(See paragraph 3.5.7 for licensee's commitments.)
(3) The Licensing Department's review of reportability determina-L tions under procedure CCI-118 is ineffective in its collateral function of assessing if an NCR should also be initiated to ensure appropriate corrective action.
The Licensing Manager
has provided instructions to his staff to address this issue.
L Also, he committed to revise procedure CCI-118 to clarify this area by February 15, 1990.
(See paragraph 3.5.8 for licensee commitments.)
A generic weakness regarding corrective action processes is discussed l
in paragraph 3.4.
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l Observations (1) ' The licensee has several recent positive quality. initiatives:
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(a)- Quality circles for Quality Control personnel; L
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Independent Safety Evaluation Unit (ISEU) activities; and, (c) Human Performance Evaluation System (HPES) evaluations.
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(2) The licensee was generally successful in identifying and track-
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ing restart items.
(3) The Offsite Safety Review Committee (OSSRC) displayed good safety perspective during the one meeting observed by the Team,-
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(4) The Team noted a generally better sensitivity throughout much I
of the organization to problem identification through the NCR s
process.
(5) Regarding change of intent with regard to procedure changes, the Team noted some confusion with the definition but decisions are being made conservatively.
(6) The. Team noted that QA findings were not being subjected to a formal review as to restart applicability. (See paragraph 3.5.9 for licensee commitments.)
3.4 Generic-Findings The following paragraphs summarize generic insights derived by the Team. Through intensive interaction among the Team members, as is characteristic of this type of inspection, the Team made several
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observations and noted two weaknesses that applied to all functional L
. areas.
Because. these items are derived from inspection in all functional areas rather than specific discrete inspection findings, in most 1 cases they are not further amplified in paragraph 4.
L Observation l
l The Team made three generic observations, all of which reflect some-L what positively on licensee improvement efforts.
L (1) There is increased awareness throughout the station of the importance of, and requirements for, adherence to procedural requirements.
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(2) -The organization has become more sensitive to, and conscientious u
in,~ problem identification.
(3) The Nchanisms used to communicate current. management goals,
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polktas and objectives were effective in making all levels of
>the-plant staff aware of these expectations.
Because these
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mechanisms included extraordinary measures by senior management,
such as; numerous presentations by senior managers to all organ-
izational levels, the successful communication in this ' case was
not necessary a reflection on the adequacy of. routine vertical d'
communications in the organization.
Weaknesses
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(1) The~ Team classified as a generic weakness, the licensee's pro-cesses for tracking and resolution cf routine. corrective
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actions. These concerns were based on the multiplicity of sys-tems', the - size of the backlogs, and inconsistencies in methods
.i for prioritization, tracking and management. review.
Since -the restart list is a specialized mechanism and these other systems will be relied upon for corrective action management after restart, the Team considered it important that the licensee pro-
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vide-additional measures of assurance that deficiencies identi-
fied.during operation will be properly classified, prioritized, F
reviewed and tracked to assure effective corrective actions are -
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completed on appropriate schedules.
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The -licensee committed to implement before restart measures to
provide additional' assurance that deficiencies identified will be properly screened, classified and prioritized for corrective-action.
(See paragraph 3.5.1 and 4.3.)
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(2) The Team noted several indicators of licensee weaknesses in communicating with the NRC and in recognizing items of interest to the NRC.
Some positive licensee actions were. not properly conveyed to NRC. An example of this is the series of line manager presen-tations to senior BG&E manager regarding the CAL /STI related improvement actions. Insofar as these were part of a management self-assessment process, these were of interest to the NRC.
Other indicators of weak communications with NRC were noted:
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(a) The licensee failed to adequately convey to NRC the avail-ability of licensee managers during the RATI. One of the major reasons for NRC to announce major inspections is to allow the licensee to ensure availability of key personnel and convey exceptions to the NRC.
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(b) The licensee did not appear to expect the broad nature of this RATI. Further, the licensee requested the inspection
at a time when little "run-time" had been experienced on l
new programs and initial implementation difficulties were
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still being worked out.
Examples are the new maintenance i
process and procedure " changes of intent" definition. The
licensee could have achieved a better understanding of the
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inspection methodology and criteria had it attempted to do so.
I (c) The Team sensed an excessive reluctance by BG&E staff to
. consider modifying any commitments. The NRC expects 11cen-see's to place emphasis on meeting commitments.
However, i
if one proves unworkable or if a substantially safer approach is identified, NRC also expects that licensees would provide a timely, well-documented, well-supported
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change to the commitment.
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These indicators should be reviewed by licensee management in i
order to assist them in improving regulatory interfaces.
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3.5 Summary of Licensee Commitment:,
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This section w.nmarizes licensee commitments made during the inspection.
3.5.1 The licensee will implement before restart measures to pro-vide additional assurance that deficiencies identified will be properly screened, classified ano prioritized for cor-rective action.
(Detail 3.4 and 4.3.3.2)
3.5.2 Before startup, BG&E will incorporate into mode change checklists of procedure OP-6 completion certification signatures for surveillances in area ovtside the program consolidated under the STP coordinator.
(Detail 4.3.3.2)
3.5.3 BG&E will evaluate during 1990 the appropriateness of con-
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tinued exclusion of portion of the surveillance program
from consolidated program management under the STP coordi-cator.
This is not a restart item.
(Detail 3.2 and 4.2.3.2)
3.5.4 Before restart, the licensee will screen through POSRC, the results of the first phase of their contractor review of
the correlation between surveillance procedures and Tech-nical Specification surveillance requirements.
(Detail
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4.2.3.2)
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3.5.5 The licensee agreed to correct weaknesses identified in procedures for the current plant mode as follows (Detail 3.1.2 and 4.1.2):
(1) Provide an approved procedure for boration flow path using HPSI by December 1, 1989.
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(2) Clarify acceptance criteria of procedure STP-0-62-1 for boration flow path valve position surveillances by December 31, 1989.
3.5.6 Prior to restart, the licensee will implement a method to screen for mode change applicability those temporary modif-ientions controlled outside procedure CCI-117.
(Detail 3.1.3 and 4.1.3)
3.5.7 Regarding POSRC open items, before restart the licensee will add a signature in prestartup checklists to certify
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that the POSRC open item status is acceptable for startup.
(Detail 3.3 and 4.3.3.2)
3.5.8 The licensee will revise by February 15, 1990, procedure
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CCI-Ile to clarify Licensing Department review responsibil-ities, especially as they apply to determining if an NCR should be generated.
(Detail 3.3 and 4.3.3.2)
3.5.9 Before the next startup, the licensee will review open QA findings for restart applicability.
(Detail 3.3 and
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4.3.3.2)
3.6 Other Open Items for Restart This area lists open restart issues arising from the inspection that are not covered in Detail 3.5 above, i
3.6.1 Administration of the tagout program (see Cover Letter and
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Detail 4.1).
3.6.2 Licensee resolution of Shutdown Cooling (SDC)
heat
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exchanger flow / vibration issues (Datail 4.2.3.2).
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4.0 DETAILS OF INSPECTION
4.1 Operations The inspection of plant operations reviewed three broad areas. These
were:
control of plant status, control of work activities, and con-
i trol of procedures and changes.
Inspectors interviewed site person-
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nel, observed activities in progress, reviewed documentation of activities, and verified the fulfillment of procedure requirements.
l Assessments were made addressing the effectiveness of site safety
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tagging, the use of plant administrative and operational procedures.
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and the effectiveness of the control of plant status and activities.
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The following paragraphs provide a summary of the details of the -
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Team's inspection activities and conclusions denoting areas of q
improvement, areas of weakness and Team observations, j
Also, an overall statement about the performance level of the licen-see is provided.
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4.1.1.
Safety Tagging
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To evaluate the effectiveness and performance level of site safety tagging systems, inspectors performed the following l
activities:
Observed aspects of the generation and implementation
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of safety tagouts;
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Spot checked in place tagouts for accuracy;
Spot checked use and accuracy of laminated drawings
used to display tagout boundaries to the Shift Supervisor;
.
Interviewed Shift Supervisors and the Safety Tagging
Supervisor to assess understanding of responsibilities and authority; Verified assessment of safety tagout impact on plant
safety; Reviewed completion of weekly and monthly tagout
audits; and
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Verified the use and assessed the effectiveness of the
second licensed operator review in tagout preparation.
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i Improvements
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l (1) The additional licensed operator review of safety tag-
outs has increased the confidence in tagout adequacy.
l The reviews are thorough and effective in identifying
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errors during preparation of boundary packages.
i (2) The programmatic requirements of Procedure CCI-112J,
Safety Tagging, have been strengthened, particularly
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l in the areas of tagout boundary research, preparation
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and review, resulting in an improved safety product.
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(3) The use of a color coding scheme to provide highlight i
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to the identification and classification of tagout
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packages has facilitated both the preparation and re-view of the packages.
(4) The use of an equipment status board in the tagging
office provided an effective display of information to tagging personnel.
l (5) Tagging representation at planning and scheduling meetings and shift turnover briefings increases the transfer of information to shift personnel.
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(6) The tagging group was reorganized to elevate the position of Safety Tagging Supervisor to the equiva-lent level of a shift supervisor.
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Observations
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(1) The safety tagging group staffing appears inadequate to support some plant conditions, especially during a dual plant outage.
Temporary assistance has been i
required from the operating shifts to meet unantici-l pated manpower demands.
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(2) The tagging group's technical expertise in the elec-trical and instrument and control (I&C) areas is being
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strengthened by adding additional electrical and I&C technicians.
i (3) Although red safety tags are normally used to provide positive control over functional components, the team noted that in a few cases the licensee utilized red tags to provide informational control for personnel and equipment safety.
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Weaknesses (1) The licensee currently utilizes plastic-coated piping and instrumentation diagrams (P&lD) as visual aids for safety tag boundary package preparation and review.
This tool was demonstrated to be cumbersome, ineffic-1ent and only marginally useful as evidenced by the
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l following:
I Four sets of laminated prints were compared b
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against the attached tagging record sheets.
Each set contained one or more errors; A significant number of man-hours was required to
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maintain the laminated prints current; and The large number of prints required to display
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some tagouts made review by tagging and shif t personnel inefficient and confusing.
Numerous shift personnel felt more confidence in the addi-tion;1 licensed operator review than the fact that boundaries were reflected in the laminated
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prints.
The licensee is evaluating the efficacy of-this administrative tool.
(2) During a tour of the Calvert Cliffs control room on
i November 6, 1989, the Team identified a red danger tag assigned to control room panel IC06 that was actually attached to the temporary Unit I refuel water level panel.
Investigation revealed the tag had been relo-cated without-completely documenting the transfer.
Af ter the inspector identified the problem the licen-see subsequently removed the tag in question and reissued a new danger tag in accordance with the pro-cedure. While the relocation of the danger tag most likely occurred prior to the issuance of the current revision of CCI-112, the Team felt this indicated a weakness in the licensee's identification of tagging discrepancies during routine observations and audits.
L Current requirements in 001-112 provide specific instructions for the modification of tagouts.
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(3) The 30-day audits of all tagouts over 90 days old, as required by CCI-122J,Section X, had not been per-formed for the months of September and October 1989.
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When cluestioned by the inspector the tagging super-visor acknowledged the audits had been missed and initiated efforts to complete the required audits.
The weekly tag index audits were reviewed and found to have been conducted as required by CCI-112.
A non-conformance report (NCR) was written to document the missed audits.
The failure to complete the required field verifica-tion audits is a significant weakness in the adminis-tration and management of the site safety tagging sys-tem. In addition, at the time of NRC inspection, over
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a month after the audit was first missed, the missed audits had not been documented and senior operations department managers were not aware of the deficiency.
Correction of this weakness is considered vital to the implementation and maintenance of an effective safety tagging system.
Failure to complete the required audits is an unresolved item (89-81-01),
(4) Tagout errors and deficiencies did not always receive proper documentation or management review and were not always incorporated into a comprehensive and formal corrective action program for followup and resolution.
Examples include:
Monthly audit discrepancies were routinely cor-
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rected by the auditor without supervisor review; Audit discrepancies brought to the attention of
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l the tagging supervisor were in many cases not l
entered into a corrective action program nor was
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l management informed; In July 1989 an aerator tank manway was posi-
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tioned contrary to the instructions specified on the safety tag. An NCR was written but was not l
specific to the tag violation issue and was l
rejected by QC; there was no management followup, i
A specific NCR (No.
8802) was written on l
November 15, 1989, for this event after question-L ing by the NRC inspector;
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In July 1989 a condenser manway was shut by main-
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tenance personnel contrary to the requirements specified on the tags while cleaning tubes using
high pressure water spray.
A change to the i
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licensee's industrial safety manual deleting the
use of danger tags for access ways if a monitor i
was continuously present was implemented on
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July 25, 1989, but no NCR or other formal docu-mentation was generated to cover the initial l
violation of the tagging boundary.
Site manage-
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ment was not aware of this event-
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The audit performed on Novemb r 12, 1989, re-
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suited in noting a discrepancy associated with
tagout 29-602 (for MO 209-091-81812).
Two red
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safety tags had been removed from a lighting
panel electrical breaker and the breaker closed j
contrary to the requirements specified on the
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tags.
When questioned by the inspector on November 13, 1989, as to actions taken, the tag-
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ging supervisor indicated that an MR to provide
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locking devices for this type of breaker and a
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near miss report had been initiated. An NCR (No.
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l 8801) was not originated until November 15 1989.
The above examples of informally documenting, review-
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ing and resolving discrepancies associated with the
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safety tagging system is a significant weakness.
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I Also, personnel were not clear as to the appropriate mechanism - to document these deficiencies.
Informal
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documentation does not provide assurance of appropri-ate management review and resolution.
Informal docu-mentation and resolution of tagging discrepancies is
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an unresolved item (89-81-02).
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Licensee immediate actions to correct audit defici-
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encies and review audit discrepancies have been l
instituted and include:
scheduling a portion of the monthly tag audit to
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be completed each week; implementation of written guidelines for perform-
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L ing the audit;
l providing for formal documentation and review of
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audit discrepancies; and I
providing for management review of audit discrep-
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l ancies and resolutions.
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Conclusions-l While comprehensive and safe tagouts are generated and implemented, significant weaknesses were observed in the
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auditing of tagouts, and in the documentation and resolu-tion of tagging discrepancies.
In addition, the use of i
laminated drawings to display tagout boundaries to the shif t supervisor proved to be cumbersome, inefficient, and only marginally useful. These weaknesses were.not identi-fied by the licensee's quality verification team prior to
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t NRC inspection.
Improvements in the identified areas of weakness and in the overall administration and management of the safety tagging-
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process are required to assure a satisfactory level of performance can be sustained to support safe operation of the facility.
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4.1.2 Use of Procedures The inspection team interviewed control room operators, control room supervisors, shif t supervisors, workers, and
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site managers. Also, as available, the use of procedures
was verified through observation of site activities.
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Inspectors assessed understanding of site policy in the use of procedures, understanding of the meaning of change-of-intent, compliance with procedure requirements, use of pen-and-ink changes, and overall safety perspective in the use of procedures.
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Improvements The following areas of improvement were observed:
(1) All personnel interviewed showed a heightened aware-
ness of the importance of implementing procedure requirements;
-(2) Operators showed increased attention to evaluating procedure changes for change-of-intent; i
(3) An improved process for operators to implement pen-
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and-ink changes allows correction of procedure defici-encies.
Use of the pen-and-ink change is limited to five changes' on any one procedure.
At that time a procedure revision is required; and (4) Operators are reviewing procedures prior to use and stopping procedure implementation to correct procedure deficiencies.
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Observation j
Inspectors observed that site operating instructions (01)
j sections were not arranged in a logical sequence. Instead, procedure sections appeared to have been added chronolog-ically as the need for procedural guidance for additional types of systems evolutions or manipulations were identi-
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fied over the years.
Sections covering similar or comple-I mentary evo1Jtions are of ten not grouped together within j
the instruction.
This arrangement creates difficulty in identifying the applicable section of the operating i
instruction. This observation reinforces the need for pro-l cedure validation and long term procedure upgrade.
Weaknesses
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Two examples of inadequate procedures were observed. -The first involved surveillance test STP 0-62-1, which verifies
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valve positions for each plant operating mode.
For the -
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valves required for the Safety Injection (SI) boration flow i
path, no valve positions were specified.
The applicable Technical Specification was referenced, Section 4.1.2.1, but this only specified that valves be in the " correct" position.
This surveillance would permit valves, such as i
the refueling water storage tank outlet valves, to be
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either open or closed.
The licensee had previously identified this deficiency and
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was in the process of implementing a procedure revision to correct this deficiency.
The inspector reviewed the pro-posed change and verified it addressed the deficient condi-tion. The licensee committed to revising this procedure by
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December 31, 1989.
The second example of procedure inadequacy was the absence
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of an approved procedure to implement the Technical Specification-required boration flow path.
Abnormal Pro-cedure AOP-1A, used for inadvertent boron dilution, did not address using the high pressure safety injection (HPSI)
pumps.
The HPSI pump was the only boration flow path
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available as the charging pumps were not in service.
The need for approved procedure guidance for operation of the HPSI pump is safety significant, not only to provide boration in the event of inadvertent dilution, but also to provide administrative measures to limit plant pressuriza-tion due to HPSI mass addition in the event this path is used.
In certain low temperature plant conditions, excess-ive HPSI addition could exceed pressure relief capacity.
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Therefore, control at HPSI injection rate would help pro-i
,E vide over pressure protection while at low temperatures.
In the plant condition at the time - of the-inspection, over pressurization was not possible since pressurizer man-i
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ways were removed to provide over pressure protection. The
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licensee had previously identified the need for an approved
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procedure for this mode on October 25, 1989, but had con-l sidered the need to generate a procedure not to be urgent.
On November 15, 1989, af ter questioning by the inspector,
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the licensee initiated corrective action to write a pro-cedure for the current plant boration flow path.
This is another example of a condition adverse to quality which was l
not documented by site corrective action systems.
As a
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result, appropriate corrective action was not promptly
initiated.
I The licensee committed to implement a procedure addressing
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the.use of the HPSI system as a boration flow path by i
December 1, 1989. The absence of an approved procedure for
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use of the HPSI pumps as a boration flow path is unresolved i
(UNR 89-81-03).
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' Earlier NRC inspections had identified a concern involving the use of General Supervisor Nuclear Operations (GSNO)
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standing instructions.
Some were being used to direct operator actions that could affect nuclear safety.
The licensee had committed to identifying and eliminating these standing instructions after incorporating the directions i
H they provide into appropriate procedures.
In a letter to l
NRC Region I office, dated October 27, 1989, the licensee l
indicated completion of this commitment.
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NRC review identified that one of the standing instructions
identified as a concern by the NRC Special Team Inspectic.n,
nine additional instructions identified by the licensee, and another providing interim instructions for temporary modifications, were still in place after incorporation of these requirements into approved procedures. This was con-I trary to what was stated in the October 27, 1989 letter.
In addition, the licensee's quality verification check did not identify that these were still in place.
l Prior to the completion of the inspection, NRC inspectors verified the standing instructions in question were deleted.
Continued management attention is required to ensure appropriate use of these instructions.
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Conclusions Overall, the licensee has been effective in improving per-l formance in the control and use of site procedures. Oper-
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ators displayed their commitment to adhere to procedure
requirements and the resolve to stop implementation in order to _ correct procedure deficiencies. With the excep-
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tion of the procedure deficiencies identified above, an improved level of performance in the use of procedures has been achieved.
4.1.3 Control of Plant Status and Activities Inspectot s conducted plant tours and observed the use of site tags, observed identification of out-of-service equip-i ment, and assessed the general use of tags at the site.
Inspectors observed shift turnovers and verified the trans-fer of plant status information, the use of turnover check-lists and the conduct of panel walkdowns.
Control room operators were interviewed to assess their knowledge of plant status, ongoing activities, and the usefulness of
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information transfer systems.
Reviews were conducted of control room logs, documents and applicable procedures.
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Improvement
Inspectors concluded that steps taken to make plant status information available to operators were improvements.
Shift briefings are-effective at transferring plant status information from one shift to the next as well as identify-ing uccoming activities.
Other mechanisms include the use of equipment status sheets during shift turnovers, the use of improved daily tagout printouts and planning and sched-uling representative presence at shift briefings.
Inspec-tors observed an expanded use of equipment out of service
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(005) tags to display equipment status to operators.
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The Team determined that CCI-117, " Temporary Modification
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Control," Revision 1 dated September 30, 1989, provides adequate controis to ensure review for plant safety impact prior to implementation.
CCI-117 requires a design engi-neering evaluation to be performed for each proposed TM, A questionnaire is employed to screen TMs for unreviewed safety questions or effects on nuclear safety and POSRC review is required. This detailed review is regarded as an
improvement.
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i l-Observation i
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Inspectors noted during physical inspection of control room panels that a large number and variety of tags were pre-sent.
These were predominantly temporary notes used to identify post-maintenance testing requirements, but also
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included safety and equipment 005 tags. The number of-tags
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increases the likelihood of valve and component conditions
being concealed and this presents a potential human factors concern. Since it is anticipated that these tags will be removed prior to startup, the safety concern should be.
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alleviated.
Further licensee management attention is war-i
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ranted to verify the removal of unnecessary tags from the '
panels.
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Weakness s
During review of procedures that employ TMs but are exempt
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from control by CCI-117, the team determined the licensee j
does not programatically ensure these TMs are reviewed for safety impact prior to mode c.hanges. This was. regarded as
a weakness. The licensee has committed to implement prior
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to startup, a formal safety screening of TMs installed outside CCI-117 as a prerequisite to mode changes.
Conclusions Overall, the licensee has been effective in improving per-
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formance in the control of plant status and activities.
- Effective measures are in place to assure control room operators and shift supervisors are aware of equipment
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status and relevant plant activities.
With the exception
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of the weakness identified above, a satisfactory level of
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performance has been achieved in the control of plant
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status and activities to support $6fe operation of the
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facility.
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4.1.4 General Items Inspected (1) NRC inspectors observed that the schematics used to provide aid to the operators in the operation of ser-vice water valves did not evidence review and
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approval.
The licensee was in the process of incor-porating these diagrams into their operator aid pro-gram.
Prior to the completion of the !nspection, NRC
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inspectors verified that these diagrams had been I
labelled and. had been entered into the licensee's
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operator aid program.
The inspector had no other
questions, i
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(2) The inspectors questioned the securing of equipment mounted on wheels in the #1-cable spreading room. The
licensee had previously performed an evaluation of
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his equipment and had concluded the method of secur-t ing was satisfactory.
The inspector had no other l
questions.
.(3) During plant tours, NRC inspectors identified plant
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temporary modifications that were controlled outside
of the Procedure CCI-117, " Temporary Modification t
L Control."
The inspector reviewed the. corresponding
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pt-ocedures which controlled installation and removal of these temporary modifications. The inspector ver-
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ified that each procedure incorporated the same level of installation and verification as would be required by CCI-117.
No unacceptable conditions were identi-i fied relative to installation and verification.
A 7l weakness regarding screening of these items for mode change applicability is discussed above.
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(4) The Team reviewed active TMs for Unit 1.
Three TMs
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were walked down and no discrepancies were noted.
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Detailed reviews were made of the safety evaluations
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for selected TMs. These safety evaluations adequately addressed the appropriate safety issues.
Quarterly audits were found to be documented. One minor admin-istrative discrepancy noted was that two TMs could not be immediately located in the TM log. They were later found by the licensee.
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(5) During plant tours and panel walkdowns, inspectors identified unlanded cables and wires which were - not labelled as spare or otherwise controlled by approved
,
procedures. These cables were compared against cur-
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rent plant design and in each case were found to have been spare or abandoned cables.
No unacceptable
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conditions were identified.
(6) As a result of the concerns identified in the use of General Supervisor Nuclear Operations (GSNO) Standing Instructions, GSNO Notes and Instructions were re-viewed for plant operating instructions.
GSN0 Notes and Instructions are a lower-tier guidance mechanism than the GSN0 Standing Instructions.
No unacceptable use of notes and instructions was identified.
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(7) The Team reviewed the safety tagging associated with
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the rewiring of the boric acid selector and control l
L switches.
At on9 point during this. work, the #11 boric acid pump operating switch had a red safety tag i
applied while all wiring was removed. The Team verif-
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ied that at no time during the performance of this j
work was an actual safety or equipment hazard present, s
The Team questioned the suitability of applying a red
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safety tag to a switch with no control wires present.
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The licensee responded that this was conservative in
that it ensured control of the equipment ofter the
L wires were relanded.
No unacceptable conditions were identified.
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During the performance of the modification mentioned i
above,. boric acid operating switches #226X and #226Y
were removed from the control room panel.
The h
Team verified that the removal of these switches was within the scope of the modification package.
No unacceptable conditions were identified.
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(8) The Team noted that partial performance of surveil-lance test procedures requires a' procedure change.
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This results in added work to control room-operators l'
and to the POSRC in reviewing and approving these changes.
The licensee has indicated, as a long term
improvement effort, the intent to write surveillance
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test procedures to allow partial implementation when
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appropriate.
No unacceptable conditions were identified.
4.2 Maintenance and Surveillance Maintenance and surveillance activities were inspected within the context of the three broad areas outlined in NRC's May 25, 1989 CAL No. 89-08. These areas are:
(1) control of system status, (2) pro-r l
cedures use and control of procedure changes, and (3) control of work activities.
The Team interviewed site personnel, observed mainten-
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ance and surveillance activities, and reviewed various documents to i-support an assessment of the licensee's performance in these three
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I areas.
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4.2.1 Control of System Status 4.2.1.1 Scope of Inspection
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The Team verified in the plant that tagouts
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hr.d been correctly applied for selected mechan-ical and electrical corrective maintenance orders and an instrumentation and controls modification.
The equipment status board and the control room
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supervisor's acknowledgement of - selected main-tenance order tagouts were also verified.
The Team verified through. interviews and reviews of
tagout clearances that job supervisors were per-
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forming proper pre-job tagout walkdowns.
4.2.1.2 Findings
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In performing the above inspections, no defici-
encies were identified.
l The Team observed that separate tagouts were j
applied for each maintenance order; therefore, a
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piece of equipment may have multiple tagouts.
This provided effective control of system status when several jobs were being worked on the same system.
4.2.1.3 Conclusion
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Within the scope of the maintenance activities inspected, the Team concluded that a satisfactory level of performance was observed in the control of system status to support the safe startup and operation of the plant.
4.2.2 Procedure Use and Control of Procedure Changes 4.2.2.1 Scope of Inspection l
The Team verified that procedures were properly I'
followed by observing the performance of main-tenance, modifications, surveillances, and test-i
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l ing. The Team observed the licensee's identifi-E-
cation of procedural problems and the processing of procedure changes.
The Team also reviewed completed maintenance packages, surveillance pro-cedures, and procedure changes.
Interviews were conducted with workers and supervisors to deter-mine if a policy of procedure adherence is under-stood and accepted.
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i 4.2.2.2 Findings Procedures were properly followed in all activ-ities observed.
The Team observed one occasion where work was stopped and-two occasions where the start of work was delayed when the person using the pro:edure encountered a problem with the procedure.
Al-though there are still procedural quality issues, the licensee staff has demonstrated that they are eiert to procedural deficiencies and that they Vill stop to correct them.
Licensee personnel established a good awareness of change of intent considerations when evalua-ting maintenance and surveillance procedure changes.
Test procedure feedback sheets were a useful tool for recommending upgrades to test procedures.
Maintenance orders now have a section for record-ing a s'ummary of actions taken and a section for recording a detailed narrative of the actions taken. The maintenance orders reviewed all had adequate descriptions of the work performed.
Operators and technicians reviewed procedures prior to use.
Operators also walked the proced-ures through at the control panels prior to use.
Workers and supervisors expressed a commitment to adhere to procedures and to work toward their improvement.
Continued licensee emphasis on
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verification of procedural adherence is warranted particularly since the long-term procedures up-grade program is still in its early stages.
4.2.2.3 Conclusions The licensee has been effective in improving the use of procedures.
Licensee staff shows a com-mitment to adhere to procedures. They are also alert for procedural problems and will stop and fix them.
The licensee's use of procedures and control of procedure changes is adequate to sup-port the safe startup and operation of the plant.
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I 4.2.3 Control of Work Activities
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I 4.2.3.1 Scope of Inspection j
The Team reviewed the tracking, prioritization j
and scheduling of maintenance orders.
The ade-
quacy of pre planning was evaluated through dis-l cussions with supervisors, planners and workers
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i and by reviewing work packages and observing on-
going work in the plant.
The supervisory job F-observation program was reviewed. The documenta-
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tion of completed work was reviewed.
The Team
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observed and reviewed the development, tracking, performance, and evaluation of post-maintenance
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testing.
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The Team evaluated the scope of the consolidated surveillance test program.
Surveillance test i
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procedure scheduling was reviewed.
Surveillance
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tests were observed by the Team.
Selected per-l manently installed instruments were verified to
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be calibrated.
Corrective actions for non-conformance reports on uncalibrated instruments, maintenance orders, and a surveillance trends i
report were reviewed.
Test coordinators were interviewed.
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4.2.3.2 Findings The Team noted a significant program strength,
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in that the maintenance department Ms estab-lished a supervisory job observation program.
This consists of supervisors. observing mainten-ance and testing in progress, evaluating the work, and having followup feedback sessions with
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those involved.
The goal is for each supervisor
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to spend one-day per month in the field. Twenty-
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seven of thirty-five supervisors completed docu-L mented observations for the month reviewed by the Team. The supervisors made meaningful, critical, and constructive observations and comments. Main-tenance management intends to formalize this pro-gram by January 1990.
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The Team r.oted two areas of substantial
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F (1) The administrative procedure for control of i
maintenance (001-200) is a good procedure
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that should provide strong control over
maintenance.
It provides for better docu-
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mentation of the initial problem, more
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nical information and better documentation
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of completed work.
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(2) Controls and accountability for surveillance
scheduling have been improved and assure
proper scheduling in the areas assigned
functional test coordinators.
The Team observed that the scheduling function is
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developing rapidly.
The licensee has implemented a
three-day schedule and work groups interviewed d*s-played an understanding that they must use the scheduling process.
BG&E had a corrective maintenance backlog of about 2700 maintenance orders of which several hundred are priority A, i.e., to be completed before startup. The actual number of maintenance tasks is less than the
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number of work orders. The difference in those num-bers is due to the licensee's practice of subdividing a task into several maintenance orders, partly to
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achieve better control over work activities.
The Team found that detailed work packages were pre-pared and in use in the field with adequate job spec-
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ific instructions to accomplish the assigned tasks.
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No ad-hoc changes of the work scope were observed.
Quality engineering review of safety related work
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prior to scheduling and the final supervisory review of work packages for completeness were notable improvements.
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Maintenance and QC personnel have been trained in, and were knowledgeable about, the new program and proced-ure requirements.
Although the new controls were deemed cumbersome by some, overall worker attitudes about the new procedures were positive.
Personnel performing the work were qualified, as verified by the training and qualification status book maintained by the first-line supervisors and the assistant generel supervisors.
Post-maintenance testing guidelines are incorporated into the maintenance administrative procedure, C01-200, by reference.
These guideline documents include-an individual matrix for each type of compo-nent. The matrix describes the post-maintenance test reouirements for each type of maintenance task.
The Team reviewed a sample of on going maintenance tasks and evaluated the technical adequacy of pre-
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scribed testing.
No deficiencies were noted, except in the one case where no acceptaice criteria were
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specified for the test.
Specifically, post-mainten-ance testing following inspection / replacement of the spring pack for a Limitorque motor operated valve operator under MO 209-285 required valve stroke time test and measurement of running current either at the valve actuator or at the breaker. However, no accep-tance criteria were specified.
In response to this finding, the licensee retrained the responsible sys-tems engineer, planner, and the contractor's QC personnel.
The Team observed that the licensee is still working out implementation and coordination difficulties with respect to the new maintenance controls. This results
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primarily in efficiency problems.
Although this was not a safety concern to the Team, the NRC could become concerned during operation, if equipment important to plant safety undergoes unnecessarily long out-of-service times due to unreasonable delays in starting or coordinating work.
Within a sample reviewed by the Team, noncenformance reports in maintenance and surveillance were responded to adequately.
One surveillance nonconformance re-viewed by the Team was the result of an adverse trends report from the Independent safety Evaluation Unit for a ten-month period beginning in December 1988.
The
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i resolution of these concerns was based on improvements due to consolidation of the surveillance test program, i
specific corrective actions completed for each event,
and performance of surveillance test procedure
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reviews.
Tne surveillance test procedures reviews i
have recently begun.
The licensee informed the
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Team that a contractor will complete the first phase
of their review (referred-to as the level 1 review)
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and that BG&E will screen their findings for safety significance and make a recommendation to POSRC as to disposition prior to startup.
The Team reviewed several technical issues and i
developed one significant observation and three unre-i solved items as discussed below.
The Team observed that licensee controls over motor
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operated valve (MOV) torque switches are behind indus-try general practice.
The Team also noted, however, l
that the licensee's use of torque switches in motor
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operated valves differs from typical industry practice
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in that the licensee uses the limit switch as the pri-mary control device in opening and closing.
This practice lessens the importance of the torque switch somewhat.
Regarding torque switches, the Team was still concerned that, if set too low, the torque switches might unnecessarily stop valve motion when a
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dynamic condition is combined with a slightly degraded valve condition (e.g.,
tight or dry packing, worn operator).
This is an unresolved item (50-317/
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89-81-04), but, based on the Teams understanding of the licensee's overall MOV program, is not considered a restart issue.
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The Team reviewed the licensee's ongoing root cause
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analysis on the recurring concern of noisy shutdown cooling heat exchangers under some flow conditions.
Both Unit I shutdown cooling heat exchangers have a documented history of rattling noise at certain flow rates. On November 10, 1989, the licensee conducted a multi-disciplined group meeting involving representa-tives from Operations, System!. Engineering, Design
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Engineering, Performance Engineering, ISI, Chemistry, s
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Health Physics, Outage Management, Materials Lab, and consultants for vibration analysis.
The licensee
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plans to conduct additional flow tests in conjunction
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with acoustic / vibration analysis. The Team determined that the licensee's approach to root cause analysis and developing corrective actions appeared to be thorough and technt: ally conservative.
The licensee also initiated a CCI-118 form on November 14, 1989, to evaluate reportability.
The licensee stated that a Licensee Event Report will be issued documenting their root cause analysis and corrective actions.
Resolu-tion of this concern has been identified as a Unit I restart concern (UNR 317/89-81-05).
In reviewing operating history of the shutdown cooling heat exchangers, the Team noted that the licensee had identified in June 1988, that the component cooling water flows to the shutdown cooling heat exchangers were found throttled to approximately 2200 gpm single pump flow as documented on the Possible Reportable Event Report dated June 2, 1988.
It also stated that the FSAR Table 6-5 and 9-14 require total flow rate 'of 4820 gpm through the two shutdown cooling heat exchangers.
This flow rate is used to show by analysis that, under post-LOCA conditions, the con-tainment can be cooled down to 120 degrees F in 17 days by the containment sprays and containment coolers.
The licensee had subsequently repositioned the heat exchanger inlet valves to increase flow. An engineer-ing analysis was performed to generate a new post-LOCA containment response curve using the reduced flows in effect prior to June 1988.
The licensee determined that the duration of the LOCA profile increased from 17 days to 23 days at a flow rate of 2200 gpm to each heat exchanger.
The licensee examined the new pro-files in light of environmental qualification require-ments and concluded that. the 23-day profile was enveloped by their design profile and, therefore, did not invalidate the original EQ evaluation.
The possible reportable event. report also concluded that this event was not reportable. The Team however, is of the opinion, that this event should have been reported per 10 CFR 50.72(b)(ii)(B).
This item is unresolved pending further staff review of the issue for appropriate enforcement action if warranted (UNR 317/89-81-06).
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Within the areas reviewed, the Team classified one item as a licensee weakness. In order to improve con-i trol and accountability over Surveillance Test Program-i (STP), the licensee had consolidated many program i
responsibilities under a STP coordinator.
However,
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BG&E took a narrow approach to the centralization of
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the surveillance test program in not -including 'all surveillances under the surveillance test program.
Examples of areas not included in the. consolidated
h program under procedure CCI-104 are radiological, chemistry, environmental and core engineering surveil-
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lances.
This decision. appears to have been made on r
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the basis on a qualitative assessment that these other
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areas did not have the degree of scheduling and track-
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ing problems as other areas.
However, the decision did not appear to have been fully thought out.
For
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example, mode change checklists incorporate completion
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i justification signatures for Technical Specification i
surveillances, but only for those functional areas in the consolidated program.
The licensee committed to
incorporate certification signatures for the other surveillance areas into the checklists (Procedure
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OP-6) before startup.
(See Section 3.5.3)
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Further, the Team did not concur with the logic pre-
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sented thus far for leaving program responsibilities distributed (i.e., unconsolidated), nor believe that the licensee had fully evaluated the degree to which
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scheduling and tracking problems had occurred or could
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potentially occur in the unconsolidated areas.
As detailed in Section 3.5.3, the licensee agreed to-evaluate this area over the next year. Completion of this evaluation is not a restart item,
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4.2.3.3 Conclusions The supervisory job observation program is a strength
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and should be a useful tool in verifying procedure use and control of work activities. Improvements in plan-ning, scheduling, and procedure adherence have resulted in better control of work activities.
In-cluding all surveillances in the consolidated surveil-lance test program should be evaluated.
The licen-see's control of work activities is adequate to sup-port the safe startup and operation of the plant.
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4.3 Safety Assessment and Quality Verification j
4.3.1 Introduction and General Scope of Inspection This portion of the inspection assessed BG&E's effective-l ness in making improvements in quality assurance and assessment of safety areas.
The inspectors emphasized their assessments on the following:
1) control, use and l
changing of procedures; 2) identification, control and prioritization of conditions adverse to quality, including
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evaluation of restart issues, and 3) management communica-t tion of goals and expectations.
The Team reviewed procedures that controlled safety-related work. This included evaluation of the newly required ver-batim adherence and change of intent issues.
The inspec-l tors assessed the methods for identification of conditions adverse to quality and the prioritization and control of
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corrective actions.
The methods reviewed included noncon-
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formance reports (NCRs), quality assurance surveillance and audit findings, open item lists for plant and off site review committees, and the restart item list of items that
needed closure before Unit I restart.
The evaluation of
communications of management goals and objectives included assessment of the effectiveness of these efforts based on discussions with plant personnel.
The Team reviewed
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several engineering issues to determine the acceptability
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of reportability and evaluation issues.
4.3.2 Procedure Use and Control 4.3.2.1 Scope of Review l
BG&E had committed to identify areas related to procedures that needed improvement.
This had
been necessary to correct deficiencies that led to several violations of containment integrity and other less severe problems.
The major cor-rective action taken required verbatim adherence with procedures and an increased awareness of changes to the intent of procedures.
The inspectors examined procedure content, usa-bility and the understanding of procedures by BG&E personnel.
Particular interest was paid to the application and acceptance of this require-ment.
The inspectors reviewed procedure change
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processes and change of intent determination pro-
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cesses and evaluated worker ' understanding and implementation of these processes.
The inspec-tors assessed the human performance evaluations
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system (HPES) _ reviews to determine if they had i
appropriately. completed identified areas of cor-
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rective action to pre';ent these instances in the future.
They reviewed the long term Procedure
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Upgrade Program (PUP) to evaluate management's r
commitment and initial efforts in this area.
4.3.2.2 Findings The Team observed the use of procedures by BME
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These observations showed that BG&E
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personnel were following procedures properly.
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These personnel had a good questioning attitude and stopped when necessary to resolve procedure difficulties.
The policies for procedure use,
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changes, and the investigation of noncompliance
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issues were effective.
The Team concluded that BG&E made demonstrable progress in the area of
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procedures.
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The Team determined that the plant staff under-stood the strictly defined and enforced policy on verbatim adherence.
These policies have nearly
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eliminated instances of procedural noncompli-ances. While people understood this new require-ment, several individuals stated that they felt as if they could not use their knowledge of the
- i plant or systems. Licensee management recognizes
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this and was continuing efforts to attain full support and complete proper understanding of pro-cedure adherence policiec.
Management is also
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encouraging identification and correction of pro-
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cedural deficiencies. The plant staff has docu-mented a significant number of procedural defici-encies.
Workers interviewed cited management
attention to correct procedure problems as one of
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the factors responsible for the improvement in the identification of these deficiencies.
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l BG&E personnel understood the methods for com-j pleting a procedure change. Implementation of a
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revised CCI 101 (procedure development)
ad-dressed, through a checklist the determination of whether a given change would cause the. intent of
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a procedure to change. This appeared to be ade-quate, but the inspectors observed that questions
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asked on the form were difficult to interpret and l
implement.
The plant staff substantiated this
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observation during discussions.
However, BG&E
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personnel were making conservative determinations j
as to which procedure changes constituted changes of intent.
The team questioned whether during i
plant maneuvering, the cumbersomeness of this
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form might distract operations _ personnel atten-tion from the plant while pursuitig procedure changes. Management was aware of theses concerns and considered that the importance of placing the plant and equipment in a safe and stable condi-tion before pursuing a procedure change is well understood mong operators.
Licensee staff understanding of the checklist for intent change determination can be expected to improve.with use of the form.
The Team determined that when a change of intent would not occur, BG&E procedures now allow a " pen and ink" procedure change.
This type of change requires the approval of two senior reactor oper-ators.
Personnel interviewed indicated that improved procedures for correcting errors through this process and a more responsive document con-trol system had contributed to improved procedure use.
BG&E's Quality Assurance Independent Safety Eval-uation Unit (ISEU)
conducted thirteen HPES reviews of procedure noncompliance violations since the beginning of 1989.
ISEU investigated examples of inadequate procedures, inattention to detail by personnel and other human performance problems. The Plant Manager received the correc-tive action recommendations from each of the HPES reviews.
The Team examined several of these reviews, finding them to be appropriate and able
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to identi fy root causes.
The Team determined l
that the straightforward procedure recommenda-
tions were implemented.
However, the more com-i plex programmatic issues, such as a recommenda-j tion to establish a separate shift supervisor on i
the unit undergoing outage, were still under con-
sideration by BG&E management.-
It _was also j
observed that there was no formal prioritization
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process for HPES open items.
Therefore, there
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was the potential for issues being lef t-unre-solved for an unduly long time.
The HPES investigation of the July 17, 1989
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reactor coolant system filling incident, which
occurred on mid-shif t, was exceptionally note-worthy.
The effectiveness of these evaluations
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resulted in the operations department electing to
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limit the performance of scheduled surveillance
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testing to the second shift.
BG&E also made
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shift personnel aware to be more attentive to potential errors on the first two days of mid-shift.
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The Team reviewed the Procedure Upgrade Program (PUP)
and interviewed responsible personnel.
Management commitment to this project was evident i
from the assignment of a Program Manager and-the
approval of a program plan and of extensive monetary and personnel resources. The Team found
that the program had a significantly broad scope.
The goals and' objectives appeared to address the concerns raised during the Special Team Inspec-tion (STI).
The schedule and budget for imple-mentation appeared adequate.
The Program Man-
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ager's organizational skill and determination to
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implement the program were noteworthy.
4.1.2.3 Conclusions i
The Team concluded that BG&E has taken adequate action to address the issues related to proced-ural compliance.
Plant personnel understood the need for verbatim adherence to procedures. The change of intent determination process, although complex, properly controls the use of the pen and ink change. The pen and ink change allowance has removed some of the constraints and administra-tion burden of the change process.
Although in some instances these new requirements have slowed work, they have been effective in getting per-formance to a higher standard.
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The HPES reviews were seen as a positive step and
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have generated numerous procedural changes to
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prevent specific procedures from causing the same
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problems twice. However, the Team observed that
there was no formal prioritization process for
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these items.
The more programmatic issues iden-
tified in HPES reviews needed appropriate manage-l
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ment attention and prioritization to allow their
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disposition.
Initial indications were - that the PUP had re-
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ceived adequate attention and support thus far.
4.3.3 Corrective Action Systems a
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r 4.3.3.1 Scope of Review
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BG&E committed to improving the identification
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and control of conditions that potentially did not conform to quality standards.
The Team re-viewed the various systems employed by BG&E to
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perform this function.
These systems included committee open items, Nonconformance reports (NCRs), Quality Assurance surveillance and audit i
findings, the Independent Safety Evaluation Unit
(ISEU) findings and functions of the on-site and of f-site review and plant operating assessment i
committees (POSRC, OSSRC and POEAC).
BG&E per-
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sonnel's understanding of these systems was assessed during interviews. The major corrective action systems were " walked down" by the team to evaluate the methodology used, the flow of infor-mation, and the screening and the resolution pro-cesses used.
The Unit One Restart List was re-
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viewed to determine if it was effective in iden-
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tifying and tracking issues that needed resolu-tion before restart.
4.3.3.2 Findings The Team found that the methods of identification of conditions with the potential of being adverse to quality were diverse.
Further, they identi-fied that the interactions of these systems were not well defined and subject to interpretation.
The Team identified that QA audit findings did not get formal review to determine if NCRs were
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needed.
The Operations Department reportability determination process for identification of L
potentially nonconforming issues was not fully adequate.
However, even with the diversity and poor interaction of methods, the Team determined that BG&E was for the most part, though initia-
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tive and conscientiousness of plant staff, iden-tifying and correcting appropriate conditions.
The POSRC and OSSRC exhibit a good safety ethic.
p Internal BG&E ISEU - reviews of the NCR process were reviewed by the Team and found to be proper.
The Team determined that the POEAC was doing an -
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adequate job of identifying potential issues raised by the industry. The Unit 1 Restart list -
was reviewed and found to contain the appropriate conditions that needed resolution before restart.
The Restart List was highly visible and manage-ment was encouraging staff to bring forward early those emerging issues which could require dis-position before restart, Activity in the NCR system had increased over the last several months.
The General Supervisor Quality Assurance (GS-QA) issued a memo, in July 1989, to all General Supervisors, which encour-aged a lower threshold for writing a NCR.
This
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memo focused attention onto the areas of defic-ient material, failures or malfunctions of sys-tems and components, and inadequate control and documentation. Before the lowering of the thres-hold, individuals other than Quality Control (QC)
generally did not write NCRs, QC has trended the NCR generation rate, which shows that the total number of NCRs generated on a monthly basis has increased.
Further, the percentage of NCRs gen-erated by the QC organization has decreased while the percentage generated by other plant organiza-tion has increased. The Team determined that the process for issuing and tracking NCRs was cumber-some.
However, the Team reviewed numerous NCRs and determined that personnel were implementing the process properly, despite its cumbersomeness.
j The NCRs reviewed by NRC appeared to be properly categorized relative to restart.
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The Team questioned _ the appropriateness of the methods used to inform operations personnel _
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promptly of nonconforming conditions.
The -NCR
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review process was not well defined in this re-i gard and could lead to confusion.
Recent revis-i ions to CCI 116 (Control of Deficiency-and Non-conformance Reports), included a check to deter-I mine the potential reportability of a given con-dition.
The supervisor of the pers'on generating the report completed this first review. If there were questions or if it was clearly reportable,
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this person notified the shift supervisor. The
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shift supervisor then took the required action to determine system operability and/or. reportability requirements.
But there-was no_ set time limit
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for this determination, which could lead to oper-E ability concerns not being addressed in 'a timely
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manner.
This process reflected more concern for
quality control than for operational considera-
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tions.
This procedure appeared to be more in line with the requireme its of a plant under con-
struction, where the timeliness of operability
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deterrination was not of great concern.
However, (
the team reviewed numerous NCRs and, while the process was not formal the Team identified.no'
failures to inform operations personnel in a suf-
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ficiently timely-manner of nonconformances.
The Team reviewed several QA Audits and the 'ac-companying findings.
They determined that there
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was no formal-review process for these finding
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to determine if an NCR needed to be written.
QA audit findings did 'get reviewed 'during the audit ~
process but the communication of NCR type condi-tions was not formal. Identified problems during
an audit were passed to the responsible super-
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visor or shift supervisor verbally.
If QA then felt that action would be taken, no formal docu-mentation would be completed.
The Team was con-cerned that audit findings were not' fully re-viewed for nonconforming conditions. Also, audit findings were not formally reviewed to evaluate
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whatever corrective measures should be restart prerequisites. Based on the Team concerns, BG&E
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performed a review of all outstanding QA findings for reportability/ operability concerns.
BG&E completed this review during the inspection with no additional NCRs or restart items added. BG&E also committed to formally _ review audit findings
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to determine which corrective actions should be a-restart prerequisites.
The Operations Department process for analyzing; potential operability and reportability concerns is documented in procedure CCI-118 (Nuclear Oper-ations' Initiator Reporting Requirements).
When the shift supervisor receives information that could cause ' a safety-related system / component to be inoperable, he fills out a form from CCI-118.
This form -addresses the operability and/or repcrtability requirements.
The procedure -' con-tains no specific guidance regarding the poten-tial need for a review of NCR requirements.
If an NCR was not generated, an issue that requires correctiu action, if not reportable, might not
'have been addressed.
In discussions with the licensing staff in charge of this review, neither the requirements nor the procedure were clear in this case.
The Team viewed this as a weakness.
Late in the inspection, the Licensing Manager provided instructions to his staff to initially address ' this issue.
Further, he committed to revise procedure CCI-118 to. clarify this area by-February 15, 1990.
The ISEU has been reviewing the NCRs processed to determine any significant trends.
Two specific-trends interested - the. inspectors.
First,' -ISEU observed a trend in surveillance tests identified with inadequate acceptance criteria.
Second, ISEU observed a trend in instances where the scope of a maintenance order was changed subse-quent to starting work.
The Teams review of these issues is incorporated in the surveillance.
and maintenance. area.
The job being done in identification of these trends was noteworthy; however, because of the limited time the program has been functioning, there was not sufficient information as yet available for the Team to
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reach a conclusion on how well line management is using the trend information, i
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The Team. observed OSSRC. and POSRC meetings and
' determined each~ to be-performing a proper safety function. The OSSRC meeting attended showed that-members were able to discuss items freely and able to ask good probing questions.
The OSSRC-open item. list was short and well managed.
The Team identified several inappropriate aspects of POSRC procedure review process and committee makeup.
The Plant Manager' had delegated-his authority as ' the. POSRC Chairman to two General Superintendent (GS-0 and GS-QA) and' to a. person
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who is filling in as an Administrative Assistant to the Plant Manager. 'The use of the GS-QA as an alternate Chairman represented an inappropriate-cross-connect of the quality assurance and plant line management. It was of interest that QA per-sonnel had questioned this before the Team.. The i'
Acting Chairman was also-signing for the. Plant Manager on procedures which were forwarded by the POSRC for approval.
The -Team found this to be inappropriate because the Plant Manager provides-a line management function in approving proced-ures recommended by POSRC.- Further, the Plant Manager might not in all cases approve POSRC l
recommendations, and in such a case, a' higher-
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level of management would be informed of-the dif-ference.
Again, the use of the GS-QA in the management function of approving procedures would
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not be appropriate unless he ' were -removed from
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concurrent QA duties.
Regarding. committee-j makeup, two alternate members, in addition to an
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alternate chairman, were sometimes beingicounted:
I as part of the POSRC quorum. -The Team considered-i this to be an excessive use of alternates on the.
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POSRC. The Team informed the Vice President of i
these findings. The Vice President took actions j
to limit the signing of procedures to the Plant Manager or Acting Plant Manager, and to allow the-l GS-QA to be the Acting Plant Manager or Acting i
POSRC Chairman only when he is relieved of QA l
duties. After the inspection, but prior to issu-j ance of this inspection _ report, the licensee also
changed the POSRC procedure, CCI-103, to clarify
quorum requirements.
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The POSRC open item list had a large number of open items-(approximately 200) and a large' number-(about 70) of delinquent items. The Team found l
that-this-number of open items was excessive and
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showed weak tracking and prioritization of issues
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and pursuit of resolutions. - BG&E committed to
incorporating a signoff in 'OP-6 mode change
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check 1ist for startup to ensure that this list is reviewed and' those required to be complete prior j
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to restart are complete. As part of an avalua-
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tion of the validity of POSRC item closures, the
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Team reviewed a closed - POSRC item dealing with.
the ECCS pump. room unit cooler.
The evaluation
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presented to the POSRC by ; engineering' personnel was factual and properly prepared to allow final closeout. One minor deficiency was noted in that there was not a final statement in the evaluation to indicate that the design basis for the -system had not been changed.
After the end of the inspection, but prior to issuance of this -report, the licensee issued a POSRC Presenter's Guide, as part of a revision to' the POSRC procedure, CCI-103, which specifies the necessary attributes of for presenting an item for POSRC review, evaluation, and closeout.
- The POEAC open item list is long (i.e., over 120
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open items).
However, the Team determined the
number of items that sent out to specific indivi-duals which required more than 'information only was relatively small.
The' Team did check the
followup based on-one event dealing with safety -
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L related 4160 KV circuit breakers.
The event in-i volved failure of a spring ^ in the same type.
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breakers used 'at Calvert Cliffs that would cause -
failure of the breaker to stay closed.
BG&E re-ceived information on this event through the INP0 network.
POEAC ' determined there was not enough
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information to require further review. The POEAC sent this item to the circuit breaker specialist
in the engineering group.
The Team requested p
that the engineering staff get enough information to review this event for applicability to Calvert Cliffs.
The engineering staff received the-
l, necessary information and sent a revised com-L mitment to the POEAC Chairman to allow tracking E
for closure.
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The Restart List._ set up to track restart issues--
was working-well.- The Plant Manager designated the items that should be on-the list.. The items
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considered by the Plant Manager have been main-tenance requests, NCRs', engineering field change-requests, POSRC open items and others. The Team requested that BG&E review the numerous correc -
tive action system to determine. if = any other
-_ items needed to'be incorporated.
BG&E completed this review on November 17.
Throughout the inspection, the Team' looked for technical issues which may have - been omitted from the_ restart list, misclassified, overlooked, or inadvertently deleted. No such errors in the restart list were identified.
4.3.3.3 Conclusion The Team concluded that a uniform and standard-ized system of problem identification and prior-itization did not exist.
There were numerous apparently fragmented identification / tracking systems on-site which feed through unclear inter-faces to the NCR process.
Although concerned with this, the Team considered these systems to be for the most part functioning acceptably to capture and cause evaluation of safety signifi-cant concerns.
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The Team was -confident in the current. restart.
list because-of aggressive management attention.
Since the restart list is a specialized mechanism and the 'other multiple systems will be relied upon during operation, the' Team considered it
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important that the licensee provide additional assurance that deficiencies identified during operations will be properly classified, priori-tized, reviewed and tracked to ensure appropriate corrective actions.
This item is discussed in Detail 3.4 and a licensee commitment is included in Detail 3.5.1.
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4.3.4-Communication of Goals and Expectations 4.3.4.1 Scope of Review The Team assessed the status 'of. management in-
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volvement, control and communication of: goals and
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expectations to.the staff. This was done through interviews of corporate management-and plant per-
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sonnel.
.The Team reviewed the. continuing cor-.-
porate' support for the L Performance Improvement
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Plan.
i 4.3.4.2 Findings
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The Team found that the attitude of a typical'
plant worker has changed. BG&E's development and
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communication of these new goals and expectation
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has been effective.
The development of the corrective action based on
the STI and. CAL was done primarily at the general
superintendent level and above.
The actions taken for the most _ part have been effective.
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However, it' does not appear that -- all levels of site staff commented on and made a difference in the development of the corrective - actions.
The Team noted that some personnel in the operations
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ranks were' disappointed that they did not get the
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opportunity to participate in. development of actions that would directly affect them.
Management communication techniques were effec-tive.
The knowledge of goals.and expectations has increased at the worker level. The Corporate and site management interviewed were committed to
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improving the communication of these goals. The Team interviewed other employees from several levels who indicated a high degree of awareness
of management goals and expectations.
This in-cluded the areas of identification of problems, use of procedures and the overall emphasis on nuclear and personnel safety.
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4.3.4.3 Conclusions
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BG&E's personnel understanding Lof company-poli-
-t cies and management expectations was obvious to-the Team. Although the. Team noted a spectrum in-a the degree to' which staff had' accepted these new.
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policies, the acceptance appeared to be steadily improving.. The Team noted the extraordinary efforts taken_ on the part of management and that -
these were commendable, j
4.3.5 Licensee Training Program-Initiatives-BG&E made -improvements in two specific areas dealing with.
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training. First,- a program for training of supervisors was
in the development phase. 'A detailed job task analysis was
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included and was found to be a good practice by the inspec-
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tors.
Second, a program for trainingL the system engineers was develope <1.
This program included a classic Systematic
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Approach to Training guideline and includes introductory,
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nuclear systems and in plant operational training.
These
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. initiatives should increase supervisory and system engi-neering skills.
4.3.6:
Overall Conclusions
.Overall BG&E has taken-appropriate action to correct defic-iencies in the area of procedures and identification of.
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management. goals and expectations.
The identification of-items that require corrective action has' :also improved.
However, the review process and tracking of these items was fragmented.
The process did - not ensure consistent review
.for -operability and reportability. determinations and prioritization for corrective actions, -although-st:ff initiative is in many cases compensating for program
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weaknesses.
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5.0 UNRESOLVED ITEMS
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An unresolved item is ' an item' for which more information is needed to.
I determine if the item is acceptable, a violation, or a - deviation.
Six unresolved items have been opened in this report:
j MOV torque switch controls (Detail 4.2.3.2).
(89-81-04)
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Reportability for SDC heat exchanger flow information from June 1988
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(Detail 4.2.3.2).
(89-81-06)
Licensee resolution of SDC Hx flow / vibration issues (Detail 3.6 and j
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4.2.3.2).
(89-81-05)
a Three unresolved items re'ated to procedure adherence and corrective
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actions in the operations area (Detail 4.1).
(89-81-01-through 03)
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- 6.0L MANAGEMENT MEETINGS
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At periodic intervals during the inspection period, the Team Leader held meetings with senior facility management to discuss the inspection. scope and preliminary findings.
A final exit-interview-was conducted -on November 20, 1989.
At the exit meeting, the Team -Leader described the preliminary inspection findings, including both the preliminary overall conclusions and the ' preliminary findings and observations in each func-
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tional area. The Team Leader also confirmed licensee commitments at-the exit meeting.
The_ Team Leader and Team Manager discussed how the Team findings will be used in NRC deliberations' regarding facility restart readiness..The BG&E Vice Chairman and the Vice President (Nuclear Energy)
attended along with station management at the General Supervisor and Manager level.
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APPENDIX A Acronyms BG&E Baltimore Gas and Electric Company
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CAL Confirmatory Action Letter
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CCI Calvert Cliffs Instruction
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.Calvert Cliffs Nuclear Power Plant CCNPP
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EQ Environmental Qualification
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FSAR Final Safety Analysis Report
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GS Genera 1ESupervisor
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General Supervisor Nuclear Operations GSN0
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HPES Human Performance Evaluation System *
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.HPSI.
High Pressure Safety Injection
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I&C Instrumentation and Control
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ISEU Independent Safety Evaluation Unit
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IST In-Service Testing
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LER-Licensee Event Report
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LOCA Loss-of-Coolant Accident
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M0 Maintenance Order
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MOV'
Motor Operated Valve
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MR Maintenance Request
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NCR Non-Conformance Report
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NRC Nuclear Regulatory Commission
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005 Out-of-Service
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...Ap~pendix A / Acronyms 2.
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OSSRC Offsite Safety Review Committee
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P&lD Piping and Instrumentation Diagram
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PIP Performance Improvement Plan
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POEAC Plant Operating Experience Assessment Committee
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Preventive Maintenance
'I-PM
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POSRC Plant Operations Safety Review Committee
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PUP Procedure Upgrade Program
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QA Quality Assurance
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QC Quality. Control
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RATI Readiness Assessment Team Inspection
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.SALP Systematic Assessment of Licensee Performance
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SAQV Safety Assessment and Quality Verification
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SRO Senior Reactor Operator
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STI Special Team Inspection 50-317/89-80 and 50-318/89-80
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i STP Surveillance Test Procedure or Surveillance Test Program
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ST Surveillance Test
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TS Technical Specification
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UNR Unresolved Item
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ENCLOSURE 2 Maryland Department of Natural Resources
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Tidewater Administration Tawes State Office Building 580 Taylor Avenue Annapolis, Maryland 21401
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William Donald Schaefer Torrey C. Brown, M.D.
Governor S.cretary December 6, 1989 Mr. James T. Wiggins United States Nuclear Regulatory Commission Region I 475 Allendale Road
King or Prussia, PA 19406
Dear Jim:
Thank you for the opportunity to participate on behalf of the State of Maryland in the recent Readiness Assessment Team Inspection at Calvert Cliffs.
I appreciate the cooperation I received from Randy Blough and other members of the team.
Enclosed is a copy of a memorandum from me to Secretary of Natural Resources Torrey C. Brown.
This memorandum represents my report regarding the inspection.
As required by the agreement I have signed with the NRC, this report will not be made public prior to the publication of the NRC's final inspection report.
Sincerely,
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Thomas E. Ma t
, Manager Nuclear Pro a
TEM /mpd Enclosure Telephone:
DNR TTY for Deaf: 301-974-3683
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STATE OF MARYLAND
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DEPARTMENT OF NATURAL RESOURCES'
ENERGY ADMINISTRATION.
-l TAWES STATE OFFICE BUILDING (
ANNAPOLIS 21401 x
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(331) 269 2788
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MEMORANDUM'
i November 29, 1989
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TO:
Torrey C. Brown, M.D.
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VIA: -' James C. Peck f
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7TROM:: Thomas E. Magette I
SUBJ:
Readiness A'ssessment Team Inspection at Calvert Cliffs
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The information contained in this memorandum was obtained 'during an inspection of the Nuclear-
-Regulatory Commission.
This information is
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y considered'by the NRC to be confidential until a
. publication of their inspection report...Under the State of Mnryland's agreement with the NRC, i
this informatior.
cannot be made'public until that time.
I From November 6-17, 1989, the Nuclear Regulatory Commission l
(NRC) conducted a Readiness Assessment Team Inspection (RATI) at thu Calvert Cliffs Nuclear Power Plant.
The purpose. of the inspection was to evaluate BG&E's readiness to operate Calvert Clif f s. safely.
This was a performance based inspection, and focused on' direct observation of work.
The results of this inspection, regardless of whether-or not
they were favorable, could not lead.to a decision to approve
- restart - of the plant.
This is because there are several items currently being addressed by BG&E and/or being separately evaluated by the NRC.
These items are thus outside the scope of the RATI.
They are evaluations of:
TTY for Deaf Annapolis 269 26@, Washington Metro 565 0450 (\\
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BG&E'c corrtetiva actions for ths-48 raatert g
' commitments 1to the NRC.'
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The physical readiness'of the plant for operation'.
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BG&E's' corrective action on AOP-9..
4.
The' adequacy of Operating Procedures.
Favorable reviews of each of these items will be required prior to
'I reaching;a. decision on restart.
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The RATI evaluated performance in three broad areas:
1.
Maintenance and Surveillance
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2.
Operations
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3.
Quality Asses,sment/ Safety-verification The area of operations was further broken down into: use of
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procedures; -safety -tagging; and control of plant status and activities.
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The inspection was conducted by a
team of eight NRC'
inspectors.
Of the inspectors, three were head resident inspectors at other' Region I plants, one was a resident inspector at another Re.gion I plant, three were from the regional office, and'one was
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a consultant.
I accompanied the team during the entire inspection-as an observer on behalf of the State of' Maryland.
s This report presents the results of ' my observations.
My conclusions are in most respects very similar to thoso of the team.
This-report is not intended to be a comprehensive discussion of the results of the inspection.
The NRC report will adequately serve
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that purpose.
Rather, I have noted those observations which I believe to be most important, and those observations-which may differ somewhat from those of the NRC.
There are very few items-
in the'latter category.
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Within each area inspected the team noted strengths, weaknesses, areas that have shown improvement, and observations.-
Observations may be either positive or negative, but not significant enough to be considered a strength or weakness.
Onc strength and several areas of improvement, weaknesses, and observations were noted during the inspection.
The team also decided whether or not BG&E's performance in each area was adequate to support safe operation of the plant.
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The team concluded that within the areas of Maintenance / Surveillance and Safety Assessment / Quality Verification BG&E's performance had improved to the point where it was adequate to support safe operation of the plant with some exceptions.
The exceptions are explained in more detail below.
Within the area of procedures, the team found that performance in use of procedures and control of plant status and activities was adequate to support safe operation of the plant with exceptions.
Performance in the area of safety tagging was found to be inadequate to support safe operation of the plant.
The observations of the team in each of the areas inspected are briefly summarized below.
MAINTENANCE AND SURVEILLANCE The area of maintenance and surveillance was generally the strongest of the areas inspected.
The only strength noted by the team was in this area. The strength was the initiation by BG&E of a Maintenance Supervisory Job Observation Program.
This program.
requires each supervisor in Maintenance to spend approximately one dcy per month in the plant directly observing ongoing work and to report the results of his observations.
The number of supervisors is adequate to provide for daily coverage.
The team noted a weakness in this area regarding BG&E's new
Surveillance Test Program.
The new program was developed to centralize surveillance tests; however, certain surveillance tests intentionally were not included in the new program.
In addition, BG&E did not have in place a mechanism for ensuring that those surveillance tests not included in the centralized program were completed prior to restart.
BG&E has committed to revising their procedures to ensure that these surveillance tests are completed prior to restart.
The team also observed that there is a significant number of maintenance tasks which must be completed prior to restart (over 400 at the end of the inspection).
BG&E's schedule called for completing physical work by November 15, 1989.
The number of open maintenance orders actually increased slightly during the two weeks of the inspection.
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Safety Taccina-The area of Operations-Safety Tagging was found by the team to be inadequate to support safe operation of the plant.-
Nonetheless, the team noted significant improvement in this area.
Of:BG&E's 48-specific commitments, 10 involved improvements-in the area of safety tagging.
Several were successful 1 in ' improving performance, most notably, _ the use of _ two _ licensed _ operators. to review tagouts, involvement of the Supervisor of Safety Tagging in planning / scheduling meetings, and the elevation of the tagging unit
'
within the Calvert Cliffs organization.
- The team also identified significant. weaknesses within the area.
These include failure to meticulously administer the,
program, a lack of management oversight, and a failure to formally track tagout deficiencies.
The most serious example of this final weakness was the. discovery by the team that BG&E had not conducted
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since September an audit of tags over 90 days old.
This audit is j
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supposed to be conducted monthly.
The results of the September audit had not yet been reviewed by management.
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BG&E immediately corrected this problem by conducting an audit'
i on Sunday, November 12, 1989.
The audit identified approximately i
20 ' deficiencies, mos t of which were minor in nature.
However, one involved the removal of two tags and repositioning of electrical-C
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switches in violation of the tags.
The team considered this to be a serious deficiency.
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The team concluded that the area of Safchy Tagging was not ready for this inspection.
There was also concern that BG&E's own management review process failed to identify problems in this area.
j The NRC has asked BG&E to report.to them the following:
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L 1. The reasons for the weaknesses 2. The reasons why BG&E management found this area acceptable 3. BG&E's corrective actions 4. BG&E's methods for ensuring acceptable performance l
prior to follow-up inspection.
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'Use of Proc-~dures
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The team-observed clear improvement in this area.
There'has been -significant improvement throughout the plant regarding-e adherence to procedures.
The process for changing procedures and
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' the _ f ormality and limits to.* pen and ink" changes to procedures are both: notable improvements _in this area..
The team. observed that
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operators are stopping to correct procedure problems.
This is a significant improvement over past' practice.
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The team also noted some weaknesses in this area. 'One of note was BG&E's -failure to meet a commitment regarding the-use of General Supervisor, Nuclear Operations' Standing _ Instructions.
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Standing Instructions are used by the General Supervisor, Nuclear i
Operations GSNO to communicate information to _ the licensed operating cr(ews. ) The Special Team Inspection (STI) conducted
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the NRC last spring noted that several Standing Instructions
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contained information which should have been contained in formal procedures.
Following that inspection, BG&E committed'to review
'
all Standing Instructions, remove those which could affect nuclear safety, and incorporate them into appropriate procedures..
BG&E incorporated into procedures those Standing Instructions -
-identified during the STI a'a important to nuclear safety.
They'
reviewed. the Standing Instructions, identified additional instructions containing information which should be in procedures, and'incor
~however, porated these into appropriate procedures.
They failed, to remove t.he instructions from the GSNO Standing Instructions.
. In addition, the team identified an additional instruction which should have been removed and put into procedures.
Control'of Plant Status and Activities The team noted improvements in this area.
They include new plant status aids for the operators, the expanded use of out-of-service tags to. label control panels, and the safety review of
- temporary modifications to-the plant.
The one weakness in this area also. involved temporary modifications.
The team noted that
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not all temporary modifications were controlled in a way that would ensure their review ' prior to restart.
BG&E has committed to correct this.
SAFETY ASSESSMENT / QUALITY VERIFICATION i-Three improvements were noted in this area The Procedure
. Upgrade Project, supervisory training, and system engineer training..
The Procedure Upgrade Project (PUP) is a part of BG&E's Performance Improvement Plan, which the NRC required BG&E to prepare to identify necessary long-term improvements.
The PUP will encompass the review of all procedures and rewrite them to meet much higher standards.
The PUP is well managed and appears to be well underway.
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.Tha tecm notcd ecvsral w22kntssas in thic croa, m ny r:garding
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= the. Plant Operations a and Safety Review l Committee: (POSRC)c The POSRC; exists to advise the Plant Manager of all matters related to L
nuclear safety.
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Because lthe~
composition,-.
function, responsibilities, ~ and authority of:the POSRC are established by. the plant's Technical Specifications,--- strict compliance is a regulatory.
requirement.
The team identified the following weaknesses
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regarding POSRCi 1. POSRC's structure and relationship to line-management 2. The delegation-as alternate POSRC Chairman r
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and the delegation-of Plant-Manager signature authority to the General Supervisor, Quality Assurance without provision to remove him from his Quality--Assurance function 3. Excessive use-of alternates in meetings I
'4.' Unacceptably high number of POSRC open items.
At the ~ time ot the-RATI,- there were over 200 POSRC open items, 74 of which were overdue.
BG&E has committed to review all POSRC'
open items prior to restart.
The' team also noted a weakness regarding. how BG&E reviews problems to determine if and when they must be reported to. the NRC.
The ' final' review of such items is conducted by the Licensing section at Calvert Cliffs.
The inspection found the licensing-reviews to be ineffective at determining reportability.
OVERALL
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The team noted a clear increase in awareness of the importance I
of-and-adherence to procedures.
The entire organization is also j
more sensitive to identifying problems.
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~ The team also noted two serious generic weaknesses.
The first j
is that BG&E has no single process for tracking and resolving routine problems.
Many problems which are identified are dealt with informally rather than via any specific - system.
Those problems which are addressed formally may be handled by one of
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several different systems.
A single, formal tracking system is i-important to ensure that all problems are treated consistently, j
p reviewed for reportability (to the NRC), and corrected.
Finally, corrective actions must be verified as complete and effective.
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BG&E has committed to implement a formal tracking system prior to restart.
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The second ganaric weakness identified by the team is BG&E's problem in communicating with the regulator.
This problem was
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manifested in several ways both before and during the inspection.
One key example was BG&E's failure to have senior management available for the inspection.
Several Managers and General Supervisors he two levels of management immediately below the Vice Presidoit Nuclear Energy) were sporadically present during the early part of the inspection.
Ma.ager was out of town for the entire RATI.More importantly, the Plant While his absence had been previously scheduled, the NRC was not so notified until arriving onsite November 6 to begin the inspection.
It is critical to an inspection such as the RATI that senior management be available during the inspection.
Another example is what the team described as BG&E's fixation the list of 48 commitments to the NRC.
It is on important for any licensee to keep commitments it makes to the NRC.obviously BG&E has been f aulted by the NRC in the past for weaknesses in keeping commitments.
However, the NRC also requires each licensee be unworkable or ineffective.to make productive commitments, and to revise th The team identified - one commitment which was weak.
of service on piping and instrumentation drawings.This comm that the commitment was not accomplishing its objectives.It was apparent evident by the This was failure of the tagging staff to properly maintain the drawings (errors were found on all
sets of drawings reviewed),
and the lack of use of the drawings by the Shift Supervisors.
BG&E's own verification process (the process by which they confirmed to themselves that their commitments had been successfully accomplished) identified this commitment as being ineffective over two montha ago.
Yet at the time of the inspection, BG&E stated only that they were continuing to evaluate this approach.
with the regulator was their failure to understand the scope intent of the RATI before requesting it.
BG&E did not expect, nor were they prepared to undergo, a comprehensive, performance based inspection.
Rather, focused on their implementation of the 48 commitments.they anticipated
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Tha team also notsd that BG&E rcquOstid ths RATI b] fore some s
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programs had been in place long ~ enough to become _ fully.
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effective.
The team observed programs that it. believed.would
become effective for solving problems, but was in the position of
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could be conclusively demonstrated.
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found in spite of the large number of improvements BG
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ROOT CAUSES-
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<A The issue of root causes was not addressed in detail' during
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the inspection.
It is
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fundamentally important,_however, because BG&E must appropriately identify the
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sources of their problems before_they can solve them.
This is a restart-issue because the NRC's May 25, 1989 Confirmatory Action - Letter requires
"
... determine and correct the root cause(s) of the problems..."
BG& E.. to n
BG&E has addressed the issue of root causes in two separate The Performance Improvement Plan ways.
(PIP, which ' they were long-) term improvements, -
required by NRC to prepare to describe identifies 11 root causes.
and is not expected to be. completed prior to restart.The NRC's review identified! root causes in each of the reports addressing their 4B BG&E also restart commitments.
These reports still being reviewed by NRC resident inspectors at Calvert Cliffs.(or "clo
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At the time of the RATI, there was no single list of root causes which addressed the CAL requirement.
In response-to a
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question-from the team, BG&E prepared a
brief paper which-
specifically addressed root causes in the context of the CAL.
paper was not' available, however, until the final day of the This inspection.-
BG&E concluded that. the root causes listed and described in the PIP the root
,
long-term correction) (are the causes of the problems requiring same as thoso - for the short-term problems listed in the CAL.
Thus, that addressing root causes is germane to restart. portion of the PIP The NRC has not analysis.
formally. commented on BG&E's root cause be added to BG&E's list.They have. suggested that an additional root cause shou This additional root cause is Inadequacy of Procedures'.
I consider the issue of whether or not
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appropriately identified root causes to be open.
BG&E has
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As stated. above, - the _information. gathered reported herein
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by the. NRC - and is : predecisional.
It is change pending review by NRC management.
therefore subject - to anticipated, however,1because senior management has been briefedN
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on-these results.
confirmed in writing to the NRC, including dates b b_e completed.
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inspection and-from areas not covered by this inspectiT
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closed out.
Additional inspection will be required.
on, will be in the form This may come of inspection by. resident inspectors, _ Region-I-specialists, or another team inspection.
TEM /mpd
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cca James M. Teitt Paul Massicot Larry Ward, MDE
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