IR 05000320/1988010

Safety Insp Rept 50-320/88-10 on 880605-0707.No Violations Noted.Major Areas Inspected:Defueling & Decontamination Activities,Including Proper Implementation of Housekeeping & Fire Protection Measures

ML20151R220
Person / Time
Site:	Three Mile Island
Issue date:	07/29/1988
From:	Cowgill C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20151R214	List: IR 05000320/1988010 ML20151R211
References
50-320-88-10, NUDOCS 8808120099
Download: ML20151R220 (16)

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b U. S. NUCLEAR REGULATORY COMMISSION REGION 1-Report N /88-10 Docket N License N OPR-73 Priority --

Category C Licensee: GPU Nuclear Cor.coration P. O. Box 480 Middletown, Pennsylvania 17057 Facility Name: Three Mile Island Nuclear Station, Unit 2 Inspection At: Middletown, Pennsylvania'

Inspection Conducted: June 5, 1988 - July 7, 1988 Inspectors: R. Conte, Senior Resident Inspector D. Johnson, Resident Inspector T. Moslak, Resident Inspector (Reporting Inspector)

A. Sidpara, i ent Inspector Approved by: [l k N b C.Cowgill,Chiefg(RepctorProjectsSection1A j

7bd1 Date Inspection Summary:

Areas Inspected: Routine safety inspection by site inspectors of defueling and de-contamination activities, including the proper implementation of housekeeping and fire protection measures and the review of selected events. There was also a management meeting to discuss recent human performance events of concern to NRC scaff. Other areas reviewed included licensee event reports and proper implemen-tation of selected sections of the radiological controls progra Results: In general, licensee personnel properly implemented procedures, except ,

as noted for certain events listed within this report. The inspector identified !

no adverse conditions with respect to the licensee's radiological controls and fire l protection programs. Minor implementation problems continued to be noted, j For the events reviewed in this report and at the management meeting of July 1, 1988, the NRC ;taff determined that the licensee is to take appropriate. actions to enhance performance and this area is to be closely monitored by both the licen-see and NRC staf PDR G ADOCK 05000320 l puu i

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TABLE OF CONTENTS'

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' 1.0' Introduction'and 0verview.....................................'....... :1 1.1 Licensee Activities............................................. 1 1.2 NRC Staff Activities............................................ 2 1.3 Persons Contacted............................................... 2 2.0 Defueling/ Decontamination Activities (NIP 71707)..................... 2-2.1 Scope of Review................................................. 2 2.2 G e n e ra l Fi n d i n g s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2.3 Housekeeping /Fi re Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2.4 Event Review (NIP 93702).~....................................... .5 Decontamination /Defueling Summary............................... 5 3.0 Radiological Controls Program Implementation (NIP 71709)....... ..... 6-4.0 Licensee Event Reports (NIP 90712)................................... 8 5.0 Management Meeting - Defueling/ Decontamination ~ Events-(NIP 30702).... 9 I

6.0 Exit Meeting (NIP 30703)............................................. 14

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ATTACHMENT 1 - TMI-2 Human Perforcance Events - January to May 1988

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1 ;H DETAILS 1.0 Introduction and Overview 1.1 Licensee Activities Progress continued to be made in cutting and removing sections of the Lcwer Core Support Assembly (LCSA) to provide access for defueling the lower head of the reactor vessel. Decontamination of external surfaces-and plant systems continued. One plant area was isolated and placed in-an interim Post-Defueling Monitored Storage (PDMS) status. Five other plant areas were in the process of being verified to meet the interim ~

PDMS criteri Using the plasma arc torch, defueling crews completed cutting the upper flow distributor into four sections. Preparations were being made to remove these sections and place them in storage in a-modified core floo tank. The flow distributor was the second of five plates that would be removed from the LCSA. In preparation for cutting the -flow distributor,-

workers cleared this plate of core debris and completed trimming the'

periphery of the lower grid rib section to remove potential . interference The next section to be cut into sections and removed will be the grid'

forging. Failures of electrical components in.the plasma arc cutting equipment slowed the overall progress of cutting the LCSA. The licensee established a task force to examine the nature of these failures and to provide _ recommendations to improve the reliability _of the cutting equip-men The licensee reported that defueling operations were completed in the pressurizer using a robotic mini-submarine. 'The submarine picked up rock-like material and placed it into buckets that were eventually loaded into defueling canister Four and one-half. gallon buckets of debris were removed from the pressurize No shipments of casks containing core debris were made during this re-porting perio Scabbling, steam vacuuning, and hands-on decontamination continued in the auxiliary and fuel handling buildings. To date, 119 of 143 cubicles were decontaminated to end point criteria. The remaining cubicles con-tained highly contaminated plant systems that first must be cleaned be-

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i fore the cubicle is decontaminated. Flushes of these systems were being performed to lower dose rates in the cubicle Attempts to transfer highly contaminated resins from the "A" make-up demineralizer wert unsuccessful. To better access this problem, a video

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i camera was inserted into the tank to evaluate the resin consistency and quantitie I

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Aseriesofholesweredrilledinthe'concreteb1$ck'wallintheRB basemen The wall was filled and drained with. water in an attempt to flush contamination from the wall. -The contaminated water was subse-quently processed through the submerged demineralizer system to remove the contaminant The licensee implemented'the initial phase of assessing specific plant-areas for eventual placement of these areas into a PDMS condition. ~ Fol-lowing the assessment, the seal return cooler / filter room was isolated from plant activities to assure that it would not become re-contaminated nor be impacted by other plant operations. Five other areas were to be verified that they .aeet the criteria and would also be isolated from the balance of the plan .2 NRC. Staff Activities The purpose of this inspection was to assess licensee activities during defueling and decontamination activities. The inspectors made this assessment through actual observations of licensee activities, interviews with licensee personnel, measurement of radiation levels, or review of listed applicable documents. NRC staff inspections use the acceptance criteria and guidance of NRC Inspection Procedures (NIP's). These NIP's are annotated in the Table of Contents to this repor The inspector also reviewed the implementation of the licensee's site security program related to TMI-2 as documented in NRC Inspection Report No. 50-289/88-13 for TMI- I.3 Persons Contacted During this inspection, the following key licensee personnel provided substantial information in the development of the inspectors' finding *J. Byrne, Manager, TMI-2 Licensing

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S. Levin, Defueling Director

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• Marshall, Operations Engineer

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W. Potts, Director, Plant Operations

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• R. Rogan, Director, Licensing and Nuclear Safety

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• E. Schrull, TMI-2 Licensing Engineer

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J. Tarpinian, Manager, Radiological Engineering Turner, Director, Radiolos' cal ~ Controls

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D. Tuttle, Manager, Radiological Field Operations

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• M. Williams, Manager, Plant Maintenance 2.0 Defueling/ Decontamination Activities 2.1 Scope of Review The inspector observed and/or reviewed licensee defueling decontamination activities to: (1) ascertain factual status of such activities; (2) as-sure proper adherence to applicable procedures; and, (3) select and re-

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view significant events warranting further inspection follow-up. .The inspector also made observations in facility spaces.with respect to proper housekeeping, fire protection, and radiological controls. The general' acceptance _ criteria for.this review was Section 6 of the TMI-2 Technical Specification In response to recent events at TMI-2 and based on other relevant in -

formation, the TMI Resident Office provided augmente'd coverage-for acti-vities at TMI-2 between June 17 and July 1,1988. This included addi-tional back shift inspections and increased daily coverage for the uni In performing the above inspections, the inspectors focused on the fol-lowing areas of licensee performance:

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control of operations in progress by supervisory personnel;

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knowledge of the task by technicians and support persons;

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appropriateness of governing documents, including procedures and Radiation Work Permits (RWP's), .

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alertness of various controlling station personnel;

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assess the quality of implementation of selected evolutions wit-nessed; and,

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assess the material condition.of the plan l The inspections were made at random intervals and frequently between the hours of 10:00 p.m. and 6:00 .

Date/ Day Time Periods 6/12 Sunday 10:30 a.m. - 11:30 [

6/17 Friday 4:45 p.m. - 5:45' '

6:00 p.m. - 7:00 /18 Saturday 9:00 a.m. - 10:00 :30 p.m. - 9:00 l 6/19 Sunday 11:00 a.m. - 12:30 /22 Wednesday 4:00 a.m. - 6:00 /24 Friday 4:00 a.m. - 7:00 /25 Saturday 11:30 p.m. - 2:30 /28 Tuesday 8:45 p.m. - 10:15 /29 Wednesday 9:00 p.m. - 11:30 /30 Thursday 9:00 p.m. - 11:30 /1 Friday 5:00 a.m. - 7:00 a.m.

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2.2 Gpneral Findings As a result of the routine and augmented review noted above, the inspec-tors identified no major discrepancies. In general, licensee represen .

tatives properly implemented procedures, except as noted for certainc events listed within this report. Addressed below were specific obser-vations in the ~ area of housekeeping, fire protection, .and event revie Of particular note was the licensee's low th' eshold r for. documenting and reporting off-normal events'that were below reporting requirement thres'-

hold .3 Housekeeping / Fire' Protection On June 8,1988, two resident inspectors accompanied a licensee's fire protection engineer on an inspection of reactor building (RB) space s The inspectors noted overall improvement of the implementation of house-keeping and fire protection measures. Along with the fire protection engineer, the inspectors noted certain discrepancies, howeve The fire protection engineer recorded these discrepancies for follow-u Generally, these discrepancies were: motor or lubricating oil in unap-proved containers; loose (unused) or empty spray paint containers not properly stored or discarded; macF' ery oil leaks; plastic bags with apparent contaminated material and untagged; and/or radioactive material

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tags loose (not attached to bags).

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Throughout the rest of the period, the inspectors made observations in other facility spaces. Again, the inspector noted licensee attention

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to these areas to maintain existing standards for housekeeping and fire protectio The discrepancies noted were similar to-those.found in the RB. The inspectors discussed these items with licensee management for follow-u This area will continue to be routinely reviewed by.the NRC resident inspector '

2.4 Event Review A number of events were identified by the licensee in their internal reporting system and they were reported to the resident _ inspector On June 9, 1988, six pages of word puzzles were found in the proce- l dures book (operations procedures manual) at the defueling platform in the R On June 9, 1988, the defueling platform was being rotated and a jib crane hit and severed a 480 volt electrical line causing arcing and sparking. No personnel injuries resulte .. .

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On June 9 and 23, 1988, the containment ventilation (purge) system was not operating during plasma arc operation as require On June 17, 1988, there was an inadvertent start of' fire protection

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deluge pumps at the waste handling and-packaging facility durin instrument-and control technician work.on the deluge syste On June 17, 1988, the fire service supply valve (FS-V-639) for the RB was not shut during a heavy load transfer of the Power Cutting Incorporated (PCI) "x y" bridge and this'was contrary to facility procedure The licensee reported other events to the inspector that appeared to be due to equipment malfunctions or failures. The events listed above were of interest to the NRC staff because the root causes appeared to be poor human performance deficiencie These events were added to'the list of other events reported in 1988 concerning root causes involving the human element. The NRC staff dis-cussed this concern with licensee management in a meeting in the Region I office on July 1, 1988 (see Section 5).

The inspector also reviewed licensee internal report Serial No. 4420-88-0050, 1988, by the Safety Review Group (SRG), dated June 2, 1988, on the recent (March 23 to May 23, 1988) radiological occurrence / incident event The report compared the recent event data to periods in 1986 and 198 It presented information on the status of the events and percentage of events due to various causes, including personnel error and underlying causes for the personnel errors; e.g., communications, procedure inade-quacy, human error, training, etc. The report concluded that there was an increase in the rate of such occurrences previously due to human causes, after a period of relatively successful "error free" operations, and that this trend needed to be halted before it affected more critical aspects of the recovery effor Additional information on licensee management perspective on these events is discussed in Section 5, along with corrective action With respect to the SRG report, the inspector concluded that it was thorough and it provided useful information to licensee management on which they could focus appropriate corrective actions. The inspector ;

also concurred with the trend noted in the licensee's report (see also NRC Inspection Report No. 50-320/88-08).

2.5 Defueling/ Decontamination Summary ,

The defueling/ decontamination activities were proceeding as planne The above-noted events did not result in significant radiological con- .

sequence The licensee's reporting system was noteworthy. However, I additienal NRC staff review was needed to further assess underlying l causes, j

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Overall, housekeeping in several areas has s,3nificantly improved; how-ever, substantial licensee attention was necessary to maintain. facility cleanliness and fire protection standard .0 Radiological Controls Program Implementation 3.1 Scope of Review The inspector conducted a review of the implementation.of the licensee's radiological controls program. The inspector performed this review dur-ing- routine and back shift plant tours by observation of on going de -

fueling and decontamination activities; review of Radiation Work Permits (RWP's); and, supporting documentation and review of general radiological conditions, including verification of the status of locked high radiation areas and review of the ALARA (as low as reasonably achievable) progra .2 Radiation Work Permits The inspector reviewed RWP Nos. 17386 and 17398 for performing'defueling operations and for conducting resin transfers from the make-up deminera-lizers, respectively. Through this review, the inspector determined that the RWP's contained the following informatio Radiation / contamination levels

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Concentrations of airborne radioactivity

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Respiratory / protective clothing equipment requirements

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Dosimetry

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Special precautions

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Expiration dates

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Radiological controls coverage

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Job descriptions For work in the RB (RWP 17386), the inspector attended the pre-job briefing conducted in support of defueling operations, observed actual work performed, and determinad the following. The licensee adequately informed the defueling crew of radiological conditions, precautions to

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be taken while performing tasks, and dosimetry, respiratory / protective clothing requirements. Workers encountered no-radiological problems'that

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were not previously addressed by the RWP or its supporting documentation, including radiological surveys, ALARA Reviews, or within the limits / pre-cautions or prerequisites of the applicable operating procedures. There was an adequate understanding of the RWP requirements by personnel. The inspector noted no problems with the implementation of this particular RW In reviewing the implementation of the radiological controls for per-forming resin transfers from the make up demineralizers (RWP 17398), the inspector examined the ALARA Review (ARN 880042) tnat the licensee pre-pared. Through this examination, the inspector determined that the ALARA Review consisted of the following information:

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task time study;

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dose rates based on real measurements or anticipated worst case estimates;

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emergency actions for specific aspects of the task being oerformed; e.g., operation of the plunger pump, air sparging, and for use of a hydrolance;

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pre-job 5riefing and post-job debriefing requirements;

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reference to specific prerequisites and limiting conditions for continued operations contained in the operating procedures (4215-OPS-3233.27); i.e., Stop Job Points;

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dosimetry and radiological monitoring requirements;

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exposure tracking action levels; and,

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mock-up testing and trainin The above review indicated that the Radiological Engineering Department addressed the appropriate aspects of an ALARA program to support the transfer of resin from the make-up demineralizer .3 Control of Locked High Radiation Areas l

Licensee technical specifications required that any area accessible to personnel with dose rates greater than 1 R/hr be locked to prevent un-authorized entry and be conspicuously poste On June 25, 1988, between the hours of midnight and 2:30 a.m., the in-spector checked a representative sample (approximately forty locks) of locked high radiation areas to verify compliance with the requirement stated above, by challenging the latching mechanism and by observing the postings. The inspector did not identify any examples of non-adherence to existing administrative control Through discussions with radiological controls technicians and supervi-sors and through examinations of logs, records, and the applicable pro-cedure (9200-ADM-4110.06), the inspector determined that the licensee verified '.he status of these locked high radiation areas at least once each shif The inspector had no further questions on this aspect of the licensee's radiological controls progra _ ._ .

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8-3.4 ALARA The inspector discussed implementation of the licensee's ALARA program with a cross section of managers, supervisors, engineers, and technicians responsible for performing various functions within the Radiological Controls organization. From these discussions, the inspector. determined that the staffing of radiological engineers and of radiological-controls technicians was appropriate for the defueling/ decontamination activities being performed.. An adequate number of technicians and supervisors trom the Radiological Engineering Department were available or all shift The overall pace of these activities appeared to be controlled to permit adequate coverage to assure implementation of the requisite radiation protection measure The inspector determined that mock-up training was extensively used on such tasks as-pressurizer and decay heat drop leg defueling to anticipate and resolve exposure control problem The inspector reviewed the licensee's procedures that implement the ALARA program, specifically 4000-PLN-4010.01, "TMI-2 ALARA Program Plan,"

9200-ADM-4010.01, "TMI-2 Radiological Controls ALARA Program," and 9200-ADM-4010.02, "ALARA Review Procedures," and examined selected ALARA Reviews. The inspector determined that the licensee effectively coordi-nated the various aspects of the ALARA progra .0 Licensee Event Report Follow-Up The following Licensee Event Reports (LER's) were reviewe The inspector verified that the reporting requirements were met, causes were identified, corrective actions were appropriate, generic applicability was considered, and the LER forms were complet LER 88-005, dated May 20, 1988, addressed radiological occurrences on April 21 and 23, 1988. The two events involved removal of trash con-taining solid contaminated debris in excess of established limits from a radiologically-controlled area (RCA) without proper release survey The primary cause for both events was a lack of awareness of survey .re-quirements for material removed from an RCA and/or inattention to re-quirements posted at all exits to RCA's requiring frisking / survey of such material. The measured contamination levels did not constitute a sig-nificant personnel exposure hazar LER 88-006, dated June 2,1988, concerned the exposure of a minor. As a result of falsification of his date of birth, the individual received exposure in excess of the limits of regulatory requirements. As correc-tive action, the individual was removed from Three Mile Island (TMI) and has been denied future access to the sit i I

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.LER 88-007, dated May 27, 1988, addressed the discovery of a' containment personnel airlock being maintained open on April 28, 1988; The root cause of this event was-personnel error by the airlock' attendants an the RB entry supervisors, based on a lack of understanding of the above technical specifications (TS) requirement. Contributing causes included a failure of the operating procedure for the airlock doors to specify the referenced TS requirement and a misunderstanding.on the part of some licensed operators concerning the requirement of this TS as it related to frequent containment acces LER 88-008, dated June 3,1988, addressed radiological occurrences on May 4 and 8, 1988, which. involved removal of trash containing solid con-taminated debris in excess of established limits. These events were similar in nature to LER 88-0 LER 88-009, dated June 10, 1988, addressed the operation of the "x y" bridge flush wand on May 13, 1988, with an inappropriate water sourc The applicable procedure required that the flush wand be connected to the water jet supply pump, VAC-P1, which is submerged in the reactor vessel (RV). However, at the time of the event, VAC-P1 was inoperable; thus, the task supervisor and lead engineer decided to perform the flushing operation using the borated water storage tank / fuel transfer canal fill (BWST/FTC) system as the source of flush water, which was contrary to facility procedure The inspector noted the repetitive nature of some of these events and the fact that roct causes related to poor human performance. The LER's addresse appropriate specific corrective actions (planned or taken). The NRC staff generally discussed the human performance aspects of these events with the licensee in a management meeting (see Sectior 5).

5.0 Management Meeting - Defueling/ Decontamination Events 5.1 Introduction At 1:00 p.m. on July' 1,1988, the below-listed licensee and' NRC staff personnel participated in a management meeting to discuss recent events (1988) at TMI-2 that were of concern to the NRC staf GPU Nuclear Corporation (GPUNC)

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C. Clawson, Vice President and Director, Communications

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E. Kintner, Executive Vice President

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R. Rogan, Director, Licensing and Nuclear Safety

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F. Standerfer, Vice President and Director, TMI-2 _ _ ._, . .._- ___ ,, ._ _ _ _ -. ._ _ , -

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NRC Staff

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L. Bettenhausen, Chief, Reactor Projects Branch No. 1, Division of Reactor Projects (DRP), Region I-(RI)

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R. Conte, Senior Resident Inspector (TMI), RI

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C. Cowgill, Chief, Reactor Projects Section No. lA, DRP,' RI

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W. Johnston, Acting Director,' Division of Reactor Safety, RI

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W. Kane, Director, DRP, RI

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M. Masnik, Project Manager (TMI-2), Office of Nuclear Reactor Regulation (NRR)'

Also, a representative of the Commonwealth of Pennsylvania, Ajit Bhattachayyra attended the meeting. No written material was exchanged at the meeting. A summary of the discussion follow .2 Overview -

The NRC's Director of DRP, RI, summarized the purpose of the meetin The purpose was for licensee representatives to provide their perspective on the recent events'(listed in Attachment 1 and Section 2,4-of_this report). The NRC staff's concern fo:used on the causes of the events apparently attributable to poor human performance. Underlying causes were to be discussed, such as complacency, with respect to the changing plant status leading to post-defueling monitored storage and/or the in-fluence of poor procedures or work instructions,_for exampl The GPUN Executive Vice President led off the licensee's discussion by assuring the NRC staff that these events do not indicate a breakdown in the quality assurance program at THI-2. Their performance indicators revealed a leveling off of performance in distinction to improved or degradation of performance and the licensee planned corrective actions oriented toward enhancing performanc i l

The licensee representative acknowledged- the potential for apathy in light of the end of the cleanup project. .He. indicated that licensee management was sensitive to other possible personnel attitudes and they were taking measures to mitigate such behavior on the part of its per-sonnel (details discussed later).

5.3 Special Task Force I

Licensee representatives then discussed the results of a special task

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force designed to review the subject events and related aspects on how site personnel process the documentation and review (critiques) of such events. The licensee initiated this task force review when the NRC staff requested this meeting. The task force had recommendations and forwarded the report to the Director of TMI-2 for review and respons , . _ _ - . _ _ . - - _ _

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The task force noted positive aspects on the performance of TMI-2 Divi-sion. Corrective actions for major problems of the past year or so were effective. Examples noted were: hot particles contamination, fires, unlocked high radiation doors and improper lif ting of heavy loads. Al-though the number of events per month increased somewhat in the March -

April 1988 time period, the yearly number to date was about par with previously years (average of about ten events / month). The task-force also recognized the ambitious program for review of such events and the relatively low threshold for reporting in light of TMI-2 unique condi-tions compared to operating reactor However, the task force noted a leveling off of performance (with respect to the licensee performance' indicator curves) and it recommended that the TMI-2 Division needed to provide action in certain areas oriented toward improved performance. The areas included: root cause analysis, specialized review of the human performance element, and procedure ade .

quacy and adherenc The conclusions of the task force were:

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the events had no significant impact on nuclear safety;

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there was a leveling off or flattening of performance indicator curves; i.e., measure of performance; and,

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low threshold for reporting was better than industry-wide perform-anc .4 Corrective Actions As a result of the above. the licensee representatives provided the fol-lowing planned (or taken; corrective action Meetings between the TMI-2 Director and division supervisors (190 --

82 done with 108 due) and the major contractor management to re-emphasize: (1) quality of operations; (2) review all thirty-four events for 1988 attributable to personnel errors or procedure in-adequacies; and, (3) review the latest performance indicators (ex-pected to be completed by July 8,1988).

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A policy memorandum was issued June 27, 1988, banning all non-company reading material within the protected are Decide by July 14, 1988, what type of re-review was needed to re-solve the issue of making procedures better or "user-friendly."

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Enhance the adequacy of critiques by improving root cause analysis and by having personnel trained in human performance analysis pre-sent at critique ... . ,

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GPUN Office of the President reissue of policy to all GPUN divisions .

on the .use .of procedures; namely, to follow the procedure or fix -

it if it cannot be followe In response to the licensee's request for feedback on these actions, the NRC staff suggested enhanced use of the licensee's management-off shift'

tours to focus on the management of idle time during back shift hours and at remote locations.in the plant, such as at the defueling water cleanup station on the operating floor of the fuel handling buildin Licensee representatives acknowledged the staff's comment The NRC staff tentatively agreed with the licensee's proposed or taken actions. The staff indicated that they would continue to closely monitor licensee performance; and, if the performance did not improve, another meeting at the end of this year may be warrante Accordingly, this area is' unresolved pending completion of licensee ac-tion as stated above and further review by NRC Region I (320/88-10-01).

5.5 Special Measures The licensee representatives also summarized GPUN's plan for managing the "end of project" employee relations. To be done right, the plan included factoring in the career needs of personnel _at TMI-2, use of contractors at THI-2 integrated into the organization, application of existing resources at TMI-1, and providing for a means for departing personnel to air any safety concerns. The licensee representatives indicated that the reduction of 130 licensee (not contractor) personnel occurred to date by attrition (transfer ur early retirement), not by terminatio The major reduction in force in the TMI-2 organization will come as con-tractors phase out their wor Further, any personnel terminating employment at TMI.have the opportunity to air safety concerns on a form developed by the Division of Human'Re-source The GPUN Executive Vice President summarized that it was the company's desire to be able to place all employees prior to position termination, preferably within the company or by attrition, and that existing measures for employees to air safety concerns were adequat .6 Meeting Conclusion / Summary The NRC staff summarized the licensee's perspective on the subject event Licensee management was not content with the loveling off of performance indicators. The licensee oriented corrective actions toward the human '

performance element. There was no adverse impact on nuclear safet l

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The NRC staff considered licensee proposed or taken action tentatively acceptable pending further Region I review. The collective affect of these actions were to be reviewed in a future inspection or management meetin .0 Exit Meeting The inspectors discussed the inspection scope and findings with licensee man-agement at a final exit interview conducted July 7, 1988. Senior licensee personnel attending the final exit meeting were noted in Section The inspection results, as discussed at the meeting, are summarized in the cover page of the inspection repor Licensee representatives indicated that none of the subjects discussed contained proprietary or safeguards infermatio l J

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TMI-2 HUMAN PERFORMANCE EVENTS JANUARY TO MAY 1988 Date Inspection Description 1/88 88-01 Inattentive worker to duties in RWP area 1/88 88-01 Worker' enters locked high radiation area without proper dosimetry 2/22/88 88-05 Fire at decortamination facility.in RB 2/27/88 88-05 Fire at decontamination facility in RB-4/1/88 88-08 Hose rupture during "A" spent"resin tank decanting apparently due to banging clogged line (clogged line repetitive event - same line previously ruptured due to. improper crimping to fitting)

4/4/88 88-06 High airborne in RB due to hole drilling in stairwell block wall with wrong type of tool - RB evacuated 4/12/88 88-06 Turbine building work - electric hoist hook : napped free knocking a worker unconscious 4/28/88 88-08 Containment outer door left open without people transiting contrary to TS 5/5/88 88-06 CA-V-238 and OH-V-163 found open after inadvertent transfer of BWST water to bleed tank 5/2/88 & 88-09 Locked high radiation doors found open 5/31/88 5/13/88 88-08 "x y" bridge for plasma arc equipment flushed with BWST water contrary to procedures 5/23/88 88-08/09 Worker falls into reactor vessel

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