IR 05000336/1988010
| ML20153D447 | |
| Person / Time | |
|---|---|
| Site: | Millstone  |
| Issue date: | 08/04/1988 |
| From: | Gagliardo J, Stewart P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20153D441 | List: |
| References | |
| 50-336-88-10, NUDOCS 8809020209 | |
| Download: ML20153D447 (27) | |
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APPENDIX B
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U.S. NUCLEAR REGULATORY COMMISSION
REGION I
Report No.:
50-336/88-10 Operating License: DPR-65 f
Docket:
50-336 f
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Licensee:
Northeast Nuclear Energy Company P.O. Box 270 L
Hartford, CT 06101-0270 i
Inspection At: Millstone Unit 2
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Inspection Conducted: May 10-17, 1988
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Inspector:
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hPe{ry5 I
art, Reactor Inspector. Operational Datt
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g mgra Section Division of Reactor Safety.
Region IV
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Team Members:
J. O'Brien, Senior Reactor Inspector, Region V L. Defferding, Licensing Examiner
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C. Tolbert, Human Factors Specialist l
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S. Sun Reactor Systems Engineer P. Bi3b, Resident Inspector St. Lucie i
P. Ha bighofst, Resident Inspector, Millstone 2 j
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Approved By:
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J. E. TegliaVdo, Chief Operational Programs Date i i
Branch, Division of Reactor Safety Region IV
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Inspection Sumary Inspection Conducted May 10-17. 1988 (Report 50-336/28-10)
Scope: This special announced inspection was conducted in the area of Emergency Operating Procedures, including the implementation of vender Generic Technical Guidelines (GTG), validation and verification pregram, and the performance of adequate training on the E0Ps.
Results:
No unsafe operational conditions were identified. One apparent deviation (missing procedural steps, paragraph 3) was identified. Other discrepancies requiring followup were noted in specified E0P technical review items and human factor element review items, h$k ObbK$$
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DETAILS 1.
Persons Contacted
- S. Scace, lit 11 stone Station Superintendent
- J. Keenan. Unit 2 Superintendent
- J. Smith, Unit 2 Operations Supervisor
- H. Wilson, Unit 2 Operator Training Supervisor
- S. Brinkman, Unit 2 Operations Engineer
- J. Becker, Unit 2 Assistant Engineering Supervisor
- Denotes those present at the exit meeting on May 17, 1988.
The NRC inspectors also contacted other members of the Operations and Training Departments.
Also in attendance at the exit meeting on May 17, 1988, were the following NRC and NRC contracted staff personnel:
L. Bettenhausen, Chief, Projects Branch 1, Region I J. Persensky, NRR Section Chief. E0P Program Manager J. Gagliardo, Section Chief. CE E0P Manager, Region IV J. Stewart, CE E0P Team Leader, Region IV D. Jaffe, NRR Hillstone Project Manager J. O'Brien, Reactor Inspector, Region Y H. Bibb, St. Lucie Resident Inspector, Region II C. Tolber., SAIC, Human factors Engineer W. Rap ond, H111 stone Sen nr Resident Inspector P. Habigherst, Millstor.e 2 Resident Inspector G. Barber, Hillstone 3 Resident Inspector 2.
E0P/ Generic Technical Guidelines (GTG) Comparison (25592)
A ccmparison of the plant's E0Ps and the Combustion Engineering Owners Group (CEOG) GTGs centained in CEN-152 was conducted to ensure that the licensee had generated procedures iii accordance with the CEN-152 recomendations. The E0Ps reviewed are listad in Appendix ! of this report. The comparison included a review of licensee letters issued to docurent changes made from the CEN-152 recommendations and interviews with personnel to determine the bases for the changes.
i The inspectors reviewed the contents of CEN-152 Revision 2 and Hillstone 2 l
E0Ps. The licensee had incorporated all emergency events with the exception of "Loss of Forced Circulation." The inspectors reviewed the guidelines in CEN-152 concerning the loss of Forced Circulation event and
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I cencluded that the licensee had incorporated the guidelines into plant i
specific E0Ps with few exceptions.
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i The inspectors noted that the licensee had exceeded the CEN-152.
Revision 2, guidelines by implementation of E0P 2528 "Electrical Emergency." The team reviewed this procedure and has no outstanding observations.
E0P 2528 addresses operator actions on in-plant electrical distribution degradation. The operator censiders the use of E0P 2528, in
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the standard post trip actions of'EOP 2525.
The inspectors reviewed the licensee's Procedure Generation Package (PGP),
Revision 1, to review the incorporation of the CEOG Emergency Procedure Guidelines EPGs i'.to the plant specific E0Ps.
This effort was accomplished in four principle steps.
l The first step of the review consisted of the verification of the licensee's incorporation of a writer's guide, and the deviations from
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the CEOG emergency procedure guidelines into the Hillstone 2 E0Ps.
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writer's guide for E0Ps is a plant specific document that provides instruction on writing E0Ps. The writer's guide was based on industry development of Emergency Operating Procedure Writing Guideline (INPO 82-017). The licensee had incorporated this guide into ACP-QA-3.02, Revision 1. "Writers Guide for Millstone Procedures," Attachment A.
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The second step of the inspector's review censisted of E0P verification.
The inspectors determined that the licensee reviewed the draft E0Ps to
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ensure applicable generic and plant specific technical information was I
incorporated.
The verification process consisted of the following:
an operations review, use of an E0P verification checklist, a tabletcp review, control room walk-throughs, and a safety evaluation conducted by the licensee's Safety Analysis Branch, and a Plant Operations Review Comittee (PORC) review.
The third step examined was the development of the licensee's E0P validation program, which assessed the control room operator's ability to manage emergency conditions using E0Ps.
The licensee's review consisted of observing operating crews exercise the E0Ps on the CE simulator at Windsor, Connecticut.
At the end of each E0P exercise, licensee coments on performance of the procedure were incorporated into the draft E0P procedure.
The fourth area examined was the development of the E0P training program.
The inspectors determined that the licensee required the operators to have a significant knowledge level to implement a specific E0P. The training program had four major cbjectives. The four objectives were to enable the operator to understand the structure and format of all E0Ps, to enable the operator to understand the technical basis of all E0Ps, to ensure all safety functions for E0Ps have been satisfied, and to provide operator experience in using all E0Ps under simulhted control room condition _. _ - _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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The inspector had no additional corrents in regard to the methods the licensee had implemented to incorporate generic guidelines into specific E0Ps.
No violations or deviations were identified.
3.
Independent Technical Adequacy Review of the E0Ps (25592)
The Millstone 2 E0Ps listed in Part I, Appendix I, were reviewed to ensure that the procedures were technically adequate and accurately incorporated the guidelines of the CEOG CEN-152. This review verified that the vender step sequence was followed, the exit / entry points were correct, transfer between procedures was well defined and appropriate for procedures perferned concurrently, that ninimum staffing was met, and that notes and cautions were used correctly. Each deviation from the CEN-152 was reviewed to ensure that safety significant deviations were reported to the
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NRC as required, safety evaluations were perforned per 10 CFR 50.59, all deviations warranted by the specific plant design were incerporated, and prioritization of accident mitigation strategies were correct. Adverse containment values were also verified to be present in the procedures.
The team determined that, in general, the E0Ps accurately incorporated the procedure guidelines of CEN-152 and were technically adequate. This determination was based on the following findings observed during the review of the Millstone 2 procedures:
The E0Ps generally followed the CEN-152 (Revision 2) step sequence
- ith detailed instructions for the operator actions required to cool
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down the plant or place the plant in a stable condition.
l Entry / exit points in the ECPs were clearly stated and could be
followed by trained reactor operators.
Notes and Cautions within the E0Ps were generally clear and were
appropriately located in the E0Ps.
The plant specific values were consistent with the plant design.
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The CEN-152 prioritization of the accident safety function hierarchy
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I was maintained in the E0Ps.
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During the course of the E0P review, however, the tean identified a r.uitber of technical concerns in the Millstone 2 E0Ps and they are listed along with the licensee's responses in Appendix II of this report. The ccreerns i
nainly focus on two areas:
(a) additions or onissions of major steps l
specified in the CEN-152 guideline without providing documentation for the technical basis to justify the additions or the omissions; (b) deviations from the suggested procedural steps listed in CEN-152 without providir.g
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technical basis or justification for the alternative sters contained
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within the plant-specific EOFs.
In response, the licensee either provided i
clarification of the deviations from CEN-152, or acknowledged the I
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technical deficiencies identified by the inspection team, and agreed to correct the E0Ps as required to be consistent with CEN-152 in the next revision of the lii11 stone 2 E0Ps. The team determined that the resolutions presented by the licensee were acceptable.
The team determined that the following deficiencies as discussed in Appendix !! of this report may impair the effectiveness of the safety function controls and require correctiun in the next revision of the E0Ps.
The E0Ps, except for RCP operation in the functional recovery E0Ps,
contain a deficiency in the identification of RCP NPSH requirements.
CEN-152 specifies a NPSH curve in the figure titled, "typical post-accident pressure-tenperatures limits," which is included in many sections of the CEN-152 guidelines.
Instead, the licensee used a 30*F subcooled margin pressure-temperature curve as acceptance criteria for operation of two RCPs. The team compared the required minimum NPSH curve with the 30'T subcooled margin curve, and determined that use of the 30*F subcooled margin curve to operate the two RCPs is only adequate for RCS temperatures greater than approximately 480'F, where the RCS pressure is greater than the RCP NPSH pressure requirenents. For RCS coolant temperatures less than 480*F, the pressure for the 30*F subcooling margin is less than pressure required to satisfy the RCP NPSH requirerents. Thus, use of the 30*F subcooled rargin pressure-temperature curve to operate the two RCPs may result in damage to the RCPs below 480'F, and in turn, l
degrade the post-accident RCS heat removal capability of the plent.
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The licensee agreed to evaluate the use of a caution or otherwise clarify the proper temperature band for utilizing the 30'F thumb rule for the NPSH requirer,ents of the RCP.
Resolution of this deficiency will be followed up in a subsequent inspecticn. (50-336/88-10-01).
E0P 2532 does not include a procedural step to eliminate the RCS
voiding in the SG tubes, while step 41.d of the LOCA procedure in section 5.0 of CEN-152 specifically includes guidelines to elimirate voiding in the RCS SG tube side. 0 mission of this step may impair
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the effectiveness of the plant safety functions to cooldown the plant or bring the plant into stahle conditions. The san,e deficiency was
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also noted in the Steam Generator Tube Rupture (SGTR) procedure.
E0P 2534. CEN-152, Section 6.0, Steps 34 and 35.d identify the CEOG l
guidance for the SGTR event which will eliminate the voiding.
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The above noted deficiency is a deviation (50-336/88-10-02) from the licensee's comitments to CEN-152.
l 4.
Review of Validation ProgrF n d I N ependent Verification
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of the E0Ps (25592)_
As a result of the THI-2 Accident, NUREG-0899 was issued in Auoust 1982 to establish the guidelines for the development and implementation of E0Ps which would provide the operaters with directions to nitigate the consequences of a broad range of accidents and equipment failures.
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Paragraph 3.3.5 of this NUREG stated that, after development, the E0Ps were to undergo a arocess of verification / validation to determine that the procedures are tecinically adequate, address'noth technical and human factors issues, and can be accurately and efficiently carried out.
t The licensee srovidsd documentation to show that their verification program not t1e following purposes:
to confirm the correctness of the procedures;toensurethatEPGandplantspecifictechnicalguidancewas properly incorporated into the E0Ps and to verify that appl.cetion of luman factors aspects had been addressed.
The licensee's verification program contained the following elements:
Old E0P to new E0P comparison.
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EPG to new E0P comparison.
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New E0P compliance with the Writer's Guide.
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Operations review.
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Table top review.
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Control Room Walk-through.
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PORC review and approval.
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NUSCO Safety Analysis Branch review.
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The itcensee also provided documentation to demonstrate that the validation program assured that the actions specified in the new E0Ps
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could be used by the operators to manage energency conditions effectively.
l The two eierents of the validation program were:
Three 2-day sessions at the CE simulator in Windsor Locks in i
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mid-1983.
The E0P project team observed accident scenarios for each
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draft E0P, provided corrents, and the proposed changes where
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appropriate.
Eleven 1-week sessions were held in late 1983 to accomplish final r
simulator validatien and operator training.
Each licensed operator
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performed some role in each E0P to assure that they could effectively manage emergency conditions. Coments from these scenarios were incorporated in the final version of the new E0Ps.
The inspection team conducted its own control room, simulator, and plant f
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walkdewns of the E0Ps listed in Part A of Appendix I of this report to ensure that the procedures were validated and verified by the licensee.
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During the walkdown, instruments and controls were verified to be i
correctly labeled (except for those deficiencies indicated in f
Appendices III and IV). The tean also verified that indications l
referenced in the procedures were available to the operator and values j
were not too specific for the indicators available. Administrative
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procedures were reviewed to ensure that adequate controls existed to j
incorporate changes to the E0Ps, that the latest revision was available to
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the operators, and that they were easily accessible.
Documentation of the licensee's validation and verification program was reviewed to ensure discrepancies noted were adequately addressed and corrected, cortprehensive reviews were ccnducted, table top reviews were adequate, walkdowns were completed and documented, and that human factors analyses were incorporated in the program.
During the performance of one of the simulator scenarios, the team identified several deficiencies with the use of the SPDS by a reacter operator during the perfornance of E0P 2540.
The inspectors noted that in five instances the SPDS, which is used in place of Form 2540-1
"Functional Pecovery Safety function Status Check (list)," was in
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disagreement with Form 2540-1 (Form 2540-1 is used only when the SPDS is I
l not available). The five technical deficiencies, which were identified by the NRC were:
(1) Sump Recirculation Actuation Signal (SRAS), which was used as one of the elements to satisfy the acceptance criteria in the Pressure and Heat Removel safety functions in the SPDS, was not included in Form 2540-1 for these safety functions; (2) the containment pressure
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parameter listed in Condition 1 of the Containment Integrity safety function of the SPDS was listed as 5 PSIG, which is in disagreement with
the value of 2 PSIG contained in Form 2540-1; (3) the containment hydrogen concentration parameter listed in Conditions 1 and 2 of the Centainment Integrity safety function was listed as 3%, which was in disagreement with
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the value of 2% contained in Form 2540-1; (4) the feedwater parameter listed in Condition 1 of the Heat Removal safety function lists both main and auxiliary feedwater flow, and also provides a r;inimum acceptable value of 300 GPH for auxiliary feedwater flow, this was % disagreement with the description contained in Form 2540-1, which provided n0 guidance on the amount or type of feedwater flow for the acceptable conc.4 tion; (5) the P.KST liquid level parameter when listed as an eierent for evaluation of i
acceptable ecoditions in the safety functions, was listed in a different logic format (with a different numerical value in some cases) in the
SPDS, than that in Form 2540-1.
The licensee agreed to evaluate each of i
these five concerns and to revise either the SPDS, or the Form 2540-1 as appropriate, to have the two systems in agreement with one another.
This iten will be followed up during a future inspection (50-336/88-10-03).
l The inspcetion team determined, based on the observations of the use of the SPDS that the SPDS would be an excellent tool in assisting the reactor cperators in mitigating the consequences of a design base accident. The reactor operators were able to monitor the status of the six safety functions on a continuous basis, rather than at ten minute intervals, as recommended in the generic guidance of CEN-152. The SPDS provided a visual alarm indication on the visual computer display, and also provided
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a continuous status of plant parameters and safety equipment, which were
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the elements used to determine if a safety fur.ction was currently in a satisfactory condition for the mitigation of an accident.
Based on interviews with the SPDS ccgnizant engineers, and the above noted cbservations, the tean indicated to the licensee that the fli11 stone plant
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staff had exceeded the flRC requirerents in this area and that it was recognized that considerable effort was expended in developing the SPDS to its current capability.
In addition, the inspectors, during the control room, simulator, and in-plant walkdowns, identified other deficiencies as listed in Appendix IV.
The licensee comitted to make the appropriate procedure revisions as noted in Appendix IV. The licensee's revision of the E0Ps and associated documentation for the correction of the noted procedural deficiencies will be followed up in a later inspection (50-336/88-10-04).
No violations or deviations were identified in this area.
5.
E0P Training (25592)
The inspectors assessed the adequacy of the E0P training by reviewing three areas. The first dealt with observing two unrehearsed operatine crews performing the E0Ps on the site-specific simulator with scenarios designed to exercise each of the E0Ps. The second effort was to review the lesson plans and training records for the het licensed and requalif W u an operator training programs as it pertained to E0P training.
Fsnally, interviews were conducted of a selected sample of the cperatiens staff, a.
Simulator Scenarios The team's liccrse operator examiner and reactor inspector developed scenarios similar to those used for licensed operator exams and the facility's E0P training. During the performance of these scenarios with the unrehearsed eperating crew, the entire NRC E0P inspection team had the opportunity to:
observe operator performance to validate er dismiss any concerns that may have been raised during the hRC table-tcp reviews of the E0Ps; assess the licensee's operating philosophy (possibly as it differs fron CEOG guidance in CEN 152);
assess the human facters elements (place keeping, assignment of duties, physical interference, etc.) associated with the performance of the procedures in a "real tine" atmosphers, and observe how the l
cperators diagnose accident conditions and transition from ene E0P to another.
The tean made the following observations:
the operators exhibited adequate knowledge of the E0Ps and the
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CEN-152 guidance.
the operators used the SPDS to verify the safety functions
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status check in lieu of the approved OPS Form 2540-1 contained in the E0Ps.
See section 4 of this report for additional infernation concerning the SPDS.
Other human Factors observations are addressed in Section 7
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and Appendix III of this report.
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Formal Training Programs Lesson plans and simulator scenarios used for E0P training were reviewed to determine whether the training covered the technical basis for the procedere as well as the structure and fornat. The lesson plans, procedures and material reviewed are listed in Part !!!
of Appendix !!. This review included a review of attendance sheets for selected lesson plans, and a review of how the licensee handled makeup training for those who miss the normally scheduled training.
The training program met, or in seme areas exceeded, the requirements as comitted to by the licensee, c.
Operater Intervicws Operators were interviewed to determine their understanding of the E0Ps and their respersibilities and required acticos, both individually and as a tean. Additionally, operators were interviewed to determine if they felt that actions were duplicated by other operators, thht they were knowledgeable of the requirements for transitioning from one procedure to another, and that training was conducted on revised E0Ps before they were irplemented.
Four training issues were expressed by operators during the interviews. One operator comented that the simulator training did not include the realism that accompanies a reactor trip.
The reactor trip?, in the simulator were relatively straightforward, without maw inter uptions.
In contrast, reactor trips in the control rocm are matted by increased noise and stress levels due to
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the presence of acoitional versonnel and phone calls.
A sinilar concern voiced during an interview was that STAS are not included in the simulatar training of the shift supervisor (SS).
Since these two Operators would work closely together following a trip, especially if an energency was evolved, it would seem beneficial to include botn in simulator training.
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Consistent with the foregoing, plant equipment operators (PEOs)
shculd also be required to simulate their E0P-related actions out in the plant. Stress levels, time limitations, and other environmental conditions (e.g., noise) should be simulated to the extent possible.
Those conditions that could not be sinulated would be incorporated into the PE0's role-playing of the scenario.
Also identified in operator interviews was the need to require traineet to use placekeeping techniques of checkoff spaces provided in docuu nts. This is especially critical when using E0Ps, since the cperators must monitor nany parareters simultareously.
If operators
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were required to use checkoff spaces during training, the behavior would become a natter of habit. Other placekeeping methods should also be exercised during simulator training.
No violations or deviations were identified in this area.
6.
On-going Evaluation of E0Ps Administrative procedures (listed in Part D of Appendix !) were reviewed to ensure that the licensee had an effective program in place to maintain the E0Ps up to date and provide feedback from operator experience, simulator exercises, control room / plant walkthroughs, and plant design changes.
These administrative procedures contained forms for the user to fill out describing the proposed change, identifying the change by a specific number, and providing justification for the change.
Several of these completed forms were reviewed by the inspector and found to be satisfactory.
I:o violations or deviations were identified in this area.
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Human Factors Analysis of E0Ps (25592)
An integral part of the E0P inspection effort was to identify human factors consideraticns in the implementation of Millstone 2 E0Ps. The human factors review covered a number of domains including analysis of the procedures, observations of instruments in the control room required for E0Ps, observations of instruments outside the control room required i
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for E0Ps, and environmental factors. The data were obtained via several methods:
Table-top review of the E0Ps.
- Table-top review of the Writer' Guide.
- Walkthrcughs of the Unit 2 control room.
- Walkthroughs of the Unit 2 plant.
- Observation of simulator scenarios.
- Interviews with operators.
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The findings are categorized below by area of concern.
Examples are
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previded in Appendix III.
l a.
Writer's Guide A number of human factors concerns pertaining to the Writer's Guide were raised. Some concerns were noted in the lack of guidance provided by the Writer's Guide, others pertained to inconsistencies between the Writer's Guide and the E0Ps. The concerns included:
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Lack of guidance in the Writer's Guide on the location of E0P identification information, e.g., procedure number, revision, page number.
2.
The Writer's Guide does not include guidance on the provision of checkoff spaces for substeps.
3.
Definitions for the verbs, such as "verify," "refer," and
"consider" were not clearly defined in the Writer's Guide.
4.
Vague terminology, such as "excessive" is used, rather than a numerical limit, as stated in the Writer's Guide (page 5).
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Wording and structure of steps is unclear and awkward.
6.
Inconsistencies in fornat were noted. These inconsistencies included spacing between steps, use of emphasis, and punctuation.
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Notes were not highlighted by a berder or additional space between the Hote and the steps.
In addition, the different functions of Cautions and Notes were not always clear.
B.
Steps for which the sequence of performance was not mandatory were not identified as such, b.
Control Room The following cencerns were identified in the control room:
1.
The absence of grouping for acceptance criteria in Safety function Status check sheets, and cf logic statements in the Safety Parameter Display System check sheets, nade the appropriate interpretation more difficult.
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Many inconsistencies were noted between the written Safety function Status Check sheets and the SPDS.
3.
Several labeling concerns were identified, many of which had been identified by the licensee during the Detailed Control Room Design Review (DCRDR) and were already scheduled to be corrected. The concerns are as follows:
a.
Labeling of parels and components was difficult to read, b.
Three out of four steam generator gauges had scales which were difficult to rea _
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Extraneous labels, for example, manufacturer names, and markings were noted on panels and instrumentation.
4.
The followtiig concerns were noted with procedure revisions:
a.
E0P 2540, Revision 4 was in the C-10 Equipment Locker; the current revision in the control room is Revision 5.
The licensee agreed to investigate and correct this problem, b.
Handwritten changes were noted in E0Ps and ops.
c.
Changes documented on the "Change Form" were not also documented within the procedure. Thus, if the cperator did not remember to look at the form at the appropriate step, revisions would be overlooked.
c.
Simulator Scentrios The inspectier.te.am observed two different shifts (Shift 1 and Shift 2) perform va"tous scenarios on the simulator. The following concerns were identified:
1.
Training:
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The comunication within Shift 1 was infrequent and as a resul? the Supervising Control Operator did not always have the in'ormation he needed, b.
Although the E0Ps have checkoff spaces for major steps, operators were not accustomed to using them. The team osserved placekeeping difficulties during the scenarios.
2.
Lack of table sp0ce to lay down procedures which resulted in several documents piling up on top of each other.
3.
Figures are difficult to use because the gridmarks are too salient.
4.
Pental calculation of ecolant delta-T and shutdown margin are required.
d.
Local Control Stations The following concerns are identified during the execution of local E0P actions:
1.
Unavailability of support equipment.
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Unavailability of an additional set of procedures needed to complete local actions.
The Plant Equipment Operator (PEO) had to either take the control room operator's copy with him, or make a copy of it in the control room.
3.
Atmospheric steam dump valves are difficult to locate and access because they are 15 to 20 feet above the ground.
If both valves need to be operated simultaneously, two PE0s would be required.
In addition, comunication is difficult due to noise produced by the steam.
4.
The hydrogen analyzer is difficult to access due to the out-of-service gauges located underneath it.
In addition, the labeling was handwritten and faded.
5.
Potential for operator exposure to high radiation levels in the safeguards room, auxiliary building and enclosure building.
6.
Extension cords used with headphones interfere with the PE0 carrying out his task.
They may get tangled in ladders or operators may trip over them.
7.
Component location information is needed for local actions in the ops.
8.
l.ocal in-plant and control room actions were not identified as such.
Additional hun.an factors items are addressed in Appendix III of this report. The licensee agreed to review and evaluate these itens for possible irgrovements. The above items will be reviewed in a future inspection.
(50-336/88-10-05)
8.
Exit Interview The inspection scope and findings were sumarized on May 17, 1980 with those persons indicated in paragraph 1 at the conclusion of the inspection. The inspector sumarized the purpose and scope of the inspection and the findings. At no time during this inspection was written material provided by the inspectors to the licensee.
The Itcensee did not identify as proprietary any of the material provided to or reviewed by the inspectors during this inspectio _ _ _ _ _ _ _ _
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APPENDIX I LIST OF PROCEDURES REVIEWED A.
E0P REVIEWED ON TABLE TOP, ON $1HULATOR, AND DURING PLANT WALK 0nWN 1.
E0P-2525 (Revision 2): Standard Post-Trip Actions 2.
E0P-2526 (Revision 1): Reactor Trip Recovery 3.
E0P-25?! (Revision 1): Electrical Emergency 4.
E0P-2532 (Revision 3): Loss of Coolant Accident 5.
E0P-2534 (Revision 4): Steam Generator Tube Rupture 6.
E0P-2536 (Revision 3):
Excess Steam Demand 7.
E0P-2537 (Revision 3): Loss of Feed 8.
E0P-2540 (Revision 5): Functional Recovery 9.
E0P-2540A(Revision 1): Functional Recovery of Reactivity Control 10.
E0P-2540B(Revision 1): Functional Recovery of Maintenance of Vital Auxiliaries (AC and DC Power)
11. E0P-2540C(Revision 1): Functional Recovery of RCS Inventory and Pressure 12. E0P-2540D(Revision 2): Functional Recovery of Heat Removal 13. E0P-2540E(Revision 2): Functional Recovery of Containment Integrity B.
PROCED' IRES REVIEWED WHICH WERE REFERENCED IN E0PS 1.
MS-2-AOP 2553 (Revision 2):
Plant Cooldown Using Natural Circulation 2.
MS-2-0P 2207 (Revision 8):
Plant Cooldown 3.
MS-2-OP 2301C(Revision 8): RCP Operation l
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MS-2-OP 2309 (Revision 4):
Containment Spray Systen i
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MS-2-0P 2310 (Revision 9):
Shutdown Cooling Systen 6.
MS-2-OP 2313A(Revision 5): Air Recirculation and Cooling System 7.
MS-2-0P 2313C(Revision 8):
Containment Post-Trip Incident Hydrogen Control
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8.
MS-2-CP 2319B(Revision 7):
Cendensate Storage / Surge System
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MS-2-OP 2322 (Revision 8):
Auxiliary Feedwater System 10. MS-2-OP 2398 (Revision 8):
RC Vent Procedure C.
E0P TRAINING f%TERIAL AND LESSON PLANS REVIEWED 1.
NUCLEAR TRAINING MANUALS a.
NTH-3.054 Licensed Operator Recualification Training b.
NTH-3.051 Licensed Operator Initial Trainine c.
ACP-QA-8.08 Hillstone Reactor Operator Training Program d.
ACP-8.09 H111 stone Licensed Operator Requalification Fregram 2.
CLASSR00H PRESENTATIONS
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a.
M2-0P-RO-TA-2026 Mitigating Core Damage b.
H2-0P-RO-TA-2525/6 Introduction to Etergency Oper,',ing Procedures
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H2-0P-REQ-EOP-2500 Trip 2/ Leave 2 Basis 3.
$1HULATOR BRIEFING R00H SESSIONS a.
R02-28(B)
Electrical Emergency b.
R02-29A(B)
Loss of Primary Coolant c.
R02-29B(B)
Steam Generator Tube Rupture d.
R02-29C(b)
Excess Steam Demand e.
R02-29D(B)
R02-31(D)
Loss of Feedwater/ Functional Recovery g.
R02-34(B)
Key Parameters and Trends h.
R02-35(B1 Diagnostic Skills & Thought Processes 1.
R02-39(B)
General Operating Skills J.
R02-40(B)
Therro/ Accident Assessment /E Plan k.
SR2-11(B)
SPTA & TR
$1MULATOR LESSON PLANS a.
R02-28(S)
Electrical Emergencies b.
R02-29(S)
c.
R02-30(S)
R02-31(S)
LOAF / Functional Recovery e.
R02-32(S)
Ernergency Exercises
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R02-36(S)
Operational Exercise g.
R02-38(S)
Operational Exercise h.
RQ2-500-1 Trip Two/ Leave Two Strategy
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1.
RQ2-525-1(S)
Failure of Auto Trip j.
RQ2-525-2 E0P 2525 Review k.
RQ2-532-1(S)
Loss of Reactor Coolant Saturated Conditions 1.
RQ2-536-1(S)
Steam Line Break m.
R02-536-2(S)
Steam Leak in Turbine Building n.
RQ2-537-1(S)
Feed Water Leak Inside Containment o.
RQ2-537-1(S)
Loss of All Feedwater p.
RQ2-537-2(S)
Less of All Feedwater i
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RQ2-537-3(S)
Loss of All Feedwater l
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RQ2-569-1(S)
Steam Generator Tube Leak s.
RQ2-800-5 In House Electrical D.
PGP ADMIN!$TRATIVE VALIDATION AND VERIFICATION PROCEDURES REVIEWED OTBI-6, Revision 1 Operator Training Branch Instruction Operating Plant Procedure Change ACP-QA-3.02A Writer's Guide for Hillstone Procedure ACP-QA-3.02 Station Procedures and Forms ACP-QA-3.10 Preparation, Review and Disposition of Plant Design Change Records (NEO 3.03)
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OP-2253 Biannual Procedure Review Rules 2-0PS-3.08 Emergency Operating Procedures Writer's
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Guide Letter from Counsil NE E0P Procedures Generation Package to Miller NRR date 1/30/85 Millstone II, Supplement 1 to NCREG-0737, Attachment 1 l
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APPENDIX II TECHNICAL REVIEW C0liMENTS The following are inspector comments as a result of the technical revicws of the Millstone ? E0Ps.
The licensee either clarified the concerns to the inspector's satisfaction or cemitted to correct the deficiencies in the revised E0Ps. Section 3 of this report provides further discussions regarding these issues.
1.
MS-2-E0P-2525 (Revision 2):
STANDARD POST-ACTION TRIPS a.
A note prior to step 3.1 specified boration time: for each CEA not fully inserted, the boration time was 12, 18, and 36 minutes for boration with 3, 2 and 1 charging pumps, respectively.
In response to the concera regarding lack of technical basis, the licensee stated that, the criteria to determine the boration time was to satisfy the shu fown margins in the Technical Specifications. The calculational results were documented in 2-ENG-012, dated 8/18/77. The inspector determined the technical basis was adequato.
b.
Step 3.3.d, contingency action used the 30-degree F subcooled pressure-temperature curve to trip the last two RCPs.
CEN-152 specified NPSH requirements for the RCP operation. A NPSH curve in the figure titled "typical post-accident pressure temperature limits" was included in many sections of the guidelines. The inspector found that the use of 30'F subcooled margin cu,ve to trip the last two RCPs is adequate only for the temperatures greater than or equal to 480*F since in this temperature ange, the 30*F subcooled pressure is greater than the NPSH requirements. Use of 30*F subcooled pressure to trip the last two RCPs for temperature less than 480'F may darege the RCP and, in turn, degrade the safety function of removing the RCS heat. The licensee comitted to corrr. this deficiency to be consistent with the CEN-152 NPSH requirements in the next revision, c.
Contingency action of step 3.3(b) specified a preference to trip B and D RCPs instead of A and C.
This is a plant specific operator action. However, no technical basis was provided.
In respense, the licensee stated that based on the start-up testing data, certain combinations were found to provide a greater spray flow. The startup test data showed that for operatien with one pump operational in each loop, B and D RCPs provided the largest spray flow.
Therefore, RCPs D and D were tripped if the spray flow was excessive. The inspector l
determined the technical basis was adequate.
d.
A note prior to step 3.1.6 specifies a delay time of 3 minutes 25 seconds for Automatic initiation of Auxiliery feedwater. The licensee was requested to provide the technical basis for the specific delay time.
In response, the licensee stated that the technical basis, per PDCR 2-182-79, is to ensure that (1) the peak containment pressure and teroperature do not exceed design values and, (2) the core performance satisfies the safety criteria.
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inspector found that the technical basis for the specific delay time
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2.
E0P 2532: LOCA a.
Entry condition.
CEN-152 (Revision 2) listed high quench tank level temperature and pressure as entry conditions for LOCA events.
E0P 2532 did not include these entry conditions. The licensee was requested to provide the justification for the deviation from CEN-152. They responded that the quench tank parameters were not unique enough to conclude that a LOCA had occurred.
For example, any high pressure trip events will lift PORVs and elevate quench tank parameters. The inspector found the omission of entry conditinns for the quench tank for LOCA events was adequate.
b.
Steps 3.6 and 3.7 addressed containment integrity items, v.t.ile step 3.8 addressed RCS inventory. This deviated from the safety function hierarchy in CEN-152, which addressed RCS inventory prior to containment integrity. The licensee responded that step 3.6 and 3.7 were action steps to verify the proper response of containment spray and Enclosed Building Filtration Actuation Slrstem (EBFAS) systems.
Safety functions were being continuously monitored by the SPDS in parallel with these steps which were part of the safety function status check.
The inspector found that even though the safety function hierarchy in E0P-2532 deviated from CEN-152, continuous check of the safety function status will appropriately direct the operator to mitigate the consequences of LOCA events.
c.
Step 3.21 did not address the voiding in the SG tube while step 41.d of CEN-152 addressed elimination of the voiding on the SG tube side.
Omission of removing steam voids from the SG tubes may impair the effectiveness of the safety functions to cool down the plant. The licensee comitted to add appropriate steps to be consistent with CEN-152 in order to address the concern for voiding en the SG tube side of the RCS.
3.
E0P 2525 ESD a.
The note between steps 3.11 and 3.12 should be a step. The licensee responded that the note did not contain an action. therefore, cannot be a step.
However, the note should be moved to precede step 3.11.
The licensee agreed to incorporate this correction into the next revision. The inspector found the response and corrective action adequat i
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APPENDIX III HUMAN FACTORS REVIEW COMMENTS The following coments resulted from the human factors review of the E0Ps. The licensee committed to review and correct these concerns where appropriate.
Several of the following items are identified in Section 7 of this report, however additional examples and details of noted concerns have been provided.
I.
Writer's Guide A.
Guidance Needed 1.
The Writer's Guide recommends that each page of an E0P be identified by procedure number, revirton number, and page number. liowever, no detail was provided on where such information should t,e positioned on each page. As a result, page identification is positioned at the bottom of each page, and is not errphasized in any way. Furthermore, the title of the E0P is not provided.
During simulator scenarios, the team observed the SCO turning to the E0P folder label for E0P identification. Consistent emphasis and formatting is needed.
2.
The rule requiring space for operator checkoff prior to each instruction step did not state that substeps should also have checkoff spaces. As a result, checkoff spaces were not provided in the E0Ps.
3.
The meaning of "verify" is unclear.
It could mean "to visually check" or "to perform."
Ic E0P ?.534, Step 3.20.a. it is not clear what actions are required by the term "verify." "Verify"
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is not defined in the Writer's Guide.
4.
The verbs "ensv e" and "monitor" are not clearly defiaed in the l
Writer's Guide. Two definitions v.ay be implied by the verb l
"ensure":
"to make certain," and "to take action." The verb l
"monitor" is defined in the Writer's Guide in three separate ways:
"Keep track of," "regulate," and "control."
Consequently, the use and interpretation of these verbs in the E0Ps may be inconsistent or incorrect.
B.
E0P Inconsistencies with Writer's Guide 1.
Numerical Limits a.
E0P 2525, Contingency Action (C.A.) 3.3.b.
"If main spray flow is excessite..." The te a "excessive" is not numerically defined.
b.
E0P 2532, Step 3.3.1. Step 3.18 should t,e referenced in Step 3.3.1 so that the operator has an easy method of determining safety injection termination criteri _ _ _ _ _ _ _ _ _ _ _ -
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c.
E0P 2540, Step 3.6.b.
"Steam generator level is 10-80% or there is adequate flow".
Tha term "adequate flow" is not numerically defined.
d.
E0P 2540, Safety Function Status Check, Heat Removal, Condition 1, Acceptance Criterion 4.b.iii.
"Adequate feed flow is not numerically defined.
2.
Clarify Concerns a.
E0P 2525, Contingency Action 3.3.c.iii, was too long and required either a coma or rewording.
b.
E0P 2525, Instruction 3.3.c should be reworded to eliminate the negative, c.
E0P 2525, Instruction 3.9 contains two actions and is very long.
d.
E0P 2525, Step 3.14.g.
The verb "closed" is at the end of the phrase and the operator must read the entire phrase before understanding it, e.
E0P 2525, C.A. 3.25.a.
This entire substep is confusing because it begins with "diagnose" and then directs the operator to the Break Identification Chart (1). A colon or "by:" at the end of "Diagr.ose event and go to the appropriate E0P" tay clarify this redundancy.
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EOF 2525, Step 3.17.c.i. & ii.
It is not clear whether
"return" and "control" are actico verbs, requiring the operator to do something, or passive verbs requiring the operator to check to ensure something actuated.
E0P 2',25, Step 3.14.
The initial statement,
"Establish...", is inccmplete; the instruction is unclear regarding what action is to be taken, and whether er not all substeps must be performed, h.
E0P 2525, C.A.3.17.d.
The word "all" is needed to clarify to the operator that all subsequent substeps must he performed. An action verb should also be included (e.g.,"
...by doing all the following:").
i.
E0P 2536, Step 3.24.
The step does not clearly state whether all four criteria must be met, nor is it clear whether the substeps are criteria or actions. Modifying the initial phrase to '.iclude "all" and "criteria" would help resolve this issue.
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E0P 2525, C.A.3.17.
Grouping a. (i. and 11) separately from b. would facilitate the interpretation of "and" and
"or".
Boxes, brackets, or some other technique could be used for this purpose.
k.
E0P 2540, SFSC, Pege 6 of 13. Acceptance Criteria 4.b.i-111. Subitems i and 11 should be combined into a single substep; and the "and" between 11 and iii should be replaced by "or".
The corresponding parameter column should be changed to reflect this. The licensee has agreed to evaluate the need for this change.
1.
Only two typographical errors were found, however, one was extremely critical. E0P 2534, SFSC, 3 age 2 of 10, Condition 2 Acceptance Criterion 1.).1, "level creasing...." The significance is that the omit'.ed letters ("in" or "de") completely change the crterion.
The licensee has agreed to correct this in the next revision of the E0Ps.
4.
Format a.
E0P 2525, Step 3.17.
The large amount of blank space following step b could mislead the operator into believing that he had completed this step, when in fact, it is continued with step c on the next page. Also, the word
"all" should appear in the initial phrase,
"...by all the following:."
b.
E0P 2M4 Page P.
All text ir, positioned in the upper
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third of tha page, followed by a large blank space. Since the procedure continues on page 9, a "(cont.)" or other
indication is necessary.
In addition, extra space between the headingt 2nd instruction steps would provide better visual bahance.
c.
E0P 2525, Page 15. Additional space should be added
between the headings and the instruction steps.
This modification helps separate and emphasize the headings.
d.
E0P 2525, Step 3.14.
Somt indication that substep g.
exists on the subsequent page is needed.
e.
E0P 2525, Page 10. Following the contingency actions, a
"cont."
or similar indication is needed to inform the operator that the procedure continues on the subsequent page. This example is especially critical because the last substep directs the 500 to consider using another E0P.
In rany cases, operators are referred to other E0Ps only at the end of the pro"dure which they are currently using.
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E0P 2534, Page 6.
C.A.3.9 on this page is too close to
"page 6".
Page identification should be clearly separated from the surrounding text.
g.
E0P 2536, Safety Function Status Check sheet (SFSC), Page 2 of 11. Acceptance criteria column is hard to follow because insufficient space (or other demarcation method)
exists between subitems.
E.g., between 11 and b.,
Condition 1 and between b.i and c., Condition 2.
1.
E0P 2540B.C,A,3.4 When the word "or" is surrounded by lengthy text, it is not imediately apparent.
In this step, for example, "or" supersedes the other logic terms because it defines the relationship between 1. and 11.
In cases such as these, additional space might be added above and below "or."
j.
E0P 2540, SFSC, Page 8 of 13. Acceptance Criteria 5.a.i-5.c.
These criteria are not ear.ly distinguishable form one another due to insufficie.. space (or grouping)
between subitems.
k.
E0P 2525, Step 3.3.c The **not" should be underlined, or
"not open" should be replaced with "closed."
E0P 2525, Caution, and E0P 2528, Caution.
"Slowly" sho(1d be emphasized with underlining, capitalization, or both,
m.
E0P 2525, C.A. 3.16.b.111. The second "override" thould be underlined for clarity.
n.
E0P 2525, Peges 3, 8 and 15. The "primary plant operator", "secondary plant operatnt" and 'SS/SC0" I
headings should be further emphasized.
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Colons to intrcduce actions would provide increased precision.
This applies to virtually all E0Ps.
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E0P 2525, C.A.3.3c.iii. 1his step needs punctuation as it is very long.
3.
Notes and Cautions a.
E0P 2528 Page 12, Note.
This note is en example that illustrates the need to further distinguish all notes.
They should be further separated from surrounding text by adding more space and either boxes or line *
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II. Control Room A.
Safety Parameter Display ^,ystem (SPDS)
The following discrepancies were found between written E0P Safety Function Status check sheets and the corresponding SPDS acceptance.
1.
E0P 2532, Containment Integrity. Written SFSC, Condition 2.b.ii indicates "less than 2%" vs. SPDS which indicates
"less than 3%."
2.
E0P 2532, Containment Integrity. Written SFSC, Condition 1.a. indicated "less than 2 psig", vs.
SPDS which indicates "less than 5 psig."
3.
E0P 2532, Vital Auxiliaries. Written SFSC, 6.q indicates
"greater than 90 psig" vs. SPDS which indicaf.ts "normal."
4.
E0P 2540, Reactivity Control. Written SFSC, Condition 3.4.d.i and 11, indicate "1. greater than 9.5% or ii.
If less than 6-9.5% than SRAS" vs. SPDS which indicated only "greater than 6%."
5.
E0P 2540 Heat Removal. Written SFSC, Condition 1.b.iii, indicated only "feed flow" vs. SPDS which indicates a minimum value of 300 gpm for Auxiliary Feed.
B.
Precedure Revisiens 1.
E0P 252'3, Step and Contingency Action 3.19.
"Change 1" was handwritten on an otherwise t, lank page that fol' owed the Change Fcrm. The hardwritten changes were almost illegible.
2.
E0P 25400 had a Change Form, followed by three handwritten changes that were very difficult to read. Furthernere, the stess to which they refered did not reference the Change Torm.
The operator would not be aware of the changes unler,s he remenbered to look back at the form.
III. Simulator Scenarios _
1.
In the LOCA scenario, the SPDS operator knew that the HPSI flow curve was being violated and mentioned this to the 500.
The SCO correctly increased HPSI flow, however the increase was insufficient and the SPDS operator did not relate this information to the SCO.
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In contrast, Shift 2 operators spontaneously provided relevant information to the SCO, and the SS requested information as well. The differences between shifts suggests that the importance of conninication may need to be stressed more in training.
2.
The team observed placekeeping difficulties during the scenarios. Operators used their fingers or lost their place.
Two operators were heard talking about how to record which steps had and had not been completed.
3.
Mental calculations are required for RCS delta-T and shutdown margin.
To calculate RCS delta-T operators had to either obtain two temperature (T) values on C04, and subtract them, or obtain wide-range i from the RPS panel which was some distance from C04.
In either case, the operators had to subtract the Ts mentally or on paper.
Both the location of the temperature gauges and the need for hand calculations increase the potential for operator error.
To calculate the shutdown margin, the SPDS operator had to locate a series of numerical values and transfer them to cceputation sheets, which then guided the o3erator's calculation. The entire calculation took a)out 10
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minutes, and required the operator's full attention as he
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was required to remerber how to perform the calculation.
The operator was unable to perform other tasks until he completed the shutdown margin calculation. The complexity of the calculation makes it highly prone to error, and the time taken to cortplete it is excessive.
IV. Local, Control Stations A.
Cfmpon'ent Location and Labeli_n3
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In many E0Ps, the locations (panel identification or "local")
of cited comnnnents were omitted. This was inconsistent with the prevailing format, which was to always identify corrponents locations.
Below are exampics:
1.
E0P 2534, C.A.3.9.
This step does not identify whether it is a local or control room action.
2.
E0P 2540A, Step 3.3.a.
"C02" should be added after "10%."
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E0P 2540A, Step 3.3.b Add "C02" after "2-CH-514."
4.
E0P 2540A, Step 3.3.e.ii.
"C01" should be added after
"open."
5.
E0P 25400, Step 3.2.b.viii.
No location information is provided.
6.
E0P 2540D, Step 3.4.d. 1-iv, and corresponding contingency actions. No location for cited components are provided.
7.
E0P 25400, Step 3.6.j 1-iii, and corresponding contingency action. Location of cited components is not identified.
S.
Several labels in local contr.1 stations were difficult to read due to small or handwritten labels.
In addition, some labels lacked needed information. For example, the
"emergency button" in the diesel room has no label indicating whether the button starts or stops the diesel.
The licensee stated that new labels for plant components had been ordered to replace the old one,
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APPENDIX IV VERIFICATION / VALIDATION REVIElf COMMENTS Specific coments on the control room walkdowns and the review of the verification and validation programs are provided below. The licensee cennitted to correct these weaknesses or review specific steps for potential changes.
Section 6 of this report provides further discussions regarding verification and validation.
1.
GENERAL LABELING a.
SGFP reset push buttons are difficult to read.
b.
HPSI to charging pump cross tie valve 2-SI-440 does not have a label.
c.
RCP purrp designation is hard to read on the label, d.
LPSI valves 2S1 635 & 2S1-645 breakers are labeled HPST.
The licensee states that the DCRDR modifications will include improved (and corrected) labels.
2.
E0P 2525 SPTA Sixteen of the scales on control room instrurrents (C05) that are used to read SG pressure and level are faded and cust be read at close range.
The licensee stated that this will be corrected as part of the DCRDR work.
3.
E0P 2532 LOCA a.
Control Board Locations.
(1) Step 3.9.6 indicated the acoustic monitor alarm location on panel C02, and should also specify panel RC 05E.
(2)
Step 3.15d notes that T Hot indication is located on panel C03; and it should also state that T Hot can be read on panel C101.
The licensee agreed to include these changes in the next revisions of the E0P.
(b) Safety Function Status Check.
Several discrepancies exist between the safety function statur check sheets and the SPDS. (Discussed in Section 4 of this report and Section 7.)
4.
E0P 2534 SGTR a.
Step 3.20 should include the statement "RCS cooldown to cold shutdown using forced circulation" The licensee will evaluate ard consider changing this during the next revision, b.
Step 3.20a These action substeps should be done for both the primary step or the contingency step.
The licensee will evaluate and consider changes during the next revisio Y
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c.
Step 3.24 The caution before this step should contain a statement to check the main steam line radiation monitors before sending the Plant Equipment Operator (PEO) to complete the local operation, d.
Step 3.24.a.ii and iii Sub step iii should be completed before substep 11 in order to reduce the potential exposure to the PE0 when he adjusts the blowdown flow.
The licensee indicated that they would rework Step 3.24 to include the needed changes.
5.
E0P 2540E Functional Recovery-Containment a.
Step 3.1.a.iii Place Hydrogen monitor in service per OP 2313C.
During the walkdown of OP 2313C the following deficiencies were identified.
(1)
The operator could not find the temperature indication for the cabinet (which is to be verified to be 100*F).
(2) Gauges and valves were not marked very c1carly and the operator had to crawl in the cabinet to identify valves and gauges.
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(3) Only the zero hydrogen gas was hookup up with a regulator and tubing to the analyzer.
The calibration gas bottle with hydrogen was in the bottle rack, but there was no regulator or tubing connecting it to the analyzer.
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b.
Step 3.3 This step needs to include actions to help the operator
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recover the containment temperature when it is out of specifications.
The licensee will (svaluate and consider changes upon incorporation of CEN 152, Revision 3.
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