IR 05000344/1988044
| ML20206F262 | |
| Person / Time | |
|---|---|
| Site: | Trojan File:Portland General Electric icon.png |
| Issue date: | 10/25/1988 |
| From: | Mendonca M, Obrien J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20206F254 | List: |
| References | |
| 50-344-88-44-MM, NUDOCS 8811210065 | |
| Download: ML20206F262 (5) | |
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I U. S. NUCLEAR REGULATORY COMMISSION
REGION V
i Report No.
50-344/88-44 Docket No.
50-344 License No.
NPF-1 l
Licensee-Portland General Electric Company
121 Salmon Street Portland, Oregon 97204 Facility Name: Trojan Nuclear Plant
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Inspection at: Portland Gen ral Electric Headquarters Offices, Portland,.
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N Report Prepared by:
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Date Signed
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'O r1e, y oject Inspector Approved by:
For
/O-Zf-d M. f'. Mend 6nca,' Chief Date Signed
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Reactor Projects Section 1 t
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Meeting Summary:
Meeting on October 7, 1988 (Meetina Report No. 50-344/88-44)
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A management meeting was held in the PGE Portland Office on October 7,1988 to discuss NRC concerns developed as a result of the September 1988 reactor trip and subsequent forced outage activities.
Concerns were raised regarding i
control of locked valves, adequacy of procedures / instructions and pre-evolution briefings, personnel performance errors and attention to t
procedures, root cause evaluations, and Quality Assurance effectiveness.
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During the meeting, the PGE staff presented the status of aspects of their
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action plan to address lessons learned from the forced outage.
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DETAILS
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Meeting Attendees a.
Licensee Attendees D. W. r,ockfield, Vice President, Nuclear D. K. Carboneau, Vice President, Generating Division C. A. Olmstead, Plant General Manager L. W. Erickson, Manager, Nuclear Quality Assurance T. D. Walt, Manager, Nuclear Safety and Regulation R. P. Schmitt, Manager, Operations and Maintenance D. L. Bennett, Branch Manager, Maintenance J. M. Anderson, Manager Trojan Materials T. O. Meek, Branch Manager, Radiation Protection C. M. Dieterle. Supervising Engineer, Nuclear Plant Engineering R. E. Fowler Supervisor, Maintenance Support J. A. Russell, Supervisor Quality Audit P. A. Morton, Branch Manager, Plant Systems Engineering M. h. Snook, Branch Manager. Quality Support Services D. D. Wheeler, Branch Manager, Quality Inspections T. L. Warnick, Engineering Supervisor, Plant Modifications E. Peterson, Supervisor, Mechanical Maintenance S. E. Hoag, Manager, Trojan Programs C. A. Bauer, Manager, Nuclear Regulation Branch D. L. Nordstrom, Nuclear Engineer, Nuclear Safety and Regula W n b.
NRC Attendees B. H. Faulkenberry, Deputy Regional Administrator, Region V A. E. Chaffee, Deputy Director, Reactor Safety and Projects J. P. O'Brien, Project Inspector G. Y. Suh, Resident Inspector c.
State of Oregon Attendees H. F. Moomey, Oregon Department of Enargy 2.
Details of Management Meeting
'After the completion of the Maintenance Team Inspection exit meeting, Mr. Faulkenberry opened the management meeting by recognizing the value of NRC-licensee informational meetings. He stated that the purpose of the meeting was to review three principal items of concern following the most recent reactor trips and the September 1988 forced outage. The concerns were outlined as follows:
The apparent inadequacies of the Trojan Locked Valve Program.
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The inadequacy of procedures / instructions and inadequate pre-work
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The apparent problem of people not thinking sufficiently about what
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they are doing, and proceeding in the face of uncertainty.
He further indicated that if time allowed, he would like to discuss two other issues:
Root Cause and Problem Identification Program and examples of
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lingering resolution of these problems.
The effectiveness of the quality assurance organization,
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i Mr. Faulkenberry then led the discussion to the first issue, and outlined i
two recent instances of poor locked valve control:
Service water system valve (SW-237), which is the supply to a Safety
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injection pump lube oil cooler, which was required to be open, was
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recently found shut.
However, it was verified to be open by a two man verification crew in May and June of 1988.
A main steam line drain (MS-16), that was required to be shut, was
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found to be open about five turns after being verified closed by a two man verification team.
Mr. Faulkenberry commented that these instances initially appeared to be
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irdicative of a deficient independent verification program, but instead may reflect a locked valve program deficiency. Based on available
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information, it was unclear which issue had led to the observed incorrect i
valve positions.
Mr. Olmstead noted that PGE is planning the use of a seal program to supplement the locked valve program, such that tampering with selected r
valves would be detected.
In addition, he noted that they have reviewed the existing programs and known work activities and found no reason why
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the service water valve was out of position. He outlined that the clam
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fouling inspections have recently resulted in valve manipulations and non-normal valve lineups. Mr. Cockfield commented that it appeared the improper position of MS-16 was due to operator error.
The valve operator was subsequently found to bind as the valve closed, and it appeared that
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the operators erroneously thought the valve was closed.
Repair of the j
valve operator was being evaluated, as well as relocation of the pressure gauge which had led to manipulation of valve MS-16.
Mr. Faulkenberry suggested that PGE consider:
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Reviewing the verification systems to ensure they are sound.
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Examining the plant for those valves that are difficult for the l
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operators to manipulate, and installing valve position indicators
for manual valves where appropriate.
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Mr. Faulkenberry then discussed his observations concerning inadequate i
work instructions and personnel performance errors.
He cited the example
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of the overtemperature delta temperature reactor trip on September 16,
i 1488, wherein a technician tripped the wrong bistable because the work
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instruction had directed the technician to the wrong instrument channel rack. A further example was the September 19, 1988, depressurization transient in which the operator was directed by procedure to select as the controlling channel the pressurizer pressure instrument that was to be removed from service by that procedure (PT-457). Mr. Faulkenberry indicated that he had reviewed the work instructions and walked down the plant component; involved in the reactor trip event to ensure that the components were easily identifiable, properly labeled, and located in a well lit location.
It was quite apparent to him that the procedure indicated an incorrect cabinet location for the technician and the event raised questions regarding whether the technician was thinking through his actions and whether a proper review of the procedure was done. This led the discussion into the issue of people not thinking sufficiently about what they are doing, and proceeding in the face of uncertainty.
Mr. Faulkenberry stressed the significance of this event as indicative of the need for improvement on the above items.
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Mr. Cockfield stated that his review of the problems experienced during the recent reactor trip indicated that people do want to do the job right.
The licensee had performed a detailed critique which revealed an inadequate work procedure and a number of opportunities to prevent the event.
During the subsequent forced outage, a great deal of work was
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performed on procedure verification. Also, a formal pre-work briefing system has been instituted. An additional area of concern was personnel accountability. Mr. Olmstead added that they are conducting Lessons
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Learned meetings to ensure that management expectations are being clearly
communicated. He has also conducted personal discussions with various
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levels of plant staff management to assess the effectiveness of f
management's comunication of expectations. The results of these discussions indicate that the communication process has been effective, but could be improved.
Mr. Faulkenberry stated he ceuld not emphasize enough the NRC's concern
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in the areas above. He indicated that PGE progress in these areas will be followed, and offered a further example from the maintenance team l
inspection observations of operations personnel leaving and re-entering radiological controlled areas without properly logging out as required.
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Concerning the additional items, hr. faulkenberry offered the following
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observations:
l There has been no significant improvement in QA effectiveness over
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the past several months.
There has been a lack of QA involvement in the evaluation and
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followup process. He noted the maintenance inspection team found a l
general absence of QA presence in areas reviewed.
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There has been a lack of QA involvement in the day to day activities
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of maintenance and surveillance, even when QC hold points were involved.
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There has been a lack of aggressiveness and initiative by QA to dig J
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into and understand issues.
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There has been a number of problems that have been lingering for a
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number of years without adequate resolution.
These are lingering concerns that need to be addressed.
Concerning these issues, Mr. Faulkenberry stated:
Although the Patrformance Monitoring and Events Analysis group has made good progress, problems are not being addressed or resolved in a timely nanner. The first-out solution does not always seem adequate. The problem may r.eed reanalysis, and possibly a new action pursued. Examples offered were:
Lack of a preventive maintenance program for spare equipment in the
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warehouse. This problem was identified some time ago. An action plan is being developed, but no interim program is in place.
Fouling of service water coolers dates back to 1981, and an action
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plan is still being developed.
Silt problems in service water instrument lines, which have been
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repetitive since 1986, have not been adequately resolved.
Mr. Faulkenberry emphasized that in some of the cases, actions were ineffective due to inadequate root cause evaluations directing work in the wrong direction. These ineffective solutions need to be identified and the related root Cause evaluations need to be revisited.
19 the other situations the involved organizations have not implemented a timely resolution.
Mr. Cockfield agreed that there is a need for improvement in this area.
He stated that PGE needed to get a better understanding of the real problems, considering the generic implications, and to get the solution right the first time.
Mr. Faulkenberry concluded the meeting by restating the NRC concerns and emphasizing that the NRC is looking for improvements in the accuracy of procedures, personnel performance, and an increase in QA involvement and effectiveness.