IR 05000344/1989011
ML20245A743 | |
Person / Time | |
---|---|
Site: | Trojan File:Portland General Electric icon.png |
Issue date: | 05/30/1989 |
From: | Mendonca M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
To: | |
Shared Package | |
ML20245A740 | List: |
References | |
50-344-89-11-MM, NUDOCS 8906220150 | |
Download: ML20245A743 (30) | |
Text
-__ - __
_-
.
'
,
,
.
U. S. NUCLEAR REGULATORY COMMISSION
REGION V
Report No. 50-344/89-11 Docket No. 50-344
\
License No. NPF-1 Licensee: Portland General Electric Company 121 S. W. Salmon Street Portland, Oregon 97204 Facility Name: Trojan Nuclear Plant Meeting at: Portland General Electric Company Headquarters, Portland, Oregon Meeting Conducted: April 13, 1989 Inspectors: R. C. Barr Senior Resident Inspector G. Y. Suh Resident Inspector Approved By: .
M. M. Mendonca, Chief NeA C/Je/F7 Date Signed Reactor Projects Section 1 Meeting Summary:
Meeting on April 13, 1989 (Meeting Report No. 1-344/89-11)
Scope: Management meeting to review the Systematic Assessment of Licensee Performance (SALP) results for the period from December 1, 1987, through December 31, 1988, and to discuss a recent plant transient and recent activities in fire protection and outage management.
l 8906220150 DR 890602 ADOCK 05000344 PNU '
__ - _ _ _ _ _ - _ _ _ _ - _
.
.
.
DETAILS 1. Meeting Attendees a. Licensee Attendees K. L. Harrison, Chairman of the Board and Chief Executive Officer W. J. Lindblad, President, PCE Generating Division D. K. Carboneau, Vice President and Controller
- 0. W. Cockfield, Vice President, Nuclear
- C. P Yundt, General Manager, Trojan Plant R. P. Schmitt, Operations and Maintenance Manager
- J. W. Lentsch, Personnel Protection Manager l *T. D. Walt, General Manager, Technical Functions I *L. W. Erickson, Manager, Nuclear Quality Assurance ,
- A. R. Ankrum, Manager, Nuclear Security I
- A. N. Roller, Manager, Nuclear Plant Engineering
- R. E. Susee, Manager, Outage Management and Plant Scheduling-
- G. A. Zimmerman, Manager, Nuclear Safety and Regulation
. *M. J. Singh, Manager.. Plant Modifications ?
J. D. Reid, Manager, Plant Services s S. E. Hoag, Manager, Trojan Programs / I J. M Anderson, Manager, Material Services b. NRC Attendees -
J. B. Martin, Regional Administrator , y R. J. Pate, Branch Chief, Radiation Safety and Safeguards - ,
-
'
M. M. Mendonca, Section Chief, Reactor Safety and Projects 4 l
,
e R. C. Barr, Senior Resident Inspector s q
-
G. Y. Suh, Resident Inspector- ' ~
q l
c. Oregon Department of Energy L
M H. Moomey, Manager, Reactor Safety i
- Denotes attendees for the presentation on fire protection and outage management. J Other licensee managers and supervisors were also in attendance, as well i as one representative from the Bonneville Power Administration.
l l 2. Meetlag Summary i
l
'
A management meeting was held to discuss the results of the NRC Systematic Assessment of Licensee Performance (SALP) for the Trojan Nuclear Plant as documented in Inspection Report 50-344/88-51. Other topics of discussion included a steam generator level transient which occurred in March 1989, licensee activities in the fire protection area, and outage management for the 1989 annual refueling and maintenance outage. .
a__-_-______-_. __. _ - - ._ _ ._ _ _ - _ -
.
.. 2
.
The NRC assessment of Trojan performance stressed the following points: i (1) Management has set the ' stage:for ifnprovements and. attainment of- 1 desired performance. Management must assure that the licensee staff know what licensee management expects of their performance.
(2) Problem areas, such as, an inability to identify ' problems through an effective Quality ~ Assurance Department . security effectiveness, and conduct-of maintenance and work control, require aggressive management attention and give an overall negative performance assessment.
(3) Improvements have been noted in the' areas of Operations, Radiation Protection, Engineering,' Emergency Preparedness, and :
Licensing. It is recognized that a great deal of effort was needed to attain the observed improvement. It was also noted that continued emphasis is required to sust5in and nurture improved performance in these areas.
Mr. Martin stressed that for over six years no clear improvement has been -l evident in the quality assurance area, and that a nuclear power plant can I not consistently improve performance without intrusive and aggressive !
quality organizations. Organizational changes within the QA department
{
appear needed in order to improve expertise in the operations, radiation protection, instrumentation and control, and engineering areas. Mr.
Martin also expressed the position that if there is not a strong QA group, then that may indicate that utility executives do not aggressively pursue and correct their problems.
PGE's position was summarized by Mr. Cockfield. Although groups such as the Performance Monitoring and Event Analysis (PM/EA) have shown strong performance, he clearly sees the need for improvements in the quality assurance organization. Security department performance is improving, and there is a strong manager currently leading the Department. He stated that maintenance is the biggest problem and an area where a great deal of improvement will be effected. He currently has two strong leaders in the Trojan Plant General Manager and the Technical Functions General Manager.
Following the SALP discussion and r .etailed discussion of the March 1989 steam generator water level trans ent, Mr. Harrison provided the following concluding remarks. His expectations are that anything other than excellence will not be accepted, and he will assure his expectations are made clear. The results of the recent SALP report are related to the report last year, with about 75 percent of the problems being people related. Specifically, concerns dealt with the somewhat inconceivable lack of understanding that a team effort is needed on the part of all groups, and that the quality organization is there to help the rest of the plant. Another concern Mr. Harrison expressed dealt with Operations personnel not taking a leadership role for plant ~ activities and that if a problem exists which appears to be a turf issue, then it will not be allowed to exist any longer. Mr. Harrison stated that he.will' support his people with his time and hard decisions, and give.them the support f
_ _ _ _ _ . _ _ _ - _ _ _ _ _ _ _ _ _ _ _ . _ _ . _ _ _ _ . _ . _ _
___-__ __ _ _ _ - _
,
. 3
.
w which comes only from detailed understanding. Mr. Harrison stated that PGE will change and the change will not be effected by merely the issuance of memoranda or the statement of a few words. If people do not understand that management expects excellence, ther, they will not be i retained. He indicated that he is not afraid to make the hard decisions.
3. Detailed Meeting Minutes The meeting commenced at about 8:05 a.m. PDT. Mr. Martin stated that given the nature of the recent SALP report, there was a need for a management meeting to discuss the assessment. This annual assessment found some improvement. However, quality assurance is a weak performance area and will need considerable attention. The management. meeting was also to discuss recent inspection findings which brought into focus observed problems in the maintenance area.
Mr. Mendonca summarized SALP results for each functional area, beginning with safety assessment and quality assurance. Highlights of the review presented at the meeting are presented below. Although self critical assessments were being done by the Plant Review Board and Trojan Nuclear Operations Board, the overall effect of QA was one of negative impact, especially as demonstrated in the area of procurement. There appears to be the need for organizational changes, with no clear direction within the QA department at the current time.
ll Mr. Martin related that over a six year period, he had seen no clear improvement in the QA area. He expressed the position that one cannot run a nuclear plant without an intrusive and aggressive QA group.
Organizational changes appear necessary with no present expertise within QA in the areas of radiation protection, instrumentation and control, and engineering. Mr. Martin stated that if there is not a strong QA group, then that indicates utility executives do not want to know what their problems are. In addition, one can never become a first class organization without a strong QA group.
Mr. Cockfield and Mr. Lindblad indicated their disagreement with the statement of utility executives not wanting to know the problems. Mr.
Cockfield stated that the Performance Monitoring and Events Analysis group and the Plant Review Board are effective in their activities. Mr.
Walt stated that he and Mr. Yundt would need to be more supportive of QA and to move the right people into QA.
Mr. Pate discussed the assessment of the Security area in which a minimum compliance level of performance had been observed with the' issuance of a civil penalty during the assessment period. A recent team inspection raised additional concerns in the areas of safeguards information and guard training. On the other hand, initiatives have been seen for improved performance. Mr. Martin urged that these security problems get attention. He added that PGE may want to ponder how this situation developed and why management did not know about it prior to it being identified in the recent team inspection. This is an example of where strong QA performance is needed.
-
.
. 4
.
In the area of Maintenance, a brief discussion was held of. the large -
number of reportable events, many related to work planning and control,-
which occurred in the assessment period. A more detailed discussion was deferred until the discussion of a March 1989 steam generator water level transient, discussed below.
In the area of Engineering, Mr. Martin recommended strongly that PGE look in some depth into an apparently high number of field changes processed against some design packages. Engineering performance has substantially improved but this is an area the NRC may scrutinize in the near future.
In Operations, a need for improvement'was perceived for operations personnel to take the lead in plant activities and exhibit a sense of ownership. Mr. Martin stated that the last few years have had significant events of concern but these appear to have tapered off during the last assessment period. Operations appears to be on the right track and will need nurturing to assure continued improvement, in much the same way as Engineering. There continues to be the need for operations personnel to keep control of plant activities and, in some cases, it is unclear whether maintenance or operations runs the plant. Mr. Yundt replied that he has told operations shift supervisors that they need to take control, and there have been instances in the past where the shift supervisor should have stopped work.
Radiation Protection was another area where compliments were deserved.
Continued attention was urged, and an identified area of concern dealt with control of waste products. Mr. Martin stated that the situation present in the 1987 refueling outage was a severe problem but the plant has improved since that time.
Emergency Preparedness was identified as PGE's strongest area. Two years ago, the emergency drill raised a great deal of concern. This was an area where Mr. Cockfield's personal involvement was=very evident in effecting improvements in the utility's performance. Recent inspection findings indicate that maintenance of skills between drills is an area which needs attention. -
.
.
\
Following a brief~ synopsis by Mr. Mendonca of NRC SALP results for all ]
areas, Mr. Cockfield provided the following summary of PGE. views. .A j strong program has been established across the board. The need for l improvement in QA.is clear, notwithstanding good performance by groups j such as PM/EA. Improvement in Security is_ progressing with a strong leader currently heading the department. .He stated Maintenance was the
, biggest roblem area where a great deal of, improvement will be effected. ,
!
He felt he currently has two strong leaders as General Managers of the !
Trojan plant and of Technical Functions. 1 l Mr. Martin expressed the sense that Trojan appeared to be in the bottom half of Region V plants and perhaps of all plants nationally. Although the stage has been set for achieving management performance goals, the negative assessment is a result of problems in the areas of maintenance, work control, and an inability of the QA department to identify problems.
i i
. _ - _ _ _a
-- . ,
,
. 5
.
A discussion followed on which Region.V plants had superior QA organizations, on the inter-relationship between QA performance and performance in line organizations, and on the time frame in which improvements can be effected throughout an organization.
Following a break, the discussion focused on the Maintenance area, and in particular on a March 1989 steam generator level transient. Mr. Barr provided a presentation on the level transient, which was discussed in detail in Inspection Report 50-344/89-05.
'
Mr. Harrison reviewed the major ideas of the presentation as beingi
'
(1) A similar event occurred in August 1988, about six months '
earlier.
(2) Although general procedures existed for the asso'ciated
,
maintenance activity, there were no specific and detailed procedures.
3 (3) Existing procedures, appropriate to the work, were'not >- ;
specified in the work instructions.
(4) The quality assurance reviewer incorrectly drew the inference that the work package dealt with only a few calibrations, when in fact it controlled approximately 450 calibrations.
Mr. Yundt stated that it was a bit misleading to say that the work instructions consisted only of one piece of paper. In any case, as a result of this transient, plant management was working to develop more specificity and detailed work instructions for this type of maintenance activity.
At this point, Mr. Moomey of the Oregon Department of Energy, made some general comments and concluding remarks.
In summarizing NRCs evaluation Mr. Martin expressed the view that PGE had expended a great deal of effort in the areas of.0perations, Radiation Protection, Engineering, Emergency Preparedness, and Licensing and these areas appeared to be in the mainstream with regard to performance. He cautioned, however, that by emphasizing the problems within Maintenance and QA, he was not placing less importance on the other areas.
Mr. Harrison provided the following comments at the conclusion of the SALP and level transient discussion. He indicated that he does not want to sit through a presentation of this type of report, again; and tnat the NRC has competent people, and without undermining PGE personnel, he accepted the NRC assessment. Mr. Harrison indicated that it is possible that his expectations have not been clearly communicated to all PGE l personnel; that it never occurred to him that he would have to tell PGE personnel that he will accept nothing less than excellence and that if that is not understood, then he will tell them. He stated that he does not see the negative assessment as solely a QA problem and that the I results' discussed were not unrelated to the report of last year. He indicated that 75 percent of'the problem is people related; and that it l
-8 F
'( F
.[7
.. , .
'
'
,
4 .g .
'
-
. . ,.
!
. is almost inconceivable that there:may,be aflack,o'f understanding that the plant consists of groups _ which need to work together, and _QA is there .
~
L to help the-rest of the plant. Mr. ~ Harrison stated that operations must take responsibility and a leadership role, and all plant staff must function as part of an integrated group. He indicated that if:there.is an issue of turf between groups, .it' won't be allowed to exist any longer.
He stated that he will support his people. Mr. Harrison indicated that the support will be through.hard decisions'and time,-and.he'will give _,. _
them.the support which can come only from detailed understanding of the~
- issues. Mr. Harrison stated that'if.PGE has people who do not understand'
his expectations for excellence, then those people will not be retained.
He indicated he is not afraid to make hard decisions, and'that PGE~does have1the people, more than a few, who are able to effect. improved performance. '
Following a break, the meeting resumed with two PGE presentations on the-areas +f fire protection and outage management by Mr. -Lentsch and Mr.
'
Susee, respectively. The handouts distributed at the meeting are enclosed as attachments to this-report. Mr. Lentsch' stressed the increased management attention that has been_ devoted to the fire protection area which enabled the consolidation of fire protection functions into one on-site group. He noted_ increased; accountability and an aggressive attitude' for improvement. ~ He also noted 'a major new program to improve the control of fire do9rs and the development ofo
,. performance indicators to gauge progress. 'Other improvement; programs are l outlined in the attached enclosure. Mr. Susee provided an overview of the current refueling outage and discussed.new concepts such as_the'use l of area coordinators to provide oversight:of all' activities in a given
.
plant area. Other improvements include continued and expanded use of.
system engineering walkdowns, provisions for specific backshift work activities, and project leader training. Further information is outlined in the attached en~ closure. _
f
>
f
'
i ,
g,
'
'
.;
.
.,
a
'l.
.
-
l
< , ;
,
l f
)
~c. ,
.
'
'
J
.
, _ .
. . . . . . . .
... ..
. .. .. . . . . . . . . . . . . , . .
?
.,f * p us l
,
,6 ~
o UNITED STATES 3 8" , n NUCLEAR REGULATORY COMMISSION A
~j REGION V
0,, 1450 MARIA LANE,SulTE 210 1 ( *i % . . . .'+ g WALNUT CFtEEK, CALIFORNIA 94596 MAR - 91989 {
Docket No. 50-344 i Portland General Electric Company 121 S. W. Salmon Street, TB-17 Portland, Oregon 97204
,
Attention: Mr. David W. Cockfield Vice President, Nuclear i
Gentlemen:
SilBJECT: SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE
,
1 The NRC Systematic Assessment of Licensee Performance (SALP) Board has com)leted it's evaluation of the performance of your Trojan facility for the period from December 1, 1987 through December 31, 1988. The performance of your Trojan facility was evaluated in the functional areas of plant-operations, radiological controls, maintenance / surveillance, emergency preparedness, security, engineering / technical support, and safety assessment / quality verification. The criteria used in conducting this assessment and the SALP Board's evaluation of your performance in thest functional areas are contained in the enclosed SALP report. Specific recommendations have been made in Section IV of the attached report for each functional area. I
\
Based on discussions between our respective staffs, a management meeting to discuss the results of the SALP Board's assessment has been schedpled for 1:00 p.m. on March 21, 1989 at your Portland offices. Additionally, we understand that, after the SALP discussion, you would iike to discuss your upcoming outage activities and some of your fire protection efforts. Arrangements for this management meeting will be discussed further with your staff in the near future.
Overall plant performance during this SALP period has been acceptable and i improved performance has been noted in several functional areas, e.g.,
i emergency preparedness and radiological controls. Although your overall ;
activities at Trojan have been found to be directed toward safe operation, the i SALP Board's assessments in almost every functional area indicate that increased management attention is required to assure timely, thorough resolution of plant problems. ,
This concern was key in the Board's findings in the Safety Assessment / Quality Verification functional area. Recent concerns, with the procurement of commercial grade materials for safety-related feedwater piping and the ,
accuracy of related information provided to the NRC, are indicative of a '
Quality Assurance (QA) department which has not effectively established the ability to identify and focus on problem areas and affect timely, conservative resolutions. This is particularly bothersome in light of Portland General Electric's historical weakness with QA program effectiveness, and management's stated intention to improve performance in this area. Contributing to these j@ + n 0
- ,
J wff ;
, iv a 5
,
. ,
I
._. . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
. _ _ _ _
l
.,., ,,
'
-2- MAR - 91989 problems was the fact that the quality organizations appeared to be insufficiently involved in the initial review of events and plant problems, and were not providing independent verification that management's policies were being successfully implemented. In some specific post-event cases, the NRC found it necessary to supply the impetus for the licensee's review and verification of planned actions. ,
The SALP Board also found that although you were defining and taking actions to improve overall performance, progress was being made slowly. This problem was most evident in the Category 3 areas of Safety Assessment / Quality Verification and Security, and in the functional area of Maintenance /
Surveillance. This situation was to the point where the slowness of the actions became a negative perception.
Since your performance was evaluated Category 3 in the Safety Assessment /
Quality Verification functional area and in the Security functional area, you are requested to provide a written response within 30 days after our forthcoming meeting which addresses your plans to improve perfomance in these functional areas. Comments on other portions of the SALP report may be provided as appropriate.
In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10. Code of Federal Regulations, a copy of this letter and the enclosed ( SALP report will be placed in the NRC's Public Document Room, as well as any comments you may wish to submit to NRC regarding the content of the SALP report.
The NRC's Office for Analysis and Evaluation of Operational Data perfomed an assessment of licensee event reports submitted for Trojan. This assessment was provided as an input to the SALP process; a copy-is therefore provided as Enclosure 1 to the enclosed SALP report.
- The response requested by this letter is not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
Should you have any questions concernin SALP report, we will be pleased to discuss them with you.
Si cerely, ,
. hAEEbt J. B. Martin Regional Administrator
Enclosure:
SALP Report No. 50-344/88-51/
(
REGION V==
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE FOR PORTLAND GENERAL ELECTRIC COMPANY TROJAN NUCLEAR PLANT l
REPORT NO. 50-344/88-51
[( EVALUATION PERIOD: 12/1/87 - 12/31/88 FEBRUARY 9, 1989 SALP BOARD ASSESSKENT CONDUCTED:
)
l
!
.
I
!
-!
,
,
,
l [^'s
, 0i O /.
.
~ - - - - - - - - - - - - - - _ _ . - _ _ _ _ ___
f f -
e
,.i
.
1
SUMMARY (12/1/87 - 12/31/88) j TROJAN NUCLEAR PLANT Inspections Conducted Enforcement Items Inspection * Percent Severity Level **
Functional Area Hours of Effort I II Ill 'lV V Dev 1. Plant Operations 1142 21.9% 0 0 0 4 0 0 2. Radiological Controls 282 5.4% 0 0 0 3 3 0 3. Maintenance /
Surveillance 1654 31.7% 0 0 0 9 1 0 !
4. Emergency Preparedness 212 4.1% 0 0 0 0 0 0 5. Security 301 5.8% 0 0 1 7 0 0 q i
6. Engineering / 1 Technical Support *** 184 3.5% 0 0 'O O .O 1 1 :
l / 7. Safety Assessment /
Quality Verification 1441 27.6% 0 0 0 2 0 0 1 (
TOTAL -5216 100% 0 0 1 25 2 1
- Allocations of inspection hours to each functional area are approximations based upon NRC Form 766 dat !
- Severity levels are in accordance with NRC Enforcement Policy (10 CFR 1 Part 2. Appendix C). -
'
- Two violations were proposed in the Engineering / Technical Support functional area, and the severity levels are yet to be determined.
Data reflects Inspection Reports 87-42 through 88-51.
i l
l l
.
.
.
.. O .
-
TABLE 2 TROJAN NUCLEAR PLANT ENFORCEMENT ITEMS i
Inspection Severity Functional i Report No. Subject Level Area 88-01 Quality records for ASME Section IV ,,
-3 XI testing were filed without proper review and signature of the appropriate plant engineer ]
Radiological hot spots were V 2 88-04 not posted properly 88-05 Failure to provide IV 5 1 the required level of illumination in all exterior areas of the protected area.
88-13 Inadequate 10 CFR 50.59 review IV 7 l of temporary modification l Failure to follow locked IV 1 controlled valve procedure
{(g and license conditions Inservice testing ASME Code IV 3 '
Class 1 valves indicated degraded stroke times, and required additional surveillance testing not performed Incomplete evaluation of failed IV 3 Code Class 1 inservice testing 88-16 Failure to secure floor panels IV 5 providing direct access to a vital area.
Failure to provide an IV 5 adequate search for contraband.
Failure to properly screen IV 5 personnel granted unescorted access to the protected .'rea.
.
L l
_ --___ ___ --___-_--_-
.
.: . q
!
-
F 2 I
A .l I
Inspection Severity Functional i l
Level Area Report No. Subject Fire detectors not installed as IV 1 88-17
,
required for 93 foot elevation of , .l fuel building Incomplete radiation dose IV 2 88-20 assessment as required by
'
Plant management failed to IV 3 88-24 control overtime of workers perfonning safety related j maintenance
\
Wrong acceptance criteria used IV 3 1l 88-26 for ASME Section XI inspection of pipe supports No documented instruction or IV 3 procedure prescribing the ( engineering evolution process for ASME Section XI inspections of pipe supports 1 Written safety evaluation for IV 2 i 88-27 radioactive materials being stored outside the protected area was not performed.
V 3 l 88-30 Pretest calibrations were not l
'
performed, and post maintenance l
testing records were not !
maintained for ASME Section XI inservice tests ;
!
Plant management failed to IV 3 control overtime of workers performing safety related maintenance l
!
Control access procedures and IV 2 survey procedures for '
.
radiological controlled area not complied with. I Prucedural compliance per IV 3
,
[ 10 CFR 50 Appendix B Criterion V l
( not complied with !
.,
.
_.
.
.A-3-Inspection Severity Functional Report No. Subject Level Area 88-33 Failure to provide IV 5 the required level of illumination in all exterior
' '
areas of the protected area.
88-34 Safe shutdown emergency lighting IV I not installed for three areas of intake structure and circulating building 88-36 Seismic Class I instrumentation Deviation 6 not installed for condensate '
l storage tank level as per Reg. Guide 1.97.
88-40 Procedure violation for a IV 1 ladder improperly stored in a safety related switchgear room j
'
(( Incomplete maintenance request that did not provide appropriate IV 3 work instructions to return safety related equipment to service following repair.
88-43 Procedure violation of quality IV 7 assurance procedures for failure to document a non-conforming maintenance activity -
88-45 Failure to properly compensate III 5 for a degraded security barrier. (Composite)
Failure to properly search and escort a visitor.
Failure to provide a vital area barrier.
Failure to report security IV 5
'
system vulnerability.
Failure to properly secure IV 5 sensitive documents.
L
,
.
a 5
-
!
,
l(g- - -4-Inspection Severity Functional Report No. Su.bject Level Area Procedure violation of quality * 6 88-46 assurance procedures for not ' '
performing engineering evaluations for commercial grade equipment.
Procurement of safety grade 6 main feedwater piping without acceptable quality verification-
- Severity levels to be established.
I(L i
.
e
L
__ _ . _ _ _ . _ _ _ - _ - _ _ _ _ . _ _ - - _ _ . _ _ _ _ _ _ _ _ _ _ _ _
.
,,
'. ' .
.
'
TABLE 3 TROJAd :UCLEAR PLANT.
SYNOPSIS OF LICENSEE EVENT REPORTS **(12/1/87-12/31/88)
Functional SALP Cause Code *
Area A B C D E X_ , ,
Totals 1. Plant Operations 5 1 2 1 6 0 15 2. Radiological Controls 1 0 0 2 0 0 3 3. Maintenance / Surveillance 12 4 1 5 2 0 24 4. Emergency Preparedness 0 0 0 0 0 0 0 ,
5. Security 3 2 0 2 0 0 7 6. Engineering / Technical Support 0 2 0 0 1 1 4
'
7. Safety Assessment /
Quality Verification 1 0 0 0 0 0 1 (( *
22 9 3 10 9 1 54 Cause Codes:
A - Personnel Error B - Design, Manufacturing C - External Cause D - Defective Procedures E - Component Failure X - Other
- Synopsis includes LER Nos. 87-35 through 88-47 (LERs 88-25, 34, 38 cancelled)
l
.
. ' a
- '
.
'
A
)
l TABLE 4 TROJAN NUCLEAR PLANT j 1. LICENSEE EVENT REPORTS (12/01/87 - 12/31/88) I Salp Area /Cause Code LER Title Fire doors made inoperable due to 1/D ,
87-35 ~
personnel error ,
!
Seismic monitoring instrumentation 3/A ;
87-36 ~l 1/E !
87-37 EHC switch failure caused load rejection reactor tripped manually Reactor trip due to failed overpower 3/E 88-01 delta temperature channel l 88-02 Containment ventilation isolation on 2/D high containment radioactivity signal due to inadequate procedure Single failure mechanism discovered wM ch 6/B 88-03 could overpressurire containment electrical
{g penetration seals ( Containment penetration not verified 1/B :
88-04 closed as required by T.S. 4.6.1.1 l 88-05 Surveillance interval for chilled water 3/A j
return valves exceeded 88-06 Centrifical charging pump seal leakage 1/E greater than FSAR assumed limits
,
Control room normal air conditioning 1/E 88-07 system isolation due to spurious high chlorine signal 88-08 Pressurizer safety valve setpoint found 3/D out-of-tolerance during surveillance testing 88-09 Missed hourly fire patrol for inoperable 1/A fire door 88-10 Containment ventilation isolation on 3/D high radioactivity signal
c,
. '.. ,
.
.
.
-2-
)
l Title Salp Area /Cause Code j LER 88-11 New fuel assembly handling violated T.S. 3/A l
88-12 Fire door made inoperable due to personnel error , 1/A 88-13 CCW valve position not verified as required 3/D by T.S. 3/4.7.3 ,
I l 88-14 Containment ventilation isolation due 2/D !
to high containment radioactivity signal l 88-15 Containment ventilation isolation due to 3/A <
personnel error during testing 88-16 Steam generator water level instrument 6/X high-high turbine trip /feedwater isolation setpoint set outside T.S.
Table 3.3-4 ,
.
88-17 Hourly fire patrols for inoperable fire 1/A l barriers missed 88-18 Excessive unfiltered in-leakage affected 3/B operability of control room ventilation system 88-19 Surveillance required after containment 3/A hydrogen vent system adsorber replacement by Technical Specifications not performed 88-20 Overpressure mitigation system actuation 3/D due to inadvertent letdown isolation 88-21 Operational mode change made without 3/A having performed the required technical specification surveillance.
I l 88-22 Train "A" safety injection initiation 3/C during plant heatup 88-23 Containment ventilation isolation due to 1/C l spurious spike on PRM-1C
{ Control room emergency ventilation system 3/E 88-24 inoperable due to failed damper i
88-25 Cancelled
.
_ _ _ _ _ _ _ - _ _ _ _ _ _ _ - - _ _ _ - _ . _ _
.
2,. ,
.
'
-3-Title Salp Area /Cause Code LER 88-26 Reactor trip due to venting a flow 3/D transmitter with common sensing line j with other flow transmitters , ,,
88-27 Volume control tank isolation capability 3/A was lost on loss of power to charging pump suction valve l
88-28 Reactor trip due to inadequate work 3/A i l
I procedure and personnel error 88-29 Safety-related component operability 3/B threatened due to service. water fouling with clams 88-30 Safety injection pump inoperable due to 1/A mispositioned valve 88-31 Offsite power source surveillance not 3/A )
)
performed 88-32 Control room ventilation system 3/B inoperable due to open door 88-33 Radiation monitor not receiving 6/B-representative sample 88-34 Cancelled 88-35 Surve111arce of gaseous.radwaste 3/A oxygen monitor was not perfonned 88-36 Containment ventilation isolation 3/A signal locked in due to technician caused short-88-37 High energy barrier defeated due 6/E to broken door latch 88-38 Cancelled 88-39 Incomplete calibration of safety 3/A 3 system RTD's due to assumed drift value of zero !
88-40 Centrifugal charging pump seal failed 1/E i
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
,! 2 .
.
.
l-4-LER Title Salp Area /Cause Code 88-41 Voluntary entry into technical 1/E ,
'
specification 3.0.3 to'do post-maintenance testing on safety '
injection valve
-
Instrument air line soldered joint 3/8 l 88-42 failure 88-43 Reactor trip oue to a main feedwater 1/E valve controller failure 86-44 Auxiliary feedwater auto-start 1/A '
,
due to 10-10 steam generator level 88-45 Reactor coolant system check valve leak 7/A j
rate not measured due to construction error ,
{
' )
88-46 Containment ventilation isolation 1/C signal generated by electronic spike 88-47 Partial containment isolation due to 2/A personnel error while sampling j 2. LICENSEE SECURITY EVENT REPORTS LER Title Salp Area Cause Code
87-505 Inadequate compensatory 5/D post -
i 87-S06 Degraded barrier 5/8 l Degraded barrier 5/B l 88-501 88-502 Inattentive security officer 5/A
,
88-S03 Unsecured safeguards information 5/A .
88-S04 Inadequate protection of 5/D .
vital equipmer.t j 88-505 Unsecured safeguards information- 5/A
i
,
- %. .
. !
4 I
Enclosure 1 AEOD Input to SALP Review for Trojan LER Review During the assessment period, 44 LERs were submitted to the NRC. These <
reports, reviewed by AE0D, consisted of the following LERs: , ,
87-35 to 88-24 88-35 to 88-37 88-26 to 88-33 88-39 to 88-44 Significant Events Utilizing AE0D's screening process, the following six LERs were categorized as potentially safety significant:
88-18 )
Excessive unfiltered room ventilation systeminleakage (design /affecting operability)of installation problem . the control I 88-24 Inoperability of the control room emergency ventilation system due to a failed damper (random equipment failure).
88-27 Loss of volume control tank isolation capability due to loss of i power to centrifugal charging pumps suction valve (other personnel !
(( 88-29 error).
Operability of centrifugal charging and safety injection pumps
!
threatened due to service water fouling with clams (maintenance problem).
88-30 Safety injection pump "A" inoperable due to mispositioned valve (licensedoperatorerror).
88-32 Control room ventilation inoperable due to open door I
.
(design / installation problem).
Causes ]
Root causes associated with the remaining 38 LERs are:
two licensed operator errors, thirteen other personnel errors, four design / installation / fabrication problems, nine administrative control problems, one maintenance problem .
eight random equipment failures, and l one undetermined. l Of the nine administrative control problems identified above, seven were procedural. In addition, nine of the events were associated with inadvertent ( containment or control room ventilation isolations, or inoperability of these systems, i
L _ - - ---------------_----
!
d
,
a '. ' .
l
I
.
-2-l
LER Ouality LERs submitted adequately described the major aspects of each event, including The identifying component or system failures that contributed'to the event.
reports were well written, easy to understand, and typically compitte, except for one with an unidentified root cause. Corrective actions taken or planned to prevent recurrence were generally specified.
Preliminary Notifications From AE0D's review of preliminary notifications issued by Region V, it appears t Nat the April 18, 1988 event involving a containment purge isolation signal de :ribed in PNO-V-88-026 is reportable. However, no LER on this subject was found.
l l
l l
.
l l
l
!
l l
l f
\
k l
,
,
- - - - , - . - - . - - - - - _ _ - - - - _ - - - - - - - - - - - - - - _ - - - - , - - - - - - - - _ -
--
. .. .
.
-
.
-
.. -
-
,, _ _
- 4 PbrtlandGeneralBechicCompany
.
~C David W. Cockfield Vice President, Nuclear quso REGldh y
j t
n er, 4 og a 17 ala: 30 i May 15, 1989 Trojan Nuclear Plant Docket 50-344
License NPF-1
<
l l
l U.S. Nuclear Regulatory Crmmission l ATTN: Document Control Desk Washington DC 20555 I
. >
Dear Sirs:
1988 Nuclear Regulatory Commission (NRC)
Systematic Assessment of ticonsee Performance (SALP)
The NRC SALP Board evaluation of safety performance at the Trojan Plant i for the period from December 1,1987 through December 31, 1988 was '
provided by your letter dated March 9,1989. Overall Plant performance during the period was acceptable and found to be directed toward safe ,
operation, with improved performance noted in several functional areas. "
However, performance in the functional areas of Security and Safety Asr.essment/ Quality Verification was evaluated as Category 3.
l Portland General Corporation has established a goal to achieve sustained I
superior performance in the area of nuclear operations. To realize this goal, Portland General Electric Company (PCE) is taking proactive and aggressive actions to improve performance in all areas of operation of- <
the Trojan Nuclear Plant. This improvement is being accomplished through a commitment of support from Nuclear Division management and the personal involvement of Corporate Management.
l
.
'"'
>
--
.) hY '
J
.. Salmon Street, Portland. Orgon 97204 1 - - - - - _ . _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _
WMMM
'
.
,
Ddcument Control Desk
.
May 15, 1989
Pete 2 _
.
i i
The specific concerns identified in the SALP Report and the actions being l taken to improve PGE's performance are detailed in Attachment A for the i area of Security, and Attachment B for the area of Quality Assurance.
Sincerely,
/ 1 W/ l
Attachments
c: . John B. Martin Regional Administrator, Region V U.S. Nuclear Regulatory Commission Mr. William T. Dixon State of Oregon Department of Energy ~
Mr. R. C. Barr NRC Resident Inspector Trojan Nuclear Plant l '
.
!
j l
l
,
!
.
l
.
<
l
,
- - _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ . _ _ _ _ _ _ _ _ _ _ .
__ _ _ _ _ _ .
,
-
Trojan Nuclect Plsnt i
,
D cument Control Dxk
,* . Dolk^.t 50-344
.
May 15, 1989 {
Licen o NPF-1 Attachment A 1
. '
.
Page 1 of 7 NUCLEAR SECURITY DEPARTMENT I
1. Concern: A continuing lack of effective management involvement in assuring quality for the Security Program. Security Program ]
j operations and support are functioning at a minimum compliance level j rather than striving to excel.
l l
Improvement Coal: Conduct security operations in a manner that l
meets and exceeds regulatory requirements. l Improvement Plan:
a. The Nuclear Security Department has been separated from Corporate Security to increase Nuclear Division involvement and to provide increased visibility to Nuclear Division Management j (Revision 23 Trojan Security Plan). I b. A new Nuclear Security Department Manager and a new Branch Manager Security Operations (BMSO) have been appointed. The current department manager's licensing experience provides added
,
sensitivity to regulatory concerns.
c. The Nuclear Security Department Manager has relocated his office from Portland to the Trojan Plant to provide more direct over-view of Security Program activities and to improve coordination !
with Plant Management (Revision 26. Trojan Security Plan). (
d. The Nuclear Division Managers have committed to increased support for security activities in their 1989 goals and
,
objectives.
2. Concern: Poor past performance with security action plans, speci-fically the redefinition and reassignment of responsibility and the failure to meet milestone dates.
Improvement Coal: Formulate effective action plans that have been reviewed and agreed to by support organizations; complete all action items by the scheduled dates.
Impr6/ement Plan:
"
a. A number of long-term NRC concerns are being completed in 1989:
- The Closed Circuit Television (CCTV) camera installations at the Cooling Tower Cate were completed on schedule, allowing for the removal of a compensatory guard post.
-_____-____-__2
l i- Trojtn Nuc102r Plent. Dzcument Centrol D3ck 'i
,,
Dockst 50-344 .
May.15, 1989 :
L,icenso NPF-1 Attschment A i Page 2 of 7
-
.
l
- CCTV upgrades at the Main Cate and Technical Support Center (TSC) Building areas are on schedule; these modifications will j allow for the removal of two additional compensatory guard !
posts.
I
- CCTV upgrades at the Intake Structure are being designed and are funded for installation this year; this will allow for the.
removal of one other compensatory guard post.
- Secondary Power Supply System upgrades are scheduled for completion by December 31, 1989.
- A task force' was established to address continuing problers i with insdequate protected area lighting. Design work is in.
progress, with installation of new lighting scheduled after-the 1989 refueling outage.
- Control Room security door upgrades are scheduled for com-plation during the 1989 refueling and maintenance outage.
b. A Nuclear Security Department security officer, qualified as a Security Watch- Supervisor, has been assigned to a staff position and given the responsibility of working daily with operations, Maintenance, and- other support personnel to coordinate, monitor, and expedite security-related activities, c. The Commitment Tracking List (CTL) is being utilized to assure that all open security items are being monitored. Nuclear Division Management will be kept aware of open item status so that appropriate priority and management direction can be established to assure that items are completed on schedule. .,
!
d. The following examples provide evidence of improvement in this i area:
- When maintenance problems were identified with.the explosives" detectors at the main entrance'to the Plar.t. procurement was expedited and two new detectors were on site and operational-within one month. One hundred percent pat-down searches of all entering personnel during periods When the detectors are !
not functional was also implemented-(Nuclear Security .)
Procedure 600-6,' Revision 4).- I i
- When a deficiency was identified in barriers at the Turbine :l Building, modifications to resolve the deficiencies were q installed in three weeks (Safeguard Event Report-89-801-00). .;
-
<
!
!
-- _ _ - _ _ = _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _
' *
.
,
Trajtn Nuciccr Plcnt Document Centrol Desk
,,
Dock;t 50-344 May 15, 1989
Licento NPF-1 Attcchment A Page 3 of 7
'
.
3. Concerg: Violations were identified by regional inspectors that had been identified earlier by the Nuclear Security Inspector but had not been corrected.
Improvement Goal: Utilize the Security Inspector to provide an internal review of the Security Program and take positive and timely action to resolve program deficiencies.
Improvement Plan:
a. A monthly report tracking the status of all open items from the Security Inspector's inspection reports is being issued to the Plant General Manager, General Manager, Technien1 Functions and the Vice President, Nuclear.
b. Daily meetings are held between the Security Inspector and the Manager Nuclear Security or the Branch Manager, Security Oper-ations to discuss concerns and identify inspection objectives.
c. The Nuclear Security Inspector now reports directly to the Manager, Nuclear Security in lieu of the Plant General Manager.
This improves communication and allows inspection activities to better focus on areas of concern. The responsibility for an independent overview of the Security Program is maintained by the Quality Assurance Department.
4. concern: A comprehensive review of security management effective-ness, as committed to in a security action plan, was reduced to a narrow review of a single area.
Improvement Goal: Complete a comprehensive review of Security Program effectiveness and modify the program as required.
Improvement Plan:
a. A comprehensive, independent review of security management effectiveness was conducted by the Quality Assurance Deparbment in December 1988. A report of the findings and recommendations has been issued. The Security Department has taken appropriate action on recommendations in the report, and a response will be provided to the Quality Assurance Department by June 15, 1989.
b. An internal review of security operations will be completed by l December 1989. .
l
_ _ _ _ _ _ - - _ _ _ _ _ _ _ - _ _ _ _ _ _ - -_
'
~
Trajcn Euc10:r Plcnt D cument Control D:ck
Dock:t 50-344 M y 15, 1989
,
Licen;G NPF-1 Attcchment A Page 4 of 7
.
.
5. Concern: Communication problems within the security organization have contributed to past security events.
Improvement Goal: Reduce to zero the number of security events resulting from poor or improper communication. I
Improvement Plan:
a. As part of his " striving for excellence" program, the Nuclear Security Department Manager has instituted a policy of more open i communications within the department and with outside organi- ]
zations. Emphasis has been placed on assuring that personnel at :
all levels are familiar with the requirements and expectations, and assume responsibility for their assigned jobs. I
b. A program has been established which requires that security managers and other affected plant pe:tonnel receive specific
training on major modifications to security systems to assure they are familiar with the associated equipment and barriers, as well as any new or revised security program requirements. }
c. The Branch Manager, Security Operations assures that knowledge-able security representatives attend pre-job planning meetings 1 and that they are aware of the responsibility to report and resolve any concerns that arise.
d. Improvements in this area are evident from the excellent coordi-nation that has occurred between Nuclea; Plant Engineering, 1 Maintenance, Plant Modifications, Quality Assurance and Security personnel. Examples are resolution of the Turbine Building barrier deficiency (Safeguards Event Report 89-S01-00) and the activities in progress to upgrade barriers at the Intake Structure.
6. Conce rn: Marginal performance has continued in the area of tech-nical resolution of security issues, with respect to the implemen-tation of compensatory measures.
l Improvement Coal: Ascure appropriate priority is assigned to resolving security barrier deficiencies. Strive to minimize the total number of compensatory posts.
Improvement Plan:
a. Th( Nuclear Security Department Manager and Division management are committed to a proactive response in resolving security l
deficiencies. An example of improvement in this area is the implementation of 100 percent pat-down searches when explosives or metal detectors are not functioning prior to the regulatorfy requirement for doing s ! _ _ _ - _ -
'
. Tr jtn NuclOcr Plfnt D;cument CIntrol Drck '
Dock 2t 50-344 May 15, 1989 Y Licenso NPF-1 Att chment A l 4 Page 5 of 7
.
I b. A status of the number of compensatory posts currently in place )
at the Plant is included in the monthly Nuclear Performance ~
l Report for the Trojan Nuclear Plant. The status identifies the number of posts relative to previous months and provides an indication of progress made toward eliminating compensatory posts.
c. To ensure that compensatory actions are not terminated prema- )
turely, Security Department procedures have been revised to j require preparation of a modification or maintenance acceptance I checklist with sufficient lead time to allow review before the !
work is completed (Nuclear Security Procedure 300-2, Revision 2). )
l l
7. Concern: The proposed barrier criteria document failed to adequately consider all of the design threat parameters of 10 CFR 73.1.
Improvement Goal: Formulate a barrier criteria document that is practical, cost-effective, and in compliance with regulatory requirements. 3 l
Improvement Plen:
a. The existing barrier criteria document has been reviewed with respect to the applicable regulatory requirements, b. An action plan is being prepared to detail the appropriate )
analysis and testing required to resolve open issues in the l criteria. The action plan will be issued by June 30, 1989. !
8. Concern: Certain security violations which were identified during the FALP period have .been the subject of previous enforcement action or discussed in NRC information notices. The previous SALP Report recommended that corrective actions implemented as a result of past problems and NRC notices be periodically reevaluated for applicability.
Improvement Goal: Determine the root cause of security problems at.t initiate effective corrective action such that the number of repeat offenses is minimized.
Improvement Plan:
a. The Security Inspector will review two previous problem areas each month to assess the impact of the corrective actions to j address those problems. The items and findings will be I
specifically addressed in the Security Inspection Reports.
_ _ _ _ _ _ _ _
'
. Trojtn Nuc1ccr Picnt -D:cument Control D2ak Dock:t 50-344 May 15, 1989 (
Licen23 NPF-1 Attcchment A 4 Page 6 of 7
.
b. A preventive maintenance program for appropriate security equip-ment will be formulated and implemented by December 1989. I c. All Safeguards Event Reports will include descriptions of i
previous similar events. This provides another mechanisr. for evaluating the effectiveness of previous corrective actions.
'
l 9. Concern: Security organization statements of responsibility and
- authority appear to overla Improvement Coal
- Assure that the Nuclear Security Department organizational structure is well defined and understood by personnel )
both within and outside the department.
Improvement Plan:
a. The reorganization which separated the Nuclear Security Depart-ment from the Corporate Security organization (Revision 23, I security Plan), and the relocation of the Nuclear Security I Department Manager to Trojan (Revision 26, Trojan Security Plan) j has streamlined the organization. J l
b. The Security Inspector now reports to the Manager, Nuclear Security Department in lieu of the Plant General Manage i l 10. Concern: The Trojan Fitness for Duty program is considered weak- ;
because it lacks a requirement for random testing after employment.
Improvement Coal: Develop a random drug-testing program to be j implemented once the NRC issues a Final Rule on the Fitness-for-Duty 1 l Program.
l .
i Improvement Plan:
l l
a. PGE will proceed with development of a random drug testing !
'
program following publication of the Fitness-for-Duty Rule, anticipated by the end of May, 1989. An action plan is being i developed detailing responsible parties and required action for ,
a random drug testing program for Nuclear Division and other !
employees badged for unescorted access to the Trojan Nuclear Plant.
.
L____________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ . _ _ - . _ _ _ _
,
. . 1,
.
.
Trajcn Nucidcr Plcnt D3cument Crntrol Dack
.; D ck-t 50-344 May 15, 1989 Licenso NPF-1
'
- Attachment A
,
Page 1 of 7 )
.
The annual audit of the Security Program by Quality Assurance is sche-duled for August 1989. The scope of the audit will include review of security procedures and practices (including proper handling and storage of Safeguards Information), an evaluation of the physical protection system effectiveness, review of:the physical Security System Maintenance I and Testing Program, and a review of the commitments for response ~
established by local law enforcement authorities. This audit will allow management to assess the improvements discussed above and maintain their overall commitment to the Security Program.
GAZ/SAB/PGN/mr 2998W.0589 l l
l l 1
<
,
O
__ . . _ _ . . . _ _ _ _ _ _ _ _ . _ - -_ _ _ _ . . _ _ . _ _ . _ _ _ _ _ _ _ _ _ . _ _ _ - - - . -
_ - - - _ _ _ _ _ _ _ - _ - _ _ _ _ _ _
'
. Trojcn Nuclose Plcnt D;cument Cgntrol Desk Dock 3t 50-344 M3y 15, 1989 ,
Lic n30 NPF-1 Attechment B l 4 Page 1 of 6
.
SAFETY ASSESSMENT /0UALITY VERIFICATION Portland General Electric Company (PGE) acknowledges the weaknesses in the Nuclear Quality Assurance Department (NQAD), and is committed to umjor changes and improvements in this area. This commitment has the full support of the Chief Executive Officer, the President of the Generating Division, and the Vice President, Nuclear, who are giving their personal attention to correcting these weaknesses.
Significant changes have already been made and are achieving the desired result of transforming NQAD into a proactive and performance-oriented organization. Changes have been made in three of the top four management positions within NQAD. The individuals placed into these management ,
positions are top performers from the line organization who were selected l because of their demonstrated ability to be intrusive, to ask hard questions and to surface root causes to problems. Additionally, technical experts have been added to NQAD in the areas of electrical j engineering, mechanical engineering, radiation protection and instru- '
mentation and control. These changes were made to ensure NQAD has the capability to review the technical details and adequacy of work activities.
These actions are just the beginning stages of a major transformation of l the NQAD. NQAD will become a problem-finding, performance-measuring i organization, Which will serve to be a catalyst for higher Nuclear Division performance standards. This is our commitment. To demonstrate ]
the results achieved, we will provide you a followup report by August 31, !
1989.
The specific concerns identified in the SALP Report are addressed below:
1. Concern: The quality organizations appeared to be insufficiently <
involved in the review of events and Plant problems, and were not providing independent verification that management policies were being successfully implemented.
Improvement Goal Quality organizations will actively participate in the review of events and Plant problems and provide $pdependent verification that management policies are implemented.
Improvement Plan:
a. The Performance Monitoring / Events Analysis group has actively participated in the review of events in order to verify quality of the responses. NQAD is now participating more actively in the event report process, including attendance at event report I critiques, and in the examination of Plant problems. NQAD involvement in recent Plant problens, such as Containment electrical penetrations, has resulted in the identification of additional technical concerns which are being evaluated and resolved by the appropriate line organizations.
_____- _ - _ _- -__ -____ - ____ - -- - _ - _ ___ _
. . Trajtn Nucicar Plcnt Document.Centrol Dssk
',, Dockst 50-344 May 15, 1989
.
j
+
.Licen33 NPF-1 Attechment B i
,
4 Page 2 of 6 <
)
b. NQAD will review adherence to management policies and NRC commitments during scheduled audits and surveillance. Senior PCE management expectations are that audits and surveillance will go beyond determining if minimum compliance is being j achieved, and will be a means to ensure that management expec-tations are carried out in every aspect of Plant operation. l
'
l
'
.. .
.
i 2. Concern: A Quality Control'(QC) inspector observed a nonconforming ]
maintenance activity and did not document the observation as. '
required by NQAD procedures. Procedural compliance had been a major j concern in the-last SALP. ]
Improvement Goal: Achieve a clear understanding by all personnel of the management expectations for procedural compliance. j Improvement Plan: Specific actions for the QC inspector incident were identified in PGE's response to Notice of Violation dated January 11, 1989. Additional actions include: j a. Procedural compliance expectations were stressed by Plant and QA j management during the General Employee Retraining sessions in 1989.
b. Memoranda to and meetings with NQAD personnel have emphasized that any observed procodural noncompliance will be documented and corrected. Recent Quality Inspection Observation Reports .i and Nonconforming Activity Reports (NCARs) indicate an increased I attention to procedural compliance concerns.
l
c. Nuclear Division managers and supervisors are being held ;
accountable to assure their personnel comply with procedures.
!
,
3. Concern: Audits in the areas of engineering, instrument control, health physics and radiological controls ~(areas where a lack of experience is perceived) were frequently compliance based.
Improvement Goal: Develop a performance-based audit and surveil- ,
lance program utilizing experienced personnel. j Improvement Plan:
a. In February 1989, 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> of Plant-specific training on performance-based audits and sueveillances was provided to NQAD managers, supervisors and auditors, b. A recent audit of Mechanical Maintenance used performance-based concepts; this technique is being applied to other areas in 1989.
l
. _ _ - _ - _ _ _ _ _ _ _ _ _ _ _ _ _ .
. Trojen Nucioar plant Docum2nt Control Dask Docket 50-344 May 15, 1989
-
Liesnse NPF-1 Attachment B 4 Page 3 of 6 c. The QA audit procedure is being revised to shif t the focus of audits from reviewing documents to reviewing activities impor-tant to safety and reliability. This will ensure continued use of performance-based concepts in future audits.
d. Several staffing changes have been made in NQAD to strengthen expertise in engineering, instrument control, health physics and radiological controls. Details are provided in Item 9, below, 4. Concern: Significant deficiencies were identified in the procure-ment program, in that it allowed the use of commercial-grade replacement pipe in the Main Feedwater System without validating the supplier Certified Material Test Reports, and existing procedures for dedicating commercial-grade products for use in safety-related applications were not appropriately implemented. NQAD failed to prevent this, although presented with several opportunities.
Improvement Goal: Ensure required lovels of quality are applied to materials used in safety-related service by use of qualified suppliers, receipt inspection, and testing.
Improvement Plan:
a. Responsibility for the procurement procedures was transferred to the Material Services Manager in December 1988 to allow NQAD to conduct a more independent assessment of the program, instead of directing its implementation.
b. procurement documents are now prepared by a dedicated procure-ment engineerin8 group. Dedicated personnel have been assigned within NQAD to review procurement documents. In-depth NQAD reviews of material engineering evaluations (MEES) are also being performed. MEE reviews include physical verification and documentation of component attributes identified as critical characteristics.
c. Additional resources have been applied to qualify commercial-grade suppliers. A review of evaluations approving commercial-grade suppliers, as well as higher quality code suppliers, is in progress to ensure that all approved vendors meet applicable i requirements. Several deficie.scies have been identified and corrected, d. A materials testing program will.be initiated by August 1989 for verification of commercial-grade material. Materials testing
,
l activities are currently being specified with each procurement, I as needed.
- _ _ _ _ - _ _ _ _ _ _ _ _ _ .__.
% Trojen Nuclose PIEnt D cum;nt Centrol Desk
'
D:ckst 50-344 R:y 15, 1989
'
Lic n;3 NPF-1
^
Atttchment B 4 Page 4 of 6
.
5. concern: Inaccurate information was provided to NRC management in a procurement-related presentation.
Improvement Goal: Provide accurate information at all times.
Improvement Plan:
a. Disciplinary action was taken with the individual responsible for conveying unverified information to the NRC. He has since accepted a position outside of the NQAD.
b. The importance of properly ve rifying information as well as the consequences of providing #,saccurate information to the NRC has been amphasized to all pet sonnel.
6. Concern: Until recently .a program to trend plant events, Noncon-formance Reports (NCRs) and NCARs did not exist. A program was implemented in January 1989 by NQAD to track and trend various alaments of the licensee's corrective action programs.
Improvement Goal: Effectively use deficiency trending to identify recurring problems.
Improvement Plan:
a. Programs for trending of NCRs and NCARs have been in existence since 1975. Since past trending methods have not been effective in identifying some recurring problems, a new NCAR trending !
program was implemented by NQAD in January 1989. j i
b. This new NCAR trending program includes a database keyed on l subject / topic to supplement the current root cause database and i allow more timely identification of recurring events.
c. A major revision of the corrective action programs will be completed by December 31, 1989, and will include a common data base to allow identification of problems recurring in the various systems (Event Reports, Nonconforming Activity Reports, ';
Nonconformance Reports, etc.).
d. NCAP/NCR trending information is teing more effectively used to communicate performance and compliacce concerns with line I management. The trending informatio? will continue to have more
! impact as line management's understanding and use of the infor- '
! mation improves.
l
!
- -
.
Trsjcn Nuclose Plant Document Control D2sk
,*
Dock 3t 50-344 M y 15, 1989 Lietn20 NPF-1
'
Attcchment B 1 4 Page 5 of 6 )
-
l 7. Concern: The quality organization's non-conservative approach to problems and inadequate root cause/ problem resolution efforts were a major contribution to a decreased performance rating.
, Improvement Goal: Meet and exceed regulatory requirements and industry standards for quality.
l Improvement Plan:
]
a. Principles and standards of NQAD operation have been promulgated to NQAD personnel, including avoidance of minimum compliance approaches.
b. NQAD personnel are taking a more rigorous and conservative l approach in evaluation of root causes and corrective actions.
This is particularly evident in NQAD involvement with the NCR/NCAR process. Incomplete evaluations and/or corrective j actions are being rejected by NQAD and returned for rework.
8. Concern: The NQAD and Plant management have had only limited i success in dealing with major recurring Plant problems.
Improvement Coal: Prevent recurring problems.
Improvement Plan:
a. The NQAD staff has implemented action to involve higher levels of management in cases of inadequate corrective actions and in providing more timely resolution of deficiencies.
b. The NQAD staff performs real time trending of deficiencies and informs responsible management of developing trends for each deficiency so that corrective action can be-taken, c. NQAD has become more assertive in reviewing the adequacy of.
problem evaluations and corrective actions to ensure thet all causes have been identified and that generic implications have been adequately addressed.
9. Concern: The licensee should thoroughly examine the NQAD and strengthen weaknesses. The experience level of the QA organization l requires strengthening.
Improvement Goal: Assess the functions, staffing, and experience of the NQAD and make necessary changes.. Improve the experience level of the department through the selection of personnel experienced in areas other than QA, and provide training to current personnel.
- - _ - _ _- ___ __
.
... Trojcn Nucicar Picnt Document Centesl Dask id
' '
.. Dock:t 50-344 May 15', 1989
'."- Licenso NPF-1 - Attcchment B
'
4 Page 6 of 6 q
. a
.
Igorovement Plan:
a. In April 1989, a number of. staffing changes were implemented:
(1). An individual with experience in licensing.and compliance was; appointed the Branch Manager for Quality Assurance operations and also the Acting Quality Assurance Manager.
(2). An experienced Trojan manager with Quality' Assurance 4 background was appointed as Quality support Branch Manager.
(3) The Performance Monitoring / Event ' Analysis Manager has been transferred into NQAD for a.two-month period (prior to a i one-year assignment to'INPO). He will be the acting Quality Operations Branch Manager.
(4) A Nuclear Engineer with experience in safety analysis and regulatory issues was appointed as Audit Supervisor.
"
(5) An Electrical Engineer, Mechanical Engineer and Radiation Protection Engineer were added to the Audit staff.
(6) An experienced Instrumentation and Control (I&C) technician was contracted for I&C field observations.
In addition, other staffing changes are' currently in the process- j of being-implemented to further supp1Raent the experience level of the NQAD.
b. To ensure that the NQAD develops into an engineering and technical-based organization, existing and new NQAD engineers :
specialists and supervisors will be enrolled in.the accredited Technical Staff Training Program.
c. WQAD will continue to supplement audit teams with appropriate technical personnel from outside the, department.
.
i
!
l SAB/PGN/mr I 2998W.0589
,
!
.
l
!
l l
l
.
l
- _ _ _ _ _ _ . _ _ . _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ . _ _ _ _ _ _ _ _ _ . _ _ _
i E %
C ~ $
N AT n MN i o
RA t c
OL F P t
e o
r R R h c P 9 E A sl 8 P E t nn e 9
N C,L en ,
L o 3 O U .sr 1 I
TN We.P l
i r
C A p
EN J r
,
TA eg OJO a n
R a P R M T .
E R
I F
,
n en s .
i oi t l d n
t u e 9 cO T r
t e n t s
e
1 oip n c rt e n r Pt na m e
v a
m r
f o
o ees r
r p f o
r l
s a
i e m e o Fr P I P G
- * *
-
.
-
-
_
_
_
l l
'-
)
l y
k e
e W
&
n y l
a l i
a s P D s *
( l t o
.
t n n s s r e n e t a
e y m o i r
Ftc P m e i t
s h v c e
i p p,e erde vt n e o r p v s p s s isay Li D o
r l
o i m i n l o
r g-ne slp o
ee i
h t p n P n n n idrh n aicE m o o o o i a gF t m i t
l a
i t
c i
t c C ri al I
i a
z i t
c t
e t e r o
TrBrWra i e e n i r o o d n a C r r o e eien r r e g P P D viai r - oFRFG o f e e e r p -
e l
e r r r R S i
F i
F i
F I m////
- * * * * *
.
.
.
' lilll1
__-
_
On-site Fire Protection Organization Plant GeneralManger l,
m l
Manger Personnel Protection
.
!
'
-
Personnel !
Pmtection Committee i
Manager Manager Supervisor Plant Safety Radiation Pmtection Chemistry Rre Pmtection Coordinator '
N M
Clerk i
__ _ .9fft.L n_te_rfac1_ l
- * l---
Mre Protection Rre Protection Mre Pmtection I-- Corponete Loss Engineers inspector Specialist l Pawntion Ertgineer (2) (1) (1)
en A New Trojan Positions in1988
.
- ,.
.. . . . . . . . . . . . . .
_
.
-
.
.
_
_
.
_
,
.
.
.
-
-
.
l s _
) o r
-
d t e a s
r t
a P
/
)
%
-
e l
o s .
-
r r ( _
t - e a e r
u s
e c
-
.
c
_
_
in i
(
f I s )
i v -
.
.
/ r do i s s (
% e _
.
_
.
nt c t e S _
_
r h
_
I -
e o c l e f et o p s
t a b o _
_
e a -
.
cr nP R
l t
o r W r e
p t
u -
_
.
a e O aer t n
e P i F
r o n s
-
-
mF r
i E
v e r d I
s m e
-
-
o i
F r e i e o t s
f r e d f
i o y s l D S e n e
e s
a u
P i c i s q n i e
r i e
r L M U F F
- * * * o
.
Fire-Related Licensee Event Reports By Quarter 3 -
2 ,
-- *
"' ' ' '
O "
1 2 3 4 1 2 3 4 1 2 3 4 I 87 I 88 I 89 i
,
..
Improvements e increased Accountability / * Improved Training Management involvement
- Fire Protection
- PMEA Review Inspections
- Upgraded Patrol e Fire Door Controls Qualifications
~
- 8W8/8A8 Hourly Reviews
- Improved Turnovers
.
+
_ _ - - _ _ _ _ . _ _ _ _ _ - - .
!
!
Missed or Not Established Fire Patrols i
3 ---
- * -
I l
I
!
, . . . . . .
......
O A" ' ' '
1 2 3 4 1 2 3 4 1 2 3 4 l 87 l 88 l 89 l l
.
Improvements
..
- flew Door Signs e increased Accountabi!!ty/
Management involvement
- Integrated Door Procedures * PMEA Review
- Improwd Laymen Training * Upgraded Patrot Qualifications e improved Turnovers i
- Improved Training l
- SWS/SAS Hourly Reviews
1
..
.
-
.
l
. _ _ _ _ _ _ _ .__n
i I
!
Unqualified Fire Watches / Issuers / Patrols
14 14 -- --
12 =
10 ~~"~
8 -~~"-
8 --
S
.
g g 2 -- -
,
-
-
-
'
0 9 N\\\\ hw 9 9 o .
. , ,
1 2 3 4 1 2 3 4 1 2 3 4 I 87 1 88 l 89 l ag
.
Improvements
.-
- Quality Checks of e lacreased Accountability /
i Weld Permits Management involvement l
- Personnel Qualification e improved Training Lists s l
l
.
%
. _ - - - _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _
- - - - - -
Fire Doors Inoperable (Discovered by inspection)
% of Total Fire Doors
30 -- -- -
.
26 --
16 --~
11 11 11 10 , ---
6 6 O .
.
.
9 i , .
1 2 3 4 1 2 3 4 1 2 3 4 I 87 I 88 l 89 l
.,
l l
Improvements
.
- Task Force * Increased Accountability /
Management involwment
- Door Replacements e improwd Training
- Spars Parts in Stock
- Fire Protection
- Increased Maintenance inspections Priority / Frequency /
Scheduling * Integrated Door Procedures
e e' i
- e e
_.___._____.._.._m_ - . _ - - - _ - - - - - -
,
Fire System Out-of-Service (%) l 3 -
l 2.5 =
2.3" 2.2 1.7 1.5 - - - -
- y,3 "
1.2 1.2 l
0.6 - - -
-
--
'
0 ~ ' ' '
1 2 3 4 1 2 3 4 1 2 3 4
<
l i SS l 89 l J E Total 1 I Modifications E Failures I iPMs
improvements ,
- Higher Maintenance
- Increased Accountability / *
Priority Managentent Attention
- System Engineering * Fire Protection
/ o hoothg inspections
/ Testing
.
O e
-
t m n a e s r m
.
g m r o u a t
s P r c o
l A
-
n l D y
-
-
-
-
-
e t o
r i
s r o
-
m n s s o a
-
- i e v
-
-
-
-
- C B r
-
v e o
-
-
-
-
-
l e n g
p u
_ r b i s
s S p i t
s e w e
-
u D m
-
-
-
-
I m b i
v e e
-
-
m n R t
s
- r o s o y e n i
-
-
-
C a t
c e S .
e d h
l t p t o e
-
-
t n e r o C r e r O
-
i
_ i P P F s A n
_ a e r e r
P w
-
r i i F e
-
-
T F F N N
- * * * *
-
-
-
0 0 0 5 9
~
l s
o r
t a
P
/
l sno s r
s y
.
ait e a u
oce s s
D
)
Gt o I
/
s 7 )
%
%
(
e
.
r > (
y 9P h c e e t i
8er s t
a l
b a
l b
a l
i b
9i l o W r r l a
1F t r e p e.
p i
a a e o o v P i r
n n A F i i e m i
r d s r
s r e F i e o o t s
d f
i o o y D
l e a D S s u i
s q n
e r
e r e r
i i M U i
F F F
- * * * *
-
_
i
-
.
_
.
IllhL
- - - - - - - -
..
.
.
Trojan Excellence
'
Our Way of -
Doing Business
.
e
_ _ _ _ _ _ _ _ _ _ _ - _ - - - - - - - - - - - -
E G
A T
U t n
O e m
G eg gn N al u i
I n
LW E
ead e
8 UI E sMe u
h c
1 FV S egS ,
ER .
at
1 RE Et u n a
l V
i r
NO R.OlP p
,
A A rd e
J gan a
O n R a T M
8
1
_
I
n o s s i s e
.
t a t g i
c i z
n n
o n
e n
a p
i a t a m h C
o O g
r i z
n l
E e
T a g y e
g t
n r e a y e O K t
u e m e e l
e u O K
t r g g d a
p a a e 9 t t h 8 e e u u c 9 D O O S 1
. . *
-
-
-
-
-
-
_
_
_
-
)
Outage Management and Plant Scheduling Organization Trojan GeneralManager Paul Yundt M
Mantnger Outage Management and Plant Scheduling Bud Suses
- ummmur l
'
Clerk
!
-
I Qutage Manager SchedulingSupervisor Beck Jarnes Jim Chaffin M M Outage Coordinators Lead Scheduler Plant Schedulers (3) (3)
M M l
Outage Project Leaders Scheduling Technicians As Assigned (2)
.
.
G
_- - _ _ - - _ _ _ _ - -
. .
l 1989 Refueling Outage Organization Plant Manager Paul Yundt M
Manager Outage Management and Plant Scheduling Bud Susee M
Cutage Manager Beck James .
M Backshift Manager SchedulingSupervisor Rich Russell Jim Chamn I
\
l I
Major Job Coordinator Area Coordinators Maintenance Coordinator ROC / Turbine /
Main Generator Coordinator 7 7 E l - Eroelon/Corroelon - Containment - Electrical Maintenance - Main Generstar
- S/G ECT - Bloshleid -I&C - Main Turbine
- Snubbers - Turbine / Auxillary - MechanicalMaintenance - Main FW Pump Turbine !
- ISI -Instrument Air - Pumpe
- S/G Sludge Lance - 4.0Ve - HVAC-IST - LLRT - Weldirng ,
- Refuellig - Valven j
- Sl5/ECCS Check \talvee
.
.
.
,
i l
Outage Key Elements
- 65 Day Schedule
- Critical Path - Refueling i
- Modular Competitive Contracts
- Area Coordinators 4
- Shift in Backshift Activities Philosophy
/ Senior Backshift Manager & Coordinator
/ Containment Scaffolding l
/ Containment insulation
- Emphasis on Schedule Adherence
/ User Friendly
/ Daily, 3-Day, 2-Week
.
I
..
.
_ . _ _ _ _ _ _ _ _ _ _ _ _ -
M
_
-
_
_
_
T M'
_
.
R _
A m Q H _
]ilC _
_
a B
_
Mdn FC1
UE L 7Et 4 Lf OMO TES T
-
-
-
.
m _
Y R
= [EV i
w O C
H M [m i
< S p
s s
<
l bFI RC p 9 s B I
3 Y l
z I A a H'
l 0 i
z 3D 5 2 i
a E
Y A t
e i
m s
- i NRO T
v l C
ev A
= si s E i
R n 9 9 g B 8L Y Y i
r a
Al A $
)
l i N C
N C
T S
Sf $ 3 1 N i J V t l l A e D l E e R
i O r 9 C Es FL
/A l
c OI Y
AS D
A
[GN I
s Ov F t
1 MI 3 L O
L
$I iS
_
EE I T
3 A E YE A 1
_
.
_
( ]N p
IN lR M
_
_ : A I C
_
E 9 /
_
S n L
_
E ii T
O I
_
_
T I
l w N YA I
_
e
)
v p H a E & 9 l
R O
T CM X 1 7 0 T A*E Ft S p a N C A
H*fA{
TSf. O
{
P p
s A f.
AEDS C T k 4 2 E IR PI S A T (i G LI)
AY1 C)(N E
IL M
+
I IO C 9D _ _
n Nl D R .__
ITE1 TCt y A P
I n A IIAF CGt {K a
p
) A
O.
A 2
N D 9 C. _
D e N 1 J L
L tl S t s i
W B. I oI t _
FIWDE IW O l A
E LR
P a$ D 6 D.
m9B m LENA/
C i L P O s eA l
e _
I*J-
-
K A
i
C O MA I
BT m (3 nN o A _
E*tO- C, F D A (N i
O ; B i, 9 _
l*s
.
M c
_
_
S*i ; A 8 P 0 1
_
_
y 4 5 y P I
A X 1 I a _
_
n n e
A N 1 C E 9 W 1 O
_
u l
a n r 1 N _
M e
o l i
1 BO A m 5D
_
J p L
+s PT
[Emv
_
t S
a S
P G
_
_
_
_
e
_
A _
_
9 O Cm l
. e , I _
.
.
.
K 1 .
E AcTE r 9
I lCLQ 9 e 5NN 9
II I
s I
0 i-[T A _
IL N6
5
n
_
.
Ne( s9 . _
1 P P s E T 9 A A 4 D B T A e T94DA
_
C 1 f
_
E P _
L 1 E E 0(A R )N T A ~ _
t4TIA 6 NeP5FD ~
O _
e m
, _
_
_
.
_
- k
!
f i
! d..l
,
)'
ll[
'
li:e
~
Y i
aM i
)
.
e
' 9
c4 l
9 8
- w
-
E =4s g
r
=
g_
gm
.
ml. _-g_
3_
P1 .g -a 03'
E- W I
I RE a"
8I y" l WR
.-
5r: --
- Ilo3 8 gjE
'
, n. .
)
ed - .
,
O
- - - - - - - - - - - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ - _
. , j
r o s s t a e e
.
i i
n i t
g ds v r t i o ac t n A c
a ot Cn o h eC k
r C n w r g
aae W o
e d o e g u r t
g k l
aOA n
t f
i a h t
a W m
a add Mtee k s
e aa t
c u g n
T r ogg nn B a
O i r
e t
f i
i ii nss c e h eee i 9 n s SDD f i
i g
k c c e 8 E n
B a /// p 9 S 1 = * .
_
j
.
.
_
d .
t e
a p
g i c
i n i t
r n P a r e s n
a i
l i l r s a r
i k
T d r
e T S s e
r a g l
a g u q
n e L e i n
n t e n o
i l
u i
t i
r d i i
s i
s d C a t c a r f s e Of e f
e e T h t j
o o c n L r f o
r S e P dPe s d u
c
-
t t d c x s y cy n i f
S t
i uB a i c
j e s
- D a d g e t _
o y nd o e n p n e
r t e CL i S l n e n l e
P e w h r
// l n
a i t
e c x
T T P S E
- * * * *
_
- =.
'-
.
. f
l
.
Summary l
l
!
- Engineering Walkdowns !
/ Shutdown
/ Startup i
,
- New Scheduling Tools-Credible / Usable
{
/ Area Schedules ;
/ One Day
/ Three Day ;
/ Two Weeks i
- Manloading Critical Areas (eg, Bioshield)
l
!
- Area Coordinators
- Job Coordinators and Teamwork
Ready-for-Startup Program
/ Outage Management Responsibility
/ Continuous Tracking During Outage
,
"'
,. .
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ - - _