IR 05000344/1990009
| ML20056B523 | |
| Person / Time | |
|---|---|
| Site: | Trojan File:Portland General Electric icon.png |
| Issue date: | 08/15/1990 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20056B243 | List: |
| References | |
| 50-344-90-09, 50-344-90-9, NUDOCS 9008290121 | |
| Download: ML20056B523 (39) | |
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i SALP BOARD REPORT-s. -
U. S. NUCLEAR REGULATORY COMISSION
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REGION V
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SYSTEMATIC ASSESSMENT OF LICENSEE PERF0 7ANCE i
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.i PORTLAND GENERAL ELECTRIC COMPANY TROJAN NUCLEAR PLANT i
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JANUARY l', 1989 THROUGH MARCH 31, 1990
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s" TABLE OF CONTENTS l
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I.
Introduction l
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Summary of Results
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Overview I
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Results of Board Assessment 2-d,
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Changes in SALP Ratings.
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III. Criteria
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' IV.
Performance Analysis
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Plant Operations
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Radiological Controls
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Maintenancs/ Surveillance
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Emergency Freparedness
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Security
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17-F.
Engineering / Technical Support G..
Safety Assessment / Quality Verification'
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V.
Supporting Data and Summaries
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A.
Licensee Activities ~
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' Direct Inspection and Review Activities 24-
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Eniorcement' Activity:
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D.
. Confirmation'of Action Letters
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AE00 Events Analysis.
24-F.
DI Status 24-
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TABLES j
Table 1 - Inspectio c Activities and Enforcement Summary
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Table 2 - Enforcement' Items-Tabis 3 - Synopsis of Licensee Event Reports Attachment 1 - The Office for Analysis and Evaluation of Operational Data-
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Input to SALP Review
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INTRODUCTION:
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The Systematic Assessment of Licensee Performance (SALP) rogram is an t
integrated NRC staff effort to collect available observat ons and data on i
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a periodic basis and evaluate the licensee's performance based on this-l infoTsation.. The program is supplemental to normal regulatory processes used to ensure compliance with NRC rules and regulations.
It is intended
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to be sufficiently diagnostic to provide a rational basis for allocating NRC resources and to provide meaningful feedback to the licensee's
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. management regarding the NRC's assessment of their facility's performance.
in each functional area.
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This report is NRC's SALP Board assessment of the licensee's safety-
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performance at the Trojan Nuclear Power Plant, for the period January 1,
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1989 through March 31, 1990.
A NRC SALP Board, composed of the members
listed below met on May 24 1990, to review the observations and data on.
i performance In accordance wlth NRC Matual Chapter 0516, "Systsmatic Assessment of Licensee Performance." The guidance and evaluation criteria are summarized in Section III' of this report. The Board's
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findings and recommendations were forwarded to the NRC Regional
Administrator for approval and issuance.
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The SALP Board for Trojan was composed of:
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R. P. Zimmerman, Director,' Division of Reactor Safety and Projects (Board Chairman)
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R. A. Scarano, Director Division of Radiation Safety and Safeguards
Chief keactorProectsBranch-
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S. A.' Richards, Acting, Director, Pr ject. Directorate V, NRR'
J. T. Larkins
C. M. Trammell,ief, Emergency Preparedness and Radiological Prot ProjectDirectorateV,NRR G. P. Yuhas, Ch
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Branch-R. C. Barr, Senior Resident Inspector
II.. Summary of Results A.
Overview The Board found that the licensee had improved performance in three
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functional areas and that performance had declined in two functional
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areas.
Overall, the Board concluded that the changes in performance
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largely reflected the degree of management oversight of the area or a lack thereof. The Board considered that-the functional areas of Operations'and Security clearly improved due to increased management emphasis.- Conversely the decline in performance in Emergency Preparedness was attributed to a reduction in licensee attention to j
this area, articularly during the first half of the period.
The
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Maintenance Surveillence functional area was rated as declining i
following the previous SALP period.
The Board concluded that this
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area did decline and was not seriously addressed b licensee management until the latter part of this SALP peri d, The Board recognized that midway through the SALP period, the licenseetookmajorstepstoenhancetheTrojanmanagementteam,and
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to implement broad sco e improvements through the Nuclear Division
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Improvement Plan (NDIP.
Many of the changes envisioned by the NDIP.
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'have yet to occur and several key management positions were vacant, being temporarily filled, or were in transition as'the SALP period
- ended. Therefore the results of the licensee's efforts are only recently beginning.to be observed, however in general positive results-have been seen.
The Board recommended continued im lementation of the Nuclear i!
Division Impovement Pogram (NDIP, increased management oversight-
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in areas of weak or fluctuatin performance, and close monitoring of l
the effectiveness of actions i lemented under the NDIP, such that
,1 revisions to the plan can be quickly made when expected results' en
not achieved.
B.
Results of Board Assessment Overall the SALP Board found the performance of NRC licensed
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activitles by the licensee to be acceptable and directed toward safe-
operation. ' The SALP Board has made specific recommendations-in most H
functional areas = for licensee management consideration. The results of the Board's assessment of the-licensee's performance in each functional area, including the previous assessments, are as follows:
Rating Rating
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Last This
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Fenetional Area-Period Period Trend *
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Plant 0 erations
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Radiolo ical Controls
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Maintenance / Surveillance
3 Improving D.
-2 E.
Security-
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-En ineering/ Technical S port
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G.
Sa e Assessment /Quali
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Veri cation The trend indicates the SALP Board's appraisal of the
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licensee's traction of performance in a functional area such
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that: contin tion of this trend may result-in a change in 4,
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performance level. Determination of the performance trend is-a made: selectively and is. reserved for-those. instances when it is necessary to focus NRC and licensee attention on an area with a declining performance trend, or to acknowledge an improving trend in licensee performance.
It is not necessarily a
. comparison of performance during the current period with the previous period.
C.
Changes in SALP Ratings The chsnges to the SALP ratings from the previous SALP were in the functional areas of Plant Operations, Maintenance / Surveillance, Emergency Preparedness, Security and Safety Assessment / Quality Veri 11 cation.
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Plant' Operations improved from Category 2:to Category 1, primarily due to:the event free operation of the plant and the impro'ted y~
supervision of operations activities by the Shift. Supervisors.
Security and Safety Assessment / Quality Verification both improved
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,.from Category 3 to Category 2, as a result of increased management i
emphasis in sucessfully addressing concerns from the previous.
assessment period.
The sal.P rating for Emergency Preparedness, assessed as Categorin th The change was due in part to fluctuations in performance noted in thit
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function 0 area.
Maintenance / Surveillance, previously rated as Li Category 2, declined to Category 3; however.an improving trend was notedintheMaintenance/SurveillancefunctIonalareaattheendof.
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the period.
The decline resulted primarily due to weak control of activities in this area.
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Further discussion and detail of each individual functional area analysis is contained in Section IV of this report.-
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III. CRITERIA
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Licensee performance is assessed in selected functional areas, depending on whether the facility is in a construction u operazional phase.
Functional areas normally represent areas sigMficant.to nuclear safety and the-environment.
Some functional areas may act be assessed because
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of little or no licensee activities or lack of meaningful observations.
Special areas may be added to highlight significant observations.
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The following evaluation criteria were used, as applicable to assess each
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functional area:
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Assurance of quality, including management involvement and control; l
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Approach to the resolution of technical issues from a safety-L standpoint;
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Responsiveness to NRC initiatives;
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Enforcement history;
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Operational and construction events (including response to, analyses l
of,. reporting of, and corrective actions for);
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Staffing (including management); and 7.
~ Effectiveness of the training and qualification program.
However, the NRC is not limited to these criteria and others may have been used where appropriate.
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On the basis of the NRC assessment, each functional area evaluated i:
rated according to three performance categories.
The definitions of l
these performance categories are as follows:
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Category 1
. Licensee management attention and-involvement are
>reaany evident and place emphasis on superior performance of
' nuclear safety or. safeguards activities, with the resulting f-
performance substantially exceeding regulatory requirements.
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~ticensee. resources are ample and effectively used so that a high
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j ilevel of plant and personnel performance is being achieved.
Reduced
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.NRC attention may be appropriate.
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Category 2.
Licensee management attention to and involvement in the
,:l performance of nuclear safety or safeguards activities are good.
t The: licensee has attained a level of performance above that needed
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Licensee resources are adequate yi and reasonably allocated so that good plant and personnel i
performance is being achieved.
NRC attention may be maintained at normal levels.
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Category 3, Licensee management attention to and involvement in the
. performance of nuclear. safety or safeguards activities are not sufficient. The licensee's performance does not significantly exceed that needed to. meet minimal regulatory requirements, j
Licensee resources appear to be strained or not effectively used, i
NRC atte:ition should be increased above normal levels.
IV.
PERFORMANCE ANALYSIS-
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The following is the Board's assessment of the licensee's performance in each of the functional areas, plus the Board's conclusions for each area
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and its recommendations with respect to licensee actions and management-esphasis.-
A.-
Plant Operations-
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Analysis
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i the licensee's plant operations During the assessment period,inely by.both'the resident inspectors activities were observed rout and the regional staff.
A total of more than 1240 hours0.0144 days <br />0.344 hours <br />0.00205 weeks <br />4.7182e-4 months <br /> of inspection effort was devoted to this functional area.
The licensee's performance in this functional area during the
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previous SALP period was; rated as Category 2.
Prominent-issues of
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the previous SALP warranting management attention were control and shift turnover quality; operations-
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execution of plant activities;lvement in plant activities; event management monitoring and invo evaluation and root cause identification; and timely corrective action implementation.
The licensee's response to these issues has
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been generally appropriate.
Noteworthy achievements in this functional area during this SALP
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period included relatively event free plant operations; completing a
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record 167 day at power run; continuing a strong commitment to minimizing the number of continuously lit annunciators; and an increasing focus by shift management on improving plant material condition.
Several operating events, e.g., slow recognition of a i
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rod misalignment and inoperability of rod monitoring ecuipment,l and =
revealed the need for continued strong focus on commancl, contro
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execution of plant activities, and critical thorough assessment of
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plant events.
'The licensee's approach to the resolution of te m ical issues was.
generally conservative, sound and thorough.
This was illustrated by the close oversight by operations of the overtemperature delta temperature loose electrical connection concern.
The Operations-
Department, on its own initiative, The inspection: identified the inspected selected protection and
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s control instrumentation cabinets.
need to increase the scope of the program to insure the adequacy of
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Other examples of conservative actions e
included the identification of an improperly connected fire damper,
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the shutdown of the reactor upon identification of out-of-specification setpoints for the steam flow trip points and the reduction in power during initial reactor startup from the 1989 Refueling Outage when the Operations Department recognized a data-collectionoversIght.
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The licensee was generally responsive to NRC initiatives.
For-example, in the previous SALP, shift turnover and quality of control room logs were recognized as requiring improvement The licensee
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revised shift turnover' sheets, restricted acces's ti the control room n.
during turnovers revised log keeping procedures and increased managementoversightofturnoversand100 keeping. The results 'of these changes were favorable.
Additionally, procedural compliance was a concern during the previous SALP.
Licensee management has effectively addressed this issue by continuing with their procedure
improvement program, which is revising procedures to improve their technical content and useability. While procedure comp 11ance is stil1 an issue, the number and significance of procedure
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L noncompliances have decreased'over this SALP period..
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L During the assessment period there were three Severity Level IV
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enforcement-actions and nine Licensee Event Reports (LERs) in the
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operations area. The most significant of the enforcement actions
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The violation resulted from an apparent knowledge weakness
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N associated with the rod deviation monitor and its relationship to l-technical specifications.
Of the nine LERs related to this t
functional area, eight resulted from a combination of personnel
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rimarily occurred early
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error (procedural compliance problems that p(that appear to have been l
in the SALP cycle) or defective procedures E
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found due to the licensee's procedural improvement effort).
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Licensee initiatives in improving procedure quality and useability L
are continuing.
With respect to operations staffing, the Operations and Maintenance Department was divided into two separate departments
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b at the midpoint of the SALP period.
The organizational change l
resulted in the addition of a Department Manager for each organization.
For the Operations Department, the change has
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improved the focus on Department weaknesses without impacting management oversight of day-to-day activities.
Presently, PGE is L
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searching for a permanent Operations Department Manager. While
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on-shift staffing normally' exceeded regulatory requirements, high activity periods, such as outages and special plant evolutions, resulted in high overtire rates for extended periods for licensed:
,,,and nonlicensed operators.
Additionally, the implementation of the work control center and operations personnel relocations has. reduced
.the number of active licenses to forty-three.
.The licensee's operations training program was improved by the i
addition of a-hcgh quality site specific' simulator and a new training facility.
The 1989 initial operating examinations l
identified a generic weakness in the operators' knowledge of some
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e immediate operator. actions for emergency, dant evolutions and transitioning from off-normal instructions to system operating procedure).
A licensee Quality Assurance a idit identified a R
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. weakness in the administration of the regrr. Jing technique for
, written examinations. The weakness couir. generally be attributed to o
inadequate management oversight and admitdstrative controls of-l examination regrading. Additionally, Ne Training Department-appeared not to effectively trend perfomce on examinations based t-on repeated weak performance by three opetc' ors on two previous
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L requalification examinations.
The licensee did not appear to; j
recognize the long term trend of these operators, nor had effective l~
measures been taken to remedy their repeated margina1' performance on examinations.
An NRC requalification examination, after the SALP period,-found the licensee's operator requalification program to be g
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B acceptable. Weaknesses were observed in crew coordination and communications.-
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One problem area which developed this assessment period was the
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L control and coordination of plant activities (maintenance,
H surveillance and'special; tests).
For example, while conducting a f
. special plant test to soak the secondary side of the steam a Residual Heat Removal generators in a weak boric acid solution,d.
The operators initially i
(RHR) System heat exchanger was overheate e
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did not recognize the significance of the event nor was the event
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properly communicated to appropriate -levels of m,anagement.. Event
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assessment determined that the engineering safety evaluation and subsequent operation review failed to recognize that elevated reactor coolant system temperature in' conjunction with very limited
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cooling flow could result in heat exchanger overheating. Two other occurrences which also illustrate this concern involved inoperability of the RHR system due to performing a flow switch
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calibration at an inappropriate time, and an event wherein the containment hydrogen vent system was not properly aligned. To
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control and execution the address weaknesses with command,lemented.a work control center to licensee, on March 21 1990, imp remove the administra{ive burden of tracking and coordinating maintenance, surveillance and special tests from the shift management.
The impact of this change is presently under evaluation and has not yet proved to be effective.
This is further discussed In the maintenance / surveillance functional area.
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2.
Performance Rating
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Performance Assessment - Category 1. ~The Board deliberated at length in considering whether a Category I rating was warranted in this functional-area.
The board ultimately concluded that the
'relatively event-free operation of the plant and the overall-performance in this functional area outweighed the concerns e
regarding control and coordination of plant activities and
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weaknesses identified with the training of licensed' ope,rators.
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-Board Recommendation
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Areas warranting additional licensee management attention include s
(1) filling the positicn of Manager, Operations, (2) correcting
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weaknesses in training of licensed operators and (3) improving command control-and execution of plant activities with emphasis on operabilitydeterminations,theinterfacewithmaintenancepersonnel and the performance of non-routine events.
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B.
Radiological Controls 1.
Analysis Seven inspecti ns were conducted in the area of radiological controls, incluaing one special inspection addressing the storage of
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hydrogen gas-i One routine In.and a team inspection in the area of water chemistry.
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spection was performed shortly after the end of this assessment period.
Approximately 445 hours0.00515 days <br />0.124 hours <br />7.357804e-4 weeks <br />1.693225e-4 months <br /> of inspection effort were expended,ities by the resident inspectors.in addition to routine obse controls activ
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Dur.ing the previous assessment period,diological control programs.an i identified in management support of ra Continuation of this support was evidenced during this assessment-period, in efforts to maintain a well-qualified, well-trained staff.
The understaffed ALARA-planning group was improved by the addition.
of one permanent' staff member and outage augmentation of the group with experienced ALARA planners; future plans include the addition of.a plant design engineer to the group.
Key positions within the personnel protection department were well-defined, and the.
qualifications of new staff appointees received appropriate licensee scrutiny.
Consultants were occasionally used to supplement staff expertise, particularly during Nuclear Quality Assurance Department audits.
Completion and use of the new training facility was consistent with the. effort to maintain worker understanding and adherence to procedures.
Dedicated areas in the new facility were provided for the radiation protection and chemistry departments.
Development of an-effective laboratory for chemistry training, however, was-delayed due to cost constraints.
No events or recurrent problems during this appraisal period were identified as having their root cause in inadequate training.
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Management support in the areas of staffing and training was
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commensurate with-overall management involvement in radiological controls.
- licies were d?1ineated and understood.
Radiological
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Event-Reports and Nonconforming Activity Reports, in general, and
,. received timely review, adequate root cause assess effective corrective action.
Departures from this stan however, included a lack of quality assurance initoring of:
active waste processing facilities.and control and the need fc-improved quality control in the nonradioactive iemistry i
. measurements program.
H In addition, although advances were made in the staffing and structure of the ALARA program, management assurance of quality in planning aspects of ALARA warrants improvement. : A September 1989 i
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' inspection noted that the annual ALARA goal _ had already been y
exceeded, and that less than half of the annual refueling outage tasks were accomplished within + 20% of the task goal. ~ A subsequent inspection; performed shortly after the end of this assessment t
revealed that the development of a healthy ALARA program-period,dered by plantwide problems with inefficient outage L'
was hin L
coordination, inconsistent job scope evaluation, and ineffective
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planning.- It is noted that total collective dose has been increasing since 1987. The 1989 total collective dose was-420 L
L person-rem.
The need for repeated NRC promptings in the area of ALARA appeared
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somewhat reflective of slow licensee responsiveness to NRC p
initiatives.- Similar responsiveness was exhibited in the continued storage of radioactive material in marginal facilities such as.
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trailers and exposed, outdoor areas; problems with solid waste storage and processing facilities were items carried over from the
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previous assessment period.
Another recurring issue was the which, in this adequacy of containment gaseous effluent samplingIlure to conduct assessment period, resulted in a deviation for fa e
isokinetic sampling of the hydrogen vent system effluent line
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during containment pressure reductions.
In each of-these I
instances, considerable NRC effort has been needed to obtain resolution.
Licensee resolutioiBof technical issues generally exhibited sound 4,
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i judgment and safety consciousness. The licensee has implemented excellent contamination controls, thereby enhancing performance of a major fuel reconstitution program completed in late February 1989.
Surveys and postings have also improved over the period. -The chemistry team inspection revealed a strong erosion / corrosion control program and good water quality control.
Both the environmental monitoring and radioanalytical programs exhibited strengths, including good measurement verification and measurement m
control practices.
Several areas, however, appeared to require further technical resolution.
The program for transportation of radioactive materials i
appeared technically weak, with deficiencies identified both by the licensee's quality assurance organization and by the NRC, including
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a violation for failure to-concentrationsfor.awasteb$pment.perlyestimateskecificradionuclide..
L In. addit on, the hydrogen vent
system deviation previously mentioned appeared to depart from the licensee's usual standard of safety consciousness, in the temporary
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,.use of makeshift materials and construction.
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Three LERs, one of which was supplemental, were submitted in this
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functional area.
Two concerned monitoring of gaseous effluents and
one. involved environmental sample collection.
These events were l
reported in a timely manner, and appeared to be accurately J
identified.-
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One deviation and three severity level IV violations were identified during this appraisal perioo.
The deviation and one violation have-
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already been outlined; of the remaining violations, one involved a failure to follow procedures for tagging temporary lead shielding installed for the refueling outage, and the other documented
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inadequate work control practices resulting in improper installation
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of a temporary modification to the containment gaseous effluent
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system.
The violations and deviation did not indicate a
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programmatic breakdown in management controls.
However, they were
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o indicative of a need to increase management attention and technical vigilance in the areas involved.
2.
. Performance Ratino j
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Performance Assessment - Category 2 3.
Board Recommendations
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Improve ALARA through better work planning and control.
Consider l
alternatives regarding improvements in areas where performance does not-significantly exceed that needed to meet minimum regulatory j
requirements, such as solid radwaste stora e, processing and v
transportation.
C.
Maintenance / Surveillance
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-t 1.
Analysis
This-functional area was observed routinely during the assessment period by both the resident and regional staff.
Approximately 824 i
hours of inspection effort were devoted to this functional area.
Prominent issues. discussed in the previous SALP for this functionai
area, which was rated as'a Category 2 declining, were programs for corrective action measuring personnel and equipment performance,d supervisory implementation, compliance with procedures, an observation of work in progress.
In general, the licensee did not begin to adequately address these issues until the last quarter of
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a this assessment period.
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During this SALP period the licensee's maintenance and surveillance programs were characterized by inconsistent implementation of administrative controls, supervisory oversight of in progress work,
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- and root' cause analysis and corrective action implementation.. The majority of plant operational events.that occurred were rooted in-this functional area. -Weaknesses were particularly prominent'in the
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administration ~and conduct of the surveillance program.
One event
,.that clearly highlighted the major weaknesses within-this functional area was the containment sump cleanliness and design control issue.
Technical Specifications required inspection of the sump for-cleanliness and design adherence,iteria.or organizational but surveillance procedures did not :lefine adequate acceptance cr i
responsibility.
Insufficient management presence existed over the years to verify that the intent of.the surveillance requirement was-beingmet.
Even-though licensee workers pointed out that debris had
i been previously found in the sump prior to 1989, management did nott
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effectively evaluate and determine the root cause of the debris entering the' sump, nor did management require supervisors to assurei actions were taken to guarantee future acceptable cleanliness andt design adherence.
Another significant example of maintenance'
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program weaknesses, which occurred shortly after the SAI.P period ended involved poor planning of maintenance activities for the 1990 refueling outage, which resulted in numerous maintenance jobs being
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deferred.
Events in the maintenance and surveillance functional area were-generally more apt to' occur when the repair or surveillance effort..
crossed departmental boundaries.absorberwasreplacedinthewrongfilter, ho For instance wh
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amajor contributing cause was miscommunication between a system engineer, the maintenance supervisor and operations.
Examples.of inadequate coordination included inoperability of both containment hydrcgen vent trains and inoperability of-the RHR system due to a flow switch calibration.
Both of these events resulted in unrecognized entries into Technical Specification 3.0.3.- The licensee, through the-Nuclear Division Improvement' Plan and the Maintenance Improvement Plan, have identified a number of actions which have the potential to substantially i rove the quality of maintenance and surveillance activities. ;The ma crity of these actions, d establishment of clear such as the:
implementation of t e work control-center an guidance for supervisor oversight of maintenance / surveillance work, have been partially implemented and should be closely monitored.
The licensee's understanding and resolution of technical issues in e
this functional area was also inconsistent.
For example, maintenance electricians properly notiffr.' plant system engineering
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that an improper retaining nut had been us d on an air loc ( door; however, other cases have been identified where instruments have
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been found out of calibration and not questioned.
Additionally, nonconservative technical positions have resulted in violations in the area of inservice testing.
Until the fourth quarter of 1989, the licensee had been slow in addressing and responding to NRC concerns.
Continued NRC scrutiny i
was necessary to initiate action, and even after the licensee took
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action, NRC follow-up was required to verif that corrective actions were effectively implemented.
Additionall, licensee corrective
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. actions _ frequently corrected the isolated noncompliance but failed
to address the broader concern.
Examples. include administration and implementation of the surveillance program, quality of work
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procedures, and compliance with procedures.
Specifically, missed or inadequate surveillances such as those associated with control room
' emergency. ventilation,fIredampers,containmentspraypump measurements, sump screen integrity and steam flow instrument setpoints, exemplify the recurring issue of inadequate surveillance-program implementation.
On the other hand, since October 1989,hethe licensee response to NRC concerns has greatly improved due>to t Maintenance Manager tracking issues identified by the NRC.
During the assessment period, there were 15 Severity Level IV-violations and 3. Severity Level-V violations.
Eight LERs were submitted in the maintenance / surveillance function area.
The.
violations were. generally caused by inadequate control. of. work that
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stemmed from inadequate field supervision,-poor quality work
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instructions, noncompliance with procedures and-inattention to detail.
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'With respect to maintenance staffing,.the Operations and Maintenance Department was divided into separate departments midway through the SALP period. -The change resulted in the addition of.a Department Manager for each organization. The Department' Manager was-
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permanently assigned in November 1989 and since has focused on implemented to correctly prioritize work actIvhe had actions Maintenance Program weaknesses.
For example'
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ities and reduce the maintenance backlog. Additionally, he participated in the-implementation of measures to improve the control of work.
He has increased maintenance supervisor field observations and is in the
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process of establishing standards for supervisory field. observation.
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The licensee's maintenance training program was well defined and implemented with dedicated resources. With the construction of the
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new training facility, dedicated training-laboratories have been established for each craft.
The laboratories are in the process of being. furnished.
This will afford technicians the opportunity to train on sensitive routine maintenance activities prior to
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conducting the activity in the plant. To date, the licensee has
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constructed shop mockups-for complex activities such as steam
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generator tube plugging.
Inadequate training has not been a significant contributing factor to plant events caused during maintenance and surveillance work.
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2.
Performance Rating Performance Assessment - Category 3, Improving Trend l
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3.
Board Recommendation i
Licensee management should continue to focus on im) roving the=
control of plant work activities.
Specifically,. tie. licensee should continue to-implement the work control center concept, improve
, planning and scheduling, and improve the quality of maintenance and L
surveillance procedures. The licensee should also define clear'
t expectations for middle management to the first line supervisor with j
l respect to quality performance and individual responsibilities, i
D.
Emeroency Preparedness l
1.-
Analysis The previous SALP analysis identified several strengths _and no-
specific weaknesses associated with the licensee's emergency preparedness.(EP) program.
Management support of the EP program and EP training were noted as strengths.
The licensee was rated as a SALP Catego
'l performer during the last SALP assessment period, after havin been-rated as a Category 2 during two previous.SALP periods.~. D ring the last SALP. period, the Board recommended that
licensee management continue its oversight to ensure that the EPL J
program maintained the demonstrated level of performance, and that1
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identified problems be corrected in a thorough and timely manner.
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During this.SALP period, Region V conducted two routine inspections
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The exercise involved full-offsite participation and was evaluated by the Federal Emergency
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ManagementAgency-(FEMA).
The routine inspections assessed the
operational status of the EP and the licensee's response to
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previous inspection findings. program,imately 186 hours0.00215 days <br />0.0517 hours <br />3.075397e-4 weeks <br />7.0773e-5 months <br /> of direct
. Approx inspection effort were expended in the EP functional area.
The two strengths identified during the last SALP period (e.g., management-be. port of the EP program and training) were no longer considered to sup strengths, but notable in)tovement in these two areas was observed toward.the end of tie SALP period.
Also staffing levels withintheEPprogramwere'notadequatewithoutsignificantovertime
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and appear to have resulted in some decline in performance.
The licensee's responsiveness to NRC initiatives was identified as a strength during this SALP period.
The inspections conducted during this assessment period indicated a decrease in the previous high level of management oversight of the EP program.
During the first part of the SALP period, a management
decision was made-to separate EP overview training from general employee trainin.
The execution of this decision taxed the
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licensee's abili to implement its EP training program and
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demonstrated a 1 k of prior planning.
As a result, the full three month grace period had to be used to complete EP training requirements for about 75% of the emergency response organization (ERO).. Management support of the EP program improved toward the end of the SALP period, but only after the results of an internal audit, and the EP exercise, showed that corrective actions were necessary to improve the EP program.
The internal audit was conducted during
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September and October 1989:and. identified problems with incomplete QB training, notification:of emergency response personnel, and command
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and. control-in the O i
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'the audit findings;)perat onal-Support Center (OSC Support Center (TSC.. Corrective actions were taken as a result of-l 7J however, the licensee's corrective actions were ti-not effective, as evidenced by the results of the annual exercise conducted on November 15, 1989.
The NRC, identified three exercise-
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weaknesses during the exercise. Weaknesses were associated with a delay in the classification of the site area emergencyIth-the dose
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.with se management and control of activities in the TSC; and w assessment area.
Based on the results of the exercise, licensee e
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i management authorized the EP staff to increase the technical' staff position responsibilities,perations Facility (EOF), redefine certain in the TSC and Emergency O s
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revise procedures, enhance the training program, and make facility modifications.
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The licensee's approach to resolution of issues from a safety
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standpoint is generally timely and conservative.
Inspections conducted during this appraisal period identified two examples where conservatism was not exhibited. One example. involved the licensee's-failure to classify an unusual event, based on identified pressure q
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boundary leakage, as required by its emergency plan implementing g
procedures (EPIPs).
Theeventactuallyoccurredattheendofthe previous SALP period however the NRC s evaluation took place i
during this SALP perlod.
AVIolationwasissued'forfailureto.
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implement an EPIP. The other example involved a modification to the licensee's classification. procedure. The procedure was. changed to
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provide-additional guidance to the user, but the change.could have classifications due to unnecessary, resulted in delayed emergency'gency action levels (EALs). The coenge redundant assessments of emer provided for a 15. minute period to assess the validity of emergency indicators (e.g., alarms, instrument readings, observations) before-declaring events.,
A strength was identified with respect to the licensee's-responsiveness.to NRC initiatives. This strength was demonstrated when the licensee responded to the NRC's concerns about its performance during the annual exercise and its procedure for
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classifying emergencies.
The-actions taken in response to these L,'
concerns were considered to be timely and effective. The licensee has taken action to improve emergency procedures.
The NRC recognizes the licensee's work and encourages continued effort to refine and improve emergency procedures.
i h
One violation of NRC requirements was identified during this SALP l
period. Details regarding this violation have been described above.
This violation did not represent a programmatic breakdown, and the L
licensee's corrective action was prompt and effective.
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The licensee had one opportunity to implement its emergency plan ll cam og this SALP period.
An unusual event was declared in March
,
1990, due to the initiation of a plant shutdown required by l
i Technical Specification 1.
The licensee's response was timely, and e
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in accordance with-EPIPs.
Notifications to the offsia authoritie's
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L were made in a timely manner.
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The licensee experienced some instability in the EP program staffing a
,, during the SALP period.
The individual who worked with the offsite
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agencies left in April 1989. The position remained vacant until September 1989,' at which time a contractor was hired. Another-contractor was subsequently hired as an assistant.
Between' April
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and September 1989, the licensee reassigned the remaining staff (two
individuals) to cover critical onsite and offsite activities.. Some
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deterioration in the interface with the offsite agencies was noted during the: September / October internal audit, and EMA identified five. deficiencies during the 1989 annual exercise.
The EP group was
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not considered to be fully-staffed until December 1989, when a
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J full-time, PGE employee was added to the EP staff. The results of
the 1989 annual exercise prompted the licensee to initiate an m
t aggressive series of corrective actions, both onsite and.offsite.
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Implementation of the corrective actions required the staff to work-
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a great deal of overtime.
The inspections conducted during this appraisal period showed that the licensee's training and qualification program was' adequate.
Shift supervisor interviews conducted during the first part of the
+j SALP ~ period indicated a need for more practice at classifying higher
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level events and recommending protective actions at the higher.
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levels.- eThe licensee's training program partially contributed to
the three weaknesses identified during the annual exercise.
The licensee strengthened its training program as a result of the exercise.
The-licensee has replaced its table-top training sessions-
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using-the licensed operator simulator with integrated drills,ive the real-time emergency response actions.
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training sessions-to dr All-ERO members must participate in at least one of these drills to
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maintain their training qualifications.
Shift supervisor
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' interviews, conducted near the end-of the SALP period,'showed
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improvement.
ThestaffreviewedthechangesmadetotheTrojanemergencyplan during the appraisal period.
The changes were acceptable and a
continued to meet NRC requirements.
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2.
Performance Ratina
$
Performance Assessment - Category 2 3.
Board Recommendation Licensee management should adopt a proactive approach to EP matters, and ensure that a consistent level of support and staffing is provided to the EP program to minimize fluctuations observed during
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this period. The effectiveness of training should be closely i
monitored to ensure a constant level of preparedness.
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E.
Security
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1.
Analysis-o.
During this SALP perio'd Region V conducted four physical security.
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' inspections.
Over 430 hours0.00498 days <br />0.119 hours <br />7.109788e-4 weeks <br />1.63615e-4 months <br /> of inspection effort were expended by
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regional safeguards inspectors.
In. addition, the resident.
inspectors provided observations in this-area. The previous SALP -
rated the licensee a Category 3 in the security functional area.-
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.0verall, for this SALP period, the licensee's security program was
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acceptable, but satisfied only minimum requirements in the area of
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access control of personnel, as discussed below.
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The last SALP report encouraged the licensee to take a fresh look at-
the Security Department with respect to understanding why mana!ement
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l had not been effective in improving performance.
The last sal
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report also-encouraged the licensee to' improve the Security
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Department's internal management procedures and assignment ci
responsibilities.
Both of these actions have been completed.
During this SALP period, the licensee's Quality Assurance Department completed a comprehensive independent review of security management
effectiveness. TheSecurltyDepartmentcompletedappropriate corrective actions to.he recommendations in this QA review.-
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Additionally, the Security Department completed an internal review of security operations to ensure that all requirements of the
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Security Plan and the Training and Qualification Plan were
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appropriately addressed,.and that security training material adequately addressed these requirements. A number of procedure L
revisions were completed as a result of this review. -Further, the
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H N xlear Security Department Manager effectively improved j
r.:amunications within the Security Department, and with other plant
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departments.
Emphasis was placed on assuring that personnel at all
1evels are familiar with the requirements and expected performance
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oftheirassignedjobs. The licensee's overall management l
involvement and control demonstrated evidence of planning and
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assignment of priorities.
The previous SALP report also discussed the licensee's past pattern
of inattention to identified security concerns.
During the current
SALP period, the licensee's performance in this area has improved in a
that more emphasis has been placed upon meeting milestone dites, and correcting deficiencies and weaknesses identified in the-course of both internal and NRC security inspections.
During this SALP period, the licensee completed upgrades to their protected area
~1 lighting.
Further in response to weaknesses identified during the L
November 1966 Regulatory Effectiveness Review, the licensee installedadditionalclosedcirctittelevision(CCTV)camerasinside the protected area. The upgrade of the CCTV cameras also effectively reduced the num)er of long-term compensatory security posts.
The licensee's resolution of identified technical issues has
improved.
An understanding of issues is generally apparent, and
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~ solutions are viable, and generally sound and thorough.
The
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. previous SALP report indicated that the. number of, security" events
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and inspector observations reinforced the perception that the security program operations and support is functioning at a' minimum
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compliance level..." During this SALP period the licensee's
improvements in resolving identified technical issues have'resulted i
m (following a Notice of Violation) in improved storage and handling.
j of documents containing safeguards infomation-(SGI).. Additionally,
the licensee effectively reduced the number of personnel with access
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to SGI.
Further again following a Notice of Violation), the-licensee effectiv(andelyImprovedtheirsecurityoffic'ers' ability.to
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qualify with required firearms.
Control of personnel being processed in the access control facility, i
and the adequacy of backup po m sources for. security systems-
'i continue to be issues. The cresent access control facility is congested and the personn'el ' search-trains are confined to an
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extremely small search siea.
The flow rate of personnel through the access control facility, especially during hours of-shift change, causes extremely crowdsd conditions at the search trains and the'
badge-issue windows. As a result, the licensee's access control i
program in this area'carely meets minimum requirements.-lThe
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licensee has included a new access control facility-in the design of-anewon-sitebuildingluationofthebackuppower:sourcesforscheduled for comple
licensee's ongoing eva l
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security systems may necessitate modifications to their backup power
sources.
During the SALP period, two-information notices.and one generic a
letter related to security were issued. The licensee responsiveness and actions as reviewed to date, were found to be viable and generally sound and. thorough.
The enforcement history for the SALP period involved issuance of'
a The three i
three Level-IV violations $e nd two non-cited violations.
violations pertained to t licensee's failure of certain on-duty
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armed security officers to demonstrate firearms proficiency, failure I
to properly protect safeguards information, and failure to-adequately search packages entering the protected l area. The two non-cited violations pertained to an inattentive security,
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and the failure of an on-duty. security officer to watchperson, ired security equipment.Additionally, an enforcement-
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possess requ conference was held to discuss the first two violations.
In response to these items, the licensee's corrective actions were thorough and effective.
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During this SALP period, the licensee reported eight safeguards-events.
Seven of these events resulted from personnel error:
secure documents containing safeguards informatIon (ilure to properly Positive fitness for duty test for a supervisor fa two),
inattentive security officer, inadequate background screening records, security officer posted as compensatory measure wit 1out proper security equipment and inadequate search of packages entering
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the protected area; and one resulted from a design deficiency:
Degraded vital area barrier.
Key positions and responsibilities within the Security Department, (
with the exception of the security training section were generally DuringthisSALPperiod securityofficerattrition well defined.
was reduced, but con 6inued focus is stIll needed in this area.
During the first half of the SALP period NRC identified deficiencies in the licensee 4 security Iraining program. 6 violation was identified (as a result of certain on-duty security officers failing to demonstrate fiream proficiency)f the SALP, and numeron, weaknesses were identified. During the last half o period, the licensee's corrective measures significantly improved the overall quality of security training and the quality of firearms training for each security officer. The licensee developed a higher standard fer weapons proficiency which exceeds NRC requirements.
This new standard, increased testing rates, and additional practicetogether w training program times hasresulledinadecreasedfailurerateandincreased overall weapons proficiency scores for security officers.
2.
Perfomance Ratino Performance Assessment'- Category 2 3.
Board Recommendations
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The SALP Board recommends that licensee management reassess the flow rate of personnel processing through the access control facility.
Further, the licensee is encouraged to complete their evaluation of the adequacy of backup power sources for security systems, and to Additionally licensee management resolve any identified problems.
is en:ouraged to continue their emphasis upon Independent reviews of i
securH y, and the conduct of security training and weapons qualification.
F.
Engirtee_rjnp/Technicai Rort
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1.
Analysis
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This functional area was reviewed routinely by both reofonal inspectors and the resident staff.
A total of 812 inspection hoars was expended in this functional area, not including NRR s'.sff activities. These reviews focused on Nuclear Plant Ercineering
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(NPE) and Plant System Engineerin (PSE), the organizations f
responsible for plant design and lant systems, respectively e
Additionally, an NRC followup of he licensen's 1988 Safety System i
Functional Inspection (SSFI) on the control room heating and ventilation system and the 120 volt preferred power system was conducted.
Following the previous SALP period, the licensee's performance in this functional area was rated as a Category 2.
The SALP Board recomtnended that the licensee continue strengthening the system
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intering and the Design ~ Basis Document (DBD) programs, and the a
s ety evaluation and event assessment functions.
S In general nsee was responsive to these concerns; however, instances, the li red where management followup was not totally effective in the oce impi ntation of corrective actions.
For example, training was
+ cond ed to improve the quality of engineerir.3 evaluations but events 'uch as overheating of an RHP, heat exchanger during a, boric acid so of the steam generators continued to occur in port due to engineer review problems.
During this ALP period, the assurance of quality was generally accep".able t recurring weaknesses in administrative controls for designworka design calculations were identified. General
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examples which oint out these weaknesses include examples of not maintaining dra ngs current, not adequately updating the FSAR after design changes t high number of old Temporary Mod 1fications trans)latedtochaneand engInee ino
'culations that were not properly (TMs
' ant safety setpoints. The specific most recent example +'
s 'esthemajorityoftheseweaknesseswas the incorrec+
Additiona!*
setpoint for main steam line flow.
'uations of plant procedures to ensure a high qua.
Examples of teet procedure were not consistent, t
9 test procedures for the remote
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a shutdown stat C/
id soak of the steam generators.
Licensee subm1 y-ied in quality. The large number
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of license cha u g
tially as a result of attention to improved plan V ~
O 'cedures, appear to have received good tee.
'e other hand the ATws/AMsAC design review took (f,
mplete as a, result of initia11 providing tion to NRR, and due to insuffic a t engine *>
t,.
The licensee's approach
' technical issues was at times reactive and not a
't outside organization involvement.
This was ex,
[/ nsee identifyinb NRC
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aissing top fine mesh scres i, sump after t identified debris in the sui.
. sump screen. The NRC i
also identified other missink reens two days after the licensee identified the missir.
A1
, NRC questioning was
'i needed after the plant trip on.
.vaporatu'
delta temperature to
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identify concerns about the RCS emperature i ccuracies.
q Particularly evident during these events was a trong need to
improve the coordinatic,. vetween PGE desion and stem engineering groups.
On the other hand the licensee Identiff an issue with circumferential cracking of the steam generator tu s and then inspected all affected tubes to fix and resolve the roblem.
AdditionallykafetyValve(PSV) disc.the licensee was continuing an evalua
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Pressurizar.
The licensee's
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erosion / corrosion program was also considered to be te ically sound and thorough.
The engineering groups have generally been responsive to N and industry initiatives. The improvement initiatives for the reconstruction effort and walkdowns appear to be improving t
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en ineerin and the Design Basis Document (DBD) pro rams, and the sa ety eva uation and event assessment functions.
n general, the i
licensee was responsive to these concerns; however instances i
occurred where management followup was not totally, effective in the implementation of corrective actions.
For example training was i
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conduct'd to improve the quality of engineering eva,luations, but e
events such as overheating of an RHR heat exchanger during a boric (
acid soak of the steam generators continued to occur in part due to engineering review problems.
During this SALP period, the assurance of quality was generally
acceptable, but recurring weaknesses in administrative controls for i
design work and design calculations were identified. General
examples which point out these weaknesses include examples of not maintaining drawings current, not adequately updating the FSAR afte"
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design changes the high number of old Temporary Modifications (TMs)latedtochangesofplantsafetysetpointsmiengIneeringj trans he specific most
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recent exampie that recognizes the majority of these weaknesses was
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the incorrect ESF instrument setpoint for main steam line flow.
Additionally, engineering evaluations of plant procedures to ensure a high quality, technically correct procedure were not consistent.
Examples of problems included the test procedures for the remote shutdown station and the boric acid soak of the steam generators.
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Licensee submittals to NRR have varied in quality.
The large number of license change applications, partially as a result of attention to improved plant performance and procedures, appear to have received good technical review.
It is noted, however that because
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of the licensee's delay in arriving at a final design,for ATWS/AMSAC,TrojanwillbeamongtielasttoimplementAMSAC,an
important safety feature.
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The licensee's approach to the resolution of technical i% ues was at times reactive and not always thorough without outside organization involvement..This was exemplified by the licensee ih ntifying missing top fine mesh screens on the containment suno after tie NRC identified debris in the sump and gaps.in the sump s:reen.
The NRC also identified other missing and damaged screens twe days after the licensee identified the missing screen.
Also, NRC qttstioning was
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needed after the plant trip on overtemperature delta emperature to identify concerns about the RCS temperature inaccuracits.
Particularly evident during these events was a strong need to improve the coordination between PGE design and system engineering groups.
On the other hand, the licensee identified an issue with circumferential cracking of the steam generator tubes and then inspected all affected tubes to fix and resolve the problem.
Additionally $afetyValve(PSV) disc..Thelicensee'sthe licensee was con Pressurizer erosion / corrosion program was also considered to be technically sound and thorough.
The engineering groups have generally been responsive to NRC and
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industry initiatives.
Tha improvement initiatives for the DBD L
reconstruction effort and walkdowns appear to be improving the g
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design basis understanding. This DBD effort was reassessed after an
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escalated enforcement action on the containment sump.
As corrective
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action for the enforcement action, the licensee embarked on an
,i effort to re-perform system walkdowns to identify and resolve plant
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problems.
DBDs are being developed in accordance with the
licensee's. schedule.
DBDs are also addressed in engineering procedures which require DBD consideration during the preliminary design phase and again when processing the as-built packages.
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The licensee embarked on their own SSFI and has initiated i i improvements after NRC SSFIs on the plant.
During the SALP period, thelicensee'sQAgrouphasperformedanSSFIontheServiceWater System with engineering involvement.
The NRC assessment of this
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$5FI was that it was generally acceptable and showed signs of I
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continuet'
u+. wesents.
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There w n 22 aforcement actions taken in this functional area during t '-
.LP period of which 10 were Severity Level IV i
violation,
nd 2 were $everity Level V violations. There were also 12 LERs inued to this functional area by the ifcensee.
The violations related to the control of design work and modifications, modification implementation, engineering evaluation, and existing
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plant design deficiencies, some of which were from original construction.
The issues relate # to operational and construction events included
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engineering work that was not done correctly to the orillinal design,
design modifications. g experience that was not transmi".ted intoAn ;
and new plant operatin as assumed by safety analysis was different than the plant, was the hangers on the control room emergency ventilation system ductwork.
One.cf the issues, where operating experience gained from Trojan and other power plants should have changed the design, was related to
the hydrogen and nitrogen storage tanks on the control building roof.
After NRC identification of this issue, the licensee performed a design change during the last refueling outage that moved the hydrogen tanks off cf the control building.
Inspections have generally shown the experience level and qualification of personnel to be acceptable but the licensee should assurethatengineeringpersonnelstaffinglevelsareadequateto deal with the ty>e of concerns previously mentioned. The licensee has experienced 11gh attrition of plant system engineers over the SALP period which appears to be partially attributable to high work loads associated with assigning multiple systems per engineer and due to continuing re definition of job tas<s.
The plant system engineering grou) staffing has now apparently stabilized and increased.
The >SE Branc1 manager was reassigned to another 1989. The new branch manager for non-nuclear part of PGE in August,imately six months.Staffing PSEhasbeenonthejobforapprox levels for the NPE group have remained essentially constant for 1989.
NPE had several engineers leave due to the plant moving the corporate engineering staff out to the site in 1988-89. The electrical NPE group experienced losses in 1989, but their number t
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has stabilized. The NPE Manager was reassigned in January 1990 and i
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en acting individual was assigned to that position. -The licensee has been in the process of converting contract personnel to-3 permanent plcnt employees for the engineering groups.
A training j
program for system engineers is being implemented and a training
' program for design engineers is being developed. At the end of the
$ ALP period an engineering excellence program was being developed and used.
j g
2.
Performance Retino Performance Assessment - Category 2 3.
Board Recommendation
.
The licensee should place emphasis on its controls over design work andsafetyevaluationsi.e.lationsandassumptions,.qualityof setpoint methodology
licensing submittels calcu The licensee should aggressively Identify where the original design intent of the
-
plant is not being met and where industry experience and design J
problems relate to the plant.
The licensee should also pursue stabilizing the engineering staff and permanentl position of Manager, Nuclear Plant Engineering. y filling the G.
Safety Assessment /0uality Verification
,
1.
Analysis
)
This. functional area was observed routinely during the assessment period by both the resident and regional inspection staffs.
'
Approximately 861 hours0.00997 days <br />0.239 hours <br />0.00142 weeks <br />3.276105e-4 months <br /> of inspection effort were devoted ta this functional area. The performance of Quality Operations, Outi ty Support Service, Quality Inspections, Performance Monitoring / Event Analysis (PM/EA),includedinthisassessment,aswellasthethe Trojan Nucle Review Board was l'icensee organizations involved in the review of regulatory and industry initiatives.
'
During the previous SALP period, the licensee's performance in this functional area was'. rated as Category 3.
Significant issues that
,
required licensee attention included Nuclear Quality Assurance
'
,
Department involvement in plant problem areas, trending of plant events, and middle level management involvement in plant activities.
the licensee, via the Nuclear Division Improvement Plan In general,lity Assurance Improvement Plan, has or is addressing and the Qua these issues.
With respect to management involvement and control in the assurance i-of quality, the Quality Assurance organizations have de:nonstrated
'
consistent, methodical improvement since the midpoint of the SALP period.
Of particular note were the improvements in the depth and
'
thoroughness of QA department audits and surveillances, and in
,
!
safety related materials procurement.
Audits in the areas of fire protection, emergency preparedness, maintenance, training and
!
'
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radiation protection identified program weaknesses in addition to b
.
isolated cases of noncompliance.
The imarovement in the quality and thoroughness of audits was largely attrisuted to increased QA
<
management oversight and assuring that the auditors were technically knowledgeable in the areas assessed.
The surveillances conducted by
'
' the QA department improved their focus on plant activities and i particular, trended activities that rf presented recurring Issues.n
>
Examplesofsurveillancefindingrepro,udedinadequatelatchingof s ine
.
I reactor trip breakers missed f tection Technical Specificationsurveillancesandinadtquateclosureofelectrical terminal boxes.
The licensee also conducted a Safety System
Functional Inspection (SSFI) on thr. Service Water System, which was productive in that configuration control weaknesses were identified.
Additionally, the licensee, on February 23, 1990, revised the Corrective Action Program (CAP) to consolidate the multiple internal problem reporting systems.
The effectiveness of this change is presently under evaluation.
With regard to resolution of technical issues from a safety standpoint the licensee demonstrated extremes of involvement and effectivene,ss. On one hand, the licensee thoroughly evaluated the
!
safety significance of loose wires found in containment electrical
<
penetrations and the fracturing of a pressurizer safety valve disc during testing.
On the other extreme, licensee management failed to properly assess the significance of debris found in the containment
_.
recirculation sump or the incorrect protective system setpoint for
$
steamline flow. ' Additionally, licensee safety evaluations (10 CFR 50.59 reviews) were not always thorough and well-documented.
For example, the review conducted for the boric acid flushing of steam generators failed to identify that the procedure placed the residual heat removal heat exchanger in a condition for which it was not designed.
The licensee should continue to focus on conservative decisions on the part of management. -A positive example of conservative action was the reduction of reactor power to 97% while i
evaluating Tave concer.1s.
!
!
The licensee has been generally responsive to NRC initiatives during l
this SALP period.
As an interim measure to improve the quality of audits, the licensee augmented its staff with auditors recognized throughout the industry in their area of expertise.
The quality of
,
'
the audits improved significantly.
As a long term measure, the licansee identified the qualification characteristics the Quality l
Assurance Department should strive to attain. To identify Quality Assurance inspector knowledge requirements,irements necessary toan i l
has been developed that identifies the requ improve inspection capabilities. The licensee's responses to NRC l
Generic Letters and Bulletins have generally been thorough and l:
conservative.
The licensee voluntarily participated in an NRC sponscred initiative that assessed the integrity of reactor vessel E
supports with respect to increased seismic loading and neutron embrittlement.
The licensee has also recognized the need to improve the effectiveness of the independent safety review connittees:
the
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Trojan Nuclear Operating Bestd (TNOB) and the Plant Review Board
(PRB).
A dedicated staff o' three engineers has been assi provide administrative and technical support to the TN08. gned to
,
Both the TNOB and PRB staffs have undergone recent membership changes directed at improving the Boards' performance.
The Boards' reviews
,
of plant procedures and tests, plant events and Nuclear Division s
E organizational effectiveness may wanant strengthening.
For
example, the apparent decline in p rtermance in the maintenance / surveillance functional area is an area where oversight
by these committees could affect early identification of negative
]
trends in program performance.
'
Duringtheassessmentperiod,therewerenineenforcementactionsin
this unctional area: one Severity Level II violation fiv Level IV violations and three Severity Level V violations.e Severity Collectively, the violations indicated weaknesses in line management commitment to ensure the performance of quality work, and in tie QualityAssuranceorganizationtoidentifymajorprogrammatic weaknesses through surveillances and audits.
The ma-ority of these violations occurred prior to the midpoint of the SALE period and the
.
'
implementation of the licensee's initiatives to improve performance.
As a result of aggressive management actions that include organization personnel and program chan j
violations ge,nerally have not recurred. ges, these types of
'
-
The licensee's program for operational event evaluation root cause i
determinationandcorrectiveactionimplementationhasImprovedover this SALP period. The licensee has initiated critiques that
,
assemble participants of a plant event within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the event
,
so that event reconstruction can occur widle the causal factors are
fresh in the minds of the participants.
However, the licensee did not consistently identify event root cause and the Performance Monitoring / Event Analysis (PM/EA) group did not always critically review root cause determinations performed by other Nuclear Divisions.
PM/EA also did not always ensure that event evaluations and root cause determinations used proven analysis techniques e.g.,
MORT change analysis and event causal factors.
The timeliness and
'
qualItyofLERsubmittalswasgenerallyacceptable. However, the licensee's initial LER submittals included relatively frequent use
,
of abstract submittals. Weaknesses were observed with the tracking and implementation of corrective actions.
On several occasions, t1e licensee believed and reported that corrective t.ctions had been implemented when the corrective actions actually had not been fully completed.
In general, the commitment tracking program has a large backlog of overdue commitments and is not used well as an administrative tool.
With respect to Quality Assurance Department staffing, Manager level
'
the licensee elevated the Quality Assurance Manager to the General and inserted proven a management positions.ggressive personnel in supervisory andAdditionally, permanent staff positions from approximately 45 positions to 78 due to assimilating contract personnel; the overall number of personnel dedicated to QA has not significantly changed.
In doing so, the
_.
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licensee stabilized the inspection force.
The licensee continues to
'
-
lack specific expertise in certain disciplines such as electrical engineering and fire protection.
The licensee plans to augment its
'
inspection staff with contract experts until permanent staf f with gngineering expertise can be hired.
'
The licensee is in the process of developing a formal training program for Nuclear Quality Assurance Department personnel.
During this SALP period, QA inspectors have received training with respect
,
to event analysis, performance based inspection and front-line leadership.
,
Per,formance Ratino 2.
e Performance Assessment - Category 2 3.
Board Recommendation The licensee is encouraged to continue strong emphasis in im) roving the Nuclear Quality Assurance Procram, with the goal being tie continual performance of high quality, critical audits.
The licensee should continue to pursue their goal of establishing a Quality Assurance Department with an appropriate cross-section of technical experts and engineers. The licensee should closely follow the implementation of the CAP and improve commitment tracking. The TNOB and the PRB should improve their focus on broader plant safety
issues.
"
V.
SUPPDRTING DATA AND SUMMARIES
!
I_
A.
Licensee Activities l
In eneral, Trojan operated acceptably during the assessment period.
t'
Tro an began the assessment period operating at 100% power. On l
Mar h 4,1989, a steam generator water level transient was experienced durino 100% power operations as a result of attempting
'
an instrument callbration that should have been done while shutdown.
The reactor was shutdown for the annual refueling outage on April 6, 1989. Majoroutageactivitiesincludededdycurrentexaminationof
.
incore flux thimbles and steam generator tubes, reactor vessel
.
inservice inspection, and followup of problems with containment electrical penetration wire connections and with containment recirculation sump cleanliness and confi uration.
The reactor was taken critical on July 25, 1989.
On Jul 27, 1989 a dropped control rod was experienced and the plant was sh tdown for investigation and
repair.
Restart occurred on August 1, 1989, and the reactor operated until August 9 1989 w1en an overtemperature delta temperature (OTdT) trip, occurred from 50% power.
Restart was on August 14, 1989, but problems with the OTdT circuit continued until September 16, 1989 when the plant was shutdown to repair a leaking pressurizer safety valve.
During this shutdown maintenance was conducted to clean and tighten protective cabinet connections to The licensee limited operation to 97%perations on The plant returned to power o address the OTdT issues.
pending October 3, 1989.
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resolution of reactor coolant system (RCS) temperature
!
.-
non-conservatisms in plant control and protective functions.
The plant essentially continued operations at 97% power until January 12, 1990 when the RCS temperature concerns were resolved, and power i
was escalated to 100% on January 14, 1990. The plant operated at
>
'100% power until March 19, 1990 and was then shutdown, because of non-conservatisms in steam flow protection setpoints.
The licensee commenced their annual refueling outage which was ongoing through
.
'
the end of the SALP period.
Plant rtatus at end of SALP period Trojan ended the evaluation period with the unit shutdown for a
scheduled refueling outage.
B.
Direct Inspection and Review Activities j
A total of about 4800 hours0.0556 days <br />1.333 hours <br />0.00794 weeks <br />0.00183 months <br /> et direct inspection was performed during this SALP period.
Table 1 provides a summary of those inspection activities.
C.
Enforcement Activity
Along with a summary of inspection activities, a summary of
~s enforcement items resulting from those inspections is provided in
'
.
Table 1.
A description of the enforcement items is provided in
-
Table 2.
D.
Confirmation of Actions Letters (CAls)
No CALs were issued during the assessment period.
l E.
Off' ice of Analysis and Evaluation of Operational Data (AEOD) Event Analysis AECD reviewed the licensee's events and prepared a report which is included as Attachment 1.
AE00 reviewed LER's and significant j
operating events for quality of reporting and effectiveness of identified corrective actions.
F.
Office of Investigation (01) Status 1989, O! had no matters open and pending relevant to On January 1, inquiries were opened and closed in the period of Trojan.
Two January 1, 1989 through March 31 1990.
No matters were open and pending as of March 31, 1990, relevanttoTrojan.
,
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N TABLE 1
!
R
'i, INSPECTIONACTIVITIESANDENFORCEMENTSUMMARY(01/01/89-03/31/90)
4^
TROJAN
!
,
-
m Inspections Conducted Enforcement Iteml Inspection Percent Severity Level
Functional Aree Hours of Effort I
II III IV V Dev
,
'I.
Plant Operations 1246
3 2.
Radiological Controls 445
3
3.
Maintenance / Surveillance 824
15
'
4.
1
5.
Security 432
3
"
6.
Engineering /
Technical Support 812
10- 2
"
7.
Safety Assessment /
Quality Verification 861
1
3
.
Totals-4806 100
40
1
Allocations of inspection hours to each functional area are approximations based upon NRC form 766 data.
These numbers do not include inspection hours by NRC contract personnel.
Severity levels are in accordance with NRC Enforcement Policy (10 CFR Part 2, j
AppendixC).
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TABLE 2
.
TROJAN ENFORCEMENT ITEMS
'
(01/01/89 - 03/31/90)
,
Inspection Severity Functional Report No.
Subject Level Area
!
,
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89-01 Radiation monitor calibration IV
test procedure was not changed
'
as stated in a licensee event-i report
.:
89-01 Test personnel performed a steam V
nonerator level test in a mannet
<nconsistent with the procedure
,
,
89-01 Charcoal absorber was replaced in IV
a containment vent system not tagged out or cleared for work.
No work was performed on the vent system specified in the work instructions
.
.
89-01 A quality control inspector did IV
not note and document failures to follow approved procedures during testing 89-D2 Certain on duty armed security IV
- officers were unable to demonstrate firearms proficiency
,
8 9- 04 Plant staff determined pressure IV
bounda y leakage existed but did-not declare an unusual event 89-05 An NCR regardtng nonconforming weld IV
,
...
filler material was not processed 3,
in accordance with QA program procedures
-
89-05.
Engineering drawings were not IV
updated within the time specified by :)lant procedures or when the num>er of change notices exceeded a limit
- .
89-08 Safeguards information was left IV
unattended and improperly stored i
i L
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TABLE 2 (continued)
TROJAN ENFORCEMENT ITEMS
[01/01/59 - 03/31/90)
Inspectioq Severity Functional Report No.
Sub.iect level Area
,
'
89-09 Various calculations and design IV
changes hold incorrect assumptions,
-
resulted in exceeding design i
criteria, or did not include design verifications i
,
89-09-Loss of AC instrument bus procedure V
had not been revised to reflect a design modification in the control room
,
E.actrical test and measurin IV
l 89-0S equipmentwerenotcalibrate!
prior to being placed in operation
89-09 Surveillance testing of the control IV
room emergency ventilation system was performed with a supplemental cooling system in operation 89-09 Nonconformance reports for IV
conditions related to the inverters were not issued
,
89-10
- Recording of entry to Mode 2 IV
was made in the control room log eight days after the avent 89-10 Vibration testing of a containment V
spray pump was performed using an instrument less accurate than required 89-12 Review of ultrasonic test records V
indicated improper documentation of weld examinations, and equipment calibration was not performed.
Improper marking of welds was also observed.
- 89-12 A radiography indication greater V
than specification had not been evaluated 89-12 Weld inspection reference IV
points and identification was unacceptable
.
,
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TABLE 2 (continued)
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TROJAN ENFORCEMENT ITEMS
,
(01/01/59 - 03/31/90)
Inspection Severity Functional i
Report No.
Subject Level Area 89-12 Ultrasonic weld examinations V
data were not properly specified 89-12 Examinations given to NDE IV
,
contractor personnel did not j
cover the required test area and were open book vs. closed book 89-13 Testing did not verify permissive IV
and interlock features of a RHR suction isolation valve after modification. Subsequently, the permissive and interlock features were found to be inoperable 89-14 Maintenance tags had not been IV
.
assigned or used to identify temporary lead shielding installed
'_
in the reactor containment building and the auxiliary building 89-17 A maintenance instruction did not-IV
indicate that the plant was to be
_ performed at 100% procedure was shutdown, and the power which resulted.in a steam generator water level transient. Another work
'
instruction was not performed as written 89-17 Personnel identified boiling IV
in the RHR/CCW heat exchangers but did not promptly document the
.
boiling as a nonconforming activity.
89-17 Personnel performing a maintenance IV
procedure did not follow the procedure as written and did not
'
obtain a change 89-17 Oily rags on components and open IV
containers of oil near com)onents were noted at the end of tie work day
.
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TABLE 2 (continued)
.
i TROJAN ENFORCEMENT ITEMS
[01/01/59 - 03/J1/90)
r)
Inspection Severity functional I
, Report No?
Sub.iect Level Area 89-17 Failure to resp'ond to " Request IV
for Evaluation in accordance
,!
with procedures 89-17 Wire pulling to verify containment IV
penetration condition without work
,
instruction or supervisor approval 89-17 Inaparopriate procedure results IV
in RiR Heat Exchanger boiling 89-18 Actions to correct design IV
deficiencies in the hydrogen gas supply system had not been
,
taken 11 months after an i
operational assessment j
~
89-19 Containment sump screens were II
,,
found missing or damaged.
Inspections had not noted the
conditions.
A containment sump l
inspection had not been performed
'
as documented.
Appropriate corrective actions for identified
, conditions were not taken 89-20.
The position of each rod was IV
not verified once each four hours
-
when the rod position deviation monitor was inoperable 89-23
..A search of packages entering the IV
-
-
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-protected area was identified as
-
being inadequate
,
89-24 Dial indicators used to inspect IV
thrust bearing clearances for the
!
centrifugal charging pump shaft, were not in the calibration program 89-24'
A detector voltage measurement IV
L outside the criterion range dId i
not result in an out-of-calibration investigation l
l l
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TABLE 2 (continued)
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. ~.
TROJAN ENFORCEMENT ITEMS
[01/D1/59 - 03/31/90)
Inspection Severity Functional Reoort No.
Sub.iect Level Area 89-26 An emergency fire procedure IV
contained insufficient details for connecting the service water systems and fire manifolds
.
89-26 Calculation for fire hose IV
.
length was not correct 89-27 Applicable limiting conditions IV
were not noted on a maintenance requect and a residual heat removal pump was rendered
"
inoperable when a flow switch was removed from service 89-27 Maintenance work for RHR flow IV
'
switch not properly authori ed by
shift foreman
._
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89-30 Work was performed on train B of IV
'
the hydrogen vent system but was signed off as completed on train A.
Personnel reviewing the documentation
<
did not note the discrepancy.
89-30
' Failure to comply with specific IV
activity limitations for transportation requirements.
A radioactive shipment used the volume of the resin liners for determination of radionuclide
-
concentrations rather than the resin, resulting in an under-
,
,
estimate of the concentration
'
89-30'
The physical configuration of a D
^
sample Ifne installed in the hydrogei, vent system, resulted in samples that were not representative of the flow 89-31 Failure to comply with approved IV
procedures for calibration of Diesel Generator Oil Temperature Instrument ll
.
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TABLE 2 (continued)
TROJAN ENFORCEMENT ITEMS I
[01/01/59 - 03/31/90)
i Inspection Severity Functional Report No';
Subject Level Area 90-02 Testing of ECCS check valves IV
'
'
resulted in entry into
.
>
Technical Specification 3.0.3 i
and no action was taken to get
'
out of specification within one hour
.
90-02 Compensatory measure for IV
inoperable chlorine monitors was not satisfied
-
90-02 Modifications to plant were V
not properly reflected in i
Final Safety Analysis Reports 90-02 Temporary Modification not V
'
aroperly reviewed 14odification paper. Temporarywork improperly modified, ion Tags not properly
-
and Temporary Modificat removed 90-06 Steam flow trip setpoints were IV
greater than technical specification allowable values.,
.
90-06 A corrective action request was IV
closed, indicating a circuit breaker had been replaced.
The circuit breaker had not been replaced.
,
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TABLE 3
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TROJAN SYNOPSIS OF LItTN5TE EVENT REPORT _5 l
Functional SALP Cause Code *
Area A
s
.c p
3 Totals
~
1.
Plant Operations
4
9
.
2.
Radiological Controls
1
3.
3.
Maintenance / Surveillance
1
1
4.
5.
Security
1
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c
.-
6.
Engineering / Technical
7
12 Support 7.
Safety Assessment /
1 Quality Verification
,
Totals zo 10.
a z
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,
Cause Codes:
D Ng nulacturing or Installation Error B
C - External Cause j
0 - Defective Procedures E - Component Failure
'
X - Other
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Attachment 1
AE00 INPUT TO SALP REVIEW FOR THE TRDJAN NUCLEAR PLANT For the assessment period of January 1,1989 to March 31, 1990, AE00 review l
encompassed LERs 89.-01 through 90-06.
1.
JaportantOperatinoEvents
'
'
Utilizing AEOD's screening process, the following eight LERs were
'
categorized as important events:
LER 89-01:
'
An incorrect electrical light bulb was used to replace a missing
indicating light in the remote shutdown panel, causin an electrical short.
The short created a low pressurizer level sig al, which resulted in closure of an ESF valve (the letdown orifice isola ion valve).
Work instructions for the lamp replacement were found to be inadequate.
Also i
e
the design utilized a common power supply for both the instrument loops,
i
and the panel indication circuits. A similar occurrence occurred at
Beaver Valley 1.
(Event date: 1/5/89).
,
.
.
LER 89-15:
'
I-The hydrogen and nitrogen storage facilities were round to be located on I
i the roof of the building housing the control room.
Gas discharge from
'
relief valves, or leak &ge of gas from the storage facilities near the intakes to tv.e control room ventilation and emergency pressurization system, could potentially incapacitate the control room operators or
'
introduce a flammable or explosive ges mixture into the control room.
Other po'tential-issues, resulting from the location of the storage facilities include structural damage to safety related equipment upon
'
detonation,of a hydrogen storage tank or hydrogen delivery truck.
The system design basis documents did not address the a' ve issues. As corrective action, the hydrngen storage facility was re.xsted to a remste location at the plant which is over 900 feet from safety related components and structures.
(Eventdate7/13/89).
.
LER 89-16:
Deficiencies in the containment building recirculation sump were identified which included a missing 3/16 inch wire mesh screen, gaps in the existing screen, and debris in the sump.
Items found in the sump included insulation duct tape, muslin material, pieces of metal wire, pipefittings,andfabricatedsteel.
Debris in the containment sump couldbedrawnintothesuctionofthesafetyinjectionpumps, containment spray pumps, and the residual heat removal pumps during the recirculation phase.
The deficiencies had existed for at least one year, and could have seriously degraded the ability of ECCS components to fun.ction.
.
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The apparent cause of the missing screen was failure to complete
'
,
construction activities.
Debris in the sump was attributed to inadequate
'
compliance with post work cleaning requirements, failure to perform post
,
'
work inspections, and inadequate procedures.
LER.89-18:
Technical Specification 3.0.3 was entered for a period of 30 minutes when both trains of RHR were declared technically inoperable.
When making a setpoint change to the "B" RHR pump automatic recirculation flow control
,
valve, the operations crew incorrectly determined the work did not render i
the "B" RHR train inoperable.
Prior to completing post maintenance
testing on the "B" RHR train the "A" train of component cooling water i-(CCW) was declared inoperable, to initiate biocide treatment, and was
'
cross connected to the "B" CCW train.
Both RHR trains then became
'
technically inoperable.
j administrative controls, and inadequate work planning.Causes of th inadequate (
9/8/89).
LER 89-21:
i Plant personnel, on several occasions, locked opened a manual " bypass"
valve around the volume control tank outlet isolation valves during testin.
In this configuration, both high head safety injection pumps
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could otentially be rendered inoperable due to hydro a SI s gnal occurred while the bypass valve was open. gen gas binding, if Causes included
inadequate test procedure review and evaluation.
(Event date 10/30/89).
LER 90-03:
A design basis document review revealed that both boron injection tank (BIT)inletisolationvalvescouldhavebeenclosed,withtheplantin Mode 3,lation valves, in accordance with the surveillance test procedu during surveillance testing of associated components.
Closing the iso would make both centrifugal charging pumps insperable.
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The causes of this situation were procedural inadequacy and inadequate technical review.
(EventDate: 1/19/90).
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LER 90-05:
Room cooling calculations revealed that room temperatures in the "A"
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I engineered safety features (ESF) electrical auxiliary room and the "B" ESF switchgear room would exceed the FSAR design basis of 104 degrees F under certain postulated conditions.
The conditions postulated were 1)
service water train "A" out-of-service, 2) service water train "B" subjectedtodesignbasisheatloads,and3)summerdesigncondition
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l temperatures.
Basr.4 on plant historical data theTrojanplanthadpreviouslyoperated
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wif.h a combination of inoperable room coolers and service water system
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. temperature which placed the plant in an unanalyzed condition, or in a
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condition outside the design basis of the plant.
Cause of the occurrence was attributed to original design inadequacies.
(Event Date: 2/16/90).
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LER 90-06:
Both trains of emergency core cooling were made inoserable during l
performance of a " periodic operating test" (PDT), wiile the plant was in Hot Standby.
This constituted an entry into Technical Specification 3.0.3.
The POT was being performed on the second off check valves in the RHR discharge lines to the RCS hot legs. As specified in the POT a normally closed motor-operated isolation valve in the discharge lIne from the safety iniection (SI) pumps to the loop 2 and 4 hot legs was opened.
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If a SI signal had occurred with the isolation valve open ECCS flow would have been simultaneously directed to both the RCS hot legs and cold legs.
In this configuration, pump runout could occur.
In addition,lve on the SI pump discharge to the common injection hea the POT specified closing the normally open motor-operated
isolation va
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to the RCS cold legs.
Thisrenderedtrain8ofthesafetyinjection c
i system inoperable, i
l Cause of this event was attributed to inadequate safety review of a l-revision to the PDT.
(EventDate: 2/19/90).
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2.
Preliminary Notifications l
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One preliminary notification (PN) was issued by Region V during the I
assessment period.
AEOD verified the licensee submitted an LER on the described event.
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3.
LER Overview l
l Causes of the events are distributed among various categories, however an L
inordinate number of the LERs were associated with inadequate procedures L
or work instructions.
Also a number of the LERs were associated with L
problems..with the control ro,om ventilation system.
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4.
LER Timeliness and Quality l'
LERs submitted by the licensee were generally acceptable, but a number of improvements might be warranted regarding the following:
Recent LERs (89-29, 89-30 and 90-03) were submitted in Abstract form, presumably to meet the 30, day time requirement.
Supplements were then to be forwarded in accordance with the utility's stipulated schedule.
Question 25.9 on pag"e 30 nf Supplement No. I to NUREG-1022 " Licensee 1.
Event Report System, inquires as to the acceptability of submitting a
description of the entire event in the abstract space, only.
The NRC's l'
reply indicates this to be acceptable.in its reply that "We expect that few reporta However
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events will be so simplistic that they can be adequately described in 1400 characters."
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[u The licensee's recent frequent submittal of Abstract only LERs in order L
to meet the 30 days requirement is unorthodox, and should be utilized
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p only in rare cases.
Two of the LER$ numbers (89 26 and 89-31) were not utilized. The NRC l
i answer to question 25.3 on page 30 of Supplement No. I to NUREG-1022
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indicates the NRC prefers that all LER numbers be used, rather than
l 1eaving holes in the numbering sequence.
A)pendix D in Supplement No. 2 to NUREG-1022 provides a LER " Text Outline C4ecklist," which could be used to improve the
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D-4, item V indicates " Additional Information" quality of LERs.
On page should be provided in the i
text c' the LER and should include "the LER number events (if no previous similar events, state 'none(s) of previous similar i
).
j From a review of the LERs submitted during this evaluation period, it appears the " Additional Information" format is not being utilized, and similar events are not being methodically identified.
For example,
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underlying problems associated with the following LERs appear related,
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but were not identified as such:
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89-05 and 88-37 89-20 and 89-22 89-21, 90-03, 90-04, and 90-06
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More information regarding reporting of previous occurrences is provided in response to Question 12.9 on page 20 of Supplement 1 to NUREG-1022.
5.
10 CFR 50.72 Reports
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Based upon our review of preliminary information provided by'the licensee in immediate notification reports submitted pursuant to 10CFR50.72, it appears that all LERs required by 10CFR50.73 were submitted to the NRC.
6.
Abnormal Occurrences and Other Events of Interest OneeventoccurringattheTrojanplantwasclassifiedasanAbnormal
.0ccurrence for inclusion in the NUREG-0090 Congress.
Theevent,reportedinLER89-1$,Vol12wasdIscu.3reportto No ssed above.
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One other event involving storage of hydrogen on the control room roof (LER 89-15) was reported as a NUREG-0090, Vol. 12, No. 2 "Other Events of Interest" item.
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AE00 Reports AEOD Technical Review Report T916 " Debris in Containment Recirculation Sumps" was issued September 29,in LER 89-16 was included in this re) ort.
1989.
A description of the July 8,
,
1989,eventatTrojanreported Information Notice No. 8F77 addressed the occurrence reported in LER 89-16.
AEOD Engineering Evaluation Report E910 " Potential for Gas Binding of High Head Safety Injection Pumps Resulting From Inservice Testing of VCT
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Outlet Isolation Valves" was issued on December 28, 1989.
This evaluation assessed the Generic applications of the event described in
LER 89-21, and resulted in Supplement 2 to Information Notice No. 88-23.
Information from the event reported in LER 90-03 is also currently being evaluated by AEOD for generic implications.
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