IR 05000352/1990010
| ML20034A942 | |
| Person / Time | |
|---|---|
| Site: | Limerick  |
| Issue date: | 04/06/1990 |
| From: | Bonnett P, Conte R, Easlick T, Florek D, Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20034A939 | List: |
| References | |
| 50-352-90-10, 50-353-90-09, 50-353-90-9, NUDOCS 9004250096 | |
| Download: ML20034A942 (22) | |
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U.-S. NUCLEAR REGULATORY COMMISSION
REGION I
50-352/90-I0
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Report Nos. 50-353/90-09 l.,
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Meeting No. 90-33 50-352 i
Docket Nos.
50-353 i
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License Nos. NPF-83-Licensee:
Philadelphia' Electric ' Company F.O. Box A Sanatoga, Pennsylvania 19464 Facility Name:
Limerick Generating Station, Units 1 & 2 f
Inspection At:
Sanatoga, Penn gigania
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Inspection Conducted:
February 12, 1990.to March 2, 1990 Inspectors:
N V-6-fo T. Easlick, Operations Engineer date
$0.Flork,Sr.Oper"ationsEngineer
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P B'onWelt, ' Operations Engineer date
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Reviewed by:
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'date R. Conte, Chief, BWR Section
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Approved by:.Rdbert -M.
Gallo, Criief, 0perations, Branch 4:iate
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Division of Reactor Safety l
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e Executive Summary A special announced inspection (operator evaluations) assessed the results of the Lienerick requalification examinations administered by the licensee from
January 15, 1990, to February 23, 1990. The inspection included a review of
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all written examinations' administered during the six week period, facility comments on the week 1 and 2 operating test, and the video tape of the week 4 operating crew's simulator examination. Additionally, the inspectors ~ assessed the performance of operating crews by observing the:. simulator portions of the examinations administered during week 5 and 6 of the examination period. The l
inspection also included a review of the Emergency Operating Procedures (T-200
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series) in response to a licensee commitment of-February 5, 1990, to perform a
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human factors review of said procedures by February 16, 1990.
L The results of this inspection indicated that several weaknesses identified during the NRC administered requalification examination of January 29, 1990, were observed throughout the six' week examination cycle. These weaknesses,
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also identified by the facility evaluations, included crew communication and
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l coordination, Emergency Operating Procedure familiarity, and knowledge of plant systems. No additional failures were identified during this inspection and'.the NRC staff and facility evaluation.of the week 5 and 6 simulator examinations were consistent, s
The T-200 series procedures were revised to include figures and' attachments depicting the internal arrangements of the logic panels. This. revision will greatly iniprove operator ability to locate relays and terminal boards as
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e required by the T-200 procedures. Addit!cnal licensee enhancements are to be completed by May 15, 1990.
A meeting with the licensee (Meeting No.90-033) was conducted on March 15,
1990, at the NRC rwgion I Office in KQng cf Prussie to discuss root causes and.
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corrective actions which address the weaknesses identified-during the NRC administered requalification examination of January 29,1990,' through February
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2, 1990, and subsequent inspection of-February 12, 1990, through' March 2, 1990.
The licensee presented its root causes and co' erective actions, as per Confirm-atory Action Letter (CAL) I-90-003, Item 3.
The licensee's letter dated March 9,1990 was reviewed by the NRC staff and found to be acceptable.
The primary causes as identified by the licensee were:
insufficient management. emphasis on-
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staff licensee training and operating personne~1 meeting fainimum standards not driven to improve. Other contributing causes were noted but an important common factor was the apparently ineffective actions which had been taken.in attempts to correct certain deficiencies.
These deficiencies had been identi-fied as a result of either the last NRC administered requalification examina-'
tion and the periodic evaluations conducted during the weekly continuous training sessions for both staff and operating crews.
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DETAILS 1,
Introduction The NRC administered a requalification examination at the Limerick Generating Station Units 1&2 on January 29, 1990 to February 2,1990, during the third of six weeks of annual' licensee administered.requalification examinations. As a result of the NRC examination the-Limerick Requalification
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Program was declared unsatisfactory (Unresolved Item No. 352/353 90-01-02)..
I This inspection was conduc,ted-to assess the operator performance during >
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the ' subsequent examination periods (3 weeks) and to review the results.of the entire six weeks of examination.
Three operating-crews were evaluated-
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from weeks 5 and 6 of the examination using selected processes and criteria q
described in NUREG-1021, " Operator Licensing Examiners-Standard," Rev. 5, i
section ES-601, " Administration of NRC Requalification Program Eva'luations."-
The inspection also included a review of the Emergency Operating Procedures (T-200 series) in response to a licensee commitment, made during the February 5,1990 exit meeting, to perform a human factors review of the procedures. The T-200 procedure deficiencies were identified during the NRC requalification examination.
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2.
Operating Test Evaluations During the weeks of February 12 and February 20, 1990 the NRC observed ~
three operating crews (15 individuals) during the simulator portion of their licensee administered requalification examination.
The NRC evaluation i
team consisted of three examiners.
Prior to the examination-each crew I
received a four hour training session summarizing the strengths and weaknesses'
l identified during the NRC administered requalification examination. The results of the evaluation indicated that all crews and individuals performed
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satisfactorily and the NRC team noted-an improvement in performance over
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that observed during the NRC administered examination.
The improvement is attributed, in part, to the four hour training session.. These crews also
.'I exhibited relatively good proficiency. The improvements, included increased
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monitoring of important parameters, attempting to recover inoperable components during scenarios, appropriately spraying the-suppression pool when needed per TRIP procedures and attempting to insert control rods during an ATWS conditions. Other strengths and weaknesses are described i
in section 4 of this report.
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The inspector reviewed the facility comments from the week 1 and 2 operating tests.
The comments included both staff and operating crew
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i performance during the simulator portion of the examinatien. No video
tape record of the first two weeks of examination was available, so-that i
the operator performance could only be evaluated from the facility comments.
Significant weaknesses that were identified during the NRC administered.
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examination were evident in the facility comments for the first two' weeks observations.
Both~ operating and staff crews exhibited these weaknesses which are discussed in section 4 of this report.
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In addition, review of a video tape from the week 4_ simulator examination was conducted at the Region I. office.
Two operating crews were evaluated by: NRC examiners based on this video viewing. Weaknesses that were observed'
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in other' operating crews were identified during this_ evaluation. The week'
4 video tape was also reviewed, at-the Limerick training center, by the inspector and a member of the _ training staff. The NRC evaluation of the video tape was compared to the facility-comments,:from the week 4 examina-tion and it was apparent that the facility evaluators also identified and.
documented similar weaknesses.
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In all cases the NRC evaluation of the operating _ examinations were in agreement with the facility evaluation.
No additional failures were identified in the operating examination assessments.
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Audit of Written Examin.ations
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The inspector reviewed written examination results from the six-week examination period.
Selected examinations wereJregraded on'a sampling basis using the criteria ~doscribed in ES-403, " Grading of Written Examina-.
tions," Attachment 1, " Examination Administration-Quality Assurance Checkofff
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Sheet." The facility grading was accurate and consistent with NRC regrading.
The NRC and facility grading were in agreement with no additional e iten examination failures. The training department incorporates a gra; ;q <:udit-process which appears to be effective. - The1only problem.identi'iea, at of the 32 examination regraded by-the.NRC, was an incorrect grade' point total (19.0 instead of 18.5) on one of the reactor operator examinations.
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The' inspector had no:additionalLcomment.
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4.
Generic Strengths and Weaknesses a
The following is a summary of the generic strengths and weaknesses of the program and individuals observed during the NRC assessment.
These strengths-and weaknesses were generally observed across all operating and staff crews.
Some of the weaknesse.s-noted below are similar to those identified in
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Inspection Report Nos 50-352/90-01 and 50-353/90-01.
This'information is-i being provided to aid the licensee in upgrading the requalification training program.
No licensee response is required.
Strengths Written examinations provided discrimination' between strong and weak
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performers.
Facility evaluators' ability to assess crew performance during the
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simulator portion of the examination.
Facility audit process for the written examination grading.
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3-i SR0s ability to properly classify' events in accordance with
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Emergency Classification Procedures.
Weaknesses'
q Ineffective correction of previously identified generic weaknesses
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from the' November, 1988 NRC requalification' examination'.-
Overall crew communication, as evidenced by the use of slang terminology,
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imprecise communication and inconsistent repeatbacks or: acknowledgements.
Plant status, changed conditions or parameter updates were inconsistent and often.not heard.or acknowledged by the crew members.
Crew control and coordination under transient conditions was lacking
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in some crews. -Shift Supervisors (SSVs) did not adequately address =
orders-to specific operators in all cases. Many SSVs lacked the l
command presence needed to control the. crew activities-during-a
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Emergency Operating Procedures (EOPs) were.not always implemented
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correctly, with some SSVs exhibiting problems transitioning between-i TRIP procedures, j
Knowledge of plant systems including component operation and
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interlocks.
Lack of procedure use as a follow up to actions taken during the
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simulator examinations.
5.
General Observations
The NRC conducted a requalification program evalu: tion at.the Limerick Generating Station in November,1988.
The results of that evaluation were documented in Inspection Report No. 50-352/88-21 (OL),c dated February 17, 1989. A review of the generic weaknesses from that report indicates a
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similarity to those identified during the' January,1990 requalification examination and subsequent followup inspection.
These weaknesses-included crew communications breakdown during transients, operator roles that vary j
from crew to crew, proper implementation of T-102 suppression pool spray and the operators cbility to locate cabinet bays and select correct keys durina Job Performance Measures (JPMs). The: reoccurring weaknesses indicate
an ineffective correction of previously identified problems.
The review of the written examination results over the six week period indicate that the weaknesses cannot be attributed to any one section of the examination, "A-1", "A-2" (static. exam) or "B" (open reference). The weaknesses appear to be in all sections, indicating a dependence on the
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individual taking_the examination and not the examination itself. The individual dependence can also be seen week to week with some of the weekly performances on the written examination being significantly better than others.
- i During the simulator portion of the examination it was observed-that_the operators exhibited an unusual reliance on the non-licensed Shift Technical
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Advisor (STA) for knowledge and guidance. Although this 'is a credit to the STA program it may be masking knowledge deficiencies with.the operating; Crews.
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Emergency Operating Procedures, (T-200 Series) Riview (Unresolved Item Nos. 352 and 353/90-01-01, Open!
During the NRC administered requalification examination in.1990 a repetitive
weakness for the 1988 examination-was identified during the walk-through portion in that the operators had difficulty. locating relays and terminal-boards as required by the T-200 series procedures-(Unresolved Item No.
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352/353,90-01-01). As a result, during the exit meeting of February 5,
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1990 the licensee committed to perform a human factors review of the T-200 t !
series and to supplement these procedures by February 16, 1990. A review?
of the procedures was conducted on February 22, 1990. The review-indicated that twenty T-200 procedures were revised and supplemented as per-the.
licensee's commitment. The changes included the addition of logic cabinet i
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key numbers, logic cabinet bay identifications, and maps depicting' the
inside of.the logic panels showing relay and terminal board locations. _
j Additionally portions of T-240, " Maximizing CRD Flow," were = rewritten to a
make the procedure more understandable.
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At the meeting on the licensee's root cause analysis, the licensee representatives indicated that the overall procedure deficiencies: remained
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uncorrected due to a combination of a lack of involvement by end users.
(operators) and because of system engineer unfamiliarity with in plant component labeling. The licensee committed to additional enhancement actions to.be completed by May 15, 1990. Accordingly, the adequacy _of.the l
E0P T-200 series procedure remains unresolved.
7.
Exit Meeting
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An inspection exit meeting was held in the Region I office at the conclusion-j of the inspection on March 2, 1990. The personnel in attendance are listed in Attachment 1.
The inspection scope and preliminary findings =were.
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summarized at the meeting.
Requalification examination results were D,
discussed along with generic strengths and weaknesses of the program.
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As noted in Section 8, another meeting was conducted March 15, 1990 to discuss the licensee's root cause analysis. The personnel in attendance are-listed in Atca hment 1 l
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Meeting on Root Cause Analysis
I (Unresolved Item Nos. 352 and 353/90-01-02, Open)
I 8.1 Introduction i
j On March 15,-1990 at the NRC Region I.0ffice in King of Prussia, Pennsylvania, the personnel whose names are listed in Attachment 1 of this report met to discuss the root causes of and corrective actions for the weaknesses of the Limerick Generating Station licensed operator requalification: program (Meeting No. 90-33).
Confirmatory Action Letter (CAL) I-90-003, Unsatisfactory Licensed Operator q
Requalification Training ~ Program, requested that the licensee identify problems and root causes as to why.the_ requalification program was unsatistactory and submit the root cause analysis and corrective actions to Region I.
.The NRC management introduced these topics and asked the licensee to present its position, perspective and basis for the root causes and corrective actions.
-i 8.2 Licensee Presentation The text of the licensee presentation is included in this report,as Attachment 2.
The licensee identified the root causes as follows:
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Insufficient management emphasis on staff licensee training.
- Operating personnel meeting minimum standard not driven.to improve.
- Contributing or secondary causes were also noted:
Written exam time validation not adequate.
- Proper communication not emphasized outside the simulator.
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Performance standards not enforced in weekly requalification
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l No training during two months prior to examination.
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Questions in bank do not solicit desired answers.
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T-200 procedures not optimally. human factored.
- Training not sufficient to ensure consistent manipulation of
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kr systems during events.
During the presentation the licensee addressed the basis, corrective
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actions and objectives for each of the causes identified.
Refer to Attachment 2 of this report for the details of the licensee's presentation.
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8.3 Discussion The NRC staff questioned the licensee on a number of-issues throughout
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the presentation. The first question concerned tFe need for staff l
licensed operators at the Limerick Generating Station. The licensee is currently undergoing a review to' determine the need for each staff
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license on a case-by-case basis.
The: licensee has subsequently terminated ten SR0 licenses.
Regarding tha issue of time validation on the written examination,
. l the NRC staff was not convinced thar this problem was a cause for the operator failures on the written test. The licensee acknowledged the:
concern and stated that it may not have necessarily caused the failures,-
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but it was an overall problem.
This conclusion was drawn from the fact that many of the operators finished the examination, but'had no time to review the test afterwards.
The NRC staff then-questionedi how the examination time validation was conducted. The training department: time validates each question individually and acknowledged
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that this method is not accurate and there is a need for validation when questions are combined to make an examination. The licensee also stated that this time validation froblem was different from the i
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problem that occurred during the November, 1938 requalif,1 cation
examination. At that time, the written examination was not terminated at the proper time and allowed to run beyond the established limit.
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Regarding the issue of the question bank not soliciting the proper-4 answers, the licensee stated that a full question bank review was ongoing with 75% of the bank reviewed and corrected. The NRC staff
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asked when the review would be completed.
The licensee committed to j
having the review completed by the next requalification examination
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period (January 1991).
The issue of reoccurring weaknesses from the last requalification.
period (November 1988) was discussed. The licensee stated that the weakness identified with the implementation-of T-102 suppression pool'
spray during the January 1990 requalification examination, was different from the weaknesses that occurred during the November, 1988.requali--
fication examination and therefore was not repetitive. The NRC~ staff acknowledged this and agreed that although it was a different problem,
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it was still an identified weakness. Other weaknesses identified during the November 1988 requalification period were-discussed during the meeting. These weaknesses included:
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i Crew communications breakdown during transients;
Operator roles that vary from crew to crew; and,
Operators ability to locate cabinet bays and keys during job
performance measure per E0P T-200 series procedures (See also Section 6),
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8.4 Conclusion p
The licensee stated that after the November,.1988 ~ examination
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oweaknesses were identified and action was taken to correct.these~
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weaknesses.
However, the corrective actions may not have been adequate or'of sufficient-depth to be effective.
Also, once the
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corrective actions are in place, they will be revisited periodically to ensure they.are adequate and complete; I-On the issue of a requalification program-re-evaluation the licensee l
requested that_ ample time-be given for the corrective actions to._
_c become effective, before the NRC administers the-next requalification;
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examination.
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' The NRC. staff. agreed withithe -licet.,ee's conclusions and ' corrective j
actions, emphasizing the need for increased management attention-in
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- the area of requalification and-operator performance. standards.
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Attachments:
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1.
Persons contacted 2.
Licensee-Presentation '
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ATTACHMENT 1
Persons Contacted Philadelphia Electric Compay R. Nunez, Operations Training Supervisor (3)
-i M. Baughman, Requalification Instructor (1)
G. Leitch, Vice President Limerick (1, 3)
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V. Cwietniewicz, Training Superintendent (1, 3)
V. Warren, Site Licensing (1)'
G. Stewart, Engineer Licensing Branch (1, 3)
R. Krich, Licensing Branch Head (1)
L. Hopkins, Operations' Superintendent (1, 3)
R. Klemm, Manager of Nuclear Training (1)
M. McCormick, Plant Manager (1,-3)
G. Madsen, Regulatory Engineer (3)
' R. Helt,.PECO NTD (3)
K. Walsh, PECO Technical (3)-
J.-O'Rourke, Quality Division (3)
P. Dieckhaus, Operation Staff (3)
State of Pennslyvania
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A. Bhattacharya, Nuclear Engineering PA. DER (3)
Nuc. lear Regulatory Commission
.i D. Florek, Senior Operation Engineer (2)
i P.Bonnett,OperationsEngineer(2)
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T. Easlick, Operation Engineer (1, 2, 3)
R. Conte, Chief BWR Section (1, 3).
R. Gallo, Chief Operation Branch (1, 3)-
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W. Hodges, Director, DRS (1, 3)
T. Kenny, Senior Resident Inspector (1, 3)
T. Martin, Deputy Regional Administrator (3)
S. Cooley, Chief, RSOS, NRR (3)
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L. Doerflein, Chief, RPS, 28 (3)
l S. Pullani, Sr. O',isi Eng. (3)
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R. Blough, Chier, PB2 (3).
Notes:
(1) Attended Exit Meeting March 2, 1990-(2) Member of NRC Evaluation Team I
(3) Attended Management Meeting March 15, 1990
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ATTACHMENT 2 LICENSEE PRESENTATION
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. LIMERICK GENERATING STATION 1990 LICENSED OPERATOR
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REQUALIFICATION PROGRAMLWEAKNESSES
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l REVIEW OF ROOT CAUSES AND
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CORRECTIVE ACTIONS I
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INSUFFICIENT MANAGEMENT EMN'HASiS ON. STAFF. LICENSEE TRAINING-V)
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- LSTAFF PERSONNEL-DO-NOT ATTEND
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ASSIGNED WEEK
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STAFF PERSONNEL. DO NOT PRACTICE-
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WITH THE EXAM CREW
MANAGEMENT DOES-NOT OBSERVE AND
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EVALUATE STAFF IN SIMULATOR A
- CORRECTIVE ACTIONS
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MANAGEMENT EVALUATION OF NEED
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ISSUE POLICY STATEMENT ON COMMITMENT TO SUPPORT OF TRAINING
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MANAGEMENT SIMULATOR OBSERVATION
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OF STAFF CREWS
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- OBJECTIVES-ENHANCE CONTROL-ROOM SKILLS y
- TEAM WORK
- COMMAND AND-CONTROL
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- ROLE DEFINITION
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MAINTAIN THIS LEVEL OVER: TIME
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- CORRECTIVE ACTIONS INCREASE EMPHASIS-ON. TRAINING-l
PERFORMANCE IN JOB.PERFCRMANCE EVALUATION PROCESS-i
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ENFORCE PERSONAL ACCOUNTABILITY
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WRITTEN EXAM TIME VALIDATION NOT ADEQUATE
- BASIS PERSONNEL INTERVIEWED FELT EXTREME
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TIME PRESSURE DURING THE WRITTEN EXAM EXTRA TIME WAS AUTHORIZED
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VALIDATION WAS NOT PERFORMED AFTER
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CHANGES WERE MADE
-- CORRECTIVE ACTIONS
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ISSUE TRAINING GUIDANCE TO NUCLEAR TRAINING EXAM PREPARERS REQUIRING TIME VALIDATION OF FINAL VERSION
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ENSURE EVALUATION OF PERSONNEL KNOWLEDGE IS NOT INFLUENCED BY EXCESSIVE TIME PRESSURE
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PROPER COMMUNICATIONS NOT EMPHASIZED OUTSIDE SIMULATOR-l
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INCREASED EMPHASIS ON COMMUNICATIONS
IN SIMULATOR DUE TO PREVIOUSLY IDENTIFIED WEAKNESS E
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WEAKNESS NOT EFFECTIVELY CORRECTED SIMILAR EMPHASIS NOT APPLIED IN
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DAY-TO-DAY OPERATIONS
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COMPONENTS OF GOOD COMMUNICATIONS ARE NOT SECOND NATURE
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OPERATIONS TO DEVELOP ACTION PLAN l
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INCLUDING IMPLEMENTATION SCHEDULE 9'
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EMPHASIZE COMMUNICATIONS DAY-TO-DAY
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COMMUNICATE STANDARDS
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ESTABLISH FOLLOW-UP MONITORING
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MAKE PROPER COMMUNICATIONS
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PERFORMANCE STANDARDS NOT ENFORCED IN WEEKLY REQUAL TRAINING Ig
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. WEEKLY SIMULATOR EVALUATIONS NOT CONDUCTED TO FORMAL STANDARDS-RAPIDLY PROGRESSING EVENTS NOT'
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WEEKLY TEST TIME LIMITS NOT ENFORCED'
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APPLY FORMAL EXAM CRITERIA WEEKLY
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SCENARIOS FOR EVALUATIONS.
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CONTROL AND KEY PARAMETER AWARENESS
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ENSURE MANAGEMENT OBSERVERS FOCUS
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NO TRAlNING DURING TWO MONTHS PRIOR TO EXAM
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BASIS
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- STAFF CONTROL ROOM SKILLS SUCH AS-COMMAND-AND CONTROL DEPEND HEAVILY'
ON SIMULATOR: PRACTICE AND-DEGRADE i
OVER TIME WITHOUT REINFORCEMENT
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PERSONNEL RECEIVED TRAINING ON LATEST TRANSIENT RESPONSE IMPLEMENTATION PROCEDURE REVISION DURING TWO CYCLES PRIOR TO BREAK
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LATEST REVISION-SIGNIFICANTLY I
DIFFERENT-THAN PRIOR REVISlON-
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CORRECTIVE ACTIONS
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REVIEW LICENSED OPERATOR REQU ALIFICATION TR AINING SCHEDULE, REVISE AS NECESSARY TO MINIMlZE BREAKS
I OBJECTIVE
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ACHIEVE AND SUSTAIN DFSIRED l
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PERFORMANCE LEVEL
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QUESTIONS IN' BANK DO NOT SOLICIT DESIRED ANSWER BASIS
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QUESTION BANK ANSWERS INCLUDE ITEMS BEYOND SPECIFIC INFORMATION REQUESTED BY QUESTION
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PREVIOUS TESTING METHODS CONDITIONED-PERSONNEL TO RESPOND SPECIFICALLY WITH NO-
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y" EXTRA INFORMATION CREATES FRUSTRATION
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SECONDARY FACTOR, NOT AN ACTUAL l
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EXAM PROBLEM
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CORRECTIVE ACTIONS
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AS QUESTIONS ARE CHANGED, NUCLEAR TRAINING SECTION WILL ANNOTATE i
MASTER TEST COPY
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MASTER TEST COPY WILL BE SOURCE FOR EXAM QUESTIONS
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UPDATE EXAM BANK PERIOD!CALLY l
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ENSURE REVISIONS TO QUESTIONS AND
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ANSWERS ARE INCLUDED IN SUBSEQUENT EXAMS AND COPIES OF THE BANK
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T-200 PROCEDURES NOT OPTIMALLY HUMAN FACTORED
-- BASIS
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- WEAKNESSES IN QUICK LOC ATION AND a
IDENTIFICATION OF EQUIPMENT WERE:
NOTED-IN JOB PERFORMANCE MEASURES i
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PROCEDURAL WEAKNESSES HAD BEEN-IDENTIFIED PREVIOUSLY
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PROCEDURE HUMAN FACTORS REVIEW s
PERFORMED BY SYSTEM ENGINEERS
WHO WERE FAMILIAR' WITH' RELAY AND TERMINAL LAYOUTS.
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END USERS NOT INVOLVED i
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- CORRECTIVE ACTIONS
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ATTACH SUPPLEMENTAL EQUIPMENT
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LOCATION AND IDENTIFICATION DOCUMENTATION TO PROCEDURES HUMAN FACTORS REVIEW-OF-PROCEDURES-
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AND EQUIPMENT LABELING' BY REACTOR OPERATOR AND TRAINING INSTRUCTOR i
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- OBJECTIVES d
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ENHANCE PROCEDURES AND LABELING TO u
FACILITATE EQUIPMENT IDENTIFICATION.
ENSURE PROCEDURE USABILITY IS I
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CHECKED BY END USER
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TRAINING NOT SUFFICIENT TO ENSURE CONSISTENT MANIPULATIONS DURING EVENTS
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- BASIS
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DURING SIMULATOR EXAMS, PERSONNEL WERE NOT CONSISTENT IN SYSTEM MANIPULATIONS SUCH AS SECURING
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HIGH PRESSURE COOL ~ ANT INJECTION-
- -TRAINING HAS NOTL CONCENTRATED ON MANIPULATION OF KEY SYSTEMS DURING RAPIDLY PROGRESSING EVENTS i
- CORRECTIVE ACTIONS
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REVIEW SYSTEM PROCEDURES.
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IDENTIFY-PROCEDURES REQUIRING
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HIGH DEGREE OF FAMILIARITY INCLUDE THESE PROCEDURES IN l
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TRAINING SCHEDULE FOR 1990 j
- OBJECTIVES
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ENSURE MANIPULATIONS ARE CONSISTENT-WITH PROCEDURES j
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ENHANCE OPERATOR SYSTEM KNOWLEDGE j
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SALP A special announced inspection (operator evaluations) assessed the results of the Limerick requalification examinations administered by the licensee from
January 15, 1990 to February 23, 1990. The inspection included a review of all written examinations administered during the six week period, facility comments j
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on the week 1 and 2 operating _ test, and'the video tape of the week 4 operating crew's simulator examination. Additionally, the inspectors assessed the performance of operating crews by observing the simulator portions of the
examinations administered during week 5 and 6 of the examination period. The-l inspection also included a review of the Emergency Operating Procedure (T-200
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series) in response to a licensee commitment of February 5, 1990, to perform a-
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human factors review of said procedures by February 16,-1990.
The results of this' inspection indicated that several weaknesses identified during'the NRC administered requalification examination of January 29, 1990,
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were observed throughout the six week examination cycle. -These weaknesses,
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also identified by the facility evaluations, included crew communication and-coordination, Emergency Operating Procedure familiarity, and knowledge of plant j
systems. No additional failures were identified during this inspection and the
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NRC staff and facility evaluation of the week 5 and 6 simulator examinations
were consistent.
l The T-200 series satellite procedure were revised to include figures and
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attachments depicting the internal arrangements of the logic canels. This
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revision will greatly improve operator. ability to locate relays and terminal boards as required by the T-200 procedures.. Additional licensee enhancements i
are to be completed by May 15, 1990.
I A significant licensee meeting (Meeting No.90-033) was conducted on March 15, a
1990 at the NRC Region I Office in King of Prussia to discuss root causes and
corrective actions which address the weaknesses identified during the NRC administered requalification exa.nination of January 29, 1990 through February-l 2, 1990 and subsequent inspection of~ February 12, 1990 through March 2, 1990.
l The licensee presented its root causes and corrective actions, as per Confirm-atory Action Letter (CAL) I-90-003, Item 3.
The licensee's letter dated March
,9, 1990 was reviewed by the NRC staff and found to be acceptable. The primary causes as identified by the licensee were:
insufficient management emphasis on-i staff licensee training and operating personnel meeting minimum standards not
.l driven to improve.
Other contributing causes were noted but an important common
factor was the apprently ineffective actions which had been taken in attempts
to correct certain deficiencies.
These deficiencies had been identified as a result of either the last NRC administered requalification examination and the -
periodic evaluations conducted during the weekly continuous training sessions for both staff and operating crews.
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