IR 05000373/1986014

Insp Repts 50-373/86-14 & 50-374/86-14 on 860421-25.No Violation or Deviation Noted.Major Areas Inspected: Effectiveness of Licensed Operator Training & Nonlicensed Staff Training

ML20198D295
Person / Time
Site:	LaSalle
Issue date:	05/14/1986
From:	Eng P, Hare S, Phillips M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20198D276	List: IR 05000373/1986014 ML20198D272
References
50-373-86-14, 50-374-86-14, NUDOCS 8605230212
Download: ML20198D295 (10)

Text

F

.

.

U. S. NUCLEAR REGULATORY COMMISSION

REGION III

Reports No. 50-373/86014(DRS); 50-374/86014(DRS)

Docket Nos. 50-373; 50-374 Licenses No. NPF-11; NPF-18 Licensee: Commonwealth Edison Company P. O. Box 767 Chicago IL 60690 Facility Name: LaSalle County Station, Units 1 and 2 Inspection At: LaSalle County Station, Marseilles, Illinois Inspection Conducted: April 21-25, 1986 Inspectors: Patricia L. Eng I Date ffSteve M. Kare YYh$

Date s

Approved By: Monte [fhikips, Chief I Operational Programs Section Date Inspection Summary Inspection on April 21-25, 1986 (Reports No. 50-373/86014(DRS);

50-374/86014(DRS))

Areas Inspected: Routine, unannounced inspection of the effectiveness of licensed operator training (IE Module 41701) and the effectiveness of non-licensed staff training (IE Module 41400).

Results: Of the two areas inspected, no violations or deviations were identifie _ _ _ . _ _ . -n C M 5230212 86051933 DR ADOCK 0

_

.

.

DETAILS 1. Persons Contacted G. J. Diederich, Plant Manager

• P. F. Manning, Technical Staff Supervisor

• R. D. Bishop, Services Superintendent

• R. D. Crawford, Training Supervisor

• R. Huntington, Assistant Superintendent, Operations

• S. R. Harmon, Operations Training Group Leader

• D. A. Winchester, Senior Q. A. Inspector

• Denotes those in attendance at the exit meeting on April 25, 1986.

The inspectors also talked with and interviewed other members of the licensee's staff during the course of the inspectio . Licensed Operator Training Licensed Operator Training Overview Section 13.2.2 of the licensee's Updated Final Safety Analysis Report (UFSAR) specified a licensed operator requalification program established to satisfy 10 CFR 55, Appendix A. The licensed operator requalification program was submitted by Commonwealth Edison Company (CECO) on November 20, 1985, and approved by the Nuclear Regulatory Commissio The requalification program provided a biennial review of subject areas administered by the Site Training Supervisor and included lecture, simulator, and on-the-job training segments. Each segment of the licensee's requalification training program required periodic updates of the training lesson plans and materials to ensure that licensed operators were being kept aware of changing plant conditions and recent event During the course of the inspection, the inspector determined that the reactor operator, senior reactor operator and non-licensed operator training programs had been accredited by INP The licensee stated that the self evaluation reports for the remaining training programs were scheduled to be submitted to INP0 for review by September 198 The licensee also provided the following statistics regarding their licensed operator training programs:

License Type Year Number of Exams Given % Passed R0 1984 27 96 SR0 1984 46 98 R0 1985 25 100 SR0 1985 46 98

L

.

-

.

In order to determine whether current licensed operator training was sufficient to have prevented or mitigated the consequences of recent abnormal events, the inspector reviewed recent selected Licensee Event Reports (LERs), inspection findings, and licensee generated Deviation Reports (DVRs). Corrective actions taken by CECO were also reviewed to determine if associated lessons learned were subsequently incorporated into the licensee's training progra The licer.see's training program provided several means of disseminating information related to operating deficiencies and recent events to licensed operators. These means were: periodically issued required readings, " tailgate" sessions, postings on a flip chart located in the control room, and incorporation of lessons learned from past events into the classroom training subject matte Training records of several licensed operators were reviewe Remedial training for those trainees whose quiz scores fell below the 70% acceptance criteria were not documented; however, requiz scores were noted. Although not required, the licensee required those trainees whose past quiz scores on a given subject fell between 70% and 80% to achieve a score above 80% on subsequent quizzes on the given topic. Generally, trainee records included r:opies of the most recent annual examinations and quizzes, attendance lists for required lectures, documentation of required control manipulations, the most recent performance evaluation, and documentation of the completion of required reading b. Training Program Updates (1) Tailgates Should an occasion arise such that information must be promptly communicated to licensed personnel, " tailgate" sessions were conducted by the various shift foremen with members of their shif A tailgate session consisted of a briefing for a given shift crew held by either the Shift Foreman, Shift Engineer or a member of plant managemen For those cases where documentation of a given tailgate session was deemed necessary by the Operating Engineer, a Training Completion Form (TCF) was circulated among those in attendance. Completed TCFs were routed to the Operations Training Coordinator who was responsible for identifying those trainees who were not present to ensure that they were subsequently trained on the pertinent materia Discussions with members of the operating staff indicated that it may take as long as three weeks to contact an individual trainee who has missed a documented tailgate session, depending on his schedule. The training department stated that material disseminated via documented tailgates was generally followed up by inclusion of the material in the next required reading package; however, a cross check between tailgate topics and required reading content was not performed. The inspector noted

-

.

that this practice allowed up to 81 days in the worst case before action must be taken to ensure a given operator received information since required readings were not required to be complete for up to 60 days following issuanc (2) Postings The licensee stated that in some cases, it was appropriate to disseminate information quickly without holding a tailgate session. Notifications of completed modifications and revist...

of Technical Specifications were given as examples. For information falling into this category, the Training Department may post copies of pertinent memos, modifications or other notices on the flip chart in the control roo The flip chart was an aid to those personnel in the control room for keeping track of any limiting conditions for operation (LCOs) time clocks that may be in effect. Use of the flip chart was instituted after several LCOs were exceeded resulting in LER The licensee stated that use of the flip chart was not mandatory for shift turnover and that although personnel were not required to note any postings on the flip chart, most of the operating staff routinely reviewed the chart and any attached posting Discussions with members of the operating staff indicated that the exact purpose of the flip chart and of any postings on the chart was not consistently defined. The licensee indicated that reading the notices posted on the flip chart was not required; however, any important information posted on the flip chart would also be included in the next required reading package and as such would be documented via the completed TCF associated with the required readin (3) Required Readinj The training department specified that completion of required reading assignments be documented by trainees via a Training Completion Form (TCF) within 60 days cf issue. Warning notices were sent to trainees who had not yet submitted a completed TCF both 30 and 45 days after issuance of the reading package to notify the trainee that the deadline for required reading training documentations was imminen Completed TCFs are collected and kept by the training department, which was also responsible for identifying those trainees who had not completed the required reading. Although most trainees completed the required reading assignments within the 60-day time limit, there was no evidence that either Operations or Training groups verified that any given trainee had read the required material prior to performance of tasks addressed in the required readin _ ,

,

't

.

.

.

.

~

Eightrequiredreadirkpackageswereissuedduring198 The inspector noted that synopses of past occurrences were included as were procedure revisions and some modification package ~~

Interviews with several members of the' operating staff reveM ec'

that lessons learned from occurrences were routinely facto Q d into the required readings as well as classroom discussion Members of the training staff indicated that examination questions regarding certain events were being developed and would be incorporated into the exam question bank for future us Analysis of Recent Occurrences

,, --

The inspector investigated 6 LERs,'5~DVRs and 4 violations identified

' during the period A.Qust,1984 through JaTiary,1986. The root cause, for the occurrences revievied by the inspector Jell into three basic categories: failure to perform a correct shift turnover, failure to identify off-normal conditions, and testing of modifications. The inspector determised that only one of'theae three areas was ,

identified as a specific task in the licensee's job task analysis compiled to satisfy the INP0 training accreditation requirement It was noted that CECO generally defined procedure titles as specific tasks to be p y, forme "

(1) Shift Turnover .

-

,

,

Emphasis on conducting shift tur'overn was addressed in various

" tailgate" sessions held by each Shift Foreman with his staf The inspector reviewed the required reading packages issued within the last year and noted that events for which inadequate shift turnover had been identified as the root cause were specifically addressed. TrMning records reviewed revealed that all licensed personnel had subreitted a signed Training Completion Form (TCF) to the training department indicating that

,

they had read and understaod the material Review of those training segments which addressed shift turnover rev eled that based on training lesson plans and trainee recbrds, adequate training was provided to have prevented the occurrences reviewed by the inspector. Discussions with members of licensee management indicited that information pertaining to the identified occurrences and the importance of a detailed shift turnover as specified in the shift turnover procedure was frequently addressed in trainee' required reading (2) Identification of Off-Normal Conditions Discussions with members of the licensee's training staff revealed that although trainieg on the identification of off-normal conditions was not explicitly conducted, training on normal operating conditions should provide trainees with sufficient skills to identify off-normal condition .

>

- ~

._ -.

.

The licensee also stated that in an effort to address the need to identify off-normal conditions, the simulator training i program was being revised to evaluate trainee competency regarding identification of off-normal condition Specifically, trainees, upon a simulated completion of shift turnover would be required to perform an individual independent board walkdown and identify any off-normal conditions input to the simulator by the instructo The licensee stated that this revision was due to the recent increase in failure of the operators to note off-normal conditions as noticed by the inspector and evidenced by the increase in LERs identifying this deficiency as the root cause. The inspector reviewed the licensee's list of potential "out of normal" corditions and noted that several items had previously been identified by DVRs, LERs, and violation (3) Modifications Members of the licensee's training staff stated that due to past difficulties with the training associated with plant modifications, all proof testing of any component requiring tests other than normal operating surveillance tests, would be administered and witnessed by the member of the Technical Staff responsible for the modificatio In addition, to avoid declaring a modification operable prior to appropriate training for all operators, the modification approval procedure had been recently revised to require that training, if required prior declaring the modification operable, be completed and TCFs received from all operators prior to declaring the modification operable. The Training Supervisor stated that this was in part due to the comment raised during the recent Brookhaven National Laboratory technical review of the LaSalle County Station modification progra The inspector noted that, in some cases, a description of a given modification may be posted by the Training Department on the flip chart in the control room; however, completion of training was documented by TCFs associated with required reading d. Assessment of Training Program for Events The inspector noted that in place training programs should have been sufficient to have prevented the occurrences investigate Discussions with members of the operating staff indicated that the operators generally acknowledged the adequacy of training received and attributed the occurrences chosen for investigation to be due to

'

lack of attention to detail possibly due to the absence of positive

, reinforcement based on performance. Counselling sessions with those operators who had committed operational errors were generally not documented. The licensee stated that if the occurrence was serious enough a mention may be made in the operator's personnel file.

l l

l l

_ . . _ . _ .

. .

Lessons learned from occurrences were factored into existing training programs as deemed necessary; however, dissemination of such information may take as long as 81 days in the worst cas Training records indicated that all trainees required to read the required reading packages typically did so within the time constraints established by the licensee; however, no verification that a given trainee had completed the required reading was performed by either Training or Operations prior to assignment of tasks addressed in the reading. It was possible for an operator to perform a task prior to reading pertinent training material The significance of the flip chart located in the control room and any postings attached to it was unclear. Interviews with licensed personnel did not determine whether the flip chart was required to be looked at as a part of shift turnover. The inspector noted that the flip chart was not mentioned or required in any licensee procedur The licensee stated tha'. the flip chart served as an aid in tracking running time clock With respect to training for modifications and return to service, the inspector noted that the lesson plans addressed the licensee's procedure for out-of-service equipment. Although the procedure discussed the steps to be taken prior to returning equipment to service from an administrative standpoint, the requirements for operability testing and associated surveillance testing to ensure that equipment was, in fact, able to perform its function were not specifically addressed. It was not clear to the inspector whether equipment operability effects on interfacing systems were addressed elsewhere in the licensee's training progra e. Summary Although several methods of informing licensed operators were used by the licensee, required reading was the only consistently documented mean The licensee stated that the other methods, i.e., postings and tailgates, had been implemented as supplements to the required reading in an effort to decrease the number of occurrences. It was not clear whether providing the same information by different methods detracts from or enhances the effectiveness of required reading Those licensed personnel interviewed consistently stated that the training they had received was adequate to have prevented the occurrences reviewed by the inspector. It was their opinion that the scope and depth of the training material was commensurate with assigned tasks and that occurrences were not the result of inadequate or deficient trainin The licensee positively addressed the incorporation of lessons learned into the licensed operator requalification program. Although the methods used may not disseminate information in a timely manner, operators were kept appraised of current events and that periodic updates to the training program were performe .

3. Non-licensed Staff Training The inspector reviewed operational events (Deviation Reports over previous year), recent modifications, and interviewed plant personnel to evaluate the effectiveness of training programs for the licensee's non-licensed staf Operational Events The inspectors reviewed approximately 25 Deviation Reports (DR) to determine if: (1) they were caused by personnel error; (2) the personnel error was caused by deficient training, and (3) if any lessons learned from the event had been factored into the training program. Of these 25, the inspector chose 4 deviation reports for further review as listed below:

Deviation Report Number Description 1-1-85085 Charging valve mispositioned 1-2-85086 Failure of limitorque torque switch 1-1-85089 ADS inoperable / switches wired wrong 1-1-85164 Reactor trip / personnel error Deviation Report 1-1-85085 addressed a control rod drive charging water stop valve that was found mispositioned after the performance of a surveillance procedure. The licensee attributed the mispositioned valve to personnel error on the part of an Equipment Attendant (EA). The licensee was unable to provide the name of the subject EA to the inspector therefore an interview was not performed nor training records reviewed. The inspector reviewed the subject surveillance procedure and noted the only way this valve could have been left mispositioned is if the EA had violated the procedure by skipping the step requiring the valve be returned to its' normal position. The licensee had counseled the EA on the importance of attention to detai Deviation Report 1-2-85086 dealt with Limitorque Operator torque switch failure and was chosen for further review because of the recurring problems experienced with Limitorque Operators at LaSalle and throughout the Nuclear Industry. The cause portion of the DR identified dirty contacts and the corrective action portion stated the limit switch was replaced which corrected the problem. The inspector reviewed training records of Electrical Maintenance (EM)

personnel and noted they were regularly trained on Limitorque Operator maintenanc Deviation Report 1-1-65089 dealt with the inoperability of the Automatic Depressurization System (ADS), Division II, because of level switches being incorrectly wire This problem was further compounded because the post maintenance test that should have identified the problem failed to do so because of personnel erro . *

The procedure in use (LIS-NB-104) at the time the error occurred had been identified for revision to " minimize the potential for errors of this type." Further review by the inspector revealed the error involved the incorrect reading of a Voltage /0hm meter by Instrument Maintenance (IM) technicians. Since IM's regularly used these instruments, the error can be attributed to personnel error /

inattention to detail and not to inadequate or incomplete trainin Deviation Rc;; ort 1-1-85164 addressed a Reactor Scram caused by a Turbine trip which in turn was caused by an IM technician incorrectly filling and repressurizing an instrument lin This resulted from the IM not following the required procedur Since this was not the first instance in which the IM had caused a Reactor Scram by not following procedures, the licensee's corrective action was to relocate the individual into a less demanding jo The inspectors found that no specific lessons were learned from the above events that could be factored into the licensee's training program. However, the inspector noted the training department reviewed all Deviation Reports and factored any lessons learned into the training progra b. Modifications The inspector reviewed the qualifications and training records of several EM personnel and Technical Staff (TS) engineers that were associated with the post modification testing of the ADS syste This modification incorporated a number of changes to the ADS logic and was identified as Modification No. 1-1-84036. The inspector noted the EM personnel (one A man, one B man) satisfied the qualification requirements for A and B men and had classroom and on the job training that addressed the tasks required for the portion of the test in which they were involved. The inspector noted the TS engineers received general training which among other areas included system courses. After the required courses and in addition to any other regularly scheduled courses, the TS Department relied heavily on on-the-job training and the technical background and competency of the engineers. The TS engineer's qualifications and training records were in order and through personal interviews, they appeared competent and well able to perform their assigned duties. The inspector found the details of this modification had been reviewed by the Training Department for inclusion into the training progra In addition to the personnel involved with the above modification the training and qualification records for several QC inspectors were reviewed. The inspector found no inconsistencies in their training records arid noted inexperienced QC personnel were not allowed to inspect areas in which they were not trained or knowledgeabl . . . . Interviews The inspector performed interviews with the majority of the non-licensed personnel identified above. During these interviews the inspector questioned the personnel regarding the training they received to perform their assigned tasks in addition to their general knowledge in the following areas:

Nuclear Security

Industrial Safety

Quality Assurance

Radiation Safety Emergency Response The personnel questioned felt the training they received was ,

adequate for their job, and the inspector found their knowledge in the above areas was goo Summary The inspector found that the training received by non-licensed personnel was in all cases sufficient for the performance of their duties and that changes from plant modifications and lessons learned from events were factored into that training progra The inspector noted while reviewing the deviation reports a large number of the corrective action statements stated, " . . . the individual was counseled on the importance of attention to detail." In addition, of the DVRs generated over the last year for both units, 53 were a result of personnel errors, and of these, 34 involved Technical Specification items with two resulting in Reactor Scrams. While this was not the focus of this inspection, it would be to the licensee's advantage to address what the inspectors perceived as a problem with personnel errors that could, for the most part, be attributed to inattention to detai . Exit Interview The inspectors met with licensee representatives (denoted in Paragraph 1)

on April 25, 1986, to discuss the scope and findings of the inspectio The licensee acknowledged the statements made by the inspectors with respect to items discussed in the report. The inspectors also discussed the likely informational content of the inspection report with regard to documents or processes reviewed by the inspectors during the inspectio The licensee did not identify any such document / processes as proprietary.

!

l

!

l

,