IR 05000373/1998025
| ML20198F312 | |
| Person / Time | |
|---|---|
| Site: | LaSalle  |
| Issue date: | 12/16/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20198F293 | List: |
| References | |
| 50-373-98-25, 50-374-98-25, NUDOCS 9812280087 | |
| Download: ML20198F312 (20) | |
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U.S. NUCLEAR REGULATORY COMMISSION REGION lil Docket Nos:
50-373,50-374 License Nos:
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Report Nos:
50-373/98025(DRS); 50-374/98025(DRS)
Licensee:
Commonwealth Edison Company (Comed)
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Facility:
LaSalle County Station, Units 1 and 2 Location:
2601 N. 21st Road Marseilles,IL 61341 Dates:
November 2 - 6,1998 Inspectors:
H. Peterson, Lead Inspector, Operations Branch, Rll!
D. Desaulniers, inspector, Human Factors Assessment Branch, NRR D. Muller, inspector, Operations Branch, Rill Approved by:
Melvyn Leach, Chief, Operator Licensing Branch Division of Reactor Safety 9012280087 981216 PDR ADOCK 05000373 G
PM j
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EXECUTIVE SUMMARY
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LaSalle County Station, Units 1 and 2 NRC Inspection Report 50-373/98025; 50-374/98025 This inspection report contains the findings and conclusions from the special inspection of the licensee's Operator Workaround (OWA) program. The inspectors used the guidance in NRC temporary instruction TI-138," Evaluation of the Cumulative Effect of Operator Workarounds."
Plant Operations In general, the control room activities were observed to be conducted in a professional
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manner. Control room shift turnover and shift briefing were satisfactorily conducted with good participation by licensed and non-licensed operators. The control room operators were readily aware of plant conditions, and appropriately acknowledged and cleared control room annunciator alarms. In-plant activity for the diesel generator surveillance test was performed satisfactorily with appropriate coordination by the field supervisor.
(Section 01.1)
The operators were adequately knowledgeable of OWAs and operator challenges (OC),
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and with their compensatory actions. However, some operator knowledge deficiencies were identified concerning two OWA compensatory actions. Also, the inspectors concluded that the OWA books located in the control room were not adequately maintained. (Section 04.1)
The licensee had established a program with procedural guidance that adequately
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addressed the pertinent issues concerning OWAs. However, the licensee had recently changed the definition of OWAs to recategorize a deficiency affecting normal plant operations as an OC. The new definition of OWA was considered limiting, but the inspectors concluded that the implementation of the OWA and OC procedures collectively had the capability of addressing the overall plant workaround issues.
(Section 06.1)
The inspectors concluded that the licensee was actively emphasizing the identification,
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tracking, and timely resolution of OWAs. However, the inspectors found that these areas still needed some improvement. For example, several nonconforming conditions were identified by the inspectors that appeared to be OWAs or OCs, but were not identified as such by the licensee. These items included problems associated with Offgas Building ventilation, reactor water level instrumentation, turbine driven reactor feedwater pump (TDRFP) turning gears, a valve indication for the 1B TDRFP, a main condenser vacuum breaker, and the 1 A reactor recirculstion flow control valve. However, the inspectors determined that these additional items were adequately identified and monitored by other tracking methods (e.g., action requests, control room distractions, and work requests).
(Section 06.2)
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The inspectors concluded that the OWA procedure did not address individual
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assessments of direct and potentialimpacts of OWAs. For example: (1) the program
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did not assess the potential for operator error; and (2) it did not assess the probability of causing an abnormal or emergency plant condition. The inspectors also concluded that
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OWAs and OCs for the more pertinent and safety significant items were adequately reflected in the simulator. However, the inspectors determined that there was a lack of specific guidance or requirement for the LaSalle training department to systematically j
review and incorporate OWAs and OCs into the simulator on a periodic bases. (Section 06.3)
In general, the licensee had performed an aggregate assessment of the cumulative
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effects of OWAs; however, the inspectors concluded that the program: (1) lacked specific guidance on how to perform an aggregate assessment of the cumulative effects of OWA on safe plant operation; (2) there was a lack of procedure or guidance to keep accurate documentation of the assessment process; and (3) the program did not require the consideration of the proceduralized compencatory actions from closed OWAs and
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OCs in the aggregate assessment. Based on the small cross-sectional review of select items, the inspectors concluded that the existing discrepancies identified and tracked by the licensee would not have prevented the safe operation of Unit 1. The inspectors also determined that the licensee had deficiencies on Unit 2 that required correction prior to
. unit startup. The licensee's plans to address these were appropriate. (Section 06.4)
The inspectors concluded that the licensee's performance in assessing and resolving
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OWAs was, in general, adequate. Also, the inspectors cone'uded that the Workaround
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Board decisions conceming assessment and resolution of OWAs were, in general,
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consistent with the licensee's program. However, the inspectors concluded that: (1) the licensee was inconsistent in performing the aggregate assessment of OWAs, within the past year only one quarterly assessment driven by the OWA program was performed; (2)
the licensee placed additional attention on resolving OWAs sad many OWAs were closed, but many were also rescheduled or reclassified as OCs; and (3) the inspectors identified one OWA that appeared to be prematurely closed, and one OWA and OC that appeared to not accurately represent current plant status. (Section 06.5)
Although the licensee's two self-assessments of its OWA program wera influenced by
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the NRC's planned inspection, the inspectors concluded that the assessments were very critical. The self-assessment performed by the Nuclear Oversight Department noted that the management of the OWA program was inadequate; however, it concluded that the cumulative effects of the workarounds provided minimal challenge to safe operation.
(Section 07.1)
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l Reports Details
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l l. Operations
Conduct of Operations 01.1 Control Room and Plant Observations a.
Insoection Scope (71707)
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Using the guidance of Inspection Procedure 71707, " Plant Operations," inspectors observed actual control room and plant operations. The inspectors observed routine control room and in-plant activities during full power operations on Unit 1 and outage l
condition on Unit 2, including the Unit 0 common diesel generator surveillance test. The
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Inspectors performed a panel walk-down, reviewed control room documents, and questioned operators about plant and equipment status. In addition, a shift turnover and a shift briefing were observed.
b.
Observations and Findinas The inspectors found that the shift briefing was conducted by the Shift Manager and held
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in a separate briefing room just outside the control room. The control room operators
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listened to the shift briefing via a teiephone conference. The inspectors observed that both licensed and non-licensed operators actively participated in the shift briefing, with good exchange of detailed plant information.
Operator performance concerning response to plant conditions were also observed. The operators properly responded to annunciators and took the appropriate actions based on
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the annunciator response procedures, as necessary. No annunciators were left unattended for any length of time, as the operators took actions to quickly acknowledge and clear the alarms. When asked by the inspectors, the control room operators readily answeied questions and were knowledgeable of plant conditions.
The inspectors found the Unit 0 common emergency diesel generator (EDG) testing was conducted satisfactorily by operations personnel with system engineers taking surveillance test readings. The inspectors observed that the test was well coordinated and was attended by the field supervisor, c.
Conclusions in general, the control room activities were observed to be conducted in a professional manner. Control room shift turnover and shift briefing were satisfactorily conducted with good participation by licensed and non-licensed operators. The control room operators were readily aware of plant conditions, and appropriately acknowledged and cleared
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control room annunciator alarms. In-plant activity for the diesel generator surveillance test was performed satisfactorily with appropriate coordination by the field supervisor.
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Operator Knowledge and Performance 04.1 Ooerator Knowledoe of Ooerator Workarounds l
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Insoection Scope (Tl 138)
Using the guidance of Temporary Instruction 138," Evaluation of the Cumulative Effect of Operator Workarounds," the inspectors evaluated control room operators' knowledge of operator workarounds (OWA) and the licensee's additional category of Operator Challenges (OC). The inspectors performed a panet walk-down and reviewed control
l room documents. The inspectors conducted interviews with four non-licensed operators, two licensed reactor operators, and one shift manager about plant and equipment status
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concerning workarounds and challenges. The inspectors also questioned a shift manager, a unit supervisor, a field supervisor, and two licensed reactor operators during the control room and in-plant observations. The following procedure pertaining to certain OWAs was reviewed:
LaSalle Surveillance Procedure LOS-DG-Q1,"O Diesel Generator Auxiliaries
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inservice Test." Rev. 30 July 23,1998.
b.
Observations and Findinos During the interviews, the inspectors identified that the operators provided the correct licensee definitions for both OWAs and OCs. In addition, the operators provided an adequate overall description of the licensee's program for identifying, tracking, and resolving OWAs and OCs.
The operators were specifically asked questions pertaining to existing OWAs and their associated compensatory actions. The operators were generally aware of the OWAs and their associatad compensatory actions. However, specifics of some compensatory actions were not readily understood. The inspectors identified two OWAs where operator knowledge was deficient:
(1)
WA-261 was an open workaround for Unit 2, which stated, in part, that the performance of LOS-DG-Q1 causes the unavailability of certain emergency core cooling systems (ECCS). When the operators were questioned about this OWA, they stated that performing LOS-DG-Q1 still affected the service water supply to one division of Unit 2 ECCS equipment, which was why the OWA was still open for Unit 2. However, the operators incorrectly believed that performing LOS-DG-Q1 no longer affected Unit 1 ECCS components. The operators stated that additional flow gages had been installed on Unit 1, which was why performing LOS-DG-Q1 no longer affected Unit 1 ECCS. The operators believed that this was the basis for closing the similar open workaround (0WA 219) for Unit 1. The inspectors determined, through discussions with additional licensee personnel and through a procedure review of LOS-DG-Oi, that performing LOS-DG-Q1 still l
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affected both Unit 1 and Unit 2 ECCS. The work associated with the additional flow gages was completed for Unit 1, but the most current revision to the
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procedure had not been updated and still Indicated that Unit 1 ECCS would be affected by the performance of LOS-DG-Q1.
(2)
OWA-188 was an open workaround for Unit 2, which stated, in part, that installing jumpers to bypass Main Steam Tunnel temperatures and differential j
temperatures created problems for operators. When the operators were questioned about this OWA, the operators incorrectly stated that jumpers still needed to be installed for Unit 2 when restoring reactor building ventilation. The inspectors determined that for both Unit 1 and Unit 2, keylock switches were currently employed to bypass Main Steam Tunnel temperature and differential i
temperatures when restoring reactor building ventilation. The inspectors found that both the OWA information and the operators were not updated with the equipment status.
The operators were asked how new OWAs and OCs, along with their compensatory actions, were relayed and updated to the operators. The operators were unsure exactly how new OWAs or OCs were relayed to the operators. In general, the operators assumed that during the shift briefing these types of information would be relayed to the operating shift personnel. The inspectors also noted that a hard copy reference book of updated OWAs and OCs was placed in the control room for reference and use by the operators. However, the inspectors identified that this book was not routinely updated.
The Inspectors found three OCs that were closed, but were still indicated as being open,
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listing the required compensatory actions. (See Section 06.2 for additional details.)
Upon further questioning by the inspectors, the workaround coordinator indicated that the hard copy OWA/OC log in the control room was a recent addition. Also, the coordinator noted that the intention was to have the operators review the intranet E-mail for the most recent update of OWAs and OCs. The OWA program expected that periodic updates of OWA and compensatory actions would be maintained in the computerized format and forwarded to each operator via the E-mail. Also, the coordinator roted that the plan-of-the-day meeting communications package would also incorporate the OWA updates.
c.
Conclusions The operators were adequately knowledgeable of OWAs and operator challenges (OC),
and generally with their compensatory actions. However, some operator knowledge deficiencies conceming two OWA compensatory actions were identified. Also, the inspectors concluded that the OWA books located in the control room were not j
adequately maintained.
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Operatiu: Organization and Administration (Operator Workarounds)
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06.1 Ooerator Workaround Procedures and Criteria a.
Inspection Scoce The inspectors reviewed procedures and criteria that the licensee used for identifying, tracking, and resolving operator workarounds and evaluating their cumulative effects.
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The procedures reviewed included the following-l Common Work Fractice Instruction (CWPI)-NSP-OP-1-3, " Conduct of Operations a
Manual of Common Work Practice Instructions - Instr ction Three - Operator Workaround Program," Rev. O, August 14,1998.
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LaSalle Administrative Procedure (LAP)-200-3, "Conouct of Operations - Shift
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Operations - Section 21 - Operator Work-Arounds," Rev. 30, November 7,1998, and Rev. 31, May 26,1998.
LaSalle Administrative Procedure (LAP)-200-3," Conduct of Operations - Shift
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Operations - Section 21 - Operator Challenges," Rev. 36, October 31,1998.
b.
Observations and Findinas l
The inspectors found that the LaSalle County Station's procedure for describing the methodology for the identification, tracking, planning, scheduling, and minimizing of operator workarounds was initially noted in LAP 200-3, Revision 30, dated November 7, 1997. However, this procedure underwent several changes within the past year, with the most significant change made on Revision 31 dated May 26,1998, that changed the licensee's definition of OWA. The procedure change resulted in a more limiting definition of OWA compared to the NRC definition per Tl 138. The inspectors determined, from the procedure reviews, that the licensee's current definition for OWA was:
Operator V3rkaround: An equipment or program deficiency that provides an obstacle to safe plant operations by requiring operations personnel to take compensatory actions to comply with procedures, design requirements or technical specifications. If compensatory actions have been proceduralized, but were not intended as part of the equipment operating design, the issue should be considered an operator workaround.
This definition change to OWA was an initiative to establish a common definition and a corporate wide procedure on how to control OWAs. Subsequently, the Commonwealth Edison Company (Comed) developed a corporate procedure, CWPI-NSP-OP-1-3. This corporate wide procedure incorporated the existing definition of OWA, but made it consistent through out all Comed nuclear plants.
l The new definition substantially reduced the number of items tracked as operator workarounds. Those items which no longer met the licensee's new criteria for an
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operator workaround were reclassified and referred to as " operator challenges". The
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licensee, to adequately track and resolve OCs, revised procedure LAP-200-3 in Rev. 36,
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i dated October 31,1998. The procedure prescribed a process similar to that for OWAs.
The inspectors found that although the guidance for OWAs excluded some conditions that fall within the NRC definition, the licensee's procedure for OCs addressed most of l
those conditions. The licensee's definition of an OC was:
I Operator Challenge: An equipment or program deficiency that provides an l
obstacle to normal plant operations by requiring operations personnel to take
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compensatory actions to comply with procedures, design requirements or l,
technical specifications. If compensatory actions have been proceduralized, but i
were not intended as part of the equipment operating design, the issue should be considered an operator challenge if it does not fit the definition of an operator workaround.
The inspectors noted additional program criteria within the licensee's procedures. The licensee's workaround procedure, CWPI-NSP-OP-1-3, assigned a " work-around board".
The board was comprised of representatives from all departments with recent inclusion of the plant and operations managers. The board had the responsibility for performing a quarterly review of the caution card, degraded equipment, and temporary alteration logs i
for potential operator workarounds. On a quarterly bases the board was to review equipment deficiencies to assess the cumulative or aggregate effects of OWAs on operators' ability to respond effectively to plant transients.
The workaround procedure also required that the shift operations supervisor (SOS) be responsible for assuring that a quarterly aggregate impact assessment was performed for all open workarounds and to adjust work priorities and scheduling accordingly.
In addition, the procedure and criteria were noted by the inspectors as more reactive rather than proactive. For example, the licensee's definition of OWA specifically took into account a compensatory action that was performed during transients or emergency l
conditions. However, the licensee's procedure end definition did not consider a compensatory action for a deficiency that could have the potential for causing a transient or emergency condition as an OWA.
c.
Conclusions
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The licensee had established a program with procedural guidance that adequately addressed the pertinent issues concerning OWAs. However, the licensee had recently f
changed the definition of OWAs to recategorize a deficiency affecting normal plant operations as an OC. The new definition of OWA was considered limiting, but the inspectors concluded that the implementation of the OWA and OC procedures collectively had the capability of addressing the overall plant workaround issues.
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O6.2 Identification of Operator Workarounds
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a.
Insoection Scope l
The inspectors reviewed the established operator workarounds, conducted interviews with licensed and non-licensed operators, conducted main control room observations and panel walk-downs, and accompanied equipment operators on system tours in order l
to assess knowledge of known workarounds and to identify any previously unidentified j
workarounds. The inspectors also reviewed a blank Problem identification Form (PlF), a blank problem identification screening form, the station's OWA and OC procedures, and a sample o a,tation procedures (alarm response, normal operating, surveillance, plant
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startup, abnormal operating, emergency). The following procedures were reviewed:
LaSalle Administrative Procedure (LAP)-200-3," Conduct of Operations - Section
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l 1 - Shift Relief," Rev. 36, October 31,1998.
l LaSalle Surveillance Procedure (LOS)-DG-Q1, "O Diesel Generator Auxiliaries
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i inservice Test," Rev. 30. July 23,1998.
j LaSalle General Operating Procedure (LGP) 1-1, " Normal Unit Startup," Rev. 57,
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July 22,1998 l
b.
' Observations and Findinas
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Based on interviews, the inspectors found that the operators were gen,erally knowledgeable of current workarounds and the necessary compensatory actions. The
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inspectors found that operators received OWA/OC information by four basic methods: (1)
turnover communications between off-going and on-coming watchstanders, (2) shift j
turncver briefings, (3) reviews of daily orders, and (4) reviews of the OWA/OC reference l
books maintained in the main control room. The inspectors also noted that operators l
were able to access a computer-based list of operator workarounds in the control room.
Although methods (1) through (3) above were a required part of shift turnover, the l
inspectors determined by a review of LAP-200-3, Section 1, " Shift Relief," that method (4), reviews of the OWA/OC reference books, was not a required action. During the
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interviews, the operators stated that although a review of the OWA/OC books was not a i
required part of shift turnover, it was a good practice to review the OWA/OC books at some point prior to or during their shifts. However, the inspectors identified that the reference books were not routinely updated.
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The inspectors identified three previously closed OCs (OCS 220,232, and 289) that were still being maintained as open items in the control room OWA/OC reference books.
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In addition, the inspectors found a Unit 1 workaround (WA 219) that was closed, but the compensatory action was still required as noted in the referenced surveillance procedure, LOS-DG-Q1, "O Diesel Generator Auxiliaries Inservice Test." The workaround resulted in securing service water to certain Unit 1 emergency core cooling system equipment motor and room coolers; thereby, making the affected systems inoperable during the performance of the surveillance test. Based on discussions with
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plant management personnel, it was apparent that the control room OWA/OC books
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were not being maintained up to management expectations.
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During the review of the control room OWA/OC books, the inspectors determined that l
the level of detail of the OWA/OC log sheets was not consistent, in some cases the description provided on the log sheets appeared adequate to describe the nonconforming condition and what compensatory actions were required. In other cases
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only the nonconforming condition was explained, and the log sheets did not adequately describe the conapensatory actions. For example, the log sheet for OC 177 stated that the 2A turbine driven reactor feedwater pump high point vent valves leaked and were welded shut. However, the log sheet for OC 177 did not describe any compensatory actions for this nonconforming condition. When plant operators were questioned, they l
were unaware of the compensatory actions for OC 177. The inspectors found that the compensatory action was to vent the 2A discharge header using the B side vent valves.
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The inspectors noted that the potential for prescreening a PlF as an OWA issue appeared to be lacking. Normally, only one or two Corrective Action Program staff personnel with limited operational experience were responsible for the PIF prescreening of potential OWAs. Also, the inspectors considered that the overall responsibility of the department head PlF screening was to concentrate its focus on resolving the PlF issue rather than just identifying an OWA item. During interviews, the inspectors found that the operators were encouraged to identify degraded equipment conditions and were recently informed to specifically identify the condition as an operator workaround, if applicable, when completing the problem identification form. This was to ensure that the condition was reviewed as a candidate for the operator workaround list.
During the main control room panel walk-downs on Unit 1, the inspectors identified the following nonconforming conditions which met the NRC's definition of an OWA, but have not been identified by the licensee as either an OWA or OC.
(1)
The Offgas (OG) Building ventilation dampers required manual (local) assistance to open/close. This problem was identified for the "A" OG building supply damper on August 9,1998, and for the "A" OG building exhaust damper on September 11,1998. These dampers were designed to operate automatically when the associated fan was started up or secured. The compensatory actions were to locally assist these dampers during changes to the OG building's ventilation lineup (startups, swapping trains).
(2)
The "A" narrow range reactor water level instrument indicated high and oscillated.
This problem was identified on January 16,1997, and an action request was used to identify the problem. Through discussions with the operators, the inspectors understood that the operators were to not rely on the "A" instrument's indication and to not select the "A" instrument as the input for reactor water level control.
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The turning gears for both turbine driven reactor feedwater pumps (TDRFP) were l
tagged out-of-service in pull-to-lock, to prevent oil leaks. This condition had l
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existed since 1994. During a shut down of a TDRFP, the turning gear was
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designed to automatically engage when the turbine had finished coasting down.
The compensatory actions were that when a TDRFP required to be on the turning gear (startups or shutdowns), the tags were cleared, and the oil lineup was
restored to the system. Once the turning gear was no longer needed, the oil lineup was secured, the control switch was taken to pull-to-lock, and an out-of-service was hung.
(4)
The valve indication for the 1B TDRFP high pressure steam stop valve (valve 1B21-F422B) indicated " dual" when the valve was closed. This condition was l
identified on August 12,1993. The compensatory actions were that when this l
valve needed to be closed (e.g., during a shut down of the 18 TDRFP), the position of this valve would be checked locally.
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Main condenser vacuum breaker 1TE11 leaks by. This condition was identified on August 10,1998. The vacuum breaker leaking by caused an associated decrease in this valve's seal water level. The compensatory actions required refilling the water seal when water seal low level alarms were received.
During the review of procedures, the inspectors identified an additional nonconforming condition that appeared to meet the licensee's definition of an OC, but was not identified
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as an OC by the licensee. The nonconforming condition concerned the operation of the 1 A reactor recirculation flow control valve during plant heatup and pressurization in LGP 1-1, " Normal Unit Startup," Rev. 57, July 22,1998, precaution D.14.1 stated,
" Maintain the 1 A reactor recirculation flow control valve <92% open when reactor
pressure is <500 pounds per square inch gage (psig)." This valve was subsequently fully opened in step E.9.11.1 of LGP 1-1, when reactor pressure was increased above 500 psig. However, the inspectors found that the valve per design was to be fully open during vessel pressurization and heatup to rated conditions. Based on discussions with licensee personnel, the inspectors found that this valve had a history of binding, and was therefore not fully opened until greater than 500 psig. It appeared to the inspectors that the 1 A flow control valve was not operating as designed, which required operator compensatory actions.
c.
Conclusions The inspectors concluded that the licensee was actively emphasizing the identification, tracking, and timely resolution of OWAs. However, the inspectors found that these areas still needed some improvement. For example, several nonconforming conditions were identified by the inspectors that appeared to be OWAs or OCs, but were not identified as such by the licensee. These iterns included problems associated with Offgas Building ventilation, reactor water level Instrumentation, TDRFP tuming gears, a valve indication for the 18 TDRFP, a main condenser vacuum breaker, and the 1 A reactor recirculation flow control valve. However, the inspectors determined that these additional items were j'
adequately identified and monitored by other tracking methods (e.g., action requests, control room distractions, and work requests).
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06.3 Assessment of Individual Workarounds a.
Insoection Scooe The inspectors reviewed the licensee's current listing of 27 open and 131 closed OWAs, and 49 open and 36 closed OCs. The inspectors reviewed a sample of OWAs and OCs to assess individual impact on plant operational safety. Examples included:
workarounds on the reactor recirculation system flow control valve controls, the emergency diesel generator service water surveillance test, and the reactor feedwater controls. The inspectors also interviewed plant personnel to determine the effectiveness of the licensee's assessment of OWAs. Additionally, the inspectors reviewed equipment deficiencies, as identified by the licensee's OWA and OC list, to determine if they were reflected in the simulator.
b.
Observations and Findinas i
Although the workaround procedure covered many of the aspects noted in Tl 138, the inspectors found that the procedure did not address all the attributes for individual assessments of workarounds. The procedure did not prescribe any method for conducting individual assessments or establish any requirements for documenting the results of such assassments. The operator challenge procedure similarly lacked the guidance for perfor ing these activities.
The inspectors nosJ that the licensee's assessment of OWAs, in general, took into account operatoi c rden, impact on system reliability and availability, and impact on crew response to aonormal or emergency plant conditions. However, the inspectors observed that the licensee's OWA and OC programs did not specifically assess the potential for operator error, and the probability of causing an abnormal or emergency plant condition (i.e., consider a condition as an OWA that had the potential for causing a transient or emergency condition). For example, if the compensatory action for Unit 1 OC 212, which required increased monitoring of panel 1PL15J/75J (Division 1 Containment Sampling and Monitoring Panel) with specialized logs to maintain panel operation, was not performed, then it would lead to a potential loss of one division of containment monitoring instrumentation.
Although some deficiencies were identified by the inspectors that were not necessarily tracked as an OWA or OC, the licensee was adequately tracking these deficiencies by other tracking methods. The inspectors did not !dentify any significant safety issues that were not already identified and adequately monitored by the licensee.
Based on interviews with select training department personnel, the inspectors found that not all OWA items were modeled into the simulator. The inspectors determined that depending on the length of time an OWA item existed in the control room, then that item would be consistently configured into the simulator. The inspectors reviewed the existing
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OWA and OC list, along with inspector identified items that were not ois the OWA/OC list,
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and compared it with the plant specific simulator. The inspectors identified that significant operational burden OWAs were modeled in the simulator. For example, the l
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reactor recirculation flow control valve controller problem. Additionally, the inspectors found that the simulator would incorporate certain OWAs and OCs, depending on their
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safety significance. The inspectors noted that it was individual initiative (simulator instructor) to decide what OWA would be modeled, and it appeared that there was no specific guidance for the training department to systematically review and incorporate OWAs or OCs into the simulator. However, the inspector was informed that the operations training supervisor performed monthly in-plant observations, with specific emphasis on comparing the condition of the control room to that of the simulator to assure adequate configuration of significant problems. Also, the inspectors observed that some simulator scenarios had incorporated OWAs and OCs.
c.
Conclusions The inspectors concluded that the OWA procedure did not address individual assessments of direct and potentialimpacts of OWAs. For example: (1) the program
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did not assess the potential for operator error; and (2) it did not assess the probability of
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causing an abnormal or emergency plant condition. The inspectors also concluded that OWAs and OCs for the more pertinent and safety significant items were adequately
reflected in the simulator. However, the inspectors determined that there was a lack of I
specific guidance or requirement for the LaSalle training department to systematically
.eview and incorporate OWAs and OCs into the simulator.
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06.4 Cumulative Effect of Ooerator Workarounds a.
Insoection Scope The inspectors reviewed the licensee's program for assessing the cumulative effects of operator workarounds. The inspectors reviewed procedures and conducted interviews.
Also, the inspectors reviewed select items of OWA and OC to ascertain the cumulative effects on safe plant operation.
b.
Observations and Findinas The inspectors identified that the licensee's program required the implementation of an L
aggregate assessment of OWAs each calendar quarter. This assessment was intended to determine the cumulative effects of OWAs on safe plant operations. The primary responsibility to perform such an assessment was given to the shift operations supervisor. However, in the last year, only three aggregate assessments were l
conducted. One assessment was performed in response to t'RC concerns on past OWAs. Another assessment was performed in response to the restart review of Unit 1.
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l-The inspectors found that the first true aggregate assessment driven by the licensee's L
OWA program was performed and presented to the plant operational review committee (PORC) on October 28,1998. This assessment included the review of OWAs, OCs, control room deficiencies, maintenance backlog, and out-of-service log. However, the PORC noted that the assessment did not take into account human performance factors i
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or procedure changes. ' Overall, this assessment concluded that safe plant operations could be continued. In addition, the inspectors noted that there was a lack of specific
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guidance on how to perform an aggregate assessment of the cumulative effects of
OWAs on safe plant operation.
The inspectors also determined that the program, based on procedure review, had the following apparent contradiction. The licensee's definition of OWA specifically noted that if compensatory actions have been proceduralized, but were not intended as part of the equipment operating design, the issue should be considered an OWA. However, the inspectors identified that the procedure criteria for closing out an OWA allowed for the permanent inclusion of compensatory actions into procedures with proper justification (50.59 review, FSAR change, or Technical Specification change). This action allowed for closure of OWA per documentation purpose, but did not correct the issue per the original design or condition. In general, by permanent inclusion of the compensatory j
action, the OWA was being accepted and closed, but the operator burden and the potential plant safety considerations still existed.
Additionally, these permanent compensatory actions, from closed OWAs and even closed OCs per procedure change, were not included in the aggregate assessment of the cumulative effect of OWAs on safe plant operations. The inspectors noted that although such permanent changes were performed per existing safety assessment criteria, such as 50.59 safety reviews, the potential existed that the aggregate
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accumulation of proceduralized OWA compensatory actions could lead to over burdening the operators to perform time-consuming operator actions during transients and emergency conditions, or which could lead to potential transients or emergency conditions.
The inspectors identified that the licensee was tracking numerous deficiency items and
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that the number of open items (27 OWAs and 49 OCs) appeared to challenge plant
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operators. However, the majority of the items were associated with Unit 2 which was still shutdown and in an outage status. The licensee was specifically tracking only three common unit OWAs,12 common unit OCs, six Unit i OWAs, and 11 Unit 1 OCs. In general, the inspectors, after reviewing select OWAs and OCs, found no specific items which would prevent the licensee from operating Unit 1 safely. However, for Unit 2 the inspectors identified that several workarounds required resolution prior to unit startup.
The licensee had appropriately noted and scheduled specific workarounds and challenges for correction prior to unit startup. For example, the Unit 2 workaround (OWA 218) for the 2B residual heat removal service water piping, which potentially caused water hammer during system startup due to improper fill and vent, was scheduled to be modified per an engineering design change. This design change was completed successfully on Unit 1.
c.
Conclusions in general, the licensee had performed an aggregate assessment of the cumulative effects of OWAs; however, the inspectors concluded that the program: (1) lacked specific guidance on how to perform an aggregate assessment of the cumulative effects of OWA on safe plant operation; (2) there was a lack of procedure or guidance to keep
i accurate documentation of the assessment process; and (3) the program did not require i
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the consideration of the proceduralized compensatory actions from closed OWAs and
OCs in the aggregate assessment. Based on the small cross-sectional review of select items, the inspectors concluded that the existing discrepancies identified and tracked by the licensee would not have prevented the safe operation of Unit 1. The inspectors also determined that the licensee had deficiencies on Unit 2 that required correction prior to unit startup. The licensee's plans to address these were appropriate.
06.5 Licensee Performance in Assessment and Resolution of OWA a.
Insoection Scope The inspectors evaluated the licensee's assessment and resolution of operator workarounds. The inspectors reviewed the licensee provided list of open and closed OWAs and OCs. Also, the inspectors attended a meeting of the Work-Around Board and had discussions with the workaround group personnel to determine the status of a sampling of OWAs and OCs. The inspectors also interviewed station operators and plant management personnel, and conducted control room panel walk-downs to determine the status of a sampling of plant equipment affected by OWAs and OCs. In addition, the inspectors reviewed the following procedure:
LaSalle Surveillance Procedure (LOS)-DG-Q1, "O Diesel Generator Auxiliaries
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inservice Test," Rev. 30, July 23,1998. Included Temporary Procedure Change 260-98, dated September 18,1998.
LaSalle Instrument Procedure (LIS)-LC-401, " Main Steam Isolation Valve
(MSIV)."
b.
Observations and Findinas The inspectors identified that although the concept of an OWA had existed for some time, the license just recently paid additional attention to resolve OWAs. Within the past two years the licensee accumulated numerous OWAs, and based on plant restart issues, the definition change of an OWA, and added attention by the NRC, the overall number of
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OWAs was reduced. Many OWAs were only reclassified as OCs, but many were also corrected or resolved. By procedure the licensee was allowed to close out an OWA to a procedural change. The OWA compensatory actions were accepted and included in the plant procedures, but the workaround condition still existed and still could be considered an operator burden. The inspectors identified that the licensee's assessment and resolution of OWAs did not include consideration of the proceduralized compensatory actions from previously closed OWAs in the aggregate cumulative assessment of OWAs.
(See Section O6.4 for additional details.)
The inspectors reviewed the licensee's plans for resolution of open workarounds and challenges. Recently, the licensee appeared to be aggressively working towards resolving OWAs. During the past year, many OWAs were closed, but many were rescheduled or reclassified as OCs. Of the items that were closed, the inspectors identified some discrepancies.
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The inspectors determined that one workaround (WA 219) appeared to be improperly
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closed out. OWA 219 was a Unit 1 workaround, which stated, in part, that performing LOS-DG-Q1 caused the unavailability of certain (Unit 1) ECCS. This item was documented closed on June 2,1998, by the installation of additional flow gages to resolve the problem. By closing this OWA, the inspectors assumed that Unit 1 ECCS equipment was no longer affected by the performance of LOS-DG-Q1. However, based on the review of the most current revision of LOS-DG-Q1, Unit 1 ECCS equipment was still made unavailable during the performance of LOS-DG-Q1. This was due to the failure of updating the surveillance procedure to remove the compensatory action. At the j
time of this inspection, when asked, the workaround coordinator could not explain why
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the OWA was closed, with the compensatory action still in place. Following completion of the inspection, the licensee subsequently verified and informed the inspectors that the
modification was completed but that the procedure had not yet been updated.
The inspectors also determined that one workaround (OWA 182) appeared to not represent the status of current plant equipment. OWA 182 was a Unit 1 workaround,
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which stated, in part, that the recirculation suction (F023) and discharge (F067) valves experience galling, and that these valves would be caution tagged and not operated electrically. However, during the Unit 1 control panel walk-downs, the inspectors noted that only the F0238 valve was caution tagged. Based on discussions with the control i
room operators, the inspectors determined that the restriction to not operate recirculation valves electrically only applied to the F023B valve. Some modifications had been completed to the F023A, F067A, and F067B valves, such that it was permissible to operate these valves electrically. This appeared to the inspectors to be a case where the workaround status did not match the actual plant status.
Finally, the inspectors determined that one operator challenge (OC 271) that was still open did not apply to current plant operatioris. OC 271 was a Unit 2 OC which stated, in part, that during the performance of LIS-LC-401, * Main Steam Isolation Valve (MSIV)
Leakage Control System Functional Test," that certain instrument stop valves leak by, However, the inspectors determined that the MSIV leakage control system has been a
retired in place, and that all LIS-LC procedures (including LIS-LC-401) had been deleted.
The inspectors attended the Workaround Board meeting that reviewed several items as
potential workarounds. The inspectors found that board decisions concerning whethar or not the individual items were workarounds appeared to be consistent with the i
licensee's definition. Also, following discussions with the inspectors, the board discussed plans for developing guidance for conducting aggregate assessments of operator workarounds.
The inspectors found that during the past year, one quarterly assessment of the aggregate impacts of operator workarounds was not performed. Only one of three assessments performed by the licensee was found to be conducted in accordance with the requirements of the OWA program. Also, the inspectors noted that documentation of
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the aggregate assessments was not adequate to evaluate the methods used to conduct the assessments. The inspectors interviewed the individual that performed the most recent quarterly assessment of OWAs and found that although the assessment included
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a broad scope of degraded conditions (e.g., operator workarounds, operator challenges, l
main control room distractions, maintenance backlog) the evaluation was performed l
L without any formal evaluation criteria, it was not clear to the inspectors which degraded I
conditions were considered in combination and what operating conditions were assumed for the aggregate assessment.
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Conclusions i
The inspectors concluded that the licensee's performance in assessing and resolving OWAs was, in general, adequate. ~ Also, the inspectors concluded that the Workaround Board decisions concerning assessment and resolution of OWAs were, in general, l
consistent with the licensee's program. However, the inspectors concluded that: (1) the
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-licensee was inconsistent in performing the aggregate assessment of OWAs, within the j
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past year only one quarterly assessment driven by the OWA program was performed; (2)
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the licensee placed additional attention on resolving OWAs and many OWAs were closed, but many were also rescheduled or reclassified as OCs; and (3) the inspectors identified one OWA that appeared to be prematurely closed, and one OWA and OC that
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appeared to not accurately represent current plant status.
07.0 Quality Assurance in Operations j
07.1 Licensee's Self-Assessment of OWA Proaram a.
Insoection Scope The inspectors reviewed whether or not the licensee performed a self-assessment of its OWA program. The inspectors reviewed the following self-assessment documents:
LaSalle Nuclear Oversight (NO) Assessment of the Operator Workaround
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Program, QVS 01-98-077, October 20,1998.
Operations Support Self-Assessment on Operator Workarounds, Report Number
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373-251-98-SA00092.00, Dates of Assessment October 2 - 8,1998.
b.
Observations and Findinas
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The inspectors identified that the licensee had recently performed a self-assessment on its OWA program. The inspectors also found that such assessment was performed primarily due to the NRCs concerns for OWAs and the expected specialinspection of OWAs per temporary instruction Tl 138. The inspectors were informed by plant management that it was the management expectation that any announced inspections would be preceded by an in-house assessment of the inspection area. Therefore, the inspectors concluded that the licensee's two self-assessments were implemented based on Tl 138.
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The inspectors found that the NO assessment was critical and went so far as to note that the management of the OWA program was inadequate. The NO assessment also
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concluded that the cumulative effects of the workarounds found in the site program provided minimal challenge to safe operation. However, when OCs were included, the cumulative effect could result in considerable challenge to operators. The inspectors found that the operations support self-assessment satisfactorily identified areas within the OWA program that required enhancement. The support staff assessment also concluded that the program was functioning in accordance with the procedural requirements, in general, the inspectors identified that the two self-assessments found similar issues to those identified by the inspectors. However, some differences were l
noted. For example, one item that was not identified in the licensee's self-assessment was the issue of including the accepted compensatory actions of closed OWAs, per l
permanent procedure change, in the overall aggregate assessment of cumulative effects l
of OWAs on safe plant operations.
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Conclusions Although the licensee's two self-assessments of its OWA program were influenced by the NRCs planned inspection, the inspectors concluded that the assessments were very critical. The self-assessment performed by the Nuclear Oversight Department noted that the management of the OWA program was inadequate; however, it concluded that the cumulative effects of the workarounds provided minimal challenge to safe operation.
l V. Manaaement Meetinas l-
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X1 Exit Meeting Summary J
The inspectors presented the inspection results to members of licensee management on November 6,1998. The licensee acknowledged the findings presented. The inspectors asked the licensee whether any materials held by the inspectors following the inspection could be considered proprietary. No proprietary information was identified.
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PARTIAL LIST OF PERSONS CONTACTED
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Licensee P. Barnes, Regulatory Assurance Manager J. Burns, Operations Staff Supoort Supervisor E. Connell lil, Design Engineering Supervisor D. Farr, Operations Manager G. Heisterman, Maintenance Manager G. Kaige, Site Training Manager
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R. McConnaughay, Shift Operations Supervisor T. O'Connor, Station Manager J. Pollock, Engineering Program Supervisor W. Riffer, Nuclear Oversite Manager B. Stone, Workaround Coordinator N.R.C '
M. Huber, Senior Resident inspector INSPECTION PROCEDURES USED Temporary Instruction TI-138, " Evaluation of the Cumulative Effect of Operator Workarounds" Inspection Procedure 71707," Plant Operations" ITEMS OPENED, CLOSED, AND DISCUSSED NONE
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' LIST OF ACRONYMS USED
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'CFR'
- Code of Federal Regulations Comed Commonwealth Edison Company CWPl Common Work Practice Instruction DRS-Division of Reactor Safety '
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ECCS Emergency Core Cooling System EDG Emergency Diesel Generator EOP Emergency Operating Procedure FSAR Final Safety Analysis Report IP inspection Procedure LAP LaSalle Administrative Procedure
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.LaSalle Abnormal Operating Procedure l
.LOCA Loss of Coolant Accident l
LOS LaSalle Surveillance Procedure
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l NRC Nuclear Regulator Commission
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NRR NRC Office of Nuclear Reactor Regulation OC
. Operator Challenge OG Off Gas OOS Out-of-Service OWA Operator Workaround l-PDR Public Document Room P!F-Problem identification Form l-TDRFP Turbine Driven Reactor Feedwater Pump l-TI Temporary Instruction l
VR Reactor Building Ventilation
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