IR 05000382/1994012
| ML20149H384 | |
| Person / Time | |
|---|---|
| Site: | Waterford  |
| Issue date: | 11/15/1994 |
| From: | Pellet J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20149H369 | List: |
| References | |
| 50-382-94-12, NUDOCS 9411220155 | |
| Download: ML20149H384 (14) | |
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APPENDIX U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Inspection Report:
50-382/94-12 License:
NPF-38 Licensee:
Entergy Operations, Inc.
P.O. Box B Killona, Louisiana facility Name:
Waterford Steam Electric Station, Unit 3 Inspection At:
Killona, Louisiana Inspection Conducted:
September 12-23, 1994 Inspectors:
J. Keeton, Resident inspector T. Meadows, Reactor Engineer
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Approvedy _lih l._Pil_let CF ef.
perations Branch Date Jo
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inspection Summary Areas Inspected:
Routine, announced inspection of the licensed operator requalification program and plant procedures.
Results:
Plant Operations Overall, the licensed operator requalification training program
effectively implemented a systems approach to training (Section 1.1).
i Annual examinations observed were comprehensive and discriminated at the appropriate level, but could be improved by adding specific performance
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criteria to critical tasks. (Section 1.1)
Operator performance observed met or exceeded the minimum acceptable
performance thresholds (Sectien 1.2).
The t raining material could be improved by identifying those tasks whose
adequate performance requires completion within a fixed time (Section 1.1).
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9411220155 941116
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DR ADDCK 05000392 PDR
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The procedure change, review, and approval process were vulnerable to
allowing procedures changes, rather than revisions, when the latter would have been more appropriate under the governing administrative procedure (Section 2.1.1).
Not all plant procedures had fully incorporated the recent change in the
facility licensee's procedure compliance policy (Section 2.1.3.1).
Some procedures had steps less precise or explicit than set forth in the
guidelines in the governing administrative procedure (Section 2.2).
!i;Lrtagement Overview increased management attention to the procedure changes necessary to a
implement the recently revised procedure compliance policy is appropriate (Section 2.1.3.1),
Summary of Inspection Findinas:
No violations, deviations, unresolved items or open items were
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identified in this inspection.
Attachments:
Attachment 1 - Persons Contacted and Exit Meeting
Attachment 2 - Simulator Fidelity Report
Attachment 3 - Documents Reviewed
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LICENSED OPERATOR REQUALIFICATION PROGRAM EVALUATION (IP 71001)
During the inspection, the licensee's requalification program was assessed to determine whether the program incorporated appropriate requirements for both evaluating operators' mastery of training objectives and revising the program in accordance with 10 CFR Part 55.
The licensed operator requalification program assessment included a review of training material for the past year, evaluation of the program's controls to assure a systems approach to training, and evaluation of operating crew performance during annual requalification examinations.
This included review of the f acility licensee's remediation training program, the sampling plan used by the licensee to construct requalification examinations, and the administration of requalification examinations.
1.1 Licensed Operator Requalification Examinations Overall, the licensed operator requalification operating tests, composed of dynamic simulator and walkthrough portions, were found to be comprehensive and adequate evaluations of licensed operators' mastery of training objectives.
lwo areas of potential vulnerability were identified by the inspectors and presented to licensee representatives for potential program improvements, as described below.
first, in the dynamic simulator portion of the operating test, the success criteria for scenario critical tasks did not contain objective thresholds for unsatisfactory performance. A representative example from one of the administered scenarios was, " Manually initiate CSAS when 2/4 Hl/H1 Containment Pressure Bistables are exceeded." Without a bounding objective criteria suun as containment pressure or elapsed time, evaluation of this critical task was vulnerable to subjective evaluator judgement.
No such cases were identified, as described in Section 1.3 below.
Second. none of the tasks in the facility licensee's job task analysis were identified as " time-critical." A " time-critical" task is defined as one that requires completion within an elapsed time or specific plant conditions to be successful.
Theref ore, no job performance measures used in the walkthrough portion of the operating examination were identified as time-critical.
The inspectors expressed concern that this appeared to represent a departure from the licensee's commitment by reference in training program administrative procedures to the requirements of NUREG-1021, " Operator Licensing Examiner Standards," Revision 7.
The facility training staff stated an intent to evaluate this area.
1.2 ()po ra t or Pe r f ormanc e lhe inspa tors observed two shift crews and an administrative crew during the d,nanic s mulation and walkthrough examinations.
All individuals and crews paued all port ions of t he examination.
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NRC Inspection Report 50-382/94-24 documented deficiencies in reactivity e
control as exemplified by several reactor coolant system dilution events.
- During this inspection, the inspectors observed another instance of a i
deficiency on the part of one individual regarding boration/ dilution
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reactivity control.
Specifically, during a walkthrough task, an examinee incorrectly calculated the volume of water needed to reduce the reactor coolant system boron concentration by 3 ppm.
The examinee calculated that
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60,720 gallons of water would be needed when the correct solution was
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380 gallons, in addition to making an error of two orders of magnitude, the examinee did not self-check the calculation before beginning the dilution.
When later asked why he had not checked the calculation using the computer in i
the control room, the examinee responded that he did not know how to use the computer.
1.3 Evaluations The evaluators appeared to be conscientious and exhibited good techniques.
- The evaluation was in accordance with the facility requirements, which parallel the examiner standards in NUREG-1021.
The inspectors agreed with the i
facility evaluators' grading of the examinees and crews.
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The inspectors observed licensee practices that demonstrated sensitivity about the importance of minimizine operator stress and ensuring examination security.
for example, operator stress was reduced and security heightened
through good practices undertaken to ensure minimal delay between scenarios.
1he examinees were given staggered report times, which also minimized the wait i
and helped ensure examination security.
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).4 Remediation
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Based on their observations, the inspectors concluded that the remediation l
training program was adequate, including the process used to select
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reexamination items.
1.5 Opprator license Condition Tracking and Adherence
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I 1he inspectors interviewed an operator who was in the process of making his i
senior reactor operator license active and found that his activities were in excess of those required by licensee policy (01-024-000, " Maintaining and l
Active SRO/R0 Status") and the applicable regulations.
A review of his
training record revealed that the facility maintained complete and detailed l
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records of training activities and used an efficient computerized record tracking system.
I The inspectors also reviewed the licensee's program for ensuring medical fitness, lhe licensee was found to demonstrate good practices in satisfying
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the medical fitness regulatory requirements for licensed operators.
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-5-1.6 feedback Process The inspectors reviewed the systems used to provide feedback to the training department, and found that the channels for communication with training that should precipitate program changes existed at all levels.
l.7 Simulator Fidelity
The simulator performed very well. No performance deficiencies were observed.
2 REVIEW 0F PLANT OPERATING PROCEDURES (42700)
The inspectors reviewed the licensee's programmatic controls for developing and maintaining plant operating procedures.
The inspectors also evaluated a selected sample of administrative, normal, abnormal, and emergency operating procedures for technical adequacy, human facters considerations, and compliance with governing programmatic procedures.
2.1 Review, Approval, and Maintenance of Procedures
The inspectors reviewed the records documenting reviews and approvals of revisions (modifications of procedures that resulted in the re-issuing of new procedures in their entirety) and changes (modifications of procedures that resulted in the issue of marked-up replacement pages) to the procedures listed in Attachment 3.
For each procedure, the inspectors examined the forms that had been used to document the review and approval of the revision of each procedure current at the time of the inspection.
The inspectors then reviewed in detail all changes that had been issued between the time of that revision and the inspection.
The inspectors also surveyed archive records that documented earlier reviews and approvals for some of these procedures.
The inspectors also interviewed licensee personnel who had participated in procedure reviews and approvals in the following roles:
technical reviewer, plant operations review committee chairman and members, and general manager of plant operations.
lhe inspectors determined that the process for maintaining procedures was t
adequate but vulnerable in the following ways:
Maint enance and revision practices reviewed sometimes required special
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consideration to conclude facility licensee guidelines were followed.
1he review and approval process actually followed was not always clear.
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lhe material required to be retained as supporting documentation for a
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procedure modification was sometimes unclear.
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" Procedure Initiation, Review and Approval; Change and Revision and Deletion,"
as described below.
procedure UNT-001-002 provides guidance that:
Revisions, rather than changes, should be used when changes "would
render a procedure difficult to read or comprehend due to multiple addendum pages and/or extensive strikeouts" and when a change is
" extensive in nature."
A revision should be implemented after the third change is made to a
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procedure.
Changes should be clearly marked with a change bar in the margin and
annotated by change number, date, and initials of the person making the change.
The inspectors identified the following examples where procedures were not being maintained or revised in keeping with the above guidelines:
i OP-002-003, " Component Cooling Water System," had accumulated five
changes in Revision 9, with the three-change threshold having been reached on October 22, 1993.
Over one third of the pages of the procedure had been changed (53 pages out of a 155 page procedure).
Change 3 resulted in changes to 40 pages. Change 1 added caution statements to the procedure (on pages 19 and 31), but the review and
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approval sheet for Change 1 made no mention of these caution statements having been added.
OP-001-003, " Reactor Coolant System Drain Down," contained four changes,
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affecting 33 pages and adding 11 addendum pages.
Further, the ?rocedure had changes that were layered on other changes.
For example, taange 1 modified page 15 and added page 15a; Change 2 modified page 15a and added pages 15b and 15c; and Change 3 modified page 15b.
In OP-002-019, " Control Room Emergency Breathing Air System," the
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marginal notations pertaining to changes had been lost in duplication of i
procedure pages.
The inspectors verified that this deficiency existed in the control room controlled copy of the procedure and in the master copy in document control.
OP-002-010, " Reactor Auxiliary Building HVAC and Containment Purge," had
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four changes affecting 11 pages.
These changes included the addition of three addendum pages (28a, 30a, and 34a), and the third-change threshold was reached on September 3, 1991.
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-7-OP-903-090, " Shutdown Margin," contained a work sheet with pen and ink
changes that increased the difficulty of its use.
OP-903-090 contained a cross reference to the emergency boration
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procedure that included an incorrect procedure identification number.
All of these vulnerabilities were identified in both master and controlled copies of procedures, including those in the control room and the simulator.
While none of the identified change process weaknesses contributed to operator errers during the inspection, this is an area where the inspectors considered that increased licensee attention to the guidelines of the governing procedure were appropriate.
2.1.2 Review and Approval Process Change 4 to Procedure OP-002-005, " Chemical and Volume Contrei," added a new section to the procedure to permit placing the deborating ion exchangers in series operation with the purification ion exchanger.
The review and approval process for Change 4 was reduced in scope from that normally applied to procedure changes.
Upon analysis, the inspectors concluded that all required steps in the review and approval process for Change 4 to Procedure OP-002-005 were performed, but that some " extra" activities that were typically performed were omitted from the process. On August 25, Licensee Condition Report 94-799 recommended further review of Procedure OP-002-005 with respect to a potential challenge to makeup capabilities during ion exchanger rinsing with multiple charging pumps.
The condition report was written in response to a
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boration/ dilution event that occurred when the new portion of the procedure was used on August 19, 1994.
While the inspectors concluded that this event was not caused by procedure deficiencies, the inspectors encouraged the facility licensee to evaluate the need to revise the procedure review and approval process to formally include those " extra" activities omitted in this case.
2.1.3 Procedure Change / Revision impact The inspectors noted that no system was in place to ensure that the impact of changes in procedures that affected other procedures was analyzed and that affected procedures were appropriately modified.
Examples of such changes included a change in operations policy addressing compliance issues associated with step sequencing and the changing of the procedure identification numbers for abnormal operating procedures.
2.1.3.1 Procedure Compliance Policy Impact The inspectors reviewed recently issued Policy W2.101. "Pelicy Statement on Procedure Compliance," and concluded that it required stricter procedural i
adherence than had been previously allowed.
This stricter expectation was
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exemplified in the following excerpts from Policy W2.101:
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" Deviating from a procedure will only be tolerated when there is
IMMEDIATE OVERRIDING SAFETY CONSIDERATIONS...." (Procedure Compliance Policy Statement in Policy W2.101)
" Noncompliance with a procedure shall only be allowed when there is
IMMEDIATE OVERRIDING SAFETY CONSIDERATIONS.
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"Due to the potential for severe consequences resulting from improper
performance, willful or repeated violations of procedures will not be tolerated by management and could result in disciplinary action up to and including termination." (Section 5.2.5.1)
The change in compliance policy was a change in rules of procedure usage.
Under the prior policy, procedure users were allowed to perform procedure steps out of sequence unless specifically instructed otherwise.
The policy was changed to expect performance of steps in the sequence in which they were presented, unless instructed, that variations of sequence were allowed.
Additionally, Section 5.7 of Procedure UNT-001-002, " Procedure Classification, Type, Content, Numbering, format, and Use," required a classification of
" continuous use" for activities that " require specific sequence or signoffs."
lhe schedule for implementing this policy for the operating procedures could not be provided by the licensee.
The inspectors noted that implementation of this policy would require revision to multiple procedures to classify them as
" continuous use."
2.1.3.2 Procedure Numbering Change Impact The inspectors had similar concerns about an inaccurate reference to a procedure in a cross reference.
The inspectors found that a cross reference
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in Procedure OP-903-C90, " Shutdown Margin," to Procedure OP-901-103,
" Emergency Boration," did not provide the correct procedure identification numbers for the emergency boration procedure (it was identified as Procedure OP-901-013 rather than Procedure OP-901-103).
Licensee personnel stated that the ei ror probably occurred as a result of a failure to identify the need for a modification in the shutdown margin procedure when the number of the emergency boration procedure, along with all the numbers of the abnormal operating procedures, were changed.
As in the case of the change of the compliance policy, the licensee could provide no documentation of how the impact of changing the numbers of an entire class of procedures upon other procedures was evaluated.
2.1.3.3 Supporting Documentation Future Impact The inspectors were concerned that there was a lack of understanding or appreciation about possible future uses for documentation associated with procedure modifications. For example, licensee personnel stated that, in the review and approval process, the initiator of the proposed change or revision would make a judgment about what documentation reviewers would need to consider and, on occasions, not include all of the information that had been i
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gathered and temporarily stored during the procedure revision prceess.
Licensee personnel stated that the information so judged as relevant might or
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might not include all of the documentation that had been gathered.
This set
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of documents, along with any others requested by reviewers, would ultimately I
become the record of supporting documentation that was permanently archived.
j The inspectors did not identify any mechanism or standard practice used to ensure that supporting documents that were not essential for a particular review but might be important at a later date, were retained.
2.2 @tneral fiuman Factors Observations The inspectors evaluated the usability of a sample of operating procedures and j
emergency operating procedures to determine whether the procedures provided effective operating tools and conformed with the licensee's writers' guides and administrative requirements.
These evaluations were performed using table top reviews, simulator walkdowns, and observation of operators performance in the dynamic simulation examinations.
lhe inspectors found imprecise procedural detail that was inconsistent with the guidelines provided in Procedure OP-100-013, " Writer's Guide for Operating Procedures."
Procedure OP-100-013 stated in Section 5.2.4, "Use specific words that precisely describe the task or action of the operator.
Avoid ambiguous instructions such as ' check frequently' or ' throttle slowly.'
Whenever possible, use specific intervals or guidelines."
l Some examples of specific instances of imprecise wording were noted in Procedure OP-002-005, " Chemical and Volume Control," Section 8.17.
The following are examples of the imprecise wordings observed:
Rep Lague Terms 5.3
"if needed,"
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" periodically sample," and to
"When is no longer needed."
Procedure OP-100-013 stated in Section 5.2.2, " Human factors considerations to reduce mistakes should be used at all levels" [of detail] and that greater l
detail should be used when procedures describe tasks that are infrequently performed and if the consequence of error is high.
Additionally, Procedure UNT-001-002, Section 5.4.3.6 stated that procedure steps should state who is to perform a task.
l lhe inspectors found that procedure steps for tasks performed outside of the
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control room frequently did not provide any information about where the steps would be performed or by whom.
For example, Procedure OP-002-005, " Chemical and Volume Control." Section 8 17, directing valve manipulations, provided valve lists without indicating that some of the valves could be manipulated from the control boards and others could only be manipulated locally.
Although the lack of location information in this procedure was not a contributor in the recent boration/ dilution events at the plant, the
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-10-inspectors concluded that this valve list met the criteria for increased detail, in that the task was infrequently performed (the need for these valve manipulations had only been identified a few weeks prior to issuing the procedure), and the consequences of error were high (the task involved reactivity control).
2.3 Procedure Guidance For Steam Generator Tube Rupture
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On March 3, 1993, the Palo Verde Nuclear Generating Station experienced a
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steam generator tube rupture event in which operator adherence to procedures
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and procedure adequacy were issues.
During this inspection, the inspectors
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found that the emergency operating procedure diagnostic tree used at Waterford 3 exhibited the same flaw, if followed verbatim, as the Palo Verde procedures that contributed to an significant delay isolating the affected steam generator.
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The inspectors brought this to the attention of the facility licensee personnel, who indicated their training practices and operating policies were to apply the diagnostic tree procedure intelligently, based on understanding of the intent of the procedure, rather than verbatim to the exact wording.
The facility licensee staff also informed the inspectors that an emergency operating procedure revision was in development which would correct the
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diagnostic tree wording.
The inspectors expressed concern that management
expectations regarding operator response to a steam generator tube rupture event had not been formally promulgated.
Further, the inspectors pointed out that a recent shift in operating philosophy (as identified in Policy W2.101,
" Policy Statement on Procedure Compliance") requiring stricter procedural compliance may have sent conflicting messages to the operators, which could have resulted in management expectations regarding response to a steam
generator tube rupture event not being met.
On September 21, 1994, the facility licensee posted formal written guidance in the control room containing management expectations regarding response to a steam generator tube rupture event.
Inspectors identified no evidence of operator performance contrary to management expectations during the inspection.
2.4 Changes in Technical Specifications. License Revisions, and Procedure Change Conformance to 10 CFR 50.59(a)
No deficiencies were identified in the processes used to ensure that changes in technical specifications and License Revisions were incorporated into procedures.
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ATTACHMENT 1 1 PERSONS CONTACTED 1.1 licensee Personnel 0. Pipkins, Senior Engineer, Licensing
- G. Davie, Quality Assurance Manager D. Matheny, Operations Superintendent
- J. O'Hearn, Manager, Training D. Packer, General Manager, Plant Operations R. Starkey, Acting General Manager, Plant Operations A. Lockhart, Quality Assurance Manager
- T. Brown, Shift Supervisor, Operations Training
- T. Gaudet, Supervisor, Licensing
- G. Scott, Engineer, Licensing
- D. Vinci Licensing Manager
- G. Koehler, Supervisor, Operations Quality Assurance
- C. Fugate, Supervisor, Operations
- R.
Barkhurst, Vice-President, Operations
- R. Azzarello, Director, Design Engineering
- J. Houghtaling Technical Services Manager 1.2 NRC Personnel
- E. Ford, Senior Resident Inspector, Waterford 3
- I. Gwynn, Director, Division of Reactor Safety, RIV
- T. Pruett, Resident Inspector, Waterford 3 in addition to the personnel listed above, the inspectors contacted other personnel during this inspection period.
- Denotes personnel that attended the exit meeting.
EXIT MEETING An exit meeting was conducted on August 26, 1994.
During this meeting, the inspectors reviewed the scope and findings of the inspection.
The licensee acknowledged the inspection findings as they were presented.
The licensee did not identify as proprietary any information provided to, or reviewed by, the inspector.
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o ATTACHMENT 2 SIMULATION FACILITY REPORT Facility Licensee:
Waterford, Unit 3 Facility Docket:
50-382 Operating Tests Administered at: Waterford, Unit 3 Operating Tests Administered on:
September 12-23, 1994 These observations do not constitute audit or inspection findings and are not, without further verification and review, indicative of noncompliance with 10 CFR 55.45(b).
These observations do not affect NRC certification or approval of the simulation facility other than to provide information which may be used in future evaluations. No licensee action is required in response to these observations.
During the dynamic operation of the simulator in support of the operating tests, no previously unidentified simulator fidelity problems were observed.
ITEM DESCRIPTION None
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ATTACHMENT 3 DOCUMENTS REVIEWED i
Procedure Title Rev.
OP-002-005 Chemical and Volume Control
f OP-002-003 Component Cooling Water System
OP-002-019 Control Room Emergency Breathing Air System
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OP-002-010 Reactor Auxiliary Building HVAC and
Containment Purge OP-903-102 Safety Channel Nuclear Instrumentation
Functional Test OP-001-002 Reactor Coolant Pump Operation
OP-902-005 Loss of Offsite Power / Station Blackout
Recovery Procedure OP-010-001 General Plant Operations
OP-903-107 Plant Protection System Channel A B C D
Functional Test OP-901-513 Spent Fuel Pool Cooling Malfunction
OP-009-003 Emergency Feedwater
OP-500-008 Annunciator Response Procedure Control Room
Cabinet H OP-903-026 Emergency Core Cooling System Valve Lineup
Verification OP-500-009 Annunciator Response Procedure Control room
Cabinet K OP-004-009 Incore Nuclear Instrumentation
OP-500-Oll Annunciator Response Procedure Control
Cabinet M OP-500-013 Annunciator Response for Control Room Cabinet
SA OP- 002-00 7 Freeze Protection and Temperature Maintenance
OP-902-005 Loss of Of fsite Power / Station Blackout
Recovery Procedure OP-902-001 Uncomplicated Reactor Trip Recovery Procedure
Site Directive Records Management System
W5.101
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-2-Procedure Title Rev.
Site Directive Procedure Compliance
W2.101 UNT-001-003 Procedure Initiation, Review and Approval;
Change and Revision and Deletion UNT-004-009 Control, Distribution, Handling and Use of
Plant Procedures UN1-001-004 Plant Operations Review Committee
UNT-001-002 Procedure Classification, Type, Content,
Numbering, format, and Use UNT-100-013 Writer's Guide for Operating Procedures
UNT-001-012 Emergency Operating Procedure Development,
Review and Approval: Revision; and Deletion
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UNT-004-002 Field Control of Technical Documents
UNT-007-012 Development, Review and Implementation of
Technical Specification Changes 01-019-000 Development of Operations Procedures
Administrative Group UNT-005-027 Infrequently Performed Test or Evolutions
01-024-000 Maintaining and Active SR0/R0 Status
uni-005-015 Work Authorization Preparation and
Implantation (