IR 05000387/1995025
| ML17158B130 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 03/04/1996 |
| From: | Pasciak W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17158B129 | List: |
| References | |
| 50-387-95-25, 50-388-95-25, NUDOCS 9603130287 | |
| Download: ML17158B130 (83) | |
Text
Inspection Report Nos.
License Nos.
Licensee:
Facility Name:
Inspection At:
Inspection Conducted:
Inspectors:
UNITED STATES NUCLEAR REGULATORY COMMISSION
REGION I
50-387/95-25; 50-388/95-25 NPF-14; NPF-22 Pennsylvania Power and Light Company 2 North Ninth Street Allentown, Pennsylvania 18101 Susquehanna Steam Electric Station Salem Township, Pennsylvania December 19, 1995 February 5,
1996 M. Banerjee, Senior Resident Inspector, SSES B. McDermott, Resident Inspector, SSES Approved By:
ascsa
,
se Reactor Projects Branch No.
4 a
e 9603130287 960304 PDR ADQCK 05000387
EXECUTIVE SUNNARY Operations Susquehanna Inspection Reports 50-387/95-25; 50-388/95-25 December 19, 1995 - February 5,
1996 The recent Operations management effort towards achieving a "black board" is a
very positive initiative, and over sight of progress towards this goal at the Monthly Status Review Meeting should ensure appropriate prioritization of corrective actions.
A review of active status control tags found no problems of safety significance, however the number of minor deficiencies was not being effectively prioritized for resolution.
The new Monthly Status Review Meeting initiative is also expected to address this concern.
Two unresolved items in the operations area were reviewed, and one was closed.
The unresolved item related to operation of the reactor feed pump with all trip functions disabled was not closed as one of the corrective actions has not yet been completed by the licensee after almost two years.
URI 50-388/94-09-01 (CLOSED)
Naintenance/Surveillance Regarding simultaneous preventive maintenance on the 'A'nd 'C'mergency service water (ESW)
pump motors as an on-line maintenance activity, the inspectors found that the work activities did not necessitate the simultaneous removal of both pumps.
Sequential work on the 100X capacity pumps would have allowed the ESW loop to remain functional.
Although the licensee's actions were allowed by Technical Specifications, including the option of sequential work on redundant components in the risk assessment would have been an improvement.
Maintenance work on Appendix R emergency lighting was 'not appropriately prioritized due to a lack of guidance in the licensee's program for work planning.
Corrective actions are being taken to provide such guidance.
Engineering/Technical Support On January 25, 1996, PP8L discovered that a modification to the containment instrument gas system control logic prevented automatic transfer of the 150 psi header to its backup nitrogen bottle supply.
Although the system's dynamic response would be difficult to predict in the design process, the post modification testing was inadequate because it did not verify a basic function of the control logic, being able to transfer supplies on loss of header pressure.
The licensee is taking corrective actions to ensure that design modifications maintain the system design functio An unresolved item regarding the July 12, 1993, Unit I turbine blade failure was closed after review of PP8L's final root cause report.
The corrective actions appear adequate to prevent the recurrence of similar problems and appropriate testing and evaluation was preformed for Unit 2.
URI 50-387/93-11-01 (CLOSED)
Plant Support Two trends developed in licensee identified Health Physics deficiencies.,
A number of items with contamination above the licensee's criteria for release have been found outside the Radiologically Controlled Area (RCA).
A search of buildings outside the RCA for contaminated items was underway at the close of the inspection period.
A second trend has developed in the HP area regarding inadequate surveys, postings, and barriers for high radiation areas.
A rebase-line of all station postings was underway at the close of the report period.
At this time, no radiological consequences (i.e., over exposures)
have been identified and are not expected based on the level of contamination or locations of the high radiation areas with deficient controls.
An upcoming Radiological Controls inspection will assess the licensee's corrective actions for both trends.
Safety Assessment/guality Verification Some progress has been observed regarding documentation of operability determination during this period, however, continued management attention will be necessary to ensure continued improvement in documentation for operability based on investigations that do not positively identify the problem.
Improved use of trend information was evident at the licensee's Corrective Action Team meeting.
One of the areas where a negative trend is identified involved the maintenance work control and performance.
A team has been established to resolve this issue.
Use of a master condition report (CR) to evaluate and document root causes and corrective actions for the trend, rather than resolving each CR separately is an improvement of the corrective action proces TABLE OF CONTENTS EXECUTIVE SUMMARY.
SUMMARY OF FACILITY ACTIVITIES..................
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OPERATIONS 2. 1 Plant Operations Review
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2.2 Status Control Program Review 2.3 Operations Open Item Followup URI 50-387/94-09-01 (UPDATE),
Functions Disabled URI 50-388/94-11-01 (CLOSED),
Inoperable SRN 2.4 Licensee Event Reports
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4, MAINTENANCE AND SURVEILLANCE 3.1 Maintenance Observations 3. 1.1 Emergency Service Water On-line Maintenance Maintenance Of Appendix R Lighting Surveillance Observations
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3.2 3.3 ENGINEERING
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4.1 Containment Instrument Gas (CIG) Modification.......
4.2 Engineering Open Item Followup URI 50-387/93-11-01 (CLOSED) Unit 1 Turbine Blading Failure Root Cause
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PLANT 5.1 5.2 5.3 5.4 SUPPORT Radiological and Chemistry Controls
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5. 1. 1 Radiological Controls for RWCU Pump Security Emergency Preparedness Emergency Preparedness Open Item Review
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URI 50-387/90-18-01 (CLOSED), Conformance Guidance
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Inspect 1 on Of EALs With NRC
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h SAFETY ASSESSMENT/QUALITY VERIFICATION 6. 1 Corrective Action Process...
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MANAGEMENT AND EXIT MEETINGS 7. 1 Resident Exit and Periodic Meetings
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7.2 Other NRC Activities
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DETAILS 1.
SUNNARY OF FACILITY ACTIVITIES I
Susquehanna Unit 1 Summary Unit 1 began the report period at 100X thermal power, with indicated power reduced by 2 HW, due to inaccuracies discovered in the heat balance calculation in December 1995.
On Friday January 12th power was reduced to perform main turbine valve testing and a control rod sequence exchange.
Reactor power was returned to 100X on Saturday January 13th and maintained at this level throughout the remainder of the inspection period.
Susquehanna Unit 2 Summary Unit 2 began the report period at 100X thermal power with the indicated power reduced to account for the same heat balance calculation inaccuracies affecting Unit 1.
On January 14th a routine power reduction was made to perform main turbine valve testing.
Full power operation continued throughout the remainder of the inspection period.
2.
OPERATIONS (71707, 92901, 93702)'.
Plant Operations Review The inspectors routinely observed the conduct of plant operations to independently verify that the licensee operated the plant safely, and according to station procedures and regulatory requirements.
The inspectors conducted regular tours of the various plant areas and periodically reviewed logs and records to ensure compliance with station procedures, to determine if entries were correctly made, and to verify correct communication of equipment status.
These records included various operating logs, turnover sheets, blocking permits, and bypass logs.
The inspector observed plant housekeeping controls including control and storage of flammable material and other potential safety hazards.
Over the course of the report period the number of lit control room annunciators increased due to maintenance related problems with various plant equipment.
Operations management identified this trend and initiated a review of the causes and corrective action plan for each alarm.
At the start of this initiative there were 23 alarms sealed-in and the licensee found that twelve of these did not have active work documents to correct the conditions.
The technical issues behind these alarms were well understood but due to their long standing nature, efforts towards eliminating them had not been aggressive.
By the close of this report period, the number of sealed-in alarms had been reduced by 3 and work documents were in place to address 13 of the 20.
The inspector considered the licensee's work towards achieving a
The inspection procedure from NRC Manual Chapter 2515 that the inspector used as guidance is parenthetically listed for each report section.
"black board" a very positive initiative in the operations area, and the evaluation of progress at the Honthly Status Review Heeting should ensure appropriate prioritization of corrective actions.
2.2 Status Control Program Review The inspector reviewed a sample of active status control tags (SCTs) for Unit 1 equipment to determine whether the specific applications were in accordance with NDAP-gA-0302, System Status and Equipment Control, and whether the degraded condition of the equipment had been appropriately evaluated.
The Status Control program was put into effect in Harch 1995, and previous inspections found that the number of status control events had decreased.
This review was performed to assess the licensee's performance regarding management of the "backlog" of Status Control items.
The inspector did not identified any equipment issues during this review that present an immediate safety concern.
The vast majority of effected equipment is not safety-related and the SCTs provided additional information regarding operations of these systems.
NDAP-gA-302 states that SCTs can not be applied to devices for longer than six months but allows for a review of these items to determine whether it is acceptable to extend this deadline.
The inspector found that the Operations management review of extensions for SCTs greater than six months old is being performed but is not well documented.
The inspector believes that the informal review has led to minor deficiencies, which do not individually have any safety significance, and is allowing long term operator
"work arounds" to remain unresolved.
It was also noted that the status control program does not require periodic assessment of status control tag identified deficiencies for their cumulative impact on the ability of the operators or plant systems to respond during transients.
These. findings were discussed with Operations management who were in agreement.
with the inspector's observations.
The licensee believes that these concerns will be addressed by a newly created Honthly Performance Review Heeting, led by Operations.
The purpose of the meeting is to provide a broad overview of the work process, to assess performance at meeting station goals and objectives.
An aspect of performance to be evaluated and given prioritization during this meeting is progress on corrective actions for status control tag identified problems.
The inspector considered the Honthly Performance Review concept a good initiative in management oversight and prioritization.
2.3 Operations Open Item Followup (92901)
URI 50-387/94-09-01 (UPDATE), Operation Of RFP With Trip Functions Disabled This item was left open pending completion of licensee's final corrective actions to prevent recurrence of the event during which Unit 1 reactor feed pump turbine (RFPT) trip functions were lost due to a 125 VDC ground, and Shift Supervision kept the reactor feed pump in operation an excessive amount of time with all trip logic functions disabled.
This information was not well communicated to plant management and no actions were taken to secure the
'A'FPT or enter the appropriate technical specification (TS) Limiting Condition of Operation (LCO).
The plant TS dictates a 72 hr LCO upon loss of two of the three trip channels.
The TS does not provide an action statement for the condition when all three trip channels are inoperable.
The TS bases section indicates that the feedwater system/main turbine trip functions are provided to protect the reactor core in the event of failure of feed water controller under maximum demand.
The FSAR Chapter 15 analyzed the feedwater flow controller failure in maximum demand.
Additionally, the SSES SER Supplement 7 discussed a failure of one of the three feed flow signals with disabling of the trip circuit of one of the three feed pumps.
The SER concluded that the results of the licensee's RETRAN computer run indicated that the event was bounded by the FSAR Chapter
analysis for thermal limits considerations, and in addition, the resulting conditions were within the capabilities of the plant operator and the safety systems.
The licensee verified that the event of feed water controller failure in maximum demand with an existing failure of the trip functions of one of the three RFPTs is also bounded by these analyses.
The licensee initiated a Significant Operating Occurrence Report, and reviewed the event to identify required corrective actions.
Operations procedure OP-AD-001 was revised to state the requirement of removing equipment from service promptly after identifying protective features are disabled.
The inspector noted that the licensee's new condition report process has vastly improved problem identification, communication, and management involvement in problem resolution.
Increased first line supervisory oversight and management's presence in the field is also being emphasized.
As part of the corrective actions, the licensee sought to clarify expected operator actions regarding inoperable RFPT trip devices with a TS interpretation.
The inspector found that this guidance had not yet been issued, almost two years after the event, and that the draft document incorrectly interpreted the TS action required when all three trip channels are not operable.
The licensee is revising the TS interpretation document to better define the trip channels and clarify the required actions.
The inspector concluded that the licensee's corrective action regarding preparation of a TS interpretation was not timely and this item will remain open until completion of the effort.
URI 50-388/94-11-01 (CLOSED), Core Alterations With Inoperable SRN During the Unit 2 6th refueling outage in May-1994, the day shift failed to-identify the 'C'ource range monitor (SRH)
was inoperable due to an error in their calculation of the monitor's signal to noise ratio.
Technical Specification 3.9.2 requires an operable SRH located in the core quadrant where fuel is being moved.
Because of this error, operators continued to load fuel with an inoperable SRH in the affected quadrant.
The error was identified by night shift operators later the same day.
A lack of clear guidance in the surveillance procedure as to the acceptable values of the SRMs, and the operators not questioning the reason for discrepancy in the SRH count rates may have contributed to the event.
The licensee's investigation
also found the operator involved in fuel move, did not follow the procedure when he moved a certain fuel bundle before the SRM operability was established.
The licensee established an Event Review Team (ERT) to investigate the root causes and determine corrective actions.
In addition to the ERT, the licensee's Independent Safety Evaluation Services (ISES) also reviewed the event.
NRC review of ISES report is addressed in Inspection Report No. 95-80.
The inspector reviewed the ERT report, verified completion of the corrective actions and control room operators'nderstanding of the S/N calculation method.
The actual safety significance was considered minimal because shutdown margin remained acceptable.
The inspector concluded that the licensee has taken reasonable corrective actions.
This item is closed.
2.4 Licensee Event Reports (92712)
The inspectors performed an in-office review of the following Licensee Event Reports (LERs)
and found them acceptable for close out.
The conclusion to close them out was based on the report being adequate to assess the subject event, the cause appearing to have been accurately identified, the corrective actions appearing appropriate to correct both the deficient condition and the cause, and the generic applicability having been considered.
Unit LER No.
Title
92-007-01 ESF Actuations Due To.EPA Breakers Tripping
95-009-00 Reactor Recirculation MG Set Stops Set Incorrect
94-005-01 Shutdown Due To Check Valve Surveillance Failure
95-011-00 Main Steam Line Penetration Leak Rate Test Failure After in-office review of the above LERs the inspectors performed on-site followup of selected reports to determine whether PPSL had taken corrective action as stated in the LERs and if responses to the events were adequate.
Unit t 93-008-01 Reactor Scram Following Turbine High Vibration This revision to the LER documented the licensee's final conclusions regarding the turbine blading failure that occurred on July 12, 1993.
An NRC unresolved item on the issue is closed in Section 2.5 of this report.
3.
MAINTENANCE AND SURVEILLANCE (62703, 61726, 92902)
3. 1 Maintenance Observations The inspector observed and/or reviewed selected maintenance activities to evaluate whether the work was conducted in accordance with approved procedures, regulatory guides, Technical Specifications, and industry codes or standards.
The following items were considered, as applicable, during this review:
Limiting Conditions for Operation were met while components or systems were removed from service; required administrative approvals were
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obtained prior to initiating the work; activities were accomplished using approved procedures and quality control hold points were established where required; functional testing was performed prior to declaring the involved component(s)
operable; activities were accomplished by qualified personnel; radiological controls were implemented; fire protection controls were implemented; and the equipment was verified to be properly returned to service.
Maintenance observations and/or reviews included:
WA S57336 WA P52543 WA S63082 TP-024-143 WA V53907 WA P52006 WA C53296 TIP Ball Valve Inspections, January 2,
1996.
'A'SW Pump Motor 18 Month Inspection, January ll, 1996.
Inspection And Lift Check For CIG PSV-12648, January 24, 1996.
Post Maintenance Testing 'B'mergency Diesel Generator, February 1,
1996.
Disassemble, Inspect and Rework Ball Valve in Standby Liquid Control System, December 19, 1995.
'C'DG Air Compressor Combined Annual and Semi-annual PH, January 9,
1996.
Delete HSIV-Leakage Control System Piping and Supports, January 18, 1996.
Based on observation of selected portions of the above maintenance, the inspector concluded that the work was conducted and completed appropriately, with due concern for plant safety and procedures.
An observation.regarding the scheduling of preventive maintenance on the 'A'oop of Emergency Service-Water is discussed in Section 3.2 of this report.
3. 1.1 Emergency Service Water On-line Naintenance On January 11, 1996, the licensee performed preventive maintenance on the
'A'nd
'C'mergency service water (ESW)
pumps during a scheduled work window.
The ESW system supplies cooling for safety related components in both SSES Units.
The shared system is comprised of two loops, or Divisions, with each loop having two IOOX capacity pumps.
Simultaneous maintenance on both pumps disabled the entire 'A'oop (Division 1) and required entry into a 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> TS Action Statement.
In comparison, sequentially performing the work on these pumps would keep the 'A'oop functional and require entry into a 7 day TS Action Statement.
After reviewing the scheduled maintenance the inspector found that none of the jobs required 'A'oop piping or valves to be out of
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service.
Inierviews with personnel in Unit Coordination revealed that the work was scheduled in accordance with the safety based guidelines of the TEAM Manual but was also driven by other considerations.
The inspector questioned whether the risk associated with taking an ESW loop out of service versus taking a
single ESW pump out of service was considered during scheduling of the simultaneous maintenance on both pumps.
The licensee stated that the overall risk of on-line maintenance for an ESW loop had been evaluated, was found to be acceptable, and provided the basis for the TEAM Manual guideline.
However, risk associated with the sequencing of jobs within the work window was not considere The inspector found that the appropriate TS action statement was entered and that the licensee had limited the equipment out of service time to 10.25 hours2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br /> of the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> TS allowed outage time.
The inspector concluded that although the licensee's actions were acceptable, an assessment of risk associated with the sequence of work options would be an improvement in the licensee's scheduling of on-line maintenance.
The licensee agreed to take this concern into consideration during future scheduling of on-line maintenance.
3.2 Haintenance Of Appendix R Lighting On November 6, 1995, during a plant tour, the inspector found the emergency lighting in the 'B'mergency diesel generator (EDG) room to be deenergized.
The loss of lighting resulted from a 480 volt breaker tripping problem, and a
work authorization (WA) was initiated on October 13, 1995 that determined a
ground in a light fixture to be the cause of the problem.
The initial WA was closed and four separate WAs were written on October 24, 1995, with WA S51432 on the emergency lighting.
This WA was assigned a priority 3, and the problem remained uncorrected.
On November 6, 1995, the licensee wrote a condition report to determine the generic implications of Appendix R lighting work priority codes.
The licensee's investigation concluded the TEAN Hanual, that provides guidance on
'cceptable maintenance practices, did not explicitly address the importance of Appendix R emergency lighting.
Also the plant component data base did not identify the Appendix R lighting.
All these factors contributed to not recognizing the need for higher priority for Appendix R lighting work.
The licensee is currently revising the TEAH Hanual regarding guidance on prioritization of Appendix R lighting work.
In the interim all WAs associated with reactor building and control structure are being handled as Priority 2, unless clearly determined to be non-Appendix R lights.
The inspector concluded that the event indicated a need for improvement in prioritizing Appendix R lighting maintenance work, and appropriate guidance in the TEAH Hanual will help in this area.
3.3 Surveillance Observations The inspector observed and/or reviewed surveillance tests listed below to determine whether the following criteria, if applicable to the specific test, were met:
the test conformed to TS requirements; administrative approvals and tagouts were obtained before initiating the surveillance; testing was accomplished by qualified personnel in accordance with an approved procedure; test instrumentation was calibrated; Limiting Conditions for Operations were met; test data were accurate and complete; removal and restoration of the affected components were properly accomplished; test results were appropriately communicated with regard to TS and procedural requirements; deficiencies noted were reviewed and appropriately resolved; and the surveillance was completed at the required frequenc Surveillance observations and/or reviews included:
SO-151-002 Core Spray Loop 'B'uarterly Flow Verification, January 29, 1996.
SE-070-013 Standby Gas Treatment System 18 Month Surveillance, January 12, 1996.
SI-258-304 18 Month Calibration of SDV Level Transmitter/Switch, January 10,1996.
No problems were observed during the inspector's review of selected portions of the above sur veillances.
The inspector concluded that they were completed with appropriate consideration for safe plant operation and administrative control.
4.
ENGINEERING (71707, 37551, 92903)
4. 1 Containment Instrument Gas (CIG) Modification On January 25, 1996, the licensee discovered that a modification to the CIG system control circuit prevented automatic transfer of the 150 psi header to its nitrogen backup bottle supply.
The post modification testing had been satisfactorily completed and the problem was identified when the header failed to transfer as expected during a test unrelated to the modification.
The CIG system provides compressed nitrogen to two 150 psi headers which each supply three Automatic Depressurization System (ADS) safety relief valves.
The 150 psi headers are normally.-supplied from nonsafety-related compressors and each header has a safety-related backup nitrogen bottle supply.
The bottle supply is needed for long term'peration of the ADS valves for post accident core cooling.
Accumulators inside containment for each ADS valve provide a backup short term supply of nitrogen for the valves'apid depressurization function.
The CIG logic is designed to transfer the 150 psi header supply from the compressors to the backup bottles on a primary containment isolation signal, a
loss of power, or loss of pressure on the 150 psi header.
The control logic modification (DCP 94-9013)
added time delay relays to prevent unnecessary transfers to the backup bottle supply during minor electrical system perturbations.
The design review and post modification testing focused on the changes to the system logic.
Both the design review and the post modification testing failed to identify the impact of this logic change on the dynamic response of the CIG system to a loss of 150 psi header pressure.
NRC Inspection Report 95-01 discussed two previous modification problems that were not detected by their post modification testing.
However, in the IR 95-Ol examples the post modification test did not verify a critical design objective was met.
For the CIG logic modification, the critical design objectives were confirmed by the testing but the test was not broad enough to verify the modification had not impacted the system function.
The inspector reviewed the original design change and associated safety evaluation, the details of the event, and the licensee's revised modification.
Based on this review, the inspector concluded that although the dynamic system
response would be difficult to predict, this design change was inadequate because the interface with the pneumatic portion of the system was not evaluated in the design review or captured by the post modification testing.
The licensee is currently in the process of approving a corrective action plan and scheduling its implementation.
The inspector's review of the licensee's progress thus far found appropriate corrective actions plans and adequate management involvement.
The inspector believes that this was an isolated incident, that corrective actions for the previous modification issues would not be expected to preclude this problem, and that the licensee's corrective action process was addressing the generic issue regarding scope of post modification testing.
The licensee was focused on the logic change (electrically)
arid following this lead, the post modification test focused on confirming the logic changes were as planned.
The licensee is currently in the process of approving a corrective action plan and scheduling its implementation.
The inspector's review of the licensee's progress so far found appropriate corrective actions plans and adequate management involvement.
The inspector concluded that this was an isolated incident, that corrective actions for the previous modification issues would not be expected to preclude this problem, and that the licensee's corrective action process was addressing the generic issue regarding scope of post modification testing.
4.2 Engineering Open Item Followup URI 50-387/93-11-01
{CLOSED) Unit 1 Turbine Blading Failure Root Cause On July 12, 1993, with Unit l.operating at 100X power, a reactor scram resulted due to a main turbine trip at greater than 24X power.
The main turbine trip was caused by high vibration that resulted when two turbine
blades on the 'C'ow pressure turbine failed, separating from the turbine rotor.
The plant was safely shutdown in accordance with normal procedures and there were no safety consequences resulting from this event.
The transient was within the bounds of the turbine trip analysis described in Chapter 15 of the Final Safety Analysis Report.
NRC Inspection Report 50-387/93-11 reviewed this event but left the issue as unresolved pending the licensee's final root cause determination.
Outstanding questions at that time were in regard to susceptibility of Unit 2 to this phenomenon and feasibility of normal negative phase sequence current as the initiator for the failures.
In October 1995, EC-093-1003,
"Final Report SSES Unit I Turbine Blade Failure Root Cause Evaluation,"
was approved by PP&L.
This final report contains information from the interim report and documents the subsequent inspection, analysis, and test results.
PP8L's conclusions reached in the final report are consistent with those presented in the initial root cause report issued in August 1993.
The final report included analysis performed by General Electric and MPR Associate The licensee has concluded that the root cause of the Unit 1 turbine blading failure was high cycle fatigue induced cracking of the blade dovetail fingers to final overload caused by the generator negative phase sequence currents being in resonance with the turbine rotor 20'" torsional vibration mode.
Other potential causes such as flow induced vibration, harmonic excitation, water induction, corrosion, material strength, and material/manufacturing/assembly issues were investigated and shown not to be contributors.
Torsional testing on Unit 1 after addition of the mass ring showed a 118. 1 Hz frequency versus the 117.8 Hz calculated frequency that was discussed in IR 50-387/93-11.
Testing on Unit 2 showed a natural frequency of 121.3 Hz and PPKL has concluded that the magnitude of the energy imparted by normal operation at this mode is not excessive and is acceptable.
The inspector reviewed PPSL's final root cause report and discussed the conclusions with cognizant corporate engineering personnel.
The inspector found the licensee's evaluation of other potential causes for the failure appropriate.
The licensee had a reasonable basis for concluding the turbine
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blade failures resulted from torsional vibration due to "normal" negative phase sequence currents.
Since the exact and continuous balancing of the generator phase currents is not practical, the inspector considered the licensee's corrective actions to reduce the effects of the induced torsional vibration appropriate.
On the basis of the Unit 2 torsional test results, the inspector considered the licensee's decision not to modify the Unit 2 turbine reasonable.
Based on review of the licensee final root cause evaluation.
report and the licensee's plans to retest the TGs when changes to their mass or physical configuration are made, the inspector considered this item closed.
5.
PLANT SUPPORT (71750, 71707, 92904)
5. 1 Radiological and Chemistry Controls As part of routine tours of the Radically Controlled Area
{RCA) and observation of work activities, the inspectors observed the implementation of selected portions of PPLL's radiological controls program.
During these general observations, the inspectors checked utilizatio'n and compliance with radiological work permits
{RWPs), descriptions of radiological conditions, and personnel adherence to RWP requirements.
No deficiencies were identified during these general observations.
On December 7,
1995, the licensee discovered a radioactive laundry container that had been released from the RCA had internal contamination.
The container was located near the Unit 2 RCA access point and a Health Physics (HP)
technician identified the contamination during a random survey.
A frisk of debris inside the container, when concentrated, indicated 120 counts per minute (cpm)
above background.
This exceeded the licensee's criteria of less than 100 cpm for release from the RCA.
The licensee's search for other contaminated items has identified additional items that should not have been released from the RC At the close. of this report period the licensee was taking actions to clarify expectations regarding individuals frisking personal items for removal from the RCA and had embarked on a search of buildings outside the RCA for contaminated tools.
In response to the growing number of contaminated items being identified, the licensee formed an Event Review Team.
The team itself grew to include representatives from the various work groups, Nuclear Assessment Services, and an outside consultant.
The inspectors consulted with representatives of the Region I, Radiation Safety Branch, regarding the contaminated items found outside the RCA and concluded that the licensee was taking appropriate steps to address the evolving issue.
Based on the inspectors'ssessment of the individual licensee findings, there do not appear to be any immediate safety concerns that the licensee has failed to address.
The licensee's corrective actions and a more detailed assessment of these events will be included in an upcoming Radiological Controls inspection.
A second trend has developed in the HP area regarding inadequate surveys, postings and barriers for high radiation areas.
At this time, no radiological consequences (i.e., over exposures)
have been identified and are not expected based on the locations of the high radiation areas with deficient posting/controls.
These licensee findings were also discussed with representatives of the Radiation Safety Branch.
In response to this trend the licensee has initiated a re-base line effort for the radiological postings.
Plant areas were prioritized for this review based on access to the area and the surveys were being performed on an expedited basis.
The inspectors considered the licensee's actions to address this trend appropriate.
The specific examples of inadequate posting and control of high radiation areas will also be evaluated during the upcoming Radiological Controls inspection.
Based on the locations of the radiation areas being identified as inadequately posted
'and the licensee's use of alarming pocket dosimeters, the inspector considered the risk of an unplanned exposure low and the actual impact on radiation safety minimal.
5. I.I Radiological Controls for RMCU Pump Inspection On January 31, 1995, the inspector observed the Unit I 'B'eactor water cleanup (RWCU) pump/motor disassembly and inspection work through a closed circuit TV camera.
The inspector also reviewed the radiological controls in place to keep workers exposure to ALARA.
According to the licensee, this was the first time such disassembly and inspection were undertaken after replacement of the RWCU pumps with new pumps of a different design several years ago.
Although the maintenance workers had mockup training, the radiological exposure exceeded the dose projection due to problems encountered during pump disassembly.
At some point during the disassembly the level of airborne increased from 0.3 DAC to 0.697 DAC, and the workers were required to wear a negative pressure respirator after the ALARA review was reevaluated.
However, during cleaning of the flange surface, the airborne dose increased to 53.4 DAC on January 22, 1996, and RWP 96-045 was
revised to require positive air pressure respirators (PAPRs).
While working with pump intervals, the licensee calculated the highest internal dose of a worker was approximately 10 mr.
The inspector observed continuous health physics (HP) coverage use of HEPA filtration and hot particle control.
The reactor building ventilation maintains a negative pressure in the RWCU pump room.
Since there was no flag at the open doorway that would indicate direction oF air flow, the inspector asked how the airborne boundary was being confirmed.
The HP technician covering the job indicated that air flow direction could be felt at the door thus confirming air flow into and not out of the room.
The inspector was told that the ventilation louvers above the pump were closed to reduce spread of contamination.
The inspector noted that no formal method or documentation were used to ensure the louvers were returned to the normal position after completion of the work, although the system engineer had reviewed and approved closure of the louver during the maintenance wor k.
The inspector raised the issue to plant management and considered implementation of a method to control such louver repositioning an enhancement to the plant equipment configuration control program.
Based on observation of parts of the maintenance work, HP controls and discussions with the HP personnel, the inspector concluded that licensee implemented reasonable HP controls.
The timeliness and adequacy of control of airborne levels will be further evaluated in an upcoming radiological controls inspection.
5.2 Security PP8L's implementation of the physical security program was verified on a
periodic basis, including the adequacy of staffing, entry control, alarm stations, and physical boundaries.
These inspection activities were conducted in accordance with NRC inspection procedure 71707.
The inspector reviewed access and egress controls throughout the period.
5.3 Emergency Preparedness Licensee's response to the January 7,
1996 snow storm event was very good.
Following the storm forecast, the licensee verified that the on-call emergency, responders were able to respond during a storm situation.
Where primary responders were not able to respond, backup responders were contacted.
The duty roster was updated to indicate available responders.
In addition, some preliminary arrangements were made to have appropriate vehicles be available to bring responders from the Allentown office.
5.4 Emergency Preparedness Open Item Review URI 50-387/90-18-01 (CLOSED), Conformance Of EALs With NRC Guidance
'(his item was opened to assure that all emergency action levels (EALs) were clear and unambiguous pending completion of licensee's evaluation for conformance with NRC guidanc On January 21, 1993, PP&L submitted their proposed revision to the Emergency Plan that implemented the NUMARg NESP-007 methodology for revised EALs.
This revision is currently being reviewed by NRR and is being tracked as a
licensing action item.
Hence the unresolved item is administratively closed.
6.
SAFETY ASSESSMENT/EQUALITY VERIFICATION (90700, 90712)
6. 1 Corrective Action Process The inspectors observe the licensee's corrective action process on a day-to-day basis.
Part of this observation includes a routine review of Condition Reports (CRs)
and their associated operability determinations.
In the past, the inspectors have noted instances where CR operability determinations were incomplete in that they only discussed applicability of TS action statements and did not address why the identified condition did, or did not, impact operability (past or future).
The examples included the visqueen sheet found in the Unit I suppression pool during the Unit's 8'" refueling outage (reference IR 95-08)
and high resistance contacts on a diesel generator control relay (IR 95-24).
Host recently, Operations management raised questions regarding documentation of operability determinations, especially when the exact cause of the problem can not be identified because of its intermittent nature.
The December 31, 1995, HPCI flow controller power loss (reference LER 1-95-016)
and the January 8,
1996, trip of the 'E'iesel generator (reference CR 96-17) were two examples identified by the licensee and discussed in the Corrective Action Team (CAT) forum.
Managers at the meeting were directed to reinforce the importance of documenting investigative'ctions and bases for operability determinations as part of the CR process.
By the close of this report period the inspectors had observed some level of improvement in CR documentation of operability, however continued management attention will be necessary to ensure performance improves and becomes consistent.
Inspection Report 50-387/95-80 indicated that the stat:ion did not have an effective method to conduct an integrated approach for trending performance history of various conditions.
At the February 2,
1996 CAT meeting, the Operating Experience Services (OES) group presented trend information in four different areas involving work control and work practices at the station.
These included bypasses/unauthorized modifications, modification process, work authorization (WA) work plans, and WA process/
use of investigative WAs.
Various past documents, e.g., existing condition reports, NRC identified issues from inspection reports, and industry information were used to establish a trend.
A "Master CR" was established to document resolution of the trend, rather than documenting resolution of each individual CRs separately.
A team was established to investigate the negative trend observed in work control and work practices at the station.
The inspector concluded improved use of trend information was evident at these CAT meetings, which improved the licensee's problem resolution and corrective action proces.
NANAGENENT AND EXIT MEETINGS (71707)
7.1 Resident Exit and Periodic Meetings The inspector discussed the findings of this inspection with PP&L station management throughout the inspection period to ensure timely communication of emerging concerns.
At the conclusion of the reporting period, the resident inspection staff conducted an exit meeting summarizing the preliminary findings of this inspection.
Based on NRC Region I review of this report and discussions held with licensee representatives, it was determined that this report does not contain information subject to
CFR 2.790 restrictions.
7.2 Other NRC Activities On January 4,
1995, an enforcement conference was held with PP&L and a former security supervisor at the NRC's Region I office in King of Prussia, Pennsylvania.
The enforcement conference (EA 95-250)
was held to discuss the Secretary of Labor's Occision and Order of Reprimand, dated October 20, 1995, and the apparent violation of 10 CFR 50.7,
"Employee Protection."
Attachment 1 contains the licensee's handout issued during the enforcement conference.
A physical security inspection was conducted by Mr. E. King between January 22.
and January 26, 1996.
The results of his inspection will be documented in a combined Inspection Report 50-387,388/96-02.
An inspection of fire barrier. penetrations was performed by Mr.- P.
Ray of the Office of Nuclear Reactor Regulation (NRR),
and others, between January 30 and February 2, 1996.
The results of this NRR inspection will be documented in combined Inspection Report 50-387,388/96-20 ATTACHM PP&L PRESENTATION TO THE USNRC:
THE OCTOBER 20, 1995 SECRETARY OF LABOR DECISION AND ORDER OF REMAND JANUARY4, 1996 USNRC REGION I OFFICES KING OF PRUSSIA, PA
TIME 1992 SON D
1993 AMJ JA 1994 J F MAMJ J ASOND 1996 J
F M
A M
J J
A S
N D
REPORT TO NRC PP &LINVESTIGATION ENFORCEMENT CONFERENCE WSS ASSESSMENT NOTICE OF VIOLATION a-o eAXhaauS IDENTIFICATIONOF CONCERN SYNERGY ASSESSMENT OF SECURITY FILINGS ALJ RULING SOL RULING PPEL ASSESSMENT OF SOL RULING 0--+
SYNERGY ASSESSMENT OF NSCP
PPEzL MANAGEMENTPERSPECTIVE Independent Assessments Have Been Performed
>> Our Safety Culture Remains Strong.
>> Opportunities to Improve our Performance Have Been Identifie PP8zL MANAGEMENTPERSPECTIVE We Accept the Secretary of Labor's Decision.
>> The Security Organization Work Environment Did Not Meet Our Standards.
>> Internal Newsletter Communications Exacerbated This Proble.PP8zL MANAGEMENTPERSPECTIVE Aggressive, Comprehensive Corrective Actions Are Being Taken
>> Reinforce Open Climate to Raise Concerns.
>> Negotiations to Settle the DOL Complaint are Underway.
>> Personnel Actions Have Been Taken.
>> Senior Management Has Held Open Discussions with the Security Shifts.
>> Our Objective is to Implement Long Term Solutions.
Security Section and Department-Wide Effectiveness Will Be Monitored
>> Lessons Learned Will Be Institutionalized Corporate-Wid AGENDA PP8zL PRESENTATION TO THE USNRC JANUARY4, 1996 INTRODUCTION....:...........:..............
R.G. BYRAM Senior Vice President - Nuclear Vice President - Nuclear Operations OPERATIONS MANAGEMENT....... H.G. STANLEY PERSPECTIVE EVALUATIONAND
..........................
G.J.
KUCZYNSKI CORRECTIVE ACTIONS Manager - Nuclear Plant Services THE ROLE OF ASSESSMENT
......... W.E. BURCHILL Manager - Nuclear Assessment Services CONCLUSIONS................................
R.G. BYRAM
OPERATIONS MANAGEMENTPERSPECTIVE Management Expectations for Security
>> New Management Team: Culture Change
>> Continue High Standards for Technical Performance
>> Open, Honest Communications for All Issues
>> Training of Supervisors
>> Increased Assessment
OPERATIONS MANAGEMENTPERSPECTIVE lridependent Assessments
>> February 23, 1995 Enforcement Conference Limitations of PP8L Investigation
>> Periodic NSCP Assessment Positive Results
>> Focused Self Assessment in Security July 14, 1995 NRC Letter Taken into Account Organizational Culture
OPERATIONS MANAGEMENTPERSPECTIVE Security Culture
>> Recognized Superior Performance SALP Record Strong People
>> Command 8 Control Oriented
>> Functionally Isolated from the Department Autonomous: Allowed to Set Their Own Standards
OPERATIONS MANAGEMENTPERSPECTIVE Management Lessons Learned
>> Strong Performance May Mask Cultural Issues.
>> Objectivity in Investigations is Essential.
>> We Must Enhance Our Supervisors'bility to Deal with Employee Concern OPERATIONS MANAGEMENTPERSPECTIVE Personnel Actions
>> Disciplinary Actions Accelerate Culture Change Reinforcing Standards
>> New Management
. Assimilation Into Site Organization
ROOT CAUSE The existence of cultural weaknesses within the Security section that adversely impacted personnel morale and employees'illingness to question management practices or personnel matter EVALUATIONACTIVITIES Security Assessment
>> Objective
>> Approach Interviews
~ No Reluctance to Raise Nuclear Safety or Physical Security Issues Was Identified Validated Themes
. Self Assessment and Action Planning Feedback
THEMES VALIDATEDBY THE SECURITY ORGANIZATION
~
ADDRESSING EMPLOYEE ISSUES AND CONCERNS
~
SUPERVISORY SKILLS DEVELOPMENT
~
COMMUNICATIONS, TEAMWORKANDTRUST
~
EMPLOYEE INPUT, FEEDBACK, AND RECOGNITION
~
JOB SECURITY
~
IMPACT OF THE 1992 EVENT ON THE SECURITY ORGANIZATION
~
STAFFING
~
PERFORMANCE EVALS, PROFESSIONAL DEVELOPMENT, AND PRQMOTIONS o
WORKING CONDITIONS 8 JOB SATISFACTION
~
PROFESSIONAL STANDARDS AND CONSTRUCTIVE DISC.IPI INE POLICIES
~
IMPROVINGTHE BUSINESS PROCESS, TOOLS, AND CAPABILITIES
~
BALANCINGEMPOWERMENT AND COMMAND8 CONTROL
EVALUATIONAND CORRECTIVE ACTIONS Key Evaluation Issues
>> Profile of the Security Section Culture
>> Training Incident
>> Failure of Internal Process
>> Security Section Work Environment
>> Complaint with the Dept. of Labor
>> 1995 NRC Enforcement Proceedings
>> July 14, 1995 NRC Letter
FACTS 8z CAUSALFACTORS Profile of fhe Security Section Culture
>> Facts Highly Structured Business Process Command 8 Control Recognized Industry Leader Functional Isolation Cultural Weaknesses Failure to Recognize Weaknesses
FACTS Ez CAUSALFACTORS Profile of the Security Section Culture
>> Causal Factors MilitaryModel Unquestioned Support of Management Direction Inadequate Communications Limited Exposure to Site Culture Limited Management Oversight Limited Independent Oversight
FACTS Ez CAUSALFACTORS Profile of the Security Section Culture
>> Actions to Prevent Recurrence New Management Team Personnel Actions Improve Communications Establish Issues Team Supervisor Training Increase Assessments
FACTS k. CAUSALFACTORS Training Incident
>> Facts Supervisor Gave Officers Answers to a Missed Exam Question The Supervisor Encouraged Officers to Change Their Answers The Individual's Actions Led to Violation of Company Policy and NRC Requirements Initiated and Suspended Investigation
FACTS 8z CAUSALFACTORS Training Incidenf
>> Actions to Prevent Recurrence Personnel Actions Require Use of Qualified Instructors Improve Training for Instructors
~ Expectations Enhance Academic Honesty Policy
FACTS 8z CAUSALFACTORS Failure of infernal Process
>> Facts Employee Witnessed Violation of Requirements Did Not Report to Line Management Did Not Report to the NSCP
>> Causal Factors Lack of Trust Limitations on Internal Reporting Misunderstanding of the NSCP
FACTS k CAUSALFACTORS Failure of Infernal Process
>> Actions to Preient Recurrence Change Culture Supervisor and Shift Training on ECP Establish Security Issues Team Management Meetings with Shifts
~ Expectations
~ Open Dialogue
FACTS 8z CAUSALFACTORS Security Section Work Environment
>> Facts Animosity and Divisions Developed Supervisor 8 Employee Requested Reassignments Requests Not Granted Employee Was Treated Differently
>> Causal Factors Interpersonal Conflicts Failure to Address the Issues or Separate the Parties Failure to Understand Larger implications
FACTS 8z CAUSALFACTORS Security Section Work Environment
>> Actions to Prevent Recurrence Change Culture Establish Issues Team Train SupervisorslManagers
FACTS Ez CAUSALFACTORS Complaint with the Department of Labor
>> Facts PP&L Accepts SOL Decision Employee Was Not Treated Properly Within Work Environment PP&L Did Not Recognize the Discrimination
FACTS Ez CAUSALFACTORS Complaint with fhe Oepartment ofLabor
>> Causal Factors Insufficient Information Lack of Appreciation of Impact on Environment Failure to Recognize Impact of Actions Lack of Understanding of DOL/NRC Process Unrealistic Expectations on Resolution Need for Timely Senior Management Involvement
FACTS &: CAUSALFACTORS Complaint with the Department ofLabor
>> Actions to Prevent Recurrence Establish Team to Manage Response to Issues
~ Includes Corporate Resources Assure Independent Investigations Training of Supervisors/Managers Timely Senior Management Involvement Corporate Policy on Employee Protection
~ Task Force Established
FACTS Ez CAUSALFACTORS 1995 NRC Enforcement Proceedings
.>> Facts PP&L Reinitiates Investigation
~ Same Security Section Investigator PPB L Attends Enforcement Conference We were Dissatisfied with Our Preparation Level III Violations Issued Independent Assessment Initiated
FACTS &CAUSALFACTORS 7995 NRC Enforcement Proceedings
>> Causal Factors Lack of Clear Objectives for Investigation
~ Lack of Objectivity Inadequate Investigation
~ Lack of Independence Inadequate Preparation for Enforcement Conference
~ Lack of a Systematic Process
FACTS Ez CAUSALFACTORS 1995 NRC Enforcemenf Proceedings
>> Actions to Prevent Recurrence Independent Assessment
~ Establish Team to Manage Response to Issues
~ Assure Independent Investigations
~ Define Cause and Corrective Actions
FACTS 8z CAUSALFACTORS Ju/y $ 4, 1995 NRC Lefter
>> Facts Intended to Respond to Newspaper Article NRC Issued Chilling Effects Letter Significance of Underlying Culture Became Apparent Senior Manager Placed in Charge of PP&L Corrective Actions Independent Security Assessment Initiated
FACTS Ez CAUSALFACTORS July 14, 1995 NRC Letfer
>> Causal Factors Inadvertent Representations
~ Defending the Supervisor
~ Didn't Understand Significance of NOV Lack of Awareness of Facts, Cultural Problems
~ Unanticipated Employee Reaction
>> Actions to Prevent Recurrence Assure Independent Investigations Enhance Sensitivity to Cultural Issues Management of Response to Issues
EVALUATIONAND CORRECTIVE ACTIONS Key Evaluation issues
>> Profile of the Security Section Culture
>> Training Incident
>> Failure of Internal Process
>> Security Section Work Environment
>> Complaint with the Dept. of Labor
>> 1995 NRC Enforcement Proceedings
>> July 14, 1995 NRC Letter
I
THE ROLE OF ASSESSMENT Independent Assessmenf
>> An Essential Service Manage NSCP Independent InvestigationslAssessments Systematic Self Assessment
>> Tools Continue to Evolve Compliance Performance Culture
'I
ASSESSING THE EMPLOYEE CONCERNS ENVIRONMENT Background
>> 1989: Concerns on Reporting of Design Issues ECP Established
~ Assist Employees in Identifying Issues EDR Process Established
~ Identify and Manage Technical Issues
~ Many Issues Raised Initially
>>.1990-1992: Design Issue Management Continues to Evolve Management of Technical Issues Improves People Issues a Continuing Challenge
~ User Friendliness of Processes Enhanced/Monitored
ASSESSING THE EMPLOYEE CONCERNS ENVIRONMENT Background
>> 1993: Assessments Periodic Review of EDR Program Independent Assessment of ECP
~ Healthy Program with Room for Improvement
~ NRC Inspection Provided Positive Feedback
~ NSCP Established
>> Enhanced Features Include Site, GO Reps.
>> 1994-95: CR Program Established User-Friendliness Further Enhanced
ASSESSING THE EMPLOYEE CONCERNS ENVIRONMENT Ongoing Work
>> 1995 NSCP Assessment Periodic Strong Nuclear Safety Culture Line Management had Shown Improved Sensitivity Employees 8 Contractors Willing to Raise Concerns
>> Review of Condition Report Program Employees are Willingto Identify Deficiencies Employees are Sensitiye to Perceived Process Impediments
ENHANCINGASSESSMENT Assessment Activities
>> Assure Independent Investigations for Significant Issues
>> Techniques for Assessing Cultural Impacts Are Under Development
>> Line Management Self Assessment Training Functional Unit Plans
>> Performance Management
>> Follow-up Independent Assessments Will Occur Security
CONCLUSIONS PPELis Committed to Open and Honest Communicafion.
PPEL's Safety Culture Remains Stron CONCLUSIONS We Have Taken Actionin Security.
>> Sr..Mgmt. Has Held Open Discussions with Security Personnel.
>> 10CFR50.7 Training Has Been Completed.
>> Personnel Actions Have Been Taken.
>> Efforts to Settle the DOL Complaint Are Underway.
>> Security Employees Are Addressing the Issue CONCLUSIONS independent Assessments Have Defined Opportunities for Enhanced Department Performance
>> Supervisor Development: People Sensitivity
>> Assessment Techniques: Cultural Issues
>> Management Involvement: Assuring Objectivity
CONCLUSIONS Management and Employees Are Working Together.
>> Required for Lasting Solutions.
>> Communication is Essential.
>> Monitoring and Adjustment Will Continue to Occu ~
CONCLUSIONS Lessons Learned WillBe Institutionalized
.
>> Department and Corporate-Wide.