IR 05000397/1991043
| ML17289A348 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 02/11/1992 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17289A347 | List: |
| References | |
| 50-397-91-43, NUDOCS 9203030035 | |
| Download: ML17289A348 (25) | |
Text
U. S.
NUCLEAR REGULATORY COMMISSION
REGION V
SYSTENATIC ASSESSMENT OF LICENSEE PERFORMANCE SALP BOARD REPORT No. 50-397/91-43 WASHINGTON PUBLIC POWER SUPPLY SYSTEM WASHINGTON NUCLEAR PLANT NO.
SEPTEMBER 1, 1990 THROUGH DECEHBER 31, 1991 9203030035'202il PDR ADOCK 05000397 G
TABLE OF CONTENTS I.
Introduction
.
.
.
.
.
.
.
.
.
.
.
II.
Summary of Results A.
Overview..'.
.
.
.
.
.
.
.
.
B. 'esults of Board Assessment
.
~Pa e
~
~
~
~
III. Performance Analysis A.
Plant Operations.
B.
. Radiological Controls
.
.
.
.
C.
Maintenance/Surveillance.
.
.
D.
.
.
.
E.
Securityo
~
~
~
~
~
~
~
~
~
~
F.
Engineering/Technical Support G.
Safety Assessment/equality Veri IV.
Supporting Data and Summaries
~
~
~
ficatiori.
~
~
6
11
15
A.
B.
C.
D.
E.
Licensee Activities
.
.
.
.
.
Inspection Activities
.
.
.
.
Enforcement Activity Confirmatory Action Letters
.
Licensee Event Reports.
.
.
.
22
~
.
23
I.
INTRODUCTION The Systematic Assessment of Licensee Performance (SALP) is an integrated NRC staff effort to collect available observations and data on a periodic basis and to evaluate licensee performance based on this information.
The program is supplemental to normal regulatory processes used to ensure com-pliance with NRC rules and regulations.
It is intended to be sufficiently diagnostic to provide a rational basis for allocating NRC resources and to provide meaningful feedback to licensee management regarding the NRC's assessment of their facility's performance in each functional area.
An NRC SALP Board, composed of the members listed below, met in the Region V office on January 16, 1992, to review observations and data on the licensee's performance in accordance with NRC Manual Chapter 0516,
"Systematic Assessment of Licensee Performance."
This report is the NRC's assessment of the licensee's safety performance at Washington Nuclear Plant
(WNP-2) for the period September 1,
1990 through December 31, 1991.
The SALP Board meeting for WNP-2 was attended by:
Board Chairman R. Zimmerman, Director, Division of Reactor Safety and Projects, RV
'oard Members M. Virgilio, Assistant Director for Regions IV and V Reactors, NRR T. quay, Director, Project Directorate V, Division of Reactor Projects, NRR F. Wenslawski, Deputy Director, Division of Radiation Safety and Safeguards, RV S. Richards, Chief, Reactor Projects Branch, RV D. Kirsch, Chief, Reactor Safety Branch, RV
,P. Johnson, Chief, Reactor Projects Section 3, RV P.
Eng, NRR Project Manager C. Sorensen, Senior Resident Inspector, RV Other Attendees K. Perkins, Deputy Director, Division of Reactor Safety and Projects, RV S.
Shankman, Regions IV and V Coordinator, OEDO G. Yuhas, Chief, Reactor Radiological Protection Branch, RV J.
Reese, Chief, Safeguards, Emergency Preparedness and Non-Power Reactors Branch, RV L. Miller, Chief, Operations Section, RV K. Johnston, Project Inspector, RV A. Mcgueen, Emergency Preparedness Analyst, RV L. Norderhaug, Safeguards Inspector, RV L. Carson, Radiation Specialist, RV D. Proulx, Resident Inspector, RV C. Holden, NRR/LPEB P.
Ray, NRR/LPEB
II.
SUMMARY OF RESULTS A.
Overview This assessment reflects the licensee's failure to sustain the momentum observed 'during the previous assessment period.
In contrast with the previous assessment, the Board did not find management to be demonstrating an eagerness in some instances to identify programmatic weaknesses and aggressively pursue them.
Instead, the licensee showed a tendency to rationalize shortcomings.
This was best illustrated by senior manage-ment's initial reluctance to accept the NRC's conclusion of poor operator performance during licensed operator requalification examinations.
Additionally, although weaknesses in Emergency Operating Procedures (EOPs)
were highlighted in the last SALP report, appropriate corrective action was taken only after an extended shutdown prompted by the requalification program failure.
The Board's assessment of the Safety Assessment/guality Verification area as a Category 3 reflects its conclusion that licensee management did not recognize, without significant NRC involvement, the significance of the licensed operator requalification failures and the weaknesses in the EOPs.
Although the performance of the quality verification organizations demonstrated their ability to conduct effective audits and to identify issues, aggressive pursuit of identified issues was not always demanded by guality Management.
NRC-observed weaknesses in the motor operated valve program and failure to maintain the containment atmospheric control system also eroded the Board's confidence 'in the adequacy and scope of management oversight.
Although operator performance was good during actual operation of the plant, the extent of problems in the operator requalification program and EOPs and the potential safety significance associated with these short-comings resulted in a Category 3 rating.
Particularly troubling was the licensee's failure to anticipate these problems, as indicated by the findings of the 1990 EOP inspection, and to apply industry knowledge and experience to WNP-2 programs.
Although performance improved late in the period, management must assure that continuing attention is focused on this area.
Continuing program improvements were observed in the Maintenance/Surveil-lance and Engineering/Technical Support functional areas, including the new work control process, improved review of design issues, and develop-ment of a reliability centered maintenance program.
Overall, however, the Board found that the progress of improvements in both functional areas had slowed, indicating a need for more follow-through on initiatives.
Insuf-ficient attention to plant material condition was also at times evident.
Weaknesses noted in the Engineering/Technical Support functional area included the motor operated valve program and the quality of technical work supporting submittals to the NRC.
The Board found the licensee's performance in the Radiological Controls and Emergency Preparedness functional areas to have been clearly satis-factory, although continuing attention to some basic issues in these areas is still neede Performance in the Security functional area was seen to have improved.
Positive results from programmatic and physical improvements were observed, and weaknesses in the fitness for duty program were identified and addressed.
The Board considered that the licensee's performance in this area had risen to Category I.
However, management must recognize the importance of maintaining appropriate support to retain the performance level attained.
Overall, the licensee's management and staff were found to be well quali-fied and committed to the safe operation of WNP-2.
However, management's failure to recognize significant program deficiencies and its lack of aggressiveness in ensuring that problem areas are corrected were a major concern.
Renewed commitment to the standards demonstrated during the previous SALP period is strongly encouraged.
B.
Results of Board Assessment Overall, the SALP Board found the performance of NRC licensed activities to be acceptable and directed toward safe operation of WNP-2.
The SALP Board has made specific recommendations in most functional areas for licensee management consideration.
The results of the Board's assessment of the licensee's performance in each functional area, along with the results from the previous period, are as follows:
'unctional Area Rating Last Period Rating This Trend Period Trend A. Plant Operations B. Radiological Controls C. Maintenance/Surveillance D. Emergency Preparedness E. Security F. Engineering/Technical Support G. Safety Assessment/
guality Verification III. PERFORMANCE ANALYSIS
2
2 Improving I
Improving
Improving The following is the Board's assessment of the licensee's performance in each of the functional areas, along with the Board's conclusion for each area and its recommendations with respect to licensee actions and management emphasis.
A.
Plant 0 erations l.
~nal sis Approximately 39N of the total direct inspection effort was devoted to the Plant Operations area during this assessment period.
.Strengths in this functional area were demonstrated by relatively uneventful operations.
No major operational events occurred as a
result of operator error, and the operators'esponse to the three
reactor scrams, as well as operator performance during routine evolutions, was conservative and deliberate.
The most significant problem in this functional area was insufficient corporate and plant management attention to the emergency operating procedures (EOPs)
and the operator requalification program.
This weakness in leadership, along with excessive isolation from industry experience, led to uns8tisfactory performance in these areas, in that during requali-fication examinations administered by NRC examiners, a number of licensed operators were unable to implement the EOPs in response to accident scenarios presented to them in the plant simulator.
These problems delayed restart from the plant's refueling outage from -June until the end of September 1991.
This functional area was rated Category 1 during the previous SALP period.
The previous Board found that management had demonstrated continuing commitment to improved performance, and that the Opera-tions staff indicated a commitment to deliberate execution of plant evolutions.
The Board 'recommended that weaknesses identified in EOPs be aggressively pursued and that continued management attention be given to control room communications and the requalification program.
Timely procurement of the new plant simulator was also encouraged.
During this SALP period, while observing simulator examinations, the NRC identified significant weakness in operator communications, com-mand and control, procedural compliance, and use of EOPs,.along with weaknesses in the technical adequacy and usability of EOPs.
Licensee management did not appear to benefit from industry experience and existing guidance to anticipate and correct these weaknesses.
These problems were identified by the NRC during a series of inspections and examinations.
These included EOP team inspections in September 1990 and August 1991, and various operator examinations and evalua-tions in February, March, June, August and September of 1991.
The licensee's operator requalification program was declared unsatisfactory based on an examination conducted in February and March 1991.
Failures also resulted from four of the five successive examinations conducted to assess the readiness of the Operations staff prior to resumption of plant operation following the 1991 refueling outage.
Crews failed 7 of the 15 simulator evaluations which were performed during this period.
These recurring crew failures indicated the depth and severity of the weaknesses, which licensee management appeared unwilling to accept until several examinations were failed.
The principal finding of the EOP inspections was that the EOPs were usable by trained operators, but'ere potentially confusing, and that many deviations from generic guidance had been made with insufficient technical justification.
Because of ineffective communication of management expectations, the Operations staff also widely regarded the EOPs as guidance, a condition which contributed significantly to the requalification examination failures.
By September 1991, the licensee had made many short term special operator training and evaluation improvements, and had completed an
interim revision of the EOPs.
These were adequate to warrant resump-tion of p'ower operation of MNP-2.
By that time, licensee management had initiated a number of strong. operational and training standards which were resulting in improved operational performance during emergencies.
Operator. response to plant events and actions during routine opera-tion was generally good, and indicated a deliberate and conservative approach to plant operations.
The operators performed several startups and shutdowns and executed core alterations (during the 1991 refueling outage) with little or no problem.
During an event late in the assessment period, involving a total loss of feedwater flow, reactor scram, and an emergency core cooling system actuation, opera-tors responded well and quickly mitigated the event.
The intense retraining program following the requalification program failure ap'peared to have had a positive effect on"operator performance during the event.
Six Severity Level IV violations were cited in the Plant Operations functional area, and three non-cited violations were noted.
Four of
LERs and two of these violations involved insufficient procedure guidance or Operations personnel not following procedures.
A Tech-nical Specifications (TS) violation also occurred when Operations permitted untorquing of the reactor vessel head to begin before reactor temperature was reduced below the maximum of 140oF allowed'or refueling conditions.
The EOP weaknesses discussed earlier and several observed failures to follow procedures indicated inadequate communication of management expectations regarding procedure. implementation.
In general, however, Operations procedures were adequate for safe operation of the facility.
Operations procedures are prepared and maintained by past-and present licensed operators to aid in improving procedure.
quality.
The licensee has committed to perform a Verification and Validation (V&V) of all operating and surveillance procedures and to include a
V&V in the biennial review of these procedures.
Although the V&V process, when properly implemented, appeared to improve routine operating procedures, weaknesses in V&V contributed to the poor quality of the EOPs.
The Clearance Order Review Committee (CORC) remained in effect throughout this assessment period, and had an overall positive effect on plant operations by researching and issuing the large number of clearance orders (tagouts).
This enhanced the ability of control room operators to concentrate on plant operations.
Operations staffing appeared to be satisfactory during actual opera-tion of the facility.
In some instances, however, limited staffing contributed to license requalification program problems.
At the beginning of the assessment period, the plant was operating with a six-crew rotation.
Each crew had 3 licensed Senior Reactor Operators (SROs).
In addition, the licensee intended to man each operating crew with 3 licensed ROs.
However, the delay in fulfillingthis intention appeared to have a direct effect on the ability of the
operating crews to handle complex scenarios during the requalifica-tion exams.
The licensee instituted a five-.shift rotation before plant restart, with each shift having three ROs.
2.
Performance Ratin
Performance Assessment:
Category 3, Improving Trend 3.
Recommendations The Board recommends that management maintain active involvement in monitoring the performance of the operator requalification training and EOP improvement programs.
The Supply System is also strongly encouraged to continue its active participation in the various nuclear industry groups, to stay abreast of current initiatives and lessons learned from other BWR licensees.
The licensee is also encouraged to pursue identified control room staffing initiatives.
B.
Radiolo ical Controls l.
~aa1 sis Thirteen radiological controls inspections were conducted during this assessment period, representing approximately llX of the total inspection effort.
The licensee's performance was generally good.'trengths were noted in the level of management involvement in reducing occupational exposure, changes in staffing, and increased oversight by the quality assurance organizations.
Weaknesses were observed in the areas of exposure control and shipment of radioactive material for disposal.
The previous SALP Board rated performance in this area Category
and recommended that the licensee emphasize to all employees the importance of adhering to good radiological work practices and procedural controls.
The Board also suggested that health physics staffing, training, and exposure reduction activities receive additional management attention.
Evidence of prior planning was noted in efforts to reduce occupa-tional exposure.
The Senior ALARA Committee actively established and revised goals throughout the period, resources were allocated to the ALARA planning group, and accomplishments were plotted and analyzed.
During 1990 the licensee accumulated 536 person-rem.
Cumulative exposure for 1991 was about 400 person-rem.
This reduction was part-ly a result of decreased scope of outage work during the 1991 (R-6)
refueling outage.
However, a comparison of common work activities between R-5 (1990)
and R-6 showed that exposures were less in R-6 despite higher radiation levels.
Extensive planning is in progress for a major outage (R-7) which.may result in approximately 800 person-rem.
Liquid and gaseous effluents continued to be a small fraction of the Technical Specification limits.
The volume of solid radioactive waste transferred for disposal was 15,247 cubic feet in fiscal 1990 and approximately 10,722 cubic feet in 199 The licensee used memoranda, training, safety meetings and general employee discussions with plant management to emphasize their expec-tations with regard to implementing good radiological work practices and following procedures.
However, several examples indicated that procedures were not clear, were not followed, and that policies were not well understood.
Specifically, the licensee's privileges for disposal of radioactive waste were suspended on three occasions.
These suspensions resulted from inadequate procedure guidance and failure to follow procedures.
Three workers received unplanned radiation exposures in excess of the licensee's daily administrative dose limits.
These unplanned exposures resulted from failure to clearly communicate management expectations and failure to implement basic radiation safety practices.
There was an adequate level of involvement by the offsite support organizations.
The quality assurance organizations had improved their oversight of activities in this area.
However, the Corporate Chemistry Committee was generally ineffective in implementing its oversight responsibilities during most of this period.
Root cause analyses were performed For several incidents, and were observed to be genera11y timely and thorough.
However, the assessments of the April 1991 resin spill and excessive exposures were neither timely nor thorough; accordingly, long term corrective actions were slow to be developed and implemented.
Corrective actions were. not fully adequate to address the underlying concerns that resulted in the repeated problems with. the disposal permit.
The radiological environmental monitoring and personnel dosimetry programs were of high quality.
Chemistry was maintained consistent with industry standards.
The radioactive waste processing systems were well maintained, although the liquid radwaste collection system continues to be a source of significant maintenance and personnel exposure problems.
In October 1991 the licensee resolved a longstanding technical issue
- concerning the post-accident iodine and particulate sampling system by committing to install a new system by November 1993.
Their approach seems viable and technically advanced.
The licensee has also completed'n evaluation of the increasing radiation levels in the plant.
Actions. to mitigate the sources include a cobalt minimi-zation effort, chemical decontamination, hot spot removal, and a
drain flushing program.
The licensee was cited for te'n Severity Level IV violations during this assessment period.
These violations ranged from insufficient attention to detail to failure to provide basic radiological'protec-tion for workers.
The 'immediate corrective actions were typically timely and effective.
Longer range programmatic corrections were not always as timely or as effective (e.g.,
unplanned exposures and radioactive material shipping and disposal problems).
One Licensee Event Report (LER) was directly related to this functional area.
The LER reported missed tritium sample The chemistry and health physics organizations were fully staffed with their complement of technicians.
Early in this assessment period the licensee reorganized the professional health 'physics staff.
Changes included creation of an ALARA planning group, two craft supervisor positions, and an Assistant Health Physics/
Chemistry Manager position.
Reorganization at -the corporate level initially resulted in an apparent lack of health physics expertise in management.
A certified health physicist was hired to fill a new Corporate Radiological Health Officer position.
The. corporate organization does not currently have a chemistry expert to provide oversight and technical support.
Coordination between the corporate organization and the onsite organizations could also be improved.
Consultants were effectively used in the audit process, with contract technicians providing support as necessary during outage conditions.
Radiation protection training for the work force appeared to be effective.
The number of personnel contaminations and err'ors has decreased.
Health physics and chemistry technician training was good; however, enforcement findings indicate that management's expectations with respect to following procedures needs reinforce-ment.
Implementation of the professional level training program should enable continued improvement in performance.
2.
erformance Ratin Performance Assessment:
Category
3.
Board Recommendation The Board recommends that licensee management continue efforts to minimize occupational exposure in view of the incr easing dose rates and the scope of work scheduled for the 1992 refueling outage.
Appropriate attention to waste shipments should be provided.
Manage-ment must also assure that basic radiation safety practices, such as exposure control techniques, are understood and implemented by all individuals and that procedures contain sufficient detail to consistently accomplish their safety objectives.
C. 'intenance Surveillance 1.
~nal sis During the SALP period, approximately 9X of the direct inspection effort was applied to the maintenance/surveillance functional area.
The licensee continued to make progress in the various elements of the Maintenance Improvement Program, including the maintenance
- procedures improvement program and implementation of the revised maintenance work request (NWR) procedure, the reliability centered maintenance (RCH) program, the maintenance training program, and the Work Control Group.
Additiona1ly, fewer personnel errors occurred during this assessment period.
Although the contribution of these programs was largely positive, a lack of management oversight resulted in problems in some areas.
Areas of weakness included
implementation of the TS surveillance program and the material condition of the plant.
This functional area was rated Category 2 during the previous assess-ment period.
The Board recommended that the licensee continue to develop and implement planned improvements to the preventive mainte-nance program, improve the quality of maintenance procedures, and fully implement the improved maintenance controls.
The Board also recommended continued attention to maintenance procedure, adherence.
Six Severity Level IV violations and
LERs were related to the Maintenance/Surveillance area.
Several of these violations and LERs involved programmatic failures by the licensee to implement TS sur-veillance requirements; One violation early in the period identified that required flow control valve positions were not established for jet pump TS surveillance tests.
Another violation cited surveillance testing of the standby gas treatment system which was not being per-formed in accordance with TS requirements.
These violations prompted the licensee to retain a consultant to perform a complete review of the implementation of TS-required surveillance tests.
The results of this review were documented in LER 91-13.
Although it is commendable that the licensee would initiate such a study of TS compliance as described in LER 91-13, the number of documented findings was a
matter of concern.
Additionally, problems with the implementation of TS surveillance requirements continued to be identified after the'ontractor's work was complete.
Other <ERs documented these problems, further indicating a programmatic problem with the strict implementation of TS surveillance requirements.
The staffing of the licensee's maintenance department remained rela-tively constant throughout the assessment period.
During the latter portion of the period, the Mechanical Maintenance Supervisor was selected to be the new Assistant Maintenance Manager, and appeared to broaden the experience base and knowledge of department management.,
It appeared that the size 'of the licensee's maintenance staff, perio-dically augmented by outside contractors, was adequate to perform the volume of maintenance work typically experienced at WNP-2.
With regard to training and qualification, the National Academy for Nuclear Training reaccredited the licensee's maintenance training department during the assessment period.
The training facility, which included a staff of about 14 full-time instructors and numerous classrooms and training aids, was seen as a strength.
The licensee
.was still implementing the Personnel gualification System, and no personnel had yet been qualified by this new system for a number of complex and specialized maintenance tasks.
The licensee continued to implement a number of pilot projects which were initiated during the previous SAt P period.
Among these were the RCH initiative and the maintenance procedure improvement initiative.
The progress made by the procedure improvement group was limited, as a number of procedure weaknesses were still being identified during the assessment period.
The RCH program, which will eventually super-sede the existing preventive maintenance program, was still in
-10-development, was behind schedule, and had not been implemented on any systems.
However, the licensee demonstrated commitment to the progr'am by increasing management oversight and is planning to increase staffing significantly in the near future'as the program is turned over from the prime contractor to the licensee.
The licensee completed the first full SALP period using an improved MWR procedure.
This appeared to enhance the quality and control of work performed (although the revised procedure was more cumbersome and tended to slow the accomplishment of maintenance activities).
MWRs were noted to be very detailed documents that specifically describe numerous aspects of work to be performed.
Adherence to procedures also appeared to have improved.
Problems were still being identified with the preventive maintenance program.
For example, lubrication schedules had not been established for the cont'ainment atmospheric control (CAC) system blowers.
Further, a periodic rotation of the motor/blower shaft was not being accomplished.
This PM might have identified the loss of lubricating oil in the
"A" train CAC blower, a condition which resulted in a
Technical Specifications violation.
During this assessment period, weaknesses in plant material condition contributed to several problems and events.
A resin spill, which ultimately resulted in significant radiation exposures to 'per'sonnel, occurred as a result of the degraded condition of condensate system valves and level switches.
One violation, which involved failure to properly maintain pressure control*valves in the diesel starting air system, could have been avoided had action been taken on a long-standing deficiency.
It was not apparent that the licensee took advantage of the extended refueling outage to improve plant material condition by eliminating a
significant portion of work backlog.
Numerous control room deficien-cies were not addressed, and deficiency tags were common on plant equipment after startup.
Additionally, material deficiencies identified in the CAC system were brought to management attention several times before appropriate action was taken.
The Work Control Group continued to mature and had a positive effect on the performance and timeliness of work.
Contributing to the improvements was the Work Control Manager, formerly a senior reactor operator, appointed early in the assessment period.
However, important work was not always assigned appropriate priority.
For example, MWRs for replenishing diesel generator bearing lubricating oil (when it reached a critical low level) were dispositioned at a
priority which allowed as much as two days for appropriate action to be taken.
2.
Performance Ratin Performance Assessment:
Category
-11-3.
Board Recommendations The licensee should focus attention on plant material condition and address identified problems,=
such as control room deficiencies, in a more timely manner.
Continued emphasis should be placed on the TS
- surveillance program to ensure that all requirements are implemented.
Cont'inued implementation of the RCM program is recommended.
In addition, the licensee should ensure renewed commitment to the procedures improvement program.
D.
Emer enc Pre aredness l.
~Anal sis The emergency preparedness (EP) functional area was assessed during two routine inspections and by observation of two annual emergency preparedness exercises.
Approximately 11X of the total inspection effort was devoted to the licensee's emergency preparedness program.
The licensee received a SALP category 2 rating in this area during the last appraisal period.
The SALP Board at that time recommended increased management aggressiveness and oversight regarding the resolution of deficiencies and weak areas in the EP program.
The, Board also encouraged licensee management to expedite resolution of discrepancies between the Emergency Plan and procedures, and'o fos-ter a more conservative approach to event classification.
A strength identified during the current assessment period was the licensee's work with offsite agencies in the resolution of deficiencies in offsite emergency planning.
No significant weaknesse's were identi-fied during the current assessment period.
Performance during the 1991 emergency exercise generally indicated improvement over 1990.
However, one exercise weakness was identified concerning communications on the emergency notification system (ENS).
It was noted that the ENS communicator in the Technical Support Center did not maintain constant communications via the ENS after such a request was made by the NRC.
This significantly hindered the flow of information between the licensee and the NRC.
A similar situation occurred with the health physics network (HPN) communicator in the emergency operations facility (EOF).
It was also noted that few attempts were made to anticipate and evaluate the consequences of future events which could impact the emergency.
For example, a
concern surfaced during the 1991 exercise regarding the ability of the Meteorology and Unified Dose Assessment Center (MUDAC) to perform timely dose projections based upon plant conditions.
Personnel in.
the MUDAC required prompting by the NRC site and base teams before attempting to project the consequences of an offsite release based upon core damage conditions specified in the FSAR.
Licensee management was normally involved in EP activities and demon-strated support by providing necessary resources to the EP staff for resolution of several offsite planning issues.
During the assessment period, the licensee worked closely with the State of Washington, local governments and the Federal Emergency Management Agency (FEMA)
- 12 in resolving several deficiencies in offsite preparedness planning.
However, two issues remain unresolved.
These issues concern recog-nizing the State of Oregon as part of the 50 mile Ingestion Planning, Zone by direct reference in the Emergency Plan and receiving final qualification of the. alert and notification system from FEHA.
The licensee's approach to the resolution of technical issues was generally conservative, timely, and appeared to be thorough.
Early in the assessment period, it was concluded that the corrective action program was weak in ensuring that the underlying causes of problems would be addressed in a timely manner.
Although the licensee implemented improvements in the corrective action program during the assessment period, the full impact of these changes have not been evaluated.
The licensee continued efforts to resolve discrepancies between the Emergency Plan and procedures identified during the last SALP period.
Two non-cited violations (NCVs) were identified during the period involving failure to submit Emergency Plan changes to the NRC in a timely manner aAd to requalify emergency response personnel in accordance with an Emergency Plan Implementing Procedure (EPIP).
Both NCVs appeared to be isolated occurrences, and corrective actions to prevent recurrence appeared timely and effective.
The licensee had five opportunities to classify and declare emergency events during the current assessment period, all involving Unusual Events (UEs).
The classification of two of these was reviewed during region-based NRC inspections.
The first was on November 4, 1990 when a
UE was declared as a result of unidentified reactor coolant system (RCS) leakage which required shutdown of the plant in accordance with Technical Specifications.
The second occurrence was on November 19, 1991 when a
UE was declared following initiation of an emergency core cooling system.
Both events were properly identified and analyzed in accordance with the Emergency Plan.
Licensee reports and review by the resident inspectors indicated that the other three events, all occurring in 1990, were likewise appropriately classified.
The licensee continued to provide adequate levels of dedicated staff to implement the programs and to interact appropriately with offsite agencies.
A new EP manager was appointed in March 1991.
EP staff and emergency response positions were clearly identified, authorities and responsibilities appeared clearly defined, and key positions were filled in a reasonable time.
Decision making authority appeared properly delegated to ensure quick identification of and response to problems and changes.
Emergency facilities continued to be adequately maintained during this assessment period and readiness of emergency kits was improved.
The licensee's training program for the emergency response staff generally met Emergency Plan comaitments.
Required drills and exercises were conducted during the period to enhance and improve emergency response'kills.
However, during interviews with some of the Emergency Response Organization (ERO) personnel, concerns were identified regarding the working knowledge level of some personnel
- 13-2.
for their ERO assigned positions.
The licensee's response to this concern appears to have been comprehensive; however, the effective-ness of these actions has not yet been evaluated.
Performance Ratin 3.
PerfIormance Assessment:
Category
Board Recommendations The licensee should continue to work on resolution of the outstanding offsite emergency planning issues involving participation of the State of Oregon and qualification of the Alert and Notification system.
The Board also recommends management attention to the reso-lution of or improvement in onsite aspects of the EP program (e.g.,
Emergency Plan and procedures discrepancies, a critical approach to root cause analysis and corrective action, and more aggressive problem solving efforts during exercises).
E.
~Securit l.
~Anal sis During this SALP period, approximately 5X of total direct inspection effort was applied to the licensee's physical security and "Fitness for Duty" programs.
In addition to region based inspections, the resident inspectors also monitored implementation of these programs as part of their routine inspection activities.
Noteworthy strengths include the licensee's Employee Assistance Program, the new security access control building, and the second perimeter fence with associated component upgrades.
A weakness in the F'itness for Duty program, identified by the licensee's gA/gC program, has been lack of continuity in program direction resulting from procedural inconsistencies and high turnover of the program coordinator position.
The licensee recognized this weakness and initiated organizational changes late in the SALP period to improve upper management attention.
The previous SALP report assigned a Category 2 rating for security.
The Board encouraged licensee management to finalize corrective actions to resolve long-standing concerns relative to onsite radio communications, vital area door closure problems, and Regulatory Effectiveness Review fi'ndings.
The Board also noted that management should continue to 'support security program enhancements; e.g.,
ensure that the support facility'onstruction schedule pertaining to security items continued to be met and that replacements for worn or less reliable equipment were procured as soon as feasible.
Finally, the Board noted that communications between security officers and first-line/mid-management should be enhanced to ensure that weak-nesses identified by security officers are properly addressed.
Hajor upgrades were completed during this assessment period, including access control search equipment (to include a new access
control building),
a new perimeter fence and CCTV cameras to improve intrusion alarm assessment, expanded and improved security radio communications, and an ongoing program of task teams (involving representatives from each security shift) to advise management on'otential program or equipment changes.
One 'item identified in the previous SALP period remains open.
An NRC Regulatory Effectiveness Review, conducted-in October 1989, identi-
.
fied a training weakness in tactical response measures.
The licensee has developed a plan incorporating recognition of prime-target vital equipment, upgraded armed response equipment, and deployment'and spe-.
cial tactical training sessions for key response personnel.
Remedial full-squad training, utilizing the recently upgraded perimeter barriers, intrusion detection and alarm assessment aids, and other strategic response measures is scheduled to be 'completed by the end of January, 1992.
Corporate management continued to be frequently and effectively involved in site activities by reviewing the implementation and operation of,the security program.
The tracking and trending of intrusion alarms used new software recently incorporated into the security computer.
Although management involvement in the Fitness for Duty program was initially weak, the licensee's guality Assurance program was particularly effective in identifying program deficien-cies.
Late in the SALP period, the Fitness for Duty program was realigned to provide increased management attention, better communi-cation between the Fitness for Duty and plant security programs, continuity of program direction, and assurance of procedure consistency.
Mith regard to resolution of technical issues, the licensee's approaches were technically sound and thorough in almost all cases.
The recent upgrades of weapons, the new protected area access control building and equipment, and the improved perimeter CCTV assessment system demonstrated deliberate and exhaustive research to effect a
viable engineering solution.
Long-standing problems with onsite security radio communications and vital area doors failing to close properly due to variable air pressure differentials, both originally documented in a 1987 NRC inspection report, hav'e been resolved, although some further equipment enhancements are planned..
No violations or safeguards events (requiring prompt reporting pur-suant to
CFR 73.71)
were identified during the SALP period.
The licensee's safeguards event log items were promptly and completely reported as required.
The licensee's root cause and trend analyses of these events determined that most related to major hardware upgrades then underway.
The frequency of occurrence has exhibited a
decreasing trend as those projects have been completed.
Licensee staffing, with the exception of the Fitness for Duty program, remained effective during this period.
Several security management promotions during the period were implemented smoothly; security guard turnover has also been extremely low.
Key positions have been identified and responsibilities are well define Decision-making authority appears properly assigned to insure prompt identification and response to program challenges.
Recent management initiatives to improve organizational stability of the Fitness for
~ Duty program appear appropriate.
The licensee's guard training and qualification program has been well defined and implemented with dedicated resources.
During this SALP period, the licensee initiated a rotational assignment program for security training instructors and first-line supervisors as a means of providing feedback of experience to all members of the security staff.
While the training programs continued to strive for further improvement, specific licensee efforts -to strengthen training in fitness for duty concepts were noted.
These included upgraded train-ing in the observable effects of drug abuse and the extension of behavioral observation training (required for supervisors)
to all employees.
2.
Performance Ratin Performance assessment:
Category
3.
Board Recommendation
'icensee management is encouraged to pay particular attention to observed weaknesses in fitness for duty management and training.
F.
En ineerin Technical Su ort
~Anal sis During the assessment period, a special motor operated valve (MOV)
inspection and three routine engineering section inspections were conducted.
In addition, resident inspectors regularly monitored the performance of the licensee's engineering organizations.
Engineering inspections constituted IIX of total inspection effort during this SALP period.
Ongoing assessment was also provided by NRR during review of licensing submittals.
The previous SALP Board rated this area Category 2, improving, and recommended that management assess Plant Technical staffing levels and responsibilities.
In addition, the Board encouraged the licensee to aggressively pursue completion of the Engineering Improvement Plan and the Design Basis Document update effort.
Management involvement and oversight during the current period were mixed between good initiatives for improvement and indications of weak oversight.
Licensee management continued to be active in improving engineering quality through their Engineering Improvement Plan (EIP)
and other initiatives.
Weak oversight was indicated by lack of progress in implementing the requirements of Generic Letter (GL) 89-10 regarding motor operated va'1ves.
Other problems indicated a lack of follow-through on identified corrective actions.
Addition-ally, the quality of some technical work, including several submittals to the NRC, indicated insufficient revie A proactive management focus on self-assessment and improvement was considered to be a strength.
The licensee made progress during this period on programs previously initiated.
For example, the design review board was restructured and provided with a written charter.
As a result of these improvements, the number of design changes requiring rework decreased.
Other improvement programs included:
(1) the
CFR 50.59 safety evaluation improvement program; (2)
a configuration management program; (3)
a guality Action Team initiated to provide management with improvement recommendations, and (4)
a system engineer quarterly walkdown" program.
Although most of these programs were too new for results to be gener ally apparent, early inspection findings indicated the licensee to be making progress in these areas.
The extent and significance of engineering weaknesses noted by the HOV inspection indicated that management had not been effective in ensuring that this important program received adequate resources and oversight.
Cognizant members of the licensee's staff also were not aware of related developments within the nuclear industry.
The NOV team found that the licensee had not adequately developed plans and procedures to address the recommendations of GL 89-10, and had not developed an adequate schedule for its implementation.
Additionally, significant deficiencies were noted in work that had been completed, indicating that Engineering needed to be more involved.
Other problems were observed which indfcated that follow-through on identified problems was weak.
One example was the recurring problems noted with bearing oil leakage in th'e Division I emergency diesel generator (EDG).
Although loss of bearing oil caused a catastrophic failure in Hay 1990, oil leakage continued until the 1991 refueling outage, and one instance was observed wherein oil levels were not-being adequately monitored.
Another example involved continuing problems with socket weld failures-(including a number of welds in the high pressure core spray (HPCS) system),
one of which required a
plant shutdown in November 1990.
Several more welds were identified
. as potentially needing repair, but were deferred to the 1992 outage.
One of the deferred welds subsequently failed in November 1991.
With regard to resolution of technical issues from a safety stand-
,point, strengths were noted in management programs for overview of safety such as improved 50.59 reviews and increased review of design changes.
Conservative engineering was noted in the determination of check valve leakage modes, and the licensee pursued in a noteworthy manner the effect of atmospheric conditions on the ability of the standby gas treatment system to maintain reactor building pressure.
However, in some instances, technical reviews were found to be less than thorough.
In the case of the EOPs, the licensee stated that technical, justifications for deviation from the BWR Owners'roup guidelines for accident mitigation strategies were based on engineering judgement; however, supporting calculations or, other engineering documentation did not exist in sufficient depth or detail to support the licensee's positio Weaknesses in licensee submittals also indicated less than'horough technical reviews.
Processing of two related WNP-2 TS amendment requests was delayed due in part to incomplete information, and the licensee did not indicate that one amendment request affected-the-other.
Consequently, both amendment requests required clarification and revision before technical review and processing could proceed.
The 'licensee was also slow. in resolving some outstanding technical issues.
For example, repeated problems have been experienced with safety/relief valve acoustic monitors, which have necessitated four emergency TS changes since 1987.
Prior to this SALP period, the licensee provided the NRC a summary of welds susceptible to intergranular stress corrosion cracking (IGSCC),
and identified those to be inspected pursuant to GL 88-01.
Review of a subsequent submittal, received during the current SALP period, revealed a discrepancy regarding the number of welds susceptible to IGSCC.
This discrepancy was still unresolved at the end of the SALP period.
Upon further review of the licensee's GL responses, the NRC identified a number of miscategorized welds which should have been inspected during a previous refueling outage.
These weld inspections were then scheduled for accomplishment during the 1992 refueling outage, and added significantly to the scope of outage work and the anticipated person-rem exposure.
Three violations and three deviations from licensee commitments were attributed to this functional area during-the assessment period, One Severity Level III violation was identified by the licensee's set-point evaluation program, involving incorrect recycle flow control-lers installed in the containment atmospheric control (CAC) system before initial plant startup, plus inoperability of Train A of the CAC system because of loss of lubricating oil.
A civil penalty was assessed for this violation in early 1992.
While this violation reflected poorly on licensee actions to correct the known problem before initial startup, the licensee initiative which identified the problem was perceived by the Board as a strength.
Two Severity Level IV violations involved inadequate evaluation of a design change to the standby'gas treatment system and late reporting of the CAC flow controller problem discussed above.
The deviations involved failure to meet commitments related to HOVs (in response to GL 89-10), delay in investigating high pressure core spray (HPCS)
system vibration, and improper sizing of HOV motors for degraded voltage conditions.
With regard to operational events, 14 licensee event reports were
,issued during the assessment period concerning engineering issues.
Several of the reports noted design errors which occurred prior to the assessment period, many of which were discovered during engi-neering reviews performed to support the design basis document (DBD)
update program.
The findings included inadequate safety train wiring separation and previously unanalyzed primary containment boundaries.
The reviews which identified these findings were considered to indicate a strong licensee effort to identify safety issues.
The previous SALP Board observed that the inability of the -licensee to address emergent issues could be attributed to the overburdening
-18-of Plant Technical Staff system engineers.
System engineers had responsibility for oversight of their assigned systems, as well as project engineering duties involving design changes, procurement of materials, and the resolution of complex issues.
During this assess-ment period, the licensee's failure to adequately address this weakness contributed to several new problems, such as the recurring
.diedel generator lube oil issue and weaknesses in the NOV program.
In the Engineering Services organization, management made significant changes near the end of the assessment period, such as establishing a
group to respond to and resolve emergent plant problems.
However, the effect of these changes remains to be assessed.
Weaknesses in the training and qualification of system engineers were identified during the assessment period.
Newer system engineers were found to lack an understanding of information systems necessary to keep abreast of system performance.
Near the end of the period, the licensee finalized and implemented a new training and qualification program for. system engineers.
2.
. Performance Ratin r
Performance Assessment-:
Category
3.
Board Recommendation Hanagement should ensure that previously established
'programs receive continued attention to ensure their complete implementation.
Addi-tional attention should be placed on the quality of technical work, including submittals to the NRC.
The licensee should also enhance the capability to address emergent issues through improvements such as those p'lanned for the system engineering program.
G.
Safet Assessment ualit Verification 1.
~Anal sis Approximately 14X of total direct inspection effort was applied to this functional area during the assessment period.
In addition, ongoing assessment was provided by NRR.
A weakness observed in this functional area, in several instances, was the failure of management to address identified problems in a timely manner.
This weakness contributed to the'repeat occurrence of some events and breakdo'wn of some programs, most significantly the licensed operator requalification and EOP programs.
In addition, reportability evaluations-were i'n some cases untimely or inaccurate and some LERs provided poor root cause assessments.
The activities of the oversight organizations, such as the Operating Experience Assessment (OEA) organization,, the Technical Assessment (TA) organi-zatio'n, and the Quality Assurance (QA) audits group, made positive contributions to safety.
However, management of the quality organi-zation failed on several occasions to focus resources at likely problem areas and missed opporturiities to identify significant problems.
Additionally, recommendations and observations of the
-19-oversight organizations were at times tempered by insufficient management follow-through, or appeared not to have been forcefully brought to the attention of line management for correction.
This functional area was rated Category 1 during the previous assess-ment period.
The Board encouraged licensee management to sustain the momentum achieved in this area and to maintain an aggressive attitude in identifying plant problems.
The Board also recommended that the licensee maintain their commitment to the root cause analysis program, the problem evaluation request (PER) process, and the resolution of identified problems.
During this SALP period, licensee management was slow to accept and address significant weaknesses in operator communications, command and control, and procedural compliance.
Similarly, management was slow to acknowledge and improve weaknesses in the technical adequacy and usability of EOPs.
Although the EOP team identified weaknesses in September 1990 and EOPs contributed to failure of the licensed operator requalification program in February 1991, adequate resources and management leadership were not clearly focused on the problem until mid-1991.
Other significant areas were identified by the NRC that indicated
.excessive isolation from the industry, insufficient management atten-tion, and weak follow-through on safety issues.
The weaknesses in the GL 89-10 HOV program appeared to stem from a failure of licensee management to adequately assess its progress and provide necessary resources to ensure a quality product.
Similarly, management was apprised by the inspectors several times of CAC system configuration control deficiencies before a comprehensive evaluation was performed.
A late report to the NRC on another deficiency which affected the operability of both trains of the CAC system apparently resulted from inadequate management follow-through.
The PER process, which identifies problems and provides 'for resolu-tion of them, continued to function well.
However, continuing problems were observed in the implementation of corrective actions.'
lack of timeliness was often observed and a significant backlog of corrective actions existed.
As evidenced by some repeat events, related corrective actions either had not been fully implemented or were ineffective in precluding recurrence.
One example of this was the 100X load rejection and resultant reactor scram in December 1990.
An identical event which had occurred approximately two years earlier apparently received insufficient corrective action.
Another example,
.
wherein more aggressive corrective actions could have prevented an unplanned shutdown involved socket weld failures in the HPCS system.
Had corrective actions planned following weld failures in November 1990 been fully implemented during the 1991 refueling outage, a weld failure in November 1991 could have been avoided.
The, licensee's quality assessment organizations demonstrated the capability to make a positive contribution by continuing to identify significant issues in several functional areas.
The recommendations provided by the OEA organization based on evaluations of events at
- 20 -,
other, plants.were consistently implemented in a timely manner.
The TA organization continued to conduct meaningful safety system func-tional inspections (SSFIs)
such as the assessment of the standby service water system, which identified approximately 70 significant findings.
A number of significant problems-were also identified by audits and surveillances conducted by the gA organization, although a
significant backlog of corrective actions remain.
Management demonstrated a commitment to quality by hiring a consultant to review several complex processes, such as maintenance work and the PER process, to identify.inefficiencies and duplication of effort.
At the end of the assessment period, the licensee was reviewing the recommendations. of this study.
Weaknesses in reportability evaluations were apparent during the latter portion of the assessment period.
For example, the.fact that a drywell personnel airlock leakage test had not been performed in the time period required was initially evaluated as not reportable, even though the TS clearly indicated that it was.
Also, the licensee's setpoint eva1uation program determined in August 1991 that the CAC system has had the wrong type of recycle flow controllers installed since before initial plant startup, rendering the CAC system inoperable.
However, the reportability evaluation for this issue took almost three months to complete, an excessively long period of time.
Weaknesses were also observed in the assessment of certain events reported in LERs.
Events dealing with the Containment Instrument Air (CIA) system early in the assessment period were an example of this.
Hanagement staffing problems also appeared to have an adverse impact on the licensee's ability to address the requalification and EOP program deficiencies.
During this critical time, the Deputy Managing Director was also acting as Assistant Managing Director for Opera-tions and the Nuclear License Training Manager was virtually absent for several months due to other duties.
This appeared to contribute to the insufficient oversight which led to breakdowns in the EOP pro-gram, the operator license requalification program and implementation of commitments concerning the HOV program.
The licensee was'low to address this lack of leadership.
Much root cause analysis training was administered to the plant staff, as well as enhanced training to the oversight group personnel.
The root cause analyses conducted by the licensee continued to improve"and mature.
They were conducted routinely by various ele-ments of the plant staff, but are the primary responsibility of the OEA group.
Management personnel. associated with the oversight groups visited other plants considered to be superior performers in the area of safety and assurance, as a learning experience.
No violations occurred during this assessment period that were directly attributable to activities associated with this functional area.
However, a number of findings were identified by the NRC that indicated insufficient aggressiveness and involvement on the part of the various oversight organizations.
Examples included findings
-21-related to diesel generator starting air, standby gas treatment, and diesel generator bearing oil.
2.
Performance Ratin Performance Assessment:
Category
I 3.
Board Recommendations Strong leadership is needed in senior management and safety oversight organizations to stay abreast of industry issues, assure a self-critical approach to improving performance, and aggressively seek to identify areas of weakness.
management should evaluate its efforts to resolve previously identified problems and to ensure that effective corrective actions are taken in a timely manner.
The licensee should also assess their program for evaluating potentially reportable events.
guality management should foster an attitude of the quality organizations aggressively seeking out significant prob-lem areas, and then forcefully bringing issues to senior management.
IV.
SUPPORTING DATA AND SUMMARIES A.
Licensee Activities September 1,
1990 The licensee entered the assessment period with the plant at full power.
The plant,operated nominally at full power during the SALP period except as follows:
September 25, 1990 Operators manually scrammed the plant following main turbine hydraulic control oil problems, caused by a broken pipe nipple in the turbine lube oil system.
November 2, 1990 December 7,
1990 April 12, 1991 September 26, 1991 Operators initiated a manual scram and declared an Unusual Event because of a crack in a high pressure core spray (HPCS)
system drain line.
An electrical fault caused a main turbine/generator trip and a subsequent reactor scram.
The fault resulted from buildup of cooling tower chemical deposits on main transformer insulators.
The plant was shut down for refueling (7 days earlier than planned) after the Division I EDG was declared inoperable because of apparent high concentrations of wear particles in a bearing oil sample.
The licensee subsequently determined that the diesel generator bearings had not been damaged and that the contamina-ti,on was residual from the 1990 bearing failure.
The plant entered Operational Condition 1 (power operation)
following its extended outage, which was extended approximately 3 months because of operator requalification program failure October I,:l991 The plant was shut down to repair turbine generator control system problems and steam leaks.
November 1,
1991 The plant shut down to repair.a condenser tube leak.
November 4, 1991 I
During plant restart following repair of the condenser tube leak, operators observed a small leak in an RHR drain line weld.
The leak was considered reactor pressure boundary leakage, requiring a plant shutdown and the declaration of an Unusual Event.
November 19, 1991 A feedwater control system malfunction caused a high reactor pressure vessel level turbine trip.
Following the turbine trip, feedwater pump trip, and reactor scram, RPV level shrank to the low level emergency core cooling system actuation setpoint.
An Unusual Event was declared in accordance with procedures.
B..
Ins ection Activities Fifty-three routine and special inspections were conducted during this assessment period (September 1990 through December 1991)
as listed below.
1.
Ins ection Data.
Inspection reports 90-17, 90-20, 90-21; 90-25 through 90-31, 91-01 through 91-05, 91-07 through 91-19, 91-21 through 91-28, 91-30 through 91-42, 91-44, 91-45, 91-47 and 91-48.
Seven of these reports documented management meetings and one documented an enforcement conference.
2.
S ecial Ins ection Summar Special inspections included the following:
91-16 Hay 20 - June 21, 1991:
A review of the licensee's Generic Letter 89-10 program for safety related motor operated valves 91-27 July 30 - August 27, 1991:
A followup review of Emergency Operating Procedures 91-37 September 5 and 6, 1991:
Temporary Instruction 2515/112; licensee evaluations of changes to the environs 91-44 October 20 - December 1,
1991:
Review of several problems related to maintenance and operation of the CAC system C.
Enforcement Activit Inspections during this period identified 25 cited violations.
One of these, involving extended inoperability of the containment atmospheric control system, was categorized as a Severity Level III violation and resulted in the issuance of a civil penalty early in 199 D.
Confirmator Action Letters A confirmatory action letter, regarding the unsatisfactory licensed operator requalification training program, was issued on March 15, 1991.
Revisions. were issued on March 25, April 15, and June 14.
E; Licensee 'Event Re orts-Fifty LERs (90-17 through 90-32 and 91-01 through 91-34) were issued during this assessment period.
No security LERs were issued.