IR 05000397/1996202

Corrective Actions Insp Rept 50-397/96-202 on 970128-0206. No Violations Noted.Major Areas Inspected:Operations,Maint, Engineering & Plant Support

ML17292A824
Person / Time
Site:	Columbia
Issue date:	04/23/1997
From:	NRC (Affiliation Not Assigned)
To:
Shared Package
ML17292A823	List: IR 05000397/1996202 ML17292A822
References
50-397-96-202, NUDOCS 9704250241
Download: ML17292A824 (73)

Text

U.S.

NUCLEAR REGULATORY COMMISSION OFFICE OF NUCLEAR REACTOR REGULATION Docket No.:

License No.:

Report No:

Licensee:

Facility:

Location:

Dates:

Inspectors:

Approved by:

50-397 NPF-21 50-397/96-202 Washington Public Power Supply System Washington Nuclear Project

Richland, Washington January 28 February 6, 1997 T. Foley, Inspection Team Leader, NRR G. West, Jr.,

NRR J.

Isom, NRR T. Pruett, RIV Donald P. Norkin, Section Chief Special Inspection Branch Division of Inspection and Support Programs Office of Nuclear Reactor Regulation 970425024i 97042$

PDR ADQCK 0500039'7

PDR

I

TABLE OF CONTENTS PAL CU I jE SIJs'iWRY o

~

~

o

~

~

~

~

~

~

~

~

~

~

~

~

~

~

o

~

~

~

I ~ Operate ons

~

e

~

~

o

~

~

~

~

~

~

~

~

~

~

~

~

~

~

~

~

o

~

~

~

~

Conduci; of Onerations...................

01. 1 Problem Identification 01.2 Corrective Action Implementation and Effectiveness

~

~

~

03 Operations Procedures and Documentation

.

03. 1 Root Cause Analysis and Evaluation 03.2 Licensee Event Reports 03.3 Self-Assessment Programs

~

~

~

~

gualii:y Assurance in Operations

.

.

.

.

.

.

.

.

.

.

.

.

.

.

II. Maintenance

.

Hl Conduct of Maintenance Hl. 1 Problem Identification H1.2 Root Cause Analysis and Evaluation H1.3 Observation of Activities During Inspection

~

~

~

~

~

~

~

~

~

~

9

20 III.

Engineering

.

-

Engineering Support of Facilities and Equipment

.

.

.

.

.

.

E2. 1 Problem Identification E2.2 Root Cause Analysis and Evaluation E2.3 Corrective Action Implementation and Effectiveness E7 guality. Assurance in Engineering Activities E7. 1 Self-Assessment Programs IV. Plant Support

.

Xl Exit Meeting Summary APPENDIX A - LIST OF OPEN ITEMS

.

APPENDIX B ACRONYMS AND ABBREVIATIONS.

APPENDIX C LIST OF ATTENDEES R7 guality Assurance in Radiological Protection and Chemistry Activities R7. 1 Problem Identification R7.2 Root Cause Analysis and Evaluation R7.2. 1 Root Cause Analyses Performed by gA

.

.

.

.

.

R7.2.2 Corrective Action Review Board (CARB)

.

.

.

.

R7.3 Corrective Action Implementation and Effectiveness R7.4 Self-Assessment Programs in guality Assurance

.

.

.

.

21

23

26

27

27

30

31

35 A-1 8-1 C-1

EXECUTIVE SUHHARY This integrated corrective actions inspection at WNP-2 was performed in accordance with Inspection Procedure 40500, and focused on aspects of licensee operations, maintenance, engineering, and plant support, including safety assessment and quality verification.

The inspection also examined self-assessment and quality assurance programs designed to identify and resolve problems through the corrective action program.

The corrective action process corrected most immediate equipment problems, resolved most significant issues promptly and was generally effective.

Tracking of issues and trending of problems using cause codes helped identify adverse trends,:

The use of problem evaluation requests (PERs),

work requests, gold cards,

'and some informal means addressed most deficiencies.

However, the program was reactive to issues that had recurred or gained management attention, rather than being proactive to preclude issue recurrence.

(Sections E 2. 1 c; 0 1. I c; M 1. 1 c)

Sometimes, the problem evaluation process did not identify or correct the underlying causes of problems to prevent their recurrence, and one cause analysis was not performed as required.

(Sections 0 3. 1 c; M 1.2 b; E 2.2 c)

Sometimes the implementation of corrective actions was not timely, and more often, the corrective actions were limited to individual problems rather than broadly applied to related equipment or human performance issues.

(Section H

1.2 b and R 7.,4 c)

guality Assurance has had mixed results in identifying issues.

Some audits provided positive indicators to management even though the plant was experiencing repetitive problems with procedural adherence, clearances, switch and valve mispositioning, and nonconformance to technical specifications.

(Sections 0 7. c and R 7.4 b)

The licensee's August 1996 performance self-assessment, which. produced a

particularly critical and comprehensive audit, was a significant improvement over previous self-assessments.

(Section E 7. 1 c)

Management's review and handling of all significant PERs and reviews conducted by the Corrective Action Review Board (CARB) appeared to be a principal contributor to acceptable root cause analysis.

The 90-percent rejection rate of root cause 'analyses presented to the CARB and the numbers of recurring events demonstrated fundamental weaknesses in the line organization's ability to determine root cause.

(Section R 7.2.2 b)

Conduct of Operations Ol.l Problem Identification

~Re ort Details

~t.

tl

'a ~

Ins ection Sco e

40500 b.

Using Inspection Procedure 40500, the inspectors reviewed the corrective action programs in the Operations area.

They interviewed selected Operations personnel including:

the acting operations manager (AON), the assistant operations support manager, two equipment operators, and an administrative specialist.

An inspector observed the watch-standing tours with the two equipment operators to assess their threshold for problem identification and their use of the corrective action process.

Observations and Findin s

The operators used PPN 1.3. 12,

"Problem Evaluation Request,"

to implement the problem identification process for hardware, procedures, programs, and personnel performance deficiencies.

A desk top instruction, the "Gold Card Program,"

was used to implement the problem identification process for "personnel problems" that do not cause undesirable consequences.

Proper use and negative use/misuse of gold cards in Operations are tracked and trended on a monthly basis.

Each gold card is binned into one of 36 human performance cause codes.

The 1996 data regarding gold card "misuse" was as follows:

self-check (50 items), effective communications (32 items),

ownership accountability (32 items),

procedure adherence (23 items),

questioning attitude (13 items), conservative decision making (6 items),

and pre-evolution briefs (2 items).

The ratio of proper use to misuse relative to the human performance cause codes for 1996 was 4.6 to 1.

The operators used Revision 8 to PPN 1.3.7A, "Initiating.a Work Request,"

to implement the problem identification process for a broke/fix type problem that did not cause undesirable consequences.

Supervisors used Revision I to Operating Instruction 9 (OI-9),

"Expectations for Supervisory and Peer Oversight,".to observe operator performance and operators used it to observe other operators'erformance.

The AON stated that OI-9 served as an oversight function rather than as a problem identification function.

The AON indicated that OI-9 observations usually average about 500 per month.

He also noted that feedback to

)h

C.

Operations personnel is

.i-. i.edi.".:.te and informal in order to make the issu~ personally rel.vant

-:;- the individual.

The inspector interviewed two equipment operators and accompanied them during their rounds..

During the rounds, the equipment operators called their supervisor when problems were identified

-'but took action to initiate wor k requests for problems that necessitated work requests.

Although anyone is permitted to

'nitiate a

PER, equipment operators report problems to their supervisors rather than independently initiate a PERs.

This was consistent with PPM 1.3.12 which states:

"Any individual discovering a potential condition or event adverse to nuclear safety, plant reliability, or quality should:

Ensure the CRS/Shift Manager...is notified immediately..."

It was noted that the equipment operators do initiate work requests independently.

Conclusions The problem identification programs in the Operations area are effective.

The licensee's PER program, the gold card program, the OI-9 observation program, and the work request program were effective in identifying problems.

01.2 Corrective Action Im lementation and Effectiveness

'a ~

Ins ection Sco e

40500 PPM 1.3. 12A, "Processing of Problem Evaluation Requests" states that a significant PER is an event or condition which results from equipment failure, program failure, or inappropriate actions and has an undesirable impact on plant safety, personnel safety, plant reliability, power production, or regulatory position.

The inspectors evaluated the implementation and effectiveness of corrective actions for significant PERs 297-0101, 296-0559,

-0519,

'-'308, 0285, and 295-0729 based on requirements in PPH 1.3.12,

"Problem Evaluation Request (PER)" and PPM 1.3. 12A; "Processing of Problem Evaluation Requests."

b.

Observations and Findin s

The corrective actions were either implemented or planned for PERs 297-0101, 296-0516,

-0558, and -0559, and 295-0729, and generally met the licensee requirements and the evaluation guidelines.

PERs 296-0308 and 0285 were designated as significant by virtue of their being associated with adverse trends and were further investigated.

Clearance Orders.

PER 296-0308, which was originated on April 29, 1996, identified an adverse trend relative to 12 PERs associated with clearance orders and tagging.

The inspectors identified 15 additional PERs associated with clearance orders and tagging that

were initiated between Hay 1, 1996 and February 3, 1997.

The

PERs were:

PERs 296-0351,

-0362, -0364, -0382,

-0415, -0428, 0497,

-0537, -0650, -0775, and -0832; and 297-0016,

-0070,

-0071, and -0073.

Of these, 6 were relevant to failure to self-check prior to beginning work.

PERs 296-0428 and -0364 concerned a work order that was worked without personnel signing on to the required clearance order.

PER 296-0497 involved a low level condition in the main condenser hotwell due to an inaccurate clearance order.

Second level and supervisory review failed to detect the error allowing the clearance order to be hung.

PER 296-0650 involved a

laborer who cleaned sump T-2 before the work request reached a

status that authorized work to begin.

PER 296-0351 dealt with a tagging error that resulted in tagging pump EDR-P-17B instead of the required pump EDR-P-18A.

PER 296-0415 dealt with three clearance orders being required to perform work; however, only one w'as hung prior to working the jobs.

Valve and Switch His ositionin

PER 296-0285 was associated with an adverse trend on valve and switch mispositioning that was identified in 1995.

The surveillance audit 296-071 associated with this'PER indicated that the adverse trend had not continued past September 1996.

For the period October 1,

1996, to February 3,

1997, the inspectors found the following examples of valve and switch mispositioning:

~

SPER 297-0071 (RHR-V-176B found open resulting in loss of primary containment integrity.)

~

PER 297-0035 (DG trip due to switch in wrong position.)

~

PER 297-0055 (Control rod drive found out of position.)

~

PER 296-0711 (Invalidated)

(While performing surveillance steps it was noted that CRD-V-157D, which is normally closed and capped, was partially open (I/2 turn).)

Gold Card 4582 (During a release of tagout 96100081, the tag for air isolation valve was missing and valve was open:

clearance order designated valve closed.)

Gold Card 4774 (EO failed to review the procedure which required minimum flow valve control from close to normal:

the valve on running pump stayed closed.)

Gold Card 4744 (CO-V-2A found out of normal valve lineup.)

The inspectors noted that

CFR Part 50, Appendix B, Criterion XVI, requires that measures be established to assure that conditions adverse to quality such as failures, deficiencies and malfunctions are promptly identified and corrected, and in the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and

4'

~

corrective action taken to preclude repetition.

PPH 1.3,48 requires that adverse PER trends be treated as significant.

3oth the clearance orders and valve and switch mispositioning issues provide numerous examples where the long-term corrective actions for problems were ineffective, apparently due to previous superficial root cause analyses, and subsequently failed to preclude repetition.

Additionally, the licensee'id not identify the 15 inspector identified clearance order examples and

inspector identified valve and switch mispositioning examples above as a significant adverse trend as required by PPH 1.3.48.

c.

Conclusions The above clearance order issue, and valve and switch mispositioning issue provide examples where corrective actions for a previously identified significant condition adverse to quality failed to preclude repetition of the condition adverse to quality, and also an example of not identifying a significant condition adverse to quality.

This is one example of unresolved item (URI 50-397/96-202-01)

Operations Procedures and Documentation 03. 1 Root Cause Anal sis and Evaluatio

'a ~

Ins ection Sco e

40500 b.

The inspectors evaluated the following significant problem

,evaluation reports (PERs) in regard to root cause analyses that were issued in calendar year 1996 and that were assigned to Operations to handle or that were related to operational issues but were handled by another department:

PERs 296-0559, -0519,-

0308, and -0285.

The inspectors evaluated the licensee's root-cause analyses against PPH 1.3.48,

"Root Cause Analysis."

Observations and Findin s

r The root cause analysis for PER 296-0559 conformed to the licensee's procedural requirements.

The root cause analysis had several strengths which included identifying and analyzing related events.

However, PERs 296-0519 and -0285 were not consistent with plant procedures as follows:

PER 296-0519 was significant because it identified a negative trend involving PERs 296-0445,

-0487,

-0495, and -0514 that documented errors in operating mode changes and Technical Specification surveillance requirements.

The root cause analysis for these PERs indicated that the main technique to be used would be "cause and effect" analysis.

Revision 6 to PPH 1.3.48,

"Root Cause Analysis," states:

"Avoid stopping too soon in the cause and effect analysis.

When an apparent root cause has been

C.

determined, ask at least two more why questions to assure that generic issues have been addressed.

If ihe '.nalysis is ')ot deep enough, the apparent solution may not preveni; recurrence."

The root cause analysis for PER 296-0519 failed to provide sufficient depth and stopped at the following level of analysis:

"Plant procedures were not effective barriers..."

and "Personnel experience and training were not an effective barrier in all these events'."

The root cause analysis would have been more effective had it asked why at least two more times as required by PPM 1.3.48.

Areas such as individual experience or training and procedure effectiveness were not explored.

In addition, the root cause analyses had the following weaknesses:

(I) limited discussion of previous similar events,and corrective actions, (2) no discussion of followup verification within a specified period of time to determine if any additional events of. this nature have occurred, and (3) no discussion of a rationale for terminating the root cause analysis.

During the root cause analysis for PER 296-0519, the cause analysis required by PPH 1.3.48 stopped after the identification of the cause code, and the analytical discussion did not reflect the two more why questions to assure that generic issues have been addressed.

This lack of questioning resulted from the failure to follow procedure PPH 1.3.48 and is considered unresolved (URI 50-397/96-202-02).

PPM 1.3.48 states that significant PERs should receive a root cause analysis.

In the case of PER 296-0285 a cause analysis was not performed but the analyst compiled a trend of the original cause codes associated with the PERs th'at were the subject of the adverse trend that was being evaluated.

This is an additional example of failure to follow procedure PPH 1.3.48 (URI 50-397/96-202-02).

Conclusions Some of the root cause analyses handled by, Operations lacked depth of inquiry to determine the underlying cause(s)

and one root cause analysis was not performed as required.

The two examples of failing to comply with PPM 1.3.48,

"Root Cause Analysis;" by not performing an analysis as required and stopping too soon, in the cause and effect analysis are collectively unresolved item (UNR 50-397/96-202-02).

03.2 Licensee vent e orts a ~

Ins ection Sco e

The inspectors reviewed the following LERs that involved Operations-related issues:

96-006,

-005, -004, and -003; and 95-010.

The inspectors assessed whether the LERs met the requirements of 10 CFR 50.73, PPM 1.3.48 and assessed the consistency between the LER and its applicable PE b.

Observations and Findin s

C.

All of the LERs reviewed were consistent with their associated PERs relative to the information that was discussed.

LERs96-006 and -004, and 95-010 met the requirements of 10 CFR 50.73 with respect to submitting the LERs within 30 days, description of what occurred, assessment of the safety significance, immediate corrective actions, and actions to prevent recurrence.

The root cause analysis for LER 96-005 (and its associated PER 296-0514)

and LER 96-003 (and its associated PER 296-0495) did not fully conform to PPH 1.3.48.

(also see section 03.l.b).

Areas such as individual experience or training and procedure effectiveness were not explored.

In addition, the root cause analysis and associated immediate corrective actions for LER 96-003 (PER 296-0495)

were ineffective in precluding the occurrence of LER 96-005 (PER 296-0514).

LER 96-005 involved a failure to verify average power range monitor flow signal channel functionality on a daily basis (i.e., omitted on June

and 23, 1996) per TS 3.3. 1.

Similarly, LER 96-003 involved a failure to verify that recirculation system loop flow balance was initiated (i.e., omitted on June 13, 1996)

per TS 4.4. 1.3).

Conclusions With the exception of the weaknesses associated with LERs96-003 and -005, the requirements of 10 CFR 50.73 were met.

The lack of depth in the root cause analysis for LERs96-003 led to recurrence of failures to conduct TS surveillance tests as identified in LER 96-005.

The weaknesses discussed above regarding the failure to meet TS requirements were previously identified in NRC Inspection Report No. 50-397/96-19.

03.3 Self-Assessment Pro rams a 0 Ins ection Sco e

40500 b.

The licensee's self-assessment of Operations was evaluated.

The longstanding issues identified in the licensee's

"WNP-2 Performance Self-Assessment (PSA)," August 1996, that had'not been resolved were evaluated.

Observations and Findin s

Control Room Deficiencies:

The PSA indicated that too many control room annunciators and other equipment are out of service following a maintenance outage, some since 1991.

The number of control room deficiencies in August 1996 were:

26 non-outage deficiencies with the average age of 48 days and 28 outage deficiencies.

The number of non-outage deficiencies as of January 20, 1997, was about 25 deficiencies with the average age of 35 days:

the licensee has a goal of 20 non-outage deficiencies or better.

The assistant operations support manager (AOSM) reported

that the plant came out of the last R-11 refueling outage with

outage item (and the goal for the R-12 refueling outage is

items).

0 erator Workarounds:

The PSA indicated that there were about

plant deficiencies categorized as operator workarounds with scheduled resolution dates and 4 without resolution dates.

Sixteen items were determined to be non-workarounds and were assigned to system engineering for resolution.

The 4 workarounds without resolution dates (and their status)

are as follows:

~

Dampers REA-AD-8 and ROA-AD-19 currently do not conform to NRC Bulletin 80-'6 in that the dampers do not remain closed upon reset of the contacts.

~

DG room HVAC systems not capable of maintaining room temperatures during adverse weather co'nditions:

temporary fix was to use portable space heaters powered by welding outlets (technical evaluation has been written by system engineering).

~

SEAL-IN function (i.e.,

no throttle capability) for six valves (MS-V-105 A & B, MS-V-108 A & B, SS-V-22A, and BS-V-22B) require an operator to be stationed at the breaker to allow jogging of the valves.

Technical Evaluation reports (TERs)

have been completed and the licensee stated that the level of effort on this item could be stepped up in priority at the discretion of Operations.

'

Control room noise:

On low reactor pressure vessel level, which has only occurred once, the Halon system loses electrical power, causing trouble alarms (audible) in panels

,in the control room.

Fire protection engineering is exploring a short-term fix and this item is part of the long-range plan for FY 98 and FY 99.

Clear nce Ordersi The PSA indicated that Operations had 31 active clearances over 1 year old.

The inspectors found that about

clearance orders had been closed subsequent to the 1996 PSA.

Tem orar Modifications:

The 1996 self-assessment indicated that too many temporary modifications existed following the maintenance outage in 1993.

Currently, the licensee has 10 temporary modifications.

The AOM indicated'that the current goal is

temporary modifications.

Of the 10 temporary modifications, 7 are expected to be closed during the R-12 refueling outage or sooner.

The inspectors found that no recent self-assessments had been performed by Operations.

The Operations Department is focusing on addressing those items from the 1996 self-assessment.

The

operations support manager stated that Operations has 4 self-assessments planned for 1997.

c.

Conclusions Operations is improving relative to the longstanding issues identified in the 1996 self-assessment.

guality Assurance in Operations a.

Ins ection Sco e

40500 b.

The inspectors evaluated the effectiveness of guality Assurance (gA) in conducting audits relevant to operational issues.

Specifically, the inspectors evaluated gA 296-079,

"WNP-2 Conformance to Technical Specifications and-License Conditions,"

and gA audit 296-071,

"Valve and.Switch Configuration Control Problems."

Observations and Findin s

gA audit 296-079, which was conducted between November 4 and 22, 1996, indicated that WNP-2 is being operated and maintained within the requirements of the Technical Specifications and license conditions.

The audit was not conducted during startup and shutdown, a time when there would be a greater probability that TS non-conformance might occur.

For example, while shut down between June 2 and 24, 1996, four PERs were written documenting errors in operating mode changes and TS surveillance requirements.

gA audit 296-071, which was conducted between September 16 and 24, 1996, stated that the negative trend in the number of valve and switch mispositioning problems, as reported by PER 296-0285, has not continued past the first quarter of 1996.

However, from October 1996, to February 1997, the following 7 examples of valve/switch mispositioning occurred:

~

.

SPER 297-0071 (RHR-V-176B was found open, resulting in loss of primary containment integrity.)

~

,

PER 297-0035 (DG tripped because a switch was in the wrong position.)

PER 297-0055 (A control rod drive was found out of position.)

PER 296-0711 (invalidated)

Gold Card 4582

I

~

Gold Card 4774

~

-

Gold Card 4744 C.

The 1996 self-assessment stated that weaknesses were noted in the gA audit process.

This self-assessment reflected an improving trend in the gA problem identification process (Section R 7.4 c).

Inspectors evaluated whether gA had significant findings (i.e.

issued a

PER related to its findings) subsequent to the 1996 self-assessment for the following gA-initiated issues:

surveillance reports 296-056 (Rey. 1), -057 (Rev. 1),

and -085; NSAD Monthly Report 296-084; and audit report 296-064.

gA audit. 296-064 and surveillance report 296-0057 (Rev.

1) resulted in PERs.

Surveillance report 296-085, NSAD Monthly Report 296-084, and surveillance report 296-056 did not identify any significant problems which met the threshold for a PER.

Conclusions With regard to audit 296-079, guality Assurance was not conducted at the appropriate time for identifying operational issues regarding TS.

Subsequent to audit 296-071, it appears that the trend in the number of valve and switch mispositioning problems has continued.

Overall, guality Assurance has shown mixed results in identifying issues that result in PERs subsequent to the 1996 self-assessment.

II. Maintenance Ml Conduct of Maintenance Ml. 1 Problem Identification Ins ection Sco e

40500 b.

The inspector reviewed documents, spoke with maintenance personnel and observed planning and scheduling activities to evaluate the work control process, work request screening, and problem evaluation process.

The inspector spoke with the assistant maintenance manager regarding the'work control 'process; planning, scheduling, problem identification, evaluations (including root cause analysis),

and correction; the preventive-maintenance program; clearance orders; performance indicators, including trending, audits, and self-assessments; minor maintenance; the maintenance rule program; and use of gold cards.

Observations and Findin s

Plant-related maintenance work is scheduled and controlled in accordance with,procedure PPM 1.3.7,

"Work Management-Passport

Process."

Attachments A-J to the procedure addressed the work

.

~<control process, such as emergency maintenance, planning, scheduling, and generation of work documents.

Plant hardware deficiencies are identified primarily by equipment operators and maintenance personnel.

The process for reporting deficiencies is documented in procedure 1.3.7, Attachment A,

"Initiating a Work Request."

All work requests are immediately routed though the control room shift supervisor for approval and then through a prioritization review group.

Work requests are evaluated for PER criteria both by the shift supervisor and at the prioritization review group.

In daily meetings, plant manager/department heads review all potential PERs prepared during the previous two shifts for significance.

Pl-.nning, scheduling, and outage management organizations schedule daily work on the basis of the rolling 12-week schedule for corrective and preventive maintenance.

The daily schedule process also has elements for immediately scheduling emerging work and identifying limiting conditions for operation that were dependent on the Maintenance organization for resolution.

The process also includes daily meetings to coordinate and monitor work.

Daily turnover meetings are conducted between the operations shift manager and a designated work control representative.

The inspector observed that valuable information was exchanged between work control and operations personnel.

Work requests generated the previous day which have been approved and emergent work are discussed at work control meetings.

Work control representatives gain (I) information they need in order to integrate emerging work into the existing schedule and (2) information regarding resource management.

Meetings are conducted between scheduling and shop supervisors to identify support needed by maintenance personnel to accomplish scheduled and emerging work.

A,revised maintenance schedule is published daily.

This schedule supports the daily work control meeting attended by representatives from each department.

During these meetings, attendees exchange information regarding work not accomplished as scheduled, emergent work, and task priority.

Each task performance group representative informs the other attendees of support that is needed from other group~uch as clearances, lineups, and radiological protection coverage.

The inspector noted that the Maintenance Department trends non-outage and total work orders, work orders by group (mechanical, electrical, instrumentation and coritrol, and the "fix it now" (FIN) team; work orders more than 90 days old (approximately 25X);

preventive maintenance; repetitive equipment deficiencies; surveillance testing; personnel errors; procedural errors (PERs);

gold card observations; specific corrective action program progress (i.e., control room deficiencies);

and many other indicators of performance.

Host performance indicators in the Maintenance Department, although somewhat high, were trending in a positive, conservative direction.

c ~

The inspector noted that Maintenance gold cards were being tracked as either positive or negative observagions and that there were about eight positive observations for every negative observation.

The. tracking did not provide a manner by which negative observations could be trended by issue, or in a manner which would ensure that corrective actions would be tracked to completion.

The Maintenance representative indicated that the gold card process requires that the gold cards be evaluated for PER criteria and if met, the issue would be placed in the PER corrective action process.

The inspector noted that the guality Assurance department tracks problem identification cause codes and identified 12 adverse trends associated with PERs during 1996.

Four adverse trends (cranes and hoist, wire. termination problems, failing to return stack monitor to service, and HPCS HI drywell pressure initiation)

were associated with maintenance.

About 120 PERs are associated with.work practices and about 115 with written procedures.

Although these are not specific to the Maintenance Department, most were attributable to either Maintenance or Operations.

The cause coding system appears to be beneficial in identifying trends.

Conclusions The maintenance process for identification of deficiencies is well documented and controlled, and appears to be functioning effectively.

The Maintenance Department, along with gual.ity Assurance tracking and trending PERs, effectively identifies and trends plant deficiencies.

The process of cause coding is a

positive attribute.

However, the use of gold cards does not ensiire that undesirable conditions identified on gold cards will be corrected, or are incorporated into a system used to identify adverse trends by cause code.

Hl.2 Root Cause Anal sis and Eva at o

Ins ection Sco e

40500 The inspectors evaluated significant PERs in regard to root cause analyses that were issued during calendar years 1995 and 1996 and assigned to Maintenance to solve or that were related to main'tenance issues but handled by another department:

Numerous PERs, as identified below, wer e reviewed.

The inspectors

evaluated the licensee's root cause analyses against PPH 1.3.48,

"Root Cause Analysis."

Observations and Findin s

AC Standb Circulatin Lube Oil Pum ":

On February 18, 1996, the motor-pump coupling for the ac standby circulating lube oil pump DLO-P-382 failed (PERs 296-0119 and -0519).

This is a safety-rel'ated pump.

Its unavailability caused emergency diesel generator DG2 (EDG) to trip on February 20, 1996 (PER 296-0122).

Its function is the motive force to supply heated lube oil to the ehgine during initial startup.

The engine vendor has stated that when the lube oil is warmer than 85 'F, the EDG will fast start in less than 10 seconds, implying that if,the EDG is not supplied with the warm oil (>85 'F), the engine may not start within 10 seconds.

These motor pump couplings failed just two months earlier (PER 296-,0007).

Additionally, these pump couplings failed three times before 1991 and three 'times in 1991.

As a result of the rash of failures in 1991, NDR 291-739 was prepared, identifying the root cause of these failures to be misalignment, system interaction, and material deficiency in the coupling.

The corrective actions consisted of performing various alignment ch'ecks frequently, in'stalling flexible hoses between the pump and surrounding hard piping, and replacing the coupling with one that does not approach the maximum torque limits for its application.

PER 296-0119 concludes that the previous adverse trend of the safety-related pump failures was addressed but that the corrective actions stated in 1991 have not been adequately implemented in that alignment checks are not being consistently performed, flexible hoses have not been installed, and the original spider couplings that approach maximum torque for the application are still being used and are stocked as replacement parts.

The inspector noted that the root cause analysis and proposed corrective actions appear appropriate; however, the implementation of the corrective actions wer e not timely and therefore could not preclude recurrence.

This is an example of where corrective actions for a previously identified significant deficiency did not pr'eclude recurrence.

Erroneous 'Wirin and Reverse Termination:

SPER 296-0693 was prepared because the plant tracking log (PTL) indicated an adverse'rend of 5 PERs associated with reversed terminations.

" The inspector reviewed PER 296-0299, dated April 26, 1996, termination at the wrong limit switch; PER 296-0686, dated September 18, 1996, termination at the wrong limit switch; PER 296-0680, dated September 15, 1996, termination at the wrong terminal block; PER 296-0690, dated Septembe}

22, 1996, reverse termination at CRD HCU;.'nd PER 296-0453, dated June 1,

1996, reverse termination at panel H 13 P650.

'

I

~

~

PER 296-02;".9 st;~,'..ed ".=t there have been numerous cases in which MOV fermi',~- ='r;.:..".~~i - '"~er; ;nc'der,uate and listed 6 additional PERs that dealt *~ii'.;:ap;';~~1 terminations specifically for motor-operated v-"..1ve<~,HOVs~,

The cause of the event was listed as

"documents o':ollowq~ correctly" (PE0209).

The corrective actions consisted of couns~ling the craft.

It also notes that the existing prccess has imltiyle barriers designed into the system to assist in identifying orrors before returning systems to service and that there i" no generic impact which requires specific action.

The inspector noted tf at the root cause analysis was terminated after the specific code (PE0209)

was identified; that these personnel errors have been numerous and continue to recur; that the search for generic applicability (performed for this PER)

was limited to just %Vs,

~nd ~hat the corrective actions rely on the thorough, accurate, and error-free performance of post-maintenance test (PHT).

PER 296-0453 describes the loss of power on division I alternate rod insertion (ARI) during the performance of an anticipated transient without scram (ATMS-ARI) functional test.

The power was lost because terminations at panel H13-P650 had been reversed.

This caused a fuse to blow and a relay to weld shut, as well as a

loss of power to the ARI.

The PER notes that ll other PERs describing erroneous wirings had been identified in the PTL.

One of these, PERA 295-386-01, categorizes other wiring errors identified between June and February 1995.

Investigation revealed that an electrical contractor had performed the work, a second person verified the work, and a post-maintenance continuity test was performed.

The PER also notes that there was a guality Control hold-point on the termination instruction that appeared to be an additional barrier that failed.

The PER notes that the cause of the event was personnel error and that the second-person verification process is in place to prevent these types of errors.

This PER was returned to the Engineering Department as a result of a review by guality Assurance because of lack of discussion regarding the description of the event and the two barriers that failed, lack of a corrective action plan, and lack of a description of previous corrective actions and whether this PER represents an adverse trend.

PER 296-0690 identifies electrical leads at the Hydraulic Control Unit (HCU) scram solenoid pilot valve (SSPV) terminal box reversed so that the power lead was on the neutral line and maintained power to system

"A" even after the fuse was pulled.

This affected all HCUs downstream of HCU 2215, including HCUs 2611, 3003, and 1807.

The PER resolution determined that the HCUs are operable and,that the power supply lead reversal does not affect the ability of the reactor protection system to perform its safety-related function to deenergize the SSPVs.

The corrective actions

were to place a "caution" tag on the switch box and alert electrici

>.s ';hat sel cted terminals within the SSPV terminals box may not be'een'ergized, to take necessary precautions to avoid injury, and to-,,check remaining HCUs for possible lead reversal.

The PTL was se,"..', ched for work performed on these specific SSPV power leads that would.have required lifting and relabeling of these specific leads.

No work was identified.

Therefore, it was concluded that the condition existed since construction.

The root cause was selected to be "improper assembly" (Eg 0423).

The cause

'as not.analyzed.

The corrective actions of checking the remaining HCUs for possible lead reversal had not been performed at. the completion of the inspection The inspector noted that the root cause analysis was terminated after the specific code (Eg 0423)

was identified; that the search for generic applicability was limited to just work performed on these specific leads; and that the corrective actions did not consider the wider implications of possible erroneous wiring of other devices in the plant.

Nor did it consider whether. the same individual who performed this work during construction also mis-wired other safety-related devices, or why pre-startup testing or other testing did not identify these deficiencies.

This is an example where corrective actions for previously identified significant deficiencies did not preclude recurrence.

Further, because the root cause analysis stops at the identification of a cause code, the underlying causes of wiring error problems are not identified.

In each case, the search for generic applicability was narrowly focused and the corrective actions taken do not address the underlying cause and were not effective in preventing recurrence.

When viewed in the aggregate, erroneous wiring appears to be a human performance issue recurring in several areas.

The underlying causes were not addressed and corrective actions have had only limited effectiveness.

Shorted Terminals in the Control Roo

SPER 296-0222 describes an event on March 27, 1996, in which the average power range monitor (APRM-CH-A) was shorted to ground during performance of job investigation sheet WR96001252.

A technician took several voltage readings correctly and then connected the oscilloscope to the wrong set of terminals, causing a short-to-ground and resulting in a loss of power and a 'half-scram.

The root cause of the event was determined to be personnel error, in that self-checking techniques were not properly applied (PE0206).

Other contributing causes focused on whether the technician should have been using the "work implementation" procedure, or the "troubleshooting plant systems and equipment" procedure and whether these procedures need revising.

The corrective action recommendations consisted of revising the two procedures to clarify troubleshooting activities, and reviewing the event with the technician, the system engineer, and the shop The inspector noted that the analysis appeared superficial and conclusions were not documented in a comprehensive analysis.

The analysis did not ask why it was a personnel error, or determine the underlying cause of the personnel error as required by the licensee's procedures.

PER, 296-0692 describes an event on September 23, 1996,'n which an electrician shorted out terminals 3 and 4 on a relay extender card during an emergency bus degraded under-voltage relay calibration procedure, PPH 7.4.3.3.1.74.

This short circuit blew fuse F24-2 and damaged a relay casing.

The PER notes that similar events occurred in March and April 1996.

However, PERs 296-0227 and-0293 were not related to taking voltage measurements and, therefore, this instance was considered an isolated case.

The root cause was determined to be personnel error (PE0212,

"tools used not designed for the job") and the use of the wrong test leads.

Additionally a chart of all maintenance personnel errors by month was attached to the PER; it reflected 75 maintenance personnel errors through August 1996.

The PER states that there is a steady downward trend in personnel errors, which indicates that corrective actions have been effective.

The inspector noted that this PER was not deta'iled or thorough.

The root cause analysis did not follow any root cause analysis technique as described in section 3.2.2 of procedure PPH 1.3.48,

"Root Cause Analysis," nor did it address the human error or inappropriate actions discussed in PPH 1.3.48.

It appeared that minimal analysis was performed and only a cause code was selected from the basic root cause chart listed in PPH 1.3.48.

The process did not address why the personnel error occurred, and did not address the underlying cause of the error.

The analysis took a

very narrow view of the electrician shorting out the circuit and did not attempt to consider other personnel errors, even though

personnel errors occurred in Maintenance during the preceding eight months.

SPER 297-0039, dated January 13, 1997, describes where the "B" rod block monitor (RBH) power supply failed when an electrician dropped a screwdriver into the B-RBM drawer during a calibration,

'ausing the RBH-B power supply to short out.

The PER hotes that there were two previous PERs in 1996 that were similar to this event-PERs 296-0222 and -0692.

The root cause of this event was stated to be "not having the proper tool at the work site" (PE0214).

This was justified by stating that the electrician should. have used an insulated screwdriver.

The analysis stated that the fact that the "tweeker" was dropped is probably not preventable, but the impact of such an event could be minimized by using nonconductive tools and installing barriers over power supplies.

The corrective actions were to provide the electricians with insulated

"tweekers" and to establish a policy for use of

(

I

insulated tools where appropriate.

~;ddit!onally,, the new power supplies to be installed are to have

<<".over.:-

o-.;

<'".em.

Thi's-design change, however, is currently on hold.

The inspector noted that this was likely a personnel error.

That the licensee did not broaden their analysis to try to solve this problem.

There was no apparent reason to:wait for a design change to insert temporary covers or other shielding to i'solate the area while working.

The root cause and corrective actions in this PER were narrowly focused.

Issuing insulated tweekers puts an additional barrier around the problem but does not address the underlying cause of the problem; The root cause analysis did not follow any root cause analysis technique as described in the root cause analysis procedure, nor did it address. the human error actions discussed in the PPH.

No analysis was documented and a

cause code was just selected from the basic root cause chart.

This is an example where corrective actions for previously identified significant deficiencies did not preclude recurrence.

Other Issues Related to Human Performance

PER 296-0831 describes an event that occurred on December 4, 1996, involving the failure to follow procedures by both a, planner and maintenance electricians.

The planner did not follow the vendor's instructions on disassembling deaerator feed pump motor CO-N-P/l.

The electricians did not follow the first step of their instructions to verify that the pump was isolated.

Subsequently, the pump casing drain plug was removed and steam and water poured from the pump cavity and did not stop as expected.

After operators isolated the leak, the electricians continued to work without hanging a'roper tag, which is contrary to the clearance order procedure.

The PER states that a search revealed no prior history of problems associated with proper clearance order preparation and implementation for'these pumps.

The root cause of this event was determined to be failure to follow written instructions (PE0209,

"documents not followed correctly" ).

Corrective actions were to review, discuss, and counsel the craft and those involved concerning lessons learned from this event, reinforce/communicate expectations for performance of.work instructions, and add notes that these four pump/motor combinations form a pressure boundary.

The inspector noted that the root cause analysis did not appear to follow any root cause analysis technique as described in the root cause analysis procedure, nor did it address the human error actions discussed in the PPM.

It appeared that a cause code was just selected from the basic root cause chart.

The sort for previous similar 'problems was overly restricted to "these pumps."

The "conclusions" of the PER provided good discussion regarding the potential underlying causes.

However, the underlying causes were not addressed as part of the corrective actions.

PER 297-0035 describes an event on January 13, 1997, of an operator loading the high-pressure core-spray (HPCS) diesel with the droop switch in the isochronous position, thereby instantaneously loading the diesel to maximum load.

This resulted in the HPCS diesel generator being declared inoperable.

The PER discusses the event thoroughly, presents a barrier analysis in accordance with the root cause procedure, and concludes that the root cause was

"documents not followed correctly" (PE0209).

A PTL query was performed to identify similar events that may have happened.

Searches performed under the words "parallel,"

"isochronous,"

and "droop" found multiple entries, but none were similar in nature.

The corrective actions consisted of placing the operator'nto a human performance improvement plan that focuses on attention to detail, changing the procedure to require independent verification of the droop switch position prior to parallel,ling, and holding discussions with the operators and reiterating management'.s expectations.

The inspectors noted that this PER was much more structured and comprehensive than other PERs performed by the Maintenance Department.

The corrective actions appeared to be more appropriate and may hei'p preclude this specific event from recurring.

However, the underlying cause of why the operator failed to follow the procedure, or why operators did not pay attention to detail was not discussed.

The PER search for similar events for inattention to detail was'imited to "droop,"

"parallel," and "isochronous,"

which overly restricted the search for similar human performance problems.

Although much improved, these corrective actions did not address related personnel errors under similar conditions, or on similar equipment or due to similar causes and therefore may not preclude recurrence of -this or. similar events.

611

PRR 296-6618 p

Id p1 I

d root cause.analysis.

It notes that on August 2, 1996, seven Appendix R emergency lights failed their 8-hour battery test.

The PER discusses why each light failed; gives the history of the lights; and describes a comprehensive search on the PTL for

"battery-powered emergency lighting."

A search of the Materials Management System data base revealed how many batteries have been issued to electrical shops; and other searches. of the PTL for various codes such as "light" and "battery" are described.

A complete, logical discussion was provided regarding each PER or failure identified.

The root cause was noted to be "inadequate vendor support of change" (MM0304).

This was preceded by the most apparent cause, short battery life due to failure to adjust charger card float voltage, which was caused by a required higher setting of a new model battery.

The required higher voltage was recognized in the substitution evaluation, but was noted as acceptable on the basis of an enclosed letter from the manufacturer that the new 12-699 model battery could be used with the existing chargers.

The manufacturer now believes the difference in float charge would'xplain the premature failures and that the chargers need to be set at a higher voltage.

The corrective actions consisted of replacing existing charger circuits to ensure the batteries receive required voltages, establishing a baseline of data and a

trending program, and revising procedures to provide guidance on operability of batteries during discharge and recharge periods, and determining compensatory actions needed for times when emergency battery lighting is out of service.

The. inspector noted that this PER did a thorough search for similar events on a broad bases; that the root cause analysis sought to determine the underlying cause of the lighting failure, the cause of the low battery voltage, the cause of the charger applied voltage being set too low, and the reason why the replacement batteries were acceptable, and.then applied extensive corrective actions to address the final cause, and also fix the immediate problem.

Root Cause Pro ram Concerns:

The inspector discussed how root cause determinations were made for PERs reviewed with the Maintenance representatives, and with the guality Assurance supervisor.

Through discussion, the following topics regarding the root cause process were identified by the licensee's representatives as areas of concern.

~

Prioritizing and categorizing problems:

Approximately 90-150 root.causes are processed each year.

Without a priority scheme, each root cause appears to receive the same depth of analysis and appears to receive the same level and quality review, and the quantity being

, processed lends itself to diminished quality in the final product.

~

Timeliness:

The inspectors noted an adverse trend of missing the 14-day time limit for completing a root cause analysis and corrective actions.

The time limit is needed if the event is related to a licensee event report (LER). It appears that when some PER handlers perform 2-3 root ca'uses.

a month, as a collateral duty, the 14 days could be restrictive and could limit the quality of the analysis'.

Training and knowledge:

The depth, the quality, and the frequency of root cause analysis training and the fundamental knowledge and understanding of attempting to arrive, at the underlying cause(s)

to prevent recurrence appears to be lacking.

Host PER handlers were trained through a 2-day root cause training course in 1993 and have had no refresher training since.

Managers, responsible for s'etting the quality standards for acceptance, have received even less training.

Recently, system engineers have received refresher training in response to the 1995 SALP.

The process:

Many root cause analyses are performed by a single individual, i.e., in the Maintenance Department one technician performs most root cause analyses.

Because it is not specifically detailed in procedures, each department does root cause analysis differently.

The root cause procedures implies that a "team" performs the root cause analysis.

Sometimes the person who makes the error, does the analysis.

Some departments have a single individual who performs the'oot cause analysis as a collateral duty.

This allows for variation in quality and lacks the technical expertise and team synergy required to arrive at the underlying cause..

Coding root causes is required by procedure in order to categorize and to look for adverse trends.

These codes are necessary'and a positive attribute, but the codes may be lulling the analyst into thinking that after identifying the problem cause code, the underlying root cause has been determine and can stop.

The root cause procedure requires that the analyst delve deeper to identify additional underlying cause(s).

There appears to be an overemphasis on fixing individual performance problems.

~..

Management's expectation:

Managers are responsible for the acceptability standards for root cause determinations.

Department managers sit on the Corrective Actions Review Board as another "barrier" to help ensure the quality of root cause determinations.

The inspector's reviews indicate that poor root cause analyses unnecessarily challenge the CARB and the GARB often acts as the sole mechanism which forces much of the cause analysis (see section R 7.2.2).

Conclusions The inspectors concluded the following:

One PER reviewed demonstrated that the licensee has the capability to do effective root cause analysis.

For it, the root cause procedure was followed verbatim, and these actions will likely preclude this and similar events from recurring.

Other PERs were much improved from earlier PERs but did not address generic human performance issues, and some analysis stopped too soon to be fully effective.

l

In general, however, the root cause analyses handled by Maintenance lacked depth of inquiry to determine the underlying cause(s)

and therefore, would'not preclude repetition.

Root cause analyses had the following weaknesses:

(1) corrective actions more often addressed the immediate cause than the underlying'cause, (2) implementation of some corrective actions were protracted, (3) there was limited discussion of why previous corrective actions were ineffective, and (4) there was no discussion of a rationale for terminating the root-cause analysis after a cause code was selected.

Because of these weaknesses, several examples were noted where corrective actions for previously identified significant deficiencies did not preclude recur rence and are considered part of unresolved item (URI 50-397/96-202-01).

/

Ml.3 Observation of Activities Durin Ins ection a 0 Ins ection Sco e

b.

During the onsite inspection, an inspector reviewed one ongoing activity that involved Maintenance; The activity concerned the licensee's response to an APRM channel A thermal trip RPS-A half-scram which occurred during a calibration.

Observations and Findin s

RPS-A Half-Scram: During performance of the flow unit C channel calibration on February 4, 1997, at 09:13, per PPM 7.4.3.6.24, a

half-scram occurred.

The half-scram occurred as an instrumentation and control technician reinstalled circuit board card Z6 per step 7.7. 12 of the procedure.

The immediate corrective action was to stop the channel calibration and reset the half-scram.

On February 4, 1997, at 19:54, a system engineer for the APRN initiated PER 297-0101 related to the half-scram.

The inspectors discussed the event with the system engineer and determined that:

(1)

a similar event occurred at the plant in 1989 (PER 289-0942);

(2) no similar events had occurred previously at other plants, and (3) discussions between the vendor and plant personnel have not as yet revealed the underlying causes of the event.

Discussions with the system engineer indicated that preliminary investigation and data collection indicated that the installation of the circuit board card causes the half-scram.

This is due to the potential to spike the APRM flow input signal(s)

as momentary signal transients occur during circuit board reinstallation and power-up.

The system engineer indicated that the long-term corrective action will be to change the procedure so that the card 16 is not removed in order to complete the subject calibration.

l

Co Conclusions The inspectors concluded that problems associated with the calibration were appropriately entered into the PER system.

The immediate cor'rective action of stopping the calibration when the half-scram was received was judged to be appropriate and conservative.

The evaluation of the root cause was not complete at the time of the inspection and was not assessed.

However, an interim measure of not removing card Z-6 in future calibrations was considered to be a prudent corrective action.

III.

En ineerin E2 Engineering Support of Facilities and Equipment E2. 1 Problem Identification

'a ~

ns ection Sco e

0500 b.

The inspectors reviewed the Engineering programs to assess the problem identification, evaluation and resolution process.

Observations and Findin s

PER Process:

495 PERs, about 56X of all PERs in 1996 were assigned to some department in the Engineering organization.

The system engineers were assigned the majority of these for resolution..

Most of these dealt with hardware failures.

The inspectors attended several morning PER meetings and observed effective dialogue among the managers who ensured that the scope of the problems was defined and understood and that immediate action, if needed, was taken.

The inspectors noted that several issues were discussed and because of the managers recollection, the staff was requested to do additional research and write PERs if additional issues of the same nature were identified.

Several issues were addressed at the morning meetings that became PERs at the direction of management due to their significance.

a Gold Card S stem:

Because the PER process was used to identify more significant issues, the licensee developed the gold card system to identify human performance issues which, if left uncorrected, may contribute to a significant event.

The gold card system was initiated in 1996 to identify strengths and weaknesses in human performance.'he inspectors found that some gold cards contained potential engineering or hardware issues as follows:

Gold card 4207 Decision to eliminate low conductivity recirculation drive trip on all four drives.

Additional wiring changes required.

Original PMT on RRC-IMD-1A/2 was inadequate.

Correct design function (initiated FCR 87-2044-6-50).

'21

Gold card 4727 Reviewing generic issues associated with SW-P-IA trip, indicated that the OLC relays for LPCS-P-1 should be set up higher to provide more. margin (initiated FCR 85-0528-0-06).

The licensee appeared to have taken. appropriate corrective actions by initiating field change requests (FCRs).

However, it appeared that PERs should have been initiated instead of gold cards 4207 and 4727.

This is indicated by paragraph 1 of attachment 7. 1 to the PER procedure which requires that a

PER is to be initiated for a condition which affects equipment relied upon in the plant licensing basis, structures, systems, or component malfunction, damage, or degradation considered sudden or unexpected, or outside the anticipated performance of the item.

Whether the licensee should have initiated a

PER for problems identified through gold cards 4207 and 4727 is an inspector followup item (IFI 50-397/96-202-03).

E-i1

<<:

B qip tp b1 h

t h

certain threshold. of significance to warrant a

PER, the inspectors found that the some departments used the plant e-mail to communicat'e less significant engineering issues with the System Engineering Department."

The inspectors reviewed a limited number of these e-mail messages and found that none appeared to be safety significant.

Some examples of these equipment deficiencies are as follows:

~

"Tonight on Hids (11-3) the HPCS dryer appeared to be clogged..."

"... got low oil temp alarm on dg2 eng 2... oil temp was well within spec....suspect that the low'temp in the diesel room maybe be'affecting the exceptionally long run of gas tubing from the switch to the temp well..."

"annunciator checks of DG-1 drop 9-2 failed to light...This is the alarm that identifies that the DG-1 engine 1A1 air start motor has failed to operate given a valid start signal... this is a problem with the annunciator card, not an operability issue..."

~

"control rod drive (CRD) 38-35 temperatures have been trending up lately..."

~

"CRD-FI-4A has been found to be down scale 3 times out of the last 4 days...."

The inspectors considered that good communication was taking 'place between the operators and the system engineers to resolve equipment problems; however, some of the above examples appeared to meet the criteria of a PER.

C.

Conclusions E2.2 Root Overall, the licensee's ability to identify problems in the engineering area through the use of PERs and the gold card system was good.

Although the implementation of the gold card system was satisfactory, there was still some confusion on the part of the plant staff on the use of the gold card system.

This appeared to have resulted in a few non-human performance issues being identified through the gold card system.

The inspectors *concluded that there were no safety concerns with equipment problems which were being identified through the plant e-mail.

The daily PER meetings were an effective way for the plant management to address significant issues at the plant in a timely manner.

The inspectors concluded that the higher threshold of the PER system tolerates the use of the e-mail system to identify less significant equipment deficiencies, and lessened the opportunity for management to become involved with the problem at an early stage.

This permits issues to rise in significance or recur before receiving management attention.

Cause Anal sis and Evaluation I s ection Sco e

40500 b.

The inspectors evaluated the following PERs that were assigned to Engineering for resolution:

PERs 297-0020 and 293-0346.

Observat'ons nd F'in s

The licensee provided to the inspectors root cause analyses associated with PERs 297-0020 and 293-0346.

The root cause associated with PER 297-0020 in which operators cross-connected the drywell to the air space of the suppression pool through the containment atmospheric control (CAC) system failed to address the following aspects associated with the event:

(1) acceptability of the operators performing an Operations procedure without.fully understanding the results of their actions; (2) why previous comprehensive corrective actions taken for PER 293-346 which documented a nearly identical event in 1993 failed to prevent this problem from occur ring in 1997; (3) to what extent lack of training given to the operators on the modification which installed the test switches contributed to this event; (4) to what extent performing maintenance activities during power operations-which were previously performed during outages-contributed to the event.

This event was potentially safety significant because cross-connecting the drywell to the air space of the suppression pool bypassed the pressure-suppression function of the wetwell.

By technical specification 3.6.2. 1 b, the licensee was limited in its drywell-to-suppression chamber bypass leakage to be less than

percent of the acceptable design value of 0.05 square foot in

e

C.

Hodes 1,

2, and 3.

Opening of the containment isolation valves associated w'th the CAC system could potentially challenge this drywell-to-suppression chamber bypass leakage limit.

The licensee determined that the bypass leakage during'he event on January 8,

1997, was 97 percent of allowable value.

The inspectors'iscussion with the licensee indicated that the large number of root cause analyses being performed (about 100)

by a limited number of people, with limited time constraints appeared to reduce the ability of the licensee to investigate the event in sufficient depth and detail necessary to provide the quality of the root cause analysis which meets management's expectations.

Conclusions The'nspectors concluded that the licensee's root cause analyses associated with the PERs reviewed were adequate.

However, the inspectors also concluded that root cause analyses appeared to lack the depth necessary to identify effective corrective actions to prevent similar events in the future.

E2.3 Corrective Action Im lementation and Effectiveness a ~

ns ection= Sco e

40500 b.

The inspectors evaluated the implementation and effectiveness of corrective actions for PERs 297-0020, 293-0346, and 292-0231 against PPH 1.3. 12,

"Problem Evaluation Request (PER)"

and PPH 1.3. 12A, "Processing of Problem Evaluation Requests."

Observations and Findin s

In the past, the licensee had dealt with issues similar to problems identified in PER 297-0020.

'I The licensee first became aware of this problem in 1992 (PER 292-231)

when an engineer discovered that the valve test push button in the CAC system was vulnerable to single failure because the failure of the push button could result in opening of the containment isolation valves.

Therefore, leads were lifted from this push button under a temporary modification.

The long-term resolution to this single-failure vulnerability was to add a

second switch in series with the valve test push button under a

permanent design modification.

The test switch (formerly known as the push button before the plant modification) was not needed to operate any of the containment isolation valves in the CAC system.

In 1993, operators discovered that the bypass condition between the drywell and the air space of the suppression chamber existed whenever the Instrumentation and Control technicians performed their CAC instrumentation surveillance (PER 293-346).

The licensee performed an exhaustive investigation of the root causes

t I

fC

which resulted. i;": PER 293-346 and reported the findings in NCR

.'"'ii>; ".r, i

.ppeared that the licensee took reasonable co>"rective

'iciti.'i~ to 'ddress the individual deficiencies each time these problems,",:;ere identjfied, most of the corrective actions (CAs) tal:en (24ibn all) for PER 293-346 were directed in one form or another to

~improve human performance to prevent an event in which the d:"ywell became cross-connected to the airspace of the suppression pool.,

Corrective actions associated with PER 293-346 invol.ed revising various plant procedures and informing many plant employees of the event to heighten their sensitivity to this issue..

The licensee stated that these corrective actions appeared to have bee;> effective for some years as evidenced by lack of similar events identified in the PERs between 1993 and 1997.

However, over time, as personnel rotated in and out of positions tiNe co"porate m mory lessened and the corrective actions taken in response to PER 293-346 appeared to become ineffective.

In 1996, the system engineer and the operations procedure writer decided to use the test switch to enhance the Operations Department procedure used to repressurize the CAC system with nitrogen (PPN 2.3.3.A).

The inspectors concluded that the inadvertent introduction of a new initiator for this event through enhancement of the Operations Department's nitrogen procedure was not something that could have been reasonably prevented through the PER investigation performed in 1993.

The engineer and the operator believed the operation of the test switch would improve operator ability to repressurize the CAC system with nitrogen after a maintenance activity.

Although both 'had successfully revised other surveillance procedures which utilized the test switches, they failed to ensure that PPH 2.3.3.A contained steps to open the breakers to the containment isolation valves before operating these switches.

As a result, when the operators performed section 5.5 of PPH 2.3.3.A, it resulted in connection of the drywell to the suppression chamber.

The inspectors reviewed the corrective actions proposed in PERs 297-0020 and a sample of corrective actions associated with PER 293-346 and found that the licensee had'performed corrective

= actions in a reasonable time period after the problems were identified.

For PER 297-0020, all but corrective actions 5 and

were completed.

Co clusions The licensee's corrective actions'appeared to have been ineffective in dealing with an apparent CAC design deficiency for the long term.

As a result, the licensee continued to experience problems with personnel cross-connecting the drywell to the air space of the suppression chamber.

0'

On the basis of their review of root causes and corrective actions associated with PERs 293-346 and,297-0020,,the inspectors concluded that the licensee may have put too much emphasis on correcting human performance 'concerning containment isolation valves rather than addressing a'esign deficiency.

This is another example where corrective actions for previously identified si'gnificant deficiencies did not preclude recurrence

'and is considered part of unresolved item (URI 50-397/96-202-01).

E7 gualit'y.Assurance in Engineering Activities E7.1 Self-Assessment Pro rams s ection Sco e

40500 The licensee's self-assessments and quality assurance audits relative to engineering were evaluated.

b.

Obs'ervations and Findin s

The licensee performed a self-assessment (WNP-2 Performance Self-Assessment, August 1996) of its performance deficiencies in 1996.

The assessment was critical, thorough and broad based.

It made recommendations that appeared to address the underlying causes of the identified engineering deficiencies.

However other gA audits lacked findings and indicated a much more trouble-free Engineering organization than the self-assessment.

gA audit report

"WNP-2 Design Control Audit (audit 296-017)" identified only the following minor deficiencies with the quality of site design engineering work:

problems with missed special design reviews for modification packages (The audit inspectors had found that the reactor engineering group had not reviewed the adjustable speed drive (ASD) modification.)

'quipment qualification review not performed on modification for the ASD and digital feedwater(DFW)

problems with quality of licensing-basis impact determinations and design safety analyses (10 CFR 50.59 evaluation for the ASD modification failed to take into account the impact of the temperature stratification after loss of forced recirculation.)

field change not documented by issuance of a field change request to the design package (No FCR was initiated when mounting bracket was not installed as described in the design package.)

C.

Additionally, the licensee's correcti.ve action audits (WNP-2 Corrective Action Program (Audit 296-0'07)) contained no findings and WNP-2 Corrective Action Program (audit 296-059)) identified one finding which involved premature removal of a followup assessment of operability from the control room.

The 1996 self-assessment found the following problems with the site design group:

~

Engineers need to be more involved with design modifications prepared by outside organizations.

~

Modifications prepared years ago are now being implemented without adequate review and planning.

The licensee's 1996 self-assessment stated that "problem resolution, while much improved, was not successfully achieved in a number of important instances where quick fixes took the place of solid root cause analysis."

After reviewing "repeat" events, the inspectors arrived at the same conclusion as the licensee's self-assessment i.e., that

'he licensee's corrective action was effective in resolving problems for the short term, but not effective in resolving problems for the longer duration.

As a result, events recurr'ed.

Conclusions The licensee's ability to proactively identify problems and its ability to assess overall plant performance were mixed.

The 'inspectors concluded that gA and the corrective action program audits were not effective in identifying weaknesses in the Engineering Department and that the licensee's self-assessment performed in 1996 indicated a more accurate and critical assessment of Engineering's performance on site.

IV. Plant Su ort R7 ual't Assurance in adiolo ical Protection and Chemistr Activities R7. 1 Problem Identification a. 'ns ection Sco e

. 40500 b.

'he inspectors reviewed procedures, interviewed personnel, and attended various corrective action program meetings to determine the licensee's ability to identify deficiencies.

Observations and Findin s

The inspectors reviewed monthly human performance trend reports for 1996 and noted a steady decline in human performance errors-.

The trend report only considered PERs that found human performance

co as the primary root cause.

Adverse trends in human performance noted as secondary root causes

~n PERs, 0o:umented on gold cards, or noted through the management observation program (OI-9), were not considered in assessing overall human performance.

This is of part'icular concern given the large percentage of adverse human performance observations involving procedural compliance and self-checking noted on gold cards.

Conclusions R7.2 Root The inspectors determined that the licensee utilizes several processes for identifying deficiencies.

The combined result ensures that problem identification at the facility is good.

Licensee management does not effectively utilize all of the tools available to it to ensure that human performance trends meet expectations.

Cause Anal sis and Evaluation

'a ~

Ins ection Sco e

40500 b.'he inspectors reviewed two root cause analyses performed by Radiation Protection:

The licensee selected PER 296-0357,

"Failure to Write PERs to Document Plant Problems,"

as a good example of a root cause analysis performed by Radiation Protection.

The inspectors selected PER 296-0839,

"Adverse Trend Related to the Failure to Label Radioactive Haterial in Accordance With Supply System Procedures,"

to assess whether corrective actions from PERs prevented recurring problems.

Observations and Findin s

PER 296-0357 (Nay 1996) identified two root causes:

(I) the gold card program was inadequately presented to Radiation Protection and (2) inadequate review of gold cards failed to ensure timely initiation of PERs.

Contributing causes included subjective criteria for initiation of nonreportable radiological PERs, management's coaching of personnel to initiate gold cards instead of PERs, and gold cards initiated without review of the PER threshold criteria.

The inspectors noted that the root cause analysis provided a good assessment of the failure to initiate radiological event PERs.

However, the root cause analysis did not assess why previous corrective actions concerning failure to write PERs by other departments, did not preclude occurrence of a similar problem in the Radiation Protection Department.

The corrective actions for subjective criteria for initiation of nonreportable radiological PER consisted of an E-mail message to personnel requiring them to review the PER initiation criteria.

However, Procedure 1.3. 12,

"Problem Evaluation Request,"

provided threshold criteria for nonrepor table radiological events but did not contain specific guidance for initiating a PER.

The

inspectors noted that gold cards continued to be initiated for nonreportable radiological occurrences and that the corrective actions to improve the gold card review process were ineffective as reflected by PER 296-0839 which was subsequently initiated to document an adverse trend for improper labeling of radioactive material not previously noted by radiation protection management.

PER 296-0839 (December 1996)

was initiated by Radiation Protection following gA's identification that gold cards were being used to document inadequate labeling of radioactive materials.

The root cause analysis determined that the errors in labeling radioactive material resulted from (I) poor work practices on the part of radiation workers, (2) general employee training not providing adequate guidance, and (3) procedures not specifying responsibility for ensuring that radioactive materials were labeled.

The root cause analysis did not determine why previous corrective actions from seven PERs concerning inadequate labeling of radioactive materials were ineffective in precluding recurrence and why Radiation Protection did not identify the adverse trend through its independent review of gold cards.

Corrective actions for PER 296-0839 included:

(I) revisions to health physics procedures to clearly define labeling responsibilities, (2)

a recommendation for the training advisory group to address labeling requirements in the general employee training GET, engineering, maintenance, and laborer training programs, and (3)

a recommendation'o conduct an employee time-out prior to the next refueling outage to reenforce management expectations on labeling of radioactive materials.

The inspectors noted that the corrective actions did not include provisions for interim actions to improve labeling practices prior to the outage and did not address whether improvements to the radiation protection training program were necessary.

Conclusions

'ne root cause analysis was very detailed, yet lacked substantive corrective actions.

A second root cause analyses lacked the depth required to implement effective corrective actions.

Ineffective corrective a'ctions for.inadequate labeling of radioactive materials resulted in recurrence of this condition adverse to quality and is considered part of unresolved item (UNR 50-397/96-202-01).

R7.2.1

~

~

Root Cause Anal ses Performed b

A R7.2.2 PER 296-0587 (July 1996)

was initiated in response to an NRC notice of violation involving the cancellation of a TS required procedure.

gA performed an in-depth root cause analysis and planned to perform a review to determine if other procedures required by TS administrative section.

Cor ect've ction ev ew Board C

RB b.

ns ection Sco e

40500 The inspectors assessed the impact of the corrective actions review board with respect to timeliness constraints on root cause quality.

Observations and Findin s

Significant PERs require a root cause analysis.

In 1996, the licensee performed approximately 100 root cause analyses.

Many of the significant PERs are due to adverse trends of repetitive events that are similarly coded.

Each root cause analysis is discussed at a weekly GARB meeting to ensure underlying causes were identified and addressed by suitable corrective actions.

Overall, about 90 percent of all PERs reviewed by the GARB are returned for modification.

A small percentage are rejected.

The inspectors attended a

GARB meeting.

The meeting provided a forum for brainstorming and creative thinking to facilitate the identification of underlying caus'es.

The inspectors determined that the GARB process enhances the quality of the root cause determination, and that the GARB was a principal contributor to acceptable root cause.

However, the 90 percent rejection rate and the numbers, of recurring events presented to.the CARB appears to indicate that there remained a weakness in the line organization's ability in determining root cause.

Several individuals interviewed who perform root cause analyses stated that they were reluctant to request extensions beyond the 14-day time limit for completing the root cause analysis.

They believed that requesting an extension was viewed by management as an inability to meet personnel performance expectations.

Several individuals stated that the quality of the root cause analysis occasionally lacked substance due to the perceived time restraints placed by management on the reviewer.

Based of these statements, the insp'ectors were concerned that the reluctance of reviewers to request extensions may be affecting the quality and depth of root cause analyses.

Conclusions:

The CARB provided adequate oversight of root cause analyses and proposed corrective actions.

The quality of root cause analyses

may occasionally be diminished because reviewers are reluctant to request extensions beyond the 14-day goal for completing root cause analyses.

Based on the numbers of recurring events and the 90 percent rejection/modification rate of root causes presented to the CARS, there appears to be a fundamental weakness in the line organization's ability to determine root cause.

R7.3 Corrective A tion Im le entat'

f ect'veness

'a ~

b.

Ins ection Sco e

40500 The inspectors reviewed five PERs that had been initiated by gA to determine whether or not deficiencies requiring a gA response were appropriately resolved.

bser ations and F

din s PER 296-0489:

PER 296-0489 was initiated by gA on June 13, 1996, to document concerns with the failure to initiate a PER for two operational even'ts involving an inadvertent start of recirculation pump RRC-P-1B during testing and a trip of reactor water cleanup pump RWCU-P-1A due to air in the train A filter/demineralizer.

The inadvertent start of recirculation pump RRC-P-1B was identified when gA reviewed the operating logs.

gA believed that a

PER was warranted since the inadvertent pump start resulted in a failure to meet TS 4.4. 1.4 surveillance requirements.

TS 4.4. 1.4 requires that the temperature differentials and flow rate be determined within the limits (15 minutes)

before startup of an idle recirculation loop..

Operations initially determined that a

PER would serve no purpose even though the inadvertent recirculation

'pump start met the PER threshold.

gA reviewed the response and required Operations to address the impact on plant operation, the temperature and flow requirements required by the TS, and the generic impact of the event.

Operations subsequently determined the following:

(1) the pump start did not affect safety of the plant, (2) no generic, impact existed since the test was only to be performed for initial installation of a new plant modification, (3) the failure of the testing circuit caused the pump start, and (4) the TS-required temperature and flow rate were verified following the pump start and determined to.meet the TS requirements.

The licensee's review did not address all of the potential contributing causes of the event or deficiencies resulting from the event.

Specifically, corrective actions did not address (1) Operations'nitial failure to note the unplanned entry into a TS action statement, (2) why the testing circuit failed, (3) whether or not subsequent maintenance or modifications to the

'

system would require the performance of similar testing, (4) whether or not the test procedure needed to be revised to require compensatory actions (e.g.,

opening of pump circuit breaker prior to. testing, increased monitoring of system parameters, or calibration of the test circuit prior to use),

and (5) why Operations did not initiate a PER for an unplanned, entry into a TS limiting condition for operation.

In response to the inspectors'oncerns, the licensee stated that a

PER should have been initiated for the event and that an additional review would be performed.

The inspectors noted that the entry into the TS action statement could not have been reasonably been prevented, but this adverse condition could have

.

been promptly identified and a review of the inadvertent recirculation pump start including the failure to determine the temperature differentials and flow rate within the T/S limits could have been conducted.

CFR Part 50, Appendix 8, Criterion XVI,.requires that measures be established to assure that conditions adverse to quality such as failures, deficiencies and malfunctions are promptly identified and corrected, and reported to appropriate levels of management if significant.

In this case

.

the deficiency was not promptly identified or reported to management.

This is an additional example of failing to meet the requirements of 10 CFR 50 Appendix 8 criterion XVI, and is considered an unresolved item (UNR 50-397/96-202-01).

gA identified the unplanned trip of reactor water cleanup pump RWCU-P-, lA during a review of operating logs which indicated that while placing filter/demineralizer RWCU-FD-1A in service, filter/demineralizer RWCU-FD-18 isolated causing low flow on RWCU-P-lA and a subsequent trip.

gA believed that a

PER was warranted since the event was sudden and unexpected and because failure of the RWCU system could have a generic impact on plant safety.

System engineering believed that the event was caused by air in the train A filter/demineralizer following draining of the system.

Engineering believed that a

PER was not required because the event had no safety significance since it occurred at a low reactor vessel pressure during Mode 4 operations.

gA discussed the event with management and was informed that the system engineer duties and work order process are intended to solve problems similar to the inadvertent trip of the RWCU pump and, therefore, was not a condition that required a

PER.

gA indicated in PER 296-0489 that it would determine the validity of management's conclusion.

The inspectors found that gA had not performed or scheduled a review to determine if the system engineering duties and work order processes were correcting deficiencies below the, PER threshold.

~

s I

~

C.

On January 31, 1997, Operations reconsidered whether or not a

PER should have been initiated and determined that a

PER would not be warranted because the event did not have any actual impact on plant safety.

The inspectors noted that the licensee did not consider the generic impact of restoring a drained system to service following maintenance on plant systems or if the event could have resulted in a release of resin to the reactor vessel had a larger air pocket existed in the system.

imeliness of PERs and Cor ect e Aetio s:

The inspectors noted that several PERs had been initiated to document untimely resolution of-PERs.

PER 295-0915 (August 1995)

was initiated to determine why PERs were not addressed within 30 days.

PER 296-0272 (April 1996)

and -0735 (October 1996) were initiated to document several gA-initiated PERs that were not dispositioned within 30 days.

PER 296-0709 (October 1996)

was initiated to determine why significant PERs were not handled within 14 days.

PER 297-0027 (January 1997)

was initiated to determine why interim corrective actions were not properly dispositioned.

PER 297-0043 (January 1997)

was initiated to determine why PER corrective actions were not implemented when required.

Each of the PERs addressed timeliness goals for a specific PER and corrective action but did not address timeliness as a generic concern for many PERs and corrective actions.

The generic implications of not meeting corrective action program timeliness goals is an inspector followup item (IFI 50-397/96-202-04).

Conclusions The licensee failed to identify a missed TS surveillance requirement and to meet corrective action program timeliness goals.

gA demonstrated a good ability to recognize conditions warranting a

PER during reviews of control room logs.

R7.4 Self-Assessment Pro rams in ualit Assurance a 0 Ins ection Sco e

40500 The inspectors evaluated how gA surveillances

'and audits

.

identified and resolve deficiencies.

b.

Observatio s and Findin s

Corrective Action Pro ram udits:

The inspectors reviewed corrective action audit reports 296-007 (March 1996),

-059 (August 1996),

and -088 (January 1997).

The audits were performed to implement the TS 6.5.2.8.c requirement for performing an audit of actions taken to correct deficiencies in unit equipment, structures, systems, or method of operation that affect nuclear

'afety.

~

~

~ The Harch 1996 report primarily focuses on the number of PERs initiated and,timeliness of corrective actions and did not assess why the licensee continues to identify recurring deficiencies.

Specifically, gA stated that there had been no reduction in the percentages of PERs generated with cause codes involving work practices, procedures, and communications.

Additionally, gA did not identify continued deficiencies in valve and switch manipulations, clearance order process, and.self-checking.

gA determined that corrective actions in response to previous audit findings were implemented, but did not assess if the corrective actions improved human performance.

The August 1996 report specified that the PER process was consistently applied, management was involved in the corrective action process, and there was no increase in the number of repetitive problems or issues.

gA did not assess why corrective actions were not successful in preventing repetitive problems and issues from recurring.

The inspectors noted this "no increase in the number of repetitive problems or issues" to be inconsistent with the number and frequency of recurring issues identified by the inspectors during the review of the corrective action program.

The January 1997 audit contained a more thorough review of recurring problems.

gA initiated PERs to review deficiencies involving timeliness of corrective actions, the failure to implement 1993 SALP commitments, inadequate handling of interim corrective actions, and discrepancies involving the updated final safety analysis report.

Although the quality of the January 1997 corrective action program audit was improved, some discrepancies indicated the need for additional improvements to the audit process.

Specifically, gA noted that past corrective action for keep-fill pump bearing failures did not resolve the problem.

However, there were no corrective actions to review why previous analyses were not adequate in preventing additional bearing failures.

gA indicated that no new trends were identified.

However, the inspectors determined that based on a review of PERs and gold cards, there continued to be repetitive occurrences of valve and switch mispositions, clearance order problems, procedural compliance issues, and poor self-checking.

Clearance Order Surveillance Activit :

gA surveillance report 296-045,

"Clearance Order Process,"

on surveillance activities performed between Hay 13 and July 16, 1996, concluded that clearance order documentation appeared to be adequate, that maintenance craft walkdowns were observed by gA with no problems, and that there were no problems with the maintenance order clearance process.

The inspectors requested a search of all PERs related to the

'learance order process and determined that between May 13 and July 16, 1996, there were four PERs (296-0382,

-0415, -0428, and-0497)

due to inadequate implementation of the clearance order process:

The inspectors determined that the failure to review the

,PER data base to identify clear ance deficiencies during the audit gave management a false-positive indication of the clearance order process.

Cor ective Action P ocess o

ocedure Adherence Issues:

gA surveillance report 296-086, on surveillance activities performed in December 1996, evaluated gA concerns regarding the criteria used to initiate a PER for procedural adherence deficiencies.

gA noted that procedure NOS-30,

"Control of Nonconformances and Corrective Actions," required a

PER to be initiated to document the failure to follow safety-related procedures.

However, lower tier procedure 1.3. 12,

"Problem Evaluation Request," did,not require a

PER to be initiated whenever there was a failure to follow procedures.

gA initiated PER 296-0813 to resolve the discrepancy.

gA identified 61 misused gold cards initiated in 1996 for the failure to follow safety-related procedures.

gA initiated PER 296-0834 to review why gold cards were initiated instead of PERs.

However gA d'id not assess the generic implications beyond the 61 Gold Cards c ~

Conclusions Corrective action program audits were improving; however, assessment of recurring deficiencies was not always adequate.

The identification of procedural noncompliance issues documented on gold cards was considered a good audit finding.

However, no assessment of generic implications was made, and gA surveillance repor,t 296-045 gave management a false-positive indication of the clearance order process.

V.

Ma a ement Meetin Xl Exit Meeting Summary On February 6,

1997 the observations and findings of this inspection were summarized with members of licensee management.

See Attachment

for a listing of attendees at this meeting.

~

k

~

~

APPENDIX A LIST OF OPEN ITEMS This report categorizes the inspection findings as unresolved items and inspection follow-up items in accordance with the NRC Inspection Manual, Manual Chapter 0610.

An.unresolved item is a matter about which more information is required*to determine whether the 'issue in question is an acceptable item, a deviation,'a.nonconformance, or a violation.

The NRC Region IV office will issue any enforcement action resulting from their review of the identified unresolved items.

An inspection follow-up item is a matter that requires further inspection because of a potential problem, because specific licensee or NRC action is pending, or because additional information is needed that was not available at the time of inspection.

Number e ort Sectio Concern URI 50-397/96-202-01 URI 50-397/96-202-01 URI 50-397/96-202-01 URI 50-397/96-202-01 01.2c M1.2c E2.3c R7.2b Recurrence of clearance order errors and valve/switch mispositionings and failing to identify recurring errors.

Multiple examples in the area of maintenance of recurrence of significant conditions adverse to quality.

Recurrence of containment bypass.

Recurrence of inadequate labeling of radioactive materials.

URI 50-397/96-202-01 URI. 50-397/96-202-02 I FI 50-397/96-202-03 R7.3b 03.1c E2.lb Identification of a significant condition adverse to quality.

Procedure PPM 1.3.48 not followed.'hether

'the licensee should have initiated a

PER for problems identified on gold cards 4207 and 4727.

IFI 50-397/96-202-04 R7.3b Corrective action program timeliness goals not met.

A-1

APPENDIX B Acron ms

bbreviatio s

ADS APRH ARI ASD ATWS AOSM CAC CRD CIA CRS DC DFW DG ECCS EDG EOP EO EPG FSAR FCR FIN gpm GET HCU HPCS HVAC hr IFI IKC IP ITS kw LAN LER LOCA LOOP LPCS LPCI HDS HDR HG NOV NWt NCR NDE NPSH NRC NRR Automatic Depressurizati.on System Average Power Range Honitor Alternate Rod Insertion Adjustable Speed Drive Anticipated Transients Without Scram Assistant Operations Support Hanager Containment Atmospheric Control Control Rod Drive Containment Instrument Air Control room Supervisor Direct Current Digital Feedwater Diesel Generator Emergency Core Cooling Systems Emergency Diesel Generator Emergency Operating Procedures Equipment Operator Emergency Procedures Guidelines Final Safety Analysis Report Field change request Fix it Now Gallons per Ninute general employee training Hydraulic Control Unit High Pressure Core Spray Heating Ventilation and Air Conditioning hour Inspection Followup Item Instrumentation and Control inspection procedure Improved Technical Specifications kilowatt Local Area Network Licensee Event Report Loss-of-Coolant Accident loss of offsite power low pressure core spray Low Pressure Coolant Injection master data sheet Material Deficiency Report motor generator motor-operated valve megawatts thermal nonConformance report Nondestructive Examination net positive suction head Nuclear Regulatory Commission Nuclear Reactor Regulation B-I

'1 c

PSA PER PERA PHT PTL PPH QA QC RCA RCA RCIC RHR RBH RPS RRC RWCU SSPV SALP SRV SSFI SPER TS TER Operating Instruction Operating Experience Review Performance Enhancement Strategy Performance Self Assessment Problem Evaluation Request Problem Evaluation Request Action Post Haintenance Test Plant Tracking Log Plant Procedures Hanual Quality Assurance Quality Control Root Cause Analysis Radiological Controlled Area Reactor Core Isolation Cooling residual heat removal Rod Block Honitor Reactor Protection System Reactor Recirculation Reactor Water Clean Up Scram solenoid pilot valve Systematic Assessment of Licensee Performance safety relief valve safety system functional inspections Significant Problem Evaluation Request Technical Specification Technical Evaluation Report Work Request

.8-2

NAME TITLE LIST OF ATTENDEES ENTRANCE INTERVIEW January 28, 1997 EPT.

R. Brownlee Alfred P. Gorlich W. H. Barley R. J.

Barbee Tom Foley Garmon West, Jr.

Dave Swank G. L. Gelhans P.

S. Ingersoll R.

E. Fuller David L. Strote Dale Atkinson Daljit s.

Hand Gary Sanford Terry Alton Steve Kirkendall James A. Isom Troy Pruett Rod Webring Andy Langdon Lourdes Fernandez John F. Peters Vaughn R. Harris Joe Mutt John C.

Hanson Harrilee Bartel H. Lisa Poznanski Carlos Leon NAME.

James A. Isom Tom Foley Garmon West, Jr.

Troy Pruett George Replogle Gregory 0. Smith Andy Langdon Hatteo M. Monopoli John F. Peters Joseph J.

Muth Lourdes Fernandez R. L. Webrong

'ic.

Eng.

Haint. Specialist Hanager Quality System Engineering Manager Sr. Engineer, Team Leader Engineering Psychologist Regulatory Affairs Hgr.

Asst.

8 Gen.

Hgr of Eng.

-Sys.

Eng. Supervisor Rx Engineer Operations Support Hgr.

Hgr. Rx/Fuel Eng.

Hgr. Design of Proj.

Eng.

Maintenance Manager Tech Specialist PSO Manager Operations Engineer RI - Waterford-3 VP Operations - Support Acting Ops.

Hanager Licensing Manager Quality Programs Supv.

Asst. Haint. Mgr..

Quality Services Chemistry Gen.

Supv.

Admin. Asst. Quality Tech Support Specialist PER Coordinator EXIT INTERVIEW February 6, 1997 TITLE Operations 'Engineer Sr. Engineer, Team Leader Engineering Psychologist RI Waterford-3 Resident Inspector Plant General Hanager Acting Ops.

Hanager, Operations Quality Programs Supv.

Quality Services Licensing Hanager VP Operations Support C-I Licensing Maint.

Quality Eng.

NRC NRC RA Eng.

Eng.

Rx Eng.

Ops.

Eng/Quality Eng.

Ops.

Quality PSO NRC NRC WPPSS SS SS SS SS SS SS SS Quality/SS Quality QEPT.

NRC NRC NRC NRC NRC SS SS SS SS SS SS

"SS

a

0

P.

R. Betris Alfred P. Gorlich Douglas L. Williams Linda M. Mar M. Lisa Poznanski G. L. Gelhans J.

W. Hassey C.

Leon R. J.

Barbee R.

E. Fuller P.

S. Ingersoll Gary Sanford Dave Swank Rod Webring W. H. Barley R. Brownlee R.

V. Roberts.

Amanda Barber Linda S.

Woosley David L. Strote Marianne Collins Dale Atkinson John Swaites VP Nuc. Ops.

Haint. Specialist Nuc.

Eng.

Tech Support Spec III Tech Support Sepc IV Asst.

Gen.

Mgr of Eng.

QA Tech Spec.

PER Program System Engineering Manager.

Rx Engineer Sys.

Eng. Supervisor Maintenance Manager Regulatory Affairs Mgr.

VP, OPS Support Manager Quality

.Lic. Eng.

Admin. Asst.

Quality Lead Quality Lead Operations Support Hgr.

Quality Eng.

Hgr. Rx/Fuel Eng.

Gen.

Mgr. Eng.

SS Maint.

OPA Admin/Quality Admin/Quality Eng.

QA QA Eng.

Rx Eng.

Eng.

Ops.

RA OPS Support Quality Licensing AA Quality Quality Ops.

Quality Eng/Quality

'ng.

C-2

Distribution Sheet Priority: Normal From: Kim Brown Distri99.txt gd

@-go/

Action Recipients:

NRR/DLPM/LPD4-2 J Cushing Internal Recipients:

TTC C-TNN RidsNrrDripRexb RidsNrrDipmOlhp RidsNrrDipmlipb RidsManager RidsEdoMailCenter RidsAcrsAcnwMailCenter RGN 4.FILE 01 OGC/RP OEMAIL OE NRR/DRIP/REXB NRR/DIPM/OLHP NRR/DI CENTER

ACRS Copies:

Not Found Not Found

.1

1 Not Found OK OK OK OK OK

OK Not Found Not Found OK Not Found Not Found

Not Found Not Found Not Found Not Found Not Found External Recipients:

NOAC INEEL Marshall Not Found Not Found Total Copies:

Item: ADAMS Document Library: ML ADAMS"HQNTAD01 ID: 003678934 Subject:

NRC INSPECTION 50-397/96-201 OPEN ITEM 96-201-03 COMMITMENTSTATUS UPDATE Page

Body:

Distri99.txt Docket: 05000397, Notes: N/A Page 2

ENERGY NORTH I/VEST PO. Box 968 a Rich(and, Washington 99352-0968 January 21, 2000 G02-00-016 Docket No. 50-397 U.S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C.

20555-0001 Gentlemen:

Subject:

NRC INSPECTION 50-397/96-201 OPEN ITEM96-201-03 COMMITMENTSTATUS UPDATE Reference:

Letter GO2-97-120, dated June 16, 1997, PR Bemis (Supply System) to NRC,

. NRC Inspection Report 96-201 Response to Open Items The purpose of this letter is to inform you of a change to a commitment made in response to an open item associated with Inspection Report 96-201.

In the reference, we committed to review and revise WNP-2 Design Requirements Documents (DRDs)

by an estimated completion date of December 31, 1999.

Although several DRDs have been reviewed and revised as planned, three DRD reviews remain to be completed, and eleven of twenty-seven DRDs reviewed remain to have comments incorporated.

These reviews have been delayed due to reassignment of personnel to emergent and priority issues such as the fire protection system flooding event and Thermo-Lag reduction efforts.

It should be noted that the WNP-2 DRD program has been reestablished and is an ongoing program.

Actions to complete the final reviews and follow-up revisions are being tracked to completion and will be completed as soon as practica OPEN ITEM96-201-03 COMMITMENTSTATUS UPDATE Page 2 of 2 Should you have questions or require additional information pertaining to this letter please contact me or DK Atkinson at (509) 377-4302.

Res tfully, DW Coleman Manager, Regulatory Affairs Mail Drop PE20 cc:

EW Merschoff - NRC-RIV JS Cushing. - NRC-NRR NRC Sr. Resident Inspector - 927N DL Williams - BPA/1399 TC Poindexter - Winston &Strawn

'I