IR 05000423/1990080

Insp Rept 50-423/90-80 on 900416-25.No Violations Noted. Major Areas Inspected:Development of Sufficient Procedures in Appropriate Areas to Cover Broad Spectrum of Accidents & Equipment Failures

ML20056A947
Person / Time
Site:	Millstone
Issue date:	08/02/1990
From:	Bissett P, Eselgroth P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20056A946	List: IR 05000423/1990080 ML20056A945
References
50-423-90-80, NUDOCS 9008100196
Download: ML20056A947 (29)

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- 4-V. S. NUCLEAR REGULATORY COMMISSION INSPECTION REPORT FACILITY DOCKET NO.

50-423 INSPECTION REPORT NO.: 50-423/90-B0 FACILITY LICENSE NO.: NPF-49 LICENSEE: Northeast Nuclear Energy Company

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P.O. Box 270 Hartford, Connecticut 06141 FACILITY: Millstone Plant, Unit 3 INSPECTION DATES: April 16 - 25, 1990 INSPECTION TEAM:

Team Leader: P. Bissett, Senior Operations Engineer, NRC Team Members: B. Hughes, Senior Operations Engineer, NRC K. Kalaczyk, Resident Inspector, Millstone, Unit 3 0. Moy, Reactor Engineer, NRC P. Reagan, Systems Engineer, COMEX M. McWilliams, Human Factors Specialist, SAIC SUBMITTED BY: .b/

Ppg H. Bissett O/' 7-20-7o Date

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Sienior Operations Engineer, PWR Section APPROVED BY:

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. Peter W.15elgroth,'Jhiel Date PWR Section, Opera'

Division of Reacdo'tions r Safety Branch

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9008100196 900807 PDR ADOCK 050004'3

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• + TABLE OF CONTENTS -

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Section

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h' f: '1;01 . Executiv'e ' Summary - -

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4 :- @  ;: Basic Comparison of. Owner's Grou'p. ERGS iwith Facility! E0Ps-(Taskul)

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1 b T3:0 'Independeht' Technical Adequacy Review of: ' '

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.the Emergency Procedures (Task'2)- >

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fs .4,0 rReYiew of the EmergencyLProcedures by .

i p Control Room and Plant Walkdowns-(Task 3)g g ,-

F S ' 5~. 0 Simulato'r/0bservations'(Task 4) , ,

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'. 66,0! 10n-Going ' Evaluation of the Emergency Procedures (Task. 5)

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7,0L .EOP 'UserfInterviews (Task 6)- '

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! 8,0 Management' Meetings- T

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-Att'achments '

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1,." : Documents Reviewe .

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2!- Deficiencie s-Identi fied : o y" ' y; . '

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L 3. 4 List of Weaknesses! Identified as' Ne;eding Correction s'N-

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i DETAILS

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. EXECUTIVE SUMMARY

A.special, announced team inspection was, conducted of the Millstone Plan [

Vnit 3 emergency procedures. .The purpose of the inspection was to '

determine if the emergency procedures used at the Millstone Plant Unit 3 g were technically correct; if their specified actions could be physically i accomplished using the existing equipment, controls and instrumentation; and if the available procedures had the usability necessary to provide

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I the~ operators with an effective operating tool, For this inspection, the '

term emergency procedures included the E0Ps, AOPs, and all procedures ;

l referenced directly within the E0Ps and AOPs. The inspection consisted of reviewing facility documents and procedures; performing procedure

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walkdowns, both in the control room and in the plant; and interviewing-

' facility personne .The overall assessment:of the Millstone Plant, Unit 3 emergency procedures, in place at the time of the inspection, is that the program for generation and maintenance of the procedures is adequate. It should be noted that a '

new revision to the E0P writer's guide (OP 3266) had recently been developed and all emergency operating procedures are currently being reviewed and i revised as necessary. At the time of this inspection, three (3) E0Ps ;

(E-0 E-1, & E-2) had been revised and approved, but not implemente (Prior to implementation, the licensee ensures that all licensed operators have received training on the newly revised procedures.) The inspection team determined that E0P readability and usability for those recently ;

revised had improved over those procedures' presently in plac ' BASIC COMPARISON OF OWNERS GROUP ERGS WITH FACILITY E0Ps PURPOSE:-

To ensure that the licensee had developed sufficient procedures in the appropriate areas to cover the broad spectrum of accidents and equipment failure .2 ' SCOPE: -

The inspection team compared the Westinghouse Owner's Group (wdO)

list of Emergency Response Guidelines (ERGS), Revision 1 of the High Pressure Version, to the Mi; -tone Unit 3 E0Ps that are now in effect.. Additionally, several draf t procedures that were written to the requirements of the revised writer's guide were reviewe The comparison was performed to ensure that the licensee developed procedures in accordance with the WOG recommendations or adequate justification was provided to substantiate why the guidelines were r not followe !

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The licensee has developed plant specific emergency operating  !'

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procedures that are consistent with'the WOG. Additionally,'the team noted that the licensee has decided to utilize the two column i

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format when developing abnormal operating procedures (AOPs) and b ;, .

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procedures for addressing other emergency events that are not-D specifically addressed in the WOG guidelines. Examples include the in ,

actions to be-taken in response to a dropped fuel element, performance' :

% of a shutdown and cooldown outside of the control' room, and, responses

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required for a station fir The team concluded that the licensee- ;

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,, -decision to use the two column format when developing these procedures i W

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L would improve readability and usability during an even ,

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- CONCLUSION: i g The team concluded that the licensee had developed and implemented ,

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appropriate procedures for addressing a broad spectrum of accidents ;

a at Millstone Unit ~

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m No violations or deviations were identified with respect to this

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functional are '

-l-3.0- ' INDEPENDEWT TECHNICAL ADEQUACY REVIEW 0F THE EMERGENCY PROCEDURES t t .

- PURPOSE:

Review the emergency procedures to assure that procedures are 1:

~#' technically adequate and accurately incorporate the guidelines of- :

the ERG '

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4 SCOPE:

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The scope of the review includes the procedures listed in Attachment

, 1. The E0Ps were reviewed to verify that appropriate priority of ai ' accident mitigation strategy is incorporated, as directed by the ERGS, *

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,y FINDINGS:

A PRIORITY OF ACCIDENT MITIGATION STRATEGY

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The recommended step sequence in the ERGS is closely followed in the E0Ps. The team found no major deficiencies in accident

'J mitigation strategy. Entry and exit points are generally well '

defined and appropriat '

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j l DEVIATIONS BETWEEN E0Ps and ERGS o 2  ;

The E0Ps generally follow the-guidance provided in the ERG' . i Deviations, warranted by plant specific design, are incorporated; into the E0Ps. But, justification of deviations 15 not adequately. documented in all cases. For example, step j

[ 18.d of E0P 35 ES-0.4 states "Added. step to direct operato '

to disable all but one charging pump and all but one SI pum :i L prior to cooling down to less than' 350 F." :This. describes j

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what the deviation is but does not explain why the deviation ,

exist .

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but the documentation was either lacking in detail or not completely develope For example,' step 5 of.E0P 35 E-2 uses

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an 80,000 gallon setpoint for'DWST level. The ERG uses a  !

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setpoint of 14,993 gallons. The Setpoint Document states i 80,000. gallons'is used because it is " conservative for operator- +

readability as well as in consideration of operator training." cl p

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Although 80,000 gallons may be a reasonable setpoint, the ,

Step Documentation provides no engineering justification for-  !

this deviatio ,

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Also, the Step Documentation does not ccerelate justifications 'I with the affected part of the E0P step. Thus, it is difficul to accurately assess the validity of deviations from the ERGS 1

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The licensee agreed to review and ensure that adequate j justification is provided for all deviations. Other examples l are. listed in Attachment 2. In light of the fact that all'of l the. EOPs'are currently being reviewed and revised, it:is appropriate that adequate documentation for deviations b si completed thortly after the revisions are complete. This will be tracked as Item No. 243/90-80-0 '

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c .- SAFETY SIGNIFICANCE OF DEVIATIONS  !

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The Team found no instance of' failure to perform a required '

safety evaluation, i

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d, DEVIATIONS WARRANTED BY PLANT SPECIFIC DESIGN l

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~I The Team found that deviations warranted by plant specific  ;

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design are adequately incorporated in the E0P L

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. SETPOINT DOCUMENTATION _

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Several plant specific setpoints were selected from the E0Ps , :

and compared to the setpoint documentation. Setpoints selected !

from the?EOPs matched the setpoint documentation. The _

documentation is adequately controlled. Adverse containment? l p values are provided when require DECISION POINTS

> ' Decision points in the E0Ps a're generally well defined. Senior reactor operator. licensed personnel demonstrated a good- l l understanding and ability to discriminate among decision i points, however some weaknesses exist in this-regard. Fo :

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example, step 18.d of E0P 35.ES-0.4 instructs the operator to i

" Disable all but one Charging Pump, ....." There is not

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! uniform understanding among all operators whether this means i racking down the breaker versus placing the control switch in- '

pull to lock... Also, in E0P-35 ES-0.4, step 21.d requires the -;

operator to determine if the " Entire RCS < 200 F" but does

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not clearly state how this is determined; Weaknesses such as ;

these examples warrant further review during the E0P revision process presently in progress. The licensee is currently

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reviewing and revising, as appropriate, all emergency operating _ l procedures. As of this inspection, E0Ps E-1, E-2, and E-3 'l have been reviewed and revised. Training and subsequent .

implementation of.the new E0Ps are currertly in progres Significant' improvements were noted when comparing the new

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procedures with the old. The licensee agreed to continue this -i review and revision of the remaining E0Ps without. dela l 3.4 ' CONCLUSIONS:

The Team determined that.the E0Ps generally follow the recommended- ;

ERG step sequence except where site. specific design dictates L otherwise. Entry, exit and procedural transition points are correct ,

and can be followed. The E0Ps are technically adequate and  !

incorporate the guidance'and intent of the-Westinghouse Emergency :

Response Guidelines. The weakness. identified in Paragraph 3. above will be tracked under Item No.. 423/80-90-0 P No violations _or deviations were identified with respect o this i functional are )

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o; < i o 4.0: REVIEW OF THE EMERGENCY PROCEDURES BY CONTROL ROOM AND PLANT WALK 00WNS ,

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i' ' PURPOSE:

o t To assure that the emergency operating procedures (EOPs) and  !

,' abnormal operating procedures (AOPS) can be: successfully ..

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Licensed and nonklicensed operators' were used to walkdown 'the !

x , Emergency Operating and Abnormal Operating procedures listed in *

, Attachment 1. The walkdowns were conducted on the simulator, in W+

the control room and in the plant to ensure that: (1) actions !

required by the procedure could be' accomplished using the installed 1

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S , equipment, instrumentation and controls; and (2) _ procedural guidance l was clear enough that operator confusion and error can be avoide J

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_ generally clear and provided sufficient detail for the operator to -

complete the required actions, o 'm FINDINGS: '

4 .During the review and-control room walkdowns of-the Emergency a j y

Operating procedures, deficiencies were identified and-discussed with the licensee prior to the_ exit meeting. The

.o licensee acknowledged and commi;ted to correction of the identified deficiencies. In many cases, the licensee had l

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already identified the deficiency and corrective action rad- i K been started. Deficiencies considered to be generi ;

A, procedural weaknesses are listed below:  :

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however, some' label tags are still of the old typ !

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kj - Control room equipment labels were not consistent with the .

nomenclature contained within the procedures. The team found

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T(s no instances of operational errors (by licensed control room i j 1- operations personnel) due to either nomenclature or label ~

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P' But, the potential for errors does exist, The following are examples of the differences between Control Room labels and

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.EOP 35 N _ Noun P m control Room Label' -

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ES- Main Steam Line SI- MAIN STEAM PRES SI h

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-ES- PZR SI - BLOCK A/B PZR PRES SI - BLOCK A/B c FR- Containment Recirculation PP SUCT ISOL  !

h- Pump Suction Isolation Valves j o FR- Containment Recirculation SPRAY HDR ISOL- ,

L Pump Spray-_ Header Valves

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FR- Containment-Recirculation $W IN l

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Heat Exchanger Service l Water Inlet -Valves '

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Containment Recirculation SW OUT

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Heat Exchanger Service  !

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The licensee has agreed to evaluate the extent of differences 1

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between the control room labeling and what.is designated within b .the E0Ps. Following this evaluation, a course of corrective '

action.will be taken to address this concern;:This will be  ;

tracked as' Item No.' 423/90-80-02, a During the walkdown of the E0P 35 FR-P.2, Response To Anticipated Pressurized Thermal Shock, a problem was noted j

with Technical Specification Figure 3.4-3, " Reactor Coolant l

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Cooldown. Limitations" which is referenced within FR-P.2. AL  :[

decimal point was'omitted from an axis, thus presenting invalid  ;

" numerical values.- The licensee stated that Figure 3.4-3.will ,

be updated and a revised figure will be submitted in the next .'

Technical Specification amendment submittal. Also, several operators expressed a. concern with the readability of-the j

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Integral Rod Worth vs. Rod Bank position chart, as referenced '

in Ops. Form 3209-10. The licensee has agreed to review the ,

chart in question and revise it accordingl l Those deficiancies identified within specific procedures are m listed in Attachment 2. The above items will collectively be a tracked as Item.No. 423/90-80-0 J

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4.4 CONCLUSIONS: ,

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The inspection team determined that the E0Ps could be successfully accomplished using the installed equipment, instrumentation and l control *

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5.0 $1blATOROBSERVATION(TASK-4)

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To. assure that the emergency operating. procedures (EOP) can be

Vi correctly implemented during emergency conditions, to= further ' evaluate concerns about E0P useability, and to assure that E0P- .

[ training-provides the operators with the necessary backgroun !

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Utilizing the plant referenced simulator, the team assassed the ,

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adequacy of the training on the E0Ps by observing the actions of l 0 ;r two crew:, of licensed operators during unrehearsed scenarios designed i to exercise crew familiarity with and the ability to use the EOP '; 1 The scenarios were developed with the intent of providing the team'

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the opportunity to, ,

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4 Observe the crew's performance to validate or resolve concerns ;

resulting from review of the E0Ps or A0Ps, j y -

. Assess the licensee's usage instructions with respect to the !

,. 'EOPs and A0Ps, especially chere initial reviews identified J differences from the ERGS.

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' [ Assess the human factors <lements associated with the>.

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performance in a real t'.mt situation.

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~ Assess the opergting crew's diagnosis of accident conditions j

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~ and transitions from one E0P to another E0P or'A0P.

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The scanarios consisted-of.the following (information enclosed in d

a parenthesis identifies expected procedure usage).  ;

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Scenario 1: Steam generator A has a 25 GPM tube leak. The turbine driven auxiliary feed pump is 00 [

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The reactor operator is the fire brigade leade :

u Fire occurs in the B diesel generato !

F' Loss of vacuum turbine' trip without reactor tri _i

[' Steam generator B safety valve fails open, q'p (FR-S.1, E-0, E-2, E-3, AOP-3555)

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No violations oc deviations were identified with respect to thi ;

functional are l L 5.0' SIMULATOR'0BSERVATION (TASK-4) l 5.1- PURPOSE:

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To assure that the emergency operating procedures (EOP) can be o correctly imr'emented during emergency conditions, to further y evaluate concerns about E0P useability, and to assure that E0P training provides the operators with the necessary backgr.oun . ' SCOPE:- -

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A Utilizing the' plant referenced simulator, the team assessed the ;

adequacy of the training on the E0Ps by observing the actions o two crews _of licensed operators during unrehearsed scenarios designed ;

to exercise crew familiarity with and:the ability to use the E0P '

The scenarios were developed with the intent of providing the team- :

the opportunity to:  !

t Observe the crew's performance to validate or resolve concerns I

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resulting from review of the E0Ps or AOP ,

' Assess the licensee's usage instructions with respect to the !

E0Ps and AOPs, especially where initial reviews identified .

' differences from the ERG l F

. Assess the human factors elements associated with the performance in a real time situation, Assess the. operating crew's diagnosis of accident conditions ,

and transitions from one E0P to another E0P or=AO ,i The scenarios consisted of the fo'llowing.(information enclosed in !

. parenthesis identifies expected procedure usage),

Scenario 1: Steam generator A'has a 25 GPM tube leak. The turbine driven auxiliary feed pump is 00 $

The reactor operator is the fire brigade. leader.-

Fire occurs in the B diesel generator,

, Loss of vacuum turbine trip without reactor tri ,

Steam generator B safety valve fails ope (FR-S.1, E-0, E-2, E-3, AOP-3555)

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i Scenario'2: Both B'and Turbine auxiliary feed pumps 005 l

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Loss of C-9 (steam dump permissive). '

Steam break with auto safety injection blocke ,

p Station blackout with B diesel: auto start failur '

(E-0 ECA-0.0 FR- local start of D/G)

h Scenario 3: LRC leak'through PORV-455 [/.

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Loss of DC bus '

Loss of off site power reactor tri i Natural circulation cooldow ;

i (E-0, AOP-3563, ES-0.1, ES-0.2 ) l i- Scenario 4: Identified 5 GPM leak in B' steam generato '

Fire in B diesel generato .< Reactor trip with loss of outside. powe No. 2 HP stop valve fails ope J Steam generator A tube rupture 700 GP (AOP-3356,3509 E-0 E-2 E-3 )

Scenario 5: Design base LOCA with A steam generator faulted inside containmen No. 3 HP stop valve fails to clos i (E-0, FR-Z.1, E-2, E-1 ) Findings .

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Both crews observed were capable of using.the.pr_ocedures to mitigate $

l the unset conditions. Tne operators. demonstrated a focused approach ,

a :1 utilizing the E0P and A0P network to mitigate complex failure ;

Communications between crew members was adequate, repeat backs and !

information exchanges were timely and appropriat j

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5.4: Conclusions:

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Based 'on the observations of the operating crews during the simulator exercises, the team determined that the E0Ps and A0Ps can be implemented during an emergency. The team has determined that the i

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Millstone 3 E0Ps have adequate usability, and training in E0P

implementation has been effective, ,t No violations or deviations were identified with respect to this functional a.ea, t

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6.0 ON-GOING EVALUATION OF THE EMERGENCY PROCEDURES

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Determine if the licensee has. established a long term evaluation n program for the emergency procedures as recommended in Section i 6.2.3 of NUREG-089 ,

O 6.2- SCOPE:

s Performance of this. task entailed a review of the administrative programs, procedures, and activities related to.the evaluation !

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and maintenance of E0Ps at Millstone Unit 3. Specifically, this -

review' examined the adequacy of: * the E0P' change and revision process; I verification and validation activities;  ? the. E0P Writer's Guide: involvement of independent quality assurance organizations

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in the evaluation process;

.# ~6 .3 FINDINGS: [ The E0P change and revision process is described in OP 326 Revision 2 to this procedure has recently been issued and, with minor '

exceptions, appears to provide satisfactory guidance in controlling l revisions to the E0Ps. One area however, where the licensee's program .,

was found to be deficient was in' allowing hand-written changes to .J-be incorporated into the procedures pending issuance of the next '

revision. No limits were established regulating the length of time -l such changes can remain in effect before.the procedure must be i revised. Many of the E0Ps that were reviewed evidenced change ;

that were made several months earlier. The licensee's procedure maintenance system appears to impede timely updates and revisions to the E0Ps. Other areas where weaknesses were identified included the. lack of formalized processes for providing feedback to operators who initiate procedure change requests, and for ensuring timely .,'

notification to operators of changes to the E0Ps. The licensee has .

been evaluating various computerized systems that, once implemented, t should alleviate many of the concerns identified above. However to

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date, no final decision has been made. Because of the importance of -

maintaining and updating emergency operating procedures, timely l resolution is needed. The weakness identified above will be tracked as Item No. 423/90-80-0 t

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b. Requirements for E0P verification and validation are described in OP 3258 and OP 326 In general, the V&V program described in recently issued versions of these procedures appears to be comprehensive and etnsistent with guidance provided in NUREG 089 Some weaknesses were noted, however, including a lack of stipulated requirements to verify local equipment labeling and accessibility, and appropriate scaling of instrumentation. The Millstone 3 staff reported that these activities were done as a matter of course, however the licensee agreed to add appropriate wording to the V&V instructions. As part of the current E0P upgrade effort, the licensee has recently completed walkdown validations of local actions using the most recent version of OP 3268. In reviewing the results of these walkdowns, it was observed that with few exceptions, the problems that were noted during walkdowns by the inspection team had also been identified by the licensee. Licensee corrective action regarding identified deficiencies will be completed during the revision of the E0Ps currently in progress (discussed in Paragraph 3.3.f).

c. Guidance for the development and revision of E0Ps is provided in OP 3266, " Emergency Operating Procedure Writer's Guide." Revision 2 of this document has recently been issued and incorporates a number of enhancements over the previous version that was submitted as part of Millstone 3's Procedure Generation Package. In general, the current version appears to provide adequate direction for procedure development and revision, and is consistent with accepted human factors principles and guidance pruvided in NUREG-0899. There are a few areas however where inconsistencies were noted or where guidance warrants additional detail. These areas are identified belo Additionally, a nether of typographical Prrors were observed which detract from the useability of the documen Foldout Pages (Section 6.1.3.5) - Additional information is needed on the format and content of foldout pages. More

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detail 13 required as to the treatment of recurrent steps if this is where they are to be addresse Level of Detail (Section 6.1.6) - This section cautions the writer against use of excessive detail and directs him not to include information which the operator is required to know. This caution does not appear to take into consideration the knowledge level of the " newly qualified" operator as well as the potential for performance degradation which occurs under stressful condition Component Identification (Section 6.1.8) - This section describes three acceptable methoas for referring to a component or piece of equipment. However, no guidance is provided as to when each method is preferre '

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Use of Logic Terms (Section 6.2.6) - T$e Writer's Guide does t h' 1 not give examples of misuse and cautir,n against highlighting AND/0R when.used as simple coriunctioas or using them together-

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in the same sentenc "

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Transition Expressions (Section 6.2.9) - Instructions for -

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. references to non-EOPs do'not require identification o ,

L the specific steps or sections to be performed by the i operato W; Tables and Figures - Discussion of tables and' figures, --,

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including graphs, is not included in the writer's guid ! :d. Ongoing evaluation of.the E0Ps by an independent quality assurance

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organization has been extremely limited. The Quality Assurance . !

Department is currently developing a plan for performing periodic '

L audits of the E0Ps. During the conduct of this inspection, it was ~ .t i determined that the Quality Assurance group had commenced, in .

February, an audit of .the conformance of the E0PS to the Writer's J ' Guide.'The. audit, however, was not scheduled to be completed until L '

mid-May. Discussions with Quality Assurance personnel indicated .:

that preliminary results paralleled those of the NRC in that the i TJ < E0Ps often did not follow the Writer's Guide. However, they too

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I recognized the fact that only three E0Ps had been recently rewritten !

M, ; in accordance with the newly revised Writer's Guid The lit.ensee agreed to inform the NRC of the results of the audit A60499, and of the schedule of planned periodic audits of the Emergency ;

' Operating Procedure *

-, CONCLUSIONS:

i The team determined that with the exception of the weaknesses identified above, the licensee's program for ongoing evaluation j)

-and maintenance of the E0Ps was adequate. The licensee agreed ;

to resolve those deficiencies noted abov .

No violations or deviations were identified with respect to this functional are ..

-7.0 'E0P USER INTERVIEWS .!

, PUROPOSE:

To augment and clarify findings from other inspection tasks through interviews with procedure users, developers, trainers, and other appropriate plant staf .

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< SCOPE:

Operators (R0s and SR0s) were interviewed to determine their understanding of the E0Ps and their responsibilities in executing the procedures as part of the control room team. Additionally, operator opinions were solicited regarding adequacy of training on the E0Ps, opportunities for operator input in revising the E0Ps, and overall satisfaction with the technical accuracy and useability of the procedures. Interviews were also conducted with non-licensed operations staff regarding their roles i supporting the implementation of the E0Ps, and E0P developers regarding procedure development, revision and verification and validation (V&V) activitie .3 FINDING $:

In general, licensed operators demonstrated a good understanding of the E0Ps and expressed no significant concerns regarding the accuracy or usability of the procedures. There were some instances where operators said that additional clarification or guidance might be helpful, but none were viewed as safety problems. Most operators felt that their training was adequate, however some stated that additional training in the ERG basis documents would be helpfu Operators stated that revisions to E0Ps are addressed in each requalification cycle, but that they are not always notified of changes prior to trainin Interviews with the E0P coordinator and development staff indicated a thorough knowledge of the recently revised procedures governing E0P change and revision V&V, the procedure writers guide, and

. industry /NRC guidance related to E0Ps. In discussing preliminary findings of the inspection, it was determined that many of the team's concerns were already being addressed as part of the current E0P revision effort. Several draft revisions to the E0Ps were provided to the inspection team confirming that these changes were being incorporate .4 CONCLUSIONS:

Overall, interviews with the E0P users corroborated the findings of the inspection team as described elsewhere in this repor Interviews confirmed that the operators have confidence in the technical accuracy and useability of the E0P No violations or deviations were identified as a result of this functional are .

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i F ' 8 '. 0 ' MANAGEMENT' MEETINGS i

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The major inspection findings were presented and the remainder of the~

p~ . findings were summarized to all personnel.present at the exit meeting as- :

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noted in paragraph 9.0.

l:. l 9;0 Personnel Contacted-

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Licenseef i C. Clement, Millstone Plant 3 Director a e K. Covin, Operations Assistant /EOP Coordinato ;

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F.. ~ DiCarlo, Quality Services Specialist- i e M. Gentry, Operations, Manager W J. Gionet, Quality-Services. Engineer 6 J. Harris, Engineering Manager 1 K.-Jensen, Assistant Reactor Engineer '

p R. Joshi,. Senior Licensing Engineer _;

, .T. Kulterman, Operations' Engineer j J. LaWare, Senior Engineering Technician 1 y < C. LibbyE:. Supervisor,J Assessment. Services.

f S. Rovin, E0P Procedure Editor e

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R. Stotts, Supervisor, Operator Training 1

, T. Trump, Human-Factors Specialist NRC:

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PT Bissett,' Senior Operations Engineer s

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O. Hughes, Senior Operations Engineer  :{

.K. Kolaczyk,: Resident: Inspector, Unit 3  :

D. Moy, Operations Engineer i W. Raymond, Senior: Resident Inspector' q

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NRC Contractors: ,'

M. McWilliams, Human. Factors Specialist, SAIC P. Reagan, System Engineer, COMEX Corporatio . -j

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. ~b ATTACHMENT l'

DOCUMENTS REVIEWED  !

' 4 Document < Document Number Title REV

' EMERGENCY OPERATING PROCEDURES i

E0P 35 E-0- REACTOR TRIP OR SAFETY INJECTION 5 E0P 35 ES-0.0L REDIAGNOSIS -2 -

E0P 35 ES- REACTOR TRIP RESPONSE 6- ;

E0P 35 ES- NATURAL CIRCULATION COOLDOWN . 3 1 E0P 35 ES- NATURAL CIRCULATION C00LDOWN WITH STEAM VOID *

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IN VESSEL (WITH RVLMS) 3 E0P 35LES-0,4 NATURAL CIRCULATION C00LDOWN WITH STEAM VOID IN VESSEL (WITHOUT RVLMS) , 3 I E0P 35 E-1- LOSS OF REACTOR OR SECONDARY COOLANT 4 1 E0P'35 ES-1.1- SI TERMINATION 5 E0P 35 ES-1.2- POST 1LOCA C00LOOWN AND DEPRESSURIZATION 3 E0P 35 ES- TRANSFER TO COLD LEG RECIRCULATION 3 E0P 35 ES-1.4' TRANSFER TO HOT LEG RECIRCULATION 3 E0P.35 E-2 FAULTED STEAM GENERATOR ISOLATION 3 E0P 35 E-3 STEAM GENERATOR TUBE RUPTURE 5 -

E0P 35 ES- POST-SGTR C00LDOWN USING BACKFILL 3 E0P'35 ES-3.2: POST-SGTR C00LDOWN USING BLOWDOWN 3 i E0P 35 ES- POST-SGTR C00LDOWN USING STEAM DUMP 4 s

.EOP 35 ECA- LOSS OF ALL AC POWER 4 E0P.35 ECA- LOSS OF.ALL AC POWER RECOVERY WITHOUT 4

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SI REQUIRED E0P 35 ECA- LOSS OF ALL AC POWER RECOVERY WITH SI 3'

REQUIRED E0P~35 ECA- LOSS OF EMERGENCY COOLANT RECIRCULATION 3-

.EOP 35 ECA-1,2

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LOCA OUTSIDE CONTAINMENT 2

,E0P 35 ECA- UNCONTROLLED DEPRESSURIZATION OF ALL 4 STEAM GENERATORS

E0P 35 ECA- SGTR WITH LOSS OF REACTOR COOLANT - 4 SUBC00 LED RECOVERY DESIRED E0P 35 ECA- SGTR WITH LOSS OF REACTOR COOLANT - 3 SATURATED REC 0VERY DESIRED-EOP 35 ECA- SGTR WITHOUT PRESSURIZER PRESSURE CONTROL 4 .

E0P_.35 FR- RESPONSE TO NUCLEAR POWER GENERATION /ATWS 3 .

E0P:35.FR- RESPONSE TO LOSS OF CORE SHUTDOWN 2 <

E0P 35 FR- RESPONSE TO INADEQUATE CORE COOLING- 3 E0P 35 FR- RESPONSE TO DEGRADED CORE COOLING 3 E0P.35 FR- RESPONSE TO SATURATED CORE CONDITIONS 1 E0P:35 FR-H'1 .

RESPONSE TO LOSS OF SECONDARY HEAT SINK 3 E0P 35 FR- RESPONSE TO STEAM GENERATOR OVERPRESSURE 3

'EOP 35 FR- RESPONSE TO STEAM GENERATOR HIGH LEVEL 2

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E0P 35 FR- RESPONSE TO LOSS OF NORMAL STEAM RELEASE 3

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CAPABILITIES E0P 35 FR- RESPONSE TO STEAM GENERATOR-LOW LEVEL 2 E0P 35 FR- '

RESPONSE TO IMMINENT PRESSURIZED THERMAL 4' ,

SH0CK CONDITION C EOP 35 FR- RESPONSE TO ANTICIPATED PRESSURIZEb 3 ,

-THERMAL SHOCK CONDITION E0P 35 FR-Z 1 RESPONSE TO HIGH CONTAINMENT PRESSURE 3-E0P-35 FR- RESPONSE 10 CONTAINMENT FLOODING 2

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E0P 35 FR- RESPONSE TO HIGH CONTA!NMENT RADIATION . 1 E0P'35 FR- RESPONSE TO HIGH PRESSURIZER. LEVEL 3 1 EOP 35 FRE RESPONSE.TO LOW PRESSURIZER LEVEL 2

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, EOP 35 FR- RESPONSE ~TO VOIDS IN REACTOR VESSEL - 3- l E0P 3505 LOSS OF SHUTDOWN COOLING (RHR) 2  !

E0P 3509 FIRE FMERGENCY .

4 ~AOP 3550 TURBINE / GENERATOR' TRIP 1- 1

'AOP'3554 *

REACTOR COOLANT PUMP TRIP OR SEAL FAILURE' 1 LAOP.3555 REACTOR'C00LANT LEAK . 'l A0P 3556 STEAM GENERATOR TUBE LEAK 0 OP l3265 EMERGENCY 0PERATING PROCEDURE CHANGES 2 AND REVISIONS -

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OP 3268 EMERGENCY OPERATING PROCEDURE VALIDATIONS 1

0P.3266 EMERGENCY OPERATING PROCEDURE WRITERS 2 ,

- GUIDE i 0P 3258 EMERGENCY OPERATING PROCEDURE VERIFICATIONS 2-l

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ATTACHMENT 2

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DEFICIENCIES IDENTIFIED i

GENERAL FINDINGS APPLICABLE TO VARIOUS E0Ps:

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t Certain procedure steps- require that plant personnel have necessary

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• ' keys for doors and locks. The E0Ps do not designate either the areas or'

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equipment that may be locke ' a.ne E0P steps require either fuses to be' pulled or breakers to be racked awn . Licensed norrations personnel did not provide.a clear and con-sistent descr a tren of the method they would use to tag and log such items (e.g., pulled <>t:s, lif ted leads, breaker and valve positions). Consistently use the term " locally" in regard to equipment operatio The term " locally" is sometimes confused with the term " manually." '

, The team found that some E0P steps involve operation of infrequently used equipment. Without specific guidance, particularly for the Plant F

Equipment Operators, there is an increased potential for either delays or operational errors. Attachment A to E0P 35.E-2, revision-4 (not yet approved), is_ an example of the licensee's current endeavor-to improve guidance in'that regar + The E0Ps reference other procedures, including certain Operating Procedures (ops). In some cases, the referenced procedure is a long complex document, making lacation of the desired entry point in the referenced procedure i somewhat-difffcult. In other cases, a seldom performed action or RNO has

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no procedure reference. The licensee recognizes this deficiency and m intends to. improve the Writer's Guide instructions for referencin . The reading precision of the instrument is a key factor in determiration of'

the; numeric values used in E0Ps. The Writer's Guide provides guidance in' >

this regard. Some E0Ps contain numerical values that cannot be read on the instruments'available to the operato Examples of this deficiency include E0P 05 ES-0.1, Step 5.a (1892 PSIA) and E0P 35 FR-Z.1, Step 2,a (22.7 PSIA). The-licensee recognizes this deficiency and it is being '

addressed as the E0Ps are revise t Pressurizer spray effectiveness is affected by which reactor coolant i: pump (RCP)is runnin RCP 2 is most effective, while RCP 1 is not

particularly effective when operating alone. Either Notes or Steps in several E0Ps provide a priority order for running the RCPs. For example,

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the Note above E0P 35 ES-0.1, Step 9 says "... order of priority (2, 1, s_ then 3 or 4)." Interviews with operators indicated additional guidance fis necessary to clearly remind the operator which RCP and RCP combinations are the recommended priority orde ,

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- FINDINGS APPLICABLE TO SPECIFIC-EOPs:

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E0P 35 E-0-REACTOR TRIP OR. SAFETY INJECTION

. Step 1 A pressure boundary door in the ccr.tr;l evum is missing a handwhee This would prohibit operation of the door from outside the control roo '

' Step 15 RNO Requires' local operation of instrument air' valve 3HVC-AOD 134. Operation of this . valve requires leaving the control room af ter all entrances to the control room have already been closed and dogged in step . Step 2 Valves named in the procedure do not match the control-identification tag E0P 35 E-1 LOSS OF REACTOR OR SECONDARY COOLANT Step 2, RNO Specifics are not listed for isolating a S/G

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1 Step 11.c-

. Specific-0P (including step) needs to be listed for aligning a D/G for standby operation E0P 35 ES-0.1 REACTOR TRIP RESPONSE Step 2, RNO 2. As writ'en, t this conforms with the ERG but does not conform with the Writer's Guide. The acronym "AFW" is provided with no action statemen . Step-4, RNO 4. This step requires closure of the orifice valves, then closure of the letdown isolation valves. During procedure walkdowns, all operators did not immediately recall this sequence. It is not defined in the E0 ,- Step 4, RNO 5.b.1 (pressure > 2250 PSIA)

The Writer's Guide requires capitalization of all engraved switch position indications. Thus, "off" should be capitalize E0P 35 ES-0.2 NATURAL CIRCULATION C00LDOWN Step 1.a and 1 These references to OP-33010 and OP-3208, respectively, do not conform with the Writer's Guide requirements for transition expression . . . _ . . . _ _

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3 Step The setpoint of "< 50 F/0 Hour" does not agree with the Setpoint Documen This may be a typographical erro ; STEP 1 The Sl Accumulator Isolation Valve breakers are normally locked ope These valves cannot be closed without first unlocking and closing their breaker .

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E0P 35 ES-0.3 Natural Circulation Cooldown with Steam Void in Vessel (with-RVLMS). Cautions, Page 3 Caution 1 is a contingent transition based on SI actuatio Caution 2 is a verification of entry conditions. Neither meets criteria for caution statements as described in writer's guid . Notes, Page 3 Note 2 is not clear in indicating the preference for starting multiple RCPs as operators indicated would be helpfu . Step Reference to OP 3301D-does not indicate applicable section (A new section 7.4 recently added to cover RCP emergency start.) Step 6.a (RNO)

Contingency action does not direct operator to complete all of step 6 when requirements are met, not just . Step 6 b&d .

These step: are not identified as local actions and reworded to more clearly indicate desired action (i.e. close, open breakers at MCC).

. Step Step'd Cirects operator to disable pumps prior to cooling down to <350 degrees. However, according to verification of criteria in substep a,: operator can only get to step d if RC3 is already < 350 degree .- Step Step does not provide reference to OP3301.1 for arming COP . Step 10 Does not reference applicable operating procedure for shutdown (OP 3208, Section 5.3.4) Step 1 Does not reference applicable operating procedure for vessel head vent letdown (OP 3304A, Section 7.15.)

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E0P~35 ES-0.4 NATURAL CIRCULATION C00LDOWN WITH STEAM VOID IN VESSEL-

[WITHOUTlVLMS)

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- ~ Step The setpoint of "< 50 F/ Hour" does not agree with the Setpoint Document. . This may be a typographical erro . Step The SI Accumulator Isolation Valve breakers are normally locked ope These valves cannot be closed itnout first unlocking and closing their breaker . Step 1 The reference to OP-3310 and OP-3208 does not conform with the

- Writer's Guide. The correct expression for referencing is "using", not

"as follows."

E0P 35 E-2 FAULTED STEAM GENERATOR ISOLATION The Team reviewed revision 3 and revision 4 of this procedure. Revision 4 is' not yet approved. But, revision 4 contains useful enhancements such as the attachment, " Guidance for the Local Isolation of a Faulted Steam Generator." Further, Revision 4 is indicative of the licensee's efforts to improve the E0P The following comments apply to Revision . Step 4 Pulling control power fuses 3FWS*CTV41A through 0 may be necessary during this step. Tagging and logging equipment status changes, such as pulling fuses, lifting leads and racking down breakers, is_gcVerned by plant procedures during normal operation. But, neither the E0Ps nor the ERGS contain definitive guidance on the issue of tagging and~ logging-equipment status during emergencies. The lack of clear guidance in this regard has the potential to negatively affect au.ident mitigation and recovery activitie . Step If the operator is not ai! to identify the faulted SG by checking SG pressure, operator is di etted to check various lines and equipment for signs of initiating break,'followed by direction to proceed to step As these checks (all local actions) could take some time to complete, the direction to'preceed to step 5 may be placed earlier in the step so that the operator knows not to w.it until completion of all checks before going

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on. The ERG specifically states that operators should not delay recovery actions in the event that the faulted SG cannot be identified at this poin . Step 5 (RNO)

Reference to OP 3322 for instructions on shif ting AFW pump suction to CST does not identify applicable section of this procedure (7.5).

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Valves 3DTM-V936&7 are located under a floor grating and difficult to find,' indicating need for above grating tags and/or note in attachment-to new procedure. These valves would also be extremely difficult to operate locall Local. operation of 3SSR-V46 requires key to access High Rad Are This requirement'is not indicated on Attachment A to Rev t Step 6'a'RNO-Contingency action transitions operator to E-3 based on either radiation trend abnormal or SG level increasing in an unexpected manner. 'The-left hand column, however provided no direction'to check SG level. If this is a valid indicator of SG tube rupture, the left

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hand column needs to provide direction for making this check.-

ES-0.0 REDIAGNOSIS 1 ~. - Step 1 & Negative wording adds potential for confusio i ES-0.1. REACTOR < TRIP RESPONSE 1, Page two'and Foldout page torn in Control Room E0P se . Step 3 ,

Stepthas operator verify All Control Rods inserted. RNO: column gives direction based on-two or more NOT inserted. .No guidance provided for condition where one rod NOT inserte . Step 9 RNO High level step directs operator to start'RCP. Substep, however gives direction for establishing start up criteria; Step needs to be reworded such that direction for startup is .not given until statup conditions' verifie ,

ES-0.2 NATURAL CIRCULATION C00LDOWN I

1; Note, Page 8 Note prior to step 12 refering operator to ES-03 or ES-04 is misplaced and appears to belong immediately prior to Step 14. Also, phrase " refer to" may be revised to clearly indicate that operator is to branch to a ,

new procedure, i ES-1.1 SI TERMINATION Step 3 No guidance provided if one instrument air compressor is not running.

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Specific ! valves are not liste .- - Step 8-Range or direction of pressurizer level to be maintained is not liste ES-1;2 POST'LOCA C00LDOWN AND DEPRESSURIZATION 1;- Step 3 RNO-does not match the step-documentation provide , Step!16 _

'Does not designate which cold leg injection valve needs to be close ' RNO Step'18 Doest not specify appropriate section'of OP 33010, RCP Operatio . ' Step 22,c Does not state Accumulator Isolation. valve ES-1,3 COLD LEG RECIRCULATION l ', Cautio Requires memorization of HPSI pump shutoff head pressur ES-3.1 POST-SGTR C00LDOWN USING BACKFILL Entry condition, Step la-Step numberHis 40 instead of step 39 as stated in the procedur . Step OP 3208, Plant Cooldown appears to be incorrect. OP 3310A,_RHR Cooldown appears to:be correct procedur ES-3.2 POST-SGTR C00LDOWN'U5ING BLOWDOWN- Step.5.b FN0 OR is incorrectly highlighted'as a logic term. Also, operator is not provided guidance as to when it is appropriate to use a faulted steam

. generator vs transitioning to ECA-3.1 rather than indicating they are equally acceptable alternatives. Same in step 14 . Step 13 0P 3310A and applicable step are not include . Step 1 Step 5.28 is needed in the procedur . . . . . . - - - - -

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ES-3.'3 PO'ST'SGTR C00LDOWN USING STEAM DUM '

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2.: - Step 13 b Step 5.28 is needed in the procedur ,

, 3! Step 12-Typograpqical error. Should read GP ECA-0.0 LOSS OF=ALL AC POWER

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' Step calls for verification of AFW flow to steam generators. Operator states, however that on loss of= AC power,; flow indication is los .Same: problem with'RNO-step a requiring verification of TO AFW pump runnin . Step = ldentify actions as locally performe l Step 8

- Step directs operator to place valve switches-in close position,

' ? however operator reports that spring return prevents switches from

'being placed in close '

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4 '... Step'11

Step' directs operator to check SG tubes for rupture by dispatching personnel-to check Main Steam Lines using portable survey instrument ' Operator reports unlikelylto get much information in this manne . Step 15 RNO

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Contingency directs operator to establish communications with MSVB using sound powered phone. Closest outlet, however is a considerable distance from MSVB locatio ,

ECA-1.1; LOSS OF COOLANT RECIRCULATION a ' Procedure-OP 3304C and initiating step are not liste w J RNO Step Unable to reach RNO if logic, as written, is followe . Step Unable to read indicator value as listed for containment pressur l

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.Does'not list appropriate valve .)

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li - 3 :. Unable to read-ir,dicator value as111sted for RWST leve '

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Procedure 0P 33108 and initiating step are not liste ' 4

' ' Step 27,a'and 2 Unable to read indicator value as listed for SG pressures, ns 1 .

RNO Step 2 I

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g (Je' . Should be opposite step 27d vice 27 ,;

, 1 Step 2 ;g Unaole to read indicator value as listed for SG pressure,

'1 RNO Step'2 *z-Applicable procedure and initiating step are not listed for venting an 9r >

unisolated accumulato '

1 : Step.33.a r = Applicable procedure (s) and initiating steps are not listed for operating the RHR syste '"

ECA-1,2 LOCA OUTSIDE CONTAINMENT 4 Step 2.a,b,c Valve 3CHS*CV8160 is located inside containment, therefore will be j

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unable to locally operate Valves 3CHS*MV8105 &MV8106 were not  ;

labeled. Valve 3CHS*MV8100 had an old label attache .e Step' No valve label for 3RHS*MV8701 !

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q 9 i ECA 3.1 SGTR WITH LOSS Step 7 b No RNO action is provided if radiation levels are greater than norma . Step 28

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This step. incorrectly. requires the shutting down of one circulating pump'per ba ' Step 3 .

- RNO requires reading the post-accident: neutron monitor to 10E-10 amps .

yet indication is available to only 10E-8 amp Problem also identified in ECA 3.2 and ECA-3.2 SGTR WITH LOSS OF REACTOR COOLANT SATURATED REC 0VERY DESIRED ' Step 3 Negative wording in step is confusing. Step may be rewritten in accordance with recent Wesinghouse guidanc . Step 22.a-This step does not , identify which AC emergency buses should be re-energize ECA-3.3 SGTR WITHOUT PRESSURIZER PRESSURE CONTROL Step:16 This step does not identify which AC emergency buses should be re-energize 'FR-C.3 RESPONSE TO SATURATED CORE CONDITIONS

' Entry Conditions Procedure. specifies Mode 4 as being applicable, yet WOG procedures were written for Modes 1, 2, or 3 only. Entry into the E0Ps during-Mode 4 warrants a step by step evaluatio ' '

FR-H.1 RESPONSE TO LOSS OF SECONDARY HEAT SINK z . Step').b No adverse containment value for RCS temperatur . Caution Unable to read on indicators values as listed for RWST level and contaiment pressur FR-H.2 RESPONSE TO STEAM GENERATOR OVERPRESSURE NOTE AND Step Unable to read on indicators values as listed for SG pressure l

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. FR-H.3 RESPONSE TO STEAM GENERATOR HIGH LEVEL

' _ Step The conditional phrase,-(if SG blowdown is isolated) is presented after the' contingent action. Also. logic terms not highlighte .

FR-S.1 RESPONSE TO NUCLEAR POWER GENERATIOP ATWS

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Contingency step b directs' operator to take action IF boration flow

< 33. However, main step only directs operator to'open boration path-and does.not give direction to check flow. Same problem in A0P 3566, Immediate Boratio . Step 8 RNO During the simulator exercise, IF NOT wording in the RNO column caused the operator'to inadvertantly go to step 12 when in fact the condition for the transition was not satisfie , -FR-S.2 RESPCNSE TO LOSS 0: CORE SHUT 00WN Step 2 Change-to "Startup Rate Channel" vice " Source Range Channel."

E0P 35 FR-Z.1 RESPONSE TO HIGH CONTAINMENT PRESSURE .The SPOS-includes an entry-condition for containment H2 > 0.5%. That

' entry.. condition is not shown on either the E0P or the hard copy of the tree . Step The stated.,alue-is-22.7 psi That conforms with the ERG, but can not be observed by the operator at such accurac . . Step After starting the pump, there is no requirement to check the Containment Recirculation Pump for proper operation and flow. Thus, the RNO column is not complet . -Step 6 Does not include valve numbers to ensure the appropriate valves will be correctly positione . Step 1 Does not specify that this step is accomplished by starting the Hydrogen Monitoring System, If in an adverse containnient condition, the SPDS display of the Heat Sink Tree does not display the "(34*4)" value labe .

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E0P 35 FR-Z,2 RESPONSE TO CONTAINMENT FLOODING w Step 2 .

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Sampling of the containment sump is performed by Chemistry personnel using EPIP-4224, Operations personnel support Chemistry personnel by operating

<. certain valves. .Some'of-these valves (3 SSP-SCL3-834, 835 and 845) are located in a potentially high-radiation area (post accident), By procedure, said valves are to be verified open. TFst activity could result in d; unnecessary personnel exposur '

4:  : E0P-35 FR-Z,3 RESPONSE TO HIGH= CONTAINMENT RADIATION

'1, Step 2 .

Sampling of the containment atmosphere is performed by Chemistry personnel using _ EPIP-4225~, Operations personnel support Chemistry personnel by N operating certain valve >

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. ATTACHMENT 3L

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LIST OF-WEAKNESSES ID'ENTIFIED AS NEEDING CORRECTION- -

' Item N Para. N Description  :

90-80-01- 3. Following review and revision of E0Ps,

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correct deviation document errors and more fully k

= document deviation justification ~

'90-80-02 -4. Id'entify . labelling'versus.EOP. procedure discrepancies. Evaluate and identify actions

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,.90-80-03 4. Review deficiencies identified during.NRC'

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90-80-04 -6. Further evaluateLimproved system for control and'

revisionLof E0P .,.

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