IR 05000443/1997005
| ML20212D856 | |
| Person / Time | |
|---|---|
| Site: | Seabrook  |
| Issue date: | 10/27/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20212D821 | List: |
| References | |
| 50-443-97-05, 50-443-97-5, NUDOCS 9710310206 | |
| Download: ML20212D856 (30) | |
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Enclosure 1 U. S. NUCLEAR REGULATORY COMMISSION
REGION I
Decket No.:
50-443 License No.:
N.F.-86 Report No.:
50-443/97-05 l
Licensee:
North Atlantic Energy Service Corporation Facility:
Seabrook Generating Station, Unit 1 Location:
Post Office Box 300 Seabrook, New Hampshire 03874 Dates:
August 25,1997-September 10,1997 Inspectors:
William J. Raymond, Group Leader Eben L. Conrier, Project Engineer Scott C. Flanders, Project Manager Approved by:
Richard Conte, Chief, Reactor Projects Branch No. 8
. Division of Reactor Projects
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EXECUTIVE SUMMARY NRC Inspection Report No. 50-443/97 05 Problem Identification / Root Cause Analysis / Corrective Actions The problem identification process had generally improved having been consolidated into one process and with a lower threshold for reporting issues. The Adverse Condition Report (ACR) process was administered well to provide trend, status and closeout data on probiern resolution. ACR files were well organized and support information was readily retrievable. Programs are in place to trend issues and track the backlog. The ACR data demonstrated a good questioning attitude at the station, and the vigor with which the line organization and oversight organizations identify, investigate and analyze events. The Management Review Team (MRT) appeared to be effective in ensuring the quality of event evaluations and appropriate corrective action assignments. Operability evaluations were generally of good quality with reasonable basis for their conclusions.
The root cause analysis (RCA) and corrective actions for issues reviewed were generally good, with some good expansion of scope where warranted. Exceptions to good performance were noted in the adequacy of cause identification for some problems, and in the development of effective corrective actions. Corrective actions in the past did not always address generic concerns, or did not always address cuntributing causes of adverse conditions. The appropriate level of management involvement appears to be present, as reflected in the number of initiatives implemented or in progress to improve the current programs and the corrective action process at the station. Although significant backlogs were noted, the licensee was aware of the reasons for these problems and actions were in progress to reduce the backlog. Recurrent themes and barriers to success in the area of effective problem analysis and resolution include the need to more consistently identify the causes for performance issues, and take effective corrective measures based on trends, to effectively deal with the backlog of a high volume low threshold process, and to effectively
control process improvement changes. Except for the deficiency tagging and evaluation process, these problems had been recognized by you before the inspection; the effectiveness of your recent initiatives remains to be demonstrated.
Oversight Groups The Operating Events Review program appears to be effectively implemented and a strength. The review of selected industry events demonstrated good implementation of lessons learned. Assessments of industry events were quickly distributed with good evaluations. The concerns for a review backlog and information overload were known by the licensee and were being addressed.
The NSARC and SORC satisfied their oversight requirements and appeared to be effective in assuring quality. One exception to good performance involved untimely resolution a NSARC concern about a PORC approved safety evaluation. Both committees displayed a good questioning attitude and appear to focus appropriately on issues important to nuclect safety, ii i
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Self Assessments The Oversight and Self Assessment processes appear to meet licese requirements and were effective in identifying problem areas and providing performance feedback. Recent audit reports indicated that, in spite of the delays in trend analysis, repetitive findings were being identified and properly characterized for corrective action. Audits and surveillances
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were of good quality and were effective to identify significant issues. Licensee responses
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to address the adverse conditions identified by audits and surveillance were generally appropriate and tim ily. Licensee actions to enhance Oversight functions through more assessment of the line activities appears to be appropriate, but the success of these efforts remains to be demonstrated.
Tagging Processes Although the licensee has experienced a number of work control tagging problems, considerable corrective actions have been implemented. Recent process changes appear to be improving work control tagging performance. Poor implementation of the latest i
initiatives had a short term detrimental effect on tagging.
The team noted some lack of attention to detail in the implementation and oversight of the deficiency tagging p.ocess, The overall problem identification in this area was acceptable based on the thoroughness and large number of deficiencies identified through the deficiency tagging process. The deficiency evaluation process was acceptable but weak.
The team identified wesk definition and formalized controls regarding the use the deficiency evaluation tags and poor staff understanding of the process resulting in sporadic use. The team noted the considerable effort to reduce the deficiency backlog. However, corrective actions were ineffective in certain instances as evident by an extensive number of dr.ficiency tags that resulted from deficiencies not routinely corrected during system week outages, iii
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TABLE OF CONTENTS Paae EX EC UTI V E S U M M A RY.............................................. il TA8 LE O F C O NT E NT S.............................................. iv REPORT DETAILS
.................................................1 1.0 In s pe ctio n Pu rpo s e............................................. 1 2.0 Problem Identification, Root Cause Evaluation and Corrective Actions........ 1 2.1 Adverse Condition Resolution Program........................ 1 2.2 Problem R e solution....................................... 6 3.0 Operating Experience Program.................................... 9 4.0 Self Assessment & Independent Oversight........................,,.12 4.1 Oversight and Sponsored Audits............................ 12 4.2 Station Department Self Assessments (SA).................... 15 4.3 Conclusions for Self Assessment and independent Oversight........ 18 5.0 Safety Committees
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5.1 Nuclear Safety Audit Review Committee (NSARC)................ 18 5.2 Station Operation Review Committee (SORC)................... 20 5.3 Oversight Committee Conclusions........................... 20 6.0 Tagging Proc esse s........................................... 20 6.1 Work Control Tagging.................................... 21 6.2 Deficiency Tagging
.....................................23 7.0 Summary
.................................................28 8.0 M a nageme nt Mee ting s........................................ 2 9 PARTI AL LIST OF PERSONS CONTACTED............................... 30
INSPECTIO N PROCEDURES USED..................................... 31 I T E M S O P 5 N.................................................... 31 LI ST O F ACRO NYM S U S ED.......................................... 31 I
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REPORT DETA!LE
1.0 Inspection Purpose The purpose of the inspection was to evaluate the effectiveness of the process for identifying, resolving, and preventing issues that degrade the quality of plant operations or safety at Seabrook Station. This review was performed per Inspection Procedure IP 40500. The team gathered data on program performance in the areas of problem identification, root cause analysis, and corrective action, with a focus on the adverse condition resolution (ACR) process. The evaluation included the processes for operating experience review, trending, tagging, and self assessments, as well as the audits and reviews performed by the safety committees and oversight groups. The team reviewed the activities of the line organization and the independent oversight groups to determine whether these groups are effective in resolving problems.
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2.0 Problem identification, Root Cause Evaluation and Corrective Actions The purpose of this inspection was to review the program to implement corrective actions in accordance with 10 CFR 50, Appendix B at Seabrook Station. The team reviewed the process for implementing corrective actions as defined in the Adverse Condition Resolution Program. The team then reviewed the effectiveness of the program by assessing how well the licenses addressed selected problems dispositioned through ACRs.
2.1 Adverse Condition Resolution Program a.
Inscection Scooe The team reviewed the adverse condition resolution (ACR) process to determine the licensees effectiveness in problem identification, root cause analysis, and corrective actions. In the licensee's corrective action program, items such as LERs, QA audit fiadings and NRC findings are also derignated as an ACR. As a result, most conditions adverse to quality are addressed by ACRs. A summary of the team's assessment of specific ACRs reviewed is provided in Section 2.2 below.
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Observatior.s and Findinos Problem Identifieglign The requirement' of the corrective action program are described in chapter 2 of the
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Seabrook Station Operating Experience (SSOE) Manual. The SSOE defines an adverse condition as a condition that is adverse to quality, or an unexpected or undesirable occurrence. All employees have the respont.ibility to report adverse conditions. Supervisors are required to review ACRs prepared by their workers to assure that the ACR contains sufficient informat;on for an effective evaluation, to provide recommendations, and take the ACR to the control room within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
Recently, the licensee has lowered the threshold for preparing an ACR by orecting individuals to write ACRs for situations in which the adverse condition is not
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obvious or may be questionable. This has resulted in a significant increase in the number of ACRs prepared,530in 1995 to over 1900 thus far in 1997. Site management stated that this ihreshold helps provide greater assurance that all adverse conditions are identified, in general, ACRs were prepared when required by the SSOE and included the information specified by the SSOE. From the team's review and the ACR data, it appears that a good questioning attitude exists at the plant and the majority of problems are self identified. The team noted improvement in trend of who identifies issues at Seabrook, with 60% identified by the worker and supervisor at Seabrook 20% by the independent oversight groups, and 20% by other organizations.
Licensee organizational efforts were appropriate to increase problem identifications at lower threshold levels.
Manaaement Review Team (MRT) ACR Review The MRT is made up of station managers. The MRT membership was changed from the supervisor to manager level to empower the MRT with the ability to commit resources to correct identified deficiencies. After an ACR is generated, the MRT review it to determine the significance level and priority. The MRT determines the type of evaluation required (root cause, apparent cause, trend only, corrective action only) and the responsible manager. The MRT's final review varies depending on the significance level of the ACR. For more significant ACA, the MRT will review the ACRs evaluations and corrective actions prior to submittal to the Station Operating Review Committee (SORC). For less significant issues, the MRT delegates the final closeout authority to the department manager and the Technical Projects Supervisor performs an independent review.
To evaluate the MRT's review of ACRs, the team interviewed station personnel and attended MRT meetings. It appeared that the MRT process was being implemented consistent with the SSOE. ACRs appeared to be given the appropriate priority and significance level. The MRT generally provides timely and thorough reviews of ACRs. However, the team noted examples where the MRT review appeared to lack i
the depth necessary to identify problems with the ACR evaluations. This was the case in the review of ACR 971288,which was written to address burst hoses during testing of the charging system. The MRT review did note the root cause
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evaluation which emphasized human error, but did not adequately consider programmatic controls as a cause.
The MRT has a backlog in eeatuating ACRs. The team noted a positive trend in-reducing the backlog, however, significant progress remains to be demonstrated.
The team noted that more ACRs are requiring trend only evaluations, approximately 83%, due in part to the licensee's revised approach to take immediate corrective actions. No problems were detected by the team's review of the ACRs assigned to the trend only status.
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Root Cause Evaluation The SSOE Manual defines the root cause evaluations threshold for ACRs. Although the MRT determines if a root cause evaluation is required for an ACR, the SSOE Manual defines the criteria the MRT must use in making this determination. The criteria providad in the SSOE is based on the significance level of the ACR.
Additional guidance for individuals performing root cause evaluations is contained in the Operating Experience Reference (OERE). If a root cause evaluation is not required, the MRT will often require an apparent cause evaluation. An apparent cause evaluation is a determination of the most probable cause based on readily available information.
The team reviewed several root cause (CCE) and apparent cause evaluations. Root cause and apparent cause evaluations appear to b completed when required and consistent with the SSOE and OERE. The evaluations are detailed and appear to be of sufficient depth to identify the most probable cause for the event. The recommended corrective actions were most often good, and addressed the mr.jor contributing factors as well as the probable cause. However, despite detailed root cause evaluations, some of the recommended corrective actions were not always effective. During interviews with plant personnel, the team was informed that in many instances the root cause evaluation concluded that human error was the most probable cause. However, the problem involved a specific form of human erru (inattention to detail, f atigue, personal problems, etc.) but the evaluation stopped short of identifying a specific form of human errer because the licensee did not have the necessary tools in these instances, the licensee would, typically, recommend corrective actions such as procedural changes. To address this concern, the licensee adopted the problem prevention, detection, and correction methodology of Performance improvement International (Pil). The licensee believes this method will assist in identifying specific forms of human error and ultimately improve the effectiveness of its corrective actions program.
The team noted the licensee initiatives to improve the focus and quality of RCEs under the new corrective action program (CAP) group. Open RCEs are being tracked, and 3 were open for 203 days). The processing of one RCE (regarding procedure steps that implement regulatory commitments) was delayed due to transfer of assignments between Oversight and the CAP Group. The reasons for delays were understood and actions were in progress to complete the evaluations.
Corrective Action Proaram and Problem Prevention The CAP program was revised over the years (relative to the status described in inspection 94-80), with actions taken to: simplify the problem identification process; to eliminate lower tiered problem reporting systems and consolidate the various systems into the ACR process; to better communicate management expectations to initiate ACRs; to enhance root cause and apparent cause investigations processes; and, to better track CA for completion and effectiveness.
However, despite the process changes and the completion of RCEs for several issues, past corrective actions were not always effective as noted by the repetition
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of adverse findings and repeat ACRs. The licensee found that past RCEs did not always identify the causes to correct deficiencies.
Currently, the corrective Action (CA) program is defined in the SSOE Manual, Revision 12. The processes for handling adverse conditions and for implementing corrective actions were described in SSOE Chapter 2. The SSOE describes specific attributes that are required for ACR corrective actions. ACR corrective actions are tracked on the commitment tracking system. Allimmediate corrective actions (e.g.,
temporary signs or covers, fire watches, etc.) are documented in ACRs. Once an ACR has received final review and approval, any changes to the corrective actions must be reviewed by the M3T, SORC, or both.
The team noted the licensee starting to conduct self assessment (SA) in the Fall of 1996 in certain program areas that were identified to have weaknesses as evident in recurrent problems. The licensee conducted common cause evaluations (CCE)
using the Pil methodologies to identify the reasons for weaknesses in programs and procedures. Using Pil methodologies, the licensee completed CCEs for the Maintenance and Procedure programs, and for human error prevention. A CCE for station tagging was in progress, and a station-wide CCE was scheduled to begin in September 1997. This action was an indicator of a good station safety attitude to improve performance.
The licensee made further process changes starting in 1997 by lowering the threshold for reporting, and by forming a Corrective Action Program (CAP) group to supplement the ACR administration group. The CAP was staifed with 9 personnel and a full time CAP manager to provide better focus on corrective actions at the station. The result was an increase in the number of generated ACRs, the assigning of a larger number of ACRs to the trend only status after the completion af initial corrective actions and screening by the MRT, and the performance of a larger number of RCEs on issues deemed to warrant higher priority of attentien. The impetus for these changes was to reduce the administrative burden due to ACR administration, which was manpower intensive for the line organization. As of this inspection, the ACR program was still in transition, with more changes planned to imr 've processing (electronic ACRs) and trending of findin0s through the development of better key performance indicators ( KPls). These changes were scheduled into 1998 for completion.
The team reviewed the status and trend data for ACR administration, and assessed the disposition of issues within the ACR system through a sampling review of the 1996 and 1997 ACRs. While immediate corrective actions were good and the priority of long term items seemed appropriate, the implementation of long term corrective actions was weak in light of the relatively large backlog of open actions.
The team noted over a 1000 items on the action request (AR) list, with the most notable backlog, approximately 200 each, in the maintenance and engineering areas. The licensee has started an initiative to reduce the backlog. The initiative includes reviewing the 10 oldest ARs weekly and prioritizing them for completion.
The team reviewed a sample cf the items in the backlog and identified no issues that warranted immediate licensee attention.
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Trendina The licensee has had programs in place for a number of years to trend performance.
The Oversight group had responsibility for trending performance data from the deficiency identification and self assessment processes, and for providing reports to management on station performance. Trend and KPl reports in the past were routinely provided to management and were beneficial to identify recurrent problems (e.g., personnel errors, equipment failures, problems with configuration controlb to identify new adverse conditions, and to track the status of performance against set goals. One example of an good KPl report was the Work Control Report ("The Big Picture"), which was published weekly and provided feedback on the status of performance relative to goals in the areas of work request backlog, priority 2 work, temporary modifications, fire protection system deficiencies, and minor maintenance backlog.
Notwithstanding performance deficiencies being identified, the licensee concluded that some trend reporta provided limited benefit, b3cause the trend tool r roWded no help in understanding the reasons for the performance problems. In response, tha licensee changed the process. Starting in 1997, responsibility for trending station r
performance was transferred from the Oversight group to the Corrective Actions Program (CAP) group. The CAP group began to revise the trending programs to include more data when capturing the performance problems. This included, in addition to the INPO codes for personnel errors, the Pil failure prevention codes that would help identify the causes for performance deficiencies. The new codes were used to help identify what part of the program or process was responsible for the performance deficiency, and thus allow identification of better corrective actions. These changes were in the process of being implemented.
The Oversight group issued the last quarterly trend report for the fourth quarter of 1996. The CAP group did not issue a trend report for the first quarter of 1997. A trend report for the second quarter of 1997, employing the new methods and developed in a new format, was in preparation at the time of this inspection. Based on a review of the work in progress, the team noted that new quarterly trend report provided a good focus on the major issues captured in the ACRs, provided an analysis of the trends relative to overall performance of the corrective action process relative to each plant department, and summarized the progress made against performance goals. Effectiveness could not be assessed at this time, c.
Conclusions The administration of the ACR process was working well to provide trend, status and closeout data on problem resolution. ACR files were well organized and support information was readily retrievable. Programs are in place to trend issues and track the backlog. The ACR data demonstrated a good questioning attitude at the station, and the vigor with which the line organization and oversight organizations identify, investigate and analyses events.
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The corrective action process was in transition to enhance the evaluation of the
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causes for repetitive performance problems and to assure more effective corrective actions. Although significant backlogs were noted in the number of ACRs open for final review and in the completion of final corrective actions, the licensee was aware of the reasons for these problems and actions were in progress to reduce the backlog. Licensee effectiveness in this'brea remains to be demonstrated.
2.2 Problem Resolution a.
Insoection Scope The team revieweri +he ACRs summarized below to determine how well the licensee implemented the E requirements, and to determine whether the licensee was effective in the ks,y elements of problem resolution: problem identification, cause evaluation and corrective action. The team reviewed a broad range of topics, with an emphasis placed on the tagging process, the focus of the team's vertical assessment. The team reviewed the 11 ACRS in detail related to station safety and deficiency tagging: ACR 96-81 and 97-254,289,443,1013,1187,1283,1403, 1507,1863, and 1892.
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Observations and Findinas ACR 96-0152This ACR addressed the deficiencies in programs, procedures, practices, or policies as they relate to 10 CFR 50.59 requirements. This review was comprehensive and the corrective actions were appropriate to assure appropriate administrative controls were applied when implementing change.
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ACR 97-0226This ACR addressed problems found during a QA effort to verify that raceway and cable installations meet design bases. Deficiencies were corrected and other conditions were evaluated " acceptable as is." The apparent cause was the design errors in interpreting separation requirements. The ACR evaluation was acceptable.
ACR 96-137 This ACR was an example of a good evaluation of the process used to maintain equipment described in the UFSAR but was no lorqer operated. The corrective actions were appropriate to clarify the status of systems in long term lay up.
ACR 971448(LER 9710)This ACR was an example of self identified problem that was promptly brought to the attention of management, and reported to the NRC in a
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timely manner. The cause evaluation was complete and corrective actions were appropriate.
ACR 961337 (LER 96-07)This ACR was an example of good problem identification during the development of design change DCR 96-034. The corrective acuons appeared to be appropriate and were timely completed.
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h ACRs 96-1372 and 97-1401 Root Cause Analysis - Failed fuen 31 Cycle 5. Licensee
'j evaluat;ons for this issue were thorough to identify the apparent causes for failed fuel.
ACR 961451 This ACR was for a lack of resps 1se to NSARC concerns related to revising procedures. ACRs 95-0511 and 96 0750 cover this issue and this ACR h
was closed based on the recommendations in these ACRs. The corrective actions proposed in ACR 95-511 and 96-750 appeared appropriate and addressed the
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causes for both the technical and programmatic reasons for why this issue
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occurred. This was an example of good problem identification by the NSARC, but untimely follow through by the station and the NSARC on corrective actione, in that
it took 1.5 years to resolve the concern.
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ACR 97 0254This ACR addressed a program deficiency in that there were no system lineup positions for the non-operations controlled valves. The CA appeared appropriate to Evaluate the program and correct the deficiencies.
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ACR 96-0081 This ACR documents a review during the IPAP where the NRC findings of 29 deficiency tag (DT) problems were also found by the licensee but to a greater extent. Licensee acticus were good to identify the apparent causes and to implement procedure changes to clarify the guidelines and expectations on
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responsioilities for the process.
f.CR 97-1507 This ACR i', a followup to ACR 96-81 where 17 DTu were left on componants after the work requests were closed,16 OTs did not have open work requests,1 DT was not signed by system engineer,2 OTs where work requests were voided based on e taluations but DE tags were not installed,17 DTs having
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documentation problems, and 3 old style DTs. The team found the continuing review of this problem acceptable.
E ACR 96 0263 Based on ACRs 96-0226,96-0243, and 96-0257, QC and Safety review indicated that there was some degree of misunderstanding of individual responsibilities concerning the tagging program. Corrective actio7s were appropriate and the resolution of this issue was acceptable.
ACR 97-0289This ACR oddressed concerns with the implementation of the new computer based tagging program. The AITTS data iMicated assignments were completed by April 8,1997. The corrective actions were acceptable.
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ACR 97-1015 This ACR addressed problems with changing the tagging program fcur months before outage OROS, not freezing OROS scope, and the lack of personnel and/or time to adequately review tagouts. CAs were to evnluate the work control and tagout program. The AITTS is approprStely trackirg 'ile CAs for completion for OR06.
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ACR 97-1187 This ACR addressed the need to clarify the tagging procedure, which was prone to human error. The CAs were that lessons learned should be reviewed
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for possible revision of the tagging procedure. The disposition of this issue was acceptable.
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ACR 97-1403 This ACR addressed a labeling problem with AC and DC fuses. The J
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corrective actions were to label fuses to be consistent in all units and to verify the tagging system database accuracy as it related to these devices. The AITTS
showed the CAs have a due date of October 1,1997. This appears acceptable for (
W this detailed work.
f ACR 97-253 This ACR was an example of untimely actions to address a concern
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regarding the missed commitments that should have been captured in station procedures as " protected steps", but wete inadvertently deleted. The licensee elected to perform a RCE for this issue. The ACR and RCE were ir.nlally assigned to the Oversight group on February 6,1997, but action was deferred due to limited resources. Responsibility for the RCE was later reassigned to the Corrective Action
Group after thet group was formalized on July 1,1997. The RCE for ACR 97-253
was listed as open for 203 days on the tracking list or " ongoing" RCEs as of August g
29,1997.
ACR 97-1288 This ACR was an example of an inadequate root cause evaluation completed for recurrent incidents where low pressure (tygon) tubing was installed during testing of high pressure plant systems, resulting in burst hoses and the spread of radioactive contamination in some instances. The evaluation emphasized the human errcr contributor to the most recont event, but did not adequately consider the programmatic controls of low pressure tubing.
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Conclusions
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Overall, the licensee has an acceptable problem resolution process. A good questioning attitude exists at the site which results in a large number of self-identified problems. From the ACRs reviewed by the team, the immediate corrective actions taken by the licensee were generally good and perfonned in a timely manner. The licensee made soro operability determinations and timely reportability determinatioas. The team no; d that the priority of long term follow-up actions seerned appropriate.
The team's independent review confirmed the !!censee self-assessments that recurrent performance problems occur because of cumbersome procedures or incomplete processes (ACR 97-1187,97-254, 97-1403,96-152), program requirements were not fully understood (ACR 97-1507,96-263,97 289,97-1013),
or due to human performance e rors (ACR 96-81,97-226). The recurrence of some deficiencies was evident in the ACR data, such as the problems with tagging (ACR 96-81,97-1507,96-253,97-289,97-1013, and 97-1187). The performance reflected in the ACR data shows the need to better define procedures and expectations, as is uncerway with the licensee common cause evaluations on station programs, and particularly in the area of station tagging. The data also I
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shows the need to control program changes; licensee initiatives in this aiea were noted in the " Change Management Plan" for Human Error Prevention, Detection and Corie tion.
Exceptions to good performance vere noted in the adequacy of cause identification for some problems, and the develop nent of effective corrective actions. Corrective actions in the past did not always at dress generic concerns, or did not always address contributing causes of adverse conditions. The appropriate level of management invo!vement appears to be present, as reflected in the number of initiatives implemented or in progress (common cause evaluations on station processes) in an attempt to improve the current programs and the corrective action process at the station.
3.0 Operating Experience Program a.
fr.soection Scone The team evaluated the adequacy of the licensee's programs that implement
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Technical Specifications (TS) 6.2.3, Technical Review Program, requirements. At Seabrook, the Nuclear Safety Engineering (NSE) organization, consisting of one supervisor and thres engineers, performs an Operationa! Experience Review Program (OERP) to meet this TS. The team's focus was on the licensee's effectiveness ?c, assess, to inform appropriate personnel of the resulta, and to initiate corrt.ctive actions for information obtained both within and catside the licensee's organization.
b.
Observations and Findinas The implementing procedure for OERP at Seabrook, OE 7.1, was designed to insure the NRC requirements were met by screening information from all sources (NRC, INPO, vendors, Seabrook, NU and other plants) and providing needed information to the NAESC staff in a user friendly format. The format selected was a concise writeup normalsy issued (separats or in combination with other writeups) at the daily plant staff meeting as an Operating Experience Summary (OES). All OES data is stored in a searchable text file in the licensee's shared computer system accessible to all the plant staff.
The team interviewed the NSE supervisor and reviewed numerous NSE output documents including OESs and monthly reports to ascertain the licensee's effectiveness in problem identification, cause evaluations, and corrective actions.
Problem Identification The NSE engineers make extensive use of the Internet to capture NRC, INPO, vendor, arid other source information in July 1997,INPO went on-line with a revised format for their Nuclear Network. On a daily basis during the work week, NSE evaluations were generated from editing the captured source information, dete mining the relative importance to Seabrook, and preparing the final product - a coct.se NSE independent evaluation. These evaluations were used to make a quick
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notification of plant management of significant safety or a personnel hazard, combined with other evaluations in an OES single page report for the daily Station Directors' meetings, or used in training and pre job briefs. All NSE evaluations were posted on the plant E-mail bulletin board and kept in a searchable computer file on the company local area network (L AN).
Information from the NRC, such as Event Notifications (ens) required by 10 CFR 50.52, Licensee Event Reports (LERs) required by 10 CFR 50.53, Preliminary Notifications (PNs), and Morning Reports (MRs) to NRC upper management, as well as Information Notices (ins) were daily retrieved from the various Internet sources and well coordinated to get operating experiences to the plant staff very quickly.
NRC Bulletins and Generic Letters, both normally requiring licensee response to the NRC, cre not coordinated by NSE but by Plant Licensing.
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Cause Evaluation The daily NSE Operating Experience Summaries were technically of high quality and were normally very timely. Examples for high quality were the NU Worker injured in Trans*ormer Explosion, Cook Component Cooling Water Design Deficiencies, and Dukovany (Russia) Unauthorized Switch Manipulation. Examples for timeliness were the Beaver Valley Containment isolation Valves Not Meeting UFSAR Requirements of July 10,1997 given as an OES on July 14,1997 and the Haddam Neck Halon event of August 7,1997 presented as an OES for the August 22,1997 morning meeting. All OESs were easily assessable to the plant staff in a searchable format on the LAN.
The NSE evaluation findings and other NSE activities were summarized in a monthly report to NAESC management. The July 24,1997 report was reviewed by the team, it reported on the evaluations and plant tours performed during the refueling outace and during plant startup, discussed activities related to providing Nuclear Network access to plant personnel, provided six evaluation results including three recent NRC Information Notices, and outlined future activities.
Corrective Actions At the team's request, NSE provided a recent example of an OE succets. NSE had gleaned from a Callaway LER a near-miss that applied disoctly to Seabrook The LER reported a steem generator levu perturbation caused by a broken retaining clip on the ma:n feedwetor regulatint W (MFRV) positioner. Followup inspection and review by NAESC indicated that we same incurrect orientation of the positioner cam follower and retaining clip existed at Seabrook. The positioners for all Bur MFRVs were reouilt by replacing the entire cam follower assembly, thereby eliminating a possible feedwater transient that could have caused a reactor trip.
NSE has been providing about one OE per month to the INPO Nuclear Network information database. This database consists of more than 6,000 searchable issues available to INPO members. The team reviewed two recent NSE contributions to
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this network. The first report was on the May 10,1997-automatic reactor trip and
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subsequent feedwater isolation duo to intermediate range nuclear instrumentation f
automatically unblocking duiing a normal shutdan. The second covered the fuel
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f ailure experience at Seabrook from the first identification of an increase in coolant activity in December 1996, to the separation of five fuel pins during the July 1997, outage investigation. Both evaluations provided short abstracts, detailed event descriptions, good probable cause and/or safety significance evaluations, and corrective actions taken or planned at Seabrook. The team found thet,e evaluations to be comprehensive and well written.
NSE is currently running a review backlog of about 70 issues. These issues have been identified as possible OEs of interest but the NSE evaluations have not been completed. The team reviewed the AITTS open list under NSE responsibility to determine the importance of this backlog. For NRC issues, the lists shows that ins 91-20, PVC Insulation,92 04, MDR Relay Failure,92-52. Seats Between Mild and Harsh Environments, and 94-10, Failure of MOV Motor Pin Gear Pins, were still being reviewed, in each case the review has been assigned to other organizations and due-dates established and extended, but final evaluation has not been receivsd.
For example, detailed review of licensee activities for IN 94-10 (on MOV) shows that all but three safety-related valve MOVs have had inspections of the shaft keys.
These last three valve MOVs are scheduled for completion during OR06, the next refueling outage. The NSE supervisor said he does not close out AITTS issues until all corrective actions have been completed and documentation received to so indicate. This supervisor informed the team that the backlog of NSE evaluations has been decreasing. Bccause initial evaluations have occurred on all identified issues and final closeouts were being delayed by documentation only, the team concluded that the review backlog was acceptable, a
in addition to the TS required independent t6chnical review of OEs, NSE performs worker pre-job / event briefings of selected high risk activities. The team reviewed a
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recent NSE evaluation prepared for Unit Substation Transformer Replacement. This evaluation, provided to work control for inclusion in future substation activities, documented seven Seabrook and industry past events or near-misses related to this s
type of work. Another NSE activity has been plant / system walkdowns to share OEs with workers, observe and evaleste selected activities, and learn from them concerns plant personnel may have. The team found the pre-job / event briefings and plant / system walkdowns good licensee initiatives.
The team attempted to determine the plant staff knowledge of recent OEs. At lease in one case, the lack of knowledge of the Beaver Valley containment isolation valvec not meeting UFSAR requirements by the assigned system engineer, was identified. The concern for a possible staff information overload was expressed by the NSE supervisor. He indicated that various presentation options were being used to heighcen plant staff awareness of OEs.
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Conclusions l
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The team found the OERP was well established and meets the TS 6.2.3 l
Independent Technical Reviews requirement. The problems and events identified at
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Seabrook and other facilities by the NSE staff were numerous and quickly distributed, with good evaluations to the plant staff. Corrective actions, such as the main feedwater regulating valve posi'ioner issue, were timely and inputs to the INPO Nuclear Network were well written. The licensee's activities to reduce, the 70 issue review backlog and the possible staff information overload was good. Overall, the term concludes that the Seabrook Operational Experience Review Program was well managed and a licensee strength.
4.0 Self Assessment & Independent Oversight The team reviewed the organization and functioning of the Oversight group to determine its compliance with 10 CFR 50, Appendix B, the Seabrook Quality Assurance Manual, and UFSAR Chapters 13 and 17. The team assessed licensee se;f-assessment activities to determine whettier the licensee conducted critical evaluations of itself.
4.1 Oversight and Sponsored Audits a.
Insoection Scoce The team reviewed the Oversight activities involving audit and surveillance activities to assess its effectivenee as part of the problem resolution process.
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Observations and Findinas
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The licensee made changes to tne oversight program, which included the assignment of a new manager and how the oversight groups were organized. The past organization was aligned along the traditional lines of oversight activities, with inspection, Surveillance and Audit groups. The licensee found this structure lacked a centralized functional area contact for the line organization. Starting in January 1997, the licensee organized Oversight along the functional areas of Operations, Maintenance, Engineering and Plant Support, with a supervisor for each group. The new organization established a single point of contact between the line and oversight organizations, that would improve communications and integration of assessment findings by functional erea.
The licensee intended each group maintain the quality assurance and quality control funct;ons as required by 10 CFR 50, Appendix B. There was a decrease in the (
emphasis on the traditional roles of QA and QC, with a emphasis on the one
organizational function of oversight. The Oversight group plans to develop and maintain a " partnership" with the line crganization in the review and oversight of activities affecting quality and safety. The licensee views the Oversight organization as in " transition" to the ne v mode, and is developing strategies to
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process by mid 1998.
The licensee developed and implemented the changes to the Quality Assurance
Program under 10 CFR 50.54(a), and concluded that the changes did not decrease the effectiveness of the QA program. The team reviewed a sample of program
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changes and associated 50.54(a) assessments as described on memorandum OP#97092 (SSP #970104)and OP#96232 (SSP #960226). No discrepancies were -
identified. The changes were reflected m subsequent revisions to UFSAR Chapter-
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13 and 17.2. The licensee's audit group identified findings in this area, as
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described further in item (5) below.
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The Quality program changes and functional alignment were good to enhance the
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effectiveness of oversight activities and improve the interface with the line
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organization, and the effectiveness of the self-assessment programs. The success of these initiatives remains to be demonstrated.
The team reviewed the overall self assessment program to verify that major station l
functional areas were reviewed as required by the quality assurance audit program.
J No deficiencies were identified, and all the areas required to be audited by 10 CFR 50, Appendix B appeared to be included in the 5 year audit matrix and schedule.
The team reviewed the results of selected audits and surveillances to determine if i
they were critical self-assessments of licensee activities, and whether they were effective in resolving problems. Several ext...ples are summarized below.
(1)
QA evaluated performance with respect to the work control requirements in MA 3.1 and 3.2 on the deficiency tagging. The surveillances identified numerous tagging problems, as documented in QAIRs 96-64 through 75,77, 79,80,82,88,89,90,91, and 142 (ACRs 96-81,96-137). QAIR 97-0221 (ACR 97-1507), GAIR 97-372 (ACR 97-1863).The most common problems included deficiency tags that were hung after the work had been completed, and deficiency togs hung but there was no associated work item identified in the work control system to address the problem. The oversight group proposed appropriate solutions. The licensee used the QA surveillances to.
tiack performance with the administrat!ve requirements (ACRs 96-81, and 97-1507 and 1863).
(2)
Audit No. 97-AOS-01 provided the assessment of the conduct of refueling outage OROS. -This audit assessed the performance by the line organization to conduct the refueling and maintenance activities, and to complete the scheduled and emergent work and testing.1he findings were in the areas of training (ACRs 97-1242,1243), NDE activities (ACR 97-1396,1397), SORC review of procedures (ACR 97-1423),foreien material exclusion controls (ACRs 97-1660,1658,1659), and design control (ACRs 97-1573,1663).
The corrective actions were appropriate. The audit findings were not indicative of programmatic or process breakdowns, f
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(3)
Audit 97-A04-02 provided an assessment of the Security Program, which identified findings in the areas of following safety practices (ACRs97-739, 740), control of safeguards material (ACR 97 698), and the control and testing of security systems (ACRs97-916,918 and 919). The disposition of these issues was acceptable.
(4)
Audit 96-A10-01 provided an assessment of the implementation of the technical specifications (TS), which identified inconsistencies between TS 6.8.1.6b and the Cycle 5 Core Reload Safety Evaluation analytical methods for the Cycle 5 Core Operating Limits Report. Corrective actior.s were appropriate.
(5)
Audit 97-A04-01 assessed the Corrective Action Program, and identified four problems that were not considered generic or programmatic issues. The findings included implementation of commitments (ACR 97-804,806), the ins protection program (ACR 97-805), and, the process to make changes in the Oversight Organization per 10 CFR 50.54(a)(ACR 97-807). The team reviewed the actions in response to ACR 97-807 to verify that the evaluations per 10 CFR 50.54(a) were completed, and that the required updates to the quality assurance manual and the UFSAR were made or in progress (UFCR 97-37).
(6)
The evaluations sponsored by the Joint Utilities Management Audits (JUMA)
for 1996 and 1997. The 1996 audit asseseed the Quality Control and Corrective Action programs. The audit identified the need to improve addressing adverse trends in ACRs, arrJ to ass'.gn these trends as a higher priority to drive actions toward time corrective action; the failure to identify possible adverse trends of untimely or inappropriate corrective actions; the need to improve tracking and closure of QA findings entered into the ACR process; and, the need to reduce the backlog of priority 3 ACRs (which in 1996 was over 300, with many greater than 120 days old). The licensee formally tracked the recommendations and completed appropriate corrective actions.
The 1997 JUMA audit assessed the Trending Program, the Quality Audit Program and the alignment of the Oversight organization. This audit identified several recommendations to improve the trending process, the audit process, and the " marketing" of the functional alignment approach for partnership with the line organization. The audit identified one weakness, which was an area of concern consistent with the team's independently developed observations, related to the need for the Oversight organization to perform more formal self-assessments to minimize weaknesses while developing the new partnerships with the line organization and better target areas for surveillances. The licensee's response to the 1997 audit findings were under development at the end of this inspection.
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(7)
The O.ersight Group demonstrated a good capability to work with line organization to improve performance in plant programs and activities, as summarized in the Nuclear Safety Oversight Integrated Refueling Outage Assessment Report for OROS. In the Maintenance Oversight Functional area, 325 independent oversight activities (inspections and surveillances) were performed, which were summarized in 280 published reports. Several examples of successes in improving programs and controls in the areas of valve maintenance, foreign material exclus;on, scaffolding controls, weld quality and acceptance, and containment cleaning and closure inspections.
(8)
The Quality Programs group generated condition reports (CDRs) as part of the surveillances of receipt inspection activities. At the team request, the licensee provided a listing of all CDRs for the last two years. The team selected six CDRs with disposition actions completed for a detailed review.
Those selected were: 96-0011,97 001,97 012,97-020,97-022, and 97-l 024. The team independently evaluated the issues described in the CDRs, the licensee evaluation and corrective action.
The team conr.luded the engineering evaluations and licensee dispcsition was acceptable in each case. The tracking of CDR closecuts was recently transferred to the Corrective Action department. This data showed most were closed with a small backlog (14%) still open pending resolution (three s
of 25 CDRs for 1996, and four of 22 for 1997). The team found tne disposition of receipt inspection condition reports acceptable, r'.
Conclusions Based on the above, the team concluded that audits and surveillances were of good quality and wc." effective in identifying significant issues. Licensee responses to address the adverse conditions identified by audits and surveillance were generally appropriate and timely. The self assessment findings reflected program and process
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implementation problems by both the line and the oversight groups. The Oversight g'oups were generally effective in working with the line organization to correct problems. The licensee effectively used outside oversight groups to assess the corrective action program. Program changes to enhance Oversight functions through more surveillance and assessment of the line activities appears to oe appropriate, but the success of these efforts remains to be demonstrated.
- 4.2 Station Department Self Assessments (SA)
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Inspection Scooe The team reviewed a sample of department self-assessments to evaluate the quality of the assessments and to determine how self-criticalline management was of its own performance.
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Observations and Findinos Station practices for SA were established per NM 12300, Self Assessment Guideline, which defines the program to be used by individual departments and establishes the management expectations. The management policy was to not be overly prescriptive in defining SA format and methods, so as to allow individual group leaders the latitude to define the practices within the respective departments.
The team noted some examples of good efforts at self-assessment by the W organization, based on a sample review of completed work in the Maintenance, Oversight and Engineering areas.
Sixteen Engineering Self Assessment Reports (ESARs) were initiated in 1996, covering a variety of issues ranging from process questions, to a major effort in support of the NAESC response to the NRC's 10 CFR 50.54(f) letter. The assessments were of generally good quality, with evaluation of the issues and l
corrective actions appropriate to address the initial problem. Most 1996 ESARs were " reactive" evaluations completed in response to identified problems. This type of issue is now evaluated in the ACR process, and the 1997 ESARs are limited to pre-planned proactive evaluations of program performance.
l Not all designated 1996 evaluations were completed in 1996: ESARs 96-04 and 96-08 were stillin progress as of August 1997. Similarly, of eight assessments planned by engineering in 1997, only two ESARs were initiated as of August 1997, and both were still open at the time of this inspection. The major reason for the deciease is engineering SA activity was resource limitations due to personnel assignments away from Seabrook station, and the extensive resource allocations
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required to complete the 50.54(f) effort, which continued until February 1997.
After February 1997, engineering focus remained on preparations for OROS and other higher priority activities identified by station management.
In the Mcintenance area, the self-assessrnent process is dsheibed in procedures
MGDI 0003.000, Maintenance Group Self Assessme,it Program, and MGDI 0003.001, Maintenance Group Field Supervisory Surveillances. The Team reviewed l
a sample of Maintenance Group SA activities, which were described in Self-j
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Assessment Team weekly meetings for April 1996 and May-June 1997, a 1996 MOV Self-assessment, a Maintenance Training Assessment comp!eted in August
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1996, and, a self-asseesment documentation repor: (SADR) completed in July 1996 in response to an NRC finding related to the process for tracking items. While these assessments appeared to be self-critical and identified appropriate actions to improve perform <mce, some efforts (those on MOV, training, and the 1996 SADR)
appeared to be incomplete and not approved by Maintenance Management.
However, unlika the informal efforts described above, the Maintenance Group also completed a formal ascessmat of the maintenance programs and practices, as described in the Maintenance Group Common Lause Assessment dated November, 1996. This assessment was initiated following the 1996 culture survey and after station management concluded that, although human performance had improved
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following the Personnel Error Response Team (PERTi efforts in 1994, station performance in personnel error reduction had " flu.tened." The scope and methods of this asser sment were thorough and self-critical, t.: d the results were effective to identify reasons and solutions for weaknesses that underlie performance issues in the Maintenance area. The results of the assessment included recommendctions to provide better cominunication of department mission, goals and feedback of performance through KPls; better communications vertically within the department; improved accountability; and, to address weaknesses in the administrative and work control processes.
In the Oversight area, four self-assessments were completed in 1997. The assessments were self-critical to evaluate the past audits in the security (SADR 97-Audit-002 and SADR 97-003) and Oversight areas (SADR 97-audit-001) and the Corrective Action area (SADR 97-004). The assessments identified audit strengths and areas for improvement, such as the need to better document and repoit deficiencies regarding corrective action effectiveness to station managernent (reference ACR 97-1288). Three of the four SADRs completed by the Oversight organization in 1997 were reactive to identified problems. In discussions with the Nuclear Quality Manager, the team noted that informal self assessments of Oversight activities were contained in meeting notes which critiqued the audits.
Oversight management recognized the need to conduct additional formalized self-assessments.
One'me;or licensee self-assessment reviewed by the team was the Service Water System (SWS) Functional Audit. The audit by the former Quality Program Group was to perform an NRC inspection Procedure 2515/118 "SWOPl" evaluation of the -
SWS to assess the actions in response to GL 89-13. The audit resulted in 2 findir.gs and 4 observations. The team verified that the corrective actions were appropriate and completed in a timely manner, and were verified to be satisfactory by the auditing organization.
During this inspection, station management announced the selection of a manager to champion the SA process, with the intention to provide renewed emphasis in this area.
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Conclusio_na The use and quality of self-assessment (SA) practices varied within line organization groups and acrossihe site. There are indications that SA are not conducted
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routinely or considered useful, or have fallen into informal practices (Maintenance and Oversight). The general decline in the conduct of SA includes the Oversight group, who was responsible for championing the process across the site. The licensee recognizes the need to improve SA practices and has initiatives in progress for this area station wide.
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4.3 Conclusions for Self-Assessment and independent Oversight The Oversight and Self-Assessment processes were functioning adequately and
improving. The major station functional areas were reviewed as required by the l
quality assurance audit program. The Oversight program under 10 CFR 50 j
Appendix B, and the hdependent Self-Assessment processes are generally effective in providing independent evaluation of. quality activities. The inspection,
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surveillance and audits are effective to identify significant issues. SA by the i
, Oversight organization have identified the need to improve audit activities in some
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Findings by the Oversight and sponsored audit organizctions were timely reported,
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and corret tive actions were timely and effective. Feedback was provided to
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management via trend reports and individual reports. Oversight demonstrated a good capability to work with line organization to improve performance in plant
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. programs and activities. Several examples of successes were noted. The interface
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meetings provide ongoing feedback of findings and real time feedback of
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assessments.
a The continued review and oversight of the station corrective action process has i
Leen generally effective. Continued use of sponsored audits were effective to assess the status and areas for improvement. Several 1997 initiatives, such the i-development of " partnership" strategies within Oversig,ht, and the centralized
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trending c' performance (by CAP group), appear to be appropriate to enhance program effectiveness. The team noted that the oversight organization and a
programs were in transition as the staff was developed to provide broeder overview of station process and program performance.
5.0 Safety Committees The team reviewed requirements established by the Technical Specifications (TSs),
administrative procedures, and other licensee documents associated with Seabrook Station Safety Committees.
5.1 Nuclear Safety Audit Review Committee (NSARC)
The NSARC provides independent oversight of the operations, maintenarice, engineering, and other support groups. The committee reports directly to the
' Executive Vice President and Chief Nuclear Officer. The NSARC chairmar describes the role of the committeo as i.eing the last line of defense in ensuring nuclear safety; this role is performed by observing the plant from a broad perspective 'from 50,000 feet" with a focus on nuclear safety. The lines of defense are described as the worke., supervision and management, and quality programs.
The NSARC implements the requirements of Seabrook Station Technical
- Specifications (TS), Section 6.4.3 and the updated final safety analysis report (UFSAR) Sections 13.4 and 17.2. TS 6.4.3 describes the requirements for the
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- Additional NSARC operating procedures are included in NM 11250," Nuclear Safety
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Audit Review Committee (NSARC) Operation."
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^ To evaluate the effectiveness of the NSARC, the team reviewed meeting minutes from 1996 and 1997, and interviewed committee members, including the chairman.
No NCARC meetings were held during the inspection.
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- From a review of the meeting minutes, it appeared that (1)
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in accordance with TS requirements, and (3) the NSARC reviews are of sufficient l.
- o'epth to identify safety concerns.
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During the team's review of the meeting minutes, it became apparent that NSARC
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members thoroughly and critically reviewed 50.59 evaluations completed by station i
personnel. As a result of these reviews, the NSARC sent some 50.59 evaluations i
back to the station for further review. The NSARC also recommended that station j
managers clarify their expectations for 10 CFR 50.59 evaluations. Such NSARC j
actions have prompted station management to evaluate and revise 50.59
procedures.. The NSARC review of the root cause evaluation of the failed fuelin b
cycle 5 also appeared through. The discussion, during the NSARC meeting resulted in a recommendation to determine if axial offset is an indicator of off-normal conditions in the core that could lead to fuel failures.
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management'to prepart.d ACRs for issues that NSARC members believe reach the
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threshold for an ACR. The licensee believes this addition assures that NSARC-
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Issues which reach the threshold of an ACR are appropriately prioritized.
It appears th'e NSARC reviews plant trending data and uses this information to -
provide recommendations to management. ' The NSARC has also assigned members to review the trending process and provided recommendations for Limprovement. ' The NSARC review of third party audits appears to be adequate.
l Although the self assessments performed by NSARC appear to be good, the NSARC is currently in the process of revising its self assessment process. The intent is to
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5.2 Station Operation Review Committee (SORC)
The team reviewed a sample of SORC meeting mir utos from 1996 and 1997, attended a SORC meeting, and interviewed the vice chairman of the SORC.
The SORC implements the requirements of TS 6.4.1 and UFSAR secRns 13 and 17. TS 6.4.1 describes the requirements for the committee. The SORC charter includes additional operating procedures. The attendance of SORC members was good. Participation by the Station Dire-tor and Assistant Station Director wac good. Either the Station Director or Assistant Station Director attended aim at all SORC meetings. From a review of the meeting minutes,it appeared that the SORC is operating in accordance with its TS.
The SORC appears to be effectively tracking its action items. A review of SORC action items did not identify any concerns. During the interview with the SORC vice chairman, he indicated that the implementation of the SQR program has reduced the work load of the SORC. The data seems to confirm this conclusion, in (
1993 the SORC reviewed 4220 items,3440 were procedure revisions, changes, cance.lations, and periccic review. Ir.1996 the SORC re.iewed 784 items,189 of which were procedures and procedure changes. In 1997 the SORC reviewed 588 items,91 were procedure or procedure changes.
The team concluded the SORC reviews are of sufficient depth to identify safety concerns with some exceptions. These exceptions were evident by 50.59 evaluations being returned by NSARC and the review of ACR 97-1288. ACR 97-1288 was written to address burst hoses during testing of the charging system.
The SORC review did not identify weaknesses in the root cause evaluation which emphasized human error but did not adequately consider programmatic controls.
The SORC did recognize the need to modify its 50.59 procedures.
The SORC self assessments appeared to be good. The last SORC self assessment was performed in 1996. This self-assessment identified that SORC members needed to review the 50.59 procedures and take additional 50.59 training.
5.3 Ovrisight Committee Conclusions Based on the limited review, the team concluded that the NSARC and SORC were 6 fective and satisfy their oversight requirements. Both display a good questioning f
attitude and appear to focus appropriately on issues important to nuclear safety.
6.0 Tagging Processes The team selected two types of tagging operations, where noted problems had been identified, for review during this !nspection. This review was to confirm the adequacy equipment control requirements of ANS N18.7, Administrative Controls for Nuclear Power Plants (Quality Assurance Plan).
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6.1 Work Control Tagging a.
Inscection Scoce The team selected work control (WC) tagging as a focus topic for a collective vertical slice review by all team members to determine how well root cause evaluations were performed, and to assess all aspects of the licensee actions to address past performance problems.
b.
Observations and Findinos During the IPAP inspection in February 1996 (IR 96 80), a recurring WC tagging problem was identified by the NRC and by the licensee during the 1994 operations refueling outage (OR03). This team reviewed the licensee's corrective actions including operations assuming greater control of the master tagout process.
Although the total number of tagging errors was less during OR04 than for the OR03 outage, the daily number was, according to QA, actualty greater. The licensee said that this was due in part to lowering the reporting threshold for the ACRs so less significant issues were captured and the resultant lessons learned. In 1995, the licensee initiated an on-line maintenance (OLM) program. After the initial OLM performance did not meet expectations, operation's management stopped OLM Just prior to the 1995 outage to provide for analpis and improvement of the process. The probable cause was identified to be a iack of planning.
Other problems with WC tagging were discussed in more recent NRC inspectit n reports, such'as 9511 and 95-12, and in numerous licensee issued ACRs, sucts as96-263, 97-254,97-289, 97-326,97-443, 97-469, 97-1 187, 97-1283,97-14C 3, 97-1479,97-1588,97-1679,97-1680, continuing danger tagging problems have been identified.
-The team reviewed the last three revisions of MA 4.2, Equipment Tagging and Isolation, and held discussions with the tagging supervisor. The plant had been using the Millstone tagging program but converted to an independent program in
. late 1996. A new specially developed computer program was developed and placed in service in February 1997. The effects of these changes were evaluated in this review.
Problem Identification
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Team review of the number of WC tagging error ACRs showed an increase during the last three years from seven in 1995, to 44 in 1996, and then 54 in 1997 (to date). However, while the numbe of tagging error ACRs has increased, the total number of ACRs about tripled from 1995 to 1996 and will nearly double from 1996 to the projected end of 1997. The team agreed that the deliberate lowering of the reporting threshold could have contributed to this increase, but this was good for identifying tagging errors so corrective actions could be taken.
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Cause Evaluation During the team's inspection, the licensee was nearing the completion of a detailed i
l Common Cause Assessment of the Seabrook Station Tagging Program. This report provides a good analysis of past tagging problems and discusses corrective actions taken. The licensee's evaluation of tagging ACR data over the last three years shows the largest number of tagging errors has occurred during the preparation of the tagging clearance orders.
The licensee stated that upgrading to a new tagging computer program in February 1997, implemented a couple of months later then originally planned, along with moving up the start of OR05 refueling outage by two months, required by reduced power generation by company and area sources, resulted in increased WC tagging errors. Corrective actions have been taken as addressed below. The team noted the considerable licensee effort to identify and evaluate the problems with the WC tagging program and believes that !mprovemnts should result.
Corrective Actions The licensee has made numerous changes to the WC tagging program in the last few years to resolve self identified and third party identified problems. Thesc included freezing the outage work scope earlier, providing more preparation time, and requiring all departments to participate in the development of the master tagout (MTO) in 1994, and initiation of all tagging orders by qualified operations personnel, independent SRO review of tagging orders, and independent verification of tags hung by qualified operations personnelin 1995 and 1996. For 1997, the licensee
edded Blue Tags with special locks (for partial clearance for testing), implemented a matrix concept to tie specific tags to specific work, implemented computer on line approvals of clearances, including maintenance acceptance to their tagging program. These enanges have been implemented by procedure changes and major revisions to MA 4.2, Equipment Tagging and Isolation, MA 4.5, Configuration Control During Maintenance and Troubleshooting, and related procedures.
The team received detailed information on the new tagging computer capabilities.
The concept was that of developing a clearance matrix for each system undergoing maintenance. The tag number and equipment to be tagged in a required status (valves, electrical power, etc.) were listed down the vertical axis and the work packages across the horizontal axis. This allowc for a graphic presentation to improve planning, work control, operations and maintenance review of the tagging boundaries, and control of tag removal as certain work packages or all work was
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completed. The Blue Tag system, developed as a part of the new computer system to simplify equipment testing after completing some work activities, was also reviewed. A further change was the electronic approval process made available to all reviewers.
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The team noted that several ACRs were critical of the implementation of the new system in early 1997. They state that the new system was poorly coordinated with inadequate individual computer access and training before the system became
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operational. Because of this, the system was initially not accepted well by the plant staff. However, the startup problems have been resolved and the system is now well accepted by the plant staff. The licensee stated that the delay in placing the system on-line along with moving up the outage caused these problems. The team agreed that, although the new system has good potential for improving the control of the tagging process, the poor implementation had a short term detrimental effect on the WC tagging program. The licensee's reported that rate of tagging errors is currently about 2 percent overall, and about 0.85 percent found in the field.
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Conclusions Although the licensee has experienced a number of WC tagging problems, as
- identified by NAESC and third party reviews, considerable corrective actions have beer, identified and implemented. More recent improvements, such as the new tagging computer with its clearance matrix and electronic concurrence capabilities along with the Blue Tag system to simplify equipment testing, appear to be improving the tagging program performance. The poor preparation for the implementation of these latest initiatives had a short term detrimental effect on the WC tagging program.
6.2 Duficiency Tagging a.
Insoecuon Scoce The team reviewed the deficiency acceptance process to determine whether the program was adequately defined and understood by the Seabrook staff. The relationship between the "fix-it-now" and the deficiency acceptance process to assure that discrepancy plant material conditions were properly classified for impact on plant operations and addressed in a timely manner in the maintenance program was reviewed.
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Observations and Findinas D aring the IPAP inspection in February 1996 (IR 96-80), weaknesses were identified in the deficiency tagging system in that sometimes deficiency tags (DTs) were not removed even after the work was completed. A followup audit by the licensee found additional DTs were not cleared and come deficient items in the plant identified by DTs were not placed in the WC system. More recently, during the June 1997 inspection (IR 50-443/97-03),a detailed listing of all DTs in both EDG rooms was made. The total number of DTs was 22 and problems were identified with inaccurate or incomplete tag information and work. request identification for each DT. The issue of the lingering deficiency tags was left unresolved as UNR 50-443/97-04-01.
Deficiency tags are controlled by maintenance procedures MA 3.0, Work Control Practices, and MA 3.1, Work Request. MA 3.0 defines a plant deficiency and specifies when DTs and deficiency evaluation tags (des) are to be used. Different types of DTs are available for general plant, control room, and MCA use. MA 3.1
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provides guidance for DT originator, work control supervisor, shift manager, system engineer, and planning personnel. Following appropriate evaluation, DTs may be replaced with des.
For this inspection, the team reviewed the status of deficiency tags in the EDG rooms, the spent fuel pool (SFP) builoing, the service water (SW) pump house, the closed cooling water (CCW), safety injection (SI), and other miscellaneous areas of the auxiliary building, and the control room (CR) to ascectain the licensee's offectiveness in problem identification, cause analgses, and corrective actions.
Problem Identification The team observed that the plant staff aggressively identifies operating and maintenance deficienciesin the noncontaminated areas of the plant. For the systems / areas physically inspected,23 DTs and two des were recorded in the EDG rooms, two DTs and nine des recorded in the SFP building,10 DTs recorded in the SW pump house,20 DTs and three des recorded in the auxiliary building, and seven DTs/ des recorded in the control room. Note, this was not an extensive listing of deficiency tags in the areas teured by the team.
This review of DTs and des identified the following issues that needed further review.
96-206184-1SI-P-6A Heavy Boron Leakage (Mechanical Seal)
A resident inspector observed boric acid accumulation at the pump's mechanical seal during a surveillance test of the "A" safety injection (SI) pump on August 25, 1997. The inspectors discussed the deficiency with the operator and reviewed the impact of the accumulated boric acid and the engineering processes for evaluating and correcting the deficiency. The operator stated that he believed that the boric acid leaks were identified and referred to Health Physics for cleanup. The Health Physics cleanup of boric acid from plant components was performed through quarterly repetitive task sheet (RTS 97RH00033002). The inspectors review showed that the last cleanup on the pump seal was October 11,1996. The boric acid leakage at the "A" Si pump was not identified to be cleaned during the current RTS period. Tl e operator corrected this situation by having HP add this pump shaft seal to the current RTS.
~.he "A" Si pump mechanical seal replacement was postponed from the past refueling outage to the next refueling outage. Based on the "B" SI pump replacement and inspection, the "A" Si pump seal leakage was determined to be acceptable until the next refueling outege. The inspectors observed that boric acid had accumulated around the "A" SI pump mechanical seal, Gc seal basin and the drain for the seal basin. The drain appeared to be clogged. The "B' S! pump had experienced the same type of boric acid accumulation. During the outage in June 1997, the vendor replaced the "B" Si pump mechanical seals. The as-found condition of the "B" mechanical seals was "as new" according to the vendor.
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The inspectors questioned the system engineer on the design purpose of the drain.
After reviewing the UFSAR, the vendor's manuals, and discussions with design
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engineerlag, the system engineer determined that the drain did not have any design purpose besides directing the leakage to the floor.
The team further questioned the system engineer in regards to meeting NUREG-0737 (TMI Accident) system integrity outside containment requirements which are specified in the UFSAR and in TS 6.7.6. The licensee provided operating procedure EX 1801.002, Leakage Reduction Program Surveillance, and ES 1809.001, Master Integrity Test Procedure. This later procedure provides a definition of a leak and states that, " Boric acid deposits do not mean the joint is leaking, only that leakage or weeping has/had been present." The system erigineer stated that the SI pump seals leak a small amount when first started and then d y up as the seals seat. He also indicated that the DT's wording, " Heavy Boron Leakage" was not really the condition. To confirm the acceptability of the Si minor leakage, the team requested the licensee estimate the area personnel dose rate for the buildup observed. A health physics technician performed the calculation using concentrations from the UFSAR, Table B-3. The results did not pose a design basis problem.
During the review of adverse conditions, the team became aware of ACR 96-113, Potential Contaminated Minor Leakage Sources Outside Containment. This ACR documents six DTs for system leakages. The AITTS indicates that five assignments were made to repair the minor leakage, clarify procedures, brief HP of requirements, provide training for maintenance and planning. The licensee provided information to show these assignments were completed.
96-1780 - 1-DC-C-2A Air Compressor Oil Level Switch LSL-9519A was generating a false low oillevel alarm locally and also DG "A" trouble point DS579 at the main control board. The DG "A" trouble alarm was locked in and prohibits the MCB from receiving further trouble starms.
The team noted in the control room that the DG "A* trouble alarm digital point for the main computer was not in the alarm condition. The work control data for 96 WOO 2638[ tied to DT 96-1780] indicated temporary modification 96TMOD0035
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had been completed to disable the DG-LSL 9519-A level switch at the same time the DT was initiated. The justification for this was the lack of spare parts to repair
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the switch. Team review of the temporary modification request and the 10 CFR 50.69 evaluation showed good engineering review and consideration of UFSAR changes. The noted problem was the lack of feedback to the DT that a TMOD had been made. However, since the aopropriate information was available in the work control computer, the accurate condition was determined. To ensure adequate oil level was maintained in the air compressor, the licensee added a level verification item to the auxiliary operator rounds.
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97-4494 - 1-CS-PIC -3, Letdown Degassifier Auxiliary Steam Controller, listed the location as CP-126 letdown degas control panel PAB 25.
However, the team found the tag on the bulkhead adjacent to security door F203 in the SFP building, l
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The licensee's conclusion was that since the work to closecut this tag had been completed, the worker or someone else had removed this tag from CP-126, put it in his pocket, and dropped it near the security docr. They speculated that the tag was found by someone who placed it on the bulkhead for some unknown reason. The team questioned why other plant personnel had not noted the DT beiore. The team concluded personnel exhibited a weak attention to detail in the implementation of their plant walkdown program.
97-1903 1-FP-CP380 Zone 2 Locked in Trouble Alarm. [ Trouble alarm light
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and 97-5269 - 1FP-CP-474 Detector 0206 is in Alarm with No Apparent Cause (reference attached RTS). Zone is bypassed. Scaffolding required.
INo attached RTS - Trouble alarm light on]
The team requested assistance from the licensee to evaluate the effect of these fire protection DTs. A fire protection brigade member responde-I with the Fire Protection impairment / Disablement Status Loc, the Daily Fire inspection Continuation Sheet, the Detector Layout Zone 1 and 2 Maps, and the Non-Routine Surveillance Log for Secondary Fire Patrol. The subject areas where the detectors were out of service were on the hourly surveillance log and were being appropriately monitored. The team's review found these condit ons acceptable.
i The team found some DTs were missing data such as dates, correct locations, and WR numbers. Missing data on the DTs indicates a lack of attenuon to detail by the plant worker, the WCS/USS who are to review the copy of all tags, and management oversight. However, there were no plant deficiencies identified by the team that were not identified by a DT or DE. The team concluded that the identification of deficiencies at Seabrook was acceptable.
Cause Evaluation During the review of the deficiencv controlliN procedures, MA 3.0 and MA 3.1, the team found the guidance provided was difficult to follow and understand. This was especially true during the later stages of the process and as it described the control of Deficiency Tags and Deficiency Evaluations. In discussions with plant personnel and after reviewing several ACRs (such as 96-08197-1507,97-1863, and 97-1892), the team concluded that these prowdures were also not well understood by the plant workers either. Per MA 3.0 and 3.1, the system engineer was responsible for performing a deficiency evaluation for equipment identified with a DT where the deficiency has been determined to be acceptable as documented. In this case, the DT is to be replaced with a DE and the evaluation was to be attached to the closed
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work request. The team noted that only about 38 DTs have been replaced with des and the use of des was not uniform; only two were found in the EDG rooms while only two DTs remained in the SFP building. The population of tags was about the same. in another case, a system engineer stated he; did not know how to go about having DE tags cleared for two issues he wanted to void out since the conditions no longer existed. In addition, he did not know if the DE tags should be replaced with DTs for fou; conditions he was returning in the work control system for repair. des were not subjected to independent technical or safety reviews.
Overall, the team identified weak definition and formalized controls regarding the use the deficiency evaluation tags, to assure proper linkage with the processes for operability reviews, TS reviews,10 CFR 50.59 safety evaluations, and the treatment of degraded and nonconforming conditions. The licensea issued ACR 97-2032 to evaluate the programmatic controls necded to limit the evaluation process and provide the expectations for System Engineer responsibilities.
Corrective Actions The licensee provided information on the total number and age of unresolved deficienciesidentified in the plant as follows:
YEAR TAG HUNG NUMBER REMAINING 1990
1991
1992
1993
1994
1995
1996 428 1997 604
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TOTAL 1189 The team was concerned about the large number of identified deficiencies at Seabrook. Review of the assigned priority indicated that the majority of deficiencies were Priority 3, defined as those repairs, replacements, or modificatiora which may be performed as manpower or other scheduled activities allow. The licensee data shows only 1 Priority 1,69 Priority 2,901 Priority 3, and 11 Priority 4 work requests open on August 16,1997. In addition, no Priority 1 and only 19 Priority 2 WR were older than three months. The licensee has been working on initiatives to address the backlog. However, many deficiencies identified on a particular system were not worked during system outages. This was very apparent in the EDG rooms where most of the minor type deficiencies observed by the inspector in June had still not been corrected at the time of this inspection even after several EDG system outages. Despite these initin.:ves, the team concluded DT reduction has not been very effective, potentially retarding additional identification by licensee staff and equipment operators.
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Conclusions Although the team identified some weak attention to det' ail by the plant workers, d
overall problem identification was acceptable based on the large number of deficiencies identified and based on no plant deficiencies identified by the team that were not already identified with deficiency or evaluation tag. The team considered the deficiency evaluation process to be weak in that system engineer responsibilities are not well defined and formalized with controls, and there was an unclear linkage to processes that address safety evaluations and plant design changes. Further, corrective actions were ineffective in certain instances as evident by an extensive number of deficiency tags that resulted from deficiencies not routinely corrected during system week outages. Additional NRC staff foliowup is planned (IFl 443/97-05-01).
7.0 Summary The team noted an evolving self-assessment and corrective action program at Seabrook, with many initiatives in place or under development for critical self-evaluation and to improve performance. Noteworthy initiatives both within the line and the independent oversight groups, included the changes in the management of the corrective action program, the development of the " partnership concept" by oversight, and the use of failure prevention methodologies and common cause evaluations.
In the areas of problem identification and cause evaluation, the CAP is very good and improving. However, there are areas where the staff has not identified the correct cause for tne problems. In the area of CA effectiveness, the corrective actions have been generally good, but continue to show mixed performance. While there appears to be a good process for identification of deficiencies and performance weaknesses, barriers to success were observed, including the need to effectively manage backlogs, to effectively manage program in transition, to consistently identify the causes for performance issues, and take effective corrective measures.
.A good questioning attitude is at Seabrook, as seen in the self-critical evaluations and the efforts (apparently station wide) to improve performance. The team concluded that the independent oversight function remains effective. Overall, the team noted a generally positive trend in corrective action and self-assessment program performance (relative to 1994). Notable advances were in problem identification and evaluation, particularly with the adoption of the failure prevention
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methodologies. Recurrent themes and barriers to success include high backlogs, staff overload, the need to improve processes (work control), and consistent effective corrective actions. The CA and SA processes are in transition in several respects, with mrsny seemingly good initiatives. Effectiveness remains to be determined.
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8.0 - Management Meetings Meetings were held periodically with licensee management during this inspection to discuss inspection findings.' A summary of preliminary findings was also discussed at the conclusion of the on-site inspection on September 10,1997. No proprietary
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information was identified as being included in this report.
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PARTIAL LIST OF PERSONS CONTACTED Licensee B. Beuchel, Engineering Performance Manager *
A. Chesno, Maintenance Department Manager *
R. Ct oney, Assistant Stet'on Directcr*
M. DeBay, Assistant Operations Manager *
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W. DiProfio, Station Manager *
J. Dolan, Technical Projects Senior Engineer *
B. Drawbridge, Director of Services T. Feigenbaum, Executive Vice President T. Grew, Technical Training Manager *
J. Grillo, Oversight Manager-
.M. Harrington, PE Supervisor G. Kline, Technical Support Manager F. Laird, Root Cause Evaluator *
W. Leland, Chemical /HP Manager M. Lewis, Maintenance Services Manager M. Malpwocz, Corrective Action Manager J. Marchi, Audit Manager G. Mcdonald, Nuclear Quality Manager C. Moynihan, Trend Analysis T. Murphy, Technical Projects *
M. O'Keefe, NSE Supervisor *
J. Pescher, Regulatory Complianca Manager *
J. Peterson, Maintenance Manager T. Pucko, NRC Coordinator B. Seymour, Security & Safety Manager-R. Sherwin, Plant Scheduling & Outage Manager *
J. Sobotka, Regulation Compliance Supervisor E. Soretsky, Technical Projects Gupervisor L. Walsh, Station Staff C. Welch, Reactor Engineer R. White, Mechanical Engineering Manager
denotes those in attendance at the exit interview on September 10,1997 NB.G P. Bonnett, Senior Resident inspector E. Conner, Haddam Neck Project Manager
S. Flanders, NRR Project Manager W. Olsen, Resident inspector W. Raymond, Senior Resident inspector s
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INSPECTION PROCEDURES USED IP 40500:
Effectiveness of Licensee Lntrols in Identifying, Resolving, and Preventing
Problems ITEMS OPEN 50-443/97-05-01 IFl DT and DE Process Weakness LIST OF ACRONYMS USED ACR Adverse Condition Report AR Acticn Request CCE Common Cause Evaluations CFR Code of Federal Regulations CAP Corrective Action Program DCR Design Change Request DRP Division of Reactor Projects DRS Division of Reactor Safety ESAR Engineering Self-Assessment Report FSB Fuel Storage Building HP Health Physics IP Inspection Procedure JUMA Joint Utilities Management Audit KPl Key Performance indicator MRT Management Review Team NDE Non-destructive Examination NRC Nuclear Regulatory Commission NSRC Nuclear Safety Review Committee OERE Operating Experience Reference OROS Refueling Outage # 5 PAB Primary Auxiliary Building Pil Performance improvement international QA Quality Assurance QC Quality Control RCA Radiologically Controlled Area RCE Root Cause Evaluation ROR Radiological Occurrence Report RP&C Radiological Protection end Chemistry SADR Self-Assessment Documentation Report SI Safety injection SSOE Seabrook Station Operating Experience SWS Service Water System TS Technical Specifications UFSAR Updated Final Safety Analysis Report
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