IR 05000458/1998019
| ML20196D362 | |
| Person / Time | |
|---|---|
| Site: | River Bend  |
| Issue date: | 11/20/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20196D360 | List: |
| References | |
| 50-458-98-19, NUDOCS 9812020217 | |
| Download: ML20196D362 (11) | |
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ENCLOSURE l
U.S. NUCLEAR REGULATORY COMMISSION
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REGION IV
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' Docket No.:
50-458 l
i License No.:
NPF-47 l
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Report No.:
50-458/98-19
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Licensee:
Entergy Operations, Inc.
. Facility:
River Bend Station
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Location:
5485 U.S. Highway 61 l
St. Francisville, Louisiana
Dates:
Octeoer 19-23,1998
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inspectors:
Michael E. Murphy, Senior Reactor Engineer (Examiner)
Norm Garrett, Resident inspector David Desaulniers, Human Factors Analyst
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' Approved By:
John L. Pellet, Chief, Operations Branch i
Division of Reactor Safety i
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i ATTACHMENTS:
Attachment:
Supplemental Information
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L 9812020217 981120 F
PDR ADOCK 05000458
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l EXECUTIVE SUMMARY i
River Bend Station NRC Inspection Report 50-458/98-19 Operations l
l The current operator workaround program guidelines were incomplete. The guidelines
provided a broad definition of operator workarounds that encompassed most conditions described in Tl 2515/138. However, the guidelines contained no guidance for
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documenting the screening of workarounds or documenting the assessment of the l
effects of operator workarounds, or in closing out workarounds that were not maintenance related items (Section 01.1).
. The licensee had effectively communicated to plant personnel the importance of
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identifying and resolving operator workarounds and the licensee's efforts to identify i
operator workarounds were being adequately implemented. The workarounds documented by the licensee on the workaround list were consistent with the definition in the established guidelines (Section O1.2).
Individually, the existing operator workarounds would not significantly impact plant
operations (Section 01.3).
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The current number of workarounds had not adversely affected personnelidentifying or
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reporting material deficiencies. However, a single event could strain the available resources and the cumulative effects of workarounds could impact plant operations (Section 01.4).
The licensee had performed limited scope assessments of operator workarounds but
had not applied any formal evaluation criteria. Past assessments of workarounds had not addressed the potential for operator error during, or resulting from, the implementation of workaround compensatory measures. Despite the informal nature
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and limited scope of the assessments, the licensee appeared to be emphasizing the timely resolution of operator workarounds (Section 01.5).
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-3-Report Details 1. Operations
Conduct of Operations This inspection was conducted to evaluate the cumulative effect of operator workarounds on the ability of operators to safely operate the plant and effectively respond to abnormal and emergency plant conditions. Information gathered during this inspection will be used to support an evaluation of the need for additional NRC industry guidance concerning operator workarounds.
01.1 Procedures and Criteria a.
Inspection Scope The inspectors reviewed the licensee's guidelines used to identify and evaluate operator workarounds and evaluate their cumulative effects.
b.
Observation and Findinas The licensee's principal guidance document for the identification, assessment, and resolution of operator workarounds was entitled," Operator Work Around Main Control Room Deficiency Program," Revision 6 dated October 12,1998. The inspectors reviewed this guidance document and found that the licensee had defined operator workarounds as:
1.
Equipment operated outside of its normal design or intended mode of operation. For example, a piece of equipment being operated in manual that should otherwise be operated in automatic as part of its design.
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Operator action is required during a plant transient or normal operation to compensate for degraded equipment condition that is not part of the plant design or is the result of an ineffective design.
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Any equipment abnormalities or design inadequacies that result in procedural development or revision to compensate for these occurences.
The inspectors considered this definition to be generally consistent with the definition of operator workarounds provided in Temporary Instruction 2515/138, which states that an operator workaround is ". a degraded or non-conforming condition that complicates J
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the normal operation of plant equipment and is compensated for by operator action."
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The only difference noted was that the licensee's definition was limited to equipment conditions whereas the definition provided in Temporary Instruction 2515/138 refers to a i
" degraded or non-conforming condition," which can be interpreted to include material, l
environmental (e.g., radiological), structural, or personnel (e.g., staffing) conditions that
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complicate the normal operation of plant equipment.
The inspectors reviewed the licensee's guidance for assessing the cumulative effects of operator workarounds and noted that the licensee's guidance assigned responsibility to i
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the work management supervisor for reviewing the cumulative effect of operator workarounds on plant operations during monthly meetings with the operations superintendent. The guidance document did not directly address who performed the assessments although inspector interviews with licensee personnel indicated that these assessments had been performed by the work control supervisor and work
l management supervisor. Past assessments of the cumulative effects of operator l
workarounds were performed without specific guidance pertaining to how the
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assessments were to be performed. The assessments were not documented, however, personnel interviews indicated that these assessments were largely focused on determining whether adequate time and personnel were available to perform the
workaround compensatory actions and had not focused on the potential for operator l
error during the performance of the workarounds due to the additional burden. The inspectors noted that the workaround guidance had been revised during the week prior i
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to the inspection to establish guidance for assessing the cumulative effects of operator i
l workarounds, provided in Section 03.04 of the temporary instruction.
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Most operator workarounds were identified during the development of work items or the review of work packages by the work control center. The program guideline contained I
an operator workaround submittal sheet, however, there was no formal method to document and track this type of workaround submittal nor were there guidelines on documenting the screening of the potential workaround. The current process for tracking and assessing workarounds was managed by the work control center and documented on the work management system. All workarounds were entered into the l
system as a maintenance item.
The inspectors identified a workaround remaining on the list for which the initiating maintenance action had been completed. This workaround required the operators, upon loss of normal service water, to close the backup standby service water isolation valves to prevent pressurizing the normal service water surge tank and loss of inventory
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in the standby cooling tower since the automatic isolation valves leaked excessively.
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These automatic isolation valves had since been repaired, however, the licensee elected to leave the contingency actions in the procedure and the program guidelines did not address removal of workarounds under these conditions. The only workarounds removed from the list were completed component repairs with elimination of the need for operator contingency actions.
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5-c.
Conclusion The current operator workaround program guidelines were incomplete. The guidelines provided a broad definition of operator workarounds that encompassed most conditions described in Tl 2515/138. However, the guidelines contained no guidance for documenting the screening of workarounds or documenting the assessment of the effects of operator workarounds, or in closing out workarounds that were not maintenance related items.
01.2 Identification of Operator Workarounds l.
a.
Inspection Scoce The inspectors reviewed the established operator workaround list and conducted interviews with licensed and nonlicensed operators, instrument and control, mechanical, and electrical maintenance technicians, chemistry technicians, and system engineers, and accompanied equipment operators on system tours to assess knowledge of known workarounds and to identify any previously unidentified workarounds.
The inspectors also reviewed the following procedures to identify workarounds that had l
L been proceduralized:
i OSP-0027 - Daily Log Report - Main Control Room l.
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OSP-0043 - Freeze Protection and Temperature Maintenance
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AOP-0016 - Loss of Standby Service Water
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AOP-0052 - Fire Outside the Main Control Room in Areas Containing safety-
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l related Equipment AOP-0053 - Severe Weather Operation
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SOP-0053 - Standby Diesel Generator and Auxiliaries
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SOP-0062 - Fuel Building Ventilation System l
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RNBP-089 - Hurricane Readiness
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b.
Observation and Findinas The inspectors found that operations personnel and systems engineers were familiar
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l with the items on the workaround list and that operators knew and understood the
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compensatory measures required by the workarounds. Other plant personnel that were interviewed had been briefed or had been otherwise sensitized to the importance of
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identifying workarounds and resolving workarounds in a timely manner. None of the
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personnel that were interviewed identified conditions that they considered to be
workarounds that were not already on the licensee's workaround list.
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l-6-The inspectors did not identify additional operator workarounds incorporated in the reviewed procedures. The inspectors also noted that the licensee had conducted a recent review of operating and abnormal operating procedures to identify additional l
workarounds. Although the results of this review had not been documented, a work management supervisor informed the inspectors that the review had not identified any additional workarounds.
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The inspectors reviewed three items identified as potential workarounds by the resident inspectors during direct observations and review of condition reports and work items that the licensee had not identified as such. These items were discussed with and subsequently evaluated by the licensee during the inspection. One item, difficulty in
tripping the reactor water cleanup pumps when bringing the demineralizers on line, was i
added to the operator workaround list; a second item, the control room annunciator for
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HVK (control room ventilation) inoperability, remained under evaluation as a potential
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.workaround; and the third item was found to be a design function of the system and not j
an operator workaround.
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Conclusion The licensee had effectively communicated to plant personnel the importance of identifying and resolving operator workarounds and that the licensee's efforts to identify operator workarounds were being adequately implemented. The workarounds
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documented by the licensee on the workaround list were consistent with the definition in
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l the established guidelines.
01.3 Assessment of Individual Workarounds a.
Inspection Scope i
The inspectors evaluated the effect of individual workarounds on plant operational i
safety.
b.
Observations and Findinas At the initiation of the inspection, the licensee's workaround list contained 23 items. All of these items, except three, were entered on the ' - 4 thin the last eight months. The three other itemm were from one to three years 4 4 v.ere considered to be of minor significance. The inspectors assessed all of ths.
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- the list and selected the three items that appeared to present the highest potential for agnificant integrated impact on plant operations.
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l-7-The standby service water system workaround required the shutting of manualisolation valves to prevent leakage from the standby service water to normal service water when l
the systems were required to be separated. During the evaluation of this workaround, it was discovered that the plant condition creating this workaround was corrected during Refueling Outage 7(September - October 1997), but the workaround was not removed from the list. The licensee had elected to leave the contingency actions in the abnormal operating procedure due to the potential for subsequent excessive isolation valves leakage.
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The emergency diesel generator workaround required the installation of compressed
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air bottles to the diesel control air system to supply control air on loss of the diesel nonsafety control air system, such as on a loss of all ac power. This workaround required operators to move compressed air cylinders into the diesel generator rooms, attach the cylinders to the air system using a regulator assembly, and perform increased or continuous monitoring of the diesel engines. If the proper operator actions were not taken on a loss, normal control air to the diesel generator, the emergency diesel engines would trip when the air in the installed nonsafety air system was depleted. This condition existed without a workaround contingency plan from 1985 to 1990, at which time the licensee recognized the need for backup air, but did not identify the condition as an operator workaround or demonstrate an effective contingency plan. The establishment of a proceduralized contingency action with prestaged supporting equipment and compressed air bottles that operators were trained
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l to implement was not in place until June 1998 following a walk-through drill in which l
operators failed in the first two attempts to install the air bottles. This condition was
identified and reported during a previous inspection and the details are contained in
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NRC Inspection Report 50-458/98-13.
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Auxiliary Building Door PWO95-02 required a crowbar and a mechanical chainfall to j
manually open from the T-tunnel side when the standby gas treatment filter fans are in
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service. This condition inhibited access to several safety-related systems that would require local operation during an event that activated the standby gas treatment system.
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Conclusions
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Individually, the existing operator workarounds would not significantly impact plant l
operations.
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01.4 Cumulative Effects of Operator Workarounds a.
Inspection Scope The inspectors evaluated the cumulative effect of the current workarounds at the site through interviews and the performance of a table-top scenario.
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Observations and Findina Inspector interviews with plant staff indicated that the current number of workarounds
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had not adversely affected personnel sensitivity toward identifying or reporting material
deficiencies. To the contrary, the prevalent view of the individuals interviewed indicated l
that plant management had encouraged the reporting of degraded conditions and that l
their experience had been that problems identified were resolved in a timely manner, l
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The scenario constructed for the table-top exercise began with the loss of off-site power l'
at 3 a.m. on Sunday. Shift manning was at a minimum in accordance with the technical specifications. The available crew was, thus, restricted to a shift superintendent, control room supervisor, three reactor operators and a shift technical advisor in the control i
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room. The available in plant crew consisted of four nonlicensed equipment operators
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I and a normal complement of instrumentation and control, maintenance, security, j
l chemistry and health physics personnel.
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The scenario commenced: A loss of off-site power occurred, with a concurrent reactor i
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scram and a turbine generator trip. The diesel generators started, standby service l
l water isolated and the standby gas treatment system activated (this imposed all three l
l operator workarounds previously discussed). Control room personnel entered the
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required abnormal operating procedures and emergency operating procedures. Two
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l reactor operators assumed power, pressure, and level control and the third operator l
assumed other balance of plant actions as required by procedure. One equipment l
operator was dispatched to monitor the diesel generators, one equipment operator was
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dispatched to verify standby service water was operating, subsequently, a third operator was dispatched to assist in isolating normal service water from standby service water.
The fourth equipment operator was dispatched to assist in the installation of the backup air supply bottles to the diesel generator air system. Under these conditions, all available operators were involved in essential contingency actions. Subsequent actions l
required would have been further complicated by the difficulty in accessing the auxiliary building.
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Conclusions The current number of workarounds had not adversely affected personnelidentifying or reporting material deficiencies. However, a single event could strain the available resources and the cumulative effects of workarounds could impact plant operations.
01.5 Licensee Performance in Assessment and Resolution of Operator Workarounds
a.
Insoection Scope i
The inspectors evaluated the licensee assessment and resolution of operator workarounds.
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Observation and Findinas The inspectors found that the licensee guidance did not require documented assessment of individual or cumulative operator workarounds. As a result, it was not
possible for the inspectors to review specific or cumulative workaround assessments or the past or planned resolution schedules relative to these assessments. Further, the licensee did not establish criteria for cumulative assessments until its October 12,1998,
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revision to the guidance document. Personnel interviews concerning the assessment of
workarounds indicated that the assessments were largely focused on determining l
whether adequate time and personnel were available to perform the workaround compensatory actions and had not focused on the potential for operator error during, or resulting from, the performance of the workarounds. Although system engineers were incorporating information concerning workarounds in system health reports, the licensee did not consider these reports to be formal assessments of the potential impact of l
workarounds on system reliability or availability.
The inspectors reviewed licensee records summarizing the number of nonoutage operator workarounds more than 60 days old for the past 18 months to identify trends in i
the resolution of workarounds. The data indicated that ihe licensee had maintained the number of workarounds to 10 or less for the period April 1997 through February 1998.
Following a low of 4 workarounds in December 1997, the inspectors noted a trend of
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increasing number of workarounds beginning January 1998 until the inspection in October 1998 when the licensee's operator workaround list for October 16,1998, contained 23 workarounds. The individual responsible for maintaining the workaround
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l list, the work control supervisor, stated that he believed the apparent adverse trend was i
l misleading in that it reflected an increased site emphasis on the identification of l
workarounds. He believed that although the number of identified workarounds (i.e.,
maintenance items tracked as workarounds) had increased, the actual number of workarounds had been substantially reduced. The inspectors found no evidence to dispute this assessment and also noted that part of the increase in workarounds resulted from items that previously only appeared on the significant equipment issues list, which have been formally identified and tracked on the workaround list since the I
latest definition of operator workaround was promulgated. interviews with plant operators also revealed a general opinion that material condition in the plant had been improving and the number of operator workarounds had been reduced.
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In reviewing licensee resolution of operator workarounds the inspectors noted that of the l
three workarounds that the inspectors had assessed for cumulative impact, one workaround had been resolved and the other two were currently being evaluated for
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possible resolution through design changes.
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Conclusions The licensee had performed limited scope assessments of operator workarounds but
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had not applied any formal evaluation criteria. It appeared that past assessments of
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l workarounds had not addressed the potential for operator error during, or resulting from, l
the implementation of workaround compensatory measures. Despite the informal l
nature and limited scope of the assessments the licensee appeared to be emphasizing l
the timely resolution of operator workarounds.
V. Manaaement Meetinas X1 Exit Meeting Summary
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The inspectors presented the inspection results to members of the licensee management at the conclusion of the inspection on October 22,1998. The licensee acknowledged the findings presented.
i l-The licensee did not identify as proprietary any information or materials examined during l
this inspection.
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ATTACHMENT
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SUPPLEMENTAL INFORMATION i
PARTIAL LIST OF PERSONS CONTACTED l
Licensee I
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L. Ballard, Supervisor, Quality Assurance R. Biggs, Licensing Specialist R. Buell, Acting Director, Site Support
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O. Bulich, Superintendent, Plant Engineering
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l C. Bush, Jr., Superintendent, Operations l
M. Cantrell, Supervisor, Operations Training l
V. Carlson, Operations Shift Supervisor L
D. Dormady, Manager, Plant Engineering T. Fredieu, Outage Management T. Hildebrandt, Manager Maintenance H. Hutchens, Superintendent, Plant Security D. Lorfing, Supervisor, Licensing J. McGhee, Operations Staff Coordinator l
D. Mims, General Manager, Plant Operations B. O'Malley, Operations Manager
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D. Pace, Director, Engineering l
D. Pipkin, Control Room Supervisor A. Spencer, Operations Coordinator R. Walton, Control Room Supervisor i
D.-Williarr, son, Senior Licensing Specialist
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j INSPECTION PROCEDURES USED Temporary Instruction 2515/138," Evaluation of the Cumulative Effect of Operator Workarounds" l
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