IR 05000461/1989030

Insp Rept 50-461/89-30 on 890925-1003.No Violations Noted. Major Areas Inspected:Licensee Integrated Plant Operations & Performance of Organizations That Control & Support Plant Operation

ML19354E410
Person / Time
Site:	Clinton
Issue date:	01/22/1990
From:	Knop R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML19354E406	List: IR 05000461/1989030 ML19354E405
References
50-461-89-30, NUDOCS 9001310150
Download: ML19354E410 (38)

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U. S. NUCLEAR REGULATORY COMMISSION

REGION III

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Report No. 50-461/89030(DRP)

Docket No. 50-461 License No. NPF-62

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Licensee:

Illinois Power Company 500 South 27th Street Decatur, IL 62525 i

Facility Name:

Clinton Power Station

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Inspection At:

Clinton Site, Clinton, Illinois

Inspection Conducted:

September 25 - October 3, 1989

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Inspectors:

W. L. Forney, T am Leader M. A. Ring P. B. Brochman B. Drouin

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J. B. Hickman

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S. P. Ray

W. G. Rogers J. A. Gavula l

M. C. McCoy l

A. B. Sutthoff

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Approved By:

Richard C. Knop, Chief i

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ReactorProjectsBranch3 Date

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Inspection Summary j

Inspection on September 25 - October 3, 1989 (Report No. 50-461/89030(DRP))-

Areas Inspected:

An operational safety team inspection (OSTI) was conducted to review the licensee's integrated plant operations and the performance of those organizations that control and support plant operation including engineering, maintenance, management oversight, surveillance and quality assurance.

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PDR ADOCK 05000461 (-

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_Results:

No violations or deviations were identified. The OSTI determined that the licensee was operating the plant in a safe manner.

However, several concerns were identified including the following:

the material condition

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ofbalanceofplant(BOP)equipmentwaspoorandcertainimportanttosafety equipment was unreliable, thus requiring compensatory actions which burden the i

operators. Short term fixes for equipment problems had been frequently

utilized. A culture of "getting around" specifications and procedures appeared j

to be developing at the site. Engineering involvement in solving operational problems was slow or ineffective in some cases.

In areas with no direct

regulatory or safety correlation, plant staff morale appeared low and there appeared to be a discontinuity between Clinton management and Clinton staff.

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O TABLE OF CONTENTS

.Pagg E xe c ut i v e S umma ry.................................................

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Persons Contacted...........................................

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Introduction................................................

2.1 Background..............................................

2.2 Scope............................................-......

'9 2.3 Methodology............................................

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Inspection Findings.........................................

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3.1 Operations........................................

3.1.1 Scope of Review..............................

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3.1.2 Material Condition of the Facility...........

3.1.3 Administrative Controls......................

12-3.1.4 Operator Performance.........................

3.~ 1. 5 Factors Impacting on Operator Effectiveness..-

13-3.1.6 Surveillance.................................

3.1.7 Turnover Shift...............................

3.1.8 Non-Routine Pl ant Evolutions.................

3.1.9 Conclusion...................................

3.2 Ef fectiveness of Pre-iures........................

3.2.1 0verview.....................................

3.2.2 Procedure Deficiencies.......................

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3.2.3 Conclusion...................................

3.3 Radiological Controls.................................

3.3.1 Observations.............................'....-

3.3.2 C o n c l u s i o n................................ -...

3.4 Ma i n te n a n c e............................ ~................

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I 3.4.1 0verview.....................................

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3.4.2 Maintenance Work Requests....................

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3.4.3 Conclusion...................................

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3.5 Effectiveness of Engineering Support..............

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3.5.1 0verview.....................................

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3.5.2 System Engineer Program......................-

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I 3.5.3 Operations Interface.........................

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3.5.4 Engineering Evaluation.......................

3.5.5 Conclusions..................................

24-3.6 Management 0versight...................................

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3.6.1 0verview....................................-

3.6.2 Interviews...................................-

3.6.2.1 Methodology.............................

3.6.2.2 Interview Results.......................

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3.6.3 Corrective Actions...........................

L30 3.6.4 Conclusion...................................

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S umma ry o f F i nd i ng s.................................... -

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Unresolved Items.......................................

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Exit Meetings...........................................-

.33 Appendix A - Documents Reviewed

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i Executive Summary

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As a result of poor performance during the first refueling outage and

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subsequent attempts to return to power at the Clinton Power Station, the NRC decided to perform an Operational Safety. Team Inspection (OSTI) at the Clinton site to verify whether the plant was being operated in a safe manner and to assess the effect of the outage problems on current or future operations.

The OSTI utilized both personnel interviews and observation of activities.

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The most important conclusion from the OSTI activities was the Clinton Power

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Station was safe to operate and was being operated in a safe manner.

The basis for this conclusion included the following:

The Emergency Core Cooling Systems (ECCS) and other key safety systems appeared to be in good material condition, the shift alignment of responsibilities was good for allowing the

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operating crew to keep in touch with actual plant conditions, the onshift personnel were well qualified and functioned well as a team, the non-licensed operators were conscientious about identifying equipment deficiencies, the t

plant had demonstrated good routine performance for the previous two months and continued to do so while the OSTI was onsite, planning, communication, control and coordination of the non-routine effort on an electro-hydraulic control (EHC) fluid leak was executed well, the valve position configuration program appeared strong, radiological controls were understood and followed by operators and surveillances were generally adequate and performed well.

Notwithstanding the OSTI Team's major conclusion, several significant

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concerns were noted as described in the following paragraphs.

P The material condition of balance of plant (B0P) equipment was viewed as poor.

Some examples which led to this conclusion included:

steam leaks on the shaft of the motor driven feed pump, hydraulic leaks on the recirculation system flow control valve hydraulic power units, piping leakage in the plant service water system, several temperature regulating valves which were malfunctioning and two steam leaks on the reheater drain tank from the B moisture separator

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reheater.

The material conditicn of certain important to safety equipment appeared degraded or unreliable.

Examples which led to this conclusion included:

steam, air and room cooler leaks in the reactor core isolation cooling (RCIC) room, repetitive problems with the hydrogen / oxygen analyzers, leaks on the diesel fire pumps and leaks on the fuel pool cooling system.

These and other material condition problems were placing an unnecessary excessive burden on operating personnel.

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with the results of interviews, led the team to conclude that interim fixes to work around problems had frequently been used to allow continued operation rather than ensuring complete and thorough corrections to root causes for problems.

The OSTI team observed that operating practice at Clinton appeared to be developing a culture of "getting around" specifications, procedures, or operational conditions versus making them correct.

In addition to interview

results, examples which led to this conclusion include:

operation of the reactor water clean up (RWCU) isolation system on bypass, jumpering out signals.

to the reactor protection self test system in modes 4 and 5, and personnel

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ignoring the drywell continuous air monitor.

The practice of using j

procedures, jumpers and repetitive entry into LCOs to keep the plant in

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operation was thus suspect.

Engineering involvement in solving operational problems appeared to be slow in that some design changes which would have improved operating conditions for

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the operators had not been implemented or had been disapproved.

This may have

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contributed to the belief expressed by operators, that they were not consulted I

regarding priority of things to be fixed.

The system engineer program was in place at Clinton and appeared to contain the appropriate attributes of a strong program, however, implementation did not appear to be effective.

The engineering i

situation may also contribute to the observed large backlog of maintenance work

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requests at Clinton which, at current completion rates, was about seven months worth, i

I The OSTI also examined areas which do not have a direct' regulatory or safety correlation.

In these areas, results of the personnel interviews showed that j

a high percentage of Clinton staff personnel were actively looking for other

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employment.

Lack of understanding or confidence in career path opportunities, lack of sensitivity in the downsizing and resultant layoffs, and an inability to understand the basis for personnel actions contributed to an apparent low morale situation.

In the management oversight area, the OSTI team determined that overall there was a discontinuity between Clinton management and the Clinton staff.

There was a perception of a lack of trust in both directions between Illinois Power management and the work force at the Clinton station.

The team-work concept which management was trying to foster had not yet taken hold between r

management and staff. These problems were of concern to the OSTI team because of their potential impact on the quality.of plant operation.

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DETAILS 1.

Persons Contacted Illinois Power Company (IP)

• D. Hall, Senior Vice President l

J. Perry, Assistant Vice President

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• K. Baker, Supervisor, I&E. Interface

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• T. Arnold, Licensing Staff Engineer l

• R. Campbell, Manager,. Quality Assurance

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• J. Palchak, Manager, Nuclear Planning and Support

• R. Freeman, Manager, Nuclear Station Engineering Department

• D Holtzscher, Acting Manager, Licensing & Safety

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P. Hall, Director, Nuclear Program Assessment

• J. Miller, Manager, Scheduling & Outage Management

• J. Weaver, Director, Licensing

• J. Cook, Manager, Clinton Power Station i

• R. Wyatt, Manager Nuclear Training

• F. Spangenberg, III, Manager, Licensing and Safety

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J. Brownell, Project Engineer / Specialist

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Soyland/WIPC0

• J. Greenwood, Manager, Power Supply

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• E. Greenman, Director, Reactor Projects, Region III M. Clausen, Acting Deputy Director, Reactor Projects

• Denotes those attending the exit meeting on October 3, 1989.

l The inspectors also contacted and interviewed other licensee and

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contractor personnel.

2.

Introduction (93802)

2.1 Background

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The NRC decided to conduct an Operational Safety Team Inspection (OSTI) at the Clinton Power Station as a result of the problems the

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licensee encountered during Clinton's'first refueling outage-(RF1).

The decision was reinforced by the subsequent equipment failures that occurred as Clinton resumed power operations at the end of RF1.-

Several of these problems are described in the following paragraphs.

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RF1 began on January 2, 1989, with refueling activities commencing January 19, 1989.

With the onset of outage activities an increase in identified problems began.

Seven licensee event reports (LER)

were initiated in January, six due to personnel error.

Region III issued a confirmatory action letter (CAL) RIII-89-005 regarding i

refueling activities (control of contractors, adherence to site procedures, personnel errors) on February 1, 1989.

Refueling was

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resumed on February 15, 1989, and completed on February 22, 1989, but Illinois Power continued to experience performance problems resulting in the initiation of four additional LERs.

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i In March 1989, Region III completed a maintenance team inspection

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with no significant deficiencies and generally good results.

However, on March 20, 1989, service air to the inflatable dryer pool gate

seal of the upper containment pool was isolated, the seal deflated,

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and 30,000 gellons of dryer pool water flowed into the drywell.

A Region III followup Environmental Qualification (EQ) inspection for a previous Severity Level III violation identified problems with i

electrical splices and submergence concerns (weep holes) with EQ

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equipment in March 1989.

The EQ issues prolonged RF1 and raised

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concerns about the engineering / technical support'to the plant.

Six additional LERs were initiated in March.

In April the focus of plant activity continued to be EQ corrective actions, verifying / correcting splices and weep holes in EQ components to prevent submergence.

Three additional LERs were initiated in

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April.

In May the motor driven feedwater pump regulating valve (FRV) failed to respond properly during preparations to roll the main turbine on start up resulting in a manual scram of the reactor.

Three additional LERs were initiated in May.

On June 1, 1989, both of the "B" reactor recirculation pump seals failed catastrophically.

While attempting to conduct a controlled shutdown of the reactor for this event the motor driven feed pump FRV failed again, resulting in another manual scram.

Region III issued another CAL (RIII-89-016) to document the licensee's commitment to determine the.cause of the seal, FRV and associated support equipment failures which occurred during the event.

On the startup following the recirc pump. seal failure, the licensee experienced additional problems including improperly calibrated room temperature instruments, an improper valve position on the seal pressure instrument, and management's failure to communicate the CAL commitments to the onshift personnel.

On June 28, 1989, the sudden pressure relay of the C phase main transformer failed, resulting in a generator trip and an associated automatic scram of the reactor.

Five LERs were generated during-June.

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the operators were unable to control reactor water level while l

attempting to recover from a loss of condenser vacuum event.

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i Region III analysis of the problems and equipment failures identified no significant trend or root cause which could explain the problems

which occurred during RF1 and subsequent resumption of power operations other than feed system performance and lack of operator experience with technical specifications, abnormal system configuration and procedures in other than the power operations mode.

The RF1 performance was not consistent with power operations immediately preceding RF1.

For this period, Clinton operation was

considered a SALP 2 with an improving trend.

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These problems resulted in an NRC decision to perform an Operational Safety Team Inspection (OSTI) at Clinton.

The purpose of the OSTI was to review integrated plant operations and the performance of the organizations that control and support plant operation to verify whether the plant was being operated safely in conformance with requirements and whether issues resulting in the previous problems could impact on current or future operations.

2.2 Scope The OSTI reviewed the following areas:

Conduct of operations both inside and outside the control room

including operator professionalism, attentiveness, awareness of plant status, conduct of plant evolutions, response to alarms and indications and overall control of activities.

Effectiveness of communications among plant staff.

• Expertise / training of personnel to accomplish their plant

duties.

Material condition of the facility, systems and components.

• Effectiveness of maintenance support to operations.

• Effectiveness of procedures.

• Availability of resources in support of operations.

• Effectiveness of engineering in technical support of plant

operations.

• Effectiveness of corrective actions.

Management's oversight, including involvement and effectiveness

in plant activities, attitude toward operational safety, perception of what is going on in the plant, and worker understanding of goals, directives and policies.

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t 2.3 Methodology In order to accomplish the inspection objectives, the OSTI team placed considerable emphasis on direct observation of activities, personnel interviews, and reviews of applicable procedures and documentation.

These efforts included direct observation of portions of over 15 operating shifts (approximately 120 hours0.00139 days <br />0.0333 hours <br />1.984127e-4 weeks <br />4.566e-5 months <br /> of coverage),

structured and informal interviews of over 60 Clinton plant staff members, reviews of selected engineering support actions, maintenance and surveillance activities and specific corrective actions.

The OSTI team began observation of activities on the midnight shift on September 25, 1989, and concluded on October 3, 1989.

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Inspection Findings 3.1 Operations 3.1.1 Scope of Review The onshift observation involved accompanying the non-licensed operators on their tours, witnessing routine licensed operator activities in the control room, witnessing select surveillance activities and interviewing nu'nerous onshift personnel on their duties, responsibilities and interactions with support organizations.

In addition, the results of structured and informal interviews with operations personnel away from their work station were factored into the Team's findings, particularly where interview results and field observations corroborated each other.

3.1.2 Material Condition of the Facility Overall the material condition of the facility was observed to be acceptable for continued safe operation.

This conclusion was based primarily on the condition of the key safety systems.

Most of the important-to-safety equipment was in good working order.

The material condition of the emergency core cooling systems (ECCS), the thermal recombiners, the emergency diesel generator fuel oil system and the emergency diesel generators was excellent.

Minimal leaks or deficiencies were observed.

Housekeeping throughout the facility was considered good.

However, the material condition of the balance of plant equipment was poor.

Examples on which this observation was based include the following:

three of the four offgas refrigeration vault chillers were out of service, the B plant service water pump had a large leak, and several leaks existed on the plant service water piping.

In addition, there were long standing leaks on the hydraulic power units for the reactor recirculation flow control valves; problems l

existed with the circulating water discharge valve positions;

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numerous temperature regulating valves were malfunctioning; there was a steam leak on the shaft of the motor driven feed water pump; and there were two steam leaks on the reheater drain tank for the B moisture separator reheater.

The main control room panels were generally acceptable, but there were four long standing identified deficiencies.

On the Chi screen for the main steam system, valve B21A98A, an isolation valve for the Main Steam Isolation Valve Leakage Control System (MSIVLCS),

indicated closed instead of the correct position, open.

This condition had existed since February 1988.

The Post Accident Sampling System (PASS) and H /02 annunciators were designed such

that they were constantly in an alarm condition even when the systems were in standby.

The deluge valves for both divisions (eight valves total) of the control room ventilation system were mislabeled and improperly positioned from a system mimic perspective on the control boards (right side valve supplied left side components and vice versa).

This condition had existed since 1987.

Some of the important-to-safety equipment was degraded or unreliable.

During the time the OSTI team was onsite, both Division I and II hydrogen / oxygen (H 0 ) analyzers were inoperable,

which placed the plant in a 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> Limiting Condition for Operation (LCO). While the station repaired the H 02 analyzers in time to

successfully exit the LCO without having to shutdown, according to interviews the H 02 analyzers had been a recurring problem for some

time. A brief search of the logs indicated the plant had been in LCO action statements on these components four times in September alone.

In addition, interviews with operating personnel indicated the source range monitoring system had been a problem since initial startup.

Both diesci fire pump systems were leaking with one of the leaks dating back to December 31, 1988.

Two steam leaks were present on the RCIC system, one from August 1989, and the RCIC room cooler leaked such that water covered about one fifth of the room's floor.

A control room radiation monitor had been out of calibration from August 11, 1989.

The backup air supply relief valve for the Automatic Depressurization System (ADS) leaked as did the regulator, resulting in a need to recharge the air bottles daily.

Leakage had been identified on the suction valves for the Standby Liquid Control (SLC) system resulting in a temporary modification to prevent buildup of the sodium pentaborate.

The Standby Gas Treatment System (SGTS) radiation flow meter had been out of service since August 14, 1988, and several leaks existed on the Fuel Pool Cooling System.

Air in-leakage (probably from the Instrument Air System) into the drywell was sufficient to cause the licensee to periodically " burp" (depressurize)

the drywell in order to not exceed drywell pressure setpoints.

This condition, if not fixed, would be expected to eventually cause plant shutdown from the Technical Specification restrictions on the opening of the vent and purge valves,

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While the licensee was aware of most of these previously noted conditions, and individually they are not of major regulatory concern, collectively they are of concern and are not indicative of a well maintained plant.

Continued operation with these conditions or further degradation would be expected to result in the need for further maintenance outages or an increased forced outage rate.

3.1.3 Administrative Controls The inspectors reviewed the licensee's programs for identifying equipment out of service (005), identifying malfunctioning control room annunciators, valve lineup / position control, tracking of LCDs, controlling locked valves tracking surveillances, and maintaining a statusofmaintenanceactIvitiesapprovedbytheoperations organization.

Through interviews the inspectors ascertained that personnel had a good understanding of the locked valve program.

The inspecturs witnessed proper implementation of the. locked vc1ve program on two valvet in the SLC system.

The inspectors noted that the quality of the locking devices used in some instances was poor.

Only a twisted wire without a seal was observed on the diesel fuel oil supply valve to diesel fire pump A and suppression pool level instrument test connection valve IE22F381B (a containment isolation valve).

The issue of locking device quality will be followed as an open item pending further inspection review (50-461/89030-01).

Through interviews the inspectors ascertained that licensee management had established a strong valve position control program.

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inspectors witnessed utilization of the LCO tracking program and found it satisfactory.

The inspectors reviewed the control room annunciators and noted that the malfunctioning ones were properly recorded.

The inspectors audited selected information and safety tags in the control room against the tagging logs and noted no inconsistencies.

Weaknesses were observed in tl.e surveillance tracking program.

Situational surveillances not assigned to be performed by operations were not tracked by the shift, such as Emergency Diesel Generator (EDG) fuel oil or HEPA filter analyses due 30 days after extracting the oil / filter sample.

Notificiation of chemistry and radiation protection surveillance completion was accomplished via the telephone without the operating authority reviewing the sample results against established criteria until up to a week later.

No quantitative acceptance criteria had been established for shiftly/ daily channel checks.

Qualitative type guidance had been issued in the. form of a Standing Order.

Also, operating personnel were using compensatory measures under the annunciator malfunction program to meet a Technical:

Specification channel check requirement instead of revicing the channel check procedure.

The annunciator in question was the drywell sump high level alarm.

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lhe maintenance activities status program was weak.

The program

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consisted of a planned maintenance activity schedule.

A status book

or computer generated list of all maintenance activities which had

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been approved for performance by operations was not available.

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3.1.4 Operator Perfoimance During the OSTI inspection period, the inspectors observed that the

licensed operators performed in a professional manner and maintained

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appropriate decorum for a control room environment.

The licensed

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operators promptly acknowledged alarms and used procedures in the

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performance of their duties.

Out of service equipment was properly l

tagged and deficiency tags were present on nalfunctioning

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equipment.

Log entries were proper.

Performance of Reactor Core

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Isolatlon Cooling (RCIC) valve surveillance testing was properly controlled, including the critical operation of opening the outboard steam isolation valve.

Through interviews the inspectors ascertained that the non-licensed f

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operators (NL0s) had a good knowledge of the equipment they were operating or observing and through observation that they knew how to

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inspect equipment for proper operation.

The operators were conscientious about hanging deficiency tags and adhered to proper

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radiological practices while in contaminated areas.

Through interviews the inspectors ascertained that the specialized equipment training being received by the NL0s was a significant benefit in improving their performance in the power block.

This recent

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training initiative was mentioned by all of the NL0s interviewed as

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a good practice.

Overall, the inspectors concluded that the shift members functioned as a team.

Thoir attitudes toward safety were appropriate and positive.

The assignment of responsibilities to the two assistant

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shif t supervisors significantly reduced the paperwork burden on the shift supervisor, allowing him the ability to routinely tour the facility.

However, the shift supervisors were not observed to regularly exercise this option during the OSTI.

The rotation of the licensed operators into the non-licensed operator tours allowed

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licensed operators to remain in touch with the material condition of the facility.

The shift briefings and turnovers generally contained the appropriate content.

3.3.5 Factors Impacting on Operator Effectiveness

The OSTI team noted four areas which reduced the effectiveness of shift crews:

the material condition of the facility was straining

shift activities; the line and staff assistant shift supervisors were burdened with clerical tasks (personnel callouts, pulling

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surveillance procedures, transferring tagouts/surveillances) due to a lack of administrative support on the backshifts; the support to

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i changing / revising procedures was minimal; and the operating crews appeared to be uncoupled from the rest of the organization in terms of input to equipment repair and engineering priority.

Onshift personnel were burdened by compensatory measures being taken to deal with malfunctioning or unreliable equipment as described in the following examples.

As noted in Paragraph 3.1.2 onshift personnel had to daily recharge one division of backup ADS gas

bottles due to a leaking regulator and a leaking relief valve.

The

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SLC suction pressure had to be checked locally by manipulation of drain valves and reading a temporarily installed pressure gauge to determine leakage past the suction valves.

Personnel were entering confined spaces to locally observe the position of all the circulating water discharge valves.

One of the feedwater temperature computer points had been out of service since March 1, 1989, requiring the Shift Technical Advisor (STA) to insert a substitute value when performing a heat balance calculation.

The temperature of battery

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room 1B1 had to be routinely tracked due to a failed chilled water temperature regulating valve.

Local valve manipulation was periodically necessary to maintain the appropriate component cooling water temperature due to malfunctioning temperature regulating valves.

Since the SGTS radiation flow meter was out of service, grab sampling had to be peformed every time the SGTS was utilized.

There appeared to be a resource limitation on procedure support, NLO area tour sheets were in need of revision.

Some of the

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aformation required by the tour sheets was unnecessary.

The tour sheets contained checks on instrumentation associated with chlorine detection even though the chlorine monitors had been removed from the control room ventilation system over a year ago.

The acceptance

criteria on service water pump cooling pressure had not been changed even though a modification to the cooling system had been performed

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during the refueling outage which reduced the pressure.

This would be annotated as an abnormal cordition by the operators when one did not exist.

The RCIC valve surveillance procedure, 9054.02, did not contain information on the annunicator alarm setpoints and there was l

no caution on opening the outboard steam supply valve.

The shunt

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trip surveillance procedure, 9532.60, did not contain all the expected actuations.

These observations, coupled with numerous interview statements about the lack of personnel involved in the procedure

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support area led the inspectors to conclude that procedure support was limited.

In response to this NRC concern the licensee indicated that an overall procedure support / coordination effort was already underway and would be in effect in November 1989.

The operators perceived an inability to provide input or receive feedback concerning improvements to the material condition of the facility based on their lack of success in this area.

In some cases, the interface between NSED system engineers and operators was infrequent, which made it difficult for operator suggested

equipment problem " fixes" to be communicated well to the system l

engineer.

Recommended design changes to the EDG carbon dioxide l-

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System to preclude cycling between the two tanks, a recommendation to add reach rods to manipulate valves for the Reactor Water Cleanup

.(RWCU) pumps in a 600 mr/hr field in order to lower exposure which was disapproved due to insufficient cost benefit, and improvements to' venting the RHR heat exchangers to preclude climbing 30 feet up a ladder with a poly bottle had not produced results satisfactory to plant operators and were examples which supported operator perceptions.

The numerous compensatory measures required by operators and the continual indication of the same deficiencies on local alarm panels without any repair activities being conducted led the inspectors to the conclusion that the onshift personnel were decoupled from the engineering / maintenance effort.

3.1.6 Surveillance During the inspection several surveillances were observed by the inspectors.

Surveillances were generally good with the following exceptions:

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RCIC valve surveillance procedure 9054.02 (discussed in Section 3.1.5 of report).

b.

Shunt trip surveillance procedure 9532.60 (previously discussed in Section 3.1.5 of report).

c.

Surveillance 9000.020002 refered to chlorine monitors, which the operator annotated NA (Not Applicable), but provided no justification in the remarks section of the procedure.

The monitors had been removed from operation through a design change for over a year.

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There were no quantitative acceptance criteria.for channel checks, e.

The channel check procedure was not changed when the drywell sump alarm was inoperable.

The majority of the surveillance deficiencies noted were due to a lack of timely procedural changes.

Another concern regarding the survcillance program was the lack of participation by the NSED system engineer.

Most of the surveillances

were conducted on the midnight shift while the system engineers are routinely on days.

Since none of the licensee's meetings on dayshift provided a good discussion of which surveillences would be performed on midnights, there was little system engineer involvement.

The licensee is addressing system engineer responsibilities which are discussed in the Engineering Support Section (3.5.2) of this report.

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3.1.7 Shift Turnover Shift turnovers for the Shift Supervisor and Line Assistant Shift Supervisor did not utilize formal checklists on turnover sheets but utilized handwritten notes.

However, Shift Supervisors utilize the daily planning guide as a living document by annotating it with updated information.

The line assistants use the formal turnover sheets created by the reactor operator turnovers as part of their turnover.

As mentioned in Section 3.1.4 of this report, content of the turnovers was generally good but personality dependent. The lack of a formal turnover could aggravate any existing communications problems.

An example occurred on the midnight shift September 27, 1989, involving the "B" control rod drive (CRD) pump removal from service for a change of oil.

After the pump had been taken out of service, the earlier swing shift had determined that maintenance personnel performing the B pump oil change should defer the work i

for 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in order to recharge the backup air tanks for the "A" train of the ADS.

The decision to defer maintenance on the "B" pump until the following day (September 28) and maintain the pump in an out of service status was not passed on to the midnight operating crew.

The licensee was developing a formal shift turnover checklist in response to the OSTI concern.

3.1.8 Non-Routine Plant Evolutions During the OSTI, operator action was observed on September 25, 1989, when the Number 4 Combined Intermediate Valve (CIV) for the turbine developed an electrohydraulic control (EHC) fluid leak at its test plug.

The inspectors observed control room response to decreasing EHC pressure and discussions involving Operations Department personnel on the plan of action for the CIV repair.

These discussions

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addressed problems to be encountered while operating with one CIV i

closed and a safe power level at which the evolution could be accomplished.

Technical Specifications were reviewed for operational limite, including allowable flow adjustments as they related to the instability region of the power to flow map.

The licensee's staff determined that the fast acting solenoid for CIV #4 could be closed and gagged to allow replacement of the "0"

ring seal around CIV #4 test plug which was believed to be defective J

and the cause of the fluid leak.

The staff also decided that closing CIV #4 would not adversely imp'act on low pressure turbine operations; furthermore, the test plug "0 ring replacement could be performed with the turbine 6..~ line.

Another meeting of the licensee's staff was conducted to review the Maintenance Work Request (MWR) D11828, "EHC Leak On Test Plug," to discuss all the possible saftty and operational implications of the

"0" ring replacement.

Various safety checks were discussed to ensure the safety of the maintenance workers.

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At approximately 3:30 p.m. work on the WR began.

The offgoing control room crew was held over to ensure proper control of operations while the work was in progress.

The Shift Supervisor maintained close communications with the Calibration and Instrumentation (C&I) Supervisor in charge of the WR as the work was being performed.

The CIV #4 was closed, gagged and tested.

The

"0" ring to the test plug was replaced.

CIV #4 was tested and placed back in service by 4:00 p.m.

The Shift Supervisor maintained excellent control of the entire operation.

Critical parameters such as turbine vibration and feedwater heating were closely monitored.

The entire process from initial analysis, WR development and planning, and execution was performed in an exemplary manner.

One of the planning considerations was the preparation of WRs on other plant systems with deferred work that would have been initiated if WR D11828 was unsuccessful and a plant outage became necessary to repair the EHC fluid leak.

3.1.9 Conclusion The plant was being operated in a safe manner as evidenced by operator performance in routine and non routine evolutions, generally good surveillances, the material condition of key safety systems, a strong valve position control program and good shift teamwork.

Operators were knowledgeable of equipment status, degraded equipment, and their duties and took appropriate actions during routine and non-routine events.

In contrast, the material condition of BOP equipment was poor and certain important to safety equipment was degraded or unreliable.

Operators were burdened with compensatory measures resulting from inadequate equipment design and/or short term equipment repairs effected to keep the plant running rather than make the equipment reliable.

No violations or deviations were identified during review of this area.

One open item discussed in Paragraph 3.1.3 was identified.

3. 2 Effectiveness of Procedures 3.2.1 Overview Inspectors conducted procedure reviews and interviews and observed

the execution of procedures in the field, The procedures utilized

in operating the plant were determined to be generally clear and of

adequate depth to be effective in operating the ple.nt with the following deficiencies.

3.2.2 Procedure Deficiencies Several discrepancies were noted in Section 3.1.6 of this report.

The following procedural deficiencies were also noted:

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The Alarm Response Procedure (ARP) 5066.36 involving the SLC system referenced an incorrect tank low level setpoint.

The actual installed low level setpoint was accurate and in accordance with Technical Specifications.

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Caution tags were being employed in lieu of procedure changes to operate various items of equipment.

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Manipulations of certain items of equipment were not properly controlled through approved procedures.

One example was the refilling of the Component Cooling Water (CCW) expansion tank which was routinely performed without a reference on the level gauge.

Another example occurred on September 24, 1989, when the clearwell level controller failed.

While trying to correct this problem radwaste operators removed the fuse to the controller to reset the instrument.

However, the fuse also controlled the pumps from the filtered water tank to the circulating water pump seals which deenergized.

Quick action was taken by operators to restore the pumps and normal cooling to the circulating water pumps.

Clearly, the operators should have researched the ramifications of pulling this fuse more completely and subsequent actions should have been performed in accordance with defined procedures, d.

Certain actions involving MWRs and the prescribed method of identifying deficient equipment were not in accordance with CPS No. 1029.01, " Preparation and Routing of Maintenance Work Requests," although the actions are to be incorporated into the next revision of the procedure (refer to Section 3.4.3 of the report for additional information).

The inspectors concluded that the procedural deficiencies were partially attributable to a lack of procedure revision support.

The licensee responded to the concern by developing a dedicated procedure revision team which will be implemented by November 1989.

3.2.3 Conclusion The procedures were adequate to facilitate the safe operation of the plant, however, the licensee should be alert for needed procedure changes and make them promptly.

No violations or deviations were identified in review of this area.

3.3 Radiological Controls 3.3.1 Observations Several observations were noted in the area of radiological controls during the conduct of the OSTI.

The operators were knowledgeable of radiological control practices and demonstrated good compliance with radiological control procedures and practices.

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The number of personnel contaminations was notably low, although j

some conditions were observed which could potentially lead to the I

spread of contamination.

At some exit points (low personnel

traffic) from radiologically controlled areas there were no i

" friskers" available which required personnel to travel several hundred feet to utilize a frisker.

There was no clear line of demarkation when exiting the elevators at the 802 level (control room) to separate personnel who had successfully negotiated the personnel contamination monitors from those who were waiting to use

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the monitor.

Therefore contamination could be spread by a monitored person who came into contact or crossed paths with waiting personnel.

3.3.2 Conclusion Based on the OSTI observations of Clinton plant staff action in the radiologically controlled area, the radiological controls were adequate and proper compliance by plant staff was being demonstrated.

No violations or deviations were noted in review of this area.

3.4 Maintenance 3.4.1 Overview The area of maintenance was reviewed from the aspect of its integration with and support of plant operations.

The team members conducted interviews, reviewed maintenance work requests and reviewed specific maintenance work and activities to assess the effectiveness

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of maintenance support to operations.

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3.4.2 Maintenance Work Requests (MWRs)

The licensee's success at eliminating the material condition deficiencies noted in paragraph 3.1.2 of this report was negatively impacted by the large number of backlogged MWRs for corrective and planned maintenance and an apparent lack of adequate engineering support for equipment reliability concerns (engineering support is discussed in Section 3.5 of this report).

As of September 29, 1989, there were a combined total of 1006 planned and corrective MWRs outstanding.

At an estimated closure rate of 139 MWRs per month the 1006 MWRs represented a 7.2 month backlog.

The OSTI determined that MWR backlog was having several effects on the plant staff.

Interviews identified a perception by the operators that they had little input into the corrective maintenance system and that the maintenance staff dictated plant maintenance priorities.

A maintenance staff initiative attempted to consolidate similar MWRs on the same item of equipment, i.e., oil leaks on an EDG, to efficiently plan and schedule similar work.

The initiative artificially reduced the number of MWRs as similar MWRs were included in one combined MWR.

The consolidation action generated some complaints that MWRs generated by operators had been arbitrarily l

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cancelled by someone outside of the operating authority without the author's knowledge.

Discussions with the Supervisor of Work Activities (SWA) indicated that the complaint had surfaced on occasion and stemmed from the operators' lack of knowledge concerning the MWR process.

The current SWA had only cancelled a few MWRs and the basis for cancellation was the actions should have been accomplished through a system other than the MWR, such as the collection of tools in a work area.

Under Procedure CPS No. 1029.01, " Preparation and Routing of Maintenance Work Requests," dated October 11, 1988, Revision 23, individual MWRs which are cancelled by consolidation must have the associated equipment tags removed and replaced with a combined MWR equipment tag within three days of individual MWR cancellation.

The removal of individual equipment tags, after the individual MWRs had been combined, had created the impression to some operators that-the MWRs they initiated were arbitrarily ignored and cancelled.

The elimination of the individual MWR equipment tags also created a related problem which burdened operators.

The operators, when observing a deficiency, would have to review the one combined tag to determine whether the deficiency was previously identified versus an individual tag at the point of the deficiency.

To correct the operator perception, the SWA had initiated a policy of notifying the MWR author whenever an individual MWR was included in a combined MWR, The SWA also has eliminated the requirement to remove individual equipment tags when individual MWRs are included in a combined MWR, The tags are now annotated with the combined MWR number and the individual MWRs which are rolled into combined MWRs are now included in the outstanding MWR count.

The initiatives taken by the maintenance staff had not, as yet, been incorporated into CPS 1029.01 but would be expected to be included in the next revision.

The SWA also was presenting a 30 minute class to the operating crews during their training cycle to improve operator understanding.

As of this report one of the five operating crews had been briefed.

The SWA was meeting with the shift supervisor (SS) daily at 8:15 a.m.

and the swing SS in the afternoon, and the assistant SWA was meeting with the mid shift SS to discuss MWR priorities.

The SWA coordination with the SS was a licensee initiative to ensure appropriate consideration was given to operators during the MWR process.-

Another effect of the MWR backlog was the perception that maintenance

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was performed to accomplish short term fixes to keep the plant running rather than provide more reliable equipment by performing a complete fix.

The perception was supported by several OSTI observations:

temporary patches on the service water piping, H 02 9 anal operability,and numerous operator compensatory actions (yzerpreviously discussed) for malfunctioning equipment such as recharging backup l

air tanks to the ADS.

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The licensee had taken actions to increase manpower resources to resolve the WR backlog and to uddress the NRC concerns.

The licensee hired 19 Stone and Webster (SW) contractors to augment the existing maintenance staff in reducing the WRs.

An aeditional 10 contractor personnel had been hired to assist in WR planning.

Long term licensee action plans included:

establish a high level committee / team to avaluate improvements in the WR system, review r

the successful WR programs at other utilities, and implement the

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necessary improvements.

3.4.3 Conclusion The poor condition of BOP equipment and the large WR backlog were not indicative of well performed maintenance.

The increased burden on operators from compensatory actions increased the potential for personnel error.

The failure of inadequately maintained B0P equipment could result in unnecessary challenges to safety systems.

No violations or deviations were identified in the review of this area.

3. 5 Effectiveness of Engineering Support 3.5.1 Overview r

Engineering support to operations was reviewed by examining the

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system engineer program of the Nuclear Station Engineering Department (NSED), utilizing interview results to establish the perception of system engineer interface with operations and performing evaluations i

o/ actual engineering actions.

3.5.2 System Engineer (SE) Program i

Engineering and technical support to the plant is provided by NSED.

Within this organization, the SEs provide one of the main interfaces between operations and engineering.

The concept of a system engineering position was established approximately 18 months ago and at the time of the OSTI the responsibilities and duties were still being refined.

Interviews with operations personnel indicated that support from the engineering organization was not considered timely and that some SEs were not sufficiently knowledgeable of their systems.

At the time of the inspection there were approximately 27 SEs who-were assigned an average of four systems each.

Some engineers had a single system while others had seven or more.

The licensee was still making some refinements in balancing work loads through

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reassignment of systems to other SEs.

The current work load appeared to be taxing some of the SEs with " troublesome" systems.

Insufficient time to fully understand the systems and the subtleties of individual

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role rather than a proactive role for the SEs.

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Recent refinements to the system engineer concept had delineated more explicitly the duties of. each SE.

Mandatory system walkdowns-on a weekly or biweekly schedule to survey specific attributes had been implemented.

Certain system parameters were being monitored by the SE for components that warrant additional attention.

The reactor recirculation pump seal pressures, for example, were being independently trended by the SE.

3.5.3

,0perations Interface During discussions with plant staff, it was perceived that on a routine basis the SEs did not observe the normal surveillance tests for their systems, for specific problems or other extraordinary circumstances, the SEs apparently did get involved in surveillance testing; however, for the routine tests this was not necessarily the case.

One contributing factor to this situation is described in paragraph 3.1.6 of this report and deals with the fact that most of the surveillances are performed on a shift where the SEs are not available.

Surveillance participation was an example of the reactive instead of.proactive nature of the SE.

Recently attempts had been made to increase the SE8 s involvement with surveillance testing-by making tr,e surveillance schedules more readily available to the engineers.

Other refinements to the SE program included an aggressive training schedule for upgrading the-technical-and practical experience for the SEs.

The training schedule included General Electric (GE)

systems training on the major safety-related systems.and design basis training by Sargent and Lundy-(S&L).

In addition, some condensed operator simulator training was being considered to emphasize the operators' perspectives _toward systems.

Based on discussions with individual SEs, a general understanding of the systems was demonstrated.

However, a lack of detailed understanding

~~g for the operation of certain key system components was evident.

The Containment Hydrogen /0xygen Analyzer was an example of this weakness.

In order to overcome this situation' generically, consideration has been given to selected component training,

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which would provide more detailed information and would benefit the SE.

The basic tool available to the SE for tracking the status of each system is the System Engineer Report. This. computer printout lists

'all outstanding commitments, condition reports, pending design changes, maintenance-work requests, preventive maintenance requirements, and surveillances for'any specific system.

This appeared to be a useful tool for the SEs and functioned as a backup

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system to highlight any new condition reports or maintenance work j

requests which were made without the engineer's knowledge.

One complicating aspect associated with timely support of plant operations was the fact that NSED could not perform any safety-related design work.. Currently all safety-related design

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or modification work is performed by either the GE or S&L

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Although no specific timing problem was noted during

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the inspection, this factor caused simple design tasks to be performed

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by an outside organization and could result in slow response tine.

An example of this aspect was associated with solving the Main Steam

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Isolation Valve (MSIV) leakage problems.

Although the various

'l alternatives were evaluated in-house GE had to revise and certify the Class-I Design Specification for the MSIVs because NSED was not approved for safety-related design work.

This relatively simple task had i

to be assigned to an'outside organization.

The licensee indicated steps were.being taken to change this situation within the next year.

3.5.4 Engineering Evaluation

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During the course of the inspection the following Condition Reports

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(CR) were reviewed for technical adequacy, root cause evaluation, and corrective actions, t

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1-89-08-008:

An error was discovered in an S&L calculation which resulted in an incorrect Boron Injection Initiation Temperature (BIIT) curve.

NSED Analysis Log No. 195 determined.the correct BIIT curve in accordance with the BWR Owners Group Emergency Procedure Guidelines.

The calculation used the corrected mass value for the liquid in the reactor pressure-vessel and resulted in a 0.55% change in the reactor power initiation point.

1-89-08-011:

Multiple failures of Division II NSPS Inverter fuse.

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Based on discussions with the engineers-involved, the l

failures represented a separate problem for each i

occurrence and in each case correct actions were taken.

1-89-08-015:

Second failure of reactor recirc conductivity. cell.

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l Based on discussions with the engineers involved, some additional operational considerations have-to be j-implemented.

During power ascension, the pressure must, i

be manually controlled at the inlet to the conductivity l

cell.

Additional precautions were added to the operating l

procedures to accomplish this.

In addition,_a design l

change to increase the pressure rating of the-cells by l

using a higher strength material was being. researched l-to allow additional ~ operating margins.

l 1-89-08-022:

A system walkdown found a vent valve on a filtered water line that was not indicated on the isometric.

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b Based on discussions with the engineers involved, the size of the vent line was inconsequential to-the attached large bore piping system.

The inspector-concurred with the assecsment.

1-89-08-012:

Maintenance workers used.800 psig nitrogen to " blow out" a clogged radwaste line that was designed for l

150 psig.

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NSED Analysis Log No. 235 evaluated the technical aspect of the CR.

Based on the calculation, the systen, could sustain c 2000 psig pressure and still meet-ASME code requirements.

In addition to the above technical aspect, a Critique of the incident was performed by Operations

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and Maintenance Support Engineering.

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corrective actions were recommended that included

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obtaining concurrence from.both NSED and Industrial Saf ety prior. to pressurization of components with compressed gas or to any condition outside the design parameters of the system.

1-89-09-064:

One of the four attachment bolts for a Switchgear Heat Removal Panel was found missing by the NRC inspector.

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NSED Analysis Log No. 237 evaluated the as-found-

condition and concluded that even with the une bolt j

missing the panel was still qualified.

The bolt was replaced to return the panel'to its designed condition.

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adequate. Where analyses were required to evaluate-the as-found l

conditions, conservative assumptions and proper analytical techniques-l were utilized.

The appropriate priority appeared to have been

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j 3.5.5 Conclusions Based on the reviews and discussions conducted during this inspection, it appeared that the technical staff had the capabil'ity i

to effectively support the operation of the plant.

Although some

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weaknesses existed with regard to detailed knowledge of certain

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aspects of some systems, this was apparently recognized by management and steps were being taken to correct the weaknesses.

All of the j

individual system engineers contacted had a-good attitude toward

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supporting plant operation, however, some work overload was noticed.

The backlog caused a reactive environment which limited the extent i

to which a system engineer could get involved in solving problems l

and had restricted the time available for the engineer to become

knowledgeable of the system prior to attempting to solve a system l

problem.

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.4 Evaluations of plant problems appeared to be comprehensive in

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nature.

Good communication with the rest of the industry was evident on several problem evaluations with the intent of learning from other's experiences and avoiding "reinvention of the wheel."

A tentative approach appeared to be used in some cases toward resolution'ef gcoeric problems.

In the case of the SRM noise problems, the licensee planned to purchase a new drawer with the intent.of replacing the other three if it solves the problem.

The action can be considered prudent judgment but is not very responsive or timely in that the plant lives with the problem until the cycle of purchase, installation, test, repurchase, installation and test.

is complete for all drawers.

No violations or deviations were identified in review.of this area..

l However, one issue discussed in.Section 3.5.4 (CR 1-89-08-012) is

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also discussed in'Section 3.6.3 of this report and is being followed

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as an unresolved item from that section.

i 3. 6 Management Oversight 3.6.1 Overview

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The Team's evaluation of Clinton management oversight as it related to operations placed a heavy emphasis on personnel interviews,

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direct observation of activities, evaluations of selected corrective i

actions, and reviews of applicable documents.

l 3.6.2 Interviews

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l 3.6.2.1 Methodology The personnel interview portion of the OSTI was conducted through a review of assorted documents and by interviews with a total of 64 Clinton Power Station (CPS) staff members representing site upper.

management and a wide range of staff levels in the following j

departments:

a Plant Operations d

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Control and Instrumentation Electrical i

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Training Operations Training Maintenance and Technical Training Nuclear Station Engineering Design and Analysis Engineering Operations and Maintenance Support Systems and Reliability Engineering Nuclear Planning and Support Department Industrial Safety Quality Assurance Quality Verification

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Quality Engineering

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Material Maintenance The interviews were conducted in the-following different formats:

short structured interview, long structured interview, focus group, and informal interviews at the individuals'. job locations.

Extreme consistency of responses was noted through all levels of personnel}zationalstrengthaswellasproblems.in addition to a willingness to ac and organ As a result of this, and the methodology used, the OSTI Team' believed that the

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staff perceptions addressed in this report were generally reflective of the entire CPS organization.

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3.6.2.2 Interview Results Many of the issues described in the following subparagraphs to Paragraph 3.6.2.2 do not have a clear, direct correlation to regulatory requirements-or to safe operation of the Clinton plant.

However, these issues involve interpersonal relationships, managerial actions, and the perceptions of Clinton staff members which could i

influence the operation of the Clinton Station.

Therefore, the l

following subparagraphs of 3.6.2.2 are included as findings of

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3.6.2.2.1 Organizational Structure

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Overall, CPS staff members reported a clear understanding of'

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their job responsibilities and reporting relationships.

A strong majority had written job descriptions (which were reviewed by the OSTI Team) and felt that their everyday duties -

matched those designated in their job descriptions, i

Supervisory relationships were clear and accurately reflected I

the organizational chart.

Almost all CPS staff stated that-the

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chain of command at Clinton was clear and well defined.

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Relationships between most departments were considered by the

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between staff in the various departments.

When problems did occur l

in the coordination of functions between departments, the l

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3.6.2.2.2 Training CPS staff felt that the training provided for the performance of their job was satisfactory.

Most of the staff were aware of other types of training available to them and felt that CPS

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management placed a moderate amount of emphasis on this additional training.

However, a number of individuals indicated

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that limited staffing in their departments had prevented them

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from taking the time necessary to avail themselves of additional-supplemental training.

Control room operators reported that current simulator training t

conflicted with the behavior expected of them in the plant.

In particular, they reported that the extremely formal t

communication required in the simulator was unrealistic and not used in actual operating circumstances in the plant.

For example,

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the use of formal titles and exact action repeat' backs was required in the simulator but not used in the control room.

Unit attendants consistently reported that the individual providing their technical training was doing an excellent job.

Reactor operators indicated that the technical training

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provided the unit attendants would be of significant benefit to them, due to their rotations that include in plant responsibilities.

CPS Management has indicated that this training will soon be made available to the reactor operators, as well as the unit attendants.

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3.6.2.2,3 Accountability Goals for performance were established between staff and supervisors on a generally regular basis at CPS.

Informal feedback on performance was reported to be received regularly by a majority of staff interviewed.

Ratings of the fairness of personnel actions taken in response to errors was mixed.

Overall, the average rating of' interviewees

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was "somewhat fair." This issue elicited a number of' intense concerns with staff interviewed.

Of greatest concern'to employees

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was their perception that personnel action was inconsistently applied.

Variations in the personnel actions taken in response to errors were often attributed to the specific' management individuals-involved.

The' staff reported that the most visible errors resulted in the most drastic action against personnel.

Reports of a focus on identifying an individual to blame for any problems were widespread among interviewees.

Some interviewees indicated that sometimes shift-crews will defer performing surveillance or maintenance rather than run the risk of doing something and making an error.

This condition may have contributed to some of the late surveillances or the large

maintenance backlog.

Nevertheless, a strength noted in the interview

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process was personal accountability in that individuals appeared to

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take their jobs seriously, took pride in their work, and respected their peers.

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The CPS staff generally reported that;they were well informed about CPS issues related to the safe operation of'the plant.

On interpersonal issues, such as promotion or transfer.. lower level staffers indicated dissatisfaction with management's communications downward, however, a number of: individuals noted recent improvement

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in this area.

Some personnel believed that communication from upper management was_ filtered or stopped at the supervisory level.

The staff stated overwhelmingly that horizontal communications between workgroups was very good and improving.

CPS employees indicated that they felt very free to make constructive criticism up the ranks.

However, staff felt that their comments had very little influence on management.

Almost all interviewees noted that, as a recent improvement,-

CPS management was staying current on the experiences of.other nuclear plants.

3.6.2.2.5 Organizational Problem Solving The-Clinton staff reported that the timeliness of actions taken in response to problems varied, depending on the~ nature of the-problem.

Prompt' action was reported when problems directly challenged the ability of the plant to stay on-line, with less-attention directed at balance of plant issues.

In addition, a widespread perception existed of a management emphasis on interim fixes rather than a careful analysis and repair of the complete problem at hand.

Staff reported that this approach resulted in.a plant where interim fixes often resulted in multiple repairs of the'same element, when an initial careful and complete repair would have eliminated the need.for later work.

A further discussion of these problems is contained in

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Section 3.6.3 of this report.

Timeliness of root cause correction was considered less than adequate.

A number of individuals stated that root cause correction never takes place.

Others indicated that simple, straightforward analysis was conducted, however more complex

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problems requiring sophisticated analysis-were not addressed.

Examples of corrective action, root cause, and timeliness issues are further discussed in Sections 3.1.2 and 3.6.3 of this report.

CPS staff felt that decisions were made at an inappropriately high level.

Interviewees indicated upper management ~ involvement in control room operations, maintenance and repairs, engineering activities, and training, in decisions that staff felt should have been handled at a lower level of management.

Numerous individuals-

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stated that the expertise of the workers was generally not utilized in decision making and problem solving at CPS, hence the best available technical expertise may not be being applied to the problems.

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3.6.2.2.6 Management Involvement CPS staff. members believed that management was just beginning to learn from past experience.

However, concern was expressed that management had not recognized the burden on staff that results

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from redundant repairs required by the interim fix approach.

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Site wide morale was considered low by interviewees.

CPS staff attributed this condition to a number of organizational problems such as the manner in which the downsizing in the spring of 1989 was

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handled which led to a site-wide feeling of uncertainty about the-

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future, and lack of a clear career path.

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It should be noted that managers and above all estimated morale across a variety of CPS departments as higher than the stafi members themselves.

3.6.2.2.7 Conclusions Overall, a discontinuity existed between CPS management'and staff.

There appeared to be a lack of congruence between staff and management perceptions.

The staff held a strong distrust for management and perceived distrust.from. management towards

them.

The teamwork concept which management indicated it was attempting to foster did not appear to have taken hold yet between management and staff.

A high level of unce nainty existed for the CPS staff.

Due to the m'anner in which last spring's downsizing was handled, staff members felt no assurance that their future was secure.

Management was perceived as emphasizing identification of someone to blame for any problems that arose.

Lack of staff involvement in decisions and a lack'of appreciation for staff professional expertise by management was seen as widespread by the CPS staff.

Staff members-felt-that their opinions had little or no influence.

In addition, lower level staff members felt that upper management was involved.in decisions at a lower organizational decision level.than was appropriate.

The staffing in some positions, most notably the non licensed

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operator position, was tight. The licensed operatorLstaffing was ample which served to minimize the. shortness of NL0s.

This interview result was of concern because a high percentage of staff interviewed indicated that they were currently looking for other positions or anticipating looking for other employment in the near future.

This could result in a loss of high quality CPS personnel.

Of particular concern were the ways these issues'related to-potential safety of the plant.

Low levels of' morale;can'

result in reduced performance effectiveness of workers.

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Reduced effectiveness resulting from the heavy burden placed

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on workers by rapidly changing priorities and the many out-of-service pieces of equipment, could potentially lead to

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an increase in personnel-errors.

The interim fix approach at CPS h'as resulted in equipment that required numerous redundant repairs.

Because. staff resources i

were devoted to repairing primary system equipment as a first prior.ity, balance of plant equipment had fallen into disrepair and was generally in poor condition.

Because balance of plant equipment supports the primary plant systems, this condition

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may result in increased challenges to the safety systems of the plant.

This also contributes to a plant condition where a potential increase in the number of forced outages can result.- (Examples _of problems concerning B0P equipment are described in Sections 3.1.2-and 3.4 of this report).

3.6.3 Corrective Actions A review of licensee corrective actions appeared to confirm

interview results which. identified a licensee tendency to take an expedient approach to problem resolution such as interim fixes and a non-conservative attitude on occasion.- The following are examples of this attitude which were noted during the inspection.

a.

The RWCU system experienced spurious automatic isolations during startup conditions as a result of high differential flow (HDF) between the RWCU system inlet-line and the combined flow to the two discharge lines.

The RWCU design includes a HDF by pass switch which the licensee would routinely employ in startup.

The inspector reviewed a licensing. interpretation, LDI 88-01, on bypassing the RWCU isolation on differential flow.

The LDI basically circumvented the real problem which was a design deficiency in_the RWCU system.

The inspectors met with licensee personnel on this matter on September 29, 1989.

During the meeting the licensee indicated that Westinghouse had reviewed the differential flow isolation and concluded that the isolation itself could be eliminated.

At the time of the inspection, the licensee was reviewing that report'for action. ;In addition, the licensee intended to pursue any necessary design or operational changes associated with.the RWCU

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system.

Completion date was scheduled for June 15, 1990.

b.

While reviewing the HDF bypass switch operation, the inspectors noted that control room logs reflected that the

bypass switch had been in operation for one hour and f

fifty-nine minutes.

Technical Specifications (TS) implied that the bypass switch would be used infrequently and in all cases less than one hour.

Further investigation by-30

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a

t the inspectors concluded that the operators had probably operated the switch for 59 minutes, then reset the switch, then operated-the switch for anotlier 59 minutes.

Although literal compliance with the written TS was demonstrated, the intent was circumvented.

This approach was indicative of an attitude of "getting around the issue" so that the plant can. operate rather-than resolving the fundamental design issue.

c.

An additional example of'"getting around" the situation-

involved The solid state Self Test System (STS) of the reactor protection system, which required jumping-out

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of various signals in Modes 4 and 5'to avoid further restrictive TS action statements, because it was not designed to distinguish between reactor modes for equipment.that would normally not be. in operation; The

excessive bypassing to meet periodic TS requirements has resulted in personnel errors / licensee event reports (LER)'

because the STS design does not support all reactor modes.

ThebygassingoftheSTSaddstoanatmosphereof"getting around TS.

The licensee was preparing a TS amendment to-address the STS design problem.

d.

Radiation monitor, IRIXPR023, Drywell Continuous Air Monitor, located at the 803 foot level of containment was constantly in an alert status with a rotating amber-

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light.

While this monitor is not required by TS there

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was no indication (equipment tag) that the monitor was t

not functioning and the monitor was-in the described i

condition during the entire inspection.

However, personnel were ignoring the indication and not informing Radiation Protection.

The' conditioned response to-ignore the alarm was contrary to fostering a safety first attitude among employees.

The monitor represents another example of living with malfunctioning equipment rather than taking appropriate action to correct the problem.

e.

As described in previous sections of this report, operators-had to routinely recharge air tanks which back-up the ADS-I system, because of a leaking relief valve.

The relief valve leaked because a malfunctioning pressure regulator was not reducing the air pressure below the valve set point.

The inspectors viewed tank recharging as another example of_

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living with a problem and operators offered the same perception-during interviews.

f.

Essential Switchgear Cooling fans IVX03CA, IVX03CB were observed to be windmilling backwards from normal ventilation flow during the inspection; fan B at an estimated 50 rpm.

The licensee could not produce an analysis addressing the currents necessary to overcome the reverse direction of the fans nor the impact of a start under worse case

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conditions, i.e., degraded bus voltage, or EDG sequencing.

The fans provide cooling to the essential switchgear room and if they become inoperable a limiting condition for operation (LCO) would be entered (2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />).

The licensee was aware of the issue due to a previous NRC inquiry during the 1989 maintenance team inspection but the licensee had not recognized the potential safety implications of the windmilling fans under the worst case conditions.

The licensee wrote a condition report to analyze this condition which will be followed as an unresolved item (50-461/89030-02).

Concerns were noted regarding the. effectiveness of licensee i

operational event trending.

The system was not computerized

and a manual review was initiated only after five similar

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events had occurred within a three month time frame.

As a

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result, the system would be incapable of identifying any trends or equipment reliability issues that could surface as.the result

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of activities spread over a period longer than 3 months, such I

as 18 month surveillances.

Root cause analysis did not go beyond a personnel error /

equipment failure determination to identify conditions which might contribute to the errors or failures.

Licensee corrective actions examined by the 0STI were generally

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adequate.

However there had been indications that the critique j

program did not always address all issues surrounding an event.

'l In one critique reviewed by the inspector,, a safety issue

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involved the over pressurization of piping to remove pipe i

blockade (refer to Section 3.5.4 of this report).

The pipe had-to be cut to remove the obstructing substance, then welded-

together.

The critique noted that the weld had not been hydrostatically tested as required by ASME code.

Corrective action required a test be conducted.

The critique,.however,

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did not evaluate the causal agent which resulted in-the failure

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to test.

This issue will be followed as:an unresolved item (50-461/89030-03).

The licensee was aware of the NRC concerns.

The Quality Assurance (QA) trending program was undergoing revision and

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scheduled to.be implemented by December 31, 1989.

The Plant

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Manager was in the process of developing a cadre of investigators who.would conduct root cause investigations.

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3.6.4 Conclusions

Management's tendency to operate with problems and implement short term fixes and the approach of "getting around" conditions to~ keep-the plant running has resulted in an' undue burden on plant'

i operational staff.

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4.

Summary of Findings The inspectors identified no conditions resulting in a violation or deviation.

The. licensee was operating the plant in a safe manner and the 60 days preceding the inspection represented good plant performance.

Shift personnel were qualified, knowledgeable of their responsibilities, conscientious, and worked as a team.

The two assistant shift supervisors provided the shift supervisor with good flexibility to get out into the plant.

~ 1 ECOS was well maintained but the balance of plant (B0P)-equipment was poorly maintained.

The backlog of MWRs, equipment reliability, quick fixes, and a tendency to live with the problem were contributing factors to the condition of B0P equipment.

Compensatory measures required by the condition of B0P equipment were unnecessarily burdening the operators and increased the potential ~ for personnel.

error.

The state of B0P equipment potentially represented

unnecessary challenges to reactor safety systems during BOP failures.

The tendency to "get around" issues or live with problems was perceived by the staff as a significant management. shortcoming.

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In the areas examined by the OSTI which did not have a direct

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correlation to safety or regulatory requirements, the team observed

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that morale was low and communications between Illinois Power i

management and the Clinton staff were poor.

5.

Unresolved Items j

.i Unresolved Items are matters about which'more information is required

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in order to ascertain whether they are acceptable items, violations,

or deviations.

Unresolved items identified during this inspection i

are discussed in paragraph 3.6.3.

l 6.

Exit Meetings (30703)

The inspectors met with licensee representatives (denoted in j

Section 1) throughout the inspection'and at the conclusion of the i

inspection on October 3, 1989 and summarized the scope and findings j

of the inspection activities.

The licensee acknowledged the l

inspection findings.

The inspectors also discussed ~the likely informational content of the inspection report with regard to i

documents or processes reviewed by the inspectors during the

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inspection.

The licensee did not identify any documents / processes

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as proprietary.

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APPENDIX A Documents Reviewed Computer printout of all outstanding CPS commitments to the NRC RIDS Docket No. 0500461/ Facility 50-461 Clinton Power Station, Unit 1 IP/

Accession Number 0905030306/ Subject:

Ensures that docket accurately reflects recent information regarding issuance of State of Illinois Commerce commission rate order.

RIDS Docket No. 0500461/ Facility 50-461 Clinton Power Station, Unit 1, IP/

Accession Number 8905230035/ Subject:

Forwards Maintenance Team Inspection Report 50-461/89-03 on 890123-26, 0227-28 & 0313-0407 and Notice of Violation.

RIDS Docket No. 0500461/ Facility 50-461 Clinton Power Station, Unit 1, IP/

Accession Number 8911070209/Subjec:

Forwards SALP Report 50-461/88-01 for September 1987 through August 1988 CPS USAR, Chapter 13, Revision 0, September _1988 CPS USAR, Section 13.2, Training, Revision 1, September 1989 (unapproved by NRC)

IP Nuclear Program /NRC Discussion / June 12, 1989 (overheads)

Memo and attachments /A. Bert Davis to V. Stello/ Subject:

Illinois. Power Company Meeting on June 12, 1989 CPS September 1989 operating crew schedules IP Nuclear Program, Clinton Power Station, Monthly Performance Monitoring Management Reports:

July 1989 and August 1989 IP Nuclear Program, IP Employee Man-Hour Reports, February 5, 1989 CPS sick leave record summaries by department _for all personnel,1989 year to date (Septemter 1989)

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CPS sick leave record summaries by department for bargaining unit personnel only, 1989 year to date CPS Nuclear Organization Monthly Personnel / Manpower Changes reports by department, 1/1/88 to date CPS Nuclear Organization Monthly Personnel / Manpower Changes reports by department, 1/1/88 to date CPS sitewide attrition records by month,' July 1986 to date

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2'.

y List of positions deleted during 1989 downsizing a

Sample IP recommendation for salary increase form i

Sample IP performance review form for non-union personnel Sample IP performance review form for bargaining unit personnel Labor agreement between Illinois Power Company and Local Union 1306, International Brotherhood of Electrical Workers, dated August 16, 1988 Labor agreement between Illinois Power Company and Local Union No. 51, International Brotherhood of Electrical Workers (Affiliated with American Federation of Labor), dated August 16, 1988

' Labor agreement between Illinois Power Company and Local Union No. 51,

International Brotherhood of Electrical Workers (Affiliated with American

Federation of Labor), dated August 16, 1988 Letter to Local 51 members of employees at CPS from John H. Browning, Business Manager, Local 51 Misc. copies "The Clinton Communicator" Misc. copies IP "QP Update" Misc. copies IP "The Reporter:

News for Employees" Misc. copies IP " Bulletin" Misc. copies IP "IP Nuclear Program News" Misc. IP memos to all employees Misc. CPS memos to all personnel CPS Nuclear Program Environment brochure Illinois Power Company Nuclear Program, Performance for the Future Program Report, dated September 14, 1989 Illinois Power Company Nuclear Program, INP0 Operating Plant Evaluation Findings (overheads)

IP " Transmission," October 1988, including results of IP employee general attitude survey Executive Summary, results of 1988 IP employee attitude survey on communication IP Engineering Review Task Force Report, Phase 1 of 3, July 17, 1989

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IP Licensed Operator Pipeline Training Strategy, Executive Briefing, February 23, 1989, by Tim D. Martin and Associates, Inc. (overheads)

IP Nuclear Plant Staffing Trends Briefing, December 2, 1988, by Tim D. Martin l

and Associates, Inc. (overheads)

IP Assessment of the Temple, Barker and Sloane 1988 Utility Staffing Study, Executive Briefing, December 2, 1988, by Tim D. Martin and Associates, Inc.

(overheads)

IP Nuclear Program Career Development Manual, December 2, 1988, revision and January 23, 1989, revision IP Career Developement Program Briefing, December 9, 1988, by Tim D. Martin and Associates, Inc. (overheads)

Notification and attendance lists from career development program briefing with

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Nuclear Planning and Scheduling department held September 9,1989

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IP Nuclear Power Program, Management Education Program brochure Sample schedule and lists of attendees for all sessions of the management education program held to date CPS weekly training schedules from December 27, 1988 to present CPS staff Technical Training Program September through December Class Schedule, 1989 Clinton Power Station organizational charts Job descriptions:

Supervisor, Plant Operations Supervisor, Plant Operations Support

Supervisor, Maintenance Planning Supervisor, Mechanical Supervisor, Electrical Supervisor, Controls and Instrumentation Supervisor, Plant Radiation Protection Supervisor, Radiological Engineering -

Supervisor, Radiological Operations Supervisor, Radiological Support Supervisor, Radiological. Environment Supervisor, Nuclear Supervisor, Plant Fire Protection Supervisor, Radwaste Supervisor, Chemistry Supervisor, Plant Support Services Assistant Supervisor, Plant Support Services Supervisor, Security

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Supervisor, Compliance'

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Supervisor, Industrial. Safety Programs Supervisor, Plant Testing

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Manager, Scheduling and Outage Management Manager, Clinton Power Station-

Assistant Manager, Clinton Power Station Manager, Nuclear Training

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Manager, Quality Assurance Manager, Licensing and Safety

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Manager, Nuclear Program Coordination

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Manager, Nuclear Planning and Support-

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Director, Nuclear _ Program Assessment Director, Nuclear Projects s

Director, Plant Maintenance Director,, Plant Technical Director, Plant-Radiation Protection Director,. Plant.0perations Director of Plant Support Services Director, Operations Training Director, Maintenance and Technical Training Director, Nuclear Program-Scheduling

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Director, Outage' Maintenance Support

Director, Outage Maintenance Programs Director, Operations Monitoring Programs Director, Design and Analysis Engineering

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Director, Engineering Projects Director, Operations and Maintenance Support Engineering

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Director, Systems and Reliability Engineering

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Director, Planning and. Programming

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Director, Industrial Safety

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Director, Material Management Director, Licensing Director, Nuclear Safety

Director, Emergency Response Procedures:

Nuclear Policy Statements (12)

Corporate Nuclear Procedures (36)

Indexes:

Emergency Plan Implementing Procedures Licensing and Safety Department Procedures

Nuclear Planning and Support Department i

Procedures Nuclear Training Department Procedures Quality Assurance Procedures Scheduling and Outage Procedures Nuclear Station Engineering Department Procedures Nuclear Station Engineering Approved Forms-Miscellaneous checklists and forms (11)

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1001.01 Rev.6 Clinton Power Station Organization, Responsibilities and Minimum Qualifications

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1001.03 Facility Review Group I

1001.04 Facility Review Group Review of Assigned

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Documents

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1001.05

. Authorities and Responsibilities of Reactor Operators for Safe Operation and Shutdown 1001.10.Rev.2 Control of Working Hours

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1001.11 Work Priority Assignment and Implementation l

1002.01 Rev.9 Control of Working Hours j

1005.01 Rev.26 Preparation,. Review, Approval,-and

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Implementation of and Adherence to Station Procedures and Documents.

1005.02 Rev.8 ' Organization of the Station Operating Manual 1005.03 Rev.12 Control, Distribution, and Statusing of Station Procedures and Documents 1005.05 Rev.8 Standing Orders and Night Orders 1005.07'

Temporary Changes to Station Procedures and Documents 1005.08 Rev.3 Periodic Review of Station Procedures and Documents 1005.09 Emergen:y Off-Normal Procedure Preparation 1005.10 Rev.2 Emergency Off-Normal Procedure Verification

and Validation Program

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1006.01 Rev.5 Document Control i

1006.04

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Review of Operating Experiences

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1011.00 Rev.1' Surveillance Testing Program.

1011.05 Rev.4 CPS Surveillance Guidelines l

1014.01 Safety Tagging Procedures 1014.03 Temporary Modifications 1016.04 Rev.3 CPS Licensee Event Reports (LER)

1016.05 Rev.1 Conduct'and Documentation of Investigations

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and Critiques 1017.02 Rev.6 Training Records 1018.02 Rev.3 Response to External Audits 1021.01 Rev.4 Site Communications

1024.65 ALARA Program

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l 1029.01 Rev.23 Preparation and Routing of Maintenance Work

Requests i

1034.01 Station Preventative Maintenance l

1301.01 Technical Department Organization,

Responsibilities, and Minimum Qualifications j

1302.06 Rev.0 Test Engineer Qualification

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1401.01 Conduct of Operations 1402.01 Rev.4 Indoctrination of OPS Department Personnel 1402.04 Rev.4 _0perations Department Watch Standing

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Organization and Qualifications i

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1402.05 Shift Technical Advisor Training 1501.01 Rev.4 Maintenance Department Organization, Responsibilities and Minimum Quali_fications 1501.02 Conduct of Maintenance 1960.01 Rev.4 Radwaste Organization, Responsibilities,

and Minimum Qualifications 1962.01 Rev.4 Radwaste Department Personnel Indoctrination

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2200.01 Rev.4 Station Nuclear Engineering Routines.

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