IR 05000461/1998029

Insp Rept 50-461/98-29 on 981214-990217.No Violations Noted. Major Areas Inspected:Review of Circumstances Surrounding High Number of Licensed Operator Failures That Occurred as Result of 1998 Annual Operator Requalification Exam

ML20204J521
Person / Time
Site:	Clinton
Issue date:	03/24/1999
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20204J512	List: IR 05000461/1998029 ML20204J507
References
50-461-98-29, NUDOCS 9903300110
Download: ML20204J521 (21)

Text

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, U. S. NUCLEAR REGULATORY COMMISSION REGION lli Docket No: 50-461 License No: NPF-82 Report No: 50-461/98029(DRS) ,

l Licensee: lilinois Power Company

Facility: Clinton Nuclear Power Station j Location: Route 54 West Clinton,IL 61727 Dates: December 14,1998 through February 17,1999 Inspectors: M. Bielby, Reactor Engineer D. Muller, Reactor Engineer Approved by: David E. Hills, Chief, Operations Branch l Division of Reactor Safety

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9903300110 990324 PDR ADOCK 05000461 G PM

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, EXECUTIVE SUMMARY l

Clinton Power Station, Unit 1 i NRC Inspection Report 50-461/98029 I This inspection included a review of the circumstances surrounding the high number of licensed operator failures that occurred as a result of the licensee's administration and evaluation of the 1998 annual licensed operator requalification examination (August 24 -

September 25,1998). This inspection report contains the inspectors' and licensee's findings and conclusions based on operator performance during the 1998 annual licensed operator examination, the subsequent training sessions, and dynamic simulator scenario re-examinations (January 4 - February 12,1999). This inspection report also contains inspector findings and conclusions conceming licensed operator requalification training, examination administration and evaluation, operator dynamic simulator scenario examination performance, operator remediation and re-evaluation, root cause investigation and corrective actions, simulator performance, and licensed operator medical record !

Operator Knowledae and Performance

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The licensee determined that licensed operator performance during the 1998 licensed operator requalification examination was poor. The licensee identified a large number of operator errors and operators demonstrated weaknesses with Emergency Operating Procedure usage, system and equipment control manipulation, communications, teamwork, and emergency action level classification. (Section 04.1) ,

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The inspectors observed continuous improvement in crew communications, teamwork, i and event diagnosis during the multiple dynamic simulator training exercises. The j licensee's training staff conducted these exercises to address the poor operator !

performance noted during the 1998 licensed operator requalification examinations, l

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Overall operator performance during the dynamic simulator scenario re-examinations had improved when compared to the operator performance observed during the 1998 l licensed operator requalification examination. (Section 04.3)

Operator Trainina and Qualification

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. The licensee developed a fairly comprehensive program for remediation and re-evaluation of unsatisfactory crew and individual performance following the 1998 licensed operator requalification examination. The use of various remediation and re-evaluation techniques, which depended upon the nature of the failures, was appropriate. The licensee's use of video reviews and simulator exercises appeared to be effective in remediating poor operator performance. (Section 05.1)

-- The licensee's investigation and root cause report associated with condition report number 1-98-09-281, * Unacceptably High Number of Failures in the 1998 Licensed Operator Annual Requalification Examinations," was thorough, resulting in the

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, licensee's identification of a number of licensed operator requalification training l program deficiencies. (Section 05.2)

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The licensee identified a number of problems with the Licensed Operator Requalification Training (LORT) program, including inadequate use of available feedback to improve the LORT program, insufficient simulator training time, poor change management, poor examination results documentation, lack of a sample plan for the 1998 examination, and a lack of operator performance trending in the simulato However, the licensee did not realize the extent of the problems until a large number of operator performance issues surfaced during the annual licensed operator requalification examination. (Section 05.3)

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The licensee developed and implemented appropriate corrective actions for the LORT program based on the root cause analysis for the unsatisfactory operator performance identified during the 1998 licensed operator requalification examination. (Section 05.4)

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Overall, the licensee's process for administering examinations and evaluating both crew i and individual operator performance during the dynamic simulator scenario re-examinations was acceptable. (Section 05.5)

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The inspectors identified some operator performance deficiencies during the dynamic j simulator scenario re-examinations which were not identified by the licensee i evaluators. (Section 05.5) )

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The inspectors concluded that the licensee's simulator staff effectively identified and corrected simulator discrepancies in a timely manner. The licensee's plant specific control room simulator generally provided consistent and realistic plant response under normal, abnormal, and emergency conditions. (Section 05.6)

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During the dynamic simulator scenario re-examination, one simulator component malfunction did not activate when required. (Section 05.6 and Enclosure 2, " Simulation Facility Report")

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The inspectors identified that the licensed operator medical records were complete, physicals were timely, and required medical restrictions had been incorporated into associated individuallicenses. (Section 05.7)

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Report Details

- 1. Operations 04 Operator Knowledge and Performance 04.1 Operator Performance Durina 1998 Annual Reaualification Examination Inspection Scope (71001. 41500)

The inspectors reviewed the training staff's operator performance and competency evaluation forms for the respective crews and individuals that participated in the

, dynamic simulator scenario portion of the 1998 annual licensed operator requalification examinatio Observations and Findinas The training staff identified that a large number of licensed operators (29%) and crews (57%) performed unsatisfactorily during the dynamic simulator scenario portion of the 1998 annual licensed operator requalification examination. The examination was administered by the licensee between August 24 and September 25,1998. The licensee conducted 28 simulator scenarios to evaluate 32 senior reactor operators (SROs),19 reactor operators (ROs), and 7 crews (5 operating and 2 staff) of licensed operators. Each crew consisted of a shift manager (SM), control room supervisor (CRS), work center supervisor (WCS), shift technical advisor (STA), and two control room operators (CROs). The SM, CRS, and WCS were licensed SROs, and the CRO position was filled by licensed ROs. The training staff evaluated individual and crew L performance during dynamic simulator scenarios with the following results:

• Four of 7 crews were evaluated as unsatisfactory due to crew performance weaknesses (57%).

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Eleven of 32 SROs were evaluated as unsatisfactory due to individual performance weaknesses (34%).

• Four of 19 ROs were also evaluated as unsatisfactory due to individual performance weaknesses (21%). l The licensee identified that a higher percentage of STAS and SROs failed when compared to ROs. The licensee attributed this discrepancy to the fact that when a CRS (licensed SRO) made an error, the STA, SM (licensed SRO), and WCS (licensed SRO)

on that crew were also held accountable for the CRS's decisio During the administration and evaluation of the dynamic simulator scenarios, the licensee identified and documented a large number of operator performance errors and operator demonstrated weaknesses in the following areas:

Difficulties or errors in the usage of emergency operating procedures (EOPs), -

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Unnecessary delays in taking required procedural actions, especially during rapid plant shutdowns,

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Incorrect equipment and system control manipulations,

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Poor crew briefings,

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Poor three-part communications,

. Poor command and control,

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Incorrect emergency action level classification, and

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Poor self-checking and peer-checkin Conclusions The licensee determined that licensed operator performance during the 1998 licensed operator requalification examination was poor. The licensee identified a large number of operator errors and operators demonstrated weaknesses with Emergency Operating Procedure usage, system and equipment control manipulation, communications, teamwork, and emergency action level classificatio .2 poerator Performance Durina Dynamic Simulator Trainina Exercises Inspection Scope (71001. 41500)

The inspectors observed the performance of one operating crew during simulator training exercises conducted by the licensee's training staff on December 14 and 15, 199 Observations and Findinas On December 14,1998, during dynamic simulator training exercises conducted by the licensee, the inspectors observed operator performance weaknesses similar to those identified by the licensee during the 1998 licensed operator requalification examinatio During the first exercise, the inspectors observed that the CRS had difficulty with following and implementing the Anticipated Transient Without Scram (ATWS) EO During the second exercise, the inspectors observed that the crew was slow to identify which Altemating Current (AC) buses were lost, and slow to identify the plant effects of the partial loss of AC power. The inspectors observed individual operator performance weaknesses in the areas of command and control, and communications. The training staff identified similar deficiencies in these same two area ,

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On December 15,1998, the inspectors observed operator performance during two simulator training exercises conducted by the licensee. The inspectors did not identify I

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. any significant performance issues during the first exercise. During the second exercise, the inspectors observed that the CRS did not perform a proper anticipatory blowdown using main turbine bypass valves. As the week progressed, the inspectors observed significant improvement in the crew's communications, teamwork, and event diagnosis when compared to how the crew perfomied in these areas durin0 the previous day's simulator scenario exercise Conclusions The inspectors observed continuous improvement in crew communications, teamwork, and event diagnosis during the multiple dynamic simulator training exercises. The licensee's training staff conducted these exercises to address the poor operator performance noted during the 1998 licensed operator requalification examination ,

04.3 Operator Performance Durina Dynamic Simulator Scenario Re-examination ' Inspection Scope (71001. 41500)

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The inspectors observed the licensee's training staff and operation's management evaluate and critique the performance of the crew and the individual operator competencies for one staff and three operating crew Observations and Findinas The licensee's training staff administered dynamic simulator scenario examinations to two staff and five operating crews between January 8 and February 12,1999. Each crew consisted of a shift manager (SM), control room supervisor (CRS), shift technical advisor (STA), and two control room operators (CROs). In contrast to the 1998 licensed operator requalification examination, the Work Control Supervisor (WCS)

position was not manned and the SM position was manned by personnel who were specifically assigned as a SM on a plant operating cre The dynamic simulator scenario examinations consisted primarily of off-normal and emergency events. Because there were not any daily plant operations or challenging usage of Technical Specifications incorporated into the scenario events, the inspectors did not evaluate operator performance in those areas. There were no individual or crew failures identified by either the training staff or inspectors during these examinations. The inspectors identified strengths in the following areas:

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briefings and updates,

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self-checking and peer-checking, 1

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EOP usag In some instances, the inspectors and training staff observed operator performance deficiencies during the dynamic simulator scenario examinations, including:

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inconsistent operator response to annunciators (some operators identified expected alarms before they were received, others did not),

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errors in plant control (specified water level bands or pressure bands were exceeded and not communicated),

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deficiencies in command and control, and a

errors in procedure usage, Conclusions Overall operator performance during the dynamic simulator scenario re-examinations had improved when compared to the operator performance observed during the 1998 licensed operator requalification examinatio {

05 Operator Training and Qualification 05.1 Licensed Operator Remediation and Re-evaluation Proarams Inspection Scope (71001. 41500)

The inspectors reviewed the licensee's remediation and re-evaluation programs that were tailored to address the unsatisfactory operator performance during the 1998

annual licensed operator requalification examination.' Observations and Findinas Based on the results of the 1998 annuallicensed operator requalification examination, the licensee's training staff developed and then administered a remediation and re-evaluation program for those operators who demonstrated unsatisfactory performanc The training staff identified three basic pattems of unsatisfactory operator performance during the 1998 annual licensed operator requalification examination:

(1) Unsatisfactory crew performance as a whole, (2) Unsatisfactory performance by multiple individuals on a single crew, and (3) Unsatisfactory performance by one individual on a specific cre For crews that demonstrated unsatisfactory performance as a whole, the licensee removed all members of that crew from licensed duties. For individual operators that demonstrated unsatisfactory performance (several individuals on a single crew or an individual on a specific crew), the licensee removed only those individuals from licensed duties. One operator's license was terminated based on a history of poor performanc The licensee developed a remediation program using a process similar to the one used j to upgrade licensed operators who have been removed from shift due to performance 1

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, weaknesses. For unsatisfactory performance by a crew as a whole or unsatisfactory j performance by multiple individuals on a single crew, remediation consisted of an instructor facilitated review of a videotape of the exercise (s), followed by simulator practice sessions with the crew (or multiple individuals), to incorporate the lessons 4 leamed from the video review. For unsatisfactory performance by a specific individual on a crew (isolated case), remediation consisted of self-study and one-on-one training with an instructor. For all types of remediation, the process generally took one to two days to complet The re-evaluation program was similar to the remediation program. For unsatisfactory crew performance, the licensee conducted evaluated dynamic simulator scenarios for the entire crew. Similarly, for unsatisfactory performance by multiple individuals on a single crew, the licensee conducted evaluated simulator exercises, with surrogate operators added to complete the crew complement. For unsatisfactory performance by a specific individual on a given crew, the licensee administered an individual level of knowledge examination. The licensee remediated, re-evaluated, and returned to licensed duties all licensed operators who failed the 1998 annual licensed operator requalification examination with two exceptions. One operator's license was terminated shortly after the 1998 examination, and another operator's license was terminated due to the operator's failure to successfully complete remediation and re-evaluatio Conclusions The licensee developed a fairly comprehensive program for remediation and re-evaluation of unsatisfactory crew and individual performance following the 1998 licensed operator requalification examination. The use of various remediation and re-evaluation techniques, which depended upon the nature of the failures, was 1 appropriate. The licensee's use of video reviews and simulator exercises appeared to !

be effective in remediating poor operator performanc ,

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05.2 Root Cause Analysis for Unsatisfactory Operator Performance on the 1998 Licensed '

Operator Reaualification Examinations Inspection Scope (41500. 71001)

The inspectors conducted interviews and document reviews to verify the quality of the licensee's Root Cause Report (RCR). Specifically the inspectors performed the following:

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. Reviewed the licensee's RCR associated with condition report number i 198-09-281, " Unacceptably High Number of Failures in the 1998 Licensed j Operator Annual Requalification Examinations" l

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' Reviewed a licensee prepared summary of operator performance and individual critique sheets associated with the dynamic simulator scenario portion of the 1998 annual licensed operator requalification examination;

• Reviewed the 1997 and 1998 training topic schedules;

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Conducted interviews with licensed operators and the licensed operator requalification program lead instructor; and

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Reviewed licensee assessments of the training departmen i b. Observations and Findinas Licensee's RCR i l

The licensee initiated a condition report (1-98-09-281) on September 18,1998, to prompt a root cause investigation of the large number of crew and individual l examination failures during the September 1998 licensed operator requalification i examination. The licensee conducted full day workshops on October 3, and 10,1998, I with licensed operators and members of the training staff. The purpose of these workshops was to discuss the observed operator performance deficiencies and to involve the operators in the initial stage of the root cause and corrective action process. )

On November 2,1998, the licensee completed its RCR. Plant management approved j the RCR and associated proposed corrective actions on November 16,199 The licensee concluded in the RCR that there were two priniary root causes for the high number of examination failures:

(1) Inadequate change management. Change management within the operations and training organizations (including changes to the roles, responsibilities, and expectations for licensed operators) was ineffectiv (2) Weak corrective action program and lack of program oversight. The operations

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and training organizations had failed to follow through on corrective actions (using the existing processes and programs) to maintain and improve the LORT program due to a weak corrective action program and lack of program oversight by both operations and training personne In support of these primary root causes, the RCR contained the following additional findings:

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Total simulator contact hours, including time spent working with the EOPs and off-normal procedures, by licensed operators during LORT had declined during the previous few year .

Significant changes to the operating crews' composit% were implemented in the spring and summer of 1998 before the annuallicensed operator l requalification examination was administered. The crews did r.ot have sufficient time to use the simulator to develop into effective team .

The licensee had developed changes in expectations regarding the duties, roles, and responsibilities of all licensed operators, but had not adequately communicated or reinforced the new expectations in the classroom prior to 4 implementation in the plan r

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During part of 1998, the LORT program lacked effective leadership, which resulted in a breakdown in the coordination and planning of activities to support the LORT progra *

In the past, the licensee had not conducted any trending of operator i

. performance in the simulator. This resulted in the licensee failing to recognize a 1 decline in training quality and operator performanc The investigation team noted several examples where ineffective assessments of the LORT program were conducted and where follow through on several

. LORT corrective actions was inadequate. In addition, the licensee did not use other feedback sources as inputs to improve the LORT progra ' The licensee discovered other LORT program deficiencies including poor documentation of pass / fail examination decisions, a lack of a sample plan for the 1998 annual licensed operator requalification examination, and deficiencies with instructor certification record The inspectors determined that the licensee, in conducting its RCR, did not evaluate the quality of training. The inspectors determined, primarily through interviews with licensee personnel, that past simulator exercise critiques were not effective at improving crew performance. Also, the inspectors determined that classroom presentations typically did not adequately involve the student Conclusions The licensee's investigation and root cause report associated with condition report number 1-98-09-281, " Unacceptably High Number of Failures in the 1998 Licensed

. Operator Annual Requalification Examinations," was thorough, resulting in the licensee's identification of a number of licensed operator requalification training program deficiencie .3 LORT Prooram Problems Inspection Scope (41500. 71001)

The inspectors reviewed two procedures associated with the LORT program:

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lilinois Power Nuclear Program Training Program Description, " Operations Continuing Training Program Description," Rev. 7, September 22,199 * Clinton Power Station Nuclear Training and Support (NT&S) Guideline,

" Licensed Operator Examinations-Continuing," September 199 Observations and Findinos The inspectors determined that several problems existed in the licensee's LORT ;

program, although the licensee identified these problems during the root cause i

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, investigation. The licensee identified some of these problems based on a review of past licensee LORT program assessments. The most probable causes for these problems were (1) the lack of leadership in the LORT program (the lead requalification instructor position was vacant or filled with multiple persons for five months during 1998) and (2) LORT was a low licensee priority. The inspectors identified five basic problem areas: (1) the use of feedback to improve the LORT program, (2) simulator training time, (3) training quality, (4) change management, and (5) examination results documentation and other issue LORT Proaram Feedback in general, during 1998 there were multiple examples of the licensee not incorporating available feedback to improve the LORT program. The licensee, in its RCR, identified that only 25 items in the nuclear training department (NTD) feedback database had been reviewed for implementation, although approximately 530 items in the NTD database pertained to suggestions for training improvement. Another finding of the RCR was that at the time of the September 1998 annual licensed operator requalification examination, corrective actions for 10 condition reports (CRs) concerning operator performance in the simulator had not been completed. In addition, training cycle and course closeout packages (another feedback source) had not been reviewed since the beginning of 199 Simulator Trainino Time The licensee identified that there had been a reduction in the total number of licensed operator simulator contact hours during LORT over the previous few years, including a decline in hours trained on the simulator for emergency and off-normal procedures. For 1998, the simulator was unavailable for six weeks due to simulator modifications and an unexpected simulator power outage. The licensee did not provide for additional simulator training time to make up for the lost time, in addition, on some occasions, the licensee added one or two staff SROs to an operating crew during training. The addition of SROs meant that during simulator training exercises, one or two SROs were not fully involved in the exercise Chanae Manaaement The licensee identified that during 1998 there were three occasions where the LORT staff failed to adequately plan for change. The first occasion where the licensee did not adequately manage change involved significant personnel changes on the operating crews. In April of 1998, the licensee assigned the majority of the personnelin the SRO positions to different crews. The second occasion of ineffective change management involved the change, in April of 1998, in the role of the WCS from that of an extra control room operator who manipulated plant control switches to that of a verifier of proper procedure usage and crew actions who was not allowed to manipulate plant control switches. The third occasion of ineffective change management pertained to changes in management expectations conceming operator performance. On all three of these occasions, the LORT staff did not adequately anticipate the effects of these changes on crew performance. The LORT staff also did not allow for sufficient

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simulator practica time with these changes in place, and did not adequately communicate or reinforce management expectations during trainin Documer'tation and Other lasues There were other issues identified by the licensee and inspectors which pointed to additional problems with the LORT program. One issue related to the licensee's lack of

. justification for pass / fait decisions on dynamic simulator scenarios reflected in the documentation on individual and crew competency forms. The inspectors observed examples where, based on the competency forms, it appeared that an entire crew should have failed, but, in fact, only part of the crew failed. A second issue, identified by the licensee, involved the development of an annual licensed operator requalification examination which was not based on a sample plan. A sample plan is used, in part, to ensure that the content of the examination is appropriate for the training that has been received. A third issue pertained to the licensee's failure to trend operator performance in the simulator. This is a primary reason why the licensee was unaware of the decline in operator performance, especially in the area of EOP usag Conclusions The licensee identified a number of problems with the Licensed Operator i Requalification Training (LORT) program, including inadequate use of available feedback to improve the LORT program, insufficient simulator training time, poor change management, poor examination results documentation, lack of a sample plan for the 1998 examination, and a lack of operator performance trending in the simulato However, the licensee did not realize the extent of the problems until a large number cf operator performance issues surfaced during the annual licensed operator requalii; cation examinatio O5.4 Licensee Corrective Actions and Recent improvements in the LORT Proaram Inspection Scope (41500. 71001) l To understand what corrective actions the licensee was taking to address the identified problems in the LORT program, and to verify implementation of those corrective actions, the inspectors reviewed the following items:

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The licensee's RCR and recovery plan for the LORT program (document ;

No. DMA-084-98, dated November 12,1998);

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Licensee documents concerning the identification and treatment of feedback items, including CRs, NTD database items, and cycle and course closecut packages;

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Recent training cycle schedules;

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Clinton Power Station (CPS) procedure No. 1401.16, " Organizational Changes,"

Revision 0, dated December 23,1998, which addressed change management;

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The sample plan for the recent examinations conducted from January 8 through February 12,1999; and

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Licensee trending documents conceming operator performance in the simulato The inspectors also observed operator training during the week of December 14,1998, and discussed corrective actions for the LORT program deficiencies with members of the licensee's training and operations staff b. Observations and Findinos The licensee conducted a root cause investigation and documented the findings in a RCR, which included corrective actions. Part of the corrective actions included additional training for areas in which personnel repetitively failed during the 1998 annuallicensed operator examination. The licensee categorized the remainder of the j corrective actions, similar to the LORT program problems discussed in section 05.3, into five basic areas: (1) the use of feedback to improve the LORT program, (2) !

simulator training time, (3) training quality, (4) change management, and (5) other issues. As of January 8,1999, the licensee had completed most of the corrective actions. The only significant actions left to complete were in the area of feedbac ;

l Additional Trainina J Additional training was conducted in November and December of 1998 and included:

- EOP usage,

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Rapid plant shutdowns,

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Command and contro The licensee covered these training areas during classroom lectures and reinforced the training concepts during dynamic simulator scenarios. This training typically involved an additional 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> relative to a typical 36-hour training wee LORT Feedback The licensee developed corrective actions, per the RCR, to address items in the NTD feedback database, CRs, other open corrective actions, and items from past LORT self- assessments. In addition, the RCR addressed completing the training cycle and course closeout packages. Based on a review of documents provided by the licensee and discussions with licensee staff members, the inspectors determined:

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The licensee had reviewed and dispositioned approxiraately 70 percent of the items in the NTD feedback database concerning the LORT progra ;

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. The number of open corrective actions and CRs pertaining to the LORT program decreased from 51 in September 1998 to 20 in December 199 .

The licensee had completed training cycle and course closeout packages for the formalized operator training conducted in 1998. At the time of this inspection, training and operations department personnel were reviewing these package .- Further reviews of LORT rassessments, NTD feedback items, and station events were ongoing to identify and develop any additional LORT corrective action Efforts were also underway to develop accounlability to ensure a continued sensitivity to LORT feedbac Simulator Trainina Time The licensee developed corrective actions, per the RCR, to increase simulator training time. Based on a review of documents provided by the licensee and discussions with licensee staff members, the inspectors determined:

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The licensee increased simulator contact hours from the past practice of about 14 hours1.62037e-4 days <br />0.00389 hours <br />2.314815e-5 weeks <br />5.327e-6 months <br /> per training cycle to an established new minimum standard of 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> per, training cycle. The inspectors noted that for the training sessions observed during the week of December 14,1998, approximately 26 hours3.009259e-4 days <br />0.00722 hours <br />4.298942e-5 weeks <br />9.893e-6 months <br /> of simulator training occurred, with the majority of this time devoted to off normal procedures sad EOP l

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The licensee formed staff crews with training for these crews conducted separately from operating crew Trainina Quality Although the issue of training quality was for the most part overlooked in the RCR, the licensee developed and implemented corrective actions in this area. Based on direct observation of specific training activities and a review of other training activities, the inspectors determined:

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The quality of simulator training had improved. In particular, during the observed training sessions the week of December 14,1998, the inspectors noted an effective use of video taped exercise reviews, coached exercises, and non-coached exercises. In addition, the inspectors noted that the Director of Operations was very involved in the training sessions and that effective post exercise critiques were conducted. Based on discussions with licensee training and operations department oersonnel, the inspectors concluded that this represented a significant improvement over past simulator training practice The quality of classroom instruction had not appreciably improved. During the week of December 14,1998, the inspectors observed that the instructor did not involve the students during most of the presentation. The students also did not

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take the initiative to involve themselves in the classroom instruction. This was also noted by a licensee manager who was monitoring the classroom instruction.-

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The licensee informed the inspectors that it would reinforce management expectations for instructors before each training cycle commence <

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The licensee implemented corrective actions, per the RCR, to develop a change management program. Based on a review of documents provided by the licensee and discussions with licensee staff members, the inspectors determined:

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The licensee developed a procedure, CPS 1401.16, for implementing change The licensee planned to keep the lead LORT instructor in his current position for some time to maintain training continuity and to reinforce operator performance standard *

The licensee stated that if future changes in crew members were planned, the licensee would implement these changes during that crew's training cycle. This would allow the newly configured crews practice time in the simulator prior to assuming on shift dutie Other issues The inspectors determined that the licensee had implemented corrective actions to address other issues- 1-l

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The licensee developed a program to trend operator performance in the simulator. Graphs and data depicting operator performance in the simulator i were readily availabl R

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The licensee developed a program to track and display the organizational performance of the nuclear training departmen Conclusions The licensee developed and implemented appropriate corrective actions for the LORT program based on the root cause analysis for the unsatisfactory operator performance identified during the 1998 licensed operator requalification examinatio .5 Observed Examinations Inspection Scope (71001)

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The inspectors observed the licensee's process for conducting examinations and evaluating operator performance during a portion of the dynamic simulator scenario

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, re-examinations between January 8 and February 12,1999. In addition, the inspectors reviewed the associated simulator exercise evaluation guides and operator competency sheet b. Observations and Findinas During dynamic simulator scenario examinations, the licensee's operator evaluation team generally consisted of three training staff personnel. The evaluation team used two evaluators to observe the management of the crew (SM, CRS, and STA), and the team used one e- uator to observe both control room operators. In addition, the Director of Operations, Director of Operations-Training, a quality assurance department representative, and the lead LORT instructor participated in the evaluation Immediately following each scenario, the evaluation team would meet to discuss and document critical task completion and other crew performance issue In general, the inspectors agreed with the findings and conclusions of the licensee's evaluation team. However, during the examination administration, the inspectors

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observed the following deficiencies:

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On some occasions, the inspectors observed that operator performance deficiencies were not noted by the evaluation team. For example, the evaluation team did not identify that one control room operator exceeded the prescribed reactor water level band or that operators were inconsistent in their response to annunciator The impectors observed some problems with simulator exercise guides, which incle .d not listing all of the required actions for one particular event, listing l alarms and actions which were not expected during another event, and f inconsistent referencing to objectives in all the guides reviewe .

On one occasion, t% inspectors determined that a simulator exercise was stopped prematu%. Although the simulator guide contained steps for initiating a plant cooldown, the exercise was stopped at the point when the cooldown evolution was being discussed by the crew, before actual initiation of the cooldow c. Conclusions Overall, the licensee's process for administering examinations and evaluating both crew and individual operator performance during the dynamic simulator scenario re- i examinations was acceptable. However, the inspectors identified some operator l performance deficiencies during the dynamic simulator scenario re-examinations which l were not identified by the licensee evaluator J

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j' 05.6 Simulator Fidelity j Inspection Scope (71001)

The inspectors evaluated the effectiveness of the licensee simulator staff in identifying j and correcting simulator discrepancies, and informed the staff of specific simu!ator j fidelity issues identified by the inspectors during operating examination !

l Observations and Findinas The inspectors reviewed the licensee's simulator deficiency list and records for trending

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simulator availability. The licensee had 23 open Simulator Problem Reports (SPRs). ,

The trending of open SPRs indicated a high of 33 and low of 20 SPRs since April 199 l The inspectors noted that simulator discrepancies wereddentified and resolved in a l timely manner. The simulator availability tre.nd indicated an overall increasing availability since April of 1998. The licensee attributed the availability increase to !

improvements in the instructor station softwar During administration of the simulator scenarios, the inspectors observed that the j simulator model provided realistic plant response to changing conditions during normal, !

abnormal, and emerge icy conditions. Although the simulator generally modeled the i required component malfunctions, on one occasion a component malfunction did not I activate. The licensee identified that this type of problem had occurred infrequently in the past and wrote a SPR to document the recent problem. The failure of the component to malfunction did not significantly affect the licensee's ability to evaluate the operators using simulator scenario Conclusions

, The inspectors concluded that the licensee's simulator staff effectively identified and

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corrected simulator discrepancies in a timely manner. The licensee's plant specific i control room simulator generally provided consistent and realistic plant response under normal, abnormal, and emergency conditions. During the dynamic simulator scenario re-examination, one simulator component malfunction did not activate when required (Enclosure 2, " Simulation Facility Report").

05.7 Operator Medical Records Inspection Scope (71001) l The inspectors randomly selected and reviewed 10 licensed operator medical records )

to verify that physical examinations were being administered in a timely manner,

- medical restrictions were updated on the operator's license, and that the records were complete in accordance with American National Standard Institute /American National j Standard (ANSI /ANS) 3.4-198 >

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E l Observations and Findinos {

The inspectors reviewed copies of medical records which were maintained on site for 10 of 51 active licensed operators. The licensee had administered the physical examinations within the two-year required period. The inspectors reviewed the licensee's medical results and verified that the required medical restrictions had been incorporated into associated individual licenses. The medical documentation was complete with the proper signatures and date Conclusions The inspectors identified that the licensed operator medical records were complete, physicals were timely, and required medical restrictions had been incorporated into associated individuallicense Miscellaneous Operations issues--

08.1 (Closed) NRC Manual Chapter 0350. Case Specific Checklist (CSC) Item 11.5 - Provide Reasonable Assurance that Deficiencies Found Durina Reaualification Examinations Have Been identified and Corrected l l

The inspectors reviewed the licensee's activities relating to NRC Manual Chapter 0350 CSC item 11.5. In determining whether this CSC item was ready to be closed, the inspectors conducted the following activities:

(1) Reviewed the licensee's root cause assessment and evaluated identified cause (2) Reviewed the licensee's corrective action plan for identified causes, to assure appropriate actions were scheduled prior to restar (3) Observed and evaluated implementation of corrective actions, including remedial training, training program improvements, and re-examinations to assure appropriate actions had been taken by the licensee to address the various operator performance weaknesses exhibited during the 1998 annual requalification examinatio Based on these activities, the inspectors determined that CSC item 11.5 is close V. Manaaement Meetinas ,

l Exit Meeting Summary

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X1 The inspectors presented the inspection results to members of licensee management on February 17,1999. The licensee acknowledged the findings presented. The inspectors asked the licensee whether any materials examined during this inspection should be considered proprietary. No proprietary information was identifie ,

PAR'.iAL LIST OF PERSONS CONTACTED Licensee J. Forman, Licensing Representative J. M. Gruber, Director-Corrective Action J. Hanson, Director-Nuclear Training G. Hunger, Station Manager J. Kantner, Training Department M. Lyon Training Department W. Maguire, Director-Operations J. McElwain, Chief Nuclear Officer J Neuschwanger, Training Depatment NRC T. Kozak, Chief, Reactor Projects Branch 4 T. Pruett, Senior Resident inspector i

INSPECTION PROCEDURES USED IP 71001: Licensed Operatot Requalification Program Evaluation IP 41500: Training and Qualiftation Effectiveness s

ITEMS OPENED, CLOSED, AN[' DISPUSSED None

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LIST OF ACRONYMS AC , Altemating Current CFR Code of Federal Regulations CPS Clinton Power Station CR Condition Report CRO Control Room Operator CRS Control Room Supervisor CSC Case Specific Checklist EOP Emergency Operating Procedure -

LORT Licensed Operator Requalification Training NTD Nuclear Training Department NRC Nuclear Regulatory Commission RCR Root Cause Repod RO Reactor Operator SM Shift Manager SRO Senior Reactor Operator STA Shift Technical Advisor SPR Simulator Problem Report WCS Work Center Supervisor i

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, Enclosure 2 SIMULATION FACILITY REPORT i

Facility Licensee: Clinton Nuclear Power Station Facility Licensee Docket No: 50-461 Scenario Retake Examinations Observed: Weeks of January 4 - February 8,1999 The following documents observations that were made by the NRC inspectors during the licensee's administration of scenario retake examinations subsequent to a large number of failures during the annual requalification examination. These observations do not constitute audit or inspection findings and are not, without further verification and review, indicative of non-compliance with 10 CFR 55.45(b). These observations do not affect NRC certification or approval of the simulation facility other than to provide information which may be used in future evaluations. No licensee action is required in response to these observation During the conduct of the simulator retake examinations, the following item was observed:

ITEM DESCRIPTION 1 A malfunction for turbine vapor extractor high temperature was assigned to Remote 2, but did not activate when button was pushed the first time. When Remote 2 button was pushed the second time, the malfunction assigned to Remote 3 activate I

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