IR 05000482/1997019
| ML20199K326 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 11/25/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20199K273 | List: |
| References | |
| 50-482-97-19, NUDOCS 9712010082 | |
| Download: ML20199K326 (33) | |
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ENCLOSURE 2 i
U.S. NUCLEAR REGULATORY COMMISSION
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REGION IV -
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Docket No.:
50 482 License No.:
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Report No.:
50 482/97 19 Licensee:
Wolf Creek Nuclear Operating Corporation Facility:
Wolt Creek Generating Station
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Location:
1550 Oxen Lane, NE Burlington, Kansas
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Dates:
September 22 through November 2,1997 inspectors:
J. F. Ringwald, Senior Resident inspector B. A. Smalldridge, Resident inspector D. N. Graves, Senior Project Engineer D. G. Passehl, Senior Resident Inspector, Callaway J. A. Arildsan, Senior Operations Engineer Approved By:
W. D. Johnson, Chief, Reactor Project Branch B
ATTACHMENT: Supplemental Information
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EXECUTIVE SUMMARY Wolf Creek Gene, rating Station NRC Inspection Report 50 482/97 19 Operations Safe and cor. trolled plant evolutions were effectively supported by consistent use of
three way communi.ation by all operators. During the fiist week of Refueling Outage 9, control room operators permitted activities that challenged their ability to monitor the control boards. After the inspectors raised this concern, operators responded by implementing effective controls on potentially distracting activities.
(Section 01.1).
The licensee performed an adequate but inadequately documented operability
evaluation of a centrifugal charging pump drain flange that appeared to be inadequately nupported during an engineering and maintenance field review.
(Section 01.2).
Nonficensed operators assigned to monitor extended emergency diesel generator
operation demonstrated inadequate attention to detail by not noting two material condition issues that were subsequently identified by the inspectors (Section 02.1).
The inspector noted operators using a plant drawing with uncontrolled handwritten
information to provide necessary information in suppo.( of plant operations (Section 03.1).
The licensea's response to an undefined problem with the rod control system did
not meet with NRC or management expectations. Operators demonstrated a lack of a questioning attitude and lack of system knowledge when responding to repeated unexpected occurrences of outward control rod demand signals and a step counter rod position indication mismatch (Section 04.1).
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The licensee has implemented a detailed site wide program for tracking and
evaluating human performance errors. The success of the program was highly dependent on the accuracy with which identified items were coded, which was not
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performed accurately for the first 6 months of data. No comprehensive action plan had been generated to review, evaluate, or implement the recommendations from the first common cause analysis of human performance errors (Section 07.1).
The licensee had conducted extensive training regarding human error reduction, and
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personnel interviewed acknowledged a heightened awareness of human error prevention _ techniques. (Section 07.2).
.The licensee had initiated a number of programs in order to assess human
performance on a real-time basis. These programs were very recently implemented and their effectiveness has yet to be determined (Section 07.3).
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Problems were clearly identified with acceptable determinations of causes and
corrective actions. Reviews of the effectiveness of the implemented corrective actions were not performed as required for a number of performance improvement requests (PIRs) (Section 07.4).
The observed licensee meetings demonstrated an aggressive focus on safety with a
good questioning attitude (Section 07.5).
Maintenance The failure of maintenance personnel to comply with their main steam safety valve
testing procedure resulted in an inadvertent opening of an atmospheric relief valve.
The quality specialist properly identified this error, but failed to raise the con:ern in an effective manner and, therefore, missed the opportunity to prevent the plant transient (Section M1.3).
The f ailure of maintenance personnel to reinstall a shield hatch cover over a
radwaste filter prior to closing out the filter replacement procedure led to operations personnel operating the filter without adequate shielding and resulted in an unposted locked high radiation area (Section M1.4).
One team of electricians performed a very effective inspection of a safety related
battery and identified two conditions that warranted quarterly monitoring in the future. Another team performing the same irispection f ailed to identify similar r 7nditions that were present (Section M1.5).
On two occasions the inspectors identified maintenance practices that differed from
the vendor technical manual guidance. A subsequent engineering evMuation concluded that, in these cases, the maintenance practice would not impair future equipment operation (Section M1.6).
The inspectors noted that ineffective housekeeping in containment provided the
potential for migration of small pieces of debris into plant systems. In addition, maintenance conducted in the higher radiation areas around the reactor coolant system loops was performed without regard for housekeeping such that clean up efforts could have resulted in unnecessary radiation exposure (Section M4.1).
Enaineerina Engineering personnel performed an effective evaluation and provided appropriate
recommendations in response to the discovery of eight motor operated valves which were found to have overthrust condhions during diagnostic testing (Section E1.1).
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Engineering personnel failed to perform an evaluation they planned to perform in response to inspector questions in 1994 on the minimum bolting requirements for the containment equipment hatch missile shield. As a result, the licensee removed bolts while in Mode 4 (Section E2.1).
Plant Suocort A mechanic's inattention to detail resulted in the inadvertent use of a contaminated
gauge using a radiation work permit which did not allow the use of contaminated tools (Section R4.1).
Three licensee identified examples of workers in the raulologically controlled area
without dosimetry demonstrated that the licensee had not effectively resolved this
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repetitive concern (Section R4 2).
- The licensee provided excellent "just in time" training to every radiation worker just
prior to the start of Refueling Outage 9 (Section R5.1).
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Report Details Summarv of Plant Status The licensee operated the plant at essentially 100 percent power from the start of the inspection period until October 2,1997, when operators began reducing power in preparation for Refueling Outage 9. Operators shut the plant down and entered Mode 3 on October 4,1997. At the end of the inspection period, all fuel assemblies had been moved to the spent fuel pool.
l. Operations
Conduct of Operations 01.1 Control Room Observations a.
Insoection Scoce f71707)
Inspectors observed control room operations on a daily basis throughout the inspection period, b.
Observations and Findinos Throughout the inspection period, the inspectors observed consistent use of three way communications between control room operators during the conduct of both complex and routine operations. The inspectors determined thet this contributed to safe and controlled operations, including nonroutine evolutions such as the reactor shutdown and transition to shutdown and refueling modes.
The inspectors noted the good practice of operators using engineered safety features status panel alarm and bistable status sheets to keep track of expected versus unexpected indications and alarms during periods when changing plant conditions caused the expectad alarm configuration to change frequently.
On several occasions during the first week of the outage, the activity levelin the control room increased to the point that it challenged the operators' ability to monitor the control boards. On one occasion, a reactor operator called a timeout in order to get the attention of the supervising operator due to excessive noise in the control room resulting from an excessive number of personnel in the control room adjacent to the control boards. On another occasion, the inspector noted that all three reactor operators and the supervising operator were simultaneously engaged in activities that prevented them from devoting their entire attention on monitoring the control boards.
On October 5,1997, the inspactor observed a management and procedure briefing prior to a main stocm valve fast close test in the control room that was interrupted frequently by component cooling water alarms. While operaters stopped the briefing each time an annunciator alarmed and resumed it after operators completed the alarm response, one resumption of the briefing was interrupted approximately 5 seconds later when another annunciator alarmed. These alarms subsequently led
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-2-the supervising operator to direct the engineer conducting the procedure briefing to continue while the supervising operator and two operators conferred on plant conditions. After observing these multiple annunciations, the inspec*or asked the snift supervisor if the current plant conditions supported the conduct of such a major briefing. The shift supervisor responded by interrupting the briefing and statir g the expt.ctation that the briefing only continue if plant conditions permitted it. The supervising operator subsequently stopped the briefing and delayed it for aprioximately 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> while operators realigned component cooling water to stop the frequent alorms.
Shift supervisors and operations management responded to the inspector's observations and took action to m;nimize control room distractions. The shift supervisors and supervising operators limited the number of personnel in the control rtiom adjacent to the control boards and only authorized activities in the control room that did not interfere with the reactor operators' ability to monitor the control boards, c.
Conclusions Safe and controlNd plant evolutions were effectively supported by consistent use of three way communication by all operators. During the first week of Refueling Outage 9, control room operators permitted activities that challenged their ability to monitor the control boards. After the inspectors raised this concern, operators
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responded by implementing effective controls on potentially distracting activities.
01.2 Inadeouate Ooerability Evaluation Documentation a.
Insoection Scope (71707)
The inspectors reviewed an operability evaluation for Centrifugal Charging Pump A discharge piping drain valve and 'lange, b.
Observations and Findinas The inspectors reviewed the control room log entries and the operability evaluation required by Procedure AP 26C-004, Technical Specification Operability, Revision 1, completed by tho shift superviur on October 16,1997, regarding a potential problem that was discovered during an engineering / maintenance walkdown of Centrifugal Charging Pump A and associated discharge piping.
The problem description in PIR 97-3217 stated that Valve BG V0375, the Centrifugal Charging Pump A discharge drain valve, was improperly configured and supported. As a result, thu drain flange appeared to be resting on the floor. The operability evaluation determined that the valve and valve flange were operable, but did not provide an adequate basis for this conclusion. PIR 97-3217 described the pipe support looseness as causing not only a lateral gap betweea the pipe and the
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-3 support, but also axial rotation of the flange and valve body. The operability evaluation only addressed the operability impact of the lateral gap in the support and the consequential effect of this gap on_the flange.
After the inspectors questioned the basis for the operability determination,.
operations and engineering personnel explained that civ;l engineering personnel
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performed an engineering judgement evaluation of the configuration and informed the shift supervisor that the valve, pipe, and flange had adequate support. -The-inspector subsequently reviewed the engineering evaluation with engineering personnel and cor.cluded that the evaluation was adequate, c.
, Conclusions The licensee performed an adequate but inadequately documented operability evaluation of a centrifugal charging pump drain flange that appeared to be inadequately supported during an engineering and maintenance field review.
Operational Statut of Facilities and Equipment O 2.1 Emeroency Diesel Generator Material Deficiencies a.
Insoection Secoe Inspectors pe: armed detailed inspections of the emergency diesel generators approximately 15 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br /> after the -tart of the 24-hour surveillance run required by Technical Specification 4.8.1.1.2.g.(6),
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Eindirigs and Ob_servations
, On October 5,'1997, the inspector noted that Emergency Diesel Generator A exhibited an intake manifold air leak and observed that the rubber gasket protruded out from under the clamp that held the intake manifold sections together at Cylinder 13. On October 7,1997, the inspector noted that one of the four fasteners holding the jacket water inspection port cover on Cylinder Head 13 of Emergency Diesel Generator B had vibrated loose and backed out approximately 3/4 inch.
The licensee evaluated both conditions and determined that neither condition affected the. operability of the diesel generators. The basis for the intake manifold leak operability determination was the considerable air intake margin and the small s
size of the leak. The basis for the loose bolt operability determination was the f act that.the remaining three bolts remained tight and the cover did not leak. The inspectors reviewed the licensee's operability. evaluations and concluded that they
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-discovery of the loose bolt and Action Request 24419 following the discovery of the air. leak and protruding gaske..
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Conclusions--
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operation demonstrated inadequate _ attention to' detail by not noting two material:
.-condition issues _ that were ' subsequently ' identified by the inspectors.
Operations Procedures and Documentation 03.1: Untentrolled Ooerator Aid a.
Insoection Scope (7QQL-1
'The inspector noted one example where operators used an annotated plant dr.1 as an operator' aid, without the controls required by administrative' procedures, b.
' Observations and Findinas un October 8,1997, the inspector noted that operators had a laminated copy of
- Drawing EID-OOO3 in the control room for ready reference and use to correlate levels _in the pressurizer with levels _in the refueling cavity, reactor vessel, and
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reactor coolant system. The inspector noted that Instrumen BB Ll1462,_ wide range cold pressurizer level, was calibratad in inches, while Drawing EID-OOO3 listed the levels in percent. The inspector as6 t < the operators what the pressurizer level was and received a response in inches. Operators were not able to immediately providc a correlation between that and the percent levelin the pressurizer, in response to the inspector's inquiries, the operations managir directed the shift engineer to calculate the appropriate correlation between inches and percent and provide a tool so that the operators could eficctively utilize this drawing. The-inspector noted later that this cahlation had been completed and markings on this drawing had been made to provic s this correlation. The licensee also initiated PIRs 97 3127 and -3442 to address these concerns. On October 22,1997, the inspectors noted that these markings were still on this drawing and that operators used and referred to this drawing to assist them while operating the plant. While
. operators used a reference mark on the tygon tube levelindicator to monitor and control level in the refueling cavity, the inspectors observed operators refer to this drawing while making operating decisions. After the inspector questioned whether the use of this drawing in this manner was appropriate, the shif t supervisor directed operators to remove the annotated drawing _from the control room.
Procedure AP 21D-003, " Control of Information Tagging," Revision 1, Step 6.6.10, requires each operator aid to be approved by the shift supervisor. The annotation and use of Drawing EID 0003 as an operator aid, without the approval and control required by Procedure AP 21D-OO3, is a violation of Technical _ Specification 6.8.1.a.
(50 482/9719-01).
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Conclusitns The inspector noted operators using a plant drawing with uncontrolled handwritten information to provide necessary information in support of plant operations.
' Operator Knowledge and Performance 04.1 Bod Position Indication a.
Insoection Scoog The inspector reviewed the cause and licensee's response to unexpected control
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rod motion.
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Observations and Findinas Beginning at 9:25 p.m. on September 20, Control Bank D, Group 1, control rods experienced an outward demand signe.1 from 231 steps four times in the following 26 hours3.009259e-4 days <br />0.00722 hours <br />4.298942e-5 weeks <br />9.893e-6 months <br />. The demand signal was not attributable to a condition that the rod
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control system should have responded to with outward rod motion. The result was an indicated demand position of 232 steps for Group 1 and 231 steps for Group 2.
However, control rods were not physically able to exceed 231 steps, resulting in a-one half step mismatch between Control Bank D, Group 1, actual and demand position. On each occurrence, operators manually inserted Group 1 control rods one step. As a result, the Control Bank D, Group 1, step counter indicated 231 steps while the actual position was 230 steps. The operators were not aware of the mismatch between actual and indicated control rod position.
The lack of a questioning attitude toward unexpeved control rod movement demand signals and lack of knowledge about the rod control system while operating with control rods fully withdrawn in a normal configuration did not meet management's expectations.
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At 11:20 p.m. on September 21, operators identified that the rod insertion limit display on the plant computer indicated that Control Bank D, Group 1, control rods indicated 230 steps, which disagreed with the 231 steps indicated on the step counter. At 11:53 a.m. on September 23, operators contacted reactor engineering who, after some discussion, decided to begin monitoring and/or investigating the following day. At 11:42 a.m. on September 22, reactor engineering recommended that operators withdraw Control Bank D control rods until the Bank D full withdrawn alarm (ANN 82F) was received. This allowed the use of an existing alarm response procedure to restore Control Bank D rod position indication to expected values.
Operators followed the recommendation and restored Control Bank D rod position indication _to expected values by driving Group 1 rods out to the alarm setpoint.
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The delay in responding to the rod control system problem and the response to address the problem did not meet management's expectations.
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On' September 23, after prompting from the inspector, reactor engineering initiated PIRs 97 2905, 2906, and 2907 to document the problems with the rod position indication mismatch.
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Conclusions The licensee's response to an undefined problem with the rod control system, the primary means of reactivity control, did not meet with NRC or management expectations. Operators demonstrated a lack of a questioning attitude and lack of system knowledge when responding to repeated unexpected occurrences of outward control rod demand signals and a step counter rod-position indication mismatch.
Quality' Assurance in Operations 07.1 Monitorina of Human Performance a.
Inspection Scope (40500)
The inspectors reviewed the licensee's methods for monitoring, tracking, and
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evaluating human performance.
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Observations and Findinas The licensee's principal instrument for documenting human performance continued to be the PIR. As a PIR was initiated, the central work authority screened the request for system operability, reportability, and significance and assigned it to a responsible manager if additional action was required. The request was also sent to the performance improvement and assessment group for review, where the information was assessed for generic implications. PIR information was also trended in the licensing and corrective actions department, which was created in a reorganization that occurred September 15,1997. The licensing function remained under the engineering department until af ter the current refueling outage (approximately December 1,1997). This department was also tasked with tracking, trending, and improving human performance.
Each department had an assigned PIR coordinator who.was tasked with processing of the request through completion. A major task of the coordinator was the identification and assignment of cause codes to the request upon closure of the
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request. The coding of the closed PIR provided the basis for analysis of the issue and fed into the data utilized for subsequent determination of whether additional corrective actions would be applicable. Human performance errors would be identified, and subsequently trended, as a iesult of this process. The coding information from all PIRs was compiled by the trending analysts in the licensing and
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corrective actions department. Periodically, this data was analyzed as part of a common cause analysis, and corrective actions, if warranted, were recommended based on the reruits of the analysis.
The licensee maintained a human performance evaluation system with one trained coordinator, but the functions provided by the system had been incorporated _into the PIR system and, according to the licensee, the human performance evaluation system as a separate process was being phased out.
One common cause analysis had been completed and covered the first 6 months of 1997.- The results of the analysis were dependent on the accuracy of the PIR codes assigned by the department PIR coordinators. Given the complexity of the coding and the accuracy required, the licensee utilized the consultants that provided the initial training on human performance improvement to assist in the analysis.
Approximately 1200 PIRs had been closed and coded during the analyzed time period. The consultants identified that the cause codes had been improperly assigned, and thus the analysis would not be correct without proper codes assigned. From the original population of closed PIRs,200 were selected and recoded with consultant assistance. From this analysis, a list of recommended corrective actions was generated.
The licensee report discussing the common cause analysis was issued on September 10,1997. A letter to all employees was issued on August 22,1997, describing the analysis results and recommendations. During the inspection, it was apparent that some of the recommendations had been partially implemented, but as of October 23 no comprehensive action plan had been generated to revie 4, evaluate, or implement the recommendations.
Recommendations where at least partialimplementation was observed included communication of expectations, initiation of real-time performance indicators, and increased accountability. Several departments were in the discussion stages for developing handbooks, or similar methodology, regarding communication of expectations.
A second common cause analysis covering data from the third quarter of 1997 was in progress at the time of this inspection, in addition to the site wide system used to identify and correct human performance issues, each department had a system for tracking PIRs. These individual department tracking systems were not standardized and each department used their own system. The operations department tracking system was reviewed and found to be well developed. Guidance was provided in Procedure Al 28E-004, " Operations Trending," Revision 1. The trending methods for other departments were not reviewed, but the licensee informed the inspectors that the operations department trending system was more detailed than most other department specific trending systems, s
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? The inspectors reviewed the personnel error indicator yearly comparison for the -
. September 1997 Monthly Management Report. This comparison used a weighted
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scale which assigned points to various documents. A significant PIR was 1 point:
noncited violations were 1 point; licensee event reports were 3 points; LevelIV NRC violations were 4 points; and Level lli NRC Violations were 8 points. The inspectors noted that the cumulative weighted scale indicators for 1995,1996, and 1997 have been greater for each year's respective month. - Furthermore, the cumulative points for each month in 1997 have been approximately twice the points for the corresponding months in 1996.
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Conclusions The licensee has implemented a detailed site wide program for tracking and '
evaluating human performance errors. The success of the program was highly depoadent on the accuracy with which identified items were coded. This was not performed accurately for the first 6 months of data. No comprehensive action plan had been generated to review, evaluate, or implement the recommendations from the first common cause analysis of human performance errors.
t 07.2 Human Error Reduction Trainino a.
Insoection Scoce The inspectors reviewed the training provided to licensee employees as part of the human performance improvement effort.
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Observations and Findinas Training was made available to all site employees. All but eight employees had attended at least one of the formal contractor-designed training classes during the past year addressing the improvement of human performance. The course attendance varied according to individual position and duties. The courses offered included the following:
"A Comprehensive Course in Human Error Reduction for Individual
Contributors," a one-day course for all employees;
"A Comprehensive Course in Human Error Reductio, From a Supervisory
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Perspective," a 2-day course for supervisors;
" Seminar for Organizational & Programmatic improvements and Human Error
Reduction from a Management Perspective," a one-day course for managers;
"A Comprehensive Course in Advanced Prevention and Reduction of
Organizational & Programmatic Failures for Nuclear Power Plant Applications," a 4 day course for PIR coordinators (38 attendees).
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In addition to the training specifically for human error reduction, managers and supervisors attended training on improving management and supervisory skills (Management Analysis Results Corporation).
During interviews with employees (17), all expressed a heightened awareness to human performance problems as a result of the training provided. The employees indicated that expectations regarding performance were well communicated and
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understood. The inspectors queried severalindividuals specifically regarding expectations when difficulties or uncerteinty were encountered during conduct of work in the field. Allindicated that they were well aware of the expectation to stop, inform their supervisor, and receive clarificat;on or resolution prior to continuing the task Part of the human error reduction training package included reminder cards containing human error reduction information. The individuals specifically queried about the cards either had the cards on their person at the time or had them readily available. The individuals also indicated that their supervisors fully supported that philosophy, and they had no hesitation to stop their task if they
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Conclusions The licensee had conducted extensive training regarding human error reduction and personnel interviewed acknowledged a heightened awareness of human error prevention techniques.
07.3 Human Performance Measurino and Feedback a.
Insoection Scope The inspectors reviewed the licensee tools utilized to meature human performance and provide feedback to individuals.
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Observations and Findinas The licensee utilized several systems to observe and assess individual performance and provide feedback to the individuals regarding their performance.
The inspectors reviewed Procedure Al 30F-001, " Engineering Personnel Work Product Evaluations," Revision O. Engineering department managers recently developed the work product evaluation process. The procedure was issued in March 1997 and was a method to provide feedback to plant engineers on the degree to which engineering management's expectations were being met on assigned work. The work product evaluations emphasized " key concepts" developed from the licensee's review of significant events.
The key concepts were developed from a review of significant human performance events that occurred over the past several years, including the frazil ice event of
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- 10-January 1996. Tne licensee identified causes and contributing factors common to each of the events. The licensee then developed the key concepts to address each of the common causes. Some of the key concepts were:
Communication skills
Team work / cooperation
Ownership / responsibility
Professionalism
Reliability
Safety
Adherence to polic es and procedures
Engineering supervisors were required to perform at least one work product evaluation for each employee per calendar quarter. The inspector reviewed a sample of work product evaluations to determine that the work product evaluations were being performed as intended. The inspectors identified no concerns.
The inspectors interviewed several engineers who had received work product evaluations. All of the engineers found the work product evaluations to be a good way to communicate engineering management's expectations.
The inspectors noted that the engineering vice president had reviewed several work product evaluations and provided good feedback on the quality of the work product evaluations. Some work product evaluations were of good quality and others were not. For example, the work performance evaluation for Design Change Package 05711 (auxiliary boiler system modification) was an excellent evaluation with good specific feedback on expectations. On the other hand, the evaluation for Procedure STS PE-200 (test new containment penetration) was below expectations, with insufficir.nt feedback to enforce expectations to the employee. This evaluation was repeat 0d in an acceptabla manner. The inspectors agreed with the engineering vice president's comments and identified ro concerns.
The inspectors concluded that work product evaluation was one appropriate method to communicate engineering management's expectations on human performance.
e The quality of work performance evaluations varied.
The inspectors reviewed Procedure Al 28D-001, " Field Observation Program,"
Revision O. This program was initiated in early October 1997 and was a pilot program to provide a real time indicator of personnel performance. The program consists of a card containing 17 specific attributes that were evaluated as
" acceptable," " area for improvement," or "not observed." A space was also provided for comments. The program was intended for supervisors to frequently, at least once a week, evaluate specific tasks and individual performance in the field.
The information was then collected and compiled by the performance assessment department. The inspectors noted that a number of observation ferms had been
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11-completed and that the data was being collected. The licensee & knowledged that they were still early in the data gathering stage and an assessment of the data had not yet been performed.
The inspectors queried several workers as to whether they had been evaluated under the field observation program. While most of the individuals queried were familiar with the program, only two had been evaluated. They had not received any specific training on the use of the forms, and only one of the individuals interviewed had used one of the observation forms. In accordance with the program, they had been informed that they were being observed, but did not get any immediate feedback from the observer. The inspectors noted that the guidance contained in the procedure did not provide for on the-spot feedback to the individual.
Another program, initiated in September 1997, was the engineering assessment request. This program was not proceduralized and was being utilized primarily as a mechanism for operations personnel to assess the support they were receiving from engineering personnel. The assessment forms contained a list of 10 behaviors that were to be evaluated as " excellent," "satisf actory," "needs improvement," or "not observed." The behaviors assessed included questioning attitude, clear communications, documentation, timeliness of response, turnover, safety awareness, job scope understanding, thoroughness of answers, initiative, and teamwork. The data was collected daily and entered into a data base maintained by engineering. A manager was assigned to collect the forms and discuss with the shift supervisor any observations or concerns noted regarding engineering support.
Two shif t supervisors queried on the program indicated that they felt the program was useful as a mechanism to improve and ensure good engineering support.
in May 1997, the licensee issued the Wolf Creek Communication Plan to all employees. While this was not a specific assessment program, the plan provided a comprehsasive collection of the various methods used by the organization to communicate both internally and externally. The stated objective was to enhance and strengthen communications within the organization with an appraism of the communications program performed annually. A review of the plan by tne inspectors concluded that it was comprehensive and should promote effective communications, if implemented properly. Of the personnel interviewed and asked specifically about communications, responses were mixed, with some indicating that communications had improved, while others expressed a need for enhancing communications within the organization.
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Conclusions The licensee had initiated a number of programs in order to assess human performance on a real-time basis. These programs were very recently implemented and their effectiveness has yet to be determine..
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07.4 Review of Corrective' Action Documents
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Insoection Scope
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T_he inspectors reviewed 12 completed PIRs related to human performance errors for.
adherence to Procedure AP 28A 001, " Performance improvemeat Request,"
Revision 8.
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_Obserygions and Findinas The inspectors noted that the'PIRs clearly identified the problems. The inspectors reviewed the licensee's investigations into root causes and corrective actions. The inspectors found the licensee's investigations'to be acceptable, although minor administrative omissions were noted. The inspectors found the licensee's proposed-corrective and preventive actione to be acceptable. The inspectors noted that of 223 significant (Level I or ll) PIRs initiated in fiscal year 1997, most had been downgraded to nonsignificant (Level 111 or IV). For example,13 of the 19 PIRs
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initially classified as significant in September 1997 had been downgraded. The licensee acknowledged that the threshold for classification as significant was an area that needed addidonal guidance. Five significant PIRs were noted to be overdue in September. Level I and ll PIRs require the performance of a root cause analysis as part of the item resolution. The inspectors noted that there were 31 individuals qualified to perform root cause analyses end, with the inf.equency of
.the conduct of formal root cause analyses, this number may not support each individual maintaining proficiency through performance of a root cause analysis.
For Significance-Level I and ll PIRs, an effectiveness followup was required per Step 6.11.1 of Procedure AP 28A-001. The inspectors obtained a list of Level I and i
il PIRs for the operations department that were initiated during the past year. The inspectors identified that effectiveness followup reviews were not performed for two of the three PIRs, with effectiveness followup reviews due within the past year.
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An e,'setiveness followup review wts due for PIR 96-2966 on August 13,
1997. The effectiveness followup review was not performed.
i An effectiveness followup review was due for PlR 96 2989 on June 27,
1997. The effectiveness followup review was not performed.
The failure to perform the required effectiveness followup reviews is a violation of
10 CFR Part 50, Appendix B, Criterion V (50 482/9719-02).
The licensee subsequently identified approximately 35 additional Significance LevelI and 11 PIRs for which effectiveness followup reviews were not parformed. The-licensee initiated PIR 97 3346 to assess the generic implications.
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Conclusions Problems were clearly identified with acceptable determinations of causes and corrective actions. Reviews of the effectiveness of the implemented corrective actions were not performed as required for a number of PIRs.
07.5 Sionificant Meetinas a.
Inspection Scope The inspectors attended various plant meetings to determine the level of involvement of management and level of focus on safety.
b.
Plant Safety Review Committee On October 22,1997, the inspectors observed the weekly meeting of the plant safety review committee. The committee was chaired by the integrated plant scheduling manager. The inspectors noted that the committee conducted a detailed review of the items presented, including document revision requests, and provided an appropriate concern for nuclear safety. The inspectors reviewed the minutes from the previous week's meeting which included unreviewed safety question determination items. The inspectors noted the participat'on of the chief operating officer and the plant manager, c,
Corrective Action Review Board The inspectors observed four presentations made before the corrective action review board on October 22,1997. The board was chaied by the plant manager and its membership included senior management (chief administrative officer, integrated plant scheduling manager, and licensing and corrective actions manager).
The board aggressively exhibited a safety-conscious and questioning attitude and used the meeting as a means to clarify senior management expectations. The board emphasized the use of proceduralized protocols and clearly defined standards and iterated a requirement for the board to receive upcoming agenda item materialin advance of the meeting to allow ample time for detailed review. The board called for improved electrical troubleshooting techniques and interim protective measures prior to implementation of programmatic co rective actions. The board sent the reports which were presented back for adoitional work.
d.
Daily Manaaement Meetina
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The inspectors noted that the senior managers probed into status and planning regarding current plant status and activities. The meeting was well disciplined and afforded participating personnel a reasonable opportunity for feedback to management.
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Outane Safety Meetina The inspectors reviewed the agenda for the October 23 outage safety meeting.
Outage safety meetings were typically held during certain shift turnovers and as necessary. The reviewed meeting included examinations of four cases of inadequate human performance and encouraged discussion of means to prevent these types of errors.
f.
Conclusions The observed licensee meetings demonstrated an aggressive focus on safety with a good questioning attitude.
Miscellaneous Operations issues 08.1 Review of the World Association of Nuclear Operators Plant Evaluation Reoort a.
Insoection Scoce (71707)
The inspector reviewed the World Association of Nuclear Operators Peer Review Report, dated July 11,1997.
b.
Observations and Findinas The institute of Nuclear FJant Operations used the 1997 Wolf Creek World Association of Nuclear Operators Peer Review as their basis for their regularly scheduled plant evaluation. During the inspection period, the inspector reviewed the resulting report and found that the findings were generally consistent with recent NRC inspection issuer..
c.
Conclusions -
The findings described in the July 11,1997, World Association of Nuclear Operators Peer Review were consistent with recent NRC inspection issues.
11. Maintenance M1 Conduct of Maintenance M1.1 General Comments on Maintenance Activities a.
[nsoection Scone (62707)
The inspectors observed all or portions of the following work activities.
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.104265,, Task 41 Main steam isolation v61ve accumulator ventingi 107032, Task 12 '
Install annunciator repeater relays and associated internal wiring in NE01 and NE03 114626, Task 1 NG004 load center inspection, cleaning and
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test 114730, Task 1-Emergency Diesel Generator B alternator.
inspection 114932, Task 1 -
Emergency Diesel Generator B lube oil
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cooler power pill repte::ement
'116305, Task 15 '
Postmaintenance testingfuel handling assembly
.116548 Motor-Operated Valve EHV88078 acceptance testing 117922, Task 3 Auxiliary feedwater pump turbine
' disassembly and inspection 122906, Task 3 Centrifugal Charging Pump B rotating assembly replacement MPE EOO90-02, Revision 28 Inspection and test of 13.8kV and 4.16 kV circuit breakers MPE GOOP-07, Revision 10 Motor control center / control rod cleaning MPM M0210-02, Revision.11 Auxiliary feedwater pump turbine disassembly & inspection b.
Observations and Findinos Except as noted in Sections M1.4, M1.5, M1.6, and M4.1, the inspectors found no concerns with the maintenance observed.
c.
Conclusions Except as noted in Sections M1.4, M1.5, M1.6, and M4.1, the inspectors concluded that the maintenance activities were being performed as required.
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M1.2 General Comments on Surveillance' Activities a.
Insoection Scope (62707)
'The inspectors' observed all or portions of the following surveillance activities.
STS IC 550A, Revision 8 Channel calibration steam generator wide range' -
level
- STS IC-890A and B, Revision.8 Met tower calibration-wind speed
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STS MT-008, Revision 8 Main steam safety valve settings STS MT-020, Revision 14 125 Volt DC battery inspection / charger operational test STS RE-018, Revision 1 Multiple rod-drop time measurement b.
Observations and Findinns Except as noted in Section M1.3, the inspectors found no concerns with the surveillances observed.
c.
Conclusions
- Except as noted in Section M1.3, the inspectors concluded that the surveillance activities were being performed as required.
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M1.3 Inadvertent Atmosoheric Relief _ Valve Actuation
a.
Insoection Scope (61726)
The inspectors witnessed and reviewed the licensee's response to an inadverteat opening of an atmospheric relief valve during main steam safety valve testing using the Furmanite Trevitest Method.
- b.
Observations and Findinas On September 30,1997, maintenance personnel performed Surveillance Procedure STS MT 008,' " Main Steam Safety Valve Settings," Revision 8. While
. preparing to test relief valves on Steam Line C, the mechanics shut Valve AB V0028, instrument root valve for Steam Line C atmospheric relief valve.
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The mechar'ic subsequently opened Valve AB V0028, causing a rapid pressure rate increase on Steam Line Pressure Transmitter AB PT0003, which generated a signal causing the Valve AB PV0003, Steam Line C, atmospheric relief valve, to open.
-The reactor operator noted the inadvertent lif t promptly and immediately responded i
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- Procedure STS MT-008 was categorized as a continuous use procedure and maintenance personnel used the controlled copy in the field. The mechanic
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referencing the procedure and signing for the completion of the proceoure ' steps did not go out onto the platform near the main steam safety valves and therefore did
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not have close communication _with the mechanic performing the procedure steps.
As a result, the procedure steps ware not closely followed in a stepwise fashion.
Procedure STS MT-008, Section 4.3, required the test perforr.iers to not operate the
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root valves indicated on Attachment C. A_ quality specialist observed these j
activities and noted the error. The cuality specialist did not question the_ mechanic,
- nor inform the control room, but contacted a maintenance planner to raise this concern. By the time the planner understood the concern, the atmospheric relief-valve had already lifted.
The shift supervisor directed maintenance personnel to stop the procedure and restore from the evolution. Operations personnel initiated PIR 97-2955.
Management directed an investigation and disciplined the appropriate workers.
After completing the investigation and initiating additional centrols as immediate-corrective actions, the licensee restarted Procedure STS MT-008.
The failure of maintenance personnel to comply with Procedure STS MT-003, Section 4.3, is a violation of Technical Specification 6.8.1.a (50-482/9719-03).
c.
Conclusions The failure of maintenance personnel to comply with their main steam safety valve testing procedure resulted in an inadvertent opening of an atmospheric relief valvs.
The quality specialist properly identified this error, but failed to raise the concern in
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an effective manner and, therefore, missed the opportunity to prevent the plant transient.
M 1.4 Uncosted Locked Hiah Radiation Area due to incomotete Maintenance a.
Insocction Scoce (62707)
The inspector reviewed the maintenance aspects associated with the discovery of
an unposted locked high radiation area. The remaining aspects were reviewed in NRC Inspection Report 50-482/97-20.
d b.
Observations and Findinas On October 12,1997, maintenance personnel replaced the filter element in the
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liquid radwaste evaporator feed filter. During the filter replacement, one of the filter i
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housing cover swing bolts failed, and the mechanics were not able to obtain a replacement bolt promptly. At the direction of outage control center personnel, the mechanics secured the cover with the~ remaining threa bolts and were to coordinate-
-with operations personnel to verify that the cover did not leak after returning the filter to service. Mechanics initiated Work Package 124337, Task 1, to repair the broken bolt, and closed Procedure MCM M7230 01, NSSS [ nuclear steam supply system] Filter Changeout," Revision 9. Since the broken bolt had to be replaced, the mechanics lef t the ladder in the filter houeng pit, left the hatch cover out, and
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exited the area. Operations kept the filter li. service after the leak check demonstrated that the cover did not leak with three bolts. As the filter removed e
particulates, the radiation levels rose tri 3 Rem per hour,'12 inches from the filter housing and 10 Rem per hour at the filter housing surface. ' After disenvering the unposted locked high radiation area, the licensee initiated PIR 97 3199.
Procedure MCM M7230 01, Section 8,4, required the mechanics to re-install the hatch cever over the e.quipment compartment. The failure of the maintenance
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personnel to complete this step prior to closing out the procedure is a violation of Technical Specification 6.8.1.a (50-482/9719-04).
c.
Conclusions The failure of maintenance personnel to reinstall a shield hatch cover over a radwaste fhter prior to closing out the filter replacement procedure led to operations personnel operating the filter without adequate shielding and resulted in an unposted locked high radiation area.
M1.5 Safetv-Related Batterv Insoections a.
hsoection Scoce (61726)
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The inspector observed two teams of electricians perform portions of the safety-related battery irisp?ctions following the capacity discharge test.
b.
Obs.grvations and Findinas
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On October 6,1997, electricians performed Procedure STS MT-020, "125 Volt DC Battery inspection / Charger Operational Test," Revision 14, on the NK12 and NK14 safety-related battery banks. A portion of this test involved a detailed inspection of
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the batteries.
One team of electricians inspecting the NK14 battery observed a number of unusual characteristics and raised questions regarding these observations. Engineering personnel provided the specifics of these observations to the battery vendor, who reviewed the information and provided technical guidance to resolve the concerns.
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Specifically, the electricians observed some lead flaking on a vertical member that connected the horizontal positive plates together, some pink material around some negative posts, a white ring around some negative posts, and a white material that appasred to have built up on some negative plates.
The inspector found that the team of clectricians inspecting the NK12 battery did not observe any of the unusual conditions that another team of electricians found -
on the NK14 battery. The inspector subsequently found that some of the conditions the electricians found on the NK14 battery also existed on the NK12 battery. The licensee initiated PIR 97 3352 to evaluate this concern.
The vendor concluded that none of these conditions affected current battery operation, but asked the licensee to monitor the lead flaking and the pink ring on a quarterly basis because these conditions could cause long term battery deterioration. The licer.see will revise Procedure STS MT-019, "125 VDC Class 1E Quarterly Battery inspection," to perform this quarterly monitoring, c.
Conclusiorn One team of electricians performed a very effective inspection of a safety-related
- battery and identified two conditions that warranted quarterly monitoring in the future. Another team performing the same inspection failed to identify similar conditions that were present.
M1.6 Differences Between Maintenance Practices and Technical Manual Guidance a.
Insoection Scope (62707)
The inspector noted 2 examples out of 19 maintenance and surveillance activities reviewed in which the maintenance practices differed from the associated vendor technical manual recommendations, b.
Observations and Findinas-On October 6,1997, during the intercell connector torquing required while performing Procedure STS MT 020, ~125 Volt DC Battery inspection / Charger Operational Test," Revision 14, the electricians used an opan end, 2-point wrench.
The vendor technical manual recommended that the electricians use a 6-point box
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wrench to ensure a good connection and avoid the possible breaking of the lead posts and connector bolts. The electricians looked in the tool room and found that there were no 6-point box wrenches on site. The electricians changed their practice
= and began using only the 12-point box wrench to complete the torquing. The system engiaeer evaluated this practice and concluded that, with appropriate care, this practice provided adequate assurance that good connections would be assured.
The licensee initiated PIR 97-3349 to evaluate this issue.
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' On' October 8,1997, while i erforming the Emergency Diesel Generator B alternator -
inspection, the inspector no.ed that the electrician sanded a flat spot on one of the brushes'using a back ar.d forward motion. The vendor technical manual provided-the following guidance:'"Do not sand-in brush with a back and forward motion.
Always sand them in the direction of rotation." The electrician acknowledged'that the practices differed ano was not aware of this technical manual guidance. The electrician modified the f achnique and completed the brush sanding in accordance
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with the vendor recommended guidance. The electrician's supervisor contacted the engineering window manager who concluded that this practice did not affect the function of the brush, particularly since the electrician finished the sanding in a-unidirectional rnanner. The electrician initiated PIR 97-3119 to document this concern, c.
Conclusions On two occasions the inspectors identified maintenance practices that differed from the vendor technical manual guidance. A subsequent engineering evaluation concluded that, in these cases, the maintenance practice would not impair future equipment operation.
M4 Maintenance Staff Knowledge and Performance M4.1 Debris in Containment a.
Insoection Scope (62707)
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Inspectors observed general housekeeping effectiveness in containment.
b.
Observations On several occasions the inspectors noted that, in general, housekeeping in containment had the potential to result in entry of foreign materialinto pleat systems. On one specific occurrence the inspectors noted debris which consisted of small pieces of wire and tie wrap ends within a few feet of the exclusion area boundary near the reactor vessel head lay down area. These small pieces could easily have been inadvertently kicked or knocked into the reactor cavity. The inspectors identified this condition to the containment coordinator and the outage manager who took steps to remedy the condition. The licensee initiated PIR 97-3522 to document this concern.
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O_n two separate occasions several days later, the inspectors again observed debris
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in containment near exclusion area boundaries which could have been knocked into the reactor cavity. On one occasion th'e inspector asked the foreign material exclusion monitor about some debris approximately 7 feet from the reactor cavity.
The monitor replied that detailed attention had been limited to 4-6 feet away from
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consisted of a kick plate and a hand rail sometimes augmented with a snow fence
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type barrier.
The inspectors also noted that maintenance conducted in the higher radiation areas near the reactor coolant system loops was performed without regard for housekeeping such that cleanup efforts could have resulted in unnecessary exposure to radiation.
c.
Conclusion The inspectors noted that ineffective housekeeping in containment provided the potential for migration of small pieces of debris into plant systems. In addition, maintenance conducted in the higher radiation areas around the reactor coolant system loops was performed without regard for housekeeping such that cleanup efforts could have resulted in unnecessary radiation exposure.
M8 Miscellaneous Maintenance issues f92902)
M8.1 (Closed) Insoection Followuo item 482/9624-03:. This issue involved the discovery of water in a barrel of safety-related oilin the warehouse and the subsequent response. NRC Inspection Report 50-482/96-24 concluded that the licensee had responded to the discovery of water in safety-related oil in a prompt and appropriate manner. The report also established further inspection / review of the associated generic issues associated with the results of the licensee initiated PIR 97 0039 of January 6,1997.
The licensee determined that the root cause for entry of water into the barrel of safety-related oil was a failure on the part of craft personnel to maintain Level C storage requirements on the particular barrel. A contributing factor was an inadequate procedure which resulted in the lack of inspection criteria for tool room attendants to receive oil back from the field versus the warehouse. The corrective actions approved by the corrective action review board included revision of AP 24E 002, " Maintenance Material Storage and Handling Procedure, Revision 0, and training of maintenance support and maintenance technicians.
The revision to Procedure AP 24E-002 was to include delineation of methods for maintaining Level C storage for oil drums, provision of inspection criteria for receipt of material to the oil storage area, and instructions to address materials requisitioned directly from the warehouse. The training of maintenance support and maintenance technicians was to include short-term instruction on the details regarding the specific drum and long-term training for these same groups who handle and store oilin the tool room and who requisition oil products from the warehouse directl (I
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22-l The inspector reviewed Revision 1 to Procedure AP 24E-002 and noted that, while the revision addressed the storage and inspection criteria for bulk lubricant containers, it did not address corrective actions for smaller portable containers used by tool room attendants to issue smaller quantities of bulk lubricants for use in the field. Through interviews with tool room attendants and maintenance personnel, the inspector determined th." training on the specific event surrounding water found in the oil drum and on the revision to Procedure AP 24E-002 was provided.
Throug' discussions by the inspector with maintenance personnel regarding the use of small portable bulk lubricant containers, it was determined that no clear expectation or inspection criteria governed the return of lubricants issued in small portable containers. The inspector noted that the failure to include storage and inspection criteria for small portable contair.ers used to issue bulk lubricants did not meet the corrective action plan approved by the corrective action review board and did not meet with management or NRC expectations. Once this was identified, maintenance personnel agreed that a revision to Procedure AP 24E-002 was in order and initiated On-the Spot Change 97-0432.
The inspector considers the on-the-spot change to Procedure AP 24E-002 to include inspection and storage criteria for small portable containers used for the issue of bulk lubricant, adequate for closure of Inspection Followup ltem 482/9624-03.
Ill. Enaineerina E1 Conduct of Engineering E1.1 Motor-Ocerated Valve Overthrustina a.
Inspection Sco3e (37551)
The inspector reviewed the licensee's response following the discovery of 8 motor-operated valves out of 46 that were tested during Refueling Outage 9 that were found to have. as found stem thrust values that exceeded the maximum allowable stem thrust ratings, b.
Observations and Findinas On October 7,1997, engineering personnel initiated PIR 97-3048 to document the identification of overthrust conditions on Valve EM HV8814A, Safety injection Pump A mini-flow recirculation valve, and Valve EM HV8835, accumulator injection cold leg isolmion valve, The as-found stem thrust values were 19,098 and 17,989 lbs, for Valves EM HV8814A and EM HV88% respectively. Engineering and maintenance personnel corrected the overthrust cc -iition by adjusting the torque switch in both valves and changing the spring pack in one valve. The as left thrust values were well below the original Limitorque actuator thrust ratin o
0 23-The engineering personnel performed an evaluation that determined that neither valve experienced an overthrust condition that exceeded 162 percent of the original Limitorque actuator thrust rating and, in all other aspects, met the assumptions of the Kalsi Engineering study that justified the acceptability of overthrust conditions
- within this range. The inspettor verified that all the assumptions of the Kalsi Engineering methodology were met for both valves and concluded that thew overthrust conditions did not damage the valves nor the actuators or affect their operation.
b The inspector asked engineering personnel why the overthrust conditions occurred.
The engineers explained that, since these actuator torque switch settings were completed, the stem lubrication techniques improved enough to lower the actuator stem coefficierd enough to cause the overthrust condition. The reason for this
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improved lubrication was the improved preventive maintenance training and preventive maintenance techniques. Since March 1993, when the licensee last performed diagnostic tests on these valves, the licensee began to completely remove all of the old stem grease and dirt prior to applying new grease to the stem.
Since 1993, maintenance personnel also began stroking the valve after cleaning and
lubricating all accessible portions of the stem, to complete the preventive maintenance activity on portions of the stem that had not been completely cleaned and lubricated prior to 1993.
Following this evaluation, engineering personnel reviewed the change in actuator to stem coefficient since tne last diagnostic test. The engineers found that, for approximately half of the valves tested during this outage, there have been notable reductions in stem coefficient that they attribute to improved stem cleaning and lubrication practices.
The six additional overthrust conditions were less significant than the two examples discussed above. Two were approximately 8 percent above the normal operating thrust limit for the actuator to yoke bolts, but below the seismic limit. The observed overthrust condition in these two examples was the result of a testing methodology that only opened the valve slightly, then reclosed it, resulting in a rapid acceleration followed by a rapid deceleration. Since this was not typical of normal valve operation, the higher seismic limits applied and bounded the observed thrust. The remaining four overthrust conditions were all approximately one percent above the limit and were bounded by available margin, c.
_Qonclusions Engineering personnel performed an effective evaluation and provided appropriate recommendations in response to the discovery of eight motor-operated valves which were found to have overthrust conditions during diagnostic testing.
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-C-24 E2 Engineering Support of Facilities and Equipment E2.1 - ' Containment Eouioment Hatch Missile Shield a.
Insoection Scope (37551)
The inspector noted and reviewed the licensee's response to the removal of a
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majority of the bolts from the ' containment equipment hatch missile shield with the'
plant in Mode 4.
b.
Observations and Findinos On October 5,1997, the inspector noted that the licensae removed a majority of the bolts from the containment equipment hatch missile shield with the plant in Mode 4. The inspector reviewed the licensee's response to a similar issue in 1994 as documented in NRC Inspection Report 50-482/94-10, Section 7.- The licensee
stated that they would review the missile shield bolting requirement and determine j
the minimum number of bolts needed to meet the safety requirement. The
inspector usked to review this evaluation. The licensee stated that this evaluation had never been performed.
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During a subsequent evaluation, the licensee determined that, with the bolts in place in Mode 4 on October 5,1997, the bolting was just barely adequate to support the shield during a seismic event. Under the maximum outward seismic force, the licensee determined that the lower supports would yield, but would not part and would thus be just able to provide adequate support.
At the end of the inspectico period engineering personnel were still working on minimum bolting requirements for the containment equipment hatch missile shield and planned to incorporate this information into appropriate procedures prior to the next refueling outage.
c.
Conclusions Engineering personnel failed to perform an evaluation they planned to perform in response to inspector questions in 1994 on the minimum bolting requirements for the containment equipment hatch missile shield. As a result, the licensee removed bolts while in Mode 4.
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o-2 5-IV. PlaDt Support R4 Staff Knowledge and Performance R4.1 Mechanic Use of an Internally Contaminated Gaune a.
Insocction Scope (71750)
The inspector observed a mechanic use an internally contaminated gauge on a clean system in a manner not permitted by the radiation work permit, b.
Observations and Findinas On October 5,1997, the inspector observed a mechanic use a vent rig with a pressure gauge to vent nitrogen from a main steam isolation valve accumulator.
Radiation protection personnel had labelied the gauge internally contaminated at some time prior to this work activity. After the mechanic began using the gauge, the inspector questioned whether the vent path could draw some contaminated material out of the gauge and blow it out into the room. The mechanic said that it was not likely and continued venting.
After the inspector left the area, the mechanic contacted radiation protection personnel and reported the use of the vent rig with an internally contaminated gauge. After confirming that the mechanic entered the radiologically controlled area using Radiation Work Permit 970009, Revision 0, the technician determined that the mechanic's use of the internally contaminated gauge was not permitted by the radiation work permit. The radiation protection technician directed the mechanic to stop using the internally contaminated gauge and to exit the radiologically controlled area. Rodiation protection supervision subsequently suspended the mechanic's access to the radiologically controlled area until the mechanic completed refresher training on radiation worker fundamentals. Radiation protection technicians surveyed the work area and found that the venting did not spread contamination.
Radiation protection technicians also surveyed the gauge and found that it had been internally contaminated. The radiation protection technician initiated PIR 97-3017 to address this issue.
The raechanic's use of an internally contaminated gauge while in the radiologically controlled area under Radiation Work Permit 970009 was an example of a violation of Technical Specification 6.11 (50-482/9719-05).
c.
Conclusions A mechanic's inattention to detail resulted in the inadvertent use of a contaminated gauge using a rediation work permit which did not allow the use of contaminated tool b o.
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-26 R4.2 Radioloaicallv Controlled Area Entry Without Reauired Dosimetry-a.-
Insoection Scone (717591 The inspector reviewed the circumstances associated with three' workers who entered the radiologically controlled area ~without the dosimetry reouired by the
= applicable radiathn work permits, b.
Observations and Finditiga On October 10,1997, a contractor exited the radiologically controlled area and logged out of Radiation Work Permit 972601.' The contractor removed a piece of -
equipment Som the radiologically controlled area that had not been released by radiation protection technicians. When the technicians informed the worker that the piece of equipment needed to be surveyed, the worker re-entered the radiologically-controlled area with the piece of equipment, without dosimetry, and without signing-onto a radiation woik permit. The radiation protection technicians escorted the contractor to the monitors so the contractor could properly exit the radiologically controlled area,-then surveyed and released the piece of equipment. Radiation protection supervision then suspended the contractor's eccess to the radiologically controlled area and initiated PIR 97-3125. The contractor's entry into the radiologically controlled area without signing onto a radiation work permit and
without dosimetry is an example of a violation of a violation of Technical Specification 6.11 (50-482/9719-05).
On October 26,1997, a worker logged onto Radiation Work Permit 970034 and entered containment without the alarming dosimeter required by the radiation work permit. The worker identified the lack of the dosimeter and returned to access control. Radiation protection supervision then suspended the worker's access to the radiological!y controlled area and initiated PIR 97-3418. The worker's entry into the radiologically controlled area without the required dosimettv is an example of a violation of Technical Specification 6.11 (50 482/9719-05).
On October 27,1997, e worker logged onto Radiation Work Permit 970009 and entered the radiologically controlled area without the required thermoluminescent dosimeter. The worker identified the error and returned to access control.
Radiation protection supervision then suspended the worker's access to the radiologically controlled area and initiated PIR 97-3433. The worker's entry into the radiologically controlled area without the required dosimetry is an example of a
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violation of Technical Specification 6.11 (50-482/9719 05).
In response to these issues, the superintendent of radiation protection and chemistry met with each of these workers and their supervisors and verified the completion of adequate retraining in radiation worker practices. The superintendent also imposed a ban on all talking in the access control area, except at the window where radiation workers discuss the radiological asoects of their work with the
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health physics shift technician or.other radiation protection personnel. - The superintendent also stationed an individual at the door into the raciologically '
controlled area for the remainder of the outage to verify that each individual entering the radiologically controlled area wore both_ a thermoluminescent and an alarming dosimeter.
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Conclusions Three iicensee identified examples of workers in the radiologically controlled area without dosimetry demonstrated that the licensee had not effectively resolved this repetitive concern.
.R5-Staff Training and Qualification RS.1 Just in Time Trainina
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Inspection Scope (71750)
The inspectors participated in the just-in-time training provided by health physics
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personnel to all radiation workers prior to the start of Refueling Outage 9.
b.
Observations and Findinas During September 1997, the superintendent of radiation protection and chemistry directed health physics personnel to provide training to all radiation workers prior to the start of Refueling Outage 9. The training included a 2-hour lecture on the radiation protection program and a practical training session which required all I-participants to enter the radiologically controlled area following an extremely thorough briefing on the radiation work permit and demonstrate their ability to properly don and remove protective clothing.
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The inspectors found that the lecture was adequate and provided several comments to the superintendent'of radiation protection and chemistry for iraprovement. The inspectors noted that the practical training in the plant was excellent. The instructors engaged each individual worker and provided an extremely detailed and thorough briefing on radiation work permits, survey maps, and protective clothing use, c.
Conclusions l
The licensee provided excellent "just-in-time" training to every radiation worker just prior to the start of Refueling Outage h...
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. 28 V. Manaaement Meetinas I. X1
' Exit Meeting Summary
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The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection on October 31,1997.. The licensee acknowledged the findings presented.
The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was-identified.
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. ATTACHMENT
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SUPPLEMENTAL INFORMATION
PARTI AL LIST OF PERSONS CONTACTgQ Licensee
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M. J. Angus, Manager Licensing and Corrective _ Action -
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G. D. Boyer, Chief Administrative Officer O. L. Maynard, President and Chief Executive Officer B. T.' McKinney, Plant Manager R. Muench, Vice President Engineering
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W. B. Norton, Manager, Performance Improvement and Assessment C. C. Warren, Chief Operating Officer INSPECTION PROCEDURES US.E.Q IP 37551 On:ite Engineering -
IP 40500 Effectiveness of Licensee Controls in Identifying, Resolving, and Preventing _ Problems IP 61726 Surveillance Observations IP 62707 Maintenance Observations IP 71707 Plant Operations
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IP 71750 Plant Support Activities IP 92902 Followup-Maintenance ITEMS OPENED CLOSED, AND DISCUSSED Ooened 50-482/9719-01 VIO Uncontrolled operator aid (Section 3.1)
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50-482/9719-02 VIO Effectiveness followup reviews not performed-(Section 07.4)
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50 482/9719-03 VIO Inadvertent Atmospheric Relief Valve Actuation (Section M1.1)
50-482/9719-04 VIO
' Unposted locked high radiation area due to incomplete maintenance (Section (M1.2)
50-482/9719-05- _ VIO Radiation work permit violations (Section R4.1)
Closed
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50-482/9624-03 IFl Water contamination of safety-related oilin the warehouse (Section M8.1)
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