IR 05000483/1986012
| ML20198J306 | |
| Person / Time | |
|---|---|
| Site: | Callaway  |
| Issue date: | 05/28/1986 |
| From: | Darrin Butler, Phillips M, Wohld P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20198J297 | List: |
| References | |
| 50-483-86-12, IEB-84-03, IEB-84-3, NUDOCS 8606030072 | |
| Download: ML20198J306 (10) | |
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U. S. NUCLEAR REGULATORY COMMISSION
REGION III
Report No. 50-483/86012(DRS)
Docket No. 50-483 License No. NPF-30 Licensee: Union Electric Company P. O. Box 149 St. Louis, M0 63166-Facility Name: Callaway Nuclear Plant, Unit 1 Inspection At: Callaway Site, Steedman, M0 Inspection C
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, 1986 CM f//(
Inspectors: Peter. Wohld Date S/2MN D vid S. Tutler Date
- [#f Approved By: Monte P. Phillips, Chief Operational Programs Section bate Inspection Summary:
InspectiononMay~Ttoutine,announcedinspectionofactlon))s'takenon 5-8, 1986 (Report No. 50-483/86012(DRS Areas Inspected:
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previously-identified open items, Bulletin followup, the effectiveness of licensed ope.rator training (IE Module 41701) and the effectiveness of non-licensed staff training (IE Module 41400).
Resul ts: Of the four areas inspected, no violations or deviations were identified.
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DETAILS 1.
Persons Contacted
- C. D. Naslund, Magager, Operations Support G.- L.. Randolph, Manager, Callaway Plant
- P.:T. Appleby, Assistant Manager, Support Services
- J. D. Blosser,. Assistant Manager, Operations and Maintenance J. R. Peevy, Assistant Manager, Technical Services
- J. M. Price, Superintendent, Training
- J. E. Davis, Superintendent, Compliance M. E. Taylor, Superintendent, Operations
- J. C. Gearhart, Superintendent, Quality Assurance - Operations Support
- M.. S. Evans, Senior Training Supervisor
- W. O. Jessop, Senior Training Supervisor
- R. E. Burris, Senior Training Supervisor
- E. M. Thornton, Quality Assurance Engineering Evaluator
- Denotes those in attendance at the exit meeting on May 8,1986.
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The inspectors 'also talked with and interviewed other members of the-licensee's staff during the course of the inspection.
2.
General The inspection' consisted of a review of events which had occurred during the period March 1,1985 through March 31, 1986, to determine the effectiveness of the training program, i.e., whether the training received before the event was sufficient to either prevent it or mitigate its effects.
In addition, the inspectors evaluated what modifications to the-training program had been made as a result of these. events to preclude recurrence.
The inspection was not designed to be an evaluation of the licensee's overall training program. This evaluation is currently per-formed by the Institute for Nuclear Power Operations (INP0) as part of the training accreditation process. At the time of this inspection,-all ten of the' licensee's training programs subject to accreditation had been accredited by INP0. These were (1) Non-licensed operator, (2) control room operator (RO), (3) senior control room operator (SR0), (4) shift technical advisor (STA), (5) instrument and control technician, (6)
electrical. maintenance personnel, (7) mechanical maintenance personnel, (8) radiological protection technicians, (9) chemistry technicians, and (10) onsite technical staff and managers. At the time of the inspection, only two other licensees had received complete INP0 accreditation.
The inspectors reviewed approximately 650 Incident Reports (irs) to determine if they were caused by personnel error; whether the personnel error was caused by c'eficient training; and, if any lessons learned from the event had been factored into the training program. All of the licensee's irs were categorized with respect to root cause, with one of the major headings being human. performance. The human performance heading was further divided into the following subheadings: (1) deficient procedures; (2) failure to follow procedures; (3) miscommunications; (4)
supervision; (5) work place deficiency; (6) deficient planning and scheduling;-(7) improper or inadvertent actions; (8) policy problems; (9)
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lack of knowledge or training; and (10) other.
In addition, the training subheading was further divided into received but not effective, none received, and other. The irs reviewed indicated that the licensee tended to focus on one root cause, rather than identify all items which might have contributed to the event.
In the future, the licensee should consider identifying all potential causes for an event on the IR.
3.
Licensed Operator Training Effec _tiveness (41701)
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a.
Review of Abnormal Events or Unusual Occurrences Of the 650 irs reviewed, the inspectors chose seven incident reports for further review as listed below:
Incident Report Number Description 85-146.
Reactor trip due to steam dump operation 85-148 Inadvertent PORV lifting 85-173 Inadvertent.JRV lifting-85-477 Dilution of RWST below TS concentration 86-054 Steaming shell side of heat exchanger 86-063 Failed to notify NRC per license rqmt 86-071 Failed to properly perform transformer swap Incident report 85-146 dealt with a reactor trip which resulted during the use of the steam dump. None of the operators had been trained on the rate compensating nature of the pressure drop signal prior to the event, and when the steam dump was suddenly opened, the rate compensation of the signal resulted in a full reactor scram and safety injection on potential " steam line rupture." As a result of this event, formal operator requalification training lesson plans were modified. In addition, the procedure used by the operators at the time was modified to include a caution statement.
Incident report numbers85-148 and 85-173 both dealt with the inadvertent lifting of the power operated relief valve (PORV) on the pressurizer at the cold overpressure protection setpoint (COPPS).
In these cases, a modification to the setpoints had been completed (CMP 84-226C), but none of the operators had been trained on the operational effects of the change that had been made. As a result, the technical specification curve and associated procedures which indicated the setpoint were in error. When the operators eventually referred to the setpoint curve, they were misinformed, and the PORV lifted when the setpoint was reached. Although the first operations crew to have this happen to them subsequently drew up their own curve and taped it near the instrumentation, a subsequent crew had difficulty reading the new curve which also resulted in an inadvertent PORV lifting seven days later. As a result of these events, the formal operator requalification training lesson plans were modified to create an entire lesson plan just on the COPPS.
In addition, part of simu-lator required training is the performance of the surveillance
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procedure which was being implemented by the operators in both instances when the PORV lifted. The effect of modifications on operator training is discussed below.
Incident report 85-477 dealt with the dilution of the RWST below Tech Spec minimum boron concentration when the operators began using a new filter bed, which had not been borated, to " clean up" the water in the RWST. Neither the procedures nor the training program addressed the need to ensure that the filter bed be borated prior to using it to recirculate the RWST. The initial review of this event by the training department ha indicated that there were no training implications; however, during the inspection, one of the formal lesson plans was targeted for modification to incorporate the inspector's concerns regarding training implications. Although the failure to borate the new filter bed was not a licensed operator responsibility, the subsecuent lack of determining whether the filter bed had been borated was an eperator responsibility. As a result of this event, the radwaste training program was to incorporate the specifics of ensuring that all filter beds for primary water include boration specifications.
In addition, the training department decided to modify lesson plan T61.06.11/S-24 to ensure that operators were aware of the boration status of filter beds prior to use.
Incident report 86-054 resulted in the steaming of the shell side of a component cooling water heat exchanger during a heatup evolution of the plant. No training in this evolution had been covered prior to the event, which was caused by a decision to heat up the plant during shutdown operations, e.g., while the plant was cooling down, a decision was made to heat back up to perform an LLRT on a check valve. The operators had forgotten to unisolate and leave shutdown cooling. No procedure existed for this operation. As a result of this event, the formal licensed operator requalification lesson plan was targeted for revision to address the details of this event.
Incident report 86-063 dealt with the failure to notify the NRC of inadequate environmental qualification of equipment as required by one of the conditions of the operating license. The training program in place at the time of this event did not address license condition reporting requirements, and neither did the procedure used by the operations staff to determine the reportability of events. At the time of this inspection, the licensee had not indicated that any modification to the training program would be made as a result of this event. Licensed personnel were made aware of the event and reminded to make required notifications through the requirement to review all Incident reports before assuming shift duties.
In addition, Callaway licensing personnel had informed the plant that compliance with license condition 2.F was no longer required to meet 10 CFR 50.49 requirements. Therefore, since the subject license condition no longer applied, training on its implementation was no longer necessary.
Incident report 86-071 dealt with the improper transfer of power from the auxiliary transformer to the startup transformer. This event was caused by skipping a step in the transfer procedure because the
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operators were in a hurry. The training program described the proper completion of this evolution. Although no modifications were made to the formal training program after this event, the Operations Superintendent issued a memo to all operations personnel reminding them of the necessity to follow all procedural steps.
Interviews with members of the operating staff involved in all of the above events indicated that the operators generally acknowledged the adequacy of training received. Operators were aware of their opportunities to input suggestions for revisions to the training program.
In most of the above cases, lack of adequate training could be partially attributed as the cause.
In all of the above cases, the formal training program was modified, if appropriate, to address the event and prevent its recurrence, b.
Licensed Operator Training The licensea's training program provided several means of disseminating information related to operating deficiencies and recent events to licensed operators. These means were: required readings, memos to personnel, and incorporation of lessons learned from past events into the classroom training subject matter.
Required reading consisted of two areas. One dealt with things which were required to be read as part of shift turnover.
Included in this list were all incident reports generated. Since any operational abnormal event would also show up as an incident report, every operator was, by shift turnover procedure, required to become aware of events at the time they occurred, rather than waiting for formal training.
The other form of required reading dealt with procedure changes. At the time of this inspection, the licensee was implementing a program of describing the significant changes to the procedures as part of the required reading package. Both forms of required reading were documented, although not the same way. Shift turnover required reading was documented on the shift turnover log sheet, whereas procedural change required reading was documented on the required reading attestation form which was maintained by the operations department.
For significant events where the licensee felt imediate corrective actions were necessary, a memo would be issued by the Operations Superintendent to all operations personnel.
If this was the result of some abnormal event or unusual-occurrence, the memo would be included in the incident report package that was maintained by the licensee's compliance department.
The licensee's formal training program for all operations personnel had been accredited by INP0, and as such included the basics of task analysis.
Instructors appeared to be well qualified, and were required to stand one operations watch per month as part of their training staff job. As part of the training department's procedures, all incident reports, LERs, modification packages, INP0 SOERs, and NRC correspondence were reviewed by the Senior Training Supervisors to determine if any modifications should be made to the formal
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training program.
If modifications were deemed appropriate, the specific lesson plan was marked up, and was required to be revised prior to the next class that would use that lesson plan. The training department maintained a listing of all courses which had been taken by personnel.
The licensee provided the following statistics regarding their license exam results for operators:
License type Year Number of Exams given
% Passed R0 1983
85 SR0 1983
85 R0 1984
100 SR0 1984
95 R0 1985
0 SR0 1985
100 Training records of several licensed operators were reviewed. All test scores reviewed indicated that the individual had passed all portions of the test and no remedial training was necessary.
Generally, trainee records were distributed throughout the plant such that the inspectors had a difficult time in completing their review of the records. Test scores were microfiched and stored outside the protected area in a different building from the training department.
Attendance lists for required lectures were stored at the training
. department, as was part of the documentation of required control-manipulations (the remaining portion being kept in a log in the control room). The most recent performance evaluation was maintained in the individual's personnel records with the personnel department.
Documentation of the completion of required readings was maintained by_the Operations Department. There was no location where all of the records required by 10 CFR 55 were brought together for an individual.
The inability to readily retrieve records based on an individual's name was identified as part of the licensee's Quality Assurance audit of the training program (Audit Report AD5A8511B).
Interviews with selected operators indicated that the records reviewed were repre-sentative of the training actually received.
- As a result of the search for records, the inspectors found that the term " annual" as used by the licensee was not compatible with the definition in the licensee's Tech Specs. The Tech Specs defined the term annual to mean at least once every 365 days, while the licensee interpreted annual to mean at least once within a 12-month cycle.
After considerable effort in putting together a listing of required operator manipulations, the inspector found that for several of the manipulations, the training interval had been in excess of 16 months, with one example stretching to 20 months. The licensee had been interpreting the term annual to mean at least once during the period May through the following April (May was used as the starting month
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as that was the month the operating license was issued).
In the case of the 20 month period, the licensee had performed the manipulation in May 1984 (May 84 to April 85 term) and in January 1986 (May 85 to April 86 term). This period did not appear to be in conformance with the intent of the annual training requirement. The meaning of the term " annual" as it applies to the licensee's operator requalification program is an Open Item (483/86012-01). This item will be forwarded to NRC Headquarters for resolution.
The licensee's program to ensure that modifications made to the plant are reflected in operator training was. examined in detail. As noted earlier in this report, all modification packages are routed to the training department to determine if training needs to be conducted on the modification; however, the training department does not see the package after it is completed in sufficient time to conduct training prior to the modification being considered complete. Therefore, although training will be conducted on the modification, it may not be conducted prior to the modification being placed in service.
Interviews with several of the operators indicated that they were not adequately trained on modifications which affected plant operations in a timely manner.
In addition to the modification described in section 3.a above, the individuals interviewed also referred to a modification which resulted in changes to the delta flux curves.
Based on the above findings, the following items should be considered for improvement:
The licensee should consolidate records on an individual basis
to ensure that all required training is completed and not missed as a result of a recordkeeping error.
The licensee should revise appropriate procedures to ensure that
operations personnel are trained on appropriate modifications prior to their being declared operable.
4.
Non-licensedStaffTrainingEffecti_v_ene_ss_(_4_14_0M Of the 650 irs reviewed, the inspectors chose the following eleven incident reports for further review:
85-200 Improper Safety Tagging 85-204 Failure to notify QC as required by procedure 85-238 Improper lubricant used on 0-ring 85-265 PROMS incorrectly inserted in sockets85-422 Improper calibration technique 85-428 Rx trip due to procedure noncompliance 85-453 Failure to declare fire detection system inoperable 85-379 Non UE contractor work on energized equipment 85-439 Non UE contractor Ice House Fire 85-125 Failure to follow standing order during EDG fuel tank refilling 85-416 Improper issuance of CC hold material.
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These eleven were in the areas of maintenance, contractors, and stores; and involved non-licensed operator, electrical maintenance, mechanical maintenance, and instrument and control technician. Supervisory and craft personnel were interviewed on selected irs.
Maintenance related irs chosen for further review were IR 85-204 (Elec),
- IR 85-238 (Mech), IR 85-265 (I&C), IR 85-422 (I&C), IR 85-428 (I&C), and IR 85-453 (Elec).
Interviews with craft personnel indicated that they were knowledgeable on applicable procedures and how to conduct maintenance activities. The irs were isolated cases and caused by personnel error.
Formal training would not have prevented their occurrences. Group supervision provided instruction to the individuals involved with these events. The individuals clearly understood their errors and how to prevent recurrence. However, as a result of these interviews, the inspectors determined that craft personnel felt the following training areas could be strengthened:
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Develop a print usage course on how to use the various types of prints, how to cross reference the different prints, and how to locate prints.
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Develop a plant systems training course on integrated systems operation. This should help communications between operations and maintenance.
Contractor related irs chosen for further review were IR 85-379 and IR 85-439. Union Electric had developed a policy to reduce non-Union Electric contractor irs. Contractors working within the site boundary were required to read a brief statement on plant practices and sign the statement.
In addition trained plant personnel were assigned to oversee the contractors when they were onsite.
Regarding Union Electric contractors, IR 85-200 was evaluated. The crafts were trained on safety tagging in the General Employee Training (GET) program. This IR appeared to be an isolated case and caused by personnel error. Formal training would not have prevented the incident. The individuals were instructed, and administrative procedure APA-ZZ-00401 was adequate for controlling contractor qualifications and record retention.
Stores related irs chosen for further review were IR 85-125 and IR 85-416.
The storeroom personnel were knowledgeable on applicable procedures and how to conduct storeroom activities. These irs were isolated cases and caused by personnel error.
Formal training would not have prevented the incidences. Group supervision provided instructions to the individuals involved. The individuals clearly understood their errors and how to prevent recurrence. However, the length of the on-the-job training program for storeroom personnel receiving off shift assignments appeared to be rather short. The inspector recomends a longer training program for these individuals prior to them being giver, off shift assignments.
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All of the personnel interviewed were qualified to perform their job assignments. Both formal and on-the-job training were provided to plant personnel.
Feedback between the plant personnel and the training department was good.
For example, IR 85-453 was caused by a procedural deficiency. The training departrcent developed and was conducting Power Block Fire Detection training for the electricians. The electricians stated that the module was well structured for their needs and the course will help them in the field. The non-licensed training program was meeting the regulatory bases for an acceptable training program.
5.
Licensee Actions on Previously-identified Open It_em_s
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(0 pen) Unresolved Item No. 483/85-007-01: Closure surveillance testing of normally closed check valves that perfonn a safety function in the closed position. Union Electric had agreed to periodically closure test check valves in this category and had developed procedures and already successfully performed testing on six of the valves. The following valves were on the list for testing:
Valve Number-Functional Description Test Procedure BG-8546A Pump Suction, RWST/CCP ETP-BG-0101A BG-8546B Pump Suction, RWST/CCP ETP-BG-0101B EM-8926A Pump Suction, RWST/ SIP ETP-EM-01001 EM-8926B Pump Suction, RWST/ SIP ETP-EM-01001 EN-V-0003 Pump Suction, RWST/ CSP ETP-EN-0101A EN-V-0009 Pump Suction, RWST/ CSP ETP-EN-0101B EJ-8730A RHR Heat Exchanger Discharge OSP-EJ-P001B EJ-87308 RHR Heat Exchanger Discharge OSP-EJ-P001A i
EJ-8958A Pump Suction, RWST/RHRP OSP-EJ-P001A EJ-8958B Pump Suction, RWST/RHRP OSP-EJ-P001B Test techniques and criteria were discussed and appeared to represent good engineering judgement in assuring acceptable valve function and specifying efficient test techniques. Additional documentation and review was needed of the valves included to be tested. The licensee agreed to provide a list of safety related check valves from which the review can begin. This
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item remains open pending the receipt of the list and check valve test program review.
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(Closed) Open Item No. 483/85007-02: Reactor cavity seals. Union Electric provided documentation showing verification of the reactor cavity seal gap field dimensions in correspondence dated March 11, 1986, from Mr.
K. R. Bryant to the NRC, and of Bechtel's evaluation of seal strength adequacy in Bechtel letter number BLSE-14076 dated June 25, 1985. The inspector discussed the information with the licensee and determined that the issues have been satisfactorily addressed. This closes the last of any items pending for the closure of Bulletin 84-03 on reactor cavity seals.
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All of the personnel interviewed were qualified to perform their job assignments. Both formal and on-the-jeb training were provided to plant personnel. Feedback between the plant personnel and the training department was good. For example, IR 85-453 was caused by a procedural deficiency. The training department developed and was conducting Power Block Fire Detection training for the electricians. The electricians stated that the module was well structured for their r.; ads and the course will help them in the field. The non-licensed training program was meeting the regulatory bases for an acceptable training program.
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Licensee Actions on Previou_ sly _ identified Open Items (0 pen) Unresolved item No. 483/65-007-01: Closure surveillance testing of normally closed check valves that perform a safety function in the closed
_ position. Union Electric had agreed to periodically closure test check valves in this category and had developed procedures and already successfully performed testing on six of the valves. The following valves were on the list for testing:
Valve Number Functional Description Test Procedure BG-8546A Pump Suction, RWST/CCP ETP-BG-0101A BG-8546B Pump Suction, RWST/CCP ETP-BG-0101B EM-8926A Pump Suction, RWST/ SIP ETP-EM-01001 EM-8926B Pump Suction, RWST/ SIP ETP-EM-01001 EN-V-0003 Pump Suction, RWST/ CSP ETP-EN-0101A EN-V-0009 Pump Suction, RWST/ CSP ETP-EN-01028 EJ-8730A RHR Heat Exchanger Discharge OSP-EJ-P001B EJ-87308-RHR Heat Exchanger Discharge OSP-EJ-P001A EJ-8958A Pump Suction, RWST/RHRP OSP-EJ-P001A EJ-8958B Pump Suction, RWST/RHRP OSP-EJ-P001B Test techniques and criteria were discussed and appeared to represent good engineering judgement in assuring acceptable valve function and specifying efficient test techniques. Additional documentation and review was needed of the valves included to be tested. The licensee agreed to provide a list of safety related check valves from which the review can begin. This item remains open pending the receipt of the list and check valve test program review.
(Closed) Open Item No. 483/85007-02: Reactor cavity seals. Union Electric provided documentation showing verification of the reactor cavity seal gap field dimensions in correspondence dated March 11, 1986, from Mr.
K. R. Bryant to the NRC, and of Bechtel's evaluation of seal strength
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adequacy in Bechtel letter number BLSE-14076 dated June 25, 1985. The
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inspector discussed the information with the licensee and determined that the issues have been satisfactorily addressed. This closes the last of any items pending for the closure of Bulletin 84-03 on reactor cavity seals.
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L_icensee Actions on IE Bulletins (Closed)-IE Bulletin 84-03, Refueling Cavity Water Seal: The licensee had competed all requirements of the bulletin and addressed all questions raised by Region III (see inspection report Nos. 50-483/85007 and 50-483/85014, and paragraph 5 of this report). Therefore, this bulletin is considered closed.
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Exit Interview The inspectors met with licensee representatives (denoted in Paragraph 1)
on May 8,1986, to discuss the scope and findings of the inspection. The licensee acknowledged the statements made by the inspectors with respect to items discussed in the report. The inspectors also discussed the likely informational content of the inspection report with regard to documents or processes reviewed by the inspectors during the inspection.
The licensee did not identify any such document / processes as proprietary.
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