IR 05000498/1999008
| ML20210U138 | |
| Person / Time | |
|---|---|
| Site: | South Texas  |
| Issue date: | 08/16/1999 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20210U130 | List: |
| References | |
| 50-498-99-08, 50-499-99-08, NUDOCS 9908200014 | |
| Download: ML20210U138 (23) | |
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ENCLOSURE l
U.S. NUCLEAR REGULATORY COMMISSION i
REGION IV
Docket Nos.:
50-498;50-499 License Nos.:
50-498/99-08;50-499/99-08 Licensee:
STP Nuclear Operating Company Facility:
South Texas Project Electric Generating Station, Units 1 and 2 Location:
FM 521 - 8 miles west of Wadsworth Wadsworth, Texas Dates:
May 17 to 21, and June 7 to 10,1999 Inspectors:
S. McCrory, Senior Reactor Engineer, Operations Branch W. Sifre, Resident inspector, Reactor Projects Branch A Approved By:
J. L. Pellet, Chief, Operations Branch, Division of Reactor Safety ATTACHMENT:
Supplementalinformation 9908200014 990816 ADOCK0500g4y0 PDR
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EXECUTIVE SUMMARY
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South Texas Project Electric Generating Station, Units 1 and 2 NRC Inspection Report No. 50-498/99-08; 50-499/99-08 The inspectors performed a routine core inspection of the corrective action program implementation at the South Texas Project Electric Generating Station, Units 1 and 2. An in-office inspection was conducted from May 17 to 21,1999, which was followed by an onsite inspection that was conducted from June 7 to 10,1999. The inspection was conducted in accordance with the guidance provided by NRC Inspection Procedure 40500.
The corrective action program was effective at identifying, resolving, and preventing issues that degraded the quality of plant operations. The inspectors determined that site personnel and management clearly understood the importance of this program.
Operations The licensee implemented a condition reporting and corrective action program that was
well understood by the licensee's staff, who exhibited very low thresholds for entering information into the process (Section 07.1).
The licensee's classification scheme and program performance trending resulted in
appropriate prioritization of reported conditions that led to timely and effective corrective actions. The small number of repeat problems demonstrated the overall effectiveness of the corrective actions. The licensee understood long-standing open actions and made reasonable progress consistent with the complexity and significance of the condition (Section 07.1).
The licensee adequately dealt with regulatory compliance issues that included a
comprehensive response to problems related to the employee concerns program (Section O7.1).
Maintenance The licensee experienced comparatively few repetitive maintenance rule functional
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failures and addressed them adequately (Section M7.1).
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The licensee appropriately controlled vendor and industry operating experience that
resulted in acceptable corrective actions. The licensee ensured that shift supervisors were promptly notified of operability and reportability issues and that evaluations were conducted in a timely manner (Section E7.1).
Plant Support The licensee implemented effective corrective actions in the area of radiation protection
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and developed a plan for further program enhancement (Section R7).
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Reoort Details Summary of Plant Status Both units of the South Texas Project Electric Generating Station operated at approximately full power during the entire inspection period.
I. Operations 07.
Quality Assurance in Operations O7.1 ~ Corrective Action Proaram a.
Inspection Scooe (40500) '
This inspection consisted of a review of the licensee's programs that were intended to identify and correct problems discovered at the facility. The inspectors reviewed over 1700 condition report summaries that related to risk significance systems, components, and operational activities, from a total condition report population of over 20,0000 generated over the last year. That sample also related to program performance
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indicators, such as prioritization and classification of condition reports, open condition report age, and repetitive issues. The inspectors selected over 89 condition reports for more detailed review that included the risk significant areas of main steam safety valve
- sticking problems, emergency diesel generator load stability occurrences, and human performance errors related to equipment clearance order processing. The review
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The identification and reporting threshold for adverse conditions,
The setting of problem resolution priorities that were commensurate with
operability and safety determinations, i
i Program monitoring used by the licensee to assure continued program
effectiveness, Program measurement or trending of adverse conditions, i
The understanding of the program by alllevels of station personnel,
The ability to identify and resolve repeat problems, and
Resolution of noncited violations, and other enforcement actions.
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b.
ObservatiGns and Findinos (1)
Threshold of Reporting The licensee generated approximately 20,000 condition reports in the year preceding the inspection. The licensee designated about 65 percent or 13,000 of these documented conditions as " conditions not adverse to quality."
The inspectors interviewed 15 individuals from the licensee's staff that included shift operators, maintenance technicians, design and system engineers, and line-and middle-level supervisors. The interviews covered several topics including thresholds for condition reporting. During interviews with the licensee's staff, all of the interviewees exhibited a very low threshold for initiating a condition report. The interviewees provided exampies of low threshold items that they had entered into the condition reporting system, which included burned out instrument lights, tracking vacation schedules, component filter replacements, etc. During the inspectors' review of the details of over 80 condition reports and over 1700 condition report summaries, they observed condition reporting thresholds similar to those reported by the licensee's staff.
In the April 1999 " CAP [Qorrective Action Erogram] Pedormance Effectiveness indicators" report, the licensee reported a negative trend with regard to regrading condition reports to a higher condition report classification level after review by the operational events group. During April 1999, the operation events group regraded 46 of 2049 condition reports,37 to a higher classification and 9 to a j
lower classification. When compared to the average numbers of 7 regrades per 1300 condition reports per month, this represented a change from about 0.5 percent to about 2 percent. None of the regrades resdted in raising the classification to a Significant Condition Adverse to Quality (see the discussion of
the classification scheme under" Priority of Resolution" below). The potential consequence of classifying a condition at too low a level was that it would receive a less rigorous root cause determination and a lower priority that could i
lengthen the time to complete corrective actions.
The licensee determined that the operational events group was applying the classification guideline more thoroughly than many CAP supervisors. The licensee conducted refresher training with CAP supervisors on the condition report classification guidelines. The May 1999," CAP Performance Effectiveness Indicators" report indicated that only 15 of 1191 condition reports (about 1 percent) were regraded by the operational events group,9 higher and 6 lower.
During their review of detailed condition reports and condition report summaries, the inspectors did not identify any conditions that should have been raised to a higher classification level. The inspectors determined that the licensee had effective checks and balances to ensure that conditions adverse to quality were properly classified and that recent corrective actions to address a negative reporting trend had been effectiv i-5-
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I (2)
Priority of Resolution The licensee determined the priority of problem resolution through their classification scheme which reflected the safety significance of the condition or event. The licensee gave the highest priority to conditions assigned as significant condition adverse to quality (SCAQ). Exam problem, and a loss of off site power in which an emergency diesel generator output breaker did not close. The next level, condition adverse to quality -
station (CAO-S), also focused on conditions of high safety significance.
Examples included several human performance errors on equipment clearance orders related to safety equipment or personnel hazard, and the main steam safety valve " wisping" leakage (discussed below). The main difference between SCAO and CAO-S condition report treatment was in the level of root cause investigation. The licensee performed an in-depth root cause investigation and determination for SCAO conditions and a less formal apparent root cause determination for CAO-S conditions. The condition review group (CRG) tracked the status of SCAO and CAO-S condition reports during weekly meetings. The group responsible for the corrective actions associated with a particular SCA CAO-S condition report had to obtain CRG approval to extend a due date. The CRG focused additional attention on the 10 oldest SCAO or CAO-S c reports during the weekly meetings. The licenseo classified conditions of low safety significance and lower priority as a condition adverse to quality -
department (CAO-D). An example was the emergency diesel minor load variations while operating in the test mode that did not affect emergency operation or operability. The condition not adverse to qua condition reports used for tracking purposes only.
The inspectors reviewed the list of condition reports greater than a year old.
There were about 460 ccndition reports over a year old. Most of these, about 70 percent, were between 1 and 2 years old. Of the condition reports over 2 years old, only about 69 remained open due to material conditions, of which only 6 were at the CAO-S level. The inspectors reviewed several of the older open condition reports in greater detail to assess the basis for them not being closed. Among the condition reports reviewed were 96-1816,96-1817, 96-15701,96-16224,96-16225,96-16226, and 97-6107, related to leakage past the main steam safety valves. The licensee characterized the leakage as
" wisping" and had evaluated operation of the units with this condition until resolution could be reached regarding the sticking condition observed in a number of other main steam safety valves before repairing the leaks. The safety-relief function of the valves had not been impaired by the small amou leakage as demonstrated through periodic surveillances to test the relief setpoint. In addition, the inspectors noted that the low leakage rate did not pose an exposure hazard at the site boundary. Through document review and discussions with licensee staff the inspectors determined that the bases for the older condition reports remaining open did not constitute untimely corrective l
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6-(3)
Effectiveness of Program The licensee's program required a review of the effectiveness of corrective actions 6 months after the completion of a corrective action or group of corrective actions. The inspectors reviewed several effectiveness reports in conjunction with other licensee internal audit and assessment reports regarding corrective action effectiveness. The licensee was in the process of preparing a negative effectiveness report regarding corrective actions taken to address a voltage imbalance on Emergency Diesel Generator 21. The problem was first observed during a surveillance test in December 1997. The licensee replaced the voltage regulator and an integrated circuit board. Tne problem recurred approximately a year later and was reported in Condition Report 99-41. The licensee instrumented the emergency diesel generator and determined that there was a bad contact in the potential transformer. The licensee determined that emergency diesel generator operability was not affected. Part of the subsequent corrective action was to instrument the emergency diesel generators during surveillance testing to improve the ability to detect problems that could be evaluated only when the emergency diesel generator was running. This was the only negative report regarding corrective action effectiveness noted by the inspectors.
The following discussion regarding the licensee's response to recognized human performance errors was a good example of the licensee's effectiveness in dealing with a complex issue that did not readily lend itself to traditional system or design engineering solutions.
The inspectors noted 51 condition reports generated over the past year related to human performance errors in the equipment clearance order (ECO) process.
This was approximately 31 percent of all condition reports related to human performance errors generated over the past year. The errors ranged from failure to properly fill out required paperwork, to discovery of energized equipment once maintenance activities had started, failure to fully restore systems after tag removal. As a result of the licensee's observed trends regarding ECO's, the licensee initiated an ECO enhancement task force in early 1998. The task force analyzed the performance errors and sorted them into different causal categories including knowledge errors (not understanding system design or operation and k
procedural requirements), human factors (design, installation, and environmental l
conditions), and choico errors (not using all available tools or bypassing process requirements).
The licensee developed and implemented several corrective actions to address human performance related to ECO's. The licensee made several enhancements to the Governing Procedure OPGP03-ZO-ECO1," Equipment
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Clearance Orders." The more significant enhancements included independent
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verification of virtually all components identified to be tagged in a clearance order, increased system walkdown requirements, and increased supervisory involvement. The licensee also revised and clarified the certification
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requirements for all phases of the ECO process. The licensee modified the computer data base software used to generate equipment clearance orders to prevent the system from generating the clearance for installation until all required reviews and approvals had been completed in the proper sequence. The licensee developed enhanced training and evaluation tools to measure performance for further training needs or program enhancements. The licensee made extensive use of the STAR (Stop Think Act Beview) trainer, and developed performance measures similar to the job performance measures used in the licensed operator training program. The STAR trainer provided simulated situations designed to challenge an operator's self verification skills regarding component identification and manipulation. The performance measures evaluated process knowledge and ability regarding preparation, review, and closure of equipment clearance orders.
Statistical information, developed by the licensee, demonstrated that significant human performance errors regarding equipment clearance orders had declined approximately 50 percent since the implementation of the corrective actions developed by the task force. Additionally, the licensee's "1999 Human Performance Composite index" showed an overall improvement trend in human performance.
(4)
Program Measurement The licensee used the monthly " CAP Effectiveness Performance Indicator Grade Sheet" with accompanying details as the primary means of measuring and reporting program performance. The licensee evaluated each of the following categories monthly:
Reporting threshold,
Timeliness and workload management,
Root / apparent cause determinations / corrective action (s) appropriateness,
Recurrence, a
Trending, and
Database / process implementation.
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Some of the specific metrics used by the licensee for these evaluations included:
Upper and lower investigation thresholds for the number of condition
reports generated each month, Number of classification level re-grades to a higher or lower level,
Timeliness of SCAO and CAO-S investigations (30-day goal),
Timeliness of condition report entry af ter condition identification (3-day
goal).
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8-Timeliness of supervisory reviews of newly entered condition reports
(3-day goat), and Number and age of actions overdue when closed.
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The inspectors reviewed the licensee's reporting threshold, root cause activity, and recurrence in connection with the inspection activities discussed in Sections 07.1.b.(1),07.1.b(3),07.1.b(6), and R7.1.b. Additionally, the inspectors assessed condition report and associated corrective action age, volume, and backlog trend as further indicators of program measurement.
The inspectors observed that the average age of an open condition reports designated as a " condition adverse to quality - department" (CAO-D) was about 200 days over the past year, and that the average age for CAO-S and SCAO condition reports during the same period was about 100 and 70 days, respectively. At the time of the inspection, the inspectors observed that the total number of open condition reports for CAO-D and higher levels was about 3100 with 94 percent at the CAO-D level. The inspectors determined that the total number of open condition reports at CAO-D or higher level was about 44 percent of the number generated over the past year. During interviews, the manager for the corrective action program stated that the average age and number of open condition reports had remained relatively constant over the past 2 years with comparable numbers of condition reports being issued each year.
The inspectors reviewed seven licensee audit and self-assessment reports generated over the past year regarding the condition reporting and corrective action program. The reports identified no significant issues. The inspectors determined that the audits and self-assessments contained appropriate breadth and depth.
The inspectors determined that the licensee used appropriate program measurements that allowed effective assessment of program performance.
(5)
Program Understanding During the interviews with the group of licensee staff noted in Section b.(1)
above, the inspectors questioned the interviewees regarding their understanding of the condition reporting and corrective action process. From memory, the interviewees consistently described a process that contained the significant requirements of Procedure OPGP03-ZX-0002," Condition Reporting Process,"
Revision 17. The group of interviewees included system engineers, task group leaders, and managers who had significant involvement with the issues related to the main steam safety valves, emergency diesel generator loading, equipment clearance order problems, health physics issues, and the employee concerns program. These individuals contributed significantly to corrective action determination, implementation, or tracking. All of them demonstrated a good understanding of the corrective action proces.g.
(6)
Repetitive Problems During the review of the 1700 condition report summaries, the inspectors looked for indication of repetitive problems. The inspectors performed a more detailed review of four areas with regard to repetitive problems. Human performance j
repetitive problems were discussed in Section b.(3) above and Section R7.1 below. Additionally, in Section M7.1 below, the inspectors repor1ed on repetitive maintenance rule functional failures. The inspectors reviewed in greater depth
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the following risk significant safety systems which the inspectors assessed as i
representative examples of the licensee's treatment of repetitive problems.
The inspectors interviewed the system engineer and reviewed the licensee's corrective actions associated with the repeated failures of main steam safety valves lifting higher than the setpoint during surveillance tests. Through analysis of test results, the licensee determined that the condition was limited to six valves that had been repaired to correct seat leakage. The repair process was to lap the valve nozzle to a mirror finish. The valves originally had gray finishes on both the nozzles and the discs. When the valve sticking condition was first identified in 1997 and documented in Condition Reports 97-1760,97-4410, and 97-6490, the licensee attributed it to the fact that only the nozzle was lapped to a
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mirror finish and not the disc. The prescribed corrective action at that time was to lap both seating surfaces to a mirror finish. This process was performed in Valves 7430A and 7430B in Unit 1. The licenses then retested the valves in April 1998, after 180 days of service. The valves lifted above the setpoint again.
The licensee wrote Condition Report 98-5270 and assigned it a SCAO classification level. A task force was assembled to determine the root cause and recommend corrective actions.
The licensee performed a detailed evaluation that included discussions with vendors and industry peers, who were experiencing similar problems. The licensee concluded that the problem was due to micro-galling of the mirror finished seating surfaces. The corrective actions were to lap the disc and
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nozzle to a gray (40 micron) finish and test the valves on a 56-day frequency to verify setpoint and oxidize the seating surfaces in an effort to prevent micro-galling.
In December 1998, Valve 7440 in Unit 2 (one of tha six repaired valves) opened
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above setpoint. The licensee resumed its investigation and through discussions with vendors and with industry peers, concluded that the difference in materials i
between the disc and nozzle could be contributing to the problem. The discs were made of 422 stainless steel and the nozzles were made of 316 stainless steel. The licensee concluded that there was enough difference in heat-i expansion behavior in the two materials that it would contribute to the micro-
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galling problem. The vendor recommended changing the disc material to inconel 750 because it was more compatible with the nozzle material.
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The licensee chose not to replace the discs until it had more fully evaluated the root cause and corrective actions, in February 1999, the licensee held a users group meeting with industry peers, vendors, and Electric Power Research Institute. As a result of this meeting, an Electric Power Research Institute
" Tailored Collaboration" was established to research the valve sticking phenomenon. The project involved collecting and analyzing test data from users and providing recommendations for correction and prevention. In addition,in April 1999, the licensee replaced the discs in Valves 7430A and 7430B in Unit 1 with discs made of inconel 750. The licensee did not plan to replace the discs in any of the remaining main steam safety valve's until the collaborative activities were completed and the results analyzed.
The inspectors reviewed a summary listing of condition reports related to the
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emergency diesel generators. The inspectors noted that there were several condition reports that appeared to be related regarding operating performance of the diesel generators. The inspectors interviewed the system engineer for the emergency diesel generators. The licensee initiated Condition Reports97-300, 98-10113,9812830,98-20059,99-3551, and 99-5497 regarding emergency diesel generator operating stability problems related to generated power or frequency. The system engineer provided a detailed description of each of the problems. Each of the problems had a different source and each affected the control circuits for parallel (test) operations, but not emergency operation of the diesel generators. All of the problems related to the speed controller. The speed controller design was the one that accompanied the original emergency diesel generator installation, in 1995, the licensee identified that the existing speed control system would become a maintenance burden due to age and lack of repair part support.
The licensee developed Modification 95-5765-8 to replace the analog speed controller with a digital one from the same manufacturer. The licensee installed the modification on Standby Diesel Generator 11 during Refueling Outage 1RE08 and scheduled the modification to be installed on all standby diesel generators by September 2002. The qualification process for the new speed controller and turnover of key engineering personnel contributed to the long lead time before the first installation of the modification.
The licensee demonstrated persistence in understanding and working toward a final resolution for complex problems, such as those discussed above, while maintaining an appropriate regard for operability and safety.
Additionally, the inspectors reviewed the timeliness of entering conditions into the reporting system, and determined that 95 percent of the over 22,000
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condition reports generated over the last 13 months were entered within 3 days l
of discovery. The inspectors concluded that reporting timeliness, coupled with very low thresholds for entering information into the system, often resulted in similar or repetitive problems being identified before corrective actions were formulated or implemented.
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(7)
Notice of Violation Followup The inspectors reviewed Condition Reports 98-4818,99-2674,99-5232, and 99-5374 related to enforcement actions that were either noncited, did not require a response to the notice of violation, or were still awaiting followup inspection.
The events and activities related to Condition Reports 99-5232 and 99-5374 were reported in inspection Report 50-498;499/99-07. Condition Report 99-5232 concerned performing work in an area before current survey information was J
available at the satellite health physics control point. Condition Report 99-5374 I
concerned workers being in the overhead cable trays without contacting health physics prior to performing work to obtain a survey of the area. The licensee held counseling sessions with the individuals involved in both events and reinforced performance expectations to all employees in the affected groups.
Additional corrective actions included updating survey copy books and placing facsimile machines at satellite control points for transmission of updated area surveys.
Condition Report 98-4818 related to a notice of violation described in NRC
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inspection Report 50-498; -499/98-04. The violation cited a failure to obtain NRC permission to revise the facility final safety analysis report due to an unresolved safety question. When an error in the calculation for dose received in the control room and technical support center was corrected, the resulting dose increased from 22.67 rem to 23.26 rem. In a letter to the NRC dated May 13,1998, the licensee denied that a violation occurred in part because the new result was still bounded by General Design Criteria 19 of Appendix A of 10 CFR Part 50. At the time of the inspection, the licensee stated no corrective actions were warranted or planned prior to receiving the NRC response to the denial. The inspectors determined that the violation, even if sustained, represented an issue of little or no safety significance and that the licensee's decision to await the agency's response before determining or taking corrective action was acceptable.
Condition Report 99-2674 related to a notice of violation described in NRC Inspection Report 50-498;- 499/98-15. The violation cited a failure by the licensee to declare Unit 1 Channel lli 125-volt Battery Bank E1811 inoperable following a 7 hour8.101852e-5 days <br />0.00194 hours <br />1.157407e-5 weeks <br />2.6635e-6 months <br /> discharge when Train B 4160 volt bus, Switchgear E1B was de-energized due to a fire in the switchgear. In a letter dated March 10,1999, the licensee denied the violation, but reported the completion of several corrective actions. The NRC's letter of May 28,1999 sustained the violation, but acknowledged that the wrrective actions were responsive to the violation and required no further action by the licensee. The licensee stated that no further l
corrective actions were planned as a result of the sustained violation. The inspectors confirmed the implementation of the corrective actions contained in the licensee's March 3 letter and determined that they were adequate.
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-12 Employee Concerns Proaram Review The inspectors also reviewed the licensee's actions to address the commitments stated in the June 9,1998, Confirmatory Order (EA 97-341). The Order documented the following commitments:
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Conduct a " Comprehensive Cultural Assessment" survey and document any plans necessary to address issues raised by the survey results.
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Conduct annual ratings of supervisors and managers by employees utilizing the licensee's " Leadership Assessment Tool."
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Conduct the following mandatory training for all supervisors and managers.
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Scheduled training on building positive relationships with the objective of reinforcing the importance of maintaining a safety conscious work environment.
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Annual training on the requirements of 10 CFR 50.7 including, but not limited to, what constitutes protected activity, what constitutes discrimination, and appropriate responses to the raising of safety concerns by employees.
4.
Issue a site wide publication to inform the employees and contractor employees of the Confirmatory Order and their rights to raise safety concerns to the NRC and their management without fear of retaliation.
Comprehensive Cultural Assessment The inspectors reviewed the results of the comprehensive cultural assessment conducted in June and July 1998. The assessment consisted of a survey questionnaire and employee interviews. Approximately 80 percent of the South Texas Project workforce responded to the survey and a representative cross-section of approximately 50 employees were interviewed. The assessment was divided into three main focus areas: Nuclear Safety Culture, General Culture and Work Environment, and Leadership, Management and Supervision. In general, the assessment results indicated that the licensee has a strong safety culture with 99.5 percent of respondents indicating that they felt a responsibility to identify and write condition reports. In addition,98.7 percent stated that they would inform their supervisor of adverse conditions and 96 percent indicated that they would be supported by their supervision for having done so. The survey also indicated that 92.3 percent of employees feit they would be supported in reporting issues to the employee concerns prograrn (ECP). There were no nuclear safety items identified as requiring additional management attention.
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- 13-The assessment results for the two remaining focus areas were generally positive with the following items identified as requiring additional management foces:
General Culture and Work Environment:
Communication and reinforcement of vision and values, I
Increasing trust in management,
Workload and resource management,
Compensation Programs, and
Rewards and recognition.
- Leadership, Management, and Supervision:
Consistency in quality of supervision,
Performance evaluation,
Change management, and
Workload and resource management.
- The inspectors reviewed Condition Reports 98-17935,98-98-17956,98-17956, 98-17959,98-17960,98-17961, 9817962, and 98-17963, which were written to track actions to addres:$ the corrective actions for the items identified by the comprehensive cultural assessment in each division. Each division held employee feedback sessions to clarify survey response and develop action plans. The action plans included followup surveys and mini-surveys to measure
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plan effectiveness. The inspectors considered the licensees approach to correcting the identified focus areas to be appropriate.
Leadershio Assessment Tool The inspectors reviewed the licensee's leadership assessment tool and found that the results were consistent with the comprehensive cultural assessment.
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reports, the inspectors found that the licensee's actions to address identified
deficiencies were reasonable.
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i Mandatory Trainina
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The inspectors reviewed the training booklets and attendance rosters for the j
" Safely Speaking" course described in the licensee's commitments to the June 9,
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1998, Confirmatory Order. The course discussed the basic characteristics of a safety-conscious work environment and specific method for raising, receiving, and resolving concerns. In addition to generic industry practices the material reenforced site expectations and policies for raising issues and the corrective l
action program. The material also included lessons learned. The licensee taught the course in 13 training sessions during April, May, and June 1998. All site supervisors and managers attended the course.
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-14-The inspectors reviewed the lesson plans and attendance rosters for the licensee's 10 CFR 50.7 training for managers and supervisors. The training covered the following specific topics as specified in the Confirmatory Order:
The requirements of 10 CFR 50.7,
What constitutes discrimination,
What constitutes protected activity,
The appropriate response to the raising of a safety concern, and
The importance of maintaining an environment where employees feel
free to raise safety concerns without fear of retaliation by their supervisors and managers.
The licensee held the training in several sessions from January through March 1999 and all site supervisors and managers attended.
The inspectors interviewed the sample of the licensee staff described in Section b.(1) above and asked them to describe their personal threshold to bring concerns or issues to the ECP. The interviewees consistently stated that they would try to exhaust all other means, e.g., the condition reporting process or escalating the concern through the supervisory and management chain, before bringing a matter to the ECP. None of the interviewees had used the ECP and did not know first-hand of anyone who had. Further, none of the interviewees were aware of any problems arising from employee use of the ECP over the past 2 years. However, all the interviewees expressed confidence in the program and no hesitation to use it if necessary.
c.
Conclusions The licensee implemented a condition reporting and corrective action program that was well understood by the licensee's staff who exhibited very low thresholds for entering information into the process.
The licensee's classification scheme resulted in appropriate prioritization of reported conditions that led to timely and effective corrective actions. The small number of repeat problems demonstrated the overall effectiveness of the corrective actions. The licensee had a good understanding of long-standing open actions and was making reasonable progress consistent with the complexity and safety significance of the condition.
The licensee applied adequate program metrics to allow effective measurement and trending of program performance.
The licensee adequately dealt with regulatory compliance issues and responded comprehensively to problems related to the ECP.
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-15-II. Maintenangg M7
- Quality Assurance in Maintenance M7.1 Maintenance Rule a.
Insoection Scoce (40500)
An in depth inspection of the licensee's implementation of the maintenance rule was conductad March 23 to 27,1998. That inspection determined that the maintenance rule had bears adequately implemented by the licensee. Therefore, this inspection limited its focus to repetitive maintenance rule functional failures.
b.
Observations and Findinas in the May 1999, Effectiveness Performance Indicator Report," the licensee reported some decline in the use of the corrective action program data base and process regarding repeat issues. The inspectors reviewed the list of repetitive maintenance rule functional failures that had occurred since January 1,1998. The list contained 33 items that related to nine different systems or components that included instrument air, emergency diesel generators, main steam safety valves, and steam generator power operated relief valves. The inspectors reviewed the eleven items related to steam generator power operated relief valves due to their safety significance, and the fact that others such as the main steam safety valves and diesel generators had already been reviewed.
The steam generator power operated relief valves provided a flow path to permit reactor coolant system cooldown during a small break loss-of-coolant accident with the main condensers not available. The steam generator power operated relief valves had experienced a number of failures in the pressure switch diaphragm that were discovered and reported in the period of April to June 1998. The failure of the diaphragm caused the nitrogen accumulator to slowly depressurize. This caused remote or automatic operation of the valve to rely solely on the hydraulic pump assist. A loss of electrical power with a depressurized accumulator would cause the valve to fail shut, which would require local manual operation of the valve for cooldown purposes.
The diaphragm failures did not affect the technical specification operability of the steam generator power operated relief valves. The inspectors reviewed the South Texas Project Technical Specifications and Final Safety Analysis Report and determined that
- the nitrogen accumulators were not included the required safety grade components of the valve. i-16-The diaphragm was made of a Teflon coated polyimide material. The vendor-performed post-manufacture testing of the pressure switch for qualification and verification resulted in a change in the performance characteristics of the diaphragm that had the effect of premature aging and early failure. The licensee replaced the pressure switches with ones that had a stainless steel diaphragm under Design Change Package 95-10256 once the failure mechanism was understood and an equivalency determination was made. The problem did not recur after the installation of stainless steel diaphragms.
As a result of a problem identified at another facility, the inspectors reviewed the licensee's tracking of fuse failures for identification and evaluation of repetitive failures.
The licensee's threshold for documenting fuse failures was to enter 6very failure into the condition reporting system. The inspectors reviewed a list of fuse failures from January 1,1997, that contained 33 entries. The inspectors did not identify any adverse trends or repetitive problems.
c.
Conclusions The licensee experienced few repetitive maintenance rule functional failures and addressed them adequately.
Ill. Enaineerina E7 Quality Assurance in Engineering Activities E7.1 Vendor information and industry Operatina Exoerience a.
Inspection Scope (40500)
The inspectors reviewed a summary report of 60 condition reports that were written to track the screening of industry operating experience reports for applicability to South Texas Project. The inspectors reviewed the licensee's dispocition of six condition
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reports associated with vendor information and 17 condition reports that had been identified as applicable to the site between January 1998 and May 1999. The inspectors also reviewed the results of an operating experience effectiveness review performed by industry peers in February 1999. The inspectors interviewed engineering and operations personnel and the operating experience group manager about the licensee's
program for review and disposition of operating experience and vendor information.
Specific aspects of the licensee's industry operating experience activity were:
Threshold for placing issues in the corrective action program,
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Assessment of the immediate impact on the facility and the determination of
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equipment operability, Effectiveness of immediate and long-tem corrective actions, and reportability
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determinations,
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-17-Prioritization of corrective actions, and
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The overall effectiveness of the program.
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b.
Observations and Findinas The inspectors found that management and engineering reviews were conducted in a timely manner. The licensee reviewed operating experience reports screened within 7 days and performed plant impact evaluations, as needed in accordance with Plant General Procedure OPGP03-ZX-0013," Industry Events Analysis," Revision 4. The operating experience group promptly notified shift supervisors of operability and reportability issues. The inspectors four.d that the licensee's program required an initial screening by an operating experience group evaluator for applicability and to determine if prompt corrective action was required. If an issue required prompt action, the licensee wrote a separate condition report. The licensee also initiated a plant impact evaluation for all other issues that applied to the site. A plant impact evaluation required a detailed i
analysis by cognizant site personnel and recommended actions to correct undesirable conditions. Based on a review of condition reports and plant impact evaluation's the inspectors ascertained that the licensee maintained a low threshold for placing industry issues in the corrective action program. The inspectors determined that the plant impact i
evaluation's reviewed were thorough and the corrective actions were appropriate. The j
licensee performed operability and reportability determinations in a timely manner.
l During the interviews with the group described in Section 07.1.b.(1) above, the inspectors determined, from operations and maintenance personnel, that industry operating experience, particularly events involving human performance, were routinely used during training and pre-evolution briefings. Engineers, who were interviewed, stated that they were familiar with the industry operating experience process and its implementation.
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Conclusions The licensee appropriately controlled vendor and industry operating experience that resulted in acceptable corrective actions. The licensee ensured that shift supervisors j
were promptly notified of operability and reportability issues and that evaluations were
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conducted in a timely manner.
IV. Plant SuDDort R7 Quality Assurance in Radiation Protection and Chemistry Controls a.
Insoection Scope (40500)
The inspectors reviewed a summary of 100 condition reports generated in the health physics area over the previous year. Of these,19 were materiallabeling errors and i
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-18-22 were personnel failing to follow their radiation work permits or improperly donning or removing protective clothing. The inspectors also reviewed the enforcement history for this functional area for the previous year and identified three violations of regulatory requirements. The three violations identified a total of four examples.
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Observations and Findinas The inspectors noted that the reported violations related to radiation protection were of low regulatory and safety significance. Two of the violations were reported as noncited.
i and the third was a Severity Level IV that required no response based on corrective actions already taken. The condition reports reviewed by the inspectors covered these violations. However, the remainder of the condition reports related to minor contamination events and failure to meet the licensee's performance expectations beyond the regulatory requirements.
The inspectors noted, and the licensee's the radiation protection manager confirmed, that most of the condition reports were generated during outage periods. In the outage conducted during the autumn of 1998, the licensee entered 1200 personal contamination events into the condition reporting system. Following that outage, the licensee assigned health physics technicians as area owners in the radiological controlled area as part of their corrective actions. Each area owner was responsible for policing his or her area for posting and labeling issues, as well as, identifying and documenting emergent conditions in the area. During the outage in the spring of 1999,
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the licensee observed only 300 personal contamination events. As previously noted, the licensee's threshold for condition reporting was very low and remained the same for reporting personal contaminations di' ring each of the last two outages.
The radiation protection manager stated that, although this was a significant improvement, it was higher than th a national average (estimated to be between 150 - 200 events for the same threhold requirements) and needed more improvement.
The licensee formulated additional corrective actions that included:
Adding " practical factors" to the general employee training,
i Conducting benchmark visits to sites that have had success in correcting j
radiation protection problems, and An arrangement for an industry peer review of the radiation program in July
1999.
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Conclusions The licensee implemented effective corrective actions in the area of radiation protection and developed a plan for further performance improvement.
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V. Manaaement Meetinas l
X1 Exit Meeting Summary The inspectors presented the inspection results to members of licensee management at
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l the conclusion of the onsite inspection on June 10,1999. The licensee's representatives acknowledged the findings presented.
The inspectors asked the licensee staff and management whether any materials -
examined during the inspection should be considered proprietary. No proprietary information was identified.
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i ATTACHMENT SUPPLEMENTAL INFORMATION PARTIAL LIST OF PERSONS CONTACTED Licensee A. Kent, Manager, Electrical and Instrumentation and Control Maintenance M. Berg, Manager, Mechanical Maintenance D. Gephart, Unit Supervisor E. Hudson, Assessment investigator D. Stark, Manager, Technical Support W. Valaguar, Assistant Manager, Operations M. Lashley, Manager, Reliability Engineering J. Calvert, Manager, Operations Training J. Johnson, Manager, Engineering Quality S. Hart, Consulting Engineer J. Crenshaw, Manager, System Engineering G. McGee, NPMM Coordinator J. Phelps, Manager, Unit 1 Operations J. Cottam, Supervisor, Design Engineering Department, Engineering D. Rencurrel, Design Engineering Department, Electrical and instrumentation and Control J. Hartley, Supervisor, Modifications W. Russell, Supervisor, Operations W. Dowdy, Manager, Unit 2 Operations E. Halpin, Manager, Unit 2 Maintenance S. Thomas, Manager, Design Engineering Department B. MacKenzie, Manager, Operational Events Group W. Cottle, President and Chief Executive Officer W. Mookhoek, Licensing Engineer P. Arrington, Licensing Engineer T. Jordon, Manager, Systems Engineering J. Lovell, Manager, Generation Support G. Powell, Manager, Health Physics D. Leazar, Director, Nuclear Fuel and Analysis j
S. Head, Supervisor, Licensing S. Horak, Quality Specialist J. Drymiller, Supervisor, Security.
R. Puggett, Senior Quality Assurance Specialist G. Gonzalez, lil, Engineering Specialist M. Berrens, Manager, Waste Control
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NRC N. O'Keefe, Senior Resident inspector J. Pellet, Chief, Operations Branch L
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-2-INSPECTION PROCEDURES USED IP 40500: Effectiveness of Licensee Process to identify, Resolve, and Prevent Problems LIST OF DOCUMENTS REVIEWED Procedures OPGP03-ZX-0002, " CONDITION REPORTING PROCESS" Revision 17 OPGP03 ZX-0006, " Event Review Team" Revision 4 OPGP03-ZX-0013," industry Events Analysis" Revision 4 Nuclear Group Policy. " Corrective Action Program", Revision 0
- Condition Reoorts 95-12059 98-1573 98-9163 98-14561 99-318 y
96-1816 98-1758 98-9180 98-15214 99-922 96-1817 98-1759 98-9896 98-16271 99-1704 96-11127 98-1760 98-9965 98-17935 99-1708 96-13195 98-1761 98-10009 98-17956 99-2905 96-15701 98-1762 98-10020 98-17958 99-2674 96-16224 98-1763 98-10021 98-17959 99-2925 96-16225 98-3581 98-10022 98-17960 99-3551 96-16226 98-4818 98-10113 98-17961 99-3684 97-5754-98-5270 98-10842 98-17962 99-5232 97-6107 98-6388 98-11246 98-17963 99-5374 97-9648 98-6473 98-12830 98-17986 99-5632 97-18192 98-7314 98-13284 98-17989
~ 99-5947 98-002 98-7808 98-13801 98-18468 99-6843 98-020 98-7916 98-13804 98-19114 99-8914 98-682 98-8586 98-13937 G8-20059 98-1250 98-8660 98-14536 99-292 Other PORC Meeting 99-023 Minutes (May 26,1999)
List of all repetitive MRFF between January 1,1998 and May 26,1999 DCP 95-10256 (replaced pressure switches in SG PORVs with new design diaphragms)
Condition Report Engineering Evaluation 98-20193-6 CAP Effectiveness Performance Indicators for April and May 1999 1999 Human Performance Composite Index (through May 1999)
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G i-3-Equipment Clearance Order Error Rate annual data for 1995 through 1998 and monthly data for January - May of 1999 Condition Review Group Meeting Agenda for June 8,1999 w/ " Condition Report Level Guideline Recommendations" attached Corrective Action Program Issues for Condition Review Group Discussion ran on June 7,1999 Summary list of open Condition Reports greater than 1 year old as of June 10,1999 Summary list of all fuse failures from January 1,1997 through May 26,1999 i
Summary list of condition reports generated after April 1,1998 and related to:
Human Performance (tagouts, system / equipment operation)
Contamination Contiof, Dose Control and Radiation Worker practices The Reactor Protection System Main Steam Safety Valves Diesel Generators Maintenance Instructions, Documentation and Procedures
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instrument Air Regulatory Actions (NOV's, NCV's, etc.)
LIST OF ACRONYMS I
CAP Qorrective action Erogram CAO-D Qondition adverse to Quality - Department CAO-S Gondition Adverse to Quality - Station CNAQ Qondition Not Adverse to Quality CRG Qondition Beview Group ECO Equipment Glearance Qrder ECP Employee Goncerns Erogram SCAO Significant Gondition Adverse to Quality STAR Stop Think Act Beview f
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