IR 05000528/1990053
| ML17305B437 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 11/30/1990 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17305B436 | List: |
| References | |
| 50-528-90-53-01, 50-528-90-53-1, 50-529-90-53, 50-530-90-53, NUDOCS 9104090060 | |
| Download: ML17305B437 (49) | |
Text
FINAL SALP REPORT U.
S.
NUCLEAR REGULATORY COMMISSION
REGION V
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE INSPECTION REPORT NOS.
50"528/90-53, 50"529/90-53, 50-530/90"53 ARIZONA PUBLIC, SERVICE COMPANY PALO VERDE NUCLEAR GENERATING STATION NOVEMBER 1, 1989 THROUGH NOVEMBER 30, 1990 (,C 9104090060 910329 PDR ADOCK 05000528
,J i
I I
l il t
TABLE OF CONTENTS Z.
Introduction
~Pa e
II.
Summary of Results A.
Overview B.
Results of Board Assessment C.
Changes in.SALP Ratings III. Performance Analysis A.
B.
C.
D.
E.
F.
G.
Plant Operations Radiological Controls Maintenance/Surveillance Emergency Preparedness Security Engineering/Technical Support Safety Assessment/equality Verification
9
13
18 IV.
Supporting Data and Summaries
A.
- 8.
C.
D.
Licensee Activities Direct Inspection and Review Activities Enforcement Activity AEOD Events Analysis
23
24
)j
]
l I
I.
INTRODUCTION The Systematic Assessment of Licensee Performance (SALP) program is an integrated NRC staff effort to collect available observations and data on a periodic basis and to evaluate licensee performance on the basis of this information.
The program is supplemental to normal regulatory processes used to ensure compliance with NRC rules and regulations.
It is intended to be sufficiently diagnostic to provide a rational basis for allocating NRC resources and to provide meaningful feedback to the licensee's management regarding the NRC's assessment of their facility's performance in each functional area.
An NRC SALP Board, composed of'he staff members listed below, met on
,January 10, 1991, to review observations and data on performance, and to
- assess licensee performance in accordance with NRC Manual Chapter 0516,
"Systematic Assessment of Licensee Performance,"
dated September 28, 1990.
This report is the NRC's assessment of the licensee's safety performance at Palo Verde Nuclear Generating Station for the period November 1, 1989'hrough November 30, 1990.
The SALP Board for Palo Verde was composed of:
R..Zimmerman, Director, Division of Reactor Safety and Projects, Region V (Board Chairperson)
J. Dyer, Director, Project Directorate 5, NRR K. Perkins, Deputy Director, Division of Reactor Safety and Projects, Region V
F. Menslawski, Deputy Director, Division of Radiation Safety and Safeguards, Region V
D. Kirsch, Chief, Reactor Safety Branch, Region V
S. Richards, Chief, Reactor Projects Branch, Region V
G. Yuhas, Chief, Reactor Radiological Protection Branch, Region V
J.
Reese, Chief, Safeguards, Emergency Preparedness, and Non-power Reactor Branch, Region V
H. Mong, Chief, Reactor ProjectsSection II, Region V
R. Huey, Chief, Engineering Section, Region V
C. Trammell, Project Manager, PD 5, NRR C. Holden, SALP Program Manager, NRR D. Coe, Senior Resident Inspector, Region V
M. Ang, Project Inspector, Region V
H. Cillis, Senior Radiation Specialist, Region V
P. squalls, Reactor Inspector, Region V
K. Prendergast, Emergency Preparedness Analyst, Region V
L. Norderhaug, Safeguards Inspector, Region V
J. Sloan, Resident Inspector, Region V
- Denotes voting members in all functional areas.
Other persons advised the Board in their areas of cognizanc )
,r
II. Summar of Results A.
Overview Licensee performance during the assessment period improved in most functional areas due in large part to management initiatives to upgrade weak areas and to address Board recommendations from the previous SALP.
The improved performance was best demonstrated'by the relatively event free operation of all three units.
Oedication to improved performance was exemplified by the increased degree of management involvement in day-to-day plant activities and several management and organizational changes that strengthened various departments in most functional areas.
'Management involvement and support in the Emergency Preparedness area was superior and resulted in an improved rating (Category 1)-
from the last SALP period.
The change was the result of continued improvement in the program throughout the SALP period brought about by continued attention from licensee management.
The guality Audits and Monitoring and the guality Systems groups were considered strengths in the Safety Assessment/guality Verification (SA/gV) functional area.
Effective quality monitoring, programmatic evaluation, and coordination of quality data by these groups were noted.
However, continued management involvement was considered to be the most needed in this functional area (Category
after considerable Board deliberation),
as reflected by the SALP Board recommendations.
Insistence on consistent self-evaluation is
.still needed.
The civil penalties regarding inadequate correction of emergency lighting discrepancies and licensed operator medical records discrepancies appeared to stem from a lack of management insistence for aggressive self-evaluation.
The lack of guality Assurance in the emergency lighting and licensed operator medical records area was a notable contributory cause of the problems.
The licensee conducted an electrical system self-assessment; however, it failed to identify deficiencies formed by the NRC's EDSFI related to design basis calculations.
This indicates a need to be more self-critical and to conduct a more in-depth review.
Additional attention in the SA/gV functional area is also considered necessary to improve performance of line organization verifications and gC inspections.
Effort will also be necessary to assure continued improvement of performance of safety assessment groups (NSG, PRB, ISEG, PSAG, and OSRC).
A recognition of improved safety performance resulting from initiatives in the Maintenance/Surveillance functional area resulted in a Category 2 rating.
However, there were extended Board deliberat)ons in this functional area due to continuing weaknesses.
Continued attention is needed to establish clear and complete work instructions and to improve procedural adherence.
Continued emphasis is warranted for timely and effective corrective actions to maintenance problems.
The Maintenance organization should actively involve the Engineering organization in maintenance problems when appropriat Engineering/Technical Support performance (Category 2) improved due to implementation of plans to address past weaknesses in this area.
Continued implementation of those plans is recommended.
Increased involvement in site activities and in resolution of plant problems should be continued.
The roles and interfaces of the site and corporate nuclear engineering organizations need to be clear and consistently implemented.
Continued emphasis on conservative and comprehensive response to plant engineering problems is war ranted.
Relatively event free operations of the three Units and an improving saf~ty performance tr end were noted in the Operations functional area (Category 2, improving).
However, fu'rther improvement is still needed in the conservatism of management decisions, in the llperations staff's attention to detail and in ensuring that appropriate 'technical support groups are included in Operations decision making.
Continued attention to improvement of identified-weaknesses in the Operations functional area, such as the lack of control over licensed operator medical examinations, is recommended.
Licensee management involvement in the Radiological Controls (Category 2) and Security (Category 2, improving) functional areas was apparent.
Continued focus in pursuing effective results from improvements initiated in these areas is encouraged.
Results of.Board Assessment Overall, the SALP Board found the performance of NRC licensed activities by the licensee to be directed toward safe operation of Palo Verde.
The SALP Board has made specific recommendations in most functional areas for licensee management consideration.
The results of the Board's assessment of the licensee's performance in each functional area, including the previous assessments, are as fol1ows:
Functional Area A.
Plant Operations B.
Radiological Controls
'C.
Maintenance/Surveillance D.
Security f.
Engineering/Technical Support G.
Safety Assessment/equality Verification Rating Last Period Rating This Period 7reod" improving improving
The SALP report may include an appraisal of the performance trend in a functional area for use as a predictive indicator.
Licensee performance during the assessment period was examined by the Board to determine whether a trend exists.
Normally, a performance trend will be indicated only if (1) a definite
C.
trend is discernible and (2) continuation of the trend could result in a change in performance rating.
The performance trend is intended to predict licensee performance during the next assessment period and should be helpful in allocating NRC resources.
Chan es in SALP Ratin s
The licensee's performance rating in the Emergency Preparedness functional area improved to Category 1 from Category 2 for the previous SALP period.
The improved rating in the Emergency Preparedness area resulted from continued improvement in management attention to, and licensee self-initiative in, the implementation of the Emergency Preparedness Program throughout the SALP period.
The licensee s ratings in the Haintenance/Surveillance, Engineering/
Technical Support and Safety Assessment/equality Verification functional areas improved to Category 2 from Category 3.
The improved ratings, in general, resulted from improved performance brought about by management initiatives and organizational changes.
III. PERFORMANCE ANALYSIS The following is the Board's assessment of the licensee's performance in each of the functional areas, plus the Board's conclusions for each area and its recommendations with respect to licensee actions and management emphasis.
A.
Plant 0 erations 1.
~Ana1 sis During the assessment period, the licensee's plant operations were observed routinely by both the resident and the regional staff.
A total of 2699 hours0.0312 days <br />0.75 hours <br />0.00446 weeks <br />0.00103 months <br /> of inspection effort were devoted to this functional area, approximately 36 percent of the total inspection effort.
The licensee's performance was rated as Category 2 during the previous SALP rating period.
The previous SALP report emphasized the need for continued attention to formal and conservative operations, particularly valve and system manipulations; more thorough evaluation of problems; and encouragement of a working
~
atmosphere conducive t'o thoughtful and critical assessments of all phases of plant operations.
During the current SALP period, the licensee conducted a comprehensive assortment of plant operations, including completion of extended maintenance outages, mid-loop operations, one complete refueling outage, and full power operation of all three units for several months.
These evolutions were conducted safely and generally indicated that the licensee's performance in the area was good and had improved from the previous SALP assessment.
However, several events occurred during this period which indicate a need to continue to emphasize conservatism in decisions and attention to detail on the part of the Operations
>!
I H
staff..
There were approximately. the same number of operations related NRC enforcement actions and licensee submitted LERs for each unit, which supports the NRC observation that there is relatively little difference in performance between units.
The number of violations, excluding those associated with operator medical records, and LERs was approximately the same as the previous SALP period and collectively does not indicate a program breakdown.
Licensee management is routinely involved in this area and has on several occasions demonstrated conservatism in operations judgement.
These have included dealing with defective 0-rings in main steam and
'eedwater isolation valves, shutdowns of'nit 1 to repair a steam generator tube leak, and prompt inoperability determinations of seismically deficient emergency diesel generators.
In addition, the licensee improved the conduct of mid-loop operations since the previous SALP period.
Finally, licensee management was effective in overseeing and coordinating the actions required by the NRC to resolve a Confirmatory Action Letter for Units 1 and 3, issued as the result of a March 1989 Unit 3 event.
However, several events reflected the need to continue to emphasize conservatism in decisions and better involvement of supporting groups such as engineering, licensing, and radiation protection.
Those were:
deenergizing all logarithmic power neutron flux instruments in Mode 5, venting reactor coolant system gaseous activity into containment during outage maintenance activities, loss of reactor coolant while repacking a shutdown cooling valve in an operating loop, and restart of a unit following a reactor trip without first determining whether the event was bounded by existing analysis.
These events were not of major safety significance.
The licensee is generally prompt in dealing with safety concerns, but still occasionally requires NRC involvement to ensure that timely corrective actions are taken.
For example, slow licensee followup regarding the proper control of required licensed operator medical records resulted in a subsequent NRC finding of a significant programmatic deficiency in this area and resulted in escalated enforcement action.
The licensee has made sustained progress toward improving plant simulator performance, a longstanding NRC concern, and is making a
major financial commitment to purchase a second full scale simulator to support required licensed operator training needs.
The licensee's program to certify the existing simulator has been reported to be on schedule, although an extension may be required should any delays be encountered.
The completion of the Emergency Operating Procedure (EOP) rewrite program experienced some delay due to 1) the licensee not fully recognizing the scope of rewrite effort needed following the findings of the EOP team inspection, and 2) the impact of the simulator upgrade project on the EOP training and validation process.
Operations personnel are generally knowledgeable and professional, and their response to the relatively few events which occurred during the assessment period was good.
However, some deficiencies were noted which indicate that continued emphasis on operator
pi There were approximately the same number of operations
'RC enforcement actions and licensee submit'ted LERs for each
'h supports the NRC observation that there is relatively
.rence in performance between units.
The number of
~xcluding those associated with operator medical ERs was approximately the same as the previous SALP
.ctively does not indicate a program breakdown.
Lice
't is routi has o.
s10ns dern judgem.
.re inclu main st~
'.er isol repair a
'r tub determinat
'cal 1 In addition, imp operations si
>US management was r
required by the Units 1 and 3, i However, several a
conservatism in dec groups such as engin.
Those were:
deenergiz instruments in Mode 5, activity into containmen of reactor coolant while i
operating loop, and restan, without first determining wh analysis.
These events were, nely involved in this area and onstrated conservatism in operations ded dealing with defective 0-rings in ation valves, shutdowns of Unit 1 to e leak, and prompt inoperability y deficient emergency diesel generators.
roved the conduct of mid-loop SALP period.
Finally, licensee erseeing and coordinating the actions a Confirmatory Action Letter for ult of a March 1989 Unit 3 event.
the need to continue to emphasize er involvement of supporting
',
and radiation protection.
mic power neutron flux coolant system gaseous maintenance activities, loss tdown cooling valve in an
'lowing a reactor trip
't was bounded by existing safety significance.
The licensee is generally prompt but still occasionally requires h.
timely corrective actions are takei followup regarding the proper contr~
medical records resulted in a subsequ significant programmatic deficiency iA escalated enforcement action.
'th safety concerns, to ensure that o., slow licensee licensed operator qofa
'esulted in q plant making a
s>mulator The licensee has made sustained progress t simulator performance, a longstanding NRC c.
major financial commitment to purchase a seci to support required licensed operator training licensee's program to certify the existing simu reported to be on schedule, although an extensioi should any delays be encountered.
The Emergency L
Procedures rewrite program has been delayed by anot.
delays by contractors providing the writer's guide.
second significant delay to this program.
Operations personnel are generally knowledgeable and pro and their r'esponse to the relatively few events which occam during the assessment period was good.
However, some defi~
were noted which indicate that continued emphasis on operato attention to detail is appropriate.
These include: refueling v1e d
attention to detail is appropriate.
These include: refueling operations resulting in a stuck fuel assembly and a mispositioned fuel assembly, missed boron samples following charging pump lineup changes, over-dilution of the RCS during power ascension testing, exceeding the limit for RCS heatup rate, and spills of RCS and refueling water tank water due to valve misalignments.
It is noted that a dilution event occurred just after the end of this SALP period and reemphasizes the continued need for operator attention to detail.
None of these events were considered to have resulted in a significant safety problem nor did they indicate a major deficiency in this area.
They do however indicate an area for additional attention.
Although there were no NRC administered licensed operator examinations conducted during this period, the licensee training program for licensed and non-licensed operators was found to implement an effective Systems Approach to Training and was generally supported by facility personnel.
However, facility procedures governing the licensee administered annual operating tests could have allowed an operator who failed the test to return to shift work prior to passing a second test, which is contrary to NRC requirements.
This weakness and the lack of control over licensed operator medical examinations noted above indicated a
general weakness in meeting
CFR Part 55 administrative control requirements which is further addressed in the Safety Assessment/equality Verification section.
The licensee's fire protection program was viewed to be adequate, except in the areas of emergency lighting and gA program coverage, which is addressed in the Safety Assessment/equality Verification section.
Overall, the Board concluded that the licensee's performance
.in this area had improved over the previous SALP period as evidenced by the relative absence of significant operations related events.
2.
Performance Ratin Performance Assessment - Category 2 improving 3.
Board Recommendations In order to more thoroughly and critically evaluate operations problems and improve operations decision making processes, the licensee should continue to work to better involve supporting organizations as appropriate.
Continued emphasis toward conservatism in Operations decisions, toward attention to detail during daily operations activities and to a critically questioning approach to problems is also warranted.
Program controls over
CFR Part 55 requirements need increased scrutiny and continued emphasis is warranted toward accomplishing simulator certification as required by 10 CFR Part 5 li I,'(
f (
ft 1r
l pe.
detc sl gnl
'in thl attent4 as resulting in a stuck fuel a sembly and a mispositioned
<<bly, missed boron samples following charging pump lineup er-dilution of the RGS during power ascension testing,
. limit for RCS heatup rate, and spills of RCS and
<<r tank water due to valve misalignments.
It is noted event occurred just after the end of this SALP hasizes the continued need for operator attention to
'hese events were considered to have resulted in a-oroblem nor did they indicate a major deficiency do however indicate an area for additional Although,t,
'RC examination.
r program for, implement an a
generally suppo.
procedures govern tests allowed an
~
work prior to passl requirements.
This
,
operato~ medical exam, weakness in meeting
requirements which is fu.
Assessment/equality Verifii The licensee's fire protects except in the areas of emerge, which is addressed in the Safe'i section.
administered licensed operator ing this period, the licensee training
<<n-licensed operators was found to ms Approach to Training and was ty personnel.
However, facility
-.ee administered annual operating
<<,'il d the test to return to shift
= a<X, st, which is contrary to HRC
<" X he lack of control over licensed
+~~', above indicated a general
~<', 'ministrati ve control
~~'
in the Safety viewed to be adequate,
'd gA program coverage,
'luality Verification Overall, the Board concluded that.
area had improved over the previous relative absence of significant opera 2.
Performance Ratin performance in this
'videnced, by the events.
Performance Assessment - Category 2 improv.
3.
Board Recommendations In order to more thoroughly and critically evali problems and improve operations decision making p licensee should continue to work to better involve organizations as appropriate.
Continued emphasis ti conservatism in Operations decisions, toward attenti~
during daily operations activities and to a critically approach to problems. is also warranted.
Program contro.
CFR Part 55 requirements need increased. scrutiny and conl.
emphasis is warranted toward accomplishing simulator certl as required by 10 CFR Part 5 B.
Radiolo ical Controls 1.
~Ana'I sis The licensee's radiation protection program was observed during routine operations and outage periods by both the regional and resident inspectors.
Approximately 605 hours0.007 days <br />0.168 hours <br />0.001 weeks <br />2.302025e-4 months <br /> of inspection effort, approximately 8 I of the total inspection effort, were devoted to this functional area.
The licensee's performance in the radiological controls area has improved during this assessment period.
The previous SALP Board recommended that the licensee be more aggressive in maintaining plant equipment and that management assure that occupational radiation protection measures are accomplished and that questions concerning the reliability of the radiation monitoring system (RHS)
are resolved.
The licensee has demonstrated management strengths by continuing the reorganization of the radiation protection and chemistrv groups, including the staffing of key positions with highly qualified individuals.
Assurance ot quality and management's effectiveness were demonstrated in the reduction of personnel exposures, the surveillance programs for the Post-Accident Sampling System and RHS, the General Employee Training (GET) program, and in control of contamination in plant areas.
Collective personnel exposure had declined from an average of 223 person-rem/Unit during 1989 to an anticipated 169 person-rem/Unit in 1990.
These reductions were exemplified by a reduction of exposure during the 1990 Unit 2 refueling outage compared to the prior outage.
The licensee was also successful in reducing personnel contamination incidents.
Control of secondary water anions and condensate oxygen had improved and a new reactor coolant pH regime was initiated to reduce system dose rates.
The licensee formed a separate group to oversee effluents and the RHS.
RHS reliability has improved, the number of associated Licensee Event Reports (LERs) have decreased, and the cause of numerous special reports related to surveillances is being addressed.
The licensee continued to maintain effective programs involving transportation of radioactive materials, solid radwaste processing and environmental monitoring during this assessment period.
The licensee's timely implementation of corrective actions was weak, as evidenced by the failure to control locked high radiation areas.
Attempts to improve in-line monitors for secondary chemistry had mixed success, as new sodium monitors were unreliable.
Examples of untimely corrective action in response to internal audit findings included:
failure,to implement procedures to evaluate abnormal releases, failure to complete an evaluation of possible radioiodine plateout in RHS sample lines, failure to resolve RHS alarm setpoint determinations, failure to resolve the isokinetic sample design for the high range effluent RHS, and failure to resolve vendor audit findings involving radioactive waste processing from 1985 and 198 L On two occasions, decision-making was conducted at a management level that did not result in adequate reviews of activities prior to implementation.
This was exemplified by the decision to release approximately 26 curies of fission product gases to containment while personnel were present and the use of junior radiation protection technicians for senior radiation protection technician tasks during a labor action.
The licensee's approach to the resolution of significant technical issues was typically thorough.
One exception involved mana'gement of water processing using the boric acid concentrator system.
The evaluation was not thovough nor completed in a timely manner.
Four Severity Level IV violations and six non-cited violations were identified during the course of the assessment period.
Host of the violations resulted from failure to follow procedures, poorly stated procedures and failure to implement timely corrective actions.
One Enforcement Conference associated with the failure to properly control high radiation areas was held during this assessment period.
Mhile the violations and weaknesses are important, collectively they did not indicate any programmatic breakdown.
There were weaknesses in the licensee's training program for junior contractor health physics (HP) technicians as evidenced by their poor performance during the HP technician labor action.
This was highlighted by NRC enforcement actions concerning radiologically controlled area ingress and egress.
Problems with issuance of proper dosimetry and control of alarming-dosimeter alarm setpoints were clearly associated with inadequate training.
HP technician staffing was adequate and the professional health physics staffing was improving.
Authorities and responsibilities were defined by management and understood by the staff.
Key positions were filled on a priority basis.
During this period there were several occasions involving poor communications related to workers bringing safety concerns to NRC attention.
Although no violations were identified, the licensee demonstrated responsiveness to the problem by restating their position and reviewing their performance.
2.
Performance Ratin Performance Assessment - Category 2 3.
Board Recommendations The licensee should take a more aggressive role in ensuring corrective actions are promptly and effectively accomplished, and that procedures are clearly stated, understood, and implemented.
Efforts should continue to focus on completion of the organizational changes and conservative decision makin I
C.
Maintenance/Sur veil 1 ance l.
~Anal sis This functional area was observed routinely during the assessment period by both the resident and regional inspection staff.
In addition, a Diagnostic Evaluation Team (DET)'valuated maintenance and'urveillance as part of their broad-based evaluation effort.
Approximately 701 hours0.00811 days <br />0.195 hours <br />0.00116 weeks <br />2.667305e-4 months <br /> of inspection effort were devoted to this functional area, about 9 percent of the total inspection effort.
A noted strength was,the licensee's willingness to confront hardware problems directly, although problem resolution was not always seen to be completely effective.
Improvements were noted in the establishment of a Site-Maintenance Manager, initiatives to improve preventive maintenance and repetitive work order consistency, the incorporation of 12 week work planning schedules, formal Work Planner/Coordinator training, and improved maintenance mockup facilities.
Several examples were noted where major maintenance activities were conducted with thorough planning, control, and execution.
Noteworthy examples included work to repair the Unit 1 steam 'generator tube plug leaks, the Unit 2 molded case DC circuit breaker replacements, and the Unit 3 main feedwater isolation valve 4-way valve replacements.
Three broad areas of weakness were identified during the previous SALP period:
inadequate work planning; inadequate attention to detail in work implementation; and inadequate problem resolution.
During the current SALP period, work implementation varied considerably.
Major work activities which benefitted from close management attention, as noted above, were executed very well.
Other examples noted below reflect some weaknesses in routine maintenance activities.
These weaknesses are categorized into the same three areas previously identified to be weak, although some improvement has been noted.
Continued attention to these areas is warranted..
In the area of work planning, as noted above, the licensee has taken steps to train personnel and improve their work planning system.
Some improvement was noted, however instances of poor work planning were observed and resulted in incomplete or inaccurate work order instructions contributing to problems such as:
inter-system leakage due to inadequate retest requirements for motor operated butterfly valves, inadvertent dilution of the RCS during steam generator hydrolazing, and damage to the fuel building ventilation boundary during ventilation system maintenance.
Inspector identified problems included lack of jobsite checks by work planners as required by procedure, freeze seal instructions which lacked contingency measures for a loss of seal and work orders which required field workers to use a motor operated valve (MOV) database having 34 change notices.
Additionally, weaknesses in work scheduling practices resulted in scheduling valve repackinq work on an operating shutdown cooling loop, thereby causing a sign>ficant RCS leak; inadvertently rendering an emergency diesel generator inoperable due to steam cleaning work; and a loss of.valuable
as-found information during troubleshooting on an MOV due to other work being performed on the valve.
Although few significant operational events were attributed to maintenance or surveillance activities, several lesser events indicate a need to increase attention to detail in work implementation.
Examples include a loss of al'1 shutdown cooling due to ICC work, an RCS leak from a newly installed vessel level indication system due to poor work boundary control, a balance of plant engineered safety feature actuation due to a missed procedure step, a spray pond pressure transmitter left isolated following calibration, and several examples of failure to document work steps as the steps were performed.
Corrective actions for problems in this area were generally initiated, but were not fully effective in some cases.
For example, instances were noted in which as-found conditions were not preserved for root-cause-of-failure determination.
One example of inadequate corrective action was a failed relay in an auxiliary feedwater pump control circuit which rendered the pump inoperable.
The previous month the same relay had failed in a different unit and no root cause of failure analysis had been conducted, which was contrary to, licensee procedures.
The Material Nonconformance Report (MNCR) program was initiated near the beginning of the evaluation period and improved as the assessment period progressed.
Several problems with its implementation were identified by inspectors, including failure to initiate an MNCR when appropriate.
In some cases, program problems were corrected by changing the program and associated procedures.
In other cases, it appeared that workers were reluctant to follow or did not understand the program requirements.
Work Control personnel now review Work Requests for MNCR conditions and have initiated MNCRs where required.
While this is not the ultimate expectation of the program, it appears to be adequate corrective action at this point.
Additionally, workers still occasionally lack an inquisitive, probing approach to plant problems.
In one example, a
technician inadvertently caused a hydrogen monitor to alarm while making a routine adjustment and did not evaluate its significance.
in another case, a worker noticed a valve handwheel detached from its valve and took no corrective action until prompted by an NRC inspector.
Although relatively few plant events were attributed to weaknesses in the preventative maintenance program, several instances were noted which indicate that the licensee's initiative to improve this program should continue.
The Electrical Distribution System Functional Inspection (EDSFI) team found a number of safety-related relays, breakers and electrical distribution panels which lacked any scheduled preventive maintenance or testing.
Similarly, the EDSFI identified that safety-related motors lacked a program for routine monitoring of motor insulation resistance.
Inadequate preventative and corrective maintenance for the emergency lighting system was part of a larger issue which was subject to escalated enforcemen While the number of violations and LERs in this functional area was.
somewhat higher than in the previous SALP period, these did not reflect the same degree of safety significance as in the past and did not indicate a program breakdown.
The DET identified numerous motor operated valve maintenance problems including the absence of a program to address progressive degradation, and a lack of aggressive followup on industry initiated check valve advisory documents.
In addition, the DET noted that vendor technical manuals were not always kept current.
Maintenance material support was variable.
Improper storage of reactor coolant pump oil resulted in moisture contaminated oil being used in the Unit 1 reactor coolant pumps.
Corrective action for material support problems included assigning a procurement contact person for each unit to attend morning meetings and provide coordination, which appears to have improved the situation.
The basic surveillance program was considered to be sound, however some problems were noted at this ttlree unit site.
In one case, test performers signed off steps as complete when it was not possible to perform the steps as written.
In one case, problems getting the expected results prompted invalidation of the test rather than documentation of the problem.
In another case, workers were reluctant to seek assistance.
Licensee event reports identify a few surveillance tests which were missed, although during the last months of the evaluation period no further similar events have been reported.
Some surveillance test procedures had deficiencies including inadequate acceptance criteria, inadequate verification of test equipment operation, unclear directions which permitted inconsistency between units, inadequate detail to assure consistent test data, and errors in supporting operating procedures.
However, the licensee has strengthened the supporting program by completing cross reference documents which ensure all surveillance requirements are implemented by procedure.
Mhile some problems were noted, the surveillance testing program is viewed as stronger overall than the maintenance program.
Overall, maintenance personnel have'shown the capability to perform quality maintenance.
Some instances of inadequate inquisitiveness were still apparent.
Program effectiveness has improved, but is still hindered by weaknesses in work planning, scheduling, and corrective action for identified problems in the maintenance area.
2.
Performance Ratin Performance Assessment - Category
3.
Board Recommendations The Board conducted extended deliberations in this area.
The Board's previous assessment of Category 3 performance was partly a reflection of the maintenance weaknesses highlighted by the operational events during that period.
During the current evaluation period there have been no maintenance issues similar to those of the previous period and the Board has recognized the
11lt I
t
It t1I'
licensee's current initiatives in the maintenance area.
The licensee should clearly recognize the need to continue the initiatives that have been started.
The Board recommendations are identical to those of the previous cycle.
The licensee should continue to work to establish clear and complete work instructions.
Emphasis continues to be needed toward procedural adherence.
Maintenance personnel should actively involve engineering when appropriate and engineering should strive to be aware of ongoing maintenance issues.
Maintenance managers should continue efforts to observe routine ongoing work and to carefully manage safety 'equipment outage schedules.
Continued attention to establishing timely and effective corrective action is warranted with respect to concerns in the maintenance area.
9.
Emer enc Pre aredness 1.
~Anal sis During this SALP.per.c18, approximately 168 inspection hours, approximately 2X of the total inspection effort, were utilized to assess the licensee's Emergency Preparedness (EP) Program.
This included the observation of one exercise and three routine inspections.
The previous SALP board recommended an emphasis on management attention to timely implementation of corrective actions and continued management involvement in the program.
Management involvement has been effective in improving the EP program.
This was evidenced by the improvement and upgrading of Emergency Response facilities and equipment (i.e.,
new emergency response vehicles and efforts to upgrade the offsite assembly and backup
'EOF crab'ilities), and being proactive in improving the Emergency Plan Implementing Procedures (EPIP's)
and the Emergency Plan to conform to NUREG 0654.
Management support and participation was also evidenced by the conduct of two accountability drills and superior performance during the annual exercise.
The licensee'
'gA program provides for an in-depth independent audit of the EP Program.
The licensee used a Senior EP supervisor from San Onofre to participate in the audit, contributing a level of expertise not usually obtained in annual EP audits.
Audit findings and recommendations were well documented, entered, tracked, and were corrected in a timely manner.
The licensee's efforts to resolve technical issues from a safety standpoint appeared to be effective.
The effort to revise the Emergency Plan and EPIP's to be consistent with NRC guidance documents was being performed largely on the licensee's initiative after the NRC's identification of inconsistencies.
The performance of two effective accountability drills, one on a weekend and one during work hours, also demonstrated management's willingness to improve plant performance.
There was one violation of an NRC requirement during the evaluation period.
The violation involved a failure to declare an Unusual
Event for a fire within the power block lasting more than ten minutes.
The licensee's corrective action for the violation was prompt and effective to prevent recurrence.
However, it is noted that this event was the only Unusual Event (reportable} which occurred in this rating period and appeared to result from a lack of conservatism in management decisions.
Subsequent events were correctly classified, although none were significant enough to be classified as an Unusual Event or higher.
Staffing of the EP Program appears adequate.
Positions are identified and authorities and responsibilities are well defined.
Vacant key positions are filled on a priority basis.
Needed expertise is available within the staff.
Consultants are used as appropriate to supplement the staff for major occurrences such as the annual exercise.
The licensee appeared to have an effective program to ensure that adequate emergency response personnel are onsite and are current in all of the required training for their specified positions.
The licensee appears to have a good emergency preparedness training and qualifications program.
The program appears to be effective in ensuring that personnel in key positions are fully qualified and have all required training.
Interviews with a number of Shift Supervisor personnel disclosed a good understanding of the Emergency Plan and event classification.
No weaknesses were observed during those interviews.
2.
Performance Ratin Performance Assessment - Category
3.
Board Recommendation The licensee should continue support of the EP program.
Management-emphasis is appropriate to ensure aggressive problem solving, to validate the 'effectiveness of recently implemented corrective actions, and to ensure that plant events are properly classified.
E.
~Securit 1.
~Anal sis During the assessment period, Region V conducted four. physical security inspections.
Over 336 inspection hours, approximately 5X of the total inspection effort, were expended by regional inspectors.
In addition, a team inspection and the resident inspectors provided continuing observations in this area.
With regard to involvement in assuring quality, corporate and plant management continued to review the operation of the overall security program.
Significant weaknesses had been noted early in the assessment period in the areas of security event analysis and alarm trending to identify root causes.
The large number and age of
uncompleted maintenance requests for security-related equipment was also identified as an area needing attention.
Additionally, communication between levels of security management and between security and other disciplines was found to be weak.
There was significant improvement during the assessment period in response to NRC concerns.
Licensee organizational changes appear to have remedied these weaknesses.
The licensee has established a "Site Services Division Action Plan" aimed at improving tactical training, site exercises, strategic planning and target analysis, to assure that the contingency plan implementing procedures prov>de proper response to the design basis threat.
Improvements were made to facility hardware to reduce the need for compensatory security measures.
guality assurance and quality control programs and policies are generally adequately stated and understood.
However, Region V noted that further dialogue appeared warranted between reactor operations and security personnel so that armed response strategy and tactics could be initially focused on protecting the most critical safety systems and components first.
The previous SALP report encouraged licensee management to complete their review of closed circuit television (CCTV) camera coverage and illumination necessary for adequate protected area barrier alarm assessment, and to limit overtime effects on guard alertness, including expediting the implementation of their planned expanded security training program.
The licensee's study to relocate cameras and illumination to improve coverage, completed during the latter part of the assessment period, appears quite satisfactory.
However, the current CCTV cameras require a very high l,evel of maintenance to remain operational due to the severe environmental conditions under which they must function.
Evaluation of alternate camera suppliers is continuing.
To limit overtime effects, the licensee has, during the latter part of the assessment period, completed their expanded
training program and improved access control system reliability to reduce the number of compensatory posts.
The licensee has also abandoned the 12-hour work shifts for security officers, implementing a standard 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> per day, 5 days per week duty schedule.
Identification and resolution of technical issues, while slow in some cases, has been generally sound and thorough.
Early in the assessment period, lack of thorough analysis of root cause and systematic implications of equipment failures were identified.
Improvements in trending and analysis of equipment/human failures has been noted in later inspections.
During the assessment period, licensee action relative to three information notices dealing, respectively, with radio communications, review and analysis of safeguards event logs, and potential weakness with certain types of security equipment were reviewed.
Mith the exception of the review of event logs, the licensee's actions, as reviewed to date, were found to be appropriat I,
,I I h I
I
The enforcement history for the period November 1,
1989, through November 30, 1990, includes 3 violations identified early in the assessment period, which were related to a licensee identified (but repeated)
failure to provide a vital area barrier as described in their approved security plan, failure to provide proper escorted access to vital areas, and failure to properly package safeguards information for mailing.
Additionally, the enforcement history includes a non-cited violation regarding implementation of an unapproved training program of simulated night firing.
During this SALP period, the licensee reported four safeguards events.
Three of these events resulted from personnel error:
failed security compensatory measures (two) and an uncontrolled pathway to a vital area (one).
The remaining event resulted from a design deficiency related to a vital area barrier vulnerability.
Mith respect to staffing, key positions were identified and, although limited by staffing considerations, position responsibilities were generally well defined.
The security training staff is continuing their special advanced training program on their own initiative and augments current offsite security resources to meet the special security demands of the plant's isolated location.
2.
Performance Ratin Performance assessment
- Category 2 improving 3.
Board Recommendations The licensee is encouraged to complete their review ot CCTV camera designs to improve the performance characteristics of the alarm assessment system.
The licensee should continue the use of management action plans to critically review their security program, identify problem areas and promptly resolve problems when they are identified.
F.
En ineerin /Technical Su ort 1.
~Anal sis This functional area was reviewed routinely by both the regional and resident staff of the Region Y office, and by the staff of NRR.
Over 411 inspection hours were expended in this functional area, approximately 5 percent of the overall inspection effort.
These reviews focused primarily on the effectiveness of the engineering organizations and in the quality of their work.
The licensee has restructured the engineering organizations and filled most remaining key management positions during this assessment period.
In February 1990, the new position of Vice President - Engineering and Construction, was created and filled.
In April, the permanent Site Technical Director position was filled.
The Engineering Evaluation Department, which includes the System Engineers, was reorganized under the Site Technical Director,
i J
i ti I
creating four new departments.
These changes included formation-of a Component and Specialty engineering group which established component engineers to address motor operated valves and safety relief valves, check valves, motors and pumps, and a group to monitor component performance and maintenance data.
This appears to have improved the focus of the Site Technical Support personnel,-
although the interrelationship and responsibilities of System Engineers and Component Engineers is not always clear.
In July, the Director of Site Nuclear Engineering and Construction position was created and filled, and the Site Nuclear Engineering Department (SNED) was formed, providing greater onsite design engineering expertise and support.
In October, these engineering functions, including the corporate-based Nuclear Engineering Department, were consolidated under the Vice President - Engineering and Construction.
The Director - Nuclear Engineering position was not filled until after the end of this assessment period.
Additionally, the licensee's Business Plan was developed and is being implemented, providing specific goals intended to enhance the effectiveness of the engineering organization.
This Plan addresses weaknesses and recommendations from the Diagnostic Evaluation performed by the NRC early in the assessment period and incorporates the licensee's Engineering Excellence Program.
In general, engineering work addressed significant problems in a typically timely and thorough manner.
Improvement was specifically noted in the responsiveness of engineering to plant events.
Positive examples included involvement in resolution of embrittled pins in safety-related butterfly valves, retrieval of a broken incore detector, resolution of auxiliary feedwater pump pressure'ulsations, assessment of improper backup rings in four-way valves which control the feedwater isolation valves, control element assembly coil testing to prevent slippage during surveillance testing, and retrieval of a heated junction thermocouple sheath.
Additionally, Engineering has proactively pursued problem identification, having identified several deficiencies during the design basis reconstitution process and during fire barrier walkdowns.
System engineers appeared to 'have improved their ability to identify deficiencies in their systems.
Examples include inappropriate paint on the fuel metering ports of an emergency diesel generator, and a deficient splice in the atmospheric dump valve control system.
Although the licensee's performance in this area has clearly improved as a result of management involvement and initiatives, there were several instances which indicate that more than minor weaknesses still remain to be addressed.
Host notable of these examples was the continuing problems with the emergency lighting system.
Problems with the system have persisted for years and were not dealt with in a thorough, integrated fashion, resulting in civil penalties in both 1989 and 1990.
In this instance, critical self-assessment of the issue was clearly lacking and the licensee's approach to resolution of the associated technical problems was poor.
Other examples of weak engineering work included inadequate testing of motor operated butterfly valves, configuration
control problems with the Core Operating Limits Supervisory System (COLSS}, not clearly limiting the torque value for a Pressurizer instrument valve gland nut in an associated work document, using invalid assumptions in determining how to compensate for temperature changes for the ADV nitrogen drop test, inadequately justifying waivers for some preventive maintenance tasks, and failure to recognize the significance of the loss of preload on HOV spring packs.
Licensee engineering and contract personnel performed a desion review of the electrical distribution system prior to the NR5 Electric Distribution System Functional Inspection (EDSFI}.
Mhile the performance of these types of reviews are considered a strength, the subsequent NRC EDSFI identified an electrical system power configuration which could have potentially caused overloading of a startup transformer.
The EDSFI also identified load calculation errors and a 1990 diesel load calculation which used incorrect data from a superseded 1989 calculation.
These problems were not noted by the earlier licensee reviews and were indicative of deficiencies iv the licensee's design control and verification process, and of the licensee's overview review in this area.
In spite of the increased focus on the engineering program, the backlog of open Engineering Evaluation Requests has decreased only about ten percent, to approximately 2000, during this evaluation period.
However, these'ave been prioritized by the 1icensee based on their significance.
Hanagement of engineering resources to address these items will require continued attention.
Training programs for Electrical Haintenance, and for Instrumentation and Controls Haintenance were found to be acceptable.
The licensee's efforts to implement the Systems Approach to Training for the technical staff appeared to be effective and generally supported by facility personnel.
Mith regard to enforcement in this area, with the exception of the emergency lighting civil penalty, all other violations were considered minor and did not indicate a programmatic breakdown.
2.
Performance Ratin Performance Assessment - Category
3.
Board Recommendations Efforts to clearly define the role of System Engineers should continue.
Corporate and Site Nuclear Engineerinq should solidify their organizations and continue to increase their involvement in site activities and problem resolution, however the roles and interfaces for all organizations need careful definition due to the organizational changes which have occurred.
The licensee should continue the emphasis being placed on responding conservatively, deliberately, and comprehensively to plant engineering problems, and ensure the involvement of all appropriate supporting organization J<(l i
,f r
I P
4'
'
18 G.
Safet Assessment/ ualit Verification 1.
~Anal sis During this assessment period, approximately 2457 inspection hours, approximately 33 percent of the total inspection effort, were expended by resident, region-based, and headquarters inspectors.
Included in this functional area are the inspection hours associated with followup to the emergency lighting problems and the restart of Units 1 and 3 following the issuance of Confirmatory Action Letters.
Inspections were conducted in the areas of Quality Assurance (QA)
and Quality Control (QC), Independent Safety Engineering Group (ISEG), Plant Review Board (PRB), Nuclear Safety Group (NSG),
Management Review Committee (MRC), Offsite Safety Review Committee (OSRC), Plant Safety Assessment Group (PSAG),
and the Licensing organization.
Licensee management demonstrated an increased degree of involvement in day-to-day activities which contributed to improvement in this area.
Although improvements were noted in all safety assessment groups required by Technical Specifications (TS),
and some instances of strong performance were observed, overall some of the groups are perceived as not performing as effectively as they could.
Licensee actions to correct past weaknesses regarding the problem identification and corrective action programs, root cause analysis programs, and the effectiveness of QA and oversight organizations, are apparent.
Although programs are in place and have improved, the resultant improvement in safety performance still remains to be fully demonstrated by more committed implementation and follow-through from all levels of the licensee's organization.
A past weakness regarding the lack of sufficient technically experienced staffing of the QA organization was in the process of being corrected by strengthening of the Quality Department staff.
Meaknesses of the NSG in its effectiveness in identifying and recommending changes to weak programs were noted to have improved during this assessment period.
NSG's assessments and recommendations regarding the PRB composition and the 10 CFR 50.59 program implementation appeared to be contributing to nuclear safety improvement.
Based on a NSG recommendation, the licensee submitted, obtained approval, and implemented a Technical Specification change to the composition of its PRB.
The inclusion of all Unit Plant Hanagers and the Director of Standards and Technical Support in the PRB appeared to initially have resulted in substantive review of plant problems and recommendations for resolution of those problems.
However, during the same period, the PRB's review of the October 20, 1990 Unit 3 simultaneous opening of seven Steam Bypass Control Valves and the associated reactor trip appeared to have been weak and was not sufficiently probing to identify that the condition had a potential of subjecting the plants to a condition that was beyond their design basis.
This demonstrates a continuing need to foster a probing and questioning attitude by all oversight groups.
ISEG was noted to also have made some improvements in its reviews and the presence of ISEG's engineers in the field was more visible.
However, the effective utilization of ISEG, the consistency of ISEG reports, and the technical accuracy of ISEG investigations continue to warrant improvemen The licensee utilized a non-TS required HRC to provide senior level.
oversight of restart activities associated with the extended shutdown of the units in 1989.
The HRC oversight appeared to have contributed significantly to minimizing problems associated with completion of restart action items and during the restart operations activities.
Upon restart of all the units the HRC was disbanded.
The advantages and benefits brought about by the HRC oversight were recognized by the licensee and were subsequently continued on to the operations phase by the formation of the OSRC.
The non-TS required PSAG appeared to have been contributing to plant safety in its review and generic evaluation of the various oversight committee reports and identification of safety concerns that were not readily apparent in the individual reports.
PSAG still had limited success in effectively coordiaating review activities of the various oversight groups.
Although overall performance in this functional area is considered
+o Rave -imprvrad ~";d ~he licensee's many initiatives are recognized, two escalated enforcement actions during the period create doubt regarding whether the improvements in this area can be sustained.
One civil penalty was related to long standing deficiencies in the emergency lighting area.
Of particular concern was both management's and gA's apparent reluctance to critically assess the technical situation and then deal with it promptly and thoroughly.
Mith regard M the civil penalty associated with operator medical records, the licensee had substantial prior notice of problems in the area, yet the full extent of the problems was only realized following an NRC inspection.
These two events bring into question the depth of senior management's commitment to critically assessing their organization, and to reacting decisively when significant issues demand it.
There were a number of other lesser enforcement actions in this area, however those lesser violations were not indicative of a major problem.
The licensee's quality verification functions were accomplished by second party (non-equality Department) verification, specified gC inspections, gA monitoring and gA audits.
The second party verification process and the gC inspection process generally met all requirements.
The licensee has implemented its HNCR and (DR corrective action programs and they generally appeared to be also effective and appeared to correct many of the previous programmatic weaknesses.
However, occasional weakness in the implementation of the programs have still been noted, as discussed in the maintenance section of this report, in the apparent occasional hesitance to write HNCRs or gDRs in favor of work requests or EERs.
equality monitoring was viewed as a strength of the licensee's gA program.
It was generally utilized effectively in areas of concern such as control room unit restart activities and provided primarily performance-based quality overviews of ongoing activities.
The quality of gA audits improved in scope and performance from previous years as demonstrated by audits performed on TS surveillances and on refueling operations.
The management of both the equality Audits and Honitoring and the equality Systems group were considered strengths
of the licensee's equality Department.
Significant support of, and involvement in the gA program by the Executive Vice President, Nuclear, was clearly demonstrated by his detailed comments and followup of both gA audits and audits of the gA program by independent parties.
The staffing level and qualifications of personnel in safety assessment and quality verification organizations generally appeared to be adequate.
Key positions in the equality Department and on the
.PRB, whose functions were previously performed on an acting bases, were filled late in the assessment period by the appointment of a equality Department Deputy Director and the appointment of a Manager of Plant Support, who serves as the PRB chairman.
The gC inspection staff assigned to perform inspections in the units appeared to be small and usually required significant contractor augmentation during major outages.
The small equality Systems staff appeared to be contributing significantly by its involvement in quality improvement projects, such as its cont'inying oversight of the nonconforming condition reporting program improvements and by its quality data evaluation, trending, and reporting.
The licensee self assessment programs included an electrical distribution system functional assessment, a diesel generator safety system functional inspection and independent audits/evaluations of the gA audit functions.
However, subsequent NRC inspections identified additional problems to those identified by these self assessments.
The licensee's action demonstrated a continuing desire to improve performance in this functional area, although more critical assessments are needed.
The NRC Office of Nuclear Reactor Regulation (NRR) staff conducted substantial review activities in support of licensee submittals during the assessment period.
The licensee's suhmittals were generally acceptable for the most part.
Occasional lapses were noted.
In one notable example, the licensee's original submittal to extend the interval for steam generator eddy current examination was inadequate because the licensee had submitted insufficient information.
As a result, the NRC staff could not perform an independent analysis to support the proposed amendment.
Subsequent inquiries by NRR revealed further pertinent information that was not included in the initial submittal.
Responses to generic communications were generally timely and appropriately detailed.
A cooperative attitude was exhibited throughout most discussions regarding the licensee's methodologies and basis for analysis as well as approach to resolution of issues.
The licensee's responses to NRR staff questions were generally complete and timely, thereby facilitating the staff's review.
2.
~Pf
RR Performance Assessment - Category
f
,I f
l
3.
Board Recommendations The Board assessment for this functional area recognizes the licensee initiatives to improve performance in this area.
However, the assessment was the result of considerable Board deliberation.
The Board strongly recommends continued attention to performance in this area.
The licensee needs to continue to require that the equality Assurance (gA} organization be more critical and aggressive in their reviews, such that major problem areas will be identified prior to becoming self-revealing.
Management fai lures to recognize problems and the lack of gA oversight in both the operator licensing medical records area and emergency lighting demonstrated a
continuing need for improvement.
The equality Department, the oversight groups, and engineering should develop a more questioning and probing attitude to ensure in-depth root cause review and thorough, prompt corrective actions.
Further strengthening of the-gC organization, gC inspections and line organization verifications is also recommended for continued good performance in this functional area.
Visible, strong support for the gA program, from all levels of management, should be demonstrated.
The licensing organization needs to increase awareness of plant operations and status, and ensure that all licensing submittals contain all information pertinent to the subject.
The communication and participation between the corporate organizations and the site (operations personnel)
also needs to be improved as discussed in the plant operations functional area, as a joint effort.
IV.
SUPPORTING DATA AND SUMMARIES A.
Licensee Activities During this assessment period, Units j. and 3 completed extended refueling outages which began in March 1989.
Numerous corrective actions were taken by the licensee in response to an NRC Confirmatory Action Letter based on the circumstances surrounding the unit shutdowns.
.Following selected NRC review of these actions, the letters were rescinded in December 1989 for Unit 3 and June 1990 for Unit 1.
Both units restarted immediately tollowing this NRC action.
Unit 2 operated during this assessment period, and also completed a five month refueling outage.
Specific operational events were as follows:
Vnit 1 Unit 1 was in Mode 6 in the midst of a refueling outage at the onset of this assessment period.
Fuel loading was completed and Mode 5 entered on January 9, 1990.
Mode 4 entry occurred on April 17, l990, and Mode 3 was entered on April 18.
The Unit was cooled down to Mode 5 on May 4, 1990, to repair Steam Generator tube leaks and a
Reactor Coolant Pump seal.
During mid-loop (reduced inventory}
operations, a complete loss of Shutdown Cooling was experienced on May 9, 1990.
Repairs were completed and Mode 4 was entered on June
i'
I
13, 1990, followed by Mode 3 entry on June 14.
The Confirmatory Action Letter of December 24, 1989, was lifted on June 24, 1990, and Mode 2 was entered that day.
On June 25, 1990, a manual reactor trip test was performed and the reactor was returned to Hode
operation.
A'lipped Control Element Assembly event occurred during startup testing.
Mode 1 was entered on June 30, 1990 and the Unit was brought to 100 percent power.
A reactor trip occurred on August 14, 1990, following a manual turbine trip initiated because of a loss of cooling to the main transformer.
The reactor was restarted on August 18, 1990, and Mode 1 was entered on August 19.
A forced downpower and manual reactor trip occurred on September 13, 1990, due to leakage past a primary Pressure Safety Valve.
The Unit was subsequently cooled down to Mode 5 for repairs.
Heatup to Mode 3 on September 19-20 revealed leakage from the pressurizer vent system, forcing a return to Mode 4 for repairs.
Heatup to Mode 3 was completed on September 23, 1990, and the reactor was started up on September 24.
A Hain Feedwater Pump tripped, causing a Reactor Power Cutback to about 50 percent power to occur on October 2, 1990.
The Unit was restored to full power. operation the same day.
Power was reduced to about 64 percent on November 24-25, 1990, to allow repair of secondary equipment.
The Unit was operated at 100 percent power for the remainder of the assessment period.
Unit 2 Unit 2 began this assessment period in Mode 3 to resolve CEDH ground indications, incorrect HPSI flow orifices, and brittle restraining pins in containment purge valves.
A reactor trip occurred on November 1, 1989 due to three independent problems in the Plant Protection System.
A three week shutdown resolved these issues and other maintenance work was accomplished.
During the heatup in Mode 4,
RCS heatup rate limits in the Technical Specifications were exceeded and the plant was returned to Mode 5 to assess the impact and need for corrective measures.
After one week, the plant startup was delayed after reaching Mode 2 due'to CEA grounds, but the unit achieved 100 percent power on December 5, 1989.
The reactor was shutdown on February 23, 1990.to commence the second refueling outage.
This outage included defueling the reactor, steam generator inspection and tube plugging, reactor coolant pump overhaul, CEA repair for grounds, and diesel generator
"8" overhaul.
The reactor entered Mode 2 on July 14, 1990 and following a series of unrelated problems with high condens'er sodium levels, loss of power to a cooling tower, a tripped condensate pump, and a
COLSS failure, the unit achieved consistent 100 percent operation on August 17, 1990.
The unit operated at approximately this power. for the remainder of the assessment period.
Unit 3 The unit began the SALP period in Mode 5 in its first refueling outage.
At the completion of outage work the unit entered Mode 3 on November 30, 1989, then returned to Mode 4 for several days due to
problems with steam-driven auxiliary feedwater pump pressure oscillations.
When these problems were resolved the unit returned to Node 3.
Additional auxiliary feedwater pump work necessitated a
second-return to Mode 4 on December 22, 1989 and the unit returned to Mode 3 on December 24, 1989.
The NRC lifted the Confirmatory Action Letter dated June 28, 1989 on December 24, 1990, permitting entry into Mode 2.
On December 26, 1989 the unit entered Mode 2 and began low power physics testing.
An internal fault on the "A" phase main transformer occurred shortly after the main generator was synchronized to the grid and the reactor was manually shutdown to Mode 3.
Node 2 was entered on January 18, 1990 after replacement of the transformer and the unit entered Mode 1 on January 19, 1990.
Power ascension testing followed and the unit increased power to 98 percent while the licensee evaluated the reason for output megawatts being higher than expected.
Resolution of the output megawatts issue permitted the unit to proceed to 100 percent until a reactor trip occurred as a result of a dropped rod on April 14, 1990 during monthly CEA testing.
The unit proceeded from Node 2 to Node 1 on April 19, 1990 and increased power to 90 percent where it remained for repairs of feedwater heaters 5B and 6B.
Repair of these heaters required a downpower to 50 percent and the unit proceeded to 100 percent on April 29, 1990.
On May 29, 1990 a reactor cutback occurred due to the tripping of the "A" main feedwater pump during preventive maintenance.
The unit returned to 100 percent power on May 30, 1990 where it remained except for minor testing until a slipped CEA and unsuccessful recovery required an orderly shutdown on August 5, 1990.
The unit returned to Node 2 later that same day but returned to Mode 3 because of additional CEA problems.
Repairs were completed and the unit proceeded through Mode 2 to Mode 1 on August 7, 1990.
The unit reached 100 percent power on August 9, 1990 and remained there until a reactor cutback occurred on September 8,.1990 due to a trip of the "B" main feedwater pump due to a failed logic control circuit card.
The unit returned to 100 percent power on September 9, 1990.
A reactor trip occurred on October 20, 1990 as a result of a sudden opening of all in-service steam bypass control valves.
The unit proceeded to Mode 2 and Mode 1 on October 21, 1990 and reached 100 percent power on October 23, 1990.
On October 30, 1990 the "A" emergency diesel generator tripped on a faulty vibration switch.
The switch was repaired and the diesel generator was returned to operability within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.
,The unit was forced to reduce power on November 26, 1990 because of a
COLSS malfunction.
The unit returned to 100 percent power later that day and remained at 100 percent until the end of the SALP period.
B.
Direct Ins ection and Review Activities Three resident inspectors were assigned to Palo Verde during the SALP assessment period.
Forty-six routine and special inspections were conducted during this period. Significant team inspections included
f (
l I
f
I l
.
er 2.
On December 26, 1989 the beg, hysics testing.
An internal main
".curred shortly after the m
synchro grid and the reactor was Mode. 3.
+tered on January 18,
the tran e unit entered Hode 1 o Power asc.
followed and the unit percent wh,
.e evaluated the reas being highe>
Resolution of th issue permitt proceed to 100 pe trip occurred, a dropped rod on monthly CEA tes.
+ proceeded from April 19, 1990 ai.
iwer to 90 perce for repairs of fee 5B and GB.
R required a downpowe.
and the un'ercent on April 29, 9,
1990 a
occurred due to the t>
preventive maintenance.
rned to May 30, 1990 where it re.
r mino slipped CEA and unsuccess, uired on August 5, 1990.
Theun'de but returned to Mode 3 becau
+a+ al C
- were completed and the unit p.
'qh August 7, 1990.
The unit reaci 1990 and remained there until a September 8, 1990 due to a trip c
to a failed logic control circuit.
percent power on September 9, 1990.
October 10, 1990 as a result of a su~
steam bypass control valves.
The unit, 1 on October 21, 1990 and reached 100 p, 1990.
On October 30, 1990 the "A" emerge tripped on a faulty vibration switch.
Th~
the diesel generator was returned to operab The unit was forced to reduce power on Novem, a
COLSS malfunction.
The unit returned to 10'hat day and remained at 100 percent until the period.
B.
Direct Ins ection and Review Activities with steam-driven auxiliary feedwater pump pressure ins.
When these problems were resolved the unit returned Additional auxiliary feedwater pump work necessitated a
'n to Mode 4 on December 22, 1989 and the unit returned
')ecember 24, 1989.
The NRC lifted the Confirmatory iated June 28, 1989 on Oecember 24, 1990, permitting unit entered Mode 2 and fault on the "A" phase ain generator was manually shutdown to 90 after replacement of n January 19, 1990.
increased power to 98 on for output megawatts e output megawatts rcent until a reactor April 14, 1990 during Mode 2 to Node 1 on nt where it remained epair of these heaters t proceeded to 100 reactor cutback eedwater pump during 100 percent power on r testing until a an orderly shutdown 2 later that same day EA problems.
Repairs Mode 2 to Mode 1 on power on August 9,
.k occurred on feedwater pump due
't returned to 100 ip occurred on all in-service Node 2 and Node n October 23, aerator
~paired and
'2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.
ecause of
~ later p
Three resident inspectors were assigned to Palo Verde SALP assessment period.
Forty-six routine and special were conducted during this period. Significant team insl.
included
NRC Diagnosti c Eval uati on Training Inspection Electrical Distribution System Functional Inspection A total of over 7378 hours0.0854 days <br />2.049 hours <br />0.0122 weeks <br />0.00281 months <br /> of direct inspection were performed during this SALP period.
In addition, three Enforcement Conferences and four Management Meetings were held with APS.
C.
Enforcement Activit The 46 inspections conducted during this a'ssessment period iden%Hied approximately 66 cited violations and approximately 26-non-cited violations. Although counted individually, many of those violations were common to multiple units.
The significant violations are discussed in the individual performance analysis sections of this report.
Fifteen of the violations identified during this assessment period involved Emergency Lighting and 10 CFR Part 50, Appendix R, Fire Protection Program violations, and licensed operator medical records violations.
Those violations resulted in the imposition of a
$125,000 and a $75,000 civil penalty respectively.
D.
AEOD Event Anal sis The Office for Analysis and Evaluation of Operational Data (AEOD)
reviewed the licensee's events and provided the following input.
Arizona Public Service Company submitted 28 Licensee Event Reports (LERs) for the three units at Palo Verde, not including updates, in the assessment period from November 1, 1989 to November 30, 1990.
The AEOD review included the following LER numbers:
UNIT 1 UNIT 2 UNIT 3 89-021 to 89-024 90-001 to 90-008 90-001 to 90-009 The review of these LERs follows:
1.
Im ortant 0 eratin Events89-011 90"001 to 90-006 None of the LERs submitted in the assessment period were identified as important operating events by the AEOD screening and review process.
However, the review did not include the reactor trip at Unit 3 on October 20, 1990 that resulted in all steam bypass valves opening or the identification that the jacket water return line supports for both emergency diesel generators at Unit 2 did not meet seismic qualifications on November 10, 1990 because the respective LERs have not been received at the time of this revie Y ~
t I
2.
AEOD Technical Stud Re orts No AEOD technical studies were initiated from the reports submitted by Arizona Public Service Company for Palo Verde Units 1, 2, and 3 in the assessment period.
3.
Abnormal Occurrences There were no events classified as AOs at Palo Verde during this period.
In addition, no events were reported as Appendix C items ("Other Events of Interest" ) jn the quarterly AO reports.
4.
~BD.72 R
The licensee submitted 52 50.72 reports'n the assessment period.
Many of these reports were duplicates for each unit.
These reports were compared to the 50.73 submittals to determine if the licensee is reporting all LERs that they are required to report.
All events reported by these calls were addressed by an LER, were too recent for an LER to be received or were not reportable under 10 CFR 50.73.
5.
LER ualit The LERs reviewed were professional quality technical reports.
The information was well organized, detailed, informative and submitted on time.
Many reports were updated as more information became availabl ai.~
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