IR 05000528/1992012

Insp Repts 50-528/92-12,50-529/92-12 & 50-530/92-12 on 920406-10.Weaknessess Noted.Major Areas Inspected:Emergency Operating Procedures

ML17306A768
Person / Time
Site:	Palo Verde
Issue date:	05/14/1992
From:	Miller L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML17306A767	List: IR 05000528/1992012 ML17306A766
References
50-528-92-12, 50-529-92-12, 50-530-92-12, NUDOCS 9206080212
Download: ML17306A768 (52)

Text

U. S. NUCLEARREGULATORYCOIVMISSION INSPECTION RRZ'ORT

DOCKET/REPORT NOs. 50-528/92-12, 50-529/92-12 and 50-.530/92-12 LICENSE NOs.

LICENSEE:

FACILITY:

NPF-41, NPF-52 and NPF-74 Arizona Public Service Company Post Office Box 52034 Phoenix, Arizona 85072-2304 Palo Verde Nuclear Generating Station Units 1, 2 and 3 Wintersburg, Arizona INSPECTION DATES:

April 6 -,10, 1992 INSPECTION TEAM:

Team Leader:

Team Members:

B. Norris, Project Engineer, NRC, RI D. Pereira, Examiner, NRC, RV J. Russell, Examiner, NRC, RV B. Olson, Project Inspector, NRC, RV D. Schultz, Systems Engineer, COMEX M. M'Williams, Human Factors Specialist, SAIC APPROVEDBY's F. Miller, Jr., Chief Reactor Safety Branch Date There are four Attachments to this report:

Attachment 1 Exit Meeting Attendees Attachment 2 Documents Reviewed Attachment 3 Procedural Deficiencies Attachment 4 Open Items Identified e

9206080212 9205i5 PDR ADOCK 05000528

PDR

o TABLEOF CONTENTS EXECUTIVE SUMMARY oo'

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~ ll 1.0 INTRODUCTION; 1.1 Background...

1.2 Scope 1.3 Methodology..

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2.0 COMPARISON OF OWNERS'ROUP ERGs WI'MFACILITY'S 2 ~ 1 Purpose

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2..2 Methodology...............................

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EOPs

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3.2 Methodology......

3.3 Findings.........

3.4 Human Factors Review

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3.0 REVIEW OF EOPs BY CONTROL ROOM AND PLANT WALKDOWNS

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4.0 TRAINING 4.1 Purpose..

4.2 Methodology..

4.3 Findings.....

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10-5.0 REVIEW OF PROGRAMS 5.1 Purpose......

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5.2 Methodology.....,

5.3 Findings........

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FOR CONTINUINGEVALUATIONOF THE EOPs 12.

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... 12 6.0 INTERVIEWS 6.1 Purpose....;,

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6.2 Methodology....

6.3 Findings.......

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... 13

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'7.0 UNRESOLVEDITEMS...................................

8.0 EXITMEETING....... ~,.....,.....

EXECVIXVE INTRODUCTION Previous inspections of the Emergency Operating Procedures (EOPs) at Palo Verde noted that the procedures were overly complex and had numerous inconsistencies.

This inspection had three objectives:

(1) to verify that the new Palo Verde EOPs were technically correct; (2) that

'their specified actions could be meaningfully accomplished using the existing equipment, controls, and instrumentation; and (3) that the available procedures had the usability necessary to provide the operators with an effective operating tool. In addition, the team was to ascertain the licensee's success in resolving past problems with the EOPs.

OVI34Q L CONCLUSIONS The team determined that the operators would be able to use the new EOPs to mitigate emergency or accident conditions.

The licensee had made substantial progress in correcting previous problems through an intensive upgrade program involving a multi-disciplined approach and dev<;lopment of a comprehensive writers'uide.

Nevertheless, several significant problems still existed, some of w':.'ch should be corrected prior to implementation of the new procedures.

At the exit meeting, senior management committed to make those identified corrections.

Most of the issues identified would have been recognized earlier by the licensee if an aggressive verification and validation program was in place, including an independent quality review process.

COMPARISON OF OWNERS'ROUP ERGs WITH FACILITY'SEOPs In general, the EOPs were technically adequate and accurately incorporated the procedural guidance of the Combustion Engineering Owners'roup, as defined in CEN-152, "Combustion Engineering Emergency Procedure Guidelines."

Significant deficiencies which warrant immediate attention include: (1) inadequate isolation strategy for a loss of coolant accident outside ofcontainment, (2) conflicting information when confronted with a steam generator tube rupture in one steam generator coincident with an excessive steam demand event in the other steam generator, (3) incomplete information when adverse containment conditions exist, and (4)

inconsistent application of CEN-152 standard post trip actions with regard to verification of

'safety functions.

REVIEW OF EOPs BY CONTROL ROOM AND PLANT WALKDOWNS The licensed and non-licensed operators were generally able to complete the procedures, as written.

Numerous labeling inconsistencies were noted; the licensee recognized this problem and already had a program initiated to ensure that accurate labels were on the component t

TRAINING EOP lesson plans were reviewed and found to be technically adequate.

Observation of licensed operators in the simulator identified that the procedures generally were adequate.

The training staff was quick to correct operator performance problems observed during training. Specifically, command and control of a crew improved after remediation by the training staff, and the crew'

management.

One concern was conflicting direction given to the operators with respect to procedural adherence when in the EOPs; the licensee committed'to clarifying management's expectations in this area.

ON-GOING EVALUATIONOF THE EOPs The teani found that some aspects of the Palo Verde system for on-going evaluation were well done; specifically, a comprehensive Writers'uide was developed and a multi-disciplined approach was adopted.

Nonetheless, one important aspect was missi'ng, namely, an independent quality review of the'process.

Although the Quality Assurance organization was involved to some degree, the involvement was lacking in several areas.

QA did not perform any independent validation of the procedures, and there was minimal oversight of the verification process.

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DETAILS 1.0,INTRODUCTION 1.1 Background The last inspection of the Palo Verde Nuclear Generating Station Emergency Operating Procedures (EOPs) was conducted in March 1989. Atthat time, itwas noted that the procedures were overly complex and had numerous inconsistencies, but that the operations staff could utilize the EOPs to mitigate an accident condition.

These findings were consistent with earlier inspections of the EOPs, indicating that, at that time, the fundamental problems affecting quality and useability of,the EOPs had not been corrected.

Other concerns identified in the earlier inspections included the inabilityofthe simulator to replicate certain plant conditions, and a poor working relationship between the training and operations organizations.

After the March 1989 inspection, the licensee outlined a program to completely revise the EOPs.

The inspection recommended that Palo Verde adopt a multi-disciplinary approach for the EOP revision, including extensive human factors input, a well defined verification and validation progran, and use of a full scope writ",r's guide..Based on the magnitude of revision'required, Palo Verde committed to a complete rewrite ofthe EOPs, with an initialcompletion date ofJuly 1990. Since the effort was more extensive then expecte'd, the new revision was later rescheduled for implementation by May 22, 1992.

After this inspection, the implementation date was amended to August 17, 1992, to complete essential corrective action from this inspection and from additional licensee verification and validation program findings.

1.2 Scope The scope of the inspection was to evaluate the new revision of the licensee's EOPs, and to ascertain the lice'nsee's success in resolving past problems with the EOPs.

The inspection team was chartered with three objectives:

(1) to verify that the Palo Verde EOPs were technically correct; (2) that their specified actions could be meaningfully accomplished using the existing equipment, controls, and instrumentation; and (3) that the available procedures had the usability

'necessary to provide the operators with an effective operating tool. Inspection procedure 42001,

"Emergency Operating Procedures,"

was used as guidance by the inspectors.

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" Methodology To measure the overall effectiveness of the EOPS, the team performed a detailed review of the EOPs against the Combustion Engineering Owners'roup (CEOG) recommended procedure guidelines.

This included a technical review of some of the procedures, a walkdown in the plant and control room of selected portions of the procedures, and interviews with the staf.0 COMPARISON OF OWNERS'ROUP ERGs WITHFACILITY'SEOPs 2.1 Purpose The purpose of this functional area was to ensure that the licensee had developed sufficient procedures in the appropriate areas to cover the broad spectrum of anticipated accidents and equipment failures, and to assure that the procedures were technically adequate and accurately incorporated the guidelines of the Owners'roup Emergency Response Guidelines (ERGs).

2.2 Methodology 2.2.1 Basic Comparison I

I The list of Palo Verde EOPs was compared to the CEOG list of ERGs contained in CEN-152, Revision 3, to ensure that the licensee had developed the basic procedures in accordance with the CEOG recommendations.

2.2.2 Technical A adequacy Review of EOPs The Palo Verde EOPs were reviewed to ensure that the procedures were technically adequate and had accurately incorporated the guidelines of CEN-152, Revision 3.

This encompassed a

verification that:

(1) the vendor step sequence was followed, (2) the exit and entry points were correct, (3) the transfer points between procedures were defined and appropriate for procedures performed consecutively, (4) the notes and cautions were used appropriately, and (5) the minimum staffing was adequate.

Based on CEN-152 guidance for developing and writing of EOPs, Palo Verde developed a Plant Specific Technical Guideline (PSTG) for each of the required procedures.

Generally, it is common practice to include within the PSTG a correlation, between the EOPs and the recommendations of CEN-152, and a written justification ifthe step sequence is not followed, or ifa recommended step is not utilized.

Each deviation from CEN-152 was reviewed to determine that:

(1) safety significant deviations

.were reported, (2) all deviations wa'rranted by plant specific design were incorporated, and (3)

prioritization of accident mitigation strategies were correct.

Adverse containment values were also reviewed for inclusion in the procedures.

2.3 Findings 2.3.1 The team determined that, in general, the EOPs accurately incorporated the procedural guidance of CEN-152 and were technically adequate.

This determination was based on the following observations during the review of the Palo Verde procedures:

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By a review of the table of contents of the EOPs, it was determined that the facility had adopted a basic philosophy for the EOPs consistent with CEN-152.

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Generally, the EOPs followed the CEN-152 step sequence, with'etailed operator actions to place the plant in a stable condition.

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Entry points for the EOPs were clearly stated and could be followed by trained reactor operators.

Exit from the EOPs to the Functional Recovery Procedure was required ifthe Safety Functions status checks indicated a loss of another safety function.

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Notes and cautions within the EOPs were generally clear and appropriately located in the procedures;

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Plant specific values were consistent with the plant design.

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The CEN-152 prioritization of the accident safety function hierarchy was maintained within the EOPs, 2.3.2 During the inspection, the team identified a number of technical deficiencies.

Certain of

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those deficiencies were significant enough that corrective actions were requested prior to implementation of the new revision of the EOPs.

Those particular concerns are listed in the following paragraphs.

The licensee agreed to incorporate these changes prior to the EOP implementation, and to train the operators on the changes.

2.3.3 If a loss of coolant accident (LOCA) occurs outside of containment, CEN-152 recommends that action be taken to locate and isolate the leak. Ifthe leak cannot be located or isolated, CEN-152 directs initiation of a rapid cooldown to minimize the loss of reactor coolant inventory to the environment.

The EOPs did not adequately address the isolation of a leak outside of containment, and subsequently, delayed the restoration ofcontainment integrity. Also, the EOP did not implement

, the rapid cooldown at a point equivalent to the CEN-152 step sequence, but much later within the procedure.

When the procedure did direct a cooldown, itwas a controlled vice a rapid plant cooldown. The urgency implied by CEN-152 was not transferred to the station EOPs, nor was the deviation adequately justified.

Prior to implementation, the licensee committed to revise the LOCA procedure to address the leak outside of containment, and to revaluate the step sequence for the cooldown.

This is an open item.

(Inspector Followup Item 92-12-01)

2.3.4 The operators were directed to go to the "Functional Recovery" procedure, 41EP-1RO08, in the event of a steam generator tube rupture (SGTR) in one steam generator and an excessive steam demand event (ESDE) in the other steam generator.

As a result of the SGTR, step 3.22

of the procedure directed the Control Room Supervisor (CRS) to continue within the procedure and to concurrently perform Attachment 5 to the procedure.

Concurrent performance of procedures is contradictory to CEN-152 guidance.

Secondary consequences of this concurrent performance were:

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Contradictory steps - example:

step 3.26 of the procedure directed the isolation of the steam generator affected by the ESDE.

However, step 5.8 of Attachment 5 specified raising the level of both steam generators prior to initiating a plant cooldown.

The steps were contradictory in that the level of the isolated steam generator could not be raised ifit were isolated.

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Do loop - after completion of Attachment 5, the operators were directed to return to step 3.14 of the procedure.

In step 3.22, the operators would again be directed to Attachment 5 as a result of the SGTR.

This cycle could continue forever so that no progress in the procedure would occur past Step 3.22.

Prio. to'mplementation, the licensee indicated that the Functional Recovery procedure would be revised to correct the discrepancies identified.

This is an open item.

(Inspector Followup Item 92-12-02)

2.3.5 High containment temperature can adversely impact the accuracy of instruments whose transmi'tters are located inside containment (e.g., pressurizer level and pressure, steam generator pressure and level, etc.). AtPalo Verde, when containment temperature exceeds 150'F, adverse containment conditions exist, and operators are expected to take into account possible instrument inaccuracies in using the EOPs.

Although a separate pressure/temperature limit curve was provided for adverse containment conditions, only a list of instrument inaccuracies was provided for other parameters, such as pressurizer level. The list did not indicate whether the inaccuracy was to be added or subtracted to the normal values or ranges.

NUREG-0899, "Guidelines for,the Preparation of Emergency Operating Procedures,"

states that the calculations within the EOPs should be minimized because of the time required and the possibility of operator error.

When calculations are required; they

,should be as simple as possible.

Although the STA may be available to assist in calculating the new values using this table, this would be a cumbersome and unreliable method of dealing with the adverse containment issue.

'During interviews, some operators expressed significant reservations regarding their ability to effectively perform these calculations while working through flow charts and other procedures.

Prior to implementation, the licensee agreed to incorporate the adverse containment values directly into the EOPs, thereby eliminating the need for calculations.

This is an open item.

(Inspector Followup Item 92-12-03)

2.3.6 The first procedure in the CEOG recommendations is a check of the safety functions against acceptance criteria.

All safety functions are checked to give the operators a complete status regarding plant conditions. The licensee's equivalent procedure, "Emergency Operations,"

41EP-1EO01, contained three deviations from CEN-152 that could not be adequately justified.

They are:

~ If no 4.16 kilovolt (kV) alternating current (AC) vital buses were energized, the EOP directed a transition to the Blackout procedure, "Blackout," 41EP-lR007, prior to completion of the check of the safety functions.

CEN-152 checks all safety functions prior to any transitions.

~ Ifall vital AC and vital direct current (DC) busses were deenergized, CEN-152 directs the operators to the Functional Recovery Procedure; Palo Verde directs the transition to the Blackout procedure.

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One of the parameters'reviewed according to CEN-152 is the combustible gas concentration in the containment.

The licensee did not address this parameter in the Emergency Operations procedure.

e Prior to implementation, the licensee agreed to revise the Emergency Operations procedure to correct these deficiencies.

This is an open item.

(Inspector Followup Item 92-12-04)

2.3.7 Other concerns identified during the technical review were specific to individual procedures and are listed in Attachment 3 to this report.

These concerns focused on the areas listed below:

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Written justification in the PSTG for deviations from CEN-152 was sometimes insufficient, and further information needed to be provided to clarify acceptability of the deviation.

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In some cases, even with additional information, the basis for the deviation was not adequate and did not support the deviation.

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The wording and detail contained in similar steps within a procedure, between procedures, and between the PSTG and the associated procedure, was frequently inconsistent.

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The ordering of some procedural steps was not adequately verified prior to approval of the procedure.

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The conventions contained within the Writer's Guide are not consistently applied.

In response, the licensee. acknowledged the deficiencies.

For future revisions of the EOPs, the licensee agreed to review each identified technical deficiency and either correct the specific

problem or to provide adequate justification why it was not a deficiency.

In some'cases, the deficiencies had been identified by the licensee and corrective action had already been started.

The team determined that the specific resolutions presented by the licensee were acceptable.

The deficiencies identified in Attachment'3 are an open item.

(Inspector Followup Item 92-12-05)

3.0 REVIEW OF EOPs BY CONTROL ROOM AND PLANT WALKDOWNS 3.1 Purpose The purpose of this'unctional area was to assure that the emergency operating procedures could be successfully accomplished using the existing equipment, controls, and instrumentation.

Walkdowns,were also used to confirm the merit of issues identified during the technical review of the EOPs. Methodology The inspectors walked down approximately 10 percent of the procedures and associated'ppendices listed in Attachment 2 to this report. The procedures were reviewed against both the

'ontrol room and the plant, as appropriate.

The inspectors were accompanied by a Palo Verde licensed reactor operator (RO) or an auxiliary operator (AO) during the walkdowns.

Significant observations made during the walkdowns were summarized on a daily basis for licensee representatives.

3.3 Findings 3.3.1'uring a walkdown; one inspector noted that the Automatic Feed Actuation System (AFAS) reset setpoint was set at 40.8% wide range steam generator level.

A comparison of Chapter 15 of the Palo Verde Updated Final Safety, Analysis Report (UFSAR) indicated that the

. AFAS reset setpoint was 80% wide range steam generator level.

This discrepancy was previously noted by the licensee's Quality Assurance department setpoint methodology audit in September, 1991.

As a result, a Quality Deficiency Report (QDR) was issued requesting clarification of this difference in AFAS reset setpoints on the setpoint document.

The facility's Nuclear Fuel Management group conducted a review, dated March 24, 1992; this review indicated that the AFAS reset setpoint had been changed from 30.8% to 40.8% in November 1984 in accordance with a Combustion Engineering memorandum.

The AFAS setpoint has

. remained at 40. 8% wide range steam generator level since commencement ofpower operations.

The UFSAR setpoint of 80% wide range steam generator level is the bounding limit for the analyses conducted in Chapter 15 of the UFSAR and has not been changed.-

This item is considered closed.

3.3.2 Palo Verde contracted with Combustion Engineering (CE) to perform a review of the

3.3.2 Palo Verde contracted with Combustion Engineering (CE) to perform a review of the PSTGs against CEN-152 to ensure that all deviations had been identifie, and that all deviations had adequate justification. The CE review was completed on April 2, 1992,. just prior to the inspection.

Due to the short time between the CE review and the NRC inspection, it was not feasible to review the CE comments nor the licensee's actions based on those comments.

The licensee agreed to an NRC request that the CE comments be reviewed, and that any safety significant procedure changes would be incorporated prior to the implementation of the EOPs.

The review of the licensee's actions to incoqmrate the CE study recommendations, as appropriate, is an open item.

Pnspector Followup Item 92-12-06)

3.3.3 In the east penetration room of the auxiliary building, there was a temporary effluent sample monitor (RU-52) staged in a permanent manner as a back up to RU-01.

The monitor was energized and connected to the radiation monitoring system via a temporary connection box.

The monitor was not installed in accordance with the licensee's temporary modification system, and has reportedly been in place for many years.

RU-52 is described in the UFSAR, Section 11.5, as the "movable airborne monitor" attached to a "portable monitor connection box."

The inspectors observed that ifit was intended that RU-52 be a permanently installed back up t

to RU-01, then the UFSAR should have been revised to reflect this design change.

This is an unresolved item.

(Unresolved Item 92-12-07)

3.3.4 Palo Verde Technical Specification 6.2.2 specifies the minimum shift crew composition during all modes of operation.

This specification requires only two AOs to be on-shift during plant operations.

The team observed instances where implementation of the EOPs would require more than two AOs to perform the tasks.

An example of this was:

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The procedure for a loss ofall AC electrical power, "Blackout," 41EP-1RO07, would require AOs to operate steam generator atmospheric dump valves, start emergency diesel generators, align circuit breakers, start and operate auxiliary feedwater pumps, and regulate nitrogen pressure to the instrument air header.

This would require at least four AOs.

The licensee indicated that the existing administrative requirement for a minimum of four AOs per shift would be maintained.

The inspectors concluded that this licensee commitment adequately addressed this issue.

This item is closed.

3.3.5 In addition to the deficiencies discussed above, the inspectors identified other weaknesses pertaining to individual procedures.

These comments are includ'ed in Attachment 3 to this report.

The weaknesses are generally categorized in the following areas:

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The procedure would not work as written.

~ Allof the options recommended by CEN-152 for addressing a particular event or component malfunction were not utilize ~

The inability of the AOs to communicate with the control room during a casualty due to physical constraints or radio interference.

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Labeling inconsistencies between plant equipment and EOP nomenclature.

These deficiencies willbe addressed similarly to those identified in Section 2.3.7.

3.3.6 While performing the walkdowns, the inspectors noted three issues that could affect personnel safety, especially when responding to an emergency situation in less than ideal conditions.

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The licensee did not require the wearing of hardhats while in the auxiliary building.

The team observed areas in the auxiliary building where overhead pipe supports and hangers could result in an injury, particularly when normal lighting was not available.

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The team observed areas in the auxiliary building where exit signs were not specific.

The exit sign directed personnel to open stairwells.

Once in the stairwell, personnel were not.

directed by signs as to the direction to proceed for the exit.

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The entry turnstile to the auxiliary building was such that a person could become trapped within the turnstile without being able to free himself, The licensee was informed of each of these conditions and acted on them expeditiously.

This item is closed.

3.4 Human Factors Review The Palo Verde EOPs were reviewed for consistency with human factors principles, as prescribed in NUREG-0899,

"Guidelines for the Preparation of Emergency Operating Procedures,"

and the Palo Verde "Emergency Procedures Writers Guide." 40DP-9AP02.

In general; the writer's guide was found to provide clear, comprehensive instructions for procedure development, and the procedures were found to incorporate sound human factors guidance.

While examples were found where the guidance was not adequately incorporated, it did not

..appear to be the result of general programmatic weaknesses, as was identified during the 1989 EOP inspection.

Overall, the procedures reflected significant improvements in the human factors area, and were indicative ofa multi-discip>inary effort to develop and use a comprehensive EOP writer's guide.

Specific areas of improvement included:

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Minimal transitions outside of the EOP set, with consistent methods for transitions, when required.

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Elimination of vague terminology, and instructions.

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Increased detail for accomplishing task e

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Prioritized methods when multiple options exist.

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Incorporation of component identification numbers and locations for in-plant equipment.

Despite the overall improvements in usability that were observed, a number of problems remained.

A description of these inconsistencies follows, with additional examples contained in Attachment 3.

3.4.1 Although the EOPs generally complied with the writer's guide requirement to provide component name and identification number forinfrequently used equipment, inconsistencies were observed.

These included:

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Inconsistencies in the methods of presenting the equipment identification numbers.

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Inconsistencies between the name found on the label and the name referenced in the procedure.

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Inconsistencies between equipment references in the same procedure (e,g. sometimes common name only, sometimes common name and label plate number, and sometimes label plate name and number).

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Inconsistencies in capitalization of references to label plate names.

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Cautions incorrectly identified as notes and placed following the applicable step.

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After having the operator position breakers, the procedure required the operator to recall the positions of the breakers.

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Inconsistencies between units for color bandings on instrumentation.

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A decision table governing the adjustment of auxiliary feedwater valves was not included for all applicable steps, 3.4.2 Other specific concerns included:

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The writer's guide defined several terms as having specific meanings.

The distinctions made by these terms impacted the way procedural steps would be interpreted and completed.

In some cases, these distinctions were not maintained in the emergency procedures.

As an example, the terms "check" and "ensure" were to be used to differentiate between when an operator is to observe a condition (check) as opposed to when the operator is to take actions to effect the desired condition (ensure).

This distinction was not maintained throughout the emergency procedures.

Other instances were found of "verify" being used in place of "ensure", "any" versus "all", and "if"versus "when".

I

.

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A number ofadministrative or typographical errors were found in the procedures.

The large number of errors was unexpected in a set of documents that should have been subjected to a thorough review, including a formal verification and validation program.

Although most of the specific errors observed were minor in nature, references to incorrect step numbers can be confusing and can result in improper actions being taken.

Other errors included incorrect page numbering, missing words, misspelled words, and grammatical inaccuracies.

4.0 TRAINING 4.1 Purpose.

The purpose of this functional area was to ensure that EOP training had provided the operators with the necessary information background and to ensure that the EOPs could be correctly implemented under emergen'cy conditions.

4.2 Methodology Normally, the major portion of this functional area would be accomplished by the observation of a normal shift crew during unrehearsed operations in the site specific simulator.

The scenarios used would be designed to exercise the crew's familiarity and ability to utilize the emergency procedures.

Because the EOPs had not yet been implemented nor completely trained on, this portion of the inspection was postponed.

The inspectors examined the training provided to the operator for use of the EOPs, both technical and administrative.

Specifically:

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Review of the lesson plans for technical completeness.

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Review of the attendance records to ensure that all operators had received training on the revised EOPs.

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Verification that the requalification training assured that the licensed operators maintained proficiency on the current EOPs during the transition to the new EOPs.

" 4 3 Findings 4.3.1 The Palo Verde EOPs are written in columnar format; the left column is "Actions" and the right column is "Details." The licensee described the left column as the "step," all of which'ad to be completed; and the right column as the "guidance" as to how the step was to be completed.

At first, the licensee stated that all of the components of the Details column did not have to be completed, as long as the operator felt that the intent of the step had been accomplished.

The inspector questioned the expectations of Palo Verde management as to the procedural adherence requirements for the licensed reactor operators.

Upon further discussion, the licensee clarified their earlier explanation, They stated that the operators were expected to

complete all portions of the Details column; ifthat was not possible, then the operator was expected to inform the Control Room Supervisor and obtain concurrence for a procedural deviation.

This expectation was not explicit in the procedure that discussed procedural usage,

"Emergency Operating Procedures Technical Guidelines,"

40DP-9AP05.

The licensee committed to revise 40DP-9AP05, prior to the EOPs becoming effective, to make the stated expectations for procedural adherence explicit. The licensee also committed to reinforce this expectation during the next training cycle on the EOPs.

This is an open item.

inspector Followoup Item 92-12-09)

4.3.2 The inspector observed training of licensed operators during exercise scenarios on the simulator. In general, the inspector observed that the EOPs did not cause operators to physically interfere with each other, nor to unnecessarily duplicate actions.

I Weaknesses identified by the inspector were also identified by the training staff and noted to the trainees.

Specifically, the command and control function during a normal reactor trip recovery was less formal than expected.

After a critique by the training staff, the inspector noted that, in subset ent events, the command and control function was more evident.

4.3.3 The inspector reviewed several lesson plans for the EOPs and determined that they were technically adequate.

The lesson plans included the technical basis, and were structured to provide detailed information for each EOP.

The training schedule indicated that all licensed operators would have at least two cycles of training on the revised EOPs prior to implementation.

The inspector verified that proficiency on the current EOPs was being maintained while the training for the new EOPs was being conducted.

4.3.4 During the walkdowns, several issues were identified concerning the training of the Auxiliary Operators (AOs):

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The licensee had not cross referenced the tasks contained within the EOPs to the Job Task Analysis used for the qualification card of the AO to ensure that the AOs had been trained on all EOP tasks.

For example, the AOs had not been trained on how to place a differential pressure cell into service.

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For EGP training, the AOs were provided an overview of the EOPs, but not detailed directions on the implementation of the EOPs.

For example, the AOs had not been trained on the difference between "check'nd "ensure."

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One AO was not able to properly check a valve in the open position. Initial and continuing training lesson plans indicated that training had been conducted on the proper method for verifying valve position; i.e., that an open valve was checked in the closed direction, then returned to the fullyopened position, subject to normal precautions backseating valves, The name of the individual was provided to the licensee and remedial training was conducte.0 REVIEW OF.PROGRAMS FOR CONIINUINGEVALUATIONOF THE EOPs 5.1 Purpose The purpose of this functional area was to determine ifthe licensee had established a long term evaluation program for,the emergency operating procedures, as recommended in Section 6.2.3 of NUREG-0899.

5.2 Methodology A review of the Palo Verde system of on-going evaluation and revision of the EOPs was conducted to assess whether the licensee had an effective program to ensure high quality EOPs over time.

The inspection criteria were:

(1) the completeness of'a method for ensuring that changes in plant design, technical specifications, owners'roup technical guidelines, writer'

guide, referenced plant procedures, and control room design were promptly reflected in the EOPs; (2) completeness of a method for revising the EOPs to reflect findings from operational experience and use, training experience, simulator exercises, and control room and plant walkdowns; (3) the timeliness ofrevisions to the EOPs when incorrect or incomplete information is identified; (4) the adequacy of the system for determining training, validation, and verification when procedures were changed or revised; (5) the adequacy ofbasis documents, including plant specific technical guidelines and writer's guide; (6) the adequacy of verification and validation; and (7) the effectiveness of a system of soliciting and utilizing feedback from procedure users and other cognizant personnel.

5.3 Findings 5.3.1 The inspection team found that some aspects of the licensee's program were well done.

- Specifically, a

comprehensive Writer's Guide was produced and generally utilized in development of the new EOPs; a multi-disciplined approach was adopted; feedback from the operators during training was encouraged; labeling of components in the plant had improved

. from the last EOP inspection; and access to plant equipment had been enhanced.

5.3.2 One important component of a program that was missing at Palo Verde was an independent quality review of the process.

To assure an adequate review of procedures, an independent quality group review shou)d be.incorporated into the development and the maintenance of the procedures.

While it appeared that an effort was made to incorporate the Quality Assurance (QA) organization into the process, QA involvement was lacking in several areas, QA did not perform anygndependent validation of the procedures; their role was a monitoring of the process as performed by others.

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QA monitored the validation of the control room portion of the procedures by observation in the simulator only.

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QA had performed no monitoring of the validation of the in-plant portion of the EOP e

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QA had performed minimal monitoring of the verification process of the procedures.

The licensee acknowledged the need to strengthen the involvement of the QA department.

This is an open item.

(Inspector Followup Item 92-12-09)

5.3.3 The inspection team determined that most of the issues found by the team would have been identified by the licensee ifan aggressive Verification and Validation (V&V)program was in place, including an adequate independent quality review process.

The licensee agreed to perform additional V&Vof a significant sampling of the procedures prior to implementation.

6.0 INTERVIEWS 6.1 Purpose The purpose ofthis functional area was'to determine the emergency operating procedures users'pinions of the procedures and their technical evaluation of the adequacy of the procedures.

6.2 Methodology Interviews were conducted with licensed and non-licensed operators to assess their (1) familiarity with the bases for the EOPs and the tasks contained withinthe procedures, (2) confidence in the procedures, (3) involvement in the development process, and (4) opinions regarding training. on the procedures.

Interviews were also conducted with members of the Operations. Standards Group, the organization responsible for the development of the EOPs at Palo Verde, and facility management.

6.3 Findings The licensed operators were apprehensive when presented with the first draft of the new EOPs.

During the training, over 1,200 comments were submitted by the operators; the comments were neither prioritized nor tracked for closure.

After inclusion of the majority of the comments, the operators indicated that the new procedures would be much easier to use than those currently in place.

No operators were aware. of any technical deficiencies in the procedures that would prevent the procedures from working.

Palo Verde had recently amended the system for, procedure reviews to prioritize and track comments.

However, the old comments that had not been included were not incorporated into the new system.

Although training had been conducted on all of the new procedures, with the exception of the Functional Recovery procedure, several operators indicated that they did not yet feel comfortable with them.

Despite this, the operators felt that they would be able to implement the new EOPs to safely mitigate an accident condition.

Given the choice of the new EOPs or those currently in use, all operators indicated a preference for the new one,

7.0 UNIUSOLVEDITEMS An unresolved item is a matter about which more information is required in order to ascertain whether it is an acceptable item, a deviation, or a violation.

8.0 EXITMEETING The team leader met daily with technical and management representatives to ensure o'en communications, and to discuss developing issues and outstanding requests.

At the end of the inspection, on April 10, 1992, the team conducted an exit meeting to summarize the significant findings and conclusions.

NRC Region V and licensee senior management participated in the exit meeting.

The Vice President, Nuclear Production, for Palo Verde was asked to confirm the facility's commitments with respect to the open items identified as requiring resolution prior to the implementation of the new EOPs.

He reiterated that the facility would corre."t, prior to implementation, the open items identified as such in Attachment No. 4.

e At no time during the inspection was written material provided to the licensee by the inspectors.

Based upon NRC review of this report and discussions held with licensee representatives during this inspection, it was determined that, this report does not contain information subject to 10 CFR 2.790 criteri e LICENSEE EXITMEETINGATA<22DEES Attachment

T. Bradish, Manager, Compliance M. Burns, Supervisor, Setpoint Control L. Clyde, Manager, Unit 3 P. Coffin, Compliance Engineer G. D'Aunoy, Quality Engineer J. Dennis, Manager, Operations Standards Group E. Firth, Manager, Training R. Flood, Plant Manager, Unit 2 L. Florence, Senior Advisor, Operations Standards Group D. Gouge, General Manager, Plant Support B. Grabo, Supervisor, Licensed Operator Continuing Training P. Hughes, General Manager, Site Radiation Protection B. Hunnicutt, Administrative Supervisor, Operations Standards Group W. Ide, Plant Manager, Unit 1 D. Johnson, Supervisor, Compliance

. Levine, Vice President, Nuclear Production R, Nunez, Operations Training J. Proctor, Assistant Shift Supervisor, Unit 2 F. Riedel, Operations Manager, Unit 1 J. Scott, Assistant Plant Manager, Unit 3 Administration M. Selland, Senior Advisor, Operations Standards Group G. Storey, Supervisor, Safety D. Swan, Shift Supervisor, Unit 3 P. Wiley, Manager, Operations Unit 2 REPRESENTATIVES FROM JOINT OWNERS S. Gross, Manager, El Paso Electric R. Henry, Site Representative, Salt River Project L. Miller, Chief, Reactor Safety Branch, Region V B. Norris, Project Engineer, Region I - Team Leader B. Olson, Project Inspector, Region V D. Pereira, License Examiner, Region V J. Russell, License Examiner, Region V D. Schultz, Field Inspector & Systems Specialist, COMEX (Contractor)

M. McWilliams, Human'actors Specialist, SAIC (Contractor)

D. Coe, Senior Resident Inspector, Palo Verde Pg 1 of 1

DOCUMENTS REVIEWED

'Attachment 2 DOCUMENT ER DOCUMENT T E COMBUSTION ENGINEERING OWNERS'ROUP CEN-152 Combustion Engineering Emergency Procedures Guidelines EMERGENCY OPERATING PROCEDURES 41EP-1EO01 40EP-9RO01

.

40EP-9RO02 40EP-9RO03 40EP-9RO04 41EP-1RO05 41EP-1R 006

¹'1EP-1RO07 41EP-1RO08 Emergency Operations Reactor Trip Loss of Coolant Accident Steam Generator Tube Rupture Excess Steam Demand Loss of All Feedwater Loss of Offsite Power Blackout Functional Recovery ADMINISTRATIVEPROCEDURES 40DP-9AP02 40DP-9AP05 02PR-OOP01 40AC-9OP11 40AC-9OP12 40DP-9AP06 40DP-9AP07 40DP-9AP08 40DP-9AP09 40DP-9AP10 40DP-9AP11-40DP-9AP12 40DP-9AP13 40DP-9AP05 N001.1.01-841-1 Emergency Procedures Writers'uide Emergency Operations Procedures Technical Guideline Emergency Operating Procedures Program

~ Emergency Operating Procedures Verification Emergency Operating Procedures Validation-Emergency Operations Technical Guideline Reactor Trip Technical Guideline Loss of Coolant Accident Technical Guideline Steam Generator Tube Rupture Technical Guideline Excess Steam Demand Technical Guideline Loss of AllFeedwater Technical Guideline Loss of Offsite Power Technical Guideline Blackout Technical Guideline Functional Recovery Setpoint Document Pg 1 of 2

TRAININGDOCUMENTS EOP Lesson Plans B33-00-RC-001-002 L70-00-'RC-001-000

'L71-00-RC-001-000 L72-00-RC-001-000 L73-00-RC-001-000 L74-00-RC-001-000 L75-00-RC-001-000 L76-00-RC-001-000 Briefing on Old vs. New EOPs Emergency Operations Reactor Trip Loss of Coolant Accident Steam Generator Tube Rupture Excess Steam Demand Loss of All Feedwater Loss of Offsite Power S59-00-RS-001;000 Loss of Offsite Power

'42-02-RS-001-000 Blackout EOP Simulator Scenarios S11-02-RS-001-000 Reactor Trip S36-01-RS-001-000 Small Loss of Coolant Accident

$08-03-RS-001-000 Steam Generator Tube Rupture S10-01-RS-001-000 Excess Steam Demand S09-02-RS-001-000 Loss of All Feedwater e

QUALITYASSURANCE Monitoring Reports DOCUMENTS MR91-1247 MR91-1622 MR91-1705 MR92-0119 MR92-0312 MR92-0347 MR92-0425 MR92-0560 MR91-1290'R91-1626 MR91-1729 MR92-0121 MR92-0316 MR92-0350 ME92-0427 MR92-0561 MR91-1433 MR91-1639 MR91-1751 MR92-0205 MR92-0321 MR92-0379 MR92-0439 MR92-0590 MR91-1439 MR91-1653 MR92-0085 MR92-0207 MR92-0332 MR92-0393 MR92-0440 MR92-0630 MR91-1568 MR91-1665 MR92-0086 MR92-0248 MR92-0333 MR92-0402 MR92-0470 MR91-1610 MR91-1696 MR92-0118 MR92-0299 MR92-0334 MR92-0410 MR92-0559 Audits Audit 91-013

"Emergency Plan" Section 3.2 "Emergency Operating Procedures Upgrade

.Program" Management Reports Management Observation Report, "Simulator Assessment of Licensed Operator. Training" dated January 29, 1992 Pg2of2

lt l

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PROCEDURE DEFICIENCIES Attachment 3 NOTES:

1. Deficiencies specific to individual procedures that were not addressed in the body of the report are listed here.

2. Detailed reviews were only performed on portions of procedures and the associated appendices, these comments reflect that sampling.

LOSS OF COOLANT ACCIDENT, 40EP-9RO02

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PSTG, Step 3.0, Task 8-LOCA Isolation Outside Containment, Action 8:

stated "IfRCS leakage into the nuclear cooling water system is indicated, then perform..." The EOP, Step 3.19, Appendix A, page 14 of 90, stated "Ifall of the following conditions are met:

Requiring all conditions to exist was inconsistent with the PSTG, the deviation was not justified,

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PSTG, Step 3.0, Task 9-Temperature Control, Actions

and 2:

required RCS'Tc teinperature to be stabilized between 560'F and 570'F.

Steps '3.26 and 3.27 of the LOCA EOP directed the Secondary Operator to stabilize RCS Tc below 570'F.

The deviation between the PSTG and EOP was not addressed.

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EOP Step 3.10, Appendix A, page 7 of 90:

stated "IF the RWT level is less than 7%,

THEN ensure that ESF pump suction has shifted to the containment sump."

The details column directed the operator to "check" containment level instruments for an indication, but included no logic conditions ifthere was no water in the containment sumps available for ESF pump suction.

Also, no caution was provided to alert the operator to potential ESF equipment damage ifsuction is shifted to an empty sump.

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EOP, Step 3.35, Appendix B, page 11 of 48: required the operator to, "Override and adjust the AFW valves to establish the steam generator levels between 72 and 80% WR."

A decision table that determined the desired flow rate, was absent from the procedure; to establish the desired flow rate, the operator had to memorize the table, or refer to another procedure.

For concise diagnostic tables such as this, the operator should not have to refer to other documents.

LOSS OF ALLFEEDWATER, 41EP-1%005

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Nuinerous examples of the wrong step number being given for transitions within procedures:

Appendix A, step 7.16:

reference to step 8.1 should be 7.24 Appendix C, page 5:

reference to Step 3.27 should be 5.27 CRS step 3.28:

indicated GO TO step 3.53 should be 3.51 Pg 1 of6

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SO steps 3.4 and 3.5 were inconsistent with SO step 3.6:

in that, the first two steps used

"IF-THEN"statements and the last step used a "WHEN-THEN"statement.

The steps should be consistent.

SO steps 3.5 and 3.6:

directed the starting of all three auxiliary feedwater pumps, and then start feeding the steam generators.

A reactor operator indicated that starting all pumps would take several minutes; due to the time involved in starting the pumps, the operator stated that feeding of the steam generators should start as soon as one pump was started.

Step 3.11:

presented conflicting information; in that, it directed the sampling lines to be isolated, but allowed for certain sampling valves to be left open.

No subsequent action was directed to close the valves that were left open.

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- CRS steps 3.20, 3.22, and 3.25:

indicated that the SO would be starting various pumps.

The pumps had actually been started in previous steps.

The SO was aligning the flow paths for the pumps during these three steps.

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SO step 3.36:

directed all available condensate pumps started, but only directed the opening of one discharge bypass valve, The discharge bypass valve for each pump that.vas started should be opened.

0'O step 3.41:

indicated that each was closed by using a separate pushbutton.

One pushbutton would close both of the MSIVs for a single steam generator.

Step 3.38:

provided conflicting information; in that, it stated that condensate flow was'o be established, but the step directed starting of the charging pumps and minimizing letdown.

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SO step 5.12;

~ appeared to be missing the provision to "Continue in this procedure" after completing the action of the step.

~.

CRS steps 5.13 and 5.14:

conflict SO steps 5.13 and 5.14; in that, the SO steps indicated

"SCBS is ~NT available" and the CRS steps indicated

"SCBS is ~NT maintaining Tc between 560 and 570 F" PO step 5.23:

allowed for the use of spray with the reactor coolant pumps running.

The RCPs had been stopped in step 3;1.

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Step 5.25:

directed securing of the containment spray pumps based on pressurizer pressure.

A more appropriate basis for securing the pumps would be containment pressure.

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=- PO step 7.11:

checked RCP motor amperage after starting the pump. The PSTG indicated that the motor current should not exceed 353 amps when hot ("When hot" was not defined).

The value appeared conflicting because the RCPs were observed to be running at about 400 amps when the plant was at normal operating temperature.

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Step 9.3:

indicated that the injection of 1350 gallons of borated water would provide adequate shutdown margin during the plant cooldown.

Determining that the appropriate volume had been injected was based on the amount of time the charging pumps had been running prior to reaching the step.

A reactor operator indicated that it would be difficultto determine the time the charging pumps had been running prior to reaching the step; a

licensed operator indicated that it would be easier to start the pumps upon reaching the step and then time the operation.

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Step 9.3:

the procedure states that 1350'gallons of borated water would be sufficient to ensure shutdown margin during the plant cooldown.

The licensee had been informed, prior to approval of the procedure, that the value of 1350 would not be adequate under all conditions, including having one control element stuck out.

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SO Attachment B-5: the procedure designated AFN-V502 as "Brg Clg Supp Frm AFP" but the valve was labeled "Seal Pump Brg Water Outlet;" also, valve AFN-V500 was named Brg designated as "Clg To AFP" but was labeled "Seal Pump Brg Water Inlet."

LOSS OF OFFSITE POWER, 41EP-IRO06

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EOP, Step A-4.1, Attachment A-4, Appendix A, page 81 of 91:

required the operator!o

"Unlock and adjust SDCHX A Outlet Isolation Valve, EWA-HCV-53,..." The location of t

the valve was not specified; similarly, for most valves listed in the attachments.

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EOP, Step A-4,4, Attachment A-4, Appendix A, page 82 of 91:

required the operator to,

"Adjust the flow to achieve the desired flowrates."

This step appeared redundant to Steps'-4.1 and A-4.3, which adjusted EW flows on the heat exchanger and chiller; the operator performing the walkdown was confused as to what he was supposed to perform in addition to what had already been accomplished.

BLACKOUT,41EP-1RO07

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Appendix A, Attachment A-10, step A-10.11:

details column directs "Check" any of the ammeters.

All should be checked.

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Appendix A, Attachment A-21, step 1:

details column directs operator to open breaker

"1-ENAN-S06J to TSC 480 V LC NGN-L50 and to the Administration Annex Bldg EOF 480 LC." Breaker 480 V LC NGN-L50 is labeled "A-E NGI L51", and the Annex Bldg EOF 480 LC breaker is labeled as "LOAD CENTER."

Pg 3of6

FUNCTIONALRECOVERY, 41EP-1RO08

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The condition for entry into harsh containment is 150'F.

Since the temperature detectors in containment are not environmentally qualified (EQd); the backup condition is 3 psi, using pressure detectors which are EQd. The procedure should reference the parameter that would most likely be available.

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CEN-152 uses unit transformer backfeed as a means of reestablishing offsite power during a loss of vital auxiliaries.

This method, although possible, is not presented as an option at Palo Verde.

Further justification for this omission is required.

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In the Loss of AllFeedwater procedure, reactor coolant pumps are immediately stopped.

In the Functional Recovery procedure for similar conditions, the RCPs are not stopped until a later point, This is inconsistent for the same event and requires further justification.

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Step 3.2.1:

directs actions for the "affected" steam generator.

Ifone steam generator is faulted and the other is ruptured, there is confusion over which would be the "affected" steam generator.

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Step 3.18: within the procedure, this is a continuous action step that is to be performed any e.

time that an auxiliary spray valve is to be opened.

It is not included on the continuous action page.

Step 3.20:

conditions indicating an ESDE require further justification.

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Step 3.29:

specifies opening of the atmospheric dump valves after unisolating a steam generator.

This may cause an excessive cooldown and is not.,sufficiently justified in the PSTG.'

-. Step 3.35: the step states "Perform all of the followingto place the charging pumps in PULL TO LOCK." The substeps address isolating RCP bleed off.

Step 4.7.5; in a previous step, the operator was directed to place all breakers on Panel PNA-D25 to the OFF position, this step directs the operator to return all of the breakers that had been in the ON position back to the ON position.

No caution was given to have the operator note which breakers had been in the ON position.

J Appendix FO, Attachment FO-5, step FO-5.2:

the operator, is directed to check for a voltage of 120 VAC on the inverter panel, However, the inverter panel has meters for both "Output Voltage" and "Bypass Voltage."

The step should specify which voltage is required.

Appendix FQ, Step 1.3:

this step is a decision table.

The equipment identified as being necessary for success is not consistent between the success paths.

Example, HV-532 is not uniformly identified as necessary for charging pump suction to the RWT.

Pg4of6

'ppendix FQ, step 1.23:

would not be performed; step 1.22 directs the operator to GO TO step 1.24.

Appendix FQ, step 1.27: directs the CRS to raise RCS'pressure by raisihg pressurizer level.

This step requires further justification since the normal method would be via pressurizer

'heaters.

Attachment 5: does not define what "condenser available" means.

The intent was explained as available for blowdown; however, the operators interpreted this as available for SBCS per the control room annunciator.

This could cause the CRS to unnecessarily blowdow'n a ruptured generator to the environment vice to the condenser.

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Attachment 5: directs the CRS to fast close the MSIVs on a ruptured steam generator, prior to ensuring that RCS temperatures are below the corresponding pressure setpoint for the steam generator safety valves.

This could cause unnecessary lifting (and possible sticking open) of steam generator safety valves, resulting in an unnecessary release.

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Attachment 5, steps 5.1, 5.2, and 5.4:

directs the operator to adjust'cooldown rates and setpoints; however, the cooldown is not directed until step 5.8.

This caused confusion for th.. ~operators.

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'ttachment 5, steps 5.3 and 5.5:

do not reference the applicability of harsh containment pressure and temperature conditions.

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Attachment 12, step 12.2:

directs the operator to cooldown using both steam generators.

In the SGTR procedure, steps 3.75 and 3.76, the CRS is directed to cooldown using the intact steam generator.

As a SGTR may be present during an event in which the Functional Recovery is utilized, there is an inconsistency between procedures which may be mitigating the same type of event.

STA FLOWCHART

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Numerous boxes direct the STA to ensure that certain conditions exist or that actions have been taken.

As the STA is not allowed to perform most of the actions required to "ensure" conditions, the use of "ensure" is not consistent with the usage defined by the writers'uide.

PLANT DEFICIENCIES

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The three charging pump cubicles in U-3 were not identified as such.

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A remote operator was provided for 3-PCHA V755, the charging pumps 1 and 3 suction crosstie isolation valve, through the biological shield in ¹I charging pump ante room.

No directional indication was provided on the remote operator to signify the open and/or close direction.

Pg5of6

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A laminated charging pump room valve list was available outside each of the charging pump rooms (similar postings were posted outside several other rooms).

Although the list was a beneficial operator aid, the lists were neither controlled or approved, nor were they adequately mounted.

Pg 6of6

OPEN XHMPs XD Attachment 4 0>~~~%<gg~g~:

92-12-01 Inadequate isolation strategy for a loss of coolant accident outside of containment.

PRIOR TO IMPLEMENTATION Paiigr'aph.';

2+3+3 92-12-02 Contradictory steps when 'confronted with,a,steam generator tube rupture in one steam generator, coincident'with

'an excess steam demand event in the other steam generator.

PRIOR TO IMPLEMENTATION

. 2.3.4 92-12-03 Incomplete information provided to the operators for adverse containment conditions.

PRIOR TO IMPLEMENTATION 2.3.5 92-12-04 Inconsi:tent applic":lion of the CEN-152 standard post trip actions with regard to verification of safety functions.

PRIOR TO IMPLEMENTATION 2.3.6 92-12-05 Deficiencies specific to an individual procedure, as listed in Attachment 3.

2.3.7 92-12-06 Licensee review of the Combustion Engineering comments, and incorporation of safety significant procedure changes prior to implementation.

PRIOR TO IMPLEMENTATION 3.3.2 92-12-07 Temporary radiation monitoring cart permanently installed in the auxiliary building, and not consistent with the UFSAR.

92-12-08 Conflicting direction given to the operators with respect to procedural adherence when in the EOPs.

PRIOR TO IMPLEMENTATION 3.3.3 4.3.1.

92-12-09 Less than adequate quality organization involvement, specifically related to independent verification and validation.

5.3.2 Pg 1 of 1