Text

Meeting Repts 50-528/93-50,50-529/93-50 & 50-530/93-50 on 931115.No Violations Noted.Major Areas Discussed:Status & Schedule of EOP Rewrite Program & Assessment of Recent Operator Performance Issues
	ML20059A215
Person / Time
Site:	Palo Verde
Issue date:	12/02/1993
From:	Vandenburgh C, Wong H; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:	;
Shared Package
ML20059A178	List: IR 05000528/1993050; ML20059A176;
References
	50-528-93-50-MM, 50-529-93-50, 50-530-93-50, NUDOCS 9312300058
	Download: ML20059A215 (40)
	v • d • e

.

_

-.

.

..

.

.3

?'

.,

. <-

...r.

.

,

-

.

.o

-

U. S. NUCLEAR 4EGULATORY COMMISSION l

^

REGION V

_

Report Nos.

50-528/93-50, 50-529/93-50, and 50-530/93-50

.I i

Docket Nos.

50-528, 50-529, and 50-530 License Nos.

NPF-41, NPF-51, and NPF-74 l

Licensee Arizona Public Service Company

P. O. Box 53999, Station' 9082

.l Phoenix, AZ 85072-3999 l

t Facility Name Palo Verde Nuclear Generating Station

.;

Units 1, 2, and 3

,

Meetino

,'i Conducted November 15, 1993

!

Meetino I

location NRC Region V Office, Walnut Creek, CA Prepared By H. J. Wong, Chief, R ctor ProjectsSection II i

' WM9)

d Approved By

-

C. A. VanDenburgh,flief Date Signed ia Reactor Projects B6each y

Summary:

A management meeting was held on November 15, 1993, to discuss'the status and schedule of the emergency operating procedure rewrite program,'and the

.;

assessment of recent operator performance issues (i.e., operator examination

!

failures and a reactor coolant system draindown~ event in Unit 1). The meeting

'

agenda and a copy of the slides used during the licensee's presentation are i

enclosed.

l

)

i

,

l

-

)

9312300058 931202 PDR ADOCK 05000528 G

PDR

,-

-

.

"

!

1;

'

,.

', 3r.

,.

-

.

-

-DETAILS j

t

-

.

1.

Meetino Attendees

,

!

Arizona Public Service Company (APS)

!

J. Levine, Vice President, Nuclear Production-W. Ide,' Unit 1 Plant Manager R. Gouge,-Director, Plant Support i

E. Firth, General-Manager, Nuclear Training

,,

i J. Dennis, Manager, Operations Standards M. Baughman, Supervisor, Requalification Training

.;

L. Florence, E0P Coordinator r

P. Wiley, Unit 2 Operations Manager R. McKinney, Unit 1 Operations Supervisor B. Grabo, Supervisor, Nuclear Regulatory Affairs P. Coffin, Nuclear Regulatory Affairs

,

NRC

,

B. Faulkenberry, Regional Administrator K. Perkins, Director, Division of Reactor Safety and Projects S. Richards, Deputy Director, Division of Reactor Safety and. Projects l

'

L. Miller, Chief, Reactor Safety Branch H. Wong, Chief, Reactor ProjectsSection II J. Sloan, Senior Resident Inspector

r G. Johnston, License Examiner K. Johnston, Project Inspector L. Tran, Project Manager, NRR

'

D. Lange, Acting Chief, Human Factors Branch, NRR

'

2.

Meetina Summarv A.

Openino Remarks-Mr. Faulkenberry provided introductions and opening comments for the -

meeting and stated that the issues to be discussed in the meeting

were significant in emphasizing to APS management the need for'

l improvement in the areas of operator performance and attention-to-

.

l Mr. Perkins added that he saw three princip(le areas which detail.

contributed to operator performance: (1) training, 2) procedures, and (3) attitudes and expectations, and noted that all three araas had to be addressed for overall improvement. Mr. Levine '

-

acknowledged the comments and stated that the discussions during the

,

'

meeting would cover these areas.

<

F B.

Operations -Program Overview

,

Mr. Gouge provided a summary of the developmental history of the-

-j emergency operating-procedures (E0Ps) and responded to comments in a j

recent NRC inspection report which identified weaknesses-in the E0Ps and in the APS oversight of:the E0P revision process.. He -.

i acknowledged that he was responsible for assuring the consistency of j

the operations program and was also the ' interface for operations, i

!

,

- - -

-

..

.

-

r

- *

ye-

,

Mr. Gouge described that earlier E0Ps had weaknesses in-the " human -

. factors" area and~ that APS obtained a consultant to address the.

-

issue. However, this effort resulted.in detailed E0Ps which could

~

handle almost all situations, but were complex to use..Mr. Gouge acknowledged.that the' current'E0Ps were very operator training intensive and were too detailed to be easily used by operators. He also noted that in February 1993, APS identified the need to improve the E0Ps and noted that the NRC had made similar comments.

Mr. Dennis described the APS ' actions which had been underway and ~

those planned to rewrite the E0Ps. He noted that a steering committee had been established previously to guide the development of the E0Ps and to review the E0Ps of other Combustion Engineering-(CE) facilities. The steering group recommendations to APS senior management were to: adopt the standard CE format (CEN 152),

establish a procedure philosophy which placed greater reliance on-operator knowledge, train operators on the tasks in the E0Ps,- and maintain just a few simple rules for E0P use.

In essence, the new E0Ps would be less detailed and use more operator' knowledge to'

handle events.

Mr. Florence described the current E0P rewrite schedule which consisted of four phases: preparation, development of the procedure framework, development of the procedures, and final review and training. Mr. Florence stated that the phases would be continuous such that procedures could be in any of the phases at any one time and would avoid the production and review of procedures in blocks.

The projected timeline showed. completion of rewriting all E0Ps and training by August 1995. Possible NRC inspection points were discussed: March 1994 for review'of the APS procedure framework, late April 1994 for review of post trip actions, September 1994 for review of recovery procedures, April 1995 for overall E0P' rewrite review, and September 1995 for an E0P inspection.

C.

Trainina Proaram Mr. Firth reviewed the history of the Palo-Verde operator training program and the results of NRC-licensed operator examinations since 1991. Mr. Perkins noted the APS assessment of the examination failures included instances of operator inattention-to-detail,-which was common to the reactor coolant system draindown event to be discussed later.

Mr. Firth also highlighted some of the enhancements in the operator training program based on their assessment. He noted that improvements in training were made to emphasize teamwork and communication and also to' formally incorporate job performance measures (JPM) training into the training program. Also, with the recent addition of the second simulator, more simulator time would be available to support training. Mr. Wiley noted that operator crews were recently observed to be more forthright in directing their training to best suit their needs and indicated that

R[.;

individual performance to better communicate managemen_t ~

[

s'.

ja-

,.

,

-

operations managers and supervisors were evaluating crew and s

'

.

,

.

expectations. APS management expressed a desire to further discuss

the most recent initial operator examinations with the Region V i

staff in the next few weeks. Mr. Perkins stated that the NRC was interested in understanding any licensee comments regarding the examinations and directed the regional -staff to' contact APS

!

personnel to set up_ these discussions.

D.

Unit 1 Reactor Coolant System Draindown Event Mr. McKinney described the details pertaining to the Unit 1. reactor

coolant system (RCS) draindown event which occurred on November 3-l

?

1993. Mr. McKinney described the plant initial conditions and

.

background of the evolution. The reactor ooerator was attempting to

,

maintain the RCS level at just below the _ reactor vessel flange to -

l minimize the differential pressure across the installed steam generator nozzle dams. The operator lowered RCS level'by'having a

portion of the shutdown cooling ~ flow go to the refueling water tank.

Because in-leakage to the RCS had been occurring due to a leaking

~

,

valve from the refueling water tank to the shutdown cooling system,

,

the reactor operator had performed the draindown evolution nine

times in his last two shifts. The evolution normally takes about

two minutes.

,

Mr. McKinney described that after beginning the draindown evolution, the reactor operator was distracted by other activities in the control room and took actions to secure the-draindown only after a

.

'

second reactor operator noted a decreasing RCS level (eight minutes after the evolution was started). RCS level was then raised to its

normal band just below the reactor vessel flange.

Mr. Ide summarized the. licensee's' corrective actions. Subsequent to

the event, the licensee removed the control room crew from duty to participate in the investigation, provided specific directions on.

!

the control of RCS inventory, briefed control room staff on the

!

event, moved trend recorders for RCS level closer to'where the valve controller was located on the control panel, and conducted high

'

intensity training for the crew involved in the event to emphasis -

communications and teamwork.

Mr. Ide stated that APS' conclusions on the causes of the event

-

the operator lost safety sensitivity to the evolution because were:

he had performed the operation several times, communications in the control room were inadequate, and shift management had not been successful in maintaining adequate communications.

Mr. Levine reemphasized that APS management considered this event to

,

be significant and that broad actions were being taken to resolve-

!

the issues identified. Mr. Faulkenberry stated that the event caused the NRC significant concern particularly regarding operator

control of activities.

.

,

9

n;

y

-

'

.

..

'

,; '

'm y

7>

s,,,.

,.

--

LE.

Closina Remarks

-

l

!

-.

-

Mr. Faulkenberry added that the weaknesses' evident in the operator

,

examination failures, the weaknesses in the E0Ps, and weaknesses

evident in RCS draindown event should not be occurring at this stage i

of Palo Verde operations. He added that'the NRC was concerned that operations management had not been paying s"fficient attention to

,

crew and operator performance, and that operators not paying

attention to detail is a highly significant. issue..

,

'i Mr. Levine acknowledged the comments and' stated th'at comprehensive-corrective actions had been taken to address the_ issues, including i

i, emphasis on operator knowledge, moving standards personnel closer to those that use the procedures, and emphasizing accountability.

The meeting was then concluded.

!

,

a t

,

f

'I J

'

.1 l

I

1 l

ll

E

.

.,

..

.

$

_.,

--

-

.

-

!

I

~I

,

i p

a

,

.

APS/NRC STATUS MEETING

.

+

NOVEMBER. 15, 1993 ~

l

.

..

.

P

,

i

!

i

)

f

'!

_.,

I I

,

i

.

<

?

i

i

..

.

.-

-.

.. -.

.

.c

-

q

.

-

.

.c..

o

..

,

.

..

-

_

APS/NRC STATUS MEETING

-

^

NOVEMBER 15, 1993

1 AGENDA

'

I.-

OPENING REMARKS J. M.-LEVINE

'

f-iq II.

OPERATIONS PROGRAM OVERVIEW

INTRODUCTION R.-E. G00GE'

,

E0P REWRITE PROJECT i

BACKGROUND-J. W. DENNIS

!

-

ACTION-PLAN AND SCHEDULE

.-L. A. FLORENCE.

.

-

.

$

III.

TRAINING' PROGRAM E. G. FIRTH

}f e

1992-1993 ENHANCEMENTS

'

e APS EVALUATION OF i

INITIAL LICENSE EXAMINATION q

J IV.

UNIT 1 INVENTORY CONTROL

't, e

EVALUATION R. S. McKINNEY, o

CORRECTIVE ACTION W. E. IDE-j V.

CLOSING REMARKS J. M. LEVINE-i

!

. -..

-

.

r'

'

.

...

.

,

~

~~

OPERATIONS PROGRAM OVERVIEW

.

e INTRODUCTION e

E0P REWRITE PROJECT

-

BACKGROUND

-

ACTION PLAN AND SCHEDULE

-

-i

<

!

'

i

-

l REG-1-i 11/15/93-

-

..

-.

.

-

.

e'

-

.-

-

OPERATIONS PROGRAM 0VERVIEW

.

INTRODUCTION

PROGRAM CONTENT SINGLE POINT OF ACCOUNTABILITY

.

REG-2 11/15/93

.

,,

.

.~

i

-

. EMERGENCY OPERATING PROCEDURES (E0P)

REWRITE PROJECT i

BACKGROUND

-

!

o UPGRADED E0Ps IMPLEMENTED - AUGUST 1992 o

HEED TO SIMPLIFY E0Ps IDENTIFIED - FEBRUARY 1993.

i E0Ps COMPLEX AND LENGTHY

-

CHANGE TO CEN-152 FORMAT

-

.

NO CHANGE IN TECHNICAL GUIDELINES OR STRATEGY

-

o E0P IMPROVEMENT SCOPE AND SCHEDULE APPROVED PHASE 1:

CONVERT DLT T0 DFC; MODIFY SPTAs -

OCTOBER 1993

PHASE 2:

REWRITE FRP; CONVERT ACTIONS AND DETAILS TO INSTRUCTIONS AND

,

CONTINGENCIES - SEPTEMBER 1994

'

~

NRC REQUALIFICATION PROGRAM INSPECTION - AUGUST 1993 e

E0Ps ADEQUATE; OPERATORS CONTINUE TO HAVE

-

,

DIFFICULTY IMPLEMENTING

,

i OPERATIONS /0PERATIONS STANDARDS DECISION-MAKING-

-

PERSONNEL HAVE LIMITED EXPOSURE TO OTHER CE-g FACILITIES' E0Ps

JWD-1 11/15/93

.

,

-

.

..

.

.;

.

'

~

BACKGROUND (CONT'D)

.

o E0P STEERING COMMITTEE (E0PSC) ESTABLISHED CHARTER

-

,

STUDY OTHER CE FACILITIES' E0P PROGRAMS PROVIDE DIRECTION FOR CURRENT E0Ps MEMBERSHIP (CROSS-SECTION MANAGEMENT /FRONTLINE

-

PERSONNEL OPERATIONS:

OPERATIONS SUPERVISOR SHIFT SUPERVISOR REACTOR OPERATOR TRAINING:

TRAINING SUPERVISOR

>

INSTRUCTOR ENGINEERING:

SHIFT TECHNICAL ADVISOR

'

OPERATIONS STANDARDS:

OPERATIONS STANDARDS MANAGER (CHAIRMAN)

E0P COORDINATOR

,

BENEFITS

-

DEFINES E0P ACCOUNTABILITY PROVIDES CLEAR METHOD FOR E0P PROBLEM RESOLUTION i

FOSTERS TIMELY DECISIONS INCREASES CREDIBILITY WITH USERS

l JWD-2 11/15/93 I

-.

.

~

-

.,

.

BACIGROUND(CONT'D)

~

,

E0PSC REVIEWED ONG01HG AND PLAHNED E0P CHANGES o

,

PHASE 1 AND PHASE 2 FORMAT CHANGES PUT ON HOLD

-

E0P CHANGES TO IMPROVE TECilNICAL QUALITY TO

-

CONTINUE E0P REVISION IMPLEMENTED OCTOBER 29, 1993 REVISION OF EPTGs TO BE COMPLETED BY DECEMBER 30, 1993 E0PSC STUDIED E0P PROGRAMS AT 5 PLANTS

<

o SUCCESSFUL E0PS DEFINED AS:

-

CLOSELY FOLLOW CEN-152

,

'

SIMPLE TO USE TECHNICALLY' ACCURATE USERS' ACCEPTANCE AND C0HFIDENCE ABSENCE OF E0P ISSUES WITH REGULATORS AND OVERSIGHT ORGANIZATIONS PROVEN ABILITY TO HITIGATE ACTUAL EVENTS FACILITIES OBSERVED

,

-

FORT Call 100N AH0-2 CALVERT CLIFFS MAINE YANKEE DIABLO CANYON

,

>

JWD-3

-

11/15/93

.

,

...

.

.-

.

_. -

.

ya

,j

,

>~

${ '

.

'.

.

,..

~

4 BACKGROUND (CONT'D)

.

c

.

t

$

..

!

OVERALL CONCLUSION 1;

-

o

%

.

!

SUCCESSFUL E0Ps HAVE FORMAT CLOSE T0 GENERIC-GUIDELINES AND' PHILOSOPHY OF USE THAT EMPHASIZES.

j

-

OPERATOR KNOWLEDGF.

!

L:

i RECOMMENDATIONS PRESENTED TO SENIOR MANAGEMENT-l l

-

y:

i ADOPT-CEN-152 FORMAT, INCLUDING SPTA

- i IMPLEMENTATION ESTABLISH-NEW. PROCEDURE PHILOSOPHY WHICH PLACES

GREATER. RELIANCE ON OPERATOR' KNOWLEDGE i

.

-

f TRAIN OPERATORS ON TASKS IDENTIFIED IN_E0Ps.

,j

- KEEP TO A FEW SIMPLE RULES FOR--USE -

qi

-

E0P-REWRITE SCHEDULE-DEVELOPED INCORPORATING LESSONS i

.

e LEARNED FROM E0P UPGRADE-

l f

.i i

!

t i

-;

I

t

!

i JWD-4 i

11/15/93'

!

,

!

.

i; i

-

.

-

.

,.

,

~

.E0P-REWRITE PROJECT TASKS

-

TRAIN WRITERS AND REVIEWERS ON CEN-152

DETERMINE PLANT SPECIFIC STRATEGIES AND CHOOSE METHOD.

TO IMPLEMENT THE CEN-152 FORMAT DEVELOP DETAILED FORMAT AND RULES FOR USE BASED UPON e

SUCCESSFUL CEN-152 PLANTS WRITE THE PROCEDURES AND PERFORM DEVELOPMENTAL

VALIDATION e

VERIFY THE PROCEDURES INTERNAL REVIEWS

-

OUTSIDE REVIEWS

-

VALIDATE THE COMPLETE SET OF PROCEDURES

PERFORM FINAL REVIEWS TRAIN THE USERS WITH TWICE THE SIMULATOR CONTACT

HOURS AS PRIOR E0P REVISIONS MAINTAIN USER PROFICIENCY ON CURRENT E0P'S

-

CONDUCT AN OUTSIDE ASSESSMENT OF THE REWRITE AS IT

PROGRESSES LAF-1 11/15/93

-

.

-

-.. -

_

.

w_

)

'-

-

...

..

.

'

- -.

JEOP' REWRITE RESOURCES

.

TITING TEAM

OPERATIONS :-SHIFT -SUPERVISOR--

.

-

SENIOR TRAINING INSTRUCTOR (NON-PVNGS SRO)

-

SAFETY ANALYSIS ENGINEER:

I

-

OPERATIONS STANDARDS PROCEDURE WRITER j

-

!

DEVELOPMENTAL VALIDATION PARTICIPANTS

.

e INTERNAL REVIEW TEAM j

i

. INTERNAL OVERSIGHT TEAM i

e OUTSIDE TECHNICAL REVIEWER l

OUTSIDE HUMAN FACTORS REVIEWER

-

'

,

WRITER'S GUIDE REVIEW

-

'

DEVELOPMENTAL VALIDATION OBSERVATION

-

,

PROCEDURE REVIEW y

-

OUTSIDE PROJECT REVIEWER (DESIGNATED SKEPTIC)

,

- i LAF-Z 11/15/93

t

'

h

~,

..,

,

-,. -

-

,

,,,.n.a._,.

m

.

...

-

,..

,

E0P REWRITE MILESTONES-

.

PHASE 1 - PREPARE TO WRITE CEN-152 TRAINING

-

PROCEDURE FORMAT AND STRATEGIES DIRECTION

-

DETERMINED BY E0P STEERING COMMITTEE START:

11/29/93 FINISH: 12/31/93 e

PHASE 2 - DEVELOP FRAMEWORK

-

DEVELOP WRITER'S GUIDE

-

DEVELOP PROCEDURE TEMPLATE

-

START:

01/03/94 FINISH: 02/27/94

!

-

'h

[

s f

f

LAF-3-

)

11/15/93 l

-

.

--

q

-

+

,

.c

..

'

-E0P REWRITE-MILESTONES (CONT'D1

.-

PHASE 3 - DEVELOP PROCEDURES

WRITE PROCEDURES AND PERFORM DEVELOPMENTAL

[

-

VALIDATION

'

.

}

VERIFY PROCEDURES

.l

--

START:

02/28/94 FINISH: 03/06/95-j

.

!

PHASE 4 - FINAL REVIEWS AND TRAINING

VALIDATE THE COMPLETE PROCEDURE SET

-

WRITERS AND QUALITY SYSTEMS PERFORM FINAL' REVIEWS

-

APPROVE PROCEDURES

-

TRAINING PRESENTED DURING TWO WEEKS OF

-

REQUALIFICATION TRAINING

.

START:

03/07/95 FINISH: 08/24/95 LAF-4 -

11/15/93~

--

-

.,

. n

.

-

EOP Rewrite Overall Schedule

-

1994 1995 ID Mama Scheduled Start Scheduled Finish NlD J

F M

A-M J

J A

S O

N D

J F

M A

M J

J A

S O

N D

J

'@

.

...

.

..

PREPARE TO WRITE 11/29/93 12/31/93 s

.,...

..

.

. J.

.,..

{/7g I

it

}

DEVELOP FRAMEWORK 1/3/94 2/27/94

4

..

.a..

.J..l..J...L.

. J.,

. J...l..

..l...

. L.

4.

.L.

.

i9jyg/4974//gk/4<yg7/j97/g.97,ygd3 l

l

DEVELOP PROCEDURES l

2/28m4 l 3i6/95 e

i 1-

~

-

--

-

-i-

- *- j -

-

'

VJ /7/7A

4 VAllDATION & FINAL REVIEW l

3f7/95 l 5/30/95 a

-

. j...

.

..

...

..p.

.

4 t.

4..

. J.

4......l.

.

APPROVAL 5/31/95 l 5/31/95

a

.i.

f/f787f]

G TRAINING 6/1/95l 8/24/95

.t.

.

...

3...r -

-4-

--

4

....[.

l i$ -

-

PROCEDURES EFFECTIVE 8/25/95 l 8/25/95 j

...

.

l

.j.........

..

.

8..

..t.

.

.a.

. j..

..t..{..

.,.

.

PREUMINARY ASSESSMENT 2/22/94i 3/794 l

W I

i i

...

.J.

. J..

5.. J.

Q]

l

FIRST INSPECTION WINDOW 3/8/94 4/18/94 l

.

..

...

.

.,...

.

.....

POST TRIP ACTIONS ASSESSMENT 4/G/94 4/19/94

%

I,

-

--

e

-:

P i

.r -

.E.~.~j i

l

SECOND INSPECTION WINDOW 4.20/94 5/31/94

.,.

..i..

. j..

.

...

.

l

-

r-1-

t-r-

-*

,

.,.

.

..r-

RECOVERY PROCEDURE ASSESSMEN'

8/29/94 9/9/94

l Wj

.

.,.

...

-

j l

S.

.

4...

..

@

THIRD INSPECTION WINDOW 9/12/94 j 10/21/94 i

.t.

.

.p.

.

..

.

e j

.t.

..

.

4..

FINAL ASSESSMENT 3/27/95 4/7/95

I i

W

,

r-

-

'l I - 1 I -

'l- -

-

.t.

--1-

-

-

.

'..r -

.

..

..,..

. $..

.. j.

.

....

.

....

..}.. {.

.

@

I 1

FOURTH INSPECTION VANDOW 4/10/95 5/19/95

.t'

I

28

EOP INSPECTION WINDOW 9/11/95l 10/27/95

',

,

..I..

,J..

.

..

.

,,

.

.e..

,

l l

@

Critical W/742774E//zM Progress -

Summary y y

Project EOP Rewrite

,

.-

-

..

.

,

p,

e

'

G.'

-

..

p

,

.T TRAINING: PROGRAM

.

c e

HISTORY.

e 1992-1993 ENHANCEMENTS-APS EVALUATION.0F. INITIAL LICENSE EXAMINATION!

APS. EVALUATION OF JPM EXAMINATION-

-

,

APS EVALUATION.OF SIMULATOR-EXAMINATION

-

APS EVALUATION OF WRITTEN EXAMINATION

-

INITIAL /REQUALIFICATION EXAM COMPARISON:

-

SUMMARY OF PLANNED CHANGES

-

APS CONCERNS NEEDING FURTHER DISCUSSION

-

EGF-1^

11/15/93

,

.

-

.

..

.

.-.

.

+

.

,

.

'

}.,

j

,.

...

,

~~

TRAINING PROGRAM

-

'

-

.

-

.

>

,

HISTORY a

.

I e

1991 RESULTS

.I 16 0F 18 R0s PASSED

-

)

2 R0s FAILED SIMULATOR-

-

,

e 1992 RESULTS

.

.3 OUT OF.3 SR0s PASSED

-

!

13-0UT OF-14 R0s: PASSED

!

-

1 R0 FAILED WRITTEN

-

i e

1993'RESULTS

,

2 OUT OF 5 SR0s PASSED li

-

2 SR0s FAILED SIMULATOR-

'

-

>

1 SRO FAILED SIMULATOR AND WRITTEN a

-

o 9 OUT OF 12 R0s PASSED

-

2 R0s FAILED JPMs

-

o 1 R0 FAILED SIMULATOR AND JPMs

-

,

i

!

EGF-2J i

11/15/93

!

.;

,

-

..

.

-

J1

-

.

..

,

, -.

,

as

~

j

.

.;

n

...

.,

.-

-

l.

..

.

,f992-1993' ENHANCEMENTS

.

i INITIAL AND REQUALIFICATION. PROGRAMS e

h TEAMWORK AND' COMUNICATION TRAINING

-

JPN TRAINING INCORPORATED INTO PROGRAMS j

-

i REQUALIFICATION PROGRAM q

e

'

NUMBER OF SIMULATOR CONTACT HOURS INCREASED BY i

-

APPROXIMATELY 30% DURING THIS TRAINING YEAR HIGH INTENSITY TRAINING PROVIDED T0 ALL CREWS

-

INDUSTRY EVENTS HOW TESTED TO IMPROVE 0PERATOR

-

KNOWLEDGE RETENTION l

WEEKLY SIMULATOR' EVALUATIONS;USINGLANNUAL

.!

-

EXAMINATION FORMAT TO ASSESS PROGRAM l

EFFECTlVENESS l

POST-SIMULATOR. SCENARIO CRITIQUES STRENGTHENED BY

-

REQUIRING SHIFT SUPERVISORS TO: LEAD CRITIQUES i

i

';

i

.

f

!

-.j

..

EGF-3 l

11/15/93 i

. _ - -

-

.

. - -- -

.-

-

.-

.,.

-

.

.-

u

,

.

-

..

,

,1992-1993 ENHANCEMENTS (CONT'D)

,;

.

B

INITIAL PROGRAM

'

REQUALIFICATION EVALUATION SCENARIOS-ADDED TO

-

INCREASE COMPLEXITY l

'

REQUALIFICATION TRAINING INSTRUCTORS USED TO

-

SHARE-LESSONS LEARNED FROM REQUALIFICATION

PROGRAM j

OUTSIDE EVALUATORS FROM RE" TON IV & V PLANTS;USED i

-

TO ASSESS CANDIDATE READINmSS

!

OPERATIONS MANAGEMENT USED TO ASSESS CANDIDATE-

-

..

READINESS

!

REVIEW SECTION ADDED TO SYSTEMS EXAMS T0. IMPROVE.

'

-

OPERATOR KNOWLEDGE RETENTION

.!

l.

'

i

'

$

l

.

,

EGF-4 11/15/93

!

-

,

.

--

<

,.

-

..

.

,

~APS EVALUATION OF JPM EX 'HINATION

.

,

e ISSUE FAILURE OF JPM EXAMINATION BY 3 REACTOR OPERATORS

-

CAUSES OPERATOR 1

-

INATTENTION TO DETAIL / INADEQUATE SELF-CHECKING (USED WRONG ANNUNCIATOR RESPONSE PROCEDURE, DATA ENTRY ERRORS)

'

OPERATOR 2

-

INATTENTION TO DETAIL / INADEQUATE SELF-CHECKING'

'

INADEQUATE KNOWLEDGE RETENTION AND USE OF RESOURCES (BYPASS PPS, SIT TECH SPEC, ECCS DESIGN CRITERIA)

TRAINING PROGRAM WEAKNESS IN AZ TILT CALCULATION KNOWLEDGE OPERATOR 3

-

INATTENTION TO DETAIL / INADEQUATE SELF-CHECKING

,

INADEQUATE KNOWLEDGE RETENTION (SBCS OPERATION)

TRAINING PROGRAM WEAKNESS IN AZ TILT CALCULATION KNOWLEDGE EGF-5 11/15/93

.

%.

.

+

.

-

.

,

..

,

JU)S EVALUATION OF JPM EXAHINATION(CONT'D)

.

JPM TRAINING 32 NOURS PER CANDIDATE DEDICATED TO JPM TRAINING

-

e CORRECTIVE ACTIONS CONTINUE TO STRESS SELF-CHECKING ON THE JOB AND

-

IN BOTH INITIAL AND REQUALIFICATION TRAINING CONDUCT JPM " TECHNIQUE" TRAINING IN INITIAL AND

-

REQUALIFICATION TRAINING PROGRAMS REVISE INITIAL TRAINING PROGRAM TO ENSURE AZ TILT

-

CALCULATION IS EFFECTIVELY ADDRESSED

EGF-6 11/15/93

,

'

-

--

..

.

,

APS EVALUATION OF SIMULATOR EXAMINATION

.

ISSUE FAILURE OF SIMULATOR EXAMINATION BY 3 SR0'S AND

-

1 R0

CAUSES SR0 1

-

INCORRECT ASSESSMENT OF PLANT CONDITIONS SR0 2

-

INABILITY TO PROVIDE APPROPRIATE DIRECTION T0.USE AUXILIARY FEEDWATER TO FEED STEAM GENERATORS FAILURE TO USE AOP WHICH LED TO FAILURE TO CALL-LOAD DISPATCHER AND REVIEW TECHNICAL SPECIFICATION CONCERNS

.

SR0 3

-

TRAINING'S ASSESSMENT IS THAT THE INDIVIDUAL PASSED EXAMINATION.

R0 1

-

'P00R RECOGNITION OF MULTIPLE INSTRUMENT FAILURE IMPACT ON PPS

,

DIFFICULTY PERFORMING LEAK RATE CALCULATION AND B0 RATION SIMULTANE0USLY EGF-7 11/15/93

-

.

.-

. -

'

.

-

s.

..

.

..

.

[hPS: EVALUATION OF SIMULATOR EXAMINATION (CONT'D).

j y

.a

!

GENERIC CAUSES t

.i TRAINING PROGRAM WEAKNESSES REGARDING MULTIPLE'

-

INSTRUMENT FAILURE IMPACT ON PPS

!

a DIFFERENCES IN PERFORMANCE EXPECTATIONS BEDIEEN.

-

TRAINING PROGRAM AND NRC

.

CORRECTIVE ACTIONS REVISE INITIAL TRAINING PROGRAM TO ADDRESS:

.j

-

DETERMINATION OF RELEASE T0' ATMOSPHERE (SIGNIFICANT SINGLE EVENT)

OPERATION OF AUXILIARY FEEDWATER SYSTEM (SIGNIFICANT SINGLE EVENT)

MITIGATION OF HULTIPLE-EVENTS REVISE INITIAL AND REQUALIFICATION1 TRAINING

-

PROGRAMS TO-INCORPORATE RECOGNITION OF: MULTIPLE INSTRUMENT FAILURES ON PPS IDENTIFY AND EVALUATE PERFORMANCE-EXPECTATION-

-

DIFFERENCES AND INCORPORATE. EXPECTATION. CHANGES?

AS APPROPRIATE EGF-8 11/15/93

.

-

.

. -

.

- -.

..-

-

w

i

^~-

..

.

.

,

.

~

. PS EVALUATION OF WRITTEN EXAMINATION

.

il e

ISSUE

'i

.

GENERIC WEAKNESSES IN THE FOLLOWING AREAS:-

l

-

' AUTOMATIC ACTIONS FOLLOWING ANLAFAS SIGNAL MODIFICATION TO UNIT.2 ADV-CONTROLLERS j

AUTOMATIC SEQUENCING TO 1-PBA-S03 FOLLOWING i

ENERGIZING FROM UNIT 3 DIESEL GENERATOR ACTIONS ASSOCIATED WITH VCT LEVEL TRANSMITTER

-

FAILURES h.

'l

ESCORT REQUIREMENTS l

PRESSURIZER PRESSURE CONTROL SYSTEM RESPONSE

CEDMCS REED SWITCH POSITION SIGNALS l

^

RVLMS KNOWLEDGE

j FEEDWATER CONTROL SYSTEM RESPONSE TO REACTOR. TRIP

OVERRIDE

=

r.<USES

!

~LINADEQUATE OPERATOR KNOWLEDGE RETENTION 1AND

--

TRAINING REINFORCEMENT j

e CORRECTIVE ACTIONS t-INCORPORATE EXPANDED TESTING INTO INITIAL PROGRAM

!

-

TO-MONITOR OPERATOR KNOWLEDGE-RETENTION

EGF-9 i-11/15/93-

,

i

.

. I

,. -.

,

__

.1-

-.

.u,

.

...

-

.

n.

...

-

.

,

.

,

INITIAL /REQUALIFICATION EXAM COMPARISON

.

WRITTEN EXAML NO COMMON KNOWLEDGE OR SKILL WEAKNESSES

--

INITIAL REQUALIFICATION AUTO ACTIONS FOR AFAS RSDP: CONTROL OF.PZR HEATERS RCP TRIP CRITERIA ESFAS RESET ADV RSDP CONTROLLER ESFAS-LOADING SEQUENCES.

LOGIC DURING LOP RCP HOT / COLD PZR HEATER CONTROL WITH:

START CRITERIA SIAS/ VITAL AUX RESTORATION 86 LOCK 0UT EFFECT ON ESFAS e

CONCLUSION THREE YEAR HISTORY OF HIGH PASS RATE

-

NO APPARENT CONNECTION BETWEEN WEAKNESSES IN

-

INITIAL AND.REQUALIFICATION EXAMINATIONS;

.

EGF-10 11/15/93

.. -.

.. -

..t

,..

.

-

.

-..

.

,

INITIAL /REQUALIFICATION EXAM COMPARISON (CONT'D).

l e

JOB PERFORMANCE HEASURES INATTENTION TO DETAIL /SELF_-CHECKING IDENTIFIED-AS

-

GENERIC WEAKNESS

-

INITIAL REQUALIFICATION-

,

CEDM MG SET OPERATIONS EDG' OPERATIONS 72ST-1RX03 PERFORMANCE MODE 3 RCP START PPS BYPASS CVCS OPERATION

ECCS RESTORATION EMERGENCY l

AFTER LOCA CLASSIFICATION RECOGNITION OF AZ MANUAL STEAM GENERATOR

!

TILT OUT OF SPEC FEEDWATER CONTROL j

CONTROL ROOM EVACUATION

.

e CONCLUSIONS

STRUCTURED JPM TRAINING NOT INCLUDED IN

-

REQUALIFICATION PROGRAM HAD BEEN INCORPORATED IN l

INITIAL PROGRAM

!

JPM " TECHNIQUE" TRAINING IN INITIAL-AND

-

REQUALIFICATION PROGRAMS

,

'!

i,

.

EGF-11 i

11/15/93-i u

.

-

.

..

.

,

INITIAL /REQUALIFICATIDH EXAM COMPARISON (CONT'D),

o SIMULATOR EXAM NO COMMON TASK WEAKNESSES

-

INITIAL REQUALIFICATION EVENT DIAGNOSIS FEED / STEAMING OF STEAM GENERATORS

'

RECOGNITION OF ELECTRICAL PLANT AWARENESS PPS FAILURES RECOGNITION OF TIME TO PERFORM E0PS AFAS INITIATION

CONCLUSION ALTHOUGH NO SPECIFIC TASK TIES, IMPROVEMENTS

-

NEEDED IN OVERALL CREW PERFORMANCE IN TEAM SKILLS, COMMUNICATIONS, AND E0P USE

,

i

,

'

EGF-12

'

11/15/93 t

.

_.

_.. ~

-

,

-

SUMMARY OF PLANNED CHANGES

\\

.

~

'*

REQUALIFICATION PROGRAM l

q

,

SIMULATOR CONTACT HOURS TO BE INCREASED-U

-

WEEKLY STATIC SIMULATOR EXAH T0 BE ADDED

-

,

q REQUIRED READING FOR LICENSED OPERATORS

-

JPM " TECHNIQUE" COURSE TO BE. DEVELOPED

-

,

.

U INITIAL PROGRAM

,

JPM " TECHNIQUE' COURSE TO BE DEVELOPED

-

INSTRUCTORS TO SPEND TIME ON SHIFT TO OBSERVE..

-

PROCEDURAL ADHERENCE /SELF-CHECKING /JPM-i PERFORMANCE j,

MULTIPLE EVENT / INSTRUMENT FAILURE SCENARIOS TO BE

'

-

DEVELOPED-AND IMPLEMENTED

.

j ADDITIONAL MALFUNCTIONS WILL BE ADDED TO EXISTING

-

SCENARIOS TO INCLUDE VCT LEVEL TRANSMITTER'

l FAILURES STRUCTURED END-0F-SCENARIO CRITIQUES WILL BE l

-

CONDUCTED

SYSTEMS TRAINING WILL INCLUDE A GREATER:

[

-

' PERCENTAGE-0F REVIEW 0.UESTIONS l

,

-

REVISE INITIAL TRAINING. PROGRAM T0 -ENSURE' AZ: TIj

-

CALCULATION IS EFFECTIVELY ADDRESSED PROGRAM ASSESSMENT TO DETERMINE IF FURTHER j

-

ENHANCEMENTS NEEDED

-

j)

EGF-13 11/15/93'

j

,

.

..

.

_

.

..

.

-

.

7,

.

..

.

.,.

,

INVENTORY CONTROL INCIDENT.

-

l e

EVALUATION i

INITIAL CONDITIONS

.

-

l

!

i EVENT DESCRIPTION

-

INITIAL CORRECTIVE ACTION

-

PRIMARY CAUSE

-

SAFETY EVALUATION

-

i l

'

ADDITIONAL ISSUE

!

-

CORRECTIVE ACTION

.

?

t

.i

.!

RSM-1 11/15/93_

'

-

_

.

..

.

a

.

I'NITIAL CONDITIONS

~

j

.

-*

HODE 5

EQUIPMENT HATCH OPEN

TRAIN B 3HUTDOWN COOLING IN SERVICE i

l RCS LEVEL BEING MAINTAINED JUST BELOW FLANGE e

(112-113' FEET)

IN THIS CONDITION SINCE OCTOBER 25, 1993

-

PERIODICALLY DIVERTING / DRAINING-RCS TO RWT

-

SHIFT SUPERVISOR ACTING AS CONTROL ROOM SUPERVISOR.

i ASSISTANT SHIFT SUPERVISOR WITH L

-

AUXILIARY OPERATOR IN PLANT

<

^

REACTOR OPERATOR HAD PERFORMED DRAINING EVOLUTION

!

NINE (9) TIMES IN LAST TWO (2) SHIFTS

-

'

ALL CREWS RECEIVED DETAILED BRIEFING

-

PRIOR TO BEGINNING.MID-LOOP OPERATION-j WALKTHROUGH CONTINGENCY PLANNING DURING INITIAL

[j

-

PERFORMANCE y

REACTOR OPERATOR EVALUATED CHANGING' CONDITIONS

.

-

,

i

OTHER ACTIVITIES j

i PREPARATION FOR VACUUM l

-

/>

MOV TESTING ON CIRC WATER

-

'I RSM-2

11/15/93

.)

[

'

.

-

.

. _

_ _

. -.

-

..

>

%

.

..

,

e-

,

s

..

.

SHUT DOWN COOLING LOOP

'

.

.i Si si

.

696 658-

,

Oj k

%

SI SI Sl

652 -

654

. 656

. -

)

+

P RlF-

'

-

T SI

--

'

SDC FROM

'}

094'

RC LOOP

y4

,

PURIF.

LPSI o

g g

TO SDC Si

r '

i

..

SI 307

-

PUMP

_

l r

692

%

- gg-k.

"

RWT 668-CH 5-

-

TO

- TO

' 530

- Sg-

- RCS RCS-

.

659 LOOP" LOOP"

-- 2B 2A-

..

_.

+-N=se e

-=Whe pw f we-

up 9 era W-- WWeh't %wh:B' M Gr4 e &' Wen $

Te2%v t.ee-*veW'-*'6Wr-t'Tt'seu1^nDCWW#'urMt-'4um-wup ei WM>tsew sPr

'r't-

- iwws y*t g-gt-+4,wWADw u*-mi P W*e-en=$

1-W'rew47 seveu W%dw'*di'b W 7 em 9 'AWtt-T*tW#

-'7W*

EE+9wwr'-tt'-4e+MY'-'tM

-2 ' W ef*tY-B'TFW'*M'

-4e-1-+*e

'tr-m9*@--4'y*r9

. - -

,

.

RC RC 108 109 RCS VENT-SYSTEM

.

l

.

k l

RC

,.,

105-

..'

To Safety RC Valves 103 RC r

101

)

'

,

e i

RC TO RDT X

?*C 106

RC

'

- -

TO CONwpENT

,,

OR IE

,-

-

i i

l I

.

/'N

'

- - - -

f - - - -} - - - - - - - ~

~~ ~ ~ ~ ~

11T'

- - -

-

- - --

-

Partially *

.

,

i f-

'

Drained i

i

~

"

II1'

- ~ ~

-

~ ~ ~~'~

~~~~~

Redwed-Inventory i

Mid-loop

[.:C'-

.

2 2.'

==

From *

V'

Hot Leg t

>

-

Injection

-

Fro m To SDC SDC.

0224-93 -

.

m..-.

-mm-

.m ---

..

m

.- m. u m

_,.m-ew4------

--

+

-

.- -

-

--

..

.

.-

.

"-

_

s

<<

,,,

. -

EVENT DESCRIPTION

~

.

e LEVEL AT 113 FEET

.;

REACTOR OPERATOR ANNOUNCED INTENTION TO REDUCE. LEVEL

!

e TO 112' FEET

THIRD: REACTOR OPERATOR ACKNOWLEDGED AND WENT TO BACK i-0F CONTROL ROOM

NO OTHER ACKNOWLEDGEMENT

e REACTOR OPERATOR OPENED SIB-UV-668.AND BEGAN' DRAINING-

-

REACTOR OPERATOR CHECKED EXPECTED LEVEL DECREASE THEN.

e BECAME DISTRACTED-BY 0THER ACTIVITIES

-

SECONDARY REACTOR OPERATOR NOTICED RCS DECREASING-TOWARD 108 FEET

,

o REACTOR OPERATOR STOPPED DIVERTING. WATER AND: BEGAN

' MAKEUP LEVEL WAS RESTORED TO 112 FEET, 4 INCHES e

RSM-3 11/15/93

.

-

.

..

.

o

.

~.

,,,

,

..

.

iNITIALECORRECTIVE:' ACTION'

'

.

i

.:

SPECIFIC INTERIM DIRECTIONS ISSUED FOR CONTROL.

e OF RCS INVENTORY l

,

l

.

CONTROL ROOM STAFF BRIEFED ON THE EVENT AND NEED FOR

l

'

CONTROL OF. SAFETY SENSITIVE ACTIVITIES.

-:

i

.

REFUELING WATER' LEVEL INDICATORS PLACED ON

TREND RECORDER CLOSER TO VALVE CONTROLS l

l ij CONTROL ROOM STAFF REMOVED FROM-SHIFT TOLPARTICIPATE-

e IN INVESTIGATION

,

l J

ll

!

't

!

!

'

.

RSM-4-.

11/15/93 j

.:

,

._

. _..

_.

_

...

.

-.

.

-

.

-.

.

,

.

,

.

,,

.

..

.

>

PRIMARY CAUSES-

'

.

i i

,

OPERATOR. LOST HIS LEVEL OF: SENSITIVITY TO THE SAFETY

~a e

SIGNIFICANCE OF THE EVOLUTION BECAUSE HE HAD PERFORMED IT REPEATEDLY y

'i

,

OPERATOR'S COMMUNICATION WAS UNDIRECTED AND i

PROPER ACKNOWLEDGEMENT WAS NOT RECEIVED-j

.

.-

SHIFT SUPERVISION HAD NOT BEEN SUCCESSFUL IN

'

MAINTAINING COMMUNICATION STANDARDS i

-

,

..

?!

l

.

~

.

l

!;;

l

l RSM-5

=!

'

11/15/93

-!

l

., -. -

.-

.--,

-.

.. -.

.. -

,,.

-

,-

.

s

,

m:

3.,

,,,,

.,

-

SAFETY EVALUATION ~

!

-

..

q PARTICULAR INCIDENT HAD NO : SAFETY SIGNIFICAN e

>

!

INDICATED LEVEL WAS--108 FEET,.6 INCHES-

.(ACTUAL LEVEL DECREASED 1TO 111 FEET, 8 -INCHES)

-

IF DRAINING HAD CONTINUED:'

.

ALARM AT 101' FEET, 7 INCHES WOULD HAVE-ALERTED l

-

OPERATOR

IT WOULD. HAVE TAKEN 138 MINUTES TO l

-

VORTEXING

IT WOULD HAVE TAKEN 34 MINUTES TO REACH CO BOILING AFTER LOSING SDCS AT THE. POINT 10F--

-

.

f VORTEXING-THE SIGNIFICANCE-0F THE-EVENT IS THE LOSS OF C a

0F ACTIVITY.AFFECTING A SAFETY FUNCTION-

!

!ll

!

y n

11

1

'!

I

{ :-

v-

-

n 1,

.,,,,.,

.-

,

.

,

CORRECTIVE ACTION

.

o TEAM TRAINING IMPROVE TEAMWORK j

-

J

IMPROVE COMMUNICATIONS

-

r DEMONSTRATE. ABILITY TO MEET' MANAGEMENT

~

--

EXPECTATIONS

.

EVALUATE SHIFT SUPERVISION PERFORMANCE

1j BRIEF OPERATIONS DEPARTMENT / MANAGEMENT e

j

--

q EMPHASIZE THE OVER-RIDING HEED TO CONTROL j

-

CRITICAL SAFETY FUNCTIONS J

.

EMPHASIZE THAT CONTROL MUST BELAPPARENT

-

EMPHASIZE THAT NOTIFICATION MUST BE PROMPT-

-

_

REVIEW HOW AN INCIDENT IS VIEWED'IN THE. INDUSTRY'

-

REVIEW POTENTIAL RESULTS OF AN" INCIDENT-

_

.

.WEI-2-i 11/15/93-L u

.

..

__

-

..

.

u

IR 05000528/1993050

Text

REGION V

==

Navigation menu

Search