ML060580726
| ML060580726 | |
| Person / Time | |
|---|---|
| Site: | Salem, Hope Creek  |
| Issue date: | 10/14/2004 |
| From: | Rutigliano K - No Known Affiliation |
| To: | Cobey G Office of Nuclear Reactor Regulation |
| References | |
| FOIA/PA-2005-0194 | |
| Download: ML060580726 (7) | |
Text
Tb iGene Cobey Page 1 of 7 2004-10O-14 15:57:07 (GMT) 15016328862 From: kymn-tutigliano 1s FAX COVER SHEET
- ro Gene Cobey COMPANY NRC FAXNUMBER 16103375349 FROM kymn rutigliano DATE 2004-10-14 16:04:44 GMT RE PSEG NUCLEAR SAFETY NOTIFICATION . -
COVER MESSAGE GENE, As discussed.
Also, please determine if a thorough post maintenance test was done of HPCI following the change in the orafice, set point data change in the procedure, and was there a 5059 evaluation completed? If all this was done during the LCO window that was exited on July 29, 2004, why would HPCI aB not operate as designed? If all this was not done, was HPCI even "operable" since July 29?
Thank you.
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To: Gene Cobey Page 2 of 7 2004-10-14 15:57:07 (GMr) 15016328862 From: kymn rytigliano 2004/OCT/14/THU 10:50 AM Nuclear Training Ctr FAX No. 1856 339 399 7 P.001 O
Notification Overview ,:
Run Date: iC /1 4/2004 I SE Run Time:
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1C):38:38 1 Iof Notification 202136978 6
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Notif carion 202069 76 Notification type N1 Dcscription NUCLEAR SAFETY ('ONCERN HCISALEM EVENT' Nuc. Maint. Request Reporter LEGRAND. 2558 14:33:25 Nordication date 10/1 3/20CC4 Stat date 10/13/20C End dare 11/13/2004 Stail time 14:33:25 End time 14:33:25 Priortry 1 Immediai rte Sig. Ievel 2 Main WorkCtr. X-NUCR Funcr. location Cl COMMON rO ALL NBU UNI7S' Equiment 1 Assembly Order PM planner grp 099 Mt,rlonar Default
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NOTIFICATION
SUMMARY
mVnirY CURRENT REQUIREMENTS CONTAINED IN
- **** VNC.WM-AP.ZZ-0000(Q) 'NU FIHATION PROCESS I K "* *
- 1) DESCRIBE THE ACTUAL CONDITION? (Do not U3C individual's namefe); you may use computer ID's or badge numbetJ) a Nuclear Safety Cutiuern surrounding cvents at Hopc Creck and Salem from October 9, 2004 thrAligh October 13, 2004.
Notifications tlat were reviewed orc in SAP. Specifio notifications relative to my concern for tha TirnP period are listed in Table 1.
A. Nuclear Sofcty Issue t . .
A eoquenco of events for the rs.Ai'nr Trip and post-trio response should be captured in the Significance I Levul 1 root cause tcport for the opplicabic notification (2020 631). However, thA rOnT nat19e will most.
likelv jirnit the perspective to the particular events In the trip ;nd speoific plant and opcrotor rsporn3c3.
The root cause e'viuation may' misk significant organizational and programmatic issues and Opportunities fur imnprovement. .
I The sequence of events for th4%. nroani7atinn can be traced back many months, with indicat'ons of I wuaules dentfie bv1 WAANO in thc 2002r ot Seifclv --u Organization Duiiiig lhe last year. we have continucd rcorganization efforts with ineffective ehAngs m nrg ment. -
Work supervisors are continually challenged tu pituduc results while administrative workloods aro increiAs:rr. Snme supervisors routinely provide oversight of up to 20 employees or more, far exceeding the capability of even thc bcst trainod and equipped supervisors to be .fferrivn. During the August - October period., several key management positions have bueti vwicaited due to rcsi gnetiona or training asrignmernte, as wPIl Aq Arstablishing rotational positions with Exelon management. The gaps left In the organizatiuie- -
during thc changoc causes ineffective communicationrs laik of trust between management and the workforce, lack of consIstency ill uxpmulutLiuns. and an unsafe work cnvironmcnt.
While training Leadership Effectiveness and Safety Conscious Work Environment are two very important keys -co future success, these are not the only choices, nor are they the solution to all problems. Many
To: Gene Cobey Page 3 of 7 2004-10-14 15:57:07 (GMT) 15016328862 From: kyrnn rufighJano 'i.
2004/OCT/14/'THU 10:50 AM Nuclear Training Ctr FAX No.1 856 339 399' 7 P.002 . .
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Notification Overview fl PSFlC W A A1 h 1
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10/1412004 10:38:38 2 of 6 --
Notification 20206978 soft skills training programs have been provided at the site in the past, each with the potential to provide long-term positive effects. The training merely provides the tools. The effectiveness of the programs must corme with senior management reinforcement to middle management that the time and effort will LVe taken to u3c the tools. Middle management rnm"-' nhsq.rve and reinforce tool usage with superintendents..
and supervisors. The Leadership Effectiveness and SCWE training provides the tools, but our plans a--rt faii ^shotin thea actualn imnlnmPntatinn hv spenir mankgement and mriddlen minaqePrnT itn reinforce and support ure of the tools with the suipArvision.
Crisis Management As the station responded to the Hope Creek transient, workers could almost 'hear" the sigh ot relief from management. Management responded to the crisis in the typical fashion, putting other plans to the sidk`
And Astablishing a plan to respond. Managers and workers were pulled [urti their plans and the station" A\
staffed to respond. An effective Central Outage Group would have contingencies in place with specific names o1 people to Stafr specific positions in support of a forced outage. The forcerd nAitrAo work plan ,
would dictate the work being done, with additional work based on the plbfit transient.
Our station response has been one of crisis ranagemcnt. Rather than approach this forC-Ad otage in methodical and systematic manner, it "appears" that we are scurrying tu itestart the plant to stay aheds of the outago. Yet, we are n6t sure whoT we want equipment we want to work , nor if we really want m start up the unit. StaLiuII management must stcp away from task management and rrm~nj rho ttlff With a 'big picture' aoproach, making appropriate decisionS that ensure nucluat sifety, radiological safety, oaif industrial safety. *"
Significant Issue Duc to tack management and a narrow focius, we are unable to see the "big picture."
As a result, we are uiiwble to recognize significant iscucs. When workers try to bring isiejs To our->-
attention les a manaqement team), we tend to minimize the siguificance of the concern or avoid the workcr%; concern. During this forced nuitage, do the workers feel like they can walk into any menagej -
office and express a culticem without repercu3siona? Tho question has been asked. Workers.arr not feeling a difference. V-z Nuclear Safety Revereimuu The various issues arising during the trip and post-trip evenrs iiidicate a potential nuclear 3cfety issuc..
Conaidering the notifications and the tAnntrpnt within the notifications. safety equipment did not work par ..
design. HPCI, fiCIC, RWCU, rCIG, and SRVs did not respond in a manner tn ;eapport safe plant operations. Numerous notitications have been written SbUUL tile various systcms and they orc li3tcd irn While equipment reliability during a transient Is an Issue, it it ucumpounded by an apparent knowicdgo dcficicn~oy on the part of the control rnnm si-aff. Reactor vessel water level was difficult to maintain with the equipilcint that wao available. Dcsign basie and technical specifistntinn knowledge and aoplicktion did not appear adequate during the post-trip response bused ui tiotifications.
Generically, thelc are numerous notifications in 2004 that indicate a Denernl inahility to apply technical specification requirements by most Salem and Hupe Ciekc Operations Lican3cd Operators and Supervicorc-..
Further investigAtion is virirranted to determine the full extent and cause of this apparent Operator deriuiieicy. 4:
B. Work Management Issue Long Standing Issues E'ven with numerous communications and the expectations to bring forward problems, notification ;'
20206783 was written as a 'long standing issue that complicates operator interface." It appears that operators are willing to work around long standing safety system issues that affect equipment reliability.
l
I Ilo Gene Cobey Page 4 Or/ 2004-10-14 155707 (GMT) 15016328862 From: kynn rutigliano 2004,/0CT/14/'THU 10:50 AM Nuclear Training Ctr FAX No.1 856 339 3997 P. 003 Notification Overview Run Date: 10/14/2004 Run Time: 10:38:38 Notification 20206978 Considering the notifications written during and after the trip on October 10th, numerous issues have been raised concerning HPCI and RCIC. Reliability of these safety systems is of paramount importance to evisuring nuclear safcty. Yct, we have numerous notifinritons and an apparent lack of understanding of system design by Operations staff, based on notifications. An additional note is a generic weakness _ -
relative to HPCI identified during recent Licensed Operator Requal Annual Exams.
Additionally, what effect did the recent setpoint paper-only modifi cation have on actual HPCI System .,
perform-.nnra during the post-trip response? The data should be available and evaluated to ensure that)h?
right decision was made in pursuing the change that occurred.
Operations Ieandership Several notifications from both stations, along with other notifications , indicate a general weakness in consistent crew performance. Aut essential ingredient of nuoloar eafety is having a predictable or.Arnrinr..
crew. (pArATing crew performance is becoming more unpredictable, with widu vaiiatiolns in their exhibited abilities to occomplich work, as well as mew conservative decisions. Several factors affect this, including Operations Managers resigning (tile lost two at Selem. one at Hope Creek). Need to evaluate the impapt.
To Operations staff and the effectiveness of our change management plans. As well, there are few SPt3 licensed individuals in respo'nsible managemAnt positions as a rotation from Operations. Ihis has a negative effect on the organizailiuii, leaving operations knowlodge in the control room and creatino Additional communication and trust barriers.
Other Issues Ontrher is the culmination of many activities. some taking place over the endits year. SCWE training b mandatory for all porconnel. Leadership FffintivAness training is mandatory for all supervisors and abover.--
Work Management and CAP uainuiuiy will start soon as mandatory training. Accredited Training is nngoing with LOR Annual Exams for Salem and Hope Creek, Maintenance Acuteditation preparations, initial tr inrg for chemistry and ongineering. and ongoing mninTnnnnce training. Extensive outage training is ongoing 'for a planned supplemental worklugie of 1200. The she6r volumo of training makeq it difficult to irliAnTify who is available for work in the plant. Add vacatIons (approachiiiy viid of the year) and flu season to absencts. Arc wo effectively managing otir rpsmirces to accomplish the work we planned} We are adding additional work to an aiuady stressed staff, just looking at the training burden.
Zcnior and Middlo Management changed extf-nsivnly over the last year. The reorganization last year go reduced supervisors in late very place we moy nccd thorn most, working with thefiving Arqltipment.
Stiprtrvisors of bargaining unit workers end up supervising 5 to 30 peuople during a routineshift. Weput additioral administrative burden to en'Vire otherr things get done-.Yet, we give them no admniws.Vative 9 assistance. We havidsupervisors and journeyman doing administrative work. A hAtrar way to works'j.
wnoild be provide maintenance supervisors with administrative assisl;ailute to help withsome edminiatrati'VP functions, allowing more rupervision time. Changes in middle management and senior management Save caused a 'wait aridsac" attitude across thoorganization. Many people are reticenr To point out issues hi-.a'ise of concern for "back-door" politicstaking reprisals. While vvetaie quick to train with industry-cxpcrts;. we are notas ready toliiRTn to workers who are saving, "I can't feel any ditterence.
Ourepproach to managing relationships and encourauijiy tiust lhas been heartfelt by somcIcadcrchip7-yet haenot permeated the managemerht ran ks. Manv managers are continuing business as usual. The --
subculture persists where it is atill do it the way I say do it (becas.tr- I said so). Arneffective organization takes the time to listen to employees, thent lakes action. The action may be 'no', but the-employee is still given fedrlhack.
In order to ettect change and create a nucltai sufety culture, menagemcnt must licton toemployeest '.
Rather thanminnrating actions. we must cooperate with workers and find the most effective and efficrent solutions. Workers know how to dothe jots. we must remove barriers and give them the tools to do the work safer and better.
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I D: Gene Cobey Page 5 of 7 2004.10-14 15:57:07 (GMT) 5016328862 From: kymnorutigliano 2004/OCT/14/THU 10:51 AM Nuclear Training Ctr FAX No. I856 339 3997 P.004 Notification C)verview O PSEG Run Date: 10/ 14/2004 r' Run Time: 10: 38:38 ;... -
Page: 4 ol f 69 6 - .
Notification 20201)6978 .
- 2) HOW DOES THIS ISSUE IMPACT PLANT OR PERSONNEL SAFETY? .
Nuclear Safety i3 brought into question by the safety eqtlipmAnt reliability following the Hope Creek Trjp on 10111/04. Ongoing operator workarounds end challenges increase the potential for a significant eemnt to occur.
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RArnnT nntifications, as well as notifications identified in the Event Free Clock Reset criteria, have identified Technical Specification compliance issues by the operating crews in both stations. Failure to, comply with license conditions increases the potential significance should an event occur, similar to the plent ram.ponse following the Hope Creek Trip on 1U/1 1/04.
41 WHAT CAUSED THE CONDITION? .
iI InI.ffAntivA change management. as well as perceived continuously changing priuriliu.
causcd imany individuals to become stresse.i. This may be validated by evaluation of other indicators such as gbsenteelsm (sick lime) atid increased doctor viSit3 (mcdioal costs).
Work, overloadrhas
- 5) WHAT ACTIONS, IF ANY, HAVE BEEN TAPFN TO CORRECT THE CONDITION? I Notified direct supervision, initiated notification. No other immediate actIons requifte. r..
t .,
- 6) RECOMMENDED ACTION/CORRECTIVE ACTION AND WORK CENTER _I~.
'L7 RESPONSIBLE tOR CORRECTING CONDITION.
(U3c Tidc/Position, not name)
Heeommend assign to Vice Piusideuit-Operation3.
- 7) ANY OTHER RELEVANT INFORMATION INr-l tIDING ANY CRITICAL DATES FOR COMPLETING THE ACTIONS.
(I.E. ROOM NUMBER, BUILPING ELEVATI11N, COLUMN NUMBER.
DISTANCE FROM FLOOR, WHO, WHY, n:rcnl[NCES, ESTIMATED COST. WMIS TAC3,ECT). (A Notificotions roviowod lamong all others):
Table 1 I -e 10/O/1W 1aturday ~ * - .:. &..f-t I 2020,5551 Rod Bluu.k Munitor Alorms SIL3 I
20206561 Fire in HC Substation #4 SL2 20206582 62-60Q24 Bkr Tripped on grounrl fAutir SL3 I
20206562 13.8 kV disc for IHC 5ubstation #8 foiled unable to restore power to TR? RI R 10110/04 Sunday 20206626 PipinJ tuptuse between at condenacr pcnctration SL1 -I.
20206604 HPCI Vacuum Pump overloads trip 72-251021 SL3 20206596 Switch Stntinn Nn. 2 Circuit Termination SL3 I
10(11104 Monday 20206631 Rx Scramn t1IA tn steam leak SL1 20200632 Automatic SCRAM following Manual SCRAM SL3 20206569 NAP-b hour limits exceeded by 3 RP Ltu;lis 3L3 2020957R3 RCI(C nperation at low flow SL3 20206634 HPCI Vacuum Pump repeated trips SL3 20206633 HPCI not operating properly SL3 I
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'To: Gene Cobey Page 6 of 7 2004-10-14 15:57:07 (GMT) 15016328862 From: kymn rntMgliano 2004/OCT/14/THU 10:51 AM Nuclear Training Ctr FAX No. 1856 339 399 7 P.005 0 PSEG Notification Overview Run Date: 1O1 4/2004 Run Time: 10:38:38 Page: 5 of 6 {J. .
Notification 20206978 0, r-. '
I 20206f365 BJ-HV-F008 did not open in press control SL3 20206587 PPC I CMS Problems on SCRAM S'L3 O;:, . - - -
202061335 RPT breakers failed to trip SL3 20206763 Evolution plan required during SO-Rr:-fl) SL3 20206726 Barricades-barriers-safety tape - near miss SL3 (Salem) 20206549 Schedule pressure exerted by Ctrl Rm supervision to install CW fish gates during high vvinds;'
SL3 (S-3lcm) 10/12/04 Tuesday 20206808 Checkpoint delays SL3 S.-. -
20206863 QA missed 2 yr periodicity of attribute SL3 20206902 Safety violations in Work Gang lBox SL3 20206606 LCO challenges with both RHR Loops inoperable SL3 20206689 Valvu luuiid out of position 5L3 20206811 Condensate Transfer Design deticiency SL3 20206848 Tech Spec 3.4.9.1 endl .R.4.9.2 compliance issue SL3 20206849 Teul Sptei 4.0.4.1 compliance issue 8L3 20206766 Possible faulty RWCU flow controller SU 20206953 Minor Maintenance ~/n WCS Authorization SL2 (Salem) 20206905 Husu Cutitiol Program Non-Compliencc SL,3 20206668 RMCS Lockup SL3 10113/04 Weditusday Z0206772 Torus Level 188-19' out ot but'rd nigh SL3 20206926 1 & 2 A,B,C Htr trip Olwiring Rx Scram - response unexpected SL3 20200946 Repeat Pumiip Motor Trip on Thermal Overload SL3 LOCATION OF THE COMPONENT:
Affects Salem and Hope Creek Stations, 8S well as all support lutiuliuis.
- 8) DESCRIBE HOW THE ISSUE WAS IDENTiFIED?
Identified following review of notifictinnc and discussions with various olant staft. As acting Human Petfuinuoiwe Leader. I considered the organizzational and human performance isstleS thnr did nnt appear to be addressed by other groups in the organizatIon.
- %. e* *c* . 5*@X
= NA FOR SIGNIrICANCE LEVEL X NOTIFICATIONS Upduded. DONALD LE GnAND 10.13.2004 14:33:27 10/13/2004 20:21:53 MICHAEL REED (NUMFR) 10/14/2004 Ub:38:23 A. CAROLYN TAYLOR (NUACT)
CAP Note: The majority of is.ucs, condition6 and causal factors. cited Ahnvp, have been previously identified, evaluated and are being addressefl undet a iiumbei of SL-1 loot Cause evaluation3. AdditiodtaIly, their indlividtial and collective safety significance has been tully evaluated with concurrencs from the CARB, INPO end thc NRC.
Importantly, each of the five (5) focus areas (that this N1is collection of issues presents)are bounded by and have been validated to be encompassed within Level 1 and Level 2 Business Plans for; 1. Leadersb;p,
- -X ,
. Irp: Gene Cobey Page 7 of 7 2004-10-14 15:57:07 (GMT) 15016328862 From: kymn rurigliano 2004/OCT/14,'THU 10:52 AM Nuclear Training Ctr FAX No. 1 856 339 3997 P. 006 Notification Overview 0 PSIG Run Date:
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10/14/2004 10:38:38 6 of Notification 20206978 6
operation 0110; this validates that the Business plan items are comprehensive and effectively targeted. I SL-1 RCE 20161225 / 70034303, Uncorrected, Global and Interactive Organizational & Programmatic Factors, SL-1 RCE 70032416, Work Management, Teamwork and LCO Windows under 70032416.
Equipment reliability istzues under -$ -1 RCE's 70037087 (as an examole),
Maintenance and SupplernenTal Personnel performance under SL-1s 7flfl33541,70028106. 70035233 lConfiquration Control),
Om Operations under SL-1 70036556.
I C-nnrnrns. regarding HPCI flow setpoint change are identified through 20190704.
Additionally, I have already infutitiud Lhis Initiator that we are doing a Common Cause Evaluation of npArarnr knowledge-based. and rule-based performance in lech Spec /TSAS entries. Alsu, I Jwave
'bullctizcd', and this Initiator copied, a chart of qignifirant individual events and shift nerformance that I have validated are belng addressed utider a major nCC of the Hopc Crcok multi-soram events of 10/1112004.
Given the bctIvltles already beiny uuitducted by PFE3G-Nucleer, ond a; CARB Mentor & Advisor, managerment needs To specifically determine what issue or condition this Initiator feels needs to be evaluaLud audnl iv not addrcatcd by proviouely identified NUS, NI.CR ewAhiaIinns. CRCAs and Business plan items.
If a further EVAL of NI 20206978 (this one) is conducted, the scope needs to be clearly buuiidrd diwd statcd 3o as not to further duplicate our efforts nAr rlTract from any activities relevant to the Businesi Pan Focus Item Areas, which inutludo "fixing the plant'. t5 4 Not Applicable TSCO MllCHAEL F REED REQ Review RequiituJ TSOS t
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