ML083030316
| ML083030316 | |
| Person / Time | |
|---|---|
| Site: | Byron  |
| Issue date: | 09/08/2008 |
| From: | Grundmann W Exelon Generation Co, Exelon Nuclear |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation |
| Shared Package | |
| ML083030310 | List: |
| References | |
| BYRON 2008-0096, IR-08-003 | |
| Download: ML083030316 (24) | |
Text
Root Cause Investigation Report Content and Format 2ause Being Addressed Nork Management procedure 2uidance is generic in nature and loes not discuss dual function risk
- omponents.
3U-AP-104, Shutdovvn Safety Management Program E3yron/Braidwood Annex, and OU-AA-101-1005, Exelon Nuclear Outage Scheduling are silent on opposite unit OLR considerations.
Not Cause Related Corrective Action (CA) or Action Item (ACIT)
- 6. CA to create guidance that lists dual function risk components that if unavailable in conjunction with its redundant component would result in an orange or red condition.
- 7. CA to identify and designate dual function high-risk components that if unavailable in conjunction with its redundant component, would result in an orange or red risk condition in work management andlor clearance and tagging tools (Passport -Work Management, Equipment Tagout, Issue Reporting) to alert applicable personnel the potential risk significance.
- 8. ACIT to consider plant labeling of risk significant components such that people know that they may be affecting risk by manipulation.
Take additional actions based this review.
- 9. ACIT to consider adding guidance to OU-AA-104 and / or OU-AA-101-1005 to evaluate the non-outage OLR when performing outage-scheduling activities. Take additional actions based on this review.
- 10. QREC to process report to meet records management retention requirements.
- 11. ACIT to identify other processes that operations personnel participate that may succumb to this type of root cause.
- 12. ACIT to document department clock reset as defined by the causes identified by this investigation to applicable departments Owner A8851 NESPR A881 OOP A8801 RAPR A881 OOPSRM A881 OOP A8840WC Due Date 1 2/16/08 Page 21 of 73
Root Cause Investigation Report Content and Format
- 13.
EFFECTIVENESS REVIEWS (EFRS)
I ~~~~~
13.1.
CAPR I CA being addressed CAPR to develop, implement, and reinforce expectations that include clear direction on roles, Closure criteria: Expectations created, implemented, and reinforced with all shift managers and supenrisors.
Effectiveness Review Action EFR to review effectiveness of CAPR. CAPR will be deemed effective by the absence of any missed unplanned risk evaluation resulting in an adverse color change using CAP, NOS, or NSRB data.
responsibilities and owership regarding risk management for shift managers and shift supervisors.
Owner A881 OOP Ensure that procedure and training actions have been appropriately imp,emented.
Due Date
- 1. Less than adequate site awareness of auxiliary building internal flooding with respect to affected processes and procedures.
- 15.
PROGRAMMATICIORGANIZATIONAL ISSUES The site did not perform a review or response on generic letter 88-20 as it was performed at the corporate level. It is unclear, through existing documentation, what processes, programs, or procedures were reviewed.
For example, as documented in AR 8412, Safety Evaluation Report for Individual Plant Examination of Generic Letter 88-20, the NRC noted that a potential vulnerability existed involving a dual Unit loss of Programmatic and Organiational Weaknesses
- 1. ACIT to review generic letter 88-20 for potential process, Owner Corrective Action (CA) or Action Item (ACIT) procedure changes or site communication. Document the results of the review and take additional actions as necessary.
Due Date
- 2. ACIT to review regulatory guide 1.200, An approach for determining the technical adequacy of probabilistic risk assessment results for risk informed decisions, to ensure I
adequate implementation.
Page 22 of 73
Root Cause Investigation Report Content and Format essential wrvice water from flooding, and indicated that a modification was being addressed which will reduce the CDF from 1 E-4Jyear to 1 E-Glyear.) In the SER cover Better, NRC requested that they be informed when the modification is complete so that the correct CDF may be attributed to Byron. The actual SEF3 indicates that the modification is to a vent duct on the 330 ft. elevation of the Auxiliary Building.
Programmatic and Organizational Weaknesses It further states that, in conjunction with a procedural change, this modification would result in the CDF contribution for dual loss of essential service water due to pipe breaks decreasing from 1 E-4lyr to about 1 E-Glyr.
The procedural changes (SX procedures; OBOA PRI-8, Auxiliary Building Flooding, and BOP SX22, Essential Service Water Leak Isolation) have been completed, and have a measurable effect on flooding CDF because they are aimed at identifying and stopping the leaidflood.
Two vent modifications were initiated, (Design Change Process (DCPs) 9700734 & 9700735 (Work Request (WR) 980005294 &
98000531 4). These modifications were presented and approved by PHC and PRC but have not been installed to date. This action remains open to notify the NRC on the decision not to install the modifications, Corrective Action (CA) or Action Item (ACIT)
- 2. Limited management oversight related to risk management process. (Extent of Cause)
Majority of management foeus is on the outage unit because of the massive amounts of activities being performed. Little Owner
- 3. ACIT to status SX system modifications that would reduce OLR and review has PHClPRC for high priority consideration.
Document the results in this assignment and take additional actions as necessary.
Due Date
- 1. ACIT to consider adding a task into the FMS database for OLRlSDR activities. Take additional actions as necessary based on this review.
A8851 NESPR A881 OOP 911312008 Page 23 of 73
Root Cause Investigation Report Content and Format I
I r
documented management observation of OLWSDR activities.
1 2. AClT to identify opportunities to I A88100PSRM
/
08127108 1
Programmatic and Organizational Weaknesses FMS data was queried for t3yron from 01/01/08 to 07/01/08 that identified - 12300 fundamentals scored. A keyword search was pedormed using "risk that identified 19 observations for either OLR or SDR. This represents - 0.15 % of the population. The median value for this population is 0.4% with the average value being 1.1 O/O. Upon further review of FMS a task does not exist to assign OLR or SDR obsentations.
use the behavior observation process for documentation of OLWSDR performance results.
Set expectations on observation quantity and quality based on opportunities identified.
Document opportunities identified and expectations on quantity and Corrective Action (CA) or Action Item (ACIT)
I
)
quality in this assignment.
1 1
Page 24 of 73 Owner Due Date
Root Cause investigation Report Content and Format both valves are incapable of closing from the main control room.
IR 759929 - Clearance Order 57893 was cleared to closed from the MCR. Credit was taken for local trol room. SX procedure OBOA
-8, Auxiliary Building Flooding, ntains a caution related to wetted the Aux. Bldg. and risk was restored to green. The 1 SX033 and/or 1 SX034. This will put the dedicated al Service Water Leak NLO in the line of fire and risk of his or her life. Credit n, does contain various should not be taken for putting someone in the line of fire. As this event pertains to OLR, crediting an is procedure lists various SX lines room. This IR will be addressed in the "Other Issues" of this report.
If3 759455 -This It? documents the disagreement of the removal of a circuit breaker for the 1 SX027A as it is a big part of the SX flowpath and provides interlock functions for the 1A SX pump, part of the start circuit for the reactor containment fan coolers (RCFCs), and containment chillers. With this breaker removed, the valve cannot be closed from the main control room if I needed to for IeaMflood isolation. This issue was evaluated for Unit Two
- 17.
OTHER ISSUES A881 OOPSRM Other Issues identified during investigation Complete 9/8/2008 Page 25 of 73 Corrective Action (CA) or Action Item (AC1T)
Owner Due Date
Root Cause Investigation Report Content and Format
- 2. As part of evaluating the consequences of this plant configuration it was suspected that a large amount of margin was present in the risk model calculation. Although this configuration would have resulted in a unplanned risk change, the magnitude may be much less. The calculations that support this model in other areas may possess the same magnitude of margin thus not giving a realistic picture of risk.
- 1. ACIT to evaluate the extent of condition of the risk model calculations to identify unrealistic margins. Take additional actions as necessary based on the evaluation.
i Other Issues identified during investigation Owner Corrective Action (CA) or Action Item (ACIT) 3, No formal mechanism was found in place to ensure that adequate transfer of knowledge related to OLRl SDR when personnel changes are made particularly in work management.
Upon interviews with applicable personnel it was found that no training (formal classroom or on the job training and evaluation, self paced, certification guide) exists. This is particular factor with new Outage risk or cycle manager personnel in the future.
Due Date A8851 NESPR
- 1. ACIT to develop and implement a method to accommodate transfer of knowledge related to OLR when personnel changes are made. This method could include development of a certification guide or programlprocess notebook similar to Engineering.
- 2. ACIT to develop and implement a method to accommodate transfer of knowledge related to SDR when personnel changes are made. This method could include development of a certification guide or programlprocess notebook similar to Engineering.
08129108 Page 26 of 73
Root Cause Investigation Report Content and Format COMMUNICATIONS PLAN Lessons Learned to be Communicated Licensed operator training learning objectives, lesson plan content does not address or reinforce the necessary knowledge of dual function high-risk components and their potential affect on OLR.
Cycle Managers and Outage Risk Managers do not receive training for risk assessment activities nor is there a method to ensure that knowledge elements are appropriately transferred when personnel changes occur.
Dual function high-risk components are not identified in rule-based guidance Less than adequate site awareness of auxiliary building internal flooding with respect to affected processes and programs.
Limited management oversight related to risk management process. (Extent of Cause)
I Communication Plan Action
- 1. Revise NER to communicate event to the fleet
- 2. NNOE to communicate event to the industry
- 3. Provide an article to the site weekly communication.
Owner A88100P 759945-09 A881 00P 759945-1 1 A88100P 759945-24 Due Date 08120108 Page 27 of 73 4
- 19.
ROOT CAUSE INVESTIGATION REPORT QUALITY CHECKLIST Page 1 of 2 I Critical Content Attributes I YES 1
NO I
I I
Is the condition that requires resolution adequately and accurately identified?
I I
X Are inappropriate actions and equipment failures (causal factors) identified?
Are the causes accurately identified, including root causes and contributing causes?
X X
Are there corrective actions to prevent recurrence identified for each root cause and do they tie DIRECTLY to the root cause? AND, are there corrective actions for contributing cause and do they tie DIRECTLY to the contributing cause?
Page 28 of 73 X
Have the root cause analysis techniques been appropriately used and documented?
Was an Event and Causal Factors Chart properly prepared?
Does the report adequately and accurately address the extent of condition in accordance with the guidance provided in Attachment 4 of LS-AA-125-1003?
Does the report adequately and accurately address plant specific risk consequences?
Does the report adequately and accurately address behavioral, programmatic and organizational issues?
X X
X X
X Have previous similar events been evaluated? Has an Operating Experience database search been performed to determine useful lessons learned or insights for sed to arrive at the conclusions?
4 Root Cause Investigation Report Quality Checklist Page 2 of 2 I Miscellaneous Items 1
YES
/
NO I
Did an individual who is qualified in Root Cause Analysis prepare the report?
X Are the format, composition, and rhetoric acceptable (grammar, typographical errors, spelling, acronyms, etc.)?
I I
I 1
- Actions will be entered into passport and trend codes applied after MRC approval.
This is tracked by assignment 759945-20.
X Have the trend codes been added or adjusted in Passport to match the investigation results?
Page 29 of 73
- 20.
ATACHMENT 1 - ROOT CAUSE INVESTIGATION CHARTER Page 1 of 1 IR Number: 759945 Sponsoring Manager: Bill Grundmann, Regulatory Assurance Manager Qualified Root Cause Investigator:
Robert Lloyd (verified in LMS)
Team Investigator(s):
Training Gary Wolfe 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> Work Control Dave Coltman 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Engineering Programs Joe Edom 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Scope:
Investigate the issues that led to an unplanned Unit 2 on-line risk (OLR) Orange Condition including:
Training and qualification associated with how well the (a)(4) process is understood (i.e. as a Configuration Risk Management process) and of the level of understanding of risk and insights provided by the PRA, and review operator response actions to flooding, Technical review of risk evaluation sheets and other risk documents, Organizational and programmatic potential latent weaknesses associated with risk management, IRs related to operator response credited to mitigate flooding in the auxiliary building; 757507, 757930, 759455,759929, and 759930.
The root cause methodologies used may include event and causal factor charting, TapRootB, task analysis, and causeleffect analysis.
Interim Corrective Actions:
OLR is evaluated on a daily basis after the updated outage schedule is released and any necessary adjustments are performed.
Communication was made to all SROs to ensure that any configuration changes on EPNs listed on the risk evaluation sheet are questionedlcommunicated to the Cycle Manager such that risk can be reviewed if necessary.
Root Cause Report Milestones:
- 1. Event Date
- 2. Screening Date
- 3. Completion of Charter
- 4. Status Briefing for Ghaeer
- 5. Two Week Update
- 6. Sponsoring Manager Report Approval
- 7. Review by MRC
- 8. Review by PORC
- 9. Final Root Cause Investigation Due Date Page 30 of 73
AnACHMENT 2 - EVENT AND CAUSAL FACTOR CHART Page 1 of 6 RIZTR 759945 -- Unplanned Unit 2 On-line Risk [OLR) Orange Condition S N C C System Checklist 001 Manipulated to improve 1 SX.034 rot and power c C O isolates 1 SXI3 Page 31 of 73
- Event and Causal Factor Chart Page 2 of 6 RCR 759945 -- Unplanned Unit 2 On-line Risk (OLR) Orange Condition Checklist 001 lrfuai from C O 5789 Page 32 of 73
- Event and Causal Factor Chart Page 4 of 6 RCR 759945 -- Unplanned Unit 2 On-line Risk (OLR) Orange Condition Started 1A DG ISXU33 schedule IBOSR 8.1.10-1 U2 OLR eualuated 0 M W 8 2308 CB CIS for 1 SXO Cycle Manager 2 unaware o 1 SXO33 and 1 S m 3 4 manually open and No change to U2 OLR as determined by Cycle U2 OLR not evaluat Cycle Manager 2 turned Page 34 of 73
- Event and Causal Factor Chart Page 5 of 6 RCR 759945 -- Unplanned Unit 2 On-line Risk [OLR) Orange Condition 1 BOSR 8.1.a-1 0LkUBIDS 0954 0410810S 0954 nager for I S M 3 3 B 4 datu nge for both valves open a termined worst ca Valve Team reports:
Both valves open IS)c1333 Manually Opened 1 Electrically Opened -jJ outage schedule update that power available to both valves to position from MCB and both A
\\
Two cases open.
( I.
Both valves unable to ooen j
- 2. Both valves unable to close u
/ p R i f Engineer determines:
- 1. Both unable to Open -- Green
- 2. Both to Close -- Orange Page 35 of 73
ti CI 0
IL" -
ctt tn 3
u3 O r TI 0 C
(0 E g P a W
ATTACHMENT 3 - TAPROOT@ TREES Page 1 of 8 Page 37 of 73
- TapRoot@ Trees Page 2 of 8 Page 38 of 73
- TapRoot5 Trees Page 3 of 8 Page 39 of 73
- ~ a p ~ o o t @
Trees Page 4 of 8 Page 40 of 73
- TapF#ootQD Trees Page 5 of 8 Page 41 of 73
- ~ a p ~ o o t @
Trees Page 6 of 8 Page 42 of 73
- TapRootm Trees Page 7 of 8 Page 43 of 73
- TapRootQD Trees Page 8 of 8 Page 44 of 73