ML13329A215
| ML13329A215 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 12/24/1992 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML13329A214 | List: |
| References | |
| 50-206-92-28, 50-361-92-28, 50-362-92-28, NUDOCS 9301120074 | |
| Download: ML13329A215 (28) | |
See also: IR 05000206/1992028
Text
U. S. NUCLEAR REGULATORY COMMISSION
REGION V
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE
INITIAL SALP BOARD REPORT
Nos. 50-206/92-28, 361/92-28, 362/92-28
SOUTHERN CALIFORNIA EDISON COMPANY
SAN ONOFRE NUCLEAR GENERATING STATION UNITS 1, 2 AND 3
AUGUST 1, 1991 THROUGH NOVEMBER 30, 1992
9301120074 921224
PDR ADOCK 05000206
a
TABLE OF CONTENTS
Page
I. Introduction
........ . . . . . . . . . .........
1
II. Summary of Results..................................
1
A. Overview....................1
B. Results of Board Assessment..::*:::::::.:*::::::
3
C. Changes in SALP Ratings........ ..............
3
III. Performance Analysis................................
3
A.
Plant Operations.........................
4
B. Radiological Controls..........................
6
C. Maintenance/Surveillance.......................
9
D. Emergency Preparedness..........................
12
E. Security.....................................
14
Engineering/Technical Support
................
16
G. Safety Assessment/Quality Verification ............ 19
IV. Supporting Data and Summaries.......................
21
A. Licensee Activity ..........................
21
B.
Inspection Activities.......................
23
C. Enforcement Activity...........................
23
D. Confirmatory Action Letters................
23
E.,
Licensee Event Reports.......................
24
I.
INTRODUCTION
The Systematic Assessment of Licensee Performance (SALP) program is an
integrated NRC staff effort to collect available observations and data
on a periodic basis and to evaluate licensee performance on the basis of
this information. The program is supplemental to the normal regulatory
processes used to ensure compliance with NRC rules and regulations. It
is intended to be sufficiently diagnostic to provide a rational basis
for allocating NRC resources and to provide meaningful feedback to the
licensee's management regarding the NRC's assessment of their facility's
performance in each functional area.
An NRC SALP Board, composed of the staff members listed below, met on
December 15, 1992 to review observations and data on performance, and to
assess the licensee's performance pursuant to NRC Manual Chapter 0516,
"Systematic Assessment of Licensee Performance," dated September 28,
1990.
This report is the NRC's assessment of the licensee's safety performance
at SONGS for the period August 1, 1991 through November 30, 1992.
The SALP Board was composed of:
- K. Perkins, Director, Division of Reactor Safety and Projects,
Region V
- R. Scarano, Director, Division of Radiation Safety and
Safeguards, Region V
- M. Virgillo, Assistant Director for Regions IV and V Reactors,
F. Wenslawskl, Deputy Director, Division of Radiation Safety and
Safeguards, Region V
- L. Miller, Chief, Reactor Projects Branch, Region V
J. Reese, Chief, Reactor Radiological Protection Branch, Region
V
R. Pate, Chief, Safeguards, Emergency Preparedness, and Nan-Power
Reactor Branch, Region V
H. Wong, Chief, Reactor ProjectsSection II, Region V
- M. Fields, Project Manager, SONGS 2 & 3, Project Directorate V,
J. Bradfute, Project Manager, SONGS 1, Project Directorate V, NRR
- C. Caldwell, Senior Resident Inspector.j SONGS
T. Sundsmo, Project Inspector, Region V
A. McQueen, Emergency Preparedness Analyst, Region V
D. Schuster, Senior Physical Security Specialist, Region V
- Denotes voting members in all functional areas% Other persons
advised the Board in their areas of cognizance.
11.
SUMMARY OF RESULTS
A.
Overview
The licensee's performance during this SAP periodcontinued to
demonstrate a professional and responsible approach to operation of the
2
San Onofre Nuclear Generating Station. As a result of improved operator
monitoring of plant conditions, the number of significant events
attributed to causes under operations control decreased. In addition,
operator response to plant events demonstrated the operators' ability to
handle plant challenges. This resulted in Unit 3 having a long
successful run, and Unit I setting a site record for continuous
operation which exceeded one year. As a result of Operations continued
improved performance from the previous SALP period, the SALP Board
concluded that.a Category 1 rating was appropriate. The rating during
the last SALP period was a Category 2, with an improving trend.
Continued management attention to further improve the Operations
Department interface with other organizations, attention to detail to
reduce operator errors, and planning and procedure enhancements is
essential to sustain a high level of performance.
Continued superior performance was observed in three areas (Radiological
Controls, Emergency Preparedness, and Security) which were again rated
Category 1.
In the Maintenance/Surveillance area, the SALP Board concluded that
licensee performance remained a Category 2. The Board noted some
improvement in this area in the last half of the assessment period, but
did not consider the improvement to be sustained for sufficient time or
at a sufficient rate to warrant an "improving trend" in this assessment
period. The licensee's surveillance testing program failed in some
instances to identify degrading plant equipment, significant maintenance
related errors continued, and weaknesses in the measuring and test
equipment program were identified. Management should continue with the
implementation of initiatives such as the Partners For Success program,
with periodic assessments of their effectiveness.
In the Engineering/Technical Support area, a weakness was identified in
some cases wherein licensee engineers and management displayed a
tendency towards apparently expedient rather than thorough resolution of
emerging issues. In the last SALP period, weaknesses were evident in
the areas of timely evaluation and resolution of emergent issues. In
this SALP period, similar weaknesses were observed, involving either a
tendency toward expediency, or in underestimating the scope and
complexity of the problem. Management should emphasize the need to
resist this tendency. Additionally, improvement in the interface
between engineering and other organizations, and assessment of the
responsibilities of system engineers is encouraged.
The Safety Assessment/Quality Verification (SA/QV) area continued to
improve in certain aspects during this assessment period. The SALP
Board concluded that a Category 2 rating, with an improving trend, was
appropriate recognizing the Nuclear Oversight Division's superior
performance in assessing plant performance. However, certain weaknesses
in management effectiveness are reflected in the SA/QV area and need
further attention. In particular, SCE management's assessment of
emerging issues were in some cases too narrowly focused or
communications with the NRC on these issues were not effective. In
3
addition, corrective action followup was not always thorough or timely,
and inaccuracies were evident in some submittals to the NRC. Management
should pursue more aggressive corrective action followup and provide
emphasis on accuracy of submittals to the NRC. In addition, more
effective management involvement in assessment and resolution of
emerging issues is recommended.
B.
Results of Board Assessment
Overall, the SALP Board found the performance of NRC licensed activities
by the licensee to be good and directed toward safe operation of the
SONGS facility. The SALP Board made specific recommendations in most
functional areas for licensee management consideration. The results of
the SALP Board's assessment of the licensee's performance in each
functional area, including the previous assessments, are as follows:
Rating
Rating
Last
This
Functional Area
Period
eriod
Trtnd*
A.
Plant Operations
2 Improving
I
B.
Radiological Controls
1
1
C.
Maintenance/Surveillance
2
2
D.
1
1
E..
Security
1
1
F.
Engineering/Technical
2 Improving
2
Support
G.
Safety Assessment/
2 Improving
2
Improving
Quality Verification
The SALP report may include an appraisal of the performance trend
in a functional area for use as a predictive indicator. Licensee
performance during the latter portion of the assessment period was
examined by the SALP Board to determine whether a trend exists.
Normally, a performance trend will be indicated only if (1) a
definite trend is discernible and (2) continuation of the trend
could result in a change in performance rating. The performance
trend is intended to predict licensee performance during the next
assessment period and should be helpful. in allocating NRC
resources.
C.
Changes in SALP Ratings
One change in SALP ratings was in the area of Plant Operations, in which
the licensee demonstrated superior performance. The number of
significant events attributed to causes under Operations control
decreased from the previous SALP period. When reactor trips did occur,
operators successfully diagnosed and responded to them.
III.
PERFORMANCE ANALYSIS
The following is the SALP Board's assessment of-the licensee's
4
performance in each of the functional areas, along with the Board's
conclusions and recommendations regarding licensee actions and
management emphasis.
A.
Plant Operations
1.
Analysis
Eleven routine resident inspections were conducted during this
SALP period. Review of Operations activities during these
inspections accounted for approximately 37 percent of the total
San Onofre (SONGS) inspection effort.
The NRC rated the licensee's Operational performance in the last
SALP cycle as Category 2, improving. The SALP Board
recommendations were for continued management support of the
Operations staff to promote close monitoring of plant conditions,
and management attention to proper application of Technical
Specification (TS) requirements. The Board also recommended that
the licensee continue to enhance operator development and training
programs, and the quality of operating procedures.
The performance in this area continued to improve from the
previous assessment period and demonstrated superior performance.
Strengths identified were operator response to events,
improvements related to the previous Board recommendations, and
the fire protection program. Weaknesses identified were
occasional examples of: inattention to detail,.incompleteness of
operational surveillances, and poor interface between Operations
and other organizations.
Operator monitoring of plant conditions improved as a result of
recommendations initiated in part by the licensee's Work
Authorization Task Force. This was achieved by moving work to
support maintenance out of the control room. As a result,
operators were provided more time to monitor plant conditions. In
addition, the high operator attrition of the previous SALP period
has been effectively terminated.
The number of significant events attributed to causes under
Operations control decreased from the previous SALP period. As a
result, Unit 3 had a long successful run, and.Unit I set a site
record for continuous operation, exceeding one year.
Additionally, when challenged by events, operators responded
promptly and correctly. For example, operators manually initiated
emergency feedwater and a rapid power reduction after loss of a
main feedwater pump, thereby averting a reactor trip. When
reactor trips did occur, operators successfully diagnosed.and
responded to them. The four automatic trips that occurred in the
three units this period resulted from three separate equipment
failures and a Maintenance personnel error.
5
Some minor operational errors occurred during the Unit 3 Cycle VI
outage and were largely attributed to insufficient attention to
detail or to the performance of evolutions without adequate
consideration and planning. Examples were an inadvertent de
energization of an Engineered Safety Feature Actuation System
power supply which caused a fast start of a diesel generator, and
the initiation of core alterations without the audible neutron
count rate instrument in containment operable.
However,
operators adequately responded to these events and others before
they became significant. An example was the case of a spent fuel
pool drain down event, caused by an inadequate system alignment,
in which control room operators promptly recognized, diagnosed,
and terminated the drain down before reaching the pool low level
limit.
Improvement in operator training contributed to a reduction in
operator errors, although continued effort in this area is needed.
The passing rate of the requalification examinations for Units 2
and 3 was 100 percent for eight individuals and three crews. This
reflected encouraging performance. The Unit 1 initial license
examination showed a decline in performance from past
examinations. In this examination, six of twenty-one candidates
failed, which indicated inadequate preparation by Training.
Subsequently, five of the candidates retook the examination and
passed. The SALP Board noted that there were some unique
conditions since this was the final examination prior to the
permanent shutdown of Unit 1.
The licensee effectively utilized feedback tools such as
Operations Division Event Reports (ODERs) to assess weaknesses and
implement improvements where necessary. Based on a quarterly
assessment of ODERs, the licensee identified the need for
additional training on attention to detail in operations outside
the control room. To further improve operator performance,
Operations management initiated actions to place an additional
licensed senior reactor operator on every shift to provide
additional supervision outside the control room, and to support
the work process.
Operations interface with other organizations was identified to be
a weakness on several occasions near the end of the period. For
example, during the performance of thermographic testing of
reactor coolant pump switchgear, maintenance and engineering
personnel caused a reactor trip due in part to.-inadequate
oversight by Operations. In addition, following a saltwater
cooling valve inservice test, the seal water supply valve was not
positioned properly using an engineering procedure. The licensee
recognized the need for improvement in this area and initiated
corrective actions at the end of the period.
Toward the end of the assessment period, Operations management
established a formal program to define management expectations
6
with respect to good operating practices. The program provided
for formalized training,.monitoring, evaluation, and feedback of
good operating practices. The intent was to further enhance
operator performance. In addition, in response to events that
were related to programmatic deficiencies during the previous
period, Operations management initiated efforts to upgrade
operating procedures. However, the effectiveness of these efforts
was not observed in this period.
2.
Performance Rating
Performance Assessment - Category 1.
3.
Board Recommendations
The Board recommends continued management attention to further
improve the interface with other organizations, attention to
detail to reduce operator errors, and planning and procedure
enhancements in order to maintain the Category 1 rating.
Effective communication of management expectations and follow
through on their effectiveness is encouraged.
B.
Radiological Controls
1.
Analysis
Nine region-based inspections of the licensee's chemistry and
radiation protection programs were conducted during this SALP
period. One inspection was a team inspection of the licensee's
chemistry program, including their radiological, non-radiological
chemistry programs, and their erosion and corrosion inspection
programs. The regional review of chemistry and radiation
protection programs accounted for approximately seven percent of
the total SONGS inspection effort.
The NRC rated the licensee's chemistry and radiation protection
programs performance in the last SALP cycle as Category 1.
Strengths were noted in management attention to programs, training
of staff, and the planning and conduct to radiological work
operations. The Board recommended that the licensee continue to
provide support to site and corporate staff initiatives aimed at
improving the performance level of the chemistry and radiation
protection programs. Also, the Board recommended that emphasis
should be directed toward ensuring that facility upgrades are
carried out and contract personnel fully benefit from the
licensee's formal training programs. Further, the Board
recommended that the licensee should be-particularly sensitive to
performance in those areas in which management positions within
the Health Physics Department have been filled with individuals
who do not have a strong health physics background.
These recommendations and others were addressed by the licensee
7
during this period. The performance of the chemistry and
radiation protection staffs, and of the radiological workers
remained the same (except for one notable occurrence during the
Unit 3 Cycle 6 outage). The licensee continued building the South
Yard radioactive material storage and processing facility. The
number of chemistry and radiation protection related events
remained low with no events being significant. Training of staff
personnel, especially in the area of chemistry activities, showed
improvement. Adequate staffing remains a strong factor in the
licensee's performance in the radiation protection area. Toward
the end of the SALP period the licensee had significantly reduced
the use of contractors in radiation protection positions without
any apparent reduction in performance. The licensee did not
routinely use contracted personnel in the operational portions of
the chemistry program.
The licensee's total personnel radiation exposure expenditure for
the site of 411 person-rem (137 person-rem per unit) was
significantly below their goal of 680 person-rem for 1991. The
licensee's ALARA program is well staffed and proactive in its
activities. There is consistent evidence of prior planning and
assignment of priorities as evidenced by special projects
planning, such as, the reactor coolant pump hydrostatic bearing
inspection. The radiation "Hot Spot" trending and removal program
appears to be effective, as is the engineered shielding program.
The licensee's Chemistry Department continues to perform well.
Most notable were the development of procedures, facilities
(including training), and the secondary plant chemistry and
erosion/corrosion programs. The licensee had a carefully planned
and well developed erosion/corrosion program which met the
requirements of Generic Letter 89-08. A comprehensive NRC
Chemistry team inspection of the licensee's radiological and non
radiological programs during this appraisal period identified
several noteworthy program attributes. The licensee's
radiochemistry program performance in the confirmatory measurement
portion of the inspection was very good. The condensate/feedwater
pH optimization study, steam generator hideout return studies, and
use of the Secondary Chemistry Corrosioq Index exemplified
management's commitment to water chemistry control.
The licensee achieved improvements in the areas of personnel
dosimetry by implementation of state of the art digital readout
and alarming dosimeters to replace the self reading pocket ion
chamber (PD/SRD/PIC). The licensee installed new high sensitivity
personnel monitors during this period.
The licensee continues to implement a good quality assessment and
quality assurance programs that comprehensively probe the
licensee's chemistry and radiation protection operations. Quality
assurance and control continued to be implemented in a
satisfactory manner. Audits and assessments were of proper depth
8
and breath. Findings were normally resolved in a timely manner.
The licensee's approach to identification and resolution of
technical problems was very effective. The licensee routinely
utilizes the Independent Safety Evaluation Group, other
disciplines, or in-house root cause analyses for identifying the
underlying problems. This was most notable in the licensee's
review of whole body and extremity dosimetry issues raised during
a review of the dosimetry program. Also, the licensee's
investigation and technical resolution to the iodine uptakes by
over 30 workers during a Unit 1 outage in October 1991 was very
detailed and thorough. Identification of uptake pathways via skin
absorption during the use of decontamination solutions was an
example. The licensee's corrective actions for this problem were
expedient and comprehensive. Actions were developed and
effectively implemented for an outage in Unit 1 the following
month. The licensee streamlined the process of installing
temporary lead shielding so that extensive and time consuming
engineering work-ups for typical shielding packages were
eliminated.
The number of enforcement actions were similar to the last
appraisal period and were comprised of non-repetitive, less
significant findings (severity level and less NRC-identified
findings) than the previous inspection period. Only two cited and
five non-cited violations were identified by the NRC inspection
staff during this appraisal period. Only two areas, radioactive
material labeling and missed chemistry surveillances had
indications of becoming areas of concern and the licensee quickly
performed corrective actions to bring these areas back into
compliance. Corrective actions were effective as indicated by the
lack of repetition of events and enforcement.
Staffing in both the HP (including the corporate HP Group) and
Chemistry departments continues to be a positive factor in the
licensee's level of performance in these areas. Personnel changes
and reassignments, while not infrequent, prevented stagnation and
are for the most part are well received by the staff. Recent
reductions in contract personnel use have been judiciously applied
and do not appear to be weakening the licensee performance. The
Chemistry Department staffing is steady, but may change with the
decommissioning of Unit 1.
2.-
Performance Rating
Performance Assessment - Category 1.
3.
Board Recommendations
None.
9
C.
Maintenance/Surveillance
1.
Analysis
In addition to routine resident inspections, five Region V
inspections, and one NRC headquarters inspection were conducted in
the maintenance area during this SALP period. Review of this
functional area accounted for approximately 21 percent of the
total SONGS inspection effort.
At the end of the previous SALP period, the SALP Board rated the
licensee's performance as Category 2 in this functional area. The
Board recommended that the licensee continue initiatives such as
the Work Authorization Task Force (WATF) and the Reliability
Centered Maintenance (RCM) program. The Board recommended that
more attention be focused on the reduction of personnel errors and
reducing scheduled maintenance impact on safety. Enhancements to
the post-maintenance testing (PMT) program, work control process,
quality of maintenance procedures, and training program were also
recommended.
In general, performance in this area remained a Category 2 during
this assessment period. The Board noted some improvement in this
area, particularly during the last half of the period, but did not
consider the improvement sustained for sufficient time or at a
sufficient rate to warrant designating a trend for this assessment
period. The major strength during this period was viewed to be
the licensee's aggressiveness in addressing previous Board
recommendations. This was accomplished by implementation of new
programs designed to reduce errors, enhancements to procedures,
improvement to work control and planning processes, more detailed
training, and more critical self-assessments. In addition, PMT
was more effectively implemented, and containment leak rate
testing was also considered a strength. Some maintenance and
surveillance activities adversely impacted plant operations,
although the number of errors decreased significantly from the
previous assessment period. Weaknesses were observed with missed
or inadequate surveillances and inadequate implementation of the
measuring and test equipment (M&TE) program.
The licensee focused considerable effort on enhancements to
previously identified weaknesses in the maintenance process. In
addition to continued activities in RCM, the licensee initiated a
number of new programs such as "Partners for Success," intended to
enhance the interface among craft, planners, and supervisors.
This program was fully implemented in Unit 1 and contributed to a
reduction in rework, more effective maintenance orders, and less
personnel errors. The licensee was still in the process of
implementing this program in Units 2 and 3 at the end of the
assessment period. Other initiatives, such as the "STOP" and
"AWARE" programs, implemented late in the period, were intended to
further enhance Maintenance effectiveness-by providing better
10
guidance for tailboards and turnovers.
The licensee expended considerable resources to enhance procedures
this assessment period. Procedures in general were more detailed
and provided better information to the craft. The licensee
expects to complete this effort early in 1993. Recommendations
for enhancements to the work control process by the WATF included
the establishment of a work authorization coordinator and a work
window manager, both of which contributed to an improved interface
with operations on specific work activities.
The licensee performed more training this assessment period for
maintenance personnel in such areas as basic plant systems,
process controls, and human effectiveness. In addition, a
training program for maintenance planners was initiated near the
end of the period.
As the SALP period progressed, the licensee was observed to be
more self-critical in dealing with maintenance related problems.
Early in the assessment period, the valve bonnet for Unit 1 safety
injection related valve HV-852B was dropped. The event was
downplayed by the responsible Maintenance foreman, which set a
poor example to the craft with regard to handling problems when
encountered. The licensee management implemented a supervisory
training program to minimize the potential for similar events, and
by the end of the period, root cause investigations were routinely
implemented and were more critical of performance. The licensee
also was aggressive in reducing the number of backlog maintenance
items.
In general, maintenance and surveillance activities were conducted
more effectively and were better documented than in the past. For
example, the licensee's efforts to repair cracks on Unit 3
pressurizer instrument nozzles and the licensee's containment
integrated leak rate test program were implemented effectively.
In addition, post-maintenance testing was more effective this
period. Problems that did occur during the period were most often
associated with personnel errors due to inattention to detail,
inadequate documentation to support the activity, or poor
interface and communication. These weaknesses resulted in a few
events, such as a shutdown of Unit 1 due to excessive air leakage
from a pressurizer power operated relief'block valve and a reactor
trip of Unit 2 while performing thermography of reactor coolant
pump switchgear.
While the licensee satisfactorily completed a large number of
surveillances, personnel errors resulted in delinquent
surveillances of such components as reactor coolant pump flywheels
in Units 1 and 3, and vital batteries in Unit 3. In addition,
weaknesses in or lack of surveillances resulted in the: inability
to detect accumulation of moisture in the steam lines to the Unit
2 turbine driven auxiliary feedwater pump, accumulator piston
11
misalignment of Unit I safety injection valve HV-852B, and
inoperability of the Unit 1 4160 VAC switchgear room Halon system
(due to inadequate maintenance in 1988). The inoperable Halon
system, combined with an inadequate assessment of the condition,
resulted in escalated enforcement action this assessment period.
Numerous weaknesses in the licensee's M&TE program were observed
during the SALP period by a licensee Quality Assurance audit and
by the NRC. In particular, the accuracy of some M&TE was
questionable and the program, as designed, could result in
equipment being out of calibration for long periods of time. In
addition, some calibration failure evaluations were inadequate and
documentation of M&TE usage was not correctly performed
approximately 22% of the time. The latter weakness resulted in a
number of calibration failures not being evaluated for impact on
plant equipment. An extensive effort by the licensee verified
that no significant safety issues existed due to the failed
calibrations, although documentation of some of the assessments
supporting that conclusion was found to be weak.
One instance regarding the negative impact of scheduled
maintenance on safety was observed. It involved a Unit 3 high
pressure safety injection (HPSI) pump which was out of service for
troubleshooting and repair for more than six weeks. Although
licensee management considered that the spare pump was installed
for operational flexibility, a probabilistic risk assessment
performed for work on a Unit 2 HPSI pump of a similar duration
determined that this resulted in an approximate 10% increase in
core damage probability.
One escalated enforcement action was taken in this area, a
Severity Level III violation in which a continuous fire watch was
not established when both banks of the Halon system for the 4160
volt switchgear room were inoperable due to maintenance errors in
1988.
2.
Performance Ratina
Performance Assessment - Category 2.
3.
Board Recommendations
Some improvement was recognized in this area, particularly in the
last half of the assessment period, but it was-not of sufficient
duration or rate to be designated a trend. The Board recommends
that SCE management continue with implementation of initiatives
such as the Partners For Success program and make periodic
assessments of their effectiveness. In addition, effective
implementation of detailed surveillances to identify degrading and
inoperable equipment is recommended. Strengthening of the M&TE
program and continued sensitivity to the impact of maintenance on
safety is encouraged.
12
D.
1.
Analysis
Two routine emergency preparedness (EP) inspections and two EP
annual exercise team inspections were conducted during this
assessment period. Review of the EP program accounted for
approximately six percent of the SONGS inspection effort.
The licensee's EP performance in the last SALP cycle was rated as
Category 1. The SALP Board recommended that management provide
continuing attention to improving the effectiveness of emergency
response staff training and maintain its support of the EP
corrective action and offsite programs. The Board also
recommended that the licensee continue efforts to improve public
address (PA) system performance. Also in the last SALP report, a
concern was identified about the effectiveness of the retraining
of the emergency response staff.
Strengths identified during the current assessment were in the
areas of EP staffing, training, and conscientious attitudes toward
accomplishing established goals. A weakness was noted in the area
of health physics emergency response activities during annual
emergency exercises. Generally, licensee performance in the
emergency preparedness area appears to be consistent with its past
performance record.
Licensee management was actively involved in EP activities and
demonstrated support by providing the necessary resources to the
EP staff. Management apparently took particular interest in
correcting problems and responding to NRC findings indicating need
for corrective action.
During the assessment period, the
licensee worked closely with the state, local county governments
and FEMA in resolving issues in offsite preparedness planning.
Licensee management's approach to the resolution of technical
issues was generally timely and appeared to be thorough, with one
exception. In one instance, the NRC expressed concern about the
timeliness of the licensee's corrective actions to establish an
adequate capability for monitoring/decontaminating personnel (and
vehicles) evacuated from the site. The licensee expedited
corrective actions in response to the NRC concern.
During the SALP assessment period, one EP exercise weakness and a
non-cited violation (NCV) involving a late report to the NRC were
identified. Otherwise, there were no enforcement actions taken in
the EP area. The exercise weakness involved the health physics
response during the 1991 annual exercise. Most elements of the
weakness were specifically addressed in the 1992 exercise,
although there were some common shortcomings in both exercises
which indicated a need to improve health physics planning for in
plant response teams. Otherwise, performance in the 1992 exercise
13
indicated improvement over the 1991 exercise.
The licensee reported three unusual events to the NRC during the
assessment period. The events, involving two earthquakes and one
Technical Specification (TS) required shutdown, were properly
identified and analyzed in accordance with Emergency Plan and
Emergency Action Level (EAL) requirements. Notifications to the
NRC and offsite agencies were likewise in accordance with
regulatory requirements.
As indicated above, EP staffing was identified as a strength.
Personnel losses during the assessment period prompted re
adjustment and realignment of functions and responsibilities,
which appeared to have been accomplished effectively and with no
notable impact on the program. No significant changes occurred to
the composition of the emergency response organization (ERO)
during the assessment period, and the licensee's systematic method
to ensure that new ERO personnel were properly trained prior to
assignment continued to be effective. EP staff and emergency
response positions were clearly identified, authorities and
responsibilities appeared clearly defined and key positions were
filled as appropriate. Decision making authority appeared
properly delegated to insure quick identification of and response
to problems and changes. Emergency facilities continued to be
appropriately maintained and ready for rapid activation. The
licensee continued to provide adequate levels of dedicated staff
to implement the programs and to interact appropriately with
offsite agencies.
The licensee's efforts during the assessment period to improve the
emergency preparedness training program were considered a
strength. The licensee has an effective system to ensure that
required training is conducted and that training due dates are not
exceeded, by tying accomplishment of EP training requirements to
unescorted access privileges. To supplement and reinforce routine
annual training, a program of quarterly integrated drills, mini
drills, and tabletop training sessions were conducted.
2.
Conclusion.
Performance Assessment - Category 1.
3.
Board Recommendations
The licensee should focus management attention in improving health
physics planning for in-plant response teams during emergencies to
prevent recurrence of the type of shortcomings observed in the
last two emergency exercises.
14
E. Security
1. Analysis
Three routine physical security inspections and one Operational
Safeguards Response Evaluation (OSRE) were conducted during this
inspection period. Review of security activities during these
inspections accounted for approximately three percent of the total
SONGS inspection effort.
The NRC rated the licensee's Security performance in the last SALP
cycle as Category 1. Strengths were observed in Management
involvement in assuring quality, security staffing, security
training and qualification program. Several proactive security
upgrades were also identified.
Generally, in this area the licensee continued to be proactive and
innovative in their approach to maintaining and enhancing
security. In most areas the licensee was found to exceed minimum
requirements. One weakness was identified and corrected as a
result of increases in the number of security events.
During this period several licensee initiatives to upgrade
security areas were completed. These upgrades were: Protected
Area (PA) barriers; Organization/Responder Post Enhancements; and
Target Analysis. The licensee continues to make significant
progress for a series of additional enhancements in the areas of:
tactics; training; weapons/uniforms and equipment; computer
systems; and personnel access. These upgrades to security exceed
minimum security practices and requirements.
The security organization has a program to cross-train in other
licensee organizations. These include assignments in: security
training; refueling group; operations; corporate quality assurance
group; and emergency preparedness. These assignments afford those
security officers an insight into other divisions perceptions of
security and an appreciation of the other group's trials and
tribulations. As a result of this cross-fertilization, improved
communications have resulted.
A security Training Compound was opened during this period. It
was observed that this compound affords security responders the
opportunity to practice actual tactical response related
activities in simulated plant environs, fire blank ammunition,
employ the MILES Integrated Laser Engagement System, and to fire
paint pellets from handguns during shoot-don't-shoot exercises.
It was also determined that a significant increase in performance
based refresher training has occurred for security officers.
Enforcement action was limited to one non-cited violation
pertaining to a failure to test security equipment. Had the
licensee not taken prompt corrective action, this deficiency could
15
have led to unauthorized access to a vital area.
The licensee performance with respect to security events was mixed
in effectiveness. The licensee submitted copies of the safeguards
event log on a quarterly basis as required. During the beginning
of' this SALP period there was a significant increase (181 events
versus 114 the previous quarter) in the number of events
indicating a declining trend in the security program and
warranting additional management attention. The increase in
events was attributed to human errors (102 events) as a result of
a substantial increase in the number of personnel authorized
during a refueling outage. By the end of the SALP period, it was
determined that licensee management had taken a series of actions
which resulted in a significant reduction of security events.
Examples of actions taken were: one-on-one briefings with the
responsible individual; one-on-one briefings with the individual's
first line supervisor; updated monthly news magazine articles and
briefings to organizations on the problems associated with the
violations. As a result of these actions security events for the
last quarter of the SALP were reduced to 86 events, of which 41
were caused by human error.
The experience and effectiveness of the licensee's security staff
supporting the overall security program was considered a strength.
Key positions were identified and responsibilities are well
defined. Some shifting of resource have occurred, reducing
overhead positions and increasing armed responders.
An OSRE was conducted by NRC personnel assisted by members of the
U.S. Army Special forces. One objective of the OSRE is to
evaluate the licensee's abilities to respond to an external threat
by focusing on the interactions between operations and security in
establishing priorities for protection of equipment and on the
defensive strategies used.
Based on the high quality of drills, exercises, and demonstrations
observed by the team and the results of interviews, the team
concluded that SONGS had an excellent contingency response
capability. In addition, effective provisions were in place to
assure that safeguards measures did not adversely affect the safe
operation of the facility. The licensee's success were attributed
to:
strong management support involving senior management, e.g.,
actual involvement in drills and providing necessary funding;
major improvements in tactical responses; and training of a four
person adversary team that truly tests the licensee response
capabilities.
2.
Performance Rating
Performance Assessment - Category 1.
16
3.
Board Recommendations
Licensee management should continue to monitor the trend of the
security events.
F.
Engineering/Technical Support
1.
Analysis
In addition to routine resident inspections, nine engineering
inspections, and one NRC headquarters inspection were conducted in
this functional area during this SALP period. Review of
Engineering/Technical Support activities during these inspections
accounted for approximately seven percent of the total inspection
effort.
Licensee performance in this functional area during the previous
SALP period was rated Category 2, with an improving trend. The
SALP Board recommended that the licensee continue improvements in
support of engineering programs, continue development of the
setpoint methodology program, ensure proper calculational
assumptions, strengthen the effectiveness of engineering and
technical work on emergent issues, and strengthen technical
reviews.
During the current period, several improvements were noted in this
area, but performance was inconsistent. The licensee successfully
implemented Board recommendations with respect. to the enhancement
of engineering programs and setpoint methodology. Improvement in
engineering design changes and training programs was also noted.
Strengths were observed in the licensee's in-house analytical
capabilities, supporting such topics as the erosion/corrosion
program. Weaknesses continued in the areas of timely evaluation
and resolution of emergent issues and inadequate independent
verification. In addition, weaknesses in the non-destructive
examination (NDE) program, inservice testing (IST) program,
procurement program, and a weak interface between Station
Technical and Operations were observed during this period.
The licensee showed aggressiveness toward improving engineering
programs and activities. For example, the licensee issued their
formal Instrument Setpoint Calculation Program document, which
included an instrument calculation design standard to provide
specific guidance for performing instrument calculations. In
addition, the licensee initiated efforts to establish engineering
design standards aimed at improving the quality and consistency of
design documents.
Several design change packages, reviewed during this period,
showed an improved quality of engineering work. Examples included
an Anticipated Transient Without Scram design change for Units 2
and 3, and a Temporary Field Modification (TFM) to the Unit 2
17
containment mini-purge system.
Engineering training was enhanced by the initiation of several new
programs and policies. Examples included the development of a
system engineer qualification guide, and the establishment of a
document which formally promulgated the roles and responsibilities
of Station Technical personnel. These were initiated in order to
achieve a consistent level of performance among engineering staff.
In addition, the licensee developed guidance for the selection of
supervisory personnel and initiated an assessment to identify
training needs for current first-line supervisors.
With respect to the licensee's engineering analytical capability,
an NRC Chemistry team inspection reviewed the licensee's
erosion/corrosion program and found it to be well developed. In
addition, detailed analyses of the plant, such as a design basis
reconstitution, identified several significant problems including
a potential environmental hazard to several auxiliary feedwater
valves in Units 2 and 3.
As discussed in the previous SALP report, engineering and
technical activities associated with shorter term or emergent
issues did not always result in satisfactory resolution the first
time. During this period, some instances of similar weaknesses
were observed, involving either a tendency toward apparent
expediency, or in underestimating the scope and complexity of the
problem. This tendency towards addressing issues in a less than
thorough manner caused extended discussions with the NRC to
resolve the issues. Examples included a technical evaluation of
leakage from the Unit 1 feedwater/safety injection valve actuators
that did not sufficiently characterize the significance of the
leakage (due to insufficient knowledge), the initial assessment of
Unit 1 refueling water storage tank leakage which did not fully
characterize the corrosion mechanism or the possible extent of the
corrosion, and an assessment of vital battery cracking that did
not adequately baseline existing flaws.
Weaknesses in the interface between the Station Technical and
Operations divisions contributed to several events this period.
For example, a deficient engineering procedure that directed
operator actions contributed to the misalignment of a Unit 2 salt
water cooling pump seal supply valve,-and a Unit 2 trip resulted
from deficiencies in communication during thermography work.
An area of continuing concern was observed with independent
verification of engineering work. For example, the Motor Operated
Valve (MOV) inspection team identified that the independent
verification of MOV design setpoint calculations was not effective
in identifying numerous errors. Another example involved an
environmental qualification evaluation for a TFM to the Unit 2
safety injection system in which neither the initial assessment
nor subsequent reviews identified a potential chemical spray
18
hazard to safety-related equipment.
The NRC mobile non-destructive examination (NDE) laboratory
performed an inspection of the licensee's NDE program. The
examination found that revision 5 to the Inservice Inspection
Program was issued without the required approvals, final
radiographs for a number of American Society of Mechanical
Engineers (ASME) Code Class 2 welds were not retrievable, and
management oversight was inadequate to ensure the proper levels of
program control.
Early in the period, IST inspections conducted by Region V
revealed weaknesses with maintenance and surveillance areas of the
IST program. Weaknesses included the lack of valve stroke time
trending for failed surveillance tests and difficulties in
detecting valve degradation. In addition, discrepancies between
field recorded data and surveillance instructions were observed.
The licensee detected numerous check valves that should
have been included in the reverse flow surveillance testing
program. These deficiencies were promptly corrected when found.
An NRC inspection of the licensee's program for the procurement
and dedication of commercial grade items used in safety-related
applications at SONGS identified some weaknesses. These
weaknesses included incomplete identification of appropriate
safety functions, and incomplete specification and verification of
specific safety function performance characteristics.
To the
licensee's credit, many of the dedication program weaknesses had
been self-identified before the NRC's inspection, and the licensee
has committed to fully upgrade their procurement program to staff
guidelines by January 1993.
Late in the assessment period, the licensee made several changes
to the engineering organization and was evaluating interface
points with other organizations in an effort to enhance
performance in this area. The effectiveness of these changes
could not be evaluated during the period.
2.
Performance Rating
Performance Assessment - Category 2.
3.
Board Recommendations
While some improvement was recognized in this area, it has been
inconsistent and a number of areas identified for attention in the
last SALP report showed little improvement. The Board determined
that the current rate of improvement does not justify a trend.
Licensee management should emphasize the need to resist the
tendency toward expedient resolution of emerging issues. More
thorough and independent reviews of engineering work are
encouraged. In addition, improvement in the interface between
19
engineering and other organizations, and assessment of the
responsibilities and workload of system engineers is encouraged.
G.
Safety Assessment/Ouality Verification
1.
Analysis
Routine resident inspections, with ongoing assessment by NRR, were
conducted during this SALP assessment period. Review of this
functional area during these inspections accounted for
approximately 19 percent of the total inspection effort at San
Onofre.
Following the previous SALP period, the licensee was rated
Category 2, with an improving trend. The Board recommended that
the licensee emphasize more thorough assessment of plant problems,
enhance the effectiveness of the corrective action program, and
improve the quality and timeliness of licensing submittals. The
Board also recommended that the licensee update the Final Safety
Analysis Report (FSAR) and emphasize effective implementation of
the Quality Assurance (QA) audit program.
Licensee performance in this functional area continued to improve
in certain areas during this assessment period. In particular,
the Nuclear Oversight Division (NOD) became a very strong
contributor in assessing plant performance. This was accomplished
through implementation of self-assessment programs in many of the
functional areas, detailed root cause evaluations, probing audits
and surveillances, and enhanced plant monitoring. Progress was
made by the licensee in updating the FSAR during this period.
Progress was also made in addressing previous Board
recommendations, but recent observations indicated continued
weaknesses in: management assessment of emerging issues, including
effective communication with the NRC on these issues; corrective
action followup; and accuracy of submittals to the NRC.
The NOD expended more effort on self-critical evaluations this
period, focusing on excellence in addition to compliance.
Examples included outage activity surveillances, probabilistic
risk assessments (PRAs), and organizational common cause analysis
of programs. Some significant issues were identified and Quality
Action Teams (QATs) were implemented to address many of the
program weaknesses identified.
Root cause evaluations were more proactive during this period.
The licensee performed in-depth root cause assessments of
programs, human performance, organizations, and equipment
deficiencies, such as a detailed evaluation of the root cause for
leakage from secondary safety valves, resulting in setpoint drift.
The licensee implemented a fully integrated -surveillance and audit
plan this period. Many audits included performance based
20
surveillances designed to make program implementation assessments.
Program weaknesses identified during these audits and
surveillances included inadequate control of weld filler material
and improper control of temporary modifications. To support the
effort, the licensee prepared systems training booklets to enhance
the effectiveness of NOD personnel in performing audits and
surveillances. Additional training was conducted in performance
of root cause analysis, and was attended by personnel from many
different organizations. In addition, QA and QC personnel were
certified in accordance with Institute of Nuclear Power Operations
standards during the period.
The licensee further enhanced their plant performance monitoring
programs during this assessment period. The NOD published
quarterly performance assessment reports to identify areas of
strength and weakness, which were embraced by the responsible
organizations. The Area Monitoring Program was also refined to
provided more in-depth walkdowns of plant systems and areas.
The licensee was involved in several projects that exhibited a
commitment to improve the safety of the plant and its operation.
Examples included the licensee's participation in the Technical
Specification improvement program and compilation of the current
licensing basis for Units 2 and 3. The licensee is also using
probabilistic risk analysis techniques to calculate the core
damage risk due to actual equipment unavailability, which assists
the plant staff in maintaining the plant at the optimum safety
level.
Some instances were observed in which the licensee management
permitted assessments of problem situations that were too narrowly
focused, or communicated their assessments to the NRC in an
ineffective manner. For example, the original assessment of the
Unit 1 RWST leakage issue did not adequately address the extent
and mechanism of corrosion of the tank. The licensee was not
effective in communicating the basis of their understanding of the
location of a leak and the configuration of the piping components
in a Unit 3 pressurizer instrument line and initially resisted
staff recommendations to visually inspect the source of the
leakage. The initial operability assessment of the cracks
discovered in the vital batteries in Unit 3 was not comprehensive
and the NRC staff was not informed in a timely manner of this
issue. In addition, the initial assessment of a valve accumulator
piston misalignment did not identify the potential of the valve to
become inoperable. As a result of this concern, the licensee
committed to improve its communications of emergent issues with
the NRC staff, which has been evident in the latter part of this
SALP period.
The licensee's efforts to improve the corrective action program
were generally effective, but the results were not uniform in that
several instances of inadequate corrective action followup were
21
noted during the period. For example, surveillances implemented
as a result of a Unit 2 turbine driven auxiliary feedwater (AFW)
pump overspeed event in 1990 were ineffective in preventing a
subsequent overspeed trip of the pump, and corrective actions for
a .1990 QA audit were inadequate in preventing similar M&TE
problems this assessment period.
Toward the latter part of the SALP period, NOD implemented a peer
review of all problems resulting in either a corrective action
request or problem review report, in an attempt to ensure that
issues were properly categorized and that effective corrective
actions were proposed.
While the licensee expanded efforts to improve the quality and
timeliness of submittals to the NRC, the results during the SALP
was mixed. In some instances, submittals were timely and
accurate, such as for Station Blackout, but others were not. For
example, a licensee event report (LER) for Unit 1 Halon system
inoperability contained inaccurate information. Together with the
inoperability of the Halon system, these problems resulted in
escalated enforcement. A temporary waiver of compliance to
facilitate testing of Unit 2 low pressure safety injection check
valves and a relief request from ASME Section XI Code requirements
also contained errors. Early in the period, revisions to four
LERs were outstanding for a long period of time. The licensee was
attempting to reduce the backlog, although a few still remained
outstanding (two years or more) and were still awaiting revision.
2.
Performance Rating
Performance Assessment - Category 2, improving.
3.
Board Recommendations
The Board acknowledged the superior performance of the Nuclear
Oversight Organization during this period. However, more
effective management involvement in assessment, resolution, and
communication with NRC of emerging issues is recommended. In
addition, more aggressive corrective action followup and more
emphasis on accuracy of submittals to the NRC was encouraged.
IV. Supporting Data and Summaries
A.
Licensee Activities
The three units operated routinely at nominal full power (for Unit
1, 91%) during the SALP period, except for the events or outages
identified below.
Unit I
October 17, 1991
Automatic trip caused by automatic bus
22
transfer failure. Unit operation resumed
on October 22, 1991.
November 15, 1991
Shut down to conduct an inservice
inspection of all three reactor coolant
pump flywheels. Unit operation resumed on
November 19, 1991.
Unit 2
August 17, 1991
Shut down for Cycle VI refueling and
maintenance outage. Operation resumed on
November 21, 1991.
March 13, 1992
Shut down to perform design basis testing
of the safety injection miniflow motor
operated valves. Unit operation resumed
on April 2, 1992.
April 24, 1992
A turbine trip caused a reactor trip. The
turbine trip was due to the loss of a 480
VAC transformer which supplied several
turbine control system and main feedwater
pump auxiliary equipment loads. Operation
resumed on April 26, 1992.
July 31, 1992
Automatic reactor trip due to a sensed
undervoltage condition-created when a
potential transformer drawer was opened.
Operation resumed on August 2, 1992.
Unit 3
January 24, 1992
Shut down for Cycle VI refueling and
maintenance outage. Operation resumed on
March 30, 1992.
April 21, 1992
Shut down for main generator vibration
problems. Operation resumed on April 23,
1992.
April 24, 1992
A manual reactor trip was initiated when
control bleedoff flow for reactor coolant
pump P004 decreased to-zero. Operation
resumed on May 9, 1992.
May 15, 1992
Automatic trip due to a low departure from
nucleate boiling ratio (DNBR) occurred.
The low DNBR signal was generated when a
reactor coolant pump tripped as a result
of one of the pump motor surge capacitors
faulting to ground. Operation resumed on
23
May 20, 1992.
September 16, 1992
Shut down to repair the pressurizer
pressure instrument root valve, and the
core protection calculator channel "C"
cold loop temperature detector. Operation
resumed on September 19, 1992.
B.
Inspection Activities
Forty-seven routine and special inspections were conducted during
this assessment period (August 1, 1991 through November 30, 1992)
as listed below. Significant inspections are listed in paragraph
IV.B.2.
1.
Inspection Data
Inspection Reports 91-21 through 91-37, 91-39, 91-01 through
91-13, and 91-15 through 91-30.
2.
Special Inspection Summary
Special inspections included the following:
91-32
Fire protection inspection
91-36
4160 Volt switchgear room Halon system
inspection
92-02
January 13 through February 11, 1992: Team
inspection on safety-related motor operated
valves.
92-15
April 6 through April 27, 1992: Team inspection
on operability and reliability of check valves
in safety-related systems.
92-19
August 24-28, 1992: Chemistry team inspection.
C.
Enforcement Activity
Inspections during this period identified 35 violations, of which
16 were non-cited violations. Two of the cited violations were
categorized as a Severity Level III problem and resulted in the
issuance of a civil penalty (Inspection Report No. 91-36).
D.
Confirmatory Action Letters
None.
24
E.
Licensee Event Reports
LERs were issued for the three units during this assessment period
as shown below.
Unit
No. of LERs
LER Numbers
1
10
91-14 thru 91-21; 92-01 thru 92-02
2
22
91-10 thru 91-19; 92-01 thru 92-12
3
10
91-03 thru 91-09; 92-01 thru 92-04
4
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B. Faulkenberry
Commissioner Rogers
G. Cook
Commissioner Curtiss
C. Holden, NRR
Commissioner Remick
P. Ray, NRR
Commissioner de Planque
SALP Board Members
J. Taylor, EDO
SALP File
J. Sniezek, DEDO
Docket File
J. Mitchell, OEDO
T. Murley, NRR
F. Miraglia, NRR
J. Lieberman, OE
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Resident Inspector
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