ML14114A612
| ML14114A612 | |
| Person / Time | |
|---|---|
| Site: | San Onofre, LaSalle  |
| Issue date: | 12/10/1980 |
| From: | XYZYX INFORMATION CORP. |
| To: | |
| Shared Package | |
| ML14114A613 | List: |
| References | |
| S231C.80.10, NUDOCS 8012300446 | |
| Download: ML14114A612 (19) | |
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44 EVALUATION O~TAXZ.5
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.4 Human Factors Checklist 4
10 44 Expansion of Wgative Comments 16 I
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On '21. Movibber.1900,, thQ-Procedu~oo lI aod 'ioTabld l. Wro
- ' Ovaluated for. -the first, time. A orelioana Y :r~jort. was, Lo..
uiobut lim i ted to f actorsa viilqo only, in the ocit theosolvea.
LASALE OCOUIMS, OBAWUATC.
By ft YX NURSER"-
TVMZR~SOJ SU LGA-0l Lovol Control.
34 1-3-00 LGA-0Z2 Shutdomn 31~c0 LGA-.03 Cotainnant' Control,
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LQA-04
.Lovol-Roctoration 2,
130 LGA-05S RFV Flooding, 3
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LGP-3-2 Reactor ScraM 62' On 29-3 Novemiber 1900,, a site vibit'ad mcde to cover fae,.
tors visible. in. the r~ork environjint.
The following kinag of, things, were. evaluated in the 'control ro=~ and smltr Nomenclatur o pnes controls, and indicators Control panel mrig
.,.Prequency, of: practice byoperators,,..
- Access to emergency poedures.
ID* Control. of emergency preocedures
- Methdo eif y ing. operator actxio'nsi
- Ability: of opperatoirs to locate 'and identify e
con-trols and. indica'tors e
Ability of operators to, funhctio-n wi'thout assistance' beyond the.,proced'ures 9
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The following attattene apply to avndesrbed here.
This evaluation doe oddres procedural complete neas or cuterCY W2 onp of hOse properties re quires kinowledge of
- a. o ect system not avaiable to the present reviewer.
IA identlifyin ki~ids of 4,oie nig.,
no eoilws sade to specify Iadive8uil a
astances within kind e
cept to cite examples.
- 3. -All deretence noated are coneda&red to be correct able prior to active use of the poedures.
Inspection of the revised procedures the control room, the simulator, and a LCA exercise with a typical crew of opera tors led to the following conclustons I L.
Procoduros Th. updated procedures are sitghtly tioroved over those evaluated in the preliinery report. Sovever the taprovement is not reflected equally in al eate qories. The diotribution of iaprovaeent is suinearised below by ind of deficiency within category.
I a) ProoonattiOn Style 1
Deficiencies remediej in e pieces but not allt orqanisation of. data for multipleva-rt able <decisional plecement-of cautionsi provi siaon of workheets.
2 Deficiencies
-ot emedled anywherev content of cautions and notest contingency provi sionsi adequacy of charts and graphs nd cants of the need tor more than one operator.
- b. Level of Detail No deficiencies rem died this category.
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.6tion tewoo f coio ci evenzo in wlf~tOO8 GituatOw gh coato o2eets oO tggs e, nT oeaondi the~po Quoaw~.'. O10oO or. cpatn o to c9U~OG on. tonsccu 9ar o the teann practic id eei thoA paricpnt onot yet kaowho, thef a~riU conto on~ tOfOtl th re O 'c eo a d thie eav thus Laereon,ttanin P*Cdu,0 qbpeeeo toen lene
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wer A:,,,,
RBCONE M TIONS The following recomendationsa are preoented in pursuit of, effective emergency procedures at La Salle.
- 1.
Revise the procedures to incorporte the kinds of pro visions cited below.
- a.
On actions whore decaotong, apt be booed on more than two variables, reorg the copy so as to make it clearer.
Conside r ng further use of the mattix approach used onf Page 3 of LGA-04.
In add it ion consider the method modeled below.
- 7. MONITOR RFv water leve for-minutes.
S. 9 level is decreasing, go to step I evel has stabilized, g ato step
.f loveq is increasing, continue.
- b. Remove all command stateaente from ations and notes. Whore operator acti6n arerequired, pro vide command stops.
Be sure to place cautions and notes immediately before the applicable step(s).
- c. Whenever a procedure requires the use of other
'docuaents, reference these docanents in the appro priate step and provide a listing of all such doc uments up front.','
Provide the operator with alternativ, actions to' cope with all logidal contingeries..
- e. Provide graphs and charts where needed. Clearly reference these charts in the applicable steps.
Where applidable, reeence.worksheto (e.g., Long Term, Trend Sheet) in the procedures and/or provide them as attachments.*
.Where necessary9 W..n'icate the heed for more than one operator drid provide directions for part tion Ing the work amchg them.
- h. Express all actions at the t:a
- level,
.e., as direct conueand verbs -against specif ic controls and indicators.
Provide specific control positions and indicator vales.
-I
i Provide sign-off Iinea for every step and require the SCRU to verify each opeator action.
Providea sethod to help the SCRB tr is WaY trough the procedures.
. WLiit teferences, to ex e n tp o e ue oisitua.
P. b~wa ext-n tion whore it would be inconvenient for the oper ator to have the entire reterenced instruction re iterated.
- 1.
Paginste LGP-3-2 pe he method used n the othe procedures evaluated Place -
t wo pages of Attachment A in their proper
- 2.
Revise either the apsilicable procedures or the hard ware to assure that the nomenclature in the procedures matches that placarded on the control panels.
- 3.
Continue to keep the human eh. iheering features of the control room up to date, so that operators will be furnished with locator cues external to the proce dures 4.,
If possble, provide more frequent opportunities for operators to practice each emergency ptocedure.
S. Provide detail-level information in the procedures even where (at times) operators may appear not to need it. Such information is vital StQ training and to emergency situations where stress is experienced.
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1V4 I7l eVAwAifOm DETAILS
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-OSFATZ0L TU Documnt Items
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OW LA BALLS 8KEN C POCSDURES IS PRZSBNATION Th te
- 3. wbeen 0n uOt be made based on a
than up o
ablesO information is not aRvo 9.t or osd to a t such a decision.
So tepa 6 through 9.ages 3 to 4 of LGA-for an evample of poorly organised dedision ihformation, t
4 Cautions and notes should always be placed issaediately ahead of the steps to which they apply. Any other 14cation incurs the risk of their being read too early or too late for loost1eftective use.
In LGA-02, for ex ample, several cautions ae separated from the applicable stOps by bing placed at the bottom of the precwding page.
- e.
Catons and notes should NBBR be ased to deliver comand data.
Any intended action or-dediston'abould be numbered' to ind icate.
that the operator Must do something.
For a violation of this tule, see the example be low from L041, Pae 1.
If equipment is operating outside the range specified by the procedure, th operator is not always told wat action to take. "it' statements are selden accompanied by corre spondiing "wIt not "tOeMentO.
On some cases, (eg. Step P,
P
, 4 oft LGA*02) the word is omitted
- rely item 7.
Because all charts/graptiha.oe miasing from the procelures evalaitedj 'it is impossible to judge their ad"quacy.
These issing charts aCe 1ooly referenced in the applica ble at *ps.-~
Item 8.
A Long Tesm Trend She*t" ia being developed at the time of the site visit, but was not ready for review. Thia orkhtoii not referenced in the proced l 0 d
te 9.
Althog i
a e
(e.g., LGA-03) sever al act ons must be performied concurrently her4 is no indication of how the work should best be partittoned or controlled.
S231C.80.
O
Item~ 10.
a1oroncoo-to crztdrnal
§Pr~OdUroa are not 1iritcd, to 01tucitIono To~o it tbul.,ba in-;:
Dttoova to atrooal ino tho baoic cz0900oy pZ66cauzoo 0 'oulto inroeIUreo 'that p~OW ny
- a t~I~a O~t
.o oilt actiono roquir04" t00~o~
w~ro rt othor doj~onta o uofitly.
O th Quat roaiOr~ to OQVQ3001 at the 6=01 t W~e.
t
- _Tte0_ 11.- xtornally Zroi1o od.proccdureo are liated att. the end of the procodura.
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'o1:a'IV pcimovo voicea 44=10~ are I~r 01 rGcs L thoy be ou. onod e.
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O roly bro o1poifie eontrola cad indicatoiro waot Lnod.
too.'. 2e Whbro opbelic 6controlao re '10'ntoned,' CPO.
- cigLc. Foottiold, Ore gnorally givo.
-cow ovor~.0 oo td In' Itcn I.b'Q ocifiL C cotrolo aloeo~o it spcoe ifi WV6U00 are qgfone iy go-W1 ov o noted :in Itom 'I abaoe opocifoicin dicatov.
o rowoly prixdo~d.
hpro uth-htG A
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ld in the, Orocoduroo.:
Ztei 4. ontrol/'lndica or, panel loecatiorw r
ot prov id od.
Itefa S.
Bodouoo 'tke procedurodoovo uatod art teo
- genoral in.nature 9 p the. niaenclature, uced rarelV. m~atehou the.. upoeigEtc placarding-on tha:.control ponold.
gVon.whoro 090ieCM conroo oe ~tntino 0
-he niat h.
Ld not
.0lwayu porfoet (e.g.,1 ASIV in the prcedure apl t c ar dd SLXV onthe control panel).
- ~ ~
w n ddtiLon, a yorp Ie error in*
Stop: 2i-a of LGA-603 (Page 2') 'oo u tod In fur Iteff.,Opor
.toro
'.t prcte each Goaorgeney! procedure onl1y oncde per yeb 17 S~1C80. 10
III.
ADMINISTRATIV3 CONTROLS Item 2.
The titlos af the procedures evaluated reflect the purpose of the procedure rather than the entry conditions.
This probles is smlo lotated by the requirement that operatoresorae the entry conditions.
Item S. In all the procedures evaluated except LGP-3*32 the finI oge is clearly idontifted via the page of method.
In LGP-3-2, this nethod is aot eMoya.
Furthermore, the final two paqes (Attachment A) are out of order and mismarked.
This msay be a reflection of inadequate editorial control.
Signff lines are provided atte as steps ut not all.
.is may be a reftction of inadequote editorial control.
Item 1.
Verifying operator action s left to the SCR-.
In the simulator exercised performed
<ur ing the site visit, the signoff lines were rarely used.
I.
OPURATIOALT tem 4.
Because of th general nature of these tor codures (see comaents on Level of Detait above), operator memory is relied on heavily fot details on how to porform the actions.
Should the operator's taemory fail him in a stressful situation, precedures ae availa ble. to provide the debitled "how too infor mation he needoo 19 t,
these detailed instructions are not refqrenced in the emer gency proeduer 18 S231C.80.10 0,E