ML16152A495
| ML16152A495 | |
| Person / Time | |
|---|---|
| Site: | Oconee  |
| Issue date: | 10/16/1985 |
| From: | Stolz J Office of Nuclear Reactor Regulation |
| To: | Tucker H DUKE POWER CO. |
| References | |
| NUDOCS 8511010299 | |
| Download: ML16152A495 (18) | |
Text
OCT 1G~
Dockets Nos. 50-269, 50-270 DISTRIBUTION and 50-287 Docket File ACRS-10 NRC PDR RIngram L PDR HNicolaras ORB#4 Rdg Gray File Mr. Hal B. Tucker HThompson EBrach Vice President - Nuclear Production OELD HOrnstein Duke Power Company Edordan WPaulson P. 0. Box 33189 BGrimes GEdison 422 South Church Street JPartlow
?ersiAco Charlotte, North Carolina 28242
Dear Mr. Tucker:
SUBJECT:
SITE VISIT TO OCONEE NUCLEAR STATION, UNITS 1, 2 AND 3 Through a review of operating experience, we have identified a significant number of loss of safety function events that occurred as a result of operator actions performed on the wrong train of systems with redundant trains' or at the wrong unit of a multi-unit facility. Such events could have a high safety significance under circumstances when the loss of a safety function exists for a period of time. Although misidentification of equipment by personnel was reported as the cause of most events, other factors such as defective and inadequate procedures, labeling and training have also been identified as probable causes contributing to the errors.
To develop guidance for both the industry's and NRC staff's use in precluding these types of human-error related events, several activities have been initiated. These activities include specific provisions within the NRC's Maintenance and Surveillance Program and Human Factors Program, and INPO's Human Performance Evaluation systems. Most of these programs are long-term, with scheduled completion dates three to five years in the future. In the interim, certain relatively simple, low cost improvements specifically directed at wrong unit/wrong train errors may be appropriate. Accordingly, we have initiated a short-term effort centered around site visits and discussions with the licensee's staff to survey existing practice and solicit recommendations for improvements.
As part of this effort, we would like to visit the Oconee Nuclear Station, Units 1, 2 and 3. We are coordinating this visit with a visit to McGuire Nuclear Station for the week of October 21, 1985.
Participants will include Mr. D. Persinko and Ms. A. Ramey-Smith, Division of Human Factors and Mr. G. Trager, Office of the Analysis and Evaluation of Operational Data.
We would appreciate your arranging a short tour that will highlight the labeling and identification schemes used at the plant, and a meeting with representatives from the plant staff. Meeting discussions will address specific wrong unit/wrong train events that have occurred at the plant (LERs 269-82-012, 269-85-002). Therefore, please arrange to have the plant staff members involved in those events available for the discussion sessions. In addition, we would appreciate your having other licensee staff available for 8511010299 851016 PDR ADOCK 05000269 P
Mr. H. B. Tucker Oconee Nuclear Station Duke Power Company Units Nos. 1, 2 and 3 cc:
Mr. William L. Porter Mr. Paul F. Guill Duke Power Company Duke Power Company P. 0. Box 33189 Post Office Box 33189 422 South Church Street 422 South Church Street Charlotte, North Carolina 28242 Charlotte, North Carolina 28242 J. Michael McGarry, III, Esq.
Bishop, Liberman, Cook, Purcell & Reynolds 1200 Seventeenth Street, N.W.
Washington, D.C. 20036 Mr. Robert B. Borsum Babcock & Wilcox Nuclear Power Generation Division Suite 220, 7910 Woodmont Avenue Bethesda, Maryland 20814 Manager, LIS NUS Corporation 2536 Countryside Boulevard Clearwater, Florida 33515 Senior Resident Inspector U.S. Nuclear Regulatory Commission Route 2, Box 610 Seneca, South Carolina 29678 Regional Administrator U.S. Nuclear Regulatory Commission 101 Marietta Street, N.W.
Suite 3100 Atlanta, Georgia 30303 Mr. Heyward G. Shealy, Chief Bureau of Radiological Health South Carolina Department of Health and Environmental Control 2600 Bull Street Columbia, South Carolina 29201 Office of Intergovernmental Relations 116 West Jones Street Raleigh, North Carolina 27603 Honorable James M. Phinney County Supervisor of Oconee County Walhalla, South Carolina 29621
Mr. Tucker
-2 the discussion session; specifically, those staff members responsible for operations, maintenance, training, procedure writing and other aspects of facility operation germane to this issue (e.g.; Maintenance Supervisor, I&C Supervisor, QC Supervisor, Operators, Auxiliary Operators, Maintenance Personnel and I&C Technicians).
The agenda for this meeting is enclosed. We will finalize with your staff the date for the Oconee site visit.
Sincerely, John F. Stolz, Chief Operating Reactors Branch #4 Division of Licensing
Enclosure:
As Stated cc w/enclosure:
See next page OR 4:DL HN aras;cr JS 1 1t/85 10 85
OCONEE WRONG UNIT/WRONG TRAIN AGENDA (APPROXIMATELY 2 DAYS)
Introductory remarks by NRC Brief description of the WU/WT event(s)* by plant supervisor familiar with the event(s) (i.e., what occurred, actions leading up to the event, personnel involved, conclusions reached regarding why the event occurred, actions taken after the event to preclude future WU/WT events from occurring)
View areas in the plant where the event occurred**
View other plant areas (including control room) to obtain a representative sample of component labelling in effect and any other plant features which may inhibit/contribute to the occurrence of WU/WT events**
Discuss the WU/WT event(s) in detail with plant supervisors using the protocol as a guide Discuss the WU/WT event(s) with plant personnel who were directly involved in the event(s), especially personnel who actually performed the action on the wrong/unit/wrong train Closing discussion with plant supervisor on any remaining items Events described in LERs 269-82-012; 269-85-008 We would like to photograph areas of interest
DISCUSSION ITEMS INTRODUCTORY REMARKS A. Purpose is to gather information regarding WU/WT events to determine root causes B.
Not here to assess blame Questions refer to all types of work and all people who may have been involved in the WU/WT event (e.g., operations, maintenance, I&C, QC, etc.)
ii ENTRANCE QUESTIONS eDescribe the sequence of events involved in the WU/WT event.
A. What organizations (operations/maintenance/test/QG etc.)
B. Work order/procedures in effect C. Couunications
- 2. Describe any significant features of the area where the WU/WT took place (e.g., contaminated, accessibility, temperature, humidity, ventilation, noise, lighting, etc.
ILABELS (The following questions are NOT referring to labels in the control room but rather those "in the plant at the time of the event.")
- 1. Are permanent name labels provided on all controls, displays, and other equipment items that must be located, identified, or manipulated by plant personnel? If not, where in the plant is the lack of labels mcst prevalent?
- 2.
Does the content of the labels correspond to the nomenclature in the user's procedures (if procedures exist)?
- 3.
Do the labels contain Train and Unit designations?
r
LABELS (CONT'D)
- 4. Is color or symbol coding used consistently to distinguish between systems, Trains and Units?
- 5. Are there instances where the labels are not readable, for example, lettering is too small, view of the label is obstructed, poor label contrast, or not enough light available?
- 6. Must labels be removed to perform maintenance? If so, do procedures include replacement of labels?
LABELS (CONT'D)
- 7.
Describe the plant's label maintenance program.
- 8. How is color coding/labeling used to.identify hazards.
- 9.
Does an administrative procedure cover labelling and identification?
Are plant personnel trained on this?
IV PROCEDURES
- 1. Was a procedure being used for this event?
- Obtain copy
- 2. Are written procedures, instructions, or orders available to operations, maintenance, and surveillance and testing personnel performing work in:
the plant? If yes, explain how plant personnel use them.
A.
Are procedures other than written used?
- 3. q.Do the procedures, orders, or instructions contain the appropriate unit/train designations for the work being performed? Do the reference designations include the component labels or color coding?
- o. What plant procedures help ensure the correct identification of units, trains, and systems? Ca-tdomshck.preocamZ t
PROCEDURES (CONT'D)
- 4. Describe the cues available for differentiating between untts/trains and whether these cues are called out by the procedure.
A. Do procedures contain conditions or warnings where error may be likely?
- 5.
Describe the plant procedures for sign off, verification, initiation, etc. of work performed out in the plant.
o QC involvement Establishing plant conditions o Post maintenance testing prior to initiating work o Administrative procedures 0 Independent vs double verification
- 6. Who controls the quality and technical content of the procedures?
1T.
What plant procedure(s) governs commnications?
What sttps have been taken to help ensure oral conmunications are not misunderstood?
V.
SHIFT MANNING SCHEMES
- 1. Shift Information A. Shift on which event occurred and approximate time or shift; most prevalent shift for maintenance work B. Shift rotation (recent occurrence relative to event, order C. Shift change (recent change relative to event) how is on-coming shift notified of work completed by previous shift, on-going work, and work to be performed establishing plant conditions to allow work to be performed.
- 2. Personnel Involved A. Number of people and discipline B. Overtime worked during or prior to event; maximum amount permitted
- c.
Contract people.
VI TRAINING AND OUALIFICATIONS
- 1. Experience level of personnel, both cortractor and non-contractor A. Minimum qualifications B. Entry level screening C. Verification D. Length of time worked at plant.
- 2. Training A. Any received by personnel involved in the event.
o equipment location o relative safety significance of equipment B. When received C. Who receives training D. Are personnel retrained after plant events, unnecessary rework, plant modifications, plant procedural changes or industry operating experience?
- How is it factored back into the training programs?
E. Status of accreditation programs with INPO.
TRAINING AND QUALIFICATIONS CONViD)
- 3. Assignment A. Personnel dedicated to one unit only, one site only, nuclear only, PWR or BWR only, etc.
B. Equipment important to safety treated differently 4.- Had personnel involved in the event worked at other nuclear units or non-nuclear units prior to the event?
A. When did they transfer to the site relative to the event?
B. How long at other site?
- 5.
How do the training programs address the labeling and identification schemes utilized at the facility?
COMPOSITION OF PLANT WORK FORCE I. At the time of the event (outage vs non-outage)
On the average A.
Percent of contract personnel (by discipline (operations/maintenance/QC, etc.)
B. Average total personnel by discipline UQ6-
MISCELLANEOUS
- 1. What functions (e.g., maintenance, testing) are done in-hobse and what is contract out?
- 2. Interface A. What people and at what levels is maintenance work coordinated with other plant activities? (e.g., operations, testing, etc.)
B. Organizational structure C. How many interfaces exist to carry out maintenance work?
- 3. How are pieces of equipment that are due for maintenance identified?
A. Computerized B. Equipment history
MISCELLANEOUS (CONT'D)
- 4. How is systen status monitored?
- 5. How are events investigated?
When corrective action is recommended, who determines whether it will be taken? Who ensures completion and on what schedule?
6..
How is information exchanged between facilities and utilities on wrong unit/wrong train events other than through IE Information Notices.
- 7. Were any programmatic changes implemented as a result of IE Information Notices 84-51, 84-58 and/or Item I.C.6 of NUREG 0660 and NUREG-0737.
. In general, what is the rate of occurrence for this type of error at this plant? Many operations on an incorrect unit/train do not result in reportable events, although they might under different circumstances.
How is the occurrence of such errors monitored at this plant?
q-What steps in the planning and control of work. are taken to help prevent occurrence of this type of event? (e.g. group discussiors prior to performing tests).
SUMMARY
QUESTIONS
- 1. In your opinion, what were the contributing factors to the WU/WT event?
A. Most significant factors
- 2. What corrective actions (if any) were taken?
A. Who participated in the corrective actions?
B. Problem looked at generically or narrowly.
CL