ML17059C203
| ML17059C203 | |
| Person / Time | |
|---|---|
| Site: | Nine Mile Point  |
| Issue date: | 08/11/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17059C202 | List: |
| References | |
| 50-220-98-13, 50-410-98-13, NUDOCS 9808180007 | |
| Download: ML17059C203 (36) | |
See also: IR 05000220/1998013
Text
i
U.S. NUCLEAR REGULATORYCOMMISSION
REGION I
Docket/Report Nos.:
50-220/98-1 3
50-410/98-1 3
License Nos.:
NPF-69
Licensee:
Niagara Mohawk Power Corporation
P. O. Box 63
Lycoming, NY 13093
Facility:
Nine Mile Point, Units 1 and 2
Location:
Scriba, New York
Dates:
July 20-24, 1998
Inspectors:
J. Trapp, Group Leader
S.
Dennis, Operations Engineer
C. Osterholtz, Resident Inspector - Ginna
Approved by:
Richard J.
Conte, Chief
Operator Licensing and Human Performance
Branch
Division of Reactor Safety
9808180007
9808 L.i
ADQCK 05000220
G
0
EXECUTIVE SUMMARY
Nine Mile Point Unit 1
50-220/98-13
July 20-24, 1998
The management standards
and expectations for plant operators were appropriate
and clearly documented
in the Operations Manual.
Operations personnel
consistently adhered to expectations regarding communications, control room
access,
control board awareness,
and shift turnovers.
Log keeping and annunciator
response were acceptable.
Operations personnel were effectively tracking technical
specification equipment status but operators were unclear as to management
expectations
on the equipment status log entries.
The administrative guidance governing safety and configuration tagging was
appropriate to protect workers and the integrity of safety-related systems.
The
implementation of the safety,and configuration tagging administrative requirements
by plant operators was effective.
Plant operators. were effective in identifying deficient plant equipment and had
established
appropriate thresholds for including deficiencies in the corrective action
program.
However, the inspectors noted that a poor interface existed between
operations and the work planning organization in identifying and resolving deficient
or incomplete work packages.
The administrative guidance for temporary modifications, control room deficiencies,
and operator work-arounds was appropriate.
However, the effectiveness of the
implementation of the programs could not be determined,
as operators were still'in
the process of developing a comprehensive list of deficiencies and work-arounds.
Appropriate procedure guidance was available for the risk significant operator
actions reviewed.
The procedures were walked down in the field with licensed
operators and the operators were found to have a thorough understanding of the
procedure guidance.
The surveillance procedures
used for the tests observed were
of good quality.
Operators implementing several surveillance tests exhibited good procedure
adherence
skills. Operators interviewed were fully aware of management's
expectations for verbatim procedure compliance.
Control room and plant operators demonstrated
appropriate knowledge of plant
systems and administrative requirements necessary to safely operate the plant. All
operations and testing evolutions observed were conducted in a safe and controlled
manner.
The shift supervisor provided appropriate oversight of shift activities and pre-
evolution briefs were well managed.
Operations management was observed
providing appropriate oversight of control room activities.
Operations department management was proactive in initiating quality assurance
surveillances and establishing the mentoring program.
The self-assessment
and
quality assurance
audits were effective in identifying the recent decline in
operations performance.
The assessment
of DER trends, the mentoring program,
and quality assurance's
1997 audit of operations and recent surveillance collectively
provided a thorough assessment
of the operations organization performance.
The licensee appropriately resolved past inspection findings and appropriately
identified and acted on violations dealing with senior reactor operator duties in the
control room.
(NCV 50-222/98-13-01,02)
Re ort Details
~Back round
Nine Mile Unit 1 remained at rated power throughout the duration of this inspection.
The
inspectors directly observed approximately 50 hours5.787037e-4 days <br />0.0139 hours <br />8.267196e-5 weeks <br />1.9025e-5 months <br /> of operator performance during
routine plant operations and scheduled surveillance testing.
The objective of this
inspection was to verify the licensee was aware of the recent decline in Unit 1 operations
performance and was taking appropriate corrective actions to address the root causes.
Inspection Procedure (IP) 93802 was considered in the scope of review for each section of
this report and the staffing for this inspection was at a reduced level.
I. 0 erations
01
Conduct of Operations
01.1
Control Room Observations
a.
Ins ection Sco
e
The team verified that operators were meeting management expectations
in the
areas of communications, control room access,
control board awareness,
annunciator response, shift turnovers and operator log-keeping.
b.
Observations
and Findin s
General Comments
The inspectors found that plant management was cognizant of the decline in
performance and has taken corrective actions to address the causes.
A new
operations management team was recently established.
The new management
team had established
an Operations Manual (common to both Units
1 and 2) that
clearly established standards
and expectations for the operations staff. This
inspection verified overall that the operators were appropriately implementing the
standards
and expectations provided in the Operations Manual.
Communications and Control Room Access
The inspectors observed that the operator's consistently used 3-way
communications during routine evolutions, shift turnovers, and system surveillance
tests.
Control room decorum and professionalism was consistently maintained
during the team's observations.
Control room operators appropriately controlled the
access of non-operating personnel in the at-the-controls area of the control room.
Additionally, non-technical reading material, and other material not required for
station operation were not observed in the control room.
Control Board Awareness and Annunciator Res
onse
The inspectors reviewed the expectations contained in the Operations Manual
pertaining to control board awareness
and verified that the operators were alert and
attentive to control board indications during steady state conditions and surveillance
testing.
The inspectors observed that the control room operators properly responded to
alarms in accordance with the guidance in the Operations Manual with one minor
exception.
The Operations Manual recommends that the alarm response
procedure
be referenced for the first alarm occurrence each shift. The inspectors noted one
example
where the alarm response
procedure was not referenced
as recommended
by the Operations Manual ~ Operatio'n's management
had identified other examples
where this expectation was not satisfied and had reemphasized
the need to
reference the alarm response
procedure during the shift briefings.
Effectiveness of Shift Turnovers
The inspectors observed eight shift turnovers and found them to be consistent with
Nine Mile Point Unit 1 (NMP1) administrative requirements.
The responsible control
room and/or plant operators were knowledgeable of tagged equipment, unusual or
abnormal conditions, upcoming tests, and ongoing work in the plant.
The Senior
Shift Supervisor (SSS) and Assistant Senior Shift Supervisor (ASSS) elicited
participation from all crew members and reinforced safety and communication
standards
adherence
as part of each turnover.
On several occasions,
due to
background noise, some crew members had difficultyhearing information provided
during the turnover and in most cases requested the information to be repeated.
Lo
Kee in
The inspectors reviewed the previous month of ASSS and Chief Shift Operator
(CSO) narrative logs and the shift control room equipment status log. While the
inspectors found the ASSS logs to be consistent with established
standards,
the
CSO log entries were less consistent with those standards.
c.
Conclusions
The management
standards
and expectations for plant operators were appropriate
and clearly documented
in the Operations ManuaL
Operations personnel
consistently adhered to expectations
regarding communications, control room
access,
control board awareness,
and shift turnovers.
Log keeping and annunciator
response were acceptable.
/
3
02
Operational Status of Facilities and Equipment
02.1
Safet
Ta
in
and E ui ment Control
a.
Ins ection Sco
e,
.The inspectors reviewed the guidance and implementation of the safety tagging and
equipment control processes
for protecting workers and the integrity of safety-
related systems; general administrative procedure GAP-OPS-02, "Control of
Hazardous Energy and Configuration Tagging;" and additional guidance in the
Operations Manual pertaining to safety tagging to verify proper implementation and
that appropriate tagging requirements had been established.
'b.
Observations
and Findin s
The inspectors reviewed markups associated with the fuel pool cooling system and
the instrument air compressor,
and found them in compliance with administrative
procedure requirements.
Valves and control switches for the 102 emergency diesel
generator were properly aligned.
Labeling of some switches on panels located
outside the control room were occasionally different than the description in the
procedures.
A preventive maintenance
procedure had been recently implemented
to formally check the control room valve and switch positions every shift. This was
an appropriate corrective action for a recent failure to properly align a containment
spray valve in the control room.
However, the inspectors identified that there was
no similar expectation to periodically verify switches and valves located outside of
the control room.
In response,
license management
agreed to review this specific
area.
c.
Conclusions
The administrative guidance governing safety and configuration tagging was
appropriate to protect workers and the integrity of safety-related systems.
The
implementation of the safety and configuration tagging administrative requirements
by plant operators was effective.
The corrective actions for a valve alignment problem in the control room only
encompassed
control room operated equipment.
02.2
Corrective Actions and Work Controls
Ins ection Sco
e
The inspectors assessed
operator's threshold for including plant equipment
deficiencies into the corrective action program and also reviewed the interactions
between operations and planning and scheduling organization.
Observations
and Findin s
The inspectors conducted plant tours with auxiliary operators and found they were
knowledgeable of plant equipment deficiencies.
During the tours, the inspectors
noted several minor deficiencies nearly all of which had been previously identified
by the auxiliary operators and included in the corrective action program.
The items
that were not in the corrective action program were added,
The material condition
of the reactor building was good in that plant operators were cognizant of the
importance of maintaining good housekeeping
efforts.
Operators were not always aware of projected start and finish times for work
scheduled for safety-related equipment.
This may place an additional burden on
'operators to assess
the plant risk. associated with simultaneous work activities.
The
inspectors noted that the recently implemented daily management meeting to
review maintenance activities was helpful in establishing maintenance priorities.
The inspectors conducted interviews with operations personnel and reviewed
several deviation/event reports (DERs).
Based on the interviews, the inspectors
found that several operators were not confident with the quality of support provided
by the work planning organization.
The team noted two DERs (1-98-1740 and 1-
98-1972) had recently been written by operations in response to work packages
that contained deficiencies that were not identified until final review by the
operating shift for establishing safety markups.
DER 1-98-1740 was written due to
a work package for preventive maintenance
on a power supply that did not identify
that relay replacements
were required as part of the maintenance,
and subsequently
did not contain the necessary
parts.
DER 1-98-1972 was written due to a work
package for preventive maintenance
on a diesel generator heat exchanger that did
not contain plans or parts in the event of a failure while performing the
maintenance.
Both work packages
had been closed out, but neither of them
indicated that a DER had been generated
in response to the noted deficiencies.
It
appeared that the work planning personnel responsible for closing the work
packages were unaware that operations had generated
the DERs.
Conclusions
Plant operators were effective in identifying deficient plant equipment and had
established
appropriate thresholds for including deficiencies in the corrective action
program.
However, the inspectors noted that a poor interface existed between
operations and the work planning organization in identifying and resolving deficient
or incomplete work packages.
0
02.3
0 erabilit
Status of Safet -Related Com onents
a.
Ins ection Sco
e
The inspectors reviewed the processes
for tracking plant status and the operability
of safety-related equipment.
b.
Observations
and Findin s
The guidance for maintaining safety system configuration control was documented
in an Equipment Status Log (ESL). The inspectors interviewed operations personnel
regarding what the threshold was for,equipment to be included in the log. Some
operators indicated that only Technical Specification (TS) and maintenance
rule
equipment needed to be included in the log, while others indicated that all plant
equipment out-of-service be included in the log. The ESL was not being
appropriately maintained at. the start of the inspection due to a computer program
failure that occurred the week prior to the inspection.
However, actions to update
the log were completed during the inspection.
The inspectors noted that a status board was being maintained in the control room
to track TS limiting condition for operations (LCOs) as well as safety-related
equipment out of service.
The inspectors found that the status board was being
appropriately updated.
C.
Conclusions
Operations personnel were effectively tracking TS equipment status but operators
were unclear as to management's
expectations on ESL entries.
02.4
Tem ora
Modifications Control Room Deficiencies
and 0 erator Work-grounds
a.
Ins ection Sco
e
The inspectors reviewed the licensee's programs for temporary modifications (TMs),
control room deficiencies, and operator work-arounds to verify that operator
responsibilities for these programs were properly implemented.
li
b.
Observations
and Findin s
There were a total of 11 TMs installed, none of which affected safety-related
equipment.
The operators log, tagging, and approval of the TMs were all in
accordance with the administrative requirements.
The inspectors did not identify
any problems with operations implementation of the TM or annunciator processes.
The programs for tracking control room deficiencies and identifying and tracking
operator work-arounds had recently been incorporated into the Operations Manual.
There were 32 identified control room deficiencies and a computer database
was
used to track the status of each deficiency.
The program guidance for tracking
operator work-arounds was added to the Operations Manual one week before this
inspection.
The identification of operator work-arounds was discussed
during shift
briefings and the SSS encouraged
operators to evaluate current deficiencies for
inclusion into the program.
c.
Conclusions
The administrative guidance for temporary modifications, control room, deficiencies,
and operator work-arounds was appropriate.
However, the effectiveness of the
implementation of the programs could not be determined, as operators were still in
the process of developing a. comprehensive list of deficiencies and work-arounds.
03
Operations Procedures
and Documentation
03.1
General Observations
ae
Ins ection Sco
e
The inspectors assessed
the quality of selected operating procedures
and also
verified that risk significant operator actions, identified in the Individual Plant
Examination, were included as procedure instructions.
The inspectors verified that
operators appropriately complied with procedure requirements during plant
evolutions.
b.
Observations
and Findin s
The sections of the procedures reviewed were consistent with the licensee
procedure writers guide and the instructions were appropriate for conducting the
intended task.
The licensee was in the process of improving the shutdown from
outside the control room procedure by identifying steps that were described in the
licensing basis analysis for fires and those that were not credited for safe shutdown
of the plant.
The delineation between required and optional steps was important to
inform operators that optional operations performed may not have the benefit of
emergency area lighting and would only be performed provided that sufficient time
was available to complete required actions.
The inspectors determined that the
operations support staff was taking appropriate steps to include these procedure
enhancements.
The risk significant operator actions for station blackout, recovery
of offsite power, and evacuation of the control room were all properly incorporated
into the procedures.
Operators were aware of management expectations for procedure compliance and
they appropriately conducted operation and surveillance test procedures
in
compliance with the approved procedure instructions.
c.
Conclusions
Appropriate procedure guidance was available for the risk significant operator
actions reviewed.
The procedures were walked down in the field with licensed
operators and the operators were found to have a thorough understanding of the
procedure guidance.
The surveillance procedures
used for the tests observed were
of good quality.
Operators implementing several surveillance tests exhibited good procedure
adherence
skills. Operators interviewed were fully aware of management's
expectations for verbatim procedure compliance.
04
Operator Knowledge and Performance
04.1
General Observations
a0
Ins ection Sco
e
The inspectors observed operations personnel performing routine tasks and
surveillance testing to assess
operator knowledge of procedures,
systems,
and
administrative requirements.
The control room observations
also provided the
inspectors
a basis for assessing
the quality of shift supervision and assure that plant
management was providing clear expectations, setting proper standards,
and
conducting effective oversight of operations activities
b.
Observations and Findin s
The inspectors conducted operator interviews and determined that operators have a
good understanding of plant system operation, equipment status and administrative
requirements. The inspectors accompanied plant operators on four sets of rounds in
the reactor building and found all operators to be knowledgeable of systems and
familiar with the bases for the log readings they recorded.
The inspectors observed the SSS and ASSS conduct several shift turnover meetings
and pre-evolution briefings for surveillance tests.
The supervision and direction
giving to plant operators during the shift turnover and pre-evolution test briefings
was appropriate.
The shift supervisors were observed to discuss safety
considerations
and plant contingencies prior to performing testing evolutions.
The
shift supervisors effectively controlled work activities to minimize distractions for
the reactor operators.
The inspectors found that management standards were clearly defined in the
recently issued Operations Manual.
However, differing opinions exist among
operations personnel concerning whether the standards
were requirements or
guidelines. Operations management was frequently observed in the control room
discussing expectations
and standards with the shift operators.
c.
Conclusions
Control room and plant operators demonstrated
appropriate knowledge of plant
systems and administrative requirements necessary to safely operate the plant. All
operations and testing evolutions observed were conducted in a safe and controlled
manner.
The shift supervisor provided appropriate oversight of shift activities and pre-
evolution briefs were well organized.
Operations management was observed
providing appropriate oversight of control room activities.
Management
expectations were clearly articulated in the newly developed Operations Manual.
07
Quality Assurance in Operations
07.01 General Observations
a.
Ins ection Sco
e
The inspectors assessed
the quality of the self assessment
and independent
oversight of the operations organization.
b.
Findin s and Observations
At the request of the Operations Manager, the quality assurance
organization
conducted
a surveillance of the operations in June 1998. The quality assurance
staff used the NRC inspection procedure (93802) to conduct this review. The
scope of the surveillance was similar to this inspection.
The conclusion of the
surveillance report stated that "overall, conduct of operations meets expectations."
The licensee's surveillance team found opportunities for improvement in the area of
operator log keeping, implementation of the Shift Technical Advisor (STA) function
and a lowering of the threshold for writing DERs.
The surveillance findings were
generally consistent with those noted during this inspection.
The licensee had initiated a control room mentoring program in June of 1998 to
provide feedback to the operators regarding performance expectations.
The
inspectors reviewed a select sample of the mentor's observation reports and found
that they were candid assessments
and met the program expectations.
Several
operators stated that they believed the mentoring program would assist in
understanding
and complying with management expectations.
An August 1997 Quality Assurance annual audit of operations identified a
"...general decline in Conduct of Operations."
The audit reviewed the conduct of
operators, management performance, administrative controls and procedures.
~
0
The inspectors reviewed the licensee's self assessment
program for operations.
The administrative controls for the program provided explicit observation area
objectives and standards.
Performance records were maintained for each
performance objective.
The 1998 performance records indicated that observations
were frequently conducted and were self critical. The operations department also
assesses
performance by trending DERs.
The DER trend reports indicated that the
1998 personnel error rate for operations was slightly higher than the business plan
goal and the trend was not declining.
The information in the trend report provided
operations management with a good basis for assessing
performance:
Operations
department management reviewed the quarterly trend'reports
and documented
an
assessment
of the data.
C.
Conclusions
Operations department management was proactive in initiating a quality assurance
surveillance and establishing the mentoring program.
The self-assessment
and
quality assurance
audits were effective in identifying the recent decline in
operations performance.
The assessment
of DER trends, the mentoring program,
and quality assurance's
1997 audit of operations and recent surveillance collectively
provided a thorough assessment
of the operations organization performance.
08
Miscellaneous Operations Issues
08.1
Closed
Violation 50-220 5 50-410 96-10-04: Multi le exam
les of failure to
follow rocedures
This violation cited three separate
examples of failure to follow procedures.
The
failures occurred during a surveillance test on the core spray topping pump (Unit 1),
during the installation of a markup on a hydraulic control unit (Unit 1) and during
maintenance
by ISC on the hydrogen/oxygen monitors (Unit 2). The inspectors
verified the completion of selected corrective actions provided in Niagara
Mohawk's, December 26, 1996, Notice of Violation response letter to the NRC.
The inspectors verified that Procedure Writer's Guide was revised and included
enhanced
guidance regarding independent verification of calculations.
Also,
surveillance test procedure (U1-ST-Q18) was revised to be consistent with the
guidance provided in the writer's guide.
The inspectors reviewed the Operations Manual to verify that appropriate guidance
was provided for independent verification during application and clearing of
markups.
Operations Manual, Section 3.10.3 recommends that when applying and
clearing markups on safety-related systems that independent verification is required.
The inspectors observed markups being applied and cleared and noted that the
operator's were conducting independent verifications in accordance with the
Operations Manual.
The inspectors observed the operators applying self checking
techniques provided in the Operations Manual which was instituted as an
enhancement to reduce human errors.
10
The licensee has recently set new standards for self checking and verification to
improve the personnel error rate and reduce the incidence of failure to follow
procedures.
The licensee monitors the personnel error rate on a quarterly basis and
has established
a business plan goal for personnel errors.
The inspectors
determined that the licensee's corrective actions to reduce personnel errors and the
trending and goal setting for reducing the personnel error rate provides an
appropriate basis for closure of this violation.
Closed
Violation 50-2205 50-410 97-06-01: Multi le exam
les of failure to
follow rocedures
The corrective actions implemented by the licensee in 1996 to reduce the instances
of failure to follow procedures were not completely successful.
In 1997, a second
NRC violation was written for additional examples of failure to follow procedures.
The 1997 violation cited four examples of failure to follow procedures that occurred
during the month of July. The examples included inadvertently operating the wrong
valve during a containment spray surveillance test, opening the wrong breaker
during an isolation of a motor generator set, not following test procedure steps
during fire system testing, and the failure to properly restore
a radiological waste
system to service.
The inspectors verified the completion of selected corrective
actions described in the Niagara Mohawk's, October 15, 1997, Notice of Violation
response letter to the NRC.
The inspectors conducted extensive observations of operators conducting
surveillance tests and the implementation of markups.
The operators were found to
be implementing good self checking and verification practices.
Management
expectations regarding self checking and verifications were clearly articulated in the
Operations Manual.
Pre-job briefings for these activities were thorough.
The labels
on the normal and maintenance supply breakers for the process computer were
appropriately revised.
The licensee now monitors the personnel error rate and has established
goals for
personnel errors.
Closure of this violation is based on the current inspection results
of strict adherence to procedures,
on the licensee's corrective actions to reduce
personnel errors, and on the trend of personnel error rate which appears to be
holding steady.
08.3
Closed
VIO 50-220 EA96-541-1013:
Failure to control reactor
ressure vessel
water level followin
a scram resultin
in water enterin
the main steam lines.
On November 5, 1996, following a reactor scram, a reactor vessel overfill occurred
'which resulted in fillingthe main steam lines with approximately 30,000 gallons of
water.
The details associated with this issue are documented
in NRC Inspection
Report 50-220/96-13. As a result, a notice of violation and proposed imposition of
civil penalties letter was issued by the NRC to Niagara Mohawk Power Corporation
(NMPC), dated April 10, 1997.
NMPC provided their response to the violation in
their letter dated May 12, 1997, to the NRC.
11
The inspectors conducted an on-site review to assess
and verify corrective and
preventive actions stated in the response
by NMPC in the areas of design change,
procedure, training, and organizational enhancement.
Specifically, the inspectors
conducted document reviews and interviewed the responsible engineer and general
supervisor of operations (GSO) and assessed
and verified the following:
~
New training scenarios which were developed and are currently in use to test
overfill events and the modification made to the high pressure coolant
injection (HPCI) and feedwater (FW) trip system.
~
Post trip reviews which were used to verify consistency between simulator
and plant response to events.
~
Plant operating procedures which were revised and now provide more
explicit direction for vessel level control and reflect the modification made to
the HPCI/FW trip system.
~
Technical specifications which were amended to reflect the reinstatement of
the GSO position to provide additional operations oversight.
Additionally, the inspectors reviewed five subsequent
plant shutdown post-trip
reviews and found no instances of level control problems.
The licensee's root
cause and analysis and related corrective and preventive actions were acceptable.
This violation is closed.
08.4
Licensee Event Re orts
LER 50-220 98-07and
LER 50-220 98-14:
Closed
On dut
SRO tern oraril
leaves the control room
LER 98-07
On April 24, 1998, with NMP1 at full power, the on duty ASSS left the control
room to discuss ongoing maintenance with an electrical technician; the SSS was
out of the control room attending to other business.
This resulted in no SRO in the
contiol room as required by TS 6.2.2.e.
After about two minutes, the ASSS
realized the error, returned to the control room, and immediately notified the SSS.
The ASSS was subsequently removed from licensed duties following a NMP1
management
investigation.
NMP1 management
initiated DER 1-98-0983 and
subsequent
LER 50-220/98-07to document the event and initiate a root cause
analysis.
The inspectors conducted an on-site review of the root cause analysis and
associated
corrective actions for this event.
The event was licensee identified.
Additionally, through review of past NMP1 and NMP2 LERs and interviews with
plant management,
the inspectors found that the event was an isolated case and
non-repetitive.
The inspectors concurred with the licensee's determination of root
,cause as inadequate
managerial methods and a contributing factor of inadequate
verbal communications., The inspectors selected associated
corrective actions for
review which included verification of physical barriers put in place to remind
operators of the control room envelope boundaries, review of an event notification 0
~
~
12
to all operating staff, and verification through training records that the individual
involved received additional training and developed
a lessons learned memo.
The
team determined the corrective actions to be acceptable
and this LER met the
requirements of 10CFR50.73.
The inspectors concluded that LER 98-07 is closed
and the event was a violation of NMP1 TS 6.2.2.e.
(NCV 50-220/98-13-01)
0 en
On dut
SRO fails to satisf
trainin
re uirement
LER 98-14
On June 16, 1998, with NMP1 at full power, an unqualified SRO assumed the
position of ASSS for approximately four hours and was the only SRO in the control
room for approximately 45 minutes during that time. The SRO was not qualified
because
on the previous day, June 15, 1998, the SRO had failed an evaluated
requalification simulator exam and per NMPC training procedure NTP-TQS-102,
"Licensed Operator Requalification Training," Section 3.5.7.b.3, completion of
remediation is required prior to an individual resuming licensed duties following a
failure. The required remediation was not completed when the SRO assumed the
position of ASSS for 4-hours.
Therefore, the TS 6.6.2.e. requirement for having a
qualified SRO in the control room during power operation was not satisfied during
the 45 minute period when the SSS was out of the control room to attend the
morning meeting.
Also, the NRC identified that the "unqualified" ASSS did not
meet the requirement of TS 6.6.2.a.
The SRO was assigned to the ASSS position by the GSO to allow the normally
scheduled ASSS to attend an offsite meeting.
Additionally, the GSO and SRO were
aware of the failure when the assignment was made, but did not realize at the time
that the failure should preclude the SRO from assuming the position of ASSS until
remediation was complete.
The event was brought to the attention of NMPC
management
on June 17,1998,
by a trainer who had been observing the shift on
June 16,1998, as part of the operations mentoring program. NMPC initiated DER 1-
98-1882 and subsequent
LER 50-220/98-14to document the event, initiate a root
cause analysis, and develop corrective actions.
The inspectors conducted
an on-site review of the root cause analysis and
associated
corrective actions for the event described in LER 50-220/98-14and
DER
1-98-1882. The team noted the event was licensee identified. The inspectors
concurred with the licensee's determination of inadequate
managerial methods.
However, the inspectors determined that an additional root cause was inadequate
verbal communications which the licensee had stated in their LER was a
contributing factor to the event.
The inspectors reviewed selected corrective
actions to assure that both root causes were addressed.
The inspectors verified
that:
a crew remediation and successful reevaluation were performed, a lessons
learned memo was distributed to all operations staff, and training procedure NTP-
TQS-102 "Licensed Operator Requal Training" was revised to provide more explicit
and formal direction regarding the communication and notification process for crew
and individual failures.
Due to the complexity of this event, additional review will
be conducted by the NRC to verify that all root causes
are identified and corrected.
LER 98-014 willremain open pending that review.
13
Conclusion for Followu
of LERS 50-220 98-07and 98-14
The inspectors determined that both events occurred under distinctly different
circumstances
and causes.
For both events, the same NMP1 requirements for
control room SRO staffing as specified in TS 6.2.2.a and e applied.
V. IVlana ement Meetin
s
X1
Exit Meeting Summary
On July 24, 1998, a meeting was held to discuss the findings of this inspection.
management at the exit meeting did not dispute any of the team's findings or conclusions.
Based on the NRC Region
I review of this report, and discussions with NMPC
representatives,
it was determined that this report does not contain safeguards
or
proprietary information.
PARTIALLIST OF PERSONS CONTACTED
B. Booth
J. Conway
J.
Dreyfuss
D. Topley
General Supervisor of Operations, Unit 1
Vice President, Nuclear Generation
Operations Support
Operations Manager
INSPECTION PROCEDURES USED
Operational Safety Team Inspection
Administrative Procedures
PROCEDURES REVIEWED
4
GAP-OPS-01,
GAP-OPS-02,
GAP-OPS-03,
GAP-DES-03,
GAP-PHS-03,
GAP-PSH-01,
GAP-PSH-03,
Rev. 9
Rev. 9
Rev. 3
Rev. 7
Rev. 2
Rev. 18
Rev 2
Administration of Operations
Control of Hazardous Energy and Configuration Tagging
Control of Operator Aids
Control of Temporary Modifications
Control of On-line Work Activities
Work Control
Control of On-line Work Activities
S-400-ND D-CON
'-500-ND D-OPS
Configuration Management
Operations
NIP-ECA-01
NIP-OUT-'01
Deviation Event Report
Shutdown Safety
N1-PM-S5
Control Room System Lineup Verification
14
0 erations De artment Procedures
N1-ODP-OPS-0101, Rev.10
Operations Manual
Shift Turnover and Brief
Effective Date 4/17/98
0 eratin
Procedures
N1-0P-13, Rev. 29
N1-OP-45, Rev. 23
N1-OP-38C, Rev. 15
N1-OP-40, Rev. 12
N1-OP-43B, Rev. 0
N1-OP-43A, Rev. 4
Emergency Cooling System
LPRM/APRM
Reactor Protection 5 ATWS Systems
Balance of Plant Startup tk Shutdown
Reactivity Control
S ecial 0 eratin
Procedures
N1-SOP-18, Rev. 5
N1-SOP-9.1, Rev. 4
N1-SOP-5, Rev. 9
N1-SOP-7, Rev. 4
N1-SOP-1, Rev. 9
Station Blackout
Control Room Evacuation
Loss of 115 KV
Service Water Failure/Low Intake Level
Reactor Scram
Deviation Event Re orts
1-98-0983
1-98-1 882
1-98-0632
1-98-0008
1-98-0708
1-98-0143
1-98-0204
1-98-0323
1-98-0965
1-98-1094
1-98-091 9
1-98-2006
SRO left the control. room
Failure to comply with NRP-TQS-102
Avoidable loss of EDG availability hours
Inappropriate Operator Action
Trending DER for EDG 103.fuel oil tank level
Procedure inadequacy
FSAR discrepancy - Manual spray initiation does not
agree with EOP
Procedure inconsistency N1-SOP-9.1 (Control Room
Evacuation)
Failure to implement TS action statement
Procedure violation - failure to follow n1-OP-43A
Unrecognized violations of secondary containment
Incomplete procedure change review
Qualit
Oversi ht
Audit Report 97009, Operations, Surveillance and Test
Surveillance Report 98-0066-1, Unit 1 Operations Branch Assessment
Deviation Event Report Program - Trend Summary Report Second Quarter 1998
Deviation Event Report Program - Trend Summary Report First Quarter 1998
NMP1 Operations - Evaluation of DER Trend Report First Quarter 1998
Unit One Operations - Performance Observation Report
Control Room Mentoring Program
15
ITEMS OPENED, CLOSED, AND UPDATED
Closed
50-220 8L 410/96-010-04
50-220 8t 410/97-06-01
VIO
Multiple examples of failure to follow
procedures
Multiple examples of failure to follow
procedures
50-220/EA96-541-1 01 3
Vessel overfill event
50-220/97-03-01, 50-220/
98-07
NCV/LER
On duty SRO temporarily leaves control
room
~Udated
50-220/98-14
LER
On duty SRO fails to satisfy training
requirements
LIST OF ACRONYMS USED
ASSS
CFR
CSO
DER
GSO
LCO
LER
NMP2
NRC
OSTI
TM
Average Power Range Monitor
Assistant Station Shift Supervisor
Code of Federal Regulations
Chief Shift Operator
Deviation/Event Report
Equipment Status Log
Feedwater System
General Supervisor of Operations
Limiting Condition for Operation
High Pressure
Coolant Injection
Licensee Event Report
'iagara Mohawk Power Corporation
Nine Mile Point Unit 1
Nine Mile Point Unit 2
Nuclear Regulatory Commission
Operational Safety Team Inspection
Station Shift Supervisor