ML17158A063

AIT IR 50-387/93-80 on 931029-1109.No Violations Noted. Major Areas Inspected:Circumstances,Causes,Corrective Actions,Safety Significance & Generic Implications of Events Which Occurred on 931006,26-28

ML17158A063
Person / Time
Site:	Susquehanna
Issue date:	12/08/1993
From:	Temps R, Jason White NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML17158A062	List: ML17158A061 ML17158A063
References
50-387-93-80, NUDOCS 9312300017
Download: ML17158A063 (79)

See also: IR 05000387/1993080

Text

U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Docket No.

Report No.

License No.

Facility Name:

Inspection At:

Inspection Dates:

50-387

50-387/93-80

NPF-14

Susquehanna

Steam Electric Station (SSES)

Berwick, Pennsylvania

October 29, 1993 through November 9, 1993

Inspectors:

Robert Summers, Project Engineer, DRP

Carl Sisco, Operations Engineer, DRS

David Desaulniers,

Human Factors Specialist, NRR

Scott Morris, Reactor Engineer, DRP

David Mannai, Resident Inspector - Susquehanna,

DRP

Observer:

David Ney, Commonwealth of Pennsylvania

Team Leader:

R.R. Temps, Project

Division of Reacto

oj

Date

Approved By:

J.R.

'te, Section C

ef, B

2A

D'sion of Reactor Projects

.D

Inspection Summary:

See Executive Summary

9312300017

9'31208

PDR

ADOCK 05000387

Q

PDR

EXECUTIVESUMMARY

Between October 6 and 28, 1993, while the plant was shut down for a refueling outage, four

events occurred during fuel handling operations at Unit 1 ofPennsylvania Power and LightCo.'s

(PP&L's) Susquehanna

Steam Electric Station (SSES).

These events are described below.

Event

1 occurred on October 6, 1993, when a peripheral fuel bundle was incorrectly removed

from core location 31-56 (instead of from core location 29-55).

Upon discovery of the error,

the bundle was inappropriately returned to its original location in the core.

Further fuel moves

were suspended

while PP&L developed

and implemented corrective actions.

Core offload

recommenced

three hours later and was completed on October 9.

Event 2 occurred on October 26, 1993, the same day that PP&L commenced core reload. While

lowering a fuel bundle into the core, a 10-inch section of the telescoping mast "hung up" and

subsequently slipped, creating a loud noise. Afterdetermining that the fuel bundle had not been

affected, the operator's completed lowering the bundle into its core location and then secured fuel

handling activities. Maintenance personnel examined the mast and determined that the mast was

unusable because of a bend in the 10-inch section.

Event 3 occurred on October 27,

1993, after resumption of refueling activities and while using

the Unit 2 refueling bridge. While a double blade guide was being moved from the core to the

spent fuel pool, it hit the inner wall of the reactor pressure vessel.

Bridge operators, who noted

.that the mast was not high enough to allow the blade guide to clear the vessel flange, had

stopped bridge movement; however, momentum allowed the blade guide to hit the vessel's inner

wall. The mast was then fully raised and the blade guide was taken to its designated

location

in the fuel pool.

After comprehensive

inspection and testing of the mast (which revealed no

observable problems with the mast) and the institution of new procedural controls, refueling

activities were resumed.

Event 4 occurred on October 28, 1993, while the mast was being lowered in preparation for

grappling a new fuel bundle in the fuel pool. While lowering the mast, a section of the mast

"hung up" and then unexpectedly released.

PP&L suspended all further fuel movements pending

completion of an internal Event Review Team (ERT) investigation.

Subsequent

inspection

revealed that a section of the mast was bent.

An Augmented Inspection Team (AIT) was dispatched by the NRC to determine and assess

the

circumstances,

causes,

corrective actions, safety significance, and generic implications of the

events.

The AIT began its inspection on October 29,

1993, and completed

onsite review

activities on November 9, 1993. PP&L met with Region I management on November 18, 1993,

and presented the findings ofits internal reviews and its plans for resuming refueling operations.

The AITpresented its preliminary findings in a public exit meeting on November 22, 1993 (see

Attachments 7 and 8).

The AITconcluded that operator errors were the immediate causes of Events 1, 2 and 3. Event

4 was caused

by operation of the refueling bridge, with the mast in a weakened

condition

following Event 3.

The AITfound that several of the short-term actions taken by PP&L prior to resumption of fuel

handling activities after each event were inadequate.

Further, the AITdetermined that Events

1 through 4 were all repetitions of similar events going back to at least

1984.

The AIT

determined

that the root-cause

evaluations for these previous events were not thorough and

lacked independence of review, and that corrective actions were generally directed toward

counseling individuals, adding procedural precautions,

and reviewing the events in operator

training, rather than implementing proscriptive procedural

controls.

Consequently,

these

corrective actions were ineffective in preventing recurrence.

In reviewing PP&L's response

to previous events,

the AIT noted that PP&L had not treated

some fuel handling activities as safety-significant operations.

The AIT observed

repeated

instances where evaluations had stated "no safety significance" or "increased outage time" as the

consequence

of the event reviewed.

PP&L's response

to the repeated

maintenance

and

replacement of bent mast sections appeared

to be more concerned with economic factors (i.e.,

maintaining the timeliness of core offioad/reload) than in treating the problem as one affecting

a safety-significant activity.

The most. telling evidence of this was that for recent refueling

outages,

a spare mast was routinely kept on the refueling floor due to PP&L's history of mast

problems and the expectation that a spare would probably be needed.

The AITwas particularly concerned by PP&L's response to recommendations

made in 1986 and

1987 as a result of an engineering review of problems involving fuel handling equipment.

Although the recommendations

were designed to reduce the wear and tear on the fuel handling

equipment, PP&L did not adopt them.

Had PP&L paid attention to the recommendations,

many

of the problems encountered

recently may have been prevented.

The AITconcluded that operations management's

oversight of fuel handling activities was weak

and their failure to take more rigorous corrective actions from previous events allowed the

problems to recur.

In the past, senior operations management

has delegated oversight of these

activities to the refueling floor senior reactor operator (SRO).

This decision was apparently

made under the belief that having a higher management

presence on the refueling bridge would

distract the operators from their duties. However, although the desire to reduce distractions was

commendable,

senior managers did not hold their people accountable,

nor obtain feedback,

so

the managers

remained unaware of concerns

and practices known at the working level.

For

example,

senior

operations

managers

stated

they

had

never

heard

of complaints

from

maintenance

personnel that fuel handling equipment problems were caused by the manner in

which operators were operating the equipment, yet many operations personnel at the level of

Shift Supervisor and lower knew of this complaint.

Senior managers

were unaware of the fact

that double blade guide handles could be hit when double blade guides were moved in the spent

fuel pool, although this fact was reported by two operators during the AITinterviews.

Lastly,

human performance problems during fuel handling operations have repeatedly occurred over the

years, yet operations management

oversight of these activities remained unchanged.

TABLEOF CON'H<WTS

Introduction

1.1

AITScope and Objectives ..

1.2

AITProcess

Desc

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rlptlon of Events

Assessment of Pennsylvania Power and Light Co.'s (PP&L's) Response

to, and

Corrective Actions Following, Each Event.......................

3.1

. Assessment of PP&L's Short-Term Corrective Actions for Each Event .

3.2

Adequacy of Short-Term Actions in Light of Previous Similar Events

3.2.1.

Previous Events Involving Impact to the Mast/Grappled

Components............................

3.2.2.

Fuel Bundle and Blade Guide Movement Errors......

3.2.3.

Mast Damage Attributed to Unknown Causes

3.3

Final Actions Taken Prior to Resumption of Fuel Loading

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Fuel Handling Procedures...................................

Schedule, Staffing, and Overtime ............................

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7.5

7.6

7.7

Maintenance/Surveillance

Issues

Identified During the Outage

Related

to the

Refueling Bridge Main Grapple (Mast)...........................

7.1

Installation of Non-Q Grapple............................

7.2

Failure To Perform Required Surveillance Test .............

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7.3

Bridge Travel Interlock Failure..........................

7.4

Summary of Concerns

on Maintenance

and Troubleshooting

on the

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Review ofthe Maintenance History of the Refueling Bridge Main Grapple

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Summary of Concerns on Maintenance History

Potential Generic Concerns

7.7.1

Operational Concerns

7.7.2

Design Concern...............................

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Human Factors Issues ..................

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Safety Significance and Management

Oversight and Control of Fuel Handling

ACtlVltleS

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TABLEOF CONTENTS (CONTIMH~W)

Attachment 1:

Attachment 2:

Attachment 3:

Attachment 4:

Attachment 5:

Attachment 6:

Attachment 7:

Attachment 8:

AIT Charter

Personnel

Contacted

Detailed Timelines for Events

1 through 4

Previous Impact Events Since 1984

Bundle/Blade Guide Movement Errors

Human Factors Concerns

Slides Shown at the PP8cL Management Meeting

Slides Shown at the AITExit Meeting

DETAILS

1.

Introduction

Because of the series of fuel handling events which occurred in October

1993 at Unit 1 of

Pennsylvania Power and Light Co.'s (PP&L's) Susquehanna

Steam Electric Station (SSES), the

Nuclear

Regulatory

Commission

(NRC)

Region I Regional

Administrator,

and

senior

management

from the Office of Nuclear Reactor Regulation and the Office for Analysis and

Evaluation of Operational Data, determined that an Augmented Inspection Team (AIT) should

review the events and evaluate their significance.

The reasons for sending the AITcentered on

understanding the cause(s) of these events, the fact that the events were. repetitive in nature, and

that there may have been generic implications.

The AITwas assembled

and sent to the site on

October 29, 1993.

1.1

AITScope and Objectives

The charter for the AIT(Attachment 1) was issued on October 29, 1993.

The charter directed

the team to conduct an inspection that accomplished

the following objectives:

ao

Review and evaluate

the adequacy of PP&L's corrective measures,

in concert with

Region I management, prior to agreeing to resumption of refueling activities.

b.

Conduct.a thorough and systematic review of the circumstances

surrounding each of the

refueling events which occurred since October 1, 1993, and develop a detailed sequence

of events for each occurrence.

C.

Collect, analyze,

and document relevant factual information to determine the causes,

conditions, and circumstances

pertaining to each event.

d.

Review qualifications of the refueling operators

and training they received

on fuel

handling operations.

e.

Evaluate PP&L's review of and response

to each event and implemented corrective

actions, as well as their plans for resumption of refueling activities.

Review and assess

the adequacy of PP&L's refueling, surveillance, and test procedures

as they existed before these events; and review and assess

the changes

made in these

procedures after each event.

g.

Evaluate PP&L's procedures

regarding

senior reactor

operator

(SRO)

and reactor

operator (RO) responsibilities during fuel handling operations.

h.

Determine ifthere were any generic implications that should be considered for further

review or evaluation by the NRC staff.

i.

Determine the adequacy of management

oversight and control of refueling activities.

j.

Assess

the

safety

significance of each

event

and

communicate

to regional

and

headquarters

management

the facts and safety concerns related to problems uncovered.

1.2

AIYProcess

From October 29 to November 9, 1993, the AIT performed an independent

inspection and

review of the circumstances

associated

with the fuel handling events.

The team inspected the

fuel handling equipment and observed associated troubleshooting and repair activities; conducted

formal interviews with the personnel involved in the events; held discu'ssions with operations,

maintenance,

and

engineering

personnel;

reviewed

fuel handling procedures

and training

documents; reviewed documents pertaining to previous occurrences ofrefueling events; reviewed

operators'ogs;

and reviewed management oversight of fuel handling activities.

Attachment 2

lists personnel contacted by the AIT.

2.

Description of Events

The following information is a brief synopsis of the four events that were the focus of the

inspection.

Attachment 3 contains detailed timelines for each event, as constructed

from the

team's review ofoperating logs, and also provides relevant details and circumstances

developed

through interviews with various personnel involved in the events.

Relevant technical information

resulting from PP&L's review.of the events has also been factored into the timelines for Events

2 and 4. Other issues were identified concerning maintenance and surveillance practices on the

refueling equipment, and these are discussed

in Section 7.

On September 25, 1993, PP&L shut down Unit 1 and entered a refueling outage.

On October

1, 1993, core off-load to the spent fuel pool commenced.

Event

1 occurred on October 6, 1993,

when a peripheral fuel bundle was incorrectly removed from core location 31-56 (instead of

from 29-55, adjacent to 31-56). When the error was discovered, the bundle was inappropriately

returned to its original location in the core.

Further fuel moves were suspended

while PP&L

developed and implemented corrective actions.

Core off-load recommenced

three hours later

and was completed on October 9.

Event 2 occurred on October 26, 1993, the same day that PP&L commenced core reload. While

.'owering a fuel bundle into the core, a 10-inch section of the telescoping mast "hung up" and

subsequently slipped, creating a loud noise.

Operators on the refueling bridge finished lowering

the bundle into its core location and then secured fuel handling activities.

Surveillances were

performed

on the mast and maintenance

personnel

determined

that the mast was unusable

because there was a bend in the 10-inch section.

Consequently, PP&L decided to use the Unit

2 refueling bridge to complete the Unit 1 refueling activities.

Event 3 occurred on October 27,

1993, after resumption of refueling activities and while using

the Unit 2 refueling bridge. While moving a double blade guide from the core to the spent fuel

pool, the blade guide hit the reactor pressure vessel inner wall. Bridge operators noted that the

mast was not high enough to allow the blade guide to clear the vessel flange and had stopped

bridge movement; however, momentum allowed the blade guide to hit the vessel inner wall.

The mast was then fullyraised to clear the flange and the blade guide was subsequently

placed

into its designated location in the fuel pool. After comprehensive

inspection and testing of the

mast, which revealed no problems with the mast, and the institution ofnew procedural controls,

refueling activities were resumed.

Event 4 occurred on October 28, 1993, while the Unit 2 refueling bridge mast was being

lowered in preparation for grappling a new fuel bundle in the fuel pool.

While lowering the

mast, a section of the mast "hung up" and.then unexpectedly released.

PP&L suspended

all

further fuel movements

pending

completion of an

internal

Event Review Team

(ERT)

investigation.

Subsequent

inspection revealed that a section of the mast was bent.

3.

Assessment

of Pennsylvania

Power and Light Co.'s (PP&L's) Response

to, and

Corrective Actions Following, Each Event

The AITreviewed and assessed

the actions that PP&L took for each event before resuming'fuel

handling activities.

The AIT also reviewed

the adequacy of these actions in light of the

historical record of numerous similar events which have occurred at SSES since at least 1984.

The AITidentified deficiencies,

as described below.

3.1

Assessment of PP&L's Short-Term Corrective Actions for Each Event

In the following discussions,

refer to Attachment 3 for details about each event.

VENT 1'

1 Bun l Err r

PP&L's immediate corrective actions to this event included "Hot Box" training (guidance which

must be read before operators assume their shift duties) which discussed

the requirements for

the bridge operators to communicate to each other the cell orientation of the fuel bundle and to

confirm correct mast orientation/alignment, with respect to core location, before grappling the

bundle.

The training also clarified that once a bundle clears the top guide, during offloads, then

the bundle must not be reloaded into the core.

Operations

management

also counseled

the

individuals involved in the event regarding proper communications

practices.

Defueling

activities resumed

within three hours, with operations

management's

understanding

that a

procedure

change approval form (PCAF) would be issued by the next day to formalize the

information in the Hot Box training memorandum regarding cell orientation of the bundle and

mast orientation before grappling a bundle.

The team assessed

that these actions were inadequate for the following reasons:

(1)

PP&L's corrective actions did not address

the serious breakdown in the command and

control of fuel handling activities that occurred during this event .

Procedure RE-081-

032, "Refueling Operations," states that shift supervision is responsible for directing fuel

handling activities; however, the bundle was improperly placed back in the core without

the knowledge or concurrence of the shift supervisor (SS).

Instead, the central figure

directing the recovery actions for this event was the outage supervisor.

By procedure

RE-081-032, this individual is not responsible for directing fuel handling operations,

especially recovery actions.

No training emphasizing

the command

and control of

refueling activities, especially when unexpected events occur, was given to the operators

preceding the resumption of defueling.

(2)

The outage supervisor was counseled by operations management

on his responsibilities

during fuel handling activities, yet after two interviews with the individual by the AIT,

it was apparent that the counseling he received,

as to his responsibilities,

had not been

clearly communicated or understood.

(3)

Defueling was allowed to resume without a PCAF in place, under the assumption that

it would be issued by the following day.

The AITfound that the PCAF was not issued

until 12 days later.

Therefore,

the remaining 3 days of defueling were performed

without the PCAF in place.

Operations management

was not aware that the PCAF had

not been issued on time until the AITtold them.

VE

2

M

n "Hn

Following this event, PP&L maintenance

personnel

determined

that the Unit

1 mast

was

unusable

and the Unit 2 bridge and mast were readied

to support refueling.

Operations

management interviewed all refueling operators to determine ifthe operators had hit anything.

All of the operators interviewed replied they had not hit anything.

Refueling recommenced,

once the Unit 2 equipment was verified operable.

The AITidentified that these corrective actions were inadequate for the following reasons:

(1)

PP&L did not fullyexplore the physical evidence of the markings on the flange protector

before resuming fuel reload.

Subsequent evaluation (a week later) by PP&L determined

that the mast's grapple had been dragged across the reactor vessel flange protector and

that this most likely bent the mast.

(2)

PAL proceeded

with refueling without resolving how the mast was damaged.

Even

though the operators said they had not hit anything, considering the bent mast section and

flange marking, operations management

suspected

that the mast had hit something,

All

operators involved in the current refueling outage were interviewed and all stated they

had not hit anything with the mast.

The interviews were then expanded to include all

operators who had participated in refuelings in the past.

During one of these interviews,

an operator,

responsible for an impact event in 1992, stated that when that incident

occurred, he did not feel any impact.

From this, PP&L concluded that an impact might

have occurred during Event 2 and that operators could have been unaware of it. Reactor

Engineering then proceeded to prepare a PCAF for the refueling procedures which would

have been more proscriptive concerning

mast elevation; however, Event 3 occurred

before the PCAF was implemented because refueling had recommenced before all of the

interviews were completed.

(3)

The fault lockout on the bridge which occurred while traversing

the transfer canal

("cattle chute") was never fully explained prior to resumption of refueling.

VE 'l

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ctor V

l Inn rW 11

Following this event, refuel activities were temporarily halted.

A PCAF was subsequently

issued to place restrictions on the mast elevation before movement through the transfer canal,

Maintenance personnel checked out the bridge and mast and saw no observable damage to the

mast.

Operations

management

also assigned

an SS to monitor refuel floor activities and to

report his observations

to them.

The AITconsidered

these actions inadequate

because:

(1)

The PCAF, specifying that the mast be in the normal up position before proceeding past

the central area of the core,

was only issued

to one of the two affected refueling

procedures.

The PCAF was entered in Procedure RE-081-032, "Refueling Operations,"

the reactor engineer's procedure,

but Procedure OP-181-001,

"Refueling Operations,"

the one used by the operators,

did not receive the PCAF.

The AITnoted this fact.

(2)

The SS assigned by operations management to review and report on refuel flooractivities

only observed 20 minutes'of actual refueling operations before he left the refuel floor.

This, apparently,

was the extent of management

oversight over the resumption of

refueling for this event.

3.2

Adequacy of Short-Term Actions in Light of Previous Similar Events

The events of October 6, 26, 27, and 28, 1993, had all happened

before at SSES.

The AIT

assessed

that PP&L's root-cause evaluations for these earlier events, and the corrective actions

implemented, were inadequate

because

the same events recurred.

The AITdivided these past

events into three areas

as described

below.

The AIT's assessment

of PP&L's root-cause

analyses

and corrective actions for these events follows:

3.2.1.

Previous Events Involving Impact to the Mast/Grappled Components

Events of this type are safety significant because they can occur while irradiated fuel bundles

are being moved, or while components

are being moved over irradiated fuel bundles,

and

damage to irradiated fuel can result in significant radiation exposure.

Fortunately, none of the

impact events, reviewed by the AITat SSES, have involved irradiated fuel bundles.

However,

several other impact events have occurred at SSES in the past; these are listed in Attachment 4.

The AIT assessed

that PP&L's corrective actions for these past events were inadequate,

as

evidenced by their recurrence.

The AITfound that PP&L's corrective actions consisted mainly

of discussing the events in training, counseling the individuals involved, and adding procedural

precautions to the fuel handling procedures,

but PP&L did not investigate why personnel

had

made

mistakes.

The reviews for these

events

were performed

by the line organization

responsible for the operation, and were not subjected to independent review or other assessment,

The AIT cited the following as examples of inadequate

investigation and independence

of

review:

(1)

There

appeared

to be

no followup to an

operator's

statement

made

during the

investigation of an event that occurred

on April 13,

1989.

In an attachment

to the

significant operating occurrence

report (SOOR) issued for this event,

the following

statement was made by the operator involved: "When moving a double blade guide from

the fuel pool to the Rx I bumped the blade guide in the cattle shoot (sic) but it didn'

seem very hard compared

to some bumps I'e seen...."

The AIT interviewed the

individual concerning that statement and learned of the concern about double blade guide

impact in the fuel pool as described

in Section 7.2.

The AIT had heard this same

concern from another operator.

PP&L senior operations management

had never heard

of this concern until the AITtold it to them.

(2)

An SRO involved in an event that occurred on October 16, 1992, was asked to review

the event and report to operations

management.

His report, attached

to the SOOR

documenting this event,

stated that "this was an isolated event" and "procedures

are

adequate."

These same words appear in the final resolution to the SOOR, which led the

AITto question the true independence of the review, especially since several events of

this type had occurred in the past.

Further, this was the same individual, who, when

interviewed following Event 2, stated that he detected no impact when he ran the mast

into the transfer canal in October 1992. A more thorough and independent review at that

time might have elicited this fact and could have affected PP&L's response to Event 2.

3.2.2.

Fuel Bundle and Blade Guide Movement Errors

The AIT assessed

that the safety significance of these

types of events

is relatively low.

Placement of a fuel bundle or blade guide in an incorrect location in the fuel pool has no safety

significance.

However, placement of a fuel bundle in an incorrect coie location, and reactor

operation

in this configuration if undetected,

could damage

the fuel and

thus

has

safety

significance.

The AIT documented

numerous

instances of previous

occurrences

of bundle/blade

guide

movement errors.

These previous occurrences

are listed in Attachment 5 to this report.

In

reviewing PP&L's corrective actions to these events, the AITnoted that the actions usually were

directed toward training and counseling.

No concerted effort was made to look for ways to

improve the procedures or implement practices to prevent recurrence of the events,

The AITdetermined that this was due to a "mind set" that first appeared

in SOOR 2-88-091,

dated April 15, 1988.

In the section of the SOOR titled "Resolution and Actions to Prevent

Recurrence,"

the following statement appeared:

"In light of the measures

presently in place to

preclude a refueling error, combined with the inconsequential repercussions ofsuch an error due

to the plans being implemented, Reactor Engineering concludes that no further actions to prevent

recurrence are required." That same SOOR contained a quantitative analysis ofrefueling errors

which appeared

to accept that an average of 2 or 3 occurrences

out of 2000 component moves

during a core offload/reload was acceptable because the occurrences

were minor in nature and

the errors would likely be detected during Reactor Engineering verification.

This same thought process appeared again in a SOOR (1-89-127) dated April 13, 1989, in which

a Human Performance Evaluation System (HPES) report attached to the SOOR stated in part:

"The number of errors, 2 to 3, is acceptably low, considering the number of moves" and in

reference

to achieving a goal of zero defects

that "Zero defects

is a goal, but, as stated

previously, core offload or reload has been analyzed such that a minimal number of errors is

tolerable."

In the resolution section of the SOOR, Reactor Engineering stated that: "Allsteps

known to prevent errors have been taken and no further actions to prevent recurrence are known

or being taken."

Because ofthis mindset, the AITconcludes that operations management chose to accept not only

that these errors would occur during refueling outages but also that errors were acceptable.

PP&L's lack of effective corrective actions indicates this.

3.2.3.

Mast Damage Attributed to Unknown Causes

The AITnoted that PP&L performed excessive repetitive maintenance on the refueling masts.

This maintenance

history and the AIT's assessment

of PP&L's response

to the repetitive

maintenance are discussed

in detail in Section 7.5.

3.3

Final Actions, Taken Prior to Resumption of Fuel Loading

Afterthe AITconcluded its site activities, PP&L undertook an exhaustive review ofits handling

of these issues,

as well as an expanded review ofits handling ofsimilar issues involving human

error or design deficiencies.

PP&L developed

short, intermediate,

a'rid long-term corrective

actions to address its findings in these areas.

A public meeting was held in the Region I office

on November

18,

1993, in which PP&L managers

presented

their findings and plans for

resuming refueling operations to senior NRC managers.

Attachment 7 contains PP&L's slides

used at the meeting.

After the meeting, regional management

and the team members met again to discuss PP&L's

presentation.

On the basis of the information submitted, and after factoring in the AIT's and

resident inspector staff's independent reviews of the corrective actions, regional management

agreed that PP&L's actions were sufficient to resume refueling on November 19, 1993.

4.

Operator Training

The AIT determined that all refueling bridge operators

and refueling bridge supervisors

had

successfully completed the facilities refueling bridge training program and that the program was

adequate.

The AITreviewed the refueling bridge training program.

The program is described in facility

procedures

OP-O20, "Refueling Bridge Training and Qualification," and OP-O11, "Operator

Refuel Training." The program consists ofclassroom instruction followed by on-the-job training

conducted on the refueling floor. The classroom training is followed by a written examination.

The refueling bridge training was conducted about one month before refueling activities.

In

addition, several refueling bridge operators

had attended refueling bridge operations training

conducted by the General Electric (GE) Company at the GE training facilities in San Jose,

California, about a month before refueling activities were started.

5.

Fuel Handling Procedures

The AIT determined

that operator actions concerning refueling activities were contained in

procedures RE-081-032, "Refueling Operations," and OP-181-001, "Refueling Operations." The

AITverified that these procedures were present on the refueling bridge and in the control room.

The AITdetermined that the procedures concerning refueling activities were generally adequate

as far as the mechanics of fuel handling were concerned.

While there were precautions in the

procedures that addressed

confirmation of fuel bundle location and movement of the mast so as

to avoid contact with objects, the procedures were not proscriptive enough to prevent the human

errors which occurred.

Despite past occurrences of human error and recommendations

made

in 1986 on operation of fuel handling equipment,

the procedural

methodologies

remained

essentially unchanged until the occurrence of Event 3.

Section 7. of the report contains details on inadequacies

identified in certain fuel handling

equipment maintenance

and surveillance procedures.

The responsibilities ofthe Refueling Floor SRO and Refuel Bridge Operator during refueling are

contained in procedure RE-081-032 "Refueling Operations" Section 4. The AITconcluded that

the procedure adequately described the necessary responsibilities ofthe Refueling Floor SRO and

the Refuel Bridge Operator.

6.

Schedule, Staffing, and Overtime

The AIT,determined

that refueling activities were conducted

with sufficient numbers of

personnel

that PP&L did not have to use overtime.

The work schedule

during refueling

consisted of three hours on the refueling bridge and three hours elsewhere in the plant for the

Refueling Floor, SRO.

The Refuel Bridge Operators worked four hours on the refueling bridge

and four hours elsewhere in the plant.

7.

Maintenance/Surveillance

Issues

Identified During the Outage

Related

to the

Refueling Bridge Main Grapple (Mast)

The AITreviewed records of work authorizations for the plant refueling equipment, including

the bridge and main grapple (or mast).

The AIT found that PP&L had been performing

preventive and corrective maintenance,

applying appropriate priority to these activities.

Prior to commencing refueling activities, PP&Lperformed appropriate mechanical and electrical

pre-operational checks ofthe refueling bridge and its attendant equipment using procedures. MT-

081-001,"Refueling Platform (Mechanical Inspection)," and MT-081-002, "Refueling Platform

(Electrical Inspection)."

As required by technical specifications (TS), appropriate

tests of the

refueling equipment interlocks and liftingcapabilities were also performed using surveillance test

procedures SO-1(2)81-001, "WeeklyRefueling Platform," and SO-1(2)81-002, "Refueling Bridge

Main and AuxiliaryHoist." The AITnoted that PP&L encountered difficultyin calibrating the

load cell for the main mast.

A recent modification of the load cell necessitated

that a new

methodology be performed.

Prior to commencing

the refueling activities, this method was

conducted using an approved work plan in lieu of an approved calibration procedure.

The AIT

determined that the method was appropriate; however, use of a work plan was inconsistent with

normal calibration or surveillance activities performed by PP&L since the work plan had not

been reviewed by PORC nor approved by station management.

However, the work plan was

10

performed in accordance

with an approved work authorization,

and the load cell calibration

methodology

had received

a technical review by both electrical

maintenance

and

system

engineering before implementation.

Afterreviewing the events that occurred during the present

refueling outage, PP&L made a formal procedure change to the electrical inspection maintenance

procedure which formally adopted the steps in the aforementioned work plan into the procedure

to calibrate the various load cells used on the refueling bridge.

Subsequently, PP&L found that the surveillance procedures were inadequate because the portion

ofthe tests that demonstrate the interlock features ofthe bridge travel and reactor manual control

system (to prevent inadvertent insertion of a fuel bundle and simultaneous

withdrawal of a

control rod) failed to require special operator controls as stated in the'plant TS.

Specifically,

the surveillance test required placing the reactor mode switch in the run or startup/hot standby

mode; and the TS required that a second licensed operator or other qualified individual verify

that all control rods remained fullyinserted at that time. This second verification process was

not incorporated into the procedures and, therefore, the TS requirement was never met until the

present change.

During the current refueling outage, the AITdetermined that a number of maintenance-related

activities associated

with the fuel handling equipment were not fully adequate.

These issues

were also identified by PP&L during its concurrent investigations.

The AIT reviewed the

proposed corrective actions and found that PP&L was appropriately addressing

the root causes

of these issues as described below in Sections 7.1 through 7.4.

7.1

Installation of Non-Q Grapple

During core offload on October 4, 1993, the Unit 1 grapple began to leak air.

On October 5,

mechanical maintenance removed the grapple from the Unit 1 mast and replaced it with a spare

grapple that was available on the spare mast present on the refueling floor. This work was done

using a "generic" support work authorization (WAH20382) that was approved for maintenance-

supporting activities for refueling.

Mechanical maintenance

was aware that there had been a

quality control (QC) hold on the spare mast since it was non-Q; but found no hold tag on the

spare mast and assumed

that the matter had been resolved and the materials had been released

for installation.

Unknown to mechanical maintenance,

QC had removed the hold tag from the

equipment to ensure that the tag would not be lost on the refuel floor; and assumed

that any

work to install the equipment would require a specific work authorization that QC would review

and thereby ensure that the non-Q issue was appropriately resolved before use.

The AITwas concerned about PP&L's failure to adequately control materials not approved for

use.

Specifically, for this piece of equipment, it was subsequently

determined

by safety

evaluation on October 22, 1993, that the non-Q grapple was acceptable for use.

Before that,

on October 5, 1993, an operability assessment

was completed per Non-Conformance Report 0

(NCR)93-112 that concluded that the grapple could be used pending final resolution of the non-

Q issue.

However, the equipment had already been placed in service prior to an appropriate

11

operability determination or adequate

resolution of the QC hold on use.

PP&L has taken

corrective actions to prevent recurrence including: use ofa specific WA for this type ofactivity,

additional controls to prohibit release of components for use when under QC hold, and revision

to the Final Safety Analysis Report to change the design criteria for refueling equipment.

The

AITconsidered these corrective and preventive actions adequate.

The AITconcluded that better

interdepartmental communications and management oversight could have prevented this problem.

7.2

Failure To Perform Required Surveillance Test

After mechanical maintenance replaced the grapple on the Unit 1 refueling mast on October 5,

1993, a post-maintenance

operability test was performed to prove proper equipment function

prior to commencing fuel handling activities, As previously stated, the grapple repair work was

accomplished

per a generic support WA.

A work plan was developed

and included EFR

R40382, which specified that the post-maintenance

test would be SO-181-002.

Subsequently,

a discussion was held between operations,

maintenance,

and the refueling manager in which a

change was made to the post-maintenance

testing so as to perform SO-181-001 in lieu of SO-

181-002.

SO-181-002 is a more rigorous test of the equipment's

load lifting capacity and

confirms operability of the refueling platform (bridge), its respective hoist, and some of the

bridge interlocks also tested in SO-181-001, which tests the interlock features of the refueling

platform and reactor manual control system.

After completing the post-maintenance

test, refueling activities recommenced

at 3:40 a.m. on

October 5, 1993.

Approximately 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> later, after noting that the grapple was still not

"qualified," a decision was made to perform SO-181-002.

This test was then performed, at

which time the interlock feature that prevents bridge travel over the reactor vessel while control

rods are withdrawn was found inoperable (see Section 7.3).

PP&L has since determined that

because a load-bearing component had been changed, SO-181-002, which tests the load capacity,

should have been performed before commencing refueling activities.

As a result, PP&L failed

to adequately test the operability of equipment after maintenance.

PP&L has

proposed

several

corrective

and preventive

actions

including:

modifying the

surveillance procedures

to have a specific procedure for each refueling bridge hoist; assessing

the adequacy of guidance for post-maintenance

testing for the refueling bridge; and providing

specific work instructions and proper post-maintenance

testing for refueling bridge work. The

AIT considered

these actions adequate.

7.3

Bridge Travel Interlock Failure

It was determined by PP&L that while the bridge was technically inoperable due to failing the

surveillance

test

and

fuel-bearing

components

had

been

moved

during

that period of

inoperability, the interlock would have prevented bridge motion over the core if a real fuel

assembly had been grappled in the main mast.

The test weight used for the surveillance activity

weighs between 350 and 400 pounds (ib). Electrical maintenance found that the interlock reset

12

value, while acceptable,

was set too high (close) to the interlock setpoint.

This resulted in the

interlock resetting with the test weight still loaded on the mast.

Since fuel elements

weigh

approximately 600 lb, the interlock should have performed acceptably ifbridge movement had

taken place with a fuel element instead of the test weight. The problems encountered by PP&L

in demonstrating

the operability of the bridge interlocks indicates a weakness

in developing

appropriate acceptance criteria. This may require PP&L to take action to pursue changes to the

plant TS in order to have sufficient margin in the operability tests.

PP&L plans to revise the

operability tests and the TS, as necessary,

to support appropriate acceptance

criteria.

7.4

Summary of Concerns on Maintenance and Troubleshooting on the Mast

(1)

After completing a modification to the load cells on the refueling bridge, calibration

procedures were not formally updated and approved by station management prior to use

of the equipment, resulting in the use ofa "work plan" instead of a station procedure for

calibration.

Updating of station procedures

due to facility modifications should be

completed before using the equipment.

(2)

A "non-Q" component

(grapple)

was installed in a "Q" system

and used

to move

irradiated

fuel.

Positive separation,

identification, and control of nonconforming

components

should prevent such use such for activities that are important to safety.

(3)

A generic or supporting WA was

used

to perform corrective

maintenance

on the

refueling equipment.

Corrective maintenance activities on components that are important

to safety provides valuable failure and performance data, as well as an opportunity for

QA/QC to observe

activities that are important to safety.

Use of a generic WA

potentially results in lost valuable information on the work performed and the practices

employed.

(4)

Ineffective interdepartmental communications on the refueling floor twice resulted in less

than

acceptable

conditions.

The first involved the installation

(and

use) of the

nonconforming component (grapple) on the refueling mast, and the second involved the

change to the post-maintenance

test requirement following that same activity.

(5)

Insufficient

guidance

exists

for

determining

appropriate

post-maintenance

test

requirements for the refueling equipment.

This led to using the wrong post-maintenance

test following the replacement of the grapple.

(6)

Surveillance activities, especially those used to determine the operability of the refueling

bridge interlocks required by facilityTS, have acceptance

criteria that appear to be too

restrictive for the instruments and test weights being used.

The refueling bridge TS, the

facilityprocedures,

and the standards (weights) used to calibrate and test the operability

of the required interlocks should be reviewed to ensure that the appropriate acceptance

criteria are established and achievable and that all requirements of the "Refuel Mode" TS

are being met.

13

7.5

Review of the Maintenance History of the Refueling Bridge Main Grapple (Mast)

The AITreviewed prior maintenance activities on the refueling mast to ascertain ifuncorrected,

repetitive conditions were present.

On the basis of this review and discussions with PP&L staff,

it appeared

that PP&L had not treated the fuel handling equipment with the care and attention

commensurate with equipment used for the safety-related activity of fuel handling.

PP&L had not, until these recent events, tracked or trended any corrective maintenance for the

refueling platform and fuel handling equipment.

In addition, the'SOOR, NCR, EWR and WA

history files all contained valuable information regarding the repeated

failures of the main

grapple (mast); however, PP&L apparently did not use this information in an effort to better

understand

the root causes

of the problems

and

then determine

effective corrective

and

preventive actions.

The AIT was concerned

that PP&L had sufficient information at least in

1986 or early 1987 that should have led to corrective actions at that time, and that may have

prevented these repeated failures.

On the basis ofPP&L trends that were performed during the AITinspection, the refueling masts

have been bent, or similarly damaged, about 15 times at SSES.

By independent review, the AIT

was aware of 13 such events.

On each occasion, PP&L repaired or replaced the bent sections

ofthe mast.

When damage was caused by operator error, additional corrective actions consisted

of training and counseling the operators involved, as described in Section 3.2.

These actions

were generally ineffective.

Moreover, during interviews with both maintenance

and operations staff, it became evident to

the AITthat craft personnel were aware of, and expressed concern to station management about,

the ineffective corrective actions.

Further, maintenance personnel stated that the mast problems

were caused by the way operators performed refueling activities. Similarly, operations personnel

stated that the masts were "weak" or improperly maintained.

The AIT found no evidence that

these

concerns

were

known by senior

operations

managers

or effectively addressed

by

maintenance

managers.

In 1986, five masts were damaged or bent during two separate refueling outages.

PP&L was

concerned about the high frequency offailure, and coincident costs, and began investigation into

the causes

so it could determine how to make the equipment more reliable.

An independent

assessment,

conducted by GE, at that time indicated that the masts were failing as a result of

operator actions.

GE proposed corrective actions to PP&L that included better barrier controls

to prevent operators from accidently hitting the mast or carried loads into objects along the path

of travel.

New operator actions were proposed to minimize the wear of the mast by restricting

travel, both in terms of acceleration

and deceleration,

and by limiting the degrees of motion.

Atthe time, and until the present, operators were permitted to move the mast/refueling platform

in three directions simultaneously and at any speed.

While the 1986 recommendations

clearly

stated that one of the root causes

was due to impact, the recommended

corrective actions also

reduced the operational stresses

resulting from the unrestricted bridge/mast movement methods

14

used by the operators

during refueling.

As stated

earlier,

had PP&L implemented

these

recommendations,

additional similar failures in 1987, 1988, 1989, 1992, and 1993 could have

been prevented.

No basis was found for PP&L's failure to implement GE's recommendations.

As a result of the failures in 1986, PP&L attempted to improve the reliability of the mast for

critical path refueling activities.

PP&L established

a reliability task team to improve the

performance of the equipment.

This team attempted to quantify the reliability of the type of

mast/refueling bridge used at SSES and elsewhere in the industry and to compare that with other

possible designs.

A pilot barrier control system was studied; however, it was determined that

it was subject to a high rate of "downtime" due to high humidity on the refuel floor affecting

the system's processor.

The barrier control system was not pursued." Having compared

the

performance of different mast designs, it was not clear to PP&L that a modification to a

different type of mast would prove beneficial.

During the 1990-1991 period, the reliability of

the equipment seemed

to improve.

As a result, the activities of the reliability task team were

given a low priority.

To reduce the schedule and cost impact of fuel handling equipment failures during refueling

outages, PP&L made it a practice to have both refueling platforms ready during unit outages,

and for the last two outages,

stored a spare mast on the refueling floor in case it would be

needed.

Their history of mast problems apparently indicated that masts would be bent and

PP&L wanted to be able to replace them in a timely manner.

The AITwas concerned

that in

spite ofevidence available to PP&L regarding more effective corrective actions to prevent mast

failures, management,

by its inaction, condoned the practices leading to repeated failures of this

equipment.

7.6

Summary of Concerns on Maintenance History

(1)

Ineffective failure data trending forimportant-to-safety equipment resulted in management

not being aware that its expectations were not being met in the area ofcorrective actions.

In a memorandum

to various plant managers,

contained

in an EWR package

that

documented

the investigation of the 1986 mast failures,

management

clearly expected

that corrective actions recommended

by GE were to be implemented.

However, these

actions were not implemented and no formal mechanism existed to ensure feedback of

performance

data to management

to show the effectiveness

(or in this case the lack

thereof) of the actions.

(2)

PP&L management

should have been aware of the staff concerns regarding the repeat

failures of the refueling

equipment.

In addition, PP&L management

apparently

considered

the failures to be nothing more than a financial loss, due to lost time on

critical path, rather than indicative of a potential concern of safety significance.

15

7.7

Potential Generic Concerns

While there are a number of potential causal

factors,

the AIT considered

that two failure

mechanisms of the mast bending/binding problems are highly probable.

The most likely cause

is either striking an object while in transit or movement of the bridge while the grapple is still

engaged

to a load that has been seated in its respective core or spent fuel pool location.

The

second likely cause is excessive moment forces caused by drag and unusual wear of the bearing

points, causing the structure to become

less rigid, and resulting in subsequent

failure with

continued use.

7.7.1

Operational Concerns

Preliminary AITinspection findings indicated that the vendor stress analysis is bounding only

for specific conditions, such as movement of the mast in the "X" or "Y" directions with a fuel

assembly load in the normal up position.

However, vendor-supplied information on the use of

the equipment does not specifically prohibit different operations, such as simultaneous movement

in three directions or fast acceleration/deceleration

while the mast is extended either loaded or

unloaded.

In addition, vendor-supplied training information on refueling operations also does

not specifically prohibit certain types of operations nor does it specify design restrictions or

limitations.

On the basis of this information, the AIT identified the following three potential operational

concerns:

(1)

acceptability of simultaneous three direction motion

(2)

acceptability of "fast" acceleration or deceleration with the mast fully extended

(3)

acceptability of the drag forces when moving double blade guides

PP&L surveyed the industry regarding the experience of refueling equipment failures.

PP&L

found that while this information is hard to find, other utilities have also experienced

similar

failures; although, not to the extent ofSSES.

PP&L also found that some utilities have very few

such problems.

The plants with better performance records had one or more of the following

attributes:

(2)

(3)

(4)

some form of boundary protection, either by electrical interlock or through operational

procedure limitation on movement

short shifts for operators performing fuel maneuvers

(1.5 to 3 hr.)

, significant pre-outage preventive maintenance inspection program for the bridge and mast

fuel moves performed by a dedicated team or contractors

This information is still preliminary in nature.

At the conclusion of the inspection, PP&L was

still engaged in extensive engineering discussions with the refueling equipment vendor.

16

V.7.2

Design Concerns

The design of the spent fuel pool at SSES and its storage cells results in inadequate clearance

between the bottom ofa double blade guide suspended from the grapple at its normal up position

and the top of the bail handles for stored double blade guides.

This results in obstructions in

the spent fuel pool that can be accidently struck during refueling operations.

This can result in:

(1) bending the mast; (2) damage to the load that could cause a loss of debris into the reactor

vessel;

(3) or bent blade guide handles,

which could result in improper grappling and a

subsequent drop of the load onto fuel or interference with the proper insertion of a fuel bundle

into a fuel cell in the core.

Although the apparent damage to equipment at SSES is limited to

bent masts, possibly bent double blade guide bail handles, and superficial marks on the reactor

vessel wall and the reactor vessel flange protector due to impacts, it appears fortuitous that no

irradiated fuel has apparently been damaged,

according to PP&L records.

8.

Human Factors Issues

During the inspection, the AITidentified several instances in which human factors issues played

a role in the events.

These

included

concerns

on coordination of refueling

tasks

and

communications between the operators,

and operation of the refueling equipment.

A summary

of issues identified is contained in Attachment 6 to the report.

9.

Safety Significance and Management

Oversight and Control of Fuel Handling

Activities

Refuelings

are

relatively infrequently

performed

activities

which involve unusual

plant

conditions, potentially significant radiation exposures,

the opportunity to introduce. foreign

material into vital reactor plant systems,

and the need for well-defined and well-coordinated

responsibilities among several organizations.

As such, refueling operations constitute a safety-

significant activity, with the concomitant responsibility that it be treated

as such by plant

management

and personnel.

In reviewing PP&L's response

to previous events,

the AIT noted that some

areas of fuel

handling activities had not been treated

as safety-significant operations.

The AIT observed

repeated

instances where past evaluations stated "no safety significance"

or "increased outage

time" as the consequence

of the event reviewed.

In reviewing PP&L's response

to repeated

maintenance or replacement of bent mast sections, PP&L appeared to be more concerned with

economic factors (i.e., maintaining the timeliness of core offload/reload) than in treating the

problem as one affecting a safety-significant activity. The most telling evidence of this was the

fact that for recent refueling outages, PP&L routinely kept a spare mast on the refueling floor

in response

to the history of mast problems and the expectation that the spare would probably

be needed.

Although a contractor was hired to review mast bending problems in 1986, the

contractor's recommendations

for reducing wear and tear on the refueling equipment were not

implemented by PP&L.

17

The AITconcluded that operations management's

oversight of fuel handling activities was weak

and their failure to take more rigorous corrective actions from previous events allowed them to

reoccur.

Senior operations management

has always delegated oversight of these activities to the

refueling floor SRO.

The Operations Manager stated that this decision was made under the

belief that having a higher management

presence

on the refueling bridge would distract the

operators from their duties. However, while the desire to reduce distractions was commendable,

senior managers did not hold their people accountable,

nor communicate with them, so senior

managers

remained

unaware of concerns

and practices

known at the working level.

For

example,

senior

operations

managers

stated

they

had

never

heard of complaints

from

maintenance

personnel that fuel handling equipment problems were caused by the manner in

which operators were operating the equipment, yet many operations personnel at the level of

shift supervisor and lower were aware of this complaint.

Senior managers were unaware of the

fact that double blade guide handles could be hit when moving double blade guides in the spent

fuel pool, although this fact was learned from two operators during the AITinterview process.

Lastly, human performance problems during fuel handling operations have repeatedly occurred

over the years, yet operations management

oversight of these activities remained unchanged.

Other examples of the lack of senior operations management

oversight included:

(1) a PCAF

which was supposed

to be issued within a day after Event

1 was not issued until 12 days later,

a fact which the AITidentified to the operations senior managers;

and (2) a Shift Supervisor

assigned to observe and report back on refueling activities following Event 3 only observed 20

minutes of refueling activities before he left the refuel floor. The AITconcluded that this was

an inadequate amount oftime to verify the effectiveness ofprocedure changes implemented after

Event 3.

~

~$ REgy

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Nos.

50-387

MEMORANDUMFOR:

FROM:

SUBJECT:

UNITED STATES

NUCLEAR REGULATORY COMMISSION

REGION I

475 ALLENDALEROAD

KING OF PRUSSIA, PENNSYLVANIA19406-1415

October 29,

1993

Richard W. Cooper, II, Director, Division of Reactor Projects

Thomas T. Martin, Region Administrator

AUGMENTEDINSPECTION TEQvfCHARTER FOR REVIEW

OF REFUELING ACITVITIESAT SUSQUEHANNA

Over the last two weeks, multiple problems have been encountered during refueling operations

at Susquehanna Unit 1 involving fuel handling equipment.

Because the cause(s) of these events

is uncertain, there were repetitive instances of problems,

and there may be possible generic

implications, I have determined that an Augmented Inspection Team (AIT)inspection should be

conducted to review and evaluate the circumstances,

safety significance, and generic implications

that are associated with these problems.

The NRC staff needs to fullyunderstand the cause(s)

of these events and determine whether further actions willbe required.

This is consistent with

AITselection criteria 05.02, b, c, e and fin NRC Inspection Manual 0325.

Accordingly, the DivisionofReactor Projects (DRP) is assigned the responsibility for the overall

conduct of this Augmented Inspection.

Rob Temps, Project Engineer, DRP, is appointed as

Augmented Inspection'Team Leader (Other AITmembers are identified in Enclosure 2). The

Division of Reactor Projects

(DRP) is assigned

the responsibility for resident and clerical

support, as necessary;

and the coordination with other NRC offices, as appropriate.

Further,

the Division of Reactor Projects is responsible for the timely issuance of the inspection report,

the identification and processing

of potentially generic

issues,

and

the identification and

completion of any enforcement action waiTanted as a result of the team's review.

Enclosure

1 represents

the charter for the Augmented Inspection Team and details the scope of

the inspection.

The inspection shall be conducted

in accordance

with NRC Management

Directive (MD)8.3, NRC Inspection Manual 0325, Inspection Procedure 93800, Regional Office

Instruction 1010.1, and this memorandum.

Thomas T. Martin

Regional Administrator

Enclosures:

1.

Augmented Inspection Team Charter

2.

Team Membership

Richard W. Cooper, II

cc wlencls:

J. Taylor, EDO

J. Sniezek, OEDO

T. Murley, NRR

J. Partlow, NRR

J. Calvo, NRR

C. Rossi, NRR

L. Nicholson, Acting PD I-2, NRR

F. Miraglia, NRR

C. McCracken, NRR

F. Rosa, NRR

W. Russell, NRR

J. Richardson, NRR

A. Thadani, NRR

.

B. Grimes, NRR

J. Roe, NRR

E. Jordan, AEOD

D. Ross, AEOD

V. McCree, OEDO

W. Kane, DRA, RI

R. Cooper, DRP, RI

W. Lanning, DRP, RI

J. White, DRP, RI

W. Hehl, DRSS, RI

S. Shankman, DRSS, RI

S. Barber, SRI, Susqeuhanna

J. Stone, PD I-2, NRR

C. Sisco, DRS, RI

I.. Bettenhausen,

DRS, RI

W. Hodges, DRS, RI

E. Wenzinger, DRP, RI

K. Abraham, PAO, RI

M. Miller, SI.O, RI

ENCLOSURE 1

AUGMENT%) INSPECTION TEAM (AIT) CHARTER

The general objectives of this AITare to:

Review and evaluate the adequacy of the licensee's corrective measures,

in concert with

Region I management,

prior to agreeing to resumption of refueling activites

2.

Conduct a thorough and systematic review of the circumstances

surrounding each of the

refueling events which have occurred since October 1, 1993, and develop a detailed

seqqence of events for each occurrence.

3.

Collect, analyze,

and document relevant factual information to determine the causes,

conditions, and circumstances pertaining to each event.

Review qualifications of the refueling operators and training they received on refueling

operations.

5.

Evaluate the licensee's review ofand response to each event and implemented corrective

actions, as well as their plans for resumption of refueling activities.

6.

Review and assess the adequacy oflicensee s refueling, surveillance, and test procedures

as they existed before these events; and review and assess

the changes recently made in

these procedures.

'I

7.

Evaluate

the licensee's

procedures

regarding

SRO and RO responsibilities

during

refueling operations.

8.

9.

Determine ifthere are any generic implications that should be considered for further

review or evaluation by the NRC staff.

Determine the adequacy of management oversight and control of refueling activities.

10.

Assess

the

safety

significance of each

event

and

communicate

to Regional

and

Headquarters

management

the facts and safety concerns related to problems identified.

Prepare

a report documenting the results of this review for signature of the Regional

Administrator within thirty days of the completion of the inspection.

ENCLOSURE 2

AITMHHBKRSHIP

Robert Temps, AITLeader, Project Engineer, Division of Reactor Projects (DRP), Region I

(Rg

Robert Summers,

Assistant AITLeader, Project Engineer, DRP, RI

Carl Sisco, Operations Engineer, Boiling Water Reactor Section, OB, Division of Reactor

Safety, RI

David Desaulniers,

Human Factors Assessment

Specialist, HHIFB, NRR

Scott Morris, Reactor Engineer, DRP, RI

Other NRC personnel,

consultants, or contractors willbe engaged in this AIT, as needed.

ATTACHMENT2

PERSONS CONTACTED

Pnn

lv

i Pwr

Liht

C. Boudman, Jr.

R. Byram

K. Chambliss

T. Dalpiaz

A. Dominguez

A. Fitch

T. Gorman

R. Heim

G. Jones

D. Karchner

J. Kenny

G. Kuczynski

V. Kelly

R. Lengel

D. Marinos

T. Markowski

K. Mattern

D. McGann

J. Miltenberger

L. O'eil

H. Palmer

D. Roland

D. Roth

A. Sabol

R. Saccone

H. Stanley

H. Woodeshick

P. Zabawa

Asst. Foreman, Mechanical Repairs

Senior Vice President - Nuclear

Supervisor, Maintenance Production/Outage

Manager, Nuclear Maintenance

NSAG Site Supervisor

Operator Training

Senior Engineer, Systems Analysis

Senior Quality Control Specialist

Vice President - Engineering

Power Production Engineer

Supervisor, Nuclear Licensing

Manager, Nuclear Plant Services

Sr. Maintenance Project Eng., Maintenance Technology Group

Project Engineer, Nuclear Steam Supply Systems

Senior Nuclear Plant Specialist

Supervisor, Dayshift Operations

Supervisor, NSS Maintenance

Supervisor, Nuclear Compliance

Manager, Nuclear Safety Assessment

Special Assistant, Sr. Vice President - Nuclear

Manager, Nuclear Operations

Operations Shift Supervisor

NSSS Supervisor, NSE

Manager, Nuclear Quality Assurance

Manager, Nuclear Systems Engineering

Vice President, Nuclear Operations

Special Assistant to the President

Electrical Maintenance

ene

1 Electric

D. Rousal

Senior Engineer

ATTACHMPfT3

DETAILEDTIIVKLINESFOR EVENTS 1 THROUGH 4

Unit 1 reactor shutdown.

Refueling outage commenced.

+1~/1 Q

Surveillances SO-181-001 (Weekly Refuel Platform Operability) and SO-181-002

(Unit

1 Main/Aux Hoist Operability) completed

satisfactorily on the Unit

1

refueling bridge.

2117

Core offload commenced with the Unit 1 refuel bridge.

Mtt94L92

Unit 1 refuel mast grapple developed an air leak. A spare, "non-Q" grapple was

installed on the mast as a replacement (NCR 93-112 had been initiated previously

to make the component "Q").

The spare grapple had been pre-staged

on the

refuel floor prior to the start of the outage.

(See Section 7.0.)

0320

Completed a partial SO-181-001 surveillance (i.e., did not perform the Control

Rod Out & Bridge Travel Interlock test) on the repaired Unit 1 mast.

0340

The bridge operator was "uncomfortable" with the refuel bridge mast because SO-

181-002 was not conducted as post maintenance testing, so he grappled and lifted

the 1200 pound test weight to verify mast integrity before continuing fuel moves.

Defueling operations were then resumed.

0826

Stopped defueling to accommodate

a manual scram in support of CRD activities

under the reactor vessel.

Surveillance procedure

SO-181-002 was performed

because of questions raised about the operability of the Unit 1 mast after the new

grapple was installed.

1500

Unit 1 mast failed SO-181-002 when the interlock which prevents bridge travel

over the core with a load on the mast and with a control rod withdrawn one notch

failed.

Operators

prevented

actual movement over the core.

Maintenance

personnel were called in to troubleshoot.

(See Section 7.0.)

AIN683

Electrical Maintenance personnel recalibrated the load cell on the Unit 1 bridge

hoist.

Surveillance SO-181-002 complete.

0115

0220

Surveillance SO-181-001 complete.

Resumed fuel offload.

0744

K

NT

1: A peripheral bundle was incorrectly removed from core location

31-56 (vice 29-55, adjacent to 31-56).

Contrary to procedural

requirements

(Precaution 6.2.1 ofOP-AD-107), the bundle was returned to its original location

in the core after the SRO on the bridge received direction from the outage

supervisor to place it there.

The bridge SRO was under the assumption that the

outage

supervisor's

decision

had

the concurrence

of the reactor

engineer.

However,

due

to miscommunication

by the outage

supervisor,

the reactor

engineer thought the bundle had already been placed back in the core and he

stated that he was going to check procedures to see ifany requirements had been

violated as a result ofplacing the bundle back in the core.

The outage supervisor

thought he had permission from the reactor engineer to place the bundle back in

the core and relayed this to the bridge SRO. The Shift Supervisor was not aware

of any of these activities until after the fact, although by procedure,

he is

responsible for directing fuel handling activities.

1033

Defueling resumed following corrective actions by operations management.

M/99LB

0113

Core offload completed.

ML22K

1755

Completed surveillance procedures

SO-181-001

and SO-181-002 on the Unit 1

refuel bridge.

ML22l93

0737

Commenced core reload.

=0950

While moving the unloaded refuel bridge from the reactor cavity to the spent fuel

pool, the mast grapple head contacted the reactor vessel flange protector, bending

the mast (deterinined by PP&L 1 week after the event) causing a "Fault Lockout"

on the bridge and leaving a distinct scrape marking on the reactor vessel flange

protector.

Operators were unaware of the cause of the lockout: the lockout was

reset and refueling continued.

1008

~NT:

D

U* * Rl

• ,

Ill

1

g.*f lb

dl

location

13-48,

a 10-inch

section of the telescoping

mast

"hung up" and

subsequently dropped 10-15 inches.

Operators stopped lowering the mast at 375

inches and verified that there was no slack cable alarm p'resent (i.e., the bundle

itselfdid not move during the event).

Operators on the bridge checked the bundle

and core top guide for interference, then lowered the fuel bundle into its intended

location. The operators then moved the mast to a defueled region of the core and

attempted to recreate the event by extending and retracting the mast.

On the third

cycle of the mast, the condition was reproduced.

The operators

reported the

incident to the Shift Supervisor and fuel handling activities were suspended.

=1100

Mechanical

maintenance

personnel

identified a bend

in the mast following

inspection of it. Maintenance recommended

the use of the Unit 2 bridge for the

completion of refueling.

ML2ZLM

0630

0850

Surveillances SO-181-001 and SO-181-002 completed on Unit 2 bridge.

Commenced refueling with the Unit 2 bridge.

1538

EVENT¹: A double blade guide (removed from core locations 37-22 &39-

24) impacted the pressure vessel wall during its movement from the core to the

fuel pool. Just prior to impact, the SRO on the bridge realized that the mast was

not raised high enough for the blade guide to pass through the transfer canal

(grapple height was 150 inches which is satisfactory for mast movement without

a load attached).

The bridge was stopped (and its direction actually reversed)

prior to the mast impacting the wall, but the momentum of the blade guide

allowed it to swing forward and strike the vessel wall. The mast was then raised

to the proper height and the blade guide moved to its intended location in the fuel

pool.

1945

Mechanical Maintenance

personnel

conducted

a visual inspection of the mast

using a video camera

and identified a distinct "bow" in the 10-inch section;

however, they did not identify any contact/friction points or other observable

damage.

The mast was cycled up and down several times without any abnormal

indications.

The 1200 pound test weight was lifted to ensure

mast structural

integrity. After concurrence by operations and maintenance personnel,

the mast

was cleared for use.

The vessel wall was also inspected using the video camera

and no non-conforming conditions were noted.

2349

Resumed fuel reload after plant management

modified the refueling procedures

(e.g. requiring the mast to be fullyraised prior to moving the bridge between the

reactor cavity and the fuel pool, raising the mast in "slow" speed only) and

implemented other short term corrective actions.

ML2E93,

0231

Refueling operations were suspended

when operators were unable to seat a fuel

bundle in core location 13-24 due to interference from a bent blade guide handle

in the adjacent cell.

The fuel bundle was returned to the fuel pool at position

DD-29 per reactor engineer direction.

The interfering double blade guide (in positions 13-22 and 15-24) was moved to

the fuel pool.

Refueling operations resumed.

0707

2 more bundles moved into the core (within 9 minutes).

0710

EVENT

4: While lowering the mast in preparation for grappling a new fuel

bundle in the fuel pool, one of the telescoping mast sections "hung up" and then

suddenly dropped. A large amount ofbubbles were observed in the pool for 5-10

seconds followingthe event. Final mast conditions indicated a normal air system,

mast position of 206 inches, load cell reading of 193 pounds, and no slack cable

alarm.

No radiation alarms were received.

Refueling operations were stopped.

Inspection of the mast revealed

that the 10-inch section

was bent,

(PP&L

subsequently determined that the cause of this event was due to weakening of the

mast from EVE%I'

and subsequent

mast weakening and eventual bending from

hydrodynamic forces on the mast as a result of rapid bridge movements.)

Preparations were made to replace the mast on the Unit 1 bridge in order to ready

it for refueling.

1130

The SSES Vice President - Operations directed a halt to'fuel loading pending the

completion of an'vent

Review Team

investigation

and implementation of

comprehensive corrective actions.

1700

The previously

damaged

Unit

1

mast

was

removed

from its bridge.

By

agreement with Region I management,

PP&L agreed to curtail further refueling

activities.

~1/2

$Q

1200

NRC Augmented Inspection Team arrived on site.

ATTACHMENT4

PREVIOUS IMPACT EVENTS AT SSES SINCE 1984

(1)

3/29/84; Unit 2: A fuel bundle hit the transfer canal ("cattle chute"). PP&L attributed

the root cause to one oftwo possibilities; slippage of the fuel hoist or a stuck downbutton

on the hoist.

The bundle was inspected,

no problems

were noted,

and no other

corrective actions were taken beside maintenance activities.

(2)

3/31/84; Unit 2:

An operator forgot to retract the hoist after releasing

a blade guide.

The bridge was moved and the mast was bent when the grapple caught on a blade guide

bail handle.

Cause of the event was attributed to the operator's

overzealousness

and

inexperience.

Corrective actions comprised improving training and ensuring that any

operator moving fuel for the first time would be supervised by someone who had actual

fuel handling experience.

(3)

3/22/86; Unit 1:

The mast

experienced

binding while lowering

a fuel bundle.

Maintenance

determined

the binding was due to an "external force" which bent the

sections.

The mast was replaced with Unit 2's mast.

No explanation of the "external

force" was given, nor did the SOOR issued for this event address or explain what the

force was. (See Section 7.)

(4)

4/13/89; Unit 1:. Operators were unable to release a double blade guide from the hoist.

The blade guide had to be physically pried from the grapple.

The cause was attributed

to a bent bail handle.

Before this event, the bridge operator had banged the blade guide

into the transfer canal.

The SOOR for this event stated that how or when the handle was

bent could not be determined.

The SOOR discounted the impact as the cause for the bent

handle.

(5)

10/16/89; Unit 2: An operator was heading for the transfer canal when he realized his

Y coordinate was wrong.

He stopped bridge movement and moved the mast in the Y

direction.

However, he ran the mast into the side railing of the chute and damaged

the

mast.

Root cause was attributed to the operator being tired and anxious for turnover and

inattention to detail.

Corrective actions were administrative in nature.

(6)

10/16/92; Unit 2:

The mast was damaged

when it contacted the transfer canal.

The

bridge was being moved to the spent fuel pool.

The root cause

was attributed to

inattention to detail.

The SOOR for the event stated that it was an isolated instance.

ATTACHMI<2lT5

BUNDLE/BLADEGUIDE MOVEMENTERRORS

The following history of bundle/blade guide mis-manipulations

was compiled from various

SOOR's.

SOOR numbers appear in parentheses.

m r2

1

2-

1

EVENT:

Fuel bundle found in incorrect position in the core.

CAUSE:

Operator error.

ACTION:

Incorporate lessons learned into training before the next outage.

S

tern

r 27

1

7

1- 7-27

and 271

EVENT:

CAUSE:

ACTION:

3 double blade guides removed from wrong location.

Failure to follow procedure; operator error.

Issued management letter to all licensed operators.

EVENT:

CAUSE'CTIO¹

Fuel bundle removed from wrong location in the core.

Failure to follow procedure;

operator error.

Issued management letter to all licensed operators.

A

11

1

2- -1

EVENT:

CAUSE'CTION:

Wrong fuel bundle placed in the core.

Operator error.

Incorporated lessons learned into operator training; purchased

a new "sight box"

to aid in peripheral vision; Reactor Engineering revised RE-TI-004 (to provide

copies of all changes

to the core component movement sheets to Operations

so

that it can trend the number of mispositioning occurrences).

1-

-127

EVENT:

CAUSE'CTION:

Fuel bundle placed in wrong location in the fuel pool.

Operator error.

Essentially none. In the SOOR analysis, Reactor Engineering stated that all steps

known to prevent errors were taken and no further actions were needed to prevent

recurrence.

m

r

1

1

2-

-12

EVENT:

Wrong fuel bundle moved during core reload.

CAUSE:

Operator error.

ACTION:

Counseled operators.

7

EVENT:

CAUSE:

ACTION:

Moved fuel bundle without verifying all initial conditions.

Operator error.

Address

in

operator

training;

Enhanced

procedures

regarding

suspending/reinitiating

fuel movements.

2

1

2

1- 2-

EVENT:

CAUSE'CTION:

3 fuel bundles found in wrong position in the fuel pool.

Lack of attention to detail; operator error.

Verified accuracy of position counters; permanently label trolley beams.

ATTACHMENT6

HUMANFACTORS CONCERNS

1.

COMMUNICATIONS

During Event I, the operators'esponse

to an incorrect fuel bundle being pulled from the core

was compromised by a communication error between

the outage supervisor and the reactor

engineer.

The reactor engineer understood that an incorrect bundle had been removed from the

core, and replaced in the core, in its original position.

In reality, the bundle had not yet been

returned to the core.

As a result, the reactor engineer did not state that the bundle should not

be replaced in the core. The outage supervisor believed that he had communicated to the reactor

engineer that he intended to return the fuel bundle to that location from which it had been

removed.

In the absence ofreceiving any prohibition from the reactor engineer concerning this

action the outage supervisor directed the fuel to be returned to the core.

The SRO on the bridge in charge ofrefueling activities, having recognized that an incorrect fuel

bundle had been withdrawn from the core, terminated the fuel movement and communicated to

the control room his recommendation

that the fuel be placed in a location in the fuel pool that

had been reserved for placement of fuel in emergency conditions.

When the outage supervisor

directed

the fuel to be returned

to the location within the core from which it had

been

withdrawn, the SRO understood this decision to have been made based upon consultation with

Reactor Engineering and as a result he did not question the decision.

2.

OPERATOR VIGILANCE

Interviews with operators

involved in the four events

revealed

that the majority of. these

individuals described their refueling bridge duties as "boring" and "monotonous."

Although

reflecting

a professional

attitude regarding

their responsibilities,

most of the individuals

interviewed indicated that they generally did not look forward to assignments on the bridge. The

novelty and enjoyment of working on the bridge quickly was supplanted by boredom, and it

became difficultto maintain the level ofconcentration required by the task. In contrast, a small

minority of the operators

interviewed stated that they enjoyed refueling bridge assignments.

Most of the interviewees indicated that they had been assigned

to refueling bridge activities.

Many of them also indicated that they would like refueling bridge assignments

to be voluntary.

The opinions of the individuals regarding refueling activities did not appear to be affecting the

professionalism

of the staff in completing

refueling activities.

However,

the boredom

experienced by the operators

can be a direct precursor to lapses in attention.

Whereas

lapses

in attention due to the repetitive nature of the task did not appear to be causal factors in these

recent events, such lapses in attention can be reasonably expected to degrade the performance

of the operators in conducting refueling activities.

3.

WORK SCHEDULES

Many operators noted that the length of time that individuals were assigned to refueling bridge

operations had been decreasing in recent years and that during the current refueling outage Ros

were assigned to be on the bridge for two 3-hour stints during their 12-hour shift. Time offthe

bridge was considered

rest periods.

SROs are now assigned 4-hour stints on the bridge.

The

reduced number of consecutive hours on the bridge was viewed positively by the individuals

interviewed, considering their views concerning the repetitive nature of the job.

4.

HUMANSYSTEM INTERFACE

The inspector examined the refueling bridge controls while the bridge was under quarantine and

consequently not operating and displays not illuminated.

The inspector interviewed an RO and

SRO on the bridge regarding their tasks during bridge operations,

and

the controls

and

indications used to perform these tasks.

4.1

Uncontrolled Operator Aid

The inspector observed a placard hung at the controls ofthe refueling bridge which had numbers

written in grease pencil that gave the operators information, including mast height required for

clearing the transfer canal with no load on the mast,

and mast extension

points at which

operators need to slow down. However, derivation and controls on the use of this operator aid

could not be determined.

4.2

Team Work

Events 2 and 3, and an event from the 1992 Unit 2 refueling outage (SOOR 2-192-127) in which

the mast struck the flange protector, all demonstrated

inadequate team work. In these cases, the

SROs

were performing activities related

to fuel movement,

but failed to provide timely

verification that the Ros were operating the bridge and mast clear of obstructions.

4.3

Task Design/Equipment Configuration

Events have occurred while using the other unit's refueling bridge. For example, a Unit 2 1992

refueling outage event (SOOR 2-192-127) involved the Unit 1 bridge "backing" into the transfer

canal with the mast extended.

Using the bridge of the opposite unit for fuel movement activities results in the operator

"backing" a bridge from the reactor vessel into the transfer canal.

As a result, operators turn

their attention from the mast (Z coordinate) to verify proper X and Y coordinate alignment with

the transfer canal.

Consequently,

such configurations increased

the probability that the bridge

operator

could lose track of mast

status

and approach

the transfer

canal with the

mast

inadvertently extended.

A GENDA

PPdkL/NRC IVD&AGKMKNTMEETING:

FUEL HANDLINGAIT

November 18, 1993

1VRQMGEMENTPERSPECTIVE.......

R. G. Byram,

LESSONS LEARNED/

CON%ECTIVE ACTIONS ..........

H.G. Stanley

SUMMARY ......................

R. G. Byram

MANAGEMENTPERSPECTIVE

The NRC AIT provided a valuable independent

perspective.

Recurring problems with fuel handling practices

have caused us to examine the effectiveness of our

assessment

and corrective action programs.

We'e

completed

a

comprehensive

review

to

identify issues and take corrective actions.

Short term corrections, including generic issues,

have been implemented.

Intermediate

(by March,

1994

Unit

2

RFO)

corrections

have

been

identified

and

are

in

progress.

~

A long term evaluation ofthe broader implications

is being performed.

We are confident that the results will be effective

for the long term, and as a result will strengthen

our organization.

MANAGEMENTPERSPECTIVE

PPd'cL has a strong record regarding the resolution of

issues

related

to

the

design

and

operation

of

Susquehanna.

We

take

aggressive

measures

where

safety

is

challenged.

Our people do high quality work

Our management

is involved.

MANAGEMENTPKRSPKCTA"E

PPckL

recognizes

that

our

actions

have

been

ineffective in resolving long standing problems with

fuel handling activities.

The

individual

events

had

broader

safety

implications.

Our actions were inconsistent with our phi1osophy

on shutdown risk.

We did not provide our people with the tools they

needed to succeed.

We have not met our values in this area; we are changing

our standards.

MANAGEMENTPKRSPKCTA'K

The duration ofa refueling outage is defined by the

time it takes to ensure the safe performance of all

activities and safe operation for the next cycle.

Questioning attitudes will ensure safety remains

'our top priority.

Reinforcement of this expectation

is a required.

response to the internally driven pressure of highly

motivated people.

Management must lead by example, listen, and be

vigilant

to

ensure

that

critical

path

never

supersedes

safety.

MANAGEMENTPERSPECTIVE

'PPckL

is

taking

aggressive

actions

to

resolve

identified problems, and to continue to assess

the

broader implications.

We have analyzed the information both specifically

and generically.

Short

term

corrective

actions

have

been

implemented that address both the specific events

and their commonalities.

Intermediate

and longer term actions have been

identified.

Independent,

outside insight will be sought and

utilized.

R.G. BYRAM

Senior VP Nuclear

H.G. STANLEY

VP - Nuclear Operations

A.R. SABOL

Manager - Nuclear

Quality Assurance

G.J. KUCZYNSKI

Manager-

Nuclear Plant Services

J.R. MILTENBERGER

Manager - Nuclear

Safety Assessment

~ Verification Of Actions

~ NQA Performance

~ Refueling Floor Management

~ Event Commonalities

~ Station Culture

~ Department Culture

~ Self Assessment

~ Department Response to NRC AIT

~ NSAG Performance

MANAGEMENTPERSPECTA

"E

LESSONS LEAEUVED

~ Clearly set forth management

expectations.

~ Solve recurrent problems

~ Preserve

and

enhance

strong

Susquehanna

safety

culture.

October 6, 1993

Core Offload Error

October 26, 1993

Unit 1 Refueling Bridge Mast

Non-Load Bearing Telescoping

Section Dropped

October 27, 1993

Double Control Rod Blade Guide

Impacted Vessel Wall While Being

Moved

October 2S, 1993.

DifficultyExperienced With Aligning

Fuel Bundle In Core

Unit 2 Refueling Bridge Mast

Non-Load Bearing Telescoping

Section Dropped

V.P.- Nuclear Operations Stopped

AH Refueling Activities

(Later, Same Day) AITAnnounced

By NRC Region I With

Confirmatory Action Letter

EATTSTIGA2VONAl'G)ANALFSIS

~

Seven Event Reviews

~

Station Management Review Of Each Event

~

NSAG Assessments During Event Reviews

h

~

Management Review Teams

Management Of Refuel Floor

Look For Commonalities With Other Station

Operating Events

Station Culture

Department Culture

Effectiveness Of Self-Assessment

REFUELING OPERATIONS HISTORICAL

PERSPECTEVE

~

Several

Previous

Occurrences

Of Bent Mast

Assemblies At Susquehanna

~

Higher

Frequency

Of

Occurrences

At

Susquehanna

Compared To Industry

~

Each Event By Itself Was Not Judged

To Be

Significant

Incomplete Determination Of Root

Causes

Did Not Identify Adverse Trends

Generic Implications Not Assessed

BASICROOT CAUSES

~

Management Oversight

Command and Control

Structured

Monitoring Of Fuel

Handling

Activities

Followup On Corrective Actions

Communication Of Management Expectations

Self Assessment

~

Procedures

Design Limitations/Operating Constraints

OffNormal Procedure

Comprehensiveness

(Operations

And

Maintenance)

User Friendliness

BASIC ROOT CAUSES (continued)

~

Training

Consistency With Management Direction And

Expectations

Monitoring

Significance Of Refueling Activities

~

Culture

Threshold For Taking Management Action

Acceptance Of Human Error As Root Cause

Without Further Inquiry

Perception Of Expectations For Critical Path

Activities

Integrated Management

Structure For 'Refuel

Floor Activities

Follow-Up On Implementation Of Corrective

Actions

'

COKRF<CTEVEACTIONS

~

Near Term (Prior To Commencing

Unit

1 Core

Reload)

~

Intermediate Term (Prior To Unit 2 6th Refueling

Outage - March '94)

~

Long Term

)VEER TERiVCOEREC17VE< ACTIONS

MANAGEMENT

~

Establish Refueling Floor Manager

SRO Certified

Recognized Leader

TechnicaHy Competent

Reinforces Chain of Command

~

Strengthen Engineering Support For Refueling Floor

Activities

System Engineer Assigned

Implement Short Term Recommendations

~

Leadership

Listening

Communication

Teamwork

Resolution of Concerns

1VEAR TERM CORRECTIVEACTIONS

PROCEDURES

~

Upgrade Maintenance

Procedures For Maintaining

The Refueling Bridge

~

Develop Integrated Single Procedure For Conducting

The Unit 1 '7th Refuel Outage Core Reload

~

Develop

Specific

Procedure

For

Off Normal,

Refueling Bridge Operations

N

~

Revise And Perform Specific Surveillance Procedures

For Refueling Bridge Operability

~

Institute

Refueling

Floor

Management

Administrative Procedure/Program

1VEAR TERM CORRECTIVE< ACTIONS

TRAINING

~

Complete Training For Operations

On Refueling

Bridge Operation And Procedure For Unit

1 7th

Refuel Outage Core Reload

1VEAR TEEiVCORRECTEVEACTIONS

CULTURE

~

Communicate Expectations To Station Personnel

High Standards

Zero. Defect Goals

Supervisory Follow-Up And Monitoring

Teamwork

Listening And Acting On Issues

Management Visibility

Schedule Pressure

~

Institutionalize

The

Concept

That

Root

Causes

Attributed To Human Error WillBe Probed Deeper

To Determine Why Human Error Occurred

IN)WRMZDJATETERM CORRECT?lVE ACTIO1VS

RJOR TO ANT2 6TH REEEJEL OUTAGE

MANAGEMENT

~

Critique Unit I 7th Refuel Outage Core Reload With

Refueling Floor Manager Concept/Adjust Program

For Unit 2

~

Select/Train

Permanent

Personnel

For Refueling

Floor Management

~

Assess

Operation

Support

Staff

Performance,

Training, Qualifications And Organization

~

Evaluate Actions Required On The List Of Other

Equipment/System

Issues

For Unit 2 6th Refuel

Outage Work

~

Implement

Short- Term

Engineering

Recommendations

On The Unit 2 Refueling Bridge

~

Communicate Lessons Learned To Industry

I1VTERMZDIATETERM CORRECTEVZ-ACTIONS

RIOR TO ANT2 6TH REFUEL OUTAGE

PROCEDURES

~

Review

Fuel

And

Core/Fuel

Pool

Handling

Procedures

To Be

Used For Unit 2 6th Refuel

Outage and Revise Accordingly

~

Enhance Refueling Bridge Test Weight Issues

Tech Spec Changes

Procedures/Work Controls For Weights

INTEMCZDIATETERM CORtK'CTEPZ ACTIONS

RIOR TO UlVET2 6TH REFUEI. OUTAGE

TRAINING

~

Identify

Specific

Training

Needs

For

Fuel

Handling/Core Component Handling Activities And

Adjust/Conduct Training Accordingly

INTEN/MEDIATETERM CORRECTIVE< ACTIONS

RlOR TO ZUVTT2 6TH REFUEL OUTAGE

CULTURE

~

Perform

A 'DACUM'rocess

For Supervisory

Training In.Areas Of:

Listening

Follow-Up

Monitoring

High Standards

include In Employee Concerns Module)

INTERMEDIATETERM CORRECTIVE ACTIONS

(PRIOR TO UNIT 2 6TH REFUEL OUTAGE)

Cu1ture (Cont.d)

~

Communicate

Expectations

To

Department

Personnel

High Standards

Zero Defect Goals

Supervisory Follow-Up And Monitoring

Teamwork

Listening And Acting On Issues

Management Visibility

Schedule Pressure

INTERMEDIATETERM CORRECTIVE ACTIONS

(PRIOR TO UNIT 2 6TH REFUEL OUTAGE)

Culture (Cont.d)

~

Lower The Threshold

For Writing SOORs

and

Improve Corrective Action For Repeat Events

~

Lower

The

Threshold

For

Conducting

NSAG

Investigations

~

Revise Scheduling 'Terminology'

Conduct Thorough Human Factors Review Of SSES

Refueling Platforms

LONG TERM COEtK'CTIlVE ACTIONS

MANAGEMENT

~

Benchmark The Industry For The Be'st Refueling

Floor Management

~

Conduct/Host An INPO Assist Visit On Refueling

Floor Management

~

Institutionalize

Refueling

Floor Assessment

And

Monitoring

~

Strengthen The Operations Staff Support Function

~

Implement The Results Of Evaluation Performed

For List Of Other Equipment/System

Issues

~

Implement

The

Long

Term

Engineering

Recommendations

On The Refueling Bridges

~

Review Root Cause/Corrective

Action Process

and

Recommend Changes

LONG TENN COP/K'CTIME ACTIONS

PROCEDXH&S

~

Perform A Review Of Related

Refueling

Floor

Procedures And Upgrade Accordingly

~

Perform A Review Of Work Controls (Preventive

And Corrective) For Refueling Floor Work And

Upgrade Accordingly

LONG TERM COEtK'CTIjVEACTIONS

TRAINING

~

Review

And

Upgrade

Training

Programs

For

Personnel

Who Perform Work Activities On The

Refuel Floor

LONG TERR CO%)V<CTEVZACTIONS

CULTURE

~

Conduct Re-training For All Personnel On Nuclear

Department

Supervisory Training Matrix On The

Expectations Of:

Listening

Follow-Up

Monitoring

High Standards

Employee Concerns

~

Institutionalize A More Stringent Corrective Action

Program For Dealing VVith Repeat Events

~

Implement

Human

Factors

Review

Recommendations

On Both Refueling Platforms

fBK4THAVE PX LEANVED?

~

Clearly Set Forth Management Expectations

Communicate Individual Performance Objective

Of Zero Defects

,Conduct Verifications With Questioning Attitude

Provide Checks And Balances Through Effective

Oversight

Reinforce Teamwork

Lead By Example

~

Solve Recurrent Problems

Lower Threshold To Initiate Action

Identify True Root Causes - Particularly For

Human Performance

Strengthen AbilityTo Detect Recurring Problems

Generic Implications

Status Control

WHATHAVE WE LEARNED? (continued)

~

Preserve And Enhance Strong Susquehanna

Safety

Culture

Reconfirm Commitment That Safety Is Not

Compromised By Schedule

Better Utilize Assessment

Resources And Listen

To Their Messages

Strengthen Elements Of Defense-In-Depth

(Training, Procedures,

Design) Commensurate

With Expectations

MANAGEMENTPERSPECTA'E

PPdlL is committed to learning from these issues and

strengthening our organization for the long term.

We are taking a comprehensive, aggressive look

at ourselves.

We willlisten, and face the facts openly as they

unfold.

We are setting new standards,

and will take

steps to ensure behavioral changes occur.

The results will be effective for the long term,

and

ensure

an environment of cooperation,

communication, and teamwork.

V

U.S. NUCLEAR REGULATORY

COMMISSION

REGION I

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SUSQUEEDd~A

AUGMEXIEDINSPECTION TEAjM

EXIT

NOVEMBER 22, 1993

PURPOSE OF AN AIT

~

LOWEST LEVEL OF NRC INCIDENT

INVESTIGATIONPROGRM4 FOR RESPONSE

TO OPERATIONALEVENTS

~

CONDUCT A TIMELYAND THOROUGH

INSPECTION WITH THE EMPHASIS ON

FACT-FINDING

~

COLLECT AND ANALYZETHE FACTS TO

DETERlvtINE CAUSE(S) OI'HE EVENT

~

ASSESS THE SAFETY SIGNIFICANCE OF THE

EVENT

AN AIT~E

HQX:

~

DETERMINE WHETHER NRC RULES WERE

VIOLATEDOR RECOMMEND

ENFORCEMENT ACTION

~

ADDRESS THE APPLICABILITYOF GENERIC

CONCERNS TO OTHER PLANTS

EXIT AGENDA

~

AIT CHARTER

~

EVENTS DISCUSSION AND FINDINGS

~

ADEQUACY OF CORRECTIVE ACTIONS IN

LIGHT OF PREVIOUS SIMILAREVENTS

~

FUEL HANDLINGPROCEDUI&S

SAFETY SIGNIFICANCE OF FUEL HANDLING

ACTIVITIES

MANAGEMENTOVERSIGHT A2'G) CONTROL

OF FUEL HAM)LINGACTIVITIES

MAINTENANCEASSESSMENT

~

GENERIC IMPLICATIONS

~

POST AITACTIVITIES

AIT CHARTER

WEIY THE AIT%AS CONDUCTED

~

SCOPE AM) OBJECTIVES

(1) Determine the cause(s) of each event

(2) Determine the adequacy of PP&L's

response

to each of the events

~

ASSESS SAFETY SIGNIFICANCE

~

DETERMINE ADEQUACYOF MANAGEMENT

OVERSIGHT

~

REVIEW ADEQUACYOF PROCEDUI&S AND

TANNING

~

DETE

POSSIBLE GENERIC

IMPLICATIONS

AITMEMBERS

TEAM

LEADER

TEAM

MEMBERS

R. Temps

Project Engineer, DRP

R. Summers

Project Engineer, DRP

D. Desaulniers

Human Factors Specia1ist, NRR

D. Mannai

Resident Inspector, DRP

C. Sisco

Operations Engineer, DRS

S. Morris

Reactor Engineer, DRP

EVENTS DISCUSSION R FINDINGS

~

EVENT 1:

October 6, 1993

"FUEL MOVEMENTERROR"

~

EVENT 2:

October 26, 1993

"MAST DROP"

EVENT 3:

October 27, 1993

"BLADEGUIDE IMPACT"

~

EVENT 4:

October 28, 1993

"MAST DROP"

~

OTHER CONCERNS

THE FOLLOWINGWILLBE DISCUSSED FOR

EACH EVENT:

(1) Event Details

(2)

Cause

(3) Corrective Actions

(4) AIT's Assessment of Corrective Actions

ADEQUACYOF CORRECTIVE

ACTIONS IN LIGHT OF PREVIOUS

SIMILAREVENTS

~

MMEROUS EVENTS OF THIS KINDHAVE

OCCUIGXD AT SSES SINCE 1984

~

ADEQUACYOF CORI&CTIVEACTIONS

ASSESSED IN TMREE &AREAS:

(I) Events Involving Impact to the Mast/Grappled

Components

(2) Bundle and Blade Guide Movement Errors

(3) Mast Damage Due to Unknown Causes

~

INADEQUACIES IDENTIFIEDBY THE AITIN

PPEcL's ROOT CAUSE EVALUATIONS,

INDEPENDENCE OF REVIE%, AND

CORRECTIVE ACTIONS

SAFETY SIGNIFICANCE OF FUEL

LING ACTIVITIES

~

REFUELING OPERATIONS ARE SAFETY

SIGNIFICANT

~

TREATMENT OF FUEL HA2'G)LINGAS A

SAFETY SIGNIFICANTACTIVITY%AS

LACKINGIN PPEcL's RESPONSE TO FUEL

HANDLINGPROBLEMS

~

PAST EVALUATIONSSTATED "NO SAFETY

SIGNIFICANCE" OR "INCREASED OUTAGE

TIME" AS A CONSEQUENCE

~

RESOLUTION OF BENT MAST SECTIONS

MORE CONCERNED %ITH ECONOMIC

FACTORS;

i.e. MAINTAININGTIMELINESS

OF'CORE OFFLOADlRELOAD

~

SPARE MAST STAGED DURING REFUELINGS

DUE TO HISTORY OF PROBLEMS

~

CONTRACTOR's RECOMMENDATIONSMADE

IN 1986 ON REDUCING %"EAR A, TEAR ON

FUEL HANDLINGEQUIPMENT WERE NOT

IMPLEMENTED

MANAGEMENTOVERSIGHT OF FUEL

LINGACTIVITIES

~

OPERATIONS MANAGEMENTOVERSIGHT

OF FUEL HANDLINGASSESSED AS WEAK

~

DELEGATIONTO REFUELING BRIDGE

SENIOR REACTOR OPERATOR

~

UNAWARE OF BRIDGE OPERATOR's

PRACTICES AND CONCERNS

~

EXPECTATIONS NOT MET

~

DESPITE PERFORMANCE PROBLEMS OVER

THE YEARS, MANAGEMENTOVERSIGHT

REMAINED UNCHANGED

MAINTENANCEASSESSMENT

I.

CUIKWNTAC

~

NON-"Q" COMPONENT USE

~

INADEQUATEPOST MAINTENANCE

TEST

~

LOAD CELL CALIBRATIONAI'G)

RELATED ISSUES

NANCE HISTORY

~

AITFOUM) 13 EVENTS OF BENT MASTS

SINCE 1984

~

NO CO$3&CTIVEMAINTENANCE

TRENDING

~

1986 MAST BENDING EVENTS AM)

INVESTIGATION

~

INTERVIEWRESULTS OF STAFF

POTENTIAL GENERIC CONCERNS

I.

OPERATIONAL CONCERNS:

ACCEPTABILITYOF THREE- DIRECTION

MOTION .

~

ACCEPTABILITYOF ACCELERATION4,

DECELERATION FORCES FOR FULLY

EXTENDED MAST

~

ACCEPTABILITYOF DRAG FORCES OF

DOUBLE BLADE GUIDE MOVEMENT

II. DESIGN CONCERNS:

U

~

INTERFERENCE %ITH DOUBLE BLADE

GUIDE HAP'G)LES IN SPENT FUEL POOL

NRC POST AITACTIVITIES

~

COMPREHENSIVE REVIE% OF REVISED

REFUELING MG) RELATED PROCEDURES

~

DIRECT OBSERVATION OF "DRY RUN"

WALKTHROUGHOF REVISED PROCEDMM

~

VERIFICATIONAND VALIDATIONOF

OPERATOR TANNINGAND QUALIFICATION

~

LICENSEE hGMAGEMENT MEETING TO

DISCUSS REFUELING EVENTS A5lD

CORI&CTIVEACTIONS