ML17158C157

Forwards Enclosure 2 to Plant Insp Repts 50-387/97-02 50-388/97-02,submitted on 970506

ML17158C157
Person / Time
Site:	Susquehanna
Issue date:	05/06/1997
From:	Gallagher K NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Bill Dean, Poslusny C, Stolz J NRC (Affiliation Not Assigned), NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO)
References
50-387-97-02, 50-387-97-2, 50-388-97-02, 50-388-97-2, NUDOCS 9705200058
Download: ML17158C157 (84)

See also: IR 05000387/1997002

Text

0

MEMORANDUMTO:

FROM;

Nay 6,

1997

W. Dean, OEDO

J. Stoiz, NRR

C. Poslusny,

NRR

F. Talbot, NRR

N. Per.y,

I imerick

R. Ragland,

DRS

Kay L. Gallagher, Secietary

Division of Reactor Projects

Region

I

~

A

'L,P

SUBJECT:

SUSC UEHANNA INSPECTION REPORT 97-02

Attached is Enclosure

2 to Susquehanna

Inspection Report 97-02, which was e-mailed to

you on May 2, 1997.

9705200058

9'70506

PDR

ADOCK 05000387

8

POR

'Hay 6,

l."9

e

MEMORANDUMTO:

FROM:

SUBJECT:

W. Dean, OEDO

J. Stolz, NRR

C. Poslusny,

NRR

F. Talbot, NRR

. N. Perry, Limerick

..R. Ragland,

DRS

Ka'y L. Gallagher, Se

.ary

Division of Reactor

F o .cts

Region

I

SUSQUEHANNA INS

E

TION REPORT 97-02

Attached is Enclosure

2 to Susquehanna

Inspectior

Report 97-02, which was e-mailed to

you on May 2, 1997.

LNCI.OSURt.

2

PENNS YLVANIAPOWER Sc LIGHTPRESENTATION

TO THE U;S. NUCLEARREGULATORYCOMMISSION

USNRC Region I Offices

KingofPrussia, Pa.

March 21, 1997

MANAGEMENTPERSPECTIVE

~

8'e Have Responded Aggressively to the Issues

and 8'e Are Implementing Valuable Lessons

Learned.

Our Actions Are Directed At Improving Long Term

Performance

>> We Have Strengthened Management and

=;; 'Supervisory Oversight

>> We Have Implerriented Improved Assessment

Practices

>> We Have Address

d Individual Performance Issues,

Reinforced Our Expectations, and Verified That

They Are Being Met

2

0

~

.

~

MANAGEMENTPERSPECTIVE

G. T. JONES

VP - NUCI.LAROPERATIONS

~

REVIEW OF ISSUES

G

• J. KUCZYNSKI

GENERAL MANAGER- SSES

~

ASSESSMENT PERSPECTIVE

. W. E. BURCHILL

MGR - NUCI.EAR ASSESSMENT

~

SUMMARY

G. T. JONES

MANAGEMENTPERSPECTIVE

~ PP&L 's Standards

Conservative Safety Philosophy

Compliance With the Regulations

Strong Procedures That Are Followed

Capable, Accountable People

Questioning Attitude

Good Teamwork

MANAGEMENTPERSPECTIVE

~ PPckL Has Responded Broadly and

Aggressively to the Issues.

I

Immediate Corrective Actions

Comprehensive Internal and

Independent Investigations

Broad, Comprehensive Reviews Searching For

Definitive Causes and Generic Implications

Actions to Prevent Recurrence

MANAGEMENTPERSPECTIVE

Management

Ec Supervisory Oversight

Assessment'Effectiveness

Performance ofCertain Individuals

~

1

It

k

(

~ General Manager-SSES Perspective

~ Core Spray Containment Isolation Valve

~ Standby LiquidControl Heat Trace

~ "E'iesel Generator

'PO Rounds

.Operations Shift Supervision

. Improvements in Operations Management and

Supervision

GENERALMANAGER S SES

PERSPECTIVE

~

We 've Reviewed Our I996 Performanc e'

Fewest Operating Transients Ever,.

Equipment Performance Was Excel lent

t

Generation Was at'a Record Level

~

Event Investigations Have Been Broad, Comprehensive,

and Intrusive

~

The "E"Diesel Generator Everi t Was An Emotional Event

For The Station, and Especially For Operations

We IIave I.mproyed Performance,

Individuals

Management Oversight

Independent Assessment

44

PREVIEW

Core Spray Containment Isolation Valve

Technical Specification 3.6.3 Was Not Met

Safety Significance Was Minimal

Our Corrective Actions Werc Tiincly and Are Complctc

r

Standby LiquidControl Heat Trace

Status Control Procedure Not Properly Implemented

We Identified the Event, and Safety Significance Was Minimal

Our Initial Corrective Action Was Not 'I'imcly;AllCorrective Actions Are Now

Complete

"F."Diesel Generator

The Misalignment Event Was Straightforward, Hut The Follow-on issues Werc

Subtle

We Identified the Event and the Follow-on Issues

The Safety Significance ofthe Event Was Minimal

Our Corrective Actions Were Prompt and Comprehensive

.We Aggressively Pursued the Potential Generic Implications

OUTLINE

~ General Manager

SSES Perspective

~ Core Spray Containment Isolation Valve

~ Standby LiquidControl Heat Trace

~ "E"Diesel Generator,

NPO R'ourids

Operations Shift Supervision

Improvements in Operations Management and

Supervision

EVENT: CORE SPRAY

CONTAINMENTISOLATIONVALVE

. ~ 730/W: Unit 1 Core Spray~F01

$B (Single PCIV

in FullFlow Test Return Line to Suppression

Pool) Valve Backseated and Repacked at Power

~ Technical Specification 3.6.3 Does No

S ecificallyAddress Single Valve Penetrati ons

Informal Interpretation. Evolved Based on

Footnote ('c) iri Tech Spec Table 3.6.3-1.:

Re uirement for Redundant Valve Was Interpreted

to Be Met by Integrity ofRedundant Boundary

F004B

F006B

F005B

F037iS

I

Qi'~

I

T'015B

F031B

1P206B

1P206D

M

F001B

~gCST

F002B

F,O;'

Core Spray "B" Loop Simplified

PROMPT FOLLOW'-UP: CORE SPRAY

CONTAINMENTISOLATIONVALVE

~

.

~ Immediate Corrective Actions

We Stopped the Practice

We Issued a Formal, Technical

Specification Interpretation

SAFETY SIGNIFICANCE: CORE SPRAY

CONTAINMENTISOLATION.VALVE

~ Safety Significance 8'as Minimal

F0158 Does Not Conimunicatc Directly With Either

the Primary Containment Atmosphere Or the Reactor

Coolant Pressure Boundary.;:

~

Penetration.and

Associated Closed System Piping,

Remain Water Sealed Post Accident

1

>> Primary'ontainment Integrity Maintained

Regardless'of'0158

Position.

'- >> PP&L Actions Weri Focused on Maintaining Water Seal

>> Additional Protection Afforded by Maintenance ofValve

• " Backseats

'

Effectiv'eniss ofWater Seal was Basis for- Recent Lliminatlon

'

of Tech Spec LLRTon This,Penetration

I

~

~

INVESTIGATIONRESULTS: CORE SPRAY

CONTAINMENTISOLATIONVALVE

~ Investigation Results

Technical Specification 3.6.3 Was

Misinterpreted

>> Causal Factor: Tech Spec Footnote Wording

A Formal Tech Spec Interpretation Was Not

Processed

>> Missed Opportunities for Additional.Review

An Informal Document Was Used as the Basis

for An Operational Decision

15

CORRECTIVE ACTIONS: CORE SPRAY

CONTAINMENT.ISOLATIONVALVE

t

u

a

f

~ Actions to Prevent Recurrence

4

We Completed Training

>> Operations Training-

>> Engineering Training Regarding Proper

Documentation ofEngineering Guidance

I

We Enhanced the Program

>> Explicit Direction in Operations Policy

I

16

~

.

CORRECTIVE ACTIONS: CORE SPRAY

CONTAINMENTISOLATIONVALVE

~ Actions to Prevent Recurrence (Cont'd)

k

We Defined arid Documented for Closed

Systems:

,>> Those Used As Redundant Isolation Boundaries in

Single Valve Penetrations

>> Testing Requirements

>> Acceptable Methods ofAltering Boundaries

.17

CORRECTIVE ACTIONS: CORE SPRAY

CONTAINMENT ISOLATIONVALVE

~ Actions to Prevent Recurrence (Cont 'd)

We Completed Technical Specification

Reviews

>> Ensured No Other Informal Guidance Was Being

Utilized in Support ofPlant Operations

>> Reviewed SSES ITS Submittal to Ensure

Consistency With Event Resolution

P

V

~

.

CONCLUSIONS: CORE SPRAY

CONTAINMENTISOLATIONVALVE

~ Core Spray Containment Isolation Valve

'echnical

Specification 3.6.3 Was Not Met

t

The Event Had Minimal Safety Significance,

. and Resulted in No Safety Consequences

Our Corrective Actions Wer'e Prompt and

Comprehensive,

and Are Complete

OUTLINE

General Manager

SSES Perspective

~ Core Spray Containment Isolation Valve

~ Standby LiquidControl Heat Trace

~ "E"Diesel Generator

NPO Rounds

t

Operations 'Shift Supervision

'

Improvements in Operations Management and

Supervision

20

0

EVENT:

STANDBYLIQUIDCONTROL HEAT TRACE

4

. Event: Inadvertently Deenergized Heat Trace

As-built Drawing Discrepancy Was Identifted

. Temporarily Controlled.Via a Status Control Tag

The "8" SLC Pump Heat Trace Was Unknowingly

Deenergized

• .,

>> Status ControlTag Was llung Improperly

>> NPO Didn t Question thc Applicabilityof thc Status Control

Tag

~ ~

I

e

l

le

7l

I ~ ,

e

~

~

'

Iev '

~

e

~

~

~

~

~

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0

~

~ ~

~

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RI.'.

t

~

~

'~

~

~

~

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QQI<<

~ ~ s

-"il

f

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Ifs'OT

'

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h

~

~ )

.KP,'I,... >>>V,m~..vm>P'

- '

~ ~

,

~

~

~ el

I

I'D

~

~

I

I

cf

PROMPT FOLLOW-UP:

STANDBY LIQUIDCONTROL HEAT TRACE

~ Immediate Corrective Actions

'

We Closed the Breakers'-

We'Flushed the "B". Pump to Verify

Flowpath

- We Applied Status Control Tags Directly

to the Breakers

24

SAFETY SIGNIFICANCE:

STANDBYLIQUIDCONTROL HEAT TRACE

~ Safety Significance 8'as Minimal

The Purpose ofthe Heat Trace is to Prevent

Sodium Pentaborate From Precipitating Out of

Solution

Solution Concentration and Ambient

Temperature Data During the Time ofthe

Event Indicate That Precipitation Could Not

Have Occurred

"B" SLCS Pump Would Have Functioned

25

INVESTIGATIONRESULTS:

STANDBYLIQUIDCONTROL HEAT TRACE

~ Investigation Results

g

InitialActions to Correct Drawings Were Not

.

Timely

Status Control..Tags Should Have Been Applied

to,Individual Breakers Rather Than the Panel

Door

The NPO Should Have Questioned the

Applicabilityofthe Status Control Tag

CORRECTIVE ACTIONS:

STANDBYLIQUIDCONTROL HEAT TRACE

~ Actions to.Prevent Recurrence:

'- We Corrected the Drawings

"We Counseled Operato'rs on Proper Placement

.'fStatus Control Tags and on Questioning the

,:Applicabilityof Status Control Tags

4

Z

27

CONCLUSIONS:

STANDBYLIQUIDCONTROL HEAT TRACE

Standby LiquidControl Heat Trace

Our Status Control Procedure Was Not

Properly Implemented.

.We Identified the Event

The Event Had Minimal Safety Significance,

and Resulted in No Safety Consequences

Our Initial Corrective Action Was Not Timely;

AllCorrective Actions are Now Complete

I

/

OUTLINE

~ General Manager - SSES Perspective

~ Core Spray Containment Isolation Valve

~ Standby LiquidControl Heat Trace

~ "E",:Diesel Generator

NPO Rounds

1

I

Operations Shift Supervision

Improvements in Operations Management and

Supervision

29

DESIGN: "E" DIESEL GENERATOR

t.

~

'l'he Tvvo Susquehanna

Units Have Shared Diesel

Generators

Four (Normally A, B, C, 8c D) are Required to be Aligned

~ AFifth DG, "E ", is Designed to Substitute forAny One of

the Other Four

'

'."E" is Testable:When Not Substituted

."E"Essential Auxiliaries Have Two Power Sources:

>> IE, From "E" D/G

'

Non-IE, Normally Aligned-

Substitution is Accomplished By Physically Moving Circuit

Breakers

30

Units 1 and 2 ESS Buses

SU Bus 't0

River

Intak

I

I'I

I

OA510A

I

I

I

I

I

I

I

I

I

I

L

OA510C

OA510B r

'I

I

I

I

I

I

L

OA510D

13.8 KV

l UJJJ ,'varr

FAClulY

~

~

J

4KV

D

CUBICLES'

I

I

2

I

I

I

I

3

~

t

I

4

I

I

~

= I

I

I

I

I

I

7

.'6

0 t

03

I

SPARE

I

02

05

04

I

PT Cubicle

I

OB565

lESU Bus 10

I

OA510

4.16 KV

460 y

I

OS569

~

OX565

I 11N2

I

OATS556

01A

01B

OSS57

[ESU Bus 20

4M V

13KV

"E" Diesel Layout Simplified

EVENT

"E" DG MISALIGNMENT

~

Cr/14/96.NPO Misaligned the "E"Diesel Generator

Essential Auxiliaries Breaker

Went to the Wrong Breaker and Assumed It Was Misaligned

Informed Control Room, No Follow-up Supervisory Verification

Condition Report Initiated Based on Perceived Misalignment

"Corrective Realignment" Created the Misalignment

~ " Three Subsequent Survei LLances Failed to Detect

Misalignment

~

7/4/96 - Misa'lignment Detected by NPO During Rounds

32

PROMPT FOLLOW-UP:

"E" DG MISALIGNMENT

~ Immediate Corrective:Actions

We Declared the "E" DG Inoperable

We Realigned the Breakers, and Conducted

Surveillances

'e Initiated Iiivestigations

'

~

1

~'

Management Performed Surveillances and

Confirmed Breaker Alignments

4I

We Increased Oversight ofField Activities

33

SAFETY SIGNIFICANCE:

"E" DG MISALIGNMENT.

~ Actual Safety Significance Was Minimal

Given a Start Signal, AllFour DGs Would Start and

Energize Their Respective Buses

The "E" DG Would Have Run Until the Day Tank Ran

Out ofFuel

.. >>, Over Eighty Minutes

>> Three Diesels Remain Operable

Susquehanna

is Designed to Respond to AllDesign

Basis Events'With Three Diesel Generators

~ I":aiiud eof S.ome Opei ators to Prope~ lyPerform

Rounds and Sur'veillances was Significari t

INVESTIGATIONSE

UENCE:

"E" D'IESEL GENERATOR

PLANT

MANAGEMENT

ESTABLISHES

EVENT REVIEW

TEAM

EVENT REVIEWTEAM

IDENTIFIES

SURVEILLANCEISSUE

"E" OIESEL

EVENT

INDEPENDENT

SAFETY EVALUATION

SERVICES (ISES)

BEGINS

INDEPENDENT

REVIEW

ISES PURSUES

- TIME IN BUILDING

~ DRY RUNS OF ROUNDS

~ ESTABLISHES ALARM

TEST ISSUE

PLANTMANAGEMENT

REQUESTS

CORPORATE AUDITING

REVIEWOF

MISALIGNMENTEVENT/

SURVEILLANCEISSUE

35

ISSUES RAISED BY INVESTIGATIONOF

"E" DG MISALIGNMENT

I

~ 1: NPO Performance During DG Substitution

2: Supervisory Oversight

~ 3: Testing Of"E'GW'he,n Substituted

I

~ 4: Procedures

~ 5: Kriowledge of "E"DGDesign

~ 6: "E"DG Human Factors,

~

7; NPO Performance ofRounds ck Surveillances

~

~

CORRECTiVE ACTIONS:

"E" DG MISALIGNMENT

~ N: NPO Performance During DG Substitution

We Applied Company Policies on Performance Deficiencies

>> NPONo Longer Works in Operations

~

P2: Supervisory Oversight

We Counseled the Supervisors Who Failed to Respond to the

Initial Status Control Event

4

We Trained A11 Operations Personnel on the Event

We Provided Expectations forAssistant Unit Supervisor

Performance to Shift Supervision

We Expanded the Operations Supervisory Oversight ofRounds

We Added a Requirement i'or the Shift Supervisor to Walk Do~n

Status Control Events

37

CORRECTIVE ACTIONS:

"E" DG MISALIGNMENT

~

¹3: Testing of "E" DG H%en Substituted

%e Revised Test Procedures

>> Included ExplicitBreaker Position

~

¹4: Improved Procedures

We Expanded Operations SelfAssessment Program

>> Provided More,.Comprehensive Checklists

>> More Management Oversight

We Revised Procedures

>> Included Explicit Breaker Position Verification in Surveillance

>> Realigned Administr'ative Control Procedures for Consistency

>> Improved Operations Investigation Guidance

>> Clarified Wording in Operating Procedures

38

CORRECTIVE ACTIONS:

"E" DG MISALIGNMENT

¹5: Knowledge of "E"DG Design

We Trained Operations I'ersonnel on "E"DG Design, Including

Function.and Operation

¹6: "E"DG Human Factors

We Revised Procedures

We Relabelled the Switchgear

We Performed a Modification to Provide a Lighton, Cubicle p6

r

¹7: NPO Performance ofRounds

d'c Surveillances

We Retrained Operations Personnel on Expectations

We Performed Further Investigation ofNPO Performance

39

OUTLINE

General Manager - SSES Perspective

~ Core Spray Containinent Isolation Valve

~ Standby Liquid.Contro/ Heat Trace

~ "E"Diesel Generator

NPO Rounds.:-

Operations Shift Supervision

Improvements in Operations Management and

Super vision

40

INVESTIGATIONSE

UENCE:

"E" DIESEL. GENERATOR

PLANT

MANAGEMEHT

ESTABLISHES

EVENT REVIEW

TEAM

EVENT REVIEW TEAM

IDENTIFIES

SURVEILLANCEISSUE

"E"DIESEL

EVENT

INDEPENDENT

SAFETY EVALUATION

SERVICES (ISES)

BEGINS

INDEPENDENT

REVIEW

'ISES PURSUES

SIBYE!LLIltI!RL%llF'

TIME IN BUILDING

- ORY RUNS OF ROUNDS

~ ESTABLISHES ALARM

TEST ISSUE

NUCLEARASSESSMENT I

PLANTMANAGEMENT

PURSUE ALARMTEST

ISSUE

PLANTMANAGEMENT

REOUESTS

CORPORATE AUDITING

REVIEW OF

MISAI.IGNMENTEVENTI

SURVEILLANCEISSUE

PLANTMANAGEMENT

REOUESTS

CORPORATE AUDITING

REVIEW OF

AIARMTEST ISSUE

PPkL EXPECTATIONS:

NPO ROUNDS

4

~ Ppd'cL Expects NPO's To Perform Their

Rounds In Accordance 8'.ith The Rounds

Sheet and Their, Training, and to Consult

Their Supervisor IfThey Are Unable to

Coinplete Their Rounds.

~ '

42

'ome NPO

's DidNot Perform an Alarm

Test, and Indicated That They Had

Performed It on Their Rounds Sheet

ALARMTEST OC577E

~ The Alarm Test was a Change to NPO-

Rounds

Condition Report Corrective Action Beginning

12/26l95

Included:

>> Push Alarm Test Button on OC577E

>> Receive Alarm on OC577E

>> Receive Alarm in Control Room

44

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OI-PL-OITI, Rev. 8, Page

1 of 10

COMMUNICATIONS:

NPO ROUNDS

~ Communication ofthe New Alarm Test

Requirement

Was Clear

2

The Rounds Sheet Is Clear

~ NPO's 8'ere Trained On How To Do Rounds

Initial Training

Continuing Training

Classroom

,Onthe Job Training

~ The Requirements

Were Clear In Operations

Proce,dures

46

INVESTIGATIONRESULTS:

'NPO ROUNDS

~ The Pattern ofAlarm Testing Indicates:

Many NPO's Performed ihe Test Without Error

Some NPO's Performed the Test on Almost All

'ccasions;

Their Few Misses Were Attributed to

Human Error '

Some NPO's Did Not Perform the Test initially,But

Once They Commenced Testing, They Performed it

Consistently

. Some NPO's Appeared to Understand the Requirement

But Failed to Perform it on Numerous Occasions

47

INVESTIGATIONRESULTS:

NPO ROUNDS

~ Investigation Results

Some NPO's Didn't Do Rounds Properly

Operations Supervision Didn t Identify and

Correct NPO Performance Deficiehcy

(.

48

0

- CORRECTIVE ACTIONS:

NPO ROUNDS

~

We Applied Company Policies on Performance

Deficiencies

>> Letter in File

>> Decision Making Days Off

>> Termination

~

We Restressed Our Expectations 8'ith the NPO's

SAFETY SIGNIFICANCE:

NPO ROUNDS

~ Safety Significance

Actual Safety Significance Was Minimal

'

>> The Alarm Test Was Not Safety Significant

Potential Safety Significance Existed

>> Failure to Perform Rounds Properly Could

Contribute to Undiscovered Degradation

OUTLINE

~ General Manager

SSES Perspective

~ Core Spray Containment Isolatiori Valve

'. Standby Liquid Contr'ol Heat Trace

"E,"Diesel Generator

NPO Rounds

Operations Shift Supervision

Improvements in Operations Management and

Supervision

INVESTIGATIONSE

UENCE:

"E" DIESEL GENERATOR

PLANT

MANAGEMENT

ESTABLISHES

EVENT REVIEW

TEAM

EVENT REVIEWTEAM

IDENTIFIFS

SURVEILLANCEISSUE

"E"DIESEL

EVENT

INDEPENDENT

SAFETYEVALUATION

SERVICES(ISES)

BEGINS

INDEPENDENT

REVIEW

ISES PURSUES

- TIMEIN BUILDING

- ORY RUNS OF ROUNDS

- ESTABLISHES ALARM

TEST ISSUE

NUCLEARASSESSMENT l

PLANTMANAGEMENT

PURSUE ALARMTEST

ISSUE

PlAN'T

MANAGEMENT

RECEIVES

ALLEGATIONON

MCP PERSONNEL

NOT PERFORMING

TASKS

PLANTMANAGEMENT

REOUESTS

CORPORATE AUDITING

REVIEWOF

MISALIGNMENTEVENT/

SURVEIllANCEISSUL

PLANT MANAGEMENT

REOUESTS

CORPORATE AUDITING

REVIEWOF

AlARMTFST ISSUE

DEPARTMENT

MANAGEMENT

RFOUESTS

CORPORATE

AUDITING

INVESTIGATION

52

0

SUPERVISION ISSUE:

PPkL EXPECTATIONS

~ PP&L Expects Operations Supervisors to

FollowAllDepartment Procedures.

During

Off-hours, the Shift Supervisor is the Senior

Mana ement Persori Onsite, and as Such, is

Ex ected to Exercise Judgment on Many

Issues. Ifthe Shift Supervisor Determines

That He is Unable to Meet a Requirement,

He is Expected to Provide Documentation

and Inform Management.

53

HIFT

PER I I

I

E

~ Identified Through Our Internal Processes

~ Aggressively, Broadly, and Independently

'nvestigated

~ Some Sup.ervisors Failed to .Meet Management

Expectations for Performance ofIn-Plant

MonitoringFunctions

.Shift Supervisor General Station Inspection (GSI)

Assistant Unit Supervisor Monitoring ofNPO Rounds

54

SUPERVISORY TASKS

General Station Inspections (GSI's)

B

L

To Be Performed by Shift Supervisors on Night Shift

'

Specific Acceptance Criteria Not Documented

,, >> Expectation Was That GSI's Included Areas Outside the

. Control Room for a Reasonable Period ofTime

w

W

~ Monitoring ofNPO Rounds

To Be Performed by Assistant Unit Supervisors During

NPO Rounds

55

INVESTIGATIONRESULTS:

SUPERVISION ISSUE

~ In'dependent Investigation Results

A Difference in Understanding Existed Between

Operations Management and Some Shift Super'vision

g'f

'

'oor Judgment was Exercised by Some Shift

Supei visors.,,

. >> Some Individuals Believed They Could Comply With tke QSI

Requirement%itkout Leaving the Control Room

w

The Monitoring Activityas Written and Performed Did

'

Not Reflec Management Expectations

56

CORRECTIVE ACTIONS:

SUPERVISION ISSUE

~

We Applied Company Policies on Performance

Deficiencies

Letter in File

Severance

~ GSI's

Senior Nuclear Management Restressed

Our

Performance Expectations With Shift Supervisors

~ Monitoring Activity

We Restressed

Management Expectations With the

AUS's

57

SAFETY SIGNIFICANCE:

SUPERVISION ISSUE

~ Safety Significance 8'as Minimal

7

Most GSI s and Monitoring Activities Were

Done Properly

The Plant Condition Was Not Compromised

l

The.Abilityto Detect and Mitigate a Transient

Was Not Compromised

58

GENERIC IMPLICATIONSREVIEW: OVERALL

PERFORMANCE OF ROUNDS

Overal/ Performance ofRounds

125,000 Items Observed

.

>> AllStation Work Groups

'

Operations

~ Security

~ Health Physics

~ Firewatch

~ Maintenance

>> Performance Met Expectations

59

INVESTIGATIONSE

UENCE:

"E" DIESEL GENERATOR

PLANT

MANAGEMENT

ESTABLISHES

EVENT REVIEW

TEAM,

EVENT REVIEWTEAM

IDENTIFIES

SURVEILLANCEISSUE

PLANT

MANAGEM'ENT

REQUESTS

EXTERNAL

CONTRACTOR

REVIEWOF

OPERATIONS

"E"DIESEL

EVENT

INDEPENDENT

SAFETY EVALUATION

SERVICES {ISES)

BEGINS

INDEPENDENT.

REVIEW

ISES PURSUES

- TIME IN BUILDING

- DRY RUNS OF ROUNDS

- ESTABLISHES ALARM

TEST ISSUE

NUCLEARASSESSMENT I

PLANTMANAGEMENT

PURSUE ALARMTEST

ISSUE

PLANT

MANAGEMENT

RECEIVES

ALLEGATIONON

MCP PERSONNEL

NOT PERFORMING

TASKS

PLANTMANAGEMENT

REQUESTS

CORPORATE AUDITING

REVIEWOF

MISALIGNMENTEVENT/

SURVFtl I ANCF. IS"..IK

PLANTMANAGEMEN'T

REQUESTS

CORPORATE AUDITING

REVIEWOF

ALARMTEST ISSUE

DEPARTMENT

MANAGEMENT

REQUESTS

CORPORATE

AIIDlT(NG

INVESTIGATION

60

OUTLINE

~ Cr'eneral Manager - SSES Perspective

~ Core Spray Containment Isolation Valve

~ Standby Liquid Cont~ ol Heat Trace

~ "E" Die.sel Generator

. NPO Rounds

Operations Shift Supervision

'Improvements in Operations Management and

Supervision

IMPROVEMENTS IN OPERATIONS

MANAGEMENTA SUPERVISION

~ External Assessment

Independent Outside Consultant

-Interviewed 125 People in Operations

Focused on Organization/Management. Issues

.. >> Communications

>> Roles k Responsibilities

>> Environment

62

IMPROVEMENTS IN OPERATIONS

MANAGEMENT@ SUPERVISION

~ External Assessment: Identified Strengths

. Competent, Committed People

Good Material Condition

Good Procedures

Good Plant Operation

Ease ofRaising Issues

63

IMPROVEMENTS IN OPERATIONS

MANAGEMENT&, SUPERVISION

~ External Assessment: Identified Concerns

Work Management::

'

Communications.':

- '

Feedback on Performance:

Clarity-ofExpectations-,

/

Self Assessment

Practices

/

1's

~

I

IMPROVEMENTS IN OPERATIONS

MANAGEMENTk SUPERVISION

~ Ongoing Improvement Initiatives

We Adjusted the.-Work Management Structure

>> Enforced Schedule Discipline

>> increased the Manning of%ork Control Center

Supervisory Roles and Expectations

>> %e Are Refocusing the Roles ofOperations Management and

'hiASupervision to Emphasize:

~ Communications

IIandIing Issues and Concerns

~ Time in the Field

Performance Feedback

Expectations

Assessment

65

4

IMPROVEMENTS IN OPERATIONS

MANAGEMENTk, SUPERVISION

1

~ Future Improvement Initiatives

Unit Supervisor Rotations Between the Control Room

and the Field

'

We Requisitioned Additional Senior Reactor Operators

On-Shift to Enhance:

>> Work Management Interface

\\

>> Communication

>> Field Oversight and Immediate Feedback

>> Assessment nfField Operations

GENERAL MANAGER- SSES

PERSPECTIVE

~

8'e 've Reviewed Our 1996 Performance

Fewest Operating Transients Ever

. .-'quipmentPerformance%as

Excellent

-'=-.

Generation Was at a Record Level

" ~: Everi t Investigations Have Been Broad, Comprehensive,

and Intrusive

~

The "E"Diesel Generator Event JFas A.n Emotional Event

ForThe'Station,"and Especially For Operations

~

8'e Have Improved Performance

Individuals

Management Oversight

Independent Assessment

67

E

ME T

TLINE

'verview ofPP>L Self-Assessment

~ Response to NRC Information Notice 92-30

~ Assessment'Response

to E-Diesel Ev

t

~ Insights

~ Improvements in Assessment Practices

~ Conclusions

0

PPRL ASSESS

ENT MATRIX

(.'ON'I'IN(J()(JS

PI'.I(101) I( '

RI'.VI'.N'I'IVE

COI<REC'I'IVI.'.

INI)IVIDIJAI,'8 &,

-

a. Shin turnover review

+01(K (1R()IJPS

b. Alertness to anomalies

c. STAR

d. 20(1% accountability at

inlcrfaces

c. I mploycc gaiety Progrant

a. (foals status reporting

b. Ihnploycc dcvclopmcnt

progranl

c. I)A('.IIM(S'I'(:P-QA- I I2)

d. Training Curricululn

Conlnllllccs (i%I(.P-QA- I I I)

a. Tailboartl conferences

b. 50.59 safety cvah1ations

c. Job completion walkdowns

d. Indcpcndent (I)csign)

verification

c. Prc &. Post job AI.ARA

Review

a. Troubleshooting

b. Post-event lailboards

c. Root cause analy~es

SUPEI<VISION 4,

MANAGEMENT

t

a. MBWA(management by

walking around)

'. Field supervision

c. Coaching &, counseling

'. Reviewof logs& testresults,

e. Maintenance self-assessment

'rogram

f. Radiological Evaluation

Program (NEIM-OO-I070).

a. Iimployec Perfonnance

Rcvicws

b. Prc-SAI.P 4 prc INPO Review

c. Per formancc indicator review

d. Process rc-engineering

e. Plant tours

f. ERC

g. Station AI.ARAColnmiltce

a Contingency planning

b. Outage readiness asscssmcnt

c. PORC startup review

d. Post outage review

a. License Event Review

b Condition Rcport event reviews

c. Post-evolution critiqucs

d. SRC review ofplant events

e. Response to NRC Notice of

Violation

f. Response to Audit Findings

IN I)1'.PENDI.'N'I'

I!X'I'fil<NAI.

i. QA Surveillances

b. QC Inspections

• c. QC ln-Process Corrected Error.

Program

d. Condition Report Program

e. ISES Oversight

a. NRC Inspector routine

inspections

a. QA Audits

b. ISFS Surveillances

c. SRC Reviews

a. NRC SALP

b. INPO Evaluation"

c. PuC Audit

a. QA Observations

b QA Recommendations

c. NAS Assessincnts

a. NRC review ofsafety

evaluation involving an

Unrcviewed Safety'Question

b. NRC rcvicw ofTech Spec.

Change Request

a. ISES Investigations

b. Condition Report Program

a. NRC Augmcntcd htspcction

Tea In

b. Notice ofViolations

Oalt t19S a:04 Aht

h1A'I'8IX.I)0('

PPkL

INDEPENDENT ASSESSMENT

.CONTINUOUS

.

PERIODIC

PREVENTIVE

CORRECFIVE

INDFPFNDFNT

QA Surveillances

QC Inspections

QC ICE Program

CR

Program'SES

Oversight

QA Audits

ISES Survcillances

SRC Reviews

QA Observations

QA Recommendations

NAS Assessmcnts

ISES Investigations

CR Program

70

RE

P

ET

NR

I

2-

'tation Personnel Were Briefed on IN 92 30

~ QA Surveillance Per IN 92-30 Verified Logged

Entries March June, 1992

~ QA Surveillances Per IN 92-30 Quarterly 92Q3 to

Date Verified Logged Entries

~ QA'Surveillances Evaluated Adequacy of

'perator Rounds

~ QA Audits Evaluated Operator Rounds Lo s

RESPONSE TO NRC IN 92-30

~ These Assessments

Were Necessary to

Confirm That .'.': '::

'ecurity Entries Were Made As'Required

Logs Were Completed A's Required

.

Operators Performed Well (Under Observation)

~ But, They Were Nnt Sufficient

~ A More Questioning Approach Could Have

Detected The NPO Performance l~s>>v.

A

E

MENTRE P N ET

E-DIE EL EVENT

I

~ ISES Investigation Determined

= Certain Ent'ries Were Too Short to Perform

Rounds k Surveillance Tasks-

Certairi Logs Showed OC577E Alarm Check

Not in Plant Computer Record

The Same NPO's Had Short Entry Durations @

. Missed Alarm Checks

Interviews Were Required to Explain Data

- >> Recommended Corporate Auditing 1nvestigation

4

73

E

MENT

E P

E-DIE EL EVENT

~ Operations Management Oversight and

A Surveillance.; '

24.-Hour Coverage: for 50:Days

247 Ev'olutions Obse:i ved

Random Observations ofAllNon-Licensed

Operator Positions

Observed Every NPO and ASO on Shift During

.. Period

a,

Principal Focus on Operator Rounds

O.

E P

E

E-DIE EL EVENT

~ QA Real-Time Surveillances ofOperator

Rounds

Weekly Unannounced Observations Thru EOY

Observed NPO's, ASO's, and AUS's

Questioned Those Observed On

II

>> Management Expectations

>> Procedures

>> Bases

>> Duties

And Provided Immediate Feedback

E

MEN

E P N ET

E-DIE EL E ENT

~ QA Surveillance of Security Entries Vs.

Documentation Logs

Involved 125,000 Individual Tasks

>> Operations

>> Maintenaric'e

C

i> Fire Watch

>> Security

>> Health Physics

Perfi~rman~e

W.'l~t Expectations

76

E

MENTRE P

ET

E-DIE EL EVENT

~ Operations Management Assessment

Independent Outside Consultant

Interviewed 125 People in Operations

Focused on OrganizationlManagement

Issues

>> Communications

>> Roles & Responsibilities

>> Environment

-DIE EL EVENT

~ ISES'1996 Oper'ations Surveillance

'24-Hour Surveillance for 4 Days During Unit 1

Shutdown

z

T

Involved 6 Nuclear Assessment

Personnel,

1 Trainirig Person,

8c 2 Industry'eers

164 Hrs in Control Room, 182 Hrs in Plant

CONCLUSION.'Operations Conducted in

Safe, Professional Manner

78

~ Be More "Skeptical"

~ Increase QA Surveillances of Remote, Infrequent,

or. High Risk Activities

~ Increase Use ofIntrusive Techniques Including

Attention on Supervision

~

Escalate Issues More Quickly

~ Apply More "Preemptive" Techniques

~ Increase Comparison To Industry Best Practices

~ ., More Skeptical

Security Entry Times Are Analyzed

~

More QA Surveillance

Added QAContractors During Outage

~

More Intrusion

Questioning Workers

-.

- >> AboutPerformance

>> About Supervision

Questioning Management

~

Quicker Escalation

Trend Condition Reports at Next Iiigher Significance Leyei

80

E

MENT P

T I

TI E

~ More Preemptive Assessments

.- QC Work Group Briefings on Precursors

ISES Investigation ofPlant Material Problems

-:

'. Worker Performance Checklists

~ Increased Comparisons to Industry Best

Practices

NAS Assessment Reports Since 96Q3

4

81

~ "E".:Diesel Event Led to Recognition of

NPO Performance Deficiencies

~ This Produced An Assessment ofOur

Independent Oversight Functions

~ This Assessment Identified Opportunities

for Improvement

.

~ NAS. Independent Assessment Practices

Have Been Improved