ML17284A429
| ML17284A429 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 06/23/1988 |
| From: | Caldwell C, Johnson P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17284A428 | List: |
| References | |
| 50-397-88-23-MM, NUDOCS 8807130441 | |
| Download: ML17284A429 (35) | |
See also: IR 05000397/1988023
Text
U.
S.
NUCLEAR REGULATORY COMMISSION
REGION V
Report
No.
Docket No.
License
No.
Licensee:
Facility Name:
Meeting at:
50-397/88-23
50-397
Washington Public .Power Supply System
P.
0.
Box 968
Richland,
99352
Washington Nuclear Project
No.
2 (WNP"2)
Region
V Office
Meeting Conducted:
June 7,
1988
Prepared
by:
W. Caldwell, Project
nspector
Approved by:
P.
H
Johnson,
Chief
Rea
r Projects
Section
3
~Summar:
Da e
S gned
</zan/gp
Date Signed
A Management
Meeting was held on June 7, 1988 to continue the dialogue
between
Region
V and the Supply System
on items of mutual interest
and recent
enhancements
to programs in response
to the Systematic
Assessment
of Licensee
Performance
(SALP) and the safety
system functional inspection
(SSFI) that were
conducted in 1987.
In addition, the meeting participants
discussed
concerns
regarding the
number of personnel
errors
and near misses that have occurred at
WNP-2 since the beginning of 1988.
8807130441
88062~
ADOCK 05000~97
6
PNU
DETAILS
Mana ement Meetin
Partici ants
NRC Partici ants
J.
B.
B.
H.
D.
F.
R.
A.
R.
P.
M.
B.
J.
L.
F.
A.
P.
H.
C. J.
C.
W.
A.
D.
G.
N.
Martin, Regional Administrator
Faulkenberry,
Deputy Regional Administrator
Kirsch, Director, Division of Reactor Safety
and Projects
Scarano,
Director, Division of Radiation Safety
and Safeguards
Zimmerman, Chief, Reactor Projects
Branch
Blume, Regional
Counsel
Crews,
Senior Reactor
Engineer
Wenslawski, Chief,
Emergency
Preparedness
and Radiological
Protection
Branch
Johnson,
Chief, Reactor Projects
Section
3
Bosted,
Senior Resident Inspector
Caldwell, Project Inspector
Toth, Reactor Inspector
Cook, Public Affairs Officer
WPPSS Partici ants
D.
W. Mazur,
Managing Director
G.
D. Bouchey, Director, Licensing
and Assurance
A.
L. Oxsen, Assistant
Managing Director - Operations
J.
P.
Burn, Director, Engineering
C.
H.
McGilton, Manager,
Operational
Assurance
Programs
C.
M. Powers,
WNP-2 Plant Manager
L. T. Harrold, Manager,
Generation
Engineering
Bonneville
Power Administration
R.
F. Mazurkiewicz, Chief, Operations
Branch
D.
L. Williams, Nuclear Engineer
State of Washin ton Ener
Facilit
Site Evaluation Council
C. Eschels,
Chairman
W. Fitch, Executive Secretary
~Back round
On June 7, 1988,
a management
meeting
was held at the Region
V Office with
the individuals identified in paragraph
1 in attendance.
The purpose of
the meeting
was to continue the dialogue
between
Region
V and the Supply
System
on items of mutual interest
and recent
developments
in program
enhancements
in response
to SALP and the safety system functional
inspection
(SSFI) that were conducted in 1987.
Recent
NRC concerns
have focused
on several
areas
since the beginning of
1988.
These
concerns
were concentrated
on personnel" performance errors,
clearance
order/system
lineup deficiencies,
engineering
design errors,
weaknesses
in documenting/reporting
plant problems,
performance of root
cause
analysis of events,
management
awareness
of plant problems,
and
follow through
on commitments.
Repetitive personnel
errors
and clearance
,order deficiencies
which have
impacted plant operations
or resulted
in
near misses
have
been of particular concern.
Examples
included:
a.
Operations
personnel
errors
January
18 - Nisoperation of safety/relief'alves
resulted
in an
actual
low reactor pressure
vessel
level following a normal
shutdown.
February
13 - Erratic operation of the turbine bypass
valves
(following a manual
caused
level excursions
and masked
a
diversion of water through the reactor water cleanup
system to
the condenser
(a path not previously
known to exist).
February
14 - Control
room and equipment operator errors in
restoring
the reactor building heating
and ventilation
(HVAC)
system resulted
in building overpressurization
and rupture of
the roof.
March
12 - Control rod 46-51
was unknowingly mispositioned
from
step
48 (full out) to step
36 while taking rod drive stall flow
measurements.
April 30 - Main steam isolation valves
(MSIV) closed following a
reactor
shutdown
due to failure to adequately
anticipate plant
conditions
(underestimated
rate of pressure
drop).
May
1 - Approximately 9600 gallons of reactor coolant were
drained to the suppression
pool
due to improper control switch
operation while realigning Residual
Heat
Removal
(RHR) Train
B
from shutdown cooling to suppression
pool cooling mode.
May 12 - A resin spill (and consequent
Unusual
Event) occurred
due to two open valves in a sample line.
b.
Clearance
order/system
lineup deficiencies
Nay 3 - An electrician unknowingly worked on an energized
4160
VAC potential transformer
drawer
due to a tagging error.
Nay 6 - Reactor building vent fans automatically tripped
on
actual
high reactor building pressure
due to closure of
ventilation exhaust isolation valve during surveillance
.(operators
did not check the consequences
of pulling fuses for
testing).
II'ay
16 - An electrician
was flash burned while working on an
energized
bus for a tower makeup
pump (load side of breaker
was
energized
since motor was
powered from an alternate
source).
May 17 - Two condensate
valves
opened
when power was restored
after
a Division I bus outage which resulted in draining about
200 gallons of condensate
into a feedwater heater
where
two
mechanics
were working.
c.
Maintenance
personnel
errors
February
4 - Instrumentation
and control (I&C) personnel
initiated a reactor
scram while performing
a surveillance test
(technicians
tested
a second trip channel without asking
operators
to reset the channel
already tripped).
May 25 - Electricians
improperly installed
a design
change
on
No.
1 diesel
generator
(found during post-modification testing);
local start switch would not function because
one wire had been
incorrectly determinated.
April 1 - Two fuel bundles fell over onto the refueling floor
after uprighting of shipping container
due to the failure of
mechanical
maintenance
personnel
to attach securing brackets.
April 11 - A mechanic
stepped
on
a new fuel bundle while
preparing the bundle for inspection.
In the area of engineering
design effectiveness,
a number of concerns
were
identified by the
SSFI team,
the resident inspectors,
and the licensee.
These
concerns
related to inadequacies
in the design data base,
weaknesses
in the design
review process,
and possible
weaknesses
in the design
organizational
structure
(one manager for every
30 - 35 engineers).
Additional concerns
identified during 1988 related to weaknesses
in
documenting/reporting
plant problems
and follow through
on timely
completion of commitments.
In particular,
nonconformance
reports
(NCRs)
were not initiated on the fuel assembly that was stepped
on nor on recent
motor operated
valve
(MOY) problems.
In the case of the
MOYs, not issuing
an
NCR resulted in plant management's
not being fully aware of the extent
of problems with MOYs.
A recent licensee
event report
(LER 88-06) also
did not disclose that operating
crews did not understand
the severity of
the transient
described
and did not identify corrective actions to prevent
future backflow of reactor water through the feedwater
system.
With
regard to follow through
on commitments,
the Supply System stated in LER
87-24 that,
"Engineering efforts already in progress
to upgrade Electrical
Wiring Diagrams to top-tier status will be expedited."
However, this
effort was apparently discontinued in December
1987 and remained
on hold
thereafter
due to realignment of priorities.
The meeting
convened at 10:00 a.m.
Mr. Martin opened the meeting
by stating that these
meetings
have
been
useful in maintaining communications
and minimizing misunderstandings
between
the
NRC and the Supply System.
0
Mr. Mazur began the Supply System's
presentation
by discussing
the purpose
of the visit and by briefly describing recent performance
enhancements
and
prospective
organizational
changes
at MNP-2.
After introductory remarks,
Supply System representatives
made
presentations
on the following subjects:
Organizational Initiatives
Mr. Oxsen presented
the agenda
and discussed
recent
management
and
organizational initiatives.
He identified that the last operating
cycle was marred
by too many personnel
and performance
problems.
Mr.
Oxsen stressed
the
need for more management
involvement and personnel
accountability in the conduct of activities at MNP-2.
He stated that
these
enhancement
efforts should result in fewer
human errors, better
design products,
and
a safer
and more reliable plant.
Personnel
Performance
Issues
Mr.
Powers discussed
recent problems in the area of personnel
performance.
He category ized the performance
errors
and discussed
other items
such
as
inadequate
clearance
orders that led to some of
the recent events.
Mr. Powers detailed the
new discipline policy in
response
to poor performance
and outlined proactive
items designed
to
provide positive reinforcement to aid performance.
This presentation
was followed by a series of questions
to further understand
the
licensee's
enhancements.
Mr. Oxsen
summarized
the initiatives by
stating that the Supply System is unhappy with past performance
and
Mr. Mazur
emphasized
the fact that management
is
trying to penetrate
and improve existing attitudes of personnel.
Mr. Martin responded
to these initiatives by stating that correcting
the problems
leading to inadequate
clearance
orders
should
be
a
number
one priority.
He also identified that the
NRC has
become
increasingly concerned
over the negative trend in operations
personnel
performance.
In particular, the February 13,
1988 reactor
water level excursions
and the
May 12,
1988 resin spill events
have
raised
concerns
about the knowledge levels of some operators.
In
addition, there
has
been
an apparent
lack of penetrating
management
involvement and ability to turn around the operating crews'ttitudes
and performance.
Mr. Martin stated that
he sensed that no one
approach
would produce
a change in performance.
Instead,
he
suggested
that
a combination of items
may be necessary
to bring about
an effective change in attitudes.
Design Issues
Mr. Burn provided
an outline of the internal
and external
evaluations
that had been performed
on engineering
and des'ign issues
during the
last 12 months.
These evaluations
were performed primarily due to
deficiencies identified during the SSFI conducted
by, Region
V in
August 1987.
Additional concerns
were raised
by the
NRC in February
1988 as
a result of an inadequate
anticipated transient without scram
(ATWS) design
change that was being installed in the plant.
Mr. Burn
identified that
a re-review of design'ackages
implemented during
refueling
outage
(R-3)
had
been
performed
as
a result of these
internal
and external
concerns.
He identified that
no safety
problems
were found during these
reviews.
Nr. Burn also discussed
the "Engineering
Improvement Plan" that is being
implemented to make
enhancements
to the design
program.
Mr. Powers followed by
providing a description of the plant modification request
(PMR)
implementation
improvement program.
He stated that it was believed
that the enhancements
to these
programs
would minimize the
possibility of inadequate
design
changes
reaching the plant for
implementation.
Nr. Mazur summed
up these
program changes
by
identifying that
a
QA audit would be performed prior to the end of
1988 to evaluate
the effectiveness
of the changes.
Mr. Nartin responded
to these
enhancements
by stating that
engineering
is
a full partner with operations
in conduct of
activities
and must share
the responsibility for plant operations.
He reiterated
Nr. Burns'oncern
that the Supply System engineering
department
must get over its construction mentality.
Nr. Martin also
stated that the Supply System must delve into problems,
before they
identify themselves
at
a significant level.
He also suggested
that
the Supply System look at the single-unit Region
V utilities and talk
to them individually about engineering
program enhancements.
QA/QC Initiatives
Nr. Bouchey presented
the
QA/QC initiatives that were being
instituted to enhance
the effectiveness
of the quality programs.
In
particular,
a number of program
improvements
and management
enhancements
have
been planned,
such
as the issuance
of a
new policy
statement
on quality and
an increased
level of management
participation in quality matters.
Nr. Martin stated that
QA needs
to be more aggressive
in identifying
problems.
He stated that the test will be to see if QA has
a hand in
identifying future significant issues
before they identify
themselves.
Nr. Martin stressed
the concern that problems
need to be
identified to the appropriate
levels of management
at an early enough
time so that they can
be properly dealt with.=
He noted that
sometimes it may be necessary
to raise the issue prior to finding
proof that it is
a bona-fide problem.
Mr. Martin also stated that if
the Supply System could wait until problems are self-revealing,
then
they would not need organizations
such
as
QA.
He further noted that
opinions
and intditions are worth hearing
because
often they are
correct.
Nr. Martin summed
up the NRC's concerns
by stating that he
sensed
that the Supply System
has the capability to make
QA more
effective.
Balance-of-Plant
System Survey
Mr. Powers
presented
a brief description of the balance of plant
system
survey that was instituted to assess
systems for
susceptibility to wiring deficiencies
such
as those
found in the
reactor building overpressure
event that occurred
on February
13,
1988.
He described
the criteria that were established
as guidelines
for the survey and summarized
the results of the effort.
The results
found, in general,
were that systems
were adequately
tested
and
had
performed
as designed.
The remaining actions to be performed
by the
Supply System
wer'e to execute
the technical
support center
(TSC)
ventilation interlock verifications and complete the control switch
verifications
on 8 switches that
had similar installations to the
reactor building supply and exhaust
fans.
Refueling Outage Status/Restart
Program
Mr. Powers
provided
a brief description of the restart evaluation
process
and its results.
He identified the work that had
been
completed
and the remaining
items to be worked prior to startup.
Issues
assessed
within the restart evaluation
process
were stated
to
include the status of 27 functional
programs,
the operability of
balance-of-plant
systems,
management
review of deferred maintenance
tasks,
and more rigorous documentation of plant readiness
for
restart.
Mr. Powers also stated that the results of the restart
evaluation
would be presented
to Supply System
managers
upon
completion.
Mr. Powers
completed his portion of the agenda
by identifying the
scram frequency reduction efforts that were initiated in response
to
the
1987
SALP recommendations.
The primary focus of this effort was
to strengthen
performance
requirements
and emphasize
procedure
compliance.
In addition,
such things
as divisionalization of
surveillance
procedures
had
been
implemented to reduce the potential
for working on the wrong train while performing surveillances.
Mr. Martin suggested
that it may be worthwhil'e to contact the
Institute for Nuclear
Power Operations
( INPO) and other organizations
to det'ermine
what efforts have already
been
performed in the area of
scram reduction.
Conclusions
Mr. Mazur concluded
the Supply System's
presentation
by emphasizing
that
he would maintain strong vigilance on the work load,
management
involvement,
and organizational -strength of the Supply System.
He
stated that efforts would concentrate
on the proper establishment
of
priorities, that "not enough
time"- to perform. activities would not be
a valid excuse,
and that the threshold for questioning faulty work
would be decreased.
He stressed
that
he would open
up minds
and
attitudes
to the necessity for constructive self-criticism.
Mr.
Mazur identified that .he was promoting
an exchange
program between
the Supply System
and the Swedish State Power'Board.to
exchange
information and personnel.
He also identified that
he was initiating
an effort to increase
the operational
experience of the Corporate
Nuclear Safety. Review Board.
Mr. Mazur stated that these additional
initiatives were being established
to enhance
and expedite the
quality of Supply System activities.
Mr. Mazur sumarized
the Supply System's
problems
as
an inability to
work as
an effective team
and to be self-critical.
In the attempt to
satisfy everybody,
he felt that they had satisfied
nobody.
Selected
slides
from the licensee's
presentations
are enclosed
with this
report.
~C1
1
R
1
In closing, Mr. Martin responded
to the Supply System's
presentation
by
summarizing
the
NRC's concerns.
He restated
the need for additional
management
emphasis
on personnel
performance
and attitudes, for raising
issues
to appropriate
management
at an early stage,
and for optimizing gA
effectiveness.
In addition,
he also stressed
the need for the proper
allocation of resources
to make effective changes
(e.g.,
management
involvement),
and
a commitment to excellence
in training (e.g., simulator
upgrades
and adequate
operator instruction).
Mr. Martin stated that
enhancements
appeared
to be well thought-out for the majority of the
programs,
but that operations
performance
needs
to be turned around
by
more direct action
and management
involvement.
The meeting adjourned at 4:00 p.m.
Enclosure:
Slides
from the licensee's
presentations
ENCLOSURE
SELECTED SLIDES
FROM THE LICENSEE'S
PRESENTATIONS
NRC/SUPPLY
SYSTEM AGENDA
JUNE 7, 1988
WALNVTCREEK, CALIFORNIA
AGENDA
A OPENING
REMARKS
JB Martin
DW Mazur
B
PRESENTATION
BY SUPPLY
SYSTEM
I INTRODUCTION
II PERSONNEL
PERFORMANCE
III DESIGN ISSUES
~
Root Cause Assessment
Results
Integrated Plant Modification
Improvement Program
Design Engineering
Implementation Initiatives
IV QA/QC INITIATIVES
V BOP SYSTEM SURVEY
VI R3 STATUS/RESTART PROGRAM
Vll SALP
VIII CONCLUSIONS
C ISSUES OF CURRENT NRC INTEREST
~
Personnel Performance/Involvement
in
Recent Plant Problems
~
Engineering/Design Control
~
Documentation/Reporting of Plant Problems
~
Recent Limitorque MOV Problems.
D OTHER TOPICS OF INTEREST
E CLOSING REMARKS
AL Oxsen
CM Powers
GD Bouchey
JP Burn
GD Bouchey
CM Powers
CM Powers
CM Powers
DW Mazur
10
30
50
20
30
5
II.
P ERSONNEL
P ERFORMANCE
C.M. Powers
~
Categorization
of performance
lapses
~
Management
initiatives on
procedural
compliance.
~
Selected
corrective
actions
in each
category
~
Summary
PERSONNEL
PERFORMANCE
ISSUES
~
Categorization Of Performance Lapses
~
Individual Performance Errors
RHR valving
MSIV isolation surveillance error
Reactor vessel level/pressure control
Fuel handling
Control rod mispositioning
MSIYclosure
PERSONNEL
PERFORMANCE
ISSUES
(cont'd)
~
Inadequate Clearance Order Boundary Established
Reactor building overpressurization
Improper tagging on SM-4
Feedwater heater flooding
Electrical switchgear near misses
MANAGEMENTINITIATIVES
ON PROCEDURAL COMPLIANCE
~
Discipline policy and implementation directed
squarely at procedural compliance issues
Meted out fairlyand consistently
Escalating penalty for severity and repetitious
performance
Termination of employment for failure to support
our mission
. MANAGEMENTINITIATIVESON PROCEDURAL
COMPLIANCE (cont'd)
C
~
Plant management developing a "sense of
stewardship" in all employees
Increase management's
involvement in problem
.resolution
Better recognition of successes
and positive
feedback to individual contributors
Develop "quality circles" in each functional area to
identify and address morale problems
Develop pay-for-performance comp'ensation for
employees
MANAGEMENTINITIATIVESON PROCEDURAL
COMPLIANCE(cont'd)
~
Restructure
Bargaining Unit contract to support complete
right of selection
of foreman, control room operators,
and training
~
Reorganize
Maintenance
Department to apply stronger
control of work activities and better planning
~
Modify problem identification programs
to emphasize
potential problems
and implement dedicated
root cause
program
~
Institute other reorganization
initiatives to strengthen
planning capabilitites
and build stronger station
management
team
SELECTED CORRECTIVE ACTIONS (cont'd)
~
Reactor Vessel Level/Pressure Control
General Operating Procedures revised to direct
level management strategy when isolated
New procedure created to direct shift from normal
shutdown to hot standby
Upgrade simulator model to more accurately
followreactor inventory behavior
SELECTED CORRECTIVE ACTIONS (cont'd)
Operations Management to conduct simulator
crew evaluations and guidance sessions on level
management
Operations Management to "close ranks" on policy
and plant initiatives
Personnel performance issues are pursued and.
discipline used to reinforce expectations
Long-term design change is to install a small
capacity, motor driven feed pump
SELECTED CORRECTIVE ACTIONS (cont'd)
~
Inadequate
Clearance
Order Boundary
Suspended
all high voltage, switchgear,
and
transformer work
Conducted
electrical shop meetings
on ramifications
of near miss
Instituted a Clearance
Order review process
on
outstanding
R3 electrical switchgear work
SELECTED CORRECTIVE ACTIONS (cont'd)
Required component-by-component
testing for
de-energization
prior to work
. Identified known backfeed
circuits on switchgear
.Established
new independent
Clearance
Order
Control Group on all remaining
R3 work to ensure
work description
and Clearance
Order boundaries
are adequate
0
SELECTED CORRECTIVE ACTIONS (cont'd)
~
Valve Control in Radwaste
Reassess
adequacy
of procedure
controls on
deactivated
solid radwaste
system
interface with
liquid radwaste
operations
Ensure other deactivated
valves are adequately
isolated
Modify management
response
to Unusual
Event
declarations
Plant Manager or Assistant will respond
on all
unusual
events
plus affected department
manager
DESIGN
ERROR
ROOT
CAUSE
ASSESSMENT
BACKGROUND INFORMATION
~
Too many errors were being discovered
during design
implementation. Therefore, QA requested to do indepen-
dent root cause analysis
.
Polled several groups about problem PMRs plus looked at
recent PMRs with numerous FCRs-initial resulting list was
23 PMRs
Concentrated on errors that represented
incorrect techni-
cal information-not opinion preference, field interferences,
or administrative detail
~
Screening against established erior criteria resulted in the
eight PMFts (approximately 11 errors) which were analyzed
in detail for root causes
CONCLUSIONS
~
General
~
Difficultdata base and lack of elementary diagrams
~, Insufficient planning/scheduling
~
Management control in l&C/electrical (span of control,
adequate technical oversight by managers, etc.)
~
Errors concentrated
in I&C/electrical discipline, but
similar problems not ruled out in other disciplines
CONCLUSIONS
(cont'd)
~
Design Process
~
Improved up front communication/design criteria definition
~
Errors could be reduced. by creating "FOR CONSTRUCTION
ONLY"drawings
~
Engineering department system engineers not always
.
involved with all system changes
~
Lack of sufficient personnel feedback on problems, in-line
quality measurements,
and self-assessment
programs
CONCLUSIONS (cont'd)
~
Checking, Verifying, and Review Processes
~
Lack of up front communications/design
criteria definition
affects these functions also
insufficient time scheduled for thorough checking, review-
ing, and verifying
The necessary expertise has not always been selected for
~ these functions
There has been a lack of accountability associated with
reviewer signatures
Waiver of optional review steps has not received manage-
ment scrutiny
~
QA Overview
~
QA involvement too little and late
"ENGINEERING IMPROVEMENT PLAN"
~ Post SSFI/ARI Activities
~
Design engineering meetings
Checking/verifying changes
~
Rereview R-3 design packages
~
Q.A. Auditing upgraded
~
Generation. engineer internal evaluation
880435.45
PMR IMPLEMENTATIONIMPROVEMENT
PLAN
~
PMR Implementation Commitments from SSFI
1.
Process improvements
Focus on Closure of work-'OCS'
Partial implementation formalized
Preimplementation revews
Post implementation reviews
2.
Post Modification,testing/training
Clarified who is responsible for what (with regard to testing)
Mandatory use of appropriate PMT forms for each type of work
performed
3.
Implementation package review of selected
R-3 mod's
-10% sample of R3 work (significant impact)
Noted areas for improvement-documentation
. l3edicated function within technical staff
PMR IMPLEMENTATIONIMPROVEMENT PLAN (cont'd)
~
Additional Supply System Reviews Since SSFI
Supply System audit by Q.A.-¹88-434
Result - Similar issues as in SSFI
Conclusion - SSFI corrective actions still valid
Line verification effectiveness review'
Reaffirmed integrity of PMR process
Recommended
improvements:
- Generation Engineering (Design)
- Plant Technical (implementation)
- Purchasing and Materials Management
- Records Management and Plant Administration (close-out)
- Quality Assurance (Receipt inspection, QC and QA
processes)
- Maintenance (Testing Review)
SAFETY ASSURANCE AND QUALITY
INITIATIVES
(1)
Management Enhancement Initiatives
~
Organizational & Staffing
~
Training/Qualifications
~
Attitudes/Organizational Norms
Planning
~
Information and Feedback Systems/Communications
(2)
Program Improvements
~
Evaluation of Engineering Design Activities
~
QA/QC Program Improvements
~
Root Cause Assessment/Corrective
Action Programs
~
Nuclear Safety Assessment
Initiatives
~
Licensing/Regulatory Compliance Initiatives
BALANCE OF PLANT SYSTEM SURVEY
(Corrective Action Follow-Up to NCR 288-050)
~ Qbjective
~
Assess other systems for susceptibility to similar type
wiring deficiencies
~ Discussion
~
Safety related systems/components
are not considered
likelysubjects for similar wiring errors due to technical
specification surveillance tests that are routinely performed