ML17286A396

by plant walkdowns,

an evaluation of the

EOPs using

simulator exercises,

a review of the

EOP training program,

and

a sampling

review of engineering calculations

supporting the

The inspection

team used Inspection

Procedure

No. TI 2515/92, Revision

1 as

guidance during the inspection.

Results:

~

The inspection

team concluded that the

WNP-'2 EOPs,

although adequate,

were,

in places, difficult for operators

to use, with a potential for causing

safety-significant errors.

08'DR ~DOC~~ 90'p

0

OCK Ogpoo>9

F'NU

There were weaknesses

in technical justifications for significant deviations

from'he Owners

Group Guidelines

and

some

areas of the

EOPs did not conform to

the'equirements

of the writer's guide.

Procedure

walkdowns with operators

indicated that the verification and

validation of EOPs

and support procedures

were marginal.

Calculation errors

resulted in errors in the

EOP graphs.

The specific inspection findings are documented

in Section

1, "Inspection

Details," of this report.

These findings were discussed

with the licensee's

staff identified in Attachment

C of this report.

Summar

of Violation:

None

Summar

of Deviations:

None

0 en Items

Summar

(Open)

Open Item 50-397/90-20-01,

Primary Containment

Venting Deviation

Justification

(Open)

Open Item 50-397/90-20-02,

Primary Containment Flooding Deviation

Justification,

(Open)

Open Item 50-397/90-20-03,

(Open)

Open Item 50-397/90-20-04,

and

EOP support procedures

Steam Cooling Deviation Justification

Development

and Verification 8 Validation of

(Open)

Open Item 50-397/90-20-05,

Instruments,"

concerning operabil

temperature

conditions

(Open)

Open Item 50-397/90-20-06,

Implementation of EOP Caution 1,

"RPV Level

ity limitations due to reactor building

Calculation Errors in EOP Graphs

INSPECTION DETAILS

TABLE OF

CONTENTS

SECTION

PAGE

NO.

1.

Comparison of the

WNP-2

and

the

BWR Owners'roup

Emergency

Procedure

Guidelines

(Task 1)........................

2.

Technical

and

Human Factors

Review (Task 2)..........

2.1

Technical Review................................

2.2

Human Factors Review............................

3.

Review of EOPs

by Plant Walkdowns

(including the Control

Room)

(Task 3)................

3.1

3.2

Plant Walkdown Evaluations......................

Verification and Validation

Program Evaluation..............................

12

4.

Functional

EOP Evaluation

(using the simulator),

and

an

Evaluation of EOP Operator Training (Task 4).........

4.1

Simul ator Evaluations...........................

4.2

Evaluation

EOP Operator Training................

5.

Ongoing Evaluation of EOPs

(Task 5)..................

6.

Exit Meeting and Persons Contacted...................

Attachment A:

Deficiency Details....................

Attachment

B:

Flowchart Deficiency Examples

and Simulator Scenarios.............

13

15

16

17

27

Attachment

C:

NRC Personnel

and Persons

Contacted...

Attachment

D:

Documents Reviewed....................

28

30

Note:

Task 6, "Interviews with EOP users,

developers,

and

other appropriate plant staff", was incorporated

into Tasks

1-5 by the inspection

team.

1,

,

INSPECTION DETAILS

Com arison of the

WNP-2

and the

BWR Owners'rou

Emer enc

Procedure

ul

e ines

s

as

The team inspection

compared

the

WNP-2 Emergency Operating

Procedures

with

the

Revision 4, to ensure that the licensee

had generated

procedures

in accordance

with the owners'roup

recommendations.

The

reviewed are listed in Attachment

D to this report.

Where significant

deviations

between

these

documents

were identified,,the

team verified that

the deviations

were adequately justified and documented,

except

as follows.

The team identified the following three deviations

and one deficiency

during the comparison

review.

0 en

0 en Item 50-397/90-20-01,

Primar

Containment Ventin

Deviation

ust1 lcatlon

EOP 5.2.1, "Primary Containment Control," Revision 5, Primary Containment

Pressure

flowchart contained

a significant deviation from the

Revision 4.

The deviation concerns

venting containment with core

damage

greater

than

10$ .

The

EPG criteria requires venting containment to the

environment if containment

pressure

cannot

be maintained

below the Primary

Containment

Pressure

Limit (PCPL). If primary containment

pressure

cannot

be reduced,

the

EPG directs spraying the drywell (at the expense of core

cooling, if necessary,

since water would be redirected to containment

spray,

from direct Reactor

Pressure

Vessel

(RPV) injection) to reduce

primary containment

pressure.

If core

damage is less

than lOX, WNP-2 uses

the

same

guidance

as the

BMROG EPGs, which is to vent first (regardless

of

core damage).

However, if core

damage is greater than

10$ , the

WNP-2 criteria is to

spray the drywell first. If the drywell cannot

be sprayed,

the

MNP-2

guidance is to then vent the primary containment to the environment.

The licensee justification for the deviation is documented

in the

WNP-2

EPG Deviation Document,

Primary Containment Control,

pages

19 - 22.

The

licensee justification emphasizes

that because

the containment is not

expected to "actually yield" until pressure

is we'l above the

PCPL, the

potential off-site dose is not warranted.

MNP-2 states that the criteria

to vent "before" the

PCPL is reached is inappropriate.'owever,

the

MNP-2

justification does

not provide engineering calculations

or documentation

to support this conclusion.

The trade-off between venting containment,

at risk to the general

population,

and the potential to exceed

the

PCPL due to a delay in venting

should

be based

on well justified and documented calculations.

The team

concluded this issue

was significant,

and that the philosophical

and

technical

issues still need to be resolved.

The licensee

acknowledged this finding, and committed to pursue the issue

with the

BWROG.

This issue

was referred to the Office of Nuclear

Reactor Regulation for evaluation.

0 en

0 en Item 50-397 90-20-02,

Primar

Containment

Floodin

Deviation

usta icat)on

EOP 5.1.4,

EOP Flooding, Revision

0 contained

a significant deviation from

the

Revision 4.

The deviation concerns initiation of primary

containment flooding if the

RPV water level remains

below the top of

active fuel (TAF), after the initiating event

and attempts at mitigation

with emergency

core cooling systems

(ECCS).

The

BWROG EPG, Revision

4 requikes

containment flooding initiation if the

RPY water level remains

below the TAF (for ATWS and

non-ATWS conditions).

WNP-2 deviates

from the criteria for both

ATWS and

non-ATWS conditions.

For non-ATWS conditions,

WNP-2 did not require primary containment

flooding, but instead directed all available

ECCS

be aligned for.RPV

injection, with a suction from the suppression

pool.

For

ATWS conditions,

WNP-2 directs flooding only if: I) RPV level cannot

be maintained

above 2/3 TAF with either High Pressure

Cooling System

(HPCS) or Low Pressure

Cooling System

(LPCS) injecting at rated flow,

or 2)

RPV level cannot

be maintained

above

TAF, without HPCS or LPCS

injecting at

a flow rate greater

than

6000

gpm, or 3)

RPV level is unknown

and neither

HPCS or LPCS injection flow is above

6000

gpm.

The team concluded additional justification and further review would be

required.

The licensee

acknowledged

the issue

and committed to resolve

the issue with the

BWROG.

The issue

was referred to the Office of Nuclear

Reactor Regulation for review and evaluation.

(0 en

0 en Item 50-397/90-20-03,

Steam Coolin

Deviation Justification

EOP 5.5.1

RPV Control, Revision

7 contains

a significant deviation from

the

Revision 4.

Revision

4 to the

BWROG

EPG requires that

with no

RPV injection source available

when

RPV levels drops to minus

210

inches

(about 2/3 core height),

Emergency Depressurize

the

RPV (to maximize

the steam cooling effects,

given the limited RPY water'nventory).

However, the

EOPs specified that, with no

RPY injection source available

other than

RCIC,

CRD,

SLC or

ECCS Keep-Full

pumps, continue to inject

into the

RPV with RCIC,

CRD,

SLC or

ECCS Keep-Full

pumps.

The

did not require emergency

depressurization

until

RPV level

can not be

determined,

rather than at minus 210 inches

(which is within the

indicating range).

The issue is when to initiate emergency

RPV depressurization,

under

various

RPV level

and injection availability conditions.

The concern

deals with determining the best core cooling method (to maintain

an

adequate

eoolable

core geometry)

under very low core water level degraded

conditions.

The team concluded that additional justification and further review was

required.

The licensee

committed to resolve the issue with the

8'DEROG.

The issue

was referred to the Office of Nuclear Reactor Regulation for

review and evaluation.

0 en

0 en Item 50-397/90-20-05,

Im lementation of EOP Caution I, "RPV

eve

nstruments,

concernsn

o era

s st

smltatsons

ue to reactor

ul

sn

tern erature

con itsons

EOP Caution I, "RPV Level Instruments,"

EOP 5.0.0,

"EOP Cautions,"

Revision I, concerned

the temperature

effects

on instrument line runs which

affect

RPV level instrument accuracy.

The caution required operators

to

know the temperature

near

RPV level instrument line runs in the secondary

containment,

to determine if fluid in the instrument lines

was near the

saturation

temperature for the

RPV pressure.

If the temperatures

in these

areas

reached

or exceeded

saturation conditions,

RPY level indications could

be erroneously high.

This would mislead operators,

and could lead to

further degradation of the event.

However,

WNP-2 does

not have remote

or local reading

temperature

instruments for instrument line runs to

determine

these

temperatures.

Also, portable instruments

were not

pre-staged

and available to compensate

for the lack of installed

instrumentation.

It was also noted that the licensee

changed

the wording of the caution

from the

EPG, Revision

4 guidelines.

The wording was changed

from keep

the temperature

"below the saturation

temperature"

to do not permit the

temperature

to go "above the saturation

temperature."

The change

was

non-conservative

as the

WNP-2 wording omits the case of temperature

"equal

to the saturation

temperature."

If the temperature

near the instrument

lines

was equal to the saturation

temperature,

reliable

RPV level reading

could not be assured.

The caution,

as it was

implemented

by the licensee,

was non-conservative

and could result in operators

using unreliable

RPV level instruments.

This open item was acknowledged

by licensee

personnel

who indicated that

corrective action would be formu1ated.

Technical

and

Human Factors

Review

Task

2

The team reviewed the

EOPs listed in Attachment

D to ensure that the

procedures

were technically adequate

and appropriately incorporated

the

guidelines

provided to the licensee

by the Owners'roup.

During this

review, the team considered

the following criteria:

The prioritization of accident mitigation strategies

in the

was

appropriate.

The step

sequence

of the

BMROG guidelines

was followed or deviations

were adequately justified.

EOP entry, decision,

and. exit points were clearly specified

and correct.

Transitions within and between

procedures

were appropriate

and well

defined.

Deviations

between

the

WNP-2 EOPs,

as defined by the licensee's

Plant

Specific Technical

Guidelines

(PSTGs),

and the

BWROG guidelines

had

been identified and justified.

Deviations required

by the plant-specific design

had

been

incorporated

as necessary.

Notes

and caution statements

were used properly.

Plant-specific

values

and setpoints

were correct,

and adverse

containment

values

were provided.

The

adhered to the requirements

of the plant-specific

writer's guide.

The following deficiencies resulted

from the technical

and

human factors

reviews of the

WNP-2 EOPs

and supporting procedures,

during this phase of

the inspection.

2.1

Technical

Review

a ~

Deficiencies in

EOP Develo ment

The following are examples of deficient

EOP development

which

were identified by the inspector.

They are organized

under the

associated

procedure

reviewed during this portion of the inspection.

(1.)

EOP 5.3.1,

Secondary

Containment Control, Revision 6:

See Attachment

B, Example fl for the flowchart under

discussion.

The decision block that stated, "If an area

temperature

exceeds

its maximum safe operating temperature

in more than one area

(Table 1)," could be misleading.

Table

1 referenced

by the

step contains

many "areas" (left to one's interpretation of,

"area").

Both areas

and

rooms are called locations

on the

table.

For example,

the table references

the

RWCU Pipe Routing

Area

R511 and the

RWCU Pump

Room,

and if the operator interpreted

this area

and

room as only one area,

appropriate action would

not be taken.

The intent of the step is to take action when any

two "locations" exceed

maximum safe operating temperature.

Misreading the step could result in failure to depressurize

the

plant as required.

This

same style decision block appears

in

all three legs of this procedure.

This

human factor deficiency

should

have

been identified during the

EOP developmental

phase.

Cl

(2)

(3)

b.

EOP 5.1.2, "Failure To Scram," Revision 6:

See Attachment B, Example f2 for the flowchart under discussion.

The procedure

had

a confusing step which had potential to cause

errors in performing safety-significant actions.

The

EOP step

that started with "If Necessary,

Override

ECCS Valve Logic per

5.5.1,

.

. ." was confusing to operators,

because "If necessary"

could be taken to apply to the entire step of lowering

RPV level

rather than just to the action of overriding

ECCS interlocks

using

an

ESP support procedure,

as intended.

The step should

start with and emphasize

the required action.

In this case

the

action is obscured

by the long procedure title and modifier, "If

necessary."

The step should

be clarified.

This wording is

contrary'o accepted

human factors standards.

The significance of this concern

was confirmed during interviews

with the licensed operators

in the operating

crew performing

the simulator functional test of the

(see Section 4).

See Attachment

B, Example

83 for the flowchart under discussion.

The procedures

direct operators

to perform actions in a specific

manner through the use of a number of different terms (e.g.,

"with the following systems,"

"using only those

RHR pumps

"...via RFW-PCV-10A/B").

Because

operators

are trained to

respond to differences

in structure

as equal to differences

in

meaning,

performance of these

steps

may be delayed or confused

as operators

attempt to interpret the steps

and identify the

needed actions.

To prevent this problem, similar steps

should

be written using the

same terminology.

This inconsistency in

structure is the result of incomplete directions in the writer'

guide.

This is contrary to accepted

human factors standards.

Numerous other examples of deficient

EOP development

are

provided in Attachment A, section Al.

Verification and Validation Deficiencies

The following are examples of deficient

EOP verification and validation

which were identified by the inspection.

They are organized

under the

associated

procedure

reviewed during this portion of the inspection.

See Attachment

B, Example

No. 4 for the flowchart section

under

discussion.

0 en

0 en Item 50-397/90-20-06,

Calculational

Errors in EOP

Gra

s.

E

P

.

rap s,

ev>s

on

,

eat

apac ty

emperature

Limit (HCTL) and Pressure

Suppression

Pressure

Limit

(PSPL)

curves did not agree with the calculations

from General

Electric and

WNP-2 engineering,

NE-02-89-20, Revision 0, and

NE-02-89-27, Revision 0.

The inspector

found a non-conservative

error in the

PSPL where the

EOP graph did not match the

calculation.

The licensee

acknowledged

the error and considered

the event reportable.

The error was subsequently

reported to

the

NRC under

10 CFR 50.72.

0

Upon further review the licensee identified another error in

the

HCTL curve.

These errors would have allowed degraded

plant

conditions to continue in the "unsafe regions" of these

graphs.

The licensee

subsequently

documented

the errors in Problem

Evaluation Report

(PER) 290-698

on September

13, 1990.

Control

room instruments

CMS-LR-3 and CMS-LR-5, suppression

pool

level, were red-lined at

a value different than

EOP 5.1.1,

"RPV

Control," Revision 7, specifies.

For the

EOP step

"Can S.P.

Level

Be Maintained

Below 52 Ft," the operators

would use

suppression

pool level instrument

CMS-LR-3 and CMS-LR-5.

The

instrument

had

a red line at 51 feet rather than

52 feet.

The

meters

should

have

been

marked consistently with EOP steps.

The

same instruments

in the simulator were not marked with a red

line.

This item was turned over to the licensee for correction.

The mismarking could result in operators

misreading

the indicators

and terminating all injection earlier than necessary,

causing

additional core

damage.

Several

other examples of deficient

EOP verification and

validation are provided in Attachment A, Section A2.

The team concluded that, in general,

the Plant Specific

Technical Guidelines

were technically adequate

and accur'ately

incorporated

the

BWROG EPGs.

Deviations from the

BWROG EPGs

with some exceptions (identified in the previous section)

were

adequately justified and documented.

2.2

Human Factors

Review

The

WNP2 Symptomatic

Emergency Operating

Procedures

Writer's Guide,

Plant Procedure

Manual 5.0.2

(PPM 5.0.2), selected

EOPs,

ESPs

and other

PPMs were reviewed for consistency with human factors principles described

in NUREG-0899 and

NUREG-1358.

The desktop review identified a number of

human factors concerns,

two of which were in areas

considered

highly

related to human error-decision

steps

and transitions within and between

procedures.

Specific examples in this area

are provided in Section

3 of this report,

as the findings were gathered

during the plant walkdown portion of this

inspection.

However, the technical

human factors issues

are presented

here for completeness.

The most significant

human factors concern identified in the

WNP2

EOPs/ESPs

was

a weakness

in the design

and implementation of decision

steps,

also

known as conditional or logic steps.

Decision making plays

an important role in the performance of EOPs.

Because this capability is often degraded

during periods of high

stress, it is important that decision steps

be presented

to operators

as simply as possible,

in clear

and consistent structure.

Inconsistent

and complex presentation

of decision

steps will make the

procedure

more difficult to use

and increase

the possibility of

error.

Operators will interpret the meaning of variations in

presentation.

Different operators

may interpret the variations in

different ways, leading to difFerences

in execution of the

procedures,

some of which will be incorrect.

Operators

faced with

complex

and inconsistent

procedure

steps

wi'11 be more likely to

abandon

the use of the procedure

and depend

on their own experience

and training to address

the event at hand.

Several different types of weak decision steps

were identified

in the

MNP2 EOPs/ESPs.

Some were due to inadequacies

in the writer'

guide.

Examples

4a and 4b, of Attachment

B illustrate the following

human factors concerns:

E

The

MNP2 writer's guide allowed

alternative

designs for the

same

type of logic step.

The "continuation condition step" described

on

page

38 was essentially

the

same type of step

as the "hold point"

described

on page 39.

Because

the flowchart format of the

used

design

as well as the content of a step to convey meaning, different

designs

suggested

different meaning

and therefore different types of

action to operators.

The writer's guide design for "continuation condition" steps splits

the condition from its contingent action.

The condition was attached

to the previous action symbol. This structure

suggests

a relationship

that may not exist, it increases

the length and complexity of the

step,

and it interferes with the link between

a condition and its

contingent action.

The failure to use

some form of emphasis

to

clearly identify the contingent action (such

as

"THEN") also reduced

the link between

the condition and contingent action.

Two different

operators

experienced difficulty in using this type of structure

during simulator exercises.

This indicated

a potential for operators

errors

on safety-significant actions

during emergencies.

The

MNP2 writer's guide also allowed the use of qualifiers that could

confuse

and cause error.

When

an action step followed by a clause

beginning

"EXCEPT," "WHEN," or "other than," the position of the

qualifier clause

may cause it to be read

AFTER the action is begun.

In addition, the complexity of the step is greatly increased

by the

use of such clauses.

An operator error occurred during simulator

exercises

due to incorrect performance of such

a step.

The team also observed that inadequate verification against

the writer's guide requirements,

also resulted in inconsistencies

within the procedures.

Some examples of this are included in

Attachment A, Section A.l, "EOP Development."

This was of particular concern,

considering the complex symbology

incorporated in the

EOP flowcharts (see Section 4.1 for examples

where operators

were confused

by complex

EOP flowchart structure).

In most cases

where

such problems

are identified in a desktop review,

the findings must be presented

as related only to potential error.

However, at

WNP2 the team observed

the effect of these overly complex

and inconsistent

decision steps

during the simulator scenarios

described

in section

4 of this report.

The operator errors that

resulted

from difficulty in execution of decision steps

provide

evidence of the safety significance of these

issues.

b.

Transitions

C.

Movement within and between

procedures

can

be disruptive and

confusing,

and cause

unnecessary

delays

and errors.

Therefore,

when

it is necessary for an operator to reference

other procedures

or exit

one procedure

and branch to another procedure, it is particularly

important that the instructions

be clearly and consistently

structured.

The

WNP2 writer's guide directions

on referencing

and

branching

(pp. 13, 31-32)

was unclear.

Its definitions of referencing

vs. branching provided

no clear distinction.

Examples

4a and 5, of

Attachment

B, illustrate these

concerns.

In addition, variation in the presentation

of transitions

was found

within the procedures,

as

a result of inadequate verification against

the writer's guide

(see Section

3 of this report).

Other writer's

vide issues

The

WNP2 writer's guide contains

several

weaknesses

other than those

mentioned previously that could contribute to operator difficulty in the

use of the procedures.

Examples

5 and 6, of Attachment

B are examples

of those

weaknesses.

"Contingency condition callouts," such

as

"RPV FLOODING IS RE(VIREO,"

are used within the flowcharts.

However, these callouts are placed

within an action'tep

symbol.

As a resu1t,

they appear to direct the

operator to transition directly from the callout to the necessary

contingency.

During simulator exercises,

an operator attempted to

transition directly from such

a symbol, which would have resulted in

skipping an important decision

symbol.

(See

Example 5, of

Attachment B).

Cautions call operator attention to potential

equipment

damage or

personnel

injury.

Because of the critical nature of this

information, cautions

should

be emphasized

and located

where they

.

will not be overlooked.

WNP-2's

EOPs place all of the

EOP cautions

in

PPM 5.0.0,

"EOP Cautions."

This placement of cautions in a

separate

procedure

makes it difficult for operators

to use the

information.

During simulator scenarios,

operators

did not always

read the cautions.

If the information in cautions is truly critical,

operators

should not be required to transition to another

location

to read it. If the information in a caution is'uperfluous, it should

not be contained

in a caution.

(See

Example 6, of Attachment B).

To minimize inconsistency,

an inclusive list of approved action verbs

is an important part of an

EOP writer's guide.

The action verb list

within the

MNP2

EOP writer's guide

was noninclusive.

In addition, it

contained

verbs having the

same

meaning (e.g., control

and maintain;

stop

and terminate).

This was not consistent with basic

human factors

criteria.

The team concluded that the writer's guide design for decision steps

and

also for transitions,

contained

human factors deficiencies that had

a

potential for causing operator difficulty and error in the use of the

procedures

(see Section 3,

Open Item 84).

3.

Review of EOPs

b

Plant Walkdowns

includina the Control

Room

Task

3

3. 1

Plant Malkdown Evaluations

The team conducted detailed

walkdowns of all

and

EOP enclosures.

This

included

a sampling of applicable sections of supporting procedures

referenced

by the

During walkdowns,

team members

asked operators

to

locate

and demonstrate

or simulate the demonstration of equipment

necessary

to carry out the

EOP.

The inspectors

requested

operators

to

obtain

hand tools, jumpers,

spanners,

hoses,

ladders

and other equipment

and physically demonstrate

use where possible.

Additional walkdowns were

conducted to resolve questions

and to evaluate

the ability of a cross

section of operators

to implement the'EOPs.

Shift Managers,

Control

Room

Supervisors,

Shift Technical Advisors, Reactor Operators,

and Nuclear

Equipment Operators

participated in the walkdowns

and discussions.

Selected

walkdowns were evaluated

by the team

human factors specialist,

in

order to complete the

human factors evaluation.

The team concluded that, with the exceptions

noted, the operators

were able

to execute or simulate executing

the

and supporting procedure

steps.

Most steps

and actions were carried out with little difficulty or

assistance.

The team noted the relay and jumpering locations were well

specified

by the procedure,

and with few exceptions

the operators

were

knowledgeable

in the execution of enclosure

steps.

a.

Exam les of Deficiencies in the

Found Durin

the Plant Malkdowns.

ey are organize

un er t e assoc>ate

proce ure t at was 1nspecte

,

unless stated

otherwise.

The method of procedure retrieval

and verification used

by operators

for emergency

support procedures

could cause significant delay in

implementing

emergency actions:

Controlled copies of emergency

support .procedures

were not available

for Reactor Operator

and Equipment Operator

use during emergencies.

The operators

had to remove procedures

from controlled volumes in the

main control

room and radwaste

control

room and

make copies

on local

copy machines.

This delayed

implementing

ESPs

from 5 to 15 minutes

during the walkdowns

and could do the

same during emergencies.

Additionally, copy machines at both locations

were powered from

non-safety electrical

buses

which may not be available during

emergencies.

10

1

Additional delay was encountered

because

operators

called the control

room to verify the procedure

was the latest revision.

Verification

during emergencies

would burden the control

room with unnecessary

calls,

and was contrary to the requirements

of PPM 1.2.3

"Use of

Controlled Plant Procedures,"

Revision 14, Paragraph

1.2.3.5.B. 1

which indicated verification was not required for procedures

from the

main or radwaste

control rooms.

EOP 5.1.2, "Failure To Scram," Revision 6:

The procedure

had

a confusing step which had potential to cause

errors in performing safety-significant actions.

The

EOP step that

started with "If Necessary,

Override

ECCS Valve Logic per 5.5.1,

." was confusing to operators

because "If necessary"

could be taken to

apply to the entire step of lowering

RPV level rather than just to the

action of overriding

ECCS interlocks using

an

ESP support procedure.

The step should start with and emphasize

the required action.

In

this case

the action is obscured

by the long procedure title and

modifier, "If necessary."

The step should

be evaluated

and

clarified.

This finding was discovered

during interviews with

operators

during this portion of the inspection.

This concern

was also observed

during the simulator portion of this inspection

(see Section 2.1.a (2) and 4.1).

EOP 5.1.4,

"RPV Flooding," Revision 0:

The procedure

contained

a step concerning

Minimum Alternate

RPY

Flooding Pressure

(MARFP) that was confusing to operators

due to

complex logic and branching.

The-MARFP action of exiting from the

step "If No SRVs

Can

Be Opened," to the step

"Can At Least

5

SRVs

Be

Opened,"

was confusing.

The licensee

should evaluate

reworking the

step or providing additional training to operators.

ESP 5.5.17,

"Primary Containment Flooding," Revision 0:

Steps

2 and

3 of the procedure

are "if statements"

that require the

Shift Manager or Control

Room Supervisor to concurrently recheck

entry conditions while executing all other flowchart EOPs.

The

additional "if statements"

not contained within the flowchart EOPs

add difficulty and burden to the operators.

Major decision points

should

be on the flowcharts to ensure viability and continued tracking.

PPM 2.3.3,

Containment Atmospheric Control, Revision 14:

Section 5.1, Step

5 refers to Board Kl(K2).

This

same

board

was

referred to as

P827 in other procedures.

This problem was generic to

other procedures

where in some

cases

the General Electric H13-PXXX

designation was'sed,

and other times the letter designation

was used.

The procedures

should

be reviewed

and revised to insure consistency

in panel identification.

PPM 3.3.1,

"Reactor

Scram," Revision 12:

11

Step 3.3.1.5.3

references

the use of PPM 2.2.3,

Revision

12 (Reactor

Water Cleanup).

The inspector found that the

PPM 2.2.3, Revision

12

in the control

room included

numerous

deviations (i.e., temporary

procedure

changes).

Some of the deviations

made in the procedure

(pen

and ink changes)

where not listed on the deviation form at

the beginning of the procedure.

Additionally, the copy quality

of the altered

page

12 of 69 was poor and difficult to read.

The

licensee

should consider upgrading their procedure deviation system.

PPM 2. 10. 1, "Reactor Building HVAC, Revision 13":

Step

6 directed the operator to place the damper control in AUTO.

The operator stated that

common practice

was to insure the indicating

needle is within the red circle prior to going to auto.

The extra

operator

action was not specified in the procedure.

Step

10

appeared

to indicate

REA-FN-3 was in the

CRD repair room.

The

operator located the fan (after a delay)

on the level above.

PPM 2.3.3,

"Containment Atmospheric Control," Revision 14:

Section 5.8, Steps

3 and

4 required operation of keylock switches,

CAC-FCV-1A(1B) and CAC-FCV-4A(4B).

The installed switches

were

correctly labeled,

but they were not of the keylock switch type.

PPM 2.10.1,

"Reactor Building HVAC", Revision 13:

Section 5.1 contained

several

steps that

had deficiencies.

The

inspector

identified the following deficiencies:

Step

5 required placing control switches

ROA-FN-1A(1B) in the

AUTO position.

There

was

no AUTO position indicated for the

switches.

Steps

11 and

12 indicated that the REA-FIC-3A setpoint should

be

adjusted

by the operator.

The operator did not know, and the

procedure

did not specify, that the adjustment

was

an internal

adjustment.

Other controllers

had adjustment

knobs external to

the controller housing.

The procedure

should

be specific or

more training should be provided to operators.

ESP 5.5.19,

"RPV Draining To Restore

RPV Level Indication," Revision

0:

Paragraph

5.5.19.2 specifies

one

15 foot step ladder

(RHR-A pump

room) for use in reaching

RHR-V-67 to open the valve.

The prestaged

ladder

was

an 8 foot step ladder, which was inadequate

to safely reach

and

open the valve.

The licensee

replaced

the ladder with a

10 foot

ladder and plans to write a procedure deviation to specify the

10 foot

ladder.

The inspector considered

the action appropriate.

I

12

ESP 5.6.1, "Station Blackout," Revision 0:

Step 5.27 directed the operator to reference

another procedure.

The actions

involved are simply the closure of five breakers

listed

in ESP 5.6.1

and

a few simply related actions.

If this is in fact

a simple task of which all licensed operators

are aware, the use of

this procedure

should not be disrupted

by a transition to another

procedure.

Step

12b. of the procedure

performed isolation to prevent

a reactor

core isolation cooling (RCIC) system isolation or reactor trip on

high exhaust

pressure.

The step shuts isolation vaIves

RCIC-PS-9A and

RCIC-PS-9B to isolate the pressure

switches

but does

not remove

instrument line caps

between the valves

and pressure

switches.

With

an unvented

dead leg, valve leakage or temperature

changes

could cause

an

RCIC isolation and defeat the purpose of the step.

The step should

be evaluated

and revised.

The blackout procedure listed no tools or equipment to execute

the

procedure.

At a minimum, flashlights,

keys for failed doors,

and

wrenches to replace

compressed air bottles would be needed.

The

procedure

should

be reviewed

and necessary

tools and equipment

shou1d

be listed and prestaged.

Step 5.4.a directs operators

to shut

HPCS-V-4 when

RPV water level

reaches

40.5".

A WNP-2 operator believed that this was technically

incorrect and stated that the appropriate

action was to allow the

valve to shut automatically (which it should

do at 55.5").

Other findings in this area are detailed in Attachment A.

3.2

Verification and Validation Pro ram Evaluation

The team also reviewed

WHP2's verification and validation program (VSV).

The V8Y process

is necessary

to assure that the procedures (I) integrate

WNP2 plant-specific technical

information, including setpoints;

(2) are

written using the format and structure defined in the

WNP2 writer's guide;

(3) reflect the plant labeling used in the

WNP2 control

room and plant;

(4) can

be understood

and used

by operators

to mitigate potential plant

events;

and (5) can successfully

be used to bring the plant to a

safe'hutdown

condition.

Verification and Validation Pro

ram Desi

n

The team concluded that the verification and validation program design

was

generally sound, with the following weaknesses.

PPM 5.0.4

(Emergency Operating

Procedures

Flowchart Validation) indicated

that validation of revisions to the procedures "... need only encompass

the changes

made to the previously approved

procedures."

Depending

on

the nature of the changes,

and the magnitude of the changes,

the impact

on procedure usability may extend

beyond the discrete

changes.

For example,

an engineering

change to relief setpoints

on the safety relief valves could

have broad impact on the

13

Verification and Validation Im lementation

Despite the general

adequacy of the verification and validation program

design,

the

WNP2 EOPs/ESPs

contain

numerous

indications that verification

and validation implementation

was inadequate.

Section 2, 3.1,

and Attachment A, section A.2, of this report, detail the

specific findings in this area.

In addition, simulator exercises

yielded several

operator errors

due to

complex and inconsistent

procedure decision steps

(see section

4 of this

report).

The failure of the

WNP2 validation process

to identify these

problems

suggests

that the validation program

was weak.

Despite the difficulty in use of the procedures

experienced

by operators

during the simulator exercises,

mitigation of the simulated events

was

accomplished

(see Section 4).

0 en)

0 en Item 50-397/90-20-04,

Develo ment and Verification 8 Validation

of

E

s and

E

su

ort

roce ures

The team concluded that the writer's guide design for decision steps

and

also for transitions

contained

human factors deficiencies that had

a high

potential for causing operator difficulty and error in the use of the

procedures.

The number of errors in the developmental

process

for EOPs,

and the large

number of verification and validation weakness

identified in

EOP walkdowns

(see section 3) indicated

weak program implementation.

The team concluded that the verification and validation program design

was

generally adequate,

but that implementation of this program

was deficient.

Again, the result of this inadequate verification and validation of the

EOPs/ESPs

was procedures

that did not thoroughly reflect the writer'

guide or the plant,

and that were in places difficult for operators. to use

with a potential for causing safety significant error.

Functional

EOP Evaluation

usin

the simulator

and an Evaluation of EOP

erator

rain

n

as

Simulator

Evaluations

The team conducted simulator exercises

using the

The licensee

provided an operating

crew to participate in five simulator exercises

(see

Attachment B).

Use of the simulator enabled

a dynamic evaluation of the

capability of the

EOPs to guide successful

mitigation of accident

consequences.

The team eva'luated

EOP use including entry into and exit

from EOP and

EOP support procedures,

transitioning between

procedures,

placekeeping, ability of EOPs to direct operator mitigative action,

adequacy of training on procedures,

and the interface

between personnel,

procedures

and the control

room.

t

During the scenarios,

situations

required

imp'lementation of multiple

enclosures

to the

Execution of enclosures

was riot evaluated

during

the scenarios.

14

During post-scenario

discussions,

operators

indicated that the wording of

EOP 5.1.2, "Failure to Scram," Revision

6 was confusing

on the step "Is

more than one rod not fully inserted7"

The phrase "is more than

one rod

not" was confusing

as it implied verifying what "was not" rather than "what

was."

The wording should

be evaluated.

On

EOP flowchart 5.1. 1,

RPV Control, Revision 7, two similar step blocks

caused

confusion in two separate

exercise

scenarios.

The block step that

starts with "Line up for injection, start

pumps

and increase

RPV injection

flow to maximum with all of the following... ," confused operators.

In Scenario

85, the

CRS proceeded

past this block to the block "Terminate

sources

external

to the primary containment,"

then realizing his mistake,

returned to this block, and then proceeded

to the Primary Containment

Flooding

EOP.

In Scenario

5'6,

a different

CRS misinterpreted

the

same steps

and waited at those blocks, failing to make

a decision whether

or not to go to the Primary Containment

Flooding

EOP,

as required.

The

EOP steps

and training on the steps

should

be evaluated.

Example 4a, of

Attachment

B, is the flowchart of concern.

On

EOP flowchart 5.2.1, "Primary Containment Control," Revision 5,

(Example

Sa of Attachment

B) the spraying

and venting initiation logic

and philosophy as the

PCPL is approached

should

be evaluated.

When

containment

pressure

is increasing

towards the

PCPL and pressure

mitigation action

has

been or is unlikely to recover containment

pressure

control, delaying spray initiation until

PCPL is reached

may not be

prudent.

EOP 5.2.1 stated, "Ifwetwell pressure

cannot

be maintained

below the PCPL," which conflicts with the

BWROG intent (see

Example 7,

of Attachment B).

The

BWROG,

EPG, Revision

4 wording indicates that

sprays

are initiated "before reaching" the maximum limit.

The

distinction between the

and the

EPG phraselogy is that the

permit operators

to wait to make

a decision (to spray) until the

PCPL

has

been

reached

or exceeded,

rather then making this decision prior

to reaching the

PCPL.

This structure actually delayed operator action

during the scenario.

Consideration

should

be given to revising the

step to meet the intent of the

BWROG guideline.

On

EOP Flowchart 5.5.1,

"RPV Control," Revision 7, the operating

crew in

the simulator took an incorrect path

on

a decision block which resulted in

a decision to depressurize

the

RPV when it was not required.

The decision

block read:

"Is any injection system,

or alternate injection system other

than RCIC,

CRD, SLC, or ECCS...

running?" During the third scenario

the

operators

miss-read this block as

a "yes" answer

and did not depressurize

the

RPV as required.

This is another

example of the complicated structure

of the

EOP flowchar ts.

Consideration

should

be given to restructuring

them,

as noted elsewhere

in the report, incorporating accepted

human

factors guidelines.

15

The team concluded that the

EOP flow charts

could be used to mitigate the

accident scenarios

demonstrated

in the simulator. Occasional

errors in the

flow charts

were made by the Control Operations

Supervisor

(CRS) during

the demonstration;

however,

the required major mitigation action

was

demonstrated

in all cases,

in that

no safety significant further

degradation of the event would have occurred

because

of the operating

crew's actions.

4.2

~Trainin

Initial and periodic training for all licensed

and non-licensed

operator

who execute or interface with the

EOPs during accident conditions

was

evaluated.

The evaluation included review of lesson plans,

interviews

with operators

and training instructors,

and

a review of tests, critiques,

and documentation of training.

5.

The team reviewed the

WNP-2 Hot License/Requalification

program for EOP

training for licensed operators

and shift technical advisors.

The program

is contained in Lesson

Plan 82-RMD-0901-LP, "Licensed Operator/STA

Training,

EOP Training," revision 1.

The team found that training program

for the operators

interviewed appeared

adequate.

On oin

Evaluation of EOPs

Task 5)

Section 6.2.3 of NUREG-0899 establishes

a criteria that licensees

establish

a program for the ongoing evaluation of EOPs.

NUREG-0899

further specifies that the ongoing evaluation

program should include

the evaluation of the technical

adequacy of the

on the basis of

operational

experience

and use, training experience,

simulator exercises,

and control

room walkthroughs.

Section 6.2.4 of NUREG-0899 specifies that

processes

should

be established

to ensure timely revision of EOPs

based

on

input from these evaluations

and assessment

of the

EOP effects of design

modifications

and changes

to technical specifications,

technical

guidelines,

and the writer's guide.

The inspection

team assessed

the

WNP-2 program's

provisions for ongoing

evaluation of EOPs.

The procedures

that defined program elements

and

other documentation

was reviewed

and interviews were conducted.

Although

EOP evaluation at WNP-2 was not addressed

by a single program,

the essential

elements

were adequately

addressed

within the Plant Procedure

Manual

(PPM).

The programs

described

in

EOP 5.0.2,

"Symptomatic

Emergency Operating

Procedures

Writers Guide," Revision

0 and

EOP 5.0.3,

"Emergency Operating

Procedure Verification," Revision

0 provided that

and support procedure revisions

were to be addressed

in the

same

manner

as

initially developed

procedures.

The procedures

required the

same

verification and validation for revisions

as for new procedures.

Procedural

requirements for changes

to plant equipment described in

PPM

1.4. 1, "Plant Modifications," Revision ll required

a plant procedure

checklist

and plant procedure revision list to be used.

PPM 1.3.51, "Plant

Labeling Program," Revision

1 required the Plant Labeling Coordinator to

16

ensure

label

changes

were coordinated with the procedures

control group to

ensure

procedures

were updated.

PPN 1.4.3, Revision of Master Data

Sheets

and Setpoints,"

Revision

9 included provisions to review and

update plant procedures

when setpoints

changes

were necessary.

PPM 1.2.4,

"Plant Procedure

Review, Approval, and Distribution," Revision

12

required

a bi-annual

review of all procedures.

The team concluded, that

except the deficiencies identified below, the program for ongoing

evaluation of EOPs

was adequate.

The team noted the following deficiencies:

PPM 1.2.3,

"Use of Control Plant Procedures,"

Revision 14, Section

1..2.5.F described

the procedure for making deviations to procedures.

The deviation procedure

appeared

to apply to EOPs.

The team

concluded that deviations

were not appropriate for EOPs.

Deviations

procedures

did not provide for the

same level of preparation,

review,

approval

and verification and validation.

The deviation procedure

did not include provisions that would contain

a review of associated

procedures.

The review of associated

procedures

would be important

for EOPs where

numerous cross-ties

and interfaces exist.

The

licensee

should consider

upgrading the provisions for implementing

deviations to their EOP's,

such that

a review of associated

EOPs is

incorporated.

PPM 1.3.51, "Plant Labeling Program,"'Revision

1 did not provide for

any independent verification of label attachment

on safety-related

systems.

The plant labeling program interfaces with activities

affecting safety and should

have independent verification that the

label

changes

are correct. Also, the procedure

does

not appear to

provide for integration of the plant labeling program with the

Control

Room Design Review

(CRDR) effort.

The lack of integration

could cause

degradation of the Control

Room Design Review Effort over

time.

Labeling replacements

and changes

may invalidate portions of

the verification and validation for the particular component/

procedure.

The licensee

should review the plant labeling program

procedure to ensure that standardization

and quality of labels is

maintained.

6.

Exit Meetin

and Persons

Contacted

On September

13, 1990, the, team and other

NRC representatives

held an exit

meeting with licensee

personnel

and discussed

the scope

and findings of

the inspection.

Persons

contacted

by the team and attendees

at the exit

meeting are identified in Attachment

C.

The licensee

did not identify as proprietary any of the material provided

to the team during this inspection.

The licensee

representatives

acknowledged

the inspection findings

presented.

17

ATTACHMENT A

DEFICIENCY DETAILS

Al.

~EO

0

PPM 3.3.1,

"Reactor Scram," Revision 12:

The note preceding

step

3 actually refers to step

2 actions.

It is

incorrectly placed after the step.

PPM 3.3.1,

"Reactor Scram," Revision 12:

Step

34 includes incorrect punctuation (e.g.,

ARM's and IRM's) and

the use of and/or.

EOP 5.1.2, "Failure To Scram," Revision 6:

The acronym

"ATWS/ARI" violates writer's guide requirements for use

of a "slant line."

This item is

a reflection of inadequate

verification against

the writer's guide.

The acronym

"ATWS/ARI" fails to match the related control board

label, which uses

the acronym "ATWS-ARI." This item is

a reflection

of inadequate verification against plant labeling.

The writer's guide directs that periods

should

be omitted in

abbreviations

"except in cases

where the omission would result in

confusion.

The procedures

contain examples of abbreviations that

violate this guidance (e.g.,

"chg. hdr. isol. valve" ).

This item is

a reflection of inadequate verification against the writer's guide.

The writer's guide describes

use of a unique flowchart structure for

conditional statements

followed by additional criteria which must

be

met before the associated

action can

be performed.

The

EOPs include

examples of the use of this structure that are not preceded

by a

conditional step.

This item is a reflection of inadequate

verification against the writer's guide.

The

RPV level control path includes

a step written with four

qualifying terms: if necessary,

irrespective,

except,

and until.

The

use of even

one qualifier adds decisions

and complicates

a step; this

step is unnecessarily

complex and difficult to perform.

EOP 5.1.3,

"Emergency

RPV Depressurization,"

Revision ll:

A step in this procedure

includes

use of'he complicated logic

sequence

beginning "until..." when it could be simply reworded

as

"Ensure

a total of 7 SRVs are open.).

This is an example of

inadequate verification against

the writer's guide.

18

~

A2.

Verificati on and

Va1 idati on

PPM 3.3.1,

"Reactor Scram," Revision

12:

Step 4.c incorrectly indicates "printout" when in fact operators

would merely look at the screen.

Step 3.a.6 is found at the bottom of page

4 of 14, as well as at the

top of page

5 of 13.

Step 3.b references

section

B of PPM 2.4.6.

No section

B exists.

Step 3.d references

section

D of PPM 2.4.4.

This section

does not

exist.

The note prior to step

4 uses

the unit identifier psi/sec.

This

should read psig/sec.

Step

9 directs that valves will indicate

"CLOSED."

The use of all

capital letter indicates

exact label representation

per the writer'

guide.

There is no label written as such.

Operators

use the green

light to verify valves closed.

Step

11 references

"Panel C."

The board labeling indicates

"Board

Il

Step

14 is

an example of inconsistency

in spelling out vs.

acronyms

(e.g.. graphic display system vs.

GDS).

Step

23 appears

to include

an implicit reference

to

PPM 4.12.4.6

according to a licensed senior operator.

Step

17 included

a series of STA actions within a procedure

intended

to direct operator actions.

This series'f

STA actions

would appear

to more appropriately

be included in

PPM 1.3.5.

Procedure 2.3.1, "Primary Containment Venting, Purging,

and Inerting,"

Revision 15:

Section 5.1, step

2 requires

a noble gas activity reading from

recorder

BD-RAD-22(23).

The recorder

was

a two-pen recorder with one

pen reading noble gas

and the other particulate.

The pens

had

no

identification as to which pen

was which other than

"NG" and

"particulate" written in pencil

on the instrument nameplate.

The

recorder

nameplate

should

have permanent

approved labeling for the

pens specifying which pen is noble gas.

Section 5.1, step

11 requires

a controller setting at "5X above"

which was confusing to operators.

The valve being controlled was

100$ open

when the controller indicator was

a OX.

The value

"5%

above"

was used elsewhere

in the procedure

but included

an example

illustrating what "5X -above" means.

The step should

be made clearer

or examples of how to properly use it added to the step.

19

PPN 3.3.1,

"Reactor Scram," Revision 12:

Pagination for this procedure is incorrect.

For example,

the

procedure

page

number block at the bottom of each

page alternates

between

page

"1 of 13," "2 of 14," and

"3 of 13."

Step 3.3.1.5.A contains

a reference

to

PPH 1.1.8.

This procedure

essentially directs operators

to follow the requirements

of Radiation

Work Permits

(RWPs).

This step

appears

to be unnecessary.

Attachment

A includes

a listing of valves,

sometimes

according to board

position,

sometimes

not, making the verification task awkward and

time consuming (e.g.,

SGT-V-4A-1 follows SGT-V-3B-2 on the list,

however they are found on different panels

in the control room.

Attachment

A includes

RHR-V-123A and

RHR-V-123B.

These valves cannot

be closed

from the control

room.

Procedure,2.10.1,

"Reactor Building HVAC," Revision 13:

Procedural

steps

required operation of the

HVAC condensate

return

valves in the northeast

corner of the reactor building, elevation

572

feet.

There

was

no platform from which to operate

the valves.

An

operator could possibly fall to the

501 or 471 foot level.

A

platform or special

precaution

should

be evaluated.

The thumbwheel setting in step

8 should

be -0.6 rather than +0.6 as

the procedure specifies.

The face/bypass

damper control temperature

switch ROA-TIC-3

identified in step

15e

had

no identification label.

EOP 5.06,

"EOP Tool and Equipment List," Revision 0:

Under procedure 5.5.3, the gate valve that is installed

on the fire

hydrant is not listed as being required.

Only two 2-1/2 inch hoses

are specified

as being required for connecting

condensate

pump A

suction to the fire hydrant.

The hoses in the fire locker

(as

specified

by

EOP 5.06) are

50 foot hoses

and the distance to one

hydrant is about

140 feet and would require

3 hoses.

The procedure

specified the spanner

wrenches

attaching

hoses

but did not specify

hydrant wrenches for removing hydrant caps or operating the hydrant.

EOP 5.06 did not li~t the station blackout procedure 5.6.1.

Under procedure 5.5.8, the hose adapter that is attached

between the

hose

and the Standby Liquid Control relief valve flange was not

specified.

20

EOP 5.1.2, "Failure To Scram," Revision 6:

The note indicating that the

RPV level section of the procedure

provides

guidance for RPV level control is unnecessary.

Basic use of

the procedure entails that the user

be in all paths,

including the

RPV level path.

The contingency condition callout for emergency

RPY depressurization

is not used prior to every transition to

PPM 5.1.3.

The contingency

condition callout for emergency

RPV flooding is not used prior to

every transition to

PPH 5.1.4.

These inconsistencies

are the result

of inadequate verification against the writer's guide.

Abbreviations

and acronyms

are found in the procedure that conflict

with those listed in the writer's guide (e.g.,

SP vs. S.P.).

This is

a reflection of inadequate

verification against

the writer's guide.

EOP 5.1.3,

"Emergency

RPV Depressurization,"

Revision ll:

The "wait until" symbol is inconsistently structured within this

procedure (e.g.,

some of these

symbols include the direction "then

proceed.").

This is an example of inadequate verification.

EOP 5.2.1,

"Primary Containment Control," Revision 5:

Note:

See Attachment

C, example 7:

The writer's guide describes

use of a unique flowchart structure for

conditional statements

followed by additional criteria which must be

met before the associated

action

can

be performed.

The

EOPs include

examples of the use of this structure that are not preceded

by a

conditional step,

but rather

use qualifying clauses prior to the

"additional criteria."

This

procedure also includes the use of

dotted lines in this symbol, which is not addressed

in the writer'

guide.

This item is a reflection of poor verification against

the

writer's guide.

The writer's guide defines the use of the term "per" to indicate

references

to other procedures.

This procedures

also

uses "refer to"

to indicate references.

This item is a reflection of poor

verification against

the writer's guide.

This procedure

uses

the symbols

"N" superscript

2, "N" subscript 2,

and the word "nitrogen."

This inconsistency is

a reflection of poor

verification.

This procedure

uses

the acronym "DSIP."

This acronym should

be

"DSIL." This is

a reflection of poor verification.

Brackets

are

used in this procedure,

in conflict with writer's guide

directions that brackets

are not to be used in

procedures.

This

item is a reflection of poor verification against the writer's guide.

(

21

ESP 5.5.9 Boron Injection,Via

RWCU, Revision 0:

This procedure alternates

between

use of the term

"RWCU Demineralizer

Control Panel"

and "Graver control panel."

According to a plant

operator,

there are multiple Graver control panels,

and therefore,

the consistent

use of the term

"RWCU Demineralizer Control Panel" is

important to the use of this procedure.

This item reflects

inadequate verification.

A dymotape

label

was found on TWCU-MX-5.

Dymotape,is

temporary

and

uncontrolled.

It should not be found on any plant equipment.

If

additional labeling is necessary,

official controlled plant labels

should

be used.

The valve operators for the manual

valves listed in step ll.b of this

procedure

are

on the floor at the valves,

however, they are not

dedicated for EOP/ESP

use.

In step 10.e.,

the word "FILTER" is shown in all capital letters,

suggesting

per the writer's guide that it is an exact representation

of plant labeling. 'n fact the label is

"LOW FLOW RESET

VESSEL A."

This is an example of inadequate verification against

plant

labeling.

Step 13.e. is

a similar operator action to step 11.e,

however, it is

structured in a very different manner.

This is an example of

inadequate verification.

Step 14.g directs the operator to "Confirm the

PRECOAT CONPLETE alarm

is illuminated.

Because

the writer

s guide definition of the term

"confirm" directs the operator to take action, it is unclear

how an

operator could take action to make the

PRECOAT COHPLETE alarm

illuminate if i't were not illuminated.

The note preceding step

16 of this procedure

appears

to be

inappropriate at this point in the sequence

of actions.

5.5.3, "Firewater to Condensate

Crosstie," Revision':

During the execution of this procedure,

the Turbine Building rollup

door has to opened to connect the fire hose. The inspector identified

that the procedure did not contain

a note or caution concerning

adverse conditions prior to the step which wou')d require opening the

turbine building rollup.

Radiological conditions during an emergency

may 'require special

precautions

to exit the building.

ESP 5.5.5,

"Defeating

RCIC Low RPV Pressure

Isolation Interlock," Revision

O

~

The format in step

2 is different from identical steps

in other

procedures

such

as

ESP 5.5.1, steps I, 2,

3 and 4.

Operators

should

be presented

with consistent

formats for similar actions

as required

by the writers guide.

22

5.5.8,

"Boron Injection Via RCIC," Revision 0:

The procedure specifies

the uses of crescent

wrenches

(adjustable

wrenches)

on safety-related

equipment.

Although an emergency

may

dictate using any available tools, prestaged

tools should

be of the

proper type for the job.

A ratchet drive and socket or proper size

box end wrenches

would expedite the action

and prevent

damage

to'quipment.

5.5.8,

"Boron Injection Via RCIC," Revision 0:

The procedure

uses

valve numbers without using

a noun

name for the

valve, contrary to the requirements

of the writer's

guide."'.5.11,

"Bypassing

RSCS

Rod Blocks," Revision 0:

This procedure

includes

a note prior to step

2 that attributes

the

human cognitive process of thinking to the

RSCS.

5.5. 17, "Primary Containment Flooding," Revision 0:

Panel

H13-622

had penciled terminal layout markings

on the inside of

the panel door.

Unapproved operator aids should

be removed

from

panels.

ESP 5.5.18,

"Control

Rod Insertion by Overpiston Venting," Revision 0:

Step

3 is not

a separate

action from Step 4, but rather directions to

accomplish

Step 4. It would more appropriately

be integrated into

Step 4, rather than separately

numbered,

suggesting

to the operator

that two distinct,tasks

are involved.

5.5.19,

"RPY, Draining To Restore

RPV Level Indication," Revision 0:

Procedure

steps

4h.

and 4i. specified valve numbers without using

noun

names for the valves contrary to the requirements

of the writers

guide.

5.6.1, "Station Blackout," Revision 0:

Dymotape is used to indicate open/close for PI-VX-262, PI-VX-263,

PI-YX-264, and PI-VX-265.

Dymotape is temporary

and uncontrolled.

If the information is necessary,

the tape should

be replaced with

officially controlled labels.

N

Control panel

E-CP-DG-RP/3

as referenced

out of this procedure

uses

dymotape to label position of the droop switch.

No label is pre'sent

for the switch name.

Step 5.13 fails to indicate which

HPCS and

RCIC room doors to open.

This is an example of inadequate verification.

i

23

Step 5.19.g requires

operator to move

upstairs

to read pressure

on

gauge H2-PI-1/1.

Operator believed that

he could also read this

information on H2-PI-3 and H2-DPIT-l, which are convenience

to valves

manipulated,

rather than

move upstairs.

Step 5.22 contains

a second action that should

be located after 5.23.

This is an example of inadequate

validation.

Step 5.22 leads to action of valving in the

DG building corridor CIA

bottles.

The JPA for these actions is located in the reactor

building truck lock.

An operator

had difficultywith the corridor

actions.

This is an example of inadequate

validation.

5. 1.1

RPV Control, Revision 0:

The contingency condition callout for emergency

RPY depressurization

is not used prior to every transition to PPN 5.1.3.

The contingency

condition callout for emergency

RPV flooding is not used prior to

every transition to

PPM 5. 1.4.

These inconsistencies

are the result

of inadequate

verification against

the writer's guide.

References

to ESPs

are formatted with the procedure

number alone in

parentheses

following a list of the related

systems, for examples

"RHR SW Crosstie (5.5.2)."

This deviates

from writer's guide

directions

on the format of references

and is

a reflection of

inadequate verification against the writer's guide.

The writer's guide defines

the use of "EXCEPT" as

a qualifying term.

This procedure also

uses

the term "other than" in lieu of "EXCEPT."

This item is

a reflection of inadequate verification against

the

writer's guide.

In procedure

steps directing the operator to accomplish

a high level

task through specific means,

the procedure

does not use directives in

active voice to direct the action (e.g., "Stabilize

RPV pressure.

. .

using

.

RWCU

.

. bypassing filter/demineralizers

.

. .")

Specific actions that an operator is to perform should

be stated

directly, as indicated in the writer's guide (e.g., "Stabilize

RPV

pressure.

Use

RWCU.

Bypass filter/demineralizers.").

This item is a

reflection of inadequate verification against the writer's guide.

This procedure

includes the step "IF the continuous

SRV nitrogen

supply is or

becomes unavailable..."

This step is actually an

override step structured

as

a conditional logic step.

This

inconsistency is

a reflection of inadequate verification against

the

writer's guide.

ESP 5.5. 1, "Overriding ECCS Valve Logic To Allow Throttling RPV Injection,

Revision 0:

The procedure

did not fully meet the requirements

of the writers

guide. If the entire procedure is performed,

the step

sequence

of

steps

1, 2, 3, 4, and

5 requires

operator s to alternate

back and

24

forth between division I and division II control

room back panels.

During discussions,

licensee staff did not indicate

any reason for

the specified

sequence.

Additionally, the procedure

specified relay numbers in steps I, 2, 3,

4, and

5 and did not use

noun

names of the relays.

Procedure 2.3.1,

Primary Containment Venting, Purging,

and Inerting,"

Revision 15:

Section 5.2, step 45f requires

operation of valve CSP-Y-800-5,

and 6.

Revision

15 added the steps to operate

the valves.

The operator

found that the valves

wer'e not listed in the Master Equipment List

(MEL).

The valves should

be added to the

MEL as the valves are not

routinely operated

and the

MEL is used to locate the valves.

Section 5.2 of the procedure

had several

steps that were not easily

usable

by the operators.

For example:

Step

2 caused

operator confusion.

The step called for

containment

pressure

but did not specify wetwell or drywell.

In the execution of step 3, the operator

confused

"manual set"

with "tape strip set."

In step 5, operator confusion resulted

from inconsistent

labeling on control

room controller CAC-RMC-5A.

The control

room labeling was different than the procedure.

Section 5.8, steps

3 and

4 required operation of keylock switches,

CAC-FCV-1A(18) and CAC-FCV-4A(4B).

The installed switches

were not

keylock switches.

The procedure

and equipment

shou'Id

be evaluated'nd

changes

as appropriate.

EOP 5.1.2, "Failure To Scram," Revision 6:

The step

"Terminate boron injection if initiated" is

a conditional

step structured in a manner that violates writer 's guide requirements

for conditional statements.

This item is

a reflection of inadequate

verification against the writer's guide.

In contrast to writer's guide directions that state "location

information should

be given in parentheses

following the

identification," the procedures

include inconsistent structuring of

location information.

For example,

"At P609

and P611, remove..." "At

P603, depress..."

and

"Are all scram valves

open2

(blue lights on

P603)."

Conversely,

parentheses

following the step are also used for

information other, than locations

For example,

"Maintain RPV water

level above

-161 in. (TAF).

This item is

a reflection of inadequate

verification against the writer's guide.

<s

P

25

5.5.3, "Firewater to Condensate

Crosstie,"

Revision 0:

Step

2 required condensate

discharge

valves

COND-V-107A, B, and

C be

closed.

Operators

stated

they would use

a pneumatic tool and

a

2

inch socket to close the valves.

Prestaged

dedicated

tools were not

available to perform the action.

The valves could be closed using

the manual

handwheel;

however, the pneumatic tool would save about

15

minutes.

The valves required

150 - 200 turns to close

each valve.

The inspector

noted the handwheel

nuts

on

2 of the

3 valves were

damaged

from previous operations

with pneumatic tools.

Deficiencies

tags for the

damages

were attached.

Step

3 of the procedure

required running firehoses

from the

A

condensate

pump suction to fire hydrants outside the turbine building

rollup door.

Step

3 did not contain instructions to install

a gate

valve on the second

hydrant outlet to allow hydrant use for fire

protection with the hoses

to condensate

connected.

The licensee

found that the step

was in the procedure

approved

by the Plant

Operations

Committee

(POC) but was inadvertently omitted in typing.

The deficiency was corrected prior to the end of the inspection.

5.5.8,

"Boron Injection Via RCIC," Revision 0:

The procedure

requires routing of several

hundred feet of rubber

hose

from the

SLC tank relief valves to the suction of the

RCIC pump.

The

route take the hose

down two levels through

an equipment

hatch

and

through

a floor penetration

above the RCIC'room.

The job would be

difficult for a single 'operator

under

normal conditions.

Consideration

should

be given to installing the hose

on a hose reel

or specify additional operators

to assist with the task.

5.5.17,

"Primary Containment Flooding," Revision 0:

Step

5a is not clear on instructions to flood containment.

Step

5

states

"flood the primary containment

as follows."

Step 5a. states

"if not already aligned for RPV injection, lineup the following

systems for RPV injection."

Step

5a should

be clear that once

systems

are lined up, flooding should

commence.

A3.

Other Ins ection Deficienc

Findin s

I

Procedure 2.10.1,

"Reactor

Building HVAC," Revision 13:

Step

5 required the controller be set at 0.25 inches

W.G.

The

inspector

and operator found the controller was set differently than

the procedure

required.

The procedure

and "as found" setting should

be evaluated

to determine which is correct.

26

ESP 5.5.3, "Firewater to Condensate

Crosstie,"

Revision 0:

The inspector noted that the fire lockers near hydrant

FP-HT-1F

containing the prestaged

tools were in poor condition.

The top was

off one locker, the tops

and sides

were bent,

one locker had

a tamper

seal - one did not, door hinges

were rusty and frozen,

some

hoses

were not faked

down and the lockers were dirty.

Surveillance

procedures

on these

lockers should

be evaluated for adequacy.

ESP 5.5.19,

"RPV Draining To Restore

RPV Level Indication," Revision 0:

There

was

a white tag dated

1983 attached

to the valve noting the

valve had

a packing leak.

The operator thought the leak had been

fixed, but someone

had not removed the tag.

The item was turned over

to the licensee for action.

27

ATTACHMENT B

FLOWCHART OEFICIENCY EXAMPLES

(see attached

EOP f1owcharts)

maxbnum wle operating

tanpa stree (Tab4 1),

its maxlmcxn wle opsrsUng

tempsrattxe

Inmate than ans

area (Tab4 1) ~

Entet PPM 5.1.1, APVControl

and execute ccncurrentty.

REACTOR SHUTDOWN

IS REOUIRED.

Enter PPM S.1.1

~ RPV Control

~nd execute cancurrendy.

Farl etw 4mperatcxe EXCEEDS

Ita mxx4tum sale operating

tampeiatcxe

In tnae than ons

maa (Tab4 1),

Enter PPM 3%1, Normal

Shutdown to Cold Shutdavm

~nd execute ccncurrandy.

IF sn area rad4tion level

EXCEEDS the naxieum as4

opetaUng 4vel In more than cne

~iwI(Tsb4 3)

ELIERGENCV RPV

OEPRESSURIZATIOH IS

AEOUUIEO.

EMEAGENCV RPV

OEPAESSURIZATIOH 15

REOUIAED.

Enter PPM S.1< Ema gsncy

RPV Oepiewuttxs don and

~xacute canctÃfenUy,

Enter PPLI S.ld, Emergency

RPV DeprewurtxsUcn and

~xscu4 ccxlculre ndy

Qp'AwW~ c'.=

LOCATIOH

PANEL

INSTRUMENT

ALARM('F)

MAXIMUMSAFE

OPERATING VALUE('F)

-'. ','"-:,,,:;;,; "-

TABLE't'ECONDARY

CONTAINMENTTEMPERATURES

TABLE2

= SECONDARY CONTE

DIFFERENTIAL TEMP E

RWCU Pum

(1A) Room

RCCPum

Room

P632/642

LD.TE 3A 38)

F632/642

LO.TE~(48)

RWCU

Rout(ng Area - R511

F632/642

LD-TE 2lC l2iD)

LOCATION

RWCU Pump 1A Room

RWCU Pump 18 Room

PANEL

P632/6l2

P532/642

LDTI

LO-Tl

RWCU/ACIDRoom 313

AWCU Pump (18) Roan

PLI2/642

LO TE 24J (2lK)

P632/642

LD-TE-3C (3D)

RWCU HW Aoom

P 612/642

LO-Tl

LO TI

RWCU Pi

Roudng Ares ~ R408

F632/642

LD.TE 24E (24F)

RWCU Pipe Routing Area ~ RS00

F632/642

LO-TE.24A (248)

RWCU Pipe Roudng Ares - 8400

P632/642

LD-TE-24G (24H)

RHR 8 Pump Room

MS. Ttnns(

AHR A Pump Room

P632/642

F632/642

P632'642

LO TI

LDTl

LO TI

Steam Tunnel

RHR 8 Pump Roam

RHA 8 HJ(. Room

R HR A HX. Roam

AHR A Pump Room

F632/642

LD-TE.31A.B.(3ICJ))

P632/642

LDTE.ISJJ. (18K.LI)

140/130

P632%42

LO TE 1SE.G(ISFJI)

130/1SO

F632/642

LD TE 18A (188)

212

g~ IC-IgC,(rfb)

H2 Rec. Room A

H2 Aec. Roam 8

DC MCC Room

Anslyxsr Room A

Anslyxer Room 8

Div. 1 MCC Room

84J

84 J

84J

84 J

84J

84 J

RRA Tl 13

RRA.TI-14

RRA ll-12

RRA.T(.15

RRA Tl.ty

RRA.TI.11

104

TP

SECONDARY CONTi

Div. 2 LICCRoom

PCS Pumo Room

PC Ectca pmsnt Rocm

HPCS Pump Room

CRD Pump Room

84J

BdJ

84 J

RRA.ll 10

RRA-TL20

RRA Tl 1

RRA.T)-2

RRA.TI 18

104

128

LOCATIOH

FDR.A.1 (RHA A Pump Roam)

FDR R.2(RHR 8 Pump Room)

FDA-R4 (HPCS Pump Room)

FDA-A<(RHAC Pump Room)

LPCS Pump Room

HPCS Pump Roan

RHA Pump Room A

RHR Pump Room 8

RHR Pump Aoom C

RCIC Pump Aooin

CAD Pump Room

ALARMI

(ELEVA'10'I

418'i

418".

41 7"r

~ EOR4 alarm 4vst ls 420'0; Soor 4vsl ls 42Fl

SAE

ls any

MSIVopenl

1. Bypass low RPV 4vel MSIV

4cladon Interlocks per PPM

SS.0, Sypassfng MSIVand MSL

Drain Isolation Valve Low Level

40Isdon bttertocks.

2. Alignfire water coogng dlrecdy

to the CAS compreasors per

PPM 20.1, CAS System.

Iinecessary, ovenlde ECCS valve logic per

PPM SS.t, Ovenfding ECCS Valve Logic to

AllowThrotdlng RPV lnjecdon and lower

RPV water 4vel hraapecdve

of any reactor power or RPV level

oecQtadone, by throttgng RPV Injecdon

EXCEPT from boron Injecdon systems or

CRD VKTS

~ RPV4vel4between-101

kt.and-192bt

or

~ Reactor power drops be4w 0%, or

~ Ag SRV's remakt cltwed end

dryweg pressure renwins below 1.00 palg.

2

3

a

7

Qdntah RPV level at dta bvsl to wtdcft Itwss

dsgbersady laweced chow, vddt 0>> Iogowhg

ey¹smo;

~ Csrtdsneatscfeeds>>br

(vh RFVFOCV.tOA/8j

~ CAD

~ RCIC, ddsedng low RPV pc>>esca>> lsdadon

Inter&ebs Kncesesry, per PPQ NSS,

aaaactng ACIDLow Pteeewe Ieobdon

hisrlock.

~ HPCS, onty ffboron la bohg Injected vb gte

SLC eyetsnt.

As nac>>eaary, recktc>> RPV preeecae whhh 0>>

egovrad 100'Aa'. cool down r¹a te aNow

~webb RPV btjsctbn ay¹sm to recover RPV

lnel.

Can RPV

YES

bvel ba tnshtshsd

~bow-102 In.t

~)cyme'<<3

EMEAGEHCVRPV

DEPRESSUAIZATIOHIS

REOINAED.

Enter PPM 5.1S, Emergency RPV

Depresscshsdon

and a eocene

c<<veteran

dye

Tsmdnats and prevent ON lnjecdon

Into the RPV EXCEPT tram boron

Injscdon systems, CRD, end RCIC.

IF no SAVcan

WHEH RPV

be opened,

prescore ia t>>low

d>> QARFP,

j NUMBEROF

j OPEN SRV'a

RPV PRESSURE j

(Pdgj

INNIIRIMALTERNATERPV

j FLOODIHQ PRESSURE (MARFPj j

3

a

7

C<<cvnsnce end slowly In<<sass RPV Injection

to restore and maintain RPV bvel abcwe-14t

In. (TAFjwith0>> fdlowing aye ten>>t

~ Condensatsi Fred>>ster (vts RFW~.IOArgj

~ CRD

~ RCIC, detesting low RPV presscse bdsdon

Intntocka tfaccessary, psr PPM NSS,

Defeating RCIC Low Preswre isoladon

hisrlock,

~ HPCS, only H boron ls betng lnjrcced vta the

SLC system.

14$

I+at

Qstntsh RPV bwl abow.102 In.

IF RPV water level cannot be n>>htslned

~bove tgt ln(TAFj,

Rest<<e snd msincah RPV levet

~bow -102 In.

IF RPY bwl carvtot be restored

and mslntsk>>d above .1 02 In

Knecessary, ovenlde ECCS

valve logic psr PPM SS,I,

Owrriding ECCS Yslw Logic to

ANowThrotding RPV hjscdon

and corno>>nce end slowly

Increase Injection Into U>> RPV

lvlthtt>> fodowhg systems;

~ HPCS

IF rnoce than one

contrd rod 4 not

fogy Inserted,kgf(

Whge exscudng the

Rattan to above.

foNowing¹sg reactor

power commences end

candle>>a to In<<esse,

I

HOTEt

1

j A drop ln SLC isnk bvet to2S40

~

gsgons wdl ec>>tve ths hjscdon ot j

j thfa smoUht of boron and b<<fc

I

j adcL

I

WHEN $00 lb. Olboron hew

been fnjected,

0

h

HEATCAPACITYlEVELLIMIT(HCLL)

HEATCAPACITYTEMPERATURE LIMIT(HCTL)

26

20

'10e

SAF6

100

f

160

I

170

0

20

40

00

80

100

120

dT?he~

bT?rpa HCTL00nw Supplooofon Poor Torrrperaturo

0

200

400

600

000

1000

RPV Prooouo Iporg

SRV TAILPIPE LEVELUMIT(SRVTPLL)

55k

PRESSURE SUPPRESSION PRESSURE LIMIT(PSPL)

61

~ eee

~ ~ e ~

~ e ~ 1

~

40

41

10

0

200

400

000

$00

1000

RPY Proarwro Ipolgl

0

'10

20

40

50

60

102

21

ii

Sapproaoion PoOI Wold Lcvd (h)

MAXIMUMCORE VNCOVERYTIMELIMIT(MCUTL)

PRIMARYCONTAINMENTPRESSURE UMIT(PCPL)

STA

48 40

604m

~100

"5$4 '4

e?00

000

goL

16

6?5

e5

518

~

~ e ~ ~ ee

S15

~ ~ e ~ e ~ e ~\\

~

A

~ e ~ e ~ e

10

CO

~ 44

40

3

so

g

~ ARRL

~ RIN

Afo

et least 2h)ecthn

systems <<no<<up fcr

RPV h)ocdtmy

RPV lovel

Increasing y

0

100020003000

~

Rc

Is at 4sec

<<>> In)ac<<on

ey¹om <<nod up

wt<<f ~ pulnp-

funfklgy

Uns up fbut do not scan pumps In)

ss mony of <<>> fo<<owing S)MID<<tk

h)ec<<cec eyacon>> aa pooalb4:

~ SLC fboron tonk)

~ RHR SW Croeech f<<SS)

~ Are Wecor to Condense>>

Cross<<s f<<SS)

~ ECCS koepfu<<pumps

Start pumps lneg a)MIDA)L

In)oc<<on ey¹oma that <<o

<<nod up fcr RPV In)ac<<on.

Uns up for In)oc<<on, scoff pumps

~nd Increase APVhjoc<<on Sow co

maxknum withAjjot <<>> to<<owhg

, ey¹en>>t

~ Condeno¹e

Coftdone¹o

Boo¹er

~ IKS

~ IPCS

~ RHR4

~ ARAKI

~ RINC

g el<<ter cd <<>> fo<<owhg

con<<I<<or>> etd¹c

~ RPV lewl cannot bs molncafned

at or above -21 0 h.

~ I<<fCS or LPCS la Dgllnjocthg

et rated Sow,

1200

Ti~ 1000

HPCS Pul

0

1000 2000 3000 ~

Rc

IF RPV level drops to

I<<Ih. fIAF),

g~ 9A

STEAM COOUHQ IS REQUtRED.

Enter PPM S.t S, Emergency

RPV DoOnoourtco<<on end

~recuco c ncceron<<yo

la any

hjocthn system, or

to In)octton ay¹em othe

YES

then RCIC, CRD, SLC or ECCS koop

du<<pumps <<ned up tor RPV

)oc<<on whtl~

rtetnhgy

EMERQEHCY

DEPRESSURIEATIOH IS

REOUNED.

Uno up for Injoctfon, atoft pumps

~nd hcroaee RPV In)ac<<on liowto

matdmum withAjjof<<>> following

~yotomoc

~ SLC fboron tank)

~ RHR SW Cfoaoch 0LL2)

~ Bto Wa err to Condono¹e Tle

fSSS)

~ ECCS keogh'tenps

tleither ot <<>> fo<<owhg

cont<<<<<<>> s14u

~ RPV level cannot be rnokaained

et <<above -21 0 h.

~ HPCS or tPCS 4 DtttIn)oahg

at >>cod '<<ow>>

Ur>> up for RPV tnjoc<<on and

operate HPCS and IPCS whh a

~uc<<on from <<>> SP.

Etdt the RPV level ccnotd

eoc<<on of this procodtee

~nd enter the RPV

pfooours control coo<<oft

ot thto Pfocedtas.

ls

AjtbtLHPCS or LPCS

h)oc<<ng kao tho RPV with

~ suction from cr>>

SPT

ls

HPCS or LPCS

HO

RPV hjoc<<on <<owrato

above <<000 gpm2

PRNARY CONTANLIENT

FLOODINQ IS AEOUNED.

Termfnaw RPV hjoc<<on from

~otscoe otftornof to ttw prkn<<y

contohmonL

Erft tho RPc

ot th4 proof

perform PPI

Conte hfnoe

~ ~

StabQhe RPV preewre below

1037 polg with8>> n>>ln turbb>>

bypass valves.

" SP4vel4

~bove 17 tt.

Stsbgtzs APVFreutse

below 1037 palg with

SRV's.

o.a

> 11.Ii"

l>c r,><<1 I

lelc >ol ~ > >5

>

n>l "I 1 I> 'l~

I << I'a:

IF

8>> oonthucato SRV

THEN

nhrogsn wppiyls or

becomes ta>>val4b4

ptas>> aN SAVcontrd

ewltchee In the AUTO

pbttgon,

el

oo> o.,

'l~ ~ > M

>1'> 1>IW> il

61

IIII

v

> t>Ii

r 'we&> I.:>

' >i>'

.'Con

RPV pressure be

HO

casbgfaed below 1037

pslg wist SRYa7

.

~

2

3

a

5

8

~ll

~

>

VES

~ carat

.~ ~

Stabl gas APVPnsswe below 1 037 Palg

uabtg ot>> or mcc>> d 8>> 48owlng

eyswllN'

ACID

~ Mabt Comhneor vfa:

o Main Steam Une Drabs

SJAE's

~ -Sugng Stwn System.--

~

~ RFW Turbk>>a

OIFgss Prehsaun

~ AWCU (recbcutadon mode).bypassing

Nfttt/demlnotafit>>ra and Ifneceas<<y

RWCU lsdation Intodocks per PPM

5$ .a, Overtldng RWCU lactation

kit<<locks

~ RWCU fbfowdown mode), only Ifboth d

the fdfowing condl dms en met:

~ no borcn haa been Injected boo the

RPV

~ no core damage 4 Indcatod as

determined by reactor coolant unyQ

rewlts.

WAITUHTLany ftta

ofd>> fdlowfng ccndtlcna exlsb

~ AN control rods an tufty k>>ected.

~ SLC.TK-t haa been Injected into

the RPV.

~ 2787 lb. ot borh od d and 2885 lb.

ot bonx in aolutfcn has been-

InJected Into the RPV.

~ lthas boon dote tndned that the

~sector wglnmaln shutdown

under ag cond dona without

boton,

thon proceed.

~~MiN~(M

Depnawtfcs the RPV and maintain cooldown rate below 10<PFihr.

SRV'e an being used to

depnaw rice tf>> RPV

THEN

AND

watalnod SAV opening

The contlnuws SRV nitrogen

to conserve nitrogen.

wpply 4 or becomes

UnavaBabfe.

WHEN bodt ol the fogowlng condidor>> on n>>t:

~ The RHR shutdown cooling Inta tfocks can be reset.

~ RPV 4vel can be main tab>>d above+1 3 In-

lnida4 RHR shutdown coogng per PPM2A2, RHA.

WHEN RHR Shutdcwm Cooling

IF RHR Shutdown Coogng

ls eatablhhed,

comet I>> estsbf4hed.

1

,~

RPV CONTROL, 6.1.1

"Aw(~ ln. RPV water level) Signal Auto Actions

1. Reactor Scraln.

2. MSlVlaolatton.

3, HPCS Pump Start.

4. HPCS D/G Start.

5. RCtC Start.

B. RWCU System lactation.

7. RRC Sample Vne lsolatfon.

L RHR Shutdown Cooling lsolatlon.

9. TIP Withdrawal and lsotstfon.

10. Drywall EDR snd FDR Sump Discharge Header Isolation.

11. CWW-1C Trip.

12. TSW-P-1B Trips llBoth TSW Pumps were Running.

13. RCC Pumps Trip.

14. RCC Containment lactation.

15. Breakers 75-72 and 8&82 Trip.

18. RRC Hydraulic Vnes isolate.

17. DrywellAtmosphere Sample Vnes Isolate,

1L RRC Pumps Trip.

19. MC-7C, MC.7F MC~ and MC4E Deenerghfk

20. R.B. HVAClsolatlon and Fans trip.

21. SGT System Start.

22. CEP and CSP Contalnlnent lsotatfon.

23. CN Containment Isolation.

24. Control Room HVACand TSC HVACSystems Start and Align to

Remote AlrIntakea.

25. R.B. Emergency Room Coolers (Except ECCS Pump Rooms) Start.

28. R.B. Vghtlng QUENCH.

27. R.B. EOR and FOR Sulnp Discharge Header lactation.

"""+j"t'~"~'%M':"&@Flax<'"~"" al4ri'a~v""%i:~

'4g+~%~gg(s~sf<clb@gta,<r<,g~g'y~~'"

kthfe>> each of the fogowlng whkh

~hould have Inlda4d but did not:

~ 4c4tlon

~ ECCS

~ Emergency 04eel Ger>>ratora

~~~ ~x< g

a nol Inhaled I22CU

'Io prevent automaec

depreaaurfxation.

Ik

required.

Can

RPV Level

be datenninady

Execute the loll owing three

RPV FLOODING IS REoulRED

Are a'I 4aat 7

ffo

SRV'a open

Extt th4 Frocedtxe

and enaar PPMS,tS,

Emergency RPV

Oepreaaurtzatlon.

IF core damage 4 Indicated,

la¹ate faedwater linea by

doalng RFW V4SA and

RFW.V%$8, feedwatar block

vafvee wltltln20 llllnutea

f¹lowingceaaatlon of

feedwater how.

IF both ol the f¹lo

conditlona are m>>

~ Core damage 4

~ RPV preaa<xe l.

SS pale<

lnit4to the Mat.C

per PPM 22.6. Mr

Exit th4 procedtxe

and enter PPM S.1A,

RPV Flooding.

EOP CAUTIONS, 5.0.0

Qt

To prevent taking acdon based on erroneous Rpv level Indlcathn, an Rpv water level Instrument may Sgf be

used to determine RpV water level Ifeither of the followingcondhlons exist forthat Insuumentr

a The temperature near the Instrument run Is 8)IEXEthe RPV Saturathn Temperature.

RPV SATURATIONTEMPERATURE

s

g't

C

"~ 600

Eg

EE

RPV Pressure (pslg)

1200

b. For any ofthe Instruments In the lollowlngtable, the Instrument reads)ta)gxf the Minimum Usable Level.

1

INSTRUMENT

Wide Range

Fuel 2one Range

Upset Range

Shutdown Range

RANGE (In.)

~150 to +60

~310to 110

Oto+180

0 to F00

MINIMUM

USASLE

LEVEL(ln.)

Q2

RCIC operation with pump suctfon aligned to the SP, when SP temperature ls above liPF, may result In high

turbine lube oil and bearfng temperatures.

Q3

Operating the RCIC turbine below1000rpm may result ln unstable governor operation and equipment damage.

Qi

Elevated wetwell pressure may trip the RCIC turbine on high exhaust pressure.

Q6

IIan ECCS pump Is taking suction fromthe SP and SP temperature exceeds the NPSX Umlt, the pump may be

damaged and become Inoperable.

HPCS NPSH LIMIT

RCIC NPSH LIMIT

2io

h

E

230

I

3~

220

oO

Vl

~I

a. 210

to

10

pslg'sfg'ig

I

Yl4

230

0

II

220

ro

10 psig'

psig'sig'

2

i

8

10

XPCS Pump Flow (X 1000 gpm)

210

0

2

i

6

8

10

RCIC Pump Row (X 100 gpm)

ll40llAlLJV f VL 4Q1ll 0 J'5 L 4% 4

QA1Cs ~

Oi JJi 7'I

~SIMULATOR

OPERATOR CUES

Initiate R-1

(Loss of TR-S)

{Loss of SH-7)

LEVEL RECOVERY RITH ALTERNATE SYSTEMS

g~ "A>A/ds /

PLANT RESPONSE

S PARAMETERS

OBJECTIVE

OPERATOR ACTION

N/A

No EOP action required

COHHENTS

Initia'te R-2

RPV/L < 413"

(TR-N Lockout)

{Loss Cond Vac)

I.A.a

aa

Direct a manual scram

Depress all 4 Pb's

Mode Switch to S/D

Verify all rods full in

Verify APRHs downscale

Exit to PPH 3.3.1

/ gr ~r +(7

~pre

p~y i~wc-cr

III.A.b

Direct RPV/P below 1037 w/ BPVs

bb

Verify BPVs in AUTO 9 930k

II.B.a

aa

Direct RPV/I between

413

8 454.5"

Initiate:-

RCIC

HPCS

RHR A

Initiate R-3

RPV/L < -50

~(HPCS Trips)

HSIVs close

<{RCIC Trips)

~(RHR-2B/C Trip)

RPV/P > 1076$

II.A

Verify Isolations

III.A.a

. Direct RPV/P reduced to 930k

~i'/ SRVs "

aa

Operate

SRVS to reduce

RPV/P

to 9304

b

Direct RPV/P

< 1037g w/ SRVs

bb

Operate

SRVs to maintain RPV/P

< 1037$

'1

SfHULKTOR

OPERATOR

CUES

SCQAKJU

5 O'L-ÃtS 151l-Sly

LlhTL: b/ lo/ VO

LEVEL RECOVERED RITH ALTERNATE SYSTEMS

~~~/ OX

/ z~p g

PLANT RESPONSE

& PARAHETERS

OBJECTIVE

OPERATOR ACTION

RPV/L < -129"

III.C.a

Direct resetting

ADS timers

aa

Reset

ADS timers,

ADS does not

initiate

COHMENTS

/

R>~ . ~/g~r i~pc c.<r ~~

sr

r~

g

QgrA

//CANWJCC7rA

i

II.B.e

Direct Alternate Injection

system alignment

(SLC, RHR/SN

X-tie, Pire Hater/Cond)

ee

Align RHR/SN X-tie for injection

No normal injection II.B.f

system is aligned

Direct starting Alternate

injection pumps

ff

Verify SN- P-2B operating

RPV/L = "161"

II.C.a

Direct Emer.

Dep. per

PPM 5.1.3

aa

Open all

7 ADS SRVs

RPV/P

< SM-P head

II.B.a

Direct RPV/I between

413

& 454.5"

n ~W

sw

'

aw-cr

J':(f-s

c'a 'cK)

RPV/L > 413"

II.B.aa

Throttle injection to maintain

RPV/L between

413" and 454.5"

RPV/L is stable

between t13"

&

454.5"

III.D.a

Direct cooldown 5

< 100>P/hr

aa

Initiate cooldown

Freeze Simulator

al'lrCEIAlllVf V4 IVY ~ JW J

aJ ~ al

SPRAT COOLING

QAIO ~

V/ I4/ O'P

'IMULA'TOR

OPERATOR

CUES

PLANT RESPONSE

& PARAMETERS

OBJECTIVE

OPERATOR ACTION

COMMENTS

nitiate R-1

1494

LOCA)

(RCIC Pails)

(HPCS Fails)

(RHR-V-42A

(fails shut)

(Loss SM-8)

Initiate R-2

(CPs trip)

DM/P > 1.680

I.A.a

aa

IV.D.c

Direct a manual scram

Depress all 4 Pb's

Mode Switch to S/D

Verify all rods full in

Verify APRMs downscale

Exit to PPM 3.3.1

Direct

MM Spray

cc

Cannot Spray

(No RHR-Ps)

II.A

Verify Isolations/EDG/ECCS

HM/P > 8g

IV.D.d

Direct

DH Spray

dd

Cannot

Spray

DN (No RHR-P)

RPV/L ( -161"

II.C.a

Direct Emer Dep per

PPM 5.1.3

aa

Open all 7 ADS SRVs

II.D.c

Direct LPCS injection v/ S.P.

suction

cc

Inject w/ LPCS at rated flow

CUE:

~.RM/P 8 24f

IV.D.e

Direct Emer Dep

ee.

Ho action required,

already

depressurixed

Cue:

W/P > 45$

IV.D.a

Direct RM Venting

aa

Vent MN per

PPM 5.5.14

NOTE:

The simulator vill

not support

jumper

installation.

Freexe the

simualtor at this

point.

f

>reexe Simulator

e a snapshot

and store for use with Scenarios:

2"RMD-09Bl-S16/S17

a)L hlllU(JV f

OC h!UJ

' 70L

o)WP

CONTAINMENT FLOODING

S c ~'~~~ r'o

c/

yngr..

ogxogve

SIMULATOR

OPERATOR

CUES

PLANT RESPONSE

6 PARAMETERS

OBJ ECTIVE

OPERATOR ACTION

COHHENTS

Initiate R-1

10PC

LOCh)

(RCIC Pails)

(HPCS Fails)

(RBR-P-2A/B

trip)

(Loss

SM-7)

(CPs Trip)

DN/P

> 1.684

I.A.a

aa

IV.D.c

Direct a manual scram

Depress all 4 Pb's

Mode Switch to S/D

Verify all rods full in

Verify APRHs downscale

Erit to PPM 3.3.1

Direct NN Spray

cc

Cannot Spray

(No RHR-Ps)

II.A

Verify Isolations/EDG/ECCS

'I.B.e

Direct Alternate injection

system alignment

ee

Align RHR/SN X-tie

II.B.f

Direct Alternate injection

Pumps started

ff

Ensure

SN-P-2B is running

HN/P > 8g

IV.D.d

Direct W Spray

dd

Cannot Spray N (No RHR-P)

RPY/L < "161"

II.C.a

Direct Emer Dep per PPH 5.1.3

aa

Open all 7 ADS SRVs

RPY/L < -210"

NO Spray System

0 rated flow

II.F.a

Direct Containment Flooding

per PPH 5.5.17

= aa

Ezecute

PPH 5.5.17

NOTE:

The MSIVs cannot

be reopened after

closure.

Freexe

the simulator and

walkthrough

PPH

5.5.17

eexe Simulator

a)I 5!lhKJV f

OC Why y7tL o)LJ

LJA'L'Ee 0/ LJ/ 0l

HTDRADLIC ASS,

RPV FLOODING

S~ c~w~

SIMULATOR

OPERATOR CUES

PLANT RESPONSE

6 PARAMETERS

OBJECTIVE

OPERATOR ACTION

W~ADC

P r

Z

COMMENTS

itiate R-1

Hyd ASS)

Initiate R-2

(Turb Trip)

No Change

Scram Signal

N/A

None

I.A.a

Direct a manual scram

ENA,1

(Floodup

indication

upscale)

aa

I.E.a

Depress all

4 pb's

Mode Switch to S/D

Verify all rods full in

Verify APRMs downscale

Direct ARI initiation

aa

Place both ASS/ARI

Switches to TRIP

I.C.a

Direct RRC-PCYs be placed to

minimum and X-ferred to LFMG

aa

Inform CRS that RRC-Ps are

operating

on the

LFMGs

NOTE:

The ASKS logic

trips the RRC-Ps

to the

LPMGs on

high RPV/P

I.C.b

g

bb

Direct RRC-Ps tripped

Trip RRC-Ps

RPV/P

> 1076$

SRVs cycle open

III.A.a

Direct 'RPV/P reduced to 930f

aa

Operate

SRVs to reduce

RPV/P

to 930$

. III.A.b

Direct RPV/P

< 1037g w/ Bus

and

SRYs

bb

Yerify SP/L

>

17'perate

SRVs and monitor BPVs

Rods still out

RPPs Trip

RPV/L < +13H

I.F.a

Direct ADS inhibited

aa

Place both ADS Inhibit

Switches in INHIBIT

II.B.c

II.B.b

Direct RPV/L between

-161" and 454.5"

Direct RPY/P reduction to

5-600'

~ '

SIHULATOR

OPERATOR CUES

SCENARIO 0 82"RHD"P9Pl-S13

DATE: 6/15/9P

HTDRAULIC ATHS,

RPV FLOODING

PLANT RESPONSE

& PARAMETERS

OB3ECTIVE

OPERATOR ACTION

bb

Reduce

RPV/P to 5-600g v/

SRVs and

BPVs g

< 100'F/hr

cc

Align CBPs

Maintain RPV/I between

-161" and F54.5" w/

CBPs and RCIC

WP d'cc

2

Z

COHHENTS

SP/T

> 90oF

IV.A.a

Direct SP Cooling

aa .

Initiate SP Cooling

RPV/I

< "50"

II.A

Verify Isolations

Scram cannot

be

I.B.a

Direct ARI be reset

reset

aa

Place both ASS/ARI Switches in MTO

Depress

both Pushbuttons

9 P650

I.E.e

Direct control rod insertion

from P603

Activate IOA-R-1

ee

Start

2nd

CRD pump'-

Direct CRD-V-34 shut

Drive rods via RHC 6 P603

I.B,c

'irect

RWH bypassed

cc

Bypass

RHH

Initiate R-3

(CRD-Ps Fail)

4

I.B.d

Direct RSCS bypassed

dd

Bypass

RSCS

NOTE:

The Simulator vill

not support

jumper

installation

SP/T

= 1100F

I.D.a

aa

Direct SLC injection

Verify ADS Inhibited

Initiate both SLC pumps

Verify RHCO isolates

tivate R-4

Loss of RPV/L

ss of all

indication

/L indication)

II.E

Direct RPV Flooding Per

PPH 5.1.4

I.F.b

Direct all injection terminated

w/e SLC

core damage bean

dtennine d Io be sbegd

1ÃLpar PPM SDM,

Core Damage

Evahrsdony

b die@1

IF wetwag pressure cannot be

maintainedbelow the PCPI

Ines pecdve Kwhether adequate core coogng le assured:

~

0 ~ OO ~ 0 ~ ~ 0 ~ ~\\

~ ~ ~

~ ~ ~ ~ 0 ~ 0 ~

~ ~ ~

~

~ ~

brespactlve of the otlal4 rsdloecdvity re4ase rata or whether

adequs4 core cocgng la saatsed t

IF

THEH

SP 4vel ls below 52

lest

kddata SP sprays.

IF

SP levK la below 52

lest

Vent the wetweg per PPM

58.1C, Emergency Wetwail

Yarning.

IF

SP 4vK4 below 52 tL

~nd dryweN temperature

~nd pressure are wtddn

the OSIL

IF

SP4vK4sbo

52

lsK or Nte wstwag

cannot be vsnwd

Vent ths dryweg per P

PM

SS.I5, Emergency OryweN

Vandng.

IF wetweN pressure exceeds ths PCPL.

IFwetwsN pressure exceeds the PCPI

Irrsa pectl vs of the ofhlte rsdioscd vltyrelease rs4 or wtwttwr

~dsqusts core cooling 4 assured:

IrrsapecUve of whether adequate core cooNng Ia

aaauledI'F

THEN

SP level ls below 52

4st

Vent the wetweg per PPM

SS.I C, Emergency Watwsll

Venting.

IF

SP 4vel ls below S2

feet

THEN

lnidste wppresaion pool

sprays.

IF

SP 4vel la above 52 feet

THEH

a the wetweN cannot bs

venwd,

Vent the dryweN per PPM

SS.15. Emergency Oryweg

Vendng.

IF

SP 4vsl I~ below 52 ft.

and drywag temperature

~nd pressure are within

ttw DSIP limit

THEN

inhiate dryweN sprays.

ATTACHMENT C

NRC

PERSONNEL

AND PERSONS

CONTACTED

NRC

PERSONNEL

Name

Title

L. Miller

¹*P. Eng

+¹ C. Sorensen

+¹*T. Meadows

+¹ D. McNeil

+¹*M. Good

+¹*A. Sutthoff

Chief, Operations

Section,

RV

WNP-2 Project Manager

Resident

Inspector

Team Leader,

RV

Systems Specialist, RIII

COMEX, Systems Specialist

SAIC,

Human Factors Specialist

WNP-2

PERSONNEL

CONTACTED

Name

Tit'le

A. Oxsen

C. Powers

+J.

Backer

+¹*S. McKay

+¹*S. Kirkendall

+¹*B. Barmettlor

+¹*T. Messersmith

B. Mazurkeiwicz

D. Merhar

¹*D.. Kobus

+¹*S. Washington

J. Vause

L. Sharp

L. Harrold

<<A. Hosier

M. Baird

E. Villaruell

M. Comstock

S. Jenkins

M. Naulty

L. Rowden

R. Tingley

R.

Gumm

M. Kappl

G. Bishop

D. Moore

M. Gallager

A. langdon

G. Hendrick

M. Woods

Deputy Managing Director

Director of Engineering

Plant Manager

Operations

Manager

Supervisor,

Nuclear Systems

and Analysis

Manager,'echnical

Training

Operations

Engineer

BPA, Operations

Branch

Operations

Procedures

Manager, Technical Training

Supervisor,

Compliance

Principal Engineering Tech.

Assessment

Principal Nuclear/Mech.

Engineering

Manager,

General

Engineering

Licensing Manager

Control

Room Supervisor

Reactor Operator

Equipment Operator

Shift Manager

Control

Room Supervisor

Reactor Operator

Shift Manager

Control

Room supervisor

Reactor Operator

.

29

Name

G. Kozlick

N. Zimmerman

0. Strote

A. Herrington

J. Rueckert

R. Nelson

A. Woods

WNP-2 OPERATING

CREW

E

Titie

Shift Manager

Control

Room Super visor

Shift Support Supervisor

Reactor Operator

Shift Technical Advisor

+Attended Exit Meeting on 9/13/90

+Attended Entrance

Meeting 9/4/90

attended

Pre-Exit Meeting on 9/12/90

30

ATTACHMENT D

DOCUMENTS REVIEWED

Note:

Procedures

13.1.1, 9.3.22,

82-RMD-0901-LP,

and the licensee's

developmental

procedures

were reviewed

by the team during the "table

top" preparation

phase of the inspection.

This review also included

on-site interviews with selected

plant staff.

The 5.0 - 5.4