ML17291A915
| ML17291A915 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 07/20/1995 |
| From: | Pellet J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML17291A912 | List: |
| References | |
| 50-397-95-19, NUDOCS 9507260023 | |
| Download: ML17291A915 (23) | |
See also: IR 05000397/1995019
Text
ENCLOSURE 2
U.S.
NUCLEAR REGULATORY COMMISSION
REGION IV
Inspection Report:
50-397/95-19
License:
Licensee:
Washington Public Power Supply System
3000 George Washington
Way
P.O.
Box 968,
MD 1023
Richland,
99352
Facility Name:
Washington Nuclear Project-2
Inspection At:
Richland.
Inspection
Conducted:
June 5-20.
1995
Inspectors:
S.
McCrory, Reactor
Engineer,
Operations
Branch
Division of Reactor Safety
T. McKernon, Reactor
Engineer,
Operations
Branch
Division of Reactor Safety
R. Lantz. Reactor
Engineer.
Operations
Branch
Division of Reactor
Safety
D. Proulx, Resident
Inspector/WNP-2
Approved:~ on
.
e
e
.
ie
,
pera ions
rane
Division of Reactor Safety
'7-2.o - '/5
a e
Ins ection
Summar
A~tt d.
d
tt
.
d
1
p tt
1
t.
1
p
during reactor startup.
Results:
~0erations
~
Command. control
(which included procedure
use
and compliance)
~
and
communication of the control
room shift operators
were adequate
for safe
operation
but marginal in some areas
(Sections
1.2, 1.3,
and 1.4).
9507260023
950720
ADQCK 05000397
8
-2-
~
Corrective action measures
to date continued to be ineffective in
producing significant improvements
in performance in command
control,
and communication
(Section 2).
~
The operations staff continued to accept
and tolerate
conditions'onduct.
attitudes,
and performance that were conducive to errors
(Sections
2. 1 and 2:2).
~
The operations
organization did not effectively assert its leadership
role at the facility, especially outside of the operations
department
(Section 3).
~
The licensee's
50.59 evaluation,
which allowed deleting the shift
turnover procedure,
was superficial
and flawed (Section 1.3)
~
Licensee oversight
management
observations,
although fulfilling
managements
expectations,
were not routinely at the level of detail
and
interaction required to improve individual performance of watchstanders
(Section 4).
Summar
of Ins ection Findin s:
~
Violation 397/9519-01
was opened
(Section 1.3).
Attachments:
~
Attachment
1
- Persons
Contacted
and Exit Meeting
~
Attachment
2 - Management
Oversight Observation
Summary
-3-
DETAILS
1
SUSTAINED CONTROL ROOM OBSERVATION (71715)
As a result of multiple plant events reflecting problematic licensee operating
performance.
the
NRC determined that it was necessary
to conduct
an extended
observation of licensee control
room crew performance to confirm that control
room operating
crews were performing in accordance
with licensee
expectations
and procedures.
Recent
events
indicated that while the operating staff may
have
been
aware of and cognitively attempted to meet licensee expectations,
in
times of increased
stress
they often reverted to habitual
behavior patterns
that were no longer acceptable.
Those included, failure to maintain
command
and control,
use of very informal communication techniques,
failure to inform
other crew and management
of actions
and issues,
failure to use effective
team-building
techniques,
and informal procedure
use
and adherence.
The
intent of the inspection
was to observe control
room crew perf'ormance during
startup activities with a focus
on human performance
issues.
including command
and control practices.
crew briefings.
communication
frequency
and
effectiveness,
procedure
use
and adherence,
and log-keeping.
Two inspectors
were assigned to perform extended
observations
in the control
room on
a rotating basis.
The inspectors
used specific guidance,
specially
prepared for the inspection,
to focus thei r observations.
They took detailed
observation
notes which were provided to the team leader at the end of each
observation
period.
Additionally, they debriefed with the team leader daily.
After the departure of the inspection
team,
the resident inspector continued
control
room observations
as
a part of the inspection.
A third inspector,
assigned
as the team leader,
was responsible for
integrating the observations
of the other inspectors
and for interfacing with
the facility licensee.
In addition to reviewing the observation results,
the
team leader interviewed pertinent plant staff personnel'eviewed
various
licensee documentation'nd
observed daily outage closeout
and startup status
meetings.
1. 1
Control
Room Observations
During the period of June
5 - 12,
1995, the inspectors
observed activities in
the control
room.
These activities included operations
surveillance testing,
control
room operators'ommunication
practices,
control board operations,
shift-turnover, prejob briefings,
outage activities, supervisory oversight.
log taking,
command
and control.
and others.
During the observation period,
the plant transitioned
from outage activities to initial plant startup
and
power ascension
to about
15 percent
power.
The inspectors
observed
various
crew compositions
on day and night shift periods.
During the refueling outage
and preparations
for reactor plant startup,
two
crews were assigned
to the shift, with the additional licensed
personnel
utilized to help with the administrative
requirements
and production work of
the shift.
One crew was designated
as the on-shift crew, including
a shift
manager.
control
room supervisor.
lead reactor operator,
and reactor
operator.
Substantially
above average
background noise levels in the main control
room
were
a historic and well known control
room characteristic
at WNP2.
The noise
was generated
from various sources,
including ventilation, the plant computer,
and the physical configuration of the control
room and back panels.
At the
beginning of the observation
period. while the plant was in the last phase of
an outage, it was apparent that the operators
were challenged
not only by the
ambient noise.
(e.g.. ventilation and plant process
computer)
but also by the
number of simultaneous
functions being conducted in the control
room area.
These activities included surveillance testing of the fire protection system,
standby
gas treatment
system work, shift technical adviser's
work, operations
work control activities,
alarm annunciation
response.
and
a number of other
activities.
It was apparent that the number of ancillary functions
contributed'o the congestion
and noise level of the control
room without
contributing directly to the operation of plant systems
or components.
1.2
Command
and Control
The inspectors
observed
instances
of weak
command
and control during the
inspection period.
There were several
trainees
in the control
room at any
given time.
and they were frequently used to take logs'ormally without
direct supervision.
At one point, operators-in-training
were assigned
the
task of taking instrumentation
recordings
and data logging and failed to alert
the control
room supervisor or lead reactor
operator of an out of limit
drywell temperature
condition.
Average drywell temperature
was required to be
maintained
above
70 degrees
F for stress
consideration of large support
structures
in the drywell.
Across
a full day of log-taking,
encompassing
three shifts. all average
readings
were below 70 degrees
F, with no red
circled readings
and no action taken.
The control
room logs contained
a large
note (paragraph)
that di rected adjusting reactor
component cooling flow to
RCA-FC fan cooler units to maintain average
drywell temperature
greater
than
or equal to 70 degrees
F.
While preparing the next day's logs, the shift crew
recognized the out-of-limit readings
and secured the drywell fans to increase
drywell temperature to specification.
They then informed plant engineering
and requested
an, evaluation of the consequences
of the low temperatures.
The
inspector also noted that the day shift control
room supervisor
had not
reviewed the logs.
Control
room shift management
acknowledged the lapse in
adequate
oversight of the operator trainees
and failure to review the data
logs.
During the
same time period. the inspectors
observed
another
instance in which
prompt and thorough action was not taken in response
to an out-of-limit log
reading.
The control
room logs for Battery
Room 2 specified that
IMMEDIATE
action was required
when
room temperature
was less than
74 degrees
F (the
Technical Specification
minimum was
60 degrees
F).
Two consecutive
log
-5-
readings
indicated less
than
74 degrees
F during the day shift (8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />
apart).
The readings
were red circled, but no action was taken to increase
the temperature.
The day shift had noted that the room heater
was not
working.
When the evening shift took the next log readings
which was still
less
than
74 degrees
F
~ they investigated
and found that only the heater
controller was malfunctioning, in that it would not automatically shut off.
A
clearance
had been prepared.
but not hung.
Therefore,
the evening shift
manager
decided to turn on the heater to restore the
room temperature
and
monitor heater
performance
and
room temperatures
more-frequently.
The
inspector noted that although this was
a positive action to restore
and
maintain the battery
room temperatures
above specified limits, the direction
given to the operator for maintaining battery
room temperature
was vague.
The
control
room supervisor only told him to maintain the temp above
74 degrees
F.
The di rection did not give
a range within which to control the temperature.
In another instance,
a number of outage work or surveillance
work packages
were not logged out as completed
by the control
room staff.
As
a consequence,
the control
room supervisor
and assistant
control
room supervisor
had to
subsequently
retrieve the packages
from the work control center.
Corrective
action was taken to change the sequence
of package
review and signout from the
control
room.
An inspector
observed
the control
room supervisor receive
a phone call from
technicians
in the field who were conducting
position logic tests.
The technicians
requested
status of the main steam
isolation valve position indications in the control
room,
and requested
the
main steam isolation valve isolation logic push buttons
be depressed
to reset
the logic.
The control
room supervisor
went to the appropriate
panels
noted
the valve positions,
and then reset the logic by depressing
the two reset
push
buttons.
The control
room supervisor
then reported his actions to the
technicians.
The control
room supervisor told the reactor operator that the
logic was reset
when the reactor operator questioned
the control
room
supervisor
on the status of the test.
This same control
room supervisor
stated later that he routinely depressed
all main control board logic reset
push buttons during turnover.
This was confirmed during observation of
turnover.
The inspector
asked the management
oversight observer if the above
actions
by the control
room supervisor were appropriate.
The management
oversight observer stated that it was inappropriate for the control
room
supervisor to operate
panel
switches
except in cases of an emergency,
and that
the control
room supervisor
should remain in a position of oversight
and
di rection of activities.
(On Harch 3,
1995.
management
had communicated,
in
the form of an electronic
memorandum, explicit expectations
that shift
supervisory
personnel
not operate
equipment controls except in an emergency.)
The practice of resetting logic during turnover was also noted
as
inappropriate.
however. this expectation
had not been promulgated to the crews
prior to the inspector's
observation.
-6-
The inspectors
noted frequent
changes of the panel reactor operator
between
the shift crews.
and in one instance,
for approximately
one minute, only the
nondesignated
reactor operator
was in the "at the controls" portion of the
control
room.
All of the other operators
and senior operators
were either
outside the control
room or at the work table in between the instrument
panels.
Management
stated that this was permitted
by Technical
Specifications.
but was not
a desired situation.
The inspector also noted
that when the switch between
panel
operators
was done, little or no status
turnover was given to the operator taking the boards..
Towards the end of the observation
periods
the inspectors
noted
a marked
improvement in control
room decorum.
A focused. alert.
and directed effort
was placed
on transitioning into the plant startup procedure.
Activity in the
control
room was orderly and nonintrusive to the activities of the control
board operators.
The prestartup briefings were focused
and well conducted.
Control of the approach to criticality was good as were the coordination of
heatup
~ reactor core isolation cooling test preparation,
and placing the
turbine bypass
valves in automatic.
1.3
Procedure
Ade uac
While conducting main steam isolation valve isolation logic tests,
the crew
received
an unexpected full main steam isolation valve isolation.
The main
steam isolation .valves stroked
from full open to full shut.
After
investigation,
the crew discovered
the procedure
was inadequate if the reactor
mode selector
switch was not in the
"Run" position.
Additionally, the
procedure did not identify expected
main control board alarms.
The inspector
observed
good response
by the crew and others to evaluate the cause of the
unexpected
isolation signal.
This was reported to the
NRC and
a Problem
Evaluation Request
was written.
While conducting reactor
core isolation cooling turbine testing,
the operators
started the reactor
core isolation cooling turbine and received
an unexpected
alarm which indicated
low cooling water flow to the lubricating oil cooler.
The procedure failed to establish
cooling water to the lubricating oil cooler.
During an automatic start of the turbines this valve opens to supply
lubricating oil cooling.
On June 9,
1995,
an inspector
observed
the shift and relief turnovers in the
control
room.
The inspector
noted that most of the operators
were on 8-hour
shifts.
However,
one pair of reactor operators
was
on 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> shifts to cover
the absence
of the third reactor operator.
This pair of reactor operators
turned over in the middle of the shift rather than with the rest of the crew
at the beginning of the shift. The inspector
noted that the operators
on
12-hour shifts did not fill out and sign
a shift turnover checklist.
The
shift turnover checklists generally directed
the operators to discuss
important plant parameters
to ensure that
a formal and precise
exchange of
information occurred.
-7-
The inspector discussed
this observation with the shift manager,
the
operations
manager,
and the plant manager.
These licensee
representatives
stated that turnover between the operators
on the 12-hour shifts without the
checklist did not meet management's
expectations.
They stated that use of a
separate shift turnover checklist
was expected
whenever
an operator turnover
occurred
more than 30 minutes later than the crew turnover..
The inspector
researched
the licensee's
procedures
to ascertain
what
expectations
concerning shift and relief turnover
had been
communicated
by the
licensee in plant procedures.
The inspector
noted that the licensee did not
have
a plant operations
committee
approved
procedure that contained the
requirements
for shift and relief turnover.
Technical Specification 6.8. l.a.
referenced
and required
a procedure for "Shift and
Relief Turnover ."
In addition, Technical Specification 6.8.2 required
each
procedure of Technical Specification 6.8. 1 to be reviewed by the plant
operations
committee
and approved
by the plant manager.
Technical Specification 6.8. l.b required procedures
to implement the requirements of
Item I.C.2 of NUREG-0737 'equired
turnover procedures
to include
a shift and relief checklist.
Because
the licensee did not have
a plant
operations
committee approved
procedure for shift and relief turnover that
included
a shift turnover checklist, this was
a violation of Technical Specifications 6.8. l.a. 6.8. l.b,
and 6.8.2 (Violation 397/9519-01).
In further researching this issue,
the inspector
noted that the licensee at
one time had
a turnover procedure for the operators,
but this procedure
had
been deleted recently.
The expectations
for shift turnover had been relocated
to Operating Instruction 19.
Operating instructions
were internal department
instructions that were not reviewed by the plant operations
committee.
Mainly, they contained
recommendations
for good operating practices that the
operators
were not specifically bound to follow.
The inspector
found that the shift turnover procedure
had been deleted
as part
of the procedures
improvement program.
The licensee's
program included the
goal of deleting or streamlining all procedures
that appeared to be
unnecessary
or burdensome.
When performing the
10 CFR 50.59 evaluation for
deleting the shift turnover procedure
requi rements,
the licensee
performed
an
inadequate
review of Technical Specification 6.8. l.a, Regulatory Guide 1.33.
and
As part of the
10 CFR 50.59 reviews. the licensee did not
actually read the requirements.
The reviewers
performed
a word search,
using
an electronic version of their licensing basis
documents.
to determine
where
requirements
or commitments
were located.
In this instance,
the reviewer
used
a word string that did not match the exact words of the Final Safety Analysis
Report or Regulatory Guide 1.33.
Therefore,
the inspector
noted that the
licensee's
system for performing
10 CFR 50.59 evaluations
using the electronic
database
was not always fully effective in identifying requirements
and
commitments.
-8-
The inspector
informed licensee
management of this issue.
The licensee
acknowledged
the inspector's
finding and drafted
a procedure for the shift and
relief turnover.
However. the licensee's
new procedure for shift turnover
still contained
weaknesses,
and was not in accordance
with NRC requirements
and licensee
procedure writer s guidelines.
To address
the inspector's
concern,
the licensee
issued
a deviation to Plant
Procedures
Manual 1.3. 1 "Conduct of Operations-Department
Policies.
Programs
and Practices."
to reinstate
the shift and relief turnover requi rements in
formal plant procedures.
The licensee
added Section 4.20. l.h stating that if
an individual relieved
a position 30 minutes past the crew's turnover.
a shift
turnover checklist should
be filled out.
Howevers
the licensee did not appear to follow its own guidance in developing
this procedure
as
shown in the examples
below.
WNP-2 Plant Procedures
Manual
1.2.2 "Plant Procedure
Preparation"
defines the use of the word "shall" as
"used to denote regulatory requirements'xternal
commitments'nd selective
specific management direction."
Plant Procedure
Manual 1.2.2 defines
use of
the word "should" as
"used to denote
recommendations
but not enforceable
regulatory requirements
and managements
expectations."
When these
concerns
were conveyed to the licensee,
the licensee's
response
was to assert that most
other licensees
treated the situation
manner similar to the one that they had
chosen.
The revision to Plant Procedures
Manual 1.3. 1. Section 4.20 'tated that
control
room staff should fill out and sign
a shift turnover checklist
in accordance
with Operations
Instruction 19.
The inspector
noted that
a shift and relief turnover checklist was
a requirement of NUREG-0737
and was committed to by WNP-2 in thei r Final Safety Analysis Report.
Section 4.20 of this procedure
also stated that
a licensed operator
should only be relieved by a licensed operator.
The Technical
Specifications
required certain positions to be filled only by licensed
individuals.
~
Finally. Section 4.20 stated that the operators
should not take the
watch if they were unfit for duty,
and the offgoing operator
should not
allow himself to be relieved if he believed that his relief was unfit
for duty.
Fitness for duty requirements
for licensed operators
are
found in 10 CFR 26.
and
1.4
Communications
1.4. 1
Shift and Relief Turnover Observations
The oncoming crew individually conducted turnover,
which included various log
and equipment status
reviews
and
a main control
room board walkdown and
discussion with the off-going watch.
The inspectors
noted good information
exchange
during operator turnovers while performing control board walkdowns.
-9-
The on-coming shift crew members
were advised of specific control board status
and on-going work activities.
After all members of the oncoming crew relieved
the shift, the enti re crew assembled
in the control
room for a shift brief,
which lasted
from 10 to 30 minutes.
The brief was led by the control
room supervisor.
and each operator
was given
an opportunity to discuss
his observations
during turnover.
Communications
observed
during shift briefings were marginally adequate.
The inspectors
noted that several
of the briefers
spoke too softly to be easily heard over
the control
room background noise.
In some instances.
either the shift
manager or
a management
observer
would request the briefer to speak
louder,
but this did not always occurs
and that portion of the brief was missed
by
some of the crew.
The day-shift manager
conducted
good post-Plan-of-the-Day
meeting crew briefings that clarified the objectives for the day,
lessons
learned.
and items of significance.
Howevers
in one instance.
shortly after
shift turnover on the night shift,
an inspector
asked the shift manager
about
the activities that were to be accomplished
during the shift and thei r
priorities.
The shift manager
admitted that he did not know and had to obtain
the information from the management
oversight observer.
During one turnover.
an off-going shift manager
gave permission for personnel
to enter the drywell under vessel
area,
to remove shielding
and other
materials.
This permission
was given over the phone directly from the shift
manager to the technicians
requesting
the entry.
The off-going control
room
supervisor
had received the request
by phone originally. and
had attempted to
get the shift manager's
permission
by talking loudly across
the control
room.
Both the control
room super visor and shift manager
had to request
a repeat of
the other's request/report
due to inability to hear clearly.
Finally, the
shift manager
picked up the phone
and took the call directly.
After granting
the permission,
the shift manager
did not make
a positive report to the
control
room supervisor
that he had granted the permission.
After turnover,
the inspector
asked the
new shift manager
why personnel
had entered the
drywell, to which he stated for inspection
and evaluation of potential
needed
work: he did not know the reason for entry primarily was to remove staged
material.
The inspectors
noted several
other examples
where turnover
information was either incorrect
or incomplete.
During another turnover'
high pitched,
recurrent
alarm at
a back panel
of'he
control
room, initiated two-three times per minute throughout the turnover
.
The alarm was
a security alarm, which was the result of security testing
badges
whose access
had been
revoked.
This was
an unnecessary
distraction to
the turnover.
1.4.2
General
Communications
Control
room communications
were sometimes difficult because of multiple
activt,ties being conducted
simultaneously
and the background noise level.
At
times. inconsistent
acknowledgements
of control panel
alarms were observed.
Typically. communications
conducted
during more formal settings
such
as the
performance of surveillance tests
were more disciplined.
Communications
were
-10-
generally adequate;
however,
the inspectors
observed
several
examples
where
communications
reverted to informal jargon or lax discipline that was
sometimes ineffective and did not meet
management
expectations.
Communications
recipients
accepted
inappropriate
communications,
indicating
a
lack of questioning attitude.
During testing of relays for proper operation of Valve RCC-V-6. the reactor
operator controlling the test in the control
room directed the assisting
reactor operator to "watch the 6 valve,
need it open when I start the pump."
After the evolution was completed.
the inspector
asked the assisting
reactor
operator what he understood
the direction to mean, to which he stated
he was
not sure,
but thought that he was being told to verify Valve RCC-V-6 opened
after the second reactor
component cooling pump was started.
The reactor
operator stated that he thought it only had
an auto-close feature.
but that
the di rection he received
made him think it might auto-open.
A shift
technical
advisor in senior reactor operator
upgrade observation training
stated that he too thought the valve would auto-open
based
on the direction
given by the first reactor operator.
When the valve did not auto open, the
reactor operator
attempted to open the valve.
After the third attempt,
Valve RCC-V-6 stroked open.
The reactor operator then checked the appropriate
valve logic prints and verified that the valve would only auto close,
and had
a 10-second
time delay for both an auto-close
and manual
open.
The original
di rection from the reactor operator
was unclear
and confusing.
Several
instances
were noted
when nonspecific communication were used.
"Still
got 176 (no system or units)," "the va1ve position relays?
(no system said),"
watch Valve 6 (no system),"
"1825,
CRD Pump Swap (configuration not
specified)." were examples of communications
observed that were not specific
and subject to misinterpretation.
The inspector
also noted
a frequent lack of
positive feedback
from the performer of an order that the task was
accomplished.
For example, after
a
pump was started
as ordered,
the reactor
operator did not routinely report back to the control
room supervisor that the
pump started
normally.
Several
instances
were noted when the control
room
supervisor did not acknowledge reports,
and the reactor operator did not
insist on an acknowledgement.
All of these
were contrary to the
communications
expectations
of licensee
management.
The inspector
noted that operators
in the control
room did not utilize
headphones.
The inspector also noted the practice of yelling across
the
control
room from the back panels while conducting the main steam isolation
valve logic checks.
Phone jacks were available,
but not utilized.
When
questioned,
the operators
stated that they had always conducted this test in
the manner observed.
and did not know if the phone jacks worked.
Similarly,
the inspector
observed that phone jacks were not utilized during testing of
the reactor core isolation cooling turbine.
After the reactor core isolation
cooling turbine was started
from the control
room.
a muffled noise
came over
the radio in the control
room.
The control
room supervisor
keyed the mike and
requested
a repeats
to which the reply came s".owly but still not very clear,
"STOP
THE RCIC TURBINE."
The control
room supervisor
then ordered the turbine
tripped.
The poor
communications
delayed tripping the turbine for
-11-
approximately 30-45 seconds.
The inspector
asked if phones
were considered
for this or other tasks.
especially in high noise areas.
The operators
stated
that phones
were not used,
and that they were not sure that the capability
existed.
When the test
was attempted
again.
the oper'ators
used the control
room phone
and
a local phone in the reactor core isolation cooling room for
direct communications
between the control
room and the reactor core isolation
cooling pump room.
The reactor operator
stated that the communications
were
much clearer.
A note on the microfiche printer in the control
room said do not use the print
feature since it burned paper.
However, the note was not conspicuous,
and did
not cover the button to print.
The shift technical
advisor used the printer
which resulted in a strong
smoke smell in the control
room.
That invoked
action from the control
room supervisor,
a reactor operator.
and security
personnel.
Although the response
by control
room personnel
was rapid and
appropriate.
the incident was
an unwarranted distraction to the crew that
could have been prevented
through adequate
communication of the equipment
deficiency or proper controls to prevent operation of the print button.
2
IHPACT ON PERFORHANCE
The preceding information provided numerous
examples of weak performance
on
the part of WNP2 personnel
that help to form the basis of the
NRC conclusion
that operational
performance
has not improved significantly from that
summarized in
NRC Inspection Report 50-397/95-07.
The lead inspector
integrated
and analyzed these observations
with information obtained through
interviews.
review of licensee documents'nd
observation of peripheral
activities such
as the morning and afternoon status
meetings.
After
completing the integration
and analysis,
the inspection
team concluded that
several
conditions existed that created
an envi ronment favorable to a high
frequency of performance errors
and high consequences
when errors occurred.
The conditions
and the resultant
behaviors did not create
an immediate safety
concern nor constitute
a failure to comply with regulatory requirements.
with
one exception
as described
in Section 1.3 above.
However, they did represent
conditions
and behaviors
conducive to poor performance that could result in or
aggravate
adverse
operational
consequences.
2. 1
Conditions Conducive to Poor
Performance
The high control
room ambient noise level
has
been
recognized for some time as
a condition that adversely
impacts
communication in the control
room.
Further.
such
a condition can induce
an additional stress
level for operators
required to work in such
an environment for extended
periods of time.
This
can increase
the incidence of errors.
-12-
The layout of the personal
work stations
in the control
room near the systems
controls'ndicators.
and alarms
increased
the vulnerability to operational
errors.
The placement of the shift technical
advisor work station
and
administrative processing
work stations
in near'proximity to the control
room
watch stations
increased
the amount of activity in the area that was not
related dir ectly to controlling the plant.
Two different standards
of conduct of operations
were implicitly promoted
by
procedures
and policy.
There was
a definitive checklist of requi red
communication techniques
in Section 4. 10.3 of Plant Procedures
Manual 1.3. 1,
"Conduct of Operations,"
which began with the statement:
"In addition to
standard
Communication Techniques,
the following are required During Abnormal
Conditions or (when) Entry into the
EOPs is necessary."
Further,
an inspector
who had recently observed
crew performance
in the licensee's
simulation
facility. observed
a significantly different level of performance in the
control
room during extended
observations.
Actual control
room behavior
was
much less
formal and rigorous.
An observation
by a licensee control
room management
oversight participant
regarding inconsistent
and poor electrical distribution component labeling
prompted
management
to consider training plant staff to cope with inconsistent
or poor labeling rather than revising the priority or pace of the label
upgrade
schedule to correct the problem.
Poor labeling had been previously
identified
as contributing to errors
made while establishing
a clearance
for
electrical
maintenance
(NRC Inspection
Report 50-397/95-07).
Other equipment
and component labeling concerns
or weaknesses
have also been reported in NRC
Inspection
Reports
50-397/94-12,
94-26.
and 94-27.
NRC inspection activities regularly identified procedural
inadequacies.
deficiencies,
or weaknesses
that affected plant operations
and activities in
the plant.
(Refer to
NRC Inspection Reports
50-397/94-12,
14,
17,
19.
21, 24.
27. 32. 34, 95-03.
05,
07,
and 09.)
During the inspection,
additional
procedural
problems
were identified,
some of which contributed to unplanned
plant responses.
Licensee
management
indicated that there was
a focused
program for improving alarm response
and abnormal
operating procedures:
however.
improvement of other procedures
was expected to result from the
regular biennial
reviews.
None of the procedural
problems identified during
the inspection related to alarm response
or abnormal
operating
procedures.
While many of the procedural
problems were licensee identified and
some
had
di rect impact on system
or equipment operation or testing,
the licensee
was
not pursuing
a comprehensive
approach of enhanced identification and
correct>on of nonalarm or abnormal
procedural
problems.
The plant and operation
managers
reenforced
a policy of making shift
supervision
and licensed operators
responsible for correcting the various
performance
weaknesses
identified by both the licensee
and
NRC inspectors,
in
this and previous inspections.
However. it was unclear that the licensee
had
assured
that the shift operators
and supervisors
were adequately trained
and
equipped to carry out that responsibility.
After the crew involved in the
April 9.
1995. reactor water cleanup
system event
(NRC Inspection
-13-
Report 50-397/95-17)
was reconstituted.
the
new crew received
a day of team
building training which consisted
largely of discussion
topics
and reviews of
previous events.
Apart from that and an expressed
intent to implement
a
general
reconstitution of crews in October
1995, operations
management
did not
identify to the inspectors
any aggressive efforts in progress
or planned to
enable operators
to correct the operational
performance
weakness
identified in
this and other
recent inspection reports.
2.2
Behavior Conducive to Poor
Performance
During an outage/startup
status
meeting,
the electrical
maintenance
manager
displayed
a lack of aware'ness
of or sensitivity to shutdown risk concerns.
The manager
complained that the control
room was interfering with the timely
and efficient completion of some relay testing
by prohibiting his workers from
starting
some of the work in accordance
with their schedule.
An operations
representative
at the meeting
had to point out to the manager that the actions
of his workers would have rendered
both diesel
generators
inoperable during
the time the testing
was being performed.
Even after that, the manager
continued to focus
on getting operations to cooperate to permit his people to
complete their scheduled
work.
On two separate
occasions.
control
room observers
(one.
a licensee
management
oversight observer)
witnessed
periods in which only one licensed operator
was
in the control
room in the vicinity of the equipment controls,
instruments,
and annunciators.
In both cases.
when the situation
was pointed out to the
on-shift crew, the response
was essentially that Technica'I Specifications
only
required
one operator to be in the controls area while shutdown.
In both
cases'he
shift was staffed with an augmented
crew,
and in neither case
was
an emergency condition present that warranted
leaving the area of the controls
staffed with only one operator.
In the instance
observed
by the
NRC
inspector,
the sole operator
was
engaged
in a surveillance test
and not fully
attentive to general
plant indications.
Neither case
appeared
an appropriate
alloCation of augmented
crew resources
available.
As previously discussed.
an inspector
observed
a shift manager
and control
room supervisor
shouting to one another
across
the control
room while the
control
room supervisor
attempted to be
a link with another party on the
telephone.
After two failed attempts at information exchange,
the shift
manager
came to the phone
and spoke with the party directly.
An inspector
observed
two operators
performing
a surveillance test which
required
them to be on opposite sides of an electrical cabinet.
Rather than
using the phone jacks installed to assist
communications for that type of
activity. the operators
shouted
over and around the cabinet.
During
a test of the reactor core isolation cooling system.
operators
were
using radios to communicate
between the control
room and local areas of the
plant where conditions for radio communication were known to be poor.
The
local operator called for a trip of the reactor core"isolation cooling turbine
during the test but because of poor radio conditions, it took an additional
30 to 45 seconds
to clarify the communication
and then trip the turbine.
Instances
of nonadherence
to procedures
were observed with regard to the
battery
room and drywell temperature
logs as noted in. Section 1.2 above.
An additional
instance of confusing communications
during
a valve relay test
is described
in Section 1.4.2 above.
3
OPERATIONS ORGANIZATION LEADERSHIP ROLE
NRC Inspection Report 50-397/95-07
noted that operations
department
ownership
of the plant was not evident
and gave several
supporting
examples.
During an
interview for this inspection,
the operations
management
expressed
strong
disagreement
with that perspective.
The principal example of how ownership
was being exercised
was to point out that augmenting the control
room crews
during the outage
had been effective in controlling outage activities.
A
closer examination of that situation by the inspectors
revealed that augmented
crews were more effective in dealing with the challenges
and obstacles
created
by support organizations.
Many of those challenges
and obstacles
arose
as
a
result of poor planning and scheduling.
lack of sensitivity to operational
impact.
or
a lack of recognition of operations'eadership
authority.
Moreover, operations
had not communicated,
at middle and upper
management
levels.
standards
of conduct
and performance for activities in the plant
control
and equipment
spaces
that applied to all site personnel
regardless
of
their organizational
alignment.
To the extent that any such attempt
was
made,
it relied on the on-shift operators
to police and correct performance
deficiencies
on the part of support personnel.
It has already
been noted that
the operators
themselves
did not sustain the desired level of performance
and
leadership
by example. without the added responsibility to effect performance
and behavior
changes
in support organization personnel.
4
LICENSEE MANAGEMENT OVERSIGHT EFFECTIVENESS
The inspectors
observed
management
oversight of the operating
crews.
The
inspectors
noted that. in most instances'eedback
took the form of
end-of-shift briefings with the shift manager
and written input to operations
department
management
of broad issues
and performance
suggestions.
The
inspectors
witnessed
some
management
oversight feedback briefings during shift
turnover.
The oversight
managers
appeared
to be fulfillingtheir role in
accordance
with management
expectations.
However, their activities
had not
been
focused
on feedback to improve individual operator
performance,
such
as
were described
in Section 2.2 above,
An inspector
reviewed the written feedback
provided by the oversight managers.
The inspector
concluded that management
oversight activity had.produced
many
-15-
good findings.
The operations
manager
summarized
the strengths
and weaknesses
from the oversight observations
which is provided in Attachment 2.
However,
the inspector concluded. after discussions
with the plant and operations
managers'hat
the licensee did not consider aggressive
action warranted to
address
most of the observed
weaknesses
identified by the oversight managers.
Moreover. the observations
of the
NRC inspectors
highlighted earlier in this
report contradicted
some of the strengths
summarized
from the oversight
observations:
~
Communications:lax or informal communications
~
Crew turnovers:important
information not transferred
~
Procedure
compliance:fai lure to act promptly for log readings
~
(juestioning attitude:failure to understand
battery
room temperature
control capability
~
Surve'i llance Tracking:test completions not logged initially
5
CONCLUSIONS
Operations
management
had taken
some corrective actions to improve the
performance of operations
department staff. including
a performance
measurement
process to track and trend performance
data that provided
comparisons
between operating
crews.
Howevers
most of the corrective actions
taken or planned were of low intensity and loosely structured or focused.
Many of the observations
made
by the inspectors
were similar to previous
observations
made during recent inspections.
The inspectors
concluded that
a
number of conditions existed that presented
continual challenges to successful
operating
crew activities and decision making.
Those continual challenges
were characterized
as conducive to potential failure because
they represented
barriers to successful
operating activities or provided incentives to err.
The operations
organization
was often ineffective when attempting to assert
its leadership
role due to weaknesses
within operations
and resistance
or
insensitivity from support organizations.
ATTACHMENT 1
Persons
Contacted
and Exit Meeting
1
PERSONS
CONTACTED
Washin ton Public Power
Su
1
S stem
- V. Parrish
~ Vice President
Nuclear Operations
- P. Bemis, Regulatory
and Industry Affairs Director
~J.
Swai les.
Plant General
Manager
- C. Schwarz,
Operations
Manager
- D. Swank,
Licensing Manager
- B. Hugo. Compliance
Engineer
U.S. Nuclear
Re ulator
Commission
- K. Brockman,
Deputy Director, Division of Reactor Safety
- J. Pellets
Chief, Operations
Branch, Division of Reactor Safety
- J. Clifford. Project Manager, Office of Nuclear Regulatory
Research
- D. Corporandy,
Acting Chief. Reactor
Projects
Branch
E, Division of Reactor
projects
The inspectors
also interviewed various control
room operators'hift
supervisors,
shift managers,
management observers'nd
management
personnel.
- Denotes those
who attended
the exit meeting
on June
20 '995.
2
EXIT HEfTING
An exit meeting
was conducted via teleconference
on June
20,
1995.
During
this meeting,
the inspectors
reviewed the scope
and findings of the report.
The licensee
acknowledged the inspectors'indings.
The licensee did not
identify as proprietary any of the information provided to, or reviewed by,
the inspectors.
ATTACHMENT 2
(Developed by the Licensee)
MANAGEMENT OVERSIGHT OBSERVATION STRENGTHS
l.
,
Increase
in performance in communications
(three (3) part, formality).
2.
Crew turnovers:
good quality.
3.
Annunciator response
4.
Management
involvement in critical activities.
5.
STAR techniques
- pulling fuses'anging
tags.
6.
Procedural
compliance
- crews ensuring strict compliance with
procedures.
7.
Professionalism.
8.
Crew briefs for evolution.
9.
Questioning attitude
- excellent for nonroutine evolutions
- need
improvement for routine.
10.
Ops crew interactions with management
personnel.
ll.
Attention to detail
- good
STAR techniques
caught problem with NCTL.
12.
Technical'pecification
awareness/reference
for evolutions.
13.
Surveillance Tracking - annunciator/test
in progress.
14.
Response
to emergencies
- injured personnel.
15.
Teamwork during outage
improving.
16.
Computerized
T/S/LCO logs.
17.
Attitude.
-2-
HANAGEHENT OVERSIGHT OBSERVATION WEAKNESSES
1.
Communication
- three (3) part communication,
inconsistent for routine
evolutions.
2.
Support personnel
needs
improvement in support of Operations activities
such
as
LOOP/LOCA testing.
3.
Look ahead at evolution - prepared for activities coming up.
4.
Procedure
compliance
- analysis paralysis.
5.
HCR noise level high, hindering communications.
6.
CRO - some inconsistencies
between
crews in providing leadership
for shift.
7.
Backing each other up
- inconsistent
between
crews.
I.e..
S/D clg
removal
from service.
8.
Schedule discipline
- need to be more knowledgeable of schedule.
9.
SH involvement in low valve (value) activities, provide more oversight.
10.
Admin load for CRS high,
needs
work.