ML17304A847
| ML17304A847 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 12/23/1988 |
| From: | Martin J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | Karner D ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR |
| Shared Package | |
| ML17304A848 | List: |
| References | |
| TAC-69593, TAC-69594, TAC-69595, NUDOCS 8901090153 | |
| Download: ML17304A847 (89) | |
See also: IR 05000528/1988038
Text
AC CELERY'TED
D1STMBt 'TlON
DEMONiTRXTION
SY~gy.
REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
ACCESSION NBR:8901090153
DOC.DATE: 88/12/23
NOTARIZED: NO
DOCKET
FACIL:STN-50-528 Palo Verde Nuclear Station, Unit 1, Arizona Publi
05000528
STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona Publi
05000529
STN-50-530 Palo Verde Nuclear Station, Unit 3, Arizona Publi
05000530
AUTH.NAME
AUTHOR AFFILIATION
MARTIN,J.B.
Region 5, Ofc of the Director
RECIP.NAME
RECIPIENT AFFILIATION
R
KARNER, D. B.
Arizona Nuclear Power Project (formerly Arizona Public Serv
I
SUBJECT:
Forwards
SALP Board Repts 50-528/88-38,50-529/88-36
&
50-530/88-36 for Nov 1987
Oct 1988.
DISTRIBUTION CODE
IE40D
COPIES
RECEIVED:LTR
ENCL
SIZE:
TITLE: Systematic
Assessment
of Licensee
Performance
( ALP) Report
NOTES:Standardized
plant.
Standardized
plant.
Standardized
plant.
05000528/
05000529
050005'30~
RECIPIENT
ID CODE/NAME
PD5
LA
CHAN,T
DAVIS,M.J.
INTERNAL: ACRS
AEOD/DSP/TPAB
DEDRO
NRR/DLPQ/HFB 10
NRR/DOEA/EAB 11
NRR/DREP/RPB
10
NRR/DRIS/SGB
9D
NRR/PMAS/ILRB12
B
,J
FIL
02
EXTERNAL: H ST
LOBBY WARD
NRC PDR
NOTES:
COPIES
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1
1
1
1
1
1
1
1
RECIPIENT
ID CODE/NAME
PD5
DAVIS,M
AEOD/DOA
COMMISSION
NRR SHANKMAN,S
NRR/DLPQ/PEB 11
NRR/DREP/EPB
10
NRR/DRIS DIR 9A
NRR/DRIS/SIB 9A
NUDOCS-ABSTRACT
OGC/HDS1
RGN5
FILE
01
LPDR
COPIES
LTTR ENCL
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R
I
NIXIE K> ALL "RIDS" RECIPrWrS.
PLEASE HELP US TO REXJCE MSTE.'XM'ACT 'IHE DOCUMERZ CONTROL DESK,
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35
Docket Nos. 50-528,
50-529
and 50-530
Arizona Nuclear
Power Project
P. 0.
Box 52034
Phoenix, Arizona
85072-2034
Attention:
Mr. D. B. Karner
Executive Vice President
Gentlemen:
SUBJECT:
SYSTEMATIC ASSESSMENT
OF LICENSEE
PERFORMANCE,
REPORT
NUMBERS
50-528/88-38,
50-529/88-36
AND 50-530/88-36
The
NRC Systematic
Assessment
of Licensee
Performance
(SALP) Board
has
completed its periodic evaluation of the performance of the Palo Verde Nuclear
Generating
Station for the period November
1,
1987 through October 31,
1988.
The performance of Palo Verde was evaluated
in the functional
areas
of plant
operations,
radiological controls, maintenance/surveillance,
emergency
preparedness,
security, engineering/technical
support,
and safety
assessment/quality
verification.
The criteria used in conducting this
assessment
and the
SALP Board's evaluation of your performance
in these
functional areas
are contained
in the enclosed
SALP report.
Based
upon discussions
with your staff,
a management
meeting to discuss
the
results of the
SALP Board's
assessment
has
been
scheduled for January
25,
1989, in the Region
V Conference
Room.
Arrangements for the management
meeting will be discussed
further with your staff in the near future.
Overall, the
SALP Board found the performance of licensed activities at Palo
Verde to be satisfactory
and directed
toward safe facility operation.
However,
as reflected
by the
SALP categories
assigned
to several
functional
areas,
the Board considered
the overall performance of activities to have
declined
when compared to the previous
SALP assessment
period.
Specific
areas
of concern are discussed
below.
In the functiphal.area
of operations,
the strong
performance of Unit 3
throughout )he assessment
period,
and the generally
good performance of Unit
2, particularly during the latter half of the assessment
period, were well
recognized
by the Board.
However, in assigning
a
SALP category of 3 to this
functional area,
the clearly poor performance of Unit 1 was heavily weighted
by the Board in their deliberations.
Events at Unit
1 which are illustrative
of the Board's
concern include:
(1) the early criticality event;
(2) the
sustained
inoperable condition of both trains of the safety related Essential
Chilled Mater System which occurred with the unit at full power; (3) the
- ~~0i0501s3 gq-23
AOOCK 0 <00052S
Q
. p)'
operation of the unit without an operable
High Pressure
Safety Injection
Pump
for about 1.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />
due to operator error; (4) the trip from 1005 power due to
operator error in turning the wrong disconnect
switch;
and (5) the trip from
12K power due to operator error in controlling temperature
and
power during
startup.
Additionally, the Board roted that Unit
1 tripped
on six separate
occasions
as
compared
to one trip at both Units
2 and 3.
The weak performance
of Unit I is considered
to be indicative of a failure by management
to
establish
the proper working atmosphere
at the unit in that
many of the events
which occurred at Unit
1 during the assessment
period
may have
been avoided
had the personnel
involved conducted
themselves
in
a more conservative,
questioning
manner.
The Board's
concern with your Radiation Protection
program extends
to all
three units.
Events
such
as the personnel
at Unit 2, the
inappropriate
defeating of the lock on an entrance
to
a high radiation area at
Unit 3,
a locked high radiation area at Unit I being inadvertently left open,
and the failure of the
ALARA Board to meet for over
a year's
period, all led
the Board to conclude that
an appropriately
high level of respect for
radiation
has not been established
at Palo Verde, nor has
management
oversight
or line supervision
been sufficient to address
the numerous
problems in this
functional area.
The NRC's concern with your Radiation Protection
program is
best exemplified by our proposed
imposition of a
$200,000 civil penalty
on
December
1, 1988, for various violations of regulatory requirements
associated
with Radiation Protection.
In the functional
area of Safety Assessment/guality
Verification, the Board's
concerns
were primarily with your review of plant events
and the effectiveness
of the quality oversight groups.
Your reviews of several
significant events
were found to be weak.
These events
included the introduction of foreign
material into the reactor
vessel
at Unit 1 during refueling leading to a
stuck rod, the early criticality event at Unit I, and the personnel
event at Unit 2.
The Board considers
the ability to thoroughly
learn -from experiences
to be critical in the operation of a nuclear reactor
facility, and, therefore,
recommends
that you consistently
demand that
critical, in-depth reviews
be conducted for all notable events.
With regard
to the quality oversight groups,
the Board concluded that they have not
demonstrated
an ability to identify major weaknesses
in the operation of the
facility prior to those
weaknesses
becoming self-revealing,
and
on occasions
where significant problem areas
were identified, the problems
were not always
elevated
to the proper level of management.
As we have discussed
with you recently,
we recognize
the plans you have
developed
to;=improve your performance
in various areas.
We generally regard
your proposed actions to be positive.
We encourage
you to follow through with
those actions, with particular attention to your efforts to recruit high
caliber personnel
to assume
presently vacant
management
positions.
l
t
t
t
~J
A management
summary of this assessment
is provided in Section II of the
enclosed
report.
Perceived
strengths
and weaknesses
and Board recommendations
are discussed
in Section
IV, Performance Analysis.
You are requested
to provide to this office, within 30 days of the management
meeting,
a written response
which addresses
the three functional
areas
assessed
by the
SALP Board as Category 3.
This response
should d'escribe
actions
which you have taken or plan to take to provide improved performance
in these functional areas.
Actions described
in previous
correspondence
may
be included
by reference if appropriate.
Your response
may also include
comments
on or amplification of the
SALP report in other areas,
as
appropriate.
In accordance
with Section
2.790 of the NRC's Rules of Practice,"
Part 2,
Title 10,
Code of Federal
Regulations,
a copy of this letter, the enclosed
SALP report,
and your response will be placed in the NRC's Public Document
Room,
The NRC's Office for Analysis
and Evaluation of Operational
Data performed
an
assessment
of licensee
event reports
submitted for Palo Verde.
This
assessment
was provided
as
an input to the
SALP process;
a copy is, therefore,
provided
as Attachment
1 to the enclosed report.
The response
requested
by this letter is not subject to the clearance
procedures
of the Office of Management
and Budget
as required
by the Paperwork
Reduction Act of 1980,
PL 96-511.
Should you have
any questions
concerning
the
SALP report,
we will be pleased
to discuss
them with you.
Sincer.e.ly,
.
~ ~
J.
B. Martin
Regional Administrator
Enclosure:
SALP Report
No. 50-528/88-38,
529/88-36,
530/88-36
Attachment
1 Enclosed in SALP Report
cc w/enclosures
( 1) and (2):
J.
G. Haynes","Vice President,
Nuclear Production
W.
F. guinnq;Director, Nuclear Safety
and Licensing
R. Papworth'",~Director, guality Assurance
State of Arizona
l
II
I'
I
1
bcc w/encl osures:
Project Inspector
Resident
Inspector
docket file
G.
Cook
B. Faulkenberry
J. Martin
Commissioners
T. Murley, Director,
M. Johnson,
OEDO
bcc w/o enclosures:
J. Zollicoffer
M. Smith
REGION V/ ot
JBurdoin
1
RMhar ds
125$ /88
L ilier
12@+88
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REQUEST
COPY
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BOARD REPORT
U. S.
NUCLEAR REGULATORY COMMISSION
PEGION
V
SYSTEMATIC ASSESSMENT
OF LICENSEE
PERFOPMANCE
50-528/88-38,
529/88-36,
530/88-36
ARIZONA NUCLEAP,
POWER
PROJECT
PALO
VERDE NUCLEAR GENERATING STATION
NOVEMBER 1,
1987
THROUGH OCTOBER 31,
1988
TABLE OF
CONTENTS
I.
Introduction
A.
Licensee Activities
B.
Direct Inspection
and Review Activities.
II.
Summary of Results
A.
Effectiveness
of Licensee
Management
B.
Results of Board Assessment
C.
Changes
in,SALP Ratings
III. Criteria
I
IV.
Performance
Analysis
A.
. Plant Operations
B.
Radiological
Controls
C.
Maintenance/Surveillance
D.
Emergency
Preparedness
E.
Security
F.
Engineering/Technical
Support
G.
Safety Assessment/guality
Verification
V.
Supporting'ata
and Summaries
A.
Enforcement Activity
B.
Confirmation of Action Letters
C.
Other
TABLES
Table
1 - Inspection Activities and Enforcement
Summary
Table
2 - Enforcement
Items
Table
3 - Synopsis of Licensee
Event Reports
Attachment
1 - The Office for Analysis
and Evaluation of
Operational
Data
Pa
e s)
1
-2
6
9
13
15
18
20
21
25
25
25
26
27-29
30-32
33-35
N/A
I
1
I .
INTRODUCTION
The Systematic
Assessment
of Licensee
Performance
(SALP) is
an
NRC staff
integrated effort to collect available observations
and data
on
a
pe'riodic'asis
and evaluate
licensee's
performance
based
on this
information.
The program is supplemental
to normal regulatory processes
used to ensure
compTia'nce with NRC rules
and regulations.
It is intended
to be sufficiently diagnostic to provide
a rational basis for allocatina
NRC resources
and to provide meaningful
feedback
to the licensee's
management
regarding
the
NRC's assessment
of their facility's performance
in each functional area.
An NRC
SALP Board,
composed of the members listed below, met in the
Region
V office on December
6,
1988, to review observations
and data
on
the licensee's
performance
in accordance
with NRC Manual Chapter 0516,
"Systematic
Assessment
of Licensee
Performance,"
dated
June
6,
1988.
The
Board's findings and
recommendations
were forwarded to the
NRC Regional
Administrator for approval
and issuance.
This report is the
NRC's assessment
of the licensee's
safety performance
at Palo Verde for the period November
1,
1987 through October
31,
1988.
The
SALP Board for Palo Verde was
composed of:
- (i
- S
- +Q
- R.
- H
- M
. **T
- M
- AT
- J
- p
- L.
F. Kirsch, Director, Division of Peactor Safety
and Proiects,
Region
V (Board Chairman)
M. Knighton, Director, Project Directorate. V,
A. Richards, Acting Chief, Reactor Safety Branch
P.
Yuhas, Chief, Emergency
Preparedness
and Radiological Protection
Branch
F. Fish, Chief, Emergency
Preparedness
Section
S. North, Acting Chief, Facilities Radiological Protection Section
D. Schuster,
Chief, Safeguards
Section
L. Chan, Units
1 and
2
NRR Project Manager
J. Davis, Unit 3
NRR Project Manager
J. Polich, Senior Resident
Inspector
F. Burdoin, Project Inspector
Cillis, Senior Radiation Specialist
R. Norderhaug,
Safeguards
Inspector
- Denotes voting member in functional area of cognizance.
- Denotes voting member in all functional areas.
A.
Licensee Activities
In general, all three units operated satisfactorily during the
assessment
period.
Units
2 and
3 were relatively free of problems;
however,
the number
and type of events
which occurred at Unit I set
that Unit apart from Units 2 and 3.
Specific operational
events
were is follows:
I
Unit
1
Unit
1 was in its first refueling cycle at the beginning of this
assessment
period.
Startup following refueling was delayed until
March 8 because
pump shaft cracking problems
and
the binding of Control Element Assembly
(CEA) 56 during rod drop
testing.
A ball bearing
was found in the
CEA 56 Guide Tube.
On May
14 following a reactor trip, the reactor experienced
an early
criticality and
a subsequent
reactor trip while returning the unit
to service.
The reactor
was again returned to service
May 16.
On
July 6,
a
13.8KV bus fault resulted
in
a major electrical failure in
the unit auxiliary transformer,
which kept the uni t down until
Augus+
18.
The unit returned to power and operated
at essentially
100K power through the
end of the assessment
period.
Unit 2
Unit 2 entered
the assessment
period at
100K power and operated
essentially
at
1004 throughout the period until February
20,
when
the unit was
shutdown to commence its first refueling outage.
Startup initially scheduled for May 12 was delayed until early June
to complete
outage
maintenance
work and surveillance testing.
The
reactor went critical on June
18 and operated essentially
at
100K
power during the balance of the assessment
period.
Unit 3
Unit 3 was
shutdown
on the first day of the assessment
period after
having completed
low power physics testing associated
with the
issuance
of the initial low power license.
The unit was restarted
November
23 in anticipation of receiving
a full power license,
which
was issued
November 25.
Power was increased
to above
5X for the
first time on November 26.
Power ascension
testing continued with
some minor problems until January
1, when the unit was
opera+ed at
100% power for the first time.
The unit operated at essentially
full power until July 31,
when the "8" phase of the main transformer
faulted due to
a lightning strike,
and the unit was placed in
Mode 3.
The unit was returned to service
on August
18 following
repairs
to the main transformer
and the completion of other short
notice outage work.
The unit operated
at essentially
100% until the
end of the assessment
period except for a reduction to 50K on August
25 because
of a "8" main feedwater
pump problem and
a reduction to
204 on September
22 to repair
tube leak.
Palo Verde ended the evaluation period
on
a more positive note with
all three units operating at full power.
Unit
1 ended
the period in
its 61st continuous
day on line, Unit 2 with 131 continuous
days,
and Unit 3 with 74 continuous
days.
Direct Ins ection
and Review Activities
Approximately 5935 on-site inspection
hours
were spent in performing
a total of 49 inspections
by resident,
region-based,
headquarters,
t
and contract personnel.
Inspection activity in each functional
area
is summarized
in Table l.
II.
Summar
of Results
A.
Effectiveness
of Licensee
Manaqement
P
Overall site performance'during
.this
SALP period
has
been declining.
Since the. major- reorqanization=-of
the site in November
1987, that
separated
the single site organization into three separate
unit
organizations,
several
key manaqers
have left the organization.
The
former plant manager left the licensee after the reorganization
and
resulted
in the loss of a strong central directing force for the
site.
Other departures
from the licensee
management
team included
the sit. radiation protection manager,
central
chemistry
and
radiation protection manager,
emergency
planning manager,
and the
site maintenance
manager.
In the latter part of the
SALP period the
former Executive Vice President,
Mr. E.
E.
Van Brunt, announced
his
retirement.
The experience
level of licensee
upper management
has
.
been
a major
NRC concern for several
years.
The experience
level
has
not improved significantly as the individual units
came
on line;
and these
recent departures
have
caused
increased
concern.
The
reorganization
into three separate
unit organizations
has
placed
additional
demands
on the senior management.
There
appears
to be
a growing gap between
the site's
problems
and
the licensee 's capability to deal with them.
In response
to NRC's
concerns.
the licensee
has
announced
plans to add five senior
management
positions to the site organization.
The search for
- -- - qualified personnel
to fill these positions is currently in
progress.
B.
Results of Board Assessment
Overa)1,
the
SALP Board found the performance of NRC licensed
activities by the licensee
to he acceptable
and directed
toward safe
'- operation of Palo Verde.
The
SALP Board has
made specific
recommendations
in most functional areas for licensee
management
consideration.
The results of the Board's
assessment
of the
licensee's
performance
in each functional area,
including the
previous
assessments,
are
as follows:
Functional
Area
A.
Plant Operations
B.
Radiological Controls
C.
Maintenance/Surveillance
D.
Emergency
Preparedness
E.
Securitv
F.
Engineering/Technical
Support
G.
Safety Assessment/equality
Verification
Rating
Last
Period
Ratina
This
Period
Trend
Improving
I
C.
An improvino trend is defined as:
Licensee
performance
was
determined
to be improving near the close of the assessment
period.
Chanqes
in SALP Ratinqs
The licensee's
performance
in the'lant operations
area
declined
.rom
a Cateqory
2 to
a Cateaory
3.
It is recognized that Unit 3
performance during'he
assessment
period
was
good
and several
siqnificant records. were set durina
power ascension
testinq
and
commercial operation.'nit
2 performance
was noted to have
improved
and unit management's
involvement in plant operations
increased
during the evaluation period.
The decline in performance
is
primari lv due to events
at Unit I and senior management 's irabi 1 ity
tn establish
a working atmosphere
which encourages
critical
assessment
during the conduct of operations
and is reflective of a
divergence
between
management
expectations
and staff performance.
Unit
1 operators
willingness to conduct safety significant
evolutions withou't
a questioning
and cautious attitude
overshadows
the acceptable
performance of operators
at the other two units.
The licensee's
performance
in the areas
of radiological controls
and
safety assessment/ouality
verification declined
from Category
2 to
Category
3 during this period.
The decline
in- the radiological
controls
area
is perceived
to be due to inadequate
technician
sta<fing levels, untimely replacement
of a permanent site radiatinr
protection
manager position,
and
weak training of technicians.
The licensee
performance
in the emergency
preparedness
area declined
from Category
1 to Category
2.
The cause of this is perceived to be
a reduction in upper management's
attention to the problems
in the
emergency
preparedness
program,
which contributed to
a failure to
understand
work requirements
and the necessity for adherence
to
procedures
in the
EP area.
The licensee's
performance
in the'Safety
Assessment/equality
Yerification area declined
from Category
2 to Category 3.
While'the
title of this section
changed
from the previous
SALP period the
items involved in the assessment
of this area
are essentially
the
same with the addition of licensing activities.
The decline is due
to several
failures of management
oversight
and direction,
some of
which resulted-in escalated
enforcement
actions
in the areas
of
plant operation,
radiological controls
and enqineering/technical
support.
In general,
management
failures
have combined to produce
situation's
which permit working level errors to continue to go
unchecked until the errors
are self-revealed
by events.
III. CRITERIA
,Licensee
performance
is assessed
in selected
functional areas,
depending
on whether
the facility is in
a construction or operational
phase.
Functional
areas
normally represent
areas significant to nuclear safety
and the environment.
Some functional areas
may not be assessed
because
of little or no licensee activities-or lack of meaningful observations.
Special
areas
may be added
to highlight significant observations.
The following evaluation criteria were used,
as applicable,
to assess
each functional area:
1.
Assurance of qualitv, including management
involvement
and control.
2.
Approach to resolution of technical
issues
from a safety standpoint.
3.
Pesponsiveness
to
NRC initiatives.
4.
Enforcement history.
5.
Operational
events
(including response
to, analysis of, reporting
of,
and corrective actions for events).
6.
Staffino (including management).
7.
Effectiveness
of the training and qualification program.
However, the
NRC is not limited to these criteria
and others
may have
been
used
where appropriate.
On the basis of the
NRC assessment,
each functional
area
evaluated
was
rated according
to three performance
categories.
The definitions of
these
performance
categories
are
as follows:
Cate or
1:
Licensee
management
attention
and involvement are readily
evident
and place
emphasis
on superior performance of nuclear safety or
safeguards
activiti'es, with the resulting performance substantially
exceeding
regulatory requirements.
Licensee
resources
are ample
and
effectively used
so that
a high level of plant and personnel
performance
is being achieved.
Reduced
NRC attention
may be appropriate.
Cate or
2:
Licensee
management
attention to and involvement in the
performance of nuclear safety or safeguards
activities are good.
The
licensee
has attained
a level of performance
above that needed
to meet
regulatory requirements.
Licensee
resources
are adequate
and reasonably
allocated
so that
good plant and personnel
performance is being achieved.
NRC attention
may be maintained at normal levels.
~Cate or
3:
Licensee
management
attention to and
invo1vement in the
performance
of nuclear safety
or safeguards
activities are not
sufficient.
The licensee's
performance
does
not significantly exceed
that needed
to meet minimal regulatory requirements.
Licensee
resources
appear
to be strained
or not effectively used.
NRC attention
should
be
increased
above
normal levels.
IV.
PERFORMANCE ANALYSIS
The following is the Board's
assessment
of the licensee's
performance
in
each of the ~unctional areas,
plus the Board's conclusions for each
area
t
I
}"
I
and its recommendations
with respect
to licensee
actions
and management
emphasis.
A.
Plant
0 erations
1.
~Ana1 sis
'Inaspite of'several-significant
operational
accomplishments
at
Units
2 and 3, plant operations
has declined from the previous
assessment
period.
This decline is primarily due to events at
Unit
1 and the lack of prompt and decisive efforts by corporate
senior
management
to establish
a working atmosphere
which
encourages
critical assessment
during the conduct of
operations.
This low level of self critical assessment
and
direction allowed individual unit performance
to diverge to the
'oint where Unit
1 performance
was clearly poor several
times
during this evaluation period.
Management.
also failed in their
responsibility to demand consistency
and accountability
of
overall site activities,
and failed,to take adequate, corrective
measures
when such actions
were clearly warranted.
Only in the
last month of the assessment
period were management
changes
made at Unit I and
a clear set of management
expectations
established.
During the assessment
period,
the licensee's
plant operations
activities
wer e observed routinely by both the resident
and the
regional staff.
A total of 2945 hours0.0341 days <br />0.818 hours <br />0.00487 weeks <br />0.00112 months <br /> of inspection effort
were devoted to this functional area.
The licensee
achieved
several
accomplishments
in the operations
area during this
period.
These
included
214 days of continuous
operation at
Unit 3 following a successful
power ascension
test. program
as
well as
a second
continuous
operating
run of 74 days following
only one reactor
shutdown during the commercial
operation
portion of the
SALP period.
Unit 2 had
131 days of continuous
operation following its first refueling outage.
Other positive
operational
experiences
were the problem free core reloads at
both Units
1 and 2; the core unloading,
inspection
and fuel
reconstitution at Unit 2; and the chemical
decontaminations
of
the primary coolant systems
at Units
1 and 2.
In spite of
these
accomplishments,
events did occur at Units
1
and
2 which
contribute'd negatively to the plant operating history.
These
events
were due in part to the lack of procedural
compliance,
personnel
errors,
and
a willingness
on the part of staff to
proceed with plant evolutions prior to having
a full
understanding
of the conditions relating to the evolution.
The licensee's
responsiveness
to
NRC initiatives was maintained
at about the
same level
as during the previous report.
The
licensee
accepted
NRC initiatives in a positive spirit.
While
resolution of some of the matters
are still in progress,
their
correction
has
proceeded
slower than expected.
Some of these
efforts include the need for correcting
bogus annunciators;
increasing
management
staffing; reducing
personnel
errors;
and,
in one significant case involvino an earlier than expected
H
l
)
t
criticality at Unit I, thoroughly Tdentifying the root cause of
the event.
In several
of the meetings
held between
the
NRC and
management,
during which plant operations
were discussed,
the
licensee
expressed
a determination
to complete actions related
to initiatives wfiich would result in improved operations.
However, the repeated failure
o
managers
to devote significant
time to direct observation of plant activities is not
consistent
with ANPP management's
desire to improve activity
performance.
The licensee's
self-initiating approach
to the technical
resolution of plant problems resulting from operational
events
has
shown little improvement during the assessment
period.
Some examples of where licensee
management
resolutions
were
timely.-and technically sound
were related to the auxiliary
transformer fire (Unit I) and the replacement
of the reactor
coolant
pump shafts
(Units I and 2).
However,
both of these
issues
received
a high level of NRC attention,
and it is not
clear whether, left to their own initiative, the licensee
would
have arrived at the
same position.
Examples
where unconservative
actions
were taken'or
problem
identification was
weak included the early criticality at
Unit I where significant root causes
were not identified,
and
the failure of diesel
generator
intercooler drain plugs
on
Unit 2, three
months after the
same event occurred
on Unit 3.
.In several
of the meetings
held between
the-ANPP
and
NRC
management
the licensee
was informed that many of the problems
involving technical
issue resolutions
were related to
management's
failure to perform penetrating self-critical
assessments
of events,
and
demand that level of performance
from subordinates.
Escalated
enforcement
was taken in this functional area at
Units I and 2.
One such action dealt with
a series of
violations which were related to operating with an insufficient
number of auxiliary <eedwater
pumps,
due to an improper valve
alignment (Unit 2), failing to bypass
low pressurizer
pressure
protection
according
to procedures
which resulted
in an
engineered
safety feature actuation (Unit 2),
and entering into
Mode
4 without an operable
high pressure
safety injection pump
(Unit I).
A second
escalated
enforcement
action dealt with"
both trains of essential
chilled water inoperable
due to an
incorrect valving alignment (Unit I).
A third enforcement
action,
which is pending,
involved an earlier than expected
condition of criticality (Unit I).
In addition,
two other violations were identified in this
functional area.
These dealt with valving errors at Units I
and 3.
The number of LERs (25) submitted to the
NRC remained
the
same
as the
number submitted during the previous
period.
Nine were caused
by personnel
error.
However, of'he
operations
related
LERs, 60" (l5) of the total
and
78%%u (7) of
those
caused
by personnel
error were attributable to Unit 1.
During the
SALP period unplanned reactor trips were generally
associated
with Unit 1.
Four of the six trips which occurred
at Unit
1 were associated
with personnel
error or control
problems.
Units 2 and
3 experienced
only one unplanned
reactor
trip each during the period.
The Unit 3 trip-occurred during
power ascension
testing.and
the Unit 2 trip was
caused
by
control
prob1ems
during startup
from the refueling outage.
Four emergency diesel actuations
occurred durino the period.
One was related to an equipment malfunction, the other three
were due to personnel
or procedure
causes.
None of these
actuations
involved an interruption in plant operation.
One
safety injection/main steam isolation/containment
isolation
actuation
occurred at Unit 2 due to personnel
error.
During this
SALP period the regional licensing examiners
conducted
one replacement
examination
and
one licensed operator
requalification program evaluation.
The operator
replacement
examination results indicate that the trainino provided to
initial and upgrade
license candidates
is satisfactory.
However,
the pass/fail ratio has
decreased
during this
period from 19/1 to 18/3.
The licensed operator
requalification program evaluation indicates that the facility
training examination material, questions,
scenarios
and iob
performance
measures,
appear to be objective with evaluation
standards
that adeauately
evaluate
an operators
depth of plant
and operating
knowledge.
From the program evaluatior
and
operating
exams administered
the overall evaluation of the
licensed
operator requalification program appears
to be
satisfactory.
The licensee is involved in
a long term upgrade
program to
increase
simulator capability and fidelity to better reflect
actual plant responses.
The licensee
has
been
implementing
these
upgrades
slower than expected
due to debugging
problems
wi,th the more complex models
and the increased
licensed
operator simulator training time.
Licensed operator simulator
training time increased
from an average
24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per year
reported in the previous
SALP period to
a projected
60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br />
per year.
The narrowed window to implement the more complex
upgrades,
which require longer debugging
and testing times,
has
resulted in licensee
management
frequently having to delay
simulator training or extend
upgrade
schedules,
both of which
negatively impact effective training.
The licensee's fire protection
program has
remained
at
a high
level of performance.
Two major fires involving the Unit
1
auxiliary transformer
and the 525
KV switchvard transformer
were quickly extinguished
by the on-site fire department.
Two
ongoing unresolved matters still have not closed.
These
are
related
to inadequate fire door design
and ongoing work related
to sealing of penetrations.
Overa11,
operations
personnel
are knowledgeable
of plant system
performance
and generally
responded
properly to significant ard
complicated operational
events
even
though
some of
the events
were self initiated.
Plant shift crews generally
conduct thorough shift turnovers/briefings
which include
discussions
not only with the operation staff but also include
other unit departments
such
as chemistry
and radiation
protection.
Also. t'here
have
been
several
events
during the
SALP period which led to improper isolation of equipment
due to
the failure of operating
personnel
to properly implement the
clearance
procedure.
2.
Performance
Ratin
Performance
Assessment
- Category 3, Improving
3.
Board Recommendations
The licensee
must strive to ensure
that operations
are
conducted
in
a formal, conservative
manner
at all units.
Licensee
management
should continue actions initiated to assure
that there is both sufficient management
staffing and
appropriate
management
involvement in problem evaluations
and
resolution, particularly at unit 1.
Priority attention
should
be given to conducting
thorough evaluations of problems
ard
establishing
a working atmosphere
which encourages
thoughtfully
critical assessments
of all phases
of plant operations.
B.
Radiological Controls
1.
A~nal sis
A total of eleven routine inspections
related to radiological
controls were performed
by the regional
and resident
inspection
staff during this, assessment
period.
Over 860 hours0.00995 days <br />0.239 hours <br />0.00142 weeks <br />3.2723e-4 months <br />
were
expended
in the areas of:
Organization
and Management
Occupational
Radiation Safety
Transportation of Radioactive Materials
Radiological Efflvent Control
and Monitoring
Radioactive
Waste
Management
Training and gualifications
LWR Water Chemistry Control
Licensee
Event and Special
Reports
During the previous
SALP period,
a total of three Severity
Level
IV and
one Severity Level
V violations were identified in
Unit 1, one Severity Level IV violation was identified in Unit
2 and
no violations were identified in Unit 3.
These
violations did not represent
a programatic
breakdown.
For +he
last assessment
period, the licensee
was assigned
a Category
2
rating and the board
recommended
that the licensee
improve
performance with respect
to the reduction of the numbers of
1
t
1
'I
l
10
license
event reports attributable to personnel
error, posting
requirements
and radiological controls.
During the last half of this 'assessment
period there
have
been
several
examples
where the level .of management
involvement has
not been sufficient to assure
a high level of quality
"
performance.
Specific examples
include:
key management
positions resulting from the November
1987 reorganization
remained unfilled for extended
periods,
the
ALARA-Committee
failed to meet for over
a year, ouality assurance
and other
internal audit findings were not resolved in a timely manner,
significant numbers of workers were unfamiliar with required
controls for entry into high radiation areas
and
some workers
perceived
a lack of commitment to good radiation protection
practices
on the part of ANPP management.
Following an unplanned
exposure
event in May 1988,
NRC
identified violations involving control, posting
and access
to
in July, August
and September
1988.
An
Enforcement
Conference
was held
on August 17,
1988 to discuss
the unplanned
exposure
and other concerns.
The licensee's
presentation
of their assessment
of the radiation protection
program problems,
as highlighted by the unplanned
exposure
event,
was narrow and not adequate
to convince
NRC that
additional
enforcement
actions
would not be necessary.
A
second
more thorough review of the unplanned
exposure
event
was
presented
to
NRC on September
14,
1988.
This second
evaluation
was broader in scope
and indicated that the licensee
needed
to
expand
the investigative
process
in the area of problem
identification, deve1op
supervisory/management
skills and
increase
management's
awareness
of deficient conditions.
Subsequent
events
involving the prying open of a locked high
radiation area
gate at Unit 3, starting work prior to
completion'f required
ALARA reviews at Unit 2 and leaving
a
high radiation door open at Unit
1 indicated that initial
management
actions
were not fullv effective.
Following the
events
noted above,
the licensee initiated more aggressive
corrective actions including appointment of a,temporary site
Radiation Protection
Manager
and replacement
of the Unit 2
Radiation Protection
Manager.
The licensee's
resolution of a technical
issue associated
with
the decontamination
of the Unit 2 refueling cavity was
ineffective.
The planning
and schedule for accomplishing
the
work was not thorough, ponrly coordinated
and appeared
to place
operational
considerations
ahead of good radiation protection
practices.
Several
opportunities to decontaminate
the cavity
in accordance
with the nuclear industry standards,
such
as
performing
a thorough
vacuuming and/or hydrolazing of the
cavity, which could have prevented
the unplanned
exposure
event,
were missed during the refueling outage.
It appears
that additional effort is needed
in 'assuring that critical work
is thoroughly planned
and scheduled.
11
The program established
and
implemented for cortrolling hot
particles
was observed
to contain weaknesses
reflecting on the
resolution of technical
issues.
The licensee's initial program
for. controlling hot particles did not take into full account
requirements
for extremity monitoring of personnel
sorting hot
particle trash, training of personnel
in hot particle detection
and
a -rel'iable'method for calibration of instruments
used to
monitor for hot particles.
During this
SALP period the licensee
has
been generally
responsive
to
NRC initiatives and concerns.
These
included
management's
continued support of the reactor coolant
pump
bearing
and wear ring replacement
program to remove the
antimony .and cobalt containing material
in Unit 2 that had
been
conducted at Units I and
3 during the previous
SALP period.
The licensee
was effective in carrving forward to Unit 2 the
lessons
learned during the Units I and
3 antimony removal
process.
-Improved results
were obtained during the Unit'2
antimony clean-up
process
over those achieved
in Unit l.
Additional strengths
included
an
INPO accredited training
program and
an effective dosimetry program.
Housekeeping
was
effective in minimizing contaminated
areas.
As
a result of the
licensee's
efforts, discussed
above,
ANPP was well below the
1987 national
average collective dose of 371 person-rem
per
'react'or.
The licensee's
average collective dose
was
230
person-rem
per reactor,
despite
having
a partial refueling
outage in Unit I and
an initial refuelina outage in Unit 2.
The collective dose of ?.8 person-rem
in Unit 3,
a plant that
is scheduled
to undergo its first refueling outage
shor tlv,
indicates effective personnel
exposure
control consistent
with
the
ALARA concept.
This is considered
to be
a significant
-accomplishment.
Another improvement noted during this
period
was the licensee's
construction
and activation of a
permanent respiratory protection facility with state of the art
equipment for processing
respiratory equipment.
The licensee's
enforcement history during this
SALP period
included:
one apparent Severity Level III violation at Unit 2
as
a result of deficiencies identified'during the unplanned
exposure
event of Hav 23 and one apparent Severity Level III
violation .at Units
2 and
3 as
a result of the deficiencies
related
to the control, posting
and access
to high radiation
areas
which were identified during the third quarter of 1988.
The principal root causes for these
events
were attributed to
personnel
proceeding
in the face of uncertainty
and personnel
error.
These violations resulted
in an escalated
enforcement
act
on with imposition of civil penalties.
Additionally,
during this
SALP period,
there
were three Severity Level IV
violations
and two Severity Level
V violations identified at
Unit I, three Severity IV violations and one apparent Severity
Level
V violation identified at Unit 2 and one Severity Level
IV violation identified at Unit 3.
Corrective measures
for the
two apparent
Severity Level III violations were neither timely
or effective in that repeated
violations in the areas of ALARA
12
program implementation
ard posting
and control of high
radiation areas
were identified.
Additional weaknesses
identified during this
SALP period include:
(1) the use of
"permissive" terms
and lack of specificity in the radiation
protection program implementing procedures,
and (2) the failure
to implement
a coordinated,
consistent
radiation protection
prooram for the site and
each Unit.
The declining performance
in. the- radiation protection program was observed following the
,licensee's
site wide reorganization of November
1987.
Collectively, the above violations
and weaknesses
appear to
indicate that ther e has
been
a significant breakdown in the
radiation protection
program.
The number of reportable
events
in this functional area
included fourteen special
reports involving radiation
monitoring units which were reported to be inoperable for
greater
than
a 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> period.
Additionally, there were
numerous
licensee
event reports
(LERs) involving the failure to
perform the sample analysis
required
by the
RETS and the
failure of process
and effluent monitoring
(PERM) equipment to
function properly.
Two of the reportable
events
were related
to the apparent Severity Level III violations that are
discussed
above.
Many of the
LERs were attributable to
personnel
error.
The number of reports attributable to
personnel
error was raised
as
a concern during the previous
SALP period.
In addition, of particular concern
was the high
incidence of reports involving the failure of PERMs to functior
properly.
It appears
that additional
management effort with
respect
to improving the reliability of the
PERMs and reducing
the number of reportable
events
due to personnel
error is
needed.
Experienced
technician staffing levels at each of the units
appeared
to be adequate
to support
normal plant operations.
Technician staffing levels of the central radiation protection
group technicians
appeared
to be marginal following the
reorganization of November 1987.
The licensee
became
aware of
this problem and took immediate action to supplement
the
central radiation group with additional
personnel
during the
last quarter of this
SALP period.
Managements
efforts to
secure
a permanent
replacement for the site Radiation
Protection
Manager position has not been effective or timely.
Weaknesses,
apparently attributable to traininq, were also
identified during this
SALP period.
These include the training
of technicians
in the methods for detecting hot particles
and
assuring that workers'nowledge
concerning control
and posting
is clearly understood.
Performance
Ratin
Performance
Assessment
- Category
3
ll
13
Based
on the serious
nature of events
and weaknesses
identified
the licensee's
performance
in this functional area
has
shown
a
significant decline from the rating assigned
during the
previous
SALP period.
3.
Board Recommendations
The licensee
should focus their immediate attention
on
completion of the assessment
of the radiation protection
program,and
implementation of corrective actions to assure
that
basic occupational
radiation protective
measures
are
accomplished.
The licensee
is encouraged
to create
a working
atmosphere
in which workers clearly understand
and discharge
their responsibilities,
are held accountable,
do not proceed
in
the face of uncertainty,
and feel comfortable
when bringing
concerns
to licensee
management
and to the NRC's attention.
Significant improvement is needed
to reduce
the
number of
events
leading to licensee
event reports attributable tn
personnel
error,-.and to improving the reliability of PERM
operatiors.
The licensee
is further encouraged
to improve the
scope
and quality of the evaluation of events
and in assuring
that corrective actions
are both timely and effective.
C.
Maintenance/Surveillance
1.
A~na1 sis
This functiona I area
was observed
routinely during the
assessment
period by both the resident
and regional
inspection
staff.
Approximately 712 hours0.00824 days <br />0.198 hours <br />0.00118 weeks <br />2.70916e-4 months <br /> of inspection effort were
devoted to this functional area.
Strengths
included the
successful
completion of several sigrificant maintenance
tasks
such
as the replacement
of the Units
1 and
2 reactor coolant-
pump shafts,
replacement
of the Units
1 and
2 auxiliary
pump impellers within the
3 day Technical
Specification action time period
and the restoration of the
damaged auxiliary transformer
and related electrical
equipment
at Unit l.
Several
events
which reflect negatively
on the maintenance
fun'ctional" area
include the introduction of ball bearings
into
the Unit
1 Upper Guide Structure
(UGS) preventing
movement of a
Control Element Assembly
(CEA) (Unit 1), the bendino of a
extension
shaft (Unit 2) and the under torauing of the Reactor
Coolant
Pump shaft impeller nuts (Unit 2).
All of these
events
were caused
by inadequate
controls and/or insufficient
supervisory
involvement.
The first event also indicates
a
laxness
on the part of maintenance
personnel
in the reporting
of problems
to management.
The level of responsiveness
to
NRC initiatives was about the
same
as during the previous
SALP.
One concern which the
NRC
discussed
with the licensee
on several
occasions
was the
reduction of maintenance
backlog work items.
The licensee
implemented actions
to more closely monitor backlog.
h'hile the
backlog
has
decreased,
approximately half the site backlog is
associated
with Unit .1.
The control of work and the conduct of maintenance
continued to
be areas
of concern that
showed little improvement during the
assessment
period.
The work control procedures
were modified
during .the period.
The action was prompted in part by the
reorganization
and by the recoonition that changes
were
needed
to improve 'work coordination,
scheduling,
operations
involvement, retesting
and the quality of instructions.
Deficiencies in work controls resulted
in several significant
operational
problems during the period.
These
included
rendering auxiliary feedwater
pumps inoperable
(Units I and 2},
the introduction of ball bearings
into the
UGS (Unit I), the
tripping of a startup transformer (Unit 3),
and the bending
o<
a
CEA extension
shaft (Unit 2).
- Instances
of deficient post-
maintenance
retesting
were still being observed
during the
latter part of assessment
period.
The coordination with operations
on the issuance
of effective
clearances
continues
to require management's
attention
as
several
cases
of incomplete deactivation of equipment
associated
with work orders
were experienced
during the period.
There
have
been
no plant shutdowns directly attributable to
maintenance
personnel
errors,
although in one instance
a
turbine trip occurred
due to an incomplete troubleshooting
effort (Unit I) and
a secondary
plant transient
(loss of a Main
Feed
pump) occurred
due to poor job planning (Unit 2).
Two violations related to maintenance
were issued during the
SALP period.
One
was related to an incorrect restoration of an
access
door on
a vital static inverter (Unit 1), the other
was
due to
a failure to follow procedures
(Unit 2).
The quality of implementation of the surve'illance
program
has
been
equal
to that of the previous
assessment
period.
Of the
nineteen
LERs related to the functional area
seven
were due to
exceeding
the testing frequency time requirements.
The
ASYiE
Section
XI surveillance
program requirements
appear to be well
coordinated.
The licensee maintains
a qualified staff
dedicated
to this effort.
The licensee
has demonstrated
good performance
in chemistry
surveillance
and control to reduce degradation of the reactor
coolant, pressure
boundary.
Performance
weaknesses
were limited
to the sensitivity of reactor coolant system fluoride analysis
and control of condensate
polisher sodium ingress
to the
secondary
system.
The Chemistry Standards
Department
has
established
an aggressive
program for independent verification
of analytical
performance
using spiked
and replicate
samples.
I
15
Expertise within the maintenance
organization
generally
has
been
adequate
to repair
and maintain equipment in an operable
condition except
when multiple or extended
cutages
occur.
The
licensee
has contracted
assistance
from vendors
on work
requiring very specialized
knowledge.
An INPO accredited
maintenance
program for the crafts
was developed
and-
implemented during the period.
I'n spite
o'f this, several
observations
of inadequate
documentation
on work orders
were
made during the period.
Planner/coordinators
are
key personnel
in the proper implementation of the licensee's
work control
program;
however,
the experience
and training of these
individuals varies
great'1y
and
needs
improvement.
There is no
real engineering capability in the maintenance
organization,
and the'ork planners
only seek
help from system engineers if
thev see fit.
A decline in performance
was observed
due to the
significant organizational
and program changes
during
a period
of extended
workload (back to back refueling outages).
In the
later part of the assessment
period, while all three units have
operated
at essentially
fu11 power, conduct of maintenance
and
the control of work have not shown signs .of improvement.
2.
Performance
Ratin
Performance
Assessment
- Category
2
3.
Board Recommendations
Licensee
management
should strive to instill an inquisitive
attitude in their maintenance
personnel.
Maintenance craft and
work planners
must think beyond
the immediate work they do and
assess
how it affects
equipment operability.
Additionally,
planner coordinators
must
be more aggressive
in enlisting the
system engineers
support in the correction of non-routine
equipment
problems.
Maintenance
manaoement
must increase
efforts to observe
ongoing work and provide corrective feedback
into the maintenance
program.
0.
Emer enc
Preparedness
Analvsis
Approximately 313 hours0.00362 days <br />0.0869 hours <br />5.175265e-4 weeks <br />1.190965e-4 months <br /> of direct
NRC inspection effort was
spent
in this functional area during this
SALP period.
The
inspections
included
two annual
emergenc v preparedness
exercises
and
one routine preventive inspection.
h~hile management
has
been effectively involved in the emergency
preparedness
(EP) program,
the level of involvement appears
to
have diminished during this
SALP period.
For instance,
a
problem involving the delay of emergency
response
teams
being
processed
through security
was brought to management's
attention several
times through the licensee's
own
EP exercise
critiques,
NRC exit interviews
and
NRC inspection reports.
It
was also noted that firefighters responding
to the Unit
~
l
f
I
16
auxiliary transformer fire in July 1988 were unnecessarily
del.ayed
3-4 minutes while being processed
through the security
access
control point.
In another
instance,
congested
radio
traffic caused
bv routine use of an emergency
radio channel
was
brought to management's
attention during the licensee's
critique of the December
1987 exercise.
It has
been
noted that
congested
communications
occurred during the response
to the
1988 Unit -1 auxiliary transformer -fir'e.
Diminished management
involvement
,rom previous
SALP periods
was also 'indicated
by
the absence
of management
representatives
at the 'licensee's
latest
( 1988)
annual
exercise critique.
The only management
attendees
were from the
EP Department itself; no corporate
management
or representatives
from 'other departments
were
pr'esent.
(However, copies of the critique report were provided
to the various managers,
inc'luding those at the corporate
level. )
Corrective actions
are usually taken,
but there were instances
of ineffectiveness
in correcting 'the root cause of the problem.
As an example,
several
problems in identifying field monitoring
team locations
have
been identified during previous
annual'xercises.
Even after corrective actions weri taken, similar
problems
were identified in the
1988 exercise.
In another
instance,
the
NRC identified
a conflict between
procedural
protective action
recommendations
for the
same conditions.
After corrective actions
were taken,
the
NRC identified an
identical conflict in still another
procedure.
The licensee,
however,
has displayed
an above-average
capability of
self-assessment
of emergency
events.
The post trip report,
PTRR 1-88-004, of the July 6,
1988 Unit
1 Auxiliary Transformer
Fire and Reactor Trip is
a good example of this capability.
The occurrence
was analyzed,
cognizant individuals interviewed,
conflicting information identified and resolved,
and
documentation
provided to management
in clear
and objective
reports.
The licensee's effort to resolve technical
issues
from a safety
standpoint is generally
sound,
but resolutions
are not always
timely.
For instance,
a problem with providing reliable backup
emergency
communications
was first identified by the
NRC in
1986.
The:issue
was included in the 1987
SALP report because
the licensee still had
no concrete
plan of action to resolve
the issue.
It appeared
that the licensee
was attempting
a more
comprehensive
resolution
than
was actuallv required to satisfy
the concern.
Their plan for resolution called for purchasino
existing communications
lines from Mountain Bell and rerouting
them to a new facility constructed
to house the backup
comrunication svstem.
The licensee
now has installed
a number
of cellular portable
phones
as the backup
emergency
conmunications.
Implementation of NRC initiatives and policies
has
been timely
and effective,
and the licensee consistently
meets
expectations
with regard to schedule
or content.
17
There
have
been
no
NRC enforcement
actions
in this functional
area.
The
EP program staffino has
undergone
a major reorganization.
During this period the licensee's
executive vice president
retired,
the nuclear.,vice
president
was
removed from the
emergency
preparedness
chain of,responsibility,
and the
emergency
planning manager resigned.
The result
was
a
.considerabl.e.
aggregate
.l,oss .of. EP experience, within a short
period of'ime.
Expertise,
however,
has
been usually available
within the staff and consultants
have
been appropriately
used.
There
has
been
some
concern
about adequate staffing in the
emergency
response
organization.
The
NRC had expressed
in
a
report during the previous
SALP period
a concern that an
adequate
number of trained personnel
may not be available to
respond
to emergencies.
A licensee
post trip report,
No.
PTRR
1-88-004,
also indicated
a lack of staffing to respond to that
situation
when the services
of the Shift Technical Advisor was
unavailable
because
he was occupied maintaining communications
with the
NRC.
For some
time the emergency
planning department
has
been joined
with the fire department
under
a single manager.
The merged
departments,
along with the security,
nuclear trainirg,
material control,
and administration
departments
now operate
as
service organizations
under the Director of Site Services.
Organizationally,
these
are not associated
with the site
reactor operations.
It appears
that the present
organizational
setup provides little opportunity for direct site operations
interface with the emergency
planning program.
The licensee's
gA program continued to meet the
NRC re-
quirements
to provide
an independent
annual
review of the
emergency
preparedness
program
and evaluate
the adequacy of
interfaces
with State
and local governments.
Audits were
conducted
in
a timely manner
and audit
teams
were
composed of
members
who had
no direct responsibilities within the emergency
preparedness
program.
The training and qualification program contributes
to an
adequate
understanding
of work and adherence
to procedures.
Several training problems,
however,
were manifested
during the
Unit 1 auxi liarv transformer fire.
For instance, it was
necessary
several
times for firefighters to interrupt their
efforts to ask bystanders
to move back from the fire scene.
In
addition,
as previously mentioned,
unauthorized
use of an
emergency
radio channel for routine operations
disrupted
emergency
communications.
Both instances
are indicative of
inadequacies
in general
employee
emergencv
preparedness
training.
2.
Performance
Ratin
Performance
Assessment
- Category
2
18
3.
Board Recommendations
The licensee
is encouraged
to evaluate
the interface
between
the emergency
planning
and site operations
departments.
Additionally, emphasis
on timely resolution of identified
deficiencies seem-critically important to improving performance
in this area.
E.
~Securi t
A~ina 1
s i s
During the assessment
period from November I, 1987 throuqh
October 31,
1988,
Region
V conducted
three physical security
inspections.
A total of approximately
285 hours0.0033 days <br />0.0792 hours <br />4.712302e-4 weeks <br />1.084425e-4 months <br />
o+ direct
inspection effort was expended
by regional
inspectors.
In
addition,
the resident
inspectors
provided continuing
observations
in this area.
There were
no material control
and
accounting
inspections
conducted
during this assessment
period.
With regard to management's
involvement in assuring quality,
corporate
and plant management
continued to review the
operation of the overall securitv program.
They have generally
implemented
remedia1
measures
to correct deficiencies
identified in the course of both internal
and
NRC security
inspections.
The previous
SALP report encouraged
licensee
management
to
continue their augmented
support of the station security
program, particularly with respect to: engineering
support
of'he
security program
and the planned
upgrade of vehicle
and
personne1
access
control areas.
During this
SALP period
package
search
equipment
has
been
upgraded
and construction
was
begun
on
a
new vehicle access
portal.
Since February
1987, specific
NRC. concerns
with the suitability
of roll-up doors
as vital area barriers
has
been raised.
Although various design concepts
to improve the resistance
of
such doors to penetration
have
been considered,
each
has
been
evaluated
and rejected
by the licensee's
engineering staff and
the specific concern
remains
unsolved.
After nearly two years,
these potentially vulnerable barriers
remain
augmented
by
compensatory
measures.
The previous
SALP report identified major program upgrades
underwav (particularly in the area of alarm station operation,
access
control, radio communications,
and physical barrier
evaluation)
as requiring continued
management
attention.
During this assessment
period,
the security management
essentially
completed
the upgrade of their radio communication
equipment.
The alarm station
upgrade is nearly complete.
The
licensee
has initiated actions to incorporate suitable barrier
characteristics
into their security plan.
However,
19
considerable
engineering effort remains
to be completed
on the
development of the necessary
barrier evaluation criteria.
During the assessment
period, four information notices related
to security were issued;
. The licensee.'s; actions,
as reviewed
to date,
were found to be appropriate.
- As
a result of the.
NRC
Regulatory Effectiveness.
Review conducted
during the
period,
the licensee
has initiated an evaluation proiect to
consider
upgradinq
the perimeter barrier system to include
a
double fence barrier enclosing
an isolation zone with detection
systems
and continuous
CCTV surveillance
for immediate alarm
assessment.
In response
to the August 1986,
NRC policy statement
on Fitness
for Duty of Nuclear
Power Plant Personnel,
corporate
and plant
management
continued to support their established
Fitness for
Duty Program.
As designed,
this program requires that all
applicants
seeking onsite
employment must satisfactorily
complete
a pre-emp'loyment urinalysis test.
Individuals granted
unescorted
access
to the protected
area
are subject to annual,
but scheduled,
urinalysis drug screening.
The licensee's
current Fitness for Duty Program
does not follow the industrial
standards
published
by Edison Electric Institute (EEI) i.e.,
the requirement for random testing is not included.
The enforcement history for the period November
1,
1987 throuah
October 31,
1988 includes
two violations,
one related
to the
licensee's
failure to alarm all protected
area
access
portals
and the second
relates
to the licensee's
failure to properly
secure
safeguards
information.
During this
SALP period,
the licensee
reported
seven
safeguards
events.
Four of these
events
resulted
from personnel:
error
one from failed security compensatory
measures;"
one from
unauthorized
access
to a vital area
and
one from an
uncontrolled
pathway tn the protected
area.'ith
respect
to staffing,
key positions
were identified and
responsibilities
were generally well defined.
The security
training staff has initiated
a special
advanced training
program which exceeds
the requirements
of regulation,
and
augments
current offsite security resources
to meet the special
security
demands
wrought by the plant's isolated location.
2.
Performance
Ratin
'I
Performance
assessment
- Category 2.
3.
Board Recommendations
Licensee
management
is encouraged
to complete their
'construction project of an alternate
vehicle access
control
point and to expeditiously address
the engineering
issues
associated
with the evaluation of roll-up doors serving
as
I
20
vital. area barriers
and the upgrade of the perimeter barrier to
eliminate potential vulnerabilities identified hy,the
RER team.
Further,
the licensee
is encouraged
to reexamine their current
Fitness for Duty Program with respect
to the
EEI guidance
pertaining to chemical testing of body fluids.=
.
F.
En ineerin /Technical
Su port.
~Anal sls
This functional
area
was observed routinely during the
assessment
period by both the resident
and regional
inspectior
staff.
Approximately 184 hours0.00213 days <br />0.0511 hours <br />3.042328e-4 weeks <br />7.0012e-5 months <br /> of inspection effort were
devoted
to this functional area.
These
inspections
showe'd the
licensee's
engineering
and technical
support organizations
to
be staffed with experienced
personnel.
However,
a
number of
significant weaknesses
were observed.
These
include:
sionificant errors in design basis
documents;
engineers
lacked
a sufficient knowledge of the design basis;
inadequate
implementation of the design
change
process;
and management
inattention to the Technology Transfer
and System Engineer
Programs.
Technical
issues
have, generally,
been appropriately resolved
in a timely manner after identification.
However,
self-revealing
events
or inspection findings have surfaced
many
of the technical
issues.
The need for management
to insist
upon
a pro-active rather than reactive
approach
in identifying
technical
issues
has
been discussed
in several
inspection
reports
and management
meetings
during the assessment
period.
The licensee instituted
a Technology Transfer
program to assure
that design basis
documentation
developed
by Bechtel for Palo
Verde
was effectively transferred
to the cognizance
of ANPP
engineering
personnel.
The Safety System Functional
Inspection
(SSFI)
team found ANPP had not adequately
reviewed the design
basis analysis
to assure
that
a complete
and accurate
design
basis is available for use in future plant design
and
modification efforts.
This is one of several
areas
where
manaqement's
inattention to an established
proqram allowed
results
to diverge from management's
expectations.
The System Engineer
Prooram
has
been established
for several
years at Palo Verde.
However, management's
expectations
and
program performance
also diverged;
due, here,
to
a lack of
management
oversight.
This was evident from several
events
and
inspection findings including:
multiple failures withir. the
engineerinq
organization to identify work that rendered
the
steam driven Auxiliary Feedwater
pumps at Units I and
2
System Engineer lack of knowledge of design basis
and/or walkdown functions;
and the lack of system engineer
involvement with complex work planning
and significant
maintenance activities.
t~sanaaement's
poor definition of the
f
t
t
!
i
I
21
system engineer's
responsibilities
and duties in relation to
the workload appears
to be
a contributing factor to the
problems that occurred this assessment
period.
In response
to
NRC initiatives and inspection findings,
management
instituted evaluation
and improvement
programs ir
the system-engineer,
design engineer,
and configuration
management
areas.
These
programs
required considerable effort
and re-evaluation of long range goals.
h'hile most of these
programs
began
in the first half of the
SALP period the initial
effort was spent in assessments,
evaluations
and long range
planning.
Thus,
most of the implementation will not
be
completed until well into the next
SALP period.
Although ANPP
management
has
been
involved in the early stages
of these
improvement
programs,
continuous
management
oversight will be
required to prevent
a relapse of the divergence
between
performance
and expectation.
No plant trips were attributable to the engineering
and
technical
support organizations
during the assessment
period.
However,
inadequate
technical
review of engineering
work did
play
a major role in rendering
the steam driven auxiliary
pumps
inoperable at Units I and 2.
Escalated
enforcement
action resulted
from this event.
Engineering
involvement in trending
and performance monitoring of equipment
history and planning of significant maintenance
and testing
activities
was notably absent
when several
operational
events
and transients
were investigated (for example,
in the Unit
1
early criticality event deficiencies
were noted in the fuel
management
and reactor engineering
groups that contributed to
shortcomings
in the Cycle
2 Core Data
Book and the
program
used in calculating the estimated critical conditions).
Staffing, qualifications
and training of both the site
and
corporate engineering
departments
has
been under review as part
of the System Engineer,
Technology Transfer
and Engineering
Excellence
programs.
These
reviews
have concluded that
increased
training and staffino are required to meet the long
range goals of ANPP management.
Thus,
management
has committed
to increase
both the site
and corporate engineering staffs to
better
manage
the workload of a three unit site
and reduce
the
current backlog.
2.
Performance
Patin
Performance
Assessment
- Cateoory
2
3.
Board Recommendations
The licensee
appears
to have initiated appropriate
programs
to
improve performance
in this area.
The licensee is encouraged
to closely monitor the implementation of these
programs.
G.
Safet
Assessment/Oualit
Verification
I
22
~Anal sis
This functional area
was observed routinely during the
assessment
period bv the resident
and reoional
inspection
staff.
In addition, several
inspections
focused specifically
on events
which were indicators of significant weakness
in this
area.
Over 636 hours0.00736 days <br />0.177 hours <br />0.00105 weeks <br />2.41998e-4 months <br /> of inspection effort were devoted to this
functiorial area.
This
SALP period evidenced significant
weaknesses
in problem identification, self-criticism of
identified problems
and management
oversight.
Underlvinq these
weaknesses
was the breakup
and re-formation of departmental
responsibilities
and lines, of communication,
brought about
by
the November
1987 reorgarization.
Furthermore,
the experience
level of upper management,
which has
been
a major
NRC concern,
was
reduced
when several
key managers left ANPP after the
reorganization
.
- This reorganization left many licensee
personnel
unsure of their new responsibilities,
and unclear of
the expectations
held by the
new management
organization.
Without clear management
direction, institutionalized
'elf-critical
assessments
via Quality Assurance
(QA), Quality
Control
(QC), Independent
Safety Assessment
Group
(ISEG) ard
other problem finding arms of the organization failed to
identify operational
and engineering
weaknesses.
The lack of
strong
management
interest contributed substantially to
inaction
and subsequent
self-revealing
problems.
The licensee's
ability to initiate thorough
and self-critical
event assessments
was called into question
several
times during
this
SALP period.
These
included
an Auxiliarv Feedwater
pump
unknowingly rendered
inoperable following maintenance
(Units I
and 2), the loss of Multi Stud Tensioner
coaster
bearings
which
resulted
in
a stuck Control Element Assembly (Unit 1),
an early
criticality during reactor startup (Unit I), and
a radiation
(Unit 2).
In each
case
the licensee's
assessment-
was found to be lacking or inadequate.
Although
QA inspected
in areas
such
as safety system
engineering
and radiation protection,
they have not been at the
forefront in assessing
the safety significance
o
their
results,
demandino
prompt and effective corrective action, or
aggressive
in clearly surfacing significant findings to senior
management
for resolution.
Furthermore,
management
review of
QA findings has not been sufficiently critical to require that
this
be routinely made
a part of QA audits.
In another
instance,
QA properly identified
a possible deficiency with
automatic pre-action fire suppression
systems;
however,
they
accepted
an engineering disposition which was incomplete in
addressing all the technical
issues.
On several
occasions,
the conduct of maintenance
proceeded
with
poor procedures
resulting in significant errors which failed tc
be questioned
by the involved maintenance,
operations,
engineering,
or QA/QC organizations.
Two steam driven
pumps were'endered
inoperable following
engineering
approved
adjustments
to the steam
admission
valves
(Units I and 2).
Reactor
Coolant
Pump
(RCP) impeller nuts were
under
torqued during assemblv
(Unit 2).
These
two situations
are
a demonstration
of poor performance
of technical
work by
engineering
and maintenance
organizations.
The licensee
was idertified as havinq good procurement qualitv
controls.
Also, the Nuclear Analysis department
identified
a
non-conservative
computer
code error which directly affected
shutdown margin calculations.
This is noteworthy
due to the
difficulty in locating such
an error in the extensive
computer
codes
used.
However, this detailed review was conducted after
and in response
to the early criticality event.
Response
to
NRC initiatives such
as Generic Letters,
NPC
Bulletins,
and
NRC Notices are adequate.
Past
licensee
practices of allowing regulatory issues,
such
as compliance
with the Anticipated Transient Without Scram
(ATWS) rule, to be
handled
by other parties (i.e. the
NSSS vendor),
are
now being
more aggressively
pursued
by the licensee's
own organization.
The licensee
continues
to be responsive
on
a daily basis
to
issues
NRC inspectors
bring to their attention.
In addition,
some
NRC concerns
in areas
such
as
improvements
in the
technical
adequacy of engineering
work, in general,
and in the
investigating
and root cause
methods
employed following events,
have resulted
in licensee efforts to institutionalize programs
meeting or exceeding
industry standards.
The. effects of these
and similar programs
have not yet been fully realized,
but
appear
to be
an in-depth
response
to these significant issues.
The licensee's
Compliance
department staff was
reduced
significantly after the reorganization
and resources
now appear
strained.
For example,
NRC open
item status
is tracked
as
a
collateral duty of a single compliance-engineer.
The status
of
licensee
followup to.these
items often requires
prompting by
NRC inspectors.
The events
discussed
in the enforcement
conferences
held during
the
SALP period appear to have resulted
from several
basic
failures
on the part of'NPP management.
These
include
an
inability"to establish
a, working atmosphere
.which encourages
step-by-step critical assessment
during the conduct of
operations,
an inability of gA and other oversight groups to
identify and correct significant problems prior to their
becoming self-revealing,
and
a failure to demand
thorough,
critical assessments
of events
such that root causes
can
be
clearly identified and effective corrective action taken.
Additionally, ANPP management
has
not devoted sufficient time
to direct observation
of plant activities during
a period when
programs
and policies were not being implemented to management
expectations.
Inspection findings throughout the
SALP period have indicated
a
high degree of non-compliance with established
procedures.
t
f
If,
]
I
24
Although this is sometimes
due to
a lack of knowledge or to
.. procedural
vagueness, it often appears
that the working
environment
and attitudes of first line supervisors,
gC
personnel,
and others
accept less-than-strict
adherence
as
an
acceptable
means of conducting business.
Contributing to this
a'ttitude is the unacceptably
high backlog of Procedure
Change
Requests
(PCR)
and
a growing frustration
on the part of
personnel
that their inputs are ineffective in creating
'constructive
change.
'he experience
level of the
gA organization is low in
operations
and engineering expertise,
contributing to
a lack of
confidence,
and
a reluctance,
to clearly identify poor
practices
when these
areas
are being assessed.
However,
following the inoperable auxiliary feedwater
pump event,
the
.NRC review determined
the need for better training to achieve
a
clearer understanding
of integrated plant operations,
- fundamental
theory, procedural,
and regulatory requirements.
Although staffing of the
ISEG organization
meets
Technical
Specifications
minimum requirements, it has
been insufficient
to reduce
an administrative
backlog
and
has detracted
from
their ability to monitor plant activities
on
a routine basis.
The licensee's
approach
to the resolution of licensing
issues
generally exhibits conservatism,
timeliness,
and
an
understanding
of the issues.
Licensing activities at the
beginnino of the evaluation
period were focused primarily on
actions
in support of the issuance
of a full power license
on
Unit 3.
The full power license
was issued
on November 25,
1987.
This
SALP period
has
been
marked
by a series of events
and
inspection findings which, when taken
as
a whole, indicate
significant weakness
in the licensee's ability to self-identify
and effectively correct technical
and organizational
problems.
Organizations
such
as Operations,
Training, Maintenance,
and
Engineering
do not always work toward
common purposes,
nor do
functionally related entities,
such
as onsite
and offsite
enaineering,
communicate sufficiently to their mutual benefit.
Corrective actions
have
sometimes
failed to be effective
because
of inadequate
establishment
of root causes
and
insufficient communication of the actions
and the basis for
them to all affected organizations.
Senior
management
began to
strongly stress
the theme of teamwork,
communication,
and
attention to detail during the last portion of the
SALP period.
Performance
Ratin
Performance
Assessment
- Category 3.
Board Recommendations
Licensee
management
should continue to implement initiative
programs
such
as Radiation Protection
improvements,
the
gA
i
,k
25
Improvement
Program,
Engineering Excellence,
and Event
Investigation procedures.
The
new organizational
structure
must. be. solidified with clearly defined authority. and
accountability.
Management
must demonstrate
and encourage
increased self-criticism, at all organizational
levels,
but
particularly at the highest levels.
In parallel with increased
self-criticism must
be the creation of an atmosphere
where
such
criticism is eagerly sought,
analyzed,
and strongly acted
upon.
Corrective actions
must
be personally identified with by all
affected personnel.
Departmental
intercommunications
must
be
increased,
and
a
common goal to support safe plant operations
must
be strengthened.
The licensee
established
efforts to date
toward these
goals are noted
and encouraged.
The
QA organization
needs
to obtain personnel
experienced
in
operations
and engineering activities to enhance their
abilities tn effectively assess
these
areas.
Increased
inspection
coverage of daily in-plant activities is
recommended,
with emphasis
on procedure
compliance
and
communication.
Increased
inspection
by licensee
oversight
groups
QSEE,
ISEG,
NSG,
PRB) is also strongly
recommended.
V.
SUPPORTING
DATA AND SUMMARIES
A.
Enforcement Activit
Three resident
inspectors
were, essentially onsite during the
assessment
period.
Forty-nine inspections,
including
a team Safety
System Functional
Inspection
(SSFI) in Januar.v
and February
1988,
were conducted
during this period for a total of 5935 inspector
hours.
A summary of inspection activities is provided in Table I
along with a summary of enforcement
items from these
inspections.
A
description of the enforcement
items is provided in Table 2.
During
this
SALP period
a two part escalated
enforcement
item ($ 100,0000
Civil Penalty)
was identified concerning operating with turbine
(AFW) pump steam isolation valves
improperly
modified and operating with less
than three
(units I and 2, November 1987).
A three part escalated
enforcement
item ($ 150,000 civil penalty)
was identified, concerning
an early
criticality event at Unit I (May 14);
a personnel
radiation
event which occurred at Unit 2
(May 22-23);
and
an
inadvertent rendering
inoperable of the Essential
Chilled Water
System at Unit I, in violation of Technical Specification
reauirements
(May 20-29).
B.
Confirmation of Action Letters
One Confirmation of Action Letter was
issued
on June
23,
1988
concerning introduction of nonconservative
information into channel
B Core Protection Calculator.
The licensee's
letter of July 21,
1988 responded
to the concerns.
f
t
26
C.
Other
The Office for Analysis
and Evaluation of Operational
Data
(AEOD)
reviewed the licensee's
events at Palo Verde and prepared
a report
which is included
as Attachment I.
AEOD reviewed the
LERs
and
significant operating events for quality of reporting
and
effectiveness
of identified corrective actions.
'l
hi
lt
TABLE
1
INSPECTION ACTIVITIES AND ENFORCEMENT
SUMMARY (11/01/87 - 10/31/88
Pal o Verde Unit
1
Functional
Area
nspec-t
> on
Hours
ercent
of Effort
Ins ections
Conducted
Enforcement
Items
ever>ty Leve
I
II
III
IV
V
C'.
Radiological
Controls
345
A.
Plant Operations
1270
47.7
13.0
19
3
1
3
A
C.
Maintenance/
Surveillance
D.
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
G.
Sa fety Assessment/
Quality Verif.
374
105
143
74
351
14.0
3.9
5.4
2.8
13.2
I¹
3
1
1
1
Totals
2662
100.00
3
12
3
1
Allocations of inspection
hours to each functional area
are
approximations
based
upon
NRC form 766 data.
These
numbers
do not
include inspection
hours
by NRC contract personnel.
Severity levels are in accordance
with NRC Enforcement Policy (10 CFR Part 2, Appendix C).
No violation was issued,
but
a deviation
was identified.
9
-One
NOV pending in this area.
This violation which resulted
in a civil penalty also applies to Unit 2.
TABLE 1
INSPECTION ACTIVITIES AND ENFORCEMENT
SUMMARY (ll/01/87 - 10/31/88)
Palo Verde Unit 2
Functional
Area
Ins ections
Conducted
Inspection"
Percent
Hours
of Effort
Enforcement
Items
Severity
Leve
I
II
~
I I I
IV
V
A.'lant Operations
871
48.3
1¹
B.
C.
Radiological
Controls
Maintenance/
Surveillance
291
16.1
25
3
.1
200
D.
Emergency
Prep.
E.
Security
Engineering/
Technical
Support
104
86
5.8
5.3
4.8
Safety Assessment/
156
Quality Verif.
8.6
Total s
1804
100.00
4
3
1
If
Allocations of inspection
hours to each functional
area
are
approximations
based
upon
NRC form 766 data.
These
numbers
do not
include inspection
hours
by
NRC contract personnel.
Severity levels are in accordance'with
NRC Enforcement Policy (10 CFR Part 2, Appendix C).
No deviations
were identified during this
period.
This violation which resultd in a civil penalty also applies
to Unit l.
&
One of these violations which resulted in
a civil penalty also .applies to
Units
1 and 3.
29
TABLE
1
INSPECTION ACTIVITIES AND ENFORCEMENT SUMMARY (11/01/87 - 10/31/88)
Pal o Verde Unit 3
Functional
Area
Ins ections
Conducted
Enforcement
Items
Hours
of Effort
I
I I
III
IV
V
A.
Plant Operations
B.
Radiological
Controls
C.
Maintenance/
Surveillance
D.
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
804
224
138
104
56
54.7
15.2
'.4
7.1
3.8
1.0
1&
1
G.
Safety Assessment/
129
Quality Verif.
8.8
Totals
1469
100.00
1
2
Allocations of inspection
hours to each functional area
ar'
approximations
based
upon
NRC form 766 data.
These
numbers
do not
include inspection
hours
by
NRC contract personnel.
Severity levels are in accordance
with NRC Enforcement Policy (10 CFR Part 2, Appendix C).
No deviations
were identified during this
period.
&
This violation which resulted
in a civil penalty also applies to Units
1
and 2.
f
30
Table
2
Pa~oVer
e
Enforcement
Items
Report
Number
Unit
1
Subject
Severity
Functional
Level
Area
87-37
87-37
Limitorque valve operators
inside containment
were
4
not shown to be qua'lified because
of deviations
from qualification test
specimen configuration.
ANPP files di d not
a dequa te 1y document
qualification of skinner solenoid valves
because
design
and material differences
between
the plant
equipment
and test speciments
were not evaluated
in detail.
87-40
Radiation
areas within the west mechanical
access
room of the auxiliary building
were not conspicuously
posted.
87-40
88-01
88-01
88-01
West mechanical
access
room of the
auxiliary building had
two areas
where the
intensity of radiation measured
between
100 and
800
millirem per hour and were not posted
An access
door, vital static inverters,thumb
screws,and
battery spacers
were found contrary to
their respective
drawings. Eyewash station
installed without comparison
to seismic category
9
requirements.
Licensee did not consider or make calculations
to
demonstrate
that pressure relief valves were sized
to accommodate
flows from failure of upstream
regulating valves in the fully open position.
A temporary modification that installed tanks to
supply hypochlorite for emergency
spray
ponds
was
completed with an unacceptable
written safety
evaluation.
88-01
88-02
Spacers
were missing
between battery jars
and
eyewash stations
were installed without revising,
the calculation isometric drawing and were never
compared
to seismic category
9 requirements.
Unit
1 entered
mode
4 and operated for
approximately
one hour and twenty-five minutes
without an operable
pump.
31
Tab'le
2
Pa~uuerde
E
Report
Number
~Sub 'ect
Severity
Level
Functional
Area
88-03
A copy of the notice of violation involving
"v'adiol'ogical working conditions received
by the
licenses
was not posted.
88-07
88-12
Contrary to tech specs,
unit I operated
with only
two operable
independent
pumps. Modifications to valves were not reviewed
by
plant manager
or other proper authority.
Contrary to Reg Guide 1.97, wide range
steam
generator
level instrumentation
had
a range from
32
to 112K of the range described
in the
Reg
Guide.
88-13
88-14
Licensee
radwaste
shipments
were made with loose
chain restraints
and
had shifted during transport
as evidenced
by loosened
or broken bracing.
Nonconservative
operator
performance
combined with
errors in information used to calculate
concentration
resulted
in an inadvertent
criticality.
88-15
Protected
area portals
were not alarmed
and
monitored
as required.
88-18
Contrary to stated
requirements,
a valve was found
4
to be in the open position following the addition
of chemicals
to the system.
88-24
Contrary, to specific technical specification
reouirements
while Unit
1 was operating in Mode I,
both loops of the essential
chilled water system
were rendered
88-27
No written safety evaluation
addressing
the
processing
of radioactive
equipment in
a trailer
recently converted into a respiratory processing
facility was performed.
88-31
Improper Protection of safeguards
information
Unit 2
88-02
Unit 2 operated with less
than
3
AFW pumps
due to the discharge
valve, on
a
pump
being closed.
I[
32
Table
2
Palo Verde
Enforcement
Items
Report
doeber
88-OS
Sub.iect
Operation occurred with only two AFW independent
pumps operable.
Valves were
modified without review by the proper
individual/group.
Severity
Functional
Level
Area
3
G
88-08
A principle
gamma emitter analysis
performed
on
a
gas
from waste
gas
decay tank did not
achieve
the required
LLD.
88-14
Radioactive
noble fission product gases
were
vented
from portions of the gaseous
radwaste
system without prior evaluation of the potential
release.
88-22
An enclosed
area with a door which was not locked
had
an intensity of radiation accessible
to
a
major portion of the body measured
up to at least
3 Rem/hr.
88-26
Failure to provide
an exposure
report.
No written safety evaluation
addressing
the
processing
of radioactive
equipment in
a trailer
converted into a respiratory processing facility
was performed.
88-22, Occupational
radiation exposure
in excess
cf the
26/27
quarterly limit.
Failure to perform radiation
surveys.
Failure to implement the ALARA program.
Unit 3
88-18
Valves were found to be in the open position
following the addition of chemicals
to the system.-
88-25
No written safety evaluation
addressing
the
processing
of radioactive
equipment
in
a trailer
recently converted into
a respiratory processing
facility was performed.
88-33
Failure to control access
Enforcement action is being considered for this item.
(
U
Deviation from regulatory requirements.
t
I
1
1'
33
TABLE 3
SYNOPSIS
.OF PALO.,VERDE I LICENSEE
EVENT REPORTS
LERs)
Functional
Area
A.
Plant Operations
B.
Radiological
Controls
C.
Maintenance/
Surveillance
D.
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
G.
Safety Assessment/
equality Verification
SALP Cause
Code+
A
B
C
D
E
X
2
6
I
I
3
1
Totals
15
Totals
20
I
4
7
I
33
The above
data
are
based
upon
LERs 87-24 through 88-24
.
LERs 88-09, 88-20,
and 88-23 will be included in the next
SALP assessment
period.
LER 84-01
was
received during this
SALP assessment
period.
- Cause
Code
A - Personnel
Error
8 - Design, Manufacturing or Installation Error
C - Externa,l
Cause
D - Defective Procedures"
E - Component Failure
X - Other
il
t
34
TABLE 3
SYNOPSIS
OF
PALO VERDE 2 LICENSEE
EVENT REPORTS
LERs
SALP Cause
Code*
Functional
Area
D
E
X
Tota1s
A.
Plant Operations
B.
Radiological
Controls
C.
Maintenance/
Surveillance
D.
Emergency
Prep.
E.
Security
2
I'
3
2
I
F.
Engineering/
Technical
Support
Safety Assessment/
equality Verification
Totals
9
2
2
3
I
16
The above
data
are
based
upon
LERs 87-18 through 88-13.
- Cause
Code
A - Personnel
Error
B - Design, Manufacturing or Installation Error
C - External
Cause
D - Defective Procedures
E - Component Failure
X - Other
I
'I
li
TABLE 3
SYNOPSIS
OF
PALO VERDE 3 LICENSEE
EVENT REPORTS
(LERs)
Functional
-- Area=
A.
Plant Operations
B.,Radiological:."..
Controls
C.
Maintenance/
Surveillance
SALP Cause
Code*
--"A-
B
C
D
E
X
I
I
I
Total s
D.
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
G.
Safety Assessment/
equality Verification
Totals
5
I
2
I
The above data
are
based
upon
LERs 87-03 through 88-06.
- Cause
Code
A - Personnel
Error
B - Design, Manufacturing or Installation Error
'C -'External
Cause
,D - Defective Pnocedures ..
'
- Component Failure
X - Other
I
n~,
~ s
~
n
I
ATTACHMENT 1
ENCLOSURE
PALO VERDE
Arizona Public Service
Company submitted about
52 reports for the three units
at Palo Verde, not including updates,
fn the
SALP assessment
period from.
November 1,
1987 to October 31, 1988.
This review fncluded the following LER
numbers:
Untt
1
87-025 to 87-028
88-001 to 88-024
Unit 2
87-018 to 87-021
88-001 to 88-012
Untt 3
87-004 to 87-005
88-001 to 88-007
Our findings from the'eview of these
LERs follows:
1.
Abnormal Occurrences
There were
no abnormal
occurrences
fn the assessment
period.
However,
an event
that occurred in late October
1987 (just prior to the start of the assessment
period) at Unit 1 was identified as
an Appendix
C item, and reported fn the
fourth quarter
1987 Report to Congress.
In the event, ultrasonic testing
revealed
cracks fn all four reactor coolant
pumps
(RCPs).
Althouoh the
failure of one
RCP is an analyzed accident,
concerns
were raised that there
could be
a potential for tultiple RCP shaft failures.
However, additional
analysis
concluded that once
a crack initiates, the crack propogates
slowly in
a circumferential
manner over millions of stress
cycles.
No LER was submitted
for this event.
2.
Si nfficant 0
ratino Events
There were four events,
each at Unit 1, fn the assessment
period that were
identified as particularly significant by the
ROAB screening
and review process.
These events were:
(a)
LER 88-010,
"Ground Fault in 13.8
KV Bus Causes
Fire fn Unit
Auxiliary Transformer
and Reactor Trip," on July 6, 1988;
(b)
LER 87-025 "Modfffcation to Steam to Turbfne Driven Auxiliary
Pump Isolation Valves Render
Pump Inoperable,"
dated
November 27, 1987;
(c)
LER 88-013 "Auxiliary Feedwater
Pump Degradation,"
dated March 25,
1988;
and
(d)
LER 88-022 "Shutdown Cooling Systems
Valve Bolting Failure," dated
July 25, 1988.
r
3.
AEOD Technical
Stud
Re orts
There were no events identified at any of the units that were considered
sufficiently, serious to merit an in-depth technical
study by AEOD in this
assessment
pe~iod.
4.
Pks Issued in Assessment
Period
There were many Preliminary kotification of Event or Unusual
Occurrence
issued for the three units.
For the
Pks that were issued for reportable
events,
the licensee
submitted
a
LER for each event,
so by this method of
verification, the licensee
appears
to be reporting all events that are
required to be reported.
The content of the information in the
LER was in
substantial
agreement with the event
as described in the
PH, so the licensee
appears
to be reporting these
events accurately.
5.
LER ualit
The
LER submittals for all units were identical,
so this review would be
applicable to any of the three units.
The licensee
used
two format styles in
the assessment
period;
a narrative form prior to about mid-1988 and
an outline
form subsequently.
Me found the narrative style to fully comply with the reporting guidelines
listed in pages
5 through 7 of NUREG-1022.
All aspects
of the event
were described in substantial
detail
and
we thought the submittals vere
uni formly outstanding.
The outline form of LER submittal
was an improvement over the previous
narrative form.
Me thought these later
LERs were the best of any. licensee
that we review.
Previous similar occurrences
were properly'referenced
in the
LERs as applicable.
The licensee
updated
several
LERs that were promised to be updated in the
assessment
period.
The updated
LERs provided
new information and the portion
of the report that was revised
was denoted
by a vertical line in the right
hand margin so the
new information could be easily determined
by the reader.
lio reports
were submitted
on a voluntary basis in the assessment
period.
As
stated
on page
10 of NUREG-1022, licensees
are encouraged
to report any event
that does not meet reporting criteria, if the licensee
believes that the event
might be of safety significance, might be of generic interest or concern
or
contains
a lesson to be learned.
6.
Effective Corrective Action
There were 43 events at the three units available for imnediate review where
a designated
root cause
had been fully determined for the event.
The casual
distribution of these
events were:
1
Human Factor Deficiency
32 events
74K
Equipment Failures
8 events
19K
Spurious Halfunctions
2 events
5X
Inadequate
Plant Design
'
" "
I events
2X
The
Human Factor Deficiencies would include:
personnel
errors
25 events,
inadequate
procedures
4 events,
bad engineering evaluation,
inadequate
administrative controls
and error in the work document, I each.
Although there
seemed to be
a relatively high frequency of human factor
deficiencies in the casual
pattern of LERs, only one of the events
rated
as
significant by ROAB was caused
by cognitive personnel
error
(LER 87-025).
The
root cause of the other three events
were equipment -failure.
p
I.