ML17305A431
| ML17305A431 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 11/22/1989 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17305A430 | List: |
| References | |
| 50-528-89-48, 50-529-89-48, 50-530-89-48, NUDOCS 8912110100 | |
| Download: ML17305A431 (76) | |
See also: IR 05000528/1989048
Text
SALP BOARD REPORT
U.
S.
NUCLEAR REGULATORY COMMISSION
REGION V
SYSTEMATIC ASSESSMENT
OF LICENSEE
PERFORMANCE
50-528/89-48,
50-529/89-48,
50-530/89-48
ARIZONA NUCLEAR POWER
PROJECT
PALO VERDE NUCLEAR GENERATING STATION
NOVEMBER 1, 1988
THROUGH OCTOBER 31,
1989
TABLE OF
CONTENTS
I.
Introduction
II.
Summary of Results
A.
Effectiveness of Licensee
Management
B.
Results of Board Assessment
C.
Changes
in SALP Ratings
III. Criteria
~Pa
e
IV.
Performance
Analysis
A.
B.
C.
D.
E.
F.
G.
Plant Operations
Radiological Controls
Maintenance/Surveillance
Emergency
Preparedness
Security
Engineering/Technical
Support
Safety Assessment/equality
Verification
5
8ll
13
15
17
19
V.
Supporting
Data and Summaries
A.
Licensee Activities
B.
Direct Inspection
and Review Activities
C.
Enforcement Activity
D.
Confirmation of Action Letters
E.
, AEOD Events Analysis
TABLES
22.
22
23
24
24
24
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
INTRODUCTION
The Systematic
Assessment
of Licensee
Performance
(SALP) is an integrated
NRC staff effort to collect available observations
and data'n
a periodic
basis
and to evaluate
a licensee's
performance
based
on this information.
The program is supplemental
to normal regulatory processes
used to ensure
compliance with NRC rules and regulations.
It is intended to be
sufficiently diagnostic to provide
a rational basis for allocating
NRC
resources
and to provide meaningful
feedback to the licensee's
management
r'egarding 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 November 13,- 1989, to review observations
and data
on
the licensee's
performance
in accordance
with NRC Manual Chapter 0516,
"Systematic
Assessment
of Licensee
Performance,"
dated August 16, 1989.
The guidance, and evaluation criteria are
summarized in Section III of
this report.
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, 1988, through October 31, 1989.
The
SALP Board for Palo Verde was composed of:
~"A. Chaffee , Deputy Director , Division of Reactor Safety
and Projects ,
Region
V (RV) - Board Chairman
- "G.
Knighton , Director , Project Director ate
V,
- "D.
Kirsch , Chi ef , Reactor Safety Branch ,
RV
.
"*G. Yuhas , Chief , Emergency
Prepar edness
and Radiological Protecti on
Branch ,
RV
- R. Pate , Chief , Nuclear Material s Safety
and Safeguards
Branch ,
RV
"*S. Richards , Chief , Reactor Projects
Section II,
RV
- L. Miller, Chief , Operations
Section ,
RV
"R.
Huey , Chief , Engineering Secti on ,
RV
"R. Fish , Chief ,
Emergency
Preparedness
Secti on,
RV
""T. Chan , Project Manager,
PD 5 ,
""H. Davis , Project Manager ,
PD 5 ,
""T. Pol ich , Seni or Resident Inspector ,
RV
- M. Ang , Project Inspector ,
RV
H. Cillis , Seni or Radi ati on Speci al ist ,
RV
- L. Norderhaug , Safeguards
Inspector ,
RV
"Denotes voting member in functional area of cognizance.
- "Denotes voting member in al l functional areas.
II.
Summar
of Results
A.
Effectiveness of Licensee
Mana ement
The momentum of previously existing weaknesses
resulted
i'h a general
continuance
of past weak performance of the site during the first
half of the
SALP period.
In recognition of the magnitude of the
problems at the site,
APS instituted
numerous
changes
in Palo Verde
management.
A new Executive Vice President,
Nuclear,
was appointed
to head
Palo Verde and
assumed
those duties in May, 1989.
Other
changes
in the Palo Verde management
team included replacement of-
the Vice President,
Nuclear Production;
replacement of the gA
Director; addition of a Vice President,
Nuclear Safety
and
Licensing; addition of a Plant Director; replacement
of the Director
of Standards
and Technical
Support;
replacement
of the Nuclear
Training Manager;
replacement
of two of the Unit Plant Managers;
and
addition of a Relief Plant Manager.
Most changes
appeared
to be
positive in nature despite
the resultant perturbations
caused
by the
interruption of management
continuity.
The
new management
team continued to implement existing improvement
programs
and instituted additional
needed
improvements to attempt to
identify and correct weaknesses.
These
programs
included;
Revamping the nonconformance
identification and corrective
action programs
Performance'f
a Preventive
Maintenance
Program self-assessment
Performance
of a Design Configuration Assessment
Formation of unit restart task forces to improve plant restart
performance
Formation of three training program project .management
task
forces to improve the management
and performance of training
activities
Formation of a Management
Review Committee to provide
management
oversight of the restart of Units 1 and
3
Contracted for and received
an independent
assessment
of- safety
oversight groups
'Contracted for and received
a self-initiated
Contracted for and received
a self-initiated Maintenance
Team
Inspection
Requested
performance of an
INPO design engineering
assessment
The
new Palo Verde management
team was receptive to NRC initiatives
and exhibited
an eagerness
to improve identified weaknesses.
Although improvements
have
been noted during the last six months of
the assessment
period,
the above noted management efforts had not
been fully completed
as of the end of the period, therefore the full
impact of these actions
remains to be seen.
A need for increased direct observation of plant activities by Palo
Verde management
continued to exist.
Strong management
support
and
insistence
in full implementation of all new programs is
recommended.
The licensee
also
needs
to conduct periodic
assessments
of the effectiveness
of their performance
.improvement
initiatives to provide for timely mid-course corrections,
as
needed.
B.
Results of Board Assessment
Overall, the
SALP Board found the performance of NRC licensed
activities by the licensee
to be acceptable
and directed toward safe
operation of Palo Verde.
The
SALP Boar d 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
Rating
Rating
Last
This
Period
Period
Trend*-
A.
B.
C.
D.
E.
F.
G.
Plant Operations
Radiological Controls
Maintenance/Surveillance
Emergency
Preparedness
Security
Engineering/Technical
Support
Safety Assessment/equality
Verification
improving
1mprov1 llg
The trend indicates
the
SALP Board's appraisal
of the
licensee's
direction of performance in a functional area
near
the close of the assessment
period such that continuation of
this trend may result in a change in performance
level.
Determination of the performance
trend is made selectively
and
is reserved for those instances
when it is necessary
to focus
-.NRC and licensee attention
on an area with a declining
performance trend,
or to acknowledge
an improving. trend in
licensee
performance.
It is not necessarily
a comparison of
performance
during the current period with the previous
period.'.
Chan
es in SALP Ratin
s
Licensee
performance in the Radiological Controls area
improved from
a category
3 to a low category 2.
The increased
rating resulted
from licensee
improvements of its Radiological Controls procedures,
organization, training and day-to-day performance.
Licensee
performance
in the area of Plant Operations marginally
improved to a category
2 rating due to a reduction of significant
events directly attributable to the operations
department. 'owever,
the Board recommendations
also emphasize
several
improvements that
are considered
necessary
to maintain the category
2 rating.
Licensee
performance in the Safety Assessment/guality
Verification
area
remained
a category 3.
This was attributed to a lack of
management utilization of gA and the oversight groups to identify
weak areas of performance,
and the failure in many cases
to
implement meaningful corrective actions,
although
improvement was
noted toward the end of the period.
Licensee
performance in the Maintenance/Surveillance
area declined
from a category
2 to a category
3.
This was attributed to existing
past weaknesses
that remained uncorrected
and were finally
manifested significantly during this period.
Host noteworthy of
these
weaknesses
were maintenance
practices that resulted in
multiple equipment malfunctions during the March 3, 1989 Unit 3
Unusual
Event.
Licensee
performance in the Engineering/Technical
Support area
declined from a category
2 to a category
3.
Much of the decline was
attributed to long standing
weaknesses
in the management
of the
System Engineering organization,
which the licensee
has
been unable
to effectively address.
The lack of a sense of ownership and
acknowledgement
of responsibility by both corporate
and .system
engineers
appeared
to contribute to plant performance
problems.
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 quality, including management
involvement and control;
2.
Approach to the resolution of technical
issues
from a safety
standpoint;
3.
Responsiveness
to
NRC initiatives;
4.
Enforcement history;
5.
Operational'and
construction
events (including response to, analyses
of, reporting of, and corrective actions for);
6.
Staffing (including management);
and
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 is
rated according to three performance
categories.
The definitions of
these
performance
categories
are as follows:
1.
Cate or
1.
Licensee
management
attention and involvement are
rea
s y evident
and place
emphasis
on superior performance of
nuclear safety or safeguards activities, 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.
2.
Cate or
2.
Licensee
management
attention to and involvement in the
per ormance of. nuclear safety or safeguards
activities is 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.
3.
Cate or 3.. Licensee
management
attention to and involvement .in the
per ormance 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 functional areas,
plus the Board's conclusions for each
area.
and its recommendations
with respect to licensee
actions
and management
emphasis.
II.
~PI
t II
tt
1.
~Anal sis
During the assessment
period, the licensee's
plant operations
activities were observed routinely by both the residents
and
the regional staff.
A total of 2627 hours0.0304 days <br />0.73 hours <br />0.00434 weeks <br />9.995735e-4 months <br /> of inspection effort
were devoted to this functional area.
During this
SALP period
significant site operations
management
changes
have occurred,
including:
new or different Plant Managers at each unit; a new
Vice President,
Nuclear Production;
the addition of three
Assistant Plant Managers,
a Relief Plant Manager
and a Plant
Director.
Experienced
personnel
were hired for the positions
of Executive Vice President;
Vice President,
Nuclear Safety and
Licensing; Site Services, Director; guality Assurance, Director;
Radiation Protection
and Chemistry Manager,
and Training
Manager.
Most of the
new managers
were hired during the last
half of the assessment
period, with the majority reporting in
t
the last quarter.
Increasing
management
experience
and
staffing are considered positive accomplishments,
however the
ability of the
new management
team to improve plant operations
has not yet been fully demonstrated.
The licensee's
performance
was rated
as Category
3 improving
during the previous
SALP rating period.
The rating had
declined primarily due to events at Unit 1 and the lack of
prompt and decisive efforts by senior corporate
management
to
establish
a working atmosphere
which encourages
critical
assessment
during the conduct of operations.
During this
period, several
events
occurred in which the licensee
continued
to exhibit non-conservative
attitudes
toward operations
and an
inability to learn from previous problems,
however actions
taken for several
operational
type problems at the end of the
assessment
period were considered
conservative
and appropriate.
With the exception of .increasing
management
staffing including
a completely different operations
management staff at Unit 1,
the previous
SALP Board recommendations
concerning striving to
ensure that plant operations
are conducted in a conservative
formal manner
and that problems
be promptly addressed
continue
to be appropriate.
The licensee
accepts
NRC initiatives in a positive spirit;
however, the resolution of these matters often requires
continued
NRC scrutiny to ensure corrective actions
are taken.
Some
examples
are slow progress
in improving simulator
fidelity, licensee
management's
lack of direct observation of
plant activities and'everal
examples of failure to control
equipment
and system status.
Several
events
which reflect negatively
on the plant operations
functional area included:
an auxiliary operator failing to
completely close
a Hain Feedwater
Pump
(HFP) bypass
valve
resulting in the fatigue failure of a drain line and
a forced
outage at Unit 2;
a licensed operator failing to perform a
procedure
step while flashing the main generator field
resulting in a turbine trip at Unit 2; and
an operations
support technician repeatedly
operating the condensate
demineralizer
system after abnormal
indications were observed
at Unit 2.
Escalated
enforcement
was taken in this functional area for
inadequate training and incor rect operation of the Atmospheric
Dump Valves during the Unit 3 Unusual
Event of March 3, 1989.
In addition, several
other violations were identified in this
functional area.
These violations all dealt with failure to
follow procedures
which resulted in:
unnecessarily
increasing
(RCS) cooldown at Unit 2; rendering
the only operable
ADV at Unit 1; expired flammable
storage
permits posted
on flammable storage
containers
at Unit
1; lowering the Spent
Fuel
Pool level to less than the
Technical Specification
minimum a't Unit 1; spil.laqe of RCS
water into the refueling cavity at Unit 3; not switching the
ji
nuclear instrumentation
High Voltage meter from Startup to
Control
as required during a reactor startup at Unit 2; and not
making a required licensed operator report on time.
During this
SALP period the regional licensing examiners
conduct'ed
two replacement
examinations
and are in the process
of completing
a licensed operator requalification program
evaluation.
The operator
replacement
examination results
indicate that the traininq provided to initial and upgrade
'icense
candidates
is satisfactory.
The pass/fail ratio during
this
SALP period has increased
from 18/3 to 33/1.
Even though
the upgrade
and the initial licensed operator training progi ams
appear
to be satisfactory,
there is a need for greater
ownership
and involvement in the training program from the
units'perations
departments.
For the past several
SALP periods the'issue
of training
provided by the facility's plant specific simulator has
been
a
continuing concern.
The concern
was reconfirmed
by the
operator's inability to operate
the Atmospheric
Dump Valves,
(ADVs) from the control
room using the methods taught in the
simulator, during the Unit 3 Unusual
Event.
I
The licensee
has recently contracted with a simulator
manufacturer to. upgrade
and make repairs to the site specific
simulator.
This action was taken after years of in-house
efforts that failed to produce
a reliable simulator,
and to
meet the
NRC requirements
that each facility have
a certified
simulator by May of 1991 in order for NRC operator
licensing
examinations to be administered.
Non-licensed operator training was also questioned
during the
Unit 3 Unusual
Event due to Auxiliary Operators
(AO) being
called
upon to perform valve operation at the remote
shutdown
panel without any previous training on the equipment.
In
addition-, during the
same event,
one
ADY was
damaged
when an
improperly operated
the valve.
This was attributed in part to
inadequate
training of the
AO.
A review of the licensee's
Emergency Operating
Procedures
(EOPs) conducted during this
SALP period indicated that the
EOPs were usable but were overly complex and contain
numerous
problems
and inconsistencies.
Two previous inspections
identified similar problems.
This indicates
an inability of
the management
to correct this
known deficiency.
Two
examinations
in this period also identified a reluctance
by
some operators
to use or refer to normal operating procedures.
This resulted in significant valve 'lineup errors during the
examinations.
The licensee's fire protection personnel
responded
to one major
fire during this assessment
period involving a capacitor
bank
fire in the
525
KV switchyard.
Although this fire was brought
under control, it burned for over an hour before sufficient
Aqueous Film Forming
Foam was available to extinguish the fire.
In addition, -a recent violation and ongoing un'reso]ved matters
concerning qualifications of the Fire Protection Supervisor
and
maintenance'ersonnel,
coordination of offsite fire department
assistance,
and engineering
evaluations
on fire doors indicate
a decline in fire protection. program performance
since the last
SALP period.
Overall, operations
personnel
are knowledgeable of plant
systems
performance.
However, during several significant and
complicated operational transients,
weak operations
personnel
performance
was attributable to inadequate training.
Plant
shift crews generally conduct thorough shift turnovers
and
briefings which include discussions
with other unit departments
such
as chemistry, radiation protection and work control.
However,
improper valve status
and system lineups during both
complex and routine plant operations
continue to be a problem.
The ability of the
new site and corporate
management
team to
effect a long term change in plant operational
performance is
still unproven.
2.
Performance
Ratin
Performance
Assessment - Category
2
3.
Board Recommendations
The licensee
should strive to ensure that all operations,
especially valve and system manipulations,
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.
Training,
specifically, requires
improvement
and greater
management
attention.
Priority attention should be given to conducting
thorough evaluations of problems
and establishing
a working
atmosphere
which encourages
thoughtful, cr'itical assessments
of
all phases
of plant operations.
B.
Radiolo ical Controls
1.
~Anal sis
Nine routine
and two special
inspections
related to
'radiological controls were performed by the NRC's regional
office and resident staff during this assessment
penod.
Over
869 hours0.0101 days <br />0.241 hours <br />0.00144 weeks <br />3.306545e-4 months <br /> of inspection time were expended in this functional
area.
During the previous
SALP period
a total of two Severity Level
III vtolations,
seven Severity Level IV violations and two
Severity Level
V violations were identified.
= The Severity
.Level III violations resulted in an escalated
enforcement
\\
action with the imposition of civil penalties.
For the last
assessment
period the license
was assigned
a Category
3 rating.
The licensee
has
been responsive to the previous
SALP report
and other
NRC initiatives in this functional area.
Policies
for assurance
of quality and management's
commitment to the
implementation of a strong radiation protection program were
emphasized
and conveyed to the staff'during this
SALP period.
This is reflected
by the licensee's
overal] performance in .
radiological controls, which showed
improvement during extended
periods of continuous multiple reactor
outages.
Many of the
licensee's
radiological control procedures
were strengthened.
Other
improvements
included:
organizational
changes
intended
to strengthen
the Chemistry and Radiation Protection group;
filling of a key management position vacated during the
November'987 reorganization;
increases
in the chemistry and
radiation protection technician staffing levels;
ALARA planning
and preparation for radiological work during outages;
General
Employee Training and Advanced Radiation Workers Training
programs;
and the evaluation of events.
The licensee's
selection criteria and training program for contractor
radiation protection personnel
were also strengthened.
The
licensee's
laboratory measurements
of radioactivity in
effluents were determined to be satisfactory.
Transportation
of radioactive materials,
waste
management
and environmental
monitoring were performed without incident during this
peri Od.
Although management
has
been very responsive
in addressing
NRC-
concerns,
corrective actions
are sometimes
delayed
and
may not
be effective in correcting the root cause of the problem,
as
indicated
by occasional
repetition of events.
In addition,
several
examples
were identified indicating a need for more
pro-active
management
involvement.
For example:
(1)
The licensee audit findings involving the Americium check
sources
were not resolved in a timely manner.
(2)
Instances
of chloride, sulphate
and sodium intrusion into
the condensate
from polishing demineralizer
systems
continue to occur, particularly at .Unit 1..
The condition
of in-line instrumentation
used to monitor water quality
had declined.
(3)
There
have not been major improvements in the reduction .of
personnel
skin and clothing contamination events.
II
(4)
Numerous deficiencies in the implementation of basic
radiation protection measures
by the refueling contractor
went unreported to APS management until it was brought to
.
their attention by the
NRC.
(5)
An individual exceeded
his administrative whole body
exposure limit becau'se
of poor surveys,
and
due to a
10
failure to properly review survey records
and the
individual's prio~ exposure
records.
This problem was
similar to the events
leading
up to the over exposure
event during the last
SALP period.
(6)
. ALARA exposure
estimates
established
for performing eddy
current inspection
and repair of Unit 1 Steam Generators
were exceeded
in part due to the erroneous
plugging of one
tube.
(7)
Weaknesses
in the training of Radiation Protection
Instrumentation
Technicians
were
known to exist for at
least two years before
an acceptable
training program was
developed
and approved in Hay of 1989;
however, the
new
training had not been
implemented
as of September
1, 1989.
The licensee's
efforts to improve the reliability of the
Radiation Honitoring Systems
(RHS) does not appear to have
been
fully effective.
This is reflected
by the numbers of LERs and
Special
Reports that have
been identified in this area during
this and the previous
SALP period.
During this
SALP period,
approximately
90K of the fifteen LERs and ten Special
Reports
related to radiological controls were associated
with the
RHS.
The total occupational
doses in Units 1,
2 and
3 through
October 19, 1989, were 332 rem,
respectively.
The annual
ALARA goals established
for these
Units for 1989,
were 340 rem,
50 rem and 215 rem, respectively.
The reason for exceeding
the
ALARA goals in Unit 3 was
attributed to the extended refueling outage
and it appears that
Unit 1's
dose could have
been
lower if it had not been for the
licensee's
performance in the inspection/repair of the Unit 1
The licensee's
enforcement history during this
SALP period
showed considerable
improvement over the previous
SALP period.
There were five Severity Level IV violations.
The violations
involved improper posting of a high radiation area,
improp'er
posting of a contaminated
area,
improper labeling and control
of non-exempt quantities of Americium-241 sources,
a radiation
monitor which did not have any sampling media installed
and an
environmental
monitor's flow meter which was not properly
adjusted.
In addition,
two Non-cited Violations were
identified during this
SALP period.
They included
one Severity
Level IV violation involving the failure to perform a leak test
of one check source
and one Severity Level
V violation
- involving an unauthorized entry into a high radiation area
by a
worker.
2.
Performance
Ratin
Performance
Assessment
- Category
2
3.
Recommendations
11
The Board emphasizes
the need for continued
improvement in this
area
and specifically recommends that the licensee
be-
aggressive
in maintaining radiation monitoring equipment,
instrumentation,
and practices for chemistry control -and
. analysis.
Management
should take
a more pro-ac'tive ro'te in
assuring that basic occupational
radiation protection measures
are accomplished
Haintenance/Surveillance
l.
~Anal sis
The licensee's
performance
was rated
as Category
2 during the
last
SALP period.
Strengths
included
a good chemistry
surveillance
and control program, only two violations and
no
plant shutdowns attributable to maintenance.
Weaknesses
last
SALP period included
a large maintenance
backlog,
poor or
inadequate
work planning and little improvement in the conduct
of maintenance.
During this assessment
period the corrective
maintenance
backlog continued to increase
and several
events'ere
directly attributable to poor maintenance.
In general,
work planning
and the conduct of maintenance
has continued to
be weak inspite of management's
efforts to correct these
areas,
and in several
respects
the significance of long standing
weaknesses
was more clearly focused during this assessment-
period by several
operational
events.
This functional area
was observed routinely during the
assessment
period by both the resident
and regional inspection
staff.
The Augmented Inspection
Team which investigated
the
March 3, 1989'Unusual
Event at Unit 3 had significant findings
in this functional area.
A Maintenance
Team Inspection
was
conducted during this assessment
period.
Approximately 1556
hours of inspection effort were devoted to this functional
area.
Strengths
included the rigorous maintenance
performed
by
the Operational
Computer System personnel
and
a dedicated
snubber testing facility and staff.
Additionally, the licensee
has recently established
a 12-week rolling schedule to
coordinate preventive
maintenance
and reduce safety system
unavailability due to maintenance.
Several
deficiencies in the Maintenance/Surveillance
area were
noted in the Augmented Inspection
Team (AIT) report and were
the subject of escalated
enforcement:
failure to properly
maintain
and test
emergency lighting in the area of the
Atmospheric
Dump Valves (ADVs); failure to implement an
adequate
Preventive
Maintenance
(PH) program to ensure
'perability
of the ADYs; and failure to correct the Steam
Bypass Control System
(SBCS) permissive timer problem
identified in a July 1988 Unit 3 Post Trip Review Report.
The Maintenance
Team Inspection
(MTI) noted three major
concerns:
inadequate
attention to detail in work
12
implementation;
inadequate
work planning;
and inadequate
pr oblem resolution.
An example of inattention to detail in work implementation
was
noted by the MTI during an emergency diesel
generator
surveillance test.
The voltage to be adjusted
was between
3694
and 3794.
The fixed volt meter
used to measure
the voltage
had
100 volt divisions, which appeared
to be outside the accuracy
. limits needed.
Furthermore,
the technician
recorded
an
out-of-specification reading of 3795 and signed off the task as
complete without noting the discrepancy.
Licensee
management
developed
and implemented short term
maintenance
actions
as
a result of the Unit 3 Unusual
Event
prior to restarting Unit 2.
However, significant programmatic
improvements
and changes
were not evident late in the
period.
For example,
the NTI noted deficiencies in the
development of maintenance
work plans, in the implementation of
maintenance
work instructions,
and in the root cause
analyses
which should
have resulted in the development of comprehensive
corrective action plans.
The licensee exhibited
an inability to resolve long standing
weaknesses
in the control of equipment status
(maintenance
backlog), including both the adequacy of governing procedures
and work instructions,
and adherence
to procedures
and
instructions
by the plant staff.
Such deficiencies resulted in
notices of violation for failure to follow procedures
which
resulted in an Emergency Diesel Generator
(EDG) fuel line
disconnecting
from the cylinder while the
EDG was running at
Unit 1, and
an
ADV nitrogen supply regulator being assembled
at
Unit 2 on verbal instructions,
which deviated
from the approved
work order and technical
manual.
The licensee
often did not get to the root cause of problems,
and in several
cases,
known problems persisted
because
they
were not thoroughly addressed.
For example,
galvanic corrosion
which occurred
(EDG) intercooler
drain plugs at Unit 3,
and then at Unit 2 during the last
period recurred in April 1989 on a Unit 2
EDG intercooler elbow
fitting before all susceptible
steel fittings were replaced.
Late in the
SALP period, the licensee
stated their intentions
to establish
a basis for.all maintenance
tasks.
This
initiative appears
to be good.
However,
program implementation
remains to occur.
Overall, maintenance craft are knowledgeable
and capable of
performing quality maintenance.
The craft still need to
develop
a more inquisitive attitude regarding the performance
of work.
In several
instances
maintenance
personnel
were
hindered
by inadequate
work planning, lack of supervisory
guidance,
lack of engineering direction and management's
13
failure to respond to maintenance
program deficiencies in the
past.
2.
Perfor mance Ratin
3.
Performance
Assessment
- Category
3
Board Recommendations
Licensee
management
should strive to ensure
work 'control
instructions
are clear and complete.
The licensee
maintenance
craft should ensure
they follow procedures,
and request
management
and engineering
assistance
when problems
are
encountered.
Additionally,. planner coordinators
should
be more
aggressive
in enlistinq the system engineers'upport
in the
correction of non-routine equipment problems.
Maintenance
management
should increase efforts to observe
ongoing work and
provide corrective feedback into the maintenance
program.
0.
Emer enc
Pre aredness
1.
~Anal sis
During this
SALP period, approximately
116 hours0.00134 days <br />0.0322 hours <br />1.917989e-4 weeks <br />4.4138e-5 months <br /> of inspection
effort were utilized to assess
the licensee's
Emergency
Preparedness
(EP) Program.
This included the observation of
one exercise
and two routine inspections.
The previous
board
recommended
an emphasis
on timely resolution of
identified deficiencies
and encouraged
the licensee to evaluate
the interface
between the emergency planning and site
operations
departments.
Management
involvement affecting the
EP Program
has increased
since the last appraisal.
This was evidenced
by management
directives prior to and during the 1989 exercise in support of
emergency
preparedness
and by management participation during
the exercise.
Management
presence
during
NRC exit interviews
was also noted to have increased.
Policies regarding the
conduct of the dress
rehearsal
and the exercise
were well
stated
and understood.
The licensee's
gA program continued to meet
NRC requirements
and to provide for an independent
audit of the
EP Program
including evaluation of the interface with state
and local
governments.
The licensee's
efforts to resolve technical
issues
from .a
safety standpoint
were generally
sound,
but resolutions
were
not always timely.
For instance,
the licensee
had identified
numerous
areas
on. site where the plant public address
system or
may be inaudible.
This problem was
known to the
licensee for a number of years;
however,
the resolution of the
problem was scheduled for 1991.
It appears
the licensee
had
focused
on a more comprehensive
resolution than was actually
14
needed to address
the concern.
The licensee'as
added
numerous
facilities and personnel
to the emergency notifications lists;
added
more security
sweeps;
and provided pocket pagers
to key
personnel
to insure personnel
are notified of emergency
events
and instructions.
Licensee
management
has demonstrated its responsiveness
to
NRC
initiatives.
Items identified by-the
NRC have been evaluated
by
management
and- acted
upon.
Three areas
addressed. in NRC
inspection reports
were checked
and all were noted to have
been
improved.
The three areas dealt with General
Employee Training
(GET) for the Mater Reclamation Facility personnel;
further use
of the simulator for emergency
preparedness
traininq; and
activation times for the emergency
response facilit)es.
There were
no violations of NRC requirements
observed in the
area of emergency
preparedness
during this
SALP period.
1
Two operational
events
were examined this
SALP period.
One
involved a loss of communications capability for Unit 1.
The
event
was promptly and conservatively classified
as
an Unusual
Event and appropriate notifications and reports
were completed
in a timely manner.
The Augmented Inspection
Team noted
communications
problems that occurred during the March 3, 1989
Unit 3 Unusual
Event.
Staffing of the
EP Program appears
adequate.
Key positions
are
identified and responsibilities
are well defined.
Expertise is
usually available within the licensee's staff,
and consultants
have
been appropriately
used to address
problems affecting
emergency
preparedness.
Vacancies within the
EP Program
have
usually been'illed in a timely manner;
however, there
have
been three vacancies
open during the last year and only one
has
been filled.
The vacancies
when filled should further provide
resources
to expand the
EP drill program and to provide more
reactor operations
experience
to the
EP Program.
The licensee
appears
to have
a good emergency
preparedness
training and qualifications program.
Records of training and
inter views with control
room personnel
demonstrated
a good
understanding
of the principles of emergency
preparedness
and
also indicated
improvements to the
EP training program.
Improvements in the training program for dose
assessment
were
also noted.
Some areas
were identified where training in
emergency
response
capabilities
would be beneficial,
such
as
for the Mater Reclamation Facility.
The licensee
had initiated
plans to provide training for certain additional facilities, or
groups
on or near the site,
who do not receive routine general
employee training.
Performance
Ratin
Performance
Assessment
- Category
2.
Licensee
performance
was
determined to be improving during this assessment
period.
IJ
15
3.
Board Recommendation
The licensee
needs to continue
management
support of the
Program to assure
the program continues to improve.
-The board
recommended
active involvement by the
new members of'he
new
management
team.
In addition, the board
recommends
licensee
management
attention to accomplishment of corrective actions in
,
a timely manner.
E.
~Securit
1.
~Anal sis
Ourinq the assessment
period,
RV conducted four physical
security inspections.
Over 147 hours0.0017 days <br />0.0408 hours <br />2.430556e-4 weeks <br />5.59335e-5 months <br /> of direct inspection
effort was expended
by regional inspectors.
In addition, the
resident
in'spectors
provided continuing observations
in this
area.
One material control
and accounting inspection
was'
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 security program.
In April of 1988,
staffing limitations were imposed
on the security organization.
Routine staffing levels were limited to that needed to provide
for normal security operations.
Additional security officers,
needed for the extra work related to refueling, etc.,
were to
be hired and trained coincident with planned plant outages.
At
that time the
NRC noted the problems of unplanned
equipment
failures
and the lead time necessary
to recruit and train the.
additional security "outage" cadre.
Of particular concern,
as
expressed
at the time,
was the fatigue factor associated
with
holding security officers over their normal
12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> shift and
the difficulty of providing adequate relief of officers when
operating with several
compensatory
posts.
The current unplanned station-wide outage,
which began in March
l989,
has
imposed
demands
on'the security organization for
which'additional staffing could,not
be expeditiously provided.
This resulted in substantial
overtime work by the security
officers and was,identified in the last physical security
inspection
as
a contributing cause of compensatory officers
falling asleep
on post.
In response
to that inspection,
the
licensee
stated their intent to expand the training for
contract security personnel
normally used outside the protected
area.
This will provide
a larger reservoir of trained guards
to supplement
the permanent plant security force during periods
of peak security workload.
equality assurance
and quality control programs
and policies are
generally adequately
stated
and understood
although the lack of
acceptance
criteria for CCTV image quality resulted in the
inappropriate
acceptance
of substandard
images
from aged
CCTY
cameras
used for protected
area barrier alarm assessment.
The
review and upgrade of the security maintenance
program
and
procedures
is proqressinq,
albeit slowly.
Of the 43 procedural
review tasks originally sdentified,
21 remained to be reviewed
's
of August; 1989.
Concerns
were also identified with the
adequacy of past corrective actions for a licensee-identified
problem related to the Security Access Control computer,
which
resulted in enforcement action during the current evaluation
period.
-The previous
SALP report encouraged
licensee
management to
complete the construction of an a]ternate
vehicle
access
control point, to expeditiously address
the
engineering
.issues
associated
with the evaluation of roll-up
doors serving
as vital area barriers,
and to upgrade
the
perimeter barrier to eliminate potential vulnerabilities
'dentified by the Regulatory Effectiveness
Review (RER) team.
During this
SALP period, construction of an inner protected
area
fence
and
a new vehicle access
portal were completed.
The
upgrading of the roll-up doors
has
been completed for two of
the three units.
Identification and resolution of technical
issues,
while slow,
has
been generally
sound
and thorough.
However,
two issues,
the
image quality of CCTY cameras
and the licensee's-initial
assessment
of the vulnerabilities of the personnel
access
hatches
to.conta'inment
were identified as being inadequate.
Durinq the assessment
period,
two information notices
and one
gener>c letter related to security were issued.
The
licensee's
actions
were found to be adequate.
The enforcement history for the period November
1,
1988,
through October 31,
1989, includes three violations and one
devi'ation, related,
respectively,
to inadequate
assessment,
aids; lack of positive computerized
access
control; inattentive
compensatory security officers; and failure to complete
as
committed (or to report delays in the comp'Ietion of) an
investigation into the causes
of a security event.
During this
SALP period, the licensee
reported six safeguards
eve'nts.
Five of these
events
resulted
from personnel
error:
failed security compensatory
measures
(three); lack of
positive access
control (one);
and an uncontrolled pathway to
a vital area (one).
The remaining event resulted
from a
design deficiency of a vital area barrier vulnerability.
Mith respect to staffing,
key positions were identified, and,
although limited by staffing considerations,
position
responsibilities
were generally well defined.
The security
training staff is continuing their special
advanced training
program.
This program exceeds
regulatory requirements,
and
augments
current offsite security resources
to meet the
special
security
demands
caused
by the plant's isolated
location.
17
2.
3.
Performance
Ratin
Performance
assessment
- Category
2.
Recommendations
Licensee
management
is encouraged
to expeditiously complete
their review of CCTV camera
coverage
and illumination necessary
for adequate
protected
area barrier alarm assessment
and to
limit overtime effects
on guard alertness,
to include
expediting, the expanded
implementation of their planned
security tr'aining program.
F.
En ineerin /Technical
Su
ort
~Anal sis
This functional area
was reviewed routinely by both the
regional
and resident staff of the Region
V office, and by the
staff of NRR.
Over
260 inspection
hours were expended.
These
reviews focused primarily on the degree to which the system
and
corporate
engineers
are involved in plant operations
in a well
focused
manner,
and the quality of the work they contribute.
The System Engineer program
has continued to lack management
direction during this assessment
period and the results of this
group's efforts have generally
been disappointi'ng,
in spite of
an initiative by the licensee to achieve
improved performance.
The inspectors
have found the System Engineers to'e typically
capable,
however,
the broad scope of their responsibilities
and
an apparent
lack of clear prioritization of activities
has left
many of the System Engineers frustrated
and unfocused
on more
important tasks.
Although the licensee
took action to increase
both the number of System Engineers
and the number of
supervisors,
this positive action was
somewhat cancelled
out by
a lack of continuity at the senior management
level.
During
the
SALP period, three individuals have occupied the Director,
Standards
and Technical
Support position.
At the close of the
SALP period, the position was being temporarily filled while
the licensee
continues to search for a permanent Director.
The System Engineer's
lack of focus
has
been highlighted by
their failure to identify and promptly resolve technical
issues
prior to the issues
becoming self-revealing via a plant event.
The Augmented Inspection
Team (AIT) review of the Harch 3, 1989
Unit 3 reactor trip/loss of offsite power event identified that
long-standing engineering
issues
regarding the operation of the
atmospheric
dump valves
had not been promptly addressed.
Additionally, the AIT found that the emergency lighting system
testing
was not adequate
to verify that the lighting system
could meet its design requirements;
a previously identified
problem with a Steam
Bypass
Control System
(SBCS) permissive
timer card
had not been
addressed
and contributed to the event;
the nitrogen backup
system for the
ADV had not been properly
18
tested;
and engineering
issues
regarding the compressed
gas
system
had not been fully addressed.
In summary,
the AIT,found
that if previously identified problems
had been thoroughly
addressed
by engineering in a timely way, the siqnificance of
the parch
3 event would probably have
been greatly lessened.
The event re'suited in a prolonged
shutdown of all three units
and
a $250,000 civil penalty.
Other examples of long-standing
known engineering'issues
not being promptly addressed
included:
excessive
leakage
past the pressurizer
spray valves;
deficiencies in the
EE580 Cable
Raceway Tracking 'System;
questions
regarding the proper storage of safety related
materials;
recurring problems with the radiation monitoring
system;
an issue regarding the operation of emergency diesel
generator
excess
flow check valves associated
with the air
starting system;
and
a long delay in implementing
a spent pool
level switch modification at Unit 1, which contributed to a
loss of level event.
The performance of the System
Engineers
in responding
reactively to events
which occurred durinq the assessment
period was also considered
weak in severaT
cases.
Troubleshooting of a part length control element
assembly
(PLCEA) drop at Unit 1 was considered to be incomplete,
and
allowed a second
PLCEA to drop the following day.
Hore
illustrative
was the inadvertent overpressurization
of main
feedwater piping at Unit 2 following a unit trip.
The
engineering
review of this significant occurrence
was
considered
to be hastily performed, initially poorly
documented,
and based
on assumptions
which later proved to be
incorrect.
In contrast to those failures
and weaknesses
listed above,
which occurred earlier in this period, several
examples of good
technical
work were observed late in the period which
demonstrated
the licensee's
capability to react correctly and
thoroughly when properly guided by management.
Examples
observed
included the response
to a diesel
rocker arm failure
at Unit 3; the engineering
response
to questions
concerning
main steam safety valve ring settings;
the identification and
resolution of. issues
regarding high pressure
safety injection
flow to the reactor coolant system hot legs;
and the
engineering
response
to address
the identification of
counterfeit switches in the 125
VDC system.
These
examples
provide a hopeful indication of positive changes
in the
licensee
s approach to engineering activities.
Another indicator of difficulties with the technical
support
area is the backlog of issues
which needed to be addressed.
Significant backlogs or overdue
items have existed for
Engineering Evaluation Requests,
Post-Trip Review actions,
Special
Event Evaluation Report actions,
and Incident
Investigation
Report actions.
Late in the
SALP period, the
licensee
displayed
a good recognition of the problems with
backlogs
and stated their intention to reduce the total backlog
j
ll
f
>C
f
'Ji
I
t
l
1l
t
19
to a more manageable
size.
Some reduction
was noted toward the
end of the per>od.
With regard to corporate engineering,
the licensee
continues
to'mplement
their Engineering Excellence
program,
which includes
'econstitution of the plant design
bases
and increased
technical training of engineers.
A section of the corporate
engineering staff has
been relocated to the site,
and
'lessons
learned"
reviews of design
change
packages
have
been started.
In conjunction with the site System Eng>neers,
the corporate
engineers
have
commenced
scheduled
walkdowns of their systems.
'lthough the corporate engineering staff appears
to be headed
towards increased
involvement in site activities, their
effectiveness
remains to be assessed.
2.
Performance
Ratin
Performance
Assessment
- Category
3
3.
Board
Recommendations'he
licensee
appears
to have defined the problems with the
System Engineer'rogram
as, primarily a lack of focus
on
important issues.
The licensee
should permanently fill the
Director, Standards
and Technical
Support position,
and should
provide the System Engineers with clearly defined
and
prioritized tasks
focused
on ensuring the reliable operation of
their systems.
The System Engineers
should then
be held
accountable for the performance of their systems.
Corporate
engineerinq
should continue to increase their involvement in
site activsties
and problem resolutions.
The licensee
should
continue the emphasis
being placed recently
on reacting
conservatively,
deliberately
and comprehensively to plant
engineering problems..
G.
Safet
Assessment/ ualit
Verification
1.
~Anal sis
This functional area
was observed routinely during the
assessment
period by both the resident
and regional inspection
staff.
Approximately 1663 hours0.0192 days <br />0.462 hours <br />0.00275 weeks <br />6.327715e-4 months <br /> of inspection effort were
devoted to this functional area.
Strengths identified in this
functional area
were manifested in the licensee's
willingness
to correct past weaknesses
in both the gA/gC organization
and
program, and,in the licensee's
responsiveness
to NRC
initiatives.
However, weaknesses
observed
appeared
to be
a
continuation of past weaknesses
that had yet to be corrected.
These
weaknesses
included (1) root cause
analyses
that were
limited in scope,
(2) lack of effectiveness
of the gA and
oversight organizations,
and (3)
a lack of sufficient
technically experienced staffing of the
gA organization.
2D
Significant management
changes
in the gA department
had been
made by the =licensee during this period.
The gA Director was
replaced;
the
gC Manager
was appointed temporarily as the
new
gA Deputy Director;
a new gC Manager
was temporarily appointed;
and
new managers
were selected for guality Engineering
and
equality Systems.
These
changes
appeared
to be positive
corrective action for past weaknesses
of the gA/gC
organization.
However, the need to permanently. select
a Deputy
gA Director and
a gC Manager
was viewed as
a weakness
in that
both selections affect the efficient functioning'.of the
gC
organization
and the
gC inspectors.
The other notable weakness
of the
gA organization
was the relative lack of technically
experienced
and operations
experienced
personnel
to allow
detailed technical evaluations
and to provide insightful and
subjective observations
to manaqement
regarding conduct of work
by organizations
such
as operations
and maintenance.
During this evaluation period,
improvement of the licensee's
root cause analysis
process
had been noted.
Examples of
'mproved root cause
analyses
were:
(1) the Emergency Diesel
Generator
(EDG) rocker arm failure analysis,
and (2) the fire
suppresion
system test records investigation.
However, through
the evaluation period,
lapses
in the depth of root cause
reviews were still noted.
Significant examples of these
were:
(1) the
AOV and compressed
gas reports for the Unit 3, March 3,
1989,
Unusual
Event were limited in scope in that the hardware
problems
appeared
to have
been evaluated
but the root cause of
how the hardware
problems persisted
did not appear to have been
addressed;
(2) a Unit 2 post-trip review failed to recognize.
signs of a leaking check valve which eventually resulted in the
overpressurization
of the
MFM piping.
The equality Assurance
and oversight organizations
have not been
a visible force in the operation of Palo Verde, particularly
during the first half of the assessment
period.
Senior
Management
has not demanded that these
groups
be sufficiently
crit>cal and aggressive
in their reviews,
such that major
problem areas
could be identified prior to manifesting
themselves
and affecting safe plant operations.
The
-effectiveness
of the licensee's
gA and oversight organizations
was predominantly marginal although
improvements
were noted
toward the
end of the evaluation period.
The Nuclear Safety
Group
(NSG) was ineffective .in identifying and initiating
changes
to existing weak programs.
The Plant Review Board (PRB)
'as
predominantly occupied
by review of procedure
changes.
The
PRB often missed opportunities to provide recommendations
to
the
NSG that were meaningful.
The gA and Independent
Safety
Evaluation Group participation in the Unit 3 mid-loop
operations
were ineffective in recognizing
needed
changes to
operating procedures,
orqanizational
interfaces
and operating
policy.
gC verified satisfactory installation of a Unit 1
fuel line that was installed in accordance
with procedure
but
not in accordance
with vendor instructions.
The fuel line
connection failed during subsequent
testing.
Similarly, prior
It
~
II'
to Unit 2 restart,
gA/gC failed to identify that the procedure
utilized for adjusting
AOY nitrogen. pressure
regulators
was
based
on verbal information rather than documented
vendor
manual instructions.
Toward the end of the rating'peiiod,
licensee
management
utilization of the gA organ)zation'and
the increasing
involvement of the department
became visible in the Unit 2 Main
Steam Relief Valve and Pressurizer
Safety Valve blowdown ring
setting problems.
Independent
gA evaluations of the
Engineering Evaluations
Department analysis
was performed
and
significant gC coverage of the subsequent
testing
was observed.
Also, in June
1989,
a Project Self Ass'essment
Group
(PSAG) was
formed to coordinate oversight functions.
This appeared
to be
a
needed
change but actual results
were not yet evident at the
end of this
SALP period.
In the area of licensing activities, evaluations
related to
licensee
amendments
and
10 CFR 50.59 evaluations
were generally
adequate
.
However,
two license
amendment
requests
were found
to lack adequate
bases
to support the requested
changes,
and
one facility change applied under
10 CFR 50.59 regarding fire
protection
was found to have
been inappropriately
implemented..
Responses
to generic communications
were generally timely and
appropriately detailed.
Two exceptions
were noted:
,submission
of followup information to
NRC Bulletin 88-04, "Potential
Safety Related
Pump Loss" regarding Ingersoll-Rand
pumps
was
repeatedly
delayed;
and the licensee's
response
to Generic Letter 88-14 "Instrument Air Supply System
Problems Affecting
Safety-Related
Equipment"
was limited in scope.
The licensee
is very responsive to
NRC special
requests
that
require quick responses
and is prompt in addressing
NRC
concerns
regarding written communications
and licensing
evaluation.
It appears
that the licensing organization
needs to maintain
an
increased
awareness
in plant operations
and status,
and that
this is being limited by poor communications
and participation
between
the corporate
licensing organizations
and the site
operations
organization.
2.
Performance
Ratin
Performance
Assessment
- Category
3 - Improving Trend
3.
Board Recommendations
r
Licensee
management
should continue to demand aggressive
and
technically competent
reviews by the gA and oversight
organizations.
The licensee
is encouraged
to continue to
include technically competent
personnel
in the oversight
organizations staff.
Strong management
support
and insistance
il
t
22
in the thorough implementation of changes
to the gA program
such
as the
new nonconforming condition reportinq
and
corrective action procedures
and the
new correct)ve action
request
procedure is encouraged
to assure effective
continuation of corrective actions that have
commenced.
Further strengthening
of the root cause analysis
program should
be performed to 'prov)de greater
depth
and scope
and
sn turn-
result in more meaningful corrective'ctions.
V.
SUPPORTING
DATA AND SUMMARIES
A.
Licensee Activities
In general, all three units operated satisfactorily during the
assessment
period.
Units- 1 and
3 operated relatively free of
problems until both units experienced
reactor trips in March.
Both
units have been in refueling outages
since that time.
Unit 2 has
been hindered
by generic problems,
and voluntarily shutdown three
times to address
)ssues identified on the other units.
Specific
operational
events
were as follows:
Unit 1
Unit 1 entered
the assessment
period at lOOX power.
After'perating
at essentially full power for 170 consecutive
days,
on February 17,
the unit .substantially
reduced
power to investigate
and repair
and condenser
tube leaks.
The unit returned
to'00X
power -on February
22.
The reactor tripped
on March 5 due to a
failure of a processor
board
on Control Element Assembly Computer
(CEAC) No. 2. 'his outage continued .to allow testing of Atmospheric
Dump Valves
(ADVs), which had failed to operate
remotely on Unit 3.
The unit remained
shutdown for the duration of the assessment
period
to modify its ADV's and conduct its second refueling outage.
I
Unit 2
Unit 2 operated at 100K power 'from the beginning of the assessment
period until November 16, when
a shutdown
was initiated due to
excessive
unidentified
RCS leakage.
The reactor tripped on low
level
due to problems experienced with the
control
system during
MFW swapover.
The unit returned to service
on
November 23,
and operated at essentially
100X power until
December
23, when the turbine tripped due. to an inadvertent
isolation of a moisture separator
drain valve.
The turbine was
returned to service the following day.
On February 16, the reactor
tripped
on low steam generator
level
due to a feedwater
control
system malfunction and the unit again returned to service
on
February 28.
The plant was voluntarily shutdown
on March 15, to
test
and repair atmospheric
dump valves.
A Confirmatory Action
Letter was issued to confirm licensee
commitments to correct in Unit
2 'significant discrepancies
identified in Unit 3 during .the March 3,
1989 event.
The confirmatory action letter was lifted for Unit 2 on
June
28.
The unit was returned to service
on June
29.
The plant
down powered to Mode 2 for two days
on July 4 to repair
an
'I
1
23
unisolable feedwater
bypass drain line break.
The plant operated at
100K power until July 12,
when a fuse failure for a potential
transformer
caused
the loss of electrical
bus
NAN-S02 and resulted
in a reactor trip.
The unit was returned to service
on July 21.
The turbine tripped and
a reactor power cutback was experienced
on
August 4 due to
CEDH control, system problems.
The turbine was
restarted
on August 6.
On September
6, the plant was voluntarily
shutdown to inspect main steam safety relief valves,
and was
returned to service
on September
22.
On October
14
the plant was
again voluntarily shutdown to replace
two potential)y 'counterfeit
electrical
breakers
in the 125
V DC distribution system.
An attempt
to restart the reactor
on October 14'was
abor'ted
due to Control
Element Drive Mechanism
(CEDH) coil grounds.
The reactor
was
restarted
on October 30, but tripped from 66K power on October
31
due to various plant protection system
element failures."
The unit
ended the assessment
period in Mode 3.
Unit 3
Unit 3 entered the assessment
period at lOOX power.
A shutdown
was
performed
on January
6 due to a diesel
generator failure ending 141
continuous
days of power operation.
The unit was returned to
service
on January
21 and operated
near
100X power until March 3.
On that date
a grid disturbance
resulted in a reactor trip on low
steam generator level.
The unit entered its first refueling outage
and was shutdown for the remainder of the assessment
period.
Plant status at end of SALP
eriod
Palo Verde ended the evaluation period with Unit 2 operating in Mode
3 and i Confirmatory Action Letter in effect that acknowledges
licensee
committments for corrective actions prior to restart of
Units 1 and 3.
The licensee
was preparing Units 1 and
3 for restart
at the end of the period.
B.
Direct Ins ection
and Review Activities
An average of approximately three resident inspectors
were assigned
to Palo Verde during the
SALP assesment
period.
Forty inspections,
five team inspections,
and five management
meetings
were conducted
during this period. Significant team inspections
included
. Augmented Inspection
Team in response
to the March 3,
1989
Unusual
Event
.
Emergency Operating
Procedures
inspection
team
. Health Physics
team inspection
. Maintenance
team inspection
.
Emergency
Preparedness
exercise
A total of 7198 hours0.0833 days <br />1.999 hours <br />0.0119 weeks <br />0.00274 months <br /> of direct inspection were performed during
this
SALP period.
Table
1 provides
a summary of those inspection
activities.
C.
Enforcement Activit
A summary of inspection activities is provided. in Table 1 along with
a summary of enforcement
items resulting from those inspections.
A
description of the enforcement
items is provided in Tab]e 2. During
the
SAl.P period
a three part escalated
enforcement action ($250,000)
was identified concerning the March 3,
1989 Unit 3 Unusual
Event.
D.
Confirmation of Action Letters
A Confirmatory Action Letter
(CAL) was issued
on March 3, 1989,
resulting from the Unit 3 Unusual
Event, to assure that multiple
equipment failures experienced
during the event were thoroughly-
investigated
and to assure that
NRC was informed of the. results of
those investigations
and the corrective actions taken prior to
restart of Unst 3.
The
CAL was expanded
on March 7, 1989 and March
28,
1989 to assur e that lessons
learned
from the Unit 3 event
and
a subsequent
Unit 1 event would be applied
by the licensee in all
three
Palo Verde units.
On June 23,
1989 and June 28, 1989, 'the licensee certified that
restart corrective actions for Unit 2 had been completed.
A CAL was
again
issued
on June
28,
1989 to allow Unit 2 restart
and to
reconfirm the necessary
licensee
actions for restart of Units 1
and 3.. Licensee actions for this last
CAL had not been completed at
the
end of this
SALP period.
E.
AEOD Event Anal sis
The Office for Analysis and Evaluation of Operational
Data
(AEOD)
reviewed the licensee's
events
and prepared
a report which is
-. included
as Attachment l.
AEOD reviewed the LER's and significant
operating
events for quality of reporting and effectiveness
of
identified corrective actions.
1
I
Table
1
INSPECTION ACTIVITIES AND ENFORCEMENT SUMMARY ll/Ol/88 - 10/31/89)
Palo Verde Unit 1 ***
Functional
Area
Ins ections
Conducted
nspec
son
ercen
Hours*
of Effort
Enforcement
Items
Severit
Level*"
I
~ Q
A.
Plant Operations
B.
Radi ologi cal
Controls
C.
Maintenance/
Surveillance
D.
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
G.
Safety Assessment
equality Verif.
Total s
702
331
75
93
637
29
14
21
27
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).
"** Does not include inspection report 89-45.
Table 1
Page
1
Table
1
'INSPECTION ACTIVITIES AND ENFORCEMENT SUMMARY (11/Ol/88 - 10/31/89
Palo Verde Unit 2 "**
~
Functional
Area
Ins ections
Conducted
Enforcement
Items
nspec
ion
ercen
Severit
Level""
Hours*
of Effort
D
A.
Plant Operations
B.
Radiol ogical
Controls
C.
Maintenance/
Surveillance
1095
252
501
"
18
3
1
2
D.
Emergency
Prep.
47
E.
Security
36
F.
Engineering/
78
.Technical
Support
G.
Safety Assessment
705
equality Verif.
Total s
-
-
2762
26
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'SALP period..;:
- "" Does not include inspection report 89-45.
Table 1
Page
2
Table 1
=INSPECTION ACTIVITIES AND ENFORCEMENT
SUMMARY (11/01/88. - 10/31/89
i
Palo Verde Unit 3 **""
Functional
Area
A.
Plant Operations
830
39
Ins ections
Conducted
nspec
ion
ercen
Hours**
of Effort
Enforcement
Items
Sever it
L'eve 1*"."
D
1*
3
B.
Radiological
Controls
C.
Maintenance/
Surveillance
D.
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
G.
Safety Assessment
equality Verif.
Totals
286
541
25
36
83
321
14
26
15
1*
2
1*
2
A'250,000 Civil Penalty
was issued for the three Severity Level III
violations associated
with multiple equipment failures during the March 3,
1989 Unit 3 Event.
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).
- "*Does not include inspection report 89-45.
Table
1
Page
3
Re ort
Ttuum>er
UNIT 1
Table
2
p'aaaee rd e
Enforcemen
ems
~Sub 'ect
Severity
Fun'ctional
Level
Area
88-40
Environmental Monitoring flowmeter
was
improperly adjusted.
89-10
An operator
who tested positive was not
placed in follow-up test program.
'9-10
Failure to compensate
for unusable
camera.
89-10
Failure to provide positive access
control.
4
~
89-16
LLRT conducted with unapproved criteria.
ADV N2 isolation valve closed not iaw
procedure
rendering
ADV inop.
EDG fuel line
installed not iaw procedure
and disconnects
while engine
was running.
89-24'ome
non-exempt Americium-241 sources
were
not tracked,
inventoried, or labeled
correctly.
89-25
89"28
was not posted
as
such.
Inadequate
corrective action to preclude
repetitive
EDG Cooling system plug and elbow
failures.
B
89-30
Three flammable liquids lockers with
expired permits were found in the aux
building and radwaste building.
C
89-32
89-34
Inattentive compensatory security officer.
4
Post-trip review corrective actions
were
not completed in a timely manner.
Table
2
Page
1
Table
2
paeee
erde
E~t
Re ort
S
ue er
~Sub 'ect
89-36
Spent fuel pool level was unintentionally
lowered below technical specification limits
due to valve not being shut and not being
verified shut.
everity
Functional
Level
Area
't
4
A
89-36
EDG excess
flow isolation valves were not
shut despite
design calculations requiring
them to be shut
due to procedural error.
89-43
Five T/S violations did not receive
a written
4
PRB evaluation
as required by T/S.
UNIT 2
A
88-31
Diesel Generator
maintenance
was done
without documentation of previously
.
completed steps.
88-39
Environmental monitoring flowmeter was
improperly adjusted.
89-03
Radioactive effluent monitors did not have
sample media; therefore,
they were
89-06
A contaminated
area was-not posted
as such.
89-06
Failure to place the steam generator
economize<
flow control in automatic
and
insure
FMCV was shut after a reactor trip.
89-16
LLRT conducted with unapproved criteria.
89-28
Inadequate
corrective action to preclude
repetitive
EDG Cooling-system plug and
elbow faHures.
89-30
Work was
done
on an Atmospheric
Dump Valve
nitrogen regulator valve not in accordance
with the approved work order or technical
manual.
Table
2
Page
2
C
Il
Re ort
um er
89-34
Table
2
Pa~o~er
e
Enforrcem~n
Reme
~Sob'ect
Corrective actions to change operating
procedur'es
were not accomplished
four
months after the required date.
Severity
Functional
Level
Area
89-36
89-43
89-43
89-43
EDG excess
flow isolation valves were not
4
shut despite
design calculations requiring
them to be shut
due to procedural
error.
,Five T/S violations did not receive
a written 4
PRB evaluation
as required
by T/S.
Contrary to procedure
a
CR operator did not
5
switch the
HV meter from start
up to control
and an assistant shift supervisor
signed off
accomplishment of the step.
In addition,
a
mechanic
used
a gauge other than the one
required by the work order for HS code
safety valve blowdown ring adjustment.
Operator
licensing report not submitted
on
4
time.
UNIT 3
88-38
89-06
89-13
Environmental
flowmeter was improperly
adjusted.
equality related work activities did not
receive
a quality review.
Inadequate
emergency lighting design,
maintenance
and testing.
4
D
89-13
89-13
89-16
Inadequate training and incorrect operation
3.
of Atmospheric
Dump Valves.
Lack of appropriate corrective action
3
concerning Atmospheric
Dump Valves,
Steam
Bypass Control Valves,
and compressed air
lines.
LLRT conducted with unapproved criteria.
Table
2
Page
3
1
I
Table
2
paeeo
erde
E~t
Re ort
um er
~Sub 'ect
h
Sever ity
Functi onal
, Level
Area
89-16
RCS drain operation procedure
had incorrect
4
.
F
correction curve for RCS level durinq
midloop ops.
Procedure
had ineffective
provisions to prevent vortexing causing air
entrainment.
89-28
Inadequate
corrective action to preclude
repetitive
EDG Cooling sytem plug and
elbow failures.
'4
89-28
Core Protection calculator work order steps
4
were completed without performance of
required sign-offs.
89-32
Failure to meet 'commitment in LER.
89-36
89-36
89-36
89-43
EDG excess
flow isolation valves were
not shut despite
design calculations
requiring them to be shut due to
procedural error.
Corrective action for an Engineering
4
Evaluation Report requirement to shut
Cooling system
excess
flow isolation valve
was not complied with.
Containment
Spray system valve lineup
procedure
was not followed resulting in
loss of control of RCS inventory.
Five T/S violations did not receive
a
written
PRB evaluation
as required
by T/S.
Table
2
Page
4
It
(t
TABI E 3
- SUMMARY OF
PALO VERDE 1 LICENSEE EVENT REPORTS
LERs
Functional
Area
A.
Plant Operations
B.
,Radiological'ontrols
C.
Maintenance/
Surveillance
D.,
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
G.
Safety Assessment/
equality Verif.
Totals.
SALP Cause
Code"
A
B
C
D
E
X
2
1
2
1
Totals
3
The above data are based
on
LERs 88-09, 88-20, 88-23
, 88-25 through 89-14,
89-16,
88-S08,
89-S03, and 89-S08.
" Cause
Code
- A - Personnel
Error
B - Design, Manufacturing or Installation Error
C - External
Cause
D - Defective Procedures
E - Component Failure
X = Other
Table
3
Page
1
Ij
TABLE 3
SUMMARY OF
PALO VERDE 2 LICENSEE EVENT REPORTS
LERs)
Functional
Area
A.
Plant Operations
SALP Cause
Code*
A
B
C
D
2
1
1
E
X
1
Totals
B.
Radi ol ogi cal
Controls
C.
Maintenance/
Surveillance
D.
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
G.
Safety Assessment/
equality Verif.
Totals
1
1
1
The above data are
based
on
LERs 88-14 through 89-06, 89-08, 89-09,
89-S01 and
89-S02.
- Cause
Code
A - Personnel
Error
B - Design, Manufacturing or Installation Error
C - External
Cause
D - Defective Procedures-
E - Component Failure
X - Other
Table
3
Page
2
TABLE 3
SUMMARY OF
PALO VERDE 3 LICENSEE EVENT REPORTS
LERs
SALP Cause
Code*
Functional
Area
A.
Plant Operations
B.
Radiological
Contr ol s
C.
Maintenance/
Surveillance
D.
Emergency
Prep.
E.
Security
F.
Engineering/
Technical
Support
G.
Safety Assessment/
equality Verif.
Totals
A
B
C
D
3
2
1
2
Totals
3,
The above data are based
on
LERs 88-07 through 89-09,
and 89-SOl.
- Cause
Code
A - Personnel
Error
B - Design, Manufacturing or Installation Error
C - External
C'ause
0 - Defective Procedures
E - Component Failure
X - Other
Table
3
Page
3
I
hi
J
Attachment
1
AEOD In ut to SALP Review For Palo Verde
Arizona Nuclear Power Project submitted
37 Licensee
Event Reports
(LERs) for
the three units at Palo Verde, not including updates,
in the assessment
period
from November 1, 1988 to October
31,
1989.
Our review included the following
LER numbers:
UNIT1,,
UNIT 2
UNIT 3
88-020
8( 025-
89-001 to- 89-014
88-014 to 88-017
89-001 to 89-009
88-008
89-001 to 89-009
~ Four
LERs in the assessment
period were considered significant by the
AEOD LER
screening
process.
These
LERs were:
Unit 1
.
LER
89-005
Unit 2
LER
89-001
Unit 3
LER
89-001
The manufacturer
determined
excessive
internal valve
.
leakage
could result in the inability to remotely or
manually operate
the Atmospheric
Dump Valves (ADV's).
The
event was considered significant because
credit is taken
for the ADV's to remove decay heat from the steam.
generators
in the event that the main condenser
is una-
vailable for service for any reason
including a loss of AC
power.
Contamination
from mineral deposits
from misting of the
cooling towers led to rain saturation of the
transformer
and
a complete loss of offsite power
(LOP).
The diesel
generators
started
and assumed all
safety-related
loads
and the plant remained stable at
approximately
100K power.
ROAB considers all
LOP events to
be safety significant.
'n
electrical grid disturbance
caused
the units main
generator
output breakers to open.
The steam
bypass
control system malfunctioned
and the reactor tripped from
low steam generator
(S/G) pressure.
After a main steam
isolation system activation, control
room personnel
attempted to remove decay heat
and control
S/G pressure
with the Atmospheric
Dump Valves (ADVs).
Control
room
personnel
could not remotely operate
the ADV's from the
control
room or from the remote
shutdown panel.
Heat
removal
was subsequently
established
by manually opening
the ADV's after one main steam safety valve had cycled to
reduce
S/G pressure.
li
Unit 3
LER
89-007
During post installation testing of Potter and Brumfield
relays,
approximately
25X of the
new relays malfunctioned.
The relays are used in the engineered
safety features
actuation
systems
and cause safety-related
components
to
. actuate
when de-energized.
The cause of relay malfunction
was inadequate
design.
A breakdown of the root causes attributed to the
LERs submitted in the assess-
ment period were:
Root Cause
Unit 1
Unit.2
Unit 3
Total
Personnel
Error
Procedural
Problems
Equipment Failures
Design/Installation
Not Determined Yet
Other
5
2
3
3
3
0
3
3
11
1
0
3
-4
3
10
1
1
5
0
'
6
2
0
2
The distribution of root causes
seem typical and do not reveal
any programatic
weakness.
Many LERs were promised to be updated. in the assessment
period.
These
LERs
were either
updated
by the promised submittal date,
or revised with a
supplemental
report with a new promised submittal date.
The
LERs were clear, specific, complete
and informative.
They satisfied all
"
reporting requirements.
The only suggestion is to include root cause classi-
fications, similar to those
used in the root cause table above,
in addition to
existing narrative
cause description.
There were 14 Preliminary Notifications of event or Unusual
Occurrence
(PNs)
. issued for the three units at Palo Verde in the assessment
period.
Our review
of the
PNs indicate that the licensee
reported all events with an
LER that were
reportable.
Me reviewed
55 reports received pursuant to 10CFR 50.72 in the assessment
period.
Many of these reports were duplicates for each unit.
All events
reported
by these calls were addressed
by an
LER, were too recent for an
LER to
be received or were not reportable
under
The only exception
may
be
EVT 026548,
which reported
on 4/10/89 that the ADV's at Unit 1
were incapable of remote operation
due to isolation of all pneumatic valve
operator
sources.
However,
LER 89-005,
dated 4/12/89 reported the
inoperability of all
ADV s due to excessive
internal valve leakage.