ML17305A466
| ML17305A466 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 12/13/1989 |
| From: | Miller L, Pereira D, Royack M, Sundsmo T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17305A465 | List: |
| References | |
| 50-528-OL-89-02, NUDOCS 9001030287 | |
| Download: ML17305A466 (28) | |
Text
Ex'amination Report No.:
50-528/OL-89-02 Facility Licensee:
Palo Verde Nuclear Generating Station Facility Docket No.:
50-528, 50-529, 50-530 Facility License No.:
NPF-41, NPF-51, NPF-74 Licensed operator requalification examinations administered at Palo Verde Nuclear Generating Station, Wintersburg, Arizona.
Chief Examiner:
ic ae gayac Licensing Examiner Dat igned Examiner:
David Pereira Licensing Examiner
~u<Ip'ate Signed Examiner
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~ SClwiDSmD To un smo Licensing Examiner
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ate Signed Approved:
er, r
Chief, Operat sSection I z/s3/gy
~ate
> gned Summary:
An NRC administered Requalification Program Evaluatio'n was conducted at the Palo Verde Nuclear Generati'ng Station Units 1,2, and 3 during the period of October 10 through November 2, 1989 (Report No. 50-528/OL-89-02).
Results:
The facility Licensed Operator Requalification Program was determined to be satisfactory.
- However, two findings of concern were identified by the NRC examination team:
The first concern was the lack of Palo Verde Nuclear Generating Station management involvement with the Licensed Operator Requalification Examination Program.
9001030287 891222 PDR ADOCK 05000528 PDC
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The second concern was several instances of procedural and Technical Specification noncompliance (previously identified in the August 1989 Palo Verde operator replacement examination Report 50-528/OL-89-01).
Observations were made that some operators did not perform plant evolutions in accordance with plant operating procedures and Technical Specifications.
Examination Results Summary:
The following table summarizes the test scores of individual operators and operating crews as graded by the NRC:
Total Tested Total Passed Total Failed Operating Crews Individual Operators RO 15 15 SRO 20 19 Total 35 34 Licensee and NRC Examination results are in agreement except that the licensee failed one additional operator on the simulator portion of the examination and one operator in the written portion of the examination.
One of the Reactor Operators was only administered a simulator evaluation since that operator had been evaluated as unsatisfactory in this area in the previous Requalification Program evaluation.
This is in accordance with NUREG 1021, Revision 5, ES-601.
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REPORT DETAILS Personnel NRC Personnel:
B. Faulkenberry, Deputy Regional Administrator
- M. Royack, Chief Examiner
- T. Sundsmo, Examiner
- D. Pereira, Examiner
- T. Polich, Senior Resident Inspector
- P. Isaksen, NRC Contract Examiner
- F. Jagger, NRC Contract Examiner J.
- Hanek, NRC Contract Examiner J.
- Kvamme, NRC Contract Examiner Supervisor Palo Verde Nuclear Generating Station Personnel:
+ J. Levine, Vice President, Nuclear
"¹D. Gouge, Unit 3 Operations Manager
- ¹R. Schaller, Unit I Assistant Plant Manager
- ¹R. McKinney, Unit I Operations Supervisor
- E. Firth, Training Manager
- D. Brown, Simulator Project Manager
- ¹D. Craig, Supervisor Training
- T. Cannon, Lead Simulator Instructor
- ¹S. Zerkel, Unit I Training Coordinator
- T. Bradish, Compliance
¹ A. Peroutka, Requalification Training Supervisor
,¹ F. Riedel, Unit 3 Operations Manager
¹ D. Ensign, Unit 2 Shift Supervisor
¹ R. Adney, Unit 3 Plant Manager Identifies personnel present at November 3,
1989 exit meeting.
Identifies management personnel who observed simulator scenario examinations.
Pur ose of Examination The evaluation was conducted to determine the effectiveness of the Palo Verde Nuclear Generating Stations Licensed Operator Requalification Program and to evaluate licensed operators for renewal of their six year term licenses.
The evaluation was administered in accordance with NUREG-]O2I, ES 6OI, Revision 5, "Administration of NRC Requalification Program Evaluations."
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Pro ram and Examination Develo ment Prior to the examination, the licensee provided Region V with a complete set of simulator scenarios, Job Performance
- Measures, and banks of questions for Category A (static simulator),
and Category 8
(classroom written) examinations.
NRC review of the PVNGS NRC Licensed Operator Requalification Program identified several problem areas in both the program and examination development.
All of the issues that were identified were directly tied to the lack of PVNGS management commitment to establish requalification examination question banks and trained evaluators.
The licensee appeared to consider that since the initial evaluation of, the PVNGS Licensed Operator Requalification Program was satisfactory, further development of the program or examination material was not needed.
The licensee's staff stated that the majority of examination material which was to be provided to the NRC for the examination was not updated since the previous NRC Requalification Program evaluation, which occurred approximately eleven months prior to this evaluation.
Licensee management stated that work on Category A written examination questions and simulator examination scenarios was not performed due to problems associated with the site specific simulator fidelity and upgrade programs that were in progress.
Specific NRC identified problem areas and weaknesses included:
a.
Program Standards The -training department did not have a specific program or instructions outlining the procedures and methodology for conducting Licensed Operator Requalification Program Evaluation examinations in accordance with NUREG 1021 Rev.5, ES-601.
The licensee has not established any formal qualification or training requirements for evaluators used to implement this program.
b.
Examination Security The licensee did not have a written set of procedures to ensure licensee examination security.
An informal security process was developed and used by the licensee examination team.
Formal examination security measures were not instituted by licensee management until an error which occurred on October 5, 1989 caused a compromise of the examination schedule.
The NRC evaluation of this incident is detailed in Section 9 of this report.
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Category A and B Written Examination guestions The development of the Category A written examination material for this examination started after the facility examination team was put together.*
This occurred after the issuance of the ninety day letter by the NRC which provided requirements for the examination administration.
The Category A and B question bank submitted by the licensee examination team met the criteria of ES-601 for the number of questions to be developed by October 1989 (235 Category A and 435 Category B questions provided).
The questions selected and developed for the examination met the criteria of ES-601 for sampling of recent requalification cycle material, recent LERs and industry events.
However, the. documentation of a facility sampling plan for the examination did not meet the requirements of ES-601 and the questions provided were not developed to the standards required by ES-601 Attachment 14.
The quality of the questions provided by the licensee required the NRC examination team to expend excessive amounts of time in the restructuring of the questions to meet the criteria of ES-601 Attachment 14.
Typical question development problems included:
Double jeopardy questions for which the operator had to know the correct answer to Part A in order to correctly answer Part B.
Different questions that tested the same testing objective are also double jeopardy, and were identified.
guestions that required proctor cueing to a specific data point in order to be correctly answered.
guestions giving away answers to other questions in the same examination.
True/False type questions.
This included questions for which there were only two or three conceivably correct answers.
For example, "Which steam generator is ruptured?"
Open ended questions that were ambiguous enough that several answers correctly answered the question.
For specific examples of questions that require development
- work, see Attachment B of this report.
More than half of the Category A and 8 written examination questions provided for this examination required NRC examination team input to meet the requirements of ES-601 Attachment 14.
The NRC examiners also noted that a majority of questions in the licensee question banks were of a lower quality, in terms of these criteria, than those provided by the licensee for the examination.
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Simulator Scenarios The simulator scenarios provided by the licensee for the examination were the same scenarios that were used for the last NRC Licensed Operator Requalification Program evaluation.
These scenarios required several days of examination team time to pre-run, due to previously identified simulator modeling problems associated with the PVNGS site specific simulator.
Additional examination team input was also needed to modify the sc'enarios to meet ES-601 criteria for "individual simulator critical task"
( ISCTs) requirements.
The simulator scenarios should have been pre-run and all critical items validated prior to the NRC examination team preview week visit.
Simulator performance problems are noted in Enclosure 4 of the of the cover letter to this report.
Job Performance Measures (JPMs)
The Job Performance Measure package submitted by the licensee exceeded the minimum number of JPMs required by ES-601.
The minimum number of JPMs required was 75, and 77 were submitted.
The JPMs were evaluated to the criteria of ES-601 attachment 12, JPM quality check list, and found to be generally satisfactory.
However, the NRC examination team identified certain areas which require attention:
(1)
All critical steps were not verifiable. Several JPMs indicated critical steps that required an operator to verify
- an indication or a component condition which would require no physical action on the operator's part.
There would not be a
verifiable method of establishing an operators actual performance on these steps.
(2)
All critical steps that required evaluator cuing were not properly annotated to ensure that the operator was provided with the proper response to his actions.
(3)
The post JPM questions provided were not developed in accordance with ES-601.
Examples of problem areas
- were, knowledge and abilities numbers were not referenced, references for the questions were not provided, double jeopardy questions, answer keys not responsive to the question, and about 25K true/false type questions.
Evaluator Training The NRC examination team noted that evaluator training for this examination consisted of a four hour in house briefing.
Evaluators made numerous mistakes during the first week of the examination.
The number of mistakes made by the evaluators decreased as their experience increased.
However, it is not the intent of the examination process to train evaluators.
Facility staff designated to conduct requalification examinations should be properly trained in the evaluation process.
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These problems (a through f), collectively, were indicative of management inattention to the Licensed Operator Requalification Program.
Licensee efforts just prior to and during the examination were significant, but could not overcome the continued lack of long term management support in the areas of program development (Items a, b, and f), ayd question bank improvement/development (Items c, d, and e).
0 erator Selection The operating crews were selected by the licensee in accordance ES-601.
Operator selection and crew composition were reviewed and approved by the Chief Examiner.
Examination Administration An NRC Licensed Operator Requalification Program evaluation examination was administered at Palo Verde Nuclear Generating Station during the weeks of October 9 through October 20, 1989 and October 30 through November 3, 1989.
The PVNGS site specific simulator operated satisfactorily during the performance of the scenarios,
- JPMs, and the Category A snap scenarios selected for this evaluation.
- However, some simulator fidelity problems were identified by the NRC examiners, these anomalies and fidelity problems are documented in Enclosure 4, "Simulation Facility Report" of the cover letter to this report.
0 erator and Crew Performance Thirty four of the thirty five operators examined during the Licensed Operator Requalification Program evaluation were evaluated as satisfactory by the NRC, and will be eligible for renewal of their six year term license.
One individual was evaluated by the NRC and facility evaluators as being unsatisfactory in the simulator portion of the examination and was immediately removed from licensed duties.
licensee representative stated that this operator was remediated in the identified areas of
- weakness, reexamined by the facility, and returned to licensed duties in accordance with ES-601.
The licensee evaluated one additional operator as unsatisfactory in the simulator portion of the evaluation and one other operator as unsatisfactory in the written portion of the examination.
The NRC evaluated these operators as satisfactory.
A licensee representative stated that two operators were removed from licensed duties and remediated in the areas of weakness.
A licensee representative stated that the operator who was evaluated as unsatisfactory by the licensee in the simulator was reexamined, and returned to licensed duties.
A licensee representative also stated that the operator who was. evaluated by the licensee as unsatisfactory in the written examination will be reexamined and if found satisfactory, will be returned to licensed duties.
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All seven of the crews that were examined by the NRC were evaluated as Satisfactory.
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Evaluation of Licensee Evaluators The licensee evaluators selected by the licensee for this examination were satisfactory as evaluated by the criteria of ES-601,.
exhibited performance which could be categorized as marginal.
- However, some examples of weak performance were noted.
The low level of evaluator training and experience contributed to this lower than expected level of performance.
The lack of program standards detailing examination requirements was also a key performance factor.
Typical facility evaluator mistakes included:
Allowing the operator being examined to leave the simulator test area after the operator was given the JPM cue to be performed.
This was quickly rectified by the senior facility examination team leader by instructing the evaluator and issuing a
new JPM for that operator to perform.
The action of the lead facility examiner eliminated the possibility of an examination compromise for this individual.
Licensee evaluators not properly cuing operators when a step was not completed by the operator.
Written examination proctors not giving all operators the same clarification on all questions.
Asking leading questions during an operator's performance of a JPM.
A licensee evaluator initiated a Category A static simulator examination, then left the operators alone in the simulator while discussing examination administration at the simulator control station.
The licensee evaluator's performance improved as the examination progressed, however, greater emphasis needs to be placed on licensee evaluator training and establishing program standards.
These issues were discussed with the licensee, and the licensee agreed to investigate and resolve the problem.
8.
Pro ram Evaluation Notwithstanding the deficiencies noted in sections 3, 5, 6 and 7 of this report the NRC evaluation of the Palo Verde Nuclear Generating Station Licensed Operator Requalification program, conducted in accordance with ES-601, is evaluated as satisfactory.
Two issues'of particular concern were stressed with the licensee.
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Management Involvement with the Licensed Operator Requalification Program I
The NRC evaluation of the PVNGS Licensed Operator Requalification Program identified several problem areas in the program.
All of the issues identified by the NRC can be directly related to the lack of continued long term management attention and involvement in the program.
The licensee staff indicated that since the material for the NRC evaluation of the program was satisfactory the previous year that a minimum effort would be required to update the material for the present examination.
Program development was then placed in a dormant state for approximately eleven months.
The PVNGS NRC Licensed Operator Requalification Program does not have a set of written procedures or standards for conducting the program evaluation, updating the program, security of examination material once it is developed, or training of facility evaluators.
The process has no'uidance as to how the program should be run.
The NRC program evaluation is intended to be an evaluation of the program as it is executed to routinely evaluate the licensed operators, not as an examination process to meet the NRC requirements.
The licensee representatives were informed that the efforts presented by the licensee for this evaluation were marginally satisfactory.
Licensee representatives stated that a program and procedures were being prepared to insure that there would be an ongoing upgrade and manpower force dedicated to the program.
Procedural Compliance and Technical Specification Compliance During the conduct of the simulator portion of the examination there were instances of operators performing both normal and abnormal plant evolutions without referencing procedures, or while referencing a procedure, not performing the steps correctly.
The performance of plant evolutions incorrectly may place the unit in an unanalyzed condition or challenge a safety function.
Examples of these conditions were:
Some operators did not borate in accordance with the boration procedures.
An operator ordered the only operating main feedwater pump tripped at a reactor power of 35'A.
The procedure which he was referencing required the reactor power to be reduced to 25 prior to tripping the main feedwater pump.
The NRC and licensee examination teams also identified a weakness in the interpretation of and compliance with Technical Specification 3.3. 1 and 3.3.2.
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Technical Specifications 3.3.1 and 3.3.2 requires that the affected plant protection system (PPS)
- channel, which includes steam generator level I and 2, steam generator-pressure, and (T.S. 3.3.2 only) steam generator delta pressure (I greater than 2 or 2 greater than 1),
be bypassed upon failure of a steam generator pressure channel.
Ouring the conduct of this event in the simulator scenarios eleven of the twenty five operators understood that the steam generator delta pressure was required to be bypassed.
The operators pointed out the statement in Technical Specification 3.3.2 was confusing and that the steam generator delta pressure was not required to be bypassed during surveillance testing of the steam generator safety channel (36ST-95B02, PPS Bistable Trip Units Functional Test).
It was identified by the NRC examiners that the alarm response procedures 41AL-1RK5B and 41AL-1RK5A were inconsistent in the required steps to be taken for an invalid trip or pretrip of a steam generator safety related pressure channel.
The licensee training staff stated that this was a problem that they had also identified, however it was only being addressed when it came up in actual training situations.
The observation of procedural compliance was discussed with a licensee representative.
The licensee representative stated that the PVNGS Conduct of Operations procedure (40AC-90P02) allows the operators to perform tasks without referencing the specific procedure.
However the license representative concurred that the evolution must be performed in accordance to the procedure whether the the procedure was referenced or not.
The license representative stated that this issue was under continued review, based on the September 29, 1989 Examination Report, 50-528/OL-89-01, and that this recurrence would require further licensee investigation for a complete resolution and response to the NRC.
9.
Review of Examination Schedule Com romise On October 5, 1989, the Chief Examiner was advised by the ANPP Lead Simulator Instructor, T. Cannon, that copies of the schedule of scenarios and job performance measures (JPMs) for the requalification examination which was to begin on October 10 had been distributed by the Training
- Manager, E. Firth.
The NRC was also advised that the persons to whom the schedule was distributed had not been authorized by a security agreement to have knowledge of this information.
After discussions between Region V and ANPP 'management it was agreed that the examination would be postponed pending an NRC inspection of this occurrence.
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On October 10-11, 1989, the examination team and the Chief, Operations
- Section, Region V, reviewed the circumstances of the apparent compromise of the examination by interviewing the involved personnel, reviewing the associated documents, and inspecting the physical, security arrangements for examination material.
The inspectors determined that the Training Manager had distributed a
schedule of scenarios and JPMs to ten managers on October 2, 1989.
The schedule had been distributed to advice these managers that they should attend a portion of the requalification examination as an observer.
The Training Manager did not recognize that he was distributing examination material which should have been kept secure.
The Training Manager stated that he had not closely reviewed the enclosures to his memorandum to ensure-that they did not contain any examination related material.
The material was not marked to indicate that it was examination related material.
The schedule contained the assignments (by serial number of scenario and JPM) for each operator and crew which was to be examined.
The serial number for each scenario and JPM was slightly different than the serial number which had been previously used in training for scenarios and JPMs, but was closely associated to it.
- Thus, a person familiar with the numbering system for scenarios and JPMs used in earlier training could have readily surmised the scenarios and JPMs which were to be given to each crew or operator.
The inspectors further determined from interviews that on October 5, an Assistant Shift Supervisor and Unit 1 Training Coordinator, S.
2er kel, received one of the ten copies of the schedule.
He was provided the schedule by the Unit 1 Operations Supervisor, S. McKinney, who had received it in his capacity as the Acting Unit 1 Operations Manager.
He was acting for the Unit 1 Operations Manager, J. Scott, who was one of the ten addressees.
Mr. Zerkel coincidentally was part of the requalification examination
- team, and was authorized by a formal security agreement to have knowledge of the schedule.
He immediately recognized that the information in the schedule was not appropriate for distribution to personnel who were not authorized by a security agreement to have it.
He notified the Lead Simulator Instructor, T. Cannon, of the schedule.
Mr. Cannon, in turn, promptly notified the NRC and E. Firth, the Training Manager.
1 The licensee then attempted to recover all ten copies of the schedule, and executed security agreements for the managers who had seen it.
Three copies of the schedule could not be recovered.
Of these, two addressees believed they had read and discarded the schedule, and one addressee (R.
Middleton) stated that he had never received it.
The inspectors noted that Mr. Middleton was the only manager who was scheduled to be examined during this examination.
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The inspector concluded that the examination schedule had been potentially compromised, in that three copies of it were unaccounted for. It could not be determined whether or not, as a result, someone participating in the exam had seen the schedule.
Region V requested that a
new schedule be developed to ensure that no operators received scenarios or JPMs for which they had originally been scheduled.
The licensee readily agreed to do this.
The revised schedule was reviewed and accepted by the examination team on October 11.
The inspector observed that the physical security procedures for the storage and physical control of examination material were rudimentary, but effective.
Material was stored in a locked file cabinet or the Training Manager's desk when not in used.
The material was developed in a room which was clearly limited to personnel authorized by the security agreement.
However, the inspectors also noted that no licensee procedures for control of examination material existed.
No requirements for special
- marking, inventory, copy control, or custody receipts had been developed.
The inspectors concluded that this compromise could have been avoided if the Training Manager had been alerted by physical marking of the material or a required receipt for it that it was examination material which was supposed to be kept secure.
At the. Exit Interview on October ll, 1989, the inspectors presented their conclusions.
A licensee representative agreed to immediately reemphasize to all personnel involved the importance of examination security.
In addition, the licensee committed to promptly enhance existing controls after reviewing industry practice.
In letters dated October 16, 1989 the licensee described these actions and the action plan.
The plan stated that the new security procedure would be written and implemented by February 1,
1990.
Exit Meetin An exit meeting was held with the NRC examiners, the PVNGS senior resident inspector, and representatives of the licensee's staff on November 3, 1989 to discuss the program evaluation and the NRC findings.
The licensee staff acknowledged the examination team's findings.and indicated that steps were being taken in these areas to correct them.
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ENCLOSURE 4 SIMULATION FACILITY FIDELITY REPORT
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ENCLOSURE 4 PALO VERDE NUCLEAR GENERATING STATION OCTOBER NOVEMBER 1989 LICENSED OPERATOR REQUALIFICATION PROGRAM EVALUATION SIMULATION FACILITY FIDELITY REPORT The fifteen simulator scenarios submitted for this examination were prepared by the facility.
The scenarios were pre run and validated by the NRC and facility examination teams.
The simulator scenarios provided by the facility for the examination were developed to meet the requirements of NUREG 1021, ES-601 for simulator scenarios.
The scenario events required extensive simulator operator effort and input to insure proper simulator performance of standard facility listed malfunctions.
Due to the extensive effort of the simulator operations team the simulator appeared to operate satisfactorily.
However, the examiners did note specific simulator malfunctions and anomalous events during the examination.
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Noted malfunctions and anomalous events:
- Pressurizer pressure/level response was not correctly modeled for extended accident condition simulation.
- Steam Generator pressure response; the steam generator repressurizes after it has been blown down to the containment.
Failure of the steam bypass control system (SBCS) to actuate following a power cutback and take automatic control when required.
Steam Generator Pre Trip - Trip for Low Low Level did not clear after level regained.
Heater drain pumps do not trip as required on loss of suction.
Condenser vacuum spiked low during a loss of suction.
The video trend recorder failed, needed to be reset=by simulator operator.
The Main Steam Isolation Valves (MSIVs) closure modeling not consistent with units.
MSIVs close faster in the simulator.
As noted in Examination Report 50-528/OL-89-01 simulation facility fidelity report, the number of initial conditions
( ICs) and operable simulator malfunctions is limited, which indicates a continued low level of simulator capability.
- Items noted in Examination Report 50-528/OL-89-01 simulation facility report.
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