ML17305B022
| ML17305B022 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 08/23/1990 |
| From: | Kirsch D, Miller L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17305B021 | List: |
| References | |
| 50-528-90-36, 50-529-90-36, 50-530-90-36, EA-90-147, NUDOCS 9008310008 | |
| Download: ML17305B022 (16) | |
See also: IR 05000528/1990036
Text
U. S.
NUCLEAR REGULATORY COYiNISSION
EA 90-147
REGION
V
Report,Nos.
.50-528/9Q
36.; 50-529/90-36;
50-530/90-36
'
s'
Docket.Nos; .;:" SG-528,
5G-.5".9., 50-530
"
License +os.,"NPF-41, 'NPF-.51,
and NPF-74
urr
~ (, pro'm
n
~
>Qci<. ~
n(. I cb
-.Licensees;-J--.-.Arizona
Public Service
Company
P. 0.
Box 52034
- ,
- ,, Phoenix;. Arizona 85072-2034.
Facility:
Palo Verde Nuclear Generating Station Units 1, 2, and
3
Inspection
Conducted:
July 16 -august 7, 1990
~on
Accompenying
Persoghe1:
A. Johnson,
gnfogement Officer, Region
V
Approved By:
'
~P'-..-',;...
D. F.;Kirsch..Chief,,Reactor
Projects
Branch
Ins ection Sumnar:
Ins ection
on Jul
16 - Au ust
7
1990
Re ort Nos. 50-528/90-36
50-529 90-36
and 50-530 90-36
During this inspection the following Inspection
Procedures
were used:,
30703
and 92700
Results:
Three apparent violations were identified:
inaccurate certification
of the completion of pre-license
medical.exams,
failure of licensed
operators
to
complete biennial medical
exams,
and failure to report medical
impediments of
operators.
Multiple examples of each apparent violation were identified.
General
Conclusions
and
S ecific Findin s:
Si nificant Safet
Matters:
The program to ensure
operators
and operator license candidates
were
medically qualified was determined to be ineffective.
The administrative
tracking program to ensure
operators
were maintaining watchstanding
proficiency was determined to be weak.
Summar
of Violations:
As Stated
Above
Sumar
of Deviations:
None
0'
Persons
Contacted
DETA1LS
. <<*
W. F. Conway; Executive Vice President
<<*
W. C. Harsh, Director, Operations
and Maintenance
E.
G. Firth, Training Manager
F.* Buckingham, Plant Support Manager
<<<<,. B. E. Ballard, Director, guality Assurance
K. Byers, Training Project Coordinator
<<.;<<<<.;,J.
Schleqer,,Senior..
Nurse. ..,
G. Clyde, Senior Nuclear Licensing Engineer
<<* J.
N. Bailey, Vicy,,President,
Nuclear Safety
and Licen
- ** K. D. Davis, Director,
Human Resources
- <<*
S. Zerkel,,Unit 1 Training Coordinator
D. Ensign, Unit 2 Training Coordinator
- .<<<< - R. Fullmer, Manager, guality Audits and Monitoring
D. Carnes,
Unit 3 Training Coordinator
- - J. Baxter,
Compliance
Engineer.
- ~
J. Blantorr; Supervtsor-;-Safety-and
Health"
<<**
W. Rudolph, Operations
Training Supervisor
R. Rouse,,
Super visor, Compliance....
<<*
P. Wiley, Manager,
Operations
T. Bradish, Manager,
Compliance
t
The inspector also had discussions
with other licensee
the inspection.
- Attended the Exit Meeting on July 17, 1990.
Attended the Exit Meeting on August 7, 1990.
I
2.
~Bk
d
sing
personnel
during
On May 14 - 18, 1990, the
NRC conducted
an inspection
(50-528, 50-529,
and
~"=- 50-530/90-16) of thy facility's .training program.
This inspection
determined that "there was
no methodology present to ensure that [a
licensed] operator received
a physical examination that conformed to the
requirements for operator licensing
and renewal."
At the Exit Interview
for that inspection,
the facility committed to review the licensed
operator medical records to ensure that all licensed operators
had been
medically examined at the required frequency.
That facility review was completed
and documented
by the facility as
Incident Investigation Report (IIR) 3-1-90-027 dated July 5, 1990.
This
report was provided to the inspector during this inspection (i.e.
Inspection 90-36).
The report indicated that the following errors
had
occurred:
a.
One licensed operator
had
a disqualifying medical condition.
b.
Nine other licensed
operators
did not have
a current two year
physical
exam as required
by 10 CFR 55, at the time of the report.
~
i
<<
c.
Two other licensed operators
never
had
a complete physical.'hat
is, pre-license
medical
exams did not include
a blood test or EKG, as
"required by 10 CFR 55,
and the individuals
had not received
a
complete phyqical since their licenses
had been issued.
S
~
d.
39 licensed"operators
had current medical examinations,
but the dates
.,
on which;these-medical
examinations
were given-were over two years
after the previous medical. That is, the current medical
examination
~
had.been
givenlate.
~ e..:. Six .other. licensed operators
had current medical examinations,
but
., their: pre-license
medical examinations
lacked either blood or
EKG
. tests.,
I
The report stated that the -11 licensed operators with late or incomplete
medicals at the time of the facility's review were removed from licensed
~
duties until they completed the required medical
exam.
~ I
~ I
1 ~
" Licensee
Event Report
(LER) 90-09 provided
a summary of this information
.on. July,19, 1990.,
On July 16-17, 1990,
a followup inspection
was begun to assess
the
accuracy
and completeness
of the report,
assess
whether any violations of
regulatory requirements
had occurred,
and determine whether
any unique
restrictions .or conditions of. the individual operator licenses
had
been
observed,,:-
Ins'pection of records
continued in the Regional Office from July 18-
August 3, 1990.
The inspection
was concluded onsite
on August 6-7, 1990.
3.
Review of Medical Records
a.'he
inspector first reviewed IIR 3-1-90-027
and discussed it with
licensee
personnel.
Representatives
of the training, licensing,
".' .quality assurance,
operations,
and.medical
departments
were
,"-interviewed.
A sample of eleven of the'22 licensed
operators'edical
records
was audited.
This sample included five records with
no reported deficiencies,
two records with late medicals,
three
records with incomplete medicals,
and the record for the operator
who
was subsequently
determined to be medically ineligible.
At the beginning of the inspection,
the facility had not performed
an
independent
audit of the medical records.
Rather, the IIR had been
developed
from the review done by the medical department.
The
department
had developed
a review abstract for each medical record,
and in most cases,
these
appeared
to have been accurately filled out.
The inspector concluded
from a review of these abstracts for the
eleven records
reviewed, that the facility's medical
department
review had been extensive.
However, the diversity of individual
medical
records
and medical examination dates
made the review
~
i
technically complex,
and the medical
department
reviewers
were not
trained
as auditors.
It was apparent
from the inspector's.sample
review, that an, independent audit,
done to predefined audit
" standards,
and-written acceptance
criter ia,
had not been performed.
At the Exit Interview held
on July 17,'990,
a facility
representative
c'oranitted the'aci'lity to perform such
an audit
- - within thr'ee: to'our weeks,
and to advise the
NRC of any further
significant: discrepancies
which were identified. Subsequently,
a
""licensee'epresentative
advised the inspector that no significant
discrepancies
had been identified by this audit.
I
uzi I
t 1,
, Is
. r
'Th
n'spector 'ev iewed'h'i s a~dit ; qua 1 ity Monitoring Report 90- I975 ,
dated July 20 , 1990 .
The audit wa s quite
1 imited in scope , in that
it only addre's s ed
whether al 1 operators
had
an
"up to date" medical
""- r'ecord'hi ch documented that
a 1 1 components
of the medical
exam had
been completed .
The regu 1 atory or procedural
standards for the audit
'
" " were not part of the audit .
The auditor
wa s not familiar with the
detai 1 ed requirements of 10 CFR 55 rel ati ng to med ica 1 exami nati ons .
- "'or-:example ",the
aud itor'a s unfamiliar with the requirement of 10 CFR 55 . 23 for a facility repr esentati ve to certify that
a complete
. medical
exam had been
performed for each
1 icensed
operator
applicant . Final ly; at the Exit 'nterview on August 7 , 1990 , the
"'
" "
gual
'ity Assurance
Manager stated that he
ha d not considered it
necessary to'irect
a comprehens ive audit of the medical
records ,
'- -"'- '
s ince
- he 'ons idered that .the original medical
depa rtment review had
been comprehensive
.
He further stated that
his department
was not
planning to do
a complete audit of the medi ca 1 depa r tment '
records
~for licensed'operators.
The -inspector concluded that the 'restriction by management
of the
...... '. scope of the .audit,
and the unfamiliarity of the auditor with the
requirements of 10 CFR 55 had severely limited the effectiveness
of
the audit. This resulted in an audit which failed to accurately
diagnose
the status of medical examinations
and records.
b.
The inspector then reviewed in detail the medical record abstracts
provided by the licensee for each operator's
medical
records in the
Regional Office.
The inspector noted that the current medical
requirements of 10 CFR 55 became effective May 26,
1987.
Therefore,
this date
was used
as the starting date for the inspector's
review.
The inspector determined
from the abstracts
that all of the
deficiencies identified by the facility had
been correctly
characterized.
However, the inspector identified several
additional
instances
of incomplete medical examinations
which were not
identified by the facility.
These instances
were:
1.
The inspector identified seven additional operators
who had been
certified by the facility to have completed
a medical
examination to the standards
of ANSI/ANS-3.4-1983, "Medical
Certification and Monitoring of Personnel
Requiring Operator
Licenses for Nuclear
Power Plants,"
when, in fact, they had not
~
<
completed that exam on the indicated date.
- specifies that medical
exams for licensed operators
are to be
~
,completed to the standard
Facilities are
required
by -10
CFR 55.23 to certify that operator
license
applicants
have completed medical
examinations
to the standard
.;of,Form .39,6,.
'";... During::.the inspection,
the facility provided additional
- - information.detailing the specific reasons
for the
- .--;::incompleteness. of.the pre-license
medical
exams of the eight
- - ...operators
identified by-the facility.
The inspector
observed,
from the facility's IIR, that the required blood and
electrocardiogram
tests
were missing from seven of the eight
medical
exams, which-were used
by the facility as the basis for
- -;-the;(nitlal,license application.
In addition, medical history,
.;;--peripheral.;vision,
pulmonary function, urinalysis, or
examination
by a l.icensed physician were missing from several
of
-*.
the eight exams.
The nine additional operators identified by
.-; ...the inspector
had -a similar distribution of missing
exam
~ -"
components.
The inspector concluded that authorized representatives
of the
faci,lity had incorrectly certified that the
15 licensee
.applicants
had completed
a medical
exam which met the
.
- requirements. of NRC Form 396, Certification of Medical
- ..:",Examination.:..(See
Enclosure
3 for dates.)
The certifications
apparently..violated
the requirement of 10 CFR 55.23 for a
facility representative
to certify that
a pre-license
physical
had .been
completed
as specified fn ANSI/ANS 3.4-1983 in that
the
15 medical
exams
which were certified to have
been
done were
incomplete.
2.
The inspector identified four additional operators
who had
exceeded
two years 'between
complete medical examinations
during
the terms of their licenses.
Of these,
two operators
had
exceeded
the biennial anniversary year of their medical
exams,
h le the other two exceeded
the biennial anniversary
dates
of their medical
exams.
For example,
a medical
exam given
o
~
g
n
-June 1, 1988 would have
a biennial anniversary
date of June
1,
1990,
and would exceed its biennial anniversary year on
December 31, 1990.
For purposes
of this review, any substantive
medical
examination
completed prior to May 26, 1987,
was
considered
complete.
Both of the operators
who had exceeded
the biennial anniversary year of their medical examination
had
an intermediate, partial medical examination in the period
between
complete examinations.
The inspector also reviewed
a list of operators
provi
y
ded
b
the
faci sty
a
e
'1'h t the facility had determined did not have complete
NRC medical
exams within 24 months of their previ ous
exams.
The facility's review, documented
in the IIR, identified 48
operators
who had delinquent medical
exams at one time or
another since
1987.
3.
Eleven of the operators
identified by the facility (in Para.
3.b.l and 3.b.2 above)
also
had incomplete medical
exams of
record at the time of the review.
The facility removed
these
individuals from.licensed duties until they successfully
completed
me'dical
exams,
and promptly notified the
NRC of this
discovery.'he
inspector.'ot'ed
that, of the eleven operators,
four had
deli'nquent'medical
exam's for relatively short periods,
up to
near'y 11'eeks,. Representatives
of the medical
department,
and
/he,'Incident Inv'estigation Report, stated that these short term
delinquencies,were
due to operator cancellations
of scheduled
medi'cal
'exams."'One 'licensed operator volunteered that his
understanding'f,.the.
requirement for medical
exams
was that they
needed,to
be 'cosipleted
by the
end of the biennial anniversary
year, rather than the biennial anniversary
date of the previous
m'edical
exam.
The
names of the 'operators identified are provided in Enclosure
2'.
The inspector concluded from the large
number of incomplete
and delinquent medical
exams that more than half of the
licensed
op'erators
had not completed
a biennial
(two year)
medical. exam to the standards
These
instances
apparently violated the medical
exam requirements
of
10
CFR .55,21, 55.53(i)
and 55.23.
The inspector'eviewe'd'a
chronology provided by the facility during
the inspection concerning the operator
whose medical
exam had
expired,
and who could not pass the medical
exam when it was given in
June
1990.
The inspector
reviewed the operator's
medical record,
interviewed the operator
and his Supervisor,
and develo'ped
a modified
chronol ogy:.,
Q
~
November 30,
1988
Partial
NRC medical
exam conducted with
no. discrepancies
identified by operator
on exam
history.
April 21,
1989
Operator restricted
by the medical
depa rtment
from working alone in the Control
Room, or
operating
power equipment
due to medication
prescribed for viral infection (resulting in
disturbance of equilibrium),
(Operator stopped
standing
watches
due to side effects of
medication.)*
April 28, 1989*
May, 1989-Present
Operator stopped
taking medication,
advised
supervisor,
and
resumed watchstanding.
Medical
department
did not indicate this in the
operator's
medical record.
Medical
symptoms recur at intervals of one to
three
weeks for a period of several
hours.
Onset
of symptoms
was gradual
enough that operator
could
summon assistance.
~
i
June,
1989>>
Operator diagnosed
to have Meniere's
disease
by
personal
specialist physician.
Placed
on
" medication
(meclazine)
which he stated
"knocks
him out."
Medication is changed
(Diamox,
scopolamine),
and
he stated
side effects
were not
apparent.
Supervisor verbally advises
medical
department,
and is verbally advised that
no
restrictions
on his duties are required.
Operator's
medical
record
does
not reflect that
discussion.
Medication reduces severity'of
- symptoms to some degree.
,'
December 29",1989 'artial
NRC medical
exam conducted.
Operator
disclosed
on exam history that he was being
treated for Meniere's disease,
and was taking two
different medications
than the one disclosed
in
April 1989.
January 4, 1990*
Medical department
physician examines
operator.
No medical
impediment noted.
June 22,
1990
The inspector
observed that the requirements
of 10 CFR 55.25 for the
facility to notify the
NRC within thirty days of learning of a diagnosis
of an adverse
physical condition had apparently
been violated, in that the
operator in question
had
been medically unqualified from June
1989 through
June 1990, without notification to the
NRC of this medical
impediment.
(The inspector
also noted that this operator did not have
a complete
NRC
medical
exam from the time one
was given on December 6, 1986, until the
one given June 22, 1990.
This deficiency was also identified by the
facility in its
medical department
review,
and is one of the deficiencies
noted in Para.
3.b.2 above.)
Other personnel
were interviewed
and selected
medical
records
reviewed to
determine
whether additional operators
had
a medical condition which made
them ineligible for duty with no restrictions.
Three additional operators
with unreported
medical conditions were identified by the inspector in
a
sample of twenty medical
records
reviewed.
Operator is reexamined
by different physician
after medical
department
review identifies
Meniere's
disease
on patient's
December
1989
. visit.
Physician
recommends
operator
be
- considered
temporarily medically unqualified due to
Meniere's
disease
pending further review.
I ~
July 23, 1990*
.
Facility notifies Regional Office of operator's
medi cal
impediment.
Modifications to facility chronology based
on interview of operator
on
August 7, 1990.
One of these
operators
required corrective
lenses
to meet the vision
requirements.
.One operator
had diabetes mellitus, for which he required
periodic insulin injections.
One operator
had been restricted
by the
medical
department
from operation of power equipment or driving while he
was taking medication for a back injury.
That operator took the
medication from t1arch until June,
1990.
The
NRC was not notified of these
medical conditions.
All three operators
continued to stand watches
as
'icensed
operators.
The failures to notify the
NRC of these conditions
within thirty days of their occurrence
are additional
examples of apparent
violations of 10 CFR 55.25 in that the operators
no longer met the medical
requirements
Finally, the inspector
reviewed Inspection Report 89-43 dated
November 21,
1989,
and
a Notice of Violation in that report, which concerned
a failure
to make
a timely notification of the medical
impediment of another
operator.
The operator
was evaluated
as medically unqualified
on July 6,
1989, but this was not reported to the
NRC until September
15, 1989.
As
corrective action for this violation the facility stated
on December
21,
1989, that:
"Implementation of Nuclear Administrative and Technical
Manual
procedure
93GB-OLC09 should ensure
no fut ther violation of the cited
regulation.
As an additional activity however,
a systematic
review
of 10 CFR 55 and
has
been performed to identify all
additional
requirements for licensee notifications .and submittals
related to Operators
Licenses.
Procedures
to ensure controls exist
for all notifications required
by 10 CFR Part 55 and
will be developed."
The inspector noted that the revised
procedure
93GB-OLC09 became effective
Nay 12, 1990.
The inspector
concluded that the licensee's
corrective
actions for this violation had not been in effect for sufficient time to
affect the timeliness of notifications.
However, the inspector
noted
that sufficient time had passed
since the original violation for the
licensee to perform a comprehensive
review and the failure to perform
this review had been
a missed opportunity to i.dentify and correct the
deficiencies
which were subsequently
identified by the
NRC and the
licensee.
Review of 0 erator Matchstandin
Proficienc
Records
The inspector, requested
objective documentation that each operator
considered
to be actively performing licensed duties
as defined
had actively performed licensed duties in the previous calendar
quarter.
The facility was unable to provide the requested
objective
documentation.
The inspector determined that site procedure
"Operations
Department Operating Guideline Instructions," assigned
the Operations
Hanager the responsibility to ensure that this requirement
was met, but
did not indicate
how that should
be accomplished.
The procedure
did
adequately
recapitulate
the requirements
of 10 CFR 55.53 (e) and (f).
The inspector determined,
by interviewing the three Unit Training
Coordinators, that the method in use to ensure
the requirement
was met was
to review the recent watchstanding
history of persons
returning to shift
after an extended
absence".:
Such'ersons
were said to be scheduled
to
complete
a reactivation
plan to ensure
they were reactivated
as required
by 40DP-90P07
and
10 CFR 55.53(f). Following the completion of this plan,
the Operations
Manager
or his designee
would certify that the operator
had
completed the requirements'or
reactivation of his or her license.
The
inspector
reviewed several
o'f these certifications.
The inspector
concluded that no formal ti acksng
system for operator activity existed,
and considerable
potential existed for inadvertent violations of the
active status
requirements'.*"
At the Exit Interview on July'0,
1990;
a facility representative
comnitted to develop
a system to provide objective documentation that all
licensed operators
actively performing licensed duties were maintaihing
active status.
At the Exit Interview on August 7, 1990, licensee
representatives
outlined
a system to track individual watchstanding
hours
which had not been completely implemented.
No violations or deviations
were identified.
Re uglification Trainin
Re uirements
This subject area
was previously reviewed in Inspection Report 90-16.
No
violations were identified in that inspection.
In this inspection,
the
inspector reviewed the sumnary records of the annual
operating
and
biennial written requalification examinations for the last examinations
given.
The inspector determined
from the
summary record that each
licensed operator
had apparently
been given an exam as required.
Newly
licensed operators,
and operators
who directly participated in the
formulation of the exams,
were exempted
from the exam,
as permitted
by the
licensee's
requalification program at the time.
The licensee's
program
was subsequently
modified to prohibit anyone other than newly licensed
operators
from not taking an
exam during the annual
or biennial cycle.
No violations or deviations
were identified.
Exit Interview
The inspector met with licensee representatives
(see
Paragraph I) and
suomarized
the scope
and results of the inspection,
and the potential
violations which had been identified.
Licensee representatives
acknowledged
the findings of the inspection,
and
made the coomitments
indicated in Paragraphs
3 and
4 of this report.
ENCLOSURE
3
Listi'ng of inaccurate facil'ity certifications,
Palo Verde Units 1, 2,
and 3.
(Reserved)-