ML17305B359
| ML17305B359 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 01/31/1991 |
| From: | Martin J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17305B358 | List: |
| References | |
| 50-528-90-53, 50-529-90-53, 50-530-90-53, NUDOCS 9102180052 | |
| Download: ML17305B359 (48) | |
See also: IR 05000528/1990053
Text
INITIAL SALP
REPORT
.U.
S.
NUCI EAR REGULATORY COMMISSION
REGION V
SYSTEMATIC ASSESSMENT
OF
LICENSEE
PERFORMANCE
INSPECTION
REPORT
NOS.
50-528/90-53,
50-529/90-53,
50-530/90-53
ARIZONA PUBLIC SERVICE
COMPANY
PALO VERDE NUCLEAR GENERATING STATION
NOVEMBER 1,
1989
THROUGH NOVEMBER 30,
1990
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TABLE OF
CONTENTS
I.
Introducti on
~Pa
e
II.
Summary of Results
A.
Overview
B.
Results of Board Assessment
C.
Changes
in SALP Ratings
III. Performance
Analysis
A.
B.
C.
D.
E.
F.
G.
Plant Operations
Radiological Controls
Naintenance/Surveillance
Emergency
Preparedness
'Security
Engineering/Technical
Support
Safety Assessment/equality
Verification
4
7
9
12
13
15.
18
IV.
Supporting
Data and Summaries
21
A.
B.
C.
D.
Licensee Activities
Direct Inspection
and Review Activities
Enforcement Activity
AEOD Events Analysis
21
.23
24
24
I
I
f
II. Summar
of Results
A.
Overview
Licensee
performance
during the assessment
period improved in most
. functional areas
due in large part to management initiatives to
upgrade
weak areas
and to address
Board recommendations
from the
previous
SALP.
The improved performance
was best demonstrated
by
the relatively event free operation of all three units.
to improved performance
was exemplified by the increased
degree of
management
involvement in day-to-day plant activities
and several
management
and organizational
changes
that strengthened
various
departments
in most functional are'as.
Management
involvement and support in the Emergency
Preparedness
area
was superior
and resulted in an improved rating (Category 1)
from the last
SALP period.
The change
was the result of continued
improvement in the program throughout the
SALP period brought about
by continued attention
from licensee
management.
The equality Audits and Monitoring and the equality
Systems
groups
were considered
strengths
in the Safety Assessment/equality
Verification (SA/gV) functi'onal area.
Effective quality monitoring,
programmatic evaluation,
and coordination of quality data
by these
groups
were noted.
.However, continued
management
involvement was
considered
to be the most needed
in this functional area
(Category
2
after considerable
Board deliberation),'as
reflected
by the
Board recommendations.
Insistence
on consistent self-evaluation is
still needed.
The civil penalties
regarding
inadequate
correc.ion
of emergency lighting discrepancies
and licensed operator medical
records discrepancies
appeared
to stem from a lack of management
insistence for aggressive
self-evaluation.
The lack of equality
Assurance
in the emergency lighting and licensed operator medical
records
area
was
a notable contributory cause of the problems.
The
licensee
conducted
an electrical
system self-assessment;
however, it
failed to identify deficiencies
formed by the NRC's
EDSFI related to
design basis calculations.
This indicates
a need to be more
self-critical and to conduct
a more in-depth review.
Additional
attention in the SA'/gV functional area is also considered
necessary
to improve performance of line organization verifications and
gC
inspections.
Effort will also
be necessary
to assure
continued
improvement of performance of safety assessment
groups
(NSG,
PRB,
ISEG,
PSAG,
and
OSRC).
A recognition of improved safety performance resulting from
initiatives in the Maintenance/Surveillance
functional area resulted
in a Category
2 rating.
However, there were extended
Board
deliberations
in this functional area
due to continuing weaknesses.
Continued attention is needed to establish clear and complete work
instructions
and to improve procedural
adherence.
Continued
emphasis
is warranted for timely and effective corrective actions to
maintenance
problems.
The Maintenance
organization
should actively
involve the Engineering organization in maintenance
problems
when
appropriate.
lt
I(
3'ngineering/Technical
Support performance
(Category 2) improved due
to implementation of plans to. address
past weaknesses
in this area.
Continued implementation of those plans is recommended.
Increased
involvement in site activities and in resolution of plant problems
should
be continued.
The roles
and interfaces of the site and
corporate
nuclear engineering organizations
need to be clear and
consistently
implemented.
Continued
emphasis
on conservative
and
comprehensive
response
to plant engineering
problems is warranted.
Relatively event free operations
of the three Units and
an improving
safety performance
trend were noted in the Operations
functional
area
(Category 2, improving).
However, further improvement is
still needed
in the conservatism
of management
decisions,
in the
Operations staff's attention to detail
and in ensuring that
appropriate
technical
support
groups are included in Operations
decision making.
Continued attention to improvement of identified
weaknesses
in the Operations
functional area,
such
as the lack of
control over licensed operator medical
examinations,
is recommended.
Licensee
management
involvement in the Radiological Controls
(Category 2) and Security (Category 2, improving) functional areas
was apparent.
Continued
focus in pursuing effective results
from
improvements initiated in these
areas
is encouraged.
Results of Board Assessment
Overall, the
SALP Board found the performance of NRC licensed
activities by the licensee
to be directed toward safe operation of
Palo Verde.
The
SALP Board has
made specific recommendations
in
most functional areas
for licensee
management
consideration.
The
results of the Board's
assessment
of the licensee's
performance
in
each functional area,
including the previous
assessments,
are
as
follows:
Functional
Area
Rating
Rating
Last,
This
Period
Period
Trend*
A.
Plant Operations
B.
Radiological Controls
C.
Maintenance/Surveillance
D.
Emergency
Preparedness
E.
Security
F,
, Engineering/Technical
Support
G.
Safety Assessment/equality
Verification
2
improving
2
2
1
2
improving
2
2
Th'e
SALP report
may include
an appraisal
of the performance
trend in a functional area for use
as
a predictive indicator.
Licensee
performance
during the assessment
period was examined
by the Board to determine whether
a trend exists.
Normally,
a
performance
trend will be indicated only if (1) a definite
~
0
The Systematic
Assessment
of Licensee
Performance
(SALP) program is an
integrated
NRC staff effort to collect available observations
and data
on
a periodic basis
and to evaluate
licensee
performance
on the basis of
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
regarding the NRC's assessment
of their facility's
performance
in each functional area.
An NRC SALP Board,
composed of the'staff
members listed below, met on
January
10,
1991, to review observations
and data
on performance,
and to
assess
licensee
performance
in accordance
with NRC Manual Chapter 0516,
"Systematic
Assessment
of Licensee
Performance,"
dated
September
28,
1990.
This report is the NRC's assessment
of the licensee's
safety performance
at Palo Verde Nuclear Generating Station for the period November 1,
1989
through November 30, 1990.
The
SALP Board for Palo Verde was
composed of:
R.
Zimmerman, Director, Division of Reactor Safety
and Projects,
Region
V (Board Chairperson)
J.
Dyer, Director, Project Directorate 5,
K. Perkins,
Deputy Director, Division of Reactor Safety
and
Projects,
Region
V
F. Wenslawski,
Deputy Director, Division of Radiation Safety
and
Safeguards,
Region
V
D. Kirsch, Chief, Reactor Safety Branch,
Region
V
S.
Richards,
Chief, Reactor Projects
Branch,
Region
V
G.
Yuhas, Chief, Reactor Radiological Protection
Branch,
Region
V
J.
Reese,
Chief, Safeguards,
Emergency
Preparedness,
and
Non-power Reactor Branch,
Region
V
H. Wong, Chief, Reactor Projects
Section II, Region
V
R.
Huey, Chief, Engineering Section,
Region
V
C. Trammell, Project Manager,
PD 5,
C. Holden,
SALP Program Manager,
D.
Coe, Senior. Resi'dent Inspector,
Region
V
W, Ang, Project Inspector,
Region
V
M. Cillis, Senior Radiation Specialist,
Region
V
P. Quails,
Reactor Inspector,
Region
V
K. Prendergast,
Emergency
Preparedness
Analyst, Region
V
L. Norderhaug,
Safeguards
Inspector,
Region
V
J.
Sloan,
Resident
In'spector.,
Region
V
- Denotes voting members in all functional areas.
Other persons
advised
the Board in their areas of cognizance.
<!
l
>4
>t
trend is discernible
and (2) continuation of the trend could
.result in a change
in performance
rating.
The performance
trend is intended to predict licensee
performance
during the
next assessment
period and should
be helpful in allocating
NRC
resources.
Chan
es in SALP Ratin
s
The licensee's
performance rating in the Emergency
Preparedness
functional area
improved to Category
1 from Category
2 for the
previous
SALP period.
The improved rating in the Emergency
Preparedness
area resulted
from continued
improvement in management
attention to, and licensee self-initiative in, the implementation of
the Emergency
Preparedness
Program throughout the
SALP period.
The
licensee
s ratings in the Maintenance/Surveillance,
Engineering/
Technical Support
and Safety Assessment/equality
Verification
functional areas
improved to Category
2 from Category
3.
The
improved ratings,
in general,
resulted
from improved performance
brought about by management initiatives and organizational
changes.
III. 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.
A.
Plant
0 erations
1.
~Anal sis
During the assessment
period, the licensee's
plant operations
were
observed routinely by both the resident
and the regional staff.
A
total of 2699 hours0.0312 days <br />0.75 hours <br />0.00446 weeks <br />0.00103 months <br /> of inspection effort were devoted to this
functional area,
approximately
36 percent of the total inspection
effor t.
The licensee's
performance
was rated
as Category
2 during the
previous
SALP rating period.
The previous
SALP report emphasized
the need for continued attention to formal and conservative
operations,
particularly valve and system manipulations;
more
thorough evaluation of problems;
and encouragement. of a working
atmosphere
conducive to thoughtful
and critical assessments
of all
phases
of plant operations.
During the current
SALP period, the
licensee
conducted
a comprehensive
assortment of plant operations,
including completion of extended
maintenance
outages,
mid-loop
operations.,
one complete refueling outage,
and full power operation
of all three units for several
months.
These evolutions were
conducted safely and generally indicated that the licensee's
performance
in the area
was good and had improved from the previous
SALP assessment.
However, several
events
occurred during this
period which indicate
a need to continue to emphasize
conservatism
in decisions
and attention to detail
on the par t of the Operations
staff.
There were approximately the
same
number of operations
related
NRC enforcement actions
and licensee
submitted
LERs for each
unit, which supports
the
NRC observation that there is relatively
little difference in performance
between units.
The number of
violations, excluding those associated
with operator medical
records,
and
LERs was approximately the
same
as the previous
period 'and collectively does not indicate
a program breakdown.
Licensee
management
is routinely involved in this area
and
has
on several
occasions
demonstrated
conservatism
in operations
judgement.
These
have included dealing with defective 0-ri'ngs in
and feedwater isolation valves,
shutdowns of Unit 1 to
repair
tube leak,
and prompt inoperability
determinations
of seismically deficient emergency diesel
generators.
In addition, the licensee
improved the conduct of mid-loop
operations
since the previous
SALP period.
Finally, licensee
management
was effective in overseeing
and coordinating the actions
required
by the
NRC to resolve
a Confirmatory Action Letter for
Units 1 and 3, issued
as the result of a March 1989 Unit 3 event.
However, several
events reflected the
need to continue to emphasize
conservatism
in decisions
and better involvement of supporting
groups
such
as engineering,
licensing,
and radiation protection,
Those were:
deenergizing all logarithmic power neutron flux
instruments
in Mode 5, venting reactor
coolant system
gaseous
activity into containment
during outage
maintenance activities, loss
of reactor coolant while repacking
a shutdown cooling valve in an
operating
loop,
and restart of a unit following a reactor trip
without first determining whether the event was bounded
by existing
analysis.
These
events
were not of major safety significance.
The licensee
is generally prompt in dealing with safety concerns,
but still occasionally requires
NRC involvement to ensure that
timely corrective actions
are taken.
For example,
slow licensee
-followup regarding the proper control of required licensed operator
medical
records resulted in a subsequent
NRC finding of a,
significant programmatic deficiency in this area
and resulted in
escalated
enforcement action.
The licensee
has
made sustained
progress
toward =improving plant
simulator performance,
a longstanding
NRC concern,
and is making a
major financial commitment to purchase
a second full scale simulator
to support required licensed operator training needs.
The
licensee's
program to certify the existing simulator has
been
reported to be on schedule,
although
an extension
may be required
should
any delays
be encountered.
The Emergency Operating
Procedures
rewrite program
has
been delayed
by another year
due to
delays
by contractors
providing the writer s guide.
This is the
=
second significant delay to this program.
Operations
personnel
are generally knowledgeable:and
professional,
and their response
to the relatively few events
which occurred
during the assessment
period was 'good.
However,
some deficiencies
were noted which indicate that continued
emphasis
on operator
attention to detail is appropriate.
These include: refueling-
operations
resulting in a stuck fuel assembly
and
a mispositioned
fuel assembly,
missed boron samples
following charging
pump lineup
changes,
over-dilution of the
RCS during power ascension
testing,
exceeding
the limit for
RCS heatup rate,
refueling water tank water due to valve misalignments.
It is noted
that a dilution event occurred just after the end of this
period and reemphasizes
the continued
need for operator attention to
detail.
None of these-events
were considered to have resulted in a
significant safety problem nor did they indicate
a major deficiency
in this area.
They do however indicate
an area for additional
attention.
Although there
were
no
NRC administered
licensed operator
examinations
conducted
during this period, the licensee training
program for licensed
and non-licensed
operators
was found to
implement
an effective Systems
Approach to Training and was
generally
supported
by facility personnel.
However, facility
procedures
governing the licensee
administered
annual
operating
tests
allowed an operator
who failed the test to return to shift
work prior to passing
a second test,
which is contrary to
NRC
requirements.
This weakness
and the lack of control over licensed
operator medical
examinations
noted above indicated
a general
weakness
in meeting
10 'CFR Part
55 administrative control
requirements
which is further addressed
in the Safety
Assessment/equality
Verification section.
The licensee's fire protection program
was viewed to be adequate,
except'in the areas
of emergency lighting and
gA program coverage,
which is addressed
in the Safety Assessment/equality
Verification
section.
Overall, the Board concluded that the licensee's
performance
in this
area
had improved over the previous
SALP period as evidenced
by the
relative absence
of significant operations
related events.
2.
Performance
Ratin
Performance
Assessment
- Category
2 improving
3.
Board Recommendations
In order to more thoroughly and critically evaluate
operations
problems
and improve operations
decision making processes,
the
licensee
should continue to work to better involve supporting
organizations
as appropriate.
Continued
emphasis
toward
conservatism in Operations
decisions,
toward attention to detai
1
during daily operations activities
and to a critically questioning
approach to problems is also warranted..
Program controls over 10 CFR Part 55 requirements
need increased
scrutiny and continued
emphasis
is warranted
toward accomplishing simulator certification
as required
by 10 CFR Part 55.
Radi ol o ical Controls
l.
~Anal sis
The licensee's
radiation protection program
was observed
during
routine operations
and outage periods
by both the regional
and
resident inspectors.
Approximately 605 hours0.007 days <br />0.168 hours <br />0.001 weeks <br />2.302025e-4 months <br /> of inspection effort,
approximately
8 X of the total inspection effort, were devoted to
this functional area.
The licensee's
performance
in the radiological controls area
has
improved during this assessment
period.
The previous
SALP Board
recommended
that the licensee
be more aggressive
in maintaining
plant equipment
and that management
assure that occupational
radiation protection measures
are accomplished
and that questions
concerning the reliability of the radiation monitoring system
(RMS)
are resolved.
The licensee
has demonstrated
management
strengths
by continuing the
reorganization of the radiation protection
and chemistry groups,
including the staffing of key positions with highly qua'lified
individuals.
Assurance of quality and management's
effectiveness
were demonstrated
in the reduction of personnel
exposures,
the
surveillance
programs for the Post-Accident
Sampling
System
and
RMS,
the General
Employee Training (GET) program,
and in control of
contamination in plant areas.'ollective
personnel
exposure
had
declined
from an average
of 223 person-rem/Unit during 1989 to an
anticipated
169 person-rem/Unit in 1990.
These reductions
were
exemplified by a reduction of exposure
during the 1990 Unit 2
refueling outage
compared to the prior outage.
The licensee
was
also successful
in reducing personnel
contamination incidents.
Control of secondary
water anions
and condensate
had
improved and
a new reactor
coolant
pH regime was initiated to
reduce
system
dose rates.
The licensee
formed
a separate
group to
oversee effluents
and the
RMS.
RMS reliability has
improved, the
number of associated
Licensee
Event Reports
(LERs) have decreased,
and the cause of numerous
special
reports related to surveillances
is being addressed.
The licensee
continued to maintain effective
programs involving -transportation of radioactive materials,
solid
radwaste
processing
and environmental
monitoring during this
assessment
period.
The licensee
s timely implementation of corrective actions
was weak,
as evidenced
by the failure to control locked high radiation areas.
Attempts to improve in-line monitors for secondary
chemistry
had
mixed success,
as
new sodium monitors were unreliable.
Examples of
untimely corrective action in response
to internal audit findings
included:
failure to implement procedures
to evaluate
abnormal
releases,
failure to complete
an evaluation of possible radioiodine
plateout in
RMS sample lines, failure to resolve
RMS alarm setpoint
determinations,
failure to resolve the isokinetic sample
design for
the high range effluent
RMS,. and failure to resolve vendor audit
findings involving radioactive waste processing
from 1985'and
1987.
PP
l
On two occasions,
decision-making
was conducted at
a management
level that did not result in adequate
reviews of activities prior to
implementation.
This was exemplified by the decision to release
approximately
26 curies of fission product gases
to containment
while personnel
were present
and the use of junior radiation
protection technicians for senior radiation protection technician
tasks
during
a labor action.
The licensee's
approach to the resolution of significant technical
issues
was typically thorough.
One exception involved management
of
water processing
using the boric acid concentrator
system.
The
evaluation
was not thorough nor completed in a timely manner.
Four Severity Level IV violations and six non-cited violations were
identified during the course of the assessment
period.
Host of the
violations resulted
from failure to follow procedures,
poorly stated
procedures
and failure to implement timely corrective actions.
One
Enforcement
Conference
associated
with the failure to properly
control high radiation areas
was held during this assessment
period.
While the violations and weaknesses
are important, collectively they
did not indicate
any programmatic
breakdown.
Ther e wer e weaknesses
in the licensee's
training program for junior
contractor health physics
(HP) technicians
as evidenced
by their
poor performance
during the
HP technician labor action.
This was
highlighted by
NRC enforcement
actions
concerning radiologically
controlled area
ingress
and egress.
Problems with issuance
of
proper dosimetry
and control of alarming-dosimeter
alarm setpoints
were clearly associated
with inadequate training.
HP technician staffing was adequate
and the professional
health
physics staffing was improving.
Authorities and responsibilities
were defined by management
and understood
by the staff.
Key
positions
were filled on
a priority basis.
During this period there
were several
occasions
involving poor communications
related to
workers bringing safety concerns
to
NRC attention.
Although no
violations were identified, the licensee
demonstrated
responsiveness
to the problem by restating their position and reviewing their
performance.
2.
Performance
Ratin
Performance
Assessment
- Category
2
3.
Board Recommendations
The licensee
should take
a more aggressive
role in ensuring
corrective actions
are promptly and effectively accomplished,
and
that procedures
are clearly stated,
understood,
and implemented.
Efforts should continue to focus
on completion of the organizational
changes
and conservative
decision making.
li
0
Maintenance/Survei
1 1 ance
1.
~Anal sis
This functional area
was observed routinely during the assessment
period by both the resident
and regional inspection staff.
In
addition,
a Diagnostic Evaluation
Team
(DET) evaluated
maintenance
and surveillance
as part of their broad-based
evaluation effort.
Approximately 701 hours0.00811 days <br />0.195 hours <br />0.00116 weeks <br />2.667305e-4 months <br /> of inspection effort were devoted to this
functional area,
about
9 percent of the total inspection effort.
A
noted strength
was the licensee's
willingness to confront hardware
problems directly, although problem resolution
was not always
seen
to be completely effective.
Improvements
were noted in the
establishme'nt
of a Site Maintenance
Manager, initiatives to improve
preventive maintenance
and repetitive work order consistency,
the
incorporation of 12 week work planning schedules,
formal Work
Planner/Coordinator
training,
and improved maintenance
mockup
facilities.
Several
examples
were noted where major maintenance
activities were conducted with thorough planning, control,
and
execution.
Noteworthy examples
included work to repair the Unit 1
tube plug leaks,
the Unit 2 molded case
DC circuit
breaker
replacements,
and the Unit 3 main feedwater isolation valve
4-way valve replacements.
Three broad areas
of weakness
were identified during the previous
SALP period:
inadequate
work planning;
inadequate
attention to
detail in work implementation;
and inadequate
problem resolution.
During the current
SALP period, work implementation varied
considerably.
Major work activities which benefitted
from close
management
attention,
as noted above;were
executed
very well.
Other examples
noted below reflect some weaknesses
in routine
maintenance activities.
These
weaknesses
are categorized
into the
same three
areas
previously identified to .be weak, although
some
improvement
has
been
noted.
Continued attention to these
areas
is
warranted.
In the area of work planning,
as noted above,
the licensee
has taken
steps
to train personnel
and improve their work planning system.
Some
improvement
was noted,
however instances
of poor work planning
were observed
and resulted in incomplete
or inaccurate
work order
instructions contributing to problems
such as:
.inter-system
leakage
due to inadequate
retest
requirements for motor operated butterfly
valves,
inadvertent dilution of the
RCS during steam generator
hydrolazing,
and
damage to the fuel building ventilation boundary
during ventilation system maintenance.
Inspector identified
problems included lack of jobsite checks
by work planners
as
required
by procedure,
freeze
seal instructions which lacked
contingency
measures
for a loss of seal
and work orders which
required field workers to use
a motor operated
valve
(MOV) database
having 34 change notices.
Additionally, weaknesses
in work
scheduling practices
resulted in scheduling valve repacking work on
an operating
shutdown cooling loop, thereby causing
a significant
RCS leak; inadvertently rendering
an emergency diesel
generator
due to steam cleaning work; and
a loss of valuable
t
10
as-found information during troubleshooting
on an
MOV due to other
work. being performed
on the valve.
Although few significant operational
events
were attributed to
maintenance
or surveillance activities, several
lesser
events
indicate
a need to increase
attention to detail in work
implementation.
Examples
include
a loss of all s'hutdown cooling due
to I8C work, an
RCS leak from a newly installed vessel
level
indication system
due .to poor work boundary control,
a balance of
plant engineered
safety feature actuation
due to a missed procedure
step,
a spray
pond pressure
transmitter left isolated following
calibration,
and several
examples of failure to document work steps
as the steps
were performed.
Corrective actions for problems in this area were generally
initiated, but were not fully effective in some cases.
For example,
instances
were noted in which as-found conditions were not preserved
for root-cause-of-failure
determination.
One example of inadequate
corrective action was
a failed relay in an auxiliary feedwater
pump
control circuit which rendered
the
pump inoperable.
The previous
month the
same relay had failed in a different unit and
no root
cause of failure analysis
had been
conducted,
which was contrary to
licensee
procedures.
The Material Nonconformance
Report
(MNCR) pr'ogram was initiated near
the beginning of the evaluation period
and improved as the
assessment
period progressed.
Several
problems with its
implementation
were identified by inspectors,
including failure to
initiate an
MNCR when appropriate.
In some cases,
program problems
were corrected
by changing the program
and associated
procedures.
In other cases, it appeared
that workers were reluctant to follow or
did not understand
the program requirements.
Work Control personnel
now review Work Requests
for MNCR conditions
and have initiated
MNCRs where required.
While this is not the ultimate expectation of
the program, it appears
to be adequate
corrective action at this
point.
Additionally, workers still occasionally lack an
inquisitive, probing approach to plant problems.
In one example,
a
technician inadvertently
caused
a hydrogen monitor to alarm while
making
a routine adjustment
and did not evaluate its significance.
In another
case,
a worker noticed
a valve handwheel
detached
from
its valve and took no corrective action until prompted
by an
NRC
inspector.
Although relatively few plant events
were attributed to weaknesses
in the preventative'aintenance
program,
several
instances
were
noted which indicate that the licensee's initiative to improve this
program should continue.
The Electrical Distribution System
Functional
Inspection
(EDSFI) team found a number of safety-related
relays,
breakers
and electrical distribution panels
which lacked any
scheduled
preventive
maintenance
or testing.
Similarly, the
EDSFI
identified that safety-related
motors lacked
a program for routine
monitoring of motor insulation resistance.
Inadequate
preventative
and corrective maintenance
for the emergency lighting system
was
part af a larger
issue which was subject to escalated
enforcement.
While the number of violations and
LERs in this functional area
was
somewhat higher than in the previous
SALP period, these
did
not reflect the
same
degree of safety significance
as in the
past
and did not indicate
a program breakdown.
The
DET identified
numerous motor'operated
valve maintenance
problems including:the
absence
of a program to address
progressive
degradation,
and
a lack
of aggressive
followup on industry )nitiated check valve advisory
documents.
In addition, the
DET noted that vendor technical
manuals
were not always kept current.
Maintenance material
support
was variable.
Improper storage of
pump oil resulted in moisture contaminated oil being
used in the Unit 1 reactor coolant
pumps.
Corrective action for
material
support problems
included assigning
a procurement contact
person for each unit to attend morning meetings
and provide
coordination,
which appears
to have improved the situation.
The basic surveillance
program
was considered
to be sound,
however
some problems
were noted at this three unit site.
In one case, test
performers
signed off steps
as complete
when it was not possible to
perform the steps
as written.
In one case,
problems getting the
expected results
prompted invalidation of the test rather than
documentation
of the problem.
In another
case,
workers were
reluctant to seek assistance.
Licensee
event reports identify a few
surveillance
tests
which were missed, 'although during the last
months of the evaluation period
no further similar events
have
been
reported.
Some surveillance test procedures
had deficiencies
including inadequate
acceptance
criteria,
inadequate
verification of
test equipment operation,
unclear directions which permitted
inconsistency
between units,
inadequate
detail to assure
consistent
test data,
and errors in supporting operating procedures.
However,-
the licensee
has
strengthened
the supporting
program by completing
cross
reference
documents
which ensure all surveillance
requirements
are
implemented
by procedure.
While some problems
were noted, the
surveillance testing program is viewed as stronger overall than the
maintenance
program.
Overall, maintenance
personnel
have
shown the capability to perform
quality maintenance.,
Some instances
of inadequate
inquisitiveness
were still apparent.
Program effectiveness
has improved, but is
still hindered
by weaknesses
in work planning, scheduling,
and
corrective action for identified problems in the maintenance
area.
2.
Performance
Ratin
Performance
Assessment
- Category
2
3.
Board Recommendations
The Board conducted
extended deliberations in this- area.
The
Board's previous
assessment
of Category
3 performance
was partly a
reflection of the maintenance
weaknesses
highlighted by the
operational
events
during that period.
During the current
evaluation period there
have
been
no maintenance
issues
similar to
those of the previous period and the Board has recognized
the
12
licensee's
current initiatives in the maintenance
area.
The
licensee
should clearly recognize
the need to continue the
initiatives that have
been started.
The Board recommendations
are
identical to those of the previous cycle.
The licensee
should continue to work to establish clear and complete work
,instructions.
Emphasi's
continues to be needed
toward procedural
adherence.
Maintenance
personnel
should actively involve
engineering when'ppropriate
and engineering
should strive to be
aware of ongoing maintenance
issues.
Maintenance
managers
should
continue efforts to observe routine ongoing work and to carefully
manage safety equipment
outage
schedules.
Continued attention to
establishing timely and effective corrective action is warranted.,
with respect
to concerns
in the maintenance
area.
Emer enc
Pre aredness
l.
~Anal sis
During thi s
SALP per iod, approximately
168 inspecti on hours,
approximately
2X of the total inspection effort, were utilized to
assess
the licensee's
Em'ergency
Preparedness
(EP) Program.
This
included the observation
of one exercise
and three routine
inspections.
The previous
SALP board
recommended
an emphasis
on
management
attention to timely implementation of corrective actions
and continued
management
'involvement in the program.
Management
involvement
has
been effective in improving the
'program.
This was evidenced
by the improvement
and upgrading of
Emergency
Response facilities and equipment (i.e.,
new emergency
response
vehicles
and efforts to upgrade the offsite assembly
and
backup
EOF capabilities),
and being proactive in improving the
Emergency
Plan Implementing Procedures
(EPIP's)
and the Emergency
Plan to conform to
Management
support
and participation
was also evidenced
by the >conduct of two accountability drills and
superior performance
during the annual
exercise.
The licensee's
gA program provides for an in-depth independent
audit
of the
EP Program.
The licensee
used
a Senior
EP supervisor
from
San Onofre to participate in the audit, contributing a level of
expertise
not usually obtained- in annual
EP audits.
Audit fin'dings
and recommendations
were well documented,
entered,
tracked,
and were
corrected in a timely manner.
The licensee's
efforts to resolve technical
issues
from a safety
standpoint
appeared
to be effective..
The effort to revise the
Emergency
Plan
and EPIP's to be consistent, with NRC guidance
documents
was being performed largely on the,licensee's
initiative
after the
NRC s identification of inconsistencies.
The performance
of two effective accountability drills, one
on a weekend
and one
during work hours,
also demonstrated
management's
wH lingness to
improve plant performance.
There
was
one violation of an
NRC requirement during the evaluation
period.
The violation involved a failure to declare
an Unusual
0
13
Event for a fire within the power block lasting more than ten
minutes.
The licensee's
corrective action for the violation was
prompt and effective to prevent recurrence.
However, it is noted
that this event was the only Unusual
Event (reportable)
which
occurred i n this rating period and appeared
to result from a lack of
conservatism
in management
decisions.
Subsequent
events
were
cor'rectly classified,
although
none were significant enough to be-
class'ified
as
an Unusual
Event or higher.
Staffing of the
EP Program appears
adequate.
Positions
are
identified and authorities
and responsibilities
are well defined.
Vacant
key positions
are filled on
a priority basi s.
Needed
expertise is available within the staff.
Consultants
are
used
as
appropriate
to supplement
the staff for major occurrences
such
as
the annual
exercise. 'he licensee
appeared
to have
an effective
program to ensure that adequate
emergency
response
personnel
are
onsite
and are current in all of the required training for their
specified positi.ons.
The licensee
appears
to have
a good emergency
preparedness
training
and qualifications program.
The program appears
to be effective in
ensuring that personnel
in key positions
are fully qualified and
have all required training.
Interviews with a number of Shift
Supervisor personnel
disclosed
a good understanding
of the Emergency
Plan
and event classification.
No weaknesses
were observed
during
those interviews.
2.
Performance
Ratin
Performance
Assessment
- Category
1
3.
Board Recommendation
The licensee
should continue support of the
EP program.
Management
emphasis
is appropriate
to ensure
aggressive
problem solving, to
validate the effectiveness
of recently implemented corrective
actions,
and to ensure that plant events
are pr'operly classified.
~Sec unit
1.
~Anal sis
During the assessment
period,
Region
V conducted four physical
security inspections.
Over 336 inspection
hours,
approximately
5X
of the total inspection effort, were expended
by regional
inspectors.
In addition,
a team inspection
and the resident
inspectors
provided continuing 'observations
in this area.
a
With regard to involvement in assuring quality, corporate
and plant
management
continued to review the operation of the overall security
program.
Significant weaknesses
had
been
noted early in the
assessment
period in the areas
of security event analysis
and alarm
trending to identify root causes.
The large
number
and age of
t
0
14
uncompleted
maintenance
requests
for security-related
equipment
was
also identified as
an area
needing attention.
Additionally,
communication
between levels of security management
and between
security
and other disciplines
was found to be weak.
There
was
significant improvement during the assessment
period in response
to
NRC concerns.
Licensee organizational
changes
appear to have
remedied
these
weaknesses.
The licensee
has established
a "Site
Services Division Action Plan" aimed at improving tactical training,
site exercises,
strategic planning
and target analysis,
to assure
that the contingency plan implementing procedures
provide proper
response
to the design basis threat.
Improvements
were
made to
facility hardware to reduce the need for compensatory
security
measures.
equality assurance
and quality control programs
and policies are
generally adequately
stated
and understood.
However,
Region
Y noted
that further dialogue
appeared
warranted
between reactor operations
and security personnel
so that armed
response
strategy
and tactics
could be initially focused
on protecting the most critical safety
systems
and components first.
The previous
SALP report encouraged
licensee
management
to complete
their review of closed circuit television
(CCTV) camera
coverage
and
illumination necessary
for adequate
protected
area barrier alarm
assessment
and to limit overtime effects
on guard alertness,
including expediting the implementation of their planned
expanded
security training program;
The licensee's
study to relocate
cameras
and illumination to improve coverage,
completed during the latter
part of the assessment
period,
appears
quite satisfactory.
However,
the current
CCTV cameras
require
a very high level of maintenance
to
remain operational
due to the severe
environmental
conditions
under
which they must function.
Evaluation of alternate
camera suppliers
is continuing.
To limit overtime effects,
the licensee
has,
during
the latter part of the assessment
period, completed their expanded
training program and improved access
control system reliability to
reduce
the number of compensatory
posts.
The licensee
has also
abandoned
the 12-hour work shifts for security officers,
implementing
a standard
8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> per day,
5 days per week duty
schedule.
Identification and resolution of technical
issues,
while slow in
some cases,
has
been generally
sound
and thorough..
Early in the
assessment
period, lack of thorough analysis of root cause
and
systematic
implications of equipment failures were identified.
Improvements
in trending
and analysis of equipment/human
failures
has
been
noted in later inspections.
During the assessment
period, licensee
action relative to three
information notices dealing, respectively, with radio
communications,
review and analysis of safeguards
event logs,
and
potential
weakness
with certain types of security equipment
were
reviewed.
Mith the exception of the review of event logs, the
licensee's
actions,
as reviewed to date,
were found to be
appropriate.
15
The enforcement history for the period November
1,
1989, through
November 30,
1990,
includes
3 violations identified early in the
assessment
period,
which were related to a licensee identified (but
repeated)
failure to provide
a vital area barrier as described
in
their approved security plan, failure to provide proper
escorted
access
to vital areas,
and failure to properly package
safeguards
information for mailing.
Additionally, the enforcement history
includes
a non-cited violation regarding
implementation of an
unapproved training program of simulated night firing.
During this
SALP period, the licensee
reported four safeguards
events.
Three of these
events
resulted
from personnel
error:
failed security compensatory
measures
(two) and an uncontrolled
pathway to a vital area
(one).
The remaining event resulted
from a
design deficiency related to 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
on .their
own initiative and augments
cur rent offsite security resources
to
meet the special
security
demands
of the plant's isolated location.
2.
Performance
Ratin
Performance
assessment
- Category
2 improving
3.
Board Recommendations
The licensee is encouraged
to complete their review of CCTV camera
designs
to improve the performance characteristics
of the alarm
assessment
system.
The licensee
should continue the
use of
management
action plans to critically review their security program,
i'dentify problem areas
and promptly resolve problems
when they are
identified.
En ineerin /Technical
Su
ort
l.
~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 411 inspection
hours were expended
in this functional area,
approximately
5 percent of the overall inspection effort.
These
reviews focused primarily on the effectiveness
of the engineering
organizations
and in the quality of their work.
The licensee
has restructured
the engineering organizations
and
filled most remaining
key management
positions during this
assessment
period.
In February 1990, the
new position of Vice
President
= Engineering
and Construction,
was created
and filled.
In April, the permanent Site Technical Director position was filled.
The Engineering Evaluation Department,
which includes the System
Engineers,
was reorganized
under the Site Technical Director,
I
,I
I
t
I
e
16
creating four new departments.
These
changes
included formation of
a Component
and Specialty engineering
group which established
component
engineers
to address
motor operated
valves
and safety
relief valves,
motors
and pumps,
and
a group to
'onitor component
performance
and maintenance
data.
This appears
to
have
improved the focus of the Site Technical
Support personnel,
although the interrelationship
and responsibilities of System
Engineers
a'hd Component
Engineers is not always clear.
In July
the
Director of Site Nuclear Engineering
and Construction position was
created
and filled, and the Site Nuclear Engineering
Department
(SNED) was formed, providing greater onsite design engineering
expertise
and .support.
In October,
these engineering functions,
including the corporate-based
Nuclear
Engineering
Department,
were
consolidated
under the Vice President - Engineering
and
Construction.
The Director -'Nuclear Engineering position was not
filled until after the end of -this assessment
period.
Additionally,
the licensee's
Business
Plan was developed
and is being implemented,
providing specific goals
intended to enhance
the effectiveness
of
the engineering
organization.
This Plan addresses
weaknesses
and
recommendations
from the Diagnostic Evaluation performed
by the
NRC
early in the assessment
period and incorporates
the licensee's
Engineering Excellence
Program.
In general,
engineering
work addressed
significant problems in a
typically timely and thorough manner.
Improvement
was specifically
noted in the responsiveness
of engineering to plant events.
Positive
examples
included involvement in resolution of embrittled
pins in safety-related. butterfly valves, retrieval of a broken
incore detector,
resolution of auxiliary feedwat'er
pump pressure
pulsations,
assessment
of improper backup rings in four-way valves
which control the feedwater isolation valves, control element
assembly
coi 1 testing to prevent slippage during surveillance
testing,
and retrieval of a heated junction thermocouple
sheath.
Additionally, Engineering
has proactively pursued
probl.em
identification, having identified several
deficiencies
during the
design basis reconstitution
process
and during fire barrier
walkdowns.
System engineers
appeared
to have improved their ability
to identify deficiencies in their systems.
Examples
include
inappropriate paint on the fuel metering ports;of an emergency
diesel
generator,
and
a deficient splice in the atmospheric
dump
'valve control system.
Although the licensee's
performance in this area
has clearly
improved as
a result of management
involvement and initiatives,
there were several
instances
which indicate that more than minor
weaknesses still remain to be addressed.
Most notable of these
examples
was the continuing problems with the emergency lighting
system.
Problems with the system
have persisted for years
and were
not dealt with in a thorough, integrated fashion, resulting in civil
penalties
in both 1989
and 1990.
In this instance, critical
self-assessment
of the issue
was clearly lacking and the -licensee's
approach to resolution of the associated
technical
problems
was
poor.
Other examples of weak engineering
work included inadequate
testing of motor operated butterfly valves, configuration
~
~
17
control problems with the Core Operating Limits Superv'isory
System
(COLSS), not clearly limiting the torque value for a Pressurizer
instrument valve gland nut in an associated
work document,
using
invalid assumptions
in determining
how to compensate
for temperature
changes for the
ADV nitrogen drop test,
inadequately justifying
waivers for some preventive
maintenance
tasks,
and failure to
recognize
the significance of the loss of preload
on
MOV spring packs..
Licensee engineeri ng and contract personnel
performed
a design
review of the electrical distribution system prior to the
NRC
Electric Distribution System 'Functional
Inspection
(EDSFI)..
While
the performance of these
types of reviews are considered
a strength,
the subsequent
NRC EDSFI identified an electrical
system
power
configuration which could have potentially caused
overloading of a
startup transformer.
The
EDSFI also identified load calculation
errors
and
a 1990 diesel
load calculation which used incorrect data
from a superseded
1989 calculation.
These
problems
were not noted
by the earlier
licensee
reviews
and were indicative of deficiencies
in the licensee's
design control
and verification process,
and of
the licensee's
overview review in this area.
In spite of the increased
focus
on the engineering
program, the
backlog of open Engineering Evaluation
Requests
has
decreased
only
about ten percent,
to approximately
2000, during this evaluation
period.
However, these
have
been prioritized by the licensee
based
on their significance.
Management of engineering
resources
to
address
these
items will require continued attention.
Training programs for Electrical Maintenance,
and for
Instrumentation
and Controls Maintenance
were found to be
acceptable.
The licensee's
efforts to implement the Systems
Approach to Training for the technical staff appeared
to be
effective and generally supported
by facility personnel.
Mith
,regard to enforcement in this area, with the exception 'of the
emergency lighting civil penalty, all other violations were
considered
minor and did not indicate
a programmatic
breakdown.
2.
Performance
Ratin
Performance
Assessment - Category
2
3:
Board Recommendations
Efforts to clearly define the role of System Engineers
should
continue.
Corporate
and Site Nuclear Engineering
should solidify
their organizations
and continue to increase their involvement in
site activities
and prob1em resolution,
however the roles
and
interfaces for all organizations
need careful definition due to the
organizational
changes
which have occurred.
The licensee
should
continue the emphasis
being placed
on responding conservatively,
deliberately,
and comprehensively to plant engineering
problems,
and
ensure
the involvement of all appropriate
supporting organizations.
H
tf
18
Safet
Assessment/
ualit
Verification
1.
~Anal aia
During this assessment
period, approximately
2457 inspection hours,
approximately
33 percent of the total inspection effort, were
.expended
by resident,
region-based,
and headquarters
inspectors.
Included in this functional area are the inspection
hours associated
with followup to the emergency lighting problems
and the restart of
Units 1 and
3 following the issuance
of Confirmatory Action Letters.
Inspections
were conducted in the areas of Quality Assurance
(QA)
and Quality Control
(QC), Independent
Safety Engineering
Group
(ISEG), Plant Review Board (PRB), Nuclear Safety Group (NSG),
Management
Review Committee
(MRC), Offsite Safety Review Committee
(OSRC), Plant Safety Assessment
Group (PSAG),
and the Licensing
organization.
Licensee
management
demonstrated
an increased
degree
of involvement in day-to-day activities which contributed to
improvement in this area.
Although improvements
were noted in all
safety assessment
groups required
by Technical Specifications
(TS),
and
some instances
of strong performance
were observed,
overall
some of the groups
are perceived
as not performing as effectively as
they could.
Licensee actions to correct past weaknesses
regarding
the problem identi,fication and corrective action programs,
root
cause
analysis
programs,
and the effectiveness
of QA and oversight
organizations,
are apparent.
Although programs
are in place
arid
have
improved, the resultant
improvement 'in safety performance still
remains to be fully demonstrated
by more committed implementation
and follow-through from all levels of the licensee's
organization.
A past weakness
regarding the lack of sufficient technically
experienced staffing of the
QA organization
was in the process
of
being corrected
by strengthening
of the Quality Department staff.
Weaknesses
of the
NSG in its effectiveness
in identifying and
recommending
changes
to weak programs
were noted to have improved
during this assessment
period.
NSG's assessments
and
recommendations
regarding the
PRB composition
and the 10 CFR 50.59
program implementation
appeared
to be contributing to nuclear
safety
improvement.
Based
on a
NSG recommendation,
the licensee
submitted,
obtained approval,
and implemented
a Technical Specification
change
to the composition of its PRB..
The inclusion of all Unit Plant
Managers
and the Director of Standards
and Technical
Support in the
PRB appeared
to initially have resulted in substajtiv'e
review of
plant problems
and recommendations
for resolution'f those'problems.
However, during the
same period, the PRB's review of -the October 20,
1990 Unit 3 simultaneous
opening of seven
Steam
Bypass Control
Valves and the associated
reactor trip appeared to have
been weak
and was not sufficiently probing to identi'fy that the condition had
a potential of subjecting the plants to a condition that was beyond
their design basis.
This demonstrates
a continuing, need to foster
a
probing and questioning attitude
by all oversight groups.
ISEG was
noted to also
have
made
some
improvements in its reviews
and the
presence
of ISEG's engineers
in the field was more visible.
However, the .effective utilization of ISEG, the consistency of ISEG
reports,
and the technical
accur'acy of ISEG investigations
continue
to warrant improvement.
19
The licensee utilized a non-TS required.MRC to provide senior level
oversight of restart activities associated
with the extended
shutdown of the units in 1989.
The
MRC oversight appeared
to have
contributed significantly to minimizing problems associated
with
completion of restart action items
and during the restart operations
activities.
Upon restart of all the units the
MRC was disbanded.
The advantages
and benefits brought about by the
MRC oversight were
recognized
by the licensee
and were subsequently
continued
on .to the
operations
phase
by the formation of the
OSRC.
.The non-TS required
PSAG appeared
to have .been contributing to plant safety in its
review and generic evaluation of the various oversight committee
reports
and identification of safety concerns that were not readily
apparent in the individual reports.
PSAG still had limited success
in effectively coordinating review activities of the various
oversight groups.
Although overall performance in this functional area is'onsidered
to have
improved and the licensee's
many initiatives are
recognized,
two escalated
enforcement actions during the period
create
doubt regarding whether the improvements in this area
can
be
sustained.
One civil penalty was related to long standing
deficiencies
in the emergency lighting area.
Of particular concern
was both management's
and QA's apparent
reluctance
to critically
assess
the technical
situation.and
then deal with it promptly and
thoroughly.
With regard to the civil penalty associated
with
operator medical
records,
the licensee
had substantial
prior notice
of problems in the area, yet the full extent of the problems
was
only realized following an
NRC inspection.
These
two events bring
into,question the depth of senior management's
commitment to
critically assessing
their organization,
and to reacting decisively
when significant issues
demand it.
There were
a number of other
lesser
enforcement
actions in this area,
however those
lesser
violations were not indicative of a major problem.
The licensee's
quality verification functions were accomplished
by
second party (non-Quality Department) verification, specified
inspections,
QA monitoring and
QA audits.
The second party
verification process
and the
QC inspection process
generally met all
requirements.
The licensee
has
implemented its
MNCR and
corrective action programs
and they generally appeared
to be also
effective and appeared
to correct
many of the previous programmatic
weaknesses.
However, occasional
weakness
in the implementation of
the programs
have still been noted,
as discussed
in the maintenance
section of this report, in the apparent
occasional
hesitance
to
write MNCRs or QDRs in favor of work requests
or EERs.
Quality monitoring was viewed as
a strength of the licensee's
program.
It was generally utilized effectively in areas
of concern
such
as control
room unit restart activities and provided primarily
performance-based
quality overviews of ongoing activities.
The
quality of QA audits
improved in scope
and performance
from previous
years
as demonstrated
by audits performed
on TS surveillances
and on
refueling operations.
The management
of both the Quality Audits and
Monitoring and the Quality Systems
group were considered
strengths
20
of the licensee's
equality Department.
Significant support of, and
involvement in the
gA program. by the Executive Vice President,
Nuclear,
was clearly demonstrated
by his detailed
comments
and
followup of both gA audits
and audits of the
gA program by
independent parties.
The staffing level
and qualifications of personnel
in safety
assessment
and quality verification organizations
generally appeared
to be adequate.
Key positions in the equality Department
and
on the
PRB,
whose functions were previously performed
on an acting bases,
were filled late in the assessment
period by the appointment of a
equality Department
Deputy Director and the appointment of a Manager
of Plant Support,
who serves
as the
PRB chairman.
The
gC inspection
staff assigned
to perform inspections
in the units appeared
to be
small
and usually required significant contractor
augmentation
during major outages.
.The small equality
Systems staff appeared
to be contributing
significantly by its involvement in quality improvement projects,
such
as its continuing oversight of the nonconforming condition
reporting program
improvements
and by its quality data evaluation,
trending,
and reporting.
The licensee self assessment
programs
included
an electrical
distribution system functional assessment,
a diesel
generator
safety
system functional inspection
and independent
audits/evaluations
of
the
gA audit functions.
However,
subsequent
NRC inspections
identified additional
problems to those identified by these self
assessments.
The licensee's
action demonstrated
a continuing desire
to improve performance
in this functional area,
although
more
critical assessments
are
needed.
The
NRC Office of Nuclear Reactor Regulation
(NRR) staff conducted
substantial
review activities in support of licensee
submittals
during the assessment
period.
The licensee's
submittals
were
generally acceptable
for the most part.
Occasional
lapses
were
noted.
In one notable
example,
the licensee's
original submittal to
extend the interval for steam generator
eddy current=examination
was
inadequate
because
the licensee
had submitted insufficient
information.
As a result,
the
NRC staff could not perform an
independent
analysis to support the proposed
amendment.
Subsequent
.
inquiries by NRR revealed further pertinent information that was not
included in the initial submittal.
Responses
to generic
communications
were generally timely and
appropriately detailed.
A cooperative attitude
was exhibited
throughout most discussions
regarding the licensee's
methodologies
and basis for analysis
as well as approach to resolution of issues.
The licensee's
responses
to
NRR staff questions
were generally
complete
and timely, thereby facilitating the staff's review.
2.
Performance
Ratin
Performance
Assessment
- Category
2
f
21
3.
Boar d Recommendations
The Board assessment
for this functional area recognizes
the
licensee initiatives to improve performance
in this area.
However,
the assessment
was the result of considerable
Board deliberation.
The Board strongly recommends
continued attention to performance in
this area.
The licensee
needs to continue to require that the
equality Assurance
(gA) organization
be more critical and aggressive
in their reviews,
such that major problem areas will be identified
prior to becoming self-revealing.
Management failures to recognize
problems,
and the lack of gA oversight in both the operator licensing
medical
records
area
and emergency lighting demonstrated
a-
.
continuing need for improvement.
The equality Department,
the
oversight groups,
and engineering
should develop
a more questioning
and probing attitude to ensure
in-depth root cause
review and
thorough,
prompt corrective actions.
Further strengthening
of the
gC organization,
gC inspections
and line organization verifications
is also
recommended for continued
good performance
in this
functional area.
Visible, strong support for the
gA program,
from
all levels of management,
should
be demonstrated.
The licensing organization
needs to increase
awareness
of plant
operations
and status,
and ensure that all licensing submittals
contain all information pertinent to the subject.
The communication
and participation
between the corporate
organizations
and the site
(operations
personnel)
also
needs
to be improved as discussed
in the
plant operations
functional area,
as
a joint effort.
IV.
SUPPORTING
DATA AND SUMMARIES
A.
Licensee Activities
C
During this assessment
period, Units 1 and
3 completed
extended
refueling outages
which began in March 1989.
Numerous corrective
actions'were
taken
by the licensee
in response
to an
NRC
Confirmatory Action Letter based
on the circumstances
surrounding
the unit shutdowns.
Following selected
NRC review of these actions,
the letters
were rescinded in December
1989 for Unit 3 and June
1990
for Unit 1,
Both units restarted
immediately following this
NRC,
action.
Unit 2 operated
during this assessment
period,
and also
completed
a five month refueling outage.
Specific operational
events
were
as follows:
Unit 1
Unit 1 was in Hode
6 in the midst of a refueling outage at, the onset
of this assessment
period.
Fuel loading was completed
and
Mode 5
entered
on January
9, 1990.
Mode 4 entry occurred
on April 17,
1990,
and
Mode
3 was entered
on April 18.
The Unit was cooled
down
to Mode
5 on Hay 4, 1990, to repair Steam Generator
tube leaks
and a
Pump seal.
During mid-loop (reduced inventory)
operations,
a complete'oss
of Shutdown Cooling was experienced
on
May 9, 1990.
Repairs
were completed
and
Mode 4 was entered
on June
I
(
22
13, 1990, followed by Mode
3 entry on June
14.
The Confirmatory
Action Letter of December
24, 1989,
was lifted on June
24, 1990,
and
Mode 2 was entered that day.
On June 25, 1990,
a manual reactor trip test
was performed
and the reactor
was returned to Mode 2
=operation.
A slipped Control Element Assembly event occurred during
startup testing.
Mode 1 was entered
on June
30,
1990 and the Unit
was brought, to 100 percent
power.
A reactor trip occurred
on August 14, 1990, following a manual
turbine trip initiated because
of a loss of cooling to the main
transformer.
The reactor
was restarted
on August 18, 1990,
and
Mode
1 was entered
'on August 19.
A forced downpower and manual reactor trip occurred
on September
13, 1990,
due to leakage
past
a primary
Pressure
Safety Valve.
The Unit was subsequently
cooled
down to
Mode
5 for repairs.
Heatup to Mode
3 on September
19-20 revealed
leakage
from the pressurizer
vent system,
forcing a return to Mode 4
for repairs.
Heatup to Mode
3 was completed
on September
23, 1990,
and the reactor
was started
up on September
24.
A Hain Feedwater
Pump tripped,
causing
a Reactor
Power Cutback to about
50 percent
power to occur on October 2, 1990.
The Unit was restored
to, ful'l
power operation the
same
day.
Power
was reduced to about
64 percent
on November 24-25,
1990, to allow repair of secondary
equipment.
The Unit was operated at 100 percent
power for the remainder of the
assessment
period.
Unit 2
Unit 2 began this assessment
period in Mode
3 to. resolve
CEDH ground
indications, incorrect
HPSI flow orifices,
and brittle restraining
pins in containment
purge valves.
A reactor trip occurred
on
November 1,
1989
due to three independent
problems in the Plant
Protection
System.
A three
week shutdown resolved these
i.ssues
and
other maintenance
work was accomplished.
During the heatup in Mode
4,
RCS heatup rate limits in the Technical Specifications
were
exceeded
and the plant was returned to Mode 5 to assess
the impact
and
need for corrective measures.
After one week, the plant startup
was delayed after reaching
Mode 2 due to
CEA grounds,
but the unit
achieved
100 percent
power on December 5, 1989.
The reactor
was
shutdown
on February 23,
1990 to commence the second refueling
outage.
This outage
included defueling the reactor,
inspection
and tube plugging, reactor coolant
pump .overhaul,
repair for grounds,
and diesel
generator
"B" overhaul.
The reactor
entered
Mode 2 on July 14,
1990 and following a series of unrelated
problems with high condenser
sodium levels,
loss of power to a
a tripped condensate
pump,
and a
COLSS failure, the
unit achieved consistent
100 percent operation
on. August 17, 1990.
The unit operated at approximately this power for the remainder of
the assessment
period.
Unit 3
The unit began the
SALP period in Mode
5 in its first refueling
outage.
At the completion of outage
work the unit entered
Mode
3 on
November 30, 1989, then returned to Mode 4 for several
days 'due to
C
23
problems with steam-driven auxiliary feedwater
pump pressure
osci llations.
When these
problems
were resolved the unit returned
to Mode 3.
Additional auxiliary feedwater
pump work necessitated
a
second return to Node
4 on December
22,
1989 and the unit returned
to Mode
3 on December
24, 1989.
The
NRC lifted the Confirmatory
Action Letter dated
June
28,
1989 on December
24, 1990, permitting
entry into Mode 2.
On December
26,
1989 the unit entered
Mode 2 and
began
low power physics testing.
An internal fault on the "A" phase
masn transformer
occur'red shortly after the main generator
was
synchronized
to the grid and the reactor
was manually shutdown to
Mode 3.
Mode 2 was entered
on January
18,
1990 after replacement
of
the transformer
and the unit entered
Node
1 on January
19, 1990.
Power ascension
testing followed and the unit increased
power to 98
percent while the licensee
evaluated
the reason for output megawatts
being higher than expected.
Resolution of the output megawatts
issue permitted the unit to proceed to 100 percent until a reactor
trip occurred
as
a result of a dropped
rod on April 14,
1990 during
monthly
CEA testing.
The unit proceeded
from Hode.2-to
Mode 1 on
April 19,
1990 and increased
power to 90 percent
where it remained
for repairs of feedwater
heaters
5B and
6B.
Repair of these
heaters
required
a downpower to 50 percent
and the unit proceeded
to 100
percent
on April 29,
1990.
On May 29,
1990 a reactor
cutback
occurred
due to the tripping of the "A" main feedwater
pump during
preventive maintenance.
The unit returned to 100 percent
power on
May 30,
1990 where it remained except for minor testing until
a
slipped
CEA and unsuccessful
recovery required
an orderly shutdown
on August 5,
1990.
The unit returned to Node 2 later that
same
day
but returned to Node
3 because
of additional
CEA problems.
Repairs
were completed
and the unit proceeded
through
Mode 2 to Mode
1 on
August 7, 1990.
The unit reached
100 percent
power
on August 9,
1990
and remained there until a reactor cutback occurred
on
September
8, 1990 due to a trip of the "B" main feedwater
pump due
to a failed logic control circuit card.
The unit retur ned to 100
percent
power on September
9, 1990.
A reactor trip occurred
on
October 10,
1990 as
a result of a sudden
opening of all in-service
steam
bypass
control valves.'he
unit proceeded
to Mode
2 and Node
1 on October 21,
1990 and reached
100 percent
power on October 23,
1990.
On October 30,
1990 the "A" emergency diesel
generator
tripped
on a faulty .vibration switch.
The switch was repaired
and
the diesel
generator
was returned to operability within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.
The unit was forced to reduce
power on November 26, 1990 because
of
a'OLSS malfunction.
The unit returned to 100 percent
power later
that day and remained at 100 percent until the end of the
period.
Direct Ins ection and Review Activities
Three resident
inspectors
were assigned to Palo Verde during the
SALP assessment
period.
Forty-six routine arid special
inspections
were conducted
during this period. Significant team inspections
included
f
f
NRC Diagnostic Evaluation
Training Inspection
Electrical Distribution System Functional Inspection
A total of over 7378 hours0.0854 days <br />2.049 hours <br />0.0122 weeks <br />0.00281 months <br /> of direct inspection
were performed
during this SALP'period.
In addition, three
Enforcement
Conferences
and four Management
Meetings
were held with APS.
C.
Enforcement Activit
The 46 inspections
conducted
during this assessment
period
identified approximately
66 cited violations and approximately
26
non-cited violations.
Although counted individually, many of those
violations were
common to multiple units.
The significant
violations are discussed
in the individual performance
analysis
sections of this report.
Fifteen of the violations identified during this assessment
period
involved Emergency Lighting and 10 CFR Part 50, Appendix R, Fire
Protection
Program violations,
and licensed operator medical
records
violations.
Those violations resulted in the imposition of a
$125,000
and
a $75,000 civil penalty respectively.
D.
AEOD Event Anal sis
The Office for Analysis and Evaluation of Operational
Data
(AEOD)
reviewed the licensee's
events
and provided the following input.
Arizona Public Service
Company submitted
28 Licensee
Event Reports
(LERs) for the three unitsl at Palo Verde, not including updates,
in
the assessment
period from November 1,
1989 to November 30,
1990.
The
AEOD review included the following LER numbers:
UNIT 1
UNIT 2
UNIT 3
89-021 to 89-024
90-001 to 90-008
89-011
90-001 to 90-009
90-001 to 90-006
The review of these
LERs follows:
1.
Im ortant
0 eratin
Events
None of the
LERs submitted in the assessment
period were
identified as important operating
events
by the
AEOD screening
and review process.
However, the review did not inclu'de the
reactor trip at Unit 3 on October 20,
1990 that resulted in all
steam
bypass
valves opening or the identification that the
'jacket water return line supports for both emergency
diesel
generators
at Unit 2 did not meet seismic qualifications
on
November 10,
1990 because
the respective
LERs have not been
received at the time of this review.
25
2.
AEOD Technical
Stud
Re orts
No AEOD technical
studies
were initiated from the reports
submitted
by Arizona Public Service Company'for Palo Verde
Units 1, 2,
and
3 in the assessment
period.
3.
Abnormal Occurrences
There were
no events classified
as
AOs at Palo Verde during
this period.
In.addition,
no events
were reported
as Appendix
C items ("Other
Events of Interest" ) in the quarterly
reports.
4.
~57472
2
4
The licensee
submitted
52 50.72 reports in the assessment
period.
Many of these reports
were duplicates for each unit.
These reports
were compared to the 50.73 submittals to
determine if the licensee is reporting all
LERs that they are
required to report.
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
5.
LER
ualit
The
LERs reviewed were professional
quality technical
reports.
The information was well organized,, detailed,
informative and
submitted
on time.
Many reports were updated
as
more
information became available.
t
~'M
( ~
l
0