ML17313A209
| ML17313A209 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 02/11/1998 |
| From: | Pellet J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | Kirsch D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| References | |
| NUDOCS 9802190187 | |
| Download: ML17313A209 (16) | |
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UNITEDSTATES NUCLEAR.REGULATORY. COMMISSION REGION IV 611 RYAN PLAZADRIVE, SUITE 400 ARLINGTON,TEXAS 760114064 ha February 11, 1998
SUBJECT:
Dennis Kirsch, Chief, Project Branch F h
FROM: 'ohn Pellet, Chief, Operations Branch, DRS ASSESSMENT FEEDER INPUT FOR OPERATIONS FUNCTIONALAREA FOR SALP ON PALO VERDE STEAM GENERATING STATION-4 Listed below are the feeder inputs from the Operations Branch for use in the subject SALP assessment:
Basis for Comment R 98-11 (draft) Operations personnel.
exhibited intra-and inter-organizational communication deficiencies that contributed to the acid spill event. This included a failure to log the abnormal occurrence (a significant volume of highly acidic liquid in a concrete trench) when it was identified the day before the acid spill.
IR 98-11 (draft) Operations personnel exhibited a lack of questioning attitude regarding the presence of a significant volume of unidentified liquid in the concrete trench containing piping running
'rom the sulfuric acid storage tanks and the neutralization tanks and the flowpath that was used for disposal ofthe 96 percent suifuric acid solution.
IR 9?W22 The lack of adequate-inter-departmental communications during concurrent work activities was a large contributor to the inadvertent dilution event in the Unit2 spent fuel pool.
Comment Operators chronically have exhibited event I
precursor behavior over two evaluation periods. 'In some cases that behavior has contributed to event initiation or complication.
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IR 97-015 Corrective actions to a 6/96 event, to prevent personnel from opening hatches in the main steam support structure while in Modes 1X were
.ineffective. As a result, a hatch was opened while Unit 3 was in Mode 1.
IR 97-014 Unit 1 operators opened drain valves on low pressure safety injection system A rendering it inoperable as a result of erroneous instructions provided by a control room supervisor (CRS). [Due to
- insufficient attention to detail on the part of i;,r-. the CRS.]
IR 97-014 Unit 3 operators bypassed the reactor protection low steam generator level signals instead of the required engineered safety features level signals.
[Less than adequate attention to detail by the Unit 3 operators.]
IR 97-005 Inconsistent implementation of operations communications standards:
particularly, the failure to consistently accomplish closed-loop communications during certain Unit 3 startup activities and weak-nesses in the thoroughness of logkeeping, particularly the failure to identify changes in major equipment status and plant problems in the logs.
IR 97-004 Communications between the control:room and other departments were not always thorough. [Evidenced by unexpected control room alarms during planned refueling outage work activities.]
IR 96-016 The Unit 1 operations midloop team did not ensure proper completion of all prerequisites prior to initiating the drain down of the RCS to reduced inventory. Afterit was identified that the lineup was incorrect, auxiliary operators (initial positioner and verifier) reperforming the valve lineup failed to identify an incorrectly positioned valve. This is a violation of requirements to follow procedures.
Both of these issues are repeat events from previous violations of the same plocedul e.
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IR 96-013 Operator performance, shift supervision command and control, and overall communications were not effective in preventing a SG overfill event.
IR 96-012 0'perations personnel demonstrated weakness in attention to detail; however, the resulting events had,minimal safety consequence.
SALP REPORT 96-99 Improvements were not'consistently demoristrated throughout the assessment period.
Instances of not being aware..of and attentive to plant conditions and system configuration, and lapses in the use of and compliance with procedures, were observed.
Operations Branch Input to last SALP - see attachment.
We believe that this is a long standing performance problem which we have poorly characterized and communicated.
Further, the licensee appears to be knowledgable of this problem but unable to correct it.
Ifyou have any questions, please contact me at extension 159 or S. McCrory at extension 265.
Attachment:
Operations Branch Input to 1996 SALP cc w/
Attachment:
A. Howell D. Chamberlain D. Corporandy S. McCrory e
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Operations Branch Input to 1996 SALP Attachment Dennis Kirsch, Chief, Project Branch F.
John Pellet, Chief, Operations Branch, DRS MEMORANDUMFOR:
FROM:
SUBJECT:
AREA FOR ASSESSMENT FEEDER INPUT FOR OPERATIONS FUNCTIONAL SALP ON PALO VERDE STEAM GENERATING STATION Listed below are the feeder iriputs from the Operations Branch. for use in the subject'SALP assessment:
Operators have exhibited procedure adherence/usage problems throughout the assessment period.
'R 94-'37 Operators failed to independently verify the
'osition ofthe essential chiller disconnects as required by procedure.
r IR 94-38 The operating crew failed to implement valve alignments required by procedure.
IR 95-03 Operators did not implement a procedure prerequisite when starting an essential cooling water pump.
IR 95-06 A standby gas turbine generator tripped during testing when operators did not followprocedures.
IR 95-16 An auxiliary operator failed to followan alarm response procedure and inadvertently discharged water from the gas stripper to the volume control tank.
IR 95-18 A control room supervisor reviewed the wrong section ofthe steam generator blowdown system procedure, which led to exceeding licensed thermal power.
IR 95-18 Operators failed to properly align and independently verify a valve required for reactor coolant system draindown.
IR 95-25 Operators failed to followthe shutdown margin procedure requirements to continue boration until reactor coolant system boron concentration was confirmed to meet shutdown margin requirements.
Operations Branch Input to 1996 SALP U
Attachment The command, control and communication skills of operators have been consistently noted as
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Communications effectiveness between operations and support organizations has been mixed.
IR9646 A reactor operator failed to followa procedure which resulted in a toss of offsite power and a loss ofshutdown cooling.
IR 95-01 Crew communication skills and discipline were
, evaluated as performance strengths.
IR 95-04,Overall command, control, and communications were good.
IR 95-06 Operators demonstrated good communications, and operations super vision
'emonstrated good command and control.
IR 95-15 The team observed generally good command, control and communications.
IR 96-22 Crew communications, command and control were good.
IR 96%5 The inspector observed the control room staff exhibit strong command and control while responding to a fire in Unit 2.
IR 9646.Operators demonstrated good command, control and communication during the shutdown of Unit 1.
IR 95-01 The communications and interface between the operations and training organizations had improved significantly.
IR 95-12 Excellent communications and coordination between operations and maintenance personnel in addressing an emergency diesel generator problem.
IR 95-26 Inadequate communications between the operations," maintenance and engineering organizations resulted in the failure to perform a required operability determination evaluation.
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Operations Branch Input to 1996 SALP Attachment Operators have repeatedly exhibited a to lack of attention to detail and a lack of awareness of plant conditions or response.
This b'ehavior has often resulted in performance errors that have created inoperability conditions and events that challenged plant" safety systems.
While behavior of this nature continued through the end of the assessment
- period, some positive performance was observed in the latter part of the assessment period, particularly on the part of non-licensed operators.
IR 95-14 Operators failed to properly evaluate and resolve an observed estimated critical rod position discrepancy prior to continuing with a reactor startup.
IR 95-14 Operators failed to properly evaluate and correct the cause of a control room annunciator until questioned by the NRC inspector.
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IR 95-15 A'generic weakness was iderltified in operator knowledge of the steam bypass control system, and application of that knowledge in an emergency event.
IR 95-15 A licensed reactor operator was removed from licensed duties as a result of poor panel operator performance during an examination for a senior reactor operator license..
IR 95-16 Operations management recognized that the cause of many of the performance problems was inattention to detail.
IR 95-16 Auxiliaryoperators in Unit 3 missed opportunities to promptly identify an adverse condition involving discharged breaker closing springs in the train B low pressure safety injection pump breaker.
IR 95-16 An auxiliary operator in Unit 3 improperly hung a clearance tag on the Train B low pressure safety injection pump breaker.
IR 95-16 An auxiliary operator in Unit 3 displayed a questioning attitude when working with maintenance personnel, but did not display a questioning attitude when dealing with the control room during a functional test of the emergency diesel generator.
IR 95-18 An auxiliary operator in Unit 3 displayed good attention to detail for identifying non-seismic qualified scaffolding in safety-related equipment rooms.
IR 95-18 A reactor engineer in Unit 3 displayed a lack of attention to detail resulting in a mispositioned fuel assembly in the spent fuel pool. Also, refueling personnel exhibited insensitivity towards a reactivity management issue.
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Operations Branch Input to 1996 SALP Attachment IR 95-1 8 A work control senior reactor operator in Unit 3 failed to properly review a work order clearance, resulting in a loss of reactor coolant system inventory.
IR 95-21 An auxiliary operator, attempting to close a pneumatically operated condenser vacuum breaker, did not meet licensee expectations in that he did not inform the control room prior to taking actions, nor had he previously identified an apparent deficient
. condition.
IR 95-26 A Unit 3 shift supervisor demonstrated a good questioning attitude prior to a moderator temperature coefficient test. The in depth questioning contributed to the Identification of excessively conservative shutdown margin calculations and an inaccurately drawn transient insertion limitcurve. In addition, the shift supervisor responded promptly to concerns regarding a deficiency with an EC valve which contributed to the discovery of other system control setpoint deficiencies.
IR 96-26 Operators failed to ensure that adequate precautions were taken prior to attempting to return a Unit2 condensate pump to service. As a result, a loss of pump suction caused the trip of both main feedwater pumps and a subsequent reactor trip.
IR 96W2 An auxiliary operator exhibited good attention to detail by identifying that bolts were missing or loose on the emergency diesel generator starting air manifold during a walkdown of the diesel.
IR 9642 Operators exhibited weak board awareness on two separate occasions.
IR 962 Nonlicensed operators demonstrated a
strong knowledge ofthe gas turbine generators.
IR 9645 An auxiliary operator exhibited good attention to detail by identifying a loose conduit on the Emergency Diesel Generator 1A
Operations Branch Input to 1996 SALP Attachment Operators have consistently performed midloop operations well.
Operators have responded satisfactorily to plant events.
However, the lack of proactive performance to reduce reliance on automatic protective actions has been questioned in the latter part of the assessment period.
IR 95-06 The use of dedicated midloop operators was seen as a positive step towards enhancing midloop operations.
The midloop operations crew in Unit 2 appeared to have a better understanding of the evolution and caught some errors made in the preparation for midloop.
IR 95-10 The Unit 1 midloop operation went'very smoothly. Inspectors observed a cautious approach to the evolution, with good crew briefings and well established command and control.
IR 95-21 Operators performed Unit 3 midloop operations in a controlled manner.The use of a designated midloop operating crew was seen as a strength.
Operator response to plant transients and trips was not directly addressed in reports in the early part of the assessment period even though there, were events of
'hat type. Performance is presumed to'have been satisfactory but unremarkable.
IR 95-21 Operator response to a Unit 1 loss of load transient and subsequent reactor trip and main steam isolation was adequate.
However, operations management plans to review expectations and guidance to operators concerning taking manual control of automatic systems and when to initiate manual scrams.
IR 96W2 Unit 2 operations'personnel performed a well coordinated downpower and plant stabilization after identification ofthe main transformer temperature alarm.
IR 96%2 Operators effectively responded to the main turbine trips in Units 1'and 3.
The most recent plan performance reports (96-01 8 96-02) remarked to operations performance declines: After reviewing information for the entire assessment period, it appears that the licensee has been marginal at best in improving performance that was identified as weak in the
. last SALP report. Procedural use and adherence, and individual operator performance (questioning attitude, attention to detail and plant awareness) continue to challenge the licensee.