ML18038A327

Rev 3 to Nine Mile Point Requalification Program Action Plan.

ML18038A327
Person / Time
Site:	Nine Mile Point
Issue date:	06/30/1990
From:	NIAGARA MOHAWK POWER CORP.
To:
Shared Package
ML18038A326	List: ML18038A325 ML18038A327
References
PROC-900630, NUDOCS 9009170174
Download: ML18038A327 (46)

Text

NMP2 REOUALIFICATION PROGRAM ACTION PLAN JUNE 1990 REVISION 3 00920 qpp9170174 ~ggpp410 PDP ADPCK PN P

NMP2 REQUALIFICATION PROGRAM ACTION PLAN The Nine Mile Point Unit 2 Operations and Operations Training Departments )3 underwent an evaluation of individual performances and of the requalification (

program during the weeks of July 17 and July 24, 1989. During this evaluation, 10 of 24 licensed operators failed one or more sections of the examination. In addition, 1/2 the crews (3 'of 6) exhibited sufficient deficiencies to warrant failure as teams by the Nine Mile Point Unit 2 evaluators. Based on this evaluation, Nine Mile Point Unit 2 implemented an )3 Action Plan to correct these deficiencies.

Our initial evaluation of the program revealed the specific issues discussed below. In addition, Niagara Mohawk has completed an independent assessment of the Unit 2 Requalification Program and'as identified the underlying root causes for these weaknesses. The Assessment Team recommended that four (4)

I additional actions contained in the report recommendations be included in the Unit 2 Requalification Action Plan. They further stated that nine (9) additional recommendations be seriously considered by NMPC. The four (4) subject actions are included on page 5 and 6 of the attached corrective action (3 list. Item 1.C.5 of the attached Requal Action Plan, which required NMPC to evaluate the remaining nine (9) recommendations, has been completed. Each 'of (

these recommendations has been evaluated and entered into the Nuclear Training Center Internal Tracking System as appropriate. I A follow up assessment has been conducted to review the adequacy of the (3 corrective actions taken. The six (6) recommendations from this report have been evaluated and entered into the Nuclear Training Center Internal Tracking System as appropriate for implementation.

The specific actions contained in this document are designed to correct the program, individual, and crew performance problems noted during the evaluation period, with particular emphasis on those issues of examination content and crew failures in the simulator. The specific issues include:

1. The NMP-2 Requalification Program was judged unsatisfactory by both NMPC and NRC.

-1 June 1990

2. Evaluation of the wri tten examination by the NMPC Instructional Technologist group raised concerns about examination structure.

3. Evaluation of the written examination by the NMP-2 Operations Instructional Group raised concerns about Operator knowledge deficiencies.

4. Neaknesses were noted in crew communications

5. STA involvement in plant assessment and event control was not consistent between crews Operator actions were not always in accordance with guidance as provided in the Emergency Operating Procedures (EOP's)

7. Operator actions were not always in accordance with guidance as provided in normal operating procedures during emergency events Dynamic simulator scenarios used in the evaluation were not always realistic, manageable and within the 50 minute standard as set forth in ES-601

9. Teamwork, including prioritization, of crew actions, evaluation of plant conditions and communications were weak during emergency events.

-2 June 1990

Specific Issue ¹1 Res onsibili ties -

~im 1. Date C~om . Date A. The NMP-2 Requalification Program was judged as unsatis-factory by the NMPC Training Department and the NRC, in that:

1. >2S% of the licensed operators (10 of 24) failed at least one section of the examination, failing overall.

2. >25/ of the licensed operators (7 of 24) failed the written examination.

3. >1/3 of the crews (3 of 6) failed the simulator team evaluation.

B. Corrective Actions Perform an examination analysis of the written (class- Sei fried N/A 7/29/89 room) examination.

2. Develop an exam development process description. Dort N/A 7/29/89

3. Perform an examination analysis of the simulator Smith/Heimer 7/26/89 examination.

Interview operators to determine: Montgomery 7/29/89

1) Reason for high failure rate.

2) Attitude concerning examination process.

Develop Plan and schedule for remediation and for Kaminski/Cigler/ N/A 7/29/89 evaluation of D Shift. Smi th Conduct evaluation of D Shift. Heimer/Smi th N/A 8/3/89 Analyze the cause of exam failures and develop Action Heimer 7/29/89 Plan to correct.

-3 June 1990

Specif ic Issue ¹1 (Cont'd): Res onsibili ties ~Im 1. Date

'0 C~om . Date

8. Conduct an independent assessment of the NMP2 Rivers 9/15/89 10/27/89.

Requalification Program which wi 11 include, but not be limited to, determining:

a. Why NMPC (Facility Management) was not able to detect the problems with operator performance and knowledge deficiencies (including BWR Power Oscillation concerns) prior to the NRC conducting the requalification examination and the underlying reasons why the deficiencies exist

b. .Determine whether the simulator scenarios were realistic and manageable and why NMP2 operators were not properly trained to handle complex emergency situations prioritization (Corrective Actions (9.B.10)

c. The extent to which organizational interface difficulties led to program deficiencies.

d. If there is/was an attitude problems with some operators.

e. Why NMPC failed to generate an examination bank of high quality written questions and simulator scenarios. (Corrective Actions 3.B.5 and 8.8.4)

f. Why NMPC failed to properly time-validate written examination questions and simulator scenarios.

(Corrective Actions 3.B.6 and 8.8.6)

-4 June 1990

Specific Issue ¹1 (Cont'd):

If the quality of the classroom/simulator training

~lt ibili i ~1. t ~tl g.

including training materials was adequately conducted during the 19&8/1989 Requalification Program.

h. If training and evaluation adequately addressed operator knowledge/performance weaknesses.

i. If the NHP2 Requalification Program Action Plan adequately addresses all issues pertaining to the Requalification Program and individual operator failures.

9. a. Prepare a summary of "lessons learned" to prevent Rivers/Abbott N/A 10/29/89 recurrence.

b. Develop a process to ensure that lessons learned Abbott/Dahlberg 1/2/90 3/30/90 at Unit 1 (Unit 2) are communicated to Unit 2 (Unit 1).

10. Conduct a followup independent assessment to measure the Rivers 4/1/90 4/30/90 effectiveness of the actions taken in this action plan.

ll. Prepare a "lessons learned" transmittal to address the Rivers/Abbott 10/1/89 11/1/89 importance of ensuring that upper level management is aware of and agrees with major program changes.

C. Corrective Actions/Independent Assessment Report

l. Develop an integrated plan which includes completion of Sei fried N/A 10/31/89 the SAT Project, upgrading of training material and completion of the Examination Bank.

-5 June 1990

0 0

Res onsibilities ~Im 1. Date ~Com . Date Develop and implement a simulator instructor training Seifried 11/2/89 3/31/90 program which incorporates Operations and Training management standards and expectations.

Develop, implement and commit to a schedule which wi 11 Rivers/Willis/ N/A 12/1/89 ensure that Operations and Training Management partici- Peifer pate in the observation and evaluation of requalifi-cation training.

Establish a Unit ¹2 OTPAC and a Site Training Advisory Abbott/Wi 1 1 i s/ N/A OTPAC 10/27/89 Board (TAB). . Peifer TAB 12/8/89 Evaluate Unit 2 Independent Assessment Report recommen- Rivers/Willis 2/28/90 dations 4.5 through 4.17. Incorporate those accepted Peifer into the internal training action item tracking system with the appropriate schedule for implementation.

-6 June 1990

Specific Issue ¹2: Res onsibi i t 1 ~Im i. Date C~om . Date Evaluation of the written examination by the NMPC Instruc-tional Technologist Group resulted in several concerns, in that;

1. Test item construction is not clear.

2. Point values for multiple part answers were not specified.

3. Several double jeopardy questions were noted.

4. Questions requiring multiple responses were not separated out.

B. Corrective Actions Provide training to Operations Training Instructors LeCl air N/A 3/1/90 involved in writing open reference examinations, on examination development techniques (i.e., test taking, test construction, and question construction).

Review all current examination questions contained LeCl air 1I2I90 4/30/90 within the requalification examination bank for format and correlation to learning objectives. Formalize this process in a Training Instruction.

Review all future annual requalification written exami- LeClair 1/2/90 4/30/90 nations for format and organization prior to examination implementation. Formalize this process in a Training Instruction.

4. Formulate a plan to complete the Systematic Approach to Neimer/Smi th N/A 10/31/89 Training Process.

-7 dune 1990

Specific Issue ¹3:

A. Evaluation of the written examination for knowledge area deficiencies by the NMP-2 Operations Training Group raised the following concerns, in that;

1. SRO's experienced difficulty in;

a. Determining the actions necessary for a loss of Stator Cooling Water when less than the runback setpoint.

b. Selecting the necessary response to a short period annunciator.

Determining Primary Containment Isolation Setpoints for various isolation groups.

Understanding operations of the EHC system Load Limiter Set.

e. Determining the capacity/limitations for operation with one Reactor Feed Pump.

Determining Limiting Plant Conditions on a loss of 2NPS-SWG003.

g. Determining possible scram signals as a result of a Loss of Instrument Air.

Causes and Effects of Reactor Level Swell.

Calculating single Loop MAPLHGR.

Determining Pressure response to an MSIV isolation following a reactor scram.

-8 June 1990

0 Specific Issue ¹3 (Cont'd):

2. Both SROs and ROs experienced difficulty in;

a. Ascertaining Operator actions on a loss of Low Pressure Feed Heater string.

b. Determining the actions necessary for a sympathetic alert.

c. Describing the EOP basis which allows for HSIV re-opening during an ATNS.

d. Defining the effects of Loss of Extraction Steam on Reactor Power.

e. Calculating total core flow when in a single loop configuration.

f. Ascertaining the negative response time of the Turbine Control Valves and the Turbine Control

.Valve Setpoint.

g. Determining the followup actions required following a Circulating Hater Pump Trip.

3. ROs experienced difficulty in;

a. Determining Operator actions on a loss of RBCLC.

b. Ascertaining the steps necessary to override Con-tainment Purge Valves following isolation.

c. Ascertaining the steps required to place CSH System in a Tank to Tank Lineup following initiation.

d. Determining immediate actions on a Loss of H2 Seal Oi l.

-9 June 1990

Specific Issue ¹3 (Cont'd): Res onsibilit ~li. t C~i. 0 t

e. Recognizing indications of an OFG H2 Explosion.

f. Determining notifications required as a communi-cations aide.

g. Recognizing EOP entry conditions for an ATWS situa-tion.

h. Recognizing feedwater effects on Reactor Pressure.

Describing plant response on a Loss of Vacuum.

Identifying limitations placed on operation of Main Condenser Vacuum Breakers.

B. Corrective Actions Review examination results with all licensed operators Kaminski N/A 7/31/89 requiring remediation.

2. Develop a Remediation Plan for examination failures Kaminski N/A 7/31/89 to be conducted between 8/1/89-8/15/89.

Perform re-examination of all examination failures Weimer/Smi th 8/16/89 8/18/89 between 8/16/89-8/18/89.

4. a. Include all questions where >20/ of examinees Weimer N/A 3/20/90 missed the item into the 1990/1991 year Requalification Program Schedule.

b. EOP weaknesses and usage deficiencies will be Weimer 8/21/89 10/6/89 reviewed with all Licensed Operators (See 6.B.l, 6.B.2 and 7.B.l)

5. Analyze the quality of written examination questions Rivers 9/15/89 10/27/89 used in the Requalification Program examinations. (See Corrective Action 1.B.B.e)

6. Determine why NMPC failed to properly time validate Rivers 9/15/89 10/27/89 written examination questions (See Corrective Action 1.B.8.f)

-10 June 1990

Res onsibi i t 1 ~Im I. Date ~Com . Date Specific Issue //4:

A. Heaknesses were noted in crew communications, in that:

l. Operators used inprecise language

2. Directions were non specific

3. Reports/directives were not always acknowledged

4. Repeatbacks were often not noted or weak.

5. Orders were not directed at one individual, sometimes resulting in no accountability.

B. Corrective Actions

1. Train operators, in the simulator, to ODI 1.06, Verbal Ci gl er 7/31/89 10/6/89 Communications.

Train instructors in ODI 1.06, Verbal Communications, Cigler 7/31/89 8/21/89 and reinforce the policy to train to these standards during simulator training.

Develop a program by which observations will be Hillis/Peifer 8/21/89 5/14/90 conducted by management personnel (e.g. General Superintendent, Station Superintendent, Operations Superintendent and/or other Operations Management Staff) during each Requalification Cycle that includes simulator training. Include direction for implementing this program in a Training Department Procedure or Instruction.

-11 June 1990

Specific Issue ¹4: (Cont'd) Res onsibilit ~Im 1. Date ~Com . Date 4, Develop a program by which observations will be Peifer 8/21/89 5/14/90 conducted by management personnel (e.g. Manager Nuclear Services, Superintendent of Training, Assistant Superintendent of Training and/or other Operations Training Staff) during each Requalification Cycle that includes simulator training. Include direction for implementing this program in a Training Department Procedure or Instruction.

Schedule the Unit 1 training instructors to evaluate a Neimer/Sanaker 10/2/&9 5/2/90 selected crew at least once per quarter during 1990 and provide report to Operations Superintendent. Include a task to reevaluate effectiveness at end of 1990 into the Nuclear Training Center Internal Commitment Tracking System.

Establish a Training Program for Simulator Instructors Seifried 10/9/89 3/31/90 in the use of video tape in post simulator exercises to more effectively critique communications teamwork and prioritization.

7. Investigate feasibility of establishing cross crew Heimer/Smith 10/2/89 1/31/90 evaluations.

-12 June 1990

Specifi e ¹5: Res onsibi lit ~Im 1. Date ~Com . ate A. STA involvement in plant assessment and event control was not consistent between crews, in that;

1. Some STA's provided little or no assessment of events to the SSS/SED other than updating parameters and classifying events.

2. Some STA's did not provide the SSS with support in ensuring all EOP actions were completed.

3. Some STA's did not correct inappropriate actions or recommend appropriate actions.

B. Corrective Actions Formalize management expectations (beyond what is Smith/Abbott N/A 7/28/89 defined in EPP's and AP's) for the actions of the STA during EOP's.

Train STA's (all SRO's) in the standard during Cigler 7/31/89 10/6/89 simulator training.

Train instructors in the standard and reinforce the Cigl er 7/31/89 8/21/89 policy to train to these standards during simulator training.

4. Develop a program by, which observations will be Wi 1 1 is 8/21/89 5/14/90 conducted by management personnel (e.g. General Superintendent, Station Superintendent, Operations Superintendent and/or other Operations Management Staff) during each Requalification Cycle that includes simulator training. Include direction for implementing this program in a Training Department Procedure or Instruction.

-13 June 1990

Specific e //5: (Cont'd) Res onsibilit ~lm 1. Date Com . ate . [3

5. Develop a program by which observations will be Peifer 8/21/89 5/14/90 conducted by management personnel (e.g Manager Nuclear

~

Services, Superintendent of Training, Assistant Superintendent of Training and/or other Training Staff) during each Requalification Cycle that includes simulator training. Include direction for implementing I3 this program in a Training Department Procedure or I Instruction. I Schedule the Unit 1 training instructors to evaluate Heimer/Sanaker 10/2/89 5/2/90 I implementation of standards on a Unit 2 selected crew at least once per quarter during 1990 and to provide a report to the Operations Superintendent. J3 Investigate feasibility of establishing cross-crew Heimer/Smi th 10/2/89 1/31/90 I evaluations. I

8. Schedul e the Uni t 1 and Uni t 2 Operations Heimer/Randall 10/2/89 5/14/90 I Superintendents to evaluate team performance of selected opposite plant crews during the 1990-1991 Requal Program. [3 I

f3

-14 June 1990

Specific e ¹6: Res onsibi i t 1 ~Im l. Date Co te A. Oper actions were not always in accordance with Gui e as provided in the EOP's, in that;

l. One crew violated EOP's by securing Standby Liquid Control pumps with all rods not in following an ATWS, although the RO's knew it was not an appropriate action.

2. One crew never implemented vessel flooding in accordance with EOP's, although the STA knew or suspected that conditions were met and the requirement existed.

3. Five (5) crews failed to adequately control water level n-"by~Ill <<1. f i ltd with RO's and one (1) SRO as to what normal water level was in the EOP's. In three (3) events, the water level rise was slow and controlled.

4. One (1) SRO fai 1 ed to ful ly impl ement guidance for vessel flooding.

5. Two (2) SRO's failed to recognize that a diamond decision block is not an action statement, in that; when asked if 3(2)SRV's could be open they opened 3(2)

SRV's when procedurally 7 were to be opened.

6. One RO suspected that an order to open 2 SRV's was incorrect, but did not question the SSS because he believed the SSS was being guided by EOP's.

8. Corrective Actions

l. a. Develop and ~im lement a 2-3 day EOP refresher Williamson 8/21/89 10/6/89 training session on EOP usage and bases. This training should emphasize the significance of water level control and overfilling events.

-15 June 1990

Specific ue ¹6: (Cont'd) Res onsibi i t 1 ~lm 'I. Date 'o te

b. Ensure development and implementation of lesson Hilliamson 1/2/90 1/24/90 plans covering those portions of mitigation of Core Damage not covered in EOPs by tracking these tasks through completion with the Nuclear Training Center Internal Tracking System.

Review specific EOP usage deficiencies and problem Nilliamson/ 8/21/89 10/6/89 areas noted during the requal examination with all Cigler licensed operators during the EOP refresher training.

This will include requirement of RO's to question perceived inappropriate orders.

Include EOP basis questions during the remainder of the Kaminski 10/2/89 12/31/89 1988/1989 requalification program.

Develop a program by which observations wi 11 be Hi 1 1 i s 8/21/89 5/14/90 conducted by management personnel (e.g. General Superintendent, Station Superintendent, Operations Superintendent and/or other Operations Management Staff) during each Requalification Cycle that includes simulator training. Include direction for implementing this program in a Training Department Procedure or Instructions Develop a program by which observations will be Peifer 8/21/89 5/14/90 conducted by management personnel (e.g. Manager Nuclear Services, Superintendent of Training, Assistant Superintendent of Training and/or other Operations Training Staff) during each Requalification Cycle that includes simulator training. Include direction for implementing this program in a Training Department Procedure or Instruction.

-16 June 1990

Res onsibi i t 1 ~Im 1. Date ~Com . ate Establish formal management expectations for EOP usage, including communications, command control, and STA Smith/Abbott N/A 7/28/89 responsibilities in carrying out EOP's.

Specific Issue ¹7:

A. Operator actions were not always in accordance with Guidance as provided in normal operating procedures during emergency events, in that;

1. Some crews had difficulty in carrying out N2-0P-97, Section H.2 per EOP-RQ.

2. Although crews could work through OP-29 during a recirc pump trip and recovery, two crews wasted 45 minutes doing administrative tasks that were not necessary and one crew did not realize a recirc pump could not be started in the restricted zone and drove recirc flow further into the zone in an attempt to restart the pump. (Observed during NMPC Evaluation Week)

3. Several RO's did not correctly place RHR in SP Cooling or DW/SP Spray when required in an emergency situation.

B. Corrective Actions:

Review specific deficiencies concerning EOP required Williamson/ 8/21/89 10/6/89 actions during EOP refresher training. Cigl er

2. Identify those Simulator JPH's that should be able to Brown/Smith N/A 1/2/90 be performed without the use of a procedure and include 1990/1991 Requal Program.

Establish formal management expectations for Smith/Abbott N/A 8/21/89 verification of immediate actions taken during emergency conditions.

-17 June 1990

Specific ue ¹8: Res onsibilit ~Im 1. Date Co te A. Dyna imulator scenarios used in the evaluation wer t always realistic, manageable and within the 50 minute standard as set forth in ES-601, in that:

1. One scenario involved an ATNS following an NSIV isolation due to failed fuel (>3XNFPB isolation). In addition, the SDV ruptured in the Reactor Building causing a direct leak from the vessel to the secondary containment. The SSS was in 14 different EOP's.

a. This scenario was beyond the boundaries of the NMP2 FSAR.

b. This scenario was unmanageable in that two crews took manual pressure control as directed by EOP's, then required the same operator to inject with both SLC pumps. Both crews lost control of manually overridden automatic functions resulting in vessel depressurization and subsequent overfill.

2. All scenarios exceeded the 50 minute time guidelines.

B. Corrective Actions:

Develop a plan to implement each of the 15 exi sting Kaminski 1/2/90 1/30/90 scenarios into the 1990/1991 requalification program Revise each of the 15 existing scenarios as necessary Kaminski 1/2/90 2/21/90 and validate during the 1990/1991 Requal Program.

Schedule the development of 10 new 50 minute scenarios Kaminski 10/9/89 6/19/90 by incorporating into the 1990/1991 Requal Program Schedule.

-18 June 1990

Specific ue ¹8: (Cont'd) Res onsibilit ~tm 1. Date "Co te yze the quality of simulator- scenarios us n Rivers 9/15/89 10/ 9 Requalification Program examinations. (See Corrective Action 1.B.S.e)

5. Determine whether the simulator scenarios used in the Rivers 9/15/89 10/27/89 Annual Requalification were realistic and manageable.

(See Corrective Action 1.B.8.b)

6. Determine why NHPC was unable to properly time validate Rivers 9/15/89 10/27/89 simulator scenarios used in the Annual Requalification Examination. (See Corrective Action 1.B.S.f)

-19 June 1990

Specifi e ¹9: Res onsibi lit ~Im 1. Date ~Com . ate A. Teamwork, including prioritization, evaluation and communication, were weak, in that:

1. Several crews tended to "cluster" around problems.

2. One crew took an action in violation of EOP's even though the Reactor Operator knew the action was incorrect.

Several crews allowed alarms to continue for up to ten (10) minutes, trying to verbally communicate above the alarm noise during EOP's.

4. Some crews SSS'ere not aware of sources of water that were injecting into the vessel causing overfill.

Several crew members did not effectively screen plant parameters to ensure pertinent EOP parameters were communicated to the SSS.

Several STA's were more concerned with classification of events than assessment of plant conditions.

SSS'id not always effectively prioritize crew actions during EOP's.

Two crews did not correctly evaluate system status of recirc pumps being tripped prior to drywell spray being initiated.

9. Some RO's did not effectively communicate their actions so that other members could react (i.e. Rod Insertion following an ATNS that directly impacted vessel depressurization).

B. Corrective Actions:

Establish formal management expectations for the roles Smith/Abbott N/A 7/28/89 and responsibilities of crew members during emergency conditions.

-20 June 1990

Specifi e ¹9: (Cont'd) Res onsibilit ~Im l. Date C~om . ate

2. Incorporated into 9.8.3.

3. Train instructors and crews to the standard and Cigl er 7/31/89 8/14/89 reinforce during simulator training.

Establish a requirement to perform team evaluations on Sei fried 10/2/89 4/30/90 each crew each requalification training cycle that includes simulator training and individual evaluations twice per year.

5. Develop a program by which observations will be Ni 1 1 is 8/21/89 5/14/90 conducted by management personnel (e.g. General Superintendent, Station Superintendent, Operations Superintendent and/or other Operations Management Staff) during each Requalification Cycle that includes simulator training'nclude direction for implementing this program in a Training Department Procedure or Instruction.

Develop a program by which observations will be Peifer 8/21/89 5/14/90 conducted by management personnel (e.g. Manager Nuclear Services, Superintendent of Training, Assistant Superintendent of Training and/or other Operations Training Staff) during each Requalification Cycle that includes simulator training. Incl.ude direction for implementing this program in a Training Department Procedure or Instruction.

Schedule the Unit 1 instructor(s) to evaluate Neimer/Sanaker 10/2/89 5/2/90 implementation of standards on a selected crew at least once per quarter during 1990 and to provide a report to the Operations Superintendent.

-21 June 1990

V Specific e ¹9: (Cont'd) Res onsibi i t 1 ~Im 1. Date C~om . ate

8. Investigate feasibility of establishing cross-crew - Heimer/Smi th 10/2/89 1/31/90 evaluations.

9. Schedule the Unit 1 and Unit 2 Operations Superintendent Heimer/Randall 10/2/89 5/14/90 to evaluate team performance of selected opposite plant crews during the 1990-1991 Requal Program.

10. Determine the reason for operators inability to handle Rivers/Smith 9/15/89 10/27/89 complex emergency situations. (See Corrective Action 1.8.8.b)

-22 June 1990