ML18038A457
| ML18038A457 | |
| Person / Time | |
|---|---|
| Site: | Nine Mile Point  |
| Issue date: | 04/12/1989 |
| From: | Capra R Office of Nuclear Reactor Regulation |
| To: | Boger B Office of Nuclear Reactor Regulation |
| References | |
| NUDOCS 8904180071 | |
| Download: ML18038A457 (22) | |
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+**y4 UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20555 April 12, 1989 Docket Nos.
50-220 and 50-410 MEMORANDUM FOR:
Bruce A. Boger, Assistant Director for Region I Reactors Division of Reactor Pro'ects I/II FROM:
SUBJECT:
Robert A. Capra, Director Project Directorate I-1 Division of Reactor Projects I/II COMPARISON OF THE 1986 NMP-1 I&C TECHNICIAN ALLEGATIOI'IS WITH RESULTS OF 1989 NMP I/2 SPECIAL TEAM INSPECTION FINDINGS As requested by the Deputy Director, NRR, we have compared the preliminary findings of the March 1989 NRR Special Team Inspection (STI) at Nine Mile Point Units I and 2
(NMP I/2) with the July 1986 allegations made by an NMP-1 Instrument
& Control (I&C) technician.
The purpose of the comparison was to determine whether any of the original allegations were still found to exist.
In order to put this comparison in perspective, it must be recognized that the 1989 NRR STI did not specifically review the original I&C Technician's allegations.
It is also necessary to understand the licensee's and NRC's actions taken in response to the allegations and to understand what has taken place at NMP between the time of the allegations in July 1986 and the NRR STI in February/March 1989.
Enclosure I provides a chronological summary of major actions associated with the allegations and related programmatic issues from July 1986 through March 1989.
The I&C Technician's allegations (see Attachment A to Enclosure
- 1) were independently evaluated in 1986 by a Region I Special Team Inspection.
The team concluded that most of the circumstances described in the allegations were substantially true, but the technical significance of the substantiated allegations was found to be generally minor and no immediate safety concerns were identified.
However, the team did conclude that there were some major programmatic weaknesses in the NMPC management system that allowed these problems to develop and go unresolved.
Since the majority of the IIC Technician's concerns were very specific technical allegations, there is no direct comparison between the original I&C Technician's allegations and the preliminary listing of significant findings from the 1989 NRP. STI (see Attachment B to Enclosure 1).
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- However, as with the 1986 RI STI, many of the the preliminary findings from the 1989 NRR STI represent continued deficiencies in organizational effectiveness and procedural inadequacy and noncompliance, and are examples of why NMP-I has remained shutdown under Confirmatory Action Letter.
These broad programmatic weaknesses at NMPC, particularly at NMP-1, have been documented consistently in NRC inspection reports and in the licensee's own internal audits and self-assessments.
These include inspections and audits prior to the allegaticns such as the Construction Assessment Team report (CAT) of NMP-2 in January 1984 and the Management Analysis Company (MAC) report of NMP-2 in March 1985.
Specifically, the 1986 STI indicated that procedural inadequacy and noncompliance were contributing factors to many of the technical allegations substantiated by the inspection team.
The 1989 STI reaffirmed that this major weakness still existed at both units, particularly in the areas of operations, surveillance testing and maintenance.
following the 1989 STI, NMPC clarified existing corporate and station policy regarding procedural adherence and conducted additional training on this subject prior to the April 1989 Unit 2 startup from their midcycle outage.
The 1986 STI found that methods used to identify shortcomings and potential problems had not been implemented and consequently, problems identified by NMPC staff were not always brought to management attention for resolution.
The 1989 STI found examples of simi lar problems still occurring in surveillance
- testing, maintenance, design 'change control, corrective action programs, training and onsite and offsite committee activities.
The 1986 STI also found that organizational ineffectiveness, manifested in weak NMPC review methods and management oversight, limited their ability to accurately identify problems and evaluate program effectiveness.
The licensee recognized these problems and effected various corporate and site management
- changes, including the hiring of a new Executive Vice President - Nuclear Operations in October 1988, to implement increased oversight of station operations.
Although some progress has been
- made, the 1989 STI identified that many organization effectiveness issues remain to be resolved.
The 1986 STI found that the operational quality assurance (gA) program was ineffective in helping the line organization to identify and correct problems.
The 1989 STI found that while the gA surveillance organization provided good performance-based findings, shortcomings still existed in the gA Audit program.
The team found that audit schedules were slipping, the auditor training program was weak, the gA Audit Group was understaffed, unaware of current issues and unable to proactively audit plant activities.
In summary, the 1989 NRR STI did not identify recurrence of any specific issues originally identified as part of the 1986 I&C technician allegations.
- However,
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many issues dealing with'program weaknesses and organizational effectiveness identified during >the 1986 RI STI were also identified during the 1989 STI indicating that corrective actions were largely inadequate.
These items have been identified for. resolution in the licensee's Restart Action Plan and Nuclear Improvement Plan.
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Enclosure:
As stated Robert A. Capra, Director Project Director I-1 Division of Reactor Projects I/II cc w/enclosure:
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ENCLOSURE 1
COMPARISON OF THE 1986 NMP-I ISC TECHNICIAN ALLEGATIONS WITH RESULTS OF 1989 NMP-I/2 SPECIAL TEAM INSPECTION FINDINGS PURPOSE:
As requested by the Deputy Director, NRR, we have compared the preliminary findings of the March 1989 NRR Special Team Inspection (STI) at Nine Mile Point Units I and 2
(NMP I/2) with the July 1986 allegations made by a NMP-I Instrument 5 Control (15C) technician.
The purpose of the comparison was to determine whether any of the original allegations were still found to exist.
In order to put this comparison in perspective, it must be recognized that the 1989 NRR STI did not specifically evaluate followup of the original 18C Technician's allegations.
It is also necessary to understand the licensee's and NRC's actions taken in response to the allegations and to understand what has taken place at NMP between the time of the allegations in July 1986 and the NRR STI in February/March 1989.
This comparison provides a chronological sugary of major actions associated with the allegations and related programmatic issues from July 1986 through March 1989.
INITIAL NRC ACTIONS REGARDING THE IKC TECHNICIAN ALLEGATIONS:
On July 11, 1986, while observing maintenance on local power range monitor (LPRH) connectors at NMP-l, the NRC Resident Inspector received allegations concerning the connector qualifications and installation techniques from an IKC technician.
The technician subsequently met with NMPC to convey his concerns.
On July 22, 1986, the technician came to the NRC Region I office to discuss his concerns.
Following the transcribed
- meeting, he provided a
sworn statement regarding his concerns.
On August 11, 1986, the NRC sent a letter to NHPC enclosing a summary of the I&C technician's a'/legations (Attachment A).
The letter acknowledged the ongoing NMPC investigation into the concerns and requested a written report on the results.
In a letter dated August 15, 1986, NMPC outlined its approach to investigation of the allegations and provided a
summary report of the investigations and associated conclusions.
NMPC concluded that no activities were found which would jeopardize the safe operation of the station.
A meeting was held with NMPC in the regional office on August 18, 1986 to discuss the findings.
By a follow-up letter dated August 31, 1986 NMPC provided:
(1) its investigation findings relative to the allegations, (2I its evaluation methodology, (3) its proposed short-tenn and long-term remedial actions, and (a) its means to measure the effectiveness of those actions.
REGION I FOLLOWUP ACTIONS:
Between August 25-29, 1986 a Region I special team inspection (STI) independently examined the I&C technician's allegations related to operations, surveillance, maintenance and quality programs at NMP-1.
For each allegation, the inspection reviewed the allegation, determined the basic concern, and focused on the root cause of the technical issues from the perception of the NRC to assess the impact on Unit I and 2 programs.
The inspection also reviewed portions of NMPC's investigation of the allegations to assess its effectiveness.
Also, an evaluation of the quality assurance programs at Units I and 2 was performed to evaluate the ability of these programs to identify and correct the problems associated with the allegations.
RESULTS OF THE 1986 REGION I SPECIAL TEAM INSPECTION:
The results of the Region I STI were documented in a combined inspection report issued January 22, 1987 (50-220/86-17; 50-410/86-61).
The team concluded that most of the I&C Technician's allegations were found to be factually correct;
- however, the individual safety implications were determined to be minor and no immediate safety concerns were identified.
Nevertheless, the team did conclude that there were some programmatic weaknesses in the NMPC management system that needed to be addressed.
In particular, the team concluded that:
1.
Methods within the organization to identify shortcomings and potential problems have not been effectively implemented.
As a result, problems identified by NMPC staff are not always brought to the attention of management for resolution.
2.
Once issues are identified, there are weaknesses in the NMPC review methods and management oversight which in some cases effect the ability to:
- determine contributors to the problems or event,
- identify the root causes, and
- evaluate the impact on broad program effectiveness.
3.
The NMPC Operational Quality Assurance (QA) program was not as effective as it should be in helping the line organization to find and correct problems.
The inspection team acknowledged the alleged harassment of the I&C technician by his peers and supervisor for bringing these issues to NMPC QA and to the NRC.
- However, as documented, in an NRC letter dated August 18, 1989, the NRC recommended that these issues be presented to the U.S. Department of Labor (DOL) by the alleger and that further NRC action would be dependent upon DOL action and NRC review of'he final NMPC investigation report..
I'
ENFORCEMENT ACTION STEMMING FROM THE ALLEGATIONS:
As a result of the Region I special team inspection report and two other inspections related to the allegations, an Enforcement Conference was held on February 19, 1987.
A Notice of Violation and Proposed Imposition of Civil Penalty was issued on April 29, 1987.
The letter of transmittal identified underlying weaknesses in the control of licensed activities at Unit l.
In particular:
(I) problems identified by NMPC staff were not always brought to the attention of management for resolution; (2) problems were not adequately analyzed to determine their root causes; (3) corrective actions taken for identified problems lacked thoroughness and depth; and (4) the guality Assurance Department had not been effective in assisting the line organizations in identifying and correcting problems.
The specific violations included numerous examples of failure to follow station procedures when performing maintenance and surveillance testing, and when controlling measurement and test equipment; failure to properly evaluate test results; failure to perform adequate radiation surveys; failure to follow procedures for personnel radiation protection; and failure to provide adequate radiation surveillance in the work area.
The transmittal letter stated that these weaknesses further demonstrated an apparent complacent attitude among certain members of the NMPC staff which may have contributed to declining performance and an increase in the number of operational problems at Unit 1.
Additionally, the violations also indicated NMPC's system for resolving employee concerns was inadequate in that the IAC technician had discussed his concerns with supervision prior to contacting the NRC, but timely and effective action was not taken to analyze and resolve his concerns.
In the aggregate the issues were classified as Sever ity Level III and a
cumulative
$50,000 Civil Penalty was assessed.
NMPC'S
RESPONSE
TO THE ENFORCEMENT ACTION STEMMING FROM THE ALLEGATIONS:
On May 19, 1987, NMPC responded to the April 29, 1987 Notice of Violation and Proposed Imposition of Civil Penalty.
In its response, NMPC stated that it had taken extensive actions to resolve each deficiency discussed in the NOV and to develop or enhance programs to prevent recurrence.
As a long-term
- measure, NMPC implemented a formal Management Effectiveness Program.
This program included the following: developing of Division policy statements and charters; streamlining of procedures; identifying individual responsibility and accountability; and measuring success and providing feedback to management on performance and problems.
The next few pages discuss the major activities that took place between closeout of the IKC technician concerns and the NRR STI.
P'
INEFFECTIVE CORRECTIVE ACTIONS - ADDITIONAL CONCERNS:
As a result of a major feedwater system transient, Unit 1 was manually scrammed on December 19, 1987.
The Unit has remained shutdown since that time.
In October 1987, deficiencies in the licensee's 'ISI program were identified by the NRC.
Discrepancies known by the licensee to exist during the 1986 refueling outage were not properly reconciled prior to the end of that outage.
In 'January 1988, during a review of records, the licensee determined that many other inspections had been missed.
To complete these inspections, the licensee decided to enter the 1988 refueling outage early.
On January 7, 1988 an Enforcement Conference was held to discuss the ISI deficiencies.
On March 14, 1988, a Notice of Violation and
$ 100,000 Civil Penalty was issued as a result of ISI deficiencies.
An inspection of the licensee's licensed operator requalification program, conducted during January 1988, revealed discrepancies in their requalification training program.
On March 13, 1988, Confirmatory Action Letter (CAL) 88-13 was issued to formalize the licensee's actions to correct the problems identified with the requalification program for licensed operators.
In March 1988, the licensee discovered that numerous safety-related fire barrier penetrations were not properly sealed.
An Enforcement Conference was held on July ll, 1988.
However, after considering the matter, escalated enforcement action was determined to be inappropriate and two Severity Level IV violations were issued.
In June
The results of this inspection showed that the operators lacked knowledge of the EOPs and their use.
JUNE 1988 SENIOR,MANAGEMENT MEETING AND ISSUANCE OF CAL 88-17:
At the June 1988 NRC Senior Management Meeting (SHH), NHP-1 was added to the list of facilities requiring closer NRC monitoring.
At the meeting, it was determined that NMPC's actions represented a trend in performance that was of significant concern to the NRC.
In particular, the most recent SALP report expressed concern about leadership weaknesses and NMPC's failure to seek out and correct technical and management problems before they became regulatory concerns.
It was also noted that previous licensee efforts to bring about long-term changes in performance at NMP-1 had met with limited success and that NRC was concerned regarding the lack of 'a comprehensive plan to correct the root causes of major program deficiencies including inservice inspection, fire protection, emergency procedures, and operator training issues to support restart of Unit 1.
On July 25,
- 1988, a meeting between NMPC and Senior NRC Managers was held on site.
At the meeting, CAL 88-17 was delivered.
With the issuance of CAL 88-17 (which superseded CAL 88-13)
NMPC agreed that the following actions would be taken prior to restart of Unit I:
Determine and document the root cause(sl of why NHPC management has not been effective in recognizing and remedying problems.
Prepare a proposed restart action plan (RAP) and submit it to the NRC for review and approval.
The RAP should document and justify short-and long-term actions to address the identified root cause(s).
Provide a written report relative to the readiness of NMP-I for restart.
Include in the report, the bases for readiness to restart, a
self-assessment of RAP implementation, and conclusions regarding whether NMPC's current line management has the appropriate leadership and management skills to prevent, or detect and correct, future problems.
On July 20, 1988, the licensee formed a Restart Task Force to act as the focal point in completing the actions required by CAL 88-17.
DECEMBER 1988 SENIOR MANAGEMENT MEETING:
At the December 1988 SHM, NHPC's activities to develop a comprehensive plan to address actions required by CAL 88-17 were discussed along with recent corporate and site management changes.
In addition, the first year of Unit 2's operating history was discussed.
Because of Unit 2's overall performance with respect to scrams, safety system actuations, design deficiencies, recent personnel
- errors, and since Units 1 and 2 have common senior management and technical support organizations, it was determined that Unit 2 also warranted closer monitoring by the NRC.
As a result of the SMM, it was also determined that part of the closer NRC monitoring would include an NRR Special Team Inspection.
SUBMISSION OF THE RESTART ACTION PLAN AND DEVELOPMENT OF TME NUCLEAR IMPROVEMENT PLAN (NIP):
On December 22, 1988.
NMPC met with the NRC Staff and presented its Restart Action Plan (RAP).
The RAP contains items that must be corrected prior to Unit 1 restart.
The licensee has also developed a Nuclear Improvement Plan.
The NIP contains issues which must be resolved by NMPC but are not required to be completed prior to Unit 1 restart.
Many of the management and program issues identified by the staff in CAL 88-17 were the same as the issues originally identified fn the NRC's follow-up to the I8C Technician's allegations.
Therefore, one of the major staff concerns regarding the RAP,
I was to understand why the licensee believed the RAP would succeed in light of the failure of the program developed to address the I&C technician allegations.
In addressing this issue in the RAP, the licensee stated that it believes that shortcomings in past initiatives resulted from deficiencies in management and organizational effectiveness as evidenced by the absence of buy-in by line management; resources applied to NMP-2, at the expense of NMP-I; too narrow a focus in identifying root causes and corrective actions; and too short an evaluation time.
The licensee believes that these shortcomings will not appear in implementing the RAP because of the following actions which were taken in the present proces's to address management and organizational effectiveness:
1.
2.
3.
4 ~
5.
6.
A more comprehensive effort to identify issues; A more structured analysis with formal root cause assessment and emphasis on human performance; An iterative effort involving a process of buy-in by the line organization relating to the identification of issues, root causes and corrective actions, and implementation of the required actions; An issue analysis with emphasis on a deeper look at management, including a comprehensive look at past problem areas for trends and common root causes; A comprehensive look by all levels of supervision to identify, track,
- resolve, and close out problems not previously documented; and A systematic review by senior management and experienced, outside consultants.
In addition to the above, one of the Specific Issues identified in the RAP is closeout of programmatic issues associated with the I&C technician allegations.
Subsequent to the submission of the RAP the staff has met on two occasions with the licensee regarding questions concerning the RAP.
Formal staff review of the RAP is ongoing.
NRR SPECIAL TEAM INSPECTION:
During the months of February and March 1989, the NRR Special Team Inspection (STI) directed by the December 1988 SMM was conducted.
The objective of the NRR STI was to assess the effectiveness of licensee management oversight, including self-assessment, of the operational safety performance of the facility.
Emphasis was placed on attempting to determine the root causes and contributing factors to fundamental, underlying problems previously identified, and to determine if management develops and ensures implementation of timely and effective corrective action for identified problems.
I
A complete, but preliminary, listing of significant findings from the NRR STI is included as Attachment B.
In general, the team concluded that the majority of its findings had been previously identified by the
- NRC, INPO, and the licensee.
- However, some corrective action was ineffective and progress on implementing the corrective actions was slow with limited success to date.
COMPARISON OF 1989 NRR STI FINDINGS WITH THE 1986 ISC TECHNICIAN ALLEGATIONS AND FINDINGS OF THE RI STI:
The ILC Technician's allegations (see Attachment A) were independently evaluated in 1986 by a Region I Special Team Inspection.
The team concluded that most of the circumstances described in the allegations were substantially true, but the technical significance of the substantiated allegations was found to be generally minor and no immediate safety concerns were identified.
However, the team did conclude that there were some major programmatic weaknesses in the NMPC management system that allowed these problems to develop and go unresolved.
Since the majority of the ILC Technician's concerns were very specific technical allegations, there is no direct comparison between the original IAC Technician's allegations and the preliminary listing of significant findings from the 1989 NRR STI (see Attachment B).
- However, as with the 1986 RI STI, many of the the preliminary findings from the 1989 NRR STI represent continued deficiencies in organizational effectiveness and procedural inadequacy and noncompliance, and are examples of why NMP-I has remained shutdown under Confirmatory Action Letter.
These broad programmatic weaknesses at NMPC, particularly at NMP-I have been documented consistently in NRC inspection reports and in the licensee's own internal audits and self-assessments.
These include inspections and audits prior to the allegations such as the Construction Appraisal Team (CAT) report of NMP-2 in January 1984 and the Management Analysis Company (MAC) report of NMP-2 in March 1985.
Specifically, the 1986 STI indicated that procedural inadequacy and noncompliance were contributing factors to many of the technical allegations substantiated by the inspection team.
The 1989 STI reaffirmed that this major weakness still existed at both units, particularly in the areas of operations, surveillance testing and maintenance.
Following the 1989 STI, NMPC clarified existing corporate and station policy regarding procedural adherence and conducted additional training on this sub'ect prior to the April 1989 Unit 2 startup from their midcycle outage.
The 1986 STI found that methods used to identify shortcomings and potential problems had not been implemented and consequently, problems identified by NMPC staff were not always brought to management attention for resolution.
The 1989 STI found examples of similar problems still occurring in surveillance testing, maintenance, design change control, corrective action programs training and onsite and offsite committee activities.
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The 1986 STI also found that organizational ineffectiveness, manifested in weak NMPC review methods and management oversight, limited their ability to accurately identify problems and evaluate program effectiveness.
The licensee recognized these problems and effected various corporate and site management
- changes, including the hiring of a new Executive Vice President
- Nuclear Operations in 1988, to implement increased oversight of station operations.
Although some progress has been
- made, the 1989 STI identified that many organization effectiveness issues remain to be resolved.
The 1986 STI found that the operational quality assurance (gA) program was ineffective in helping the line organization to identify and correct problems.
The 1989 STI found that while the gA organization provided good performance-based findings, shortcomings still existed in the gA program.
The team found that the gA Audit Group was understaffed and audit schedules were slipping; the auditor training program was weak; and, because the audit group was omitted from the distribution for LERs, ORs, or SORC and SRAB meeting minutes, they were unaware of current issues and unable to proactively audit plant activities.
SUMMARY
In summary, the 1989 NRR STI did not identify recurrence of any technical issues originally identified as part of the 1986 ISC technician allegations.
- However, many issues dealing with program weaknesses and organizational effectiveness identified during the 1986 RI STI were also identified during the 1989 STI indicating that corrective actions were largely inadequate.
These items have been identified for resolution in the licensee's Restart Action Plan and Nuclear Improvement Plan.
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