ML19332C690
| ML19332C690 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 11/21/1989 |
| From: | Philips J NRC OFFICE OF ADMINISTRATION (ADM) |
| To: | Williams O JRA ASSOCIATES |
| Shared Package | |
| ML19332C691 | List: |
| References | |
| FOIA-89-471, RTR-NUREG-0737, RTR-NUREG-737 NUDOCS 8911280427 | |
| Download: ML19332C690 (2) | |
Text
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RESPONSE TO FREE OM OF X low I
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INFORMATION ACT (FOIA) REQUEST gy ; ; )gg e
DOCktt NVM0 IRE $1 fit aps scam) u 8ttOut5TE8e Ms. Ophelia G. Williams PART 1.- AGENCY RECORDS RELE ASED OR NOT LOCATED ISee chec&ed troacs)
No agency recoeds oubsect te, the request have been focated.
No addfttonal egency records outgect to the request have been located.
Requested records are evellable through another public disuibution proprem. See Comments Section.
Agency records subsect to the request that are adentefed on Appendialesh are already available for putac 6nspecten and copy 6ng m the NRC Public Document Room Pt?O L Street. N W., WasNngton. DC 20%b Agency records subrect to thu request that are identatred on Append'aient A
,,e being made e,,iiabie fo, pubi,c inspeci on and copying in the N
NRC Public Document Room. 2120 L Street. N W., WasNngton, DC, en a folder undee this FOIA numter and requester name.
The nonpropnetary worsion of the proposof ts) that you spreed to eccept in e tenephone conversation with a member of my staff is now t>erng made available for public anspeciton and copymg at the NRC Public Document Room 2120 L Street. N W., WesNngton. DC. 6n a folder undes this FOIA numtier and reaaver name.
Agency records subject to the request that see identified on Aporndimiesi may t.e anspected and copied et the NRC Local Public Document Room identifed in its Comments Section.
Enclosed 6s information on how you may otgeen access to and the charges for copying records placed m the NRC Public Document Room. 2170 L Street. N W4 Washmpton, DC.
Agency records subsect to the request are enclosed.
t Records subsect to the request have toen referred to another Federal agencylies) for review and direct response to you
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You will be billed by the NRC for fees totaling 4.4 9' 7b in v6ew of NRC's response to thie request, no further acten is bemg taken on appeal letter dated
. No.
PART 11. A-INFORMATION WITHHELD FROM PUBLIC OlSCLOSURE Certain mformaten in the regasted reco#ds is bemg withheld from putet disclosure pursuant to the enemptions destnbed in and for the reasons stated in Part it, sections B. C and D Any released portions of the documents for wNch only part of the record is bemg withheld are teing made evadatde for public mspection and copymg m the NRC Putec Document Room. 2170 t Street. N W.. WasNngton. DC m a folder under tNs FDI A numtier and reovester name COMMENTS This confirms your agreement with Dick Lavins in a telephone conversation on November 16s 1989, to pay the costs associated with the processing of your F0IA request.
The fees are as follows:
Professional Search / Review - 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> = $49.76 Total = $49.76 e
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p APPENDIX A 1.
6/18/85 Memorandum from Regan to Russell with' attached memorandum from Regan to Stolz enclosing 6/14/85. Pre-Implementation Audit of the Detailed Control Room Design' Review of the Davis-Besse Nuclear Power Station (43pages)
L 2.
11/8/85 Memorandum from Regan to Stolz. subject: Minutes of Meeting.
ll with Toledo Edison Held October 9, 1985 in Bethesda (24'pages),
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M18 N HfE0 Files MRegan urrn Momtiers i
i ttrHonANDuM fop William f, Russell Ac t ino Director Divisionofl'unenfactorssafety IR0ft:
William H. Regan, Jr., Acting Chief Hunan Factors Engineering Branch Divis Sn of Hunan Factors Safety SUBlECT:
STATUS OF DAVIS BESSE DETAILED CDtiTROL RDDM DESIGN REVIEW (DCRDR) i In light of the recent event at Davis Besse, the femation of an NRC fact finding tean, and the possibility that hymn error or control panel confusion or. curred during the incident, I am providing you with the status of the Davis
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Besse DCROR.
Although Toledo Edison Company (TED) submitted a very good Program Plan for conducting the DCRDR, the execution of that Plan was poor, ospecially in the area of documentation.
Based on the good quality of the progran Plan, we did not perfortn an in-progress audit. However, based on the incnt'pleteness of the Davis Resse Sutrary Report (SR) we infamed the licensee of nur plans tn conduct an audit af ter. receipt of its Supplemental Surr.ary Report ($$P).
The nred for an audit was confimed af ter review of the licensee's unacceptable January 1985 SSR which reprioritired (dewn graded) all safety significant HEDs identified in its SR, and scheduled the completion of ten OCRDD studies and the resolution (proposed corrections) for all HEDs for the Sprinn of 1989.
l Bawd on our April ?9-May 3,1985 audit at Davis Besse, we detemined that since. lune 1984, nininal effort has been expended and progress made on conpleting the DCRDR.
Also, no human factors expertise has been involved in developing HED corrective actions or in the reprioritiration of safety significant IIEDs, nor did TED plan to involve them in nine out of the ten planned studies. At the time of the audit, the licensee stated that hunan factors personnel are only being used to develop a panel label specification for one of the studies.
During the audit, we found that TED had no docunented romal plan or statencnt of ob,1cctives for perfoming the ten studies.
These were to be done on a "when we have the tire" basis. We were told that two of the studies were underway, but, no documentation was available to validate this.
1 Based on our review thus far, we are unable to close out any of the DCROR l
clenents.
In order to resolve the problems associated with the OCROR, we recorrenced to DL that an NRC/TED nanagement meeting be held in Bethesda, l
af ter the licensee receives the NRC Audit Report.
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inclosed is a copy of.the audit report and my letter of transmitta) to DL.
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i William H. Regan, Jr., Act.ing Chief l
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.Dtvision of Itunan ractors Safety
Enclosures:
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.MEFORANDIJM FOR:
John Stolt, Chief Operating Raaetort Branch Nn 4 Division nf Licensing FROM:
William H. Regan, Jr., Acting Chief Hunan Factors Engineering Branch Division of Hunan Factors Safety
SUBJECT:
DETAILED CONTROL ROOM DESIGN REVIEW, PRE-lMPLEMENTATION AUDji REffRT, DAY 15 8 ESSE UNIT 1 In accordance with the requirements of Supplement I to NUREG-0737. Toledo Edison Companv (TED) was required to cerduct a detailed control room design review (DCDDR)fortheDavisBesseUnitIcontrolroem, j
Based on the quality of the licensee's Progran Plan, the staff detemined that an in progress audit was not necessary. However, based.On the inconpleteness of the licensee's Sumary Report (SR) submittal dated June 29, i
1984, and a comitment ir the SR to provide detailed schedules for completing e.hnrt tern actions and the ten special studies in January of 1985, the staff scheduled a pre-implementation audit to be conducted af ter receipt of the Supplemental Sumary Report.
The Januarv 31, 1985 submittal did not provide a detailed schedule for completing the ten special studies. However, it did provide for the following unacceptable actions:
(1) a rescheduling comitment to complete the ten studies proposed and previde for disposition (proposed corrective actions) of all HEDs by the spring of 1989, and (2) the reprioriti:;tien (down grading) of 29 safety significant HEDs, which TED indicated unuld be corrected "pronptly" in it's Sumary Report of June 1984 A pre-implementation audit was perforned April 29 Mav 3,1985 by the NRC staf f, supported by consultants from SAIC and Conex Corporation. Pesults of the audit, which are docunented in the enclosed audit report (TER) prepared by SAIC, indicate that TED has made mininal progress and expended nininal effort toward completing the DCRDR requirenents since submitting its SR.
Also, our review of TED's execution of its Progran plan for conducting the DCRDR, as described in the Sumary Report was fnconclusive dua to the bgo 6
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i lack of detail in the information provided and the incompleteness of HfD resolution.
Therefore, we are unable to close out any of the ninc requiret."ents atsociated with conductirg A DCROR in accordance with i
Supplement 1 of flDREG-0737.
5 Desed on rur review of the licensee subnittalt and the audit perfomed, we i
preposed that en NRC/TED management macting ba held in Bethesda to discuss the status of the Davis Besse L' nit 1 DCROR. We sug0est the nacting t.ato e
place within 60 days af ter TED receives the enclosed Pre-!rnplerentation fudit Report.
W. will provide an anenda wit.hin thirty days of this memorandur, whie.h will reflact the information centained in the "Conclusicrs and I
Derorvendations" Section (p9s. ?'-31) of thn enclosed audit report.
Please transmit 'he enctored rr. port to the Itcansce for its use in prepariro
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for the forthconing meetinq end for plar ning the cor'pletion of its DCRDO.
j William H. Regan, Jr. Actinti (bief Hunan Factors Engineering Branch Division cf uunan Factors Safety
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PRE lMPLEMENTATION AUDIT j
OF THE DETAILED CONTROL ROOM DESIGN REVIEW OF THE Davis-BESSE NUCLEAR POWER STATION i
June 14. 1985 L'
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Prepared for:
l U.S. Nuclear Regulatory Comission l
Washington D.C. 20$$$
i Contract NRC 03-82-096 l
l Prepared by:
I Science Applications International Corporation 1710 Goodridge Drive McLean. Virginia 22102 gd* II
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l 11 PRI-]MPLEMENTAT105 AUDIT a
0F THE DETAILCD CONTROL RW. tE51GN Rtyltw i
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Prepared for:
U.S. Nuclear Regulatory Corneission Washington, D.C. 20555 Contract NRC-03-E2 096 t
Prepared by:
Science App 11catter.s International Corporation 1710 Goodridge Etwe McLean, Virginia 22102 O %
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FORCWit3 i
This report documents the findings from a pre implementation audit of the Detailed Contrel Room Design Review (D RDR) being conducted by Toledo (dison (TED) for its Davis-Besse Nuclear Power Station.
The pre-implementation auf tt was conducted by a four-man team comprised of one representative from the Hvcan Factors tagineering tranch of the NRC's Division of Munan factors Safety, two renesentatives from Science Applica-tions International Corporation (5 Alt), and one representative from Comen Corporation, a subcontractor to SAIC.
The pre implementation audit consisted of extensive discussions held the week of Apr1129.1985, with representatives of TED and its consultants, W
! spell (nuclear engineerin (human factors engineering)g, operations, and !&C) and Cssex Corporation DCRDR sethodologies, data forms and Human Engineering Discrepancies (NEDs) were reviewed.
Where clarification of HEDs reviewed was needec. the relevant systems and components were examined at L
the control room m>ck-up.
A visit was made to the control room and Remote Shutiown Panel at the beginning of the pre-implementation audit.
Salt's participation was provided ender Contract NRC-03 82-096 I
Technical Assistance in Support of Reactor Licensing Actions:
Program !!!.
SAIE previously participated in the evatsation of TED's DCRDR Program Plan and Summary Report for Davis-lesse Nuclear Power Station.
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TABLE OF C04TtWT3 Section Pm B&OKGROUND..............................
1 PLANN!hG PHASE 3
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Qualifications and Structure of the DCRDR Teen.......
3 iI REv i E W PH A$t.....................
5 1.
Func t ion a rd Ta s k Ana l ys i s................. I 5 2.
Comparison of Display and Control Re Control Room inventory.......quirements With a 9
3.
Control Room Survey
.................... 10 4.
Operating Experience Reviev
................ 11 AS5ESSMENT AND IMPLEMENTATION PHASE
........ f'12 1.
As s e s sme n t o f HE Ds...................
12 2.
Selection of Design Improvements............
. 15 3.
Verification That Improvemts Will Provide the Necessa y Corrections Without Introdu: tag ken HEDs.......... 2D 4
Coordtaation of the DCRDR wi Programs..........th Dthee !sprovement
................ 21 AkALYS15 0F PRDPcSED CORRECTIVE ACTIDES AM LEFT UNCORRECTED.............D Ar$TIFICAT!DtS T0F HEDs
......22 1.
Proposed Corrective Actions
................ 23
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Justifications for HEDs left Uncorrected.......... 24 CDsA* USIONS AND RIC0+.INDATIONS
................... 27 RE rE R E M CE S............................... 32 AP:iMD11 - Attencees of the Meetings Held During the Pre.ls;1ementation Audit of the Davis.Sesse belear Powe r St a t i o n D CA DR.................... 34 g $
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PRI-lMPLEp.IRTA*10N AJDIT 0F TE DETAILID CONTRD: AD DESIGN REVIEW I
DAY 15 BESSE NU*LIAF POWEF STATION This report documents 19e findings from a pre ieplementation audit of the lietailed Control hoe. Design Feries (DCOR) being conducted by Toledo Ediscn (TED) for its Davis Besse h.t:1ea' Power Station.
The basis for the 6ecision to conduct a pre-ir:1ementatiot audit was the review of the DCRDR
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hamary Report for the Davis lesse nuclear Power Station (Reference 1).
The requirements set forth in RUREG 0737, Sup;1esent 1.
- Requirements for Emergency Response Capability.' De:embe-1982 (Reference 8), served as the basis of the $vasary Report evaluatiot and the pre-implementation audit.
The purpose of the pre-ist'eeentatidt audit was to clarify the review l
mettedology, to audit do:veentatics ci' the review, and to provide feedback l
to tse 'ticenset on the accertability of the review conducted.
Participants in the audit mettings are fototif tet in the A:pendis.
j The DCRDR began with t*t subritta? of the Program Plan to the NRC on June 15,1983 (Reference 2;. The NRC staf f consents on the Program Plan were forwarded to TED on Oct.:ter 7.19t3 (Reference 3).
The D:tDR Suse.ary Repoet was subs titet to the NRC c-Jute 29.19E4 (Reference 1). The NRC staff comments on the Scara y Repcrt tre-e foewarded to TED on October 10, 1964 (Reference 4). On Janwe y 31. 1965 TED subsitted a revisee assesseent of HIDs and implementstion uSedule for corre: tion of HEDs asso:iated with special studies (P.eference 5'..
The find igs c' the pre-implerentation audit follos a brief overview of tte bact;eown: of t*>e 0;RDR requirerer.ts.
EACGRON
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f, Licensees and applicants for o; erat ng li:enses are requiref to condu:t a Detailed Contrcl Roor Ctsign tevie. (D;tDR).
The objectise is to
- - isprove the ability c f r..: lear pewt p14'.t control room c;erators to prevent accidents er core n th at:idetts if they occur by is; roving the irforsation provided to thea' (h?RIS-06t.:. Itet I.D.1 ).
The neet te conduct a DCCk was cenfirmed in k;:tG 0737 a$d in Supplerent I to spets 0737 D;RD8 reesirements in Su;;1erent I to KREG !?37 replaced those in earlier t
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documents.
Supplement 1 to NUREG.0737 re;uires each applicant erflicenset to conduct its DCRDR en a schedule negotiated with the NRC. Guidelines for conducting a DtRDR are provided in NUREG-C'00 while the assessment processes for the NRC are contained in NUREG-0800. (The NUREG documents cited are listed as References 6 through 10).
A DCRDR is to be conducted according to the licensee's own Program Plan (which must be submitted to the NRC). Ac:ording to NUREG 0700c it should include four phases:
(1) planning, (2) review. (3) assessnesit, and (4) reporting. The product of the last phase is a Summary Report which, accord-l ing to 5vpplement 1 to NURtG-0737, must include an outline of proposed control room changen, their proposed sciedvies for implementation, and summary justification for human enginetring discrepancies with safety significance to be left uncorrected or partia11s corrected. Upon receipt of l
the licenste's Summary Report and priot to implementation of proposed changeh, the NRC must prepare a Safety Evaluation Report (SER) indicating the acceptability of the DtRDR (not just the Summary Report).
The NRC's evaluation encompasses all documentation e: we'l as briefings, d iscussions, and audits, if any were condweted.
The purpose of this pre-implementattan aedit report is to assist the NRC by providing a technical evaluatiot of the TED DCRDR p. cess ard results.
l The DORDR requirements as stated in $wpplesent I to NUREG-0737 can te sum.arized in terns of the nine specific e'.esents Itsted telow:
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1.
Estat11thetect of a qualified mul:1 disciplinary revie team.
I 2.
Use of function and task anal ses to identify control f
roce operator tasks and information and control requirements during l
energency operations.
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A coeparison of display and cort ci eequirements with 5Mtect ro:e inventory.
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A control room survey to identiff denations from accepted-hurtae factors principles.
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5 Assessment of human engineering discrepancies (N[Os) to determine which MEDs are significant and should be corrected.
6.
Selection of design improvements that will correct those discrep.
ancies.
7 Verification thaf. selected design improvemer.ts will provide the nece$stry correeti on.
8.
Verification that improvements can be introduced in the control room without creating any unacceptable human engineering l
discrepancies.
9.
Coordination of control roca improvements with changes resulting from other improvement programs such as SPDS. operator training.
new instrumentation (Reg, Guide 1.97. Rev. 2) and upgraded emer.
gency operating procedures.
P U M lleG PH ASE f
The ERC staf f review concluded that the TED Progras Plan, in general.
l was well structured and covered all the ma,jor requirements for a D;RDt. The staff also concluded that although the scope of the review effort for each requirement discussed in the Progras Plan varies a great deal. TID's plans for cenducting a DCRDR. If properly esecsted, should ' result in the identification and correction of serious HEDs in the control roca.' The NR staff's review cf TED's esecution cf its plee.s for conducting the DCRDR as described in the Summary Report was inconc'lusive due to the lack of detail in the information provided and the incompleteness of HED resolutions.
1.
(Nalifications and Structre of the DCRDR Team table 2 in the Progres flagitsts the activities coeprising the D RDR and ite intended involvement Ef'idisciplines in each activity. Based upon this table and resumes provided in the program Plan, the NR: staff con:19ded that *...a qualified multidisciplir.ary review team has been asserbied to conduct the DCRDR* (Reference J
- p. 4).
A review of the information provi6ed is the Summary Report'en the actual tavolvesent of the disci;1ines e*-
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!I in each activity found discrepancies between it and what was said in the f
progran plan.
The discrepancies were confirmed through discussions held i
during the pre-isplementation sudit with TC. Whereas the Program Plan and
$vemary Report state that human factors Spettalists will be involved in the
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L selection af design improvements and the verification that the design j
improvements provide the necessa*y correctist without introducing new NEDs, i
L TED actually is not going to levolve huset factors specialists in these
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activities as integral members of the D:RDR team. TEC stated in discussions held during the pre implementation audit that it wt11 involve human factors specialists in the remaining D:ROR activities when it determines such assistance is necessary. The SRC audit team stated that human factors involvement should not discontinue at the eat of the review and asses phases of the DCRDR but should be included le the actiettles remaining to be completed, including the special studies. selection of design improvements.
and verification that the taprovements provide the necessary corrections o
i without introducing new HEDs.
In its evaluation of the Program Plan tse ht: expressed a coecern with the worklost placed upon the DCRDR Project Administrator, which included
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coordinating not only the DCRDR. but also %.sany other improvements in j
energency response and the integration and coordination of other husen factors prog ans' (Reference 3
- p. 5). Darin; the pre-implementation audit, i
the NRC audtt teas confirmed that the DCR!t Project Adeinistrator was responsible for or participated in not otly the 03DR but also TED's 1
responses to the WAEG.0737. Supplement I regdresents for the Safety Param.
eter Display System (SPDS), the v; grading of Emergency Operating Procedures (CDPs), and the review of Reg. Guide 1.17 instrusentation.
The excessive workload pla:ed upon this positic+ as a coordinator of NUREG-0737, supple.
sent 1 initiatives and as a participant in tse 03DR a:tivities appears to have affectec the tNality of the LORDR.
In sustary, several activities ressin to be cor:leted in the DCROR.
Although it a: pears that the 0 RD: Proje:t Actinistrat:r has the authority T
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- Q' presently planning to include h6ean factors spe participant.
Human factors specialists shoul: be integ-al, active ser.bers 3 of the DCRDR tese for the activities that rewn to be completed, including 7.
all of the special studies, selection o' design improvements, and
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t verification that the icprovecents provide the necessary corrections without
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introducing new HEDs.
Information concerning the levels of involvement of i
human factors specialists and other disciplines in each of the special studies and the selection and verification of design improvements should be provided by TED after these activities have been completed.
Until this inforsation has been provided for review, the adequacy of TED's DCRDR teas quellfications doesn't appear to meet the requirements of MUREG 0737, Sup-plement 1 for the remaining DCRDR activities.
TED's espressed plan not to include human factors specialists in the remaining activities would violate the requirement for a qualified, mutt 1 disciplinary review team.
REVIE)I PHASE The activities included in TED's Control Room Review which were dis-cussed during the pre-implementation audit correspond to the following J
NUREG 0737. Supplement I requirements:
J 1.
Functica and Task Analysis 2.
Comparison of Display and Control Requirements With A Control Roon Inventory 3.
Control Room Survey In addition, the Operating Experience Review was discussed during the pre isplementation audit. Although the Operating Experience Review does not specifically correspond to a requirement of NUREG-0737. Supplement 1 the results of this activity are integrated into required DCRDR activities and therefore will be given attention in this report.
1.
Function and Task Analysis from its review of the Sussary Report, the NRC staff concluded that
'Although the task analysis methodology described was rigorous and comprehensive, and satisfies the requirements of Supplement I to NUREG 0737 to the extent that it was performed. It does not identify operator informa-l-
tion and control needs in teras of instrueent and control characteristics *
(Re ference 4, p. 7). In the Conclusion section of the NRC staf f corments, the following iters were listed as those areas of TED's System Futettons i
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Review and Task Analysis ($FR&TA) which could not be evaluated due to the need for more information than that given in the 59senary Report:
e A description of the types of persossel used to perform the system functions review, task analysis, verification of equipment avail-ability and the eatent of each individual's responsibility and participation in cor&cting these activities.
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e A description of the criteria used tu analyze oporator traffic
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l patterns and the specific HEDs identified from this' analysis, j
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A description of the process used and the analysis conducted to 1
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L existing control room ita'.runettation which are extentive enough to encompass s' comprehenst re set of operator [0P tasks.
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'i Through discussions held with TEt representatives during the pre-1splementation audit, the IIRC audit teas learned that a multidisciplinary
- l team performed the SFR&TA.
Included in the TID DCRDR review test were two consviting organizations. Personnel fros one consultant provided the disci.
p11nes cf ' nuclear engineering, operatians, and !&C. Personnel free the l
second consultant provided the disciplines of husan factors engineering and operations.
l l
TED's revier team, which was split into two groups (by consultants),
performed the systes functierts review atd at identification of high level tasks using a ' para 11el' approach. This approach consisted of two system functions reviews:
(1) a procedure baset system functions review, and (2) a l
top-down system functions review. The first group performed the procedure-based system functions rev.e which was based upon Davis-8 esse Anticipated Transtent Operating Guidelines (AT0Gs) that were tailored by Babcock and Wilcox (B&W) to the Davis-Besse control rson. The top-down systes fuections review was performed te compensate for any bias introduced irto the i
procedure based system functions review due to the use of Davis Besse-l specific ATOGs. This dus) effort inc14ded the identification of the (1)
Davis-lesse critical safety functions; (2) safety systems; (3) system l
functions; (4) the operater actions or tasks spelled out in the upgraded, symptom based energency operating proced2res; (5) high level informatten and 4
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I control requirements (i.e., part meters and control functions); and (6) the
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actual control room testruments and contr:1s.
TfD's DCRDR tese did not identify the required ckracteristics of instruments and controls.
TED's husen factor 16 consultar.ts performed the task analysis be; inning with the high-level tasks and information ard control requirements identi-fled by the first group. Independent of the first group's identification of f
actual control room instruments and controls, the human factors consultants entracted the proce6arat steps from the two system functions review efforts and developed task data foras which detailed the elements that comprised the tasks the operator performs in the procedy al steps (see p. 5-10 of the
$wanary Report).
TED stated during the pre-implementation audit that its human factors consultarts did a further idettification of information and control requirements fna the two system fun:tions review efforts. Howeve',
the Tto DCRDR team did, not identi'y the ryqu' red characteristics of ins'ru-ments and controls, f
Using Davis-Besse sperators TED's consu'tants performed a verification of task performance capbility.
This activity, referred to during the pre.
implementation audit as MV,' cenststed of three subattivities:
(1)ans-lyze operator traffic patterns; (2) verify equipment availability; and (3) verify human engineering suitability of avaitable equipment. Operator traf.
fic patterns were evalmted by documenting caerator movements during the
- }
performance of tasks it. the content of event sequences and applying relevant criteria from NUREG-0700. Equiprent availability was evaluated by coepering f
the high-level information art c:ntrol regw' resents with the contrc1 room during walk-and talk-throughs of the operator task sequences that were developed la the task analysis. Through d:scussions with the TED review J
team during the pre-implementatice audit, the NRC audit team confirmed that the task analysis did not identify required instrument and control charac.
c
- teristics and that the verification of human engineering suitability of
~
available etaipment was not based upon such a list of required characteris.
tics but upon the ability of the persoenel to identify unsuitably designed instruments and cortrots.
The cr.aracteristt:s of instrueents and controls that were listed in ite system functions review and task analysis data sheets were not reqJired ct.aracte istics but were the characteristics of the actual control roon instrutents and contro1L e
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In addition to discussions'with the TED review team, the NRC audit tese conducted a review of the plant-specific Daits-lesse ATOGs to determine
~
their_ adequacy _as a basis for _the systes' functions' review and talk analysis.
The review found that the Davis-Besse ATOGs relative to other Babcock &
Wilcox plants reviewed, are comprehensive with respect to encompassing all operator emergency tasks. Howeve, one area which is not contained in the Davis-Besse AT0Gs is the set of operatar tasks necessary to monf ter and assess the various challenges and failure modes of the radioactivity release critical safety function (C5F). The ATOGs esfer frequently to emergency plan procedure El 1301.1 in cases where a release of radioactive material is possible. The failure to include operator tasks associated with monitoring radiologica1' conditions appears to be the most frequently overlooked aspect of an SFR&TA conducted at other licensee facilities (i.e., this problem does not appear to be unique to the Davis-lesse DCRDP.).
In addition to not consider [ing Radioactivity Release, the mR sadit team found in jose cases-l (i.e. Steam Generator Tube Rupture) that tte listing of information and L
cortrol -requirements was much less comprehensive than those suggested by the ATOGs.
The NRC audit team reviewed the V1T do:amentation and HEDs,fider.ci and found this effort to be systematically pe-formed. The 88 HEDs that were identified from the V1V included HIDs centerling unavailable and unsuitably designed instruments and controls as well as inadequate control / display integration and panel layout.
Although the 4tY was found to be systematic-ally performed and many HEDs were identifiec, the NPi audit team concluded that:
(1) the verification of equipment availability was based upon an incomplete analysis of all operator emergen:y tasks, and (2) the verifica.
tion of human engineering suitability cf available equipment was not based upon an a priori analysis of required chara:teristics of instruments and controls which is used to comprehensively aid objectively verify the human l:
engineering suitability of available instruments and controls.
1 In summary. TED's syster. function revie and task analysis was found to be lacking in the following areas:
%a.,
1.
A comprehensive analysis of cpera*.or tasks, informatior: and con-trol requirements, and r: quired chracteristics of instrut.ents and E
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i controls necessary to monitor and assess the various challenges i
and fallere modes of the Radioactivity Release CSF.
2.
A comprehensive analysis of information and control requirements and required characteristics of instruments and controls for 5 team Generator Tub Rupture.
t 3.
An a priori comprehensive analysis of required characteristics of I
instruments and controls for all operator emergency tasks.
In order _ for TED to meet the function and task analysis requirement of HUREG-0737. Supplement' 1. It must satisfactorily perform and document the three areas of activities above.
We recommend that for ~the performance of
-ites number 1. TIO should use the following scenar os or applicable steps i
from.the Emergency Operating procedures:
L e
A small break 5BLOCA e
A major re'. ease up sain vent stack e
An unsonitcred release path i
L Although ites number 2 was pe-formed to a limited extent and ites nusber 3 can no longer be performed a priori..these activities must be performed as well as _ ltes nenber 1-in order to ensure that the availability and suitability of egaipment needed to support all operator emergency tasks can be comprehensively and adequately verified. Until trD has satisfactorily performed and documented these activities for NRC res
, the Supplement 1 to NUREG-0737 requiresent for a function and task analysis is considered incomplete.
2.-
Comparison of Display and Control Requirements With a Control' Room i
Inventory TID's DCCR activities which (ddress this requirement are the verifica-tion of equipsent availability's herification of human engineering suitability. As previously discussed in the Function and Task Analysis section of this report. TED's verification of equipment availability was based upon an incosplete analysi;if all operator emergency tasks and information anc control requirements.7TED's verification of human engineer-9
,g a-
lG 4
,4 ing suitability was not based on an a priori, comprehensive analysis of j
required characteristics of instruments and controls used to support operator energer.cy tasks. These verification activities were performed using the control room sock-up rather than an inventory of the control room.
The use of the control room sock-up for these activities was found to be acceptable by the RC audit team.- Since the system function review and task gnalysis was found to be inadequate, and this work is the basis for the verification of instrument and control availability and suitability, the pomparisen requirement of Supplement 1 to NUREG-0737 has not yet been met.
In order for TED to.seet this requirement, it must satisfactorily perform and document the three activities described in the Function and Task Analy-sis section of this report and perform and document a verification of instrument and control availability and suitability for the requirements.
developed from these activities.
We recommend that TED also validate the
' control room for the operator tasks included in the scenarios used for performing the Radioactivity Release CSF.
3.
Control Room Survey L
L f
The NRC staff concluded from a review of the Summary Report that "the is methodologies and findings described in the summary report were 1
-comprehensive Ant indicative of-a valid approach" (Reference 4. p.12).
This conclusion was confirmed during the pre-implementation audit through discussions with TED and Essex representatives and a review of the survey
. documentation.
To review further the adequacy of the survey of the Davis-8 esse control roor, the NRC audit team compared the HEDs it identified in a
'h "sini survey" of tse control room with the HEDs identified by TED. With the exception of one DED. the comparison found every HED identified by the MRO audit team to have been identified by TED in its survey. The one HED not identified concerned the incomprehensible annunciator system flash patterns.
[
This HED should be reilewed and resolved by TED.
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During a visit tc the control room, discussions with operators revealed ths.gew components have been added to the control room since the survey was
[
cShdJcted. As parL cf the DCRDR. TED should evaluate the adequacy of these
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components based woon human engineering principles. These components should be. eval. sated by sirvey and verification and validation techniques.
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-In sussary, the control room survey performed by TED vp to this time L
has been adequately performed.
In order to complete this activity and meet the requirements of MULEG-0737. Supplement 1. TED should evaluate the human engineering adeque:y of the new components added to the control-room since the survey was-perforsed In addition. TED should include the. annunciator system flash patterns in its review, assessment and resolution of HEDs.
4.
Operating Experience Review -
SAIC found that the operator interviews and historical documentation review were acceptable as described in i.he Summary Report. - However, discus-siens held with IID DCRDR representatives during the pre-implementation audit and a' review of the operator interview and historical documentation review results by the ERC ' audit teas revealed the following problems:
l e-It appeared that the interviews were conducted by inexperienced-personr.e1 who lacked knowledge of reactor plant systess. thus,
limiting the. extensiveness and effectiveness of the interview data.
e Recordia; of operator interview results was performed in a cursory manner, with very little detail annotated. Valuable additions to the potential HED data base appear to have been lost in this process. It appears that this lack of detail was due to a lack of faalliarity with reactor plant systems and terminology on the part of the interviewers, r
e Operator responses to questions which indicated the existence of generic problems were not pursued to the point of documenting specific examples of the problem.
}
l e
Where the interviewer / recorder did write down a specific instrument or control name, the specific nature of the deficiency asso:iated with the gevice was not well documented.
e Some specific examples of the poor recording techniques are as follows:
11 L
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Rany ' things" are labeled differently la the control room-q r
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than what operators call-them.
The ' things" were not 1
_ listed.
c.
C Many CRT displays are confusing or unnecessary.
No des-cription of the problems with the displays was provided.
- -PAM panel meters are cot; fusing or difficult to read.
Again, no specifics were provided on which seters have the i
problems.
e The 1978 loss-of-feedwater event at. Davis-lesse, which many g
believe was the_ precursor to the accident at TMI. did not appear-to be included in the review of applicable operational events.
Since the Operating Experience Review is not itsted among the require.
ments. of Supplement 1. to NUREG-0737 this subject and the problems E
-identified by the NRC audit teas..were not pursued-during the pre.
L implementation audit. Based on the documentation made available by TED. the L.
NRC audit' team found that the operator interviews were not fully auditable and appeared to be less than satisfactory for the potential-utility of this data collection technique.
A review and conclusion on the adequacy of historical documentation review could not be made during the pre-implementation audit since no LER files, etc., were made available by TED DCRDR members to the NRC audit team.
ASSESSMENT AMD IMP'DEKfATIOR PHASE 1.
Assessment of HEDs In its review of the Summary Report, the NRC staff concluded that "The l
methodology and criteria for assessing HEDs appear to be sound' and that
- With the exception of the absence of a logic diagram which is planr.ed for use in assigning scheduling priorities for correcting Category 1 HEDs. the information provided in the summary report demonstrates that TED possesses the knowledge and capability for assessing HEDs and meeting this requirerrent of Supplement 1 to NUREG-D737* (Reference 4. p.13). Through discussions held with TED during the pre-implementation audit, it was learned that II
l
.l.? :
. Category -1 NEDs (those HEDs that have been identified as documented errors)
~were assessed for their'significante relative to plant safety. The NRC
.s
= audit team concluded that the assessment of Category 1 HEDs was satisfactory.
TED submitted a letter, dated January 31, 1985, to the NRC which docu-mented the reprioritization of 29 HEDs which were deferred to 'special studies" (Reference 5). In this letter TED states "To help establish the schedule for the coMutt cf these stud ies, we' decided to re examine the sost safety significant HEDs to further prioritize them and thus determine which of the studies would provide the most significant benefits."
TED reprior.
. itized those HEDs deferred to the special studies which were originally prioritized as 'As* and '55.*
The original prioritization schese, once HEDs were placed into either Categories I. II, or 111 based upon the judged probability of error occurrence, was to determine the priority for implemen-tation of correctioni based upon the judged potentift effect the hypothe-sized errors could have spon plant safety. Based on this judgment, the following priorities were assigned to the HEDs:
p e
Priority A - Prcept - first outage (fif th refueling outage over-all), given engineering lead time, availability of materials, and coordination with the Integrated Living Schedule.
y l-e Priority 8 - Near tera - second outage (sinth refueling outage overall), given engineering lead time, availability of materials
-and coordinattun with the Integrated Living Schedule.
e Priority C - Long term (seventh refueling outage overall)
For example, all HEDs assigned a priority of '8' would have associated l
corrections implemented by the end of the sisth refueling outage regardless l
of HED categortration. The dates for each of the refueling outages were L
determined by TED to be as follows: fif th = Spring of 1986; sixth = Fall of 1967; and seventh = Spring of 1989.
TED's reprioritiratice of "A" and *B' HEDs was undertaken to the D;RDR l
team (with the exception cf the human fa: tors specialists) and ea:h cf these 13 4
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f 29 NElk was'~prioritized for ' disposition" (i.e., resolution), not implemen.
tation, using the following rankings:
. e High'- The hypottesized error will prevent or degrade a safety function.
e Medius - The hypcthesized error will challenge a safety system or could potentially degrade a safety function.
y Low - The hypothesized error could potentially challenge a safety 1
system.
l These rankings or-priorities translate to the following refueling outages for determining the disposition of HEDs:
High a fifth; Medius a sixth;_and j
Low = seventh._ The results of TED's reprioritization of these 29 HEDs were U
that only one was detfraised to have high safety significance, eight HEDs were determined to have setium safety significance, and the remaining twenty HEDs were determined to have low safety significance. The one HED deter-aimed to have high safety significance was divided into three sections of c.
which one section was rated High, another Medius, and the other Low. In effect, the reprioritizatian downgraded the safety significance of a11 - 2g
/'
HEDs. Functionally, the resrioritization postponed the correction implemen-l tation commitments for 11.se 25 HEDs in _ xcess of 18 and 36 months (since e
l
- only the disposition will be ' determined at those times, not the implemen-f tation of corrections). The NRC audit team found the downgrading of the safety significance of these HEDs and the postponement _of the implementation of corrections to be unsatisfactory.
In addition, the lack of human factors specialist participation is this reprioritization, particularly with respect to hy;othesizing the poter*tal human errors that could occur was found to
!^
be unsatisfactory.
l In reference to the eriginal prioritization process and that used for the 29 HEDs the NRC audit teau discussed with TED representatives the L
consideration of cumulative and interactive effects in assessing the
- pctertial for human erre-and the s
- ificance of human error to plant D
safety. TED stated that 1: had no systematic review or consideration of the l
cumulative and interactive effects of individual H~Ds during HED assessment.
TED did cite the Steam Feedwater Rupture Control Syster. (5FRCS) study as an r -
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instance wtere cumulative and interactive effects of individual HEDs upon panel layovt were considered, but this appears to be more applicable to the selection of design improvements rather than assessment.
In sussary.-TED's original prioritization process for all HEDs was found to be acceptable except for the consideration of cumulative and interactive effects of individus) HEDs. The !reprioritization of 29 HEDs involved in special stucies was found to k unsatisfactory because it downgraded the safety significance of these tkDs. postponed the commitment sade in tM Suasary Report for taplementing corrections, and did not involve human factors specialists. We recommend that TED should (1) perform and document a systematic review of the cumulative and interactive effects of individual HEDs; (2) review the new prioritization of the 29 HEDs using human factsrs specialists; (3) use human facters specialists in any further HED reprioritization; and (4) provide docusentation to the NRC of the justi-fication for the reprioritization of each HED affected. Until documentation of the consideration of cumulative and interactive ef fects of individual I
HEDs and j stifications for the reprioritization of each HED affected are provided, this requirement of Supplement ) to NUREG 0737 has not been I
adequately addressed.
2.
Selection of Design Improvements in its review of the Summary Report, the NRC staf f found that TED "did not descrik the process or analysis it used to select design improvements to correct significant HEDs" (Reference 4. p.14).
In addition, the NRC l
staf f stated that 'the licensee has opted to conduct a number of 'Special ll Studies' te determine the disposition of all 'HEDs and in January 1985. TED L
will. provide detailed schedules for the completion of the short ters actions and the special studies.' Based on these facts, the NRC staff concluded that
- the scheduling information and disposition of HEDs contained in the TED summa *y report are not conclusive end therefore, no judgement as to their adecuacy can be made at this time" an:3bg'...the licensee has not complied with the requirements for this elemert oE4 DCRDR and for a summary f
report.'
Throu;h discussions held daring the pre-imp 1erentation audit witn TED.
the NRC audit teas learned that little rrogress had been made towards the 15 gme
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- 3.
w a.
resolution of HEDs since the submittal of the Summary Report on June 30
!!24.
No systematic, rigorous process for identifying alternative correc.
tions to HEDs and selecting final dispositions has been developed or employed.
In addition. -there is presently no human fattors participation l
and expertise involved in the selection of HED dispositions with the excep.
tion of the development of a specification for labels and location sids.
A g
review of the 347 HEDs listed in the Summary Report found that approximately 50% of tha HEDs have been dispositioned by TED.
These HEDs have been disposed qf either by correction, justification for no correction, or dele.
tion. The disposition of the remaining 50% of the HEDs in the Summary Report has - been deferred untti a series of special studies has been completed. These special studies are the following:
e Annunciator study (31 EDs)
L l
e Computer study (14 HEDs)
[
e Controls study (23 EDs) l e
Displays study (47 HEDs) e Engineering study (5 HEDs) e 111vaination and Lighting study (5 HEDs) e
/ Labels and Location Aids study (31 HEDs) e Noise stdy (4 HEDs) e Operations study (3 HEDs) l e
Steam Feedwater Line Rupture Control System ($FRCS) study (10HEDs) l As indicated in the January 31, 1985 letter tc the MRC. TED has committed to complete its special studies and the disposition of all HEDs by Spring of L
1969.
During the pre. implementation audit the NR* audit teas learned that only three studies are currently being pursued:
Displays. Labels and loca-tion Aids, and SFRCS. Given the long lead time TED has established in its January 31, 1985 letter to the ht'. metting its own deadline for completion of the special studies does not sees to be a problem.
However, the establishment of such a long lead time can have detrimental effects upon an integrate 3
- 1y control roor. spgrade prog *am.
The evaluation and selec-tion of HE]D dispositions across approximately five years (i.e., Summer o 1984 to Spring of 1989) for the remaining SDt of all HEDs will not allow TED to ensure that the HED cisposittens selected wit *.in a special study (1) are compatible wi-th dispositions selected before and already implemented, and 16 b:r w
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/.V (2) wil1 provide the necessary correction without introducing new HEDs. TED j
~
stated during the pre-implementation audit that its stedies will provide for the consideration of cumulative and interactive effects of ladividual HEDs.
However, the consideration of cumulative and interactive effects appears to l
be only feasible for those MEDs associated with.the same special study.
Due to the eacessive amount of time TED has scheduled for completion of each of the special studies and the dispositioe of associated HEDs.:many HED l
dispositions will have been selected and implemented in the control room by TED prior to knowing how the remaining HEDs will have been dispositioned and without adequate consideration of an overall integrated control rooni upgrade j,
packspe.
Overall. TED's excessive time schedule for resolving HEDs in the special studies promotes a piectneal approatt to selecting and taplementing HED dispositions rather than the united, integrated approach needed.to ensure HED dispositions provide the necessary corrections without introdu-cing new HEDs.-
During the pre-implementation audit, the MRC audit team reviewed the l
available documentation on the three special studies currently being conducted; namely, the Displays study. Label and Location Aids study, and the SFRCS study. In addition to noting the current inadequate amount of L
hunian factors participation in these special studies, the NRC audit team's comments on these specific special studies were given as suggestions. The-NRC audit team suggested that TED consider the following in its Label and Location Aids study: (1) the Standard Abbreviations / Acronym list-that is being developed should be applied not only to the control room labels and procedures, but also to the SPDS and other operator interfaces throughout the plant; (2) ensure that the specification being developed by TED's con-y sultant for labels and location aids is used for DCRDR related and future operator interface modifications; (3) ensure that the labeling and location i
aid specification is compatible with consentions TED will establish for color coding, luminance contrast. etc.; and (4) labeling provided for newly e
impleatnted components should be verified for accuracy using background documents such as palDs and instrument lists. Other than recommending the active participation of human factors specialists, no suggestions were given concerning the Displays study and the SFRCS study.
The plant design change process and the HED documentation were reviewed Dnce the by the NRC audit team during the pre isplementation audit.
t' 17
. &yO.4,,te,;.
m m
4
. decision to make a design change has been made, a design change undergoes the following process:
h 1.
Development of objectives, scope methodology, and criteria for 0
design change evaluation.
r 2.
Evaluation of options for seking design change and selecting q
l specific design change.
3.
Initiatiation of a Tacility Change Request (FCR).
1:
.4.
Engineering review and approval of proposed design change.
5.
Prioritiration Subcommittb review and approval of proposed design
_i change.
5.
Procurement of funds for-implementing design change.
I 7.
Assignment of responsibilities to implement design change.
8.
Implementation' of design change.
At the time of the pre-implementation -avdit. several HEDs associated with the $FRC$ study had entered this process and were involved in several F
FCRs.
The FCRs had been signed off by the 1&C Engineer and the DCRDR I
Project Administrator. 'who are responsible for approval of design changes coming from the DCRDR.
However, as previously stated. no-systematic methodology including participation of husan factors specialists was used by TED DCRDR personnel to identify and evaluate alternative corrections and select final dispositions for engineering review.
j A review of the HED documentation found that many HEDs did not have adequate information for use in assessing and resolving the HEDs.
The descriptions of the HEDs were sometimes ambiguous, generic, or inaccurate.
e The assessment and disposition of HEDs were soretimes ambiguous, contradic.
[
tory, or missing. The reasoning behind many HED dispositions was not obvious and was not documented in most HEDs. Many of the HEDs which TED deleted should have been kept as valid HEDs with documented assessments and 4
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justifications for not taking coqrective a: tion. The MEDS in many instances
)
'could not be traced back to the specific discrepant components. In addi-tion, operator interview comments could not be traced to HEDs due not only to inadequate HED documentation but to inadequate documentation of the operator comments on the interview data ec11ection forms. Approximately 17
~^
HEDs were reported in the Summary Report (P!Ds $9115) but were found not to have been documented or assessed on HED forms.
A comparison of the HED files with the HED listing provided in Apperdia C in the Summary Report -
i found discrepancies concerning Hl:D assessments and dispositions.
- Overall, the HED documentation was found to be inadequate as a basis for performing i
the assessment, selection, and verificatiot of design improvement activities in the DCRDR.
la addition to the overall inadeg.acy of the HED documentation, the NRC audit taas found some, proposed corrective actions and justifications for not taking corrective actions to be eithe* un: lear of inadequate for resolving the HED. Specific connents related to ttese findings are provided in the Analysis of Proposed Corrective Acticns and Justifications for HEDs Lef t Uncorrected section of this report.
la suneary. TED has made little progress toward the disposition of HEDs since the submittal of the Suasary Report on June 30. 1984 Approximately 50% of the HEDs identified in the DCRDE are still unresolved and will not be l
until the seventh refueling outage, wrich will occur in the Spring of 1989.
TED has not set the MUREG-0737. Supplemert I requirement that the licensee
- shall subeit a summary report cf the ccepleted review outlining proposed.
control rooe changes including the'.r pro;csed schedules for implementation" and that the Summary Report will provide 'a summary justification for human engineering discrepancies with safety sig*ificance to be left uncorrected er partially uncorrected." The NRC audit team found the following inadequacies l
g, in TED's approach for selecting desigt is rovesents:
(1) the absence of a l
systematic. rigore
- rethodology for identifying alternative corrections to HEDs and selecting final dispositiers; (2) the absence of human f actors participation and expertise with the es:epiton of the developrent of a specification for labels and location sics; (3) the overly extended piece-seal approach for disposition of the retaining HEDs; (4) inadequate HED documentation; and (5) inadequate dispos tior. of sore HEDs.
TED's presen*
approach does not meet the requiremeats of UREG-0737. Supplement 1 for 6
k..
e z.
selecting design improvements.
In order for TED to meet the requirements successfully, it should (1) perform and docurent a systematic, rigorous j
methodology for selecting (and verifying) design improvements; (2) involve human factors $Ncialists as active. Integral members of the DCRDR team for selecting (and verifying) design' improvements; (3) perform and ' document a methodology that considers cumulative.and interactive effects of individual HEDs upon the whcle integrated control room improvement package; (4) improve HED documentation so that it is complete, unambiguous, accurate, and audit-able; and (5) develop solutions to HEDs and implementation schedules '. hat-are agreeable to the NRC. TED should provide documentation to the NRC w/.ich details its r,esponse and approach to resolving the inadequacies that pres-ently exist and are listed above.
3.
Verification That leprovements Will Provide the Necessary Corrections Without introducing New HEDs In its eview of the Summary Report, the NRC staff fcund no metho logy which described icw TED was going to ensure that the selected improvements provided the necessary corrections withcat introducing new MEDs.
The NRC
~
staff concluded that from the information provided in the Summary _ Report.
l TED had not demonstrated either the understanding of this requirement or the
. comettment necessary in order to meet successfully this requirene'nt of L
NUREG-0737. Supplement 1.
l Through discussions held with TED representatives during the pre-implementation audit, the NRC audit team learned that no human fa,ctors l'
engineering verification of selected design improvements had been performed, l~
TED stated that its design change process, via FCRs. provides for the
(
verification af design changes.
Mcwever, this verification is an engineering !&t review rather than a human factors engineering-oriented review. As in tk case of the selection of design improvements. TED has not f
developed and esployed a systematic, rigorous methodology for verifying l
selected design improvements. TED preser.tly has not met these requirements 0
of NUREG-0737. Supplement 1.
In-order to meet these requirements. TED s houl d (1) develop and employ a systematic, rigorous human facTerg L
engineering-oriented methodology fcr verifying that the selected design' trorovements pr: vide the necessary corrections without introdacing new WIDs; i
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and (2) involve husen factors specialists as active, integral members of the l
DCRDR team'for verifying (and selecting) desigt improvements.
4.
Coordination of the DCRDR With Other lepravement Programs In its review of the Summary' Report, the NRC staff found that 'Estept for the description of the role the.EDPs serve in the system function review and task analysis, no other refereke was made concerning-the coordination and integration of the DCRDR progrps with other ERC initiatives * (Reference 4, p.16). The NRC staf f concluded that 'from the information provided by TED in the summary report, the coordination of the DCRDR with other improve-ment programs was sintaal and did not demonstrste either the understanding of this requirement or the commitment ne:essary to successfully meet this requirement of Supplement I to RUREG-D737.*
g Through discussions held w' th TED representatives during the pre-implementation audit, the NRC audit team confirmed that sinimal coordination of the DCRDR with other improvement pregrams had occurred.
With the excep-tion of the use of the EDPs as the basis of the SFR&TA, no evidence was.
found that'any coordination had o'ccurred. The Technical 3ection group of
' Davis-lesse, headed by the DCR3R ' Project Adalaistrator. is responsible for-performing the emergency respor.se capabilur initiseives. The fact that the DCRDR Project Administrator is responsible for the DCRDR, SPDS, E0P upgrade, and Reg. Guide 1.97 instrumentation review is a characteristic of the Davis-l Besse organizational structure which should enunce TED's ability to coordi-nate these initiatives adequately.
In addition, several operations and 1&C personnel. involved 'n the DCRDF are also involved in the SPDS, E0P upgrade and Reg. Guide 1.g7 instrumentation review. H: wever, a systematic approach
' has not been established to coordtaate these initiatives and integrate the ressiting changes into each other or into training, which would take i
j advantage of the Davis-Besse organizational structure.
The lack of coordi.
nation and integration in these improvement progress became obvious during l
the pre-implementation audit when the Uit audit tear learned that new instrumentation had been added to %i%ertrol roer since the DCRDR review phase without any human factors cor.sidef ation or re iew given.
l l
l In summary, Davis-Besse's organizational structure as discussed above l
shos1d enhance TED's ability to coeedjnete imrovevent programs adequately.
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J However TED skuld perform and docusent a formal program which ensres that 1
the individual improvement programs receive the fv11est possible benefit free the other improvement programs. TED should maintain auditable documen-L tation in the farm of plans, procedu*es, and resvits which ensores adespate coordination aid integration of the DCRDR with training, SPD$.10Ps, and Reg. Guide 1.97 instrumentation. Ontil documentation is provided by TED-j which demonstrates adequate coordination and integration of these improve. -
kent programs, this requirement of EUREG-0737. Supplement I will not have u
- f been set.
J AMALYS!$ OF PPJPDSED CORRECTIVE ACTIONS AND JUSTIFICATIONS FDR REDS LEFT UNCORRECTES
. As previcasly stated, approatsately 505 of the 347 HEDs reported in Appendix C of the $Ummary Report have been deferred to the yet-to-be-com;1eted special studies. The Janary 31, 1985 letter _ from TED ts.the NRE L
has established a deadline for TED-tt determine dispositions for all.NEDs by l
the seventh refaeling outage occurring in the Spring of 1989. The remaining 50% are these IEDs for which TED has proposed corrective actions, jsstifica-l tions for mot taking corrective actions, or deletions. As stated is the-Selection of Design improvements.se: tion of this report, some of the dele-tiots'were foznd to be valid HEDs for which TED should have developed justifications for not taking corre:tive actions rather than deleting thee.
The MEDs referred to do not include REDS that were deleted becasse they were rededant with other HEDs.
In a review of t:.e HC docusestation during the pre-implementation audit, the NRC auf.t team found inc:nsistencies between the MEDs described in the Summary Report and the infraation presented on the individual HED forms. There were inconsistencies is several HED assessments and in numer-ous HED descr:ptions and proposed dispositions. Therefore, the review of L
the MEDs described in the Summary teport will need to be repeated. Watil TED has dispositioned all HEDs and documented the HEDs, assessments, and disresitices it enough detail to be audited, final revie., and decisiors by NRC concerning the adequacy of TE 's disposition of HEDs should be rost-poned. TED sh:uld provide detailed justifications for deletin5 HE3s or leaving them ancorrected and shc.1d address relevant operatianal and
'l behavioral fact:rs. TED's current 5:5edule towards resolving HEDs post:ones
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a final. HED review untti at least the Spring of 1989.
We believe this -
schedule creates an unacceptable delay of a final HED review.
~
In order to provide TED with feedback regarding the type of HED review that will be performed and the detail of the HED information needed to-perform the review, examples of HED reviews are provided below. The example '
reviews inclede HEDs that were not described in enough detail-to allow a-review to be performed HEDs' for which the proposed corrective actions were not satisfactory, and HEDs for which justifications for HEDs' left 4
uncorrected were proposed but were found to be unsatisfactory.
1.
proposed Corrective Actions
- a. The description of the proposed corrective action is too brief, y
general, or ambiguous to allow an adequate evaluation.
More information is needed regarding the discrepancy and/or the proposed corrective action.
p.l.6-6 (p. C-5 of the Summary Report) - The discrepancy is described as merely
- signal discrisiaability.' The proposed review disposition states 'FCR in place to add annunc. for fire L
alars. PN1. C5731.* The description of the discrepancy is too-brief, and the proposed restew disposition does not state how the added annunciator for fire alars resolves the signal discrimin-ability problem.
P.1.71 (p. C-6) - The discrepancy is that recorder supplies and fuses are not stored in the contrc1 room. The proposed review disposition is
- review rules for changing bulbs 8 etc. with ops. &
18C to make supplies available to operators CR.*
The proposed review disposition'is not a resolution but an action ites. TED L
needs to state the resolution of this HID.
P.1.7-3 (p. E-6) - The discrepancy is that " tools needed to change bulbs that are not available in the control room.' The preposed L
review disposition is that the tool is available and this HED is L
not a problem.
TED's proposed review disposition seens to contradict the HED.
Either the author of the HED did not 23
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c:% y adequately survey the contral room for this item or the HED author 7.'
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felt that the tool it0 says is availsbie was not suitatie for
. p% g changing bulbs. Ttt should provide an explanaticn'cf how this y ~'
M tool is suitably designed far changing hvibs.
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Proposed corrective action only partially corrects the discrepancy
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p.2.12 (p. C-8) e The discrepancy descrubed in ttis finding is that the Gaitronia cords' are located in tra f fic paths'.
The-proposed review dispositioe is to replace periodically the cords -
45 necessary. However, the issue i twofold:
(1) the co'rds may
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l be damaged due to escessive trampling or contact; and (2) they may present an obstacle in the-traffic flow.
The HID dispcsition addresses the' first aspect of the discrepancy, but does not resolve the second aspect of the probles, c.
Preposed corrective action does not correct the discre;4ncy e
l P.g.2-37 (p. C-37)
The discrepancy is that sone displays are not-readable to the reesired a: curacy.
The proposed review dispost-tion is to revise the ' procedure to allow for instrusent error.'
Such corrective action sculd leave the discrepancy ucorrected.
If an analysis of tasks has determined'that the displays aust be read at a level of accuracy that the display destgr.s 6: not allow.
revising the procedure wstch addresses these tasks and displays will not change the actual test requirement for disCay design or the display design itself.
Revising a procedure does not resolve L
an ut. suitable display design.
We believe that ttis type of compensation or resolsttom of discrepancies (caanging the hF rrocedure to fit the desty) is genere11y not an acce;tatie means
.l.c of correcting HEDs.,,
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Justifications For H[DS Lef t Un:cerected h.
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The justificatioe (ce MID cesc 1:tton, cospera nt cescr ;ticr.. etc.)
or does not su ficiertly adfress t*e f
c is too brief, ger.eral, antigue.t.
(tscrepancy to allow an adegaate evahation te te n. ace.
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P.2.1-4 (p. C-8) - The discrepancy _is that the loudness of the.
. c ;j.;. g ringing is not adjustable at the individual telephones.- The 4
review disposition is that it is 'not a probles, no action.' This justification 15 not adequate because it does not explain why the
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HED-is' not a probles.
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J P.3.1-31 (p. C-13) - The discrepancy is that the turbine generator System first out annunciator panel is not located above the-f4}
turbine panel..The proposed review disposition is that the ' panel
'ji is accessible if operators need to get%o it.'
The discrepancy 1
2
'does not descript where the turbine-generator systes first out annuntiator panel is with respect to the turbine panel, and the justification does not elaborate on how it is accessible and why this is satisfactory for operator performance.
P.9.2-46 (pt C-3f) - The discrepancy is that there is excessive operator worklodd (simultaneous tasks),
The proposed review dis-position is that adequate task performance was verifief during walk-throughs of procedures.
TED needs to provide detailed j;~
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inforcation in its justification which addresses operational and behavioral factors.
f I:
l b.
The HED has been deleted although itlts a valid nasan engineering discrepancy. The HED should remain in the valid, active HED file, and justification for~ 1eaving the HED uncorrected should be provided.
I P.5.1-8 (p. C-22) - The discrepancy is that the logarithmic. scale used thculd be linear. The proposed review dispcsition is that it is not a probles and is deleted. 'TED should net delete this HEE-
,1 simply because it has determined that fixing the scale is not feasible.
TED should provide a justification for leaving this HED vncorrected that is based on operational / behavioral factors.
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The justification contradicts the HED idertified s
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P. *. l. 8 ( p. C a 6 ) - T h :, discrepancy is that operators ha ve l
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prctective eqsipitent.
The preposed revien dis;csition indicates i
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< that' this is:not a probica" end that operations verified that one..
can commusicat'e. Such'a finding and disposition are contradic.
tory. TED should clarify the actual situation in operational /
'l behavioral: terms, i
P.3.1-3 (p. C-10) - The discrepancy is that the anunciator panel labels are'not easy to-read from the primary operating area.
The justification, however. Indicates that this is not a problem 1
becesse the annunciator satisfies the guidelines.
If this HED has 4
been identified or referenced to RutEG-0700. the justification appears contradictory.
TED should better explain the justifica-l I
tion.
P.6.16 (p. C-27) - The discrepeacy is that the symbols'are not a consonly accepted configuration., The justification argues that it there are no uncommon symbolsjon panel. TED should provide a detailed description of-these syebols and an explanation why this HED has been identified -if the justification is accurate.
4.
The justification is not adequate -
I P.2.19 (p. C-9) --The discrepancy is that the annunciator alare is nondirectional. The proposed review disposition is that the error assessment is low due to the size of the control room. This justification.needs to cite. in d4 tail, the operational and v.
behavioral factors involved in detersining the error assessment to i
be low and te justify why this ED should be left uncorrected.
P.9.2 33 (p. C-35) - The discrepancy is'that there is inadequate control / display capability (dilution pump speed control / display) to accomp1..h the task walked throsgh in the V8V activity. The proposed review disposition is that it~1s not a problem and that a
~
local contrcl 1:, available. TED's justification does not appear to be adequate since this HED was ideetified relative to a control room functior in the V1V. emergeri:y igh walk-throughs.
P.9.2-93 (p. t-42) - The discrepancy is that there is inadequate inforestion concerning the Reacter and the incore TC trend
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' tion is available on the $PD$. Justifying the availability of needed information on the $PD$ is not s&tisfactory becesse'the
$PD$ is not qualif ted. It equipment. A hardwired, qualified i
backup display of this information is necessary in case of $PD$
' failure.-
f CONCLUS IDR$ AND RIcopMENDAT10R$
Minimal progress or effort has been made of expended on the DCRDR since subsittal of the Summary Report on June 30. 1984 At a point nine months after submission of the Summary Report the Davis lesse DCRDR is at a level of detail and state of completeness equivalent to most other licensees' DCRDRs at the point when the NRC conducts in-progress audits. Based-on TED's }chedule for determination of dispositions for all MIDS by the Spring of 1989, implementation of most HED corrections will apparently not occur y
untti some time in the 1990s. Although changes or FCRs have to compete with other projects for funding within TED's Integrated t.iving $chedule, we believe that TED has not placed an appropriate emphasis upon the timely.and satisf actory conduct of its DCRDR. This lack of emphasis is evident not only.in the excessive time schedule and slow rate of progress for the special studies, but in TED's near-exclusion of human factors expertise from the DCRDR since submittal of the Summary Report.' With the exception of the development of a labeling and location aids specification, no human factors assistance has been obtained during'the time between the Suasary Report submittal and the pre-implementation audit.
The NRC reqsires that a multi-disciplinary team including persons with human factors espertise remain intact untti tne DCRDR is completed. This multidisciplinary DCRDR team should be involved in studies that relate to the DCRDR.
Presently, some planned control room modifications and studies do not appear to be coordi.'
mated with or under the cognizance of the DCRDR team. These includif (1) ahie nuisance alara study; (2) a plan to replace all minieture PAM panel meters; s
and (3).Iemoval from service of broken or unnecessary annenciator tiles.
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Because of a lack of rigorous recordin; techniques to date, the remaining special studies progeams will require the repetition of detailed work. It 1.5 strongly suggested that the special studies projects empicy personneircapable of understanding technical deficiencies and recording same 4
27
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Between now and the commencement of the special Studies, an ef fort should te endertaken to better collate, correlate and y cross-reference the hard data contained in entsting DCRDR records.
l
[
le addition to these general comments, the fo11eving is a list of-the f.7,
activities, areas of improvement, and documentation that TED shovid' satis.
E factor 11y perform in order to meet the NUREG-0737. Supplement I requirements for a DCRDR:
1.
On.alifications and structure of the DCRDR Tese l
e include human factors specialists as integral, active sesbers of the
~
DCRDR team for the activities that ressin to be completed.
e' Document the responsibilities and levels of involvement of the human factors specialists and all other disciplines in each of the special studies and the selection and verificattom of design taprovements.
L 2.^
Function and Task Analysis
'. c i.:# '
Y s Analyze operator-tasks, information and control requirements, and required characteristics of. instruments and controls necessary to monitor and assess the various challenpes and failure modes of the Radioactivity Release critical safety functies, o Comprehensively analyze information and control requirements and required characteristics of instruments and controls for Steam Generator Tube Rupture.
c, 1
e Analyze required characteristics of instruments and controls for all h
emergency operator tasks.'. VM. o.. W4 WM.
N
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Ccaparison of Display and Centrol Requirements With a Control Room leventory Verify equipment availability and human engineerlag suitability for a
the requirements that are developed from the three activities listed under Function and Task Analysis, a.g';{U;.
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Centrol Room Survey c
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to the control room since the survey was performed.
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-.m 7{l e Review, assess and resolve the annunciator systes flash patteras, n
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Assessment of MEDs e Perform and document a systematic review of the cumulative ame
.i t
interactive effects of individual EDs.
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e Review, document, and justify the new prioritization of the 29 son using hvaan factors specialists.
L 4.
Selection of Design Improvements e Carry est and document a systematic process of select 185 desiS*
u.
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MA. improvements.
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- 3y e Ensure cumulative and tatsractive effects of individual MC3s some
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the whole integrated control room improvement package are jp j
considered.
e Improve E0 documentation for completeness, clarity, acewracy, arme l.
suditability.
l Develop solutions to HEDs and toplementation schedules that am e
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agreeable to the RRC.
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7' j ~ ' f ' M S.. Verification that laprovenents $111 Provide the Recese Corrections Without Introducing New EDs
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e Perform and document a systematic, rigorous method 1:3
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verifying design taprovements.
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Coordination of the DCRDR With Other !sprovement Programs
-[3 e - Perfore and docusent plans, procedures, and results of a ftsres*
S program.which ensures adequate coordination and inte1ratim af snur L j [3,j.
DCRDR with training, $PD$. EDPs, and Reg, Guide 1.97 tastvweerte-L
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In addition to these activities, there are several atvas etc see recommend that TED improve upon. The following recossendations er e em:
Intended as additional requirements but to escourage the fe'lest pax =shi.e benefit of the DCADR:
o Validate the control room for operator tasks includet in taw scenarios used for performing the Radioactivity Release cri-: can-safety function, e Apply standards, specifications, and conventions to a'1 z' arr.
operator interfaces. including the cor. trol room, pro:ed.ures. 7,4, r
remote shutdown panel, and other local plant interfaces.
e
- p.
e Review the human engineering suitability of the resote saus: cup-panel not only from the static stand;-ciat provided ny the neve.
checklists but also from a dynamic steedpoint providet by t,w tasse analysis and V&V.
o Review and ensure the completeness of the tiistorical docextasr review including plant-specific LERs and relevant bdustw m LERs.
e Review and ensure that operator interview consents fr ide-::"ytrue;
~' 5f/f R deficiencies and improving the control room have been docuse-cast ns 4
HEDs.
e Develop and maintain plans. criteria, aat p*ocedares 'br s'em:*m; human engineering review of proposed post-D RDR ctan;e: *= t"w
^
control roos, remote shutdown panel. ar.: otNr plant scerat:- r e -
faces.
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fe reconnend that Tt0 be asked ts sabet a supplerental Suasary Report m c~.
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- which documents as a alaisus the perfse1setze of the activities listed in f tens 1-9 above. The descripttons, assesseecs, dispositions, and toplemen-
.. p' '
tation schedules af HEDs.shes'd be la eranugt setail to allow an evaluation by the NRC to be performed (see essapies pmvided in the Analysis of pro. '
// My' posed Corrective-Actions and Justifications %r HEDs left Uncorrected sec.
W tion of this repcrt). TID's present schHluleior completion, as established la its January 31, 1985 letter, delays tk submittal of a supplesental n
f Summary Report untti approxiantely sto to hate 1989.
We suggest that NRC l '
and TCD negotiate a schedule br a more time';y completion of the DCRDR and
~
e submittal of a supplenkatal Lasary hyL 8
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>. v REFERENCES
[
s
~1..
" Detailed Control Room Design Review for the Davis-Besse Nuclear Power Plant
- Summary Report, attachment to letter from R.P. Crouse. TED. to
' J.F. 5t012. kRC. dated June 29. 1984 i
't.,
' Detailed Control Roon Design Review, Program Plan for Davis-lesse Nuclear Power Plant." attachment to I ttter from R.P. Crouse. TED to J.F. Stoir. NRC.' dated June 15. 1983. i L
l-3.
_ 4RC Review Comments on. Davis-lesse's DGtDR Program Plan." attachment -
to memorandus from W.T. Russell NRC, to G.C. Laines. MRC. dated October 7.1983.
p i
4.
Numan Factors Engineering Branch Detailed Control Room Design Review j
Safety Evaluation for Davis-8 esse Nuclear Power Station. Unit he.1.*
attacMent to memorandum from W.T. Russell. USNRC to G.C. Laines, i
USNRC, not dated.
L
- 5. - ' '$upplement 1. to NUREG-0737 Detailed Control Room Design Review Implementation Schedule." attachment to 1etter from R.P. Crouse. TED.
to J.F. Stola. USNRC dated January 31,1985.
L 6.
WUREG-0660. Vol.1. "NRC ' Action Plan Developed as a Result of the TMI-2 l.
Accident." USNRC. Washington, D.C., May 1980; Rev.1. August 1980.
[
7.
NUREG-0737 " Requirements for Energency Response Capability." USNRC; Washington, D.C.. November 1980.
8.
RUREG-0737 Supplement 1
" Requirements for Esergency Response Capability.' USNRC. Washington D.C.. December 1982, transmitted to reactor licensees via Generic Letter 82-33. December 17, 1982.
9.-
NUREG-0700. " Guidelines for Contro11% Design aeviews." USNRC.
Washington, D.C.. September 1981.
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3m 10.- NUREG-0800.
- standard Review Plan for the Review of Safety Analysis @p 3
' Reports for Nuclear Power Plants.' Section' 18.1., Rev. L O.- USNRC. c' Ai =
Washington. 0.C.. September 1964
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t MEMORANDUM FOR:
John F. Stolz, Chief Operating Reactors Dranch No. 4 Division of Licensing i
i FROM:
William H. Pegan, Jr., Acting Chief Hunan factors Engineering Branch 4
Division of Human Factors Safety
SUBJECT:
MINUTES OF HEETING WITH TOLEDO EDISON HELD OCTOBER 9, 198 IN DETHESDA by our technical assistance contractor, Science Appli, c p
i Corporetion(SAIC).
We understand that Toledo Edison plans to provide a submittal of Revision 4 to the Davis-Desse Course of A Please provide a copy of these minutes to Toledo Edison to ensure that the submittal addresses all outstanding man-machine interface issues associated with the DCRDR and the June 9, 1985 event.
We plan to provide DL with an SER which addresses both the a<icquacy of the Davis-Besse DCRDR and actions taken to meet requiremetits 'or restart as relate to the man machine interface.
af ter reedpt of a satisfactory subhittal.The SER will be providt:1 two weeks
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i William H. Reger,, Jr., Ar. ting Chief human Factors Engineering Branch j
i Division of Human lectors Svety i
Enc'esure:
As stated 3
cc:
A. Desgazio L
J. Donohew I
M. Fineberg, SAIC T. O'Donoghue, SAIC G. Johnson, LLNL i
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j 0511210533 051100 05000346 e
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I RGR4/ DAVIS BESSE MEETING MINUTES
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INF0bnL ftCHW1 CAL COP 9CN!CA110N l
Datt October 31, 1985 70:
R. Ramire!
FROM:
M.L. Fineberg U.S. Nuclear Regulatory Conrtission Washington, D.C. 20555
$ctence Applicationi Internations) Corp
- 1710 Goodridge Drive i
McLean. VA 22102 j
Attention:.
i
Reference:
$Al Project 1263 03 D20 XX NRC Contract NRC 03 82 076 i
NRC TAC No.-
sal Task 1 263 07 557 11 t
Title:
_ Detailed Control Roon Design Review tvaluations. Phases !!!.y
Attachment:
Minutes of NRC Meeting with Toledo [dison Concerning the Detailed i
Control Room Design Review of Davls Besse Nuclear Power Station.
FINAL Message:
Transmittal.
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NRC cc:
- 5. Bajwa SAI cc:
R. Liner J. Moyer i
D. Tondi D. Jackson N. Mtytr T. O'Donoghue h"1210 B51109
.7 2 pp Task file: 1 263 07 557 16
- 7. Cn 05000346 (f
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[ltfOltW ItCelCAL (99WW1 CATION
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TO:
R. Ramirer ngg; M.L. Finebers 9.S. Atlear Reguletery Cennissten
$clence Applicationi International Corp.
tieshtngton, D.C. 20655 1710 GoodriMe Drive Nclean. VA 22102 I
t Attentlen*
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.1
Reference:
$Al Project 1 263 03-020 11 i
ARC Contract NRC 03-42 0M NRC 1AC ho.
$Al Task 1 263 07-557 11
Title:
Detailed Control noom Des 19n Review tvaluations. Phases !!!-V j
AttacWnt: Minutes of EC Meeting with Tolede [ctson Concerning the Detailed
.j Control poor Design Review of Davis Besse 4.sclear Fower Stattor.
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R. Liner J. Moye r D. Tondi D. Jackson W. Meyer T. O'Donogha Task File: 1-2(3 07 557 16 M 1 1 2 1 h ' B 'A M CF ADOCK 050D g g..
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RRC Meettog With Toledo (dison Conceratag the Deta tted Centrol Los Design Review of Osvis Eesse Actear Power Station L
The ht: ett with Toledo (dison (T[0) on October 9.19t$. to discuss the Detailed Centrol Roos Design Review (D:RDP) for Davis Besse hutlear Power 5tation.
Specifically, the areas addressed dering the setting wert (1) the 6.-
concerns of (M ht from the pre te/lesentatte audit coiducted at Davis.
s' tesse the weet of Aprt) 29, 1985; and (2) the questions the NRC had concerning TID's $ystes Pet tew and Test Program.
The res61ts of discussten
(
in these areas are presented in this report, this report represents the observattoes conclusions, and recoprendations of the h1C staff and 5 Alt.
I The setting attendeel are listed in Attachrent 1 of ttis report.
,q DCRDR Based on tM resvits cf the pre.tsplerentation autit, the RRC concluded
.y that none cf the DCRDP elements could be closed out. Tt4 N R: audit tese found that TIO had made staten1 progress and expended sintoal effort toward s 3: f toopleting the MRBt requirteents sirte subsittal of Its Sussary Report.
i Bt Detoter 9.1985, acetto) was held to discuss the status of the D RDR and to resolvt the pret'est associatti with the DCtn Ptetteg attendees 3., ;
rece13rd t: dra't of 1[h p14% f t,"
f espostthg ts enh of the PC's lj tencvres.
"he restlh of the D!W portion of the stetisg cre preseeted below as ttey pertair to each of tre nthe eieretts that ces;rtse the hgR[&.
,f; D2h $spptreert 1 f eQv rent,ts for a D;RDP.
t 2
j, 1.
- Qustif trutions and Strut tert of the b RDR 7tte The NR: aptit '.eas fowsd during the pre teplementatio' autit that T[t*s plans for p<rforming the activities retaintag to be etapleted did est tac 19de en adewate level of involvesent of husen fatters spettalists.
The rtsaining MRDi attivities were the developrent and tend.r.t of the special stuttes etd the developetnt ant verification of H[t corrections. In the setting.1[0 a*d its bure f at tors consvitant. [sses Corporation, stated that human fatters spectslists for these and other activities will be tavolved as follows:
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e A dedicated proje:t leader from Essen Corporation has been estab-11thed.
e A baan factors specialist wr1 be dedicater to each special study, e Naan fa: tors spe:ialists wC1 he involved in the development and verification of O correctiers.
o Nese factors spe:ialists wr1 he involved in L. upgrading of the f
Systes functisr, art! Task Anaissis, the survej of components added to e
the coetrol roca since tte servey was last performed, the reassessment of NIDs. the presisction of centrol roos design standards ard conventieris, and the unrafing of DCRDR data collection anc M[t foros.
The RI: fewnd this cometteer: far involveeert of human factors g
spects11sts in the DCC8t 1: satisfy tw cancerns of the We: audit team. For the NRC to close out on this elemnt of the DCIOR. TID shc,uld provide decumentation describing ttis come tteret.
2.
Fun: tion atd Task Ana'isit j
Dsring the pre.ierlesertatier audit, the NRC autit tes e fourd T(O's I
Systes fun:tio* and Task Analysis (ITTA' to be incieplete. The WRC audit
]
e test conc 1gfed that tM fe'icving actsvities should let per fcered in order to meet t$e Fu*:tten and Tast Ana'ysis enstremot:
E 1.
Aralyze operator tasts. intareation and cintr:1 reasirement? af.d rtastred charact4ristics of instruments eW cae.tects necesaary to sentt:r and assess tw varuus challenges e4 failure modes of the Radioa:tivity hef ea:4 crittal safety function.
2.
Ceeprehenstrely analyze irtraitton and c::nt 21 requirements and required characteristics If isstruments anc controls for 5 tear Generator Tute k.;tn.
3.
Is adfition to tiers 1 and O. enelyze res41 red characteristics of it.str.sents and controls fsr all emergents erster tasks.
s t
4 In the meeting. TED stated that it will upgrade the 5FTA. Ytcstated that the 5FTA vegrade ottivities wl11 incivde the followleg:
1.
An analysis of operator tasks, informatten and centra'l retutre.
ments, and required characteristics of instruments and centrols necessary to monitor and assess the vartogs cha11entes and failure modes of the Radio #ctivity Release critical safety fonction including the following scenarlos and ap;11 cable ste:S free the toergergy operating procedures:
I e'
e A Small break $8t0tA s A major release up main vest stack e An wnmonitored release path l'
2.
An analysts of required characteristics of irstreserts and controls for all emerttacy operate
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DJring the pre.tsplementation avitt, the RR audit test ford that the analysts of inforsation and control requirements and required char 6:terts.
3 tics of testruments ans controls fo+ 5 team Centrator Tute tatsre was performed to a lintled ester.t. That, ts, the idensificatica or tilting of 19forsattor, and cer.troi reoutNeents art needet 6 sign the arteristics cat testruments ord contr$1s sas not as toegrehensive as that soggested by tM l
AT0ct.
In the setting. it0 stated test *.he analysis of ir fo estien and l
tontrol requireser,ts (not int 19 ding the nteded chartAtcrist'cs of ILC) performed for Stree Generator Twt 4 Aupture copected to be cos:rewnstw, J r.
h order' to desDestrate thAt its ant,1 sis et ib.forsatte and coet ci reqstre.
7 b
sents ($ as competeestre as the AT042 svgtest. it0 sho.14 erovide documentation of this analysis for Stese Generatet Tube R.rpt6ee.
)
L A revtew of Tf D's proposed
- Method for Updating 5FTA eed :6C teostre '
meets Vertf tcation" found no probless with the proposed 3pproact however,
)
T[D should be esplicit ir its docusestation of the final setiedcle;y of l
which characteristics cf needed tristrueents and controls will tw identified 45 requirements to be subseqsently vertfled 19 tte control two.
In summary. T[D'. utgrade of its 5FTA aprears to satts's t*e kRC's I
concernt if it (1) follees the sethcdology proposed in its
- method for l
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Upc ting SFTA *; (2) demorstrates a cosPrehensive analysts of information and contro1 reguirements far Stras Generator tube Rupture; (2) describes espitettly tse type of restred characteristics identified for instruments and controls; and (4) Seent'f tes these reestred characteristics at a level to the satisfaction of ste htC.
The StiA performed to satisfy DCRDR regetrements should be se estersion of the ht: approved 5f 7A pe'foreed to develop the spgraded plaat-spec tf tc [0Ps. The hit will conctwde on the adequacy of the 5fiq perfc-set to satisfy C*RDP requirements a f ter itD receives WRC approval of t*e $rTA perforeed to develop the plant specific
[0's.
{
j 3.
Corparison of Otspies one Control Requirements With a Control toor Inventory i
The RRC audit teas cc':lided thpt dse to the interpleteness of the 5ffA. the camparison er verificatt.on of the irforretton and contrc1 requirtaer.ts and required c1ars:teristics of instrwtents and controls with the control reos sect-o; casic not be corsidered corplete. The Pt: audit team conc 1 sort that in orde* te close est this eierert of the DCCR require.
~
otats. T[0 sust perfore a wrif tration of equipsent availet t11t,v and human engletering suitability fre tM rf 4stresrets thet are developed fro
- the activitias w:essary to at;*ide t6e $f f A tc cerpletion.
le the sketing and in its proprce; $FTA wppeset aNeoach. TF.t Indicated that this will be done.
lh order to clase out tHs *CPN renwireat t, itD shsv1d ptovide dotosente-tlan of this verteicatic' pre:ess and icentify acy resdting HIDs.
Ite asetwacy of :* s vurificat'te r*ocess evill te deperient on the a6etsacy cf t tu $ f! A.
I 4
Control b e Survey The NRC oudit tese fo.nd that the cce. trol reor survey condscted up to
(
the time of the pre.istieseetattta avdit was satisf actory, however, the i
fellowing aspects of the cc4tect roer were not evalwatec-9 o The new corponeets acted to the tentec) rete stece the surety was pe r fsemed.
e The ennsatlater sys.se flash pa t terns.
4
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Tf D stated in the settles that the new or esded components in the control room will undergo a husen factors evaluation. In addition. the annunciator system fissh patterns have undergone a review by Esse,s and v111 be handled as an HED in the annunciator study. In s+ der to close out this element of the DtRDR, itD should provide documettation describing the results of the human factors review of new or acted components to the l
control room, including any resultant H[Ds. Documentatie of the assesseent and resolution of the Hl0 asso:1sted with annun:later-syster flas' patterns should t>e included in the documented results of the mesrciator stbey.
I 5.
Assessment of HtDs g;
The att audit tese contivded during the prt.ir:1eventation audit that itD's assessment of HIDs was not acceptable due t: de ficiencies in the fol) wing areas:
o T>e cor sideration cf cueulative ard eteractive ef fects of individual MIDS.
l
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o TM reprioritization of 29 safety.related HEh.
/
J The tR audit tear four.d 18 4t there was nc systeratic review of individual NIDS to deterrine the presence of cuedative one $nteractive i
effe:ts upon the astessment of HIDS.
In the meetin;. t% ht lesroed that throw;h the use cir an UED datetast possessed by [55es. T!J will consider the ces.1stive and interartiet e f fe:ts of ir,dividual Hth woon the Ht: assess.
sents.
A review of the capabilities of the coepsteMJe.! NIC database fomd that the apprcach proposed sto.1d be e f ftttive 17 16.t t* ping couulative and intera:tive ef fects.
Tne prop: sed ap; roach is to ne various HID database fields (e.g., probler type or n' RIG.D7DD gsideline fiscrepancy, corporer.t J
title or type) to enable the 16eetification of competent or problen inte*ac-tions.
TED stated that in instaeces where interre*ated HIDs witt war.ing categerlaations are fosed Iower categorized HEDs wC1 tt upgraded..
l T[D's intent in the reprioritizatior, of the 29 sa fety signif t f[Ds l
associated with the special studies was to estat11th s:heduling p'lorttles l
in tk cctpletion of the ten special studies.
A retalt of this retrioriti-j 2ation was the downgrading of the safety significerce cf all 29 HIDs 5 it b
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relttet to the toplementattoo of MED corrections. The reprierttiration assigned later toplementation dates to the torrections of these 29 safety.
)
significant M[tA la addition to this delay in the tepienentation sihedule i
of corrections to ufety.stgmificant HtDs, the ht: avttt tese found the reprierttitatten to be unsettsfactory done to tk absence of human factors
{
input.
Dreral), the NRC found the repriertttratton of the 29 safety.
significant H[Ds tc be unacceptelle since (1) the safety. significance of l
. each of these 29 Ht:5 was dorn;raded froe i ts original assessPent. (2) the repricritiration did not inc16ade hwean factors inp.t w+4reas the original assesteent did, ahi (3) the justification for repricrittring these 29
[
safets significant 40s was not satisfactory.
In the steting. T[D stated that it and [sses will reassess the 29 safety significant KDs.
TED stated that while some of the k[D corrections will be performed petor to the rest, all corrections to the 29 HIDs will get priority attentice.
The NRC retstres that the corrections of sa fety.
significant HEDs assottated wit % the stese reedester Rsptvet Contet) Syster (5tRt$). Feedwater (Fil) Syste n, an! Post Accident Mortteria-WM) Syster te irplemented prior ta restart, All other safety siprificant Utc corrections should be implerented by !$e erd af the f t f th re fuelinglutage (presiintly schetsted for Spring of 1985). A11 cther HID corrections thos1d be teFlerented by the end of the sisth rifveling vettge (tresertly schetsiet for Fall of 1987).
i In sversry, the plans TID has proposed for reassessing HtDs for cur.;1stire and inte active e ffe:ts and its trplerentatto. c? HID ccrrec tions relative to HIO assessrer't s; pet
- to be accettatie. 1.D should sub.**
t docurentation of its finalizet plans for these D R: activities, inclutte; the FID correctiers to be perforset prior to restart, in order for this l
ele et to be closet out.
6.
- 41ect ion of Des tga. ;<= pro rearet s f ased on *5e ' Adir,$ t
- re.te;1erentation a.f tt, the htC audit tear conclaM.t.ai the to11 ooh tivities were ne: esse *y in order for Tit 30i.*
r ee u i. esen : -
' c act t
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<1 e Carry out and detunent a systematte process of selecting design y
improvements.
e Intyre cumulative and interactive effects of indteldeal WDs that will be corrected not corrected, or partially terrected open the whole integrated control two leprovement patlage ore constdered.
f e Irprove MID docueentation for completeness, claelty, actvtaty, and auditability.
e Develop solutions to NtDs and toplementatten schedviet that are agreeable to the NRC.
At the itse of the pre toplementation audit. T(D had eade little i
p*sgress teward the identtficettee and resolutten of M[t corrections since tve sitetttal ten conths prior af the $worary Report.
to systeestic, rigotws process for (dentif teg ard selecting among alternative corrections f
- t. Hits had been developed er esployed.
TID het developed corrective 4:ttons or justifications fer not tatng corrective cette6s for only 50s of g.
t*e HICs Itsted in the $uessry Resnt. In the setting. T[D discussed its p*ocess far Selecting MCD correctisms.
TfD needs to dotveent this process eu prestat flow disgress tilustrating this process to tM htC.
j l
Tne ERC aWit tver foung eo uttegrated appror.ct to the deitlopment of C to+rectio*S.
'he approach tak ty IID appearet to peorote a piecerea) etthof of telectirs and ist teettle; FID correctior) without adeq6 ate i
tisit*erettoe of turulative anc triterac tive e f fec ts of H!Ds.
In the
)
eettin;. TID responded to this concern by stating that the HID database will
)
etable curs 1stive and interactivt ef fects of HIDs to t,e toesidered. The i
DCDs tensidered util include all ef Ds. mot just these assottated with the special studies. As sentioned tr the Assessment of HIDs section of this re p o rt, the H[D database appears to be tuttable for performing this fec t iaa.
TID stated in the steting that it vegraded and costleted the H[D dotv.
sentation fosed during the pre-taplementation sedit to be incomplete, j
antignas, and tr. accurate. TED stated that 411 corpotents involved with each PCD here been recorded for trateat*11ty through the MID torrection process.
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8 i
1 In order to document this effort. f t0 should revide several HED samples whics demonstrate the upgrading of M[0 documentstieA A review of the $vneary Report found many testaeces where the responses l
to KDs wtre not finalised, and were esbiguous, entr.*ormative, or otherwise unatteptable to the WRC.
The WRC avdtt tese stated in the pre.
toplerentation audit report that in order te seet the reqvtrerents of Sup;'esent 1 to NUtIG 0737. TID should develop solutions to HtDs and teple.
mentation schedsles that are approved by the RR:. TC stated in the setting i
that it intends te do so.
In order for htC to ctsplete its revtes and apperval of H[D resolutions. T[D shesid propose Mtc corrections aed imple.
sentation dates that are atteptatle to the RRC, until dotveentation of all l
HID resolutions is provided, the ht;'s rettee is tacomplete. HID docusente-i ttor should be destelptive er.osgh to allow an irformed eve 1wation by the NR l
to te made. The level of detail of the informatter necessary to allow an eve 14ation is presented in the Davls Beste MID report.
In sawry. T[D needs ik provide do:vmertation af the following e The pro:ess for selecting HID correctioes, including acy suppo ting tilsstrations.
l l
e The eethodology for evaivating cumuletive &nd intera:tive effects l
=
vpon HID &rettions and justifications for mot isking correctlee a:tions.
l o An integrated appros:h to the developsett enf irplerettation of H[D corrections.
o Sat;ie HIDs deconstrating the upgrading of KD docuwntation.
l In addition do:weentation of all HtD resolutions for NR review should be provided on a 5thedsle agreeable to the ARC and TED.
8
I i
7.
Verificatten That leprovements Will Provide the hecessary Corrections
(,
Withest Introdwetag New MtDs I
the sRC audit tese found that no systematic, rigorous process for I
vertfying NED corrections was developed or emplopet.
In addition. TtD's design change process (sta FCits', did not in:1vde a been factors revie, in
[j verifying design changet. The ht: audit team concluded in its report that a systesatic, rigorous set %odology for verifying design topro esents $4sid t>e performed and that 16.15 process shos1d involve husen factors spet talists as j.
attive, lategral tesbers of the DCP.DR tee::. 1[0 stated.in the preting that j 7
espert judgment with the aid of the control race sock up served as the
^I process for verifytog stee of the ' simple
- FIDS.
For "comples* NIDs, such as tho4e tavolved in 5FM5. criteria wert use( as tk basis of the verifica.
{'
tion. T[0 stated tsat a human factors specialist w111 be 1 evolved in the J
FCR process during the CCRDR-After the DCRDR. a koan fatters specialist j' sill be lavalved it the FCR process en an as needed bests.
le order for r p
this element of the D*R'8 to be closed out. TID needs to proitde doturer.ta.
tien descrit leg its sethodology for verifyin5 H[D eorrectier.s and the taroleereet of humae factors specialists.
k.
Coordination of the DCCR trith Other leprovement frograes
^
l The CRC avdtt tese cordvded free its findings that althcug* Davis.
Besse's ce ganizstional strutture should enhance TID's ability te cocrdnate j
isproverent prograss, there was no evidence that any cocrdleation had occurred other thee t*e use of the EOPs as the tests of 'tre 5FTA, A
systerstic approats tc integrate the impreve.-*nt prograss had r.ot teer e s t a bi t sbe d.
In tSe setting. TIO cited its at tlity to cocro tra te the is;rovetent progress throggt its organizaticeal strutture are the FCR
~,
l process. However, the actual poiets of integration or interfaces and the iterative processes ame'.3 the taprovement prograts appea ed to t.e vn:ertain.
Tf D should docurer.t act only the stans by which it util coord trate the taprovement progrees. but also how these progrars have and will be I
trtegrated.
This docteentation should inc19te a description ef ttose aspects of each of the teproverent progrars which will relate to or integrate with the cthe 5.
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$Um ARe 1[D has addressed all of the conceres identified in,the pre.
j implementation audit report reistive to DCRDR req 61 resents.
In addition.
TfD has updated operator coevent forms, has eesured al) NtDs idertified in the operator foros are dec.eer.ted, and is establishing human factors
)
standards and conventions fo' sont aspects of the Davis tesse co' trol roon design.
Based on f isc6ssicrt with TID and its proposed schedwie for cos;1eting the D R?Rn '[0 has corritted to the followle; ettestones:
l
'f o Completed price t: restart loplementa t ten o f correc tient to sa fety-significant HIDs essxisted.it. sn:s. m. and m.
1 5
c' the/
o Corpleted by the er fif th re f 6eltr i outse e (currently scheduled for sprm; cf 198L):
i; 3
$pettel stwiles
!*plementatic c' co' rec tions to a!1 ethe sa fety significart MIDS.
o Cortleted by the e': c' the sisth re fweit r; outa ge (twi rently scheduled for fai' o' 195'):
i l
Ir4 ew*tatio' c f tre rer.a tning MID ccrrec tio*5 1
i Cos;1etion cf t'4. ?.;i.
l l
Li Ir. order for the hi; a'd 1[C to work tc.ard tte corp 1etten of the i
DCROR the follovieg areas 5%14 be documerted by T[C:
o O>alificatier.5 at: St s: 1.re o f the D*U ita r The hveen fatt:rs trvclierent in the re ainte; 00RDt attivities.
t E
)D
i e Function and Task Analysis The finalized approatt for vpgrading the 5FTA.
The analysis performed for 5 team Generator Tube Rupture.
The type of reg. ired characteristics identified for instrueents and controls, i
l c (ceparison of Display ar.t Control Regwirerents With a Control Roor I
leventory The process for 19 temperison or verificatiot of inforration and tortrol avillability and suitatility and any resulting HIDS.
c Ccetrol Root Survey T he results of the human factors rehiew of new or added toeponents to the tortrol room. including lany resultant HIDs.
The essesssent and resolution of the' HID as sociated with annunciator systre flash patterns (which should be included in the documented results of the annunciator stofy).
o Assentrent o.' HIDs The final mether:logi for evaivating and corrensating for the tsrsistive a41*ters:tive e f fects of individ.41 HIDS.
Tre finalized reessessment a p;roac h, trioritization, and schedsled ieplementation of corrections for the 29 HIDs.
o Selection of Design Imprciements The process for sele: ting corrections toy!(s. including flow diagrars wt.ith illustrate tMS process.
q * '_M, I
T ht final peth:fology for evolusting the curslative and inter.
l active effects u*on tM resolution of HID corr'ettions.
?-
i t
i 11 t
I*
4 An lategrated appreett to t% developeent sad topleatetetten of IED correc tions.
Sangles of vegraded a0 documentatten.
f A preposed lthedwie far the tubelttal cf N[h fer te review.
'e Vertf tcatten That !*t ove eents W111 Prae 1st the setetsary Corretttoes Withovt !*tectstles tre MIDS The methodology fee.ertfs tng MID terrettleas tativitng the partit tpatite of Nov f ac to*t spet ta1tsts, e to:ediaattee of the D*e:t uits Other Im;*ctesert Progrees The nears by eAlth t% laprovement prsgrams elli be teerfinated.
how the terrevesent progreen have and etil be tetegrated.
/
incivdteg thcSe att+c11 of each of the progrees which et11 relate it a*d tetegrate wit
- t'e etMrs.
l e ScNfvileg of the D;e:s l
$thedsie fe' s.trittal of the dc.6*eetat te* listet in this reptet.
l' Cce 1etion sches.i, tv;19tts; daten if post tle for tM spet tel t
i Stuttel.
SCMSele for the tesimtatten cf M( cc rrec tieas.
Coe:1 e t i r o f t he L* e **.
11 p
i 1
l SYSTEM ttVitw AND ftST PtostAM In response to the June 9,1985, event at Dar ts lesse,, f(D ha s
]
developed and is perfereing a Systes Revlem and Test program.
The objectives of this progree are (1) to identify problems which may potential.
ly tapatt tot abtitty af those systems to perfore the fonttlers they must perfore fo* safe operatten of tne plants (2) ta identify the correctlee i
attions necessary to resolve these problers; and (3) to 1dentify any spet1al j
testing of the system tsat should be performed during restart power estersion. The prograr util also review the scope of surveillance testing i
conducted of thest systeps to ensure they are prt$perly tested.
TID snettled d'tweentation of its pre. gram to the NRC.
The RRC's
}
review of ttis dotsoemt produced a nuuber of questions which were documented in a Settester ??, lit!, ht* semorandse transattted free W.H. negan, Jr. to l
J. Stola.
Prior to the October 9 sceting. TfD obtained a copy of the sencrandwe and had respasses to the questions preparet for the steting.
Many of the respovses were references te ;rtelous discussion in the meeting concerntng the DCCe.
Some of TID's DCRDR opgraer atttons are performed as i
part of the Systes Reetes and Test Progras, in order to det.rease the redwadsety of 61stwsstoa to these areas, many of TID's responses destrit>ed below will re ference prestows discussion in the DORDR section of this re por t.
The discusstor t>elow in structured in at NRC question. TID response j
foerat.
Tit's responses are not quoted directly tsut reflect the kPC's irterpretat'on or underst4 Ming of TID's responses.
StCT!O% ll.C.5 1.
As part of tw '5fstees Arview and Test protees.* Systems nre ten f,rosts wt11 c:e. sider the sly lfitant MIDS identified by the DORDP.
k8: besttoa: Does t4vis.lesse plan to reassess the priority and sched 'e for tettementing corrective attices for all 29 HIDs reported on in its Arne 79,196a, $ons.a.y Report ?
13
),
TfD sponse: f(5. Of the il atDs involvet, it were reassessed as part of the St&TP and the etWs as part of the DCRDR.
As previously sentioned. [sses human factors specialists i
will be involved in the reassessmeet.
2.
This reassessment will be accospitshed as pe-t of the *5ystems heview and Test Program' in Section II.C.7 of the Daits-lesse 4eport, 1
y kkt bestion: What is the schedsle for perfoming II.C.??
l l
k Tip nesponse: The 5ttf P. er II.C.f. will te perfereed during the present outage prior to restart.
}l 3.
Tt0 states 'All significant generic HIDs will be considered as well as j
]
the specific HtDs related to systems being reaieved eder the program.* l j.
t 3.1 Ntt bestion: Describe the difference between generic and spec t fic Hits.
1, TfD ksponse: Gegric Ntos invalve problems pervading the cortrol room I'l soth as inadeguate labeitng. Spe:t f tc Ntos rela te to probless associated with spectf tc componeets.
The difference apparently is the degree of pervastieness of the problem in the control roos.
5 Lf l 3.2 ht: bestion: Will human facters specialists le iP'Isded in these reviews and to w4t entent?
)
i TfD Aesponse: Vli.
The project leader from Esses is dedicated to the cospletion of the remaining ICRD1 activities and this i N' -
area of the 588TP. For further discussion, refer to the balifications end 5truttare af tw DORDs. Teae section of the DCRDR portion of this rupert, w'
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4.
TfD - fach NED will be assessed to determine whether correction is reteired in the short ters (prior to restart). and these will be i
)
resolted.
I BRC bestient Define ' resolved.'
l i
it0 Desponse: 'Itesolved' and 'dispositioned* sean the same thing as i
inplement a tion.
I 5.
,hemaining N!Ds wt11 be addressed 45 part of the cortinuing irplerents.
tion of the DCRDR program.
l tRC bestion: Discuss what this means.
l TfD tesponse: This seans that 0 corrections not needed for restart will be addressed after restart.
i 6.
Regardtag significant HEDs which affsted the ihne 9 event, appropriate compensatory er corrective actions will be irplemented prior to
~
restart.
WRC W estion: Proposed actions should be sube tted for ht: review and acceptance. Will thep!
i TEC Response: (kone.
hP; will need to discuss 1615.)
t i
t l
7.
Actions described tc correct 5f RC$ HtDs [11.0.5 (pg. 76. 2nd pa ra.
gree.)] appear to be okay.
l TIO states. 'The new arrangerent has been reite et for human facters considerettons.*
- ! bestion: Were these reviewed b hue.an factes specialists?
l T[0 Response: 1[$.
Re fer to the answer to questio* 3.2.
4, ja.,;
35 1.
8.
Other sabr control reos 4esign problem. Puswwtton arrangement for
- e startup feedwater valves for aligning startep feedeater pump.
TfD no longer considers this probles relevant state the new motor driven feedwater pump wtil be aligned differently and any operettenal coesid.
erations related to use of the new pump are betyg tensidered as part of the design process, r
C'. ! RRt Ovestion: Does the
- design process
- tacInde hu man factors engineerit.g support for evalwattrg required controls and displays and integrating these teto the esisting tortrol room t: tis for the new feed.eter P.ses?
Tf D Response: YES. nefer to the answer to questtec 3.2.
8? kRC Ouestion: Also, will an M.f. engineer participate in developing control and display arrangeme*ts for the differer.t valve alignment for the riew motor (+1ves feed pwApt TID e/spense: Yl$. nefer to the answer to question 3.t./
p.
A change (HID) not identifled in the DCD2R isvolves PORY position l
Indication now on the PAM panel which v111 be depittated at the
- sition adjacent to the P3eV control swittk.
RD: Ovest ten : Why didn't the D*RDR ideett fy th s KD?
It should have l
been distceered furing the panel layout and control /
display reistionship surveys.
Tets raises the qsestion of adequacy of process and penome) ased for perforsing the surveys.
Please discuss.
TfD tesponse: This partlevlar probles was missed in t he Ot tDR.
However. this ene instance is not indicattie of the survey or Persotet1 Used.
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4 SECTION 11.C.7 $rstee newtew and Test Pronras (Ps. 81]
- 10. Introduction Rev iew is intended to identify penblems whits say potenttally tepct i
I the abtitty of those systems to perfors tk functions they oust perfore for safe operation of tk pleet, to identify corrective actions necessary to resolve thosp prob 1tes, and to identify special testthg of the systee that should be perftemet during testart power ascension.
10.1 RRt Ovestion: Explain what is meant by *...probleer which eay potentially bpect the oblitty of those systems...'
\\
Tf D Respo se: The probless referred te were not design problees related t Naan fatters At te the syster engineering.
10.2 WRC @estice: Are human factors specialists involved in this reitew and test progras, and to what enter.t will they partici.
I pate?
Tf D Rest:ese: TES. Hasan fatters spetlalist(s) will be.inecived in l
the review of docusented equipsent problems aM bathfits
- i subseqsent to the Systees heview Group's evaluation.
hDC Centwets: TED shos1d imitate tut those systers incivded tr the June 9 event have undergot.e a huwan fatters reties. and i
associated MEDs will be resolved to the satisfaction of I
the NRC.
10.3 NDC Ouestio+: Will new N!Ds be identified avJ evaluated as part of the revtes and test progras?
If answer to question IC.2 15 no, by wSor v111 they be identified?
The poter.t7a14. ists for me. (Os to be identified, It0 Response:
m.
17
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1 I
II. lachartund (Pa. 81)
TfD tencivded it was necessary to evaluate satt twipstat history to idthttfy significant or tecurring equipment pr341 fees to er.svet that the root cause is identified and corrected.
3 l
i tRC b estion: Does this seen that only equipacit problems stil be
]
evolvated or does it also int 14de man nathine interfate problems ?
]
TCD Response:
It includes san machine interface arotless to the entent i
that HtDs identified from the ICCr will be reviewed.
1
- 12. Program Otdret tves (Pe. 8?)
The 115t of five objectives did not indicate w' ether huren factors concerns would be addressed.
W111 human factors considerattans sr addressed?
NRC besticn:
TfD Response: Yts, to the entent allowed in tw mies of HEDs identi-j fied from the DCRDR and by the role given to human factors spettallsts as reviewrt.not participants of doeurented equiprent probless and ackfits deterstned by the engineering and operations.orseted Systess Review Groups.
l I
- 13. Procree 4; roach (Ps. 86)
Five Systes Review Groups ($RCs) will be estakt shed to conduct this program. $ystems are assigned per gr Dupings listed in Table !!.C.7.1'
' )i/f (Pgs 84 and 85).
The groups consist of Teleat Edison eagineering l
personnel and experienced support personnel f-es the nuclear industry, f
s "hihe support personnel are highly que11 fled 'nicatry representatives empertenced in system design, operation, and ast og.
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4-e 13.1 het M stion: Are human facters sPetta11st6 facloded in the review groups?
TfD trsponse: NO. - Refer to the answer to qwtstten it.
i a
\\i 13.2 _ Ret bestion: Provide detatt as to tM compositten of each team with l
i respect to todtvidual areas of espertise.
i Tt0 hesponse: Refer to tk answer to questtan 12.
13.3 Wet bestion: Will these groups tensider own.sacktne Interface h
troblem>?
Tf D nespen,Jte: Only throvsk the rettew of KI3a estos.
There is no other activity in the 5RLTP to restew espiltitly san.
sect.tne inter face.
I!
?
14 The resvits of the 5kG efforts will be docemented and then will be l
I reviewed and approved by an Independent Precess Review Croup (IPRG).
This group is corposed of senter T[D engineerleg personnel and other top level industry esperts operating in &Cco-dance with a formal charter.
14.1 t#: 4estion: Descrite areas of espertise of eeth member of the IPRG.
Tto Response: The areas of espertise represeetet t*y the aesbers of the IPRG do not include human fatters.
14.2 Ret bestipa: Provide a cspy of the ' formal the-ter" for WRC review.
- q..
Tf D tesponse: The NRC has a copy of the forset charter.
'.N.k;.-,
- 15. $ysten perferaante Revtew (P s. 87 88)
Q A review of past equipment performente regesres an ensetnation of historical inforsation on the system. Such infsrsation is available in many dif ferent formats. A Itst of types of Dtsterical information
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betan ceasidered is provided.
Facluded in the Itst is % san Engineer.
ing Defittencies (NEDs) which were developed os part of the DtRDR.*
The WDs document deffettwies related to the een.nechtne interface between the operator and control room indications sad tent: st g.
.c.
15.1 tRC Questten: Why are tk reviews limited to only EDs identified free the 0 RDR?
TfD nespons_e: (hone.)
I 15.? kPC Avstin: Why doesn't the sen pachine later face go beyond indicators and controls to int 1wde the equipment being s
contro11et?
Tit nesponse: T[D states that the approach is comptehensive of ran.
f l
snachtne itterface within the scope of the DCRDR.
w l
y
'D;.
StpHAtt y,
With several eaceptions, it0 responded to the Rt". questions concerning the S M TP. Yne enceptions refer to met questions nasbered 6 and 15.1 to which TED did not respond. In reference to NRC question avsbered 6. Tf D should subatt detvoentatice of its proposed attists for NRC review and a pproval.
la et ference to ts* question musbered 15.1, T[0 should documer.t a response for Sk? review.
NR question numbered R? reeds
'Why doesn't the san.sathine inter-f ace 30 beyond indicators ad centrtill to totivde the equipment beirg j
controlled?' $tated in anot'er way, t.he Ret question 16. *Does.the review of san eschlee. taterface coesider the plant equipmeet controlled from the control roon for which the panels provide an operator interfaceT* TfD
~
should docustat a response tt this question as restatM for WRC reitew.
In addition. TED should provide documentation of its responses to all the ht:
que s tiens.f. '. <
m...l:.
l' (.,
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^: fp;n -
r0 1
1 e
l l
l ATTAt mCNT 1 i
l Attendees of the Meeting Held ktober 9,1985 to Discuss the Davis lesse DCtDe
!li TfD Depresentatives TfD
' Jetgue lingenfelter Issen Co poration Richard Morrissa I
Sart4ra Paracere Isses (c poratier.
TED b bert Peters a
i U$tt0 Representatives i
Al De Agatto g5Nat Joe Moyer
$ Alt 11nothp D'DonogSve 5AlC U5at:
W1111ao hepen Bee 1mic Tendi U542C
$1!$75 Mort Defilm Duquesne Light tcmany
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