ML20011D165
| ML20011D165 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 12/31/1989 |
| From: | Bird R BOSTON EDISON CO. |
| To: | |
| Shared Package | |
| ML20011D164 | List: |
| References | |
| NUDOCS 8912210172 | |
| Download: ML20011D165 (98) | |
Text
Pilgrim Nuclear Power Station FINAL ASSESSMENT REPORT
- DECEMBER, 1989 1
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- EDISON wwnane P
t BOSTON EDISON COMPANY PILGRIM NUCLEAR POWER STATION FINAL ASSESSMENT REPORT DECEMBER 1989 Approved:
d_____.
12/14/89 Ral~ph G.
Bird Senior Vice President-Nuclear
Table of Contents I.
Executive Summary and Introduction 1
II.
Assessment of Key Operational Experiences During Power A,icension 12 A.
RCIC Event 13 B.
Feedwater Regulating Valve Event 15 C.
Condensate Pump and Suction Piping Overpressurization Event 16 D.
Actions and Improvements in Response to the Three Key Operational Experiences 17 1.
Pre-Evolution Briefings 17 2.
Authorization of Emergent Work During Plant Operation 18 3.
Independent verification 19 4.
Operator Attention to Plant Status 21 5
Procedural Improvements 21 6.
Strict Adherence to Procedures 22 III.
Assessment of Other Experience During the Restart and Power Ascension Programs 25 IV.
Assessment of Experience During the 1989 Surveillance / Maintenance Outage and Post-Outage Operation 29 A.
Outage Significant Positive Indications 30 B.
Outage Areas for Improvement 32 C.
Post-Outage Operation 33
i lL l V.
Processes for Sustaining Improved Performance.
35 A.
Improved Efficiency and Effectiveness of Procedures and Directives for Routine Activities and Decision-Making.
35 1.
Administrative Procedures and Directives 36 2.
Process Documentation.
36 3.
Working-Level Procedures and Instructions 37 B.
Management Oveisight and Self-Assessment Processes 38 1.
Management Oversight and Assessment 38 2.
Peer Evaluator Program 40 3.
Quality Assurance Monitoring Activities 40 4.
Management Backshift Monitoring and Watchstanding Program.
41 C.
Improved Long-Term Planning and Problem Identification Processes 41 1.
Long Term Plan 42 2.
Improvement Action Database 43 3.
Corrective Action Clearinghouse 44 D.
Effective Management Organization and a Plan to Provide Continuity of Qualified and Experienced Managers 44 1
l'
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VI.
Integrated Lessons Learned 49 A.
Integration and Prioritization of Activities 49 B.
Establishment, Communication and Maintenance of Objective Performance Standards 50 C.
Management Oversight and Critical Self-Assessment 50 D.
Organization, Experience and Succession 51 E.
Procedure Validation and Verification Si F.
Procedural Adherence 52 G.
Ensuring That Nuclear Organization Expectations Are Understood and Implemented at Each Working Level 53 H.
Design Information 53 I.
Effective Maintenance Planning, Scheduling and Execution 54 J.
Operational Heat Sink 54 VII.
Conclusions 56 APPENDIX A A-1 ATTACHMENT 1 1-1 ATTACHMENT 2 2-1 ATTACHMENT 3 3-1
u, I, Executive Summary and Introduction Throughout Boston Edison Company's implementation of the Pilgrim Nuclear Power Station (PNPS). Restart Plan and Power Ascension. Program, Boston Edison has engaged in a process of critical self-assessment and evaluation.
The major elements of that assessment process have been:
the evaluation of PNPS management practices presented to the NRC by Boston Edison's Senior Vice President-Nuclear on September 24, 1987; the evaluation of programs, plans and actions necessary for restart embodied in the PNPS Restart Plan;
.in-depth assessments of maintenance and radiological controls which resulted in the Material Condition Improvement Action Plan (MCIAP) and the Radiological Action Plan (RAP);
the Restart Readiness Self-Assessment (RRSA),
which provided Boston Edison's overall assessment.of PNPS readiness for restart; the assessments undertaken by the Management Oversight and Assessment Team (MO&AT) at each of the assessment points specified in the Power Ascension Program; and investigations and critiques of specific events that have resulted in measures to prevent recurrence and otherwise improve management of nuclear activities.
These self-assessments have culminated in this Final Assessment Report, which provides the bases for closure of the Power Ascension Program and demonstrates satisfaction of the conditions of CAL 86-10 and its Supplements.
i
.e 2-The conclusions of this Report are also based upon observations w"
.and results obtained through testing at the 100% power plateau 1/, conduct of the October-November 1989 surveillance / maintenance outage, and post-outage operation under the-Power Ascension Program.
The first CAL Supplement (August 27, 1986)-required,
-jamong other things, that Boston Edison implement a program that lincludes:
(a) formal assessment of... readiness for restart (and) hold points at appropriate stages such as criticality, completion of mode switch testing, and at specific milestones during ascension to full power.
Authorization to proceed beyond each hold point'will be contingent upon'[ Regional Administrator) approval and will be based on (the NRC Staff's) evaluation of the operational performance of the plant.
The second CAL Supplement (December 30, 1988) stated that
"[sjuccessful conpletion of the Power Ascension Test Program is necessary for final closecut of CAL 86-10."
Boston Edison has concluded that the conditions of CAL 86-10.and its CAL Supplements have been met, based upon
' satisfaction of five criteria.
Those five criteria are listed if Two operations originally scheduled for the 100% power plateau.(the recirculation pump motor generator scoop tube position determination and the traversing in-core probe alignment) have not been completed.
These two operations will be performed at a later date.
The Power Ascension Program has been revised to reflect this change in accordance with the process set forth in the second Supplement to CAL 86-10.
Je
- below, along with the measures through which Boston Edison has determined that the five criteria have been satisfied:
1.
The plans,_ programs, and actions defined in the PNPS Restart i
Plan as necessary for safe and reliable restart and continued operation have been satisfactorily completed, as demonstrated by the followings a.
The Restart Plan and RRSA were reviewed and found satisfactory by the NRC (Letter, Samuel J. Collins to Ralph G. Bird (May 6, 1988); Letter Samuel J.
Collins to Ralph G. Bird (July 11, 1988));
b.
The bases for restart established by Boston Edison management in the Restart Plan have been satisfied (RRSA Chapter V);
c.
Improved SALP performance has been achieved, particularly in those SALP areas for which increased regulatory attention had been indicated (SALP Report 88-99; Final Assessment Report Section III); and d.
Valuable lessons have been learned in the course of execution of the Restart Plan and the RRSA and appropriate actions have been taken to address areas identified for additional management attention (Final Assessment Report Section III; Appendix A).
2.
The actions defined in the PNPS Power Ascension Program as necessary to demonstrate that PNPS could achieve safe and
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reliable restart and continued operation have been satisfactorily complet%$. as demonstrated by the following:
.a.=
The Power Ascension Tregram was reviewed, subjected to intensive on-site coverage, and found satisfactory by the NRC (Letters, William T.
Russell to Ralph G. Bird (December 30, 1988; March 3, 1989; June 26, 1989; August 18, 1989; and October 6, 1989));
b.
Each element of the current Power Ascension.
Program-has been completed.
As discussed on page 2 above, two operations will be conducted at a later date. (Final Assessment Report Section-III);
and c.
Valuable lessons have been learned in the course; of execution of the Power Ascension Program and appropriate actions have been taken.
(Final Assessment Report Section III; Appendix A); and d.
Valuable lessons have been learned in the course of the 1989 surveillance / maintenance outage and 1
post-outage operation, and appropriate actions are being-identified for implementation in future outages (Final Assessment Report Section IV).
3.
Boston Edison has examined the key operational experiences occurring during the course of power ascension, and has taken appropriate action to incorporate that experience into PNPS operations, as demonstrated by the followings
5 a.
Management has institutionalized specific q
requirements and improved practices for pre-k
. evolution briefings (Final Assessment Report Section II.D.1);
b.
Improved field controls over emergent work have been instituted (Final Assessment Report Section II.D.2);
c.
Nuclear Organization expectations as to the meaning of " independent verification" have been effectively clarified (Final Assessment Report Section II.D.3);
~d.
The Conduct of Operations procedure now requires increased operator attention to plant status (Final Assessment Report Section II.D.4);
e.
Processes for procedure validation havo been improved and expanded, and an upgrade of Station procedures is in progress (Final Assessment Report Section II.D.5); and f.
Management has communicated the need for strict adherence to procedures and experience to date with operating procedures indicates this has been effective.
Improvements in administrati'.re processes are still required and are being pursued.
(Final Assessment Report Section II.D.6).
1 k n 4.
Boston Edison has established the bases for sustained improvements in performaace at FEPS, as demonstrated by the followings
- a..
' Efficiency and effectiveness of procedures and diicctives for routine activities and decision-
. making are being improved (Final Assessment-Report Section V.A);
b..
Effective management oversight and critical self-assessment processes heve been established and are in place for the long term (Final Assessment Report Section V.B);
c.
Improved planning and problem identification processes are in place and are being refined (Final Assessment Report Section V.C); and d.
An effective and stable management organization is in place, adequate resources are available, and a succession plan is in place to provide continuity of qualified and experienced managers in the future (Final Assessment Report Section V.D).
5.
Boston Edison's cumulative experience, from initial formulation of the Restart Plan through completion of the Power Ascension Program, has yielded valuable lessons and resulted in appropriate actions, as demonstrated by the following:
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Actions to improve integration and prioritization of activities (Final Assessment Report Section-VI.A);
b.
Establishment, communication and maintenance of objective performance standards (Final Assessment Report Section VI.B);
c.
Implementation of management oversight and i
critical self-assessment processes (Final
(
Assessment Report Section VI.C);
d.
Improvements in organizational' structure, management experience and planning for management succession (Final Assessment Report Section VI.D);
e.
Implementation of improved procedure validation and verification (Final Assessment Report Section
]
VI.E);
f.
Actions to ensure strict adherence to operating procedures (Final Assessment Report Section VI.F);
i g.
Measures to ensure Nuclear Organization i
expectations are understood and implemented by i
managers, supervisors and personnel operating and maintaining the plant (Final Assessment Report Section VI.G);
h.
Efforts to improve definition and use of design basis information in operations and maintenance (Final Assessment Report Section VI.H);
's 1.
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Actions to improve efficiency of maintenance planning, scheduling and execution (Final Assessment Report Section VI.I); and j.
Measures to enhance operational heat sink capability.(Final Assessment Report Section VI.J).
l Section II of this Report focuses on the three key operational experiences which resulted in-the most fundamental
- programmatic improvements initiated by Boston Edison during power ascension.
Those three experiences are the (1) April 112, 1989 RCIC system event; (2) May 3, 1989 feedwater regulating valve event;.and (3) August 2, 1989 condensate pump and suction piping overpressurization-event.
As-a result of Boston Edison's self-assessments and evaluations of these experiences, the fundamental importance of strict adherence to procedures, independent verification and pre-evolution briefings has been highlighted for the Nuclear Organization, from the most senior levels of management to those with hands-on responsibility for plant operation and maintenance.
j i
Operator monitoring of evolutions and control over emergent work are improved. Procedural inadequacies are being systematically identified and corrected, and the validation process is being strengthened.
The importance of taking adequate time to achieve desired results is being stressed throughout the organization.
a 4
_ _ _ _.Section II demonstrates that Criterion 3 for closure of the Power Ascension Program and CAL 86-10 has been satisfied.
Section III of-the Report discusses the status of the Restart Plan and Power Ascension Program and introduces Boston Edison's assessment of its cumulative experience during its implementation of those programs.- The results of that assessment are presented in Appendix A to this Report.
Section III and Appendix A demonstrate that additional
-significant improvements in overall performance, including
. improvements in those areas where SALP reviews had indicated the need for increased regulatory attention, have been achieved.
Accordingly, they also demonstrate that Criteria 1 and 2 for closure of the Power Ascension Program and CAL 86-10 have been satisfied.
Section IV of the Report summarizes Boston Edison's experience during the 1989 surveillance / maintenance outage and post-outage operations to date.
Section IV confirms Boston Edison's ability to safely and reliably operate the plant, and satisfaction of Criterion 2 for closure of the Power Ascension Program and CAL 86-10.
Section V of the Report discusses the integrated program established by Boston Edison to ensure that improvements in performance attained during the Restart and Power Ascension Programs are sustained into the future.
Four interrelated components are discussed:
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Improved efficiency and effectiveness of procedures and directives for routine activities and decision-making; Management oversight and self-assessment
. processes; Improved long-term planning and problem identification processes; Effective management organization and a plan
~to provide continuity of qualified and experienced managers into the future.
Section V demonstrates that Criterion 4 for closure of the Power Ascension Program and CAL 86-10 has been satisfied.
Section VI of the Report provides the " integrated lessons learned".from.the overall critical self-assessment process' undertaken during implementation of the Restart Plan and the Power Ascension Program.
The lessons learned discussed-in that Section provide a perspective on the actions necessary to sustain improved performance into the future.
Section VI demonstrates.that criterion 5 for closure of the Power Ascension Program and CAL 86-10 has been satisfied.
Based upon the information presented in the prior-Sections of this Report,Section VII provides Boston Edison's overall conclusions.
It concludes that Boston Edison has demonstrated that its programs to ensure safe and reliable restart and operation are effective; that programs, plans and personnel are in place to ensure that improvements will be sustained; and that the conditions of CAL 86-10 and its Supplements have been satisfied.
l i "
While many improvements in performance at Pilgrim have-been achieved, Boston Edison remains mindful of the potential for problems in the future, and of the need to continue our efforts-i to improve.
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.. II.
Assessment of Key Operational Experiences During Power Ascension The purpose of this Section of the Report is to focus on three operational experiences during the Power Ascension Program which have been the primary impetus for many of the programmatic improvements initiated by Boston Edison, and which therefore deserve special attention.
These experiences focused the attention of the Nuclear Organization on the need for specific changes and improvements in PNPS operation, and resulted in-many significant changes.
These three experiences were the April 12, 1989 RCIC system event; May'3, 1989 feedwater regulating valve event; and August 2, 1989 condensate pump and suction piping overpressurization event.
Presented first are brief summaries of the three key operational events, including descriptions of their causes.
Because many of the actions and improvements undertaken in response were the result of-Boston Edison's assessment of more than one of these experiences, the actions and improvements are then treated collectively.
Each of these events has been previously reported to and reviewed with the NRC.
These three experiences were of particular value and importance.
They revealed areas where fundamental improvements could be made to PNPS operations and procedures.
As a result of these experiences, Boston Edison has undertaken actions intended to ensure that the importance of
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strict-adherence to procedures, and effective independent verification and pre-evolution briefings has been. highlighted
-l throughout the organization, from'the most senior levels of h
management to those.with hands-on responsibility for plant operation and maintenance.
Actions have been taken to improve operator monitoring of evolutions and' controls over emergent j
. work, to-address procedural inadequacies, and to improve valve lineup and tagout procedures.
In addition, the overall procedure tvalidation process is being strengthened.
The importance of l
taking adequate time to achieve desired results is being stressed.
f
- throughout the organization.
-i i
A.
RCIC Event On April 12, 1989, the RCIC system was declared inoperable as a result of reverse leakage past the system's injection check valve.
The leakage occurred during a scheduled 3
i RCIC system logic system functional. test and resulted in i
overpressurization of the system's suction piping and the discharge of water from the suction pressure relief valve to the j
i RCIC floor drain.
The event is documented in Licensee Event Reports (LERs) 89-014-00 and 89-014-01.
Four aspects of the RCIC system event revealed areas
. here significant improvements could be achieved:
w (1)
The Nuclear Watch Engineer (NWE) incorrectly determined that performance of the RCIC surveillance procedure
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in was' routine and therefore a formal pre-evolution: briefing was not necessary..This was contrary to the Nuclear-Organization expectations.that-detailed briefings would be conducted prior to complex or infrequently performed activities which were-significantLto safety or plant operations, or which involved interface-with the, Control Room.
-(2)- LIn executing-the tagout procedure for the RCIC surveillance, operators incorrectly positioned and/or verified
~
-the positions of circuit-breakers for several motor-operated
' valves.
Investigation revealed that the operators involved did not understand the Nuclear Organization's expectations as-to the meaning of,the' term " independent verification."
Additional interviews with operations personnel showed that while almost all operators understood the requirements for independent judgment
=and accountability in verifying tagouts, some did not understand
.the organization's expectation that separation of the verifiers-in space and time was an integral part.of independent verification.
(3)
An incorrect circuit breaker number in the test procedure led to a breaker being opened erroneously.
Further effort was required to ensure adequate validation of procodures and eliminate ambiguity.
Walkdowns to identify deficiencies in procedures needed to be done in a consistent manner.
Revisions were needed to reflect input from all cognizant functional areas.
, (4)
In the period immediately prior to the RCIC event, sufficient indications were available in the Control Room to have permitted the operator to dotect the improper lineup of motor-operated valve circuit breakers, if the operator had been briefed on thr;.vtails of the surveillance to be conducted and if the operator had been closely monitoring those particular indications.
This event pointed out the need for raising the level of operator awareness of plant evolutions which could affect the Control Room.
B.
Feedwater Regulating Valve Event on May 3, 1989, a high reactor vessel water level occurred that resulted in an automatic turbine trip, generator trip and reactor scram.
The high water level resulted from the unexpected opening of a Feedwater System regulating valve (FRV) while personnel were troubleshooting the actuator controls.
The primary cause of the valve opening was inappropriate use of the General Troubleshooting Procedure for troableshooting the Feedwater System Train "D" regulating valve actuator controls.
The procedure did not. require a detailed work plan and the pre-evolution briefing that was conducted was not adequate.
In addition, an inappropriate determination of urgency led to NWE authorization of maintenance without the normal pre-planning processes.
Thus, the troubleshooting was ad hoc and the valve was not reset per the Feedwater Control Valve Isolation and
7. -. j Maintenance Procedure.
This event is documented in LER 89-015-00.
l Two aspects of the FRV event revealed areas where further improvements could be achieved (1)
Investigation revealed that the Nuclear Organization's expectations as to the extent of pre-evolution briefings for complex ovolutions were not fully understood; and (2)
The WWE made an inappropriato determination of urgency which led to authorization of maintenance under the General Troubleshooting Proceduro.
This revealed the need for better controls over emergent work.
C.
Condensato Pump and Suction Piping _Overpreggurization Event On August 2, 1989, while restoring the "C" condensato pump and its piping to operation following removal of the suction strainer, the pump and suction piping were overpressurized.
An operating condensate pump was cross-connected to the "C"
pump through small-diamator, samplo piping to backfill the isolated suction piping.
The vont path was inadequato and the auction piping was, thoroforo, overprossurized.
Two aspects of the event revealed areas whore improvemonts could be achieved:
(1)
Operators erroneously proceeded with an evolution for which there was no procedure by adapting an existing procedure rather than stopping to have a formal procedure written
i and approved.
This raised the question as to whether operators fully understood the Nuclear Organization's expectation that strict adherence to procedures is necessary with respect to non-safety related, as well as with respect to safety-related systems; and (2)
Inadequacies were revealed regarding the filling, venting and draining procedures.
D.
Actions and Improvements in Response to the Three Key Operational Experiences j
Numerous actions and improvements were taken in responso to the experiences discussed above.
The most important of these are summarized below.
1.
Pre-Evolution Brieffngs An initiative had begun before the RCIC event to implement an INPO Good Practice concerning pre-evolution briefings.
Observation had shown that improvements in both I
quality and consistency were needed.
provided added impetus to those efforts.
The initiative in process was subsequently completed, and the requirements for pre-evolution briefings were proceduralized.
Training of operations personnel has stressed the importance of identifying during briefings expected sequences of_ events, individual responsibilities end actions to be taken in foreseeable contingencies.
- Additional actions were also undertaken, including the assignment of senior managers to spend about one week with NWEs on shift to provide instruction on the expectations for pre-evolution briefings and then observe and critique performance.
In addition, as each surveillance procedure is revised, a signoff provision is added to the procedure which requires.9at the NWE document accomplishment of the pre-evolution briefing.
These actions have improved the understanding of the organization's expectations.
Observations during the Power Ascension Program by line management and peer evaluators and through OA surveillances demonstrate that thorough pre-evolution briefings are now being consistently conducted.
In addition, a counterpart of pre-evolution briefings -- pre-job briefings -- is also being used by the Maintenance Section to improve work execution.
2.
Authorization of Emergent Work During Plant Operation In the case of the FRV event, the NWE chose to use the General Troubleshooting Procedure rather than the planning and review process normally used for non-urgent emergent work.
That normal process would have decreased the likelihood of a problem such as was encountered.
Actions were taken to improve the control of emergent work and to provide better guidance to NWEs in authorizing work to proceed.
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! The training conducted by the senior managers discussed in Section YI.D.1 above included considerations for making the decision to proceed with emergent work during plant operations, such as urgency, controls required, available people, available tools and processes, and potential consequences.
On an interim basis, Plant Manager approval for use of the General Troubleshooting Procedure on safety-ralated work and Maintenance Section Manager approval on non-safety-related work was required.
Subsequently, a new procedure with improved controls over troubleshooting of emergent work has been adopted.
These actions have improved the control of emergent work while retaining the ability of the NWE to proceed with essential work and troubleshooting when necessary.
Observations by management since implementing those actions have confirmed that NWEs have a good understanding in this area and that they are making appropriate decisions on emergent work items during plant operation.
3.
Independent verification Another improvement implemented primarily in response to the RCIC event was the clarification of the organization's expectations with respect to " independent verification."
Operations personnel were instructed by the Senior Vice President-Nuclear, the Station Director or the Plant Manager.
In addition, procedures governing tagouts and conduct of operations were revised to more clearly specify requirements for independent
b verification, and operators were instructed and tested on these requirements.. A major revision of the tagout procedure was implemented, strengthening the tagout verification steps and modifying the danger tags to include equipment description, device number, desired position and tag number.
This activity significantly increased the attention directed to tagouts and improved the effectiveness of system status control through verification.
Observations during the Power Ascension Program by management observers and peer evaluators indicate that the substantive requirements for tagouts and tagout verifications (i.e., lineups are correct and correct components are tagged) are
. consistently being conducted.
However, as discussed in Section IV, adherence to the administrative requirements and controls for tagouts needs additional improvement.
In particular, results of NRC audits and subsequent Boston Edison audits of the new tagout procedure issued in October indicate that additional effort is needed to ensure that tagout documentation is completed in accordance with applicable administrative requirements.
To address this issue, a number of actions have been taken.
Control Room administrative assistants have been instructed on the specific requirements for tagout reviews.
Watch crows have been briefed.
Regularly scheduled monthly tagout audits by operations are being conducted.
The management watch program has targeted this and other administrative requirements for close monitoring.
And in
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early 1990 the Quality Assurance Department (QAD) will conduct a surveillance to verify continued procedural adherence.
In addition, QAD will continue to routinely perform surveillances of the tagging process.
4.
O_nerator Attention to Plant Status 6
As a result of the RCIC event, the Conduct of i
Operations procedure was revised to require a second licensed operator in the Control Room during specified types of evolutions which interface with the Control Room or affect Control Room f
indications.
This second operator is stationed to monitor the panel af fected by the evolution and keep the operator at the controls advised, thus increasing the overall awareness of and attention to such evolutions.
Observations by management observers and peer evaluators during the Power Ascension Program confirm that this action has been effective in improving operator awareness of plant activities, and that the second Control Room operator is being stationed when appropriate.
Attention to Control Room indications has also improved, i
5.
Procedural Improvements One of the most important actions taken as a result of the RCIC, PRV and condensate pump and suction piping overpressurization events was the expansion in the scope of the ongoing upgrade of Station procedures.
This expansion 9
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incorporated nomenclature verification (walkdown and visual reconciliation of component numbers and nomenclature with that of reference documents and procedure content).
The procedure l
validation process has been revised to clarify the instructions for walking through upgraded procedures before their reissue, thus providing tested steps that are logical, consistent and effective in achieving procedural intent.
Because fill, vent and drain operations are not currently included in certain PNPS l
procedures, action is being taken to write instructions for i
accomplishing these evolutions and to include them where appropriate. 'This is part of the long-term upgrade of Station procedures.
The RCIC, FRV and condensate pump and suction piping overpressurization events reemphasized the need for high quality procedures, which foster compliance with the Nuclear Organization's strict procedural adherence policy.
Appropriate management attention has been provided by placing the Station procedure improvement effort under the Vice President-Nuclear Administration.
6.
Strict Adherence to Procedures i
One of our most important actions was to reemphasize the need for strict adherence to procedures.
The Vice President-Nuclear Administration conducted a review of the Nuclear Organization hierarchy of guidance and directions and identified
E I,
those areas where additional emphasis on procedural adherence was needed.
The Conduct of Operations and General Troubleshooting procedures are being modified.
The thrust of those improvements, l
which are presently being implemented, is to explicitly require that if the intent of a procedure or any particular step in a procedure is unclear or in error, action must stop and the matter brought to the attention of appropriate supervision.
The procedure must then be clarified or corrected as appropriate.
Similarly, in response to the condensate pump and suction piping overpressurization event, related operating procedures were reviewed, and changes made where required.
Watch sections were individually interviewed by management and instructed on procedural adherence, rihese interviews revealed that, while most personnel clearly understood that strict adherence to procedures for safety-related systems was required, there were individuals who did not understand that the same standard applied to procedures for non-safety-related systems as well.
The Senior Vice President-Nuclear met with operations personnel and clarified the requirements for procedural adherence, as well as the Nuclear Organization's expectations.
The adoption of ever rising standards of performance presents a further challenge to the Nuclear Organization to communicate those rising standards and to monitor performance.
Inevitably, some individuals will fall short of the required level of l
performance.
As these situations are identified, Boston Edison I
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[.- -will continue to ta e aggress ve correct ve act on to ensure that k
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i standards are met.
The improvements described above resulting from the three experiences discussed in this Section demonstrate that Boston Edison has learned significant lessons from its Power Ascension Program experience.
Boston Edison has taken and is continuing to take appropriate action to address each area requiring additional management attention.
Accordingly, criterion 3 for closure of the Power Ascension Program and CAL 86-10 has been satisfied.
- III.
Assessment of Other Experience During the Restart and Power Ascension Programa This Section of the Report summarizes the status of the Restart Plan and Power Ascension Program and introduces the detailed results of the self-assessments performed by Boston Edison during implementation of those programs.
A summary of the specific results is contained in Appendix A.
Boston Edison's Restart Plan described the programs, plans and actions necessary to ensure safe and reliable restart and continued operation of PNPS.
As documented in Attachment 1, almost every Restart Plan action item has been closed.
Those remaining open were recognized to require longer term action.
They have been transferred to Boston Edison's Improvement Action Database for tracking and resolution.
Boston Edison's May 26, i
1988 "Self-Assessment of Readiness for Restart" Report documented the process, bases and conclusions of the RRSA.
The RRSA was conducted by Boston Edison Nuclear Organization management under the auspices of the MO&AT.
The Restart alan therefore is essentially completed and 1
the bases for restart have been satisfied.
Remaining open items requiring longer term action are being tracked for resolution.
Significant improvements in performance achieved during the restart process, as well as areas where additional management attention is required, are discussed in Appendix A.
The Power Ascension Program was originally documented in BECo Ltr. #87-163 (October 15, 1987), and was revised in BECo
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Ltr. 488-129 (August 31, 1988).
It is the principal mechanism by which Boston Edison has demonstrated the effectiveness of its programs, plans and actions to ensure safe and reliable restart l
and continued operation.
The Power Ascension Program defined a series of power ascension steps and associated tests to be performed, described various management assessment periods and assessment points, and established five NRC Approval Points.
The MO&AT conducted assessments at each of the designated assessment points.
Throughout power ascension it has conducted routine assessments of the plant and of the performance of plant personnel.
Specific tests were undertaken during the Power Ascension Program to address each of the issues identified in CAL l
86-10.
Their results have been addressed during Boston Edison's various NRC Approval Point presentations.
With respect to the tests related directly to the CAL 86-10 issues:
Testing of the MSIVs to verify that they open with normal differential pressure across the valves was performed to address the first CAL-issue; Monitoring of the low-pressure portions of the RHR system for in-leakage from the reactor was conducted to address the second CAL issue; and i
Testing was performed to confirm that the MSIVs remain open during reactor l
depressurization after the mode switch is l
shifted from "RUN" to "STARTUP" in order to L
address the third CAL issue.
These tests, as well as the others required by the Power Ascension Program, were successfully performed.
Testing at the i
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\\
l 100% power plateau also has been successfully performed.
Overall, operational performance in conduct of testing during the Power Ascension Program has been excellent.
This was 4
l particularly demonstrated by performance during the complex shutdown from outside the Control Room Demonstration and during
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the most recent off-normal events discussed elsewhere in this report (Section IV.C). 2/ Other actions required for power I'
ascension to 100% power steady state operation have been successfully completed, as documented in the NRC Regional Administrator's October 6, 1989 letter approving reactor operation at full power.
Accordingly, the Power Ascension Program has been successfully completed.
Significant improvements in performance achieved during the Program, as well as areas where additional management attention was required, are discussed in Section II above and in Appendix A.
Throughout the Restart and Power Ascension Programs, Boston Edison has achieved significant improvements in overall performance, including improvements in those areas where SALP reviews had indicated the need for increased regulatory 2/
As discussed on p. 2 above, two operations originally scheduled for the 100% power plateau (the recirculation pump motor generator scoop tube position determination and the traversing in-core probe alignment) have not been completed.
These two operations will be performed at a later date.
The Power Ascension Program has been revised to reflect this change in accordance with the process set forth in the second Supplement to CAL 86-10.
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attention.
Boston Edison's critical self-assessment process, however, has continued to identify areas where~ additional improvements can be carried out in the Company's effort to l-
_ achieve excellence.
Management has taken or is taking appropriate action to address such areas.
Moreover, operational i
experience during power ascension has contributed insights which have resulted in significant improvements for the future.
t Based upon the results and findings set forth in this Section and Appendix A, Boston Edison has demonstrated improved overall performance; has shown that it has learned lessons from i
i its experience in executing the Restart Plan and Power Ascension Program; and has documented that it has taken and will continue to take appropriate measures to address those areas where additional management attention is warranted.
Accordingly, Boston Edison has satisfied the first and second criteria for closure of CAL 86-10 and its Supplemente.
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i IV.
Assessment of Experience During the 1989 Surveillance /
Maintenance Outage and Post-Outage Operation This Section of the Report addresses Boston Edison's assessment of its experience during the 1989 surveillance /
maintenance outage and post-outage operation.
It summarizes the major work elements planned for the outage and. significant emergent work items.
A critique presently is underway to identify further improvements in the processes for planning and accomplishing outages.
The most significant positive indications and areas for improvement identified as a result of the outage and post-outage operation are summarized below.
The major work elements planned for this outage included conduct of the second phase of the shutdown from outside Control Room demonstration, torus vacuum breaker testing, battery capacity testing, excess flow check valve leak testing, and almost 600 surveillances; and closure of 105 maintenance requests, five of which were Plant Design Changes (PDCs).
Several significant. emergent work items arose during the outage.
These included the repair of:
(1) the Automatic Depressurization System (ADS) which failed pressure drop testing during surveillance; (2) a broken RBCCW heat exchanger divider plate and leaking tube plugs; and (3) a body to bonnet joint seal leak in a 20-inch RHR valve.
Following outages, Boston Edison conducts critiques to l
identify strengths and ways of improving performance in future outages.
An Outage Review Plcn has been issued in order to i
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I obtain feedback from the various Nuclear Organization j
Departments.
The purpose of the Outage Review Plan is to assess t
the outage for strengths and lessons to be applied in future i
outages.
The most significant positive indications and areas for improvement identified as a result of the outage and post-outage i
operation are summarized below.
A.
Outage Significant Positive Indications i
Overall, planned activities as well as emergent work were well understood, properly staged and expeditiously
[
performed.
Over 200 MRs, 5 PDCs, and almost 600 surveillances l
were completed.
The Outage Control Center, instituted prior to the outage, provided an effective focal point for communications and problem resolution.
The broad participation of the Nuclear Organization in the schedule development process improved planning and helped to ensure a realistic schedule.
Pre-evolution and pre-job briefings were effectively used to focus oncoming shift work, adjust to changing plant conditions and accomplish work in a timely fashion.
Use of Shift Work Coordinators expedited resolution of issues and facilitated administrative closure.
Finally, effective pre-planning of work l
packages, including preparation of tagout sheets and tags, was demonstrated.
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! Most of the work planned for completion during the outage was accomplished within the planned outage duration.
As expected, planned surveillances resulted in identification of l
1 additional work.
About 100 emergent MRs were generated and efficiently completed within the original outage duration.
)
Successful completion of most of the planned as well as emergent work within.the original duration demonstrated Boston Edison's ability to plan, schedule and execute the outage.
Three emergent work items (the ADS, RBCCW heat exchanger and RHR valve repairs identified above) caused the outage to extend beyond its scheduled completion date.
Efficient planning, integration and execution of these emergent tasks minimised the length of that extension.
Another positive indication during the conduct of the outage was the absence of ESF actuations, technical specification-violationa, or unplanned entrance into LCOs.
This demonstrated that planned and emergent work was well integrated and that plant status, work prerequisites and work impacts were well understood.
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The third significant positive indication is the Company's ability to further improve plant material condition during the outage.
Completion of the large number of L
surveillances and MRs during the outage, including effective control and implementation of turbine control valve l
troubleshooting and repair, has resulted in significant l
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improvements in material condition, thus confirming the benefits of undertaking mid-cycle outages.
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B.
Outage Areas for Improvement Additional improvements are needed to ensure better i
l attention to detail in carrying out the administrative requirements of procedures.
Observations indicate that the field requirements for tagouts and tagoat verifications are consistently being conducted.
Additional effort is needed, however, to ensure that tagout documentation is completed in accordance with applicable administrative requirements.
Documentation discrepancies identified during NRC and subsequent Boston Edison audits include failure to specify a sequence for isolation or removal, or to sign a portion of a tagout package; and components without clear identification.
A newly revised and improved procedure was implemented just prior to the outage.
Causes of the documentation discrepancies include loss of the services of two spare NWEs used early in the outage to prepare tagout packages; the need for better monitoring of procedure implementation during its early stages of implementation; and the need for enhanced training on the actual hands-on process for completing tagout documentation.
Neither the NRC nor the Boston Edison audit identified any actual incorrect tagging or valve positions.
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.- C.
Post-outage operation A normal reactor startup was conducted on November 6, 1989.
During the startup, high reactor water level caused an unplanned Group I isolation due to a misaligned bypass valve for the feedwater regulating startup valve.
The primary cause of the event was imprecise communications during valve positioning on the previous day.
Valve lineup verifications conducted as a result of this event showed no other valves out of position.
Instructions for operations communications are being revised to preclude recurrence of this type of error.
LER 89-033-00 has been submitted to describe this event.
The "A" Recirculation Pump Motor Generator tripped twice between November 10 and December 6, 1989.
In conjunction with these trips, the machine also exhibited some speed and voltage oscillations in remote speed control when near full load.
Each time the machine tripped, and during a four day forced outage from December 8 to December 12, 1989, extensive troubleshooting with vendor assistance was accomplished, including checking of regulator components, replacement of marginal components and installation of performance monitoring instrumentation.
The machine exhibits stable operation in local manual speed control, where it will be operated until the planned March-April 1990 outage.
A program for full load testing of the Recirculation Pump Motor Generator Set using a load bank is being
4,
considered for accomplishment during the outage as an alternative to on-line testing at high power.
On December 8, 1989 a scram occurred as the result of an erroneous low reactor water level signal generated during calibration of a Reactor Building local reading level instrument.
This instrument shares common level sensing lines with level instruments that provide protective functions.
The potential for a false scram was recognized, detailed pre-evolution briefings were held and the technician took great care in performing the surveillance; however, an unavoidable momentary pressure fluctuation in the common sensing lines caused the scram.
This event, and the corrective action identified, will be reported to the NRC in LER 89-039-38.
The reactor was returned to operation on December 12, 1989.
Overall, the plant has operated well since completion of the outage.
Operators have dealt effectively and professionally with the off-normal events which have occurred.
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The experience during the outage and in the post-outage period confirms:
(1) the effectiveness of the Restart
- Plan and Power Ascension Program in achieving long-term improvements at the Pilgrim Nuclear Power Station; and (2) that as discussed in Section III, Boston Edison has satisfied the second criterion for closure of CAL 86-10 and its Supplements.
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l V.
Processes for Sustaining Improved Performance Boston Edison has established the processes described in this Section to ensure that improvements in performance attained during implementation of the Restart Plan and Power
{
Ascension Program are sustained into the future and that further improvements are achieved.
Completion of the Power Ascension Program will not diminish Boston Edison's commitment to strive for rising standards of excellence.
There are four interrelated t
components of Boston Edison's continuing processes :
P Improt&d officiency and effectiveness of procedures and directives for routine activities and decision-making; Management oversight and self-assessment processes; Improved long-terra planning and problem identification processes; Effective management organization and a plan to provide continuity of qualified end experienced managers into the future.
A.
Improved Efficiency and Effectiveness of Procedures and Directives for Routine Activities and Decision-Making The first component of Boston Edison's continuing program is systematic analysis and refinement of procedures and directives in order to improve efficiency and offectiveness of routine activities and decision-making.
During restart and power ascension, numerous actions were taken to strengthen technical control of key processes such as maintenance, system status and l
"t h P problem identification.
Steps will continue to be taken to maintain these technical controls while streamlining these key i
processes.
1.
Administrative Procedures and Directives Administrative procedures and directives include the Mission, Organization and Policy Manual, Nuclear Organization Procedures, Quality Assurance Manual, Emergency Plan, and other similar documents.
Boston Edison is continuing to clarify and streamline these procedures and directives.
Through this effort,
. i the processes of identifying work to be performed, organizing and
~
tracking such work, planning and allocating resources, assigning responsibility, planning and scheduling, work execution and performance evaluation will be made more easily understood as r
i well as effective and efficient th&oughout the Nuclear Organization.
2.
Process Documentation Process documentation includes specific process implementing procedures and directives such as those governing l
the control and planning of maintenance work, implementing the Operating Experience Review Program (OERP), or governing the tagging of systems and components.
Boston Edison is continuing to refine these documents in an effort to make them easier to implement, to reduce duplication of effort, and to improve i
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interfaces among procedures, organizations and personnel in executing these documents.
At the present time, the primary focus is on streamlining processes which affect the planning and accomplishment of maintenance work.
A number of improvements are i
being implemented.
These include actions to clarify responsibilities, improve definitions, reduce redundancy among procedures, and make the level of detailed guidance in procedures better correspond to the degree of personnel training.
Procedures governing MRs, maintenance work permits, temporary modifications, preventive maintenance and other areas are being modified.
3.
Working-Level Procedures and Instructions Working-level procedures and instructions comprise the bulk of the documents which direct the day-to-day Nuclear Organization activities.
They are the detailed procedures and instructions which provide the specific steps to follow in accomplishing particular tasks such as surveillances, plant evolutions, preventive maintenance and repairs.
Several actions have been completed or are well underway to improve the quality of these documents and the technical control of specific work tasks.
A principal action (the upgrade of Station procedures) is discussed in other sections of this Report, particularly Sections II.D.5 and VI.E.
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i B.
Management Oversight and self-Assessment Processes 1
The second component of Boston Edison's processes to ensure that improved performance is sustained into the future i
includes (1) effective management assessment of decisions made; and (2) effective management oversight of the decision and assessment process.
During restart and power ascension, the level of oversight and assessment of routine activities and I
decision-making has been intense.
As described below, Boston Edison will maintain a program of augmented management oversight and critical self-assessment of plant and personnel performance after termination of the Power Ascension Program.
1.
Management Oversight and Assessment During the Power Ascension Program, Boston Edison utilized the MO&AT, comprised of senior level managers, chaired by the Senior Vice President-Nuclear.
MO&AT members observed personnel and equipment performance, and performed assessments of readiness for restart and increased power operation at specific assessment points.
Input for MO&AT assessments was provided by i
direct observations and interviews, written reports and oral l
l presentations by responsible line managars, peer evaluators, QAD surveillances and audits, and from the management backshift 1
monitoring and watchstanding programs.
After completion of the Power Ascension Program, Boston Edison will rely more on routine management processes in the
1
, t conduct of day-to-day business.
The following restructuring of j
the management oversight and assessment process will also be carried outs (1) Periodically, the Senior Vice President-Nuclear and the Vice Presidents and Directors reporting to him will meet in order to assess performance and evaluate the effectiveness of the Department Manager's assessments of operations.
(2) The Nuclear Organization Department Managers will routinely meet (approximately six times per quarter) for the i
foreseeable future to critically assess their conduct of plant operations.
Periodically these meetings will be held jointly with the senior managers.
i (3) Assessments by the Section Managers will be l
conducted semi-annually and presented to Department Managers, Directors and Vice Presidents.
The Section Managers will have growing responsibility for routine operational decisions.
Semi-annual meetings will permit executives to assess the effectiveness of the oversight and assessment functions, as well as the quality of decision-making at the Section and Department levels.
4 Section and Department manager self-assessments have been'one of the most important inputs to the MO&AT process.
At present, line managers evaluate a number of specific areas (such as staffing levels, adequacy of budget, identification and 1
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i resolution of technical issues, and proceduros), and the effectiveness of their organizations in each of these areas.
2.
Egor Evaluator Program Another important aspect of the self-assessment process that will be preserved after completion of the Power Ascension Program is the peer evaluator program.
Peer evaluators will t
continue to be trained on performanco standards and ovaluation guidelines.
They will continue to provido an experienced perspectivo for observation of plant oporations and timely feedback for analysis and correctivo action.
The froquency of observations will be adjusted based on experienco, as has been the caso during the Power Ascension Program.
3.
Quality Annuranco Monitoring _ Activities The QAD conducts surveillances and audits in accordance with the Boston Edison Quality Assurance Manual (BEQAM) and applicable procoduros and instructions.
The Survoillanco Division of QAD focuses on monitoring of ongoing plant activities, and providos an additional source of information on personnel and plant performanco.
The results of survoillancos are used to dotormino the scopo of scheduled audits.
During the Power Asconsion Program, QAD findings from audits, survoillancos and inspections were increased and utilized by the MO&AT to identify or confirm areas requiring additional management
~.
attention.
QAD surveillances will continue at their normal level and will continue to be used in the self-assessment process.
4.
Management Backshift Monitoring and Watchstanding Programa
)
A group of experienced managers has been providing coverage of operations during selected backshift hours when the plant is operating.
This coverage has been provided to identify conditions requiring improvement, and to assist in imparting Nuclear Organization expectations to onshift crews.
This program will be used when Station management identifies the need and in any event periodically to observe and assess performance.
In addition to the backshift monitoring, the plant is monitored periodica.'.ly during backshift hours through a program of scheduled management watchstanding.
This program, which includes most of the managers in the Nuclear Organization at and above the Section level, will continue for the foreseeable future.
Station management will adjust this program, and focus attention on particular areas, as has been the case during the Restart and Power Ascension Program.
C.
Improved Long-Term Planning and Problem Identification Processes Improved long-term planning and problem identification are primarily provided through implementation of Boston Edison's processes to develop the Long-Term Plan (LTP) and Improvement L ".
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Action Database, and through the Corrective Action Clearinghouse.
These processes are summarized below.
1.
Long Term Plan Boston Edison has established a program intended to provide an integrated, efficient process for long-term planning of Nuclear Organization activities, self-assessment and l
identification of items requiring management attention, and prioritization, budgeting, ownership, tracking and resolution of such items.
This program continues to be refined.
The centerpiece of this program is the Nuclear Organization's LTP.
The process to produce the LTP has been institutionalized, and is more comprehensive than the long term plan submittal requirements of the PNPS license.
It provides for planning. Nuclear Organization activities over a period of five I
years.
Through a process of identifying and evaluating potential improvements against established Nuclear Organization strategies, the process provides a mechanism for screening and prioritizing l
improvements.
Critical self-assessment is a source of improvements.
Items for action identified through the self-assessment process are prioritized to ensure that necessary resources are provided, and that effective planning to ensure resolution is implemented.
Priorities take into account r,afety significance, effect on plant performance, effective resource utilization and assurance of regulatory compliance.
Boston
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Edison has.also established processes for tracking and ensuring implementation of corrective and improvement actions.
These are g.;
' the Improvement Act!.on-Database (IADB) and the Corrective Action
. Clearincghduse (Clearinghouse).
2.
Improvement Actiori Database The IADB is an automated tracking system for identified issues and associated, non-recurring improvenent action items.
The IADB tracks open items from thS various improvement action plans such as the MCIAP and the Restart Plan.
Restart Plan, Volume 2, Appendix 10 items remaining for closure are contained in the IADB.
In addition, the'IADB is used to track, among other things, items resulting from INPO evaluations and remaining MO&AT items.
Improvements listed in the Compliance Division's NRC Commitment Control Tracking-System and other items are presently being reviewed for possible entry into the system.
Using input from self-assessments and other mechanisms, the IADB assists in the development of the major improvement
' issues and the business planning process, and documents assignment of specific actions to responsible managers.
The IADB also'provides for. progress tracking, documentation, and closure of action items.
Items meeting the requisite resource criteria are dispositioned through the LTP process.
Other items are resolved using the Clearinghouse process described below.
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Corrective Action Clearinghouse Through use of a single reporting form -- a Recommendation for Investigation or Improvement (RFI) -- any
//
Boston Edison employee or onsite contractor-can report a problem is' or provide a recommendation for investigation or improvement.
The Clearinghouse process hse been proceduralized to ensure that such recommendations are evaluated for action and controlled in an efficient, centralized manner.
The Clearinghouse process provides for prompt assessment of problems that are of immediate safety concern, conversion of RPls to appropriate corrective action forms, reportability evaluation, tracking and disposition and compliance with the BEQAM.
It includes recommendations and items identified through self-assessment or through internal Boston Edison activities.
D.
Effective Management Organization and a Plan to Provide Continuity of Oualified and Experienced Managers An effective management organization and plan for succession is the third component of Boston Edison's coordinated
' processes to ensure that improvements in performance are sustained into the future.
In the Restart Plan, Boston Edison committed to establish a stronger Nuclear Organization by increasing nuclear management experience ar.d implementing an orderly transition to a sound, long-term organization.
At the
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h y time that the RRSA was issued, many of these improvements had already been made and were discussed in Section IV of the RRSA Report.. This Section summarizes the key organizational changes and improvements in Nuclear Organization management experience undertaken since the RRSA, and discusses the process for ensuring 1
that improvements made to date will be sustained in the future.
The current organizational structure for Boston Edison's long-term Nuclear Organization is depicted in Attachment
~3.-
It is similar to the organization described in the RRSA.
Report..The organization has demonstrated overall stability.
i The principal organizational changes made subsequent to the RRSA are briefly summarized below.
The Station Director has been made Vice President-Nuclear Operations and Station Director and continues to report directly to the Senior Vice President-Nuclear.
A new position, Vice President-Nuclear Administration, reports directly to the Senior Vice President-Nuclear, and is responsible for union
. relations,. Station procedures, the Clearinghouse and INPO coordination.
The Director of Nuclear Engineering has been made-the Vice President-Nuclear Engineering, still reporting directly to the Senior Vice President-Nuclear.
Within the Plant Department, the Radwaste and Chemistry functions have been combined into a Section which reports directly to the Plant Manager, along with the other three key operational and support functional Sections (Operations, Maintenance and Technical).
In
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addition, Boston Edison is continuing to refine its Nuclear-Organization through its self-assessment process, with particular attention on improving the effectiveness and efficiency.of routine activities, while retaining assurance of quality, safety and technical control.
Apart from the organizational improvements summarized-above, Boston Edison has significantly increased the experience of its Nuclear Organization.
At the time of the RRSA,-
j a cadre of experienced managers had been-put in place, including-the. Senior Vice-President-Nuclear, Vice President of Nuclear Operations and' Station Director, Director of Special Projects, j
Plant Manager,' Nuclear Engineering Manager 2/, Quality Assurance Department Manager, Business Planning and Budget Control Manager, i
and Special Assistant for Human Resources.
The individuals who filled these positions at the time of the RRSA continue to do so.
In addition, the Nuclear Organization has filled 12 key
.. managerial and supervisory positions 1/-through a balanced mix of (promoting experienced and qualified individuals from within the Company-(seven positions), and augmenting that experience and 2/=
This individual is presently acting as Regulatory Affairs Manager.
A/
These 12 positions are:
Training Department Manager; Plant Support Department Manager; Planning and Outage Department Manager; Security Section Manager; Deputy Plant Manager; Radwaste and' Chemistry Section Manager; Plant Operations Section Manager; Chief Operating Engineer; Plant Maintenance Section Manager; Radiological Section Manager; and Deputy Maintenance Section Manager (two positions).
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4 knowledge base by selective hiring from cutside the Company (five positions).
Finally, significant improvements in reducing reliance
-on contractors and building the permanent Nuclear Organization have been made.
The number of contractor personnel has dropped.
I from 1,820 in July 1987 to under 300.
This number includes a contracted security force of about 130 persons and about 50 manual or clerical personnel.
Only about 110 contractors are professional personnel; none of these is assigned to the Plant Department.
At the time of the RRSA, there were several organizational and staffing areas noted for additional management attention.
Significant progress has been made in addressing these areas including:
the 32 additional Boston Edison Maintenance Section positions were filled; vacancies in the Planning and Outage Department were filled with permanent employees; the Shift Work Coordinator and Shift Planning Coordinator positions were created and filled; 5/
5/
The Shift Work Coordinators oversee and coordinate PNPS production work, interface with various other Nuclear Organization divisions, and mobilize resources to support emergent Priority E and Priority 1 work.
The Shift Planning Coordinators work under the Work Coordinators' direction.
They update production schedules, progress Maintenance Work Plans through the review cycle and materials to the work site, and review upcoming Maintenanco Regrast packages to assure they are task ready.
9 permanent appointments have now been made to-the positions of Planning and Outage Manager and Maintenance Section Manager; and the.Workforce Information-Program, initially developed for a six week period to assist in informing the workforce regarding changes in programs, policies or equipment, has been established.aus a permanent.PNPS program.
Improvements-in manning will be sustained through the succession planning' process that has been established for the Nuclear Organization.
Under that process, annual'" Management Back-Up Reviews" are conducted to (1) identify individuals with the potential to fill key management positions; and (2) identify the experience and training that those individuals need to meet their potential.
In short, through the actions discussed in this Section of the Report, Boston Edison has implemented processes for sustaining improvements in performance at PNPS.
Therefore, the fourth criterion for closure of CAL 86-10 and its Supplements has been satisfied.
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! VI.
' Integrated Lessons Learned The Restart and Power. Ascension Programs have provided Boston Edison with a set of fundamental lessons learned regarding-the management and operation of PNPS, which provide an overall perspective on the actions necessary to sustain improved performance.
They are:
Integration and Prioritization of Activittes Establishment, Communication and Maintenance of Objective Performance Standards Management oversight and Critical Self-Assessment Organization, Experience and Succession Procedure Validation and Verification a
Procedural Adherence Ensuring That Nuclear Organization Expectations Are Understood and Implemented at Each Working Level Design Information Effective Maintenance Planning, Scheduling and Execution Operational Heat Sink A.
Integration and Prioritization of Activities i
Nuclear Organization procedures and directives must continue to be streamlined to ensure that routine activities and decision-making are carried out more effectively and I
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efficiently. 1/. Long-term planning processes (such as the process used to develop Boston Edison's Long Term Plan) have been institutionalized and are being further refined.
These processes
-must continue to provide a mechanism for focusing management attention and resources on improvements which achieve rising standards of excellence.
i B.
Establishment, communication and Maintenance of Objective-Performance Standards Both the Restart Plan and Power Ascension Program were
-characterized by the development and satisfaction of objective
. performance standards.. Through the Nuclear Organization operating plan and performance goals, objective performance standards-have been adopted for use in-evaluating the long-term performance of the organization.
The process for updating the operating plan has been institutional 1 zed.
1 C.
Management Oversight and critical Self-Assessment A sufficient level of management oversight of Nuclear P
Organization activities must be maintained to ensure the effectiveness of critical self-assessment and programmatic 1/
Throughout the following discussion of lessons learned, the imperative "must" is used to connote an important element for success.
The term is intended to state a principle that will guide future Nuclear Organization management activities.
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The scope of oversight must be periodically reevaluated and adjusted ~to respond to changing circumstances.
The processes-for oversight and self-assessment have been or are j
being institutionall' zed.
j D.
Organization. Experience and Succession j
An improved organizational structure has been implemented.. Experienced and knowledgeable managers are j
i directing the activities of the Nuclear: Organization.
In 1
addition,.a plan'is in place to provide continuity of qualified and experienced managerstinto-the future.
The organization must continue to be refined through self-assessments.
E.-
Procedure Validation and Verification One of the most important lessons learned is the need
'to ensure that procedures are complete,. accurate, and usable.- In i
order to achieve that objective, the procedure development and j
- validation process has been significantly strengthened by limplementing'an applicable INPO Good Practice.
Other p
improvements have been made to the upgrade of Station procedures.
A procedure content verification process has been implemented j
- which requires visual confirmation that components, locations, i'
nomenclature,. references and procedure wording agree.
Specific guidance documents are being implemented which provide clear l
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I 1 direction for procedure writing or revision and subsequent review and' proofing..
'To ensure continued progress in this effort, the responsibility for directing the upgrade of Station procedures has been assigned to the Vice President-Nuclear Administration.
F.
Procedural Adherence The necessity for strict adherence to procedures and
- attention to detail must be ingrained throughout the Nuclear Organization.
Management must continue to emphasize the
' importance of this concept and provide an~ environment which fosters strict adherence to the administrative aspects of procedures, as well as to their field execution.
One of the most effective steps in establishing the appropriate environment is
-aggressive management investigation to identify and correct the root causes of procedural adherence problems which do occur.
Establishing clearer and more easily usable procedures also assists in providing the appropriate. environment, as discussed above.
In addition, a review of the hierarchy of Nuclear Organizttion policies, procedures and instructions has been conducted, and modifications have been made as needed to ensure that.the concept of strict procedural adherence is clearly expressed.
Through such mechanisms as notices to all plant employees, "all-hands" meetings, personal interviews and periodic training, management has and will continue to reemphasize the
0:
y 2 neod for strict procedural adherence, both administratively and
- 1'n. field ' execution.-
G.-
Ensuring That Nuclear Organization Expectations Are Understood and Jmplemented at Each Working Level The Nuclear Organization's expectations for procedural adherence, attention to detail and other means of ensuring quality and safety must be reemphasized to and met at each working level, particularly by those persons with hands-on responsibility for operating or maintaining the plant.
Reemphasis of those expectations through the Workforce Information Program, "all hands" meetings and notices to all plant employees must continue to be complemented with appropriate disciplinary action'for those who fail to adhere to and achieve Nuclear. Organization expectations.
H.
Design Information Experience during the Power Ascension Program emphasized the importance of well-defined design bases, consistent use of controlled plant design information in operations and maintenance, accuracy of design documents, and document control.
LTP projects have been initiated to implement the necessary improvements.
Design basis reconstitution and increases in the accuracy of plant design information are being furthered through the Vendor Equipment Technical Information
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Program, Design and Configuration Control Program, and the Drawing Update Program.
I.
Effective Maintenance Planning, Scheduling and Execution Boston Edison has established effective processes.for planning, control and coordination of maintenance, surveillance and testing-work required to support plant operation.
Continued
. refinements to these processes are' ongoing to improve their effectiveness-and efficiency.
The recently created Work Coordinating Division, ensures that production and production support efforts support the approved schedule, and assists in resolving conflicting priorities among emergent items which may arise.
Two Deputy
-Maintenance Section Managers have been added.
In addition, a turnover sheet is_ prepared for the backshifts and is delivered to the Control Room and the Maintenance shops.
This turnover sheet provides the basis from which the Shift NWE executes those operational activities necessary to support scheduled production work, consistent with plant status.
J.
Operational Heat Sink During the biologically active seasons, PNPS experienced significant fouling of the seawater cooling systems by both animal (mussels) and vegetable (seaweed) intrusion.
Repeated back-flushing of the seawater systems was required to
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i maintain' adequate cooling.
This experience prompted management to pursue-both short-term and long-term improvements to the seawater systems.
Short-term corrections have been made.
They include a remote video camera inspection of the internal surfaces of the seawater. pipes, scraping of these. surfaces to remove animal growth, similar cleanout of the intake forebays before and after the travelling screens, head removal and manual cleanout of major heat exchangers and condensors, repairs to the hypochlorination systems, and repair of bypass paths found in the screens by
- underwater visual inspections.
Long-term projects include completion of installation of a trash rack rake to improve removal-of seaweed and other debris from the trash racks, and a betterment program for the screenhouse.
.These actions are being conducted as LTP projects.
As evidenced by the information provided in this Section of-the Report, Boston Edison has demonstrated that it has learned valuable lessons from its cumulative experience throughout the Restart and Power Ascension Programs and has taken and continues to take appropriate actions.
Accordingly, the fifth (and last) criterion for closure of CAL 86-10 and its Supplements has been satisfied.
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, VII.
Conclusions Boston Edison has demonstrated that the following criteria have been satisfied:
1.
The plans, programs, and actions defined in the PNPS Restart Plan as necessary for safe and reliable restart and continued operation have been satisfactorily completed; 2.
The actions defined in the PNPS Power Ascension Program as necessary to demonstrate that PNPS could achieve safe and reliable restart and continued operation have been satisfactorily completed; 3.
Boston Edison has exanfaed the key operational experiences occurring during the c rse of power ascension, and has taken appropriate actio s to incorporate that experience into PNPS operations; 4.
Boston Edison has establt. 71 the bases for sustained improvements in performar.ce at PNPS; and 5.-
Bs !.on Edison's cumulative experience, from initial forn.ulation of' the Restart Plan through completion of the Power Ascension Program, has yielded valuable lessons, and resulted in appropriate actions.
Based on the criteria above, Boston Edison has demonstrated that the conditions of CAL 86-10 and its Supplements have been satisfied and requests closure of both documents.
Y APPENDIX A Assessment of Experience During Implementation of the Restart Plan and the Power Ascension Program This Appendix summarizes the results of Boston Edison's self-assessments, including the final assessments, during implementation of the Restart Plan and the Power Ascension Program.
The RRSA identified the following major areas which required completion of specific actions prior to restart:
PIANT AND EQUIPMENT PERFORMANCE Material condition and cleanliness; Maintenance, planning and scheduling; Plant testing and readiness; OPERATIONAL PERFORMANCE System line-ups; Operations performance; Formality of communications; Procedural adequacy; Drawing completeness and accuracy; and MANAGEMENT AND ORGANIEATION Institutionalization of good practices.
Boston Edison has assessed its cumulative experience during implementation of the Restart Plan and Power Ascension Program.
The results of that assessment are presented in this Appendix in the context of the major areas from the RRSA listed above. 1/ Within each of those areas, this Appendix first 1/
This Appendix focuses on the broad areas of concern identified in Chapter II.A of the RRSA, rather than the specific, detailed action items which arose out of the RRSA.
(continued...)
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l
5 summarizes the positive indications and action items noted in the RRSA and provides the current status of Boston Edison's implementation of those actions.
Once the.RRSA results are summarized, Boston Edison's experience during the Power Ascension Program is discussed.
For each area discussed in the RRSA, the mejor MO&AT observations or areas-for improvement from significant operational experiences not addressed in Section II of this Report are identified, followed by summary descriptions of the actions which have been taken or which remain to be taken in response.
Before discussing the' specific RRSA areas, it should be noted that SALP Report 88-99, issued September 21, 1989, documented continuing improved performance by Boston Edison, including improvements in Radiological Controls and Security and Safeguards.
No Category 3 ratings were issued.
SALP 88-99 documented improvements in several of the areas addressed in the RRSA as well as in other areas of plant management and operation.
- 1. Material condition and cleanliness Boston Edison's experience during implementation of the Restart Plan and Power Ascension Program in the areas of material condition and cleanliness is discussed below.
8.
Restart Plan Positive Indications and Action Items:
1/(... continued)
Boston Edison identified 94 such specific action items, 90 of which have been resolved.
The status of the remaining four is provided in Attachment 2.
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l
The RRSA noted that responsibility for housekeeping and cluanliness in defined spaces--and for individual plant systems
.had been' assigned. -With regard to material condition, th'e RRSA' found the process-for reporting deficiencies and initiating corrective action to be cumbersome.
Changes were needed to-improve efficiency and to enhance the timeliness of corrective actions.
Actions to improve this process included the establishment of-the Recommendation for Improvements or Investigation (RFI) and the Corrective Action Clearinghouse (Clearinghouse).
The RFI form is a supplement to the existing corrective action. forms and can be used by any employee or on-site contractor to document any type of discrepancy at the Station.
In addition, responsibilities for plant cleanliness have been specified and clarified in the PNPS Housekeeping Manual, which has been promulgated and is in use.
Management tours-are regularly conducted to identify areas in need of cleanliness improvement.
b.
Power Ascension Experience and Resulting Actions:
Boston Edison has conducted an aggressive housekeeping program, resulting in an excellent state of plant cleanliness.
' Efforts continue to further improve cleanliness and housekeeping.
The material condition of the plant is good and has been steadily improving during the Power Ascension Program.
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~
l zReport 88-99 noted that plant material condition was being.
G generally well maintained.
However, some material problems did occur'during the~ Power Ascension Program that contributed to two unplanned automatic scrams.
Those problems were unrelated, did not represent a~ trend, and were few in number.considering the scope and length of the prior outage.
These_two unplanned reactor scrams-are discussed below because of their relationship to_ plant material condition.
These scrams, however, posed no
-threat to public health and safety, violated no technical specifications and caused no loss of safety system function. 2/
L Also, condenser. fouling and Salt Service Water System performance
- are discussed because of their potential to affect plant-L reliability and material condition.
1.
March 4. 1989 Unplanned Scram from Power:
A spurious trip and reset of a vacuum trip in the turbine control system resulted in an unplanned scram during turbine-generator coastdown.
Actions Tazen A post-trip review was
. conducted.
A multi-disciplinary investigation using Kepner-Tregoe techniques was conducted to determine the reason for the trips.
Also, a controlled test replicating the March 4, 1989 plant conditions was performed, and the event could not be repeated.
Further system checks and tests were performed which confirmed the satisfactory condition of the systems involved.
2/
An additional unplanned scram, the FRV event, is discussed in Section II of this Report.
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h The event was reviewed in detail with NRC Region I Staff on March-9,_1989.
Actions Remaining:
No corrective action commitments are outstanding.
ii.
August 30. 1989 Reactor Scram Due to Failed Potential Transformer:
A Sensing potential transformer for the voltage regulator failed internally, causing a generator voltage excursion, and a high-pressure scram following turbine runback.
Actions Taken Engineering analyses were performed and appropriate equipment tests done to determine whether any equipment has been damaged by the over-voltage.
'There analyses and tests detected no damage to the main
. generator, main transformer or any other equipment.
The failed potential transformer was replaced.
An original design discrepancy in the wiring of the voltage balance relay, which prevented automatic transfer of the voltage regulator when the transformer failed, was discovered in the replacement process and was corrected.
The correct wiring of other similar relays was verified prior to restarting the plant.
Actions Remaining:
The root cause of the potential transformer failure has been determined to be a void in the potting compound near the high voltage bushing, resulting from a manufacturing defect.
The final report of the investigation and formulation of recommended tests for this defect in similar transformers are being prepared.
Testing and corrective action will be conducted as necessary.
- Moreover,
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g I
since the voltage :>alance relay wiring discrepancy was corrected, if a similar failure should occur in the' future, the main
? generator voltage regulator will shift to the manual mode; an annunciator in the Control Room will sound; the main generator will not experience an overvoltage; and the unit should not scram.
iii.
Main Condenser Fouling:
Due to marine growth 4
fouling and debris carry-over from storms, l
low condenser vacuum, high circulating pump amperage, and condenser temperature rise have occurred.
Actions Taken:
Since plant restart, periodic backwashing has been performed more frequently than in the past I
in-order to manage condenser vacuum, circulating water pump amperage and condenser differential temperatures.
Recently, as a result of manual cleanout and decreasing seawater injection temperatures, it has been possible to decrease the frequency of
- backwashing.
Condenser performance has been primarily hampered by j
i the accumulation of mussels ir. the intake piping and structure 1
L due to low condenser temperatures during the outage.
Most of the i
U accumulated mussels have now been killed by thermal backwashes, mechanically loosened from the structure by divers, and dredged or backwashed out of the system through the intake structure.
Thermal backwashes will continue to be performed in the future to prevent mussel and slime growth.
Full power was achieved on' October 10, 1989 without cooling problems caused by
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t
E4 e
condenser fouling.
However, some backwashing in excess of historical norms may still be necessary.
Actions Remaining:
A number of actions are being taken, not only to address the specific issue of macro fouling, but also to improve overall condenser performance.
A
~
trash rack rake designed to decrease macro fouling is being installed and tested.
Additional inspections of the screenhousv and inlet piping, and removal of mussels and debris, as necessary, were conducted during the 1989 surveillance / maintenance outage.
Two task forces have also been established.
The first task force is focusing specifically on the development of.more explicit criteria governing the conduct of backwashes, in an effort to further reduce their number and optimize their efficiency.
The new criteria will be incorporated into applicable procedures.
The second task force is considering
.other methods for improving overall condenser and Salt Service Water (SSW) System performance.
It will develop a prioritized list of actions to be taken to improve condenser and Salt Service Water System performance.
l iv.
SLlt Service Water System Performance: A L
decrease in indicated SSW flow to Reactor Building Closed Cooling Water (RBCCW) heat exchangers required investigation, including the opening of both heat exchangers for inspection and cleaning.
Actions Takens The "A" RBCCW heat exchanger was backwashed and then opened, mechanically cleaned and inspected in early October.
A moderate amount of live marine
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t
- life was removed.
The heat exchanger' pressure drop and flow instrumentation _was rece.librated, but the system still indicated
-insufficient flow.
This was determined to be the'rcsult of mussel-fouling in the piping, heat exchangers and related Jinstrumentation,cwhich caused an incorrect indication of substantially~1ower'than actual seawater flow.
This was corrected during the 1989 surveillance / maintenance outage.
Investigation into the cause of the mussel fouling that existed identified-insufficient chlorination as the probable cause.
Grab samples were taken at the SSW-pump discharges rather
-than at the normal heat exchanger sample points after the residual chlorine monitors failed in service. -This resulted in reduced chlorine' injection rates to ensure compliance with limits on residual chlorine in discharged water.
The small amounts of residual chlorine present in the process flow leaving the pumps 1
were consumed before reaching the heat exchangers, and thus contributed to the observed fouling.
Both SSW Systems were shock chlorinated during the 1989 surveillance / maintenance outage and the marine life was removed by backwashing.
The "B" RBCCW heat exchanger and inlet piping, including the flow element, were opened, inspected and cleaned of dead marine life.
Both systems were tested satisfactorily. The residual chlorination sample point has been shifted to ensure more representative results.
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s Actions Remaining:
The task force will focus on future improvements in SSW System performance as previously discussed.in item 111. above, concerning main condenser fouling.
2.
Maintenance. Planning and Scheduling-Boston Edison's experience during implementation of the Restart Plan and Power Ascension Program in the area of maintenance, planning and scheduling is discussed below, a.
Restart Plan Positive Indications and Action Items:-
The RRSA noted several positive indications in this area including control of the maintenance backlog; implementation of the MCIAP; improved responsiveness to Operations by the Planning and Outage Department and the Maintenance Section; and improved access for maintenance through decontamination efforts.
Several of those positive indications were also noted in SALP Report 88-99.
Certain additional actions were to be taken before restart.
These included issuance of an improved and updated Maintenance Section Manual to formalize existing improvements;-
revision of the General Troubleshooting Procedure to more clearly document work activities; and capturing remaining improvements in appropriate formal PNPS documents.
Priority attention was to be directed to filling 32 newly authorized, permanent Boston Edison positions.within the Maintenance Section.
Personnel hiring was also to continue to fill planning and scheduling positions.
An integrated schedule for restart-related surveillance and testing
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t-
"r.
was prepared.
Restart-related maintenance work was to continue being addressed.in the Plan-of-the-Day; and resources were to continue being focused on meeting scheduled dates for restart-related maintenance work.
Longer term actions included further development of the capability to construct detailed schedules for maintenance, surveillance and testing.
The Maintenance Section Manual was revised as stated, as was the General Troubleshooting Procedure.
Other improvements in the program were captured in other formal PNPS documents, such as the Work Control Procedures and the Post-Work Testing Procedure.
The 32 Maintenance Section positions were filled.
The requisite planning and scheduling personnel were hired and the integrated' surveillance and testing schedule for restart was
. developed and implemented.. Restart-related maintenance work was included in the Plan-of-the-Day and necessary resources were applied to meet schedules for such work.
Boston Edison has continued to include scheduled maintenance work in the Plan-of-the-Day.
b.
Power Ascension Experience and Resulting Actions:
1.
Mo&AT Observation:
Several instances have occurred of maintenance work plan discrepancies, conflicting supervisory duties in the performance of maintenance activities, and inefficiencies in maintenance work practices.
Actions Taken:
Pre-job briefings, modeled on pre-evolution briefings, are routinely conducted prior to carrying out each maintenance job.
Maintenance personnel have
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a-i received training in the conduct of pre-job briefings.
The Plan-
.of-the-Day is used to coordinate maintenance activities with
.other plant activities. -The Work Coordination Division has been established to stage and coordinate work and resolve problems.
In addition, two Deputy Maintenance Section Managers have been added.
Actions Remaining:
Continue actions as described above.
The coordination process is being further refined through improvements to emergent work controls.
In addition, the scheduling organization is being restructured so that on-line, off-line and long-term scheduling efforts are better integrated.
Increased engineering support to maintenance is being provided through design engineers on-site.
Close
~ involvement by the design engineers in daily maintenance activities should further improve the effectiveness and efficiency of maintenance activities, 11.
Mo&AT Observation:
Several instances have occurred of difficulty in ensuring the availability of materials, parts, or tools when needed.
Actions Taken:
A Materials Management
-Section was established-as a part of the Plant Support Department to provide a single focal point for identifying, setting stock levels for, and procuring parts, tools and materials needed to support the plant.
As a result, a procurement contract, which had been established for contractor support to supplement Boston Edison's organization, has been terminated.
A Station
- All -
i
. Instruction was written'for the integration of on-hand procured material into Boston Edison inventory.
This project is approximately 90% complete.
The procurement process has been streamlined through the use of new computer software enhancements and a new procedure for requesting material and-stock authorizations.
The number of maintenance requests restrained by the unavailability of parts or materials has been substantially reduced.
The applicable procedure was modified to incorporate a Materials Management Section review for spare part requirements and/or obsolescence for new Plant Design Changes and Modifiestions.
A set of performance indicators to monitor the Materials Management Section performance was established.
A Materials Task Force was formed to study, and make recommendations to management for the resolution of materials and procurement issues.
Actions Remaining:
Continue actions described above.
l iii. Mo&AT observation:
The open Maintenance Request (MR) count presently exceeds the goal established in the Restart Plan.
Actions Taken:
Several factors combined to cause the increase including two major factors: (1) the way in which MRs are defined and generated; and (2) the commitment, during the latter half of 1989, of maintenance personnel to the validation of nomenclature in surveillance procedures, and to completion of accredited training of maintenance personnel.
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P
The total MR count is composed of outage MRs, system outage MRs, preventive maintenance MRs and on-line corrective maintenance or running repair MRs.
Outage MRs can only be accomplished with the plant off-Lline.
Thus, they are long-lead time work items and are identified for future outages.
Outage maintenance is routinely identified as the operating cycle progresses and plans for planned outage periods are established.
The number of open outage MRs, therefore, increases steadily throughout an operating cycle.
System outage MRs require the affected system to be out of service for the maintenance to be accomplished.
System outage maintenance requires taking a normally operable or operating system out of service.
For safety-related systems, it may require the plant to enter a Technical Specification Limiting Condition for Operation (LCO).
PNPS management presently does not normally voluntarily enter a Technical Specification LCO in order to perform maintenance.
As a result, system outage MRs increase during operating periods, just as outage MRs do, until planned (or forced) outages provide an opportunity to accomplish the work.
Preventive maintenance MRs include periodic maintenance, predictive maintenance and planned maintenance.
Corrective maintenance (running repairs) MRs are those which can be accomplished during plant operation, with the required minimum systems in service.
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ro p
Ve As a' result of an effort to perform more prevent (ve maintenance, the number of preventive maintenance MRs has
. increased, while the number ~of corrective maintenance (running repair) MRs has increased gradually over the Power Ascension Program.
The number of open' running repair MRs in the Power
~ Block depicts the plant matorial condition more accurately than
-total open MRs.
That number has remained essentially constant
!.L through the Power Ascension Program.
As expected, the number of 1
outage MRs and system outage MRs grew during operations in the Power Ascension Program, will continue to grow between now and h
the mid-cycle outage in 1990, and then will decrease as a result j
of maintenance work performed during the outage.
-I A second contributing factor to the increase in the number ofcopen MRs is Boston Edison's commitment of maintenance personnel toltwo labor intensive activities of a one-time nature.
-The Company has undertaken an effort to complete major components of INPO accredited training of maintenance personnel, as well as
- an initiative'to validate nomenclature in surveillance procedures.
Both of these efforts have significantly reduced, for the time being, the number of personnel assigned to carry out L
maintenance.
With the scheduled completion of these programs in L
early 1990, Boston Edison expects to increase -- without increasing the permanent maintenance complement -- the availability of maintenance personnel for reductions to the corrective maintenance (running repair) MR backlog and for additional preventive maintenance.
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b*
1 t, S Actions Retaining Continue actions described above.
Continual analysis and tracking of the open MRs shows ffective management control of the maintenance backlog.
In addition, efforts are underway to develop more refined
' indicators.
3.
Plant Testing and Readiness Boston Edison's experience during implementation of the Restart Plan in the area of plant testing and readiness is discussed below.
3.
Restart Plan Positive Indications and Action Itemmt In order to support restart and power ascension, the RRSA called for completion of #arious testing reviews and conduct of any additional testing determined to be necessary.
As documented in PNPS Nuclear Operations Department Temporary Procedure 87-114, testing necessary to support restart and power ascension has been completed, except for two operatior.s originally scheduled for the 100% power plateau.
These nperations (the recirculation pump motor generator scoop tube
. position determination and the traversing in-core probe (TIP) alignment) will be performed at a later date.
The Power Ascension Program has been revised to reflect this change in accordance with the process set forth in.the second Supplement to CAL 86-10.
Results of testing were independently reviewed by the
.Startup Test Organization to ensure that applicable criteria were satisfied.
SALP Report 88-99 noted that the planning and
- A15 -
i i,
i i-
....im..
.i,ui,
F p
I evaluation of pre-startup activities were thorough and well managed, and that plant management and the Operations Review Committee exhibited a conservative and safety conscious approach.
4.
system Lineups Boston Edison's experience during implementation of the Restart Plan and the Power Ascension Program in the area of system lineups is discussed below, a.
Restart Plan Positive Indications and Action Items:
Prior to restart, necessary reviews of procedures and practices and implementation of changes to improve control over valve positioning were to be completed.
In particular, the tagout procedure was to be revised to limit the types of tags used and to clarify and place additional controls on their use; a plan was to be developed to implement the INPO Good Practices for valve lineups and labeling of instrument isolation valves; and instrument-specific valve lineup sheets were to be developed for safety systems and balance of plant systems.
A revised tagout procedure was issued in September 1988.
It eliminated the use of Red Tags to mark lifted leads and placed additional controls on the use of Test Tags and NWE Thgs.
The INPO Good Practice for component labeling published in September 1988 was implemented through the Operations Equipment Labeling procedure effective August 1989.
Finally, instrument valves have been added to lineup sheets for safety systems and I
balance of plant systems.
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b.
Power Ascension Experience and Resulting Actions:
As a result of the RCIC system event, further procedural and practice changes have been made for improved control over valve positioning and line-up.
These are discusced above in Section II of this Report.
The tagout procedure was again revised in September 1989.
This revision phased out the use of NWE tags and further improved control of tagouts.
A new procedure has been developed and implemented that formalizes the requirements for periodic review of tagouts by the line organization.
5.
Operations Performance Boston Edison's experience during implementation of the Restart Plan and the Power Ascension Program in the area of operations performance is discussed below, a.
Restart Plan Positive Indications and Action Items:
Boston Edison had recognized that performance errors were likely to be encountered following the long Pilgrim outage.
That this commonly occurred at plants during initial periods of operation is documented in NUREG-1275.
To diminish the likelihood of occurrence, Boston Edison had initiated various steps, including extensive operator training on the simulator, walkthroughs of certain complicated tests, extensive operator involvement in post-modification tests, and formalized Control
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l I
Room communications.
Boston Edison also had recently completed a etudy of PNPS unplanned ESP actuations.
Prior to restart, management review of the study was to be completed and further actions were to be taken to reduce the likelihood of unplanned ESP actuations.
In addition, during the Power Ascension Program, additional management oversight of operations was to be provided through pe n 3 valuation, and frequent management presence.
A third SRO was to be assigned to
-augment each shift.
Review of the ESF actuation study was completed and the results and corresponding corrective and preventive actions were described in a September 22, 1988 letter to the NRC (BECo Ltr.
- 88-139).
Substantially increased management oversight of reactor operations was a central element of the Power Ascension Program.
Peor evaluation, senior management backshift monitoring and watchstander oversight were all utilized.
The third SRO on shift program was implemented prior to restart.
Subsequently, on completion of testing at 25% power, watch sections returned to
.two SROs per shift upon establishing a six-section watch rotation.
b.
Power Ascension Experience and Resulting Actions:
During power ascension, some unplanned ESF actuations and a manual scram occurred as a result of personnel or procedural errors.
As with the unplanned scrams discussed above in Appendix A, Section 1.b, these eventa posed no threat to
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public health and safety, violated no technical specifications, and caused no loss of safety system function.
- Overall, operations performance during the Power Ascension Program improved from adequate to excellent as demonstrated by, among other things, operator performance during both Phases I & 11 of the Shut-Down from Outside the Control Room (SDOCR).
1.
January 15, 1999 ESP Actuation (SBGT Initiationt Switch Test. Test Logicle An operator inadvertently moved the Reactor Building Isolation Control System (RBIS)
Channel "A"
(keylocked) control switch to the TEST position instead of the TEST LOGIC position during a surveillance test, causing actuation of the RBIS and initiation of the Standby Gas Treatment System (SBGT).
Actions Taken:
Investigation of the causes of the event revealed that the operator knew the correct control switch position but inadvertently moved the switch to the wrong position.
Human factors contributing to the error were the control switch location and control switch terminology.
Actions were identified to provide human factors improvements to the control switches.
Actions Remaining:
Completion of the human factors improvements to the control switches.
11.
May 20, 1989 ESF Actuation (Error by ILC Technician During Surveillance):
A utility non-licensed Electrical Maintenance technician twice failed to carry out a procedural step adequately and as a result thcre was an unplanned actuation of the RHRS/LPCI loop selection logic circuitry.
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I Actions Taken:
Operator action was taken after each occurrence and testing was suspended.
After the becond event, an investigation team was formed.
F&MRs89-201 and 202 were written and the NRC Operations Center was notified each time as required.
The investigation team verified that there were no drawing, diagram, equipment or procedural problems.
A supplemental test was prepared and performed.
LER 89-017-00 was prepared.
Past LERs were reviewed and revealed that an I&C technician had similarly failed to successfully insulate two normally closed contacts (see LER 89-012-00).
Therefore, Long Term Plan (LTP) item no. 224, " Logic System Functional Testing-Modification to Install Test Jacks," was initiated and approved.
Actions Remainings Test procedures that involve blocking of contacts of relays installed in safety-related applications will be reviewed per LTP item no. 224.
Where possible, alternative means of testing will be used to avoid insulating relay contacts and installing jumpers, iii.
September 5, 1989 ESF Actuation
("A" Emergency Diesel Generatorit An I&C technician installed jumpers on the wrong relay during-a routine surveillance.
There was an actuation of RHR/LPCI loop selection and an Emergency Diesel Generator (EDG) auto start.
Actions Taken:
As soon as the I&C technicians realized that they had jumpered the wrong relay, the Control Room was notified.
An F&MR was prepared, and the NRC was notified as required.
The test procedure was revised to include
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l
o l
verification of the steps requiring installation of jumpers or insulating boots.
Actions Romaining None.
iv. -
July 19. 1989 Manual Scram Due to Decreasing Main condenser Vacuum:
A decrease in condenser vacuum was caused by an inadequacy in the procedure for reconfiguration of the steam jet air ejectors of the Main Gas Removal System which reFulted in simultaneous operation of six air ejectors.
Operation of all six air ejectors resulted in decreased intercondenser and aftercondenser heat transfer capacity and therefore decreased condenser vacuum.
It also caused high temperature isolation of the Off-Gas High-Temperature Isolation Switches, which caused the main condenser off-gas isolation valves to close preventing recovery.
Actions Taken:
The applicable procedure was revised to include specific steps for reconfiguration of the air ejectors.
Actions Ramaining:
An Engineering Service Request (ESR 89-609) was written to explore the possible addition of a feature to the control circuitry for the Main Condenser /Offgas System vapor valves to permit the Off-Gas High Temperature Isolation switches to be bypassed.
This feature would allow greater operator manual control (where appropriate) over bypassing these switches to recover from this problem.
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)
6.
Formality of Communications Boston Edison's experience during implementation of the Restart Plan and the Power Ascension Program in the area of formal communications is discussed below.
A.
Restart Plan Positive Indications and Action Items:
The RRSA noted improved accuracy and formality of communication among Control Room operators, exceeding industry practices.
No action was required prior to restart, although Boston Edison committed to extend appropriate portions of the standards for Control Room communications to I&C technicians and other personnel who might have direct interface with the Control Room operators.
I&C technicians and Mechanical and Electrical Division personnel were trained on formal communication techniques.
During power ascension, Boston Edison management took specific steps to reinforce the need for formalization and specificity in communications among non-Control Room personnel, b.
Enyer Ascension Experience and Resulting Actigng SALP Report 88-99 cited notable enhancements in Control Room communications and improved attitudes and professionalism among the Control Room staff.
During power ascension, actions taken in response to MO&AT recommendations and to the RCIC system and FRV cvents have resulted in further improvements in formal communications and practices.
Improvements resulting from Mo&AT assessments are discussed below.
Those resulting from the RCIC
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or FRV events are discussed in Section II of this Report.
Close monitoring of formality of Control Room communications is continuing in order to ensure that improvements are being
' sustained.
i.
MOLAT observation:
Oral Communications between Non-operations personnel and Control Room personnel and among PNPS work groups were of a lesser quality and lacked the formality, clarity and precision of communications of Operations personnel trained in accordance with the Station Instruction governing operations communications.
Actions Taken I&C and Mechanical and Electrical personnel were trained in the use of the formal communications techniques embodied in the Station Instruction.
Actions Romaining:
Through continuing management oversight of Control Room activities and 6.he peer evaluator process, formality of communications between I&C personnel and Control Room personnel is being reinforced.
The Nuclear Training Department also reinforces this good practice during vcrious training sessions, ii.
Mo&AT observations operations personnel were maintaining logs largely duplicative of each other as to purpose, but not always as to content; i.e.,
the logs contained incomplete entries, untimely entries, and omissions.
Actions Taken The Conduct of Operations procedure was modified to identify the Nuclear Operating Supervisor's (NOS) log as the official Operations log.
The
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Reactor Operator's log is no longer used as the official log and is used for informational purposes only.
Appropriate uses of the respective logs have bean clarified for Operations personnel.
The procedure was further modified to provide illustrative examples of the kinds of events which must be recorded for each entry.
The administrative assistant was given the additional duty to enter the Control Room and assist in accurate maintenance of the NOS log during transients or other fast-breaking events.
Actions Remaining:
Continue actions as described above.
iii.
MOLAT Observation:
Some instances were found of apparent inattention to documentation details, such as night orders which were not timely signed or were unsigned, discrepancies on tag-out sheets, and omissions from the Nuclear Plant Reactor Operator's relief check list.
Actions Taken:
An investigation was conducted which revealed that some of these problems were related to the manner in which the systems were administered.
Appropriate administrative corrections have been made.
However, some of the instances arose from failure to sign documentation in a timely fashion or at all.
To correct these situations, the Operations Section Manager and the Nuclear Chief Operating Engineer are spot-checking the watch turnover process to ensure that it is being carried out properly.
They are holding the NOS Supervisor accountable for any lapses in sign-off.
Through this oversight process, operations management
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mm-----a m
is conveying to operations personnel the necessity for proper sign-off of documentation and ensuring that such sign-off occurs.
With respect to the tagout system discrepancies, actions as described above in Section II have been taken.
Actions Remaining:
Continue actions as described above.
As discussed in Section VI of this Report, particular attention is being given to procedural adequacy, and adherence and oversight of areas requiring additional management attention will continue.
7.
Procedural Adequacy Boston Edison's experience during implementation of the Restart Plan and the Power Ascension Program in the area of procedural adequacy is discussed below, a.
Restart Plan Positive Indications and Action Itemst The RRSA noted that the Emergency Operating Procedures (EOPs) and satellite procedures had been developed and validated, and that operating crews had been effectively trained on the EOPs through use of the simulator.
The RRSA indicated that prior to restart those procedures affected by modifications, required for start-up or revised during RFO-7 would be validated and operator training conducted.
It also stated that a procedure writer's guide would be developed.
Long-term actions included an upgrade of Operations procedures to improve human factors elements.
The Operations and Surveillance procedures were validated prior to restart and the requisite operator training
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a was completed.
The writer's guide was also completed.
Long-term actions to improve human factors elements of Station procedures were initiated.
b.
Power Ascension Experience and Resulting Actions:
Performance of plant operations and maintenance tasks associated with the power ascension program, especially those associated with the RCIC system event, the FRV event and the condensate pump and suction piping overpressurization event, revealed problems with procedural adequacy and adherence.
As these problems were identified, the scope of the upgrade of Station procedures was expanded to address them.
Maintenance procedures were included in the program.
A procedure for validating content by walkthrough was implemented.
Graphic presentations in procedures are being upgraded to im; rove clarity.
Section II of this Report also addresses enhancements to the upgrade of Station procedures Three other events which influenced the procedure upgrade effort are discussed below, i.
Discharge Permit Error:
A computational error in total activity planned to be discharged in the previous 30 days indicated that discharge activity limits would have been exceeded.
Through lack of adequate review and communications, this calculational error was not properly addressed prior to the discharge.
No discharge limits were exceeded.
Human factors inadequacies in the discharge calculation procedure contributed to the personnel errors which occurred.
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I Actions Taken:
Discharges were terminated pending procedure revision.
Similar chemistry procedures were reviewed to verify that human factors problems similar to the ones that led to the errors did not exist.
The procedure involved was revised to correct human factors problems and to include additional checks and balances to minimize the potential for recurrence of the error.
In addition, the individual who had not conducted an adequate review of the discharge permit, and the individuals who did not identify the noted error so that it could be corrected received appropriate disciplinary action.
Actions Rammining:
A revised computer program for calculating cumulative 30-day activity discharged totals allowed under the revised procedure will be qualified prior to use.
ii.
Pumn Motor Mounting Bolts:
Mounting bolts for a non-safety related fuel pool cooling pump motor were found to be machined and during post inspection reassembly, several bolts were overtorqued.
Actions Taken A review of motors was conducted which confirmed that machining of bolts had not occurred for safety related motors.
However, during reassembly, several mounting bolts were overtorqued because two work crews misunderstood the work instructions.
The overtorqued bolts were either replaced or accepted for use following engineering analysis.
Action has been taken to correct the cause of the misunderstanding by improving work instruction clarity.
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--'-=====i mii iii ii i
f Planners' work instructions provide, and in some instances highlight, specific parts of procedures in order to identify all values for torquing, resistance, etc.
A QA directive has also been issued requiring that the Quality Control (QC) Inspectors be completely familiar with the work they are inspecting.
This includes a review of the procedures, maintenance work plan and vendor manuals.
Also, the two QC Inspectors involved with the overtorquing were counseled regarding their inappropriate actions.
Actions Remaining:
None.
111.
Unlocked High Radiation Area Door A High Radiation Area door to the condenser bay Locked High Radiation Area (LHRA) was left unlocked and unattended for about one hour.
Actions Taken An investigation was conducted and it was determined that during exits from the condensor bay LHRA, the three doors from the LHRA were not verified locked as required by PNPS procedure.
A number of corrective actions were taken, including revisions to applicable procedures and training modules to reemphasize and clarify LHRA entry and exit requirements.
Clarification was also provided through the Workforce Information Program and general employee information notices.
Previously, in February, 1989 an LHRA access door had been found unlocked.
Following this earlier event, the HRA Access Control Procedure had been modified to require verification that all LHRA access doors were locked.
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d Actions Remainingt Several actions remain to 1
~be performed or completed, including hardware improvements, conduct of a QA surveillance of High Radiation Area procedures and practices, and further procedural and training revisions to provide additional improvements.
8.
Drawing Completeness and Accuracy Boston Edison's experience during implementation of the Restart Plan and the Power Ascension Program in the area of drawing completeness and adequacy is discussed below, a.
Restart Plan Positive Indications and Action Itemmt The RRSA indicated that Boston Edison had identified a need to evaluate the completeness and accuracy of Priority A Control Room drawings, and that as a result of a QAD
~ surveillance, two deficiency reports (DRs) were issued which had to be resolved prior to restart.
As required, the DRs were closed prior to restart.
Control Room Priority A drawings were audited to ensure they were up to date.
b.
Power Ascension Experience and Resulting Actionst i.
Update of Priority "B" Drawings and Documentst Our experience during the Power Ascension Program confirmed the need to update Priority "B" drawings and documents to facilitate maintenance.
Actions Takent As discussed above in Section
-VI.H, long-term projects have been initiated to implement improvements, including those being undertaken through the Vondor
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i
Equipment Technical Information Program, the Design and Configuration Control Program, and the Drawing Update Program.
Actions Remaining:
Continue actions as described above.
9.
Institutionalization of Good Practices Boston Edison's experience during implementation of the Restart Plan and the Power Ascension Program with respect to institutionalization of good practices is discussed below, a.
Restart Plan Positive Indications and Action Items:
Prior to restart, Boston Edison committed to initiate efforts to institutionalizes (1) planning, scheduling, assignment, pre-job briefing and control of maintenance practices; and (2) event investigation, critique and root cause analysis processes.
After power ascension, it committed to (3) institutionalize the peer evaluator process; and (4) develop a long-term issue-oriented database.
Revisions to the Maintenance Request, Maintenance Work Plan and other related procedures have been made in order to institutionalize improvements in work planning, scheduling and control practices.
The procedure governing torque requirements was revised.
The associated procedures and instruction have been modified to enhance the critique and root cause analysis process.
A procedure to institutionalize the peer evaluator process has been drafted and should be issued by January, 1990.
An issue-oriented database for improvement actions, the Improvement Action
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i Database (IADB), is being implemented and is discussed in Section V of this Report.
Further improvements in the planning, scheduling and budgeting of maintenance activities should be realized with the issuance of refined procedures for the control of work and testing, planned for early 1990.
b.
Power Ascension Experience and Resulting Actionst 1.
Lack of Procedure for HPES:
Implementing procedures should be developed for the HPES.
Actions Takent The Critique Procedure has been revised to require that a Clearinghouse representative participate in the initial evaluation following an event to determine the type of review to be conducted by the Boston Edison critique or investigation team.
A procedure has been approved and implemented which establishes criteria for determining when an HPES must be performed.
Actions Remaining:
None.
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I I
l ATTACIDENT 1 Status of Rostart Plan Volume 2 Action Items 1/
Items identified in Volume 2 of the Restart Plan have either been closed or transferred to the Improvement Action Database (IADB) for tracking and resolution.
The transferred items were longer-term items and not required for restart.
In particular, the status of Restart Plan items is as follows:
Restart Plan, Volums 2, Appendix 6 (MCIAP items):
Total items........................... 89 Total items closed.................... 89 Restart Plan, Volume 2, Appendix 7 (RAP items):
Total items........................... 14 Totel items closed.................... 14 Resthrt Plan, Volume 2, Appendix 10 (Restart Regulatory Responses):
Total items.......................... 522 Total items closed...........,....... 510 Total open items (transferred to IADB). 12
- /
Restart Plan Volume 2 was initially submitted on July 30, 1987.
Revision 1 was filed on October 26, 1987 and Appendix 7 " Summary Status of Restart Actions in the Radiological Action Plan" was filed on January 4, 1988.
Revision 2 of the Restart Plan was submitted on May 26, 1988.
Revision 3 of the Restart Plan was submitted on September 28, 1988. 1 -
During the process of resolving Volume 2 open items, some modifications to commitments were made.
Most of these changes were minor wording changes to actions or closure requirements undertaken for purposes of clarification.
In addition, some modifications to due dates for Appendix 10 items (Restart Regulatory Responses) were made either to change
" Restart plus" dates to calendar dates, or to account for the impact of resource availability or plant operating cycle.
No changes to due dates were made for Schedule A or B items as identified in the Long Term Plan.
Changes to these items require either prior NRC approval or notification.
Commitment changes are reflected in the Restart Plan. 2 -
ATTACHMENT 2 Outstandino RREA Action Itema
.l.
Upgrade the human factors elements of PNPS procedures -
An upgrade of Station procedures, including incorporation of human factors improvements is in progress.
Primary emphasic is being placed on Operations procedures.
To date, over 100 of 389 Operations procedures have been revised and issued and almost 200 are in process.
Estimated Completion Date:
July 1990 - Operations procedures December 1991 - Maintenance procedures 2.
Institutionalize the peer evaluator process -
A procedure which institutionalizes the peer evaluator program after completion of the Power Ascension Program is in review and is expected to be issued by January 1990.
Estimated Comnletion Date:
January 1990 (procedure issuance)
Observation of plant and personnel performance by peer evaluators will continue pending issue of the procedure.
3.
Provide operational support in the pre-planning of work in other functional areas -
Qualified Operations personnel (Watch Engineers) have been assigned to chair a work prioritization team that meets daily to plan maintenance and surveillance work.
An Operations representative must still be assigned to support Emergency Preparedness.
SRO certified individuals have now been assigned to the Planning and Outage Department.
Estimated Completion Date:
March 1990
. 1 -
i
l 4.
Develop a procedure to collect and trend plant equipment history -
Procedures have been developed for maintenance problem analysis, maintenance centered equipment failure analysis and trending of system and equipment performance.
The need for a broader, integrated program for maintaining and using equipment history information to improve the efficiency of the maintenance process has been recognized, and such a program will be developed over the next two years.
Estimated completion Dates December 1991 2 -
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