ML20028C484
| ML20028C484 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 08/17/1982 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20027A871 | List: |
| References | |
| NUDOCS 8301100259 | |
| Download: ML20028C484 (35) | |
Text
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ENCLOSURE 2
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S.' NUCLEhR REGULATORY' COMMISSION
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REGION V
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SYSTEMATIC ASSESSMENT OF LICENS$E' PERFORMANCE
- SOUTHERN CALIFORNIA EDISON COMPANY SAN ONFORE NUCLEAR GENERATING STATION UNIT 1 AU_ GUST 17, 1982 8301100259 830105 PDR ADOCK 05000206 Q
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' TABLE OF CONTENTS
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I.
Introduction II. Summary of Results 3
III. Criterla 4-IV.
Performance Analysis 5
-A.
P1 ant Operations 5
B.
Radiological Controls 6-C.
Maintenance 8
D.
Surveillance 9
E.
Fire Protection
-10 F.
Emergency Preparedness 11 G.
Security and Safeguards 11 H.
Refueling 13 I.
Licensing Activities 13 J.
Quality Assurance 13.
K.
TMI Action Items 13 L.
Design Changes and Modifications 14-V.
Supporting Data and Suninaries' 14 A.
Licensee Event Report Evaluation and Analysis 15 B.
Special Reports 17 C.
Investigation and Allegations Review 18 D.
Escalated Enforcement Actions 19 E.
Administrative Actions during the Assessment Period.
20 F.
Miscellaneous Data 21 1.
10 CFR 21 Reports 21 2.
Abnormal Occurrences 21 3.
Nature and Number of Unplanned 'l rips 21 TABLES 1
Tabular Listing of LERs by Functional Area' 22 j
Table 1 f
LER Synopsis 23 Table 2 l
Inspection Activities and Hours Summary 28 l
Table 3 f
Violations: Severity Levels and Functional Areas 29 Table 4 Causal Analysis 33 Table 5 l
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. I.
INTRODUCTION A.
Purpose and Overview The Systematic Assessment of Licensee Performance (SALP) is an integrated NRC staff effort to collect the available observations on an annual basis and evaluate licensee performance based on those observations with the objectives of improving the NRC Regulatory Program and Licensee performance.
The assessment period is July 1,1981 through June 30, 1982.
This assessment, however, contains pertinent observations and NRC and licensee activities through July 1982. Future assessment periods will be adjusted to provide more timely NRC assessment and reporting.
The prior SALP assessment' period was May 16, 1980 through June 30, 1981. -Significant findings of that assessment and the period between that assessment-and this asscssment are provided in the applicable Performance Analysis Functional Areas (Section IV).
Evaluation criter'ia.used duringsthis assessment are discussed
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in Section III below. Each criterion was applied using the " Attributes for. Assessment of Licensee Performance" contained in NRC Manual Chapter 0516.
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B.
SALP Attendees W. A. Paulson, NRR Project Manager D. M. Sternberg, Chief, Reactor Operations Projects Branch No.1 G. B. Zwetzig, Chief,. Reactor Projects Section l' L. Miller, Senior Resident Inspector, Unit 1 F. A. Wenslawski, Chief, Reactor Radiation Protection Section R. F. Fish, Emergency Preparedness Analyst W. P. Mortensen, Physical Protection Inspector J. W. Hornor, Reactor Inspector Other NRC Attendees T. W. Bishop, Chief, Reactor Projects Branch No. 2 D. F. Kirsch, Chief, Reactor Projects Section No. 3, Reactor Projects Branch No. 2
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. C.
Background
1.
Licensee Activities
- At the beginning of the assessment period, the reactor was returning to near full power after a long-term outage for extensive steam generator tube repairs.
The reactor power was limited in order to obtain satisfactory steam quality due to plugging of some of the steam generator tubes.
July 17, 1981: The reactor was shutdown for diesel generator repairs after a lube oil fire.
During the same day an explosive gas mixture was allowed to accumulate in a waste gas decay tank and subsequently exploded.
The resulting force caused a failure of the manway cover and the release of 8.8 curies of gaseous fission products.
August 16, 1981: The reactor returned to near full power at the completion of the diesel generator repair.
September 2, 1981: The reactor tripped from the loss of This loss also caused the number 1 regulated power supply (.SI) system which failed initiation of the Safety Injection to inject borated coolant into the primary system because the injection valves woulc not open against the existing differential pressure (see LER 81-20). The reactor remained shutdown until November for evaluation, modification, and testing of the SI system.
November 3, 1981: The reactor returned to near full power.
November 23, 1981: The reactor was shutdown to perform required routini hot functional testing of the SI system.
November 24, 1981: The reactor returned to near full power and remained there with only minor reductions for repairs or maintenance until the next scheduled outage.
February 27, 1982: The reactor was shutdown according to schedule for seismic upgrading, steam generator tube examinations, TMI modifications, and miscellaneous maintenance.
June 30, 1982: As of this date, the reactor will remain shutdown until resolution of seismic concerns. The evaluation should be complete by the end of August 1982 and the required modifications are scheduled for completion by November 1982, with restart scheduled for November 28, 1982.
I j 2.
Inspection Activities One NRC senior resident inspector was onsite for the entire appraisal period.
Total NRC inspection hours: 2193 (resident and region based).
Distribution of inspection activities and hours are shown on Table 3.
l A tabulation of violations is shown on Table 4, and an analysis i
of LERs is shown in Section V.
The LER Tabular data is shown in Tables 1 and 2.
J A causal = analysis of combined violations and LER's is shown in. Table 5.
II.
SUMMARY
OF RESULTS SAN OdOFRE NUCLEAR GENERATING STATION UNIT 1 FUNCTIONAL AREAS CATEGORY 1-CATEGORY 2 CATEGORY 3 1.
Plant Operations,-.,,
X 2
Radiological' Controls
. Radiation Protect' ion
. Radioactive Waste Management
. Transportation.
. Effluent Control and Monitoring X
3.
Maintenance X
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4.
Surveillance (Including Inservice and Preoperational i
Testing)
X 5.
Fire Protection and X
Housekeeping i
6.
i 7.
Security and Safeguards X
j 8.
Refueling (no activity) a 9.
Licensing Activities X
i 10.
Quality Assurance X
11.
TMI Action Items X
12.
Design Changes and X
Modifications 4
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. III. CRITERIA,
The following evaluation criteria were applied to each functional area:
1.
Management involvement in assuring quality.
2.
Approach to resolution of technical issues from a safety standpoint.
3.
Responsiveness to NRC initiatives.
~4.
Enforcement history.
5.
Reporting and analysis of reportable events.
6.
Staffing (including management).
7.
Training effectiveness and qualification.
To provide consistent evaluation of licensee performance, attributes associated with each criterion and describing the characteristics applicable to Category 1, 2, and 3 performance were applied as discussed in NRC Manual Chapter 0516, Part II'and Table 1.
The SALP Board conclusions were categorized as follows:
Category 1:
Reduced NRC attention may be appropriate.
Licensee management attention and involvement are aggressive and oriented toward nuclear safety; licensee resources are ample and effectively used such that a high level of performance with respect to operational safety or construction is being achieved.
Category 2:
NRC attention should be maintained at normal levels.
Licensee management attention and involvement are evident and are concerned with nuclear safety; licensee resources are adequate and are reasonably effective such that satisfactory performance with respect to operational safety or construction is being achieved.
Category 3:
Both NRC and licensee attention should be increased.
Licensee management attention or involvement is acceptable and considers nuclear safety, but weaknesses are evident; licensee resources appeared strained or not effectively used such that minimally satisfactory performance with respect to operational safety and construction is'being achieved.
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IV. PERFORMANCE ANALYSIS l
A.
Operations The licensee's management appears to be involved and concerned i
with nuclear safety. However, during this period, licensee resources were not effectively used. Only minimally satisfactory performance with respect to operational safety was achieved. The major fire in the number 1 Diesel Generator (LER 81-17), the discovery of serious' design flaws in the high pressure safety injection system 1
(LER 81-20), and numerous apparent seismic design deficiencies were significant occurrences in this period.
In addition, several significant operational errors were made which demonstrated an 4
1 occasionally casual approach to, procedural compliance. Specifically, l
the failure to recognize an explosive. mixture accumulation in the waste gas system (NRC Inspection Report No. 81-31), chronic i
operation of the mixed bed demineralizers with evidence of retention screen plugging (NRC Inspection Report No. 82-10), and the removal of two of three required boration flowpaths contrary to the Technical Specifications (NRC Inspection Report No. 82-17) resulted from failure to observe procedural precautions.
Recently, licensee management has vigorously emphasized procedural compliance by 1
operating personnel.
The licensee's training and requalification programs appear adequate although more emphasis on procedure compliance appears warranted.
The training and requalification programs are undergoing a significant 3
l increase in size and scope and will eventually include formal r
training for craftsmen and technicians (NRC Inspection Report i
No.82-05).
Written safety evaluations, especially the tests and experiments program, as required by 10 CFR 50.59, were being presented and approved orally by the On Site Review Comittee (OSRC). The licensee identified this problem and was in the process of changing procedures to require written safety evaluations (NRC Inspection Report No. 82-02). Procedures in general did not define responsibilities and the two year review cycle was not specifically set out in the OSRC administrative controls. As a result, several required reviews were missed (NRC Inspection Report No. 82-02).
New station orders and administrative procedures are being written to correct these deficiencies.
Conclusion t
l Category 3 i
Board Recommendation '
The Board is concerned that the licensee's performance in this area may have been adversely affected by the need for larger i
numbers of personne1~to assist in the startup program for Unit 2, I
which resulted in a less effective manning level for Unit 1 in both tne engineering and nonlicensed staff. The effectiveness of management involvement will be closely monitored during the next SALP period.
In addition, more effort should be focused on the completion of Standard Technical Specifications and the l
l Safety Evaluation Program (SEP).
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. B.
Radiological Controls Cycle 2 SALP detailed major program atic deficiencies in the radiation protection activities during the period of May 16, 1980 through June 30, 1981.
These deficiencies resulted in 16 violations of NRC requirements, two Immediate Action Letters, two Management Meetings, and issuance of a Civil Penalty. During the current evaluation period, substantive changes have been made by the licensee. These include:
Separation of the Chemistry and Radiation Protection functions.
Acquisition of a Health Physics Manager, Supervisor of Radiological Engineering, and additional technical staff members at the corporate and site locations.
Improved facilities and equipment for the conduct of radiation protection activities.
Increased management involvement.
As a result of these actions only three Severity Level V violations (failure to:
instruct workers; post a high radiation area; and follow a w11ation protection procedure) were identified during 114 hours0.00132 days <br />0.0317 hours <br />1.884921e-4 weeks <br />4.3377e-5 months <br /> of inspection effort in the areas of radiation protection and transportation activities.
Since August 1980 frequent major changes in the radiation protection organization have been made. This has resulted in some lack of continuity. Many new technicians are being intergrated into the plant staff while the licensee continues to rely heavily on contractor supplied radiation protection technicians.
Several experienced foremen have recently been promoted thereby temporarily decreasing the effectiveness of first line supervision. With the upcoming increase in retrofit activities and other major site evolutions, it is suggested the licensee direct attention to these conditions which could have a potentially negative impact.
Liquid and gaseous radioactive waste management and effluent monitoring responsibilities rest with the licensee's chemistry section. An inspection of these activities revealed a significant lack of management attention in this area. The following programmatic weaknesses were identified:
The assigned engineer was not fully aware of his responsibilities; was unfamiliar with applicable license conditions and regulatory requirements; and was not well versed in the effluent monitoring instrumentation.
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i The effluent monitoring instrumentation was not being maintained.
For example: the liquid radwaste monitor had not operated properly for nearly a par; the stack gas monitor was not operating properly when the waste gas decay tank failed; effluent monitor flow meters had not been calibrated; and the operational radiation monitor multipoint recorder frequently malfunctioned.
Several radioactive releases were not properly evaluated and reported. For example:
batch releases producing inconsistent effluent monitor responses were not evaluated; the January through June 1981 Semiannual Effluent Release Report was not submitted until requested by the NRC.
Procedures for liquid and gaseous radwaste management lacked specificity and appeared not to have been followed. For example:
procedures did not specify what item on the Gas Release Permit constitutes conditions which must be met for the release to take place; and although gas discharge flow rates were recorded as required, it appeared that the flow instrument had been bypassed to decrease discharge times.
As a result of this inspection effort, three Severity Level IV violations were cited (failure to: monitor gaseous effluent releases; perform surveys or evaluations; and develop and implement procedures) and one Severity Level V (failure to submit the semiannual effluentreleasereport).
An Enforcement Conference was held on November 25, 1981.
LFR 80-018 described the July 17, 1981 explosion in the north Waste Gas Decay Tank that resulted ~in the uncontrolled release of about eight curies of Xe133. Review of the release during the inspection discussed above confirmed the unrestricted area boundary concentration was about one tenth of the value listed in 10 CFR 20 Appendix B, Table II. Most significant is that the event appeared preventable.
Follow-up inspection effort confirmed that the licensee not only responded to the identified problems, but through effective selection and use of contract experts, has made programmatic improvements in the management of radioactive wastes. These include:
3 Complete recalibration and evaluation of effluent monitoring equipment.
Development and implementation of improved procedures.
The Region expended 182 inspection-hours reviewing this area.
During the Enforcement Conference the NRC emphasized the need for the licensee to identify and correct their own programmatic deficiencies'. The licensee performed a review of their radiological environmental monitoring program.
This review resulted in development of an action plan for upgrading this aspect of their responsibilities.
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. A January 1982 inspection (32 hours3.703704e-4 days <br />0.00889 hours <br />5.291005e-5 weeks <br />1.2176e-5 months <br />) of the radiological environmental monitoring program found that meaningful improvements were in progress as outlined in the action plan. However, one Severity Level VI violation was cited (failure to properly report an environmental sample result).
Conclusion Category 3 Board Recommendation Although considerable improvement has been made, the lack of continuity in radiation protection," programmatic deficiencies in radioactive waste management and effluent monitoring, and additional demands expected during the next year warrant continued licensee management attention and a continued increased NRC inspection program in the radiological controls area.
C.
Maintenance Between the previous maintenance inspection (NRC Inspection Report No. 81-05) and the current inspection (NRC Inspection Report Nc. 82-05) several improvements to the maintenance program were noted including the initiation of a permanent preventive maintenance program, improved procedures (with associated forms), and the establishment of an Equipment Control Program. Even with this increased effort, the documentation of safety-related maintenance activities was still incomplete and often difficult or, impossible to locate (NRC Inspection Report No. 82-05). The administrative controls covering maintenance, especially the records, lack continuity to completely verify adequate maintenance activity completion.
Two areas that need more management attention are communication between groups impacted by maintenance activities (i.e., maintenance, equipment control, operations, etc.) and the tracking and document control of maintenance records. Tracking and document control appears to be a continuing problem and was identified during the previous SALP evaluation cycle.
Housekeeping is routinely a problem at active co struction and operating nuclear facilities.
Inspections wlo nonitored housekeeping (Report Nos. 82-07 and 82-21) found many minc
.nconsistencies with station requirements both in housekeeping and fire protection.
In order to reduce fire hazards and enhance safety, procedure compliance warrants increased emphasis.
The' inspection'of procurement, receipt, storage, and handling of safety-related materials identified two significant areas requiring management attention: emergency procurement, and reverification of safety-related certification when using blanket purchase orders M
. beyond the initial purchase (NRC Inspection Report No. 82-16).
Because of the lack of procedural controls it appears possible to use non-safety grade materials and services in safety-related maintenance if purchased by one of the above methods.
Pursuant to the violations which resulted from the unauthorized modification of the refueling water pump seal water line (NRC Inspection Report No. 82-04) and the unplanned flooding of the saltwater intake structure (NRC Inspection Report No. 82-17),
a total understanding of the safety issues by licensee personnel appeared lacking. The licensee recently improved the performance of personnel by conducting training sessions concerning procedural compliance, equipment control, and authorized modifications.
Also, the licensee established a maintenance engineering review group.
In addition, a system to record machinery operating and maintenance histo *y in a usable form was initiated.
Effort has also been initiated to maintain current vendor technical manuals dnd publications, an area which never has been controlled by a formal progrsm.
In the maintenance area, licensee management attention and involvement is only marginally satisfactory. Licensee resources appear to have been strained, apparently due to the demands of Units 2 and 3 such that minimally satisfactory performance with respect to operational safety was achieved.
Conclusion Category 3 Board Recommendation d
Increased licensee management attention needs to be focused on maintenance documentation, procedure revisions, maintenance record retrieval, maintenance order approvals and close outs, maintenance department communications with other departments and formal controls on all maintenance work. Future NRC inspections of maintenance activities monitor the effectiveness of these measures in preventing further violations in this area.
D.
Surveillance The inspection program identified that no single master station document addressed the surveillance requirements at SONGS-Unit 1 (the document for Units 2 and 3 is S023-G-17).
As a result, surveillance is divided among several groups and no single position has been identified as being responsible to assure compliance with the Technical Specification surveillance requirements.
This has contributed to missed surveillances (NRC Inspection Report No. 82-20) and difficulties in documentation retrieval verifying timely completion of required surveillances (NRC Inspection Report No. 82-11).
In addition, the program for inservice testing of valves addressed the applicable ASME codes but procedures lacked the ASME required acceptance criteria.
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. Recently, the licensee reported several failures to perform surveillances occurring during the previous two years (NRC Inspection Report No.82-20). The licensee has been required to explain how a repetition of these oversights will be prevented.
The surveillance program is currently undergoing revision and new station orders and procedures, similar to Units 2 and 3, are being written.
With the exception of the above, licensee management appears attentive, involved, and concerned with nuclear safety.
Conclusion Category 2 Board Recommendation None E.
Fire Protection _
A fire protection program inspection, performed early in SALP Cycle 3, identified significant deficiencies in the SONGS Fire Protection Program (NRC Inspection Report No. 81-25) including:
the lack of administrative controls; authorities and responsibilities not clearly defined; no fire fighting strategies; and no evidence of offsite fire fighting personnel training.
In response to the violation, the licensee com'tted to a year long upgrading of the entire Fire Protection Program, to be completed by July 1, i
1982.
1 Another inspection in this. area done after the end of SALP Cycle 3 (NRC Inspection Report No. 82-21) verified that the licensee had'comitted a large ainount of effort and resources toward a
_ completely new and upgraded Fire Protection Program and was essentially completed by the commitment date. The concept of fire protection was ch,anged from a,p~ art-time responsibility to a dedicated professional full time fire brigade c'omplete with fire trucks and paramedic services.
The new Fire Protection Program appears to meet or exceed all NRC requirements, and the National Fire Protection Association (NFPA) codes.
. Conclusion Category 2 Board Recomendation -
Continued management'5ttention appears warranted to assure full and effective program implementation.
F.
Emergen~cy Prepa' redness An appraisal 'of ' he licensee's state of emergency preparedness t
was performed during the~ period of this assessment.
This appraisal disclosed ~a strong management' support for emergency planning.
One significant deficiency and a number of items for improving the program weretidentified:during the appraisal. The appraisal findings concluded that emergency preparedness was satisfactory.
Subsequent'inspectJ6ns-in connection with Unit 2 showed improvements had been made in the emergency' preparedriess program.
In most instances, the licensee responded to'theiNRC initiatives and suggestions in a timely manner.
The. staffing and final training program for emerg?ncy response were found to be acceptable.
Timely action has'been taken and is continuing in response to the NRC identified items for improving the licensee's emergency preparedness program.
Conclusion 4
Category 1 Board Recomendation No change in inspection program.
G.
Security and Safeguards During the Cycle 2 SALP evaluation period (May 16, 1980 through June 30, 1981) the licensee had incurred nine items of noncompliance; two relating to the failure to provide positive access control to vital areas and two relating to timely maintenance of the intrusion alarm system. The SALP board rated the facility as being Category 3 for security, and caused the inspection frequency for security to.be increased.
During the current evaluation period, the reactor facility has been subjected to 199 hours0.0023 days <br />0.0553 hours <br />3.290344e-4 weeks <br />7.57195e-5 months <br /> of physical security inspection resulting in eight violations. An inspection conducted September 14 through 18, 1981, notified the licensee of concerns regarding the central alarm station (CAS) logging of intrusion alarms (91-28-03).
The inspectors, although not substantiating noncompliance, voiced L
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. concern, at the exit meeting and in the inspection report, regarding the observed irregularities in logging intrusion alarm response data. The licensee committed to review the concerns and implement appropriate corrections as needed.
An inspection conducted January 10 through 12, and February 8 through 12, 1982, found that the licensee had not instituted corrective actions as committed, and a deterioration of the CAS alarm logging had occurred.
In addition, the inspector found that the CAS was receiving an excessive number of false / nuisance alarms, and the access control / alarm annunciation computer system was not performing acceptably.
During this inspection the inspector identified the following violations: failure to log alarm response data, inadequately trained watchman, failure to respond to all intrusion alarms, failure to report security incidents as required by 10 CFR 73.71(c), failure to provide positive access control at two vital area portals, failure to require two acknowledgements of each alarm, and that the SAS audible alarm signal was inoperative for an excessive duration. These violations of the licensee's approved security plan resulted in an enforcement conference and the imposition of civil penalties in the amount of $60,000.00.
During a subsequent inspection (June 21-25,1982), the inspector found a significant decrease in the false / nuisance alarm rate had occurred.
It was still apparent that the licensee was experiencing internal problems with management communication. No violations were identified.
The evaluation indicates that station middle management has not effectively conmunicated with subordinates thus contributing significantly to the observed program implementation deficiencies.
Although the licensee has been agreeable and cooperative in dealings with the regional NRC staff, eifective corrective action has not been consistently achieved. The licensee recently implemented a new management structure with new personnel at the station.
Recent improvements in the security program effectiveness have been observed by security inspectors.
A material control and accountability inspection was not conducted during this evaluation period.
Conclusion Category 3 l
Board Recommendation Maintain the increased level of inspection, determined necessary during the previous assessment period, to establish the effectiveness of the new management structure.
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H.
Refueling No refueling occurred during the reporting period.
I.
Licensing Activities See attached letter (D. M. Crutchfield to D. M. Sternberg dated August 5, 1982) on "SALP Board Review of San Onofro Unit One" (Enclosure 3).
Conclusion Category 2 Board Recommendation None J.
Quality Assurance The Quality Assurance Program implemented (see Inspection Report Nos. 81-41, 82-11, and 82-16) appears responsive to station requirements and in compliance with the site Quality Assurance Manual and 10 CFR 50 Appendix B, except in the area of corrective action.
While Southern California Edison takes aggressive corrective action to NRC identified problems, it appears that improvement is warranted in resolving internally identified problems. The backlog of incomplete corrective action requests (CAR's) continues to grow and a long term solution should be sought. The NRC recognizes that the site QA organization may not have the authority to order action by other divisions, however, this again points to a marginal level of site middle-management attention to potential safety problems.
Conclusion Category 2 Board Recommendation The Board recommends that site management develop a permanently workable solution for resolving internally identified corrective actions in a timely manner.
K.
Three Mile Islan'd (TMI) Action Plan Requirements Completion of several TMI action..itens was to be performed prior to criticality,.after the Spring 1982 outage.
Some of these action items were not complete, but due to continuation of the
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. outage for further seismic upgrades, NRR granted extensions'into November 1982 or prior to next criticality for all outstanding TMI items.
Conclusion Category 2 3
Board Recomendation None -
L.
Design' Changes'and Modifications The design change,and modification program shows a lack of continuity (NRC Inspection Report Nos. 81-12 and 82-11) and an apparent failure to consistently document adequate completion of design change and/or raodificationipackages. -The NRC identified problems in this area, including'a large backlog of incomplete design change packages, a definite lack of communication between the site personnel and SCE projects personnel, a poor document control system (multiple files and identifiers for a single project),
a lack'of ~~ updated drawings, no individual responsible for tracking the packages (especially to close out), and a poorly conducted review and approval system.
The licensee is revising the procedures specifying the controls over design changes and modifications.
Conclusion Category 3 Board Recomendation The board again feels that the pressures of Units 2 and 3 have diverted middle-management attention and resources away from Unit 1.
The implementation of the revised design change and modification controls will be examined in detail.
V.
SUPPORTING DATA AND SUtt1 ARIES A.
Licensee Event Report Evaluation and Analysis B.
Special Reports C.
Investigation and Allegations Review D.
Escalated Enforcement Actions E.
Management Conferences F.
Miscellaneous Data 1,
10 CFR 21 Reports 2.
Abnormal Occurrences 3
Nature and Number of Unplanned Trips j
, A.
LER Evaluation
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The guidance provided by Teknekron Research, Inc., dated November 26, 1980, was used for this evaluation.
The following results were obtained:
See attached Data Sheet and LER Listing.
a.
b.
The data sheet shows three causally linked event series.
The largest series consists of four events.
Numerical analysis of these events gives the following:
1.
Average Total Number of Events per Month (TNE)
This unit had 0.67 events per month which is below the recom-mended maximum of 0.7.
2.
Largest Number of Linked Events in a Chain (LNE)
LNE for SONGS is three, which is smaller than the recommended maximum of four.
3.
Average Time Between Events (ATBE)_
The ATBE for SONGS is 2.1 months which is larger than the recommended minimum of.1.9 months.
c.
Causually linked events:
(1) Both containment airlock doors stuck. open causing a breach of containment.
This has been an ongoing problem for some time at Unit 1.
The problem is always attributed to poor design, especially the cams.
It appears that inadequate corrective action and lack of management attention is the root cause because of the length of time that the problem has continued.
(2) The Safeguard loads sequencer appeared twice in the last SALP cycle and again twice in this cycle.
(3) There appears to be an ongoing or generic problem with contain-ment isolation valves.
The isolation valves anpear in orior SALP assessment periods and again four times ifi tnis assessment period.
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LER ANALYSIS DATA SHEET t From: _7/1/81 To: 6/30/82 Facility:
San Onofre Unit:
1 Docket No.
50-206 FUNCTIONAL AREA CAUSALLY MANAGEMENT PERSONNEL OTHER LINKED EVENT ERROR ERROR
- 1. Plant Operations 81-10*k1) 81-20 81-19 81-16 81-27 82-03 81-28 (2) 82-12 82-04 82-08 82- 08
- 2. Radiological 81-11 82-13 Controls 81-18 82-17 81-30 81-12,81-17,81-29,82-15 82 15 81-22
- 3. Maintenance 81-13,81-23,82-06,82-16 81 21 82-01 81-14,81-26,82-09 82- 07 82-14
- 4. Surveillance -
81-2'4 82-11 Including 81 (3)
Inservice and 82-02 Preoperational 82-05 Testing
- 5. Fire Protection
- 7. Security and Safeguards
- 8. Refueling -
Including Initial Fuel Loading
- 9. Licensing Activities TOTALS (38) 8 20 2
8 3 linked events Licensee Licensee e
C "
6 1 LER Analysis Cycle 3 Cycle 2 Acceptable tc e
directly linked to TNE 0.67 0.42 0.7 max.
ongoing problem LNE 3
2 4 max.
ATBE 2.1 S.4 1.9 min.
Numbers in parantheses indicate causally linked event numbers.
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B. SPECIAL REPORTS Docket No.
50-206 EVENT DESCRIPTION TECHNICAL EVENT LETTER REC'D IN APPARENT SPEC.
DATE DATE REGION CAUSE Follow-up report on LER 81-11 Appendix B Contaminated beach sand 5.6.3.d 5/10/81 10/16/81 10/26/81 unknown Incorrect setting on PORV controller 6/18/81 7/27/81 7/30/81 incorrect vendor data Containment spray inadvertently operated 9/25/81 11/16/81 11/20/81 component failure Inadvertent containment spray from water in sump 11/20/81 3/2/82 3/5/82 defective procedure Control rod C-7 stuck when freed, two rodlets dropped 3.5.2 12/12/81 3/5/82 3/11/82 component failure March to June 1982 Steam Generator tube inspection 4.16 TBA*
N.A.
Loss of ultimate heat sink due to flooding of intake structure 6.9.2.b 5/13/82 6/14/82 6/17/82 defective procedures Surveillance on fire protection equip.
ment not performed 6.9.3.c 5/17/82 6/16/82 6/21/82 inadequate administrative controls e
I*TBA. to be announced, but before next criticality
I C. : INVESTIGATION AND ALLEGATIONS REVIEW Allegations and Investigations On Saturday, June 27, 1981, at the Atomic Safety and Licensing Board meeting in San Diego, California, there were allegations of " shoddy" work, drug usage, and overexposure during steam generator tube repair.
After a thorough investigation, including interviews with the allegers, contracting companies, and the licensee, none of the allegations were substantiated (Report No. 50-206/81-30).
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D.
ESCALATED ENFORCEMENT ACTIONS Docket No. 50-206 4
a.
Civil Penalties
$60,000 Security and Safegurads See Inspection Report 82-01 b.
Orders None t
c.
Enforcement Conferences
-0ne enforcement conference was held atIthe Region V office on November 25, 1981, to discuss the' licensee's management of radioactive effluents.
(See Inspection Report No.-81-39).
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E.
ADMINISTRATIVE ACTIONS DURING THE ASSESSMENT PERIOD a.
SALP Management Meeting - September 1,1980 This meeting was held to discuss the results of NRC's regional Systematic Assessment of Licensee Performance (SALP) regarding activities authorized by NRC License No. DPR-13 and NRC Construction Permit Nos. CPPR-97 and 98, during the period June 1, 1980 to June 30, 1981.
b.
Confirmatory Action Letters (1)
Immediate Action Letter dated April 23, 1980, modified by letter of April 16, 1982, NRC to SCE (R. H. Engelken to Dr. L. T. Papay).
NRC approved use of portable diesel generators for emergency power only during the overhaul of. both Unit 1 diesel generators during the current outage.
(2)
Immediate Action Letter dated November 16, 1981 from NRC to SCE (R. H. Engelken to Dr. L. T. Papay), Emergency Preparedness Appraisal, Confirmation of Action Being Taken on Significant Findings. The stack noble gas monitor does not provide required information for emergency plan implementation.
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F. Miscellaneous Data
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Docket No. 50-206 1.
10 CFR 21 Reports (1)f Diesel generator governor lube oil level maintenance procedure i not provided by yendor.
Low governor lube oil caused DG to trip out on overspeed (~see LER No. 81-29).
?
'(2)l Failure of spherical washers in diesel generator pistons caused potential loss of diesel generator (see letter of November 13, 1981, Transamerica DeLaval to SCE (M. J. Hartwig to Procurement Manager)).
f (3') Sigma Lumigraph indicator failure caused by underrated resistor j
l in circuit (see LER No. 82-01).
2.
Abnormal Occurrences 1
On September 3,1981, SCE reported a failure of two safety injection yalves to open upon receipt of a Safety Injection signal (See LER No. 81-20).
3.
Nature and Number of Unplanned Trips i
l (1)l July-2,1981 - Reactor trip from relay failure in nuclear I instruments (component failure).
?
l(2) July 11, 1981 - Reactor trip from loop "C" low flow indication I caused by transmitter equalizing valve leak (component failure).
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() September 2,1981
. Reactor trip from loss of number 1 regulated pgwer supply (component failure).
This failure resulted in ESF initiation whi.ch also failed to~ function normally (see i
LER 81-20).
4
TABULAR LISTING OII.EIls'BY FUNCTIONAL AREA TABLE 1
~-
SAN ONb E UNIT 1 Docket No'. _~ 5d ' 3 2
FUNCTIONAL AREA NUMBER /CAUSE CODE TCTAL s.
s 1.
Plant Operations 1/A, 3/B,1/D, 6/E 11 2.
Radiological Controls 2/A,1/B, 1/E,1/X 5
l-3.
Maintenance 1/A, 7/B, 4/D, 6/E, 4.
Surveillance - includes Inservice & Preoperational Testin9 1/B, 1/D, 2/E 4
5.
Fire Protection 6.
Security & Safeguards 8.
Refueling - includes Initial Fuel loading 9.
Licensing Activities
- 10. Other
- a. Quality Assurance Program
& Implementation CAUSE CODES: A - Personnel Error
^
B - Design, Manufacturing, Construction, or Installation Error C - External Cause D - Defective Procedures
{
E - Component Failure X - Other i
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~23-LICENSEE EVENT REPORTS (LERs)
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Docket No.
50-206 APPARENI CAUSL LER NO.
TYPE DESCRIPTION LICENSEE LER ANALYSIS On June 3rd and 5th, containment integrity 81-10 30 day violated when both air locks'were stuck component failure management' open Beach sand contaminated from out of 81-11 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> service yard drain unknown unknown 81-12 30 day Low pressure reactor trips were set below required limits procedure error management 81-13 special' report Incorrect settings on PORV controller
~
81-14 30 day Feedwater flow oriface installed backward installation error management 81-15 30 day Low diesel generator lube oil tank personnel caused loss of unit design error error 81-16 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.,
Containment integrity violated when both air locks stuck open
. component failure management.
81-17 30 day Diesel generator lube oil fire from broken oil line component failure management 81-18 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Explosion and release from waste gas decay tank installation error management 6
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LICENSEE EVENT REPORTS (LERs)
LISTING Docket No.
50-206 LER NO.
TYPE APPARENI CAUSE DESCRIPTION LICENSEE LER ANALYSIS 81-19 30 day Seal water leak on charging pump greater than limits component failure facility 81 'O 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Both safety injection trains failed on demand signal design error management 81-21 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Failure of regulated instrument power supply caused reactor trip component failure personnel error 81-22 30 day Snubber oil seal failure component failure facility 81-23 special report Containment spray inadvertently operated component failure management 81-24
',., 24' hour Two containment isolation valves failed on demand design error management 81-25 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Two containment isolation valves failed on demand component failure management 81-26
24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Borated refueling water pumped into 8
c condenser installation error management 81-27 24' hour Boric acid concentration in refueling tank below limit defective prccedure management e
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, LICENSEE EVENT REPORTS (LERs)
LISTING Docket No. 50-206 APPARENI CAU5E LER NO.
TYPE DESCRIPTION LICENSEE LER ANALYSIS Safeguard loads sequencer No. 2 failed 81-28 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> during test design error management 81-29 30 day Loss of diesel generator from low governor oil level defective procedure management Invalid air samplinq from improper fHter 81-30 30 day installation
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personnelerro'r manademenb 82-01 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Failure of Sigma Lumigraph indicators vendor deficiency facility 82-02 30 day Containment isolation valve fails to close on demand design deficiency management 82-03 special Control rod C-7 stuck; when freed, report two rodlets dropped component failure facility Injection of sodium hypo chlorite into 82-04 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> cooling water above limits component failure facility 82-05 30 day Containment isolation valve failed to close on demand component failure management-82-06 sPeo Inadvertent containment spray from water in sump defective procedure management
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'a %
RCENSEE EVENT REPORTS (LERs)
Docket No.
50-206 LER NO.
TYPE APPAktNI CAUSE DESCRIPTION LICENSEE LER ANALYSIS 82-07 30 day Saltwater cooling pump failed due to failed discharge pressure switch component failure facility 82-08 30 day Safeguard loads sequencer failed causing other failures component failure facility 82 09 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Weld failure on feedwater pipe supports construc' tion. error management 82-10 special report To be issued before returning unit to power (steam' generator tube inspection) 82-11 30 d' y Missed surveillance on containment a
isolation, etc.
defective procedures management 82-12 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Loss of one of two required. boric acid flow paths personnel error management 82-13 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Liquid radiation release did not have required samples taken personnel error management 82-14 30 day Four empty snubber reservoirs, one snubber failed required tests
' component failure facility 82-15 special report Saltwater intake structure flooded, lost x
ulticate' heat sink defective procedure management
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.T v,N LACENSEE EVENT REPORTS (LERs)
LTSTING Docket No.
50-206 APPARENI CAUSE LER NO.
TYPE DESCRIPTION LICENSEE LER ANALYSIS New demineralizer not boron loaded, 82-16 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> reduced boric acid concentration RCS personnel error personnel error 82-17 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Unplanned release of imCi from south waste gas decay tank component failure management m
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TABLE 3 I
INSPECTION ACTIVITIES Docket No. 50-206 AND HOURS
SUMMARY
No. of Inspection Activities Inspections Manhours a.
Regional Inspection 1.
Routine operations inspection 9
330 2.
Reactive operations inspection 2
198 3.
Routine construction inspection 2
61 4.
Reactive construction inspection 0
0 b.
Resident Inspection i
(mostly operations) 12 871 c.
Health Physics 1.
Routine inspecti.on 5
328 2.
Reactive inspecti.on 1
7 3.
Health physics appraisal 0
0 d.
Environmental 1.
Routine 1
15 2.
LER follow-up 0
0 e.
Security and Safeguards I
1.'
Routine
.3 199 l
0.
O 2.
Reactive l
f.
Routine 0
0 2.
Reactive 0
0 3.
Emergency preparedness appraisal 1
184 TOTALS 36 2193
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motc,..n, o..,,, o SAN ~ON0FRE UNIT 1 Docket tio.50-20f FUNCTIONAL INSPECTION VIOLATIONS (SEVERITY LEVEL)*
AREA MAN-HOURS V
I IV III II I
82-15 1.
Plant Operations 677 82-17(2) 2.
Radiological Controls a.
Radiation Protection 72 82-19i b.
Radioactive Waste Management 182 l1
- ~(}
31: 36-c.
Transportation 42 I
d.
Effluent Control and Monitoring 32 82-03 31-31 3.
Maintenance 271 82-05 4.
Surveillance - includes 81-40(2) 255 Inservice & Preoperational 82-04 82-04 Testing 5.
Fire Protection 36 81-15 81-25 6.
Emergency Preparedness 184 7
7.
Security and Safeguards 199 82-01(3)**82-01(k **
I 8.
Refueling - includes Initial Fuel Loading 1
9.
Licensing Activities I
10.
i Quality Assurance -
l i Procram & Implementation 157 J
j
.11,.
\\TM1 Action ~ Items 20
)
l 12.
aesion Cnances & Mods 13 l
s
>13.
Other-G9 TOTAL this period 2193 9
13 4
0 0 2 TOTAL last period 2568 16 4
6 j
0 0 2
- NRC Enforcement Policy,10 CFR 2, Appendix C, 47 FR 9987, dated tiarch 9,1982.
Ilumbers indicate NRC Inspection Report Number.
- $60,000 - Civil Penalty NUMBERSINPARANTHESES()'INDICATENUMBEROFVIOLATI0ilSATTHISTIMEINTHISREPORT.
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i no t r t pun 6 1 ITEMS OF NONCOMPLIANCE
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Docket No. 50-206 NRC INSPECTION SEVERZTY DESCRIPTION REPORT NO.
LEVEL Failure to establish administrative controls for 81-25 IV*
fire protection as e gas decay tank ignM and released rad}ioactivegas 81-31 IV*
10 CFR 19.12, " Instructions to Workers," not 81-36 V*
conducted as required Failure to file a report with NRC on waste 81-36 V*
shipments and radiation ' releases N procedure for calibration of stack flow 81-36 IV*
device (needed for particulate and iodine)
Stack releases were not continuously monitored 81-36 IV*-
as required Surveys and evaluations of radiation were not 81-36 IV*
conducted or entered in report
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l No procedures for calibration of pressure l
81-40 V*r indicators on safety injection valve actuators No. procedures (Mode 1) to assure emergency nitrogen 81-40 V*'.
is available if needed 82-01 III+
Failure to provide positive access control to vital area Failure to record alarm response 82-01 III+
- Interim Enforcement Policy, 45 FR 66754, dated October 7,1980.
+NRC Enforcement Policy,10 CFR 2, Appendix C, 47 FR 9987, dated March 9,1982.
l i
t 0
I NDLF.,
at g LUilt. f ITEMS OF NONCOMPLIANCE
' Docket No.
50-206 NRC INSPECTION SEVERITY DESCRIPTION REPORT NO.
LEVEL
-Failure to respond to unanticipated intrusion 82-01 III+
alarm Failure to report as required pursuant to 82-01 III+
10 CFR 73.71(c) 82-01 III+
Failure to report as required pursuant to 10 CFR 73.71(c)
Failure to promptly repair security hardware 82-01 IV+
82-01 IV+
Failure to adequately train watchmen 82-01 IV+
Failure to require two acknowledgements of intrusion alarms 82-03 VI*
Ocean water samples indicating fission products
.were not reported 82-03 V*
A contractor radiation worker not given whole body count at termination 82-04 IV+
No design review or post modification testing for seal flushing line
".reggired instrument calibrhtion acceptanc~e 82- 04 V+
criterla in procedures Safety-related maintenance had inadequate 82-05 IV+
clearances and records 82-10 deviation
- Mixed bed demineralizers exceeded design pressure values for several years
- Interim Enforcement Policy, 45 FR 66754, dated October 7,1980.
+NRC Enforcement Policy,10 CFR 2, Appendix C, 47 FR 9987, dated March 9,1982.
inte L *.c::n ITEMS OF NONCOMPLIANCE t Docket No.
50-206 NRC INSPECTION SEVERITY DESCRIPTION REPORT N0.
LEVEL No approved procedure for performing axial and 82-15 IV+
radial flux distributions Fire suppression systems not tested at required 82-15 V+
intervals
( ss of redundant boric acM emergency 82-17 TV+
injection (3 days)
Total loss of ultimate heat sink because of 82-17 IV+
flooding of intake structure 82-19 I V+
Failure to post High Radiation Area
- Interim Enforcement Policy, 45 FR 66754, dated October 7,1980.
+NRC Enforcement Policy,10 CFR 2, Appendix C, 47 FR 9987, dated March 9,1982.
' TABLE 5 f
CAUSAL ANALYSIS ENFbRCEMENTANDLERs San Onofre Unit 1 Docket No. 50-206 CAUSE CATEGORY ENFORCEMENT LER TOTAL
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ACTIONS ANALYSIS Failure of Management er Management Control System 7
7 14 Failure to Follow Procedure 13 2
15 Defective Drawing or Procedure 5
10 15 Personnel Error 2
2 4
Des i gn/ Con s truc ti on/Manu fa c tu ri n g/
Installation Error 1
1 2
C mponent Failure 0,
13 13 0
3 3
Unknown Total 28 38 66 A