ML20058P168
| ML20058P168 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 09/27/1993 |
| From: | NRC |
| To: | |
| References | |
| NUDOCS 9312230120 | |
| Download: ML20058P168 (5) | |
Text
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h ATTACIIMENT TI 2500/028 EMPLOYEE CONCERNS PROGRAMS PLANT NAME: Three Mile Island LICENSEE: General Public Utilities Nuclear DOCKET #: 50-289 A.
PROGRAM 1.
Does the licensee have an employee concems program?
l (Yes or No/ Comments)
I Ys 2.
Has NRC inspected the program? Report #
No - Will be inspected and documented in Inspection Report 50-289/93-19.
B.
SCOPE: (Circle all that apply)
- 1. Is it for:
- a. Technical? (Yes, No/ Comments)
Yes
- b. Administrative? (Yes, No/ Comments)
No - The Ombudsman focuses on only nuclear safety concerns.
IIowever, the Employee Suggesilon Program addresses any type of issue.
- c. Personnel issues? (Yes, No/ Comments)
No - The Ombudsman focuses on only nuclear safety concerns.
IIowever, the Employee Suggestion Program addresses any type of l
issue.
I 2.
Does it cover safety as well as non-safety issues? (Yes, No/ Comments)
No - The Ombudsman focuses on only nuclear safety concerns.
IIowever, the Employee Suggestion Program addresses any type of issue.
- 3. Is it designed for:
- a. Nuclear safety? (Yes, No/ Comments)
Yes
- b. Personal safety? (Yes, No/ Comments)
No - The Ombudsman focuses on only nuclear safety concerns.
Ilowever, suggestions for improving the Radiological Controls Program and the Industrial Safety Program may be submitted through the Awareness Reporting Program.
200058
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9312230120 930927 PDR ADOCK 05000289 D
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Attachment 3
D.
RESOURCES 1.
What is the size of the staff devoted to this program?
The Manager of Nuclear Safety (the Ombudsman) has five technical personnel.
2.
What are ECP staff qualifications (technical training, interviewing training, investigator training, other)?
Technical training, Iluman performance training E.
- REFERRALS:
1.
Who has followup on concerns (ECP staff, line management, other)?
The Ombuisman tracks the resolution.
F.
CONFIDENTIALITY:
1.
Are the reports confidential?
(Yes, No/ Comments)
Yes 2.
Who is the identity of the alleger made known to (senior management, ECP staff, line manager, other)?
(circle, if other explain)
Ombudsman only.
3.
Can employees be:
a.
Anonymous? (Yes, No/ Comments)
Yes b.
Report by phone? (Yes, No/ Comments)
Yes G.
FEEDBACK:
1.
Is feedback given to the alleger upon completion of the followup?
(Yes er No - If so, how?)
Yes - A copy of relevant technical information is provided to the alleger.
A discussion is held when possible.
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- T Attachment 5
1.
ADMINISTRATION / TRAINING:
1.
Is ECP prescribed by a procedure? (Yes or No/ Comments)
Yes 2.
How are employees, as well as contractors, made aware of this program (training, newsletter, bulletin board, other)?
General Employee Training Outage Handbook Bulletin Boards ADDITIONAL COMMENTS: (Including characteristics which make the program especially effective, if any.)
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'M UNITED STATES
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NUCLEAR CEGULATORY COMMISSl2N
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- REGloN I -
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475 ALLENDALE ROAD'-
,.d MING oF PRUSSIA, PENNSYLVANIA 194061415 SEP 2 71993 Docket No. 50-289 a
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Mr. T. Gary Broughton Vice President and Director, TMI-1 GPU Nuclear Corporation l
Three Mile Island Nuclear Station Post Office Box 480-Middletown, PA 17057-0191
Dear Mr. Broughton:
1
SUBJECT:
NRC INSPECTION REPORT NO. 50-289/93-19 This letter transmits the findings of the resident safety inspection conducted by Ms. M. Evans and Mr. D. Beaulieu from August 1,1993 - September 9,1993, at the Three Mile Island Nuclear Station, Unit.l. The inspectors based these findings on observations of activities, interviews, and document reviews, and discussed them with you and other members of your staff at the conclusion of the inspection period. Inspector observations indicated safe and conservative operation.
We reviewed your corrective actions associated with several incidents that occurred during' the last refueling outage. These incidents were safety significant and occurred due to procedural and performance related problems..We noted that you have improved the quality of procedures for infrequently performed or critical evolutions and the manner in which some surveillances are performed. However, since incidents involving performance and procedure related weaknesses continued to occur during the operating cycle, we will~ continue to evaluate your corrective actions in this area.
In accordance with 10 CFR 2.790 of the NRC's Rules of Practice," a copy.of this letter and-its enclosure will be placed in the NRC Public Document Room. We appreciate your cooperation.
Sincerely, c) s A. Randolph Blough, hief Projects Branch No. 4 Division of Reactor Projects e
Enclosure:
NRC Inspection Report No. 50-289/93-19 a
4
SEP 2 71993 GPU Nuclear Corporation 2
cc w/ encl:
R E. Rogan, TMI Licensing Director M. J. Ross, Operations and Maintenance Director, TMI-l J. Fornicola, Licensing and Regulatory Affairs Director TMI-l Licensing Depanment E. L. Blake, Jr., Esquire TMI-Alert (TMIA)
K. Abraham, PAO (2)
Public Document Room (PDR)
Local Public Document Room (LPDR)
Nuclear Safety Information Center (NSIC)
NRC Resident Inspector Commonwealth of Pennsylvania
SEP 2 71993 U
GPU Nuclear Corporation 3
bec w/ encl:
Region I Docket Room (with concurrences)
J. Imning, TI 2500/028 R. Rosano, OE, TI 2500/028 bec w/enci (VIA E-MAIL):
V. McCree, OEDO J. Stolz, PD I-4, NRR R. Hernan, PD I-4, NRR 6
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U. S. NUCLEAR REGULATORY COMMISSION REGION I I
Report No.
93-19 Docket No.
50-289 License No.
DPR-50 Licensee:
GPU Nuclear Corporation P.O. Box 480 Middletown, PA 17057 i
Facility:
Three Mile Island Station, Unit I Location:
Middletown, Pennsylvania Inspection Period:
August 1,1993 - September 9,1993 Inspectors:
Michele G. Evans, Senior Resident Inspector David P. Beaulieu, Resident Inspector Approved by:
2
'O/29/r3 p F. Rogge, Chief W bate Reactor Projects Section No. 4B, DRP Insnection Summary: The NRC Staff conducted safety inspections of Unit 1 power operations. The inspectors reviewed plant operations, maintenance, engineering, and plant support activities as they related to plant safety.
Results: An overview of inspection results is in the executive summary.
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.p EXECUTIVE
SUMMARY
Three Mile Island Nuclear Power Station Report No. 50-289/93-19 Operations The inspector concluded that the licensee conducted overall plant operations in a safe and conservative manner. There was good management oversight of daily activities. The licensee reduced reactor coolant temperature on several occasions to increase power slightly during the power coast down. The inspector found that the temperature reductions were well controlled and there was direct oversight by the Lead Nuclear Engineer and Plant Operations management.
Maintenance The licensee has improved the quality of procedures for infrequently performed or critical evolutions. Specifically, the licensee's procedure enhancements to the suneillance procedure for testing of refueling system interlocks appear adequate to prevent recurrence of an incident where fuel movement occurred with the reactor building doors open (Closed, Vio 50-289/91-27-01). In addition, improvement in the manner that some surveillances are performed has been observed (Closed, Vio 90-289/91-23-02). However, incidents involving performance and procedure related weaknesses continue to exist as documented in several NRC Inspection Reports. Therefore, the inspector will continue to evaluate the effectiveness of licensee corrective actions during review of more recent open items (Update, URIs 50-289/92-22-02, 50-289/93-09-01,50-289/93-13-01, and 50-289/93-14-01).
Although the licensee's enhancement of infrequently performed or complex surveillance procedures was generally very good, one example was identified were the enhancement of a more routinely performed procedure was weak. The inspector concluded that the licensee's enhancement of the surveillance procedure for nuclear instrument power range calibration was weak, because the intent of the Procedure Enhancement Process was not met regarding removal of ambiguous terminology and proper placement of warning statements.
Plant Sunoort The inspectors concluded that the Security Plan was being properly implemented. During this inspection period, the licensee has increased the number of contractor personnel on site.
The inspectors found that security personnel maintained good control of protected area access including the inspection of packages. In addition, the inspectors observed the proper implementation of the badging and escort requirements.
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Safety Assessment and Ouality Verification The inspector concluded that the licensee has an adequate means in place to provide employees, who wish to raise safety concerns, an alternate path from their normal line management. The licensee's responses to employee concerns were thorough and appropriate corrective actions to the concerns were taken. However, the licensee's method of tracking the number and status of concerns was very informal and the licensee agreed to implement a system to formally track the resolution of concems.
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TABLE OF CONTENTS EXECUTIVE
SUMMARY
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1.0
SUMMARY
OF FACILITY ACTIVITIES................
1 1.1 Licensee Activities 1
I.2 NRC Staff Activities
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2.0 PLANT OPERATIONS (71707)............................... I 2.1 Operational Safety Verification I
2.2 Followup of Local Citizen's Concern....................... 2 a
3.0 MAINTENANCE (61726, 62703, 71707)......................... 2 3.1 Maintenance Observations.............................. 2 3.2 Surveillance Observations.............................. 2 3.3 (Closed) Violation (VIO 50-289/91-23-02) Failure to Properly Implement Surveillance Procedures 3
3.4 (Closed) Violation (VIO,50-289/91-27-01) Movement of Fuel With Reactor Building Doors Open............................ 4 3.5 Procedure Enhancement for Power Range Calibration............. 5 3.6 (Closed) Licensee Event Report (LER 93-05-000) Missed Surveillance... 7 4.0 PLANT SUPPORT (71707) 8 4.1 Security......................................... 8 5.0 SAFETY ASSESSMENT AND QUALITY VERIFICATION............. 8 5.1 Employee Concerns Program (TI 2500/028)................... 8 6.0 NRC MANAGEMENT MEETINGS AND OTHER ACTIVITIES.........
10 NITACHMENT - TI 2500/028 EMPLOYEE CONCERN PROGRAM j
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DETAllE 1.0
SUMMARY
OF FACILITY ACTIVITIES 1.1 Licensee Activities At the beginning of the inspection period, Unit I was at 100% power. On August 3,1993, the licensee began a power coast down due to fuel depletion. On September 7, they reduced power to less than 50% to support the cleaning of the 'A' side of the main condenser. At the end of the inspection period, the Unit was at about 45% power, waiting for the 10R refueling outage to begin on September 10.
1.2 NRC Staff Activities The inspectors assessed the adequacy of licensee activities for reactor safety, safeguards, and radiation protection, by reviewing information on a sampling basis. The inspectors obtained-information through actual observation of licensee activities, interviews with licensee personnel, and documentation reviews.
The inspectors observed licensee activities during both normal and backshift hours: 31 hours3.587963e-4 days <br />0.00861 hours <br />5.125661e-5 weeks <br />1.17955e-5 months <br /> of direct inspection were conducted on backshift. The times of backshift inspection were adjusted weekly to assure randomness.
2.0 PLANT OPERATIONS (71707) 2.1 Operational Safety Verification The inspectors observed overall plant operation and verified that the licensee operated the plant safely and in accordance with procedures and regulatory requirements. The inspectors conducted regular tours of the following plant areas:
-- Control Room
- Auxiliary Building
-- Switch Gear Areas
- Turbine Building
-- Access Control Points
- Intake Structure
-- Protected Area Fence Line
- Intermediate Building
- Fuel Handling Building
-- Diesel Generator Building The inspectors observed plant conditions through control room tours to verify proper alignment of engineered safety features and compliance with Technical Specifications. The inspectors reviewed facility records and logs to determine if entries were accurate and identified equipment status or deficiencies. The inspectors conducted detailed walkdowns of -
accessible areas to inspect major components and systems for leakage, proper alignment, and any general condition that might prevent fulfillment of their safety function.
p.
2 The inspectors found that there was good management oversight of daily activities. During the inspection period, the licensee reduced reactor coolant temperature on several occasions to increase power slightly during the power coast down. The inspectors found that the temperature reductions were well controlled and there was direct oversight by the Lead Nuclear Engineer and Plant Operations management. The inspector concluded that the licensee conducted overall plant operations in a safe and conservative manner.
2.2 Followup of Local Citizen's Concern On August 24,1993, a local citizen telephoned the NRC Operations Center in Bethesda, Maryland indicating that she had observed large volumes of concentrated steam emanating from the base of TM1 Unit 2 on August 23,1993, at about 2:00 a.m. The citizen documented these concerns in a letter to the NRC, dated August 29,1993.
The inspectors interviewed licensee management for Units 1 and 2 to determine if any activities had occurred which would account for the observation oflarge volumes of steam.
The licensee stated that no activities, other than normal operating activities, had been performed during the time in question. In addition, the licensee believed that the only equipment which could possibly produce stcam as described by the citizen was the Unit 1 mechanical draft cooling towers (MDCTs) which were in operation on the morning of August 23. The MDCTs dissipate the heat generated by various river water systems to the atmosphere, so that the river water will return to the river at essentially the same temperature as the water in the river.
The inspector reviewed and discussed with control room personnel the control room log entries for August 23,1993, and interviewed the security personnel who had driven around the site that moming. Also, the inspector went to the location (about 2 miles from the site) where the citizen stated that she had observed the concentrated steam. The inspector verified that operational status had not changed for either Unit 1 or 2 during this timeframe, and that no radiological releases were made. The inspector noted that from that location, any steam which could be seen from the Unit 1 MDCTs would appear to be coming from Unit 2, because of the location of the MDCTs in relation to Unit 2. Based on this review, the inspector determined that the Unit 1 MDCTs were the only equipment operating which could produce steam as described by the citizen.
The inspector reviewed the data from the licensee's offsite radiological monitoring system (Reuter Stokes) for August 23,1993, and did not note any unusual radiological readings for that day. The inspector reviewed licensee meteorological tower data and independently obtained weather conditions from the National Weather Service at the Harrisburg y
International Airport for August 23,1993, to determine if any unusual weather conditions could account for the citizen's observation. None were noted. The temperature was about 58 F, dewpoint about 56*F, there was no precipitation, winds were from the northeast at 4-5 mph, and visibility at the airport was 8-10 miles. These conditions can support high steam j
plumes.
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The citizen also attached data to the August 29th letter which showed a radiological reading of 42 counts per minute (cpm) for August 13,1993, at 3:38 a.m. The inspector reviewed the licensee's Reuter Stokes and meteorological tower data for that day. The inspector noted that the licensee's data also showed increased radiological count rate between 3:15 a.m. and 5:45 a.m., and precipitation. The inspector verified with the National Weather Service that severe thunderstorms were in the area during this time period, which would account for the increased radiological count rate. The inspector concluded that the reading of 42 cpm noted by the citizen was as expected for the weather conditions at that time.
The inspector concluded that the licensee did not conduct any abnormal activity on August 23,1993, that could account for the steam observed by the citizen. The only normal operating activity that could produce steam similar to that observed by the citizen would be the Unit 1 MDCTs. In addition, the inspector concluded that there were no unusual offsite radiological conditions for August 13, or August 23,1993.
3.0 MAINTENANCE (61726,62703, 71707) l l
3.1 Maintenance Observations l
The inspector reviewed selected maintenance activities to assure that: the activity did not l
violate Technical Specification Limiting Conditions for Operation and that redundant l
components were operable; required approvals and releases had been obtained prior to l
commencing work; procedures used for the task were adequate and work was within the l
skills of the trade; maintenance technicians were properly qualified; radiological and fire prevention controls were adequate; and, equipment was properly tested and returned to l
service.
Maintenance activities reviewed included:
Job Order No. 076394, " Install TMM in ICS/NNI Cabinets to Test the Loading of Additional DAS Points on ICS."
Corrective Maintenance Procedure 1420-Y-13, " General Circuit Troubleshooting and j
Repair," for MU-V-32.
l' Corrective Maintenance Procedure 1430-Y-35, " Bailey 721 System Maintenance."
l Overall, the inspectors found that individuals involved in maintenance activities were i
knowledgeable and work was conducted using appropriate procedures. The inspectors found L
that the troubleshooting activities associated with MU-V-32, the seal injection control valve, were good and that there was good supervisory oversight.
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3.2 Surveillance Observations The inspectors observed conduct of surveillance tests to verify that approved procedures were being used, test instrumentation was calibrated, qualified personnel were performing the tests, and test acceptance criteria were met. The inspectors verified that the surveillance tests had been properly scheduled and approved by shift supervision prior to performance, control room operators were knowledgeable about testing in progress, and redundant systems or components were available for service as required. The inspectors routinely verified adequate performance of daily surveillance tests including instrument channel checks and reactor coolant system leakage measurement.
Surveillance activities reviewed included:
e Surveillance Procedure 1302-1.1, " Power Range Calibration."
Surveillance Procedure 1303-5.1, " Reactor Building Cooling and Isolation System Logic Channel / Component Test."
Surveillance Procedure 1303-5.2, " Emergency Loading Sequence and HPI I.ogic Channel! Component Test."
Surveillance Procedure 1303-11.3, " Main Steam Safety Valves."
e Surveillance Procedure 1303-11.51, "PORV Acoustic Monitor."
Overall, the inspectors found that the surveillance activities were performed in a controlled manner using appropriate procedures. The inspector noted very good supervisory oversight and involvement during the conduct of main steam safety valve testing and reactor buildmg cooling and isolation system logic testing. Additional discussion of the power range calibration testing is included in Section 3.5.
l 3.3 (Closed) Violation (VIO 50-289/91-23-02) Failure to Properly Implement Surveillance Procedures This issue involved three separate incidents during which surveillance procedures were not properly implemented. These incidents resulted in the inadvertent auto-start of the motor.
driven emergency feedwater pumps, the inadvertent lifting of the pressurizer power operated-relief valve, and the disabling of makeup pump IC (MU-P-lC). The licensee's corrective actions included reviewing the incidents with all operations department personnel, emphasizing the need to understand the details of planned tasks especially during infrequently accomplished or complex tasks. The licensee has completed the Procedure Enhancement j
Process for 38 infrequently used or complex surveillances, which includes the three l
surveillances involved in the incidents. Operators have also received 'Be Sure' training which is a personal self checking technique designed to minimize human error.
5 As discussed in Inspection Report 50-289/93-09, the licensee's Procedure Enhancement Process for the 38 infrequently performed or critical evolutions has greatly improved the quality of these procedures. However, additional i acidents have occurred as a result of inadequate procedural guidance. These incidents Qvolved procedures that had not been enhanced. The incidents included the isolation, dypass of the decay heat river water supply to the decay heat closed cooling water system hea, exchangers (Inspection Report 50-289/93-09) and rendering the 'B' emergency diesel generator inoperable due to a lubricating oil leak (Inspection Report 50-289/93-14). There are two open items,50-289/93-14-01 and 50-289/93-09-01, that will follow up on these procedure related errors.
Although it is difficult to assess the number of human errors that have been averted as a result of the 'Be Sure' training, the inspector has noted an improvement in the manner that some surveillances are performed. In general, steps are now completed and signed offin a more controlled manner and communications among test participants has improved. In addition, pre-test briefings have been improved. These observations were documented in Inspection Report 50-289/92-06. However, incidents continued to occur due to the failure to properly implement surveillance procedures as written. These include the operation of the Fuel Hand!ing Building ventilation without placing the effluent radiation monitor in service (Inspection Report 50-289/92-22), improperly returning the reactor building radiation monitor to service (Inspection Report 50-289/92-20), improperly returning the steam generator level instruments to service (Inspection Report 50-289/92-18), and improperly returning the post-accident hydrogen monitor to service (Inspection Report 50-289/93-14). There are two open items,50-289/93-13-01 and 50-289/92-22-02, that will follow up on these performance related errors.
The inspector concluded that the licensee has improved the quality of procedures for infrequently performed or critical evolutions. In addition, improvement in the manner that some surveillances are performed as been observed. However, performance and procedure related weaknesses similar to those demonstrated in the three incidents continue to exist.
Since the inspector will evaluate additional licensee corrective actions in this area during review of the more recent open items, this item is closed.
3.4 (Closed) Violation (VIO,50-289/91-27-01) Movement of Fuel With Reactor Building Doors Open This item concerned an event where the licensee fully withdrew an irradiated fuel assembly during testing of the main refueling bridge. At the time both the personnel hatch and the emergency hatch were open. Technical Specification 3.8.6 requires that e se handling of irradiated fuel in the Reactor Building, at least one door shall be closea o.,
i the personnel and emergency hatches. The primary cause of this incident was that. arveillance Procedure (SP) 1303-11.4, " Refueling System Interlocks," was inadequate, because it did not
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6 contain a warning to ensure the required Reactor Building doors were closed prior to fuel movement. Other causes of this incident were inadequate preparation by the licensed operators assigned to perform the refueling bridge checks and, inadequate oversight and supervision of the interlock checks.
The licensee's immediate corrective actions included temporarily halting all fuel handling activities and, discussing the incident with operators who were involved in fuel handling activities, emphasizing to operators the importance of reviewing and understanding the surveillance completely prior to performance. The licensee's follow up corrective actions included the training of licensed operators on this incident prior to the 10R refueling outage (September 1993) and each subsequent refueling outage. This training emphasizes the need for pre-test preparation, supervisory oversight, and the need to be alert to indications of potential problems. In addition, the licensee agreed to enhance other surveillance procedures which are infrequently performed and which could result in potentially significant adverse consequences.
The inspector reviewed two training handouts and found that they described this incident in detail. The training handout for fuel handling limits and precautions had a specific training objective to address containment integrity during refueling, as well as, a specific examination question. The training also discussed the responsibility of supervisors to ensure proper preparation for a planned evolution and the need to provide increased oversight during the performance of infrequently accomplished or complex tasks. The licensee's training records showed that all licensed operators have received this training.
The inspector reviewed the enhanced version of SP 1303-11.4 and found the quality of the procedure was greatly improved. In one instance, one large step involving multiple tasks was broken up into 11 separate steps and one caution statement. There were several caution statements added to ensure that the prerequisites of the fuel handling procedure, which includes establishing containment integrity, are completed prior to grappling irradiated fuel.
l In addition,' the licensee has completed procedure enhancements to 38 infrequently performed or complex surveillance procedures. As discussed in Inspection Report 50-289/93-09, the
-L enhancements to the surveillance procedures were generally very good. However, during this inspection period one instance was noted where the enhancement process for nuclear instrument power range calibration procedure was weak and this is described in Section 3.5.
The inspector concluded that the licensee's procedure enhancement to Surveillance Procedure 1303-11.4 is adequate !.o prevent recurrence of a similar incident. However, as discussed in Section 3.3 of this report: th procedure and performance related weaknesses that were demonstrated by these incideMs continue to exist. Since the more recent open items discussed in Section 3.3 wir review further corrective actions in this area, this item is closed.
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7 3.5 Procedure Enhancement for Power Range Calibration On August 18,1993, the licensee conducted Surveillance Procedure (SP) 1302-1.1, " Power Range Calibration." While performing a restoration step in the surveillance, an I&C technician inadvertently took channel 'A' of the reactor protection system (RPS) out of manual bypass without resetting the flux / flow / imbalance bistable. This placed the RPS system in a one out of three logic rather than the normal two out of four. The I&C Technician immediately recognized the error and reset the flux / flow / imbalance bistable, j_
thereby resetting RPS channel 'A'. Since the technician had just successfully completed this surveillance on the other three RPS channels, the inspector determined that this was an isolated error. The inspector reviewed SP 1302-1.1 and found that the step that resets the RPS bistables was clearly written and did not contribute to this error. SP 1302-1.1 has gone through the licensee's Procedure Enhancement Process which was intended to add human j
factors and greater detail to the procedure. The inspector reviewed the procedure to evaluate L
the effectiveness of the procedure enhancement. The inspector noted several areas for l
potential enhancement and discussed these with licensee personnel as described below.
In SP 1302-1.1, a heat balance is performed and, if necessary, gain adjustments are made to the power range nuclear instrumentation in accordance with Attachment 1. Attachment 1, Step O, states that "If necessary to change range links in linear amplifiers, change links in power range test module to the corresponding position." The inspector found that there is no 1
step that instructed the technicians to change the range links in the linear amplifiers. The range links are changed to extend the range of the gain adjustment if it reaches its maximum setting. The inspector determined that Steps K and N,'which adjust the gain, should instruct the technician when to change the range links in the linear amplifier and should reference the instructions on how to accomplish this. The licensee agreed to add these instructions to Steps K and N., Step S, says " Compare NI indicated Total Flux and Imbalance with the values
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for core thermal power and incore imbalance from heat balance (also con' sider any changes that have been made in actual power level). If values do not appear to be reasonable based on plant conditions, repeat adjustment." Since one of the purposes of the Procedure l
Enhancement Process was to minimize ambiguous wording, the inspector asked the Lead
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I&C Engineer what " reasonable" meant in this case. The engineer indicated they did not want to proceduralize precisely what " reasonable" meant and they wanted to rely on the judgement of the I&C technician. The inspector questioned an I&C Supervisor and I&C j
Technician and neither of them could define or describe what reasonable meant. The inspector discussed his concern with the Manager of Plant Engineering and the licensee still' believed that the word " reasonable" provided a sufficient level of detail. The licensee indicated that the step was written to cause the technician to stop and review indications, and-I
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that the definitive acceptance criteria is located in the next step (Step T). The inspector j
determined that since the licensee uses definitive acceptance criteria in Step T, the procedure is adequate as written. However, since plant personnel who use the procedure cannot define j
or describe what " reasonable" means in this case, the licensee did not meet the intent of the 1
Procedure Enhancement Process concerning the removal of ambiguous terminology. includes a Warning statement which states that if changing of the power range test module range links is required, exercise care (deenergize test module and wear gloves) when making and breaking connections to prevent electrostatic shock. The licensee's Procedure Writers Guide indicates that Waming statements should always be placed immediately in front of the step (s) in which the 'Waming is applicable. The licensee placed this Waming on the previous page of the procedure, at the beginning of Attachment 1 (before q
Step A) rather than just prior to Step O. The inspector discussed the concerns with the
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Manager of Plant Engineering and the Lead I&C Engineer. The licensee indicated that since there was a block around the Waming, the technician is not likely to overlook it or forget about it by the time he reaches Step O and, therefore, relocating the Warning was not necessary. The licensee also pointed out that the guidance contained in the Procedure l
Writers Guide does not constitute a requirement. The inspector agreed that the proper placement of Warning steps was not a requirement. However, the importance of unambiguous and properly placed Waming statements was a lesson learned from the fuel lift incident described in Section 3.4. The inspector determined that the improper placement is inconsistent with the intent of the Procedure Enhancement Process of properly locating Waming steps to help avoid personnel injury or equipment damage.
The inspector concluded that the failure of the I&C technician to reset the flux / flow / imbalance bistable was an isolated error of minimal safety significance (short time duration) and that the error was not caused by a weak procedure step. The inspector concluded that although the licensee's enhancement of this surveillance procedure did improve the overall quality, there were several weakness which demonstrated that the intent of the Procedure Enhancement Process was not fully met. This appears to be isolated, because as discussed in Section 3.4, licensee enhancement ofinfrequently performed or complex surveillance procedures was generally very good.
3.6 (Closed) Licensee Event Report (LER 93-05-000) Missed Surveillance - Reactor Building AnnualInspection.
This issue concerned the failure to perform Surveillance Procedure 1301-8.1 " Reactor Building Annual Inspection," by the required completion date. The licensee determined that the root cause of this incident was management oversight due to inadequate tracking of surveillances. As a corrective action, the licensee has developed a mechanism for tracking to ensure the timely completion of surveillances performed by groups which are responsible for relatively few surveillances. The licensee generates a Technical Specification Task Waming
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- List weekly which is reviewed at the Wednesday management meeting. The warning list covers surveillances that have a frequency of greater than one month, are past the scheduled due date and, will be late within the next 30 days. The inspector concluded that the licensee's corrective action is adequate to prevent recurrence of a similar incident.
4.0 PLANT SUPPORT (71707) 4.1 Security The inspectors monitored security activities for compliance with the accepted Security Plan and associated implementing procedures. The inspectors observed security staffing, operation of the Central and Secondary Alarm Stations, and licensee checks of vehicles, detection and assessment aids, and vital area access to verify proper control. On each shift, the inspectors observed protected area access control and badging procedures. In addition, the inspectors routinely inspected protected and vital area barriers, compensatory measures, and escort procedures.
During this inspection period, the licensee has increased the number of contractor personnel on site. The inspector found that security personnel maintain good control of protected area access including the inspection of packages. -In addition, the inspector observed the proper implementation of the badging and escort requirements. The inspectors concluded that the Security Plan was being properly implemented.
5.0 SAFETY ASSESSMENT AND QUALITY VERIFICATION 5.1 Employee Concerns Program (TI 2500/028)
The inspector reviewed the characteristics of the employee concerns program that the licensee has implemented to provide employees, who wish to raise safety issues, an alternate path from their normal line management. Independent Safety Review (ISR), a separate division reporting directly to the Office of the President, has the responsibility for i
independently evaluating employee concerns related to nuclear safety. 'Within the ISR, there are three established means of receiving employee concerns: direct personal contact with the Independent Onsite Safety Review Group (IOSRG) personnel; the employee exit interview conducted by the Human Resources Department and; the Ombudsman program. Direct i
contacts between IOSRG and plant personnel are the most common but least formal means of getting employee input. Typically, an employee approaches an IOSRG member who is on a.
plant tour or places a telephone call to express a concern. The employee exit interview is conducted for all employees or contractors who are leaving the site. A formal question is -
asked and documented as to whether the departing individual has a nuclear safety concern; i
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a 10 the IOSRG is notifie6 if there is an affirmative response. The Ombudsman program provides a means for employees to report concerns in a confidential manner. Employees may contact an Ombudsman at the site (the IOSRG Manager) or at Corporate headquarters. Licensee personnel are encouraged to try to resolve concerns through their supervisors before utilizing the Ombudsman.
The inspector reviewed all concerns that the ISR had on file. In general, the inspector found that the ISR follow up to the concerns were very thorough and appropriate corrective actions were taken when necessary. However, the inspector found that the licensee has no log to keep track of what concerns were received and their current status. The licensee's method of keeping track of the concerns was to create a folder with the allegers name on it. The Ombudsman indicated that all concerns have been closed out, but there is nothing in the folders to formally document when an item has been closed. The licensee indicated that it is a normal practice to write to the alleger to describe the resolution to the concern. However, there was nothing in the folders to indicate that the alleger was contacted. In addition, many of the concerns that are received by direct contact do not have a folder and, therefore, the number and significance of these concerns is not tracked.
Due to the relatively low number of concerns that were addressed by the ISR (23 in last three years), the inspector questioned a number of maintenance and operation department personnel concerning the Ombudsman program. The inspector found that most of the personnel questioned did not specifically know who the Ombudsman was, but they all knew how to contact him. All of the personnel questioned knew what the function of the i
Ombudsman was. The majority indicated that they have not utilized the Ombudsman, because they have not had a significant concern which was not adequately dispositioned by plant management. However, several people indicated that they did not use the Ombudsman, because they questioned the Ombudsman 1 independence from management. They added that they would address the concern to the NRC before they would utilize the Ombudsman.
The licensee also has an Employee Suggestion Program which is a means for employees to suggest ideas to management on any topic. The program uses collection boxes placed throughout the site, assigns a responsible individual, and requires a formal response to the employee. All suggestions and responses are reviewed by the TMI Vice President.
The inspector concluded that the licensee has an adequate means in place to provide employees, who wish to raise safety concerns, an alternate path from their normal line management. An attachment is provided to this inspection report which answers other specific questions regarding the employee concerns programs. The inspector concluded that the ISR's responses to employee concerns were thorough and appropriate corrective actions to the concerns were taken. However, the licensee's method of tracking the number and status of concerns was very informal. The licensee agreed with this assessment and committed to implement a system to formally track the resolution of concerns.
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A-11 6.0 NRC MANAGEMENT MEETLNGS AND OTIIER ACTIVITIES At periodic intervals during this inspection, meetings were held with senior plant management to discuss licensee activities and areas of concern to the inspectors. At the i
conclusion of the reporting period, the resident inspector staff conducted an exit meeting with licensee management summarizing inspection activities and findings for this report period.
Licensee comments concerning the issues in this report were documented in the applicable report section. No proprietary information was identified as being included in the report.
The inspectors also attended the entrance and/or exit interviews for the following inspections during the report period:
Dale Subject Report No.
Inspector 8/2-5/93 Inservice Inspection 93-16 Kaplan 8/2-6/93 Effluents, Water Chemistry 93-17 Kotton 8/23-27/93 10 CFR 50.59 Safety Evaluation 93-21 Moy For Inspections 93-16 and 93-21, the inspectors will return to the site to complete the inspection.
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