ML20065K820

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Systematic Assessment of Licensee Performance Notes Re Facility Evaluation for 790901-800901
ML20065K820
Person / Time
Site: 05000000, Palisades
Issue date: 09/01/1980
From:
NRC
To:
Shared Package
ML082180535 List:
References
FOIA-82-261 NUDOCS 8210080144
Download: ML20065K820 (10)
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Text

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1 PALISADES Evaluation Period: 9/1/79 - 9/1/80 e

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GENERAL i

The principal reason for the "below average" rating of this licensee during the SALP-1 appraisal period l-was " human error," and " failure to adhere to proce-L ',

dure" (see Contentions A and B for details), As

.m. g the result of an NRC Order, the licensee initiated NRC Order l"

a comprehensive program to improve their regulatory 11/9/79

>w performance in these areas. However, subsequent Mi7;W.,

to the SALP-1 appraisal period the licensee was k '/,

involved in a Level III violation involving human

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error and failure to adhere to procedure. This event which occurred on January 6, 1981, resulted LER 50-255/81-01

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in both 125 volt D.C. output breakers being mis'-

aff N positioned to the open position during reactor

.%)y operation.

The consequences of this, assuming ri. p a reactor trip and loss of offsite power would be

,hidqj that there would be no automatic source of emer-M @?.9-gency power available for plant cooldown. As a 1

result of this event the NRC issued an Immediate W,y,${

Action Letter (IAL) and a Confirmatory Order.

IAL 1/9/81 N

Confirmatory OrG dd.;j 3/9/81

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'hy Qd Sin:e the SALP-1 appraisal period and as. a result of the Confirma-b,.7.-l.;3 L tory Order, the licensee has strengthened their program to improve M9.@

their regulatory performance. A*My factor in this program was the W ' "*"

contracting of a management consultant firm to evaluate'the~ company

'N' and plant organizational structure and management systems.

The major findings and recommendations of this consultant resulted in a significant company and plant management reorganization which was placed in effect on July 1, 1981.

Each of the areas of concern identified in the SALP-1 Evaluation and in the Confirmatory Order was addressed in this reorganization. The areas addressed include:

A daily audit of plant operations by a corporate management representative.

All Technical Specification surveillance procedures were reviewed by a select team of reviewers to assure adequacy prior to use.,

l All personnel performing work in vital areas reinstructed in necessity for strict adherence to procedure.

Double verification of safety related system alignments.

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Review of circuitry involved in the January 6,1981 battery output breaker event with intent to modify to prevent recurrence.

Limiting overtime hours worked by licensed operators.

~ 9210000144 820712 i

PDR FOIA UDELLB2-261 PDR

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l Corporate review of safety related events.

Contracting a management consultant firm.

Additional review of safety related procedures and the procedure t

preparation process.

Review, evaluate and modify, as necessary, the training and retraining of personnel.

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,M Review and evaluate the adequacy of the plant operations staff.

h5 Establish measures to motivate personnel adherence to procedure.

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Develop a system of audits by management to assure conformance l g,,

to procedure.

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During the latter portion of the SALP-1 appraisal period the licensee h:gT addressed the problem of inadequate procedure, and failure to adhere

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' to procedure-by the formation of a company wide 37 man task force whose 77 charter included:

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Physical " walk down" verification of each component in each safety u

gyg, related system; uograding the plant piping and instrumentation W ".3 drawings; upgrading the system line up check lists and procedures;

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$?%M double verification of procedural adequacy.

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Retraining of all licensed operators on the necessity for strict Q

attention and adhercnce to procedure.

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7" 7 During the latter portions of the SALP-1' appraisal period-the licensee

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took the following actions to reduce the incidence of " Human Error:"

Formally reinstructed all pctsonnel on the requirement for strict attention and adherence to procedure.

Assignpd permanent Shift Technical Advisors to each shift and provided a two hour overlap of this coverage on shift change.

Initiated a " double verification" of all safety related system manipulations by designated qualified personnel.

Increased the shift turn over status check list verification coverage.

Strengthened and re-emphasized the com'pany policy on disciplinary action for poor performance.

-. I I SPECIFI] (Contentions A through H below are examples of the more general contention, "The Palisades facility displayed evidence of weaknesas in the areas of plant operations, surveillance, and I

t radiatior) protection.")

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A.

Contention:

" Performance in the area of plant operations was characterized by personnel errors and failure to follow procedures."

1.

Basis There were several instances of LER 80-021 personnel error in the operation LER 80-029 f ;,,qf

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of plant equipment during the IAL 7-31-80 conduct of plant surveillance IE Inspection t;

activities.

Examples include the Report No.

~,c,t : 6 mispositioning of Emergency Core 50-255/80-12

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Cooling System System (ECCS) supply f

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valves on two separate occassions.

In both instances the operability Notice of Violation to 4J.,

of one train of the ECCS was degraded Licensed Operator during reactor operation.

50-255/80-12

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'; y In two instances, failure by the licensee r

.% 0 to follow procedure resulted in violation t

i, ; J, of Technical Specification limiting condi-tions for operation. The first event,

'/gj which resulted in a prolonged (18 month) breach.of containment integrity, was TW?,

primarily due to procedure inadequacy, 16..

but was strongly contributed to by failure W

Y.a g to adhere to work control and administra-IE Inspection Reports 2-~f '"!

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tive procedures.

In the.second instance 79-15; 80-12; 79-24 k%4 a surveillance procedure was performed LER 79-037;80-029 lN H

during power operation when the procedure specifically called for the testing to be done only during cold shutdown condition.

Performing the test during power operation placed one train of the ECCS in a degraded mode.

2.

NRC Actions Following the breach of containment integrity event of September 11, 1979 the following actions were taken:

Verification of licensee's immediate actions 9-14-79 to close the valves and correct the check lists.

Issued Preliminary Notification 9-14-79 Issued Potential Abnormal Occurrence Report 9-18-79

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Issued Inspection Report 10-12-79 Enforcement Meeting with licensee at the 11-30-79 Office of the Director NRC.

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' 11-09-79 Issued order niodify.ing p1' ant license.

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Issuef proposed Civil Penalty of $450,000.00 11-09-79 C?-

(in ajudication)... settled on 6/30/81 at

$225,000.00.

Initiated an augmented inspection program thru Januaryc

.i to verify that the order requirements were 1981

,,'gj satisfactorily completed.

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i"f;7 Following the ECCS valve mispositioning events of July 25, 1980,

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and August 19, 1980, the following actions were taken by the NRC:

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Verified licensee's immediate corrective actions-specialists dig dispatched to site.

Issued Preliminary Notifications PNO-III-80-140A, and

.... Apha PNO-III-80-155.

7:4W k%'d' Issued Immediate Action Letter.

7-31-80 O p6!.i

~' $;.g.:S Issued citations and civil penalty ($16,000.00). 9-16-80 1;3p:kd3

&T Issued Notice of Violation letters to licensed 9-16-80 2g.

operators.

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Conducted public meeting at South Haven, 12-17-80 jy;f,%

Michigan.

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Performed independant analysis of consequences August 1980

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-including review by NRR.

4R Issued Potential Abnor' mal Occurrence Report

- August 1980

...,. c N Reviewingandre'isingtheinputstothecontrolroomsequencg v

of events recorder with the objective of removing as many non-safety related signals as possible and assuring that the required safety related inputs are present.

Assuring that the sequence event recorder data sheets are reviewed at least daily, by a cognizant person not directly involved in the operations to determine if any unexplained or abnormal conditions are indicated.

Investigating the possibility of providing a key lock positio3 switch for each of the containment sump recirculation supply valves.

3.

Licensee Corrective Actions Following the September 11, 1979 breach of containment integrity violation, the following actions were taken by the licensee:

Unlocked and closed the valves.

Began an investigation.

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Began an evaluation of consequences.

All safety related systems were subjected to a "walkdown" verfiication to assure that the plant piping and instrument diagrams (P&ID's) were correct.

Plant master valve and system line-up lists were checked c

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against these P&ID's to assure their completeness.

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.i Plant procedures were checked against the P&ID's and the line-up check lists to assure their completeness and adequacy.

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.i...<.a mJ Technical advisors were permanently assigned to each shift.

YA[b 3 Following the ECCS valve mispositioning events of July 25, 1980,

.p T-and August 19, 1980, the following actions were taken by the

s-licensee

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The immediate action taken by the licensee was to correctly 1 $9 reposition the valves and begin an investigation to determine

K'Np f how and when the valves were mispositioned, and to determine "h "Y,.

the safety consequences of each event. Once the above had been determined, the following actions were taken immediately

.'.c}lgic j by the licensee:

$N h' ' Suspended the Shift Supervisor involved in the August 19, fjj:Ji e.gh 1980 event from licensed duty. g vh!3-bn ff?5@ Retraining of licensed personnel regarding strict attention

MJej and adherence to procedure.

h ~ ;. Upgrading of the shift turnover check list to include the v... L. valves in question and similar valves that may not have been on the check list. Changing the shift schedule for the shift technical advisors such that these individuals have at~1 east a two hour overlap. Installing colored markers (dots) on the panel boards adjacen9 to the valve position indicator lights on all safety related valves. The normal line up being indicated when the marker dot is aligned with a lighted position indicator. a. B. Contention " Repetitive instances of system misalignments impaired ECCS equipment operability and containment integrity." 1. Basis Major examples are the same as identified in Contention A. 2. NRC Actions ( Major eiamples ard the.same as identified'in Contention A. l

~ 3. Licensee Corrective Actions 1 Major examples are the same as identified in Contention A. C. Contention "The licensee had numerous problems with defective plant .y cperating procedures." 1 u,. i 1. Basis r. 4 -a A major example of procedural inadequacy is 1.?_5%:n also identified in contention "A", the ^ e,u T.. September 11, 1973 Breach of Containment ' ? Tj Integrity. In this event the mispositioned IE Inspection

f.4,g valves were not identified in any procedure Report 79-15

.j-Sr.q:a nor were they listed on any system valve LER 79-037 ~,F'.j line-up check list. 7 e- .:D:.n)b ' YNr _j 2. NRC Actions a "i Same as identified in Contention A. a,: .R.-; ?". 3. Licensee Corrective Actions - c'R-2S ,miMg(. Same as first six items under Licensee Corrective Actions 5-cag+.M. .g for Contention A. ttiMM 2d7 v.c.v D. Contention m f,.w1 g E M N:. There were instances where the' licensee had difficulty in completing ' 'l. adequate corrective action for identified discrepancies." 1. Basis I The major examples are the same as identified in Contention A.

2.
  • NRC Actions y

E Same as Contention A. 3. Licensee Corrective Actions Same as Contention A. l E. Contention " Weaknesses in the surveillance area were characterized by instances of defective procedures and personnel errors." 1. Basis Same as Contention A.

2. NRC Actions 4 Same as Contention A. 3. Licensee Corrective Actions ,,f Same as Contention A. I' F. Contention . 9.~ ;c "In the radiation protection area, there were items of noncompliance ' ~- regarding.... inadequate controls over release of radioactive material. . t, In addition, the health physics appraisal team inspection found j.; Palisades radiation protection programs to be below average. There were weaknesses in training and staffing, exposure control, procedure '" g, f and QA program implementation, and instrument availability." M . ' i! ! 7W 1. Basis ,6h A Health Physics Appraisal was ccnducted IE Health Physics b-7 at the Palisades site on August 4-15, Appraisal Team ,, y,., 1980. The significant appraisal findings Appraisal Report y;1g,.y included the following: 50-255/80-14 J 2:S { ""q 3 Staffing k. h'" A documented chemistry and radiation protection qual- ,M ification program is nee,,dedj to ensure that personnel

g are properly assigned work. responsibilities. Shift

, y.,A coverage must be adequate to ensure that necessary 'Y samples and measurements can be taken in accident situations to promptly evaluate radiation hazards and effect appropriate radiation precautions. f Training

  • The training program requires significant improvement in terms of actual training provided and documentation of training needs and progress.

Instrumentation Availability The instrumentation program needs upgrading to ensure adequate beta measurements, operable survey instruments, calibrated high range survey instruments, an adequate supply of CAM's to evaluate changes in airborne radio-I active concentrations, and effective monitoring of personal contamination. Personnel Exposure ( Tiie ALARA program requires significant improvement, including: formalized structure and guidance, job 4 specifi'c dose ricords'and evaluation, and development of specific. goals.

Inadequate Controls Airborne effluent controls require improved quanti-fication of gaseous releases, using both the normal and high range stack monitors, including: operating procedures, training, record clarity, monitor energy response, and readout availability. Procedureal Implementation .x ~ Procedural coverage and adherence need upgrading to include activities not presently addressed and to resolve inconsistencies between procedures and actual practices. . -J QA Program Implementation 4; The quality assurance program ne.eds to be upgraded in t'J/; the areas of deviation reporting and effectiveness of ,y corrective actions, g; n-1 2. NRC Act' ion i '. t.x The items of concern listed above plus IAL - 8/15/80 items identified during the SALP Review IE Inspection Report Jrx (9/1/79 to 9/1/80) were formally dis-50-255/80-23 71>] jp)8 cussed with licensee management. Remedial Responses: 4 actions for the more serious short-R. C. Youngdahl [ 43 comings regarding the high rangs noble to J. G. Keppler; M gas monitors identified in the HP 12/23/80. [. M Appraisal inspection were addressed

Response

in an Immediate Action Letter. A J. G. Keppler to l;j-written response was required for R. B. DeWitt; l l items of lesser concern. Licensee 1/26/81. corrective actions are under review by the NRC. The activities in many of the - above areas are routinely observed and reviewed by the site resident inspectors, i and all are periodically reviewed by l - specialists from the Region III office. 3. Licensee Corrective Actions A company wide re-organization was placed into effect on July 1,1981. Included in this re-organization was the identification of a new Director of Radiological Services, l I and a program identifying authorities and responsibilities in the following areas: OCCUPATIONAL EXPOSURE DOSIMETRY PROCESSING DOSE ANALYSIS (._ EMERGENCY PLANNING RADI0 ACTIVE MATERIAL TRANSPORTATIOR-AND CONTROL' l

-m P NUCLEAR PUBLIC AFFAIRS (< NUCLEAR LEGISLATION Corporate and plant radiation protection plans were developed and implemented recently. Additionally, the training depart-ment has been expanded, and specifically includes training and retraining for the chemical and health physics personnel. Health Physics Management personnel changes made during the SALP period are expected to result in improved licensee per-formance. G. Contention "In the radiation protection area, there were items of noncompliance , regarding personnel overexposure." 1.,. 1. Basis G" In October of 1979 an 18 year old received a IE Inspection quarterly exposure in excess of the allowable Report 79-15 ^ for an 18 year old. (1.7 rems vs 1.25 rems) .h.v; 2. NRC Actions I The licensee was cited for failure to IE Inspection s -Q jjg adhere to 10 CFR 20.101(a). The matter Report 79-15 IF,

JC was discussed with licensee management.

u f# dqd 3. Licensee Corrective Actions J... The licensee reviewed the-applicable CFR and found that they had misinterpreted the intent. H. Contention " Escalated enforcement action was taken on several~ occasions." 1. Basis During and following the SALP-1 appraisal period, escalated enforcement actions were deemed necessary to communicate the increasing NRC concern with the licensee's regulatory per-formance. 2. NRC Actions Escalated enforcement actions which were taken, include: l NRC Order (mispositioned containment 11/9/79 l valves) 1 =- l

O I T Enforcement meeting at Office of Director 11/30/79 NRC (mispositioning of cont. isolation valves). Civil penalty (mispositioned containment 11/9/79 valves). Immsdiate Action Letter (mispositioned 7/31/80 ECCS valves). Civil penalty (mispositioned ECCS 9/16/80 valves). Notice of Violation to licensed 9/16/80 operator (mispositioned ECCS valves). Conducted public me'eting in South 12/17/80 Haven, Michigan (mispositioned ECCS valves). i j Immediate Action Letter (mispositioned 1/9/81 battery breakers). Confirmatory Order (mispositioned 3/9/81 battery breakers). 3. Licensee Corrective Actions .g l (See Part I, " GENERAL.") 8 l l l l I -.}}

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