ML20081G808
| ML20081G808 | |
| Person / Time | |
|---|---|
| Site: | Sequoyah  |
| Issue date: | 06/12/1991 |
| From: | Mccrath T TENNESSEE VALLEY AUTHORITY |
| To: | NRC OFFICE OF ENFORCEMENT (OE), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| EA-91-043, EA-91-43, NUDOCS 9106130349 | |
| Download: ML20081G808 (10) | |
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JUN 121991 l
Director Office of Enforcement U.S. Nuclear Regulatory Commission ATTN:
Document Control Desk Washington, D.C. 20555 Centlemen:
In the Matter of
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Docket Nos. 50-327 Tet.nessee Valley Authority
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50-328 SEQUOYAH NUCLEAR PLANT (SQN) - NRC INSpECTIOk REPORT NOS. 50-327, 328/91 REPLY TO A NOTICE OF VIOLATION (NOV) 50-327, 328/91-04-01 AND PROPOSED imp 0SITIr:1 OF CIVIL PENALTY (EA 91-043)
Enclosed is TVA's response to S. D. Ebneter's letter to D. A. Nauman dated May 13, 1991, which transmitted the subject NOV involving the failure of operating personnel to promptly detect and respond to a7 annunciator. This annunciator alerts the operators to decreasing pressure in an accumulator on the air start system for Emergency Diesel Cenerator 2B-B.
The specific event that gave rise to the violation resulted from inadequate operating porsonnel performance, exacerbated by weaknesses in the SQN annunciator system hardware.
As noted in NRC's letter transmitting the NOV, TVA recognized the need for improvement in Operations' performance at SQN in the early fall of last year.
As a result, an extensive Operations improvement process, which included several personnel changes, was initiated. TVA requested and held a meeting with NRC in November 1990 to brief the NRC staff on initiatives intended to raise tne overall level of Operations' l
performance. While TVA has seen improvement (and the NRC staff has reported on that improvement), Operations' performance is not yet at the desired level which we are working to achieve, as evidenced by the cited violation.
TVA considers that in some areas of Operations' performance, expectations regarding standards of performance have not been adequately defined, communicated, demonstrated, and enforced.
Accordingly, ii 9106130349 910612 Y
PDR ADOCK 05000327
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U.S. Nuc1 car Regulatory Connission l
JUN 121991 significant initiativos are being implemented to reinforce appropriato standards throughout the Operations organization.
Fundamental to long-term ouccess, TVA will continuo observations and ovaluations of progress and refine performanco improvements, as neconsary.
As TVA told the NRC staff in the November meeting, it will take timo before Operations' performanco reaches the desired levol of excellence, llowever. TVA considers that the requisito path to achlovo succosa has been charted, 59 being followed, and, more importantly, has the buy-in of Operationc' department personnel.
In the NOV cover letter, NRC noted a weakness in the licennec event report (LER) describing this event.
TVA concluded that the associated incident investigation, which provided the basis for the LER, did not i
adequately address the operator performancu losuo and that full management involvement in the invootigation did not occur until very lato in the process.
Recent improvements in SQN's incident investigation proceso invoivo cito contor management in an early stage of the investigallon through a plant event review panel.
This paool is chaired by the plant Manager and consists of key site managers, the investigating team, and the individuals from the involved organizations to ensure that appropriato cognizance of the event and implications to achieved and that appropriate correctivo actions are initiated.
This proceso providos assurance that the significance of an event to recognized by management in an early stage of investigation.
Following concluulon of the investigation, the resulting hER receivos, at minimum, the samo oito senior'.aanagement level review as the incident investigation, with the Sito Vico president having ultimato accountability for final LE2 product I
thoroughness.
In addition. TVA hoo initiated actions to introve the preparation of 1.ERs to encuro that the underlying causeo and corrective actions for events are clearly determined and connuntcated.
In summary, eignificant initiativos are being undertaken to improvo and maintain performance at the desired level of excellenco throughout all levels of Operations. Continual monitoring, reinforcoment, and personnoi evaluationc, along with caphasio during training, will ensuru a lanting effect of those initiatives.
I The enclosure providos TVA's response to the violation.
Paymont of the propocod civil penuity in the amount of $75,000 is being made by electronic fund transfer.
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ti.S. Nucicar Regulatory Comtrelon JUN 121991 If you have any questionu concerning this submittal, pleaun telephone me at (615) 151 4716.
Very truly yours.
TENNESSEE VALLEY AllTil0RITY 4
T. J. McGrath, General Manager Materints, Contracts &
Administrative Support Sworn to ynd subec lbed before me d-da of q d, 1991 tit a u
t{$,a y),
d 2n Notary Public HyCommissionExpires[f pk Enclosure cc (Enclocuro):
Hs. S. C. Black, Deputy Director Project Diractorato 11-4 U.S. Nuclear Regulatory Commlosion One White Flint, North 11555 Rockvillo Pike Rockville, Maryland 20852 Mr. D. E. LaBargo, Project Manager U.S. Nuclear Regulatory Comission One White Flint, North 11555 kockville Pike Rockville, Maryland 20852 NRC Resident. Inspector Sequoyah Nuclear Plant 2600 Igou Ferry Road Soddy Daisy, Tennenoco 37379 Mr. B. A. Wilson, Project Chief U.S. Nuclear Regulatory Commiccion Region 11 101 Mariotta Street, IN, Sutto 2900 Atlanta, Georgia 30323
LNcl onpl1 i RESI'ONSE 10 NRC INSPLCTIOfi ki' PORT NOS. 50-327/91-04 AND $0-328/91-04 S.
D. LBNLTI R 'S 1.LTTI R 10 D. A. NAUMAN DAlliD MAY 13, 1991 V i o l a t i n.n, _S_0-3 2 7, 12 H / 91 -0 4 -01 Technical Specification 6.8.1.a requires that written procedures reconunended by Appendix A of kegulatory Guide 1. 33. Revision 2 l'ebruary 1978 uhall be established, implement ed, and nciint ained.
Section 5 of Appendix A of i<egulatory Guide 1.33. Revision 2, r e c onunend s procedures for abnormal, offnormal or alatm conditions. Administrative Instruction (AI) -30. Nuclear Plant Conduct of Operations, which was established to comply with this requirement, in part, implements the above by requiring in Section 7.6, Assignments of Responsibility, that operators shall be responsible for control room alarms, and in Section 11.8 that all alarms be acknowledged and given adequate response.
Contrary to the above, on January 24, 1991, licensee personnel failed to in pl emen t the requirements of Al-30 to acknowledge and adequately respond to a low air pressure control soom annunciator for one hour or more resulting in the diesel generator air start pressute (or the 2B-B emergency diesel generator decreasing to 140 psig which is below the 180 psig operability limit established by TVA.
This is a Severity 1.evel III violation (Supplement 1).
Civil Penalty - $75,000.
Admission or Denial of the Violation 1VA admits the violation.
Reason for the Violation The primary cause of the event.s noted in the violation was inadequate Operations personnel performance in naintaining proper attention and response to annunciators.
SQN's operators are expected to nionitor the control boards and be knowledgeable of plant conditions at all times.
Had Operationn' personnel promptly detected the alarm, corrective actions could have been quickly initiated, and the pressure in the actunnlator could have been restored earlier than was the case in this situation. While improvements in operator cognizance of plant status had recently been noted as a result of ongoing initiatives, this event illustrated that further improvement was needed.
TVA considers that the broader undetlying cause of this specific event is weaknesses in definition and enforcement of operating standards and is, in fact, the root co.se underlying such performance.
Although the exact rearon why operating perr9nnel did not promptly identify the annunciator could not be determined, several potential contributing causes have been identified. The estimated time the annunciator alarmed was shortly l
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1 after the operators assumed the day shifL.
This is a high activity perica in the mr.in control room (MCR) because work is beginning for the day, and 4
permission irom Operations is being requested and received before starting many daily tasks.
At the tirne of this event, activities and approvals of this nature were being handled by various operating persotusel.
The individual who I
was assigned responsibility for monitoring the panel on which the diesel annunciator is located had been extensively involved with MCR administrative activities during the period before discovery of the annunciator. Other MCR operating personnel were similarly involved in shift turnover and start of workday activities.
The second potential contributor noted was that the design of the diesel generator panel, alarms, and annunciators impeded proper monitoring irom a human factors standpoint.
Factors affecting recognition included L
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(1) limited audibility of the alarm between the conunon panel and the i
" horseshoe" area. (2) visual perception difficulty created by red annunciator backgrounds. (3) automatic silence of the annunciator after a short period of
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time (approximately 15 seconds), and (4) single alarms f or multiple panels and conditions.
4, Another potential contributing cause identified was that before earlier this year SQN had been operating f or an extended period of tirne with a large number of lit annunciators, a majority of which were nuisance alarms.
This condition may have desensitized the operators to some degree to the importance i
j of the annunciators. The overall annunciator system upgrade had been committed to NRC for completion during the Cycle 6 refueling outages as part of the control room design review (CRDR) and was expected to resolve the annunciator system weaknesses noted above and provide capability to eliminate nuisance alarms.
Efforts to expedita improvements were initiated in mid-1990. These efforts included lifting leads and modifying logic, both of which require design changes, to eliminate nuisance alarms and expediting the overall annunciator upgrade project to the Cycle 5 outages. At the time of i
this event, associated design and evaluation efforts were ongoing, but i
short-term improvements had not yet come to fruitiont however, this area was receiving cc9siderable senior Nuclear Power management attention bef ore the event.
In s uana ry, t he s t.
factors, combined with distractions created by the aforementioned high activity level, could have led to this specific event in/olving failure to identify and respond to the annunciator.
While the described weaknesses in the annunciator system and the large nwnber of lit annunciators are in no way considered an acceptable reason for inadequate operator response, they are recognized as human performance impediments.
Regardless of these factors, it is clearly the responsibility of operating personnel to maintain appropriate vigilance in and attention to monitoring of annunciators.
Corrective Steps That llave !!een _Taken and Results Achieved Before this event, an Operations improvement process, including personnel upgrades and improvements, had been initiated by TVA in the fall of 1990 as an ongoing effort to f urther achievernent of standards of excellence in operational performance. This process involved, among other things, j
management reinforcemerit and monitoring of expectations achieved by increased Te' en umrwesu
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. nuna gemen t discussions with the etews, observations in the control room ana plant, personnel changeout, and overall increased focus on Operations.
Connunication of lessons leatned, emphasis on self-verification, and increased plant ownership were inherent elements of these initiatives.
An analycle of operatitu; per sonnel also resulted in seassignment for several key positions. This analysis included independent assesstnent of operating personnel perf ornunce char acteristics against desired characteristics and development 0t a strategic long-range plan to communicate and instill appropriate Operations standards and mission and promote the appropriate sense of plant and equipment ownetship and accountability Ior plant petiormance.
Operations group expertise has been augmented through recruittnent at experienced licensed personnel whose backgrounds have demonstrated the desired standards et pertormance.
These individuals are being utilized in development and implementation of the ongoing improvement initiatives.
Just before this event, overall improvements had been observed in several areas oy both NXC and TVA, although areas for antinuing tocus were secognized. NRC has noted that improvements had been achieved regarding opetators awareness of plant status.
Action 1 taken to reduce Operations' personnel errors resulting from inadequate s if-verification have achieved positive results.
An as11st visit by the Institute of Nuclear Power Operations conducted in January 1991 concluded that effective communicationb routinely used and command and cont rol responsibilities were clearly were understoodl however, it was noted that continued focus was requited to reduce control room activity level and to enforce consistent adherence to policies and standards.
As a result of this event and feedback from the previously described ongoing self-assessment, further improvements were factored into the ongoing Operations improvement process.
Reinforcement of the operators' top priority was achieved by lengthy discussions with crews of a memorandum issued from the Operations Superintendent to all Operations personnel on February 28, 1991.
The memorandum described the event leading to his specific violation and emphasized that knowing the status of the plant and promptly recognizing and responding to alarms are f undamental operator r esponsibilities that must be accepted and cannot be dele.7ated.
The memorandum stressed the shared responsibility of the entire control room crew for proper operations, implementation of a retined " operator at the controls" concept to raise operator annunciator awareness and cognizar.cu was also introduced by the memorandum. The refinements largely involve designating a single operator at the controls for each unit to continually monitor and attend to the control panels and annunciators without attending to administrative functions.
The control room operator is responsible for the remaining control room duties.
These actions have clearly conveyed expectations relative to operator attentiveness to annunciators and have significantly raised the level of awareness of the shift crews.
NRC's letter transmitting the NOV described two annunciator response incidents that occurred subsequent to implementation of the revised operator at the controls process.
TVA considers that both examples, as described by NRC, indicated inappropriate assignment. of annunciator monitoring responsibility and reflected the neted for further improvement under special or heavy operational demands. As a result, procedures f or ensuring coreon panels are
manned during transients have been incorporated into the operator at the controls process.
The SOS is responsible for determining when operational loads warrant reassigning the responsibility, which also further reinforces the shared accountability of the entire shift crew.
Additionally, controls have been further strengthened to minimize distractions in the MCR.
Barriers at MCR entrances have been constructed as part af control room upgrtides and restricted access is being enforced. The number of telephone calls to the MCR has been limited to those that truly require interface with MCR operators.
The changes have been conveyed to the plant staff by memorandum and discussion in shift turnover and plan-of-thu-day meetings.
With regard to the annunciator system hardware, significant improvements have been achieved to date and efforts are ongoing and continuing to receive senior management attention.
In addition, interim measures have been put in place until the overall upgrade project is implemented.
These included raising the volume of the horn on the common annunciator panels and deleting the automatic silence alarm feature. As a result of efforts that were initiated in mid-1990 and expedited in the fall of 1990, the total number of lit MCR annunciators has been decreased f rom approxinately 136 to 39; and work is continuing to further reduce this number.
For example, modifications are being implemented r
to eliminate nuisance alarms caused by logic ties and setpoint changes.
Aggressive pursuit of maintenance on components affecting annunciators is continuing with success.
An annunciat.or disablement program was established l
in October 1990 and has achieved significant progress in reducing the number of nuisance annunciators.
As a result of the efforts described above, failed power supplies and cards have recently been found to be causing erratic
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annunciator system performance, including annunciator horns alarming without flashing windows and flashing windows without alarming horns.
Degraded power supplies have been replaced, and preventive maintenance instructions are being implemente'd to achieve earlier identification of degradation.
The above efforts to improve operator attentiveness to annunciators, to minimize operational distractions, and to optimize existing annunciator system hardware have combined to significantly enhance overall annunciator monitoring and response capability.
These efforts, however, are simply part of the larger effort previously described to achieve and maintain improved Operations' performance in all areas.
Recent observations indicate progress is being made, yet a need f or continued focus still exists.
l Corrective Steps That Will Be Taken to Avoid Further Violations l
Intensive management efforts to clearly communicate and reinforce standards l
and expectellons have been put in place. As part of these efforts, SQN's Plant Manager is meeting with each shift operations su, disor (. SOS) individually to express his full support and define his
<pectations to the Operations' crews.
He is conveying that the SOS has complete authority for onshift activities and management support of conservative decisionmaking relative to these activities. These meetings also provide both an opportunity for the Plant Manager to become familiar with the individuals and to receive feedback on improvement initiatives and an opportunity to assess the management skills of the SOSS.
These meetings are offering a forum to
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consnunicate his personal expectations.
The SOSs in turn pr ovide feedback trom these discussions to the assistant shift operations supervisors (ASOSs) and the shift crews.
The Plant Manager then meets with the Operat ions Man;y;er, Operations Superintendent, the SOSs. and ASOSs of each crew to ensure consistent expectations ato conveyed and implemented through the nunagement chain and to r einf orce inanagement's suppor t of the shift crews.
As previously noted, feedback from the ongoing Operationr improvement process is continuing to be utilized to rafine and enhance improvernent initlatIves.
An evaluation of recent performance indicated that expectations regarding basic standards of performance in overall conduct of operations were not clearly defined, understood, or adequately reinforced.
A teview of personnel performance of the operating crews dut ing the subject event indicated that there was a lack of diligence associated with annunciator cognizance.
The lack of individual and team accountability prompted inuoediate restructuring of responsibilities as previously dcscribed, i.e.,
the retined operator at crew the controls concept. With regar d to inore f undamental indicators, it was concluded that expectations f or standards of perf or mance across all tacets of the proper conduct of operations should be examined, defined, or redetined as appropriatel docutoentedl and, most importantly, et icctively conenunicated and reinforced throughout all levels of the Operations organization, including a tuview of the manac,enent and each member of each shif L crew.
For example, conduct of operations procedures revealed that guidance regarding annunciator response was very vague.
On the other hand, a review of the procedures governing conduct of testing indicated that guidance was very detailed and comprehensive.
As previously described, expectations relative to attentiveness to annunciators have been conveyed to the shift crewsl however, long-term refinements to overall annunciator response standards will be implemented as described below.
A review of currently published opetating stanJards has been conducted to determine if expectitions are appropr iately conveyed as written, understood, and retlect the desired level of performance.
An independent review by senior twnagement w311 be conducted to determine where interim sneasures are warranted, and additional 0ctions will be implemented as apprcpriate.
Standards will then be revised. wht re needed, to proeida the requisite long-term guidance. Where itame d i a t e claritication is warranted, interim measures are being implemented as appropriate.
Expectations are being and will le c lea r l y conuminica ted t hr oughout the organization by cascading, two-way communication meetings.
Expectations will also be incorporated into the licensed operator training program to continually reinforce standards and ensure a long-term ef f ect.
Continuing personnel analysis will be conducted to determine the optimal conununication me'.hodology f or each individual to reluforce pert or nunce cons is tent with these standards.
Additionally, actions are being undettaken to fur *her broaden exposure of Operations' nanagement to performance standards of excellence within the industry.
An Operations review team is being established to provide a peer and management evaluation of Operations' performance during events. Where exceptional performance is demonstrated, methods to incorporate this perfornunce throughout the crews will be examined. This team will assess the adequacy of, understanding of, and adherence to the standards and reconvoend areas where i.nprovements are needed.
Again, these efforts are part of the
. ongoing initiative intended to elevate overall perfornance in conduct of operations.
Fe?dback and refinement will continue to be stressed and employed as a key mechanism to ensure Operations' performance improvement is achieved.
Monitoring Operations' performance will continue to ensure that the desired level is achieved and to refine actions to further improvements.
This monitoring will include the plant Manager and the Operations staff, as well as independent assessments, and is considered fundamental to the long-term success of these improvement initiatives. As we told you in November 1990, TVA will periodically brief the staf f on progress in this area.
The schedule for the overall annunciator upgrade project is being expedited for earlier implementation than previously committed to MtC under the CRDR project. Overall improvements on the annunciator system are designed to implement the " black board concept." As part 01 the annunciator upgrade project, a microprocessor-based annunciator system, which will provide increased flexibility to the operator, including alarm suppression capability, will be installed. Several features of the system will improve the operator's cognizance of plant status, such as a ringback to indicate an alarm state has cleared and reflash capability to indicate previously alarmed conditions that have not been acknowledged.
The upgrade project will also address human factor weaknesses involving annunciator visibility and alarm audibility.
Upgrade project engineering and impicmentation preparation efforts are being conducted to support the Cycle 5 outages scheduled for fall of this year for I
Unit I and spring of 1992 for Unit 2.
Date WhenJull_Compilance Will Be Achieved Corrective actions taken and scheduled as detailad above are expected to i
result in current and future compliance.
Ilowever. TVA will continue to monitor Operations' performance to verify effectiveness of these actions.
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ENC t.0SURI'. 2 List of Convaitments 1.
Reviewing and upgrading operating standards will be completed by June 28, 1991, 2.
Cascading, two-way consnunicat ion meet ings to convey and teinfoace the enhanced standards will be completed by August 16, 1991.
3.
An Operations review team will be es.tablished by June 28, 1991.
4.
Monitoring will be conducted by the I'lant Manager and the Operstions staff.
5.
Independent assessments of Operations' performance will be ceaducted.
6.
'1VA will periodically brief the NRC staff on progress in t 'ai s a r ea.
7.
The overall annunciator system upgrade will be completeu during the Cycle 5 refuelit<3 outages.
8.
Expectations will be incorporated into the licensed operator training program to continually reinforce standards.
9.
An independent review by senior nanagement will be conducted by June 21, 1991, to determine where interim measures are warrantedt additional actions will be implemented as appropriate.
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