ML20115A789
| ML20115A789 | |
| Person / Time | |
|---|---|
| Site: | Salem  |
| Issue date: | 01/16/1985 |
| From: | SCIENCE APPLICATIONS INTERNATIONAL CORP. (FORMERLY |
| To: | NRC |
| Shared Package | |
| ML18092A563 | List: |
| References | |
| CON-NRC-03-82-096, CON-NRC-3-82-96 ZAR-850116, NUDOCS 8504160032 | |
| Download: ML20115A789 (34) | |
Text
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O PRE-IMPLEMENTATION AUDIT OF THE DETAILED CONTROL ROOM DESIGN REVIEW j
OF THE SALEM GENERATING STATION UNITS 182 January 16, 1985 Prepared for:
U.S. Nuclear Regulatory Commission l
Washington, D.C. 20555 Contract NRC-03-82-096 Prepared by:
Science Applications International Corporation 1710 Goodridge Drive McLean, Virginia 22102
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FOREWORD This Technical Evaluation Report (TER) documents the findings from a pre-implementation audit of the Detailed Control Room Design Review (DCRDR) being conducted by Public Service Electric and Gas (PSE&G) Company for its Salem Generating Station Units 1&2. The audit was conducted by a three-man team comprised of one representative from the Human Factors Engineering Branch of the NRC's Division of Human Factors Safety. Science Applications International Corporation (SAIC), and Comex Corporation, a subcontractor to SAIC.
The audit consisted of extensive discussions held the week of November 26, 1984 with representatives of PSE&G and General Physics Corporation (GPC), PSE&G's human factors consultants.
DCRDR methodologies and resultant HEDs were reviewed in detail. Where clarification of HEDs discussed was needed, the relevant systems and components were examined in the control room and the Hot Shutdown Panel.
S AI C's participation was provided under Contract NRC-03-82-096, Technical Assistance in Support of Reactor Licensing Actions:
Program III.
An evaluation of Salem's DCRDR Sum,rary Report was previously provided to the NRC by SAIC (Reference 5).
SAIC did not previously evaluate PSE8G's program plan for conducting DCRDRs of the ' Salem Generating Stations Units 1 and 2 or participate in any meetings held with PSE&G prior to the pre-implementation audit.
i
TABLE OF CONTENTS Section Page BACKGROUND............................
2 PLANNING PHASE..........................
3 REVIEW PHASE...........................
4 1.
Review of Operating Experience.............
4 2.
Control Room Inventory.................
4 3.
Control Room Survey 5
4.
Systems Function Review and Task Analysis 7
ASSESSMENT AND IMPLEMENTATION PHASE 12 1.
HED Assessment.....................
12 2.
Selection of Design Improvements............
14 3.
Proposed Schedules for Implementing HED Corrections 15 4.
Verification that Improvements Will Provide the Necessary HED Corrections Without Introducing New HEDs.......................
15 5.
Coordination of the DCRDR With Other Improvement Programs.......................
15 ANALYSIS OF PROPOSED CORRECTIVE ACTIONS AND JUSTIFICATIONS FOR HEDS LEFT UNCORRECTED 16 1.
Proposed Corrective Actions 17 2.
Justifications for HEDs left Uncorrected........
18 CONCLUSIONS AND RECOMMENDATIONS 19 REFERENCES............................
22 APPENDIX A - HEDs in which corrective actions were proposed, but were found to be inadequately described or resolved, and require further documentation by PSE&G in order for the NRC to complete its review 24 APPENDIX B - HEDs left uncorrected or partially uncorrected in which justifications were provided, were found to be inadequate, and require further consideration and documentation for NRC review 25 APPENDIX C - HEDs inadequately assessed 30 APPENDIX D - Attendees of Meetings held during the pre-implementation audit of Salem Generating Stations Units 1 and 2....................
31 11 l
Pre-Implementation Audit of the Detailed Control Room Design Review of the Salem Generating Station Units 1 and 2 This report documents the findings from a pre-implementation audit of the Detailed Control Room Design Review (DCRDR) being conducted by Public Service Electric and Gas (PSE&G) Company for its Salem Generating Station Units 1 and 2.
The basis for the decision to conduct a pre-implementation audit was the review of the DCRDR Summary Report for Salem Generating Station Units 1 and 2 (Reference 4).
The results of the DCRDR Summary Report review were documented in SAIC's report to the NRC (Reference 5) and the NRC's comments to PSE&G (Reference 6). The requirements set forth in NUREG-0737, Supplement 1
" Requirements for Emergency Response Capability."
December 1982 (Reference 10) served as the basis of the summary report evaluation and the pre-implementation audit.
The purpose of the audit was threefold:
(1) to clarify certain aspects of the review process, (2) to confirm that the review was conducted appropriately, and (3) to evaluate the results.
Participants in the audit meetings are identified in Appendix D.
The human factors engineering review of the Salem control rooms began with a preliminary design review assessment of Salem Unit 2 control room in Spring of 1980 in response to NUREG-0660 (Reference 8). The DCRDR of Salem Units 1 and 2 was initiated in November of 1982 and a program plan was submitted to the NRC by PSE&G on February 14,1983 (Reference 2).
NRC staff comments on the submitted DCRDR Program Plan were forwarded to PSE&G on October 7, 1983 (Reference 3).
The DCRDR Summary Report was submitted to the NRC on December 30, 1983 and the NRC staff's comments on it with the SAIC TER attached were forwarded to PSE&G on March 21, 1984.
PSE&G partially addressed the NRC's concerns by submitting supplemental information on September 18,1984 (Reference 7). At the time of the pre-implementation audit, PSE&G had implemented some improvements to the control rooms in response to identified human engineering discrepancies (HEDs).
However, the vast ma,iority of HEDs at the time of the pre-implementation audit had not been corrected by backfits to the control rooms or the hot shutdown panels.
The findings of the pre-implementation audit, including the review of the DCRDR methodologies and resultant HEDs, follow a brief overview of the background of the DCRDR requirements.
1
BACKGROUND Licensees and applicants for operating licenses are required to conduct a Detailed Control Room Design review (DCRDR).
The objective is to
"... improve the ability of nuclear power plant control room operators to prevent accidents or cope with accidents if they occur by improving the information provided to them" (NUREG-0660, item I.D.1).
The need to conduct a DCRDR was confirmed in NUREG-0737 and in Supplement I to NUREG-0737.
DCRDR requirements in Supplement 1 to NUREG-0737 replaced those in earlier documents.
Supplement I to NUREG-0737 requires each applicant or licensee to conduct their DCRDR on a schedule negotiated with the NRC. Guidelines for conducting a DCRDR are provided in NUREG-0700 while the assessment processes for NRC are contained in NUREG-0800.
(The NUREG documents cited are listed as References 8 through 12.)
A DCRDR is to be conducted according to the licensee's own program plan (which must be submitted to the NRC); according to NUREG-0700 it should include four phases:
(1) planning, (2) review, (3) assessment, and (4) reporting.
The product of the last phase is a summary report which, according to NUREG-0737, Supplement 1, must include an outline of proposed control room changes, their proposed schedules for implementation, and summary justification for human engineering discrepancies with safety significance to be left uncorrected or partially corrected.
Upon receipt of the licensee's summary report and prior to implementation of proposed changes, the NRC must prepare a Safety Evaluation Report (SER) indicating the acceptability of the DCRDR (not just the summary report).
The NRC's evaluation encompasses all documentation as well as briefings, discussions.,
and audits, if any were conducted.
The purpose of this Technical Evaluation Report is to assist the NRC by providing a technical evaluation of the PSE&G DCRDR process and results.
The DCRDR requirements as stated in Supplement I to NUREG-0737 can be summarized in terms of the nine specific elements listed below:
1.
Establishment of a qualified multidisciplinary review team.
2
2.
Use of function and task analyses to identify control room operator tasks and information and control requirements during emergency operations.
3.
A comparison of display and control requirements with a control room inventory.
4 A control room survey to identify deviations from accepted human factors principles.
5.
Assessment of human engineering discrepancies (HEDs) to determine which HEDs are significant and should be corrected.
6.
Selection of design improvements that will correct those discrepancies.
7.
Verification that selected design improvements will provide the necessary correction.
8.
Verification that improvements can be introduced in the control room without creating any unacceptable human engineering discrep-ancies.
9.
Coordination of control room improvements with changes resulting from other improvement programs such as SPDS, operator training, new instrumentation (Reg. Guide 1.97, Rev. 2) and upgraded emergency operating procedures.
PLANNING PHASE The review of the PSE&G Summary Report for Salem Units 1 and 2 as documented in the NRC's SER and SAIC's TER concluded that PSE&G has met the requirement of Supplement 1 to NUREG-0737 for a multidisciplinary review team. However, the involvement of the DCRDR team members in the individual review activities could not be evaluated due to lack of information on this subject in the Program Plan and the Summary Report. Through discussions with PSE&G during the pre-implementation audit concerning various review, assessment, and resolution activities and review of the supplemental 3
information provided by PSE&G, the involvement of the DCRDR team members in the individual review activities was found to be adequate in general.
Comments on the adequacy of staffing for specific review activities can be found in the applicable sections of this report.
REVIEW PHASE PSE&G review phase plans and activities include:
1.
Review of Operating Experier.ce, 2.
Control Room Inventory, 3.
Control Room Survey, 4.
Systems Function Review and Task Analysis.
The above activities are those recommended by NUREG-0700 guidelines as contributing to the accomplishment of the review phase objectives.
Activities two through four address specific DCRDR requirements contained in NUREG-0737, Supplement 1.
Of these activities, the pre-implementation audit concentrated on the control room survey and the system function review and task analysis.
A summary of the findings documented in the March 21, 1984 NRC SER and SAIC TER for the Review of Operating Experience and the Control Room Inventory will be given in these sections presented below.
1.
Review of Operating Experience SAIC concluded in its March 21, 1984 TER that the PSE&G Review of Operating Experience was fairly comprehensive and should have yielde.d significant information which would contribute to the overall DCRDR.
2.
Control Room Inventory The NUREG-0737, Supplement I requirement which addresses the control room inventory states that the licensee shall perform "a comparison of the display and control requirements with a control r.oom inventory to identify missing displays and controls."
PSE&G performed its comparison of the information and control requirements using the actual control room rather than an inventory of control room instruments and controls.
An inventory was conducted, but apparently not for the purpose of satisfying this 4
NUREG-0737, Supplement I requirement.
The inventory, in itsel f, was found to be adequate as a data base for reference.
Discussion on the Verification of Task Performance Capabilities, which addresses the comparison activity required by Supplement I to NUREG-0737, is discussed in the Systems Function Review and Task Analysis section of this report.
3.
Control Room Survey A review of the PSE&G Salem DCRDR Summary Report, as documented in the March 21,1984 NRC SER and SAIC TER, produced the following concerns:
There was no description of how the dynamically-oriented guidelines o
were addressed in the control room survey and the System Function Review and Task Analysis.
There was no description of how the checklists and environmental o
surveys were performed.
Sample checklists and environmental survey data forms were not o
provided.
o The personnel who performed the control room survey were not identified.
PSE&G responded to these concerns in its September 18, 1984 submittal of supplemental information prior to the pre-implementation audit and in discussions held during the audit.
In general, these concerns were satis-fied. The specific findings by the NRC audit team on these concerns are described below.
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The dynamically-oriented guidelines were taken from NUREG-0700 and listed in Appendix A of the supplemental information. The dynamically-oriented guidelines were evaluted in the control room survey when possible, in the talk-and walk-throughs following the System Function Review and Task Analysis, and to a further extent in the review of the talk-and walk-through videotapes. The integration and application of the dynamically-oriented guidelines appears to have been satisfactorily performed.
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5
The various environmental factors recommended by NUREG-0700 to be evaluated were addressed by PSE&G's control room survey.
The methodologies described by PSE&G during the pre-implementation audit for performing a survey of control room lighting, luminance, noise, ventilation, humidity, and temperature appeared to be adequate.
The data forms used for surveying control room lighting, luminance, and noise were provided in the supplemental information. Although no data forms on ventilation, humidity, and temperature were provided, the NRC audit team was satisfied with the methodologies described for these surveys.
PSE&G needs to provide documentation describing all the environmental survey methodologies.
PSE&G stated in the supplemental information that the checklists used to perform the control room survey were those given in NUREG-0700. The check 11 sting methodology was described by PSE&G as applying the guidelines to individual components or to a more general level of evaluation depending on the nature of each guideline. The NRC audit team found the checklists used and the methodology followed to be satisfactory.
PSE&G provided in the supplemental information the names of the personnel who performed the control room survey.
The NRC audit team concluded that personnel who conducted the control room survey were adequately qualified.
In its review of the HEDs identified from the control room survey and from visits to the control rooms and hot shutdown panels, the NRC audit team noted the existence of numerous inconsistencies in application of colors to particular functions and meanings and in the labeling used.
Few HEDs.,
singular in nature, were written on these inconsistencies.
Although PSE&G has developed a partial list of color usage in the control rooms, the list j
is not complete and a standard for color coding has not been developed.
According to PSE&G, there are no plans for attempting to standardize color j
coding in the control rooms or the hot shutdown panels.
PSE&G stated that it has standardized the abbreviations and acronyms used for annunciator tiles.
However, no attempt was apparently made to develop a standardized list of abbreviations and acronyms applicable to the remainder of the control rooms, the hot shutdown panels, nor the operating procedures.
At the time of the pre-implementation audit, PSE&G had made no i
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J plans to standardize the labeling, including label location with respect to associated components and component groupings.
In summary, the staffing and performance of the control room survey, except for the establishment of a comprehensive list o.f color coding and labeling discrepancies, appears to be satisfactory towards meeting the control room survey requirement of NUREG-0737, Supplement 1.
We believe that complete satisfaction of this requirement can be achieved by developing a comprehensive list of color coding and labeling inconsistencies /
discrepancies for the purpose of establishing standards for color coding and labeling in the control rooms and hot shutdown panels. These standards should be applied for the control rooms and hot shutdown panels for the purpose of resolving inconsistencies / discrepancies. Furthermore, PSE&G should apply these standards to the procedures, SPDS, and any new instrumen-tation planned for the control room.
PSE&G should also provide documentation on the methodology followed to conduct the environmental surveys.
4.
Systems Function Review and Task Analysis The general concern raised in the review of PSE&G's Summary Report was that the methodology for conducting the task analysis and the verification and validation processes appeared to be inadequate. Specifically, these concerns were the following:
o The identification of information and control requirements apparently was not performed independently of the existing control room.
o The verification of task performance capabilities and validation of control room functions relied on videotapes for data collection and analysis.
PSE&G responded to the first of the two concerns in its submittal of supplemental information prior to the pre-implementation audit and in discussions held during the audit with its human factors consultants present.
The revised description of the task analysis presented in the supplemental information (p. 5) states that the "I&C Needs" column of the 7
pre-fill task analysis form were developed based upon " plant drawings and related references" that were used to determine information and control requirements.
Further inquiry found the plant drawings to be definitive of the existing control room on a system level rather than on an individual component level. With the use of related references such as the FSAR and training documents in addition to these "high level" plant drawings, operations personnel from PSE&G and its consultants in conjunction with human factors specialists determined the information and control requirements.
PSE&G's human factors consultants reaffirmed that neither the control room inventory nor any other documentation of actual instruments and controls were used to determine information and control requirements.
Further discussion clarified that PSE&G listed the information and control requirements that were determined in the " System Responses" column of the pre-fill task analysis form rather than the "I&C Needs (Specific CR Equipment)" column (contrary to the supplemental information submitted by PSE&G).
It appears that the information and control requirements that were identified were determined independently of plant-specific documentation which describes the actual instruments and controls in the control room.
Although the information and control requirements listed in the " System Responses" column were apparently derived independently of the existing control room instruments and controls, the listing was not comprehensive of all needed characteristics of required information and controls.
The information and control requirements listed in the pre-filled task analysis forms were generally limited to the parameter / plant component level.
Characteristics of information requirements such as the means of displaying parameter information, the parameter units (e.g., PSIG, Inches of H 0, GPM).,
2 the range, reading accuracy or precision, acceptable tolerances and so on, were not identified.
Characteristics of control requirements such as the type of control capability needed (e.g., discrete versus continuous), the control operation if the control capability needed is discrete (e.g.,
I detented versus spring-loaded, momentary contact positioning), control positions (e.g., OPEN and CLOSE, START and STOP), and rate, gain, and response characteristics were not identified.
As an example, step 4.2.2 of the Steam Generator Tube Rupture EI, Pre-Fill Task Analysis Form, p. 7 of 51, has the column " Operator Tasks / Elements" listed as "RO-1 moniters all four Steam Generator Levels."
The corresponding " System Responses" column i
lists the information needs as "No 11 Steam Generator Level increases." The 8
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"IAC Needs (Specific CR equipment)" column was then pre-filled with the name and/or number of the indicator or control available in the control room.
The "I&C Needs" entry for the above example of "No 11 Steam Generator level increases" is:
"No. 11 Steam Generator LA 5035 IB LA 5037 IB LA 5038 IB LA 501 4B No. 12 Steam Generator LA......." etc.
As the above example shows, the determination of information requirements was limited to. identifying the parameter in the " System Responses" column. No characteristics of the required information were apparently defined prior to verifying the availability and suitability of the needed information in the control room. The purpose of identifying information and control requirements prior to examining the control room is twofold:
(1) to ensure that a comprehensive, prescriptive base of criteria is developed with which instruments and controls in the control room can be comprehensively and validly evaluated for availability and suitability and (2) to lend objectivity to this process. The level of PSE&G's analysis of tasks to determine information and control requirements is not sufficient to meet the Function and Task Analysis requirement of NUREG-0737, Supplement 1.
However, it should be noted that most pre-fill documents were completed in l
mid-1982, while Supplement I to NUREG-0737 did not become effective until January 3, 1983.
a During the pre-implementation audit the NRC audit team made'an inquiry' into PSEAG's E0P upgrade program.
A discussion was held with PSE&G's
(
consultants for preparing the upgraded E0Ps concerning their methodology and j
documentation. It was found that the upgraded E0Ps were being developed from the WOG ERGS, Revision 1. High Pressure (HP) version, in accordance
}
with current regulatory requirements and other supporting documentation.
It was also noted that instrument and control availability and suitability is 7
l being determined for each NOTE, CAUTION, and STEP of the ERGS.
Apparently, the E0P upgrade consultants are determining the availability and suitability l
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of instruments and controls in parallel with determining the information and control requirements. The approach seems to be to identify the information and control capabilities required for each NOTE, CAUTION, and/or STEP in the procedure and then verify its availability and suitability in the control room before continuing to the next NOTE, CAUTION, and/or STEP.
In any case where instrument and control design is not obvious as fulfilling the
" instrument needs" as listed in the ERG background documentation, the procedure writers are requesting a formal engineering evaluation (per normal plant administrative pr acedures) of installed instrumentation and controls to determine acceptab.11ty for the procedure step, and maintaining an auditable record of suca evaluation.
Differences between Salem and the ERG
" reference plant" appear to be minimal.
The E0P upgrade consultants stated that no instances of missing instruments or controls have been determined and that minor instances of questions of acceptability and/or suitability have been noted and subjected to engineering evaluation.
At the time of the pre-implementation audit, the status of the E0P upgrade program was:
- 1) The Procedures Generation Package (PGP) was submitted to NRC approximately one year ago. There has been no response to date. A supplement to the PGP is required because the actual methodology being used in the upgrade program is slightly different than reflected in the original PGP.
- 2) All E0Ps have been prepared as derived from the ERGS. Operator training, talk-throughs, and simulator walk-throughs have been completed twice.
Operator comments from second session are currently being incorporated where appropriate.
- 3) The upgraded E0Ps are to be fully implemented March 1985.
We believe that the Systems Functions Review and Task Analysis conducted two years ago by PSE&G and the results thereof, when supplemented with the final results of the apparent instrument and control availability and suitability check currently being accomplished concurrent with the E0P upgrade effort, will adequately fulfill the current regulatory requirements of Supplement 1 to NUREG-0737 and other supporting guidelines. PSEAG should 10
provide documentation describing how the E0P upgrade methodology and findings will supplement the following DCRDR activities since this will have a direct bearing on the acceptability of the DCRDR task analysis as accomplished:
(1) the Systems Function Review and Task Analysis and (2) the Verification of Task Performance Capabilities.
Since the qualifications of the E0P upgrade consultants apprently do not reflect the level of human factors expertise normally needed to ensure a comprehensive analysis of tasks for information and control requirements, additional analysis may be necessary.
PSE&G should perform and describe any further analysis and verification that is necessary that hasn't been accomplished by the DCRDR and the E0P upgrade program.
If the methodology and results of the E0P upgrade program and whatever necessary additional work in the DCRDR are found to be acceptable, this should satisfy the concerns regarding (1) the identification of information and control requirements and (2) the methodology for verifying task performance capabilities.
The final concern to be discussed in this section regards the use of videotapes for collecting data in the Validation of Control Room Functions.
It is felt that collecting data from videotapes can be an acceptable alter-native to on-site data collection only when a systematic and rigorous approach to data collection based on objective criteria has been performed.
PSE&G's human factors consultants stated in the task analysis methodology description submitted as part of the supplemental information that "although no explicit performance criteria were available in the industry, general criteria for performance of tasks within each operating event were used to confirm existing HEDs or to identify additional HEDs." Discussions held during the audit concerning the walk-throughs revealed that the general criteria for performance of tasks consisted of some or all of the dynamically-oriented guidelines extracted from NUREG-0700 (see Appendix A of the supplemental information).
Except for identifying four HEDs concerning procedural inadequacies, the videotapes appeared to have been reviewed to confirm existing HEDs.
Although PSE&G's validation procedure did not consist of a systematic analysis of operator traffic patterns, workload, and control / display relationships such as that which can be performed using spatial-operational / safety sequence diagrams or link analysis, the approach used by PSE8G appears to be minimally acceptable for validating control room functions, i
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In summary, the DCRDR task analysis performed by PSE&G appeared to he,e identified information and control requirements independently of the existing control room.
However, the identification of information and control requirements did not appear to be comprehensive of all needed characteristics of instruments and controls to allow an adequate verification of task performance capabilities to be performed.
After reviewing the analysis and verification being performed in the E0P upgrade program, we believe that the Systems Function Review and Task Analysis and the Verification of Task Performance Capabilities conducted by PSE&G and the results thereof, when supplemented with the final results of the apparent instrument and control availability and suitability check from the E0P upgrade effort, will adequately fulfill the current regulatory requiretrents of Supplement I to NUREG-0737 and other supporting guidelines.
PSE8G should provide documentation describing how the E0P upgrade methodology and findings will supplement the (1) Systems Function Review and Task Analysis and (2) the Verification of Task Performance Capabilities.
Since the qualifications of the E0P upgrade consultants apprently do not reflect the level of human factors expertise normally needed to ensure a comprehensive analysis of tasks for information and control requirements, additional analysis may be necessary.
PSE&G should perform and describe what further analysis and verification that is necessary that hasn't been accomplished by the DCRDR and the E0P Upgrade Program.
Finally, the Validation of Control Room Functions appears to have been minimally acceptable.
ASSESSMENT AND IMPLEMENTATION PHASE 1.
HED Assessment A review of the PSE&G Salem DCRDR Summary Report produced the following concerns:
o The HED assessment process did not appear to address cumulative or interactive effects.
o The methodology for converting answers to structured questions into an indication of HED significance was not described.
o Some safety-related HEDS may have been improperly categorized.
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PSE&G responded to these concerns in its submittal of supplemental information prior to the pre-implementation audit and in discussions held during the audit.
In general, these concerns were not satisfied.
The specific findings by the NRC audit team on these concerns are described below.
PSE&G initially stated that it had addressed the cumulative and inter-active effects of HEDs during the assessment process, but only for category 4 HEDs.
When concern was expressed by the NRC audit team that the cumula-tive and interactive effects of HEDs other than category 4 HEDs were not considered, PSE8G stated that cumulative and interactive effects were not ignored for the category 1, 2, and 3 HEDs.
PSE&G further stated that a computer sort of all HEDs by panel designation and NUREG-0700 guideline reference was performed and that this represented a concerted effort towards considering cumulative and interactive effects for HED assessment and reso-lution. Although the use of a computer sort may be an adequate means of helping to identify HEDs involved in cumulative and interactive effects,it does not constitute an analysis or assessment.
A review of the HEDs by the NRC audit team found the results to be unsatisfactory. A review of the HEDs determined by the NRC audit team to possess cumulative and interactive effects (see Appendix B, Section 2) found the assessment and resolutions to reflect an inadequate consideration of these effects by PSE8G. HEDs such as no hierarchial labeling and demarcation, inconsistency in control / display relationships, and an overall lack of enhancements, constitute a much more significant problem when considered together rather than singularly. In order for this concern to progress towards resolution, we recommend that PSE&G submit a written response describing its consideration of the cumula-tive and interactive effects of the HEDs listed under this category in Appendix B for assessment and resolution.
A concern raised in the March 21, 1984 NRC SER and SAIC TER was that the summary report did not include a description of how the answers to the structured questions used for assessing HEDs were formulated into an indica-tion of HED significance.
PSE8G responded to this concern during the audit by stating that the questions (p.18.1-A18 of NUREG-0800, Reference 12) were answered to obtain an overall feeling rather than a systematic rating of the 13
9 significance of HEDs in affecting performance and of the pntential for error. For the reasons discussed below, the determined significance of HEDs was not always translated into the proper HED categorization.
Appendix C lists 30 HEDs which were found by the reviewers to have the potential to cause operator errors of either low or high probability which could result in adverse plant conditions.
According to the categorization scheme defined by PSE&G, these HEDs should be assessed as at least category 3 HEDs. However, these HEDs were reported as Category 4 HEDs in the Summary Report.
PSE&G did not respond to this concern in its supplemental informa-tion or during the audit discussions.
PSE&G should provide a written response documenting the rationale used for the assessment of each HED listed in Appendix C.
In summary, the results of the HED assessment process, as reflected in the HED category assignments, do not demonstrate that this activity was satisfactorily performed. Documentation describing the consideration of cumulative and interactive effects of HEDs and the rationale for assessing certain HEDs as Category 4 HEDs should be submitted by PSE&G.
2.
Selection of Design Improvements A review of the PSE&G Salem Summary Report and the supplemtal information provided produced a concern regarding the extent of human factors participation in the resolution of HEDs. A review of the general methodology for arriving at design solutions (as documented in the supple-mental information) found the process to be satisfactory with the exception of human factors participation in the review of HEDs for deletion. PSE&G alleviated concerns in this area by stating that through the exchange of memos (between it and its human factors consultants) which documented the resolution of HEDs, including deletions, human factors input was adequately provided in the resolution of HEDs. PSE&G appears to have satisfactorily included human factors considerations in the selection of design improve-ments.
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3.
Proposed Schedules for Implementing HED Corrections A review of PSE&G's Salem Summary Report found the documentation to be lacking in the following areas:
Assurance that enhancements will be done promptly and will be o
integrated with all other design corrections.
Integration of DCRDR design change scheduling with the schedule of o
changes resulting from other emergency response capability initiatives.
o Calendar dates for accomplishing the design corrections.
With the exception of calendar dates for accomplishing design corrections and implementing enhancements, the supplemental information and discussions held with PSE&G during the audit satisfied these concerns.
It appears that the Design Change Request (DCR) and Engineering Design Document (EDD-1) process provides for the accomplishment and integration of changes resulting from the DCRDR and other emergency response capability initiatives. PSE&G should provide documentation providing the calendar dates for scheduling the implementation of design corrections and enhance-ments.
4.
Verification that Improvements Will Provide the Necessary Corrections Without Introducing New HEDs The concern expressed in the March 21, 1984 NRC SER and SAIC TER regarding this requirement was that PSE&G did not sufficiently address this area in the Salem DCRDR Summary Report. PSE&G addressed this cortcern in the.
supplemental information submitted to the NRC and in discussions held during the pre-implementation audit.
PSE&G essentially stated that Administrative Procedure No. 8 ( AP-8) " Design Change, Test and Experiment Program" is the vehicle to initiate the backfitting process and that Engineering Design Document No.1 is the vehicle which allows human factors review into the design change process. Both documents appear to establish a satisfactory mechanism for verifying that improvements provide the necessary corrections without introducing new HEDs. However, we are still somewhat concerned that in this late stage of the HED review process, DCRs or EDDs may be signed-off 15
as a formality without giving the sufficient and considerable human factors review they deserve.
PSE&G should provide documentation describing in more detail how it will ensure adequate human factors review, prior to sign-off, of DCRs and EDDs originating from the DCRDR.
5.
Coordination of the DCRDR With Other Improvement Programs A review of the Salem DCRDR Summary Report found that PSE&G did not demonstrate the existence of a system for coordinating changes among the improvement programs.
In its supplemental information, PSE&G included AP-8 as a response to the concern regarding the verification that improvements will provide the necessary corrections without introducing new HEDs.
While this is the vehicle for initiating design changes from any of the emergency response capability programs, this does not serve as the means or mechanism for ensuring these improvement programs are properly coordinated and inte-grated.
A review of the.EOP upgrade program revealed that the methodology and results of this program were not considered by the DCRDR team in its Systems Function Review and Task Analysis section.
Through discossion of coordination in this area and other areas (e.g., SPDS, Reg. Guide 1.97, training) it appeared that PSE&G did not establish an adequate mechanism or system for ensuring that the methodology and results of the improvement programs were properly coordinated and integrated. PSE&G should provide documentation describing how it will ensure that the results and remaining methodologies will be coordinated and integrated among emergency response capability programs.
ANALYSIS OF PROPOSED CORRECTIVE ACTIONS AND JUSTIFICATIONS FOR HEDs LEF.T UNCORRECTED During the pre-implementation audit, the NRC audit team reviewed each and every HED identified in the March 21, 1984 SAIC TER as unacceptably resolved or assessed.
Many of the HEDs had been unresolved due to the lack of information provided in the summary report or the absence of a descrip-tion and illustration of the control rooms and hot shutdown panels. Through discussions with PSE&G and visits to the control rooms and hot shutdown panels, approximately 33% of the unresolved HEDs were found by the NRC audit team to be satisfactorily resolved as stated. These HEDs will not be listed in this report.
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The remaining HEDs require further documentation before they can be adequately reviewed by the NRC.
These HEDs are discussed in general in the following two sections of this report:
(1) Proposed Corrective Actions and (2) Justifications for HEDs lef t Uncorrected. A complete listing of the HEDs relevant to each section is given in Appendices A and B.
In addition, a number of HEDs were found to be deserving of a higher assessment.
As previously stated in the March 21, 1984 SAIC TER, PSE&G should provide documentation describing its rationale for assessing those HEDs listed in Appendix C as Category 4 HEDs.
A concern discussed in the March 21, 1984 NRC SER and SAIC TER was that a large number of HEDs may not have been accounted for in Volume 2 of PSE&G's Summary Report. PSE&G responded to this concern by stating that although HEDs have been numbered up to #725, only 469 HEDs were documented in the Summary Report because.many HEDs were deleted due to redundancy with other HEDs or to invalidity. The HEDs were numbered up to f 725 due to the numbering system used before HEDs were deleted.
1.
Proposed Corrective Actions Appendix A of this report contains the complete list of HEDs (by Summary Report, Volume 2 page number) in which corrective actions were proposed, but were found to be inadequately described or resolved, and require further documentation by PSE&G in order for the NRC to complete its review. The listing is divided into two categories:
1.
The proposed corrective action as described by PSE&G during the audit discussions was found to be adequate but needs to be documented for NRC review, 2.
The proposed corrective action had not been determined at the time of the audit and should be finalized and documented for NRC review.
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2.
Justifications for HEDs Left Uncorrected Appendix B of this report contains the complete list of HEDs (by Surnmary Report, Volume 2 page number) left uncorrected or partially uncor-rected in which justifications were provided, were found to be inadequate, and require further consideration and documentation for NRC review. The listing is divided into three categories:
1.
The original justification is unsatisfactory because it cites utility, industry, or manufacturer's conventions; cites absence of previous operator errors; cites perceived degree of deviation from NUREG-0700 guidelines; or simply states "no action taken" or
" satisfactory as is."
Justifications based upon operational and behavioral safety considerations / implications are necessary.
2.
The justifications of individual HEDs do not consider the cumula-tive or interactive effect from other HEDs. Due to the serious implications of the cumulative effects upon the potential for operator error and plant safety status, and as previously recom-mended in the March 21, 1984 SAIC TER, PSE&G should provide a justification or resolution for each of the five cumulative or interative effects described in Appendix B. Section 2.
Al though some of the individual HEDs in the listing may have been found to be adequately resolved, this does not exempt them from contribut-ing to the cumulative or interactive effect and so should be considered in the justification or resolution provided by PSE&G.
3.
The original justification refers to further documentation or sample data which was not furnished in the summary report.
Although PSE&G stated that the documentation referred to was too cumbersome to include in the Summary Report, it should provide all information referenced in the justification or provide a new justification which adequately addresses the HED.
For those HEDs listed in Appendix B which also appear in Appendix C, PSE&G may provide the rationale for its assessment at the same time it describes its resolution. The HEDs on page numbers 65 and 67 of Volume 2 of 18 l
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the Summary Report should have the rationale for assessment included as part of the justification or resolution of the cumulative and interactive ef fects.
CONCLUSIONS AND REC 0f01ENDATIONS Through information provided in its submittal of supplemental informa-tion prior to the pre-implementation audit and in discussions held during the audit, PSE&G has satisfied most of the concerns the NRC had regarding the DCRDR of Salem Units 1 and 2.
However.. PSE&G needs to provide documen-tation addressing the NRC's remaining concerns regarding various aspects of the DCRDR methodology and findings.
Until documentation is provided which resolves the NRC's remaining concerns, we do not believe the DCRDR process and the resolution of findings have successfully met the requirements of NUREG-0737, Supplement 1.
We recommend that PSE&G should submit documentation providing the following information:
o Control Room Survey A description of all the environmental survey methodologies.
A description of the approach taken to establish and apply color coding and labeling standards in the control rooms and hot shutdown panels.
o Systems Function Review and Task Analysis A description of how the E0P upgrade methodology and findings will supplement the Systems Function Review and Task Analysis and the Verification of Task Performance Capabilities.
A description of what further work needs to be done in the Systems Function Review and Task Analysis and Verification of Task Performance Capabilities that hasn't been accomplished by the DCRDR and the E0P upgrade program.
Since the qualifications of the E0P upgrade consultants apparently do 19 l
not reflect the level of human factors expertise normally needed to ensure a comprehensive analysis of tasks for information and control requirements, additional analysis maybe necessary.
o HED Assessment A description of its consideration of the cumulative and interactive effects of the HEDs listed in Appendix B, section 2 for assessment and resolution.
A description of the rationale used for assessing each HED listed in Appendix C.
o Proposed Schedules for Implementing HED Corrections A description of the calendar dates for scheduling the imple-mentation of design corrections and enhancements.
Verification that Improvements Will Provide the Necessary Correc-o tions Without Introducing New HEDs A description of how it will ensure adequate human factors review, prior to sign-off, of DCRs and EDDs originating from the DCRDR.
Coordination of the DCRDR With Other Improvement Prograns o
A description of how it will ensure that the results and remaining methodologies will be coordinated and integrated I
among all emergency response capability programs.
o Analysis of Proposed Corrective Actions and Justifications for i
HEDs Left Uncorrected l
A description of the resolution of HEDs listed in Appendix A.
A description of the justification for not correcting HEDs listed in Appendix B, section 1.
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A description of its consideration of the cumulative and interactive effects of the HEDs listed in Appendix B, section 2 for HED assessment and resolution.
A description of the information referenced in the justifica-tion or of a new justification for the HED listed in Appendix B, section 3.
A description of the rationale user for assessing each HED listed in Appendix C.
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REFERENCES 1
1.
" Salem Generating Station Units 1 and 2 Control Room Design Review Program Plan," Public Service Electric and Gas Company, November, 1982.
2.
Letter from E.A. Liden, PSE&G, to S.A. Varga, USNRC, dated February 14, 1983, submitting Control Room Design Review Program Plan for Salem Generating Station Units 1 and 2.
3.
"NRC Review Comments on Salem DCRDR Program Plan," attachment to Memorandum from W.T. Russell, USNRC, to G.C. Lainas USNRC, dated October 7, 1983.
4.
" Detailed Control Room Design Review Report for the Public Service Electric and Gas Company, Salem Sta' tion Units 1 and 2, Volume 1:
Review Plan and Summary, Volume 2:
HED Documentation," December 30, 1983.
5.
" Evaluation of the Detailed Control Room Design Review Summary Report for Salem Generating Station Units 1 and 2," Science Applications, Inc., March 1934.
6.
"SER INPUT for the Salem Generating Station Detailed Control Room Design Review," attachment to Memorandum from W.T. Russell, USNRC, to G.C. Laines, USNRC, dated March 21, 1984.
7.
" Supplemental Information Detailed Control Room Design Review," includ-ed in and attached to a letter from E.A. Liden, PSE&G, to S.A. Varga, USNRC, dated September 18, 1984.
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8.
NUREG-0660. Vol.1. "NRC Action Plan Developed as a Result of the TMI-2 Accident," USNRC, Washington, D.C., May 1980; Rev. 1, August 1980.
l 9.
NUREG-0737, " Requirements for Emergency Response Capability," USNRC, Washington, D.C., November 1980.
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- 10. NUREG-0737, Supplement 1, " Requirements for Emergency Response Capa-bility," USNRC, Washington, D.C., December 1982, transmitted to reactor licensees via Generic Letter 82-33, December 17, 1982.
- 11. NUREG-0700, " Guidelines for Control Room Design Reviews." USNRC, Washington, D.C., September 1981.
- 12. NUREG-0800, " Standard Review Plan for the Review of Safety Analysis Reports for Nuclear Power Plants," Section 18.1, Rev.
O,
- USNRC, Washington, D.C.,
September 1984 l
l Salem 1 and 2 TAC Nos. 51298 and 51299 l
SAIC 1-263-07-557-61/62 NRC-03-82-096 r
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APPEhDIX A HEDs (by Summary Report, Volume 2 page number) in which corrective actions were proposed, but were found to be inadequately described or resolved, and require further documentation by PSE&G in order for the NRC to complete its review.
1.
The proposed corrective action as described by PSE&G during the audit discussions was found to be adequate but needs to be documented for NRC review.
50 176 314 452 482 156 251 369 477 161 270 370 479 172 284 378 480 2.
The proposed corrective action had not been determined at the time of the audit and should be finalized and documented for NRC review.
31 49 68 103 41 51 74 163 46 54 75 460 47 55 82 48 63 87 24
APPENDIX B HEDs (by Summary Report, Volume 2 page number) left uncorrected or partially uncorrected in which justifications were provided, were found to be inadequate, and require further consideration and documentation for NRC review.
1.
The original justification is unsatisfactory because it cites utility, industry, or manufacturer's conventions; cites absence of previous operator errors; cites perceived degree of deviation from NUREG-0700 guidelines; or simply states "no action taken" or
" satisfactory as is."
Justifications based upon operational and behavioral safety considerations / implications are necessary.
3 62 178 211 229 299 390 435 5
64 179 212 230 306 396 436 6
66 180 213 231 310 397 437 8
78 195 214 232 311 401 438 9
84 196 215 234 312 402 441 14 92 197 216 238 319 409 442 18 97 198 217 245 320 410 443 19 121 199 218 255 321 411 444 20 126 200 219 256 326 412 445 21 127 202 220 259 327 414 446 22 128 203 221 265 328 415 448 26 130 204 222 273 334 417 449 32 140 205 223 275 335 419 450 34 143 206 224 285 342 421 455 56 160 207 225 287 345 422 465 57 164 208 226 291 354 423 58 165 209 227 293 355 429 59 169 210 228 297 359 433 25
2.
The justifications of individual HEDs do not consider the cumula-tive or interactive effect from other HEDs. Due to the serious implications of the cumulative effects upon the potential for operator error and plant safety status, and as previously recom-mended in the March 21, 1984 SAIC TER, PSE&G should provide a justification or resolution for each of the five cumulative or interactive effects described below.
Although some of the indi-vidual HEDs in the listing may have been found to be adequately resolved, this does not exempt them from contributing to the cumulative or interactive effect and so should be considered in the justification or resolution provided by PSE&G.
a.
It is apparent that at least panels CC-1, CC-2, and CC-3 have layout problems. The HEDs identifying these panels described a multitude of discrepancies, such as (1) large or long groupings of controls and displays without any physical or visual break, (2) the arrangement of controls is not sequen-tially arranged, (3) a lack of functional grouping of controls and displays (4) unclear and inconsistent associa-tion of related controls and displays, (5) a lack of demarca-tion, and (6) a lack of hierarchical labeling.
PSE&G responds to each discrepancy by stating that either no cor-rective actions will be taken or that the discrepancy will be handled by training.
It is possible that perhaps one HED of this type may be able to be adequately resolved by training, but not entire panels consisting of several to many of these HEDs. The summation of the HEDs listed below indicates panel layout problems which transcend training as a sole source of corrective action.
At a minimum, operator aids such as demarcation and other enhancement techniques must be addressed.
CC-1: 128, 410, 412, 425, 429, 437, 444, 450, and 462 CC-2: 126, 127, 408, 413, 415, 426, 432, 433, 434, 438, 445, 447, 449, and 453 CC-3: 405, 406, 414, 431, 443, 447, and 448.
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b.
Individual HEDs discuss the location of controls and displays above and below the recommended range of location on panels RP-1, RP-3, RP-4, a nd RP-6.
PSE&G's justification for not taking corrective action on these discrepancies does not address the compounding effect the close proximity of these panels to the back of the console (p. 4 Vol. 2) has on the (1) readability of displays located higher or lower than the height recommended by the guidelines and (2) the operability and potential for accidental activation of controls located below the height recommended by the guidelines.
The avail-able workspace restricts the operators capability to improve the angle of his line of sight in a standing position by backing off and thus compensating for any parallax effects.
In addition, the space available for the operator to readily read the control label and operate the control in conjunction or succession with other controls may not be sufficient.
4, 9, 13, 15, 17, 18, and 19.
c.
Several HEDs cite discrepancies related to the operability of the computer /CRT system.
In summary, the operator does not have ready access to procedures and other procedural aids for operating the computer system in the control room. PSE&G essentially responds to these HEDs by stating that the procedures and cross indices for aiding in the operation of the computer are not used by the operator. However, if the operator interfaces with the computer system in a mode which requires procedural guidance, then the necessary aids must be readily accessible.
It is apparent from these HEDs that the.
operator does not possess readily accessible or attainable aids for operating the computer system.
386, 387, and 388.
d.
A number of HEOs cite labeling, illumination and other visibility / readability discrepancies in the control room.
Each HED individually may not represent a potential hindrance in reading labels and display, but the cumulative effect of 27
all these HEDs may present a real problem to the operator for reading labels and displays correctly or in a timely manner.
Two specific examples of where illumination problems may combine with labeling and display discrepancies to effect the visibility or readability of labels and displays are (1) the wind speed and direction recorders on RP-1 and (2) the fire protection legend indicators on RP-5.
In general, pSE8G response to these HEDs identified for these components may or may not create a problem. However, the combined effect of these labeling, contrast, and illumination discrepancies can potentially degrade the readability of the labels and dis-plays and thus the performance of the operator.
Illumination / contrast: 27, 28, 33, and 131 El 300' and 33' wind speed and direction recorders:
- 193, 202, 223, and 235 Fire protection legend indicators: 29, 177, 185, 214, 242, 243, 402, and 430 Others: 69 and 75; and 111.
e.
A number of HEDs discuss various discrepancies found with the annunciator system.
These HEDs cite alarms that are too frequent, too lengthy, and undistinguishable from other alarms and the auditory environment.
With the exception of one HED undergoing further investigation, PSE&G does not intend to take any corrective action.
The cumulative effect of these HEDs is a noisy environment in which the operator may have real difficulties in distinguishing individual alarms or perhaps some communications. PSE&G's justifica-tions for not taking corrective actions do not address cumu-lative effects.
34, 54, 55, 63, 64, 65, and 67.
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3.
The original justification refers to further documentation or sample date which was not furnished in the Summary Report.
Although PSE&G stated that the documentation referred to was too cumbersome to include in the Summary Report, it should provide all information referenced in the justification or provide a new justification which adequately addresses the HED.
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APPENDIX C The following HEDs (by Summary Report, Volume 2 page number) were found to have the potential to cause operator errors of either low or high proba-bility which could result in adverse plant conditions. However, these HEDs were assessed as Category IV HEDs.
We believe PSE&G should provide the rationale for this assessment of these HEDs.
6 58 119 428 446 8
62 405 429 447 18 65 410 435 449 22 66 415 437 450 56 67 422 438 453 57 114 427 445 455 l'
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APPENDIX D Attendees of Meetings Held During the Pre-Implementation Audit of Salem Generating Station Units 1 and 2 PSE&G Representatives Milton Allicock PSE&G Jay Bailey PSE&G Don Burgy GPC Cathy Gaddy GPC Larry Leitz PSE&G E.A. Liden PSE&G Jim McFadden PSE&G Bill O'Brien PSE8G R.S. Patwell PSE&G USNRC Representatives Dick Eckenrode USNRC J.C. Linville USNRC Tim O'Donoghue SAIC Dave Schultz Comex l
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