ML20117K946

Reliability Study

ML20117K946
Person / Time
Site:	Sequoyah
Issue date:	03/05/1996
From:	TENNESSEE VALLEY AUTHORITY
To:
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ML20117K930	List: ML20117K926 ML20117K938 ML20117K946 ML20117K951
References
NUDOCS 9609120257
Download: ML20117K946 (52)

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4 SEQUOYAH NUCLEAR PLANT RELIABILITY STUDY J"

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ADMTRATIVELY CONMDENEAL l

INTRODUCTION / BACKGROUND The Site Vice President requested that an assessment be investments in both personnel improvem why rge units. The assessment was structured to have four teams de e operating different sources and cross validate information Technical Support, Component Engineer am

nce, the latent hardware problems, review known hardware problem ermine why the carent hardware problems have not been corrected b o determine processes. The second team conducted a detailed review of e y relating to component performance to identify hardware p or organizational concerns. The third team performed an integra review of the heaters, drains, and vents system with respect system performance to identify hardware problems and programmat Independent Review and Analysis Departm lesser degree) to determine the underlying ca individual team findings, documents specif the good performance orperformance imp rrective ent Excellence in operations is the expected standard, anythi ssessment.

this report. Corrective actions are documentedin SQ960393PER n

findings from the integrated systematic rev is the common cause results from T charterfor this assessment.

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The five programmatic findings described have either directl will have an impact on SQN's SALP perform We output annually oa undenvayin some ofthe areas to correct performance but the tere measudng incremental performance change ough on corrective actions, ary corrections.

Station managers and supervisors have failed to consistentl the expected standards at SQN. Employees bo

, n support plant operations to standards during the course ofdaily work activities countable for achieving these Station managers and supervisors have failed to consistentl dependable, sustained operation ofthe units a operations includes the

'f minimal need for on-line corrective maintenance. Inherent in th assumption of a nuclear safety first culture.

operational definition is the Station managers and supervisors have failed to consistentl Especially troublesome is the lack of follow throug n a timely manner, entified corrective actions.

i The technicalinvolvement of the engineering organization i activities has been ineffective in improving plant reliability ands performance.

• Station managers and supervisors have failed to cons and organizational roles and responsibilities not and ss gned or not executed, unicated.

1 have a high probability of affecting future reliabil ve affected operational reliability or have the real potential to cause a two unit trip or p n operations. Three of the nine impacting full power operations. Recommendatio i

I wer probability of directly issues are contained in th b d e o y of this report, ressing the management and hardware b

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SON COMPARISON TO DESIGN STANDARD, DS-M2.5e1

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Dnry two Sc% especny he'Pa, opereeng exponenes Lees a8 MDPS =#RS indicartes enN obeut 86% per MPP T ee Bem 3 MDT & T MDT bypseeee emed ler Asl flow Leos 1 MDP LCV Yes bem & MDT & 7 MDT bypeasee saed ser hat new acSR _'n 4 Test Opn MA Drean iarme Com p Wefensee set avai4 male Mub Cepedty @ NWL 1 must 9106% NS33 NA Goed p trWercedes not availeese Floon Vent ^; -i 100% Pneenang @ 106% NS33 NA wfm APmDL3 pef Doesp Warenden not evallese 31sts head @ NWL Cruin le Carol @ &P=0 NA Ceesp Watsmies not aveJiamie l

teman Pumpe WIPumpssaedPer 100% Leed & Mas Domein AP i

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V Contacts for Heater Drains and Vent system:

Comparison ofHeater Drains and Vent system to other plants:

Plant Sequoyah Browns Ferry Zion Callaway D. C. Cook

_hygg Startup Year 1980 1971 1973 1984 1975 g9L#

NSSS W

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// of FW lienters W,BB W

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'F# Heaters w/ bypass to condenser 6 or21 6 ofI8 18 of 18 18 of 18 8 of 12 Heaterlevel controller redundancy 21 of 21 no no yes yes yes yes llDT/ pump forward systems double none single single single double

// ofcondensate & feedwater pumps 11 9

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pump redundancy no no yes no MSR reheat stages yes (exc MFP) yes (exc MFP) 2 0

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2 separate MFPT Condenser yes no no no yes (CCW yes (CCW WR4acklog-/ unit cooled) cooled) 90 50 50 40 20 25 contact Ken IIurt Joe Wheeler Rich Paul IIobbs Joel Jinesse Phil IIarwood telephone Goodman 423-843-7754 205-729-3618 847-746-2084 314-676-8310 616-465-5901 704-875-4683 ext 2313 Notes:

7 DC Cook:

2 strings of heaters, ride all heater during startup, Callaway: i ride all heaters during startup,3 strings of 4 LP htrs & 2 strings of 3 IIP htrs, only 2 sets ofcond/F l

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s FINDING ll Station managers and supervisors have failed to consistently ensure that e knowledgeable, and motivated personnel operate, maintain, and suppor expected standards at SQN. Employees, both supervisory and nonsupervisory, ha consistently assumed personal responsibility and been held accountable fo standards during the course of daily work activities.

BASIS:

The common cause assessment of124 level A and B PERs issued during 1994 indicated that, as a station, our personnel caused knowledee based errors a station average.

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Independent assessments of the site training programs have repeatedly found management involvement in and ownership of training.

j The PER common cause assessment concluded that the knowledge and expe operations crews, relative to normal clant operation. has declined in recent years the influx ofnew operations personnel and a reduction in systems training a training.

Secondary system transients and startup delays have been caused by Operatio having a less than adequate understanding of plant system operations or fa validate information. Examples include the water hammer in the extraction ste

" shocking" the RCP seals, opening the MSIVs against high delta P, response to fee heater string isolations when placing heaters in-service, and valving in the MSRs.

The common cause assessment concluded that (1) supervisors do not provide coaching or accountability, (2) craftsmen have inadequate skills or knowledge and, (3) cra'ftsmen do not fully understand or apply self-checking and questioning a techniques (STAR and QV&V). These deficiencies have resulted in improper / inc repairs, causing outage delays and system transients, challenges to system operatio startup delays. Examples include generator cooling flange leaks, stator water cooling temperature switch installation, feedwater regulator valve positioner air supply line failure condensate booster pump alignment problems, EHC setpoint change, heater d casing drain leakage, water box manway gasket leaks.

Interviews with station personnel indicated there is a strong perception that, acr (Operations, Maintenance, Engineedng, and management) knowledge of unit opera deteriorated.

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i CORRECTIVE ACTIONS:

Responsibility /

Due Date 1.

Site Vice President, Plant Manager, Engineering and Materials Manager.

and Business and Work Performance Manager review findmgs of this report All with their line supemsors and obtain a personal commitment from each that March IS,1996 they are accountable, personally, for the actions of their employees and they will be held accountable for their subordinates performance. Specifically, supervisors are responsible for ensunng that employees possess demonstrated knowledge and experience using the proper tools and procedures to perform unsupervised tasks at

. SQN, and that the expectation of the performance standards are clearly stated to the employeejust prior to performance of the task. Contracts requiring signatures will be enended down by March 15,1996.

2.

He Operations Manager and O ie'ra~tions line supervisors will ensure that l

Operations personnel with demonstrated knowledge and experience will perform Greg Enterline

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i or supervise the performance of any activity described in the Sensitive Activities March 31,1997 Manual. The Operations Manager will further ensure that Operations training, retraining, and performance monitoring programs gain, maintain, and measure knowledge and experience to reduce knowledee based errors by 70% by the end of the first quarter of calendar year 1997 Operations Manager will develop a balance ofplant requali5 cation training program incorporating systems and/or component engineers utilization.

Greg Enterline April 1,1996 Opentions Manager will revise the Sensitive Activities Manual to focus on unit.

reliability improvement and to procedurahze supervisor responsibility.

Greg Enterline March 22,1996 3.

The Maintenance Manager and Maintenance line supervisor will ensure that craft personnel with demonstrated knowledge and experience will perform or supervise the Dave Brock performance of any activity described in the Sensitive Activities Manual. The March 31,1997 Maintenance Manager will further ensure that maintenance tmining, retrauung, and performance monitoring programs gain, maintain, and measure knowledge and experience to reduce the knowledte and rule based error percentage by 30%.

Retrain Maintenance supervisors and craftsmen in STAR and QV&V by stan of U2C7 Dave Brock Increase'the amount and quality ofSeld supervision.

Start ofU2C7 Complete 4

Reissue the, SQNPersonnel Accountability Guidelines and utilize the Guidelines to hold all employens and line supervisors up to and including the department managers Bob Adney accountable for human performance errors.

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l FINDING 2:

Station managers and supervisors have failed to consistentl objective of excellence in operations. Excellence in operat operation of the units at full power with no operator challenges ncludes the dependable, sustained corrective maintenance. Inherent in this operational definition i th safety first culture.

e assumption of a nuclear i

s BASIS:

.. Department budgets and personal resource allocatio i

in operations. A review of the capital budgets over the l Security, Bomb Barriers, Fire Protection, Ch arget excellence o ects. Examples include:

and other Engineering reconciliation upgrades. The review ale, Civ review of the operating budget found the b i

o retums were too low. A that task budgets focused on individual department n ased on covering payrolls and reliability needs.

eeds rather than supporting specific plant implement routine operational, maintenance o priontize, plan, review, and SQN's tool to optimize the one team concept. The PER re iactiviti employee interviews, indicate that the site departments are notv ew 12 WeekRolling Schedule a success. Lack ofparticipatio working as a team to make the inconsistent understanding ofroles and responsibiliti n, conflicting priorities, and optimum daily schedule performance.

es are contributors to the less than The design impact re.b modification prior to impa neatation. PER reviews and per ant numerous examples of tL faihre of one or more team membe nnelinterviews provided esort.

rs to support the whole team CORRECTIVE ACTIONS:

Responsibility /

Due Date 1.

Reestablish focus areas and adhere to them Capacity factor improvement and SALP improvement driver Jim Baumstark/

U2C7 outage should be a close secondnumber 1. Nuclear safety s should be Frank Fink

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March 15,1996 it is the feedba:k loop to improve on 1 and 2 Problem iden J

priority since Fiscal responsibility and selective process improvement should come next Restructure the PRM and/or MRC to evaluate performance i th f n e ocus areas.

Jim Baumstark/

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Frank Fink April 13,1996 I

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Reestablish a plan-of-the-day type meeting chaired by the Flant Manager team members with the focus on plant operations. D Jim Baumstark Complete The code of conduct (standards, expectations, re s should be authority, commitment, and accountability) should be the inunework to caus change. Daily scheduling should be reviewed similar to an outage me 3.

Prioritize the FY 1997 Capital and O&M budget by the focus areas and a task based budget to support those priorities. Reflect this philosophy in the p

Frank Fink SQN FY 1997 Business Plan. Supervisors shon1d ensure that resources April 13,1996 expended on any task that does not support SQN focus areas.

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focus areas. Include in the report maintenance WR i are Frank Fink distractions (e.g., work arounds, lit annunciators) system health mainte May 1,1996 rule performance, and unit generator / capacity factor performance nance FTNDING 3:

Station managers and supervisors have failed to consistently ensure

g. troublesome is the lack offollow through on identifi dp equipment and personnel e corrective actions..

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BASIS:

Ineffective root.cause investigations, inadequate recurrence control temperature switch, bus duct gasket, exciter pro n mely corrective a or cooling water lost-capacity events from 1 string isolations, CCW pump trips, m ea ages, feedwater heater or had known precursors. 993 to the present indicate more than half w collective review of The lack ofinvolvement and oversight of management and site pe

. Customer Group support activities has resulted in equipm nelin vendor and capacity losses (voltage regulator analysis, EHC power supply setpo p ant repairs, bent thermocouple column, PMG ground straps, switchyard adjustments, exciter and relays, Westinghouse work on EHC RH/IV closure) rs, transformers Previous evaluation actions and program recommendations to imp Specifically, some recommendations from prev e site and plant eam.

after several years. Predictive and preventive maintenance actions a n unimplemented modifications are still in some cases in the planning stages.

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CORRECTIVE ACTIONS:

Responsibility /

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Due Date 1.

Reissue incomplete corrective actions identi5ed in previous reliability effons Bill Lagergren (May 17,1993, SWEC BOP Design Study; June 4,1993, SQN Secondary Plant March 8,1996 Reliability Study; and 1995 Draft Rehability Team Report)

Provide the reason for not implementing the action in writing to the Plant Individual Corrective Manager or provide an action plan for implementation.

Action Owners March 22,1996 2.

Revise and update quarterly the SQN Business Plan to include speci5e Frank Fink reliability improvement corrective actions. Each corrective action will March 29,1996 include an owner with due date. Department managers performance appraisals will be adjusted quarterly to reflect performance against these due dates. The actions will:

address root cause(s) be cost effective can be implemented in a timely manner 3.

Revise SSP 3.4 to include personnel quahfication requirements, for performing Jim Baumstark equipment root cause analysis.

March 15,1996 Train individuals im problem.iolving techniques.

Jim Baumstark July 15,1996

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Review an' redise Customer Group interface agreements to improve Dave Brock d

equipm nt performance problems and reduce plant capacity factor losses.

July 19,1996 5.

Review and revise Partners In Performance agreements to improve Dave Brock equipment performance problems and plant capacity factor losses.

July 19,1996 FINDING 4:

The technical involvement of the engineering organizations in maintenance. and operational activities has been ineffective in improving plant reliability and performance.

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Interviews with numerous Operations, Maintenance, Radeon/ Chemistry, and Scheduling

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personnel indicate a dissatisfaction with the level of nonemergency support from the engineering groups, both in day-to-day support and in the anticipatory look ahead reliabihty improvement area.

Based on plant operational performance, insuscient engineering resources are focused on l

activities which contribute to future plant performance and operating improvements. For example, little time is being allocated to address impending equipment obsolescence and aging, adequacy of spare parts, understanding and minimizing plant hardware vulnerabilities, analyzing corrective maintenance and repetitive problems to adjust PMs. Additionally, technical oversight to vendors has been insu5cient to ensure component reliability.

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. ' Ex/amples where a proactive look ahead or close oversight of vendor task would ha prevented past MW losses include extraction piping failures, main steam check valve failures, numerous excitor and voltage regulator failures, pressurizer safety valve leakage, condenser ugprades,. numerous turbine control failures, reactor motor and seal failures, steam dump fail 6res, and water intrusion into control air system.

Examples of'some areas where actions are underway that are correcting future reliability' issues (to date have not affected MW output) include MSIV upgrade integrated computer, feedwater chemical addition efforts, and CCW bearing tube

. water upgrades.

The SQN process (TFARs) for factoring corrective maintenance experience into the

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preventive maintenance program has been ineffective. Of over 5,000 trend reports identified since 1991, only 40 corrective action plans were developed (it should be noted that some 1

I trend reports were dispositioned by reference to existing corrective action plans). In the validated conditions were dispositioned by one-time co~rrective maintenance o MIL issue. In only a few cases was the PM program even reviewed or modified.

A revieiv of the actual schedule performance and the schedule development for the T-6 to the l

T-0 schedule indicates that a lack of engincedng involvement in the maintenance plann{

scheduling and materials procurement processes has resulted in prolonged troubleshoo diversion ofmaintenance resources. Examples: approximately 20% ofMIG work orders are closed with no problems found; an average of16 work requests are removed from the schedule weekly for lack of materials in the T-6 to T-0 schedule; participation of engi personnelin scheduling meetings is marginal.

1 Lack of engineering involvement in corrective maintenance field activities has in some cases

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resulted in poor cau'se analysis, delayed problem resolution, and has allowed repeat probl

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i This lack ofinvolvement was especially problematic in systems where Sequoyah does not or did not possess technical knowledge comparable to either a vendor or to a service provide such as the Customer Group. Examples include: RCP seals, CCW pump motors, main bank transformers, common service station transformers, switchyard breakers, EHC systems, main generator and vendor supplied support systems and components, rod control systems, and reactor trip breakers.

CORRECTIVE ACTIONS:

I Responsibility /

Due Date 1.

Reassess the engineering involvement in and support of maintenance planning, Marcia Cooper /

maintenance performance, maintenance problems analysis, trending and Mike Cooper /

data analysis to adjust the preventive and predictive maintenance progam.Mark Bur::ymki August 1,1996

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Revisit / deft c 'aaa*****at expectations for reliability, specifica!Iy the responsibilities and !=d== of TSS, CE, Scheduling' Maintenance, Outage Mea g*=--'. Project Management, Operations, and Engineenng and Materials.

(Place special emphasis on those programs or orramntions that have undergone changes in scope and nsponsibilities in the last three years and do not limit the review to only plant reliability responsibilities.) Include the following:

depth ofsite experience utilintion ofoperating experience trending e

proactiveness -

total system overview responsibilities e

PMs component failure and aging data e

equipment obsolescence j

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pans and materials sensitive equipment.(WR/WO reviews) e vendor manuals thermal perfcrmance e

In the interim, a number of actions to improve engineering effectiveness have been taken and are ongoing. These include establishment of engineering unit interface supervisors to focus day-tcKiay engineering support; conduct of ongoing engineenng/customerinterface meetings to establish agreement on responsibilities and priorities; Technical Support reevaluation and establishment ofMission, Values, Roles, and Responsibilities; increased resource focus on and reinforcement

/r of predictive / preventive activities; development of an Equipment Root Cause Program including additional root cause training and management oversight; i

improved formality and review of engineering communication (i.e., recommendations, j

action plans, operability evaluations, etc.); and establishment of more spectfic l

performance goals tied to plant reliability.

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2. Establish a U2C7 hit team to evaluate knowledge based errors spectfic to reliability improvement systems. The team will assign actions to the Larry Bryant i

Maintenance Manager t'o provide support in questionable areas.

April 1,1996

3. Perform an additional review of the trip snesitive systems to ensure that any Marcia Cooper I

component or subcomponent that is at or near end oflife or has been j

prior to U2C7 exposed to adverse operating conditions (overvoltage, heat, etc.) be replaced.

Additionally, any component or subcomponent that has demonstrated past I

reliability problems should be replaced. Recommended systems include:

Main Steam System, i

Feedwater and Condensate Systems l

Extraction and Heaters, Drains, and Vents Systems i

Main Turbine Lube Oil System I

Condenser Circulating Water System Control Air System Stator Cooling Water and Lube Oil Systems i

Main Feed Pump Control System j

' Electro Hydraulic Control System Main Generator and Exciter ElectricalDistribution Systems

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j Main Bank and CSS Transformer and Other Switchyard Components and Relays i

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FINDING 55 Station managers and supervisors have failed to consistently manage orga changes. This has resulted in essential activities being unassigned, not executed, an organizational roles and responsibilities not clearly communicated.

BASIS:

Following an organizational realignment that moved engineers out ofMaintenance responsibility for spare part identiScation andinventory maintenance, and PM program technical ownership was not clearly reassigned.

The assignment ofnew Operations personnel to shift supervisory positions did assess the potential impact of the lack of"in-plint" operating experience on plant and~ ~

personnel performance.

During outages, experienced field supervision of maintenance activities is significa reduced. Experienced craft personnel are elevated to. temporary foreman statu craft hired for maintenance support. The net result is an overall drop in craft and experience.

Transition of'the obsolete /agirig equipment program into the MIL system and the los program. owner resulted in an ineffective obsolescence program.

A number ofprograms and processes have changed over the last 18 months to reduce cost and improve productivity. With each change a number ofPERs have been generated becaus of failure on our part to implement the new processes as designed. The transition pro not being managed effectively (12-week scheduling process, clearance process, bu process, maintenance performing mods process, etc.).

The management team is allowing peripheral, nonplant reliability issues to take up a fraction of their time (process standardization,360 feedback, responding to outside assessments,. recovery efforts from personnel and/or equipment problems, nonproductive meetings, or other activities that are outside daily plant operations or site focus areas).

CORRECTIVE ACTIONS:

Responsibility /

Due Date 1.

Provide a management training course in implementing change.

Mark Shephard June 15,1996 Note: Other corrective actions for Finding S are addressed in Findings 1 through 4.

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6 ATTACHMENT 1 i

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Ha iware hsues

1. Numerous heater string isolations, loss offeedwater flow and subsequent reactor trips have occurred due to the inability of the No. 2 feedwater heaters to " pump up hill" to the No. 3 heater drain tank at low power levels.

• . Design FY 1997,1998; Implementation U2C8, U1C9 Owner: Darrell Widner, Project Management

- 2. In 1992 and again in 1995, electrical faults in the switchyard resulted in multiple condenser circulation water pumps tripping. The ensuing loss of condenser vacuum has resulted in turbine and reactor trips.

Study complete; Design FY 1996; Unit 1 implementation by end of U1C8 (pump 1C already complete); Unit 2 implementation is complete Owner: Donna Wilson, Project Management

3. Yarway Valves for the heater drain tank pumps and condensate pumps are a. continual source of problems due to the valves leaking through. These valves have been rebuilt with vendor supplied parts under vendor supervision. Leakage causes lost megawatts and possible pipe j

failure due to vibration. The condensate booster pump recirc line is currently isolated on Unit 1.

Design FY 1997,1998; Implementation U2C8, U1C9 i

Owner: John McPherson, Project Management

4. The main feed pump recirculation control valve is manually isolated due to leakage and the resulting flashing and pipe erosion down stream of the valve. This item is also a major Operator workaround. Also, valve 3-70 is experiencing hi-vibcation during startup after the installation of the breakdown orifices to resolve the flashing problem.

Study FY 1997; Design FY 1997,1998; Implementation U2C8, U1C9 Owner: Ross Malone, Project Management

5. Numerous turbine / reactor trips have occurred due to, spurious main transformer sudden pressure relay and gas operated relay actuations. Although the most recent trip has been isolated to inappropriate maintenance activities, multiple events with multiple " fixes" have been tried over the last 10 years but events continue to occur.

. Study underway; cause analysis complete; fix has been identified; management presentation planned for 4/10/96. Completed Owner: Frank Cuzzort, Technical Support Review switchyard design basis Owner Frank Cuzzort, Technical Support - Complete 9/30/96

6. The cuno filter for the seal oil system is a potential single point failure. Clogging of the filter has nearly resulted in loss of hydrogen two times within the last three years. Loss of hydrogen would result in hydrogen fires at the main generator shaft seals due to seal loss. Also, the present 61ter design does not allow for maintenance activity on the filter while the generator is pressurized with hydrogen. Redundant filters have been installed at other plants to eliminate this failure potential.

Design complete; Implementation U1C8 (Unit 2 complete U2C7)

Owner: Donna Wilson, Project Management

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t HardwareIssues i

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7. The No. 7 heater drain tank (HDT) has experienced difficulty in optimum performanc resulting in plant perturbations including reactor trips. Problems: no tank flow indication the main control room (MCR) to allow early detection of problems; poor performance obsolescence of the 6-190A spillover valve.

Provide No. 7 HDT Flowin the MCR No. 7 HDT Opt' nization I

u Design FY 1997,1998;Impi U2C8, UIC9 Design FY 1998;Impt UIC9, U2C9 e

Owner: Donna Wilson, Proj Mgmt Owner: DonnaWilson,ProjMgmt i

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8. Sequoyah has a generator trip for generator power imbalance protection which We j

states is no longer needed. The circuit has caused a turbine trip when a circuit compo failure and resulted in the intercept valves closing. This circuit has been de-activated on l

Unit 1.

Design complete; Implementation completed U2C7 - everything complete Owner: Ron Gladney and Roswell Schnur, Technical Support

9. The Sequoyah WTA voltage regulator has aging and obsolete circuit board components Electronic subcomponents on the existing cards and modules are nearing (in some c oflife.

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Design FY 1997,1998; Implementation U2C8, UIC9 e

Owner: Ross Malone, Project Management e

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10. The feedwater heater level control valves and positioners are obsolete and unreliable.

Smdy FY 1997 Owner: Doug Craven, Ops Support, Nuclear Engineering / Donna Wilson, Proj Mgm e

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11. Condensate booster pump (CBP) suction pressure switches have water leakage in j

i box; causing repetitive switch failures and calibration problems. Since this switch is p i

the CBP trip circuit, an inoperable switch could lead to pump failure and condensate j

due to spurious pump tripping.

l Study FY 1997 e

i Owner Doug Craven, Nuclear Engineering-OSG/ Donna Wilson, Proj Mgmt e

12. The main feed pump and turbine vibration monitoring is nonfunctional and obsolete. Advanc warning for eminent equipment problems is inadequate.

Design in impact review; Implementation U2 in progress, U1C8 Owner Bob O' Bannon, Maintenance 4

13. Transients in the steam seal system have contributed to several startup delays. Rep problems include the inability for the steam seal system spill over valve and the steam seal control valve to operate smoothly, causing excessive amounts of steam flow in spill over headers; undersized motor operators on FCVs; no control feedback for PCVs.

Repl Motor Operators 1&2-FCV-47-180,181 Add Position 1&2-PCV-47-189 e-Design FY 1997,Impi U2C8, UIC9 Design FY 1997,Impi U2C8, UIC9 e

Owner: Donna Wilson, Proj Mgmt Owner: Donna Wilson, Proj Mgmt

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Hardware issues

14. The station air compressors are unreliable and are high maintenance items.

i Study complete; Design FY 1997, Implementation FY 1997,1998 Owner: Darrell Widner, Project Management

15. Some of the electro-hydraulic control cabinet circuit boards electronic subcomponents are approaching end oflife.

Initiate WR's; Implementation U1C8, U2C8 Owner: Roswell Schnur, Technical Support e

16. Multiple single point failures exists in the balance ofplant, especially in the main feed pump (MFP) controls. Many utilities (Callaway, South Texas, Calvert Clifts, et. al) have designed redundancy into the MFP.

Design FY 1999; Implementation U1CIO, U2C10 Owner: John McPherson, Project Management

17. The filtered water source for the normal bearing lube water pumps is the otherwise abandoned MWPT sandfilters in the old water plant in the turbine building. These filters have failed several times causing draining of the clear well tanks and use of the emergency pump to supply bearing lube water. A failure of the emergency pumps in conjunction with draining of the clearwell tanks could effect operation of the CCW pumps and force a dual unit shutdown.

r Study complete; Design and Implementation FY 1997 Owner: Ross'Malone, Project Management

18. Modifications has been made to the PSRV tailpipe hangers to minimize nozzle loads, to pressurizer cubicle ventilation and to PSRV trim. The PSRVs still periodically exhibit leakage during pressurization to NOTI \\ resulting in startup delays.

Study in progress; Design FY 1996,1997; Implementation U1C8, U2C8 Owner: Ron Skelton, Project Management e

19. Recent failure ofRCP seals and motors have resulted in startup delays and forced outages.

Common cause analysis has been completed. Corrective action documents have been generated and dates for corrective actions implementation are being developed.

Owner: Ed Barels, Component Engineering / Mike Lorek, Nuclear Engineering

20. Preventative maintenance techniques for the main generator exciter has been inadequate to assess degradation and enable corrective action to be taken prior to equipment failure.

Completed as identified in SQ952333PER.

Owner: Gary Buchanan, Technical Support

1 HardwareIssues

21. Due to the high voltage from the batteries, numerous BOP relays are exposed to the 270 V

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potentially leading to degradation and premature failure. In addition, the 125 V system has similar high voltage.

l Technical suppon reviewing potential for damaged components. Scheduled to complete by 11/22/%.

Owner: Gary Buchanan, Technical Support Implementation station battery project - in progress, complete FY 96 Owner: Ross Malone

22. The 71L3 relay for the No. 3 HDT NPSH trip is normally energized. Failure of this relay would cause all 3 No. 3 HDT pumps to trip and result in a unit runback or trip due to the resulting transient.

WRs initiated and relays replaced in 1993. Recent review indicates relays are still reliable and rated for continous duty.

Owner: Ken Hurt, Technical Suppon

23. High temperatures in the turbine building during the summer leads to premature equipment aging. Also consider sensitive electronics adjacent to steam lines.

Systems Engineers have started a review for sensitive components. Scheduled to c

e complete 11/22/96 (both units).

Owner: Mark Skarzinski, Technical Support Manager

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l Project Pian forIntegrated Sequoyah Capacity FactorImprovement Assessment Investigation Team 3 System 6 ( Heaters Drains and Vents) Vertical Slice Vertical Slice Focus Areast A.

System 6 Design

- System Description / Design Criteria Document

- FSAR Description

- Drawings

- Vendor Information

- Component Specifications

- Calculations

- Configuration Control

- Design Limits and Operating Requirements

- Problem Reports

- SQN Comparison to Design Standard, DS-M2.5.1

- SQN Comparison to Other Sites B.

Material Condition of System 6

- TACFs

- Current Open WR/WO Evaluation

- Labeling

- Obsolete and Aging Equipment

- Maintenance Procedures

- Open Modifications

- U1 Downpower/ Trip System Comparison for 1992,93,94,& 95

- WR/WO System Comparison for 1995 and Complexity Relationship

- System 6 Open WorkItem History for Past-18 Months j

- System 6 Open WorkItem Evaluation for 1995 J

- Site Maintenance Backlog for Past 6 Months

- Site Non-Outage CM WR's/WO's By Maintenance Rule

- Site Non-Outage CM WR's/WO's By Age

- System 6 Problems Between 1-1-94 and 12-31-95 Based On SQN Unit 1 & 2 Operational Summaries i

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ProgrammaticIssues Associated With System 6

- WR Priority /12 Week Schedule

-Modification Priority System

- Operating Experience

- Review of SSP-8.50, Conduct of Technical Support

- Configuration Check ofFlow Prints D.

OrganizationalInvolvement With System 6

- Operations

- Engineering

- Technical Support

- Component Engineering

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- Maintenance

- Planning E.

. Quality ofProcedures/ Drawings Associated With System 6 F.

PM Adequacy of System 6 f:

-PM HistoricalPerspective

- Scheduling

- TechnicalInput

- System 6 PM Health

- RCM Program

- Maintenance Procedures G.

Parts Adequacy for System 6

- System 6 Parts Availability Problem Survey

-Who Is Responsible For Parts Survey

- System 6 TIIC Random Sample Survey

- WRs/WOs Removed During Schedule Development Process Due.To Material Problems H.

Operations Related Items Associated With System 6

- Operator Training

- System Operating Procedures and Prints

- Con' trol Room Deficiencies

- Work Arounds

- Sensitive Equipment Issues

- SpecialInformation/ Knowledge Required to Operate System

- System Abuse Caused by Operating Philosophy

- Complexity Relationship Between SQN and Other Plants

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Previous BOP Reliability Studies and Associated Recommendations

- May 17,1993 SWEC BOP Design Study

- June 4,1993 SQN. Secondary Plant Reliability Study

- 1995 Plant Reliability Team Report J.

Past Failure Recurrence Control Associated With System 6 Vertical Slice Findings:

1.

The prioritization and scheduling of maintenance and modification work is not aggressively focused on improving plant reliability.

2.

Site skills need to be strengthened to improve reliability.

3.

Parts / material availability is not structured to support plant reliability.

c.

4.

Communication / interface (information transfer) between departments needs strengthened.

5.

Integrated site organization responsibilities necessary to maintain high plant reliability have not been effective.

6.

Sequoyah management does not adequately promote proactive thoughts and actions.

7.

Technical Support does not take an adequate role in ensuring systems are maintained reliable.

8.

Component Engineering does not take an adequate role in ensuring plant' components are maintained reliable.

Sequoyah does not have a formal aging and obsolete equipment program.

10.

Communication of Standards -Management sends mixed messages relative to standards and expectations ofindividual performance related to reliable system operation.

11.

Technical overview of the PM program is inadequate.

12.

System Design-The design bases for system 6 are not well documented and the design is more complex as a result of original design focus on cycle efficiency and not retiability or maintenance.

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13.

The site did not effectively complete recommendations identified during previous BOP reliability studies.

Attached Data:

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SQN Comparison to Design Standard, DS-M2.5.1 2.

Complexity Relationship Between SQN and Other Plants 3.

Production Schedule. Performance, WRs/WOs Removed From Schedule During Schedule Development Process l

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Project Plad for Integrated Sequoyah Capacity FactorImprovement Assessment 1/14/96 l

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l Project Plan forIntegrated Sequoyah Capacity FactorImprovement Assessment 1/14/96 Objective j

To immediately correct identifiable plant component deficiencies that are determined to exist at Sequoyah Station which may result in continuing challenges to stable plant operation. Additionally, conduct a detailed comprehensive assessment of the Sequoyah Stations components, systems, processes, and organizations. The purpose of this portion of the assessment, in addition to identifying i

potential hardwa' e issues, is to identify the underlying common causes of the ongoing continuous r

challenges to stable operation caused by equipment, processes, and organizations. Once these common causes are identified and validated, effective corrective actions will be developed to ensure j

long term component reliability. This will be accomplished by improving' identified process i

breakdowns and organizational ineffectiveness which will ultimately improve overall plant availability through more stable plant operations.

Background

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Although steady improvements continue to be made in numerous areas throughout the Sequoyah Station, superior station performance is constantly being challenged by overall low component reliability. Evaluated individually each event may appear random in nature and isolated in occurrence.

However, when viewed collectively by overall plant performance it is obvious that component reliability is not satisfactory compared to industry high performing analogues.

Significant resources have been applied through various previous initiatives focusing on reliability l

issues and single failure type items. These initiatives have been successful, however, plant performance continues to suffer due to component unreliable operation particularly related to balance ofplant systems. Senior station management has recognized that a different approach is needed to l

r.ssist in resolving this long standing problem. The approach agreed upon as described below is that l

multiple parallel paths will be pursued concurrently to ensure a complete root cause analysis of the cause(s) ofunreliable components.

Approach The below described approach to performing this integrated investigation is based on the following i

assumptions:

component maintenance in the form of adequacy of past and cunent preventive maintenance activities or component trending have been or continue to be insufficient to prevent detection and conection of component failures, a

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Projtet Plan for Integrated Sequ:yah Capacity Factor Improvement Assessment I/14/96 Component maintenance in th$ fortr. of corrective maintenance adequacy hav less than fully effective to prevent recumng component failures, maintenance work practices, craft skills, and organization.to organization deficiencies may be contributing to the less than effective component maintenance since these are common to both preventive and corrective maintenance, incorrect operation with respect to how the original design had intended them to be operated may be contributing to premature component failures,

~~

lack of effective root cause analysis for failures may as a minimum fail to predict, therefore, prevent new failures and inappropriate corrective actions may actually contribute to increasing the failure population prematurely, lack of a' rigorous, integrated (operational, maintenance, design) review on a systematic requirements basis has never been performed. Therefore, the potential c

exists that incorrect component integration is resulting in premature failures, ineffective prioritization ofmanagement attention to emerging maintenance items that do not immediately impact plant production potentially has resulted in low sensitivity, therefore, less than adequate concerns over certain plant components, lack of an effective station work prioritization process has resulted in resource allocations that have not obtained measurable capacity factor improvements, lack of effective monitoring for adverse trends with re';pect to repetitive maintenance problems and or non safety system component.,ertormance may be allowing less than

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acceptable overall plant performance to exi;t over time.

Since these assumptions involve; equipment failure issues, individual worker skills, possible programmatic de5ciencies, and integration irregularities the investigation must be completed in a fashion to address all of these potential" drivers" to component unreliability. Once all of these areas are investigated then the common causes behind the majority of the contributing factors may be determined and corrected. Tnis approach to the investigation will ensure that as individual items are determined, those resulting in less than desirable component reliability, will individually be corrected.

Additionally, the common causes (potentially the work practices, programmatic issues, or organizationalinefficiencies) which have been allowed to exist and have resulted in low component reliability will also be resolved. Tne investigation therefore, will be divided into four main approaches as described below. These are allintended to be performed in parallel during a three week period.

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Project Plan forIntegrated Siquoyah Capacity FactorImprovement Assessment 1/14/96 Investication Team 1 This team lead by Mike Lorek will conduct a series of group discussion sessions with personnel in each of the following major disciplines: Operations, Maintenance, Technical Support, Component Engineering, and Nuclear Engineering. Each of these group discussion sessions will be structured and facilitated in a similar fashion to perform the following. Attempt to surface any known potential repetitive plant problems that are cmrently thought to exist or which might exist in the future.

Attempt to detemune the underlying reason why our normal processes, programs, or organizatiolial structures h' ave prevented these from being identi5ed and fixed previously. Use actual case studies pertinent to the subject group' which have occurred recently in the plant and ask the group to identify why they believe this problem or type of problem could have occurred. Attempt to identify how managers track plant concerns or repetitive failures such as those being discussed and how they know ifitems are being tracked or not.

Mike Lorek and Tom Nahay will be the facilitators for each of these group discussion sessions along with one or more credible members of the staff participating in the session. The objective of these sessions is three fold. First is to identify possible organizational and programmatic causes that are inhibiting our abilities to selfidentify and correct problems. Second is to help identify potential new failure items which might exist in the plant. Thirdly is that common themes across all the sessions will be evaluated to assist in long term corrective measures to increase overall component reliability and successful system operation.

Investigation Team I will produce the following results upon completion of this portion of the assessment:

1)

Consuuct a list of common concern areas identi5ed by each group with relationship to work processes / programs and organizational desciencies which the group feels may be resulting in problems not being resolved.

2)

Alist of potential hardware desciencies identified by the individuals participatirg in the group discussions. Each item, if possible, should be tracked by who, or at least what group, identified the potential problem so that if additional information is required to further identify the concern additional information may be obtained from the originator. This list will subsequently be evaluated for inclusion into a master items list for correction of deficiencies.

j 3)

Upon completion of the group discussion sessions construct a matrix ofidentified programmatic and organizational concerns by group along with a listing of hardware

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problems which were identified.

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Project Plan for Integrated l

Sequoyah Capacity FactorImprovement Assessment l

1/14/96 Investication Team 2 Dennis Lundy as Investigation Team Leader will conduct a detailed review of existing data sources relating to component performance in each of the following areas: Operations, Maintenance, Engineering / Materials. Data sources such as Business Plan, 39 Capacity Loss Events (93-95), Plant trip near misses, Con 6guration PER's, Selected PER's in the area'oT e~ valuation, work prioritization, procedure / clearance errors, system problems (ops, maint, eng/ material) blue card observations, enernal agency reviews / reports, system health reports, repetitive problems, previous reliability study results, work around lists, temporary modi 5 cations, NPRDS, open PER currently under evahiation by Paul Trudel of Tech Support concerning refueling outage identi5ed component failures, review of maintenance items being deferred from U2C7 refueling ~ outage work list, review of future design changes for partial implementation, etc.

Each area would use an integrated team approach (Sequoyah, Corporate, Browns Ferry) personnel to assist Dennis in review of the data and determination of the issues which are important to that area.

l Dennis will make final recommendations to the overallinvestigation lead. Both individual hardware items to be corrected along with common generic concerns would be compared to the Endings and recommendations of the other teams.

Investigation Team 2 will produce the following results upon completion of this portion of the assessment:

1)

Construct a list of common concern areas identined by each group with relationship to work processes / programs and orgamzational desciencies which the group feels may be resulting in problems not being resolved.

2)

A list of potential hardware de5ciencies iudicated as potential items to be corrected to increase component reliability. Each item will be tracked by the group and data source which originally identi5ed the potential problem so that if additiona!

information is required to further identify the concern that information may be obtained from the originator. This list will subsequently be evaluated for inclusion into a master items list for correction of desciencies.

3)

Upon completion of the data review sessions construct a matrix of identified programmatic and organizational concerns by g oup along with a listing of hardware problems which were identi5ed.

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l Project Plan forIntegrated Sequoyah Capacity FactorImprovement Assessment 1/14/96 Investigation Team (s) 3 4

Team leader Mark Skarzinski will perform an integrated systematic review of the heater vents and drains system with respect to all aspects of that systems performance: operational, maintenance, and design. This system was chosen from the complete list of balance of plant systems for numerous reasons. The review will identify not only the specine concerns that might be. impeding reliable

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_ operation of this system but the larger'orbimntional and programmatic issues that might be generic to all systems. The individual hardware and procedural problems along with any generic programmatic and organizational concerns will be used to compare to the common Endings of the other Investigation Team fmdings. Special orgamzational or training needs associated witi:

operations of a complex balance of plant system will be evaluated.

The method for conducting this detailed systematic review will be based on an approach used at other sites.such as Oyster Creek which have conducted similar reviews of systems. Based on the overall fmdibgs resulting from this single system evaluation and the overall investigation determinations, i

j additional systems may be suggested to undergo this similar review.

l Mark will utilize an integrated review team consisting of Operations, Tech Support, Component j

Engineering, Nuclear Engineering, Maintenance (PM, Planning, Craftsman), and Materials to ensure a thorough evaluation is made of all aspects of system reliability.

Investigation Team 3 will produce the following results upon completion of this portion of the assessment:

1)

Construct a list of common concern areas identi5ed by the review with relationship to work processes / programs and organizational de5ciencies which the group feels may be resulting in problems not being resolved on the system.

2),

Alist ofpotential hardware de5ciencies identined by the evaluation team. Each item will be tracked by the reason for identi5 cation and the potential problem which will result, if not corrected, so that if additional evaluation is required to further help prioritize the concern this data will be readily available. This list will subsequently be evaluated for inclusion into a master items list for correction of desciencies.

3)

Upon completion of the detailed review construct a matrix ofidenti5ed programmatic and organizational concerns by area of concern along with a listing of hardware problems which were identifed.

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Project Plan forIntegrated Sequoyah Capacity FactorImprovement Assessment 1/14/96 Investigation Team 4 US l

Jerry Robertsongorm a common cause analysis on the more significant events which occurred in l

1995 and produce a resulting conclusion of the root causes of these events. This would involve a l

detailed review of significant events from 1995 such as I'ER's, NOV's, PER's with root cause analysis to determine the underlying causes for these events. This will assist in determining the underlying reasons for recent events and how these causes compare to the findings of the other i

aspects oftht! investigation.

j i

Investigation Team 4 will produce the following results upon completion of this portion of the assessment:

l 1)

A detailed analysis of the various causes of the analyzed problems in various areas such as: causing organization, work process / program, organizational and l

programmatic failure mode, and what was done to prevent recurrence of the event.

l 2)

Constniet a list of the sig'nificant common concern areas identified along with.an overall conclusion regarding the analysis.

3)

Identify recommended corrective action: to prevent recurrence of the common causes l

to the observed inappropriate actions.

4)

Present the findings and conclusion of the common cause analysis to the overall j

investigation group and assist in evaluatibn of common causes identified by teams 1 through 3 to determine overall corrective actions.

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Pr: Ject Plan for Integrated l

Sequ:yah Capacity FactorImprovement Assessment l

1/14/96 Overall Investication Team l

l Bill Lagergren, the overall investigation leader, along with the team leaders Mike Lorek, Mark Skarzinski, Dennis Lundy, and Jerry Robertson from each of the individual investigation teams will form the Snal overall investigation team. This group ofindividuals will coordinate and review all l

individual team findings along with the common findings. The overall investigation team will l

appraise senior station management of the progress and status of the investigation along with' l

developing corrective actions to increase component reliability. This aspect of the investigation is l

anticipated to take two weeks.

I l

OverallInvestigation Team will produce the following results upon completion of this portion of the l

assessment:

1)

WeePJy status briefmss to the MRC on Friday of each week. These status brienngs will provide the MRC with any prelimmary findings which require immediate attention r

l to resolve, status with respect to schedule, identification of any difHeulties being encountered or needs for additional support, and other issues as determined by the overall investigation team leader or the MRC Chairman.

2)

Provide a final report with recommendations in the following main areas as a minimum:

a) organizational and programmatic corrective actions to prevent these types of deficiencies from recurring in the future, b) components requiring additional attention to ensure increased overall l

plant stability and, l

c) special insights related to the operation and maintenance of complex

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balance of plant systems.

3)

Recommendations of any follow on efforts required such as additional systems which may require full systematic assessment as performed by Investigation Team 3.

i 4)

Assessment as to the overall effectiveness of the assessment and need to perform any additional assessments not already performed.

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10 15 Quality of Supervision

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' Data laken at a West Coast plant from July 1993 to 1994 en FIGURE 15 e

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Quality of Supervision for Error Reduction

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Good Supervisors Bad Supervisors o Minimize unwanted Expect staff to work under tight scheduler pressure schedule all the time o Check on work during Only check the paper work progress o Assign-right workers for the Assign inexperienced people to right job tough jobs o Check if all needed Shy away from questions

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information is provided during work o Detect conditions that are Ignore all the traps and treat the conducive to human errors tailboard meeting as a nuisance before work

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FIGURE 16

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HUMAN ERROR CHECKLIST -

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SUPERVISORY FIELD SURVEILLANC$

Yes No 1.

Do workers have the right procedures or aids to carry out their jobs?,

2.

Aro all the tools of oquipment properly staged?

3.

Does each worker know his responsibility and work scopo?

4.

Is the work placo very distractivo?

5.

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7.

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8.

Do workers know whero to find help if abnormal or unexpected conditions crise?

g 9.

Do workers act profossionally (meet our prol'ossional standards) ?

10.

Do workers know our expectations in procedural complianco, clean-as-wo-gt.

not-procooding-In-tho-face-of-uncertainty, and OV&V allinput data?

9 = e-FIGURE 17 8

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