IR 05000285/1993001
| ML20128B487 | |
| Person / Time | |
|---|---|
| Site: | Fort Calhoun  |
| Issue date: | 01/27/1993 |
| From: | Constable G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20128B465 | List: |
| References | |
| 50-285-93-01, 50-285-93-1, NUDOCS 9302030077 | |
| Download: ML20128B487 (12) | |
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F APPENDIX V,S. NUCLEAR REGVLATORY COMMISSION
REGION IV
NRC Inspection Report: 50-285/93-01 Operating License: DPR-40 Licensee: Omaha Public Power District (0 PPD)
444 South 16th Street Hall Mail Stop 8E/EP4 Omaha,-Nebraska 68102-2247 ,
Facility Name: Fort Calhoun Station (FCS)
Inspection A FCS site, Fort Calhoun, Nebraska Inspection Conducted: Jaauary 4-8, 1993 Inspector: J. E. Whittemore, Reactor Inspector, Plant Support Section Division of Reactor Safety Approved: n- ~o / - 27- 9 ~3 gfe -G. L. Constable, Chief, Plant Support Date Section, Division of Reactor Safety inspection Summarv Areas Inspected: Routine, announced inspection of the facility licensee self-assessment capability to determine if the licensee's organization and programs were effective at problem identification and correction. The inspection additionally addressed whether the corrective actions included effective communications and followup to reduce the number and significance of future problems. The inspection also reviewed selected events and evaluated how the licensee's organization and programs treated these event Results:
- The licensee's overall program for self-assessment was dynamic with -
individual program changes and enhancements being initiated on a continuing basis. The on-site'and off-site committees were effective and demonstrated' good concern for safety. The Nuclear Safety Review Group ha's made a significant contribution to the total self-assessment effor Individual programs were well managed and integrate G30077 930127 PDR ADOCK 05000285 O PDR
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- The delivery of recent training administered for root cause assessment-and human performance evaluation had been inconsistent. The program effectiveness.had not been impacted because of strong oversight by the program administrator. The licensee had initiated corrective actions to address this inconsistency (Section 1.2.1).
- The station performance indicator program was effective even though the program was administered without written procedure or policy. The effective performance resulted from strong management support and involvement (Secti n l.2.2).
- The process for identifying adverse trends in the performance indicator program had the potential for masking declining performance over a long period (Section 1.2.2).
Summary of Inspection Findings:
None Attachment:
- Attachment - Persons Contacted and Exit Meeting
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1 SELF-ASSESSMENT (40500)
This inspection was performed to confirm that the licensee had satisfactorily 1 implemented measures to identify conditions adverse to quality in accordance ,
with 10 CFR 50 Appendix B, Criterion XVI. To attain this confirmation, it was necessary to review the licensee's internal safety review activities and to evaluate the effectiveness of the overall self-assessment effort. To meet these goals, a review of the various self-assessment processes, including charters and rarecedures was undertaken. Additionally, the inspect 0r reviewed a sample of the recent activities of those committees required by the facility
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license and other groups which had been formed to enhance the self-assessmen ,
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1.1 Or_ganitations_ Responsible for Self-Assessment
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There were a number of organizaticas res)onsible for identifying issues related to safety at FCS. The licensee lad established administrative
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requirements which created groups responsible for problem identification and self-assessment. In addition to the normal Quality Assurance / Quality Control organization, these groups included the Nuclear Safety Review Group and the incident Evaluation Team, in order to comply with facility license requirements, the licensee had established the Plant Review Committee and the Safety Audit and Review Committee, which were equivalent to the normal on-site
, and off-site review groups requir9d by facility Technical Specifications (TS).
1. Incident Evaluatic- Team (lET)
The IET had been established to support the incident report system .which was the lowest level entry into the FCS corrective action system. The incident report system was implemented through Procedure SO R-4, " Station Incident Reports," Revision 36. All events entered into the incident report system were entered via computer terminals which were available to all plant personnel. The team was chaired by an assistant plant manager and also functioned as a permanent subcommittee to the PRC. The primary function of the team was to perform the initial review of events or issues and recommend the approach to corrective action or disposition for straight-forward issue ,
Typical recommendations from the team included the performance of safety l
evaluations, investigations of human performance, and root cause analysis.
l All IET recommendations and closures were reviewed by the PRC. The team did
- not address' operability-and reportability issue The team met every Wednesday in order do the preliminary work on new incident
. reports and have the package available for the scheduled Monday PRC meeting.
I The inspector attended a meeting of the_IET on January 6, 1993. During this meeting, one incident report (IR) which reported an inadvertent ventilation -
system isolation,.was opened and the member.from system engineering was assigned to perform an initial review which would consist mainly of collecting l
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information and data for discussion during a future meeting. One issue scheduled for closure was tabled until further information could be obtaine Three issues related to an inadequate tagout, fire protection impairment, and unreported physical disqualification of a licensed operator, were recommended for closure by the IET and sent to the PRC. For those issues that were recommended for closure, personnel that had been involved in the corrective action were available at the meeting to provide information about how the issue was resolve The inspector agreed with the team decisions and observnd that the meeting was conducted formally with members exhibiting a concern f or saf ety. During several discussiont., members queried each other and presenters as to generic i
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implications or F ogrammatic issue The inspector concluded that the ICT constituted an effective method for the initial identification of problems and the initial development of corrective action .1.2 Nuclear Safety Review Group (NSRG)
The NSRG was implemented by Procedure NSRG-1, "NSRG Charter," Revision 5, and ,
four supporting procedures. The NSRG had t*cen created to provide assessment, review, and investigation of programs,-functional areas, and events. Within ,
the OPPD organization, the NSRG reported directly-to the Manager, Division of ,
Nuclear Services who also chaired the SARC. The other groups reporting to the division manager of nuclear services were the Emergency Planning group and the :i Quality Assurance / Quality Control (QA/QC) organizatio The NSRG would respond to concerns developed of it's own initiative and concerns voiced by other organizations. This group was intended to function independently of other self-assessment efforts or program The inspector attended an NSRG exit meeting held to debrief plant management on a recently completed audit of the licensee's operability determination program. This meeting served to inform plant management of specific findings, '
concerns, and recommendations that woulti be included in the final report. The inspector observed good interaction between management and the auditors :
providing the information. The auditors responded to six-specific questions they had been asked.to address prior to the audit. Additionally, they provided details in the specific areas of timeliness of operability determinations, quality and accuracy of justifications, and quality of documentatio They provided two specific recommendations for enhancing th process and three additional comments for consideration by management. These additional comments amounteo to observations and highlighted areas where management might consider implementing change The inspector reviewed two re) orts that had been issued by the NSRG during 199 The first report was tie initial investigation of the July 3, 1992 event, which occurred when an instrument power supply failure resulted in a turbine generator trip followed by a reactor t' rip and subsequent failure of a
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-5-pressurizer code safety valve. The second report provided an assessment of the licensee's setpoint control progra The inspector observed that both reports were issued and distributed in a timely manner. The final report on the safety valve failure was issued 11 days after the event occurred. The report of the setaoint assessment was approved and issued within 8 days of the completion of 11e 2 week assessmen This timeliness was considered noteworthy in view of the depth and detail observed in the reports. Both reports contained an executive summary which served to provide readers with a thorough knowledge of observations, strengths, weaknesses, and important finding A review of the NSRG activity schedule indicated that work was ongoing for one investigation, two program assessments, and 30 reviews. The investigation had been initiated by the Nuclear Operations Division. Both program assessments and the majority of the reviews had been initiated by the NSRG. The remainder of the reviews had been. initiated by on-site and off-site organizations, including SAR ,
During discussions with licensee representatives, the inspector determined that the NSRG looked in several places to generate concerns about specific areas to assess or review. Concerns were generated from reviewing events,
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allegations, QA/QC reports, information notices, and strategic issue i Noticeably missing from the unofficial list of concern generators were i i
employee concerns and station performance indicators (trending). These areas appeared to have the potential to generate concern The inspector concluded that the NSRG was providing an effective self-assessment effort for the licensee's activitie .
1.1.3 Plant Review Committee (PRC)
The PRC at FCS was implemented by Procedure 50 G-5, "fCS Plant Review
, Committee," Revision 93. The committee was staffed by nine members including ,
the plant manager, who was the committee chairperson. The facility license required the committee to meet-at least once per month,-but routine meetings were scheduled and conducted every Monday and Thursday, e The inspector reviewed the minutes of five PRC meetings to assess how effectively the committee functioned in the seas of s44ty related procedure revision, review of events, and_ operability determinations. All safety-related procedures with the exception of standing. orders-(station-administrative procedures) came to the PRC after a-detailed review by an appropriate subcommitte A cognizant PRC member had presented the review-results and the revised procedure to a quorum of the PRC.- Incident reports were reviewed and the proposed corrective action could be enhanced by the PRC, ,
-agreed to, or returned to the IET for further action. Completed Licensee Event Reports (LERs) were reviewed but not approved by the PRC. In addition, the PRC reviewed and recommended for approval, safety-related modifications, memoranda, and the justifications for operability determinations. A special L... . _ _ _ _ _ _ _ . . - _ . _ _ _ _ _ _ _ . _ . . . _ _ . . - __,.___.u_ u_
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, meeting was conducted on July 17, 1992 with the purpose of reviewing and making recommendations for the recovery and restart plan following the July 3, 1992 event. During this meeting, all startup preparations were statused and the chairman assigned specific members and other-personnel to complete or !
address specific action items prior to reactor criticality. Assignments were l also made for the completion action items tsfter the startu l The inspector attended the regularly scheduled PRC meeting that occurred on January 7, 1993. During the meeting, nine procedures were submitted requesting approval after the cognizant subcommittee had performed a detailed l review. The procedures were submitted by the cognizant PRC member who l explained the revision and arovided details of the subcommittee review. .One procedure was not approved )y the committee because the training department .
member believed that the procedure changes had been so extensive as to warrant !
revalidating and reverifying the entire procedure. A second procedure was '
withdrawn from the approval process because of concern by the reactor i
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engineering member that could not be addressed during the meeting. The-remaining seven procedures were unanimously approved by the committee. An operability determination was withdrawn from tie approval process because some
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members believed a safety evaluation needed to be performed. A report on the completion of correction action was withdrawn because the presenter could not t
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answer committee members questions about the detailed extent of corrective "
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action. A memorandum providing expanded information on the surveillance testing of the containment personnel air lock seals was approved unanimousl ;
During the meeting, the inspector observed good dialogue between individual members and presenters. Probing questions were asked and meaningful information was exchanged. There was on the-surface, an obvious concern for i safety among all the participants. During followup review, the inspector -
determined that all items reviewed during_the meeting had been addressed adequatel The inspector determined that the PRC was meeting the safety responsibilities :
and exercising the authorities delineated in FCS TS 5.5.1.6 and 5.5. ,
1.1.4 Safety Audit And Review Committee (SARC)
The safety responsibility and authority of the-SARC was delineated in FCS TS - 5.5.2.7, 5.5.2.8, and 5.5.2.9. The committee was implemented by the Safety Audit and Review Committee Charter, Revision 14. There were three procedures supporting the SARC charter. .These procedures addressed SARC documents,
- reviews, and audits. The committee was required by the facility license to-meet at least once every 6 months.- There had been seven meetings.during 1992 and no sequential pair of meetings had been more than 6 months apar To assess the SARC effectiveness, the inspector reviewed the following:
- The agenda for the next scheduled meeting which was to occur on January 15, 1993;
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- The minutes for four recent meetings; and
- The SARC Charter and supporting procedure Additionally, discussions were held with licensee representative responsible for preparation of the SARC meeting agenda and minute For an evaluation of SARC offectiveness, the inspector focused on a special SARC meeting that was held ca October 15, 1993, and the events that led to the meeting. The meeting was held in response to perceived decreasing performance indicators in specific areas. The declining trends had been surfaced in a scheduled nuclear performance meeting held on September 15, 1992, lhese meetings were normally conducted twice a year and attended by all Opp 0 exempt nuclear personnel. These meetings were conducted to provide information from nuclear managers to exempt personnel about nuclear operation performanc This particular nuclear performance meeting informed exempt personnel that declining trends had been identified in the forced outage rate, violations, preventable LERs, and lost time accidents. It appeared to the inspector that the declining performance trends had been arrived at subjectively, using multiple information sources, including station performance indicators, industry group reports, and management perspectiv In response to the apparent declining indicators identified at the nuclear performance meeting, the SARC scheduled a special meeting to address the problems. A review of the meeting agenda that was issued on September 28, 1992, indicated that upper management personnel were assigned as presenters at the meeting to address the issues and propose corrective action to reverse the trends. A review of the meeting minutes revealed that data was supplied to substantiate the declining performance. Mditionally, the following significant actions were proposed to reverse the substantiated tre7ds:
- Report all future events determined to be significant by the NRC or industry groups to the SAR * Establish and implement a task force to improve plant reliabilit * Provide self-checking training to all plant and exempt personne * Dedicate an experienced shift supervisor to concentrate on performance issues, a e Perform human performance evaluations for 29 LERs that have been issued this yea * Provide training to personnel required to perform lifting function Before the meeting adjourned, the chairperson added an agenda item for the next SARC meeting to provide a report to the committee on the effectiveness of the corrective action taken to reduce personnel error _ _ _ _ _ _ - _ - _ _ _ _ _ _ _ - _ _ - _ _ - - _ _ _ _ - _ _ _ - _
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-8-The inspector concluded that the SARC was carrying out it's license and administrative responsibilities effectivel .2 Self-Assessment Methods And Programs The licensee had established and implemented programs for station performance indicators, root cause analysis, human perfnrmance investigation, QA/QC functional area trending, and the identification of strategic issue The inspector reviewnd these programs and a selected sample of the program output I 1.2.1 Root Cause Analysis And Human performance Investigation The fCS root cause analysis program was implemented by-the Nuclear Operations-Division (NOD) Procedure NOD-QP-19, " Root Cause Analysis Guidelines,"
Revision 11. The program was administered by a supervisor in the operations department under an assistant plant manage D A review of N00-QP-19 revealed that detailed instructions were provided to analysts on the normal industry accepted methods for cause analysis. As a matter of normal practice, cause analysis would be performed within the system >
engineering group. Analysis results were subject to review by the program supervisor, NSRG, and the PRC. Station training records indicated that 141 personnel were currently trained to perform root cause analysis'(RCA). :
During the course of the inspection, a small sample of recent RCA reports were reviewed. The reports reviewed appeared to have been conducted in accordance with procedural requirements and were subjected to the proper revie The licensee had placed significant emphasis on an effort to reduce the number -
of personnel errors at FCS. This effort had resulted in a program that -
provided for the investigation of human performance related to significant events. The program was implemented by Procedure N00-QP-20, "liuman Performance Enhancement System," Revision 4. The procedure provided various methodologies for arriving at the cause of human error that contributed to or caused event The Human Performance Enhancement System (HPES) methodologies would address events that involved operations, maintenance, or any area of human performance.-
Discussions with licensee representatives revealed that the program had ,
evolved significantly since its inception. Initially, investigations were
)erformed by a single investigator of the same discipline in which the event lad occurred. One of the initial improvements had_been to initiate two person
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team _ investigations with one member belonging to an unrelated discipline. The i current program required investigations to be performed by two team-L
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- investigators with a menter, all from unrelated disciplines'or areas. The "
designated mentor was an individual who had participated in a previous-investigation and was assigned to provide oversight and guidance to the team -
1 investigators. Licensee representatives stated that the current team and mentor method had revealed the best investigative results:since the program
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inception. Training records indicated that were 119 OPPD personnel were trained to perform human performance investigations .
Previously, those individuals qualified for root cause analysis and human performance investigations had been trained by a contractor. Within the past 2 years, the licensee had implemented in-house training in these area Individuals could be trained in root cause analysis, human performance investigations, or both. The inspector reviewed training materials forLihe training. The material consisted of classroom lesson guides and exercises for ,
student evaluation. Training personnel indicated that both subjects were routinely taught together during a common 2-3 day period of instructio Training representatives stated that the combined training was administered by two instructors who integrated the two lesson guides to take advantage of tha common elements of each subjec This method involved switching back and forth between the two, lesson guides and instructors. The lesson guide for root cause analysis contained a requirement that student knowledge be evaluated by their performance of the graded exercises that were given at the end of the course. The human performance investigation lesson guide required the student to score 80 percent on a written examination. The inspector determined that the exercises had been administered and graded, but written examinations had not been administered. Licensee 3ersonnel stated that they had already identified the two issues related to tie training material and were planning corrective actio The inspector concluded that the root cause analysis and human performance programs were providing effective and accurate assessment informatio lowever, recent training was not fully consistent with the lesson guides. . The ,
success of both programs appeared to be the result of strong program oversigh ,
1.2.2 Station Performance Indicators A station performance indicator report was issued by the system engineering group on a monthly basis. One individual was assigned to collect and assemble data for about 90 indicators from 40 sources and construct the monthly trend report. In discussions with licensee representatives, the. inspector determined that the number of trended indicators had increased by about 10 over the past 2 years.- Also some indicators had been dropped or shifted to other programs._ Personnel characterized the program as dynamic because-indicators were added or deleted by management due to the program effectiveness being under continuous review. The report coordinator stated .
l that all of the information needed to assemble the monthly report-was always received in time to-issue the report on schedule. During the course of.the l inspection, discussions with several licensee personnel- revealed a consensus i that the station performance indicators were an excellent tool for self-assessmen !
There was no written procedure or policy for the station performance indicator
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program. The front pages of the monthly report book contained the only written programmatic information. The extent of this information was to L '
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-10-define positive trends, adverse trends, and trends needing increased management attentio The indicators that fell into these categories were identified in the front of the boo The inspector noted that an adverse trend was declared when an indicator exhibited 3 months straight-of decline. Unwritten policy had been initiated to require the cognizant manager (s) to submit a corrective action plan when an adverse trend was identified. Discussions revealed that a trend could decline for 2 months, steady out, and decline for 3 months before being identified as an adverse trend. Other scenarios were possible where a long-term decline would never reach the corrective action threshold. The inspector made sure that the licensee management was aware of the possibility of masking adverse performance at the exit meetin The inspector concluded that the station performance indicators program was a-strong self-assessment tool. This conclusion was based on the program popularity with OPPD personnel and the strong management support given to the effort, however the program was implemented without written procedure or polic .2.3 Quality Assurance Quarterly Trend Report And Strategic Issues A recent innovation had resulted in the QA organization-issuing a quarterly trend report. This report collected information from various sources, primarily corrective action documents, QA/QC reports, and NRC inspection reports, and assembled the information into a functional area trend report. A i total of 18 functional areas were trended. The functional areas were rated as a strength, neutral, needing improvement, or adverse. The report was issued as a color-coded performance panel with information to support performance-assessmen The inspector reviewed the 1992 third quarter report and determined that the report was accurate and would serve as a valuable information source for managers and the Safety Audit And Review Committee (SARC). I The OPPD Corporate Nuclear Planning group had initiated a practice of identifying strategic issues. These issues were defined as those safety, operational, reliability, and financial issues that could possibly affect the operation of the nuclear unit 2 to 5 years in the future. These issues were identified through a thorough review of regulatory and industry informatio The purpose of identifying issues was to provide management with the longest possible opportunity to initiate planning for issues that were expected to become importan The inspector observed that the most critical strategic issues _ were identified-for management. The present list of critical strategic issues contained 11 issues. The inspector noted that all but one (operating costs) were safety-related issues. Typical safety-related issues included shutdown risk, personnel professionalism, steam generator _ reliability, and maintenance rul ... . . . ,
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-11-The inspector concluded that the QA/QC trend report and the identification of strategic issues were valuable additions to the integrated self-assessment effort at FC .3 Sunmary And Conclusions lhe inspector concluded that the various organizations were carrying out both their administrative and license required responsibilities for self-assessmen The various programs implementing self-assessment were individually well managed and effectively integrated to provide a good total effort for self-assessment. The inconsistency of training delivery for root cause analysis and human performance investigation had not impacted program effectiveness, as program oversight was strong. The effectiveness of the station performance indicator program had not suffered from the lack of proceduralization or written policy. The potential to ignore declining performance had not occurred and management was aware of the potentia Management support was strong for the performance indicator program, and appeared to pursue effective self-assessment in all existing program .. . . - . _ _ _ _ - _ _ _ _ _ - _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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ATTAC!!MENI 1 PERSONS CONIACTED 1.1 Omaha Public_ Pow 1pijttrict Personnsi
- R. Andrews, Division Manager, Nuclear Services
- B. Blome, Supervisor, Corporate Quality Assurance, SARC Secretary 1
- J. Chase, Plant Manager, FCS
- Cook, Supervisor, Station Licensing
- S. Gambhir, Division Manager, Production Engineering
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- J. Gasper, Manager, Training
- W. Gates, Vice President '
C. Iluang, Supervisor, Root Cause Analysis and lluman Performance Enhancement
'W. Jones, Senior Vice President-
- R. Jaworski, Manager, Station Engineering J. Kollam, Operations Training Specialist
- L. Kusek, Manager, Nuclear Safety Review Group
- Lippy, Engineer, Station Licensing
- Orr, Manager, Quality Assurance and Quality Control R. Parsons, Project Engineer
- T. Patterson, Division Manager, Nuclear Operations
- R. Phelps, Manager, Design Engineering R. Plott, PRC Secretary A. Richard, Assistant Plant Manager, fort Calhoun Station D. Ross, Performance Indicator Coordinator f. Scofield, Manager, Nuclear Planning
- ll. Sofick, Manager, Security Services
- R. Short, Manager, Nuclear Licensing and Industry Affairs
- J. Tills, Assistant Plant Manager, fort Calhoun Station L. Wigdahl, Supervisor, Technical Support Training 1.2 NRC Personnel
- Azua, Resident inspector
- Denotes personnel that attended the exit meeting conducted on January 8, 199 EXIT MEETING L
An exit meeting was conducted with licensee management personnel on January 8, l 199 During this meeting, the inspector reviewed the scope and findings of the inspection. The licensee did not identify as proprietary any of the materials provided to, or reviewed by, the inspector during the-inspection.
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