ML20132E105

Submits Diagnostic Evaluation Program Report

ML20132E105
Person / Time
Issue date:	02/02/1990
From:	Jordan E NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:	Ebneter S, Murley T, Russell W NRC (Affiliation Not Assigned), NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I), NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
References
NUDOCS 9612230047
Download: ML20132E105 (19)

Text

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MEMORANDUM FOR: Thomas E. Murley, Director, NRR .

l William T. Russell, Regional Administrator, Region I  :,

Stewart D. Ebneter, Regional Administrator, Region II  !

A. Bert Davis, Regional Administrator, Region III i Robert D. Martin, Region _ Administrator, Region IV  !

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John B. Martin, Regional Administrator, Region V [

FROM: Edward L. Jordan, Director Office for Analysis and Evaluation of Operational Data

SUBJECT:

STATUS REPORT ON THE DIAGNOSTIC EVALUATION PROGRAM I The subject report will be provided to the Commission in the near future.

3 However, prior to sending the report to the Commission, I am providing it to you for information and would appreciate receiving any comments you may have by j

. 1 February 16, 1990.

/ & - l a . Jordan, Director Offic f r Analysis and Evaluation of rational Data <

Enclosure:

Status Report on Diagnostic Evaluation i/

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STATUS REPORT ON THE DIAGNOSTIC EVALUATION PROGRAf Introduction Following July meeting No.128 of the Senior Contract Review Board 19,1988, SCRB) on the SCRB recommended that the Chairman approve e(ntering i!

3 Evaluation Program. contract for contractor support for the Diagnostic year competitive December 5,1988. The Chairman subsequently approved the request on i

The SCRB also requested that AE00 report back within one year on the status of the Diagnostic Evaluation Program (DEP). This paper provides the requested status report on the progrcm. j i

Background I i

With the assignment of dedicated staff resources within AE0D for the DEP, I following the March 1987 implementation were initiated. NRC reorganization, detailed program development and Evaluation and Incident Investigation BranchInitial actions by the staff of the Diag a manual chapter on the program. (DEIIB) were directed at preparing On June 18, 1987 l I

distributed approved forfor comment and on March 3,1988 a final Manual Chapter wasa propose use.

The approved Manual Chapter 0520, "NRC Diagnostic Evaluation Program" documents the scope, objectives, and basic requirements of the OEP.

As stated in the manual chapter, the overall goal of the DEP is to promote public health and safety by independently assessing licensee performance at selected reactor facilities. Specific objectives of the DEP are to:

(1) provide addit h al information to supplement SALP, Performance Indicator (PI) and other assessment data, to enable NRC senior management to make a more {

informed decision concerning overall plant performance; and (2) evaluate in a performance and safety-oriented framework, the actions and involvement of licensee management and staff in safe plant operations.

j Discussion <

In the period since the DEP was formally authorized and staffed, a total of  ;

seven Diagnostic Evaluations (des) and one Special Evaluation have been conducted by AE00. i listed in Table 1. The r~ ants and licensees involved in these evaluations are TABLE 1.

COMPLETED DIAGNOSTIC EVALUATIONS Management Engineering

' Contractor Contractor P.l ant . Licensee Personnel Personnel Report Date Dresden Ceco 0 0 November 1987 McGuire DPC 2 3 March 1988 Turkey Point

• FP&L 0 0 June 1988 '

Enclosure

TABLE 1.

COMPLETED DIAGNOSTfC EVALUATIONS (CONTINUED)

Management F.ngineering Plant Contractor Contractor Licensee Personnel Personnel Report Date Fermi DECO i 3 0

" November 1988 Perry CEI 2 1 May 1989 Brunswick CP&L 2 2 July 1989 Arkansas AP&L 2 2 December 1989 i

Palo Verde APS 2 1 February 1990**

• Special Evaluation

• • Projected Date The plants involved in these evaluations have comprised: each of the domestic Nuclear Steam Supply System vendors; a broad range of plant operational experience in terms of the number of operating cycles and performance history; and large and small nuclear utilities and; four of the five NRC regions.

To develop consistency in the process and procedures used by a Diagnostic Evaluation Team (OET), written guidelines were developed in preliminary (trial

use) form and later finalized based on lessons learned from completed Diagnostic Evaluations (des). The final DET guidelines were issued in '

June 1989.

With time and experience, comprehensive detailed evaluation plans were also developed for each of the functional areas assessed by DETs. These 4 functional areas include operations, training, maintenance, ,

surveillance organization. / testing,' engineering support, quality programs and management and These work plans have significantly contributed to efficient planning and thorough onsite evaluations, and overall success of each evaluation.

Success of DETs is highly dependent on the capability and expertise of its members and the quality of team management. Despite the competition within the agency for the best available resources, NRR and Regional support for diagnostic teams has been very good. Consequently each team has been of a very high caliber. In addition, NRR personnel have served as either the team manager or deputy team manager for three of the des while AEOD has provided the team manager or deputy team manager for all of the OEs which have been conducted. '

DETs have identified a number of important safety issues and significant i programmatic weaknesses at the plants evaluated. Strengths and improvement initiatives have also been found at the plants visited. Table 2 lists several of by the significant performance weaknesses and strengths (or improvements) found DETs.

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TABLE 2.

PERFORMANCE WEAKNESSES, STRENGTHS, AND IMPROVEMENTS Weaknesses identified by DETs:

o Strained Resources o

o Organizational Instability Communications Problems  !

o o

Ineffective Engineering Support Limited QA Staff Capabilities o Unreliable Equipment o

Inadequate Check Valve Testing o Inadequate MOV Maintenance o

Operator Overtime Safety Issue o IST Program Deficiencies o

Poor Equipment Failure Trending i o Weak Operations Experience o

o Audits /Surveillances Programmatic vs. Technical l o

Fragmented Problem Identification Programs  !

o Problem Identification Threshold Too High o

Weak Root Cause/ Corrective Action Programs Inadequate Corporate Monitoring Strengths / improvements identified by DETs:

o o

Corporate Leadership, Oversight and Involvement Integrated Performance Plans o Staff Technical Capabilities o

o Management and Staff Attitude Toward Safety Managerial and Organization Changes o

o Programs for Improved Engineering Support Performance Monitoring /Self-Assessment o

o Operations Experience Across Station Organization Use of Technical Experts on Audit Teams ,

o Unscheduled, Performance-Based Surveillances o

o QA Staff Training and Rotational Assignments o

Proactive Offsite and Onsite Safety Review Committees Comprehensive Condition Report and Audit / Surveillance Finding Trending The most prevalent programmatic weaknesses in the safety related equipment area appear to involve motor operated valves and check valve programs. The root cause analysis programs at most plants were also found to be weak. Many of the plants had significant backlogs of known problems which were awaiting engineering evaluation or corrective maintenance.

The strain on resources which these bhcklogs imposed, coupled with a frequently insufficient design basis documentation, ineffective engineering support and the absence of effective teamwork among station support departments, were often the major impediments to performance improvement.

Except for Dresden, McGuire, and Perry, each of the plants were, at the time of the evaluation, found to be in a period of organizational transition.

Management changesassessments.

to earlier performance and organizational res'.ructuring were underway in response These organizational changes indicated that licensee senior executives responsible for these plants had already 3

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recognized higher the need performance for improved organizational effectiveness to achieve the standards.

Frequently the higher standards were being i driven or by competitive regulatory pressure. and economic realities as much or more than rising safety  !

DEis have frequently found safety issues of plant-specific and generic nature requiring further followup actions by the NRC staff.

These issues have been i documented in an EDO staff actions memoranda for action by the responsible office. Potentially generic issues have included: inservice testing (IST) .

programs which had not been approved by the NRC staff; check valve IST program i deficiencies; inadequate minimum flow in centrifugal pumps and; plant equipment degradation inside containment due to steam leaks within Technical Specification Limits. i Attachment 3 presents a perspective (from ANO) on the ,

type of plant-specific deficiencies identified by a DET.

The DEP has also matured in its ability to assess the involvement and effectiveness of licensee management in ensuring safe plant operations.

Comprehensive plans and methods for management and organizational evaluations i have been from the developed preceding and improved based upon the experience and insights gained evaluations.

This experience has allowed DETs to gauge observed management effectiveness and practices in ensuring safe plant operations plant in terms facilities. of the standards at a number of operating nuclear power ,

Management and organizational contractor personnel have also been effectively  !'

integrated to support development and implementation of the DEP. As shown in Table 1, beginning with the McGui,re evaluation, two management contractor i personnel typically have been used for each diagnostic evaluation. It has been AE00's philosophy to continue to expand the number of contractor personnel with diagnostic evaluation experience in order to increase the flexibility and i experience base in this important support area. Thus to date, a total of five i different contractor personnel have participated in DETs. I The quality of the management and organizational evaluations have received recognition from both NRC senior management and industry executives. A measure l

of the scope, depth and impact achieved in this area is reflected by '

Attachment 1 which contains illustrative examples of DET identified management and organizational weaknesses.

This attachment also shows that licensees have responded to management and organizational findings with a high degree of responsiveness and importance.

DETs have found inadequate engineering and technical support to be an important underlying cause of performance problems of many of the plants evaluated. In the engineering support area, contractor personnel have been effer.tively utilized to review safety-related organizational. effectiveness. equipment design, engineering programs and engineering j

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Attachment 2 provides illustrative engineering support weaknesses identified by DETs and the licensee responses to these ,

findings. The attachment shows that findings in this area have been significant l and well-received by licensees. i 3

An important objective of each DET is to determine the probable root causes for licensee performance problems. DETs have succeeded in identifying probable root causes due to: the broad evaluation scope; extensive use of document l l

reviews and interviews; comprehensive management and organizational reviews; 4

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and, effective team communications and experienced team management.

of some of the root causes identified by DETs is provided in Table 3. A listing TABLE 3.

ROOT CAUSES FOR PERFORMANCE PROBLEMS o

Plant Neglected in Favor of Other Priorities o Fossil Plant Attitude i o '

o Lack of Clear Performance Goals '

Ineffective Planning for Operations ,

o lack of' Staff Operating Experience  !

o o

Lack of Attention to Human Relations Matters '

Corporate Micromanagement '

o Financial Pressures to Keep Plant Operating Extensive resources diagnostic evaluations.and time are required to plan, conduct and document The large team size, mandated by the broad-based approach, coupled with the needed indepth preparation and planning, the three weeks of on-site review, and the time required to ensure a high quality report has resulted tractor in a relatively large commitment of NRC staff resources and con-support. The length of time required to prepare and finalize a fully-integrated, appropriately focused, well-written report has proven to be

• substantially longer than originally envisioned. Although a number of measures have been taken to increase report writing and editing efficiency, experience indicates that high quality diagnostic evaluation reports take a longer time to complete than the 6 weeks initially estimated. This is due to the continuing technical and preparation root cause evaluations that occur in parallel with report activities.

The most recent evaluations have each involved approximately 3.5 FTE of NRC staff resources and over $110K in contractor support. Licensee manpower costs to support DETs have also been significant. AP&L estimates that manpower to support the onsite work of the ANO DET was in excess of 3 man years while APS estimates that about 2.5 man years were expended to support the Balo Verde DET.

As currently structured, AE0D's DEIIB provides an experienced core of evaluators needed to staff and support each team. This core team ensures consistency in planning,' implementation and report preparation quality. The authorized FTE level within DEIIB, coupled with the broad based evaluation scope and extensive length of time from evaluation initiation to report completion (about 4 months) would indicate that no more than four diagnostic evaluations can be completed per year with the current approach. To allow for additional evaluations and needed increased relief time for DEIIB staff, AE00 has initiated discussions with NRR to " institutionalize" the DET approach, i.e., to standa'.dize the scope, methodology and report contents and establish an agency wide, roster for DETs. This approach would be similar to that used in the Incident Investigation Program.

The 'DEP has provided timely independent assessments of license performance to NRC senior management.

These assessments have been valuable in augmenting and calibrating SALP, PI and NRC management perspectives. Diagnostic evaluations have also provided broad-based understanding of industry and individual licensee performance problems and insights into their underlying causes. The 5

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i adequacy and effectiveness of the actions being taken and the nee for further regulatory actions have also been made mere apparent from completed assessments.  ;

Finally, NRC Diagnostic Evaluations have had important tangible but indirect benefits such as assisting licensees in better understanding their own performance weaknesses to underscore and bring focus to the need for performance improvement.

• Despite the success of the DEP, efforts will continue to be made to refine the diagnostic evaluation process to improve the team efficiency and effectiveness.

I Two extensive lessons learned assessments have already been conducted to refine procedures and a third is planned for early 1990. The sizeable number of NRC staff who have now participated in evaluations as team members or leaders has effectively established a core pool of " qualified" staff such that a more

" institutionalized" approach and staffing of diagnostic evaluation teams as  ;

discussed above may now be possible. Current funding provides contractor support for management and engineering functional areas for three des per year.

Additional des would require reductions in contractor support or reprogramming funds to maintain the quality and level of contractor support.

Summary of Conclusions On the basis of our review, we have concluded that the goals and objectives of the DEP are being achieved. The DET methods and procedures have become well established, and have proven to be highly effective in assessing licensee performance as well as the underlyi'ng causes for performance problems. The capability has also been developed to assess, in a credible and comprehensive manner, management weaknesses as an underlying cause of performance problems.

The use of management and engineering contractor support has been effectively integrated into these methods.

DETs have proven their value to the NRC and its senior managers by, augmenting and calibrating SALP, PI and inspection perspectives on licensee performance, and by providing additional insights into the underlying causes for performance problems. Technical issues both plant-specific and generic in nature have also '

been identified by DETs. Although the costs of conducting a DE are significant in terms of HRC staff resource requirements and contractor support, the benefits to the agency have been substantial and the DEP has justified these costs. Overall, the DEP is now considered a mature and highly effective NRC program.

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Attacnm:nt 1 2 l

MANAGEMENT AMD ORGANIZATIONAL FINDINGS l AND LICENSEE RESPONSES i

l McGuire 1

3 Finding

Response

The Design Engineering (DE) Depart- Design Engineering has placed a l

ment was not being fully utilized in day-to-day support of the permanent staff of six personnel operating stations. Accordingly, at McGuire Nuclear Station.

s Similar staffs have been placed l some McGuire technical issues which were not evaluated adequately at Catawba and Oconee Nuclear Stations. The primary focus of by Nuclear Production Department site engineering offices (NPD) could have benefited from will be to get involved in the greater DE involvement. The role of day-to-day issues which arise at DE was defined as providing support the station. The licensee's l when specifically tasked by NPD. The experience to date indicates that j

NPD engineering personnel normally evaluated and solved technical sometimes the site teams can

• problems and developed technical directly meet the particular problems themselves, which tended to need of the station. At other i

limit requests for DE assistance. times, the site office is the avenue by which General Office Design Engineering expertise is immediately brought to bear.

In either case, DE is more quickly and more frequently 4

involved in station problems than

, before creation of the site offices.

Fermi Although there had been some improvement in interdepart- In October 1988, a joint Nuclear mental interfaces, there was Engineering / Nuclear Production still a general lack of clarity Task Force was established to address this important area. The in the interfaces among Nuclear task force has two major objec-Engineering, Technical Engineering, tives related to this issue: '

and Maintenance and Modifications. (1) establish a clear definition No written guidance existed to of Nuclear Engineering / Nuclear defira the interfaces. Production Technical Engineering Group interface responsibilities, and (2) define areas within the

. Technical Engineering function i

where related design control activities might be shared.

Actions to achieve these objec-tives are planned to be A

completed by March 31, 1989.

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I Findings i

Response

l Perry ,

Management had developed an 1 organizational culture at Perry As a result of the diagnostic i on technical issues such as evaluation and the licensee's nuclear safety and quality own internal assessments, the i that was a positive influence licensee committed to review job descriptions, job {

on performance, as demonstrated grades, and qualification by a good work ethic, increased requirements. As a part of this productivity of teams, and

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improving technical performance i

process, comparisons will be made in several areas. There were not only with other similar jobs also negative influences on in the Company and the Nuclear culture, attitudes and morale Group, but also other nuclear caused by several personnel utilities and Centerior.

issues, and management had Corrective action has also beers not yet responded as effectively taken in several other areas having to do with personnel to these culture related cultural issues and personnel  ;

personnel issues as they had  !

to technical issues. administrative issues. These actions include additional supervisory training, United Way contributions policy change, the -

development of a new career ,

opportunities program, salary administration reviews, and i consistency in promotion l policies.

Technical problem solving and Management communications and decision making was consensus teamwork were readily evident; oriented and focused at the upper however, at lowerelevels of the management level. Meetings significantly contributed to organization it was not as good daily teamwork and apparent. We agree that there is room for improvement and have communication among the upper increased emphasis on communica-level managers. However, team-  ;

tion by periodically meeting with 4 work and communication were not all levels of our organization as universally apparent at the for question and answer sessions.

lower levels of the organization.

In some cases the working relations In order to better clarify the i of Nuclear Engineering Department role of the " system engineer"

- (NED) design engineers with Perry in NEO, changes to department Plant Technical Department (PPTD) procedures are beine developed.

was poor. There was a lack of clear These changes will delineate the definition and communication of the responsibilities of the NED NED engineer's roles, responsibili- system engineer to be cognizant ties and interfaces, relative to PTD of all the changes being mada to system engineers, in supporting the his/her system. These changes plant. In addition, some NED system will be in place by year's end.

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1 Findings  !

Response l 1

engineers were not cognizant of all

- the design changes being made to I their assigned systems.

Brunswick Current senior site managers were substantially involved Site management is increasingly l in day-to-day plant activities involved in day-to-day plant l and one of the most significant activities, and continues to seek actions initiated had been opportunities to address people issues. Several recent manage-to increase the amount ment initiatives have opened new of time managers spent in the plant. Additionally, these channels of communication at managers were sensitive to Brunswick. In addition, cultural issues and had implemented Brunswick is planning a prototype suggestion program for implemen-some corrective action measures, tation in late 1989. This such as communications and team- program will encourage employees

' work quality teams. However, to make suggestions for improve-there was not an overall effec- ments directly to site management.

tive means to respond to people Further, the corporate focus on issues.

Total Quality and post-0A manage-ment criteria are providing additional impetus towards a  ;

more open, interactive culture.

The Corrective Action Program was inadequate. There was no Root cause analysis is now being focal point of root cause pursued much more rigorously under PLP-04, " Corrective Action

-expertise within the Brunswick Program." Improvelnents planned organization, the threshold criteria for formal root for the Brunswick Corrective Action Program include: (1) cause (by procedural guidance) develop a Brunswick nonconfor-was too high, and training given nance policy, (2) establish goals to date, concerning the various and incentives for self-identifi-methods of root cause determination cation of nonconformances, (3) was rudimentary. Also, there had been a lack of corporate office issue revisions to PLP-04 to sensitivity and commitment to lower " threshold" levels and improve trending and training, the corrective action programs (4) complete additional training and processes throughout the on PLP-04, (5) identify a Nuclear tieneration Group. Brunswick corrective action Additionally, Brunswick had program coordinator, (6) not implemented a evaluation identify a senior HPES system to improve the analysis coordinator at Brunswick, and and evluation of human (7) further develop and performance problems. effectively institutionalize the i

corporate Corrective Action Program throughout the nuclear program.

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Findings

Response

The process for business planning Several improvements are planned at Brunswick was ineffective for the Brunswick business because it hampered effective planning process including: (1) communication within the site formalizing the process for organization as well as between the site and corporate office initiating and finalizing budget on Business Plan / Budget related and business plan targets; (2) matters. It also resulted in a enhance the business planning  ;

process to clarify the " roll mismatch between the Five-Year down" from the long range plan Business Plan and Budget causing i and " roll into" the budget; (3) l a substantial lessening of site utilizing the business plan i

management's sense of ownership of this plan. In addition, more effectively as a planning and management tool; and (4) inconsistencies existed between improving consistency between the current and future ~(projected) business plan, the long range modification closecut rates as plan and the backlog of modifica-

' documented in the Brunswick Five- tion projects. Budgeting and Year Business Plan. The Business accountability for support Plan forecasted a significant department activities have been

' drop in the number of modifications moved out of plant business plans performed on a yearly basis. If the actual number of completed to allow more focus of site management on the business of the j (operable) modification packages site.

drops to be consistent with the i Business Plan, the current' i modification backlog would not be reduced in a timely manner and might actually grow.

Management succession plans had Improved career development and been developed down to the job rotation processes will be supervisory level at Brunswick. developed and implemented.

However, little evidence of effective career planning and development existed, including job rotation.

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Attachment 2 ENGINEERING SUPPORT FINDINGS AND LICENSEE RESPONSES Perry Finding

Response

A large number _of design changes and work orders were As a direct result of the planned for implementation Diagnostic Evaluation Team during the first refueling discussion of the Control Complex outage. However, significant Chiller Water problems, the Independent Safety Engineering equipment problems experienced during the initial startup Group (ISEG) initiated a review of the system. This review will and first operating cycle include the following: (1) review would not be fully resolved at this time. They included of operational history of the 1 Control Complex Chillers and the problems in the control complex Control Room Energency/Recircula- '

chilled water and offgas systems, tion System, (2) data search of feedwater system vibration, fuse industry operoting experience, operating problems, and emergency diesel generator air receiver (3) determinetion of probable 1 relief valve problems. causes of irdividual problems,  !

and (4) recommendation of pos-  !

sible modifications or operational l enhancemeits. This review is in  !

progress with a report expected by the end of September  !

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Brunswick The licensee had not been In May 1989, the vendor recommenda-aggressive in identifying or tion process was incorporated closing out vendor recommen-dations. Many General Electric into ENP-20, the Ergineering Work Request procedure. A (GE) vendor recommendations were planned revision to ENP-20 will i over 10 years old and were only incorporate the licensee's new recently being dispositioned.

Scheduling and implementation of Nuclear Prioritization Process which should provide for a more corrective actions (once accurate priority for each item. l dispositioned) were also These steps will allow vendor '

inadequate and had not been recommendations to be considared revised to reflect current work for scheduling and budgeting (,o work practices,  ;

an equal basis with other plant '

projects and improvements.

Plant modifications contained To assure appropriate understand-

' an excessive number of field ing of root cause, the licensee revisions, marginal recently performed a statistical installation instructions, and evaluation of Brunswick plant .

failed to address known modification field revisions, to discrepancies between design characterize the type of cnanges requirements and as-built conditions, indicating a lack and their related frequencies of attention to detail or competence included in the field revisions.

The licensee also plans to 1

Findinos Response by the original design engineers implement a program by the end and the design checkers / verifiers.

(February 1990) of the Brunswick Unit 2 1989 refueling outage which initiates actions from lessons learned from revi,ews of plant modification field revisions and other indicators, It is expected that one benefit of this type of program i:: a reduction in the overall number of field revisions.

The design change program was in a state of change.and not Brunswick had initiated a plan to well supported by up-to-date update site procedures to reflect site procedures. Conflicts organizational and responsibility changes. In recognition of the between the "new" Company modification procedure and need for additional procedural Brunswick procedures also and programmatic enhancements, existed. the licensee established a standing committee in June 1989 with representatives from the three nuclear sites and the Nuclear Engineering Department.

This committee provides the necessary guidance to resolve conflicts between the Nuclear Plant Modification Procedure and site procedures.

In some instances, the licensee The SW system project discussed appeared to lack an understand- )

ing of the design basis of the in response to the<0ET develops a design basis report for the service water (SW) system, and the necessity for traceability service water system, documenting the basis for the hydraulic of design input to design output. requirements of the system This was caused, in part, by a including calculations demonstrat-general lack of hydraulic ing compliance. Additionally, design calculations for the SW system. the licensee is planning to perform a safety system functional inspection (SSFI) of the Brunswick SW system in 1989.

- In many jnstances, design Deficiencies identified during basis information was not the review of the SW system

. readily available, was in the highlight the need to evaluate, process of being reverified, organize, and stabilize design or could not be located. basis information and identify This situation, in combination and resolve concerns. The with'the SW system deficiencies licensee plans to accomplish just discussed, and similar this include: (1) complete the deficiencies in the high pressure United Engineers and Constructors I

coolant injection (HPCI) system (UE&C)/GE System Design Criteria 2

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Findings

\ Response found during the licensee's 1987 self-assessment, raises questions Documentation Turnover, the UE&C Piping Design Turnover, and the about the reliability and operability SW system SSFI (2) complete of safety and nonsafety equipment under credible off-normal the SW modification review project

' conditions. plan being conducted as part of of the SW flow verification project. This review is structured to determine if modifications implemented after original design may have impacted that design in an adverse manner, and (3) evaluate results of the Modifica-tion Review and SSFI findings, and the HPCI and standby liquid control (SLC) SSFI results and open items, for trends, patterns i and significance. Determine by 4 June 30, 1990, the actions and

, priorities for additional steps

& to be taken.

Numerous design and operational In response to questions raised

weaknesses were identified with during the Diagnostic Evaluation, the SW system that collectively the licensee immediately challenged its operational . initiated an SW system readiness. Examples included

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a vulnerability to single project team encompassing failure, lack of nuclear to corporate and site engineering personnel. This team developed conventional SW header leakage a hydraulic model based on as-testing, unavailable preoperations/ built drawings and performed startup test data, improperly system testing including cross-

' performed modificatirns , and the high potential for water hammer tie valve leakage festing to validate the model. Accident of the residual heat removal SW scenarios were evaluated and a loop keep fill system. The licensee Justification for Continued i

also failed to recognize existing Operation developed to nuclear SW system flow distribution support continued operation, and capacity inadequacies during the This JC0 implemented compensatory i

performance of SW studies and modifications. The licensee measures to ensure operability until design changes could be subsequently wrote a " justification implemented. A project plan for continued operation" (JCO) which was developed to ensure included numerous short and long-term appropriate short term and long corrective actions. term actions.

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- Weak engineering safety evaluations A corporate tack force under the (10 CFR 50.59) were noted during direction of Corporate Nuclear review of modifications. The Safety is developing a consistent licensee had also made nonconformance method for performing safety reports (NCR)88-055 and 88-056. reviews. The charter is to Licensee corrective actions incorporate the best features associated with the NCRs failed to from the licen:;ee's three nuclear 3

i' i Findings Response ,

address the concern or effect of sites, corporate organizations, poor, past evaluations, and the existence of potential unreviewed and the recent industry guidance safety questions. by NUMARC on this issue. The 3 results of this effort will be to raise the quality of the licensee's 10 CFR 50.59 reviews

throughout the company. The

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corporate program for accomplish-ing this will be in place by a February 15, 1990. Procedures and training necessary to i i implement the program at all three sites and the corporate l office will follow.

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Attachment

SUMMARY

OF ANO POTENTIAL SAFETY ISSUES During the course of the DE, a number of issues were identified by the team that had an actual or potential safety impact and for which the licensee took actions to correct. In some cases, those actions were immediate and, for others, the licensee committed to review the issue and take appropriate actions in the future. The most significant of those issues and the .

related status are listed below.

Item Status

1. A question was raised regarding long- Following the DE, the licensee term availability of the 14 acre chemically treated the pond and emergency cooling pond (ultimate heat later collected 1600 lbs of fish, sink) under certain design-basis The licensee plans a similar treat-accident conditions. The maximum heat ment in 6 months to determine long-sink temperature could kill fish and term action.

block SW pump intake screens.

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' 2. An extra relay contact was found to have been incorrectly wired into An LC0 was entered until the to contact was removed. An indepth the initiation logic circuitry of inspection was conducted by the Unit 1 SW pumps P4A and P4C which had existed since 1974. The extra relay licensee in both units to ensure no other similar discrepancies existed.

contact was not part of the design RIV followed up with a special and under certain conditions would inspection to review the licensee's cause SW pumps 4A and 4C to fail to ' actions.

restart following ESF actuation.

1 3.

Waterhammer in the Unit 2 SW to The licensee completed an informal containment coolers that caused evaluation of worst-case forces from cooler tube leaks was identified water-hammer and found these forces by the DET as having degraded the could exceed those' produced during i

reactor containment barrier on at a seismic event. The licensee 4

least four occasions. The DET also indicated plans to reassess water-found the worst case scenario for hammer in the SW system and take SW waterhammer had not been corrective actions, as appropriate.

evaluated. This scenario would be during an actual ESF actuation with a subsequent loss of offsite power in which the SW return line would void.

4. Unit 1 operating procedures did not Temporary procedure changes pursuant direct the operator to align the to Technical Specifications were power source for the auxiliary made while the team was onsite to cooling water isolation valve to the direct the operators to align the same EDG usea to power the SW swing power source properly.

pump. Had the operator failed to do so, a single failure vulnerability could exist in the SW system.

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Item Status

5. Unit 1 operating procedures allowed a single failure vulnerability in Temporary procedure changes pursuant the SW system in that cross-connect to Technical Specifications were valves were normally left open. made while the team was onsite  ;

With the swing SW pump in service directing the operators to leave and with the loss of one EDG, an cross-connect valves closed.

alignment could result with the running SW pump supplying both loops: ,

This would result in insufficient '

flow to supply loads during an 2

accident.

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6.  !

Uncontrolled use of valve wrenches Night orders and Nuclear Department to open/close manual and motor-operated valves resulted in directives were revised, prohibiting excessive force being applied to the use of valve wrenches by plant ,

valve operators, damaging the valves. personnel until evaluated by maintenance / engineering.

i 7.

The Unit 1 SW system contained several The licensee was investigating small nonseismically designed lines potential changes to the non-that were not accounted for in the seismic lines to correct this design basis. An evaluation by the deficiency.

licensee during the DE showed the .

SW system could not provide the required flows for a LOCA if these  !

lines were lost due to an earlier seismic event. i

8. The doorways between the two EDG The licensee was investigating the  !

rooms for both Units 1 and.2 were installation of ba'rriers to prevent not protected to prevent flow of this potential carryover of fuel oil I

l flammable liquid through the gap at between rooms.

the bottom of the doors.

9. The design basis for the sizing of the backup air supplies for the Air-operated valve design bases were air-operated valves in the Unit 1 now scheduled to be addressed by the licensee, containment cooler SW return lines was not documented. These valves were only tested to remain shut for I 30 minutes following a loss of offsite' power. No basis for the 30 minutes existed and appeared to be too short to ensure long term containment isolation following a

. LOCA.

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Item Status i

10. The fuel oil day tank support design  !

for the diesel-driven fire pump The licensee planned to modify the {

could result in a seismically . induced support fire pump holding the diesel driven fuel oil tank to hold it- i fire that would also degrade the fire in place during a seismic event and protection system and provide a fire also to install a curb to prevent I I

source in the SW pump P48 power supply. the spread of any spilled fuel oil.

11. During control room observation, thee.

The licensee issued guidance to the NRC team members noted that Unit 2 operators regarding the need to bette operators were intending to isolate understand the Technical Specif-the SW supply to the EFW pump for maintenance without entering an.LCO. ication bases and issued a i Since the SW system represented the condition report to investigate the i root causes of these problems.  !

only seismically qualified supply to the EFW system, the team questioned "

that decision. This represented a broader need for training in l the areas of operability determination and Technical Specification bases, l j

12. Completion of inspection and testing All MOVs subject to the Part 21 for i recommended in a November 1988 Unit 2 were to be replaced during Limitorque 10 CFR Part 21 report 2R7 outage in late 1989. A JC0 was 1 regarding failures of melamine torque prepared for evaluation of operation switches was not scheduled until of Unit 1 until the mid cycle outage late 1990. No engineering analysis >

for continued operations had been in Nov/Dec 1989 and melamine switches i for all MOVs subject to the Part 21-performed in view of potential will be replaced during the mid unqualified components in certain cycle outage.

~ MOVs. ,

13. The Unit 2 design basis did not include the differential pressure The licensee began to investigate these differential pressure limits limits across the intake bay screens and a reliable power source.

to prevent damage to these screens ,

and subsequent damage to the SW system. Also, the level (and differential pressure) ,

instrumentation did not have a reliable source,of power.

14. The effects of the SW strainer A condition report was initiated foundation damage on SW system to evaluate concerns.

operability were not assessed nor was the possible damage to the SW pump as a result of an unintentional j reverse rotation combined with excessive vibration evaluated.

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4 Item Status

15. No LCO log entries were made for Managenent directed operators surveillances that removed to dot. ment LCO log entries for equipment from service. There appeared to be no administrative survei' lance testing. .

controls to prevent multiple trains ,

from being 00S simultaneously.  !

i

16. Unit 1 operating procedures did not '.

Operat'ng procedures were scheduled include the manufacturer's operating to be evised to include the limits for the SW pump motors, manufa:turer's operating limits.

17. During ESF actuation and a loss of Openir;s were provided in the SW offsite power, natural circulation air cooling of Unit 1 SW pump motors intake structure to allow natural was not in accordance with the design circulation in accordance with basis.

the design basis,

18. Control of contaminated tools in the Hot Tool Room war, severely deficient. Actions were taken to ensure that the ressonsible contractor corrected the discrepancies.

19.Section XI IST testing was.not Appropriate testing on 2 of 3 pumps i being performed on Unit 2 SW pumps. was performed while the team was '

onsite. Pump flow values were compared to manufacture's pump curves, and no degradation was noted.

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