ML20134C644
| ML20134C644 | |
| Person / Time | |
|---|---|
| Site: | Salem, Hope Creek  |
| Issue date: | 01/15/1992 |
| From: | Joyner J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Blough A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| Shared Package | |
| ML20134C519 | List: |
| References | |
| FOIA-96-351 NUDOCS 9702030228 | |
| Download: ML20134C644 (16) | |
Text
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'JAN.151092 MEMORANDUM FOR: Allen R. Blough, Chief, Projects Branch No. 2, Division of Reactor Projects FROM: James H. Joyner, Chief, Facilities Radiological Safety and Safeguards Branch, Division of Radiation Safety and Safeguards
SUBJECT:
SECURITY AND SAFEGUARDS SALP INPUT FOR SALEM AND HOPE CREEK The Security and Safeguards SALP input for Salem and Hope Creek is attached. The input covers the period of August 1,1990 through December 28,1991.
0,it;inal Signed By:
James H. Joyner James H. Joyner, Chief Facilities Radiological Safety and Safeguards Branch Division of Radiation Safety and Safeguards cc w/ attachment:
M. Knapp, DRSS R. Keimig, DRSS W. Hehl, DRP J. White, DRP T. Johnson, Senior Resident inspector R. Manili, NRR P. McKee, NRR J. Stone, NRR S. Dembek, NRR SGS Licensee Folder
. Rl:DP RI: SS Al C P ' mig oyner 1 / 1/492 1//d92 0FFICIAL RECORD C OPY O b
9702030228 970116 l'"
NEI 6-351 PDR
Licensee: Public Service Electric and Gas Company Hancocks Bridge, New Jersey Assessment Period: August 1,1990 - December 28,1991 Board Meeting Date: February 11,1992 Report Draft Due Date (SG): January 10,1992 Report Draft Due Date (DRP): January 17, 1992 :
i Prepared By: N t /- /.r-ft date fJ. Albert, Physi ity Inspector Reviewed By: /[6 p A- /7-FI date ,
- p. Keimig,'Chiefgfeguards Section i
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Analysis The previous SALP rated this area Category 1. That rating was based on the licensee maintaining a performance orientated security program which reflected significant enhancements and which exceeded regulatory requirements.
During this SALP period, station security management, which consisted of knowledgeable and experienced security professionals, continued to provide effective oversight of the security program, even under adverse conditions. When a security officer sustained a serious self-inflicted injury while on duty at the station, management conducted an intensive investigation of the incident and, without regulatory mandate, contracted a team of psychological and security consultants to counsel members of the security force and to conduct a study of security operations. This was indicative of management's sensitivity to the impact of the incident on the security organization and whether the organization contributed to the incident. Morale remained high, which was an indication of good management in a time of adversity.
Management's attention to and involvement in the security program remained evident throughout this period, especially during construction of a new warehouse which required the reconfiguration of the protected area barrier. The construction project progressed without any negative program impact. The licensee continued to aggressively address NRC findings and concerns. Operability of security monitoring equipment was high as evidenced by the minimum number of compensatory posts and a decreasing number of security events that required logging.
The licensee also continued to conduct very aggressive, in-depth and comprehensive audit and self-assessment programs. These programs were very effective in identifying potential weaknesses and correcting them before they became security problems.
Staffing of the security organization was adequate, with limited use of overtime and a minimum backlog of work on security equipment. Overtime use during scheduled refueling outages was necessary and adequately controlled. Late in the period, the licensee increased its security force by 30% in order to minimize the impact of overtime on the force which was identified as a potential weakness during the security study. Security related contingency plans that were implemented during a union job action were excellent. The use of the auxiliary guard house was effective in separating work groups. Security force members were thoroughly briefed on contingency actions, and good communications among station groups were maintained.
Corporate management continued to provide appropriate financial and technical support for the security organization and the security program. This was evident early in the period when consultants were contracted to conduct a comprehensive study of the security program and organization, and throughout the period as a systematic upgrade of the aging assessment aids continued. Support was also apparent by the increase in security force staffing.
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As evidenced by responses to Fitness-for-Duty (FFD) events throughout the period, the licensee continued to implement a clear FFD policy. The policy has been effectively promulgated to employees and contractors, and measures established to implement the policy were properly maintained. In addition, supervisors continued to demonstrate their knowledge of the program and its implementation.
In addition to a team of licensee security supervisors who provided effective day-to-day oversight of the contractor security force, the licensee continued to maintain a well-developed and administered security force training program. The effectiveness and quality of the supervision and training were apparent by security officers' display of (1) knowledge in security matters, (2) attentivene:s to security responsibilities, (3) responsiveness to security problems and (4) aggressiveness in following up on identified security deficiencies. There were also a minimal number of events that were attributed to security-personnel error.
The licensee's event reporting procedures were found to be clear and consistent with the NRC's reporting requirement. Two event reports were submitted to the NRC during this period. One report involved a security officer being inattentive to duty and the other involved delayed arrival of a shipment of fuel. The licensee's reports were clear, concise and indicated appropriate responses in each case.
During this period, the licensee submitted one revision to the training and qualification plan. l The revision was of high quality, technically sound and reflected well-developed policies and procedures.
Summary The licensee continued to maintain an effective, performance-based security program which in many areas, exceeded regulatory requirements. The licensee demonstrated sensitivity and fortitude in effectively managing a very usual incident. The audits and self-assessments of the security organization, program upgrades and enhancements were indicative of excellent support from both corporate and station management for the security program.
Rating:
Category Recommendations:
Licensee:
NILC:
4
- ENFORCEMENT PANEL BRIEFING FORM Appendix B Entm Date of Board: June 20.1994 Ucensee Name: Public Service Electric & Cas - Salern 1 Docket /Ucensee Number (s): 59:272 Types of Ucensed Activities: Power Dametar Last day of Inspection: AIT - le on 4/27/94 ATTENDEES: Board Chairman: 3 Wierins Enforcement Representadve: D Holod, Coganant Secdon Chief: J White Responsible DRP Manager: E W=da-ar f.end laspector: B S-=~s Others: S Barr Potentially Escalated Violadons (include specific requirements violated): On multiple occassons the SNSS and NSS dad not update the Tannine Reauent Infor-eion Svat- (TRIS) to *=M =f: cire water -- a b.-- L- +=Ma= dis-iis enain e ----~ as read.-M by " *=etive srG e ==d TS 6.8.1.
Safety Significance / Apparent Severity Levels: Tars were renortediv h- on br-L . sienifira- is oniv for record keenina. Annarent neverity level IV. S==t====t I Root causes: M =-------M -raart=tions for onerator ar*ia= to L= al==* an-line were not elande defiaad Method of Identification (NRC, Ucense, Other State or Federal Inspector, Allegation, etc.): AIT I=e-views ;
i Corrective Actions Taken or Plaanad to Date: 1 Prior Ucensee Performance (cps, Orders, No. of Viots, Similar Viols, SALPs): 4th AIT in 4 years: a Severity Level III I violation for failure to follow omcedures with a $50.000 CP l==d in Februarv for mieht work mntrol r=l=8ad issues.
Prior Notice of Previous Problems (i.e., Audits, Information Nodces, Bulletins, NMSS Newsletters, etc.):
l Multiple Examples: See other nanaa sha=* on SRO bv===<iew cire I ear orotective interlock l
l
, Duration:
1 Delegation of Authority Determination (Materials Ucensee Only):
Board Recommendations:
h S,.
1 A.
a-
!6
\ ENFORCEMENT PANEL BRIEFING FORM Appendix B Emm Date of Board: June 20.1994 Ucensee Name: Public ServirrIlgiric & Gas - Salen 1 Docket /Ucensee Number (s): 56-272 Types of Uca==ad Activities: Power neo, Last day of T- , -:k=; AIT 8* an 4/27/94 ATTENDEES: Board Chairanan: 1 Wiseiam Enforcement Represamtative: D !" ' ';
(
Cognazant Section Chief: 1 Wh18* Responsible DRP Manager: E W- * --
Lead Inspector: B E- , Others: S Barr Potentially Facaimearl Violatsons (include specific requimts violated): On Anril 7. e '- the SNSS was f._ the
..__:. J r - . the NSS neuf - ' rod - =- : : activities - ' no ' v----' was . " '- for the ---- : l recen -
fu- -e'= as ;
- : by TS 6.I.2.
Safety Significance / Apparent Severity Levels: No SRO was . "- for the ;.._ ':S f=--4= *_"- the r= = newer was c'-- -- '= and the RO had haaa L- :- ' away frem - : of the - * -- '- ' Annarent 2-_ L level IV Root causes Method of Identification (NRC, i scaa=, Other State or Federal lamparsar, Al' ; ~, etc.): AIT ' ' .r=
Corrective Actions Taken or Plaaaad to Date:
Prior Ucensee Perfonamace (cps, Orders, No. of Viols, Similar Viols, SALPs): 4th AIT in 4 venra: a Severity Imvad III v!c.!=::aa for failure to fd -w r.r -- '-- a witii a 150.000 CP '-- ' la F.1 u v for :!:M w t --- : : c' * ' '-- i Prior Notice of Previous Problems (i.e., Audits, Informs: ion Notices, Bulletins, NMSS Newsletters, etc.):
Multiple Examples:
Duration:
Delegation of Authority Determmation (Materiale Ucensee Only):
Board Recommendations:
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j ENFOP. CEMENT PANEL BRIEFING FORM Appendix B Estm Date of Board: June 20.1994 ;
Ucensee Name: Pi hlic Service Flace se & Gas E t- 1 Docket /Lacensee Number (s): 58-272 Types of Ucanaswt Activities: Power P=dae Last day of fa===aa*iaae AIT exit an 4/27/94 ATTENDEES: Board Chairman 1 Wienins Enforcement Repramaa#ative: D Holode i
)
Responsible DRP Manager: E W=-*
r Cosmrant Section Chief: I Whida Lead laspector: B S- m Others: S Barr i
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Potentially healaead Violations (include specific requirements violated): D ;.a the Anril 7 cv=' tN ** --- did not ,
nrovide n *- ---"- infor====*iaa renard:- the -
-' ::, of the event to the NRC. See draft NOV Safety Significance / Apparent Severity Levels: I- *^*-I NRC IRC resnonne was d=8aved ===*H event was ha**ar charae *M=d b e the - ' r ' - "
- M =. Annarunt x.-div level IV Root causes:
Method of Identification (NRC, License, Other State or Federal Inspac*ar, Allegation, etc.): Self .a Corrective Actions Taken or Planned to Date: ,
1 I
Prior Uca== Performance (cps, Orders, No. of Viols, Similar Viols, SALPs): 4th AIT in 4 vaars: a Severity Level III vialasian for failure to fe!!e= - = " -a w'ih a 150 000 CP '- ' in Fd i.-a for
- h - L *-ol r" --- i i
Prior Notice of Previous Problems (i.e., Audits, Informataan Notices, Bulletins, NMSS Newsletters, etc.):
Multiple Examples:
Duration:
Delegation of Authority Deternunation (Matenals Uc-aae Only):
Board Recommendations:
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ENFORCEMENT PANEL BRIEFING FORM Appendix B Enrut s
Date of Board: June 20.1994 i
i Lican=aa Name: 7 "' - L ;c2 F! 1-- .i- & Ces " '- 1 Docket /I ac====a Number (s): 58-272 l
Types ofIJcensed Activities: Power n ==e*ar Last day of fampac* ion: AIT - ie an 4/27/94 ~
l ATTENDEES: Board Chairmaa: 1 Wi=el== Enforcement Representative: D "" ' *-
- - - ~
Cognizant Sectaan Chief: J White Responsible DRP Manager: E W land Inspector: B "- 7 Others: S Barr Potentially Fac=1=*=f Violations (include specific requirements violatadh PSEAG did ant 1) idesatafv or carrect sourious bish steam now * '
- k=* c- - --- . . ' fc." "..; 1. rke s-kr to Anril 7: - ' 2) did not c v .' t~ - e- nrablems i
with the MS-10 =-: .,: ., -- /10CFR58 Ann B. Crit XVL Corrective Aed-- )
l
^ ' by the snaarious ' * " =*-
Safety Significance / Apparent Severity Levels: The first safety inb ^*=--* - ' was - -
go, _ . p , - _. . . ,;g g, g, . g _ _2 ;7_ _ - * ,- . was -
- "- ' by the fadure of the MS-10 contrais
/ 10CfR2. Ann C. % - 1====* L C.9 Root causes: The "- - did not iA--eir, the root ---- of the sourious hish =8- !"-,- _*--- ' r *.-- to the Ansil 7 . '-
____i____g,g,,____.__;_ - _ _
_ g,, i_, e - . -
- " - - -.1 the MS10s - ' not 5=' the controls.
Method of Identification (NRC, License, Other State or Federal laspector, Allegation, etc.): Probleans were neif-revealing Corrective Actions Taken or Planned to Date: The hcensee has returned the MS-10 control circuit to its ensinal i
- l conneur- - ' - '"ned the =*an== now :.- - :-- a. E==* "'- a P A=in g ;. - - * .
j Prior Liccesee Performanca (cps, Orders, No. of Viols, Similar Viols, SALPs): 4th AIT in 4 years: a Severity Level III
- violatigri.for failure to fc"
- r.r= '-- es with a $50.000 CP * ' in FJ,.- . rv for eht.: - ". =='--a . ' -' ' '
4 i Prior Notice of Previous Problems (i.e., Audits, Information Notices, Bulletins, NMSS Newsletters, etc.): Hiah stamm now i
s' s': were - ' in nest trio d=*= fronn three r,.m.h= trins. MS-10 ea=* col r a ' - r- " == in safett valves lifd-i i occurred durine orevioins trina.
i Multiple Examples: A *---* red r-- L - ' two e - ' cidal ahew i
l Duration: MS-10 =-:-d cirVe -~a: tied in 1977. r- '*3== in c=0 wind un
- Delegation of Authority Determmation (Materials 1.acensee Only)
! Board Reco===adariaan-I 4
ENFORCEMENT PANEL BRIEFING FORM Appendix B fmm t
Date of Board: June 20.1994 Ucan=aa Name: PakHe Service FI etric gr Gas " '- 1 Docket /Lar==- Number (s): 58-272 Types of Ucensed Activities: Power MMar Last day of Inspectaan: AIT - i* an 4/27/94 A'ITENDEES: Board Chairman: J Wienins Enf
- Repr==anentive: D " '-N Cognizant Section Chief: 1 Whida Responsible DRP Manager: E W- * - --
lead Inspector: B S- == s Others: S Barr Potentially F=calatad Violations (include specific requirements violated): 1) Licemand SRO manually daned rday contacts to benans a ornigg: live la#""eci for the 12A c.*r. =!=#ar E ==. wieka
- the ==-evels m='= " hv " -4*
proceduru - d TS 6.8.1.
Safety Significance / Apparent Severity Imvels: Mananenent levd emniever knowinale violated the station administrative w_ _ '.;- e used for ha*h safetv-r=!= a' - ' - safetv-cd S " wc. 's.
- A- -.; w_ L levd IV. E-- *- ' I i
Root causes: IWar ---- ^ - = ace =*ia for eneratar =reiaa to k= a d- > . ??--- m w es== 1, ' "' - '
Method ofIdentification (NRC, License, Other State or Federal laspector, Allegation, etc.): AIT ' * * ;
Corrective Actions Taken or Plannad to Date: Phaitive disciaHa* t=I+3=*=d with SRO 4
Prior Ucensee Performance (cps, Orders, No. of Viols, Similar Viols, SA1.Ps): 4th AIT in 4 years: a Severity levd III violation for failure to follow nrocedure with a 150.000 CP issued I- n bruary for einht work control rdated issues.
Prior Notice of Previous Problems (i.e., Audits, Information Notices, B dMins, NMSS Newsletters, etc.):
Multiple Examples: See additt==8 a===8 =h==d on cire=Intar work ca=# olltmenine i~
Duration:
Delegation of Authority Determination (Materials Ucensee Only):
Board Recommendations:
4
d ENFORCEMENT PANEL BRIEFING FORM Appendix B Econ 4
Date of Board: May 41994 Licensee Name: Publien Service Electric & Gas - Salem 1 Docicet/Lic- Number (s): 50-272 Types of Licensed Activities: Power n ==atae _
Last day of Inspection: AIT a-ie on 4/27/94 1
ATTENDEES: Board Chairman: Wayne I - ' -
Enforra==# Repr==aa*= rive: Dan 18M t Cognizant Section Chief: 1^'- Whi** Responsible DRP Manager: Ed W- * -
Land Inspector: Bob ^ -m Others: Steve Barr ;
] :
i i d
Potentially F.sestated Violations (include specific requirements violated): Fd: e to '- '----? effective w.a:ive ar*4-=
f / \
for lone =* "= c ' ' - e the MS-10 c- *
-J sv ^ 'and hieh =!- - -- flow 8
- -=*:a=).Ar --- '!- B Crit XVI l s
Safety Significance / Apparent Severity IAvels: E :.a the 4/7 tr- "- ' s-_. .
v was - - "- ' ' by the .sh r e of the i
MS-10s. Alsa. the Code Safate valves - e -'- "--- .d L- '- -
'!=' for valves to not . ' after '..: a.: . L
, Root causes: 11 - - - - - - -- ' c'- - - to let - ' - - -- - - - - ' - for '-- "- -
--'-- i d- *h==
f 1 havine the - '- - - ' fi=d i
Method of Identification (NRC, License, Other State or Federal Inspector, Allegation, etc.): NRC AIT in resnoine to the t
- Anril 7 evaa*.
Corrective Actions Taken or Planned to Date: I '-- 8-~ to modife MS-le cira.ie ariar ta -*- tun of Unit 1:
4 Unit 2 = '!"1. =-- '--- ' for -* = '==a v - - :_ fin lu.c.:. ; ! : " ^' - af '* M f_. ' ' - =- :-J l r 1 Prior Licensee Performance (cps, Onlers, No. of Viol 6, Similar Viols, SALPs): AITs in - " 3 vm: ".5^K CP 4
- r=_.e, 2-- " due in 8 :. =---- : . " -
s
! Prior Notice of Previous Problems (i.e., Audits, Information Notices, Bulle*>==, NMSS Newsletters, etc.): Prahl===
i
' =:>_ _=' .;e MS-18 =-- :_ - ' safety ve:..i lin*= .: ;r.e ..; asis ;. .
- Multiple Examples: A- '-- md =- :. MU. ' . t. - ' - "-!=
- ' :. - * = w= c---
t s .n,. ,. . = - - ' = .-
$ Duration: n , ' ' t- - -+--q ,,7 with the MS-10 --- - kr * ' ' for le vm.
Delegation of Authority Detenmnation (Materials Licensee Only):
Board Recommendations:
e
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ENFORCEMENT PANEL BRIEFING FORM Appendix B En.m r s
Date of Board: May 41994 Licensee Name: PakIIca Service Electric & Gas - Salen 1 Docket / Licensee Number (s): 50-272 Types of Licensed Activities: Power n -,en, last day of Inspection: AIT Me on 4/27/94 A*ITENDEES: Board Chairman: Wayne f Enforcement Representative: Dan "" ' '
Cogannat Section Chief: John Whie, Responsible DRP Manager: Ed W- ' r Ieed Inspector: Bob E- m Others: Steve Barr Potentially Escalated Violations (include specific requirements violated): Failure to i==I-* effective corrective =r*ia==
/
for lone =8=
w' '- - wiiin the MS : . ' - ==A -
f hish = - flow t=A:eatlam f.Ana==diw B Crit XVI s
I:easad by the taik-e of the Safety Significance / Apparent Severity Ievels: D :.a the 4/7 tr- I
- recovery was e-MS-10s. Also. the Code Safety valves .se ' "---- _' Er' ^ial for valves to not m aftar e blowdownL g e,,,,,, , ,_- - _ _ _ _ _ - _. , - - _ _ g, g,, _,_;_--.__ _
. _ go, go,, ,, _ _ -- - - ,
-__ _ . _ ,__s=-__
I havine the - ' fE=ad Method of Identification (NRC, License, Other State or Federal Inspector, Allegation, etc.): NRC AIT in respo ise to the Anril 7 eva=#-
Corrective Actions Taken or Planned to Date: r *.-
-- to modife MS-10 cire=3* nrior to =*a tnan of Unit 1:
Unit 2 =c#' 1. =--- ' - ' for -e - '== V - '- fix 1;;;;.:ve.; : .u..: or as,;,.i gg,, cr -,.og _
Prior Licensee Performance (cps, Orders, No. of Viols, Similar Viols, SALPs): AITs in " 3 m 1'"K CP raca=#1v 8 --e-.d due in 8 work ea=*-ol r=Ia*=d i=====.
Prior Notice of Previous Problems (i.e., Audits, Information Notices Bulletins, NMSS Newsletters, etc.): Prahl====
C= -a with MS-10 ----^ "._ - ' fen valves 1*f'L- .'- e
. ..h tries.
Multiple Examples: A- '-- ** rod :--- - :. MSL l ;.-- - - ^ - :Li ---3 ' - - ' cire 8-*i- wa*=*
.e.L. v..i hziget Duration: Pa==* ' ' - ( - - -----i nrohlen with the MS-10 c=2-h a= ' for 10 ;; s.
Delegation of Authority DetermNtion (Materials Licensee Only):
Board Recommendations:
April 7, 1994 Salem AIT - Potential Enforcement Issues:
AREAS OF CONCERN:
a) operator errors & command and control
- poor c & c ex.: reactor not stable and operator directed a controls; NSS manipulates reactor controls w/o operator kn operators not aware of 25% power range trip t<P-10) instal command to raise reactor power to recover RCS temp not spe downpower rate possibly excessive; missed mispositioned co valve during EOP use; during EOP operators not directed to temp / secondary temp & pressure maintained below safety va b) procedure inadequacy
- rapid down power transient guidance poorly developed [
- CW alarm response procedures inadequate --
- Condenser backpressure high alarm response procedure inade -
- temporary work controls for CW maintenance not followed ,
c) corrective actions
- failure to identify cause of high steam flow indications d
- failure to take timely corrective action for MS-10 control j
h
g 6N IC: 3C h DR$ ('grm,u b
- i
' PROPOSED ENFORCEMENT ISSUES FROM THE APRIL 7,1994 SALEM EVENT B
CORRECTIVE ACTION ISSUES 4
Sourious Hiah Steam Flow Sianal i Issue (s):
' e Spikes in steam flow signals were present during three previous reactor / turbine trips, however they were dismissed after analysis determined that the condition resulted from the P-4 high steam flow setpoint change and the actual time it takes for steam flow to 4 decrease below 40E . .
e The high steam flow instruments are safety-related components directly impacting the MSIV isolation function and safety injection actuation.
Enforcement Considerations:
t
- 10CFR50, Appendix B, Criterion XVI, " Corrective Actions," requires, in part, that licensees identify significant conditions adverse to quality, determine their cause(s), and take corrective action to preclude recurrence.
Contrary to the above, spurious high steam flow signals received following the April 7, 4 1994 reactor / turbine trip had not been identified or corrected as a result of event reviews for three previous trips. The spurious high steam flow signal completed the coincident logic required to initiate the safety injection system, unneceuarily challenging the safety j system.
- MS10 Controller Deficiencies i Issue (s)
e In the 1970's PSE&G modified the automatic control system for the =tma=heric relief valves (MS10's) to prevent inadvertent opening of the valves.
e After the modification, the controller would go into saturation when the actual pressure J
was below the controller setpoint for an extended period of time. The saturated condition
- results in delayed opening of the valves in response to increasing pressure.
e The delayed response of the MS10s resulted in the code safety valves lifting. The code i
safety valve blowdown resulted in the decrease in pressurizer level and caused the second j safety injection signal.
4 e The MS10s are designed to control steam generator pressure and prevent the code safety valves from lifting.
j; e 'Ihe MS10s are not safety-relatM components and are not credited in the accident
- analysis.
. Enforcement Considerations:
e A,\\
! PROCEDURAL GUIDANCE /ADlIERENCE ISSUES ,
Byoass of Circulatine Water Pumo Protective Interlock Issue (s):
e The SNSS left the control room during the transient to over-ride a circulator pump permissive interlock and restart the 12A circulator pump in an attempt to maintain condenser vacuum.
e The circulating water pumps are not safety-related and are not credited in the accident analysis.
Enforcement Considerations:
- The procedures required by TS 6.8.1, examples of which are listed in Appendix A of !
Regulatory Guide 1.33, are specific to safety-related equipment.
- A recent violation was issued because operators placed a safety system in an abnormal lineup for existing plant conditions. Detailed procedures required for these maintenance activities, not within the skills of normally qualified personnel, did not exist.
- This may be an additional example of non-adherence to an established work practice even though it is non safety-related equipment.
Work Control At The Circulatine Water Intake Structure l Issue (s):
- Special work control procedures were established to facilitate quick restoration of failed circulating water screen shear pins.
- De special work control procedures allowed a local shift supervisor to approve work and blocking tags during screen repair, bypassing normal work control oversight.
- Records that are procedurally requimd for all work performed were not maintained during the April 7th event.
- The circulating water pumps are not safety-mlated and are not credited in the accident analysis.
- Enforcement Considerations
- Records concerning safety-related work are required by 10CFR50.
- Although not a regulatory requirement, recora retention for nom 'fety-related work is a station work practice and procedural requimment for all mainteie :e.
- This may be another example of non-adherence to an established work practice even though it is non safety-related equipment.
Licensee Communications Issue (s):
- Event Classifications and Notifications were per procedure.
- During the initial notification of the Unusual Event, NRC expectations were not. met regarding the icvel of detail of the telephone reports to the NRC and the Salem communicator's ability to discuss the event and answer questions that would enable the
> NRC to quickly assess the event to determine the appropriate NRC response posture.
Enforcement Considerations:
- No regulatory defmition for effective communications.
l
- Control of Ranid Power Reduction Ooerations Issue (s)
e The grass intmsions at the circulating water intake stmeture at Salem are a seasonal phenomenon. Grass hitrusions during t!:e spring of 1994 were more frequent than previous years.
- Procedural guidance exists for normal shutdown and for loss of condenser vacuum.
- No procedural guidance exists for the expected conditions resulting from a rapid power dccrease in response to grass intrusion, despite the fact that this type of power reduction is a recurring event.
Enforcement Considerations:
- 'Ihe procedures required by TS 6.8.1, examples of which are listed in Appendix A of Regulatory Guide 1.33, include general plant operating procedures for changing load.
- 10CFR30, Appendix B, Criterion V, " Instructions, Procedures, and Drawings" requires that activities affecting quality be prescribed by procedures of a type appropriate to the circumstances.
Contrary to the above, no procedures at Salem provide guidance on appropriate operator i
actions for rapid power decreases in response to the intnision of grass and resulting loss of the normal heat sink.
OPERATOR COMMAND AND CONTROL ISSUES See other materials
1 .
2 NOTICE OF VIOLATION
\
Salem Docket No.
License No.
During an NRC inspection conducted on March 1994 a violation (s) of NRC requirements was (were) identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix 0, the Nuclear Regulatory Commission proposes to impose a civil penalty (ies) l pursuant to Sectio 234 of the Atomic Energy Act of 1954, as !
amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. l 1
Salem Technical Specification 6.1.2 states, in part, "The Senior Nuclear Shift Supervisor or, during his absense from the control room, a designated individual, shall be responsible for the control room command function."
Contrary to the above, on April 7, 1994, at 10:47 a.m, the control room command function was vacated when the Senior Nuclear l Shift Supervisor left the control room area, and the designated individual, the nuclear shift supervisor, assumed the duties of the nuclear control operator.
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I UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMIS SION
Title:
DisCossroN or SALEM unir i aEsrAar PUBLIC MEETING LOCatiOD: RoCKVILLE, MARYLAND 1
h&[6' MAY 9, 1994 Pag 6Sl 87 PAGEs SEGRETARtAI RECORD CO NEALR.GROSSANDCO.,INC.
COURT SEPORTERS AND TRANSCRISERS 1323 Rhode Island Avenue, Northwest Washington, D.C. 20005 (202) 234-4433
{\
po m m er
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DISCLAIMER -
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i Tliis 'is an unofficicl transcript of a meeting of the United states Nuclear Regulatory Commission held on 1
MAY 9, 19'94"
?
in the Commission's office at One j
i White Flint North, Rockville, Maryland. The meeting was - .
open to public attendance and observation. This transcript e
- L i
has not been reviewed, corree,ted or edited, and it may 1
- contain inaceutacies.
1 .a The transcript is intended solely for general
- informational purposes. As provided by 10 CFR 9.103, it is
- not part of the formal or informal record of decision of 4
f the matters discussed. Expressions of opinion in this
! transcript do not necessarily reflect final determination l
l or beliefs. No pleading or other paper may be filed with the Commission in any proceeding 'as the result of, or l
, addressed to, any statement or argument contained herein,
- except as the Commission may authorise.
i l C0' Pd 62 33) ' P6. -
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1 UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION DISCUSSION OF SALEM UNIT 1 RESTART PUBLIC MEETING I
I Nuclear Regulatory Commission One White Flint North Rockville, Maryland l
Monday, May 9, 1994 I The Commission met in open session,
! pursuant to notice, at 2:30 p.m., Ivan Selin,
! Chairman, presiding.
l COMMISSIONERS PRESENT:
IVAN SELIN, Chairman of the Commission KENNETH C. ROGERS, Commissioner FORREST J. REMICK, Commissioner NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RN ISLAND AVENUE, N W.
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2 STAFF AND PRESENTERS SEATED AT THE COMMISSION TABLE:
JOHN HOYLE, Acting Secretary KAREN CYR, Office of the General Counsel JAMES TAYIDR, Executive Director for Operations WILLIAM RUSSELL, Director, NRR -
THOMAS MARTIN, Region I Administrator
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ROBERT SUMMERS, AIT Team Leader 't -
CHARIES's MARSCHALL,- Senior Resident Inspector, Salem / Hope Creek E. JAMBS FERLAND, Chairman of the Board and Chief ;
.i Executive Officer, PSEEG STEVEN ' E. MILTENBERGER, Vice President and Chief Nuclear Officer, PSEEG 4 . . . _
JOSEPH J. HAGAN, Vice President, Nuclear Operations and General Manager,' Sales Operations, PSE&G l e
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l NEAL R. GROSS !
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3 1 P-R-0-C-E-E-D-I-N-G-S 2 2:30 p.m.
3 CHAIRMAN SELIN: Good afternoon, ladies 4 and gentlemen.
5 We would like to thank the representatives 6 of Public Service Electric and Gas for coming in to 7 meet with us today. Today's presentation concerns the 8 recent event at Salem, a little bit of the history, 9 the actions Public Service Electric and Gas has taken 10 in preparation for restarting the plant.
11 After the licensee's presentation, the NRC i 12 staff will also make a presentation on their results 13 of the review of the licensee's activities, 14 particularly the AIT that was just conducted.
15 Copies of the slides for both 16 presentations are available at the entrance to the 17 room.
18 Commissioners, do you have anything?
19 Mr. Ferland, thank you for being here.
20 The floor is yours.
21 MR. FERLAND: Thank you, Mr. Chairman and 22 welcome to the other Commissioners. It's good to see
- 23 each of you again.
24 For the record, my name is Jim Ferland and 25 I'm the Chairman and Chief Executive Officer of PSE&G.
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1 I have been extensively involved in the nuclear 2 industry for more than 20 years, including duty as 3 manager of the three unit. Millstone site at Northeast 4 Utilities and have held a senior reactor operator
-5 license on Millstone Unit 1. .
6 . _
In March of this year, I,. completed a six i
7 year term on the Board for the. Institute of Nuclear 8 Power Operations, the last two years as chairman and 9 I am currently an. Executive Committee. member of tha 10 . Board of the recentl) formed Nuclear Energy Institute.
11 , PSE&G.has owpership interest in the Peach l
,12 Bottom, Salem and Hope Creek . nuclear plants and ,
13 operating responsible for the latter two. These l
14 facilities and: the investment., in them exceeds $6 15 billion and last year PSE&G's share of their output i 16 represented over 43 percent of our total electric 17 generation. The successful operation of our nuclear 18 units is of paramount importance to me and to the 4 19 organization that I represent and I hope that in my 4
20 remarks today I can convey some sense of that to you.
j 21 In a few moments I'll turn the program 22 over to Steve Miltenberger, our Chief Nuclear Officer, 23 on my right, and then to Joe Hagan on my left, our 24 Vice President and General Manager of the Salem
- 25 station for a review and discussion of the April 7th NEAL R. GROSS COURT REPORTERS AND TRANSCP.WERS 1 1323 RHODE ISLAND AVENUE. N W.
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1 incident at Salem.
2 Beyond their in-depth discussion of that 3 event, I felt it important to provide a context in 4 which you might consider this event and our response l
5 to it. Therefore, I've also asked Steve to describe 6 our very recent history at Salem, focusing on 7 important areas where we've been trying to improve our 8 performance, highlighting improvements where apparent 9 as well as areas where we clearly have not met our own 10 expectations. We'll describe how we are addressing 11 these' deficient areas and the means we're using to 12 monit'or the effectiveness of the corrective actions 13 that we are taking. l 14 '
The Salem units and Hope Creek are located ;
15 on a common site in Southwestern New Jersey. All 16 PSE&G nuclear personnel are located right at that l 17 site. The performance of our Hope Creek unit has been i
18 outstanding and this plant has been formally l
19 recognized by the nuclear industry for excellence in
, 20 operations in each of the past several years.
21 Despite its close proximity and despite 22 the common management of many of its activities, we 23 have not met our goal of bringing Salem station to the 24 same level of performance. We're very open about this 25 and within the past few weeks I reported to our NEAL R. GROSS CCURT REPORTERS AND TRANSCRISERS 1323 RHODE ISLAND AVENUE, N W. j (202) 234 4433 WASHINGTON, D.C, 20006 (202) 2344433
6 1 shareholders at our annual meeting that S,alem 2 performance had not met our expectations. Over the 3 past several years, PSE&G has committed very 4 substantial resources in terms of both personnel and 5 dollars aimed at improving Salem's performance. Steve 6 will describe in, some d e t a i l., t h e nature of this y
7 commitment.
8 - In general terms, the dedication of, these 9 resources was intended to strengthen three aspects of 10 Salem's operations, the performance of, our people, 11 including operations, engineering and ,other support 12 personnel,. the. physical condition, of our plant and its 13 equipment, and the quality of the procedures our 14 employees use to operate 'and maintain this facility.
15 As Steve will describe, we've. improved each of these 16 areas. Some very substantially, others not enough.
17 I'd like to comment very briefly on the 18 senior level oversight of our nuclear program. I had 19 earlier described the significance of our nuclear 20 program to PSE&G and, not surprisingly, senior 21 management and Board of Director oversight is 22 comprehensive. Information available ranges from 23 computerized executive information systems which 24 provide real time nuclear status reports to very 25 detailed monthly and quarterly performance indicator NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHODE ISLAND AVENUE. N W.
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7 1 reports which address more than 100 measures of I 2 performance in key areas, including safety and 3 performance and cost.
4 A summary review of nuclear operations is 5 provided at monthly board meetings and on a quarterly 6 basis our independently chartered Nuclear Oversight 7 Committee reports ~diEactily to our board. That 8 committee is chaired by Doctor Shirley Jackson, a 9 member of the board, and among its other members 10 includes Phil Bayne, Sol Levy, Neal Todreas an'd Hank
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11 Houckle.
12 At this point I suggest that Steve and Joe 13 provide their portion of our presentation. Following I
14 their presentation, I have a very brief summary of the 15 message that we've tried to convey this afternoon.
16 Being acceptable, I look to Steve.
17 MR. MILTENBERGER: Thank you, Jim.
18 I'd like to cover some of the specifics of 19 the April 7th event. I'd also like to talk over some 20 of the issues over the last several years and our 21 overall assessment of the Salem facility.
22 (Slide) As we take a look at the 23 specifics of the sequence of events from the April 7th 24 event, we see this as a complicated event that 25 challenged my staff. And as I look it overall, with NEAL R. GROSS !
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8 1 a few exceptions, my operators in the plant did l 2- perform well.
3 As we take a look at the beginning of the l 4 event, both Salem Unit 1 and Unit 2 were at 35 percent 5 power. The . reason for hobiing the,. plants at 75 6 percent power ,was the experience we'd baen .having ,
t 7 earlier in this year,due to the grass at the intake 8 structure, causing the intake screens to plug up and .
, 9 the loss of circulating water pumps., Providing .the 75 10 percent power range provided some additional, room for 11 the operators in maneuvering the. plant.and additional, 12 cushion based;on the loss cf circulating . water, pumps.
13 on this particular day.of April 7th, we 14 experienced . a . large intrusion of gras,s into this 15 intake structure. Power was rapidly. reduced because 16 of this excessive grass at the circulating water 17 intake structure. We had previously assigned special 18 crews out at the intake structure that were supervised 19 and included both operations and maintenance personnel 20 to maintain this facility around the clock, seven days 21 a week. So, we had provided some additional coverage 22 at the intake.
23 To give you some flavor of the amount of 24 grass that-we were seeing is that we actually monitor 25 and measure the grass through one of our consultants NEAL R. GROSS COURT REPORTERS AND TRANSCRISERS 1323 RHODE ISLAND AVENUE, N W.
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9 1 that we have in the Delaware Basin. Over the last 20
.. 2 years, we've been taking data and information on it 3 and during this particular year, 1994, it's the 4 highest we've seen in the last'20 years and this 5 particular ' day one of the very high peaks. We 6 experienced about four times the normal concentration 7 of grass we would see in the highest-during a spring 8 activity. This particular winter was exceptional in 9 that the large number of ice storms that we had and 10 experienced created ice back in the back marsh. As 11 you're aware, our plant is surrounded in the Delaware ,
12' Basin by the marsh and the grass. The significant ,
13 high tides we had, along with the ice, combined to 14 provide the opportunity for grass to be carried into 15 the river stream.
l 16 Power was reduced to less than ten 17 percent. Going less than ten percent (Aabled the 25 18 percent reactor trip. At this point, the shift 19 supervisor had made en decision to take the unit off l
20 line and was in preparation of doing that. The !
I 21 operator pulled the control rods to raise temperature, I l
22 causing the plant to trip at 25 percent power.
23 (Slide) One train of safety injection -- 1 24 CHAIRMAN SELIN: Before you go on --
25 MR. MILTENBERGER: Excuse me.
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10 1 CHAIRMAN SELIN: . As I understand it, there 2 was a -- I ' ll make this . a. question. Was .there a 3 certain lack of synchronization between the reactor 4 operator and the. turbine operator's. actions up to the 5 point where power dropped to ten percent?
6 , MR..MILTENBERGER: Yes. .I'la going to go 7 into that in .some ,more detail , and ,, talk about the 8 operator, actions and what we found ,as far as the root 9 cause or causal factors. That was a piece that 10 contributed. . The communications between the . shift 11 supervisor and., the . operators,,. contributed to the
- 12. temperature going low and the turnaround in pulling m
13 the rods to have temperature come back up. Trying to 14 do.that too quickly caused us to reach the 25 percent 15 power trip.
16 We had one train of safety injection 17 spuriously actuated and this also caused us to declare 18 the unusual event. This spurious signal that we 19 received was due to a pressure wave on the main steam 20 system which caused an indication of high main steam 21 flow which, combined with low temperature created a 22 very short duration spike into the system of about 30 23 milliseconds. This very short duration spike caused 24 some of the relays to actuate and others to not 25 actuate, complicating the event. So, one train
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1 actuated, the other train did not.
2 We went through intensive review and 3 analysis of those timings of the various electronic 4 spikes and found that all of the relays were in spec 5 and that if a real steam flow signal had been actuated 6 or indicated by high steam flow, both safety trains 7 would have functioned as designed.
8 <
The pressurizer proceeded to go solid and 9 the power operator relief valve cycled to maintain 10 pressure. There was additional time that was required i 11 by our operators in dealing with the emergency 12 operating procedures because of the two different I l
13 traine now being out of alignment. They had to l 14 analyze the conditions, understand what equipment had ;
15 not functioned, and put that equipment in place as 16 directed by the emergency operating procedures, which 17 they did.
18 During the next 30 minutes or so, as l 19 temperature increased in t.he primary system and
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- secondary pressure increased due to residual heat, and 21 our operators not manually opening the main steam 22 relief valves, we had a main steam safety valve that 23 opened causing the reactor plant to cool down and a
24 reduction in pressure. This cool down because the !
- 25 pressurizer was now solid is what caused the pressure l NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHODE ISLAND AVENUE. N W.
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1 in the pressurizer to go down rapidly under a solid 2 condition.
3 (Slide) That rapid reductionsin pressure 4 caused a second safety injection due to that low RCS 5 pressure. The operators went back into the emergency 6 operating procedures as directed, workad their way .
I 7 through them and then shut the safety trains back down l
8 as directed by those procedures. We then declared an 9 alert as a precautionary measure to ensure the proper 10 technical. support personnel vere in place to review 11 the plant. shutdown. This was not required by the 12 technical conditions of the plant, but we decided it 13 was the prudent action to take.'
14 ,
Later on, pressurizar level was restored, 15 emergency procedures were exited and normal cool down 16 was initiated and the alert was terminated later in 17 the day.
18 (Slide) Before we start on the causal 19 factors, let me cover how we view the event relative 20 to safety significance. The event is significant and 21 has been recognized by PSE&G by a thorough analysis 22 and corrective actions that we've undertaken relative 23 to the event. This event represented a number of 24 challenges to our safety systems to include a trip, 25 two safety injections. The second safety injection NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHOOE ISLAND AVENUE, N.W.
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13 1 was pressurizer solid that repeatedly challenged the
.- 2 PORVs.
3 Significant challenges to the operations 4 crew during this event with the rapid power reduction 5 and the low power operation, complicated event caused 6 by spurious signal, which led to a misalignment of the 7 safety injection trains. That misalignment 8 significantly contributed to the complication.
- 9 Although some errors were made by our 10 operators and a number of challenges from what was l 11 going on in the plant, the operators responded well to
- 12 really diagnose what was happening and shut the plant 13 down in appropriate fashion.
14 There's a number - of important lessons 15 learned for PSE&G and the industry and I will cover 16 those in my corrective actions.
17 We did both a plant and independent review 18 in accordance with our policies at our facility and 19 directed the plant not be restarted until we 20 thoroughly understood and made the necesrMy 21 corrections. Our review led us to the following 22 causal factors. I'd like to break these into three 23 components. The first is the reactor trip. The 24 control operator withdrew the control rods too quickly 25 and improperly monitored the plant parameters. In NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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14 1 addition, the shift supervisor inadequately carried 4
2 out command and control of monitoring the plant 3 parameters and directing the resources to the priority 4 of tasks that were needed. This addresses the earlier l
5 piece. '- y .. .
6 CHAIRMAN SELIN: Except that'that's true.
7 That's the' tactical problem in what happened at the 8 turbine'and the reactor got.out of synchronization, 9 but then there's a broader problem which is why did i
10 they try to keep power? Why didn't they just scram 11 the reactor at that point-altogether? I read a little 12 bit ahead.' 'I cheated. I'm sorry about that. But 13 that doesn't seen'tb be addressed in the other points.
14 '
MR.' MILTENBERGER: What we saw is they had 15 already made -- tNey felt that the plant was stable at 16 the time. We're working through the procedure because 17 they had made a decision to take the turbine off line.
18 They were working vigorously to do that in a very 19 planned, organized fashion and follow the procedures 20 in a methodical fashion to take the turbine off line.
21 Some additional guidance that we provided them is we 22 want them to just take the turbine off and we want i
23 them to do it by a turbine trip if that's what's I
24 called for because as you look back at this scenario ]
i 25 you can see that if they merely would have tripped the NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHOoE ist.AND AVENUE, N W.
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i 15 1 turbine and/or tripped the reactor, which would have 2 tripped all the systems, they very quickly would have i 3 come out.of this. But they felt that the plant was 4 stable and that they would methodically take the plant i 5 off-line and not challenge it by giving it the trip 6 signal. .
7 CHAIFZaN SELIN: I could see a number of 8 possible reasons for that. One is the procedures 9 weren't explicit and they just didn't know what to do. l 10 The second is they're going on an assumption that each L 11 time you trip a turbine or trip a reactor, something 1
12 might happen and . you should avoid these if not l l
13 necessary or the third is some kind of an idea that 14 it's embarrassing to have a trip and you should avoid 15 them if you can. Are any.of these the cause?
16 The information I got, and I may pass this 17 to Joe in just a minute, the information that I got is 18 I look at the picture of what they saw. They thought 19 the plant was stable and they did not want to actuate 20 a trip, not from the standpoint of embarrassing or any 21 other situation, but they felt that they did not want 22 to challenge the emergency systems or other systems --
t CHAIRMAN SELIN:
23 If they didn't have to.
24 MR. MILTENBERGER: -- if they didn't have t
- 25 to and they thought they were on a very good path to ,
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- c. l 16 1 methodically take the plant off.
, 2 Joe, do you havaianything to add? ,
i 3 MR. HAGAN: We asked the operator l l
4 specifically why didn't you trip the turbine. At the 5 point they were in the scenario, their answer, the 6 senior shift supervisor and the shift supervisor, was 7 that they were concerned about introducing assecondary
-8 plant transient until they had recovered'the primary 9 systea, which was to restore the reactor coolant 10 temperature. - We askedithem specifically, "Why did you !
11 -hesitate because that was clearly your plan of attack 12 .up.until this point in time?" .Their answer'was that 13 they wanted to make sure that the primary plant was in [
14 the condition where they felt comfortable before they 15 introduced a secondary plant transient.
16 CHAIRMAN SELIN: Are'the procedures aute 17 as to what to do in the situation? Is it too 18 specialized a scenario to go to the procedures and 19 find guidance? Do you leave that to the operators to 20 judge? I just think conversely, is it clear that 21 according to their instructions they should have l l
22 tripped either the turbine or both, but they didn't?
l I
23 MR. HAGAN: Within the guidelines that 24 they had, the procedural guidelines at the time, it's 25 up to the individual's judgment on when to do that. l l
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17 1 What we've done since that time is actually given them
, 2 explicit direction on when to take the turbine off 3 line in accordance with certain parameters. We 4 also hesitate when we give them direction, but not to 5 be too prescriptive.
6 CHAIRMAN SELIN: Is a scenario like this 7 one against which people train? Had they seen 8 something like this in their training or is this 9 somewhat new to them?
10 MR. HAGAN: There's training scenarios 11 that would involve rapid down power scenarios.< This 12 particular one, I do not believe we have an exact type 13 of scenario for a loss of circulators that follow the i
14 same pattern. There are rapid -down power trending 15 that's given.
16 CHAIRMAN SELIN: In which they normally do 17 trip one or the other of the systems?
18 MR. HAGAN: In this particular case, I 19 don't know which they would have done. I've not gone 20 back and looked at all the scenario results to see 21 which --
actually what they look at is what the 22 results have. In a certain case --
23 CHAIRMAN SELIN: Say that again. I didn't 24 understand that. What they look at is what the 25 results are?
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, 1 MR. HAGAN: What the results were in the 2 simulator scenario for rapid down power. A shift i
I 3 supervisor will make a decision on what to do based on 4 the circumstances they have. This particular l
5 circumstance I'm .sure we did not have that was 6 duplicated.over the loss of the circulators and the
) 7 way they were. going. 2 .
8 CHAIRMAN.SELIN: So they vere sort of on !
9 their own; not just because of the written procedures, l I
10 but it's yourcimpression that neither the written !
11 procedures nor the training.really covered something
]
12 very close to this scenario? i
. 13 MR. MILTENBERGER: Let me cover that a 14 little bit.. -
15 CHAIRMAN SELIN: .Okay.
16 MR. MILTENBERGER: My expectation is
. 17 through the simulator and the training activities that 18 we go through. I know that when I went through the 19 SRO certification and training program, you go through 4
20 a number of scenarios not exactly like this, but you 21 go through a number of scenarios where you look at 22 your various plant parameters. When those plant i
23 parameters get out of bounds in certain areas, that's 24 what keys you in to make certain decisions about 25 tripping the turbine and/or tripping the reactor NEAL R. GROSS COURT REPORTERS AND TRANSCReERS 1323 RHODE ISLAND AVENUE, N W.
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19 1 systems. So, within those training scenarios you 2 would find examples that would fit some of the 3 elements of this but not exactly the element of this.
4 CHAIRMAN SELIN: Which would suggest that 5 they should have tripped the --
6 MR. MILTENBERGER: Our review of this is 7 that they should have tripped the turbine. That 8 should have been an early on decision. They did make 9 the decision to take the. turbine off, but they felt 10 that they were stable enough at the time to do it 11 through a procedural removing rather than reaching up 12 and merely tripping the turbine. ,
13 CHAIRMAN SELIN: I'm not trying to ask you l
14 what three Ph.D. engineers -- we know better than to 15 trust a Ph.D. engineer --
what thrt, advanced 16 engineers would have done at this point. I'm saying 17 given the total between procedures, training, et 18 cetera, what would you have expected the operators to 1
19 do, not what you would have done yourself. 1 20 MR. MILTENBERGER: What I would have 21 expected the operators to do was trip the turbine.
22 CHAIRMAN SELIN: Okay. Thank you.
23 COMMISSIONER REMICK: Elaborate a little 24 bit on the wording that they withdrew the control rods 25 too quickly. This immediately makes me think of a NEAL R. GROSS COURT REPORTERS AND TRANSchWERS 1323 RH00E ISLAND AVENUE, N W.
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20 1 period scram rather than 25 percent. By too quickly 2 do you mean too far too soon or --
3 MR. MILTENBERGER: Too far'and too fast.
4 They were operating the unit down about eight percent 5 power at the time and they observed that T,, was below 6 set point and below the tech spec requirements for 7 that. 'They were in the process of recovering that.
8 The operator withdrew;the control rods too quickly and 9 too far over a short period of time as he was 10 monitoring temperature and looking at other parameters 11 and hit the 25 percent power trip. We never should 12 have gotten to thea25' percent-power trip. .
13 COMMISSIONER REMICK: But if you'd pulled 14 the rods quickly but not too far, you would not have 15 exceeded 25 percent. -
16 MR. HAGAN: The rate is predetermined.
17 It's the amount of control rod you withdrew.
18 COMMISSIONER ROGERS: I see. That he was 19 aware though that it would trip at 25 percent power.
20 In reading some of the background material, it sounded 21 to me as if the operators were not aware that it would 22 trip when they hit 25 percent.
23 MR. MILTENBERGER: My understanding is the 24 operator was aware of that, and Joe, you can fill in 25 some data here. Never expected to get close to over NEAL R. GROSS COURT REPORTERS AND TRANSCASERS 1323 RHODE ISLAND AVENUE, N W.
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l 21 l
1 25 percent level, yes.
~ f 2 MR. HAGAN: His intention was not to l
3 increase power to anywhere near 25 percent. It's not 1 l
4 clear to us that on our review, to make it clear from 5 what we know, we believe the individuals in the 6 interviews realized that ..they had gone below ten i
7 percent power and from their training they know what 1 8 that means as far as arming P-10. It was not clear to 9 us that they had communicated that amongst the crew so 10 the crew knew that. But from our review of the rod 1
11 reactivity increase, he had no intentions of bringing 12 power up that high. It was to. restore T, .
13 MR. MILTENBERGER: liow, you touched on l l
14 another point and Joe touched on it. That's I 15 communications amongst the crew, which is an area that f 16 we've done additional work in. They didn't feel that i
17 that was a piece and it's part of command and concrol '
. 18 and that communication fits in with that.
19 COMMISSIONER ROGERS: Maybe you'll touch 20 on it someplace along the way, but reading background 21 material on this seems to suggest to me that there 22 might have been a team training problem, a question of 23 whether these folks had really -- were functioning as i
24 well as they should as a team and been trained as a 25 team as much as they were as being held accountable as NEAL R. GROSS a
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22 1 individual operators and individual performers. I'd J
~ l 2 like you to say something sometime before you're all l l
3 finished as to how you see the team' functioning in the l I
4 kind of training that you may feel may be called upon j 5 to emphasize the team functioning much better than the 6 sum of its parts, which is what you hoped to get and 7 apparently didn't get in this case. i 8 > <
MR. MILTENBERGER: We might as well touch i 9 on that now and I'll cover some and maybe Joe will 10 touch on some. a ' T' r- >
11 q The team training and" team aspect of the )
l 12 training ;is an ' area 'that .we've~ provided some l l
13 additional training and additional work to the 14 individuals and to the groups and all of our crews 15 relative to this from the experiences of-what we've 16 learned out of it.- The communications piece really i 1
17 ties in significantly with the performance of a crew 18 and how they pull together to have the whole perform 19 better than any one individual. So, that was a piece 20 that we wanted to concentrate in and emphasize on.
21 There 8s sort of two different pictures, as 22 I look at it. If I look at the teamwork amongst that 23 team prior to the trip, the number of pieces that they
-24 missed and could have improved upon, following the 25 trip and the safety injection, which tended to be a NEAL R. GROSS COURT REPORTERS AND TRANSCMeERS 1323 MHOOE ISt.AND AVENUE, N.W.
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23 1 vary complicated event for them at that time, the team 2 seemed to come together as a team, communication i
3 seemed to change. We did have one problem later on ,
4 that I'll talk about, but tho' team really came 5 together as a team'and functioned well to manage the 6 plant and ensure what was going on in the facility.
7 So, we see two aspects of that. That's a piece that ,
8 we feel we need to work on. So, we did see both 9 aspects of that.
10 The first safety injection, the operator 11 allowed primary system temperature to go too low 12 coincident with a falso short duration high steam flow 13 pulse. This is what caused'the misalignment of the l 14 safety injection trains and caused the A' train to 15 actuate and the B not to actuate. A false high steam 16 flow signal was due to a design vulnerability which we 17 learned from this event and have proceeded to 18 institute design changes to remove that vulnerability 19 from the system. I'll talk about that some more.
20 (Slide) The second safety injection, the 21 causal factors were less than adequate group 22 communications. We talked about this some and this is 23 a piece in the second half since the trip. Recovery 24 of the temperature, as primary temperature was coming 25 up, secondary pressure was also increasing. The NEAL R. GROSS COURT REPORTERS AND TRANSCMSERS 1323 RH00E ISLAND AVENUE, N.W.
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. 24 1 ' operator, not taking manual control of the main steam l l 2 relief valve, which he had been trained 3 to do so, 3 caused us to hit the steam safety valves. The design 4 of the steam relief valve automatic control system, 1
5 which is a known. problem and a design modification J 6 that had been planned,but was not implemented.
7 ; (Slide), .I'd .now like, to. cover:-the 8 corrective actions and I'd like to cover these in 9 three different ::ategories dealing with personnel and ,
I 10 training, procedures and equipment. In many ways, 11 those.three can. tie together, but I'd like.to break 12 those into . ,the parts. -We've conducted additional 4
l 13 simulator: training for all of the operating crews to
!. 14 reinforce low power operation, solid plant operation, j 15 command and control and consunications, resource 16 management, operator actions following an automatic i
17 safety injection. In particular, train misalignment.
18 We have reinforced and clarified i 19 management's expectation to all operating crews
. 20 dealing with low power and rapid power reduction, 21 along with turbine trip and reactor trip that we've j 22 already talked about.
2 23 In the procedures area, we saw a number of 24 enhancements that we could make to our procedures to i 25 provide some additional guidance; enhanced operating
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25 1 procedures for rapid power reduction and low power
, 2 operations revised operating procedures to include 3 minimum condenser vacuum and circulators and service 4 criteria for a manual trip; revised operating j 5 procedures for restoration of pressurizer level and 6 these procedural changes were reinforced through the 7 training activities.
8 In the third area of equipment --
4 9 COMMISSIONER REMICK: Excuse me. Am I to i 10 interpret those changes had been made where it says 11 " revised?"
12 MR. MILTENBERGER: Yes.
13 COMMISSIONER REMICK: Okay.
i
- 14 MR. MILTEF3ERGER
- Those changes in i
15 procedures have been made and all of the crews trained 16 on them.
17 In the equipment, we've made modifications 18 to improve the automatic operation of the main steam 19 relief valves. As I mentioned, this modification was 20 planned, but it could have been implemented earlier.
21 We made modifications to dampen the steam flow 22 transmitter sensitivity to the pressure pulses it sees 23 from the main steam system.
24 COMMISSIONER REMICK: Was that the design i
25 vulnerability that's referred to?
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26 i i
1 MR. MILTENBERGER: This is the design l l w j .. 2 vulnerability that when the main steam stop valves i I
l l 3 close.on,a turbine tri,9 't sends a pressure wave down l
! 4 the pipe and-because of the flow transmitter having i'
j 5 two taps and it sees,that wave, it creates a _ short 6 duration oscihlation amongst those two taps and about l 7 a_30 millisecond pulse is what we saw. , i l
8 We have some planned modifications to the !
9 circulating water, traveling screens which will enhance 10 thpir. ability to cope with the grass. Even.though.I !
11 talked.about the signifipant amount of grass;that.we 12 did see this parti,cular. year, these modifications are 13 looking at lighter and faster screens, new improved [,
14 rakes and some other modifications we expect to make 15 in the future. .
16 (Slide) There were some other issues that i
17 came out of the various reviews, One of them was the l
18 reactor vessel level indication system. Because of l I
19 the identification of that by the NRC and by my staff I 20 in reviewing it, we've extended the utilization to 21 shutdown. That system was never intended for that, 22 but we see it being beneficial and utilized for that.
23 The pressurizer, power operator relief 24 valves, we're going through an extensive engineering 25 analysis of the valve internals. Our valves did NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHOOE ISLAND AVENUE, N W.
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27 l 1 perform very well, did show some signs of wear and
. 2 soma minor cracking which had to be evaluated and is 3 an ongoing evaluation. There will be some important 4 lessons for us into the future.
5 In emergency plan communications, we are 6 incorporating some additional guidance to be provided 7 from the NRC, particularly at the unusual event level.
8 There was a request for some additional technical 9 information to be provided we did not have at the 10 time. We intend to include that into.our procedural 11 guidance in the future.
12 Some of the lessons learned are being 13 shared with our Hope Creek unit and with the industry.
14 (Slide) I would like to move from this 15 specific topic to the broader picture, the Salem 16 station. We reaognized a few years ago that Salem 17 plant condition and performance was not meeting our 18 expectations. At that time, we instituted specific 19 improvements to equipment, procedures and personnel.
20 This improvement focus on these three areas.
21 Equipment dealt with materiel condition upgrade, 22 corrective and preventative maintenance and backlog 23 reduction. In procedures, procedure upgrade process, 24 we revised 3500 procedures in a facility and those 25 have been issued. In the people area, it dealt with NEAL R. GROSS COURT REPORTERS AND TRANSCRISERS 1323 RHOOE ISLAND AVENUE, N.W.
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1 28 1 supervisory effectiveness, communications, work
~
$' 2 practice, standards and teamwork.
3 As I take a look at this perspective, and 4 I'll show you some results in a minute, the equipment 5 side has made some progress and we are pleased with 6 that over the last several years, but-we still'have 7 room to go. The procedural area is essentially there 8 and has moved t6,~ I'll say, state-of-the-art in the 9 industry.' The people side --
10 COMMISSIONER REMICK: Excuse me. When you 11 say state 4f-the-art, does that include human factors <
! 12 considerations in the procedures of simple things like
-13 headings and things, make them sasier to read and l
i U
14 utaderstand? ,
15 MR. MILTENBERGER: Yes,'it does.
16
COMMISSIONER REMICK: It's not only 17 correcting them technically, but making them more j i l 18 readable.- j
.l \
19 MR. MILTENBERGER: This complete rewrite t I
- 20 of our procedures was done in a very planned '
21 methodical basis. We actually had INPO come in twice 22 early on in the process to review with the guidance l 23 that we wanted to not just improve the procedures, we i
24 expected those procedures to move to a significant 25 step change from where they were and equal in the NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHODE ISLAND AVENUE, N.W.
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l 29 1 industry and that has been done.
) 2 On the people side, we have not made the 3 progress that we expect to make. We recognize this as 4 a very tough issue and is receiving our increased 5 focus. Joe Hagan will cover this area later in the 6 presentation.
7 I don't intend to cover in detail the next 8 few slides. I intend to go through those fairly 9 quickly. .
I 10 (Slide) .On the materiel condition upgrade !
11 side, we've completed -for Unit 1 and/or Unit 2 a j l
12 number of modifications in the facility. Just a 13 couple I would mention. The control room 14 modificat. ions and human factor upgrades amounts to 15 about a $45 million . expenditure to do that. The 16 upgrade of 18,000 linear feet of service water piping, 17 safety related, is in excess of $100 million. The le switchyard expansion and upgrade is on the order of 19 $77 million.
20 As I take a look at the total expenditures 21 since 1990, we're somewhere in excess of $300 million 22 on specific upgrades to the facility. That's up to 23 1994. We expect to expand about $100 million in 24 additional in 1994 and $75 million in '94 as we're 25 moving the equipment to the state we want it to be in.
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30 1 In addition to that, as we take a look at
. 2 the design changes that have been implemented,'about 3 100 of those design changes were specifically
- 4 implemented to assist the operator and operator 5 actions. There's a lot of design changes with that.
- 6 -I brought with me'a 'very simple before and i 7 af teir . book to provide just a couple of pictures.
8 There's only about a picture of before and after in 9 the book and not really intending to cover it in 10 detail, but we could do that. As you flip through
-11 here, before is on the left and after is on the right.
12 Those - of you that have not been in the ' plant in 13 awhile, we would invite you to come, pay'us a visit 14 and take a look at the plant today."~
i 15 COMMISSIONER ROGERS: Gee, it looks like 16 you turned the whole plant.
17 MR. MILTENBERGER: If I could move ahead 18 with some of the slides, since I don't plan to cover 19 those in detail.
20 (Slide) Corrective maintenance backlog, 21 wanted to some you some history of that. We've moved 1
22 from the 2500 mark several years ago to the 1000 mark.
23 This does compare favorably with industry standards.
24 Preventative maintenance overdue, similar improvement.
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31 1 program, we have instituted on 34 programs at the
~'
2 Salem facility, 34 systems. That project is now
- 3 complete.
4 (Slide) .As I mentioned, the procedures ;
5 upgrade program, you can see the progress that we've 6 made over the. years and that project is now also j 7 complete.
8 (Slide) As I take a look at the personnel 9 side, and as I mentioned, Joe will cover this in.more i
10 detail in a minute, we've done work practices and 11 standards expectations, work monitoring by both line 12 management and a secondary monitoring by our QA 13 organization. Work . control process improvement, )
14 supervisory face to.. face time, additional root cause !
l 15 training for the organization, supervisor and l l 16 management training and manager and supervisory j 17 dialogues. We now see the personnel area where we had 18 to concentrate on three areas previously. This past j 19 year and into the future we see significant i
20 concentration of energy and effort on the personnel a
j 21 side.
22 (Slide) A couple of indicators and I just 23 pulled a couple of licensee event reports, you can see l
- 24 that we've made progress in that, and personnel error
] 25 LERs at the Salem facility, we've also made progress I
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4 J
32 1 in that area.
. 2 (Slide) The assessment of results'is we 3 see improvement achieved in a number of areas. )
i l
[ 4 Personnel performaric's improvement is noted but is not l l
5 meeting our expectat! ions. The plant performance' isi 6 also not" n'esting our iexpectations, particularly j
- 7 dealing with uneventful operations and reliability of 4
8 the facility.
j 9 -
~(Slide) Because of this and a number of 4 I
] 10 reviews,'we identified'the 'need for a comprehensive j 11' performance' assessment that~was done 'this past year.
I 1 l
l'2 This cdaprehensive performance assessment was done by j l
l 13 a full-time multi-disciplinary team of 12 people for
! 14 four months of dedicated t'ine, reported directly to me i
i 15 and performed a comprehensive assessment of i
16 occurrences over the last two years. We looked for l
17 broader root causes, failed barriers, contributing 18 causal factors and common threads. I i 19 (Slide) The results- from that j 20 comprehensive performance assessment Las defined l 21 specific problem statements within three categories: l 22 management philosophy, skills and practices; people ;
i i 23 performing the work and problem solving and follow-up.
24 (Slide)' Froni the results of that 25 comprehensive performance assessment we have defined I
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l
. ._ ~ . _. _
33 1 responsibilities for resolution, prepared action plan 2 and schedules for each problem area and identified 3 performance indicators to measure progress and 4 effectiveness at a facility. Such things as work i
5 practices and standards and both line and QA 6 supervisory face to face time and leadership feedback 7 results of the performance of our supervisors. This 8 event provided some specific lessons learned but 9 overall fit into our- comprehensive performance 10 assessment.and the broader picture that we are working 11 on.
12 At this point, I would like to have Joe 13 Hagan talk about the emphasis on people. Joe is newly 14 assigned to the Salem facility. He was previously 15 Vice President of Nuclear Operations and General 16 Manager of Hope Creek. Joe brings the Hope Creek 17 management philosophy with him and an excellent record 18 of dealing with the people side of the business.
4 Joe?
19 20 MR. HAGAN: Thanks, Steve. j 21 As Steve said on people's performance --
22 let me clarify one other thing that Steve said. I did 23 work at Salem from 1977 to 1983. I had Salem 24 experience prior to going to Hope Creek. Coming back, 25 my aim coming back was to look at the Salem NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ist AND AVENUE, N W.
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1 i
34 1 performance and the Hope Creek performance and say
. i
- . 2 what's different,.why does it.seem to work and we're ;
3 having difficulties on the other, and really look at 4 people's performance and convince people that Salem's 5 performance is truly people's performance because 6 that's what our assessment'is.- How Salem performs is 7 really a reflection on how well its people perform.
8 Going in, I talked to the managers, did a '
9 personal discussion with the managers who were there.
e ,
l '10 Did my own assessment!of where they were, what they 11 were feeling, whether they believed. that, whether the
', 12 change..was through the. people.. Based on the 13 interviews and based on what we saw elsewhere in the 14 industry, I asked the managers to put together-a plan
~
15 of improvement, letting them know that the 16 restrictions were that the --
really the only
! 17 restriction was the outcome had to be successful. We 1 18 were looking for successful organization. The 2 19 conclusion I came to was there was some people --
20 changes need at the Salem plant. Not only the number 21 of people, but who were in positions at the time. We 22 did the assessments, made some personal changes.
23 Those included most recently here the department
'24 heads. A number of the department heads who were i 25 reassessed were selected to go to other slots. )
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35 1 Additional people were promoted and brought in. We !
2 did bring some of the Hope Creek people over, keeping 3 in mind that they were people who were needed at Salem 4 and were in the position on Hope Creek side as far as !
I 5 performance, were in line for promotion. We decided 6 to give them an opportunity at the Salem plant.
7 The staffing' levels that we talked about 8 I asked the management team to put together the 9 organization, looking from my assessment on three key 10 areas that I saw that needed improvement and we 4
11 defined them as focus, ownership and teamwork for the 12 individuals in the Salem staff. They put together an 13 organization with no restraints.
1 14 Looking at the organization in place is 15 comparatively low as compared to the industry.
1 16 There's about --
at the time that I became VP of )
l 17 Nuclear Operations, it was 530 line functions, line 18 people. We increased that number to -- it was 570.
1 19 I may have said 530, it was 570. We took that to 630 l
20 people, looked at it again, looked at what the l
21 situations were in terms of work load, decided that l 22 the organization that would work the best for us was 4 l
23 partially unitized for Unit 1, Unit 2 within '
- 24 maintenance, operations and station planning, and with 1
, 25 that decided on a number of about 700 people. That's !
l i
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36 1 still up in the air a little bit with a few people, 2 but it's about 700 people, which gives us about 350 3 people per unit. 1 a
! 4 Looking at the industry and our experience 5 on Hope : Creek side, the line management right now
! 6 feels comfortable with .an organization that's going to 4
7 do the job for us. As part_of the rebidding, I said 8 the Department engineers were reselected here. .The 9 next line or next level of supervision 1,s,the senior 10 supervisor level. That's a second level supervisor.
11 They're going thrpugh an assessment process.where we i 12 had brought in an outside firm to.put together the 13 assessment. process for us. We combined that with our 14 own interviews and make seleqtions for the best people 15 or putting the right people in the right jobs, which 16 from what we see right now there's some indivi. duals 17 that are in the process of being changed out. So, we j
19 want the right people in that can do the job and get 19 the people behind them as far as doing the work.
20 Part of the areas that we're looking to 21 improve or we have our emphasis on is the training.
22 As far as people skill training, there's about 2400 23 individuals in the Nuclear Department. All those 24 individuals have gone through what we call-reaching 25 our vision training, which is overall assessment of NEAL R. GROSS count nepoareas ANo TaANacamens 1323 RHODE ISLAND AVENUE N.W.
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k 37 1 what the company is trying to do, what the department
, 2 is trying to do. We also have a set of team training, 3 we call making the difference. That's being 4 implemented now. We've just started that this year..
5 We've had a number of people through that. They go 6 through as teams. We also have developed the business I 7 leadership training for our supervisory personnel.
3 4
8 That's a five week program that's spread out over a i
^
9 six month period where you go for a week and then l 10 you're back for a month to implement the things you've i 11 learned. All..the supervisory personnel will go I 12 through that training..
13 The increased supervisory time in the 14 field, one of the. major things I'm stressing coming i
j 15 back in is to make sure that we are out in the field
+
, 16 doing essentially the supervisory skills that have to 17 be done, the monitoring and assessment of what our 18 people are doing in the field. The managers know my 19 expectation is that they will spand approximately 40 4
- 20 percent of their time in the field doing just that.
3 21 I won't say that we've been extremely successful in 22 getting the 40 percent time in the field right now, 23 but it is much improved on where it was. I use my 24 assessments when I'm out in the field. My 25 observations are what I'm seeing to judge how well NEAL R. GROSS COURT REPORTER $ AND TRANSCRSERS 1323 RHODE SLAND AVENUE, N.W.
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38 1 it's being done.
2 The accountability through performance 3 appraisals, this is an emphasis on making sure we give 4 honest feedback to people. Too many times in the'past 5 we've seen them just used as a checklist. We want i
6 honest , assessment 4 of people's performance, their
- 7 ability.and direct' feedback to the people as far as -
3 8 what the expectations are in terms of-performance.
9 We've developed the dynamics of leadership
- 10 model,. as we call it. It's training that was a
g 11 developed between myself- and the human resources 12 personnel with people who we doen to be very
- 13 successful supervisors and'those in the organizations 1
14 who are supervised and defining what they see as
! 15 behaviors for excellent supervisors. We developed the 16 training. I personally gave - the .: training to - all 17 supervisory people. There's about 440 or so.
l 18 (Slide) That's the model on the next i
19 couple slides here. The supervisory model is the 20 round model. These are a couple take aways or walk
, 21 aways that we have for the training.
l 22 What we tried to do was to develop the 23 model to build it around the sense of teamwork and the 24 elements are there.
25 (slide) The back of the card, the next i
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39 1 slide, are what I call the basic behaviors, to make it
.. 2 very simple, on what's a vected. The emphasis is on 3 the identification and the solution of problems. As 4 I said, we tried to keep it very clear in terms of my j 5 language, if you will. What it boils down to, if it l I
6 doesn't look right, feel right, small right, then say 7 something because it probably isn't right. That's 8 what we emphasize with the supervisors. That's what 9 they have to encourage from their people. This really 10 was our answer to supervisors who say, "Well, how do 11 you.want.ma to supervise? What is it that I am 12 supposed to do?" Very simple form or a' clear format 13 on, "Here's what we want to do. Here's what we think 14 is important that you be doing."
15 COMMISSIONER REMICK: Joe, what's the time l 16 period of the performance assessment and then the ;
17 corrective action that you've been referring to? :
18 MR. HAGAN: The performance appraisal --
l 19 COMMIOSIONER REMICK: Yes, how recently. {
20 MR. HAGAN: The actual enforcement and the 21 changes that we started in December. So, the changes 22 are in place, but the actual performance appraisal 23 cycle is a year. If there's performance problems 24 there, then it's really -- part of what the training i l
25 shows, it's up to the supervisor to deem whatever time
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8 l
f 40 1 frame that is. You can have performance appraisals on
.[ 2 a monthly or quarterly -basis if the performance 3 warrants that.' -
- 4 COMMISSIONER -REMICK
- ' And you mentioned 5 the form of team training that is recent. Your staff 6 in the past had the ' standard team training that 7 industry developed?
8 MR. HAGAN: Yes, the operation staff 9 within their training has the'tean training. We went 10 through the INPO. supply: team training.' That's just 11 for ithe. Ops. staff. This training is for all 12 individuals within the department. -
13 COMMISSIONER REMICK: I see. Thank you.
14 CHAIRMAN SELIN: Mr. Hagan, how long have 15 you been at Salen? -- -
16 MR. HAGAN: I've been at Sales as the 17 General Manager since the beginning of March.
18 CHAIRMAN SELIN: This program predated 19 you, this training program? I'm a little confused on 20 the chronology now.
21 MR. HAGAN: The actual training program 22 was developed by myself as the Vice President, Nuclear 23 Operations.
24 MR. FERLAND: Joe, I might be able to help 25 out here. I think I can see where the Chairman is NEAL R. GROSS count neeOntens Ano inanseneens 1323 nHOOE ISL.AND AVENUE. N.W.
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41 1 coming from.
a.
2 Prior to taking the position Joe is in now 3 as Vice President and General Manager of only Salem 4 Station and focusing all his activities there, he was 5 Vice President of Operations of both units. So he had 6 some influence over Salem, but it was not a full-time l 7 commitment. Given the situation at Salem, we just 8 thought it was sufficiently important to get the best 9 person we feel we have in our organization. And this 10 is his full-time responsibility and he's going to stay 11 there until the place is straightened out.
12 CHAIRMAN SELIN: So you got there a month 13 before this particular incident?
14 MR. HAGAN: Yes, it was about a month.
15 (Slide) The next slide is the -- with 16 anything you put in place, any program, you have 17 measurements. The next slide is the measurements that l I
18 we've put in place, work practices and standards, 19 monitoring by the line management and QA. That's the 20 actual field observation of individuals' work 21 performance to the standards and then the tabulation l l
22 of those. And the results are shared by the managers 23 with myself and we use that to trend not only that it 24 is being done but what's the quality. What are we i
25 seeing? What are the problems that we're seeing? Are NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RH00E ISLAND AVENUE, N.W.
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42 .
1 problems correcting or being corrected? I 2 The supervisory face to face time, th'at's ,
l 3 another assessment by another supervisor of how well a t
) 4 the time is spent in face to face time, what's being i
I 5 said, what's being discussed.
i ,
~
6 Ruman' performance, the ' performance 7 indicators, ' ka look 'at"the iricident reports that we j 8 have that are related to personnel matters. Those are 9 analyzed in terms of root cause and to see what common i
- 10 threads are there, what changes'need'to be done in i 11 ternis of training or reemphasizing to our people on 12 supervisory skills if it is a supervisory' issue.
. 13 The leadership feedback results are a form 14 that'we developed and we have the buy-in from our IBW l
15 Union'me'abership that this is really a form that's l 16 used to say how we're doing, to tell us flat-out how 17 are we doing. You don't put your name on it. You 18 fill it out and it's an assessment of how we walk and
- 19 we talk. Are we doing what we said that we would? We i
20 think it's important. You tell'us.
21 We talk to the union leadership, that we 22 have their buy-in, and that's something that we're 23 doing. We're doing that on a tabulation right now on l
! 24 a quarterly ~ basis. And we also encourage the l 25 supervisors and the people that are supervised to use
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43 1
1 that to give feedback to their boss or their 2 supervisor on what they're seeing. l l
3 And the comprehensive safety index is an l 4 overall performance indicator that we use. It 5 includes such things as safety system a:/ailability and l 6 reliability, contaminations, radiation exposure, how 7 we're'doing against our componite goals.
8 With that, I'd like to turn it back to 9 Steve for --
10 COMMISSIONER ROGERS: I ha/e just a 11 question, and this might be a good time to do it, on 12 this emphasis on a unitized organization or unitized 13 organizations at Salem. Can you say a little bit 14 about what the situation was that you felt needed to 15 be corrected by emphasizing taking a unitized 16 approach? Just exactly what does that mean? What 17 does it mean in terms of how the teams in Salem 1 and 18 Salem 2 interact with each other and share information 19 and so on?
20 MR. HAGAN: We're in the process of 21 actually in implementation now. The Department of 22 Engineers at the department level are the first level 23 to be unitized. This is going to be out over about a 24 year and a half, two year time frame, because we are 25 gathering additional licenses on the operations side NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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44 1 so we can have a unit 1, unit 2 licensed operator
. 2 organization.
3 We went out in the industry.and looked at 4 a couple plants who are organized. When I stepped 5 back, what I looked at and said what do we need, you 6 know, why, I didn't:go in and say,we want to unitize 7 the plants.. I went- in and . ,said,. . what seems to be 8 missing? And the areas that I came up when I looked 9 for my assessment I felt. that needed improvement .were 10 the focus. .
11 , Say focus, that',s..the discipline on what i
l 12 you're. doing, _what you're, doing, whether you're 13 cleaning up the floor or you're doing a valve repack 14 or you're doing a surveillance on a - solid state 15 protection system, maintaining your focus, or your 16 planning in the outages, keeping the. discipline on 17 what you're doing to make sure that what you're doing 18 is the best job that you can do. .
19 The other was the ownership, 20 identification and solution of problems. I just l
21 didn't have the sense of ownership, that we can make l 22 the difference, this is our plant and we have to do 23 what's right, a reliance, if you will, on somebody 24 else doing it. And therein lies the teamwork aspect
. 25 of this. I didn't see them working well as a team.
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45 1 And so, they were the elements. I went in 2 and said, well, what can we do collectively? What can 3 we do to improve the overall performance? Unitization 4 was a piece of the answer.
5 What I view unitization as is an 6 opportunity for us to improve the areas that I've laid 7 out,-just the opportunity. It's there for us to do.
8 We have to do it.
9 When I looked at the work load, say in 10 maintenance, what comes into maintenance or operations 11 as fal: as a unit in an outage or not in an. outage, 12 therein lay the opportunity to say, well, what can we 13 do in these particular groups to increase that focus, 14 ownership and teamwork? What can we do?
15 There were a couple of the departments 16 within the station that really didn't fit the 17 unitization from their focus, it seemed to be. That 18 was RAD / PRO Chemistry. RAD / PRO Chemistry can do it 19 equally well whether it's Unit 1 or Unit 2. Also, 20 System Engineering, Technical. There's some unitation 21 right now within Technical, but it's not totally that 22 way.
, 23 So the organization itself will be Unit 1, 24 Unit 2, at the department head level all the way down 25 to the technicians within Maintenance, operations, and NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W.
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i 46 1 Station Planning. 3
) 2 COMMISSIONER ROGERS: Well, I can see some 3 gains in ownership. I,just would like to point out to 4 you, though,, that you have to be very careful that-5 this doesn't lead to a competition between 1 and 2 6 that results..in people not sharing information.
7 ,
I remember one site I_ visited some years 8 ago where plants.were identical and management thought 9 it.was a. great idea to put one reactoriin competition 10 with another reactor and they, stopped . sharing 11 information,and they,all went down.and they got into 12 real problems- as a result of it. So a sense of 13 ownership is great, but I think you don't want to lose 14 the sense;that what we learn on Salem 1 can very well 15 be useful to_ improving the performance of Salem 2.
16 And if management's view is we'll put- 1 17 and 2 in competition with each other and they'll both I 18 do better because.they'll be trying harder, there are i
19 some very serious negatives that can come out of that 20 by, you know,1 doesn't want 2 to get ahead of them so 21 they just don't tell them everything, and I think that 22 can be very bad.
l 23 So the sense of ownership is great, but I 24 would just caution you to be careful that you don't do 25 anything that disturbs the sense that we're all trying NEAL R. GROE5 i count neronisms ANo inmeeneens 1323 nH00E ISLAND AVENUE, N.W.
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47 1 to make the site the best that it can be and that
-~
2 sharing information that could have safety 3 implications and result in one plant doing a little 4 bit better, one of the two plants doing a little bit.
5 better than the other one, is something that shouldn't 6 ine -- there shouldn't be any problems with that.
7 There should be very free exchange of information on 8 how to improve performance, and so I'd just caution 9 you a little bit on that because there is a temptation 10 to say, well, let's put them in competition with each 11 other and see who does best and reward that, and that 12 can lead to some serious problems.
13 MR. FERLAND: Thank you for the caution, 14 Commissioner.
15 Steve?
16 MR. MILTENBERGER: Just a brief summary.
17 We've completed our detailed analyses and 18 reviews.
19 We've completed our equipment and l
20 procedural corrective actions.
21 We are working on one piece of equipment, 22 which is the pressurizer PORVs, so there's one piece 23 of work still ongoing and we're completing that.
, 24 We have completed our required retraining 25 for the operations personnel and we've confirmed the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOOE ISLAND AVENUE. N.W.
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48 1 broader equipment and personnel issues that are
[ 2 addressed by long-term actions. A number of those 3 we've covered.today, what we're accomplishing. 1 j 4 Based on ..our analysis. and corrective -
i 5 actions that we've undertaken, I have the confidence 6 in the Salen management, team and their ability to 7 safely operate.the Salem facility. .
8 . Jim? m, 9 , MR. FERIAND: If I can, just sort of 1
10 summarize, this is a lot of.information really in a -
4 11 short time period. , , g. . ;
12 ,.
.If there were only two things you could
- 13 come away with from this meeting, I would hope that 14 those would include, one,, that the safe and reliable 15 operation of all of our nuclear facilities is of 1
16 paramount importance to our organization, which it is.
17 I would hope you'd come away feeling that i 18 the senior management and the. directors of the l
19 corporation are involved and feel fully responsible 1 20 for the activities that are going on at our 21 facilities.
22 We do acknowledge the need to further 23 improve Salem's operations. It's not at the Hope 24 Creek quality level yet. We want it to be. We are ,
l 25 committing the necessary resources to produce that
' l NEAL R. GROSS COURT REPORTERS AND TMANSCReERS i 1323 RHODE ISLAND AVENUE, N.W.
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l
49 1 result, whatever those may be.
2 And we have exhaustively analyzed the 3 April 7th event. I think we understand its safety 4 significance and our corrective actions, both the 5 short-term and the longer-term ones that we've 6 described, are responsive, we. feel, to the identified 7 deficiencies. With the improvement programs that 8 we've generically had underway for several years that ,
9 Steve has described adjusted to include some of the 10 lessons learned from this event, we are confident that 11 Salem will continue to operate safely, as it has, and 12 that its performance will continue to get better in j 13 the future.
14 Thank you very much for your time and 15 attention. We'd be pleased to answer any questions 16 you might have.
17 CHAIRMAN SELIN: First of all, we just 18 thank you for coming. We'd like you to stay until we 19 hear the staff, because there may be some questions 20 for you after they --
21 MR. FERLAND: Absolutely.
22 CHAIRMAN SELIN: The message I've gone 23 away with, let me just tell you what it is and you see 24 if you tend to agree.
25 Number one, you're a proud company, proud NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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4 50 1 of your personnel practices and what you're doing, and s
2 therefore you're embarrassed by the difference between 3 Salem :and Hope . Creek.- I mean, good corporate 4 management should lead to a certain level,of 5 continuous performance.
6 The second, you really weren't surprised 7 by the event. I don't mean the specifics, but you had 8 taken actions a while ago, hopefully right after the 9 turbine event at Salem, because, if you hadn't taken
, 10 actions, something might-happen. And in fact, it 'did.
l 11 I mean,- you just -- you know, it takes some time. You 12 didn't get to that point, but you probably were quite 13 concerned that something like the April 7th incident 14 would happen. Maybe not exactly that one, but that 15 was,the kind of thing you were worrying about.
16 And third, I think you've said it quite 17 precisely, Mr. Ferland. You've adjusted your plan, 18 but your plan was in place in advance to keep things 19 like this from happening. You may have learned some 20 particulars, but the call to action had gone out 21 already.
2.'t Fourth, you've done a whole lot of things 23 right.
24 And fifth, you still have problems.
25 So, you're not done there by any means.
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s e
51 1 Takes some time. But the problems of Salem, they're 2 not enormous problems but they go back for quite a 3 while. < '
4 I guess what you're saying is this time
~
5 you don't want to come here every two years, that this 6 time you really want to get down to the statistically ,
7 untreatable level of event and no worse than that.
8 Is that what you're saying? '
9 MR. FERLAND: I don't think, Commissioner, ' -
10 that I'd disagree with anything I heard in there. .
11 Certainly we are a proud company, l 12 embarrassed by the fact, frankly, that we'd not been 13 able to bring Salem to the levels of Hope Creek, that _
14 we'd not been able to do better than we had.
15 With regard to expectations on its 16 performance and what we thought, maybe characterize '
17 just a little different way than the way you've said 18 that. We have taken a lot of action over the past 19 several years and if you had asked me as recently, I 20 would say, as maybe even the third quarter of 1993, ,
21 because of some of the results that Steve has pointed 22 out to you today where personnel errors are going 23 down, I would have said things were looking pretty 24 good.
25 We went into the fourth quarter of last NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOOE ISLAND AVENUE, N.W.
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+ 52 1 year and we had one of the units out for an extended
[ 2 outage. We ' vere doing a lot of this backfitting, 3 found 'a problem with the - sleeves on the diesel 4 generators which the'n .:arried over and we had to take 5 down the second unit.
6
- Sometimes you learn something when you 7 reallf stress ad-organization, which we did. We had 8 one unit down for many months, a'second one down, and 9 sometites if you really stress a unit you learn a-few 10 things. 'When we started looking at some of the data 11 we were rolling up in the fourth quarter of 1993 --
l l 12 and 'it's information which INPO has since 13 substantiated and you're own staff, the regional 14 people, have come to -- we started finding some 15 personnel errors and some people not driving for 16 eicellence every time, every minute during the fourth 17 quarter, and that caused us some concern and it's why 18 we did decide that we had to take some additional 19 action well before April and shortly after the first 20 of the year we started looking at how we could realign 21 the top management at the station and the people under 22 ttem.
23 I don't want to delegate responsibility 24 for our shortcomings strictly to the people at the 25 plant, because I really feel like when you don't get NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N.W.
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4 53 l
l 1 the results that you want the management of the j 2 corporation from the first line supervisor to the CEO 3 has C) got soma 4 ccow, K.171ty and responsibility for l l
4 that. I certainly feel responsible for our inability j l
! S to get that facility where we want. 1 l l 6 We think we've taken the steps that are 7 necessary. If we haven't, we're going to learn from 8 everybody we can learn from. We'll adjust it again as 9 we go on down the road.
10 CHAIRMAN SELIN: Commissioner Rogers?
11 COMMISSIONER ROGERS: One thing that you 12 said, Mr. Miltenberger, caught my attention and it 13 somewhat connects with just this-little discussion j I
14 he rt, . That was that, in your opinion, if I've got it 15 right, very early on in this event the control room 16 team didn't quite come together the way they should, 17 but as the events unfolded they did, and that the way 18 they ultimately handled the situation was one tnat you 19 felt was well done and you felt comfortable with it so 20 that you really could look at the event as having two 21 phases in a certain sense with respect to the way the 1
2 'a '
team itself in the control room behaved.
23 Is that --
24 MR. MILTENBERGER: That's a good 25 characteristic of it.
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54 1 COMMISSIONER ROGERS: Well, if that's the 2 case, you know, then it'seemed that that's the typical 3 ' complacency problem, in a5 certain sense, that the 4 ability to do the job is there and when the pressure 5 gets high enough all of a sudden the best is-brought 6 out in everybody and the team as a group functions.
l 7 But up until that point, somehow they haven't really 8 done as good a job as they're capable of doing,2 either i
9 in'being alert to little things or whatever.-
i '10 "
- If that's the case, it seems to me that j 11 that's part of the issue that ycu have to deal with in
'12 corrective action and that is probably the biggest ,
13 problem of the whole industry, and that is that it is j 14 'very,-very difficult to keep everybody at their peak 15 all the time. -It isn't that the capability d6esn't l l
16 exist, but we've seen so often groups of people that 17 are really-- they have the resources, they have the 18 smarts, they have everything, but somehow they slip 19 because they've allowed themselves to not keep that 20 edge that really has to be there day in and day out, 21 hour in and hour out in running a nuclear power plant.
22 I would hope that somehow that in your 23 program here that you have a way of kind of testing 24 yourselves~ with respect to how close to peak 25 performance people are actually operating at, because NEAL R. GROSS court REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W.
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l 55 J
1 most of the, time you don't need it. I mean, things !
-. \
2 are running well and you feel pretty good about 3 things, but that team then has to go into operation 4 very, very quickly at its best. Not at its second 5 best, but at its best. That's a very severe challenge 6 to put on anybody or any group of people and yet 7 that's really what one has to strive for.
8 I don't know whether in your planning and 9 thinking here you've explicitly tried to deal with the j 10 question of how do we know that we aren't slipping a j l
11 little bit? It's a very di Jult question. It's not l 12 easy at all because the evidences of a slight 13 softening of the crispness ' that ought to be in an 14 organization is sometimes very difficult to detect.
15 But it seems to me that that's really what 16 management's job is all about, to be able to sniff 17 that out and detect it before it starts to get very 18 far.
19 So, your characterization of the episode 20 here is one that I think is very interesting, but you 21 may have seen yourself what your job really is.
22 MR. MILTENBERGER: That's a very good 23 perspective :> t you provided and it fits in for us, 24 particularly with the operation staff. We had the 25 ability with the simulator and an actual job NEAL R. GROSS COURT REPORTERS AND TRANSCReE8tS 1323 RHODE ISLAND AVENUE, N W.
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I 4
56
)
1 performance, us as management, in observing how that's !
,' 2 carried out. Just try to see that crispness #and, as
~ ~
'3 Jim mentioned, everybody carrying out their function i
4 to the - top all of the time and to see how that's E
5 carried out.
'6 '
The simulator gives us an opportunity to 7 do that. We'have that in place and'are continuing 8 with that, but we have some new initiatives we're !
9 working on in'that area and also actually on the job 10 place'Tand how simulator types- of -activities are 11 carried ~out in the work place and how those 12 differences' characterize themselves; That's 'our job i i
13 as line- management, to provide that type of
[ 14 observati'o n and characterization and direction'to the i 15 staff.
16 ~' -- C6MMISSIONER ROGERS: And the other one i 17 is, I guess we haven't really asked you that question ;
i 18 and you really didn't address it, but how ready are S
{ 19 you until we start?
a 20 MR. MILTENBERGER: Where we are relative l 21 to restart, we really are in the process of resolving
) 22 the PORV issue and installation of some new internals 23 in those valves. Expect that work to be done in the l
24 next day or so and then we'd be expecting to start the l
l 25 unit later on this week, early nu.t weak.
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57 1 COMMISSIONER ROGERS: Thank you.
2 CHAIRMAN SELIN: Commissioner Remick?
3 COMMISSIONER REMICK: We haven't seen the 4 AIT report yet, but it was my impression that 5 subsequent to the event you found some non-6 condensibles in the reactor vessel. What was the 7 situation there?
8 MR. MILTENBERGER: The situation with the 9 non-condensibles dealt -- and.I did mention it very 10 briefly in here, but I really didn't cover the kind of 11 detail maybe that you're looking for. That dealt with 12 the RVLIS system identified by the NRC. The RVLIS 13 system was drifting down and then observation and 14 subsequent analysis by our staff determined that we 15 indeed did have in mode 5 of operation in cold 16 shutdown with the unit depressurized and intrusion of 17 nitrogen gas that was coming out of solution in the ,
l 18 vessel and gradually moving the level of the vessel l l
19 down.
20 Subsequent analysis of that, we did vent 21 that off, determine and measure what it was and it was 22 essentially nitrogen that was coming in from the 23 volume control tank where nitrogen iin introduced in 24 that tank and equipment. We subsequently vented that 25 off. It is part of normal plant start-up conditions, NEAL R. GROSS COURT REPORTER $ AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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58 1 but in the mode we were in it was shut down. We could 2 see that drifting down and had to take corrective
~
3 action on it.
4 A lesson learned there for us is the 5 utilization of the RVLIS system in shutdown. It was 6 a systsu that was not,really designed or intended use 7 in that system, but we definitely -see that as an
'8 opportunity of equipment that is available, can 9 provide some indication of what the level is doing in 10 the vessel. There's some further analysis work and 11 some work with the owners groups for utilization of 12 that equipment, not only with our facility but with 13 other facilities in lessons learned. -
14 COMMISSIONER REMICK: Was this nitrogen 15 dissolved and then carried over and then came out
~
16 of --
17 MR. MILTENBERGER: Yes. It was dissolved 18 within the reactor coolant system. It was introduced 19 at the volume control tank, went into solution and 20 because of the difference in pressure between the 21 volume control tank and the reactor vessel, it would 22 come out of solution in the vessel.
23 COMMISSIONER REMICK: Is there any reason 24 why RVLIS hasn't been used in those conditions before?
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59 1 to use RVLIS in mode 5 because as advertised it's not i 2 a calibrated system. It's not cold calibrated. So, 3 it gives you a qualitative indi::ation of level, but 4 it's not one that you would base your procedures on.
5 As we understand the system, our mode 5 log was not a 6 required log. ' When the question was asked to the 7 operator, the answer was really in that particular 8 mode ~ they weren't used to looking at RVLIS. They .
9 didn't have a crisp answer or understand on the spot 10 what it was because we just don't take that reading.
11 COMMISSIONER REMICK: So, the indication 12 was available, but they're not used to looking at it 13 in that mode. Is that what you're saying?
l 14 MR. HAGAN: Yes, that's essentially it.
15 COMMISSIONER REMICK: I see. And although 16 not calibrated, it would show changes in level?
17 MR. HAGAN: Qualitatively.
18 COMMISSIONER REMICK: Qualitatively, yes.
19 MR. HAGAN: Qut' .atively it would.
20 COMMISSIONER REMICK: Okay. Thank you 21 very much.
22 CHAIRMAN SELIN: Let's change places and
- 23 see what our folks have to say.
24 Mr. Martin, I have to tell you. I peaked l l
, 25 at the slides and we know what an AIT is. So, why l i
- NEAL R. GROSS i COURT REPCRTERS AND TRANSCMSERS 1 1323 RHODE ISLAND AVENUE, N W. l j (202) 2344433 WASHINGTON, D C. 20006 (202) 2344433 i
60 1 don't you go lightly on the procedural stuff. and 2 concentrate on what we learned from the specific event
~[
3 compared to the prepared presentation.
4 Mr.' Taylor?
5 MR. TAYIAR: Good afternoon. .With me at 6 the table are Bill Russell from NRR and from. the 7 region, Regional Administrator Tim Martin. i Bob 8 Summers, : to my right, is the project engineer, and 9 Charlie Marschall,. who . is t.~.e senior resident at 10 Salen/ Hope Creek.-
11 The licenses has pretty well outlined the 12 course of the . event and our discussion- today will 13 concentrate on NRC's response to the event. First, 14 response to the resident and the agency's.immediate 15 response, and thsn through the augmented inspection 16 team.
17 Tin?
18 MR. MARTIN: The licensee informed the ,
- 19 resident staff of the unit trip within about 15 i
20 minutes of it occurring. The senior resident :
21 responded to the control room and notified the Region i 22 I staff subsequent to that. The senior resident was
.; 23 supported by two resident inspectors, an emergency
- 24 preparedness specialist who he used to monitor and 25 assess what was going on in the plant, and he later on NEAL R. GROSS count nooniens ANo ramseneEns 1323 Met 0DE ISLAND AVENUE, N.W.
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61 1 dispatched one of the' resident inspectors to the tech 2 support center once it was established to monitor and 3 coordinate NRC activities from that point.
4 subsequently when the NRC set up their 5 incident response center, we set up the reactor safety 6 management counterpart link which the resident came up 7 on frequently to keep us abreast of what was going on 8 from his assessment.
9 The resident staff provided continuous 10 coverage and communications for the rest of that 11 evening and until the next morning when the augmented 12 inspection team arrived.
13 (Slide) Next slide, please.
14 With regard to the regional response to i 15 the event, the licensee declared the unusual event at 16 about 11:00. It would be notified to the NRC formally i 17 at 11:31. The senior resident had already informed ,
i I
} 18 the branch chief of what was going on. The branch l 19 chief informed the deputy regional administrator. The l 20 assessment at that point was that it was a trip with 21 complications, clearly something that we needed to i
22 monitor and pretty clear it was probably going to i
23 result in an augmented inspection team, at least from 4
1 24 what we knew at that point in time.
25 The deputy regional administrator got in NEAL R. GROSS COURT REPORTERS AND TRANSCMt9ERS 1323 RHODE ISLAND AVENUE, N W.
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62 1 touch with Ed Jordan and discussed what was the proper
.$' 2 mode for NRC to respond.- .It was decided that both 3 regionrand Headquarters' would monitor this situation.
4 The region and Headquarterar activated their instant !
5 response centers and 'went into a monitoring of.the 6 activities. That continued'on until about 9:00 that 7 night.
8 '- - As you know, the licensee ' terminated the 9 alert at 8:20 that evening.
l 10 With regard to the augmented-inspection 11 teau r as I indicated earlier we-had already decided 12 that -one- was probably. appropriate," The deputy 13 regional administrator contacted NRR and AEOD and it j 14 was agreed that an AIT was warranted for this event.
1 15 That decision was made during the afternoon while we 16 were still monitoring. The AIT.was/ initiated due to 17 the event complexity and the unexpected system 18 response. '
19 The deputy regional administrator informed 20 the licensee of our plans to initiate an AIT once the 21 plant was shut down and in a stable situation. We 22 didn't want to go out there and start the 23 investigation prematurely and cause them problems. We 24 also discussed some expectations of the licensee in i
i 25 establishing stabls conditions and maintaining the NEAL R. GROSS COURT REPCW.ERS AND TRANSCREERS
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63 1 plant so that an adequate investigation could be
, } 2 conducted.
3 The management lead for the AIT was 4 assigned to our Division of Reactor Safety. Bob 5 Summers, who is down at the end, was selected as the 6 team leader and we selected team members from region, 7 NRR and AEOD based upon technical expertise. We also 8 had two state observers who participated in various 9 parts of the inspection activity, but did not stay in 10 a continuous manner.
11 (Slide) May I have slide 5, please? l l
12 The AIT charter was developed and issued 13 on the 8th, which was the day after the event. It 14 required a review of the plant trip and the response 15 of management, operators and systems. It required the I 16 development of a sequence of events. It required them 17 to perform an assessment of the personnel, procedures 18 and equipment performance. It required the 19 identification of root cause and the preparation of a 20 report.
21 (Slide) May I have slide 7, please.
22 We also issued a confirmatory action 23 letter. As a result of our plan to launch the AIT, 24 the deputy regional administrator formalized our 25 expectations with the licensee and we assured the NEAL R. GROSS COURT REPORTERS AND TRANSCRISERS 1323 RHODE ISLAND AVENUE, N W.
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64 4
1 licensee was at that point comfortable with us 1
2 starting .the AIT activities. The licensee was 3 committed to keep the plant in cold shutdown, to
, 4 cooperate and support the AIT activities, and to gain f i
5 agreement 'of the regional administrator prior to t
6 restart. .
7 -
.(Slide) May I have the next ' slide,-
8 please? '
9: COMMISSIONER REMICK: Could you explain 10 the purpose of a confirmatory action letter in a case ,
t 11 like this? .
12 MR..cMARTIN: The purpose was .-- the 13 licenses had already decided to go to cold shut down, 14 but we wanted to make sure that we understood the 15 eventr that we. understood the peculiar system 16 interactions that we saw, and we wanted to make sure 17 we had time to do that before they moved forward and 18 started up. We found no indication the licensee was 19 planning otherwise, but this.was the document --
20 COMMISSIONER REMICK: That's the point of 21 my question. I know it's a routine action for us to 22 take, but I sometimes wonder when licensees appear to 23 be willing to cooperate in all the things we're trying 24 to achieve, -why we officially issue a confirmatory 25 action letter? I've asked this question before, NEAL R. GROSS I COURT REPORTERS AND TRANSCRSERS 1323 RHODE ISLAND AVENUE. N W.
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4 65 1 but --
2 MR. RUSSELL: Yes. I believe from a 3 policy standpoint that it's important to document what 4 are the specific concerns that the NRC has and what 5 are the understandings that exist between the utility.
6 These are voluntary. If the understandings are 7 different and they so inform us, we can take other 8 actions. But this is then recognized as a useful tool 9 to have the short of formal action on tho context of 10 orders or other requirements. It does need to be 11 looked at in each case. We don't require it in all, 12 although it has been practice to use a CAL in most 13 cases. It needs to be done early to identify what are 14 the particular issues because as time goes on other 15 issues could be added and you want to have a 16 relatively high threshold for adding other items on.
17 So, it really constitutes a written 18 understanding between the licensee and the NRC as to 19 what are the issues that need to be addressed and the 20 fact that we are interested in having resolution of 21 those items prior to a restart decision.
22 COMMISSIONER REMICK: How much is it 23 influenced from an enforcement interest?
24 MR. TAYIDR: None.
25 MR. RUSSELL: I can tell you from past NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHODE ISLAND AVENUE, N W.
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i l
66 1 experience that a CAL has been recognized;and.we did' ;
l 2 revise our enforcement policy to. indicate that that 1
3 could be used. That was.actually supported in a court l l
4 case where we used a CAL in lieu of orders or other i
5 approaches. It's a tool that provides us a basis for I i
6 documenting what those agreements.are and as long as j 7 those agreements are followed,. that satisfies our need ,
I 8 and it's the least -- .
l 9, MR. , TAYLOR: It is not really an ;
10 enforcement, action parcse. ' '
i l
l 11 <MR. RUSSELL: It is not an enforcement j 12; action, but -- , .. .. .
13 COMMISSIONER REMICK: No, I realize it's 14 not an enforcement action, but does - it. serve some 15 legal purpose --
16 MR. TAYIDR: It goes a clear understanding 17 between the management of the agency and the licensee 18 of what the condition is. I think it's very useful.
19 So, we both understand before restart that the issues 20 behind an event. are clearly understood by all the 21 concerned parties, particularly the licensee and the 22 agency. That's really what it's intended to do.
23 MR. MARTIN: Commissioner, I would add, in 24 this particular event we had a desire to interview 25 people. Because of the CAL, it resulted in l l
I NEAL R. GROSS j COURT REPORTERS AND TRANSCRSERS 1323 RHODE ISLAND AVENUE, N.W.
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9, .
67 1 negotiations when certain people would be available.
2 They were going off-shift. So, basically it 3 established.a protocol for interaction. It basically 4 required them before they took pieces of equipment out 5 and started troubleshooting that we had some 6 discussion so that we wouldn't later on say, "Well, 7 why didn.'t you let us take a look at that?" So, it 8 resulted in a much more orderly interaction and as a 9 result there were then negotiations with the team..
I 10 leader and the licensee to make sure that expectations 11 were not inadvertently overlooked.
12 COMMISSIONER REMICK: Yes. And I i 13 understand the need for clearly identifying what it I l 14 is. I guess maybe I associate something with a CAL
. 15 maybe that I shouldn't. If it's purely agreement of
- 16 what we agree upon, I guess I've never quite viewed it 17 that way. But if that's it, I certainly understand.
i 18 MR. TAYLOR: And in the aftermath of an
{
19 event, it sometimes is important for this type of i
20 thing just to be simply -- it's usually a one page I I
21 type letter, i l 22 MR. RUSSELL: It's. . characterized as a 23 related administrative action in the enforcement
- 24 policy in Part C and it simply says a confirmatory l
25 action letter are letters confirming a licensee's or l NEAL R. GROSS COURT REPORTERS AND TRANSCRISERS I
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4 68 i 1 1 vendor's agreements to take certain actions to remove i
. 2 significant concerns about health and safety i
]
3 safeguards or the environment So, it's not an
-4 enforcement action per se, but it's - -
1 5 COMMISSIONER REMICK:s No; I didn't know 1
6 if it added some ; legal protection if the licensee 7- decided to . start up. without the regional i ;
8 administrator, if it gave us some additional legal --
9 ..- MS. CYR: Only in the sense of it's a 10 commitment from them aboutecertain. actions that they 11 might take. > For _ instance, notify -us. before they 12- might. It's an agressent between.us and them in that i
13 sense.
i 14 CHAIRMAN SELIN: .It's intended to protect l l
15 both parties. .It's not that the licensee would l
- 16. otherwise start up without talking to us. That would 17 be quite a foolish thing to do, but that way in a l l
18 sense we've said, "Here are our concerns," and the 19 licensee knows when those concerns are met. Then it's 20 up to them. And conversely, it protects us so that j 21 equipment is able to be examined or people are able to 22 be inttrviewed. But it's a kind of a limitation of 23 interest, not just a statement that we have certain 24 items.
25 MR. TAYLOR: I agree with that.
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69 1 CHAIRMAN SELIN: There's a question mark 2 at the end of the statement. It is my understanding 3 that --
4 MR. TAYI4R: I think that's right. We're 5 available around the clock to talk to the licensee.
6 If they were ready at 3:00 in the morning, we'd be 7 ready to act. It isn't meant to inordinately delay in 8 any way.
9 Want to continue?
10 MR. MARTIN: (Slide) Go to the 11 chronology, slide 9, please.
12 The augmented inspection team arrived on 13 the site on the 8th and they would complete their on-14 site inspection activities on the 26th. The team l
15 leader held conference calls daily with regional and 16 Headquarters managers to keep them informed of the 17 status and the inspection findings. The team leader 18 also supported an event briefing on the subsequent 19 Wednesday to make sure that NRR, AEOD and various 20 regional staff were aware of the event and what we 21 knew at that time.
22 Early that next week, the senior resident 23 identified the fact that there had been a gas pocket 24 that formed in the reactor vessel and that the 25 licensee had not recognized that. That resulted in a NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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70 1 commissioner assistance briefisg subsequently.
~
2 The licensee had described their 3 corrective action plans in letters dated 4/25 and 4 4/29.
5 COMMISSIONER REMICK: .. Excuse me. How 6 extensive was.the., gas. pocket? I meant to ask.that 7 earlier. . .
8 MR. MARSCHALL: The RVLIS was indicating 9 that 93 percent, Commissioner, and it equates to a 10- very, very small volume of gas, nothing..of any safety 11 significance at all. _
12 . COMMISSIONER REMICK: Thank you.
13 MR. MARTIN: The team leader also 14 conducted a number of briefings of congressional 15 staff, including Senator Biden's staff, the Senate 16 Subcommittee on Clean Air and Nuclear Regulation and 17 the House Subcommittee on Energy and Mineral 18 Resources. That was conducted on the 24th.
19 The AIT had their preliminary exit in the
- 20 public on the 26th at the Salem site. The team has 21 since been involved in the assessment of the findings 22 and report preparation, while the resident staff has l 23 been involved in inspecting and verifying licensee l l
24 actions and preparedness for restart. l 25 On the 5th of May, we briefed Senator NEAL R. GROSS COURT REPORTERS AND TRANSCRISERS 1323 RHODE ISLAND AVENUE, N.W.
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71 1 Biden's staff at their Wilmington, Delaware office, 2 and on the 6th of May we had a public meeting at Salem 3 again, to discuss licensee'r, status and plans for 4 restarting the facility.
5 As a result of this AIT, we have concluded 6 that there was no abnormal releases of radiation to l
i 7 the-environment as a result of the event. The event !
8 and the operator response to it challenged the RCS 9 pressure boundary through multiple actuations of the !
l 10 pressurizer PORVs, through multiple operator errors !
11 which occurred and complicated the event.
12 Management allowed problems to persist and 3
13 that made responding to the event difficult for plant i
14 operators. Some equipment was degraded by the event, i
j 15 but overall the plant performed as designed.
i
- 16 operators' use of emergency operating procedures was 17 regarded as good and the licensee investigation and l 18 trouble shooting efforts were also good.
l 19 With regard to remaining activities, tic.e i
1 20 licensee currently owes us two letters, one to
) 21 describe their evaluation of the PORV operability and
} 22 the modifications they've made, and a second to 4
- 23 describe why it is not a problem with the main steam 24 flow calibration drift that has been reported in the 25 past which had some role in this event. The second 4
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-. _. .- . . _ . _ . _ . . _ _ . _ . ~ _ . _ _ _ _ . _ - _ . _ . . _ __ ._. _
72 5
1 part is confirming to us their_believe that they are 2 ready for restart and their basis for that and 3 requesting our agreement.
4 "'he NRC must obviously evaluate the 5 licensee's rationale for,. restart.. We must 6 independently conclude that the plant is ready and we ;
7 must ccordinate with NRR and the JDO's office in 1 8 releasing the licenset from the CAL.
9 f We plan once the restart has started to 10 provide around the clock inspection coverage until the 11 plant is in a stable mode.one, situation. We'll use 12 resident and region-based staff for that activity. i 13 Wo . still need to issue the AIT report. .
14 That's due later, this month. We finally must 15 determine and direct any follow-up activities and that 16 includes some long-term actions that the licensee is 17 convaitted to relative to that specific site where we 18 have to actually verify that those are completed.
19 There may be some generic issues which we'll need to 20 hand off to NRR using task interface agreements.
21 That's formally tracked. We'll have to examine our 22 inspection plans to see if this event results in us 23 changing or needing to change those inspection plans. j 24 Obviously we need to consider what enforcement action 25 we're going to take. We have not made that decision i NEAL R. GROSS COURT REPORTERS AND TfkNSCRSERS 1323 RHOOE ISLAND AVENUE. N.W.
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73 1 yet.
2 MR. TAYIDR: So that concludes the staff's 3 presentation.
4 CHAIRMAN SELIN: I have a couple questions 5 I'd like to put. Most of the discussion that the 6 licensee put forward had to do with training and 7 personnel and I think that's ai>p'apriate. But I was 8 sort of concerned, I am sort of concerned that at the 9 time of the overspeed turbine. event there were 10 solenoids that were known to need to be fixed that 11 hadn't been fixed. We have an analogous situation 12 here, the list of -- it wasn't clear to me whether 13 they were overdue actions, but repairs that had been 14 scheduled t' be done that hadn't been done. l 15 As I remember the solenoid event, it 16 wasn't that the management had deliberately slowed l 17 down the repair, but that communications on the status 18 of some of these repairs was just sloppy and 19 management really didn't know where they stood and he 20 wasn't holding the maintenance folks and the generic 21 people to the schedule.
22 Was this a pattern or is it a fluke? Are 23 you concerned about this? Are we going to have a --
24 if there were another event, are we going to find 25 other actions well known but not implemented?
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74 i
1 MR. MARTIN: We are concerned about this.
~
2 This is one of the issues that came out of the AIT.
3 We identified several examples where management Knew 4 what the situation was but had made a decision to live 5 with .the situation.. In .other cases, they had not 6 considered the integrated impact upon the operators in 7 trying to deal.with the p7 ant when a number of these 8 equipment problems. were existing. In other cases, 9 they just hadn't yet . sold the operators that the 10 systems had been.. returned to reliable operation.
11 Sp,,,I'J.1 t;ick them off for . you. The 12 atmospheric steamr dump on the main steam -- they lived ,
13 with that problem for 17 years. Yes, they did have 14 plans to fix it, but obviously didn't get to .it in 15 time and it,certainly complicated events and was one 16 of the primary causes for leading to the second safety 17 injection. .
18 .The fact that the control rod drive system 19 had been worked on for about four weeks. There were 20 some problems with it earlier. The operators saw some 21 early response when they tried to put it in automatic 22 during the event that didn't jive with their 23 expectations based upon their previous concerns and 24 knowing that the trouble shooting hadn't been 25 completed on it. They didn't trust it. So, they NEAL R. GROSS COURT REPORTERS AND TRANSCRISERS 1323 RHODE ISLAND AVENUE, N W.
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75 1 didn't have that there to support them.
2 CHAIRMAN SELIN: Was that just a bad break 3 or was that something in retrospect? You know, I'm 4 looking at these significant findings and except for 5 the second one about the event challenging the RCS 6 pressure boundary through multiple operations of the 7 pressure-operated release valves, this could have been 8 the -finding two years ago at the overspeed. The other 9 one wasn't disaster, but management allowed equipment l i
10 problems to exist. It was degraded, the plant 11 performed its design, operators did well once they 12 were finally --
13 MR.' MARTIN: The only one that is just 34 clear the licensee tolerated too long was the 15 atmospheric steam dumps. The others, they were 16 working on them. It's a question of priority and 17 considering given all these individual problems, did 18 you consider the overall impact on the distractions of 19 operators and we don't think they did a good enough 20 job there.
21 CHAIRMAN SELIN: Okay. But it wasn't a 22 cavalier attitude towards --
1 23 MR. MARTIN: I don't think so, sir. It 24 appears they made management decisions based upon 25 their assessment of the facts at that time.
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l i
l 76 1 CHAIRMAN SELIN: Okay. Second question is 2 normally events which require AITs, I guess, are more 3 serious events But we tend to have the AIT in hand 4 before the restart comes. forward. Are you comfortable 5 that even though we don't formally have a report 6 you've gone through. the material and you know what -you 7 need to know to permit the restart?- '1 8 .MR. MARTIN: With the exception of their 9 evaluation of.~ 4the PORV, we believe that we are 10 tracking right with them in terms of their assessment
. 11 of the problems and our independent assessment of what 12 the problems are. We have examined their corrective 13 action. They committed to corrective actions back in 14 late April _. We basically came to the.same conclusion 15 those were the right corrective actions. We've been 16 monitoring those corrective actions. They seem to be )
l 17 implementing them well. The thing that remains is 18 they're evaluation of the PORVs and their affirmation 19 that they believe that they're ready to start up. If 20 we don't find any additional problems in the next 21 couple of days and we get that and we independently 22 conclude that evaluation is acceptable, then we will 23 be prepared to support restart.
24 CHAIRMAN SELIN: The Commission has not 25 taken this responsibility upon itself. We're NEAL R. GROSS COURT REPORTERS AND TRANSCRtSERS 1323 RHODE ISLAND AVENUE, N.W.
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L 77 1 monitoring what you're doing. We're not intervening 2 on the restart process.
3 MR. RUSSELL: I would characterize that 4 there is one advantage also of having the CAL and that 5 is you identify the issues that are of concern, that 6 are under discussion, review between both the NRC and 7 the' company and then the process provides that the 8 regional administrator will actually issue in writing 9 our findings as it relates to those matters and the 10 process of releasing from the CAL. Now, there may be 11 other issues that are identified in the process of 12 developing the final report, but we believe the 13 activities of briefings, the exit meetings, the 14 management' involvement, the fact that the team leader 15 reports directly to the regional administrator and 16 communicates on these matters,'that the mechanism of
, 17 using the CAL to provide the vehicle for release and 18 docueenting our findings is a substitute. It takes us
- 19 30 days or so to put the full inspection report 20 together with the findings.
21 CHAIRMAN SELIN: Well, you certainly had 22 a fair sha m of public meetings during all of these 23 discussions. I gather you're pretty comfortable with 24 the licensee's description of the situation at this 25 point.
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(
b 78 1 MR. MARTIN: We are, sir, yes.
2 , CHAIRMAN SELIN: Okay. Commissioner ,
i 3 Rogers? i 4 ,
COMMISSIONER ROGERS: Ye t, . If you could 4
5 say a little bit more about the.PORVs. Is the issue
- 6 a , question of whether they were operating correctly or 7 whether, they were damaged as a result.o.f the event and 8 correctly. repaired? ,
9 MR. MARTIN: The question is one of 10 correctly repaired,and:do we have the right material 11 in those PORVs. The plant was..taken to the point 12 where it was full of water. The pressurizer no longer 13 had a bubble in it and the PORVs operated some 200
, 14 plus times. As a result of that, we questioned 15 whether there was any damage to those valves. They 16 did open them up and inspect them and, sure enough, 17 there was abrasion on the plug. There was gauling on J
, 18 the stem, and there was a crack on the pin from the
) 19 stem to the plug.
20 Their subsequent analysis has shown that i 21 they can't be confident that with that crack in there
( 22 it wouldn't have continued to propagate, so that was 23 a decision on their part that they're going to have to 24 replace that.
25 There was also a different material in NEAL R. GROSS COURT REPORTERS AND TRANSCReERS
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79 ;
1 Unit 1 than there was in Unit 2 and it is speculated 2 that that better material resulted in less damage to 3 the valve and may have actually supporte'd more !
4 operations than occurred. The valve never stuck. f 5 When it's challenged that many times, that's a plus.
l 6 But when they went back and did their analysis, they 4
7 concluded that they're going -- my understanding of i 8 their analysis right now is that they are going back 9 to the original material, and we'll have to wait to ;
10 see what that evaluation says and whether we agree 11 with it.
12 COMMISSIONER ROGERS: Yes. Okay. I think 13 I understand the situation now, l
14 How much work do you think is necessary i
15 for you to be able to feel comfortable with the status )
I 16 of those valves? j l
17 MR. MARTIN: We obviously have seen
]
18 pictures of the valves. We've actually done some 19 inspections of the parts that were taken out. What we 20 need to do is evaluate their engineering analysis and 21 that provided by the valid vendor. Since we don't 22 have that document in hand, I can't tell you how long 23 that's going to take. But other than that, we are 24 certainly following the maintenance activities and the 25 reassembly of the valve. We're satisfied with that, NEAL R. GROSS COUfti REPORTERS AND TRANSCRSERS 1323 RHOOE ISLAND AVENUE, N W.
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80 1 if we are satisfied with the material. It's the
. 2 material issue right now that's probably the biggest 3 concern to us. ,
4 COMMISSIONER ROGERS: Who was notified?
5 What governmental agencies were notified during the 6 . time of this event? ,
7 I notice you had state observers with the 8 AIT. You _ said " observers." Were they from two 9 different states or only from one state?
10 MR. MARTIN: From one state.
11 COMMISSIONER ROGERS: New Jersey?
12 MR. MARTIN: New Jersey Department of 13 Environmental' Resources. ..
14 COMMISSIONER ROGERS: And what government 15 agencies were informed about this at the time that the 16 thing was evolving?
17 MR. SUMMERS: Commissioner, in terms of 18 the notifications of the event, the Licensee has their 19 routine notification process. It included the NRC and ,
20 then we make certain notifications of other government 21 agencies as a result of the alert declaration.
22 COMMISSIONER ROGERS: Well, I was thinking 23 of the states and communities.
24 MR. SUMMERS: Yes. States and locals were 25 notified in accordance with the licensee's plan.
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81 1 MR. TAYLOR: By the licensee.
2 MR. SUMMERS: By the licensee.
3 MR. TAYI4R: That's normally the process.
4 MR. MARTIN: And we are required to back 5 that up when we go the AIT. We did notify both New 6 Jersey and Delaware,'because they're both in the ten 7 mile EPZ.
8 COMMISSIONER ROGERS: Right, but that was 9 pretty well along in the event.
10 MR. SUMMERS: However, when the Agency was 11 monitoring and we staffed up the region's incident 12 response center, one of the positions we staffed was 13 the government liaison, and so routine contacts were I i
14 made with the states through that position also during I 15 the event.
16 COMMISSIONER ROGERS: All right. That's 17 all.
18 CHAIRMAN SELIN: Commissioner Remick?
4 19 COMMISSIONER REMICK: I noticed when 20 Chairman Selin started out he had looked through the 21 slides and I think he was concluding there wasn't too 22 much meat in there. It's the same conclusion I had 23 when I sneaked a preview. It was nore or less a 24 process, who struck John and what time, and not really 25 until he asked a question and Commissioner Rogers did NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHODE ISLAND AVENUE, N.W.
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4 82 1 the staff get into any detail. And I realize the 2 report is not out. I'm sure your findings aren't 3 formalized. Your recommendation aren't made and any i
4 decisions.of enforcement, but I guess I'm a little
~
1 5 surprised you didn't provide us a little more meat on
{
6 the findings as they stand at the moment.
] 7 Are there other things that you wish to '
8 tell us about impressions good or bad that we should 9 know about other than the AIT was formed on this date
. 10 and we went there and did this and that? I'm more i j
11 interested in your findings and your feelings,at the 12 moment. I'm thinking for the good of the order in the j i
13 future and so forth, I think we want a little bit more l 1
l 14 detail.
i j 15 MR. MAPTIN: We obviously had more detail 16 and when -- the licensee actually had two separate l 17 investigations they did and we obviously did our own i
i 18 independent investigation. We have found through the 4
19 number of public meetings we've had that we track l
j 20 almost right on top of each other, and so in the I
. 21 interest of time we did not want to repeat all those.
22 But I havs the team leader here who can i
23 amplify on anything you'd like to hear.
24 COMMISSIONER REMICK: What are some of the 25 highlights that you would like to tell us about from NEAL R. GROSS count nEroarEas ANoinANaca Ens 1333 nMODE 18 LAND AVENUE, N.W.
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83 1 your findings?
2 MR. SUMMERS: Okay. In terms of the 3 findings, much as Mr. Martin just said, the
[ 4 independent investigations tracked very closely even 5 though we weren't working together. However, we did 6 share information and toward the end of our inspection t
7 I found that the licensee's SERT process, which is 4
8 their event response team, they had almost the 9 identical charter and had almost identical facts in 10 terms of their development of the sequence of events 4
11 and.the causal factors as the AIT.
12 In terms of important findings, early on 13 in the event, much as the licensee has responded to 14 your questions today, there was a lack of command and 15 control exhibited in the control room that was 16 compounded by, as Mr. Martin just spoke about briefly, 17 a problem with the rod control system in manual. 5t 18 was a short-term problem, however during the down-19 power transient and the rapid down-power transient it 20 did compound the operators' actions, made that 21 transient more complex. It did result in the 22 operators getting out of sync, as one of your 23 questions to the licensee earlier described. That 24 type of problem early on is notably absent after the 25 reactor trip safety injection occurs.
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84 1 It appears as though the focus of the 2 shift crew in the control room changes. The following 3
of the EOPs is very good. The meeting of the 4 termination criteria of the EOPs was very well 5 established by the crew. So, there is a dichotomy in 6 performance at the beginning of the event and 7 subsequent o the reactor trip safety injection that 8 was a conc' e rn of the team trying to deal with that 9 dichotomy of response.
10 ' COMMISSIONER REMICK: I assume these were 11 system based EOPs that they were using and they
~
. 12 appeared to show familiarity with them?
13 . MR. SUMMERS: Yes. Salem has, I guess, a
. 14 unique format for PWRs. They use a flow chart format 15 and the operators were very familiar with their use.
16 There was later on in the event, as the 17 licensee explained, there were a couple of operator 18 errors that occurred later that resulted in the second 19 safety injection in monitoring primary temperature 20 parameters and secondary temperatures and pressures.
21 That was compounded again by the failure of the 22 automatic control system on the steam generator power 23 operated relief valves and not maintaining a no-load 24 set point. The operators were trained on the use of 25 that system so as to ensure that it would control NEAL R. GROSS COURT REPORTERS AND TRANSCReERS I 1323 RHODE ISLAND AVENUE, N W.
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._ i,
. 85 i i properly. Operators overlooked that part of their l f
^
- . 2 training or forgot that part of their training. I'm ,
i ,
3 not sure that they forgot. It was in the heat of the 4 battle. There were a number of other activities that i i !
I 5 were demanding their attention.
i 6 It was a very complex event for the shift j 7 because of the logic response being out of sync where ,
4 8 the A train of protection sensed the condition warning !
9 safety injection and the B train did not, resulted in i
10 many components being out of expected alignment which ,
1 i 11 the operators had to correct. The operators' response ;
l 12 - to that, that was very good.
i 13 COMMISSIONER REMICK: Thank you. As AIT i
i 14 team leader, are there any things that you found about I i 15 the type of expertise that you were provided or f 16 anything about procedures or anything on the AIT
{
17 process that you would have recommendations on or i
, 18 things that you were pleased with?
i 19 MR. SUMMERS: Well, one of your questions I
! 20 earlier, and it was really a policy question on the 1
l 21 use of a CAL --
1 22 COMMISSIONER REMICK: Yes.
I ;
23 MR. SUMMERS: I as team leader found that 24 the CAL helped establish a very good protocol between l l
25 myself and plant management in order to ensure that we NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS j
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I
. -- .. - = .-- . . - . _ . - . - . .
86 4
1 would have an appropriate chance to review an activity 2 prior to the licensee going off and completing that ,
3 activity. That ensured.that we were all working from 4 a common - work practice and that I had whatever
- 5 opportunity I needed to review their investigation as 6 well as equipment before they began an investigation >
., 7 on it.
8 COMMISSIONER REMICK: How about proper i 1 !
T 9 expertise on the team in general?
10 . MR. SUMMERS: Expertise in general, I ;
I--
~
11 found that the group -- I didn't realize what the i
- y. 12 complement was until-I had the team on site and got to l, 1- 13 -
know them. Being from the region I don't always know
~
14 all of the eadquarters personnelf,however I thought 15 that the team that was given to me was an excellent 16 team in terms of expertise as well as previous -
17 exposure to these types of events and the 18 investigation thereof, and so I was pleased with the 19 way the team worked.
20 I think that's about it on that.
21 COMMISSIONER REMICK: Okay. Thank yott 22 very much. Appreciate it.
23 CHAIRMAN SELIN: Thank you.
24 In closing, I also an a little concerned i
i 25 how sketchy the results present to us in the AIT. I'm l
NEAL R. GROSS COURT REPORTERS AND TRANSCRSERS 1323 RHOOE ELAND AVENUE, N.W.
(20f) 2344433 WASHINGTON D.C. 20005 (202) 2344433 i
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1 i
87 1 personally satisfied with Mr. Summer's description.
~
2 I take that as being an implicit compliment to the 3 licensee for having done really a quite thorough fact i
4 finding and not pulling their own punches in dealing i 5 with this themselves.
- 6 Am I supposed to . draw this conclusion?
i 7 You don't want me to go away with an unnecessarily ;
i 8 favorable conclusion of anything, do you, Mr. Martin?
, 9 MR. MARTIN: I would tell you that any j 10 time the licensee mounts a SERT, they usually do a =
~
j 11 dann good job.
l 12 ,
CHAIRMAN SELIN: Okay. Thank you very I
- 13 auch, Mr. Taylor.
l 14 (Whereupon, at 4:16 p.m., the above-15 entitled matter was concluded.)
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i 17 4
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NEAL R. GROSS COURT REPORTERS AND TRANSCRSER$
1323 RHODE ISLAND AVENUE, N.W.
(202) 2344433 WASHINGTON. D.C. 20006 (202) 2344433
i
' CERTIFICATE OF TRANSCRIBER This is to certify t'nat the attached events of a meeting of the United States Nuclear Regulatory Commission entitled: f TITLE OF MEETING: DISCUSSION OF SALEM UNIT 1 RESTART
, PUBLIC MEETING OF HEETING: ROCKVILLE, MARYLAND DATE'0F MEETING: MAY 9, 1994 were' transcribed by me. I further certify that said transcription is accurate and complete, to the best of my ability, and that the transcript is a true and accurate record of the foregoing even'es.
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- @ C ii Reporter's name
- PETER LYNCH
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HEAL R. GROSS l cover assomas Aue vaanscamens
$333 RNo0E ISLAMS AVENUE. M.W.
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MEETING WITH i
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l NUCLEAR REGULATORY COMMISSION i i
MAY 9,1994 :
1 !
l I 4
SALhM UNIT 1 TRIP' AND SAFETY INJECTION SEOUENCE OF EVENTS Plant operating at 75% power.
Rapid power reduction initiated due to excessive grass on> circulating water intake screens (10:16 am). . .
Power reduced to < 10%, enabled 25% trip. -
- Operator pulled control rods to raise temperature causing the plant to trip at 25% (10
- 49AM).
- , 9 4
_ _ - _ _ _ - _ - _ _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ - - ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _J
SEOUENCE OF EVENTS (CONTINUED) . .
One train of safety injection spuriously actuated --
" Unusual Event" declared (11:COAM).
Pressurizer went solid and power operated relief valves cycle to maintain pressure.
Main steam relief valve opened causiag reactor plant cool-down and reduction in pressure.
SEOUENCE OF EVENTS / CONTINUED)
~ ~ .
Second safety injection due to low RCS pressure l
(11:28P:M). .
- " Alert" declared as precautionary measure (1
- 16P:M).
Pressurizer level restored., emergency procedures exited, and normal cool down initiated (5:15P M).
1
" Alert" terminated (8:20PM).
,. . 4 l
t
SAFETY SIGNIFICAlVCE Event significance recognized by PSE&G Represented challenges to safety systems .
l l Significant challenges to operations crew Rapid power reduction and low power operation .
l Complicated event caused by spurious i
! signal l i i
Important lessons learned for PSE&G and Industry i
CAUSAL FACTORS : ,=. 0 Reactor Trip Control operator withdrew control rods too quickly and improperly monitored plant parameters.
. Inadequate conimand and control.
First Safety Injection . .
Operator allowed primary system temperature to go too low coincident with a false short duration high
~
steam flow signal. " ' -
False high steam flow signal due to a design vulnerability.
I
CAUSAT FACTORS iCONTINUED) ', ,
Second Safety Injection I
! Less than adequate crew communications.
Operator not taking manual control of steam relief valve. .
Design of the steam relief valve automatic control system.
t l
t m..__________..___..._.____. _ _ _ _ _ _ _ . _ _ _ __
CORRECTIVE ACTIONS Personnel / Training '- .
Conducted additional simulator training for all operating crews to reinforce:
Low power operation Solid plant operation Command and control /commumcations Resource management Operator actions'following an automatic safety injection i
Reinforced and clarified management expectations to all operating crews.
_ CORRECTIVE ACTIONS (CONTINUED)
Procedures Enhanced operating procedures for rapid power reductions and low power operation.
Revised operating procedures to include mimmum condenser vacuum and circulators in-service criteria for a manual trip.
Revised operating procedures for restoration of pressurizer level.
Procedural changes were reinforced through training.
a
CORRECTIVE ACTIONS (Continued)
Equipment Made modification to improve automatic operation .
of main steam relief valves.
Made modification to dampen steam flow transmitters' sensitivity to pressure pulses.
Planned modifications to circulating water traveling screens will enhance ability to cope with grass.
i i
t OTHER ISSUES Reactor vessel level indication system -
i
- Extended utilization to shutdown 1
Pressurizer power operated relief valves ;
1 l
- Engineering analysis of valve internals
< Emergency Plan communications
- Incorporating additional guidance from NRC f
1A
I' SALEM IMPROVEMENT FOCUS .
1 i ,, 1 Equipment - materiel condition upgrade, corrective and preventive maintenance ;
backlog reduction.
4 Procedures - procedure upgrade process, 3500 procedures issued. i i
People - supervisory effectiveness, communications, work practices and -
standards, teamwork. .
P
^
f
MATERIET CONDITION UPGRADES t
Completed for Unit 1 and/or Unit 2 - -
Control room modifications and human factor upgrades.
Upgrade of 18,000 linear feet of service water piping.
Secondary chemistry laboratory.
Switchyard expansion and upgrade. .
Bus instrument inverter replacement.
Containment steam generator blow down valve upgrade.
Pressurizer insulation replacement.
Safeguards equipment controller installation.
Installation of system to add chemicals to auxiliary feed system.
12
I MATERIEL CONDITION UPGRADES (continued) , ,
Comoleted for Unit 1 and/or Unit 2 (continued)
Circulating water mechanical upgrad6s. -
Boric acid concentration reduction.
l Ugraded boric acid and primary water flow instrumentation.
Small bore piping replacement > 5,000 feet. ,
Steam generator feed pump control oil system upgrade. .
Rod control 24 VDC power supply replacement.
i Mid loop instrumentation modifications.
Diesel generator HVAC improvements. (
S/G feed pump independent control oil system.
t l
Salem upgrades since 1990 > S300M l
l 'l
Corrective Maintenance Backlog Salem Station 3,000 2.550 2,500 2,200 2,000 l
1.soo y 1,500 j .
1,000 500 .
1990 1991 1992 1993 All Priorities 14
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Reliability CentereJ Maintenance Salem Station 40 8 35
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1991 1992 199 16
Procedures Upgrade Project Salem Station 4,000 3,525 3,000 2.548 5 . . ..
V y 2,000 h 1,559 n_ .
1,000 587 0 1993(Sep) 1990 1991 1992 (Project Complete 1 l
KEY PERSONNET ACTIONS
! Work practices and standards expectations provided.
- Work monitoring by line management and QA.
l Work control process improvements.
Supervisory face-to-face time.
Root cause training.
Supervisory and management training. ,
Manager and supervisory dialogues.
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18
1 Licensee Event Reports Salem Station 120 100 .- . .
84 .
80 g ,.,.,_..,,s, . .
58 E 60 -
z 1990 1991 1992 1993 19
i Personnel LER's so Salem Station 40
, 30 E
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1990 1991 1992 1993 2n
ASSESSMENT OF RESUI TS Improvement achieved in a nurnber of areas. .
Personnel performance improvements noted, but not meeting expectations. . .
Plant performance not meeting our expectations. .
Identified need for Comprehensive Performance Assessment. ,
i 21
COMPREHENSIVE PERFORMANCE ASSESSMENT Process ,
Full-time, multi-disciplinary, dedicated team
- of 12 people for 4 months.
Reported directly to the Vice President and Chief Nuclear Officer.
Performed a comprehensive assessment of occurrences over a two year period. .
Looked for broader root causes, failed barriers, contributing causal factors and common threads.
22
l CO MPREHENSIVE PERFORMANCE l ASSESS MENT Results Defined specific problem statements within three categories: -
t Management . Philos.ophy, Skills and~
Practices .. .
People Performing the Work ,
Problem Solving and Follow-Up 23
-.. _ _ _ _ ____ _ _ _ __ - -- __ , -. ____ - ~ - . - - _. ___ _ ____ _____ -_ _ -_____ - - -
CO MPREHENSIVE PERFORMANCE ASSESS MENT .
Actions Defined responsibilities for resolution.
Prepared action plans and schedules for each problem area.
Identified performance indicators to measure progress and effectiveness of actions.
i r
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I EMPHASIS ON PERFORMANCE THROUGH PEOPLE Management and supervisory changes at Salem Staffing increases at Salem -
Unitized organizations at Salem i
.H Re-bidding / assessment - placing right people in right job Training / development initiatives .
Increased supervisory time in field Accountability through enhanced personnel performance appraisals Dynamics of Leadership Model 25 i
I 1
BUSINESS LEADERSHIP DEVELOPMENT t
t l
Nuclear Department Dynamics of Leadership M W9 h !
together. For IndMdualand team success i
To meet tomorro#s business challenges 26
. m.
O PSEiG " -
'L- -
Nuclear Department Dynamics of Leadership e Own the identification and e Explain decisions so people will solution of problems support them . , ,: .
e Stay involved - provide timely, e Set performance standards accurate and honest feedback i e Know when to let your o Good or bad, write it down so people decide you can give valid feedback e Be a team player- give and get help '
impede performance e Support decisions i e ifit doesn't look, sound or feel e Expect and give respect right - take action because it probably isn't right e LISTEN to your people Consiseently among the best...Worki ec.c0.cr to predesce competitive electrical energy th nuclear excellence 27
MONITORING EFFECTIVENESS OF PERFORMANCE THROUGH PEOPLE Work practices and standards monitoring by line management and QA.
Supervisory face-to-face time.
Human performance indicators.
Leadership feedback results.
Personnel error Licensee Event Report.
Composite safety index performance.
28 l
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COMMISSION MEETING SALEM 4/7/94 EVENT gga , reg p? 47- .-
- * * +]
May 9,1994 Presented By: Thomas T. Martin
RESIDENT STAFF RESPONSE e PSE&G informs resident staff of unit trip i e SRI responds to control room and notifies Region I
. l
- Continuous resident staff coverage and communication maintained until Augmented Inspection Team arrival 1
4
1 2
REGIONAL RESPONSE TO EVENT i
e PSE&G declared Unusual Event at 11:00 a.m.; and Alert at 1:16 p.m.4
- Region I and HQ activate response center for evtint monitoring from 1:00 p.m. until 9:00 p.m.
- PSE&G terminates Alert at 8:20 p.m.
2
[
i AUGMENTED INSPECTION TEAM e Region I, with NRR and AEOD ~
approval, decided to dispatch AIT .
- AIT initiated due to event complexity and unexpected system responses L
i i
3
- - - . - - _ - - - - _ - - - - m - -u - - - -- - -- -- -_____- ---- --- -- - - __-__-___
i AUGMENTED INSPECTION TEAM l
i (continued)
I I
- AIT Team members selected Region I Lead Members from Region, NRR, AEOD personnel selected relative to technical expertise i
State observers 4
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- (CAL) 1-94-005 issued on 4/8/94, including Commitment to remain in cold shutdown Commitment to cooperate and support AIT activities ~
1 l -
Commitment to gain agreement of l Regional Administrator. prior to restart 7
t
i CHRONOLOGY OF AIT ACTIVITIES e AIT arrived on site 4/8/94 and completed on-site inspection activities on 4/26/94
- AIT maintained daily contact with Region and Headquarters managers
, o Gas pocket forms in reactor vessel t
head and identified by SRI
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- staff on 5/5/94 e Public management meeting with PSE&G on 5/6/94 at the Salem facility 10
^
4 SIGNIFICANT AIT FINDINGS
- No abnormal releases of radiation to the environment occurred during the event o Event challenged RCS pressure boundary through multiple operations
- of pressurizer PORVs i
e Operator errors occurred which
- . complicated the event .
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i REMAINING ACTIVITIES ;
l e Licensee confirms restart readiness e NRC releases from CAL
- NRC augmented start up coverage i
e issue AIT inspection report e Determine and direct followup activities 13
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