ML20138B271
| ML20138B271 | |
| Person / Time | |
|---|---|
| Site: | LaSalle |
| Issue date: | 11/22/1985 |
| From: | COMMONWEALTH EDISON CO. |
| To: | |
| Shared Package | |
| ML20138B265 | List: |
| References | |
| PROC-851122, NUDOCS 8512120257 | |
| Download: ML20138B271 (37) | |
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LASALLE STATION I
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PRGACTWE MANAGEENT PLAN 4
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TAM E OF C0FFERTS T
1 PAGE 2
SCRAM REDUCTION h
ESF ACTUATIONS 4
7 SCHEDULING / PLANNING I
CONTROL ROOM INMRMATION DEFICIENCIES 9
i 12 WORK REQUEST BACKI4G TIME CI4CKS/ DEGRADED EQUIPMENT IDG (DEL) 1h i
PROCEDURES BACKLOG 15 17 MODIFICATIONS 19 DESIGN CONTROL i
j COMMUNICATION WITH RESIDENT INSPECTOR 21 l
RADIATION PROTECTION PERMPFANCE 22 I
PERSONNEL PERFORMANCE 2h 27 REGUIATORY PER N RMANCE f
ORGANIZATION 28 i
GRAPHS
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MANAGEMENT PLAN IMPLEMENTATION 1
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SCRAMS 3
1 ESF ACTUATIONS 6
11 CONTROL ROOM IN MRMATION DEFICIENCIES WORK REQUEST BACKIcG 13 i
PROCEDURES BACKLOG 16 i
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CATEGORIZATION /PRIORITIZATION OF MODIFICATIONS 18 k
HI RADIATION DOOR VIDIATIONS 23 PERSONNEL ERROR LERS 25 i
CUMUIATIVE LER HISTORY (NUMBER) 26 I
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i INTRODUCTION The objective of this plan is to reali:e a significant improve-ment, in t/ue per fut un:c cf T***11a Station. Although, the primary l
focus is on improved Regulatory Performance, benefits in Ctstion availability as well as other areas are expected to result.
The plan is divided into major areas with a detailed action plan l
Where appropriate, measurement standards such i
for each area.
as trend graphs and projected completion dates are provided.
,f The plan is intended to be a living document subject to change as conditions dictate. Although some variation in meeting pro-l jected goals should be expected due to unforeseen. circumstances, the Station considers itself accountable for rigorous adherence i
to this plan.
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f LASALLE COUNTY STATION ACTION PLAN STATUS l
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1985 1986 4
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4 SCRAN REDUCTION PROJECTED ACTUAL i
COMPMTION COMPETION RFSP.
DATE DATE COM(ENTS -
a A. Establish Comunittee CES/ACS 8/6/85 l
B. Scram History Review, including list or scrams and CES/ACS 9/3/85 root causes.
I C. Review Station Conduct of Operations CES/ACS 9/26/85 1
D. Review RPS Sury. testing CES/ACS 9/26/85 E. Turbine trip channel redundancy l
- 1. Identify alternatives CES/ACS Complete Complete
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- 2. Feasibility / Cost study CES/ACS 2/28/86
- 3. Establish schedule for improvement CES/ACS 6/01/86 t hedule Depend-ent Upon Results i
of Feasibility I
Study F. Inst. line hydraulic transient RPS trips i
- 1. Identify alternatives CES/ACS Complete Complete
- 2. Feasibility / Cost Study CES/ACS Complete Complete 1
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- 3. Establish schedule for improvement CES/ACS 5/01/86 l
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l REACTOR SCRAMS i
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W htNMTim PROJECTED ACTUAL COMPIATION COMPILTION i
RESP.
DATE DATE COpttEFIS A. Task Force DSB
- 1. Form Task Force Complete Complete i
- 2. Initiate' ongoing tracking / trending Complete Complete
- 3. Review all actuations since 1/1/84 to identiry Complete Complete I
problem areas
%.-Review actuations for root cause as they occur On Coing On Going and reccamend corrective actions to prevent recurrence
- 5. RWCU delta-flow cal-data Modirleation
- a. SNED letter RFJ 12/02/85
- b. MOD to OSR 1/08/86 t
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- d. MOD installed (both units) 2/15/86
- a. Beview SNED Scoping analysis DSB 11/08/85 11/13/85 f
- b. Decision on MOD /rtmding GID/KG 11/15/85 11/15/85 Estimated cost
$324,000.
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Will do.
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- c. Modification Package engineered HFJ 1/15/85 t
- d. Modification Package installed PFM/
3/09/85 l
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- e. Submit Tech Syce Change Request DSB/TAH 3/03/85
0 ESF ACTilATIOES (ContintW)
PROJECTED AC'I1JAL COMPIJTION COMPIETION RESP.
DATE DATE C0f0fENTS
- 7. Schedule RWCU valve replacement Review MOD to decrease cost / increase Station DSB/PFM 12/22/85 options
/IG Options include - downgrade system from code
- reduce number or valves f rutalled 1
- velded instead of rianged l
Installation Decision on ibnding KG/GID 1/31/8(2 Modification schedule IEB/PFN 2/28/8(2 l
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neumsmearu p ggg PROJECTED ACIVAL C0fG>IJT. ION C0fG2I17 ION RESP.
DATE DATE COf94ENTS A. Establish a task force to evaluate implementation CES Complete Complete
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- of a Planning Department consisting of major Station departments B. Develop technique for planning:
CES/JEL
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- 1. Hefuel Outage Complete Complete e
- 2. Pbreed Outage Complete Complete
- 3. Daily 'elork (jobs which Interface)
Complete Complete C. Develop a Performnce Tracking Scheme 1
- 1. Starts / Completions / Cancels /% Compliance CES/JEL 12/09/85 l
- 2. Reports to Production Superintendent CES/JEL 12/09/85 Start Date i
- 3. Publish periodic status reports around Station CES/JEL 12/09/85 Start Date D. Implement a Planning Group f
- 1. Establish an Assistant Superintendent level position CJD 1/31/85
- 2. Organization, authority, responsibility, size, CESI/JEL 12/30/85 l
cossposition (preliminary) i
- 3. Assign operating personnel (5 Operators)
Complete Complete j
%. Assign additional department personnel CES/WES 12/30/85 i
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PfKUECTED ACTUAL COWIETION COWIETION RESP.
DATE DATE CO M irTS t
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E. Computerize the Planning Programs
- 1. Refuel Outage Complete Complete j
- 2. Fbreed Odtage complete Complete i
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- 3. Daily llork CES/JEL 3/01/86 Need Computer Type Person By j
by 1/1/86 i
j F. Inform Station personnel of Planning Department's CES/JEL 1/31/86 l
functions l
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PROJECTED AC'ItJAL COMPIEPION COMPIETION RESP.
DATE DATE COD 9ENTS A. New Control Room Work Request's (CRWR) B-1 priority.
WRll On Coing On Going (B-1 = Start work next work day and work normal hours to completion)
B. Control N Work Requests integrated into daily WE3 On Going On Going schedule (Interface WR's only)
C. Complete U-2 CRWR's requiring outage WES 12/08/85 End of current outage D. Black panel in effect on Unit 1 at startup WES 3/01/86 End of 1st Refuel Outage E. Complete U-1 CRWR's requiring outage WES 3/1/86 End of lat Refuel Outage F. Schedule and complete 25 CRWR's per week WES 11/19/85 11/19/85 Start Date G. Daily Status Report (Planned & Completed)
WES 11/25/85 11/20/85 Start Date H. Weekly plot of CRWR's WRif 12/03/85 12/03/85 Start Date I. Permanent Fix Program for repetitive equip. problems
- 1. Identify 5 repetitive problems needing long-term solutions WES/M3 1/01/86
- 2. Identify alternatives PlH Schedule depend-ent on problem definit ion
- That: Directly affect the controls used by operators during emergency situations, off-norm 1 situations or routine operations.
Results in information, relied on by operators to take action, being inaccurate or indeterminate.
Results in an annunciated Control Room alarm that reflects an off-normal condition.
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GETWE WERI INW MFICIBCIES*
PROJECTED AC'IUAL COMPIATION COMPIATION RESP.
DATE DATE C00MElflS
- 3. Perform reasibility/ cost study PPM Schedule depend-ent on problem definition
- 4. Establish schedule for resolution PPM Schedule depend-ent on problem definition
- That: Directly.arrect the controls used by operators during emergency situations, off-normal situations or routine operations.
Results in inforantion, relled on by operators to take action, being inaccurate or indeterminate.
Results in an annunicated Control Room alarm that reflects an off-normal condition.
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LASALLE COUNTY STATION
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RESP.
DATE DATE COM4ENTS 6
A. Define accountability of actual tacklog
- 1. Review of current backlog CES/WES 1/31/86
- 2. Mainte e of backlog record via improved CES/WES 2/28/86 l
reporting system i
- 3. Assign an individual to expedite Work Request processing GJD 1/01/86 I
B. Review of outstanding Work Requests on U-1 CES/WHH 1/31/86 Intent is to to identify those with safety impact which cleanup prior to restart should be done prior to U-1 startup C. Define an optisman backlog level and assess resource level CES/WES 1/31/86 i
vs. workload, actual backlog, and optimum backlog r
D. Reduce backlog to optimaam level CES/WES 9/01/86 E. Optimize parts / materials procurement CES/WES 2/28/86 F. Permanent Fix Program for repetitive equipment problems
- 1. Identify five repetitive problems needing long-term CES/WES 1/31/86 solution PFM Schedule depend-i
- 2. Identify alternatives ent on problem definition l
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- 3. Perform feasibility / cost study PFM Schedule depend-ent on problem l
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%. Establish schedule for improvement PFN Schedule depend-ent on problem definition y
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LASALLE COUNTY STATION WORK REQUEST BACKLOG 4 0 0 0-4 3500-3000-i 2500-2000-i 1500-1000-
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500-l J F M A M J 'J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D y
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PROJECTED ACTUAL COMPIFI' ION COMPIF. TION RESP.
DATE DATE COMMENTS A. Reduce # of time clocks in effect to a reasonable level
- 1. Conduct overall assessment of time clocks, i.e.,
WRII/DMP 12/20/85 ca'uses, repetitive problema, etc. *This may require a record system or log on time clocks to collect data.
- 2. Review results and make recommendations to reduce WRil/DMP 1/06/86
- of time clocks in effect WRH 12/02/85 12/02/85
- 3. Formally define priority requirements for time clock related Work Requests WRil/0E's 12/02/85 12/03/85
- h. Implement priority system WRif 3/01/86
$. Establish a preliminary target number prior to Unit 1 startup and monitor
- 6. Reevaluate with both units in power operation CES/WRif h/15/86 WRH 5/01/86
- 7. Establish a target number B. Reduce # of DEL's in effect WRil/JAA 12/02/85
- 1. Review history and commitments
- 2. Conduct overall assessment of DEL to identify WRII/DMP 12/20/85 causes for number of entries
- 3. Make recommendations to reduce the number during WRil/DMP 1/06/86 normal operation
- h. Formalize use of DEL. What goes in log, what does WRII/JAA 2/01/86
/SCRE's degraded mean, etc.
- 5. Establish a preliminary target number prior to Unit WRif 3/01/86 y
1 startup and monitor m
- 6. Reevaluate status with both units in operation CES/WHi!
5/01/86
PROCEDURES BACKLDG PROJECTED ACTUAL COMPIETION COMPIETION RFSP.
DATE DATE COMMENTS A. Improve procedures process to make it more' effective RDB/JCK 10/21/85 10/21/85 RDB/JCK 10/21/85 10/21/85 B. Establish target backlog RDB/JCK Ongoing Ongoing C. Monitor backlog RDB/JCK 2/28/86 Prior to Unit I i
D. Review procedures outstanding, especially those Startup resulting from U-1 Modifications during Refuel Outage, prior to Unit 1 Startup 3
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MODIFICATIONS
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PROJECTED ACTUAL COMPLETION COMPIETION RESP.
DATE DATE COMMENTS A. 5 Year Modification Plan RDB Complete C mplete
- 1. Establish a Modification Review Committee RDB 10/25/85 10/25/85
- 2. Develop a priority / category scheme HDB 11/11/85 10/25/85
- 3. Develop mechanism to handle new modification requests RDB 1/05/86
- 1. Redefine scope of Modification Program 4
(i.e. - setpoint changes, etc.)
HDB 1/05/86
- 5. Categorize existing modifications
- 6. Prioritize modifications within categories RDB 1/20/86 RDB 2/28/86
- 7. Review outstanding modifications for safety impact prior to Unit 1 startup
- 8. Schedale specific modifications for completion RDB 3/114/86 commensurate with established rate and publish schedule (preliminary schedule)
- 9. Review preliminary schedule with all responsible GJD/RDB h/25/86 organizations and establish final schedule consis-tent with the commitment of the responsible organizations.
- 10. Issue monthly status reports - Include RDB 12/05/85 11/20/85 Start Date executive sunnary
- 11. Hold all responsible organizations accountable KG/GJD On Going on Going for performing activities within the commited schedule
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PROJECTED ACTUAL COMPiFFION COMPIPPION RESP.
DATE DATE COMMENTS A. Improve Design Schedule & Quality i
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- l. Assign Cognizant Engineer to all Modifications
- a. Define Cognizant Engineer responsibility /
RDB/PFM Complete Complete accountability for successful completion of Modification from initial design to declar-ation of operability
- b. Training / Expectations Program for cognizant EDB/PFM 11/18/85 11/15/85 Engineers l
- c. Assign Modifications RDB/PFN Complete Complete l
- 2. Improve quality / content of modification design packages 1/25/86
- a. Implement feedback program which utilizes RDB/PI'N 4
lessons learned from deficient modification packages to improve the Modification Program
- 3. Environmental Qualification Program implementation review and corrective action as required
- a. Conduct " Big Picture" status meeting to review GJD Complete Complete total program and compliance with intent as well as letter of the law
- c. Conduct QC audit and prepare report RDB Complete Complete
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Conduct QA audit and prepare report RDB Complete Complete
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DESIGI 00rmOL (Continued)
PROJECTED ACTdAL COMPIETION COMPIETION RESP.
DATE DATE COMMENTS
- 1. Identify backlogs in the design process (other 4
than design) such as DCR's, FCR's, etc. that are potentials for future mistakes and develop trending / tracking measures to reduce to a manageable level.
- a. DCR's (1) Establish a reasonable turnaround time for RDB/PFN 1/31/86 DCR's and target for cleanup of tacklog (2) Obtain SNED concurrence KG/GJD 1/31/86 (3) Monitoring method and summary report RDB/PFN 1/31/86
- b. Other RDB/PFN 3/31/86
- 5. Post Modification / Maintenance Testing
- a. Assign / define a required committee to GJD Complete Complete review all safety related post maintenance /
Modification tests for adequacy. liigh level
- Master & T.S.S.?
O.E.?
- b. Review checklists in effect to assess adequacy IMR(NSG) 1/31/86 Itr Nuclear Safety Group
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C(ENENICATION WITH RESIIENT INSPEC'lDRS PROJECTED ACTUAL COMPIETION COMPLETION HESP.
DATE DATE COMMENTS l
A. Aggressive interaction with Resident Inspector to GJD/RDB On Going On Going better understand concerns and address, as well as
/CES/
market the good things-Depart-ment lleads B. Weekly meeting with Resident GJD On Going On Going l
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l RADIATION PROTECTION PERFUlBIANCE PROJECTED ACTUAL COMPIETION COMPLETION RESP.
DATE DATE COMMENTS
'A. Procedural Compliance 1.' Documented tailgates conducted with all personnel Complete Complete
- a. IaSalle problem areas
- b. Byron Enforcement Action
- 2. All 1st line supervisors reminded of their responsi-Complete Complete bility for procedural compliance at Expectation
-Meetings held with Station's upper management
- 3. on going program to upgrade procedures and training ongoing ongoing l
B. Prisking (See Also Item A - Procedural
- Compliance)
- 1. Setup of nine (9) frisker booths in progress.
IRA Refuel Complete Five additional booths awaiting setup.
- 2. Four (4) state-of-the-art whole body friskers en order LRA Refuel 50% Complete.
2 have bad boards. Pro-ject: 12/13/85 Five (5) more are proposed for 1986 budget LRA 1986
- 3. Forty-eight (h8) additional RM-lh friskers (handheld)
LRA Refuel All h8 rec'd.
are on order 18 in service.
Remainder in service.
12/9/85 a'
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RADIATION PR(FFECFIM PER70151ANG (Continued)
PROJECTED ACTUAL COMPIETION COMPLEPION RESP.
DATE DATE COMMENTS
- h. Five (5) IRT monitors from CAF to replace Eberline IJtA -
12/30/85 hand and foot monitors 4
IRA Refuel Complete
- 5. New step off pads on. order to remind personnel of requirement for whole body frisk
- 6. Permanent cement block frisker stations proposed IRA 1986 i
for 1986 budget.
C. Staffing i
- 1. Add an Assistant to Rad Chem Supervisor (SRO License)
RDB Refuel Complete IRA 1986
- 2. Add a Lead Foreman
- 3. Add a Timekeeper / Scheduler (should allow a IRA 1986 Complete Foreman to be in the plant 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> / day)
IRA Re fuel Complete
- 4. Contract 10-15 qualified techs for Unit 1 lat 2
Refuel including supervision
IRA /TK As Avall-On Going able Dresden/ General Office as available l
IRA As Avall-On Going
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- 6. Encourage Health Physicist exchange program able D. Space JL Refuel Complete
- 1. Convert approximately 1000 ft' of lunchroom to badge issue and RWP processing area, etc.
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- 2. Addition of approximately 500 ft* In trailer IRA Refuel Complete park for HP office to eliminate crowded conditions
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3 RADIATION PRDFECFI(N PERFoI50ANCE (Continued)-
PROJECTED ACTUAL COMPIATION COMPil. ION T
RIEP.
DATE DATE COPMENTS E. Persoenel Contamination (See also Item A - Procedural l
Compliance.)
- l. Each event is investigated by Department with Had Ongoing Ongoing Ci.= representation to determine root cause and propose corrective action
- 2. Daily report of contamination events provided to Ongoing Ongoing Department Heads and Station upper management (monthly trending).
- 3. Reviewing contamination survey.. techniques and frequency JL Refuel Complete
+
of contamination surveys for areas of known problems
'3. Developing a system to assign priority to Work Requests JL Refuel Complete Informally
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t related to contamination control and provide followup implemented, i
Procedure in i
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- 5. Continued tailgates by individual departments Ongoing Ongoing l
- 6. RCT's stationed at high traffic areas for. contamination Complete Complete control and proper frisking technique F. Area Contamination (See also Item A - Procedural j.
Compliance.)
1
- 1. Establish a Contamination Control Coordinator HDB Refuel Complete
- a. Area contamination cleanup RDB/JL On Going On Going i
- b. Event investigation RDB/JL On Going On Going i
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l RADIATION PROTECTION PERFOIBIANCE (Continued)
PROJECTED ACTUAL COMPLETION COMPIETION RESP.
DATE DATE COMMENTS
- c. Review contamination history to identify methods RDB/JL 2/17/85 for minimizing contaminating events
- d. Reclaim long-term contaminated areas RDB/JL 1986
- 2. Technical Staff to evaluate ventilation as a possible PFN 1/05/86 contributor to spread of contamination
- 3. Equipment designed to aid in contamination control DH Reruel Complete
- a. Tents
- b. Drip pans
- c. Filtered air movers
- h. More extensive use of Kelley closures to prevent Ongoing Ongoing g
spread of contamination
- 5. Contamination carts located at frisker locations LRA Refuel Complete
- 6. Major contamination event investigations to determine Ongoing ongoing root cause and propose corrective action to preclude repetition G. High Radiation Door Viointions (See also Item A -
Procedural Complianee. )
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- 1. All personnel instructed to challenge high rad doors Cctnplete Complete to assure closure.
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l RADIATION PR(FFECTI(M PERPol5GANCE (Continued)
PROJECTED ACTUAL COMPIfrION COMPIEPION RESP.
DATE DATE COMMENTS
- 2. All personnel instructed on responsibilities and Complete Complete expectations regarding high radiation door security
- 3. Reinforcement of management expectations and personnel Dept.
10/1h/85 Complete l
l responsibilities provided to all personnel lleads 1
- 4. Guidance provided in N-GET training has been expanded RDC 10/08/85 Complete to include more emphasis on responsibility of com-i pliance with high radiation door security
- 5. Responsibility assigned for assuring high rad doors Complete Complete are repaired expeditiously
- 6. Thorough investigation (DVR & ROR) conducted for each Ongoing Ongoing high radiation door violation with consideration of disciplinary action for identified violators / supervisors
- 7. Surveillance of high rad doors implemented (IAP-1100-13)
IRA Refuel Complete l
- 8. Continue evaluation of installation.of local alarru WL 3/86 l
on selected doors
- 9. High Rad Door Task Force (Corporate)
CM 10/15/85 11/15/85
- 10. Submit proposed Tech Spec revision flDB/TAII 1/05/86 12/03/85
- 11. Evaluate implementation of recommendations from LRA 12/15/85 Corporate High Radietion Door Task Force
- 12. Implement add 1+.lonal restrictions on issue of high IRA 1/17/85 radiation key-fiey cards
- 13. Attach high radiation area door security guidelines IRA 10/1h/85 Complete to high radiation keys / key cards for issuance M
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RADIATION PROTECTION PERFolgtANCE (Continued)
PROJECTED ACTUAL COMPIETION COMPIETION RPliP.
DATE DATE COMMENTS
- 14. Evaluate / implement issuance of pocket-sized Radiation MAP 12/20/85 Folders on Protection Awareness folder which includes high radia-order tion door security guidelines
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- 15. Consider periodic preventative unintenance program MAP 11/01/85 Complete Will do.
for high radiation door hardware H. Noble Gas Contamination
- 1. ALARA review required when opening Off Gas process lines Dil 10/85 Complete
- 2. Showering utilized for decontamination rather than Conplete Complete decay method until guidance provided by Corporate
- 3. SCBA utilized for areas of noble gas contamination Complete Complete if air sample is impractical or untimely 1
- 4. Additional training will be provided to RCT's and IIP's Complete Complete on noble gas contamination I. Unconditional Releases
- 1. Security Guard instructed to ensure unconditional Complete Complete j
release pass for a broader range of items
- 2. Program drastically tightened following contaminated Complete Complete i
solvent problem
- 3. Secure dumpsters JL 12/31/85
- 4. Designate a trash holding area prior to survey JL 12/31/85
- 5. Designate an enclosed area for survey of trash JL 12/31/85
- 6. Evaluate purchase of a trash compactor Complete Complete y
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RADIATION PHOTECTION PERFOI51ANCE (Continued)
PROJECTED ACTUAL COMPIEPION COMPIEPION RESP.
DATE DATE COMMENTS J. Interface with Other Departments (Communications)
- 1. Twice weekly meetings with Services Department Heads RDB On Going On Going
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- 2. Rad Chem participates in Contamination Investigations IRA On Going On Going
- 3. Had Chem participates in Scheduling Program IRA On Going On Going IRA On Going On Going Is. Daily interface with Shift IRA On Going On Going
- 5. Had Chem participates in tailgates of other departments IRA On Going On Going
- 6. Weekly Department lleads Meeting IRA On Going On Going
- 7. Outage Planning Meeting
- 8. Rad Chem representative is Chairman of Delian Task IRA Complete Complete Force Maintenance Scheduling
- 9. Rad Chem participates in Daily Planning Meeting IRA On Going On Going Dil CT: Going On Going l
- 11. Delian Team Building
- 12. Restructuring of Indging area (See Item D - Space.)
IRA Complete Complete K. Miscellaneous
- 1. Remote barrel monitor operational DH Refuel Complete
- 2. Issue contractor film indges with security lodge IRA 12/09/85
- 3. Issue Ceco film indges with security indge IRA Re fuel Complete
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PERBOM EL PERF0151ABCE 1.c., Teamwork, Effectiveness, Compliance with Requirements, etc.
PROJECTED ACTUAL COMPIETION COMPIEPION RESP.
DATE DATE COMMENTS A. Expectations Meetings
- 1. lat Line Supervisors GJD Complete Complete
- 2. Convey expectations to senior management with GJD Complete Complete emphasis on team work B. Delian Efforts GJD 1/01/86 C. Connaanication on R.P. procedure compliance GJD 9/01/85 Complete D. Missed Rad Chem Surveillances
- 1. Conduct detailed root cause review DSB/FRL 1/31/86
- 2. Identify effective corrective action (s) to DSB/FRL 2/14/86 minimize recurrence.
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M IEATIM PROJECTED ACTUAL COMPIETION COMPIETION RESP.
DATE DATE COMENTS Review of ISCS Organization KG/GJD 3/86 I
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m.,e-PROJECTED ACTUAL COMPIE1' ION COMPIETION RESP.
DATE DATE-CO M NTS A. Independent review to identify Root Causes Gerner 3/01/86
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