ML20148E391
| ML20148E391 | |
| Person / Time | |
|---|---|
| Site: | Sequoyah  |
| Issue date: | 03/17/1988 |
| From: | Gridley R TENNESSEE VALLEY AUTHORITY |
| To: | Ebneter S NRC OFFICE OF SPECIAL PROJECTS |
| References | |
| NUDOCS 8803250092 | |
| Download: ML20148E391 (70) | |
Text
TENNESSEE VALLEY AUTHORITY 5N 157B Lookout Place MAR M 1988 Mr. Stewart D. Ebneter, Director Office of Special Projects U.S. Nuclear Regulatory Comiasion MS 7D24 Washington, D.C.
20555
Dear Mr. Ehneter:
In the Matter of
)
Docket Nos.
50-327 Tennessee Valley Authority
)
50-328 SEQUOYAH NUCLEAR PLANT (SQN) - OPERATIONAL READINESS REVIEW (ORR)
In response to your request, enclosed is a copy of an early SQN ORR report dated June 2, 1987 (The "Matheny" Report).
If you have any questions, please telephone me at (615) 751-2729.
Very truly yours, TENNESSEE VALLEY AUTHORITY R.
ridley, D ector Nuclear Licensing and Regulatory Affairs Enclosure
{
1 ODI 8803250092 880317 l
PDR ADOCK 05000327 l1 l P
DCD An Equal Opportunity Employer
=_
!\\_3
.s s U.S. Nuclear Regulatory Commission nellR 171988 Enclosure cc (Enclosure):
Mr. K. P. Barr, Acting Assistant Director for Inspection Programs TVA Projects Division U.S. Nuclear Regulatory Commission Region II 101 Marietta Street, NW, Suite 2900 Atlanta, Georgia 30323 Mr. G. G. Zech, Assistant Director for Projects Division of TVA Projects Office of Special Projects U.S. Nuclear Regulatory Commission One White Flint, North 11555 Rockville Pike Rockville, Maryland 20852 Sequoyah Resident Inspector Sequoyah Nuclear Plant 2600 Igou Ferry Road Soddy Daisy, Tennessee 37379 l
l l
2
(
0FFICE OF' NUCLEAR POWER - TVA CORPORATE OPERATIONAL READINESS REVIEW SEQUOYAH NUCLEAR PLANT 1
APRIL 13, 1987 - MAY 8, 1987 l
0421Y
. 3 OPERATING PLANT ASSESSMENT - SON INDEPENDENT TEAM TVA INTERNAL TEAM DICK MATHENY - WESTINGHOUSE - CORPORATE MANAGER OPERATIONAL READINESS JIM ROSK0PH - STONE & WEBS'TER - PROJECT MANAGER, BROWNS FERRY NUCLEAR PLANT RON SEIBERLING - INP0 - MGR. NUCLEAR MANAGERS REVIEW GEORGE TOTO - WESTINGHOUSE - SITE DIRECTOR - WATTS BAR NUCLEAR PLANT BILL VATTER - INP0 - MGR. OPERATIONAL READINESS - BROWN FERRY NUCLEAR PLANT JERRY MARTIN - MANAGEMENT ANALYSIS CO. - ASST. PLA!il MGR.,
BROWNS FERRY NUCLEAR PLANT TERRY OVERLID - TVA ASST. DIR., NUCLEAR MANAGERS REVIEW GROUP TVA EXTERNAL TEAM BRIAN DEBS - IMPELL - FORMER NRC INSPECTOR BILL GERKEN - PRESIDENT - UTILITY OPERATIONS SERVICES BOB HARRIS - PRESIDENT ICAL INC. - FORMER REGIONAL MANAGE
- NUMANCO RONALD J. RODRIGUEZ - MANAGEMENT ANALYSIS COMPANY,FORMER ASST. GM, RANCHO SECO NUCLEAR SITE WILLIAM WAGNER - FORMER REACTOR OPERATIONS SUPV.
- HOUSTON L&P - WISCONSIN PUBLIC SERVICE l
COMBINED NUCLEAR EXPERIENCE: 257 YEARS e pm M 6MO 9
J Me TDO O*
l 0386Y l
s TABLE OF CONTENTS PROLOGUE I
. REVIEW TEAM ROSTER II RESilLTS AND RECOMMENDATIONS - OPERATING PLANT ISSUES III CHEMISTRY AREA III-A s -
LONG-RANGE OPERATIONS STAFFING III-B TRANSITION To AN OPERATING PLANT III-C RAPID RESPONSE OF DIVISION OF NUCLEAR III-C-1 ENGINEERING TO OPERATING PLANT DESIGN CHANGE
{'
BACKLOG MANAGEMENT III-C-2 ORGANIZE TO MAXIMIZE PLANT MANAGER'S III-C-3 l
ATTENTION TO UNIT 2 OPERATING SUCCESS IMPROVE PLANT MANAGEMENT AVAILABILITY III-C-4 TO MONITOR PLANT ACTIVITIES AND PROCEDURE COMPLIANCE RADWASTE AREA III-D PROCEDURE REVISION PROCESS III-E 1
l PROCEDURE COMPLIANCE III-F
\\-.
1 0421Y l
...e
--r---
i TABLE OF CONTENTS (CONT.)
RESULTS AND RECOMMENDATIONS - RELATED OPERATING PLANT ISSUES
~
IV GOALS AND OBJECTIVES IV-A PM PROGRAM IV-B CORPORATE MANAGEMENT STAFFING AND SUPPORT IV-C ROOT CAUSE IV-D RESULTS OF REVIEW - IMPROVEMENTS AND STRENGTHS V
(w'
~
l i
l l
t 0421Y l
a
PROLOGUE THE DECISION TO CONDUCT AN INDEPENDENT REVIEW 0F SEQUO UNDER OFFICE OF NUCLEAR POWER (ONP) SFONSORSHIP WAS A COMMITMENT AB0VE AND BEYOND THE THEN EXISTING NUCLEAR PERFORMANCE PLAN (NPP) REQUIREMENTS. THE NPP COMMITTED TO THE INDEPENDENT REVIEW PROCESS AT BROWNS FERRY NUCLEAR PLANT (BFNP)
IN VOLUME 3.
AN EXTENSIVE EFFORT WAS ONG0ING IN MONITORING AND REPO UPON THE SEQUOYAH RESTART PROGRAM.
IT WAS DETERMINED TO USE THESE RESULTS TO EVALUATE AND FORECAST POSSIBLE OPERATING PLANT PROBLEMS DURING THE INITIAL'SIX TO TWELVE MONTHS OF OPERATING PLANT HISTORY.
AND CONCURRED IN BY ONP MANAGEMENT. THIS PLAN WAS REVI THE ONP MANAGER OF OPERATIONAL READINESS WAS DIRECTED ASSEMBLE A REVIEW TEAM 0F SENIOR NUCLEAR EXPERIENCED PERSONNEL.
THE TEAM WAS MADE UP 0F PERSONNEL WORKING WITHIN THE TVA ORGANIZATION AND OUTSIDE SUBCONTRACTOR PERSONNEL, DIVIDED EQUALLY AS POSSIBLE.
TEAM PERSONNEL WERE BADGED FOR COMPLETE ACCESS TO THE SEQUOYAH POWER
(
THE TEAM ASSEMBLED ON APRIL 13, 1987 AND COMPLETED THEIR ONSITE EFFORT ON MAY 8, 1987.
TEAM MEMBERS WERE ASSIGNED TO AREAS FOR REVIEW BASED UPON THEIR EXPERIENCE.
DAILY MEETINGS WERE HELD TO REVIEW FINDINGS WITH THE ASSEMBLED TEAM.
ISSUES BROUGHT TO THE NEXT LEVEL OF DISCLOSURE WERE DISCUSSED WITH THE AFFECTED ORGANIZATIONS.ISSUES BROUGHT THE EXECUTIVE MANAGEMENT'S ATTENTION WERE THE RESULT OF TEAM CONSENSUS.
A NUMBER OF ISSUES WERE DOWNGRADED OR DELETED AS A RESULT OF THESE ESCALATED DISCLOSURES.
FORMAL DEBRIEFINGS OF WERE CONDUCTED ON APRILTHE TEAM BY MR. WHITE AND HIS STAFF 29, 1987 AND MAY 7, 1987.
MR. WHITE THEN DIRECTED THAT A FINAL REPORT BE PREPA HIS REVIEW AND FOLLOW-UP CORRECTIVE ACTION.
~
l l
0421Y
TO
SUBJECT:
CORPORATE OPERATIONAL READINESS REVIEW - SEQUOYAH -
FOOINOTES These footnotes are to be used in conjunction with the subject report.
They were compiled because a number of management personnel asked for the basis of the description and recommendations in the report.
The footnotes reflect the backup notes from various discussions and interviews.
They also reflect notes from the daily team debriefings and discussions and thus represent both team consensus and individual input where that input was considered a valid and useful opinion by the team.
i 0436y
(
CHEMISTRY AREA ISSUE:
THE SUCCESS OF THE PLANT CHEMISTRY PROGRAM IS BASED UPON OPTIMISTIC VIEW 0F HOW AND WHEN.
PROBLEMS'WILL APPEAR AND BE MANAGED.
LACK 0F SUCCESS WILL AFFECT PLANT AND COMPONENT AVAILADILITY.
DESCRIPTION:
-PROCEDURE COMPLIANCE EQUIPMENT RELIABILITY STAFFING PROBLEM MANAGEMENT LONGSTANDING PROBLEM CONDENSATE PGLISHING 4
l l
..,. ~. -
L j
t 0331Y c
.---~w..-
e.w-me-=~-*'- ~ ~ * * ' - - * - - '" * * * " " ' " - " - ' " * * ' * " " ' '
o CHEMISTRY AREA ISSUE:
THE SUCCESS OF THE PLANT CHEMISTRY PROGRAM IS BASED UPON OPTIMISTIC VIEW 0F HOW AND WHEN PROBLEMS WILL APPEAR AND BE MANAGED.
LACK 0F SUCCESS WILL AFFECT PLANT AND COMPONENT AVAILABILITY.
DESCRIPTION:
PROCEDURE ACCURACY AND ADEQUACY DEMAND STRETCH PERSONNEL SKILLS AND INTERPRETATION THAT EXPERIENCE SAYS WILL LEAD TO NONCOMPLIANCE.
EQUIPMENT RELIABILITY PROBLEMS EXIST THAT LEAD T INCORRECT ANALYSES AND DEMAND SPECIAL SKILLS OF PERSONNEL.
THE CHEMISTRY DEPARTMENT STAFFING IS INCOMPLET MANAGEMENT POSITIONS ARE VACANT OR FILLED BY TEMPORARY PERSONNEL.
MANAGEMENT CANDIDATES HAVE-
/(
DECLINED THE POSITION BASED UPON PERCEPTION OF ORGANIZATION PROBLEMS AND LACK OF PROGRESS IN ELIMINATING PROBLEMS.
PERSONNEL TRAINING AND MANAGEMENT TRAINING WHICH WOULD ENHANCE PROBLEM MANAGEMENT AB0VE IS BEING DEFERRED BEYOND STARTUP.
THE LONGSTANDING RISK OF INADEQUATE CONDENSATE POLISHING TREATMENT DESIGN NEEDS MORE AGGRESSIV ATTENTION.
ASSUMPTIONS MADE ON EARLY DETECTION BY
- SAMPLING, RESIN EXCHANGE AND PROTECTION LIMITS ARE THE BEST AVAILABLE SOLUTIONS.
THE ASSUMPTIONS ON AIR INLEAKAGE AND CONDENSER TUBE LEAKS ARE GOOD ENGINEERING JUDGEMENTS, IF CORRECT.
IF OPTIMISTIC, THEY SUGGEST IMPRUDENT MANAGEMENT.
0331y
(
CHEMISTRY RECOMMENDATIONS FILL THE MANAGEMENT POSITIONS.
PICK CAPABLE MANAGER FROM WATTS BAR/ BROWNS FERRY AND BACKFILL.
PLACE SPECIFIC RESPONSIBILITY UPON SEQUOYAH CHEMISTRY MANAGER TO DEVELOP REPLACEMENT MANAGERS OVER NEXT 6 MONTHS.
THE CRITERIA TO IDENTIFY AND DEVELOP FAST TRACK MANAGERS IS READILY AVAILABLE IN THE INDUSTRY.
BEGIN TEAM BUILDING PRACTICES IN CHEMISTRY DEPARTMENT AS S00N AS POSSIBLE.
TEAM BUILDING CRITERIA IS AVAILABLE AND CAN BE EFFECTIVELY APPLIED BY THE DEPARTMENT.
PLACE PRIORITY ON IDENTIFIED EQUIPMENs PROBLEMS, OBTAIN FUNDING APPROVAL FOR CORRECTIVE ACTION.
THE PROBLEMS ARE NOT MAJOR IN THE OVERALL SCHEME BUT THEY ARE MAJOR TO CHEMISTRY AND LACK OF APPARENT ACTION IS PERCEIVED AS LACK 0F INTEREST.
REVIEW THE TRAINING NEEDS.
SELECT SPECIFIC TRAINING ARFAS THAT FOCUS UPON TECHNICAL ISSUES LIKE STEAM GENERATOR PROBLEMS, i! EAT EXCHANGERS FOULING, PUMP SEALS, CORROSION, ETC.
USE INDUSTRY
(
OPERATING EXPERIENCE CASE HISTORIES TO SHOW VITAL IMPORTANCE OF CHEMISTRY PROGRAMS AND PERSONNEL.
BRING IN UTILITY PERSONNEL WITH SUCCESSFUL CHEMISTRY AND RADI0 CHEMISTRY PROGRAMS FOR S Ei11 N AR, DISCUSSION, MOTIVATION.
WORK OU1 A NEAR-TERM CHEMISTRY SPECIFIC TRAINING PROGRAM WITH THE DIVISION OF NUCLEAR TRAINING AND SHOW PERSONNEL WE ARE INTERESTED IN THEIR SUCCESS.
REVIEW THE LONGSTANDING PROBLEM 0F CONDENSATE WATER TREATMENT ENSURE COMPLETE DISCLOSURE OF RISKS BY CORPORATE CHEMISTRY MANAGER.
RECOMMEND VISITS TO OPERATING PLANTS WITH SIMILAR EQUIPMENT AND COOLING WATER SOURCE TO PREPARE PRUDENT MANAGEMENT POSITION.
ENSURE RISK ASSUMPTIONS ARE UNDERST0OD AND ANALYZED IN CONSIDERATION OF FISHBOWL CONCEPT.
0331Y
CHEMISTRY ISSUES FOOTNOTES:
1.
INTERVIEWS WITH PERSONNEL IDENTIFY PROCED INADEQUACIES WHICH WERE OVERCOME BY SKILLED CRAFTS.
DETAILED ANALYSIS PROCESS PROCEDURES DO NOT ACCOUNT FOR EQUIPMENT PERFORMANCE.
MAJOR EFFORT IN PROCEDURE REVISION WAS ONG0ING BUT LACK OF CONFIDENCE EXISTED IN IMPROVEMENT BECAUSE OF LACK 0F PARTICIPATION AND FEEDBACK.
2.
LONGSTANDING PROBLEM 0F P00R VOLTAGE REGULATION FOR EQUIPMENT POWER SUPPLY.
HIGH TEMPERATURE EFFECTS ON ANALYTICAL EQUIPMENT WERE PREVIOUSLY IDENTIFIED BY INP0.
3.
STAFFING PROBLEM IS PERCEIVED AS CONFLICT OF AUTHORITY ISSUE BETWEEN ONP AND PLANT, LACK OF SUCCESS OVER LONG PERIOD REFLECTS LACK 0F COMMITMENT AND PRIORITY.
4.
LACK OF CONDENSATE POLISHING SOLUTION REFLECTS BROADER ISSUE OF BETWEEN DNE/ PLANT.
INTERFACE PROBLEM 5.
l ALL ISSUES ABOVE ARE PERCEIVED BY CHEMISTRY ORGANIZATION AS INDICATION OF LOW PRIORITY, LACK OF INTEREST AND RECOGNITION BY INFORMED MANAGEMENT.
MANY PREVIOUS PROBLEMS IDENTIFIED BY INPO REMAIN OPEN.
PREVIOUS SEQUOYAH RESPONSES TO INP0 TO CORRECT THESE PROBLEMS HAVE NOT BEEN COMPLETED OR RESPONSES I
NOT ACCEPTED BY INP0.
l l
l l
l x
0331Y
~..
LONG-RANGE OPERATIONS STAFFING ISSUE:
A PROBLEM EXISTS THAT WILL AFFECT THE
~
RESTART OF. UNIT 1 AND CONTINUED DUAL PLANT 0PERATIONAL READINESS OF SON.
THIS PROBLEM IS THE LACK 0F A LONG RANGE OPERATOR AVAILABILITY FORECAST WHICH CONSIDERS THE FACTORS LISTED BELOW.
AN OPERATOR REPLACEMENT PLAN SHOULD BE INITIATED BASED UPON THE FORECAST.
DESCRIPTION:
DRAINS ON MANPOWER REQUIRED NUMBERS A NEW PROBLEM RAPID INCREASING DEMAND CURRENT PROBLEM ACUTENESS l'
0335Y
LONG-RANGE OPERATIONS STAFFING BACKGROUND:
THE SHORT TERM READINESS OF THE OPERATIONS GROUP TO SUPPORT THE RESTART OF SON UNIT 2 IS SATISFACTORY.
THE PROGRAMS, PROCEDURES, AND PEOPLE TO BE INVOLVED IN THE UNIT 2 RESTART HAVE BEEN REVIEWED.
THE PROGRESS SHOWN TO COMPLETE THE UNFINISHED PROGRAMS, CREATE AND REVISE THE OPERATING PROCEDURES AND IMPLEMENT THE UNIT 2 SPECIFIC OPERATING STAFF IS ADEQUATE BUT INCOMPLETE.
ISSUE:
A PROBLEM EXISTS THAT WILL AFFECT THE RESTART OF UNIT 1 AND CONTINUED DUAL PLANT OPERATIONAL READINESS OF SON.
THIS PROBLEM IS THE LACK 0F A LONG RANGE OPERATOR AVAILABILITY FORECAST WHICH CONSIDERS THE FACTORS LISTED BELOW.
AN OPERATOR REPLACEMENT PLAN SHOULD BE INITIATED BASED UPON THE FORECAST.
DESCRIPTION:
THE DRAIN ON OPERATOR RESOURCES IS INCREASING BY:
1.
OPERATOR SPECIFIC TRAINING.
A.
NEW 10 CFR 55 REQUIREMENTS B.
SPECIFICALLY IDENTIFIED INPO, NRC ITEMS.
C.
MASSIVE CHANGE IN PROCEDURE REVISION OVER SHORT PERIOD.
2.
NON-0PERATOR SPECIFIC TRAINING A.
SPECIFIED MANAGEMENT TRAINING B.
COINCIDENTAL PROGRAM TRAINING l
l l!
0335Y l
(
DESCRIPTION:
(CONTINUED) 3.
DEMANDS FOR SR0 LEVEL PERSONNEL.
A.
OPERATOR TRAINING INSTRUCTORS B.
INCREASED PROCEDURE DEVELOPMENT AND MAINTENANCE.
C.
UTILIZATION OF SRO LEVEL PERSONNEL BY SUPPORTING ORGANIZATIONS.
4.
BUILT-IN PERSONNEL WORK TIME LOSSES A.
INCREASING LEAVE WITH LONGEVITY.
B.
THE INTRINSIC TIME DELAY TO CREATE R0/SR0 LEVEL REPLACEMENT PERSONNEL.
1.
RO APPROXIMATELY 5 YEARS 2.
SRO -
APPR0XIMATELY 7 YEARS
(
C.
THE SRO UPGRADE PROGRAM.
5.
ATTRITION A.
LOSSES INCURRED IN PERSONNEL DEVELOPMENT B.
LOSSES IN LICENSABILITY WITH AN AGING SUPERVISORY STAFF.
C.
LOSSES THROUGH INTER-TVA TRANSFERS 0.
EXTERNAL LOSSES THIS IS NOT A NEW PROBLEM.
IT HAS EXISTED SINCE SON WAS STARTED.
THE NEW PART OF THE PROBLEM IS THAT THE DEMANDS ON THE AVAILABLE RESOURCE ARE EXPANDING MUCH MORE RAPIDLY THAN BEFORE.
l t
0335Y h
,s
{
DESCRIPTION:
(CONTINUED) l' THE PROBLEM CAN BECOME ACUTE AGAIN WHEN:
1.
THE DEDICATED SURVEILLANCE INSTRUCTION PERFORMANCE GROUP IS ACTIVATED.
(
' ASSISTANT MANAGER OF OPERATIONS STATES THAT THIS GROUP IU TO BE COMPOSED OF 3-4.
R0 LEVEL PERSONNEL.
2.
THE DEDICATED PROCEDl'RE DEVELOPMENT 'g GROUP Il05.S.f101. RETURN TO THE SHIFT INTEGRATION.
THE PROCEDURE REWRITE EFFORT WILL CONTINUE AT A HIGH LEVEL OF ACTIVITY FOR MANY MONTHS AS THE SITE
- (
PROCEDURE GROUP COMES UP TO SPEED AND FEEDBACK FROM THE FIELD IS RECEIVED FOR
[
INCORPORATION.
q 4 \\
3.
THE WBN PEOPLE RETURN TO THEIR OWN
- FACILITY,
[\\
1 i
i
's 0335Y
a b
3 LONG RANGE OPERATIONAL STAFFING RECOMMENDATIONS BEGIN THE AVAILABILITY FORECAST AS S00N AS POSSIBLE.
ESTABLISH DEADLINES AND RESPONSIBILITIES FOR THE MILESTONE EVENTS LEADING TO A COMPREHENSIVE FORECAST.
AS A MINIMUM, START WITH CURRENT MANNING LEVELS AND FORECAST SUCH THINGS AS ATTRITION, PROMOTION, TRANSFER, HPP COMMITMENTS TO ENSURE ENOUGH PERSONNEL ARE IN PIPELINE NOW FOR NEXT TWO YEARS (AU0S)
FIVE YEARS (R0S) SEVEN YEARS (SROS).
DEVELOP THE OPERATOR REPLACEMENT PLAN CONCURRENT WITH THE AVAILABILITY FORECAST.
EMPHASIZE PERSONNEL DEVELOPMENT, JOB ROTATION AMONG GROUPS OTHER THAN OPERATIONS, OPPORTUNITY TO ACT AS LEAD OR SUPERVISOR, PROJECT TASKS, SHORT-TERM TASKS TO PROVIDE NEW OPPORTUNITY AND DEPARTURE FROM ROUTINE AND REPETITIOUS WATCHSTANDING.
ESTABLISH A METHOD TO CONTINUOUSLY REVIEW THE TASK ANAL OPERATOR POSITIONS.
THE CHANGES IN OPERATING PHILOSOPHY AND THE IMMENSE PROCEDURE REVISION EFFORT MAKE THIS ESPECIALLY HECESSARY.
THE RESULT CAN BE QUICKER AND MORE ACCURATE
'FERSOMNEL TRAINING DEVELOPMENT PROGRAMS AND CONSISTENT OPER PERFORMANCE.
DEVELOP A RESOURCE DEVELOPMENT PLAN FOR OPERATIONS THAT WILL REFLECT THE INTENT OF THE CURRENT MANAGER / SUPERVISOR TRAINING PROGRAMS AND EVENTUALLY THE IMPLEMENTATION OF THE HAY PLAN OR SOME SIMILAR FUTURE OBLIGATION.
CREATE AND DISTRIBUTE A RESOURCE UTILIZATION FORM TO OTHER ORGANIZATIONS.
DETERMINE THEIR PLANS TO USE OPERATIONS PERSONNEL TO SUPPORT THEIR EFFORT IN BOTH UNITS.
INCLUDE MANPOWER ESTIMATES, DATES, SPECIAL SKILLS, ALTERNATIVES.
MANY OF THESE RECOMMENDATIONS INVOLVE CHANGE OVER EXTENDED PERIODS.
NOTHING WILL HAPPEN WITHOUT A PLAN TO BRING TO THE TABLE.
i 0335Y i
l
f-LONG RANGE OPERATIONS STAFFING y
i FOOTNOTES:
1.
THE 10 CFR 55 INTERPRETATION RANGES FROM NO AFFECT TO ADDING 200 TRAINING HOURS /0PERATOR.
DISCUSSION WITH OTHER UTILITIES, INPO, NRC SHOULD REDUCE UNCERTAINTY AND ENHANCE PLANNING.
2.
PRESENTLY, SOME 1100 HOURS (1/2 MAN-YEAR) IS NECESSARY FOR TRAINING OF SOME OPERATORS.
INP0 EVALUATION SHOWS POTENTIAL ADDITIONAL TRAINING NEEDS IN RADIATION PROTECTION, ALARA PLANNING, EXPANSION OF SIMULATOR TRAINING TO ALLOW USE OF CRITIQUES, INDUSTRY EXPERIENCE, ETC, NEW PROGRAM "FUNDAMENTALS OF TEAMWORK & DIAGNOSTIC SKILLS" FOR INITIAL AND REPLACEMENT LICFNSE TRAINING PROGRAMS.
3.
THE CURRENT CRASH EFFORT UPON PROCEDURE REVISION WILL SUPPORT RESTART.
IF PLANT f(
MANAGEMENT DESIRES TO REGAIN CONTROL OF PROCEDURE CONTENT PHILOS 0fHY, CONSISTENT APPLICATION OF PROCEDURES AND AVOIDING FIRE DRILLS AND LACK OF PRL:EDURE REVIEW TIME, THEY MUST PLAN FOR ADEQUATE QUALIFIED PEOPLE TO STAY WITH THE REVidW PROGRAM UNTIL IT REFLECTS MANAGEMENT INTENT.
033FY r
O TRANSITION TO AN OPERATING PLANT' ISSUES AND THE NEED FOR RAPID RESPONSE OF THE DESCRIPTION:
DIVISION OF NUCLEAR ENGINEERING (DNE)TO THE PLANT FOR SUSTAINED SAFE AND RELIABLE OPERATION IS RECOGNIZED BUT REQUIRES DEVELOPMENT'AND TEAM BUILDING.
LARGE NUMBERS OF WORK REQUESTS, ENGINEERING CHANGE NOTICES AND CONDITIONS ADVERSE TO QUALITY REMAIN OPEN FOR EXTENDED PERIODS OF TIME.
THIS DOES NOT SUPPORT TVA'S COMMITMENT FOR IMPR'0VED ACCOUNTABILITY AND FOLLOW THROUGH.
MITIGATE THE IMPACT OF UNIT 1 STARTUP AND POST STARTUP COMMITMENTS UPON THE PL.eNT MANAGER.
ENHANCE THE PLANT MANAGER'S SUSTAINED CLOSE ATTENTION TO DETAIL DURING THE REMAINING CORE LIFE OF UNIT 2.
<(,
REDUCE THE IMPACT OF ADMINISTRATIVE AND TECHNICAL MEETINGS ON THE AVAILABILITY OF MANAGERS AND SUPERVISORS TO MEET THE COMMITMENT OF INPLANT PRESENCE TO OBSERVE WORK ACTIVITIES AND PROCEDURE COMPLIANCE.
l l
l i
i l
l l
l 0345Y
{
c l
i
.c.
TRANSITION TO AN OPERATING PLANT (E
ISSUE:
THE NEED FOR RAPID RESPONSE.0F THE DIVISION OF NUCLEAR ENGINEERING (DNE) TO THE PLANT FOR SUSTAINED SAFE AND RELIABLE OPERATION IS RECOGNIZED BUT REQUIRES DEVELOPMENT AND TEAM BUILDING.
DESCRIPTION:
THERE 13 A STRONG PHILOSOPHICAL COMMITMENT AT THE SENIOR LEVELS OF ENGINEERING MANAGEMENT TO SUPPORT THE OPERATING PLANT IN A TIMELY AND PROFESSIONAL MANNER.
IT IS RECOGNIZED THAT TO DO THIS AND MAINTAIN POSITIVE CONTROL OF THE PLANT DESIGN PRESENTS PROBLEMS FOR DNE.
HOWEVER, DNE HAS RECENTLY ISSUED SOEP-60 FOR THE PURPOSE OF ADMINISTRATIVELY CONTROLLING EMERGENCY DESIGN SUPPORT OF THE PLANT.
THE PROCEDURE STEPS SEEM COMPLICATED AND LABORIOUS.
REVIEW BY TEAM MEMBERS RAISE SERIOUS DOUBTS AS TO THE VALIDITY OF THE PROCEDURE PROVIDING RAPID DESIGN SUPPORT.
THE EXPEDITING BY HAND CARRY ANU USE OF THE WORP "IMMEDIATE" TO CHANGE A ROUTINE PROCESS MA't RESULT IN LOSS OF NECESSARY DOCUMENTATION FOR CONFIGURATION CONTROL.
THE PLANT MANAGER ACKNOWLEDGED THAT A TRIAL RUN OF THE PROCEDURE HAS BEEN INITIAfED FOR A NON-SAFETY SYSTEM CHANGE THAT IS RELATIVELY SIMPLE FROM A DECISION STANDPOINT.
IT INVOLVES THE REMOVAL OF A BAFFLE FROM THE INSIDE OF A PIPE.
HOWEVER, HE EXPECTS THAT EVEN THIS SIMPLE DECISION CHANGE WILL TAKE SEVERAL DAYS TO GAIN APPROVAL FOR WORK TO COMMENCE.
IN FACT, DNE TURNED AROUND THE REQUEST IN LESS THAN 48 HOURS, GENE R A T IN'J sOME 24 DESIGN CHANGE REQUESTS FOR SIMILAR FUTURE WORK.
DNE SEEMED TO BELIEVE THA7 THE DESIGN CHANGE COULD NOT BE PROCESSED CY TPd PLANT BECAUSE THE PLANT HAD NOT MADE A RELATED PROCEDURE AVAILABLE FOR IMPLEMENATION.
0339Y
O DESCRIPTION:
(CONTINUED)
INOVIRIES BY TEAM MEMBERS OF DNE INDICATE THERE IS A RELUCTANCE TO ESTABLISH A DEDICATED ORGANIZATION OF ENGINEERS TO SUPPORT THE DESIGN REQUIREMENTS OF THE OPERATING PLANT.
DNE IS DESIGNATING SYSTEM ENGINEERS WITHIN THE ENGINEERING DISCIPLINES.
THE MANNING 0F THIS EFFORT IS NOT DEFINED.
THAT ENGINEERING WILL' SUPPORT OPERATING PLANT NEEDS IS UNOUESTIONABLE.
il0 WEVER, IT DOES NOT SEEM THAT A WELL CONCEIVED PROGRAM TO PROVIDE THIS SUPPORTIN A CONSISTENTLY TIMELY FASHION HAS BEEN COMPLETELY THOUGHT THROUGH TO PREVENT DIERUPTION OF DNE PROJECT WORK, LONGER TERM DESIGN CHANGES, AND DEVELOPMENT OF A "PUT OUT THE FIRE" ENVIRONMENT IN RESPONDING TO OPERATING PLANT NEEDS.
(
0339y
(
RAPID RESPONSE OF DNE TO OPERATIONS RECOMMENDATIONS CORPORATE MANAGEMENT SHOULD CONSIDER PLACING CLEARC'JT ACCOUNTABILITY WITH TECHNICAL SUPPORT SERVICES TO DEVELOP INTERFACES AND LIMITS OF AUTHORITY WITH DNE FOR PLANT DESIGN SUPPORT.
THE EFFORT SHOULD BE A PART OF THE TEAM BUILDING PROCESS BETWEEN DNE AND THE SEQUOYAH PLANT C
1 l
l l
l l
l l
l 0339Y
TRANSITION TO AN OPERATING PLANT ISSUE:
LARGE NUMBERS OF WORK REQUESTS, ENGINEERING CHANGE NOTICES AND CONDITIONS ADVERSE TO QUALITY (CA0R) REMAIN OPEN FOR EXTENDED PERIODS OF TIME.
THIS DOES NOT SUPPORT TVA'S COMMITMENT FOR IMPROVED ACCOUNTABILITY AND FOLLOW THROUGH.
DESCRIPTION:
APPROXIMATELY 2000 WORK COMPLETE WORK REQUESTS (WRS)/ MAINTENANCE REQUESTS (MRS)/SURVFILLANCE INSTRUCTIONS (SIS)ARE AWAITING QUALITi ENGINEERING (0E) REVIEW.
IN ADDITION.
APPR0XIMATELY 1190 WORK COMPLETE ENGINEERING CHANGE NOTICES REMAIN OPEN PENDING FINAL REVIEW.
THERE ARE APPR0XIRATELY 1600 OLD/NEW CA0S OPEN.
IN 1982 THERE WERE REPORTED DEFICIENCIES IN COMPLETING QUALITY ASSURANCE (0A) REVIEWS OF FIELD COMPLETE MRS (CAR-46-82-45).
NRC INSPECTION 85-24 IDENTIFIED 2000 MR/WR BACKLOG AS AN ISSUE.
NRC INSPECTION 85-45 ISSUED A
(
SEVERITY LEVEL IV VIOLATION FOR THE BACKLOG
(
ISSUE.
THIS LARGE BACKLOG OF WORK REPRESENT A POTENTIAL POST OPERATIONAL PROBLEM.
AS THE REVIEWS ARE COMPLETED, DISCREPANCIES FOUND AS A RESULT OF THE REVIEWS IN PROCEDURAL COMPLIANCE, MATERIAL USED, OR DESIGN DISCREPANCIES COULD NOT ONLY ADVERSELY i
IMPACT CONTINUED PLANT OPERATION BUT, r
THEY MIGHT NEGATIVELY IMPACT THE PERCEPTION THAT THE TVA ORGANIZATION AND MANAGEMENT CHANGES HAVE CORRECTED THE LACK 0F ATTENTION TO DETAIL AND STRONG CENTRALIZED CONTROL THAT WAS A ROOT CAUSE OF PREVIOUS PROBLEMS.
00R REVIEW 0F CLOSED WORK ITEMS TO DATE HAS SHOWN N0 SIGNIFICANT SAFETY l
ISSUES.
ITEMS OF MISSING OR POOR CLOSURE l
DOCUMENTATION, ADDITIONAL OPEN ITEMS, AND LACK i
0F TRACKING EVIDENCE WERE BROUGHT TO PROPER l
ATTENTION.
l l
\\
0342Y l
c DESCRIPTION:
(CONTINUED)
IN REVIEW 0F THESE CONDITIONS IT HAS ALSO COME TO LIGHT THAT SOME WRS/MRS APPEAR TO BE LOST.
THAT IS, COMPLETED WORK PACKAGES WERE ALLEGEDLY SUBMITTED TO QUALITY ENGINEERING FOR FINAL REVIEW FOR WHICH QE HAS NO RECORD OR CANNOT-FIND THE PACKAGE..THIS NEEDS RESOLUTION TO INSURE IT NOT A REAL ISSUE NOR A PERCEIVED ISSUE DURING THE INCREASED LEVEL OF PRE-STARTUP INSPECTIONS.
1 i
l 0342Y
BACKLOG MANAGEMENT RECOMMENDATIONS THE TOTAL RESOLUTION TO THE BACKLOG PROBLEM MAY NOT BE ACHIEVABLE BY STARTUP, HOWEVER, MANAGEMENT ATTENTION TO THE PROBLEM SHOULD BE BROUGHT TO ACCOMPLISH THE FOLLUWING:
PLAN DEVELOPED FOR WORK DOWN OF THE BACKLOG.
SUFFICIENT DEDICATED RESOURbES APPLIED TO DEMONSTRATE A SATISFACTORY TREND THAT THE BACKLOG IS DIMINISHING.
DEVELOPMENT OF GUIDANCE AND TRAINING 0F REVIEWERS.
ENCOURAGE THE DIALOGUE BETWEEN APPROPRIATE INDIVIDUALS TO RESOLVE INTERPRETIVE ISSUES MORE TIMELY THAN CAN BE ACCOMPLISHED THROUGH MEMORANDUM.
ENCOURAGE DIALOGUE BETWEEN INDIVIDUALS PRIOR TO PROBLEM DOCUMENTATION TO ENSURE PROBLEM IDENTIFICATION IS UNDERST0OD,
[L NOT REDUNDANT AND A VALID ISSUE FOR ATTENTION.
h 0342Y
TRANSITION TO AN OPERATING PLANT ISSUE:
MITIGATE THE IMPACT OF UNIT 1 STARTUP AND POST STARTUP COMMITMENTS UPON THE PLANT MANAGER.
ENHANCE THE PLANT MANAGER'S SUSTAINED CLOSE ATTENTION TO DETAIL DUPING THE REMAINING CORE LIFE OF UNIT 2.
DESCRIPTION:
THERE IS AN INCOMPLETE LONG RANGE PLAN TO MEET THE POST STARTUP COMMITMENTS FOR SON.
OF GREATER CONCERN, THERE IS NO EVIDENCE OF A DELIBERATE PROGRAM TO FULLY ASSESS THE IMPACT OF THE POST STARTUP COMMITMENTS ON THE PLANT MANAGER AND HIS STAFF.
THE NUCLEAR PERFORMANCE PLAN HAS COMMITTED TO SUBSTANTIAL IMPROVEMENTS IN THE QUALITY AND NUMBERS OF PROCEDURES, THE QUALITY OF PROCEDURE GUIDANCE GOVERNING THE MAINTENANCE AND PREVENTATIVE MAINTENANCE PROGRAM, AND TRENDING AND CORRECTIVE ACTION RESPONSIBILITY OF THE PLANT MANAGER.
THERE IS ALSO A COMMITMENT TO REWRITE ALL MAINTENANCE INSTRUCTIONS (MIS).
WE EXPECT THE TOTAL NUMDER OF PROCEDURE CHANGES AND RELATED REVIEW AND APPROVALS TO BE SUBSTANTIAL DUE TO INITIAL USE AND FOCUS UPON PROCEDURE COMPLIANCE AND
(
CORRECTION.
THERE IS NO FORMAL PLAN FOR ACCOMPLISHING THIS DURING POST STARTUP.
THIS HAS POTENTIAL FOR SIGNIFICANT IMPACT ON THE PLANT MANAGER'S STAFF.
IT IS ASSUMED THAT THESE LONG RANGE COMMITMENTS WILL BE ADDRESSED OVER A MATTER OF MONTHS AND NOT YEARS WITH INITIAL EFFORTS ACCE'_ERATING AFTER UNIT 2 STARTUP, THE PLANT MANAGER'S ATTENTION THE DAY-TO-DAY DETAIL OF SAFELY OPERATING UNIT 2 MAY BE DILUTED BY THESE COMMITMENTS.
THE INITIAL PLANNING FOR BRINGING UNIT 1 ON LINE IS UNDERWAY, THIS INITIAL CUT IDENTIFIES A GENERATOR BREAKER CLOSE DATE AT THE END OF 1987.
SOME 60 WORK PACKAGES ARE ALSO IDENTIFIED IN THIS INITIAL PLANNING EFFORT.
OPERATIONS SUPPORT FOR THE WORK EFFORT WILL APPARENTLY BE CONCENTRATED ON ASSISTING DNE IN WALKDOWNS AND ASSISTING MODIFICATION EFFORTS THROUGH CLEARING EQUIPMENT AND RETURNING IT TO OPERATION FOR TESTING AFTER THE MODIFICATION WORK IS COMPLETE.
RECOGNIZING THAT THERE IS COORDINATED PLANNING UNDERWAY BETWEEN OPERATIONS AND SECURITY TO CONTROL ACCESS WHICH MAY IMPACT THE t
UNIT #1 MODIFICATION WORK, WORK CONTROL BY PLANT MANAGEMENT TO AVOID OPERATING PLANT CONFLICTS WILL BE DEMANDING.
0338Y
(
DESCRIPTION:
(CONTINUED)
IT IS GENERALLY ACKNOWLEDGED THAT THE STARTUP 0F UNIT 1 WILL BE A MUCH LESS INTENSIVE LEVEL OF EFFORT ON THE PART OF TVA THAN THAT NECESSARY FOR UNIT 2 STARTUP.
FURTHERMORE, THE INITIAL STARTUP OF UNIT 1 AND THOSE LESSONS LEARNED APFLIED TO UNIT 2 MADE THE UNIT 2 STARTUP VERY SM0OTH.
THIS EXPERIENCE MAY GENERATE AN OVERLY OPTIMISTIC ASSUMPTION WITH REGARD TO THE IMPACT OF UNIT 1 STARTUP ON THE PLANT MANAGER'S ATTENTION TO UNIT 2.
GIVEN THE CURRENT ENVIRONMENT AND SCRUTINY WITH WHICH THE NRC, PRESS AND PUBLIC WILL PLACE ON TVA'S INITIAL OPERATION OF UNIT 2 IT IS IMPERATIVE THAT THE PLANT MANAGER BE PROVIDED THE OPPORTUNITY TO DEVOTE FULL ATTENTION To UNIT 2.
HE SHOULD BE GUIDED IN HIS DAY-TO-DAY DECISION MAKING BY THE PRINCIPLES NECESSARY TO CONVEY TO THE OPERATING ENVIRONMENT A PROACTIVE ATTITUDE TOWARD SAFETY IN ALL ASPECTS OF OPERA 110NS, MAINTENANCE, ROOT CAUSE ANALYSIS OF
(
TRANSIENTS AND AN0MALIES, AND CORRECTIVE
- ACTION, i
1 l
k l
0338Y l
l l
l L
4
(
MITIGATE IMPACT UPON PLANT MANAGEMENT RECOMMENDATIONS CHARGE A SUBORDINATE WITH THE DAY-TO-DAY RESPONSIBILITY FOR STARTUP PREPARATION FOR UNIT 1 AND MAKE AVAILABLE THE RESOUR TO CARRY OUT THAT FUNCTION, DEVELOP THE DETAILED LONG RANGE PLAN TO MEET THE COMMITMENTS, DO A DETAILED ASSESSMENT OF> CURRENT AND LONG RANGE IMPACT ON THE DILUTION OF ATTENTION OF THE PLANT MANAGER TO THE OPER OF UNIT 2.
UPON STARTUP 0F UNIT 2 SHIFT THE CORPORATE ATTENTION TO 2
OF.BROLINS FERRY AND REDUCE THE LEVEL OF EFFORT ON SON UNI UNTIL SON UNIT 2 HAS RUN SUCCESSFULLY THROUGH THE REMAINDE THIS CYCLE, REFUELED AND RETURNED TO POWER, l
l l
l l
b 0338Y
i TRANSITION TO AN OPERATING PLANT ISSUE:
REDUCE THE IMPACT OF ADMINISTRATIVE AND TECHNICAL MEETINGS ON THE AVAILADILITY OF MANAGERS AND SUPERVISORS TO MEET THE COMMITMENT OF INPLANT PRESENCE TO OBSERVE WORK ACTIVITIES AND FROCEDURE COMPLIANCE.
DESCRIPTION A-STRONG COMMITMENT HAS BEEN MADE FOR TVA's AND NUCLEAR MANAGEMENT TO MONITOR FOR PROCEDURE RECOMMENDATIONS:
NONCOMPLIANCE.
HOWEVER, THE TEAM'S REVIEW WITH FIELD PERSONNEL OF THE FREQUENCY THAT NUCLEAR MANAGERS ARE OBSERVED IN THE FIELD CARRYING OUT THE MONITORING INDICATED THAT THE COMMITMENT'S SPIRIT IS NOT BEING MET.
THIS IMPRESSION IS FURTHER SUBSTANTIATED BY THE MANAGERS THEMSELVES.
THERE IS A SINCERE EFFORT BY SOME MANAGERS TO GET INTO THE PLANT DAILY.
- HOWEVER, THE ACTUAL TIME OFTE'l IS EARLY IN THE MORNING OR AFTER NORMAL WORKING HOURS IN THE AFTERN0ON, NOT THE OPTIMUM TIMES TO OBSERVE PROCEDURE COMPLIANCE OF THE MAJORITY OF FIELD PERSONNEL.
C ONE SUBSTANTIAL REASON THAT THIS COMMITMENT IS NOT BEING MORE ACTIVELY MET IS THE NUMBER AND FREQUENCY OF MEETINGS ATTENDED BY LARGE NUMBERS OF MANAGERS AND SUPERVISORS.
MORE DISCIPLINE NEEDS TO BE BROUGHT TO THE CULTURE ASSOCIATED WITH MEETINGS.
CORPORATE MANAGEMENT SHOULD SPONSOR THIS DISCIPLINED APPROACH WITH GUIDANCE THAT INCLUDES:
- 1. PREFARATION OF AGENDAS WITH TIME ALLOCATED TO EACH TOPIC.
- 2. AGENDAS SHOULD IDENTIFY WHAT THE MEETING TOPIC RESULT IS EXPECTED TO BE I.E. A DECISION, A PLAN, INFORMATION COMMUNICATION, INVESTIGATORY FACT FINDING, TRAINING, TECHNICAL DISCUSSION, ETC.
- 3. LAPSED TIME FOR MEETINGS SHOULD BE CONTROLLED BY THE MEETING CHAIRMAN.
- 4. ATTENDEES SHOULD BE RESTRICTED TO THOSE NEEDED.
- 5. SCHEDULED MEETINGS SHOULD BE PERIODICALLY 7
ASSESSED FOR CONTINUING NEED.
0340Y
IMPACT OF ADMINISTRATIVE AND TECHNICAL MEETINGS FOOTNOTES:
THE LICENSEE EVENT REPORT ON DIESEL GENERAL LOAD SHEDDING WAS WALKED INTO PORC MEETING.THERE i
WERE 14 PEOPLE AT MEETING, SOME NOT ABLE TO CONTRIBUTE TO REVIEW.
THERE WAS NO PRELIMINARY REPORT, PRELIMINARY REVIEW.
THE REPORT WAS NOT WELL ORGANIZED FOR PRESENTATION.
A FIELD CHANGE REQUEST ON PLATFORM THERMAL GROWTH WAS PRESENTED T0 14 PEOPLE IN A MEETING.
THE PRESENTATION WAS 10 MINUTES OLD WHEN THE TOPIC WAS REMOVED FROM PORC BECAUSE NECESSARY HANGER DRAWINGS COULD NOT BE VERIFIED.
THE PORC REVIEW 0F AN SI WAS CONDUCTED BASED UPON A US0D.
THE CHANGES INVOLVED INCLUDED CLARIFICATION REVISIONS, TYP0 GRAPHICAL ERRORS AND DATA SHEET REVISIONS.
IN EACH OF THESE CATEGORIES THE REPORT SUBMITTED TO PORC INDICATED THERE WERE NO SAFETY QUESTIONS OR ISSUES INVOLVED WHY WAS PORC REVIEW NECESSARY?
eeeese e== -
e
\\
0429Y
e RADWASTE AREA ISSUE:
THE SEQUOYAH RADWASTE SYSTEMS, PROGRAM CONTROLS AND OPERAT10NAL CONTROLS NEED ATTENTION AND ACTION.
DESCRIPTION:
THE RADWASTE PROCESSING SYSTEM IS DEFICIENT THE RADWASTE PROGRAM CONTROLS ARE MARGINAL C0!iPARED TO INDUSTRY STANDARDS THE RADWASTE SYSTEM CPERATIONAL CON 1ROLS DO NOT PROMOTE GOOD PERFORMANCE i
l 1._
V 1
! (
0423Y
RADWASTE ISSUES ISSUE:
THE SEQUOYAH RADWASTE SYSTEMS, PROGRAM CONTROLS AND OPERATIONAL CONTROLS NEED ATTENTION AND ACTION.
DESCRIPTION:
RADWASTE PROCESSING SYSTEM RADWASTE PROCESSING EQUIPMENT OPERABILITY HAS BEEN MARGINAL FOR EXTENDED PERIODS.
CORRECTIVE ACTION REQUESTS ARE LONGSTANDING.
CURRENT PROBLEMS REFLECT LACK OF PREVENTIVE MAINTENANCE.
THE PROBLEMS FORCE PROCEDURE NONCOMPLIANCE AND POSSIBLE UNAUTHORIZED ATTEMPTS TO MAKE THINGC WORK.
FROM THE RADWASTE OPERATOR'S LOG:
4/13/87 - 2335 WORK REQUEST (WR) #B 228524 SUBMITTF.D ON VALVE 77-651B (WASTE COLLECTION TANK B (WCT) INLET VALVE STUCK OPEN).
4/14/87 - 1800-1820 PUMPED L&HS TANKS T0'WCT
- C.
ISOLATED WCT #A & B.
77-651B LEAKS THROUGH AND EXTREMELY HARD TO OPERATE.
OVERFLOWED WCT
- B TO FLOOR.
HP HANDLING CLEANUP.
CAUSTIC ADDITION TO CONDENSATE DEMINERALIZER WASTE EVAPORATOR (CDWE) FOR PH ADJUSTMENT IS ACCOMPLISHED USING TEMPORARY BARRELS, PUMP AND TUBING.
PH ADJUSTMENT WAS NOT PART 07 THE ORIGINAL DESIGN.
OBSERVATION OF WASTE MONITORING TANK (WMT)
RELEASE IDENTIFIED THE FOLLOWING:
(SEE ATTACHMENT PC-B PROCEDURE COMPLIANCE ISSUE) 1.
THE RELEASE FLOW RATE EXCEEDS THE DISCHARGE
- - ~ - - - - - - - - -
PERMIT WHEN INITIALLY OPENING THE OVERBOARD DISCHARGE VALVES.
THIS IS DUE TO A LACK OF A RECIRCULATION LINE DOWNSTREAM 0F THE FLOW INDICATOR OR IMPROPER LOCA!!0N OF THE FLOW INDICATOR.
Q 0423Y
DESCRIPTION:
(CONTINUED)
RADWASTE PERSONNEL BELIEVE THAN HAVE DONE EVERYTHING WITHIN THE CAPACITY TO RECTIFY THE PROBLEMS.
FOR INSTANCE THEY HAVE:
INSTALLED A' TEMPORARY HOSE FROM CDWE DISTILLATE DISCHARGE TO FCT'S TO PREVENT FLOODING BACK THROUGH THE FLOOR DRAIN SYSTEM.,
PROVIDED CONNECTIONS FOR A PORTABLE LIQUID RADWASTE DEMINERALIZER SYSTEM.
REMOVED BORIC ACID EVAPORATORS FROM THE CSSC LIST.
T REPEATED RADI0 LOGICALLY SIGNIFICANT EVENTS HAVE STRAINED RELATIONS BETWEEN RADWASTE OPERATIONS AND RAD CON.
SPILLS TANK OVERFLOWS SYSTEM LEAKS THESE EVENTS HAVE RESULTED IN RADIOACTIVE CONTAMINATION IN AREAS OF THE AUXILIARY BUILDING AND CONDENSATE DEMINERALIZER REGENERATION AREA.
LARGE AMOUNTS OF MANPOWER HAVE BEEN NECESSARY TO RECOVER FROM THESE EVENTS.
THE SYSTEM DESIGN OFTF.N RELIES ON THE FLOOR DRAIN PIPING TO ROUTE TANK OVERFLOWS AND OTHER HIGH ACTIVITY LEVEL LIQUIDS.
SPENT RESIN STORAGE TANK (SRST) LEVEL INDICATION IS INOPERABLE.
NO PERMANENT HARD PIPE DRAIN IS INSTALLED, A VALVE MUST BE TAKEN APART TO DEWATER THE SRST.
THIS ACTION It REQUIRED IN A VERY HIGH RADIATION AREA.
BECAUSE THE FLOOR DRAINS CANNOT HANDLE THE EFFLUENT VOLUME, THERE ARE OCCASIONS WHERE ADJOINING AREAS BECOME CONTAMINATED AND AIRBORNE RADI0 ACTIVITY HAS BEEN RELEASED.
k 0423Y
~
O' DESCRIPTION:
(CONTINUED) _
i RADWASTE PROGRAM CONTROLS LIQUID DISCHARGES ARE FREQUENT AND THE ANNUAL VOLUME RELEASED IS GREATER THAN COMPARABLE PLANTS.
MANY NON-RADI0 ACTIVE WATER SOURCES ARE ENTERING THE RADI0 ACTIVE DRAINS SYSTEM AND BEING PROCESSED AS LIQUID RADWASTE.
THE SOURCES OF LIQUID WASTE CANNOT BE EASILY IDENTIFIED.
THE VOLUME OF SOLID RADWASTE GENERATED HAS BEEN LARGER THAN NECESSARY.
THIS DEMONSTRATES A LACK OF PROGRAM MANAGEMENT ATTENTION AND CONTROL.
POWER STORES ISSUES MINIMUM AMOUNTS OF PARTS COMMON (EG:
B0X OF BOLTS VERSUS ACTUAL NUMBER NEEDED).
THESE EXCESS PARTS OFTEN BECOME
]
UNNECESSARY SOLID WASTE.
RADWASTE OPERATIONS HAS A LARGE PICTURE FILE TO DOCUMENT THE PARTS PROBLEM.
RADWASTE OPERATIONAL CONTROLS RADWASTE OPERATORS ARE NOT DEDICATED SOLELY TO RADWASTE.
1 THE RADWASTE OPERATORS ARE OFTEN PULLED BY THE i-------------
SHIFT ENGINEER TO PERFORM OTHER PLANT TASKS.
[
l 0423Y i
O 1
DESCRIPTION:
(CONTINUED)
RADWASTE OPERATIONAL CONTROLS (CONTINUED)
ASSIGNMENT TO RADWASTE OPERATIONS IS ON A NON-ROUTINE BASIS.
THE BASIS FOR ASSIGNMENT IS NOT ONE OF ACQUIRING AND MAINTAINING PROFICIENCY IN DEALING WITH A DIFFICULT SYSTEM IN A HAZARD 0US ENVIRONMENT.
THE AMOUNT OF ON-THE-JOB TRAINING DOES NOT APPEAR TO COMPENSATE FOR THE INFREQUENT ASSIGNMENT SHIFT TURNOVER OFTEN OCCURS IN THE MIDST OF DISCHARGES OR OTiiER TASKS, WHICH CAN LEAD TO OPERATING PROBLEMS.
PERSONNEL OFTEN PERFORM SEVERAL TASKS SIMULTANEOUSLY, WHICH DILUTES ATTENTION TO TASK AT HAND.
l 0423Y
ATTACHMENT PC-B RADI0 ACTIVE WASTE MONITOR TANK RELEASE t
THE MONITOR TANK CONTENTS WERE RELEASED TO THE ENVIRONMENT USING PROCEDURE S01-77.1C2.
THE FOLLOWING PROBLEMS RELATED TO PROCEDURE COMPLIANCE WERE OBSERVED DURING THE EVOLUTION:
1.
THE PROCEDURE GOVERNS OPERATOR ACTIONS FOR BOTH TANK RECIRCULATION AND RELEASE.
THE TIME REQUIRED FOR THESE ACTIVITIES AND TO COMPLETE NECESSARY SAMPLING REQUIRES THE PROCEDURE TO BE TURNED OVER IN PROGRESS AT SHIFT CHANGE.
SHIFT TURNOVER DURING AN EVOLUTION CAN CONTRIBUTE TO ERRORS, AND IN THIS CASE COULD BE AVOIDED BY SEPARATING THE ACTIVITIES INTO SEPARATE PROCEDURES.
2.
A TEMPORARY CHANGE WAS IN EFFECT FOR THIS PROCEDURE THAT RESULTED IN A DIFFERENT VALVE LINEUP CONFIGURATION BEING IN EFFECT WHEN SHIFT CHANGE OCCURRED.
THE DETAILS OF THIS DIFFERENCE AND ITS EFFECT ON SUBSEQUENT ACTIONS WAS NOT COMMUNICATED AT SHIFT CHANGE.
THE ONCOMING (SECOND)
OPERATOR HAD NOT CONDUCTED THIS ACTIVITY FOR SEVERAL MONTHS AND WAS NOT FAMILIAR WITH THE TEMPORARY CHANGE.
f" ADDITIONALLY, HE DID NOT REVIEW THE TEMPORARY CHANGE g,
PRIOR TO BEGINNING WORK.
3.
VALVE LINEUP VERIFICATIONS WERE NOT CONDUCTED IN AN INDEPENDENT MANNER AS REQUIRED BY SI-77.lC2, AI-37 "INDEPENDENT VERIFICATION," AND G01-6A "VALVE OPERATION."
TWO OPERATORS WORKED T03 ETHER, WITH ONE PERSON READING THE PROCEDURE AND THE OTHER CHECKING VALVE POSITIONS.
AS A RESULT, NEITHER COULD HAVE KNOWN FROM HIS ACTIONS ALONE, THAT THE VALVE LINEUP WAS CORRECT, 4.
BECAUSE THE SECOND OPERATOR WAS NOT AWARE OF THE EFFECTS 0F THE DIFFERENT VALVE LINEUP RELATED TO THE TEMPORARY PROCEDURE CHANGE, HE BECAME CONFUSED WHEN THE SYSTEM DID NOT RESPOND AS EXPECTED.
HE THEN CHANGED SOME VALVE POSITIONS IN A MANNER DIFFERENT FROM THE PROCEDURE INSTRUCTIONS. THIS CAUSED THE RELEASE FLOW RATE TO EXCEED THE PROCEDURE LIMIT.
THE FLOW METER AND CHART RECORDER
-- - ----- PEGGED AND THE ACTUAL FLOW RATE CANNOT DE DETERMINED.
l 0384Y
\\
(
5.
THE CHANGED PROCEDURE STEPS CANNOT WORK AS WRITTEN.
STEP 9 REQUIRES FLOW RATE ADJUSTMENT: HOWEVER, NO FLOW CAN BE OBTAINED UNTIL STEP 10, OPENING A SHUT 0FF VALVE, IS COMPLETED. IN ADDITION, EXACT COMPLIANCE WITH STEP 9 (FOLLOWING STEP 10) COULD RESULT IN EXCESSIVE FLOW RATES.
THE OPERATOR COMPENSATED FOR THESE PROBLEMS BY PERFORMING THE STEPS OUT OF SEQUENCE AND INTERPRETING THE ADJUSTMENT INSTRUCTIONS OF CTEP 9.
THE CHANGE HAD BEEN IN EFFECT FOR MORE THAN A MONTH AND HAD BEEN USED SEVERAL TIMES BEFORE THIS OBSERVATION.
THIS EVOLUTION IS CONDUCTED 2-3 TIMES PER WEEK.
6.
THE OPERATCR DID NOT UPDATE THE RADWASTE STATUS BOARD WHEN REQUIRED BY THE ?ROCEDURE.
7.
SOME STEPS FOR VERIFYING EQUIPMENT STATUS WERE PERFORMED OUT OF SEQUENCE FOR CONVENIENCE.
WHILE THESE ACTIONS DID NOT AFFECT THE EVOLUTION, THIS COULD REFLECT POOR PROCEDURE COMPLIANCE ATTITUDE.
8.
A PROCEDURE CHANGE TO IMPROVE THE INSTRUCTIONS WAS NOT SUBMITTED.
1
(
0384v
e-RADWASTE ATTACliMENT 1 SPENT RESIN STORAGE TANK MODS.
(SRST)
ERIORITY BY OVERALL COMPONENT 1
DCR-2225 SRST DRAIN BACKFLUSH CONNECTIONS REMOVES TACF 82-266-77 1982 DNE DESIGN AND APPROVAL NEEDED NOT BUDGETED --
2 DCR 2242 & 2206 SRST LEVEL INSTRUMENT SYSTEM
~
REMOVES TACF 85-73-77 1985 DNE DESIGN AND APPROVAL NEEDED NOT BUDGETED 3
A.
INDEPENDENT TRANSFER FOR SYSTEM NOT SHARED WITH OTHER SYSTEMS
(
B.
A SAMPLING SYSTEM TO SAMPLE RESIN PRIOR T0, CASK / DISPOSAL CONTAINER, LOADING 3
DISTILLATE DEMI-TO REDUCE ACTIVITY DISCHARGE DEMINERALIZER TO THE ENVIRONMENT IN LIQUID CONNECTIONS WASTE WATER RELEASES DCR - NONE - BEING FORMALIZED BY SITE SERVICES AND RAD-WASTE PERSONNEL M. SHANKS /S. MORROWS BUDGET - SHOULD NOT BE A CAPITAL PROJECT -
0 & M BUDGET.
CASK DECOM.
- SYSTEM MODS.
l 1
DCR 1360 1983 REPLACES CDCT PUMPS, ECN 5916 1981 FILTERS AND RECIRC. PIPING
(
TO DECREASE TANK RECIR. TIME AND DECREASE RELEASE TO ENVIRONMENT TIME.
REMOVES TACF-81-580-77, 81-00111-77.
0&M BUDGET APPROVED FOR FY 88 EQUIPMENT ONSITE - MODIFICATION RESOURCES NOT
(
AVAILABLE l
0387Y l
l
PRIORITY OVERALL COMPONENT MISC. EQUIPMENT MODS.
4 DCR 1513 1982 WASTE HEADER INSTALLATION ECN 5911 TO TRANSFER / PROCESS WASTE WB 11398.
1981-WATER, CLEAN WATER FOR 11665 1982 RELEASE.
REMOVES TACFs 82-2442-77, 82-266-77, 82-275-77.
ALL PARIS ARE ONSITE MODIFICATION RESOURCE HOLDUP BUDGET APPROVED FOR FY 88 1
iCAK REDUCTION DETERMINE THE BEST PROGRAM CORRECTIVE ACTION FOR REDUCTION, THROUGH QUICK IDENTIFICATION AND REPAIR, OF EQUIPMENT LEAKAGE INTO THE WASTE TREATMENT SYSTEM PENDING A STARTUP DATE.
DCRS WILL BE FORMULATED r
BY IMPELL CORPORATION IN CONJUNCTION WITH DNE AND
(
RADWASTE 1
1 DRY ACTIVE WASTE COMPLETION 8-87 PROCESSING EQUIPMENT / BUILDING BUDGET APPROVED FOR FY 87 CONDENSATE DEMINERALIFR WASTE EVAPORATOR (CDWE)
MODS.
2 1
FCR 4302 ECN 6658 REPAIR CDWE FLOOR AND SEAL TO PREVENT BUILDING LEAKAGE TO OUTSIDE AREA.
THIS IS AN NRC COMMITMENT **
BUDGET APPROVED FOR FY 87 THIS DATE MAY CHANGE PENDING ON NEW SOLIDIFICATION AND DEMIN. SERVICES CONTRACT. THE EXISTING CONTRACT EXPIRES 5/31/87 2
DCR 1599 ECN 5878 REDESIGN M0ISTURE SEPARATOR REFLUX SUCTION PIPING TO CORRECT INADEQUATE ORIGINAL DESIGN.
BUDGET APPROVED 0387Y FCR NEED WRITTEN BY MODIFICATIONS
4 PRIORITY OVERAll COMPONENT 3
DCR 2143-DEMINERALIZER WATER B0OSTER ECN 6351 PUMP FOR CDWE INST. PANEL t
AND DE-SUPERHEATER BUDGET APPROVED MODIFICATIONS RESOURCES HOLDUP.
4 DCR 2178 ALTERNATE RECIRC. PUMP SEAL ECN 6417 (SHOULD COME FROM PRIMARY WATER INSTEAD OF RAW COOLING WATER)
BUDGET APPROVED MODIFICATION RESOURCES HOLDUP 5
UPGRADE CDWE VENTILATION AND AIR CONDITIONING SYSTEM
(
No DCR INITIATED 6
REROUTE CDWE STEAM TRAPS FROM FLOOR DRAIN TO STEAM CONDEN-SATE TANK.
NO DCR INITIATED - STARTED BY M. SHANKS /S. MORROW 7
MOISTURE SEPARATOR DRAIN RETURN TO VAPOR BODY INSTEAD OF FLOOR DRAIN NO DCR INITIATED - STARTED BY M. SHANKS /S. MORROW 8
DCR 1106 1981 ADDITION OF (2) 2000 GAL.
ECN 5025 SLURRY TANK FOR CDWC BUDGET APPROVED - HOLD REMOVAL 0F WASTE AND AUXILIARY WASTE EVAPORATOR N
0387y
(
ECN 6363 BUDGET APPROVED MODIFICATION RESOURCES HOLDUP 10 CAUSTIC ADDITION SYSTEM FOR PH CONTROL No DCR INITIATED - STARTED M. SHANKS /S MORROW 11 DCR 2152 ECN 6352 CDWE HARD PIPING RETURNS TO FDCT.
DNE NEEDS COST REDUCTION 12 DCR 2224 FURTHER CDWE UPGRADE DISTILLATE STRIPPER COLUMN PUMP IMPELLER REPLACEMENT AMMETER-INSTALLATION.
NEEDS PLANT APPROVAL BORIC ACID RECOVERY SYSTEM
(
2 DCR 1514 UPGRADE THE BORIC ACID ECN 6217 1984 EVAPORATOR PACKAGES TO ASSURE MINIMAL OPERATOR ATTENTION AND MINIMAL DOWNTOWN.
THE EVAPORATOR PACKAGES HAVE BEEN DOWNGRADED TO NON-CSSC MODIFICATION RESOURCE H0tdVF BUDGET APPROVED REMOVED TACFS 84-576-62, 81-467-62, 82-151-62, 82-168-62, 82-213-62, 82-214-62, 82-242-62, 83-7-62 1980 - 1983 1
DCR ECN BORIC ACID TANK VENT SYSTEM REDESIGN VENT TO FILTER OFF GAS AND CONTAMINATION REDUCTION.
k 0387Y
{
RADWASTE RECOMMENDATIONS THE PARTIES INVOLVED WITH RADWASTE POLICIES AT THE SEQUOYAH SITE AND ONP AND THOSE DIRECTLY AFFECTED BY THESE POLICIES SHOULD REACH AGREEMENT UPON EFFECTIVE MEANS TO SEEK COMMON RESOLUTION.
~
A PLAN AND SCHEDULE SHOULD BE CREATED TO ESTABLISH DEADLINE FOR CORRECTION OF EQUIPMENT PROBLEMS.
A PROGRAM FOR PERSONNEL EDUCATION AND TRAINING ON RADWASTE VOLUME AND WATER MANAGEMENT VOLUME CONTROL SHOULD BE EMPHASIZ AFTER COMMON POLICIES AND PRACTICES ARE DETERMINED AMONG RADCON, OPERATIONS, MAINTENANCE, SITE SERVICES AND OTHER PAPTICIPANTS.
A PROGRAM FOR ON-THE-JOB TRAINING OF RADWASTE OPERATORC SH BE ESTABLISHED.
THE TRAINING AT POWER OPERATIONS TRAINING CENTER SHOULD BE REVISED TO TAKE INTO ACCOUNT EXISTING SYSTE AND AREA CONDITIONS RATHER THAN DESIGNED AND SPECIFIED CONDITIONS.
AN OPPORTUNITY EXISTS FOR ONP TO LEAD AND COORDINATE THIS EFFORT.
THESE ARE PROBLEMS OF MANAGING CHANGE AND IMPROVEMENTS.
AS SUCH, THEY AFFECT THE TVA SITES.
THEY ARE BEYOND THE SCOPE OF ROUTINE PLANT OPERATION AND REQUIRE INTERFACING THAT IS NOT LIKELY TO OCCUR AT A SITE WITH HIGHER PRIORITIES AND DEMANDS.
k 0431Y
-t r
RADWASTE FOOTNOTES:
INTEkVIEWS WITH PERSONNEL ASSIGNED TO RADWASTE OPERATIONS INDICATE SIGNIFICANT ORGANIZATIONAL PROBLEMS THAT CAN LEAD TO POOR PERFORMANCE.
RADWASTE IS WHERE NEW OPERATORS ARE SENT ON FIRST PLANT AS$1GNMENT, IT? THE BOTTOM OF THE LIST.
RADWASTE IS THE END OF THE LINE, N0B0DY KNOWS YOU'RE THERE AND NOB 0DY CARES.
RADWASTE OPERATORS ARE YANKED AROUND TO FILL IN WHATEVER JOB NOB 0DY ELSE WANTS.
THIS ISN'l THE RADWASTE SYSTEM WE WERE TRAINED ON.
MANY RADWASTE OPERATORS AS WELL AS OTHER OPERATIONS PERSONNEL BELIEVE THAT A RADWASTE SUPERVISOR IS NEEDED.
WITHOUT THAT MINIMUM FORM 0F RECOGNITION THERE WILL BE NO C
TEAMWORK, CHANGE IN MORALE OR IMPROVEMENT IN PERFORMANCE.
k 0430Y
PROCEDURE REVISION PROCESS ISSUE:
CURRENT PROCEDURE REVISION PROCESS REFLECTS SEVERAL CHANGES IN DIRECTION OF PROPER PROCEDURE CONTROL POLICIES.
DESCRIPTION:
NON-INTENT IMMEDIATE PROCEDURE CHANGE METHOD IS NOT EFFECTIVE.
TEMPORARY NON-INTENT PROCEDURE CHANGES ARE NOT DISTRIBUTED IN A TIMELY MANNER.
THE ADMINISTRATIVE DELAYS IN PROCEDURE PROCESSING AND DISTRIBUTION CAN RESULT IN TECHNICAL PROBLEMS IN THE PLANT.
THE PROCEDURE REVISION PROCESS REQUIRES REDUNDANT EFFORT OF MANY PERSONNEL.
C THE DIFFICULTY AND DELAY IN PROCEDURE REVISION HAS RESULTED IN DELAY AND MISSED COMMITMENTS IN THE PREVENTIVE MAINTENANCE PROGRAM.
0375Y
PROCEDURE REVISION PROCESS ISSUE:
THERE IS NO EFFECTIVE METHOD AVAILABLE FOR MAKING CHANGES TO CORRECT PROCEDURAL ERRORS DISCOVERED DURING PROCCDURE PERFORMANCE.
CURRENTLY, VIRTUALLY ALL PROCEDURE CHANGES ARE CONSIDERED "INTENT"CHANGES REQUIRING PORC APPROVAL BEFORE USE.
THIS VERY CONSERVATIVE APPROACH WILL RESULT IN SIGNIFICANT DELAYS IN COMPLETING PROCEDURES THAT NEED CHANGING AND MAY DETRACT FROM EFFORTS TO IMPROVE PROCEDURE ADHERENCE.
A NUMBER OF OTHER PROBLEMS IN PROCEDURE CONTROLS ARE EVIDENT.
DESCRIPTION:
1.
NO DIRECT METHOD EXISTS TO MAKE IMMEDIATE, PERMANENT CHANGES THAT D0'NOT AFFECT PROCEDURE INTENT.
(INTENT CHANGES SHOULD NOT BE AND ARE NOT APPROVED WITHOUT PRIOR PORC APPROVAL.)
IMMEDIATE NON-INTENT CHANGES THAT SHOULD BECOME PERMANENT ARE CURRENTLY HANDLED AS TEMPORARY CHANGES THAT EXPIRE IN A MAXIMUM 0F 45 DAYS, A REVISION RE0 VEST FORM SHOULD BE PROCESSED C
SIMULTANE00 SLY OR SHORTLY AFTER THE TEMPORARY CHANGE TO ENSURE THE CHANGE IS PERMANENTLY CAPTURED.
THIS MAY NOT ALWAYS OCCUR.
A PROCEDURE GROUP SUPERVISOR SAID THAT EVEN IF THE REVISION REQUEST IS PROMPTLY INITIATED IT IS LIKELY IT WILL NOT BE IMPLEMENTED BEFORE THE 45 DAY PERIOD EXPIRES.
MOST PLANTS HAVE IMMEDIATE, PERMANENT, NON-INTENT PROCEDURE CHANGE MECHANISMS THAT REFLECT THE NEED TO RESPOND PROMPTLY TO DIFFERENT LEVELS OF CHANGE SIGNIFICANCE.
2.
ALL TEMPORARY CHANGES ARE REMOVED FROM PROCEDURE BOOKS ON THE EXPIRATION DATE WITHOUT INFORMING THE COGNIZANT GROUP'S PROCEDURE COORDINATOR OR THE TEMPORARY CHANGE INITIATOR.
THEREFORE, CHANGE INFORMATION NEEDED TO BE PERMANENTLY APPLIED MAY BECOME LOST.
'q 0375Y
DESCRIPTION:
(CONTINUE 0) 3.
TEMPORARY, NON-INTENT CHANGES ARE NOT DISTRIBUTED TO CONTROLLED PROCEDURE BINDERS UNTIL AFTER'PORC REVIEW WHICH MAY NOT OCCUR FOR 14 DAYS.
THEREFORE. CONTROLLED PROCEDURE COPIES MAY NOT CONTAIN UP-TO-DATE, CORRECJp:lWEQRMATION.
THIS PROBLEM WAS IDENFIFIED IN THE OCTOBER.1986 INP0 EVALUATION 7 A DOCUMENT CONTROL SUPERVISOR STATED THAT SQN HAS DECIDED TO NOT TAKE ACTION TO CORRECT THIS PROBLEM, WHICH WAS COMMITTED TO INP0, BECAUSE IT WAS ADMINISTRATIVELY T00 DIFFICULT.
INP0 OBSERVED A DIESEL GENERATOR SURVEILLANCE TEST CONDUCTED WITHOUT AN OUTSTANDING TEMPORARY CHANGE BECAUSE OF NON-TIMELY DISTRIBUTION.
4.
PROCEDURE REVISIONS AUTOMATICALLY CANCEL ALL EXISTING CHANGE FORMS IN EFFECT WHEN C
THE REVISION IS ISSUED.
(CHANGE FORM INITIATORS ARE INFORMED WHEN THIS OCCURS.)
TEMPORARY CHANGES IMPLEMENTED WHILE A REVISION IS BEING PROCESSED WILL THEREFORE AUTOMATICALLY BE CANCELLED, REQUIRING ADDITIONAL WORK IN RE-INITIATING A TEMPORARY CHANGE FORM TO PREVENT THE INFORMATION FROM BEING LOST.
5.
INSTRUCTION CHANGE FORMS (ICF) RESULT IN A PROCEDURE REVISION FOR EACH CHANGE. UNLESS A REVISION IS ALREADY IN PROCESS FOR THAT PROCEDURE WHEN THE ICF IS INITIATED.
THIS CAUSES UNNECESSARY PROCEDURE REVISION PROCESSING.
MOST PLANTS ALLOW SOME CHANGES TO ACCUMULATE BEFORE A REVISION IS INITIATED.
TEMPORARY AND/OR PEN AND INK CHANGES ARE CONTROLLED TO ENSURE THIS DELAY DOES NOT IMPACT PROPER PLANT AND COMPONENT OPERATION.
'(
0375Y
DESCRIPTION:
(CONTINUED) 6.
ICFS RESULT IN TWO PORC REVIEWS AS FOLLOWS:
WHEN T'E ICF IS INITIATED, S0 THAT THE A.
H PROCEDURE CAN BE USED.
B.
AFTER THE CHANGE IS SUBSEQUENTLY IMPLEMENTED IN A REVISION.
7.
PROCEDURE CHANGES ARE NOT PEN-AND-INK ENTERED INTO THE BODY OF THE PROCEDURE.
PROCEDURE USERS MUST REMEMBER TO CHECK COVER SHEET MATERIAL FOR POSSIBLE CHANGES.
AT OTHER PLANTS, THIS PRACTICE HAS RESULTED IN CHANGE INFORMATION BEING OVERLOOKED.
8.
CHANGES IN THE PHILOSOPHY OF PROCEDURE COMPLIANCE HAVE BEEN MADE SINCE MANY f
PROCEDURES FOR PLANT OPERATION WERE LAST
\\m WHEN THESE PROCEDURES ARE USED AGAIN, USED.
PROCEDURE PROBLEMS MAY REQUIRE PROCESSING OF MANY PROCEDURE CHANGES.
9.
A RECENT NIGHT ORDER TO THE SHIFT ENGINEERS INSTPUCTED THEN TO USE THE TEMPORARY CHANGE FORMS IN EXTREMELY LIMITED SITUATIONS.
IF THIS POLICY IS CONTINUED THROUGH STARTUP MANY SIGNIFICANT DELAYS WILL OCCUR WHILE PROCEDURES ARE BEING CORRECTED.
10.
ABOUT HALF 0F THE CANCELLED OR DEFERRED PREVENTIVE MAINTENANCE ACTIV! TIES COULD NOT BE DONE BECAUSE OF PROCEDURE DISCREPANCIES.
THIS IS AN EXAMPLE OF HOW AN ADMINISTRATIVE PROBLEM (DIFFICULTY IN OBTAINING A PROCEDURE CHANGE)
CAN CAUSE A TECHNICAL PROBLEM (PREVENTIVE MAINTENANCE WORK NOT BEING DONE).
0375Y
O PROCEDURE REVISION PROCESS RECOMMENDATIONS PROVIDE AN EFFICIENT MECHANISM FOR ON-THE-SPOT PERMANENT PROCEDURE CHANGES BEFORE IT BECOMES A LARGER ISSUE.
ISSUE RETYPED PROCEDURE REVISIONS ONLY IN THE FOLLOWING SITUATIONS:
A.
CHANGES ARE COMPLEX B.
MORE THAN 3-5 CHANGES AFFECT TH
E. PROCEDURE
C.
A PROCEDURE CHANGE IS IN EFFECT THAT IS MORE THAN 6-12 MONTHS OLD. (ESTABLISH A DELIMITING PERI 0D)
D.
FORMAT IS CHANGED OR CHANGE RESULTS FROM A BIENNIAL REVIEW.
MARK PROCEDURE BODY WITil PEN-AND-INK NOTATIONS FOR CHANGES.
THIS COULD BE ACCOMPLISHED BY NOTING IN THE MARGIN THAT A CHANGE IS IN EFFECT FOR PARTICULAR STEP.
THE USER WOULD THEN BE ALERTED TO REFER TO COVER SHEET MATERIALS.
ENSURE PROCEDURE CHANGES ARE PROMPTLY ENTERED IN ALL CONTROLLED PROCEDURE BOOKS.
TAKE INTO ACCOUNT THE LARGE PROCEDURE REVISION AND VALIDATION EFFORT THAT WILL RESULT FROM INITIAL USE OF REVISED PROCEDURES AND INSTRUCTIONS.
k 0375Y
PROCEDURE REVISION PROCESS t
FOOTNOTES:
THE ISSUES OF PROCEDURE COMPLIANCE AND PROCEDURE REVISION ARE ENTWINED TO THE EXTENT THEY MUST BE ADDRESSED CONCURRENTLY.
FOR EXAMPLE:
IN THE CHEMISTRY ' AREA WE FIND THAT PERSONNEL 00 NOT ALWAYS COMPLY WITH PROCEDURES BUT ALSO THAT CERTAIN OPERATING PROCEDURES REFER TO CHEMISTRY PROCEDURE TABLES THAT ARE NOT COMPATIBLE.
IN THE RADWASTE MONITOR TANK RELEASE ISSUE WE FOUND PROBLEMS IN THE COMPLIANCE BUT FOUND THAT PROCEDURE STEPS COULD NOT BE FOLLOWED AS WRITTEN.
IN OBSERVING ruRFORMANCE OF SI-180 - FIRE PUMP START TEST, WE NOTED THAT DATA IHAT SHOULD HAVE BEEN TAKEN CONCURRENT HITH PUMP START WAS NOT REQUIRED BY PROCEDURE SEQUENCE UNTIL A 15 MINUTE RUN WAS COMPLETE.
THE PERFORMER WAS MADE VULNERABLE TO NON-COMPLIANCE BY THIS OVERSIGHT.
A PROCEDURE TRAP EXISTS IN SI-84.2.
A PANEL TAG CALLS FOR REMOVEL OF AN AC CABLE BE,"RE C
UNPLUGGING THE SIGNAL CABLE.
THERE ARE NO PROCEDURE STEPS OR LABELS CALLING FOR AC CABLE REINSTALLATION.
EVEN MORE DISTRESSING IS THE FACT THAT THESE PROCEDURE INADEQUACIES ARE ACCEPTED.
THE NECESSARY CHANGES WERE NOT MADE OR IN RECENT OBSERVATION, MADE ONLY UPON PROMPTING BY OBSERVERS.
THIS MEANS MANAGEMENT CAN'T REVIEW AND PROCESS NEELED IMPROVEMENTS.
THESE SAME PROBLEMS PROBLEMS ARE PROMINENT IN THE NMRG REPORT OF RECENT SPILLS.
INADEQUATE OR NON-EXISTENT PROCEDURES HAVE ENCOURAGED PERSONNEL TO MOVE AHEAD MAKING THEM VULNERABLE AND TVA IS EXPOSED TO SIGNIFICANT REACTION, THE CORPORATE READINESS TEAM SPENT SEVERAL HOURS DISCUSSING THESE ISSUES.
THE COMPROMISE BETWEEN MINDLESS PROCEDURE FOLLOW AND UNSTRUCTURED PLANT OPERATION REMAINS A CHALLENGE TO ALL NUCLEAR PLANTS.
THE CONSENSUS OF THIS EXPERIENCED TEAM IS THAT PROCEDURE COMPLIANCE PRECEDES PROCEDURE REVISION AND ONE CANNOT EXIST WITHOUT THE OTHER.
THE CAPABILITY TO INTERPRET AND EXHIBIT JUDGEMENT FOLLOWS A PERIOD OF PROVEN SUCCESS IN PROCEDURE.
(
COMPLIANCE AND PROCEDURE ADE00ACY.
0428Y
(
PROCEDURE COMPLIANCE ISSUE:
PLANT ACTIVITIES WERE OBSERVED WHERE PROCEDURES WERE NOT PROPERLY USED AND NOT CORRECTED WHEN NECESSARY.
DESCRIPTION:
POST MAINTENANCE TESTING 0F MOTOR OPERATED VALV RADIOACTIVE WASTE MONITOR TANK RELEASE SAFETY MEETING AND CONFINED SPACE ENTRY NMRG REPORT I-87-01-SQN REVIEW 0F WEEKLY DIESEL BATTERY CHECKS gS*W"#
0424Y 9
((
PROCEDURE COMPLIANCE ISSUE:
PLANT ACTIVITIES WERE OBSERVED WHERE PROCEDURES WERE NOT PROPERLY USED AND NOT CORRECTED WHEN NECESSARY.
DESCRIPTION:
DURING POST-MAINTENANCE TEST OF A MOTOR-0PERATED VALVE (M0V) THERE WERE SEVERAL DISCREPANCIES IN PROCEDURE ADEQUACY, COMPLIANCE AND CORRECTIVE ACTION.
(SEE ATTACHMENT PC-A)
DURINC RELEASE OF RADI0 ACTIVE WASTE MONITOR TAN EFFLUENT TO THE ENVIRONMENT, THERE WERE SEVERAL PROBLEMS WITH PROCEDURE CHANGE REVIEW, COMPLIANCE AND CORRECTIVE ACTION.
(SEE ATTACHMENT PC-B)
DURING THE CONDUCT OF A SAFETY MEETING AND SUBSEQUENT FOLLOW, THE EVIDENCE OF A NON-COMPLIANCE WITH ENTRY TO CONFINED SPACE C
REQUIREMENTS WAS NOT EMPHASIZED AND RESPONSIBILITY NOT CLEARLY UNDERSTOOD.(SEE ATTACHMENT PC-C)
THE RECENT SPILL EVENTS REPORTED IN NMRG REPORT I-87-01-SON DESCRIBE SIMILAR INSTANCES OF INADEQUATE PROCEDURES, PROCEDURE REVIEW AND COMPLIANCE.
(SEE ATTACHMENT PC-D)
DURING A TABLE TOP REVIEW OF SI-238.1 REVISION (WEEKLY DIESEL BATTERY CHECKS) BY A WAITS BAR (WBN) ELECTRICIAN AND SEQUOYAH (SON)
ELECTRICIAN, OBSERVATIONS WERE MADE AND WRITTEN.
THE SON ELECTRICIAN NOTED AN INCORRECT MEASUREMENT CRITERIA (GREATER THAN SIGN SHOULD HAVE BEEN LESS THAN SIGN).
THIS IS TECHNICAL SPECIFICATION DATA COLLECTION ITEM.
THE SON ELECTRICIAN DID NOT COMMENT ON THIS ERROR UNTIL PROMPTED TO SO DO BY THE OBSERVER.
THE OBSERVER NOTED THAT THE WBN ELECTRICIAN APPEARED MUCH MORE SENSITIVE TO READING AND COMPLYING WITH THE WRITTEN PROCEDURE THAN THE SON ELECTRICIAN WHO APPEARED MORE WILLING TO RELY ON HIS KNOWLEDGE OF HOW TO DO THE REQUIRED TASKS.
0424Y
ATTACHMENT PC-A
{
MOTOR OPERATED VALVE POST-h?INTENANCE TESTING
. VALVE 2-FCV-63-22, A MOTOR-0PERATED, COLD-LEG, INITIATION VALVE, HAD REPAIRS MADE TO ITS POWER SUPPLY CABLE. SAFE THE POST-MAINTENANCE TEST FOR THIS WORK WAS OBSERVED, AND TH FOLLOWING PROBLEMS RELATED TO PROCEDURE USE AND PROC QUALITY WERE NOTED.
1.
THE PROCEDURE FOR THE POST-MAINTENANCE TEST WAS AN INFORMAL PROCEDURE, WRITTEN BY THE MODIFICATIONS STAFF AND APPROVED BY AN ELECTRICAL MAINTENANCE PLANNE 0A REVIEWER.
THIS LEVEL OF APPROVAL MAY NOT MF.ET THE 6.8.2 AND REGULATORY GUIDE 1.33. REQUIREM THESE -REFERENCES REQUIRE PORC APPROVED PROCEDURES FOR "MAINTENANCE TVA HAS NOT MADE A FORMAL INTERPRE REQUIREMENTS EFFECT ON POST-MAINTENANCE TEST PROC 2.
THE ELECTRICAL MAINTENANCE AND OPERATIONS PERSON PERFORMED THE TEST DID NOT READ THE PROCEDURE BEFOR BEGINNING THE TEST.
THE LEAD ELECTRICIAN, WHO DIRECTED C
THE TEST, WAS NOT AWARE OF THE SCOPE OF THE TEST BEFORE BEGINNING.
3.
REQUIRED INITIAL CONDITIONS FOR THIS TEST WERE NOT PROVIDED IN THE PROCEDURE.
4.
THE FIRST TEST PROCEDURE STEP HAD BEEN DELETED BY T ELECTRICAL MAINTENANCE PLANNER. THIS STEP CALLED FOR REMOVING MOTOR POWER FROM THE VALVE BY LIFTING WIRES, WHILE LEAVING CONTROL POWER APPLIED.
INCORRECT FOR THIS VALVE, THIS STEP WAS PROVIDED FOR MOTOR AND CONTROL POWER.SINCE SEPARAT THE NECESSARY INSTRUCTION TO OPEN THE MOTOR POWER BREAKER (OR VERI OPEN) HAD NOT BEEN PLACED IN THE PROCEDURE.THIS OMISSION DID NOT CAUSE DIFFICULTY SINCE THE MOTOR PO BREAKER WAS OPEN AT THE START OF THE TEST.
- HOWEVER, PROBLEMS MAY HAVE OCCURRED IF THE BREAKER HAD BEEN INITIALLY CLOSED.
5. -- MANIPULATION OF THE VALVE CONTROLS NEEDED TO B AT THE LOCAL ELECTRICAL PANEL: HOWEVER, THE PROCEDURE DID NOT SPECIFY THIS.
THE LEAD ELECTRICIAN AND UNIT OPERATOR ATTEMPTED THE MANIPULATIONS FROM THE MAIN CONTROL BO k
0384Y t
6.
THE PROCEDURE CALLED FOR "0 PEN" AND "STOP" COMMANDS TO GIVEN THE VALVE, THE MAIN CONTROL BOARD SWITCH HAS ONLY "0 PEN" AND "CLOSE" FUNCTIONS.
THE LOCAL PANEL HAS "0 PEN," "STOP," AND "CLOSE" FUNCTIONS. THE LEAD ELECTRICIAN AND UNIT OPERATOR ATTEMPTED TO PROVIDE THE "STOP" COMMAND BY TAKING THE MAIN CONTROL BOARD SWITCH TO THE "CLOSE" POSITION, BUT'THE DESIRED RESULT (OPENING 0F ELECTRICAL CONTACTS) WAS NOT OBTAINED.
7.
THE UNIT OPERATOR THEN CONCLUDED THE PROCEDURE WAS INCORRECT, AND THAT CONTROL POWER BREAKER OPERATION WOULD BE NECESSARY TO OPEN THE ELECTRICAL CONTACTS.HE DID NOT RECOGNIZE THAT THE DESIRED RESULTS COULD HAVE BEEN OBTAINED BY OPERATION FROM THE LOCAL PANEL.THE TEST WAS STOPPED, THE CONTROL POWER BREAKER WAS OPENED, AND THE VALVE WAS MANUALLY ALIGNED TO PLACE THE SYSTEM IN A STABLE CONFIGURATION.
8.
THE LEAD ELECTRICIAN THEN CAREFULLY READ THE PROCEDURE AND REALIZED THAT THE SCOPE OF THE TEST WAS INAPPROPRIATE FOR THE MAINTENANCE WORK THAT HAD BEEN DONE.
9.
THE LEAD ELECTRICIAN AND OTHERS WHO PARTICIPATED IN THE TEST THEN CONSULTED WITH THE FOREMAN.
COLLECTIVELY, THEY DECIDED TO DELETE ALL PORTIONS OF THE TEST EXCEPT AN ENERGIZED, OPERATIONAL CHECK TO ENSURE CORRECT PHASE -
ROTATION OF THE MOTOR.
CONCURRENCE OF THE ELECTRICAL MAINTENANCE PLANNER AND THE OA REVIEWER WERE OBTAINED.
10.
THE ORIGINAL SCOPE OF THE TEST, A COMPLETE ELECTRICAL CHECK-0UT, WOULD HAVE BEEN APPROPRIATE FOR THE MAINTENANCE THAT HAD BEEN PLANNED.
HOWEVER, THE SCOPE OF THE MAINTENANCE WAS REDUCED.
THE POST-MAINTENANCE TEST HAD NOT BEEN RE-PLANNED WHEN THE WORK SCOPE WAS CHANGED.
11.
THE PROCEDURE PROBLEMS NOTED IN 3, 4 AND 5 ABOVE WERE NOT COMMUNICATED TO THE PROCEDURE AUTH0R OR OTHERWISE FORMALLY DOCUMENTED FOR FUTURE POST MAINTENANCE TESTING APPLICABILITY.
l 0384Y i
i i
ATTACHMENT PC-B RADI0 ACTIVE WASTE MONITOR TANK RELEASE THE MONITOR TANK CONTENTS WERE RELEASED TO THE ENVIRONM USING PROCEDURE SGI-77.1C2.
THE FOLLOWING PROBLEMS RELATED TO PROCEDURE COMPLIANCE WERE OBSERVED DURING THE EVOLUTION:
1.
THE PROCEDURE GOVERNS OPERATOR ACTIONS FOR BOTH TANK RECIRCULATION AND RELEASE.
THE TIME REQUIRED FOR THESE ACTIVITIES AND TO COMPLETE NECESSARY SAMPLING REQUIRES THE PROCEDURE TO BE TURNED OVER IN PROGRESS AT SHIFT CHANGE.
SHIFT TURNOVER DURING AN EVOLUTION CAN CONTRIBUTE TO ERRORS, AND IN THIS CASE COULD BE AVOIDED BY SEPARATING THE ACTIVITIES INTO SEPARATE PROCEDURES.
2.
A TEMPORARY CHANGE WAS IN EFFECT FOR THIS PROCEDURE T RESULTED IN A DIFFERENT VALVE LINEUP CONFIGURATION BEING IN EFFECT WHEN SHIFT CHANGE OCCURRED.
THE DETAILS OF THIS DIFFERENCE AND ITS EFFECT ON SUBSEQUENT ACTIONS WAS NOT COMMUNICATED AT SHIFT CHANGE.
THE ONCOMING (SECOND)
OPERATOR HAD NOT CONDUCTED THIS ACTIVITY FOR SEVERAL MONTHS AND WAS NOT FAMILIAR WITH THE TEMPORARY CHANGE.
ADDITIONALLY, HE DID NOT REVIEW THE TEMPORARY CHANGE PRIOR TO BEGINNING WORK.
3.
VALVE LINEUP VERIFICATIONS WERE NOT CONDUCTED IN AN INDEPENDENT MANNER AS REQUIRED BY SI-77.lC2, AI-37 "INDEPENDENT VERIFICATION." AND G0I-6A "VALVE OPERATION."
TWO OPERATORS WORKED TOGETHER, WITH ONE PERSON READING THE PROCEDURE AND THE OTHER CHECKING VALVE POSITIONS.
AS A RESULT. NEITHER COULD HAVE KNOWN FROM HIS ACTIONS ALONE, THAT THE VALVE LINEUP WAS CORRECT.
4.
BECAUSE THE SECOND OPERATOR WAS NOT AWARE OF THE EFFECT OF THE DIFFERENT VALVE LINEUP RELATED TO THE TEMPORARY PROCEDURE CHANGE, HE BECAME CONFUSED WHEN THE SYSTEM DID NOT RESPOND AS EXPECTED.
HE THEN CHANGED SOME VALVE POSITIONS IN A MANNER DIFFERENT FROM THE PROCEDURE INSTRUCTIONS. THIS CAUSED THE RELEASE FLOW RATE TO EXCEED THE PROCEDURE LIMIT.
THE FLOW METER AND CHART RECORDER
PEGGED AND THE ACTUAL FLOW RATE CANNOT BE DETERMINED.
(
0384Y
i 1..
5.
THE CHANGED PROCEDURE STEPS CANNOT WORK AS WRITTEN.
STEP 9 REQUIRES FLOW RATE ADJUSTMENT: HOWEVER, NO FLOW CAN BE OBTAINED UNTIL STEP 10, OPENING A SHUT 0FF VALVE, IS COMPLETED.
IN ADDITION, EXACT COMPL1ANCE WITH STEP 9 (FOLLOWING STEP 10) COULD RESULT IN EXCESSIVE FLOW RATES.
THE OPERATOR COMPENSATED FOR THESE PROBLEMS BY PERFORMING THE STEPS OUT OF SEQUENCE AND INTERPRETING THE ADJUSTMENT INSTRUCTIONS OF STEP 9.
THE CHANGE HAD BEEN IN EFFECT FOR MORE THAN A MONTH AND HAD BEEN USED SEVERAL TIMES BEFORE THIS OBSERVATION.
THIS EVOLUTION IS CONDUCTED 2-3 TIMES PER WEEK.
6.
THE OPERATOR DID NOT UPDATE THE RADWASTE STATUS BOARD WHEN REQUIRED BY THE PROCEDURE.
7.
SOME STEPS FOR VERIFYING EQUIPMENT STATUS WERE PERFORME OUT OF SEQUENCE FOR CONVENIENCE.
WHILE-THESE ACTIONS DID NOT AFFECT THE EVOLUTION, THIS COULD REFLECT POOR PROCEDURE COMPLIANCE ATT TUDE.
8.
A PROCEDURE CHANGE TO IMPROVE THE INSTRUCTIONS WAS NOT SUBMITTED.
0384Y I
ATTACHMENT PC-C SAFETY MEETING A BRIEF MEETING WAS HELD IN THE. ELECTRICAL MAINTENANCE SH DISCUSS A SAFETY VIOLATION.
THE FOLLOWING PROBLEMS WERE OBSERVED DURING THIS. MEETING.
1.
A GENERAL FOREMAN BEGAN THE MEETING BY STATING THAT T PERSONNEL HAD DONE EVERYTHING CORRECTLY, BUT HAD FAILED TO PROPERLY DOCUMENT THEIR ACTIONS.
THE LACK OF PROPER DOCUMENTATION HE REFERRED TO WAS FAILURE TO OBTAIN A CONFINED SPACE ENTRY PERMIT.
APPARENTLY, AIR SAMPLES HAD BEEN OBTAINED FROM THE CONFINED SPACE BEFORE PERSONNEL ENTERED.
~
2.
THE FOLLOWING INFORMATION WAS NOT PRESENTED AT THE MEE THE LOCATION OF THE CONFINED SPACE AND THE POSSIBLE A.
HAZARD r
B.
WHY THE PERMIT WAS NOT OBTAINED C.
THE IMPORTANCE OF OBTAINING A PERMIT WHEN NECESSARY.
D.
EACH INDIVIDUAL'S RESPONSIBILITY TO NOT ENTER A CONFINED SPACE UNLESS A PERMIT HAS BEEN ESTABLISHED 3.
RESPONSIBILITY FOR ENSURING CONFINED SPACE ENTRv PERMITS ARE OBTAINED WHEN NECESSARY WAS NOT CLEARLY STATED.
DURING THE MEETING SOME INDIVIDUALS WERE OVERHEARD TO COMMENT THAT THE RESPONSIBILITY WAS WITH THE SUPERVISOR WHILE OTHERS SAID MAINTENANCE PLANNERS SHOULD INCLUDE THIS IN THE WORK PLAN.
4.
THE SERIOUSNESS OF WORKING IN A CONFINED SPACE WITHOUT A PERMIT WAS NOT CONVEYED TO THE PERSONNEL. INSTEAD, THE IMPLICATION OF THE DISCUSSION WAS THAT THIS WAS NOT A DIG PROBLEM.
k 0384Y
(
S.
FOLLOW UP INVESTIGATION REVEALED THE FOLLOWING:
~
A.
THE CONTROLLING PROCEDURE FOR CONFINED SPACE ENTRY LACKS SPECIFIC DIRECTION FOR MULTIPLE ENTRY.
WHILE NOT SPECIFICALLY PROHIBITED, MULTIPLE ENTRY BASED UPON ONE PERMIT IS CLEARLY BEYOND THE INTENT OF THE CONFINED SPACE CONTROL PROCEDURE.
B.
THE CRAFT PERSONNEL HAD BEEN ALLOWED TO OBTAIN THEIR OWN AIR SAMPLES.
NO ENTRY OR DATA POINT IS REQUIRED TO VERIFY INSPECTION OR RESULTS OF SAMPLE.
C.
THE PROCEDURE DOES NOT SPECIFICALLY PROHIBIT ENTRY INTO A CONFINED SPACE WITHOUT A PERMIT.
D.
THIS ENTRY WAS FIRST ENTRY, UNDER CONTROLLED ACCESS PROCEDURE, MADE FOR A LONG PERIOD OF TIME.
AS SUCH IT WAS INITIALLY TO HAVE BEEN INSPECTED BY INDUSTRIAL SAFETY.
WHEN A DELAY OCCURRED, THE INSPECTION WAS DELEGATED TO THE MAINTENANCE FOREMAN.
E.
THE PROCEDURE CALLS FOR A WRITTEN EMERGENCY PLAN DETAILING ESCAPE ROUTES AND RESCUE EQUIPMENT USE.
{
NO EMERGENCY PLAN WAS WRITTEN.
k 0384Y
F-PROCEDURE COMPLIANCE FOOTNOTES:
1.
ITEMS 2-3-4-5 0F ATTACHMENT PC-A ARE' CLEARCUT INDICATION OF THE PROCEDURE PHILOSOPHY THAT DETAILS NEED NOT BE SUPPLIED TO PERSONNEL WHO HAVE SKILL AND EXPERIENCE TO PERFORM THE ACT AND OBTAIN RESULTS.
l.A.
AT THE SAME TIME, ITEMS 2-4-5-6-/ AND 8 0F ATTACHMENT PC-A SHOW THAT SKILL AND EXPERIdNCE DID NOT PROVIDE PROPER RESULTS AND THE ACTIONS REFLECT LACK 0F PROCEDURE PREPARATION, REVIEW AND UNDERSTANDING.
1.B.
WHILE IT MAY APPEAR THIS ISSUE IS ONE OF IMPROPER TEST SCOPE FOR WORK PERFORMED. THE ROOT CAUSE IS PROCEDURE CONTROL AND COMPLIANCE TOGETHER WITH LACK 0F CORRECTING PROCEDURE DISCREPANCIES.
2.
ITEMS 2-3-5-6 0F ATTACHMENT PC-B REFLECT THE C
PHILOSOPHY THAT PROCEDURE DETAILS CAN BE REDUCED BASED UPON SKILL AND EXPERIENCE OF THE PERSONNEL.
2.A.
ITEMS 2-3-4-5-7 0F ATTACHMENT PC-B INDICATE THAT THE SKILL AND EXPERIENCE AVAILABLE WAS NOT SUFFICIENT TO AVOID NON-COMPLIANCE AND OPERATING VIOLATIONS.
2.B.
ITEMS 2-5-8 INDICATE THAT THE TEMPORARY CHANGE PROCESS AND PROCEDURE CORRECTION PROGRAMS ARE NOT EFFECTI'lE.
2.C.
THE ROOT CAUSE OF PROBLEMS IN ATTACHMENT PC-B ARE VERY SIMILAR OR THE SAME AS IN ATTACHMENT PC-A.
0384Y
(
PROCEDURE COMPLIANCE FOOTNOTES:
3.
THE PROCEDURE TO CONTROL CONFINED-SPACE ENTRY LACKS. SPECIFIC DIRECTION. APPEARS TO BE MISSING A SECTION COVERING ACCESS CRITERIA "B",
REQUIRES JUDGEMENTAL DECISIONS ON CATEGORIZING ALL BUT CATEGORY "A" SPACES, IS NARRATIVE RATHER THAN STEP-BY-STEP.
IT HAS DETAILED ATTACHED FORMS BUT LITTLE DIRECTION TO PERSONNEL ABOUT COMPLETING THE FORM.
3.A.
ON THE BASIS OF ITS IMPORTANCE IN PREVENTING INJURY OR CASUALTIES WE STRONSLY RECCMMEND REVIEW AND CORRECTION OF THE PROCEDURE.
3.B.
THE ROOT CAUSE OF THE NON-COMPLIANCE IS INADEQUATE PROCEDURE CONTROL, LACK 0F EMPHASIS UPON PROCEDURE COMPLIANCE.
~(
038Liy
e s
(
RESULTS OF REVIEW - RELATED OPERATING PLANT ISSUES THIS SECTION CONTAINS ISSUES THAT APPEAR TO HAVE LESS DIRECT IMPACT UPON OPERATING PLANT RELIABILITY AND AVAILABILITY, ALTHOUGH THE TEAM FOUND IT MORE. DIFFICULT TO SHOW DIRECT EFFECT THEY HAD NO DOUBT AS TO THE NEED T0 ADDRESS THESE ISSUES.
9 C
h 0425Y
.l
)(
G0ALS AND OBJECTIVES 1
ISSUE:
G0ALS AND OBJECTIVES ESTABLISHED BY THE NUCLEAR PERFORMANCE PLAN (NPP) ARE NOT VISIBLE AT ALL LEVELS.
PLANT SPECIFIC OPERATING PLANT G0ALS AND OBJECTIVES ARE NOT ASSIGNED IN A CONSISTENT AND MEASURABLE MANNER.
(
DESCRIPTION:
THE NPP G0ALS AND OBJECTIVES ARE PROPERLY WRITTEN IN GLOBAL AND GENERIC LANGUAGE.
THESE GOALS AND OBJECTIVES HAVE NOT BEEN TRANSLATED INTO SPECIFIC IMPLEMENTING DIRECTIONS FOR THE ASSIGNED GROUPS AND INDIVIDUALS.
THE LACK 0F SPECIFIC IMPLEMENTING DIRECTIONS CONTRIBUTES TO INTERFACE PROBLEMS. MISSED COMMITMENTS, LACK 0F ACCOUTABIITY AND UNWANTED SURPRISES TO PLANS AND ASSUMPTIONS.
THE LACK OF DOCUMENTED IMPLEMENTING DIRECTIONS CAN LEAD TO LOSS OF CONTINUITY WHEN ORGANIZATIONAL CHANGES TAKE PLACE.
THE LACK OF SPECIFIC IMPLEMENTING DIRECTIONS INHIBITS ABILITY TO CHANGE WRITTEN DIRECTIONS BASED UPON LESSONS LEARNED, TRENDING RESilLTS. NPP REVISIONS, PRIORITIES, ETC.
THE BASE REFERENCE FOR ACCOUNTABILITY DOES NOT EXIST.
THE TYPICAL PLANT SPECIFIC G0ALS AND OBJECTIVES SUCH AS SCRAM REDUCTION, RADIATION DOSAGE REDUCTION, THERMAL PERFORMANCE, ETC. ARE NOT REDUCED 10 SPECIFIC, MEASURED AND UNDERST0OD RESPONSIBILITIES FOR GROUPS AND INDIVIDUALS.
/
s, 0426Y E
t
(
GOALS AND OBJECTIVES RECOMMENDATIONS A CORPORATE DIRECTIVE IS NEEDED DESCRIBING THE MINIMUM REQUIREMENTS FOR A G0ALS AND OBJECTIVES PROGRAM.THE PROGRAM i
SCOPE, FORMAT AND ASSIGNED RESPONSIBILITIES SHOULD BE ESTABLISHED.
DURING INITIAL PROGRAM IMPLEMENTATION, THE SITE SHOULD ASSIGN PRIMARY RESPONSIBILITY TO A MANAGER AND STAFF.THE TASK WOULD BE TO ESTABLISH SPECIFIC GOALS AND OBJECTIVES, PERFORMANCE MONITORING METHODS AND REPORTING DEVIATIONS.
OVER A PERIOD OF TIME ESTABLISHED BY THE SITE WITH CORPORA CONCURRENCE, THE MANAGER AND STAFF WOULD MONITOR AND TREND PERFORMANCE INDICATORS, PROVIDE INPUT TO THE LINE ORGANIZATIONS, ASSIST IN TECHNIQUES, ANALYZE ROOT CAUSE FOR RESULTS AND ENSURE MANAGEMENT AWARENESS.
IT SHOULD BE STRESSED THAT ALTHOUGH THIS SPECIAL TEAM S NOT EXIST BEYOND A FINITE TIME THE EFFORTIS NOT LIKELY TO SUCCEED BASED UPON EXISTING RESOURCES AND DEMANDS UPON TH
-mem e
.-e e, w e e w o
- O 0426Y
PREVENTIVE MAINTENANCE (PM) PROGRAM ISSUE:
NO FORMAL SYSTEMATIC PLAN EXISTS TO ADDRESS HOW SEQUCYAH INTENDS TO DEVELOP A PREVENTIVE MAINTENANCE PROGRAM TO IMPLEMENT VOLUME 2 NPP COMMITMENT, SINCE THIS ACTIVITY IS CONSIDERED A POST RESTART ITEM, IT HAS RECEIVED LITTLE OR NO ATTENTION.
LACK 0F MANAGEMENT ATTENTION TO THE EXISTING PM PROGRAM COULD RESULT IN NONCOMPLIANCE TO REGULATORY COMMITMENTS.
DESCRIPTION:
THE EXISTING PM PROGRAM HAS EVOLVED OVER PLANT LIFE IN REACTION TO EQUIPMENT PERFORMANCE PROBLEMS, REGULATING ISSUES, ETC.
CURRENTLY, SEQUOYAH IS COMMITTED TO DEVELOPING AND IMPLEMENTING A COMPREHENSIVE PM PROGRAM.
~
TO DATE, NO DEFINITIVE FORMAL PROGRAM HAS BEEN DEVELOPED TO MEET THIS NRC COMMITMENT.
AS A RESULT, SEVERAL SITUATIONS ARE DEVELOPING OR EXIST WHICH MAY BE INDICATIVE OF OTHER PROBLEMS.
SPECIFICALLY:
CURRENTLY PLANT MAINTENANCE PMS AND SOM-57 APPEAR TO BE IN CONTRADICTION TO OR NOT CONSISTENT WITH SOM-1 AND Al-4.
THE NUCLEAR QUALITY ASSURANCE MANUAL (NOAM)
APPEARS TO BE IN CONTRADICTION TO TECH.
SPEC. (TS) 6.8.1 AND REGULATORY GUIDE 1.33.
NEARLY FIFTY PERCENT OF CANCELLED PMS ARE A RESULT OF A RELUCTANCE TO CHANGE INADEQUATE PROCEDURES.
PM PROGRAM CHANGES ARE BEING IMPLEMENTED BEFORE GOVERNING APPROVED PROCECEDURES ARE CHANGED, EG. A PM CHANGE PROCESS HAS BEEN IMPLEMENTED BEFORE SOM-57 HAS BEEN REVISED TO REFLECT THE PROCESS.
THIS PRACTICE OF NONCOMPLIANCE APPEARS TO BE ACCEPTED BY LOWER PLANT MAINTENANCE MANAGEMENT.
P 0361Y
3 DESCRIPTION:
(CONTINUED)
I 1
THE LACK 0F PROGRAM PLANNING CURRENTLY l
LEAVES THE.FOLLOWING FUNCTIONS UNANSWERED AND THEIR IMPACT ON THE OPERATING PLANT UNDETERMINED:
A.
THE EXTENT OF MANAGEMENT ATTENTION REQUIRED FOR PROGRAM DEVELOPMENT.
B.
THE EXTENT OF RESOURCES NECESSARY TO DEVELOP THE PROGRAM FROM BOTH THE MAINTENANCE DEPARTMENT AND SUPPORTING OPERATIONS..
r i
i 1
i k
i 0361y I
O PREVENTIVE MAINTENANCE (PM) PROGRAM RECOMMENDATIONS RESOLVE THE APPARENT PROCEDURAL. TS AND NOAM CONFLICT THROUGH COMPLIANCE AND REVISE THE MAINTENANCE PROGRAM ACCORDINGLY.
SINCE TVA EXPECTS SOME STANDARDIZATION OF PM PROGRAMS, CORPORATE LICENSING SHOULD BE INVOLVED TO DEVELOP A UNIFIED POSITION FOR TVA.'
DEVELOP AND RECEIVE APPROVAL FOR A FORMAL SYSTEMATIC PLAN TO DEVELOP PM PROGRAM AT SEQUOYAH WHICH WILL SERVE AS A i
MODEL FOR THE OTHER TVA PLANTS.
4 FOSTER A BETTER WORKING LEVEL ATTITUDE TOWARD COMPLIANCE.
~
l SINCE OUR ORIGINAL DISCUSSION ACTIONS HAVE BEEN TAKEN BY THE MAINTENANCE SUPERINTENDENT TO INSTITUTE A PROGRAM.
1
\\
0361Y
{
CORPORATE MANAGEMENT STAFFING AND SUPPORT ISSUE:
THERE IS NO STRONG DEDICATED PRESENCE AT THE HEAD 00ARTERS LEVEL FOR DIRECTING THE IMPROVEMENTS AND MANAGING CHANGES IN MAINTENANCE AND CHEMISTRY PROGRAMS CARRIED OUT AT THE INDIVIDUAL SITES.
DESCRIPTION:
WITHIN THE RESPONSIBILITY OF THE DIRECTOR OF NUCLEAR SERVICES IS THE RESPONSIBILITY FOR ESTABLISHING, IMPLEMENTING, AND MAINTAINING PROGRAMS FOR SYSTEMATIC REVIEW AND ASSESSMENT OF TVA NUCLEAR PLANTS IN THE AREAS OF WATER CHEMISTRY AND MAINTENANCE.
AN INDIVIDUAL HAS BEEN HIRED AS THE CORPORATE CHEMISTRY MANAGER.
HE HAS BEEN DEDICATED TO SON TO ESTABLISH A SUCCESSFUL CHEMISTRY PROGRAM.
THE COMPLEXITY OF ISSUES RELATED TO THE SON PROGRAM AND ITS IMPORTANCE TO SUCCESSFUL LONG TERM OPERATION MAY WELL CONSUME HIS AVAILABILITY
(
FOR A NUMBER OF MONTHS.
HIS SUSTAINED
(
INVOLVEMENT WITH THE DAY-TO-DAY ACTIVITIES AND THE FRUSTRATION THAT CAN BE GENERATED IN THE CURRENT ENVIRONMENT WILL RENDER HIS EFFECTIVENESS AS A CORPORATE VOICE IN THE CHEMISTRY AREA TO NEAR ZERO.
HE IS ACTING MORE AS A PLANT CHEMISTRY MANAGER.
i HE SHOULD BE FIRMLY ESTABLISHED AT THE CORPORAT LEVEL TO PROVIDE FOR A CHEMISTRY SUPPORT VOICE IN HEAD 00ARTERS AND THEREBY MAINTAIN AN AWARENESS AT THE CORPORATE LEVEL THAT MANAGEMENT ATTENTION MUST BE BROUGHT TO BEAR ON THE PERSONNEL STAFFING, TRAINING, AND EQUIPMENT ISSUES WHICH EXIST IN THIS AREA.
IT IS RECOGNIZED THAT A SEARCH IS ON FOR A MAINTENANCE MANAGER.
IT IS IMPERATIVE THAT THIS POSITION BE FILLED IMMEDIATELY.
FIRST. IT WILL PROVIDE EVIDENCE TO THE OPERATING ENVIRONMENT THAT ONP MANAGEMENT IS MOVING TO CHANGE HOW MAINTENANCE OVERSIGHT IS TO BE CONDUCTED AND 0337y
C' DESCRIPTION:
(CONTINUED)
MORE IMPORTANTLY, CONTROLLED AND DIRECTED TO ASSURE SUSTAINED IMPLEMENTATION.
SECOND, IT WILL PROVIDE A STRONG VOICE AT THE CORPORATE LEVEL TO ACTIVELY PROMOTE MAINTENANCE SUPPORT FROM OTHER ORGANIZATIONS WHICH PLANT MANAGERS WILL NEED AT AN ACCELERATED PACE TO MAINTAIN PLANT'S OPERATIONAL REALIABILITY.
THE PRESENCE OF A STRONG MAINTENANCE VOICE SHOULD ALSO ASSIST IN CHANGING THE EMPHASIS FROM ENGINEERING CONTROL OF THE RESTART EFFORT TO OPERATIONAL CONTROL OF NOT ONLY THE RESTART BUT MORE IMPORTANTLY OF'THE POST RESTART PERIOD.
\\
0337y
O ROOT CAUSE g
ISSUE:
THE LACK OF ROOT CAUSE ANALYSIS AND ITS LACK OF PRIORITY IN PROBLEM RESOLUTION AT SEQUOYAH IS PERVASIVE.
DESCRIPTION:
THE RESISTANCE TO ROOT CAUSE ANALYSIS CAN BE NOTED AY NEARLY ALL LEVELS OF THE ORGANIZATION.
DURING REVIEW PRIOR 10 ISSUE OF THE ONP DIRECTIVE ON OPERATIONAL READINESS, THE USE OF THE WORDS "ROOT CAUSE" WAS CHANGED TO THE "UNDERLYING CAUSED.
THE WORDS "ROOT CAUSE" 00 NOT APPEAR IN THE SEQUOYAH OPERATIONAL READINESS REVIEW PROCEDU S0A-190 ALTHOUGH A KEY ELEMENT OF THIS PROGRAM IS IDENTIFICATION AND DOCUMENTATION OF CORRECTIVE ACTION ON OUTSTANDING ISSUES.
THE PREVIOUS CA0R PROGRAM DOCUMENTS CONTAIN DOZENS OF INSTANCES OF LACK 0F ROOT CAUSE C
RESPONSE, INAC700 ATE RESPONSE, INCORRECT RESPONSE.
MOST OF THEM WERE SIGNED OFF EVEN THOUGH THESE ROOT CAUSE INADE0UACIES EXISTED.
THERE ARE MANY LICENSEE EVENT REPORTS WHICH DO NOT INDICATE THE CONDUCT OF ADEQUATE ROOT CAUSE ANALYSIS.
THERE IS NO INDICATION THAT THE RELATED CAUSES ARE ANALYZED FOR A MORE BASIC AND COMMON ROOT CAUSE.
i THE SEQUENCE OF RECENT SPILL EVENTS ARE SYMPT 0F REPEATED PROBLEMS WITHOUT h
IN-DEPTH ANALYSIS i
i 0F CAUSE AND PREVENTIVE MEASURE WITH LONG-TERM IMPACT.
THOSE WHO PUT THE NMRG REPCRT TOGETHER i
ON THE SPILL EVENTS ARE AWARE OF THE LACK OF IN-DEPTH ROOT CAUSE ANALYSIS AND APPARENT LACK OF PRIORITY FOR SUCH ElFORT.
" - ~ ~ ~ ~
THE TEAM NOTED THE EXISTENCE OF PROCEDURES THAT CONTROL ROOT CAUSE ANALYSIS.
TRENDING REQUIREMENTS, ORGANIZATIONAL ASSIGNMENTS FOR THESE EFFORTS.
IT WAS A CLEAR CONSENSUS THAT 3
THESE PROCESSES AND COMMITMENTS WERE AT A VERY
{
LOW STATE OF ACTIVITY AND PRIORITY.
s i
0432y i
I.
^.e 4
(
DESCRIPTION:
(CONTINUED)
~
'THE MEMBERS OF THE TEAM THAT HAVE HAD GOOD EXPERIENCE AND RESULTS FROM EFFORTS TOWARD ROOT CAUSE ANALYSIS AND REPORTING INDICAiE THAT THERE MUST BE A. STATE.0F MIND TO PURSUE ROOT CAUSE AND USE IT IN PLANT MANAGEMENT.
THAT STATE OF MIND IS NOT EVIDENT AT TVA.
1 4
1 i
t 0432Y
I e
(
RESULTS OF REVIEW - IMPROVEMENTS AND STRENGTHS AS A RESULT OF THE CORPORATE OPERATIONAL READINESS REVIEW EVALUATION, THE FOLLOWING AREAS ARE NOTED AS EVIDENCE OF IMPROVEMENT AND/0R STRENGTH 0F.0RGANIZATION.
THE RADIOLOGICAL WORK PERMIT PROGRAM HAS SIGNIFICANTLY IMPROVED THE PERCEPTION OF WORK FORCES REGARDING THE CREDIBILITY OF RADCON PRACTICES AND POLICIES IN THE WORKPLACE.
THERE IS EVIDENCE OF ALARA SENSITIVITY AND IMPORTANCE IN MAINTENANCE PLANNING BASED UPON EXAMPLES OF WORK PACKAGES PREPARATION.
THE RADCON DEPARTMENT ACTIONS UPON INP0 EVALUATION FINDINGS APPEARS RESPONSIVE AND PROGRESSIVE.
THE QUALITY INHERENT IN THE SURVEILLANCE INSTRUCTION PROGRAM IS AN IMPROVEMENT.
THE GENERAL APPEARANCE OF THE SEQUOYAH UNIT 2 POWER BLOCK IS GOOD AND PRESENTS A READY-TO-OPERATE IMAGE.
THE OPERATIONS STAFFING FOR RESTART AND INITIAL OPERATIONS IS SATISFACTORY AND THE OPERATIONS STAFF IS MOTIVATED TO STARTUP AND OPERATE SEQUOYAH UNIT 2.
MANAGEMENT OF TVA IS AWARE OF THE EXISTING PROBLEMS AND CHALLENGES TO RESTART AND INITIAL PLANT OPERATING AVAILABILITY.
- t..
0427Y
\\d