ML20149J314
| ML20149J314 | |
| Person / Time | |
|---|---|
| Site: | Oyster Creek |
| Issue date: | 02/12/1988 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20149J302 | List: |
| References | |
| 50-219-86-99, NUDOCS 8802220354 | |
| Download: ML20149J314 (62) | |
See also: IR 05000219/1986099
Text
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ENCLOSURE 1
U. S. NUCLEAR REGULATORY COMMISSION
REGION I
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE
INSPECTION REPORT S0-219/86-99
GENERAL PUBLIC UTILITIES NUCLEAR CORPORATION
OYSTER CREEK NUCLEAR GENERATING STATION
ASSESSMENT PERIOD: OCTOBER 16, 1986 - SEPTEMBER 30, 1987
BOARD MEETING November 17, 1937
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8802220354 880212
gDR
ADOCK O
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TABLE OF CONTENTS
PAGE
I.
Introduction ........................................................
1
II.
Criteria.............................................................
3
III. Summary of
Results...................................................
5
A.
Overall
Summary.............................................
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5
B.
Background..............................................
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6
C.
Faci l i ty Pe rfo rma nce Ana lys i s Summa ry. . . . . . . . . . . . . . . . . . . . . . . . . . .
8
0.
Unplanned Shutdowns, Plant Trips , and Forced Outages. . . . . . . . . . . .
10
IV.
Performance Analysis.................................................
12
A.
Plant Operations................................................
12
B.
Radiological
Controls...........................................
16
C.
Maintenance.....................................................
21
0.
Surveillance / Inservice Testing..................................
25
E.
Emergency Preparedness..........................................
27
F.
Security and Safeguards,...........................
............
29
G.
Assurance of Quality............................................
32
H.
Licensing Activities............................................
36
I.
Engineering Support.............................................
38
J.
Training and Qualification Effectiveness........................
42
V.
Supporting Data and Summaries........................................
46
A.
Investigations and Allegations
Review...........................
46
B.
Escalated Enforcement Actions...................................
46
C.
Confirmatory Action Letters.....................................
47
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0.
Licensee Event Reports..........................................
47
E.
Licensing Activities............................................
48
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TABLES
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Table 1 - Inspection Report Activities
Table 2 - Inspection Hour Summary
Table 3 - Enforcement Activity
Table 4 - Licensee Event Reports
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I.
INTRODUCTION
The Systematic Assessment of Licerisee Ferformance (SALP) program is an inte-
grated NRC staff effort to collect available observations and data on a peri-
odic basis and to evaluate licensee performance based upon this information.
The SALP program is supplemental to normal regulatory processes used to ensure
compliance with NRC rules and regulations.
The SALP program is intended to
be sufficiently diagnostic to provide a rational basis for allocating NRC
resources and to provide meaningful guidance to the licensee's management to
promote quality and safety of plant construction and operation.
An NRC SALP Board, composed of the staff members listed below, met on November
17, 1987, to review the collection of performance observations and data, and
to assess licensee performance in accordance with the guidance in Chapter NRC
0516, "Systematic Assessment of Licensee Performance." A summary of the
guidance and evaluation criteria is provided in Section II of this report.
This report is the SALP Board's assessment of the licensee's safety perform-
ance at the Oyster Creek Nuclear Generating Station for the period October
16, 1986 to September 30, 1987.
The summary findings and totals reflect the
eleven and one-half month assessment period.
SALP Board
Board Chairman
W. Kane, Director, Division of Reactor Projects (DRP)
Members
S. Collins, Deputy Director, DRP
W. Johnston, Acting Director, Division of Reactor Safety (DRS) (part time)
T. Martin, Director, Division of Radiation Safety and Safeguards (DRSS)
J. Stolz, Director, Project Directorate 1-4, NRR
L. Bettenhausen, Chief, Projects Branch 1, DRP
R. Gallo, Chief, Operations Branch, DRS
R. Bellamy, Chief, Emergency Preparedness and Radiological Protection Branch,
DRSS (part time)
C. Cowgill, Chief, RPS 1A, DRP
W. Bateman, Senior Resident Inspector, RPS 1A, DRP
A. Dromerick, Licensing Project Manager, NRR
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Other Attendees
N. Blumberg, Chief, Operational Programs Section, OB, DRS
R. Conte, TMI#1 Senior Resident Inspector
R. Donovan, Office of Inspector and Auditor (0IA)
T. Dragoun, Senior Radiation Specialist, FRPS, EPRPB, DRS!. (part time)
D. Hickman, LPEB, OLPG, NRR
W. Madden, Physical Security Inspector, Nuclear Materials and Safeguards
Branch, DRSS (part time)
S. Peleschak, Reactor Engineer, RPS, IA, PB1, DRP
N. Perkins, OIA
J. Wechselberger, Resident Inspector, Oyster Creek
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II.
CRITERIA
Licensee performance is assessed in selected functional areas, depending upon
whether the facility is in a construction, preoperational, or operational
phase.
Functional areas normally represent areas significant to nuclear
safety and the environment.
Some functional areas may not be assessed because
of little or no licensee activities or lack of meaningful observations.
Special areas may be added to highlight significant observations.
One or more of the following evaluation criteria were used to assess each
functional area.
1.
Management involvement and control in assuring quality.
2.
Approach to the resolution of technical issues from a safety standpoint.
3.
Responsiveness to NRC initiatives.
4.
Enforcement history.
5.
Operational and Construction events (including response to, an6fyses of,
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and corrective actions for).
6.
Staffing (including management).
7,
1 raining and Qualification Effectiveness.
However, the SALP Board is not limited to these criteria and others may have
been used where appropriate.
Based upon the SALP Board assessment each functional area evaluated is classi-
fied into one of three performance categories.
The definitions of these per-
formance categories are:
Category 1.
Licensee management attention and involvement are aggressive and
oriented toward nuclear safety; licensee resources are ample and effectively
used so that a high level of performance with respect to operational safety
and construction quality is being achieved.
Reduced NRC attention may be
appropriate.
Category 2.
Licensee management attention and involvement are evident and
are concerned with nuclear safety; licensee resources are adequate and are
reasonably effective so that satisfactory performance with respect to opera-
tional safety and construction quality is being achieved.
NRC attention
should be maintained at normal levels.
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Category 3.
Licensee management attention or involvement is acceptable and
considers nuclear safety, but weaknesses are evident; licensee resources ap-
pear to be strained or not effectively used so that minimally satisfactory
performance with respect to operational safety and construction quality is
being achieved.
Both NRC and licensee attention should be increased.
The SALP Board may determine to include an appraisal of the performance trend
of a functional area.
Normally, this performance trend is only used where
both a definite trend of performance is discernible to the Board and the Board
believes that continuation of the trend may result in a change of performance
level.
Improving (declining) trend is defined as: Licensee performance was
determined to be improving (declining) near the close of the assessment period.
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III. SUMMARY 0]A3 TILTS
A.
Overall Summary
Site and corporate management continue to demonstrate a strong commitment
to safety.
Some important corporate level personnel and other changes
were made to improve overall management effectiveness. Adequate site
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staffing and facilities are being maintained. GPUN maintains a strong
commitment to improve performance through effective training for both
management and craft personnel.
However, performance this period, in
some critical areas, has been marked by inconsistency. While security and
safeguards continues to exhibit a high level of performance; plant
operations, surveillance, emergency preparedness, and engineering support
have experienced some reduction in performance.
Unplanned outages resulting from equipment malfunction and rework of
maintenance items continue to be a problem. On one occasion, following
a series of operational problems, management took a major step to improve
plant reliability and solve root cause equipment problems prior to re-
start of the plant by establishing three committees to identify and cor-
rect problems contributing to poor plant performance.
Initiatives of
this type to identify root causes to problems and to correct long stand-
.ing plant deficiencies should be continued.
Improvements in operator decision making capabilities and control room
professionalism have been noted. However, some significant operator
errors have also occurred.
Increased efforts are needed to assure pro-
cedure compliance, to eliminate the graded approach to procedure adher-
ence, and to encourage changing of procedures when warranted. Although
the facility has many excellent procedures, improvements are needed.
Ic addition, a method by which procedure changes are more promptly in-
corporated into procedures would serve to encourage the submittal of
needed procedure changes. Operations management support was upgraded
by the assignment of a former Shift Technical Advisor to the staff.
Improvement in the overall management of maintenance has been noted.
Continued efforts are needed to improve equipment reliability, reduce
challenges to the operators from equipment problems, and to improve plant
reliability. A licensee self-assessment identified that improvement in
communications between operations, maintenance, and the technical support
groups in identifying and correcting problems; the steps to accomplish
this should be implemented promptly.
The licensee continues to demonstrate a strong commitment to maintaining
quality training programs for all levels of personnel. However, a large
number of LERs were attributed to personnel error. A continuing evalu-
ation of plant activities and the focusing of training to identified
needs will further improve a good training program.
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An improvement in onsite QA/QC has been noted with audit and inspection
activities.
Some instances were noted, however, where inspectors lacked
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technical competence.
This was more evident in the auditing of tech-
nically specialized areas.
Another area which should be addressed is the cumbersome internal review
of documentation which has led to a number of LERs being submitted late
and also prevented the timely completion of some Licensing Action Items
(LAIs).
This has made the entire LAI system less effective.
Little change has been noted in the area of technical support with in-
consistent performance still being noted. The completion of self-
assessment in this area and initiation of corrective action is needed.
Despite the strong commitments to safety, training, and improvement of
management effectiveness, performance during this SALP period has been
inconsistent. The many good initiatives and operational performance
periods have been interrupted by significant operational events.
B.
Background
Oyster Creek is a GE BWR/2 with a Mark I containment.
The Construction
Permit was issued in December 1964 and commercial operation commenced
on December 23, 1969,
1.
Licensee Activities
At the beginning of the assessrrent period, the plant was in an ex-
2
tended refueling, maintenance, and modification outage.
Problems
were identified with thinning of the drywell shell in the sand
cushion area at the bottom of the drywell. This resulted in a delay
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in restart while evaluation of the significance of the problem was
pursued.
On December 21, 1986 the plant was restarted. On December 24, 1986
a reactor scram occurred on high-high IRM power due to cold feed-
water injection.
The plant was restarted on December 26 and the
generator placed on line on December 28. On December 29 power was
reduced and the plant manually scrammed due to a relief valve and
bellows problems on the plant's secondary side.
On January 6,1987
the plant was restarted.
On January 16 a reactor scram occurred f rom 84*.' power due to a high
power signal.
Restart commenced on January 19 but was followed by
a shutdown on January 20 due to intermediate range nuclear instru-
mentation problems. A startup occurred later on in the day and the
generator was placed on line on January 21. On February 14 a reac-
tor scram occurred from 98*' power due to a turbine trip on high
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reactor water level. The high water level signal resulted from a
loose electrical lead.
Restart commenced February 18, but nuclear
instrumentation problems caused a manual shutdown on February 19.
At this point the licensee decided to form three committees in an
. attempt to identify and correct the problems contributing to the
plant's poor performance. These committees addressed loose leads,
intermediate range instrumentation, and plant reliability. On March
9, 1987 the plant restarted smoothly and remained on line until
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April 24 when it was shut down to repair a failed electromatic re-
lief valve acoustic monitor.
Following a brief outage, the plant was restarted on May 14 and
continued to run until a reactor scram on July 30 caused by inad-
vertent closure of a main steam isolation valve. During the ex-
4
tended run from May 14 until July 30, plant operators were chal-
lenged several times but, in all cases, responded properly. On
August 4 the plant was restarted and continued to generate power
a
at less than full rated due to environmental limits on discharge
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water temperature.
On September 6 a leak was identified on the #2 main flash tank man-
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way.
Repair efforts were unsuccessful in stopping the leak.
The
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drywell unidentified and identified leak rates had been increasing
as well as torus water level, confirming a bonnet leak on a pre-
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viously worked feedwater isolation valve (V-2-35).
Because of these
concerns, the plant was shut down to effect repairs. On September
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10 the plant was shut dcwn and on September 11 a safety limit was
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violated as a result of recovery from a Reactor Building Closed
Cooling Water System leak during valve maintenance.
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Based on the projected time required to fully address the safety
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limit violation and the apparent destruction of a plant record
,
associated with the event, the licensee opted to remain shut down
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and to declare an official maintenance outage.
This commenced
September 16 and continued through the end of the SALP evaluation
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period,
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2.
Inspection Activities
Two NRC resident inspectors were assigned to the site throughout
the assessment period.
The total NRC inspection time for the
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assessment period was 5099 hours0.059 days <br />1.416 hours <br />0.00843 weeks <br />0.00194 months <br /> (resident, region, and headquarters
)
based) with a distribution in the appraisal functional areas as
shown in Table 2.
This equates to 5310 hours0.0615 days <br />1.475 hours <br />0.00878 weeks <br />0.00202 months <br /> on an annual basis.
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The annual emergency preparedness exercise was held on .May 12, 1987.
Special inspections were conducted as follows:
Region I Appendix R Team Inspection, January 5-9, 1987.
--
Region I Special Team Inspection to follow up tying open of
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torus to drywell vacuum breakers, April 24 - May 6,1987.
Region I and Headquarters Integrated Performance Appraisal Team
--
Inspection, August 10-21, 1987.
Region I and Headquarters Augmented Inspection Team inspection
--
to follow up Safety Limit violation, September 11-17, 1987.
Table I summarizes all inspection activities during the assessment
period.
Table 3 lists specific enforcement data.
C.
Facility Performance Analysis Summary
7/1/85 to
10/16/86 to
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10/15/86
9/30/87
Functional Area
Last Period
This Period
Trend
A.
Plant Operations
2
3
B.
Radiological Controls
2
2
C.
Maintenance
2
2
D.
Surveillance
1
2
E.
1
2
F.
Security and Safeguards
1
1
G.
Assurance of Quality
2
2
H.
Licensing Activities
2
2
Improving
I.
Engineering Support
2
3
J.
Training and Qualification
1
2
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D.
Unplanned Shutdowns, Plant Trips, and Forced Outages
Power
Root
Functional
Date
Level
Description
Cause
Area
Startup from Cycle 11 Refueling / Maintenance / Modification Outage on
December 21, 1986.
12/24/86 3.5%
Interraediate range
Operator Error / Equip-
Plant
high flux scram due
deficiency: Undesirable Operations
to overfeeding the
feedwater regulating
reactor with cold
valve "lockout feature"
caused valve to drif t
open. Operator failed
to recognize valve had
drifted open prior to
start of a feed pump.
Operators were pre-
viously aware of the
lockout feature and
were cautioned not to
position the controller
into lockout.
12/29/86 2%
Equipment Failure:
Maintenance
Steam Leak-Secondary
Side.
Relief Valve
and bellows
<
1/16/87 84%
High flux scram during
Operator Error: inade-
Plant
recirculation pump
quate understanding of
Operations
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start.
operation of motor
operated valve resulted
in failure to fully
close recirc pump dis-
charge valve.
1/20/87
0%
Manual shutdown
Equipment Failure:
Engineering
Intermediate range
Support
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instrumentation.
De-
tector failure appar-
ently due to vibration.
.
2/14/87 98%
Scram due to turbine
Random equipment fail-
N/A
~
trip caused by high
ure.
Spurious signal
,
reactor water level,
caused by a loose wire
dislodged during inspec-
tion.
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Power
Root
Functional
Date
Level
Description
Cause
Area
2/19/87 0%
Manual Shutdown
Equipment Failure:
Engineering
Intermediate range in-
Support
strumentation.
Detec-
tor failure apparently
due to vibration.
4/24/87 100%
Manual Shutdown re-
Equipment Failure:
Engineering
quired by Tecn Specs.
Electromatic relief
Support
Specs.
valve acoustic monitor
failure resulting from
a defective and poorly
designed cable splice.
7/30/87 70%
Scram due to high
Equipment Failure:
Maintenance
reactor pressure.
MSIV closure due to
air leak caused by
fasteners of improper
length used to assemble
valve manifold.
9/09/87 66%
Manual shutdown
Equipment Failure:
Engineering
Steam leak - secondary
side and increasing
drywell leak rate.
NOTE:
The root cause in this Table is the opinion of the SALP Board based
on the inspector (s) description of the event and may, in certain
instances, differ from the Licensee Event Report (LER).
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IV.
PERFORMANCE ANALYSIS
A.
Plant Operations (1820 hrs. , 36 *e)
1.
Analysis
The previous SALP rating in this area was Category 2.
Strengths
discussed included strong senior operations management and improving
e.ontrol room environment and operations / maintenance interface.
Weaknesses included long-standing unresolved equipment problems that
potentially affected plant operations and challenged operator per-
formance.
Recommendations included training and improvement in
shift managements' decision making capabilities.
Routine resident and specialist inspections, an Integrated Perform-
ance Assessment Team (IPAT) inspection, an Augmented Inspection Team
(AIT) inspection, and special inspections formed the basis for
evaluatien during the assessment period.
In response to the previous SALP, senior operations management took
action to emphasize the importance of on-shift decision-making.
Shift management reacted positively, resulting, with some excep-
tions, in more informed decisions.
Operations has also emphasized
training, especially in the area of teamwork, and improved the pro-
fessional environment in the control room.
Part of the benefits
realized were improved operator response to reactor water level
transients during event recovery. Operations management support was
upgraded by assignment of former Shift Technical Advisors (STA's)
to the staff.
Equipment problems continued to challenge the operators. Many
challenges, including two Unusual Events, were responded to cor-
rectly by the operators.
In several specific instances, however,
operator response was not adequate and problems resulted. An ex-
ample includes failure to properly respond to a known design defi-
ciency of a feedwater valve controller. This resulted in a valve
drifting open and a high flux scram occurring from the intermediate
range when the associated feed pump was started.
The issue of
equipment problems challenging the operators has been discussed in
,
previous SALP reports and, although substantial efforts have been
made by the licensee to upgrade the plant, there has not been a
corresponding reduction in the number of system challenges.
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Operator errors not precipitated by equipment failures continued
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in this evaluation period.
Two of these were significant.
The
first occurred during a routine plant shutdown when the drywell to
torus and reactor building to torus vacuum breakers were tied open
'
when primary containment was required, thus, compromising primary
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containment integrity.
The second occurred when operator action
was required to respond to a leak in the cooling water system to
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the two operating recirculation pumps. As part of his response,
an operator closed a fourth recirculation pump discharge valve.
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This resulted in violation of a Technical Specification safety limit.
A review of Licensee Event Reports analyzed in Section V.O., indi-
cates other examples and gives rise to a concern for an dpparent
increase in personnel errors.
Operator errors indicated a lack of
understanding of the equipment being operated. Others indicated
either lack of attention to ' detail, or lack of adherence to proce-
dures.
Lack of knowledge of motor operated valves contributed to
transients on two occasions.
When questioned by NRC inspectors about some of the procedural vio-
lations, operations personnel stated there was not a problem with
their action and that the procedures were either too prescriptive,
incorrect, or conflicted with other guidance. This response indi-
cated a reluctance of operations personnel to change procedures and
implies a graded approach to procedural adherence that is a function
of the individual performing the procedure and managtment priority.
This situation is not consistent with stated GPUN commitments re-
garding procedure compliance.
A concern that was discussed with the licensee during the previous
SALP was the effect of schedular pressure.
This pressu're has re-
sulted in operations, at times, not insisting on thorougn resolu-
tions to technical problems with the potential for subsequent nega-
tive impact. One example of this was th? cor.tainmert vacuum breaker
event: There was an operations' perception that the. torus deiner*!ng
time was increasing and holding up drywell entry.
Irstead of in-
sisting on investigation and correction of the problem, compensatory
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measures were taken that involved tying open two drywell to torus
vacuum breakers during torus deinerting in an attempt to reduce the
time.
The first few times this was done, primary containment was
not required.
However, the last time it was done, primary contain-
ment was required and a safety violation occurred.
In examining
the root causes of this event, one of the contributing factors was
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schedular pressure to deinert the torus.
However, the torus de-
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inerting time had not changed.
The results of the various special NRC inspections including the
AIT to follow up the safety limit violation and the IPAT to inde-
pendently assess Oyster Creek's performance were mixed but generally
positive.
The AIT concluded that, although several personnel errors
and misjudgments were made that resulted in both the scenario that
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required securing the recirculation pumps and the actual operator
actions to accomplish, the event did not compromise plant safety
and subsequent operator recovery was timely and correct,
One major
concern involving apparent destruction of a portion of the sequence
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y
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of alarms recorder tape by a licensed control room operator was
under investigation by both the NRC and the licensee at the end of
this SALP period.
,
The IPAT concluded that operations is strongly managed and respon-
siveness and performance of the staff reflect a proud and competent
organization.
Several areas were noted where improverents are
needed and included promulgation of management goals to lower levels
of the organization, making operators more aware of rf sk importance,
taking a more inquisitive approach to non-routine plant condP. ions,
and removing remnants of informality and lack of attention to da-
1
tail. This assessment indicated that the operations department
includes many effective programs and strong staff.
This is con-
trasted by several specific events which indicate that there are
inconsistencies in the application or appreciation of these programs
and lapses in personnel performance.
i;
During operations, housekeeping is good in frequently traveled areas
and not as good in infrequently traveled arets.
During outages,
."
housekeeping deteriorates.
This can be attributed, in large part,
to failure of workers to clean up after themselves.
This problem
has been discussed in previous SALP reports and remains uncorrected.
Routine observations by the resident inspectors identified one con-
cern that involved freezing temperatures in areas of the plant con-
taining water filled fire protection system piping.
Although none
of the specific pipes questioned by the inspectors were frozen, the
licensee did identify other pipes that were frozen and broken.
In
general, the licensee needs to upgrade their cold weather protection
prograr.. as evidenced by, not only the frozen fire water piping, but
also by the frozen and then broken condensate storage tank drain
line isolation valve that caused an Unusual Event.
In conclusion, equipment problems continued to challenge the opera-
tors despite substantial efforts made by the licensee to upgrade
the plant.
Improvements in on-shift decision making capabilities,
control room professionalism, and operations management were ob-
served.
The IPAT findings were generally positive and afforded a
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contrast with other negative findings and events during the evalu-
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ation period.
The tying open of vacuum breaker valves. thereby,
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violating primary containment integrity, incidents of graded proce-
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dural ccupliance, lack of understanding of equipment operation in
[
some casts, and an overall increase in personnel errors indicates
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there ars inconsistencies in operation's personnel knowledge of and
approach to their responsibilities.
2.
Conclusion
,
Rating: Category 3.
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Trend:
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3.
Board Recommer.dations
Licensee:
--
Perform self-assessment to determine reasons for inconsistent
performance.
Reduce operator challenges.
--
Address personnel error rate and cause.
--
--
Insist upon thorough resolution of aquipcier.t pecbiems.
RC:
Increase on-site pr:sence.
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B.
Radiological Controls (813 hrs., 16's)
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41.
Analysis
,
The previous SALP rating in this area was Category 2 with effective
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management, good staffing levels, and adequate equipment and facili-
ties in most areas.
Strong points included access control, training,
dosimetry, chemistry, and effluent controls and radwaste shipping.
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Weaknesses identified during that period included lack of timeliness
in assessing airborne activities in work areas and weaknesses in
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ALARA program, as well as poor maintenance in the Augmented Offgas
and new Radwaste Buildings.
During the current period, there were two violations in the area
' of radiological controls.
They were both in connection with a resin
-
cask filling operation in which an administrative dose limit was
'
exceeded.
Previously noted program strengths remain strong during this SALP
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,
period.
Specifically, management remains generally effective and
b
responsive, and the staffing levels and qualifications remain good.
'
, Facilities and equipment remain good in most areas of radiological
+
,
,
controls, with a significant improvement in the area of respiratory
protection as a result of construction of a new respirator issue
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and maintenance facility.
Training, including General Employee and
'
Radiological Technicians remains good.
There is currently no
training program designed specifically for the radiological engi-
neers.
However, a committee has been formed to develop such a pro-
gram.
Radiation and contamination areas were properly and clearly posted.
Access control and dosimetry issue also retain their effectiveness.
'
However, prejab briefing of technicians by their foremen remains
-
in some cases incomplete, as illustrated by an incident involving
filling aw hipping cask with radioactive resin.
This incident re-
suited in a worker receiving a dose in excess of his administrative
limit.
Supervisors also did not always spend a proper amount of
time to ensure that their technicians are aware of all important
aspects of the job.
As noted in previous 5 ALPS, management has continued to show a
,
vigorous response to such incidents, including disciplinary action,
'
if necesnry, training for the individual involved, discussions
<
'
'
about the incident with the staff, and incorporation of important
-
lessons into the regular training curriculum.
The training depart-
ment has also shown responsiveness to such incidents by modifying
-
-
,
-
lesson plans as necessary.
However, these management actions ap-
-
parently did not identify and firmly address the root causes.
4 -
t
' l
4
e
-.
_ , , . . , .
, , -
-
., , _,, - . _ -
. _ _
. . - - .. -..
- _ - - . , -
--e.
_ _ - _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -
. _ _ - _
___
__
_ _ .
__
_ _ _ _ _ _ _ _ - - _ _
_ _ _ _ _ _ _ _ _
..
-
16
'
l
Weaknesses in the Radiological Controls department administrative
procedures and quality control were identified during this SALP
period. One manifestation of these weaknesses is the fact that
different job descriptions appeared to exist for the same positions;
licensee staff was unable to resolve the differences and to indicate
the actual requirements for the positions involved. There appears
to be a lack of emphasis on carrying out the quality control func-
tions within the Radiological Controls department. Also, in some-
cases, these functions are carried out but there is no followup to
ensure that the results meet the use for determining compliance.
Much of the deficiency stems from the lack of technical support and
oversight provided by the Radiological Engineering section.
The
results of internal audits performed by Radiological Engineering
are sometimes not acted upon, apparently due to lack of followup
action by Radiological Engineering.
Management has recently recog-
nized these weaknesses and there is an apparent effort to strengthen
and formalize the audit and oversight functions of the Radiological
Engineering section.
These changes are very recent and their ef-
fectiveness has not been evaluated.
Performance in the area of ALARA, which was one of the weak areas
in the previous 5 ALP, is improving slowly.
However, the cumulative
exposure for tha 1986 outage year remains high (2d'0 man-rem) even
after consideration of the extensive outage work.
Management has
taken several initiatives to improve performance.
These include
chemical decontamination of the major systems that produce a sub-
stantial part of the exposure, establishment of committees to search
for methods to reduce exposures, and a requirement for timely sub-
mittal of work packages.
Engineers are also required to do walk-
downs of the plant areas involved in their projects to evaluate,
among other things, radiological conditions and area arrangements
to minimize persont.el exposure. There is also an effort to refine
the exposure estimates on the basis of job descriptions and his-
torical data.
However, most of these initiatives are recent and
have not yet produced a measurable effect.
Furthermore, despite
'
the initiatives mentioned above, ALARA ef forts on site remain frag-
mented because the ALARA function is vested in many individuals with
no continuous oversight by a dedicated individual, such as an ALARA
coordinator. Goal setting has not been used as an effective man-
agement tool to control the scope of work and to monitor job pro-
gress, and also to establish accountability.
The threshold for
initiating an ALARA review for a job remains high.
This results
in many jobs being performed without an ALARA review.
Such jobs
collectively contribute a significant fraction of the overall site
exposure.
There is also little formal training of the technicians
on ALARA techniques. Additional details an presented in Section
J of this report,
l
1
. - - .
--
- .
- ,
-.
,
.-
,.,
4
'
17
The licensee maintained a generally adequate chemistry program dur-
ing the 4ssessmer t period. A management commitment to and support
for an adequate program to control corrosion was evident.
Chemistry
technicians knowledgeable of the licensee's methods were trained
in an ongolag program fully accredited by INP0.
During the previous
'
assessment period, the licensee completed a hydrogen water ::hemistry
test to determine the rate of hydrogen addition necessary to reach
mitigation of intergranular stress corrosion cracking (ICSCC).
During this period, routine implementation of hydrogen water chemis-
try controls and continuous crack growth rate monitoring had not
been completed; however, the licensee has developed comprehensive
plans fer IGSCC mitigation.
In other aspects of the program, the
licensee provided state of the art analytical capabilities and close
attention to chemical parameter trends.
Review of the licensee's solid radioactive waste preparation, pack-
aging and shipping program showed the licensee was responsive to
'
weaknesses noted in earlier reviews. Changes were made to the lic-
ensee's Operational Quality Assurance Plan to increase monitoring
activities of the solid radwaste generator quality assurance / quality
contrci program, improve control of shipments and packages, modify
procedures related to package labeling and provide audits conforming
to NRC regulatory guidance.
Implementation of the changes in the
,
receipt inspection of shipping containers and liners, control of
high integrity liners and vehicle package inspections indicated
r
improved attention to technical detail in those activities had been
achieved. However, lack of adequate management oversight of con-
.
tracted solidification services resulted in unapproved changes to
key process parameter controls and incomplete solidification of a
shipment. Although this problem appeared to be an isolated event,
the incomplete solictification showed an inadequate review of con-
tractor-initiated changes to previously approved procedures and less
than optimal monitoring of contractor activities in solid radwaste
solidification.
Revised commitments to train personnel assigned
to shipping activities were implemented.
During the assessment period, the licensee began implementation of
amended Radiological Environmental Technical Specificaticns (RETS).
Licensee staff responsible for dose assessment demonstrated a good
understanding of the technical bases and methodology utilized.
A reduction in projected offsite doses resulting from plant opera-
tions was noted.
Contributing to this reduction from the previous
assessment period's projected doses were licensee improvements in
the performance of the Augmented Off-Gas (A0G) System, the reduction
of significant fuel leakage and minimal liquid releases during the
assessment period.
,
. -
-
--
-
. - .
-
-
.
, - . - - - .
-_-
_____ - _ .
.
.
18
A review of the licensee's program for radiochemical analyses and
measurements indicated that the licensee maintained a good cap-
ability for determination of quantities of radioactive material in
its liquid and gaseous effluents.
The licensee maintained a generally effective radiochemistry labora-
tory quality control (QC) program.
The licensee was responsive to
suggested improvements in the laboratory QC program in this area.
Calibrations and functional tests of the licensee's effluent moni-
tors were performed in accordance with procedures and generally more
frequently than required by Technical Specifications. A licensee
initiative to develop correlation factors for calculation of release
from monitor readings has been instituted.
Some required monitors
were out of service during the period.
The licensee used alternate
means to track effluents.
The inoperability of overboard radwaste
discharge monitors has been identified in previous SALPs.
Prolonged
inoperability of these monitors indicates a lack of prompt and
effective corrective action in this area.
Review of'the radiological environmental monitoring program (REMP)
found the program to be generally adequate. A measurement quality
control program was implemented (including participation in the EPA
Crosscheck Program). Program records were complete, maintained,
and available. Audits were thorough, timely, and resulting ap-
propriate recommendations were implemented in the REMP.
In summary, the radiological control program remains generally ef-
fective.
These include access control, posting, facilities and
equipment, and training.
Access control, posting, facilities and
equipment, and training remain strong.
Specific training for tech-
nicians in the area of ALARA, however, is weak and needs to be
strengthened.
Prejob briefings should also be strengthened.
The
quality control functions within the Radiological Controls Depart-
ment have been poorly administered and incompletely performed.
This
function shouid be formally scheduled and results formally reviewed.
The technical overview function of Radiological Engineering has been
,
weak in some areas, resulting in technical problems remaining un-
l
identified for prolonged periods of time. ALARA was identified as
l
a weak area in past evaluations and remains a weak area.
The ALARA
l
function on site should be more closely controlled by a well defined
'
entity that would also coordinate the ALARA efforts of the site and
corporate groups, particularly during outage planning.
The process
,
l
of goal setting is not effective as a management exposure control
!
tool.
It should be made more realistic and should be used as a
I
basis for assigning exposure accountability.
.
'
19
2.
Conclusion
Rating: Category 2.
Trend:
3.
Board Recommendation
,
!
l
I
. - _ _ _ - _ _ _ _ _ _ - _ _ _ _ _
'
20
'I
C.
Maintenance'(964 hrs., 18%)
1.
Analysis
The previous SALP rated maintenance Category 2.
Specific concerns
included procedure compliance, craft supervision, rework, communi-
cations, work backlog, and upgrade of secondary side equipment.
In general, improvement has been made in most areas. At the con-
l
clusion of the last SALP the facility was still shutdown and a com-
i
,
plete. assessment of the effectiveness of improvements made during
the previous SALP period could not be made until after restart.
A self-assessment was undertaken in response to the previous SALP
and identified weaknesses and plans for improvement.
The assessment
was critical of weak areas and corrective actf n taken resulted in
organizational and personnel changes and efforts to reduce the work
backlog and improve communications.
Based on plant restart performance, it appears the overall quality
of work performed during the 11R outage was somewhat improved over
previous outages.
However, significant problems resulting from
maintenance activities still existed.
These included a vessel head
seal leak due to dislodged snap rings, a recirculation pump flange
leak, and recirculation pump seal problems.
>
During this period, six unplanned maintenance outages resulted frcm
various equipment failures.
These problems included a bellows
'
failure in a relief valve discharge line, feedwater regulation valve
problems, recirculation pump and valve problems, an inadvertent MSIV
closure, acoustic monitor failures, and recurrent problems with
!
manway leaks on a feedwater heater and main flash tank.
One failure,
the inadvertent MSIV closure, resulted from maintenance performed
,
prior to this SALP period. Other failures such as the feedwater
regulating valve problem and leaky manways occurred on equipment
3
which had been worked on during past outages and never effectively
i
corrected. A relief valve discharge line bellows failure resulted
from failure to replace bellows that were known to be defective.
Not all of these problems can be attributed directly to inadequate
maintenance and indicate the importance of the need for more effec-
tive communications between engineering, operations, and maintenance.
A number of other problems associated with maintenance occurred
which resulted in 11 LERs being attributed to this functional area.
Five of these LERs were attributed to personnel error four to pro-
l
cedures and only two to equipment failure. No common cause was
I
identified in the analysis of the personnel errors.
-
-- . . . _ - , - . ~ . _ - - . , - .
.
, . . _ , - - . _ . ._
. .-.
.
__
_
_ _ _ _ -
.
'
21
In all six unplanned maintenance outages, management was effective
in quickly identifying and organizing the work to be accomplished
and in identifying backlogged work that could be worked in parallel
with critical path activities. Major efforts were expended to con-
trol workscope during these outages.
Rework and overhauled or repaired equipment that fails to perform
as expected continues to be a problem.
To verify performance of
equipment which had been worked on, the licensee has extensively
revised the post-maintenance testing program.
The past practice
of using an abbreviated surveillance procedure is no longer rou-
tinely used. Instead, generic component level test procedures have
been developed which serve as guidelines in developing specific
post-maintenance tests.
This has been a good initiative that has
contributed to a decrease in rework.
In an effort to address plant aging issues and the amount of main-
tenance rework, the licensee is establishing a reliability centered
maintenance program.
The establishment of this program is still
in the exploratory stages with some initial work already having been
done.
A large maintenance backlog had also been noted as a concern in the
previous SALP.
The licensee has assigned a senior manager to
evaluate this problem and to take action to reduce the backlog.
Additional emphasis has been placed on completion of backlog work,
and although the backlog is still relatively large, the actual num-
ber of items that affect safety-related equipment is low.
The
majority of the corrective maintenance items are prioritized in
order of importance and tracked in daily plan of the day meetings.
New items are reviewed daily by a committee from the operations,
maintenance, and plant material organizations to ensure that proper
priority is established.
One of the key individuals in the licensee's modification and main-
tenance planning effort is the planner.
This individual is re-
sponsible to generate a work package, including procedures, to per-
form a job.
The responsibilities involved in this job are substan-
tial and effective communications between the planner and all other
interfacing organizations is essential.
Based on events that oc-
I
curred during this SALP period, it is evident that interdepartmental
'
communication weaknesses exist.
For example, a job was planned to
replace reactor water level sensors.
Certain electrical leads had
to be lifted and terminal points jumpered in order to perform the
modification.
Af ter lif ting the leads and jumpering the terminal
points, it was determined the automatic initiation feature of the
standby gas treatment system had been inadvertently disabled.
This
was a Technical Specification violation that resulted from inade-
quate interfacing and input from operations and engineering support.
l
l
l
l
fo
s
22
The licensee's work ~ control and maintenance procedures are generally
considered to be. adequate. With regard.to maintenance procedures,
one violation was identified in which twenty-one Maintenance, Con-
struction, and Facilities procedures were not reviewed within the
required two year period. Also, previous Quality Assurance audits
have shown some continuing concerns in the proper completion of
short forms. Actions are being taken to correct these issues.
In an effort to streamline the processing and job planning for
individual work items, the licensee is in the process of implement-
ing a- GMS-II system for initiating, controlling, planning, and
tracking individual work items.
This system was not fully imple-
mented at the end of the period.
As has been noted in previous SALPs, the licensee has in place a-
good preventive maintenance program.
This program is being expanded
to include secondary side components.
The licensee generally maintains an adequate supply of spare parts
to keep equipment in good repair and maintains a preventive main-
tenance program on stored items which includes both safety-related
as well as non-safety related items.
The licensee is committed to craft training and has an extensive
training facility on site. ALARA awareness by craft personnel. is
evident as demonstrated by use of mock-ups in preparation for com-
plex jobs in high radiation areas.
However, as noted in Section
B, many jobs are performed without ALARA review as a consequence
of the high threshold for review. Also during this assessment
period, a new instrument calibration lab was completed.
In conclusion, the licensee continues to experience reliability and
maintenance associated equipment problems which significantly affect
reliable plant operation.
In an effort to improve overall perform-
ance, certain steps have been taken; these include personnel changes,
a critical self-assessment, establishment of committees to review
problems, improvements in post-maintenance testing, and efforts to
reduce work backlog.
Improvement is still needed in the overall
quality of work performed and communications among groups to iden-
l
tify problem equipment and correct the problems before they have
-
'
an effect on plant operations.
2.
Conclusion
4
4
Rating: Category 2.
2
>
I
..h.
i
i
,
- __
__-
.
.
.
. -
. - .
_ _ _ . , _ _ . . _
.
. .
_ _ - _ _ _ _ _ _ _ _ _ _ _
.
23
3.
Board Recommendations
Licensee:
--
None.
NRC:
Increase on-site observation of maintenance activities.
--
.:
'
24
D.
Surveillance / Inservice Testing (464 hrs., 9%)
1.
Analysis
The previous SALP rated this area a Category I noting strong admin-
istrative control of the program, improved technician training, and
generally effective inservice testing (IST) and inservice inspection
(ISI) programs.
During this assessment period, the licensee performed a containment
integrated leak rate test (CILRT) and restarted the plant from a
lengthy refueling and maintenance outage.
The CILRT was controlled
by comprehensive procedures, and performed in a proper manner, and
yielded valid results. A substantial amount of licensee effort was
expended performing a multitude of surveillances to ensure readiness
for restart which NRC inspection indicated was comprehensive and
well done.
The surveillance program is supported by procedures that
are technically adequate and now include acceptance criteria that
identify both Technical Specification acceptance criteria and other
less critical criteria.
The licensee utilizes a combination computer generated / manually
adjusted surveillance schedule that accurately issues surveillance
requirements and tracks completion status.
This system has been
effectively implemented as evidenced by very few overdue or missed
surveillances.
Surveillance results are promptly reviewed by opera-
tions personnel and deviations written when required.
In general,
individuals who perform surveillance tests are aware of the import-
ance of Technical Specification related items and the need to
promptly notify operations if problems arise during testing. Prompt
action is taken to resolve Technical Specification related equipment
problems identified during surveillance testing.
For example,
Technical Specification required monthly surveillances on the hydro-
gen monitoring system have identified a system drif t problem. As
a result, the licensee increased the frequency of this test to
weekly and is actively pursuing purchasing more stable equipment.
During this evaluation period, instances occurred during surveil-
lance testing when safety-related equipment failed to function pro-
perly.
Examples included failure of a core spray pump motor to
start and an emergency service water (ESW) pump to deliver any
appreciable flow of water just after starting.
In the case of the
3
core spray pump motor, the breaker was racked out and then back in
after which the motor started. An inspection of the breaker after
the event did not identify any obvious problem.
In the case of the
ESW low flow event, the pump was secured and restarted and normal
flow appeared.
No other troubleshooting of significance was per-
formed to determine the cause of the problem.
Management's will-
,
ingness to accept the results of a repeat surveillance without a
'
satisfactory explanation as to why the first one failed, demon-
strates lack of aggressiveness in root cause determination.
!
,
.
'
25
The NRC identified two instances where newly issued Technical
Specifications requiring surveillances where not incorporated into
the surveillance program within required time limits.
This reflects
poor communication between the various departments involved in the
overall process.
Six of the nine LERs associated with surveillance activities were
the result of personnel errors and. involved I & C, engineering sup-
port, and operations personnel.
No common cause for these errors
could be identified and the particular problems in the LERs do not
represent a significant degradation in licensee performance.
The licensee's program for implementing the requirements associated
with pump and valve inservice testing (IST) was reviewed.
The major
portion of this review was an evaluation of the IST program with
respect to procedures, conduct of testing, and analyses of results.
Overall, the review verified the technical adequacy of the proce-
dures and proper response to performance indicators. One minor
concern was identified.
The licensee's corrective action in re-
sponse to this NRC finding was prompt and thorough and identified
and corrected other similar discrepancies.
This review also deter-
mined that QA audits were performed of both the IST and surveillance
test programs and that the audit findings were addressed and re-
solved.
In conclusion, technically adequate procedures with Technical
Specification acceptance criteria clearly distinguished from lass
critical criteria are being maintained. A master surveillance
schedule is maintained which assures that tests are performed as
required.
Test data are appropriately reviewed and prompt correc-
tive action taken when problems are indicated.
Problems that have
a more difficult solution, however, are sometimes not solved and
indicate a lack of aggressiveness in root cause analysis.
Communi-
cations require improvement and management attention to address and
correct the causes of personnel errors is required.
The IST program
continues to be viable and is yielding meaningful results.
2.
Conclusion
Rating: Category 2
Trend:
3.
Board Recommendations
Licensee: None
NRC: None
<
b
?
.
'
26
E.
Emergency preparedness' (420 hrs., 8%)
1.
Analysis
During the previous assessment period, the licensee was rated Cate-
gory 1 in this area.
The last assessment was based on a full par-
.
-ticipation exercise, installation of containment high range radi-
'
ation monitors, and response during the approach of Hurricane Gloria,
resulting in a declaration of an unusual Event and activation of
'
-the Technical Support Center.
During this assessment perica, two actual Unusual Events were de-
clared, a full participation exercise was observed and there was
one routine safety inspection.
Each Unusual Event was declared in
a conservative, discretionary basis per procedure.
The Plant Operations Director declared the first Unusual Event dur-
ing back-shift hours on January 26, 1987.
Some areas of weakness
,
were noted. Of particular note was the lack of response to the
~
initial pager call-out necessitating a second call-out.
In addition,
call-out procedures were followed initially by security but they
failed to perform a required follow-up to determine response to the
pager call-out.
The Operations Support Center and Technical Support
Center were adequately staffed to respond to the plant situation
but were not fully staffed to meet requirements of their emergency
plan for three hours.
The licensee subsequently modified the call-out procedures, issued
l
reprimand memoranda to plant personnel who failed to respond, and
changed lesson plans to stress mandatory and immediate response to
emergency call-out including acknowledgement by telephone of the
i
radiopager signal.
During a routine safety inspection subsequent to the above declara-
tion of an Unusual Event, it was determined that the licensee had
responded to NRC findings and all non-exercise related follow-up
items were closed. Two unresolved items were identified. One of
these related to the delayed staffing during the January Unusual
Event and a potential deficiency in.the emergency plan, implementing
i
procedures, or management controls which could impede activation
and timely staffing of the emergency response facilities when needed.
The other was related to potential weaknesses in the Security-
Emergency Preparedness interface related to sabotage verification
and compensatory measures.
The second Unusual Event was declared on February 10, 1987 by the
Group Shif t Supervisor during a back-shift period.
Procedures were
correctly followed, and timely staffing and activation of all on-
site emergency Response facilities resulted.
,
t
.
.
.
-.
. -
.,
,, - .. , ,--- -
- - - , - - -
~~
mm
,---
--
- - - - - - - -
,
- - _ _ _ _ _ _ _ .
. . .
27
During the full participation. exercise in May, 1987, all previous
exercise related follow-up items were closed and the licensee staff
exhibited significant improvement in many operational areas in re-
sponse to previous NRC findings. However, performance in some of
these areas was minimally acceptable indicating a need for the
licensee to review emergency preparedness training to determine if
depth is adequate.
The most significant area involves the fact that
the Emergency Support Director did not formulate and communicate
a protective action recommendation (PAR) in a timely manner and that
evacuation time estimates were not used in reaching PARS.
In this
annual exercise, FEMA determined a need for two partial remedial
exercises and identified a number of areas for improvement.
The
licensee provided the required support to correct these areas.
The licensee continued to maintain and take steps to improve the
_.
offsite Alert and Notification System; siren availability was 98%
in 1986.
Licensee's tests indicated a need to install heaters in
18 sirens to prevent freeze-up.
It is estimated this will be com-
pleted by October 30, 1987.
The licensee has located a back-up
siren activation center in West Trenton and a contract has been
awarded to upgrade the siren system by installing a remote diag-
nostic system with feedback.
!
In summary the licensee has committed resources and developed sup-
porting policies for Emergency Preparedness and Associated Training.
'
Results indicate these commitments have not resulted in uniform and
consistently high levels of performance.
'
2.
Conclusion
Rating: Category 2.
r
Trend:
3.
Board Recommendations
Licensee:
Licensee should review resource adequacy and raonitor station
--
staff awareness and commitment to policy.
,
'
!@$:
None,
i
i
9
.- -
, _- . . , _ _
m
_ , . - , - - , _ _ .
___ -
r... ...
-
,__,m__
-
, .-
-_:.
-
.
.
'
28
F.
Security and Safeguards (165 hrs. , 3%)
1
1.
Analysis
During the previous SALP, licensee improved their performance in
a number of areas.
There were several program strength including
strong corporate oversight of the site security operation.
The
licensee was actively pursuing resolution of two long-standing
regulatory issues.
These were the control room barriers and upgrade
of the perimeter intrusion system. Both of these issues received
considerable attention again during this assessment period.
In addition to the August site visit, implementation of the licen-
see's security program was reviewed during two region-based routine
physical security inspections and continuing inspections by the NRC
resident inspectors. These inspections revealed that corporate
security management continued to be actively involved in all site
security program matters, including visits to the site by the cor-
porate staff to provide assistance, program appraisals and direct
support in the budgeting and planning processes affecting program
modifications and upgrades.
Security management personnel are also
actively involved in industry groups engaged in nuclear plant
security matters.
This demonstrates program support from upper
level management.
The licensee's self inspection techniques, which are independent
of the annual security program audits, were again an effective
method for providing oversight of the site security program.
Self-
assessment teams are composed of experienced security management
personnel from corporate headquarters and other licensee nuclear
facilities.
The findings of the self-inspections are reviewed at
the corporate level and forwarded to site security management for
appropriate action.
This initiative is indicative of the licensee's
desire to implement an effective security program and at least
partly responsible for the licensee's excellent enforcement history
during this evaluation period (one Severity Level V violation).
The licensee submitted two security event reports in accordance with
i
10 CFR 73.71 during the assessment period.
Both events involved
the failure of security equipment.
The events were promptly re-
,
!
ported and the written records were sufficiently comprehensive to
'
permit NRC analysis without the need for additional information.
Corrective actions and compensatory measures were promptly imple-
mented.
Extensive use of compensatory measures continues to be
i
necessary to meet regulatory requirements and licensee program com-
'
mitments pending completion of systems upgrades.
'
Staffing of the licensee's security organization is adequate and
,
the security officer training and requalification program is well
!
developed and administered by two full-time instructors.
In addi-
l
l
.
y
..
,
. , , -
-
n
--n
-_.
a
, - - -
e
~ -
-
- - - - -
..
'
29
tion to initial and requalification training, on-the-job performance
evaluations are conducted which test the proficiency of individuals
on general and specific security program requirements.
The on-the-
job performance evaluations have provided management the capability
to review and enhance the performance and job knowledge of security
personnel and to correct deficiencies as they are detected.
This
is a positive initiative indicative of the licensee's desire to
implement an effective program.
Review of the licensee's maintenance support for security equipment
during this period found it to be generally much improved over the
past assessment period.
However, two instances were identified
where compensatory measures were employed for extended periods in
lieu of repairing the equipment.
The delay in repairing the equip-
ment appeared to be the need to accomplish higher priority. work.
Security facilities and spaces were adequate and well maintained.
Records were readily retrievable, complete, and centrally located
for ease of use.
Members of the security force exhibited a good appearance and a
professional derneanor.
However, morale may be affected because of
the long term use of compensatory measures.
During this assessment period the licensee submitted two revisions
to the Security Plan in accordance with provisions of 10 CFR 50.54(p).
Generally, the revisions provided sufficient detail to describe the
changes.
However those revisions, when reviewed by NRC, were found
to contain changes that, in effect, would have modified the basis
for the NRC's original approval of the plan, therefore, should not
have been submitted under the provisions of 10 CFR 50.54(p).
The
two revisions were resubmitted late in the assessment period and
are currently under review by the NRC.
In summary, the licensee continues to implement the security program
in a manner to comply with regulatory requirements and security plan
commitments.
They have continued to implement self-assessments to
improve overall performance.
Further, they have an improved main-
tenance plan designed to reduce out-of-service equipment. Guard
force training and requalification remains strong. However, until
j
the licensee's upgrades of security equipment is complete, the use
of compensatory measures must receive licensee attention to ensure
an equivalent degree of security effectiveness is provided.
!
2.
Conclusion
l
Rating: Category 1
Trend:
l
l
-
- -.
.
.
.
.-
.
.
. - . . . .. - .
.
.
.
30
3.
Board Recommendations
None
1
I
s
- - , , . _ _ - . . - . - . _ . - - , . . , , . .
. . . - - - - - - - - - - - - - . - - - -
-
- ---
-
-
..
31
G.
Assurance of Quality (NA)
1.
Analysis
Management involvement and control f a assuring quality continues
to be considered as a separate functional area and as an evaluation
criterion for each functional area. The various aspects of the
Quality Assurance program have been considered and discussed as an
integral part of each functional area and the respective inspection
hours are included in each one.
Consequently, this discussion is
a synopsis of the assessments relating to quality work conducted
in other areas and is rot solely an assessment of the quality as-
surance (QA/QC) departments.
Management expresses a commitment to assurance of quality as de-
lineated in corporate as well as divisional goals. Adequate re-
sources have been devoted to QA/QC organization onsite. Management
goals and objectives are clearly stated and understood by upper
level management and tracked to ensure they are accomplished.
These
same goals, though, are not as clearly understood at lower levels.
The QA/QC organization onsite is involved and effective and is sup-
plemented by-effective independent oversight groups.
In general, QA/QC involvement onsite appears to have improved during
this assessment period, QA audits and inspection activities have
been generally adequate and effective.
However, despite this noted
improvement, QA/QC inspectors still lack some technical knowledge.
This became apparent with improper signoff of QC holdpoints for some
valve maintenance, discrepancies between maintenance and QC on
snubber inspection techniques and the discovery of unacceptable
Raychem splices after having been inspected and accepted by a QC
inspector. More disconcerting has been the lack of QA/QC involve-
ment in certain aspects of facility operation.
The QA group is not
adequately involved in the day-to-day activities conducted by Plant
Engineering, including both programmatic and technical assessments.
In addition, the procedure governing the conduct of calculations
was noted to be inadequate, a fact which has not been identified
by QA.
Some technical review of plant engineering is provided by
the Independent On-Site Review Group (IOSRG) and other such groups
to help assure quality of plant engineering functions, but does not
perform a charter QA function.
In other areas, QC inspection has
been inadequate as noted during the installation of hanger bolts,
V-2-11 maintenance and drywell shell thickness readings.
Improve-
ment has been noted in the vendor manual and document control pro-
gram.
The use of independent oversight groups is a strong. point,
but the QA/QC organization needs to address specific weaknesses to
improve the assurance of quality.
..
-
32
'
Management effectiveness in assuring quality at Oyster Creek takes
place in each onsite division as well as within the QA/QC organiza-
tion. The licensee on one occasion made tremendous strides in im-
proving plant reliability and their ability to solve root cause
equipment problems when management chose to establish three commit-
tees to solve long standing plant problems (see Section B.1) prior
to allowing plant restart.
This seemed to be a watershed for
building technical confidence in onsite technical support groups.
In another area, a concern with the safety review process from the
1984-1985 SALP led the licensee to conduct an assessment of the
process and find problems in the safety review of temporary vari-
ations. Management elected to implement short term corrective
action while more complete long term corrective action was formu-
lated. While this was in process, the drywell-torus vacuum breaker
event occurred (see Section A), in part attributable to deficiencies
-
in the safety review of temporary variations. Apparently the lic-
ensee did not recognize the potential significance of the extensive
use of temporary variations and did not take prompt corrective
action which might have averted the event. Management has taken
special efforts to foster a spirit of cooperation and a positive
attitude toward self-improvement which should improve performance
in this and many areas and play a key part in the success of many
improvement programs.
Maintenance Construction and Facilities (MCF) has initiated some
programs which will improve MCF effectiveness in addressing quality
issues (see Section C).
MCF's ability to initially resolve plant
equipment problems has been diluted by the number of unplanned out-
ages (6).
The number of unplanned outages has significantly di-
verted management attention and has decreased their efforts in other
areas.
Efforts to accomplish all the required maintenance activi-
ties for a particular outage led the licensee to attempt to accomp-
lish more maintenance items than are manageable for an outage period.
The attempt to balance resources with workload has impacted the
quality of the work completed, especially when a large number of
i
maintenance tasks had to be completed in a fixed time period.
Effectiveness of management in the engineering support area has been
lacking in ensuring complete and thorough evaluation of technical
i
problems. Analysis of plant technical problems have at times taken
marginal positions to resolve problems (see Section I).
In contrast,
the organization has solved some longstanding technical problems
after careful and thorough analysis which was preventing plant re-
start until a successful conclusion was reached (see section C & I).
In a related issue, the licensee needs to address the recognition,
assessment, and timely disposition of initial equipment problems.
Another related concern is the numerous equipment problems associ-
ated with the recirculation pumps which indicate a major overhaul /
upgrade is warranted.
The long outstanding original equipment and
construction deficiencies need to be addressed.
..
. - -
_
_ . _
___
__
__
_ __ __ _ . _ , _ _ _ _
-
.
.
33
The operations department has been effective in-implementing cor-
rective action to QA audit findings. Of concern with the assurance
of quality in the operations area are the issues of a graded ap-
proach to procedural compliance which to some extent may be forced
by management priorities, pressure to conduct operations expediently
but without complete concern for the quality of operations, house-
keeping in areas that are not frequently observed by plant manage-
ment does not reflect the same care given to readily accessible
areas, and operations failure to insist upon in-depth root cause
analysis and on stringent eauipment operability requiren,ents after
repair.
Radiological controls management has implemented a number of program
initiatives to improve their performance in ALARA. Additional ef-
fort is required though in some aspects of the ALARA program to
ensure the improvements are effective (see Section B). Additionally,
'
management needs to emphasize carrying out quality control functions
and ensuring applicable criteria are met in the radiological control
,
programs. Management has effectively responded to observed weak-
.
nesses in solid radioactive waste preparation, packaging, and ship-
'
ping prngram. A strong effort by upper management has achieved some
success but the matrix style organization has resulted in a com-
mittee approach to resolving problems and lacks the strong line
management approach present in other divisions onsite.
First line supervision has shown some improvement during this as-
sessment period, but has been found to be lacking on several occa-
sions in ensuring quality functions are carried out (see Section
C). Operations supervision has been responsive to QA audit findings.
A noted weak area was the plant staff's understanding of technical
specifications and plant safety design basis which became a concern
'
during the drywell-torus vacuum breaker event (see Section A).
i
,
Management continues to try to improve worker attitude toward qual-
ity workmanship and has shown some improvement but workers continue
to demonstrate a lack of attention to quality, particularly in the
balance of plant (see Section C). This worker attitude is demon-
4
strated in the relatively poor level of housekeeping in less fre-
quently visited areas.
Oyster Creek employs a number of oversight groups at the site to
4
ensure quality in their various programs.
The Independent On-Site
Review Group (IOSRG) continues to provide strong technical support
to the plant.
Post Trip Review Group (PTRG) efforts have been found
to be thorough and technically sound in assessing reactor scrams
and transients and determining the root causes.
The General Office
Review Board (GORB) has been able to address and receive prompt
attention from the licensee to correct certain problems.
1
.
>
-
, , . _ . .
.,y
-
- ,-
,_r,,
, - , - _ - ,
---
- , - , - , . . -
--
, _ , _
c.__,
_.
_
.
. 1;,
...
34
t
In' summary, assurance of quality is addressed by management on the
divisional level as well as by the QA/QC organization.
Management
goals, objectives and resources are at an appropriate level but
should be more universally understood by lower levels.
The licensee
action to establish three committees-to solve technica'l problems
was perceived as a significant accomplishment. Operations awareness
of quality issues remains at a high level and there has been noted
,
improvement by MCF. The various organizations that are re'sponsible
for the safe operation of the plant generally are effective in
assuring quality through positive approaches that contribute to
quality. However, problems have been noted ih the review of ana-
lytical work in the technical functions division, and in the use
of the quality controls function by the Radiological Controls Oe-
partment.
2.
Conclusion
Rating: Category 2.
Trend:
3.
Board Recommendations
Licensee:
__
NRC:
l
1
-
_ . ._ _ _ ,__ _ -, . - = . _ _ _ . . . .
-. _ . . , _ = _ - - -
-
- -
-
- - - - . - - - .
-
, - _ _ - . _ _ _ _ _ _ _ _ _ _ _ _ - - - . _ _ _ _ _ _ _ _ _ _ _
e -
35
H.
Licensing Activities (NA)
1.
Analysis
During the previous SALP period, the licensee was rated as Category
2 with the trend improving in this functional area.
During the current SALP period, fifty-nine licensing actions were
under review. Of these, twenty-seven were completed. The majority
of these were complex and difficult.
Thirty-two licensing actions
remained at the end of the SALP period.
The significant licensing actions completed in the SALP rating
period include the following: Mark I drywell breakers review, main
security building post accident shielding review, lattice physics
reload topical report, Cycle 11 restart.without rod worth minimizer,
Cycle 11 reload, postulated high en..gy level break within emergency
condenser drywell penetrations, vi ual weld acceptance criteria,
s
corrosion of outer thickness of lower region of the drywell shell,
and control room habitability.
The licensee has shown consistent evidence of prior planning and
assignment of priorities.
This has been shown in the productive
working relationship between the former and present NRC Project
Managers and the licensee.
This is also shown in the licensee's
positive response to SIMS and the identification of the drywell
corrosion problem and active participation in resolving this issue.
The licensee has generally made timely responses and submittals to
meet licensing deadlines.
Exceptions are the submittal regarding
the 10 CFR 50.62 ATWS Rule and responses to requests for additional
information regarding several SEP items. With respect to Licensee
Event Reports (LERs), 29 of 45 reports were submitted late. Many
of these were only a few days late; however, not submitting reports
within 30 days as required continues to be a problem. Many supple-
mental LERs were substantially late also and some 50.59 reports were
as much as three years late.
The licensee has been responsive to NRR in meeting on approximately
a monthly basis to discuss all active licensing actions including
their priorities and future submittals.
There have been fourteen
meetings in this rating period.
These meetings were generally well
conducted, well prepared for and helpful in resolving the issues.
The licensee has been responsive to NRR initiatives. The quality
of its "no significant hazards consideration" continues to improve.
An exception is the "no significant hazards consideration" the
licensee submitted related to its request for an amendment regarding
corporate reorganization.
The licensee has responded promptly to
several surveys from the staff during the reporting period.
This
4
36
was evident in the licensee's response to SIMS.
The licensee, in
response to the staff's initiative in Generic. Letter 85-07, sub-
mitted its Integrated Living Schedule in January 1987.
.The previous SALP discussed a concern about the plant's Technical.
Specifications and the need to improve them.
The licensee is in-
volved with the BWR Owners Group sponsored technical specification
development effort which does not appear to be making much progress.
Consequently, the same concern regarding the need for improved
technical specifications remains.
Management organizational changes within GPUN during this period
moved the corporate licensing group out of the Technical Functions
Division into.the Planning and Nuclear Safety Division, thereby,
correcting a perceived concern by the NRC of insufficient independ-
ence of these functions.
In summary, the licensee's performance in'this area has shown some
improvement and has been generally effective. Management attention
and involvement was responsive to licensing issues.
In general,
submittals showed a thorough understanding of the issues which.have
been found to be technically sound.
Staffing levels and quality
of staff are adequate and communication between operating staff and
management is effective.
Licensing problems have generally been
dealt with effectively and in a timely manner.
However, the licen-
see has been late with LERs and 50.59 reports.
2.
Conclusion
Rating: Category 2
Trend:
3.
Board Recommendations
Licensee:
__
NRC:
Q
.
37
I.
Engineering Support (443 hrs. , 9%)
1.
Analysi s
The previous rating in this functional area was Category 2. It was
pointed out in the previous SALP (1986) that there had been little
progress made towards addressing and correcting concerns regarding
lack of timely support, weak engineering support, and lapses in
procedural adherence discussed in the 1985 SALP report. Addition-
ally, problems were identified with a large work backlog, weak
vendor control, lack of comprehensive design criteria, and lack of
management aggressiveness in making responsible individuals ac-
countable.
The previous SALP also discussed the many improvements,
good initiatives, and timely support to help sustain plant opera-
tions.
In summary, engineering support was considered to be incon-
,
sistent and a SALP Board Recommendation was made that GPUN undertake
+
a self-assessment to determine and correct the causes of the incon-
sistent performance.
>
A review of engineering support for this evaluation. period again
indicates that most of the same problems exist.
This continues to
be contrasted by many examples of successful plant upgrades, good
solutions to problems, and timely responses to plant demands. A
licensee self-assessment in an attempt to determine the causes for
inconsistent performance was initiated during this period but no
results were available to the NRC prior to the end of the period.
The NRC was briefed by the licensee regarding the methodology of
performing the self-assessment and felt it was capable of yielding
useful results.
.
Inadequate technical support continues to result, in part, from lack
of an indepth approach to solving problems.
The reasons for this
may involve inadequate understanding of the problem, thereby, indi-
cating a lack of time, effort, or involvement during early develop-
ment stages of a task.
Examples of this include initial engineering
responses to evaluation of the concrete cracks in major structural
,
.
beams, disposition of corroded reinforcing bar in a floor in the
!
reactor building, and analysis of pipe stresses in a portion of the
core spray system that was being subjected to water hammer loading.
!
In all of these instances, the NRC questioned the technical adequacy
!
of the response because it was not sufficiently comprehensive. The
'
subsequent response, in each case, was well done and indicated that
'
a lack of technical expertise is not the concern.
Problems involving inadequate compensatory measures to control air
.
inleakage into the control room, lack of solutions to problems that
occurred just once and were not able to be repeated, inadequate
,
l
review of temporary modifications, and at times an ineffective and
misunderstood safety review process indicated confusion as to the
<
!
most ef fective way to solve a problem.
Examples included an attempt
l
l
.-- - . -
-
. _ _ _ _ _ _ _ _ _ . . _ _ _ _ _ _ _
. .
38
at administratively controlling the position of a control room
bathroom fan and damper instead of modifying the damper to close
automatically when required; a repeat of an emergency service water
(ESW) surveillance test that previously failed due to low flow
during the cold winter months but gave good results the second
attempt ignored the cause of the problem; and a safety review pro-
cess that was not well understood, proceduralized, and implemented
was tolerated rather than promptly corrected.
Other examples indicate weaknesses in engineering support result
from poor technical reviews: a scheme was developed and implemented
to replace a reactor water level instrument, but the jumpers in-
stalled bypassed the automatic start capability of the standby gas
treatment system; engineering personnel were improperly logging by-
passed LPRMs; and an independent STA review of a temporary modifi-
cation did not identify the fact that it would render the primary
containment inoperable.
The previous SALP identified a concern over long outstanding un-
solved problems. This concern remains, some examples include a
substantial GEMAC reactor water level discrepancy between redundant
indicators, continued failure of trunnion room fans, repetitive
failure of the offgas sample pump that has no redundancy and is
required by Technical Specifications, and recurring problems with
the recirculation pump drive electrical system.
1
!
The licensee continues to demonstrate insensitivity to implementing
NRC requirements.
Examples include tardy Licensee Event Reports
(LERs) and long overdue supplemental LERs,10 CFR 50.59 reports that
,
are submitted up to three years late, failure to comply with Tech-
i
nical Specification requirements to perform an instrument surveil-
l
lance using an approved procedure, and failure to meet Technical
Specification requirements that requires an explanation in the
Semiannual Radioactive Effluent Release Report as to why an in-
operable instrument was not returned to an operable status within
30 days.
In addition the licensee, in several instances, has made
commitments and then not followed through with them.
Examples in-
clude failure to non-destructively examine an isolation condenser
.
l
piping containment penetration weld until identified by NRC, failure
to meet certain requirements of c 1980 NRC Bulletin, and failure
to submit Tecnnical Specifications for Reactor protection System
t
Electrical Protection Assemblies prior to startup from the recent
11R outage.
These types of problems indicate that there may be
.
confusion within the corporate structure as to where responsibility
l
l
lies, a cumbersome management review and approval circuit, and
'
inadequate communications.
Communication both within engineering support groups and between
,
!
interfacing divisions has improved but further improvement is war-
!
ranted. Miscommunication resulted in a valve back seating error
1.
l
!
-
t
'
39
.
and failure to pressure test a new weld in the feedwater system.
On some occasion communication problems with the licensee's organi-
zation led to inaccurate submittals to'the NRC. One example was
in response to Regulatory Guide 1.97 regarding SLC poison storage
tank level indicating system.
'
Problems still remain with control of vendors, as indicated by mis-
wiring of 600-700 computer tie-in points associated, in part, with
the safety parameter display system. Also, the vendor responsible
for operation of the solid radwaste process made unacceptable
,
changes to the procedures that ultimately resulted in a shipment
'
containing an excess of free standing water.
Many examples of good work performed by engineering support groups
were evident.
Some major examples included Appendix R, drywell
shell thinning, intermediate range failed detectors, loose elec-
trical leads, pipe wall thinning, drywell cooling, control of elec-
trical load growth, and the inservice test program.
Technical sup-
'
port onsite has become more aggressive in tackling day to day prob-
lems rather than deferring to the maintenance group or corporate
,
based engineering.
The IPAT inspection focused attention on the onsite engineering
,
support group and determined that several recently implemented and
r
pending changes could result in an improved ensite engineering
,
capability.
It noted that Plant Engineering appeared to have high
morale, was a motivated group, and seemed capable of handling the
[
new challenges posed by the changes.
The team felt there were in-
adequacies in the procedures controlling calculations and a newly
implemented mini-mod design process. Additionally, they .Y t
tighter controls were required over temporary modifications, and
the Plant Review Group was under-utilized in the safety review pro-
cess and other safety issues.
It was observed that progress, al-
though slow, was being made to reduce the backlog.
In conclusion, little change was noted in this functional area dur-
'
ing this evaluation period.
For that matter, little change has been
noted over the period of time covered by the past three SALPs.
t
Examples of inadequate root cause analysis, ineffective problem
-
solution once the root cause is known, poor technical reviews, long
outstanding unsolved problems, delays in implementation of and in-
sensitivity to NRC requirements and Issues, failure to meet commit-
ments, commu..ication problems, and weaknesses in vendor control
continue to reappear in sufficient quantity to suggest that correc-
,
tive action by the licensee has been relatively ineffective. Good
>
work has been accomplished by all those involved in engineering
support.
The IPAT inspection results were generally positive, al-
though they were based primarily on newly instituted or pending
changes.
Inconsistent performance again appears t') describe engi-
'
neering support.
!
$
}
>
... , -- -
, _ _ - -
--. .
.
_ _ _ _ _ - .
-.
,
.- .-. - . . . . - - _ -
.-
-
..
.
s
,
"
40
\\
2.
Conclusion
Rating: Category 3.
Trend:
3.
Board Recommendations
Licensee:
--
Expedite completion of self-assessment and initiation of cor-
rective action plan.
Report results of self-assessment to NRC.
N_RC :
--
Review results of self-assessment and corrective ac ion plan.
,
_ - - _ _ _ _ _ - _ _ - _ _ = _ _ _ - _ _ .
'n
.
>
k
e
'
41
-(
J.
Training and Qualifica'tio'n Effectiveness (N/A)
1.
Analy Q
,
TecSn W.) training and qualification ,eff4qtiveness, while being
consic.. red a separate functional area,! continues to be an evaluation
criterion for each functional area. This functional area was con-
sidered and discussed as an integral part of other functional areas
and the respective inspection hours were included in each one.
Consequently, this discussion is a syn'opsis of the assessments
related to training conducted in other areas.
Technical training
'
effectivaness was measured primarily by the observed performance
,
of personnel and, to a lesser degree, as a review of program ade- '
quacy.
The discussion below addresses three principal areas: lic-
"
ensed operator ~ training, nonlicensed staff training, and status of
training accredita. tion by the Institute of Nuclear Power Operations
4
(INPO).
>
S
.
,
,
GPUN demonstrates a strong commitmentnto improved performance
'
through effective training programs. .0perations, Maintenance Con-
l
struction and FacW cy (MCF), Radiological Controls, Security, anti
Quality Assurance have implemented quality training programs to
improve personnel performance.
In general, personnel performance
!
,
'
has been noted to improve since the last SALP, but has been ' marred
i
'
by a large number of personnel errors as indi,cated by Table 4.
'
i
'
Section "E" describes an increase in the frequency and number of
,
LERs attributable to personnel error in comparison to the last
'
assessment period. The licensee previously achieved INP0 accredi-
tation during the last SALP evaluation period in all ten trcining
programs. Overall management support of- training programs ap Oyster
Creek is evident by program improvements.
j
'
Curing this assessment period, one senior operator oral re-examina-
j
g
'
tion was given with successful results.
Operator performance during transients has been very good in com-
!
parison to the last assessment period.
Again, as in the past, the
l
operators are required to respond to equipment failure induced
,
.
Responding to this concern and operator performance
!
during feedwater transients, the licensee conducted appropr' ate
l
operator training in this area which seems to have benefitted
operator performance. One area for operator improvement may be in
j
the understanding of motor operated valve (MOV) operation. Two
significant events have occurred as a result of operator knuledge
l
in this area.
One problem resulted in a scram and the second con-
i
tributed to the safety limit violation lato in the period. A review
!
of the MOV training program indicates recipients should have been
aware that valves are not electrically backseated from the control
switch.
In addition, procedures require overriding a local contac-
tor to accomplish electrical backseating which has been accomplished
i
i
S
i
f
'
- --
,
.
._.
_
.
_.
_-
- . ,
-
_ . ~ _
_ . . _ - , , _ ,
_
-.
. . . , . -.
.
.~
.- ,,
,
4,,
"
,
.
-
.,,
,a
t
i
/
,
'
42
-
- '
<
m
,
,
.',e
'
,
?
many times in backseating valve's during startup at Oyster Creek.
. Therefore, the ~uperators should have been f ally cegMzaot of MOV
electrical backseating proc ~edures.
/
<
,
Some operator errors indicate a need foe ifprovdd'trdf,@g ir
[
specif.ic areas, An inadvertent IRM upranging'ltu range'10 during
-
a reactor-'starcup resulted in an MSIV isolation 41gnal and in addi-
tian a rod withdrawal error resulted from lack of operator attention
to and understanding of rod worth minimizer operation. Also LERs
,
86-25, an inadvertent bus grounding and 87-18 an operators' inability
-
to manually close an air operated valve indicate a lack of appreci- '
-
ation and understanding of the signifi.cance of plant and equipment
operatient
>
-
,
,
i
In addition, sopfrecent opey^ating errors by egyipment operators
~
,
may indicate more attention sEodid be given to the equipment opera-
'
tor on-tt.e-job training' program.
Two examples of note were fire
7
dt;etolack.ofunde]r,antewhereaseriesofproceduralnoncompliance
pump diesel s gyri ' .
standing of equipment operatio.i rendered the
fire ?umf diesels inop'erable for. an automatic start and a plant trip
,
fron power narrowly avqided when an operator neglected to valve in
'
a second instrument air, filter after isolating the on-line pref,ijter.
MCF has estab?ished comprehensive trainir,ig programs for Instrumen-
A
tation and Control (I&C) technicians, mechanics, ard electrician's.
>
It appears the licensee management is pia'eing addit' onal uphasis
4
on the MCF training program with some improvemyd ncted. One cord
cern arose, though, that the maintenance perschnel a /,$ressureo f
to complete their training program prior to d'2dblisH ng full com-
'
{'
petency to~ perform assigned tasks.
LERs 86-6, 8q3! ,9nd 97-19
,
depict problems that indicate the maintenance tratrit.g Drogr es have
5
'
'(
not been entirely effective.
P
3
In response to concerns raised in the last SALP rrrort', Radiologic'i
Cortrols haC deycloped a unique interdisciplinarg dLARA awareness A
,
seminar that has become part of the cyclie trai'n nu program. An-
otherareathatthelicenseehasimplementedcurr{ecltvaactionin
r *
respon w to SALP comments was in the establishment of radiological
'
enginetring training pregram.
Some arees of concern were developed,
)
though in that Mdiological Controls tq .'4hicia..Qfe not required
_
,
to pass cyclic quizus.
The licensee his recogbized that there is
no incentive for the technicians to do well in their cyclicf'raiqing
'
3
and is investigating corrective measures.
.
.
we
The iecurity of ficer training and requaIification program is well
.'
developed and administered.
One minor violation, which was not
,
reflee:tive of overpil performance, oc'cyrred as a result of exceeding
'
a time requirement to accomplish a portfyt' (f the cyclic trainirg.
,)
'
a .
y
4
6
.
3
'
'
_
_. , _ .
,
e
43
Quality assurance has developed training programs to increase in-
spector effectiveness in the field by developing specific pronrams
to enable individuals to become knowledgeable in areas outside their
discipline.
This will increase inspector ability to recognize other
field deficiencies outside their particular areas of expertise.
One inspector's lack of knowledge of Raychem splices resulted in
subsequent identification and repair of 5 discrepant splices and
reinspection of additional Raychem splices.
As a result, the lic-
ensee conducted additional training and appears to have corrected
this problem.
Emergency Preparedness training has generally been effective at
Oyster Creek.
Some minor concerns did develop, though, with the
Emergency Director's familiarity with Emergency Operating Procedures.
.
'
Upon NRC identification of this concern the licensee initiated E0P
training for emergency directors. Additionally a problem appeared
with operator ability to locate procedures for a given scenario.
The deficiency appears to be a result of the manner in which train-
ing was conducted and in the procedure identification method.
The
licensee subsequently conducted additional training to correct the
4
deficiency. Another training concern developed as a result of the
-
Emergency Support Director's failure to formulate and communicate
a Protective Action Recommendation (PAR) in a timely manner and to
l
use Evacuation Time Estimates.
'u
A significant concern developed as a result of NRC review of the
safety review process after the drywell/ torus vacuum breaker event.
'
Some members of the operations staff appeared not to have a compre-
"
hensive understanding of the Technical Specifications and the
,,
plant % safety design basis. As part of corrective action for the
w
event, safety review training was conducted for operations staff,
'
responsible technical reviewers, and independent safety reviewers.
Later inspection activity in this area showed that the safety review
training may be inadequate.
Safety review training consists of a
four hour oral presentation with r.o measure of effectiveness of the
training.
In addition, other training concerns were developed in-
ciuding confusion on some signature procedural requirements and lack
of a formal program for preparers of safety evaluations as not all
are qualified as responsible technical reviewers.
Some recent
,
changes were made by the licensee to upgrade tM program.
'
I
Further operational events seem to emphasize the need to improve
understanaing of Technical Specification and plant safety design
i
basis.
Recent events involving a startup with an inoperable IRM
'
system, aperational night orders directing an emergency service
water (ESW) pump to be taken out of service while the diesel cup-
,
porting the redundan'. ESW system was already out of service (LER
87-04), and allowing a hydraulic control unit to remain at zero
i
I
-- -
.-
-- -
-
- - - - -
_ _ _ _ _ _ _ - _ .
.
.
44
pressure without taking timely action nor declaring the correspond-
ing control rod inoperable are examples that indicate additional
training is required in this area.
In summary, the licensee has a strong commitment to quality training
programs and, as weaknesses are identified, respond; to develop
programs to address the weaknesses.
Senior management involvement
is evident in its emphasis to improve performance through effective
training programs.
Senior management has placed considerable re-
sources in training programs and has expanded its team building
training from corporate level officers to first line supervisors.
Measures are being taken to improve the maintenance training and
training performance in this area.
The emphasis that is placed on
training programs and the improvement of those programs is not con-
sistent with the increasing number of personnel errors being iden-
tified and may be indicative of training program deficiencies, al-
though none were identified.
2.
Conclusion
Rating: Category 2.
Trend:
3.
Board Recommendations
Licensee:
i
!
_ _ _
_ _ - _ _
_ _ _ _
-.
.
45
'
V.
SUPPORTING DATA AND SUMMARIES
A.
Investigations and Allegations Review
1.
Investigations
The NRC Office of Investigations was pursuing two separate investi-
gations at the end of the SALP period. One involved a self-initi-
ated investigation to determine whether or not licensee statements
made to NRC inspectors constituted a willful material false state-
ment. The other involved investigation into the reported destruc-
tion of a portion of an alarm tape by a licensed control room
operator following the violation of a Technical Specification Safety
Limit.
2.
Allegations
During this assessment period, five allegations were received and
acted on.
Four remain open and one was closed.
In addition, one
allegation remains open from the previous SALP period, making a
total of five open allegations. Of these five, three involve
security issues, one safeguards information control, and one radio-
active contamination.
The closed allegation and the contamination
allegation were not substantiated. As a result of reviews to date
no substantial concerns have resulted from follow-up of the three
security and one safeguards information allegations.
'
B.
Escalated Enforcement Actions
1.
Civil Penalties
As a result of the event dealing with operability of containment
vacuum breakers and the subsequent NRC inspection, several civil
penalties were issued to the licensee as follows:
$80,000 - Violation of LC0 dealing with torus to drywell vacuum
breakers (Level II Violation).
$50,000 - Failure to adhere to procedures dealing with temporary
variations.
l
$75,000 - Violation of LC0 dealing with torus to reactor build-
{
f ng vacuum breakers (Level III Violation).
2.
Orders
None.
.
_
_ . _
_
_
.
. .
t
>
46
C.
Confirmatory Action Lettees
Two Confirmator/ Action Letters (CALs) were issued during the report
period as follows:
CAL 87-05:
Violation of primary containment due to blocked open
--
vacuum breakers.
CAL 87-12:
Violation of Technical Specification Safety Limit and
--
subsequent operator actions.
D.
Licensee Event Reports
During the last assessment period, 36 LERs were generated and during this
period 45 were reported.
Reports for the last SALP were generated at
the rate of 2.2/ month and for this period at the rate of 3.9/ month.
,
The largest single cause for the events reported is personnel error.
'
Twenty-nine of the 45 LERs reported (64%) were attributed to personnel
error.
The frequency of LERs attributed to personnel error appears to
.
be increasing with 15 of the last 21 reports (71%) attributed to person-
i
nel error.
During the last assessment period, only 30% of the LERs re-
suited from personnel error. Analysis of the cause of personnel errors
did not indicate a generic training problem.
A review of these reports shows that no single group is responsible for
a disproportionate number of these events.
The groups associated with
the personnel error LERs are Operations (10), Maintenance (5), Surveil-
lance (6), and Engineering Support (7).
To the extent possible during the NRC review of the LERs, where applic-
.
able, a contributing cause was assigned.
The most frequently noted con-
!
tributing cause was inadequate or poor procedure which was noted for 9
,
of the 45 LERs reported during the assessment period.
'
During the assessment period, four LERs reported containment isolations
j
and standby gas treatment system isolation events.
These all resulted
'
i
from the automatic bus transfer of power to vital AC power panel No.1
i
following some disturbance on incoming power.
The transfer time to an
'
alternate power is not sufficiently fast to prevent protective relays
l
from deenergizing. These events only occur during periods when the
i
generator is off the line.
Engineering has proposed a modification to
prevent recurrence which is being considered by management.
'
,
i
Also noted is the fact that 29 of the 45 reports were submitted in over
i
30 days,
t'though many of these were only several days late, submitting
1
reports within 30 days as required continues to be a problem. This
4
finding was also noted during a licensee QA audit and corrective action
'
was initiated on September 24, 1987.
In addition, supplementary reports
are generally submitted far beyond the expected submission date specified
in the initial report.
'
4
,
-
_-
_ . - _ .
.--
- -
__
-
.
-
-
_
_ - _
-
.
- .
..
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -
.
47
E.
Licensing Activities
1.
NRR/ Licensee Meetings - Location
Round Table Discussion of issues affecting Boiling Water
10/16/86
Reactor Directorate # 1 operating reactors NRC
Bethesda
Drywell shell corrosion - Bethesda
12/01/86
Drywell shell corrosion - Bethesda
12/10/86
Drywell shell corrosion - Bethesda
12/19/86
Mark I Containment combustible gas control systems
1/20/87
information - Bethesda
Status of Licensing Actions - Oyster Creek Plant site
2/04/87
Conceptual Design - Four Containment penetrations for
2/11/87
the isolation condensers - Bethesda
Program to mitigate Drywell shell corrosion - Bethesda
2/26/87
SALP Management Meeting - Forked River, NJ
4/01/87
Status of Piping Reverification - IE Bulletins 79-02 and
4/01/87
79-14 - Region 1
Management Meeting (Inspection 87-18).
Licensee's response 5/11/87
to CAL 87-05, related to events concerning tieing open con-
tainment vacuum breakers and a problem of water hammer in
core spray test lines during system testing - Region I
Licensing Activity Review - Bethesda
5/15/87
Enforcement Conference (Inspection Report 87-16).
Events
6/10/87
concerning operability of Drywell-torus vacuum breakers -
Regien I
Status of Systematic Evaluation Program and the sta'us
6/11/87
of drywell shell corrosion prc;,am - Bethesda
Licensing Activity Review - Bethesda
6/30/87
Methodology to develop new seismic floor - response
7/07/87
spectra - Bethesda
Methodology to develop new seismic floor - response
9/03/87
spectra - Bethesda
Safety Limit Violation Discussion - Region I
9/29/87
!
.
48
2.
Commission Meetings
None
3.
Relief Granted
None
4.
Schedular Exemptions Granted
None
5.
Exemptions Granted
None
6.
Licensee Amendments Issued
Amendment
Title
Date
108
Radiological Effluent Technical Specifications
10/06/86
109
Automatic Depressurization System Surveillance
10/27/86
110
Inoperable Protective Instrumentation Channels
10/27/86
111
Cycle 11 Reload
10/27/86
112
Drywell Pressure Setpoint
10/31/86
113
11/07/86
114
Fire Protection
3/20/87
115
Centrol Room Habitability
3/31/87
116
Containment High Range Radiation
3/31/87
117
Organization
9/30/87
i
!
,
la
.
- .
4
TABLE 1
INSPECTION REPORT ACTIVITIES
REPORT / DATES
-INSPECTOR
HOURS AREAS INSPECTED
,
86-33
RESIDENT.
10
SPECIAL REPORT T0 DOCUMENT THE FACTS ASSOCIATED
10/29/86
WITH THE INADEQUATE MOUNTING OF 80 0F 137
HYDRAULIC CONTROL UNITS.
86-34
RESIDENT
190
REVIEWED COMPLETION STATUS OF IE BULLETIN 80-08,
'
10/6-11/16/86
INVESTIGATED RECIC SYSTEM PUMP TRIP SYSTEM,
- .
AND THE CAUSE OF FAILED FUEL.
86-35
SPECIALIST
76
CONTAINMENT INTEGRATED LEAK RATE TEST
10/21-19/86
86-36
SPECIALIST
39
CYCLE 11 STARTUP PHYSICS TESTING AND CYCLE 10
11/17-21/86
FUEL FAILURE FOLLOW UP
86-37
SPECIALIST
132
ANNOUNCEO TEAM INSPECTION OF ELECTRIC POWER
11/17-21/86
SYSTEM INCLUDING DESIGN FEATURES, VERIFICATION
.
OF AS-BUILT DRAWINGS, PLANT MODS, REVIEW LOAD
STUDIES
!
86-38
RESIDENT
606
0UTAGE MANAGEMENT PREPARATIONS FOR RESTART AND
l
11/17/86-01/16/87
RESUMPTION OF NORMAL OPERATION
'
86-39
SPECIALIST
29
ROUTINE UNANNOUNCED PHYSICAL SECURITY INSPECTION
11/8-11/86
86-40
SPECIALIST
31
DRYWELL WALL CORROSION
l
12/9-16/86
86-41
SPECIALIST
82
A REACTIVE INSPECTION TO REVIEW THE CIRCUM-
i
12/15-19/86
STANCES RELATED TO UNPLANNED EXPOSURE DURING
l
PREPARATION OF A RESIN LINER / CASK FOR SHIPMENT
!
j
87-01
SPECIALIST
164
SPECIAL TEAM INSPECTION OF APPENDIX R REQUIRE-
1/5-9/87
MENTS
87-02
SPECIALIST
60
INSPECTION OF PREVIOUSLY IDENTIFIED ITEMS
1/12-16/87
.
)
87-03
CANCELLED
0
87-04
RESIDENT
319
ROUTINE INSPECTION INCLUDING PERFORMANCE DURING
!
1/16-3/8/87
TWO DECLARED UNUSUAL EVENTS AND CORRECTIVE
ACTION RE: INTERMEDIATE RANGE INSTR, PERFORMANCE
4
ij
T-1-1
i
4
a
--
-
-
-
-
- - -
.
.
Table 1
REPORT / DATES
INSPECTOR
HOURS AREAS INSPECTED
87-U5
SPECIALIST
130
INSPECTION OF EMERG. PREP. AND INFORMATION
1/27-30/87
NOTICE 83-28. OBSERVED RESPONSE TO UNUSUAL
EVENT.
EVALUATED LICENSEE SECURITY-EMERGENCY
PREPARE 0 NESS INTERFACE.
87-06
SPECIALIST
37
UNANNOUNCED REVIEW OF THE LICENSEEiS WATER
2/9-13/87
CHEMISTRY CONTROL PROGRAM.
87-07
SPECIALIST
66
UNANNOUNCED INSPECT RE: IMPLEMENTATION OF NUREG
2/17-20/87
0737-ITEM II.K.3.16 COMMITMENT
87-08
RESIDENT
206
INSPECTION OF PIPE SUPPORT INSPECTIONS, SUR-
3/9-4/19/87
VEILLANCE TESTING, AND EMER PREP. FOLLOWED UP
NUREG-0737 AND 0822 COMMITMENTS.
87-09
SPECIALIST
0
SENIOR REACTOR OPERATOR LICENSEE EXAMINATION
2/27/87
87-10
SPECIALIST
'2
SPECIAL UNANNOUNCED SAFETY INSPEC. OF STATUS
/
3/31-4/3/87
0F THE INSPECTOR FOLLOW-UP ITEMS RELATED TO
IMPLEMENTATION OF NUREG-0737
87-11
SPECIALIST
237
EMERGENCY PREPAREDNESS INSPECTION OF FEMA 08-
5/11-14/87
SERVED, FULL PARTICIPATION, EMERGENCY EXERCISE
CONDUCTED ON 5/12/87
87-12
SPECIALIST
42
SPECIAL UNANNOUNCED INSPECTION OF SOLID RADIO-
4/22-27/87
ACTIVE WASTE PREPARATION, PACKAGING AND SHIPPING
ACTIVITIES.
87-13
RESIDENT
379
ROUTINE RESIDENT INSPECTION
4/20-6/28/87
87-14
SPECIALIST
120
UNANNOUNCED SAFETY INSPECTION OF RADIOLOGICAL
5/18-22/87
PROTECTION ACTIVITIES ON SITE.
87-15
SPECIALIST
36
PROCUREMENT, RECEIVING OPERATIONS, STORAGE AND
5/4-8/87
PREVENTIVE MAINTENANCE IN STORAGE.
87-16
SPECIALIST
179
SPECIAL TEAM INSPECTION TO FOLLOW UP 4/24/87
4/24-5/6/87
EVENT (SHIFT PERSONNEL VIOLATED CONTAINMENT
87-17
SPECIALIST
75
INSPECTION OF LICENSEE ACTION ON PREVIOUS IN-
5/11-15/87
SPECTION FINDINGS, LICENSEE SURVEILLANCE ACTI-
VITIES, AND INSERVICE TESTING CF PUMPS AND
VALVES
T-1-2
.
Table 1
REPORT /0ATES
INSPECTOR
HOURS AREAS INSPECTED
87-18
SPECIALIST
12
MGT. MEETING TO DISCUSS LICENSEE ACTIONS IN
5/11/87
RESPONSE TO CAL 87-05 RE:4/24/87 CONT. VAC
BREAKER AND WATER HAMMER IN CORE SPRAY TEST
LINES
87-19
SPECIALIST
33
INSPECTION OF THE GASE0US AND LIQUID RADIO-
5/21-28/87
ACTIVE EFFLUENTS CONTROL PROGRAM
87-20
SPECIALIST
40
INSPECTION OF INSERVICE TESTING PROGRAM FOR-
6/1-5/87
PUMPS AND VALVES AND QUALITY ASSURANCE.
87-21
SPECIALIST
38
REVIEW THE IMPLEMENTATION OF SECTIONS OF NUREG-
6/8-12/87
0737 RELATIVE TO CONTAINMENT ISOLATION DEPEND-
ABILITY AND CERTAIN ACCIDENT-MONITORING INSTR.
87-22
RESIDENT
319
ROUTINE INSPECTIONS
6/19-8/9/87
87-23
SPECIALIST
27
QA RECORDS PROGRAM REVIEW AND REVIEW OF OPEN
7/2/87
ITEMS
87-24
SPECIALIST
830
INTEGRATED PERFORMANCE APPRAISAL TEAM INSPECTION
8/10-21/87
87-25
SPECIALIST
109
ROUTINE SECURITY INSPECTION
8/24-28/87
87-26
SPECIALIST
74
CONFIRMATORY MEASUREMENTS AND ENVIRONMENTAL
8/24-28/87
CONTROL
87-29
SPECIALIST
290
AUGMENTED INSPECTION TEAM TO FOLLOW UP SAFETY
9/11-17/87
LIMIT VIOLATION
T-1-3
_ _ _ _ _ _ _ _
- - _ _
.
.
TABLE 2
INSPECTION HOUR SUMMARY
Actual
Percent
1.
Plant Operations
1820
36
2.
Radiological Controls
813
16
3.
Maintenance
964
19
4.
Surveillance
464
9
5.
420
8
6.
Security and Safeguards
165
3
7,
Assurance of Quality
N/A
N/A
8.
Licensing Activities
N/A
N/A
9.
Engineering Support
443
9
10. Training and Qualification
N/A
N/A
Effectiveness
5089
100
.
,
T-2-1
l
,
.
.
TABLE 3
ENFORCEMENT ACTIVITY
A.
Violations Versus Functional Area By Severity Level
Functional
No. of Violations in Each Severity Level
Area
V
IV
III
II
I
Total
1.
Plant Operations
2
2
1
5
2.
Radiological
Controls
1
1
3.
Maintenance
1
1
4.
Surveillance
1
1
5.
Emergency
Preparedness
6.
Security and
Safeguards
1
1
7.
Assurance of
Quality
8.
Licensing
Activities
9.
Engineering
Support
1
3
4
10. Training and
Qualification
Effectiveness
Total
2
8
2
1
13
T-3-1
_____
s,
Table 3
B.
SUMMARY
Inspection
Severity
Functional
Brief
Number
Requirements
Level
Area
Description
86-37
10 CFR 50, App.B,
IV
Engineering
Changes to safety-
Crit. V, VI
Support
related electrical
systems not docu-
mented prior to
being implemented.
86-37
Technical
IV
Plant
Three examples
Specification
Operations
of failure to
6.8.1
follow procedures.
87-08
Technical
IV
Surveillance
Failure to prepare
Specification
a procedure for
6.8.1
a Tech Spec re-
quired surveil-
lance.
87-12
IV
Radiological
Solidified waste
(d)(1)
Controls
contained exces-
sive water.
87-13
IV
Maintenance
Failure to perform
a.(g)(4)
hydro after weld
repair.
Technical
IV
Engineering
Failure to perform
Specification
Support
required instru-
3.12.1.1
ment surveillances.
IV
Engineering
Failure to submit
Support
reports required
by 10 CFR 50.59.
87-16
II
Plant
Tied open suppres-
(a)(1) and Tech-
Operations
sion chamber to
nical Specifica-
drywell vacuum
cation 3.5.A.3
breakers.
IV
Plant
Failure to make
(b)(1)(ii)
Operations
required one hour
report.
Technical
III
Plant
Five examples of
Specification
Operations
failure to follow
6.8
procedures.
T-3-2
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ ,
.
.
'
Table 3
Inspection
Severity
Functional
Brief
Number
Requirements
Level
Area
Description
87-16
III
Plant
Tied open reactor
(Cont.)
(a)(1) and Tech.
Operations
building to sup-
nical Specifica-
pression chamber
cation 3.5.A.3
vacuum breakers.
87-20
Technical
V
Engineering
Use of improper
Specification
Support
test gauge during
4.3.C
inservice testing.
87-25
V
Security
Training
i
T-3-3
_ _ _ _ _ _
O
o
TABLE 4
LICENSEE EVENT REPORTS
A.
LER By Functional Area
Number by Cause Code
Functional Area
A
B
C
D
E
X
1.
Plant Operations
10
2
1
2.
Radiological Controls
3.
Maintenance
5
4
2
4.
Surveillance
6
2
1
5.
6.
Security and Safeguards
7.
Assurance of Quality
8.
Licensing Activities
9.
Engineering Support
7
5
10. Training and Qualification
Effectiveness
Total
28
7
0
4
4
2
Cause Codes:
A-
Personnel Error
B-
Design, Manufacturing, Construction, or Installation Error
C-
External Cause
D-
Defective Procedures
E-
Cemponent Failure
X-
Other
T-4-1
__ _ _ - _ _ _ _ _ - - - _ _ . _ _ _ _ - - _ _ _
-.
.-
'
Table 4
B.
LER Synopsis
86-23
SINGLE FAILURE OF CONTAINMENT SPRAY AUTOMATIC
B
INITIATION LOGIC
86-24
POSTULATED HIGH ENERGY LINE BREAK IN ISOLATION
B
CONDENSER PENETRATIONS
86-25
GROUNDING OF 4160V ELECTRICAL BUS CAUSED BY
A
PERSONNEL ERROR
86-26
REACTOR SCRAM DURING EXCESS FLOW CHECK VALVE
A
TESTING
86-27
STANDBY GAS TREATMENT SYSTEM INITIATION CAUSED BY
A
PERSONNEL ERROR
86-28
PERSONNEL ERROR DEFEATS AN AUTOMATIC INITIATION
A
FUNCTION OF STANDBY GAS TREATMENT SYSTEM
86-29
POTENTIAL INOPERABILITY OF CORE SPRAY EMERGENCY
A
SERVICE WATER PUMPS DUE TO INADEQUATE DESIGN AND
PROCEDURE REVIEWS
86-30
ISOLATION CONDENSER "A"
ISOLATION ON SPURIOUS
D
HIGH FLOW SIGNAL
86-31
REACTOR BUILDING CLOSED COOLING WATER TO DRYWELL
A
ISOLATION CAUSED BY PERSONNEL ERROR DURING
INSTRUMENT FILLING ACTIVITIES
86-32
REACTOR TRIP ON HIGH NEUTRON FLUX CAUSED BY COLD
A
FEEDWATER ADDITION DUE TO OPERATOR ERROR
86-33
STANDBY GAS TREATMENT INITIATION CAUSED BY GROUND
A
ON ARM RIBBON CABLE DUE TO PERSONNEL ERROR
86-34
MANUAL SCRAM DUE TO INADILITY TO MAINTAIN CON-
E
DENSER VACUUM CAUSED BY EQUIPMENT FAILURE
86-35
CONTAINMENT PENETRATION FOUND DEGRADED DUE TO
A
ISOLATION VALUES ACTUATOR / VALVE LINKAGE OUT OF
ADJUSTMENT
87-01
ABSENCE OF NEUTRON FLUX CONTRvL R00 BLOCK CLAMPING X
CIRCUIT DUE TO INCONSISTENCY BETWEEN TECH SPEC AND
PLANT HARDWARE
T-4-2
.
.
.-_
.-
_ .
a
,
/
{
Table 4
r
i
LER NUMBER
. SUMMARY
CAUSE
i
87-02
MAIN STEAM ISOLATION VALVE CLOSURE CAUSED BY
A-
i
OPERATOR ERROR
-
87-03
STANDBY GAS TREATMENT SYSTEM INITIATION CAUSED
E
e
BY POWER SUPPLY PERTURBATION
l
87-04
TECHNICAL SPECIFICATION VIOLATION CAUSED BY
A
IMPROPER REMOVAL OF EQUIPMENT FROM SERVICE DUE TO
PERSONNEL ERROR
87-0S
HIGH FLUX SCRAM DURING RECIRCULATION PUMP START
A
DUE TO DISCHARGE VALVE PARTIALLY OPEN
87-06
TECHNICAL SPECIFICATION VIOLATION CAUSED BY
A
IMPROPER STORAGE OF HIGHER ENRICHMENT FUEL DUE TO
PERSONNEL ERROR
!
87-07
BACKUP SAMPLE ANALYSIS INVALID DUE TO PERSONNEL
A
!
ERROR
!
87-08
LIMITING SAFETY SYSTEM SETPOINT FOR TOTAL RECIRCV- B
LATION FLOW EXCEEDS TECHNICAL SPECIFICATIONS DUE
TO INSTRUMENT DRIFT
87-09
VOLUNTARY RPT.-0PERATION OF PLANT WITH FLOW BIASED E
SCRAM & RCD BLOCK SETPOINTS OUTSIDE ANALYZED
l
REGION DUE TO RECIRC LOOP FLOW BACKFLOW
l
87-10
ELECTRICAL TRANSIENT CAUSES CONTAINMENT ISOLATION
X
I
AND STANDBY GAS TREATMENT INITIATION DUE T0
i
DES!GN CONFIGURATION
87-11
HIGH RPV LEVEL TURBINE TRIP / SCRAM CAUSED BY LOST
D
!
FEEDWATER FLOW SIGNAL DUE TO PROCEDURAL INADEQUACY
[
87-12
INOPERABLE OFFGAS DRAIN LINE ISOLATION VALVE
E
!
CAUSED BY DEBRIS ACCUMULATION DUE TO INADEQUATE
PREVENTIVE MAINTENANCE
'
87-13
SGTS INITIATION CAUSED BY IMPROPERLY INSTALLED
A
WIRE CONNECTOR DUE TO PERSONNEL ERROR
87-14
DRYWELL ISOLATION CAUSED BY LIFTING A LEAD
A
i
87-15
INOPERABLE INTERMEDIATE RANGE MONITORS DUE TO
D
i
BROKEN FLEXIBLE CONNECTION CAUSE BY IMPROPER
l
MAINTENANCE
!
!
I
T-4-3
I
.
..
- - .
....- -.
-
r --
o
'
.
'
Table 4
LER NUMBER
SUMMARY
CAUSE
87-16
SETPOINTS FOR THREE OF EIGHT ISOLATION CONDENSER
B
PIPE BREAK SENSORS OUT OF SPECIFICATION OUE TO
INSTRUMENT DRIFT
87-17
TECH SPEC VIOLATION CAUSED BY INAPPROPRIATE RE-
A
MOVAL OF SNUBBERS FROM SURVEILLANCE PROGRAM DUE TO
PERSONNEL ERROR
87-18
REACTOR BUILDING VENTILATION VALVE INOPERABLE FOR
A
MAINTENANCE AND NOT SECURED CLOSED DUE TO PERSONNEL
ERROR
87-19
LIMITING SAFETY SYSTEM SETPOINT FOR TOTAL RECIRCV- A
LATION FLOW EXCEEDS TECHNICAL SPECIFICATIONS DUE
TO PERSONNEL ERROR
87-20
TECHNICAL SPECIFICATION REQUIRED SURVFILLANCE
A
OVERDUE DUE TO INADEQUATE SHIFT TURNOVER CAUSED BY
PERSONNEL ERROR
87-21
TECHNICAL SPECIFICATION VIOLATION CAUSED BY
A
BLOCKING OPEN CONTAINMENT VACUUM BREAKERS DUE TO
PERSONNEL ERROR
87-22
PLANT SHUTOOWN REQUIRED BY IN0PERABLE ACOUSTIC
B
MONITOR DUE TO MARGINAL SPLICE DESIGN RESULTING IN
CABLE DAMAGE DURING INSTALLATION
87-23
PARTIAL PRIMARY CONTAINMENT ISOLATION DURING
A
TESTING DUE TO PROCEDURAL INADEQUACY
87-24
FAILURE TO POST A FIRE WATCH FOR A NON-FUNCTIONAL
A
FIRE BARRIER DUE TO PERSONNEL ERROR IN FAILING TO
FOLLOW PROCEDURE
87-25
PRIMARY CONTAINMENT VENT AND PURGE VALVES HAD
D
MAXIMUM STROKE IN EXCESS OF DESIGN LIMIT DUE TO
INSTALLATION PROCEDURE INADEQUACY
87-26
TEMPORARY VARIATIONS FOUND UNACCEPTABLE DUE TO
A
INADEQUATE SAFETY REVIEWS
87-27
ELECTRICAL STORM INDUCED CONTAINMENT ISOLATION
B
AND STANDBY GAS TREATMENT SYSTEM INITIATION DUE TO
AUTOMATIC BUS TRANSFER TIME EXCEEDING RPS RELAY
DROPOUT TIME
T-4-4
,
. _ _ _ _ _ _ _ _ _
r.
E
'
Table 4
LER NUMBER
SUMMARY
CAUSE
87-28
MAIN STEAM ISOLATION VALVE CLOSURE CAUSED BY
A
DESIGN DEFICIENCY DURING SURVEILLANCE TEST
,
87-29
HIGH REACTOR PRESSURE SCRAM OUE TO AIR LEAK FROM
A
DISLODGED AIR TEST PILOT VALVE CAUSED BY INCORRECT
MOUNTING CAP SCREW LENGTH
87-30
LIGHTING ARRESTOR INSULATOR FAILURE INDUCED VOLT-
B
AGE TRANSIENT CAUSED CONTAINMENT ISOLATION AND
SBGTS INITIATION DUE TO AUTOMATIC BUS TRANSFER TIME
EXCEEDING RPS DELAY DROPOUT TIME
87-31
VIOLATION OF HIGH RADIATION AREA TECHNICAL SPECI-
A
FICATIONS CAUSED BY PERSONNEL ERROR DURING RESPONSE
TO FIRE ALARM
87-32
A0G HYOROGEN ANALYZER NOT CALIBRATED IN ACCORD-
A
ANCE WITH TECH SPEC REQUIREMENTS OUE TO INADEQUATE
REVIEW OF RETS AMENDMENT
T-4-5