ML20151M804
| ML20151M804 | |
| Person / Time | |
|---|---|
| Site: | Millstone  |
| Issue date: | 07/12/1988 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20151M802 | List: |
| References | |
| 50-423-87-99, NUDOCS 8808080009 | |
| Download: ML20151M804 (54) | |
See also: IR 05000423/1987099
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ENCLOSURE 1
U.S. NUCLEAR REGULATORY COMMISSION
REGION I
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SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE
INSPECTION REPORT NUMBER 50-423/87-99
MILLSTONE NUCLEAR STATION, UNIT 3
ASSESSMENT PERIOD: March 1, 1987 to May 31, 1988
BOARD MEETING DATE: July 12, 1988
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TABLE OF CONTENTS
PAGE
I.
INTRODUCTION.........................................................
1
A.
Purpose and 0verview............................................
1
B.
SALP Board Members..............................................
1
II. CRITERIA.............................................................
2
III. SUMMARY OF RESULTS...................................................
3
A.
Overall
Summary.................................................
3
B.
Background......................................................
4
1.
Licensee Activities........................................
4
2.
Inspection Activities...............
......................
4
C.
Unit Performance Analysis Summary...............................
4
IV.
PERFORMANCE ANALYSIS.................................................
5
A.
Plant Operations................................................
5
B.
Radiological Controls...........................................
9
C.
Maintenance.....................................................
12
D.
Surveillance......... ..........................................
18
E.
Emergency Preparedness..........................................
18
F.
Security and Safeguards.........................................
20
G.
Outage Management...............................................
23
H.
Engineering Support.............................................
25
I.
Licensing Activities............................................
28
J.
Training Effectiveness..........................................
30
K.
Assurance of Quality............................................
33
V.
SUPPORTING DATA AND SUMMARIES......................
.................
36
A.
Allegation Review...............................................
36
8.
Escalated Enforcement Actions. ..............................
36
C.
Ma n a g emen t Co n f e re n c e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36
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0.
Licensee Event Reports..........................................
36
E.
Licensing Activities............................................
38
TABLES
Table 1 - Iaspection Hours and Reports
Table 2 - Enforcement
Table 3 - Licensee Event Report (LER) Summary
Table 3A - Synopsis of LERs
Table 4 - Summary of Forced Outages, Unplanned Trips, and Power Reductions
Table 4A - Forced Outages, Unplanned Trips, and Power Reductions
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I.
INTRODUCTION
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I.A. Purpose and Overview
The Systematic Assessment of Licensee Performance (SALP) is an integrated NRC staff
effort to collect observations and data and evalcate licensee performance.
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supplement the regulatory process through use of a collection of objective facts,
findings and evaluations to generate a subjective evaluation of performance.
They
are intended to be diagnostic enough for allocating NRC resources and meaningful
enough to guide licensee management on ways to promote quality and safety of
operation.
This report assesses Millstone Nuclear Power Station Unit 3 safety performance from
March 1, 1987 through May 31, 1988.
The summary findings and totals reflect a 15-
'
month assessment of operating and outage activities.
The SALP Board, composed of the NRC staff members listed below, met on July 12,
1
1988 to review performance observations and assess licensee performance in accord-
ance with the guidance in NRC Manual Chapter 0516, "Systematic Assessment of Lic-
ensee Performance." A summary of the evaluation criteria is provided in Section
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II of this report.
I.B. SALP Board Meeting Attendees
I.B.1.
Board Members
W. F. Kane, Director, Division of Reactor Projects (DRP), Chairman
S. Ebneter, Director, Division of Radiation Safety and Safeguards (DRSS)
W. Johnston, Acting Director, Division of Reactor Safety (DRS)
P. W. Eselgroth, Chief, PWR Operator Licensing Section, DRS
L. H. Bettenhausen, Chief, Projects Branch No. 1, DRP
E. C. McCabe, Chief, Reactor Projects Section No. 18, DRP
J. Stolz, Director, Project Directorate PD I-4, Office of Nuclear Reactor
Regulation (NRR)
D. Jaffe, Licensing Project Manager, Project Directorate PD I-4, NRR
W. Raymond, Millstone Site Senior Resident Inspector, DRP
I.P.2.
Other Attendees
G. S. Barber, Resident Inspector
- W. Thomas, Radiation Specialist, DRSS
- M. Shanbaky, Section Chief, DRSS
- J. Kottan, Inspector, DRS
- W. Lazarus, Chief, Emergency Planning Section, DRSS
- C. Conklin, Inspector, Emergency Planning Section, DRSS
- R. Bailey, Physical Security Inspector, DRSS
- Part-time attendee.
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II. CRITERIA
Licensee performance is assessed in selected functional areas significant to nuc-
lear safety and/or the environment.
The following criteria were used as appro-
priate to assess each functional area.
1.
Management involvement and control in assuring quality.
2.
Approach to resolution of technical issues from a safety standpoint.
3.
Responsiveness to NRC initiatives.
4
Enforcement history.
5.
Reporting and analysis of reportable events.
6.
Staffing (including management).
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7.
Training effectiveness and qualification.
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Based upon the SALP Board assessment, each functional area was classified into one
of three performance categories.
Those categories are:
Category 1.
Reduced NRC attention may be appropriate.
Licensee management atten-
tion and involvement are aggressive and oriented toward nuclear safety; licensee
3
resources are ample and effectively used so that a high level of performance with
respect to operational safcty is being achieved.
Category 2.
NRC attention should be maintained at normal levels.
Licensee man-
agement attention and involvement are evident and concerned with nuclear safety;
licensee resources are adequate and reasonably effective such that satisfactory
performance with respect to operational safety is being achieved.
Category _3.
Both NRC and licensee attention should be increased.
Licensee man-
agement attention or involvement is acceptable and considers nuclear safety, but
weaknesses are evident; licensee resources appear strained or not effectively used
such that minimally satisfactory performance with respect to operational safety
is t?ing achieved.
The SALP Board also considered categorizing performance trends over the SALP as-
sessment period. A trend was assigned only if a definite trend of performance was
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discernible and the SALP Board oelieved that its continuation might result in a-
change of performance level.
The SALP trend categories are:
Improving: Licensee performance was determined to'be improving near the close of
the assessment period.
Declining: Licensee performance was determined to be declining near the close of
the assessment period.
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III. SUMMARY OF RESULTS
III.A.
Overall Summary
During the previous 3 ALP, the licensee staff was assessed as strong, with visibly
involved managers.
Stre.19ths were observed in problem identification and response,
and in locating root causes.
There was diligent attention to performance at all
levels.
Performance improved as the period progressed.
Licensee performance continued to improve during the currect SALP period.
Strong
operations programs, procedures, and management controls were evident.
Command
and control was very good.
Activities were carefully planned and conducted, with
outages being a noteworthy example. Managers were actively involved in cecision
making and activity direction at appropriate levels. Operating supervisors and
plant personnel were knowledgeable and alert.
Strong corrective action was evident
when errors or malfunctions occurred.
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The organization was staffed with capable and knowledgeable managers and supervi-
sors. Workers attended to detail and demonstrated.a safety conscious attitude.
Procedures and programs were effectively implemented and focused on safe operations.
Morale and attitudes were good. High standards were set and followed.
Consis-
tently high performance was strived for and achieved. A high regard for plant and
personnel safety was strongly evident.
The previous SALP noted a need to decrease scrams (reactor trips) due to steam
generator (SG) level transients.
Replacement of.the SG 1evel measurement conden-
sate pots with high pressure pipe tees improved steam generator level stability.
That enhancement and improved operator handling of feedwater transients reduced
the number of scrams: there were 11 scrams during this 15-month SALP period (0.7/
month) and 16 scrams during the previous 18-month SALP period (0.9/ month). Of the
11 scrams this period, two were due to inadequate control of feedwater, a signifi-
cant improvement over the 10 such scrams 6Jring the last SALP period. While the
scram reduction efforts have resulted in improvements, there needs to be continued
emphasis on this program in the next SALP period.
Th? last SALP noted an improving, but still high, number of illuminated control
room annunciators during operation.
Licensee reassessment resulted in delaying
their commitment to achieve a "black board" from the end of the first refueling
outage to the end of the third refueling outage.
That is generally appropriate,
but some radiation alarm annunciators deserve increased attention.
Currently,
these alarms tend to desensitize operators to additional alarms on the same window.
Overall, tFis SALP reflects careful and safe performance during the first full
operating cycle.
There is, however, an ongoing licensee need to reauce avoidable
scrams and unnecessary illuminated control room annunciators.
The licensee also
needs to prioritize changes to operating and surveillance procedures and assure
that sufficient staffing is provided to accomplish those changes effectively.
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III.B.
Background
III.B.I.
Licensee Activities
The licensee completed the first operating cycle and began the sece-1 during this
SALP period. Millstone 3 operated at 70.3% capacity frcm the begi
. lg of commer-
cial oparation on April 23, 1986 until the SALP period ended on Ma,
i, 1988.
There were two unplanned, more than 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> outages and two planned outages (one
for surveillance, one for refueling) during the period.
The 5-day and 14-day un-
planned outages (June 5, 1987 and April 13, 1988) followed scrams and were extended
for maintenance. A planned outage in March 1987 was for snubber testing.
The
refueling outage began on October 30, 1987 and was scheduled to last 59 days. An
additional 45 days was taken to repair loose reactor coolant pump (RCP) locking
cups af ter seven were found on the lower core plate.
There were about 2700 acti-
vities scheduled during the outage including refueling, resistance temperature de-
tector (RTO) bypass manifold elimination, snubber reduction, steam generator sludge
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lancing, containment local leak rate testing, motor-operated valve testing, and
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safety system train-related maintenance.
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III.B.2.
Inspection Activities
Four NRC resident inspectors were assigned to the site during the SALP period.
The senior resident inspector divided his time among all three units; a resident
inspector was assigned to Unit 3.
Both of these individuals were first assigned
to the site during the SALP period. The NRC inspections represent 2425 inspection
hours (1940 hours0.0225 days <br />0.539 hours <br />0.00321 weeks <br />7.3817e-4 months <br /> per year), distributed as shown in Table 1.
III.C.
Facility Performance Analysis Summary
Last Period
This period
Recent Trend
(9/1/85 -
(3/1/87 -
(Past 3
__2/28/87)
5/31/83)
Months)
Functional Area (11 Areas)
A.
Plant Operations
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2
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8.
Radiological Controls
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C.
Maintenance
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Surveillance
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E.
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F.
Security and Safeguards
1
2
Improving
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G.
Outage Management
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H.
Engineering Support
2
2
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I.
Licensing Activities
1
1
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J.
Training Effectiveness
2
1
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K.
Assurance of Quality
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IV.
PERFORMANCE ANALYSIS
IV.A.
Plant Operations (1021 Hours, 42%)
IV.A.1.
Analysis
The plant received its low power and full power license during the previous as-
sessment period.
It was rated in Plant Operations as Category 2, improving.
Con-
cerns included scram frequency, Power Operated Relief Valve (PORV) reliability and
unnecessary illuminated annunciator reduction.
Scram frequency is still high but
has been reduced somewhat: 11 scrams (8.8/ year) this assessment period versus 16
scrams last period (10.7/ year).
Three scrams in 1987 resulted from inadequate
control of steam generator (SG) water level during startup or at power.
In 1988,
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one scram has been attributed to inadequate SG level control.
This reduction was
in part due to operator experience in handling feedwater transients and in part
due to replacement of the SG level measurement condensing pots with high pressure
pipe tees to eliminate steam generator level oscillations previously experienced
between 55% and 65% power. Although the scram frequency is being reduced, con-
tinued management emphasis is needed to ensure future reductions are realized.
PORV reliability showed marked improvement due to licensee programs that effec-
tively dealt with seat leakage problems.
The solution to this difficult problem
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involved installing flexible valve discs in the PORVs.
Redu"ion of illuminated annunciators has continued, but delays in the annunciator
reduction program have been caused by the need for significant design changes.
The origina( commitment to establish a "black board" by the end of the first re-
fueling outage was revised to achieving a "black board" by the end of the third
refueling outage. This change is generally acceptable. However, problem annun-
ciators deserve increased licensee attention.
For example, spiking on radiation
monitors causes alarms to be received, acknowledged, and reset from about 10 to
50 times per hour, hazarding operator desensitization to that particular annunci-
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ator.
In one instance this led to a high radiation condition not being discovered
by the licensee. Continued management attention is needed to ensure sufficient
priority to and timely resolution of this problem.
Overall, operating shift functioning was smooth and professional.
Activities were
conducted carefully and with sufficient formality.
The operators themselves re-
mained strong proponents of control room formality.
Operator attitudes were post-
tive and a concern for safety was avident. Attentive behavior wat routinely ob-
served in operator performance during day and backshift inspections. Distractions
such as extraneous reading material were not permitted or observed in the control
Shift turnovers were observed to be consistently thorough and effective.
room.
Briefings for tests and infrequent evolutions were detailed, and involved free
exchanges of questions and answers. Written procedures were routinely followed.
Shift logs and records were discrepancy-free during frequent review.
There were 11 scrams during the assessment period.
Four were due to equipment
failure and three were due to personnel error.
(See Table 4A for a listing of
causes.) Two of the equipment-related scrams were due to faulty Skinner solenoid
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valves. Due to high temperatures and currents, these valves have been open cir-
cutting and causing their respective feedwater isolation (FWI) valves to close.
These valves were replaced in kind prior during the first refueling outage; low
wattage valves for replacing these valves are due to arrive on site November 1988.
The majority of personnel error-related trips were due to feedwater control prob-
lems. Differences between plant and simulator response exacerbated these problems
but increased operator experience has reduced the frequency of such trips. Overall,
the scram frequency and its reduction indicate satisfactory performance.
Operator response to scrams was excellent.
Performance following the September
23, 1987 scram was an example.
Operators performed immediate actions from memory
without error and checked emergency operating procedures to verify their actions.
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They constantly referenced the procedures while performing follow-up actions.
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Operator technical knowledge was good, based on their consistently exhibiting de-
tailed and thorough knowledge of the equipment, its status, and associated re-
quirements.
New operating license candidate knowledge was satisfactory.
During
the NRC license examinations given this SALP period, 8 of 13 candidates passed,
with no significant weaknesses noted.
(Further details are prov:tded in Section
IV.J, Training Ef fectiveness.)
Licensee management support of training and operator proficiency has been evident.
The licensee conducted training on a modern plant-specific simulator with a dedi-
cated training staff of about 20 individuals.
Several experienced operators have
been promoted into the training staf f.
There was a six-shif t rotation during power
operation, .with full-time training for one shift being a regular part of that
rotation.
Station management involvement in training was evident in their knowl-
edgeable discussions with NRC personnel and in their obvious interaction with the
training staff and attendance at simulator training. Most department heads main-
tained senior reactor operator (SRO) licenses and attended requalification training.
Their dedicatiora to training and to the understanding of system operations and
interrelationships was especially evider.t in Plant Operation Review Committee
(PORC) meetings.
PORC performance was very good.
Meeting inputs were well pryared and showed a
clear understanding of issues.
The approach to problem resolution was technically
sound, very thorough, and routinely conservative.~ Root causes of problems were
actively pursued.
During meetings and in NRC discussions with higher level man-
agers, there was a licensee willingness to deal with difficult issues and an at-
mosphere of healthy self-criticism.
(Further details are provided in Section IV.K,
Assurance of Quality.)
Management attention to operations was evident in plant superintendent control room
tours and detailed weekly plant naterial walkdowns by :lealth Physics and Operations
supervisory personnel.
A significant operating event occurred on January 19, 1988 when a low temperature
overpressure (LTOP) transient was caused by pulling a fuse in a Solid State Pro-
tection System (SSPS) cabinet.
That resulted in closure of a residual heat removal
(RHR) suction valve, isolating the on-line relief valve.
Unavailability of re-
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quired LTOP cold overpressure protection systems (COPS) made the pressure transient
possible. Prompt operator action with the plant in a water solid condition held
the resulting pressure transient to less than 600 psi.
Licensee post-event analysis
showed that plant pressure could have exceeded 2500 psia before damage would have
occurred.
If pressure had risen near that level, the power-nporated relief valves
(PORVs) were operable at their high pressure setpoint to mitigate the transient.
Control of operations related activities that led to this event was deficient in
that the procedure for ensuring operability of the COPS did not adequately address
operability of supporting equipment.
Further, there was no positive indication
in the control room when tne COPS was armed.
In addition, the I&C technician who
pulled the fuse that resulted in the RHR relief valve isolation was not adequately
trained in the associated complex circuitry interrelationships. Also, the activity
was performed without a procedure and without adequate formal review.
This event
resulted in escalated enforcement action.
(Further details on procedural aspects
are contained in Section IV.0, Surveillance.)
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Three other instances of deficient operational controls were identified.
The first
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involved entering Mode 3 (hot shutdown) during heatup with one of two required
charging pumps inoperable.
The second involved entering Mode 3 with an auxiliary
feed pump and a supplementary leak control and recovery system fan inoperable.
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Procedures were then changed to require a test run of safety-related pumps prior
to entry into Mode 3 and to require danger-tagging safety-related pumps not speci-
fically lined up for service.
These procedure enhancements, along with improved
attention to detail, have enhanced licensee performance as evidenced by an absence
of problems during the most recent startup.
The third situation involved the im-
proper securing of a locking device on an AFW suction valve. A prompt reverifica-
tion of other safety-related system valve lineups was conducted, with no other in-
adequacies identified.
In these three matters, licensee response and corrective
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actions were prompt, appropriate and effective.
Personnel routinely followed procedures and operators and workers routinely recom-
mended procedure improvements.
Some changes were substantiative but most were
minor.
Procedure changes were implemented at a rate of 80-100 per month, reflect-
ing a diligent effort to eliminate inadequacies.
The licensee's expectation that
the procedure change workload would be reduced was not, however, realized.
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meetings occurred almost every other day to cope with the numerous changes.
Operations administrative personnel were continually burdened with procedure changes.
Staf fing to cope with procedure changes was adequate but, because of the work load,
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the individuals involved were not available to work on surveillance-related ad-
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ministrative problems.
(Further discussion of such problems is contained in Sec-
tion IV.D, Surveillance, and Section IV.K, Assurance of Quality.) During this SALP
period, the need to aggressively upgrade procedures continued, and a creater re-
source commitment to this function may be needed.
Housekeeping was evaluated as satisfactory in the last SALP.
Significant improve-
ments have since been seen.
Epoxy painting of the Engineered Safety Features (ESF)
building cubicles was recently completed and reduced the amount of decontamination
necessary in these areas.
Plant spaces were very clean and workers routinely
cleaned their areas when finished with assigned tasks.
One housekeeping concern
that was identified and corrected was the securing of non-safety related conduit
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covers which were removed in the upper levels of the ESF building.
These had been
left open for post-work inspection and remained open af ter the inspection was com-
plete. Otherwise, housekeeping was very good.
Licensee Event Reports were routinely reviewed and generally found to be complete,
accurate, timely and to contain adequate corrective actions.
(Further details are
provided i'Section IV.J, Training Effectiveness.)
Licensee command and control of operations were strong overall. Managers were
aware of operating status and details, and actively. asserted themselves at the
appropriate organizational level.
Shift management was knowledgeable and exerted
positive control over activities affecting operation.
Three notable exceptions
were a heatup with one of two charging pumps inoperable, the LTOP transient, and
a failure to station an additional operator during startup to manually control SG
water level (this resulted in a scram).
Subsequent procedure enhancements were
positive.
Licensee review found a lack of potential for other similar events.
Overall, licensee management was strong.
Corporate and unit goals and policies
were detailed and well communicated, and administrative controls were effectively
implemented. There was a strong safety-first orientation at all levels in the
licensee's organization.
Licensed operators were professional, knowledgeable,
thorough, and confident, and their performance improved over time.
Housekeeping
was very good.
Previous SALP concerns were effectively addressed with the excep-
tion of the masking of radiation alarms by existing backlit annunciators.
In summary, operating performance was satisfactory.
To achieve a higher perform-
ance rating, the licensee needs to reduce scrams and events such as the LTOP
transient and the mode changes without required equipment operable, to further im-
prove procedures, and to aggressively continue to reduce unnecessary annunications.
IV.A.2.
Conclusion
Category 2.
IV.A.3.
Board Recommendations
Licensee:
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Accelerate correction of radiation monitor spiking problem.
Identify and correct procedure problems based on safety significance.
Evalu-
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ate operations support staffing levels established to cope with frequent pro-
cedure changes and with surveillance-related administrative problems.
NRC:
None.
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IV.B.
Radiological Controls (334 Hours,14%)
IV.B.1.
Analysis
The Radiological Controls Program during the previous SALP period was rated as
Category 2 improving. Minor program weaknesses identified during the previous
assessment period related to lack of attention to detail in the implementation of
radiological control audits, chemistry / radiological effluents, and transportation
programs. All program weaknesses identified during the previous assessment period
were effectively addressed and corrected during this assessment period.
IV.B.1.1. Radiation Protection
An effective, well-defined, and adequately staffed organizational structure was
in place to control Unit 3 Radiological work activities.
Levels of supervisory
and technical personnel were adequate to support radiological activities.
Staffing
and oversight of significant radiological operations, such as containment entries
.at power to perform repairs, were good.
Radiological Protection ('.P) management
staff exhibited a strong "in-the-field" presence and were actively involved in the
radiation protection program on a continuing basis.
RP and Operations continue
to regularly perform joint tours of the radiologically controlled areas to identify
sources of exposure, contamination and potential radiological concerns.
As a re-
sult, the licensee successfully minimized the spread of contamination.
The number and quality of radiological operations audits of routinely performed
by the Quality Services Department with assistance from the Corporate Radiological
,
Assessment Branch (RAB) was assessed as good.
A past criticism of the audit pro-
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gram conducted by the RAB was that it tended to review station RP activities in
total without providing an in-depth review of individual unit activities.
This
weakness was corrected by planning and performing separate audits of each unit
under the direction of the Quality Services Department. Overall, during this as-
sessment period, corporate management involvement in on-site activities was fre-
quent and of high quality, with timely corrective action on audit findings.
Clear radiation protection procedures and policies were in place and effectively
implemented.
Radiation protection records are complete, well maintained and
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available for review.
Procedure adherence was a strength.
Radiation protection personnel were trained and qualified in accordance with a well
defined program, which was implemented with dedicated resources and applied to all
staff.
The licensee's integration of good training, qualification, and program
oversight contributed to safe conduct of radiological operations.
The program for surveying, posting, and controlling radiological areas continued
to be well implemented. An extensive and thorough radiation survey program to
evaluate shielding effectiveness was performed by the licensee during Unit 3
startup. The results were used by the licensee to control radiological work acti-
vities and make adjustments to the radiation work permit system.
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The ALARA program was effective with good management support, and represented an
additional program strength. ALARA reviews for planned work, completed work, and
continuous exposure evaluation of work in progress were good. A notable positive
example of the licensee's ALARA program involved the Reactor Coolant Pump (RCP)
Locking Cup Repair that extended the refueling outage for 6 weeks. The use of a
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spare RCP to plan work was viewed as a very useful mock-up that allowed workers
to couplete repairs while receiving 50% less than the projected exposure.
The licensee's ALARA person-rem exposure goal for 1987 (first refueling outage)
was 444 person-rem. Although the goal compares favorably with the industry average
for pressurized water reactors for 1987, it was not a particularly aggressive goal
when considering that the plant recently completed their first operating cycle.
Actual exposure accumulated during 1987 was 357 person-rem which was good when
consicering that the goal was not increased when repair work to the RCP locking
cups became necessary.
Overall, occupational radiological safety was a notable licensee strength.
This
is attributed to a sound program, a capable staff, and supervisory excellence.
'
IV.B.1.2. Chemistry / Radiological Effluents
Gaseous and liquid radioactive effluent control programs were inspected midway
through the SALP period.
The chemistry group was responsible for program imple-
mentation.
Clear corporate support for effective program implementation was evi-
dent. Management controls were evident in the procedures for controlling dis-
charges and for scheduling surveillances.
Radioactive effluent control instru-
mentation was maintained and calibrated in accordance with requirements. All ef-
fluent release records were complete and well maintained.
The licensee was re-
sponsive to NRC initiatives in this area.
Corporate audits of the program were
comprehensive and technically sound.
The licensee was responsive to a weakness
in the radiological measurements QA/QC program area identified by the NRC during
the previous SALP period.
Chemical measurement capability was evaluated against technical specification and
other regulatory requirements.
The licensee was adequately staffed and had state-
i
of-the-art equipment for nonradiological chemistry
They were responsive to NRC
suggestions for program improvements.
Licensee performance on NRC-supplied chemis-
try standards was good, with 28 of 30 (93%) in agreement.
A review was made of the secondary water chemistry control program implemented
during the February-December 1987 period.
Sodium, chlorides, sulfates and silica
were generally below the values that could be determined by the on line "state-of-
the-art" equipment used for analysis.
Based on these data, the licensee was responsive to NRC and industry initiatives
and maintained secondary water chemistry within EPRI (Electric Power and Research
Institute) recommended guidelines.
In the case of chlorides and sulfates, it
appears that the quantities measured were approaching the lower limit of the
equipment the licensee has available to perform the analysis.
..
.
.
.
. .
.
11
.
IV.B.1.3. Transportation
The solid radwaste/ transportation program was site administered for all three units
at the Millstone site.
During the previous Unit 3 SALP, this area was not evalu-
ated because of low radwaste activity as a result of initial startup.
Two trans-
-
portation inspections were conducted during the assessment period.
Following pre-
vious incidents which resulted in several violations and weaknesses in the last
assessment period, the licensee restructured the organization responsible for
packaging and shipping radioactive materials. 'The responsibilities and authorities
of the Radioactive Material Handling Department (RMH) were defined adequately.
Documentation of shipments has been improved and all paperwork for a given shipment
was kept as required during the SALP period. Job-related procedures and QA audit
procedures have been revised and improved.
The frequency, quality and scope of
i
QA audit activities has also improved.
The Radwaste Review Committee has been
l
reactivated.
Following violations pertaining to radwaste transportation training during the last
assessment pertec
licensee modules were completely rewritten.
All staff received
required training.
The tr61ning and qualification contributed a positive direction
,
to the effectiveness of RMH group activities.-
Close management attention to plan-
ning and implementing the program was noted, with strong pear review o# the tech-
nical aspects of preparation, packaging and shipping activities.
IV.B.1.4. Summary
i
An effective, well-organized and adequately staffed radiation protection organiza-
tion was in place at Unit 3 to control radiological work activities.
Corporate
management involvement with on-site activities was frequent and provided an ef-
fective leve'l of oversight and support.
The program for surveying, posting, and controlling radiological areas continued
to be well implemented.
The ALARA program was effective, with good management
support. Overall, in plant health physics was a notable licensee strength due to
a sound program, a capable staff, and supervisory excellence.
SALP performance in solid radwaste/ transportation during the current SALP period
was substantially improved over the previous assessment period.
IV.B.2.
Conclusion
Category 1.
IV.B.3.
Board Recommendations
None.
.
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12
-
IV.C.
Maintenance (317 Hours, 13's)
IV.C.1.
Analysis
The previous SALP rated maintenance as Catepory 1.
During that SALP period, the
maintenance program was found to be properly established, implemented and staffed.
Plant equipment was highly reliable, with only one scram attribu'ed to maintenance.
A long standing licensea-identified problem identified in the la.,t SALP, power-
operated relief valve 60RV) seat leakage, has been resolved.
In March of 1987,
the valves were disassembled, inspected and repaired.
From plant startup on April
4,1987 to May of 1988, the valves remained leak tight and their associated block
valves did not have to be closed. Technical competence was evident in the imple-
mentation of be.'h testing of the PORVs and PORV solenoids.
Further, the original
,
requirement for ae PORVs to be flanged so +. hat repairs and testing coul" be more
readily done indicated good decision making ed good technical plannina. The
finitallic discs now used have been essential:y leek-free.
]RV operability and
reliability has been consistently high.
Improper feedwater isoluion (FWI) valve packing adjustments ca . ed a failure to
isolate and an overfeeding during the last assessment period.
tffective implemen-
tation of a par .ial stroke testing program has subsequently prevented recurrence
of this type of event.
In the last SALP, three instances wer2 noted where fire, control building, or Sup-
plerental Leak Collection and Release System (SLCRS) barriers were breached by
fluid hoses or scaficiding. There wer e also three occurrences during the current
period where a fire barrier was breached or left opcn witnout a fire watch being
establishad.
LERs also identified the failure to establish required fire watches
(see LER causal analysis). These events might have been avoided if the barriers
were better labeled and identified. The licensee has since included a listing of
all SLCRS barriers and fire doors in the governing work proceJure, facilitating
prior identification of these boundaries in Automated Work Orders (AW0s).
In ad-
d tion, the licensee committed to label all doors by December 1968. These actions
vere positive and reflected management attention tc problems.
NRC Generic Le' ter 83-28 discussed actions to be taken regarding reactor t
cir-
cuit breaker reliability.
Review of the two 'icensee procedures fcr reactor t. rip
breaker maintenance showed that the licensee followed the recommendations of the
!
Westinghouse Mair..enance Program.
Further, it war
ot d that licensee procedures
were updated to reflec
T problem with bracket ci. < ing on DS-416 breakers (the
type in use at MP3) an.
Ta* V cket inspection was performed as part of the main-
tenance program. The
1*
slial.1
',y/ operability issues have been resolved.
This indicated good rn.1ar'w
and en:
> ring personnel responsiveness to NRC and
vendor guidance, and ar'
ute addr -
f applicable industry probiems.
Other maintenance acts, ;
-
-
3 the assessmer.* period included repairs
to leaking Mair Steam :se
G !s), trouble-shooting of an emergency
-
e
,
^
diesel generator (EDG), v
- -
- reserve station transformers, and re-
Fairs tc steam generator m)
^
'.
The maintenance manager and maintenance
'
,
,
. _ _ _
-_
- - -
_
.- -
- . .
- -_ _ __
.
'
13
.
engineers were actively involved in the oversight and supervision of these main-
tenance activities.
Also, I&C personnel were knowlegeable in their area of ex-
certise and were well informed of site requirements.
Administrative control of maintenance was cited in the last SALP as a problem area.
Lack of licensee control was obscrved in the commencement- of work without approved
AW0s.
Performance in this specific area improved during the current period. Work
was consistently approved prior to performance and was signed off on completion.
Maintenance and modification activities during normal plant oporations were ct.n-
trolled and performed within the bounds of Technical Specification Limiting Condi-
tions for Operation.
This was evident in the routine daily performance of 3-8
preventive maintenance activities. Maintenance activities were well thought out
and planned. Workers generally performed repair and testing activities without
During this SALP, control of maintenance and testing was generally very
error.
effective.
Review found the maintenance department fully staffed with well-trained, competent
and dedicated mechanics, electricians and machinists of diverse backgrounds.
Maintenance assirtance available from the other three Northeast Utilities plants
was frequently utilized. Observations and discussions found maintenance supervi-
i
sors and managers knowledgeable, and active in oversight of activities.
Effective planning minimized outage and operational scheduling impacts.
Coordina-
tion with other departments was excellent.
Communication and cooperation between
all departments, both at worker and management levels, was a key to timely and
effective troubleshooting and corrective maintenance on numerous occasions.
Not-
able positive examples of coordination and cooperation involved the Reactor Coolant
Pump (RCP) Locking Cup Repair that extended the refueling outage for 6 weeks and
the repair of defective primary sample valves during an unplanned shutdown.
Lic-
ensee scheduling of activities during the RCP repair shortened the original down-
tine from an estimated 10 to 12 weeks to 6 weeks.
The use of a spare RCP facili-
tited timely completion of the repair work.
Although the scheduling and coordination of previously unplanned work was a notable
strength, the completion of routine activities was untimely in a few instances.
One example was the repair of intake structure components. This was viewed as a
direct contributor to the April 13, 1988 scram. The relatively large number of
intake structure components out-of-service made the plant vulnerable to adverse
weather conditions.
Excessive seaweed impingement on the troveling water screens
would normally have been cleaned off by the screenwash system.
However, reduced
system capabilities did not permit proper screen cleaning.
Subsequently, increased
licensee attentio
o such vulnerabilities was observed by the NRC.
Continued
licensee sensitivity tc areas velnerable during adverse circumstances is warranted.
The computerized Preventive Maintenance Management System (PMMS) continued to show
benefits throughout the first operating cycle.
PMMS was used in planning, control-
ling and documenting work.
Its machinery history function was routinely used to
trand equir ,ent performance for establishing corrxctive actions.
The system was
an excellent tool for managing maintenance.
t
- - _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .
.
14
.
In summaty, the licensee had an effective and well-managed maintenance program.
Maintena1ce personnel were well trained, proficient in performing repairs, and
familiar with procedural and regulatory requirements. Maintenance managers and
main:enanco engineers were actively invalved in the oversight and supervision of
maintenance. Completed work packages were well maintained.
Controls were in place
to ensure that post-maintenance testing was accomplished, where applicable, prior
to declaring systems or components operable.
In only one instance did a mainten-
i
ance inadequacy lead to a reactor scram.
Overall, Maintenance was a licensee
strength.
,
IV.C.2.
Conclusion
'
Category 1.
IV.C.3.
Board Recommendations
None.
,
i
l
l
.
1
_
_
-
..
.
15
.
.
IV.D.
Surveillance (136 Hours, 6%)
IV.D.1.
Analysis
Surveillance was rated Category 2 during the previous SALP.
Performance and
understanding of surveillances was a strength, but weaknesses in procedures led
to incorrect safety system setpoints and five unnecessary system challenges.
One
of these was the isolation of service water to a safety injection pump heat ex-
changer.
During the current period, surveillance procedures viere found to be a detailed and
solid base for a successful program.
Changes were requested and drafted by persons
working with surveillance tests, and were processed in a:cordance with the Techni-
cal Specifications.
These actions reflected licensee determination to eliminate
procedure inadequacies.
The surveillance program was nanaged conscientiously.
Surveillance procedures were
generally performed properly, with well-documented test results that met technica'
specification (TS) requirements.
Surveillance procedures contained easy to follow
instructions and included features for ensuring that out-of-tolerance conditions
were reviewed and acknowledged by supervision.
There were provisions for ensuring
that results were trended and that recommendations were sent to management for.
action when required.
Personnel were well-trained and sufficient in number.
Technicians and operators conducting surveillances generally showed a very good
understanding of both system and procedure rcquirements.
The computerized Plant
Maintenance Management System (PMMS) tracked TS requirements.
Surveillances were
generally performed when required. As the instances discussed below demonstrate,
however, an administrative control problem was evident.
There were 19 surveillance-related Licensee Event Reports (LERs) during the period.
Typical examples were a missed diesel generator fuel oil particulate sample and
a late fire protection system surveillance. All 19 of these LERs were for licensee-
,
identified conditions, and the next surveillance showed ace-? table conditions in
each case.
Eleven of the 19 LERs documenteJ seven missed, two late and two incom-
plete surveillances; 9 of the 19 attributed the root cause to personnel error.
Although these 19 lapses represent a very small fraction of the surveillances (19
of thousands) and no out-of-tolerance conditions were missed as a result, increased
licensee attention to program implementation is needed.
This is a continuing
problem.
During a shutdown (July / August 1986) before the SALP period, required visual in-
rpettion of snubbers mandated a second inspec+. ion of certain mechanical snubbers.
For that inspection, nerformed in March of 1987, the licensee showed scfety con-
,
servatism by inspecting all snubbers, not just the two types required. NRC review
of the licensee's evaluation, which included test data and snubber disassembly and
repair records, found the testing and evaluations sound and conservative.
The licensee's eddy current testing (ECT) program was effective.
During In3ervice
Inspection (ISI) of the Unit 3 steam generators (SGs), the now standard method of
i
controlling ECT from a remote location effectively reduced radiation exposures.
Data analysis by two individuals who analyzed the same data increased the at~ rance
. _ . _.
_
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.
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-
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,
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.
16
-
,
1
that no defects were missed.
For differences in analysts' conclusions, a certified
Level III contractor examiner was used to make the determination. The SG ISI re-
sults were excellent.
The steam generators for Unit 3 are in the best inspection
category allowed by Technical Specifications since less than 5% of the total tubes
)
were degraded and no tubes were defective.
The licensee attributed these excellent
results to constant attention to steam generator chemistry control.
Eddy current testing was used by the licensee to detect incore thimble tube thin-
ning. Fourteen tubes had greater than C3% through-wall wear, and seven had 30%
to 50% through-wall wear.
The worst case tube was capped and the other tubes were
withdrawn slightly to take the worn area out of _the high vibration rcgion just
,
above the core plate.
Effective use of ECT allowed early detection of this problem.
Further evaluation of this problem is to be conducted after ECT during the second
refueling outage.
The use of In-Service-Tests (ISTs) to analyze equipment performance was a note-
worthy strength.
ISTs were well analyzed and professionally conducted, as was
evident by the IST done to identify the cause of a control bank not moving as re-
quired during routine surveillance.
This IST led to the replacement of a bad in-
strument card, correcting the problem with minimal impact on operation.
Contractors were used by the Instrument and Controls (I&C) department to perfora
some surveillance work and were trained to the same level as licensee technicians.
Contractor technician work was good with one notable exception. A contractor I&C
,
technician pulled a fuse in a solid-state protection system (SSPS) cabinet in which
he was not trained.
(This is further discussed in Area IV.J, Training Effective-
nest.) The resulting loss of low temperature overpressure protection (LTOP) sys-
tems and the overpressure transient, though mitigated by operator action, demon-
strated a need fur more stringent control of surveillances and work activitias.
In this case, the surveillance procedure also was inadequate because it did not
specify the proper steps for disabling the low temperature interlock (P-12) to the
steam dump system. After this transient, the licensee committed to restrict main-
tenance and sorteillance of complex systems such as the SSPS to specifically
- qualified technicians. The licensee also emphasized the need for better oversight
and a more formal review of work ac.tivities by qualified peers and first line
supervisors.
Corrective ar.Unos were positive and focused on providing better
control of surveillances anc werk activities.
In summary, the surveillance program is sound overall, but administrative problems
have continued to detract from overall performance.
Imp-oved technician perform-
ance and better control cf work on complex systems is needed.
Excellence was noted
in the performance of the great majority of surveillances, but the continuing
,
problems indicate that past corrective actions have not been effective enough.
IV.D.2.
Conclusion
Category 2.
,
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.
17
.
IV.0.3.
Board Recommendations
,
Licenge:
Reduce the number of inaccurate, late and missed surveillances.
--
Schedule a meeting with the NRC early in 1989 to discuss effectiveness of
--
surveillance program corrective actions.
11RC:
-- Perforc; a mid-SALP period assessment of adequacy of surveillance performance.
1
l
!
--
.
.
.
._
..
. _ -
1
-
I
'
18
.
l
IV.E.
Eme geng_ Preparedness (N Hours,1%)
IV.E.1.
Anaijsis
During the previou; assessment aeriod, licensee performance in this area was rated
Category 1.
That rating was ba;ed on observation of a full participation exercise
which included the ingestion pathway resuits of a routine safety inspection, and
on licensee support of ofisite activities in response to a hurricane warning.
During t%e current assessment period, there was one routine safety inspection and
observation of a fu!1 participation exercise for Millstone Unit 2.
Emergency Pre-
pa. redness is a site function and the Emergency Plan as well as Emergency Response
Facilities are common to all three units.
Qualified Emergency Response Organiza-
tian personnel are drawn from any unit and respond to an incident at any Millstone
unit.
Routine safety inspection indicated that the Emergency Plans and Emergency Plan
Implementing Procedures were current, and were reviewed and approved per procedures.
Emergency Response Facilities were maintained ready, as evidenced by satisfactory
checks of communications systems, instrumentation being functional and calibrated,
and plans and procedures being current. An Emergency Preparedness Training Manual
has been developed, reviewed, approved, and placed in use.
That Manual states
t
Emergency Preparedness Training policy, lists Emergency Response Organization
positions and associated qualifications, required training for each position, and
set the requalification period.
The procedures for accident classification have
been revised and incorporate human factors engineering principles. A review of
these indicate they aeet 10 CFR 50.47(b)(10) requirements, and that accident clas-
sification is based on plant status in keeping with NRC guidance. A review of
audit procedures intended to meet the requirements of 10 CFR 50.54(t) indicated
some minor improvements were needed: auditors needed an improved knowledge of
Emergency Preparedness requirements and procedures; procedures or guidelines for
preparing audit checklists needed to be developed; and documentation was needed
to demonstrate compliance with the requirement to make available to State and local
governments the results of licensee gcVernment interfaces, and an offer needed to
be made to review Emergency Action Levels with offsite authorities.
The annual exercise was observed on October 7-9, 1987 with one minor weakness .neted.
Accidents were classified promptly and correctly, offsite notifications were made
within the required time, Protective Action Recommendations were developed, the
Offsite Based Information System was available and functioned satisfactorily, pro-
jacted doses and dose commitments were performed frequently and differences between
corporate and site were quickly resolved, operation of the Post-Accident Sampling
System was demonstrated with very knowledgeable personnel, and response team ac-
tions showed the results of effective training.
The licensee has developed and maintains a sound Emergency Preparedness Program
as evidenced by very good exercise performance, well maintained Emergency Response
'
Facilities and a satisfactory working relation with offsite authorities.
'
,_._ - ~ _ _
--_,,
.
_ _ _ _ _ _ _
._ -
.
..
.
.
.
19
.
IV.E.2.
Conclusion
Category 1.
IV.E.3.
Board Recommendations
None.
,
3
k
i
_
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
-
. - .
.
20
.
IV.F.
Security and Safeguards (63 Hours, 3*4)
.
IV.F.1.
Analysis
During the previous SALP, Millstone 3 performance was Category 1.
That rating was
largely influenced by the timely completion of the Unit 3 security systems and
equipment and integration of those with the existing systems and equipment for
Units 1 and 2, while still maintaining an effective security program.
During this
assessment period, routine inspections by the Resident Inspectors continued
throughout the period.
Two routine and two special unannounced physical security
inspections were performed at the Millstone Nuclear Station (Units 1, 2, and 3)
by region-based inspectors.
Region-based security inspections were performed for
the integrated site (Units 1, 2, and 3) and it is not practicable to separate the
units for assessment purposes.
The same comments and assessments that were men-
tioned in the Units 1 and 2 SALP (SALP Report 50-245/86-99 and 50-336/86-99) were
repeated here if the inspections were current to this SALP period.
The added com-
ments reflect changes occurring during the past six months.
Corporate security management involvement in site security program matters was
apparent early in the period.
There were visits to the site by the cornorate steff
to provide assistance, program audits, and direct support in the budgeting and
planning processes affecting program modifications and upgrades.
Corporate secur-
ity management personnel were actively involved in the Region I Nuclear Security
Association and other industry groups engaged in nuclear plant security matters.
This demonstrated program support from upper level corporate management.
However,
an apparent reduction in the oversight and audit Tunction occurred as a result of
the loss of two key corporate personnel during the period, as discussed in the
following.
During the previous assessment period, the licensee was heavily involved in inte-
grating the Millstone Unit 3 security program into the existing programs for Units
1 end 2.
This was accomplished with minimum impact on the overall security program.
The licensee decided that, with the integration of the program, modifications to
and rest *ucturing of the proprietary and contract organizations would be necessary
to acccamodate the increased workload. While that decision was made in late 1985,
the licensee did not start acting upon the decision until late 1987.
Several pro-
prietary supervisory positions to which the licensee had committed were filled on
a rotating basis without ensuring that the incumbents understood their duties and
responsibilities, and without properly monitoring these individuals' performance.
Therefore, the majority of the identified increased workload remained the respon-
sibility of one person on site. As a result, effective oversight, interface and
communications between the licensee and the contractor organization began to de-
,
'
grade.
Concurrently, it appears that a complacency with program implementation
and an insensitivity to NRC requirements began to occur.
These conditions were
identified during an NRC inspection in August, 1987.
That inspection resulted in
i
the assessment of a civil penalty on the integrated security program. While the
individual violations were of low significance, they represented a significant
'
.
lapse in management attention to, and control of, the security program at Millstone.
Five violations were identified during physical security inspections and were
aggregated under the November 1987 civil penalty.
Several of these violations had
J
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.-
..
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- - -
- _
~ .
--
_
_
__
_
_
_
__
.
21
.
existed for an extended period and should have been obvious to knowledgeable and
attentive licensee security personnel. Additionally, several of the violations
were attributed to the licensee's oversight of the contractor's security force and
to the training and attentiveness of the security force.
To increase the effec-
tiveness of their oversight of the contract guard force activities, the licensee
filled all vacant positions during the last half of the Unit 3 SALP period.
Seve-
ral more positions were created and filled as well. Members of the security force,
as well as lictnsee line supervision, patrol the site frequently and should be
alert for deficiencies.
The annual audit of the security program by the licensee's quality assurance group
appeared to be comprehensive in scope and depth. However, the number of violations
identified by the NRC, several of which.had existed for a lengthy. period of time,
called into question the effectiveness of those audits relative to NRC security
objectives.
Late in this assessment period, the licensee strengthened the corpor-
ate security staff and began performing comprehensive audits as they had during
prior assessment periods.
In addition, the licensee submitted a recurity plan
amendment clarifying the audit functions of the NUSCO Quality Services Group with
regard to the annual audit of the security program to increase.their effectiveness.
In March of 1988, region-based inspectors conducted a comprehensive security pro-
gram review and determined that all previous unresolved items and violations had
been adequately addressed and corrective actions taken were effective to prevent
recurrence.
Ferther, no additional violations of NRC-approved security plans were
observed.
The licensee took strong, positive action to not only provide adequate
follow-up on past issues, but initiated several significant actions to enhance the
effectiveness of the security program.
This turn-around in direction and hands-on participation by senior management re-
sulted in a total security system upgrade, new administrative offices and classroom
facilities for the security force contractor, additional patrol vehicles and the
establishment of a sacurity review committee to review changes to security plans,
procedures, and other security related records. These actions required large
capital expenditures and demonstrated the licensee's desire to have a high quality
and effective security program.
Further, the licensee mobilized the resources of all essential plant operations
j
in preparation for a forthcoming NRC Regulatory Effectiveness Review (RER). As
'
of the most recent security inspection, the licensee had completad about 60% of
the voluntary upgrades identified by this effort.
This further demonstrated the
licensee's desire for an effective security organization and their responsiveness
to NRC concerns and initiatives.
At the end of the assessment period, the security union's bargaining unit personnel
went on strike.
Ur. ion members of the contract security force walked of fsite af ter
being properly relieved by a pre-trained strike contingency security force. An
NRC follow-up inspect an found that the picketing by contractor security personrel
d
was orderly and peaceful . All required security posts were manned, the required
.
-
.
-
-
_,
___ .
.
. . .
- . - -
-
. -
. - . -
. .
-
.
- -
a
t
->
.
s
22
.
response force was available, and all necessary compensatory measures were in place.
The walkout preplanning demonstrated that the licensee had the capability to manage
a major event that could have a significant impact on the quality and effectiveness
of facility security.
Review of the licensee's security event reports and reporting procedures found them
consistent with the NRC's regulation (10 CFR 73.71) and implemented by personnel
knowledgeable of the reporting requirements.
The reports were clear and contained
sufficient information for NRC assessment.
Licensee actions following each of the
events were prompt and appropriate.
Twenty-five reports were received during the
ascessment period.
Ten of these were attributed to security force personnel errors
which indicated a need for improved training.
The remaining events were not
causally linked.
Staffing of the contractor's security force appeared adequate.
The training and
requalification program was sound and well-developed, but because of the problems
identified during this assessment period, it needs to be reviewed for fundamental
weaknesses along with the manner in which it is being implemented.
During the assessment period, the licensee submitted four revisions to the Mill-
stone Nuclear Power Station Security Plan and two revisions to the Guard Training
and Qualification Plan under the provisions of 10 CFR 50.54(p).
The plan changes
were of good quality and indicated knowledge and understanding of NRC security
program objectives.
The licensee's security program, when properly implemented, is sound as evidenced
by the licensee's past performance record.
During the first half of this assess-
ment period, ineffective control of the integrated security program was evident
in the multiple violations of the approved security program.
During the last half
of this assessment period, the licensee actively pursued a program to correct all
deficiencies, fill all vacancies, increase oversight of the contract guard force,
-l
and increase the effectiveness and scope of the audit program.
Follow-up NRC re-
'
view of licensee corrective actions found very good correction of problem aspects,
l
plus several significant enhancements to increase the effectiveness of the security
program.
The licensee's physical security program is improving.
In summary, while substantive problems were identified earlier in the SALP period,
later assessment of the corrective actions and effective planning and management
of the security function during a strike indicated much better performance.
Ef-
j
fective continuation of this trend could restore the performance rating to its
previous high level.
'
IV.F.2.
Conclusion
Category 2, Improving.
IV.F.3.
Board Recommendations
None.
1
%
- - - - - - . -
.
. -
. - - -
.
23
.
IV.G.
Outage Management (272 Hours, 11%)
IV.G.1
Analysis
Outage management was evaluated as Category 1 in the last SALP.
Strengths were
'
noted in planning, scheduling, and overall conduct of outages. Minor .wea knes ses
were noted in tagging and the control of maintenance, leading to Mode 3 being
entered with a hot leg injection valve tagged shut.
As discussed in Area IV.A, Plant Operations, configuration control continued to
be a problem during the current period.
On two separate heatups, Mode 3 was en-
tered without the required full complement of safety equipment.
There were two unplanned outages, and one planned and one refueling outage.
The
unplanned outages were short (less than 2 weeks) and resulted when recoveries from
'
plant trips were delayed to perform maintenance. Management at the unit and da-
partroent head level proved very capable at adapting to rapidly changed conditions
to support these unplanned outages.
Department heuds quickly provided unplanned
shutdown work lists and generated detailed hourly work breakdowns for major acti-
vities.
Licensee management used unplanned shutdown time to accelerate work on
committed repairs and modifications.
Cooperation was strongly evident at ail
'
levels of management when scheduling and planning tasks and at the grass roots
level when performing work.
Unplanned outage duration was effectively limited in
'
length by aggressively prioritizing and completing work.
The first refueling outage was also well planned. Outage meetings were held at
frequent intervals in the year prior to the outage.
Planned activities were
sequenced in the licensee's sophisticated "living schedule" system.
That system
was used to generate a master outage schedd complete with bar charts, a sensi-
tivity analysis for each task that might impact the critical path, and logical ties
between tasks.
The schedule received senior and supervisory management reviews
and modifications prior to outage commencement.
Twice daily during the refueling
outage, an expanded time-base printout of the current three-day window, including
all recent updates to the master schtdult was provided to all supervisurs during
a status meeting. These meetings were characterized by accurate assessment of work
in progress and resolution of conf'1 cts.
Tight controls over the schedule and
,
plant conditions were maintaired. Many potential problems were avoided by early
'
addressal. During these meetings, NRC observers noted a strong spirit of coopera-
tion and a very positive atti.ude toward nuclear safety and high quality pceform-
ance.
Refueling outage planning was set back when foreign objects were discovered on
the lower core plate on November 17, 1987. These were locking cups for hold-down
bolts for the reactor coolant pump (RCP) internals.
The need to remove and iden-
tify these obj cts required a coinplete core off-load.
Subsquent work extended
the refueling outage for six weeks. The licerisee shortened the initial expected
duration of 12 extra weeks to 6 by effective use of a "Living Schedule."
Inspector
,
observations found that the actual performance of work was timely and safety con-
.- ,
-
-
---
, . - _ - , -
- . . _ _ . , , - - . . . , - - _ . . - - .
.
24
scious. The use of an actual RCP as a mockup substantively improved work sequenc-
ing and timeliness.
Licensee control of refueling outage activities was otherwise
strong as well.
In summary, control of outage activities was a noted strength.
The twice daily
meetings and use of the "Living Schedule" allowed excellent control and management
of outages.
IV.G.2.
Conclusion
Category 1.
IV.G.3.
Board Recommendations
None.
.
-
_
.
- _ _
- _ _ .
.
25
.
IV.H.
Engineering Support (209 Hours, 9%)
IV.H.1.
Analysis
Engineering Support was a new area for the last SALP and was rated as Category 2.
This area encompasses technical and engineering support activities provided by
onsite and offsite organizations to the line departments.
It also incorporates
line department activities that support operations, maintenance, surveillance and
other technical organizations.
In the previous SALP, recommendations were made to the licensee to resolve issues
requiring engineering attention.
The cited issues were: steam generator (SG)
feedwater flow oscillations; elimination of illuniinated control board annunciators;
power-operated relief valve (PORV) internal leakage problems; and main steam valve
building heating and cooling problems. All of these issues were addressed by the
licensee.
The SG feedwater flow oscillation (and SG level control) problem was ameliorated
by a change to the SG condensate pot design implemented during the first refueling
outage.
Installation of a high pressure tee and straightening of the condensing
line corrected the 10% level oscillation that had been observed between 55% and
65% power.
Testing and operation confirmed that the design changa corrected the
l
oscillation problem. A significant reduction in scram frequency from feedwater
oscillations has since been seen.
i
A total review of annunciators illuminated during power operation was completed
!
in 1037. At the end of the Cycle 1 refueling outage, all but 18 of the identified
annunciators had been permanently corrected.
As discussed in Section IV.A, Plant
Operations, completion of the annunciator reduction program has been delayed to
j
the end of the third refueling outage.
This delay is generally appropriate, but
continued engineering support is needed to address problem annunciators (radiation
monitor spiking) and to assure that the program is completed as expeditiously as
i
practicable.
.
When maintenance was performed on leaking PORVs, technical competence was evident
j
in the implementation of bench testing of the PORVs and the associated solenoid
1
valves. In addition, the use of 'langed joints on the PORVs was a coordinated de-
cisi m involving management, engineering and maintenance and was an example of
good decision making and technical planning.
The onsite and offsite engineering and technical support groups were very capable
and staffed with experienced, knowledgeable personnel. They were dedicated to
l
performing tasks correctly the first time.
Examples of support activities to im-
prove safety and reliability were conversion of the service water discharge valves
2
from a lined material to corrosion resistant materials, redesign of the feed pump
seal injection system to extend seal life, and shaving of the turning gear oil pump
impeller to eliminate pressure transients caused by securing the pump.
'T
i
.
. _ -
_
_ _ - __
__
.
.
_
. _ _ _ _ _ _ . _
.
_ _
. _
_
_
. . _ . _ _ _ _ _
_
._.
_ _ _ _
___
i
.
26
.
>
.
'
Two other engineering support activities were noted as being beneficial to opera-
tion.
These were the elimination of the reactor coolant system (RCS) resistance
temperature detector (RTO) bypass manifolds and the substitution of a hypochlorite
system for the existing gaseous chlorine system.
The removal of the RTL bypass
manifold will pay ALARA dividends in futureL outages.
Its removal has reduced the
'
outage radiation levels to 50*' of the previous levels.
The removal of the gaseous
chlorine system, used as a biocide in the concenser circulating water system, has
resulted in the last gaseous chlorine source being removed from Millstone Station,
i
This has allowed the removal of the chlorine monitoring requirement for control
j
room habitability. These modifications have enhanced Unit 3 operations.
Offsite corporate engineering support was evident but not always timely.
Both
plant engireering and corporate engineering dealt with the same engineering issues
at various times. This organizational relationship sometimes created conflicts.
The reliability of the Rosemount RCS flow transmitter
was an example.
Five fail-
,
ures of these transmitters occurred between March and October of 1987.
Since only
~
one failure occurred at a time, the trip functions of the flow instrumentation
'
remained operable. Af ter each failure the transmitters were replaced in kind.
No subsequent failures have been experienced.
Because of the frequency of these
failures with the same root cause, the plant evaluated the failures as a potential
substantial safety hazard reportable under 10 CFR Part 21 and forwarded their
i
findings to corporate engineering in November 1987.
Corporate engineering, after
'
contacting the vendor, disagreed with plint engineering.
Rosemount stated to cor-
porate engineering that there was an error in the manufacturing process but it had
,
already been corrected. Corporate engineering changed its position in March 1988
'
and the failures were then reported under 10 CFR 21.
Independent NRC~ followup
showed that this same failure mechanism was identified in prior transmitter fail-
ures at the J.A. FitzPatrick Nuclear Power Plant.
Corporate engineering's late
reporting of this problen unnecessarily delayed report dissemination to other
Rosemount users.
j
Two scrams in the period were caused by the failure of normally energized Skinner
solenoid valves for the feedwater system's containment isolation valves (CIVs).
3
The licensee also determined that an earlier, out-of period scram wes' due to this
solenoid's ma1 performance.
The original design uses high-wattage solenoids for
i
these fail-shut CIVs.
These solenoids have been shorting out with age. The lic-
i
ensee replaced the solenoids during the refueling outage and ordered new low-
wattage solenoids with an expected delivery date in November 1988.
Licensee ef-
forts to correct this problem have been reasonable. However, procurement delays
due to long lead times have hindered prompt correction.
2
In response to an allegation related to the seismic adequacy of the battery room
I
masonry walls, NRC review found a violation and a deviation.
Upon receipt of fur-
ther information from the licensee, the NRC concluded that the apparent deviation
was the result of an incorrect licensee assumption about the design requirements
of the masonry wc11s and that this represented an isolated oversight.
The battery
room walls were built to the same standards as the control building.
That was
,
[
i
'
!
'
'
"
,
.
l
'
,,,y-
r.-
. . ,--
,,m
--,-r,,._,7
,.
4
.c<_,_,_<
w+c.-
,-%
r-
ne,-..,,,+
..,---w
,-...,.e.e
i.-,.-,-n,,-,.-,-,-,,._#-,,W
-- m e r
. _ _ _ _ _
..
_
..
i
.
27
.
I
l
found to be adequate after detailed staff review of the licensee's reanalysis.
'
Although the walls were acceptable in the as-built condition, this event indicated
a need for attention to detail when implementing standards.
In the area of Environmental Oualification (EQ), the one inspection performed
during this assessment period identified multiple apparent violations.
The lic-
ensee's efforts to support the EQ inspection were only marginally. acceptable. At
the time of the inspection, the licensee was attempting to strengthen their staff
to upgrade the experience levels over that previously provided by contract person-
nel. Management involvement was evident in the response and participation of
management personnel with significant EQ issues.
NRC concerns raised over the
electrical EQ of Litton-Veam connectors elicited concern and an immediate response
l
from the licensee.
Cognizant personnel were gathered to discuss and address the
issue.
Engineering personnel quickly provided an analysis and a viable operation
justification statement. Management understanding, acknowledgement and concern
for public safety was evident in t;.e actions taken.
(The. enforcement considera-
.tions associated with this matter carry over into the next SALP period and will
therefore be considered in the next SALP report.)
Overall, the engittering staff did a good job c# supporting maintenance and sur-
vel'iance. Engint
ng support contributed to good and technically sound decisions
by plant manage -
alative to maintenance and surveillance activities.
l
IV.H.2.
Conclusion
Category 2.
l
IV.H.3.
Board Recommendations
l
Licensee:
!
Improve knowledge level of personnel implementing the EQ program.
Ensure high
--
level management attention is given to resolving EQ issues.
NRC:
None.
1
>
d
9
1
'
b
,
1
'
_
(,
I.
- i
>
.t
.
,'
_ - _ _ ,
-
_J
'
j.
-
+
.
28
.
IV.I.
Licensing Activities (No hours assigned)
IV.I.1.
Analysis
The previous SALP rated this area as Category 1 and r2 commended that the licensee
assure the accuracy of submittals to the NRC.
4
During this SALP pericd seventeen (17) license amendments and eightaen (18) other
licensing actions were completed.
These thirty-five (35) licensing actions in-
cluded the completion of licensee commitments, Cycle 2 reload, Resistance Tempera-
ture Detector (RTD) modification and Technical Specification improvements.
Licensee management has been aggressive in meeting commitments, promptly resolving
issues, and improving the Technical Specifications.
This attention resulted in
submittals that were mostly accurate and complete.
Frequent contacts, by meetings
or telephone, with the NRC licensing staff resulted in the prompt resolution of
issues and on satisfactory schedules for completion of licensing actions. Most
licensing actions were completed without requiring review on an exigent or emer-
gency basis.
Prompt management attention was provided to resolve issues associated
with providing overcurrent protective devices for containment electrical penetra-
'
tions, three loop operation, ATWS consideration in the Cycle 2 reload analysis,
and the improvement of licensee event reports.
The licensee submittals indicated a sound technical approach to resolving safety
issues.
They also indicated a good understanding of the safety issues, and pro-
vided technically sound proposals with reasonable justifications for resolution.
The licensee has been responsive to NRC initiatives.
Priorities and schedules
established for NRC initiativer were acceptable to both the staff and the licensee.
The licensee responded in a positive and tinely manner to provide information for
the Safety Issues Management System (SIMS), for consideration of Anticipated
Transients Withcut Scram (ATWS) in their Cycle 2 reload analysis, and for resolu-
tion of long standing issues associated with the Safety Parameter Display System
(SPDS), the Nuclear Review Board Quorum, the vendor information program for certain
safety related components, and the cleaning of feedwater venturis.
The quality of the licensee's submittals has improved; however, inaccuracies still
existed in a few subnittals: (1) in the May 20, 1987 letter on Class.IE-Containment
Electrical Penetration Protection, the analysis did not satisfy the requirements
of 10 CFR 50.59 or 10 CFR 50.109; (2) in the March 24, 1937 letter on Containment
Systems Air Partial Pressure, the "no significant hazard" finding was not correct
because the proposed change created the possibil.ty of an unevaluated accident;
and (3) the Fearuary 25, 1988 letter regarding Steam Generator Low-Low Level Reac-
ter Trip Setpoint did not provide supporting analysis for the justification.
In
addition, the licensee subsequently informed the staff that certain errors were
not considered in the analysis.
Notwithstanding the above noted instances, the licensee's licensing staff was well
qualified and supported, as necessary, by a qualified technical staff.
Requests
for information were promptly responded to in conference calls, correspondence or
' '
!
V
. _ ,
,
s
R
i
(
,
_ _ _ _ _ _ _ _ _ _ _ _
-
-
.
29
.
meetings as deemed appropriate.
Responses were usually technically sound, had
appropriate management review and approval and were submitted on or ahead of
schedule.
In summary, licensee management was aggressive in providing prompt, accurate, com-
plete and technically sound responses that were oriented toward nuclear safety.
,
Licensing resources were ample and effectively used to achieve a high level of
l
l
performance.
IV.I.2.
Conclusion
i
,
Category 1.
'
!
IV.I.3.
Board Recommendations
Licensee: Continue the effort to assure accurate submittals.
l
l
NRC:
None.
-
-
- - _ _ _ -
.
. .-
.
_
_
.
____
l
.
!
30
.
IV.J.
TrainingandQualificationEffectiveness_(Noho_ursassigned)
?
IV.J.1.
Analysis
Training and Qualification 3ffectiveness, a new area in the last assessment period,
is also an evaluation criterion for each functional area.
This area is a synopsis
'
of the assessments in the other areas.
Training effectiveness has been measured
primarily by the observed performance of licensee personnel and, to a les.er degree,
i
through program review.
Durirg the last SALP, a Category 2 rating was assigned.
The plant specific simulator was a significant benefit in operator training and
k
was used to train managers as well.
The licensee developed an experienced training
staff with over twenty instructors, three quarters of whom maintained operating
licenses. There was a strong supervisory organization to manage the training staff.
Recent promotions of key in-house people within the training organization have
helped the licensee to strengthen an already strong organization.
,
The INPO Accreditation Self-Evaluation Report for the four Northeast Utilities
operator training programs was submitted by the licensee on November 1987. An INPO
accreditation team visited in late January 1988 and Millstone 3 programs were
accredited in April 1908.
(The Technical Training Programs had previously received
INP0 accreditation in the areas of instrumentation, health physics, chemistry,
mechanical and elect-ical maintenance, and technical staff and managers.) Thus,
INP0 accreditation is complete for Millstone 3 and the station as a whole.
With
this accreditation, Millstone 3 beccme a member of the National Academy for Train-
ing by virtue of the fact that they now have received accreditation for all ten
of the INPO accreditable programs at their site.
Completion of the total accredi-
tation process for all three units reflected strongly on the licensee's dedication
to training, especially since Millstone 3 was in the NTOL (near term operating
,
license) phase until late 1985.
Review of Millstone 3 programs did not occur u.itil
after full power license issuance because of other INPO accreditation commitments.
Thirteen candidates par-icipated in the two NRC replacement examinations admini-
'
stered during the assessment perioC
Of these, five candidates failed the written
and/or 7perating portior, of the exa>mation.
This is an overall pass rate of 61%
and a decline from the overall pass rate of 83% (43 of 57) achieved during the last
SALP period.
During the simulator portion of the examinations, the performance
of crews was inconsistent.
Some crews operated quite well together with good com-
munications and the ability to diagnose problems, whereas other crews were some-
times weak in communications and prvblem diagnosis,
l'our of the five individual
failures were based partly or solely on the operating portion of the examination.
Although the number of operators examined was relatively small, this indicated that
better screening of operators by the licensee may be needed prior to NRC exam
administration.
Cooperation between the plant and the training staffs har led to effective develop-
{
ment of programs to assist the operating staff in the preparation for complex tasks.
One example was a training ;>rogram soec111cally developed to address a positive
moderator temperature coef'icient (PMTC).
This program was given to all operating
j
i
. . - .
_
.
- . .
.
u
.
.
-
_ .
.
31
.
shifts and covered reactor start-up, low power operation, and selected malfunctions
on the simulator, permitting a successful startup after the first refueling with
no operational problems associated with PMTC.
Maintenance and I&C technician training programs were in place during this assess-
ment period.
NRC observations of these programs found that they were effective.
An inadequacy was noted in an I&C contractor technicians's training when he pulled
a fuse in a SSPS panel, causing a loss of LTOP protection and an overpressure
transient (see Area IV.0, Surveillance).
The transient was partially attributable
'
to the way the technician was trained to analyze system prints for the fuse pulling
evaluation and partially attributable on the inadequate emphasis on the SSPS-COPS
interrelationship during both operator and technician training.
These programs
now emphasize this interrelationship.
Further refinement of the review of drawings
before disabling equipment was established by the licensee.
The licensee imposed
restrictions to only allow specifically qualified technicians to work certain
panels.
Licensee Event Report (LER) review found that, of 58 LERs, 28 were due to personnel
error.
Personnel errors fell into three categories: lack of attentiveness, lack
of attention to detail, and inadequate training.
The majority of events were
caused by inattentiveness or lack of attention to detail.
Examples were failing
to restore cooling water lineup to the operable charging pump, fatiure to perferm
an engineering evaluation after replacement of a defective snubber, and failura
I
to perform a required Diesel generator fuel sample.
However, training in systems,
procedures and integrated plant response was generally effective: there was no
significant challenge to safety systems other than the overpressure event (analyzed
in Section IV.A, Plant Operations.)
It is apparent from the maintenance and surveillance activities observed during
the assessment period that Millstone 3 personnel are w il-trained and carry out
j
their jobs in a professional manner. A particular instance of this was maintenance
i
department identification of a problem while installing "handhole" covers on a
Even though the covers were installed per the procedure, the
workers questioned the end result.
Because of this, a procedure change was issued
'
to install the covers via an alternate method.
Their willingness to question the
outcome of a job indicated good training of the workers.
In summary, licensee training was a notable strength. The' licensee's commitment
to training was evident in enhanced training staffing with a high percentage of
i
experienced licensed operators and expenditure of considerable resources for
training. Operators were assessed as excellent performers on shift. Also, a high
level of operator and support personnel knowledge was consistently demonstrated.
Training was generally effec +1ve in providing well qualified personnel who con-
tributed positively to safe operation, but better licensee screening of operator
candidates is needed to increase performance or NRC exams.
i
.-
-
. . . . ..
-.
.
_
.
32
.
IV.J.2.
Conclusion
Category 1.
IV.J.3.
Board Recommendations
None.
.. . - . - . - . - _ . - .. - __ _..- - _.-_ _ .. ____ ,. .. _ __. _ __ - _. _ ____ .-._ _ . _ _ ..- _ _ __._. _ . _ _,___ _ _ ___ _ . a
.
.
.
33
.
IV.K.
AssuranceofQuality(NoHoursAssigned)
IV.K.l.
Analysis
Assurance of quality is addressed as a separate functional area even though it is
an evaluation criteria in other functional areas.
The licensee's quality assurance
program is in:leded, but this assessment primarily addresses the effectiveness of
licensee management efforts to assure quality in day-to-day activities. Worker
performance, attitudes, involvement by supervisors, and the adequacy and use of
management and administrative controls were used as performance indicators.
During the previous SALP period, observations found Millstone 3 personnel to have
a standard of completing assigned work correctly.
Thi; positive attitude was re-
peatedly displayed.
During the current S.t.LP period, workers and supervisors showed pride in their
workmanship and close attentien to detail was typically demonstrated.
Department
Heads were very knowledgeable of the status of work.
Plant personnel exhibited
a good attitude towards QA and adherence to procedures.
The individuals closest
to the work (operators, technicians, mechanics, electricians, engineers, etc.)
exhibited high personal performance standards and detailed knowledge of equipment
and procedures. Worker morale was observed to be high. Additionally, it wi ; clear
that management has imbued th? workers with a sensitivity for quality in the work
place.
Workers performing maintenance and surveillance activities exhibited good work
practices and brought concerns to the attention of their supervisors.
For example,
during the installation of steam generator "handhole" covers, mechanics performing
the job questioned the installation of the covers even though all the procedural
requirements were met. As a result, the covers were removed and reinstalled using
an improved torquing sequence.
This showed a concern for and attention to quality
workmanship by the "front line" personnel doing the work.
QA/QC personnel were found knowledgeable of the tests they were monitoring, as
observed during main steam safety valve testing.
QC inspectors were found to be
trained, qualified and certified to the level of their responsibilities.
Site
staffing levels were found adequate to support and normal operations, with head-
quarters and contractor personnel available as needed.
The licensee's QA/QC organizations performed effective surveillances and inspec-
tions and promptly identified problems to management for resolution.
Discussions
j
with QA/QC supervisors and QC inspectors and review of completed work packages
indicated sufficient QA/QC involvement with site activities. Maintenance instruc-
tions were clear and appropriate QC sign-offs were included in the QC inspection
plans for each job.
In addition to routine inspection hold points, corporate
engineering QA and plant engineering QA/QC groups performed audits, surveillances
and activity observations.
Concerns identified as a result of QA surveillances
and QC inspections were resolved in a timely fashion. Management was kept apprised
of appropriate findings and resolution of findings was effective.
-
_ _ _ -
--
. _ _ _ _
.
1
.
34
.
First line supervisors provided close oversight of work activities. Maintenance,
I&C, and Production Test supervisors were generally knowledgeable of the plant
design and station administrative requirements.
They were often observed to be
providing technical guidance and oversight to workers at the work site.
Further,
Shift Supervisors demonstrated that they were generally knowledgeable of plant
activities and that they were managing activities and shift personnel on an as-
needed basis except in one instance regarding insufficient staffing for feedwater
control during startup (see Area IV.A, Plant Operations).
Plant Operation Review Committee (FORC) performance was very good. Meeting inputs
were well prepared and showed a clear understanding of issues.
The approach to
problem resolution was technically sound, very thorough, and routinely conservative.
Root causes of problems were actively pursued.
During meetings and in NRC discus-
sions with higher level managers, there was a licensee willingness to deal with
difficult issues and an atmosphere of healthy self criticism. A conservative
approach to safety was demonstrated by operating departments in the resolution of
problems and routine activities.
This was demonstrated in the Spring 1987 outage
for snubber work and, more recently, in troubleshooting to investigate and correct
the failure of a control bank to move.
There was a high regard for meeting regu-
latory requirements and commitments.
Site management was effective in establishing
nuclear and personnel safety as well as efficiency as a prime operating goal.
During revies of pincedures for testing of the containment penatratiun overcurrent
protection devices, the NRC noted that some procedures contained over thrse changes.
Licensee procedures require that, af ter three changes, the changes be incorporated
as a revision.
This particular problem was previously icentified by the licensee
in a QA Surveillance Report. At the time of inspection, the licensee stated that
the backlog of procedure revisions should be eliminated by June 1988.
The licen-
see's method for updating procedures and the manpower associated with the task
along with management attention and support of the update program may not be suf-
ficient since, as of the SALP Board meeting, 74 procedures needed revision because
they contained three or more changes. The licensee Otiled to meet their goal of
zero backlog by the end of the second quarter of 1988.
NRC inspections observed that corporate management was routinely involved in plant
activities. The licensee has successfully implemented a tracking system (con-
trolled routing) to assign corrective actions to responsible individuals for meet-
ing NRC and other commitments. The use of controlled routings as a tracking tool
for meeting commitments was a notable strength.
Corporate management responsiveness was demonstrated by their addressal of NRC
staff concerns with the environmental qualification (EQ) of Litton-Veam connectors.
The ability of the connector's internal silicone rubber gasket to be leak-free over
plant life was the focus of tae issue.
The ouestnonable EQ of these connectors
was attributed to licensee control of EQ during construction. During this SALP
period, licensee review of the design attributes allowed the NRC staff to evaluate
the connectors as posing no immediate hazard.
Connector replacement is scheduled
during the next refueling outage.
_ - _ _ _ _ _ _ _ _ _ _
-..
..
--
.
.
.
. .
.-
-.
.
35
.
Another example of a sound licensee f.pproach-to problems involved their actions
when foreign objects were disccyered on the lower core plate on November 17, 1987.
These objects were locking cups for hold-down bolts for the reactor coolant pump
' (RCP) internals.
The decision to completely off-load the core to remove and iden-
tify these objects was a prime example of the licensee's safety conscious approach.
Subsequent work extended the refueling outage for six weeks.
The licensee cut the
initial expected duration of 12 extra weeks in half by effective use of a "Living
Schedule." Use of a spare RCP as a mockup substantively improved work sequencing
and timeliness.
Licensee control of other refueling activities was equally strong.
Additional licensee attention to the timeliness of 10 CFR 21 reports was needed.
Oil leaks from the internal diaphragm of Rosemount transmitters was reported under
10 CFR Part 21 on March 24, 1988.
Five transmitter failures between March and
October 1987 were due the same root cause.
Inability of the licensee's corporate
engineering staff to obtain a complete historical record of the transmitters sig-
nificantly contributed to the delay in initiating the part 21 report.
Prompt re-
porting of this issue would have allowed other Rosemount users to benefit from the
licensee's experience (see Section IV.H., Engineering Support).
In summary, b6th licensee management and staff were committed to high quality in
operations. There was effective implementation of the formal QA/QC function and
solid support of operations and related activities. Management exhibited a con-
servative and safe approach to performing surveillances and exercised good judge-
ment in decision making and technicai nianning of maintenance. A high level of
concern and attentioa to quality work was strongly evident from the working level
to station management.
Programs were established to bring abnormal results to the
attention of supervisors and management for resolution. Changes to procedures were
underway to ensure th;t shey were current with respect to industry information and
NRC requirements.
Increased licensee sensitivity to the timeliness of 10 CFR Part 21 Reports and the backlog of procedure changes were was the only noted problems.
IV.K.2.
Conclusion
Category 1.
IV.K.3.
Board Recommendations
Licensee: Resolve the procedure change backlog problem.
NRC:
None.
.
..
. .
.
.
.
'
36
-
.
V.
SUPPCRTING DATA AND SUMMARIES
V.A. Investigation and Allegation Review
Battery walls did not meet seismic design criteria.
This allegation was sub-
--
stantiated. A violation and deviation were issued.
The licensee's response
justified-their design as equivalent to that used for the control building.
This was found acceptable by che NRC staff.
A foul smell was emanating from radioactive releases from the site.
This
--
allegation was unsubstantiated.
--
Widespread illegibility of certified material test reports (CMTRs) associated
with Millstone 3 purchase orders.
Two out of 450 CMTRs sampled were found
illegible during NRC follow-up; this allegation was unsubstantiated.
V.B. Escalated Enforcement Actions
Civil Penalties
--
$25,000 - IR 87-22, Physical-Security
550,000 - IR 88-03, Low Temperature Overpressure Transient
--
V.C. Management Conferences
November 3, 1987 at the Region I Office: to discuss station security viola-
--
tions.
Mar:h 8, 1988 at the Region I Office: to discuss a low Temperature Overpres-
--
se c transient.
V.D. Licensee Event Reports
V.D 1.
Tabular Licensing
Type of Events
A.
Personnel Error
28
B.
Desigr/ Mfg / Construction / Install Error
8
C.
External Cause
0
0.
Defective Procedure
10
E.
Component Failure
13
X.
Other
0
_
TOTAL
59
A tabulation of Licensee Event Reports (LERs) by functional area, and an LER
synopsis, is attached as Table 3.
I
!
.
,
,.m_
y-.
--t-+yw.+e7"""7-- " - - " "?
"-*-"'"
W"*'--*-
--T*W
'I
- W'#'
"Fi" 9
. _ _ - - - - _ _ _ _
.-..
..
.
..
..
. .. ..
.
.
h
37
.
Licensee Event Reports Reviewea
LER Nos. 87-08 through 88-15
V.D 2.
Causal Analysis
Millstone 3 LERs were reviewed to determine if causal links could be established,
The LERs reviewed were 87-08 through and including 88-15. These LERs are inclusive
of the SALP period (3/1/87 - 5/31/88).
Some supplemental LERs ware published by
the licensee during the period as their investigation was completed and were re-
viewed as the sole source writeup on a given event since they provided the most
up-to-date information.
LERs were reviewed with the intent of establishing causal
links, if appropriate, to events that were due to the malperformance of a procedure,
an individual, a department, a program or other commonly related items. Where
events were the result of isolated failure or deficiencies, no causal link was
established.
LERs 87-21, 87-25, 87-37, 88-09 describe reactor trips that resulted from inade-
quate integrated control of SGWLC (Steam Generator Water Level Control), steam dump
and rod control systems.
SG level oscillations were compounding the control prob-
lem between 55% and 65% power due to faulty design of t e level condensate pats
h
(see LER 87-22).
The frequency of these events is ds- .asing and the replacement
of the condensate pots with high pressure tee fittings has eliminated the level
oscillations at 55%-65% power.
LERs 87-12, 87-35, 87-39, 87-40, 87-42, 87-44, 87-45, 87-46, 87-50, 87-51, and
88-11 document the malperformance of required surveillances. Generally, the prob-
lems cited were administrative, with one notable exception being late or missed
surveillances.
Such a problem was identified in the last SALP as due to the tardy
development of procedures to implement the Tachnical Specification surveillance
p rog ram.
The continually large number of problems in this area indicates a need
for further management attention to surveillance.
LERs 87-29, 87-48, and 88-12 describe events where fire w'atches were not estab-
l
lished as required when breaching a fire barrier or intentionally disabling sup-
pression systems.
LERs 87-30 and 88-06 document events where mode changes were made inadvertently
or without a full complement of safety equipment,
The licensee's internal Plant
Incident Reporting system has also documented mode changes without a full comple-
ment of safety equipment.
-
_ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _
.
38
.
V.E. Licensing Activities
V.E.1.
NRR/ Licensee Meetings
3/27/87
Shutdown in advance of severe weather
6/2-3/87
Inservice testing program for pumps and valves
7/7/87
Interlocks for three loop operation
8/5/87
Safety Parameter Display System
9/1/87
Cycle 2 Reload and RTD Modifications
4/25/88
Safety Parameter Display System
V.E.2.
NRR Site Visits
5/20-22/87
Orientation
10/13-16/87
Review 50.59 changes (1986)
4/11-15/88
Review 50.59 changes (1987)
V.E.3.
Reliefs Granted
ASME Boiler and Pressure Vessel Code - Section XI and Applicable Addenda: 29 relief
requests granted related to inservice testing of pumps and valves.
V.E.4.
License Amendments Issued
AMENDMENT
SUBJECT
DATE
2
Engineered Safety Features Atmosphere Cleanup System
4/7/87
3
Engineered Safety Feature Response Time for Low
4/9/87
Steamline Pressure
4
Diesel Generator 18-month Inspection Schedule
5/13/87
5
Containment Purge SL,. ply and Exhaust Isolation Valves 6/15/87
Leak Test Interval
6
Organization Change - Station Services
6/15/87
7
Reactor Coolant Loops Operating During Hot Shutdown
7/9/87
8
Reactor Trip Bypass Breakers
8/7/87
l
i
_ _ _
_-_____
-
.
39
.
V.E.4 (CONTINUED)
AMENDMENT
SUBJECT
DATE
l
9
Control Cuilding Inlet Ventilation Signals
8/21/87
10
Diesel Generator Startup Time
8/24/87
11
Main Turbine Control Valve Test Interval
9/30/87
12
Cycle 2 Reload
1/20/88
13
Instantaneous Trip Element Surveillance Tests
1/20/88
14
Chlorine Detection System
2/16/88
15
Nuclear Review Board Records
2/23/88
16
Snubber Sample Plans
4/7/88
17
Reactor Coolant System Leakage Systems
4/18/88
18
Reactor Coolant System Vent Area for Cold
5/19/88
Overpressure Protection
i
_
_ - _ _ - _ _ _ _ _ __
____ _ _ _ _ _ _ _ - _ _ _ _
--
1
.
1
.
TABLE 1: INSPECTION HOURS AND REPORTS
TABLE 1A: INSPECTION HOUR SUMMARY
AREA
HOURS
% OF TIME
PLANT OPERATIONS
1021
42.1
RADIOLOGICAL CONTROLS
334
13.8
MAINTENANCE
317
13.1
SURVEILLANCE
136
5.6
EMERGENCY PREP.
34
1.4
SEC/ SAFEGUARDS
102
4.2
OUTAGE MANAGEMENT
272
11.2
ENGINEERING SUPPORT
209
8.6
TRAINING EFFECTIVENESS
0.0
ASSURANCE OF QUALITY
___
0.0
TOTALS:
2425
100.0
- The inspection hours for these composite assessments are incorporated in the other
8 functional areas listed in this table.
Note: The Licensing Activities functional area is not a direct inspection activity
and no inspection time is accumulated in this area.
TABLE 18: SYNOPSIS OF INSPECTION REPORTS
REPORT /
TYPE OF
DATES
INSPECT,
HOURS
DESCRIPTION
87-05
RESIDENT
110
SHUT 00WN PLANNING, PLANT OPERATIONS, RADI-
2/18-3/16/87
ATION PROTECTION, SECURITY, FIRE PROTECTION,
SURVEILLANCE AND MAINTENANCE
87-06
SPECIALIST
2
SOLID RADWASTE CLASSIFICATION, HANDLING
3/9-13/87
AND TRANSPORTATION, ENVIRONMENTAL MONITOR-
ING, AND RADI0 CHEMISTRY QUALITY CONTROL
87-07
SPECIALIST
57
EXTERNAL AND INTERNAL EXPOSURE CONTROLS,
'
3/26/87
FACILITIES AND INSTRUMENTATION, TRAINING
AND OUTAGE ALARA
87-08
RESIDENT
121
SHUTOOWN PLANNING, PLANT OPERATION, RADI-
3/17-5/11/87
ATION PROTECTION, SECURITY, FIRE PROTECTION,
SURVEILLANCE AND MAINTENANCE
87-09
SPECIALIST
74
MAINTENANCE ORGANIZATION AND IMPLEMENTATION,
3/30-4/3/87
TRANSFORMER PROGRAM, TRENDING
T-1-1
-_
__ - __ _ _ - - _ _ - _
_
._.
_
.
.
_
.
Table 1
2
.
' REPORT /
TYPE OF
DATES
INSPECT.
HOURS
DESCRIPTION
87-10
SPECIALIST
36
SNU38ERS, PORVS, MSIVS, CONTROL ROOM PRES-
5/4-8/87
SURIZATION SYSTEMS, SURVEILLANCE DATA
87-11
SPECIALIST
9
WHOLE BODY COUNTING PROGRAM
5/18-20/87
87-12
RESIDENT
196
SHUTDOWN PLANNING, PLANT OPERATIONS,
5/12-7/10/87
RADIATION PROTECTION, SECURITY, FIRE PRO-
TECTION, SURVEILLANCE AND MAINTENANCE
87-13
SPECIALIST
1
6/29-7/2/87
87-14
SPECIALIST
12
RADIATION PROTECTION, STATION AUDITS, AND
7/6-10/87
HOT PARTICLE PROGRAM
87-15
SPECIALIST
61
SEISMIC ADEQUACY OF THE MASONRY WALLS
6/8-25/87
AROUND BATTERY ROOMS
87-16
SPECIALIST
0
NRC EXAMINATION OF SIX SENIOR REACTOR
8/17-21/87
OPERATOR CANDIDATES
87-17
RESIDENT
201
ACTIONS ON OPEN ITEMS, SECURITY, PLANT
7/11-9/21/87
OPERATIONS, ALLEGATION RI 87-A-65 (CERTI-
FIED MATERIAL TEST REPORTS)
87-18
SPECIALIST
43
SECURITY AND SAFEGUARDS
8/31-9/4/87
87-19
SPECIALIST
17
OPEN ITEMS IN POST-ACCIDENT SAMPLING,
9/14-17/87
MONITORING AND ANALYSIS.
87-20
SPECIALIST
33
EMERGENCY PREPAREDNESS AND OBSERVATION OF
10/7-9/87
LICENSEE'S ANNUAL EMERGENCY EXERCISE
j
87-21
RESIDENT
133
PLANT OPERATIONS, SECURITY, LER REVIEW,
9/22-11/2/87
COMMITTEE ACTIVITIES
'
87-22
(REPORT CANCELLED)
87-23
SPECIALIST
0
EXAMINATION REPORT
6/12/87
.,
T-1-2
o
- . - - -
, , . - . - - . , - - , ,
- - - - , .-
. - + , - , . . _ _ - ,
.,,,,,.nn.,
, , - - , , ,
,,,-c,
, -
.m,-,-,
. - - - - - . - , , . . - - -
. _ _ _
.
l
l
.
Table 1
3
1
.
REPORT /
TYPE OF
DATES
INSPECT.
HOURS
DESCRIPTION
87-24
RESIDENT
179
OUTAGE ACTIVITIES: FOREIGN OBJECTS ON LOWER
11/3-12/7/87
CORE PLATE, ABNORMAL RWST AND RCS S0DIUM,
MAINTENANCE AND SURVEIL'_ANCE
87-25
SPECIALIST
37
GASEOUS AND LIQUID EFFLUENTS
11/16-20/87
87-26
SPECIALIST
37
ECCS SURVEILLANCE AND ACTIONS TO IMPROVE
11/16-20/87
IMPROVE REACTOR TRIP BREAKER RELIABILITY
87-27
SPECIALIST
63
REVIEW RAD PROTECTION ACTIVITIES ASSOCIATED
11/16-20/87
WITH THE UNIT 3 OUTAGE
87-28
SPECIALIST
0
EXAMINATION REPORT
12/14-18/87
87-29
SPECIALIST
21
SG EDDY CURRENT INSPECTION, WATER CHEMISTRY
11/30-12/4/87
CONTROLS, RADIATION CONTROLS
87-30
RESIDENT
90
SHUTDOWN PLANNING, PLANT OPERATIONS, RADI-
11/25/87-
ATION PROTECTION, PHYSICAL SECURITY, FIRE
1/15/88
PROTECTION, SURVEILLANCE AND MAINTENANCE
87-31
SPECIALIST
8
SURVEILLANCE OF COMPLEX SAFETY-RELATED
11/30-12/4/87
SYSTEMS, INPLANT INSTRUMENT CALIBRATION,
MEASURING AND TEST EQUIPMENT
87-32
SPECIALIST
56
NONRADI0 LOGICAL CHEMISTRY PROGRAM AND
12/14-18/87
ANALYTICAL PROCEDURE EVALUATIONS
87-33
RESIDENT
118
OUTAGE DECAY HEAT REMOVAL, UNEXPECTED
12/8/87-
SAFETY INJECTION, SNUBBER FAILURES
1/19/88
87-34
SPECIALIST
10
SOLID RADWASTE AND TRANSPORTATION PROGRAMS
12/7-11/87
88-01
SPECIALIST
5
RADIATION PROTECTION DURING THE OUTAGE
1/12-15/88
88-02
RESIDENT
123
OUTAGE ACTIVITIES, SURVEILLANCE, SECURITY,
1/20-2/22/88
T-1-3
.
_ _ _ _ _ _ _
. , _
_ _
.._
._
_.. .
_
_ _
>
Table 1
4
.
. REPORT /
TYPE OF
DATES
INSPECT.
HOURS
'OESCRIPTION'
'
88-03
RESIDENT
66~
INOPERABILITY OF REQUIRED REACTOR COOLANT
1/19-29/88
SYSTEM OVERPRESSURE PROTECTION FEATURES
88-04
SPECIALIST
153
ENGINEERING-SUPPORT
3/14-18/88
88-05
RESIDENT.
132
. PLANT OPERATIONS, EQ OF FLOW TRANSMITTERS,
2/23-4/4/88
OVERTEMPERATURE DELTA-T SPIKING, MAXIMUM
.
REACTOR POWER DETERMINATION, PLANT INFOR-
!
MATION REPORTS, SECURITY
88-06
SPECIALIST
26
SECURITY INSPECTION
3/28-4/1/88
88-07
SPECIALIST
37
RADIATION PROTECTION ACTIVITIES
4/15/88
88-08
RESIDENT
158
PLANT OPERATIONS, SAFETY SYSTEM OPERABILITY,
4/5-5/23/88
REACTOR VESSEL HEAD SEAL INNER "0"
RING
LEAK, MAINTENANCE AND SURVEILLANCE
,
1
4
,
$
I
,
4
i
e
T-1-4
,
--
-e
v
r+
+m-
- < <-
---r*-+--
--.r,ee----*-----~we
w--
-*w-
---*
mr
, - -
m+-
-
-~=s-=+-*
,-=v,
~w'
. .
_ _ _
..
- . _ .
_.
._
.
r
.
TABLE 2: ENFORCEMENT
TABLE 2A: ENFORCEMENT ACTION SUMMARY
SEVERITY LEVEL
AREA
1
2
3
4
5
OEV
TOTAL
PLANT OPERATIONS
1
2
3
RADIOLOGICAL CONTROLS
MAINTENANCE
h
SURVEILLANCE
EMERGENCY PREP.
SEC/ SAFEGUARDS
1
1
OUTAGE MANAGEMENT
TRAINING EFFECTIVENESS
ASSURANCE OF QUALITY
ENGINEERING SUPPORT (Note 1)
1
1
2
TOTALS:
2
3
1
6
TABLE 2B: SYNOPSIS OF VIOLATIONS
-
l
REPT/DATE
REQUIREMENT
SEVERITY
AREA
DESCRIPTION
I
423/87-15
4
ENG
FAILURE TO VERIFY ADEQUACY OF
l
6/8-25/87
APPENDIX C
SUPPORT
BATTERY ROOM WALL' DESIGN
423/87-15
D
ENG
DEVIATION OF MASONRY WALLS FROM
6/8-25/87
APPENDIX C
SUPPORT
FROM APPENDIX A 0F STANDARD RE-
VIEW PLAN SECTION 3.8.4
{
423/87-18
SECURITY
3
SEC/
INADEQUATE BARRIERS,'lI51 TORS
8/31-9/9/87
PLAN
SFGDS
WITHOUT ESCORT, IMPROPER COM-
PENSATORY MEASURES
.
423/88-02
4
CHANGED MODES WITH ONE CHARGING
1/20-2/2/88
PUMP IN0PERABLE
i
423/88-03
3
LTOP INOPERABLE DURING OVERPRES-
'
i
1/19-29/88
SURE EVENT WHILE SHUTDOWN
423/88-04
10 CFR
(NOTE 1)
ENG
ENVIRONMENTAL QUALIFICATION OF
3/14-18/88
50.49
SUPPORT
LITTON-VEAM CONNECTORS
423/88-05
4
AFW PUMP SUCTION VALVE NOT LOCKED
2/23-4/4/88
Note 1: Potential enforcement actions are pending.
T-2-1
J
-
_ - _
-.
. - - . . - . .
.
- --,. - . .,_. - . _ ..-.-.
. - . - . - - . . . - . - - - - - . .
.
.
TABLE 3
SUMMARY OF LICENSEE EVENT REPORTS (LERs)
MILLSTONE 3
CAUSE CODES
AREA
A
B
C
D
E
X
TOTAL
PLANT OPERATIONS
11
3
2
4
20
RADIOLOGICAL CONTROLS
MAINTENANCE
1
2
3
SURVEILLANCE
13
6
19
EMERGENCY PREP,
SEC/ SAFEGUARDS
OUTAGE MANAGEMENT
1
1
1
3
TRAINING EFFECTIVENESS
ASSURANCE OF QUALITY
1
1
4
6
ENGINEERING SUPPORT
2
3
3
8
TOTALS:
28
8
10
13
59
CAUSE CODES
A -- PERSONNEL ERROR
B -- DESIGN, MANUFACTURING, CONSTRUCTION / INSTALLATION
C -- EXTERNAL CAUSE
D -- DEFECTIVE PROCEDURE
E -- EQUIPMENT FAILURE
X -- OTHER
!
T-3-1
.
.
.
TABLE 3A
SYNDPSIS OF LICENSEE EVENT REPORTS (LERs)
MILLSTONE 3
LER
EVENT
CAUSE
FCT
NUMBER
DATE
CODE
AREA
DESCRIPTION
87-008-00
3/7/87
E
1
REACTOR TRIP DUE TO LOW LOW STEAM GENERATOR
LEVEL CAUSED BY FAILED SOLEN 0ID VALVE
87-009-01
3/11/87
E
9
EARLY LIFTING 0F PRESSURIZER SAFETIES FOR
UNDETERMINED REASONS
87-010-01
2/22/87
8
1
LOOSE P^RT DETECTION SYSTEM IN0PERABLE
CHANNEL FOR UNKNOWN REASONS
87-011-00
3/19/87
0
4
4.16KV EMERGENCY BUS TRIP SETPOINTS LOW
DUE TO SETPOINT DRIFT
87-012-00
3/20/87
A
4
MISSED TECHNICAL SPECIFICATION SURVEILLANCE
ON SNUBBER VISUAL INSTECTIONS DUE TO ENGI-
NEERING OVERSIGHT
87-013-00
3/21/87
A
10
MISSING CONTAINMENT PENETRATION SECONDARY
PROTECTION DUE TO PERSONNEL ERROR
87-014-00
3/22/87
E
3
FAILURE OF "B"
TO START IN LESS 14AN 10 SECONDS
87-015-00
3/24/87
0
1
INABILITY OF MAIN STEAM ISOLATION VALVES
TO CLOSE IN REQUIRED TIME FRAME
87-016-00
3/25/87
0
4
TRAIN A SAFETY INJECTION CAUSED BY INSTRU-
MENT TECHNICIAN 00E TO DE7ECTIVE PROCEDURE
87-017-00
3/29/87
B
10
FAILURE TO ADEQUATELY DETERMINE / MEASURE
RESPONSE TIMES
87-018-00
4/2/87
A
4
OPERATION WITH INOPERABLE CONTROL BUILDING
RADIAT:0N MONITOR DUE TO PERSONNEL ERROR
87-01?-00
4/11/87
B
10
AREA TEMPERATURE MONITORING-ES07
87-020 0
4/12/87
E
'
k_: ACTOR TR:P Cl'E TO LOW LOW STEAM GENERATOR
LEVEL CAUSED IY AIR LEAK TO FEEDWATER
REGULATI AL A.VE
Y 3A .
-
-
_ _ _ _ _ _ _ _ _ _ _ _ - _ _ -
-
~. -
>
Table 3A
,
-
LER
EVENT
- AUSE
f(r
NUMBER
DATE
CfjE
RfEA
!gSfff[il0N
E
87-021-00
4/12/?'e
A
1
iECfrc/UER ISOLATION AND REACTOR TRIP DUE
TO 'JEAM GENERATOR WATER LEVEL TRANSIENT
CAUSEO BY OPERATOR ERROR
87-022-00
4JtS/S7
8
10
1N#?.';l' RATE STEAM GENERATOR WATER LEVEL
79DICATION DUE TO SYSTEM DESIGN
87-023-01
- /5/37
E
80
64 i- "!.MPERATURE MONITORING CS01
87-024-00
5/6/87
C
4
' F. d ' LAIN EMERGENCY DIESEL GENERATOR-TRIP /
^ AI'.tME TO START IN LESS THAN 10 SECONOS
87-025-09
5/7/87
0
1
'T. ACTOR TRIP DUE TO LOW LOW STEAM GENERATOR
Lit t:L CAUSED BY PROCEDURE INADEQUACY
87 0T.6-00
f/i4/e7
A
4
r<EACTOR TRIP FROM B PEACTOR TRIP BREAKER
00iHING DUE TO UNKNOWN (SPURIOUS) CAUSES
67-92;-00
b/5/87
A
WE!CTOR TRIP DUE TO LOSS OF VITAL BUS
.
LAUSE0 BY FERSONNEL ERROR
F/ P28-00
/,/0/87
E
'.
CONTROL BUILDING ISOLATION SIGNAL DUE TO
CrlLORINE DETECTOR FAILURE
87-U29-C0
C.7/37
A
i
FAILURE TO POST FIRE WATCHES DUE TO OPERA-
TCR ERROR
87-0?:; ~JD
6/8,'8'
A
i
INADVERTENT MODE CHANGE FROM COLD SHUTDOWN
TO HOT SHUTDOWN DUE TO OPERATOR ERROR
87 031-C:
6 .'4/87
E
9
REACTOR TRIP DUE TO TURBINE TR:P ON LOW
TI-7.32-00
7/6/37
D
4
INADVERTENT DISCHARGE OF CO2 DUE TO PRO-
CEDURAL DEFECT
37 033-00
8/14/87
A
4
REFUELING WAiiR STORAGE TANK LEVEL BELGW
PLANT TS DUE TO INCORRECT LEVEL TRANSMIT-
TERS CALIBRATION AND PERSONNEL ERROR
57-034-00
9/23/87
E
10
REACTOR TRIP DUE TO LOW LOW STEAM GENERATOR
LEVEL CAUSED BY FAILED SOLEN 0I9 VALVE
87-035-00
10/16/87
0
4
SURVEILLANCE TEST METHOD NOT IN ACCORDANCE
WITH TECHN! CAL SPECIFICATIONS
T-3A-2
-
-
..
.
.
.
.
.
Table 3A
.
.
LER
EVENT
CAUSE
FCT
NUMBER
DATE
CODE
AREA
DESCRIPTION
87-036-00
10/31/87
E
10
SETPOINT DRIFT ON MAIN STEAM SAFETY VALVES
87-037-00
11/1/87
A
1
FEEDWATER ISOLATION DUE-TO HIGH STEAM
'
GENERATOR tEVEL CAUSED BY OPERATOR ERROR
87-038-00
11/10/87
A
7
PERSONAL ERROR WHEN JANITOR STRUCK BREAKER
ENCLOSURE WITH BROOM WHILE CLEANING AND
TRIPPED BREAKER
87-039-00
11/11/87
A
4
FAILURE TO SAMPLF. EMERGENCY DIESEL GENERA-
TOR FUEL OIL TAN;5 FOR PARTICULATE-
87-040-00
11/9/87
A
4
FIRE PROTECTION SURVEILLANCE PERFORMED LATE
DUE TO HUMAN ERROR
87-041-00
11/16/87
A
4
INADEQUATE TESTING OF CONTAINMENT PENETRA-
TION CIRCUIT BREAKERS
87-042-00
11/17/87
0
4
MISSED INTERMEDIATE RANGE / POWER MNGE SUR-
VEILLANCE 0UE TO PROCEDURAL INADEQUACY
87-043-00
11/18/87
E
9
BYPASS LEAKAGE IN EXCESS OF TECHNICAL
SPELIFICATION LIMITS
87-044-00
11/20/8
A
4
VENTILATION RADIATION MONITOR SURVEILLANCE
PERFORMED LATE
'
87-045-00
11/21/87
A
4
FAILURE TO SAMPLE DIESEL FUEL OIL FOR
KINEMATIC VISCOSITY PRIOR TO ADDITION TO
STORAGE TANKS
87-046-00
11/24/87
A
4
SAMPLE RIG ACTION STATEMENT SUPVElllANCE
MISSED
'
87-047-00
11/30/87
D
7
CORE ALTERATION PERFORMED WITHOUT PROPER-
COMMUNICATIONS OR SR0 COVERAGE DUE TO
P40CEDURAL ERROR
87-048-00
12/3/87
A
1
FAILURE TO MONITOR INOPERABLE FIRE
ASSEMBLIES
87-Od9-00
12/16/87
A
1
MISSED ENGINEERING EVALUATION DUE TO MIS-
INTERPRETATION OF TECHNICAL SPECIFICATIONS
i
87-050-00
12/21/87
A
4
HISSE0 AREA TEMPERATURE MONITORING SUR-
VEILLANCE DUE TO PERSONNEL ERROR
f
T-3A-3
.
- .- -
. ..
.- . ..
.
.
.
..-
-. . .
.. - - - -
.
. _ __
.
Table 3A
.
o
LER
EVENT
CAUSE
FCT
NU_MBER
DATE
CODE
AREA
DESCRIPTION
87-051-00
12/29/87
A
4
MISSED SURVEILLANCE ON FIRE RATED 000RS
DUE TO PROCEDURAL DEFECT
88-001-00
1/5/88
8
1
INADVERTENT SAFETY INJECTION DUE TO SENSI-
.
TIVE EQUIPMENT-
88-002-00
1/13/88
8
9
INSUFFICIENT SEISMIC SUPPORT OF REACTOR
COOLANT PUMP OIL COLLECTION' SYSTEM
88-003-00
1/16/88
B
1
OIESEL SEQUENCED START DUE TO SPURIOUS
RELAY ACTUATION
88-004-00
1/18/88
E
1
CONTROL BUILDING ISOLATION SIGNAL DUE- TO
CHLORINE DETECTOR FAILURE
88-005-00
1/19/88
A
1
COLO OVERPRESSURE PROTECTION SYSTEM FAILS
,
TO OPERATE OURING PRESSURE TRANSIENT
88-006-00
1/30/88
A
1
VIOLATION OF TECHNICAL SPECIFICATION-MODE
CHANGE WITHOUT REQUIRED ECCS EQUIPMENT
88-007-00
2/3/88
E
1
MANUAL REACTOR TRIP DUE TO INOPERABLE
DIGITAL R00 POSITION INDICATOR
88-008-00
2/8/88
A
9
FIRE DETECTION ZONES IMPROPERLY WIRED
DURING CONSTRUCTION
88-009-00
2/10/88
A
1
REACTOR TRIP AND FEEDWATER ISOLATION DUE
TO STEAM GENERATOR LEVEL TRANSIENT
4
88-010-00
2/9/88
8
7
IMPROPER NUCLEAR INSTRUMENT CALIBRATION
DUE TO LOW LEAKAGE CORE
88-011-00
2/22/88
A
4
MISSED CONTAINMENT LEAKAGE DETECTION SYSTEM
SURVEILLANCES OUE TO DEFECTIVE PROCEDURE
DUE TO PERSONNEL ERROR
'
88-012-00
3/18/88
0
3
FAILURE TO MONITOR AN IN0PERABLE FIRE
BUUNDARY DOOR
~
88-013-00
3/28/88
A
10
INCOMPLETE INSTALLATION OF DAMPER CIRCUIT
IN THE HYDR 0 GEN RECOMBINER SYSTEM
88-014-00
4/13/88
E
9
REACTOR TRIP DUE TO TURBINE TRIP OUE TO
LOW CONDENSER VACUUM
88-015-00
4/15/88
A
1
UNUSUAL EVENT TERMINATED W/0 A QUANTITATIVE
j
ASSESSMENT OF THE LEAK RATE
T-3A-4
!
e
,
-- .
r e
-
-
o
.
o
TABLE 4
SUMMARY OF FORCEO OUTAGES, UNPLANNED TRIPS, AND POWER REDUCTIONS
MILLSTONE 3
AREA
A
g
C
D
E
X
TOTAL
PLANT OPERATIONS
3
1
4
RADIOLOGICAL CONTROLS
MAINTENANCE
1
1
SURVEILLANCE
EMERGENCY PREP
SEC/ SAFEGUARDS
OUTAGE MANAGEMENT
1
1
TRAINING INADEQUACY
ASSURANCE OF QUALITY
ENGINEERING SUPPORT
2
2
4
TOTALS:
3
2
1
3
1
10
CAU5E CODES
A -- PERSONNEL ERROR
B -- DESIGN, MANUFACTURING, CONSTRUCTION / INSTALLATION
C -- EXTERNAL CAUSE
D -- DEFECTIVE PROCEDURE
E -- EQUIPMENT FAILURE
X -- OTHER
T-4-1
_
.
_
__
a
.
.
TABLE 4A
FORCED OUTAGES, UNPLANNED TRIPS, AND POWER REDUCTIONS
MILLSTONE 3
I
POWER
LER
CAUSE AND AREA-
DATE
LEVEL
DESCRIPTION
NUMBER-
(NOTES 1, 2, 3, 4)
3/2/87
100%
POWER REDUCTION TO RE-
--
EQUIPMENT FAILURE SEAL
PLACE FAILED PUMP SEAL
DEGRADATION (N0 AREA
IN MOTOR-DRIVEN MAIN
ASSIGNED)
.
FEED WATER PUMP (MDFWP)
~
3/7/87
100';
REACTOR TRIP FROM "D"
87-08
EQUIPMENT FAILURE - FAULTY
SG LOW-LOW LEVEL CAUSED
SOLEN 0ID ON FWI VALVE
BY FWI WHEN THE FWI
(ENGINEERING SUPPORT)
VALVE SOLEN 0ID OPEN
-
CIRCUITED
!
4/12/87
66%
REACTOR TRIP ON "D"
87-20
EQUIPMENT FAILURE - AIR
LOW-LOW LEVEL CAUSED BY
LEAK FROM SUPPLY LINE
AIR LEAK ON "D"
FRV CON-
LINE FITTING ON "0"
TROLLER
4/12/87
15*;
REACTOR TRIP DURING
87-21
PERSONNEL ERROR - INADE-
i
,
l
STARTUP DUE TO INADE-
CONTROL OF MDFWP AND FRVS
i
QUATE CONTROL 0F THE
(OPERATIONS)
'
FEEDWATER SYSTEM
5/7/87
44*;
REACTOR TRIP ON "0"
87-25
PROCEDURE INADEQUACY - PRO-
LOW-LOW LEVEL DUE TO
CEDURE DID NOT DESCRIBE
TRIPPING MDFP IN SG
POWER LIMITATIONS WITH
LEVEL OSCILLATION REGION
EXISTING SG OSCILLATIONS
,
(OPERATIONS)
5/11/87
100*4
POWER REDUCTION DUE TO
INADEQUATE DESIGN S?AL
{
--
RECURRING FEEDWATER PUMP
DEGRADATION (ENGINtERING
i
SEAL PROBLEM
SUPPORT)
l
5/14/87
69*;
REACTOR TRIP DUE TO AP- 87-26
NO CAUSE - DISCOVERED AFTER
PARENT SPURIOUS TRIP
DETAILED INVESTIGATION
PING OF "B" REACTOR TRIP
(NO AREA ASSIGNED)
BREAKER WHILE PEP. FORMING
A SURVEILLANCE ON THE
"A"
REACTOR TRIP BREAKER
T-4A-1
._
.
.
.
s
,
Table 4A
s
POWER
LER
CAUSE AND AREA
DATE
LEVEL
DESCRIPTION
NUMBER
(NOTES 1, 2, 3, 4)
6/5/87
100%
REACTOR TRIP ON LOW LOW 87-27
PERSONNEL ERROR - OPERATOR
SG LEVEL DUE TO LOSS OF
DROPPED RACKING MOTOR HELD
EMERGENCY BUS 34C
IN HAND AGAINST ADJACENT-
34C BREAKER ENCLOSURE.TO.
INITIATE TRIP (OPERATIONS)
6/14/87
100%
REACTOR TRIP DUE TO TUR- 87-31
IMPROPER DESIGN - TG0P IM-
BINE TRIP FROM LOW LOW
PELLEROVERSIZED(ENGINEER-
PRESSURE AFTER STOPPING
ING SUPPORT)
TGOP
9/23/87
100%
REACTOR TRIP OUE TO LOW 87-34
FAULTY SOLEN 0ID ON FWI VALVE
,
LOW LOW LEVEL IN "A"
(ENGINEERING SUPPORT)
CAUSED BY FWI VALVE
CLOSING
2/3/88
0%
88-07
EQUIPMENT FAILURE - DRPI
OURING PHYSICS TESTING
CARD B0WED, INDICATED R0D
ROD WITHDRAWAL DUE TO
SIMULTANEOUSLY FULL AND MID
DRPI DUAL INDICATION
CORE (N0 AREA ASSIGNED)
2/10/88
20%
REACTOR TRIP DUE TO LOW 88-09
PERSONNEL ERROR -INABILITY
LOW LEVEL IN "B"
OF OPERATOR TO CONTROL ALL
CAUSED BY INADEQUATE
FEED REG VALVES (OPERATIONS)
CONTROL OF FEED REG VALVES
4/13/88
100%
REACTOR / TURBINE TRIP
88-14
OTHER - SEAWEED IMPINGEMENT
CAUSED BY LOSS OF 2 CW
ON INTAKE SCREENS BEYOND
PUMPS DUE TO SEAWEED
CAPACITY OF SCREENWASH
IMPINGEMENT ON INTAKE
(SCREENWASH SYSTEM ORIGI?(-
SCREENS
ALLY OPERATING AT REDUCED
CAPACITY)(MAINTENANCE)
4/28/88
70%
POWER REDUCTION TO RE-
INADEQUATE INSTALLATION -
PAIR STEAM LEAK ON ORAIN
INADEQUATE WELO ON ORAIN
PIPING
PIPING (N0 AREA ASSIGNED)
Note 1: Isolated cases of equipment malfunctioning and component failure (not
directly attributable to functional area).
Multiple causally linked failures
are assigned to the area that should have prevented the recurrence.
Note 2: Cause and area assigned was the result of independent NRC review of the
events and may not agree with the licensee's identified root cause.
Note 3: Cause equals root cause and is that single element, if removed, that
would not have allowed the event to happen.
Note 4: Cause and Area Codes were assigned by NRC Region I.
T-4A-2