ML20151N506

Insp Rept 50-334/88-02 on 880201-05.Deviation Noted.Major Areas Inspected:Licensee Conformance to NRC Approved Procedure Generation Package Re Development & Implementation of Emergency Operating Procedures

ML20151N506
Person / Time
Site:	Beaver Valley
Issue date:	04/13/1988
From:	Bissett P, Dudley N, Eselgroth P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20151N483	List: ML20151N476 ML20151N492 ML20151N506
References
50-334-88-02, 50-334-88-2, NUDOCS 8804250315
Download: ML20151N506 (24)

See also: IR 05000334/1988002

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U.S. NUCLEAR REGULATORY COMMISSION  !

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Report No.: 50-334/88-02

License No.: DPR - 66 ,

Licensee: Duquesne Light Company  ;

P.O. Box 4

Shippingsport, Pennsylvania 15077 ,

Facility Name

Beaver Valley Power Station, Unit 1

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Inspection at: Shippingsport, Pennsylvania  ;

Inspection conducted: February 1 - 5, 1988

Inspectors: usM

. BissWtTSenior Operations Specialist

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vate /  ;

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N. Oudley, Hnior Operations Specialist

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date

Approved by: A '/ / Y  ;

P. Eselgroth hief,'FWR Operations Section date l

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Summary: Routine ann unced inspection on February 1-5, 1988

j (Report No. 50-334/88-02)

Areas Inspected: A routine announced inspection was conducted in the area of I

operations to review licensee conformance to the NRC approved Procedure I

Generation Package regarding the development and implementation of their

Emergency Operating Procedures (E0P). Areas examined included the Administra-

tive Program; Technical Adequacy; Writer's Guide conformance; and Independent

Verification of set point values. Temporary Instruction 2515/79, Inspection of

Emergency Operating Procedures was used as inspection guidance.

Results: An apparent deviation of the licensee's commitment to follow its NRC

approved Procedures Generation Package was issued based on the numerous

problems identified during the inspection. The technical content of the

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licensee's E0P was found to be adequate. However, a number of inconsistencies

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between the Procedures Generation Package and the E0Ps and Background

j Information documents were found in the areas examined. The basic documents

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for E0Ps were not controlled, contained errors and were inconsistent with the

, guidance contained in the Procedure Generation Package (paragraph 2.5.1). The

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! logic terms, branching statements, cautions and sentence structure of the steps

in the E0P did not conform to the guidance in the Procedure Generation Package

4 (paragraph 2.5.3). The nomenclature of plant components and instrumentation

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was not in accordance with the guidance contained in the Procedure Generation

Package and led to operator uncertainty, (paragraphs 2.0.4, 2.5.5 and 2.5.6).

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The human factor deficiencies in tne E0Ps appear to have been compensated for

{ by the raining and experience of the operators.

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DETAILS'

-1.0 PERSONS CONTACTED

1.1 DUQUESNF i.IGHT COMPANY

T. Burns DIRECTOR OPERATOR TRAINING -

R. Druga MANAGER TECHNICAL SERVICES

L. Freeland NUCLEAR OPERATIONS SUPERVISOR

K. Grada MANAGER NUCLEAR SAFETY ,

W. Lacey PLANT MANAGER l

F. Lipchick SENIOR LICENSING SUPERVISOR l

A. Mizia SUPERVISOR QA OPERATIONS  !

A. Morabito MANAGER NUCLEAR TRAINING l

T. Noonan ASSISTANT PLANT MANAGER

E. Schad SIMULATOR COORDINATOR, TRAINING

F. Schaffner LICENSING ENGINEER

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8. Sepelak LICENSING ENGINEER

G. Smith PROCEDURES ENGINEER

J. Russell SENIOR QA SPECIALIST

1.2 U.S. NUCLEAR REGULATORY COMMISSION

J. Beall, Senior Resident Inspector

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S. Pindale, Resident Inspector

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The inspectors also interviewed other licensee personnel during the

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inspection period.

• Denotes those present at the exit meeting conducted on February 5,

1988. l

2.0 EMERGENCY OPERATING PROCEDURES

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The purpose of this inspection was to verify that Duquesne Light Company's l

Emergency Operating Procedures (EOPs) were written, verified and validated

in accordance with the licensee's NRC approved Procedures Generation

Package and training was conducted on the use of the procedures.

2.1 REGULATORY REQUIREMENTS / REFERENCES

Regulatory Guide 1.33, Rev. 2 - February 1978, Quality

] Assurance Program Requirements (Operations).

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ANSI N18.7-1976, Administrative Controls and Quality

, Assurance for the Operational Phase of Nuclear Power

Plants,

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j * Westinghouse Owners Group (WOG) - Emergency Response

Guidelines (ERG) - High Pressure Version, Rev.1,

September 1983.

• Generic Letter 82-33, Supplement I to NUREG-0737, -  !

j Requirements for Emergency Response Capability. ~

• NUREG-0899, Guidelines for the Preparation of Emergency [

Operating Procedures.

• Technical Specific ~ations.  !

Emergency Operating' Procedures Generation Package,

Revision 1, April 1987. l

2.2 PROGRAM REVIEW

The licensee's program for preparation of E0Ps was reviewed to verify  :

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that: '

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The licensee has developed a Procedure Generation Package which

includes Plant Specific Technical Guidelines, a Plant Specific

Writers Guide, a description of the program used for verifying

and validating the licensee's E0Ps, and a description of the

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program for training operators on E0Ps. '

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The licensee has developed Emergency Operating Procedures

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(EOPs) consistent with the guidance of Duquesne Light Company's

and NUREG-0899.

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• The E0Ps use a consistent format, which was easy to follow and  ;

was as defined in their PGP. '

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The operators have been trained to use the E0Ps and the E0Ps  !

i were useable.  !

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• Differences between Westinghouse's Generic Guidelines and the

licensee's specific E0Ps were identified and justifiad. l

The licensee had an administrative program for developing the

E0Ps and controlling changes to them.

The E0Ps were technically adequate and capable of placing the

plant in a safo condition following a reactor trip or actuation

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of the safety injection system.

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1 2.3 PROGRAM IMPLFMENTATION

Procedures listed in Attachment A were reviewed by the inspectors against

the requirements and committents of paragraph 2.1.

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2.3.1 ADMINISTRATIVE PROGRAM

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The inspectors reviewed the program for controlling Operating

Manual Deficiencies Reports (OMOR) for the E0Ps to ascertain

whether proper controls were being exercised, Several 0MORs

1 were reviewed and the following items verified:  !

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' * An adequate description of the procedural change.

An adequate description of the reason for the change.

• Documentation of required authorization.

• The Onsite Safety Committee review and approval of the ,

change.

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Proper final disposition of each change.

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2.3.2 TECHNICAL ADEQUA,CY l

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The inspectors compared seven E0Ps against the ERGS and also

performed concurrent evaluations of the technical adequacy of the

E0Ps. During this review, the E0Ps were reviewed for consistency ,

, with the ERGS, against the step-by-step verification documenta-

i tion and against the documentation which justified those steps ,

l which deviated from the ERGS.

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2.3.3 HUMAN FACTORS

Five E0Ps were reviewed to determine the extent to which they

followed the format and content instructions committed to in '

the Dr oesne Light Company Writer's Guide and whether they met i

the objectives found in NUREG 0899.

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{ 2.3.4 VALIDATION / VERIFICATION PROGRAM

Inspectors reviewed sample documentation of the

validation / verification program for adequacy and verified the

j procedures during plant walk through and simulator scenarios,

j 2.3.5 WALK THROUGH

Inspectors conducted a walkthrough of two E0Ps in the main

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. control room. Comparisons were made between the E0Ps and

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control room main panels, and between valve lineups contained

in the Attachments to the E0Ps and components outside the main

control room, to determine whether:

The controls / displays identified in the E0Ps as being in the

control room were there;

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The control / display nomenclature used in the E0Ps was

comparable to that found in the control room;

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* The control / display to be used to complete a step were

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• The components required to be checked outside the main  !

control room were accessible and clearly. marked; and, s

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The displays could be read to the accuracy required by the E0Ps.

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2.3.6 SIMULATOR

An exercise of the E0Ps was conducted on the Beaver Valley

4 Unit 1 simulator. The exercise objectives were:

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Tc determine whether the E0Ps are usable for the level

of qualifications, training and experience of the

operating staff, and

• To determine whether the E0Ps are compatible with the  !

minimum number of operating staff. i

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l Three simulator exercises were developed to cover the subset of

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the E0Ps that had been reviewed for the audit. The exercises l

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• Reactor Trip

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Stuck open PORV which is later SHUT; Multiple instrument

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Loss of ALL AC Power

Restoration of one Emergency Bus )

All Steam Generators faulted l

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The scenarios were chosen because they exercised a large

portion of the E0Ps under review, and they covered a variety of

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emergency situations. The scenarios were developed to evaluate the

use of instrumentation, the use of branching statements and the y

use of the critical function status trees.

2.4 OA/QC INVOLVEMENT

The inspectors contacted Quality Assurance (QA) personnel in order to

determine what role QA had in the development and validation of the E0Ps.

QA management stated that their involvement to date included a review in

March 1987 of the licensee's Procedure Generation Package (PGP) against

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IE Information Notice 86-64 and Appendix B of NUREG 0899, The inspectors

reviewed QAs written comments following this review and the subsequent

resolution to these comments as provided by the Procedures Group. The QA

Supervisor stated that they had not yet performed any audits of the E0P

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program or the E0Ps themselves, however both areas are considered audit- l

able items under the QA program.

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2.5 FINDINGS

2.5.1 ADMINISTRATIVE PROGRAM

Portions of the licensee's procedural change program for E0Ps were

reviewed. The Nuclear Operation Supervisor (N05) is responsible for

approving all discrepancies prior to their incorporation into the E0Ps in

accordance with the Procedure Generation Package, paragraph VI.C.1.g. All

deviations from and additions to the Westinghouse Owner's Group Emergency

Response Guidelines (ERG) are required to be documented on E0P-ERG

Deviation forms in accordance with paragraph VI.B.1.f. No temporary ,

changes to the E0Ps are allowed, and therefore, any procedural changes i

will result in a complete reissue of the affected E0P.

The licensee has a formal program for in'tiating changes to the E0Ps by

using Operating Manual Deficiency Reports (0MDR). The OMDRs are reviewed

by the NOS prior to being given to the E0P writer for resolution. The '

OMDRs are tracked on a computerized system..There is no formal program for

disposition of the OMDRs once they are reviewed by the N05. There is no i

supervisory review of the completed OMDRs or modified E0P-ERG Deviation

fo rms. Only the E0P changes resulting from an OMDR are reviewed by i

supervisory personnel.  :

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A review of the completed E0P-ERG Deviation forms by the inspectors '

identified technical errors. In one case a set point was lined through

and a new set point written in. There was no initial or date for the line

out and the new set point did not correspond to the set point in the E0Ps.

In a second case no E0P-ERG Deviation form existed for E-0 step 29, even

though deviation forms existed for similar steps. All E0P-ERG Deviation

forms are hand written with numerous line outs of technical information

and justifications without explanation or apparent systematic controls.

Changes made to the E0Ps as a result of one Onsite Safety Committee (OSC)

meeting were not documented on the E0P-ERG Deviation forms.

The E0P-ERG Deviation forms did not contain sufficient detail to fully

explain the technical reasons for deviations. In one case, the E0P writer

needed to call the training department in order to explain the intent and

basis for changing E-0 step 1. In a second case, a high head safety

injection pump was secured without a documented engineering basis, l

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Portions of the licensee's Background Information for E0Ps was reviewed.

The background information package for each E0P provides information on

the event symptoms, entry conditions, exit conditions and recovery

techniques used in each E0P. In addition the purpose, basis, actions,

instrumentation, control equipment, knowledge and technical references for

procedural step are provided in Step Description Tables. The majority of

indications presented in the Step Description Tables do not ir.clude the

benchboard identification of the instruments to be used as required in

the Procedure Generation Package Appendix B Section IV.A 4.e. Examples of

indications which were not defined by benchboard identification include

total AFW flow and component cooling flow to RCPs. Many Step Description

Tables did not provide technical references as required by the Procedure

Generation Pr.ckage Appendix B Section IV.A.4.e.

Failurs to include the benchboard identification of the instruments to be

used in the Step Description Tables as required by the Procedures

Generation Package is a part of the deviation identified in paragraph

2.5.7 below.

As part of the review of the E0P-ERG deviation forms, a technical error

was identified in the Procedure Generation Package Section 5, paragraph

11. The paragraph states that the Beaver Valley Unit I component cooling

water (CCW) system is essentially identical to the CCW system of the

reference plant, which is without an appropriate technical basis. The CCW

system of the reference plant cools four components; the RHR heat

i exchanger, the seal water heat exchanger, the containment fan coolers and

the reactor coolant pumps. However, the CCW system at Beaver Valley Unit

I does not cool the RHR heat exchangers nor containment fan coolers, whica

result in differences between steps in the E0P and in the ERG. Review of

Section 5 of the Procedures Generation Package is needed to ensure there

are no other technical errors.

2.5.2 TECHNICAL ADEQUACY

The E0Ps compare well technically with the ERGS. Minor discrepancies were

found that were needed to compensate for the specific plant design and/or

the technical specifications. Many instances were noted where additional

steps were added over and above what was called for in the ERG. The

majority of these additional steps were to provide further clarification

and direction to the operators. E0P-ERG Deviation forms were generated

as necessary, however as stated in paragraph 2.5.1, many forms did not

contain sufficient detail to fully explain the technical basis for

deviations.

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In one instance the licensee deviated from a directive in the ERGS and did

not provide a written technical justification for the deviation. The ERGS

require that additional steps for verification of other essential equip-

ment as required by the specific plant design, should be placed after E-0

step 12. The facility's E0Ps ccntain seven additional steps prior to E-0

step 12 of the ERGS and no E0P-ERG Deviation form has been written. The

licensee stated that the EDPs contained the additional steps because the

supersedea event based reactor trip procedure contained the same step

sequences and in order to minimize the amount of operator retraining

required to implement the new E0Ps, the steps of the superseded trip

procedures were retained. Training concerns are not considered to be a

sufficient technical basis for deviating from the ERGS.

A problem was noted during the review of ECA 0.0, "Loss of all AC Power."

Several actions, such as operation of valves and pumps, are required

during the time period when attempts are being made to restore AC emer-

gency oower to these components. Many of these steps will be impossible

to couplete as long as power is unavailable. ECA 0.0 requires further

review to ensure that power would be available to all components which are

required to be coerated.

2.5.3 HUMAN FACTORS

The human factors review involved a comparison of the E0P with the

Writer's Guide and with NUREG 0899. Discrepancies were grouped into five

main areas. A summary of the major issues for each of the areas is

provided beloe. Specific comments and examples of the major istues are

provided in Attachment B.

Lcgic Terms The Writer's Guide presents definitiens and format

instructions regarding the writing of conditional statements using the

logic terms. While the instructions provided were incomplete, those which

were provided were not applied correctly within the E0Ps. Four major

areas of concern were identified:

• The use of AND and OR (together and sepsrately) within action

statements.

The inappropriate structuring of IF, THEN statements.

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The use of the implicit IF NOT in the Response Not Obtained (RNO)

column.

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The use in the RNO column, of an IF NOT statement witnout an initial '

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_ Referencing and Branching

The E0Ps contained a number of transition terms which were undefined in

the Writer's Guide and inconsistent with the guldance provided.

Notes and Cautions Cautions and Notes in the E0Ps were often misused by

their structure as directives or inclusions of inappropriate information

(i.e., non-critical information in Cautions).

Sentence Structure The E0Ps utilized inconsistent structural methods for

similar types of statements, conflicting not only with the guidance

provided in the Writer's Guide, but utilizing a number of different

structures for one type of statement within a single E0P. In addition,

action statements included two to three directives within one step.

Miscellaneous Other problems were found in the E0Ps including

use of vague terminology and inconsistent use of abbreviations and

acronyms.

The licensee's failure to follow the Writer's Guide is discussed in a

deviation identified in paragraph 2.5.7.

2.5.4 VERIFICATION / VALIDATION

Verification: The licensee's Procedure Generation Package described the

verification of the E0Ps for correctness, using the Writer's Guide as a

basis for evaluation. The program is described as being carried out by a

team of personnel from Operations, Training and Procedures groups. A

checklist is used as a guide to the process and discrepancies are

forwarded to the EOP writer for correction. A decision is made by the NOS

whether a follow-up verification or validation of the draft E0P is needed.

Verification activities at Beaver Valley were carried out by Duquesne

Light Company personnel with assistance from a human factor consultant

during the initial verification.

A control room and plant walk through by inspectors to verify selected

E0P steps identified a number of examples where the nomenclature of

instrumentation in the E0Ps was inconsistent with the nomenclature found

in the control room and the plant. Some examples where the nomenclature in

the E0Ps was different than that found on the name plate data are:

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• E-0 Entry Conditions refers to annunciator window A5-47 "Manual Reactor Trip From Main Control Board." The annunciator window

is now in position A5-9.

• E-0, Attachment 2 refers to MOV-RW-1130 "River Water to D.G.

Heat Exch." which must be checked locally. Due to a design

change MOV-RW-1130 has been replaced by MOV-RW-11301 which is in

a different room.

E-0 Attachment 2 refers to four valves which should be checked

locally at the Diesel Generators, as "River Water to D.G. Heat

Exch." The valves at the generator are labelled "RAW Water

Valves #1 and #2."

The licensee had identified that the nomenclature in the main

control room does not meet the requirements of the Writer's

Guide.

Subsequent observation by the inspectors of the use of the E0Ps on

the simulator indicated that the nomenclature disparity between the

E0Ps and the control room panels presented no confusion to the

operators. However, during the simulator scenarios the lack of

detailed sper.ifications of instrumentation resulted in the operators

using instrumentation which was not in accordance with the licensee's

plant specific background document. Some examples where incorrect

instrumentation was used during the simulator scenarios are:

E-0 step 6.a. the operator used breaker position and an

annunciator window to verify an AC emergency bus was energized.

The background document requires that the voltmeter be used.

E-0 step 9.1, the operator used an annunciator to verify

the turbine-driven AFV pump running. The background

document does not provide an instrument to check for

completing this step. It was .he consensus of the operators

that the position of steam valves are checked for ensuring

the turbine-driven AFW pump is running.

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Appendix F of the Procedure Generation Package, paragraph II. A.2.b,  ;

requires that the E0Ps be reviewed for technical accuracy of

"Operator Instrumentation and Control Needs." Failure to correctly ,

translate control room and plant switch and indicator nomenclature  !

into the E0Ps as part of the verification program is a part of the I

deviation Identified in paragraph 2.5.7 below, l

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Validation: The validation process is described in the licensee's

Procedure Generation Package as a demonstration that the operating

staff can manage the emergency condition through the use of the

procedures and that the E0Ps are operationally correct in respoct to

usability, technical correctness, operational correctness and

effectiveness. The Procedure Generation Package indicates that table

top reviews, control room walk through, or simulator exercises will

be used to validate E0Ps. The documentation for the validation of

procedure E-0 was reviewed and found to be adequate for the table top

review, simulator and control room walk through. However , the

inspectors identified discrepancies in procedure E-0 during the plani.

walk through, as described below.

2.5.5 WALK THROUGH

The walk through of procedures in the main control room

and in the plant identified deviations of E0P procedural steps and

the recommendations in the Procedures Generation Package. The Weiter's l

Guide in paragraph V.B.g states that "identification of components i

and parts should be complete." An example of a step which did not i

satisfy this requirement is:

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E-0 Symptomatic Response / Unexpected Conditions, 1 a. CRR flow to

RCP's - NO FLOW INDICATED.

The operator was uncertain what readings would be e a ptable, and the

basis document does not indicate the required ins. ..+nt.

The Writer's Guide in paragraph VI.E.1.d states that "users should .

not be required to add or subtract nembers to determine acceptable i

values." Contrary to this: l

E-0 step 17, Verify Total AFW Flow - GREATER THAN 350 GPM; l

requires the operator to sum the values from three flow

instruments.

• E-0 step 21.a.2,a, RCS/ Highest D/P - LESS THAN 150 PSIO;

requires the operator to select the highest reading from

one of nine pressure instruments and to subtract it from

the reading of a tenth pressure instrument.

• E-0 step 12. a, Steam line pressure high rate of change -

99 PSIG DECREASE IN 50 SECONDS; requires the operator to

calculate a rate of change.

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The walk through in the plant was performed to assess the acequacy of

various factors involved in the performance of ECA 0.0 "Loss of All

AC Peter." Areas reviewed which included equipment identification, acces-

sibility of equipment, and the availability of emergency lighting and-

communications equipment (dedicated Appendix R phone service line)

were found to be adequate. Valves and breakers were for the most-

part readily accessible, with the exception of a few instances'where

temporary scaf folding was in place (e.g., IA-90). Valves TV-CC-107E2

and 02 were difficult to access primarily because of piping confi-

guration.

Valve identification tags were considered inadequate, esptcially when

considering a loss of lighting, when a valve might have to be located

and subsequently operated. Identification tag deficiencies, observed

by the inspector, include tags that were missing, damaged or bareac-

able. The licensee utilizes a lightweight thin metal strip embossed

wi'.h the letters / numbers of the appropriate valve. The dimensions of

the tag are approximately 5" x 1/2" and the tag is normally attached

at one end to the valve body. The inspector found it difficult, in a

nuber of instances, to read the 10 tag, even under normal lighting

conditions. Valves TV-CC-107E2 and 02 are examples in which diffi-

culty was experienced in reading the valve identification tag

numbers. The 10 tags had to be "in-hand" in order to accurately read

them. The readability of the 10 tags presently in use is question-

able. Other examples of 10 tag discrepancies include:

1 MOV-IN-1558 - 10 tag missing

• 1 MOV-IN-ISSA - 10 tag damaged ,

MSIVs vent panel valves - 10 tags missing

1 MOV- N-151 volves - 10 ;ags missing or damaged

Dedicated A W pump valves - missing 10 tags

The licensee >tated that efforte have been underway to ensure that tag ids

are accurate ar.d in place, h: wever it is an ongoing program. Those areas

where pump, valve and breaker manipulations might be called for under loss

of lighting conditions require escalatt.d action.

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2.5.6 SIMULATOR

No procedural deficiencies were observed during the simulator portion

of the audit. Problems identified during the walk through were con-

firmed in observations and discussions with the operators in-the

simulator. Operator actions were taken in accordance with the-

E0Ps. However, the requirements contained in the ERG Users Guide

were not followed during the development of the E0Ps. For. example:

• E-0 step 1, the operator transitions to FR-S.1 prior to

checking reactor power decreasing. The ERG requires that power

be checked prior to the transition.

E-0 step 6.a, the operator reported power to the AC Emergency

Bus even though the voltmeter indicated zero volts. The ERG

requires the use of the voltmeter.

• E-0 step 24, the operator diu not check the containment

sump level recorder as required by the basis document.

Operator actions were slowed due to the wording of some procedural

steps. ECA 0.0 step 32.a contained an "AND/0R" step which t'ne

operator had to reread several times before proceeding. The operator

experienced difficulty determining subcooling margin requirements

prior to transitioning out of ECA 0.0 "Loss of All AC Power," and

finally referred to a pressure temperature graph which was not part.

of the E0Ps. From observations of operators in the simulator and

from discussions with the licensee, deficiencies identified in the

wording, structure and format of the procedural steps appear to have

been compensated for by operator training and experience instead of

rewriting the steps to correspond to the Writer's Guide,

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2.5.7 SUMMARY

The technical content of the licensee's E0Ps was reviewed in detail

and determined to be consistent with the Westinghouse Owners Group l

Emergency Response Guidelines and the licensee's Procedure Generation

Package. A human factors review of the Writer's Guida, revealed  ;

numerous deficiencies including, but not limited to the incorrect and i

inconsistent use of logic statements in the E0Ps. The documentation l

of the deviations identified by the validation program was found to I

be deficient. The basis document for the E0Ps do not include 1

detailed instrument specifications nor references in accordance with

the Procedures Generation Package. The verification program failed

to correctly translate control room and plant switch and indicator

nomenclature into the E0Ps.

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There has been no human factors or quality assurance involvement in l

the validation of the latest revision of the E0Ps. Numerous human

factors issues, related to the Writer's Guide, and numerous

deficiencies identified in the E0P-ERG Deviation Forms and the

Background Information documents indicate deviations from the

Procedures Generation Package. Based upon the above and the detailed

discussions in paragraph 2.5.1, 2.5.3, 2.5.4, 2.5.5, and Attachment

B, this is an apparent deviation of the licensee's commitment to

follow the NRC approved Procedures Generation Package

(50-334/88-02-01).

3. INDEPENDENT VERIFICATION

The inspectors independently verified that various levels and values given

in the E0Ps were consistent with the indicators found in the control room

and that the operators were knowledgeable of where various switches were

located. The inspectors reviewed the documentation of five plant specifi'c

setpoints and determined that the engineering analysis to support the

plant specific setpoints were not referenced in all cases. This failure

to reference supporting documentation contributed to the apparent

deviation summarized in paragraph 2.5.7.

4. EXIT INTERVIEW l

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An exit meeting was held February 5, 1988, to discuss the inspection scope  !

and findings, as detailed in this report (see paragraph 1.0 for  !

attendees).

At no time was written material given to the licensee. The inspector  !

determined that no proprietary information was utilized during the  !

inspection.  !

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ATTACHMENT A

DUQUESNE LIGHT COMPANY, BEAVER VALLEY UNIT 1, PROCEDURES REVIEW

E-0 Reactor Trip or Safety Injection, Issue 1, Rev. 1

E-3 Steam Generator Tube Rupture, Issue 1, Rev. 1 l

ES-1.1 SI Termination, Issue 1, Rev.1

ES-3.1 SGTR With Loss of Reactor Coolant - Subcooled Recovery l

Desired ECA - 3.1, Issue 1, Rev. 1 l

l

ECA 0.0 Loss af All AC Power, Issue 1, Rev. 1

J

ECA 0.1 Loss of All AC Power Recovery Without SI Required, Issue 1,

Rev. 1

ECA 2.1 Uncontrolled Depressurization of All Steam Generators,

Issue 1, Rev. 1

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. . . - _ . . . . . _ . . . _ ._. _ _ __

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ATTACHMENT B

REVIEW 0F WRITER'S GUIDE

1. The Writer's Guide,Section V.E., presents definitions and format

instructions regarding the writing of conditional statements using logic

terms. The instructions provided are not applied consistently within the

E0Ps. The following problem areas were identified,

a. When used as conjunctions, "and" and "or" join lists, multiple

actions or alternatives. When used as logic terms, they indicate

decision points. It is important that appropriate emphasis be used

when these words are being used in a conditional statement, to signal

to the operator that a decision point has been reached. When used to

indicate multiple actions, alternatives or a list, "and" and "or"

should not be emphasized as logic terms. The Writer's Guide does not

provide explicit direction on the different use and formatting of

"and" and "or". The E0Ps contain different types of formatting for

these words which are not consistent with the Writer's Guide.

Example: E-0, step 25.b and c.

25.b. Secondary heat sink: ,

Total feed flow to intact SGs - GREATER THAN 300 GPM

- OR -

• Narrow range level in at least one intact SG -

GREATER THAN 57.

25.c. RCS pressure - STABLE OR INCREASING

This step uses the conjunction "or" in two different formats. Because

"or" is functioning as a conjunction in both uses, it should be formatted

consistently. While the Writer's Guide lacks format information for the

use of "or" as a conjunction, neither use of "or" within the above step is

consistent with the guidance provided in Section V.E of the' Writer's i

Guide for the emphasis of the logic term OR.

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_ _ . _ . _ . , _ . - _. _ _ . , _ . .., - . _ . _ - - - _ . . . - . . , - . .

- , . .- .-- __ -- _. _ .. ___ .

...

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Attachment B 2

.

.

Other examples of this type of problem found in the E0Ps

sampled include:

E0P STEP PROBLEMS

E-0 35 -or-

E-0 36.b -AND-

ES-1.1 2 RNO AND (not a conditional statement)

E-0 13. a and

E-0 3 RNO or

E-0 13.a -or-

E-0 13.b RNO ANO (not a conditional statement)

E-0 22.a RNO and (a conditional statement)

b. The Writer's Guide provides direction on the use of the logic

sequence IF, THEN in paragraph V.E.

There are a number of IF NOT, THEN statements which-are not

formatted consistently with the guidance provided.

P

Example:

'

E-0 Step 7 RNO

Check if SI is required: ...

IF SI required, THEN manually actuate.

'

IF SI is NOT required, THEN GO TO ES-0.1, i

W '

Reactor Trip Response," Step 1.

This step conflicts with the format directions in the Writer's

Guide, which indicates that the term IF NOT will not be split.

Other examples of this problem found in the E0Ps sampled include:

E0P STEP

E-0 6.a RNO i

9.f RNO  !

>

20.a RNO j

20.b RNO

Example: I

<

ECA-0.0 step 7.a.3 RNO

Verify proper emergency alignment of AFW valves. IF NOT properly aligned,

THEN manually align AFW valves [MOV-FW-151A-F] as necessary

The step does not contain the first conditional IF.

.

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Attachment B 3

.

Other examples of this type of problem found in E0Ps sampled include:

E0P STEP

E-0 13.a.1 RNO

E-0 13.a.2 RNO

E-3 21.a.2 RNO

ECA-0.0 20.c RNO

ECA-0.0 21.b RNO

ECA-0.0 33.a RNO

ECA-1.1 13.f RNO

ECA-2.1 15.b.2 RNO

c. The two column format used in the E0Ps is structured so that

the right hand column includes an implicit "if not" relation-  !

ship to the left hand column. In a number of statements in the

E0Ps, the "if not" has been repeated in the right hand column, l

unnecessarily cluttering and complicating the procedure, and not  !

taking advantage of the RNO structure.

Examples: l

)

E-0 step 4.b RNO

)

1

IF reheater flow control block valves will NOT close, THEN

manually close main steam line trip, bypass and non-return

valves.

E-0 step 11.a RNO

a. IF CIA has NOT actuated

THEN manually actuate CIA

-0R-

Manually align CIA valves

Other examples of this type of problem found in the E0Ps

sampled include:

E0P STEP

E-0 12.b RNO

E-0 23.d

E-0 23.d RNO

E-0 25.b RNO

ES-1.1 9 RNO

ES-1.1 11 RNO

E-3 17.d RNO

E-3 23.b RNO

E-3 26

ECA-0.0 14 RNO

ECA-0.0 24 RNO

. . . ~ _ . . . . . ..- . _ - . . . . - -

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Attachment B 4

2. The Writer's Gu'ide Section V.H. 2. defines "go to" as the transition term 'l

to be used within the E0Ps and provides format instructions. The EOPs, I

however, use a number of different' terms to indicate movement within and- l

between E0Ps. The Writer's Guide does not define the minimum number of

terms necessary for clear instruction to operators on transitions.

Examples:

E-0, Step 23 RNO

GO TO E-3 "Steam Generator Tube Rupture," Step 1 AND in. i

conjunction complete only Steps 23b through 23d.

,

This step contains two transition terms which is not in accordance with  ;

the Writer's Guide and one of the terms is not defined in the Writer's

'

Guide.

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ES-1.1 Step 15 RNO  !

1

a. WHEN PRZR level greater than 18% THEN perform Step 16.

Other examples of this type of problem four.d in the E0Ps  !

sampled:  ;

E0P STEP TRANSITION TERM OSED

1

ES-1.1 27.a RNO "do" l

'

E-3 3 RNO "do"

E-3 30.b RNO "do"

ECA-0.0 18 RNO "perform"

ECA-0.0 16.b RNO "do" l

ECA-0.0 26.a RNO "G0 TO...THEN do"

ECA-2.1 7.f.2 RNO "do"

3. Cautions are used to describe a hazardous condition which can cause

injury or equipment damage and should describe the consequences of the

hazard. Notes are intended to provide supplemental information to the

operator. Neither Cautions nor Notes are to include action statements.

The human factors review revealed several problem areas related to

Cautions and Notes:

Caution (s) and Note (s) in the E0Ps sampled were found to contain ,

directives and references which are action statements. Some Cautions lack -

I

a statement of the hazard at hand and possible consequences. Following

are instances of improper use and structure of Caution (s) and Note (s): I

_ . _ _ - _ - _ _ - - - _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ - - - _ - - _ _ _ _ - _ _ - _ _ _ _ _ _ _ _ _ _ _ _ - _ - . _ _ _ _ _ _ - - _ _ _ - _ - - - _ _ - _ _ - - _ _ _ _ .

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Attachment B 5

E-0, page 23

CAUTION: RCS pressure should be monitored. If RCS

pressure decreases to less than 250 PSIG, the LHSI

pumps must be manually restarted to supply water to

the RCS.

This Caution lacks identification of the hazard and consequences

related to a low RCS pressure. The Caution also contains a

directive which more appropriately is an action statement.

Other examples of these types of problems found in the E0Ps

sampled include:

E0P PAGE PROBLEM

E-0 13 Note contains action statement.

E-0 14 Note contains action statement.

ES-1.1 10 Caution lacks identification of the

consequences of the hazard. Caution

contains action statements. i

E-3 7 Caution lacks identification of hazard

or consequence.

E-3 7 Caution contains branching statements.

E-3 14 Caution contains logic statement.

Caution lacks identification of hazard I

or consequence.

E-3 30 Caution lacks identification of i

consequence.

ECA 0.0 17 Note contains action statement,

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ECA 0.1 16 Caution contains logic statement. I

1

4. Sentence structure is an important factor in the presentation of clear l

and understandable instructions. The inspector's review identified several

problem areas related to sentence structure in the E0Ps.

a. The Writer's Guide, paragraph V.B.1 indicates that steps are to

be written concisely, describing .just the task to be performed and

that complex evolutions are to be broken down. The following step

includes more than one action:

--

- - . _. __ _ . . _ _ . _ . . . _. . .

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- Attachment B 6

.

E-3.1 step 5.C

Trend RCS temperature and pressure on the main

computer at 10 minute intervals. Initial the trend

every half hour to ensure that-cooldown does not

exceed 100F/hr in RCS cold legs.

Other examples of these type of problems found in the E0Ps

sampled include:

E0P STEP

ECA-0.0 11

ECA-0.0 26.b RNO

ES-1.1 2

ES-1.1 5.b.3

ES-1.1 22.a

ES-3'.1 5.e

ES-3.1 9.b

ES-3.1 9.e

ES-3.1 11.a

ES-3.1 33

ES-3.1 35 b.3

b. A system of step numbering and identification can assist the operator

j in moving through procedures without confusion. The review of the

E0Ps revealed an inconsistency in the use of bullets which indicate

no preferred order of completing action s ;eps. In some steps where a

check is made of multiple indications, bullets are used, in other 1

steps AND is placed between the indications; and in other steps

'

individual letters are used.

Examples;

E-0 step 3 i

Verify Turbine Trip

'

a. Throttle and governor valves - CLOSED

b. Reheat steps and intercepters - CLOSED

'

E-0 step 22 <

I

Check If SGs Are Not Faulted  !

4

NO SG PRESSURE DECREASING IN AN UNCONTROLLED

MANNER

'

N0 SG COMPLETELY DEPRESSURIZED

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Attachment B 7

E-0 step 36

Veri fy CNMT Instrument Air - AVAILABLE . . .

b. CNMT instrument air receiver pressure -

GREATER THAN 95 PSIG

- AND -

Annunciator A6-110, "CNMT

Instrument Air System - Pressure

Low" - NOT LIT

Other examples of these types of inconsistencies found in

the E0F; sampled include:

E_0P STEP METHOD

ES-1.1 1 Letters

ES-1.1 2 Bullets

ES-1.1 7 - AND -

ES-1.1 13.d.1 Single bullet

ES-1.1 14 Letters

ES-1.1 24 Single bullet

E-3 17.g AND

ES-3.1 2.a Bullets

ES-3.1 9.a Numbers

ES-3.1 10.a Bullets separated by - or -

5. A number of statements in the E0Ps are vague and do not describe specific

operator behaviors. For example, the operators are instructed to perform

an action "maintain" with no criteria provided as to what the requirements

are. In order to ensure that procedures are understood, directions should

be defined quantitatively. The following are examples of the use of vague

terms noted in the E0Ps:

TERM E0P STEP

Stable (without desired range) E-0 25.c

ES-1.1 21

Maintain (without requirements) ES-1.1 11

ES-1.1 31.b

E-3 5.a

As necess&ry ES-1.1 14.a l

ES-1.1 31.a

E-3 25.b

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_ _ - _ _ _ - _ _

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Attachment B 8

6. Other weaknesses identified during the review are noted below:

a. The Writer's Guide includes Table 2, "Abbreviations used in Proce-

dures," yet the E0Ps include a number of abbreviations and acronyms

which are not included in Table 2 or are included in Table 2 in

another form. In addition, the E0Ps include multiple forms of a

number of abbreviations. In order to minimize confusion and ensure

consistently prepared procedures, all acronyms and abbreviations to

be used in the E0Ps should be listed in the PGP.

NOT INCLUDED IN TABLE 2

IA

NCO

NSA

PID

R

Rad Con

R/hr

V

INCONSISTENT WITH TABLE 2

AMPS vice Amp

amps vice Amp

Ft vice FT

D/P vice dP

S/G vice SG

gpm vice GPM

b. The Writer's Guide paragraph V.E.2 states, "the use of AND and OR

within the same action should be avoided." ECA-0.0 steps 32.a aWd b

both contain an AND/0R logic term.

c. The Writer's Guide paragraph V.F.2 states, "the contingency actions

will be specified for each circumstance in which the expected results

or actions might be achieved." ECA-0.0 step 22.a contains tiie

response not obtained action in the left hand column. Other

verification or monitoring steps which do not include response not

obtained actions include:

E0P STEP

ECA-0.0 1.c

ECA-0.0 8

ECA-0.1 15.c

ECA-2.1 31.c

_ _ _ _ _ _ _ -

. . _ . . _ _ _ _ _ _ _ _ _

. . _ _

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Attachment 8 9

.

'd. The Writer's Guide paragraph V.C.1.a states that expected indications

should be presented in the left hand column. ECA-0.0 step 22.b

which checks for DC Bus Loads does not specify the expected

indications,

e. The use of the words OR and AND.in the example in section V.A.3 and 6

1

of the Writer's Guide is inconsistent with the section VI.C.1 of .the .

Writer's Guide which allows underlining of OR and AND only if they'

are used as logic terms. The use of lower case letters for the

expected response in section V.A.7 of the Writer's Guide is

inconsistant with the section VI.B.1.f.3 statement that "any

condition following a hyphen in the left-hand column should be

capitalized." '

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