ML20153F930

Informs of Results of Identified Instances of Problematic or Deficient Performance as Documented in Insp Repts & Lers. Requests That Util Consider Info During Preparations for 981006 Public Meeting at Fort Calhoun Station

ML20153F930
Person / Time
Site:	Fort Calhoun
Issue date:	09/24/1998
From:	Gwynn T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Gambhir S OMAHA PUBLIC POWER DISTRICT
References
NUDOCS 9809290295
Download: ML20153F930 (26)

Text

,. -

,-n

~

~.

n - _, - -..

-.. _ ~. _ - -.

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

- * ~

Mmg %,k UNITED STATES -

NUCLEAR REGULATORY COMMISSION

<<,[q

,; i REGION IV o;

- 7

.g 611 RYAN PLAZA DRIVE, SUITE 400

'V 9...../

AR LINGTON, TE XAS 760118064 SEP 2 N j

Si K. Gambhir, Division Manager Nuclear Operations L Omaha Public Power District, Fort Calhoun Station FC-2-4 Adm.

P.O. Box 399 Hwy. 75 - North of Fort Calhoun 1 i

Fort Calhoun, Nebraska 68023-0399 1

E

SUBJECT:

J z

Dear Mr. Gambhir:

1 During our last plant performance review, conducted May 15,1998, NRC perceived a potential l

decline in Fort Calhoun S^ation performance, in order for us to better ' nderstand the possible u

reasons for this perception, we conducted a review of identified instances of problematic or.

deficient performance as documented in NRC inspection reports and Licensee Event Reports.

We attempted to identify common causes of this periermance in all four Systematic 1 Assessment of Licensee Performance functional areas. Tnis btter is to inform you of the l results of our analysis and to ask you to consider this information during your preparations for

' the public meeting we have scheduled to take place at Fort Calhoun Station on October 6, 1998.

One hundred twelve specific instances of deficient or poor performance dating from January 1, 1

1997, through July 31,1998, were compared to failure mode charts which addressed Human Errors and inappropriate Actions, Organizational and Programmatic Deficiencies, and Oversight and Cerrective Actions. The major causes for Human Errors and inappropriate Actions

-a lapps e,J to be inattention to detail and misjudgement. These two failure mode categories ~.

j f accounted for approximately 60 percent of the total human error failure modes identified, in the

. Organizational and Programmatic Deficiency chart, inadequate procedure scope and detail.

7'.

accounted for approximately 45 percent of the deficiencies identified.' Oversight and Corrective

'Actiod deficiencies were more widely distributed,~with failure modes related to inadequate

! corrective actions accounting for approximately 17 percent of the total. Inadequate feedback,

j l variat'ons in expectations, and inadequate attention to training each.lecounted for

'approximately 10 percent of the Oversight and Corrective Action failures.

j

. Enclosed you will find charts' representing the most significant failure modes identified from the L

three failure mode charts and supporting examples from the NRC Plant issues Matrix. ' Also

' included is a chart indicating the functional area distribution of Human Error or Inappropriate i

(^J LAction failure modes and the numtier of failure mode hits in each functional area per hour of j

NRC inspection.

i r

j ry t

While we recognize that our evaluated sample data base was not inclusive of all deficiencies

,that have been identified at your facility, we believe that our independent review does provide -

980929029S 980924 POR ADOCK 05000285/

L',

e PDR ;

i' u

u.

... -..~ ~. -. -..

s

~

Omaha Public Power District,

insight into the causes for deficiencies that resulted in our perception of a performance decline.

L

. at the station. We encourage you to consider this information as you prepare your October 6 l

" presentation regarding the results of your own common cause analysis.;We are particularly-

~

interested in'any areas where our results differ significantly from your own.

' If you have any questions concerning this matter, please contact me (817/860-8248) or s Mr. W. D. Johnson (817/860-8148) of my staff.

l.

p-Sincer L

1 T omas P. Gwynn, irect Division of Reactor roj L

Docket No.: ~ 50-285 License No.: DPR-40

Enclosure:

As stated '

i R

cc w/ enclosure:

James W. Tills, Manager l

Nuclear Licensing Omaha Public Power District -

Fort Calhoun Station FC-2-4 Adm.-

P.O. Box 399 1

Hwy. 75 - North of Fort Calhoun Fort Calhoun, Nebraska 68023-0399 L

James W. Chase, Division Manager Nuclear. Assessments

' Fort Calhoun' Station P.O. Box 399 Fort Calhoun, Nebraska 68023 J. M. Solymossy, Manager - Fort Calhoun Station -

-Omana Public Power District l

Fort Calhoun Station FC-1-1 Plant l

P.O. Box 399 n

j Hwy. North of Fort Calhoun -

- Fort Calhoun, Nebraska 68023 i

h.

Perry D. Robinson, Esq.

- Winston & Strawn l

L Washington, D.C. 20005-3502

1400 L. Street, N.W.

[.

\\.

u r,.

...~

~

1 l

Omaha Public Dawer District. ;

Chairman ~'

Washington County Board of Supervisors Blair, Nebraska' 68008 4

Ch'eryl Rogers, LLRW Program Manager Environmental Protection Section

' Nebraska Department of Health

301 Centennial Mall, South

. P.O. Box 95007

' Lincoln, Nebraska 68509-5007 i

I l

i i

~l I~

l' p

l <

i,

Omaha Public Power District S@ 24 @

'bcc to DCD (IE51)'

j

. bec distrib. by RIV:

Regional Administrator DRS-PSB DRP Director MIS System

- Branch Chief (DRP/B) ~

RIV File Project Engineer (DRP/B)

Branch Chief (DRP/TSS)

Resident inspector W. B. Jones, DRS H. F. Bundy, DRS E._ G. Adensam, NRR (MS: 13E4)

DRP Directors, RI B. A. Boger, NRR (MS: 14E4)

DRP Director, Ril W. C. Walker, SRI, FCS DRP Director, Rlli L R. Wharton, Project Manager, NRR A. T. Howell, Director, DRS 1

1 i

I l

i

- To receive copy of document, indicate in boxi "C" = Copy without enclosqres "E" = Copy with enclosures "N" = No copy RIV:SPE:DRP/B C:DRP/B ( [

D:DRP

,N _

l l

DNGraves;dfM WDJohnspfI TPGwynn l/V/f 9/W/98 4

9/ M98 "

9/2 'f98 OFFICIAL RECORD COPY

~.

L ' [

l Omaha Public Power District 4..

SEP 2 41998 bec to DCD (IE51) bec distrib. by RIV:

Regional Administrator DRS-PSB DRP Director MIS System

' Branch Chief (DRP/B)

RIV File Project Engineer (DRP/B).

Branch Chief (DRP/TSS)

. Resident inspector W. B. Jones, DRS H. F. Bundy, DRS E. G. Adensam, NRR (MS: 13E4)

~ DRP Directors, RI B. A. Boger, NRR (MS: 14E4) 1 DRP Director, Ril W. C. Walker, SRI, FCS DRP Director, Rill L. R. Wharton, Project Manager, NRR A. T. Howell, Director, DRS i

i To receive copy of document, Indicate in box: "C" = Copy wthout enclosures "E" = Copy wth enclosures "N" = No copy RIV:SPE:DRP/B C:DRP/B ( ),

D:DRP fl _

l DNGraves;dfy WDJohnspyI TPGwynn l/V 7

/

9/W/98

\\

9/ 'YJ/98 "

9/2.198

. OFFICIAL RECORD COPY o.=a_q009 y-~

p

....__m..

ENCLOSURE-I Human Errors or Inappropriate Actions i

200 l

170 i

i t

i i

150

(

l f

As 100 78 0-i 4

Misinterpretation of InformationI Lack of Info V or V Inadequate Training I

Unawareness Wrong Assumptions Mindset Tunnel Vision

Human Errors or Inappropriate Actions 250

-- 0.3 i

f I

1 0.266 l

l 1.209 0.226 0 25 g

. = =. - -

200 t, --

192 I

I

- 0.2 2

153 150

=

a 2

. 0.14 117

- 0.15 7:

100 h

1

-!!j 0.088 s

Li

- 0.1 W

he.

1-6

+

50 m

. e

.m

-- 0.05 m

os 4

3 p

Lg l

3 w,

4 gg i

E

'$9 O

i "i

"T i

-0 Y1 Y2 Operations Plant Support Maintenance Engineenng Failure Mode Hits (Y1) i

(

Failure Mode Hits per inspection Hour (Y2) i

Failure Mode: Inattention to Detail-Unawareness Common Cauces:

inadequate Work Schedule e

inadequate Work Practice e

inadequate Communication e

==

Description:==

Not oaying attention to alarms, signals, precautions, or information that are not contained in procedures or guidelines DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 05/2098 V10 IR 98-11 NRC MAINr 1B 5A Operatens personnel d d not initiate a maintenance work document to document a defacency we Alarm Test SLIV Vatve FP-230 in accordance we Stardng Order So-O-1. This was a vdaten of 10 CFR Pad 50. Apperex B. Cntenon V.

0505/98 NCV tR 98-09 LICENSEE PS 3A The licensee failed to property label 15 bags of radioactive matenai in the radioactive waste buiteng as required by to CFR 20.1904. This nenrepetstrve, hcensee-ident&ed and corrected vdation is bemg treated as a noncited vdaten, consistent with Secten Vll.B.1 of the NRC Enforcement Poicy.

04/02/98 VIO 1R 98-09 LICENSEE OPS 1A Failure to adhere to 10 CFR 50, Apperda B. Critenon 5. resulted in inadequate procedure gudance dunng a plant SLIV 1R 98-05 cooldown. This m cceranction with operatens personnel confusion over wde range pressure instrumentaten inaccuracies, resulted m the reactor coolant system pressure being lowered to the point where Reactor Coolant Pump RC-3C cavitated. This closed t)nresolved item 285/9805 08,21/97 Weakness IR 97-17 NRC OPS The operateg crew had numerous opportunities to identify that the containment spray system was inoperable. Each of the control room operators mvolved with the event failed to demonstrate a questoning att:tude corvNg the ht annunciators. Crew supervision failed to provide adequate overs.ght dunng the performance of & arveillance test 08/21!97 V10 IR 97-17 LICENSEE OPS The shift tumover was inadequate. Operators ed not questen the cause of the contamment spray valve off-norrnal SL 111 alarms and they did not verify the status of the containtnent spray system.

06/27/97 NCV IR 97-12

.iCENSEE PS A nonoted vdaten was identif>ed involving mcomplete and inaccurate background ovestigations.

05m3'97 VIO IR 97-07 NRC ENG A violaton was identifed when engineermg personnel failed to initiate a a work request tag to identify a steam seak on SLIV the steam trap inlet valve for the turboe-dnven auxikary feedwater pump _ The same item was identifed as an operatons weakness for failing to identify the leak.

04/2197 NCV IR 97-09 UCENSEE PS The bcensee dentAed that a fire watch was not established withm the required time after placmg the fire pumps m pull-tolock ourmg the extracton steam line rupture event. The spnnkler systems were out of service for approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />. Fire watch was required within I hour.

Failure Mode: Misjudgement - Misinterpretation of Information Common Causes:

Inadequate Verbal or Written Communication Inadequate Man-machine Interface

==

Description:==

Information not used correctly in the decision-making process DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 04/24/98 VIO IR 98-07 NRC MAINT 38 As a result of a trusinterpretation of a regulatory requirement, a volation of 10 CFR 50 55a(g) was dentified for the SL IV licensee's failure to subrmt in 1984 and 1994 rehef requests following the first and second 10-year intervals for ASME Code Class welds that did not receive 100 percent full examinaton coverage.

03/10/98 Weakness IR 98-01 NRC ENG 4A There was a fadure to identify that cable quahficaton firs test entena conducted in 1971 did not support a 10 minute response pened for a cable spreading room fire. This was considered to be an engineenng weakness in the fire protecten program. Compensatory actions were irnplemented and modifications were planned to eliminate rehance on the cable quahficaton fire test entena.

08/02/97 Weakness IR 97-15 NRC PS Due to a procedural mistien sie AQ. the selfi:entained breathing apparatus regulator flow test records were not documented appropriately. Once pointed out by the inspectors, the test records were correctly documented.

06/10/97 VIO IR 97-09 NRC MAINT tt was detemuned that the hcensee had missed a potential opportunity to detect the degraded elbow by not consdenng the SLIV EA 97-280 k@i-of an upstream pipe replacement of a similar large radius elbow that had occurred m 1985 and had not adequately considered industry operating expenence in the selecten process to determine inspection locations to identify pipe wall thirring Additionally, the inspectors noted that the licensee's ana'ytical model for predictmg the relatrve wear rate of components (CHECWORKS) had not accuratety predicted the actual observed wear rates associated with large radius elbows in the fourth stage extraction steam system. 10 CFR 5045(a)2 violatiort 05/1~47 VIO 1R 97-11 NRC OPS The bcensed operators fa: led to follow procedures when they did not change the plant startup procedure to document the SLIV necessary adjustments made to the boron concentration and control rods to acheeve ent cality. This was a volation of Techrucal Specification 5 8.1.

Failure Mode: Misjudgement-Wrong Assumptions Common Causes:

Inadequate Training Inadequate Man-machine Interface

==

Description:==

Erroneous assumptions used in decision making DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 05/23/98 Negative IR 9849 UCENSEE ENG 3A dB Durmg the development of a modzfication package, design engineenng personnel incorrecuy interpreted the efted of removmg power from certam electncal estnbution penets. When power was removed from Electncal Distnbution Panet Al-41B. the desel-driven fire pump received an inadvertent start sagaal.

04/25/98 Negatrve IR 98-09 UCENSEE OPS 1A Dunng emergency desel generator restoration following maintenance, operators overtooked the fact that the offsite low signal (low bus voltage) would cause the diesel to start. When operators moved the mode selector switch from off auto to emergency standby the desel generator started as designed. This was not anticipated bv operations personnel 03/31/98 HCV IR 9845 NRC ENG 38 48 Failure to understand the requirements for use of engmeenng judgement and to property document the use of engineenng judgement resulted in a.pe vibrator being used on 3-inch pping when it had only been evaluated for use on 4-mch pping This failure is being treated as a noreted violation consistent with Section IV of the NRC Enfo cement Pohcy.

09/21/97' NOV IR 97-18 LICENSEE OPS Reactor operators faded to perform necessary me w ;y actons in response to a low tube oi; Mwel alarm on Reactor w

Coolant Pump 38.

09/13s 7 NCV 1R 97-16 UCENSEE MAINT Inadequate maintenance rule scoping resulted in the fire protection system pping and the deluge valves not bemg considered withm the scope of the maintenance rule.

02'24/97 Weakness IR 97-03 N'

MAINT A weakness was identified in that mantenance planning 6d not know how much water needed to be drained from the shutdown coolmg cross connect piping. Additionally, the planners did not identify that the peping could not be completely dramed without some esassemtty. This resulted in indviduals receivmg unnecessary radation dose.

Failure Mode: Misjudgement - Lack of Information Validation or Verification Common Causes:

Inadequate Verbal or Written Communications

+

inadequate Supervisory Methods e

D:scription: Erroneous information used in decision making DATE TYPE SOURCE ID SFA TEWLATE ITEM DESCRIPTION WDE i

12/06/97 V10 IR 97-19 NRC OPS 1C The bcensee's w4. -.; integnty operateg instruction was inadequate in that all contamment peneVations needed to SLIV estabhsh contamment integnty were not included m the operstmg instruction. Five penetrates (4 electncal and 1 papeg) were ornitted dunng the last proch revision.

10/17/97 LER LER 97-015 LICENSEE ENG 2A 4A The station battenes may not tr capable of supplyng the 8 hour9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> design capacity in all acaderd scenanos. Compensatory EN 33102 measures invoNog operator acta: ins to minirnae loads under design basis acodent conditions were implemented to restore battery cquratslity concems.

O&T/97 VIO EN 32799 LICENSEE MAINT Dunng the instial setup portion cf a surveillance test, the test lead placed the control switches for the containment spray SL lit IR 9717 header isoletion valves in the OVERRIDE posation contrary to the surveillance test procedure. Thes acts rendered the contamment spray system inoperable.

OU14/97 LER LER 97-007 LICENSEE MAINT The hcensee failed to document RCS flow voltage enessurements for one shift as required t, techrucat specifications.

06/06/97 Weakness IR 97-04 NRC PS Overall, the performance of the emergency operations facility staff was good. Emergency classatications, state and local notifications. and protective action recommendations were correct and tirnely. Bnefmgs were frequent and mcluded oput from operations. protective measures, and state representatrves. Field teams were effectively used to locate the plume and measure offsate consequences. Information control a the emergency operations facility was not always efiective.

Erroneous information concernog event classification times and radiological release start time was released oftsste, and an incorrect protective achon rmu.....

4. tion was reviewed and approved. Notifications to the NRC were not property documented. An unresobed item was identified related to signatures on notsfacation forms. The unresolved stem was closed in IR 97-16.

05/02/97 VIO BR 97 06 NRC ENG The licensee was effective in mantaining the design and operable status of the reviewed systems [auxikary feedwater, SLIV component cooling water, and raw water]. and engineers were knowleogeable of their assigned systems. However, weaknesses were dentified where surveillance test procedure acceptance entena for safety-related pumps were inadequate and where a design calculation was in error. An incorrect technical specification LCO involving the minimuo water level for the emergency feedwater storage tank was identified.

Fciture Mode: Misjudgement - Mindset Common Causes:

inadequate Training e

inadequate Supervisory Methods e

Inadequate Work Practice D:scription: Decision-making without seeking the facts and evidence objectively DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 02/26/98 VIO IR 98-05 NRC OPS 1A 3A The licensee conducted the safety-related actwity of lowenng the spent fuel pool level without a procedure contairung SLIV precautcr:s and mstructons. TNs is a violation of to CFR Part 50, Appendix B. Cntenon V.

01/17/98 VIO IR 97-20 NRC OPS 1C Operatens memorandums were t:eing used, m effect, to implement procedure changes without being processed in SLIV accordance with administrative requirements.

04/07/97 VIO 1R 97-07 NRC MAINT A volation was identified when -6 a-ws personnel faded to fonow their procedure to document the blockage of the raw SLIV l

water supply header flow transmitter sensing hnes while blowmg down the lines. Licensee was only documenting blockage if it required the use of a large nitrogen bottle source to dear the Ime_ Procedure states d r:itrogen is used. document 03'22/97 NCV 1R 97-06 NRC MAINT Three instances in wNch rnantenance personnel failed to property follow configuraten control procedures were identded (2 by NRC 1 tr/ icensee).1. (NCV) AFW inverse derivativs control relay missmg spnng 2. (NCV) SFP coolmg pumps and t

l IR 9743 demn water surge tank transfer pumps deflectors ddferent 02/08/97 NCV IR 96-18 LICENSEE MAINT The licensee identified 3 instances where.% a.

a personnel did not follow configuration control procedures. Tne items were: replacog spnngs and spiral pins on main steam line radiaten morutor isolaton valves; installing an actuator cytinder on a CCW outlet valve; and instaning a gasket on the safety injecten and refueling water tank went.

m

Failure Mode: Inadequate Skills or Knowledge - Inadequate Training Common Causes:

inadequate Managerial Methods e

==

Description:==

No training for the needed skills; trairling not complete or detailed enough DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 02/2'V98 Negative tR 98-05 LICENSEE ENG 3A 38 The methods for quahfymg new fuel recetpt inspectors were inconsistent. resu' tog in a co-op student inspectog new fuel New fuel receipt inspecton by a coep student 6d not meet hcensee management's expectatrons and resulted m the reinspection of 24 new fuel bundles.

01/27/98 Negat?ve

!R 98-04 NRC PS 1C 38 A firewatch was deterrnmed to be unsure of his duties and responsehties. The guidance promded to the cable spreading room firewatetes regar$ng notdication to the control room could not be performed as ongmally wntten.

01/17/98 NCV IR 97-20 LICENSEE PS 3A 38 Two bcensee personnet entered the radological control:ed area without proper dosimetry. This was determinea to be due to lack of persormel accountabihty, trainang deficiencies. unclear expectations.

08/02/97 VIO IR 97-15 NRC MAINT ineffective corrective action resu!!ed in a work request sticker not being removed from the control room panel as required SLIV by procedure. A second example of ineffective corrective action resulted in the lower disc wedge of the bonc sod totahzer bypass valve being broken due to overtorqumg.

05/06/97 Weakness IR 97-01 NRC OPS Mmor performance weaknesses and training deficiences were identified for bcensee and appbcant consideration and corrective action as appropnate. Subrect areas included containment spray interlocks. RCP lift oat pump mtertock, definition of major fuel damage, and RWP restnctions for work in the overhead.

Failure Mode: Inadequate Skills or Knowledge - Tunnel Vision Common Causes:

Inadequate Work Practice

==

Description:==

Actions or decisions without assessing the entire situation s

DATE TYPE SOURCE ID WA TEMPLATE ITEM DESCRIPTION CODE 04/25/98 Negative IR 98-09 UCENSEE OPS 1A During emergency desel generator restoration following rnamtenance, operators overtooked the fact that the offsae low signal (low bus voltage) would cause the diesel to start. When operators rnoved the mode selectur sutch from off auto to emergency standby, the desel generator started as designed. TNs was not antopated by operations personnel.

04/10/98 VIO tR 98-06 LICENSEE PS 1A 1C Dechnog radation worker performance was noted. Problems involving improper entry into tugh radation areas dosimetry SLIV use, and contamination control were identified. A noncited violation was identified when indviduals entered a high NCV radation area improperty. Discretum was exercised in accordance with Section vil B.1 of the NRC Enforcement Pohey.

However, a violation of Technical Specification 5.11 was identified when another radation worker entered a restncted high Weakness radation area improperty. A noncited viol.ation was identifed when an individual entered the reactor containment building without a themiolummescent dosimeter. Discretion was exercised in accordance with Sect <in Vil B.1 of the NRC Enforcement Pohey.

07/09/97 VIO IR 97-15 NRC PS The inspectors identified that licensee personnel ed not establish any compensatory measures pnor to blocking the SLIV sprinkler system in the,desel generator room.

04/21/97 NCV IR 97-09 LICENSEE PS The bcensee identifed that a fire watch was not estabhshed withm the required time after placing the fire pumps in pull-to-lock dunng the extraction steam line rupture event. The spnnkler systems were out of service for approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.

Fire watch was required within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />.

02/1M7 Weakness IR 97-03 NRC MAINT A weakness in maintenance planning when ven*ying the lower od reservoir level on a reactor coolant pump resulted in a maintenance techncan and a hee % physics techncan bemg exposed to unnecessary radiation dose.

-.1 m

1 Organizational and Programmatic Deficiencies 80 l73 i

t 70 f

~

A -Inadequate Scope B -Insufficient Detail j

~

C - Inadequate Job Skills, Work Practice, or Decision i

l Making 60 t

~~ -

D -Inadequate Communications Within the Organization i

E - Inadequate Interface Arnong Organizations F-Inadequate Self-Verification Process 50 48l

=

'j j

~

l40 40 4

t t

30 !c I

I 21 4

1 r

i 20 i-17 i17r -

l l

i 10 1

i Ol-A B

C D

E F

Failure Mode: Programmatic Deficiencies -Inadequate Scope Common Causes:

inadequate Program Design e

inadequate Feedback from the Field Work Force e

==

Description:==

Omission of necessary functions in procedures DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 05/20/98 Weakness IR 98-11 LICENSEE MAINT 28 The root cause of the madvertent deluge of House Service Transformer T1 A-3 was determined to be the tailure to pedorm preventive mantenance on the entire deluge system. This was considered a weakness in the preventwe maintenance program.

02/26/98 VIO IR 98-05 NRC OPS 1A 3A The licensee conducteo the safety-related activity of lowenng the spent fuel pool level without a procedure containng SL IV precautons and instructons. This e a volation of to CFR Part 50, Appendix B. Cntenon V.

01/27/98 Negatwe IR 98-04 NRC PS 1C 3B A firewatch was determoed to be unsure of his duties and responsituistees. The guadance provided to the cable spreading room firewatches regarding notifcation to the control room could not be performed as ongmally wntten.

01/17!98 VIO IR 97-20 NRC OPS 1C Operatons memorandums were bemg used, in effect, to implement procedure changes without being processed m SLIV accordance with administratwe requirements.

05/02/97 VIO IR 97-06 NRC ENG The licensee was effective in maintammg the design and operable status of the reviewed systems [ auxiliary feedwater, SL IV component cooling water, and raw waterl and engmeers wwe krowiedgeable of their assegned systems. However.

weaknesses were identified where surveillance test procedure acceptance enteria for safety-related pumps were inadequate and where a design calculaton was in error. An incorrect technical specifcaton LCO invo'vmg the rnmemum water level for the emergency feedwater storage tank was identifed.

05K'97 VIO EA 97-251 NRC PS The implementation of the fire protecton program was poor,in that, the inspection identifed Sve examples of the fadure to SL ill IR 97-06 property implement the fire protection program. These included. (1) diesel generator control circuits that were not EN 32510 protected from a fire, (2) an inadequate attemate shutdown procedure, (3) an inadequate water curtain, (4) an madequate LER 97-009 reactor coolant pump rnotor tube oil collecton system, and (5) inadequate control of fire pump operations. A 6th example involved failure to conduct required trainmg on fire brigade equipment. Otherwise. the fire protection program was satisfactory (equipment, detecton and alarm capability, procedures, staff, organization, administraton, and audits)

Additional weaknesses included knowledge weaknesses regarding the use of water to suppress cable hres A $55.000 CP was issued citing 5 violations as a Seventy Level til problem. The water evtain issue was not identifed as a volatron m the final action.

04/21/97 NOUE EN 32193 SELF MAINT A steam Ime break on a 12" extraction steam kne resulted in a manual reactor tnp declaraton of a NOUE due to the EN 32198 abnormal event, and initiaton of a significant asbestos hazard in the turbine building. Initial indicatons are that pNtv weaknesses in the eroson/corrosson program did not identdy the susceptitulity of this locaton to wall thinning.

021 -021 A LER 97-003

[

~

Fciture Mode: Programmatic Deficiencies -Insufficient Detail Common Causes:

Inadequate Program Design Inadequate Feedback from the Field Work Force

==

Description:==

Vagueness in procedures DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 04/10/98 Negative IR 98-06 NRC PS 1A 1C isolated weak ALARA program elements, involving the evaluaton of the effects of dose gradents on dosimetry locaton and the procedural guidance for evaluating the need for respiratory protecton equiprnent, were noted.

08/21897 Negative IR 97-17 NRC MAINT Surveillance procedure (containment spray) weaknesses included: multiple actons requered by one step. equipment nomenclature which effered from component labels; and fadure to address expected annunciators.

05/23/97 NCV IR 97-11 NRC OPS Operatmg Procedure OP-2A [ Plant Startup] had a weakness in that it did not provide guidance on actons to take if the reactor was not critical with all control rods sully withdrawn. A noncded. mmor violation was identifed for an madequate plant startup procedure. The procedure did not provide operator instruction for addressing a noncntical reactor condition with all Group 4 rods funy withdrawn. The reactor was maintamed m a safe constion, but operators delayed dnving m Group 4 rods while discussing the sduation of having all rods fully withdrawn wdhout having reached enticahty.

05/02/97 VIO IR 97-06 NRC ENG A discrepancy between the plant configuration and the Updated Safety Analysis Report was identified involving the desel-SLIV dnven auxdiary feedwater pump fuel oil day tank level. The issue was whether the tank needed to be maintained full or not to meet the USAR desenption for 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> of operation.

05/02/97 VIO EA 97-251 NRC PS The implementation of the fire protecton program was poor,in that, the inspection identified five examples of the fadure to SL !!!

1R 97-06 property implement the fire protection program. These included (1) diesel generator control circuits that were not EN 32510 protected from a fire, (2) an inadequate attemate shutdown procedure, (3) an inadequate water curtam. (4) an inadequate LER 97-009 reactor coolant pump motor tube oil collection system, and (5) inadequate control of fire pump operations. A 6th example involved failure to conduct required traming on fire bngade equipment. Otherwise, the fire protecton program was satisfactory (equipment, detection and alarm capabihty, procedures, staff, organizaton, admmistration, and audits).

Add:tional weaknesses included knowledge weaknesses regarding the use of water to suppress cable hres. A $55.000 CP was issued citing 5 violations as a Seventy Level ill problem. The water curtam essue was not identified as a violation a the feel acton.

Fcilure Mode: Organizational Breakdowns -Inadequate Job Skills, Work Practice, or Decision Making Common Causes:

Punitive Management Style Inadequate Supervision Inadequate Training or Staff Qualification Inadequate Vertical Communication Conflicting or Unreasonable Organization Goals

==

Description:==

Excessive human error rate; low morale DATE TYPE SOURCE 10 SFA TEMPT. ATE ITEM DESCRIPTION CODE 03/25/98 NCV IR 98-05 UCENSEE PS 3A Lack of proper posting by radiation protecton personnel resulted in maintenance personnel entenng mto a high radiation area to erect scaffolding This nonrepetdive, licensee-edentified and corrected violaton is being treated as a noncated violation consistent wdh Secten Vll.B.1 of the NRC Enforcernent Pohey.

12/0W97 NCV 1R 97-19 UCENSEE ENG 4B In 1995, licensee personnel failed to perform an annual evaluation of nonfuel items in the spent fuel pool.

08/21/97 VIO IR 97-17 UCENSEE OPS With all three contamment spray purnps inoperable. Techncal Specification 2.4 was not satisfed, and the und was not SL 111 LER 97-012 p aced in het shutdown or in a subentical conditon with temperature <300 deg F within the required trne mtervals of Technical Specifcaton 2.0.1.

08/21/97 V10 IR 97-17 UCENSEE OPS The shsft tumover was inadequate. Operators did not question the cause of the contamrnent spray valve off-normal alarms SL lit and they did not venfy the status of the containment spray system.

07/18/97 VIO IR 97-13 NRC ENG Engineering exhibited good performance in the disp >sition of the engineenng assist requests reviewed by the mspectors.

SLIV One example was identifed where a conditon adverse to quality was not reported on a conditon report.

Failure Mode: Organizational Breakdowns - Inadequate Communications Within the Organization Common Causes:

Inadequate Information Path Lack of Teamwork Culture Inadequate Physical Settings

==

Description:==

Important issues not addressed; breakdown of normal work processes; low staff morale DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 01/28/98 Negatwe IR 98-04 NRC PS 38 A weakness was identdied in the thoroughness of a prejob bnefing for rnovement of a radweste container in that questons conceming actions to be taken if the waste container were dropped were not answered.

08/21/97 Weakness IR 97-17 NRC OPS Several of the deficiencies ioentifed in this event (dsabling of containrnent spray) are similar to ths identifed causes for the March 18,1996 event invoMng dsatnng the low temperawre overpressure protection function.

08/21/97 VIO IR 97-17 LICENSEE OPS With al! three containment spray pumps inoperable. Technical Specdcation 2.4 was not satisted, and the unit was not SL lit LER 97-012 placed in hot shutdown or in a subentcal conditon with temperature <300 deg F withat the required tune intervals of Techncal Specification 2.0.1.

08/21/97 VIO

!R 97-17 LICENSEE OPS The shift turnover was inadequate. Operators did not question the cause of the containment spray valve offwxmai alarms SL lit and they dd not venty the status of the containment spray system.

07/09/97 VIO IR 9715 NRC PS The inspectors identified that licensee personnel dd not estabhsh any compensatory measures pnor to blocking the SL IV spnnkler system in the desel generator room.

~

s Fciture Mode: Organization to Organization Interface Deficiencies -Inad6quate Interface Among Organizations Common Causes:

4 l

Lack of Interface Formality Inadequate Teamwork or Trust Among Organizations inadequate Physical Settings e

==

Description:==

High human error rate in tasks requiring communication among organizations DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 05/20/98 VIO tR 98-11 NRC MAINT 18 5A Operations personnel dut not inmate a maintenance work document to document a dehciency with Alarm Test SLIV Valve FP-230 ir. he.c6 with Standing Order SOC-1. This was a violaton of to CFR Part 50. Appenox B. Cntenon V.

j 01/14.98 Negative IF' 93-04 LICENSEE OPS 1A 3A 48 Competing onormes and poef communcations resulted in system engineenng personnel not providing tsenety feedback to the cnntrol room operators regareng the operatukty of the i m:-- v i sarnplog system. This resulted in the entire postaccident sampling system being declared enoperable when only the gaseous portion needed to be declared snoperable.

05/09/97 NCV IR 97-02 LICENSEE PS Emergency events were correctly classified. A nonoted violaton was identifet related to a late notdicaton made to the state of Iowa regarding declarat:on of an emergency. NOUE related to a steam leak. Notification to lows in 17 mmutes vce 15.

OsM97 Weakness IR 97-07 NRC OPS Although the mantenance work document to resolve an operator work around was ready to work, operatons personnet Gd not ensure the operator work around was reso'ved in a timely manner. The work around involved a pulled annuncator card that required operators to venfy the position of each valve, and its breaker, that fed into the annunciator every four hours.

02 M 97 OBS IR 96-18 LICENSEE PS The licensee identified that sampling of an emuent release via the auxiliary buildmg ventilaton pathway was degraded because equipment necessary to sample the effluent had been relocated without the knowledge of chemistry personnel.

Lack of commurucaton arnong radiaton protecton, chemistry, and emergancy preparedness personnel was the cause.

l l

9

Failure Mode: Programmatic Deficiencies - Inadequate Self-Verification Process Common Causes:

inadequate Program Design e

==

Description:==

Program breakdown by a single human error; high program failure rate; poor procedure quality DATE TYPE SOURCE 10 SFA TEMPLATE CEM DESCRIPTION CODE 11/07/97 LER LER 97417 UCENSEE ENG 2A The low pressure safety injection system may be susceptible to water hammer loads e excess of pipeg support EN 33232 allowaNes. The hcensee bel eyes the current opersbng configuration ensores system operabsty, but the system may have been operatog in an unanalyzed condition in the past.

08/21/97 Weakness IR 97-17 NRC OPS The operating crew had numerous opportunites to identify that the containment spray system was inoperable, Each of the control room operators involved with the event failed to demonstrate a questming attitLde concerneg the ht annunciators.

Crew supenrision failed to provide adequate oversigrd dunng the performance of the surveillance test.

08V2/97 Weakness IR 97-15 LICENSEE PS The licensee determined that the enticahty mondor in the new fuel receipt area was not sensdive enough to detect a wicanty accident.

i 04/21/97 NOUE EN 32193 SELF MAINT A steam line break on a 12" extraction steam line resulted in a manual reactor tnp. declaration of a NOUE due to the EN 32198 abnormal event, and intbate of a significant asbestos hazard in the turtyne buildmg. Initial indications are that PN IV-97 weaknesses in the erosion / corrosion program did not identify the susceptibsty of this location to was thmnmg 021.-021 A LER 97-003 01/22/97 EN EN 31632 LICENSEE ENG bcensee determoed that past operations wrth one or two main steam safety valves inoperable, as aHowed by technical LER LER 97-001 specrhcations, pbced the unit m a cond: tion outside its design basis rega@ng steam generator secondary sede pressure followng certain transients. Inadequate vendor revew of code inodeling Las determined to be the cause.

i I

Oversight and Corrective Action Failures 25 23 l

I 20 i

~

i i

I i

I l

l 15 1

I 13 13 13 P

10 !-

i f

52-i l

0l i

Inadequate Feedbacit Expectation Variations inadequate Adjustment Inadequate Attention to Training l

Failure Mode: Control Errors-Inadequate Adjustment Common Causes:

inadequate Accountability inexperienced Management Lack of Technology-based Training Inadequate Scope of Adjustment Complacency

==

Description:==

Corrective actions not derived; inadequate corrective actions; no ownership DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRPTION CODE 01/17/98 NCV IR 97-20 LICENSEE PS 3A 38 Two licensee personnel entered the radclogmal controlled area without proper dosimetry Ttus was deterrruned to t e due to lack of personnel accountability, trairung defciencies, unclear expectations.

08/21/97 Weakness IR 97-17 NRC OPS Several of the deficiencies identifed in this event (dsatWing of containment spray) are smular to the identified causes for the March 18,1996 event involving dsabling the low temperature overpressure protection functiort 08/0/197 VIO IR 9715 NRC MAINT ineffectwo correct =ve action resulted in a work request sticker not being removed from the control room panel as required SLIV by procedure, A second example of ineffectue correctwo action resulted in the lower dse wedge of the bonc acid totalizer bypass valve bemg broken due to overtorquing.

07/18/97 VtO M 97-13 NRC ENG Engmeenng performance in the espositen of condition reports was good. though several problems were noted including SLIV one instance where a precondition concem was not addressed; thrue instances where generic impications were not adequately consWred; and one instance where the cause of an event was not determined. A concem related to the manner in which the licensee and the vendor handled a butterfly valve overtorquing event was also identified.

06/10/97 VIO IR 97-09 NRC MAINT h was determined that the licensee had missed a potential opporturuty to detect the degraded elbow by not considermg the SLIV EA 97-280 implications of an upstream pipe replacement of a similar large radus elbow that had occurred in 1985 and had not adequately conssdered industry operating experience in the selection process to determine inspection locations to identify pipe waE thmrung. Additionally, the mspectors noted that the licensee's analytcal model for predcting the relatwe wear rate of componer:ts (CHECWORKS) had not accurately predcted the actual observed wear rates associated with large radius elbows in the fourth stage extrachon Psam system. 10 CFR 50.65(a)2 violation.

06/06/97 Weakness IR 97-04 NRC PS Overall. the performance ci the emergency operations facAty staff was good. Cr picy classitcations. state and local notifications, and protective action recommendations were correct and t;mely. Bnefings were frequent and included input from coerations, protectwo measures, and state representatives. Feld teams were effectwefy used to locate the plume and measure offsite consequences Information control in the emergency operations facility was not afways effectwe.

Erroneous information conceming event classication times and radological release start time was released offsite, and an mcorrect protectwo action im.ummo, Ation was reviewed and aporoved. Notifications to the NRC we e not property documented. An unresolved item was identified related to signatures on notifcation forms. T% unresolved item was closed in IR 97-16.

Fcilure Mode: Control Errors - Inadequate Feedback Common Causes:

inadequate Feedback Mechanism e

Complacency inadequate Format to Cover Management, Supervision, and Workers e

==

Description:==

Root common causes not known by the right people DATE TYPE SOURCE ID SFA TEMPLATE ITEM DESCRIPTION CODE 05/20/98 VtO IR 98-11 NRC MAINT 1B 5A Operatons personnel did not irutiate a mantenance work document to document a deficency with Alarm Test SL IV Valve FP-230 in accordance with Stand;ng order SO-O-1. This was a volaton of 10 CFR Part 50, Appendix B. Cnteren j V.

03,t)3/96 LER LER 98-001 LICENSEE MAINT 28 During a self-assessment, the licensee identified that the in-Service Test Program did not provide a test to venfy satisfactory operation of the remote positen indicaton function of several passNo, safety-related valves.

07/18/97 NCV 1R 97-05 NRC PS A good radiological emnronmental monitoring program was implemented. Environmental monitonng statens were property maintained with operable and calibrated equipment. A non-cited violaton was ident: fed regardmg the failure to initiate a condition report when an environmental semple was lost.

j 06/06/97 Weakness IR 97-04 NRC PS Overall, the pedctmance of the operatons support center staff was generally good. The operatens support center was activated in a timely manner. Teams were dispatched prompt'y and generaMy able to perform assigned tasks. however, several areas for irnprovement were identified related to documentaten and briefings. An exercise weakness was identified related to the failure to demonstrate the atzhty to staff emergency response facihtes on a prolonged basis. An exerose weakness was identifed related to protective rnessures (potassium iodide) for onsite personnel.

0506/97 Weakness IR s7-01 NRC OPS Mmor performance weaknesses ed traming defciences were identified for licensee and apphcant consderaton and corrective action as appropnate. Subject areas included contamment spray interlocks, RCP hft oil pump intericck, definition of map fuel damage, and RWP restrictons for work in the overhead.

---

.o

=

6 Failure Mode: People Cultivation Errors -Inadequate Attention to Training Common Causes:

inadequate Resources Allocauon inadequate Management Expectations e

inadequate Demand for Self-Training and Improvements e

==

Description:==

Low knowledge and skills DATE TYPE SOURCE (D

SFA TEMPLATE ITEM DESCRIPTION CODE 02/13/98 VtO 1R 98-02 NRC OPS 38 5A The fadure to ensure that a quahty assurance lead audtor had completed the quahty assurance auditor quahtcation SL IV manual pnor to conductog quahty-related audts was a violation of Technical Specihcaten 5 8.1.

01/t7/98 NCV tR S~ 20 LICENSEE PS 3A 38 Two licensee personnel entered the m%.wi controGed area without proper dosunetry. This was detemuned to be due to lack of personnel aco:iuntabihty, trammg deficiencies, unclear expectations.

08/21/97 Weakness IF. 9717 NRC OPS Several of the dehciencies identifed in thss event (osabhng of contamment spray) are sunniar to the identified causes for the March 18,1996, event involvmg dsabbng the low temperature overpressure protecten funchort.

06/0& 97 Weakness la 97-04 NRC PS Overall, the performance of the operations support center staff was generally good. The operat.ons support center was activated in a tunely manner. Teams were despa*ched promptty and generaliy able to perform assigned tasks, however, several areas for improvement were identifed related to documentaten and briefogs. An exercise weakness was identihed. elated to the fadure to Jernonstrate the abihty to staff emergency response facilites on a prolonged bases. An exercise weakness was identifed related to protective measures (potassium iot / 4) for onsite personnel.

05/02/97 VIO EA 97-251 NRC PS The implementation of the fire protection program was poor, in that, the inspection identifed frve examples of the fadure to SL til IR 97-06 property imolement the fire protection program. These included: (1) deset generator control circuits that were not EN 32510 protected from a fue. (2) an inadequate altomate shutdown procedure, (3) an inadequate water curtain, (4) en inadequate LER 97-009 reactor coolant pump motor tube oil collection system, and (51 inadequate control of fire pump operatons. A 6th example involved failure ts conduct required training on fire brigade equipment. Otherwise. the fire protection prcgram was satisfactory (equipment, detecten and alarm capabihty, procedures, staff, organization, admwvstration, and audits).

Additional weaknesses included knowledge weaknesses regardmg the use of water to suppress cable f;tes. A $55,000 CP was issued citmg 5 volations as a Seventy Level sit problem. The water curtain issue was not identifed as a volation m the final action.

L

Failure Mode: Management Expectation Errors - Expectation Variations Common Causes:

Inadequate Enforcement Motivation Inadequate Supervision Too Many Expectations a

Poor Communication of Expectations

==

Description:==

Procedure non-compliance; low job performance DATE TYPE SOURCE 10 SFA TEMPLATE ITEM DESCRIPTION CoOE 1 t/21/97 V)O 1R 97-19 NRC OPS 1A 3A In general, the conduct of operations was professional and safety-conscious. However, the inspectors identaed an atmosphere which was nonprofessional in that breakfast was being cooked in the ma.n control room.

SLIV 08/21/97 VIO IR 97-17 LICENSEE OPS Failure to document the changes in the operational status of safety -W in the official control room logs, as requered.

was indcative of a tack of attention-to detail in the conduct of control room operations.

SL IV 07'18/97 NCV tR 97-05 NRC PS A non-citeo Mation was identified for the failure to submit a permanent shieleng request. Engmeennw department's review of temporary sheeldng installations dd not rnest irerspi.or.fs 6 month excectation on a number of occasens.

07/1897 Weakness IR 97-05 NRC PS The tW spot rediction program dd not meet management's expectation for timely wvaluaten and pnor$zaten for removal of some hot spots 07/1W97 VIO IR 97-13 NRC ENG Engineering exhibited good performance in the dspostbon of the engineenng assist requests reviewed by the msoectors.

One example was identified where a ::endition adverse to quality was not reported on a constion report.

SL IV 05/02/97 VK) tR 97-06 NRC ENG A dscrepancy between the plant configuraton and the Updated Safety Analysis Report was ident6ed involving the desel-dnven auxiliary feedwater pump fuel oil day tank level. The issue was whether the tank reeded to be maintained full or not SL IV to meet the USAR desenption for 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> of operation.

02/08'97 VIO IR 97-10 NRC MAINT The fhnger ring on the outboard thrust beanng of a CCW pump was not installed durmg maintenance on the pump. and the SLIV IR 96-18 conditon was not documented by the technician or communicated to staten.isie oi nt.

- v b

)