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l i CONFIDENTIAL 1
4 PP&L, INC.
CORPORATE AUDIT SERVICES Investigation of Radwaste control Room offgas Panet Alarm 1 Testing by Auxiliary system operators at susquehanna ses
! Job Number 739459-2-98 a
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DO NOT COPY OR DISTRIBUTE
' THIS REPORT WITHOUT THE PERMISSION OF THE
- MANAGER - CORPORATE AUDIT SERVICES i
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Sr. Audit Consultant: /4/ Dem"#.4. Dade TO: Mr.C.T. Jones CC: Mr. W. F. Hecht Audit Team Leader: /4/ 7fr-~ 8. M Mr.F.A.Long Reviewed By: /4/ 7X4stus 7. %
Date issued: February 10.1998 Mr. R. C. Byram Mr.R.J.Crey Mr. J. R. Biggar Mr. C. P. Pinto Mr.C.J.Kuczynski A>
! V 9902000064 990129 PDR FOIA > l .
SORENSEN99-36 PDR jj ffo208ccby-
1 February 10.1998 Comorate Audit Services ( Auditing) has completed investigations of circumstances and events at the Susquehanna Steam Electric Station (SSES) surroundine four concerns raised by a former Nuclear Plant Operator (Former NPO).
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This report focuses on the allegation made by the Former NPO that. at times.
Auxiliarv System Operators ( ASOs) did not perform required tests of the Radwaste Control Room (RWCR) Offgas Panel Alarm.
Auditing reported the investigative results of the three other concerns raised
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bv the Former NPO irithe following two reports: " Investigations of Allegations that Management Misrepresented Alarni Test Information to tfie Nuclear Ree~ulatorv Comrnission" issued October 15,1997; and, " Investigation of Allegations that Plant Control Operators Did Not Perform Certain Alarm Tests" issued December 1,1997.
The objectives of this investigation were to:
. gather the facts surroundine ASO testing of the RWCR Offgas
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Panel Alann (alarm); and. ~
. determine whether or not, at times. ASOs did not perform required tests of the alarm.
During the course of the investication. Auditing interviewed 13 individuals -
who had responsibilities for conducting tests 6f the alarm durme the period Januarv
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throuch June 1996. Of the 13 individuliis interviewed. 9 were ASOs and 4 were NPOs who performed ASO duties during thisperiod. (Note: Hereinafter in this re Auditing will generally refer to these la individuals collectively as ASOs.) port, See Exhibit A for a list of personnel interviewed in connection with this investigation.
EXECUTIVE
SUMMARY
The overall evidence 2athered in this investigation substantiates the
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allegation. Auditing concluded that. at times (prior to NPO alarm test issues in the E-Diesel Generator B~uilding), ASOs did not perform required tests of the alarm. vet signed the ASO Turnover SheetIndicating that they had. Nuclear Operations took correcti ~e actions to address issues related to the E-Diesel Generator acuvities and the evidence indicates ASOs subsequently tested the alarm as required.
The remainder of this report includes background information, our action plan for conducting this investigation and additional support for our conclusions.
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i BACKGROUND In Mav 1993 Nuclear Operations personnel added Line #7 to the Offeoine ASO Checklist (See" Exhibit B) per Nuclear Department Procedure OP-AD-003 (S5ift -
Routine). This addition provided a checkbox for ASOs to indicate that all RWCR Annunciators (which included the RWCR Offeas Panel Alarm) were tested successfully
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during their shift The Offeoing ASO Checklist did not saecifv acceptance criteria" for l performing this test. Auditing did not identify a specific Mot Box communication in 1993 !
tor this adilition to the Offgoing ASO Checklist. !
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s ACTION PLAN In performing the investigation. Auditing took various actions including: )
e interviewing the Former NPO in order to obtain details relating to l his concerns; !
e interviewing personnel required to test the alarm during the period January through June 1996 (this included all current ASOs and NPOs who were requalified to work as ASOs during this _
period):
e interviewing a Plant Control Operator (PCO) identified bv the l Former NPQ as possibly having knowledge pertinent to this mvestigation; e reviewing ASO Tumover Sheets; e reviewing documentation including, but not limited to, the history and communication of the ASO Turnover Sheet i requirement for testing the alarm:
e obtaining and reviewing computer point data of ASO testing of the alarm during the period January through October 1996; e interviewing other relevant SSES personnel: and.
. analyzing information obtained and developing conclusions.
SUPPORTING DETAILS FOR CONCLUSIONS i
Management's Excectations for Testine the RWCR Offeas Panel Alarm }[,
Auditing interviewed the [ ] who ,
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stated that Nuclear Operations management's expectation was that the alarm is to be tested once per shift. However, the [~ ] told us there were extenuating '7 circumstances that could explain why the alarm was not tested. The [ ] provided l
i the following reasons:
- e there were two ASOs assigned to the RWCR and i'. could be confusing as to which ASO was responsible for performing the test; e normally, the requirement for operator actions relating to
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equipment are on round sheets and not on the turnove sheet; and.
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'i e the ASO requalification training for NPOs working as ASOs could have better emphasized tfie n quirements for~the turnover process.
Analysis ofInterview Results and Comouter Point Data Auditing interviewed the 13 ASOs and learned that:
. 7 of 13 (54%) ASOs stated that thev performed the alarm test i during the period January through June 1996; l
. 4 of 13 (31%) ASOs stated that they performed the alarm test I since the time they became aware of the requirement (although they stated they could not recall when they became aware of the requirement); and.
. 2 of 13 (15%) ASOs made statements indicating thev did not perform the alarm test during the period January through June 1996.
Of the two ASOs who indicated that they did not perform the test during the period January through June 1996, one indicated that fie was not aware of the requirement -
to test the alarm until ader the E-Diesel Generator Misalignment event. The other ASO
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indicated that he learned about the alarm test requirement after reading it on the ASO Turnover Sheet in September 1996. He also stated that he didn't know whether or not he performed the alarm test during the period January through June 1996.
During the period Januarv through June 1996, Nuclear Operations personnel assigned up to two ASOs to 'the Radivaste building during a shift. We asked ASOs to explain their criteria for checking Line #7 of the ASO Turnover Sheet indicating that the alarm test was performed. Generally, the ASOs indicated one or a combination of the following criteria:
e performing the alarm test themselves;
- witnessing the other ASO performing the alarm test; and/or, e obtaining verbal confirmation from the other ASO that he performed the alarm test.
Auditing also interviewed a PCO identified by the Former NPO as someone who possibly had knowledge pertinent to this investigation. The PCO stated that he did not recall the alarm beir.g tested by ASOs prior to Nuclear Operations management's corrective action involving NPO alarm test issues in the E-Diesel Generatorhuilding.
Nuclear Department personnel analyzed computer point data for ASO shifts during the period January through June 1996. The results of this review indicated that for 213 out of 362 shifts (59%), there was no computer point record of ASOs testing the alarm. Although there was a question as to the overall reliability of the computer point data, Nuclear Department personnel analyzed the data and generally validated its reliability.
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CORRECTIVE ACTIONS Nuclear Operations personnel took corrective actions with regard to operator performance. These corrective actions included issuing a general Rot Box commumcation in July 1996. This Hot Box reinforced the need for Nuclear Operations personnel to completelv and concisely document operations activities. Auditing reviewed a three month sample of computer data subsequent to July 1996 and determined the effectiveness of corrective actions. The evidence indicates (with the exception of one shitt) ASOs tested the alarm as required. Additionally in November 1997. Nuclear Operations management removed the alarm test froni,the ASO Tumover Sheet and added it to the ASO Plaitt Rounds Sheet in order to include the alarm test requirement with other ASO equipment checks.
CONCLUSION The evidence in this investigation substantiates the allegation. At times, (prior to NPO alarm test issues in the E-Diesel Generator Building), ASOs did not perform required tests of the RWCR Offgas Panel Alarm, yet signed the ASO Turnover Sheet indicating that they had.
RECOMMENDATION Nuclear Department management should review the results of this report and take appropriate! action.
ACKNOWLEDGMENT D. A. Duda and T. C. Roth conducted this investigation with assistance from J. P. Kalafut and M. P. Mormak. Auditing wishes to acknowledge the assistance that Nuclear Department personnel prc,vided to us turing this investigatiort.
If you need additional information or would like clarification on any items contained in this report, please feel free to contact us.
We request a reply to this report by March 10.1998. including your response to our recommendation.
Corporate Audit Services
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-( EXHIBIT A. i l-PP&L, Inc.
Job # 739459-2-98 List ofInterviewees -
Former Nuclear Plant Operator Plant Control Operator .
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9 Auxiliary System Operators -
4 Nuclear Plant Operators (whoperformed ASO duties during the penod January through June 1996)
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EXHIBIT B
> PP& L, Inc.
Job # 739459-2-98 ASO Turnover Sheet j "Offeoine Auxiliarv Svstem Operator Checklist" i,
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