ML20210R980
| ML20210R980 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 08/19/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20210R946 | List: |
| References | |
| 50-289-97-06, 50-289-97-6, 50-320-97-02, 50-320-97-2, NUDOCS 9709040199 | |
| Download: ML20210R980 (104) | |
See also: IR 05000289/1997006
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U. S. NUCLEAR REGULATORY COMMISSION
REGION I
Docket Nos.
50-289 and 50-320
License Nos.
Report Nos.
97-06 and 97 02
Licensee:
GPU Nuclear Corporation
Facility:
Three Mile Island Station, Units 1 & 2
Location:
P.O. Box 480
Middletown, PA 17057
Dates:
June 16,1997 - July 27,1997
Inspectors:
Samuel L. Hansell, Resident inspector
John R. McFadden, Radiation Specialist
Laurie A. Peluso, Radiation Specialist
Ram Bhatia, Reactor Engineer
Approved by:
Peter W. Eselgroth, Chief
Reactor Projects Section No. 7
9709040199 970819
ADOCK 05000289
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EXECUTIVE SUMMARY
Three Mile Island Nuclear Power Station
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Report Nos. 50 289/97-06 and 50-320/97 02
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-This integrated inspection included aspects of licensee operations, engineering,
maintenance, and plant support. The report covers a six week period of resident
inspection and a supplemental inspection by a regional insper. tor in the electrical
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engineering area following the reactor trip on June 21. In addition, it includes the results
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of announced inspections in the areas of Radwaste Efiluent Monitoring and Occupational
Radiation Exposure /Non Outage for units 1 and 2.
Plant Oo* rations
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Plant personnel and equipment response to the June 21 reactor trip and loss of
offsite power were excellent, especially in light of the previous 617 day continuous
run. Excellent coordination and replacement of the faulty main generator output
breakers was noted (Section 01.2).
TMI management applied a conservative approach to safe plant operation when
they decided to remain in a heightened emergency response mode until the reactor
coolant pumps and the main condenser heat sink were restored to service (Section
01.2).
The required notifications to the Commonwealth and risk counties for the June 21
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Unusual Event (UE) were not completed within 15 minutes as required by GPU
emergency plan implementing procedures and NRC regulations. The
Commonwealth and risk county notifications were not complete until 12:50 p.m.,
24 minutes after the UE declaration. This is a repeat problem that was also noted
in two emergency plan exercises in the past 15 months. This is a violation of 10 CFR 50 Appendix E IV.D 3. and Technical Specification 6.8.1.f. (Section 01.2).
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The plant startup, heatup, and power ascension after the outage progressed at a
controlled pace. Extensive management oversight and support were noted
throughout the entire plant startup and return to full power (Section 01.2).
Maintenance
Maintenance and surveillance activities were performed well and the response of
the plant equipment to the reactor trip / loss of offsite power event reinforced the
importance of the excellent long term maintenance program at TMI. The new fuel
receipt activities were conducted without error by experienced personnel. Excellent
-oversight was provided by tha maintenance foreman and nuclear engineers. The
new fuel quality receipt inspections were thorough and the results were
documented on detailed data sheets (Section M1.1).
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Enaineerina
The abnormal transient procedures and corresponding operating procedures were
revised to ensure the decay heat removal and building spray pumps will have
adequate net positive suction head (NPSH) after a loss of coolant accident without
taking credit for Reactor Building overpressure. Engineering personnel performed
the detailed calculations and safety evaluations to resolve the potential unreviewed
safety question issue prior to plant re start (Section E1.1).
Two licensee ovent reports (LERs) Nos. 97 007-00, " Loss of Offsite Power and
Reactor Trip," and 97-008-00, " Reactor Trip and Associbsed Slow Control Rod
Insertion Times for Four Rods" were closed. The LERs provided a detailed
description of the events, assessment, and appropriate corrective actions (Sections
08.1 and E8.1).
The inspector noted that the licensee's overall performance was good in responding
to the electricalissues identified after the loss of offsite power event. The licensee
expeditiously replaced the two damaged substation breakers and other components
in the 230 kV substation.
The root cause analyses performed were appropriate to determino the cause of the
main generator output breaker failures and loss of offsite power event.
The inspector noted that the licensee had planned to determine the cause of
unbalanced current conditions observed in these breakers by a substation technician
prior to the LOOP event on June 21,1997. Even though the licensee had planned
to troubleshoot the condition, this issue was not properly documented as per the
corrective action process established procedure and plant management was not
made aware of this anomaly prior to the LOOP event. This issue will remain an
unresolved open item pending NRC additional review.
Plant Support
Personnel exhibited a high level of knowledge and experience in the areas of
external and internal exposure control and control of radioactive materials and
contamination (Sections R1.1-R1.3).
The scope and depth of nuclear safety assessment (NSA) audits related to the
radiological controls occupational exposure program were of high quality. The
radiation protection group performed numerous self-assessments and program
evaluations of significant scope (Section R7).
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- TMI continued to implement an overall effective Radiological Environmental
Monitoring Program including management controls, quality assurance audits,
radiological environmental monitoring, and meteorological monitoring program. The
- Offsite Dose Calculation Manual was implemented properly.- The 1995 and 1996 :
audit reports effectively assessed program strengths and weaknesses. No
deficiencies in the Updated Final Safety Analysis Report commitments were--
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identified (Section R7).
Personnel performance during a July 10,1997, emergency preparedness training
exercise was very good.- Positive performances were noted in the control
room / simulator for the SS's emergency classification and control room operator
recognition and response to the simulated once through steam generator problems.
A repetitive problem was noted for the initial 15 minute notification to Dauphin--
County emergency response center (Section P1.1).
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TABLE OF CONTENTS
PAGE NO.
EX ECUTIVE SUMM ARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - li
TABLE O F CO NT ENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
1. Operations
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01
Conduct of Operations (71707, 93702) . . . . . . . . . . . . . . . . . . . . . . . . 1
-01.1 General Comments
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01.2 Reactor Trip / Loss of Offsite Power on June 21,1997.........
1
08'
Miscellaneous Operations !ssues . . . . . . . . . . . . . . . . . . . . . , . . , . . . 5
08.1 (Closed) LER 50 2 8 9/9 7 007 00 . . . . . . . . . . . . . . . . . . . . . . . . 5
ll. Maintenance . . . . . . . . . . . . . . . . . . . . . . .
5
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M1
Conduct of Maintenance (62707,61776)
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M1.1 G e neral Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 5
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111. E n g in e e r i n g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
El
Conduct of Engineering (37551, 93704) . . . . . . . . . . . . . . . . . . . . . . .
6-
E 1.1 - (Closed) URI 50 2 8 9/9 6-201 14 . . . . - . . . . . . . . . . . . . . . . . . . . 6
E1.2 Replacement of Both Main Generator Output Breakers . . . . . . . . 8
E8
Miscellaneous Engineering Issues . . . . . . . . . . . . . . . .-. , . . . . . . . . . 12
E8,1 - (Closed) LER 50 2 8 9/9 7 008-00 . . . . . . . . . . . . . . . . . . . . . . . 12
E8.2 (Closed) URI 50 2 8 9/9 6-08-01 . . . . . . . . . . . . . . . . . . . . . . . . 13
IV. Plant Support
14
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R1
Radiological Protection and Chemistry (RP&C) Controls . . . , , . . . . . . 14
R1.2 Radiological Controls-Internal Exposure . . . . . . . . . . . . . . . . . . 15
R1.3 Radiological Controls Radioactive Materials, Contamination, Surveys,
and Monitoring
15
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R1.4 Radiological Controls-As Low As Reasonably Achievable
{ A L A R A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
R1.5 - Other Changes to the RP Program . . . . . . . . . . . . . . . . . . . . . . 17
R1.6 Implementation of the Radiological Environmental Monitoring
Pr o g r a m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
R1.7 Meteorological Monitoring Program (MMP) . . . . . . . . . . . . . . , , 20
R5
Staff Training and Qualification in RP&C
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R6
RP&C Organization and Administration
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(16.1 Management Controls
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R7
Quality Assurance in RP&C Activities
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R7.1 Quality Assurance Audit for the Occupational Radiation
Exposure /Non Outage Program . . . . . . . . . . . . . . . . . . . . . . . . 23
R7.2 Quality Assurance Audit for the Radiological Environmental
Monitoring Program . . . . . . . . . . . . . ._ . . . . . . . . . . . . . . . . . . 24
R7.3- Quality Assurance of Analytical Measurements
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Miscellaneous RP&C lssues
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R8.1- Updated Final Safety Analysis Report Review for the
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Occupational Radiation Exposure /Non Outage and the
Radiological Environmental Monitoring Programs -- . . . . . , . . . . . - 26
P1
- Conduct of EP Activitie s . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 26-
P1.1-- Quarterly _ Emergency Preparedness Exercise . . . . . . . . . . . . . . 26
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P3
EP Procedures and Documentation
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P3.1. In-Office Review of Licensee Procedure Changes - . . , . . . . . . . 27
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Ma nagement Meeting s . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. :. . . . . . . . . . . . . 28
X1
Exit Meeting Summary . . . . . . . . . . . . . . . . . . . . . . . .
=,
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X2
Management Meeting to Review Engineering issues Related to
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Confirmatory Action Letter 1 9 7-008 , . . . . . . . . . . . . . . . . . . . . . .
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X3
Pre-Decisional Enforcement Conference Summary
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X4
I N PO Evalu ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 2 8
PARTIAL LIST OF PERSONS CONTACTED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
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ITEMS OPENED, CLOSED, AND DISCUSSED . . . . . . . .-. . . . . . . . . . . . . . . . . . . . . 30
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O ST O F AC RONYM S U SED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
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Report Details
- Summary of Plant Status
. Unit 1 began this inspection period at 100% power. On June 21,1997, a reactor trip
occurred due to a failure of the main generator output breakers. The trip occurred after
approximately 617 days of continuous operation. The plant remained in hot shutdown
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until the repairs to the main generator output breakers were complete (section 01.2) and
- the low pressure injection pump net positive suction head unreviewed safety question
-(USO) was resolved (section E1.1). Following completion of the forced outage work, Unit
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1 was returned to full power operation on June 30.
I. Operations
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Conduct of Operations (71707,93702)'
01.1 General Comments
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Using Inspection Procedure 71707, " Plant Operations," the inspectors conducted
frequent reviews of ongoing plant operations, in general, the conduct of. operations
was professional and safety-conscious; specific events and noteworthy
observations are detailed in the sections below, in particular, the inspectors noted
continued excellent operator response to plant events. The actions taken to
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stabilize the plant in response to the June 21,1997, reactor trip and loss of offsite
power (LOOP) were examples of excellent performance for the infrequent plant -
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Reactor Triolloss of Offsite Powe on June 21,1997
01.2
a.
Insoection Scoce
Inspectors monitored the operator response to the reactor trip on June 21, the
event classification and offsite notification, equipment response including the
control rod drop times, root cause analysis, implementation of corrective actions,
and subsequent recovery of Unit 1.
b.
Observations and Findinas
Background
On June 21,1997, at 12:14 p.m., Unit 1 experienced a reactor trip and loss of
- offsite power (LOOP) from 100% power. The 'B' phase of the main generator
output breaker GB1-02, developed a fault which caused the breaker to overheat and
resulted in the ejection of the bushing and conductor from the breaker housing. The-
' Topical headings such as 01, M8, etc., are used in accordance with the NRC standardized
reactor inspection report outline. Individual reports are not expected to address all outline
topics.
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breaker fault caused the de-energization of one of the two 230 KV buses (bus 4)
that supply the safety and non-safety electricalloads, The parallel generator circuit
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breaker, GB1-12, opened as expected but experienced an arc between the partially
opened breaker contacts, known as "re strike." The re-strike damaged the 'B'
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phase of breaker GB112 which de-energized the remaining onsite electrical buses
as designed. The LOOP resulted in an immediate reactor and turbine trip. Both
emergency diesel generators started and loaded onto their respective 4160 VAC
safeguards buses as designed.
The LOOP also caused a loss of the non-safety related electrical buses. Without
balanca of plant power, the condensate, feedwater, circulating water and main
condenser vacuum pumps were de-energized. The once through steam generators
(OTSGs) were supplied make-up water from the emergency feedwater (EFW)
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system. Heat removal was accomplished through the steam generator atmospheric
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dump valves. The loss of electrical power also de-energized the reactor coolant
pumps (RCPs) resulting in a loss of forced circulation in the reactor coolant system
(RCS). An unusual Event was declared and the Emergency Response Organization
was activated.
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Reactor Trip and Loss of Offsite Power Response
The resident inspector responded to the control room and monitored operator
actions during the plant restoration. The NRC Region Iincident response center
was manned to assist in the evaluation of the LOOP and reactor trip event. The
operators stabilized the plant in a hot standby condition. With the exception of four
slow control rod drop times, plant equipment operated as designed (Section E8.1).-
All 61 control rods inserted to shutdown the reactor.
Operator response to the reactor trip and LOOP was excellent. The inspectors
verified that the RCS transitioned from forced circulation to natural circulation flow.
The EFW system was controlled by procedure to maintain the OTSG as a heat sink
for the RCS, Plant operators secured the steam driven EFW pump at the earliest
opportunity allowed by plant conditions to minimize the turbine exhaust steam path
to the atmosphere. The control room indications and radiation monitors indicated
that there was no reactor fuel pin leaks and no measurable primary to secondary
leakage in the OTSGs. TMI field survey teams verified that the radiation levels
surrounding the plant were reading normal background levels.
Sequence of Events
Time
Descriotion
12:14:35 p.m.
GB1-02 trip (failed generator breaker).
12:14:35
GB1-12 trip (parallel generator breaker).
12:14:35
12:14:35
12:14:36
230 KV Electrical Bus 4 or 8 Bus Low Voltage.
12:14:36
Reactor Coolant Pumps tripped.
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12:14:44
EG Y 1B output breaker closes on F. 4KV bus.
12:14:44
EG Y-1 A output breaker closes on D 4KV bus.
12:14:56
Manual Reactor Trip.
12:26
Unusual Event Declared, SS is the ED.
-12:50
State and Risk Counties Notified.
12:33
Natural Circulation Verified.
1:37
230 KV bus 4 power restored.
1:44
230 KV bus 8 power restored.
9:14
RC P-1C started.
9:16
RC-P-1 A started.
-9:18
RC-P-1D started.
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RC P 1B started.
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Unusual Event Terminated.
Emergency Classification and Offsite Notification
The shift supervisor / emergency direct?- (ED) classified the event correctly as an
Unusual Event (UE). Even though not required until the Alert classification level,
plant management called in additional personnel to activate the emergency response
facilities to assist le the plant recovery. The conditions necessary to terminate the
UE were met at approximately 1:55 p.m. when offsite power was restored to the
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safety and non-safety related electrical buses onsite. However, plant management
made a prudent decision to remain in the emergency response mode until forced
circulation was restored in the reactor coolant system and the main condenser heat
sink was returned to service.
TMl notified the NRC of the event in accordance with 10 CFR 50.72. However, the
notifications to Me five local counties and Pennsylvania Emergency Management
Agency (PEMA) were not performed on time as required by the federal regulations
and GPU emergancy response procedures. The weakness was documented in
corrective actiren process (CAP) Report No. T1997-0391. A quality deficiency
report (ODR) No. 972033 was written to track the performance of the root cause
evaluation ar.d completion of appropriate corrective actions related to the late
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notifications.
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The inspector determined that TMI did not implement Emergency Plan Implementing
Procedure EPIP-TMl .03, Exhibit 1, " Emergency Notifications and Call Outs," in that
the cate and local governmental agencies were not contacted within 15 minutes
afte declaring the UE. The ED declared an Unusual Event at 12:26 p.m. The :
PEMA and risk county notifications were not complete until 12:50 p.m.,24 minutes
after the UE declaration. The inspector concluded that the offsite emergency
response agencies were not notified within the required time. This is a violation
(VIO 50 289/97-06-01).
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Event Follow up:
When offsite power was available, the operator actions to restore the electrical
buses and unload the emergency diesel generators were performed in a controlled
manner after a detailed briefing by the ED. The condensate, feedwater and main
condensers ware returned to service by procedure and in the proper sequence. The
RCP re-start was performed and resulted in a smooth and controlled transition back
to forced circulation in the RCS.
The RCP operating procedure OP-1103 6, " Reactor Coolant Pump Operation,"
contained clear and concise information to perform the RCP startup. OP 1103 6
section 3.2.3, "RCP Start for Transition from Natural Circulation," contained
prescriptive notes and cautions to provide expected plant response and quantitative
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data to ensure that any abnormal indications would be recognized by the operators.
For example, note 1.c. stated that RCS pressure will decrease quickly but should
not decrease by more than 300 pounds for the first RCP startup. All RCP starts
were well controlled and resulted in a smooth transition from natural circulation to
forced flow in the RCS.
Plant Startup
Prior to the plant re start, a detailed review of the plant response to the automatic -
reactor trip was performed using procedure AP 1063, " Reactor Trip Review
Process." The review was thorough and included an evaluation of the computer
sequence of events, alarm printout, key plant parameter plots initiated five minutes
prior to the trip and selected control room strip chart recorders. The cause of the
trip, main generator breaker failure, was known and corrected. The plant response
was as designed with no identified safety issues or abnormal equipment response.
The plant review group (PRG) reviewed the reactor trip review ant. recommended to
proceed with the plant re-start.
Prior to performing the plant startup, operations management scheduled the
operations crew to receive simulator training for the infrequent evolution. The
simulator training covered the main turbine startup, main generator synchronization
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to the offsite electrical grid, and power ascension from 15% to 40% rea:: tor power.
The inspector observed the plant heatup and main generator synchronization from
the main control room. The evolution-was performed at a controlled pace and the
critical tasks were completed without error. Management oversight and support
was extensive throughout the plant startup and power ascension.
c.
Conclusions
Plant personnel and equipment response to the June 21 reactor trip and loss of
offsite power were excellent, especially in light of the previous 617 day continuous
run. The operators stabilized the plant in a hot standby condition and coordinated a
smooth transition from forced reactor coolant system (RCS) flow to natural
circulation. Plant equipment responded to the transient as designed and contributed
to the safo plant operation.
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Even though the plant conditions allowed the terrninetion of the Unusual. Event,
plant management made a prudent decision to remain in the emergency rt sponse
mode until forced circulation was restored in the reactor coolant system arm the
. main condenser heat sink was returned to service.
The required notifications to the state and risk counties for the June 21 Unusual
Event were not completed within 15 minutes as required by GPU emergency plan
implementing procedures and NRC regulations. The state and risk county
notifications were not complete until 12:50 p.m.,34 minutes after the UE
declaration. This is a repeat problem that was also noted in two emergency plan-
exercises in the past 15 months. This is a violation of 10 CFR 50 Appendix 'E'
IV.D.3. and Technica Specification 6.8.1.f.
The plant startup, heatup, and power ascension after the outage were deliberate
and progressed at a controlled pace. Prior to performing the plant startup,
operations management scheduled the operations crew to receive simulator training
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for the infrequent evolution. Extensive management oversight and support were
noted throughout the entire plant startup and return to full power.
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Miscellaneous Operations issues
08.1 iCJosed) LER 50 289/97-007-00: Loss of Offsite Power and Reactor Trip.
The event is documented in the Operatic.is and Engineering sections of this report.
The licensee event report (LER)'provided a detailed description of the event,-
assessment, and appropriate corrective actions that were completend or planned.
The LER is closed.
jl. Maintenance
M1
Conduct of Maintenance (62707,61726)
M1.1 General Comments
a.
insoection Scooe
The inspectors observed all or pcrtions of the following maintenance and
surveillance work activities:
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Job Order No. _122508, "h'ew Fuel Receipt and Inspection."
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Job Order No. 136696, "Rsplace RR-P 1B Column Flange Bolts."
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Joo Order No. 137064, " Control Room Recorder Preventive Maintenance."
Operating Procedure 11021, " Plant Heetup to 525c."
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Surveillance Procedure 130:1-3.1, " Control Rod Movement Test."
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Refueling Procedure 15031, " Receipt of New Fuel and Control
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Components."
Surveillance Procedure 130311.4, " Refueling Interlock Checks."
b.
Observations and Findinns
A portable crc..cality monitor was installed in the new/ spent fuel truck bay for the
new fuel receipt. Excellent oversight was provided by the maintenance foreman
and reactor engineer. The inspector observed good support from radiological
controls, security and maintenance. The new fuel quality receipt inspections were
thorough and the results were documented on detailed data sheets.
The surveillance test activities observed during this inspection were performed
satisfactorily and demonstrated that the associated systems could perform their
design safety functions.
c.
.Qonclusions
Overall, main *enance and surveillance activities were performed well and the
response of the plant equipment to the reactor trip / loss of offsite power event
reinforces the importance of the excellent long term maintenance program at TMI.
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The new fuel receipt activities were conducted without error by experienced
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personnel. A portable criticality monitor was installed in the spent fuel truck bay to
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provide additional monitoring. Excellent oversight was provided by the maintenance
foreman and nuclear engineers. Good support from radiological controls, security
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and maintenance. The new fuel quality receipt inspections weie thorough and the
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results were documented on detailed data sheets.
III. Enaineelng
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Conduct of Engineering (37551,93704)
E1.1
(Closed) URI 50 289/96-201-14: Potential Unreviewed Safety Question Related to
the NPSH for the Decay Heat Removal and Building Spray Pumps,
a.
inspection Scope
The inspectors reviewed the engineering safety evaluation and associated
documentation that addressed the unreviewed safety question (USO) related to the
decay heat removal (DHR) and building spray (BS) pump net positive suction head
(NPSH). The review also included the operating procedure changes, training, and
operator briefings that resolved the USO issue.
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b.
Observations and Findinas
Background
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The NRC Engineering Design Team questioned the safety evaluation that
documenteo the DHR and BS NPSH calculation. The calculated NPSH was a
potential concern during a loss of coolant accident (LOCA) when the DHR and BS
pump suctions transferred from the borated water storage tank (BWST) to the
Reactor Building (RB) sump. A review of engineering design assumptions
determined that the RB atmosphere, at the time of the swapover to the RB sump,
assumed an overpressure on the pump t,uction lines to ensure adequate NPSH. The
origina' plant design did not take credit for the RB overpressure to ensure adequate
pump NPSH. The NRC considared this unresolved item as a potential USQ.
Rosolution
The it.spector reviewed the engineering documentation and the procedure tempormy
change notices (TCNs) that supported the USQ resolution. The revised abnormal
transient procedures (ATPs), ATP 1210-6, "Small Break LOCA Coo!down," and ATP
1210 7, "Large Break LOCA Cooldown," were revised to throttle the DHR and BS
pump flows and maintain adequate NPSH, without taking any credit for the RB
overpressure. To ensure adequate pump NPSM the DHR pump flow is controlled
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between 2600 to 2800 gallons per minuto (gpm) and the BS flow is controlled
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between 1300 to 1400 gpm. The procedure guidance has been provided to direct
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the operators to throttle the DHR and BS pump flows prior to the swapover to the
To ensure that the environmental qualification (EO) temperature profile was
maintained, for components in the RB, with the new throttling requirements,
administrative cor.trols were incorporated into the daily plant operation. The
following administrative limits were implemented until individual component EQ
profile calcdations are completed.
Maintain three RB emergency fan coolers operable. Reduction to two
operable coolers requires entry into a 7 day administrative limiting condition
for operation (LCO).
BWST Temperature maintained less than or equal to 85'F.
River Water Inlet Temperature less than or equal to 90*F.
e
If any of these conditions were app.oached or exceeded, the Director of Operations
and Maintenance (O&M) and the plant review group (PRG) Chairman would be
notified immediately to further evaluate the issue. The administrative limitations
were added to the daily control room operator checklist and the daily plant meeting
report.
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Engineering personnel documented the details of the pump NPSH calculations and
associated documentation in safety evaluation No. SE 000 212 032, to
satisfactorily recolve the USQ issue, in addition, to the procedure revisions the BS
pump suction check valve internals were removed. The inspector concluded that
the TMI calculations, procedure revislor.s, and plant modifications addressed the
DHR and BS pump NPSH issue. This item is closed.
c.
Cor clusions
The abnormal transient procedures and corresponding operating procedures were
revised to ensure that the decay heat removal and building spray pumps will have
adequate NPSH after a LOCA without taking credit for RB overpressure.
Engineering personnel performed the detailed calculations eH safety evaluations to
resolve the USO issue prior to plant re start.
E1.2 Reolacement of Both Main Generator Outout Breake.n
a.
Insoection Scope (37551 and 92903)
The inspectors reviewed and assessed the licensee's corrective actions in response
to the Three Mile Island (TMI) Unit 1, June 21,1997, loss of off site power (LOOP)
event, that was caused by the failure of both 230 kV main generator output circuit
breakers in TMI's 230 kV substation. The review included the applicable substation
design documents, the root cause evaluation of the failed breakers, and the design
data of the replacement breakers. The inspector also examined the replacement
breakers and affected substation equipment, and interviewed the station and
substation relay department personnel responsible for the replacement of the
affected breakers,
b
Observations and Findinas
Backaround
On June 21,1997, TMI Unit 1 experienced a fault on one (GB1-02) of itr main
generator output breaker. The "B" phase of the breaker developed a fault causing
severe overheating and ejection of ths bushing and conductor from the breaker
housing. As a result of this condition, the bua protection scheme detected this fault
and isolated the applicable bus 4 breakers in the substation. The paiailel output
breaker (GB1-12), connected to bus 8, also opened on the fault as required and
subsequently suffered a restrike. The restrike damaged the "B" phase of the
breaker, resulting in a fault on this breaker. As a result of this fault, the associated
Bus 8 protection scheme detected this fault, as required, and opened the bus 8
,
remaining breakers in the TMI Unit 1 substation, resulting in a total loss of off-site
power (LOOP). During this event both the emergency diesel generator started as
designed to provide emergency power for safe shutdown of the unit under this
LOOP condition.
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230 kV Substation Relav Protection Scheme
The TMl Unit 1 main generator produces electric power at 19 kV, which is supplied
tnrough an isolated phase bus to the unit main transformer, which is stepped up to
230 kV voltage and delivered to the 230 kV TMI substation located adjacent to the
plant. The substation design consists of a breaker and a half scheme, and the
substation power is connected to the 230 kV network system by four feeder
circuits. The breaker and a-half substation arrangement includes two full capacity
main buses (Bes 4 and Bus 8). The Main Generator Output Breakers GB1-02 and
X
GB1-12 are connected in parallel, to supply power to its respective buses ( GB1-02
to Bus 4 and GB1-12 to Bus 8)in the substation with appropriate disconnect
switches, The basic relay protection scheme for each of the buses and the feeder
circuit consists of a primary and backup differential protection scheme along with a
circuit breaker failure backup protection scheme as described in the UpdaNd Final
I
Safety Analysis Report (UFSAR). In the event of a fault, the protective roby
scheme could independently detect the fault and trip all connected breakers on the
i
bus to isolate it from the rest of the system. Similar protection scheme is also
provided for the feeder lines.
Root Cause Evalotbn of Failed Breakers
The licensee Getermined the cause of the GB1-02 breaker failure to be high contact
resistance in the breaker. The inspector noted that the licensco's conclusion was
based on the visual damage observed on the main generator output breaker GB1-02
and its associtted components and the unbalanced current flow condition observed
on phase "B" of this breaker. Prior to the event, a relay technician observed, on
June 17,1997, that less than one-half of the expected amperes were flowing in
"B" phase of the breaker towards bus 4. Therefore, the licensee believes that the
'
fault occurred in this location of the breaker in the substation. The computer data
gathered from the station and substation fault recorders indicated that the fault was
appropriately detected by both the station bus differential protection schemes and
the applicable breakers of bus 4 including the second generator output breaker and
the turbine trip controls, appropriately signaled to trip the turbine and these breakers
to isolate the fault on bus 4. Based on the above, the licensee concluded that the
cause of this breaker failure was due to high contact resistance of the breaker that
resulted in an internal fault. Since the evidence of this breaker failure was
destroyed by the event, the licensee had no further plans to further investigate this
issue.
The inspector's review of the licensee's root cause evaluation of the GB1-12
breaker cause of failure (the second generator output breaker connected on to
bus 8) indicated that this breaker opened as required to isolate the above fault.
He vever, an arc re-struck, again during the tripping, that resulted in a "B" phase-to-
ground fault internal to the breaker. As a result of this restrike (failure), this breaker
was not able to clear the above fault, and as a result, the Bus 8 applicabie
'
differential protective relays and others also operated and tripped the remaining
bus 8 breakers, resulting in a LOOP of TMI Unit 1. The inspector noted that the
licenm'1 conclusion was based on the data recorded of voltage traces of the
1
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remaining feede.-lines associated with the bus 8 and the data indicated that either a
re-strike in GB1 12 and/or the inception of a fault had occurred in this breaker. Per
discussion with the licensee personnel, the inspector noted that the licensee had
performed a contact resistance test on this breaker's contacts. The test result and
visual observation of the breaker contact conditions indicated that an internal fault
had occurred during this fault condition. The licensee believes, based on the
breaker's interrupting ratings of 43KA capability, this breaker should have been
capable of interrupting this fault, because the fault conditions were within the rating
of this breaker. Therefore, the licensee concluded that the root cause of this
breaker failure was unknown at this time. The licensee was planning to determine
the cause of this breaker failure at a later date by further examination of the
' damaged unit.
The inspector interviewed the TMl nuclear engineering and GPU Substation Relay
department personnel and noted that the relay technician had notified the station
component engineer about his observation on June 19,1997, of an unbalanced
current flow condition on phase"B" of the main generator output breakers. At that
time, the component engineer then verified the current readings (0.7 (420A) on
,
GB1-02 and 3.5 (2100A) on GB1-12)in substation and inspected the bus and
disconnect switches associated with the generator breakers. Component engineer
<
then discussed this condition with the responsible system engineer and the GPU
relay supervisor. The unbalanced current indication was not perceived as a
significant equipment problem, because they believed that the current transformers
are known to be inaccurate at the low end of their range and the demand meters in
the substation were considered highly inaccurate. The inspector noted that the
licensee staff personnel had made plans to conduct a thermal survey of the
substation on the following week to determine the cause of this unbalanced current.
Corrective Action Taken by the Licensag
The inspector noted that the licensee had replaced both the damaged main
generator output breakers in the 230 kV substation with new breakers of a different
manufacturer. In addition, the licensee also replaced a "B" phase current
transformer and a portion of the disconnect switch component associated with the
GB1-02 breaker. These components were damaged due to the ejection of "B"
phase GB1-02 insulator during this event. At that time, the licensee was in the
process of testing these breakers and associated relay protection scheme prior to
restart the Unit.
The review of the new breakers design specification indicated that these breakers
were of equal or better design with the exception that the new breakers had slightly
less breakers interrupting capability. Per discussion with the licensee and the
review of the manufacturer correspondence, the inspector noted that these breakers
as installed without the capacitor bank had a fault interrupting rating of 40kA,
compared to the existing damaged breakers of 42kA. The licensee explained that
the new breakers were adequate in this application, because the worst-case fault
.
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recalculated at the TMI substation would be approximately 35KA. Since these
breakers had a minimum interrupting rating of 40kA, the licensee concluded that
there was still SkA minimum margin avt.ilable in this application.
The inspector also noted that the licensee had performed applicable meager and
dielectric tests (after consultation with General Electric, the manufacturer of main
generator) on main generator, isophase bus, and neutral grounding transformer to
assure that all components associated with the main generator were not damaged
during this faulted condition. In addition, the main transformer oil analysis was also
performed to assure that the main transformer did not suffer any degradation during
this event. The licensee also tested the 6pplicable portion of the protective scheme
to ensure the new breakers would perform as designed.
At the conclusion of this inspection, the licentee informed the inspector that they
would monitor the current flow condition in the new breakers. In addition, they
would also monitor SF6 gas pressure for two other feeder breakers that are similar
to the failed breakers. The licensee had established acceptance criteria for both
current and SF6 pressure in the auxiliary operator's log. Inspector review of the
data recorded on July 5 and July 11,1997, indicated no concern. The inspector
concluded that the licensee was appropriately monitoring and documenting the
,
l
performance data of these breakers.
The unbalanced current condition observed in the generator output breakers is
discussed in detail, in the above root cause evaluation of failed breakers, in section
l
E.1.1. The inspector concluded that even though the licensee's staff had planned
to troubleshoot the unbalanced current condition observed on June 17,1997 in the
following week, tl.is issue was not properly documented and the plant management
was not made aware of this anomaly prior to the LOOP event. Based on the review
of the licensee's established Corrective Action Process (CAP) procedure 1080,
Revision 2, entry of this condition into the CAP appears to have been required per
the procedure. Therefore, this issue will remain as an unresolved open item pending
i
additional NRC review (URI 97-06-03),
c.
Conclusions
l
The inspector concluded that the overall licensee's performance in response ;o the
electricalissues identified during and after the loss of offsite power event was
good. The licensee had replaced the two damaged substation breakers and other
components in the 230 kV substation. The root cause analyses performed to
determine the cause of the main generator output breakers failures and the loss of
offsite power event were appropriate.
The inspector noted that the licensee had planned to determino the cau:e of
unbalanced current condition observed in these breakers by a substation technician
prior to the LOOP event on June 21,1997. Even though the licensee had planned
to troubleshoot the condition, this issue was not properly documented per the
established corrective action orocess procedure and plant management was not
made aware of this anomaly prior to the LOOP event.
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E8
Miscellaneous Engineering issues
E8.1
(C!osed) LER 50 289/97-008-00: Reactor Trip and Associated Slow Control Rod
Insertion Times for Four Rods.
On June 21,1997, Unit 1 experienced a reactor trip and loss of offsite power
(LOOP) from 100% power. The plant computer captured the 61 tripable control rod
trip insertion time data as designed. The data was analyzed by engineering to
calculate the rod insertion times and evaluate the results, initially, three control rod
times exceeded the Technical Specification (TS) allowed limit of 1,66 seconds.
Because more than one control rod was considered inoperable per TSs the condition
was reported to the NRC within one hour as required by 10 CFR 50.72(b)(1)(ii)(8),"
a condition outside of the design basis of the plant."
During the data verification, engineering questioned the most accurate control rod
trip start time due to the LOOP as the initiating event. Control rod trip insertion
times calculated from the plant trip data did not use the same time reference for the
initiation of control rod insertion as used in the normal surveillance test. To ensure
the control rod times were representative of the TS requirements additional
surveillance testing was performed. The test concluded that a fourth control rod
time exceeded the 1,66 second insertion limit. The fourth inoperable control rod
was reported to the NRC in a follow up telephone call
,
I
Engineering performed an assessment of the safoy consequences and implications
of the control rod trip insertion times associated with the reactor trip and concluded
that the conditions found during and after the recent reactor trip were bounded by
the previous evaluations of slow times. The written safety evaluation was detailed
and provided a sound technical basis for the continued plant operation for the
remaining 70 days of the current operating cycle. All control rods that contain the
new design thermal barrier had drop times well below the TS limit. All remaining
old style thermal barriers were scheduled to be replaced in the September 1997
refuel outage. Prior to the plant startup on June 28,1997, all control rods were
tested satisfactorily in accordance with TS surveillance procedure 1303-11.1,
" Control Rod Drop Time." The final insertion times were less that the TS limit of
1.66 seconds.
Although control rod drop times in excess of 1,66 seconds have the potential to
increase the severity of transients or accidents that require a reactor trip, the as
found control rod insertion times were within the range of acceptance criteria for all
design basis accident analysis. Licensee event reports (LERs) Nos.94-002,94
004, and 95-002 described previous increased control rod trip insertion time events.
In response to the previous events, a safety evaluation was written which
concluded that a 3.0 second rod trip insertion time does not exceed the acceptance
criteria limits or increase the consequences of any postulated accidents. The
slowest time of the four control rods was 2.172 seconds.
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13
The LER provided a detailed description and assessment of the event. bNilar
previous events were listed and the explanation of the history related to the control
red thermal barrier problems was thorough. The TMI corrective actions were
appropriate for the generic Babcock and Wilcox (B&W) design problem. TMI has
planned to replace the remaining old style thermal barriers in the September 1997
refuel outage. The LER is closed.
E8.2 (Closed) URI 50 289/96-08-01: In Service Test (IST) Program Corrective Action
Related to the Exclusion of Relief Valves from the Program.
This item was identified as an unresolved item (URI) pending additional review of
TMI's corrective action system. The inspectors had identified in June 1996 that the
IST program did not include ASME Class 2 or 3 relief valves. The valves had been
tested under a preventative maintenance (PM) program, but not on the same
frequency as the IST program. TMl engineering maintained that the valves were not
required to function to mitigate the consequences of an accident. The inspectors
stated that this rationale was contrary to the explicit wording of Section XI of the
ASME Doller and Pressure Vessel Code (the Code) and section 4.3.1 of NUREG 1482. Subsequently, TMI committed to add the 26 relief valves to the IST program.
l
However, the inspectors had noted that the licensee did not initiate a quality
l
deficiency report (ODR) when they were informed of the deficiencies. Therefore,
notwithstanding the immediate corrective actions taken, no formal causal analysis
'
was performed to conside: the broader, programmatic implications of the inspection
findings, and no actions to prevent recurrence were developed or documented as of
the close of the previous inspection. On October 11,1996, the licensee initiated an
" Event Capture Form" to document the finding.
During the management meeting regarding the quality classification list (OCL)
program problems between the NRC and GPUN on July 16,1997,GPUN
management acknowledged that there were deficiencies in their corrective action
system. GPUN concluded that the weaknesses in the QCL program were also
evident in other engineering programs, including the IST program. A root cause of
the QCL problems was identified by GPUN management as, "the failure of senior
management to recognize corrective action health as essential'or 10 CFR 50
Appendix B compliance." Management committed to review the IST program from
the perspective of problems identified in the QCL program review and the root
cause mentioned above. Based on the GPUN commitment to review the corrective
action program and the IST program, this item is closed.
FSAR Review
The review of the applicable portion of Actrical system, main generator, and
substation design installed at TMI, incluaing the relay protection scheme design was
found consistent with the UFSAR.
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[L Plant Support.
R1
Radiological Protection and Chemistry (RP&C) Controls
R1.1 Implementation of the Radioloaical Environmental Monitorina Proaram
a.
luspretion Scoce (83750-01)
The inspector reviewed the licensee's control of external exposure. Information
was gathered through observation of activitie?. tours of the radiologit, ally controlled
area (RCA), discussions with cognizant personnel, and review and evaluation of
procedures and documents.
'
b.
Observations and Findinas
A review of radiation work permits (RWPs) and discussions with licensee staff
l
indicated that proper personnel protective clothing and equipment, precautions and
instructions were being prescribed for the work descriptions and radiological
conditions at the work sites. At the main HP access control point, it was a
standard practice that a radiation worker, by logging in on an RWP, acknowledged
f
that he/she read, understood, and would comply with the RWP requirements. A
computer and printer station had been set up recently near the main HP access
control point to the RCA where a worker could review and print out a copy of a
RWP for informational purposes.
The TLD processing operation was inspected and was found to be well run and well
maintained based on discussions with licensee staff, a tour of the facility, and
observation of the work process. The quality control results from the most recent
NVLAP (National Voluntary Laboratcry Accreditation Program) performance testing
and from the licensee's own semi-annual blind testing showed very good
- performance and quality. Selected individual dose records (hardcopy and electronic)
were examined and contained the required information. Documentation of current
cumulative external dose for each unit was also reviewed by the inspector. The
above reviews showed that personnel external dose controls were being effectively
implemented.
c.
Conclusions
Personnel were very knowledgeable and experienced in the area of external
exposure control. Facilities and equipment were maintained in good condition, and
the equipment in the TLD processing area was maintained vs.ry well. Personnel
external dose controls were being effectively implemented.
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15
R1.2 - Radioleoical Controls-Internal Exoosure
a.
Inspection Scope (83750-01)
The inspector reviewed the licensee's control of internal exposure. Information was
gathered through observation of activities, tours of the radiologically controlled area
(RCA), discussions with cognizant persorinel, and review and evaluation of
procedures and documents,
b.
Observations and Findinos
Discussions with licensee staff and review of internal dose documentation showed
that the licensee tracked daily internal dose by estimating derived air concentration-
hours (DAC hrs), converting that to estimated dose, and recording dose. The
licensee stated that estimates, equal to or greater than 1 mrem (millirem), were
recorded as record dose. Whole body counting (WBC) was required to be
performed if an individual's cumulative daily internal dose tracking results exceeded
greater than 10 mrem CEDE per day or 50 mrem CEDE in 7 consecutive days. The
respirator fit testing area and records were reviewed and were appropriate. The
whole body counting equipment operation and calibrations were examined. Monthly-
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quality control measurements had been made and trended. Calibrations were
performed when the monthly quality control measurement results indicated that
recalibration was required. This equipment and records were properly maintained.
The documentation of current cumulative internal dose for each unit was also
reviewed by the inspector. The above reviews showed that personnel internal dose
controls were being effectively implemented,
c.
Conclusions
Personnel were very competent and experienced in the area of internal exposure
control. Facilities and equipment were well maintained. Personnel internal dose
controls were being effectively implemented.
R1.3 Radiolooical Controls-Radioactive Materiais, Contamination Survevs, and Monitorino
a.
Insoection Scoce (83750-01)
The inspector reviewed the licensee's control of radioactive materials,
contamination, surveys, and monitoring. Information was gathered through
observation of activities, tours of the radiologically controlled area (RCA),
discussions with cognizant personnel, and review and evaluation of procedures and
documents.
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b. -
Observations and Findinas
' During tours of the RCA, the inspector noted the presence of supplemental frisking
stations in addition to frisking stations at the exit points of contaminated areas and
of the RCA. The licensee established these stations as an additional barrier against
the spread of radioactive contamination.-
Routine and job specific radiological survey records were reviewed and found to
contain appropriate information and to be readily accessible to the radiation
workers. It was the licensee's practice that dose estimated from personnel
- contamination reports, which resulted in equal to or greater than 1 mrem, were
treated as record dose.
The instrument repair and calibration facility was, inspected and found to be
maintained and operated in an excellent manner. Discussions with licensee
personnel in this calibration facility indicated a high level of knowledge and-
expertise as regards radiation instrumentation types, capabilities, repair, and
calibration techniques and requirements. Calibration records were readily accessible
and contained the proper information.
c.
Conclusions
A radiation survey and monitoring program was being appropriately implemented.
Personnel, especially those in the radiation instrumentation area, were very
knowledgeable and experienced. The radiation instrumentation repair and
calibration facility was operated in an excellent manner.
-R1.4 Radioloalcal Controls As low As Reasonablv Achievable (ALARA)
a.
Insoection Scope (83750-011-
The inspector reviewed the licensee's annual person-rem goals and actual results
and discussed these with cognizant personnel,
b.
Observations and Findinas
For Unit 1, the 1997 goal for the normal operating period was 20 person-rem with a
projection of 9 person-rem through June 30,1997. The actual person-rem was 6.3
_
-_through June 30,1997. For Unit 2, the 1997 person-rem goal was 1.0 with a
projection of 0.6 person rem through June 30,1997. The actual person-rem was
j
0.3 through June 30,1997. The 1997 goal for Unit 1's upcoming outage was'150.
1
person rem. The licensee has established and documented annual goals for
cumulative personnel radiation exposure and has tracked and trended actual versus -
projected exposure on a regular, periodic basis.
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17
c.
Conclusions
-The licensee has implemented an appropriate goal-setting and tracking and trending
program for cumulative personnel radiation exposure.
R1.5 Other Chanoes to the RP Prooram
i
a.
]nsoection Scone (83750-01)
i
- The inspector reviewed recent changes to the licensee's organization and
equipment. Information was gathored through discussions with cognizant personnel
and tours of the facilities,
l
b.
Observations and Findinas
l
Up until several weeks pricr to this inspection, the TMI Radiological
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Controls / Occupational Safety (RC/OS) Director had reported to the Corporate
!
Radiological llealth/ Safety Director. This has now changed because the Corporate
Radiological Health / Safety Director position has been eliminated. The TMI RC/OS
. Director now reports to the Oyster Creek RC/OS Director. The effect of this change
. ' ~
,
on the overall performance of both (Oyster Creek and Three Mile Island) radiation
protection programs is uncertain and requires further NRC review; of particular
concern is the disposition of responsibilities and authorities previously maintained by
the corporate director relative to review and maintenance of the GPNUC Radiation ^
Protection Plan and to the required annual review of Radiation Protection Program
content and implementation for each site; this issue will be reviewed during a
subsequent inspection (IFl 50 289/97-06-02).
Recent changes in instrumentation and equipment included the acquisition and
testing of CM 11 contamination monitors (large area gas filled probes), continuous
,
air monitors capable of remote readout, monitoring, and data processing (to be pilot
i
tested in Unit 2), and a computerized air sample data logging system.
R1.6 Imolemr,ntation of the Radioloalcal Environmental Monitorina Proaram
a.
insoection Scooe (84750)
The Radiological Env;ronmental Monitoring Program (REMP) was inspected against
Part lll of Section 8.0 of the Offsite Dose Calculation Manual (ODCM) and against
Regulatory Guide 4.1, " Programs for Monitoring Radioactivity in the Environs of
Nuclear Power Plants." The following activities were conducted to assess the
licensee's capability to implement the program:
Review of REMP procedures, the ODCM, and any changes which pertain to
REMP;
Review of the land use census results;
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Review of sample teruits to confirm sample frequency and impact of the
e
plant on the env:ronment;
e
Assessment of the method for evaluating the results of the samples;
Observation of personnel collecting samples from selected sampling
locations;
Examination of air sampling equipment relative to function, operability, and
e
estibration;
Review of results of prevalling wind determination for the last 2 years to
e
assess any significant changes since pre operation to the present.
b,
.Qbservatigf f ?nd Finding 1
Environme w Affairs continues to maintain the responsibility to implement the
REMP. Tne licensee'r sampling procedures contained appropriate information and
methods compared to industry standuds and good practices. The inspector
observed the licensee personnel exchange air particulate filters and charcoal
canisters from selected air samplers, and discussad certain sample techniques not
observed, such as collection of milk samples, vegetation, and water. Sampling
procedures and practices were used to minimize the chances of cross
contamination.
The inspector visited selected sites where air samplers, water compositors, milk
farms, vegetation and vegetab's gardens, pressurized ion chambers and
thermolurninescent dosimeters are located. Samples were collected from the
locations and at the frequencies required by the ODCM. The analytical results of
samples from these locations were reviewed from January through June 1997. The
inspector noted that the types and frequencies of analyses were performed as
required and the results showed no increnser, as a result of effluents from the plant
with the exception of surface water. Since the licensee has tritium (H 3)in liquid
effluent discharges, it is frequently detected above background levels at the REMP
sampling station J12 just downstream at the mixing zone. These results are
published in the annual environmental monitoring reports. The inspector noted that
concentrations of H 3 in the water and the radiological Jose to the public were
IcM1 than regulatory requirements and in conformance with the ODCM
tc%irements. Tritium is not detected above background levels at any other offsite
location. To enhance the data source of the environmental monitoring program, the
licensee continued to collect and analyze supplemental samples in addition te those
required by the regulatory requirements.
The inspector reviewed the on-site groundwater program. This program was
designed to analyze the levels of tritium (H-3)in the groundwater on site. During
ths recent drilling of three new wells (A, B, and C) for the service water system on
the west side of the island, the licensee had noted that the H 3 levels were higher
than normal. This was not unexpected beci. tse elevated H 3 levels had been
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19
observed for many years. According to the licensee's environmental services staff,
the elevated H 3 levels were believed to be residual from the Unit 2 accident and
the processing of the accident generated water through the EPICOR system. The
licensee sampled and analyzed all the on site wells. The licensee had been usi.ig
this program as an indication of leakage into groundwater. Tritium levels varied
throughout the site, ranging from non detectable to 450,000 picoeuries per liter.
However the H 3 levels in one well(RW 1) were higher than the levels in other
wells. The RW 1 well, located outside the Unit 1 turbine building on the east side,
had H 3 levels in samples taken in 1995 that ranged from 32,000 to 660,000
picoeuries per liter. Tritium levels from samples taken from the RW 1 wellin 1996
ranged from 590 to 450,000 plcoeuries per liter. The well used for drinking water
on the site (OSF well) had elevated readings, but none were above the EPA drinking
water standard of 20,000 picoeuries per liter. The licensee had been making efforts
to trend the migration of the H 3 to determine if there was another potential source
for the tritium in the groundwater. Other suspected sources were leaks from the
Unit 1 Borated Water Storage Tank (BWST) or from reactor building sump. Three
new monitoring wells ( MS 20, MS-21, and MS 22) were drilled in 1996 to help
determine the source of the H 3 in the groundwater. These wells are located
between the Unit 1 BWST and the OSF well. Data was preliminary and did not
indicate any correlation between the activity in the BWST and in samples taken
from the new wells. The licensee has not detected H 3 above background levels
offsite as a direct result of the H 3 in the groundwater. The licensee documented
the results in the annual environmental reports for 1995 and 1996.
The 1996 land use census was performed according to the procedure and the
ODCM requirement of Section 8.2. Performance of the land use census was
thorough and complete. No program changes (e.g., changes in sample locations)
were required as a result of the census.
The inspector reviewed the wind direction assessments (wind roses) from the past
2 years and compared them to the pre operational wind roses to detect changes, if
any, in the prevailing wind directions. No significant changes were evident. The
environmental monitoring control station locations were reviewed against the
prevalent directions and the inspector noted that the control locat!ons remained
valid in areas that are minimally impacted by the facility.
The inspec id Anderson air samplers, ISCO water compositors, and the Router-
Stokes pressurized lon chambers (PIC) were in operation and good physical
condition. The licensee had a calibration program to ensure validity of samples
collected. Every 6 months, the air samplers were cal'brated with 1 of 2 calibrated
Kurz mass flow meters, which are calibrated every year on a staggered schedule
and are traceable to National Institute of Standards and Technology (NIST).
Calibrations were performed according to Procedure 6610-PMI-4223.19,
" Calibration of Anderson Air Samplers." The licensee also has a maintenance
program to minimize the amount of sample loss due to mechanical failure by
replacing the bellows and cleaning the inside of the air and water samplers when
needed (usually indicated during calibration tests). The Reuter Stokes pressurized
s
9
20
lon chambers (PIC) were calibrated once per year using Procedure 0610 PMI-
4221.07, " Calibration of Reuter Stokes Environmental Monitoring System 100 mr/h
HPIC Sensor," and the water compositors were calibrated every 6 months using
Procedure 6610 PMl 4224.45, " Calibration of ISCO Model 2710". The inspector
reviewed results from August 1995 through April 1997 and noted that the results
were within the established acceptance criteria and frequency.
The inspector also reviewed any radiological consequences from the steam release
from the reactor trip on June 21,1997. The total activity level in the steam was
estimated by the licensee to be approximately 68 picocuries per gram due to minor
primary to secondary leakage. Table I pertains to the resultant exposure to the
public as the result of this occurrence. The inspector reviewed meteorological-
l
conditions, results from the air particulate and air lodine analyses, and data from the
i
Reuter Stokes pressurized lon chambers (real time gamma radiation monitors) during
!
the event. The meteorological conditions on June 21 indicated class A stability.
l
and the wind direction was from the southwest sector to the northeast sector. The
results from the air particulate and air iodine analyses indicated normal background
levels as did the gamma radiation monitors. Background levels around the site are
on average 5.5 millroentgens per standard month. This equates to an annual
exposure rate of 66 mitiroentgens per year. Dose consequences on site for the
entire event were equivalent to a fraction of the dose from natural background of
300 millirem per year.
TABLE 1
REGULATORY REQUIREMENT VERSUS ACTUAL RELEASE
OUARTERLY
ACTUAL SECOND
ACTUAL JUNE 21,
CRITERIA
QUARTER 1997
1997 (12:14 p.m. to
8:20 p.m.)
2.2.2.2
5 mrad (gamma), air
1,07E 5 mrad
3.87E 8 mrad
dose, site boundary
-
2.2.2.2
10 mrad (beta), air
1.88E 5 mrad
3.34E 8 mrad
dose, site boundary
2.2.2.3
7.5 mrem organ dose 4.4E 4 mrem
3.13E 4 mrem
at nearest receptor
c.
Conclusions
Based on the above review, observation, ard discussions, the inspector determined
the licensee's performance in implementing the REMP continued to be excellent.
The licensee's staff had taken substantial efforts to determine the possible sources
for elevated tritium levels in groundwater wells. Additionally, the inspector noted
that the radiologier.1 consequences of the June 21,1997, steam release were
negl;gible relative to dose to members of the public,
_
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o
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R1.7 Meteoroloalcal Monitorina Proaram (MMP)
a.
insoection Scone (84750J
The Meteorological Monitoring Program (MMP) was inspected against TS Section 6.9.4, UFSAR Table 7.3 2, and Regulatory Guide 1.23 commitments. The
,
followmg activities were conducted to assess the licensee's ability to implement the
program,
o
Review of calibration procedures and results;
e
Observation of data acquisition and availability; and
Observation of the material condition of meteorological equipment.
o
,
!
b.
Observations and Findinas
Calibration and maintenance of the meteorological monitoring instrumentction was
the responsibility of the Instrument and Controls Department. Calibration: of the
wind speed, wind direction, and temperature sensors were conducted using
Procedure 1302 23, " Meteorological Instrumentation Calibration." The inspector
reviewed the calibration results from April 1996 through April 1997. Calibration
results were within the required equipment tolerances. The meteorological
instrumentation were calibrated at the semlannual frequency recommended in
Regulatory Guide 1.23 and specified in the procedures. The inspector noted that
the instruments used to calibrate the meteorological sensors were properly verified
and validated and were traceable to NIST.
Daily meteorological data were recorded and maintained by Environmental Affairs to
ensure daily operation of the sensors and computer. This information was also used
to inform l&C of any instrumentation failures. Data were also sent to the licensee's
meteorologist where they were used to calculate distribution and dispersion values
used for dose assessment. The inspector reviewed selected data from January
through July 1997 and noted that availability of data was very high. The inspector
also noted that about 3 days of data in February and in March were unobtainable
due to loss of power at the tower, as the result of an electrical fault in a cable
splice. Electrical maintenance was able to provide power to the tower from a
temporary external source while the cable was replaced. The licensee was
scheduled to complete the project by July 11,1997. The inspector discussed the
3-day losses of data and determined that backup meteoroloc' cal data provided by
the licensee's " Simplified Environmental Effluent Dosimetry System" were used to
_
meet the dose assessment requirements by the ODCM.
I
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V
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22
c.
Conclusion
Based on the direct observations, discussions with personnel, and examination of
procedures and records for calibration of equipment, the inspector determined that
overall, the licensee's performance of maintaining and calibrating the meteorological
monitoring instrumentation was very good. The data were available as required and
were easily accessed from severallocations, The l&C performance in this area was
demonstrated through a good understanding of the meteorological instrumentation
based on qualification, training, and exporlences.
R5
Staff Training and Qualification in RP&C
'
a.
insocction Scone (83750 01)
The inspector reviewed the licensee's training and qualification program for initial
training and requalification of HP (health physics) supervisors and technicians.
Information was gathered through discussions with cognizant personnel and review
and evaluation of procedures and documents,
b.
Observations and Findinaa
Licensee's procedures for the training and qualification /requalification standards for
radiological controls technicians and group radiological controls supervisors, for
radiological support technicians, and for radiological instrument technicians were
available. These procedures were reviewed and discussed with cognizant training
department personnel. Roqualification records for selected technicians and
supervisors were inspected. The review of training records showed that the
procedurob were being properly implemented,
c.
Conclusions
Training procedures were in place, were detailed, and were being properly
implemented.
R6
RP&C Organization and Administration
R6.1
Mananement Controls
a.
Insoection Scoce (84570)
The inspector reviewed organization changes and the responsibilities relative to
oversight of the REMP and MMP, and the annual radio'ogical environmental
oparating report to verify the implementation of the TS and ODCM.
!MfSa2MMPWW f
,.
- $ ; '-
! J
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23
b.
Observations and Findings
No change 6 in the organization regarding the oversight of the REMP were made
since the previous inspection in this area. The responsibilities relative to oversight
of the REMP and MMP have essentially remained the same,
'
The annual radiological environmental monitoring reports for 1995 and 1990
,
,
provided a comprehensive summary of the results of the REMP around the site and
met the TS and ODCM reporting requirements. No omissions, mistakes, or obvious
aramelous results and trends were noted.
c.
Conclusion
'
Based on the above review, the inspector determined that the licensee implemented
I
good management control and oversight of the REMP and MMP and effectively
implemented the TS and ODCM requirements.
R7
Quality Assurance in RP&C Activities
1
j
R7.1 Ouality Assurance Audit for the Occuoational Radiation Exoosure/Non Outano
Proaram
a.
Insnection Scoce (83750-01)
The inspector reviewed the licensee's independent and self assessing processes.
Information was gathered through discussions with cognizant personnel and review
and evaluation of procedures and documents,
b.
Observations and Findinas
The licensee's Nuclear Safety Assessment (NSA) group performed independent
reviews of the radiation protection program. NSA audits the entire program every
two years in two parts. The inspector reviewed the completed audit designated S-
TMI 96 09 which covered ALARA, radiation and contamination control, airborne
radioactivity control, respiratory protection, exposure tracking, dose assessment,
records, and corrective action follow-up. This audit had a broad scope and was
also highly detailed and in depth, it resulted in the identification of two quality
deficiency reports and nine minor deficiencies. The inspector reviewed the
documentation of the deficiencies, the corrective action process for them, and
selected final corrective actions and found them to be adequate and appropriate.
The audit plan and checklist for an audit in progress, S TMI 97 06, were also
examined and indicated that the audit in progress appeared to be thorough and
comprehensive, its scope included organization, training and qual:fications,
dosimetry, technical specification surveillances, source accountability, radiation
instrumentation use, maintenance, and calibration, procedures, document control,
and records.
l
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o
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.
c.
e-
24
Self assessment efforts by the radiation protection organization were examined by
the inspector. The licensee had a internal assessment procedure which separated
the radiation protection program into a matrix of elements and required the self-
assessment of two elements por year. The inspector reviewed the two 1996 self-
assessments (ALARA and radiation Instrumentation shop) and a 1997 self-
assessmsnt on postings. The licensee's review of postings was extensive and
detailed and used numerous surveillance inspection reports from different plant
locations to gather data, in addition to the above, the inspector examined a 1996
summary and evaluation of personnel contamination events and the 1996 annual
respiratory protection program evaluation which constituted other self assessment
efforts by the radiation protection group. The inspector's review Indicated that
these self assessments and evaluations resulted in the identification of numerous
minor deficiencies and of numerous recommendations for improvement. Many of
these resulted in corrective action being implemented on the spot. Others were
captured in the radiation protection organization's action item tracking system.
c.
Conclusieng
The scope and depth of NSA audits were of high quality, and the findings were
addressed and resolved appropriately. The radiation protection group performed
numerous self assessments and program evaluations which resulted in the
correction of many minor deficiencies and in numerous recommendations for
l
Improvements.
R7.2 Quality Assurance Audit for the Radioloalcal Environmental Monitorina Prooram
ID12PSdML cone (84750)
S
a.
The following Quality Assurance (QA) audit repo ts were reviewed against Section
6.5.3.1.h of TS:
S TMl 95 01, "Offsite Dose Calculation Manual", dated March 27,1995
-
S TMI 97 01, "Offsite Dose Calculation Manual", dated April 16,1997
-
S TMI 9615, "TMI Environmental Controls", dated February 14,1996
-
S TMl 9715, "TMl Environmental Controls", dated January 16,1997
-
b.
Observation and Findinag
The Nuclear Safety Assessment department was responsible to conduct an audit of
the ODCM every 2 years and an audit of the REMP every year. The above audits
have been conducted at the appropriate frequencies. The scope of the ODCM
audits included effluent controls and meteorological monitoring programs. The
inspector reviewed the meteorological portion of the OUCM audits. The
environmental controls audits assessed the environmental monitoring program. The
inspector noted that the auditor reviewed and understood the TS, ODCM, and the
pertinent program procedures. The auditor was familiar with sampling and
analytical practices and observed collection of certain samples and reviewed the
results obtained by the analytical laboratory. The inspector determined that the
j
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9
25
as ,,itor's recommendations and findings were appropriate. Responses and
corrective actions to the findings were timely and appropriate. Followup of the
findings were completed to ensure effectiveness of the corrective actions. The
corrective actions were determined by the auditor to be effective.
c.
Conclusions
Based on the review of the audits and discussions with an auditor, the inspector
concluded that the audits were of sufficient technical depth to effectively identify
and assess program strengths and weaknesses. The audits evaluated the technical
adequacy of implementing procedures, TS requirements, and practices.
Performance of the audits was thorough, objective and of high quality as evidenced
through the report.
R7.3 Quality Assurance of Analvtical Measurements
a.
Insnection Scone (84760)
The inspector reviewed the Quality Assurance (QA) and Quality Control (OC)
programs against Section Part lil, Section 8.3 of the ODCM and recommendations
of Regulatory Guide 4.15, " Quality Assurance for Radiological Monitoring Programs
(Normal Operations) Effluent Streams and the Environment" to determine whether
the licensee had adequate control with respect to sampling, analyzing, and
evaluating data for the implementation of the REMP.
b.
Observations and Findinas
The inspector visited the laboratory and assessed the quality assurance and quality
control programs through review of procedures, quality control charts, detector
efficiency determinations, and results of split and spiked samples. Selected
procedures from the TMl Environmental Affairs Policy and Procedures Manual were
reviewed. The procedures were technically correct and incorporated standard
industry practices. The licensee had in place a program to determine the efficiency
of the detectors. The inspector reviewed the program and noted that efficiencies
were verified every year. The laboratory monitored detector efficiencies aad
recalibrated the equipment as necessary. The laboratory's quality control program
included split and spike samples provided to the laboratory technician for analysis.
The results were compared to the known values by the environmental scientist
responsible for QA and OC The inspector noted that the results were within the
established acceptance criteria, with few exceptions. Exceptions were investigated
and resolved.
The ERL implemented an interlaboratory comparison program as part of the quality
assurance program, required by the ODCM, through continued participation with
Environmental Protection Agency (EPA) drinking water program and a program
provided by Analytics, incorporated. The inspector reviewed the analytical results
t
O'
26
of the EPA drinking water program for 1997 and reviewed the results of the
Analytics program for 1990 and noted the results were in agreement. The results
for 1997 Analytics program have not been completed and were not available during
this inspection.
The inspector noted that the senior environmental scientist of Environmental Affairs
reviewed the routine and non routine REMP sample results, the interlaboratory
results, and the intralaboratory OA/OC results. Any results that appear suspect to
the senior environmental scientist were recounted, investigated, and resolved,
c.
_ Conclusion
Based on the above observations, the inspector determined that the performance of
the contract laboratory was excellent and the interlaboratory program was effective.
The performance of the ERL continued to be excellent.
R8
Misceilaneous RP&C lssues
R8.1 Updated Final Safety Analysis Report Review for the Occupational Radiation
Exposure /Non Outaae and the Radioloaical Environmental Monitorina Proarams
l
A recent discovery of a licensee operating their facility in a manner contrary to the
l
Updated Final Safety Analysis Report (UFSAR) description highlighted the need for a
special focused review that compares plant practices, procedures, and/or
parameters to the UFSAR descriptions,
t
While performing the inspections discussed in this report, the inspector reviewed
the applicable portions of the UFSAR that related to the areas inspected. The
inspector verified that the UFSAR wording was consistent with observed plant
practices, procedures, and/or parameters.
P1
Conduct of EP Activities
P1.1
Quarterly Emeroency Preparedness Exercise (71750)
a.
Scope
The resident inspectors evaluated the performance of the TMI quarterly emergency
preparedness (EP) training exercise conducted on July 10,1997. The inspection
assessed the adequacy of the licensee's on site emergency response program,
implementation of the emergency plan and implementing procedures and
augmentation of the control room simulator,
t
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27
b.
Observations and Findinal
Control Room Simulator
After the reactor trip, the operators immediately diagnosed a stuck open safety
steam relief valve for the 'A' once through steam generator (OTSG). The shift
supervisor (SS) declared an Unusual Event based on the unisolable steam leak. The
SS properly elevated the classification to a Site Area Emergency when the OTSG
experienced a 100 gallon per minute primary to secondary leak rate. The technical
support center performed an independent evaluation of the OTSG leak rate to
validate the control room's information.
An area for improvement was noted in the initial notification of Dauphin County
l
emergency center. The control room communicator did not complete the initial 15
minuto contact due to a problem with the primary phone used to contact the offsite
emergency organizations.
The communicator used Emergency Plan implementing Procedure (EPIP) EPiP TMI-
.03, Exhibit 1, " Emergency Notifications and Call Outs," to notify the State and
local governmental agencies in 11 minutes with the exception of Dauphin County
.,
which took 18 minutes. After the unsuccessful attempt to reach Dauphin County
with the primary phone, a backup phone was used to complete the notification.
The reason for the Dauphin County delay was determined to be a phone wiring
problem at the plant. The wiring problem was corrected and the other lines were
verified to be correct. The delay in notifying the offsite agencies has occurred three
times in the past 15 months, twice during EP exercises (March 1990, June 1997)
and once during the June 21,1997, Unusual Event. The inspectors will follow the
plant corrective actions for this item in response to the Notice of Violation included
in this report.
The inspectors observed the TMl self critique held on July 14,1997. The critique
of the annual exercise was objective and balanced presenting both strengths and
areas for improvements,
c.
Conclusions
The personnel performance during the quarterly emergency preparedness training
exercise was very good. Positive performances were noted in the control
room / simulator for the SS's emergency classification and control room operator
recognition and response to the simulated OTSG problems. TMl's critique of the
exercise was objective and balanced, presenting both strengths and areas for
improvements. An area for improvement was noted in the initial 15 minuto
notification of Dauphin County emergency centers.
l
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28
P3
EP Procedures and Documentation
P3.1
In Office Review of Licensee Procedure Chanoes
An in office review of revisions to the emergency plan and its implementing
procedures submitted by TMl was completed. Procedures EPIP TMI. 03,
Emergency Notifications and Call Outs," Rev. 22, and EPIP TMI .00, " Additional
Assistance and Notification," Rev. 25, were reviewed. Based on your determination
-that the changes do not decrease the overall effectiveness of the emergency plan,
and that it continues to meet the standards of 10 CFR 50.47(b) and the
requirements of Appendix E to Part 50, NRC approval is not required for those
changes, implementation of those changes will be subject to inspection in the
future.
V.
Manaaement Meetinat
X1
Exit Meeting Summary
At the conclusion of the reporting period, the resident inspector staff conducted an exit
r meeting with TMl management on August 1,1997, summarizing Unit 1 Inspection
- activities and findings for this report period. On July 11,1997, two regional inspectors-
conducted exit meetings with licensee management summarizing Unit 2 inspection
activities in the areas of Radwaste Effluent Monitoring and Occupational Radiation
Exposure /Non Outage. TMI staff comments concerning the issues in this report were
documented in the applicable report section. No proprietary information was identified as
being included in the report.
X2
Management Meeting to Review Engineering lesues Related to Confirmatory Action
Letter 1 97 008
On July 16,1997, a meeting was held to discuss the GPUN response to Confirmatory
Action Letter (CAL) No. 197 008, items 3 and 4. The presentation included the findings
of the independent Engineering and Corrective Action Prouess Assessment Team (ECAPAT)
and the GPUN response to problems identified in the ECAPAT report. The findings
included the Team's root cause analysis, associated planned corrective actions, and
assessment of the potentialimpact on other engineering processes. The ECAPAT
evaluation of the engineering process problems and planned corrective actions
appropriately addressed CAL ltems 3 and 4. The open meeting was held between the NRC
and GPUN at the NRC Pegion i Office in King of Prussia, Pennsylvania.
The slides from this meeting are attached to this report. -
eP
29
X3
Pre Declolonel Enforcement Conference Summary
On July 25,1997, a predecisional enforcement conference was held to discuss the events
and issues involving apparent vloistions related to GPUN's response to problems identified
in the Emergency Preparedness area related to the March 5,1997, annual emergency
exercise. The details of the apparent violations are described in Inspection Report No. 50-
289/97 02, dated April 24,1997. The open meeting was held between the NRC and
GPUN at the NRC Region i Office In King of Prussia, Pennsylvania. The purpose of the
meeting was to obtain information to enable the NRC to make an enforcement decision,
- such as understanding of the facts, root cause(s), missed opportunities to identify the
apparent violations sooner, corrective actions, significance of the issues and the need for
lasting and effective corrective actions.
X4
INPO Evaluation
During July 1997, the inspectors reviewed the report from the INPO Evaluation conducted
in March 1997. Because the report did not include any immediate safety concerns, no
additional regional follow up Is planned.
Attachme.it:- ECAPAT Presentation and GPU Nuclear Response
___.
e
30
PART!AL LIST OF PERSONS CONTACTED
Licensee
D. Etheridge, Acting Radiological Controls / Occupational Safety Director
J. Grisewood, Emergency Prepaiedness Manager
D. Hosking, NSA Manager
'J. Langenbach, Vice President and Director
R. Maag, Plant Maintenance Director
- L. Noll, Plant Operations Director-
M. Ross, Director, Operations and Maintenance
z
J. Schork, Regulatory Affairs
G. Skillman, Technical Functions Site Director
P. Walsh, Engineering Director
J. Wetmore, Maneger, Regulatory Aff airs
' senior licensee manager present at exit meeting on August 1,1997.
Nf1C
M. Buckley, TMl Project Manager, NRR
J. Laughlin, EP Specialist, RI
..
..
31
INSPECTION PROCEDURES USED
IP 37551:
Onsite Engineering
IP 40500:
Effectiveness of Licenseo Controls in Identifying, Resolving, and Preventing
Problems
IP 61726:
Surveillance Observations
IP 62707:
Maintenance Observation
IP 71707:
Plant Operations
IP 71750:
Plant Support Activities
IP 83750:
Occupational Radiation Exposure
IP 84750:
Radioactive Waste Treatment, and Effluent and Environmental Monitoring
IP 93702:
Prompt Onsite Response to Events at Nuclear Power Plants
IP 92903:
Followup Engineering
ITEM 8 OPENED, CLOSED, AND DISCUSSED
Ooened
50 289/97 06 01 (VIO), Failure to Notify the State and County Offsite Agencies for the
June 21 Unusual Event.
50 289/97 06-02 (IFI), TMI Radiological Controls / Occupational Safety (RC/OS) Director had
reported to the Corporate Radiological Health / Safety Director.
50 289/97 06 03 (URI), Failuro to Document the Unbalanced Electrical Current Condition
Closed
50 289/96 201 14 (URI), Potential Unreviewed Safety Quesilon Related to the
NPSH for the Decay Heat Removal and Building Spray Pumps,
50 289/96-08 01 (URI), in Service Test Program Corrective Action Related to the Exclusion
of Relief Valves from the Program,
50 289/97. 008 00 (LER), Reactor Trip and Associated Slow Control Rod insertion Times
for Four Rods,
50 289/97 007 00 (LER), Loss of Offsite Power and Reactor Trip.
Uodated
None-
.
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32
LIST OF ACRONYMS USED
Auxiliary Building
As low As Reasonably Achievable
American Society of Mechanical Engineers
Core Damage Frequency
CR
Control Room
CFR
Code of Federal Regulations
Design Basis Documents
Emergency Plan and implementing Procedure
Engineered Safety Feature
,
!
. ,jMCF
Event or Near Miss Capture Form
l
l
IFl
Inspection Followup item
Individual Plant Evaluation
IR
Inspection Report
Inservice Inspection
Inservice Testing Program
JO
Job Order
LCO
Limiting Condition of Operation
LER
Licensee Event Report
MNCR
Material Nonconformance Report
Non-Cited Violation
NRC
Nuclear Regulatory Commission
Nuclear Safety Assessment -
Procedure Change Request
PPB
Part per Billion
Part per Million
Plant Review Group
QV
Quality Verification
Radiological Control Area
Radiation Protection
NWP
Radiation Work Permits
Systematic Assessment of Licensee Performance
SF
Shift Foreman
Senior Reactor Operator
Shift Supervisor
Tl .
Temporary Instruction
.TS-
Technical Specification
Updated Final Safety Analysis Report
Unresolved item
Violation
-
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_
_
._
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.
ATTACHMENT
GPU Nuclear /SRC Meeting
.
Engineering and Corrective Action
Process Assessment Team
ECAPAT Presentation
and
GPL Nuclear Response
July 16,1997
-
--
-
_
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__
-
-____
.
_ _
_
_,
_
.
Agenda
.
Introduction and Background
- A. Rone
ECAPAT Presentation
- R. Long
GPL Xuclear Response
- A. Rone
-
.
Summary and Conclusions
- A. Rone
-
2
L
_.
-
_____
.
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_,
,
Introduction and Background
.
In February 1997 NRC inspectors identified
the issue ofinappropriate downgrades of the
quality classification of certain components
at TMI-1
3
.
_
_
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_-
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. _ _
--
.-
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_
_-
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-
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_
.
I
Introduction and Background
!
.
1
On March 4,1997 NRC issued a confirmatory
-
action letter confirming GPU Nuclear
j
commitments
- Immediate and near-term actions have been completed
- by July 1:
~
j
l
Perform an assessment to determine the root causes of the
weaknesses in the process and corrective actions, and why past
!
QA findings were not addressed in a timely manner
j
,
Determine what assessments and changes are needed for other
engineering processes
t
- Discuss with NRC by July 18
.
,
l
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,
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-.
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_
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_
_
_ _
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__
i
e
GPU Nuclear Response to
ECAPAT Recommendations
.
_-
-
___
___
_ , _
.
GPU Xuclear Response .
GPU Nuclear fully accepts and embraces the
results and recommendations of ECAPAT
- ECAPAT effort was of high value to GPU Nuclear
- Cultural and process issues were well defined,
thoroughly examined and clarified.
- Recommendations of ECAPAT are strongly linked to
the underlying causes of the identified problems
- Actions to address the recommendations are expected
to correct the identified problems
6
_
_
.
_
__
_
_
__
__
GPU Nuclear Response
Management role considered key to
properly formulating and resolving issues
GPU Xuclear is committed to expeditiously
completing all remaining actions
GPU Xuclear is committed to proper
follow-up to verify that the planned actions
produce the desired results and that the
improvements are permanent
7
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i:
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GPU Nuclear Approach to
ECAPAT Recommendations
!
!
!
GPU Nuclear senior staff has taken a broad
i
4
view of the ECAPAT recommendations in
4
l
the context of an overall process model
.
i
~
- Grouped recommendations accordingly
t
- Emphasized the importance of understandmg
j
i
the interrelationships of recommendations to
effectively address the underlying causes of
l
problems
1
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8
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-- --.- -
- -
-
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=
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Process Model
Management Systems
Jab Skills /
Culture / Values
Process
Organization
N
Information Systems
9
._____ _ _.
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,
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Culture and Values
No.
- Recesamendation
Actions
_ Target Date
6
Establish and communicate
1. Communicate expectations to all Engineering division giso..m.I
Complete
management expectations
2. Issue" Conduct of Engineering procedure
4* Qtr. '97
regarding accountability to
3. Revise GET and ESP training to incorporate management expectations
I" Qtr. '98
comply with procedures
regarding procedure compliance.
4. Perform self-assessments and NSA oversight to determine the level of
Ongoing
'
understanding of procedure compliance requirements.
12-
Clarify expectations on resolving
1. Interim guidance issued by the President, GPU Nucicar and the VP.
Complete
and escalating quality
Engineering
deficiencies
2. A 100. review of all outstanding QDRs and significam DVRs has been
Complete
completed to ensure that all have been properly escalated.
3. Explicitly im.v pui.te escalation into the CAP system. and the DVR
system.
3rd Qtr. '97
7
Re-visit and clarify " Teamwork
1. Conduct team-building worksheps with NSA and Engineering.
In progress
and Leadership" training in
2. Review Ops and Maint at both TMI and OC to determ'me ifsimilar
TMI: 4* Qtr. '97
regards to the potential
problems exist in OAM and to what extent.
OC: 1st Qtr. '98
misinterpretation or
-
misapplication of principles.
8
Emphasize management's
1. Establish and communicate expectations / responsibilities.
4' Qtr. '97
responsibilities and expectations
2. Conduct focus groups / workshops. NSA to pilot effort.
4' Qtr. '97
for conflict resolution
3. Implement conflict resolution workshops.
I" Qtr. '98
d
4.
Implement monitoring to determine the effectiveness of conflict
3 Qtr. '98
amidance/ resolution corrective actions.
15
Clarify performance-based
I. C%rity the working definition of performance-based QA.
4th Qtr. '97
Quality Assurance
2. Communicate the working definition of performance-based QA.
Ist Qtr. '98
I8
Establish expectations on the'
. Implement specific near-term improvements in the CAP /DVR systems.
4th Qtr. '97
form, content, use,
review / approvals, ownership and
oversight ofcorrective action
systems
10
.. . ..
.
..
. ..
.
...-_
_
.
.
.
..
..
-
=
.
= x;---- -- -
-
_
_.
--
_
__
_
Management Systems
No.
RecomessenJation
Actions
Target Deer
Engineering
I
Map the Quality Classification Process
Evaluate for completeness. integration with other procedures and
4* Qtr. '97
rwuscs and overall adquacy
2
Revise EP-011 for the classification of
Rev. 5 of EP-011 issued
Completed
equipment. Develop a new procedure for
Further revision of EP-01 I in progress
4* Qtr. '97
the classification ofactivities.
Development of a new procedure to classify activities.
4
Develop a Temporary Change Process
Draft procedure out for cornment.
3rd Qtr. '97
for Engineering Procedures
5
Develop basis for confidencein the
Underway at OC on a sampling basis. TMI to start by Aug. 31.
4* Qtr. '97
,
original Quality Classification Process
1997
11
Develop indicators and trend
These will be developed aller the completion of the map of the
4* Qtr. '97
performance for the QCL rw ess
QCLrwas
Oversight
17
Improve GORB activities
Develop GORB process improvement activities.
Complete
implement process improvement activities
2nd Qtr. '98
19
Improve planning for and icspnoe to
Consider covering fewer topics, but same topic at both plants each
4' Qtr. '97
CMAP audits
year. Enter CMAP findings it. a the Corrective Action S 5em
3
14
Better integrate the activities of the TMI,
Consider expanding the use of hterdisciplinary audit teams.
4' Qtr. '97
OC and Corporate NSA groups
Consider a single audit group.
20
Implement a common, high volume, low
The teams that developed the CAP /DVR systems for TMI and OC
ist Qtr. '98
threshold corrective action system
have been reconstituted to perform this task
16
Impose a tirne requirement for the
Consider changes to QA plan and/or procedures
4* Qtr. '97
completion ofISRs of audit reports
11
_
__
_
. _ _
_
_
_
.
_.
.__
_
_
_ . _ , ,
.
Job Skills / Organization
No.
Recomessendation
Actions
Target Deee
Engineering
9
Staff the QCL pucess with proper
1. Interim action taken to ensure adequate staff for current work
Compicte
number of qualified people based on the
load.
QCL process map.
2. Long term resource needs to be defined after the map of the
l' Qtr '98
QCL ruccss has been completed.-
10
Conduct training on the overall QCL
Training on EP-011, Rev. 5 completed. Training on Rev. 6
I" Qtr. '98
puccu
pending.
Oversight
13
Select a pc.. anent NSA Director.
Selection made. Selection to be announced subsequent to NRC
Pending
_
action on proposed OQA Plan change.
12
- - -
-
_
.
_
_
_
-
. . ~ .
_
_
.._
__
,
Information Systems
-
No.
Recomsmendaties
Actions
Target Date
Engineering and Licensing
3
Compile the licensing basis requirements
1. FSARs for Oyster Creek and TMI have been put into Lotus
Complete
in an accessible database to support the
Notes databases
QCL determinations
2. Information-Only copics of the Twin; cal Specifications for
Complete
both Oyster Creek and TMI have been put into Lotus Notes
databases.
3. A regulatory commitments database for TMI has been placed
4* Otr. '97
into a Lotus Notes database. Further consolidating and
upgrading is planned to make it mvre user-friendly.
4. A regulatory cuimiendence database for Oyster Creek is
~ In Progress
under development to identify commitments, design basis and
licensing basis information.
13
,
j
r
_
_.
_
_
.
. _ .
__
_
_
_, _
_
.
Other Program Assessments
No.
Recommendation
Actions
TarEet Dce
21
Perform assessments on a priority basis
1. Assess the effectiveness of the changes made to the
3rd Qtr. '98
'
of 5 listed programs and processes
Corrective Action Process
2. Setpoint Control
4th Qtr. '97
5
3. Safety Determination and Review
OC complete
-
TMI 3rd Qtr. '97
4. EQ Program
ist Qtr. '98
5. Emergency Planning Program
4th Qtr. '97
d
22
Assemble a complete list of existing
1.-
Develop the list
3 Qtr. '97
regulatoy mandated programs and screen
for further assessment
2. Use existing assessment tools and ECAPAT criteria to
4* Qtr. '97
screen
To be determined
3. Perform reviews as required
.
14
_-
,
.
_ -
- .
= = _
_ _ _ ,
-
---
-__
Continuing Actions
'
Needed actions are viewed as an integral
part of other recent initiatives:
- Process-based engineering organization
- new self-assessment process
- new corrective action process (CAP) at TMI
15
.....,.....i:........_.....................
,
. -
. . . .
_
. . . .
_=_
__
-
_ _
-
-
-
.-
_
.
Follow-Up Methods
Recently Initiated Effort
- Self-Assessments
Improved On-going Assessment Processes
-
- Nuclear Safety Assessment Audits
.
- General Operations Review Board Oversight
- Cooperative Management Audit Program Audits
-
- Nuclear Safety Compliance Committee Oversight
New Effort
-
- GPU System Internal Auditing
16
_
_
-
_
-
_
__
_
.
__
_ . ,
_
Summary and Conclusions
-
GPU Nuclear is committed to correcting the identified
-
problems
Actions are in progress to address the cultural issues
-
and will require on-going reinforcement and attention
by management
Assessments of other areas are planned
-
Follow-up activities are planned to verify
-
effectiveness of corrective actions
17
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _
_ -
_
-
_
-
_
_
_
_
_
-
-
_
_ _ _ _
Meeting Attendees
.
Outside Consultants
GPU Nuclear
-
- T. G. Broughton
President
-
Dr. Robert Long
- R. W. Keaten,
VP and Director,
Nuclear Stewardship, LLC
Engineering
- J. W. Lang ;nbach
VP and Director
-
Dr. Thomas Gerber
TMI-I
Independent Consultant
- M. B. Roche
VP and Director
Oyster Creek
-
Mr. Jack Devine
- A. H. Rone
VP and Director
Polestar Applied Technology
- J. C. Fornicola
Director,
-
Mr. William Schmidt
Regulatory AfTairs
MPR Associates,Inc.
- J. S. Wetmore
Manager, TMI
Regulatory AfTairs
- M. C. Wells
Manager,
Communications
- J. S. Schork
Tech Analyst Sr.II
TMI Reg. Affairs
18
_Z
-]C
-
_g .
~
-
- w ._
-
,
_.._
_
._. _
.-
Glossary
Corrective Action Program (TMI)
.CMAP-
Cooperative Management Audit Process
~DVR-
Deviation Report (OC)
ECAPAT
Engineering and Corrective Action Process Assen...ci.t Team
ESP.
Engineering Support Personnel
. Environmental Qualificatiori
Final Safety Analysis Report
General Employee Training
GMS-2
Generation Management System, Rev. 2 (the maintenance work scheduling program)
GORB
General Office Review Board
IIPES
Iluman Performance Evaluation System
,
IIPIP
IIuman Performance Investigation Process
Independent Safety Review
.
Motor Operated Valve
Nuclear Safety Assessment
NSCC
Nuclear Safety. Compliance Committee
QA-
. Quality Assurance -
,
QCL
Quality Classification List
Quality Deficiency Report
SQUQ
Seismic Qualification Utility Group
-19
--
_
. _ - - _ - _ _ _ _ _ _ _ _
_ _ _
_
_
_
_
z_
-_
- ._ ._- -
-- -
_.
_ . _ .
.
ECAPAT PRgggA-.TATroy
"" 5
& 16,
997
Robert L L
& Ph.D.
,Xuclear Stem' rdship, LLC
Albuquerque,;yy
1
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
. . . . .
..
_
_
- - - -
_
_
__
__
_
.
_
____
ECAPAT Presentation Outline
+ Introduction
+ Team Members
+ Charter
+ Methodology and Activities
+ Results
+ Conclusions
'
2
-
,
._.
_
--
_
_
_
_
_
_
ECAPAT Team Members
+ R. W. Cooper, II, Nuclear Consulting
+ J. C. DeVine, Jr., Polestar App ied Technology
+ T. L. Gerber, Consultant and GPU Xuclear GORB
Member
-
+ R. L. Long, Nuclear Stewardship, LLC (Team Chair)
+ W. R. Schmidt, MPR Associates, Inc.
3
L
- - -
_
-
.
_
-
_
_
_
_
. _
_
.
-.
_
+g
ECAPAT Team Members
(Continued)
+ G. R. Skillman, Director, Configuration Control,
TMI, GPU Nuclear
'
+ G. Sec uin, INPO (Apri:-May,1997 only)
+ D. C. Smit:2, Consulting Engr., OC, GPU Nuclear
'
+ J. S. Wetmore, Mgr., Regulatory Af" airs, TMI,
GPU Nuclear
4
E-
_
-
______
__
__
___
ECAPAT Charter
.
+ Perform an independent assessment of the root
causes and contributing factors that led to break
downs in the QCL engineering and corrective
action processes. . .
+ ... complete by end of June,1997...
+ ... include specific recommendations to resolve the
root cause findings.
+ ... determine what assessments and changes to
i
other engineering processes are needed.
5
i
. _ _ _ .
--
- __ ;
_=
-
-
____-
-_
+1-
ECAPAT Methodology and
u
Activities - Strategy
+ Focus heavily on QCL implementation and related
corrective action processes issues to gain
comprehensive understanding of events, causal
factors and root causes.
+ Apply the understanding gained to determine
condition of other engineering programs and
processes.
6
- - - - -
e
-
. _
= --
- __=__
.
_
.
_
_
+1[
ECAPAT Methodology and
Activities - Discovery
+ Reviews of ~280 historical (1990-1996) and current
documents: e.g., quality monitoring and audit reports;
reports of outside agencies; correspondence; QCL,
engineering and oversight procedures; and various
special documents prepared for ECAPAT by GPU
Nuclear staff.
+ Interviews of ~40 persons, including practitioners,
management and oversight personnel.
7
i
_=
_
__
_
_
_
__
_
+4
ECAPAT Methodology and
Activities - Assessment
+ Applied guidance in :NUREG/CR-5545, HPIP and
ISPO HPES.
+ Team met 7 times for a total of 17 days - meetings
included numerous presentations by GPU Nuclear
personnel.
+ Extensive work done by Team members between
meetings.
+ Followed process of developing and documenting
observations, causal factors, underlying (root) causes
and recommendations.
8
..
.
.
-
_
.
..
.
. _ .
_
_
_=
..
__
_
_
__
l
l
+,/,
ECAPAT Methodology and
Activities - E&CF Chart
,
+ Event and Causal Factor Chart developed in parallel
and helped focus on gaps and inconsistencies.
+ Chart provides QCL history beginning in ~1981.
9
. . .
- . . .
.
l!ll
1
l
.
_
_.
,
_.
,
_
tne
_
mss
_
essA
TAPA
_
C
C
I
_
f
_
o
s
t
lu
-
seR
-
-
l
____
_
__ _,
__
.-
-
+4f
ECAPAT Analysis Organized
Around Four Categories of
QCL Findings
+ Process and Procedure Adequacy
+ Process Implementation
+ Oversight Effectiveness
+ Corrective Action Effectiveness
.
11
t
.
.
=
.=_____
_
.-
_
_
___
-
-
_
_
+i/
~
ECAPAT OveraII Conclusion
RE: QCL
Failures in process implementation were the
primary cause for the QCL problems, followed by
breakdowns in oversight effectiveness, corrective
action effectiveness, and process and procedure
adequacy.
12
l
--
_ _ _ _ _ _ _ _ _ _
__
__
_
_
_
_
_
_
+1"/
.
Synopsis of QCL Proces-s and
Procedure Adequacy
+ A copy of a final analysis Table, " Synopsis of QCL
Process and Procedure Adequacy," is included in the
aandout.
+ Each of the four QCL findings categories has a similar
table.
+ GPU Nuclear has been provic ed a full description of the
analyses and detailed language of recommendations.
+ Numbers in parentheses after each recommendation
correspond to the GPU Nuclear Action Plan.
l
13
,
-
...
_.
~
g -~
~
'_
~
_ 7 ' ; _ __
__
_
Z
g
.
.
_
__ _
_
_
d/
SYNOPSIS OF QCL PROCESS AND PROCEDURE ADEQUACY
OBSERVATIONi
CAUSAL FACTORS
UNDERLYING (ROOT) CAUSES
RECOMMENDATIONS
GPU Nuclear pmcedures for quality classification
The procedures were poorly written;-
Management expectations ami
Map the QCL process,induding
have nnt been completely cons * dent with OQA
they were not effectively reviewed
guktance were insufficiently
considersaion ofindustiv
rrogram requirements, ami they have had other
ami t-sted before full-scale
communicated Speci& ally:
guilance, and prepare a pnwam
shortcomings. As examples-
implementation am! generally dit not
plan.
have ficId *1my-in."
There was no top-ticrplan o other
.
The procedural guidance for the actual
guidance &xument to integrate
e
classification work is vague.
Making changes to in. place
amicommunicate the overag
IIx the QCL Tr cedures mal
engineering proced. ares is perreived
activities, thek relationships, and
interfacirig GU2 cor,trols
- Classification of " work activities"is not
to be difficult and time-consuming;
management expectations with
Require safety revsew of
covered.
as a consequence, usen temi to " live
respect to classification wort
downgrades.
with" poor procedures rather than
imprwe them-
Management tolerated inedequate
e
Ep-011 does not require piety wiew.
e
rirocedural tools and did not
Compile licensing basis
,
'
h'rovide an effective process for
ghwnts W an M
"#
Procedures do not prescribe measures for
e
database control, unauthorized personnel can
.'RCKUla
-
'IR 4"
d lassification)
changing engineering pruedures.
change the database-
is umque m the industry, not cleariy
Derclop a temporary change
defined, and requires subjedive
h""'"'"'8#'"#nt diJ not
e
process ami consiler a permanent i
There are no requirements for methodical
interpretation by the classifier.
ene urage use of induery
e
analysis of failure modes ami effects,in
change process for engmecring
8"' '"##'
determining QCL classification, as called for by
The information needed by classifiers
procedures.
imiustry guilance. Ghis raises questions
(particularly that necessah for a
regarding both downgrades and the original
"Reguistory Required" des'ignation) is
d""
h
"'
Dereky the basis for confalence
QCL databascJ
rot readily avaital le'
&
hat resuhed frorri GU2
- P'"
"'
clas fic ion
ndertne
The Gilt NucIcar classification process is complex
The process was designed with the
amt has leen generally difficut to implement.
assumrtion that changes wouki be
ongmal QCL progran:.
infrequent, ami primarily related to
The classification system (process ami procedures)
plant smxlifications.
did not acccmmodate the high volume worikvid
caused by QCL expansion from system level to
comt'onent and sub. component levels.
14
.
--_-_____.___-:
"'
~ ~ *
~
~
"
"
~
h
--
_
.
_
_
_
_
_
. _
-_
. _ .
_
.
i
g;
Process and Procedure
Adequacy
+ Observations
+ Causal Factors
+ Root Causes
.
+ Recommendations
15
_____________ _ _
= ,_
_
_
___
_
_
'
'
t
g
Process and Procedure Adequacy
j
- Observations
.
.
!
+ QCL procedures were not consistent with OQA
Plan requirements.
i'
+ GPUN QCL process was complex and difficult to
implement.
.
t
+ Classification system (process and procedures)
,
could not handle expansion.
i
1
I
16
i
i
!
-?
!
-
. = _ = _ -
_
_ _ z_ _ .
=
__
_
t
+4
.
Process and Procedure Adequacy
- Causal Factors
.
j
'
+ QCL procedures were poorly written; no field buy-in.
l
+ Engineering procedure change process was perceived
as difficult and not used.
j
<
+ Classification structure unique in the industry.
.
+ Information needed not readi:Ly available.
!
,
.
+ QCL process designed for plant moc s.
-
!
,
t
+
!
!
17
t
!
4 .
-
_
-
_
_z
__
_
_.
.
.
t
.
Process and Procedure Adequacy
,
- Root Causes
.
'
i
i
l
+ No top-tier plan or other guidance document to
. integrate activities of classification work.
l
+ Management tolerated inadequate procedural tools.
+ Senior management did not encourage the use of
industry guidance.
+ Management did not recognize or provide for high
volume of QCL changes.
-
I
i
l
'
.
18
l
!
r
>
-__,_.;
___
______
_
.
+1/,
Process and Procedure Adequacy
- Recommendations
+ Map the QCL process,. including consic eration of
'
industry guic ance, and 3repare a program plan. (1)
+ Fix the QCL procedures and interfacing maintenance
work control processes. Require safety review of QCL
downgrades. (2)
+ Compile licensing basis requirements into an accessible
database. t'3)
19
_ _ _ _ _ _ _ _ _ _
_
_
= . _
. _
-
-_-
-
_
-
-
_ . _ ,
+a[
Process and Procedure Adequacy
- Recommendations
(Continued)
+ Develop a temporary change process and evaluate
the permanent change process for engineering
procedures. (4)
+ Develop basis for confidence in the adequacy of
the classifications made under the original QCL
program. (5)
20
_ _ _ _ _ _ _ _ _ _
.
.
-
_ - _ _ .
_
_
_
_
_
Process Implementation
4
+ Observations
+ Causal Factors
+ Root Causes
.
+ Recommendations
21
__;
_
_
_
_
_
_
_
_ _
--
---
+g
Process Implementation
-
- Observations
+ Those responsible for classification did not always
follow procedures.
+ QCL Program line management not effective.
+ Some users chose, unilaterally, not to use
downgradec classifications.
.
22
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _. ;
_-
--
-
____
---
!
l
+4 /,
Process Implementation
!
- Causal Factors
.
+ Poor procedural tools made implementation difficult.
+ Process training inadequate.
+ Personnel resources inadequate, in numbers and
qualification.
+ Problems not escalated to senior t anagement.
+ QCL personnel pressured for fast turnaround.
l
t
+ Users did not trust the downgrade process.
I
!
23
?
_ p_. ;
-_
_
_
_
. _
-
>
$
+g.
Process Implementation
j
l
- Root Causes
i
- .
!
.
,
I
l
+ Management expectations not sufficiently
j
communicated.
!
!
,
+ GPU Nuclear emphasis on " Teamwork and
l
l
Leadership" may have been misunderstood.
i
'
+ There was generally a low level of professional
respect between the QCL group and their plant
j
4
i
customers.
,
!
,
1
t
.
- - -
- -
-
- - - - -
.
_z_
_
7_
__
j
.
3.
Process Implementation
l
- Recomm.endations
.
,
+ Establish and communicate management expectations
!
-
regarding procedural compliance. (6)
'
+ Revisit, clarify and reinforce " Teamwork and
Leadership" principles:
-
,
address ECAPAT findings,
-
!
resolve organizationa conflict,
-
rebuild respect among organizational units. (7)
-
!
+ Emphasize management responsibilities and
expectations for conflict resolution. (8)
-
25
f
_
- -
_-
_
_
.
.,
{
k
'f
Process Implementation
- Recommendations
(Continued)
l
+ Based on the QCL process map:
!
- determine the number of personne_ and their
i
qualifications requirements;
]
l
- staff accordingly. (9)
+ Identify QCL training deficiencies and conduct
i
training as needed. (10)
,
,
l
+ Develop indicators and trend performance for the
QCL process. (11)
]
I
4
'
!
i
'
26
!
i
!
.
.
. . .
.
.
.
. .
.
-
- -
- - -
__
_
_
Oversight Effectiveness
+ Observations
+ Causal Factors
+ Root Causes
.
+ Recommendations
27
_ _ _ _ _
.
.
.-
.
_
_ -
-
--
=
____
._
-
_. _.
!
i
+/
i
>
'
Oversight Effectiveness
- Observations
1
.
'
+ Deficiencies not always handled properly.
i
l
+ Oversight groups pursued neither causes nor extent
of QCL deficiencies.
,
.
+ Problems / conflicts not escalated to management.
I
+ Resolution of concerns by independent safety
!
review of aucLit not timely nor effective.
4
+ GORB's observations did not yield resolution from
management.
.
l
28
i
!
-.
__-
_
.
--
_ .--
.
- -
_
-
-
-
-
_-
-
_ _ _ .
,_
_.
?
4
Oversight Effectiveness
- Causal Factors
!
+ Persistent organizational resistance to oversight.
.
!
+ Reluctance by line management to accept QDRs or
i
!
findings, viewed as " black marks".
+ Reluctance to issue QDRs or findings without line
!
i
buy-in.
.
.
l
+ Procedure for escalation of findings anc.
deficiencies not followed.
'
+ Compartmentalization ofNSA/QA into TMI, OC
{
and Corporate groups led to delays in identification
'
and resolution of c eficiencies.
,
'
29
!
_
. -
- - -
- - -
- - - - - - -
-
.
-
.
-
-
-
_
-
- -
- -
q\\ Wss-
"WW**
mM40
_
-
4.t _c:
bM
i
l
!
'
4
Oversight Effectiveness
- Root Causes
.
i
!
t
l
+ Senior management did not attach high value to the
l
identification and resolution of problems.
+ Unresolved organizational friction between Tech
Functions and QA and between site and corporate NSA.
l
}
+ Frequent management changes and long term acting
management assignments may have had adverse effects.
t
+ Possible misinteraretation of GPU Xuclear
!
1
l
" performance-based" QA pohey.
l
)
+ GPU Xuclear's emphasis on " Teamwork and
l
Leadership" may have been misunderstood.
!
,
!
f
!
30
l
i
i
-
-
-
-
_
__
_
_.
.
l
i
e/'
Oversight Effectiveness
l
i
- Recommendations
i
i
!
+ Clarify and reinforce management expectations
'
regarding the importance ofidentifying, resolving
l
and escalating quality deficiencies. (12)
l
-
4
i
+ Staff the NSA Director position with a strong,
permanently assigned individual. (13)
+ Better integrate the activities of TMI, Oyster Creek
l
anc corporate NSA groups. (14)
i
!
l
31
-
- - -
-.
- -
-
..
---
-_ -
_.
.
-
-
_______.
-.
_ .
_ . ,
'l
Oversight Effectiveness -
Recommendations
(Continued)
!
!
!
+ Clarify principles and intent of performance- aased
'
QA. (15)
,
.
+ Impose a time requirement for completion of
l
,
independent safety reviews of audit reports. (16)
+ Improve GORB activities and processes. (17)
'
!
!
!
f
i
1
!
!
i
i
i
32
i
i
r
r
_ - ~ ~ ~ ~ ~ ~
l'
_.
_ _ _ .
.._
_
_
_
_
_
_
_
_
_
_
+ Observations
+ Causal Factors
+ Root Causes
.
+ Recommenc ations
33
_ -_ _____ _ _ _ __ _
. .
..
..
.
_.
...
.
.
..
=
_
_
_
___
-
,_,
+f
l
Corrective Action (CA)
Effectiveness - Observations
~
+ QCL problems not put into the CA system.
+ Inadequate and/or untimely responses to documented
problems.
+ Numerous unresolved recurring weaknesses.
+ Evaluations of QDRs ineffective in ascertaining root
cause and extent of problems.
34
L
. .
..
.
, .
. . . . . . . . . , . , .
. . . . . .
. . . .
. . . . . . .
.
.
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i
.
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Corrective Action (CA)
Effectiveness - Cau. sal Factors
1
,
i
+ Use of multiple CA systems combined with
ineffective reporting on status contributed to CA
l
ineffectiveness.
+ CA system threshold not clearly understood by
!
line management.
+ Inadequate monitoring and reporting of deficiency
resolution.
!
,
l
-
I
35
[
i
!
!
__
_
.-
-.
-
.-
_
__
_
_
.
i
,/
!
'
Corrective Action Effectiveness
"
- Root Causes
.
+ Senior management failed to recognize corrective
l
action health as essential for 10CFR50 Appendix B
!
compliance.
i
-
-
+ Lack of company-wide corrective action system.
.
l
+ Internal organizational friction between Tech
l
Functions and QA and between site and corporate
NSA.
!
!
+ GPU Xuclear's emphasis on " Teamwork and
Leadership" may have been misunderstood.
.
[
l
36
I
,
!
-
-
-
-
l
.
_
.
-
_
_ -
_-
- _ -
_
-
--
.-
-
___
-
-
_
-
..
_
+t
Corrective Action Effectiveness
- Recommendations
t
,
+ Establish expectations regarding form, content,
!
threshold, etc., for corrective action system. (18)
.
l
+ Improve planning for and response to CMAP
'
audits. (19)
!
4
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i
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i
,
i
i
37
f
'
,
.-
.
.
.
.
. - -
-
.-
_
- - .
-
-
i
.
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Broader Implications
'
+ Many of the QCL findings / root causes potentially
apply to other processes and programs.
l
i
l
+ ECAPAT performed limited screening reviews of
. l
selected processes and programs based on:
- Similarity to QCL
- Recent inspections, monitorings, audits and
'
3
deficiency reports
- Interviews with and presentations by GPU
Nuclear personnel
- Responses to an ECAPAT developed
!
questionnaire
-
l
-Information in 50.54(f) responses
33
l
l
!
.
-
-
_____
.-
-
-
_
, _ _ .
+4
Other Programs and Processes
- with attributes, factors similar to QCL
+ Processes:
+ Programs:
- Calculations and Design
- Environmental
Verifications
Qualification
- Set Points
- Safety Review
- Corrective Action
- In-Service Testing
- FSAR Fidelity
- Software Control
39
-
-
__-
-_____
-
--
_
_
,
_.
+4
Corrective Action Processes
.
Warrant Special Attention Because:
+ Multiple, different processes.
+ Different attributes, forms, requirements.
+ Implied requirement to obtain auditee acceptance
of QDRs and findings.
+ Guidance / definition of"significant conditions
adverse to quality" nonexistent or too broad.
+ Trending / monitoring difficult.
40
l.
_ _ _ _ _ _ _
..
.
.
=
_.
___
__
_
_
_ .
.
.
+4
ECAPAT Observations
Re: CA Process
~
.
+ Actions have been recently taken to improve Oyster
Creek and TMI Corrective Action Programs.
+ CA processes are too many, too complex and have
numerous weaknesses.
.
41
_ _ _ _ _ _ _ _
_
--_
.
.
. -
.
-
-.
_ _ - - -
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_-
.
__
_
_
_ _ _
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_
_ _
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.
,
,
!
.
'i/
Correction Action Process
- Recommendation
.
4
,
i
+ Develop and implement a common, high volume,
'
low threshold corrective action process across
i
both sites and corporate.
ECAPAT recommenc s
i
a number of desirable attributes to include in the-
l
process. (20)
-
i
I
!
'
4
!
42
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h
i
I
_
_
_
_
_= _ _;
=-
____
____
_
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!
,
!-
,if
!
Other Programs and Processes
i
- Recommendation
i
i
,
-
i
!
!
+ On a priority basis, perform assessments of the
'
programs and processes listed on the next slide.
i
ECAPAT describes elements to be used in the
.
l
assessment. (21)
!
4
i
f
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l
!
i
i
i
i
!
i
43
,
,
_
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.t
.
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i
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,
__
__
__
_
_
_
-
l
0
-
i
'
k
/
t
Further Assessment
Warranted on a Priorit'y Basis
i
Process / Program
Basis
Corrective Action
For reasons stated
t
i
Set Point Control
Importance and e.g., OC
program does not include the
bases for all NSR set points
i
i
Safety Determination
Importance and indeterminate
l
status at TMI and Corporate
FSAR Fidelity
Importance-potential for errors
)
-
Environmental Qualification
Similarity to QCL issues
j
l
Importance-recent TMI
j
problems
!
r
- -
._
.
- - - _ _ _ _ -
- - -
._-
,-
.
__
_
.
_
_
_
__
_
_.
-
_
.
i
,
i
~
Further Actions on Regulatory
Mandated Programs and Processes
,
- Recommendation
1
i
!
4
!
l
+ For the remainder of the regulatory mandated programs
!
and processes:
l
- screen those not looked at by ECAPAT,
~
- establish consistent methodology for on-going
and future assessments,
i
- enter findings in a recognized corrective action
j
i
system. (22)
i
l
i
[
!
i
1
45
l
!
!
!
'
--
-
--
_
-
___
_
_
+'d
Conclusion
Root Causes of QCL Process
-
Problems
i
+ Management failed to establish, communicate and
enforce expectations for QCL process implementation.
+ Management did not apply sufficient emphasis and
attention to QCL program oversight and corrective
action activities.
+ Management did not adequately plan, prioritize and
support QCL program activities to ensure appropriate
application oflimitec resources to multiple tasks.
46
.
_
_
__
.
_
z
=
___
_
_
1
,
.,
4
Conclusion
4
,
Regarding Other Programs
i
and Processes
.
+ Evidence suggests .similar weaknesses afflict other
l
GPU Xuclear programs and processes.
4
,
+ Further assessments needed by GPU Xuclear to
i
determine any additional actions.
c
+ While ECAPAT did not highlig at them, GPU Xuclear
L
has many organizational, management and individual
l
strengths which saould provide an ample foundation
l
for oositively resoonding to all ine ECAPAT
!
!
recommendatioim.
47
.
!
!
!
--