ML20212B249
| ML20212B249 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 10/17/1997 |
| From: | Boulette E BOSTON EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-293-97-80, BECO-2.97-104, NUDOCS 9710280017 | |
| Download: ML20212B249 (13) | |
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mata, emum Pdgrim Nuclear Power Staton Rocky Hill Road Plymouth, Massachut .tts 02360 October 17,1997 E. T. Boulette, PhD BECo Ltr. 2.97-104 senior vice President - Nuclear U.S. Nuclear Regulatory Commission Document Control Desk Washington. D.C. 20555 Docket No. 50-293 License No DPR-35 Reauest for Extension for Repiv to Notice of Violation 97-80-01 i This letter requests an extension of 60 days in the required reply to Notice of Violation l
(NOV) 97-80-01. This request is made to allow sufficient time to correctly identify the root cause of the procedural compliance issues which confront the station and, thereby, to determine meaningful and effective corrective sctions to preclude recurrence. Effectively, this letter requests the date for a final response to NOV 97-80-01 be extended from J October 17 until December 17,1997.
In reviewing the record of NRC comments and violations and the trends established under our own self-assessment and corrective actions processes, procedural compliance is not meeting our expectations. The procedural violation examples cited by the NRC are symptomatic of the overall procedural compliance issue. Limiting actions to correction of the instances cited in the NOV would not necessarily establish meaningful and effective change. Sufficient information on the types of errors and their implications en human performance and organizational controls is now available in our corrective action data I base. Thus, a multi-disciplinary task force has been formed to analyze these procedural compliance data, assess root cause, correlate the relationship to the previous and current 40500 corrective action activities, and recommend meaningful solutions. This task force is intensively engaged in the process of driving out a root cause; however, the processes involved are complex and require additional time for correct characterization. An extension is necessary to allow 2,dequate time for this process to occur.
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9710280017 9710t7' '
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The roasons for the specified procedural violations cited in NOV 97-80-01 are provided as Enclosure 1. The completed corrective actions which resulted and the status of those actions to date are also included. A better understanding of the root cause of procedural compliance issues at Pilgrim Station and actions to be taken to preclude recurrence will be delineated in the response to the violation on or before December 17,1997.
Also, actions have been taken to address the NRC team's observations with respect to the implementation of our Nuclear Safety Concerns Program. These actions are described and included in Enclosure 2 to this response.
As r:oted in the inspection report, the overall implementation of the problem identification, root caJse, and corrective action processes has improved since the NRC's previous inspection in this area. We attribute this to the integrated corrective action plan activities described in BECc letter dated January 31,1997, submitted in response to NRC inspections 96-06 and 96-80 (40500 Inspection). An update of these activities is provided for information as Enclosure 3.
Should you have any questions or require fur'her clarification, please do not hesitate to contact me.
I Boulette, P D
! JDK/dmcN978001 Enclosures
- 1. Initial Reply to Notice of Violation
- 2. Nuclear Safety Concerns Program Discussion
- 3. Update of NOV 96-06-02 Corrective Action Actbeities cc w/ encl:
Regional Administrator, Region i U.S. Nuclear Regulatory Commission 475 Allendale Road King of Prussia, PA 19406 Senior Resident inspector Pilgrim Nuclear Power Station Mr. Alan B. Wang Project Manager Project Directorate 1-3 Office of Nuclear Reactor Regulation Mail Stop: OWF 14B2 1 White Flm' North 11555 Rockville Pike Rockville, MD 20852
ENCLOSURE 1 Initial Reply to Notice of Violation On September 17,1997, the NRC issued the 40600 team inspection results of the Pilgrim Station corrective action processes (NRC IR 97-80). The NRC identified three specific issues relating to procedural compliance at Pilgrim Station which became NRC Notice of Violation (NOV) 97-80-01. The violation is specified as follows:
During the NRC inspection conducted from July 21 - August 1,1997, a violation of NRC requirements was identified. In accordance with the " General Statement af Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the violation is listed below:
10 CFR 50 Appendix B, Criterion V requires in part that activities affecting quality shall be accomplished in accordance with procedures. Also, Criterion XVI requires in part that measures be established to assure conditions adverse to quality such as deficiencies and nonconformances are corrected.
Contraiy to the above, from July 29,19E7 o August 1,1997 the corrective action procedure measures were not accomplished as noted below:
(1) Procedure No.1.3.121, " Problem Report Program," revision 1, dated May 28,1997, Step 6.6.1 [9] states that "the apparent cause analysis shall be signed by the evaluator and the mentor if the evaluator was not formally trained in HPI methodologies."
For problem report PR 97.9220, trip of "B" Residual Heat Removal Pump, the individual performing the root cause analysis was not formally trained in HPl methodology nor was it evident that a mentor assisted in the evaluation.
(2) Procedure No.1.3.121, " Problem Report Program" revision 1, dated May 28,1997, Step 6.7.[5] states that "identif;ed corrective actions are required to be tracked to completion according to Action items associated with the IADB (Integrated Action Data Base) or according to other corrective action tracking processes determined to be appropriate by the OST (Operations Support Team)."
As of July 29,1997 the corrective actions identified in the March 17,1997 Training Department memorandum entitled, " Assessment of Operator Performance During RPV Level Transient and Subsequent Unit Trip Occurring February 15,1997 (Rev 1)," were not entered into the Integrated Action Data Base for proper implementation and tracking (or other process determined by OST) and as such were not completed.
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6 (3) ' Independent Oversight Team Work Instruction IOTWI.001, revision 0, dated July 15, i
l 1996, Section 5.1, states, that the IOT Manager will provide a monthly report to the Site Director summarizing the activities that were reviewed, problems that were noted, and any proposed corrective actions that are recommended. Section 7.2 states that a quarterly executive summary shall be provided to the Senior Vice President Nuclear identifying those areas that were reviewed during the previous month, areas for improvement, and recommendations to effect those improvements.
The IOT Manager failed to provide a monthly or quarterly summary of IOT activities reviewed, problems identified, or recommendations to effect improvements in the IOT's December 1996 through January 1997 Monthly Trend Reports.
This is a Severity Level IV Violation (Supplement I).
Discussion In this response, the reasons for each of the instances of procedural noncompliance are addressed along with the specific corrective actions which have been taken or are planned for each instance. The broader issue of procedural usage and why noncompliance with procedures remains an issue at Pilgrim Station will be addressed in the December response. The root cause analysis cu%ntly ongoing will idantify the overall cause of procedural compliance issues at Pilgrim Station and inclu ie the corrective steps that will be taken to avoid further violations and the date w.len full compliance will be achieved. The reasons for the specific instances of procettural noncompliance are as follows:
(1) Failure to comply with the requirements of PNPS 1.3.121. " Problem Report Program,"
in that an apparent cause analysis was not performed by, or otherwise reviewed by a person trained in HPI methodologies as was required. Specifically, in the instance of PR 97.9220, trip of the "B" Residual Heat Removal (RHR) Pump, the individual who performed the root cause analysis was not forrially trained in HPl methodology nor was it evident that a mentor assisted in the evaluation.
Reasons For The Violation The Problem Report Coordinator served as mentor to the evaluator and had attended the critique for the noted event. During the evaluation process, the coordinator provided guidance to the evaluator. However, the coordinator failed to sign the evaluation response as the mentor when the problem report was submitted to Operations Support for processing. This failure to sign as the mentor was due to an oversight during the paperwork closure.
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,Corre'ctive Steos Taken And Results Achieved The Coordinator corrected the paperwork and, because of his involvement, is aware of the issue in its entirety. Also, the Operations Support Team Leader issued a notice to all personnel qualified as mentors and to all NUORG managers to bring the circumstances of this failure to follow procedures issue to their attention. The notice re-emphasized the requirement that mentors must cosign root cause and common cause analyses in which they served as the mentor. It also reminded all that regardless of the ability of the individual involved, Procedure 1.3.121 requires a minimum qualification IcVel for performance of root cause and apparent cause analysis. Department managers were also reminded in the notice i that they also approve the analysis documents and should take steps to assure that personnel are qualified or mentored. A listing of qualified personnel was included in the notice for information.
Heightening the awareness of this missed procedural element and the ramifications i
associated with failure to follow all elements of the procedure has lead to improvemant in the overall quality of apparent cause analyses associated with the problem report process.
(2) Failure to comply with the requirements of PNPS 1.3.121, " Problem Report Program" in that identified corrective actions were not tracked to completion in the Integrated Action Data Base (!ADB). Specifically, the corrective actions identified in the March 17,1997 Training Department Memorandum entitled, " Assessment of Operator Performance During -
RPV Level Transient and Subsequent Unit Trip Occurring February 15,1997 (Rev.1)"
were not entered into the IADB for proper implementaticn and tracking and as such, post stadup action items were not completed.
Reasons For The Violation l
On 2/21/97, PR 97.0937 was written to document perceived nonconservative decisions associated with feedwater level control during a planned reactor shutdown in preparation for RFO 11. In an effort to ensure objectivity, the Operations Department Manager (ODM) requested that the Operations Training Department perform an independent assessment of the operating crew's performance; however, he did not inform the assigned training personnel that their response would be used to respond to the problem report. The operations training personnel completed the evaluation and provided a response in a memo format without specifying that any corrective actions were required but rather provided some recommendations. The noted recommendations were captured as RR 97.0030, and the problem report was closed on 3/18/97.
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4 On 3/21/97, PR 97.1363 was initiated based on NRC NOV 97-01-01, which indicated that operation of the feedwater level control system was not performed in accordance with station procedures. Tnis problem report was determined to be a Significant Condition Adverse to Quality (SCAQ) and was assigned to the assistant ODM for performance of a root cause analysis. The ODM directed the assistant ODM to utilize the training assessment in formulation of the root cause analysis. At the same time, the ODM closed RR 97.0030 based on planned pre-startup training and the misunderstanding that the remaining recommendations from the training assessment would be addresse d by the root cause analysis for PR 97.1363.
However, the root cause analysis failed to adequately consider the remaining recommendations provided in the training assessment, and the Operations manager failed to ensure the recommendations specified by the training assessment were incorporated into the root cause response when he reviewed it for approval.
Corrective Steps Taken And Results Achieved The root cause analysis for PR 97.1363 was revised to incorporate required corrective actions as PR actions in the IADB tracking system. Operations management and Operations Support have been directed to be more discriminating when describing actions to be taken to correct a problem versus actions that are recommended for enhancement.
(3) Failure to comply with Independent Oversight Team Work Instruction OITWI.001 in that required periodic reports were not submitted as required. Specifically, the 10 T Manager failed to provide a monthly or quarterly summary of IOT activities reviewed, problems identified, or recommendations to affect improvements in the IOT's December W96 and January 1997 Monthly Trend Reports as required by the work instruction.
Reasons For The Violation The IOT assessed plant data on a monthly basis to determine performance indicators that related to human performance at Pilgrim Station. A monthly human performance report was routinely submitted to the Station Director and the rest of station management. The report identified human performance problems at the station and made recommendations for improvement as appropriate. The report focused on how well the staff was self-identifying problems, reviewed human performance issues, and attempted to provide insight that would be of use to management regarding human performance. The report generally satisfied the requirements of IOTWI.001 except it failed to summarize the activities that were reviewed by the IOT in the previous month due to an oversight on the part of IOT management.
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' A quarterly executive summary was not provided to the Senior Vice-President, Nuclear as required by IOTWl.001. It was incorrectly believed to be redundant to the executive summary contained in the monthly report which was provided to the Senior Vice-President, Nuclear, and that the monthly reports provided better insight into station performance. However, the assumption that the monthly report summary was redundant to the quarterly report was an error of assumption made by IOT management.
-Corrective Steos Taken And Results Achieved The IOT work instruction was revised on 9/30/97 to clarify the information that is to '
be provided to senior management on a monthly basis, in addition, the monthly human performance report has been revised to provide more in-depth analysis of station problems. These enhancements will continue to evolve as our ability to analyze data improves.
t Quarterly reports will be submitted as requirea by the work instruction commencing with a report for the third quarter of 1997.
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ENCLOSURE 2 Nuclear Safety Concerns Program Discussion NRC Observation With respect to the implementation of your Nuclear Safety Concems Program, the team's observations of poor identification, organization, arid tracking of issues, raises doubt on the overall effectiveness of this process. As a confidential avenue and " safety net" to employees i or contract personnel who feel the normal problem reporting and corrective action processes have not satisfied their particular concem, this process's credibility appears to be severely diminished. We request that you respond to this letter and address the actions you have taken or plan to take related to your Nuclear Safety Concems Program.
Discussion The existence and function of the Nuclear Safety Concerns Program (NSCP)is communicated to employees using at least seven different methods. The program is designed to permit any employee or contractor to identify issues that he or she believes warrant investigation. At the time of the 40500 inspection, only two issues had been j identified to the program during 1997. Neither of these issues had been closed at that l time. At present, eleven concerns have been identified for the 1997 calendar year.
i The organization of the program is such that each concern is assigned a unique identifying number, and a file is created to capture all of the documentation submitted on an issue. Due to the nature of some of these issues, the files used to capture potentially relevant documentation may be large and may be difficult to understand and audit. In addition, due to the nature of some concerns, the relationship of each piece of documentation to the concern may be difficult to ascertain, particularly during the working stage. All of these files have been reviewed and organized to make them more "auditable" both before and after closure. Each current Ne has been placed in a separate tabbed binder (s). Upon closure of a concern, a comp!ete audit of each file is performed to ensure all key documents are present in the file and that it meets reasonable criteria for auditability.
The status of each concern is tracked by periodic reviews of open or unresolved concerns to determine whether timely and appropriate progress, in consideration of the potential safety significance of the issue, is being achieved. In addition, a checklist has been implemented to nnsure key actions required by the procedure are accomplished on time.
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- l With r'espect to specific inspection findings, the procedure governing the NSCP, l NOP93A2, defines those issues that are considered appropriate for the NSCP. This -.
l definition is necessary to help ensure the program is not mis-used for issues and purposes other than genuine nuclear safety issues and to ensure the NSCP does not undermine or circumvent existing corrective action processes. The procedure states that a Nuclear Safety Concern is 'Any condition, practice, or event for which an individual belioves adequate resolution has not been obtained within the line organization and which may adversely impact nuclear safety." Our definition of nuclear safety is the same as that identified in 10CFR50.2 under Basic component. As a result, certain employee concerns that do not meet this procedural requirement may be evaluated as not being nuclear safety concerns in a manner consistent with our procedure. In order fur an issue to be considered as a nuclear safety concern, there must be an attempt at resolution through the line organization, and the issue must be nuclear safety related. Confidential concerns or employeas who request anonymity need not meet these requirements.
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The inspection team's observation concerning certain procedural weaknesses is valid.
Changes / additions have been incorporated into the applicable procedures as a result.
The procedure dealing with employee exit interviews (procedure 1.3.77) has been revised so that employees are only reminded of the existence of the NSCP and are not required to sign or otherwise indicate any intent to use or to not use the prog am, thereby, preserving complete confidentiality. No contact names or phone numbers are included in this procedure; however, NSCP contact numbers are posted at a variety of locations throughout the plant, and the methods for contacting the program administrator are well publicized.
The Nuclear Safety Concern Notification Form has been incorporated as Attachment 2 to NOP93A2 in addition to its current availability at several convenient locations within the organization. NOP93A2 states that use of this form is optional, and concems may be reported by phone, in person, via electronic mail, by Fax or through any other reliable communication method. The NSCP Administrator creates the Nuclear Safety Concern Notification Form if the concern is submitted through a different media.
The procedural requirement for a Nuclear Safety Concerns Log has been eliminated.
This log served only as an administrative tool for the purpose of keeping the Senior Vice-President, Nuclear informed of the status of Nuclear Safeiy Concerns. A similar instrument and frequent face-to-face meetings with the NSCP Administrator provide high program visibility and ensure the Senior Vice-President, Nuclear is fully cognizant of program status.
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ENCLOSURE 3 Update of NOV 96-06-02 Corrective Action Activities Boston Edison Company (BECo) responded to Violation 96-06-02 by letter dated January 31,1997. That response provided a detailed description of changes taking place to the Pilgrim Station corrective action processes and provided additional details of an integrated set of corrective actions established to address procedural usage and adequacy issues identified in NRC Inspection Reports 96-06 and 96-80 (40500 Inspection).
- During implementation of the various committed ccrrective actions, the original scope, in
- some cases, has been expanded or reduced to accommodate the end results being sought. Therefore, a status update of the specific integrated plan activities including scope and schedule revisions is provided.
The integrated corrective action plan committed in the January 31,1997, letter included activities to be undertaken in the following areas:
. - Procedures Process Redesign
. MOP /NOP Revisions
. Other Procedure Changes
. Modification Process Redesign
. Training Procedures Process Redesian i The scope of this effort is to redesign and implement the process for developing, reviewing, and approving procedures. The new ensure will ensure revisions are produced in a timely manner and require less effort to maintain.
A multi-functional breakout team has identified the required process changes and is currently in the change implementation stage. The new process will streamline the review and approval process. For example, the person modifying the procedure will retrieve all applicable signatures and approvals prior to starting the word processing phase. Also, the number of signatures needed for approval is being reduced. Reducing the number of signatures and approvals prior to entering the typing and Operations Review Committee (ORC) review stage of the process will significantly reduce the time required to process procedures.
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The revised process will also provide for a broader class of field changes that allows work to continue without waiting for the full procedure change and issue process to be completed. This willimprove the usefulness of plant procedures in the work control process. In the past, delays in the completion of some tasks have been due to procedure '
interpretation and missing detail. These problems will be easily corrected using the new process, thereby, permitting work to continue in a more timely fashion.
Please note, however, that current restrictive lenguage in the Administrative Section of the PNPS technical specifications needs to be revised to allow this field change procedure revision capability to take place. The needed proposed technical specification changes were submitted for NRC review and approval by BECo letter dated September 19,1997.
It is our understanding based on feedback from the NRC Project Manager that, because this change was considered by the NRC reviewers as a partial Standard Technical Specification conversion submittal, it would not be reviewed until the full conversion was submitted. We are working with the Project Manager to pursue an alternative strategy.
l Completion of this process redesign activity is contingent upon working out a timely l :.uccess strategy. As such, additional options for breaking out this particular portion of the procedures process redesign and implementing various other portions are being studied.
We will update the status of this issue accordingly in the December submittal.
The ability to modify procedures in the field, to add missing detail or change incorrect detail will, over time, improve the quality of the procedures. All workers and their supervisors will have the ability to make timely changes to their procedures through a simplified process. This is expected to enhance worker ownership for procedures.
Continuous improvements in the detail and efficiency of procedures by the people performing the work should result in higher quality procedures that are easier to follow and comply with.
Mission Oraanization & Policies (MOP) / Nuclear Oraanization Procedures (NOP)
Reyisions A top down review of organization procedures and policies was conducted in order to integrate as many higher level policy and procedural elements of performance into lower tier implementing procedures. This effort was initiated to establish a clearer tie between policies and implementing procedures. The MOP document has been eliminated. Certain policies and aspects of others still considered appropriate have been revised as necessary and consolidated into one NOP entitled, Nuclear Organization Policies.
The NOPs were reviewed to ensure a clear reflection of high management standards for safety, compliance, error avoidance, and prevention. Elements of NOPs that could be more effectively implemented as lower tier procedures have been restructured to achieve this objective. Changes to the lower tier station administrative procedures are continuing and aie still planned for completion by the end of 1997.
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Other Procedure Chanaes This activity consisted of su'bmitting a Boston Edison Quelity Assurance Manual change by the end of September 1997 to the NRC to consolidate the Deficiency Report (DR) and Non conformance Report (NCR) processes into the Problem Report (PR) process. The reason for this activity was to provide the ability to more consistently capture data and trend human performance data through the comprehensive PR data base.
The changes to Section 16 of the Boston Edison Quality Assurance Manual (BEQAM) were approved on September 30,1997, to retire the DR process. Concurreraly, changes were approved to the governing procedure for the PR process (PNPS 1.3.121) to address prs issued by Quality Assurance as a result of oversight activities, it was originally assumed such a change would necessitate prior NRC approval.
However, subsequent review of the changes concluded the changes, as approved, did not result in a reduction in commitment. Specifically, process changes were included to ensure continued compliance to Regulatory Guide 1.144, as specified in BEQAM Section 2.
Also, the plan to retire the NCR process for reporting of nonconforming hardware items i
has been reconsidered. Instead, prior to the start of RFO#11, Quality Assurance instituted the practice of issuing a PR for every NCR. This practice ensures that potential human performance errors are explored for each identified nonconforming item. This practice fulfills our original intent to improve the quality and value of our trend reports and ensure human performance data is consistently captured and analyzed. This corrective action commitment is considered complete.
Modification Process Redesian The modification process changes consist of introducir,g a modification team concept, streamlining where possible, consolidating forms /papennork, and simplifying the close-out mechanism. The plant operations and maintenance departments will play a significantly more effective role now in the modification process as members of the modification team.
Completion of the procedure revisions and personnel training is expected to be completed on or before December 31,1997.
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Traini'na Additional classes in root cause analysis (RCA) training have been conducted for workers, managers, and supervisors. More are scheduled. Personnel trained will remain certified as long as they demonstrate proficiency in RCA and complete at least one RCA every 3 years. This corrective action commitment is considered coniplete. Additional classes in human performance error prevention for managers and workers are ongoing.
Approximately 60% of the workforce has been trained to date. We anticipate completion of the remaining workforce by the end c' the first quarter 1998.
The Plant Manager is continuing to provide training to NUORG personnel on a periodic basis to reinforce management expectations on procedural adherence.
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