ML20235B845
| ML20235B845 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry  |
| Issue date: | 11/10/1987 |
| From: | TENNESSEE VALLEY AUTHORITY |
| To: | |
| Shared Package | |
| ML082340470 | List:
|
| References | |
| 20800, 20800-V02-R03, 20800-V2-R3, NUDOCS 8902150104 | |
| Download: ML20235B845 (96) | |
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EMPLOYEE CONCERNS SPECIAL PROGRAM VOLUME 2 ENGINEERING CATEGORY SUBCATEGORY REPORT 20800 HUMAN FACTORS UPDATED i
TVA NUCLEAR POWER f22 Q NA$ N'i.\\S g9 6
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e TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REPORT TYPE:
SUBCATEGORY REPORT FOR REVISION NUMBER: 3 ENGINEERING f
TITLE:
HUMAN FACTORS PAGE 1 0F 58 l
l REASON FOR REVISION:
l 1.
Revised to incorporate SRP coments.
2.
Revised to incorporate SRP coments.
3.
Revised to incorporate TAS coments (general revision) and add Attachment C (References).
PREPARATION PREPAR Y:
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DATE SIGNATURE DATE n
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XTl;"L MANAGER OF NUCLEAR POWER DATE CONCURRENCE (FINALREPORTONLY)
SRP Secretary's signature denotes SRP concurrences are in files.
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TVA EMPLOYEE CONCERNS REPORT NUMBER:
"1800 SPECIAL PROGRAM REVISION NUMBER:
s Page ES-1 of 2 EXECUTIVE
SUMMARY
This subcategory report summarizes and evaluates the results of five Employee Concerns Special Program element evaluations prepared under the Engineering Subcategory 20800, Human Factors. Eight employee concerns are included in this subcategory.
Issues were derived from these eight employee concerns, which cited presumed deficiencies or inadequacies in the area of human f actors engineering.
There are 11 unique issues in the element evaluations. Because some issues are applicable to more than one plant, the element evaluations document the evaluation of 25 issues related to human f actors at TVA's four nuclear plant sites, Secuoyah, Watts Bar, Browns Ferry, and Bellefonte. Of the 25 findings, nine were f ound to reauire no corrective action. For the remainder, three corrective actions were identified to address all 16 negative findings. The 16 negative findings were related to inadeouate consideration of human f actors in the design of the ontrol room and to the incomplete status of the detailed control room design reviews (DCRDRs). The causes f or the negative findinos were diverse, with no single category of cause dominating. Two of the three corrective actions, which addressed 15 negative findings, were initiated by TVA bef ore tne Employee Concerns Task Group evaluations. The third corrective action is a new action recuired to resolve one negative finding.
It calls f or listing an unfinished human f actors review task f or Bellef onte on TVA's computerized open item tracking system. Only one of these three corrective actions, correcting human engineering discrepancies in the control room, was judoed to be significant.
The ceneral subject of human f actors needs to be out in context. F oll owing the Tnree Mile Island accident in March 1979, the NRC staff developed an Action Plan, NUREG-0660, in May 1980 to provide a comprehensive and inteorated plan to improve the safety of power reactors.
The TMI Action Plan required that 3 detailed control room design review (DCRDR) be conducted to address the problems caused by a lack of emenasis on human f actors engineering, if any, during the control room design process. As a result of these DCRDRs, nuclear utilities nave identified numerous human engineering discrepancies (HEDs) in their control rooms. The identified HEDs at TVA nuclear plants are similar in cuantity and safety significance to those reported f or otner commercial nuclear power plants. Thus, TVA's control room desians are comparable to most other designs.
Some employee concerns and issues examined in the course of the evaluations f or tnis subcategory were valid problems, indicating.that human f actors was an area needing improvement. The Control room modifications Droposed by TVA in its DCRDR Summary Reports f or each plant and approved by the NRC as documented l
in Safety Evaluation Reports should bring the control rooms into acceptable compliance with NRC human f actors guidelines.
2629D-R29 (10/12/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page ES-2 of 2 A review of the Corporate Nuclear Performance Plan reveals no commitinents specifically related to human factors.
The arouped evaluation at the subcategory level found no new or broader issues recuiring attention.
The causes identified and other evaluation results are beine reexamined from a wider perspective in the Engineering category evaluation.
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2629D-R30 (10/12/87)
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Preface, Glossary. and List of Acronyms for ECTG Subcategory Reports g,ISTORY OF REVISION REV NUMBER PAGES REVISED REASON FOR CURRENT REVISION 3
i To clarify that one or more attachments will help the reader I
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find where a particular concern l
1s evaluated l
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e TVA EMPLOYEE CONCERNS REPORT NUMBER: 20800 SPECIAL PROGRAM FRONT MATTER REY: 3 PAGE i OF vill Preface This subcategory report is one of a series of reports prepared for the Employee Concerns Special Program (ECSP) of the Tennessee Valley Authority (TVA). The ECSP and the organization which carried out the program, the Employee Concerns Task Group (ECTG), were established by TVA's Manager of Nuclear Power to evaluate and report on those Office of Nuclear Power (ONP) employee concerns filed before February 1, 1986. Concerns filed after that date are handled by the ongoing ONP Employee Concerns Program (ECP).
The ECSP addressed over 5800 employee concerns. Each of the concerns was a formal, written description of a circumstance or circumstances that an employee thought was unsafe, unjust, inefficient, or inappropriate. The mission of the Employee Concerns Special Program was to thoroughly investigate all issues presented in the concerns and to report the results of those investigations in a form accessible to ONP employees, the NRC, and the general public. The results of these investigations are communicated by four levels of ECSP reports: element,' subcategory, category, and final.
I Element reports, the lowest reporting level, will be published only for those concerns directly affecting the restart of Sequoyah Nuclear Plant's reactor unit 2.
An element consists of one or more closely related
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issues. An issue is a potential problem identified by ECTG during the evaluation process as having been raised in one or more concerns. For efficient handling, what appeared to be similar concerns were grouped into elements etely in the program..but issue definitions omerged from the evaluation process itself. Consequently, some elements did include only one issue, but often the ECTG evaluation found more than one issue per element.
Subcategory reports summarize the evaluation of a number of elements.
However, the subcategory report does more than collect element level evaluations. The subcategory level overview of element findings leads to an integration of information that cannot take place at the element level.
This integration of information reveals the extent to whien problems overlap more than one element and will therefore require corrective action for underlying causes not fully apparent at the element level.
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To make the subcategory reports easier to understand, three items have been placed at the front of each report: a preface, a glossary of the terminology unique to ECSP reports, and a list of acronyms.
Additionally, at the end of each subcategory report will be a Subcategory Summary Table that includes the concern numb'ers; identifies other subcategories that share a concern; designates nuclear safety-related, i
safety significant, or non-safety related concerns; designates generic l
applicability; and briefly states each concern.
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Either the Subcategory Summary Table or another ettschment or a combination of the two will enable the reader to find the report section or sections in i
which the issue raised by the concern is evaluated.
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1 TVA EMPLOYEE CONCERNS REPORT NUMBER: 20800 i
SPECIAL PROGRAM FRONT MATTER REY: 2 I
PAGE 11 0F vill j
The subcategories are themselves summarized in a series of eight' category reports. Each category report reviews the major findings and collective significance of the subcategory reports in one of the following areas:
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management and personnel relations I
industrial safety construction j
material control operations quality assurance / quality control welding engineering 1
A separate report on' employee concerns dealing with specific contentions of
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intimidation, harassment, and wrongdoing will be released by the TVA Office of the Inspector General.
Just as the subcategory reports integrate the information collected at the i
element level, the category reports integr' ate the information assembled in all the subcategory reports within the category, addressing particularly i
the underlying causes of those problems that run across more than one subcategory.
A final report will integrate and assess the information collected by all of the lower level reports prepared for the ECSP, including the Inspector General's report.
For more detail on the methods by which ECTG employee concerns were evaluated and reported, consult the Tennessee Valley Authority Employee Concerns Tast Group Program Manual. The Manual spells out the program's objectives, scope, organization, and responsibilities. It also specifies the procedures that were followed in the investigation, reporting, and closecut of the issues raised by employee concerns.
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,'....,,e TVA EMPLOYEE CONCERNS REPORT NUMBER: 20800 SPECIAL PROGRAM FRONT MATTER REY: 2 PAGE 111 OF viii ECSP GLOSSARY OF REPORT TERMS
- classification of evaluated issues the evaluation of an issue leads to one of the following determinations:
Class A: Issue cannot be verified as factual Class B: Issue is factually sceurate, but what is described is not a problem (i.e., not a condition requiring corrective action)
Class C: Issue is factual and identifies a problem, but corrective action for the problem was initiated before the evaluation of the issue was undertaken Class D: Issue is factual and presents a problem for which corrective action has been, or is being, taken as a result of an evaluation Class E: A problem, requiring corrective action, which was not identified by an employee concern, but was revealed during the ECTG evaluation of an issue raised by an employee concern.
collective significance an analysis which determines the importance and consequences of the findings in a particular ECSP report by putting those findings in the proper perspective.
concern (see " employee concern")
corrective action steps taken to fix specific deficiencies or discrepancies revealed by a negative finding and, when necessary, to correct causes in order to prevent recurrence.
criterion (plural:
criteria) a basis for defining a performance, behavior, or quality which ONP imposes on itself (see also " requirement").
element or element report an optional level of ECSP report, below the subcategory level, that deals with one or more issues, employee concern a formal, written description of a circumstance or circumstances that an employee thints unsafe, unjust, inefficient or inappropriate; usually documented on a K-form or a form equivalent to the K-form.
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TVA EMPLOYEE CONCERNS REPORT NUMBER: 20800 SPECIAL PROGRAM FRONT MATTER REY: 2 PAGE iv 0F vili evaluator (s) the individual (s) assigned the responsibility to assess a specific grouping of employee concerns.
findings includes both statements of fact and the judgments made about those facts during the evaluation process; negative findings require corrective action.
issue a potential problem, as interpreted by the ECTG during the evaluation process, raised in one or more concerns.
K-form (see " employee concern")
requirement a standard of performance, behavior, or quality on which an evaluation judgment or decision may be based.
root cause the underlying reason for a problem.
- Terms essential to the program but which require detailed definition have been defined in the ECTG Procedure Manual (e.g., generic, specific, nuclear safety-related, unreviewed safety-significant question).
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I TVA EMPLOYEE CONCERNS REPORT NUMBER: 20800 SPECIAL PROGRAM FRONT MATTER REV: 2 PAGE v 0F viii l
l Acronyms AI Administrative Instruction AISC American Institute of Steel Construction ALARA As Low As Reasonably Achievable ANS American Nuclear Society ANSI American National Standards Institute ASME American Society of Mechanical Engineers ASTM American Society for Testing and Materials AWS American Welding Society BFN Browns Ferry Nuclear Plant BLN Bellefonte Nuclear Plant CAQ Condition Adverse to Quality CAR Corrective Action Report CATD Corrective Action Tracking Document CCTS Corporate Commitment Tracking System CEG-H Category Evaluation Group Head CFR Code of Federal Regulations CI Concerned Individual CMTR Certified Material Test Report COC Certificate of Conforma:,:e/ Compliance DCR Design Chenge Request DNC Division of Nuclear Construction (see also NU CON)
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l TVA EMPLOYEE CONCERNS EEPORT NUMBER: 20800 SPECIAL PROGRAM FRONT MATTER REY: 2 l
PAGE vi OF vili DNE Division of Nuclear Engineering DNQA Division of Nuclear Quality Assurance DNT Division of Nuclear T'aining i
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l DOE Department of Energy 1
DP0 Division Personnel Officer
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DR Discrepancy Report or Deviation Report ECN Engineering Change Notice ECP Employee Concerns Program ECP SR Employee Concerns Program-Site Representative ECSP Employee Concerns Special Program ECTG Employee Concerns Tast Group EEOC Equal Employment Opportunity Commission EQ Environmental Qualification EMRT Emergency Medical Response Team l
EN DES Engineering Design ERT Employee Response Team or Emergency Response Team FCR Field Change Request l
FSAR Final Safety Analysis Report FY Fiscal Year GET General Employee Training HCI Hazard Control Instruction HVAC Heating Ventilating, Air Conditioning II Installation Instruction INPO Institute of Nuclear Power Operations IRN Inspection Rejection Notice
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. '..',.c TVA EMPLOYEE CONCERNS REPORT NUMBER: 20800 SPECIAL PROGRAM FRONT MATTER REY: 2 PAGE vil,0F viii L/R Labor Relations Staff M&AI Modifications and Additions Instruction MI Maintenance Instruction MSPB Merit Systems Protection Board MT Magnetic Particle Testing NCR Nonconforming Condition Report NDE Nondestructive Examination NPP Nuclear Performance Plan NPS Non-plant Specific or Nuclear Procedures System NQAM Nuclear Quality Assurance Manual NRC Nuclear Regulatory Commission NSB Nuclear Services Branch NSRS Nuclear Safety Review Staff NU CON Division of Nuclear Construction (obsolete abbreviation, see DNC)
NUMARC Nuclear Utility Management and Resources Committee OSHA Occupational Safety and Health Administration (or Act)
ONP Office of Nuclear Power OWCP Office of Workers Compensation Program PHR Personal History Record PT Liquid Penetrant Testing QA Quality t.ssurance QAP Quality Assurance Procedures QC Quality Control QCI Quality Control Instruction s
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k TVA EMPLOYEE CONCERNS REPORT NUMBER: 20800 SPECIAL PROGRAM FRONT MATTER REY: 2 PAGE viii 0F viii QCP Quality control Procedure QTC Quality Technology Company RIF Reduction in Force RT Radiographic Testing SQN Sequoyah Nuclear Plant SI Surveillance Instruction I
SOP Standard Operating Procedure SEP Senior Review Panel SWEC Stone and Webster Engineering Corporation TAS Technical Assistance Staff T&L Trades and Labor TVA Tennessee Valley Authority TVTLC Tennessee Valley Trades and Labor Council UT Ultrasonic Testing VT Visual Testing VBECSP Watts Bar Employee Concern Special Program l
WBN Watts Bar Nuclear Plant WR Work Request or Work Rules l
WP Workplans l
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I TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 2 of 58 CONTENTS Section Pa5e Executive Sumary ES-1 Preface i
1 ECSP Glossary of Report Terms iii Acronyms v
1 Introduction 3
2 Generic Applicability / Issues 4
3 Evaluation Process 7
4 Findings 9
5 Corrective Actions 48 6
Causes 49 7
Collective Significance 50 Glossary Supplement for the Engineering Category
.56 Attachments A
Emoloyee Concerns for Subcategory 20800 A-1 B
Summary of Issues, Findings, and Corrective Actions B-1 for Subcategory 20800 l
C References C-1 l
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TABLES Table Page-1 Classification of Findings and Corrective Actions 53 2 Findinos Summary 54 3 Matrix of Elements, Corrective Actions, and Causes 55 l
26290-R31 (10/13/87)
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l TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3
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1.
INTRODUCTION 1
This subcategory report summarizes and evaluates the results of the ECSP element evaluations prepared under Engineering Subcategory 20800, Human Factors.
The evaluations are summarized in' the balance of this report as follows:
1 o
Section 2 -- discusses, by element, the issues stated or implied in the employee concerns and addresses determination of generic 1
applicability l
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Section 3 -- outlines the process followed for the element and subcategory evaluations o
Section 4 -- discusses, by element, the findings and identifies the negative findings that must be resolve'd o
Section 5 -- highlights the corrective actions required for resolution of the negative findings cited in Section 4 and relates them to element and to plant site o
Section 6 -- identifies causes of the negative findings o
Section 7 -- assesses the significance of the negative findings o
Attachment A -- lists, by element, each employee concern evaluated in the subcategory. The concern number is given, along with notation of any other element or category with which the concern is shared; the plant sites to which it could be applicable are noted; the concern is quoted as received by TVA, and is characterized as safety related, not safety related, or safety significant.
o Attachment B -- contains a summary of the element-level evaluations. Each issue is listed, by element number and plant, opposite its corresponding findings and corrective actions. The reader may trace a concern from Attachment A to an issue in Attachment B by using the element numoer and applicable plant.
ine reader may relate a corrective action description in Attachment B to causes and significance in Table 3 by using the CATO number which aopears in Attachment B in parentheses at the end of the corrective action description.
o Attachment C -- lists the references citeo in the text 2629D-R30 (10/13/87)
l TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 4 of 58 The employee concerns provide the basis for the element evaluations and are listed by element number in Attachment A.
The plant location where the concern was originally identified and the concern applicability are also identified.
2.
GENERIC APPLICABILITY / ISSUES The aoolicability of the employee concerns in this subcategory to each of TVA's four nuclear power plant sites and the full text of those concerns are oiven in Attachment A.
2.1 Aeolicability of Emoloyee Concerns to TVA Nuclear Plants The followino emoloyee concerns related to the overall adecuacy of TVA s human f actors engineering (element 208.1) and are generic to all,four TVA nuclear olant sites:
o OE-0MS-3 o
WI-85-100-007 o
XX-85-122-020 through -022 Emoloyee Concern IN-85-102-001 addresses unanswered concerns and unfinished i
modifications for the control room at Watts Bar Nuclear Plant (WBN). Generic l
asoects of this site-specific concern are addressed as outlined below:
o
" Control room modifications have not been made." The generic asoects of this part of the concern are addressed in connection with element 208.1, issue 3 in Section 2.2 below, concerning implementation of modifications.
o "There are 1,600 outstanding unanswered concerns." The generic asoects of this part of the concern are addressed in connection with element 208.1, issue 2 in Section 2.2 below, concerning implementation of the detailed control room design review.
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" Reference Appendix 0 to the Safety Evaluation Report.
Individual considers this a material false statement." The material false j
statement to which the concerned individual refers cannot be i
ascertained from the Quotation itself. However, the ev31usters believe that the employee concern must be related to a series of submittals made by TVA to the NRC between November 1983 and October 1984 which inaccurately reported the status of WBN unit 1 l
l 26290-R31 (10/13/87) i i
2 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800
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SPECIAL PROGRAM REVISION NUMBER: 3 Page 5 of 58 control room design modifications called for in Appendix 0 to the Watts Bar SER (NUREG-0847; Ref. 9). The reason for this conclusion 1
is that on August 29, 1985, NRC Region II issued a Notice of.
Violation and Proposed Imposition of Civil Penalty to TVA for a material false statement contained in a series of status reports submitted by TVA to the NRC between November 1983 and October 1984 (Ref. 30). These status reports purported to indicate the
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completion of corrective actions related to Watts Bar unit l' control room design modifications calleo for by Appendix D to the SER.
Emoloyee Concern BLN-ONP-EC-011 is specific to the Bellefonte' Nuclear Plant (BLN). The concern states:
I "CI worried that human engineering concerns (HEC's) might not be properly reviewed due to delayed start-ep and reduction of manpower at BLN."
The wordino of this concern is specific to Bellefonte Nuclear Plant (BLN).
Moreover, the fact that the concern originated in the Office of Nuclear Power (ONP) suggests that the concerned individual was cognizant of the status of the' detailed control room design review (DCRDR) programs at other sites.
In i
any event, while there have been personnel reallocations and startup delays at other sites, they have not been as drastic as at BLN. The BLN DCRDR program j
was temporarily, but indefinitely, suspended.
Although there were temporary suspensions of the OCRDRs at Sequoyah Nuclear Plant (SQN) and WBN, they were relatively short-lived and not indefinite.
The one employee concern related to element 208.2, IN-85-102-002, is specific to WBN. This is apDarent from the wording of the concern (see Attachment A).
2.2 Identification of Issues The employee Concerns listed in Attachment A for each element and plant have been examined, and the potential problems raised by the eight concerns have j
been ider.tified as 11 separate issues. Because each separate issue may be i
applicable to more than one plant, 25 issues were evaluated in five element i
evaluations. Many of these issues were discussed in more detail during an NRC interview of one of the concerned individuals conducted on February 26, 1986.
This interview did not alter the more broadly stated concerns or the issues derived from them. As such, the issues are integrated with the concerns and resolved accordingly in the element evaluations of this subcategory.
The 11 issues evaluated under this subcategory, grouped by element, are outlined below. The applicable plants are noted in parentheses following the issues.
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TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800
- SPECIAL PROGRAM REVISION NUMBER: 3 Page 6 of 58 2.2.1 Human Factors Review Program NUREG-0700 - Element 208.1 o
Control room design review program plan is inadequate to find and resolve all problems affecting safe shutdown (all plants).
o Human f actors review has not been implemented for control panels or -
stations (all plants).
o Human f actors engineering has not been implemented for control plants or stations (all plants).
o A total of 1,600 outstanding human engineering concerns have not been resolved (WBN).
o There are too many poor engineering practices in the human factors area (all plants).
o Comoliance with NUREG-0700 is cuestioned (all plants).
o There is a possible material false statement related to Appendix C to the Safety Evaluation Report (WBN).
o Human engineering concerns (HECs) mioht not be properly reviewed because of delayed startuo and reduction of manpower at BLN (BLN).
l Element 208.1 had valid issues that recuired corrective action involving I
cossible documentation and hardware changes.
2.2.2 Control Room Desian Review by HRC - clement 208.2 o
The NRC review of the Watts Bar control room, as reported in its safety Evaluation Reoort (SER), Chapter 18 and Appendix 0, June 1082, was inadecuate. That inadecuacy is attested to by the fact that over 1,700 human engineering concerns have been ioentified during the first two phases of the TVA Detailed Control Room Design Review (DCROR) completed on February 1, 1985: (a) review of operatino exoerience, includino a oersonnel survey, and (b) an onsite control room survey (WBN).
o Had the NRC conducted a thorough review of the Watts Bar oesign (which could have identified similar concerns), it would have been olated in an embarrassing situation having previously authorized operatina licenses to SeQuoyah units 1 and 2 (which have. basically identical control rooms) in September 1980 and September 1981, respectively (WBN).
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l TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 7 of 58 4
o The NRC will not, as of early 1985, reevaluate its original Watts i
Bar control room review and revise its SER in which it approved the control room design fully aware of TVA's subsequent findings.(WBN).
I 3.
EVALUATION PROCESS This subcategory report is based on the information contained in the neolicable element evaluations prepared to address the specific employee concerns related to the issues defined in Section 2.
The element evaluation l
process consisted of the following steps:
a.
Defined issues for each element from the employee concerns.
(See Section 2.2.)
b.
Evaluated each employee concern to determine whether it was specific to a particular TVA nuclear plant or generic to two or.more plants.
(See Section 2.1.)
c.
Reviewed current regulatory requirements and TVA criteria documents related to the issues to develop an understanding of the design and licensing bases for human factors engineering and detailed control room design reviews.
d.
Reviewed applicable FSAR sections (all plants), WBN Safety Evaluation Report (SER), and NRC Safety Evaluation of the SON DCRDR l
to understand scope and basis of NRC review, to determine regulatory compliance, and to identify any open issues or TVA commitments related to human factors engineering. The review of the Sequoyah Nuclear Plant (SON) Safety Evaluation took place af ter issuance of the element evaluation.
e.
Reviewed baseline documents related to human factors engineering and I
review:
o Reaulatory requirements: TMI Action Plan (NUREG-0660 and j
NUREG-0737), and Generic Letter 82-33 (NUREG-0737 Supplement 1) o Guidelines: NUREG-0700, NUREG-0801 (draft), NUREG-0800 Section 18 o
EPRI and INPO documents on human factors engineering f.
Determined each nuclear power plant's human factors engineering activities and status of those activities.
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TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 8 of 58 g.
Reviewed TVA's generic program plan SEP 82-17, revision 0, and NRC.
comments regarding the plan.
Compared revision 2 with res:sion 0 to detennine whether NRC's connents were considered in making the revisi on. Also reviewed site-specific orogram plans f or Seouoyah (Standard Practice SQA-179) and Watts Bar (Standard Practice WB 6.3.14).
Considered significance or shortcomings in either the program or program status.
h.
Reviewed transcripts of NRC investigative interviews to gain additional information regarding the concerns.
i.
Examined TVA procedures and design guides concerning control room design changes, j.
Reviewed Detailed Control Room Desion Review (DCRDR) Action Plans, preliminary Action Plans, Action Plan Supplements, and Summary Reports, as available, f or each plant. The review of the Seouoyah DCRDR Summary Report took place af ter issuance of the element evaluation, k.
Reviewed any other documents applicable to the issues and determined to be needed for the evaluation such as correspondence, etc.
1.
Reviewed NSRS Investigative Reports I-85-241-50N, I-85-471-BFN, and I 439-B l.N.
m.
For the Browns Ferry Nuclear Plant (BFN) element evaluation 208.1 only, compared BFN's schedule f or human engineering discrepancy (HED) corrective action implementation to NRC ouidelines and to Nebraska Public Power District's schedule f or HED corrective action implementation at Coooer Nuclear St6 tion and reviewed NRC's acceptance of Cooper's implementation senedule, in order to assess whether TVA's implementation of human engineering is timely.
n.
Usina the results from steps a through m above, evaluated the issues f or each element and documented the findings in element evaluations.
The subcategory evaluation process consisted of the following additional steos:
o.
Tabulated the employee concerns, the plants at which each concern was originally identified, and the applicability to otner TVA plants (see Attachment A).
p.
Tabulated issues, findings, and corrective actions from the element evaluations in a plant-by-plant arrangement (see Attachment B).
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TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 j
REVISION NUMBER: 3 i
SPECIAL PROGRAM Page 9 of 58 I
Prepared Tables 1, 2, and 3 to permit comparison and identification c.
of common and unique issues, findings, and corrective actions among the four plants.
i Classified the findings and corrective actions from the element j
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evaluations using the ECSP definitions.
On the basis of ECSP guidelines, analyzed the collective s.
significance and and most pertinent causes of the findings from the element evaluations.
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Evaluated defined corrective actions to determine if additional l
actions are required as a result of causes found in step q.
Provided additional judgment'and information that was not apparent i
u.
at the element level.
4, FINDINGS The findings from each of the five element evaluations for this subcategory are contained in Attachment B.
The findings are listed by element number and by plant. The following subsections are a discussion of those findings.
1 4.1 General Backaround to Human Factors Before the TMI-2 accident in March 1979, there was no systematic, uniform treatment of the human f actors engineering aspects of control room design in the nuclear power industry. Regulatory and industry attention then began to focus on human factors engineering, and the application of human engineering concepts to nuclear power plant control room designs evolved from 1979 to 1992.
l In November 1980, NRC published NUREG-0737 (Ref. 6), which presented those items from the TMI Action Plan of NUREG-0660 (Ref. 3) that NRC had approved for implementation as of that date. NUREG-0737 states that:
... all licensees and applicants for operating licenses will be recuired to conduct a detailed control room design review (DCRDR) to identify and correct design deficiencies.,,.. Therefore, the Office of Nuclear Reactor Regulation (NRR) requires that those applicants for l
operating licenses who will be unable to complete the detailed I
control-room design review prior to issuance of a license make preliminary assessments of their control rooms t0 identify significant human factors and instrumentation problems and establish a scneoule 1
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c TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 10 of 58 approved by NRC f or correcting deficiencies.
[Emphasisadded). These applicants will be recuired to ccmplete the more detailed control room reviews on the same schedule as licensees with operating plants" (Section I.D.1).
The objective of the detailed control rom design review is to " improve the ability of nuclear power plant control room operators to prevent accidents or cope with accidents if tney occur by improving the information provided to them" (Item I.D.1 of NUREG-0660).
NRC oublished NUREG-0700 (Ref. 4) in September 1981. This document presents l
detailed guidelines that NRC expects applicants and licensees to use wnen I
perf orming their detailed control room design reviews. Although NUREG-0700 is not a requirement, NRC expects applicants to clearly document the apdroacn to i
reviews and to justify any deviations. NRC published draft NUREG-0801 l
(Ref. 8) in October' 1981. This NUREG presnes the criteria NRC would use when evaluating an applicant's detailed control room design review.
In September l
l 1984, these evaluation criteria were incorporated into the NRC's Standard l
(
Review Plan (SRP; Ref. 7) as Appendix A to SRP 18.1.
In December 1982, NRC issued Generic Letter 82-33 (Ref. 2) f orwarding Suppl.ement 1 to NOREG-0737 (Ref. 5), which provided further clarification of I
TMI Action Plan requirements f or the recuired detailed control room desian reviews (DCRDRs).
A concerned individual (CI) expressed a concern nearly identical to EC I
Wl-85-100-007 in a letter to the NRC (Ref 31). A review of the NRC interview j
transcript (Ref. 33) reveals that the detailed control room desian reviews j
were not in progress at the time the CI expressed the concern. However, at j
the time of the interview, the CI was aware that NUREG-0700 reviews were in progress at some of the plants.
It is also clear from the transcript that tne I
CI intended that the concerns include the human f actors engineering of all l
local control panels / stations as well as the main control room.
l The NRC reovires a review of the control room only, which NUREG-0700 defines I
as botn tne main control room and remote shutdown f acilities. Tneref ore, this l
evaluation has been limited to an examination of the TVA review of the main
{
and auxiliary control rooms, including a few remote boarcs wnicn contain I
switches recuired to transfer control frcm the main control room (MCR) to the auxiliary control room (ACR).
l 4.2 Element 208.1, Human Factors Review Procram Per NUREG-0700 4.2.1 Adecuacy of the DCRDR Program Plan ( All Plants)
Employee Concern OE-0MS-3 auestioned the adecuacy of the Detailed Control Room Design Review Program Plan to identify and resolve all human engineering concerns that could significantly affect the safe shutdown of TVA's nuclear plants.
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c TVA EMPLOYEE' CONCERNS REPORT NUMBER:'
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 11 of 58 interpretation of Emoloyee Concern. The term " human engineering' concern" is defined by TVA to refer to any item identified by a DCRDR team member as a cotential human engineering discrepancy (HED) (Ref.18). This terminology is not used in the regulatory criteria documents published by the NRC and, therefore, appears to be unique to TVA's human f actors review program. Use'of this Ich uage by the concerned individual implies f amiliarity with TVA's DCRDR proaram.*
It is conceded at the outset that no single program could identify "all human l
engineering concerns that could significantly affect safe shutdown."7ther j
methods, such as plant-specific probabilistic risk assessment and broad-based systems interactions studies would, perhaps, be better suited to this goal.
The DCRDR orogram, as it has been conceived.in the regulatory scheme, does not set so broad a goal for itself. Supplement I to NUREG-0737, Section 5.1, Detailed Control Room Design Review-Requirements, states, in part:
"The objective of the control room design review is to 'imorove the ability of nuclear power plant control room operators to prevent accidents or cope with accidents if they occur by imorovina the information orovided to them' (from NUREG-0660, Item 1.D.1).
As a comolement to improvements, of plant operating staff capabilities in response to transients and other abnormal conditions that will result from implementation of the SPDS and from upgraded emergency operating orocedures, this design review will identify any modifications of control room configurations that would contribute to a significant ieduction of risk and enhancement in the safety of operation."
[Emphasisadded]
Thus, the purpose of the DCRDR program, in this context, is not to jdentify all HECs which could affect safe shutdown, but rather to improve the operators' ability to prevent or cope with accidents (in conjunction with
~
other imornvements), to contribute to risk reduction, and to enhance safety.
With this in mind, the evaluators hhve focused on TVA's process for identifying and resolving human engineering concerns to cetermine whether the orocram, if implemented as described in the program plan, would be expected to achieve a reasonable level of improvement / enhancement in plant safety.
If the concerned individual intended to raise broader issues related to s3fe shutdown of TVA's nuclear plants (e.g., systems interaction), a new employee concern would have to be generated, since such issues are not taken to be within the scope of this element.
- Various TVA documents use the acronyms "CRDR" and "DCRDR" somewhat interchangeably to refer to this program. This subcategory report uses "DCRDR" throughout for consistency.
f 1
26290-R30 (10/13/87) l
E TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 12 of 58 Differino Professional Judoments. On August 2,1985,,a TVA nuclear engineer who was a member of the DCRDR team forwarded a memorandum to the Nuclear Engineering Branch Files (Ref. 45). The first paragraph of this memo, states:
"The purpose of this memorandum is to permit signout of a document with unresolved consnents.
It was written to document my professional judgment that the subject program olan [SEP 82-17] is not adeauate to assure identTTTeation and resolution of all human engineering concerns tnat could significantly affect safe shutdown of TVA's nuclear olants."
Underscoring has been added to highlight the identical wording to the employee concern in question.
(It should be noted that the author of.this memo is not oresumed to be the concerned individual who raised Employee Concern OE-QMS-3.
This emoloyee concern was recorded on July 25, 1986, nearly a year aft'er the subject memo. The memo itself is addressed to the Nuclear Engineering Branch Files, was.placed on RIMS, with copies to a number of other TVA employees.
l Before receipt of EC OE-0MS-3, the subject memo doubtless had widespread publication within TVA.)
In addition to the above general concern, the engineer raised six other issues in the memo.
The TVA chief electrical engineer responded to these documented concerns in a memorandum dated September 13,1985 (Ref. 47), which addressed the ceneral concern and the six specific issues. One of the specific issues related directly to the employee concern regarding review of human f actors at local control stations and is discussed herein. The other five specific issues raised in the nuclear engineer's memo are regarded as differing professional judoments that are not specifically related to the employee concerns and that are adeauately documented in the two TVA memos (Refs. 45 and 47), the nuclear l
enaineer's memo of Auaust 2,1985, and the chief electrical engineer's memo of September 13, 1985.
J The nuclear engineer's general concern is that TVA's program plan is inadeauste to identify and resolve all human engineering concerns that could significantly affect safe shutdown of TVA's nuclear plants. This, of course, l
is worded identically to the employee concern in cuestion. The chief electrical engineer's response is basically that Task 1.0.1 of NUREG-0660 (the orecursor to NUREG-0737) requires that the OCRDR program improve the l
operator's ability to prevent or cope with accidents, and that the program j
olans's scope and methodology were carefully constructed to respond to the j
l reQulatory mandate. These points have been covered in the above section on Interpretation of Employee Concern.
l The relevant, specific issue raised in the nuclear engineer's memo is that the overall scope of the review is "not responsive to the NRC's intent that plant features necessary to achieve safe shutdown during an abandonment of the main f
j i
26290-R30 (10/13/87)
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1 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 13 of 58 control room should be free of significant human engineering concerns." The chief electrical engineer's response disputes this characterization of the NRC's intent. The response notes that, since prevention of and coping with l
accidents is the NRC's stated goal of the DCROR, it must only be safe shutdown I
f rom accident conditions that is to be considered.
NRC Guidelines on Scope of Review. Because either interpretation of the NRC's intent could be disputed, it is useful to review the NRC's actual statements concerning the scope of review. Supplement I to NUREG-0737, Section 5, and NUREG-0737, Item I.D.1, (Refs. 5 and 6) call f or a detailed design review of the control room; however, neither document defines the term
" control room."
NUREG-0700 (Ref. 4) states tnat "the scope of the control room desion review described by these guidelines covers the engineering review of completed c ont rol rooms *... "
The f ootnote states: "*' Control room' as used in these guidelines includes remote shutdown f acilities - see General Design Criterion 19."
This citation refers to 10 CFR 50 Appendix A, General Design Criteria, Criterion 19, Control Room (Ref.1), which states:
"A control room shall be provided f rom which actions can be'taken to operate the nuclear power unit safely under normal conditions and to maintain it in s safe condition under accident conditions, includina loss-of-coolant accidents..."
"Eauipment at appropriate locations outside the control room shall be provided (1) with a design capability f or prompt hot shutdown of the reactor, including necessary instrumentation and controls to maintain the unit in a safe condition during not snutdown, and (T 'itn a potential capability f or subseauent cold shutdown of the ret;'. t, chrouQh the use of suitable procedures."
This criterion is, by definition, ceneral, and not conclusive with resoect to the NRC's intent regarding the scope of numan f actors engineering review of the "c ontrol room. "
Standard Review Plan (SRP) 18.1, Human Factors Enaineerino - Control Room (Ref. 7), provides the most explicit statement of the NRC's expectation on the scope of review.Section I of the SRP states:
" Nuclear power plants are provided witn a control room from whien actions can be taken to operate the unit safely under normal conditions and to maintain it in a safe condition under accident conditions.
In addition, eauipment outside the control room is provided with a design capability f or prompt hot shutdown of the reactor, including necessary instrumentation and controls to maintain the unit in a safe condition during hot shutdown, and with a potential capability f or subsequent cold shutd ow1.
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TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 14 of 58 "TheHFEB[HumanFactorsEngineeringBranch]reviewsthedesignofthe control room and remote shutdown capability to assure that the interfaces between the systems, structures and components, and the plant personnel expected to operate them have been designed and provided in conformance with good human factors engineering practice. The objectives of the review are to confirm that:
"1.
Ooerator tasks necessary for emergency operation have been identified and defined, and are appropriate to the functions they are designed to fulfill; "2.
the information, displays, controls and other interfaces necessary for operators to successfully carry out the tasks required to implement all emergency procedures have been identified and are provided in the control room and remote shutdown areas; and "3.
the information, displays, controls and other interfaces in the control room and other plant areas required for remote shutdown are designed and provided in a manner consistent with good human f actors engineering practice.
This is, the layout and environment where control stations are located, panel layout, individual control and display components, and the integration of controls, displays and other interfaces must be provided such that the personnel responsible for operating the plant from the control room and remote shutdown areas can perform their tasks in as error-free and timely a manner as possible.
"A human factors engin6ering evaluation of designs, at operating reactors, of the remote shutdown capability provided to meet 10 CFR Part 50, Appendix A, GDC-19, and 10 CFR Part 50, Appendix R is not specifically required. However, the staff recorrrnends that the scope of the DCRDR include a human factors engineering evaluation of the remote shutdown capability."
Thus, while the NRC expects the scope of review of the DCRDR to encompass the
" remote shutdown capability " this review "is not specifically requireo." It also aooears that, since emergency operations and emergency procedures are mentioned specifically, the chief electrical engineer's contention that the DCRDR should focus on accidents has some validity; however, the program should not exclude consideration of operations in nonemergency situations.
Recardless, to a areat extent, TVA's DCRDR program does provide the forum for identifying human factors engineering concerns arising from normal or abr.ormal operatina conditions (see " Generic Plan Program Specifics" below).
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x 3
, '. ~,,.
' :..,,.e.
.. u. :...
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TVA EMPLOYEE C0i" ERNS REPORT NUMBER:
20800 R
SPECIAL PROGRAM REVISION NUMBER: 3 Page 15 of 58 l
l Scoce of Review in Generic Procram Plan. The scope of review expressed ir, TVA's generic program plan (Ref. 18), Section 1.3, is as f ollows:
"This proaram plan addresses only the man-machine interf aces of the main control' room (MCR) and those portions of the auxiliary control system j
located in the auxiliary control room (ACR) and the transfer devices."
j l
Theref ore, generically, TVA has made a limited commitment to review human l
f actors outsjoe tne control roan. This approach meets the specific requirements f or the DCRDR under NUREG-0737 and Supplement 1, although it does-l not extend to the local panel level.
Scoce of Review in Site-Soecific Procram Plans. The Seouoyan site-spec 1fic program plan SQA-179 (Ref. 21) contains a scope statement i
identical to that in the generic program plan.
The Watts Bar site has committed to expand its human f actors review effort to include selected local panels; however, TVA characterized this additional
-l scope as not mandated by the NRC.
"Beyond and separate from the requirements of the program plan, Watts Bar l
is scoping a human f actors review of selected local boards. Tnese ma.v include local boards where operator manipulation is recuired to safely shut down the plant under conditions of main control room abandonment or other panels important to safety, reliability, or perf ormance. Because this is beyond and separate f rom the requirements of NUREG 0737, any modifications resulting f ran this review will not be addressed in the Summary report submitted to NRC."
(Ref. 21, p. 1.)
Other Consideration of L ocal Panels. For desion chances, TVA is i
commiTtea to conouct a numan f actors engineering review of any change that affects the operation or environment of the main control room (MCR), auxiliary control room ( ACR), or local control stations.
(Ref, 11, p.
1).
Tneref ore, while TVA has not incluced reviews of local control panels in the generic i
DCRDR program, numan f actors will be considered in implementing design changes affecting local control stations.
In aedition, an examination of the Seouoyah DCRD9 Summary Report (Ref 35) reveals that, despite the limited scope statement in the program olan, TVA did identify HEDs related to local control stations and control room abandonment.*
- Examples: HEDs 0021, 4068, 0260, 1095 2629D-R30 (10/13/87)
9 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 16 of 58 Furthermore, to the extent that the concern f or human f actors engineering of local control panels may be related to perceived inaccessibility, Suecatetory OP30500, Accessibility (Ref. 60), is dispositive. The Summary of Findinos states, in part:
"The concerns related to inaccessibility of emergency equipment were not validated since evidence was shown that access is possible. This evidence was demonstrated in several ways including walkdowns of plant local control stations, interviews witn Operations section personnel, and reviews of previous efforts in emergency ecuipment access determination.
These previous efforts had consisted of WBN and SQN Operations sections' perf ormance of the Emergency Operating Procedures Verification and V.alidation plant walk-througns. The validatiun program nad considered local actions specified in plant emergency procedures. Objectives of the program included verification that emergency equipment is available and accessible f or use by Doerations. The validation program was a result of the Procedures Generation Package submittal to NRC in 1982 wnich responded to NUREG-0737 Supplement 1 concernina uoaradina of emergency procedures at nuclear power plants. The walk-throughs were successful in determining the required accessibility for equipment necessary to implement emergency procedures at W8N and SQN."
TVA Generic Procram Plan Development.
In April 1983, TVA issued 50ecial Engineering Procedure SEP 82-1/, Rev. O, " Control Room Design Reviews f or All TVA Nuclear Plants," to meet the requirement in Supplement I to NUREG-0737 f or a DCRDR program plan. SEP 82-17 covers detailed design reviews of botn the main and auxiliary control rooms. NRC recuires that the Proaram Plan be submitted 2 months bef ore the DCRDR begins (Ref. 5). TVA submitted its generic DCRDR Program Plan (which is identical to SEP 82-17 Rev. 0) to the NRC on June 9, 1983 (Ref. 25).
The NRC returned its comments on the Procram Plan to TVA on December 23, 1983 and requested a meeting with TVA to discuss the review program (Ref. 26). NRC was concerned that the task analysis cortion of the procram plan would not satisfy requirements presented in Supplement 1 to NUREG-0737.
Thus, TVA met with the NRC staff on June 14, 1984; TVA had oreviously inf ormally Drovided its response to tne NRC comments contained in the NRC's December 23, 1983 letter. At the meetinQ, the NRC staff recuested a presentation of TVA's approacn to perf orming the DCROR task analysis. TVA described its basic approacn. These responses to the NRC are included with the TVA summary of the meeting (Ref. 42). TVA drew the following conclusion fecra this meeting: "Tne l
TVA CRDR program plan apoears completely adecuate to perf orm its intended f unct i on. Additional verbage [ sic] may be reauired to better define the TVA task analysis acoroach" (Ref. 42).
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'1.,
.. 1
...e-
~
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 17 of 58 In June 1985, the Office of Engineering issued the new Engineering Program l
Directives (OEPs) which replace the old Engineering Procedures Manual (EN DES-EPs) including SEP 82-17. The latest revision to the DCRDR prQgram plan (now called OE-SEP 82-17) was issued on August 20,1985 (Ref.18), at which time NRC coments and the lessons learned from having initiated the program were incorporated.
The following paragraphs discuss how TVA's program attempts to identify and resolve human engineering concerns (HECs) with particular emphasis on those methods which relate to HECs that could significantly affect safe shutdown.
Generic Procram Plari Soecifics. The DCRDR as described in the TVA program plan consists of the following eight main tasks:
o Perform an operating experience review o
Survey the MCR and the ACR o
Perform task analysis Assess human engineering concerns (HECs) for possible predesignation o
as human engineering discrepancies (HEDs) o Assess HEDs for priority o
Develop recommendations for corrective action o
Prepare an action plan o
Prepare the Summary Report for submittal to NRC The methodology of the program plan is discussed below; where pertinent, the above tasks are defined. Emphasis is given to tasks which attempt to identify and resolve human engineering concerns that could significantly affect safe shutdown.
Initially, a DCRDR schedule is outlined. TVA's DCRDR program plan does not develoo "a detailed schedule for each of the review tasks, and for the subseouent assessmerit and implementation phase tasks" as discussed in NUREG-0700. Rather, a tentative DCRDR schedule for all TVA nuclear plants was submitted to NRC in a meeting held on December 4,1984 (Ref. 28).
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.t TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 18 of SC HEC Identification. The DCRDR team identifies human engineering concerns (HECs) based on the operating experience review (including operator questionnaires and interviews), control room surveys by team members, and task analysis (an assessment of the control room design with respect to performance of emergency operating procedures),
o Coeratino Experience Rev.iew - DCRDR team members reviewed the plant'slocuments related to operating experience, including:
Industrywide sorts of Licensee Event Reports (LERs), INPO Significant Event Reports, and INPO Operations and Maintenance Reminders Scram and trio reports (plant specific)
Licensee Event Reports (LERs) (plant specific)
Operator questionnaires and interviews Earlier, preliminary DCRDR reports f or the specific TVA plant DCRDR reports of other TVA nuclear power plants Other utilities' DCRDR reports The operating experience review attemots to elicit pertinent HECs related to safe shutdown by identifying actual events in which numan f actors affected the initiation or outcome of the event. The reviews of LERs and otner actual operating events also garner data tending to yield HECs arising from normal or abnormal ooeratino conditions, not just during emergencies. As described further in Section 4.2.2, ooerators' knowledge of human f actors concerns wnicn coulo affect safe :,isutdown was elicited by questionnaires and interviews. Perhaps more so clian the methods f or identifying HECs, this process is designed to provide a forum for eliciting HECs related to nonemergency conditions, as well as those related to emergencies.
o Main and Auxiliary Control Room Surveys - Using checklists derived from NUR W-U/UU, the U(.RUR team members surveyed the main control roarn (MCR) and auxiliary control room ( ACR) to identify HECs related to the f ollowing:
Control room workspace Lignting 26290-R31 (10/13/87) m
9 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 19 of 58 HVAC Sound and noise Conrnunications Alarm systems Controls Visual displays Labels and location aids Comouters Control-display integration Panel layout These surveys are designed principally to identify " ergonomic" concerns, i.e., physical or psychological impediments to the operator's performance.
By improving operator comfort and reducing distractions, modifications derived from these surveys intangibly imorove or enhance plant safety. Of the listed surveys, the alarm systems and the control-display integration surveys might be expected to yield concerns with the most tangible connection to safe shutdown of the plant. All of the, listed surveys tend to elicit HECs related to nonemergency, as well as emergency, operating conditions.
o Intearated Task Analysis - Two task analyses were conducted. The first of these, tne Integrated Task Analysis, was a joint effort between the DCRDR team and a procedures team involved with developingplant-specificemergencyinstructions[calledvariously Emergency Operating Procedures (EOPs) or Emergency Operating Instructions (E0!s), depending on the site]. This phase of the orogram involved an analysis of operator tasks and system functions to support emergency operations; verification of task performance capabilities, focusing both on procedures and information needs as well as on availability and adeauacy of information and equipment; and validation of control room functions. The process involved comoletion of worksheets which detailed the activities of the operator in performing each task; a " walk-through" and
" talk-throuch" of each E0P/E01 in the actual control room and plant-specific simulator by licensed operators under the observation of the integrated task analysis team; and performance of real-time simulation for highly time-dependent emergency scenarios.
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O TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 20 of 58 The Integrated Task Analysis attempts to elicit HECs by observing both operator conduct and control room availability and response under simulated emergency conditions. This process would b6 exoected to identify HECs significantly affecting safe shutdown.
o Sucolemental Task Analysis - Because plant-specific E0Ps/E01s typically are developeo with krowledge of, and reliance upon, l
existing control room instrumentation, the Integrated Task Analysis is not satisf actory for identifying the action and information l
requirements for emergency' operations in the abstract. Therefore, 1
Supplemental Task Analysis and verification were conducted based on I
generic Emergency Response Guidelines (ERGS) developed by the nuclear steam suoply system designers. This process extracted l
aeneric operator and information requirements from the ERGS,.
converted them to plant-specific requirements, and then compared the requirements to existing control room inventories to verify instrumentation and control equipment availability and suitability.
As with the Integrated Task Analysis, the Supplemental Task Analysis attemots to identify HECs that could significantly affect safe shutdown by comparing system functional requirements for emergency I
response to existing centrol room design, but without a preconceived notion of what equipment is in the control room.
l HEC Assessment. During the HEC assessment phase, the DCRDR team evaluates each concern against identified NRC guidelines to determine the l
HEC's validity. Certain HECs may be determined to be invalid or not part of the DCROR scope. The remaining HECs are grouped into categories, referred to by TVA as " human engineering discrepancies" (HEDs).
HED Assessment.
" Human engineering discrepancy" (HED) is defined by TVA as "a characteristic of the existing control room that does not comply with the human engineering criteria used in the control room survey" (Ref.18).
NRC's definition in NUREG-0700 of HED is "the term... used to denote a deviation from some benchmark such as a preference or need, or an instrument / equipment characteristic implicitly or explicitly required for an ooerator task." TVA assigns human engineering discrepancies to one of four categories, as follows:
o Cateacry 1 - HED could result in errors which directly challenge or cause a loss of critical safety function, o
Cateoory 2 - HED could reduce or cause a loss of resources needed to maintain a critical safety function.
n Cateoory 3 - HED could adversely affect normal plant operation or has potential to affect critical safety function resources.
l l
1 26290-R30 (10/13/87)
r TVA EMPLOYEE CONCEP" REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 21 of 58 o
Cateaory 4 - HED has no significant effect on plant operations.
Action P1an. After categorizing the HEDs, the DCRDR team then prepares a oroposed HED action plan for submittal to the site director. The action plan is to include, as a minimum, the following:
o identification of each HED o
Proposed corrective action for each HED o
Priority assignment for HEDs This HED action plan is used to develop a DCRDR summary report. This summary report is required to outline all HEDs significant to safety, proposed control room changes, proposed schedule for implementation, and justification for safety-significant HEDs to be lef t uncorrected or partially corrected (Ref. 18)
NRC Review of Generic Procram Plan. The NRC has reviewed the Program Plan as a basis for conducting the DCRDRs at all TVA nuclear plants and has evaluated its adecuacy for identifying human factors discrepancies and for proposing modifications to resolve these. The results of the DCRDRs for SQN, BFN, and will be submitted at the conclusion of the DCRDR (see Section 4.2.2)y Report WBN are contained in the respective Summary Reports. The BLN Summar I
According to Appendix A of SRP 18.1:
"This summary report should be submitted to the NRC af ter the DCRDR is comoleted and before the licensee / applicant begins any major modifications to the control room...
l The following areas will be reviewed by the NRC staff in its evaluation o' the DCRDR summary reports:
(1) A description of any significant changes that were made from the program plan report that was previously submitted, and an explanation of why these changes were made.
l (2) A description of the proposed control room modifications with an explanation of how the HEDs were resolved (cnosen for correction or noncorrection).
(3) A summary justification for HEDs with safety significance to be left uncorrected or partially corrected.
l (4) A proposed schedule for implementing the modifications...
The result of the NRC staff evaluation of the licensee's/ applicant's DCRDR effort will be a safety evaluation report (SER). This NRC staff SER will be based on the staf f evaluation of the submitted program plan 26290-R30 (10/13/87)
n TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 22 of 58 report..the results of any in-progress site audit, the evaluation of the submitted DCROR summary report, and the results of any pre-implementation audit.",
Therefore, the NRC's review constitutes final assessment of the adequacy of the Program Plan for finding and resolving safety-significant human enoineerina discrepancies. The NRC published the safety evaluation of the SQN Sumary Report on August 27, 1987 (Ref. 39). As of September 20,1987, no safety evaluation had been published for the BFN Sumary Report. Since the WBN Summary Report was issued so recently (October 2, 1987), its safety evaluation is not expected to be published for several months.
Site-Soecific Procram Plans. For Seouoyah and Watts Bar only, site-specific procram plans were used. The Sequoyah plan, Standard Practice SQA-179, Rev.
- 1. replaces the generic program plan. The Watts Bar plan, Standard Practice WB 6.3.14, supplements the generic program plan.
Seauoyah. The evaluation team has reviewed SP SQA-179, Rev.1 (Ref.'19),
as a basis for conducting the DCROR and evaluated its adequacy for identifying human factors concerns and human factors discrepancies, and for proposing modifications to resolve these.
The program plan was evaluated for its site adequacy'as a plan; implementation of the plan was not addressed. The plant-specific program plan (SP SQA-179, Rev. 1) was approved for use on May 21, 1986.
For Sequoyah only, SQA-179 supersedes the generic TVA program plan.
l l
This standard practice:
I o
States that the program plan addresses the man-machine interf aces of
)
the MCR, the ACR, and the transfer devices, thus encompassing the control room as defined in NUREG-0700.
o Establishes the responsibility of all employees to identify operational and procedural matters requiring correction. Although this does not relieve the DCROR team from its responsibility to identify HECs, it does improve the probability of discovery.
o Provides guidance that is essentially a copy of NUREG-0700 l
guidelines. As such, the plan encompasses the basic requirements for a complete and comprehensive review process.
+
o Gives a listing of the required documentation which could readily serve as a road map for the conduct of a DCROR and a checklist to ensure that necessary steps in the process are completed.
It thus f
adds further assurance that appropriate action has been taken to identify HECs and-that they have been assessed and resolved.
8 26290-R30 (10/13/87) t
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 23 of 58 Coordination and integration of related programs (e.g., *.afety parameter display system) are tabulated and discussed in detail. The tabulation and discussion are sufficient to establish a program of required activitie,s. Tne task analysis portion of the DCRDR evaluates the human f actors aspects of the l
tasks of perf orming all tne emergency operating procedures (EOPs). The development of the E0Ps is part of the Procedure Generation Package that has been developed by the E0P team. The coordination of Emergency Operatina j
Procedure (EOP) and DCRDR teams in SQA-179 is clear and provides a viable l
delineation of responsibilities. The methodology described f or verification and validation of procedures using a simulator operating under a dynamic environment. This approach is consistent with typical metnods for assessing the ability of operators to demonstrate their operating skills and effectiveness. The list of 35 E0Ps has been provided separately to this evaluation team (Ref. 54).
It is the judgment of the evaluation team that the list of E0Ps meets the intent of NUREG-0737 Supplement 1 f or analysis of l
emergency procedures.
l The composition of tne DCRDR team is in accordance with NUREG-0801. The team members, some of whom are nationally recognized in the human f actors engineering field, are not listed for the plant-specific program plan.
However, they are listed, witn their backgrounds, in the status report of April 25, 1986 (Ref. 49). On the basis of their backgrounds, the team members.
are considered appropriate f or the designated assignments.
The DCRDR team manaaement and responsibility.y of the review team leader is in accordance with NUREG-0801.
In f act, Table 1 of the SQN-soecific DCRDR program plan is essentially a copy of NUREG-0801, Exhibit 2-1.
SOA-179 references the basic standards in common use in industry and government as well as throuQhout the nuclear power industry. Appendix A of 50A-179 is a copy of Section 6.0 of NUREl-0700 and, as suen, f orms a guideline 3
f or the conduct of the control room sur> ey cortions of a DCRDR.
j l
The training and preparation of the DCROR team are included in the SON-soecific DCRDR proaram plan.
In addition to includina the guidelines of NUREG-0700, the OCRDR plan, SQA-179, also considers suen items as:
o Control /disolay integration 1
o Feecback of control activation o
Safe and efficient movement of personnel during task perf ormance o
Sufficiency of staff f or crew workload distribution o
Seauential grouping of controls and displays 26290-R31 (10/13/87)
-- u, TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 24-of 58 The checklists and instructions presented in SQA-179 have their origins in standard, accepted references in the field.
Therefore, the evaluation team concludes that the SQN-specific DCRDR program plan, Standard Practice SOA-179, wnen implemented properly, will be adeouate to identify and resolve human engineering concerns, thereby enhancing plant safety.
1 Watts Bar. On January 13, 1986, TVA issued the WBN Standard Practice WB 6.3.14 (Ref. 21). The DCRDR program was thereafter under the Watts Bar l
Site Director. This procedure covers the details of the DCRDR specific to Watts Bar, including descriptions of the detailed steps and worksheets to be I
used. Some of the sections are only briefly outlined or are incomolete. They were to be amplified by the DCRDR Project Manacer with necessary details bef ore perf ormance of the subject activities. Section 2.0 of the WBN Standard l
Practice states, in part:
"The original OE procedure [ interpreted to. refer to OE-SEP 82-17] was used as the generic TVA program plan... The program plan is now controlled and issued onsite in accordance with Al-9.8 [ sic, it is clear f rom Reference 3.2.1 of the Standard Practice that this should refer to i
Al-4.8.] The standard oractice provides additional administrative I
details and responsibilities specific to the Watts Bar DCRDR eff ort..."
1 Thus, it is clear that the generic proaram plan, OE-SEP 82-17, is incorocrated by reference into WB 6.3.14.
Also referenced in this procedure is tne license condition that the Summary Report was to have been submitted to the NRC bef ore April 1, 1987.
i Section 5.1 of the Standard Practice states that "in cases of conflict between the program plan and this standard practice, the standard practice snould be f ol l owed.
Imoortant differences will be addressed in the Summary Reoort when submitted to the NRC."
The assessment methodology described in Watts Bar Standard Practice WB 6.3.14 nas been reviewed by the Essex Corporation and f ound to be acceptaole.
Documentation of this review is to be placed in the project files (Ref. 21).
I Responsibility f or translating the DCRDR team action plan recommendations into l
actual control room modifications is not assigned by WB 6.3.14 Chaoter 2 of WB 6.3.14 states:
" Implementation of enhancements is controlled and is in accordance with other established site and TVA instructions.
This standard practice may, however, coordinate, integrate, and track implementation; it does not control it."
26290-R31 (10/13/87) s
v y,'...
+
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 25 of 58 It is not clear how the responsibility f or implementing recomended -
modifications will be assigned, although WB 6.'3.14 implies that this.will be controlled at the site.
The NRC's review of the WBN DCRDR Summary Report will constitute final assessment of the adecuacy of WB. 6.3.14, in conjunction with the generic procram plan, to find and resolve human engineering discrepancies, thereby enhancing plant safety.
4.2.2 Progress of the DCRDRs (All Plants) l Employee Concerns WI-85-100-007 and XX-85-122-020, -021, and -022 asserted l
that human f actors reviews had not been implemented yet. These concerns are l
interpreted to mean tnat the f ormal DCRDRs had'not been implemented a.t any of TVA's nuclear power plant sites. A discussion of the actual progress. of the DCR.DRs at eacn site f ollows.
Seouovah. The actual implementation of the SQN DCRDR' program beaan Auoust 23, 1983, wnen a training course on human f actors was conducted f or the DCRDR team members (Ref. 41). The review of operator experience was conducted in several steps.
Initially the operators completed a basic questionnaire and the results were used to develoo an addendum to the questionnaire. This new questionnaire was then given to those operators whom the DCRDR ' team felt could best provide answers (Ref. 49).
In addition to usina questionnaires, the DCRDR team interviewed 17 operators af ter having first received instruction in effective interview techniaues from a consultant human f actors specialist.
i For the survey of industry experience, the DCRDR team reviewed an INP0 sort of Licensee Event Reports (LERs), Significant Event Reports (SERs), and INPO Operations and Maintenance Reminders (OMRs) involved either directly or indirectly with control room desion or control room operators. A detailed review was also perf ormed of all Seouoyah LERs and reactor trips to identify any with control room or operator involvement. Finally, the results of the DCRDR eff ort at Watts Bar were also reviewed f or applicability to Seouoyan.
Tnese eff orts were completed in March 1986.
Surveys of the MCR and the ACR were initiated in September 1984 The associated tasks of perf orming a sound survey, a lignting survey, ano a survey of the HVAC f or the MCR were comofeted'durina 1984 and 1985 (Ref. 46). The MCR/ACR surveys were completed in March 1986.
The DCRDR team perf ormed a task analysis f or all emergency operatino procedures (EOPs) identified f or SQN. Tnere were 35 E0Ps whicn had been developed by the site E0P team and were analyzed by the DCRDR team. The task analysis was completed in Acril 1986 (Ref. 49).
l 26290-R31 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 26 of 58 In March 1986 the Essex Corporation (Essex) reviewed the Sequoyah DCRDR documentation (Ref. 32). Essex reviewed only the document' tion related to the a
operating experience review, the control room surveys, and the task analysis, as the remaining portions of the DCRDR were not complete. Based on their review, Essex concluded that the SON DCRDR documentation is responsive to the ouidelines of NUREG-0700, adequately describes the HECs, and provides a track to data collection methods and NUREG-0700 guidelines.
The report sumarized the documentation as "... adequate and, when complete, should provide an adequate basis for control room design improvenients and for NRC audit." The report also mentioned that Essex would work with the DCRDR team to develop additional task analysis information.
In addition to reviewing DCRDR documentation, Essex has also provided consulting services in essentially all chases of the DCRDR since February 1936, including significant participation in the preparation of the Sumary Report (Ref. 55).
In November 1986,.on completion of the Sumary Report, Essex provided a sumary evaluation of the TVA DCRDR program in which they comented:
"... TVA has structured and implemented a comprehensive program to identify and resolve those issues which, from a human factors perspective, could adversely impact plant safety and operations.
In so doing, we feel that TVA has complied with regulatory requirements as presented in NUREG 0700 and NUREG 0737, Supplement 1."
(Ref. 34)
Priority assessment, corrective action recommendation, and action plan preparation were completed, and the Summary Report was transmitted to the NRC on November 26, 1986 (Ref. 35).
A possible contributing factor to the concerned individual thinking the control room design review was not in progress is the length of time which elaosed between the NRC issuing the requirements and any visible activity of the review. Part of, the reason given for the length of time the DCRDR team had taken to oerform their review was a lack of manpower committed to perform the necessary assignments, as pointed out by memo (Ref. 46) in Septem3er 1985. This problem was further clarified in October 1985 (Ref. 48) an being due to the DCRDR team management structure.
In December 1983, prior to the development of the Office of Power and Engineering and the owner / operator conceot, NUC PR requested that the DCRDR team have a co-manager and a co-team leader from NUC PR.
Under this arrangement, the co-managers and co-team leaders lacked direct control of the team members' assignments because they had no administrative responsibility over the individual team members.
This structure also increaseo the difficulty of coordinating technical and schedule issues.
In addition to these direct effects of the management structure, and the fact that the members were not dedicated to the DCRDR activity, the individual DCRDR team member's immediate supervisor would often redirect the individual to other activities the supervisor felt were the individual's primary responsibilities (Ref. 48).
l l
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1 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800
[
SPECIAL PROGRAM REVISION NUMBER: 3 Page 27 of 58 The NRC had been concerned about these deficiencies in the management of the DCRDR effort as early as November 1984 (Ref. 27). Due to the inconsistencies of TVA's reports on the status of the Watts Bar control room modifications, the NRC felt there may have been a serious deficiency in the management of the DCRDR team. The NRC was concerned that no one individual was responsible for DCRDR within TVA.
In February 1986, the co-manager, co-team leader structure was replaced by a single manager and a single team leader. Since that time, the DCRDR team operated with this structure.
l The conclusion of the NRC's safety evaluation of the SQN DCRDR is that
... the DCRDR activities for Sequoyah Nuclear Power Plants, Unit I and 2, of TVA meet all the requirements of Supplement 1 to NUREG-0737 provided that TVA submit an acceptable document as discussed... " below (Ref. 39, p. 4).
The NRC staff found that:
I l
"... TVA has conducted an appropriate program for selection of design improvements. However, in order for TVA to meet the Supplement I to i
NUREG-0737 requirement for selection of design improvements, it will be necessary for TVA to provide NRC with confirmation regarding the implementation schedule for control room modifications that was discussed with the NRC during the preimplementation audit" (Ref. 39, p. 3).
The NRC's concerns related to selection of design improvements are covered more fully in section 2.6 of the Technical Evaluation Report (TER) appenoed to the safety evaluation.
Section 4.0 of the TER lists the items to be confirmed by TVA. As stated in Section 2.6 of the TER:
J "In most cases, the audit team agreed with the proposed HED correction and schedule for implementation.
However, in a number of cases, TVA committed to modify the proposed correction or implementation schedule."
In one such case TVA comitted, in a letter to NRC dated July 14, 1987
( Attachment 13 to the TER), to provide interim corrective actions for a HED related to the location of the containment differential pressure indicating recorder on a back panel.
SAIC judged TVA's commitment to be acceptable.
TVA also agreed to accelerate implementation of corrective actions for four other HEDs; the confirmatory document still required TVA management approval at the time of issuance of the TER.
Watts Bar. During the first two phases of the WBN DCRDR (review of operating experience including a personnel survey, and the onsite control room survey) the team identified approximately 1,600 human engineering concerns (HECs).
These two tasks were completed by February 1,1985 (Ref. 43). As of February 17, 1987, more HECs had been identified for a total of 1,846 HECs.
26290-R30 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 28 of 58 The WBN DCRDR HEC assessment phase evaluates each concern against identified NRC guidelines to determine their validity. Approximately 600 HECs have been disposed of because they are either (1) duplicates of other HECs, (2) not valid, (3) previously corrected, or (4) maintenance items. Tne remaining HECs are grouped into categories, referred to by TVA as " human engineering discrepancies" (HEDs).
The prooosed resolution of these HEDs were transmitted to the Watts Bar plant management. As of February 17, 1987, corrective action plans to resolve approximately three-f ourths of the HEDs had been proposed and were being reviewed oy plant management. No further corrective action is proposed f or the remaining HEDs; justifications have been prepared. The plant had a review group comprised of senior reactor operators who were to evaluate the propos als. After the corrective actions are agreed upon by the DCRDRa tear and tne plant management review group, the proposed solutions and schedule f o-implementing them, where appropriate, were then to be submitted to the PRC in the DCRDR Sumary Report.
The Summary Report was to have been submitted by April 1,1987 as a license c onditi on. On March 25, 1987, TVA inf ormed the NRC that the Sumary Report submittal date was being slipped to August 1,1987 (Ref. 37). By July 31, 1987, the DCRDR Summary Report had been completed and prepared f or submittal to the NRC (Ref. 38). As a result of the more comprehensive and integrated DCROR, previously comoleted corrective actions identified in Aopendix 0 to the June 1982 WBN Safety Evaluation Report were going to be altered or upgraded. To ensure proper review and closure, the NRC indicated that TVA should provide an explicit correlation between the modified Appendix D corrective actions (priority 1 and 2 only) and the DCROR corrective actions. The NRC indicated that this additional information could be included in the Sumary Report or in a later supplement to the Summary Report. TVA opted to include this information in tne initial submittal of the Summary Report and submit it by October 1,1987 (Ref. 38).
The WBN DCRDR Summary Rennet actually was submitted on October 2,1987 (Ref. 56).
The NRC will review TVA's entire DCROR program f or Watts Bar, includina corrective actions, and document this review in an SER. Part of the NRC's review will include an onsite, preimplementation audit (Ref. 38).
Browns Ferry.
In 1982, bef ore the f ormal DCROR eff ort began, the Control Room Improvements Comittee of the BWR Owners' Group (BWROG) conducted a 10-day numan f actors evaluation of the BFN control panels. The summary report of this review
" identifies areas of control' room design f or whicn modifications should be considered, stated as general suggestions with the understanding that corrective action should be considered on a control room wide basis" (Ref. 24).
9 26290-R30 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 29 of 58 The BFN DCRDR was perf ormed by TVA, Impell Corporation and Impell's subcontractor, Search Technology, as a joint eff ort.
According to Section 1.2 of the BFN DCRDR Summary Report (Ref. 36), wh'ich TVA submitted to the NRC on December 30, 1986:
"A multidisciplinary core review team having expertise in the following disciplines was used:
a.
Instrumentation and Controls (I&C) Engineering l
b.
Human Factor (s) c.
Nuclear Systems Engineering d.
Reactor Operation (s)."
This multidisciplinary core team perf ormed the f ollowing review activities:
(1) Task analysis of Emergency Operating Instructions (E01s)
(2) Operating experience review (3) Human f actors enecklist survey of the control room (4) Additional task analysis (selected as a result of the operatina' experience review)
The BFN DCRDR team also used the results of the BWROG summary report to identify HECS not identified in the operating experience review, task analysis, and control room survey. These activities were completed by November 1984.
The HED assessment process then becan.
"The HECs were assessed (categorized) in terms of their severity and potential impact on safety by the DCRDR core team. Proposed corrective actions were develooed by individual team members and reviewed and approved by the DCRDR core team" (Ref. 36). The DCRDR team's recommendations did not consider f actors such as Cost, schedule, and resource requirements. The assessment process lasted until Marcn 1986.
An action plan was prepared by the DCRDR team and submitted to the Browns Ferry Site Director on July 21,1986 (Ref. 50).
Af ter the original and additional task analyses described above had been completed, as documented in the Action Plan, TVA revised the Emergency Operatina Instructions (E01s). The task analysis results were updated, based 26290-R30 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 30 of 58 on the revised E01s. Additional HEDs, beyond those listed in the Action Plan, were identified durino this update'(Ref. 53).
The Sucolemental Action Plan (Ref. 51) incorporates tne results of tnis activity.
BFN plant manacement is responsible f or final disposition of the OCRDR Team HED Action Plan and the authorization of work to be done to correct any HED, Af ter reviewing the Action Plan, plant management in some instances aoproved modified corrective actions..The proposed corrective actions f or safety sio'nificant HEDs and schedule f or implementation are presented in Aapendices A and B of the Summary Report.
As of September 20, 1987, TVA was waiting f or the NRC's response to the BFN Summary Report. The NRC may decide to perf orm an onsite pre-implementation audit bef ore, completing its review. Tne results of the NRC's review will be documented in a safety evaluation.
Bellef onte. The status or comoletion dates of tne major tasks of the DCRDR are snown below (Ref s. 40 and 20):
STATUS OR COMPLETION DATES OF BELLEFONTE OCROR MAJOR TASKS Task Status or Canaletion Date 1.
Develoo DCRDR Program Plan C onolete 2.
Survey MCR and ACR Completion date not set 3.
Perf orm Operator Exoerience Conolete Review 4
Assess HECs f or Possible Complete, except f or HECs which will Predesignation as HEDs be generated in future activities 5.
Assess HEDs Complete f or the 234 orioritized HEDs 6.
Develop Recommendations Complete, except f or HEDs wnicn sill be generated in future activities 7.
Task Analysis July 1, 1991 8.
Final Action Plan January 2, 1992 9.
Complete Surnary Report July 9,1992 26290-R30 (10/13/87) s
v TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 31 of 58 A preliminary Action Plan was prepared by the BLN DCRDR team and submitted to the Bellefonte Design Project Manager on August 15,1983 (Ref. 40). A total of 340 HEDs were identified. Of these, 234 were prioritized for corrective action. For the remaining 106 HEDs, the DCRDR team recommended that no action be taken. Subsequent to issuance of the preliminary Action Plan,19 HECs were identified during the task analysis. The task analysis, however, was not comoleted, because all DCRDR activities were suspended in the f all of 1985 due to a delay in fuel load. The DCRDR is scheduled to resume in 1989 (Ref. 20).
4.2.3 Implementation of HED Corrective Actions (All Plants)
Emoloyee Concerns WI-85-100-007 and XX-85-122-020, -021, and -022 asserted that human factors engineering had not been implemented yet.
Implementation of human f actors enaineerino, interpreted here to refer to actual implementation of corrective actions resulting from the detailed control room desian review, will take place in accordance with the recommendations and schedule contained in the DCRDR Summary Reports for each plant. The Summary Reoort is required to contain recommendations for modifications to the control room. The Summary Report is also required to present a schedule for imolementina the modifications and to provide a sumary justification for any HEDs with safety significance that are to be lef t uncorrected or partially corrected.
A discussion of the available NRC guidance on scheduling implementation of corrective actions follows.
Annendix A to SRP 18.1 specifies the criteria to develop the implementation schedule:
"The determination of an appropriate corrective action implementation schedule should be based on the degree of degradation of operator performance caused by the HED, the effect of the HED on the safety of the plant, whether the equipment affected by the HED is part of a safety system, and the availability of resources needed for correction.
Both operating and nonoperating plants are encouraged to implement all corrective actions on as short a schedule as possible to avoid problems with operator retraining" (Ref. 7, Section 2.6).
While this cuidance is helpful, it is not sufficiently specific to enable an objective evaluation of a utility's proposed implementation schedule for correcting HEDs. Consequently, the evaluation team referred other regulatory cuidance.
Draf t NUREG-0801 (Ref. 8), which preceded SRP 18.1 Appendix A, attempted to orovide more definitive criteria for scheduling implementation of corrective actions. The NUREG-0801 criteria are included here only to illustrate the kind of schedule which would be expected to be acceptable to NRC.
2629D-R31 (10/13/87)
m l
TVA EMPLOYEE CONCERNS REPORT NUMBER: '
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 32 of 58 i
1
... All discrepancies which are classified in Categories 1,11 and Ill* should be scheduled for corrective action. The priority of implementation of corrective actions for each ' category and level is indicated in Exhibit..
4.5... In all cases, for...
i ooeratina... plants implementation of corrective actions on a shorter schedulethanthatindIcatedisencouraged.
"For purposes of scheduling corrective actions for operating plants, the
]
followina designations are recommended:
l Prompt Action: Correct promptly on schedule approved by NRC. Make changes at the first refueling after submittal of the report or the first outage after receipt of equipment (expedited).
i Note: Enhancement corrections do not' require NRC approval and should be made prior to submittal of the report to NRC.
Near Term:
Correct on schedule approved by NRC. Make changes at the second refueling outage after submittal of the report.
Long-Term:
Correction of non-significant discrepancies may be (ootional) implemented at any time." (Ref. 8. Section 4.4) in aeneral, the NRC orefers that modifications be deferred until it has reviewed the Summary Report, evaluated the proposed corrective actions, and i
issued its SER.
(As noted above, " enhancements," i.e., corrections involving paint, labels, and tape, can be made without specific NRC approval.) Control room modifications arising out of the DCRDR Programs will be implemented in accordance with the established TVA engineering change notice _ process and will reflect consideration of existing TVA engineering design guides (see Section 4.2.5).
1 Exhibit 4-5 of NUREG-0801 provides a complicated, multi-tiered schedule for modifications.
Although no longer applicable, it may. indicate an acceptable comoliance position. Exhibit 4-5 specifies that some kinds of Category I and 11 HEDs and all Category !!! HEDs should be scheduled for prompt implementation. The remaining Category I and II HEDs are near-term items, j
while Cateaory IV HEDs are long-term (optional) items, i
i
- Note: There is no direct correlation between the HED categorization scheme in draft NUREG-0801 and TVA's categories.
- l 6
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20800 l
SPECIAL PROGRAM REVISION NUMBER: 3 Page 33 of 58
\\
Th'e implementation schedules proposed (to date) by TVA for correcting HEDs
- identified at each of the four sites are described and evaluated, where aooropriate, in the following subsections.
)
S eauo.vah.
In the safety evaluation of the SQN DCRDR (Ref. 39), the NRC and its consultant Science Applications International Corporation (SAIC) generally concurred with TVA's proposed implementation schedule.
In Section 2.6 of the Technical Evaluation Report (enclosure to the safety evaluation), SAIC makes
~
the following observations and comments related to the implementation schedule for Sequoyah:
"In many cases Category 1, 2, and 3 HECs [ sic, should be HEDs) are being l
orouped into integrated corrective actions that will take place during Cycle 4, 5, and 6 refueling outages...."
" Based on Summary Report Figure 6 TVA indicated that the proposed DCRDR modifications would not be completed until 1992. This five year DCRDR implementation schedule was of concern to the audit team.
In order to help resolve the audit team's concern regarding implementation of control room modifications, TVA provided NRC with Figure 1, CRDR Project Schedule."
The Cycle 4 outages are the next refueling outages scheduled for each SQN unit. Figure 6 of the Sumary Report (Ref. 35) scheduled HED modifications as follows:
o Unit 1 HEDs Category 1 - January 1989 (Cycle 4)
Category 2 - Aucust 1990 (Cycle 5)
Cateaory 3 - March 1992 (Cycle 6) l l
0 Unit 2 and Common HEDs Category 1 - July 1989 (Cycle 4)
Category 2 - February 1991 (Cycle 5)
Category 3 - September 1992 (Cycle 6)
TER Figure 1, CRDR Project Schedule, depicts a more detailed breakdown of the HED modification implementation schedule. On the basis of a July 1987 restart for SON unit 2, with unit i restarting 6 months later, this schedule indicates that physical implementation of the corrective actions will take place 26290-R31 (10/13/87) r
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 34 of 58 4 months later tnan reported in the Summary Report for most of the HEDs.
Since this implementation schedule is keyed to refueling outages, and since, as of September 30, 1987, SQN restart had not been autnorized, the schedule in Figure 6 of the Summary Report can be expected to slip at least 6 mchtns.
However, as stated in Section 2.6 of the TER:
"TVA committed to correct, to the maximum extent possible, lower priority Category 2 and 3 HEDs during refueling outages 4 and 5, rather than Cycles 5 and 6 respectively. TVA also committed to submit to NRC a revised scoedule f or modification implementation reflecting this commitment, once it has been approved by TVA management."
The actual TVA management commitment to this accelerated implementati'on schedule was pending at the time of issuance of the TER and is listed as a confirmatory item in the safety evaluation.
Browns Ferry. TVA's proposed implementation schedule is compared with a scnecule approved f or another utility.
TVA's Prooosed Implementation Schedule f or BFN. Proposed corrective actions f or TVA Category I and 2* HEDs nave been prepared, reviewed, and approved by Browns Ferry plant management. (TV? 'stegory 1 and 2 HEDs are considered " safety significant.)"
TVA has scheduled Category 1 HED corrective actions f or completion by the eno of the se:ond refueling outage on a per-unit basis following restart of each unit.
Category 2 HEDs are scheduled f or completion by the end of the third refueling outage f ollowing restart of each unit. The Summary Report indicates that corrective actions f or some Category I and 2 HEDs will be implemented on an earlier schedule. The Summary Report also states that implementation of Category 3 corrections will be on a case-by-case basis pendina further resource requirements, schedule constraints, and cost benefits." (Ref 36)
Soecific corrective actions f or Category 4 HEDs were not made because "tney were evaluated as being very unlikely to result in an operator error or to af fect olant safety." However, some Cateoory 4 HEDs will be corrected incidentally during tne process of implementing corrective actions f or Category 1, 2, or 3 HEDs.
A few HEDs reouired additional evaluation to determine the corrective action.
Documentation of proposed corrective actions for TVA Category 1 and 2 HEDs is included in the DCRDR Sunnary Reoort.
1
- Note: There is no direct correlation between the HED categorization scheme in draf t NUREG-0801 and TVA's categories.
2629D-R32 (10/13/87) m
T.,,
- 3... -
,v.
1
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I TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 h
SPECIAL PROGRAM REVISION NUMBER: 3 d
Page 35 of 58 l
Comparison with Coooer Nuclear Station's Implementation Schedule.
Because tne proposeo Browns Ferry implementation scheoule appears marginal with respect to the NRC criteria oiven above, the evaluation team compared tne TVA commitments with the implementation schedule proposed by another utility.
The Comparison plant is Nebraska Public Power District's (NPPD's) Cooper Nuclear Station, licensed on January 18, 1974.
Cooper was selected f or this comparison because it is a similar plant (i.e., BWR with a Mark I containment) of comparable vintage (i.e., operating license granted about the same time as BrownsFerry's).
NPPD submitted the Cocoer DCRDR Summary Report on February 4,1985. A total of 269 HEDs were identified in this study. A total of 137 HEDs were resolved by relatively simple corrections or enhancements. Most of these enhancements were to nave been completed by the end of the outage then in progress. All enhancements were to be completed by the end of the next refueling outage.
Tne remaining 132 HEDs were assigned f or correction by panel modifications.
3 HEDs assigned f or correction by modifications were subjected to a prioritization scheme that assessed their importance to safety.
The f ollowing scheduling philosophy was noted (Ref. 58):
"o The most safety significant HEDs should be corrected prior to return to power frcrn the next refuel.ing, if design and ecuipment lead times permit. All HEDs in this category are recommended f or correction within two operating cycles.
o Correction of moderate significance HEDs is reccrnmended prior to restart f rom the second refueling outage after the current one. A l
few items are deferred to the third refueling to allow coordination with other modifications.
o The less significant HEDs to be corrected are recommended f or correction within three operating cycles."
Eleven "particularly intractable" HEDs reuuired feasibility studies by NPPD af ter submittal of the Sumary Report to identify appropriate modifications 1
and to develop the ultimate schedule f or their implementation.
l 1
Tne NRC and contractor personnel f rom the University of Calif ornia's Lawrence Livermore National Laboratory reviewed the Cooper Summary Report and issued a safety evaluation on September 5,1985 (Ref. 58). The NRC agreed with the plan to conduct f easibility studies but recuired that a Sunrnary Report 1
Supplement be submitted to the NRC to describe the corrective action and schedule f or implementation. The NRC agreed that "the general philosophy f or
... completion dates is in compliance with the requirements of NUREG-0737, Supolement 1."
l l
2629D-R30 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 36 of 58 Even though the BFN Summary Report has been submitted, TVA still needs to conduct additional evaluation of current system capabilities and flexibility to accommodate a few HED modifications. The results of NRC's review of Cooper suggests that this approach is acceptable.
NUREG-0737 Supplement i states that " improvements that can be accomplished with an enhancement program (paint-tape-label) should be done prouptly." TVA rates all labeling HEDs as Category 1 which have nighest priority. All Category 1 HEDs at Browns Ferry are to be implemented by the end of the second l
refueling outage. This appears to satisfy Supplement 1 of NUREG-0737.
TVA has committed to have all of the Category 2 HEDs corrective actions completed by the third refueling outage. NPPD's approacn f or Cooper is l
l similar.
Apoendix A to SRP 18.1 states:
l "The SER will state whether the NRC staff concludes that the proposed modifications to the licensee's/ applicant's control room equipment and l
operations as a result of the DCRDR will accomplish the basic l
requirements established by the Commission. Any additional corrections or schedule modifications necessary to comoly with the basic requirements established by the Commi:sion will be cocumented in the SER."
In assessina the BFN implementation schedule, the evaluation team has reviewed the Cooper Summary Report (Ref. 57), the NRC review of that Summary Report (Ref. 58), and SRP 18.1 Accendix A.
The ultimate schedule f or corrective l
action implementation f or the Browns Ferry HEDs will be negotiated between TVA I
and the NRC. While the NRC may disagree with the proposed schedule f or i
correcting individual HEDs, tne general anilosophy of Browns Ferry's senedule of corrective action implementation appears to meet NRC quidelines.
l Watts Bar. The modification schedule is to be included in tne Summary J
Report. The Watts Bar DCRDR Summary Report was scheduled f or submittal by October 1,1987, and actually was submitted October 2,1987. The evaluation I
team was unable to obtain a copy of the WBN Summary Report f or review prior to issuing tnis subcategory recort.
Inasmuch as WBN is not licensed to operate, it is unnecessary f or the evaluators to conduct such a review. As described i
above, the NRC will review the proposed implementation schedule in the process of evaluating the Summary Report.
Bellefonte. As of May 1987, the Bellef onte DCRDR Sununary Report is scheduled to be completed July 9,1992; theref ore, the implementation schedule f or l
correcting HEDs has not yet been determined.
Inasmuch as BLN is still under construction and is not licensed to operate, the lack of a defined implementation schedule has no immediate safety implications, i
l a
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1 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 i
Page 37 of 58 4.2.4 1,600 Unresolved Human Engineering Concerns (WBN)
As discussed in Section 4.2.2, 1,600 HECs were identified durina the first two stages of the WBN DCRDR. As of February 17, 1987, 1,846 HECs had been identified. These HECs have been assessed to HED status, where applicable.
Corrective action plans have been proposed for about three-fourths of the HEDs. The remaining HEDs have no corrective action planned; justification has q
been prepared. The proposed HED corrective actions and the senedule f or
]
l implementing them are to be included in the DCRDR Summary Report, which was l
submitted to the NRC on October 2,1987.
Thus, all outstanding HECs have been resolved.
i l
4.2.5 Too Many Poor Engineering Practices (All Plants) l In the second part of Employee Concern (EC) WI-85-100-107 (and identical ECs XX-85-122-020, -021, and -022), the CI states, "Tnere are too many poor engineering practices in this area."
Resolution of Past Poor Human Enaineerino Practices. Because this concern is l
broaaly statec, its valicity witn respect to tne existing control room designs can only be determined by a detailed review of the control room desian. The 1
assessment of the control room design by the DCRDR team provides the basis f or I
resolving this EC.
1 The DCRDR teams have recommended corrective actions f or the safety-significant HEDs as part of their assessments.
The resolution of past poor enoineerina oractices are included in that activity.
(Some work remains to be done at BLN; see Section 4.2.8).,
TVA Procedures f or Future Control Room Desian Chances. There are several TVA procecures in place to quice tne engineering aspects of any control room l
modifications which result from corrective actions generated in the DCRDR and I
f uture modifications.
Encineerina Procedures. EEB-EP 22.32 (Ref. 11) describes:
l
"... human f actors engineering (HFE) principle compliance review of l
desion and desion changes. This HFE design review is mandatory f or any change to a nuclear power plant which:
I a.
Affects the coeration or environment of the main control room (MCR),
auxiliary (backup) control room ( ACR), or local control stations, and b.
Involves issuing new or revised Division of Nuclear Engineering (DNE) cesign input or design output documents [ Nuclear Engineering Procedures (NEPs) -3.2 and -5.1).
26290-R31 (10/13/87) 1
l TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 38 of 58 i
Tne review will ensure that the designs or design enanges nave oeen done in accordance with TVA DNE design quides, standards,,
procedures, and applicable industry standards in regard to HFE..."
"An HFE review will be accomplished by review of inf ormation on any 4
design or design change which can affect:
a.
An operator's environment.. or l
1 b.
An operator's workspace, or c.
Controls and displays in the MCR, ACR, or local control stations, or a
d.
Operational procedures.
This review will be done according to NEP-6.1 and any design inout or design output document which affects any of the above items... "
"To ensure effective t. coordination with the CRDR activities and results, each design or design chance will be coordinated with the CRDR team leader f or tne plant affected; or if tne CROR is comoleted, the desian or design change will be reviewed against tne CRDR documents.
New en6nges will be evaluated f or impact oh CRDR commitments and deviations will be documented by the HFE review."
l Division of Nuclear Engineering Procedure NEP-6.1, " Change Control" (Ref.17),
defines the Drocess by which plant changes are identified, scoped, coordinated, reviewed, and approved bef ore implementation.
Processing of
~
engineering change notices (ECNs) (the documentation tnat provides a concise scope of a design change) is described in Section 4.0 of NEP-6.1.
{
A Checklist f or the lead enQineer is Drovided in tne Drocedure to ensure tnat a human f actors review is perf ormed, if recuired. All future changes'to TVA l
nu: lear plant control room / control boards will be handled by this croceaure.
I Desian Guides. According to Section 3.0 of EEB-EP 22.32, the Electrical Engineering Branen has tne responsibility f or human f actor enaineerino reviews in TVA. For control room / control board enanges a number of engineering aesign guides are used. The principal ones are noted below:
o Design Guide E-10.1.ll This design Quide Dresents orinciples and technioues of human f actors engineering (HFE) pertinent to designing operator work stations in power generating plants.
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o Design Guide E18.1.12 This cuide describes methods and technioues.of HFE in control console and cabinet design and panel layout.. It provides a means for measuring the HFE adequacy of new designs and of modifications to existing designs.-
o Design Guide E18.1.13 l
This document defines and documents accepted HFE principles and i
standards to be employed for the design of annunciators and alarm systems.
o Design Guide E18.1.14 This design guide details the human f actors requirements f or controls and displays that are integrated into a functional' panel l
design. Criteria that will help the operator identify and operate the controls and displays quickly and efficiently are presented.
o Design Guide E18.1.15 This design cuide contains general HFF requirements f or ooerator interface with camputers and computer driven devices.
1 A review of tnese design cuides by the evaluation team indicates that the necessary features to provide proper human f actors. designs are addressed and that these procedures are adeouate to assist in modifications that may be recuired in the control room (Ref. 52).
These procedures and desian guides should ensure good enoineerino practices in
)
the human f actors area.
1 4.2.6 Compliance with NUREG-0/00 ( All Plants)
Employee Concerns WI-85-100-007 and XX-85-122-020 -021, and -022 ouestion compliance with NUREG-0700. NUREG-0700 orovides cuidelines f or licensees and l
applicants in conducting a DCRDR to ensure consideration of human f actors in I
completed nuclear power plant control room designs. The requirement to conduct a DCRDR is contained in NUREG-0737, Supplement 1 (Generic Letter 82-33). The purpose of NUREG-0700, then, is to lead utilities to appropriate levels of compliance. TVA's generic program plan, which describes TVA's approach to f ollowing the guidelines of NUREG-0700, has been reviewed by the NRC and nas subsequently been revised by TVA in response to the NRC's c omment s.
TVA has conducted three DCRDRs (at SQN, BFN, and WBN) utilizino the 26290-R30 (10/13/87) i
w.,._
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 39 of 58 o
Design Guide E18.1.12 This guide describes methods and techniaues of HFE in control console and cabinet design and panel layout.
It provides a means i
for measuring the HFE adecuacy of new designs and of modifications j
to existing designs.-
l o
Design Guide E18.1.13 This document defines and documents accepted HFE principles and standards to be employed f or the design of annunciators and alarm
- systems, o
Design Guide E18.1.14 This design quide details the human f actors requirements f or controls and displays that are integrated into a functional panel design. Criteria that will help the operator identify and operate the controls and displays Quickly and efficiently are presented.
o Desion Guide E18.1.15 This design guide contains general HFE requirements f or coerator interf ace with computers and ccrnputer driven devices.
A review of these design cuides by the evaluation team indicates that the necessary features to provide proper human f actors. designs are addressed and that these procedures are adeounte to assist in modifications that may be recuired in tne control room (Ref. 52).
These procedures and desiQn Quides should ensure good enaineerina oractices in the human f actors area.
4.2.6 Compliance with NUREG-0700 (All Plants)
Employee Concerns WI-85-100-007 and XX-85-122-020, -021, and -022 auestion compliance with NUREG-0700. NUREG-0700 provides auidelines f or licensees and applicants in conducting a DCRDR to ensure consideration of human f actors in completed nuclear power plant control room designs. The requirement - t o conduct a DCRDR is contained in NUREG-0737, Supplement 1 (Generic Letter 82-33). The purpose of NUREG-0700, then, is to lead utilities to appropriate levels of ccrnpliance. TVA's generic program plan, which describes TVA's approach to f ollowing the guidelines of NUREG-0700, has been reviewed by the NRC and has subsequently been revised by TVA in response to the NRC's c omment s.
TVA has conducted three DCRDRs (at SQN, BFN, and WBN) utilizino the 26290-R30 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 40 of 58 guidance of NUREG-0700. The BLN DCRDR has been temporarily suspended.
NUREG-0700 allows alternative approaches as long as they are identified and justified. Final compliance is achieved upon TVA's completion of the DCRDR by submittal of the Summary Reports, f ollowed by NRC review of the Summary Reports, as documented in safety evaluations. The status of the DCRDRs f or each site is described further in Section 4.2.2.
4.2.7 Possible Material False Statement Related to Appendix 0 of the Safety Evaluation Report (WBN)
Employee Concern IN-85-102-001 states:
" Control Room modifications have not been made. There are 1600 outstanding unanswered concerns. Reference Appendix D to the Safety Evaluation Report.
Individual considers this a material f alse statement."
This section of the report addresses the portion of the EC dealing with the alleged material false statement.
The material f alse statement to which the concerned individual. refers cannot be ascertained from the Quotation itself.
However, the evaluators believe that the EC must be related to a series of submittals made by TVA to the NRC between November 1983 and October 1984 whien inaccurately reported the status of WBN unit I control room design modifications called f or in Appendix D to tne Watts Bar SER (NUREG-0847) resulting from TVA's preliminary assessment of the WBN control room (see Section 4.3.1).
The reasons behind this conclusion are as f ollows:
o Under section 186 of the Atomic Energy Act, as amended, the term
" material f alse statement" essentially refers to statements made by applicants or licensees to the NRC. The last sentence in Emoloyee Concern IN-85-102-001 could be read to mean that the material f alse
<tatement was made in Appendix D to the Safety Evaluation Report since Appendix 0 is the immediate antecedent to "this."
H oweve r, the SER is written by the NRC staff, not by TVA. Thus, the SER is not a " statement" within the meaning of the regulation, o
Control room modifications not having been made does not constitute a " statement."
o It may be thought that havina "1600 outstanding unanswered concerns" l
constitutes a material f alse statement; however, as discussed elsewhere in this report, these 1,600 concerns can only refer to the 26290-R30 (10/13/87) x
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 41 of 58 human engineering concerns (HECs) identified by the DCRDR team during the initial review phases (see Section 4.2.2) which have been assessed and converted to human engineering discrepancies where appropriate. Corrective actions f or these HEDs are beina planned and implemented in accordance with the governing procedures. The entire process is to be documented in a Sumary Report to the NRC.
The WBN DCRDR Summary Report is to be submitted on October 1,1987; therefore, no " statement" nad been made to the NRC related to the 1,600 HECs at the time EC IN-85-102-001 was expressed.
o On August 29, 1985, NRC Region II issued a Notice of Violation and Proposed Imposition of Civil Penalty to TVA (Ref. 30) f or a material f alse statement contained in a series of status reports submitted by TVA to the NRC between November 1983 and October 1984. These status reports purported to indicate the completion of corrective actions related to Watts Bar Unit 1 control room design modifications called f or by Appendix D to the SER. The NRC stated that there was apparently no attempt by TVA to deliberately mislead NRC personnel.
TVA admitted the violation.
A more thorough discussion of these material f alse statements related to WBN SER Appendix D is contained in Subcategory Reoort 24500 (Ref. 61), element 201.5 f or Watts Bar, on TVA's commitment tracking procram. That element evaluation aff ords a complete treatment of the portion of EC IN-85-102-001 related to the alleged material f alse statement. The f actors which contributed to the inaccuracies in the status reports have been determined to be programmatic, that is, due to procedural deficiencies related to tracking of commitments, rather than to substantive inadequacies in the human f actors / control rocyn design review program. Theref ore, the evaluation of Subcategory Report 24500, WBN element 201.5 is adeauate to address this portion of EC IN-85-102-001, 4.2.8 Review of HECs (BLN)
Employee Concern BLN-0NP-EC-001 asserts that HECs identified micht not be properly reviewed due to a delay in startup and a reduction in manpower at BLN.
The BLN DCRDR preliminary Action Plan lists all human enaineerina concerns (HECs) identified at BLN bef ore May 12, 1983.
Tnese HECs nave been assessed f or possible redesianation as human engineering discrepancies (HEDs).
Nineteen additional HECs were identified af ter the preliminary Action Plan was issued and bef ore the DCRDR was temporarily suspended, but have not been essessed f or oossible predesignation as HEDs. Tne computerized Tracking and Reportina of Open Items (TROI) system shows 15 BLN DCRDR tasks yet to be 26290-R30 (10/13/87)
-v TVA EMPLOYEE CONCERNS REPrAT NUMBER:
20800 SPECIAL PROGRAM RF'<ISION NUMBER: 3 Dage 42 of 58 completed. Review of the 19 HECs is not included on the TROI system., The DCRDR is scheduled to be under susoension for approximately 3 to 4 years.
Since the DCRDR will be suspended for such a long time and the outstanding 19 HECs are not being tracked by.TROI, TVA could overlook the HECs when the DCRDR resumes.
4.3 Control Room Desion Review by NRC - Element 208.2 4.3.1 NRC Review of WBN Control Room Preliminary Assessment (WBN)
Employee Conccrn IN-85-102-002 asserts, in part, that the NRC review of the Watts Bar control room, as reported in its Safety Evaluation Report (SER),
Chapter 18 and Appendix 0, June 1982, was inadequate. According to the concern, that inadecuacy is attested to by the f act that over 1,700 human enoineerino concerns had been identified during the first two phases of the TVA Detailed Control Room Design Review (DCRDR) completed on February 1, 1985:
(a) review of operating experience, including a personnel survey, and (b) an onsite control room survey.
I NRC Guidelines. According to NUREG-0737 (Ref. 6), WBN could have obtained an ooerating license in advance of completion of the detailed control room design review. However, completion of a preliminary control room assessment by TVA to identify significant human factors and instrumentation problems, followed by evaluation of this assessment and an onsite review / audit by the NRC, is recuired before the issuance of an operating license. Further, WBN was l
reouired by a condition of the draft operating license to complete its DCRDR and submit a Sunnary Report before April 1,1987 (Ref. 29; Att. 2 item 1[a]).
This scheduls date has been extended twice. The Summary Report was actually submitted on October 2,1987. Since the operating license for WBN has not yet been oranted, the detailed DCRDR was actually completed before issuance of an operating license.
NUREG-0737 describes the scope of the onsite review / audit, as follows:
"The NRR onsite review / audit will be on a schedule consistent with licensinq needs and will emphasize the following aspects of the control room:
(11 The adecuacy of information presented to the operator to reflect plant status for normal operation, anticipated operational occurrences, and accident conditions; (2) The groupings of displays and the layout of panels; 26290-R31 (10/13/87)
I TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 43 of 58 (3) Improvements in the safety monitoring and human f actors enhancement of controls and control displays; i
(4) The communications from the control room to points outside the control room, such as the onsite technical support center, remote l
shutdown panel, offsite telephone lines, and to other areas within the plant f or normal and emergency operation.
(5) The use of direct rather than derived signals for the presentation of process and safety inf ormation to the operator; (6) The operability of the plant from the control room with multiple f ailures of nonsafety-grade and nonseismic systems; i
( 7) The adecuacy of operating procedures and operator training with J
respect to limitations of instrumentation displays in the control i
I room; (8) The categorization of alarms, with uniaue definition of safety alarms.
( 9) The physical location of the shif t suDervisor's office either adjacent to or witnin the control-room complex.
" Prior to the onsite review / audit, NRR will reauire a copy of the l
applicant's preliminary assessment and additional inf ormation, wnicn will j
be used in f ormulatina the details of the onsite review /au'dit."
WBN Preliminary Desian Assessment. The preliminary assessment of tne WBN I
contrel rcom tc 1centify signif1 cant human f actors oroblems started on f
January 21, 1980. TVA sent a report to the NRC on January 13, 1981, listing items TVA nad identified in the WBN preliminary assessment and the action to be taken (Ref. 22).
Tne report states:
1 "During the week of February 4,1980, a preliminary control room review was accomplisneo on the Secuoya1 Nuclear Plant (SON) unit I Control room prior to criticality. SON unit 1 is similar (basically identical) to SON unit 2 and WBN units I and 2.
A preliminary assessment conoucted f or either unit is acDrooriate f or the other units.
"This assessment was conducted by the Essex Corporation (under contract to the Nuclear Regulatory Commission, NRC) with a team of NRC and TVA personnel actively involved. Essex Corporation issued a report.
summarizing their findinas. NRC identified from the reDort the significant items reauiring immediate attention.
26290-R30 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL" PROGRAM REVISION NUMBER: 3 Page 44 of 58 "TVA provided corrections to thesE items, and they were documented in tne Seouoyah Safety Evaluation Report dated September 4,1980. These chances are also needed on WBN.
They will be completed prior to each unit's fuel l oadi ng. "
Subsecuent to the SQN preliminary assessment, TVA
"... continued the preliminary review of the WBN main control room by proceeding with internal design studies and task analyses of the control boards and by making five trips to the plantsites [ sic] and the plant simulators to identify human f actor problems. These trips involved walk througns of the operating instructions at botn the Watts Bar plant and simulat or. Detail [ sic) interviews were conducted with the operators at tne plants and at the simult; P with tne instructors.
"The control roms were also examined to identify any significant human engineering deficiencies. The inf ormation obtained from these sources was reviewed with engineering design groups to determine the significant items and identify possible ways to implement the desired changes.
These chances were then reviewed and coordinated with the plant personnel to finalize the changes to be incorporated" (Ref. 22).
AdecuacV of the NRC Evaluation of TVA's Preliminary Assessment. As a preliminary step in its operating license review process, tne NRC issued the WBN Safety Evaluation Report (SER), NUREG-0847, in June 1982 (Ref. 9).
Appendix D to the June 1982 SER contained the results of the NRC's evaluation of the preliminary control room assessment noted above. According to SER Section 18.1, an NRC staff team, assisted by human f actors consultants f rom the University of Calif ornia's Lawrence Livermore National Laboratory, Biotechnology, Inc., and the National Bureau of Standards, conducted an onsite control room design review frm October 6,1980 to October 10, 1980.
" Human engineering discrepancies, identified as a result of the onsite control room review and the applicant's preliminary design assessment, were contained in the staff's draf t control room design report and were transmitted to the applicant. The report ranked the discrepancies according to tneir importance. Observed discrepancies were given a priority rating of one, two, or three (high, moderate, or low), based on the increased potential f or operator error and the possible consequences of that error. The staff reouires the applicant to implement corrective measures for all [79) priority I and 2 deficiencies bef ore an operatino I
license is issued because the correction of these items will significantly reduce the potential f or operator error... No irmediate actions are specified [in Appendix D] f or correctino priority 3 items 26290-R30 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 45 of 58 because they will not significantly affect the safe operation of the plant.
However, the staff does reouire the applicant to report on all priority 3 items as part of his detailed control room design review and to determine the best solution."
l In Section 18.2 of the SER, the NRC concluded:
"The applicant's proposed Corrections of the discrepancies documented in Appendix D to tnis report are acceptable to the staff.
"The staff will perf orm a confirmatory audit to verify that actions have been implemented to correct control room deficiencies and report the results in a supplement to this report.
" Based on its review of the applicant's submittals, the control room review, and other clarifying inf ormation, the staff concludes that with tne implementation of the corrective actions specified in Appendix D (bef ore an operating license is issued) the potential for operator error leading to serious consequences as a result of human f actors considerations in the control room will be sufficiently low to permit safe startup and power operation of tne Watts Bar nuclear plant.
"Tne applicant must address all priority 3 items, as well as other deficiencies that may be identified, in nis detailed control room design review wnien will be perf ormed us ing NUREG-0700 f or guidance, and final resolution of all deficiencies mur: be on a schedule consistent with NUREG-0737."
A requirement substantially the same as the latter is also contained in the draf t license (Ref. 29; Attacnment 2, item 1[b]).
The WBN DCRDR team has verified that, as of March 12, 1985, all but one of the Appendix D items had been completed (Ref. 44).
As noted above, the NRC onsite review / audit was conducted f rom October 6,1980 to October 10, 1980, approximately a month bef ore publication of NUREG-0737 (Ref. 6). Tneref ore, the NRC/ consultant review team apparently did not have the benefit of knowing the aspects of a control room that NUREG-0737 specified snould be "emonasized" in the review / audit. Con'secuently, the NRC/c onsultant review team used a draf t of the NUREG-0700 guidelines to organize its review / audit report (Ref. 23).
Nevertheless, to assess tne completeness of the NRC's review, the evaluation team compared the human f actors engineering concerns raised in the review / audit report and in the SER (Ref. 9) with the nine areas of emphasis f or onsite control room review / audits listed in NUREG-0737. Six of the nine f
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TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 46 of 58 areas of emphasis were f ound to have been addressed. The evaluation team ceuld not verify whether the f ollowing three of the nine areas of emphasis had been reviewed:
(5) The use of direct rather than derived signals for the presentation of process and safety inf ormation to the operator; (6) The operability of the plant from the control room with multiple f ailures of nonsafety-grade and nonseismic systems; (9) The physical location of the shif t supervisor's office either adjacent to or within the control room complex.
With respect to item (9), although the NRC's review / audit report did not specifically address the shif t supervisor's office, the onsite team almost certainly observed its location.
In any event, the shift supervisor's office location is covered by Guideline 6.1.1.6 of NUREG-0700 and Appendix A of TVA's generic program plan. Theref ore, this item is to be addressed in the DCRDR and in the NRC's review of the summary report.
.Similarly, the use of direct rather than derived signals, item (5), should be verified during the function and task analysis phase of the DCRDR.
Multiple f ailure analysis, item (6), is not part of the DCRDR oroaram specified in Supplement I to NUREG-0737. A thorough assessment of the operability of the olant from the control room with multiple f ailures of nonsafety-grade and nonseismic systems would require a ' major systems engineering eff ort. Such a study is not a human f actors engineering consideration as the evaluation team understands it.
Bearing in mind that the onsite review / audit called f or in NUREG-0737, item !.D.1, is a preliminary evaluation, and tnat the nine items listed are aspects of the control room to be " emphasized" in the review / audit, item (6) should not be interpreted to imply such a detailed study.
At the time of the NRC's site visit, the control room at Watts Bar was consicered to be a couple of months away from completion. Many of the systems and subsystems were either not yet operational or not completely installed, tnus limiting the NRC audit team's capability to assess the' full human-macnine interface (Ref. 23).
At the time the employee concern was expressed, none of TVA's nuclear plants nad completed their DCRDRs.
The DCRDR f or SQN was completed in November 1986, and the DCRDR f or WBN was completed on October 2,1987. Thus, the preliminary assessments of the control room for botn SQN and WBN and NRC's evaluation of
. l the preliminary assessments, includino onsite review / audits, were not intended l
l to constitute tne final review of human f actors engineering at these plants.
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20800
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SPECIAL PROGRAM REVISION NUMBER: 3 Page 47 of 58 Regardless of the adecuacy of the NRC's October 1980 onsite control room review / audit and evaluation of the WBN preliminary design assessment, the j
NRC's evaluation of the WBN DCRDR Summary Report, including a preimplementation audit, if any, will provide reasonable assurance that "the operator-machine interf aces of the control room and remote shutdown areas are
~
adecuate to support safe operation of the plant" (Ref. 7).
4.3.2 Implications of NRC's Review at WBN to SQN Licensing (WBN)
Employee Concern IN-85-102-002 implies that, had the NRC conducted a more thorough review of TVA's preliminary assessment of the Watts Bar control room design (which could have identified concerns similar to the HECs identified by T"A in the later DCRDR f or WBN), the NRC would have been p r.:d in an i
embarrassing situation having previously authorized oDerating licensds to Seouoyah units I and 2 (which have control rooms basically identical to Watts Bar's) in September 1980 and September 1981, respectively.
The NRC's onsite control room review / audit was never intended to constitute its final review of human f actors engineering at WBN. Regardless of the thoroughness of the NRC's onsite control room review, tne NRC will review tne WBN DCRDR Summary Report and document this review in a sucolement to the Watts Bar SER. Further, the prior licensing of Seouoyan is irrelevant. Generic Letter 82-33 recuires that all (i.e., both operating plants and plants under construction) nuclear power plant control rooms undergo a DCRDR. As noted elsewhere, the Seouoyah DCRDR program was conducted subsecuent to tne l
expression of EC IN-85-102-002, having been completed in November 1986 witn the NRC's evaluation issued in Auoust 1987.
4.3.3 Reevaluation of NRC's Onsite Control Room Review (WBN)
The last part of IN-85-102-002 concludes that the NRC will not, as of early 1985, reevaluate its original Watts Bar control room review and revise its SER in which it approved the control rocm design fully aware of TVA's subsecuent finaings.
The NRC is on record (WBN SER 18.2) tnat it will conduct confirmatory audits to verify that actions have been implemented to correct control room deficiencies noted in tne Safety Evaluation Report. Results will L. reported in a supplement to the SER prior to the issuance of an operating license.
Similarly, tne NRC is also committed (Ref. 26) to document the results of its evaluation of TVA's DCRDR, including a new onsite (preimplementation) audit (Ref. 38) in an SER or SER supplement. The NRC has made comDietion of the DCRCR and submittal of a summary report a condition of TVA's receiving an operating license f or WBN. Theref ore, human engineering discrepancies identified af ter the NRC's October 1980 onsite review / audit will be subjected to NRC scrutiny.
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TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 48 of 58 4.4 Tabulation of Q sjg A summary of the classified findings is provided in Table 1.
Class A and 8 findings indicate that there is no problem and that corrective action is not required. Class C, D, and E findings recuire corrective action. The finding / corrective action' class, defined in the Glossary Supplement, is identified in the table by a lettet (for finding) combined with a numeral (for corrective action). For example, the designation C6 in Table 1 indicates that the evaluated issue was found to be valid and that a corrective action involving evaluation was initiated bef ore ECTG evaluation.
The summary of findings by classification is given in Table 2.
Of the 25 findings identified by a classification in Table 1, 9 were not valid and i
reauired no corrective action. Two corrective actions for 15 valid findings had been initiated before the ECTG evaluation. One finding will recuire i
corrective action as a result of the investigation.
l 5.
CORRECTIVE ACTIONS Table 2 identifies 16 findings that require corrective action. Since so% of the corrective actions apply to more than a single plant, only three different I
types of corrective actions are required to address the 16 neaative findinas.
l The detailed corrective actions are described in Attachment B.
A condensation l
of this information by element, with the apolicable olent identified in
)
l parentheses, f ollows:
i l
l o
208.1, Human Factors Review Procram NUREG-0700 l
Comolete the in-progress detailed control room desian reviews I
(WBN and BLN). SQN and BFN DCRDRs have been completed.
l According to the corrective action plan, the WBN DCRDR was to i
have been ccripleted by August 1,1987; however, this target date has changed. The WBN DCRDR Summary Report was submitted on October 2,1987. BLN's DCRDR is scheduled to be completed approximately one year bef ore the anticipated fuel load date.
Correct human engineering discrepancies identified in the detailed control roan design review (all TVA nuclear plants).
Place review of 19 HECs onto the computerized Tracking and Reporting of Open Items (TROI) system list (BLN).
o 208.2, Control Room Desian There are no corrective actions f or this element.
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-)
Page 49 of 58 To avoid making f alse statements to the NRC in-the future, TVA has implemented
.I a Corporate Commitment Tracking System (CCTS) as committed in the Corporate Nuclear Performance Plan. This computerized database now tracks all TVA commitments to the NRC.
In addition, the DCRDR team will verify completion of modifications required by Appendix D of the June 1982 Safety Evaluation Report (SER). This corrective action is not listed separately in Table 3 because it is addressed in Finding "a" of element 201.5 in Subcategory Report 24500.
The corrective actions above also appear on Table 3, along with their corresponding finding / corrective action classifications. The table indicates the plant or plants to which a corrective action is applicable by the Corrective Action Tracking Document (CATD) column where the applicable plant is identified by the CATD number.
If a CATD'was not issued, the applicable plant is listed in parentheses. A CATD was not issued for correcting tiuman engineering discrepancies (HEDs) because the schedules for this corrective action will be negotiated with the NRC. TVA's Corporate Commitment Tracking System, audited by TVA Ouality Assurance and the NRC, will ensure completion of the HED correction effort. The table shows that one corrective action is aoolicable to all plants, one is applicable to WBN and BLN, and one is applicable to BLN. With respect to corrective actions, Table 3 shows that, of the two elements in this subcategory, one required no corrective action (208.2).
In all cases, the evaluation team found the corrective action plans (CAPS) to be acceptable to resolve the findings.
6.
CAUSES Table 3 also identifies one or more causes for each problem requiring corrective action. For each corrective action, the most important Cause is irtentified; however, in one instance it was felt that the problem was the result of two causes, each of which should be identified.
For the two corrective action descriptions listed in Table 3, four causes have been identified. They are shown in the table and totaled at the bottom. The four causes are: " Untimely Resolution of Issues," "Inadeouate Design Bases,"
" Failure to Document Engineering Judgments," and " Engineering Error."
" Untimely Resolution of Issues" was chosen because, although the completion of l
the DCRDRs at WBN and BLN has not imoeded licensing, the reviews could reasonably have been complsted earlier.
" Inadequate Design Bases," was l
selected because, during the initial design stage TVA lacked bases for evaluatino human factors in the design of main control rooms and remote shutdown stations. " Failure to Document Engineering Judgments" was selected l
because, in suspendina DCRDR activity at Bellefonte, TVA failed to document work in progress in a fashion that would ensure that such work would be f
2629%R31 (10/13/87)
l TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 50 of 58 ccrnpleted upon resumption of the DCRDR program. " Engineering Error" was l
Selected because human f actors errors or oversights were made in the. initial control panel or workstation design process. " Standards Not Followed" was not l
selected because, at the time of initial design, cuidelines for assessing numan f actors for the control room were not available.
l Using the three larger groups of causes identified by the headings in Table 3, l
the totals show that one cause is in the management effectiveness category, two are in the design process effectiveness category, and one is in the tecnnical adecuacy category.
7.
COLLECTIVE SIGNIFICANCE 1
As shown in Table 3, two causes were identified related to correction of the HEDs identified in the DCROR.
It is judged from the number of HEOs and their safety significance that TVA lacked an effective design process in the area of control room human f actors. By its very nature as a summary of causes, the table does not place the subject of this report in the context of the more general subject of human f actors, as applied to the nuclear industry.
As an engineering science, human f actors was first apolied to control rocyn design by the U.S. space program in the middle 1960s. Attempts to apply these practices in the nuclear industry were I'mited, Aowever, by a continuino evolution of desian criteria (e.g., redundancy, separation); a reluctance to use state-of-the-art and theref. ore untried technioues (comDuter-based controls / displays, miniaturized control elements, etc.); and an expansion of recuired safety systems, each demanding limited control /disolay space set by I
the dimensions of the physical plant early in the design phase. Furtner, this application of space program human f actors technology to nuclear power plant control room designs was, in some cases, inappropriate. The net effect of these f actors did not become evident until the assessment of the Three Mile Island accident. Following that assessment, a program of design reviews was initiated to correct, as much as possible, the accumulated impact of those outside f actors on the final as-built control rooms existing today.
With these thoughts in mind, it is. improper to draw any more ceneral negative findings or establish any broader concerns as to TVA's overall effectiveness in this area. The latter-day application of human f actors technology to nuclear power control room design is an industrywide problem and not indigenous solely to TVA.
The evaluation team's judgment as to the significance of the corrective actions is shown in the last three columns of Table 3.
The term
" significance" as used here is rated in accordance with the type or types of I
(
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Page 51 of 58 l
changes that may be expected to result from the corrective action. As can be q
seen from tne significance columns, only one of the three corrective actions f or this subcategory is judged to be " significant." Correction of human engineering discrepancies is a "significant corrective action" beca'se it u
could result in changes that will affect the overall perf ormance of the safety-related instrumentation and control systems in the control room.
Documentation or control room hardware modifications are labeled as potential in Table 3 because modifications have not been finalized yet.
Cmpletion of the in-progress DCRDRs merely constitutes a licensee's action in response to a regulatory requirement (NUREG-0737). This corrective action j
itself is not judged to be significant because, in general, control room modifications will occur after the NRC reviews the DCRDR summary report.
Adding a DCRDR task to the TROI system is also not judged to be signi.ficant because this action does not directly result in physical changes to any safety-related component.
l The human engineering discrepancies found in all TVA control rooms would have been identified without this ECTG evaluation because the DCRDR is reauired by Supplement 1 to NUREG-0737.
TVA has engineering procedures in place to implement human f actors enoineerinc practices in future control room design changes. The procedures ensure that the principles of human f actors engineering are applied at the earliest staaes of planning. Theref ore, a comprehensive human f actors review of tne entire control room should not be needed in the future.
l The Quantity and diversity of human engineering discrepancies identified so f ar at all TVA control rooms suggest that numan f actors reoresents an area of needed improvement to meet today's standards. This situation is not uncommon to other nuclear plants, considering the circumstances under which human i
f actors engineering was applied to nuclear power plant control rooms f ollowinq l
TMI. Muen work is yet to be perf ormed at TVA's f our nuclear olants to correct i
what are per ceived as human engineering discrepancies by modern standards.
Upon completion of the DCRDR summary reports, the NRC will evaluate TVA's proposed control room modifications and prooosed implementation senedules.
These evaluations will be documented in a Safety Evaluation Report (SERI.
According to Section 18.1 of the NRC's Standard Review Plan:
"the SER will state whether the NRC staff concludes that the Drocesed modifications to the licensee's/ applicant's control room ecuipment and operations as a result of the DCRDR will accmplish the basic l
requirements established by the Connission. Any additional corrections l
or schedule modifications necessary to comoly with the basic requirements established by the Commission will be documented in the SER."
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Page 52 of 58 l
The NRC staff will then confirm whether sufficient information.has been provided to conclude:
"that the applicant / licensee meets the relevant requ'irements of
- Supploment I to NUREG-0737 f or conducting a detailed control room design review and finds evidence to indicate that the operator-machine I
interf aces of the control room and remote shutdown areas are adequate to l
support safe operation of the plant."
To assess the collective impact of the human engineering discrepancies on plant safety would require an extensive systems analysis. This was not done I
as it'is not part of the detailed control room design review specified in NUREG-0737.
However, with the prioritized implementation of ~ control room modifications on a schedule approved by the NRC, TVA's control rooms will be brought into acceptable compliance with NRC human f actors guidelines to support saf e operation.
A review of the Corporate Nuclear Perf ormance Plan by the evaluation team reveals no connitments specifically related to the subject matter in this -
report.
The findings, causes, and significance of corrective actions were considered I
collectively f or botn elements in tnis subcategory to determine'wnether new insights from the element evaluations could be established. Most of the findings / corrective actions f or individual issues were similar f or all applicable plants. As sucn, no additional'insiants over those acoarent in the element evaluations were gained.
Tne results of tnis subcategory evaluation are being combined with tne other subcategory evaluations and reassessed in tne Engineering category evaluation.
i e
26290-R30 (10/13/87) i
c TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 63 of 68 TABLE 1 CLASSIFICATION OF FINDINGS AND CORRECTIVE ACTIONS Finding / Corrective Issue /
Action Class
- Element Finding **
SON WBN BEN BLN 208.1 Human Factors Review a
A A
A A
b C6 C6 C6 C6 c
C6 C6 C6 C6 d
C6 C6 C6 '
C6 e
A C6 A
C6 f
C6 D3 g
208.2 Control Room Design a
A A
b A
C
- Classification of Findinos and Corrective Actions A.
Issue not valid.
- 1. Hardware No corrective action recuired.
- 2. Procedure B.
Issue valid but consequences acceotable.
- 3. Documentation No corrective action reauired.
- 4. Training C.
Issue valid. Cerrective action
- 5. Analysis initiated bef ore ECTG evaluation.
- 6. Evaluation D.
Issue valid.
Corrective action
- 7. Other taken as a result of ECTG evaluation.
E.
Peripneral issue uncovered during ECTG evaluation.
Corrective action reauired.
- Defined in Attachment B.
- The finding / corrective action classification is not included here because the corrective action is addressed in element 201.5, Issue "a" (see Subcategory Report 24500, Attachment B).
f 26290-R30 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 54 of 58 TABLE 2 1
1 FINDINGS'
SUMMARY
Plant l
l Classification of Findings SON ' y@3 BFN BLN Tot al l
A.
Issue not valid. No corrective 2
4 2
1 9
action required.
l B.
Issue valid but consequences' acceptable.
0 0
0 0
0 1
No corrective action reauired.
l 1
C.
Issue valid. Corrective action 3
5 3
4 15 initiated bef ore ECTG evaluation.
D.
Issue valid. Corrective action taken 0
0 0
1 1
l as a result of ECTG evaluation.
j l
1 E.
Peripheral issue uncovered during 0
0 0
0 0
1 ECTG evaluation. Corrective action recuired.
l Total 5
9 5
6 25 1
l l
l l
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TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 56 of 58 GLOSSARY SUPPLEMENT FOR THE ENGINEERING CATEGORY Causes of Neaative Findinas - the causes for findings that recuire corrective action are categorized as f ollows:
1.
Fragmented organization - Lines of authority, responsibility, and accounta0111ty were not clearly defined.
2.
Inadeauate cuality (01 trainino - Personnel were not fully trained in tne procedures established f or design process control and in tne maintenance of design documents, including audits.
3.
Inadeauate orocedures - Design and modification control methods and procedures were deficient in establishing recui emcnts and did not ensure an effective design control program in some areas.
4.
Procedures not f ollowed - Existing procedures controlling the desian process were not f ully adhered to.
5.
Inadeouate c communications - Communication, coordination, and cooperation were not f ully effective in supplying needed inf ormation l
within plants, between plants and organizations (e.a., Enaineerina, Construction, Licensing, and Operations), and between interorganizational disciplines and departments.
6.
- Jntimely resolution of issues - Problems were not resolved in a timely manner, ana tneir resolution was not accressively oursued.
7.
Lack of manaaement attention - There was a lack of management attention in enturing that programs required f or an effective desiQn orocess were established and implemented.
8.
Inadeauate desian bases - Design bases were lackina, vague, or incomplete f or oesign execution and verification and f or desian change evaluation.
9.
Inadeauate calculations - Design calculations were incomolete, used incorrect input or assumptions, or otherwise f ailed to fully demonstrate comoliance with design ' requirements or succort' desian output documents.
10.
Inadeauate as-built reconciliation - Reconciliation of design and licensing documents with plant as-built condition was lacking or inc omplete.
1 26290-R30 (10/13/87)
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20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 57 of 58
- 11. Lack of desian detail - Detail in design output documents was l
insuf ficient to ensure compliance with design requirements.
l l
- 12. Failure to document engineering judoments - Documentation ju'stifying engineering juogments used in the design process was lacking or inc omplete.
- 13. Design criteria / commitments not met - Design criteria or licensing commitments were not met.
14 Insufficient verification documentation - Documentation (Q) was insufficient to audit tne adequacy of design and installation.
- 15. Standards not f ollowed - Code or industry standards and oractices were not compliec with.
- 16. Enaineerina error - There were errors or oversights in the assumptions, metnocology, or judgments used in the design process.
- 17. Vendor error - Vendor design or supplied items were deficient f or tne intended purpose.
Classification of Corrective Actions - corrective actions are classified as belonging to one or more of the f ollowing groups:
1.
Hardware - physical plant chances 2.
Procedure - changed or generated a procedure 3.
Documentation - affected 0A records 4
Training - recuired personnel education 5.
Analysis - recuired design calculations, etc., to resolve 6.
Evaluation - initial corrective action plan indicated a need to evaluate the issue before a definitive plan could be established.
Theref ore, all hardware, procedure, etc., changes are not yet known 7.
Other - items not listed above Perioneral Findina (Issue) - A negative finding that does not result directly f rom an employee concern but that was uncovered during the process of evaluating an employee concern. By definition, peripheral findings (issues) recuire corrective action.
26290-R30 (10/13/87) m
I TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page 58 of 58
(
Significance of Corrective Actions - The evaluation team's judgment as to the significance of tne corrective actions listed in Table 3 is indicated in the I
last three columns of tne table. Significance is rated in accordance with the
)
type or types of changes that may be expected to result fron the corrective acti on. Changes are categorized as:
o Documentation change (D) - This is a change to any design input or i
I output document (e.g., drawing, specification, calculation, or procedure) tnat does not result in a significant reduction in design l
margin.
I o
Change in design margin (M) - This is a change in design interpretation (minimum requirement versus actual capability) that results in a significant (outside normal limits of expected accuracy) change in the design margin. All designs include margins to allow f or error and unf oreseeable events. Chances in design margins are a normal and acceptable part of the design and l
construction process as long as the final design margins satisfy regulatory requirements and applicable codes and standards.
o Change of hardware (H) - This is a physical change to an existina plant structure or component that results from a change in the design basis, or that is recuired to correct an initially inadeauate design or design error.
if the change resultina f ran the corrective action is judaed to be significant, either an "A" f or actual or "P" f or potential is entered into tne I
aooropriate column of Table 3.
Actual is distinguished from potential because l
corrective actions are not complete and, consequently, the scope of required cnances may not be known. Corrective actions are judoed to be significant if tne resultant changes affect the overall cuality, perf ormance, or margin of a safety-related structure, system, or component.
l l
26290-R30 (10/13/87) 1
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..,,',,.M.,,..
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUM8ER: 3-Page C-1. of 5 ATTACHMENT C REFERENCES Reculatory Documents 1.
10 CFR 50, Appendix A: Code of Federal Regulations, Title 10, Part 50, I
Appendix A, General Design Criteria 1
l 2.
Generic Letter 82-33, Requirements f or Emergency Response Capability, NRC,(12/17/82) 1 3.
NUREG-0660, NRC Action Plan Developed as a Result of the TMI-2 Accident, NRC, (05/80) a 4.
NUREG-0700, Guidelines f or Control Room Design Reviews, NRC, (11/81) 5.
NUREG-0737, Supplement 1, Requirements f or Emergency Response Capability, I
l NRC, (01/83) (Enclosure to Generic Letter 82-33) 1 6.
NUREG-0737,Section I.D.1, Clarification of TMI Action Plan Requirements, Control Room Design Reviews, NRC, (11/80) 7.
NUREG-0800, Standard Review Plan, Chapter 18, Human Factors Engineering, NRC (Section 18.1, Appendix A incorporates draf t NUREG-08U1) 8.
NUREG-0801 (Draft), Evaluation Criteria f or Detailed Control Room Desian Reviews,NRC,(10/81)
~
9.
NUREG-0847, Safety Evaluation Report (SER) Related to the Operation of Watts Bar Nuclear Plant, Units I and 2, NRC, (06/82),
TVA Documents 10.
AI-4.8, Controlled Documents, Watts Bar Nuclear Plant Administrative Instruction, Rev. 9, (09/12/86)
- 11. EEB-EP-22.32, Human Factors Engineering - Desian Review, Enaineerina Procedure, Electrical Engineering Branch, [B05 861222 534), (12/17/86)
- 12. EN DES-E18.1.11, Human Factors *Encineerina in Design of Operator Work Stations, Design Guide, Rev. O, (05/11/82)
- 13. EN DES-E18.1.12, Human Factors Engineering in Control Console, Cabinet, and Panel Layout, Rev. O (04/30/82) l 38210-R2 (10/13/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page C-2 of 5 14 EN DES-E18.1.13, Human Factors Engineering in Alarm Systems, Rev. O, (07/16/82)
- 15. EN DES-E18.1.14, Human Factors Engineering in Controls and Visual Displays, Rev. O, (04/30/82)
- 16. EN DES-E18.1.15, Human Factors Engineering in Operator /Comouter Interf ace and Dialog, Rev. O, (05/19/82)
- 17. NEP-6.1 (was OEP-11), Change Control, Nuclear Engineering Procedure, Division of Nuclear Engineering, Rev. O, (07/01/86)
- 18. OE-SEP 82-17, Control Room Design Reviews f or All TVA Nuclear Plants, Special Eng[ineering Procedure, TVA Office of Engineering, Rev. 2, (08/20/85) Originally issued as SEP 82-17, Rev. 0 (04/12/83)]
- 19. SP SQA-179, Conduct of the Detailed Control Room Design Review and Other Major Human Factor Reviews at Seouoyah Nuclear Plant, Seouoyah Nuclear Plant Stancsrd Practice, TVA, Rev. 1,(05/21/86)
- 20. TROI, Tracking and Reporting of Open Items, pp. 33-34,(05/15/87)
- 21. WB 6.3.14, Conduct of the Detailed Control Room Design Review and Other Major Human Factor Reviews at Watts Bar Nuclear Plant, WBN Standard Practice, Rev. 1,(05/05/86)
TVA External Correspondence
- 22. Letter to Schwencer (NRC) f rom Mills (TVA), Re: Results of Preliminary Design Review of WBN's Control Room, (01/13/81)
- 23. Letter to Parris- (TVA) f rom Tedesco (NRC), Control Room Desian Review / Audit Report f or Watts Bar Nuclear Plant, Unit 1, (05/27/81) 24 BWR Owners' Group Control Room Improvements Committee, Human Factors Design Review of the Browns Ferry 1, 2, 3 Control Rooms - Summary Report,
[82 022 6A0243), (02/11/82)
- 25. Letter to E. Adensam (NRC) from D. S. Kammer (TVA), Re: Submittal of TVA's Generic Control Room Design Review Program Plan f or Seouoyan, Watts Bar, Bellef onte, and Browns Ferry, [A27 830609 001], (06/09/83)
- 26. Letter to H. G. Parris (TVA) from T. M. Novak (NRC), Re: Comments on TVA Program Plan f or Control Room Design Reviews, [A02 831229 001], (12/23/83) 4 38210-R2 (10/13/87)
7 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECit.L PROGRAM REVISION NUMBER. 3 Page C-3 of 5 0
1
- 27. Letter to H. G. Parris (TVA) f rom T. M. Novak (NRC), Re: Request for l
Meetina to Discuss the Qualifications, Structure and Management of the l
DCRDR Review Team, [A02 841126 003), (11/19/84)
- 28. Letter to TVA from Kenyon (NRC), Summary of Meeting to Discuss the Detailed Control Room Design Reviews f or TVA's Nuclear Facilities,
[L44 850108 382), (12/27/84)
- 29. Letter to H. G. Parris (TVA) from T. M. Novak (NRC), Draft License and Final Draft Technical Specifications for the Watts 8ar Nuclear Plant, Unit 1, [L44 850610 537], (05/20/85)
- 30. Letter to H. G. Parris (TVA) from Grace (NRC), Notice of Violation and Prooosed Imposition of Civil Penalty (NRC Insoection Reports 50-390/84-35, 84-77, and 85-38, and Investigation Report 2-84-010,
[B45 850910 826], (08/29/85)
[A02 860224 020], (02/18/86)
- 32. Memo to J. R. Walker (TVA), Essex Control #00798/7/86 from H. P. Van Cott (Essex Corp.), Review of Secuoyan Nuclear Plant (SNP) Control Room Design Review Documentation, (03/28/86; revised 04/09/86)
- 33. Letter to S. A. White (TVA) from B. J. Youngblood (NRC), Re: Transcript of the Investigation Interview Conducted by the NRC on 02/21/86 at the First Tennessee Bank Building in Knoxville, TN, [B45 860714 832],
(06/23/86) 34.
Letter to W. 5. Raughley (TVA), Essex Control #00798/47/86 from H. D. Van Cott (Essex Corp.), (11/13/86)
- 35. Letter to Youngblood (NRC) from R. Gridley.(TVA), Re: Submittal of Secuoyan DCRDR Summary Report, [L44 861126 809), (11/26/86)
- 36. Letter to D. Muller (NRC) f rom J. Domer (TVA), Re: Submittal of the Browns Ferry Nuclear Plant Detailed Control Room Desian Review Summary Reoort, [L44 861280 803), (12/30/86)
- 37. Letter to J. Ebneter (NRC) from J. Domer (TVA), Watts Bar Nuclear Plant (WBN) - Schedule f or Submittal of Detailed Control Rocn Design Review (DCRDR) Summary Report, [L44 870325 805), (03/25/87)
Schedule f or Submittal of Detailed Control Room Design Review (DCRDR)
Summary Report [L44 870731806), (07/31/87) 3821D-R2 (10/13/87)
)
.s
- . D'v'
'j l
TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM-REVISION NUMBER: 3 Page C-4 of 5 e
- 39. Letter to S. White (TVA) from J. Zwolinski (NRC), Safety Evaluation 'f or the Detailed Control Room Design Review (DCRDR) (TAC 51203, 51204),
[A02 870902 012),-(08/27/87)
TVA Internal Correspondence 40.
Report to Project Manager, Bellefonte Design Project, Bellefonte CRDR I
Team, Bellef onte Nuclear Plant Control Room Design Review Human Engineering Discrepancy Action Plan. [no RIMS number), (08/15/83)
- 41. Memo to Electrical Engineering Files from Baumgartel, Seouoyah, Watts Bar, and Browns Ferry Nuclear Plants - Control Room Design Review (CRDR) - Core Review Team Training - Human Factors Training Course,
[EEB 830912 928), (09/09/83)
- 42. Memo to EE Files - Meeting with NRC, from M. C. Brickey, Main Control Room Design Review - All Nuclear Plants, [EEB 840626 927], (06/22/84)
- 43. Memo to J. A. Raulston from F. W. Chandler, Watts Bar Nuclear Plant -
Control Room Design Review (CRDR), [B43 850304 902), (02/27/85) 44 Memo to EE Files from J. A. Martin and J. R. Maner, Watts Bar Nuclear Plant - Control Room Design Review (CRDR) - Review f or Closure of SER Aopendix D ltems and Other Human Factors Eff orts, [B43 850312 925),
(03/12/85) l 45.
Memo to Nuclear Engineering Branch Files from E. J. Sheehy, All Nuclear l
Plants - Unresolved Comments on Program Plan f or Plants (Special l
Engineering Procedure SEP 82-17), [B45 850802 256], (08/02/85)
- 46. Memo to Electrical Engineering Files from Edwards, SQN - Control Room Desion Review (CRDR) - Status Meeting (Telephone Conference),
[B43850920938),(09/12/85)
- 47. Memo to J. A. Raulston from F. W. Chandler, All Nuclear Plants - NEB Employee Concera on the Program Plan f or Control Room Design Review (CRDR) of TVA's Nuclear Plants, [B43 850919 903), (09/13/85)
- 48. Memo to J. W. Hutton from C. F. Dilworth, Control Room Design Review (CRDR)
All Nuclear Plants, [B43 851010 923), (10/09/85)
- 49. Memo to CRDR Files from Martin, 50NP - Status of CRDR, [no RIMS number),
(04/25/86) e 6
38210-R2.(10/13/87)
..:l
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1 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page C-5 of 5
- 50. Memo to H. P. Pomrehn, BFN Site Director, from J. P. Stapleton Re:
]
Forwarding tt.e Browns Ferry Nuclear Plant Control Room Design Reyiew Action Plan, In'.luding Volume 1 of CRDR Action Plan, [B43 860723 904),
(07/21/86)
- 51. Memo to H. P. Pomrehn, BFN Site Director, f rom T. G. Chapman, Re:' CRDR j
Team Action Plan Supplement, [822 870109 099), (12/29/86)-
Evaluation Teani Correspondence 5 *..
IOM 189, TVA Concern 208, Human Factors Issues, Bechtel Memo to W. E.
Purcell from D. L. Damon, (06/17/86) 53.
10M/TCon 770, Telecon to D. Bradley (TVA) from T. R. McDonnell (.Bechtel),
(03/18/87) 54 TTB 140, List of 35 Emergency Operating Procedures f or SON, Iter 3 (10/28/86) q
- 55. Telecon to P. B. Nesbitt/J. A. Martin (TVA) from W. E. Purcell (Bechtel),
(10/14 anc 10/15/86) 56.
10M/TCon 1921, Telecon to S. Pannell (TVA) f rom T. McDonnell (Bechtel),
)
(10/06/87) i t
Other Documents
- 57. Letter to D. Vassallo (NRC) f rom J. Pilant (Nebraska PPD), Re: Submittal' of Cooper Nuclear Station Detailed Control Room Desion Review (DCRDR)
Summary Report, (02/04/85)
I 1
i
- 58. Letter to J. Pilant (Nebraska PPD) from NRC, Re: Coooer Nuclear Station Detailed Control Room Design Review (DCRDR) - Evaluation of Summary 1
Report, (09/05/85) l
- 59. TCAB-289, Employee Concern Evaluation Program
'.4atts Bar Nuclear Plant -
Corrective Action *1an (CAP) Line CAP f or Fact Sneet 208.1; CATD 20801-WBN-01, G. R. McNutt (TVA), 03/13/87) o0. OP 30500. TVA Employee Concerns Special Program, Subcategory:
Accessibility, C. W. Touchstone, Rev. 1, (08/12/87)
- 61. Subcategory Report 24500, Incorporation of Requirements, Conrnitment s, and Experience in Design, Bechtel, Rev. 2,- (08/21/87) 38210-R2 (10/13/87) l
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1
. 1 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page A-1 of 3 ATTACHMENT A EMPLOYEE CONCERNS FOR SUBCATEGORY 20800 Attachment A -- lists, by element, each employee concern evaluated in the subcategory. The concern's confidential number is given blong with notation of any other element or category with which the concern is snared; the plant sites l
to which it could be applicable are noted; the concern is auoted as received by TVA and characterized ac safety related, not safety related, or safety significant.
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1 TVA EMPLOYEE CONCERNS REPORT NUMBER:
20800 SPECIAL PROGRAM REVISION NUMBER: 3 Page B-1 of 18 ATTACHMENT B
SUMMARY
OF ISSUES, FINDINGS,' AND CORRECTIVE ACTIONS FOR SUBCATEGORY 20800 Attachment B -- contains a sunnary of the element-level evaluations. Each' issue is listed, by element number and plant, opposite its corresponding l
findings and corrective actions. The reader may trace a concern from l
Attachment A to an issue in Attachment B by using the element number and applicable plant. The reader. may relate a corrective action description in Attachment B to causes and significance in Table 3 by using the CATO number which appears in Attachment B in parentheses at the end of the corrective l
action description.
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