ML20236B100
| ML20236B100 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 05/14/1987 |
| From: | Kane W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Martin T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| Shared Package | |
| ML20236B042 | List: |
| References | |
| FOIA-88-198 NUDOCS 8903200341 | |
| Download: ML20236B100 (109) | |
Text
1 0
(' , ./ %, UNITED STATES
/'- o NUCLEAR REGULATORY COMMISSION
[ '$ REGION I l 0, 631 PARK AVENUE
%, ,o#[ KING OF PRUS$1A, PENNSYLVANIA 19406 l
j 14 MAY 1987 1
MEMORANDUM FOR: Thomas 0. Martin, Executive Coordinator for Regional Operations, DEDROGR FROM: William F. Kane, Director l Division of Reactor Projects l Region I ,
~
SUBJECT:
BACKGROUND INFORMATION 0'N PILGRIM NUCLEAR POWER PLANT FOR COMMISSIONER CARR Attached is the background information paper for Commissioner Carr's visit to Pilgrim on May 22, 1987.
If you have any questions, please contact me.
I
/
William F. Kane, Director Division of Reactor Projects i
Attachment:
As stated cc w/
Attachment:
j G. Felgate, OCM/KC B. Clayton, E00 l B. Boger, NRR R. Wessman, NRR l
\
s
's 8903200341 890310
_g98 PDR J$NS
,E/E-//
A 4
BACKGROUND INFORMATION ON h
RIM NUCLEAR POWER PLANT Utility: Boston Edison location: 4 Mi SE of Plymouth, Massachusetts County: Plymouth County, Massachusetts Docket No.: 50-293 CP Issued: 8/26/68 Operating License Issued: 9/15/72 Initial Criticality: 6'/16/72 (Based on a 20% power license issued 6/9/72)
Elec. Ener. 1st Gener: 7/19/72 Commercial Operation: 12/1/72 Reactor Type: BWR 3/4 Containment GE MKI Power Level: 670 MWe; 1998 MWt Architect / Engineer: Bechtel NSSS Vendor: General Electric Constructor: Bechtel Turbine Supplier: General Electric Condenser Cooling Method: Once Thru Condenser Cooling Water: Cape Cod Bay Licensing Project Manager: Richard H. Wessman (Telephone: 492-4937)
NRC Responsible Region: Region I, King of Prussia, Pennsylvania William T. Russell, Regional Administrator James M. Allan, Deputy Regional Administrator Div. of Reactor Projects: William F. Kane, Div. Director (Tel: 8-488-1229)
(Region I) Samuel J. Collins, Deputy Division Director (Tel: 8-488-1126)
James T. Wiggins, Section Chief (Tel: 8-488-1128)
Larry Doerflein, Project Engineer (Tel: 8-488-1132)
Senior Resident Inspector: Martin McBride, (Tel: 8-617-747-0565)
Resident Inspector: Jeffrey Lyash, (Tel: same )
Tae Kim, (Tel: same )
5/14/87
.7 c.
- } ,. . Pilgrim Nuclear Power Plant Management Personnel (Boston Edison)
-Senior Corporat'e' Steven Sweeney Chief Executive Officer Ralph Bird Senior Vice President, Nuclear '
Corporate E. Howard Vice President Nuclear Engineering and QA H. Brannan Quality Assurance Manager R. Swanson Nuclear Engineering Department Manager D. Cronin- Nuclear Management Services Department Manager s
Management Personnel Boston Edis'on (Continued) '
i Site
- K. Roberts Nuclear Operations Department Mg, nager (Flant Manager) i J. Seery Technical Section Manager N. Brosee Maintenance Section Manager S. Hudson Operations Section Manager T. Sowdon Radiological Section Manager
-E. Ziemianski Training Manager ',
Workforce Boston Edison Personnel On-Site 360 Training 59 Engineering and Corporate QA 1
126 l Total 545 Site Contractor Support Normal Refuel Outage 7 Maintenance and Modifications 160 815 Security 156 174 Radiological Control 48 211 Miscellaneous 10 74 Total 374 1274 1
Workshifts '
Five Operating Shifts (including a training shift) are mant.eu.
During plant operations, two SR0s, two licensed R0s, two unlicensed operators, and one STA man each shift. The STAS work eight to twelve-hour shifts and are usually stationed adjacent to the control room.
5/14/87 L___ --- _ -- _ _
1
( .i -
Ngrim Nuclear- Power' ' Planti I, . Reactor Operators Tsial Licensed Operators: -33: . .
' Tota 1 ' number of SR0s: . 16 SR0s.in plant operations and l 08 staff SR0s-L ,
Total number of.R0s: 9 R0s in plant operations. 1 is on medical- ;'
restriction ~and-has-been temporarily' assigned to; training.
Reactor-Operator Exazns Administered by the Region . ,
i Exam Date. No. Applied Pass- Fail- 1 December 10, 1984 .7 SR0s 4 3*
3 ' R0s . 2 1*
May 5, 1986 '2'SR0s 2 0 s 5 R0s- 4 1 >
'l l.
1
-* Passed make up exam on May 14, 1985 Date of next' scheduled exam: May 25, 1987 Number of. Applicants: 8 R0s* (No SR0s are currently in !
training)- ]
- These-will be granted a limited license until the candidates meet the NRC .l time-on-shif t and reactivity manipulation requirements. !
Plant Simulator A plant-specific = simulator has been built by CAE: Electronics in Canada. Simu-lator installation in the licensee's training facility .is occurring 'and is r scheduled for completion by the end of 1987. .
The installation was delayed to allow operators to train on the Pilgrim: simulator (in Canada) prior to plant' startup. l
.I
, Systematic Assessment of Licensee Performance (SALP)
A SALP review was conducted for the period of November 1, 1985 through
- January 31, 1987 and a report issued on April 8, 1987. A copy of the report is l
. attached.
l 5/14/87
{
Pilgrim Nuclear Power Plant Escalated Enforcement Action _s No escalated enforcement actions are pending, proposed, or under consideration.
The licensee has agreed to seek the Region I Administrator's approval prior to startup from the current outage. (Confirmatory Action Letter 86-10). The confirmatory action letter addressed three hardware problems: (1) repeated.
inadvertent pressurization of the residual heat removal system, (2) spurious closures of the main steam line isolation valves, and (3) the inability to open the outboard main steam line isolation valves after the isolations. Two of the three issues have largely been resolved. The third issue will be resolved following startup testing from this outage. A copy of CAL 86-10 is attached.
The CAL 86-10 agreement was extended in August 1986 to address issues that involve both hardwa re and management concerns. The licensee will submit a detailed assessment of startup readiness to NRC Region I at least 45 days prior to startup. The Regional Administrator will review this assessment and perform a special readiness inspection prior to recommending approval for restart.
A petition to shut down Pilgrim under 10 CFR 2.205 was filed on July 15, 1986 by State Senator William Golden and others. This petition seeks a hearing to suspend the Pilgrim license until deficiencies in plant management, containment design and offsite emergency planning are resolved. The petition is being reviewed by the NRR staff.
A closeout inspection of a Radiation Improvement Program mandated upon BECo through an NRC Order is scheduled for June 22-26, 1987.
Emergency Preparedness Pilgrim was rated as SALP Category 3 in the area of Emergency Preparedness during the previous SALP period. Significant improvement has been noted during the SALP period just ended. Improvements have been evident by demonstrated high level management attention and support to the program. The EP corporate staff has been increased from 1 to 8, with 2 more positions approved but not yet filled.
NRC Region I played in the off year exe cise conducted on December 10, 1986.
This exercise utilized the new near-site EOF. The state and local governments declined to participate in this exercise; this has raised some concerns with certain state and local political figures. No significant deficiencies were identified during the exercise. Significant improvement over the previous exercise was noted.
5/14/87
Pilgrim Nuclear Power Plant-
=The state Radiological Emergency Response Plan (RERP) for Pilgrim has not received final FEMA approval under 44CFR350. The Commonwealth cf Massachusetts has not been responsive' to FEMA Region I requests for action to resolve iden-tified plan deficiencies. FEMA made an interim finding of reasonable assurance ),
based on its observations during exercises, i i
The Secretary of Public Safety for the Commonwealth of Massachusetts (Charles V. Barry) has submitted a report to the Governor assessing the status of emergency preparedness for the Pilgrim station. The report raises several ;
issues with regard to the RERP and recommends that the state create a Techno-logical Hazards Divisicn funded by the state's nuclear utilities and staffed by personnel capable of monitoring. plant operations. Also, the report recommends ]
extending the EPZ to 20 miles. NRC Region I is committed to review this report !
prior to restart and consider ~1ts findings in the restart decision. FEMA has {
committed to perform a self-initiated review of the Pilgrim RERP, however, the !
schedule for this review has not yet been developed.
The aspects of Senator Golden's 2.206 petition which involve emergency plan-ning are being reviewed by NRC and FEMA (Region and Headquarters).
i Emergency Response Facilities (ERF) i Emergency Operations Facility (E0F) - This facility was made operational in l June 1986 and is located within five miles of the site. It was used during the annual exercise in December 1986. It is designed to meet NUREG-0737 criteria.
Technical Support Center (TSC) - This facility is designed to meet NUREG-0737 criteria and was tested during the last annual emergency exercise. j l
Operational Support Center (OSC) - This facility is designed to meet NUREG-0737 criteria and was tested during the last emergency preparedness exercise.
Plant Status (Pilgrim - Unit 1)
Recent Outages - Refueling:
December, 1983 - Recirculation pipe replacement and refueling No. 6 outage -
(13 months)
July 1986 - Refueling no. 7 outage - engoing (estimated about fifteen months)
Recent Outages - Maintenance:
January 1986 -
Turbine generator and MSIV maintenance (3 days)
March 1986 -
Repaired water hammer damage to RHR head spray piping and MSIV maintenance (4 days) 5/14/87
o y
E,
- Pilgrim Nuclear / Power Plant
- l 1
o <
Recent Outages - Maintenance (Continued)
March 1986l -
Repaired cracked weld in reactor vessel instrument line (16: days)-
April 1986 -
Repaired leaking RHR. valve and MSIV maintenance (4 days)
April-1986 -
Investigated the cause of: (1). inadvertent pressurization:
of RHR piping, (2) spurious MSIV isolations, 'and' (3)-the'
' inability to open the outboard MSIV's following the isola-tions. . Subsequently, the licensee extended the outage' to implement management program improvements. .The outage was further extended to inspect RHR pumps for impeller wear ring damage and to conduct containment . leakage testing. On July 25, 1986, the licensee announced that the outage would-be extended until early - 1987 - for three major tasks: (1) completion, of fire protection modifications required by 10 CFR 50 Appendix R, (2) implementation of certain containment enhancements, and (3) plant refueling. Other. l planned outage modifications include - installation ef a !
feedwater hydrogen addition system, installation of new !
seconda v containment dampers, installation of a- new plant '
computes, replacement of reactor instrumentation with ana-log-trip instrumentation, and relocation of reactor vessel' water level instrumentation (reference legs) outside pri-mary containment. (10 months -
expected , duration from i April, 1986). l Plant Operations - pilgrim is currently shut down'for an extended-refueling and maintenance outage' l
The Commissioner should-be aware that: i A new Plant Manager -(K. Roberts) was appointed on February 4,1987 (Mr.
Roberts had formerly been Director of Outage Management). The previous i plant manager had only been in place for nine months.
A new Senior Vice President - Nuclear (Ralph G. Bird) was' appointed on January 7, 1987, to take effect February 20, 1987.
In contrast with 1986, 1985 was the best operating year in the history of the plant.
/
5/14/87
. Pilgrim Nuclear Power Plant PlantOperations(Continued]
Pilgrim historically has a high level of worker radiation exposures due to excessive plant contamination. High radiation plant areas are due to poor radiological practices and operating with defective fuel during a cycle in 1975. Some progress has been made in reducing plant contamination in recent years. The licensee intends to extensively decontaminate the plant during the current cutage.
Some of the current licensed operator (RO) candidates have expressed interest in transferring to other jobs. If these people do not sit for the license exam in May 1987, R0 shortage could extend until 1988. ,
The Vice President - Nuclear Operations (A. Lee Oxsen) has submitted his resignation, effective June 1, 1987.
l 1
5/14/87
+ Pilgrim Nuclear Power Plant AE0D Analysis of Operational Experience at Pilgrim I. Overview As of mid-May 1987, Pilgrim remains shut down since a scram occurred on April 12, 1986 due to various equipment problems. A number of concerns have been raised regarding the licensee's. operation of the plant. These l concerns, regarding management, emergency planning, equipment, and opera- l tional issues, must be resolved before the plant is allowed to restart.
It is not expected that tt},e plant will be restarted until the second half of 1987. Numerous equipment problems have been identified during the extended shutdown period, several of which were due to design deficiencies.
II. Significant Events / Abnormal Occurrences During this period, several events reported by the licensee, either under 10 CFR 50.73 or 10 CFR 21.21, were identified as significant by the AEOD 4
screening process. These are summarized below.
(1) During the period from November 19, 1986 through March 31, 1987, the plant has experienced three separate losses of preferred offsite power (LOP) events. On November 19, 1986, the plant experienced a ;
LOP due to a severe winter storm; both offsite 345 KV transmission lines tripped due to near simultaneous faults, and both the A and B emergency diesels started and supplied power to the A and B safety busses which had lost power. On December 23, 1986, with one 345 KV line open for maintenance, the remaining line tripped when a insula-tor in the onsite 345 KV switchyard flashed over as a nearby insula-tor was being washed. On March 31, 1987, with one 345 KV line open for maintenance, the remaining line tripped when a relay opened dur-ing a heavy rain storm. '
In addition to the preferred 345 KV offside power lines, Pilgrim has an alternate, lower voltage, offsite power source, as well as the diesel generator supplied emergency power system. During both the December 23, 1986 and March 31, 1987 events, the alternate offsite power source was used to reenergize the "B" emergency bus since the "B" diesel generator was out of service for maintenance.
(2) On January 12, 1987, the licensee determined that seven General Electric type HGA relays used in safety-related systems were not seismically qualified. Subsequently, eight more such relays were identified. The licensee plans to replace the relays' deenergized function with HFA relays prior to restart of the plant. The licensee I has made interim circuitry modifications on those safety-related systems required for refueling, which contained the suspect HGA relays.
5/14/87
'~
a
}
' Pilgrim Nuclear Power Plant ,
-l p
s ..
(3) Durihg August' 1986,. thelicehsee reported that ; the ' plant's Standby.
Gas Treatment. System (SGTS) was susceptible to single- failures that- j could result in exceeding the'10 CFR Part 100 ~ design basis ;offsite '
accident dose criteria. - This determination was made while the .
licensee was addressing.. resolution of. a 1983 event associated with a
water saturation of one bank of charcoal filters in the:SGTS due to !
actuation of the water delugeLsystem. The' licensee's analyses of the !
SGTS single failure modes identified those subsystems-associated with j the water deluge system's active components -that could lead to' fail- a ure to_the SGTS to perform its design function due to a' single active j failure. 'l The licensee is performing detailed, systematic analysis of. single failure vulnerabilities of-the SGTS.and will ensure that the system's i design . basis :will be met before, reactor- startup from the. present extended outage.
l -(4) During May 1986, the licensee notified the NRC under.the provisions.
of 10 CFR 21.21. that a significant ' design deficiency had been dis-covered in the' residual heat removal system minimum flow protection ;
logic at Pilgrim. A _ postulated single failure of a flow sensing ,
instrument 'could result in. all RHR pumps running without flow. If *
.not' detected in time, pump damage .could occur and systems designed to'
-remove decay heat under both normal and accident conditions could' be severely degraded.
The licensee is evaluating both short-term and long-term corrective q
, actions. The licensee committed to implementing short-term modifica- i tions prior to restart from the current extended' outage. )
This itim was reported as an abnormal' o currence (A0 86-9, " Boiling l Water Ri actor Emergency Core Cooling System Design Deficiency") in l
. NUREG 9C 10, Vol . 9, No. 2 referenced in Item-(5) below. As discussed l in the voort, it was found 'that the same design deficiency existed ;
-in Dresde 'Inits 2 and 3, and Quad Cities 1 and 2.
(5) On April 4 and 12,1986, the Pilgrim reactor scrammed from low power [
during rou;ine reactor shutdowns. Both scrams were caused - by unex- '
pected grc up I - primary containment isolations. In both cases, -the :
isolation iignal was promptly reset, but the four outboard main steam 1 line isoittion valves (MSIVs) could not be promptly reopened. As a result, tie main condenser was not available as a heat sink during a ,
portion of the reactor cooldown. The routine shutdown on April 11,
? which led to the scram on April 12, was initiated because the resi-dual heat removal (RHR) system had been pressurized by leakage of reactor coolant past a check valve and two closed injection valves in 3- the "B" RHR loop. An Unusual Event was declared because of the RHR >
valve leakage.
5/14/87 i
, Pilgrim Nuclear Power Plant Because of concerns about tt.e recurring isolation and RHR valve leak- l age problems, an NRC Augmented Inspection Team (AIT) was sent to '
inspect and evaluate the events. The AIT's report was issued on May 16, 1986 by Region I as Inspection Report No. 50-293/86-17. i Region I is following the licensee's corrective actions.
The above event was reported in Appendix C ("Other Events of Interest") in ,
NUREG-0090, Vol. 9, No. 2 (" Report to Congress on Abnormal Occurrences: l April-June 1986").
]
III. Operational Data (1) Reactor Trips - As discussed previously, the plant has been shutdown since April 12, 1986. From January 1,1986 through April 12, 1986, there were four reactor protection system actuations (RPSs) which involved control rod motion. These occurred on January 6 and 16, 1986 (both due to personnel error) and on April 4, and 12, 1986 (both due to equipment problems).
(2) ESF Actuations -
During 1986, Pilgrim experienced eight non-RPS ,
emergency safety feature (ESF) actuations. No direct comparison to ]
an industry average can be made since the plant was shut down most of 1 the year, even though some actuations can occur whether the plant is j shut down or not. Of the eight actuations, two resulted in actua- l tions of safety equipment, four resulted in an isolation of equipment / systems, and two resulted in both. Two of the equipment actuations involved the emergency diesel generators in response to loss of off site power, one involved a high pressure coolant injec-tion, and the fourth involved actuation of the SGTS. Systems in-volved in the isolations included- the containment system, main steam system, RHR/LPCI system, and RWCU system. Causes of the ESF actua-tions were due to various reasons including spurious actuations, weather related, equipment problems, and personnel errors.
During 1987 to date, there was one ESF actuation, i .e. , a diesel generator start due to a loss of preferred offsite power on March 31, 1987.
(3) NPRDS Data -
NPRDS component failure reports were made most fre-quently on components in three systems - Main Steam (MS), Reactor Protection System (RPS) and Residual Heat Removal (RHR). V Overall, main steam system MSIVs dominated as the primary component experiencing problems. RPS reports were primarily associated with calibration problems. RHR, plus feedwater and HPCI system, reports were primarily valve leakage and flow indication problems.
5/14/87
1 Pilgrim Nuclear Power Plant j l l PILGRIM - NRR PROJECT MANAGER ASSESSMENT BECo has had a good history of a technically capable and responsive licensing organization; however recently there have been instances of slow responses to requests for additional information, poor handling of known Technical Specifi-cation weaknesses, reluctance to provide information and cancelled meetings.
BECo's recent SALP evaluation in this area was "2", down from a "1" the pre- I vious period. The following summarize major licensing issues: I
- 1. The most significant licensing action in NRR affecting the Pilgrim facil-ity is response to the 10,CFR 2.206 Petition submitted July 15, 1986, by William B. Golden and others. Petitioners request that BECo show cause why Pilgrim should not remain shutdown until BECo demonstrates that cer-tain issues are resolved. Petitioners assert as grounds for their peti-tion (1) numerous deficiencies in licensee management, (2) inadequacy of the existing radiological emergency response plan and (3) inherent defic-1encies in the facility's containment structure. Staff is developing Director's response to management and containment issues. Response on emergency response plan issue is dependent on FEMA evaluations, currently in progress.
- 2. About 15 Technical Specification changes or licensing actions are expected to be necessary in the next few months. Many of these are dependent on submittals to be received from BECo in the next 30-60 days and result from plant modifications, refueling or technical specification deficiencies identified during the current outage. Completing these actions to support restart may require extra NRR resource commitments.
- 3. BECo is voluntarily planning several enhancements to its Mark I contain-ment including modifications that would permit direct venting from the torus to the main stack, a modification to the containment spray nozzles, installation of a fire-water intertie to RHR system, procedure changes, a modification to the nitrogen system, and the addition of a third diesel generator. These will be completed before restart from present refueling outage (R0 7).
- 4. Several deficiencies in the Fire Protection Program have been identified as a result of NRC's review of the program and on inspection results.
These are in the areas of maintenance, degraded fire barriers, excessive use of fire watches as compensatory measures and inadequate training.
Staff is also reviewing the requested exemptions from Appendix R. BECo has committed to resolve all open items prior to restart from RO 7. The NRC fire protection audit was conducted the week of May 11, 1987.
i 5/14/87 4
4
, Pilgrim Nuclear Power Plant G
- 5. BECo is one of the first facilities to install a permanent hydrogen water chemistry process. This will be completed prior to restart from RO 7.
The system will inject hydrogen into the reactor coolant via the feedwater '
system to reduce the dissolved oxygen concentration. Reducing the dis-solved oxygen concentration and maintaining high purity in the reactor coolant should reduce the susceptibility of reactor piping and materials to intergranular stress corrosion cracking. _
,l_
- 6. As a result of NRC's review of the Control Room Design Review report, BECo has informed the staff of its intention to re-screen the Human Engineering .
Discrepancies using a more detailed process than previously used. The schedule for the supplemen,tary summary report is 4 months following the end of RO 7.
- 7. On July 13, 1984, the NRC staff, by Amendment No. 75 to the license, approved BECo's Plan for an integrated program for scheduling safety IL modifications at the Pilgrim Station. The program integrates the engi-neering, procurement and installation of planned NRC-required modifica-tions with BECo's own requirements for plant modifications, maintenance, refueling, and operations. The semi-annual update to this plan, however, is overdue.
- 8. Over the last few years, the licensee has requested mg TS changes which should be either withdrawn or modified to reflect the current plant design. BECo was informed and is currently reviewing all the previous TS change requests.
1 1
l 5/14/87
l
. Pilgrim Nuclear Power Plant Public Issues Deficiencies in the Commonwealth of Massachusetts emergency plan have been alleged by various citizen groups, and in a report prepared for Governor Dukakis by the Massachusetts Secretary of Public Safety (Barry) . Area j
residents have criticized the offsite plan at public meetings and j expressed concern that FEMA has not fully approved it. j i
BECo management problems have been highlighted in the press. NRC state-ments that Pilgrim is one of the worst plants in the country caused sig-nificant public concern.
Region I management and the Senior Resident Inspector have participated in numerous public meetings and interacted with the state legislature at hearings.
Region I issues bi-weekly plant status reports for interested parties and the public. These have been well received.
A report of increased cancer rates around the plant by the Massachusetts Department of Public Health has raised local public interest regarding alleged unmonitored releases from the plant. The state has not ruled out Pilgrim releases as the cause of the increased cancer rate.
The Boston Globe (and other press) has indicated that Pilgrim's Mark I containment is similar to Chernobyl, and has a high probability of failure in the event of a serious accident.
A local public interest group is alleging that Pilgrim had a significant offsite release of radioactive materials in 1982. Although radioactive resin beads were inadvertently released from the reactor building stack at that time, an NRC inspection team found no evidence that the material went offsite.
The 2.206 petition has received press attention due to the involvement of state legislators. State hearings are being held on Pilgrim. 4 Attachments: {
- 1. BEco Organizational Chart
/
- 2. Confirmatory Action Letter 86-10, dated April 12, 1986, and the August 27, 1986 Followup Letter
- 3. SALP Report dated April 8, 1987
- 4. Site Location and Area Maps 5/14/87
4 ATTACHMENT 1 Ec o s t o m Edison Campany P i 2 ca r- i m Chairman, Board of Directors and Chief Executive Officer S. Sweeney
[ !
Senior V.P., Nuclear R. Bird Onsite Staff Asuistant----------l---------------Special Assistant l
R. Ledgett I A. Pedersen I
! I V.P. Nucl ear Engineering V.P. Nuclear and Dua) i_t y Ar,r:ur ance Operati one E. Hnwar d (vacant)
Notirar Duality Nuc l ear !
Manage.
Assurance Engin. !
D. Cronin H. Brannon D. Swanson !
I i
l I t ! I Training Fire Security Nuclear E.P.
j Protection Operations Coord.
E. Ziemianski G. Wo:niak C. Higgins K. Roberts R. Si l va l
i l ! I Technical Maintenance Operations Radi ol ogi cal Secti on Section Section Section J. Seery N. Brosee S. Hudson T. Sowdon
$*t - UNITED STATES g ,.'y g _ Attachment 2 NUCLEAR REGULATORY COMMISSION W
L q,
'!l g
' REGION I
$31 PARK AVENU&
,6- KING Or PRUS$1A, PENNSYLVANIA 19406
.....+
April 12, 1986 CAL No.: 86-10 l 1
Docket Number: 293 I M-Boston Edison Company M/C Nuclear ATTN: Mr. William D. Harrington Senior Vice President, Nuclear 1 800 Boylston Street ,
Boston,-Massachusetts 02199 Gentlemen:
Subject:
Confirmation of Actions to be Taken with Regard to the Pilgrim Plant. Events Which Occurred on April 11-12, 1986 Pursuant to our telephone conversation on April 12, 1986 with Mr. Oxsen it is our understanding that you have taken or will take the following actions:
- 1. Maintain all affected equipment related to the events which occurred on April 11-12, 1986 in its as-found condition (except as necessary to maintain the plant in a safe shutdown condition) in order to preserve any' evidence which would be needed to inspect or reconstruct the events. !
- 2. Develop troubleshooting plans and procedures and provide those to the NRC Augmented Inspection Team (AIT) for their review and comment prior to initiating any troubleshooting of the affected equipment.
- 3. N ise the AIT leader prior to the conduct of any troubleshooting activities.
- 4. Make available to the NRC AIT relevant written material related to previous problems with the affected equipment.
- 5. Provide a written report to the Regional Administrator prior to restart that contains your evaluation of the following:
- a. Intersystem leakage through the motor-operated injection valves (including the check valve) of the residual heat removal system;
- b. The primary containment isolation which occurred during shutdown after the reactor mode switch was repositioned !
from the run mode to the startup mode; f
I
I r 2
4
- c. The failure of the outboard main steam isolation valves to reopen after resetting the primary containment isolation signal.
This report should include the underlying causes for the above noted events, an assessment of their relationship to previous events including the events of April 4, 1986, corrective actions taken and your basis for restart, including the criteria used and your analyses associated with these criteria.
Further we understand that restart will not occur until you receive authoriza-tion from the Regional Administrator.
If your understanding of the actions to be taken are different than those described above, please contact this office within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the receipt of this letter.
Thank you for your cooperation.
Sincerely, W 0 Thomas E. Murley Regional Administrator cc: L. Oxsen, Vice President, Nuclear Operations C. J. Mathis, Station Manager Joanne Shotwell, Assistant Attorney General Paul levy, Chairman, Department of Public Utilities Plymouth Board of Selectmen Plymouth Civil Defense Director Senator Edward P. Kirby Public Document Room (PDR)
Local Public Document Room (LPOR)
Nuclear Safety Information Center (MSIC)
NRC Resident inspector Commonwealth of Massachusetts (2)
V. Stello, EDO J. Taylor, IE J. Sniezek, EDO J. Zwolinski, NRR P. Leech, NRR
,.***g usesTED CTArts /
-( .. / k, seUCLEAR C.EGULATORY CQAAMIS3008d 1 / n an.o .
. -, ; o ,. = .v o o.
s 4- . <. e. un. = .. . v .a. . ;
%, * * * * * / -
AUG 2 7 EM6
< Docket No. 50-293 I;
Boston Edison Company M/C Nuclear ATIN: Mr. James M. Lydon Chief Operating Of ficer 800 Boylston Street Boston, Massachusetts 02199 Gentlemen:
4 *-se6 Ject: Confirmatory Action Letter 86-10 -
This letter is to provide further guidance on the requimments we espect to be met prior to the restart of the 'P11 grins plant. We acknowledge' receipt of Boston Edison Company's (BECO) letter of June 16, 1986, in response to Confirmatory Action Letter (CAL) 86-10. _ Your actions with regard to the issues in CAL 86-10 appear to .
be thorough and technically sound. My staf f .has a few remaining questions, which have been discussed with your staf f and which will be documented in Inspection Report 50-293/86-25.
In addition to the specific ' plant hardware issues involved with CAL 86-10, several other issues have been identified that require resolution prior to restart of the
. Pligrim plant. Specific technical issues of concern include: overdue serveil--
l lances, malfunction of recirculation' motor generator set field breakers, seismic qualification of emergency diesel generator differential ' relays, and completion of '
Appendix R modifications. Please be prepared to discuss these issues at our next management meeting at the plant on September 9,. 1986. We would also like to hear l at this meeting the scope and status of all your programs related to restart of l Pilgrim. These include (a) the results of your six week action plan for improve-men:s, (b) the role of BECO safety review committees, including the Program For Excellence Task Force, in assessing readiness for restart, and (c) the readiness of the plant and corporate staff to support plant startup, testing, and operations.
In 11ght of the number and scope of the outstanding issues, I am not prepared to approve restart of the Pilgrim facility until you provide a written' report that documents BECO's formal assessment of the readiness for restart operation. This assessment should include your deta'iled check list for assuring that all out-standing items have been satisfactorily resolved and that plant systems have been restored and prepared for ope-ation. A formal restart program and schedule should l also be submitted for NRC review and approval. This program should include hold points at appropriate stages such as criticality, completion of mode switch test-ing, and at specific milestones during ascension to full power. Authorization to proceed beyond each hold point will be contingent upon my approval and will be based on my staf f's evaluation of the operational performance of the plant. We will have substantially augmented NRC inspection coverage during this restart period.
Please plan to submit your readiness assessment and restart program and schedule at least forty-five days before your planned startup from the current outage. My decision on restart will be based in part on our review of these documents.
l
. , ',/ ..
2
/ Your Cooperation is appreciated.
Sincerely, Thomas E. Murley Regional AdmTaistrator -
-< C : '.M;.
L. Ogsen, Vice President, Nuclear Operations .*
K. E. Pedersen, Station m nager - -
Aul Levy, Chairman, Department qf Public Utilities ,
Edward R. mcCormack, senior Regulatory Affais's and, Program Engin'eer ,
Chairman, Board of Selectmen , .
Plymouth' Civil Def.ense Director ,,
The Honorable E. J. Markey '
J. D. Keyes ,
~
Senator Edward P. Kirby '
~
The Menorable Peter V.-Forman .
Sharon Pollard Pub 11c Document Room (POR) ,
3 Local Public Document R.oom (LPOR) .
Iluclear Safety Informatten Center (NSIC)
NRC Resident inspector .
Commonwealth of Massachusetts (2) bcc:
Region 1 Docket Room (with concurrences)
Wr.agement Assistant, DRMA (w/o enc 1)
Section Chief, D9P
'W. Raymond, SRI, Vermont Yankee T. Shediosky, SRI, Millstone 1&2 H. Eichenholz, SRI, Yankee P. Leech, LPH, NRR PA0 (2) SALP Reports Only Robert J. Bores, DRSS V. 5'ello H. Denton J. Yaylor T. Murley 1
.v .
o =cg _ . ATTACHMENT 3
- - 4 UNITED STATES -
I
[ k. NUCLEAR REGULATORY COMMISSION l a
8, 4
- f. REGION 1 431 PARK AVENUE KING oF PRUSSIA, PENNSYLVANIA 19406
' %, . . . s ,8 APR 0 8'1987 Docket Nb. 50-293 Boston Edison Company M/C Nuclear ATTN: Mr. Ralph Bird Senior Vice President - Nuclear 800 Boylston Street ,
Boston, Massachusetts 02199 Gentlemen:
Subject:
-Systematic Assessment of Licensee Performance (SALP) Report No. 50-293/86-99 The Region I SALP Board has reviewed and evaluated the performance of activ-ities at the Pilgrim Nuclear Power Station for the period November.1,1985 through January 31,.1987.
~
The results are ' presented in the enclosed report.
A meeting to discuss this assessment. will be, scheduled for a mutually accept-- )
able date. The meeting will be held. on or near the site so that appropriate-senior corporate management and plant officials can discuss 'with us . the strengths and weaknesses noted. It is our intent.that this meeting be combined with the periodic management meeting to review ~ improvement program status.
The SALP Board identified significant recurring program weaknesses in- some functional areas. Improvements, such as in the area of emergency preparedness, were also noted. However, the SALP Board found the rate of such change was slow during most of the assessment period.
We recognize that the Boston Edison Company (BECo) has made significant staff-ing and hardware commitments to improve performance.at the Pilgrim Station and we believe they are beginning to have a positive impact. As you are aware, the.
NRC is looking for progress in correcting the previously identified long term problems at the Pilgrim Station prior to plant restart, particularly in those functional areas with a Category 3 rating.
In preparation for the SALP meeting, please be prepared to_ discuss.your evalua-tion of our assessment and the status of your performance improvement programs.
Any comments you may have regarding our report may be discussed at the meeting.
Additionally, you may provide written comments within 30 days after the meet-ing. Following our meeting and receipt of your written response, -the enclosed '
report, your response, and a summary of our findings and planned actions will be placed in the NRC Public Document Room.
1 Boston Edison Company M/C Nuclear 2~ APR 0 81987
.\
Your cooperation with us is appreciated.
J Sincerely, !
l 4;^:= V Thomas E. Murley i i
Regional Administrator I i
Enclosure:
As stated j cc w/ enc 1:
L. Oxsen, Vice President, Nuclear Operations ,
K. Roberts, Station Manager Paul Levy, Chairman, Department of Public Utilities !
j Edward R. MacCormack, Senior Regulatory Affairs and Program Engineer Chairman, Board of Selectmen Plymouth Civil Defense Director J. D. Keyes 4 The Honorable E. J. Markey Senator Edward P. Kirby The Honorable Peter V. Forman Sharon Pollard Public Document Room (PDR)
Local Public Document Room (LPDR)
Nuclear Safety Information Center (NSIC)
NRC Resident Inspector Commonwealth of Massachusetts (2)
Chairman Zech Commissioner Roberts Commissioner Asselstine Commissioner Bernthal 1 Commissioner Carr I t
i l
l 4
i j
l
i 1
i i
,1 '1 U. S. NUCLEAR REGULATORY' COMMISSION REGION I 1
SYSTEMATIC AS'SESSMENT OF LICENSEE PERFORMANCE-INSPECTION REPORT 50-293/86-99 BOSTON EDISON COMPANY- .
PILGRIM NUCLEAR' POWER STATION ASSESSMENT ~ PERIOD: NOVEMBER 1, 1985 -' JANUARY 31, 1987
' BOARD MEETING DATE: MARCH 2, 1987.
'I l
L
. TABLE OF CONTENTS Page
1.0 INTRODUCTION
.................................................... I 1.1 Purpose and Overview ....................................... 1 1.2 SALP Board Members ......................................... I 1.3 Background ................................................. 2 2.0 CRITERIA ........................................................ 5 3.0
SUMMARY
OF RESULTS .............................................. 7 3.1 Facility Performance ....................................... 7 J 3.2 Overall Facility Evaluation -
................................ 8 ,
4.0 PERFORMANCE ANALYSIS ........................................... 10 i
4.1 Plant Operations .......................................... 10 l 4.2 Radiological Controls ..................................... 14 4.3 Maintenance ............................................... 19 4.4 Surveillance .............................................. 24 l 4.5 Fire Protection ........................................... 27 4.6 Emergency Preparedness .................................... 29 4.7 Security and Safeguards ..................... ............. 31 4.8 Outage Management and Modification Activities ............. 35 4.9 Licensing Activities ...................................... 38 4.10 Engineering and Corporate Technical Support ............... 40 4.11 Training and Qualification Effectiveness .................. 43 I 4.12 A s s u ra n c e o f Q ua l i ty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7 l 5.0 SUPPORTING DATA AND SUMMARIES .................................. 52 i 5.1 Investigations and Allegations Review ..................... 52 5.2 Escalated Enforcement Actions ............................. 52 5.3 Management Conferences .................................... 52 5.4 Licensing Actions ......................................... 53 5.5 Licensee Event and Part 21 Reports ........................ 55 5.6 Automatic Scrams and Forced Outages ....................... 57 TABLES Table 1 - Tabular Li sting of LERs by Functional Area . . . . . . . . . . . . . . . . 58 T a bl e 2 - LER Syn o p s i s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 9 Tabl e 3 - Inspection Hours Summa ry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 T abl e 4 - En f o rceme n t S umma ry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3 Table 5 - Inspection Report Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Table 6 - Unplanned Automatic Scrams and Shutdowns .................. 73 Tabt e 7 - Pilgrim SALP History Tabulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 FIGURES Figure 1 - Unit 1 Plant Operation Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 e
10 INTRODUCTION 1.1 -Purpose and Overview The Systematic Assessment of Licensee Performance (SALP) is an inte-grated NRC staff effort to collect observations and data on a per-iodic basis and to evaluate licensee performance. The SALP process is supplemental to the . normal regulatory processes used to ensure-compliance to NRC rules and regulations'. It is intended to be suf-ficiently diagnostic to provide a rational basis for allocating NRC resources and to provide meaningful guidance to -licensee management in order to improve, the quality and safety of plant operations.
An NRC SALP Board, composed of the staff members listed in Section 1.2 below, met on March 2,1987 to review the collection of perform-ance observations and data in order to assess the licensee's perform -
ance at the Pilgrim Nuclear Power Station. This assessment was con-ducted in accordance with the guidance in NRC. Manual Chapter 0516,
" Systematic Asses: ment. of. Licensee Performance". A summary of the guidance and evaluation criteria is provided in Section 2.0 of this report.
This report is the SALP Board's assessment'of the licensee's safetyz performance at the Pilgrim Nuclear Power Station for the ' period November 1, 1985 - January 31, 1987. The summary findings and totals reflect a fourteen month assessment period.
1.2 SALP Board Members Chairman l W. Kane, Director, Division of Reactor Projects (DRP) .
Members T. Martin, Director, Division of Radiation Safety and Safeguards W. Johnston, Deputy Director, Division of Reactor Safety W. Houston, Deputy Director, Division of BWR Licensing, NRR R. Capra, Acting Chief, Projects Branch 1, DRP J. Durr, Chief, Engineering Branch, DRS L. Bettenhausen, Chief, Operations Branch, DRS J. Wiggins, Chief, Reactor Projects Section 18, DRP M. McBride, Senior Resident Inspector R. Auluck, Project Manager, NRR
- ___A
.. 2 i
Other Attendees 1 4
J. Strosnider, Chief, Materials and Process Section, DRS J. Lyash, Resident Inspector,. Pilgrim 1 J. Schumacher, Senior Emergency Preparedness Specialist, DRSS N. Blumberg, Lead Reactor Engineer, DRS R. Nimitz, Senior Radiation Specialist, DRSS G. Smith, Safeguards Specialist, DRSS l
1.3 Background
A. Licensee Activities The unit began the evaluation period operating at 100 percent power. On January 3,1986, a reactor shutdown was initiaterf to investigate increasing main turbine generator bearing vibrat'on.
Three days later on January 6, the reactor was restarted after completion of main steam isolation valve (MSIV) adjustments and bearing maintenance. During the startup the reactor scrammed from ten percent power on low vessel water level due to feed- j water control valve leakage and operator error. Startup recom-menced on January 7 and full power was reached on January 10.
Leaking hydrogen ignited during the replacement of a regulator in the main turbine generator hydrogen supply system on January
- 9. On January 16 an automatic scram occurred due to a spurious reactor high pressure signal when a technician inadvertently bumped an instrument. The restart began two days later on !
January 18 and the unit was operating at full power by January
- 20. A severe vibration transient in a main turbine generator bearing forced reduction to ten percent power on January 29.
The unit was returned to full power following turbine generator adjustments. On February 13, in response to recurring residual heat removal (RHR) discharge piping high pressure alarms, the licensee temporarily removed the B RHR system loop from service. ;
Severe water hammer damage was identified in the head spray por- !
tion of RHR piping on March 7. The affected piping had not been used for several years and was subsequently removed and capped.
On March 15, the reactor was shut down due to a leaking reactor vessel instrument line weld. The weld crack was ' located and repaired. While shut down, a spurious primary containment group 1 isolation occurred. No cause for this isolation was identi-fied. The reactor was restarted sixteen days later on March 31.
A main turbine hydraulic system oil leak resulted in a unit shutdown on April 4. During the shutdown, a spurious primary containment group 1 isolation occurred again. This isolation caused an' automatic reactor scram. . Initial attempts to oper, the outboard MSIVs were unsuccessful.
.~ ,
. :3 The reactor was taken' critical .on April 10. Recurring RHR sys-tem discharge piping high pressure alarms prompted a plant shut-down on April 11. _ A third spurious primary containment group 1-isolation occurred during' the shutdown and' the outboard MSIVs !
could not be reopened. This isolation also caused an automatic reactor scram. NRC issued Confirmatory Action Letter 86-10 as
.a result of_ these recurring events to maintain the plant in a.
shutdown condition until the NRC could review in detail, and understand, the causes of these events and the licensee's cor-rective actions. An NRC Augmented Inspection. Team, ? consisting. J of headquarters and region-based personnel, was . dispatched ' to l the site on April 12 and reviewed the licensee follow-up to. the .
two isolations and scrams.
1 Operator licensing examinations were conducted during the week of May 5, Two senior reactor operator (SRO) and five; reactor operator (RO) candidates were examined with only one R0' failure during the period. On May 15 three Boston Edison labor unions, including operations 'and maintenance ' personnel, began a four >
week strike. On June 30 the contractor security force 'went on strike, returning on - July 1. On July 25, Boston Edison announced extension of the outage into 1987. Outage' activities were expanded to-include refueling, installation of a new pro-cess computer, installation of an analog' trip' system, completion of Appendix R modifications, and the implementation of signifi-cant primary containment enhar. cements.
Several key licensee organizational changes ' occurred during the period. The Senior Vice president - Nuclear -(VPN) 'was reas-signed and his resperisibilities were assumed - by the Chief Operating Officer (C00). A new Senior Vice President-Nuclea r was hired late in the period and assumed responsibility for the nuclear organization ' in February 1987. The ' Plant Manager who was in place at the ' beginning of the assessment period was replaced midway through the period. This new Plant Manager was replaced in turn, following the end of the period.
B. Inspection Activities A senior resident inspector was assigned to the site throughout i the assessment period. A second resident inspector was assigned in April, 1986. During the fifteen month ' assessment period, 6762 hours0.0783 days <br />1.878 hours <br />0.0112 weeks <br />0.00257 months <br /> of direct NRC inspection were performed at Pilgrim.
This was equivalent to '5475 inspection hours per twelve-month period. A detailed breakdown of the total inspection hours into SALP. functional areas is included in Table 3. A third resident ,
inspector was assigned to the site at the end of the period.
. 4 During the assessment period eight NRC team inspections were conducted:
- 1. Safety system functional readiness review
- 2. Environmental qualification program review
- 3. Special Region I diagnostic team inspection
- 4. Emergency planning remedial drill observation
- 5. Augmented Inspection Team (AIT) review of two scrams from low power in April 1986 and recurring pressurization of the residual heat removal system-
- 6. Radiological Improvement Program (RIP) appraisal
- 7. Anticipated Transient Without Scram Generic Letter 83-28 review *
- 8. Annual emergency plan exercise observation ;
The special Region I diagnostic inspection reviewed plant activ- )
ities on a twenty-four hour basis for several weeks to determine.
root causes for previous poor performance. Operator licensing examinations and an inspection of the licensed operator requali-fication training program were also conducted.
Confirmatory Action Letter (CAL) 86-10 was issued at the time of the AIT in April, 1986. CAL 86-10: (1) confirmed guidelines for the AIT, (2) confirmed that the licensee submit technical evaluations of the scrams and RHR pressurization events to the NRC, and (3) stated that NRC Regional Administrator approval ,!
would be required prior to restart. Subsequently a series of-six meetings between NRC: Region I and licensee senior management were held to discuss licensee progress on the AIT technical issues as well as other areas of concern. These meetings con-tinued through the end of the assessment period. The Confirma- '
tory Action Letter was subsequently extended to cover licensee actions to correct significant programmatic deficiencies.
Tabulations of inspection activities and associated enforcement {
actions are contained in Tables 3, 4 and 5.
i I
1 f
I
c 5 ,
2.0 CRITERIA Licensee performance is assessed;in selected functional areas, depending upon whether the facility is .in a construction, preoperational, or oper-ating phase. Functional areas normally represent areas significant to -
nuclear safety and the environment. Some functional areas may. not be assessed because of little'or 'no licensee activities, or lack of meaning-ful observations. Special areas ' may be ~ added. to highlight significant-observations.
This report also discusses " Training and . Qualification Effectiveness",
" Assurance of Quality" and " Engineering and Corporate Technical Support" as separate functionL areas. Although' these topics, in themselves, 'are assessed in the other functional- areas-.through their use as criteria, the three areas provide a: synopsis. For example, quality assurance effective-ness has been assessed on.a' day-to-day basis by-resident inspectors and as an integral aspect of specialist inspections. . Although' quality work' is the responsibility of every ~ employee, one' of the manager.ent tools : to.
measure this effectiveness is ' reliance on quality assurance inspections. H and audits. Other major factors that influence' quality, such as involve ' .)
ment of first line supervision,. safety committees, and ~ worker attitudes, are discussed in each area. .] l One or more of the following evaluation. criteria were used to assess each functional area. I
- 1. Management involvement and control in assuring' quality j
- 2. Approach to the resolution of technical issues from a safety stand-point
- 3. Responsiveness to NRC initiatives i
- 4. Enforcement history
- 5. Operational and Construction events (including response to, analyses-of, and corrective actions for)
- 6. Staffing (including management) t
- 7. Training and Qualification Effectiveness Based upon the SALP Board assessment, each functional area evaluated is classified into one of three performance categories. The definitions of these performance categories are:
1 6
l Category 1. Reduced NRC attention may be appropriate. Licensee manage-ment attention and involvement are aggressive and ~ oriented toward nuclear safety; licensee resources are ample and effectively used so that.a high '
level of performance with respect to operational safety is being achieved.
Category 2. NRC attention should be maintained- at normal levels.' -Licen--
see management attention and involvement are evident and are - concerned '
with nuclear safety; Nicensee resources are adequate and reasonably effec-tive so that satisfactory performance with respect to operational
- safety is being achieved.
Category 3. Both NRC and licensee attention should be increased. Licen- J see management attention or involvement is acceptable. and considers- j nuclear safety, but weaknesses are, evident; licensee resources appear to.
be strained or not effectively- used so that ' minimally satisfactory per-formance with respectLto operational safety is being achieved.
The SALP Board also ' assesses a functional area to compare:the licensee's performance during the last quarter of the assessment period. to that dur-ing the entire period (normally one year) in order to determine the recent trend for each functional- area. The SALP trend categories are as follows:
Improving: Licensee performance has generally improved over the last part of the SALP assessment period.
Declining: Licensee performance has generally declined over the last, part of the SALP assessment. period.
A trend is assigned only when, in the opinion of the SALP board, the trend is significant enough to be considered indicative of a likely change in the performance ' category in the near future. For example, a .classifica-tion of " Category 2, Improving" indicates the clear potential for
" Category 1" performance in the next SALP period.
~
7 i
3.0
SUMMARY
OF RESULTS 3.1 Facility Performance Functional Category Category Recent Area Last Period
- This Period ** Treno'
- 1. Plant Operations 3 2. --
- 2. Radiological 3 3 --
Controls
- 3. Maintenance
- 2- 2 --
- 4. Surveillance 2 3 --
l 5. Fire Protection ***
3 --
- 6. Emergency 3 2 ~-- !
Preparedness j
- 7. Security and 2 3 Improving Safeguards l-
- 8. Outage Management, 1 1 -- 1 Modifications and i Technical Support I Activities j l
- 9. Licensing 1 2 --
l Activities i
l
- 10. Training and ***
2 Improving Qualification Ef fectiver ess
- 11. Engineering and ***
1 --
(
Corporate Technical-Support
- 12. Assurance of ***
3 --
l i
Quality October 1,1984 to October 31, 1985
- November 1, 1985 to January 31, 1987
- Not evaluated as a separate functional area 3
~
t 8
3.2 Overall Facility Evaluation u The 1985. SALP Board found that programmatic weaknesses - existed in several functional areas. A special. Region I diagnostic team subse-quently monitored plant operations on a 24-hour basis .and confirmed the 1985. SALP conclusions. Poor management control and incomplete staffing contributed to the poor performance. Improvements. were.
noted ' during the current period, 'although the . rate ;of - change was slow. Seve~ral factors inhibited progress:during the current period, 1 including the lack of a clear sense of "who's in charge" onsite,,
continuing management changes, and prolonged st.tffing vacancies.
During the last month of the period, the pace..of change accelerated.
The onsite organization had a dual reporting chain during'much of the period,.with site disciplines reporting to both the Plant-Manager.and' the Director of Outage Management. This obscured the chain. of. com-mand and weakened accountability. The dual reporting chain was elim-inated during a site reorganization following the assessment period.
Other concurrent organizational changes were also made that ' removed several functional areas from the Plant Manager's span of . control .
The effectiveness of these.. changes in developing al ccherent site mar.agement' team.has yet to be demonstrated.
The Plant Manager.was replaced midway'through the period and the new Plant- Manager was replaced in turn following the period. Similar changes occurred in senior corporate management. Responsibility for the licensee's nuclear program was transferred from a Senior. Vice President to an Executive Vice President midway through the period '
and transferred again to a new Senior Vice President following the '
end of the period. These changes reflect BECo senior management's commitment to provide effective leadership for ~t he nuclear organization.
Significant recurring program weaknesses were identified in some functional areas, showing the effect of previously identified long-term problems. Licensee management did not correct ; many of these problems until further prompted by the NRC, reflecting weak corporate and site management control and an overburdened staff. Significant staffing vacancies in the areas of radiological controls, maintenance and operations were evident through much of the assessment period, reflecting slow corporate and site management action. Many.of the vacancies were filled by the end of the period, however.
Good performance was noted in four areas: emergency planning, outage management, corporate engineering . support and licensed operator training. The success in these areas reflects a high level of. cor-porate management. attention and substantial resource commitments' .
Plant hardware changes were also impressive, particularly the planned Mark I containment enhancements. The modifications go considerably beyond NRC recommendations and show a concern for nuclear 'stfety.
+
-__-__---__ - - - - - - - - _ - - - - - - _ _ _ _ _--_-_--__a_ _ - - - - -
--v J .l
- 9 I
l l
In summary, performance improvements are needed in various functional I areas to correct long standing problems. The lack of a clear organ- '
izational structure, recurring management changes, and chronic . staff-ing vacancies delayed the establishment of a stable licensee manage-ment team at the plant and inhibited progress during the assessment period. However, performance appeared to improve at 'the end of the period, reflecting staffing improvements and resource commitments.
The NRC SALP Board recommends that followup team inspections be con-ducted during the next assessment period to review plant operations with particular emphasis on those functional areas with Category 3 performance ratings, i.e., radiological controls, surveillance, fire protection, and sedurity and safeguards. The results of these l inspections will be a significant factor in the NRC decision as to '
readiness of the plant for restart.
i
10 4.0 ' PERFORMANCE ANALYSIS' 4.1 Plant Operations (24%, 1603 hours0.0186 days <br />0.445 hours <br />0.00265 weeks <br />6.099415e-4 months <br />) ,
)
(1) Analysis Plant operations was assessed as a . Category 3 during 'the previous SALP period. Problems included a chronic shortage of licensed re-actor operators (R0s), lack of operator overtime control, and lack.of professional -support for the Operations Department. The administra-tive control of operator overtime has significantly improved, reflec-ting licensee management attention. The RO shortage and professional.
str.f f support prob 1dms were addressed by management, but were not resolved at the end of the period.
1 Five months of power operation occurred during the initial phase of 1 the SALP period. A maintenance and refueling outage started in April 'l 1986 and extended to the end of the period.
l During this period, the operators conducted routine power operations a effectively and responded .to operational events 'in a professional ,
manner. Performance 'during two instances of closure of the main '
steam isolation valves (MSIVs) at . power and during a severe storm with loss of offsite power, demonstrated the ability of.the. opera-tions staff to handle significant plant transients. Shift turnovers were generally thorough. Operators took a conservative safety con-scious approach to technical specification limiting. conditions for operations (LCO). Strong control over plant activities during a major union labor action was evident. Two scrams were ' linked to operator error, one of which - also involved equipment failure. The second scram occurred while the plant was shut down. A third scram l
was caused by personnel error (a maintenance technician) 'and was linked to an equipment design deficiency. 5 Plant management, the Nuclear Safety Review and Audit Committee ,
(NSRAC), and the Operations Review Committee (ORC) generally exhib- '
ited a conservative, safety conscious approach to events and issues.
Reviews were thorough and deliberate. Licensee evaluation of the RHR j pressurization events and the MSIV isolations during the AIT in April {
1986 were well structured and effective. An exception to this was the ORC review of debris found -in primary containment isolation valves, i.e. the MSIVs. In this incident the licensee decided to restart the plant after a limited MSIV inspection. A thorough MSIV l
evaluation was conducted only after NRC prompting. In addition,'the ORC review of squib valve testing was initially limited. Following NRC involvement, the ORC review . was conducted carefully and-deliberately. ,
l;
.- 11 Some weakness was _ noted in attention to detail. Failure of the licensee's technical group to complete an adequate; post trip review and ' poor. control room log L keeping practices were examples. The status of inoperable, nonsafety related equipment in~ the control room! .
was not always recognized and addressed by the control: room staff.
ThisLlatter problem may be the result of a weak working relationship: i between operations and maintenance- personnel,;which fostered the view 'g' that inoperable equipment of secondary importance = would not be re--
paired. Relations between Operations- and' Radiological Controis- -1 Department personnel were also sometimes strained, reflecting'a lack j of site management attention. ' Operations management -control of high 4
radiation area keys and attention to the implications. of major system 1 isolations' were aise ' examples of sporadic problems. The isolation difficulties reflected a lack of preplanning by the operations. and outage support staff.
The' low number of licensed reactor operators .(R0s) continued. The number of R0s standing watch decreased during the period, despite.the addition of four new licensed - R0s to the Operations -Department, The dilution n of operating expertise combined with the : low ' number of operators, heightens concern .in thisl area. The' licenses has . signi-ficantly1 increased the size of the operations staff and established an aggressive recruiting and training program in response ;to the R0 shortage. Although this demonstrated strong management. action, the long lead time required to train and license operators and a recent increase in R0 attrition will result in an R0 ' shortage until at'least 1988. The specific' cause of the R0 attrition is unclear, but'its resolution is important. The licensee has experienced' senior reactor I operators who may be 'used to supplement the RO function.- However, !
the impact of the R0 ' shortage on' plant operations is not. desirable .)
because of the routine operator overtime it causes and the.. disruption i caused by placing staff personnel with licenses on -shift to operate i the plant.
The shortage of professional support for the Operations Department -
continued to strain department resources. The Operations Section Head position was filled during the period. He.has assumed some of the administrative work load from the Chief Operating Engineer (COE) allowing the COE added opportunity to directly oversee : operator per-formance. The licensee _ ass'igned two senior engineers to .the Opera-tions Department and reassigned'(at the end of the period)'the shift technical advisors (STAS) to the COE. The effect of: these actions.
was not clear, due to continuing collateral . responsibilities outside the department for most of the newly assigned individuals. Several:
examples of incomplete or ' inaccurate system operating, alarm re- <
sponse, and emergency operating procedures indicated 'the' need for additional staff attention.
I
- 4
.. . v 12 The operator training program- improved during the assessment period.
Experienced licensed operators. and .a new' licensee training coordi-nator have been. assigned to : the . training 'section showing strong management action. .The licensee received Institute of Nuclear Power Operations (INPO) accreditation for all areas: of;. licensed and non-licensed operator training with' the ' exception :of : the ? STA program.
- NRC ' license examinations' ~-in May, 1986 had .a-'high percentage of t successful candidates. .The operator requalificationi program . was .
found acceptable. A plant specific simulator was close to completion at.the end of the period.
Licensee Quality Assurance . findings associated ~with' operations were.
technically sound. Site management response to these findings how-ever, was .sometimes slow and cursory in : nature. . Senior corporate' management ; action _ was taken only after significant NRC ' prompting on this problem. The-onsite QA audit staff was significantly; increased '
near the end of~the period.
' Reportable events were acceptably handled by the control room staff Licensee. event reports were generally ' clear.. However, several ifRs did no.t. contain complete information. indicating the need for addi-tional attention to this area by the technical support staff.
~
In summary, the lack of licensed operators and the lack of an effec-tive operations support st'aff strained the Operations' Department dur-ing the period. The- licensee has taken strong action to recruit-and train new operators, during the period, however,i the high! R0 attri-tion rate remained a' significant problem. The' effectiveness of' increases in professional staff support for the Operations Department' was also not demonstrated due to delays in transferring personnel into the department and their continuing collateral . duties outside the department. Lack of prompt senicr corporate' management action '
limited the effectiveness of QA audit findings. The'. licensed opera-tor training program significantly improved during the period.
NRC observations of plant operations were -limited.'to the first five months of the assessment period due to a plant shutdown which started in April 1986 and extended throughout the period. However, these observations, including the 24-hour operations 1 shift coverage pro-vided by the Region I diagnostic team inspection, indicated that the plant was operated in a safe manner. The effectiveness of- the train-ing of upcoming RO candidate classes (as measured by the pass rate in the next several NRC license exams), the retention of'11 censed . staff, and the ef festiveness =of the Operations Department support staff will significantly affect future performance..
9
\
13-(2) Conclusion Rating: Category 2 Trend: None (3) Recommendations Licensee: --
Continue efforts to recruit, train- and retain licensed personnel. ,l NRC: --
Closely' monitor Operations Department staffing 1evels.
See Section 3.2 !
l I
l k l
-)
l I
'Il 0
l i
l l
l
. t i 14 1
.4.2 Radiological Controls (11%, 746' hours)
-This assessment covers _ radiation protection, ' effluent monitoring and
- controls, radwaste1 shipping and environmental- monitoring. . The - area -
of' radiological controls was evaluated as Category 3 last period.
Weaknesses . identified last period are discussed ; in . each T seb-area.-
Inspections this period ~ focused on f licensee, corrective action for ,
' previous problems,- planning and preparation for the outage and ade- i quacy and implementation of the current program. . Health ' physics 1 activities were: reviewed early in ' the period during a special diag-nostic team inspection to- determine the cause'of the licensee's SALP rating last period. .A'special team inspection;in. the latter part of the period' reviewed licensee - progress towards" closing out an Order Modifying License issued'la'st period.
' Radiation Protection Due to recurring p_roblems resulting in unplanned personnel.~ exposures,_
an Order? modifying license - was issued last assessment period. -The Order required that a. comprehensive review of:the radiological'_ con-x trols program be_ performed and that problems identified be corrected -
through a radiological improvement program,(RIP)'.
NRC review this period found thatsthe . licensee took action to resolve the previously identified ' problems, _ and to complete- the Order re- 1 quired upgrade through implementationof the RIP program. !
However, review this period. found that.the. implementation _ and effec-tiveness of- the program improvements' were; not closely monitored by site management. Problems indicating this were: ' generation of weak-or inadequate procedures to' satisfy RIP commitments; lack of prompt, comprehensive corrective actions to' resolve identified problems; key i
vacancies in the organization' were left open :for an extended time period; poor and sometimes hostile communications; between the radia .
tion protection group and other . station' groups, particularly the operations group, was evident; accountability of ' group or ' individuals for deficient conditions or actions was not vigorous; and an_ aggress-ive goals program was not in place. As a result of these problems, the Order was not closed out.
1
[,
~O.-
15 1
Although the licensee had ' reorganized: its Radiation ' protectior, l
~ Organization clast. assessment period to provide for .better oversight
of. in-field radiation. protection. activities, the failure to fill the vacant Chief Radiological Engineer position:in a timely _ manner was considered a significant detriment to' establishing effective over-sight of these activities. : The position ,was open ; for about. a' year..
-and reflects limited action by both. site _ and senior corporate manage-me n.t . The individual filling = the position is re'sponsibl.e for .manag-ing these activities. The position , was ~ filled late 'in the period.
In addition, the licensee initiated personnel movement' .in the organ-ization to further ' improve oversight of in-field activities, : Staff- ,
ing is considered adequate to implement the program. l Although the licensee essentia11y' revised all program procedures to. -
improve their quality this period NRC ~ monitoring of the' development 1 of new and revised program' procedures. this assessment period con- .
)
tinued to identify numerous problems involving' establishment of weak i and inadequate procedures. Repeated offorts by, the NRC were required
-to ensure adequate procedures were in place demonstrating 'a weak licensee capability in the development of procedures.
The licensee subsequently took adequate action to resolve the prob-lems. Contractor experts in the c particular program areas (e.g.
internal dosimetry) were' requested . to review program elements and procedures. Improvements made were appropriate. Revised procedures-were field tested prior to use. . Improvement _in procedure quality was -
noted at the end of the assessment. period. These procedures were adequate to implement program elements.
The licensee completely revised the radiological controls corrective action program. The program. now includes provisions for root cause analysis and timely implementation of corrective action - to _ prevent recurrence. Radiological Occurrence Reports generated by the program are ' tracked by computer. . Summaries are provided to station manage-l ment. Although corrective actions were being identified, NRC review found that, due to problems (e.g. inadequate ' communications), the actions were not fully implemented or were. -in some cases, inadequate due to weak root cause analyses. Two violations involving failure to frisk vehicles leaving the site and inadequate high radiation area controls were issued specifically due to failure to implement ade-quate, timely corrective actions. The licensee's failure to ensure ,
j adequate corrective actions for identified problems continued to be a :
chronic problem demonstrating lack of adequate site middle and upper management attention to personnel adherence to procedures and lack of well thought out corrective actions. l I
__ _ _ _ _ _ _ _ . _ . _ _ _ _ . _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ . _ _ . _ _ _ _ - . . _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ . _ . _ _ _ _m- __ _ _. _ _ _ _ _ . _ _
,y_
- 16 The. licensee established and implemented a z procedurally-described ALARA .(1.e., maintaining radiation doses As ~ Low As Reasonably l Achievable). program. However, NRC review' of this programl found- a 1 ek of an . aggressive goals program, inadequate job monitoring pro--
visions, weak interfaces. between the . program and the radiationt work -
permit (RWP)' program and non-uniform implementation. .. The licensee l corrected the majority _of the NRC concerns'in a timely' manner.
The licensee issued about eighteen procedures covering all major as-pects of the ALARA- Program. However, _ interface of the program with.
the RWP program continued to be weak. For example, ' NRC review. of fuel' pool clean-up modification work found examples of unclear _under-standing between the - operational . radiation protection . group, - the ALARA group, and the maintenance group regarding the method: of work performance. As: a - result, unnecessary discussions were - held sin- a high radiation area.
Performance in the area of ALARA was non-uniform. Despite problems with some jobs . (e.g. fuel pool. work), the ALARA : controls. on other .
work (e.g. drywell work) were commendable. Non-uniformity'in program implementation was attributed' to . lack of updating ALARA reviews when
-the job scope or work methods changed.. Lack of uniform _implementa-tion of the ALARA program is considered a - significant program.
weakness.
The radioactive and contaminated niaterial _ control, program has been. ,
upgraded. ' A management policy (Radioactive - Material; Control Plan). 1 was established.- The plan demonstrated senior ~ corporate ~ management commitment for controlling this material. A - further indication of management concern involved the extensive ' decontamination of. the plant. Major areas of the plant have been decontaminated' allowing entry without protective clothing. Licensee initiatives 1n this-~. area were aggressive.
1 Regarding facilities and equipment,-the licensee is currently modify-ing its access control point to better control access to process buildings. About eight high sensitivity portal monitors have been installed for personnel contamination monitoring.. In ' addition . to this major work effort and equipment purchase, the licensee has pur-chased several high sensitivity, state -of the art whole body ' coun -
ters. These major investments in facilities and equipment' demon-strate management's efforts 'to upgrade outdated _ facilities and equipment.
Effluent Monitoring and Controls Reviews in this area last period identified problems with unmonitored releases and failure to perform a surveillance for an effluent non-itor. A deviation from a licensee bulletin commitment and violation were issued respectively. Reviews this period found. that adequate corrective actions were taken.
17 1
Review this period indicated effective' implementation.of the effluent j monitoring and controls - program. No violations were identified this period. Liquid and ' airborne release records, procedures, instrument :
calibrations, audits, and Offsite Oose Calculations Manual implemen - J tation.were adequate. Three licensee event reports (LERs) were 'sub-mitted during this assessment period, all were of minor. safety sig-nificance. Two of the LERs,: however, indicated a potential minor: ,
programmatic breakdown :in ~ the implementation of current effluent ]
Technical Specification . surveillance requirements and - new require-ments brought about by Technical Specification changes. The licensee has implemented La review of Technical Specification surveillance-requirements in order to ensure that all requirements are being and
~
will be met.
-During this assessment period the environmental monitoring program .
was found to be generally adequate. However, problems were identi-fied in the licensee's environmental ' thermoluminescent dosimeter (TLD) program. Commitments made by the licensee during previous assessment periods to improve' the environmental TLD program were not implemented. Because of these problems, the validity of the environ-mental TLD data cannot be assured. . This indicated lack of management -
involvement in this area and a lack of understanding and thoroughness .
with regard to resolution of technical issues. ,
1 Transportation No problems were identified in this area .last period. During this period the licensee's transportation ' program has exhibited a decline in performance. One Severity Level III violation was issued 'as a result of a shipment receipt . inspection performed by the State of' South Carolina, which resulted in a $1000.00 Civil Penalty assessment by the State. A radwaste shipping package was found with a- hole in it at the burial site This violation indicated a lack of quality assurance involvement with radioactive waste transportation activities.
Two Severity Level IV violations resulted from an onsite inspection performed approximately three months after the inspection by the State of South Carolina. The violations involved failure to document radiation surveys and failure to determine if 'certain waste types shipped to the- burial site were properly dewatered. Again, the vio-1ations indicated a lack of quality assurance involvement with radio-active waste transportation activities.
Licensee's respoase to the violations indicated the intent to perform programmatic reviews as well as institute improvements in the radio-active waste transportation program to correct the violations. This was an indication of increased management' attention and commitment to this area during the period.
I q
_ --_ ___- -_-_--__ _ - _ a
t
.- - 18 Summary The licensee made. numerous improvements in the overall qualitylof the radiological controls program. - These included substantial ' upgrade of program (e.g. ' ALARA Program) procedures, staffing . of key vacant positions, significant ' reduction in the number and extent of 'contam-inated areas in -the plant, and development of a Radioactive Material Control Program. However,- implementation of the' program continues to be weak. In addition, when problems 'with program implementation or adequacy are -. identified, corrective- actions are sometimes. not ade-quate or not implemented resulting in : the need for further. NRC involvement. . In the area of effluent monitoring , and control, the licensee. implemented the new effluent technical specifications -in a.-
generally acceptable manner, however, failure to take action on sig-nificant long standing deficiencies in the environmental TLD program -
detracted from the good effort. In' the area. of radwaste transporta-tion, a decline -in performance: from the previous period was noted.
The ' decline- was attributed to ineffective - involvement by the..QA group.
(2) Conclusion Rating: Category-3 Trend: None J
(3) Recommendations Licensee: --
Aggressively supervise the radiological' controls program, Establish and implement _ measures - to verify pro-gram implementation..and implement corrective actions for deficiencies.
Interactions with personnel outside the radiolog-ical group should be significantly strengthened.
NRC: --
Continue increased inspection coverage 'in this area.
See Section 3.2.
3 e
19 4.3 Maintenance (18*4, 1196 hours0.0138 days <br />0.332 hours <br />0.00198 weeks <br />4.55078e-4 months <br />)
(1) Analysis Plant maintenance performance was assessed as a Category 2 dur-ing the previous SALP period. Weaknesses were identified in the control of vendor information, repair of control room equipment not required by the technical specifications, scheduling of second priority maintenance, scheduling of preventive mainten-ance, and maintenance staffing. These problems have all been addressed during the current period, but have not been fully resolved.
During the current SALP period, ongoing maintenance activities were routinely reviewed. Inspection activities included exten-sive review of maintenance programs and records and witnessing of maintenance work in progress. Maintenance activities were also reviewed in a safety system functional readiness review, a Region I diagnostic team inspection, an Augmented Inspection j Team (AIT) team inspection, and a special team inspection to l review the licensee's response to Generic Letter 83-28.
Maintenance staffing remained a weakness. First line super-vision vacancies in electrical, instrument and controls, and 3
)
mechanical maintenance sections existed during most of the per- l iod. Qualified lower level personnel did not in many cases I apply for the supervisor vacancies. This hindered the staffing I
process and indicated a potential weakness in the licensee's l personnel recruitment and development practices. Lack of pro-fessional support also limited the ability of the maintenance organization to respond to vendor, industry, and NRC informa- i l
tion. While high priority maintenance issues were effectively reviewed, development of programmatic improvements such as trending and preventive maintenance were impeded. The licensee responded to these problems by establishing a Section Head level position responsible for maintenance and by adding three main-tenance staff engineering positions. The licensee also plans to restructure maintenance management to reduce the work load of line supervision. In addition, contractors were being used extensively to supplement the maintenance staff. The adequacy of maintenance staffing is a crucial issue that deserves con-tinued plant and corporate management attention.
Extensive overhaul of the core spray and RHR pumps was accomp-lished by a special vendor team. This team also supplied its own QA staff. Review of the work indicated it was performed acceptably. All work was accomplished in accordance with 11cen-see approved procedures.
20 1
The licensee's approach to maintenance activities was cautious and conservative. One-time equipment failure evaluations generally focused on identification of the root causes. How- !
ever, completion of evaluations was slowed due to limited tech-nical resources and root cause evaluations of recurring problems J were sometimes weak. Maintenance trending of equipment. problems was limited in s, cope and not always effective. For example, recognition of the consequences of repeated failure of the safety related valve motor operatcrs and motor operator valve bolting occurred only in response to NRC questioning. The lack of a formal program of maintenance trending denied the . licensee important insights into equipment performance and impeded development of an effective preventive maintenance program.
Programs in place for resolution of technical issues appeared to j be comprehensive. An example of. a recurring problem, however, l was multiple recirculation pump motor generator (MG) set (ATWS) .;
breaker failures. This is an important issue that deserves continued site management attention. The physical condition of j
equipment in the MG set breaker control cabinets was permitted to deteriorate through exposure to water and' debris. There was evidence of internal corrosion of relays and other components.
While the scheduling of "A" priority maintenance was considered good, the scheduling of second and third priority maintenance was a weakness identified in the previous SALP period. Although the licensee staffed a maintenance planning section during the last SALP period, maintenance planning and priorities continued to be a problem. For example, the prolonged downtimes on both the shutdown cooling instrumentation and the~ feedwater system limited operational flexibility unnecessarily. In addition, the licensee had difficulty in completing lower priority, harder-to-do jobs. The control air dryer high moisture alarm in the con-trol room is faulty. This was identified in May 1983 and as of February 1986 had not been repaired. The "V" salt service water pump heaters have been inoperative since November 1985. The job has been incomplete because of a lack of "Q" documentation for a new motor. Each of these jobs are examples of maintenance for which there appears to be no one in charge and no clear resolu-tion of problems associated with the job. Fire protection and security equipment down time during the period was also excess-ive, due in part to poor maintenance prioritization. Inadequate planning in one case, caused an unnecessary engineered safety feature (ESF) system actuation during performance ,of an Appendix R modification. The planning difficulties did not hinder first priority safety-related work which was conducted promptly.
l 4
.y -
21
-]
During the previous SALP period the maintenance backlog was !
identified as a significant - problem. This problem continued. )
into the early part of this. SALP period with little corrective '
action taking place. Early in this SALP period, a diagnosite t.eam inspection noted that in addition to the backlog a high )
percentage of old maintenance requests (MR's) had been lost and ,
there was virtually no system for tracking - MR's. .While high l priority maintenance was getting:done, medium and low priority I jobs were being poorly tracked with little to assure that they would be done in a timely manner or be done at all - contribut-ing further to the already large backlog.
i' To correct the'se problems, the 15censee established a mainten-
~
ante planning section. The maintenance planning section has been effective in collecting and reviewing the large number of backlog maintenance requests (MR) in the station. However, it !
was only marginally effective in planning and scheduling daily maintenance activities during much of the' period because the planning function had not been integrated into the work request process. This was due, in part, to a slowness in the issuance of instructions for the planning group and other maintenance q sections. These instructions had been under . development for l most of the SALP period but had not been issued for use by the .)
end of the period. The licensee started holding periodic inter- l disciplinary planning meetings and issuing period planning docu- l ments near the end of the period, . showing management attention '
to this area. Recently, new computer'-based scheduling tools have been acquired, which aided the planning effort. Signifi-cant progress in planning was noted during the last month of the period, which indicates that managemnt attention to this group is beginning to have its desired effect.
The licensee made substantial progress in the area of control of vendor information during the period. A program was established to compile vendor manuals, validate the accuracy of the manual content and assign control numbers. However, vendor information continued to be received by many individuals in the company,.
some of whom may not always recognize the need to update vendor manuals. Although the licensee plans periodic vendor manual audits, the decentralized method of receiving and reviewing vendor information appears weak and should be evaluated for effectiveness.
The scope and administration of the preventive maintenance (PM) program were weaknesses noted during the last assessment period.
Subsequent management attention to this area was evident, al-though weaknesses were not fully resolved. Preventive mainten-ante procedures for safety-related motor operated valves and the ;
emergency diesel generators have been established. Additional j NRC prompting led to the development of a PM program for 480 VAC molded case circuit-breakers. -
i l
v o
. 22 An extensive motor operated valve (MOV) refurbishment program continued through the period. This shows initiative and demon-strates an aggressive maintenance management approach. However, other MOV maintenance was sometimes ineffective, due to a lack' of detailed instructions and an over reliance on " skill of the craft" knowledge. For example the safety system functional inspection found that MOV torque and limit switches were not being set consistently due' to a lack of detailed instructions.
Difficulties in the procurement system were identified early in the SALP. Problems with purchase order (PO) determinations and the reliance on offsite groups for evaluation of the P0 caused extensive delays in the purchase of equipment. Problems were also observed in assuring that pr.rts, once received on site, i
were promptly distributed .to the correct people. To correct this problem, the licensee established an onsite procurement group to expedite the purchase of materials for high priority-maintenance. Evaluation at the end of the SALP period has shown that the addition of. this group substantially improved the licensee's ability to promptly obtain needed parts, reducing the time important equipment is inoperable. Currently, the procure-ment process in impeded by lack of staffing. The licensee has added contractor support to this group to help with the outage.
workload and is considering further full-time staffing to assist with the non-outage workload. The effectiveness of the procure-ment group is important to the long-term reduction of the main-tenance backlog.
Maintenance program procedures were weak. Many of. the adminis-trative procedures contained only minimal information. The maintenance request procedure for instance discusses how to fill l out an MR but says little else about the process of handling I maintenance activities. There were no administrative procedures l for the newly formed maintenance planning, scheduling and pro-curement support sections. At end of the SALp: period the licen-
, see had written and was close to issuing newly established main-l tenance program procedures.
In summary, although maintenance actions were generally per-formed adequately, maintenance organization staffing and work prioritization and planning remained weaknesses through much of the period. Vacancies in first line supervision and the short-age of engineering support have affected performance in this arer. Maintenance program procedures need further development.
The new maintenance planning and procurement groups appeared to be more effective at the end of the assessment period, reflec-ting significant licensee resource commitments to these areas.
l l
l l
v- . ,
23 (2)' Conclusion l'
Rating: Category 2 Trend: None (3). Recommendations Licensee: --
Improve communications between maintenance and- !
other site organizations.
Increase the effectiveness of maintenance planning. !
Continue program improvements in the area of pre-ventive maintenance and . vendor information control. l Consider development of a monitoring system for maintenance performance.
N3: None l l
1 4
24 4.4 Surveillance (16%, 1103 hours0.0128 days <br />0.306 hours <br />0.00182 weeks <br />4.196915e-4 months <br />)
(1) Analysis Surveillance was asse: sed as a Category 2 during the previous. i SALP period. Weaknesses . in the areas of startup test schedu-ling,. test adequacy,-compliance with. procedural requirements and response to abnormal test results were observed.
I During the current assessment period NRC inspectors observed testing, performed detailed reviews of procedures, and evaluated test results. In addition,- reviews of program administration and the neasuring and test equipment-(M&TE) control program were reviewed. Surveillance testing was also evaluated during two 1 special team inspections.
Surveillance testing was generally conducted in a careful, safety conscious manner. Coordination between . the control room staff and persons conducting testing was noteworthy. Surve11-lance test procedures were generally followed. Exceptions in-cluded explosive squib valve tests, documentation of system restoration, and independent verification. These exceptions indicated that additional emphasis should be placed on procedure 1
adherence.
No centralized programmatic description of the development, maintenance and implementation of the surveillance test program existed. Responsibility for the review and upgrading of pro-cedures and the evaluation of . results and trending were not clearly defined and appeared distributed throughout the site
- organization. This programmatic weakness h'as. been exacerbated l
l by the command and control problems evident in the existing site organizational structure. The absence of clear guidance and a technical focus for the program contributed to development of j procedures which were not always standard ,in format, did not contain accurate references to technical specifications, and did not always fully implement technical specifications requirements.
The system for control of surveillance scheduling was weak, principally because the key individual involved with this activ-ity was not a technical staff member. This weakness was reflec-ted in the sporadic performance of the licensee's computerized scheduling system, the Master Surveillance Tracking System (MSTP). Similar. problems were identified during the previous assessment period. During this period local leak rate testing of many primary containment isolation valves and calibration of safety related undervoltage relays were not scheduled properly due to MSTP inadequacies. The MSTP was also ineffective in scheduling surveillance tests required based on operational con-ditions or plant events. The licensee was slow to act in this area, despite repeated NRC prompting.
4
25 Another.. recurring- problem from the' previous period involved the ;
technical _ adequacy of surveillance procedures. .Several tech- I nically deficient ~. tests were; identified: during the current per-
.iod, including logic system functional testing. Repeated NRC initiatives were required to obtain meaningful. corrective action for some. of these deficiencies. Subsequently, the licensee took strong -action to identify 'and correct ilogici system- functional i test problems. However, other potentially deficient tests have '
not been addressed. In one instance,:a technical; specification surveillance requirement known to be' deficient'.for~about 6. years was .not' addressed until it became a critical path' item for the current outage. Additional concerns regardi_ng the acceptability of test methods *and test completeness were noted. In some cases test procedures did 'not contain ' sufficient' guidance :and con--
trolled ' documents within' .the nuclear ~ organization. did. not specify 'many safety-related ' settings for. electrical equipment.
Although no examples of uncontrolled changes to -thec settings were _ identified, the latter problem could . have ' allowed . safety related settings to be changed without - a formal plant; design change. Independent verification of system restoration in test d procedures was' inconsistent and in some " cases improperlyj per- J formed.
The licensee's program for control of measuring and test equip-ment (M&TE) was ineffective. . Out of calibration instruments were not properly segregated from useabl e -' i n struments. As a ]
result, several instances of use of M&TE beyond its calibration i due date were noted. Eighteen examples of failure .to . conduct investigations to determine the impact of out of calibration M&TE were identified during a single NRC inspection. These-I concerns accentuated the need for additional site management attention to the M&TE control program.
The licensee has experienced continuing problems- meeting the
, as-found total local leak rate acceptance criteria. - The largest-contributors to local leak rate test (LLRT) leakage, the main steam isolation valves (MSIV) and. feedwater check valves, .were extensively overhauled during the 1984. outage. This licensee initiative greatly Teduced but did not eliminate MSIV leakage.
The licensee has established a team to investigate problem com- ;
ponents, identify the root cause of the leakage, and recommend - !
corrective action. These efforts show initiative. in addressing . >
a generic industry ' problem. - Administrative control over LLRT activities improved during the period.
I 4
I i
I
v l
26 In summary, individual surveillance tests were well conducted and controlled. The response to recurring local leak rate test (LLRT) failures was also positive. However, the licensee has )
been slow to recognize and correct weaknesses in the' control of 1 the program and in the scheduling and technical adequacy of sur-veillance tests. This lack of progress is reflected in the large number of surveillance-related licensee event reports and NRC violations issued during the current period. - The control of the program is fragmented and not always effective and appears to depend more on historical past practice than on a well founded, systematic approach. This is a major weakness that must be correc,ted. The licensee's M&TE control program also needs improvement.
1 It should be noted that licensee performance in this functional l area has not degraded during this period. The difference -in I conclusions between this and the previous period is due to re-curring problems which focused concerns on underlying program weaknesses. Inadequate action by site and corporate senior management during most of the period was also factored into the rating decision. Significant progress in one portion of the surveillance pt . gram, i.e., Emergency Safeguards Feature (ESF) logic system functional testing, was apparent at the end of the period.
l (2) Conclusion l Rating: Category 3 Trend: None (3) Recommendations Licensee: --
Significant site and corporate management atten-tion is needed to correct deficiencies in this area.
Place a single qualified individual in overall charge of the surveillance program.
NRC: --
Conduct a comprehensive inspection of the sur-veillance and calibration program prior to startup.
l
- - _ _ _ _ = - -
27 l 4.5 Fire protection (6%, 413. hours)
(1) Analysis j The area of fire protection was not_ evaluated as a separate functional area during the previous assessment l period. However, l the Region I diagnostic team inspection identified significant i weakness in this area. .During the present period _ several '
inspections reviewed this area. A management meeting 'was; also held during the period to? discuss fire protection program-deficiencies.
J The fire protect. ion program has relied . heavily on compensatory measures. This reflected a lack of site and corporate manage-ment aggressiveness in maintaining and improving station fire protection - equipment. For example, the diagnostic team.inspec-tion noted there were over 250 outstanding maintenance requests -
(MR) on fire protection equipment. The inspection also noted that there were locations in the plant requiring fire watches, many for broken equipment. Fire suppression systems in three of five plant areas (where these systems are required) had been out of service for extended periods of time. In these cases, the licensee relied on firi watches for long periods to compensate for the out of service equipment. Although the fire watches were an acceptable compensatory measure, the failure to promptly restore fire equipment to service is a problem. Early in the assessment period, a project engineer was assigned to reduce station dependence on compensatory measures. The effort initially resulted in improvement however continued identifi-cation of degraded components has more than off set this gain.
Personnel performing fire watch duties received little training and as a result did not always perform the required tours. Site management followup to this problem was weak, requiring 'signif-icant NRC involvement. In one case the licensee identified 17 instances of missed watches in a 24-hour period, but took no significant corrective action until prompted by the NRC. In addition, the licensee had not decided by the end of the period whether previous guidance to the fire watches on fire fighting would be continued or revised. This decision should be made and the fire watches trained appropriately.
Licensee site management has been ineffective in assuring the quality of fire brigade training. Training records were frag-mented and poorly used. Many brigade members did not partici-pate in brigade drills or quarterly training sessions. as re-quired by NRC regulations. Drill objectives and assessments were vague. Periodic drills were incomplete ~and poorly run.
Personnel serving as brigade members were not fully trained in use of the onsite fire truck, further indicating that the brigade training was weak.
~
28 Fire barrier surveillance procedures were unclear and incom-plete. Weak' licensee action allowed this condition to exist'. for a considerable period of time. The licensee has recently imple-mented an extensive station fire barrier walkdown program. This
. program has identified numerous barrier penetration seals with inadequate documentation, degraded ~ seals, and . seals not . cur-rently included in' established surveillance procedures. Con-tinued ef fort is needed to address this long standing problem.
The licensee took steps at the end of the period to strengthen the , fire protection program. A new fire protection. management -
position reporting first to the Plant Manager and later to the Vice President 'of Nuclear Operations was created and filled.
Staffing in the area has been substantially increased with indi-viduals assigned to provide fire brigade training oversight and to maintain equipment and maintenance priority status. However, ;
these actions were slow in coming and program weaknesses. were' )
still present at the end of the period. Recent fire protection l problems include missed and inadequate NRC reports and a failure ;
to compensate for loss of redundancy in the fire protection 1 system. l In summary, the licensee has been slow to strengthen the fire protection program. Problems included inadequate surveillance procedures, degraded fire barriers, inoperable fire protection system equipment, and poor quality fire brigade' training. Al- !
though action has been taken to address these concerns, the pro- 1 l gram has suffered from a chronic lack of attention and should be closely monitored.
(2) Conclusion Rating: Category 3 Trend: None (3) Board Recommendations Licen g : --
Significantly reduce the amount of inoperable fire protection equipment in the station.
I NRC: --
Schedule periodic topical meetings with the licensee to discuss program improvements See Section 3.2
^
. 29 4.6 Emergency Preparedness (4%, 249 hours0.00288 days <br />0.0692 hours <br />4.117063e-4 weeks <br />9.47445e-5 months <br />) l (1) Analysis During the previous assessment period this area was rated as Category 3. Programmatic weaknesses in the organization and administration of the emergency preparedness (FP) program, an inadequate emergency operations facility (E0F), and exercise deficiencies resulted in marginally acceptable performance dur-ing the 1985 annual exercise. Four Category A deficiencies were observed offsite by the Federal Emergency Mariagement Agency
-(FEMA), and twq onsite areas- of concern were noted by NRC ob-servers. A remedial exercise was held in October,1985 to re-solve the offsite deficiencies. Onsite areas of concern were satisfactorily resolved during January and-April of 1986.
During the current assessment period, one partial participation-exercise was observed, two routine safety inspections related to follow-up of deficiencies identified during previous emergency p aparedness inspections were conducted and a remedial emergency drill was performed to demonstrate effective control of radia-tion exposure to re-entry personnel entering high radiation areas. Throughout this assessment period the licensee has shown increased responsiveness to NRC initiatives and concerns as evidenced by frequent discussions, meetings, work activities and ;
successful closeout of all past open items. One area of inade- l quate corporate management attention was preoperational testing of the air filtration system at the EOF.
A partial participation exercise (including NRC Region I parti-cipation) was conducted on December 10, 1986. The licensee's performance was significantly improved over the previous exer-cise. Actions by plant operators were prompt and effective.
Event classification was accurate and timely. Personnel were generally well trained and qualified for their positions. No significant deficiencies were identified.
The following factors have influenced the noted improved per-formance in the area of emergency preparedness at Pilgrim. They are indicative of a high degree of licensee management atten-tion.
Increase in EP staff from one part-time position to four full-time positions.
Authorization to increase staff by three additional posi-tions (as of January 1987).
Contracting of an experienced EP consultant firm to assist in everyday planning and exercise development.
v -
-t 30 >
i I
Completion .of. a new ' Emergency 2 0ffsite Facility * (EOF),
Technical' Support Center (TSC)',- and . Operations Support Center. (OSC) . complex.
Participation in management meetings, both 'in 'the region and at Plymouth, to ensure intent and direction.
. Participation at' Exercise Entrance Meeting, and observation. ,
of the exercise,. by both the : Chief Operating Officer and the President'.
i' Increased training of - key managers,. assistants and staff.
Performance' of several: drills' and exercises to test-imple-mentation of. their' emergency plan.
i The . licensee has openly committed to a . level of. excellence, and has stated that . their goal is to have the model EP program in NRC Region I.
The licensee has made an extensives effort to gain the co-operation of offsite officials.and to provide the resources necessary to address offsite concerns even? though efforts to date have not been effective.
The licensee's ' performance . indicates: that;its* training program has been effective. Management involvement has been increas- J ingly effective,-as evidenced by, timely completion of corrective actions and the addition of. improved hardware;and EP staffing.
The licensee has been responsive to NRC concerns and has made considerable progress in this area.
(2) Conclusion Rating: Category 2 i Trend: None (3) Board Recommendations Licensee: Continue to pursue resolution of off-site issues.
E: None l
l L___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - . _ _ - - - m -
. . .31 4.7 Security and Safeguards (4%, 282 hours0.00326 days <br />0.0783 hours <br />4.662698e-4 weeks <br />1.07301e-4 months <br />)
The previous SALP identified serious NRC concerns .regarding the licensee's awareness ~of, and attention to, NRC physical security objectives and the need for additional management attention to, and support of, the security program to insure that the program was pro-perly implemented. . The previous SALP also identified NRC's belief -
that the licensee had initiated actions to resolve those concerns and that the security program was receiving increased management atten- ,
tion. However, shortly after the beginning of. this assessment per-fod, it became apparent to the NRC' that, due to the number and com-plexity of the identified problems and some other problems which were then surfaced, far more extensive management attention and resources would be required. As evidenced 'during this assessment period, the need for additional. attention and resources by the licensee continued until late in this assessment period. As a result,'little physical progress toward improving the program was accomplished by the licen-see during the period.
Two routine unannounced physical security inspections and one special inspection were performed by a region-based inspector during this assessment period. Routine resident inspections continued throughout the assessment period. Eight areas of significant concern involving major long standing programmatic weaknesses were identified during a.
special inspection in March,1986. That inspection was performed to I review the licensee's corrective actions on several long standing problems previously identified by NRC. Three management meetings between NRC and licensee management were conducted during the period to review progress on correcting the identified programmatic weak-nesses and of the security upgrade program implemented by the licen-see to address those weaknesses. During a management meeting on j January 13-15, 1987, it was agreed that progress was being made; however, corrective measures were not complete for any of the eight I
areas of concern.
At the beginning of the assessment period there was only one member of the licensee's staff assigned to security on a full-time basis. ,
l This resulted in minimal oversight of the contact security force, insufficient input to management on program problems and decision making by management based on that input. This caused inadequate and/or ineffective corrective actions on identified problems and a general unawareness, on the part of the licensee, regarding program implementation and security force performance. During the assessment period the licensee took steps to expand its security staff and, by l .
l l
C. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . - - - _ - - - - - - - - - - - - - - - - - - - - - - - -~
- 32-l the end of the assessment period, the licensee had a security staff of seven. The impact of the _ increased staff has not been fully realized since orientation and training necessary to qualify newly -i hired personnel has not yet been completed. However, the licensee's action to expand its security staff is an indication of lits' commit- l I
ment to improve the security program.
The eight areas of significant_ concern' identified in the March, 1986 Special Inspection _ indicated major programmatic problems that affec-ted many components of the security program. Due to the ineffective-and prolonged implementation of . corrective ' actions, the licensee.
resorted to the use of. long term compensatory measures, consisting primarily of security force personnel. Because of the extensive use of compensatory measures and because the contract security force was l
l understaffed,- security personnel were forced to work an excessive amount 'of overtime. The NRC expressed concern about. the . excessive overtime being worked, 'and in July 1986, the NRC identified security personnel that had worked as much as 88 hours0.00102 days <br />0.0244 hours <br />1.455026e-4 weeks <br />3.3484e-5 months <br /> in a 7 day period. At 4 that time the licensee implemented a system to limit personnel to a maximum of 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in a 7 day period. The licensee also implemented plans to increase the size of the guard force to further relieve the overtime problem.
Prior to and early in this assessment, resolution of NRC-identified problems was often delayed due to an inadequate understanding of the scope of the problems, _ insufficient knowledge of how to solve the problems and lack of corporate engineering and security support.
During the assessment period, problem resolution was given increased senior corporate management attention and it. creased corporate sup-port; however, due to the magnitude of programmatic problems, reso-lutions were not yet effected by the end of the period. Toward the latter portion of the period and in recognition that the_ existing problems were even larger in scope than had been previously thought, the licensee escalated _ the priority under which the security program ,
upgrades had been placed. I Audits of the security program conducted by corporate security per-l sonnel were complete and thorough; however, corrective actions were not always effective due to the previously mentioned lack of onsite security staff, poor communications and followup between the_ corpor-ate staff and the plant- staff and a general lack of understanding of NRC performance objectives by the plant staff. To rectify these -
problems, the licensee has assigned, on a full time basis,'a member of the corporate security staff to the site. Another responsibility ,
of that individual is to conduct an ongoing surveillance / audit of the program. The NRC did not assess the effectiveness of the licensee's l
l 33 1 j
audit program improvements during this period. The security force training program appears to'be adequate to address. routine activities.
.at this time as indicated by only two reportable instances'of per-sonnel error. In those instances, post orders were not adequate to assure a clear understanding of the. required- duties. However, with .j the magnitude of changes being made, the licensee should review the '
training program to ensure that it remains current and reflects actual security practices.
A total of seven security event reports, required by 10 CFR 73.71(C), j were submitted _ to _the NRC during this assessment period. . Three. event :1 reports were necessitated- by the ' licensee's ' findings ' of degraded vital area barriers.* Such degradations had been identified by NRC during the previous assessment period-and a civil penalty had been assessed. The first degradation was found during a licensee review to validate the integrity of all vital area barriers._ This . review -l was being conducted as a followup'to the violation which resulted in.
the civil penalty. The other two degradations of vital area barriers that required reports occurred when. openings were improperly secured ,
during work on plant systems that penetrated.the barriers. _ Two other event reports were the. results of bomb threats; another was the re- )
sult of a guard found sleeping on post; and the last was the result !
of guards that were posted as compensatory measures for failed equip- '
ment, patrolling in the wrong area. The quality of the event reports was significantly improved over the previous assessment; period; the reports were promptly submitted,- consistent, clear and generally 1 thorough. Corrective actions on the second barrier degradation were '
not totally effective since a similar event occurred the next day.
However, the licensee appears to have since applied effective con--
trols to prevent recurrence.
During the . assessment period, the licensee submitted one change to the security plan under the provisions of 10 CFR 50.54(p) and re-sponded to the miscellaneous amendments to 10 CFR 73.55, codified by NRC_in August 1986. The plan change was fnrwarded to NRC Headquar-ters because of potential policy implications and it and the licen-see's response to the miscellaneous amendments are currently under review.
The security program has been made a priority item. The licensee's on-site staff has been expanded from one full' time security member-to eight, including a group leader who has previous nuclear plant security experience. The new group leader is responsible for secur- -
ity only. Extensive engineering resources have been applied to cor-rect deficiencies and upgrade the security systems. Corrective main-tenance to equipment and hardware has been undertaken and is sched-uled to be complete prior to restart of the plant. Additionally, the
m ,
34' licensee has scheduled further upgrades and enhancements for security equipment and hardware in the future. These actions and management's. _
increased and sustained level of attention to. the program during -the latter portion of the assessment ' period are evidence .of the 'licen-see's intent to implement a quality security program.
In summary, the licensee has initiated actions to. upgrade the secur-ity program however, at the conclusion of this rating period, the hardware upgrades were not complete' and the. expanded security organ-ization had not been in place for an adequate time to evaluate cits effectiveness. At this time, the licensee security program must still rely heavily on the :use of. compensatory measures, consisting primarily of security personnel. The compensatory measures -are necessary because of -long term problems affecting ~many components of the security system.
(2) Conclusion-Rating: Category 3 Trend: Improving ;
(3) Board Recommendations Licensee: -- High level corporate and site management atten-tion at the recently established priority level for the security program upgrade should continue in order to implement commitments and develop an effective program, j
NRC: --
See Section 3.2 i Periodically meet with licensee management to assess progress in this area.
3
+
.~ .
35
-)
I 4.8 Outage Management and Modification Activities (17%,1170 hours0.0135 days <br />0.325 hours <br />0.00193 weeks <br />4.45185e-4 months <br />)
.(1) Analysis Outage managementLwas assessed as a Category I during the : pre-vious .SALP period > Completion of an extended ' recirculation system piping replacement outage and the subsequent restart were-found to be cautious and well controlled. . A significant lack of housekeeping control during the 1984 outage was indicated by the discovery of ' debris in a safety-related system. 'An additional 1984 outage housekeeping problem was discovered during the cur- 1 rent period, i.e. debris in the main steam.'line isolation valves (MSIV). .
In March 1986, a- reactor shutdown was initiated due.to a reactor -
vessel instrument line weld crack. The planning and control of the subsequent work, including. engineering support, ALARA plan-ning, and Operations Review Committee evaluations were well per-formed. In April,1986 a series of operational events resulted in a protracted forced maintenance outage. Evaluations of the-operational events were performed in-a deliberate manner, focus-ing on determination of root cause. Necessary repairs and mod-ifications. were carefully implemented. . This outage was con-tinued for several weeks in order to' inspect and repair all the residual heat removal and core spray pumps. These activities were'also conducted in a safe, controlled manner.
The licensee decided, in July 1986, to extend the April outage-into 1987 and include refueling, Appendix R modifications, and certain containment and station blackout enhancements. Other major outage tasks included the installation .of a new plant process computer; installation of an analog-trip instrumentation system for safety-related reactor parameters; installation of a hydrogen generation facility and a hydrogen injection system; major overhauls. of the emergency diesel generators, high press-ure coolant injection turbine, reactor core isolation cooling turbine, and the main turbine generator; reactor vessel instru-
. ment line modifications; control rod drive change outs; and a large number of inservice inspections of. safety-related and non-safety related piping. Because the refueling outage was init-iated without the opportunity to preplan,'the pace of activities was initially slow. This cautious. management approach demon-strated a safety conscious attitude. Many outage activities such as the inservice inspection program have also been well run. The major increase in scope of inservice inspections in the feedwater system and the drywell liner showed a prompt and aggressive response to events at the other power plants.
9
~
36 As a result of.these -shutdowns, the reactor was in an outage for two thirds of the assessment period. The slow pace of progress made in correcting' basic deficiencies in other functional areas, i .e. , fire protection,' security, surveillance, maintenance, and radiological controls, reflects an inability to. effectively deal with' these -issues during outages. A poorly-defined onsite management ' structure during outages contributed to the lack .of progress. ' The assessment of this organizational weakness is not included in this section, but is evaluated in Section 4.12,
" Assurance of Quality".
Major outage- modifications such as installation of the analog trip. system an'd Appendix R enhancements were performed largely without incident. However, increased attention to security compensatory measures, isolations of major plant components, and l post work testing are needed. Although no, specific problems.
l were identified the lack of programmatic guidance for post work l testing is a weakness that should be addressed. Also, the' ad-herence to post work test procedures should be improved. Some weaknesses were identified in a contractor-installed modifica-tion to the emergency core cooling . systems, suggesting the need for better BECo oversight of maintenance contractors.
Plant Design Changes (PDC) were generally well controlled.
However, two potential weaknesses in the PDC process were iden-tified. The first problem was associated with a PDC ~ for the installation of a new refueling -bridge, including refueling interlocks. The Final Safety Analysis Report indicates that the refueling interlocks have a safety design basis and are relied upon in the fuel handling accident analysis. 'Although the licensee does not currently classify this equipment as safety-related, it is clearly important and some QA involvement should have been provided. Significant design and construction prob-lems affecting both the bridge structural integrity and inter- l lock operability might have been avoided 'if more quality assur- I ance practices had been applied. The second problem involved the use of a nonconformance report instead- of a PDC for~ exten-sive residual heat removal pump modifications. . Although, in this case, either process could be used to control the work, the apparent desire to avoid a PDC indicates that' the process needs to be reviewed by engineering management.
In summary, implementation of outage and modifications activ-ittes has been strong. Improvements should be considered in the areas of security involvement with plant modifications, isola-tions of major equipment, control of contractors, and post work testing. The onsite outage management structure has been a significant weakness that has probably hindered program improve-ments. The discipline engineering support for the outage was i good. Plant design change packages were adequate. However, the
~
l lack of design reference documents is a continuing weakness that should be addressed.
37 (2) Conclusion Rating: Category 1 Trend: None (3) Recommendations Licensee: None NRC: None 1
l l
1 l
38 4.9 Licensing Activities !
l Licensing activities were assessed as a Category 1 in the previous SAlp period. During this 15-month rating period, the major licensing reviews pertained to masonry walls design, qualification of automatic depressurization system (ADS) accumulators, Generic Letter 83-28 ATWS '
items, recombiner capability, fire protection, calibration .frequen-cies for instrumentation,- a change in. the K-effective limit for the spent fuel pool, the annual time limitation.on_ purging / venting ,of the containment, and the safety parameter display system. - Section 5.4 provides a list of. active and completed issues. Following the Commission's denial cf a schedular extension beyond November 30, 1985.
to complete environ' mental qualification of electrical components, BECo mounted an intensive. effort which successfully met that-deadline. !
l BECo's procedures for controlling its correspondence 'with the NRC -
i requires upper management involvement with all licensing activities. I In addition to the attention given to these matters by the engineer-ing and operations executives, the.- chief operating officer is fre- ,
quently involved, thus assuring that top company management appre-ciates their importance and allocates appropriate resources. ]
! During this rating period, the licensee has been slow in providing additional information needed by NRR to complete its review in j
several areas. As an example, the licensee's ' responses to the. )
Detailed Control Room Design Review (DCRDR) and relief from the {
requirements for purge and vent lines to be automatically closed on a containment high radiation signal are overdue. The latest update of the Pilgrim Long Term Plan (integrated schedule of plant modifica-tions) is also overdue. As part of a reorganization of the engineer-ing department, the licensing group was recently put' under the man-ager who is also responsible for the engineering group which provides most of the analyses supporting licensing requests. This move has resulted in more expeditious handling of licensing. issues. . Another area where the licensee should have acted . earlier is in the area of l the control room high efficiency air filtration system surveillance l
requirements. The technical specification (TS). had been known to be l
incorrect for several. years but had not been corrected. This . re-flects a continuing weakness in processing administrative changes to i the Technical Specifications, l
The licensee has a competent technical staff whose efforts are sup-piemented by consultants as needed. Both management and staff per-sonnel participate in the activities of industry organizations such as Boiling Water Reactor Owners Group (BWROG), Industry Degraded Core Rulemaking (IDCOR) and Institute of Nuclear Power Operations (INPO) and thus benefit from sharing knowledge of technical issues and operating experience. Consultation with the ' staff has also been
(
4
39-frequent and beneficial to both parties. As a result, the licensee's submittals and presentations normally demons,trate a clear understand-ing of technical issues and the proposed resolutions are conservative from a safety standpoint. A good example of this is the. planning of provisions to' assure containment integrity in the event of an acci-dent. The licensee is. planning several enhancements to the Mark- I containment including modifications that would permit direct venting from the torus to the main stack, modification .to ,the containment spray nozzle, firewater intertie to the residual heat removal system, and the addition of a third diesel generator. The licensee has also taken the initiative to complete the BWR permanent hydrogen water-chemistry installation. Hydrogen water chemistry is an effective l method in arresting
- pipe cracking and the pipe . crack growth. rate.
The licensee maintains a large licensing staff which'has usually-been i responsive to- NRC initiatives , in a timely manner. The numerous I changes in organization and personnel during this rating period and i the necessity of dealing with -higher priority matters related to the l present outage have contributed to delays in providing additonal information requested by NRC (i.e., licensing matters such as single-loop operation, independent verification of valve and instrument set-tings, fire protection TS changes, inservice inspection relief re-quests, DCRDR and automatic closing of vent / purge valves on a high radiation signal). The licensee's quality of license amendment re-quests, especially the ' "no significant hazards consideration" im-proved significantly after the " counterpart" meeting held on January -
30, 1986 in Bethesda, where this topic was discussed in detail. The l licensee has responded promptly to various surveys conducted during the reporting period. The licensee was an active participant at the NRR counterpart meetings in January and October 1986, t
In summary, management attention and involvement was aggressive- in certain areas. This was particularly evident in BECo's commitment in Mark I containment enhancement modification and hydrogen water chem-istry installation. However, weaknesses are present which inhibit the licensing process, including: slowness in providing information j to NRC to close licensing issues, late. submittal of the Long Term i' Plan, and slowness in clarifying and correcting the Technical Specif-ications. Towards the end of this rating period, some improvement in the area of licensing activities was noticed.
(2) Conclusion !
Rating: Category 2 Trend: None 1
(3) Recommendations l Licensee: None l NRC: None l
I
. 1
40
)
l 4.10 Engineering and Corporate Technical Support (1) Analysis During this assessment period, engineering and corporate tech-nical support are being considered as a separate functional area for the first time. The various aspects of this functional area were discussed in other functional areas in this report and the respective inspection hours were included in each one. Conse-quently, this is primarily a synopsis of those assessments.
Offsite technical and engineering support was generally good during the period, as indicated by the successful completion of l the Environmental Qualification (EQ) program and the design of j several significant plant hardware modifications. -Engineering "
management was actively involved in site activities and re-sponded promptly to NRC questions and concerns. An example of this interaction was the strong site support shown during the l followup to the two scrams and residual heat removal (RHR) pressurization events in April 1986. Additional engineering support for maintenance procurement was evident, which aided site maintenance activities.
The licensee reorganized the Nuclear Engineering Department )
(NED) at the end of the assessment period, shifting from an )
engineering discipline - oriented organization to more of a site l support organization. The field engineering office was expanded !
in the reorganization and the licensing group was placed in NEO. '
Following the assessment period, the compliance group was also added to NED.
Significant plant modifications were designed and partially installed during the period, including a new plant process com-puter, an analog trip system for reactor safety equipment, a hydrogen water chemistry system, and extensive 10 CFR 50 Appendix R fire protection modifications. Few problems were identified with these projects, demonstrating the quality of the engineering work. In response to hRC concerns, engineering sup-port for the security and fire protection projects was increased and this should help resolve long-standing hardware problems in these areas.
Engineering analyses were generally complete, technically sound, and showed an adequate regard for nuclear safety. Two except-ions were noted involving differential relays for the emergency diesel generators and an RHR block valve on a torus cooling
r ~
l i, ,
41 1'
line. In. these cases, the engineering analyses were superficial' and did not probe underlying safety issues. The initial engi- !
neering evaluation of single failures in. the standby gas treat-ment system also appeared limited. The licensee was responsive to NRC. concerns 'in these cases 'and followup actions were good.
In April 1986, the pilot poppets for the main steamline isola-tion valves; (MSIVs) were found to be loose or detached from their. stems.. While the intent of a previous 1984 design modi-fication affecting the MSIV poppets was good, there was. a lack of attention to detail 'and contractor oversight on the f part of s the licensee's personnel:at that time. Specifically, the licen-see's personne) accepted the vendor's. poor design without ques--
tion, and then fully assembled eight.MSIVs in.1984 without ques-tioning an improper set screw design.to lock the pilot poppet to 1
the pilot poppet nut. .This lack of attention to. technical de-tail led to an inability of the outboard MSIVs to promptly .re-open following several reactor scrams. causing . unnecessary ' chal-1enges' to .the operators and the safety related systems. This problem did not affect the . ability of the MSIV's to fulfill their safety functions, i.e., it did not prevent them from clos-l ing. While considerable thought and effort has:been expended.on i the current redesign of the set screw arrangement, the problem could have been avoided by a good ~ engineering effort at the outset, 1
Extensive Mark I containment and' station blackout modifications were being planned at the end of the assessment period. The engineering approach to the Mark I. issues went considerably beyond NRC requirements and demonstrated a good appreciation of containment reliability issues. In addition to these modifica-tions, the licensee is preparing an extensive individual plant evaluation (IPE) as part of a safety enhancement program. This evaluation will use probabilistic and deterministic analyses to identify the major contributors to the risk of offsite release.
A team inspection was conducted during this assessment period to review the licensee's implementation of an EQ program to meet the requirements of 10 CFR 50.49. This inspection occurred after the Commission had denied the licensee's request for exemption of the 10 CFR 50.49 compliance deadline. .The licen-see's engineering management was found to be aggressively in-volved in the EQ program, especially following the denial of the exemption request.- There was evidence of adequate prior plan-ning and assignment of priorities. There were well stated, con-trolled and explicit procedures for control of EQ activities, EQ records were complete, generally well maintained and easily
42 retrievable. The EQ files supporting equipment qualification.
were:brief; however, theilicensee made good use.of qualification I reference material in a Llogical and auditable manner. EQ per-
.sonnel were knowledgeable in their responsibilities. .They were -
responsive to NRC requests during the inspection, resolving NRC EQ. questions'in a timely manner. . The' licensee had an ample. and well trained staff in the EQ area. The authorities and .respon-sibilities for the EQ staff were well defined throughout the organization..
A safety system functional readiness team inspection, consisting of regional, headquarters, and NRC-contractor staff, : closely examined offsite engineering activities' during the assessment.
pe ri od .- The team looked at the engineering designs for modifi- .
cations .to several safety - systems at the plant. ! Overall,' the -
1 team was impressed with the quality lof , current' engineering I actions.
Two weaknesses in engineering support we're' the lack o'f dethiled design basis documents,for plant equipment'and safety instrument settings and occasionalu failure to promptly implement the licen-see's corrective action program. .QA. support ' from NED was not always timely, but this reflected more a lack'of senior manage-ment action rather than a problem within NED. . ' Also, the Engi-neering Department's Plant Design Change' (PDC) process was .not'-
always used by ' site personnel, indicating' that the PDC process needs to be reviewed by engineering management. . The: expanded onsite engineering presence from the enlarged. field engineering office and the new systems engineering group should help resolve each of these concerns.-
In summary, good engineering support to the s'ite was noted dur-ing the period. Technical evaluations were typically thorough-and showed an adequate regard for safety. The. engineering approach to the Mark I containment issues demonstrated an ex-ceptional appreciation for underlying- safety issues. The lack of detailed design basis documents is an important-weakness that deserves additional management attention.
(2) Conclusion Rating: Category-l' Trend: None (3) Recommendations Licensee:. None NRC: None q
O'
y _
o
., . 43 4.11 Training and Qualification Effectiveness
.(1) Analysis During this assessment period, training and qualification effec-tiveness is being considered as a ' separate functional area' for the first time. The various aspects of this functional area were discussed in other functional areas and the respective i inspection hours have been included in each one. Consequently, j this discussion is a synopsis of those assessments. Training l effectiveness has been measured primarily by the observed per-formance of licensee personnel and, to a lesser degree,- as a review of program adequacy. ,
J During the current assessment period, resident and specialist l i
inspectors routinely reviewed ongoing training activities and I their effectiveness in assuring quality personnel performance.
An operator licensing examination and an inspection of the licensed operator replacement and requalification training pro-gram were conducted by region-based examiners.
l The licensed operator training and requalification programs have significantly improved and appeared to be functioning satisfac- ]
torily. Two senior reactor operator (SRO) and five reactor j operator (RO) candidates were examined with only one R0 failure 1 during the period. These results are improved over the previous I assessment period in which three candidates failed the initial examination and demonstrates the effectiveness of management actions in this area. Candidate weaknesses included equipment operation from alternate panels outside the control room, know-ledge of control rod blocks, Emergency Operating Procedure entry conditions, and applied thermodynamics. Strengths included knowledge of emergency systems, instruments and controls, the control room, and general familiarity with the plant. The oper-ator training material was generally of good quality.
A new coordinator and an experienced senior licensed operator were assigned to the licensed operator program during the per-tod. These two individuals demonstrated a high level of commit-ment to the training program during the period and have helped make the requalification training more plant-oriented and have increased the quality of operator training materials. These improvements have improved plant operator attitudes about train-ing by making the training more relevant to the tasks the opera-tors encounter. A plant specific simulator neared completion at the vendor's facility in Canada at the end of the period. The
44 licensee plans to begin training operating crews on the simula- -
tor in Canada in March 1987, prior to disassembly and shipment to the plant. Eventually, the simulator will be installed in the licensee's training facility. This equipment represents a . (
major commitment of resources and will further. strengthen the training program. The reactor operator and senior reactor oper- ,
ator training programs were accredited by INP0. in June 1986_.
Overall, the licensee's commitment of resources and personnel to licensed operator training have been impressive.
i The good performance of licensed operators in the control room during the SALP period indicated that their training has been effective. Only two plant scrams were linked to an operator error. One of these did not involve control rod motion because l the plant had been previously shutdown. The control room staff '
has consistently been aware of the status of important plant equipment and emergency operating procedures. One weak area was Radiological Environmental Technical Specifications training of licensed operators. No specific training was(RETS) pro-vided to the operators prior to RETS implementation in March 1986.
There are currently nine operator candidates scheduled for license examinations in May 1987. Considering the low number of experienced personnel available for shift duties, continued corporate management attention to the operator training program is a necessity.
Requalification training was acceptable, although certain managers with active licenses did not always fully participate in the program and required remedial instruction to maintain active licenses. Written examinations were only of fair quality ,
l due to deficiencies in the preparation of the procedure sec-tions. Questions tended to elicit plant system rather than procedure knowledge. The method for preparing, administering, and evaluating oral examinations was also weak in that it was not defined in a procedure.
Significant weaknesses were noted in fire brigade and fire watch training as judged by personnel performance. Examples of poor performance included fire watches not going-to the correct plant locations, fire watches nut entering areas to look for potential fires, and the inability of fire- brigade personnel to operate the site fire truck. Training records were fragmented .and poor-ly used. Brigade members were not trained and drilled at re-quired frequencies. Brigade drill quality was poor, with a heavy reliance on simulation.
45 Maintenance training appeared to be effective. One. scram was partially caused by a maintenance technician error and partially.
caused by an instrument design deficiency. Dedicated training facilities for maintenance personnel were well- equipped. A pro-gram. of license'e_ and vendor : conducted courses has been estqb-lished. The licensee. has implemented job-specific training and utilized mock-ups prior to beginning major maintenance or modif -
ication activities. .This. practice resulted in smoother perform-ance'which contributed to lower personnel exposure. Maintenance training .has continued during the' outage, demonstrating a .com-mitment to maintenance training.
Contractor tratning was adequate _ during the - period ' with few examples of poor contractor performance. Although some. training -
was provided to contractors during the period, the increasing number of contractors- onsit'e . coupled < with the low number' of experienced maintenance supervisors may mean' that contractors will require more training to perform under licensee ~ procedures and controls. In _. addition, = this training program should be formalized.
The licensee's radiation protection personnel training and qual-ification program appeared adequate. Properly trained and qual-ified personnel were found to be ' control. ling radiologically significant work activities. No instances of inadequately trained or qualified radiation -- protection - ' personnel were ob-served although problems with adherence- to procedures were ob-served throughout the period. Training records were complete and properly maintained. The licensee received INPO, accredita-tion in this area during the period.
No deficiencies in the General Employee Training (GET).and qual- l ification program were identified. The program ; included prac- I tical demonstration requirements in use of protective clothes, I step-off pads, and personnel frisking techniques. Some problems with worker contamination control practices were noted this per-iod, however, they were attributed to. worker? performance prob-lems and not to the adequacy of the training and qualification program.
During the period, INPO accreditation was received for the non-licensed operator training program and for the licensed operator and senior operator programs. : The health physics ; technician training program was also accredited. The : remaining programs; i.e., shift technical advisor, chemistry, mechanical . mainten-ance, electrical maintenance, instrument and controls. and tech-nical staff training; are in the final stages of the approval .
process. Site visits have been held for the latter programs and (
an INPO accreditation board meeting is scheduled for April 1987. '
~
!- ]
, 46 .
1 l
l The licensee has dedicated significant' resources to the training )
program. The addition of the new-coordinator /and senior licen- i sed operator to the license training programs has been a signif-icant plus.. Four. of ten training programs. have received ..INP0 accreditation, and the remaining programs are in the. final stages of that process. Fire: protection training was a signif-icant weakness 'that requires continuing attention. In summary, licensee training improved during the period.
(2) Conclusion j Rating: Category 2 Trend: Improving (3) Board Recommendations Licensee: None NRC: None I
1 l
l
.r
47 4.12 Assurance of Quality (1) Analysis During this assessment period, Assu'rance of Quality is being considered. as a separate functional area. Management involve-ment and control in assuring quality continues to be one evalua-tion criterion'for each-functional area.
The various aspects of - the _ licensee's activities involving assurance of quality have been' considered and discussed as an l integral part'of each functional area and the respective inspec-tion hours are
- included in each one. Consequently, this' dis -
cussion is a synopsis of the assessments - relating .to assurance of quality in other areas. Since this is an assessment of management's overall performance in assuring quality it conveys a broader scope than simply Quality Assurance (QA) department performance.
The NRC routinely evaluated licensee management,and QA depart-ment performance during the assessment period. .Several team and regional specialist inspections also examined assurance of quality in plant operations and maintenance.-
Recurring. problems were noted in various functional areas during the period. This indicated that licensee management was. slow to deal with the programmatic weaknesses identified in the previous SALP report and in the Region I Diagnostic Team report. Two factors likely contributed to the slow response, the lack of a stable management team during the period and a weak onsite organizational structure.
Significant organization and staffing changes were made at the Plant Manager and Senior Vice President-Nuclear level. The plant Manager was replaced midway through the period and the~
l new Plant Manager was replaced in turn. following the period, i
l Responsibility for the nuclear program was transferred from a '
Senior Vice President to an Executive Vice President midway through the -period and transferred again to a new Senior Vice President following the end of the period.
The Plant Manager position was organizational 1y weak during the period due to a parallel site outage reporting chain. During outages, the site had a dual reporting chain with each site discipline reporting to both the Plant Manager and the Director of Outage Management. However, the responsibilities and author-
- 1. ties of these managers were poorly defined; thi.s obscured the l
, ~48 i
chain of command and weakened management accountability. As-a l result, neither, manager appeared to be .able to take charge of the plant and make essential- program improvements. Following the end . of 'the SAlp assessment period, the Outage Management Group was placed under the; Plant Manager. This consolidated the reporting chain.
The dual reporting chain had been in place for several years.
The failure of corporate management to recognize its effect on SALP improvement items and to take prompt, decisive action' to correct this situation earlier in the assessment period 'is - a significant weakness. The Vice President of- Nuclear Operations moved to the site in the latter, part of the period, providing additional corporate presence. The site security and fire pro-tection groups have been . elevated and now report 'to the Vice President of Nuclear Operations. Al so, ' a - new Senior Vice ,
President-Nuclear and his onsite staff assistant were hired at '
the end of the period. The effectiveness of- these changes in developing a stable management team has yet to be demonstrated.
l The licensee's quality assurance'and quality control departments !
appeared to be performing effectively. QA audits were timely, thorough and produced technically sound findings. The licensee plans to significantly. increase staffing of the: onsite QA audit group. This should aid self ' identification of problems. NRC !
reviews of warehouse control, receipt inspections and the inser-vice inspection program confirmed the. adequacy of quality con- -]
trol activities. The licensee showed considerable initiative in the latter area, expanding the feedwater inspection program l significantly after a recent industry event. Additional initi-ative was shown in the drywell corrosion inspection program.
The inservice inspection group was well staffed with qualified and well trained individuals.
However, lack of corporate management action on certain QA find-ings was a recurring problem which degraded the effectiveness of the QA organization and required additional NRC attention i- this period. The absence of initiative was. highlighted by one l case in which a QA _ finding potentially affecting the operability of the high- pressure . coolant injection system remained unre-solved for over six months. This situation persisted even after several reports indicating the overdue. status of this and other important QA findings . were issued to the Vice-Presidents and Senior Vice-President. Increased senior management attention '
should be given to assure prompt and effective resolution of QA -
findings.
n .. . . .. .
4 49 Correct 1ve actions in response to NRC issues were also not al-ways timely or comprehensive. During the previous assessment period, management control of licensed operator overtime was a highlighted weakness. During the current period, the. licensee- ;
instituted overtime controls for- all site personnel. that were
]
considerably more restrictive than NRC guidelines. This showed l initiative and a safety-conscious' approach. However, the policy was poorly implemented as demonstrated by multiple examples _.of )
security, maintenance, and radwaste personnel who exceeded both the licensee policy and the NRC guidelines for overtime without the knowlege and approval of site and corporate management.
l Repeated NRC involvement was required to ensure that the licen-see's overtime policy (an NRC commitment) was adequately imple- 4 mented. Considerable NRC effort was also required ~ to obtain comprehensive corrective actions to surveillance, fire protec-tion, security, and health physics problems. Several extensions for NRC commitments have been requested showing a weakness in scheduling and completing NRC-related work. In some cases multiple extensions of a commitment were required. In addition, i no response to the 1985 NRC safety system functional inspection I had been submitted by the licensee by the close of this SALP period.
The licensee implemented a work contral process during the lat-ter part of 1986 which should aid t King and completing NRC commitments. Planners have been assig..ad to each section to aid in establishing detailed schedules 'and manpower requirements.
In addition, the licensee implemented a backlog clearing program for all issues identified prior to September 1986.
Onsite engineering resources were limited, hampering the licen-see's ability to deal with technical issues promptly. An onsite !
systems engineering group was formed and partially staffed in January 1987. The onsite Nuclear Engineering Department - field office was also expanded in January. Senior licensee management acknowledged the need to establish the systems engineering group in March 1986 during the Region I Diagnostic Team inspection.
The delay in forming this group slowed progress in this func-tional area. The offsite Nuclear Engineering Department ap-peared to be producing good results. For example, the environ-mental qualification (EQ) program for electrical equipment run by the engineering department was well documented and effective.
However, communication with the station was sometimes ineffec-tive.
Poor drawing quality and weak control of procedure revision issuance were noted. during the period. Although no specific instances were identified this period, use of unreadable draw-ings or out of date procedures could lead to inadequate = or incorrect maintenance and surveillance activities. Management attention in this area has been evident and should continue.
1 1
9 1
J 50 !
The licensee .has un'dertaken several major programs;- aimed at ,
improving the quality of operations at-Pilgrim. More plant per- l formance indicators will'be monitored and trended. An extensive station decontamination effort is in progress. Successful com-pletion of the decontamination effort will significantly improve the accessibility of plant safety equipment.
1 Significant Mark I containment and station blackout enhancements were initiated during the period. Planned modifications include installation of a third emergency diesel generator, a contain-ment vent, a crosstie between the station fire water.. system and the residual heat removal system, and an independent battery bank that can feed AC loads. The modifications go considerably beyond NRC requirements and show. a commendable commitment to safety. The licensee efforts to update the Emergency Operating Procedures (EOP's) are also noteworthy.
Pilgrim licensee event reports (LER) were generally of good quality. However, two weaknesses identified in the Pilgrim LERs involve the requirements to 1) provide a discussion of personnel and procedural errors, and 2) identify the _ manufacturer and i model number of failed components. . Deficiencies in the i
personnel / procedural error discussions prompt concern as to whether or not the causes of these type errors are being deter-mined so that adequate corrective actions to prevent recurrence 1 can be taken. The failure to adequately identify each component that fails prompts concern that possible generic problems may go unnoticed for too long a time period by others in the- industry. ;
Two strong points for the Pilgrim LERs are 1) the root cause )
l
' discussions and 2) the discussions concerning the failure mode, mechanism, and effect of failed components.
In summary, although the licensee has exhibited good performance in certain activities such as outage control and engineering and has displayed initiative in its safety enhancement : program, significant deficiencies still were found to exist in radiolog- '
ical controls, surveillance, fire protection and security. Some ;
of these deficiencies have existed throughout the period and ;
have been identified in previous SALP reviews, and by the licen-see's own quality assurance organization. The ambiguity of the site organizational structure and the instability in the corpor-ate and site management team have resulted in the licensee's i inability to address and . resolve these long-standing problems without repeated prompting and overview by NRC. Senior corpor-ate management was slow in confronting the problems and in :
implementing corrective. actions. Late in this assessment period and immediately following it, the licensee took steps to address !
its organizational weaknesses. However, the effectiveness of these efforts in improving the licensee's performance remains a matter of continuing NRC interest and concern. -
\ .
e e
'4
. -51 (2) Conclusion Rating: Category 3 -
Trend: None (3) Recommendations i
Licensee: Continue senior ; management. ~ attention to identified problems to ensure that they are promptly' and . effec-tively resolved.
NRC: See Sfection 3.2-l 1
4 52 5.0 Supporting Data and Summaries 5.1 Investigation and Allegations Review Seven allegations were received and evaluated during this SALP period. Three of the allegations were investigated, found to be un-substantiated and closed. Two allegations concerning possible employee drug and alcohol abuse were forwarded to the licensee for.
action. Subsequent NRC review concluded that the claims were unsub-stantiated. One allegation regarding excessive security force over-time was investigated, substantiated and brought to the attention of licensee management for resolution. This issue remained open at the -
end of the assessment period pending review of licensee corrective actions. The seventh allegation is in the security area and is still under evuluation. J No investigations were conducted during the assessment period.
5.2 Escalated Enforcement Action Confirmatory Action Letter (CAL) 86-10 was issued in response to a series of operational events in April, 1986. CAL 86-10 requested submittal of technical evaluations of these events and stated that NRC Regional Administrator approval would be required prior to re-start. The technical issues identified in CAL 86-10 have largely been resolved. The CAL however was extended in August, 1986 and remains open pending resolution of broader management concerns identified in the previous SALP and subsequent inspection reports.
One Severity Level III violation was issued for a problem with the transportation of radioactive materials. A civil penalty was issued by the State of South Carolina for this problem.
l 5.3 Management Conferences Periodic management conferences were conducted on June 12, 1986, July 30, 1986, September 9, 1986, November 24, 1986 and February 2,1987.
At the conferences, NRC: Region I and licensee senior management dis-cussed licensee progress on management and technical issues. These meetings will continue into the next SALP period. ;
1 On January 20, 1987 a management meeting was conducted in the NRC Region I office to discuss ongoing problems with the licensee's fire protection program. .
Several additional meetings were held between NRC: Region I personnel and the licensee to discuss program improvements in the area of emergency planning and security.
53 )
1 5.4 Licensing Actions (1) 'NRR/ Licensing Meetings and Site Visits' 1
October 22-23, 1985 -
Site visit - Safety Systems Readiness l j
November 4-8, 18-22, 1985 Review !
I January 13-14, 1986 -
Site visit to discuss licensing issues j Janua ry 30,.1986 -
Counterparts meeting with Boiling Water Division I (BWDI) licensees
~
March 3-5, 1986 -
Site visit, SALP and licensing issues March 6-7, 1986 -
Site visit with Region I Team Inspection March 25, 1986 -
Meeting on leaking instrument line i from reactor vessel March 31 - April 1, 1986 - Site visit on Appendix R April 16-18, 1986 -
Site visit with AIT team May 19, 1986 -
Region I on Restart' Issues June 10, 1986 -
Public meeting at Plymouth June 11, 1986 -
Braintree to discuss licensing issues 4
June 12, 1986 -
Region I to discuss restart issues with BECo- 3 l
1 June 25, 1986 -
Meeting on Appendix R schedular requirements July 30, 1986 -
Region I to discuss restart issues with BEco September 9-10, 1986 -
Site visit and discussion of licensing issues October 16, 1986 -
Counterparts meeting with BOI licensees November 24, 1986 -
Site visit and management meeting with BEco
- January 20, 1987 -
Region I to discuss Fire Protection Issues with BECo
v
~
54 I l
(2) Commission Briefing None.
4 (3) Schedular Exemption Granted =
l December 1, 1986 -
On licensee's request for exemption from Appendix J,Section III.A.6(b) to the extent that Type A test be conduc-
{
ted 18 months after.the previous test. l (4)' Reliefs Granted, February 12, 1986 -
Partial relief' from visual . examination j guidance in GL 84-11 (Inspections of q BWR stainless steel piping) ;
(5) Exemptions Granted l
None l
(6) License Amendments Issued Amendment No. 91, issued December 3,1985; raises the K-effec-l tive limit of the spent fuel storage pool from 0.90 to 0.95.
Amendment No. 92, issued February 4, 1986; changes TS Table 3.1-1, " Reactor Protection System Instrumentation Requirements".
Amendment No. 93, issued March 17, 1986", Removal from TS, the i details of the AISI Program.
Amendment No. 94, issued May 28, 1986; Reactor Pressure Vessel Pressure / Temperature limits to accurately reflect neutron exposure.
Amendment No. 95, issued May 28, 1986; Removes TS Section 6.15.
" Environmental Qualification" Amendment No. 96, issued July 1, 1986; Correcting the ASTM Standard reference for diesel fuel oil.
Amendment No. 97, issued August 6, 1986; changes the calibration frequency for reactor level, reactor pressure, and drywell' pressure surveillance instrument channels.
l l .
l
- )
1
- l l
. , 55 (7) TMI Items (Active)
I.A.1.1 Engineering Expertise on Shift I.C.1 Emergency Operating Procedures I.C.6 Guidance on Procedures for Veri fying Correct Performance of Operating Activities I.D.1 Detailed Control Room Design Review I.D.2 , Plant Safety Parameter Display System II.E.4.2(7) Automatic Isolation of Purge and Vent Valves on Containment High Radiation I
II.K.3.18 Automatic Depressurization System logic (8) Other Licensing Actions (Active or Complete)
- Visual Examination Requirements of GL 84-21
- Flame Spread Classification for Floor Covering Materials IST Program
- Modification of Vacuum Breakers Salem ATWS Followup ISI Program Fire Protection Program t
- Spiral Unloading Long-Term Plan !
- Thermal Sleeve Cracking
- Complete 5.5 Licensee Event and Part 21 Reports (1) Overall Evaluation l
During this evaluation period 36 Licensee Event Reports -(LER) were submitted in compliance with 10 CFR 50.73. Four of the reportable events were scrams involving control rod motion. The fifth scram was discussed in LER 86-008. Three of these scrams
. were caused by personnel error and two were caused by spurious MSIV closure. Two additional spurious MSIV closures with the reactor in shutdown were also reported via LER.
56' ,
An evaluation of th'e content and' quality of a representative ~i sample of the Licensee Event. Reports (LERs) submitted by Pilgrim 1 during; the November _1, 1985 ' to January 31, 1987 Systematic-Assessment of Licensee Performance (SALP) period was performed using a refinement of the basic methodology presented in NUREG-1022, Supplement, No. 2. This 'is the second time the Pilgrim LERS have been evaluated using this methodology.1The results.of this ' evaluation indicate improvement in that the Pilgrim LERs are above average in quality.
Three reports were submitted in accordance with 10 CFR' Part 21 requirements during the period. These reports identified inade--
quacies in the residual heatE removal ~ system (RHR) pump . minimum flow logic design,-. standby gas treatment system (SBGTS) design, ;
and defective safety related cable. ]
(2) _C_ausal Analysis 4
i During- the previous assessment period, common causal chains were. l identified involving inadvertent safety system actuations and'
)
missed surveillance tests. Surveillance testing continued to be i a problem during this period.- Four common causal chains were identified during the current SALP period. ]
Surveillance Test Program Adequacy Six LER's (293/85-28, 85-32, '86-04, 86-12, . 86-14,- 86-19) de-scribe surveillance tests which did not ful.ly implement tech-rical specification requirements. Five LERs (293/85-32, 86-15, 86-16,86-22,86-26) document missed surveillance tests. ~
Fire Protection l Five LERs (293/85-34, 86-20, 86-23, 86-24, 86-25) concerning degraded fire protection components and inadequate fire protec-
, tion compensatory measures were submitted.
Design Deficiencies Two LERs (293/86-13, 86-21) and two Part 21 reports were sub-mitted due to discovery of design deficiencies in safety related' systems.
. Spurious MSIV Closures Four LERs -(293/86-07, 86-08, 86-09, 86-10) submitted include spurious primary containment group I isolations. . In 'two cases the isolation of the main steam isolation valves (MSIVs) resul-ted in a reactor scram at power.
l
.57 5.6 Automatic Scrams and Unplanned Shutdowns (1) Automatic Scrams
~
The unit experienced five unplanned automatic reactor scrams during this evaluation period, four of which' involved rod motion. See Table 6 for details.
(2) Unplanned Shutdowns The licensee entered five unplanned outages and one significant unplanned power' reduction during the period. See Table 6 for details.
i l
l 1
U i
m
- 58 TABLE 1 ;
TABULAR LISTING OF LERs BY FUNCTIONAL AREA
, PILGRIM NUCLEAR POWER STATION.-
AREA CAUSE CODE !
j A B C D E X TOTAL i
- 1. Plant Operations 1 2 1 - -
8 12- l
- 2. Radiological Controls .
- - - - ~-
0
- 3. Maintenance -
1 - -
1 2 4
- 4. Surveillance - - -
1 2 9 12
- 5. Fire Protection 1 2 -
1 -
1 5
- 6. Emergency Preparedness' - - - - - -
0
- 7. Security and Safeguards - - - - - -
0
- 8. Outage Management and Modification Activities - - - - - -
0
- 9. Licensing Activities - - - - - -
0
)
- 10. Engineering and Corporate -
2 - - -
1 3 Technical Support
- 11. Training and Qualification Effectiveness - - - - - -
0 ;
- 12. Assurance of Quality - - - -- - -
0 TOTALS 2 7 2 3 1 21 36 l Cause Codes: A - Personnel Error l
l B - Design, Manufacturing, Construction, or Installation Error C - External Cause l 0 - Defective Procedure E - Component Failure X - Other I i u__________.J.__- __ _ ---
v _
. . 59 TABLE 2 LER SYNOPSIS (11/01/85 - 01/31/87)
PILGRIM NUCLEAR POWER STATION LER EVENT CAUSE j NUMBER- DATE CODE
SUMMARY
DESCRIPTION l 85-028-00 10/10/85 X INADEQUATE SURVEILLANCE PROCEDURE ,
FOR STANDBY GAS TREATMENT SYSTEM
, )
85-029-00 10/18/85 X HIGH PRESSURE COOLANT INJECTION SYSTEM AND ANTICIPATED TRANSIENT WITHOUT SCRAM SYSTEM INVERTERS INOPERABLE 85-030-00 10/30/85 X INADEQUATE RECIRCULATION PUMP START PROCEDURE 85-031-00 10/29/85 X FAILURE TO MEET MINIMUM SHIFT CREW COMPOSITION 85-032-00 11/25/85 B MAIN STEAM LINE HIGH FLOW SWITCH SETPOINT DRIFT -i 85-033-00 11/27/85 X MAIN STACK AND RBV MISSED SURVEILLANCE TEST 85-034-00 12/31/85 B TECHNICAL SPECIFICATION REQUIRED' FIRE DAMPERS FOUND DEGRA0ED 86-001-00 01/06/86 A UNPLANNED REACTOR SCRAM ON LOW 1 WATER LEVEL DUE TO OPERATOR ERROR !
86-002-00 01/16.J86 X REACTOR SCRAM DUE TO PRESSURE SWITCH SENSITIVITY 86-003-00 02/11/86 E 480 V SAFETY BUS INADVERTENTLY.
DEENERGIZED DURING MAINTENANCE 86-004-00 02/20/86 X STANDBY LIQUID CONTROL SYSTEM
. DECLARED INOPERABLE WHEN SQUIB VALVES NOT TESTED INSITU 86-005-00 03/07/86 B HEAD SPRAY. PIPING LEAK IN TORUS ROOM 86-006-00 03/16/86 B WELD LEAK ON. REACTOR WATER LEVEL INSTRUMENT LINE
_- j
)
', . 60 I LER EVENT CAUSE NUMBER DATE CODE
SUMMARY
DESCRIPTION 86-007-00 03/22/86 X MAIN STEAM LINE ISOLATION WHILE ,
REACTOR SHUTDOWN 86-008-00 04/04/86 X REACTOR SCRAM AND MAIN STEAM ISOLATION VALVE (MSIV) RESET PROBLEMS .
l 86-009-00 04/11/86 X IN SERIES PRIMARY CONTAINMENT I
, ISOLATION VALVES MO-1001-288 AND 298 INDICATING LEAKAGE PAST SEATS l 1 86-010-00 04/15/86 X MAIN STEAM LINE ISOLATION WHILE yEACTOR SHUTDOWN 86-011-00 04/19/86 X LEAKAGE PAST MSIV'S IN EXCESS OF LLRT CRITERIA 86-012-00 05/16/86 X INSUFFICIENT ONCE/ CYCLE HPCI SURVEILLANCE PROCEDURE l
86-013-00 05/30/86 B USE OF NON-SEISMIC GENERAL ELECTRIC TYPE CFD RELAYS 86-014-00 06/10/86 X INSUFFICIENT ONCE/ CYCLE RCIC SURVEILLANCE PROCEDURE 86-015-00 06/13/86 X PRIMARY CONTAINMENT LOCAL LEAK RATE TESTS OVERDUE 86-016-00 06/21/86 E BUS AS, BUS A6 AND STARTUP TRANSFORMER DEGRADED VOLTAGE RELAY CALIBRATIONS OVERDUE
, 86-017-00 07/01/86 X CONTAINMENT ISOLATION VALVE l LOCAL LEAK RATE TEST FAILURES 86-018-00 06/29/86 X GENERAL ELECTRIC AKF FIELD BREAKER FAILED TO TRIP AUTOMATICALLY 86-019-00 07/I5/86 X INSUFFICIENT MONTHLY ATWS SURVEILLANCE PROCEDURE 86-020-00 08/20/86 0 UNIDENTIFIED FIRE BARRIER WALLS AND PENETRATIONS
. 61 LER EVENT CAUSE NUMBER DATE CODE
SUMMARY
DESCRIPTION 86-021-00 08/27/86 B STANDBY GAS TREATMENT SYSTEM DELUGE SYSTEM SINGLE FAILURE MODE l
86-022-00 08/29/86 E MISSED TECHNICAL SPECIFICATION ~
SOURCE LEAK CHECK SURVEILLANCE 86-023-00 09/12/86 A MISSED FIRE WATCH AND FIRE
, WATCH PATROLS-i 86-024-00 10/07/86 X NON FIRE RESISTANT C0ATED i i STRUCTURAL STEEL 1
86-025-00 11/11/86 B MISALIGNMENT OF THE FIRE SUPPRESSION WATER SYSTEM 86-026-00 10/29/86 D FAILURE TO PERFORM RADIO-l ACTIVE MATERIAL SURVEILLANCE TEST OF STANDBY GAS TREATHENT l
)
l SYSTEM AND LIQUID RAD. EFFLUENT MONITOR 86-027-00 11/19/86 C LOSS OF 0FFSITE POWER DUE TO SEVERE WINTER STORM 86-028-00 12/23/86 X FAILURE TO RECOGNIZE THE EFFECTS OF ELECTRICAL ISOLATION RESULTING IN ESF ACTUATION 86-029-00 12/23/86 X LOSS OF 0FFSITE POWER WHILE WASHING SALT FROM YARO INSULATORS l
l l
l 4
__..__m. _ _ _ _____. ._ _ _ _ _ _ __m.-
v
~
o
, 62 TABLE 3 INSPECTION HOURS
SUMMARY
(11/01/85 - 01/31/87)
PILGRIM NUCLEAR POWER STATION Hours % of Time
- 1. Plant Operations 1603 24
- 2. Radiological Controls , 746 11 l
- 3. Maintenance 1196 18 l
l
- 4. Surveillance 1103 16
- 5. Fire Protection 413 6 I 6. Emergency Preparedness 249 4
- 7. Security and Safeguards 282- 4
- 8. Outage Management and Modification 1170 17 )
Activities
- 9. Licensing Activities * --
]
- 10. Engineering and Corporate ** --
l l
Technical Support 4
- 11. Training and Qualification ** --
l Effectiveness 1
- 12. Assurance of Quality ** --
Totals 6762 Hours expended in facility license activities and operator license activities are not included with direct inspection effort statistics.
l **
Hours expended in the areas of Training, Assurance of Quality and Engineering and Corporate Technical Support are included in the other
. functional areas.
l 1
e
-v
. 63 '
TABLE'4 ENFORCEMENT
SUMMARY
(11/01/85 - 01/31/87)
PILGRIM NUCLEAR POWER STATION A. Number and Severity Level of Violations Severity Level I O l Severity Level II 0 Severity Level III l
1 1 Severity Level IV 21 Severity Level V l 6 '
Deviation 1 Total 29 B. Violations Vs. Functional Area Severity Levels Functional Areas I II III IV V Dev Total
- 1. Plant Operations - - - -
1 1
- 2. Radiological Controls - -
1 3 - -
4
- 3. Maintenance - - -
1 1
- 4. Surveillance - - -
6 3 -
9 l S. Fire Protection - - -
5 -
1 6 l
- 6. Emergency Preparedness - - - - - -
0
- 7. Security Safeguards - - -
1 1 -
2 l 8. Outage Management and 1
Modification Activities - - -
1 1 -
2
- 9. Licensing Activities - - - - - -
0
- 10. Training and Qualification
. Effectiveness - - - - - -
0
- 11. Assurance of Quality' - - -
4 - -
4
- 12. Engineering and Corporate Technical Support
~
Totals 0 0 1 21. 6 1 29
'64 TABLE 4 (Continued)
C. Summary !
Inspection Report Severity Functional I Number Level Area Violation 85-32 V Surveillance Instrument channel tests were not being performed 1 monthly for the reactor )
. building vent and stack waste !
gas monitors.
.]
l 85-32 V Security Failure to perform a Safeguards proper search of a package brought into the protected area.
86-01 V Plant Post trip review 85-01 and Operations 86-02 lacked required recorder charts. Inadequate control- room log entries on disabled annunciators.
86-04 III Radiological 'A waste shipment of solid.
Controls metallic oxides on non-compacted trash lacked l required strong packaging and j quality control measures. '
86-06 IV Surveillance Replacement squib charges i were installed in the standby liquid control system from a batch that had not been tested during a manual initiation of the Standby Liquid Control System.
86-10 IV Radiological Radiation surveys of packaged Controls irradiated reactor components were not documented on appropriate radiation survey forms and maps.
86 IV Assurance of Quality control measures were Quality not taken in transferring radioactive waste shipments.
65 i
TABLE 4 (Continued)
C. Summary Inspection Report Severity Functional Number Level Area Violation 86-14 IV Assurance of Previously identified Quality inadequacies involving surveillance testing of the-high pressure coolant i
injection. system were not l corrected for six months. l 86-14 V Surveillance Failure to properly control measuring and test equipment. l 86-21 IV Surveillance Battery rated load discharge Test procedure was not updated to reflect system alterations and restorations.
86-25 IV Assurance of Failure and Malfunction Quality Report was'not completed by engineering personnel af ter they identified deficient station fire barriers.
86-25 V Surveillance Surveillance tests were performed without independent verification of system response and system restoration.
86-25 Deviation Fire Protection Failure to comply with the commitment to conduct quarterly fire brigade drills for all fire brigade members.
86-34 IV Security Improper package search and Safeguards inadequate follow up.
86-36 IV Fire Protection Fire brigade members had not received the required training.
86-36 IV Fire Protection Fire watches failed to perform the required hourly patrol of 4.he motor generator set room.
e e
4 66 TABLE 4 (Continued)
C. Summary Inspection Report Severity Functional Number Level Area Violation 86-37 'IV Fire Protection Inadequate fire brigade drill.
86-37 IV Modifications Safety-related modifications were not performed in accordance with applicable design requirements.
86-38 IV Fire Protection Adequate procedures and I drawings had not been I established for the station fire water system. l l
86-44 IV Radiological Failure to implement a Controls radiological control procedure for checking vehicles leaving the site. ;
87-01 IV Surveillance Failure to adhere to the procedure governing l surveillance testing of the Post Accident Sampling ,
System (PASS) system.
87-01 IV Maintenance Lack of procedure guidance on maintenance of the heat tracing control circuit relays fcr the PASS system.
87-03 IV Fire Protection Failure to take required action for inoperable fire protection equipment.
87-03 IV Radiological Failure to control a master Controls key to all locked high radiation areas.
87-03 IV Aisurance of Failure and Malfunction Quality Report not completed after a safety-related. bus transfer did not occur during a-
-surveillance test.
S 4
__.-_____________-_-_-__..-__.___--_____.,_.---.---_Q
'67 TABLE 4 (Continued)
C. Summary 1
Inspection '
Report Severity. Functional Number Level Area Violation -l l
87-04 IV Sur'veillance A surveillance test on Standby I Gas Treatment System failed to i
' meet the intent of the Tech Spec requirements.
)
87-04 IV Surveillance Failure to calibrate measuring and test. equipment.
87-04 V Modification Performing post-modification test on the refuel bridge without approved procedure changes, i J
87-04 IV Surveillance - Master test program procedures l do not adequately address surveillance test and post modification. test programs.
1 O
v e
s 68 TABLE 5 INSPECTION REPORT ACTIVITIES (11/01/85 - 01/31/87)
PILGRIM NUCLEAR POWER STATION Report l Number Inspection Dates Inspection Hours Areas Inspected I 85-30 10/22/85-11/22/85 674 Office of Inspection and Enforcement Safety System Functional Inspection 85-31 11/05/85-12/06/85 106 Routine Resident Inspection 85-32 11/17/85-11/22/85 43 Radiological Controls Program associated with spent fuel pool re-racking 85-33 -- --
Cancelled 85-34 12/02/85-12/06/85 31 Inservice Testing Surveillance Program for pumps and valves 85-35 12/09/85-12/13/85 209 Implementation of Environmental Qualifications Program 85-36 12/07/85-12/31/85 40 Routine Resident Inspection 85-37 12/16/85-12/20/85 40 Fire Protection Program 86-01 01/01/86-02/17/86 128 Routine Resident-Inspection 86-02 01/13/86-01/17/86 117 Radiological Controls Program / Follow-up
. inspection to 85-32 86-03 01/22/86-01/24/86 40 Emergency Preparedness Program
_-i_----.___--u__ ----_-__
v 69 '
l
-i TABLE 5 (Continued)
Report Number Inspection Dates Inspection Hours Areas Inspected 86-04 01/02/86 8 Inspection of radioactive waste shipment from Pilgrim by a
, representative of the' South Carolina Department of Health and Environmental Control 86-05 -- i Cancelled 86-06 02/18/86-03/07/86 962 Diagnostic special team ;
inspection 'of overall 1 plant operations' i 86-07 03/09/86-04/28/86 266 Routine Resident Inspection 86-08 03/17/86-03/21/86 34 Security & Safeguards- i 86-09 04/28/86-05/02/86 51 Radiological ;
Environm' ental Monitoring '
Program 86-10 03/24/86-03/27/86 40 Radioactive Waste i Packaging and i Transportation Program l
86-11 05/12/86-05/16/86 40 1 Corrective maintenance 4 on the Main Steam i Isolation Valves, Residual Heat Removal system valves and installation of high density spent fuel pool i storage racks 1 86-12 03/24/86-03/28/86 57 l Plant modifications !
involving analog trip system i 86-13 04/03/86 15 -
program , j 86-14 04/28/86-06/02/86 225 Routine Resident i Inspection I
. 1 1
70 TABLE 5 (Continued)
Report Number Inspection Dates Inspection Hours Areas Inspected 86-15 05/05/86-05/08/86 --
Reactor Operator Examination 86-16 04/14/86-0417/86 28 Radiological con ~trols program associated with post accident sampling and analysis 86-17 04/12/86-04/25/86 574 Augmented special l safety team inspection on operational events 86-18 -- --
Cancelled 86-19 10/20/86-10/24/86 206 Special health physics inspection on upgraded radiation protection program 86-20 --
Cancelled 86-21 06/02/86-07/07/86 346 Routine resident inspection 86-?2 06/12/86 22 Management Meeting 86-23 --
Cancelled 86-24 08/04/86-08/08/86 169 Quality Assurance and Quality Control over-view - Equipment classi-fication and vendor interface 86-25 07/08/86-08/04/86 350 Routine resident inspection 86-26 -- --
Cancelled 86-27 08/04/86-08/08/86 43 Maintenance program 86-28 08/04/86-08/08/86 20 Safeguards program 86-29 08/05/86-09/08/86 231 -
Routine resident inspection
~
71 TABLE 5 (Continued)
Report Number Inspection Dates Inspection Hours Areas Inspected 86-30 07/30/86 8 Management Meeting 86-31 09/08/86-09/12/86 60 Nuclear engineering program associated with seismic stress analysis l of safety related piping !
86-32 09/09/86 8 Management Meeting 86-33 09/30/86-10/03/86 34 Emergency preparedness program 86-34 09/16/86-10/20/86 248 Routine resident inspector 86-35 09/29/86-10/02/86- 29 Radioactive effluents program
, 86-36 10/20/86-10/24/86 50 Fire protection program-86-37 10/21/86-11/24/86 275 Routine resident- ,
inspection 1 86-38 11/12/86-11/14/86 53 Special inspection of fire protection program 86-39 12/09/86-12/11/86 160 Annual emergency preparedness exercise 86-40 11/25/86-12/31/86 360 Routine resident inspection 86-41 11/24/86 8 Management Meeting 86-42 12/08/86-12/12/86 28 Security and Safeguards program
\
72 TABLE 5 (Continued)
Report 'l Number Inspection Dates Inspection Hours Areas Inspected )
86-43 12/15/86-12/19/86 35 Maintenance program concurrent with outage management.
1 86-44' 12/17/86-12/19/86 28 ' Radiological controls -l
. program 1 86-45 09/03/86-11/07/86 --
Reactor operator requalification a
- examination j i
87-01 01/05/87-01/09/87 64 Plant modifications 1 involving reactor water 4 level instrumentation system and reactor ;
coolant hydrogen l injection system {
1 87-02 01/05/09-01/09/87 34 Surveillance program l and local leak rate !
testing l l
87-03 01/01/87-02/20/87 228 Routine resident inspection ]
87-04 01/12/87-01/16/87 104 Surveillance / Maintenance l
programs 87-05 01/12/87-01/16/87 33 Inservice inspection and surveillance program I
e
- l 1
)
73 l
TABLE 6
.]
UNPLANNED AUTOMATIC SCRAMS AND SHUTDOWNS (11/01/85 - 01/31/87) l PILGRIM NUCLEAR POWER STATION Power Date Functional Level Description Cause Area 01/03/86 100% Main turbine generator Equipment-failure - --
bearing vibration random )
required a controlled {
l plant shutdown for i
repairs l 01/06/86 Restart 1
01/06/86 10% Reactor scram on ves- Operator error and 0perations sel low level during inadequate main-restart. Caused by tenance excessive operator inattentive- leakage past feed-ness while manually water regulation controlling level and valves leaking feedwater regulation valves (LER 86-001) 01/16/86 100% With the unit in a Technician error Maintenance half scram configura- and design tion for maintenance deficiency-changeout of a hypersensitive reactor high pressure pressure switches switch, slight bump on the second pressure switch caused a false high reactor pressure scram (LER 86-002) 01/29/86 100% A recurrence of main Equipment failure - --
turbine generator random bearing vibration problems resulted in a forced power reduction to 10 percent power' e
0 6 1
4 4
,' s
m _ - - _ . __ _ _---_-_-_ _ ---- - _
74 TABLE 6 (Continued)
Power Functional Date Level Description Cause Area 03/07/86 100% Weld leak in the 4" Equipment failure Operations head spray piping required a controlled shutdown to facilitate repairs, (LER 86-005) 03/12/86 Restart
- 03/15/86 00% Increasing unidenti- Equipment failure - --
l fied drywell leakage ' random i required reactor shutdown. The licen-see found and repaired a weld leak on reactor water level instru-mentation line.
(LER 86-006) 03/31/86 Restart 04/04/86 100% A controlled reactor Equipment --
shutdown due to the failure - i detection of small oil random leak in the turbine hydraulic control system, (IR 86-07) 04/04/86 5% During a controlled Equipment failure - --
i reactor shutdown, spurious actuation automatic closure of the MSIVs of the Main Steam Isolation Valves (MSIV) initiated a reactor scram (LER 86-008) 04/04/86 0% Following the reactor Operator error . Operations scram described above, a second scram signal was received due to the scram discharge volume (SDV) high level signal (LER86-008) 04/09/86 Restart 4
4 9 -e
,...w
.:s. :
- *:. y
. .. r.
~
75 TABLE 6 (Continued)
Power Functional-M Level Description Cause Area 04/11/86 93% Indicated leakage from _ Equipment failure - --
the reactor water random recirculation system through the 'B' loop Residual Heal Removal (RHR) System injection valves forcard a shut-down for maintenance 04/11/86 10% During a controlled Equipment failure - --
reactor shutdown, spurious actuation automatic closure of the MSIVs of the MSIVs initiated a reactor scram (LER 86-008/IR 86-07) 04/12/86 0% A Confirmatory Action Letter 86-10 was issued regarding the April 4 and April 12 MSIV iso-lations and the RHR injection valve leakage.
The Confirmatory Action Letter was subsequently extended to cover correction of signifi-cant programmatic deficiencies. In July 1986, the licensee
' decided to continue the shutdown into 1987 and conduct refueling, install certain Mark I containment enhance-ments, and complete 10 CFR 50 Appendix R fire protection modifications.'
. Restart of the' unit is ',
pending NRC authori ,
i
' ,,.J: ,- ,-
,zetion in accordance,.f with Confirmatory:-
~
Action Letter 86-10. *d:i,- t" , .. .
~; '
,o ...* h.&.:p * ~M ' iAk.9y'. y 3. j;if.s . , '. t. M L9 ..
. . .. 1%
' S,y w_.:N hw;
,..i..' .: .
- ,. g s.a g,, T....,..>,o. ..,..; N ;
- .:-
. ~ ' ' k' ; .
- L C 'VMi .. .'
. ,lig"bk',.',ct.
, I .!. h,fE
- r*~* c'*
h^ if j ,;M.'YIh'.'V.,f.;0 Af '[
' $ M .(h' h.
a b . b ., .
yft,p$ , . i . $ $ $ $ M N $, g,2[
4 e
. e. . . ...
W8
.-;y.
a.
. i;;
p::y
.r.sp;. :y:.ry -
ra v;,e: p z. ., . ya 99p
.,g _a. ...
. t yq. . .q. _ v, . . ~ ..u.n.w. . %. .
y .7..
. . ;yw. - -
~
9,...e.,
t-n .*
.g-. {. ,
m.7+ ,, .x -
[
' ,p l
. l . " r.T,' M@- @ . . . 1 j h a * '- - -
"* 'A':s ? '!!. (T
, .- -s8 . . . . . . -
. r
- ,s F2
- r . . ~ . - - ~ i ou ,
dY I2; 2ii
,. c. ~ . - - -
8.s 75 7l
- a H b; 2
i.j .
~ ~ ~ ~ ~ ~ .
20 Il H =
~
>- m N z f. 0 O EU m - . . m m a LJ H gm J W wM i7 h
0 C_
51 c.
<- 0
.;j sa
~ ~ - - ~ . .
1
~ $ l w ~1 a
d e.
7 N
N ~ ~ - - a m
.O
?. ~ a ~ ~ - ~ ~
h 2
_ . .3d
- - ~ ~ ~ - - .
- 1 e.
13 ~ ~
ge - - ~ . ~
2 ;% 2" :" :: 0;
- 2d 23 da 2:
- n
- e y" en en e: e: e
- 3 52 Sa Sa 38 CE ?E
77 '
FIGURE 1 PLANT OPERATING
SUMMARY
Operating 1 5 10 15 20 25 30 Days Nov 85 *********************************************** 30 Dec 85 ************************************************ 31 Jan 86 ***** *************************************** 28 Feb 86 *********************************************
28 Mar 86 ********** ****
11 Apr 86 ***** ********
6 May 86 0
Jun 86 0
Jul 86 0
Aug 86 Extended Refueling 0 Sep 86 and 0 Oct 86 Maintenance Outage O Nov 86 0
Dec 86 0
Jan 87 0 .
1 5 10 15 20 25 30 DAY OF THE MONTH ,'
' **** Power Operation
, x . -
,n. :. y f.~L;.g. :.c k .'!.'6 -lk).]:,. :?S .'v . 9Ah...![f.hki?:'h 9 i.i'Y'kh N .l;.h;
+
g.ylUhN$$$
. n. .y..
1*
- 3. . . .
g ..
. . m,y.w
.... ,. ,;p .,.., .ws ,._ e x,, ,
.> ; p.m: .. .
w:,. www h.,
^
. :.A m' wm.v,.y
.t
. e,Le' , e . 'h< . %h. ;i s,:
. , - p. , w,
. m4+
- 3. y u
.. < o . s s bLf.m,e. v .,w 8 e & w,9, g@j*
- e f.,.
- c% . ,. ., . #.,~ - , ,
,o
- j. ^ - -
p ', y . . . , s 4 7. -
<5
, e I-3
- ,L k _. .
j W.. -
. . :l * : ,*
o
, .- 4 ji.1 - p :., ,
f
. b P4 k'+ '
's' '
44 .-y I
- - ~
T
_. /
h" g r ~. ijC
- l
'.8
\
Q
, i .,
.. t ,1 "., "
i,
t.,' p.J \ ..e D
/
' b.
s
- W( '/ .
. t ..
gg
[ ', j l/ p' 1
\. ,,f ',
W I $t' g
g , gg 7 2mw
./ ;!
, ' ~ ~
/.I, i
' , W EI
'$Em
.Q h l / /' 7 , ,
Vygg
- . b_ - h, )
v
// I .i [gy iyp,
)
- j,f . ~~V .'
- o. .
1.
j !f
.ws s -
.p 3;}' , ,
s
~..
r
)
l
/, \. *
- l
- p -
1 ,
L -r.-: N. j ( l l' ,
ma ..... 1n
. - ....: : . .e
/ ( 'i (;k. .
. , ),
g ,./l l"
., _. t
- g ..
f! li' N 3 e
" b - -
x .J.4l / .i
- i. !
{
\ l.bu.% e
, Q,. -
\ + # dit.p 9 ', i S
ZHJu
.)Fg;c I, 1:
j?;e th i
f1L.
i 1
i ii -
~ .. i2 /'*
.n em
' "'* **l g* ** Q ,
. yf.. '. 'l . .lj ',(
/j . ,i o
/r/, **
e
.f f
~e .
,, ,,,,- , 's... -
*/
/
w .j./. ' i U
fp ? ~
,,, l
..v
. s y.
" .: 'l / i
- 3. h . . .c - t - '
.s
/'
/ .<. 3
.s
/ g . ,y 't (g'#}!
1 '
it . ,. : ',
//f!f- ,/ f y,{. J.j -
' 'c ,'y 1 , .t ,l
- x
- ;.' ' \ ; ..
. __ . .%r ' %,,)., V 5'J 7 ,; e / a, . . .
/ j/ .
/
/ .
., 's. *, ,
o Z
G N XP PA O C ME s R s I
NE R I
Wa NE N G L
OP M ,
B h AM I
S P t u
Ll I o Pl L D m YP C
N R E
N O
l P
y C
EO T G F S .
R O .
E B .
M 9
E -
- i- t t ; li 1
{
. ! v
~
- e r. -
~
1
- ,c i=
f e s
' ~
c m, ;
- n. 2 o.
1 xu
_ Mr _
_ .~~ .
n e
r o
?=>
v
_ . c e e
_ o n
_ r ,
e
% m t_ J ;
=
c
_P
, L " E =.
r._.r
~
_ w- Fl f
e' W ,4. I .
_ ~-
.~
^
R s c
a m o = =E5:i . .
I RXP C ME s ump ,I8 J
NE I
R Wa OM =_
= ~~
= ,-
N G NE O L P h
AM I
S P t u -
~
L o P LU I D m y
E YP l P : " *:
C xN N
EO R O =
T
- G F S x
e o
R O E
M E
B m
L
" m
_._* r-
- p e - - , < '
x
\ !_
s ,
s' 3 ;, ., t
' i,
, a 's
% d \(
3
- -
- 5 -
' s
~
w v s
r_ .
5b's l
,, ,l _
,f ),-
I 1<
- s P
Mvv ' vv~
nn q ,,.
s, w I '
.. - J.
w66
.i, i-
.s -
l CARVER C / .; .. '
, ;... y8 0 r~, --
go, N
$5 ( ., ma
_. L . 6': [\
.g_
u -M.n s
.g
..f) (
%/ L -
P .,
p #' 4
- 4 d . ,I' . J-sA e
% l- / '
Ve,~ '
q
\ '
j '- % ., f. ~~' ,. $.. , .
_"j.R,,
4'~
i
' lll t[,.~ .. j
b d ' ;
\ r. .s u
/
9%
,f, I ,,; u. -
NN e g fN s
. 6
.M. A !
-*\
,t MI' , '. - ~-
~ **
R r
~ na
- a. .
~
. , ..,. , y * .*c.,,~
,i' ,.
y ::y .m .
~.
D
- J,L..
~
l omeuo u. . . x-
- t . -
- .'. J ,t .
so l
y(~
%. "' " [...s.o:! .
FI.7, -
" ~
fs l o o* .**- '
f , ,,, .
% h_ l/ Y D/i ..... -? e \
m p y- n. g --
e 1 m)
C
=-- .-
z -
.*..w l y w 5
g **
a::::t . ..
,/ '
y
"'*g.,. .
\ .y- 2
_ .h U
l '
- C.:. s .
} '
U / *,
,J , ,, 5 ./
,f k U .. I,
[" ,
0 05 1 Mae
\
e et _ %m - -
m oc s
i .
'I
[w 8
5 O
i
! ,' . ",. -- k . -
, , . . :., , a :
- s. * ,1 r, ., . . .
.3
. /ll lr . . 3
./ .
4 .
.f'.T..
.c
., ' 'g' ' * '. .
,n G ,. .
, h ,',. . "., ;
'. . ',. \ .' *.
? D ! Y) .
id/
..r .1;r.
, P. . . e T; ,/ e. /t -
.=g =
t: ,t ,
.,t"- f_ 'p r.'r.
- u. -
. . . s-a
.; m p/t:.Ih , *
. . a. .
,)
w ,-
ab ,l . . r J. lr *
~ - - g i ._ ,
' ' d ,9 T n .
, 3 ., -.
~, .,,y" q /; < p/*/ , .' b - *:. t s.
, s.
,. t ,- \
p ~
\
j ' r . .en A An.~
a '
g" .
- G ,,-
E ,a, e ....
7 , ..
/ t . l .., ,pv. d
'[A1,I
~ .
ilI.
s gg -
i I x ,,
3 /p \ ,
3 '
e .a .
1' ' '
O -), , ,~^
, , 4 $$ .. * '~
h r5 r o s / \
4*
a I' ' n ,S,'
,@r . a .
,. ~- ..; . ,ycrt.e])} s 4, ,.
.'$' &% 'h ,'s .
- s l 1, , e
.a , g i .,
il Q .:;- s .. v s .
,, t -
g - i Uf . _ . l__ yy Q Q $ *#
'/
.( ,
.x
.< 'nN, .: <
.m R.3 sv
- o
. f Q n(D,_'i tv ' ..
- \
Q. '
*= =
% A[a . r -.
/-
./
=
t
cn J
- JBheaC*t
,,v-j
, l 2 KINGSTON u "g* f i . -
"'/ ~p
/
-5 / g i 1
r
/
u l \ 7 l l 1 %% e '
' ^
~~6
~
, o <wf j .'
Ws .
~
f7 .. , ao CN** e es pp u , i -
~~
$ 'm '
. ==
O 9 . OO g(
,...,q..,3v.. . . m '
.u. ..
/ 7~ z, v A,r .
4 ,..'j!:. . , o sG *: %g; s?u i ..
/ , L .. ;b.. I
, ,.e
, ~y '
, j p7 ,.. m , , - @.,
' )' N p N )
. 8 ,,
, p s h
s' = 7' es n,,, i , M enpape 14
,/
0 A Q5 1Mue 12 13 14 ts N
e
! C MARSHFIELD
'#4 b #
-~
w - _ w. w 4 y
. (tSi
.' /
s
~
\=
j'
# ?."
/' ' '
~
l ... (~ ' ud f'Ib s..._.. , L ..
,;J-l.
~
#- I bh,,h
! 'r r , <
j I V{ . hGs
\, , ' \ [r
, \g /
= , .
D> K '
, ; . e
. ay.
' // (
e
,y .
w, - -
..t s
t,,., 9 . l m;
\
h1 / 1 '*0bO'I* '
*W y , .
h '
.,,,,, ?V g;
/
s ooe ** endl.s enM fef8 i ' 6 ,. sy I 14 16 16 17 ' 10 $O
! . i.
t 8 l l . .> u. f. t k. ., 8 . . - 1 v g hs y u .L;l
,,.s... .
i . * \\e, a
, t'4 L1 Mihj.{
.kN i * ' ' 2
,.:, h.
.:3,i, .
*:s* .
- s ., a;=1.;. '-
,= , .* ..
~.
g,,, . . , 9 i / Ag .e
- l. , ,
)e b :
s,
;;4,
.N
' g. ) . .
E
- , '. )
i 'g '%g f , y} ,
}4 55.
' ~
.: . ;, , .:..;...:!.^ ~ '.
g.. g
'/
X . ;:. - ,, . r, g
).. .
.. . . .s - Y'
?
vl~4l ji n % y 3
~
.) .e[;r_lgik .
3 y, . , h'(..
~
, ,,lh, y l .: s q K, g
, x..g,..s . . , . . . .l. . .
\.) ,.,
s,
\
,, y ;~ ' ^~,
,, k i \t
. ., 4 - -h ^
l'$l 1
'f.(
f ..
%. . ,, I
...,.:s .
Ng s .- dc1 ,
/
n~ , t ?'A . .. n. .. I \ $ \
.. L vN '.<
- .h$ . dt&dM .
N/hb
'A e !
f eg
.c ...
y .. e . E o &
- O g
V q f2 . s t h' Is t
\.
n*.. u
\-
'?
s f
.m_#
5 i
, ,,i ,A
, J U g, . . .' T_ . .
;Qig&1 \, I
\
I L,. __
- f . h.
s,, ~> y8 A'
'\i .'
Q i. g ll ' dYb M, V =. m- V ~ g -'
,4
-Q '
W-
- j s
f JKj
, _ " g Mkl 1
, \Ny .. .-
~~ % .
\ f't s 4
,A , . >
p
$ 5: !!nst!!!!!! !!: j!!!!!]!!ntunf?I!!:!!! Tints!!!!j!!!!:!!H!!!!!j!jnegggggy gggggggggggg g ill.iilliililliliill.ililliiiiiiiillill!Ilill ildlliliiilliiniiiillidihilillil!li 8 IHRINE54 !!}!!:!!! ; ^ P!)nnu tunnmmlummmmMMBmmmunmunnumnn l illillliliii.iliiIlli !iiililiilllIllkliliidili10il.hillisiiiiililillillii j im m gimmimmmt! min nunmmmannaistenmmmunm:m ;m:rmmum ilillill!.lil !il.lisilliilll?hlisil Ilu lilllEllIllllliliillinflillililihi l .nm!=nm sjnmnimjummm: jmru mumun=!!mm!nmm: ummn!m:::!n i hhillin H,iii llillilll!!iillilliitillainilll.lililiiili,iilllilluliiilllllill'iiiiiiiiillililliil i' .
!::;:mmmimummng:m! numummgmmum;j:mummn:= m;mmmmu illlililli!!Ihli.iliilillin,illililliliilliflhilliihillililillillinillilli lil!l.ll!latilliliiin n!!!!!::!!:mj:!!n:!;ntuntmm!!!!mm!!!nint !!! nfun!!!num!!!!!!!nm:!!" 1m!!!
l iillilliliiiniilli.iililiiiilhiilihllinlilli!mIllihihiiiilillinIlill ilh:!!!:m:!m!!!!!m!!!mn!!nm iliiiililiiIli!iilllliillitilllilllIllillilinlIlli linlisiiiifi!lilllI
~ 3 9W, ;,vi e. g tseg y r * -- 6 .
- w ,4 .
!nnu m!:tmu Ilfil
- !!:m!::!m!m!m:::!;n!!::m!!n!:!!:::!!:!n!!mn!!!! :!nn;!m:m::::::!m! rnm ilillilililiiillii!!!!illilli!iitiililIllillilill0iiIi!Hlii I .nilliniil0hihiilllilli.
.... ..:.........!!!!:11:1::!!!!::!!!!n!!!:3g!!!:::!!!!!!!m4:!!!!:::!!!p !!! !!:!!!!!;[!!n!j':!!
iiiall'inilliali,iliiili iililuliliill0liiniil ilLiiiiilidi!i lilli i li . ikii , !!!!!iii,,,I~ !
. m m , niti m , m i m ni m u m ,,,,,,,, m , m m ,
litiifiliillniill!iliii!!!illini,lillilili,1lliniLil liiiInhiid!!ililillililil?ilili minemm!nenurnuri::imetrunm!ru pumern,mmimimitpismemummernen: I!!hilililili!iin!,liillii!!!!Illililliliill/!,liliiillLliililililiiillil!i i m m : m m m m m m o n m in m aiin m m m ,,,m u m ,m ,,,,m ,m ,i m , m , m m ,,: m i, liiillilillillillillliliiil!llilli,!!llJiliiiillililllilliiiliii.,illill.lililil n; mum;nunn:n mun ::: nir ummuninnu '8""* 8""I'""'""I' "'""" h!!il,iliiiilliniillillliniili!liih!iihiihlilliiilli lInlilililillii!!illiiiiiillil nu :inm:nnn unmnmmumn m:nnm: n umm immn un;nn ;:nm n 1 N' 8 lIliill i illjihNii)gll.lgl .fN l l l l e
.l
9 E t e Ih I I E l j
. j 3 F
R 1 s 11 111 _
! is a I h}ii a e o hg=g , kl El -
E 1
.E I
]f 5 f 751 .!! 4 i MI
- Pl$j,i831.ii1}21g1[1 mEe aumEwE2m44 gg c f! !
is - m
> e } @
- em me + m + <
W M i um! :;:!nn;n!!nnunnn;!n!nn!nn!!nn:n:!;ntun:nnnun!!n!nnn!n iniiiliiiiiiiiiiiiiiiiiiiiillillillil'iiiliillihiilililillinillilillillihll
!!!! I ntu!:n!!!!! !! !!:!!:!!t!!j!!!!!!!!!j!nti! !!!!!:!!!!!:!! !!! !!!!!!! !!! Iff! :l!![!!!!!!!!! !
llllllili lill!.iiiiiiLl!!!ILllililillhinillit illllililllll.lilliiiiiiiill li!.!ilili .illllii - un:!nin n:!!!! nut!:nt!!stu :n!!:::n!! :ntt!nn:;!; !! [nin: !:n!!;!n: !:!n!!!:!!n!:! c.lilliilill ililli."liiiilliiililill lhill!ilisl lithiliillilthi.lihlillililllIllil Inmnnjninnunununun g!nunnu tunnnnunun!tsuntun!n Inn!;!;nn!:[:ns I.lilliLili !ilhilillililliliilli!Llifilliilli il liillililiiiiilliiiiiiiiiiiiil.llitlifilliliiiiil
!!!!!:!j!!!n!!!!:!!n!!!!!!!!!! !!! :!!!! I:tt!! ! !!!!:!!:!!! Itu!:!!!!!!!!!!!n!!!!!![ :f!!!jn!!!!!
illi Llil?illillllillhiihililillliifiliiiilliliiiiiiiiiillillilillihiliiililllirii i Inn:nn:nininnunusunn! nun unn un!nununununnn! nun:nnn !:n! Inn!n ' illihliiilillllllll lllIll!llillilllllhi illllll.llllllLlillliidill!dillLilliii liii
!!nn ;!!nunir!!!:Innn!!nglgninnun i!!lii!.l!)llilIIlliilill.!illlill ali!!liiillilllllllallii;lllill!ili nunnnnin;nunn lliii1}lli!.iillinili nun
!!!!!!!!!!!!!!:!!!!!n'!! ti![f!!!!!!!!!!!!!!!ft !!!!!(ftst!!!:!st!!!!!!g 'ggg:ggtt!n![!!!!ggint![
e liliiil!InL!ii!!iliihilli!!!!ii!Ililllililinililllihlnillill11l
= -
, _ _ . -}}