ML20247G894
| ML20247G894 | |
| Person / Time | |
|---|---|
| Site: | Calvert Cliffs  |
| Issue date: | 05/23/1989 |
| From: | Varga S Office of Nuclear Reactor Regulation |
| To: | Creel G BALTIMORE GAS & ELECTRIC CO. |
| Shared Package | |
| ML20247G899 | List: |
| References | |
| NUDOCS 8905310103 | |
| Download: ML20247G894 (9) | |
See also: IR 05000317/1989200
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NUCLEAR REGULATORY COMMISSION
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WASHINGTON, D. C. 20555
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May 23, 1989
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Docket Hos. 50-317
and 50-318
Mr. George C. Creel
Vice President, Nuclear Energy
P. O. Box 1535
Lusby, Maryland 20667
Dear Mr. Creel:
SUBJECT: cal. VERT CLIFFS SPECIAL TEAM INSPECTION (50-317/89-200 AND
50-318/89-200)
This letter forwards the report and executive sumary of the special team
inspection (STI) conducted by Mr. C. J. Haughney and other NRC personnel from
February 27 through March 31, 1989. The activities involved are authorized by
NRC Operating License Nos. DPR-53 and DPR-69 for Calvert Cliffs Nuclear Power
Plant, Units 1 and 2.
At the conclusion of the inspection, the team discussed
the findings with you and with members of your staff identified in Attachment A
of the enclosed inspection report.
The STI included two groups, an operations and maintenance group and a
managerent group. The operations and maintenance group examined selected
activities in the areas of operations, maintenance, quality control, surveil-
lance testing, and corrective action. The management team perfonned a review
of management effectiveness at Calvert Cliffs.
The team determined that the plant was staffed by competent, knowledgeable
people who executed their duties in a professional manner and were capable of
operating the plant safely. However, the team also identified a number of
deficiencies in the areas inspected that warrant management attention. These
deficiencies-included:
licensee maintenance procedures that did not contain
sufficiently detailed instructions to ensure siaintenance activities were
performed correctly or documented adequatcly, tte near absence of written
instructions for quality control activities, and numerous instances of untimely
and incomplete corrective actions for identified problems. The team concluded
that management's operating style, which placed primary emphasis on power
production, was a major contributor to the increased number of operational
events at the facility.
Two documents are enclosed with this letter. The executive sumary provides an
overview of the inspection team's findings in each area reviewed. The
inspection report provides a more detailed explanation of the team's findings.
We request that you respond, in writing, within 30 days of receipt of this
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letter identifying actions taken or planned to be taken to address the 14
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specific unresolved items identified in the enclosed inspection report and
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separately listed in Appendix C to the report. There are also many other
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Mr. George C.- Creel
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May 23, 1989
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weaknesses identified in the executive sumary and in the inspection report
that will also need your careful review and evaluation.
For these items, we
suggest that following your evaluation of needed corrective actions, you
arrange a meeting with the Calvert Cliffs Assessment Panel. At this meeting
you should be prepared to discuss both your current Performance Improvement
Plant (PIP) and any revision: to that plan, which are necessary to address the
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identified weaknesses.
Some of the items identified by the team may be potential enforcement findings.
Any enforcement actions will be identified by Region I in separate correspond-
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ence.
In accordance with 10 CFR 2.790(a), a copy of this letter and the enclosures
will be placed in the NRC Public Document Room.
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Mr. C. J. Haughney (questions concerning this inspection, please contact me or
Should you have any
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301-492-0967) of this office.
Sincerely,
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Steven A. Varga, Director
Division of Reactor Projects I/II
Office of Nuclear Rcactor Regulation
Enclosures:
1.
Executive Summar3
2.
Inspection Report 50-317/89-200,50-318/89-200
cc w/ enclosures: See next page
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Mr. George C. Creel
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May 23, 1989
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cc w/ enclosures:
Edward A. Crooke, President
Roland Fletcher
Utility Operations
Center for Radiological Health
baltimore Gas and Electric Company
Department of Environment
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P.O. Box 1475
2500 Broening Highway
Ba!timore, Maryland 21203
Baltimore, MD 21224
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Mr.' William T. Bowen, President
Calvert County Board of
Conrnissioners
Prince Frederick, Maryland 20768
D. A. Brune, Esquire
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General Counsel
Baltimore Gas and Electric Company
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P.O. Box 1475
Baltimore, Maryland 21203
Nr. Jay E. Silberg, Esquire
Shaw, Pittman, Potts and Trowbridge
4
.1800 M Street, NW
Washington, DC 20036
Mr. W. J. Lippold, General Supervisor
Technical Services Engineering
1
Calvert Cliffs Nuclear Power Plant
MD Rts 2 & 4
P.O. Box 1535
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Lusby, Maryland 20657
Resident Inspector
c/o U.S. Nuclear Regulatory Cossnission
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P.O. Box 437
Lusby, Maryland 20657
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Department of ' Natural Resources
Energy Administration, Power Plant
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. ATTN: Mr. T. Magette
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Tawes State Office Building
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Annapolis, Maryland 21204
Regional Administrator, Region I
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U.S. Nuclear Regulatory Commission
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475 Allendale Road
King of Prussia, Pennsylvania 19406
Institute of Nuclear Power Operations
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1100 circle 75 Parkway
Atlanta, Georgia 30339
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May 23 1989
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ENCLOSURE 1
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EXECUTIVE SUMMARY
INSPECTION REPORT 50-317/89-200. 50-318/89-200
CALVERT CLIFFS NUCLEAR POWER PLANT, UNITS 1 AND 2
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From February 27 through March 31, 1989, a team of 12 NRC inspectors performed
a special team inspection at Calvert Cliffs Nuclear Power Plant, Units 1 and 2.
The intent of the inspection was to determine the causes of recent events and
what was perceived as a general decline in the level of performance at the
Calvert Cliffs plant. The inspection team consisted of two groups, the
operations and maintenance group and the management group. The operations and
maintenance group conducted inspections in the areas of operations,
maintenance, quality control, surveillance testing, and corrective action. The
management group evaluated the effectiveness of Calvert Cliffs management
personnel in managing the safe operation of the plant.
Operations
The team observed many strengths in the operations area with respect to
conduct, professionalism, qualification, and procedure compliance. These
strengths were particularly evident during the team's observation of cosiplex
high-visibility activities such as plant startups and shutdowns. During the
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5-week period of the inspection there were three instances (not observed
directly by the team) in which operating personnel erred, resulting in a near
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loss of the main condenser or inadvertent actuations of the engineered safety
feature actuation system (LSFAS). The licensee described these errors as
cognithe mistakes or attributed them to human error in dealing with
procedures. The team, however, was concerned that such activities wem not
always conducted in the deliberate, step-by-step manner required to avoid such
errors.
The team identified programmatic weaknesses in the ama of administ:ative
controls. The licensee's procedures applicable to the control of plant
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operating and surveillance test procedure changes.wem fragmented and failed to
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fully implement technical specification mquirements. Tre team found that
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instrumentation maintenance personnel were using an inventory of pressum
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gauges for measuring and test equipment (M&TE) that were used to support
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safety-related surveillance tests, but that no controlling procedure was
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available, and there was no method of recall for gauges found to be out of
calibration. Even after the team identified the problem, the licensee did not
take timely corrective action to confom to their existing M&TE program. In
addition, the team found that the licensee's tamporary modification program was
confusing, failed to assure the proper review of all modifications by the Plant
Review Committee before their installation into the plant, and was not under
sufficient management oversight to minimize the number of temporary modifica-
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tions installed. The licensee required temporary modification tracking system
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was not being maintained in a current manner.
These administrative control weaknesses appeared to te the tusult of a gradual
decline in procedure quality because of multiple revisions and failum on the
part of the licensee's staff to insist on correct and workable procedums.
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The team observed many strengths in the qualifications and professionalism of
the operations staff.
Communications between operations and maintenance
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personnel appeared to be effective. However, the team observed less effective
communication between the engineering and operations staffs.
Interviews with
operators indicated little confidence in the qualifications of many of the
systems engineers and their ability to assist the operators,
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It appeared to the team that the licensee was making a serious effort to change
operator attitudes regarding following procedures, conducting deliberate
operations, and emphasizing safety.
Procedure adherence appears to continue
as a problem (several examples of procedure adherence errors occurred during
and after the inspection period). The present cadre of experienced operations
personnel can become more effective at ensuring operational safety, if proce-
dures are improved and procedural adherence is routinely required and practiced.
Maintenance
On the positive side, the team found that (1) craftsmen appeared to be
experienced, knowledgeable, and capable; and (2) the maintenance organization
was developing new improved maintenance procedures.
On the negative side, the work instructions used for performing the vast
majority of site maintenance activities did not contain adequate details to
ensure that the activities were being performed correctly, or to provide
meaningful acceptance criteria and hold points for quality control (QC)
inspectors. The instructions were so incomplete that craftsmen were required
to use their judgment in performing nearly every maintenance step, regardless
of the work process complexity.
Also, the licensee's procedure for controlling vendor technical manuals was not
being followed in that not all technical manuals received on site were being
sent to document control; and engineering reviews of the technical manual
changes were not being completed in a timely manner. The inspection team
identified 51 technical manuals (dating back to 1984) that had not been
reviewed. Also, the meaning, extent, and scope of the required engineering
review for vendor manuals was not clearly defined.
In lieu of an approved procedure, the licensee's instructions for issuing weld
rod were provided by memorandum. There were also instances observed where
there was inadequate control of the welding process.
Quality Control (OC)
The inspection team found that QC personnel were not effective in performing
the required independent inspection function, primarily because they had not
been provided with adequate written instructions, an essential tool for
performing this function.
In addition, these QC inspectors did not appear to
have technical skills equivalent to many of the maintenance personnel, a
situation that left them on a very unequal footing when attempting to con-
structively monitor the craft's work practices.
Deficiencies in the OC
inspection area included failure to perform all required inspections, lack of
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criteria for the QC inspector to ensure that inspections were performed
correctly, and indications of an adversarial relationship between QC inspectors
and craft personnel.
The team concluded that more licensee management attention is required in the
QC area to ensure that adequate instructions are available, and that required
independent inspections are performed correctly.
Surveillance Testing
The team found that the overall technical expertise of licensee personnel
involved with surveillance testing activities was acceptable. However, several
examples of personnel errors, which occurred during the period of this inspec-
tion, indicated that this area needed increased attention. Licensee personnel
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appeared to perfom many routine or repetitive surveillance test activities
without properly using the associated procedures. Such activities were not
always perfomed in a well-controlled and deliberate manner and sometimes
resulted in unnecessary challenges to safety systems.
The surveillance testing program appeared to be fragmented, and
responsibilities for implementing the surveillance program were diffuse.
Various types of implementation inconsistencies and a lack of clearly defined
authority contributed to a weakness regarding surveillance program control and
to difficulty in readily evaluating program effectiveness. Several factors,
including inconsistent and incomplete use of calibration stickers, the absence
of a master calibration schedule, and no verification of instrumentation
calibration status, contributed to there being no mechanism in existence to
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verify that the calibration control program for permanently installed equipment
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was properly maintained and implemented.
The team also found that several surveillance procedures were of poor quality,
in that they contained numerous technical and administrative errors. Only two
groups were found to be using a fomal procedure writer's guide.
In addition,
the licensee was not adequately evaluating vendor manual recommendations for
incorporation into surveillance procedures, was not appropriately utilizing the
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mechanism for administratively changing surveillance procedures, and was not
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initiating permanent procedure changes in a timely manner.
The team also found that, although several progrannatic changes and station
directives had been implemented recently, the continuing occurrence of plant
events and the findings of this inspection team indicated that those changes
had not been uniformly effective in addressing the fundamental deficiencies
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that encumbered the surveillance test prograia.
, corrective Action
The team found that the licensee had systems in place that could have been used
to ensure timely and effective corrective actions. However, the team felt that
the licensee had failed to effectively or fully utilize these systems.
Inadequate responses to identified concerns and deficiencies have been a
continuing problem for this licensee.
The team's review of Quality Assurance Program implementation found that t.he
quality audits and program evaluations were thorough.and effective in
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identifying specific areas in need of corrective action, and that the QA
auditors were capable and knowledgeable in a wide variety of disciplines.
In
addition, technical support personnel, including some system engineers,
appeared to be knowledgeable and aware of specific concerns involving their
systems. However, in many cases the licensee had not taken adequate or timely
corrective and preventive actions in response to significant QA audit findings
and reconsnendations, had not been timely or thorough in the determination of
root causes and safety significance of identified deficiencies, and had not
fully developed or utilized the integrated corrective action program (ICAP)
data base for trending equipment failures.
Management Effectiveness
By their actions and by aspects of their operational decisions, management
demonstrated to the plant staff an operating style that placed primary emphasis
on power production, with less attention to the safety aspects of plant opera-
tion. This style appeared to be at least partly based on a misplaced over-
confidence in the ability of their highly skilled and experienced operating and
maintenance crews to keep the plant operating safely without significant
reliance on engineering reviews or substantial involvement by QA or QC. In
addition, some plant workers interpreted an austerity pragram instituted in
the early 1980s as a message to "do more with less." The team felt that these
underlying themes may have inadvertently spurred the plant's highly skilled
workers to use their own judgment to solve problems and to take seemingly minor
shortcuts in order to achieve production goals. Unfortunately, the eventual
result of theso types of actions has been declining plant performance.
Management failed to recognize and respond to changes in the nuclear industry,
in the regulatory environment, and within their own organization. Having
remained relatively isolated from the progress in programs, procedures, and
systems throughout the industry and in the evolving nuclear regulatory arena,
the team concluded that many of the practices, systems, and controls in place
at the facility required upgrading.
The licensee staff at all levels generally lacked an understanding of the
unique'and demanding requirements for success in the complex project management
matrix organization that was in place at the facility. Project management
suffered from the lack of a shared information base, the lack of a site-wide
integrated planning and scheduling system, and the diffusion of accountability
and project ownership throughout the organization. The specialized managerial
and leadership skills required for success in the complex project matrix
organization were found to be deficient. The team concluded that the licensee
had not recognized that virtually every site activity was a project requiring
shared resources, shared goals, negotiation, c3 ordination, conflict management,
and communication.
The team concluded that senior site management had not been effective in
defining the organization's broad goals, performance expectations, and cperat-
ing philosophy. Site middle management tended to filter rather than translate
goals into measurable ar.d understandable perforriance expectations for the work
force.
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Management et all levels had been ineffective in incorporating safety and
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quality into their activities, choosing instead to respond to the ongoing
emphasis on production.
The work force has been effective at supporting power
production without benefit of adequate procedures systems, or programs, or
clearly defined work priorities and performance expectations.
The tram was concerned that unless all levels of the organization understand
t?iat quality and safety must be central to their activities and take priority
over power production, that the increased number of operational events of the
recent past could be expected to continue.
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