View source for JPN-91-026, Forwards Response to SALP Rept 50-333/89-99 Covering Oct 1989 to Jan 1991,per SALP 910604 Meeting.Efforts to Upgrade Procedures to Add Human Performance Enhancements Will Continue to Address Category 2 Rating in Plant Operations

{{Adams
| number = ML20077G356
| issue date = 06/21/1991
| title = Forwards Response to SALP Rept 50-333/89-99 Covering Oct 1989 to Jan 1991,per SALP 910604 Meeting.Efforts to Upgrade Procedures to Add Human Performance Enhancements Will Continue to Address Category 2 Rating in Plant Operations
| author name = Beedle R
| author affiliation = POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
| addressee name = 
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
| docket = 05000333
| license number = 
| contact person = 
| document report number = JPN-91-026, JPN-91-26, NUDOCS 9106270128
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE
| page count = 25
}}

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rociou nenen June 21,1991 JPN-91026 United Stat 9s Nuclear Regulatory Commission Document 'ma ol Desk Mail Ste* w PL .37 washing a s.C.20555

==Subject:==
James A. HtzPatrick Nuclear Power Plant Docket No. 50-333 Reaconse to NRC Svstematic Assessment of Licensee Performance (SALP) initial Renort 50-333/89-99 l

==Reference:==
NRC Letter, Thomas T. Martin to Ralph E. Beedle
                                                                                    .Regarding Systematic Assessment of Licensee Performance (SALP) Initial Report 50-333/89 99 Dated May 15,1991

==Dear Sir:==

The Nuclear Regulatory Commission (NRC) issued the Initial Systematic Assessment of Licensee Performance report for the FitzPatrick plant in the reference letter. A meeting to discuss the assessmo.it was held at the FitzPatrick Training Center on June 4,'1991.
The Authority's comments on each of the functional areas' evaluated in the SALP report are provided in Attachment 1. These comments constitute a formal statement of the responses'provided during the meeting and are included to provide additionalinformation regarding L                                         specific instances cited in the SALP ieport. Attachment 1 also discusses Authority performance, programs, and initiatives which were not addressed during the SALP process or detailed in the report.
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The Authority has reviewed this initial SALP report carefully. Although sorno difference of opinion exists as to the cause of specific events, the Authority agrees with the NRC assessment of performance at the James A. FitzPatrick plant and is proceeding aggressively to address those issues and improve plant performance.
This response is submitted in accordance with a revised schedule agreed upon by D. Haverkamp of the NRC and J. A. Gray, Jr. of my staff.
Very truly yours, W q' Ralph E. Beedle Executive Vice President Nuclear Generation Attachment cc:    U. S. Nuclear Reguiatory Commission Region 1 475 Allendale Road King of Prussia, PA 19406 Office of the Resident inspector U. S. Nuclear Regulatory Commission P. O. Box 136 Lycoming, NY 13093 Mr. Brian C, McCabe Project Directorate I-1 Director of Reactor Projects - 1/11 U. S. Nuclear Regulatory Commission Mail Stop 14 B2 Washington, D.C. 20555

ATTACHMENT 1 RESPONSE TO NRC INITIAL SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE PERIOD OCTOBER 1,1989 - JANUARY 31,1991 l
l New York Power Authority JAMES A. FITZPATRICK NUCLEAR POWER PLANT Docket No. 50-333 DPR-59

              ' Attachment 1 This document includes the Authority's comments on the SALP, the "9ms discussed, and the chan0cs agreed to at the SALP meetin0-
: 1. CHANGES DISCUS 3ED AT THE SALP MEETING Below are the chan00s to be made to the Initial SALP Report which were identified by the NRC at the June 4,1991 meeting.
: 1.      Page 5, Para 0raph 1, First Sentence l
Chan00 the first sentence to show that assessmnnt of plant conditions was not " hindered."
: 2.      Page 10, Paragraph 2, Last Line Delete statement regardin0 the effectiveness of the system engineer in ensuing post-work testing.
: 3.      Page 10, Paragraph 4 Delete the reference to Generic Letter 89-04.
: 4.      Page 21, Paragraph 1 Delete the reference to Generic Letter 89-04.
Page 2 of 23 l
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        ' Attachment 1 II. PERFORMANCE ANALYSIS II. A. Plant Operations This functional area was rated Category 2, declining from Cate0ory 1 in the previous SALP period.
The SALP Board concluded "there was an observed increase in the number of operator inattentioa-to-detail errors resulting in a significant increase in the accurrence of automatic reactor scrams" and that
                      " management attention to plant problems and the actions following l
inattention-to detailincidents were not always offective in preventin0 recurrence."
The Authority agrees that the number of scrams increased during this assessment period and that lack of attention to detail was a significant contributor. Attention to detail is repeatedly stressed throu0h shift meetin0s, ni0ht order entries and management review of critiques with operating shifts. Procedures have been, and continue to be, updated to do the following: add human performance enhancements; provide l                     additionalinformation to operators; improve the sections of surveillance L
tests which provide instructions for returning to a normalline-up; include evolutions previously not addressed; and, clarify notes and cautions. Efforts to up0rado procedures will continue.
An Operations Department procedure writer (a licensed RO) was added to the staff in July 1990, and a significant number of Operations Department procedures have been revised since then. Most importantly, however, mana0ement will emphasize error identification Page 3 of 23

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     ' Attachment 1 at lower levels in the organization and perform critiques and institute corrective action to improve procedures.
Specific Comments on the SALP Report Regarding the Operations Functional Area Page 4, Last Paragraph
: 1. The December 15,1990 automatic scram, (due to exceeding the 15%
;                  APRM setpoint during a reactor start up) was classified in the SALP report as an operator error due to increasing power with a steam and feed flow mismatch, o inspection Report 90-08 states that the root cause of the scram was weak operational control of the start-up process which resulted in the steam flow / feed flow mismatch. The Authority considers the root cause to be an equipment malfunction of the Feedwater Low Flow Control Valve.
l l                  o The SALP report states that operatorc did not effectively monitor steam flow / feed flow mismatch during power escalation. There is no direct measurement of steam or feed flow at the low flow conditions which exist during start-up. Operators appropriately monitored the valve controller electrical demand signal and reactor vessel water level. As soon as the operators observed water level decreasing concurrent with the electrical demand signal increasing from 60% to 100%, they promptly took the appropriate action.
Page 4 of 23

                   ' Attachment 1 Page 5, Paragraph 3 The SALP report states that trainin0 materia!s, includin0 lesson plans, were of poor quality. The license examination inspection report details the specific problems and states the lesson plans lack sufficient data on system interrelations and integrated plant operations.
A specific section for system interrelations was added to the ori0 inallesson plans as an enhancement. The section was provided as a convenient discussion mechanism for the instructors who are licensed or formerly licensed SROs and SRO certified instructors. The instructors use casualty procedures and their knowledge of the plant for instructinn on specific system interrelationships.
II.                 B. Radiological Controls This functional area was rated Category 3, declining from Category 2 in the previous SALP period, l
i The Authority is responding to the decline in this functional area in several ways. The Authority has developed a comprcnensive program to upgrade radiological performance. Several aspects of this pro 0 ram have been discussed previously and the radiological up0rado pro 0 ram was presented to the NRC at the mid-sal.P meetin0 in Au0ust 1990.
The objective of the upgrade program is to achieve a radiological protection program that will be recognized as a leader in the nuclear industry. The program includes the following specific objectives:
Page 5 of 23

m                                     ..                  . . .-__.
t Attachment 1 e Sensitivity toward radiological protection will be raised at all levels of the plant and corporate or0anize.iior, o Radiolo0 ical controls and mana0ement oversight over radiolo0 ically sl0nificant tasks will be improved.
o Radiologicalincidents during routine and non-routine activities will be prevented.
o Radiation worker performance and sensitivity toward radiological aspects of their jobs will be improved, o Performance of the Radiological Protection Department will be improved.
o The efficiency and offectiveness of the radiolo0ical pro 0 ram will be improved by streamlinin0 the administrative pro 0 ram and radiation work permit process.
o Collective radiation exposure will be reduced further.
Page 6 of 23

Attachment 1 The radiolo0 lcal up0rado program contains specific pro 0 ram elements and actions in the followin0 areas:
o Oversi 0ht and management.
o Personnel accountability and mana0ement expectations, o Radiological Protection Department organization, staffing, qualification, and trainin0-o Radiolo0 lcal worker qualification, training, and professionalism.
o Radiolo0 lcal adniinistrative program and procedures.
o Facilities and equipment.
o Reduction of high radiation sources, o Radiolo0 ical performance feedback and trendin0-Several elements of the program are described below, includin0 some items that were initiated since the end of the SALP period.
Training Radiation worker and technician trainin0 is necessary to improve radiological performance. The Authority is contracting with an outside reco0nized expert to develop and imptoment advanced training for our staff. The Authority intends to complete this effort Page 7 of 23

Attachment 1 I
before the next refueling outa00, presently scheduled for January 1992.
Management Expectations Ensuring that workers understand management expectations for procedure compliance and good radiolo0l cal practicos is a bl0 h priority. Direct observation of radiation worker performance by mana0ers and supervisors has been, anc is continuing to be, emphasized.
Contamination Control The Authority has made significant progress in reducing the number and size of contaminated areas. Approximately 90% of the FitzPatrick plant's restricted area is maintained free of radioactive contamination.
Radiation workers have received training on improved contaminatbn control practices and contamination events are thoroughly evaluated to prevent recurrence. The results are noteworthy. The rate of personnel contamination events has been reduced dramatically, trending downward consistently since 1987. The rate has declined from 0.5% in 1987 to 0.18% in 1990. So far, the 1991 rate is 0.04% - over a tenfold reduction from 1987 and a fourfold reduction from 1990. This program is fully implemented and will be continued.
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Attachment 1 Radiolo0l cal Occurrences The Authority maintains a system for trackin0 radiolo0ical occurrences. These include material deficiencies, procedure compliance problems and personnel contaminations. The rate of radiological occurrences has shown a si0 nificant decline since 1989.
The rate of radiological occurrences was cut in half between 1989 and 1990, and 1991 shows further reductions. This program is bein0 continued with the expectation of additional improvement.
Many of the recent up0rados and improvements in the FitzPatrick radiolo0i cal protection program described above were evaluated followin0 the March 19,1991 contamination event.
Section 4.6 of the Augmented Inspectiin Team's report states that "the licensee's actions and performance in re0ard to personnel protection were excellent." This report, in assessin0 the Authority's overall response, stated that the actions of the FitzPatrick radiation protection staf f were, in general, "commendeble."
The Authority is committed to maintainin0 a high quality radiation protection program that maintains worker doses as low as reasonably achievable. The Authority will continue to focus its attention on this arer and recognizes the r.eed to achieve and demonstrate improved performance.
Page 9 of 23

       .ittachment 1                                                                        ,
4 Specific Comments on the SALP Report for the Radiological Control Functional Area Page 6, Last Paragraph Th9 SALP report noted that the Authority instituted several organizational changes during the SALP period. Thcse organizational changos allow increased training and specialization for technicians in the radiological protection organization, focus additional management resources on operational radiation protection, and increase management oversight of radiation workers.
During the SALP period, the Authority increased the number of permanent radiological technician positions. The Authority has upgraded the entry level requirements from a high school diploma to a 2-year college degree or equivalent. This will allow the Authority to focus more training resources on specialized topics, producing a long term benefit.
The SALP report also notes that the number of radiation protection supervisors was increased from two io four, but implies that this change has not been effective in improving management oversight of radiation workers.
Full staffing at the increased level was not attained until October 1990.
Since that time, management presence on back shifts during outages and non-routine evolutions has increased and supervisory overtime has decreased. Inis increased management presence has been effective in improved procedural compliance.
The Authority's organizational changes have been effective. Many of the
      - Page 10 of 23

4 Attachment 1 changes were made late in the SALP period and were not in place long enou0h to demonstrate their effectiveness. The Authority believes that the benefits of these chan0es are bein0 realized now, and will be apparent in the current SALP period.
Page 7, Paragraph 2 The SALP report citos instances of failure to follow procedures. The Authority has undertaken steps to improve performance. Toward the end of the SALP period, the Authority made si 0nificant pro 0ress toward resolving several generic problems that led to procedural non compliances.
The most significant improvement was the implementation of a new Radiation Work Permit program. This pro 0 ram was developed using extensive input from plant workers and is designed to improve exposure controls and simplify administrative requiremersts. These enhancements allow Dreater oversi0ht of radiation workers and reduce procedural violations caused by unnecessarily complex requirements.
A systematic review and upgrade of radiological protection procedures was started toward the cr'd of the SALP period. This review is aimed at simpiifyin0 procedures and correcting human factor deficiencies which caused some of the procedural violations cited in the SALP report.
Mana0cment oversi0 ht of non-routine radiologically si0 nificant activities was increased substantially during this SALP period. New procedures were implemented which require progressively higher level management review and approval for evolutions based on anticipated radiological risks.
Additional guidance on defining non-routino radiologically significant work Page 11 of 23 l
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Attachment 1 has been provided to radiolo0i cal protection personnel to assure that appropriate controls and precautions are established.
The Authority is implementing a large-scale upgrade to its administrative program that will delineate management expectations on the need for and use of procedures. The program will identify activities for which procedures will be required, based upon the complexity of the task. The Authority mana0ement continues to stress the need for all personnel to comply with all procedures.
Page 7, Paragraph 3 The SALP report states that the Authority's corrective actions for identified problems were not always effective. The Authority improved the quality and thoroughness of corrective actions through severalinitiatives. The comprehensive review and upgrade of radiological procedures cited above will remedy several deficiencies. Procedures for reviewing and analyzing radiologicalincidents have been upgraded to provide better analysis of toot causes and trends, The Authority believes that significant improvements in identif,'ing and implementing appropriate corrective actions will be observed in the current SALP period.
Page 7, Last Paragraph Collective exporure at FitzPatrick is above average and the Authority is continuing efforts to reduce it. Exposure reduction efforts include the following:
Page 12 of 23

Attachment 1 o    A successful chemical decontamination of plant systems, which saved over 700 man-rom during the 1988 refuel outage. A similar effort is planned for the next refuel outage.
o    Hydrogen water chemistry and feedwater zinc addition as radiation control strategies, o    Emphasis on plannin0 and schedulin0 along with an increased management sensitivity toward radiation exposure reduction. The non-outa00 radiation exposure received during each TLD monitoring period (2 weeks) is co:.tinuously declining. At the bed inning of the SALP period, FitzPatrick averaged 12.9 rem per non outage exposure period. This was reduced to 7.6 rem per non-outa00 periods durinD 1991. Additionally, the spring 1991 maintenance outa0e was completed with radiation exposure 10% below projected values,
: 11. C. Maintenance / Surveillance This functional area was rated Category 2, unchanged from the last SALP period. S10nificant improvements and new programs have been started in this area that have resulted in improved performance. The NRC should consider the following:
o Overall maintenance activities have improved dramatically as evidenced by the positive results of the 2-week NRC maintenance team inspection, o Weak areas identified in the last SALP period involving surveillance tests (performance and operability _ issues) have been improved Page 13 of 23 l

Attachment 1 significantly, o The amount of planned maintenance performed is 40% to 60%
greater than during the pervious SALP period, o improved overall planning has resulted in better coordination and scheduling of activities during both outages and normal operation, and has helped to reduce outage radiation exposure.
: 11. D. Emergency Preparedness Emergency preparedness was given a rating of Category 1, unchanged from the previous SALP period. The report states, "This rating was based upon very good performances of Emergency Response Organization (ERO) memt'ers during two NRC-observed annual exercises, strong management involvement in the Emergency Preparedness (EP) program, and the exceptional features associated with the Emergency Operations Facility (EOF)."
Specific Comments on the SALP Report Regarding the Emergency Preparedness Functional Area Page 12, Paragraph 4 The report stated that there was a "need for closer coordination with h;           Oswego County officials in the development of offsite protective measures, since county actions were taken independently prior to the Authority recommendations."
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       .                                                                                                1 Attachment 1 The Authority has always closely coordinated the development of offsite protective measures with OswcDo County, and will continue to do so. Two factors may be contributin0 to the perception that additional coordination is necessary.
The first is that the county has the right (which it often exercises) to be more conservative and to take protective actions before they are required.
The protective actions are taken in anticipation that plant conditions will worsen and, ultimately, require that the actions be taken. The Authority will work with Oswego County to improve the timing of protective actions.
The second factor is the differences between I & E Notice 83 28 and NUREG-1210. The flow chart in the l&E Notico conflicts with the concepts contained in the NUREG. In one case, the county took protective action while Authority staff were discussing these differences prior to recommendin0 protective action. The Authority will develop a revised protective action flowchart similar to that in l&E Notice 83 28, but which incorporates the concepts outlined in NUREG 1210 and includes state and t
county considerations (weather and traffic, for example). In order for the i
Authority to do this, the differences betwoon the I&E Notice and the NUREG need to be resolved by the NRC, Page 12, Paragraph 4 The report states the Emergency Cirector "over-classified the exercise event l
l as a General Emergency." The Emergency Director's classification of a Gencral Emergency was made as a result of a fuel cladding failure indicated by a high readin0 on the main steam line radiation monitors. The scenario developers did not intend to give any indication of fuel failure and should not Page 15 of 23

Attachment 1 have given this h10 h main steam line radiation reading. Therefore, the resultin0 scenario allowed for a classification of general emergency.
Consequently, a difference in the drill scenario developed which created minor confusion among drill controllers and observers. The Authority will improve its scenario development process.
Pa0013, Paragraph 6 It was stated in the report that revisions to the 1981 Emergency Action Lovel (EAL) scheme "did not undergo an adequate PORC review." The EALs were submitted to the NRC for review in July 1990. The revision had not been implemented based on a regionalinspector's assertion that the chan00s should receive NRC review mint to implementation. The NRC review is still not complete. The revision includes updates to all fifteen event categories incorporatin0 changes which assure consistency with annunciator response procedures. A change to the Unusual Event No.1 cateDory to include initiation of ECCS as requested by the NRC is included in this revision, as well as the change resulting from the recent contamination incident.
l
: 11. E. Security and Safeguards l
This unctional area continues to be rated Category 1. The report stated this assessment "was based upon the implementation of a very effective and performance oriented security pro 0 ram."
1 The Authority places an appropriately high emphasis on maintaining its security program and will continue to do so.
1 Page 16 of 23

  ;                                                                                              l
        ' Attachment 1
: 11. F. Engineering and Technical Support Engineering and technical support was rated Category 2, which is unchanged from the previous SALP period. However, the Authority has l
l                       made improvements in this functional area that shou!d be considered for inclusion in the final SALP report.
Systems and Performance Engineering Programs These pro 0 rams have resulted in the intimate participation of engineerinDi n the daily maintenance and operation of the plant. This involvement has resulted in the self-identification and correction of many design and maintenance problems during the assessment period. Technical support provided to Operations and Maintenance by tho on site design groups was sl0nificant.
;                          The Performance Engineering Group has further developed and implemented important monitoring programs that are detecting plant problems before they become serious. These include rotating j                          machinery vibration monitoring, lube oil analysis, heat exchanger performance monitoring, and thermal performance monitoring programs. New performance testin0 capabilities have made it possible to predict and diagnose prob! cms with system hydraulic balancing, pump and fan performance, and ventilation system i
balancing, Additionally, the ASME Section XI (IST) Program is extremely effective in detecting component problems. A third party IST Program review has resulted in further enhancements to this pro 0 ram.
Fage 17 of 23 l

Attachrnent 1 Modification Program Approximately 175 plant modifications or design equivalent chanDes were implemented during the SALP period. This large number of modifications was completed using the newly imt.' imented, Authority wide Modification Control Manual (MCM) Program. The procedures and methods of control were completely updated and effectively implemented.
l The MCM pro 0 ram initiated a new modification closcout process which enhances the method for testin0 and declaring modifications operable. This process involves close coordination among all organizations responsible for design, installation, quality verification, and testin0 of the modification.
Drawing Control Program Over 4,500 drawings were updated during 1990. In addition, the followin0 were accomplished:
o     Over 325 drawin0 problems were identified and corrected, o     As part of the enhanced modification closcout process, important affected drawings are now updated and provided to the control room prior to declaring a modification operable, o     The drawing update / turn around time for the remainder of the drawings requiring update continues to improve and now Page 18 of 23 l
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Attachment 1 averaDes less than 3 months.
o     Flow process diagrams and operating procedure drawin0s for safety related systems were revised during the assessment period to eliminato differences between the two.
o     During the report period, an instrumentation loop diagram up0rado program was initiated and is in progress. Previously, loop diagrams were not part of the update process.
I Desi0n Basis Document (DBD)                                            >
This effort involves formal reconstitution of the JAF desi0n basis for selected systems. Durin0 the report period, significant pro 0ress was made on 4 DBD's with 4 additional systems planned per year. Based on the 4 systems which have been developed, there have been no significant design configuration problems identified.
Specific Comments on the SALP Report Regarding the Engineering and Technical Support Functional Area G. Safety Assessment / Quality Verification l
This functional area was rated Category 3, declining from CateDory 2 in the previous SALP period. While the Authority has conducted activities with an emphasis on safety, we have not objectively evaluated many of the activities performed at the FitzPatrick plant.
The Authority agrees with the observation "that the Authority l      Page 19 of 23 l
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* Attachment 1                                                                                 l personnel did not effectively control activities that they were performin0 and that when problems were identified, the corrective actions were often not timely or effective." The Authority recognizes the need for dramatic improvements.
In 1990, the Authority initiated a study of the Nuclear Generation Department staffing, including plant and corporate. The objectives of this study were to:
o Determine appropriate staffing levels for effective and efficient operation of both of the Authority's nuclear power plants.
o Evaluate specific functional areas and identify improvements in the Nuclear Generation department organization.
o implement recommended changes to the Nuclear Generation Department and adjust staffing levels as necessary.
As a result of this staffing effectiveness study, a number of recommendations have been evaluated and will be implemented over the next 5 years to improve the effectiveness and efficiency of the
                 -support provided to the FitzPatrick plant. The following specific actions will be take'n:
o Restructure the Nuclear Generation Department, including the FitzPatrick plant organization to better define responsibilities and provide increased management attention to technical, quality and administrative issues.
Page 20 of 23 f

! ' Attachment 1 o Consolidate all design basis engineering functions in the Nuclear Engineering Division, includin0 the formation of a Site Engineering group.
o Concentrate plant engineering resources on operations, including continuing the development of the system engineer function, o Dedicate resources to improve plannin0 and coordination of scheduled plant outages, o Perform a review of maintenance effectiveness and recommend solutions to improve performance, o Develop and implement a nuclear business plan for the Authority, linking objectives and resources.
o Create three interdepartmental general manager positions for coordinating activities under the general headin0s of Operations, Maintenance, and Site Support.
The Authority has taken steps to improve our ability to evaluate the success of our activities. These include the following:
o Quality Assurance Department skills were upgraded and quality awareness increased through extensive training of department personnel. Trainin0 ncluded i        one week courses in Audit Techniques; Electrical, Mechanical, l&C, and VT 1-4 Insprection; Non-Destructive Examination (MT, PT, RT, UT) for a total of 5 to 6 weeks training for all department members.
Page 21 of 23

         ,  e
       - Attachment 1                                                                           l o Seventeen (17) department members participated in a 6 month quality engineering course, which culminated in all 17 taking the American Society for Quality Control 6 hour Certified Quality Engineer Exam.
o A surveillance monitoring program was developed to monitor the performance of operating department personnel and identify trends.
The program was initiated in February 1991, but all development was within the SALP period, t
o Additional program assessments, some with recognized authorities as technical evaluators, are in progress or are planned for the functional areas of Licensing and Configuration Management.
Specific Comments on the SALP Report for Safety Assessment / Quality Verification l
Page 21, Paragraph 3 The SALP stated, "The adverse quality condition report program was ineffective in resolving some OA-identified conditions in that it lacked independent reviews, critical analyses of the effectiveness of the corrective actions, or follow-up on the suggested corrective actions" and "The QA Department was not always effective in eliciting corrective actions needed."
i Page 22 of 23 l
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Attachment 1 i
l During the last SALP period, the Quality Assurance Department initiated improvements to the system which documents and corrects conditions adverse to quality (the AOCR system) The AOCR system has been continuously improved since then. In Nc amber 1990 it was changed from a system utilized exclusively by OA to a system that can be used by any member of the plant staff. It is being utilized often by plant personnel.
The Authority is confident that the change in our AOCR system will provide long term improvements, Page 23 of 23
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