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{{Adams
#REDIRECT [[IR 05000254/1996001]]
| number = ML20132A409
| issue date = 12/04/1996
| title = SALP Repts 50-254/96-01 & 50-265/96-01 for 950723-961026
| author name =
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
| addressee name =
| addressee affiliation =
| docket = 05000254, 05000265
| license number =
| contact person =
| document report number = 50-254-96-01, 50-254-96-1, 50-265-96-01, 50-265-96-1, NUDOCS 9612160064
| package number = ML20132A404
| document type = SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| page count = 6
}}
See also: [[see also::IR 05000265/1996001]]
 
=Text=
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                                                                                            (
                                Quad Cities Station - SALP 13
                              (Report Nos. 50-254:265/96001)
t
      I.        INTRODUCTION
4
      The Systematic Assessment of Licensee Performance (SALP) process is used to
-
      develop the Nuclear Regulatory Commission's (NRC) conclusions regarding a
      licensee's safety performance. Four functional areas are assessed: Plant
      Operations, Maintenance, Engineering, and Plant Support. The SALP report
,
      documents the NRC's observations and insights on a licensee's performance and
      communicates the results to the licensee and the public. It provides a
      vehicle for clear communication with licensee management that focuses on plant
      performance relative to safety risk perspectives. The NRC utilizes SALP
      results when allocating NRC inspection resources at licensee facilities.
      This report is the NRC's assessment of the safety performance at the Quad            ,
      Cities Station for the period from July 23, 1995, through October 26, 1996.          j
                                                                                            '
      An NRC SALP Board, composed of the individuals listed below, met on
      October 30, 1996, to assess performance in accordance with the guidance in NRC
      Management Directive 8.6, " Systematic Assessment of Licensee Performance."
      Board Chairoerson
      J. L. Caldwell, Acting Director, Division of Reactor Projects, Region III
      Board Members
                                                                                              l
      R. A. Capra, Director, Project Directorate III-2, NRR                                  i
      H. B. Clayton, Acting Deputy Director, Division of Reactor Safety, Region III          l
      R. J. Caniano, Deputy Director, Division of Nuclear Material and Safety,
              Region III
      II.      PERFORMANCE ANALYSIS
      Plant Operations
                                                                                              l
      Overall operations performance remained good this period and major plant
      evolutions were conducted in a careful manner. Improvements noted since the
      last assessment included better implementation of performance standards by
      both licensed and non-licensed operators, improved procedural adherence,              .
      better implementation of out-of-service (005) tagouts, and improved trending          I
      and investigation of operations performance problems. However, some personnel
      errors and out-of-service (00S) tagging problems still occurred, and some
      examples indicating a weak understanding and application of Technical                  l
      Specifications (TS) and design information were identified. A few examples of
      operator knowledge deficiencies and procedure problems were also identified.
      Continued implementation of station performance standards resulted in improved
      performance of routine activities, especially in control room panel monitoring
        and communications. Major plant evolutions such as core reload and plant
                                                1                                            ;
    9612160064 961204
    PDR      ADOCK 05000254
    G                    PDR
                                            s
 
                                                                                    . .-.
      ,      ,
    -
  .                                                                                          l
      -
?
l                                                                                            1
      startups were conducted in a careful manner without significant operator
'
                                                                                            '
      performance problems. Operations assessment of damage, declaration of an
      Alert, and initiation of a Unit 2 shutdown in response to the May 10, 1996,
      severe storm was good.
I
i    The persistent reenforcement of management expectations and standards coupled
'
      with good oversight resulted in a decrease in the number and significance of
      errors; however, some personnel errors and 00S tagging problems were noted
      throughout the period. Inattention to detail during operator rounds and
      subsequent reviews resulted in a standby diesel generator and the control room
'
      ventilation system remaining inoperable for longer periods than necessary.            1
      Poor 00S preparation caused a 125 volt battery to fail and become inoperable
                                                                                            '
      and caused the shared standby diesel generator to be inoperable to one unit.
      Recent problems with verification of 00S valve positions demonstrated a lack
      of sensitivity to management expectations and lack of attention to detail by
      operators to the 00S process.
      Prioritization and control of risk significant activities improved from the
      last period. An example of good performance included the use of a computer
      program in the control room to assess risk of inoperable equipment. Weak
      performance was seen in some cases such as the low priority given Unit I
      standby diesel generator work during the QlR14 refueling outage.
      The process for Operations to prioritize the repair of important plant
      equipment improved over the assessment period and resulted in a noticeable
      decrease in the number of open control room corrective maintenance items.
      However, a large number of operator work-around issues, temporary alterations,
      caution cards, and alarming annunciators still exist. Repeat balance of plant
      issues challenged plant operations. For example, problems with the turbine
      control and combined intermediate valves, feedwater pumps, and feedwater
>    heater level control valves resulted in significant power reductions or taking
      the units off-line.
      Operator understanding and application of TS and design information was a
      weakness evident this period which was not specifically noted in the previous
      period. In one case operators inappropriately entered TS 3.0.A voluntarily
      for leak rate testing at power in order to reduce outage time. In another
      instance, operators made changes to a control rod drive test procedure which
      changed the intent of the procedure without the proper procedure review
      required by TS. Some additional knowledge deficiencies were noted such as a
      reactor trip when the turbine bypass valves opened unexpectedly. Corrective          ,
      actions to improve procedures have resulted in a number of procedure changes        '
      and some improvements in overall quality.                                            l
      The self assessment and root cause programs have generally improved.
      Operations established a low threshold for reporting problems and improved the
      trending and assessment of performance. Dedicated root cause evaluators
      assessed trends found in operators' performance and initiated corrective
      actions as needed.
      The Plant Operations area is rated category 2.
                                              2
l
                                                                                            :
                                                                                            1
 
                _  _
        ,      ,
    '
  e
                                                                                      ,
              .
        .
                                                                                      ;
                                                                                      !
                                                                                      i
      Maintenance                                                                    l
      Overall performance in the maintenance area resulted in an acceptable level of ;
      safety. Significant improvements were made in material condition and a major  i
      effort was focused on improving the work control processes. Nevertheless,
      throughout the assessment period overall plant performance was challenged with !
      continuing problems stemming from weaknesses in material condition, work      i
      control, supervisory oversight, and the quality of maintenance activities.    !
      These same areas were noted weaknesses in the last assessment period.          !
                                                                                      !
      The work control process was a major focus area in the station's Management
      Plan. Several iterations were made over the assessment period to develop the  '
      work control process. This effort included a maintenance standdown during
      October and November of 1995 to overhaul the process. Many work control        i
      process changes were implemented including the electronic work control system  :
      to track and control work issues, implementation of the 13-week rolling
      schedule, and the formation of the Fix-it-Now and interdisciplinary work teams
      to more efficiently cc plete
                              ,      plant work. However, the work control process
      remained cumbersome with problems evident in the ability to plan, schedule,
      and execute work and to meet the station's backlog reduction goals. In
      addition, some weaknessos were evident in the quality of work packages, the
      use of the problem identification system, and implementation of the 00S
      program in support of maintenance.
      Programs for the conduct of surveillance testing and inservice testing of
      pumps and valves were adequate. However, some programmatic weaknesses in
      preventive maintenance at the station were observed as indicated by recurring
      refueling bridge repairs, control room emergency ventilation (CREV) system
      failures, broken reactor building blowout panel bolts, and zebra mussel growth
      at the inlet to the diesel-driven fire water pumps.
      Supervisory development and training were emphasized during 1996 to strengthen
      performance and accountability. While good supervisory oversight was observed
      in some activities, inadequate supervisory involvement and oversight
l      contributed to problems experienced during several other maintenance            l
      activities, such as electro-hydraulic control (EHC) system adjustments,        l
      residual heat removal service water (RHRSW) impeller maintenance, and overhaul  i
      of the shared standby diesel generator.
      While several complex maintenance activities were performed well, such as the    i
      recent QlR14 feedwater regulating valve repair, significant problems were
                                                                                      '
l
'
      still evident in the quality of maintenance work. Weaknesses were identified
        in training, procedures, and work practices. This lack of quality resulted in
      plant events, increased safety equipment outage time, and unnecessary rework.
      Although increased emphasis was placed on training to improve craft skill      !
      levels and work analyst performance, training weaknesses led to rework on the
      air header compression fittings for the control rod drive hydraulic control
.
      units and the failure of a standby liquid control system squib valve to
i      operate during surveillance testing.
:
i
!                                                3
          .
 
                                                                                _ . . _ _
    ,      ,
  ~
.
    .
    Problems associated with work practices and procedures included misalignment
    of the reactor pressure vessel head, reassembly of a standby diesel generator
    room cooler in a degraded condition, and removal of the wrong source range
    monitor reactor protective system shorting links. These same problems also            :
    1ed to rework on the EHC system and ventilation system fans; miswiring of a          j
    drywell fan cooler and a low pressure coolant injection (LPCI) valve breaker;
    and wrong component work on an intermediate range monitor and standby diesel          ,
    generator cooling water pump.
                                                                                          l
    Although weaknesses in self assessment activities such as an ineffective wcrk        ;
    week critique report and the lack of a fomal self assessment process within
    the Material Controls Division were noted, some positive initiatives were            '
    started. These initiatives included improved tracking and trending of (1)
    work control and maintenance activities and (2) management or supervisory
    observations and critiques of work activities. Significant performance
    improvement from these initiatives has yet to be demonstrated.
                                                                                          .
    The Maintenance area is rated Category 3.
                                                                                          ;
    Engineerina
    Engineering performance was adequate and some improvements were noted from the
    previous assessment period, particularly during the last few months. However,
    improvement initiatives started at the end of the last assessment period were
    not successful in assuring consistently good engineering performance. The
    significant exceptions included poor corrective actions for identified                !
    structural steel deficiencies and poor engineering assessment of the severe
    storm structural damage impact on plant design. These exceptions demonstrated
    that continued management attention is warranted.
    Increased engineering involvement contributed to numerous material condition
    improvements during this period. Some of the more significant included
    upgrading the control rod drive, feedwater control, EHC, and reactor
    recirculation systems. In addition, some older engineering design issues were
    resolved in the latter part of the assessment period such as cable ampacity
    and degraded voltage issues. Engineering provided support in correcting a
    number of operator work-arounds and control room deficiencies. However, plant
    material condition issues requiring engineering resolution remained a
    challenge to operators throughout the assessment period. Equipment
    performance for some important plant systems, such as high pressure coolant
    injection (HPCI), RHRSW, and the CREV system remained poor.    Equipment
    failures also led to several forced shutdowns and plant transients.
    Problem identification improved as evidenced by a number of safety system
    deficiencies and deviations from the updated final safety analysis report
    found by engineering during this period. Items that were identified and
    corrected included improperly canceled or unimplemented modifications to
    gallery steel and HPCI pump nozzle supports; non-safety related power supplies
    to the control room ventilation toxic gas analyzer and chiller crankcase
    heater; and a single failure susceptibility in the reactor protection logic
    for the scram discharge volume level instrumentation.
                                            4
                            -- ._.              _    - . - . -          . -_.
 
    _.                                              __-            __        _          _ _ _ _
              _7.._________
      *
  .
          e
        Poor quality root cause evaluations and corrective actions were evident on
        several occasions. Inadequate corrective action for deficient structural
                                                                                                    '
        supports in the LPCI corner rooms resulted in escalated enforcement action.
        Narrow root cause evaluations contributed to repeated failures of the high
        pressure coolant injection system and the Unit 2 standby diesel generator.                  ,
        Engineering was slow to evaluate leakage test data from a residual heat
        removal service water vault, and failed to identify and correct the root cause
        of the loss of audible alarms in the control room until multiple failures                  4
        occurred. Engineering was also not fully successful in correcting
        longstanding problems with reactor building closed cooling water system
        temperature control valves and reactor recirculation motor-generator set speed
        control circuitry.
        Some engineering evaluations demonstrated a weak understanding of the plant
        design and design bases. The poor safety evaluation of missing reactor
        building siding following the May 10, 1996, severe storm event would have
        allowed plant restart with conditions outside the design basis had the NRC not
        intervened. Poor understanding of design and design bases also contributed to
        an inadequate initial submittal addressing a potential reactor water cleanup                  ;
        system line break outside the drywell and an evaluation which incorrectly
                                                                                                      '
        concluded that the high pressure coolant injection system was operable with
        associated vacuum breaker valves closed.                                                    i
        Self assessments performed by site quality verification and the independent                  !
        safety engineering group were performance based and identified good issues.
        Use of auditors from other licensees was considered a good practice. Choosing
        not to implement an engineering department self assessment program as planned
        since 1994, and choosing to postpone a safety system functional inspection
        scheduled for 1996 were missed opportunities to identify additional design and
        engineering program weaknesses.
        The Engineering een is rated Category 3.
        Plant Suonort
        Overall performance in the area of plant support was good; however, challenges
        remain in all areas. Radiation protection and chemistry performance exhibited
        continued improvement in ALARA planning, good plant water chemistry and
        increased availability of hydrogen water chemistry; however, station dose
        remained high. Security program performance was good, but some decline was
        noted in procedural adherence. The emergency preparedness program was good;
        however, there were some problems with the Alert declaration on May 10, 1996,
        and with the 1996 exercise. Fire protection performance remained adequate
        with some weaknesses noted with the maintenance and operability of the fire
        pumps.                                                                                      j
        Radiation protection performance was good, but continued to be challenged by                  ,
        emergent and long-standing engineering issues and a cumbersome station work                  l
        control process. Although total station dose was high, there was improvement
          in ALARA planning and source term reduction initiatives which resulted in a
        reasonable dose expenditure for the work accomplished. Improvements in the
        control of radioactive materials was noted as the number of items identified
                                                  5
.
                                                                                  , - ---
                                                        -=              ,                        ,
 
        . ,  c -  -
    4
        e      *
      outside of the radiologically protected area significantly declined.    However,
      numerous minor radworker performance problems continued to be observed largely
      due to an increased number of on-site contractors and poor oversight of
      contractor personnel. For example, inadequate oversight of the radiological
      waste vendor contributed to a resin spill in the radiological waste truck bay.
      The chemistry and radiological environmental monitoring programs were good,
      with excellent staff analytical (radiochemical and chemical) performance and
      several station improvements to maintain good water quality and keep
      radioactivity in effluent releases low.    Previous problems associated with
'
      completion of system modifications and cycling of hydrogen water chemistry
      were resolved, but maintenance of some chemistry sampling equipment continued
      to be a concern.
'
      Security program performance was good, but some decline was noted regarding
      procedural adherence. This resulted in problems with implementing the vehicle
      control and psychological testing programs. A contributing factor was weak
      management oversight of personnel performance. However, the overall security
      program was fundamentally sound. The licensee effectively implemented a
      tactical response drill program.
.
      Overall, the emergency preparedness program was good.    Emergency response
      facilities were maintained with recent facility and equipment enhancements
      made. The licensee successfully performed the 1996 biennial exercise; however,
i    there were some minor problems related to classification of the Unusual Event,
      slow initial NRC notifications, and slow correction of simulator problems.
      Overall performance during the Alert declaration on May 10, 1996, was good.
      However, minimum staffing of the interim corporate emergency operations
      facility was not achieved in a timely manner.                                    ,
                                                                                        1
      Fire protection program performance was adequate.    Fire protection            !
      vulnerabilities existed due to inadequate corrective action which led to
      problems such as low suction pressure for the fire pumps, and inadequate
.
      preventive maintenance which led to challenges such as a zebra mussel
  '
      infestation degrading fire system performance. In addition, there were
      continued problems with fire protection equipment failing to meet flow
      requirements which necessitated compensatory measures. The fire protection
      improvement program identified deficiencies in combustible loadings in certain
      safety related rooms.
      The Plant Support area is rated Category 2.
                                                                                        '
.
4
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1
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