ML20246K189

Dcrdr Supplementary Summary Rept

ML20246K189
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Site:	Pilgrim
Issue date:	04/30/1989
From:	BOSTON EDISON CO.
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ML20246K128	List: BECO-89-064, Forwards Dcrdr Supplementary Summary Rept, Including Addl Info Requested by NRC ML20246K189
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NUDOCS 8905170259
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April 1989 \

Detailed Control Room Design Review i

Supplementary Summary Report Pilgrim Station f

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TABLE OF CONTENTS SECTION PAGE LIST OF FIGURES ................................................... iii LIST OF TABLES .................................................... iii PREFACE ........................................................... iv SECTION I. INTRODUCTION A. Purpose .................................................. I-1 B. Background ............................................... I-l C. DCRDR Evaluation Criteria ................................ I-2 D. Activi ti es Since December 1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . I-2 4 E. Acti vi ti e s i n Prog res s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-5 F. Remaining Work ........................................... I-6 SECTION II. ASSESSMENT OF HED'S  ;

A. Introduction ............................................. II-1 B. Revised HED Assessment Process ........................... II-1 SECTION III. CORRECTIVE ACTIONS A. Introduction ............................................. III-1 B. Category A HED's ....................................... III-1 C. Category 1 -- Annunciator-Related HED's ................. III-6 D. Category 2 -- Panel Enhancements and Minor Modifications .. III-7 E. Category 3 -- Habitability-Related HED's ................ III-13 F. Category 4 -- HED's Related to Hardware Type .............. III-14 G. Category 5 -- HED's Related to Equipment Location ......... III-14 H. Category 6 -- Potentially Resolved HED's .................. III-15 I. Category 7 -- Operations (Non-Engineered) HED's ........... III-16 1 l

l SECTION IV. DCRDR SCHEDULE i 1

A. Resolution of Original HED's (1984 Set) .................. IV-1 B. Schedule for Remaining Work .............................. IV-4 SECTION V. RESPONSE TO SAFETY EVALUATION REPORT A. Introduction ............................................. V-1 B. NRC Comments and Boston Edison Responses ................. V-1 APPENDICES A. References ............................................... A-1 B. Human Engineering Observations ........................... B-1 ,

C. Human Engineering Discrepancies .......................... C-1 l D. Scope of Pilgrim Station DCRDR . . . . . . . . . . . . . . . . . . . . . . . . . . . D-1 l l

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LIST OF FIGURES l.

FIGJRE NO. PAGE III-1 Layout of Pilgrim Station Control Room III-5 IV-1 Summary Schedule - Pilgrim Station Control Room Design Review IV-5 i

LIST OF TABLES i

TABLE # PAGE I-1 Compliance with DCRDR Evaluation Criteria I-3 II-1 Pre-Screening Categories II-3

.II-2 Pre-Screening Results- II-7 II-3 Results from Quantitative Impact Evaluations II-8 II-4 Detailed Screening Results II-9 III-1 General Implementation Phases for HED Categories III-2 III-2 Category A HED's III-3 iii

i-PREFACE Boston Edison submitted .the Executive Summary Report of the Pilgrim Station Detailed Control Room Design Review Project (DCRDR) to NRC in September 1984, to comply with the. requirements of NUREG-0737, Supplement 1.

'In response, NRC issued a Safety Evaluation in.May 198S, in which NRC-requested that Boston Edison submit a supplementary summary report, with additional'information.

lThis. Supplemental Summary Report provides additional information requested by NRC's Safety Evaluation. This report _ describes progress since the previous report in 1984, identifies additional work required to complete-the DCRDR, and provides schedule commitments for the next phase of work, i

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1 SECTION I INTRODUCTION L A. Purcose l

l The purpose of this report is to update and expand upon the information in L the September 1984 Summary Report for the Pilgrim Station Detailed Control I Room Design Review (DCRDR), Reference 1.*

In summary, this report will:

• Describe the status of DCRDR at Boston Edison.

• Describe the process used for deciding upon corrective actioris, i

e Identify Human Engineering Discrepancies (HED's) for which corrective actions have been selected and their current status i and schedule for implementation.

• Identify HED's for which corrective actions are completed.

• Ider.tify HED's for which corrective actions are not yet decided {

and identify the steps underway to resolve them. l e Describe the work yet to be done, including new data collection ]

(new task analysis and inventory) in order to complete the DCRDR. )

e Respond to the NRC Safety Evaluation Report comments.

B. Backaround Boston Edison originally prepared and submitted a Program Plan and a Summary Report (References 2 and 1) in 1984. The Program Plan described the project organization and methodology for performing a human factors review of the Pilgrim Station Control Room in accordance with the requirements of NUREG-0737 Supplement 1. The Summary Report described the work completed, listed the HED's identified during the review, and .

outlined a series of corrective actions.

NRC conducted a pre-implementation audit of the DCRDR program during the week of November 26-30, 1984, and issued a Safety Evaluation Report (SER)  !

in May 1985. (Reference 3). The SER identified a number of deficiencies )

in the DCRDR program and concluded that the corrective actions were not i described in sufficient detail in Reference 1. NRC required that a i supplemental report be prepared and submitted to resolve their concerns. i i

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• References listed in Appendix A I-l l

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In August 1985, Boston Edison representatives met with NRC personnel at Bethesda, MD., to discuss the NRC's SER and Boston Edison's intended response. While the scope of the meeting included a number of topics, the central issue was NRC's concern with Boston Edison's approach to the System Function and Task Analysis (SFTA). The Technical Evaluation Report appended to the SER (Reference 3, pg. 11) concluded that substantial re-work would be required to produce an acceptable SFTA. In the August 1985 meeting, NRC concluded that Boston Edison need only perform the upgraded SFTA process for the two new Emergency Operating Procedures (EOP's) that had not been issued or reviewed during the DCRDR process.

In April 1986, Boston Edison met with the NRC Project Manager at our offices and we committed to submit this Supplemer.tal Summary report by a date four months after the end of the next refueling outage of Pilgrim Station (RF0 7). This commitment was documented in Reference 4.

In March 1989, NRC conducted an in-process review of the Boston Edison DCRDR project. This report does not address NRC's comments provided during that review (see Reference 6).

C. QCBDB Evaluation Criteria Boston Edison recognizes and is responsive to each of the nine NUREG-0737 criteria by which the NRC evaluates DCRDR Final Summary Reports. Table I-i identifies each of these evaluation criteria and the specific section(s) of this report or the revised Program Plan (to be submitted separately) that describes compliance with each criterion for the BECo DCRDR.

D. Activities Since December 1984

1. Physical Improvements in the Control Room Significant improvements have been made in the Pilgrim control room

• since the NRC audit in November-December 1984. The key items are summarized below,

a. Control Room Arrangement - Conceptual design, detailed design, procurement and installation have been completed for a major re-arrangement of the control room, including new operator " work stations." New consoles were provided for the reactor operator and shift supervisor, to replace conventional furniture previously used. Design of the consoles was integrated with design of the new plant computer system currently being installed. The new control room arrangement relocated the operating supervisor to the center of the room and placed his console on a raised floor. This provided him with a better view of the entire control room and better accessibility to safety-related panels. The console designs are based upon human engineering principles. The supervisor's console includes expansion capability for future annunciator improvements.

• See Appendix D for definition of the Pilgrim Control Room.

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TABLE I-1 COMPLIANCE HITH DCRDR EVALUATION CRITERIA 1

Criteria Reference *

1. Establishment of a - Program Plan qualified multidisciplinary review team.

2. Function and task ahalyses Program Plan to identify control room operator tasks and infor-mation and control require-

! ments during emergency operations.

3. Comparison of display and Program Plan-control requirements with a control room inventory.

4. Control-room survey to identify Section I deviations from accepted human and Program Plan factors criteria.

5. Assessment of HEDs to determine Section II which HEDs are significant and and Program Plan should be corrected.

6. Selection of design improve- Sections II and III ments. and Program Plan

7. Verification that selected Section I design improvements will and Program Plan provide necessary correction.

8. Verification that improve- Section I ments will not introduce and Program Plan new HEDs.

9. Coordination of control Program Plan room improvements with changes from other programs such as SPDS, operator training, Reg. Guide 1.97 instrumentation, and upgraded-E0Ps.

• Section numbers refer to this report; Program Plan refers to revised Program Plan to be submitted sepaiately.  !

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b. Communications Panel - The communications panel, used by control room-operators in both routine operations and emergencies, was redesigned and replaced. The new panel is integrated into the shift supervisor's console described above. The panel includes conventional telephones, radios, plant paging circuits, public address system, and automatic ring-down circuits (including the NRC. Emergency Notification System), plus evacuation alarms.

c. Panel Hardware Vooraded - Several plant design changes were made that resolved " Category A" HED's by replacing equipment. These included replacement of.the reactor mode switch (SB-1 switch replaced by SB-9 switch), replacement of about 20 recorders with a preferred- type, and partial replacement of reactor water level indication (which resolved an HED related to reactor water level common zero).

d. Additional Instruments - Two instruments were added to the panels to provide information needed by the operators while implementing Emergency Operating Procedures (E0P's). The added devices are a torus pressure indicator and a primary containment water level indicator.

e. Plant Comouter - A General Electric " Emergency and Plant Information Computer" (EPIC) is installed and will shortly be operational. This computer provides an enhanced operational information source for the operator, including a Safety Parameter Display System (SPDS). The control room layout incorporates provisions for four EPIC terminals within the new operator consoles.

2. Other Improvements to Enhance Ooerator Performance Besides the physical improvements to the control room environment, summarized above, other activities were completed that further enhance the operator's ability to prevent and mitigate an accident.

While these activities are not part of DCRDR, they are summarized here to present a more complete picture of Boston Edison's efforts to enhance operator performance.

a. Simulator - Boston Edison has constructed and is now operating a plant-specific simulator. This facility improves the quality and frequency of operator training. It provides increased opportunities for projects, such as DCRDR, to observe the control room environment, and to demonstrate and evaluate potential control room changes before committing to installation at the plant. The simulator has a transient capability to allow its use over wide range of critical events.

b. Uoaraded Emeroency Ooeratina Procedures - Boston Edison has upgraded the E0P's based upon Revision 4 of the BHR Owners' Group Emergency Procedure Guidelines. The upgraded E0P's were developed and validated on the Pilgrim simulator, and reflect plant-specific response characteristics to severe transients.

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c. Safety Enhancement Proaram - The Safety Enhancement Program (SEP) focused on understanding possible severe accidents and developing preventive and mitigative strategies. SEP was beneficial to DCRDR because severe transients are more realistically reflected in the E0P's, and because the control room was modified to include additional controls for added equipment (third emergency diesel-generator, direct torus vent). For more information on the Safety Enhancement Program, please refer to References 7 and 8.

E. Activities in Proaress In addition to completing the physical corrective actions just described, Boston Edison has progressed in several aspects of planning and analysis for the DCRDR project. (All corrective actions summarized here are described more fully in Section III.)

1. HED Assessment - Work has continued on the assessment of Human Engineering Discrepancies (HED's), including actions to resolve the NRC's SER comments. Highlights include:

a) A new process for "re-screening" HED's was conceived, developed, tested, and independently reviewed. The new process is intended to identify a logical, consistent, documented basis with which to establish the priorities for correcting HED's. The process takes into account both the technical benefits of correcting HED's (including considerations of safety and availability as well as human engineering principles) and the costs of corrective actions (monetary costs, training burden, risks of error due to change, etc.). This process is described in more detail in the Program Plan and summarized in Section II of this report.

b) The re-screening process was applied to the original 153 HED's, producing the evaluation used as a basis for the corrective actions described in this report. Results of the re-screening are discussed in Section II.

2. Panel Enhancements - Conceptual designs have been completed and approved for a " paint / label / tape" enhancement program for the main control panels in the control room (including back panels). The designs include all new labels in a hierarchical scheme, addition of a demarcation scheme throughout the panels .

(where appropriate), and improved mimics. An interim version of this enhancement program has been installed on two panels in the  ;

control room and three panels in the simulator. The interim installations have provided an opportunity for verifying concepts and for obtaining operator feedback. This project includes a replacement of meter scales that did not conform to NUREG-0700 guidelines.

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3. Switch Improvements - Preliminary design documents have been approved for switch improvements. These improvements include corrections such as new escutcheons, handle replacements, and replacement or rewiring of selected switches. In addition, a switch standard will be developed.

4. Design StandardL - Design standards have been prepared and approved for labels, mimics, demarcation, and meter scales.

These were used for design of enhancements and will be established as guidance for future panel work.

5. Annunci A. tor Conceptual Desian - Work was begun to evaluate the numerous annunciator HED's and to determine the best corrective action. Work will resume in mid-1989 (see Section III).

6. Liahtina Survev - A lighting survey was performed in late 1988, resulting in identification of several potential new HED's.

Corrective actions are described in Section III.

F. Remainina Hork The remaining work on the DCRDR project is currently being planned. The specific activities are outlined below and the schedule for completion of these activities is included in Section IV. Details of the methodology for completion of these activities will be provided in the revised Program Plan (to be submitted separately).

1. System Function and Task Analysis - When the Boston Edison Detailed Control Room Design Review began in early 1984, the symptom-based E0P's were only in a draft state, and two E0P's had not been drafted. Boston Edison committed to the NRC to perform additional System Function and Task Analysis (SFTA) on the two new E0P's when they were issued. The initial set of E0P's was based upon Revision 2 of the BHR Owners Group emergency Procedure Guidelines.

In 1987-88, the entire set of Pilgrim E0P's was rewritten and re-issued, including the two new E0P's. The E0P's were upgradetto Revision 4 of the BHR Owners' Group Guidelines, which are substantially different from the Revision 2 guidelines. Changes in the entire set of E0P's are sufficiently extensive that Boston Edison will perform a new SFTA on the entire set (rather than on only the additional two).

Details of the new SFTA are being developed and will be described in a revision of the Program Plan, to be submitted separately.

2. UDdate of the Control Room Inventory - He will update the Control Room Inventory to reflect changes in the control panel configuration and any panels added to the defined scope. The inventory will be used in the verification of Task Performance Capabilities to compare I the information and control requirements determined in the SFTA to l the actual control room configuration.

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L 3. Verification of task Performance Capabilities - Following the j completion of the SFIA, we will conduct a Verification of Task i Performance Capabilities. The objective of this activity is to '

ensure the availability and suitability of the required control room

, instrumentation and controls. J

4. Validation of Control Room Functions - We illi conduct a Validation of Control Room Functions to ensure that the functions allocated to the Control Room operating crew during emergencies can be accomplished effectively.

5. Control Room Survey - He will conduct the control room surveys that were not previously completed. These surveys include:

- Noise Survey

- Heating / ventilation / air conditioning (HVAC) survey

- Computer survey (6.7) )

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- Sections of surveys 6.8 and 6.9 not done previously  !

He will also review any plant equipment that has been installed in the control room since the surveys were conducted in 1984. In addition,'we will survey any panels added to the scope of DCRDR since the previous survey. This survey will determine whether the new equipment conforms to the NUREG-0700 guidelines and will be conducted in accornu,ce with our Program Plan.

6. Assessment of HED's and Selection of Corrective Actions - The work previously performed plus the new work described above (items 1 through 5) will result in a consolidated list of HED's. The HED's will be assessed for significance as described in the revised Program Plan (and summarized in Section II of this report). He will then select design improvements or o # r corrective actions to correct the safety-significant IIED's, unless corrective actions are not justified. (Many HED's will already be addressed by the corrective actions described in this report.)

7. Implementation and Verification - Selected design improvements and other corrective actions will next be planned and implemented. As part of the implementation Boston Edison will verify the corrective actions will provide the necessary correction and vill not introduce new human engineering discrepancies.

The results of the new data collection ef t,rt (itcic 1 through 5),

selection of additional corrective actions, anf sch Jules for implementation will be reported to the NRC in a fir 21 DCRCR summary report, by November 30, 1990.

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l- SECTION II ASSESSMENT OF HED's A. Introduction I In 'its Safety Evaluation Report (Reference 3) the NRC noted that implementation of the BECo assessment process, to determine which HED's are significant and should be corrected, had not yet been completed. This section provides an overview of the revised assessment process which has been applied to the original set of HED's, and will be used for future HED assessment.

After receipt of the NRC SER in 1985, Boston Edison started a project to l improve the HED assessment process and to use the improved process to

! re-screen the original HED's. The purpose of the improvements was to provide better documentation of the HED screening criteria and results, establish a more quantitative basis for setting priorities, and to incorporate cost-effectiveness considerations into the process. Soston Edison committed to perform the revised a:sessment by letter to the NRC (Reference 4).

The HED assessment procedure reflects the requirements of NUREG-0700, NUREG-0737 and NUREG-0800. In addition, it considers criteria for plant safety and availability.

B. Revised HED Assessment Process

1. Overview The revised assessment methodology supplements the HED assessment process described in the previously issued DCRDR Program Plan (Reference 2). It provides a method to categorize HED's for implementation, and it evaluates the potential consequences of unresolved HED's.

The products generated by this assessment methodology are:

a. A list of HEDs grouped in seven categories, according to probable methods for implementation of corrective action.

b. A list of HEDs ranked by relative importance to transient or ,

accident risk, considering the risk of contributing to the initiation of r.n event as well as the potential to affect operator performance during response to an accident or transient.

c. A list of HEDs ranked by relative importance to potential costs (costs that could result if the HED is not corrected, or costs that are avoided by correcting it). The cost impact considers four contributions: the potential for inadvertent plant scrams, equipment damage, extended outage duration, and technical specification violations.

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d. Documentation that identifies the cost and risk impact from (

selected HEDs and the qualitative and quantitative bases for their relative importance rankings.

In summary, this procedure provides the estimate of the relative risk and the relative cost (lost productivity) but does not provide absolute measures for either quantity.

2. Revised Assessment Methodoloav The revised HED assessment methodology supplements the initial classification and methodology described in the Program Plan. The overall process is as follows:

• The initial set of Human Engineering Observations (HE0's) had previously been assigned to Categories A, B, C and D on the basis of their importance to plant safety, availability, and reliability, as described in References 1 and 2. The starting point for the additional pre-screening process was the set of 153 Human Engineering Discrepancies, consisting of Categories A, B, and C.

• The appropriate DCRDR team mertbers conducted the pre-screening process which separated all the HEDs into seven implementation groups for development of the appropriate disposition.

• The team then conducted the detailed screening process which provided a detailed analysis of specific HEDs to evaluate the potential risk and the averted cost impact of the HEDs.

a. Pre-screenina Process - Performance of the pre-screening process included the following tasks:

• Review of each HED in the control room and verification of the HED as originally stated against configuration of the plant. Any changes to the as-built configuration and design documentation affecting the HED as originally stated were noted as necessary, i

• Each HED was assigned to one of the seven implementation groups in Table II-1. If applicable, any references or justifications were noted in defining the appropriate group chosen for a particular HED.

If during the review process or at any time after the completion of the review it was found necessary to transfer the HED to another category, the documentation was revised to properly track HED implementation.

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i TABLE 11-1 PRE-SCREENING CATEGORIES I

1. Annunciator-related HEDs.

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2. HED's for correction by surface enhancements (paint / label / tape / meter scale) or minor relocations of instruments, or switch handle change.

3. Control room habitability and environment-related HEDs.

4. Hardware-related HEDs associated with a less-than-desirable choice of equipment type or manufacturer based on human factors concerns.

(Example: improper shape or size of component or method of changing component status.)

5. Hardware-related HEDs associated with a less-than-desirable location i for the component relative to the operator's performance of normal or emergency procedure tasks using the component under review.

6. HED's that are potentially resolved, pending verification and validation.

7. HED's with administrative or operations disposition (Example:

operations procedure changes).

Source: F2ference 11.

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b. Detailed Screenina Process - This process provided a detailed analysis of the HEDs in three of the seven categories identified in the pre-screening: Category 1 (annunciator-related),

Category 4 (hardware type), and Category 5 (hardware location).

These three categories were chosen for the detailed analysis because of their potential cost, compicxity, and disruption to the Control Room in the implementation of corrective actions.

For the other categories detailed analysis and prioritization is either unnecessary because corrective actions for the. items is justified without the detailed analysis, or the type of HED is not suited to this type of analysis. Forty-six (46) HEDs were subjected to the complete screening analysis.

The detailed screening process was conducted on June 6-10, 1987 at the Pilgrim control room mockup with the multi-disciplinary team present including operations and human factors representatives.

The detailed analysis was performed by a team using the approved procedure (Reference 11). To guide i s team, the procedure includes forms and tables of HED rating criteria guidelines.

Details )f the process will be provided in the Program Plan

. revision to be submitted separately.

The impact of risk was determined through two types of contributions: (1) potential for the HED to affect operator performance during their response to a plant transient or accident, and (2) HEDs that can contribute to the initiation of an event by affecting routine operator performance during plant power operation, startup, shutdown, cold shutdown, or refueling. Qualitative evaluations of the relative significance of each HED are combined with quantitative information from representative probabilistic risk assessments (PRA) to evaluate j the composite risk impact based on the frequency of possible operator errors and the consequences from those errors.

The impact of averted cost (i.ee, potential cost if not j corrected) was determined through four types of contributions.

potential for the HED to: (1) cause an inadvertent plant scram, (2) cause damage to plant equipment, (3) cause unanticipated i extensions to scheduled plant outages and (4) affect the l operators' ability to maintain conditions within the limits set 'l by the plant technical specifications. The averted cost impact evaluation follows the same format as the risk impact evaluation. Qualitative evaluations of the relative significance of each HED are combined with quantitative cost data to evaluate the composite cost impact based on the frequency of possible operator errors and the consequences from those errors.

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Performance of the detailed screening included four basic tasks:

1. Identify and summarize all relevant information concerning the HED impact on the station operations procedures (normal and emergency) that use the equipment. ,

2. Develop quantitative risk impact indices for those HEDs that affect plant transient response or that may contribute to the initiation of an event.

3. Develop quantitative cost impact Indices for those HEDs that l affect any of the four cost elements identified earlier. r

4. Rank the HEDs according to their risk and averted cost impact 1 indices. These indices provide the relative benefits resulting I from the correction of the HEDs. Thus, the risk indices and the  ;

averted cost indices together provide a basis for ranking the HED's according to the benefit of correcting them.

To complete the HED prioritization process the following activities are necessar.y:

1. Identify potential corrective actions and their potential implementation costs. Preliminary designs have been done for actions to correct the HED's subjected to detailed screening.

The next step is to perform a cost estimate for implementation (engineering, construction, training).

2. Compare benefits and correction costs to set priorities.

Corrective action costs can be compared to the HED risk and cost indices from Step 4 to rank the HED's for cost-effectiveness.

This rarking will be a major factor in setting priorities for corrective actions.

During the detailed screening process, many of the HEDs (or portions of an HED) were reassigned to another implementation category for one of the following three reasons:

• Detailed investigation by the multi-disciplinary team identified that the corrective action had already been accomplished (pendirg human factors review).

• The analysis identified the recommended reassignment based on the present as-built configuration or the technical consensus of the multi-disciplinary team.

• Detailed analysis of the HED against the Pilgrim operating and ,

emergency operations procedures identified no scenarios where utilization of the equipment identified in the HED would affect the risk or averted cost in accordance with the criteria in the screening procedure.

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l The reassignments.of the HEDs to another implementation category were I documented with justification provided in accordance with the relevant l procedure. J

3. Pre-Screenina Results All of the original HEDs were re-screened by members of the

, multi-disciplinary team. The pre-screening was conducted in the Pilgrim  ;

I control room using support from the on-shift operations crew, as needed.  !

l The results of the pre-screening process are summarized in Table II-2. )

These results were used as input to the detailed screening process.

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4. D1 tailed Screenina Results l Detailed t e. lysis of the forty-six (46) Category 1, 4 and 5 HEDs resulted l in quantitative risk and averted cost impact evaluations of fifteen (15) J HEDs as shown in Table II-3. Thirty one (31) HEDs were reassigned to i j other implementation groups, as shown in Table II-4. Appendix C tabulates the individual HEDs and lists their categories as determined to date.

Following the screening analysis, the design of corrective actions proceeded on a category basis as follows:

Category 1 (annunciator) HED's - Conceptual design will begin shortly.

Category 2 (enhancement) HED's - Enhancement designs have been developed and are being finalized and implemented. l Category 3 (environmental) HED's - Additional lighting is being i designed. Noise and ventilation will be re-surveyed. l Category 4 and 5 (Panel Hardware) HED's - Conceptual designs have been developed, and corrective actions will be selected after the new task analysis verifies the nature and priority of major panel changes.  !

Category 6 (potentially resolved) - Field verification and documentation is underway.

Category 7 (non-engineered solutions) - All but two items have been completed by administrative actions; HED's will be reviewed and reassigned to Category 6 (completed items) or Category 2 (for two open items).

Details of the corrective actions planned for all categories are further discussed in Section III; schedules are in Section IV.

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,. TABLE II-2 PRE-SCREENING RESULJS.

Cateaorv # Cateaorv Name # of HED's Ill 1 Annunciator 25 2 Paint / Label / Tape (+ minor relocations) 55 3 Habitability 7 4 Equipment type 15' 5 Equipment location 27 6 Potentially resolved 30 7 Non-engineering resolutions 13_-

172 (2)

Notes: 1. Data as of June 1987, prior to the Detailed Screening.

2. Some HED's are in two or more categories; actual total number of HED's is 153.

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-TABLE II-3' RESULTS FROM QUANTITATIVE LMPACT EVALUATIONS Relative Scores (1) (3)

HED # CiLL Brief Description Risk (2) Cost (2) 4B131 4 Non-standard switch positions 110 20.5 8A008B 5 Panel C7 too crowded 109 17.9 3B047 1 Confusing auditory alarm 32 7.5 3B026 1 Lack of systematic priority scheme 28 2.0 5B067 5 Incomplete information display 28 7.5 5B119 4 Insufficient lettering height on scale 27 1.5 38028 1 Separation of controls from alarms 21 1.8 8A0078 5 Panel CP-600 not logically arranged 8.7 1.7 18005B 5 Displays too high above floor 7.6 --

1B015 5 Displays inconvenient on backpanels 0.6 --

8B101 5 Inconvenient location for sequential controls 0.1 0.4 3C012 1 No reflash capability -- 0.8 4B060B 4 Unused switch on CP-600 -- 0.1 4B051B 4 Controls violate population stereotype 0 0 8B0948 5 Display exceeds length guideline See results of #18005B

'4Bil5 4 Pushbutton " cheater" capability (4) (4)

Notes: (1) All results are rounded off (2) For definitions of " risk" and " cost", see Reference 11.

1 (3) Scores are on an arbitrary scale with no absolute meaning.

(4) HED #4B115: analysis is awaiting additional information (5) Four of 26 HED's in Category 1 were considered representative of entire category.

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I TABLE II-4 DETAILED SCREENING RESULTS i<

- 'Cateaorv # Cateaorv Name # of HEDs (1) 1 Annunciator 26 L 2 Paint / Label / Tape (+ minor) 69 3 Habitability 5 l l

J 4 Equipment type 5 5 Equipment location 7 ]

6 Potentially resolved 45 ]

7 Non-engineering resolutions 16 TOTAL 173 (2)

NOTES: (1) Data as of May 9,1988 after the completion of the detailed screening process per Reference 11.

(2) Some HED.c are in 2 or more categories: the actual total number of whole HEDs is 153 (Reference 1).

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.. 1 SECTION III CORRECTIVE ACTIONS

-A. Introduction. i This Section will describe the corrective actions for identified HED's. 'I Corrective actions include physical improvements, programs or activities to obtain additional information so that more specific corrective actions can be identified, and non-engineered corrective actions such as procedure changes.

Corrective actions c;u be separated into three broad groupings: (1) those already completed;-(2) those committed in this report for implementation by the end of the next refueling outage; and (3) those not yet committed, pending further data collection, analysis, and evaluation.

To a large extent, the HED's'will be resolved in groups according to the i screening categories described in Section II. Therefore, the following '

text is organized according to the screening categories, after a discussion of Category A HED's.

Table III-1 outlines the implementation status of the HED's, by category.-

Section I of.this' report summarizes progress to date.

Section IV summarizes the schedules for the implementation programs.

Appendix C lists all HED's, including their implementation categories.

B. .Cateaorv A HED's Category A HED's are'those that are known to have caused or contributed to an operating error, or which have the potential to cause an error of high safety consequence, under the HED categorization scheme used in the original (1984) survey. Because of their importance, Table III-2 provides a cross-reference to the current categories for all the original Category A HED's.

The status of each of the Category A HED's is as follows.

1. HED #4A003 This HED related to the reactor mode switch, which had worn and no longer had a positive detent. The mode switch was replaced with another of improved construction (SB-9 type vs. original SB-1) but with no change in appearance or function. This HED is ready for verification and closecut.

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I CATEGORY A HED's j SCREENING HED NO. TITLE CATEGORY 4A003 Mode switch - no detent- 6 5A004 Recorders not satisfactory 6 SA005 Reactor water level - zero not consistent 6

.5A009 Torus water level - zero not consistent 2,6 5A010 Drywell temperature - no indication by height 5 8A006 Panels need operator enhancement aids 2 8A007 Panel CP-600 not logically arranged. 2,5 8A008 Panel C-7 not logically arranged. 2,5 Notes:

(1) Source: Reference 1 (2) See Appendix C or Reference 1 for more complete description of HED (3) Screening Categories 1-7 are defined in Section II.

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III-3 f

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2. HED #5A004 j 1

This HED concerned eleven (11) recorders with confusing scales and f functional problems.

Of the total of eleven recorders on Panels C-170 and C-171* covered l by the HED, seven were Westinghouse recorders of conventional type l (pen and paper, with a separate scale) and four were Texas Instruments thermographic type (thermal printer, no conventional scale). Of the additional problems cited with "GE .

recorders...[which) are difficult to read and often fail", 25  ;

recorders on five separate panels were involved (22 conventional, and i' three step-print types).

All Westinghouse and GE conventional recorders were replaced (total of 29 recorders) with Tracor Westronix " series E" recorders having a  ;

scale for each active channel and felt-tip pens which cannot rip the

. paper. Three GE step-print multi-channel types were replaced with Leeds & Northrup "Speedomax" type recorders. Of the four TI thermographic type, two were replaced with Westronix type recorders ,

for non-human factors reasons, and two remain installed as satisfactory. This HED is ready for verification and closecut.

3. HED 5A005 This HED cites the differing zeros on the reactor water level indicators. As.part of the reactor water level instrumentation modifications, all read-out instruments in the control room are now referenced to a common water level zero. In addition, red zones have been added to those indicator scales which show top of active fuel and below. This HED is ready for verification and closeout.

4. HED 5A009 This HED involves inconsistencies in torus water level instrument zeros. The discrepancy was found during the previous SFTA effort.

Two different instrument ranges and six instruments are concerned.

Two instruments are on each of panels C-170 and C-171, one instrument i is on 903, and one instrument is on C-7.

1 An operator aid plaque was placed at Panels C-170/-171, explaining i the different ranges of water level in relation to the torus low l point and in relation to the torus downcomers. ,

The two distinct zero points are appropriate for the sepatate uses of I the wide range and narrow range water level meters. The operations personnel are comfortable with the distinction and are not likely to become confused because the conditions and numerical values differ i markedly between the two sets of scales. The new SFTA is expected to verify that the existing instrument scales are satisfactory.

See Figure III-1 for panel locations and Appendix D for full panel names.

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2. Some details omitted for clarity.

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l FIGURE III-1. Layout of Pilgrim Station Control Room III-5  ;

5. HED 5A010 This HED was identified during the previous task analysis. It cites the discrepancy that E0P entry conditions require knowing the temperature of the drywell air both above and below the 40-foot elevation, but no temperature monitor distinguishes the temperature relative to the 40-foot point.

He have not yet resolved HED 5A010. Revisions to the E0Ps appear to have made this HED obsolete. No action will be taken until after the )

new SFTA, which will clarify HED 5A010's status. i

6. HED 8A006 l 1

HED 8A006 involves the lack of operator enhancement aids on four ]

panels: CP-600, C-7, C-170 and C-171. Panel CP-600 has since received its interim enhancements. Design of interim enhancements for the other panels is underway. All panels will be enhanced as described in Section III.D.

7. HED 8A007 & 8A008 These HEDs deal with the arrangement of displays and controls on panels CP-600 and C-7. The addition of interim enhancements, complete for CP-600 and in design for C-7, will reduce the significance of the human engineering discrepancies. Design of rearrangements of both panels has begun, and will be finalized after the new SFTA process is complete.

C. Cateaorv 1--Annunciator-Related HED'S Twenty-seven annunciator-related HED's are included in Category 1. This is the numerically largest category of HED's not yet resolved.

The HED's in this category are:

IB005A 3B030 3B039 2C010 3B031 3B040 3B023 3B032 3B043 3B024 3B033 3B044 3B025 3B034 3B045 3B026 3B035 3B047 3B027 3B036 3C012 3B028 3B037 5B066A 3B029 3B038 HE0 #6.3.020 HE0 #6.3.020 is listed because it will be raised to HED status based on Pilgrim Station Licensing Event Report (LER) #88-023 which references the same problem previously noted in the HEO.

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a

- i Early in the DCRDR project effort it was realized that the HEDs related to ,

the annunciator system represented particularly complex issues, because  !

all panels and many human factors issues are involved. Additionally, it was decided that maintenance / reliability issues must be considered in any resolution.

An example of the complexity and trade-offs involved in the annunciator HEDs is that the HEDs indicate there are too many shared alarm windows and j alarm windows are not grouped by system. This is significant because '

there are not enough " spare" windows to separate shared alarms and to  !

rearrange the annunciator tiles, which implies a need for additional windows. The HEDs also indicate, however, that the individual alarm windows are too small to allow the proper size lettering for visibility, I but the windows cannot be enlarged because the space available for window-boxes on the panels is essentially filled. To address this conflict and the many other annunciator concerns, Boston Edison will conduct an annunciator conceptual design study, which will develop recommendations to resolve the Category 1 HEDs.

D. Cateaorv 2--Panel Enhancements and Minor Modifications Category 2 represents the bulk of the HED's for which corrective actions have been defined. A panel enhancements program is underway, to be completed by the end of the next refueling outage, which will resolve 69 HED's (partially or completely).

The corrective actions for this category include the following items:

• Control room standards

• Enhancements--Improved labels, demarcations, meter scales, mimics

• Minor relocations e Removal of abandoned equipment

• Switch enhancements--improved handles and escutcheons

• Switch modifications and replacements e Electrical distribution panel enhancements Each of these items is discussed below.

1. Control rosm standards development i Control room standards have been developed and used for the control panel enhancements program. These engineering standards will be used as guidelines for future related control panel design changes.

Additional standards may be developed as new technical or human j factors (HF) issues emerge later in the project.

Standards prepared to date are:

a). Control Panel Labels and Nameplates b). Control Panel Demarcation c). Instrument Scales ,

d). Abbreviations & Acronyms l l

1 III-7 )

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i i

One additional standard is in preparation, for control panel mimics.

(A draft version of this standard was used for design of mimics in the enhancements program.) i He will prepare a standard for control panel switch applications, as part of the effort to resolve various switch-related HED's. He will consider issuance of additional standards as work proceeds.

Potential topics for standards include:

a). control panel painting b). control room lighting c). annunciator window engraving d). color usage  :

2. Enhancements

" Enhancements" include improvements generally thought of as " paint, label or tape" plus meter / recorder scale improvements, and, resolution.

of certain HEDs that do not require major panel rework.

a). The 29 HEDs assigned to labels, nameplates, mimics and demarcation are as follows.

HED No. TITLE 8A006 Panel layout-enhancements 8A007A Panel CP-600 not logically arranged 8A008A Panel C-7 not logically arranged 4B126 Labels - Completeness of information 5B066B Displays - missing labels 6B072 Need for labels 6B073 Hierarchical label system 6B074 Label placement 6B075 Label placement 6B076 Label consistency 6B077 Label brevity 6B078 Label functional groups 68080 Label readability - letter height 6B081 Label readability - contrast 6B082 Temporary labels 6B084 Demarcation - methods 6B085 Color coding - general 6B087 Color contrast - mimics 68088 Use of mimics i 6B090 Labels - consistency with procedures I 6B091 Labels - clarity j 68092 Missing labels '

68121 Labels - system function 6B125 Labels - internal consistency 8B094A Labels - groups of similar components 8B095 Demarcation - groups of components (list continues on next page)

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4 Enhancements HED's. Coni'A 8B099 Demarcation - spacing / separation 88100 Demarcation - emergency controls IC005 Labels - shadowing These HED's have been addressed by an integrated design of panel enhancements, incorporating new labels, area-type demarcations, improved or additional mimics. Designs were based upon the  ;

newly-developed control room standards for labels, demarcation, l scales, abbreviations and acronyms and mimics (as described i above). The enhancements design for each panel will be ,

evaluated in part by interim installation of the design, either I in the control room or in the simulator or both. The interim l installation uses a combination of permanent and temporary I materials to closely emulate the appearance of the final design, I but without requiring alterations to operating procedures or plant drawings.

Once the interim enhancements are applied to a panel, plant 4 operators (R0s and SR0s) are asked to review and comment on the f improvements. The interim enhancements are revised as needed j and may be reviewed again. When the design is finalized, the 1 enhancement will be applied to the corresponding panel in the PNPS control room. One panel in the main control room (CP-600) and three panels in the simulator had received interim enhancements by April 14, 1989.

As part of the surface enhancements project, we will appropriately identify instruments and indicators as required by Regulatory Guide 1.97.

Details of the label, demarcation and mimic enhancements are as follows.

i.) Labels A label standard has been completed and a complete new set of labels has been designed for the defined control room. He are resolving operator comments on the entire set of labels. New labels are being installed at the PNPS simulator for review prior to their installation in the '

control room.

The new labels are based on a hierarchical scheme recommended by NUREG - 0700 guidelines and various human factors engineering texts. There will be three types of labelling in the control room: hierarchical system / component labels; operator informati'on labels; operator warning labels. A fourth label type may be used to identify those instruments associated with Regulatory Guide 1.97. All labels have their character height III-9

scaled so that they are visible from the proper viewing distance. The system / component labels are almond color with black characters; the information labels are light green with black characters; the warning labels are bright yellow with black characters. All characters are engraved and then filled to present'the most visible appearance and to minimize the accumulation of dust or dirt. The type font chosen for all labels is "Helvetica".

ii.) Demarcation t Demarcation involves use of color shaded areas on the control panel faces to designate areas of importance and to identify relationships among devices. Five shades of color will be used. A sixth color is the " base", or panel, color.

By judiciously varying the extent and shading of the colored areas (" patches"), we can show which controls / instruments are related to others when panel arrangements do not readily identify the relationships.

In addition, where groups of devices are related to a specific function, all devices are located on a single color. Particular areas can be made to stand out on the panel by using darker shades, and other areas recede into the background by using lighter shades.

At PNPS, demarcation by the color patch method is intended to accomplish the following:

• Functional grouping of components by task sequence.

• Functional grouping of components by system function.

• Functional grouping of components by importance and/or frequency of use.

iii.) Mimics In selected areas where mimics would be both helpful and i feasible, mimics will be applied to the panels. Mimics will consist of colored plastic strips affixed to the panels. Himic beginning and end points will be identified with either component labels or mimic "end point" labels. Color of mimic labels will be the standard almond color, not the color of the mimic itself.

b.) HEDs involving instrument scales are as follows (10 HEDs):

HED No. TITLE l 5B061 Usability of displayed values - conversion l 5B062 Visual displays - contrast l 5B063 Visual displays - parameter scales 1 5B064 Visual displays - unit graduations l l

(list continues on next page) {

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l - - - - - - - - _ - - -

4.

Scales HED's Continued  ;

1 5B065 Visual displays - direction of movement 1 5 Bill Visual displays - zone markings i SC016A Visual displays - scale selection l SC018A Visual displays - quality of information displayed SC020 Visual displays - unit scales i SCO22 Visual displays - scale graduations A plant design change (PDC) has been issued to replace all instrument scales with human engineering discrepancies that can be resolved by replacement of the scale alone. Approximately 50 meter and recorder scales will be replaced with new scales that meet the PNPS instrument scale standard. Colored zones will be added in the future, if applicable.

Please note that several meter scales are too small for proper visibility due to the size or placement of the meter (e.g., HED

1. 5B119) and are therefore addressed in Category 4.

3. Minor Relocations Eleven HEDs-have been assigned to a group called " minor relocations". These HEOs generally involve movement of' components on a single panel. Many components are in clusters where the-arrangement of the cluster does not meet human factors considerations, but resolution can be accomplished by re-arranging the cluster. Conceptual design of resolutions will begin shortly.

If design work shows that any of the corrective actions are not appropriate under the enhancement program (i.e., if the panel needs significant rearrangement), the HED will be reconsidered for possible assignment to Category 5, or for resolution by other means. The l HED's are as follows:

HED No. TITLE l

4B051A Controls - violation of population stereotype i 4B056 Controls - legend push-buttons / displays 4B057 Controls - barriers BB097A Mirror imaging BB098 Functional grouping  !

8B103 Logical arrangement 88105 Sequence of use 8B122 Layout consistency 9B106A Movement relationships 9B107A Control / display relationships 9B109A Control / display proximity i

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4. Removal of Abandoned Eauioment Certain panel devices no longer needed will be removed, to eliminate visual clutter and to provide free space. HEDs in this group are as follows (3 HEDs):

HED No. TITLE 4B060A Equipment not connected or used 58071 Unnecessary equipment 58124 Unnecessary equipment Items cited in the HEDs, plus others known to be abandoned, will be removed from the panels during the enhancements program.

5. Switch Enhancements HEDs related to switch applications not requiring replacement or rewiring of switches are as follows (7 HEDs):

HED No. TITLE

-4B048 Controls - Human suitability 4B049 Controls - covers or guards 4B052 Controls - consistency 4B054 Controls - shape coding 4B055 Controls - color coding 4B058 Controls - position indication i 68120 Controls - illegible escutcheons These HEDs will be resolved by: (1) handle shape / color coding; (2) escutcheon engraving; (3) addition of position indicating index; (4) improved means to prevent inadvertent actuation. Approximately 300 switches will be affected. Included with this group of HEDs is preparation of a standard for application of switches and associated devices in the PNPS control room.

6. Switch Modifications HEDs related to more complex issues which require replacement and/or re-wiring of switches are as follows (3 HEDs plus one previously undocumented HED):

HED No. TITLE 4B051B Controls - direction of movement '

4B115A Controls - adequacy 4B131 Controls - direction of movement HE0#6.4.024 Controls - no detent Note that HED 4B131 was determined by re-screening effort to offer the highest " benefit of resolution" of all HEDs screened. (See Section II.)

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_-___-_______--__-_____a

Approximately 150 switches will be affected by resolving the HEDs in this group. Included in this group are HEDs related to switch rotation, switch position sequencing, multiple switches with identical positions but differing arrangements, and mis-application of switch types. Most switches in this group will be replaced or re-wired to resolve the HEDs. The switch applications standard to be created as part of item (5) above will be used as basis for engineering purchases of new switches.

The HE0 listed above was recently discovered. There are .

approximately 50 "SBM" control switches on various panels having two l maintained positions with a third unused position between the active ,

positions. Such switches appear to be constructed with no detent between the active positions, an infraction of NUREG-0700, item 6.4.4.5 (2). The extent of this HE0 is being investigated.

7. Electrical Systems Panel Enhancements The Electrical Systems Panel (C-3) has six HED's to be resolved as a group, as follows:

HED No. TITLE 4B050 Controls - Covers or guards 4B053 Controls - mirror imaging 5B062 Visual displays - contrast of scales 5B069 Visual displays - consistency 6B086 Mimics - color discrimination 6B089 Labels - internal consistency Resolving this group of HEDs will involve techniques to prevent inadvertent actuation, color coding of indicator lamps, re-arrangement of certain panel components, replacement of mimics, and replacement of several meters.

Criteria and techniques are consistent with other elements of the enhancements program, but tailored to this particular panel.

E. Cateaorv 3--Habitability-Related HED's This category includes HED's related to lighting, nc,ise, and heating / ventilating / air conditioning.

1. Liahtina HEDs and HE0's related to control room lighting are as follows (two HEDs and five HE0's): i HE0/HED No. TITLE 1B012 Illumination - levels and uniformity 1B013 Illumination - glare and reflectance (list continues on next page)

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9 Liahtina HE0/HED's Cont'd 6.1.038 -Illumination--Levels and unformity 6.1.039 Illumination--Uniformity 6.1.040 Illumination--Luminance Ratios 6.1.041 Illumination--Shadowing 6.1.042 Emergency lighting--Levels The five HE0's were determined by a lighting survey completed in the fall of 1988. In general, the cause of the HE0's is insufficient light, or light provided non-uniformly.

The control room lighting will be modified to address these l observations. This modification will add ceiling light fixtures and dimming features to the PNPS Control Room to increase the intensity and uniformity of illumination.

The lighting modification will be designed to increase normal AC lighting levels to achieve a minimum of 20 foot-candles except for operator stations where a minimum of 50 foot-candles is designed to be maintained during normal operation. During emergency operations the emergency AC lighting levels will be designed to maintain a minimum of ten (10) foot-candles in operating areas. These minimum illumination values are maintained average foot-candles within the task areas of the panels.

Upon completion of this modification the lighting in the PNPS Control Room will be consistent with the guidance requirements of NUREG-0700 for all twelve (12) guidelines evaluated.

2. Control Room Noise HED #1B014 is related to control room noise. One major noise source is the existing (old) computer system peripherals. No action has been taken on this HED because the existing computer devices are scheduled to be removed and replaced with different devices related to the new, EPIC computer system. Once the EPIC computer is installed and running, a new noise survey will be taken and any identified HEDs will be resolved.

(See Section IV for schedule.)

3. Heatina/ Ventilating / Air Conditioning Existing HEDs related to heating, ventilating and air conditioning (HVAC) are as follows (2 HEDs):

HED No. TITLE i

1B011 HVAC - air quantity )

OB123 HVAC - temperature and humidity )

l III-14

A detailed survey of HVAC system operation will be performed, to clarify'the HED's and to determine the methodology for their l resolution. ' As an example, one HED documents insufficient fresh air flow into areas of the control' room. He will investigate whether the problem is in the system design, maintenance, changing conditions, or system balance. Steps taken to resolve the HED will depend on the results of the investigation. Schedule for the corrective actions will be set after the survey is completed (see Section IV).

F. Cateaorv 4--HED's Related to Hardware Tvoe l The following HED's involve incorrect equipment type:

HED No. TITLE 4B051B Controls - direction of movement 4B060B Controls - general principles 4B115A Controls - adequacy 4B131 Controls - direction of movement 5B119 Displays - readability As discussed in Section III.D above, HED #48115A, 48051B, and 4B131 will be resolved by switch changes under the panel enhancements program. HED's j 4B060B and 85B119 require hardware replacements with potential rearrangement of the panels and will be addressed after the new SFTA.

G. Categorv 5--HED's Related to Eauierent Location HED's that involve the need to relocate panel hardware (or rearrange l multiple devices) are as follows (8 HED's).  ;

HED No. TITLE

'5A010 Drywell temperature--no indication by height 18005B Console dimensions - display height 1B015 Control rm. layout - accessibility of equipment 5B067 Displays-completeness of information 8A0078 Panel layout - CP-600 not logical 8A008B Panel layout - C-7 not logical 8B094B Panel layout - clusters of components 8B101 Panel layout - sequence of use These HED's will also be addressed after the new SFTA.

H. Categorv 6--Potentially Resolved HED's The HEDs below are categorized as "potentially resolved". This indicates that either investigations or modifications are complete and no further action is required before the HED close-out process (i.e., verification) is initiated. Forty-seven HEDs are in this group. The close-out verification process will verify the extent of correction for each HED, will document justification for partial correction (or no correction), and will verify that no new HED has been created by the correction methodology.

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Potentially Resolved HED's HED No. TITLE 4A003 Reactor Mode Switch - no detent 5A004 Recorders not satisfactory SA005 Inconsistent reactor water level meters 18002 Furniture and equipment layout 1B003 Supervisor access IB008A Procedures / reference materials at consoles 18009 Desk dimensions 18128 Nitrogen flow to drywell indication 2B016 Conventional telephone system 2B018 Announcing system (volume) 2B019 Lack of priority paging 2B020 Point-to-point intercom system 45059A Prevention of accidental activation 5B070 Discrete recorders - channel select 5B127 Usability of displayed values - scale increments 5B133 Visual displays - information displayed 6B083 Tag-outs BB102 Frequency of use 88129 Sequence of use - functional considerations 1C003 Dimensions - control height IC006 Personal storage 5C015 Recorder labels SC019 Graphic recorders - visibility SC021 Usability of displayed values - scales 5A009B Usability of displayed values - ranges 18001 Accessibility of instrument / equipment 4B051C Direction of movement - controls 4B060C General principles - economy 4B115B General principles - control adequacy 4B132 General principles - suitability 5B066C Graphic recorders - placement 5B068 Light indicators - misinterpretation 58110 Usability of displayed values - scales 5B135 Visual displays - completeness of information 58136 Usability of displayed values - scales 6B079 Control position labelling - direction 8B097B Mirror imaging 9B106B Movement relationships 9B107B Control and display pairs - location 9B108 Control and display pairs - consistency 981098 Control and display pairs - proximity IC025 Equipment layout - coverage 2C009 Announcing system - general 5C016B Usability of displayed values - scales SC0188 General characteristics of graphic recorders SC026 Usability of displayed values - operator conversion 6C023 Visibility of labels - cleaning III-16

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If the close-out verification process shows that any portion of an HED requires further action, that portion of the HED will be assigned a new sub-number (e.g., an incomplete portion of #5A009B could be designated as 1 5A009C) and reassigned to the appropriate category for corrective action. I The completed portion of the HED will remain in Category 6. l 1

I. Cateaorv 7--Ocerations (Non-Enaineered) HED's i Sixteen HED's were assigned to the Pilgrim Plant (operations) Dept. for resolution, as follows. '

HED No. TITLE 18008B Use of procedures at consoles 28017 Communications - coverage in plant areas 2B021 Communications - use of face mask j 2B022 Communications - posting of procedures q 4B059B Controls - resistance to movement 58134 Displays - operator conversions l 08113 Training - maintaining proficiency 1C001 Document storage IC002 Operating expendables and tools-storage IC004 Protective equipment - availability IC026 Protective equipment - replacement 2C011 Fire system - false alarms  ;

4C013 Protective equipment - use SC014 Matching recorder paper with proper recorder 5C017 Change of lamps - proper methods 0C024 Communications - number of plug-ins These HED's deal with a variety of operational and training issues, such as furniture needs, communciations problems, need for certain training, storage of procedures and spare parts, availability of safety equipment, and other items (see HED's in Appendix C).

Corrective actions have been completed for the following HED's:

IB008--New procedure racks installed 2B022--Signs posted re: VHF communications OB113--STA training completed (continuing) 1C001--Procedures have been clearly marked The Plant Dept. has determined that the following HED's do not present operational problems and that no action is required:

2B021--Use of face masks is infrequent 4B059--Excessive switch spring loading is judgment of individual operators; decreased loading not advisable 58134--Operator aid is adequate 1C002--Recorder supplies storage is adequate 1C004--Emergency equipment storage is adequate 1C026--Air pack storage and training are adequate (list continues on next page)

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(HED's not oresentina operational oroblems Cont'd) 2C011--Fire alarms now very infrequent 5C014--Recorder scales and chart paper coordinated by procedure OC024--Current communications jacks are sufficient.

Corrective action will be taken on two HED's, as follows:

2B017--Gaitronics communications problems will be reduced by implementation of a " priority paging" system to be implemented in 1989.

SC017--Panel indicator bulb changeout tools will be purchased by May 1, 1989.

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SECTION IV j DCRDR SCHEDULE This Section describes the overall plan for the completion of_the DCRDR project. It summarizes the work plan described in greater detail in the Program Plan, previously submitted. In addition, this Section reflects recent changes to the project plan which will be described in more detail in a Program Plan revision, which will be submitted separately to NRC by June 30, 1989.

A. Resolution of Oriainal HED's (1984 Set)

The 1984 Summary Report identified 153 human engineering discrepancies (HED's). In 1987 those HED's were re-screened ar.d divided into seven categories according to type of corrective action:

Cateaory'# Category Name # of HED's 1 Annunciator 26 2 Panel Enhancements 69 3 Habitability 5 4 Equipment type 5 5 Equipment location 7 6 Potentially resolved 45 7 Non-engineering resolutions _15 173 (Please refer to Section II for more information on the screening process and on these results.)

The plan for resolution of these HED's can be summarized as follows:

o Cateaory 1 - Annunciator - Because of the number and seriousness of annunciator-related HED's, Boston Edison will undertake a detailed review of the HED's and a full range of possible corrective actions.

This study is scheduled to begin in mid-1989. It will result in a conceptual design decision by September 30, 1990, and will be reported in the Final DCRDR Summary Report by November 30, 1990.

• Cateaorv 2 - Enhancements - Work is currently underway to complete the design of the main control panel enhancements including l

demarcation, labels, meter scales, mimics, and minor switch improvements. Enhancement designs are currently being installtj temporarily in the simulator to obtain operators' review and input before finalizing the design. Portions of the interim enhancements I have been installed in the control room.

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When the enhancements are reviewed and finalized, a Plant Design Change will be issued to implement the improvements. It is ,

anticipated that improvements will be done partially while the plant i is on-line (back panels and some other work) and partially in {

cutages. Installation is scheduled for completion by the end of RF08. i Boston Edison has established two intermediate milestones for the control panel enhancements program. These milestones are:

a.) A report on the panel enhancements program will be provided to NRC by June 30, 1989. The report will outline the interim  ;

enhancements done by the date of the report, summarize tiie operator response, and summarize the permanent enhancements planned (as described in Section III.0 of this report). (This is part of Boston Edison response to NRC Inspection Report No.

88-21.)

b.) Interim or permanent enhancements will be installed on selected control room panels by the end of the outage currently scheduled for October 1989. Boston Edison has not established the exact scope of the work to be committed for the October milestone.

The scope will be defined in the report referred to in item (a) above, by June 30, 1989. Boston Edison will evaluate whether to continue installing interim versions of the enhancements, using temporary materials, or to begin installing the permanent versions.

Section III.D describes the enhancements program in more detail.

• Category 3 - Habitability - HED's relating to control room habitability and environment (i.e., those relating to noise, lighting, and heating / ventilation / air conditioning (HVAC)) are being resolved in three tasks.

The two HED's relating to HVAC will be addressed by first performing a performance test and air balance of the control room HVAC system.

These activities will be completed by May 31, 1990. Engineering recommendations for any deficiencies will be included in the Final Summary Report by November 1990.

Two of the original HED's relate to lighting. A detailed lighting survey was performed in the fall of 1988 and identified five 4 additional discrepancies. He will install additional ceiling light fixtures to correct the discrepancies (see Section III.E for description), by the end of RF0 8.

One HED concerned noise. A detailed noise survey (per NUREG-0700) will be performed after removal of the old process computer, which is being replaced. (The computer is believed to be a major component of ,

existing noise, so no useful conclusions can be drawn until the computer work is completed.) Following the survey, conceptual design IV-2

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resolutions will be identified for any deficiencies. Corrective actions for excessive noise, if any, will be described in the Final Summary Report by November 1990.

l.

• Category 4 and 5 - Eauioment Tyne and Location - In general, these l- twelve (12) HED's involve replacement or relocation of panel hardware. Therefore, these have the most potential for high cost and for impacts on operations, training, and plant availability. Because of the substantial cost and risk considerations, Boston Edison decided, after consultation with the NRC, to defer decisions on the potential major panel changes until after a new task analysis is completed. The new SFTA will help to clarify the use of panel i.

equipment in current procedures and thereby help identify what corrective actions are appropriate and their relative priority and will assure completeness and correctness. Therefore, the plan for these potential major panel changes is:

- Perform new data collection (SFTA, Control Room inventory, and survey, including identification of instrumentation and control needs).

- Develop composite list of HED's (old and new) and develop prospective corrective actions.

- Assess and prioritize HED's (see Section II and Program Plan for description of the assessment process).

- Implement corrective actions and perform the close-out verification.

The planned resolution of these potential major panel changes will be reported in the Final Summary Report by Novmber 1990.

Three of the category 4 HED's will be partially or completely resolved in the near-term switch enhancements work. These three HED's involve various switch deficiencies that will be resolved by a switch actuation design change, new switch escutcheons, revised switches, or replacement of switches (see Section III for details).

• Cateaorv 6 - Potentially Resolved - These HED's were classified as having been partially or fully resolved, in many cases by construction of physical improvements. Field verification and documentation will be done by December 31, 1989. (Any found not to be completed will be reassigned to appropriate implementation categories.)

• Cateaory 7 - Non-Engineering Solutions - Of the 16 HED's assigned to the Operations organization, 14 are completed or require no further action. Those identified as completed will be reassigned to Category 6 for closeout verification and documentation. Two HED's require corrective action. These include; a modification will be made to the Gaitronics system and a new bulb changeout tool will be purchased.

Both are scheduled for completion in 1989.

4 IV-3

B. Schedule for Remainina Work The schedule for the six remaining activities is as follows:

1. System Function and Task Analysis - The details of the methodology for the updated SFTA are currently being developed and will be submitted in the revised Program Plan (to be submitted separately).

Work is expected to be completed by April of 1990. The-results of the SFTA will be reported in the Final Summary Report by November 30, 1990.

2. Llodate of the Control Room Inventorv - The update of the Control Room

Inventory is expected to begin in 1989, on a schedule to support completion of the SFTA.

A sample of the Control Room Inventory will be provided in the Final Summary Report, November 30, 1990.

i

3. yfrification of Task Performance Capabilities - The Verification of Task Performance Capabilities will be conducted after the completion of the SFTA and Updated Control Room Inventory.

The results of the Verification activities as well as any newly identified HEDs will be reported in the Final Summary Report by lovember 30, 1990.

4. Validation of Control Room Functions - The Validation Halkthroughs will take place after completion of the SFTA.

The results of_the Validation activities as well as any newly identified HEDs will ba reported in the Final Summary Report by November 30, 1990.

5. Control Room Surveys - The surveys will be conducted concurrently with the activities described in items 1-4 above.

The results of the Surveys and newly identified HEDs will be reported in the Final Summary Report by November 30, 1990.

6. Assessment of HEDs and Selection of Corrective Actions - Any new HEDs identified in the activities described above will be assessed for significance (see Section II). He will then select design improvements to correct the safety-significant HEDs.

Several of the existing HED's are indicative of major control panel arrangement problems. (These are HED's in categories 4 and 5 under the new screening process described in Section II of this report.)

The corrcetive actions for these HED's could involve major reconstruction of one or more panels. Decisions on currently known potential major panel changes will be provided in the November 30, 1990 report to NRC, as discussed above, as well as decisions on new HED's identified in the new SFTA and survey.

Figure IV-1 summarizes the schedule for the remaining tasks.

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SECTION V i

RESPONSE TO SAFETY EVALUATION REPORT l A. Introduction NRC issued a Safety Evaluation Report (SER) and accompanying Technical Evaluation Report (TER) in May 1985 (Reference 3), in response to Boston l Edison's original Summary Report (Reference 1). The SER/TER was issued i after the pre-implementation audit held in November 1984. The NRC and l Boston Edison discussed the SER/TER in a meeting at NRC facilities on l August 21, 1985. i l

This Section discusses and responds to the SER/TER.

Please note NRC conducted an in-process inspection of the Pilgrim Station DCRDR project during the week of March 20 through 24, 1989. The formal i report (Reference 6) of the inspection was not issued before this report i was prepared and is not addressed in this report. '

Please refer to Section IV for the schedule of future activities referenced in in this Section.

B. NRC Comments and Boston Edison Resoonses This Section responds to NRC's SER/TER comments, following the criteria of NUREG-0737 in the same sequence as in the SER/TER.

1. Multidisciolinary Review Team The SER concluded that Boston Edison satisfied the relevant requirements of NUREG-0737. The Program Plan (Reference 2) will be revised to update the description of the project team and to address additional comments in the SER/TER.

2. Systems Function and Task Analysis (SFTA)

The SER/TER identified a number of concerns relating to the System Function and Task Analysis (SFTA). NRC compared the Boston Edison SFTA to task analysis requirements established in conjunction with the BWR Owners' Group. The TER identified two basic problems with the SFTA as performed:

1. The NRC concluded that there was "no systematic ' front-end' task analysis" performed during preparation of the Emergency Operations Procedures (E0P's) or prior to the walk-throughs performed in the Control Room Design Review task analysis. As a result, NRC concluded that the operator's information and control needs for emergency operations had not been fully 4 identified. j 1

2. "

... [T]he walk-through portion of the SFTA did not include a systematic interview technique to prompt the operators to describe the integrated plant operations needs".

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1 Boston Edison and NRC discussed the SFTA issue at the August 21, 1985, l meeting where we indicated that the Pilgrim Station SFTA was performed I before the BWR Owner's Group agread to the reference requirements cited by NRC. Further discussion resulted in the NRC withdrawing its requirement of Boston Edison to redo major portions of the SFTA because the discussion 1 demonstrated the SFTA was more complete than indicated in the SER/TER. I NRC instead stated the SFTA should be performed in accordance with the I NRC-BWROG guidelines only for the two E0P's which, at that time, had not  !

yet been drafted and for which no task analysis had been performed.

Boston Edison agreed to use the NRC-BWROG guidelines for performing the task analysis for the two E0P's when they were issued.

Boston Edison has since revised the entire set of Emergency Operating Procedures (E0P's) to Revision 4 EPGs. The extensive E0P revisions, together with hardware changes since 1985, warrant a new SFTA. It will be performed according to the current NRC requirements for SFTA, and will address the specific concerns raised in the SER/TER. The SFTA will begin later in 1989 and results will be reported to NRC in 1990. (See Section IV). Any HED's resulting from the new SFTA, and those resulting from upgrading the control room survey, will be addressed in accordance with project procedures.

More detail on the revised SFTA procedures will be in the revised Prcgram Plan to be submitted separately.

3. Comoarison of Disolav and Control Requirements with a Control Room Inventory These items are related to the System Function and Task Analysis (SFTA),

discussed in Section B.2 above. NRC concluded that the Botton Edison control room inventory was sufficient, but that the inventory could not adequately be compared to the operator's information and control needs, because of SFTA deficiencies.

This report does not address all the detailed NRC comments because a new SFTA (with an upgraded inventory) will be performed, since the E0Ps have been extensively revised, and because a number of Control Room alterations have occurred since the original inventory. Many of NRC's specific comments on possible HED's have been entered into our HE0 database, however, and will be reviewed (see Appendix B).

The control room inventory is further described in the Program Plan.

4. Control Room Survey The SER/TER identified certain specific shortcc,mings of the Control Room '

survey, as follows.

a) Comment Lighting levels require objective evaluation.

Resoonse: A lighting survey was conducted in late 1968. The HE0's have been reviewed, and corrective actions are described in Section III.E.

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l b) Comment (There needs to be) an adequate, objective sound survey.

Resoonse: Boston Edison has delayed the sound survey until the l installation of the new Emergency and Plant Information Computer (EPIC). Computer peripherals are a major contributor to noise  !

patterns, and we are installing new printers and other j peripherals in new control room locations. j Also, the old and new computers will be operated in parallel until the new computer is fully operational. Therefore, data from a noise survey conducted with both computer systems running would be of little value. He will conduct the noise survey after the old computer is removed.

c) Comment NRC understands that Boston Edison will consider modifying the annunciator system to provide first-out annunciator indication.

Resoonse: Boston Edison will conduct a conceptual design study that will examine the identified annunciator deficiencies, including the possibility of first-out capability. This study is scheduled to begin in mid-1989 and its results will be reported to NRC.

d) Comment NRC found five (5) specific instances of HED's that apparently had not been discovered during Boston Edison's control room survey. The five items are listed on page 14 of the TER; below is our response.

i) Item Problems with Leeds and Northrup data print recorders are mentioned in the SFTA section of the TER.

Response: The identified recorders have been replaced with newer models that perform satisfactorily.

ii) Item " Numerous annunciators have been broken or out of service for years...These were not specifically identified..."

Resoonse: Boston Edison agrees that several annunciator windows are out of service or disabled. An HED was written on this discrepancy and is included in the original Summary Report

(#3B044.4.1). The problem of disabled windows will be addressed during the annunciator conceptual design study.

iii) Item " Specific Yarway reactor vessel indicators as well as nearly all 480, 4160 and 13kV voltage, frequency and amperage meters have frosted faceplates. . ."

Resoonse: No Yarway meters in the Pilgrim controi room had frosted glass; this finding is a possible errc c in the TER. The Yarway meters were replaced as part of the reactor water level system modifications. Frosted glass faceplates on Sigma meters have been replaced with clear glass.

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l Operators have not complained about frosted glass meters on I the electrical systems control panel (C-3), but Boston j Edison will reconsider the frosted glass item during the '

survey update.

i iv) Item "The colored dot system used for new construction turnover j still exists on some meters."  !

Resoonse: The " colored dots" are not from initial construction, but are a system devised by several operators to clarify relationships between devices on panel C-3. Demarcation on this panel is evidently not satisfactory, and colored dots were added. Not all operators were aware of this informal system. We have incorporated the needs identified by the colored dot system into our labeling and demarcation ,

improvement program, eliminating the operators' need. In addition, procedural controls will be modified to require approval of such operator aids.

iv) Item "There is extensive use of plastic tape and handwritten labels in the control room".

Resoonse: This item will be resolved as part of our labeling and demarcation program. An HED (#6B082.4.5) was written on the use of temporary labels.

5. Ooeratina Exoerience Review Our responses to the comments from page 15 of TER are as follows:

a) Comment "The NRC audit team suggested that Pilgrim may want to consider revising procedures for writing LER's so more information can be recovered in the future."

Resoonse: Boston Edison has improved its LER writing process. A work instruction (NEDWI 360) was issued in 1987 to govern the details of LER preparation. More emphasis is being placed on determining the reasons for human errors, such as human engineering issues. In addition, Boston Edison has initiated a Human Performance Evaluation System, as devised by INPO, that we expect will increase the awareness of and attention to the human engineering aspects of operating incidents.

b) Comment "Although some human engineering observations were obtained from this source, a review of selected sections of the operator questionnaires by the NRC audit team indicates that the following additional HEOs should have been documented and assessed."

Response: All of the NRC's items under this comment have been listed as l HE0's and will be reviewed. (HED's not listed in the original Summary Report are tabulated in Appendix B of this report.)

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! Each of the NRC comments is summarized below, together with our specific responses.

i) Item " Core spray' discharge pressure meter is hard or impossible to read."

1 Resoonse: The core spray discharge meters PI-1450-1A, 1B are Sigma meters and the scale printing is less bold than some other meters (e.g, GE meters). These meter scales are being

, replaced under the meter scale enhancement program (part of l the panel enhancements described in Section III).

1 I

ii) Item " Main turbine steam seal header valves are confusing."

Resoonse: Arrangement of the valve switches will be clarified by the panel C-2 enhancements program, which will provide both a

_ partial mimic and demarcation to distinguish the valves.

l iii) Item "Many benchboard switches have worn detents . . ."

Resoonse: The only switch we found with this problem was the reactor mode switch. HED #4A003.4.4 was written against this discrepancy, and the reactor mode switch was replaced in 1986. He note, however, that additional worn switches may have been identified and replaced as maintenance activities. To help insure that any additional worn switches are addressed, we will survey the operators as part of our switch review in the panel enhancements program.

iv) Item "More of the feed system controls . . . should be moved to the front control panel . . ."

Resoonse: HED #5B067.5, was written to address this discrepancy and was included in the 1984 Summary Report. Boston Edison agrees that it would be desirable to relocate some of the reference controls, and a preliminary design is being studied. Further consideration will be given to this Category 4 HED after the new SFTA is completed.

v) Item " Add reactor and turbine building closed cooling water system heat exchanger backwash capability to the control room."

Resoonse: This is similar to item (d) above. These issues will be reviewed during the design selection process after the new SFTA. l i

vi) Item "The torus vacuum breaker and primary containment air supply valve controls are easily confused with each other."

Resoonse: These controls are located on panel C-7 and HED #8A008.5 was written against panel C-7's entire arrangement. This HED is in category 4 and could result in major panel V-5

changes. He are deferring a decision on this until after l the new SFTA. In addition, these valve' controls will be i addressed in the panel enhancement program. Improved-mimics, labels, and demarcation will reduce the confusion.

vii) Item "The source range nuclear instrument period meters are too far from the rod controls."

Resconse: This item will be reassessed during the control room survey j update, and in the new SFTA. j i

6. Assessment of HED's to Determine Hhich are Significant and Should be Corrected j 1

Comment "While the licensee has developed an acceptable assessment process, actual implementation of the process is not yet complete. BECo should describe the results of the assessment-process in greater detail in the Supplemental Summary Report."

Resoonse: Boston Edison has undertaken a re-evaluation of all the original 153 HED's,-using a new methodology summarized in Section II. l

7. Selection of Desian Improvements that Hill Correct Discrepancies Comment "

...BECo should describe in detail the additional efforts towards completing this requirement, such as the results and solutions from the special studies and how BECo has addressed cumulative and interactive effects of design solutions."

Resoonse: The new assessment methodology described in Section II includes the process for selection of designs for corrective actions.

8. V. verification that Improvements will Provide the Necessary Correction Without Introducing New HED's Comment "The licensee should describe the actual process to be used to complete this activity along with the results."

Resoonse: Verification has not been completed on most corrective actions. I

- Verification will be performed as part of the implementation, as l scheduled in Section IV. Procedures for verification are '

discussed in the Program Plan.

9. Coordination of Control Room Improvements with Chances Resultina from Other Imorova ment Proarams Comment " Coordination of the DCRDR with the SPDS and Reg. Guide 1.97 work is satisfactory. Coordination with the upgraded E0P effort should be improved as indicated in the TER..."

Resoonse: In 1987-88, the entire set of Emergency Operating Procedures (E0P's) was rewritten, based upon Rev. 4E of the generic BHR emergency procedure guidelines. The E0P effort was managed by V-6 I

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the Nuclear Engineering Department; the E0P project manager was also on the Detailed Control Room Design Review (DCRDR) team both before and after the E0P revision effort, which helped to ,

insure coordination with DCRDR activities. There was frequent I informal contact between DCRDR and E0P teams, but no formal joint activity.

The two projects will'also be coordinated when the new task analysis is performed. The task analysis will reflect the new E0P's and will serve both the DCRDR and E0P projects' needs.

SFTA and evaluation of information and control needs will rely heavily on the E0P technical data base.

In addition, a procedure change will be initiated to require human engineering items found during E0P verification and validation to be formally transmitted to the engineering department for resolution (if appropriate) by DCRDR project.

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In short, coordination of E0P's and DCRDR has been fundamentally j improved because both projects are now managed by a single  !

department. Coordination will be continued in the future, i particularly through the task analysis to be done on behalf of both projects.

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APPENDIX A REFERENCES A-1

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APPENDIX A l REFERENCES i (1) Detailed Control Room Design Review; Executive Summary Report; Doc. No.

l BEC0/ESR-1, September 1984, Rev. 1; Boston Edison Co.

(2) Detailed Control Room Design Review; Program Plan; June 1984, Rev. 1;

Boston Edison Co.

l (3) Safety Evaluation by the Office of Nuclear Reactor Regulation of the Detailed Control Room Design Review for Pilgrim Nuclear Power Station, a Docket No. 50-293; forwarded by NRC letter dated May 16, 1985 l (D. B. Vassallo to H. D. Harrington)

(4) Boston Edison letter to NRC BECo 87-008 dated January 20, 1987 (5) Supplement I to NUREG - 0737; Requirements for Emergency Response Capability (Generic Letter No. 82-33); December 17, 1982 (6) In-Progress Audit Report of the Detailed Control Room Design Review at Boston Edison Company's Pilgrim Nuclear Power Station, dated April 12, 1989; forwarded by NRC letter to Boston Edison dated April 26, 1989.

(7) BECo Letter 87-111 dated July 8, 1987 (R. G. Bird to S. Varga, Information Regarding Pilgrim Station Safety Enhancement Program)

(8) BECo Letter 88-131 dated September 7, 1988 (R. G. Bird to U. S. NRC, Pilgrim Station Safety Enhancement Program: Response to a Request for Additional Information)

(9) U.S. Nuclear Regulatory Commission, Standard Review Plan, NUREG 0800, Revision 1, Section 18.0 and 18.1 (with Appendix A), September 1984.

(10) BECo Probabilistic Safety Assessment, dated March, 1988 (PLG-0616, Volume 1-4)

(11) Boston Edison Company Nuclear Engineering Department Hork Instruction No. 344, Revision 1, dated May 18, 1987. " Assessment of Human Engineering Discrepancies."

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I APPENDIX B HUMAN ENGINEERING OBSERVATIONS B-1 m_______________________ _ _ _ _ _

HE0 LISTING This tabulation includes Human Engineering observations (HEu i) that have not yet been screened and categorized as Human Engineering Discrepancies (HED's) using the screening process summarized in Section II of this report. Screening may determine that an HE0 is a valid HED that requires corrective action; that it is an HED but that no corrective action is warranted; that it is not a valid HED; or that the HE0 is duplicative of en existing HE0 or HED. Resolution of these HE0's will be reported in the Final Summary Report.

ITEM # HEO # C/L ITEM

• PNL DESCRIPTION 1 6.5.049 6.6.1.1 C-1 CRU-3361 Recorder has missing label (note: this was checked & found label installed.)

2 6.5.050 6.6.1.1 C-2 PR-3392 has erroneous label 3 6.4.024 6.4.4.5(b) C-7 Two-position maintained SBM switches 904 with " dead" intermediate position.

Such switches have no detent.

Example: SV-5065-31B on 904 4 6.8.020 6.8.1.1(c) C-1 " Compartment door open" light on bench 6.5.058 6.5.3.1(d) section should be on vertical section.

Label should have more information.

5 6.5.049 6.5.1.1(c) C-1 Recorder CRU-3361 is multi-channel device, but only 1 channel used.

Should be changed to single-channel recorder.

6 6.6,031 6.6.3.1(b) C-1 " Loop select" sw. - not clear what switch does. Need more info on label.

7 6.4.025 6.4.1.1(b) C-1 " Air dryer bypass" has "do not use" tag. Is this permanent? Remove switch?

8 6.6,032 6.6.3.1(b) C-1 " Coarse / fine make-up & reject" controls not clear. N d more info on labels.

9 6.5.050 6.5.1.l(e) 903 R&G lites for CF-9068A/B show command not actual position. Need special label.

10 6.4.026 6.4.1.l(b) 905 Stabilizing valves are mechanically blocked from functioning. Should controls be removed?

"C/L" - NUREG-0700 Checklist Item Number.

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.4 HE0 LISTING ITEM # HE0 # C/L ITEM PNL DESCRIPTION 11 6.4.027 6.4.1.l(b) 904 2 P.B. switches in Retirc. Sys. (Inv.

nos. 992 & 1008) are labelled " spare".

Should be removed.

12 6.6.033 6.6.1.1 C-2 3 step-print recorders have no labels.

13 6.6.034 6.6.1.1 C-7 Switches on C-7 with erroneous escutcheons. (Ref: PCAQ #N0D 87-20).

14 6.6.035 6.6.6.1 C-7. Need for location aids. Controls for torus vacuum breakers and primary containment air supply are easily confused.

15 6.4.028 6.4.1.2 903, HPCI and RCIC trip p.b. switches  !

904 should have guards.

16 6.8.031 6.8.1.2 905 Source range N.I. readouts located too far from operator seated at rod controls.

17 6.8.022 6.8.1.2 905 Rod worth minimizer too far from operator seated at rod controls.

(Note: EPIC project will add new RHM; should evaluate based on new equipment.)

18 6.8.023 6.8.1 C-1 The off-gas hold-up line drain valve position indication does not belong on C-1. It should be on CP-600 (?)

19 6.8.024 6.8.1 C-1 The off-gas after condenser drain line valve position indication does not belong on C-1. It should be on CP-600(?)

20 6.1.035 6.1.2.5(a) CP-600 Many controls below min. height of 34 in above floor.

21 6.5.051 6.5.1.1 CP-600 Off-gas radiation not displayed in control room area.

22 6.5.052 6.5.1.1 C-7 Standby Gas Treatment System operation cannot be observed from control room operating area.

23 6.1.036 6.1.2.5(a) C-7 Hany controls too low on panel 24 6.8.025 6.8.1 903 Main Steam Isolation Valve controls should be located on C-2 with rest of turbine controls.

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HE0 LISTING ITEM # HE0 # C/L ITEM PNL DESCRIPTION 25 6.8.026 6.8.1 904 Main Steam Drain Valve controls should be on Panel C-2.

26 6.8.027 6.8.1.2 903 Panel not effectively arranged.

27 6.8.028 6.8.1.2 904 Panel not effectively arranged.

28 6.4.029 6.4.1.1 904 N2 Pressure, N2 flow and D.H. Cooler temps are not in control room.

29 6.6.036 6.6.6.4 903, Several systems need mimics, among 904 RHR, CS, HPCI, RCIC.

30 6.9.006 6.9.2.l(a) 903, Recorder CRU-El should be relocated to C-1; also recorder CRU-E2.

31 6.3.028 6.3.1 904 Alarms for demineralized system status go to home-built panel insert to turn aff lights. Should go to annunciator system.

32 6.4.030 6.4.1.1 C-1 TBCCH Hx. backwash controls not in control room. Also RBCCH.

33 6.4.031 6.4.1.1 C-1 Many feedwater controls on back panels.

Evaluate which should be brought to Panel C-1 to get more efficient operation.  !

34 6.8.029 6.8.1 C-1 Condensate pumps min. flow valve i control is with circ. water controls.

35 6.8.030 6.8.1 905 Four " half-scram" lights are on back '

panels 915/917. These should be duplicated on 905.

36 6.4.032 6.4.1.1(c) C-7 Control switch for Torus Vent Has "t-handle" grip. No other switch like this.  ;

37 6.8.031 6.8.2.3(b) 904 Mirror-imaging of recirc. and jet pump j instruments. 1 38 904 Switches for .

SV-5065-318 -358 -37A -33A l

-13B -208 -24A -26A l

-25B -278 -21A -14A l

-158 -22B -18A -11A I 1

1 B-4

HE0 LISTING ITEM # HE0 # C/L ITEM PNL DESCRIPTION 6.4.033- 6.4.1.1(c) (a)areforisolationvalves,buthad maintained contacts, so switch 1

could be in "open" and valve closed.

6.5.053 6.5.1.1(e) (b) G&R lites may not show valve position.

6.8.032 6.8.2.2 (c) do not seem to be arranged in any  ;

logical order.

39 6.4.034 6. 4.1 '.1 ( c ) 904 Switches for SV-5065-91 & - 92 are for' isolation valves, but have maintained contacts (see #38).

-40 6.5.054 6.5.3.1(c) 904 G&R lites for RCIC turbine control i valve are aff in mid-stroke. Should be na in mid-stroke.

41 6.5.055 6.5.3.1(c) 903 G&R lites for HPCI turbine control valve - same as #40.

42 6.5.056 6.5.1.5 903 LI-5008, PI-1001-69 have scales which do not meet standards.

43 6.5.057 6.5.1.1(e) 903 HPCI system - components CV-9068A/B, G&R lites do not show valve position.

44 6.1.037 6.1.2.7(a) N/A Shift supervisor's workstation has inadequate space.

45 6.8.033 6.8.2.1(c) 904 RHCU System split-up by addition of unrelated switches in its area.

46 6.1.038 6.1.5.3 Lighting levels do not meet minimum requirements on vertical panel surfaces.

47 6.1.039 6.1.5.3 Lighting does not meet requirement for uniformity within task areas on certain panels.

48 6.1.040 6.1.5.3 ** Lighting does not meet requirement for uniformity between certain adjacent task areas.

• • Lighting does not conform to shadowing 49 6.1.041 6.1.5.3 criteria in certain areas.

50 6.1.042 6.1.5.4 Emergency lighting levels do not conform to minimum requirements in certain areas.

• • Several panels and other areas of control room are affected by lighting HE0's.

B-5 I

s' &

9 APPENDIX C HUMAN ENGINEERING DISCREPANCIES C-1

APPENDIX C l HUMAN ENGINEERING DISCREPANCIES j This listing includes the 153 Human Engineering Discrepancies (HED's) referred to throughout this report.

Data included in this listing is as follows: ,

HED Number: The first 5 digits (e.g.,1B005) are the original HED numbers as used in the first DCRDR Summary Report (Reference 1). The suffixes used.in some places in Reference 1 have been dropped, because they referred to the original program of corrective actions. E.g., HED #4B048.4.4 is referred to here simply as 4B04B.

During the HED re-screening described in Section II, it was recognized that some HED's belonged in more than one implementation category. In those cases, the i HED number has been suffixed with a letter. For example, HED 18005 has been defined as HED 1B0056 in Category 1 and as HED 18005B in category 5. In effect, each such HED part is being tracked as a distinct HED.

In addition, a few HED's required investigation before the next step. Such HED's are identified with the suffix 1 The system for numbering HED's is further defined in the Program Plan (Reference 2, Section 4.4.2).

Implementation Cateaory: This refers to the pre-screening categories defined in Table 11-3.

HED

Description:

This description is reproduced from the computer database.

Note that the same description is repeated for HED's that have been divided into two or three categories; the distinct scope for each part of the HED is not described here.

Next Action: This is an abbreviated reference to the next activity for the  !

HED. In general, the HED's are tagged for corrective action programs as described in Section III. The designations should be self-explanatory except perhaps for the following terms:

SEIA refers to the System Function and Task Analysis discussed in this report, results of which are needed before deciding on certain HED's.

EQC means that a Pilgrim Station Plant Design Change has been issued to implement the modification.

l Some additional information about each HED was provided in the Appendices to i l Reference 1. Note, however, that the statements about corrective actions in  ;

l Reference 1 have been supplanted by the information in Section III of this report.

C-2 1

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i HED #.. IMPL. HED DESCRIPTION......................... NEXT ACTION.........

CATEG 0B113 7 HOW DO YOU MAINTAIN YOUR TECHNICAL PROFI VERIFY COMPLETE CIENCY? Lack of STA simulator 1 training for retaining and updating tec l hnical proficiency.

OB123 3 TEMPERATURE & HUMIDITY (Comfort Zone): T AIR BALANCE / SURVEY ouching the instrument face co ver can influence the instrument reading due to a static charge due t  !

o friction of the operators feet on the floor 0C024 7 DO ANY COMMUNICATIONS SYSTEMS INTERFERE NONE--VERIFY OK WITH CONTROL ROOM OPERATIONS?

General Requirements (Plug-in Jacks): T here is an insufficient number of plug-in phone jack positions at the console panels (one at either end of the control room panels).

1B001 6 ACCESSIBILITY OF INSTRUMENT / EQUIPMENT In VERIFY COMPLETE strumentation requiring contin uous monitoring by operators during emer gency operations: Panel C7: ,

Drywell temperatures, #1358, 1361 Conta inment purge and vent control

, #1412,1413, 1447,1448,1449,1450,1451,1 452,1453,1454,1455,1456, 1472

,1473 Torus temperature, #1427,1428 1B002 6 FURNITURE AND EQUIPMENT LAYOUT: There is VERIFY COMPLETE a limited amount of work spac e for the operator. The space available is used to hold two printers and a computer terminal. This observatio n is supported by OER-001.

18003 6 SUPERVISOR ACCESS: Shift Supervisors' Of VERIFY COMPLETE fice (Watch Engineer) does not permit prompt physical access to the co ntrol room. In addition, ther e is no dedicated communications link be tween these two spaces. This H EO is supported by observations OER-005 AND OER-010.

1B005 1B005A 1 STAND-UP CONSOLE DIMENSIONS (Display Hei ANNUNC STUDY ght and Orientation): Displays that exceed 80 in. in height include al 1 the annunicator panels, con

( tainment isolation mimic and the upper p ortion of the rod indicator li ghts. These are: Panel 903: #538,539,540 and upper portion of the cont ainment isolation mimic. Panel 904: #780

,781,782 Panel 905: #1033,1034 l and upper portion of the rod indicator l lights. Panel C2: #128,149 Pan I el C1: #1,38 Panel C3: #234,235,236,237, j 238,239,240,241,242,243,244,24 l

l C-3

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CATEG <

5, 246,247,248 1 1B005B 5 STAND-UP CONSOLE DIMENSIONS (Display Hei SFTA j l ght and Orientation): Displays '

that exceed 80 in. in height include al 1 the annunicator panels, con tainment isolation mimic and the upper p ortion of the rod indicator li ghts. These are: Panel 903: #538,539,540 and upper portion of the cont ainment isolation mimic. Panel 904: #780

,781,782 Panel 905: #1033,1034 and upper portion of the rod indicator lights. Panel C2: #128,149 Pan el C1: #1,38 Panel C3: #234,235,236,237, 238,239,240,241,242,243,244,24 5, 246,247,248 1B008 1B008A 6 USE OF PROCEDURES AND OTHER REFERENCE MA VERIFY COMPLETE TERIALS AT CONSOLES: No provis ion for use of procedures and other refe rence material at the console s (benchboards).

18008B 7 USE OF PROCEDURES AND OTHER REFERENCE MA VERIFY COMPLETE TERIALS AT CONSOLES: No provis ion for use of procedures and other refe rence material at the console s (benchboards).

1B009 6 DESK DIMENSIONS: There is inadequate war VERIFY COMPLETE k station (space) to perform a administrative tasks. This observation is supported by OER-001.

1B011 3 VENTILATION (Air Quantity): Fresh air in AIR BALANCE / SURVEY troduced into the control room is not adequate. This observation is su pported by OER-006.

1B012 3 ILLUMINATION (Levels and Uniformity): Th LIGHTING MODS e variability and control of 1 ighting levels do not conform to the gui deline criteria. See lighting survey - luminance record.

1B013 3 ILLUMINATION (Glare and Reflectance): G1 LIGHTING MODS are and reflectance on instrum ent faces is produced by the overhead li ght placement. This observati on is supported by OER-003.

1B014 3 AUDITORY ENVIRONMENT (Limit and Noise Di NOISE SURVEY stractions): The continuous ba ekground noise created by the pager syst em and printers is annoying a nd produces distractions to the operator

s. See sound survey record. Th is observation is supported by OER-007.

1B015 5 ACCESSIBILITY OF INSTRUMENT / EQUIPMENT (A SFTA rranged to facilitate coverage

): Instrumentation requiring continuous C-4

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HED #.. IMPL. HED DESCRIPTION......................... NEXT ACTION.........

CATEG t 1

monitoring by operators durin i g emergency operations located on back p l anels 915 and 917 are the sera l m solenoid lights and MSIV isolation lig l hts (2). This observation is su pported by OER-001. l 1

1B015I SEE 1B015 INVESTIGATION 1B128 6 ACCESSIBILITY OF INSTRUMENTATION /EQUIPME VERIFY COMPLETE '

NT (Present in the control Roo m): In executing the task " Start N2 Flow to DW for Additional Cooling (4T:39.00), verification of N2 system pressure can only be done outs ide the control room.

1B128I SEE 18128 INVESTIGATION 1C001 7 DOCUMENT ORGANIZATION AND STORAGE: Locat VERIFY COMPLETE ion aids to access appropriate procedures do not conform to guideline criteria to identify, disting uish and access documents. In addition, the documents are not protecte d against wear.

1C002 7 SPARE PARTS, OPERATING EXPENDABLES AND T NONE--VERIFY OK OOLS: Spare parts are not read i ily accessible. The storage space is lim l ited and there is no inventor y accounting to ensure that an adequate supply of spares and expendabi les is readily available.

1C003 6 STAND-UP CONSOLE DIMENSIONS (Control Hei VERIFY COMPLETE ght): Controls that exceed 63 in. on the benchboard panels are: Panel 903: vibration meter subpanel

1. 587,591,592,594,599. Controls that are located below 34 in, in heigh t are: Panel 903: HPCI inverter (toggle switch) Panel 904: RCIC invert er (toggle switch) 1C004 7 OPERATOR PROTECTIVE EQUIPMENT (Types of NONE--VERIFY OK Equipment): No protective equi pment other than the Scott Air Paks are available in the control room 1C005 2 ILLUMINATION (Shadowing): Labels below i PLT MODS instrumentation on vertical pan els are shadowed. This is especially tru e for recorders which project beyond the panel surface.

1C006 6 No space is provided for personal storag VERIFY COMPLETE e.

1C025 6 CONSISTENCY OF MANNING WITH EQUIPMENT LA VERIFY COMPLETE YOUT (COVERAGE): The overhead TV monitor used to display computer gen erated data at the 905 panel i s not located in a convenient position f or operator viewing. This obse C-5

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CATEG l

rvation is supported by OER-002.

1C026 7 OPERATOR PROTECTIVE EQUIPMENT (Expendabl VERIFY COMPLETE es): There are no replacement .

air tanks that are readily available. I 2B016 6 CONVENTIONAL POWERED TELEPHONE SYSTEM (H VERIFY COMPLETE andsets): The phones at the sh ift supervisor's workstation are not ide ntified or coded by circuit o r function. It should be noted that the communications equipment at th is workstation is " jury rigged" and not functionally arranged. Some ph ones are inoperative and others broken o r not connected to a live circ uit. This observation is supported by OE R-005.

2B017 7 ANNOUNCING SYSTEM (Intelligibility and C GAITRONICS MAINT overage): Loud speaker voice m essages cannot be heard in some rotating machinery areas, e.g., diese 1 generator space. Speaking from noisy a reas masks the voice message.

This observation is supported by OER-011 2B018 6 ANNOUNCING SYSTEMS (Loudspeaker Volume): VERIFY COMPLETE Speaker gain control can redu ce volume below audible level. This obse rvation is supported by OER-0 07.

20019 6 ANNOUNCING SYSTEMS (Priority): Channel 3 VERIFY COMPLETE is reserved for emergency or control room voice traffic but there is no priority procedure or capa bility for interrupting an announcement in progress. j 2D020 6 PO2NT-TO-POINT INTERCOM SYSTEMS: There i VERIFY COMPLETE -

s no point-to-point intercom b i etween the control room and the watch en gineer's office. This observa tion is supported by OER-010.

2B021 7 EMERGENCY COMMUNICATIONS (Equipment Usab NONE-VERIFY OK ility and Voice Communications

) Voice communications while wearing a f ace mask is unsatisfactory. T his observation is supported by OER-008.

2B022 7 FIXED BASE VHF TRANSCEIVERS (Procedures) VERIFY COMPLETE

Procedures are written for t his system but not posted.

2C009 6 ANNOUNCING SYSTEM (General): The 5 voice VERIFY COMPLETE channels are continuously in use. During plant shutdown, when contra ctors are at the plant, they g enerate nuisance sounds that interferes with control room communication ns. This observation is in support of OE C-6

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CATEG l l

R-007. l 2C010 1 SIGNAL INTENSITY (Comfort): The PAM alar ANNUNC STUDY m and fire alarm produce sound s that are a discomfort to the operator.

2C011 7 READABILITY-(False Alarms): Fire alarm i NONE--VERIFY OK s activated by cigarette smoke in areas of the Administration Building

, Control Room Annex and Secu rity Alarm Station (SAS). )

3B023 1 ALARM PARAMETER SELECTION (General Alarm ANNUNC STUDY s): There are several alarms t ,

hat require control room operators to di '

rect auxiliary or equipment o perators to various parts of the plant t o identify trouble, e.g., C60 ,

ventilation problem. This observation is supported by OER-047.

3B024 1 ALARM PARAMETER SELECTION (Multi-channel ANNUNC STUDY or Shared Alarms): There are at least 5 alarms that are shared: Pane 1 904: TORUS THOUGH ALARM HI/L 0 #782. Panel 904: RECIRC PUMP OIL LEVEL HI/LO #781. Panel 904: DRYWEL L PRESSURE HI/LO #780. Panel 904: REACTO R WATER HI/LO LEVEL #1033. Pan el Cl: A/B/C SERVICE WATER PUMPS LOW DIS CHARGE PRESSURE #38. This obse rvation is supported by OER-014.

3B025 1 FIRST-OUT ANNUNCIATORS (Reactor System a ANNUNC STUDY nd Turbine Generator System):

There is no first-out annunciator for e ither the reactor system or th e turbine generator system. This observa tion is supported by OER-013.

3B026 1 PRIORITIZATION (Levels of Priority): The ANNUNC STUDY re is a lack of a systematic a nn. prioritization scheme. The tiles tha t shoud be prioritized are: P anel 903: HPCI ISOLATED, OFF GAS TIME IN ITIATED. Panel 904: PCIC ISOLA TELD, CLEAN-UP HI TEMP, NONREGEN HX, DRY WELL PRESS. HI/LO - RECIRC M/G SET A GEN LOCKOUT, - RECIRC M/G SET B G EN LOCKOUT. Panel 905: Rx WATE R HI/LO LEVEL, - Rx HI PRESS. Panel Cl:

RFP TRIP - A/B/C TRIP COND PUM P TRIP, - OFF-GAS LINE GAS FULLY OPEN, A OR B SEAWATER PUMP TRIP, - TB CCW PUMP TRIP Panel C2: TURBINE STM SEAL HDR LO PRESS, -

INSTR. AIR OR N2 LVL TO DRYWELL Panel C3: INST POWER TRANSFER, - RFS M/G SET A BKR TRIP, - RPS M/G SET B BKR TRIP, - STATOR COOLING WATER. THIS OBSERVATI ON SUPPORTED BY OER-015.

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3B027 1 CLEARED ALARMS (Auditory Signal): There ANNUNC STUDY is no distinct audible signal to distinguish cleared alarms from aler ting alarms.

3B028 1 VISUAL ANNUNCIATOR PANELS (Location): So ANNUNC STUDY me annunciator tiles are on di fferent panels than their controls (e.g.

the OFFGAS TIMER tile is on Panel 903 with associated control on Pa nel C1). This observation is s upported by OER-017.

3B029 1 VISUAL ANNUNCIA10R PANELS (Labeling): In ANNUNC STUDY dividual annunciator panels ar e not all labeled.

3B030 1 VISUAL ANNUNCIATOR PANELS (Lamp Replacem ANNUNC STUDY ent): Operators have reported being shocked while replacing bulbs as well as shorting out the entir e annunciator panel. This observation is supported by OER-020.

3B031 1 VISUAL ALARM RECOGNITION AND IDENTIFICAT ANNUNC STUDY ION (Contrast Detectability):

The opaque yellow annunciators on panel 905 (#1033) are difficult to distinguish between 'ON' and 'OFF' state

s. This observation is support ed by the annunciator OER-049.

3B032 1 VISUAL ALARM RECOGNITION AND IDENTIFICAT ANNUNC STUDY ION (" Dark" Annunciator Annunc iators are lit to indicate equipment is out of service (continuous).

This observation is in support of OER-01 9.

3B033 1 ARRANGEMENT OF VISUAL ALARM TILES (Label ANNUNC STUDY ing of Axes): Annunciator pane is are not labeled to conform with this criteria.

3B034 1 ARRANGEMENT OF VISUAL ALARM TITLES (Patt ANNUNC STUDY ern Recognition): There are 63 tiles on each annunciator panel of 905.

This exceeds the maximum mat rix density of 50 tiles suggested in the guideline criteria.

3B035 1 ARRANGEMENT OF VISUAL ALARM TILES (Patte ANNUNC STUDY rn Recognition): Tiles are not grouped by logical organization because of changes subsequent to the original design. This Observation is su pported by OER-049.

3B036 1 VISUAL TILE LEGENDS (Unambiguous and Abb ANNUNC STUDY reviations) Some contain exces sive information and others contain insu fficient information. In addi tion, abbreviations and acronyms are not used consistently on all time C-8

. PAGE 7 11:09:04 26 APR 1989 HED #.. IMPL. HED DESCRIPTION......................... NEXT ACTION.........

CATEG s e.g., Delta-;/Diff Press, REAC/ Reactor

/Rx. This observation is suppo  !

rted by annunciator OER summary.

3B037 1 VISUAL TILE LEGENDS (Singularity and Spe ANNUNC STUDY cificty): Some tiles refer the

+

operator to annunciator panels outside the main control area. In add ition, there are tiles that alarm for tw o conditions, e.g., DRYWELL HI

/LO. Also K COMPUTER alarm on panel 905 .

refers operator to computer on panel C7. This observation is supported by OER-014 and OER-17.

3B038 1 VISUAL TILE READABILITY (Distance and Le ANNUNC STUDY tter Dimensions and Spacing):

The lettering size on the annunciator t iles do not conform to the gui deline criteria. This observation is sup ported by OER-016.

3B039 1 VISUAL TILE READABILITY (Type Style): Th ANNUNC STUDY e letter type style and size d iffer on the annunciator lettering. This observation is supported by OER-016, 3B040 1 VISUAL TILE READABILITY (Legend Contrast ANNUNC STUDY

): There are several annunciat or tiles that have light letters on dark background (panel 905 #1034)

. Other annunciators are labeled using d ynotape (panel C3 #248 and pan el 905 #1033).

3B043 1 CONTROL SET DESIGN (Positioning of Repet ANNUNC STUDY itive Groups etc.): All contro 1 set designs are not alike, e.g., Panel C7 has two sets, one horizon tal and one vertical. Panel C6 only has two pushbuttons and C170 has t bree pushbuttons arranged in a triangula r formation.

3B044 1 ARRANGEMENT OF VISUAL ALARM TILES (Out o ANNUNC STUDY f Service Alarms etc): Tiles 1 abeled for equipment that has not been u sed and will not be used are still included on the annunciator panels

, e.g., PLANT HEAT EXCHANGERS A AND B. This observation is supported b y OER-018.

3B045 1 SIGNAL DETECTION (Intensity): There is a ANNUNC STUDY large discrepancy in the audi ble alarm intensities. The PAM alarm is too high and the alarm intens ity on panels C1, C2 and C3 are too low.

This observation is supported by OER-021.

3B047 1 SIGNAL DETECTION (Identification): The a ANNUNC STUDY C-9

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11:09:05 26 APR 1989 HED  %.. IMPL. HED DESCRIPTION......................... NEXT ACTION.........

CATEG uditory alarm does not provide for workstation or system identification

n. This observation is suppor ted by OER-019.

3C012 1 ALARM PARAMETER SELECTION (Multi-channel ANNUNC STUDY

, or Shared Alarms): The annunc j

lator system does not have a reflash cap ability.

4A003 6 ROTARY SELECTOR CONTROLS (Positioning): VERIFY COMPLETE No positive detent feedback fo r recator mode switch on Panel 905 (#126 4).

4B048 2 GENERAL PRINCIPALS (Human Suitability): SWITCH MODS All "J" handles are the same f or pumps, valves and switches - some of two position, others are " jog

" - poor discrimination by function or m ode of operation. This observa tion is supported by OER-023.

4B049 2 PREVENTION OF ACCIDENTAL ACTIVATION (Mov SWITCH MODS able Covers or Guards): Panel C3: Switch #410 should be guarded. Back Panels: Instrument air nitrog en to drywell and FW heater block valves were identified during the OE R as controls that should be guarded. Th is observation is supported by OER-026.

- 4B050 2 PREVENTION OF ACCIDENTAL ACTIVATION (Mov PANEL C3 MODS able Covers or Guards): Protec tive covers on controls that interfere w ith adjacent controls: Panel C1: Control #122 interferes with control

1. 107, 119 and 120. Panel C3:

Control #425 interferes with control #40

3. Panel 904: Control #955 int erferes with control #960.

4B051 4B051A 2 DIRECTION OF MOVEMENT: Controls that vio CONCEPT DESIGN j late population stereotype are

Panel 904: Rotary finger switches #945 ,

, 951, 952, 956 counterclockw '

ise move- ment to open. Phnel C3: Rotary handswitch #356, 372, 377, 38 0, 404, 406 counterclockwise to increase (raise). Panel C7: Rotary fin ger controls #1357, 1359, 1360, 1362, 13 77, 3379, 1380, 1382, 1385, 13 87, 1388, 1390, 1391, 1392, 1394, 1395, 1397, 1398, 1399 increase coun terclockwise. DIRECTION OF MOVEMENT (Cont

.) Panel C7: Photos show that "J" handles #1413, 1448, 1454, 1455, 147 7 have operator notation that indicates control movement violates popu C-10 1

PA'GE. 9 11:09:05 26 APR 1989

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CATEG lation sterotype. permanent lab els on the controls. Panel C2: #192, 206

, 207, 208, 215, 216 turn coun terclockwise to raise and clockwise to 1 ower. This observation is supp orted by:OER-024.

4B051B 4 DIRECTION OF MOVEMENT: Controls that vio' SWITCH MODS

. late population stereotype are

Panel 904:.RotaryEfinger switches #945

, 951, 952, 956 counterclockw ise move- ment to open. Panel C3: Rotary handswitch #356, 372, 377, 38 0, 404, 406-counterclockwise to increase (raise). Panel C7: Rotary fin ger-controls #1357, 1359, 1360, 1362, 13

, 77, 1379, 1380, 1382, 1385, 13 87, 1388, 1390, 1391, 1392, 1394, 1395, 1397, 1398, 1399. increase coun terclockwise. DIRECTION OF MOVEMENT (Cont

.) Panel C7: Photos show that "J" handles #1413, 1448, 1454, 1455, 147 7 have operator notation th '

indicates control movement 21ates popu

-lation sterotype permanent lab els on the controls. Panel C2: #192, 206

, 207, 208,-215, 216 turn coun terclockwise to raise and clockwise to 1 ower. This observation is supp orted by OER-024.

4B051C 6 DIRECTION OF MOVEMENT: Controls that vio VERIFY COMPLETE t

late population stereotype are

Panel 904: Rotary finger switches #945

, 951, 952, 956 counterclockw ise move- ment to open. Panel C3: Rotary handswitch #356, 372, 377, 38 0, 404, 406 counterclockwise to increase (raise). Panel C7: Rotary fin ger controls #1357, 1359, 1360, 1362, 13 77, 1379, 1360, 1382, 1385, 13 87, 1388, 1390, 1391, 1392, 1394, 1395, 1397, 1398, 1399 increase coun terclockwise. DIRECTION OF MOVEMENT (Cont

.) Panel C7: Photos show that 1 "J" handles #1413, 1448, 1454, 1455, 147 7 have operator notation that indicates control movement violates popu lation sterotype permanent lab 1 els on the controls. Panel C2: #192, 206 j

, 207, 208, 215, 216 turn coun >

terclockwise to raise and clockwise to 1 ower. This observation is supp '

orted by OER-024.

4B051I SEE 4B051C INVESTIGATION 4B052 2 CODING OF CONTROLS (Consistency): There SWITCH MODS is a limited amount of color c

~

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CATEG oding on the "J" jog controls. On panel C1 and C3 some controls are c olor coded but there is no consistent pa ttern throughout the control r oom. This observation is supported by OE R-023.

4B053 2 CODING OF CONTROLS (Location Coding): Mi PANEL C3 MODS rror imaging of controls. Pane 1 C3: Mirror image controls #348/351; 34 9/350; 356/372; 357/371; 358/

370; 377/380; 378/379; 388/402. Panel Cl

Mirror image controls #97/98

99/100. This observation is supported by OER-045.

4B054 2 CODING OF CONTROLS (Shape Coding): Shape SWITCH MODS coding of controls is not use

d. The OER identified that the vacuum br eakers and containment air va lve controls were too close to each othe r and identical in shape makin g accidental activation possible on Pane 1 C7. This observation is supp orted ';y OER-023.

4D055 2 CODING OF CONTROLS (Color Coding): Excep SWITCH MODS t for Panel C3 there is no col or coding association between controls a nd displays. The color coded jog 'J' handles (green) do not adequatel y centrast with panel backgrou nd.

4B056 2 LEGEND PUSHBUTTONS (Discriminability): T CONCEPT DESIGN he rod selector pushbuttons on the bench board are the same in size an d appear- ance as the legend displays on the vertical portion of this panel. In addition, there are other legend pushbuttons and legend lab els on the vertical portion of panel 905 which are identical in size a nd shape.

4B057 2 LEGEND PUSHBUTTONS (Barriers): No barrie CONCEPT DESIGN rs provided for contiguous pus hbuttons. Panel 905.

4B058 2 ROTARY SELECTOR CONTROLS (Position Indic SWITCH MODS ation): Controls on panel C1,

1. 56 and 57 do not have position indicat ing line down the side of the rotary control knob. This condition may appear on other controls but c ould not be identified from the mockup p hotographs.

4B059 4B059A 6 PREVENTION OF ACCIDENTAL ACTIVATION (Res VERIFY COMPLETE istance to Movement): During t he OER, operators reported that rod cont C-12

_ _ _ _ _ _- _ - . - - - - - - - - - - - _ - - - - - - - - - - - - -- -- - ~ - - - --

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i CATEG i l

rol switch #1268 and notch ov erride switch #1261 have excessive sprin g loading. This observation is supported by OER-025.

4B059B 7 PREVENTION OF ACCIDENTAL ACTIVATION (Res NONE-VERIFY OK istance to Movement): During t he OER, operators reported that rod cont rol switch #1268 and notch ov

~

erride switch #1261 have excessive sprin

. g loading. This observation is supported by OER-025.

4B060 4B060A 2 GENERAL. PRINCIPLES (Economy): Controls n PREPARE PDC ot used or not connected are:

Panel 903: #638, 663, 677, 645, 690, 58 9 Panel 904: #927,1023,997,100 1,1013,1017 Panel 905: #1257 Panel C2: #

'221 Panel CP600: #512. GENERAL PRINCIPLES (Economy): The key switch on control #512 violates tech sp ecs and should be removed and circuit fr <

ozen in position 2.

4B060B 4 GENERAL PRINCIPLES (Economy): Controls n SFTA l ot used or not connected are:

Panel 903: #638, 663, 677, 645, 690, 58 9 Panel 904: #927,1023,997,100 1,1013,1017 Panel 905: #1257 Panel C2: #

221 Panel CP600: #512. GENERAL PRINCIPLES (Economy): The key switch on control #512 violates tech sp i ecs and should be removed and circuit fr  ;

ozen in position 2.

4B060C 6 GENERAL PRINCIPLES (Economy): Controls n VERIFY COMPLETE ot used or not connected are:

Panel 903: #638, 663, 677, 645, 690, 58 9 Panel 904: #927,1023,997,100 1,1013,1017 Panel 905: #1257 Panel C2: #

221 Panel CP600: #512. GENERAL PRINCIPLES (Economy): The key switch on control #512 violates tech sp ecs and should be removed and circuit fr ozen in position 2.

4B060I SEE 4B060A INVESTIGATION 4B115 4B115A 4 GENERAL PRINCIPLES (ADEQUACY): The pushb SWITCH MODS uttons #666 and 645 on panel 9 03 have a " cheater capability" to keep t he pushbutton activated 4B115B 6 GENERAL PRINCIPLES (ADEQUACY): The pushb VERIFY COMPLETE uttons #666 and 645 on panel 9 '

03 have a " cheater capability" to keep t he pushbutton activated 4B115I SEE 4B115A INVESTIGATION 4B126 2 CODING OF CONTROLS (Location Coding): Co PDC ntrol 1301 is located on panel C-13

LPAGEL 12 11:09:05 26 APR11989

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CATEG '

1 l

905 with its associated system located  !

on. panel C1.

4B131 4 DIRECTION OF MOVEMENT:~ Switches 1434, 14 SWITCH MODS 35, 1436, 1443, and 1445 have "open" at the left position-and " auto" at the right position. Switche s 1400, 1401, 1402, 1403, 1404, 1405, 14 06 and 1407.have "close" at th e.left position and " auto" at the.right position. Other switches 1410 and 1411 have three labels and two funct ion positions, i.e., "close-au to" and "open". The functional positions ofLthe controls do not confor m with convention.

4B131I' SEE-4B131 INVESTIGATION 4B132- 6 . GENERAL PRINCIPLES (Human Suitability): VERIFY COMPLETE In executing the task " Inhibit Auto ADS" (IT:.31.00), the operator mus t remember to reset ADS timer A, 653, and B, 698 (panel 903) within e very 120 seconds. Failure to r eset the timers could alter the plant re sponse such as to erroneously.

indicate to the operator that additional failures have occurred and un necessarily aggravate operator tasks.

4C013 7 GENERAL PRINCIPLES (Compatibility with E NONE--VERIFY OK mergency Gear): Operators have no experience using controls while dres sed in protective clothing.

-5A004 6 SCALE MARKINGS (Multi-scale Indicators); VERIFY COMPLETE Recorders on these' panels (43 4,439,441,444,448,449,1327,1332,1334,133 7,1339) have only one scale w ith three different colored pens. Furthe r the metal pens tear the pape

r. This observation is supported by OER-029.DO THE CHART RECORDERS PRO DUCE INFORMATION THAT IS EASY TO READ &

USE? The GE Recorders are diff icult to read and often fail. Recorder f' allure results in activating f alse annunciator alarms.

. 5A005 6 SCALE MARKINGS (Compatibility): The core VERIFY COMPLETE water level display indicator s on panels 903, 904, 905, 170 and 171 a 11 differ. Panel 903: #620, 6 34 Panel 904: #882 Panel 905: #1173, 117 4i 1183, 1186 Panel 170: #439 Panel 171: #1332 Board

Title:

Rx CLG, Rx Clnup, Rx Cont, PAM-A, PAM-B 5A005I SEE 5A005 INVESTIGATION 5A009 5A009A 2 USABILITY OF DISPLAY VALUES (Elimination SFTA C-14

P' AGE 13 11:09:06 26 APR 1989 HED #.. IMPL. HED DESCRIPTION.........................

CATEG NEXT ACTION.........

of Operator Conversion): Reco rders 439,1429 and 615 display the same parameter but use different s cales requiring conversion to compare. T his observation is supported b y OER-046.

5A009B 6 USABILITY OF DISPLAY VALUES (Elimination SFTA of Operator Conversion): Reco rders 439,1429 and 615 display the same parameter but use different s cales requiring conversion to compare. T his observation is supported b y OER-046.

5A010 5 COMPLETENESS OF INFORMATION: Monitoring SFTA the drywell (DW) temperature f or EOP entry conditions and for decision points therein, requires the temperatures above & below the 40 ft. p oint in the DW. The DW tempera ture indicators / recorder 582,637 (panel 903) and " Plant Air Temperatur e Monitor," KhYE Assembly: 1376, 1418, 1 419, 1420, 1421, 1422, 1423, 1 424, 1425, 1426 (panel C7), with multipl e readout points, do not disti nguish the temperatures relative to the 40 ft. point.

5B061 2 USABILITY OF DISPLAYED VALUES (Eliminati PDC on of Operator Conversion): In struments on panels requiring conversion are: Panel 903: #603,606,613 require multiplying by 5. Panel C2: #14 6 subtract value from 30. #147 multiply by 50 Panel CP600: #479 multip ly value by 5 This observation is supported by OER-30 and OER-033.

5B062 2 CONTRAST: Indicators with white letters PDC on black background are: Panel C3: #332, 342, 329, 318. Panel C7: 1459 5B063 2 PRINTING ON THE DISPLAY FACE (Provision PDC of Needed Message): Parameter scales missing: Panel 903: #601,604,608

,610. Panel 904: #836,880,814, 912. Panel 905: 61302, 1303, 1305. Panel C2: #145, 146. Panel C1: #24, 25,42,47,26,27,48,46,45. Panel C4: Foxbo ro indicators. Panel C170: #44 2, 443. Panel Co600: #466.

5B064 2 SCALE MARKINGS: (Values Indicated by Uni PDC t Graduations): Scale graduati on values that do not agree with guideli ne criteria for progression:

Panel 903: #602,631,632,633,635,583,584, 586,618,619,621. Panel 904: #8 C-15 I

\

P GE 14 111: 09:06 26 APR 1989 -1 HED #....IMPL. HED DESCRIPTION......................... NEXT ACTION..........-

CATEG 29, 830, 831, 875, 876, 877, 878, 889, 8-

'90, 907, 908, 1025, 813. Panel 6,

905: #1099, 1100, 1101, 1102, 1175, 117 1177, 1178, 1188, 1192, 119 l

3,'1171, 1107, 1108, 1162. Panel C2: #13 0, 133, 136. Panel C1: #14, 15

, 18, 19, 20, 25. PanelHC3: #283, 287, 2 97, 301, 345. Panel CP600: #46 8, 469. Panel C7: #1367,1368,1369,1374,1 375,1358,1378,1386,1393,1384,1 430,1361,1381,1389, 1396,1383.

5B065 2 DIRECTIONALITY OF MOVEMENT AND NUMBERING-PDC

'WITH MOVING-POINTER METERS (V ertical Straight Scales): Values increas e in downward movement.. Panel 903: #629. Panel 904: #833.

5B066

~5B066A 1 GENERAL CHARACTERISTICS OF GRAPHIC RECOR ANNUNC STUDY DERS (Placement of Recorders):

Recorders that must be verified and att ended should be located in th e primary operating area. Panels C7 and 902 both contain recorders. Re

. corder on panel C2 #16' should be on Pan el'903. Board

Title:

Cntmt Ven t, Turbine, Process Rad,Rx Clg.

SB066B 2 GENERAL CHARACTERISTICS OF GRAPHIC RECOR PLT MODS DERS-(Placement of Recorders):

Recorders that.must be verified and att ended should be located in th e primary operating area. Panels C7 and 902 both contain recorders. Re corder on panel C2 #165 should be on Pan el 903. Board

Title:

Cntmt Ven t, Turbine, Process Rad,Rx Clg.

5B066C 6 GENERAL CHARACTERISTICS OF GRAPHIC RECOR VERIFY COMPLETE DERS (Placement of Recorders):

Recorders that must be verified and att ended should be Jocated in th 1 e primary operating area. Panels C7 and )

902 both contain recorders. Re ccrder on panel C2 #165 shculd be on Pan "el 903. Board

Title:

Cntmt Ven t, Turbine, Process Rad,Rx Clg.

5B066I SEE 5B066C INVESTIGATION 5B067 5 INFORMATION TO BE DISPLAYED (Completeness SFTA s of Information): FW heater b lock (dump)(10) valve position is needed on panel C1 as well as back panel C4. This observation is supported  ;

by OER-034.

5B068 6 CHARACTERISTICS AND PROBLEMS OF LIGHT IN VERIFY COMPLETE DICATORS (Precautions to Avoid Misinterpretation): The indicator light s above controls #206, 404, 4 i

C-16

PAGE f15' 11:09:06 26 APR 1989 lHED #..~IMPL. HED DESCRIPTION................ ........ .NEXT ACTION.........

CATEG 06 have red lens on left and green lens on right (reversal from conven tion).

5B068I SEE 5B068 INVESTIGATION L5B069- 2 . COLOR CODING (Consistency of Meaning): B PANEL C3 MODS US trouble lights on Panel C3 use amber and white covers with the sam e meaning.

5B070 6 DISCRETE RECORDERS (Channel Selection Ca VERIFY COMPLETE pability): Recorder #460 does not have the capability of selecting a single channel display.

5B071 2 INFORMATION TO BE DISPLAYED (Unnecessary PREPARE PDC Information): Indicator Light s #870 and 871 not needed or used.

5B110 6 USABILITY OF DISPLAYED VALUES (Scale Ran VERIFY COMPLETE ge):. Recorder #145 uses dual p ens and a dual scale for coarse and fine readings. The pointers are n ot identified or associated with either colored pen and reading accura cy is made difficult by the scale markin gs.

-5B111 2 ZONE MARKINGS: The majority of instrumen PDC ts have no zone markings on th e instrument faces to identify opreating ranges, upper or lower limit s and danger zones used throughout the c ontrol room. Existing markings were applied without use of a standard or criteria.

5B119 4 READABILITY (CHARACTER HEIGHT): The char SFTA acter heights on meter #601 an d 610 do not subtend a visual angle of 1 5 minutes of are 5B124 2 INFORMATION TO BE DISPLAYED (Unnecessary PREPARE PDC Information): The amber light s on instruments 720,721,750,751 are dis connected and their function removed.

5B127 6 USABILITY OF DISPLAYED VALUES (Scale Sel VERIFY COMPLETE ection): RHR flow indicators 6 17, Loop A and 631, Loop B, and flow rec order 602, Loop A/B, all on p anel 903, indicate the same flow within the same range but have differ ent scale increments: o 617 & 631: 500 g pm increments o 602 : 200 gpm increments 5B133 2 INFORMATION TO BE DISPLAYED (Completeness VERIFY COMPLETE s of Information): Monitoring SP pressure for EOP entry and decision points therein requires a rang e of 0-60 psig. SP pressure is available on 862 (panel 904), having a C-17

i PhCE 16 11:09:06 26 APR 1989 HED #.. IMPL. HED DESCRIPTION......................... NEXT ACTION.........

CATEG range of -1.0 to +2.0 PSID, or by combin '

ing DW/SP Delta-P, 863 (panel  !

904), with DW pressure, 1329 or 1330 (pa nel C171). <

5B134 7 USABILITY OF DISPLAYED VALUES (Eliminati NONE--VERIFY OK on of Operator Conversion): Th e plaque, 2004, defining reactor power 1 evel vs. IRM channel range po sition specifies reactor power in KWT or MWT whereas operator decision points in the EOPs require % power. Thu s the operator must work with 2 different sets of power units during e mergency events.

5B134I SEE 5B134 INVESTIGATION SB135 6 INFORMATION TO BE DISPLAYED (Completeness VERIFY COMPLETE s of Information): During the OER operators reported that they do not have feedback as to whether t he torus or the drywell 0-2 concentration n sample points are being moni tored. This observation is supported by OER-027.

5B135I SEE 5B135 INVESTIGATION '

5B136 6 USABILITY OF DISPLAYED VALUES (Scale Ran VERIFY COMPLETE ge): The cooling water flow in the CRD hydraulic system is ~65 gpm but the flow indicator range, 11 91, is 0-50 gpm.

SC014 7 GENERAL CHARACTERISTICS OF GRAPHIC RECOR VERIFY COMPLETE DERS (Scale Compatibility): Re corder scales and recorder paper that ar e not compatible are: Panel C 170: #434, 439, 449. Panel C171: #1327, 1332, 1339. Panel 903: #615. P anel C1: #24, 25, 23. Panel C7: #1430. P anel CP902: Area Rad FR 705-4, AR 5075-A.

SC015 6 SPECIFIC RECORDER TYPES (Continuous Reco VERIFY COMPLETE rders-Labeling): There is no r ecorder labeling on Panel CP600 - #466.

SC016 SC016A 2 USABILITY OF DISPLAYED VALUES (Scale Sel PDC ection): The scales on APRM me eters #1162,1163,1107,1108 on Panel 905 and #168 on Panel C2 do not pr ovide the required precision. This obser vation is supported by OER-031 SC01Gt 6 USABILITY OF DISPLAYED VALUES (Scale Sel VERIFY COMPLETE l ection): The scales on APRM me ters #1162,1163,1107,1108 on Panel 905 a nd.#168 on Panel C2 do not pr ovide the required precision. This obser vation is supported by OER-031 5C017 7 PRECAUTIONS TO ASSURE AVAILABILITY (Bulb PURCHASE BULB TOOL C-18 l

l

\ _ __ - __ . _ - _ - _ _ - _ - _ _ -

a PAGE 17 11:09:06 26 APR 1989 HED #.. IMPL. HED DESCRIPTION......................... NEXT ACTION.........

CATEG Changing Hazard): Changing a light bulb on panel C3 caused a short a nd resulted in a " scram."

SC017I SEE SC017 INVESTIGATION SC018 5C018A 2 GENERAL CHARACTERISTICS OF GRAPHIC RECOR PDC DERS (Use): Recorder #146 prov ides confusing values. This HEO is suppo rted by OER-030.

SC018B 6 GENERAL CHARACTERISTICS OF GRAPHIC RECOR VERIFY COMPLETE DERS (Use): Recorder #146 prov ides confusing values. This HEO is suppo rted by'OER-030.

SC019 6 GENERAL CHARACTERISTICS OF GRAPHIC RECOR VERIFY COMPLETE DERS (Visibility): The channel being recorded cannot be determined wit hout opening the door and adv ancing the paper on: Panel 904: #1025 Pa nel C1: #14 and 15 5C020 2 USABILITY OF DISPLAYED VALUES (Scale Sel PDC ection): The units on instrume nts #912 and 894 are worn away and one i s replaced with tape.

SC021 6 USABILITY OF DISPLAYED VALUES (Scale Sel VERIFY COMPLETE ection): The power value is sh own in percent power to a level of 125 p ercent for #1120, 1122, 1124, 1126, 1128, 1130, 1132, 1134, 1145, 114 7, 1149, 1151, 1153, 1155, 115 7, and 1159. What does 125 percent refer to?

SC022 2 SCALE MARKINGS (Use of Graduations): Sca PDC les with more than 9 graduatio ns between numbers: Panel C170: #438, 44

9. Panel C171: #1339, 1331. P 1

anel 903: #618, 619, 621, 583, 584, 632, 633, 635, 636, 582, 602. Pane 1 904: #829, 830, 861, 862, 863, 877, 88 9, 890, 907, 908. Panel 905: #

1078, 1079, 1171, 1192, 1193. Panel C2:

1. 133, 145. Panel CP600: #466, 468, 469, 477, 478. Panel C7: #1460.

SC026 6 USABILITY OF DISPLAYED VALUES (Eliminati VERIFY COMPLETE on of Operator Conversion): Th e plaque identifying reference RPV water levels for use with 1173 & 1 174 (panel 905) contains arrows pointing to various positions on the s cale of 1173 which differ from the state d level by ~8 inches. The scal e pointer is between the arrows and scal e easily allowing the incorrec t association of the pointer with the ar rows on the plaque.

6B072 2 NEED FOR LABELING: Labels on Panel CP600 PLT MODS C-19

• PAGE 18 11:09:07- 26'APR 1989

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CATEG L

#466, 465 missing. Panel C7:

1. 1454, 1455, 1448 have operator notatio n'to' indicate the label is in.

error. Panel 903: #581 should be relabe led torus air temperature;#601

,610 have no label. Panel 903 and 904: #

626 and-842 no direction for i nerease. This' observation is supported b y OER-037'and OER-042.

6B073 2 HIERARCHICAL SCHEME: ,The limited hierarc PLT MODS hical labeling does not adequa tely satisfy these guideline criteria, T his observation is supported by OER-041, 6B074' 2 PLACEMENT (Normal Placement): Labels not PLT MODS placed above their associated controls are: Panel CP600: #472, 473, 5 L 00, 501, 527, 528, 518, 519, 529. Panel 903: #604, 608,'587, 592, 594

, 599, 591. Panel 904: #1005, 1022, 836, 866, 868, 880. Panel 905: #12 65, 1266, 1299, 1300, 1302, 13 05, many pushbuttons. Panel C1: #26, 27, 46, 48, 56, 57. Panel C4: #15 20,1521,1522,1523,1524,1525,1526,1527,15

'28.

6B075 2 PLACEMENT (Panel Labeling): All display PLT MODS labels are placed below the in strument and does not conform to guideli ne criteria.

6B076 2 CONSISTENCY (Internal Consistency and Co PLT MODS I nsistency with Procedures): No standard list of abbreviations or acron yms is used on the labels, e.

g., PREHEAT.5R/PREHTR, BLOCK /BLK, HYDROGE N/H2 This observation is suppo '

rted by OER-039.

6B077 2 BREVITY: There is an inconsistency in la PLT MODS beling, some labels use comple te words for abbreviations that are in c ommon usage by operators, e.g

., RCS/ Reactor Cooling System. This obse rvation is supported by OER-03 9.

6B078 2 FUNCTIONAL GROUPS (Functional Relationsh PLT MODS ip and Location): Controls for  !

fast start-up test and fast injection p rocedures require a set of co ntrol actuations in sequential series. T he controls associated with th ese sequential actions are scattered act oss the panel requiring the op erator to search for proper controls in sequence This observation is s upported by OER-036.

C-20

PAGE - 19 11:09:07 26 APR-1989- q HED #.. IMPL'. HED DESCRIPTION......................... NEXT ACTION.........

CATEG 6B079 6 CONTROL POSITION LABELING (Direction): T VERIFY COMPLETE ]

he direction of movement does not conform to convention on: Panel 903

#626, 599 Panel 904: #842, 9 45, 951, 952, 956 Panel C1: #45, 46, 48 (turn left to increase tempera ture) Panel C7: #1448, 1454, 1455, 1413;  !

operator pencil markings indi cate directions differ from labels Panel C3: #356, 372, 377, 380 This observation is supported by OER-024.

6B080 2 READABILITY (Character Height): Characte PLT MODS r heights are not consistent, e.g., Panel C3 - #411, 415, 421, 423. A-1so Panel C2: #146, 165. The s maller character size does not meet guid eline criteria. This observati on is supported by OER-038.

68081 2 READABILITY (Contrast): All labels are w PLT MODS hite characters on black or da rk background. This does not conform wit h the guideline criteria and contributes to the observation reported under HEO 6.6.005 (HED 6C023.7 6B082 2 USE (Necessity and Human Factors Practic PLT MODS es): Temporary labels have bee n on the panels for an extended period o f time, e.g., many dynotape 1 abels as on Panel C3: #246, 247, 248 ann unciators or C170: #450, 451, 452, 453, 454, 455, 456, 457, 1340, 1341

, 1342, 1343, 1344, 1345, 1347 1338. On Panel C7 operators have penci led in label identification wh ich conflicts with permanent label, e.g.

, #1454. This observation is s upported by OER-040.

6B083 6 USE (Adjacent Devices): Panel C7 - #1433 VERIFY COMPLETE i covers labels on #1440. Asses sment of this criteria is limited becaus e the tags were removed durin g panel photography.

6B084 2 DEMARCATION (Permanence): Stick-on tape PLT MODS is used for most of the demarc ation lines on Panels #903, 904, C1, CP6 00 Board

Title:

Rx CLG, Rx Cl nup, FW & Cond, AOG l

6B085 2 COLOR: Colors are not associated with sp PLT MODS ecific functions. Board

Title:

Rx CLG, Rx Clnup, FW & Cond, Electrical

, PAM, Cntmt Vent Board No.:

1. 903, 904, C1, C3, CP600, C7 6B086 2 i USE OF MIMICS (Color): The mimic lines o PANEL C3 MODS  !

l n Panel C3 are not color diser iminative.

I C-21 l

\ - -. - - --

! :'= PAGE 20 11:09:07 26 APR 1989 HED;#.. IMPL. HED DESCRIPTION......................... NEXT ACTION.........

CATEG 6B087 2 USE OF MIMICS (Color): Mimic lines on Pa PLT MODS nel C3 do not have adequate co lor contrast with the panel surface.

6B088 2 USE OF MIMICS (Color): The origin of all PLT MODS lines for the containment iso lation. mimic are not clear. This observa tion is supported by-OER-044.

'6B089 2 INTERNAL CONSISTENCY: The. bus indicator PANEL C3 MODS numbers do not increase progre ssively (#240 out of sequence). In addit ion, two different colored li ght caps are used.

6B090 2 CONSISTENCY (With Procedures): Panel 903 PLT MODS

Containment spray Signal lab el #755 and 770 should be changed to con tainment Spray Permissive. Pa nel 904: Displays 885,886,887 read lbs/h r times 10 to the 6th and Proc edure 2.2.84 ( pg 18 ) indicates gal / min.

Panel C2: #168 reads in mils; the instructions (2.2.99) reads in inche s.

68091 2 CONSISTENCY (Internal Consistency): Pane PLT MODS 1 904: Labels for 992 and 1008 are different but the controls perform j the same function. Panel C3:

Label wording on controls 429,430 is con .1 fusing to relate to control fu nction.

6B092 2 NEED FOR LABELING: Panel C1: Labels for PLT MODS i

lights above #36 and 31 are mi L

ssing. Panel C2: 4 lights associated wit h control #231 do not have la bels. Panel 904: Labels on 888,913 are m  :

issing. '

6B120 2 CONTROL POSITION LABELING (POSITION): Th SWITCH MODS e functional control positions are worn off or have never been etched on the control plate (escutch eon) for a large number of switches 6B121 2 NEED FOR LABELING: There are 8 key contr PLT MODS ol selector switches on each o l f the PAM panels C170 and C171. The syst em function for the use of th ese controls is not identified.

6B125 2 NEED FOR LABELING: The red and green lig PLT MODS hts associated with valve cont rols 720,721,750,751 indicate valve posi tion command as opposed to va i lve position for all other valve control l s in the control room. valve p osition is indicated on panel C171, inst rument 1338.

6C023 6 VISIBILITY (Cleaning): The number of lab VERIFY COMPLETE els obscured by dirt or foreig L C-22 i

i P'AG E 21 11:09:07 26 APR 1989 HED'#.. IMPL. HED DESCRIPTION......................... NEXT ACTION.........

CATEG n matter would indicate that no procedur e for cleaning exists. .

8A006 2 ENHANCEMENT RECOGNITION AND IDENTIFICATI PLT MODS ON Panels CP600,C7,C170,C171 1 ack operator enhancement aids. This obse rvation is supported by OER-0 43.

8A007 8A007A 2 LOGICAL ARRANGEMENT AND LAYOUT (Other Ex CONCEPT DESIGN pectations): The arrangement o f Panel CP600 is not arranged for sequen i tial operations.

8A007B 5 LOGICAL ARRANGEMENT AND LAYOUT (Other Ex SFTA pectations): The arrangement o '

f Panel CP600 is not arranged for sequen tial operations.

8A008 8A008A 2 SEPARATION OF CONTROLS: Panel C7: All co CONCEPT DESIGN ntrols are too close and too c 8A008B 5 SEPARATbNOFCONTROLS: Panel C7: All co SFTA ntrols are too close and too c luttered.

8B094 i 8B094A 2 STRINGS OR CLUSTERS OF SIMILAR COMPONENT PLT MODS S (String Length): Panel 904:

48 pairs of red / green indicator lights produce a display grouping whi ch exceeds length criteria of 20 inches.

Panel 905: Control rod matrix lights exceed maximum string length cri teria of 20 inches.

8B094B 5 STRINGS OR CLUSTERS OF SIMILAR COMPONENT SFTA S (String Length): Panel 904:  !

48 pairs of red / green indicator lights [

produce a display grouping whi ch exceeds length criteria of 20 inches.

Panel 905: Control rod matrix lights exceed maximum string length cri teria of 20 inches.

8B095 2 STRINGC OR CLUSTERS OR SIMILAR COMPONENT PLT MODS S (Number of Components): Comp onents that exceed 5 in a row or column are: Panel 904: Secondary con tainment lights. panel 905: Control rod drive indicators 1187,1188,118 9,1190,1191,1192,1193. Panel C3: Diesel generator indicators for A and

b. Ccnal and Bridgewater line indicator

s. Panel C7: Controls #1474,14

< 75,1476,1477,1478,1479,1480,1481,1482,14 l 83, 1484,1485,1486,1487,1488,1 489,1465,1466,1467,1468,1469,1470,1471.

8B097 8B097A 2 MIRROR IMAGING: Panel C1: Loop A and B f CONCEPT DESIGN C-23

PAGE 22 11:09:07 26 APR 1989 f

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CATEG j

l or RBCCW and TBCCW are mirror imaged. Panel C3: Diesel generator A an i d B controls are mirror imaged

! . Panel C3: UAT & startup transfer contr ols 359,369 are mirror imaged.

Panel 905: #1107/1108 mirror imaged wit i h 1162/1163 and their associat ed controls. This observation is support ed by OER-045.

8B097B 6 MIRROR IMAGING: Panel Cl: Loop A and B f VERIFY COMPLETE or RBCCW and TBCCW are mirror imaged. Panel C3: Diesel generator A an d B controls are mirror imaged

. Panel C3: UAT & startup transfer contr ols 359,369 are mirror imaged.

Panel 905: #1107/1108 mirror imaged wit h 1162/1163 and their associat ed controls. This observation is support ed by OER-045.

8B098 2 SEQUENCE FREQUENCY OF USE AND FUNCTIONAL CONCEPT DESIGN CONSIDERATIONS (Functional Co nsiderations): Cleanup controls #966, 96 7, 968, 969, 970, 971 separat e controls #976, 977, 978, 979, 980, 981

, 983, 984, 985, 986, 987, 988

, 989, 990, 991. This observation is sup ported by OER-022.

8B099 2 ENHANCING RECOGNITION AND IDENTIFICATION PLT MODS (Spacing): Set of controls fo r recorders #1107/1108 and #1162/1163 ar e not separated to indicate b oundaries.

8B100 2 ENHANCEMENT RECOGNITION AND IDENTIFICATI PLT MODS ON (Emergency Controls): No di stinctive enhancements are used for emer gency controls.

8B101 5 SEQUENCE, FREQUENCY OF USE AND FUNCTIONA SFTA L CONSIDERATIONS (Sequence of ,

Use): Operator must activate controls # 1 768 and 753 on Panel 903 then go to Panel Cl to activate controls #101

, 108, or 121, 124.

8B102 6 SEQUENCE, FREQUENCY OF USE AND FUNCTIONA VERIFY COMPLETE L CONSIDERATIONS (Functional C considerations): Recorder 1171 on Panel 9 05 and recorders 814 and 898 on Panel 904 values must be taken along '

with TR263-104 on panel 921 ev ery 15 minutes during heatup & cooldown.

Instrument #614 on Panel 903 used with instruments #861, 862, 863 on Panel 904.

8B102I SEE 8B102 INVESTIGATION 8B103 2 LOGICAL ARRANGEMENT AND LAYOUT (Order an CONCEPT DESIGN d Labeling): Panel C2: #218,21 C-24

_ _ _ _ - _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ _ _ = _ _ _ _ . _ _ _ _ - _ - _ _ _ _ _ _ _ _ - _ - _ - _ - - _ - _ _ _ _ - - _ _ _ _ _ _ _ _ _ - _ _ _ _ - - _ . _

• L P GE .23 11:09:07 26 APR 1989' HED 4..-IMPL. HED DESCRIPTION......................... NEXT A'CTION.........

.CATEG 9,227,228',232,233 are not arranged in a logical sequence. Panel 903:

Controls #750 and 751 do not follow sequ entially..

8B105 2 SEQUENCE, FREQUENCY OF USE,AND FUNCTIONAL CONCEPT DESIGN CONSIDERATIONS (Sequence): .Th e Primary & Secondary containment isolat ion status lights are positio ,

ned right-to-left and labels numbered fr  !

om bottom-to-top.

8B122 2 LAYOUT CONSISTENCY (REPEATED FUNCTIONS): L'ONCEPT DESIGN The' meters on HTCI and RCIC a re not in the same sequence. Meter #585 and 586 on HPSI and 831 and 8 32 are reversed. The indicator lights fo r 138,139,140,141,150,151,152, 153,154,155,156, 157,158,159,160,161,162

,163 and-164 on panel C2 are n ot in the same layout as #2,3,4,5,6,7,8, 9,10,11,12 and 13 on panel C1.

8B129 6 SEQUENCE, FREQUENCY OF USE, AND FUNCTION VERIFY COMPLETE AL CONSIDERATIONS (Functional Considerations): On the suction line fr om the recire loop for shutdow  !

n cooling using RHR, the inboard isolati on valve control (703) is grou ped with RHR loop A and the outboard val  !

ve (715) with loop B. These va  !

lves are not loop-dependent and are ~ 6 ft apart.

.98106 9B106A 2 GENERAL MOVEMENT RELATIONSHIPS (Rotary C CONCEPT DESIGN-ontrols): Panel 903: Control #

626 increases clockwise, indicator #629 increases downward. Panel 904 l

Control #842 increases clockwise, indi cator #833 increases downward.

9B106B 6 GENERAL MOVEMENT RELATIONSHIPS (Rotary C VERIFY COMPLETE ontrols): Panel 903: Control #

626 increases clockwise, indicator #629 l

l increases downward. Panel 904

Control #842 increases clockwise, indi cator #833 increases downward.

9B107 ,

9B107A 2 SINGLE CONTROL AND DISPLAY PAIRS (Associ CONCEPT DESIGN ation): Control #1185 for reco l rders 1171 and 1172 and control 1196 for controllers #1299 and 1300 a re not located so that association is ap parent.

9B107B 6 SINGLE CONTROL AND DISPLAY PAIRS (Associ VERIFY COMPLETE ation): Control #1185 for reco rders 1171 and 1172 and control 1196 for controllers #1299 and 1300 a re not located so that association is ap C-25

a P' AGE 24 11:09:08 26 APR 1989 HED #.. IMPL. HED DESCRIPTION.........................

CATEG NEXT ACTION.........

parent.

9B108 6 SINGLE CONTROL AND DISPLAY PAIRS (Associ VERIFY COMPLETE ation): The direction of movem ent of controls and light colors are not consistent with convention.

Controls (e.g., #206, 207, 208, 215, 216

) move counterclockwise to rai se. Red / Green lights above controls #206

, 404,.406 are reversed.

9B108I SEE 9B108 INVESTIGATION 9B109 9B109A 2 SINGLE CONTROL AND DISPLAY PAIRS (Proxim CONCEPT DESIGN ity): Indicator #168 and contr ol #191 are not in close proximity to ea ch other. Indicators #166 and ,

167 are distant from controls #229, 230 I

, 231. Indicators #169, 170 ar e distant from controls #204, 205.

9B109B 6 SINGLE CONTROL AND DISPLAY PAIRS (Proxim VERIFY COMPLETE  !

ity): Indicator #168 and contr  !

ol #191 are not in close proximity to ea ch other. Indicators #166 and 167 are distant from controls #229, 230

, 231. Indicators #169, 170 ar e distant from controls #204, 205.

204 items listed.

} C-26 l

l

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APPENDIX D SCOPE OF PILGRIM STATION DCRDR D-1

.: v  !

e. l APPENDIX D SCOPE OF PILGRIM STATION DCRDR For the purposes of the DCRDR project, Boston Edison defines the Pilgrim Station Control Room as the following control panels, work stations and adjacent areas used by plant operators for normal and emergency operations: J EAnel No. Panel Name i 903 Core Standby Cooling Systems 904 Reactor Auxiliary Systems 905 Reactor Control C-1 Feedwater & Condensate C-2 Turbine Control C-3 Electrical Systems C-170/C-171 Post-Accident Monitoring CP-600 Augmented Off-Gas 902 Area & Process Radiation Recording 910 Process Radiation Monitoring 911 Area Radiation Monitoring C-4 feedwater Heaters Control C-7 Containment Ventilation & Gas Treatment C-76 Shift Supervisor Console C-77 Operator Console HED's and corrective actions discussed in this report are related to the scope defined above. Potential changes to the defined control room for the remainder of the project, if any, will be identified in the forthcoming Program Plan revision.

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