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Dese: 6/20/97 5:24pm | |||
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==Subject:== | |||
This message is from DOLCE Fresa: Kathy Dolce To: JBF, BRL, RRK, PDS, CWH, LEN, MCM, DJV, hufK Dese: 6/20/97 5:05pm | |||
==Subject:== | |||
Ad-hoc panel for Monday 6/23/97 at 9 AM Mr. Fewell spoke to two individuals and the conversations are being documented and placed on an allegation receipt form. | |||
Based on a meeting with Hub, we are having an ad-hoc allegation panel at 9AM on Monday June 23,1997. This involves Ca*- ah=aa=. The two concerns are: | |||
: 1. Failure to perform tests | |||
: 2. Supervisors knew that the tests were not being performed. | |||
Mr. Fewell will provide the allegation office the receipt form and the allegation office will make copies and distribute as soon as we can. Any questions, please see Brad. | |||
Thanks for your cooperation. | |||
Kathy . -- | |||
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,y 9902000004 990129 PDR FOIA SORENSEN99-36 PDR m n-. , - - | |||
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TIME LINE FOR ALLEGATION NO. RI-97-A-00145 l 6/20/97 Fewell receives allegations from two former NPOs 6/23/97 Panel decided to have Ris gather more information from allegers 6/24/97 Ris found out that PP&L had received similar concern at the corporate attorney level. Corporate auditing was looking irdo it 6/25/97 Ris talked to allegers to get details. Found that PP&L investigation was well underway (meeting with allegers and attorneys planned). Also, allegers concerned that NRC involvement might cause PP&L to slow or stop ' | |||
investigation. | |||
6/26/97 Acknowledgment letters sent 7/2/97 Repanel with updated information. Based on alleger's concerns and Baker guidance regarding not referring allegations that NRC knows a licensee is __ | |||
investigating (due to certain identification of alleger). NRC decided to monitor PP&L's effort and obtain final reports. 5 7/8/97 Monitored status of investigation. Monthly allegation reviews updated slow PP&L progress. | |||
9/18/97 Crienjak and Anderson called PP&L auditor to impress the importance of schedule. Status was "still working," maybe they could accelerate closure of some parts. | |||
11/5/97 Meeting with PP&L to get detailed status - two of four areas done emphasized need to close ASAP. Two open issues involve additional examples of poor operator performance / falsification prior to O/96 event. | |||
11/20/97 Ris complete review of coropleted PP&L investigations - conclusions sound. | |||
Ris question PP&L regarding implications of preliminary findings of more N falsifications on present watchstanders. | |||
12/3/97 01 receives preliminary report from PP&L concluding a licensed operator had previously falsified alarm test record. Ol told that operator is now recanting I testimony. | |||
12/ /97 Ol opens case on PCO falsification | |||
^ | |||
k 11/27/97 PP&L removes a PCO from shift pending investigation of admitted falsification of control room alarm panel tests. | |||
12/1/97 Received several allegations that PCO was singled out for admitting what u everyone else did, but had denied. | |||
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ATTACHMENT 13 , | |||
pP&L Pennsylvania Power & ught Company ; | |||
i Two North Ninth Street | |||
* Allentown, PA 18101 1179 610/774 5151 | |||
[ | |||
. I RobertC.Byram ' i Senter Hee President.Gensertion and OlqfNueleer Officer , | |||
610/774 7502 Fax: 61str74 s019 ; | |||
APR 0 91997-I U.S. Nuclear Regulatory Commission . | |||
Attn: Document Control Desk Mail Station PI-137 Washington,DC 20555 1 | |||
l SUSQUEHANNA STEAM ELECTRIC STATION ENFORCEMENT POLICYREVIEW . Docket Nos. 50-387 . | |||
PI.A MA3 Frff R412 and 50-388 This is a supplemental response by Pennsylvania Power & Light Company (PP&L) to the apparent violations raised by the Nuclear Regulatory Commission (NRC) Staff at the March 21, 1997 enforcement 'ecnference. At the enforcement conference, PP&L's presentation focused on < | |||
the fundamental couses and management issues associated with the apparent violations as well as the corrective and yeventive actions necessary to preclude recurrence. Given this focus and the time constraints on the enforcement conference, PP&L's response did not explicitly address the l | |||
- application of the NRC Enforcement Policy to the -yyerent violations. This letter bric0y reviews PP&L's management perspective on the apparent violations and application of the NRC Enforcement Policy. - Attachment I contains a detailed analysis of how the Enforcement Policy i applies to each of the apparent violations from our perspective. | |||
- PP&L conducted a comprehensive review of each of the events discussed dunng the enforcement conference. They were evaluated both individually and from a wider perspective. We looked for | |||
- common themes and broader implications. PP&L concluded that these events were important, and we believe our actions reflect the priority we have placed on their resolution. We found | |||
- weaknesses in some areas which needed correction and actions by certain employees which were unacceptable. For these reasons, we took a number of corrective actions which included the 1 - termination of seven employees and severance of one shift supervisor.and one former-shin supervisor. ' However, our reviews also resulted in several positive conclusions. Some of these we believe are significant in terms of the application of the NRC Enforcement Policy. | |||
~ Specifically, PP&L requests that (1) consideration be given to credit for self-identification and corrective action and no civil penalty be assessed; (2) the apparent violations be considered as not reflecting a breakdown in management controls and no increase in severity level is warranted - | |||
for that reason; and (3) consideration be given to there being no basis to increase the severity of any of the violations. | |||
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. FILE R41-2 PLA-4603 I Document Control Desk | |||
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: 1. Self-Identification and Corrective Action Credit When we discovered the conditions associated with the violations, we saw them as serious regulatory and management issues that deserved and received vigorous attention. We immediately initiated comphive internal and indvad-at investigations and determined the fundamental causes and generic implications of the events. Our corrective and preventive actions were directed at improving long-teun performance and promoting a questioning attitude at all levels of the organi= Hon. They included: | |||
Core Spray Containment Isolation Valve issued formal technical specification interpretation conducted training ) | |||
placed explicit directions in operations policies defined and documented for closed systems: i) those used as , redundant. isolation _ | |||
l boundaries in single-valve penetrations, ii) testing requirements and iii) acceptable l methods of altering boundaries completed technical specification reviews (we insured no other informal guidance was l being utilized in support of plant operations and reviewed the Susquehanna SES improved technical specification submittal to insure consistency with the resolution of this event) | |||
Standby Liquid Control System Heat Trace corrected drawings counseled operators on proper placement of status control tags and on questioning the applicability of status control tags j | |||
"E" Diesel Generator Misalignment took disciplinary action improved supervisory oversight (we counseled supervisors who failed to respond to the initial status control event, we trained all operations personnel on the event, we provided to shift supervision expectations for assistant unit supervisor performance, we expanded the supervisory oversight of rounds and we added a requirement for the shift supervisor to walk down status contrcl events) | |||
- revised test procedures revised a number of other operations procedures cxpanded the operations self-assessment program | |||
* retrained operations personnel on the "E" Diesel Generator design addressed human factors issues (including a modification to provide an indicating light on breaker cubicle #6) retrained operations personnel on expectations with respect to perfonnance of rounds and surveillances | |||
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* FILE R41-2 PLA-4603 ! | |||
t Document Control Desk t We have placed a high priority on actions to strengthen management and supervisory l | |||
oversight and effective communications of management expectations. Improved !' | |||
assessment practices, which include increased scrutiny of supervisory oversight, are being implemented. We have also addressed individual performance issues, taken strong personnel actions against the accountable supervisors and workers, reinforced our expectations for workers and supervisors and verified that our expectations are being met. | |||
For the reasons described in Attachment 1, PP&L asks for consideration of credit for self-identification and corrective action under the Enforcement Policy and that no civil penally - | |||
be imposed. | |||
: 2. Ma==gernent controh PP&L believes that the apparent violations do not constitute a widespread breakdown in control oflicensed activities and that the violations should not be increased in severity for - | |||
that reason. Deficient performance by NPOs was identified for activities associated with i the "E" Diesel and by a shift supervisor and a former shift supervisor in connection with ' | |||
General Station Inspections (GSIs). With respect to NPO performance, PP&L implemented preventive actions in response to NRC Information Notice (IN) 92-30 that were consistent with industry norms, including briefings for station personnel, surveillance i oflogged entries, surveillances of operator rounds and audits of operator logs. Although these actions were insufficient in hindsight to provide early detection of the NPO surveillance and rounds issues, they were reasonable precautions at the time. | |||
Contemporancous NRC inspections viewed PP&L's implementation of its self-monitoring program in response to IN 92-30 as acceptable. | |||
. After PP&L's thorough investigations revealed the NPO surveillance and rounds performance issues, a series of actions were taken to determine the scope and extent of the issucs. Specifically we intensified ' operations management oversight conducted QA surveillances completed Independent Safety Evaluation Services (ISES) Operations Surveillance conducted QA reviews of security entries versus documentation logs (including security, health physics and fire protection) made a series of improvements to make assessment practices more intrusive and effective | |||
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FILE R41-2 PLA-4603 i | |||
Document Control Desk l | |||
i | |||
'lhe NPO's pattern of behavior demonstrated by the performance of surveillances and rounds was found only in a particular activity (routine, repetitive NPO rounds) in a specific ; | |||
j location ~ ("E" Diesel Building). Moreover, we found no evidence. that these issues were widespread. The successful long-term operating record at SSES would support these conclusions. The violations were self-identified before a plant ever.t occurred. .The violations did not result in the inability of safety systems to perform theit intended safety functions. Because PP&L took precautions that were consistent with industry norms and sufficient te preclude a widespread problem, there is no basis for finding a breakdown in management controls and increasing the severity of violations for that reason. | |||
l l With respect to the performance of the alarm test by NPOs, our investigation revealed that L 'some NPOs appeared to understand the requirement but failed to comply with it on numerous occasions. Other-NPOs did not perform the test initially but once they commenced testing, they performed it consistently. While'we concluded that the conduct by both groups of NPOs constituted willful misconduct, we did not find any evidence of - | |||
deliberate misconduct. With respect to the GSIs and the monitoring of NPO rounds, we i concluded that no shift supervisor or assistant unit supervisor engaged in willful misconduct. Rather, one shift supervisor and a former shift supervisor demonstrated poor ! | |||
judgment with regard to the scope of their discretion exercised as a shift supervisor and a ! | |||
l failure to meet management's expectations with respect to performing the applicable requirements end for this reason these individuals were severed from employment. To the extent NPO surveillance or alarm test records were inaccurate, these inaccuracies resulted ! | |||
' from the actions of"non-licensee officials" as defined in the Enforcement Policy. | |||
The safety significance of these events is described below. Most GSIs and monitoring activities were donc properly. Neither the plant condition nor the ability to detect and | |||
. mitigate a transient was compromised. Accordingly, these violations were limited in scopc, effect and safety significance, and they are not indicative of a widespread breakdown in management controls. | |||
: 3. Severity Level PP&L believes that there is no ba:is to increase the severity level of the violations. Our point-by-point analysis in Attachment I demonstrates that the violations should not be categorized as more than Level IIL Under IV(A) of the Enforcement Policy, Level 111 violations are not normally aggregated. Because the violations did not result in unavailability of safety systems to perform their intended safety functions, or an actual or potential impact on the public, the violations do not meet the Enforcement Policy criterin e for increased severity. Our specific conclusions with respect to the ability of each of the l | |||
affceted systems and components to perform theirintended safety functions is as follows: | |||
: a. . . . , , .. . . . . . . . . . . . . . . . . . . . . . . . . . - . . . . ,,,,,,. ,. | |||
FILE R41-2 PLA-4603 I Document Control Desk Core Snray containment knlatinn Valve - the isolation valve that was inoperable during the maintenance activity in question does not communicate directly with either the primary containment atmosphere or the reactor coolant pressure boundary. %c redundant isolation boundary for the associated penetration is provided by closed | |||
, system piping which remains water sealed post-accident. PP&L's actions in support I of the maintenance activity were focused on assuring that a water seal was maintained ' | |||
at all times. Therefore, this penetration would have performed its intended containment isolation function if required. | |||
1 e | |||
Standby Linuid Cantrol System Heat Trace - the purpose of this heat trace, which was deenergized during the event, is to prevent Sodium Pentaborate from precipitating out of solution under certain temperature conditions. Based on solution concentration and ambient temperature over the duration of the event, the heat trace was not required to ensure that precipitation would not occur. Herefore, the Standby Liquid | |||
: l. Control Pump would have performed its intended safety function if required. In - - | |||
addition, if a low temperature demand had been sensed when no current was present, l~ alarms would have occurred locally and in the control room, notifying operators of l the condition. | |||
"F" Diesel Generatnr Miulienment - Susquehanna SES is designed to respond to all l design basis events with three of its four required emergency dicsc! generators l | |||
operable. Three emergency diesel generators were available at all times during the misalignment event; therefore Susquehanna's emergency AC power system would l l | |||
have performed its intended safety function. Additional safety margin existed, l l because the fourth emergency diesel generator was inoperable only because of the i loss of its auxiliaries. Under these conditions, it would have started if called upon, i | |||
! energized its associated 4 kV bus, and continued to run until it ran out of fuel, which would not have occurred until over one hour and twenty minutes later. Furthermore, | |||
' although PP&L could not demonstrate that the "E" diesel could be restorod prior to running out of fuel, we are confident that it would ultimately have been restored in I time to support post-accident recovery, thereby providing further margin. | |||
l e NPO Alarm Test - performance of the alarm test was not necessary to confirm the operability of either the emergency diesel generator or the alarm itself. Therefore, failure to perform this specific test had no impact on the operability of any safety-related equipment. | |||
.. GSh/PMs . During the period in question, the record indicates that most GSIs and PMs were performed properly, and that neither the plant condition nor the ability to detect and mitigate a transient were ever compromised. Therefore, failure to perform these activities had no impact on the operability of any safety-related equipment. | |||
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FILE R41-2 PLA-4603 Document Control Desk Under the factors set forth in Section IV(C) of the Enforcement Policy, no increase in severity level is warranted for willful misconduct associated with NPO performance. There was no deliberate misconduct on the part of the individuals and neither the individuals nor the company gained a discemible advantage as a result of the violation. The individuals involved were not supervisory or licensed personnel. 'Ibe violations did not result in a loss of capability to perform intended safety functions. Strong personnel actions were taken. Under these circumstances, PP&L is entitled to favorable consideration for each of the factors set forth in the Enforcement Policy and an increase in severity level for willfhiness would not be appropriate. | |||
1 The foregoing violations raise matters of significant concern to PP&L. In response, PP&L has taken aggressive actions to assure that it understands' the underlying causes and generic J | |||
implications of the violations, and that corrective actions will be effective and lasting. PP&L conducted extensive reviews of the events themselves as well as thorough investigations into the bmader implications of these events. These reviews and investigations confirmed that the ! | |||
problems were not widespread throughout the station. The controls in place were sufficient to . _ | |||
detect these problems prior to the occurrence of a plant event. PP&L's investigations revealed , | |||
' l that overall performance was meeting expectations and requirements. At the same time, PP&L | |||
; believes that its efforts to self-identify and correct the violations should receive favorable consideration under the NRC's Enforcement Policy and a civil penalty should not be assessed. | |||
Management attention has been strongly focused on correcting and preventing the problems at hand and a civil penalty is unnecessary to bring about effective corrective and preventive action. | |||
I For the reasons summarized above, PP&L respectfully submits that escalated enforcement i:: not 2 | |||
warranted in this case. | |||
Very truly yours, (Signed) R. G. BYRAM R. G. Byram Attachment copy: Mr. K. M. Jenison, NRC Sr. Resident Inspector Mr. C. Postusny, Jr. NRC Sr. Project Manager . | |||
Ms. T. E. Walker NRC RegionI l t | |||
1 | |||
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ATTACHMENT 1 TO PLA-4603 Page 1 of 6 Summary of PP&L Analysis of Enforcement Policy Application to the Apparent Violations PP&L's analysis of the NRC enforcement policy's application to the apparent violations parallels the organization of its enforcement conference presentation: (1) the apparent Technical Specification (TS) violations in connection with containment isolation; (2) the apparent procedure violations associated with the Standby Liquid Control System heat trace: (3) the apparent violations associated with the "E" Diesel Cenerator events, including the apparent violations involving (a) T S 3.8.1, (b) the surveillance procedure and related records, (c) the NPO circuit breaker rounds, and (d) alarm panel tests and related records; and (4) the apparent violations involving General Station inspections (CSis) and monitoring of NPO rounds and related records. Our discussion of the Enforcement Policy's application to the apparent violations will demonstrate that the apparent violations are appropriately categorized as severity level IV, not level 111 violations. PP&L believes , | |||
that its effor'.s to self-identify and correct the violations warrant credit under the Enforcement Policy I and no civil penalty should be imposed. . _ I l | |||
To the extent the NRC may consider aggregating all of the procedural violations, such action is not appropriate under the enforcement policy for the following reasons: (1) our point-by-point analysis below demonstrates that level IV categorization is proper; (2) the apparent violations did not result in a system designed to prevent or mitigate serious safety events not being able to perform its intended safety function and did not involve actual or a high potential impact on the public; and (3) under section IV(A) of the Enforcement Policy, severity level ill violations are not normally , | |||
aggregated. PP&L's management controls were sufficient to detect the violations prior to a plant I event, and after detection, aggressive corrective actions were taken. No increase in severity level due to willfulness is warranted because there was no deliberate misconduct on the part of individuals, these individuals gained no discemible advantage as a result of the misconduct, and . | |||
PP&L took substantial disciplinary action against these individuals as contemplated by the j Enforcement Policy. ! | |||
: 1. Core Sorav Containment isolation Valve PP&L accepts that a violation of TS 3.6.3 occurred. The condition resulted from the use of an I informal technical specification interpretation which considered the requirement for a i redundant isolation valve to be met by the integrity of a redundant boundary. Although under a literal reading of Supplement I, (C)(1)(b) of the Enforcement Policy this could be , | |||
categorized as a Level 111 violation, PP&L's analysis prior to the event concluded that the ; | |||
particular configuration of the system in question assured that a water seal was maintained throughout the period in which maintenance on the single isolation valve was performed. As a result, the safety significance of the event was minimal, and it should be categorized as a Level IV violation involving a less significant failure to comply with a TS action statement. | |||
In a recent case. Shearon Harris was cited for a Level IV. Carolina Power & Light Company, Shearon Harris Unit 1, Docket No. 50 400, inspection Report No. 50-400/95-10, dated July 7, 1995, in that case, Shearon Harris TS 3.6.3 provided that, with one or more containment isolation valves inoperable, at least one isolation valve must be maintained operable in cach affected open penetration and the inoperable valves must be restored to operability within 1 | |||
l | |||
_ _ _ . . m.- _. . _ - . . _ . _ _ . _ _ . . . . _ _ _ _ _ . . . _ _ _ _ _ _ _ _ _ _ . . _ _ _ _ _ _ , | |||
. Ata a si cey 1.h im II6 aus 6 vLunnu a na nw v i v i e s e .n w n s i | |||
ATTACHMENT 1 TO PLA.4603 Page 2 of 6 four hours. The inoperable valve was not restored witbH the required time and a Level IV violation was assessed. However, the closed system ia which the isolation valves were located (the main steam system) was considered to be the operable isolation valve for L purposes of complyin5 with the TS 3._6.3 requirement to maintain at least one valve operabic. | |||
It follows that Shearon Harris is analogous and the subject violation should be assigned a Level IV. | |||
PP&L should also receive favorable consideration under Vl(8)(2) of the Enforcement Policy for comprehensive corrective action once the condition was discovered.- Operations personnel were provided training conceming program requirements for TS interpretations. Engineering received training regarding proper documentation of engineering guidance. Program changes included explicit direction in the Operations policy to preclude use of informal documentation to interpret TS provisions. We defined and documented testing requirements and acceptable methods for altering boundaries in closed systems. We conducted reviews to assure that no other informal guidance was utilized in support of operations and reviewed the l | |||
SSES Improved Standard Technical Specifications submittal to assure consistency with the resolution of the subject violation. - | |||
l | |||
: 2. hadhv iinuid Control Svstem Deanerwired Heat Trace PP&L accepts that the violation, involving a failure to implement the status control procedure, occurred. The event was not safety significant because the Standby Liquid Control pump would have performed its intended safety function, even with the heat trace de energized for more than a day. The violation should be designated as severity Level IV. | |||
PP&L's investigations of the violation determined that the status control tags should have been applied to individual breakers rather than the panel door. The NPO should have questioned the applicability of the status control tag and sought supervisor guidance or assistance with verification of the correct plant condition. PP&L also acknowledges that field oversight needs improvement. It should be noted that the condition was identified by PP&L. ' It was not | |||
!- revealed by a plant event. There was not a breakdown in controls such that the condition escaped detection before an event. l PP&L is entitled to favorable consideration for self-identification under Section Vl(B)(2) of the Enforcement Policy, and no civil penalty should be assessed. | |||
l | |||
: 3. "E" Diesel Cecerator | |||
: a. "E" Diesel Generator (DG) inoperable in excess of allowed Technical Specification (TS) 3.8.1 allowed outage time - PP&L accepts that TS 3.8.1 was violated. The violation was | |||
- the result of an unintended error. SSES is designed to respond to a design basis event l | |||
with three DC's and thus SSES systems would have performed their intended safety ! | |||
functions even with the "E" DC inoperable. Consequently, the TS violation should bc , | |||
I categorized as a less significant TS violation and assigned a severity Level IV. | |||
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-= ATTACHMENT 1 TO PLA 4603 ; | |||
Page 3 of 6 l Even if the violation is assigned a Level 111, PP&L is entitled to a credit for self-identification under Section Vl(B)(2) of the Enforcement Policy. The violation was discovered by PP&L personnel and reported to the NRC. The problem was discovered as i | |||
the result of a licensee self-monitoring effort (an NPO detected the misalignment during i rounds) and was identified before an event occurred. Under VI(B)(2)(b)(1) of the l Enforcement Policy, self-identification credit is clearly appropriate. | |||
The corrective and preventive actions were aggressive, extensively considered generic implications, and included strong personnel actions. PP&L recognizes that exercise of a more questioning attitude on the part of control room personnel, as well as NPOs, could have resulted in detection of the condition at the time of the misalignment or a more expedient resolution of the Condition Report on the "misalignrnant" initially perceived by the NPO. PP&L's corrective actions also included performance of ..i Wrnal assessment of operations management and supervision, realignment of the work maqement structure to increase supervisor coaching and time in the field, and increased staff assistance to supervisors on shift including additional manning of the work control center and requesting additional shift supervisors. | |||
Credit for self-identification and corrective action in this case is supported by recent NRC | |||
- enforcement precedent. In Comed, Braidwood Station Unit 1, Docket No. 50 546 EA ; | |||
95-265, NRC inspection Report No'. 50-456/95-016, January 29,1996, a Level ill was ! | |||
assessed where both diesel generators were inoperable for a period of 16 days. With one j diesel generator out for scheduled maintenance, the second diesel generator was l rendered inoperable because a breaker had not been fully racked irito a cubicle. The licensee's discovery of the condition in a surveillance and the subsequent comprehensive corrective actions were credited by NRC and no civil penalty was assessed. Unlike the subject violation at SSES, which involved a partial loss of one EOC's capability but ! | |||
sufficient remaining capability to withstand design basis events, Braidwood involved a loss of multiple EDC's. Consequently, PP&L should receive favorable credit for self identification and corrective action under Section VI(B)(2) of the Enforcement Policy | |||
~ | |||
and no civil penalty should be assessed. ; | |||
: b. Violations of surveillance procedure requirement to verify OA 510-05 " racked in" and open and related records . | |||
l PP&L accepts that the procedure was violated, and in at least one instance, the violation was willful. Under IV(C) of the Enforcement Policy, the violations should not bc increased in severity level because of the element of willfulness. The willful misconduct l was not by licensee officials. There was no deliberate intent and the individuals gained | |||
. no discernible advantage as a result of the misconduct. Substantial disciplinary action was taken, as contemplated by the NRC Enforcement Policy. PP&L should roccive favorable consideration for each of the foregoing factors, and there should be no increase in severity as a consequence of willful misconduct. | |||
-In response to NRC Information Notice (IN) 92 30, PP&L implemented preventive actions that were consistent with industry norms, including briefings for station personnel, surveillance of logged entries, surveillances of operator rounds and audits of operator | |||
.. logs. Although these actions were insufficient in hindsight to provide early detection of g g. .-yy g--r -r-y-e A- -. Asw i w---s+-- -wg, ,-,g | |||
_ _ _ _ . _ . - _ . _ _ . _ _ _ _ _ _ _ . _ _ . _ _ _ ._ _ __ _ _. ~ .. _ - _ . _. _._ ___ _ _ __.. . _ _ _ _ . _ . . _ , | |||
_ hs a ., a} s u s.o sisu ses. .s.- sw .. v s su . .~ . ~ . . . . wv.,s,,sw . . . . | |||
:. ATTACHMENT 1 TO PLA-4603 Page 4 of 6 the NPO surveillance and rounds issues, they were reasonable precautions in real time. | |||
Contemporaneous NRC inspections viewed PP&L's implementation of its self-monitoring program in response to IN 92-30 as acceptable. Docket Nos. 50-387/388, NRC Inspection Report 50 387/92-20; 50-388/92 20, dated September 4,1992, p.1517. | |||
After - PP&L's thorough investigation exposed the NPO surveillance and rounds performance issues, a series of actions were taken to determine the scope and extent of the issues. These actions included: | |||
. intensified operations management oversight, | |||
- * - conduct of QA surveillances, e completion of ISES Operations Surveillance. . | |||
* conduct of _QA reviews of security entries versus documentation ' logs (involving approximately 125,000 individual tasks), _ , | |||
e improving assessment practices to make them more intrusive and effective. | |||
1 The pattem of behavior demonstrated by the NPO's performance .of surveillances and _., | |||
rounds was found only in a particular activity (routine, repetitive NPO rounds) in a specific location ("E" diesel building). Moreover, we found no evidence that these issues ' | |||
were widespread. The successful long-term operating record at SSES would support these conclusions. Because PP&L took precautions that were consistent with industry norms and sufficient to preclude a widespread problem, and because strong corrective actions, including personnel actions were taken, a civil penalty should not be assessed. | |||
In a 1994 Dresden enforcement action, with facts less favorable to the licensee, a civil penalty was not assessed. Comed, Dresden Station, Docket Nos.- 50 237 and 249, EA-93-182, NRC Inspection Report No. 50-237/92-033, 50 249/92-033, April 21,1994. | |||
In that case, operating personnel attempted to conceal. control rod mispositioning in violation of procedure by not reporting or recording the event. A civil penalty was not assessed because the licensee identified the violation and took substantial corrective actions, including strong disciplinary actions against the individuals, in this case, because strong disciplinary actions, including terminations, were taken (even though there was no evidence of concealment or intentional misconduct), a civil penalty should not be ' | |||
assessed. | |||
The violation was self-identified. Moreover, as indicated in the discussion in 3.a above, the actual safety significance of the 'E' diesel misalignment was limited. Although | |||
. management controls' were imper f ect, the con d ition was detected before an event occurred. There was not a complete loss or pervasive breakdown of controls, as | |||
. evidenced by the detection and the results of subsequent investigations which point to a finite scope and location for the NPO surveillance and rounds performance issues. In | |||
- those circumstances, the violations should not be aggregated or categorized as severity Level ill on the basis of a breakdown. | |||
a | |||
'b i , . , . , , - % , .s .m. . | |||
_ _ _ - _ m. . _ . . _ _ _ _ _ . _ -..-._._ _.__._._- _..____ _._ | |||
. ' ass'- s as neu t . 3 , r a. | |||
'tru av v 5, i s t.n a s au s aa av utu,nsnu i . i t, ATTACHMENT 1 TO PLA-4603 Page 5 of 6 l-As indicated above, PP&L is entitled to favorable credit under Section Vl(B)(2) of the Enforcement Policy for self-identification and corrective action. Thus, even if the violations are categorized as severity Level til, no civil penalty should be assessed. To the extent that the NPO surveillance records were inaccurate, a violation of 10 C.F.R. 9 ~ | |||
l 50.9(a) may be involved. Any such violation, however, should be assigned severity Level ! | |||
IV since the inaccurate records resulted.from the actions of non-licensee officials as defined in Supplement Vil, C(2) and D(2) of the Enforcement Policy. | |||
' c. Procedural violations in connection with NPO circuit breaker rounds ll PP&L accepts that these procedural violations occurred. For the reasores stated in 3.b above, there was no widespread breakdown in controls and the violations should not be aggregated or assigned severity Level 111 on the basis of a breakdown. The violations occurred within a specific segment of the SSES organization and similar performance was not found in PP&L reviews across the entire organization. In any event, PP&L should receive favorable consideration for self-identification and corrective action under Section | |||
~ | |||
Vl(B)(2) of the Enforcement Policy and no civil penalty should be assessed. | |||
: d. Alarm panel test procedure violations and related records l PP&L accepts that these violations occurred, although there were instances of willful misconduct, PP&L took reasonable precautions before the violations were discovered and strong actions after discovery. Moreover, there was no pervasive breakdown in controls. | |||
Although earlier detection is PP&L's expectation, the conditions were nevertheless self-identified and found before a plant event. The controls and assessment mechanisms were consistent with industry norms in real time, but in hindsight, insufficient to promptly , | |||
detect willful misconduct. : Performance of the alarm test was not necessary to establish or confirm the operability of the EDG or the alarm itself. Thus, failure to perform this test L . was not safety significant. Consequently, the procedural violations should be assigned ' | |||
l' severity Level IV. Alternatively, even if they are assigned severity Level 111, PP&L is entitled to favorable consideration under VI(B)(2) of the Enforcement Policy for self identification and corrective action and no civil penalty should be assessed. | |||
To the extent that NRC might consider violations of 10 C.F.R. $ 50.9(a) for inaccurate alarm panel test records, a Level 111 should not be assigned. Any inaccurate records resulted primarily from the actions of non-licensed personnel, who are not " licensee officials" as defined in Supplement Vil, (C)(2) and (D)(2) of the Enforcement Policy. | |||
n 11 L | |||
l | |||
'arp o~as a t. v s.) su sss. aus ass.assaa s u n., usu,,,,,,v , , , , | |||
ATTACHMENT 1 TO PLA-460) | |||
Page 6 of 6 | |||
: 4. General statian hunections. Monitarine of NPO Rounds and estated Records PP&L accepts that violations involving the procedures governing General Station Inspections (GSis) and related inaccurate records of the GSis occu: red. However, these GSis as well as the Assistant Unit Supervisor (AUS) monitoring of NPO rounds were self-imposed procedural requirements not required by the Technical Specifications. While it is of course required to follow plant procedures, PP&L believes that neither the GSis nor AUS monitoring of NPOs and rel-ted records are within themselves regulatory requirements. There was no willful misce.vhet involved in these events, and no widespread breakdown in controls. The safety significance was minimal. Most GSis and monitoring activities were done properly. Neither the plant condition nor the ability to detect and mitigate a transient was compromised. | |||
PP&L's investigations indicated that two individuals, a shift supervisor and a former shift supervisor, demonstrated poor judgment with regard to the scope of their discretion and failed to meet management's expectations with respect to performing applicable requirements. These two employees were severed fror, employment. Consequently, even if NRC determines there are procedural violations, then such violations should be considered severity Level IV. Although the records violations were attributable to licensee officials, they _ | |||
were limited in extent and scope and did not affect plant configuration or equipment functionality. Thus, they should be assigned severity Level IV. The violations were reported to PP&L by its employees and uncovered by PP&L investigations. In any event, PP&t. should receive favorable credit for self-identification and corrective action under VI(B)(2) of the Enforcement Policy and no civil penalty should be assessed. | |||
j | |||
ASSESSMRST OLTLINE i | |||
Overview of PP&L Self-Assessment Response to NRC Information Notice 92-30 Assessment Response to E-Diesel Event - | |||
Insights Improvements. in Assessment Practices | |||
~ | |||
Conclusions 68 i | |||
PP&L ASSESSMENT MATRIX CONTINUOUS PERIODIC PREVENTIVE CORRECTIVE INDIVIDUALS & a. Shift turnover review a. Goals status reporting - a. Tailboarti conferences a. Troubleshooting | |||
: b. Alertness to anomalies b. Employee development b. 50.59 safety evaluations b. Post-event tailboards WORK GROUPS program - | |||
: c. Job completion walkdowns | |||
: c. STAR c. Root cause analyses | |||
: d. 200% accountability at c. DACUM (STCP-QA-1I2) d. Independent (Design) interfaces d. Training Curriculum verification | |||
: e. Employee Safety Program Committees (STCP-QA-I II) e. Pre & Postjob ALARA Review SUPERVISION & a. M11WA (management by a. Employee Performance a. Contingency planning a. License Event Review walking around) Reviews b. Outage readiness assessment b. Condtion Report event reviews ' | |||
MANAGEMENT b. Pre-SALP & pre INPO Review c. PORC startup review | |||
: b. Field supervision c. Post < volution critiques | |||
: c. Coaching & counseling 'c. Performance indicator review d. Post outage review d. SRC review ofplant events | |||
: d. Review oflogs & test results d. Process re-engineering e. Response to NRC Notice of | |||
: e. Maintenance self-assessment e. Plant tours Violetion program f. ERC f. Response to Audit Findings | |||
: f. Radiological Evaluation g. Station ALARA Committee Program (NEIM-00-1070). | |||
INDEPENDENT a. QA~Surveillances a.QA Audits a. QA Observations a. ISES Investigations | |||
: b. QC Inspections b. ISES Surveillances b. QA Recommendations b. Condition Report Program c.QC In-Process Corrected Error c. SRC Reviews c.NAS Assessments Program | |||
: d. Condition Report Program | |||
: e. ISES Oversight ; | |||
EXTERNAL a. NRC Inspector routine a. NRC SALP a. NRC review ofsafety e.NRC Augmented Inspection inspections b. INPO Evalaations evaluation involving an , Team | |||
: c. PUC Audit Unreviewed Safety Question b. Notice ofViolations b.NRC review ofTech Spec. | |||
C%nge Request 98/1135 8:94 AM MATRIX. DOC i | |||
9 9 | |||
6 | |||
- - . ......k .am.. | |||
PP&L INDEPENDENT ASSESSMEST .. | |||
I i | |||
CONTINUOUS PERIODIC PREVENTIVE CORRECTIVE ,. | |||
INDEPENDENT QA Surveillances QA Amlits QA Observatioss ISESInvestigations QCInspections ISES Surveillances QA Recommendations CR Program QCICE Pmgram SRC Reviews NAS Assessments i CR Pragmm ISES Oversight i | |||
70 ; | |||
h i | |||
;7 i | |||
RESPONSE TO XRC IN 92-30 .- . . | |||
Station Personnel Were Briefed on IX 92-30 QA Surveillance Per IN 92-30 Verified Logged Entries March - June,1992 QA Surveillances Per IN 92-30 Quarterly 92Q3 to Date Verified Logged Entries i | |||
QA Surveillances Evaluated: Adequacy of Operator Rounds . | |||
QA Audits Evaluated Operator Rounds Logs i | |||
71 t | |||
i | |||
RESPONSE TO XRC IX 92-30 ,, | |||
4 These Assessments Were Necessary to . | |||
Confirm That 1 | |||
- Security Entries Were Made As Required | |||
- Logs Were Completed As Required | |||
- Operators Performed Well (Under Observation) | |||
But, They Were Not Sufficient A More Questioning Approach Could Have Detected The NPO Performance Issue 72 i | |||
.1 ASSESSMENT RESPONSE TO . | |||
E-DIESEL EVENT - | |||
ISES Investigation Determined | |||
- Certain Entries Were Too Short to Perform Rounds & Surveillance Tasks | |||
- Certain Logs Showed OC577E Alarm Check Not in Plant Computer Record | |||
- The Same NPO's Had Short Entry Durations & | |||
Missed Alarm Checks . | |||
- Interviews Were Required to Explain Data Recommended Corporate Auditing Investigation 73 i . | |||
ASSESSMRST RESPONSE TO E-DIESEL EVEXT . | |||
Operations Management Oversight and | |||
~ | |||
QA Surveillance ' | |||
Hour Coverage for 50 Days | |||
- 247 Evolutions Observed | |||
- Random Observations of All Non-Licensed Operator Positions | |||
- Observed Every NPO and ASO on Shift During Period | |||
- Principal Focus on Operator Rounds | |||
. 74 | |||
ASSESSMENT RESPONSE TO E-DIESEL EVENT . | |||
.1 QA Real-Time Surveillances of Operator Rounds | |||
- Weekly Unannounced Observations Thru EOY ,l | |||
- Observed NPO's, ASO's, and AUS's | |||
- Questioned Those Observed On Management Expectations Procedures , | |||
Bases | |||
>> Duties | |||
- And Provided Immediate Feedback 75 i | |||
I ASSESSMRST RESPONSE TO '! | |||
E-DIESEL EVENT . ..! | |||
t QA Surveillance of Security Entries Vs. | |||
Documentation Logs i | |||
- Involved 125,000 Individual Tasks Operations Maintenance Fire Watch Security - | |||
i Health Physics | |||
~ | |||
- Performance Met Expectations | |||
~ | |||
76 5 | |||
. s ASSESSMENT RESPONSE TO , | |||
E-DIESEL EVENT - | |||
-l Operations Management Assessment | |||
- Independent Outside Consultant | |||
- Interviewed 125 People in Operations | |||
- Focused on Organization / Management Issues | |||
~ | |||
Communications Roles & Responsibilities . | |||
Environment 77 1 - | |||
ASSESSMENT RESPONSE TO E-DIESEL EVENT . . | |||
ISES 1996 Operations Surveillance Hour Surveillance for 4 Days During Unit 1 Shutdown | |||
- Involved 6 Xuclear Assessment Personnel, . | |||
1 Training Person, & 2 Industry Peers | |||
- 164 Hrs in Control Room,182 Hrs in Plant | |||
- CONCLUSION: Operations Conducted in Safe, Professional Manner 78 | |||
IMPROVEMENTSIN ASSESSMENT PRACTICES .. | |||
- More Skeptical - | |||
- Security Entiy Times Are Analyzed - | |||
More QA Surveillance- | |||
- Added QA Contractors During Outage More Intrusion | |||
- Questioning Workers n AboutPerformance - | |||
About Supervision | |||
- Questioning Management . | |||
Quicker Escalation | |||
- Trend Condition Reports at Next Higher Significance Level 80 i | |||
i | |||
,i | |||
=? | |||
IMPROVEMEXTS IX : | |||
ASSESSMENT PRACTICES . | |||
More Preemptive Assessments | |||
- QC Work Group Briefings on Precursors | |||
- ISES Investigation of Plant Material Problems ! | |||
- Worker Performance Checklists Increased Comparisons to Industry Best Practices | |||
- NAS Assessment Reports Since 96Q3 81 i | |||
CONCLUSIO.XS | |||
..l "E" Diesel Event Led to Recognition of l NPO Performance Deficiencies This Produced An Assessment of Our Independent Oversight Functions This AssessmentIdentified Opportunities for Improvement NAS Independent Assessment Practices Have Been Improved 82 i . | |||
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Latest revision as of 13:49, 1 January 2021
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This message is from DOLCE Fresa: Kathy Dolce To: JBF, BRL, RRK, PDS, CWH, LEN, MCM, DJV, hufK Dese: 6/20/97 5:05pm
Subject:
Ad-hoc panel for Monday 6/23/97 at 9 AM Mr. Fewell spoke to two individuals and the conversations are being documented and placed on an allegation receipt form.
Based on a meeting with Hub, we are having an ad-hoc allegation panel at 9AM on Monday June 23,1997. This involves Ca*- ah=aa=. The two concerns are:
- 1. Failure to perform tests
- 2. Supervisors knew that the tests were not being performed.
Mr. Fewell will provide the allegation office the receipt form and the allegation office will make copies and distribute as soon as we can. Any questions, please see Brad.
Thanks for your cooperation.
Kathy . --
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TIME LINE FOR ALLEGATION NO. RI-97-A-00145 l 6/20/97 Fewell receives allegations from two former NPOs 6/23/97 Panel decided to have Ris gather more information from allegers 6/24/97 Ris found out that PP&L had received similar concern at the corporate attorney level. Corporate auditing was looking irdo it 6/25/97 Ris talked to allegers to get details. Found that PP&L investigation was well underway (meeting with allegers and attorneys planned). Also, allegers concerned that NRC involvement might cause PP&L to slow or stop '
investigation.
6/26/97 Acknowledgment letters sent 7/2/97 Repanel with updated information. Based on alleger's concerns and Baker guidance regarding not referring allegations that NRC knows a licensee is __
investigating (due to certain identification of alleger). NRC decided to monitor PP&L's effort and obtain final reports. 5 7/8/97 Monitored status of investigation. Monthly allegation reviews updated slow PP&L progress.
9/18/97 Crienjak and Anderson called PP&L auditor to impress the importance of schedule. Status was "still working," maybe they could accelerate closure of some parts.
11/5/97 Meeting with PP&L to get detailed status - two of four areas done emphasized need to close ASAP. Two open issues involve additional examples of poor operator performance / falsification prior to O/96 event.
11/20/97 Ris complete review of coropleted PP&L investigations - conclusions sound.
Ris question PP&L regarding implications of preliminary findings of more N falsifications on present watchstanders.
12/3/97 01 receives preliminary report from PP&L concluding a licensed operator had previously falsified alarm test record. Ol told that operator is now recanting I testimony.
12/ /97 Ol opens case on PCO falsification
^
k 11/27/97 PP&L removes a PCO from shift pending investigation of admitted falsification of control room alarm panel tests.
12/1/97 Received several allegations that PCO was singled out for admitting what u everyone else did, but had denied.
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ATTACHMENT 13 ,
pP&L Pennsylvania Power & ught Company ;
i Two North Ninth Street
- Allentown, PA 18101 1179 610/774 5151
[
. I RobertC.Byram ' i Senter Hee President.Gensertion and OlqfNueleer Officer ,
610/774 7502 Fax: 61str74 s019 ;
APR 0 91997-I U.S. Nuclear Regulatory Commission .
Attn: Document Control Desk Mail Station PI-137 Washington,DC 20555 1
l SUSQUEHANNA STEAM ELECTRIC STATION ENFORCEMENT POLICYREVIEW . Docket Nos. 50-387 .
PI.A MA3 Frff R412 and 50-388 This is a supplemental response by Pennsylvania Power & Light Company (PP&L) to the apparent violations raised by the Nuclear Regulatory Commission (NRC) Staff at the March 21, 1997 enforcement 'ecnference. At the enforcement conference, PP&L's presentation focused on <
the fundamental couses and management issues associated with the apparent violations as well as the corrective and yeventive actions necessary to preclude recurrence. Given this focus and the time constraints on the enforcement conference, PP&L's response did not explicitly address the l
- application of the NRC Enforcement Policy to the -yyerent violations. This letter bric0y reviews PP&L's management perspective on the apparent violations and application of the NRC Enforcement Policy. - Attachment I contains a detailed analysis of how the Enforcement Policy i applies to each of the apparent violations from our perspective.
- PP&L conducted a comprehensive review of each of the events discussed dunng the enforcement conference. They were evaluated both individually and from a wider perspective. We looked for
- common themes and broader implications. PP&L concluded that these events were important, and we believe our actions reflect the priority we have placed on their resolution. We found
- weaknesses in some areas which needed correction and actions by certain employees which were unacceptable. For these reasons, we took a number of corrective actions which included the 1 - termination of seven employees and severance of one shift supervisor.and one former-shin supervisor. ' However, our reviews also resulted in several positive conclusions. Some of these we believe are significant in terms of the application of the NRC Enforcement Policy.
~ Specifically, PP&L requests that (1) consideration be given to credit for self-identification and corrective action and no civil penalty be assessed; (2) the apparent violations be considered as not reflecting a breakdown in management controls and no increase in severity level is warranted -
for that reason; and (3) consideration be given to there being no basis to increase the severity of any of the violations.
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. FILE R41-2 PLA-4603 I Document Control Desk
, l
- 1. Self-Identification and Corrective Action Credit When we discovered the conditions associated with the violations, we saw them as serious regulatory and management issues that deserved and received vigorous attention. We immediately initiated comphive internal and indvad-at investigations and determined the fundamental causes and generic implications of the events. Our corrective and preventive actions were directed at improving long-teun performance and promoting a questioning attitude at all levels of the organi= Hon. They included:
Core Spray Containment Isolation Valve issued formal technical specification interpretation conducted training )
placed explicit directions in operations policies defined and documented for closed systems: i) those used as , redundant. isolation _
l boundaries in single-valve penetrations, ii) testing requirements and iii) acceptable l methods of altering boundaries completed technical specification reviews (we insured no other informal guidance was l being utilized in support of plant operations and reviewed the Susquehanna SES improved technical specification submittal to insure consistency with the resolution of this event)
Standby Liquid Control System Heat Trace corrected drawings counseled operators on proper placement of status control tags and on questioning the applicability of status control tags j
"E" Diesel Generator Misalignment took disciplinary action improved supervisory oversight (we counseled supervisors who failed to respond to the initial status control event, we trained all operations personnel on the event, we provided to shift supervision expectations for assistant unit supervisor performance, we expanded the supervisory oversight of rounds and we added a requirement for the shift supervisor to walk down status contrcl events)
- revised test procedures revised a number of other operations procedures cxpanded the operations self-assessment program
- retrained operations personnel on the "E" Diesel Generator design addressed human factors issues (including a modification to provide an indicating light on breaker cubicle #6) retrained operations personnel on expectations with respect to perfonnance of rounds and surveillances
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- FILE R41-2 PLA-4603 !
t Document Control Desk t We have placed a high priority on actions to strengthen management and supervisory l
oversight and effective communications of management expectations. Improved !'
assessment practices, which include increased scrutiny of supervisory oversight, are being implemented. We have also addressed individual performance issues, taken strong personnel actions against the accountable supervisors and workers, reinforced our expectations for workers and supervisors and verified that our expectations are being met.
For the reasons described in Attachment 1, PP&L asks for consideration of credit for self-identification and corrective action under the Enforcement Policy and that no civil penally -
be imposed.
- 2. Ma==gernent controh PP&L believes that the apparent violations do not constitute a widespread breakdown in control oflicensed activities and that the violations should not be increased in severity for -
that reason. Deficient performance by NPOs was identified for activities associated with i the "E" Diesel and by a shift supervisor and a former shift supervisor in connection with '
General Station Inspections (GSIs). With respect to NPO performance, PP&L implemented preventive actions in response to NRC Information Notice (IN) 92-30 that were consistent with industry norms, including briefings for station personnel, surveillance i oflogged entries, surveillances of operator rounds and audits of operator logs. Although these actions were insufficient in hindsight to provide early detection of the NPO surveillance and rounds issues, they were reasonable precautions at the time.
Contemporancous NRC inspections viewed PP&L's implementation of its self-monitoring program in response to IN 92-30 as acceptable.
. After PP&L's thorough investigations revealed the NPO surveillance and rounds performance issues, a series of actions were taken to determine the scope and extent of the issucs. Specifically we intensified ' operations management oversight conducted QA surveillances completed Independent Safety Evaluation Services (ISES) Operations Surveillance conducted QA reviews of security entries versus documentation logs (including security, health physics and fire protection) made a series of improvements to make assessment practices more intrusive and effective
~. . ,
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FILE R41-2 PLA-4603 i
Document Control Desk l
i
'lhe NPO's pattern of behavior demonstrated by the performance of surveillances and rounds was found only in a particular activity (routine, repetitive NPO rounds) in a specific ;
j location ~ ("E" Diesel Building). Moreover, we found no evidence. that these issues were widespread. The successful long-term operating record at SSES would support these conclusions. The violations were self-identified before a plant ever.t occurred. .The violations did not result in the inability of safety systems to perform theit intended safety functions. Because PP&L took precautions that were consistent with industry norms and sufficient te preclude a widespread problem, there is no basis for finding a breakdown in management controls and increasing the severity of violations for that reason.
l l With respect to the performance of the alarm test by NPOs, our investigation revealed that L 'some NPOs appeared to understand the requirement but failed to comply with it on numerous occasions. Other-NPOs did not perform the test initially but once they commenced testing, they performed it consistently. While'we concluded that the conduct by both groups of NPOs constituted willful misconduct, we did not find any evidence of -
deliberate misconduct. With respect to the GSIs and the monitoring of NPO rounds, we i concluded that no shift supervisor or assistant unit supervisor engaged in willful misconduct. Rather, one shift supervisor and a former shift supervisor demonstrated poor !
judgment with regard to the scope of their discretion exercised as a shift supervisor and a !
l failure to meet management's expectations with respect to performing the applicable requirements end for this reason these individuals were severed from employment. To the extent NPO surveillance or alarm test records were inaccurate, these inaccuracies resulted !
' from the actions of"non-licensee officials" as defined in the Enforcement Policy.
The safety significance of these events is described below. Most GSIs and monitoring activities were donc properly. Neither the plant condition nor the ability to detect and
. mitigate a transient was compromised. Accordingly, these violations were limited in scopc, effect and safety significance, and they are not indicative of a widespread breakdown in management controls.
- 3. Severity Level PP&L believes that there is no ba:is to increase the severity level of the violations. Our point-by-point analysis in Attachment I demonstrates that the violations should not be categorized as more than Level IIL Under IV(A) of the Enforcement Policy, Level 111 violations are not normally aggregated. Because the violations did not result in unavailability of safety systems to perform their intended safety functions, or an actual or potential impact on the public, the violations do not meet the Enforcement Policy criterin e for increased severity. Our specific conclusions with respect to the ability of each of the l
affceted systems and components to perform theirintended safety functions is as follows:
- a. . . . , , .. . . . . . . . . . . . . . . . . . . . . . . . . . - . . . . ,,,,,,. ,.
FILE R41-2 PLA-4603 I Document Control Desk Core Snray containment knlatinn Valve - the isolation valve that was inoperable during the maintenance activity in question does not communicate directly with either the primary containment atmosphere or the reactor coolant pressure boundary. %c redundant isolation boundary for the associated penetration is provided by closed
, system piping which remains water sealed post-accident. PP&L's actions in support I of the maintenance activity were focused on assuring that a water seal was maintained '
at all times. Therefore, this penetration would have performed its intended containment isolation function if required.
1 e
Standby Linuid Cantrol System Heat Trace - the purpose of this heat trace, which was deenergized during the event, is to prevent Sodium Pentaborate from precipitating out of solution under certain temperature conditions. Based on solution concentration and ambient temperature over the duration of the event, the heat trace was not required to ensure that precipitation would not occur. Herefore, the Standby Liquid
- l. Control Pump would have performed its intended safety function if required. In - -
addition, if a low temperature demand had been sensed when no current was present, l~ alarms would have occurred locally and in the control room, notifying operators of l the condition.
"F" Diesel Generatnr Miulienment - Susquehanna SES is designed to respond to all l design basis events with three of its four required emergency dicsc! generators l
operable. Three emergency diesel generators were available at all times during the misalignment event; therefore Susquehanna's emergency AC power system would l l
have performed its intended safety function. Additional safety margin existed, l l because the fourth emergency diesel generator was inoperable only because of the i loss of its auxiliaries. Under these conditions, it would have started if called upon, i
! energized its associated 4 kV bus, and continued to run until it ran out of fuel, which would not have occurred until over one hour and twenty minutes later. Furthermore,
' although PP&L could not demonstrate that the "E" diesel could be restorod prior to running out of fuel, we are confident that it would ultimately have been restored in I time to support post-accident recovery, thereby providing further margin.
l e NPO Alarm Test - performance of the alarm test was not necessary to confirm the operability of either the emergency diesel generator or the alarm itself. Therefore, failure to perform this specific test had no impact on the operability of any safety-related equipment.
.. GSh/PMs . During the period in question, the record indicates that most GSIs and PMs were performed properly, and that neither the plant condition nor the ability to detect and mitigate a transient were ever compromised. Therefore, failure to perform these activities had no impact on the operability of any safety-related equipment.
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FILE R41-2 PLA-4603 Document Control Desk Under the factors set forth in Section IV(C) of the Enforcement Policy, no increase in severity level is warranted for willful misconduct associated with NPO performance. There was no deliberate misconduct on the part of the individuals and neither the individuals nor the company gained a discemible advantage as a result of the violation. The individuals involved were not supervisory or licensed personnel. 'Ibe violations did not result in a loss of capability to perform intended safety functions. Strong personnel actions were taken. Under these circumstances, PP&L is entitled to favorable consideration for each of the factors set forth in the Enforcement Policy and an increase in severity level for willfhiness would not be appropriate.
1 The foregoing violations raise matters of significant concern to PP&L. In response, PP&L has taken aggressive actions to assure that it understands' the underlying causes and generic J
implications of the violations, and that corrective actions will be effective and lasting. PP&L conducted extensive reviews of the events themselves as well as thorough investigations into the bmader implications of these events. These reviews and investigations confirmed that the !
problems were not widespread throughout the station. The controls in place were sufficient to . _
detect these problems prior to the occurrence of a plant event. PP&L's investigations revealed ,
' l that overall performance was meeting expectations and requirements. At the same time, PP&L
- believes that its efforts to self-identify and correct the violations should receive favorable consideration under the NRC's Enforcement Policy and a civil penalty should not be assessed.
Management attention has been strongly focused on correcting and preventing the problems at hand and a civil penalty is unnecessary to bring about effective corrective and preventive action.
I For the reasons summarized above, PP&L respectfully submits that escalated enforcement i:: not 2
warranted in this case.
Very truly yours, (Signed) R. G. BYRAM R. G. Byram Attachment copy: Mr. K. M. Jenison, NRC Sr. Resident Inspector Mr. C. Postusny, Jr. NRC Sr. Project Manager .
Ms. T. E. Walker NRC RegionI l t
1
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ATTACHMENT 1 TO PLA-4603 Page 1 of 6 Summary of PP&L Analysis of Enforcement Policy Application to the Apparent Violations PP&L's analysis of the NRC enforcement policy's application to the apparent violations parallels the organization of its enforcement conference presentation: (1) the apparent Technical Specification (TS) violations in connection with containment isolation; (2) the apparent procedure violations associated with the Standby Liquid Control System heat trace: (3) the apparent violations associated with the "E" Diesel Cenerator events, including the apparent violations involving (a) T S 3.8.1, (b) the surveillance procedure and related records, (c) the NPO circuit breaker rounds, and (d) alarm panel tests and related records; and (4) the apparent violations involving General Station inspections (CSis) and monitoring of NPO rounds and related records. Our discussion of the Enforcement Policy's application to the apparent violations will demonstrate that the apparent violations are appropriately categorized as severity level IV, not level 111 violations. PP&L believes ,
that its effor'.s to self-identify and correct the violations warrant credit under the Enforcement Policy I and no civil penalty should be imposed. . _ I l
To the extent the NRC may consider aggregating all of the procedural violations, such action is not appropriate under the enforcement policy for the following reasons: (1) our point-by-point analysis below demonstrates that level IV categorization is proper; (2) the apparent violations did not result in a system designed to prevent or mitigate serious safety events not being able to perform its intended safety function and did not involve actual or a high potential impact on the public; and (3) under section IV(A) of the Enforcement Policy, severity level ill violations are not normally ,
aggregated. PP&L's management controls were sufficient to detect the violations prior to a plant I event, and after detection, aggressive corrective actions were taken. No increase in severity level due to willfulness is warranted because there was no deliberate misconduct on the part of individuals, these individuals gained no discemible advantage as a result of the misconduct, and .
PP&L took substantial disciplinary action against these individuals as contemplated by the j Enforcement Policy. !
- 1. Core Sorav Containment isolation Valve PP&L accepts that a violation of TS 3.6.3 occurred. The condition resulted from the use of an I informal technical specification interpretation which considered the requirement for a i redundant isolation valve to be met by the integrity of a redundant boundary. Although under a literal reading of Supplement I, (C)(1)(b) of the Enforcement Policy this could be ,
categorized as a Level 111 violation, PP&L's analysis prior to the event concluded that the ;
particular configuration of the system in question assured that a water seal was maintained throughout the period in which maintenance on the single isolation valve was performed. As a result, the safety significance of the event was minimal, and it should be categorized as a Level IV violation involving a less significant failure to comply with a TS action statement.
In a recent case. Shearon Harris was cited for a Level IV. Carolina Power & Light Company, Shearon Harris Unit 1, Docket No. 50 400, inspection Report No. 50-400/95-10, dated July 7, 1995, in that case, Shearon Harris TS 3.6.3 provided that, with one or more containment isolation valves inoperable, at least one isolation valve must be maintained operable in cach affected open penetration and the inoperable valves must be restored to operability within 1
l
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ATTACHMENT 1 TO PLA.4603 Page 2 of 6 four hours. The inoperable valve was not restored witbH the required time and a Level IV violation was assessed. However, the closed system ia which the isolation valves were located (the main steam system) was considered to be the operable isolation valve for L purposes of complyin5 with the TS 3._6.3 requirement to maintain at least one valve operabic.
It follows that Shearon Harris is analogous and the subject violation should be assigned a Level IV.
PP&L should also receive favorable consideration under Vl(8)(2) of the Enforcement Policy for comprehensive corrective action once the condition was discovered.- Operations personnel were provided training conceming program requirements for TS interpretations. Engineering received training regarding proper documentation of engineering guidance. Program changes included explicit direction in the Operations policy to preclude use of informal documentation to interpret TS provisions. We defined and documented testing requirements and acceptable methods for altering boundaries in closed systems. We conducted reviews to assure that no other informal guidance was utilized in support of operations and reviewed the l
SSES Improved Standard Technical Specifications submittal to assure consistency with the resolution of the subject violation. -
l
- 2. hadhv iinuid Control Svstem Deanerwired Heat Trace PP&L accepts that the violation, involving a failure to implement the status control procedure, occurred. The event was not safety significant because the Standby Liquid Control pump would have performed its intended safety function, even with the heat trace de energized for more than a day. The violation should be designated as severity Level IV.
PP&L's investigations of the violation determined that the status control tags should have been applied to individual breakers rather than the panel door. The NPO should have questioned the applicability of the status control tag and sought supervisor guidance or assistance with verification of the correct plant condition. PP&L also acknowledges that field oversight needs improvement. It should be noted that the condition was identified by PP&L. ' It was not
!- revealed by a plant event. There was not a breakdown in controls such that the condition escaped detection before an event. l PP&L is entitled to favorable consideration for self-identification under Section Vl(B)(2) of the Enforcement Policy, and no civil penalty should be assessed.
l
- 3. "E" Diesel Cecerator
- a. "E" Diesel Generator (DG) inoperable in excess of allowed Technical Specification (TS) 3.8.1 allowed outage time - PP&L accepts that TS 3.8.1 was violated. The violation was
- the result of an unintended error. SSES is designed to respond to a design basis event l
with three DC's and thus SSES systems would have performed their intended safety !
functions even with the "E" DC inoperable. Consequently, the TS violation should bc ,
I categorized as a less significant TS violation and assigned a severity Level IV.
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-= ATTACHMENT 1 TO PLA 4603 ;
Page 3 of 6 l Even if the violation is assigned a Level 111, PP&L is entitled to a credit for self-identification under Section Vl(B)(2) of the Enforcement Policy. The violation was discovered by PP&L personnel and reported to the NRC. The problem was discovered as i
the result of a licensee self-monitoring effort (an NPO detected the misalignment during i rounds) and was identified before an event occurred. Under VI(B)(2)(b)(1) of the l Enforcement Policy, self-identification credit is clearly appropriate.
The corrective and preventive actions were aggressive, extensively considered generic implications, and included strong personnel actions. PP&L recognizes that exercise of a more questioning attitude on the part of control room personnel, as well as NPOs, could have resulted in detection of the condition at the time of the misalignment or a more expedient resolution of the Condition Report on the "misalignrnant" initially perceived by the NPO. PP&L's corrective actions also included performance of ..i Wrnal assessment of operations management and supervision, realignment of the work maqement structure to increase supervisor coaching and time in the field, and increased staff assistance to supervisors on shift including additional manning of the work control center and requesting additional shift supervisors.
Credit for self-identification and corrective action in this case is supported by recent NRC
- enforcement precedent. In Comed, Braidwood Station Unit 1, Docket No. 50 546 EA ;95-265, NRC inspection Report No'. 50-456/95-016, January 29,1996, a Level ill was !
assessed where both diesel generators were inoperable for a period of 16 days. With one j diesel generator out for scheduled maintenance, the second diesel generator was l rendered inoperable because a breaker had not been fully racked irito a cubicle. The licensee's discovery of the condition in a surveillance and the subsequent comprehensive corrective actions were credited by NRC and no civil penalty was assessed. Unlike the subject violation at SSES, which involved a partial loss of one EOC's capability but !
sufficient remaining capability to withstand design basis events, Braidwood involved a loss of multiple EDC's. Consequently, PP&L should receive favorable credit for self identification and corrective action under Section VI(B)(2) of the Enforcement Policy
~
and no civil penalty should be assessed. ;
- b. Violations of surveillance procedure requirement to verify OA 510-05 " racked in" and open and related records .
l PP&L accepts that the procedure was violated, and in at least one instance, the violation was willful. Under IV(C) of the Enforcement Policy, the violations should not bc increased in severity level because of the element of willfulness. The willful misconduct l was not by licensee officials. There was no deliberate intent and the individuals gained
. no discernible advantage as a result of the misconduct. Substantial disciplinary action was taken, as contemplated by the NRC Enforcement Policy. PP&L should roccive favorable consideration for each of the foregoing factors, and there should be no increase in severity as a consequence of willful misconduct.
-In response to NRC Information Notice (IN) 92 30, PP&L implemented preventive actions that were consistent with industry norms, including briefings for station personnel, surveillance of logged entries, surveillances of operator rounds and audits of operator
.. logs. Although these actions were insufficient in hindsight to provide early detection of g g. .-yy g--r -r-y-e A- -. Asw i w---s+-- -wg, ,-,g
_ _ _ _ . _ . - _ . _ _ . _ _ _ _ _ _ _ . _ _ . _ _ _ ._ _ __ _ _. ~ .. _ - _ . _. _._ ___ _ _ __.. . _ _ _ _ . _ . . _ ,
_ hs a ., a} s u s.o sisu ses. .s.- sw .. v s su . .~ . ~ . . . . wv.,s,,sw . . . .
- . ATTACHMENT 1 TO PLA-4603 Page 4 of 6 the NPO surveillance and rounds issues, they were reasonable precautions in real time.
Contemporaneous NRC inspections viewed PP&L's implementation of its self-monitoring program in response to IN 92-30 as acceptable. Docket Nos. 50-387/388, NRC Inspection Report 50 387/92-20; 50-388/92 20, dated September 4,1992, p.1517.
After - PP&L's thorough investigation exposed the NPO surveillance and rounds performance issues, a series of actions were taken to determine the scope and extent of the issues. These actions included:
. intensified operations management oversight,
- * - conduct of QA surveillances, e completion of ISES Operations Surveillance. .
- conduct of _QA reviews of security entries versus documentation ' logs (involving approximately 125,000 individual tasks), _ ,
e improving assessment practices to make them more intrusive and effective.
1 The pattem of behavior demonstrated by the NPO's performance .of surveillances and _.,
rounds was found only in a particular activity (routine, repetitive NPO rounds) in a specific location ("E" diesel building). Moreover, we found no evidence that these issues '
were widespread. The successful long-term operating record at SSES would support these conclusions. Because PP&L took precautions that were consistent with industry norms and sufficient to preclude a widespread problem, and because strong corrective actions, including personnel actions were taken, a civil penalty should not be assessed.
In a 1994 Dresden enforcement action, with facts less favorable to the licensee, a civil penalty was not assessed. Comed, Dresden Station, Docket Nos.- 50 237 and 249, EA-93-182, NRC Inspection Report No. 50-237/92-033, 50 249/92-033, April 21,1994.
In that case, operating personnel attempted to conceal. control rod mispositioning in violation of procedure by not reporting or recording the event. A civil penalty was not assessed because the licensee identified the violation and took substantial corrective actions, including strong disciplinary actions against the individuals, in this case, because strong disciplinary actions, including terminations, were taken (even though there was no evidence of concealment or intentional misconduct), a civil penalty should not be '
assessed.
The violation was self-identified. Moreover, as indicated in the discussion in 3.a above, the actual safety significance of the 'E' diesel misalignment was limited. Although
. management controls' were imper f ect, the con d ition was detected before an event occurred. There was not a complete loss or pervasive breakdown of controls, as
. evidenced by the detection and the results of subsequent investigations which point to a finite scope and location for the NPO surveillance and rounds performance issues. In
- those circumstances, the violations should not be aggregated or categorized as severity Level ill on the basis of a breakdown.
a
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'tru av v 5, i s t.n a s au s aa av utu,nsnu i . i t, ATTACHMENT 1 TO PLA-4603 Page 5 of 6 l-As indicated above, PP&L is entitled to favorable credit under Section Vl(B)(2) of the Enforcement Policy for self-identification and corrective action. Thus, even if the violations are categorized as severity Level til, no civil penalty should be assessed. To the extent that the NPO surveillance records were inaccurate, a violation of 10 C.F.R. 9 ~
l 50.9(a) may be involved. Any such violation, however, should be assigned severity Level !
IV since the inaccurate records resulted.from the actions of non-licensee officials as defined in Supplement Vil, C(2) and D(2) of the Enforcement Policy.
' c. Procedural violations in connection with NPO circuit breaker rounds ll PP&L accepts that these procedural violations occurred. For the reasores stated in 3.b above, there was no widespread breakdown in controls and the violations should not be aggregated or assigned severity Level 111 on the basis of a breakdown. The violations occurred within a specific segment of the SSES organization and similar performance was not found in PP&L reviews across the entire organization. In any event, PP&L should receive favorable consideration for self-identification and corrective action under Section
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Vl(B)(2) of the Enforcement Policy and no civil penalty should be assessed.
- d. Alarm panel test procedure violations and related records l PP&L accepts that these violations occurred, although there were instances of willful misconduct, PP&L took reasonable precautions before the violations were discovered and strong actions after discovery. Moreover, there was no pervasive breakdown in controls.
Although earlier detection is PP&L's expectation, the conditions were nevertheless self-identified and found before a plant event. The controls and assessment mechanisms were consistent with industry norms in real time, but in hindsight, insufficient to promptly ,
detect willful misconduct. : Performance of the alarm test was not necessary to establish or confirm the operability of the EDG or the alarm itself. Thus, failure to perform this test L . was not safety significant. Consequently, the procedural violations should be assigned '
l' severity Level IV. Alternatively, even if they are assigned severity Level 111, PP&L is entitled to favorable consideration under VI(B)(2) of the Enforcement Policy for self identification and corrective action and no civil penalty should be assessed.
To the extent that NRC might consider violations of 10 C.F.R. $ 50.9(a) for inaccurate alarm panel test records, a Level 111 should not be assigned. Any inaccurate records resulted primarily from the actions of non-licensed personnel, who are not " licensee officials" as defined in Supplement Vil, (C)(2) and (D)(2) of the Enforcement Policy.
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ATTACHMENT 1 TO PLA-460)
Page 6 of 6
- 4. General statian hunections. Monitarine of NPO Rounds and estated Records PP&L accepts that violations involving the procedures governing General Station Inspections (GSis) and related inaccurate records of the GSis occu: red. However, these GSis as well as the Assistant Unit Supervisor (AUS) monitoring of NPO rounds were self-imposed procedural requirements not required by the Technical Specifications. While it is of course required to follow plant procedures, PP&L believes that neither the GSis nor AUS monitoring of NPOs and rel-ted records are within themselves regulatory requirements. There was no willful misce.vhet involved in these events, and no widespread breakdown in controls. The safety significance was minimal. Most GSis and monitoring activities were done properly. Neither the plant condition nor the ability to detect and mitigate a transient was compromised.
PP&L's investigations indicated that two individuals, a shift supervisor and a former shift supervisor, demonstrated poor judgment with regard to the scope of their discretion and failed to meet management's expectations with respect to performing applicable requirements. These two employees were severed fror, employment. Consequently, even if NRC determines there are procedural violations, then such violations should be considered severity Level IV. Although the records violations were attributable to licensee officials, they _
were limited in extent and scope and did not affect plant configuration or equipment functionality. Thus, they should be assigned severity Level IV. The violations were reported to PP&L by its employees and uncovered by PP&L investigations. In any event, PP&t. should receive favorable credit for self-identification and corrective action under VI(B)(2) of the Enforcement Policy and no civil penalty should be assessed.
j
ASSESSMRST OLTLINE i
Overview of PP&L Self-Assessment Response to NRC Information Notice 92-30 Assessment Response to E-Diesel Event -
Insights Improvements. in Assessment Practices
~
Conclusions 68 i
PP&L ASSESSMENT MATRIX CONTINUOUS PERIODIC PREVENTIVE CORRECTIVE INDIVIDUALS & a. Shift turnover review a. Goals status reporting - a. Tailboarti conferences a. Troubleshooting
- b. Alertness to anomalies b. Employee development b. 50.59 safety evaluations b. Post-event tailboards WORK GROUPS program -
- c. Job completion walkdowns
- c. STAR c. Root cause analyses
- d. 200% accountability at c. DACUM (STCP-QA-1I2) d. Independent (Design) interfaces d. Training Curriculum verification
- e. Employee Safety Program Committees (STCP-QA-I II) e. Pre & Postjob ALARA Review SUPERVISION & a. M11WA (management by a. Employee Performance a. Contingency planning a. License Event Review walking around) Reviews b. Outage readiness assessment b. Condtion Report event reviews '
MANAGEMENT b. Pre-SALP & pre INPO Review c. PORC startup review
- b. Field supervision c. Post < volution critiques
- c. Coaching & counseling 'c. Performance indicator review d. Post outage review d. SRC review ofplant events
- d. Review oflogs & test results d. Process re-engineering e. Response to NRC Notice of
- e. Maintenance self-assessment e. Plant tours Violetion program f. ERC f. Response to Audit Findings
- f. Radiological Evaluation g. Station ALARA Committee Program (NEIM-00-1070).
INDEPENDENT a. QA~Surveillances a.QA Audits a. QA Observations a. ISES Investigations
- b. QC Inspections b. ISES Surveillances b. QA Recommendations b. Condition Report Program c.QC In-Process Corrected Error c. SRC Reviews c.NAS Assessments Program
- d. Condition Report Program
- e. ISES Oversight ;
EXTERNAL a. NRC Inspector routine a. NRC SALP a. NRC review ofsafety e.NRC Augmented Inspection inspections b. INPO Evalaations evaluation involving an , Team
- c. PUC Audit Unreviewed Safety Question b. Notice ofViolations b.NRC review ofTech Spec.
C%nge Request 98/1135 8:94 AM MATRIX. DOC i
9 9
6
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PP&L INDEPENDENT ASSESSMEST ..
I i
CONTINUOUS PERIODIC PREVENTIVE CORRECTIVE ,.
INDEPENDENT QA Surveillances QA Amlits QA Observatioss ISESInvestigations QCInspections ISES Surveillances QA Recommendations CR Program QCICE Pmgram SRC Reviews NAS Assessments i CR Pragmm ISES Oversight i
70 ;
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RESPONSE TO XRC IN 92-30 .- . .
Station Personnel Were Briefed on IX 92-30 QA Surveillance Per IN 92-30 Verified Logged Entries March - June,1992 QA Surveillances Per IN 92-30 Quarterly 92Q3 to Date Verified Logged Entries i
QA Surveillances Evaluated: Adequacy of Operator Rounds .
QA Audits Evaluated Operator Rounds Logs i
71 t
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RESPONSE TO XRC IX 92-30 ,,
4 These Assessments Were Necessary to .
Confirm That 1
- Security Entries Were Made As Required
- Logs Were Completed As Required
- Operators Performed Well (Under Observation)
But, They Were Not Sufficient A More Questioning Approach Could Have Detected The NPO Performance Issue 72 i
.1 ASSESSMENT RESPONSE TO .
E-DIESEL EVENT -
ISES Investigation Determined
- Certain Entries Were Too Short to Perform Rounds & Surveillance Tasks
- Certain Logs Showed OC577E Alarm Check Not in Plant Computer Record
- The Same NPO's Had Short Entry Durations &
Missed Alarm Checks .
- Interviews Were Required to Explain Data Recommended Corporate Auditing Investigation 73 i .
ASSESSMRST RESPONSE TO E-DIESEL EVEXT .
Operations Management Oversight and
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QA Surveillance '
Hour Coverage for 50 Days
- 247 Evolutions Observed
- Random Observations of All Non-Licensed Operator Positions
- Observed Every NPO and ASO on Shift During Period
- Principal Focus on Operator Rounds
. 74
ASSESSMENT RESPONSE TO E-DIESEL EVENT .
.1 QA Real-Time Surveillances of Operator Rounds
- Weekly Unannounced Observations Thru EOY ,l
- Observed NPO's, ASO's, and AUS's
- Questioned Those Observed On Management Expectations Procedures ,
Bases
>> Duties
- And Provided Immediate Feedback 75 i
I ASSESSMRST RESPONSE TO '!
E-DIESEL EVENT . ..!
t QA Surveillance of Security Entries Vs.
Documentation Logs i
- Involved 125,000 Individual Tasks Operations Maintenance Fire Watch Security -
i Health Physics
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- Performance Met Expectations
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76 5
. s ASSESSMENT RESPONSE TO ,
E-DIESEL EVENT -
-l Operations Management Assessment
- Independent Outside Consultant
- Interviewed 125 People in Operations
- Focused on Organization / Management Issues
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Communications Roles & Responsibilities .
Environment 77 1 -
ASSESSMENT RESPONSE TO E-DIESEL EVENT . .
ISES 1996 Operations Surveillance Hour Surveillance for 4 Days During Unit 1 Shutdown
- Involved 6 Xuclear Assessment Personnel, .
1 Training Person, & 2 Industry Peers
- 164 Hrs in Control Room,182 Hrs in Plant
- CONCLUSION: Operations Conducted in Safe, Professional Manner 78
IMPROVEMENTSIN ASSESSMENT PRACTICES ..
- More Skeptical -
- Security Entiy Times Are Analyzed -
More QA Surveillance-
- Added QA Contractors During Outage More Intrusion
- Questioning Workers n AboutPerformance -
About Supervision
- Questioning Management .
Quicker Escalation
- Trend Condition Reports at Next Higher Significance Level 80 i
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IMPROVEMEXTS IX :
ASSESSMENT PRACTICES .
More Preemptive Assessments
- QC Work Group Briefings on Precursors
- ISES Investigation of Plant Material Problems !
- Worker Performance Checklists Increased Comparisons to Industry Best Practices
- NAS Assessment Reports Since 96Q3 81 i
CONCLUSIO.XS
..l "E" Diesel Event Led to Recognition of l NPO Performance Deficiencies This Produced An Assessment of Our Independent Oversight Functions This AssessmentIdentified Opportunities for Improvement NAS Independent Assessment Practices Have Been Improved 82 i .
.