ML18094A679

Responds to Violations Noted in Insp Repts 50-272/89-15 & 50-311/89-14.Corrective Actions:Procedures Re Rod Position Indication Signal Module Calibr & Rod Drop Time Measurements Revised to Include Precautionary Note & Events Reviewed

ML18094A679
Person / Time
Site:	Salem
Issue date:	09/06/1989
From:	Labruna S Public Service Enterprise Group
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NLR-N899176, NUDOCS 8909130243
Download: ML18094A679 (13)

See also: IR 05000272/1989015

Text

Public Service Electric and Gas Company * Stanley LaBruna Public Service Electric and Gas Company P.O. Box 2'36, Hancocks Bridge, NJ 08038 609-339-4800

Vice President

-Nuclear Operations

SEP 0, 6 1989 NLR-N89176

• United States Nuclear Regulatory

Commission

Document Control Desk Washington

DC 20555 Gentlemen:

RESPONSE TO NOTICE OF VIOLATION

NRC COMBINED INSPECTION

REPORT NO. 50-272/89-15

AND 50-311/89-14

SALEM GENERATING

STATION UNITS NOS. 1 AND 2 DOCKET NOS_. 50-272 AND 50-311 Public Service Electric and Gas Company (PSE&G) has received the subject inspection

report dated August 4, 1989, which included a Notice of Violation

concerning

procedures

not properly being implemented

and surveillance

requirements

not being performed

within the specified

time interval.

Pursuant to the requirements

of 10 CFR 2.201, our response to this Notice of Violation

is provided in the attachment

to this letter. Should you have any questions

in regards to this transmittal, do not hesitate to call. Sincerely, Attachment

?ii '\'

• * Document Control Desk NLR-N89176 . C Mr. J. c. Stone Licensing

Project Manager Ms. K. Halvey Gibson Senior Resident Inspector

2 Mr. w. T. Russell, Administrator

Region I Mr. Kent Tosch, Chief New Jersey Department

of Environmental

Protection

Division of Environmental

Quality Bureau of Nuclear Engineering

CN 415 Trenton, NJ 08625

• *

ATTACHMENT

Notice of Violation.

Item A Technical

Specification

6.8.1 requires that procedures

be implemented, including

general plant operating

procedures, procedures

for calibration

of safety related equipment

and radiation

protection

procedures.

Contrary to the above, procedures

were not properly implemented

as follows: 1. On June 3, 1989, control rods were withdrawn

with one source range channel inoperable

contrary to the requirements

of Integrated

Operating

Procedure

3, "Hot Standby to Minimum Load" and Operating

Procedure

8.3.1, "Rod Control System -Normal Operation" which specify that two source range channels are required to be operable prior to energizing

the Rod control System and closing the reactor trip breakers.

2. On June 3, 1989, two control rod shutdown banks were withdrawn

together contrary to the requirements

of Maintenance

-I&C procedure

IC-8.1.002, "Rod Position Indication

Signal Module Calibration" which specifies

that one control or shutdown bank be withdrawn

at a time. 3. On May 23, 1989, a High Radiation

Area (HRA) where radiation

levels exceeded 1 R/hr was left uncontrolled

for a 10 minute period contrary to the requirements

of radiation

protection

procedure

RP-204 which specifies

that continuous

• surveillance

be provided for unlocked HRAs. RESPONSE PSE&G DOES NOT DISPUTE THE VIOLATION

THE ROOT CAUSE FOR EACH ITEM HAS BEEN ATTRIBUTED

TO PERSONNEL

ERROR. ITEMS 1 AND 2 As discussed

in the LERs which reported these events, a portion of the root cause was determined

to be inadequate

administrative

controls in that operators

were unfamiliar

with a recently issued License Amendment

aff ectinq one of these sections of the Technical

Specifications.

Licensed Operators

are directed and expected to consider Technical

Specification

applicability

prior to conducting

operational

evolutions.

The failure to follow specific requirements

of written procedures

for two operable source range channels and for control bank removal are personnel

errors. Contributing

factors to the personnel

errors were the fact that the procedures

involved were less than optimum from a human factors standpoint

and that the process for Technical

• * * Specification

Amendment

implementation

did not specifically

require notification

of each Licensed Operator of changes. CORRECTIVE

ACTIONS TAKEN Procedures

IC-8.1.002, "Rod Position Indication

Signal Module Calibration", and IC-5.2.001, "Rod Drop Time Measurement

Hot Full Flow", for both units, have been amended to include a precautionary

note immediately

before the step specifying

rod bank withdrawal.

Procedure

OP IV-8.3.1 has been revised to include a check-off-sheet

addressing

the requirements

for energizing

the Control Rods. The check-off-sheet

provides a check to assure that both* source range channels are operable prior to energizing

the control rods. The events were reviewed with the appropriate

station personnel

stressing

the need for full procedural

compliance

to all parts of the procedures.

An "Information

Directive" has been Licensed Operators, identifying

all Technical

Specification

Amendments, Operators

are aware of the changes. process will continue to be used to of recent Amendments

• issued to all recently approved to assure that the The Information

Directive

notify Licensed Operators

The Station Operations

Review Committee (SORC) will approve all Technical

Specification

Amendments

for implementation

after ensuring that all required training and procedural

modifications

necessitated

by the Amendment

are properly implemented.

ADDITIONAL

CORRECTIVE

ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS

Presentations

by the General Manager -Salem Operations

and training sessions are being conducted

to introduce

the new "Salem Handbook of Standards".

Each Salem employee will receive their own copy of the handbook at these sessions.

This handbook includes standards

for work practices

and use of written instruction.

A training video, "Attention

to Detail", has also been developed

to provide direction

to station personnel

on proper attention

to detail attributes.

station personnel

will receive the training by September, 1989. PSE&G is continuing

to stress procedural

compliance

with all station personnel.

The need to read and comply with procedure

prerequisites

and other requirements

has been discussed

with Operations'

personnel

during pre-shift

briefings

and will continue to be stressed in these discussions

throughout

the year. . .. . . -. . . . .* . . . : .. *-... -*

• * * A review of the Technical

Specification

Amendment

implementation

process has been initiated

to ensure that the appropriate

delineation

of responsibility, the appropriate

direction

for procedural

changes and the necessary

information/training

for appropriate

station personnel

is provided for. The recommended

changes and improvements

resulting

from this review will be incorporated

into AP-12, Procedure

NA-AP.ZZ-0012(Q) "Technical

Specification

Surveillance

Program" by November, 1989. ITEM 3 Procedures

RP-203, "Radiation

Protection

Key Control" and RP-204 "Posting of Radiation

Signs and Barriers" require that unlocked High Radiation

Areas (HRAs) have continuous

surveillance

where the dose rates can exceed 1 R/hr. The contract technician

failure to adequately

control the HRA was a result of personnel

error due to lack of attention

to detail. The open door was discovered

by the Radiation

Protection

Manager, who was performing

supervisory

rounds. These supervisory

rounds had been increased

prior to this event in an effort to more effectively

monitor personnel

performance, assure more effective

management

oversight

and ensure personnel

attention

to detail. CORRECTIVE

ACTION TAKEN A guard (cognizant

Radiation

Protection

person) was immediately

posted at the entrance to the HRA, to provide the required continuous

surveillance

• A "night order" was immediately

written to all Radiation

Protection

Technicians

to specify the requirements

for entry to the eves Holdup Tank Room. The night order stated that two people are required to enter the eves Holdup Tank Room, one to provide positive access control and the other to perform the necessary

surveys. The event has been reviewed by the Radiation

Protection

Department

Management

and appropriate

corrective

disciplinary

action has been administered

to the contract employee.

The event was reviewed with appropriate

Radiation

Protection

Personnel.

A work request was written requesting

the replacement

of a lockset on the gate at the entrance to the eves Holdup Tank Room. The previous lockset did not work properly and a padlock and chain were being used to control access. Subsequently, a new lockset was installed.

This lockset provides positive control of the HRA while also allowing egress from the area; thereby, negating the need for the the night order specified

above *

• PSE&G IS IN FULL COMPLIANCE

Notice of Violation.

Item B B. Technical

Specification (TS) 4.0.2 requires in part that surveillance

requirements

should be performed

within the specified

time interval.

Contrary to the above, surveillance

requirements

were not performed

within the specified

time interval as follows: 1. On February 21, 1989, it was identified

that TS surveillance

4.0.5 for inservice

inspection

and testing of the lA Diesel Generator

Service Water Valve and Prelube Oil Pump vibration

check were not performed

within the previous 92 days as required.

2. On May 5, 1989, it was identified

that TS surveillance

4.3.3.3.1

for channel check of the Triaxial Time-History

Accelographs

was not performed

within the previous 31 days as required.

RESPONSE PSE&G DOES NOT DISPUTE THIS VIOLATION

The root cause of Item 1 has been attributed

to lack of adequate administrative

controls and the root cause of Item 2 has been attributed

to personnel

error as discussed

in the respective

LERs reporting

these items. In addition to the violation

cited above, the inspection

report delineates

a concern that corrective

actions for a previous similar violation (in 1988) did not prevent these recurrences.

Corrective

actions implemented

as a result of the previous violation

included assignment

of a Technical

Specification

Administrator, establishment

of a MMIS surveillance

data base and generation

of surveillance

status reports. Those corrective

actions have reduced the occurrence

of missed/overdue

surveillances

since that violation.

As a.result of the above violations

and feedback from the program administrators, PSE&G has instituted

additional

corrective

actions as described

herein, to strengthen

the program and provide backup review. ITEM 1 CORRECTIVE

ACTIONS TAKEN The February 21, 1989 event was, in fact, attributable

to the lack of adequate administrative

controls of the program established .following

the 1988 violation.

• As a result, the following

actions were implemented

to enhance the effectiveness

of the program. -. * *' * '

., '* *** '* * **-.-*" °! * * * I * *

• * The frequency

of the MMIS Technical

Specification

surveillance

overdue report was increased, and is now printed daily at the line printer located in each department.

This report provides a 14 day "look ahead" listing of surveillances, with a greater than seven (7) day frequency, that will become overdue with the next fourteen (14) days and have not yet been completed.

The report is sorted by Unit, Department, Mode in which the surveillance

can be performed, and overdue date. Each Department

appointed

a surveillance

coordinator

who is responsible

to review the Technical

Specification

Overdue report daily, contact the line supervision

if a surveillance

is nearing (within 3-4 days) the overdue date, and to provide a single point of contact for the Technical

Specification

Administrator.

ITEM 2 The Mays, *1989 event was the result of personnel

error (failure to follow the established

program) in that the Technical

Specification

Overdue Report was not reviewed by the appropriate

personnel

as required.

PSE&G believes that this does not represent

a programmatic

deficiency

of the corrective

actions implemented

following

the 1988 violation.

CORRECTIVE

ACTIONS TAKEN All appropriate

Station Personnel

were counseled

to review and use the Technical

Specification

Surveillance

Overdue report for tracking and completion

of all Technical

Specification

surveillance

requirements.

As a backup, the Technical

Specification

Administrator

was also assigned the responsibility

of reviewing

the Technical

Specification

Surveillance

Overdue report daily and contacting

the department

coordinators

when any surveillance

is not completed

within 3-4 days of the overdue date. The Technical

Specification

Overdue report was revised, to provide the Modes of operation

the equipment

was required to be operable in, and to list all surveillances

in order by overdue date. These changes were made for human factors reasons; i.e., to provide ease of review. In summary, PSE&G believes that Salem currently

has an effective

Technical

Specification

Administrative

program. The additional

actions stated above will further assure that TS surveillances

are properly performed.

Corrective

actions taken will prevent recurrence

of the problems associated

with this violation.

• • ..

' "': * * *' :: *.L * * **: -.. *-. --. . . .. -. .. . , -. . -... '

• * ADDITIONAL

CORRECTIVE

ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS

Increased

management

attention

has been and will continue to be focused on this area. Programmatic

changes will be made as necessary

to enhance and solidify the Technical

Specification

Administrative

Program as feedback is received from users or potential

problem areas are identified.

PSE&G IS IN FULL COMPLIANCE

SUPPLEMENTAL

INFORMATION

The following

represents

information

relative to a missed surveillance

occurring

after issuance of Inspection

Report 272/89-15

& 311/89-14, and is being provided pursuant with discussions

held with Salem Resident Inspector, s. Pindale. Additionally, as required by the letter transmitting

the subject Inspection

Report, a discussion

is being provided relative to corrective

actions being taken to prevent recurrence

of missed surveillances

• After the subject inspection

report was issued, PSE&G identified

a missed surveillance

on August 11, 1989, pertaining

to venting of ECCS pumps and associated

piping per Technical

Specification

3.5.2 (Surveillance

Requirement

4.5.2.b.2}.

The missed surveillance

was identified

by a Technical

Department

engineer when reviewing

an Amendment

change in response to an Action Tracking System (ATS) open item. The root cause of the event was determined

to be inadequate

administrative

control of Technical

Specification

Amendment

processing

and implementation, which allowed the Amendment

to be implemented

with insufficient

review. A recent Technical

Specification

Amendment (No. 94) had been implemented

which had added the requirement

to vent ECCS pump casings and accessible

discharge

piping high points to the Unit 1 surveillance

Requirements (Unit 2 already had this requirement).

The Amendment

was implemented

without assuring that a thorough review had been performed

to ensure that all necessary

procedures

had been implemented.

Personnel

error contributed

to the event, as the individual

responsible

for reviewing

the ATS open item (which required reviewing

the Technical

Specification

Amendment

for procedural

modifications)

had not performed

a thorough review of the Amendment

prior to implementation

• . -. :*** .. ' _,... * ......... : .. -**: . .*** .. -, ..... **:--........ .

• * I_ Weaknesses

in the Technical

Specification

Amendment

implementation

program had been identified

by the Technical

Specification

Surveillance

Group (originated

to eliminate

missed/overdue

Technical

Specification

Surveillances

at Salem) in conjunction

with other station personnelo

Corrective

actions were instituted

as a result of these identified

weaknesses.

These actions changed the program to require all new Amendments

to be approved for implementation

by SORC. This ensures that all departments

are prepared to implement

the programmatic

or procedural

changes necessitated

by the Amendment.

In addition, ths program was revised to require computerized

tracking (using ATS) to identify personnel

responsibilities

for the implementation

of Technical

Specification

Amendments.

These processes

were put in place at the direction

of the General Manager -Salem Operations.

The draft revision of AP-12, Procedure

NA-AP.ZZ-0012, "Technical

Specification

Surveillance

Program", which will specify these changes, is now in the review process. At the time that Amendment

94 was received the corrective

actions, mentioned

above, were not in place. Had the corrective

actions (SORC review and a designated

individual

for tracking ATS open items associated

with Amendments)

been in place when Amendment

94 was received, this event would have been prevented.

There is no safety impact associated

with missing this surveillance.

There was no previous requirement

to vent the pumps and the pumps have been proven operable repeatedly, by surveillance

and use, over that duration.

The Technical

Specification

change is really an enhancement

to provide further assurance

that the pumps will perform as required when called upon. Fifty five (55) minutes after Technical

Specification

Action Statement

3.0.3 was entered for the missed surveillance, the surveillance

was successfully

completed.

In addition to the corrective

actions that had been previously

instituted, the individual

involved was counseled

stressing

the need to ensure attention

to detailo The Operations

Surveillance

Procedure

SP(O) 4o5.2b was revised to include the pump casing and piping venting requirements.

PSE&G management

is committed

to ensuring that the Salem Generating

Stations Surveillance

Program provides the necessary

controls and monitoring

to assure that Technical

Specifications

are performed

as requiredQ

The current program is significantly

improved and PSE&G is confident

that the program is now effective

in controlling

the surveillances.

Increased

management

attention

to insuring surveillance

requirements

are met as well as the continued

management

emphasis for attention

to detail should lead to continued

improvements

in the program. PSE&G management

will continue to dedicate resources

to ensuring surveillance

compliance

and encourages

all employees

to improve the process. PSE&G's actions to reduce personnel

errors and improve attention

• * to detail will be continued.

The "Attention

to Detail" video and the "Salem Handbook of .standards" are presently

being provided to every station employee, along with a General Manager -Salem Operations

presentation

and specific training to further stress attention

to detail and high work standards.

Management

will continue to focus on these areas to assure that deficiencies

in these areas are identified

and

and to insure continued

improvement

in these areas. In addition to responding

to the Notice of Violation, PSE&G was requested

to "address the adequacy of its' corrective

action program in general, relative to preventing

recurrence

of previously

identified

problems including

what improvements

in this area are needed". PSE&G believes that it has an aggressive

and responsive

incident investigation

and corrective

action program. The main elements of the program are described

in AP-06, Procedure

NA-AP.ZZ-0006(Q), "Incident

Report and Reportable

Event Program".

This program delineates

the responsibilities

and the flow path for investigation, root cause determination, and corrective

action determination

for events of appropriate

cause or significance.

The extent of evaluation

and follow-up

is relative to cause/significance, but can always be increased

at individual

discretion.

Each incident report is now reviewed by station management

at the daily.morning

meeting. If follow-up

investigation

is required, internal and external operational

experience

is reviewed for similar events. A Department

Manager/Engineer

is assigned responsibility

for the investigation

and a copy of the Incident Report (IR) is sent to the HPES (Human Performance

Evaluation

system) Engineer if human performance

problems are involved (presently

all IRs are sent to the HPES Engineer).

The follow-up

investigation

analyzes the event and determines

root cause(s), identifies

the corrective

actions, and assesses the safety consequences

and implications

of the incidente

The IR Form is used to document the investigation.

The responsible

Department

Manager approves the investigation

findings and corrective

actionse The LER Coordinator

also reviews the IR for completeness.

If the incident is reportable

the root cause and corrective

actions are specified

in the report and SORC reviews and approves them. The General Manager -Salem Operations

must review and approve these reports prior to issuanceQ

For significant

or reportable

events Quality Assurance (QA) and/or Onsite Safety Review (SRG) will often be present at the associated

SORC and special station meetings at which the root cause and corrective

actions are reviewed.

This provides each with the opportunity

to discuss and provide feedback into the process prior to final determination.

Formal review of certain reportable

events and all events involving

Reactor Trips or ECCS actuations

are performed

by SRG. These reports are utilized by management.

to assess root cause and corrective

action ,, *-.. --... , *-.

.. *'

• effectiveness.

QA also reviews various events and reports, and provides essential

feedback to the management

team. Further feedback is provided on selected (significant)

events as a result of the HPES evaluations.

Management

often requests QA, LSRG, and OSR (Offsite Safety Review) to perform special investigations

and requests to provide analysis, root cause evaluation

and recommend

corrective

actions for items relative to events sensitive

to operational

performance

concerns, programmatic

concerns, human factor concerns, and other type events for which they may have additional

concerns.

PSE&G has frequently

utilized the system engineering

group, to perform the root cause analysis and help determine

corrective

actions, for events involving

equipment

failure, system performance

and design concerns.

This has resulted in increased

technical

investigation

and often better resolution

of the problem. Even though the corrective

action program was viewed as aggressive

and thorough, management

believed that the program was not as consistent

with regard to the varying levels of investigation

and that the program did not provide a consistent

systematic

approach.

Furthermore, industry information

revealed that analyzing "near miss" events could be more significant

for preventing

future events than the actual events; therefore, it was felt that the program should be directed to place more emphasis on this. PSE&G determined

that utilizing

the INPO HPES methodology

could improve root cause analysis, provide more complete corrective

actions and better detect human performance

deficiencies.

In implementing

the HPES program, the need for formal training of key personnel

in root cause analysis was identified

and a training program was developed.

Select individuals

have been trained and this training is ongoing. PSE&G is continuing

to evaluate its root cause analysis program and is implementing

various actions to this end. These actions will be provided to the NRC, as part of PSE&G's integrated

strategic

plan for improving

operational

performance

at Salem, during the late October, 1989 meeting with Region 1, as discussed

in the SALP responsee

PSE&G does not believe that the Violations

cited in this report occurred directly as a result of the program established

as a corrective

action being inadequate, but that they were more a result of other problems i.e. lack of attention

to detail (personnel

error) and inadequate

administrative

controls for administering

the program. PSE&G is aware of and has been addressing

these problem. However, the corrective

actions in these areas had not been fully implemented

at the time of the event and are still being implemented.

These corrective

actions are included in the corrective

actions provided in the Notice of Violation

response.

• Further improvements

are also being implemented

to improve the root cause and corrective

action programs.

A formal training program to provide root cause analysis training to key personnel (those who will be involved in root cause analysis)

is presently

being developed.

A Significant

Event Response Team (SERT) has been developed

to perform thorough investigation/reports

of significant

events. This investigation

process will provide a more systematic

approach to the investigation

of future events. Implementation

of these actions will be discussed

during the October, 1989, Region 1, meetingo PSE&G management

will continue to monitor the progress of its corrective

actions for assuring surveillance

requirements

are met, increased

attention

to detail, reduced personnel

errors and ensuring administrative

controls and management

oversight

are effective

in ensuring these goals. As such, PSE&G is determined

to meet the highest operating

standards

and will ensure that all necessary

actions will be taken to attain those standards

• ** -*-** *-*-..:: *-. *.*** * < * -** ** ,_ ' -.. *-***-.*;.""*

• -=* *;; :**:* * * * * ****-* *-** * **-:.***:

* * *-

--*,** _,. * * ** * ":--:** r ** * * *' *' ** *** ** * . . --. *-.* '