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{{#Wiki_filter:A.L Uj" LCKH AZU ULDLM.DU LAUlN LJZIVBJI.IDLLML
BJlN3I8LPIVJ.tiREGULATORY
BJlN 3 I 8 LPIVJ.t i REGULATORY
INFORMATION
INFORMATION
DISTRIBUTION
DISTRIBUTION
SYSTEM(RIDS)iSSIONNBR:9103210167
SYSTEM (RIDS)i SSION NBR:9103210167
DOC.DATE:
DOC.DATE: 91/03/08 NOTARIZED:
91/03/08NOTARIZED:
YES DOCKET CIL:50-244
YESDOCKETCIL:50-244
Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH.NAME AUTHOR AFFILIATION
RobertEmmetGinnaNuclearPlant,Unit1,Rochester
G05000244AUTH.NAMEAUTHORAFFILIATION
MECREDY,R.C.
MECREDY,R.C.
Rochester
Rochester Gasl'lectric Corp.RECIP.NAME
Gasl'lectric
RECIPIENT AFFILIATION
Corp.RECIP.NAME
Document Control Branch (Document Control Desk)SUBJECT: Responds to NRC 910208 ltr re violations
RECIPIENT
noted in Insp,Rept ,50-244/90=31
AFFILIATION
on 901213-910103.Corrective
DocumentControlBranch(Document
ControlDesk)SUBJECT:RespondstoNRC910208ltrreviolations
notedinInsp,Rept
,50-244/90=31
on901213-910103.Corrective
a'ctions:dc
a'ctions:dc
distribution
distribution
panelswitchlabelsrevisedtoclarifyswitchload/function
panel switch labels revised to clarify switch load/function
&addichecklists
&addi checklists
willbedeveloped.
will be developed.
DISTRIBUTION
DISTRIBUTION
CODE:IEOIDCOPIESRECEIVED:LTR
CODE: IEOID COPIES RECEIVED:LTR
ENCL/SIZE:/3TITLE:General(50Dkt)-Insp
ENCL/SIZE:/3 TITLE: General (50 Dkt)-Insp Rept/Notice
Rept/Notice
of Vio ation Response NOTES:License
ofVioationResponseNOTES:License
Exp date in accordance
Expdateinaccordance
with 10CFR2,2.109(9/19/72).
with10CFR2,2.109(9/19/72).
/05000244 RECIPIENT ID CODE/NAME PD1-3 PD INTERNAL: AEOD AEOD/TPAB NRR MORISSEAU,D
/05000244RECIPIENT
IDCODE/NAME
PD1-3PDINTERNAL:
AEODAEOD/TPAB
NRRMORISSEAU,D
NRR/DLPQ/LPEB10
NRR/DLPQ/LPEB10
NRR/DREP/PEPB9D
NRR/DREP/PEPB9D
NRR/DST/DIR
NRR/DST/DIR
8E2NUDOCS-ABSTRACT
8E2 NUDOCS-ABSTRACT
OGC/HDS1RGN1FILE01EXTERNAL:
OGC/HDS1 RGN1 FILE 01 EXTERNAL: EGGG/BRYCE, J.H.NSIC COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME JOHNSON,A AEOD/DEIIB
EGGG/BRYCE,
DEDRO NRR SHANKMAN,S
J.H.NSICCOPIESLTTRENCL111111111111111111111111RECIPIENT
IDCODE/NAME
JOHNSON,A
AEOD/DEIIB
DEDRONRRSHANKMAN,S
NRR/DOEA/OEAB
NRR/DOEA/OEAB
NRR/DRIS/DIR
NRR/DRIS/DIR
NRR/PMAS/ILRB12
NRR/PMAS/ILRB12
RGFIL02NRCPDRCOPIESLTTRENCL11111111111111111111DDDNOTETOALL"RIDS"RECIPIENTS:
RG FIL 02 NRC PDR COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D D D NOTE TO ALL"RIDS" RECIPIENTS:
PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELIMINATE
PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.20079)TO ELIMINATE YOUR NAME FROM DISTRIBUTION
YOURNAMEFROMDISTRIBUTION
LISTS FOR DOCUMENTS YOU DON'T NEED!TOTAL NUMBER OF COPIES REQUIRED: LTTR 22 ENCL 22 A D D
LISTSFORDOCUMENTS
YOUDON'TNEED!TOTALNUMBEROFCOPIESREQUIRED:
LTTR22ENCL22ADD
   
   
IROCHESTER
I ROCHESTER GAS AND ELECTRIC CORPORATION
GASANDELECTRICCORPORATION
ROBERT C MECREDY Vice Precidenr Cinna Nuclear Producrion
ROBERTCMECREDYVicePrecidenr
~89 EAST AVENUE, ROCHESTER N.Y.14649-0001
CinnaNuclearProducrion
TELEPHONE AREA COOE 71B 646 2700 March 8, 1991 U.S.Nuclear Regulatory
~89EASTAVENUE,ROCHESTER
N.Y.14649-0001
TELEPHONE
AREACOOE71B6462700March8,1991U.S.NuclearRegulatory
Commission
Commission
ATTN:DocumentControlDeskWashington,
ATTN: Document Control Desk Washington, DC 20555 Subject: Reply to a Notice of Violation NRC Inspection
DC20555Subject:ReplytoaNoticeofViolation
Report No.50-244/90-31
NRCInspection
R.E.Ginna Nuclear Power Plant NRC Docket No.50-244 Dear Sir: This letter is in response to the February 8, 1991 letter from Thomas T.Martin, Regional Administrator, to Robert E.Smith, Senior Vice President, Production
ReportNo.50-244/90-31
and Engineering, which transmitted
R.E.GinnaNuclearPowerPlantNRCDocketNo.50-244DearSir:ThisletterisinresponsetotheFebruary8,1991letterfromThomasT.Martin,RegionalAdministrator,
Notice of Violation from Inspection
toRobertE.Smith,SeniorVicePresident,
Report 90-31.In that letter, Violations
Production
A and B were identified.
andEngineering,
This letter provides the reply to the Notice of Violation, pursuant to 10 CFR 2.201.RESTATEMENT
whichtransmitted
OF VIOLATIONS:
NoticeofViolation
During an NRC inspection
fromInspection
conducted between December 13, 1990 and January 3, 1991, violations
Report90-31.Inthatletter,Violations
of NRC requirements
AandBwereidentified.
were identified.
ThisletterprovidesthereplytotheNoticeofViolation,
In accordance
pursuantto10CFR2.201.RESTATEMENT
with the"General Statement of Policy and Procedure for NRC Enforcement
OFVIOLATIONS:
Actions," 10 CFR Part 2, Appendix C, (1990), the particular
DuringanNRCinspection
conducted
betweenDecember13,1990andJanuary3,1991,violations
ofNRCrequirements
wereidentified.
Inaccordance
withthe"GeneralStatement
ofPolicyandProcedure
forNRCEnforcement
Actions,"
10CFRPart2,AppendixC,(1990),theparticular
violations
violations
aresetforthbelow:A.10CFRPart50,AppendixB,Criterion
are set forth below: A.10 CFR Part 50, Appendix B, Criterion VI,"Document Control," states in part, that measures shall be established
VI,"Document
to control the issuance of documents, such as procedures, including changes thereto, which prescribe all activities
Control,"
affecting quality.These measures shall assure that documents, including changes, are reviewed for adequacy.9103210167
statesinpart,thatmeasuresshallbeestablished
910308 PDR ADOCK 05000244 PDR~~j,Hi l.e ap U
tocontroltheissuanceofdocuments,
Contrary to the above, in March 1989, a procedure affecting quality, namely, Procedure M-48.14,"Isolation
suchasprocedures,
of Bus 14 Undervoltage
including
System for Maintenance, Troubleshooting, Rework and Testing," was changed without an adequate review being performed.
changesthereto,whichprescribe
The specific change involved inclusion of a step in the procedure which allowed the disabling of Engineered
allactivities
Safety Feature Actuation System (ESFAS)instrumentation
affecting
while the reactor was in any mode of operation,'ncluding
quality.Thesemeasuresshallassurethatdocuments,
power.The licensee's
including
changes,arereviewedforadequacy.
9103210167
910308PDRADOCK05000244PDR~~j,Hil.eapU
Contrarytotheabove,inMarch1989,aprocedure
affecting
quality,namely,Procedure
M-48.14,"Isolation
ofBus14Undervoltage
SystemforMaintenance,
Troubleshooting,
ReworkandTesting,"
waschangedwithoutanadequatereviewbeingperformed.
Thespecificchangeinvolvedinclusion
ofastepintheprocedure
whichallowedthedisabling
ofEngineered
SafetyFeatureActuation
System(ESFAS)instrumentation
whilethereactorwasinanymodeofoperation,'ncluding
power.Thelicensee's
organizational
organizational
measuresforreview,approval,
measures for review, approval, and issuance of this procedure change, including the review by the Plant Operations
andissuanceofthisprocedure
Review Committee, did not assure that the change was adequately
change,including
reviewed in that it did not identify that implementation
thereviewbythePlantOperations
of the procedure change in a mode other than cold shutdown condition would place the plant in a condition that was prohibited
ReviewCommittee,
by Technical Specification
didnotassurethatthechangewasadequately
3.5.2.B.Technical Specification
reviewedinthatitdidnotidentifythatimplementation
6.8.1 requires establishment
oftheprocedure
of the applicable
changeinamodeotherthancoldshutdowncondition
wouldplacetheplantinacondition
thatwasprohibited
byTechnical
Specification
3.5.2.B.Technical
Specification
6.8.1requiresestablishment
oftheapplicable
procedures
procedures
recommended
recommended
inAppendix"A"ofRegulatory
in Appendix"A" of Regulatory
Guide1.33,November1972,(SafetyGuide33)AppendixA,SectionI,specifies
Guide 1.33, November 1972, (Safety Guide 33)Appendix A, Section I, specifies that maintenance
thatmaintenance
which can affect the performance
whichcanaffecttheperformance
of safety-related
ofsafety-related
equipment should be properly preplanned
equipment
and performed in accordance
shouldbeproperlypreplanned
with written procedures, documented
andperformed
instructions, or drawings appropriate
inaccordance
to the circumstances.
withwrittenprocedures,
Contrary to the above, on December 12, 1990, the licensee failed to adequately
documented
preplan and perform corrective
instructions,
ordrawingsappropriate
tothecircumstances.
Contrarytotheabove,onDecember12,1990,thelicenseefailedtoadequately
preplanandperformcorrective
maintenance
maintenance
ontheAemergency
on the A emergency diesel generator undervoltage
dieselgenerator
circuit card.Specifically, maintenance
undervoltage
procedure M-48.14,"Isolation
circuitcard.Specifically,
of Bus 14 Undervoltage
System for Maintenance, Troubleshooting, Rework and Testing," was used to perform the corrective
maintenance
maintenance
procedure
while the reactor was at 3 percent power during startup.Step 5.5.1 directed personnel to open DC circuit breakers for the A and B safeguards
M-48.14,"Isolation
logic trains which disabled the automatic and manual (push button)sequencing
ofBus14Undervoltage
of safeguards
SystemforMaintenance,
Troubleshooting,
ReworkandTesting,"
wasusedtoperformthecorrective
maintenance
whilethereactorwasat3percentpowerduringstartup.Step5.5.1directedpersonnel
toopenDCcircuitbreakersfortheAandBsafeguards
logictrainswhichdisabledtheautomatic
andmanual(pushbutton)sequencing
ofsafeguards
equipment.
equipment.
Thisstepwasbothunnecessary
This step was both unnecessary
toperformtherequiredworkandinappropriate
to perform the required work and inappropriate
forthecircumstances
for the circumstances
asitdisabledthesafeguards
as it disabled the safeguards
sequencing
sequencing
functionatatimeprohibited
function at a time prohibited
byplanttechnical
by plant technical specifications.
specifications.
Additionally, use of M-48.14 proceeded despite indications
Additionally,
that the procedure was inappropriate.
useofM-48.14proceeded
Those indications
despiteindications
included labels on the DC breaker panels warning of the possible safety injection consequences
thattheprocedure
and the initiation
wasinappropriate.
of alarm annunciator
Thoseindications
includedlabelsontheDCbreakerpanelswarningofthepossiblesafetyinjection
consequences
andtheinitiation
ofalarmannunciator
L-31,"Safeguards
L-31,"Safeguards
DCBusFailure."
DC Bus Failure." Violations
Violations
A and B are classified
AandBareclassified
in the aggregate at Severity Level III.(Supplement
intheaggregate
atSeverityLevelIII.(Supplement
1)  
1)  
REPLYTOVIOLATION
REPLY TO VIOLATION A: THE REASONS FOR THE VIOLATION Rochester Gas and Electric (RG&E)concurs that the stated violation occurred.Procedure M-48.14 was changed in March 1989, without an adequate review being performed.
A:THEREASONSFORTHEVIOLATION
There were two weaknesses
Rochester
in Ginna's procedure development
GasandElectric(RG&E)concursthatthestatedviolation
and change policy, which resulted in a technically
occurred.
incorrect procedure being approved.As discussed by RG&E at the Enforcement
Procedure
M-48.14waschangedinMarch1989,withoutanadequatereviewbeingperformed.
Thereweretwoweaknesses
inGinna'sprocedure
development
andchangepolicy,whichresultedinatechnically
incorrect
procedure
beingapproved.
Asdiscussed
byRG&EattheEnforcement
Conference
Conference
onJanuary29,1991,theseweaknesses
on January 29, 1991, these weaknesses
occurredatthelevelofthe"Responsible
occurred at the level of the"Responsible
Manager"(RM)review,andinthelackofamulti-disciplinary
Manager" (RM)review, and in the lack of a multi-disciplinary
reviewoftheproposedchange.InMarch1989,theprocedure
review of the proposed change.In March 1989, the procedure development
development
and change policy did not provide adequate guidance to an RM for.determining
andchangepolicydidnotprovideadequateguidancetoanRMfor.determining
the operational
theoperational
impact of the proposed change.Consequently, the RM (using existing policy guidance)concluded that the proposed change was"minor" and did not have any operational
impactoftheproposedchange.Consequently,
impact, since the proposed change added a step that was deleted during the last revision.Therefore, the RM did not require a multi-disciplinary
theRM(usingexistingpolicyguidance)
review.The Plant Operations
concluded
Review Committee (PORC), acting on the recommendation
thattheproposedchangewas"minor"anddidnothaveanyoperational
of the RM, did not pursue this classification
impact,sincetheproposedchangeaddedastepthatwasdeletedduringthelastrevision.
in sufficient
Therefore,
detail and recommended
theRMdidnotrequireamulti-disciplinary
approval of the proposed change.2.THE CORRECTIVE
review.ThePlantOperations
STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED RG&E personnel, with active participation
ReviewCommittee
by senior management, performed a thorough investigation
(PORC),actingontherecommendation
of the event, and promptly initiated extensive and comprehensive
oftheRM,didnotpursuethisclassification
insufficient
detailandrecommended
approvaloftheproposedchange.2.THECORRECTIVE
STEPSTHATHAVEBEENTAKENANDTHERESULTSACHIEVEDRG&Epersonnel,
withactiveparticipation
byseniormanagement,
performed
athoroughinvestigation
oftheevent,andpromptlyinitiated
extensive
andcomprehensive
corrective
corrective
actions.TheSeniorVicePresident
actions.The Senior Vice President conducted a.series of meetings, with PORC members, procedure RMs and all operating shifts to communicate
conducted
a.seriesofmeetings,
withPORCmembers,procedure
RMsandalloperating
shiftstocommunicate
management
management
expectations
expectations
formaintaining
for maintaining
aquestioning
a questioning
attitudeandtheneedforattention
attitude and the need for attention to detail.All plant procedures
todetail.Allplantprocedures
were screened for their impact on operability
werescreenedfortheirimpactonoperability
of safeguards
ofsafeguards
equipment, resulting in numerous procedures
equipment,
being placed in a restricted
resulting
status, such that.the procedure could not be used without further review (quarantined).
innumerousprocedures
The procedure development
beingplacedinarestricted
and change policy was revised to require an operational
status,suchthat.theprocedure
review of ALL proposed procedure changes, and a structured
couldnotbeusedwithoutfurtherreview(quarantined).
procedure review checklist was developed for this'review.PORC and senior management
Theprocedure
reviewed the adequacy of these short term corrective
development
actions, and Quality Performance
andchangepolicywasrevisedtorequireanoperational
reviewofALLproposedprocedure
changes,andastructured
procedure
reviewchecklist
wasdeveloped
forthis'review.PORCandseniormanagement
reviewedtheadequacyoftheseshorttermcorrective
actions,andQualityPerformance
department
department
personnel
personnel performed an independent
performed
anindependent
assessment
assessment
oftheseactions.Theseactionswerecompleted
of these actions.These actions were completed prior to startup of the plant.  
priortostartupoftheplant.  
A detailed list of short term corrective
Adetailedlistofshorttermcorrective
actions (all of which have been completed)
actions(allofwhichhavebeencompleted)
is at Attachment
isatAttachment
1.'umerous
1.'umerous
corrective
corrective
actionsthatareconsidered
actions that are considered
longtermhavealsobeencompleted.
long term have also been completed.
Thesecompleted
These completed long term corrective
longtermcorrective
actions are at Attachment
actionsareatAttachment
2.Results of these actions assure a high level of detail and consistency
2.Resultsoftheseactionsassureahighlevelofdetailandconsistency
during the performance
duringtheperformance
of safety reviews.The need for a questioning
ofsafetyreviews.Theneedforaquestioning
attitude at all times has also been reinforced.
attitudeatalltimeshasalsobeenreinforced.
A total of approximately
Atotalofapproximately
275 procedures
275procedures
were quarantined, and these procedures
werequarantined,
will remain unavailable
andtheseprocedures
for use until a thorough review for their operational
willremainunavailable
impact has been performed.
foruseuntilathoroughreviewfortheiroperational
These actions have strengthened
impacthasbeenperformed.
existing barriers (or created new barriers)within the procedure development
Theseactionshavestrengthened
and change policy, to assure that procedure changes are adequately
existingbarriers(orcreatednewbarriers)
reviewed.THE CORRECTIVE
withintheprocedure
STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS
development
RG&E personnel have established
andchangepolicy,toassurethatprocedure
a detailed corrective
changesareadequately
action plan to strengthen
reviewed.
the procedure development
THECORRECTIVE
and change policy.Personnel will be trained on the lessons learned from this event.There will be periodic assessments
STEPSTHATWILLBETAKENTOAVOIDFURTHERVIOLATIONS
of the adequacy of the proposed corrective
RG&Epersonnel
actions, and of their continuing
haveestablished
adetailedcorrective
actionplantostrengthen
theprocedure
development
andchangepolicy.Personnel
willbetrainedonthelessonslearnedfromthisevent.Therewillbeperiodicassessments
oftheadequacyoftheproposedcorrective
actions,andoftheircontinuing
effectiveness.
effectiveness.
Ongoingevaluations
Ongoing evaluations
willprovideopportunities
will provide opportunities
forchangestoorreinforcement
for changes to or reinforcement
oftheseactions.TheroleoftheRMintheprocedure
of these actions.The role of the RM in the procedure review process will be clarified.
reviewprocesswillbeclarified.
See LER 90-017 and NRC Inspection
SeeLER90-017andNRCInspection
Report 90-31 for additional
Report90-31foradditional
discussions
discussions
oftheselongtermactions.Adetailedlistoftheseproposedcorrective
of these long term actions.A detailed list of these proposed corrective
actions,including
actions, including the current scheduled completion
thecurrentscheduled
date, is at Attachment
completion
3.THE DATE WHEN FULL COMPLIANCE
date,isatAttachment
WILL BE ACHIEVED Full compliance
3.THEDATEWHENFULLCOMPLIANCE
with 10 CFR Part 50, Appendix B, Criterion VI was achieved prior to December 20, 1990.By that date, procedure quarantine
WILLBEACHIEVEDFullcompliance
had been completed, and the procedure development
with10CFRPart50,AppendixB,Criterion
and change policy had been formally changed to require an operational.
VIwasachievedpriortoDecember20,1990.Bythatdate,procedure
review of all-proposed procedure changes.  
quarantine
0 (~  
hadbeencompleted,
REPLY TO VIOLATION B.1.THE REASONS FOR THE VIOLATION Rochester Gas and Electric.concurs that the stated violation'occurred.
andtheprocedure
A Human Performance
development
andchangepolicyhadbeenformallychangedtorequireanoperational.
reviewofall-proposed
procedure
changes.  
0(~  
REPLYTOVIOLATION
B.1.THEREASONSFORTHEVIOLATION
Rochester
GasandElectric.concursthatthestatedviolation
'occurred.
AHumanPerformance
Enhancement
Enhancement
System(HPES)evaluation
System (HPES)evaluation
determined
determined
thatthefollowing
that the following were co'ntributing
wereco'ntributing
causes for the violation:
causesfortheviolation:
A.B.There was a lack of a formalized
A.B.Therewasalackofaformalized
process for the operational
processfortheoperational
review of work order packages.Procedure M-48.14 was a PORC approved procedure and was considered
reviewofworkorderpackages.
correct by the Planner, Scheduler, and Control Room Foreman.C.D.Procedure M-48.14 had been previously
Procedure
used by the Planner to successfully
M-48.14wasaPORCapprovedprocedure
implement corrective
andwasconsidered
maintenance.(However, the plant was at cold shutdown in that instance.)
correctbythePlanner,Scheduler,
andControlRoomForeman.C.D.Procedure
M-48.14hadbeenpreviously
usedbythePlannertosuccessfully
implement
corrective
maintenance.
(However,
theplantwasatcoldshutdowninthatinstance.)
Confidence
Confidence
inthevalidityofthePORCapprovedM-48.14andthePlanner's
in the validity of the PORC approved M-48.14 and the Planner's stated previous experience
statedpreviousexperience
implementing
implementing
M-48.14outweighed
M-48.14 outweighed
theControlRoomForeman's
the Control Room Foreman's questioning
questioning
attitude in his decision making to follow the procedure instructions.
attitudeinhisdecisionmakingtofollowtheprocedure
In addition, other indications
instructions.
were inadequate
Inaddition,
in informing the operators that use of M-48.14 was inappropriate
otherindications
under these circumstances:
wereinadequate
A.Switch labelling within the DC distribution
ininforming
panels lacked adequate information
theoperators
in describing
thatuseofM-48.14wasinappropriate
the switch/load
underthesecircumstances:
function.B.Required Actions in Alarm Response Procedure AR-L-31, (Safeguards
A.Switchlabelling
DC Bus Failure)were not comprehensive.  
withintheDCdistribution
panelslackedadequateinformation
indescribing
theswitch/load
function.
B.RequiredActionsinAlarmResponseProcedure
AR-L-31,(Safeguards
DCBusFailure)werenotcomprehensive.  
l  
l  
THECORRECTIVE
THE CORRECTIVE
STEPSTHATHAVEBEENTAKENANDTHERESULTSACHIEVEDThefollowing
STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED The following corrective
corrective
steps have been taken to address the contributing
stepshavebeentakentoaddressthecontributing
causes: A.RG&E has developed and implemented
causes:A.RG&Ehasdeveloped
a detailed work package review requirement
andimplemented
for Safety Re'lated and Safety Significant
adetailedworkpackagereviewrequirement
work.This includes work package reviews for technical adequacy, proper isolation/holds, operational
forSafetyRe'latedandSafetySignificant
impact, adequate testing, conformance
work.Thisincludesworkpackagereviewsfortechnical
to technical specifications
adequacy,
and quality concerns.The Technical (Discipline)
properisolation/holds,
and Operational
operational
Reviews are performed utilizing a.detailed checklist to ensure consistency
impact,adequatetesting,conformance
in the reviews.B.Rochester Gas and Electric Senior Management
totechnical
has communicated ,their expectations
specifications
for maintaining'
andqualityconcerns.
TheTechnical
(Discipline)
andOperational
Reviewsareperformed
utilizing
a.detailedchecklist
toensureconsistency
inthereviews.B.Rochester
GasandElectricSeniorManagement
hascommunicated
,theirexpectations
formaintaining'
questioning
questioning
attitudeandattention
attitude and attention to detail to Operations
todetailtoOperations
Personnel, PORC Members, and Station"planning staffs.C.Selected plant procedure groups were screened for their impact on operability
Personnel,
of safeguards
PORCMembers,andStation"planning
staffs.C.Selectedplantprocedure
groupswerescreenedfortheirimpactonoperability
ofsafeguards
equipment.
equipment.
Thoserequiring
Those requiring changes or additional
changesoradditional
information
information
werequarantined
were quarantined
fromuseuntilthechangesarecompleted.
from use until the changes are completed.
Atotalofapproximately
A total of approximately
275plantprocedures
275 plant procedures
werequarantined.
were quarantined.
D.DCDistribution
D.DC Distribution
Panelswitchlabelswererevisedtoclarifyswitchload/function.
Panel switch labels were revised to clarify switch load/function.
E.Procedure
E.Procedure AR-L-31 (Safeguards
AR-L-31(Safeguards
DC Bus Failure)was revised to incorporate
DCBusFailure)wasrevisedtoincorporate
enhanced Required Actions.F.Operations
enhancedRequiredActions.F.Operations
management
management
issuedformalguidancetotheoperators,
issued formal guidance to the operators, stating management
statingmanagement
expectations
expectations
forworkpackagereviewpriortoreleaseofequipment
for work package review prior to release of equipment to maintenance.
tomaintenance.
A detailed list of short term corrective
Adetailedlistofshorttermcorrective
actions (all of which, have been completed)
actions(allofwhich,havebeencompleted)
is at Attachment
isatAttachment
1.Numerous corrective
1.Numerouscorrective
actions that are considered
actionsthatareconsidered
long term have also been completed.
longtermhavealsobeencompleted.
These completed long term corrective
Thesecompleted
actions are at Attachment
longtermcorrective
actionsareatAttachment
2.  
2.  
~'  
~'  
3~THECORRECTIVE
3~THE CORRECTIVE
STEPSTHATWILLBETAKENTOAVOIDFURTHERVIOLATIONS
STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS
Corrective
Corrective
stepsthatwillbetakentoavoidfurtherviolations
steps that will be taken to avoid further violations
areorientedtowardstrengthening
are oriented toward strengthening
barriersandamoreformalized
barriers and a more formalized
workpackagereviewandapprovalprocess.Additional
work package review and approval process.Additional
checklists
checklists
willbedeveloped
will be developed for work package reviews performed by non-Maintenance
forworkpackagereviewsperformed
bynon-Maintenance
personnel.
personnel.
Adetailedlistoftheseproposedcorrective
A detailed list of these proposed corrective
actions,including
actions, including the current scheduled completion
thecurrentscheduled
date, is at Attachment
completion
3.4~THE DATE WHEN FULL COMPLIANCE
date,isatAttachment
WILL BE ACHIEVED Full compliance
3.4~THEDATEWHENFULLCOMPLIANCE
with Technical Specification
WILLBEACHIEVEDFullcompliance
6.8.1 and Appendix"A" of Regulatory
withTechnical
Guide 1.33, November 1972 occurred on December 20, 1991 with the implementation
Specification
of the additional
6.8.1andAppendix"A"ofRegulatory
reviews for Safety Related and Safety Significant
Guide1.33,November1972occurredonDecember20,1991withtheimplementation
work packages.Very truly yours, Robert C.Mec dy RCM dp Attach.(3)xc: Mr.Thomas T.Martin Regional Administrator
oftheadditional
Region 1 475 Allendale Road King of Prussia, PA 19406 Thomas Moslak USNRC Senior Resident Inspector Ginna Station 1503 Lake Road Ontario, NY 14519 Subscribed
reviewsforSafetyRelatedandSafetySignificant
and sworn to before me on this 8th day of March, 1991 v'AMES C.McGUIRE NTAAY PUBUC, Stats of Nsat Yctft OuaFOIinhheos
workpackages.
Carly Mf CNtatfaahn
Verytrulyyours,RobertC.MecdyRCMdpAttach.(3)xc:Mr.ThomasT.MartinRegionalAdministrator
Expha Osc.2tt,$9+4  
Region1475Allendale
RoadKingofPrussia,PA19406ThomasMoslakUSNRCSeniorResidentInspector
GinnaStation1503LakeRoadOntario,NY14519Subscribed
andsworntobeforemeonthis8thdayofMarch,1991v'AMESC.McGUIRENTAAYPUBUC,StatsofNsatYctftOuaFOIinhheos
CarlyMfCNtatfaahn
ExphaOsc.2tt,$9+4  
   
   
PageNo.'TTACHMENT
Page No.'TTACHMENT
1LISTOFSHORTTERMCORRECTIVE
1 LIST OF SHORT TERM CORRECTIVE
ACTIONS(THOSEACTIONSSCHEDULED
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)ITEM NUMBER DESCRIPTION
TOBECOMPLETED
OF THE ACTION, WHICH WAS COMPLETED IN 1990.01 02 03 04 05 06 07 08 09 10 12i4 15/Senior Management
IN1990)ITEMNUMBERDESCRIPTION
to meet with all operating shifts (prior to startup except for one shift)to communicate
OFTHEACTION,WHICHWASCOMPLETED
IN1990.0102030405060708091012i415/SeniorManagement
tomeetwithalloperating
shifts(priortostartupexceptforoneshift)tocommunicate
management
management
expectations
expectations
forquestioning
for questioning
attitudeandattention
attitude and attention to detail., Management
todetail.,Management
to meet with the maintenance
tomeetwiththemaintenance
planning staff to communicate
planningstafftocommunicate
management
management
expectations
expectations
forquestioning
for questioning
attitudeandattention
attitude and attention to detail.Management
todetail.Management
to meet with PORC members and procedure"Responsible
tomeetwithPORCmembersandprocedure
Managers" to communicate
"Responsible
Managers"
tocommunicate
management
management
expectations
expectations
forquestioning
for questioning
attitudeandattention
attitude and attention to detail.Prepare and issue a more detailed operations
todetail.Prepareandissueamoredetailedoperations
policy on the importance
policyontheimportance
of following through on procedure concerns.Prepare and issue a policy for station planners on the importance
offollowing
of identifying
throughonprocedure
concerns.
Prepareandissueapolicyforstationplannersontheimportance
ofidentifying
operational
operational
consequences
consequences
forplannedactivities
for planned activities
involving
involving safeguards
safeguards
equipment.
equipment.
InvolvetheOperations
Involve the Operations
shiftinthedevelopment
shift in the development
ofcorrective
of corrective
actionsfortheHPESoncrewperformance.
actions for the HPES on crew performance.
Performpreliminary
Perform preliminary
HPESevaluation
HPES evaluation
fortheissueofcrewperformance.
for the issue of crew performance.
Performscreening
Perform screening of all plant procedure categories, to determine which categories
ofallplantprocedure
require review for quarantine.
categories,
Identify all current"M","EM", and"CP" procedures
todetermine
that could involve safeguards
whichcategories
manipulation, Tech.Spec.'concerns, or A-52.4 concerns.Identify all other current plant procedures
requirereviewforquarantine.
that could involve safeguards
Identifyallcurrent"M","EM",and"CP"procedures
manipulation, Tech.Spec.concerns, or A-52.4 concerns.Based on the results of screening performed, quarantine
thatcouldinvolvesafeguards
any proce'dures
manipulation,
that meet the'riteria
Tech.Spec.'concerns,
for quarantining.
orA-52.4concerns.
Identifyallothercurrentplantprocedures
thatcouldinvolvesafeguards
manipulation,
Tech.Spec.concerns,
orA-52.4concerns.
Basedontheresultsofscreening
performed,
quarantine
anyproce'dures
thatmeetthe'riteria
forquarantining.
Independent
Independent
checkoftheidentification
check of the identification
ofprocedures
of procedures
forquarantining.
for quarantining.
Establish
Establish interim policy for the review of infrequently
interimpolicyforthereviewofinfrequently
used procedures
usedprocedures
as part of the work package planning process.Determine the previous uses of M-48.13 and M-48;14, and identify any other times they were used inappropriately.
aspartoftheworkpackageplanningprocess.Determine
Review AR procedures
theprevioususesofM-48.13andM-48;14,andidentifyanyothertimestheywereusedinappropriately.
to ensure the appropriate
ReviewARprocedures
level of significance
toensuretheappropriate
is imparted, and the appropriate
levelofsignificance
response to the annunciator
isimparted,
is clearly stated.  
andtheappropriate
Page No.ITEM NUMBER ATTACHMENT
responsetotheannunciator
1 LIST OF SHORT TERM CORRECTIVE
isclearlystated.  
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)DESCRIPTION
PageNo.ITEMNUMBERATTACHMENT
OF THE ACTION, WHICH WAS COMPLETED IN 1990.16 17 18 19 20 22 23 24 25 Revise those AR procedures
1LISTOFSHORTTERMCORRECTIVE
that have significant
ACTIONS(THOSEACTIONSSCHEDULED
TOBECOMPLETED
IN1990)DESCRIPTION
OFTHEACTION,WHICHWASCOMPLETED
IN1990.161718192022232425RevisethoseARprocedures
thathavesignificant
deficiencies.
deficiencies.
Upgradelabelling
Upgrade labelling of the two DC distribution
ofthetwoDCdistribution
panels and two individual
panelsandtwoindividual
DC switches in the Main Control Board.Determine any other AC or DC distribution
DCswitchesintheMainControlBoard.Determine
panels in the Control Room that require operator/training awareness, and/or upgraded labelling.
anyotherACorDCdistribution
Perform immediate read and acknowledge
panelsintheControlRoomthatrequireoperator/trainingawareness,
training on the functions of all DC switches, including SI-A1 and SI-B1, in, the 1A and 1B DC Distribution
and/orupgradedlabelling.
Panels.Provide improved direction or additional
Performimmediate
readandacknowledge
trainingonthefunctions
ofallDCswitches,
including
SI-A1andSI-B1,in,the1Aand1BDCDistribution
Panels.Provideimproveddirection
oradditional
requirements
requirements
foroperational
for operational
andpre-PORCreviewofchangestoprocedures.
and pre-PORC review of changes to procedures.
Reviewthespecifictraininghistories
Review the specific training histories and operating experience
andoperating
of those operators directly involved in this event.PORC review of the adequacy of short term corrective
experience
actions, and evaluation
ofthoseoperators
of readiness for plant startup.Perform a senior management
directlyinvolvedinthisevent.PORCreviewoftheadequacyofshorttermcorrective
review of the adequacy of short term actions completed, prior to plant startup.Initiate TCR for training on DC distribution
actions,andevaluation
panels in the Main Control Board.Initiate TCR for long term training requirements.  
ofreadiness
forplantstartup.Performaseniormanagement
reviewoftheadequacyofshorttermactionscompleted,
priortoplantstartup.InitiateTCRfortrainingonDCdistribution
panelsintheMainControlBoard.InitiateTCRforlongtermtrainingrequirements.  
   
   
PageNo.ATTACHMENT
Page No.ATTACHMENT
2,LISTOFLONGTERMCORRECTIVE
2, LIST OF LONG TERM CORRECTIVE
ACTIONS(THOSEACTIONSSCHEDULED
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990 AND ALREADY COMPLETED)
TOBECOMPLETED
AFTER1990ANDALREADYCOMPLETED)
DESCRIPTION
DESCRIPTION
OFTHEACTION,WHICHHASALREADYBEENCOMPLETED
OF THE ACTION, WHICH HAS ALREADY BEEN COMPLETED ACTUAL COMPLETION
ACTUALCOMPLETION
DATE Evaluate the safety significance
DATEEvaluatethesafetysignificance
on accident analyses, for both trains of SI initiation
onaccidentanalyses,
being disabled.Perform complete HPES evaluation
forbothtrainsofSIinitiation
on the issue of crew performance, and identify recommended
beingdisabled.
PerformcompleteHPESevaluation
ontheissueofcrewperformance,
andidentifyrecommended
'corrective
'corrective
actions.Determine
actions.Determine the priority and schedule for the corrective
thepriorityandscheduleforthecorrective
actions resulting from the HPES evaluation
actionsresulting
of crew performance.
fromtheHPESevaluation
ofcrewperformance.
Management
Management
tomeetwithanyremaining
to meet with any remaining licensed operators, training staff, etc., as needed, to communicate
licensedoperators,
trainingstaff,etc.,asneeded,tocommunicate
management
management
expectations
expectations
forquestioning
for questioning
attitudeandattention
attitude and attention to detail.Conduct training on the planner policy regarding the importance
todetail.Conducttrainingontheplannerpolicyregarding
of identifying
theimportance
ofidentifying
operational
operational
consequences
consequences
forplannedactivities
for planned activities
involving
involving safeguards
safeguards
equipment.
equipment.
ProvidetrainingonOperations
Provide training on Operations
policyregarding
policy regarding Importance
Importance
of following through on procedure concerns, and provide feedback to Operations
offollowing
throughonprocedure
concerns,
andprovidefeedbacktoOperations
management.
management.
PerformRootCauseAnalysisoftheapprovalanduseofM-48.14(thePCNprocess),
Perform Root Cause Analysis of the approval and use of M-48.14 (the PCN process), and identify any failed barriers.Recommend corrective
andidentifyanyfailedbarriers.
actions.Perform Barrier Analysis on the work planning process, and identify any failed barriers.Recommend corrective
Recommend
actions.Review recommended
corrective
actions.PerformBarrierAnalysisontheworkplanningprocess,andidentifyanyfailedbarriers.
Recommend
corrective
actions.Reviewrecommended
corrective
corrective
actionsfromtheHPESevaluations,
actions from the HPES evaluations, and develop a long term action plan to improve the process.Review results of actions.taken, HPES evaluations, and commitments
anddevelopalongtermactionplantoimprovetheprocess.Reviewresultsofactions.taken,HPESevaluations,
from LERs 90-015, 90-016, and 90-017, and add actions~to this plan.Prepare a detailed action plan for the review and release of procedures
andcommitments
from quarantine.
fromLERs90-015,90-016,and90-017,andaddactions~tothisplan.Prepareadetailedactionplanforthereviewandreleaseofprocedures
Notify the industry via NUCLEAR NETWORK of this event.Initiate long term improvements
fromquarantine.
in the requirements
NotifytheindustryviaNUCLEARNETWORKofthisevent.Initiatelongtermimprovements
for review of Maintenance
intherequirements
Work Order packages.NSARB to review the adequacy of the long term Corrective
forreviewofMaintenance
Action Plan.Issue formal guidance to the operators for management
WorkOrderpackages.
NSARBtoreviewtheadequacyofthelongtermCorrective
ActionPlan.Issueformalguidancetotheoperators
formanagement
expectations
expectations
forreleaseofequipment
for release of equipment to maintenance.
tomaintenance.
02/22/91'01/28/91 02/04/91 03/05/91 03/08/91 02/15/91 01/28/91 01/28/91 02/04/91 02/12/91 02/04/91 01/11/91 01/16/91 03/05/91 01/29/91  
02/22/91'01/28/91
Page No.ATTACHMENT
02/04/9103/05/9103/08/9102/15/9101/28/9101/28/9102/04/9102/12/9102/04/9101/11/9101/16/9103/05/9101/29/91  
3 LIST OF LONG TERM CORRECTIVE
PageNo.ATTACHMENT
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT-YET COMPLETED)
3LISTOFLONGTERMCORRECTIVE
ACTIONS(THOSEACTIONSSCHEDULED
TOBECOMPLETED
AFTER1990,ANDNOT-YETCOMPLETED)
DESCRIPTION
DESCRIPTION
OFTHEACTIONGROUPSCHEDULED
OF THE ACTION GROUP SCHEDULED ASSIGNED'OMPLETION
ASSIGNED'OMPLETION
DATE Evaluate the impact of use of M-48.13/.14
DATEEvaluatetheimpactofuseofM-48.13/.14
during power operations, for other Technical Specification
duringpoweroperations,
concerns.Establish a working group to perform task identification
forotherTechnical
of infrequently
Specification
performed operational
concerns.
Establish
aworkinggrouptoperformtaskidentification
ofinfrequently
performed
operational
activities.
activities.
Developtrainingforlessonslearnedfromthisevent.ForeachGinna"pre-PORC"
Develop training for lessons learned from this event.For each Ginna"pre-PORC" group, establish a pre-PORC review checklist or review criteria'or
group,establish
review of procedures.(This should-'e similar to the review criteria developed for the Operations.
apre-PORCreviewchecklist
group.)Revise remaining AR procedures
orreviewcriteria'or
that have deficiencies.
reviewofprocedures.
Assess the adequacy of the administrative
(Thisshould-'esimilartothereviewcriteriadeveloped
controls established
fortheOperations.
as a result of the event..Evaluate the training conducted for changes to A-503 (Procedure
group.)Reviseremaining
Adherence), for possible weaknesses
ARprocedures
in that training.Notify the NRC of RGRE's policy for declaration
thathavedeficiencies.
of an event, and of the requirement
Assesstheadequacyoftheadministrative
to notify the NRC, and to subsequently
controlsestablished
evaluate the need to notify the state and counties.MAINT 05/01/91 OPER 06/30/91 TRN-SYSTEM
asaresultoftheevent..Evaluatethetrainingconducted
09/01/91 SGP 07/01/91 OPER OPER 03/31/91 12/01/91 PM-MGMT 04/01/91 TRN-SYSTEM
forchangestoA-503(Procedure
10/14/91 Evaluate the guidance in the Emergency Plan and EPIP's, for declaration
Adherence),
of an event and/or notification
forpossibleweaknesses
to the NRC and state~and counties, after the condit'ions
inthattraining.
for the event no longer exist.GMNP-EP 05/01/91 Curriculum
NotifytheNRCofRGRE'spolicyfordeclaration
ofanevent,andoftherequirement
tonotifytheNRC,andtosubsequently
evaluatetheneedtonotifythestateandcounties.
MAINT05/01/91OPER06/30/91TRN-SYSTEM
09/01/91SGP07/01/91OPEROPER03/31/9112/01/91PM-MGMT04/01/91TRN-SYSTEM
10/14/91EvaluatetheguidanceintheEmergency
PlanandEPIP's,fordeclaration
ofaneventand/ornotification
totheNRCandstate~andcounties,
afterthecondit'ions
fortheeventnolongerexist.GMNP-EP05/01/91Curriculum
Committees
Committees
toreviewtheLER's,HPESevaluation,
to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate
andRootCauseevaluations,
forappropriate
incorporation
incorporation
intotrainingprograms.
into training programs.Curriculum
Curriculum
Committees
Committees
toreviewtheLER's,HPESevaluation,
to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate
andRootCauseevaluations,
forappropriate
incorporation
incorporation
intotrainingprograms.
into training programs.TRN-GINNA 07/01/91 TRN-MAINT 07/01/91  
TRN-GINNA
1tl 0 l'  
07/01/91TRN-MAINT
Page No.ATTACHMENT
07/01/91  
3 LIST OF LONG TERM CORRECTIVE
1tl0l'  
ACTIONS (THOSE ACTIONS SCHEDUL'ED
PageNo.ATTACHMENT
TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED'DESCRIPTION
3LISTOFLONGTERMCORRECTIVE
OF THE ACTION GROUP ASSIGNED SCHEDULED COMPLETION
ACTIONS(THOSEACTIONSSCHEDUL'ED
DATE Curriculum
TOBECOMPLETED
AFTER1990,ANDNOTYETCOMPLETED
'DESCRIPTION
OFTHEACTIONGROUPASSIGNEDSCHEDULED
COMPLETION
DATECurriculum
Committees
Committees
toreviewtheLER's,HPESevaluation,
to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate
andRootCauseevaluations,
forappropriate
incorporation
incorporation
intotrainingprograms.
into training programs.Clarify the role of the Responsible
ClarifytheroleoftheResponsible
Managers in the procedure review process,,to
Managersintheprocedure
ensure that the distinction
reviewprocess,,to
between"major" and"minor" changes is consistently'pplied, and that 10CFR50.59"consequential" changes are properly evaluated.
ensurethatthedistinction
Clarify the role of the Responsible
between"major"and"minor"changesisconsistently'pplied,
Managers in the procedure review process, to ensure that accountability
andthat10CFR50.59
for the adequacy and accuracy of procedures
"consequential"
is designated.
changesareproperlyevaluated.
Revise procedure A-601 to clarify the role of the Responsible
ClarifytheroleoftheResponsible
Managers, and provide reinforcement
Managersintheprocedure
of management
reviewprocess,toensurethataccountability
fortheadequacyandaccuracyofprocedures
isdesignated.
Reviseprocedure
A-601toclarifytheroleoftheResponsible
Managers,
andprovidereinforcement
ofmanagement
expectations
expectations
toResponsible
to Responsible
Managersandotherappropriate
Managers and other appropriate
personnel.
personnel.
Consultwithotherutilities,
Consult with other utilities, to obtain information
toobtaininformation
on how they accomplish
onhowtheyaccomplish
similar activities.
similaractivities.
Provide a plan to assure the'dequacy of the long term corrective
Provideaplantoassurethe'dequacyofthelongtermcorrective
actions.Perform a review of policies issued (or procedures
actions.Performareviewofpoliciesissued(orprocedures
changed)as a result of this event, to ensure they are consistent
changed)asaresultofthisevent,toensuretheyareconsistent
with previously
withpreviously
existing policies and/or procedures.
existingpoliciesand/orprocedures.
Incorporate
Incorporate
thepoliciesforlongtermimprovements
the policies for long term improvements
intheMaintenance
in the Maintenance
WorkOrderprocessintoformaladministrative
Work Order process into formal administrative
controls.
controls.Ensure formal guidance is incorporated
Ensureformalguidanceisincorporated
into administrative
intoadministrative
procedures.
procedures.
Ensureappropriate
Ensure appropriate
trainingisconducted
training is conducted on the formal guidance incorporated
ontheformalguidanceincorporated
into procedures.
intoprocedures.
TRN-SYSTEM
TRN-SYSTEM
07/01/91SGP04/01/91SGP04/01/91SGP07/01/91PM-MGMT06/01/91GMNP-MGMT
07/01/91 SGP 04/01/91 SGP 04/01/91 SGP 07/01/91 PM-MGMT 06/01/91 GMNP-MGMT 04/01/91 QC-ADMIN 05/01/91 MAINT 05/01/91 OPER 07/01/91 TRN-GINNA 09/01/91  
04/01/91QC-ADMIN05/01/91MAINT05/01/91OPER07/01/91TRN-GINNA
09/01/91  
   
   
PageNo.ATTACHMENT
Page No.ATTACHMENT
3LISTOFLONGTERMCORRECTIVE
3 LIST OF LONG TERM CORRECTIVE
ACTIONS(THOSEACTIONSSCHEDULED
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED)
TOBECOMPLETED
AFTER1990,ANDNOTYETCOMPLETED)
DESCRIPTION
DESCRIPTION
OFTHEACTIONGROUPASSIGNEDSCHEDULED
OF THE ACTION GROUP ASSIGNED SCHEDULED COMPLETION
COMPLETION
DATE Implement training to all applicable
DATEImplement
portions of the nuclear organization.
trainingtoallapplicable
Implement training to all applicable
portionsofthenuclearorganization.
portions of the nuclear organization.
Implement
Develop a policy for, the use or reference to procedures
trainingtoallapplicable
to respond to Annunciator
portionsofthenuclearorganization.
alarms.Conduct follow up evaluations
Developapolicyfor,theuseorreference
on the effectiveness
toprocedures
of the short term corrective
torespondtoAnnunciator
actions.Conduct effectiveness
alarms.Conductfollowupevaluations
reviews of the long term corrective
ontheeffectiveness
actions.Determine the need for added reinforcement
oftheshorttermcorrective
of the short term corrective
actions.Conducteffectiveness
actions.NSARB to review the preliminary
reviewsofthelongtermcorrective
results of effectiveness
actions.Determine
reviews.NSARB to review the final results of effectiveness
theneedforaddedreinforcement
reviews.TRN-GINNA 12/01/91 TRN-MAINT 12/01/91 OPER 09/01/91 PM-MGMT 06/30/91 OAC PM-MGMT 12/01/91 01/01/92 GMNP-MGMT 06/15/91 GMNP-MGMT 01/01/92  
oftheshorttermcorrective
't I T
actions.NSARBtoreviewthepreliminary
resultsofeffectiveness
reviews.NSARBtoreviewthefinalresultsofeffectiveness
reviews.TRN-GINNA
12/01/91TRN-MAINT
12/01/91OPER09/01/91PM-MGMT06/30/91OACPM-MGMT12/01/9101/01/92GMNP-MGMT
06/15/91GMNP-MGMT
01/01/92  
'tIT
}}
}}

Revision as of 10:10, 6 July 2018

Responds to NRC 910208 Ltr Re Violations Noted in Insp Rept 50-244/90-31 on 901213-910103.Corrective Actions:Dc Distribution Panel Switch Labels Revised to Clarify Switch Load/Function & Addl Checklists Will Be Developed
ML17309A458
Person / Time
Site: Ginna Constellation icon.png
Issue date: 03/08/1991
From: MECREDY R C
ROCHESTER GAS & ELECTRIC CORP.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9103210167
Download: ML17309A458 (23)


See also: IR 05000244/1990031

Text

A.L Uj" LCKH AZU ULDLM.DU LAUlN LJZIVBJI.IDLLML

BJlN 3 I 8 LPIVJ.t i REGULATORY

INFORMATION

DISTRIBUTION

SYSTEM (RIDS)i SSION NBR:9103210167

DOC.DATE: 91/03/08 NOTARIZED:

YES DOCKET CIL:50-244

Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH.NAME AUTHOR AFFILIATION

MECREDY,R.C.

Rochester Gasl'lectric Corp.RECIP.NAME

RECIPIENT AFFILIATION

Document Control Branch (Document Control Desk)SUBJECT: Responds to NRC 910208 ltr re violations

noted in Insp,Rept ,50-244/90=31

on 901213-910103.Corrective

a'ctions:dc

distribution

panel switch labels revised to clarify switch load/function

&addi checklists

will be developed.

DISTRIBUTION

CODE: IEOID COPIES RECEIVED:LTR

ENCL/SIZE:/3 TITLE: General (50 Dkt)-Insp Rept/Notice

of Vio ation Response NOTES:License

Exp date in accordance

with 10CFR2,2.109(9/19/72).

/05000244 RECIPIENT ID CODE/NAME PD1-3 PD INTERNAL: AEOD AEOD/TPAB NRR MORISSEAU,D

NRR/DLPQ/LPEB10

NRR/DREP/PEPB9D

NRR/DST/DIR

8E2 NUDOCS-ABSTRACT

OGC/HDS1 RGN1 FILE 01 EXTERNAL: EGGG/BRYCE, J.H.NSIC COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME JOHNSON,A AEOD/DEIIB

DEDRO NRR SHANKMAN,S

NRR/DOEA/OEAB

NRR/DRIS/DIR

NRR/PMAS/ILRB12

RG FIL 02 NRC PDR COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D D D NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.20079)TO ELIMINATE YOUR NAME FROM DISTRIBUTION

LISTS FOR DOCUMENTS YOU DON'T NEED!TOTAL NUMBER OF COPIES REQUIRED: LTTR 22 ENCL 22 A D D

I ROCHESTER GAS AND ELECTRIC CORPORATION

ROBERT C MECREDY Vice Precidenr Cinna Nuclear Producrion

~89 EAST AVENUE, ROCHESTER N.Y.14649-0001

TELEPHONE AREA COOE 71B 646 2700 March 8, 1991 U.S.Nuclear Regulatory

Commission

ATTN: Document Control Desk Washington, DC 20555 Subject: Reply to a Notice of Violation NRC Inspection

Report No.50-244/90-31

R.E.Ginna Nuclear Power Plant NRC Docket No.50-244 Dear Sir: This letter is in response to the February 8, 1991 letter from Thomas T.Martin, Regional Administrator, to Robert E.Smith, Senior Vice President, Production

and Engineering, which transmitted

Notice of Violation from Inspection

Report 90-31.In that letter, Violations

A and B were identified.

This letter provides the reply to the Notice of Violation, pursuant to 10 CFR 2.201.RESTATEMENT

OF VIOLATIONS:

During an NRC inspection

conducted between December 13, 1990 and January 3, 1991, violations

of NRC requirements

were identified.

In accordance

with the"General Statement of Policy and Procedure for NRC Enforcement

Actions," 10 CFR Part 2, Appendix C, (1990), the particular

violations

are set forth below: A.10 CFR Part 50, Appendix B, Criterion VI,"Document Control," states in part, that measures shall be established

to control the issuance of documents, such as procedures, including changes thereto, which prescribe all activities

affecting quality.These measures shall assure that documents, including changes, are reviewed for adequacy.9103210167

910308 PDR ADOCK 05000244 PDR~~j,Hi l.e ap U

Contrary to the above, in March 1989, a procedure affecting quality, namely, Procedure M-48.14,"Isolation

of Bus 14 Undervoltage

System for Maintenance, Troubleshooting, Rework and Testing," was changed without an adequate review being performed.

The specific change involved inclusion of a step in the procedure which allowed the disabling of Engineered

Safety Feature Actuation System (ESFAS)instrumentation

while the reactor was in any mode of operation,'ncluding

power.The licensee's

organizational

measures for review, approval, and issuance of this procedure change, including the review by the Plant Operations

Review Committee, did not assure that the change was adequately

reviewed in that it did not identify that implementation

of the procedure change in a mode other than cold shutdown condition would place the plant in a condition that was prohibited

by Technical Specification 3.5.2.B.Technical Specification

6.8.1 requires establishment

of the applicable

procedures

recommended

in Appendix"A" of Regulatory

Guide 1.33, November 1972, (Safety Guide 33)Appendix A,Section I, specifies that maintenance

which can affect the performance

of safety-related

equipment should be properly preplanned

and performed in accordance

with written procedures, documented

instructions, or drawings appropriate

to the circumstances.

Contrary to the above, on December 12, 1990, the licensee failed to adequately

preplan and perform corrective

maintenance

on the A emergency diesel generator undervoltage

circuit card.Specifically, maintenance

procedure M-48.14,"Isolation

of Bus 14 Undervoltage

System for Maintenance, Troubleshooting, Rework and Testing," was used to perform the corrective

maintenance

while the reactor was at 3 percent power during startup.Step 5.5.1 directed personnel to open DC circuit breakers for the A and B safeguards

logic trains which disabled the automatic and manual (push button)sequencing

of safeguards

equipment.

This step was both unnecessary

to perform the required work and inappropriate

for the circumstances

as it disabled the safeguards

sequencing

function at a time prohibited

by plant technical specifications.

Additionally, use of M-48.14 proceeded despite indications

that the procedure was inappropriate.

Those indications

included labels on the DC breaker panels warning of the possible safety injection consequences

and the initiation

of alarm annunciator

L-31,"Safeguards

DC Bus Failure." Violations

A and B are classified

in the aggregate at Severity Level III.(Supplement

1)

REPLY TO VIOLATION A: THE REASONS FOR THE VIOLATION Rochester Gas and Electric (RG&E)concurs that the stated violation occurred.Procedure M-48.14 was changed in March 1989, without an adequate review being performed.

There were two weaknesses

in Ginna's procedure development

and change policy, which resulted in a technically

incorrect procedure being approved.As discussed by RG&E at the Enforcement

Conference

on January 29, 1991, these weaknesses

occurred at the level of the"Responsible

Manager" (RM)review, and in the lack of a multi-disciplinary

review of the proposed change.In March 1989, the procedure development

and change policy did not provide adequate guidance to an RM for.determining

the operational

impact of the proposed change.Consequently, the RM (using existing policy guidance)concluded that the proposed change was"minor" and did not have any operational

impact, since the proposed change added a step that was deleted during the last revision.Therefore, the RM did not require a multi-disciplinary

review.The Plant Operations

Review Committee (PORC), acting on the recommendation

of the RM, did not pursue this classification

in sufficient

detail and recommended

approval of the proposed change.2.THE CORRECTIVE

STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED RG&E personnel, with active participation

by senior management, performed a thorough investigation

of the event, and promptly initiated extensive and comprehensive

corrective

actions.The Senior Vice President conducted a.series of meetings, with PORC members, procedure RMs and all operating shifts to communicate

management

expectations

for maintaining

a questioning

attitude and the need for attention to detail.All plant procedures

were screened for their impact on operability

of safeguards

equipment, resulting in numerous procedures

being placed in a restricted

status, such that.the procedure could not be used without further review (quarantined).

The procedure development

and change policy was revised to require an operational

review of ALL proposed procedure changes, and a structured

procedure review checklist was developed for this'review.PORC and senior management

reviewed the adequacy of these short term corrective

actions, and Quality Performance

department

personnel performed an independent

assessment

of these actions.These actions were completed prior to startup of the plant.

A detailed list of short term corrective

actions (all of which have been completed)

is at Attachment

1.'umerous

corrective

actions that are considered

long term have also been completed.

These completed long term corrective

actions are at Attachment

2.Results of these actions assure a high level of detail and consistency

during the performance

of safety reviews.The need for a questioning

attitude at all times has also been reinforced.

A total of approximately

275 procedures

were quarantined, and these procedures

will remain unavailable

for use until a thorough review for their operational

impact has been performed.

These actions have strengthened

existing barriers (or created new barriers)within the procedure development

and change policy, to assure that procedure changes are adequately

reviewed.THE CORRECTIVE

STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS

RG&E personnel have established

a detailed corrective

action plan to strengthen

the procedure development

and change policy.Personnel will be trained on the lessons learned from this event.There will be periodic assessments

of the adequacy of the proposed corrective

actions, and of their continuing

effectiveness.

Ongoing evaluations

will provide opportunities

for changes to or reinforcement

of these actions.The role of the RM in the procedure review process will be clarified.

See LER 90-017 and NRC Inspection

Report 90-31 for additional

discussions

of these long term actions.A detailed list of these proposed corrective

actions, including the current scheduled completion

date, is at Attachment

3.THE DATE WHEN FULL COMPLIANCE

WILL BE ACHIEVED Full compliance

with 10 CFR Part 50, Appendix B, Criterion VI was achieved prior to December 20, 1990.By that date, procedure quarantine

had been completed, and the procedure development

and change policy had been formally changed to require an operational.

review of all-proposed procedure changes.

0 (~

REPLY TO VIOLATION B.1.THE REASONS FOR THE VIOLATION Rochester Gas and Electric.concurs that the stated violation'occurred.

A Human Performance

Enhancement

System (HPES)evaluation

determined

that the following were co'ntributing

causes for the violation:

A.B.There was a lack of a formalized

process for the operational

review of work order packages.Procedure M-48.14 was a PORC approved procedure and was considered

correct by the Planner, Scheduler, and Control Room Foreman.C.D.Procedure M-48.14 had been previously

used by the Planner to successfully

implement corrective

maintenance.(However, the plant was at cold shutdown in that instance.)

Confidence

in the validity of the PORC approved M-48.14 and the Planner's stated previous experience

implementing

M-48.14 outweighed

the Control Room Foreman's questioning

attitude in his decision making to follow the procedure instructions.

In addition, other indications

were inadequate

in informing the operators that use of M-48.14 was inappropriate

under these circumstances:

A.Switch labelling within the DC distribution

panels lacked adequate information

in describing

the switch/load

function.B.Required Actions in Alarm Response Procedure AR-L-31, (Safeguards

DC Bus Failure)were not comprehensive.

l

THE CORRECTIVE

STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED The following corrective

steps have been taken to address the contributing

causes: A.RG&E has developed and implemented

a detailed work package review requirement

for Safety Re'lated and Safety Significant

work.This includes work package reviews for technical adequacy, proper isolation/holds, operational

impact, adequate testing, conformance

to technical specifications

and quality concerns.The Technical (Discipline)

and Operational

Reviews are performed utilizing a.detailed checklist to ensure consistency

in the reviews.B.Rochester Gas and Electric Senior Management

has communicated ,their expectations

for maintaining'

questioning

attitude and attention to detail to Operations

Personnel, PORC Members, and Station"planning staffs.C.Selected plant procedure groups were screened for their impact on operability

of safeguards

equipment.

Those requiring changes or additional

information

were quarantined

from use until the changes are completed.

A total of approximately

275 plant procedures

were quarantined.

D.DC Distribution

Panel switch labels were revised to clarify switch load/function.

E.Procedure AR-L-31 (Safeguards

DC Bus Failure)was revised to incorporate

enhanced Required Actions.F.Operations

management

issued formal guidance to the operators, stating management

expectations

for work package review prior to release of equipment to maintenance.

A detailed list of short term corrective

actions (all of which, have been completed)

is at Attachment

1.Numerous corrective

actions that are considered

long term have also been completed.

These completed long term corrective

actions are at Attachment

2.

~'

3~THE CORRECTIVE

STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS

Corrective

steps that will be taken to avoid further violations

are oriented toward strengthening

barriers and a more formalized

work package review and approval process.Additional

checklists

will be developed for work package reviews performed by non-Maintenance

personnel.

A detailed list of these proposed corrective

actions, including the current scheduled completion

date, is at Attachment

3.4~THE DATE WHEN FULL COMPLIANCE

WILL BE ACHIEVED Full compliance

with Technical Specification 6.8.1 and Appendix"A" of Regulatory

Guide 1.33, November 1972 occurred on December 20, 1991 with the implementation

of the additional

reviews for Safety Related and Safety Significant

work packages.Very truly yours, Robert C.Mec dy RCM dp Attach.(3)xc: Mr.Thomas T.Martin Regional Administrator

Region 1 475 Allendale Road King of Prussia, PA 19406 Thomas Moslak USNRC Senior Resident Inspector Ginna Station 1503 Lake Road Ontario, NY 14519 Subscribed

and sworn to before me on this 8th day of March, 1991 v'AMES C.McGUIRE NTAAY PUBUC, Stats of Nsat Yctft OuaFOIinhheos

Carly Mf CNtatfaahn

Expha Osc.2tt,$9+4

Page No.'TTACHMENT

1 LIST OF SHORT TERM CORRECTIVE

ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)ITEM NUMBER DESCRIPTION

OF THE ACTION, WHICH WAS COMPLETED IN 1990.01 02 03 04 05 06 07 08 09 10 12i4 15/Senior Management

to meet with all operating shifts (prior to startup except for one shift)to communicate

management

expectations

for questioning

attitude and attention to detail., Management

to meet with the maintenance

planning staff to communicate

management

expectations

for questioning

attitude and attention to detail.Management

to meet with PORC members and procedure"Responsible

Managers" to communicate

management

expectations

for questioning

attitude and attention to detail.Prepare and issue a more detailed operations

policy on the importance

of following through on procedure concerns.Prepare and issue a policy for station planners on the importance

of identifying

operational

consequences

for planned activities

involving safeguards

equipment.

Involve the Operations

shift in the development

of corrective

actions for the HPES on crew performance.

Perform preliminary

HPES evaluation

for the issue of crew performance.

Perform screening of all plant procedure categories, to determine which categories

require review for quarantine.

Identify all current"M","EM", and"CP" procedures

that could involve safeguards

manipulation, Tech.Spec.'concerns, or A-52.4 concerns.Identify all other current plant procedures

that could involve safeguards

manipulation, Tech.Spec.concerns, or A-52.4 concerns.Based on the results of screening performed, quarantine

any proce'dures

that meet the'riteria

for quarantining.

Independent

check of the identification

of procedures

for quarantining.

Establish interim policy for the review of infrequently

used procedures

as part of the work package planning process.Determine the previous uses of M-48.13 and M-48;14, and identify any other times they were used inappropriately.

Review AR procedures

to ensure the appropriate

level of significance

is imparted, and the appropriate

response to the annunciator

is clearly stated.

Page No.ITEM NUMBER ATTACHMENT

1 LIST OF SHORT TERM CORRECTIVE

ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)DESCRIPTION

OF THE ACTION, WHICH WAS COMPLETED IN 1990.16 17 18 19 20 22 23 24 25 Revise those AR procedures

that have significant

deficiencies.

Upgrade labelling of the two DC distribution

panels and two individual

DC switches in the Main Control Board.Determine any other AC or DC distribution

panels in the Control Room that require operator/training awareness, and/or upgraded labelling.

Perform immediate read and acknowledge

training on the functions of all DC switches, including SI-A1 and SI-B1, in, the 1A and 1B DC Distribution

Panels.Provide improved direction or additional

requirements

for operational

and pre-PORC review of changes to procedures.

Review the specific training histories and operating experience

of those operators directly involved in this event.PORC review of the adequacy of short term corrective

actions, and evaluation

of readiness for plant startup.Perform a senior management

review of the adequacy of short term actions completed, prior to plant startup.Initiate TCR for training on DC distribution

panels in the Main Control Board.Initiate TCR for long term training requirements.

Page No.ATTACHMENT

2, LIST OF LONG TERM CORRECTIVE

ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990 AND ALREADY COMPLETED)

DESCRIPTION

OF THE ACTION, WHICH HAS ALREADY BEEN COMPLETED ACTUAL COMPLETION

DATE Evaluate the safety significance

on accident analyses, for both trains of SI initiation

being disabled.Perform complete HPES evaluation

on the issue of crew performance, and identify recommended

'corrective

actions.Determine the priority and schedule for the corrective

actions resulting from the HPES evaluation

of crew performance.

Management

to meet with any remaining licensed operators, training staff, etc., as needed, to communicate

management

expectations

for questioning

attitude and attention to detail.Conduct training on the planner policy regarding the importance

of identifying

operational

consequences

for planned activities

involving safeguards

equipment.

Provide training on Operations

policy regarding Importance

of following through on procedure concerns, and provide feedback to Operations

management.

Perform Root Cause Analysis of the approval and use of M-48.14 (the PCN process), and identify any failed barriers.Recommend corrective

actions.Perform Barrier Analysis on the work planning process, and identify any failed barriers.Recommend corrective

actions.Review recommended

corrective

actions from the HPES evaluations, and develop a long term action plan to improve the process.Review results of actions.taken, HPES evaluations, and commitments

from LERs90-015, 90-016, and 90-017, and add actions~to this plan.Prepare a detailed action plan for the review and release of procedures

from quarantine.

Notify the industry via NUCLEAR NETWORK of this event.Initiate long term improvements

in the requirements

for review of Maintenance

Work Order packages.NSARB to review the adequacy of the long term Corrective

Action Plan.Issue formal guidance to the operators for management

expectations

for release of equipment to maintenance.

02/22/91'01/28/91 02/04/91 03/05/91 03/08/91 02/15/91 01/28/91 01/28/91 02/04/91 02/12/91 02/04/91 01/11/91 01/16/91 03/05/91 01/29/91

Page No.ATTACHMENT

3 LIST OF LONG TERM CORRECTIVE

ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT-YET COMPLETED)

DESCRIPTION

OF THE ACTION GROUP SCHEDULED ASSIGNED'OMPLETION

DATE Evaluate the impact of use of M-48.13/.14

during power operations, for other Technical Specification

concerns.Establish a working group to perform task identification

of infrequently

performed operational

activities.

Develop training for lessons learned from this event.For each Ginna"pre-PORC" group, establish a pre-PORC review checklist or review criteria'or

review of procedures.(This should-'e similar to the review criteria developed for the Operations.

group.)Revise remaining AR procedures

that have deficiencies.

Assess the adequacy of the administrative

controls established

as a result of the event..Evaluate the training conducted for changes to A-503 (Procedure

Adherence), for possible weaknesses

in that training.Notify the NRC of RGRE's policy for declaration

of an event, and of the requirement

to notify the NRC, and to subsequently

evaluate the need to notify the state and counties.MAINT 05/01/91 OPER 06/30/91 TRN-SYSTEM

09/01/91 SGP 07/01/91 OPER OPER 03/31/91 12/01/91 PM-MGMT 04/01/91 TRN-SYSTEM

10/14/91 Evaluate the guidance in the Emergency Plan and EPIP's, for declaration

of an event and/or notification

to the NRC and state~and counties, after the condit'ions

for the event no longer exist.GMNP-EP 05/01/91 Curriculum

Committees

to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate

incorporation

into training programs.Curriculum

Committees

to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate

incorporation

into training programs.TRN-GINNA 07/01/91 TRN-MAINT 07/01/91

1tl 0 l'

Page No.ATTACHMENT

3 LIST OF LONG TERM CORRECTIVE

ACTIONS (THOSE ACTIONS SCHEDUL'ED

TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED'DESCRIPTION

OF THE ACTION GROUP ASSIGNED SCHEDULED COMPLETION

DATE Curriculum

Committees

to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate

incorporation

into training programs.Clarify the role of the Responsible

Managers in the procedure review process,,to

ensure that the distinction

between"major" and"minor" changes is consistently'pplied, and that 10CFR50.59"consequential" changes are properly evaluated.

Clarify the role of the Responsible

Managers in the procedure review process, to ensure that accountability

for the adequacy and accuracy of procedures

is designated.

Revise procedure A-601 to clarify the role of the Responsible

Managers, and provide reinforcement

of management

expectations

to Responsible

Managers and other appropriate

personnel.

Consult with other utilities, to obtain information

on how they accomplish

similar activities.

Provide a plan to assure the'dequacy of the long term corrective

actions.Perform a review of policies issued (or procedures

changed)as a result of this event, to ensure they are consistent

with previously

existing policies and/or procedures.

Incorporate

the policies for long term improvements

in the Maintenance

Work Order process into formal administrative

controls.Ensure formal guidance is incorporated

into administrative

procedures.

Ensure appropriate

training is conducted on the formal guidance incorporated

into procedures.

TRN-SYSTEM

07/01/91 SGP 04/01/91 SGP 04/01/91 SGP 07/01/91 PM-MGMT 06/01/91 GMNP-MGMT 04/01/91 QC-ADMIN 05/01/91 MAINT 05/01/91 OPER 07/01/91 TRN-GINNA 09/01/91

Page No.ATTACHMENT

3 LIST OF LONG TERM CORRECTIVE

ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED)

DESCRIPTION

OF THE ACTION GROUP ASSIGNED SCHEDULED COMPLETION

DATE Implement training to all applicable

portions of the nuclear organization.

Implement training to all applicable

portions of the nuclear organization.

Develop a policy for, the use or reference to procedures

to respond to Annunciator

alarms.Conduct follow up evaluations

on the effectiveness

of the short term corrective

actions.Conduct effectiveness

reviews of the long term corrective

actions.Determine the need for added reinforcement

of the short term corrective

actions.NSARB to review the preliminary

results of effectiveness

reviews.NSARB to review the final results of effectiveness

reviews.TRN-GINNA 12/01/91 TRN-MAINT 12/01/91 OPER 09/01/91 PM-MGMT 06/30/91 OAC PM-MGMT 12/01/91 01/01/92 GMNP-MGMT 06/15/91 GMNP-MGMT 01/01/92

't I T