ML18094A679

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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  PSEG icon.png
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)
v • d • e


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

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  • Document Control Desk 2 NLR-N89176 .

C Mr. J. c. Stone Licensing Project Manager Ms. K. Halvey Gibson Senior Resident Inspector 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 On June 3, 1989, control rods were withdrawn with one source range channel inoperable contrary to the requirements of Integrated Operating Procedure 3, "Hot Standby to Minimum Load" and Operating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 issued to all Licensed Operators, identifying all recently approved Technical Specification Amendments, to assure that the Operators are aware of the changes. The Information Directive process will continue to be used to notify Licensed Operators

  • of recent Amendments
  • 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.

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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.

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  • 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.

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  • 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 *

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 *

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  • 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 I_

  • 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 corr~cted, 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

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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 *

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