IR 05000285/1999001

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Insp Rept 50-285/99-01 on 990208-26.One Noncited Violation Was Identified.Major Areas Inspected:Evaluation of Cumulative Effect of Operator Workarounds at Plant Reactor Facility
ML20207K625
Person / Time
Site: Fort Calhoun Omaha Public Power District icon.png
Issue date: 03/11/1999
From:
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20207K619 List:
References
50-285-99-01, 50-285-99-1, NUDOCS 9903170252
Download: ML20207K625 (14)


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ENCLOSURE U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket No.: 50-285 License No.: DPR-40 Report No.: 50-285/99-01 Licensee: Omaha Public Power District Facility: Fort Calhoun Station

. Location: Fort Calhoun Station FC-2-4 Adm., P.O. Box 399, Hwy. 75 - North of Fort Calhoun Fort Calhoun, Nebraska Dates: February 8 to 26,1999 Inspector (s): Ryan Lantz, Reactor Engineer, Operations Branch Wayne Walker, Senior Resident inspector, Projects Branch B Approved By: John L. Pellet, Chief, Operations Branch Division of Reactor Safety Attachment: Supplemental Information l 9903170252 990311 PDR ADOCK 05000285

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-2-EXECUTIVE SUMMARY Fort Calhoun Station NRC inspection Report 50-285/99-01 Operations

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The current operator workaround program guidance was adequate. The definition for

an operator workaround, the screening and closeout process, and quarterly assessment !

criteria had been recently revised (Section 01.1).

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The licensee had effectively communicated to plant personnel the importance of identifying and resolving operator workarounds. The licensee's efforts to identify operator workarounds were being adequately implemented. The review conducted by the Nuclear Safety Review Group of the operator workaround program was comprehensive and identified additional areas for improvement which were incorporated into the operator workaround program (Section 01.2).

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Individually, tt e existing operator workarounds would not significantly impact plant operations. One non-cited violation with two examples of failure to follow procedures ,

was identified. Three examples of a less than thorough assessment of individual l operator workarounds were observed (Section 01.3). '

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Quarterly assessments were effective in identifying areas that required more attention in the operator workaround program and resulted in positive enhancements to the l program. The cumulative affect of current operator workarounds did not pose a

! significant challenge to operator performance and safe operation of the facility I i (Section 01.4). j

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Although not programmatically formalized, the licensee was effective at resolving the most significant operator workarounds as a priority, appropriate to the level of safety significance of the operator workaround (Section O1.5).

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l t r-l 3-Report Deta:Is I. Operations 01 Conduct of Operations This inspection was conducted to evaluate the cumulative effect of operator workarounds on the ability of operators to safely operate the plant and effectively respond to abnormal and emergency plant conditions. Information gathered during this inspection will be used to support an evaluation of the need for additional NRC industry guidance concerning operator workaround .1 Procedures and Criteria a. Inspection Scope

The inspectors reviewed the licensee's guidance used to identify, evaluate, track, and resolve operator workaround i b. _O_ servations and Findinas The licensee's principal guidance document used to describe the operator work around program was Operations Department Policy and Directive OPD-4-17, " Control Room Deficiencies and Operator Workarounds," Revision 2, dated January 28,1999. The definition of operator workaround was enhanced in this revision as a plant condition that requires compensatory actions or complicates plant operation Directive OPD-4-17 provided the following examples of operator workarounds: j

A material condition, such as a deficient component;

An environmental condition, such as meteorological or radiological; ,

  • A structural condition;  !
  • An administrative condition;

An embedded procedura' condition; and

An other condition not pr3viously described such as a design proble The inspectors considered this definition to be comprehensive and consistent with the definition of operator workarounds provided in Temporary Instruction 2515/138, which stated that an operator workaround is a degraded or non-conforming condition that ;

complicates the normal operation of plant equipment and is compensated for by I operator actio When a condition noted at the facility was suspected of being an operator workaround,

program guidance required a condition report to be generated. The condition report j was then reviewed using a screening criteria checklist which determined if the condition l would be added to the operator workaround list. The condition was then evaluated for disposition, including compensatory measures and planned correction date. The

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-4-operator workaround would then remain on the active list until the closeout criteria ,

checklist was completed satisfactorily. These semening criteria were added in the latest revision to Director OPD-4-17. The process for tracking and assessing operator workarounds was managed by the operations depar'. nent with the manager of operations having overall responsibility for the operator workaround proces A quarterly review was required to assess the cumu'ative effects of all active operator workarounds. The latest revision to Directive OPD-4-17 enhanced the evaluation criteria for cumule.ive effects by adding two additional standards for assessment; the first was potential for operator error during performance of compensatory actions, and the second was degree of difficulty required to perform a compensatory action. The assessment was required to be conducted by the operations department with assistance as needed, then presented to the plant review committee chairman. The inspectors ;

noted that the last four quarterly assessments had been completed by an operations '

engineer and that the plant review committee had reviewed the result i Conclusions i The current operator workaround program guidance was adequate. The inspectors ;

noted that the definition of an operator workaround, the screening and closeout process, I and quarterly assessment criteria had been recently revise .2 Identification of Operator Workarounds Insoection Scope The inspectors reviewed the current operator workaround list, cond .a interviews with licensed and nonlicensed operators and system engineers, and accompanied equipment operators on system tours to assess knowledge of known operator workarounds and to identify any previously unidentified operator workaround The inspectors reviewed the following procedures to identify unknown operator workarounds that had been proceduralized:

  • EOP-20, " Functional Recovery Procedure"

AOP-17. " Loss of Instrument Air" Observations and Finding The inspectors found that operations personnel and system engineers were familiar with the items on the operator workaround list and that operators knew and understood the compensatory measures required by the operator workarounds. Other plant personnel l

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-5-that were interviewed had been briefed or had been otherwise sensitized to the importance cf identifying operator workarounds and resolving operator workarounds in a timely manner. None of the personnel that were interviewed identified conditions that they considered to be operator workarounds that were not already on the licensee's operator workaround lis .The inspectors noted that the licensee had conducted a recent review of the operator workaround program, which resulted in several addit;onal operator workarounds being identified. The results of this review were documented in Operator Workaround -

Program Review SRG-99-006, dated February 2,1999. This review also concluded that there may still be some embedded operator workarounds contained within Fort Calhoun procedures. The inspectors did not identify additional operator workarounds incorporated in the reviewed proosdure Operations staff informed the inspectors of a management expectation that operators review procedures in use for imbedded operator workarounds. Procedural biannual reviews look specifically for potential operator workarounds, and condition reports are required to be generated for all potential operator workarounds. The heightened awareness of operator workarounds and management expectations for procedural reviews should ensure continued improvement in the area of operator workaround identificatio Conclusions The licensee had effe';tively communicated to plant personnel the importance of j identifying and resolving operator workarounds. The licensee's efforts to identify operator workarounds were being adequately implemented. The review conducted by the nuclear safety review group of the operator workaround program was

comprehensive and identified additional areas for improvement which were incorporated l into the operator workaround progra l

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0 Assessment of Individual Workarounds  ! inspection Scope The inspectors evaluated the effect of individual operator workarounds on plant operational safet l Observations and Findinas The facility maintained two operator workaround lists; one of permanent, accepted !

operator workarounds, and another working list of recently identified operator workarounds that were awaiting corrective actions. The permanent list was maintained

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-6-in Directive OPD-417 in two sections, Section 5, " Components with Automatic / Manual Functions," and Section 6," Accepted Operator Workarounds." Section 5 contained 15 entries and Section 6 contained 3 entries. The working list of operator workarounds contained 13 identified operator workarounds, which was a typical number for the past year. The inspectors reviewed all of the items on the lists and selected the three items that appeared to present the highest potential for significant integrated impact on plant operations for a more detailed assessmen The first operator workaround selected was identified in Section 5.1 of Directive OPD-4-17, " Emergency Feedwater Storage Tank Makeup." The inspectors chose this example due to the safety significance of the ability of the operators to refill the emergency feedwater storage tank given in the facility Individual Plant Evaluatio The automatic refill system as-built instrumentation was not able to regulate level as required, which necessitated this operator workaround. The operator workaround ;

required the turbine building operator to monitor emergency feedwater storage tank level once per shift and refill manually as necessary to maintain the tank in technical specification limits. During normal full power operation, filling was typically required once every 1 to 2 days. The facility noted that the additional burden during full power operation was not a significant distraction from other duties since the task of refilling was not lengthy. The inspectors reviewed the procedures governing manual refill of the emergency feedwater storage tank and agreed with the evaluation of minimal burden during normal full power operations on the turbine building operato The inspectors also reviewed Condition Report 19990149 of January 29,1999, which identified a related potential operator workaround which involved the additional burden placed on the turbine building operator during startup or shutdown when FW-6, the motor driven auxiliary feedwater pump, was used to feed the steam generators. The condition report noted that Section 5.1 of Directive OPD-4-17 did not address this additional burden and should be further evaluated as an operator workaroun An operator workaround screen was conducted as required but concluded that Section 5.1 of Directive OPD-4-17 adequately addressed the concern identified in Condition Report 19990149. The inspectors noted that the reason given in the screen did not clearly address why the additional burden placed on the turbine building operator during startup and shutdown to maintain emergency feedwater storage tank level was not considered a more burdensome activity than normal full power operations, as described in the current accepted operator workaround. The licensee explained that FW-6 was not typically used for startup and shutdown. Normally, the diesel driven non-safety auxiliary feedwater pump with suction from the condensate storage tank was used and; therefore, the additional burden to refill the emergency feedwater storage tank during startup and shutdown was not routinely challenged. Based on current operating methodology during startup and shutdown, the inspectors agreed that the disposition of the potential operator workaround was adequate: however, it would not be adequate when motor driven Auxiliary Feedwater Pump FW-6 was required due to unavailability of the diesel driven auxiliary feedwater pum This was identified as one example of a less than thorough assessment of individual operator workarounds. Other examples are noted below in this section and in NRC i

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l -7-I l Inspection Report 50-285/98-19. The inspec; ors noted that although Directive OPD-4-17 contained a screening checklist for disposition of identified potential operator

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workarounds, it did not describe licensee expectations for approval.

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The second operator workaround selected was identified as item 97-04, " Low pressure safety injection pump may have inadequate NPSH prior to RAS under certain conditions," on the working list of operator workarounds. Condition Report 199700015 was written to identify that under accident conditions with only one low pressure safety injection pump available, as the level in the safety injection refueling water tank approaches the recirculation actuation signal, the pump may lose net-positive suction head. The appropriate procedures were modified to direct the operator to throttle low 1 pressure safety injection pump flow under those conditions. This was not considered to l be a significant burden and, after completion of procedure changes, the operator workaround was removed from the list of operator workarounds in May 199 i An NRC inspection in January 1999 (NRC Inspection Report 50-285/98-27), noted the ;

procedure steps that required throttling of low pressure safety injection valves and l questioned why it was not considered an operator workaround. The licensee could not locate closure documentation and put item 97-04 back on the working list in January 1999 with plans to conduct a modification during the October 1999 refueling outage, such that throttling was no longer required, which would permanently resolve the operator workaround. This was noted by the licensee and NRC as an example of informal closure controls and prompted a programmatic review to look for other instances of improper operator workaround closures and revision of Directive OPD-4-17 to incorporate more formal closure control. The review was continuing at the time of this inspectio The third operator workaround selected was identified on the working list of operator workarounds as item 98-06, "CH-208 leaks by, requiring HCV-208 to be closed."

Maintenance Work Request 9802053 was written May 29,1998, to repair Valve CH-208, reactor coolant pump controlled bleedoff return relief valve, which exhibited approximately 0.3 gallons per minute leakage during the May 29,1998, startup and prompted the operations personnel to isolate the relief valve by closing Valve HCV-208, the normally open key operated isolation valve for Valve CH-208. The compensatory action listed for the operator workaround stated that the operator must reopen Valve HCV-208 upon emergency operating procedure entry. The reason stated for the compensatory action was to prevent reactor coolant pump seal damage in the event of a containment isolation signal, which would isolate controlled bleedoff from all four reactor coolant pumps while Valve HCV-208 was closed. The inspectors noted that Step 12 of Procedure EOP-00," Reactor Trip," directed the operator to verify Valve HCV-208 was ope Valve HCV-208 was identified as a locked open, failed open valve in Piping and Instrumentation Diagram E-23866-210-120, Sheet 1 A. The inspectors questioned the statement in the facility training manual system description for the chemical and volume control system that identified Valve HCV-208 as a dual solenoid operated failed "as is" valve. The licensee investigated and stated that Valve HCV-208 did fail "as is" on loss of control power or air. Additionally, the inspectors noted that the training manual stated i

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-8-that the purpose of Valve CH-208 was to provide pressure protection for controlled bleedoff drain piping. The licensee stated that the actual purpose of Valve N 208 was ,

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not over pressure protection but to provide an alternate controlled bleedoft pth in case l of a containment isolation or other events that caused loss of the normal controlled bleedoff drain path to the volume control tank. The inspector noted that this was two instances where the training material and plant references were inconsisten Valve HCV-208 was operated from the main control boards in the main control room i with a key-locked two-position (open/close) switch. The valve has been closed with the i key installed since May 29,1998. Condition Report 199900158 was written on February 1,1999, eight months after closure of Valve HCV-208, by the system engineer l tesponsible for Valves HCV-208 and CH-208. The condition report documented the l

history of leakage and attempted repairs of Valve CH-208 on five separate occasions since its installation in 1989 under Modification MR-FC-85-169. The condition report did not question long-term plant operation with Valve HCV-208 closed. A root-cause analysis, not yet completed, was initiated with Condition Report 199900158 to evaluate the ineffective repairs, and Work Order 21288 was written to repair Valve CH-208 during l the upcoming October 1999 outage. In the condition report, the system engineer stated that Byron Jackson Pumps, Inc., had been contacted in 1992 and verified that the reactor coolant pump vapor seal would not fail under full reactor coolant system pressure for an unspecified short time, but less than 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> The inspector asked for additional documentation supporting continued operation with j

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the normally locked open Valve HCV-208 in the closed position. No additional i I

engineering analyses on the affects of reactor coolant pump operation without controlled i bleedoff flow were available. The licensee could not produce an evaluation for the potential concerns of continued operation with Valve HCV-208 close On the basis of concern expressed by the inspectors of the potential for common mode failure of all four reactor coolant pumps' seal packages, and subsequent reactor coolant system leakage from all four reactor coolant loops, the licensee conducted a 10 CFR 50.59 applicability screening and determined an unreviewed safety question determination was required. The final evaluation solicited an engineering position from ABB Combustion Engineering, which supported that an unreviewed safety question did 4

, not exist. ABB Combustion Engineering's analysis was sent to the facility in two letters, !

l the first dated February 12,1999, and the second February 17,1999. The inspectors reviewed the evaluations and agreed that operation with Valve HCV-208 isolated did not

constitute an unreviewed safety questio When Valve HCV 208 was closed to isolate the leaking Valve CH-208 on May 29,1998, the above referenced maintenance work request was written to repair Valve CH-208; however, a condition report had not been written, which would potentially have prompted an evaluation of the impact on continued operation with Valve HCV-208 closed. Section 2.2 of Standing Order SO-R-2," Condition Reporting and Corrective Action," Revision 8, l required " origination of a Condition Report for defective materials and equipment ,

l affecting systems or components, or equipment related events which potentially impact i safe and/or reliable operation of Fort Calhoun Station.' Failure to write a condition

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l report for reactor coolant leakage from Valve CH-208 and continued operation with

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Valve HCV-208 closed was identified as a violation of Standing Order S0-R- Additionally, Attachment 7.3 of Standing Order SO-O-25," Temporary Modification Control," Revision 53 required that " temporary conditions that are left in place for longer than two working days or which are left in place as a compensatory measure for another off normal condition which requires mitigation should be evaluated to determine if a TM (Temporary Modification) is required." Failure to evaluate the long-term condition of Valve HCV-208 being maintained closed as a potential temporary modification was identified as a violation of Standing Order SO-O-25. Adherence to these procedures was required by Technical Specification 5.8.1 and Appendix A of Regulatory Guide 1.3 As a result, the inspectors identified this as two instances of one violation of NRC requirements (50-285/9901-01).

This severity level IV violation is being treated as a Non-Cited violation, consistent with Appendix C of the NRC Enforcement Policy. This violation is in the licensee's corrective action program as Condition Report 199900158, which included a root cause analysi The inspector asked to review other procedures that would direct the operator to open Valve HCV-208. The compensatory actions noted for operation with Valve HCV-208 >

closed included simulator training, direction in Procedure EOP-00 to open Valve HCV-208, and direction in the alarm response procedures for high reactor coolant pump bleedoff header pressure to open Valve HCV-208 if the bleedoff header containment isolation valves were closed. Although the procedures gave good direction to ensure Valve HCV-208 was opened during emergency operating procedure entry or inadvertent containment isolations, the inspectors noted that for an uncomplicated reactor trip, Procedure EOP-00 would require the operators to open Valve HCV-208 unnecessarily, which would reinitiate a known reactor coolant leak (to the reactor coolant drain tank)

and complicate the recovery from an uncomplicated reactor trip. This less than optimal change to EOP-00 and lack of analysis of the potential consequences to sustained plant operations with Valve HCV-208 closed were considered additional examples of less than thorough assessment of operator workaround Conclusions Individually, the existing operator workarounds would not significantly impact plant operations. One non-cited violation with two examples of tailure to follow procedures was identified. Three examples of a less than thorough assessment of individual operator workarounds were observe .4 Cumulative Effects of Operator Workarounds Inspection Scope i

The inspectors evaluated the cumulative effect of the current operator workarounds at i the site through interviews, review of licensee quarterly assessments, and the i performance of a table-top scenari i

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-10- i Observations and Findina interviews with plant operators and operations staff indicated a strong, positive attitude toward identifying operator workarounds, especially given the recently expanded definition that included more than equipment deficiencies. The inspector also l encouraged future feedback from operations personnel for further evaluation of the NRC definition of operator workaround {

The four quarterly assessments and the nuclear safety review group assessment were l comprehensive and met the intent of Directive OPD-4-17 to evaluate the cumulative I effects of operator workarounds. The assessments addressed operator burden as well l as potential for operator error. The nuclear safety review group assessment was especially effective in identifying areas that required more attention in the operator workaround program and resulted in positive enhancements to the program as described above in Section 0 A table-top exercise scenario was constructed as follows to challenge the current 1 operator workarounds. Shift manning was at a minimum in accordance with the technical specifications. The available crew was restricted to a shift manager, lead senior operator, two reactor operators, and a shift technical advisor in the control roo ,

The in-plant crew consisted of three non-licensed equipment operators and a normal !

complement of instrumentation and control, maintenance, security, chemistry, and health physics personnel. The plant was at full power. The No.1 reactor doolant pump middle seal had failed last shift, and controlled bleedoff flow was adjusted to specifications. One low pressure safety injection pump was out-of-service for bearing replacement, and the turbine building operator had just entered Room 81 to monitor i emergency feedwater storage tank level, which would result in his lining up to refill the j emergency feedwater storage tan !

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The scenario commenced with a small seismic event, which created a reactor coolant to component cooling water leak from the No.1 reactor coolant pump. The component cooling water radiation monitor alarmed and charging pump flow responded to makeup for lowering pressurizer level. Control room operators dispatched chemistry to sample component cooling water and entered Procedure AOP22, * Reactor Coolant Leak." With rising reactor coolant pump temperatures, Procedure AOP 05," Rapid Shutdown," was entered. Another small seismic event occurred and the No.1 reactor coolant pump lower and upper seals catastrophically failed, pressurizing the vapor seal to full reactor coolant system pressure. Vapor sealleakage increased but held. The excess flow check valve in the controlled bleedoff flowpath failed to fully seat due to seal debris and both controlled bleedoff header high pressure alarms annunciate, then suddenly clear as the piping downstream of the containment rolation valves ruptured. The operators immediately tripped the reactor and responded in accordance with Procedure EOP-0 The loss-of-coolant accident was occurring outside containment until a safety injection actuation signal / containment isolation actuation signal was ordered or occurred automatically. With the containment isolation actuation signal and Valve HCV-208 closed, controlled bleedoff header high pressure alarms reflashed until the operators responded by opening Valve HCV-208 in accordance with Step 12 of Procedure EOP-0 *

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-11-With radiation monitors in alarm in the auxiliary building, chemistry was again deployed to conduct samples and surveys. Access to the auxiliary building was restricted. The loss-of-coolant accident had stopped outside containment, now continued through the reactor coolant drain tank into containment. When the main seismic event occurred, an unisolable steam rupture resulted in Room 81, making access unavailable. The operators diagnosed two events, a Loss of Coolant Accident in containment and a Steam Line Rupture outside containment, and entered Procedure EOP-20," Functional Recovery Guidelines." Procedure HR-3 was entered for uncontrolled cooldown, and the i associated generator was isolated and allowed to depressurize into Room 8 Approximately 30 minutes post-reactor trip, the operators anticipated a recirculation 1 actuation signal and throttled low pressure safety injection to prevent loss of net-positive !

suction head. Since Room 81 was inaccessible, the outside operator was standing by to l ensure the diesel driven auxiliary feedwater pump was ready to directly feed the intact I steam generato This scenario imposed all three operator workarounds previously discussed. Control room personnel entered the required abnormal operating procedures and emergency operating procedures. The two reactor operators assumed power, pressure, and level control and shared balance of plant actions as required. One non-licensed operator was at the diesel driven feedwater pump, another was performing actions in the auxiliary building or was restricted access due to the leak, and the third was in the turbine building performing shutdown actions. Under these conditions, all available operators were involved in essential contingency actions. Subsequent actions required would !

have been further complicated by the difficulty in accessing the auxiliary building and Room 8 Conclusions The operations staff had an open, positive attitude toward identifying operator workarounds. Quarterly assessments were effective in identifying areas that required l more attention in the operator workaround program and resulted in positive enhancements to the progra The cumulative affect of current operator workarounds did not pose a significant challenge to operator performance and safe operation of the facilit .5 Resolution of Operator Workarounds Insoection Sqop_e The inspectors evaluated the licensee assessment and resolution of operator workaround rT u-

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-12-  ! Observation and Findinos The working list of operator workarounds did not assign a priority to any given operator workaround, however, contained information such as emergency or abnormal operating procedure impact, the specific operator affected, compensatory measures, expected resolution date, and current status. The list was normally updated weekly and biweekly as a program minimum. The two most safety significant system operator workarounds listed were scheduled to be repaired at the next shutdown outage, scheduled in October 1999. Other completion dates were assessed as reasonable and appropriate to the level of significance of the operator workaroun The inspectors reviewed the last ten operator workarounds that had been removed from the working list. Of those ten, the longest duration of any on the list was 10 months. It ,

was resolved with the completion of an engineering change notice. The next two of longest durations were 9 and 5 months, and both of these were removed from the working list and incorporated into the accepted list in Directive OPD-4-14. Of the remaining seven, two were on the list approximately 2 months, and the rest were on the list less than 3 weeks. Each of them was resolved appropriatel Interviews with control room crew staff and operations managers indicated a positive, and responsive attitude toward the importance of identifying and resolving potential operator workarounds. The raw number of operator workarounds had increased only slightly over the past year, which can be attributed to a heightened awareness to identify operator workarounds, as well as a more formalized process to screen, track, and resolve operator workarounds, Conclusions Although not programmatically formalized, the licensee was effective at resolving the most significant operator workarounds as a priority, appropriate to the level of safety significance of the operator workaroun V. Management Meetings X1 Exit Meeting Summary The inspectors presented the inspection results to members of the licensee management at the conclusion of the on site inspection on February 12,1999. A final exit meeting was held by phone on February 26 after additional information was received from the licensee. The licensee acknowledged the findings presente The licensee did not identify as proprietary any information or materials examined during this inspectio I l

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ATTACHMENT l

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SUPPLEMENTAL INFORMATION PARTIAL LIST OF PERSONS CONTACTED Licensee D. Bannister, Supervisor, Operations J. Brown, Shift Manager / Operations G. Cavanaugh, Licensing Engineer J. Chase, Division Manager, Nuclear Assessment 3 R. Clemens, Manager, Maintenance I M. Core, Manager, System Engineering I M. Frans, Manager, Nuclear Licensing S. Gambhir, Division Manager NOD J. Gasper, Manager, Nuclear Projects K. Grant-Leanna, Nuclear Safety Review Specialist W. Han ,her, Supervisor, Station Licensing R. Hamilton, Manager, Chemistry J. Herman, Manager, Planning and Scheduling l

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R. Phelps, Division Manager, Nuclear Engineering R. Ridenoure, Manager, Operations H. Sefick, Manager, Security Services R. Short, Assistant Plant Manager J. Solymossy, Plant Manager J. Spilker, Manager, Corrective Action Group D. Spires, Manager, Quality Assurance M. Tesar, Division Manager, Nuclear Support J. Tills, Assistant Plant Manager Others D. Desaulniers, Hume- Cactors Analyst, NRC INSPECTION PROCEDURES USED Temporary Instruction 2515/138 Evaluation of the Cumulative Affects of Operator Workarounds

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ITEMS OPENED AND CLOSED Ooened 50-285/9901-01 NCV Failure to follow procedures, two examples (Section 01.3)

Closed 50-285/9901-01 NCV Failure to follow procedures, two examples (Section 01.3)

PROCEDURES REVIEWED l

OPD-417 " Control Room Deficiencies and Operator Workarounds," Revision ]

OI-St-1, Attachment 18, " Venting the Low pressure safety injection Header," Revision 39 Ol-RC-9, Checklist OI-RC-9-CL-A, " Reactor Coolant System," Revision 38 SO-O-R-2, " Condition Reporting and Corrective Action," Revision 8 SO-O-44," Administrative Control for Locking of Components," Revision 59 SO-O-25," Temporary Modification Control," Revision 53 OP-1, Attachment 1, " Checklist for Plant Startup from Mode 4/5 to Mode 1," Revision 45 PED-OP-2, " Configuration Change Control," Revision 27 ARP-CD-1,2,3/A2, Annunciator Response Procedure, Windows B-5U and B-5L," Reactor Coolant Pump Controlled Bleedoff Header Pressure Hl/HI-Hi" AOP-22," Reactor Coolant Leak," Revision 4 AOP-06," Fire Emergency," Revision 7 AOP-17, " Loss of Instrument Air," Revision 3 EOP-00, " Reactor Trip," Revision 13 EOP-20, " Functional Recovery Procedure," Revision 3 l

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