IR 05000293/1997080

Insp Rept 50-293/97-80 on 970721-0801.Violations Noted.Major Areas Inspected:Effectiveness of Processes for Identifying Resolving & Preventing Issues That Degrade Quality of Plant Operations & Safety

ML20211A283
Person / Time
Site:	Pilgrim
Issue date:	09/12/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20211A252	List: IR 05000293/1997080 ML20211A247 ML20211A274
References
50-293-97-80, NUDOCS 9709240192
Download: ML20211A283 (27)

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U. S. NUCLEAR REGULATORY COMMISSION

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REGION I

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,- Docket No.: 50 293 t

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i Report No.: 97 80

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j Licensee: Boston Edison Company

800 Boylston Street ,

Boston, Massachusetts 02199

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Facility: Pilgrim Nuclear Power Station Location: Plymouth, Massachusetts f

Dates: July 21 August 1,1997 ,

inspectors: W. Cook, SRI, Vermont Yankee, Team Leader i R. Arrighl, Rl, Pilgrim Station

! R. Eckenrode, Engineer, Human Factors Assessment Branch, NRR j W. Wang, Project Manager, NRR

Approved by: -

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E l filchard J. Conte, dfilef Date Reactor Projects Branch No. 8 j Division of Reactor Projects, Region i

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7 9709240192 970917 POR ADOCK 05000293 0 PDR

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EXECUTIVE SUMMARY Pilgrim inspection Report 50 293/97 80 Problem Identification / Root Cause AnalyslalCorrective Actions Problem identification via the new Problem Reporting process was observu, to be generally good, with a low threshold for reporting issues. The team determined that the root cause analysis (RCA) and corrective actions for technical issues reviewed were very good, with good expansion of scope where warranted. The Corrective Action Review Board appeared to be effective in ensuring the quality of RCAs and effective corrective action assignment However, the corrective actions for the February 15,1997 scram post trip review, which identified a procedural noncompliance, were not properly entered into the Problem Reporting process untilidentified by the team on July 29,1997. The processing of corrective actions associated with these human performance errors was contrary to corrective action procedure No.1.3.121 and 10 CFR 50, Appendix B, Criterion V and XV (VIO 97 80 01)

The team identified one instance where the individual performing an RCA was not formally trained in HPl methodology and his evaluation was not co signed by a qualified evaluator, as required by procedure No.1.3.121. This was a second example of the failure to follow corrective action procedure No. . 3.121 and 10 CFR 50, Appendix B, Criterion V and XV (VIO 97 80 01)

Although no examples of repeat problems were identified as a result of the five month l delay in completing nine RCAs, the slow implementation of subsequent corrective actions poses a vulnerability to repeat problems and does not reflect the appropriate level of attention of the Significant Condition Adverse to Quality (SCAQ) designation of the issu The IADB appears to be an effective management tool for tracking the resolution of identified problems. Information available via the lADB appeared to be accurate and up to-date. Maintenance Rule information was observed to be inconsistently tracked, potentially affecting organizational effectivenes Operability evaluations were generally of good quality with reasonable basis for their conclusions. The operability evaluations and follow-up actions were timely, with one minor exception noted - procedural inconsistency. The licensee has implemented a new procedure (NESG 16.04) to ensure that all operability evaluations are properly logged, prioritized, and tracked to a timely resolutio The team concluded that the Operating Events Review program appears to be effectively implemented at the plant. The review of selected NRC Information Notices demonstrated good implementation of industry lessons learne Il

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ie The performance data entry and analysis processes have been established and *

'j demonstrated, and baseline common cause analyses have been successfully performe This was an improvement since the previous 40500 inspection. However, performance 4 trending by the licensee remains limited. The licensee recognizes the need for further l

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guidance and experience in this area,in order to derive further benefit and performance trending insights. The limited analysis does reflect that procedural quality and use problems remain the principle burnan performance concern on site.

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Oversight Groups

. Based upon the limited Onsite Review Committee (ORC) meeting observations, 1 documentation review, and interviews, it appeared that the ORC safety oversi0 ht functions t l were being appropriately satisfied. The ORC members exhibited a questioning attitude.

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] Nuclear Safety Review and Audit Committee (NSRAC) appears to provide adequate i oversight of the facility. As demonstrated by the above, the NSRAC discussions are ,

) comprehensive and usually provide in depth discussion of current plant issues and i p concerns with a good questioning attitude. Based on this inspection, the team determined i

that NSRAC provides an objective look and oversight of the plant and that the plant acts

] on the concerns identified by NSRAC.

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Self Assessments

The team concluded that the department self assessment program appeared to have been appropriately implemented. A sampling of recently completed assessments found them to j be reasonably self critical and the findings appropriately categorized and formally tracked

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I 1 The Independent Oversight Team (IOT) was providing limited self assessment and feedback l to the line managers and staff. Consequently, this management level corrective action j process, developed in response to a previously identified weakness in the area of j independent oversight, was not demonstrated to be effective. The failure of the IOT to

provide a monthly or quarterly report summarizing the activities that were reviewed,

! problems noted, and corrective action recommendations was contrary to IOTWI.001, j " Independent Oversight Team Work instruction," revision 0, dated July 15, i396. This i was the third ext.mple of failure to follow corrective action procedures and is a violation of 10 CFR 50, Appendix B, Criterion V and XVI. (VIO 97 80-01).

The team found that QA Audits appear to be effective in identifying problem areas and providing performance feedback. Review of recent audit reports indicated that, in spite of the lack of established trend analysis, repetitive findings were still being identified and properly characterized for corrective action. The team noted repetitive findings and ongoing issues with procedural quality and proper use; but the team also noted some sign of improvemera in the area with the licensee nearing completion of their corrective action However, the team concluded that line management and overnight groups were not completely effective in substantially improving performance in the area of procedure quality and use, iii

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Also, implementation of the Performance Evaluation Program (the formal management

} observation reporting process) appeared to fall short of senior BECo management ll expectations for the program, in terms of management participation and substantive j actions to improve performance at the station, t

] Nuclear safety concerns Program (NSCP)

i l Based upon the licensee's response to their independent assessment of the Nuclear Safety i j Concerns Program (NSCP) and the team's observations, corrective actions initiated for the Identified NSCP Implementation problems have not been fully effective. Procedure quality j and use problems resulted in a lack of NSCP effectiveness as an alternative means j available to BECo employees or contractors for reporting safety concerns.

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s TABLE OF CONTENTS EX E C UT IV E SUM M ARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1 INTRMUCTION ............................................. 1 PROBLEM IDENTIFICATION / ROOT CAUSE IDENTIFICATION / CORRECTIVE ACTIONS................................................. 1 Review of Problem Reporting (PR) and Resolution Process . . . . . . . . . . . 1 Review of the Integrated Action Data Base (lADB) ................ 6 Review of Operability Evaluations ........................... 7 Operating Experience Review (OER) Program . . . . . . . . . . . . . . . . . . . . 8 Review of Common Cause Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . 9 OVERSIGHT GROUPS ........................................10 Onsite Review Committee (ORC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Nuclear Safety Review and Audit Committee (NSRAC) . . . . . . . . . . . . 11 S ELF A S S ES S M ENT S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Review of Quality Assurance Audits and Surveillance Activities . . . . . . 13 Review of Departmental Self Assessments . . . . . . . . . . . . . . . . . . . . . 14 Review of Independent Oversight Team . . . . . . . . . . . . . . . . . . . . . . . 15 REVIEW OF THE NUCLEAR SAFETY CONCERNS PROGRAM (NSCP) ..... 17 REVIEW OF FSAR COMMITMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 M AN AG EM ENT MEETINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 INSPECTION PROCEDURES USED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 IT E M S O PE N E D A N D CLO S E D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 PARTI AL LIST OF PLRSONS CONTACTED . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . 21 LI ST O F AC R O NYM S U S E D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 v

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REPORT DETAILS INTRODUCTION

The purpose of this team inspection was to evaluate the effectiveness of Boston Edison Company's (BECo's) controls in identifying, resolving, and preventing issues that degrade

the quality of plant operations or safety. The team primarily used the guidance of NRC

Inspection Procedure 40500 in conducting this evaluatio .0 PROBLEM IDENTIFICATION / ROOT CAUSE IDENTIFICATION / CORRECTIVE ACTIONS Review of Problem Reporting (PR) and Resolution Process

Insoection Scoos (4050.Q1

The PR process at Pilgrim Station serves several purposes, including

the identification and documentation of problems, the initial evaluation of the problem I

for equipment operability and reportability, the assignment of problem significance,

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and the determination of root cause(s) or causal factor (s) analysis, both of which include corrective action recommendations. The team reviewed various aspects of the implementation of the PR process to assess the overall effectiveness of the

licensee's corrective action process, Observations and Findinas 1 Problem identification

The PR process requires that any Nuclear Organization (NUORG) person who identifies a problem must initiate a PR. If one of the nineteen conditions listed on the back of a PR exists, then the individual must hand carry the PR to the Nuclear

Watch Engineer (NWE) for his review. If none of the conditions exist, then the PR is forwarded to the Operations Support Team (OST). All Pris generated are entered into the licensee's integrated action data base (IADB) for tracking and trending purposes. Additionally, procedure No.1.3,121, " Problem Report Program," step 6.1(1) states that "All hardware and non hardware (human performance,

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administrative controls, procedural deficiencies) related problems shall be documented on a PR."

Based on daily observations of the PR process and discussions with licensee personnel, the team identified that not all hardware problems were being documented on a PR. Plant walk through by the team identified that minor equipment problems, such as packing leaks, are documented on a maintenance work request tog vice a PR. Interviews with the plant staff established that housekeeping and personnel / industrial safety concerns were also considered below the threshold of prs and addressed by other established reporting systems. A follow up examination of procedure No.1.3.121 identified that steps 6.6.1.[8),

6.6.2.18], and 6.6.3 [121 stipulate that p_lj sections of Attachment 4 * Evaluation Response," and Attachment 5 " Root Cause Analysis Response," respectively, shall be filled out or otherwise notated. Based upon the review of numerous prs, including those discussed below, the team observed that all sections of

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2 Attachments 4 and 5 are not completed or otherwise notated. Follow up 1 discussions with the OST rnanager and staff revealed that it was not the intent of I the revised PR process to have all hardware and non hardware problems l documented on a PR fctm Likewhe, it was not expected that all sections of

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Attachments 4 and 5 would necessarily have to be complete l The team viewed the above findings as a minor procedural clarity problem attributable to unanticipated problems with a new PR process procedure. The licensee initiated a PR (No. 97.2442) to address this observation and proposed to change the wording of these steps in a pending revision to procedure No.1.3.12 In spite of this minor procedural clarity problem, the team observed that the PR threshold was low and that since implementation of the new PR process in January 1997, the PR volume at Pilgrim increased threefold to 1015 prs per day. This significant increase in PR volume reflected an increased sensitivity to problem identification and reporting for resolutio PR Screenina In accordancs 'with procedure 1.3.121, all prs are reviewed by the OST and the PR Screening Team, which is made up of the Operations Department Manager (ODM),

the Regulatory Affairs Department Manager, and the Deputy Plant Group Manager and/or the Deputy Nuclear Engineering Services Group Manager. A qualified alternate may be utilized to ensure a quorum. The purpose of the screening process is to establish a significance level, to make initial action item assignments to the NUGRG, as necessary, and/or otherwise disposition the P The PR Screening Team characterizes each PR as either a significant condition adverse to quality (SCAQ) or a non SCAO, depending on the safety significance of the item. They also identify the type of investigation (apparent cause, direct cause, or root cause analysis) required. The 40500 team identified that of the approximate 2800 prs issued in 1997, to date,55 (approximately two percent) have been characterized as SCAO which requires a root cause analysis. The team also determined that if the PR Screening Team or OST identifies any item of significance that had not been reviewed by the NWE, then the ODM informs the NWE In addition, all notable prs, as determined by the ODM, are presented at the 8:30 morning meeting The team attended several PR screening meetings to determine whether the prs were being assessed at the appropriate level and thereby were receiving the proper level of management attention. The team concluded that all prs observed screened were assessed at the appropriate level (SCAO or non-SCAQ) and thereby received the proper level of management attention. A quorum was present for screening meetings attende The team also attended several of the NUORG management team 8:30 morning meetings and noted that the more significant prs were discussed. There was good information exchange for each of the PR issue . _ _ -. _ _-

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Root Cause Evaluation Procedure No.1.3.121 requires that a root cause analysis (RCA)is performed for all SCAQs. In addition, all RCAs are reviewed by a corrective action review board (CARB). All non SCAO items receive an apparent or direct cause analysis and may be closed without any further action. These non SCAO dispositions are approved by the applicable department manager or higher. Individuals performing RCA or apparent cause analyses are required to be trained and/or mentored by an individual formally trained in the Human Performance Investigation (HPI) methodologie The team examined several prs to independently assess the effectiveness of the licensee's PR and corrective action process. Specifically, the team reviewed the adequacy of identifying the root / apparent / direct cause(s) and the establishment of appropriate corrective actions. A summary of the prs examined (5 SCAQs and 2 non SCAQs) and specific team observations for each event are addressed below:

- PR97.9036 (non SCAQ), Lifted leads on breaker D4-16 were re landed incorrectl PR97.9119 (non SCAQ), During the performance of load shed relay operational test, when isolating Bus A 6, the shutdown transformer feed to valve A 6 automatically closed when the startup transformer feed to A 6 was opene PR97.9226 (SCAQ), Fire in the "B" reactor feed pump motor. One of the heaters located under the motor failed producing an arc which ignited the oil and oil vapor under the moto PR97,2036 (SCAQ), Stator cooling water trouble alarm with no apparent reason. An alarm was received, but no window at panel C 100 to indicate

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the proble PR97.9294 (SCAQ), Postulated Pipe Break Pressure Relieving Pathway Boundary Door Found Open During Power Operation. A RCA was performe PR97.9220 (SCAQ), During trouble shooting of the 125 VDC battery ground, breaker 8 on Bus B-4 was cycled open and closed. Closing the breaker resulted in valve MO 100150 closing which tripped the "B" residual heat

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removal pump.

I - PR97.9111 (SCAQ), During shut down for Cycle 11 refueling outage, the

"B" feed regulating valve leaked by its seat resulting in a manual reactor scram on high water leve For PR97.9220, a RCA was performed. The RCA and identified corrective actions for this issue were determined to be good. However, the team identified that the individual who performed the investigation was not qualified in HPl methodology

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) and the individual was not mentored, as required by procedure No.1.3.121. A PR i (No. 97.2427) was issued to document this NRC team observation. The failure to

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have a mentor co sign an unqualified root cause evaluators assessment was 3 contrary to corrective action procedure No.1.3.121, step 6.6.1.l9] and was a violation of 10 CFR 50, Appendix B, Criterion V and XVI. (VIO 97 80 01)

For PR97.9111, the PR screening meeting requested a RCA and post trip review be

performed for this event. The RCA for tho technical aspect (valve seat leakage) of I this event was determined to be very good. There was a good expansion of the l scope of corrective actions to include applicable related equipmen )

i For the above listed prs, an appropriate cause analysis was performed. The team j determined that the specified corrective actions appeared to be proper and

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implernented in a timely manner. No problems were identified.

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i The post trip review for a reactor trip in February 1997 was performed by the

! training department and documented in a March 17,1997 memorandum entitled, j " Assessment of Operator Performance During RPV Level Transient and Subsequent Unit Trip Occurring 2/15/97 (Rev 1)." A number of personnel performance errors l were identified and several corrective actions, stated as " recommendations," were

specified. The team identified that the corrective actions for these human

performance errors involving the 2/15/97 reactor scram were not entered into the

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IADB as part of PR 97.9111, in accordance with procedure No.1.3.121, step

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6.7.15), which states that " identified corrective actions are required to be tracked to l completion according to Action items associated with the lADB or according to

) other corrective action tracking processes determined to be appropriate by the OST i (Operation Support Team)." This failure was to enter the actions in the IADB was contrary to corrective action procedure 1.3.121 step 6.7151 and was a violation of

10 CFR 50, Appendix B, Criterion V and XVI. (VIO 97 80 01)

Team follow up identified several missed opportunities to have prevented the procedure nonadherence noted above. First, the absence of human performance related corrective action was subsequently questioned in a related PR (No. 97.0937)

, which was closed via reference to Recommendation Report (RR) No. 97.0030. The team viewed the closure of PR 97.0937 as a missed opportunity to have properly

dispositioned corrective actions for the identified problem. The team notes that

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procedure 1.3.121 defines a RR as a suggestion or comment for

] improvement /enhaacement of existing processes or hardware.

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j Secondly, RR No. 97.0030 was identified by the team to have been generated as a result of the March 17,1997 memorandum. However, the team also viewed RR No. 97.0030 as a missed opportunity for having properly characterized the March -

J 17,1997 recommendations as corrective actions vice optional items for improvement / enhancement. Discussions with operations department representatives identified that the pre startup recommendations were completed,

but the post startup recommendations were not entered into the IADB as corrective

actions and remain unacted upon as of the end of this inspection.

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Lastly, the team determined that the licensee had generated another PR (N .1363, dated 3/21/97) to address an NRC Notice of Violation (NOV), inspection Report 97 01, dated 3/18/97 related to the same reactor trip. The NOV involved the failure to follow procedure associated witt the 2/15/97 reactor scra However, the specific " recommendations" from the March 17,1997 rnemorandum to address these procedural compliance failures (and addressed in the licensee's 4/17/97 response to the NOV) had still not been entered into the IADB as corrective actions upon review by the team. This was also viewed as a missed opportunit The licensee acknowledged this PR processing error and initiated PR No. 97.2426 on 7/29/97 to address this NRC team observatio PR Closeout The CARB reviews the RCA for technical centent, accuracy, adequacy of corrective actions, and administrative completeness. The team reviewed the CARB meeting minutes for 1997 and attended the 7/28/97 meeting. The team observed that the RCAs and identified corrective actions ware appropriately challenged by CARB members during the meeting. Based on this limited observation and meeting minutes review, the team determined that the CARB appears to be effectiv The team noted that there were 23 SCAQs for which a RCA had not been completed or reviewed by the CARB Nine SCAQs of the 23 were greater than five months old. The procedure 1.3.121 goalis that an RCA should have an initial due and " dead" date of 15 and 30 days, respectively. The team identified that extensions to exceed the 30 day goal were granted for the individual SCAQs, No examples of repeat problems were identified as a result of the delayed completion of RCAs, c. Conclusions Problem identification via the new Problem Reporting process was observed to be generally good, with a low threshold for reporting issues. The team determined that the root cause analysis (RCA) and corrective actions for technical issues reviewed were very good, with good expansion of scope where warranted. The Corrective Action Review Board appeared to be effective in ensuring the quality of RCAs and effective corrective action assignment However, the corrective actions for the 2/15/97 scram post trip review, which identified a procedural noncompliance, were not properly entered into the Problem Reporting process untilidentified by the team on 7/29/97. The processing of corrective actions associated with these human performance errors was contrary to procedure No.1.3.1 The team identified one instance where the individual performing a RCA was not formally trained in HPl methodology and did not his evaluation co-signed by a qualified evaluator, as required by procedure No.1.3.121. This was a second example of the failure to follow procedure No.1.3.12 .

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Although no examples of repeat problems were identified as a result of the five-month delay in comptsting nine RCAs, the slow implementation of subsequent corrective actions poses a vulnerability to repeat problems and does not reflect the appropriete level of attention of the Significant Condition Adverse to Quality (SCAO)

designation of the issu .2 Review of the integrated Action Data Base (IADB)

a. Inspection Scone (40o00)

At the onset of the team inspection, the team members quickly learned that the IADB was critical to the day to day functioning of the licensee's problem reporting process. The team examined the lADB to better understand the licensee's corrective action orocess and to assess its overall effectiveness as a tracking and management tool, b. Qbservatinns and Findinas The lADB is the largest data base onsite for controlling commitment dates related to the NRC and regulatory affairs actions, INPO actions, operating experience actions, Problem Reports (prs), and Recommendation Reports (RRs). The team learned that non-conformance reports (NCRs), currently tracked by the Quality Assurance Group (OAG), are planned to be incorporated into the IADB From discussions with the plcnt staff, the team determined that the IADB is used to prioritize and plan wor For example, a corrective action item sort provides a weekly status of past due and

" dead" dates for all open action items in the IADB. This sort is a measure of backlog and it flaps past due work to the appropriate supervisors and the assigned personnel. The team observed the use of the IADB in this capacity by the Nuclear Engineering Services Group (NESG) NESG uses IADB to, not only to track past due and " dead" dates, but also to track the total backlog and total open items by group, department, and individual employee for biweekly planning of departmental and individual work load The lADB can perform queries to search and collate nearly anything in its databas As part of the inspection, the team made several requests for specific sorts and all were performed with relative ease. Information provided via these sorts was evidenced to be current and accurate. Administrative limitations have been imposed by the Operations Support Team on certain queries due to the computer hardware constraints. Accordingly, it appears that the data for tracking and trending various plant performance issues is available, but is not used to it's full advantage. As a result of the maintenance rule implementation, the licensee developed procedure NOP95A4, " Nuclear Maintenance Rule Procedure," which uses lADB data. The procedure places the tracking cnd trending responsibilities for maintenance rule identified systems on the responsible system engineer. The team observed that NOP95A4 was not overly prescriptive and that the system engineer must decide how to maintain and update the system informatio .

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7 i' The team reviewed several monthly reports to see if the availability data for various systems properly reflected the out of service times in the monthly operating report While no discrepancies were noted, the details of the systems' availability records

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and maintsnance data varied between the individual responsible system engineer The maintenance rule coordinator pointed out that a new procedure was in draf t to provide more prescriptive / standardized requirements for implernentation of the

, maintenance rule availability and function failure tracking. The proposed procedure j includes an electronic data base for the maintenance rule data record keeping and j trending of performance criteria, c. Conclusionji i l

The lADB appears to be an effective management tool for tracking the resolution of l

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identified prob %ms. Information available via the lADB appeared to be accurate and '

up to date. Maintenance Rule information was observed to be inconsistently

tracked, potentially affecting organizational effectivenes .3 Review of Operabi!ity Evaluations (Update 96 08 01)

a, insoection Scoce (40500)

The team conducted a review of 1990 and 1997 prs which involved issues warranting formal operability evaluations. This review was conducted to assess the adequacy of the licensee's' operability determination process and to evaluate the timeliness of resolution of outstanding operability concerns, b, Observations and Findinas Of the sixteen 1996 operability evaluations reviewed, nine remain open. For eight of these nine open evaluations, the resolution of pending action items was determined to be appropriate. The one remaining evaluation involved an emergency diesel generator (EDG) design issue that had been open for approximately one yea Specifically, as part of a loss of coolant accident (LOCA) re analysis conducted in June 1996, the engineering staff determined that the 0.3 second delay between the diesels being connected to the 480V emergency bus and power being available at the low pressure coolant injection (LPCI) isolation and recirculation loop discharge valves was not accurate or conservative. The emergency bus is a swing bus with the "A" diesel as the preferred source. On a lost of the "A" diesel, the control logic will seek the "B" bus which adds approximately 3.6 seconds to the energization of the emergency bus. A preliminary analysis determined that this delay could cause about a 40 degrees F increase in fuel peak clad temperature (PCT), but well below the 2200 degrees F limit. A rafety evaluation (SE No. 2989) was prepared to resolve this issue. However, the Onsite Review Committee (ORC) rejected this safety evaluation because engineering had not been able to verify the delay time for the energization of the emergency bus. Team follow up with the electrical engineering department staff identified that there appears to be a reasonable basis for closure of this ORC issue and approval of SE No. 2989. The targeted completion of this work item was the end of the 1997. The engineering staff

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initiated a PR (No. 97.2440, dated 7/30/97) to identify tne apparent untirrely resolution of this outstanding ORC comment on SE No. 208 The team deterrnined that until recently, operability evaluations were prepared in accordance with Nuclear Engineering Department Work Instruction (NEDWI) 39 As a result of implementing concerns identified by the engineering staff (reference PR 97.1795) and a OA report which identified various weaknesses in NEDWI 395 involving tracking and timeliness of final resolution, this procedure was replaced by NESG 16.04, " Preparing Engineering Evaluations for input to Operability Determinations". Team review of the identified weaknesses with NEDWI 395 and the new NESG 10.04 guidance determined that NESG 10.04 adequately addressed the previous programmatic concerns. Further review by the team noted that NESG 10.04 requires a NOP83ES, Exhibit 4, " Preliminary Evaluation Checklist" for each operability evaluation completed. The team observed that there appears to be an inconsistency between NESG 10.04 and N0P83E5 because NOP83E5 does not recognize conditions for which a 50.59 evaluation may not be applicable. [ Previous NRC Inspection follow item 96 08 01 focused on NOP 83E5 adequacy and also remains open. NOP 83E5 had not addressed the need to do a preliminary safety review for degraded conditions.) The Nuclear Engineering Services Group manager acknowledged this observation and took action to address i c. Conclusions Operability evaluations were generally of good quality with reasonable basis for their conclusions. The operability evaluations and follow up actions were timely, with one minor exception noted in a procedural inconsistency. The licensee has implemented a new procedure (NESG 16.04) to ensure that all operability evaluations are properly logged, prioritized, and tracked to a timely resolutio .4 Operating Experience Review (OER) Program

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a. inspection Scone (40500)

The team reviewed nuclear organization procedure, NOP8401, " Operating Experience Review Program," and interviewed the responsible OER coordinator regarding the OER program implementation, in addition, the team reviewed selected industry operational experience reports to ensure that they had been evaluated and corrective actions developed to correct any potential weaknesses or vulnerabilities

that could result in similar events at the site, b. Observations arid Findinas The Operations Support Team maintains technical control of the OER process. All industry operating experience information is forwarded to the OER coordinator who enters each item into the licensee's integrated action item data base (IADB) for trucking purposes. The OER program includes industry, INPO, and NRC items (excluding NRC bulletins and generic letters).

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The OER coordinator screens each OER and generates an action item (AI) to perform an evaluation and identify necessary corrective actions for those items that appear to be applicable to the site. Evaluation due dates are typically 60 days from the issuance of the Al and remain open until the evaluation and allidentified corrective actions are completed. The team noted an OER coordinator initiative ( " Operating Experience News Letter")in evidence at the site. The news letter is sent to selected groups on various OERs approximately once every two/three week Each month an OER report is generated for management rev;ew that identifies new itemo received, the number of items that remaining open and those overdue. To date,109 OERs remain open; 15 of which are over one year ol The team reviewed an IADB sort and verified that all of the 1996 and 1997 NRC information notices (ins) were entered into the IADB and were being tracked. A review of the data revealsd that ins were being reviewed and evaluated even if the IN was not specifically addressed to a bollitig water reacto The team reviewed the evaluations for NRC ins 96 27,96 60,97<02, and 97 08 to assess the thoroughness of the licensee's review and effectiveness of tracking identified corrective action. The team determined that the ins were properly dispositioned, and the identified corrective actions were captured and being tracked by the IAD c. Conclusions The team concluded that the OER program appears to be effectively implemented at the plant. The review of selected NRC Information Notices demonstrated good -

implementation of industry lessons learne .5 Review of Common Cause Analyses a. insoection Scoos (40500)

The team reviewed available trend analyses performed by the licensee to assess the effectiveness of this mansgement toolin identifying problem areas and/or adverse performance trends, b. _Qbservations and Findinas The team observed that the new PR Process, implemented in January 1997, has significantly enhanced the availability of data for trend analysis. Each PR processed undergoes an apparent cause, direct cause, or detailed root cause analysis, depending upon the significance of the problem (SCAO or non SCAQ), to determine the appropriate corrective action. The determined cause is then further defined as either organizational or programmatic failures, and/or human error / inappropriate actions using a human performance investigation (HPI) methodology. Following

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assignment of cause, this information is entered into the IADB for subsequent analysi Per procedure 1.3.121, the Operations Support Team (OST) manager shall perform a common cause analysis approximately every six months. The team reviewed Common Cause Analyses (CCAs) #1 and #2 which covered the periods of June 1, 1995 to June 1,1996, and July 1,1996 to January 12,1997, respectively. Both of these CCAs were based upon utilization of data derived from the pre January 1997 PR process. Accordingly, these causal factor analyses were of limited value for Identifying a performance trend over a period of time. However, the licensee was able to validate the leading area of concern being procedural quality, adherence, and processing. CCA #1 also concluded that, because of the old PR threshold, the overall number of human performance inappropriate actions documented was below " expected industry averages and performance indicators."

Discussions with the OST manager and Independent Oversight Team (IOT) manager validated the team's observation that the CCAs and monthly performance trending by the IOT were limited, principally because of the relatively short period of time (6 months) that the new PR trending data has been collected. However, these early analyses do appear to provide a good baseline for further comparison and performance trending in future month The team noted that the Quality Assurance Group (OAG) identified via a recent audit (Audit Report 97 03, dated July 8,1997) that no clear guidance for consistency had been developed for the performance of CCAs. The team viewed this as a good finding. Thmugh discussions with the OST, the team learned that efforts were underway to establish CCA procedural guidance, now that experience had been gained with using the available data and recommended data sorts for -

developing CCAs #1, #2, and # Conclusions The performance data entry and analysis processes have been established and demonstrated, and baseline common cause analyses have been successfully performed. This was an improvement since the previous 40500 inspectio However, performance trending by the licensee remains limited. The licensee recognizes the need for further guidance and experience in this area,in order to derive further benefit and performance trending insights. The limited analysis does reflect that procedural quality and use problems remain the principle human performance concern on sit .0 OVERSIGHT GROUPS The team reviewed requirements established by the Technical Specifications (TSs), the Updated Final Safety Analysis Report (UFSAR), administrative procedures, and other

. relevant licensee documents associated with Pilgrim Station oversight groups,

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4 Onsite Review Committee (ORC) inspection Scone (40500)

l' The team reviewed a sample of the 1996 and 1997 ORC meeting minutes, attended the monthly ORC meeting on July 30,1997, and interviewed the ORC Chairman to l determine if the ORC was functioning in accordance with license requirements.

" Observations and Findinas j A review of ORC meeting minutes revealed that ORC meetings were held ar necessary to support plant operation. Ovm 30 ORC meetings have been held since

January 1997. A quorum was present, with one member holding a Senior Operating License at the unit, as reflected in the selected meeting minutes reviewed. The meeting minutes indicated a good questioning attitude by ORC i members, as exemplilled by the rejection of safety evaluation No. 2989 discussed i in section 2.0 of this repor The issues discussed during the monthly ORC mooting observed by the team included: procedures, monthly operations report, problem report and corrective action status report, summary of surveillance and audit reports to ORC, and operating experience reports. The agenda, with accompanying documentation, was issued to ORC members approximately a week in advance to allow for committee member review. During the meeting, ORC members questioned the presenters on:

procedure changes to ensure they had a proper understanding of the change; what was being done for recurrent instrumentation problems that the plant was experiencing; and reviewed the more significant operating experiences that +

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potentially apply to the site, , Conclusions Based upon the limited Onsite Review Committee (ORC) meeting observations, documentation review, and interviews, it appeared that the ORC safety oversight functions were being appropriately satisfied. The ORC members exhibited a questioning attitud .2 Nuclear Safety Review and Audit Committee (NSRAC) Insoection Scooe (40500)

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The team examined station oversight functions implemented by the NSRAC as reflected in their meeting minutes. While the team was not able to observe a NSRAC meeting, it did interview several committee members and discussed follo up questions from the team's review of the three most recent NSRAC meeting

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' Observa11gns and Fin @ngji The NSRAC is briefed during scheduled meetings by each of the plant groups (operations, Quality Assurance, engineering, regulatory affairs, and training) on major activities and recent plant activities. Quarterly Reports are prepared by each plant group for NSRAC meetings and were found by the team to provide a good overview of plant status and activities. Based on these reports and other input, the NSRAC has identified a number of plant performance issues. To track these issues

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to resolution, the NSRAC has their own concerns / action items tracking system. The team learned that when a concern / action item is identified it is provided to the Senior Vice President Nuclear (SVPN) for resolution. The SVPN then assigns the NSRAC concern to the appropriate group manager (s) for actio The team reviewed two NSRAC items that were similar to the concerns identified by this team and the resident inspectors involving trend analysis and operating work-arounds, With respect to weaknesses in the area of trend analysis, the NSRAC observed that organizational performance, functional shortcomings, concerns, and deficiencies are not easily discerned due to incomplete trending and assessment of

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the information available to the organization. As a result, effective corrective action may not be taken. For example, NSRAC stated that while QA has established comprehensive surveillance and audit programs, how the data generated by these processes was trended, assessed, and communicated to the organization for

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improvement was not clear. In response to this NSRAC observation, the plant formulated a preliminary plan of action which willinclude several ac.tlons for trending SCAO's versus time, age, and open corrective actions, significant persorinel error rate, human performance ratio, total personnel error rate and problem recurrence. This trending will be done monthly and the trend report will include a list of SCAQs which are older than 45 days and SCAQs issued in the last mont NSRAC review of an NRC v:olation regarding operating work arounds con:luded that this issue needed a harder look by management, as there may be a larger population of long standing, unidentified, and unauthorized plant modification NSRAC noted that the configuration management program may be ineffective in identifying this type of issue. As a consequence, the plant has modified their training program to heighten the sensitivity of the operations personnel to identify work arounds that may be embedded in both routine and abnormal procedures, in addition, the operations department hac formed teams to review all routine and abnormal operations procedures for operating work around conditions by the end of the yea Conclusions Nuclear Safety Review and Audit Committee appears to provide adequate oversight of the facility. As demonstrated by the above, the NSRAC discussions are comprehensive and usually provide in depth discussion of current plant issues and concerns with a good questioning attitude Based on this inspection, the team

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determined that NSRAC provides an objective look and oversight of the plant and that the plant acts on the concerns identified by NSRA .0 SELF ASSESSMENTS Review of Quality Assurance Audits and Surveillance Activities Backaround and Inspection Scone (40509)

The team examined the Quality Assurance Group (QAG) activities involving program audits and surveillance reviews to assess their effectiveness. BECo recently implemented an amendment to their Technica! Specifications (TS Amendment N , dated November 12,1996) which removed the specific audit requirements from TS section 6.5.B and transferred them to the Boston Edison Quality Assurance Manual (BEQAM). In addition, Amendment No.168 significantly revised BECo's l audit requirements to permit annual program reviews in lieu of audits in certain

. areas, Observations and Findinas The team examined BEQAM section 18, " Audits", revision 30, dated January 8, 1997, and the 1997 QAG Audit and Program Review Schedule, dated January 9,-

1997. The four most recent audit reports were also examined, including: Audit Report No. 9612,." Access Authorization Program;" No. 97 01, " Fitness for Duty (FFD) Program;" No. 97 02, " Station Security Program;" and No. 97 03, " Corrective Action Program." Audits performed, to date, were consistent with the audit

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schedule. The audits appeared to be comprehensive with a number of good findings (appropriately characterized as Deficiency Reports of Problem Reports), and areas identified for possible improvement (appropriately characterized as Recommendation Reports).

The team's review of Audit No. 97 03, " Corrective Action program," complett.d on July 8,1997, identified areas of concern cor,sistent with some of tnis team's independently developed inspection findings and observations. For exampic the Problem Report (PR) reporting threshold was viewed as low and, therefore, contributing to improved problem identification. The OAO found the effectiveness of current trend analysis " hampered by a lack of procedural guidance." The auditors also identified an item of procedural nonadherence. On balance, this audit was considered effective in providing performance feedback to the station on their implementation of the new PR proces Team follow up of a QAG trend analysis observation during the previous NRC 40500 inspection (Inspection Report No. 96 80) determined that the associated Deficiency Report (DR No. 2072, dated January 12,1996) was still open. As previously documented, this DR identified that both the line organization and the QA Group were not implementing effective trending programs to detect and report adverse performance trends. Discussions with the responsible QAG managers identified that DR No. 2072 remains open, in QAG management's judgement,

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neither the line organization's new PR process not the OAG's newly instituted audit and surveillance report coding / tracking matrix has sufficiently demonstrated (for a sustained period of time) valuable station performance trending, other than a baseline analysis. The team viewed the timeliness of the licensee's resolution of DR No. 2072 appropriato, due to the complexity of revamping the PR process and developing a reliable, accurate, and easily accessible data base to do trend analysis with. The team noted that, in spite of the absence of a fully developed trend enalysis capability, QAG audits were stillidentifying repetitive findings (reference Audit No. 97 02) which were appropriately forwarded to line management for follow up. Thai audit preparation checklist still obligates the audit team to examine previous findings in the focus area and to follow up on corrective actions effectiveness, Conclusion _n The team found that QA Audits appear to be effective in identifying problem areas and providing performance feedback. Review of recent audit reports indicated that, in spite of the lack of established trend analysis, repetitive findings were still being l identified and properly characterized for corrective action. The team noted repetitive findings and ongomg issues with procedurai quality and prope, use but also noted some signs of improvement as the licensee nears completion of their corrective actions, in light of this and the findings below, the team concluded the line management and oversight group were not completely effective in substantially improving performance in the area of procedure quality and us .2 Review of Departmental Self Assessments a, jn11mption Scone (40500)

Tht, toam examined selected riepartment self assessments to evaluate the quakty of these assessments and to assess how self criticalline management was of their own department's performance, Observations and Findjngs The team reviewed the following self assessments performed in accordance with the guidance document NOP90A4, "Self Assessments Program":

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Plant Group's 4th Quarter Self Assessment, dated January 21,1997

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Regulatory Relations Group Self Assessment 96-4, dated January 15,1997

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1997 2nd Quarter Maintenance & Projects Self Assessment, dated July 21, 1997

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Independent Oversight Team Self Atisessment, dated July 8,1997

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2nd Quarter 1997 Chemistry Department Management Level Self-Assessment, dated July 15,1997

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Operations Self Assessment,1st/2nd Ouarter 1997, dated July 3,1997

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Cross Functional Self Assessment Report 97 02, Regulatory Correspondence, dated July 15, '99 _ _ _ _ _ . _ . _ . _ . _ _ _ _ _ _ _ . _

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in general, the team found the above listed self assessments to be reasonably self-critical and thorough in their examination of the targeted areas. Recommendations ,

for improvement were considered appropriate and problems were generally captured

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by a written Problem Report (PR). The team noted that both the Maintenance and Radiation Protection departments maintain their own " action item" tracking ,

programs for follow up of self assessment findings and recommendations which did !

not achieve a PR or Recommenoation Report (RR) threshold. Both of these tracking systems appeared to be actively used and the targeted completion dates for individual items appeared reasonable. Other departments (Operations and Nuclear Engineering Services) were observed to utilize the IADB system for tracking " action items" and recommendations for improvemen c. Conclusions The team concluded that the department self assessment program appeared to have ;

been appropriately implemented. A sampling of recontly completed assessments found them to be reasonably self critical and the findings appropriately categorized and formally tracked for follow up by the cognizant department staf .3 Review of Independent Oversight Team a. l_nsoection Scope (40500)

In response to the previous 40500 team inspection findings (reference inspection report 50 293/96 80, dated April 16,1996) the BECo developed a multifaceted corrective action plan to address the areas of procedure quality and proper use, root cause analysis training, and performance monitoring and trending. To independently

assess and assist line managers in the area of performance monitoring and trending, BECo formed the independent Oversight Team (IOT). The IOT was designed to provide independent review of self assessments, root cause analyses, human performance corrective actions, and other internal and external data, as appropriat The LOT was also chartered with developing potential leading indicators, identifying common causal factors, and assessing corrective action effectiveness to provent recurrence. The 40500 team conducted a review of the IOT activities to assess their effectiveness in providing independent performance monitoring and trending, ,

, Observations and Findinas The team reviewed LOT Work Instruction IOTWl.001, dated July 15,1996,and identified that the work instruction estabilshed clear guidelines for the organization, responsibilities, and training of the IOT. These guidelines were found to be consistent with BECo's commitment to the NRC as ctated in their June 17,1996, response to the 40500 team Inspection Report 96 80. The team also reviewed the Pilgrim Nuclear Power Station Monthly Human Performance Trend Reports for the months of December 1996 through June 1997, which were prepared by the IO . - - . _ - - - _ _ -

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The team's review of the monthly trend reports for December 1996 through June 1997 identified that three principle areas were routinely discussed: assessment of i performance for the month; graphs of station self improvement performance ratio;

) and a summary listing of Problem Reports (sorted by event type, work process, and l key activity). The team noted that only the May and June 1997 monthly reports provided recommendations to address the IOT assessed trends, and that the j primary input to all of the monthly reports appeared to be problem reports and

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additional analysis of the completed Common Cause Analyses performed by the Operations Sepport Organization. The IOT monthly reports were found by the team j to not provide a summary of the activities that were reviewed, problems noted, or j

proposed correctiva ect'ons by the IOT, as stated in section 5.1 of IOTWl.001. The team identified that the mv..% trend repr'rts, to date, summarized only a small

fraction of the procedurally requires aulvities to have been assessed by the IOT and

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categorized in lOTWl.001 as IOT responsibilitie '

Team follow up with the IOT manager determined that some of the additionally i

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prescribed activities were being done (i.e., overview of the Training Department's human performance assessment of the February 15,1997 scram; follow up of j NSRAC question on the station's Corrective Action Process; and review of 1996 RP

Self Assessments). However, the IOT Manager indicated that frequently these efforts were not being formally tracked, and not reported upon in the monthly reports. In addition, the IOT manager offered that the quarterly executive 4 summaries described in IOTWl.001, section 7.2, were not reported on a quarterly i basis, but rather included in the monthly LOT reports. The team verified that each

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monthly report contained an executive summary, however, it consisted of two

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"boilerplate" paragraphs with a third table of content like paragraph. The failure of

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the IOT to provide a monthly or quarterly report summarizing the activities that were

reviewed, problems noted, and corrective action recommendations was contrary to lOTWl.001, " Independent Oversight Team Work Instruction," revision 0, dated July

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15,1996. This was the third example of failure to follow corrective action s procedures and is a violation of 10 CFR 50, Appendix B, Criterion V and XVI. (VIO

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97 80 01).

Also, the team examined the Performance Evaluation Program (IOTWl.002) and the

, First and Second Quarter 1997 reports. IOTW1.002 is the guideline for the

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Performance Evaluation Program which has the stated purpose to improve and strengthen the behaviors and competencies of all Nuclear Business Unit Personnel and improve overall station performance by providing oversight and reinforcement of desired performance levels during selected work activities." The Program is administered by the IOT Manager and is simply a tool to capture management observations "in the field" via a standardized checklist which covers 22 broad areas and associated personnel performance attributes. The IOT Manager collects the observations and documents any apparent trends os performance assessments derived from the collective examination of the observations for the calendar quarte The team found the Program to be reasonably structured and the individual area / activity checklists to be a helpful observation recording too .

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Team review of the two Quarterly Reports identified that both reports summarized the overall observation program as having been effective. However, both the reports subsequently qualified this assessment by stating that there is limited management participation (< 50% of station management participated in the second quarter). The team noted that these quarterly assessments were duplicated in the LOT's July 8,1997 self assessment repor The quarterly reports did summarize and assess collectively, those observations in selected areas (i.e., control room practices; radiological protective practices; housekeeping and material condition). The team noted that two of the  ;

approxin.ately 140 observations conducted in the second quarter 1997 resulted in '

Problem Reports. No formal follow up actions were generated (prs or Recommendation Reports) as a result of the two 1997 quarterly reports. but both reports receive broad management level distributio ,

c. Conclusleng The Independent Oversight Team (IOT) was providing limited self assessment and feedback to the line managers and staff Consequently, this management level corrective action process, developed in response to a previously identified weakness in the area of independent oversight, was not demonstrated to be effective. IOT .

performance was found to be contrary to procedure Also, implementation of the Performance Evaluation Program (the formal management observation tu orting process) appeared to fall short of senior BECo management expectations br the program, in terms of management participation and substantive actions to improve performance at the statio .0 REVIEW OF THE NUCl. EAR SAFETY CONCERNS PROGRAM (NSCP)  : Backaround and Insoettion Scoos (40500)

The team used the guidance provided in Inspection Procedure (IP) 40500 and IP 40001, " Resolution of Employee Concerns," to conduct a reviow of BECo's NSC The team's review included interviews with the current and former NSCP administrators, an interview with a concernee whose case was still active, interviews with 26 BECo employees ranging from the Senior Vice President Nuclear to engineers, technicians, operators and a detailed review of the program implementing procedures, documentation, and file The Nuclear Safety Concerns Program is governed by Nuclear Organization Proceduru NOP93A2, revision 1, dated July 1,1997. It applies both to Boston Edison and contractor personnel, Observations and Findinas The 26 interviews of technical and management staff identified that the NSCP was viewed as a necessary and important company program used to resolve nuclear

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safety concerns that cannot be successfully resolved through the Problem Reporting process. NSCP was believed to have high level management endorsement and support, believed to be anonymous and confidential, if desired, and believed that neither overt nor covert retaliation would be tolerated, if use The team determined from a records review that the following numbers of nuclear safety concerns (NSCs) have been filed: 1994 (first year NSCP implemented) 6 NSCs; 1995 - 0 NSCs; 1996 1 NSC; and 1997 (to date) 2 NSCs. The team's initial attempt to review the two 1997 NSCs was foiled due to the poorly maintained and incomplete files established for these NSCs. Prior to the conclusion of the team's onsite inspection, the files were organized, updated, and presented as complete to the team for auditing. Review of NSC 97 01 identified that some of the examples illustrating the concernee's problem may not have been appropriately captured for follow up via the NSCP Review of NSC 97 02 identified that the concern was incorrectly categorized as non safety related. Nonetheless, the concern was entered into the NSCP for revie The team learned that based upon the one concern filed in 1996, BECo requested that an independent assessment of the NSCP program be conducted (refereace Independent Assessment of Safety Related Management Attitudes and Processes at Pilgrim Nuclear Power Station, dated 10/18/96). This independent assessment concluded that: there was no evidence of production pressures in resolving engineering design problems via analysis; the NSCP program was not effective and needed to be revamped; technical responses prepared by the NSCP did not adequately answer the questions raised; training of the professional staff was needed in the area of engineering analysis, design margin, and calculational conservatism; the PR process was not as effective as it should be; and a differing professional opinion process should be established. The NRC team determined that each of these condusions was responded to by BECo in a memorandum to file by the current NSCP administrator. BECo did make changes to the NSCP p.ocess and, as discussed previously, revised the PR process, in addition, the Chief Radiological Scientist was assigned the duty of NSCP manage However, team review of NOP93A2 and Procedure No.1.3.77, " Unescorted Access Termination Transfer Process," identified a number of weaknesses which may undermine concernee confidentiality and the proper execution of the NSC The team's observations in this area follow:

- Procedure No.1.3.77 acknowledges NOP93A2 and states that the NSCP affords departing employees the opportunity to discuss nuclear safety conecms, anonymously if desired. item 8 of the termination checklist states,

"If applicable, Nuclear Safety Concerns Program interview with Program Manager completed on . (Required only if employee indicates that bri/she has any nuclear safety concern (s))." The team noted that if the date is filled in on the form, in which the employee's name appears, confidentiality / anonymity may be compromise _ _ . . _ .- _ -. .. . _ . . - _ - . . ._ . .

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The Employee Exit Questionnaire, Question #15 states, "Do you have any

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nuclear safety concerns? (If yes, you should notify the Nuclear Safety Concerns Manager and request a confident'al interview)." The team noted that if this question is answered "yes" on the form, in which the employee's narne appears, confidentiality /ancnymity r.1ay be compromised. Secondly, no guidance is provided in 1.3.77 for how the NSCPM is contacted if the

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question is answered "yes".

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Section 4.0 of NOP93A2 defines the responsibilities of both the Nuclear Program Manager (NPM) (also called Nuclear Safety Concerns Program Manager in other parts of the procedure) and the Nuclear Safety Concerns Program Administrator (NSCPA). Currently, both functions are being carried out by the same perso NOP93A2 states that ' validated etncarns should be responded to within 45 working days of receipt by the NSCPA." A review of the files indicated that three of the nine cases received an initial " response" within 45 days, two were longer than 45 days, and a response could not be determined for four NSC Section 6.2 of NOP93A2 discusses a Nuclear Safety Concerns Nntification Form (NSCNF). However, the team found no such forms in the procedure exhibits. NOP93A2 states that the NSCNF may be used for rer orting concerns. However, NOP93A2 also states that concerns received via both telephone reporting and interviews with the NSCPA shall be documented on the NSCNF. Three of nine NSCs did not have an accompanying NSCN Section 6.3 of NOP93A2 states that the NSCPA shall document the concern on the Nuclear Safety Concerns Notification Log (NSCNL) or similar computer generated log. Neither was in evidence in the files. Further, the NSCNL is i.'cluded as Exhibit 2, but the NOP93A2 provides no explanation of the in?ormation to be logged under the various column headings and neither the current nor former NSCPA could provide a complete explanatio Section 6.8 of NOP93A2 states thu the NSCPA will provide a response to

, the initiator describing the methods used to address the concern and the results of the investigation. The records on several concerns do not clearly

identdy this closeout informatio c. Conclusions Based upon the licensee's response to their independent assessment of the Nuclear Safety Concerns Program (NSCP) and the team's observations, coirective actions initiated for the identified NSCP implementation problems have not been fully effective. Procedure quality and use problems resulted in a lack of NSCP effectiveness as an alternative means available to BECo employees or contractors for reporting safety concern . - .- .

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] REVIEW OF FSAR COMMITMENTS

A recent discovery of a licensee operat og its facility in a manner contrary to the UFSAR 1

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description highlighted the need for a special focused review that cor.1 pares plant practices,  ;

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q proceduret, and parameters to the UFSAR description. While performing the inspections

] discussed in this report, the inspectors reviewed the applicable portions of the UFSAR that j related to tha areas inspected.

, MANAGEMENT MEETINGS i

l Meetings were held periodically with BECo management during this inspection to discuss

inspection findings. A summary of preliminary findings was also discussed at the

conclusion of the on site inspection on August 1,1997. No proprietary information was identified as being included in this report.

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INSPECTION PROCEDURES USED 40500 Effectiveness of Licensee Controls in Identifying, Resolving, and Preventing Problems 71707 Plant Operations (TEMS OPENED AND CLOSED OPEN/ UPDATED VIO 97 80 01 Failure to follow procedure, three examples (Section 2.1.b,4.3.b)

IFl 96 08-01 Procedure quality of safety review (Section 2.3)

pat:TIAL LIST OF PERSONS CONTACTED E. Boulette, Senior VP . Nuclear C. Goddard, Plant Manager N. Desmond, Regulatory Relations Manager T. Sullivan, Training Manager W. Rigg, Nuclear Services Group Manager M. Jacobs, Operations Manager J. Keene, Regulatory Affairs Depertment Manager T. Sowdon, Chief Scientist J. Gerety, Nuclear Engineering Services Group Manager H. Oheim, General Manager, Technical Support S. Wollman, Operations Support Team Leader W. Dicroce, Maintenance and Projects Manager S. Landahl, Radiation Protection Manager J. Alexander, Quality Assurance Manager W. Stone, independent Oversight Team Leader i

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. 22 e LIST OF ACRONYMS USED

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TS Technical Specifications

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RCA Root Cause Analysis

SCAO Significant Condition Adverse to Quality lADB Integrated Action Data Base i NESG Nuclear Engineering Services Group ORC Onsite Review Committee

NSRAC Nuclear Safety Review and Audit Committee QA Quality Assurance OAG Ouality Assurance Group

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IOT Independent Oversight Team NSCP Nuclear Safety Concerns Program 1- OST Operations Support Team

. PR Problem Report i NUORG Nuclear Organization l ODM Operations Department Manager 1 CARB Corrective Action Review Board

HPl Human Performance Investigation ( RPV Reactor Pressure Vessel i

INPO Institute of Nuclear Power Operations

i RR Recommendction Report NOP Nuclear Operating Procedure

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SE Sab:y Evaluation PCT Peak Clad Temperature

? LPCI Low Pres.: .e C solant Injection OER Operatin g twecace Review IN Informatior, hotice CCA Common Cause Analysis UFSAR Updated Final Safety Analysis Report BEQAM Boston Edison Quality Assurance Manual

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