ML20244A802

SALP Rept 50-312/88-39 for July 1986 - Dec 1988

ML20244A802
Person / Time
Site:	Rancho Seco
Issue date:	03/28/1989
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML20244A790	List: IR 05000312/1988039 ML20244A788 ML20244A802
References
50-312-88-39, NUDOCS 8904180195
Download: ML20244A802 (41)

See also: IR 05000312/1988039

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H SALP BOARD REPORT i

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l' U.-S.' NUCLE R REGULATORY COMMISSION

REGION V

SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE.-

, 50-312/88-39

SACRAMENTO MUNICIPAL' UTILITIES DISTRICT

-RANCHO SECO NUCLEAR CENERATING STATION

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JULY 1, 1986 THROUGH DECEMBER 31, 1988

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TABLE OF CONTENTS

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Page j

I. Introduction 1

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A.. Licensee Activities 1

B. ' Direct Inspection and Review Activities 2

.II. Summary of Results 2

A. Effectiveness of Licensee Management. 2

D. -Results of Board Assessment 3

j < C. Changes in.SALP Ratings 4

III.' Criteria 4

IV.*-Performance Analysis 5.

A. Plant Operations 5'

3. Radiological Controls 9

C. Maintenance / Surveillance' 13

D.. Emergency' Preparedness 15

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E. Sec.urity 16

F. " Engineering / Technical. Support 19

G. Safety Assessment / Quality Verification 21

H. Startup Testing 24

.V. Supporting Data and Summaries 25

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A. Enforcement Activity '

.? B. Confirmation of Action Letters 26

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C. AEOD Events Analysis: 26'

Detailed Description of Licensee Activities

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., Table 1 - Inspection Activities and Enforcement Summary 19 i

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Table.2 - Enforcement Items 30'. ,

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? Table 3 - Synopsis of Licensee Event Reports 34 a

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y . ~A t tachment 1 - AEOD Review of Licensee Event Reports 35

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I. INTRODUCTION

The Systematic Assessment of Licensee Performance (SALP) is an NRC staff

integrated effort to collect available observations and data on a

periodic basis and evaluate licensee's performance based on this

information. The program is suppleetntal to normal regulatory processes

used to ensure compliance with NRC rules and regulations. It is intended

to be sufficiently diagnostic to provide a rational basis for allocating

NRC resources and to provide meaningful feedback to the licensee's  ;

management regarding the NRC's assessment of their facility's performance

in each functional area.

An NRC SALP' Board, composed of the members listed belou, met in the

Region V office on February 2, 1989, to review observations and data on

the licensee's performance in accordance with NRC Manual Chapter 0515,

" Systematic Assessment of Licensee Performance," dated June 6, 1988. The

Board's findings and recommendations were forwarded to the NRC Regional

Administrator for approval and issuance.

This report is the NRC's assessment of the licensee's safety performance  !

at Rancho Seco for the period JuJy 1, 1986 through December 31, 1988. 1

)

The SALP Board for Rancho Seco was composed of: ,

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• • A. E. Chaffee, Acting Directar, Division of Reactor Safety and Projects,  !

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Region V (Board Chairman)

• • G. W. Knighton, Director, Project Directorate V, NRR

• • G. P. Yuhas, Chief, Emergency Preparedness and Radiological Protection

Branch

• H. S. North, Acting Chief, Facilities Radiological Protection Section

• M. D. Schuster, Chief, Safeguards Section

• R. Fish,. Chief, Emergency Preparedness Section

• • L. F. Miller Jr., Chief, Reactor ProjectsSection II

• • R. P. Zimmerman, Reactor Projects Branch

• • G. Kalman, NRR Project Manager

• • T. D'Angelo, Senior Resident Inspector

• • W. P. Ang, Project Inspector

• C. Pendergast, Emergency Preparedness Analyst

• D. Schaefer, Safeguards Inspector

• n. Pate, Chief, Nuclear Materials Safety and Safeguards Branch

• • Denotes voting member in all functional areas.

A. Licensee Activities

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Rancho Seco was in an extended shutdown outage from the start of the

evaluation period until March 30, 1988. After being granted

Commission approval, a gradual approach to full power commenced with l

plant startup on March 30, 1988 until the end of the evaluaticn l

period. The gradual approach to full power included a rigorous

power acension test program. In general, Rancho Seco operated

satisfactorily from March 30, 1988 through December 31, 1908. A

detailed discussion of the significant occurrences during the period

is provided in Section V.D of this report.

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B. Direct Inspection and Review Activities

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Approximately 15,427.on-site inspection hours were spent in

performing a total of 100 inspections by resident, region-based,

headquarters, and contract personnel. Inspection activity in each

functional area is summarized in Table 1.

The unusually large number of-inspection hours was a result of the

extended SALP interval and a large inspection program prior to

restart on March 30, 1988.

II. SUMMARY OF RESJLTS

A. Effectiveness of Licensee Management

The licensee's management organization stabilized somewhat in mid-

1987 with the appointment of a Chief Executive Officer (CEO),

Nuclear on May 4,1987, and the formation of a new organizational

structure. Subsequent to restart, on June 16, 1988, a new CEO,

Nuclear was appointed, and the organization's subordinate managers

have changed assignments, in some cases, as well.

During this SALP period SMUD senior management initiated several

major programs for improvement of Ranche Seco performance. These

included:

An Action Plan for Performance Improvement

A Systems Review and Test Program

An Engineering Action Plan

A Procurement Action Plan

Installation and Testing of a Safety Grade Emergency Feedwater

Initiation and Control System

Installation and Testing of Two Additional Emergency Diesel

Generators

The improvements undertaken by management are reflected in the

improved SALP ratings. However, numerous tasks remain to be

completed by the current management to improve plant reliability.

Included in these are commitments to the NRC such as the

establishment of design basis documents, and an effective

engineering oversight. The need for increased involvement by the

current senior plant management in important plant evolutions was

evidenced by the December 12, 1988 feedwater transient. This senior

management involvement should be in sufficient detail to assure

greater caution and a more thorough understanding of plant

activities. Management attention needs to be focused on assuring

plant standards for performance established by the startup and test

program for testing are not relaxed as was evident by the auxiliary

feedwater overpressure event which occurred after the SALP period.

B. Results of Board Assessment

The SALP period was unusually long (July 1986 to December 1988) and

covered a period of plant operationc that was characterized by

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f severalchangesinplantmanagementandorganizationandCby'[iverse ,

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plant evolutions. associated with SMUD attempts to upgrade. Rancho

Seco following an NRC imposed plant shutdown on December 26, 1985.:

The plant restarted in March 1988 and commenced a power. ascension

program which was completed in December 1988. .This SALP focused on

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post-restart operations and on the current management and staff.

Discussions of pre-restart' evolutions and performances are included

when these events appeared relevent to the evaluation of currently.-

existing plant conditions and personnel;

- Overall, the SALP . Board found the performance of NRC licer.aed

activities by the licensee to.be acceptable and directed toward safe

operation of Rancho Seco. The SALP Board has made specific

-recommendations in most functional areas for licensee l management

consideration. The results of the Board's assessment of the

licensee's performance in each functional area, including the

previous assessments, are as follows:

Rating Rating

Last This

Functional Area * Period Period ' Trend **

A. Plant Operations 3 2

B...

Radiological Controls- 3 2

C. Maintenance / Surveillance 3/2 2

.D. Emergency Preparedness 3 2 Improving.

E.- . Security 3 2

F. Engineering / Technical Support 2 2

G. Safety Assessment / Quality 3- 2

'H. Startup Testing Not Rated 1

• Maintenance.and Surveillance were separate functional. areas

duringfthe last SALP period. Safety Assessment / Quality

Verification is a new functional area this period. . It is

similar to, but more comprehensive-than, the Quality Programs

and Administrative Controls Affecting Safety functional area

which it replaced. Other functional areas rated separately

during the last SALP period, such as.. Fire Protection and

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Training, were evaluated as appropriate within the scope of the

functional areas listed cbove.

• • The trend indicates the SALP Board's appraisal of the

licensee's direction of performance in a functional area near

i the close of the assessment period such that continuation'of

this trend may result in a change-in performance level.

Determination of the performance trend is made selectively and

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is rest.rved for those instances when it is necessary to . focus

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2 NRC and licensee attention on an area with a declining

performance trend, or to acknowledge an improving trend in

,- licensee performance. It is not necessarily a comparison of

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performance daring the current period with that in the previous

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period.

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C. Changes in SALP Ratings

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Performance during this SALP period has' improved from.that of the

previous SALP period. These improvements occurredsbecause major

changes were made to equipment, personnel, and programs during the

extended shutdown. Satisfactory accomplishment of these changes was

indicated by the Nuclear Regulatory Commission's approval of' plant-

restart on March 22, 1988. The Plant Operations, Radiological

Controls, Maintenance, Emergency Preparedness, Security, and Safety

Assessment and Quality Verification-areas improved from Category 3

to Category 2 ratings.

III. CRITERIA

Licensee performance is assessed in selected functional areas, depending

on whether the facility is in a construction or operational phase.

Functional areas normally represent areas significant to nuclear safety

and the environment. In this evaluation, a special area of Startup

Testing was added due to the large amount of testing which was conducted

by the licensee prior to restart in March, 1988.

The following evaluation criteria were used, as applicable, to assess

each functional area:

1. Assurance of quality, including management involvement and control.

2. Approach to resolution of technical issues from a safety standpoint.

3. Responsiveness to NRC initiatives.

4. Enforcement history.

5. Operational events (including response to, analysis of, reporting

of, and corrective actions for events).

6. Staffing (including management).

7. Effectiveness of the training and qualification program.

However, the NRC is not limited to there criteria and others may have

been used where appropriate.

On the basis of the NRC assessment, each functional area evaluated was

rated according to three performance categories. The definitions of

these performance categories.are as follows:

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Category 1: Licensee management attention and involvement are readily -l

evident and place emphasis on superior performance of nuclear safety or I

safeguards activities, with the resulting performance substantially

exceeding regulatory requirements. Licensee resources are ample and

effectively used so that'a high level of plant and personnel performance .

is being achieved. Reduced NRC attention may be appropriate. l

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Category 2: Licensee management attention to and involvement in the

performance of nuclear-safety or safeguards activities are good. The

licensee has attained a level of performance above that needed to meet

regulatory-requirements. Licensee resources are adequate and reasonably

allocated so that good plant and personnel performance is being achieved.

NRC attention may be maintained at normal levels.

Category 3: Licensee management attent_fon.to and involvement in-the

performance of nuclear safety or safeguards activities are not

sufficient. The licensee's performance'does not significantly exceed

that needed to meet minimal regulatory requirements. Licensee resources

appear to be strained.or not effectively used. NRC attention should be

increased above normal levels.

IV. PERFORMANCE ANALYSIS

The following is the Board's assessment of the licensee's' performance in

each of the functional areas, plus the Board's. conclusions for each area

and its recommendations with respect to licensee actions and management

emphasis.

A. Plant Operations

1. Analysis

During the SALP period, approximately 4029 hours0.0466 days <br />1.119 hours <br />0.00666 weeks <br />0.00153 months <br />'of direct

inspection effort were applied in the Plant Operations area.

Plant Operations has improved significantly during this SALP

period. The most important accomplishments were the improved

professionalism of operators, and the reduction of operator

errors during intricate plant manipulations. Other strengths

were observed such as improved equipment control procedures and

significant upgrading of procedures. However, improved

communication among managers at different levels in the

organization appeared warranted.

Prior to plant restart in early 1988, the licensee began a

performance improvement program designed to enhance the quality

of future plant operations. The program included:

(a) Plant Emergency Operating Procedures were completely

rewritten in accordance with the latest Babcock and Wilcox

and NRC guidance.

(b) The Safety Parameter Display System (SPDS) was added to

enable plant operators to quickly assess critical plant

parameters. The system provided Rancho Seco operators

with a useful, user friendly display and helped them to

respond correctly to transients.

(c) The Technical Specifications (TS) were upgraded in format,

Limiting Conditions for Operation (LCO) were added, and

previously included LCO's were modified to clarify the

i Rancho Seco TS.

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(d) The licensee requested that Rancho Seco be a lead plant in i

adopting the " Improved B&W TS" which are currently being '

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' finalized by Babcock and Wilcox and the NRC. l

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The resident' inspectors observed licensee operation daily,

including random backshift observations. Operations staffing

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was observed to be correct, and operations personnel were

consistently observed to be knowledgeable and attentive to

plant conditions. Control room demeanor was always observed to .l 4

be professional.

One negative observation was that during the event on December i

12, 1988, decision making on the appropriate actions to be

taken was made by operations management without the involvement l

of senior plant management for review. Senior plant management

subsequently recognized this weakness in communications and

decision making and established an action plan to improve in

this area.

Management presence within the plant has steadily increased

following the implementation of the licensee's management

monitoring program. _ Frequent tours of the-power block by all j

levels of plant management were observed by the, resident '

inspectors.

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A weakness existed in the oversight . ole which plant management

performed in its control of the specific plant departments. An ,

example was identified which concerned the progress on near i

term commitments made to the NRC prior to plant restart in

early 1988. The commitments which wece made involved

improvements to the plant which had ';een identified by the

licensee's programs established as a result of the December 26,

1985 event. The inspectors noted that plant management was not  !

knowledgeable of the status of some of the significant  ;

commitments which had been made to improve engineering and

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procurement, in particular. The licensee responded to the

issue in a timely fashion with goals established for the

facility to complete previously identified items.

The licensee's approach to the resolution of operational safety

issues was generally sound. Conservatism was routinely

exhibited by the control room staff when the potential for

safety significant failures existed. During the startup

program, detailed tests such as the Loss of Offsite Power Test,

Emergency Feedwater Initiation and Control System Test and the

Steam Generator Secondary Pressure Test were properly conducted

and performed. These tests used significantly abnormal valve-

lineups of both the electrical and mechanical plant systems.

The December 12, 1988 reactor trip was an exception to this

overall trend. In that event, the licensee kept the reactor

operating despite a double failure in the controls for the

steam supply to the main feedwater pump. Also, the AFW

overpressure event demonstrated weakness in the conduct of post

maintenance testing. q

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Throughout this extended SALP period, the licensee's

responsiveness to NRC initiatives has been rapid and thorough,

particularly prior to the March 30, 1988 restart of Rancho

Seco. This was evidenced by the implementation of several l

major programs resulting from NRC observations or inquiries.

These included:

An Action Plan for Performance Improvement

A Systems Review and Test Program *

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An Engineering Action Plan

A Procurement Action Plan

Installation and Testing of a Safety Grade Emergency

Feedwater Initiation and Control System

Installation and Testing of Two Additional Emergency ,

Diesel Generators (EDG)

Three Severity Level IV violations were issued during.the

assessment period involving the failure to provide reports

required by 10 CFR 50.73. Licensee management satisfactorily

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resolved the deficiencies through clarification of their

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'. procedure for controlling notifications to the NRC. , '

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A total of 36 LER's were submitted in this functional' area.

Most of the LER's were attributable to personnel error. Nine

of these dealt with fire protection discrepancies that

predominately involved missed fire watches. During these

periods extensive modifications.and testing were in process

with the plant in off normal configurations. The remaining

LER's appear to be attributable to weak procedures and isolated

events. Those LERs received additional management attention to

ensure improved performance and procedures. The licensee

developed an Operations Department Action Plan in December 1987

which resulted in improved performance and few LERs since have

related to personnel error or procedural deficiencies.

In the early phases of the test program, a number of

operational errors were committed during testing which

ultimately lead to suspension of testing during the Loss of

Offsite Power tests. In response to the difficulties

experienced at the time, the Operations Department Action Plan

mentioned above was developed. Operator performance since that

time improved considerably with no significant operator errors

being detected.

The licensee conducted an extended power ascension program

which included significant Integrated Control System (ICS)

tuning and two preplanned reactor trips. During this phase,

the control room operators were also challenged by two

unplanned reactor trips, one which led to the reactor coolant

system being on natural circulation. During these events,

performance by the control room personnel was sound and timely

in response to the unexpected plant transients which had l

occurred. In addition, the ICS and main feedwater system

caused several plant transients which were correctly addressed

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by the plant operators who prevented a reactor trip by quickly

identifying the condition and correcting the cause for the

abnormal condition.

The licensed operator training program was effective during the

SALP period. This was evidenced by a high pass rate of 90

percent (9 passes of 10 candidates) on annual requalification

examinations and a 100 percent pass rate (17 out of 17) on the

1987 and the 1988 replacement examinations. The licensee has

started construction of an Engineering and Training Building

during this SALP period with completion (ready for training)

. scheduled for the Summer 1990. Arrival and startup of the site

specific simulator is scheduled for mid-1990. The licensee's

operations staff has remained stable throughout this SALP

period. 'All licensed operator positions are filled and only

one vacancy occurred in the last year.

During this SALP period, the licensee's overall fire protection

program improved. Some deficiencies in fire barriers, fire

alarm systems, fire suppression systems, fire brigade training

and the performance of fire pumps continued; however, both a

plan and resources for' correction of these deficiencies were

established by the licensee.' . Routine and corrective

maintenance activities appeared to be responsive to the need

for safe.and' reliable performance of fire protection systems.

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Conclusion

Performance Assessment - Category 2

Board Recommendations

The-Board recommends that the licensee continue to emphasize

improving communication and decisionmaking among mid and upper

level plant managers. Action should also be taken to enhance

specific plant knowledge among the plant management staff to

improve assessment and recognition of unusual or abnormal plant

conditions.

B. Radiological Controls

1. Analysis

A total of thirteen routine and four special inspections were

conducted by the regional staff during this assessment period

in the areas of organization and management, occupational

radiation safety, radiological effluent control and monitoring,

radioactive waste management, transportation of radioactive

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materials, training and qualifications, and confirmatory

measurements. In addition, the resident inspectors provided

continuing observations in this area.

For the last assessment period, the licensee was assigned a

Category 3 rating. The board had recommended that the licensee

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implement the reorganization of the Chemistry, Radiation.

> : Protection and.the Technical Support group in a timely fashion,

and fill,the vacant Chemistry Superintendent's position'as

- quickly as possible; improve the NRC commitment tracking

system; amend the Technical Specifications to improve the

Radioactive. Environmental Monitoring Program.to' assure

compliance with'10 CFR Part 50, Appendix I; complete the

- installation and testing of the Post Accident Sampling System

(PASS).

There has been significant improvement in management support in

the' radiological controls area. During the beginning of this

assessment period, management was slow in providing the needed

support. However, changes in upper management during the'last

two years'have resulted in increased support and improved

performance. Specific examples include: . implementation of an

effective NRC commitment tracking system; demonstration of an

operable PASS prior to reactor restart (March 1988); revision

of the Technical Specifications and Off-Site Dose Calculations

Manual to improve the Radiological Effluent and Environmental

Monitoring programs, and assure compliance with 10 CFR 50,

Appendix I. The QA organization has been effective in ,

providing independent critical review, particularly, in the

area of the radioactive effluent control and monitoring.

program. Surve111ances conducted by the Corporate Health

Physics and Chemistry Services group have been effective in

identifying deficiencies in the radiation protection and

effluents programs. A monthly management observation program

was instituted which resulted in increased involvement of site

management in plant activities. Weekly supervisory plant

valkdowns have been effective in identifying and correcting

deficiencies and improvement in housekeeping practices.

A continuing concern involved the frequent changes in

management personnel, organization, and assignment of

responsibility for implementation of the radioactive effluent

programs. During the latter part of 1987, the responsibility

for offsite dose calculations was transferred from the

Radiation Protection Department to the Environmental Monitoring

& Emergency Preparedness (EM&EP) Department, with liquid and

gaseous effluent sampling being performed.by Radiation

Protection, and sample counting by Chemistry. On July 15,

1988, responsibility for implementing the effluents program was

transferred to Chemistry. By February 1, 1989, Chemistry will

have responsibility for effluent sampling. The instability

resulting from continuing changes in responsibility for

management of'the effluent programs has inhibited the

establishment of a program with well-developed procedures and

experienced personnel. Due to these changes, the licensee has

not always been timely in responding to and taking corrective

action for deficiencies identified through internal

assessments. During the last month of this assessment period,

the Chemistry group appeared to be aggressively working to

develop an effective program.

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On February 4, 1988, the licensee experienced an event that.

/ resulted in a worker receiving a calculated dose to a small

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area of skin of whole body in excess of the quarterly limit

. from a " Hot Particle." Review of this event indicated a lack'

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of management oversight with respect to communications. .

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training and implementation of the procedures to control hot f

, , particles. Shortly after the incident, management recognized

the seriousness of the problem and took prompt and extensive

- corrective actions to prevent recurrence. The licensee

accelerated implementation of their hot particle program and

completed training of all onsite workers on the hazards and ,

I controls related to hot particles by April, 1988. 1

The licensee resolved most technical issues with appropriate

conservatism, technical competence, and supporting

documentation. This was notably demonstrated in the licensee's

response and corrective actions to the February 4, 1988 hot

particle incident. With respect to the effluents program, in

implementing their new Radiological Effluent Technical

Specifications (RETS), the licensee identified counting times j

required to meet new lower limit of detection (LLD)

requirements for radioactive liquid pre-batch releases and

composite samples that were unattainable for certain gamma

emitting isotopes. The long counting times (about 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />)

resulted in difficulties in making releases in a timely

fashion. It appeared that the licensee had failed to properly

evaluate their capabilities for meeting the LLD values prior to

submission of the request for license amendment. After a more

thorough review of this matter, the licensee submitted a

proposed license amendment changing the LLD for specific ,

radionuclides, without affecting the bases of the LLD values,

thereby reducing the counting times.

The licensee's responsiveness towards resolving the operational i

aspects of the liquid effluent issue has not been fully

satisfactory. While many plans have been presented, NRC j

inspection findings, licensee audits and operational events '

continue to reveal the need for additional management

attention. Changes which would allow operation within the j

envelope of expected events without exceeding 10 CFR 50

Appendix I values should be completed.

During this assessment period, the licensee has been generally

responsive to NRC initiatives and concerns. This included j

implementation of the SALP Board's recommendations from the l

previous assessment, management's continued support of the I

radiation protection program and improvements in facilities and

management of the dry radioactive waste program. Housekeeping ,

has been effective in minimizing contaminated areas. A number  !

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of long outstanding items have been addressed.

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One Severity Level III, nine Severity Level IV, and six

Severity Level V violations were issued during this assessment

period. The Severity Level III violation involved (1) an

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occupationaldosetoaimallareaoftheskinof-the'wholebody

of'a worker t'aat' exceeded the regulatory limit, (2) the-failure

to notify an individual in writing of his exposure,.(3)'a

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failure to properly instruct workers in precautions and

procedures for_ minimizing exposures when working in a " Hot

Particle Zone"', and (4) the failure of certain individuals to

adhere.to procedures for. control.of personnel exposure. An

enforcement conference s was held to discuss the apparent ~

violations and the license'e's corrective actions to prevent-

recurrence. . Based on the' licensee's prompt and extensive

corrective actions to prevent recurrence, a Notice Of Violation

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was issued without it civil penalty. The other violations

identified during:this long assessment period as indicated in

- Table 2,' appeared:to.be isolated occurrences.that did not

indicate a programmatic breakdown in the management of the

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radiological controls program. In addition, prompt and

effective corrective actions were taken to prevent recurrence.

-A' total of 22 LERs were submitted in this functional area.

Most:of.the LERs were' attributable to personnel error. One of

the LERs was related to the Severity Level III violation and

the others appeared to bet isolated events. It appears that

additional management' attention is needed to reduce the number

'

of personnel errors.

During the early part of this assessment period, several

weaknesses were identified in the ALARA program. The

weaknesses were attributable to a lack of QA involvement,

training for engineers and foremen, and poor planning.

Management's support for the ALARA program, resulted in the

implementation of an effective training program for

supervisors,' engineering, and the design review staffs. The

work planning procedures were revised to include ALARA planning

in the initial phases of processing work requests. A new ALARA

Policy was issued and ALARA procedures were revised to

strengthen the program. For 1986, the licensee expended about

505 person-rem with a goal of 165 person-rem. In 1987, the

goal was set at 350 person-rem with 299 person-rem expended.

For 1988, the licensee's initial goal of 250 person-rem was

adjusted to 95 person-rem with about 79 person-rem expended as

of November 30, 1988. The long shutdown time and consequent

lower source term was a major contributor to the exposure

reduction.

There has been significant instability in organization and

staffing during this assessment period. During most of the

assessment period, the. Radiation Protection Manager's (RPM)

position was filled on a temporary basis by several

individuals. The Chemistry Superintendent's position was

staffed with contract employees and experienced a high rate of

turnover. The EM&EP group also experienced several management

and organizational changes. The changes in responsibility for

management of the effluent programs has been a major

contributor to these changes. During the last six months, the

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Radiation Protection group appears to have stabilized with keyL

positions staffed with permanent employees that included

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additions-to the technical staff.- In July 1988,.the RPM's .

position was filled with a permanent . employee, :and as of

October 1988,.the'EM&EP Manager's position was staffed on a

. permanent basis. The Chemistry group continues to be staffed

by contract employees in key supervisory and technical:

positions. The EM&EP Department also has a high number of

contract employees filling positions. .-

The licensee has.made sigr_ificant improvements in the-traiEting

~

program. During the last year, the licensee has received full

accreditation of their training programs from.the Institute of

Nuclear Power Operations. A new upgraded General Employee;

Training Program will be. initiated in January,'1989. The

licensee's training and qualification program also included'

contract employees. During this assessment period, there were

several events where deficiencies in training were identified

-

as causitive' factors. The licensee took prompt action to-

correct the deficiencies to prevent recurrence.

The licensee has established a satisfactory program for-

performing radiochemical measurements. -Laboratory quality

control and quality assurance activities were substantially-

improved during this period due to improvements in procedures.

Inter-laboratory comparisons of radiochemical measurements were.-

also improved, as the licensee began participating in a new

contract. laboratory intercomparison program. Onsite

intercomparisons with NRC measurements were successful.

2.- Conclusion

Performance Assessment - Category 2

3. Board Recommen'ations d

The licensee'needs to continue their efforts in the staffing of

Chemistry and EM&EP.with permanent employees,.in the

identification and! correction.of deficiencies in the

radioactive effluent programs, and in the control of liquid

waste.

,

,

C. Maintenance / Surveillance; *

1. . ' Analysis

During the SALP period,_approximately 2096 hours0.0243 days <br />0.582 hours <br />0.00347 weeks <br />7.97528e-4 months <br /> of direct

inspection effort were applied in the area of Plant Maintenance

and'Surve111ance. ' Strengths were observed in the work request

system with the installation..of an automated computer based

generation, tracking and retrieval system for work request

documents. Preventive maintenance procedures were completely

revised during this SALP period and included monitoring and

trending of machine vibration, thermography, oil analyses and

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mean failure. times. A continuing weakness'during the SALP-

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[ D period. involved the failure to identify and document material ,/ .e

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deficiencies when. discovered during repair or. rework of plant'

p equipment. For example, repeated trips of.the feedwater heater

drain pump were not aggressively investigated.

The licensee programs to ensure follow-up and trending of

failed surveillance, clearance of! equipment performance of

required maintenance and surveillance, Land quality control of

safety related materials were found-to be adequate in this

period. A strength was.noted in'the generation and revision of

maintenance procedures for specific plant equipment. Such

procedures had included extensive use of graphics with enlarged

views of equipment showing internals. Some weakness was

demonstrated in the control of post maintenance testing during

'the overpressurization of the AFW system after the SALP period

ended. Staffing of maintenance and surveillance organizations-

was considered adequate.

The licensee had some difficulty in maintaining' secondary

dissolved-oxygen levels within procedural requirements late in

this assessment period. On one occasion, feedwater oxygen

concentration limits were exceeded with the consent of

management. However, the need to exceed the procedural

requirement was not recognized as a deficiency to be_ evaluated

by the licensee's deficiency reporting system.

Licensee management was actively involved in the-scheduling and

coordination of maintenance and surveillance activities. The

licensee was considered to be responsive in addressing NRC

. concerns. Maintaining and utilizing current day industry

standards for prevenrive and predictive maintenance activities

appeared to be a goal of the Maintenance Department management.

Action was also taken to reduce work request backlogs, to

control and reduce valve packing leaks, and to successfully

conduct a secondary side hydrostatic test of the Main Steam

system following the large number of significant modifications

t made to that system.

The principal maintenance weakness observed during this SALP

period was insufficient identification and documentation of

deficiencies observed during the conduct of planned work f

activities or plant evolutions. For example, as discussed

above, difficulty in maintaining secondary side chemistry was

.> not documented as required. Another example was the licensee's

-

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used for the repacking of the auxiliary feedwater pump during a

repair effort. Subsequent failure of the pump seal was

"

,

- encountered during a start of the pump due to this error. As

.

noted above, after the SALP period, the overpressurization of

-

,

AFW indicated post maintenance testing as another area of ,

significant concern.

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"An'industryLaccredited training program for maintenance and

f; ifsu've111ance

r personnel.was developed and initiated. However,

if the -training of these personnel was: deficient on at least one

l

i occasion' late in the period in that' maintenance personnel-and

supervisors did.not' reject kinked hydraulic hoses that they

were'avare of on;a feedwater~ valve controller.

'

Ten Severity Level'IV'and two Severity Level V violations, and

one deviation'were issued during the SALP period. The majority

, .

of the' enforcement' action was related to a failure to follow

/ ~ procedures or to have an adequate procedure for the work.

activity in process. While none of the violations was

individually indicative of'a programmatic breakdown, taken

collectively ~it appears that additional management attention is

needed to reduce the. number of maintenance personnel errors.

During the SALP period, 20 LER's were issued in the area of

maintenance and surveillance. Of these 20'LER's, six involved

personnel error, 4 involved installation error, nine involved

defective procedures and one involved a component failure., The.

.LER's adequately described the major aspects of the events and

the corrective actions taken or planned to prevent recurrence.

Extensive maintenance program development (which included

procedure revisions) appeared to have resolved the conditions

which were~ reported.

Conclusion

Performance Assessment - Category 2

Board Recommendations

Plant management should focus special attention on

identification and documentation of discrepant material

conditions and improvement in post maintenance testing.

Licensee management should continue to emphasize the

development of-work procedures for specific plant equipment,

and to improve personnel performance and procedure adherence,

including the chemistry area.

D. Emergency Preparedness

1. Analysis

The area of emergency preparedness (EP) was the subject or.12

inspections, including the observation of three (3) exercises,

during this.SALP period. These inspections represented

approximately 590 hours0.00683 days <br />0.164 hours <br />9.755291e-4 weeks <br />2.24495e-4 months <br /> of direct inspection effort. The

resident inspectors assisted the regional inspectors in

accomplishing the inspections. The previous SALP assessment

concluded that'the performance in the area of EP was a Category l

3. - Recommendations to improve management support and oversite

, in numerous. areas of'the EP program were made to Plant

Management by the previous SALP report.

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There has been a significant improvement in the management

support of the emergency preparedness program during the SALP

period. At the beginning of the period management support was

poor, reflective of the SALP 3 rating. The changes in upper

management during the last two years have brought increased

support for emergency preparedness to the extent that presentiv

it is considered a strength, particularly with respect to

devoting resources necessary to insure an adequate capability

is maintained. Considerable contractor support was obtained to

provide adequate support for the changes needed to be made in

emergency preparedness. The required changes included a major

rewrite of the Emergency Plan and implementing procedures and

significant improvements in the records system and emergency

preparedness training program.

Technical issues associated with dose assessment and

meteorology have been addressed during this SALP period.

Needed improvements in the area of meteorology were identified

and are being implemented. In the interim, the licensee has

made adjustments to the dose assessment program to better

address the uncertainties in the meteorological data.

The licensee has displayed an increasing responsiveness to NRC

initiatives. The changes to the Emergency Plan and

implementing procedures that were made support this finding.

In addition, the responses to the violations identified during

the SALP period have been more complete during the latter part

of the period.

Three minor violations of NRC requirements were identified

during.the course of the assessment period. Two of the

violations' appeared to result from a failure by aiddle

management (EP managtement at the time) to assure identified

deficiencies were corrected in a timely and thorough manner.

There was considerabia variation in the licensee's emergency

preparedness staffing during the SALP period. At the beginning

of the period the supervision and staffing was weak. Shortly

thereafter, supervision was strengthened in an effort to

correct the many problems that existed. In addition, a number

of contractor personnel were hired to provide adequate staffing

to accomplish the numerous tasks to be performed. During the

last half of the SALP period supervision of emergency

preparedness was in a state of flux due to several persons

filling the supervisor's position. At the present time the

staffing appears to have stabilized with the hiring of a new

employee to the position of Manager, Environmental Monitoring

and Emergency Preparedness. Also, permanent emergency

preparedness positions have been established to eliminate most

of the need for contractor support.

At the beginning of the SALP period the emergency preparedness

training program was considered to be a significant weakness.

During the last two years the licensee has expended

!

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considerable' effort to improve this training ~ program. The

program is now well defined and lesson plans'have been.

prepared.- The exercise results have demonstrated the

111censee's ability to. respond to emergencies and identified

. areas for improvements.

l

2. Performance Rating

' Category 2, improving trend.

3. Board Recommendations

Continued management oversite to insure emergency preparedness

continues to improve and that identified problems are corrected'

in a thorough and timely' manner.

E. Security

1. Analysis

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During this SALP assessment period, Region V conducted seven

physical security inspections at Rancho ~Seco. _ App oximately

480 hours0.00556 days <br />0.133 hours <br />7.936508e-4 weeks <br />1.8264e-4 months <br /> of direct inspection effort were expendeo by regional

inspectors. In addition, the resident inspector s provided

continuing observations in this area. There were no material

control and accounting inspections conducted during this

assessment period.

The previous SALP report recommended that licensee management

' "

expand their support.to the overall security' program. Since

the initial operation of Rancho Seco..the Security Department

, reported directly to Corporate Security, located approximately

>

<35 miles from the site. In January.1988, the site Security

Department severed their direct tie with Corporate Security!'

,

and commenced reporting directly to plant management. This-

change, together with a major reorganization of the security

a- organization has improved the efficiency of the Security

Department by realigning key security positions and

responsibilities. The reorganization of the Security

Department has also improved the licensee's ability to s

implement remedial measures to correct deficiencies identified ,

in the course of both internal and NRC security inspections.

<

On March 7, 1986,.approximately four months prior to this SALP

period, the licensee published a Security Performance

Improvement Plan (SPIP) for security operations at Rancho Seco.

This SPIP identified 79 separate actions the licensee intended

to complete in order to upgrade their security program to'

resolve earlier NRC concerns. Additionally, in response to the  ;

'

September 1987 NRC Regulatory Effectiveness Review (RER)

report,'the licensee identified 19 additional actions. The

majority of these actions have been completed, and have

provided the licensee with an increased capability to defend

against the design basis threat.

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The previous SALP$ report also identified problems'with security

force training. During this assessment. period,as a~ result of .'o

the Security Departments' reorganization, the Training ~Section.-

assigned a' permanent supervisor, increased their training

staff, and acquired larger training support facilities.-

Increased management emphasis.resulted in development of a

Special Weapons and Tactics (SWAT) security response force, and

upgraded annual refresher training.

The previous SALP report also encouraged licensee management to

increase the frequency of compliance monitoring-of the. security

program. As a result of their SPIP, and the reorganization of.

their Security Department, the full-time security auditor

< (assigned to Corporate Security) coordinates his compliance-

review with the licensee's Quality Assurance Department'.

Security management has continued to' demonstrate a coordinated

effort with other plant staff in preventing safetylsecurity

problems at Rancho Seco. Currently, a new site radio _-

communication system is being installed which will increase the

overall communication ability'of the Operations and Security- -

Departments. The licensee anticipates initial operatian of-

this new radio system by January, 1989.

During the assessment period, thirteen information notices

. related to security were issued. The licensee's actions, as

reviewed to date, were found to be appropriate.

The enforcement history.for the period-of July 1, 1986 through

December 31, 1988 includes-five Severity Level IV violation's

for the licensee's failure to: . provide adequate illumination

'of an area inside the protected area; provide two physical

barriers for the protection of vital equipment; provide proper

storage protection for safeguards information; deny site-access

to' unauthorized personnel; and, test access alarms for certain

,. vital-area portals. Additionally, tiue enforcement history

included'one deviation for the licensee's failure'to adequately.

. revalidate security badges every 31 days.

L. _s

During"this SALP p3riod,. Rancho Seco reported 51 safeguards .

events. Three of these events. occurred after the October 1987

change (in the reporting requirements of 10 CFR 73.71(c), and

, thus were reported in the Licensee Event Report (LER) format. l

These events reinted to: repositioning plant toggle switches  !

' :(21); unauthorized (mistaken) entry into plant vital areas

'(14); loss of security computers (4); bomb threats and

threatening telephone calls (4); unlocked vital area portals

(2); inadequate compensatory measures (1); degraded vital area

barrier (1); drugs found inside protected area (1); cutting of

equipment wires (1); unescorted visitor inside protected area

(1); and security-related document found on site (1); The '

,

majority (94%) of these events occurred during the first half

of the SALP assessment period. j

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In' response'to the August 1986, NRC! policy statement on' Fitness.

for Duty of nuclear power plant personnel, licensee management;

continues toisupport.their established Fitness for Duty.

Program. This program, applicable to all licensee and contract

. personnel, consists primarily'of: Pre-Enployment Drug

Screening; Medical Clarification Examinations;~ Routine Testing ,

After. Employment; For-Cause Drug Testing;-and an Employee

Assistant Program. The medical clarification examination is

. administered on 'a rardom basis, and. consists of a short.

. physical examination designed.to: determine the presence of.

drugs and alcoho1~in the employee's system, plus a medical /

psychological. evaluation. Licensee employees who work'on or

operate vital; equipment, and contract employees granted access

to' site vital areas, qualify for this examination.. If, in the-

judgement of the examining practitioner, the employeeLis.

considered to have indications of drug or' alcohol use, the

employee is required to submit to.a drug and alcohol urine

screen. ,The. routine testing after employment,.is required when

a' physical ~ examination is. mandated by a' regulatory' agency.

Additionally, the licensee's Program includes the random'.

unannounced use of' drug detection dogs inside the protected

area.

'

'2. .' Conclusion-

Performance Assessment - Categ'ory 2.

,

3. Board Recommendation

Licensee management is encouraged to continue their support to

the overall security program, and to finalize ongoing

improvements identified in the Security Performance-Improvement

Plan, and the responses to the RER report.

F. Eng,ineering/ Technical Support

1. Analysis

During the SALP period, approximate 1. 1902 hours0.022 days <br />0.528 hours <br />0.00314 weeks <br />7.23711e-4 months <br /> of direct

inspection effort were applied to the Engineering / Technical

Support area. In addition to continuing coverage by the  !

resident inspectors, a NRC Augmented System Review and Test

Program (ASRTP) team inspection was performed along with

enhanced observation by senior regional staff. The major

weakness in this area involved the discovery of significant

inadequacies in the control of. design and engineering work,

largely resulting from'a poorly defined plant design basis and

insufficient attention to plant design details. In contrast, a

strength observed during the latter part of the SALP period

involved the self-critical attitude demonstrated by senior SMUD

management in acknowledging the need for improved' performance

,

in this area, including engineering reorganization.

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'The initial findings of the NRC ASTRP inspection identified

several weaknesses in engineering involvement in the resolution

of problems identified by the licensee's . systems ' review and l

test program. The team also identified.several deficiencies

with some engineering analyses for ongoing system

modifications. SMUD management subsequently developed and

,

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implemented an innovative Engineering Action Plan (EAP) to

restore confidence in' the Rancho Seco engineering design and

design process. The EAP included organizational,

administrative, and cultural changes to provide a better

definition of responsibility and authority for engineering

activities. -SMUD also contracted with an independent group of

technical consultants to perform an expanded ASTRP (EASTRP)

inspection similar to the NRC inspection on the. remainder of

tha systems not previously inspected by the NRC.

.

A revision to the EAP provided further technical aspects of the.

plan. This included:

Upgrading the engineering design change process to improve

the control and quality of future work.

~* Review of calculations for technical accuracy and

completeness.

Review of' technical work performed during the outage to

assure design adequacy.

Reestablishment of the plant system design bases.

The EASTRP was performed and the EAP initiated prior to

restart. An evaluation of E.iSTRP by the NRC ASTRP inspection

. team concluded that the EASTRP' inspection process provided

adequate confidence that any significant problems with the

design of Rancho Seco were being identified before restart.

The NRC ASTRP team also assessed the EAP and concluded that the

EAP appeared to improve the quality of calculations and analyses

performed to support system design. Although many aspects of

the EAP were completed prior to plant restart, many other

portions of the EAP remain to be completed. The second

revision'of the EAP, dated September 16, 1988, was issued to

"

identify items completed and the long range items still to be '

.

,

, finished. One of the more significant aspects of the EAP that

remains to be completed is the establishment of system design

basis documents. The licensee has agreed to complete the

. initial portion (14 systems) of this very extensive program by

the'end of the next refueling outage.

)

- Plant restart was contingent on several major system additions

and modifications. Engineering performance to support these

• '

projects.was excellent. Operational safety was enhanced

, significantly by the addition of the Emergency Feedwater

Initiation and Control (EFIC) system and the Safety Parameter

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Display System (SPDS). Hardware reliability and human

engineering features associated with these, relatively complex,

systems are indicative of SMUD's capacity for engineering

excellence.

The addition of two diesel generators and modifications to the

emergency electrical distribution system are additional:

examples of excellent engineering capability and performance.

Diesel engine vibrations and cable routing discrepancies,

tasked the engineering organizations ability to respond to

, . unexpected problems. In both instances, these complex issues

were resolved in a thorough and professional manner.

Three enforcement items were identified in this functional

area. Specifically, one Severity Level IV violation was

identified for failure to establish written procedures for

radiographic inspections of decay heat removal pump drain

lines; one Severity Level V violation was identified for an

inadequate drawing - four different welds had two redundant

weld number identifiers; and a deviation was identified for the

use of silicone sealants in the essential HVAC system.

During this SALP period 11 LERS were attributed to this

functional area. All of the LERs resulted from technical

discrepancies such as the lack of channel isolation devices for

two channels of the Reactor Protection System power summing

amplifier.

The extended outage during this SALP period required increased

technical manpower to support the varied modifications that

were initiated and completed. Licensee technical staff was

heavily supplemented by contract personnel to' support the

workload. The supplemental contractor work force was reduced

following completion of the modifications and upon plant

restart. Despite the heavy workload, no significant

discrepancies were attributed to the adequacy of technical

4

staffing. Similarly, effectiveness of training and

qualifications of the technical staff appeared to be sufficient

for the technical tasks that were being performed.

'

The licensee has been very responsive to NRC initiatives and

has taken extensive corrective action to improve the quality of

~ engineering's activities. For example, a new design control ,

process utilizing a design change package (DCP) approach was ,

4

established. Although the licensee's corrective actions

c

'

appeared to be extensive and complete, no new engineering ,

,

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products were available for audit to determine the

~e effectiveness of the licensee's revised design control process.

f

A number of significant weaknesses were identified by both the

NRC and licensee in past procurement practices utilized by the

licensee in the purchase of safety-related parts. Of specific

concern to the NRC was the practices used to upgrade commerical

,

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grade parts for use in safety-related' systems. The practices

utilized in procurement'before July,'1987 were not adequate.

The licensee revised their procurement program to incorporate

improved practices to prevent use of substandard parts in

safety related-systems.

Afterithe SALP period, the overpressurization of the AFW system

event revealed >two weaknesses:in this area as related to this

event: weak engineering oversight of maintenance activities

and continued weakness _in procure.,ent.

Conclusion

Performance assessment - Category 2

Board Recommendation

Management attention is needed to maintain a permanent, stable

site engineering staff. Engineering efforts to complete the

design basis records' project should continue, and a review of

the effectiveness of the current design change process should

be conducted once a representative sample is available.

Management attention is needed to enhance engineering oversight'

of maintenance activities in light of the AFW overpressure

event.

G. Safety Assessment / Quality Verification

1. Analysis

During the SALP period, approximately 5739 hours0.0664 days <br />1.594 hours <br />0.00949 weeks <br />0.00218 months <br /> of direct

inspection effort were applied in the area of safety i

assessment / quality verification. Significant strengths noted

during the SALP period included the implementation of a root

cause analysis process and an aggressive approach by management

to involve outside organizations, mainly INPO, in reviewing

problem areas and providing recommended corrective action.

However, several significant weaknesses were also noted in this

functional area. These included the need for more aggressive

use of the licensee's nonconforming condition reports (termed

potential devia: ions from quality (PDQs) by SMUD), and a lack

of progress in the completion of several post-restart

commitments such as the creation of design bases.

Over the lengthy evaluation period, many technical submittals

were reviewed by the staff. These included technical

specification change requests, NUREG-0737 items, exemption and j

relief requests, responses to generic letters, licensee j

activities related to resolution of safety issues, and

responses to other regulatory initiatives. The plant was shut

down for a significant portion of the evaluation period because

of major problems at the plant that required full technical

resolution prior to restart. Several of these issues involved

a substantial interface with the NRC technical staff. Issues

_ _ _

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included addition of two emergency diesel generators,

environmental qualification, fire protection, upgrades to

emergency feedwater and instrument air systems, addition of

hydrogen recombiners, establishment of a minimum meteorological

monitoring program, system review and test program, reactor

trip system reliability modification, and others.

Licensee submittals were generally found to be adequate and

responsive to the subject matter. Contractor assistance and

licensee management ~ oversight of the contractors appeared to be

adequate as reflected by the submittals.

A conservative approach to fire protection issues has been

evident. However, two supplemental changes were submitted up

to a year after the original amendment submittal. This was

indicative of a lack of attention to detail. Specifically, all

parts of the technical specifications that needed to be changed-

were not considered. These changes resulted from oversights

that failed to incorporate original plant areas in tables and

charts. .This oversight appeared to be inconsistent with other

submittals and was considered to be an isolated case.

"

Inspection activities during the SALP petiod resulted in the

' identification of twelve enforcement items. Specific

enforcement topics included two Severity Level IV violations

for inadequate closure of nonconforming condition reports;

three Severity Level IV violations for inadequate control of

safety related material in the warehouse; one Severity Level IV

violation for not performing a 10 CFR 50.59 evaluation for

~

gagging two decay heat removal (DHR) system relief valves; one

Severity Level IV violation for failure to perform cable

routing inspections; one Severity Level IV violation for

performance of liquid penetrant inspections of the spent fuel

pool liner plate without appropriate acceptance criteria; one

Severity Level IV violation for numerous housekeeping

violations; and one Severity Level V violation for failing to

retain radiographic records of degraded DHR lines.

The two violations identified for failing to write

nonconforming condition reports were indicative of a persistant I

hesitancy on the part of licensee personnel to report

nonconformances properly. A preference to use work requests

for identifying and correcting nonconforming conditions was

noted on several occasions. This demonstrated the reed for

greater management emphasis to enaure nonconformances are

properly identified.

No LERs were specifically attributed to this area. However,

weaknesses in the licensee's safety assessment and quality

verification performance contributed to numerous LERs such as

the cable routing problems, the AFW pump packing material

discrepancy, and non-inclusion of containment isolation valves

in the local leak rate test program.

- - - - - - - - - - - - - - _

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.

' On 'several ' occasions during this SALP. period, the licensee

demonstrated a willingness to review its own programs to

" identify weaknesses. These reviews included EASTRP, INPO

readiness for operation evaluation, Babcock and Wilcox

transient assessment team evaluation, and independent

assessments of the QA program. These reviews demonstrated

p' increased willingness by the licensee to be self-critical and

to learn from the expertise of outside organizations.

The licensee's qu'ality verification program has shown

improvement in various areas such as increased on-the-job QC

inspectAon of maintenance and modifications, performance of QA

surveillance and the implementation of a new nonconforming.

condition reporting program.

In March, June and August of 1988, an enhanced operational NRC

inspection team evaluated performance of operating crews and

supporting organizations during the plant's power ascension

from the extended shutdown period. The team observed that the

Plant Review Committee (PRC) did not include department level

managers. This weakness has since been corrected by inclusion

of several department managers on the PRC. During an extended

inspection of the Augmented System Review and Test Program

(ASRTP) between December 1986 and February 1987, it appeared

that QA and the Management Safety Review Committee (MSRC) did

not actively review closeout of audit findings. Additionally

QA audit and surveillance programs were not providing plant  ;

management with adequate feedback of safety activities.

Subsequent inspections by the inspection team confirmed that

these problems had been corrected.

Staffing, training, and qualifications of the licensee's

,

Nuclear Quality Department and Licensing Department appeared to

'

be adequate during the SALP period. 1

Toward the end of the SALP period, Region V inspections

observed that the licensee was not completing post-restart

commitments as scheduled. Management meetings between the

licensee and NRC Region V, on November 14, 1988, and December

12, 1988, were held to review SMUD's commitments.for work to be

accomplished post restart, including the various aspects of the

EAP that remain to be completed. During the meetings, the

licensee agreed that numerous near and long term items still

remained to be completed, but reaffirmed its original

commitment to promptly resolve the near term items.

2. Conclusion

Performance Assessment - Category 2

3. Board Recommendations

The licensee should ensure the full use of the established

system to identify and resolve nonconformances. The licensee

i

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_ . _ . _ _ . _ _ _ _ _

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,

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-24

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.

is encouraged to complete action on the near term commitments

as previously agreed upon.

H. Startup Testing .

Analysis

During the SALP period, significant inspection of startup testing

was performed. Strengths were observed in the integrated system

functional testing approach and in the development of a system

status report which documented known past problems with specific

plant systems. A significant strength observed was an. initiative by

the licensee to develop and implement an inspection technique which

was patterned after the NRC's Augmented System Review and Test  !

l

Program (ASRTP) inspections that identified. plant system performance

or documentation problems. A weakness identified during the early

portion of the SALP period was the initial planning and completeness

of the test program.

The NRC inspected licensee startup testing activities during hot

functional testing and power ascension, with particular attention to

the adequacy of special test procedures and clearance boundaries,-

where used. Evaluations were made of the adequacy and depth of the

testing to determine whether the specific system under test was

performing according to the design bases of that system. A specific

strength was noted in the licensee's responsiveness to NRC

identified problems in the Auxiliary Feedwater system and the onsite

electrical distribution system during the ASRTP inspection.

Licensee management actively participated in the generation of the

test program purpose and scope. An extensive program was undertaken

to identify and document known past problems with the thirty-three

selected systems which were determined by the licensee to be

important to safety. This high integrity system was used as an

input source to the test program development.

Specific system functions and test requirements were soundly and

thoroughly documented within a system status report (SSR) document.

Technical and management reviews were conducted by the Plant Review

Committee and were effective in identifying potential underlying

test problems. 10 CFR 50.59 reviews were conducted prior to the

conduct of each test with adequate documentation of the test's

technical rationale. The program was conducted slowly,

methodically, with high management attention to ensuring preparation

for each testing evolution.

A weakness was observed in the identification and documentation of

conditions which were potentially detrimental to quality.

Specifically, during a portion of the loss of offsite power testing,

a deficiency was identified with an emergency diesel generator. The

deficiency was not reported on the Jicensee's nonconformance

reporting system. Significant management attention was subsequently

devoted to the identified problem with both the specific hardware

,

-- _ _ _ _ _ _ _ _ _ _ _ _ _ _

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- - - - - - - - - - - - - - - - - - -

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a <

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25

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deficiency being resolved and the programmatic > problem being

resolved.

No enforcement action was issued during the SALP period in this

fun'tional

e area. 'Two LER's'were submitted documenting a start of

the emergency diesel generator (emergency safety features -

equipment start) and a reactor trip following a preplanned turbine

generator trip. The licensee's corrective action for these LERs was-

appropriate.

During the period of significant testing, staffing was adequate and

commensurate with testing in process. Expertise of the testing

staff was adequate for both the management of the program and

conduct of testing.

Conclusion

Performance Assessment - Category 1

Board Recommendations

The licensee's effort in this functional area has been completed

except for some minor testing at the 100% power plateau. Lessons

learned-from this program should be evaluated for application to

routine post maintenance testing in light of the auxiliary feedwater

overpressurization event.

V. SUPPORTING DATA AND SUMMARIES

A.. Enforcement Activity

Three resident inspectors were assigned to Rancho Seco during the

SALP assessment period. 100 inspections were conducted during this

lengthy SALP period that encompassed the extended shutdown of Rancho

Seco. Significant team inspections included:

Two NRC headquarters Augmented Systems Review and Test Program

Inspection Teams during 1986 and 1987

NRC headquarters Operational, Readiness Inspection Team in 1988

NRC headquarters Procurement Inspection Team in 1988

Regional Enhanced Operational Inspection Team in 1988

A total of 15, 27 hours3.125e-4 days <br />0.0075 hours <br />4.464286e-5 weeks <br />1.02735e-5 months <br /> of direct inspection were performed during

this SALP period. A summary of inspection activities is provided

in Table 1 along with a summary of enforcement items from these

inspections. A description of the enforcement items is provided in

Table 2.

B. Confirmatory Action Letters

- - _ _ _ - _ _ - _ _ _ _ _ _

_ _ - _ -

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. 26  ;

l

..

One Confirmatory Action Letter (CAL) was issued ouring this

assessment period. The letter confirmed licensee corrective action

activities for the December 12, 1988 main feedwater pump trip event.

Shortly after the appraisal period ended, a CAL was also issued

concerning the licensee's planned actions following the

January 31, 1989 auxiliary feedwater system overpressurization

event.

C. AEOD Events Analysis

The Office for Analysis and Evaluation of Operational Data (AE00)

reviewed the licensee's events at Rancho Seco and prepared a report

which is included as Attachment 1. AE00 reviewed the LERs and

,

significant operating events for quality of reporting and

4

effectiveness of identified corrective actions.

L D. Detailed Description of Licensee Ac.tivities -

,

'*

,"

Before the December 26, 1985 transient, a number of criteria

(performance level monitoring, plant performance statistics, ,

~ and systematic assessments of licensee performance had

'

.

'

.

'

indicated that Rancho Seco was below the industry norm for

similar plants. This, plus a 1984 evaluation by a consultant,

'

.

-

moved the licensee's Board of Directors to take action to

,

improve the performance level at Rancho Seco. Before these ,

actions were implemented, a number of undesirable operating >/

experiences, culminating in the event of December 26th, further

i demonstrated the need for performance improvement. On the

,

" ,

besis of the review of the December 26th event by the NRC and

the utility, the licensee developed the " Rancho Seco Action

Plan for Performance Improvement."

The initial portions of that plan were implemented as the Plant

Performance and Management Improvement Program (PPMIP). The

PPMIP was designed to systematically evaluate the plant, its

systems'and their operation, and the management programs and

organization necessary to support the safe and reliable

operation of Rancho'Seco. The specific goals of the PP&MIP

were to: (1) reduce the numoer of reactor trips, (2) reduce

challenges to safety systems, (3) ensure that the plant remains

within allowed ranges of rea,: tor coolant system pressures and

temperatures immediately follwing a reactor trip, (4) ensure

compliance with license requirements, (5) minimize the need for

operator actions outside the control room, and (6) improve the

reliability and availability of the plant. On the basis of

anticipated benefits from the PP&MIP, the licensee established

near-term performance goals for retur ning Rancho Seco to power

operations. Those goals included plant availability exceeding

60%, a forced outage rate of less than 10%, and fewer than

three reactor trips per year.

During the extended shutdown period, the licensee developed a

system review and test program (SRTP) the objective of which ,

was to demonstrate, before plant restart, that systems f

i

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. _ _ _ _ _ _ _ _ _ - _ _

.

27

.

-

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.

important to safety were capable of performing their required

function. The SRTP was performed by the licensee to provide a

comprehensive review and functional demonstration of 33-

selected systems that were important to safe plant operation.

The licensee's SRTP identified the functional decription for

the 33 systems, design changes or modifications required for

the systems, testing necessary to demonstrate functions

important to safe plant operations, and final acceptance of the

L ,

systems. .

t -

On November 21, 1986, while attempting to fill, vent and

pressurize the primary system, approximately 11 of 35

pressurizer heater. bundles were damaged when the heaters were

energized without sufficient water covering them. Operators

disregarded correct pressurizer level indications due to'

incorrect status information for properly functioning level y

chcnnels. The operators relied on the remaining level ~ channel,

which had a drained reference leg caused by loosely controlled

troubleshooting of the level channels (operators being Onaware

of that condition).

On March 15, 1988 and on March 21, 1988, while the plant was in

hot standby, letdown system relief valves PSV-22031 (March 15,.

1988) and PSV-22024 (Harch 22,1988) lifted and resulted in a ,.

discharge of water from the letdown system to the Reactor 4

"

Building sump. The cause of both events was a steam / water

transient involving isolation of letdown system piping and heat

exchangers, flashing of water to steam in the low pressure

area, and rapid expansion of the steam.

On August 6, 1988, as part of a planned Emergency Feedwater

Initiation and Control System (EFIC) test, the reactor was

manually tripped from 80 percent power and EFIC was manually  ;

initiated. Both auxiliary feedwater (AFW) pumps started as

designed. Approximately one hour after both AFW pumps started,

smoke was observed in the vicinity of the outboard packing

gland of AFW pump P318. P318 was immediately secured and the

EFIC test was completed using the other AFW pump, P319.

Subtequent licensee investigation determined that an identical

AFW pump packing overheating event had previously occurred on

July 7, 1988. The event was attributed to the installation of

incorrectly sized vendor supplied packing.

On December 12, 1988, while conducting a plant startup, with

the reactor at 12 percent power, and one of two Main Feedwater

(FW) pumps inoperable, feedwater flow to the Once Through Steam

Generators (OTSG) was reduced significantly by fluctuations of

the steam pressure to the operating FW pump turbine. The

reduced FW flow resulted in low OTSG 1evels reaching the EFIC

system actuation setpoint and initiation of EFIC. Proper OTSG

1evels were reestablished by EFIC. The operators subsequently

manually tripped the reactor with the belief that main

feedwater was no longer available. The initial response of the

plant to the reactor trip was normal. However, the licensee

_______________ -

_ _ _ _ . __ - - - - - _

i

,e  !

2 8 ..

.o

4

soon became concerned that the reactor coolant system was

cooling down more than expected, due to continued steaming from

the?"B" OTSG, and, by procedure isolated AFW flow to the "B"

OTSG. This resulteduin emptying the 'B' OTSG for approximately

15 minutes. The licensee located an unexpected steam demand

from the auxiliary steam supply to the fourth point FW heater,-

~

isolated the auxiliary steam to the fourth point FW heater, and

- refilled the "B" OTSG. Subsequent licensee analysis attributed

the initiation of the event to operator actions while manually

controlling.two different auxiliary s, team pressure reducing

stations for the steam. supply to the' low pressure FW pump

turbines.

On January 31, 1989, after the SALP period, while testing a )

newly installed governor for the. dual-driven auxiliary ,,

feedwater pump, the steam turbine for the pump oversped. The

auxiliary feedwater system pressure was estimated'to have

reached approximately 3800 psig for about three minutes. The

system design pressure is 1325 psig. The NRC and licensee

investi'/ation of this event revealed weaknesses in post

maintenance testing, communications, maintenance program, use

of generic information, and procurement.

,

l

1

l _ _ . _ _ ____j

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TABLE 1

INSPECTION ACTIVITIES AND ENFORCEMENT SUKHARY_,(Gi/01/86 - 11/30/88)

RANCHO SECO

Inspections Conducted Enforcement Items

Functional Inspection * Percent Severity Lovel**

Area *** Hours . of Effert I II III IV V D

A. Plant Operations 4029 26.1 - - -

3 - -

B. Radiological 664 4.3 - -

1 9 6 -

Controls

C. Maintenance / 2096 13.6 - - -

10 2 1

Surveillance

D. Emergency Prep. 590 3.8 - - -

3 - -

E. Security 407 2.7 - - -

5 -

1

F. Engineering / :1902 12.3 - - -

1 1 1

Technical Support

C. Safety Assessment / 5739 37.2 - - .

12 2 -

Quality Verif.

__ _ _ _ _ _ _.

Totals 15427 100.0 1 43 11 3

• Allocations of inspection hours to each functional area are

approximations based upon NRC form 766 data.

• • Severity levels are in accordance with NRC Enforcement Policy (10 CFR

Iart 2, Appendix C).

• • • Inspections hours for the special functional area of startup testing were

not distinguished in the NRC Form 766 data. Those hours were included in

the other functional areas and predominant 1v were included in the hours

for plant operations.

, ,

- - _ - - _ _ - _ _ _ _ - -

. _ .- . - . _ .

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.

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-Table'.2' .

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gY

IRancho Seco I

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't

Enforcement Items" .,[. i

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Report > F , , ., Severity ~ Functional;

.

b ' Number- Subject' ,

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Level ;Areay. -

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P

• '86.27 FAILURE'TO REPORT TS TABLE 3.16-1*

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' ^

4 ,

B

. RADIOACTIVE GASEOUS' EFFLUENT VIOLATION. :i

y< >

G

8G.27 FAILURE TO POST'AND CONTROL HI RAD AREA 'B -

+4- B

'OTSG LOWER CHANNEL HEAD.

4

86.30 FAILURE T.O ESTABLISH WRITTEN PROCEDURES'FOR' 4, =F,

RADIOGRAPHIC INSPECTIONS. i

86.30 FAILURE TO RETAIN RADIOGRAPHIC RECORDS OF 5. ' JG -

DEGRADED DHR DRAIN LINES.

t86.35.INADE UATE ILLUMINATION INSIDE PROTECTED 4 E

AREA.

.m

86.37:PROCEDURESLNOT PROVIDED FOR TESTING AND -4' B

CALIBRATING RAD MONITORS R15701 AND 15702.

86.37 CLEARLY VISIBLE LABELS FOR LICENSED 5 B

MATERIAL NOT PROVIDED IAW

l

10CFR20. 2 03 (F) (2) .

86.38 PROCEDURE:FOR FUNCTIONAL TESTING OF 4 C.

SNUBBERS-DID NOT PROVIDE APPROPRIATE

ACCEPTANCE = CRITERIA ~FOR LOCK-UP VELOCITY -

VELOCITY-NOT CORRECTED.FOR TEMPERATURE AS

RECOMMENDED BY THE VENDOR. l

87.01 FAILURE TO SPECIFY CONTENT-OF EMERGENCY 4 D

PROCEDURES.

87 01 NO. PROCEDURE FOR CRIMPING TOOL CALIBRATION 4 C

AND CONTROL.

" '

87.01 CR/TSC HVAC HI AIR FLOW RATE DURING 4 C

12-26-05 EVENT.

87.02 UNUSUAL EVENT NOT.. DECLARED FOR SECURITY 4 D

ALERT AND ESCALATED SECURITY MEASURES.

~

87.03' INADEQUATE DRAWING'- REDUNDANT KELD 5 F

IDENTIFICATION NUMBERS ON F.?E2 DRAWING FOR '

DIFFERENT WELDS.

.

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f

ja

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_ - _ _ _ _ _ _ _ _ _

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e

,

87.05 FAILURE-TO PERFORM TS REQUIRED SR-89 AND 90

4 B

, ANALYSIS.

87.05 INADEQUATE YELLOW SHIPPING LABELS FOR 4 B

RADIOACTIVE MATERIAL SHIPMENT.

87.06 STORAGE OF EXPIRED SHELF LIFE ITEMS NOT 4 G

CONTROLLED.

87.06 FAILURE TO NOTIFY NRC OF ACTUATION OF 4 A l

l

EMERGENCY DIESEL GENERATOR (EDC}. FAILURE

TO REPORT CR/TSC HVAC MALFUNCTION.

. 87.06 NO PROCBDURE FOR GREEN TAGGING PARTS IN 4 G

,'

-

WAREHOUSE. , i

87.06 ABNORMAL TAG NOT WRITTEN FOR TEMPORARY 4 C i

MODIFICATION ON "A" TRAIN NUCLEAR SERVICE ~ I

RAW WATER SYSTEM.

i ,

87.0C VOIDING OF NCR WITHOUT DETERMINING CAUSE OF 4 '

G.'

< i

.i /- EMERGENCY DIESEL GENERATOR NONCONFORMING

CONDITION. ,

,

87.06 NCR NOT WRITTEN FOR NON-ISOLABLE PIPE 4- G

LEAKAGE.

87.06 FAILURE TO PROVIDE 10 CFR 50.73 REPORT FOR 4 A

MISCELLANEOUS CONDITIONS.

87,07 FAILURE TO PROVIDE TWO PHYSICAL BARRIERS 4 E

l FOR PROTECTION OF VITAL EQUIPMENT.

!  !

! 87.07 FAILURE TO PROVIDE PROPER STORAGE 4 E

PROTECTION FOR SAFEGUARDS INFORMATION.

87.11 SURVEILLANCE PROCEDURES NOT REVISED TO D C

REQUIRE DOCUMENTATION OF CALIBRATION DATA

IAW COMMITMENT ON PREVIOUS VIOLATION

RESPONSE.

87.13 CLEANLINESS PROCEDURE NOT FOLLOWED FOR A 5 C

CLASS 1 WORK REQUEST.

87.13 LIQUID PENETRANT INSPECTION OF SPENT FUEL 4 G

POOL LINER NOT CONTROLLED BY PROCEDURE WITH

APPROPRIATE ACCEPTANCE CRITERIA.

( 87.13 REPLACEMENT FILTER FOR CBAST ISSUED AND 5 C

INSTALLED WITHOUT SMUD ACCEPT TAG.

87.14 FAILURE TO WRITE NCR FOR BROKEN REACTOR 5 G

COOLANT PUMP CAPSCREW.

1

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, _ _ _ _ _ - _ _ _ _ _ _ - - - - _.

• "

4

.

87.14 FAILURE TO COMPLY WITH COMMITTED CODES AND D F

,

'

STANDARDS, USE OF SILICONE SEALANTS IN

ESSENTIAL HVAC.

87.16 STROKE TIME NOT MEASURED FOR TESTING OF 4 C-

TV-1,2,3,4. SIM-19,20,21,22 NOT FULL STROKE

TESTED EVERY COLD SHUTDOWN.

87.19 LICENSEE FAILED TO CORRECT DEFICIENCIES 4 D a

IDENTIFIED DURING 1986 HEALTH l

PHYSICS / MEDICAL DRILL.

87.20 HEAT TREATING OF VALVE YOKE WITHOUT 4 C

PROCEDURE.

87.20 FAILURE TO PROVIDE REQUIRED CABLE BEND 4 C

RADIUS AND CABLE TRAY EDGE BUMPERS.

87.21 FAILURE TO PERFORM CABLE ROUTING 4 G

INSPECTIONS DURING 1983-1985 TIME FRAME.

87.22 MISCELLANEOUS VIOLATIONS OF'ALARA PROGRAM. 5 B

87.26 RADIOACTIVE MATERIAL INSIDE RV HEAD STAND 4 B

NOT SURVEYED.

87.26 DAILY SOURCE CHECKS NOT PERFORMED WHEN 4 B

R15020 WAS OPERABLE, RHUT CONTAINED KNOWN

ACTIVITY AND RELEASES MADE VIA THIS

PATHWAY.

B'7.26 RADIOACTIVE MATERIAL INSIDE RV HEAD STAND 4 B

NOT POSTED AS HIGH RAD AREA.

87.37 FAILURE TO FOLLOW MAINTENANCE WORK REQUEST 4 C

INSTRUCTIONS.

87.37 FAILURE TO WRITE AN NCR FOR CR/TSC 4 s G

REFRIGERATION UNIT NONCONFORMING CONDITION

OF AS BUILT WIRING.

87.44 NCR CLOSURE BY QE PRIOR TO COMPLETION OF 4 G

WORK. CORRECTIVE ACTION INCORPORATED INTO "

-

l ECN WITHOUT PRIOR CLOSURE OF ECN;

\

,

!

88.04 FAILURE TO REVALIDATE SECURITY BADGES EVERY D E

31 DAYS.

88.04 FAILURE TO DENY SITE ACCESS TO UNAUTHORIZED 4 E

SITE PERSONNEL.

88.06~ EXPIRED SHELF LIFE ITEMS IN STOCK. REPEAT 4 G

VIOLATION.

L________._____

_

_ - .

._

.

.. -

88.12 CR/TSC HVAC ACTUATION NOT' REPORTED'WITHIN 4 'A :

6* FOUR HRS.

-

j

1

'88.13, LICENSEE DID NOT MAINTAIN ON FILE RECORDS. 5 B'- ,

FOR RADIOACTIVE MATERIAL SHIPMENT. l

.

88.13 LICENSEE DID NOT OBTAIN WRITTEN 5 B

CERTIFICATION FOR EMERGENCY SHIPMENT OF- ,

RADIOACTIVE MATERIAL.

88.17 FAILURE TO SUBMIT. REQUIRED' ANNUAL EXPOSURE' '5 Bf l

< REPORT. -

r

88.20 FAILURE TO POST, MONITOR,~ CONTROL HOT- c 3 ', B

PARTICLE ZONE. " r

l

t  ;

88.23 TEMPORARY MODIFICATION'FOR AFW PUMP P318 , '4 C

OUTBOARD SEAL WAS NOT CONTROLLED AND

DOCUMENTED IAW PROCEDURE.- #, t j

88.24 INDIVIDUAL DID'NOT WEAR TLD IAW RWP.  :

41 lB

!

!

88.25TWO PORTABLE DOSE RATE METERS EXCEEDED 5 'B

!

CALIBRATION: FREQUENCY. ,

88.29 ALARMS FOR CERTAIN VITAL AREA DOORS NOT 4 E

TESTED.

88.31' Calibration interval-:for EFIC. pressure 4 C j

transmitters changed _without proper

j

.

approvals required by procedure.

88.32 DHR RELIEF VALVES GAGGED WITHOUT ADEQUATE 4 G )

10 CFR 50.59-REVIEW. i

88.33 NUMEROUS HOUSEKEEPING VIOLATIONS'- '4 G .l

a UNSECURED LEAD SHIELDING, UNSECURED ROLLER

CARTS,~ LADDER TIED' TO SAFETY RELATED M

CONDUIT. i

88.33 PDQ FOR FEEDWATER OXYGEN CONCENTRATION NOT 4 G' l

' DELIVERED TO OPERATIONS TECHNICAL ADVISOR

-WITHIN 4 HOURS AS REQUIRED BY PROCEDURE.

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TABLE 3

1

SYNOPSIS OF RANCHO SECO LICENSEE EVENT REPORTS (LERs)

l

SALP Cause Code * l

Functional

Area A B C D E X Totals

l

A. Plant Operations 11 8 3 3 10 1 36

B. Radiological 11 4 - 4 1 2 22

Controls

C. Maintenance / 6 4 -

9 1 -

20

Surveillance

D. . Emergency Prep. - - - - - - -

E. Security 2 -

1 - - -

3

F. Engineering /

Technical Support 5 4 -

2 - -

11

C. Safety Assessment /

Quality Verification - - - - - - -

Totals 35 20 4 18 12 3 92

,

The above data are based upon LERs 86-11 through 88-19.

• Cause Code

A - Personnel Error '

B - Design, Manufacturing or Installation Error

C - External Cause

D - Defective Procedures

E - Component Failure

X - Other

!

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Attachment 1

,

AEOD Input to SALP Review for Rancho Seco ,

'

i LER Reviev.

'

' ' Duringithe assessment period, 84 Licensee Event Reports (LERs) were submitted

to the NRC..

a These reports, reviewed by AE0D, consisted of LERs 86-14 through

. 88-16.

t . .

Significant Events

Utilizing AEOD's screening process, the following 18 LERs were categorized as

y safety significant:

wc '

,

~86-14 Decay heat removal-(DHR) system train B rendered inoperable due to a-

.leakihg weld.on the pump casing drain line, while theit rain A

~

emergency diesel generator was out-of-service.

'

.- 86-16' Loss of DHR capability'for a period of3 1 minutes duringicold

shutdown as' result of inadvertent closure of the DHR' system suction

dropline isolation valve. Electrical arcisg from I&C technician

troubleshooting activitie9 Caused the valve closure. ,

86-25' "

Spent fuel. pool liner leakage while containing 316 spent fuel

assemblies. Contaminated water seeped through<the concrete walls of-

the fue11 storage building to an uncontrolled storm drain. About 275

gallons were released offsite, creating ansestimated whole body

dose of,0.14 mrem.' r

,

87-02 Fire ~ protection deficiency involving potential loss of alternate

.

shutdown capability. A control room fire could cause an electrical

short in the protective circuitry of a diesel generator's output

breaker, causing the breaker to trip. A 1oss of offsite power is

~

U assume'd to occur at the same time as.the control room fire.

87-06 Problems with safety related motor-operated valves identifed in

response to IE Bulletin No. 85-03. Problems included over' thrust'

conditions, incorrect brake voltage ratings, undersized power-

cables, lack of stem nut staking, valve internals damage,

unqualified operator grease, and incorrect pickup / dropout voltages.

87-08 Inadequate automatic sequencing of the high pressure injection pumps

onto the emergency diesel generator bus,-due to the pump lube oil

pressure bypass circuits defeating a three second time delay.

87-10 Fire protection inadequacy whereby the reactor coolant system high

l point vent valves were susceptible to opening from electrical

.

shorts.

L 87-11 Safety related snubbers failed functional testing after temperature

I considerations were factored into lock-up velocity and bleed rated

acceptance criteria.

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l 87-15 Fire protection carbon dioxide deluge system left deactivated

l without appropriate compensatory measures.

l . ,

87-23

'

Inadequate electrical isolation on the reactor protection system

total nuclear power channels. Channel isolation devices required by

IEEE-279 and General Design Criterion 20 were not provided.

87-29 Inadequate surveillance testing of unsupervised control room fire

alarm annunication circuits. Required monthly testing was not

performed since 1976.

87-34 High pressure injection (HPI) pump mini-flow recirculation lines

were not seismically supported since original plant construction due

to improper classification. Failure of the lines coincident with a

LOCA would render HPI capability indeterminate.

87-36 Blockage of bearing cooling water system piping to both reactor

buf1 ding spray pumps due to fouling.

87-41 Non-seismic level switches installed on nuclear service water pumps,

which could prevent the pumps from starting on a safety features

actuation signal (SFAS).

87-42 Failure of electrical connectors due to residual coating from

cleaning solutions. Systems affected included the reactor

protection system, integrated control system, SFAS, and non-nuclear

instrumentation.

87-44 Loss of nuclear services electric building essential heating,

ventilation and air conditioning system, due to inadequately

designed isolation dampers between Seismic I and Seismic II ducts.

88-02 10 CFR 21 report regarding a manufacturing defect in undervoltage

devices, causing improper operation of the control rod drive trip j

breakers.

88-11 Auxiliary feedwater pump inoperability due to incorrectly sized

vendor supplied packing in packing gland.

Other Events

AE0D's review also identified the following events,.while not necessarily

being individually categorized as safety significant, collectively represent

adverse trends in plant performance worthy of additional plant management

attention.

Inadequate fire protection compensatory measures:

LER 86-18 Disabled smoke detectors in the reactor building with-

out compensatory measures (fire watch) due to licensed

operator error.

LER 86-31 Hourly instead of continuous fire watch in 480 volt

switchgear room due to licensed operator error.

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LER 86-32 Missed fire watch in-the east nuclear services battery

room due to nonlicensed personnel error. Additionally,

LER 86-18 regarding missed compensatory measures, was not

referenced in this LER.

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LER 87-01 Hourly rather than continuous fire watches on 1/17

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and 1/27/87, due to licensed operator error. No reference

to LER 86-18 included.

LER 87-03 Continuous fire watches not posted on_ 12/27/86,

12/29/86, 12/30/86, 1/2/87, 1/3/87, 1/5/87, and 1/20/87.

LER 87-04 Abandoned continuous fire watch post in nuclear

services electrical building (NSEB) due to nonlicensed

personnel error. No reference to the above 1987 similar

LERs was provided.

LER 87-15 Carbon dioxide fire protection systems were

deactivated without establishing fire watches on 17

occasions in 1/87 and 2/87 due to nonlicensed personnel

error.

LER 87-19 Continuous fire watch posting not performed in the

NSEB due to licensed operator error.

LER 87-33 11 missed hourly fire watches in 77 inspection zones

due to administrative problems. Previous LERs on this

subject not referenced except for 87-04.

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LER 87-35 Continuous fire watch ar fire alarm panel abandoned

due to nonlicensed operator error.

LER 88-09 Missed hourly' fire watches on NSEB fire barrier

penetrations on 7/21/87 and 7/25/87 due to licensed

operator error.

LER 88-10 Missed fire watches on 7/14, 7/19, 7/25, 7/27, 7/28,

and 8/10/88 due to nonlicensed personnel error,

f Effluent monitoring deficiencies:

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LER 86-19 Missed auxiliary building noble gas grab sample due

to nonlicensed personnel error.

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LER 86-22 Missed continuous sampling of the auxiliary building  !

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gas due to procedural inadequacies. i

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LER 86-27 Lost data from reactor building duct particulate air

sample filter due to nonlicensed personnel error. ,

LER 86-29 Sample valves open on auxiliary building stack

exhaust sample line, rendering previous samples i

inaccurate.

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LER 86-33 Failure of a continuous noble gas monitor on the

reactor building exhaust duct on two occasions, due to

loss of electrical power when non-safety related loads

were applied to a safety related power supply.

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LER 87-40 Required surveillance (daily source check) not

performed from 8/84 to 8/87 on regenerant hold-up tank

discharge monitor during periods of known tank activity

due to procedural error.

LER 87-43 Unmonitored releases from the auxiliary building

during effluent monitor and ventilation system testing due

to nonlicensed personnel error.

'LER 87-47 Missed continuous sampling of reactor building purge

effluent on two occasions due to licensed operator error.

LER 88-01 Reactor building effluent particulate filter lost

prior to gross alpha activity analysis due to unknown

causes.

Causes

Root causes: associated with the 84 LERs, categorized on a yearly basis, were:

1986 1987 1988 TOTAL

Licensed operator errors 3 7 3 13

Other personnel errors 'S 10 3 18

Maintenance errors 0 4 0 4

Design / installation / fabrication 6 13 2 21

Administrative control problems 15 12 2 19

Random equipmen't failures 1 1 2 4

Licensee Unidentified 0 1 4 5

Of the 19 administrative control problems identified,14 were ast;ociated with

inadequate procedures, and 3 were related to programmatic deficiencies.

The licensee did not identify root causes on five LERs. . Additionally, the

supplemental report specified in'LER 88-06 (event date 4/14/88) Las not yet

been received.

LER Quality

LER quality has improved since the end of 1986, when the utility adopted a new

LER format. LERs submitted adequately described the major aspects of each

event, including identifying component or system failures that contributed to

the event. .The reports were well written, easy to understand, and typically

complete except for those with unidentified root causes. Corrective actions

taken or planned to prevent recurrence were generally specified. However, in

writing the LER text, the use of the word " operator" should be clarified to

indicate nonlicensed or licensed operator, as requird by 10 CFR

50.73(b)(2)(ii) (J)(2)(iv) .

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Preliminary Notifications

AEOD's review of preliminary notifications issued by Region V concluded that

no additional LERs were required of the licensee.

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