ML20244A802
| 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: |
| References | |
| 50-312-88-39, NUDOCS 8904180195 | |
| Download: ML20244A802 (41) | |
See also: IR 05000312/1988039
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J
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
" 25
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
s
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.
V
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
~
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
"
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- 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.
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
t
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
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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.
- - - - - - - - - - - - - - _
i
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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
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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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- - - - - - - - - - - - - - - - - - -
-
9.
a <
.
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
- - _ _ _ - _ _ - _ _ _ _ _ _
_ _ - _ -
i
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.
. 26 ;
l
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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.
,
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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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-Table'.2' .
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gY
IRancho Seco I
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Enforcement Items" .,[. i
.a i '4
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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*
-
' ^
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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_ - _ _ _ _ _ _ _ _ _
.
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________._____
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._
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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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