ML20128D735

SALP Repts 50-295/93-01 & 50-304/93-01 for 911101-921130. Overall Performance Improved

ML20128D735
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	02/01/1993
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20128D700	List: ML20128D695 ML20128D735
References
50-295-93-01, 50-295-93-1, 50-304-93-01, 50-304-93-1, NUDOCS 9302100215
Download: ML20128D735 (17)

See also: IR 05000295/1993001

Text

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SALP 11

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INITIAL SALP REPORT

U.S. NUCLEAR REGULATORY COMMISSION

REGION III

SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE

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Inspection Report No. 295-304/93001

,

Commonwealth Edison Company

Zion

November 1, 1991, through November 30, 1992

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CONTENTS

Page

1. INTRODUCTION ............................ 1

II. SUMMARY OF RESULTS ......................... 2

111. PERFORMANCE ANALYSIS ........... ............ 3

A. Plant Operations ....................... 3

B. Radiological Controls . . . . . . . . . . . . . . . . . - , . 4

C. Maintenance / Surveillance ................... 6

D. Emergency Preparedness .................... 8

E. Security ........................... 9

F. Engineering / Technical Support . . . . . . . . . . . . . . . 10

G. Safety Assessment / Quality Verification . . . . . . . . . . . 13

IV. SUPPORTING DATA AND SUMMARIES . . . . . . . . . . . . . . . . . . 14

A. Major Licensee Activities ................15

B. Major Inspection Activities ................15

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I. INTRODUCTION

The Systematic Assessment of Licensee Performance (SALP) program is an

integrated U. S. Nuclear Regulatory Commission (NRC) staff effort to collect

available observations and data on a periodic basis and to evaluate licensee

performance on the basis of this information. The program is supplemental 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 the facility's

performance in each functional area.

An NRC SALP Board, comprised of the staff members listed below, met on

January 13, 1993, to review the observations and data on performance and to

assess licensee performance in accordance with the guidance in NRC Manual

Chapter 0516, Systematic Assessment of Licensee Performance."

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

Zion for the period November 1, 1991, through November 30, 1992.

The SALP Board for Zion was comprised nf the following individuals:

Board Chairman

W. L. Forney, Deputy Director, Division of Reactor Projects (DRP)

Board Members;

H. B. Clayton, Chief, Branch 1, DRP

J. D. Smith, Senior Resident Inspector, DRP

J. E. Dyer, Director, Project Directorate III-2, Office of Nuclear

Reactor Regulation (NRR)

T. O. Martin, Acting Director, Division of Reactor Safety (DRS)

C. P. Patel, Project Manager, Project Directorate Ill-2, NRR

W. L. Axelson, Deputy Director, Division of Radiation Safety

and Safeguards, (DRSS)

! Other Attendees at'the SALP Board Meetinq

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A. B. Davis, Regional Administrator

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R. W. Cooper, II, Director,-DRSS,-Region I

C. E. Brown, Reactor Engineer, Technical Support Staff, DRP

M._J. Farber, Chief, Section lA, DRP

R. B. Landsman, Project Engineer, Section lA, DRP

R. J. Leemon, Resident Inspector, DRP

C. D. Pederson, Chief, Reactor Programs Branch, DRSS

T. J. Ploski,. Senior Emergency-Preparedness Analyst, DRSS

M. J. Miller, Reactor Engineer, Section 1B, DRP

W. G. Snell, Chief, Radiological Controls Section 1, DRSS

P. L. Louden, Radiation Specialist, DRSS

J. E. House, Senior Radiation Specialist, DRSS

T. J. Madeda, Senior Security Inspector, DRSS

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J. R. Kniceley, Senior Security Inspector, DRSS

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W. E. Scott, Jr., Rlli Evaluator, Performance and Quality Evaluation

Branch, NRR

11. SUMMARY OF RESVLTS

The assessment period was from November 1, 1991, through November 30, 1992.

The licensee's overall performance level .during this ~ assessment period was

good. The SALP Board noted that improved management effectiveness was a-

common trait' in all functional areas.

Of particular note are the _ improvements in the areas of Maintenance and

Surveillance, Emergency Preparedness, and Security. The areas of Ope' rations,

Engineering and Technical: Support,; Radiological Protection, and Safety

Assessment and Quality Verification retained their category 2 ratings.

Maintenance and Surveillance improved primarily. as-a result of improved

planni_ng and scheduling, increased preventive maintenance, and a' reduction in j

the corrective maintenance backlog. Challenges remain in foreign material

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exclusion,' rework tracking,_ and overall plant leak reduction.

Management attention, combined with excellent staffing, resulted in

improvements in the Emergency Preparedness and Security-functional areas'. One j

challenge -in- the Emergency Preparedness area is the corporate need for timely--

staffing of Emergency Operations facilities, j

in the Plant Operations area, significant improvements inE some performance

aspects were offset by the recurrence of personnel errors. Radiological

Controls retained its category 2 rating. At:the end of the_ assessment-period,

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broad scope corrective actions, in response;to poor performance during-the-

unit I refueling outage, appeared-to be effective.

Engineering and Technical Support was again rated ' category 2. Some'

improvement was noted;-however, increased management attention is needed in-

the areas of temporary. alterations to the plant, post-maintenance-or post--

modification testing, and. initial licensed operator training.

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Performance in the Safety Assessment and Quality Verification area remained-atm

category 2. The-root cause investigation program has become a. strength,-but

the station still faces' challenges with the technical thoroughness of. the '

onsite review committee evaluations, and.with- the quality of clicensing -

submittals.1

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Theperformanceratingsduringtheprevious'assessmentperiod_anld'this

assessment period according to functional-areas are given below:

.- Rating Last Rating This

Functional Area - PerioJ-(Trend) Period (Trend)

Plant Operations 2 -2

Radiological Controls - 2 2

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Maintenance / Surveillance 3 (Improving) _2

Emergency Preparedness 2 1

Security 2 (Improving) 1

Engineering / Technical 2 2

Support

Safety Assessment / Quality 2 2

Verification

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111. PERFORMANCE ANALYSIS

A. Plant Operations

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l. Analvsis

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Evaluation of this functional area-was based on the results of routine

inspections by resident and regional inspectors and assessments by the NRC

i Zion Review Team.

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Enforcement history was good; two Severity Level IV violations were issued

during_the assessment-period.

Management effectiveness in ensuring quality during routine operations and--

outages-was good with the' exception of personnel errors. During thelprevious-

, assessment period, the failure of management to- tho' roughly investigate

previous events and operator difficulties with equipment operation led

directly t_o two reactort trips. . _ Good management, maintenance,Jand operator

effectiveness eliminated reactor trips caused by recurrent equipment problems

this assessment period. Management also was effective. in further improving

the morale and work quality-of the:operationsidepartment. These-improvements

were demonstrated by better control room logs, operater professionalism,

attitude, cooperation with other departments, and a significant, reduction and

resolution of both current and long-standing operator grievances.

Management actions to control personnel errors:were not always. effective.

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Operator errors, primarily-in equipment configuration control,: increased .

during this assessment. period. ~The mispositioning of.a uotor-driven' auxiliary

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feedwater pump. discharge-isolation valve resulted in a-degraded auxiliary

feedwater system.. Another personnel _ error was_the failure of an operator to

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verify,,by procedure pre-requisites,-that a. test was_ appropriate for the

existing plant conditions. This resulted inl a momentary lossuof shutdown -

cooling, . reactor coolant _ being sprayed into the containment through the

containment-spray header, and.an

inadvertent reactor coolant system-

depressurization. An-increase in engineered-' safety feature'actuations-.(ESFs)

was 1argely' the result of personnel error. and procedure deficiencies. _ - A major

. contributor to equipment misalignments may have been the large number of less.'

' experienced auxiliary operators that was added-to the staffs during the last 2-

- y e a rs .- Shift supervision was augmented to. evaluate and_ assist these newer

-auxiliary operators.- An improved root-cause program has led to identification-

of_ the primary and contributing causes of the personnel: error _ increase.; At

the'close'of this assessment period significant management attention was

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focused on the implementation of corrective actions.

The approach to _identifyinq and resolving technical issues from a safety 1

standpoint improved and was good. Unlike the last assessment _ period, no

repetitive events of significance occurred and events in general were reduced.

Industry technical issues were promptly addressed. Examples-included (1) a 4

station policy to not enter mid-loop operation _without defueling (to address

the:possible loss of decay heat removal), and (2) the development and

implementation of an excellent-shutdown risk program. A computerized out-of--

service (005) editor system was-implemented during this assessment period to

provide better control and allow operations to have instant-feedback on

equipment configuration problems. This computerized 00S tag system allowed

faster repair and return to service of safety _ equipment, reducing operating

risks.

Operator response to events was excellent. Prompt, correct operator actions 1

minimized the impact of a reactor trip _and safety injection from full power,  !

and failures of- instrument : inverters and other major equipment. . Excellent

communication and coordination, between operations and other departments,

minimized the time the plant was in a limiting condition.for operation-(LCO)-

due.to failed safety related equipment. _When repairs were completed, a

operations quickly established the conditions needed for testing and return to

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service.

Staffing was excellent; the operating shift's- had a full complement of

auxiliary operators, two licensed operators, and one senior licensed operator

on each unit. The control of overtime was good; overtime was significantly-

reduced when compared to the last assessment period. Requalification training.

was good as demonstrated by a'95-percent pass rate. New equipment operators

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were receiving training as expeditiously as passible.

2. Performance Ratina

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Performance rating is Category 2 in this area. -Performance rating was

Category 2 during the previous assessment period.

3. Recommendations

None.

l B. Radiological Controls ,

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1.- Analysis

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Evaluation of this functional area was based on the results of'six inspections

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k and assessments by the NRC--Zion Review: Team.-

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L ' Enforcement. history was excellent. There was one Severity Level;IV violation-

involving a shipment of contaminated equipment.that left the site without the:

required 1abeling and shipping documentation.

Management effectiveness in ensuring quality was good although some examples-

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of poor performance were evident. Management provided good support toward the

resolution of problems identified during the previous assessment period, such

as radiation monitor reliability and operability and qualifications of

supervisory personnel. Management also supported an extensive peer-review

audit of the station's as-low-as-reasonably-achievable program, effectively

maintained water quality consistent with industry guidelines, and ensured

chemistry procedures were implemented during the Unit 2 outage which aided in

reducing overall source term within the unit. However, management did not

identify some problems early in the Unit I refueling outage, which contributed

to an overall poor performance during the outage in the spring of 1992. These

problems included inadequate planning and scheduling of work activities, poor

interdepartmental communications, and an unplanned crud burst prior to

shutdown. All of these contributed to radiation worker exposures being

approximately 293 person-rem higher than estimated for the outage. In

response to these problems, management implemented a number of broad scope

changes that not only affected the radiation protection department but also

the operations, planning, technical staff, and maintenance departments.

Initial reviews of these changes, performed at the end and immediately

following the assessment period, indicated that they were effective.

There were several problems with corporate management oversight of the

radiological environmental monitoring program (REMP) and the vendor laboratory

that performs the analyses for the program. Inadequate corporate direction of

the program contributed to a lack of participation by the station and an

overall lack of understanding of some specific REMP responsibilities.

Additionally, internal station audits identified many weaknesses with

implementation of the quality control program at the vendor laboratory.

Resolution of these problems was ongoing at the end of the assessment period.

The approach to identifying and resolving technical issues was good. Good

technical initiatives to reduce dose included the use of wireless remote

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dosimetry, video cameras, and decontamination by steam cleaning in both the

auxiliary building and in containment. The station also performed early

boration while shutting down for the Unit I refueling outage; however, the

results of this dose reduction effort were inconclusive. Even'though

indications suggested good chemistry results from the early boration, a crud

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burst a few months before the scheduled outage precluded a determination of

the effectiveness of the process. Additionally, problems with extensive check

valve and residual heat removal system repairs resulted in .an outage dose _of

763 person-rem. Radiation exposures during the first 11 months of 1992 were

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929 person-rem. This number was higher than anticipated and is more than

exposures recorded for previous refueling outage years. Personnel

contamination events for 1992 were also relatively high at 418. This weak

contamination control performance was primarily due to working on systems and

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components with unexpected high contamination level increases caused by the

crud burst, and, to a lesser extent, ventilation problems, laundry-problems,

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and poor radiation worker practices.

Chemistry proficiency was excellent in the corporate radiochemistry

interlaboratory comparison program with 94-percent agreements and in the NRC l

nonradiological chemistry comparison program with 100-percent agreements.

Radioactive effluents continued to be well below regulatory limits.

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Staffing levels and training and qualification effectiveness were excellent.

Two vacated professional health physicist positions were filled in a timely '

manner with individuals holding advanced degrees but limited industry

experience. The radiation protection manager's understanding of plant systems

and operating conditions was considered beneficial to the radiation protection

program. Radiation protection technician staffing-encountered no turnover

during the assessment period and the number of American National Standards

Institute qualified technicians increased from 12 to 22. Additionally, the

station hired appropriate numbers of contract technicians to support the

refueling outage during the assessment period. Radiation protection,

radioactive waste management, and chemistry staffs continued to receive good

training to improve their technical competence and perform their assigned

tasks.

2. Performance Ratina

Performance rating is Category 2 in this area. Performance rating was

Category 2 during the previous assessment period.

3. Recommendations

None.

C. tiaf ntenance/Surveill ance

1. Analysis

Evaluation of this functional area was based on the results of routine

inspections by resident and regional inspectors, special regional-inspections

of emergency diesel generator (EDG)_ maintenance and three assessments by the

NRC Zion Review Team.

Enforcement history was good with only two Severity Level IV violations issued

this assessment period.

Management effectiveness in ensuring quality in the maintenance and

surveillance area continued to improve and was-good at the end of the

assessment period. Management spent more time in the plant, which resulted in

better communications with the maintenance staff. More effective use of

resources resulted from planning and scheduling improvements. - An example of

this is long-range planning taking place for the upcoming dual unit outage.

Management was effective in reducing the-number of control room caution cards,

annunciator problems, and out-of-service equipment. Management acted to

reduce the outage corrective maintenance backlog by extending the Unit One

refueling outage length. Extensive maintenance work performed during outages,-

as well as an expanded preventive maintenance program, demonstrated a positive

change in management's attitude toward lower-tier equipment maintenance.

Other improvements included planning and scheduling of work requests, plant

testing and inservice inspection (ISI) activities, the low backlog of non-

outage corrective maintenance work requests, the completion of reliability

centered maintenance (RCM) system reviews, and increased efforts to improve

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. the EDG systems. Maintenance received appropriate engineering support and

vendor representatives were available when needed. Management's

reorganization of the procurement group greatly increased its efficiency.

Preplanning and earlier formulation of work packages allowed earlier parts

ordering and provided the necessary lead time for timely parts delivery.

Consequently, the negative effect on safety from equipment being returned to

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service late because spare parts were unavailable has decreased. Increased

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management oversight was provided in the root-cause analysis, electrical

procedures, implemen+ation of preventive maintenance recommendations on the

system and control c aters, troubleshooting activities, the oil sampling and

trending program, and training of some system engineers on their specific

systems. Early in the period, open items relating to the EDGs and

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recommendations from the RCH reviews on safety-related systems were not

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implemerted in a timely manner. Ineffectual EDG failure analysis and

troublesbootiag activities resulted in considerable rework activities,

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recurring failures, and delays in returning EDGs to operable condition. The

rework tr.icking system was not effective in identifying maintenance errors

because the system only tracks problems that occur after the equipment was

returi.ed to service. Plant material condition was good.- Improvements were

noted in painting and preservation in the auxiliary building areas, in the

material condition of the electrical distribution system, and in the reduced

total of leaks in the plant. However, many water, steam, and oil leaks still

exist in the station.

Performance of the surveillance program was good. Although one surveillance

was missed because an iodine cartridge had not been installed in a monitor,

all other tests were performed by the due date. Surveillance testing of EDG

equipment was acceptable. A technical specification (TS) surveillance test-

requirement, issued in May 1989, for an operability test of the reactor trip

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bypass breaker trip circuit had never been performed due to lack of management.

oversight in reviewing TS requirements.

The approach to identifying and resolving technical issues from a safety

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standpoint improved from acceptable to good by the end of the assessment

period. Engineering or other support was obtained as needed to resolve

significant problems or technical issues such as the failures of instrument

inverters and the 2A centrifugal charging pump speed changer. Maintenance was

performed by knowledgeable workers using mechanical maintenance procedures

which had been revised to be more detailed and user friendly. Excellent

performance was noted in the installation and testing of the Eagle 21 reactor

protection system modification by the instrument mechanics.

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Maintenance response to operating events caused by equipment failures was

good. Careful planning, scheduling, and coordination resulted in the timely

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return to service of the 2A centrifugal charging pump. Other examples of good

maintenance performance included instrument inverter repairs and the repair of

a hydrogen leak in the main generator. However, poor maintenance work-

practices (a nut inadvertently left in the pump) in August resulted in damage

to the 1A auxiliary feedwater pump in September. This indicated a problem

with the implementation of Zion's foreign-material-exclusion program.

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Staffing was good. The maintenance staff was effective in achieving and

maintaining a low non-outage-work backlog and in performing extensive outage work.

The effectiveness of training and qualification program was good; however, some i

weaknesses were identified in the training program for EDGs and electrical .

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- components. Station maintenance personnel and contractors have the required

. expertise to perform their functions. Personnel' performing maintenance =

i activities were qualified,- knowledgeable, and attentive to their assigned work.

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The control and oversight of contractors was gooc. About 120 hours0.00139 days <br />0.0333 hours <br />1.984127e-4 weeks <br />4.566e-5 months <br /> of training

1 was.provided to the maintenance craft personnel, which was above.the 80 haurs .

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recommended by the industry. Root-cause analysis training had improved and'

i appeared comprehensive.-

l 2. Performance Ratina

P vformance rating is Category 2 in this area. . Performance rating was Category 3

, d improving during the previous assessment period,

i 3. . Recommendations

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i None.

! D. Emergency Preparedness

1. Analysis

Evaluation of this functional area was based on the results of three inspections

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by regional inspectors and observations by the-resident inspectors.

l Enforcement history remained excellent with no violations identified,

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i Management effectiveness in ensuring quality improved and was excellent'by the end

- of the assessment period. One generic concern, discussed below,-was the

i exception. Emergency response facilities were maintained in an excellent state of

readiness; thorough and effective corrective. actions were completed on the-

- ventiletion system for the emergency operations-facility (EOF). Interfaces with-

State and local agencies were excellent.

l Untimely E0F staffing was identified:as a concern generic to all Commonwealth

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Edison Company (Ceco) stations. Minimum staffing for any CECO E0F, using

personnel from the corporate-office and other_ stations, _could take up to 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />.

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Resolution of this generic concern was ongoing-at the end of the assessment-

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period.

- The approach to identifying and resolving technical issues was excellent. Actual-

i emergency declarations were correct and timely. 0ffsite officials were initially

notified in a detailed manner within the regulatory time limits; however, the NRC

Operations Center was not notified of the termination of-one unusual event in a

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timely manner.- The licensee's evaluation and corrective actions were' thorough.

Several operating procedures were revised, follouing NRC identification, to

clearly indicate how event classification, offsite notifications, and- activation-

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of the onsite emergency organization would be accomplished following a control

room evacuation.

Overall performance during the 1992 exercise was excellent although a

contamination control concern was identified. Effective corrective actions were

demonstrated on concerns identified during previous exercises. Challenging

aspects of the exercise scenario included the simulated failure of a computer

system providing plant parameter data to several response facilities, the use of

actual meteorological data, the dispatch of two-dozen inplant repair teams, and

the use of a response cell to simulate actions of NRC and State officials.

The dedication and expertise of the station's full-time emergency planning (EP)

group was excellent. The corporate EP group's staffing level remained excellent.

The onsite and EOF response organizations' staffing levels also remained

excellent. Semi-annual, off-hours drills successfully demonstrated the capability

to staff the onsite response facilities in a timely manner.

The onsite emergency organization's training program went from good to excellent-

by the middle of the assessment period. In response to a concern identified at

, another station, the EP instructor assumed responsibility for ensuring that all

onsite EP-related. lesson plans remained current. The instructor expanded his

training tracking program to include training provided by corporate EP staff .to

certain Zion Station-personnel.

2. Performance Ratina

Performance rating is Categcry 1 in this area. Performance rating was Category 2

during the previous assessment period.

3. Recommendations

None.

E. Security

1. Analysis

Evaluation of this functional area was based on the results of three inspections.

Enforcement history improved and was excellent with no violations identified.

Management's effectiveness in ensuring quality was excellent. An extensive audit

of the security program was performed by experienced security personnel from other

Commonwealth Edison nuclear stations. Strong site management support for-

improvements to the security program was evidenced by upgrades to-the access

control card readers and metal detectors. Additionally, the engineering and

construction building was reconfigured to accommodate an inprocessing facility,

which consolidated fitness-for-duty, picture badging, and general employee

training. The use of monthly trending reports was an excellent management tool to

monitor and evaluate the effectiveness of the security program. Site management's

liaison with local law enforcement agencies (LLEA) was excellent as demonstrated

by the establishment of a training program allowing LLEA use of the licensee's

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firearms training system facility. The corporate security management provided

excellent support and guidance to site security management.

The approach to the identification and resolution of technical issues was

excellent and resulted in program improvements in vital area barriers,

maintenance, and personnel errors. Using root-cause program concepts, security

management took an aggressive approach to identify measures needed to resolve

program issues. The perimeter camera and access card reader upgrades

significantly reduccd compensatory measure and maintenance hours.

Security operational events were properly identified, analyzed, and documented.

The program for required reporting of security events was excellent. Required

reports and logs were accurate and timely. Communication with the NRC Region III

security staff was excellent.

Security staffing continued to be excellent. Several upper _ management contract

security force personnel changes improved the effectiveness of day-to-day

operational activities and resulted in improved communication between tfie

contractor and the licensee.

The effectiveness of the training and qualification program was good. The

licensee continued to implement and improve its tactical response contingency

training program with assistance from a professional security consultant. The use

of the computerized firearms training system has enhanced security officer

de:ision making capabilities.

A new fu . ity was established for the fitness-for-duty program and management

continued to provide excellent attention and support.

2. Performance Rating

performance rating is Category 1 in this area. Performance rating was Category 2

improving during the previous assessment period.

3. Recommendations

None.

F. Engineering / Technical Support

1. Analysis

Evaluation of this functional area was based on the results of 12 inspections, 2

operator licensing examinations, and assessments by the NRC Zion Review Team.

Enforcement history was good. The few violations issued were neither programmatic

nor repetitive.

A majority of the reportable events resulted from design deficiencies from

previous assessment periods. The remaining events resulted from a lack of

attention to detail during test performance or procedure development.

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Management effectiveness in ensuring quality was good. During the last half of

the assessment period, management combined the onsite corporate engineering and

project engineering support groups. Some of the more experierced technical staff

engineers were transferred into the site engineering organization (SE0). The SE0

has shifted its focus from short-term problems to more long-term-engineering

concerns and provided additional plant support for design changes and modification

implementation. The SE0 also reduced the large workload on the station technical

staff. The most significant reduction was in the number of out.,tanding

modifications. Other positive canagement actions included the development of a

thermography program, corporate engineering involvement in the snubber reduction

program, the lessons learned program which addresses issues identified at- other

Ceco sites (e.g., the degraded voltage issue), and the use of daily meetings to

monitor plant status and respond to site needs.

In the operator licensing and requalification area, management took an active role

during the preparation and administration of examinations. As a result,

examination material required very few changes, job performance measures included

mid-loop tasks, and unnecessary examination delays were prevented. However, as

evidenced by the high number of examination failures, significant weaknesses were

noted in the licensed operator training program for new candidates. Examples of

programmatic weakness include lack of emphasis on crew dynamics, simulstion

training completed early in the training sequence, and lack of student performance

feedback.

While engineering products were typically thorough, weaknesses in management

effectiveness were evident in the temporary alteration (TA) program. Safety

evaluations did not always address the consequences of potential failures. For

example, engineering failed to evaluate the potential for a leaking valve to

create a significant water hammer for a TA to the safety injection system. While

the licensee set goals on the age and number of TAs, neither goal was met and

there was little improvement toward meeting them during the assessment period.

Another weakness was the technical adequacy of post-modification and post-

maintenance testing. In one case, a post-modification test caused an ESF

actuation, Also a failure to properly test a residual heat removal (RHR) valve

following maintenance resulted in a degraded emergency core cooling system (ECCS)

for 9 months.

The approach to the identification and resolution of technical issues was usually

good. The technical staff and site engineering organization were more involved

with routine plant activities than during previous. assessment periods and provided

excellent response to plant conditions. Engineering involvement-in the root cause

analysis for a feedwater valve failure led to the identification of a problem with

the 1A auxiliary feedwater pump. Also, a system engineer identified and corrected

a motor-driven auxiliary-feedwater pump common-mode failure caused by a previous

modi fication. Review of industry events and inspection findings, such as the

degraded voltage issue identified at Dresden, were appropriately addressed by the

engineering staff. Hydrogen concentration trending of the Unit 2 system auxiliary

transformer resulted in its replacement before failure. The engineering staff

also supported several major station activities; for example, good engineering

involvement was noted during the Eagle 21 digital reactor protection system

installation and response time testing. There was good cooperation between the

technical-staff and SE0 engineers during formation of the new EDG team. However,

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communication problems were noted between specialty engineers and system .

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engineers. The latter were sometimes not included when equipment problems were

communicated to specialty engineers.

Although engineering support for issues-was usually good -there were several  ;

examples of inconsistent engineering involvement.~ The methodology used to i

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determine the root cause for EDG-trips was, at-times, inadequate.-. For example,

the troubleshooting procedure-was not always used appropriately before initiating

corrective work requests. This often led to an uncoordinated approach to problem

identification, which resulted in the necessity for additional troubleshooting.

Early in the assessment period the leader of the EDG improvement team was

reassigned with a resulting deterioration in team effectiveness. Subsequently,

EDG performance problems surfaced and resulted in redefining the EDG team charter

- with a broader scope than the original team's charter. The new team was effective-

in ensuring adequate technical support and EDG performance has improved.

Other examples of engineering problems; included (1) the failure to consider the

potential of obstructions by Zebra mussels, following implementation of: the

chlorination modification, resulted in' the inoperability of safety equipment, (2)

'

the failure to recognize the effect that the. opening of the missile door between

- the auxiliary building and the laundry: trailers had on the-auxiliary building

ventilation system, and (3) thel failure to identify a potential common-mode

failure during modification of the EDG room fire doors.

Engineering and technical support ' staffing was good. Experienced engineers were

transferred from other locations, including the corporate office, to the SE0 with

plans to add another five in 1993. The relative inexperience of the technical

staff engineers was at_ times balanced by the improved team work with the more

ex)erienced SE0 engineers. While the number of qualified nuclear engineers .

(tiree) was sufficient to perform assigned duties, six additional engineers were

being trained as part of management's commitment to strengthen the nuclear-

engineering group.

Training department staffing also was good. Initial operator license training and

requalification program effectiveness was' mixed based on passing rates of 67

percent and 95 percent, respectively. _ Initial operator licensing program results

l indicated that operator performance problems continued to occur. . Technical-

i support staff training was good. System engineers' training included plant

'

systems and simulator time. Nuclear engineering training had improved.

2. Performance Ratina

,

Performance rating is Category 2 in this area. Performance rating was Category 2

during the previous. assessment period.

3. Recommendations

None.

12

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

- -

.,

'

G. Safet_y Assessment /0uality Verification

-

1. Analvsis

-

'

Evaluation of this functional area was based on the results of routine inspections

by the resident inspectors, assessments by the NRC Zion review team, and a review

of the licensee's submittals.

Enforcement history was excellent; no repetitive or programmatic violations were

issued.

Management's effectiveness in ensuring quality was good as illustrated by the

improvements noted in all functional areas. In particular, management's attitude

'

toward maintenance improved performance and resulted in fewer maintenance-related

personnel errors during this evaluation period.

'

Management became more proactive in the use of Probabilistic Risk

Analysis / Individual . Plant Examination (PRA/IPE) results for scheduling and

prioritization of maintenance activities. The use of PRA was particularly

apparent during the replacement of the Unit 2 system auxiliary transformer.

'

, increased risks identified by the IPE were promptly factored into changes to the

Emergency Operating Procedures. The licensee is also purchasing a computer to

allow real-time _ update of risk perspective during equipment outage situations.

Additionally, broad scope changes affecting operations, planning, technical staff,

and maintenance organi7ation activities were implemented to significantly reduce

outage exposures.

"

Resolution of engineering technical issues was good. As the root cause analysis

program matured, it became a strength. A daily root cause meeting was held with

representatives from each department to evaluate events and issues for further

-

review and followup. The number of major problems was reduced by the group's

decisions to investigate the root cause of low thres'nold events.

However, ineffective management consideration of risk applications in work

scheduling, followed by inadequate root cause evaluation of equipment problems,

resulted in the loss of all five EDGs when both units were shut down. Management

failed to develop a comprehensive plan to address all previously identified

problems and take the additional steps needed to identify the root cause of

observed diesel problems. Following this event, management assembled a special

'

panel of nationally recognized, independent diesel experts to review all aspects

of EDG performance. The licensee accepted and began implementing the panel's

recommendations, including re-establishing the station's dedicated EDG improvement

team. EDG reliability has subsequently improved.

As noted during the last assessment period, the Onsite Review Committee did not

always demonstrate the expected questioning attitude. During this assessment

period, activities of the Onsite Review Committee did not always ensure that

issues of a routine nature were given adequate technical review. For example,

lack of in-depth-technical review of a special test for the 0 EDG cross-trip

modification resulted in actuation of the 1A service water (SW) and the OE

component cooling (CC) water pumps. In contrast, the onsite nuclear safety group

continued to perform well in ensuring plant pfety.

'

13

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i

'

!

1

Significant resources were applied to implement and improve the shutdown risk

, arogram. Station personnel ' ore kept aware of equipment required to be operable i

{ ay the morning meeting minutes and TV monitors throughout the auxiliary building. l

1 Shutdown risk was reduced further by requiring senior management's approval for i

any major changes to the outage-work schedule. Shutdown and operating risk

i

reductions also resulted from the implementation of the PRA/IPE, which was

'

completed earlier in the assessment period.  !

l

,

Management was effective in providing adequate resources to ensure design change

<

packages were prepared in advance. However, many 10 CFR 50.59 safety evaluations

j for temporary modifications lacked sufficient detail for a complete determination

, of safety impact. l

.

! Station and corporate-based nuclear quality program staffe performed routine

! audits and surveillances. Particularly, the audits in the radiological controls,

security, and emergency preparedness functional areas were a positive contributing

'

j factor to the station's improved performance.

While the quality of some licensing submittals was good, others lacked adequate

information. Requests for additional information were frequently required to

complete reviews, such as for the transient analysis envelope, fracture toughness

. for protection against pressurized thermal shtck, and fuel pool rerack. Also

! there were some instances demonstrating a lack of commitment scheduling and

{ tracking. The quality of responses to generic letters and bulletins was good.

'

The monthly operating reports sometimes lacked sufficient review to ensure

accuracy.

'l

The responses to operational events were good. Root-cause analysis teams, using

well-qualified management personnel, were formed for significant events. These

i managers did an excellent job analyzing the caur,es and proposing appropriate

l corrective actions. Reports were timely.

Management staffing significantly im) roved. A site team focused on personnel

4

accountability, quality work, and scledule adherence has been assembled and

improvements have been noted. Quality Verification staff qualifications and

training were excellent.

,

2. Performance Ratina

Performance rating is Category 2 in this area, Performance rating was Category 2

.

during the previous assessment period.

3. Recommendatio n

None.

IV. SUPPORTING DATA AND SUMMARIES

A. Majnr Licensee Activities

14

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

, .

). On September 27,1991, Unit 2 entered a scheduled surveillance outage. The

unit was returned to service on November !!.

2. On November 7, 1991, Unit I trippeo as a result of the loss of instrument

Bus 114. The unit was returned to se,'vice on November 20.

3. On December 7. 1991, Unit I was placed in hot shutdown to repair a hydrogen

leak in the main generator. While it was shut down, a leak on the 10 steam

generator cold leg manway was discovered requiring the unit to be brought to

cold shutdown on December 16. The unit was returned to service on January

2, 1992.

4. On February 27, 1992, Unit I was shutdown initiating its ZlR12 refueling

outage. The unit was returned to service on August 13.-

5. On April 4, 1992, Unit 2 entered a planned outage to replace the system

auxiliary transformer. The unit remained in cold shutdown because the 0 ,

and 2A diesel generators failed. In addition, an inadvertent reactor

coolant system depressurization occurred on May 13 requiring replacement of

the 2A and 20 reactor-coolant pump seals. The unit was returned to service

,

on June 20.

.

'l

6. On September 17, 1992, Unit I was shutdown as a result of the 1A auxiliary

feedwater pump inoperability. The unit was returned to service on October

i 3.

i 7. On November 12, 1992, Unit 2 entered its Z2R12 refueling outage. The unit

is expected to return to' service on february 23, 1993.

l

B. Major inspection Activities

! The inspection reports discussed in this SALP are listed below.

.

Unit 1, Docket No. 50-295 - Inspection Report Nos. 91026-91027, 92002 through

9202), and 92023 through 92020.

Unit 2, Docket-No. 50-304 - Inspection Report Nos.- 91026-91027, 92002 through

! 92007, and 92009 through 92029.

I Saecial electrical distribution system functional inspection, conducted January 6

t1 rough February 7, 1992. Inspection Report Nos. 295-304/92003.

Special DC electrical distribution and EDG main'tenance inspection, conducted March

23 through May 8, 1992, inspection Report Nos. 295-304/92009.

-Special engineering inspection, conducted October.5 through October 29, 1992 .

Inspection Report Nos. 295-304/92023.

Special maintenance / electrical inspection, conducted October 13 through

,

October 23, 1992. Inspection Report Nos. 235-304/92025.

.

15

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