IR 05000250/2007009
| ML080240106 | |
| Person / Time | |
|---|---|
| Site: | Turkey Point  |
| Issue date: | 01/24/2008 |
| From: | Vias S Division Reactor Projects II |
| To: | Stall J Florida Power & Light Co |
| References | |
| IR-07-009 | |
| Download: ML080240106 (21) | |
Text
January 24, 2008
SUBJECT:
TURKEY POINT NUCLEAR PLANT - NRC FOLLOW-UP PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000250/2007009 AND 05000251/2007009
Dear Mr. Stall:
On December 21, 2007, the U. S. Nuclear Regulatory Commission (NRC) completed a team inspection at your Turkey Point Nuclear Plant, Units 3 and 4. The enclosed inspection report documents the inspection findings, which were discussed on December 21, 2007 with Mr. M.
Nazar and other members of your staff.
The inspection was a focused examination of activities conducted under your license as they relate to the identification and resolution of problems addressing a substantive cross-cutting issue last documented in CY 2007 Mid-Cycle Performance Review and Inspection Plan Letter dated August 31, 2007. Within these areas, the inspection involved examination of selected procedures and representative records, observations of activities, and interviews with personnel.
On the basis of the samples selected for review, there were no findings of significance identified during this inspection. The inspectors concluded that problems were properly identified, evaluated, and resolved within the problem identification and resolution programs (PI&R).
However, during the inspection, the inspectors identified several examples where corrective actions to prevent recurrence had not been fully implemented and contract engineers had not completed training requirements to perform certain condition report evaluations.
In accordance with 10 CFR 2.790 of the NRCs Rules of Practice, a copy of this letter and its enclosure will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of the NRCs document system (ADAMS). ADAMS is accessible from the NRC Web-site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Steven J. Vias, Chief Reactor Projects Branch 3 Division of Reactor Projects Docket Nos.: 50-250 and 50-251 License Nos.: DPR-31 and DPR-41
Enclosure:
Inspection Report 05000250/2007009 and 05000251/2007009 w/Attachment: Supplemental Information
REGION II==
Docket Nos.:
05000250, 05000251 License Nos.:
05000250/2007009 and 05000251/2007009 Licensee:
Florida Power & Light Company (FPL)
Facility:
Turkey Point Nuclear Plant, Units 3 & 4 Location:
9760 S. W. 344th Street Florida City, FL 33035 Dates:
December 17-December 21, 2007 Inspectors:
T. Hoeg, Senior Resident Inspector, St. Lucie, Lead Inspector J. Zeiler, Senior Resident Inspector, V.C. Summer T. Walker, Senior Project Engineer, Region I Approved by:
Steven J. Vias, Chief Reactor Projects Branch 3 Division of Reactor Projects
Enclosure
SUMMARY
OF ISSUES
IR 05000250/2007-009, 05000251/2007-009; 12/17/2007 - 12/21/2007; Turkey Point Nuclear Plant, Units 3 & 4; follow-up inspection of substantive cross-cutting issue in the area of identification and resolution of problems.
The inspection was conducted by two senior resident inspectors, and one senior project engineer. No findings of significance were identified during this inspection.
Identification and Resolution of Problems Summary The licensee was generally effective at identifying problems and initiating condition reports (CR) as required by program procedures. The inspectors determined that the licensee utilized their corrective action program to evaluate, assign corrective actions, and identify adverse trends, including low level issues. In most instances, the licensee properly assigned, prioritized, and evaluated issues identified at the site. The inspectors reviewed the licensees corrective action program improvement plan and actions to address evaluation quality, timeliness, and overall CAP effectiveness. In general, the inspectors found the evaluations to be adequate with the CR backlog and evaluation timeliness having been reduced since the last problem identification and resolution (PI&R) inspection completed in June 2007. Overall, corrective actions were effective, but the inspectors identified a number of weaknesses associated with corrective actions to prevent recurrence (CAPR) put in place to address the substantive PI&R cross-cutting issue, first identified in 2006. The inspectors identified several examples where corrective actions to prevent recurrence had not been fully implemented and contract engineers had not completed training requirements to perform certain condition report evaluations.
Licensee self-assessments and audits were self-critical and generally effective in identifying problems which were properly documented in their CAP. On the basis of interviews conducted during the inspection, and the results of the licensees safety conscious work environment (SCWE) surveys the inspectors determined that those employees felt free to raise concerns without fear of retaliation.
NRC-Identified and Self-Revealing Findings
None
Licensee-Identified Violations
.
None
REPORT DETAILS
OTHER ACTIVITIES (OA)
4OA2 Problem Identification and Resolution
The purpose of this inspection was to conduct a focused assessment of the licensees problem identification and resolution (PI&R) program and evaluate the licensees effectiveness in addressing a continuing substantive cross-cutting issue in the PI&R area that was initially identified and documented in the NRCs mid-cycle 2006 assessment letter dated August 31, 2006, as well as in the NRCs end-of-cycle 2006 assessment letter dated March 1, 2007, and the mid-cycle 2007 assessment letter dated August 31, 2007. The assessments were based, in part, on issues identified and evaluated during the period, June 1, 2007 (the last problem identification and resolution team inspection) to December 21, 2007. Also, as part of this focused inspection, the effectiveness of the licensees efforts to improve weaknesses previously identified in the stations safety conscious work environment (SCWE) was assessed to determine if the program promotes a willingness to raise safety concerns without fear of retaliation, fear of criticism, or fear of increasing the condition reporting (CR) backlog.
a.
Focused Assessment of the Corrective Action Program (CAP)
- (1) Inspection Scope The inspectors assessed the effectiveness of the licensees actions in addressing the substantive cross-cutting issue in the PI&R area and addressing weaknesses in the SCWE program by conducting the following activities and reviews:
- Reviewed corrective actions to prevent recurrence that were developed from CRs 2006-20551 and 2006-25531, which were initiated to address the substantive cross-cutting finding first identified by the NRC in the mid-cycle 2006 assessment letter,
- Reviewed CRs and corrective actions initiated following the last PI&R inspection conducted in June 2007. These areas included moisture intrusion issues, scaffolding usage problems, and the failure to initiate CRs for plant equipment problems identified in the work request system,
- Reviewed the licensees independent verification process, as it related to several recent problems in that area,
- Reviewed the licensees recent corrective action program improvement initiatives as it related to their Road to Excellence initiative, including the pilot process for improving the timeliness of CR evaluations,
- Attended various plant meetings to observe management oversight and daily functions of the corrective action process, including the Work Assessment Group (WAG), Condition Report Oversight Group (CROG), and Corrective Action Program Coordinator (CAPCO),
- Reviewed recent CRs from self assessments and audits of the CAP,
- Reviewed a number of Employee Concerns Program (ECP) files and evaluated the actions taken,
- Reviewed the adequacy of management oversight, safety leadership, and work prioritization, and
- Reviewed the licensees corrective action program (CAP) procedures which described the administrative process for initiating and resolving problems through the use of condition reports (CRs).
Documents reviewed are listed in the Attachment to this report.
- (2) Assessment Corrective Action Program Meetings The inspectors observed that CAPCO and CROG meetings were well attended and members were prepared to discuss the issues. Generally, the assignment of significance level and investigation types were in accordance with the licensees CAP procedures and guidance. There was consistently a large number of condition reports being reviewed by CAPCO and CROG on a daily basis, which challenged meeting participants to properly identify some important issues and assign the appropriate priority level. For example, the inspectors became aware of an October 2007 missed opportunity to identify and communicate a reactor plant overpower vulnerability condition where both CAPCO and CROG had not recognized the need for greater attention and priority needed for the issue as documented in CR 2007-37078.
In one instance, the inspectors identified that CROG failed to assign an apparent cause evaluation for a CR involving work control and compensatory measures for maintenance on a fire protection system. The CAPCO had screened the CR as a significance level 2 and recommended an apparent cause (B) evaluation, specifically to evaluate for rework, configuration control, and a potential Maintenance department event clock reset.
Although this recommendation was reflected in the screening comments from CAPCO, the CR was inadvertently computer coded as a 3C (no apparent cause review) in the CROG review package. The CROG appropriately upgraded the CR to a significance level 2, but failed to recognize the need for an apparent cause evaluation due to the potential organizational impact of the issue. NAP-204, Corrective Action Program, requires justification for not performing an apparent cause evaluation for a significance level 2 issue. When the inspectors brought this issue to the attention of the Maintenance CAPCO, the CR was upgraded to a 2B and CR 2007-42216 was initiated to address the issue.
In general, there was good discussion and interaction among the group members with a proper focus on safety. However, the inspectors noted a small number of CRs where the level of detail was lacking to arrive at a conclusive assessment regarding the most appropriate investigation type. Also, the inspectors noticed there were a large number of CRs screened by CAPCO that had the recommended significance level or investigation type changed by CROG indicating a difference in interpretation of the NAP 204 guidance document between the two review groups.
Identification of Issues The inspectors determined that the licensee was generally effective in identifying problems and entering the issues into their corrective action program. Condition reports reviewed by the inspectors were written in a timely manner, provided enough detail to understand the problem, and were entered in the licensees CAP database. The inspectors noted a large number of CRs generated over the last year and the increased effort and resources required to manage the CAP database. During the last two years, the licensee had averaged over ten-thousand CRs per year.
During the last NRC PI&R inspection conducted in June 2007, the NRC identified numerous equipment performance issues that were entered into the licensees work order database and not entered into the CAP database as CRs. Based on the limited review performed during this inspection and review of the licensees corrective actions to address this issue, the inspectors determined that the licensee had implemented changes to the work prioritization process and WAG process to ensure all performance issues are entered into the CAP database as CRs.
Prioritization and Evaluation of Issues The inspectors determined that problems were generally prioritized and evaluated in accordance with the licensees CAP procedures and NRC requirements. The inspectors found that in the sample of root cause and apparent cause evaluations reviewed, the licensee was generally self-critical and thorough in evaluating the causes of the problems with some weaknesses noted. The inspectors found that new processes for evaluating condition reports provided immediate results in improving the timeliness of the backlog and generally improved the quality of the evaluations.
In November 2007, the licensee implemented a pilot process to aid in reducing the backlog and improving the timeliness of CR evaluations. This process allowed selected corrective only (C) condition reports to be addressed without a formal evaluation.
Specifically, for conditions that did not require a causal analysis and where appropriate corrective actions could be readily identified by the CAPCO or a technical expert during the screening process, corrective actions could be determined without a formal evaluation. This pilot process also placed stricter controls on the timeliness requirements for completion of formal evaluations. The inspectors observed that the average age of open CR evaluations had decreased significantly since the pilot process was implemented. The inspectors did not identify any CRs that had been inappropriately dispositioned without a formal evaluation, but they did observe cases where stricter controls for evaluation timeliness were not always applied. Specifically, some evaluations were not assigned an initial due date of 15 days as required by the pilot process. The inspectors also observed that the Operations department was not consistently documenting CR screening comments. Based on this, it appeared that the Operations department was not fully implementing the pilot process in that they were not identifying CRs that could be dispositioned without a formal evaluation. The licensee initiated CR 2007-42248 to address the lack of Operations department CR screening comments.
The inspectors determined that changes had been made to the CAP procedures to provide expectations for issue resolution, including consideration of safety and risk significance in determining the level of evaluation required and the timeliness of resolution. Revisions were also made to provide additional guidance for addressing repeat and recurring issues. Although the definition of a repeat event was clarified, the guidance for dealing with lower significance recurring issues that collectively could have more significance was inconsistent. Additionally, although instructions were added to consider special reviews for repeat and recurring issues, the CAP procedure did not provide explicit guidance on when these special reviews should be conducted. The inspectors noted a recent increase in the number of repeat condition reports, but did not identify any repeat or recurring issues that had not been prioritized appropriately.
The inspectors also noted deficiencies in several condition reports where the licensees evaluation lacked appropriate rigor or quality. Examples of weak evaluations identified by the team include:
- CR 2006-34325 (Jumper left installed following restoration from 4A Safeguards testing): The inspectors determined that the apparent cause evaluation was weak, in that, the extent of condition was too narrowly focused and did not address the configuration control aspect of leaving the jumper installed after testing had been completed. Previously, the maintenance CARB had also reviewed this CR, as well as the Performance Improvement Department. Both groups identified similar weaknesses as the inspectors; however, no action was taken to correct the issues. A subsequent licensee review of the concerns identified by the inspectors identified that the maintenance CAPCO representative had erroneously closed the CR by approving the original evaluation versus assigning it for correction. The licensee initiated CR 2007-42211 to re-open the CR and conduct the necessary re-evaluations. The inspectors determined this to be an isolated human performance error and not considered an example of a conscious decision to accept an inadequate CR evaluation,
- CR 2007-22507 (Issuance of engineering department trend report two weeks late): This CR documented that the engineering department CAP trend report for 2nd Quarter 2007 would be two weeks late. The inspectors noted that the subject trend report was never issued and the CR was closed without addressing this fact or another CR initiated for the condition. This condition is further discussed in the next section of this report relating to CAPR #2,
- CR 2007-33233 (Reactor core exit thermocouple P-8 reading low): This CR identified a failed core exit thermocouple. While the evaluation identified the core exit thermocouple to be safety related, as well as affecting Technical Specifications, the review for Maintenance Rule applicability and impact was not performed. Based on review of the licensees Maintenance Rule program and discussions with the appropriate system engineers, the inspectors determined that the CR should have been evaluated for Maintenance Rule applicability.
Based on a subsequent review of the licensees Maintenance Rule functional failure criteria for core exit thermocouples, the inspectors determined that this would not have been classified as a Maintenance Rule functional failure had the proper review been performed. The licensee initiated CR 2007-42220 to address the missed Maintenance Rule review.
- CR 2007-37742 (Bypassed Quality Control holdpoints during the 4A Emergency Diesel Generator preventive maintenance): This CR addressed a condition where a maintenance technician failed to notice three procedural holdpoints associated with turbocharger overhaul activities, resulting in equipment rework.
The licensees apparent cause identified a contributing cause for the error was the procedure format for annotating holdpoints not being in accordance with industry good practice. However, there was no corrective actions assigned to address correcting the procedure or need to conduct an extent of condition to determine if the problem was more widespread. The inspectors discussed the problem with the Maintenance Department Manager during the week of the inspection and he indicated that this CR was being reviewed that same day by the CARB and similar concerns with the corrective actions had been identified.
Effectiveness of Corrective Actions
In general, corrective actions developed and implemented for problems were timely and effective, commensurate with the safety significance of the issues. For significant conditions adverse to quality, the corrective actions addressed the cause and prevented recurrence. The inspectors concluded that the licensee had been generally effective and focused on correcting problems identified in their CAP. The inspectors reviewed a number of trend charts being used to track condition report corrective actions and noticed a significant decrease in the number of open actions since the last PI&R inspection completed in June 2007.
For some corrective actions to prevent recurrence (CAPR), the inspectors found examples where corrective actions were not performed in their entirety, partly due to the large number of changes to the CAP improvement plan and the stations Road to Excellence Plan which placed more emphasis on CAP backlog reduction and not the corrective actions to address the PI&R substantive cross-cutting issue from 2006. The inspectors noticed a number of weaknesses associated with corrective actions from CR 2006-25531 which addressed the substantive cross-cutting issue identified in 2006 as follows:
C CAPR #1 (CR 2006-25531, corrective action #2): Required periodic CROG reviews of CAP trend reports. The licensee identified that the 2nd quarter 2007 CAP trend report review was not performed by CROG. This was a missed opportunity for the CROG to identify that individual departments had not performed their reviews during that quarter.
C CAPR #2 (CR 2006-25531, corrective actions #5 - #13): Proposed CAPR actions involved adding CAP accountability measures for the purpose of consistent implementation and mentoring of CAP principles by establishing department level performance monitoring groups (Corrective Action Review Boards -
CARBs) with oversight by the CROG. Details of this program were included in a revision to procedure 0-ADM-533, Corrective Action Program Performance Monitoring and Trending
Analysis.
The responsibility of each department CARB was to provide the results of monthly and quarterly reviews in documented quarterly trend reports to the Performance Improvement Department (PID) for review and comparison with independent PID quarterly trend reviews. In addition, the CROG was responsible for quarterly review of these reports as part of their management oversight function. Based on initial review of the engineering department trend reviews, the inspectors noted that engineering had not conducted and documented the 2nd quarter and 3rd quarter trend review. An engineering CAPCO member indicated that the trend reports were not conducted due to competing priorities and other routine job activities (especially, the impact of a 3rd quarter refueling outage). Subsequent investigations by the licensee indicated that several of the departments had prolonged their trend reviews during the periods in question and had not issued the reports. The licensee initiated CR 2007-41961 to address this issue.
C CAPR #3 (CR 2006-25531, corrective actions #14 - #22): Proposed CAPR involved developing a qualified group of CAPCOs for effective monitoring and mentoring of CAP expectations for each department. The CAPCO candidates were required to go through formal training qualifications and be approved by both the Performance Improvement Department and CROG. The inspectors noted that since the selection, training, and approval of the twenty-three initial department CAPCO primary and alternate members in the mid-2006, considerable member turnover had occurred resulting in only thirteen of the original members being left. Some of the newly assigned replacement members were recent plant new hires or contractors and while most of these contractors had numerous years of nuclear industry experience, most had little familiarity with Turkey Point plant specific operation or knowledge of its programs and operating history before being assigned. In addition, based on a review of CAPCO training records, the inspectors identified that a security department CAPCO member attending meetings during the inspection week, had not yet completed all CAPCO training requirements. The inspectors also noted that the CROG had not reviewed and approved several recently qualified CAPCO members that were actively attending CAPCO meetings. The inspectors did not identify any performance issues associated with the new CAPCO members observed during this inspection period. The licensee initiated CR 2007-41985 to address these issues.
C CAPR #4 (CR 2006-25531, corrective action #24): Required a matrix to track training completion of personnel qualified to perform certain condition report evaluations. The team found that three of five contract engineers being used to reduce the backlog had not completed engineering training required for such reviews and were not tracked on the matrix. The inspectors did not identify any deficiencies associated with evaluations performed by the subject contract engineers. The licensee initiated CR 2007-42052 to address this issue.
C CAPR #5 (CR 2006-25531, corrective action #25): Required revision to the NAP-204 procedure. The team found some inconsistencies in the guidance for identifying and evaluating repeat issues as previously discussed in the Prioritization and Evaluation of Issues section of this report.
- (3) Findings No findings of significance were identified.
b.
Assessment of Self-Assessments and Audits
- (1) Inspection Scope The inspectors conducted a review of the licensee's Self-Assessments and Audit programs to verify actions were completed in accordance with licensee procedures NAP-202, Self-Assessments and QI-18 QAD 3, Scheduling of Quality Assurance Department Audit Activities. The inspectors reviewed a sampling of self-assessments and audits to verify that identified deficiencies and areas needing improvement were entered into the CAP tracking system. The inspectors reviewed the licensees analysis of the results of the most recent safety conscious work environment (SCWE) survey and a site culture survey to verify that areas needing improvement were identified and appropriate actions were planned to address the identified issues.
The inspectors reviewed department specific SCWE action plans for the major site departments and those with the most negative survey results. The inspectors also reviewed communication plans and training material developed to address issues identified from the survey.
- (2) Assessment Licensee self-assessments and audits were self-critical and generally effective in identifying problems. The inspectors found that self-assessments and audits were performed to identify deficiencies and areas needing improvement. For the deficiencies and areas needing improvement, the inspectors confirmed that the items were entered into the CAP tracking system.
The inspectors determined that the licensee had thoroughly analyzed the results of the SCWE and site culture surveys, and had identified actions to address areas needing improvement. The licensee identified areas that needed to be addressed both site-wide and at the department level. Some of the licensees actions were already planned or in progress as part of the Return to Excellence Plan, and additional actions for training and communication were planned. Individual departments involved department staff in development of department-specific plans, and implementation of these plans was in progress.
- (3) Findings No findings of significance were identified.
c.
Assessment of Safety Conscious Work Environment
- (1) Inspection Scope The inspectors reviewed department specific SCWE action plans for the major site departments and those with the most negative survey results. The inspectors also reviewed communication plans and training material developed to address issues identified from the survey.
During the problem identification and resolution inspection in May and June 2007, the NRC inspectors determined that there was reluctance by site personnel to identify low level issues that may result in further increases to an already large CAP backlog. During this inspection, the inspectors conducted interviews and held discussions with plant staff to understand the current views of the staff regarding the corrective action program and to determine if there were indications of conditions that could cause employees to be reluctant to raise safety concerns. The inspectors also reviewed CR initiation data for 2007, trend reports, anonymous CRs, and selected ECP files for indications of a reluctance to raise issues or initiate CRs.
- (2) Assessment The inspectors determined that the licensee had thoroughly analyzed the results of the SCWE and site culture surveys, and had identified actions to address areas needing improvement. The licensee identified areas that needed to be addressed both site-wide and at the department level. Some of the licensees actions were already planned or in progress as part of the Return to Excellence Plan, and additional actions for training and communication were planned. Individual departments involved department staff in development of department-specific plans, and implementation of these plans was in progress.
Safety-Conscious Work Environment Based on interviews and discussions with plant staff, the inspectors did not identify any conditions that indicated employees were reluctant to raise safety concerns. Plant employees were aware of the actions being taken to reduce CAP backlogs, and, while acknowledging that it would take time to see results, did not indicate any reluctance to write CRs in fear of increasing the database backlog. As previously indicated, actions had been taken to ensure that CRs were initiated when needed in conjunction with work requests, and no anomalies were identified in CR initiation rates. Employees were aware of the ECP as an alternate venue for raising concerns and did not indicate any reluctance to use the process.
- (3) Findings No findings of significance were identified.
4OA6 Management Meetings
On December 21, 2007, the inspectors presented the inspection results to Mr. M. Nazar, and other members of his staff who acknowledged the findings. The inspectors informed the licensee that proprietary information that was examined during the inspection will not be included in the report.
ATTACHMENT:
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
- J. Alvarez, Performance Improvement Department Assistant
- J. Antignano, Fire Protection Supervisor
- L. Bandel, Maintenance CAPCO
- W. Burrows, Acting Maintenance Manager
- R. Coffey, Maintenance Manager
- J. Connolly, Performance Improvement Department Assistant
- M. Downs, Employee Concerns Program Coordinator
- O. Hanek, Licensing
- G. Hettel, Plant General Manager
- D. Hoffman, Operations Superintendent
- P. Infanger, Licensing Department Manager
- W. Jefferson, Site Vice-President
- B. MacKenzie, Lead Corrective Action Coordinator
- M. Murray, Emergency Preparedness Supervisor
- K. OHare, Performance Improvement Department Manager
- W. Pravat, Work Controls Manager
- S. Russ, Maintenance Department Programs Supervisor
- K. Smith, Maintenance CAPCO
- G. Warriner, Quality Manager
NRC Personnel
- S. Ninh, Senior Project Engineer, RII
- S. Stewart, Senior Resident Inspector, Turkey Point
- M. Barillas, Resident Inspector, Turkey Point
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened and Closed
None