ML20005D934

Initial SALP Repts 50-295/89-01 & 50-304/89-01 for June 1988 - Sept 1989

ML20005D934
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	12/15/1989
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20005D933	List: ML20005D932 ML20005D934
References
50-295-89-01, 50-295-89-1, 50-304-89-01, 50-304-89-1, NUDOCS 9001020285
Download: ML20005D934 (35)

See also: IR 05000295/1989001

Text

%

gir.. ,

m.L huh %

.L,

&

-

..-

M

m~

.

~

s

'

,mv w. p,

s _. s

n.

.

,

--

>

f;; ;v,n

m

o

-

a

'ty ' [y $,[t y .

,

'f,04

,

e

.i

'

_

-t

<

--

p

c

I'k[, :

I{: '

'

' '

p'j,p$

"y't .

!

-

-

r

,,

e j,

E4

gr

,.;,

.s

gng' y i'

n

~

'

,

rMA. y'Q,e E

_i

,

-

r

y Tl

lgfp

'

-

.g

/J1 T - ,

.

W

',

SALP18:--

'

'

.~-:%p",..}" _

,.

y-

Q .

, . . i

.t

t

-

_ p'-

.e,

.,-

.e>~

s

,

'

"

5' h

s

r

e

v.

--

,

g, l ,, _ &%m ,

-LINITIAL SALP1 REPORT,

_ ,

c

,

-l', f.'.

- - o m

,o

-

+

.

r: '. n,

.e.'

<t

t'

. ,h '? _ Y , b.'

1

t

e m.

p a7. ,

.

,

, , -

,

e

N- f ,f,; ,

!

.

i .' k ',

'

.. U.dS[ NUCLEAR: REGULATOR COMMISSION 5

l

$%g f

h.

, ,

,

,

,

-

,

.

,

.. f

..

ir

i-

',

'

,

-REGION III'

.

-. ..

y

s,

I-e

g

'

%) . .;

.

a

'

'

,

yf:- %

e,

,

v,

,

,

,

pg

"

.

,

,

,

'+S

'

g

j

l "

j

< t.e. a

-

.

,

,,

,

( ;,- ;0: , ;

'

,,

'

'

"r

tgs

' ' ,

1 SYSTEMATIC ASSESSMENT OF: LICENSEE PERFORMANCE:'

..

n, -

..:s

.

.o

,

,s

W,

<

- 4 ;. .

.n

150-295/89001: I50-304/89001!

>

,

,

Inspection Report Nos,

,

,

<

. ,

,

g

4

'

i- -

3.

j,.~y'.

_

_'a'

0'^-

Y

.

[CommonwealthEdisonCompany

-

',

1

.

'l

'

s. :

_

Name'of Licensee-

s

b f.b. k., ' . *

'

,- g:

,

'

Zion Station,' Units 1 and-2.

'

S:

'

.

Name-of Facility;

o

x

! ;

t i

i

j

"

' J une l',1 1988 throuah September' 30, 1989

1

"-

Asses", ment Period:

..

, _

-']'-

i

.;.

>

-#

,

3

.:

e.

,

' .

~?

4

-

<

i

i

> <

r

..

.

f

9001020285 891215

i

J

'3 , : PDR- ADOCK 05000295

!

e " nG

PNV

,

p - (['-

'

'

p.-

3'

j

,

,

me

e .

,

'

-

'

-

-

-

-

m"

j:%.i b ,

!

f .-=

"

r

!

-

-

t

x

s

ens .

s

.~ ..-

1

"

L'-

wp.slM < ..m,

s

iu

a

w

y.

p., < ; -y

-

y,, y

9 9_ , ,.

!399

w - . h , s.

8;

m:

,

.

By.w w~

[TABLEOFCONTENTS

u

M

-w

a,

-

w ,.

.

g,

<

.

3> a;,

-

,

'

1

m y

.

we w

>

.

,

s.

gm

m-

-

r;

t.

._

Page No,.

t

<>

p: ' s

, ;9 :-

,

-'

• -;:

-

.. LIST LOF; ACRONYMSi

k. w

~

,

, g; a

, :I'y l I NT RODUCT I ON ) . - -.. . . . . . ; . . . . . . . . . . . . . .. . . . . .. . . . . . ; . . . .. . . c. . . -

'l

'

.

.

.

,

.N

I I ; 5 S UMMARY 0 F. R E S V LT S e. . . . . . '. . . . . . . ; . . . . . . . . . -. . . . .. . . . . . . . . . . .

31

.t

'

~

'

,

.

.

.

-

,

Ac ^ 0 v e r v i e w . . . ', . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - . . . . . . . . . .

3,

y

'

Bf : Othsr Area s of ,Inte re st . . . . . . . . . . . . . . . .-. . . . . . . . . . .

3-

p

.

,

.4

._ o

- -

-4L

1..

I I I . - - C R I T E R I A f . . . . . . :. . ; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

-

'

-

-

-

,

.

'; i'

i{

. . .

. . . - - . -

2.

, =

9-

_

S I V .3 ' P E R FO RMAN C E : ANALY S I S ' . . . '. . . . . . . . . . . . . . .. . . . . . . . -. . . . . . . . . . .

6-

N .< r. a

-

1. .

w

t

1

.

,

J'. 3~

,. 4-

-

E

L A'; -Plant Oper'ations ....................................

6:

'

,

.

18.

Radiological" Controls:.............................

10'

'

m.

.

,

C.

. Maintenance / Surveillance ..........................

12L

..

D '.

Emergency Preparedness ~..........................,.

.14

2

W,

'

'

E,

- S e c u r i ty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ._ . . . . .

17,

q

<

F.

-Engineering / Technical Support .....................

19 '

.

.

,

G.

Safety Assessment / Quality Ver_ification..............

22-

,,

-.

.

c4

. ,

,.

.

.

.

-

V..

SUPPORTING'DA.TA'AND SUMMARIES ..........................

27=

Jq

i A' u . Li cen see : Acti vi ti e s . .. . . . . . . . . . . . .- . . . . . . . . . . . . . . . . .

-27

d

'B.

/ I n spect i on Ac ti vi ti e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

'29

'

C.

Escalated Enforcement Actions.

_30

M' ;

. . . . . . . . . . . . . . . . . . . . . . -

'

D.

Confirmatory Acti on' Letters (CALs) . . . . . . . . . . . . . . . .

31;.

..;

s

E.

Review of Licensee Event Reports'...................

31

'

,

I.

y

I

,,3

..{

h j;

!

i

1

2

V

m

4

,

.

-

.

.

Mw

- L

Y

$

k

i

,_

-

h

f

.

y

4

4

l1

,

,

,-

.e

v

Q @(

'w

9

.

,

,

a

n

,qsh y

.

W.

n

~

O ST OF ACRONYMSE

-

h' '

4

ALARAT

as-low-as reasonably-achievable

f

ATWS'

, anticipated. transient without' scram

b

AFW6

' a'uxiliary _ feedwater

-CAL

. Confirmatory Action. Letter

"CFR

Code of Federal Regulations

1

4

s.

CS-

containment spray

. .

il "

.DCRDR

Detailed Control, Room Design' Review

[

-DRP-

'

Division of Reactor Projects.

>

L

"

DVR'-

deviation report

=DRSL

Division of Reactor.Safetyg

'

b

EDG;

Emergency' Diesel Generator

i

EHC'

electro hydraulic control

&

E0F;

Emergency Operating Facility.

@

.EQ .

Environment Qualification.

P

. ERO .

emergency response-organization

'

.ESF

engineered' safety feature

.FSAR:

- Final: Safety Analysis' Report -

GL

F

.HPES,

generic letter

Human Performance Evaluation = System

IN-

Information Notice

ISI

Inservice Inspection:

>

',

JPM

Job Performance Measure

g

LER~

Licensee Event Report

b

.MSSV-

. main: steam safety' valve

MTI

. Maintenance Team Inspection

p',

J

.NRR:

Nuclear Reactor Regulation-

~

p

PIP.

Performance Improvement Plan

'

PM.

preventive: mai ntenance

PSV

pressurizer-spray valve

QA/QC

quality assurance / quality control

RCS

reactor coolant' system

L

-RER-

Regulatory Effectiveness Review

'

RM

radiation monitor

R0

. reactor. operator

RP

radiation protection

_

,

.RPT-

radiation protection technician

1

RPS:

reactor protection system.

i

SALP.

-Systematic Assessment of Licensee Performance

Ji

SG

steam generator

SS0MI

Safety System Outage Modification Inspection

SRO

senior reactor operator

'

TS

Technical Specifications

j

,

TSC

Technical Support Center

.

-

!

t

!

1

I

'o2

.

i

.

..

~I.

INTRODUCTION

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

integrated 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 su)plemental to normal regulatory

'

processes used to ensure compliance witi 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 staff members listed below, met on

November 21, 1989, 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."

The guidance and evaluation criteria are summarized in Section III of this

report. 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 Zion station for the period-June'1, 1988, through September 30, 1989.

The SALP Board for Zion Station was composed of:

Board Chairman

• H. J. Miller

Director, Division of Reactor Safety (DRS)

Board Members-

• E. G. Greenman

Director, Division of Reactor Projects (DRP)

,

• J. W. Craig

Project Directorate III-2, Nuclear Reactor

Regulation (NRR)

• W. D. Shafer

Chief, Reactor Projects Branch 1, DRP

• L. R..Greger

Chief, Reactor Programs Branch, DRSS

• J. D. Smith

Senior Resident Inspector, Zion, DRP

• C. P. Patel

Project Manager, NRR

• • H. A. Walker

Reactor Inspector, DRS

• • • G. C. Wright

Chief, Operations Branch, DRS

1. W. G. Snell

Chief, Radiological Controls and

Emergency Preparedness, DRSS'

HJ. R. Creed

Chief, Safeguards Section, DRS

l

Other Attendees at the SALP Board Meeting

A. B. Davis

Regional Administrator

C. J. Paperiello

Deputy Regional Administrator

,

J. M. Hinds

Chief, Projects Section 18, DRP

i

J. Weschselberger

Operations Engineer, NRR

R. J. Leemon

Resident Inspector, Zion, DRP

A. M. Bongiovanni

Resident Inspector, Zion, DRP

M. P. Phillips

Chief, Operational Programs Section, DRS

R. B. Landsman

Project Engineer, DRP

S. D. Burgess

Reactor Inspector, DRS

.

-

- - . -

-

- -

- - - -

F ~

l

0o

..

,

eI'.

G.~M. Christoffer

Physical Security Inspector, DRSS

P. Eng:

Project Manager, NRR

'

C. F. Gill

Radiation Specialist. DRSS

R. B. Holtzman

Radiation Specialist, DRSS

'

T. J. Ploski

Emergency Response Coordinator, DRSS

T. E. Vandel

Reactor Inspector, DRS

• Denotes voting members.

• • Voting member Maintenance / Surveillance only.

J

• • • Voting member Engineering / Technical Support only.

1. Voting member Emergency Preparedness and Radiological Controls only.

1. 1. Voting member Security only.

!

a

i

I

l

l

l-

'

,

-

p

.

l-

1

l

1

l

2

.

-

'

J'

L

1. h : .

'

.

e

,

~a

,

11. SUMMARY OF RESULTS

A.

Overview

.

This assessment period is from June 1. 1988, through September--30,

1989. Both units operated routinely with the exception of short

outages necessitated by steam generator manway gasket leaks,

pressurizer spray valve leaks and other equipment failures. During

hteber 13 through December 28, 1988,, Unit 2 was shutdown for a.

a

refueling outage.

Unit 1 ended the assessment period in a refueling-

outage.

',

i

The areas of Plant Operations, Maintenance / Surveillance,'and

Radiological Controls each received a SALP Category 2, remaining at

a consistent level. The area of Engineering / Technical Support

received a SALP Category 3, indicating increased management attention

is necessary. Security was rated a SALP Category 2 with a declining

trend compared to a Category I during the previous assessment pe-fod.-

t

The performance decline was attributed to weaknesses in the security

program resulting-in insufficient evaluation of the impact of the

new service building construction on security barriers and weak-

nesses in management effectiveness.

Emergency Preparedness was

rated a SALP Category 2, a decline from the previnus assessment

period.

The decline in this area was attributed to weaknesses

identified during the September 1988 exercise. One new area, Safety

Assessment / Quality Verification, was rated a SALP Category 2 during

this assessment period.

The performance ratings during the previous assessment period and

,

this assessment- period according to functional areas are given below:

Rating Last

Rating This-

l

Functional Area

Period

Period

Trend

Plant Operations

2

2

Radiological Controls

2

2

Maintenance / Surveillance

2/2

2

Emergency Preparedness

1

2

Security

1

2

Declining

Engineering / Technical Support

3

3

Safety Assessment / Quality

• NR

2

Verification

• NR = a new functional area that was not rated during the previous assessment.

B.

Other Areas of Interest

None.

3

hp9

y

s

G ', , ,

%

'

'

'

l5$ .

~

'

a

<

u

.

.'

p. p g <

E'

III. CRITERIA?

!

w

-

3 [,

t

\\*

.

. Licensee performance =is assessed in selected functional areas'

Functional

';

areas normally: represent' areas significant to nuclear safety and-the

,

environment'. ySome functional areas may not.be assessed because of.little'

-i

,Bu

Lor no licensee activities or lack of meaningful observations.

Special-

'!

'

~ areas may be added to highlight-significant: observations..

(

jh

The following evaluation criteria-were used to assess:each functional

I

gr

. area:

l '. -

Assurance of quality, including management involvement and control;

v

Y

'2.-

JApproach to:the identification and resolution of technical issues

,

{'

from a1 safety standpoint;

'3..

Responsiveness to NRC initiatives;

y;

y

4L

Enforcement history;

'

,

'

'

5 .'

Operational events (including response to, analyses of, reporting

I

,

of, and corrective actions for);

~

l

16.-

Staffing;(including management); and

>-

,

7.

Ef fectivenesst of training and qualification program,

JHowever, the NRC is .not limited to these criteria .and others may have

/

been'used where appropriate.

'E

'On the basis-of the NRC assessment, each functional area evaluated is

rated according to three performance categories. The definitions of

these; performance categories are as-follows:

<

b

. Category 1:

Licensee _ management attention and involvement are readily

,

evident.and place emphasis on-superior performance of nuclear safety or

safeguards activities, with the resulting performance substantially

exceeding' regulatory requirements.

Licensee <resou'rces are ample and

,

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

'is being achieved. - Reduced NRC- attention may be. appropriate.

.

.

.

>

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 attention 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.

4

'

__ _

ff

g

-

i

~ '

,

n -r;

<

.

k .2;&j;

f.)ijp:- f e;r.

~

'

-

f

e;

,

• - . x;

.

j

'

The' SALP Report may', include an _ appraisal ~of the performance trend in a

-

,

functional ~. area for. use as ~a predictive-indicator.f Licensee performance

'

-

during.the.' assessment period should be examined'to determine whether a-

' trend: exists.-7Normally, this' performance trend.should only be used if-

h

4

B

~both,a-definiteLtrend is discernable and continuation of the trend may:

g.

,

result in.a change'in p'erformance' rating.

i

e .g

l'

The1 trend, if.used,;is defined as:

~ !

s

-s ,

,

"

-

Improving:

Licensee performance was determined to'be'-improving-..during-

[

,

lg ,.

Lthe-assessment period..

k,

)

. ,

I'

.

.

..

7

Declining:- -Licensee performance was determined:to be declining during

S

, ,

Lthe asse:,sment period,'and the licensee had not taken ' meaningful steps to:-

4

,

-address-this pattern.

m

'

]

Q

, '

1

.[h

.

,

4

.-

'

p

[g

'-f

i;> '

1

6

>

'

-

i

,.4 2

1

.. f

a

n

-

i

4

- f.

~

,,

.

l.

w

5

-

,

t

,

3'

i

..

f.

' ' Y_ -

l

g

..

g

.

,

._

i

p

a-

,

34_m

4,

-IV.

Performance Analysis

A.

' Plant Operations

i

1.

. Analysis

i

Evaluation'of this. functional area was based on -the results of

nine routine inspections and one special inspection conducted

by the resident

inspectors.

_

k

The' enforcement history for this functional area showed

t

,

improvement from the previous _ period.

Four Severity. Level 1IV

violations were issued, compared with six Severity' Level IV-

[_

violations and one Severity Level _ V violation issued during

F

the previous-assessment period.

The four violations involved

6

operator' personnel errors.

Two violations were identified.in

which the licensee failed to' comply with Technical

Specification (TS)-limits on operation:

Unit'1' operated with

L.

one containment spray-(CS) train in. operable beyond the248-hour

'

. limit that warranted escalated enforcement consideration and

mode changes were made'with the pressurizer power-operated

relief valves inoperable.

The licensee has initiated a Performance Improvement Plan-

(PIP), which includes the Human Performance Evaluation System

.A

(HPES), designed to evaluate Deviation Reports (DVRs) and

)

Licensee Event Reports (LERs) to identify the root-cause,

Through the identification-of the root-cause of the human

ierror; human-performance has shown improvement and operator

personnel error events have declined.

=C th regard to events, the' station's trip performance declined

d

somewhat during this assessment period,

Unit I trippea three

times from power; Unit 2 tripped twice from power and also

D

-

tripped from 0% power during control rod withdrawa'l for a.

j

startup. One of the trips resulted from. operator personnel

9

errors. There were 10' engineered safety feature.(ESF) actuations

-

..

associated with Unit 1 and 4 ESF actuations associated with-

'

Unit 2.

The total of 14 is comparable to _the 13 ESF'actuations

reported during the previous assessment period.

Eleven of~the

ratuations, including four of the reactor trips, occurred during

j

aaintenance or surveillance activities as discussed in

q

Section IV.C., Maintenance / Surveillance.

In spite of the

q

perturbations resulting from the maintenance and surveillance

activities and system upsets, the operating crews handled the

-j

off-normal situations in an excellent manner.

1

The number of events that resulted in LERs issued during this

{

18 month assessment period that were attributed to plant

i

operations represents a slight decline from the number of

f

operations-related events during the previous 16 month period.

j

Several events resulted from personnel errors, including inree

j

1

1

6

$

h

w

i

q

,

.. .

.

>

G.

.in which TS requirements were not met by shift personnel.

One

of these, events resulted in a violation.' However, the number

F

of events related to personnel error declined from that of the

E

previous assessment period, and the operations-related events

'

'

accounted for a smaller percentage of the total events.

This

improved performance may be attributed to'the licensee error

evaluations and the implemented elements of the HPES.

,

L

- Management involvement to assure quality;in the: operations _

[

area was mixed. Operating decisions sometimes involved narrow

'

interpretations of TS requirements concerning component

operability. This resulted in failures to enter action

L-

statements for inopereble safety-related components or trains.

The operations staf_f does not routinely consult with the

technical staff'regarding operability concerns.

In one

,

example, a concern was raised by the technical staff regarding

I

changing the flow rate with the lower capacity Auxiliary

Feedwater (AFW) pump -aligned -to the crosstie header. The

concern was disregarded by the' operations staff. NRC attention

was often necessary before the licensee made conservative

.inoperability declarations.

Examples include:

inoperability

of the 28 AFW pump following discovery of incorrect installment

l

of the steam jet impingement shield; inoperability of a service

'

water strainer backwash isolation valve; inoperability of a CS

train following discovery.of an inoperable supply valve; and

i

inoperability of the turbine-driven AFW pumps following

identification of a design deficiency.

In addition, there was

s

an instance in which the licensee continued operation without

e

'

addressing worsening equipment trends.

This. instance involved

i

back leakage through AFW check valves that resulted in elevated

d

casing temperatures leading to the potential for steam binding

'j

.

of the AFW pumps. The Region issued a Confirmatory Action Letter

(CAL-RIII-88-017) documenting the actions associated with the

'

repair of the AFW valves.

There were, however, examples of conservative operating decisions

4

to address equipment problems.

These included unit shutdowns

!

or power reductions to address pressurizer spray valve (PSV)

packing leakage, a malfunctioning individual rod position

indicator, and an AFW pump operability question involving the

-

anti pump feature. Shutdowns to address equipment problems were g,

j

typically conducted in an orderly manner.

Other examples of good control of operational events by on-shift

managers included the prompt and effective response to an acid

,

spill and electro hydraulic control (EHC) oil leaks experienced

j

on Unit I when the alertness of operators allowed the Unit tc be

1

maintained in a stable condition.

In addition, operator action

j

was effective in mitigating the impact on both units during an

{

offsite grid disturbance and the resulting voltage drop on a

]

Unit 1 ESF bus. Also, operator actions were exemplary when

3

PSV packing leakage problems caused operators to take manual

l

7

pp

yy

-

--

-

g

&

,r

..;

.

3

control.of the reactor and maintain reactor coolant system (RCS)-

pressure by using the pressurizer heaters, thus preventing a

' reactor trip.

The operating staff has been very responsive to

n

and effective'in controlling different plant evolutions.

The-licensee's responsiveness-to NRC initiatives was generally

good. The licensee's resolutions of resident inspector

~

'

identified safety issues were generally sound and thorough.

Licensee efforts to resolve the operability concerns detailed

-above were usually thorough, although inspector follow-up.

was often necessary to initiate action.

The material condition, housekeeping and fire protection of the

plant fluctuated.

In late 1988, around the time of the Unit 2-

.

refueling outage, the number of oil, steam, and water leaks was

a concern, as was the number of continually back-lighted

annunciators and inoperable instruments in the control

room.

Station housekeeping / fire protection procedures were

revised and improved to resolve these concerns. -The plant's

material condition has since improved, including a high degree

of cleanliness in the turbine building.

The licensee has

'

undertaken a substantial painting program, as part of its model

space concept, in order to improve the appearance of the plant.

As a result of the company's INTROSPECT Reorganization Plan,

the licensee provided a staff engineer and an- Assistant Fire

Marshall to support the fire protection program.

Control room conduct and professionalism were generally

adequate.

Operators generally adhere to corporate and plant

procedures regarding control room decorum.

Control room

,

conduct has improved with a few exceptions that include

congestion during shift turnover and surveillance activities

i

and loitering by non-licensed personnel.

Late in the

assessment period, the licensee implemented a quiet hour policy

in the control room during shift change to-improve the quality

,

of the shift turnovers.

Operator knowledge of plant status was

generally good, but failures to recognize or correctly implement

regulatory requirements still result in events and violations.

.

During this assessment period, six senior reactor operator (SR0)

and four reactor operator (RO) replacement examinations were

'

given. All candidates passed the replacement examinations,

maintaining the pass rate of 100% exhibited during the previous

assessment period.

In addition, six SRO and six R0

requalification examinations were administered.

Four SR0s and

three R0s passed the requalification examinations, yielding a

pass rate of 58%. No requalifications exams were given during

the previous assessment period.

8

c

E

a w

.

'

..-

Staffing was adequate overall; however, staffing was reduced due

>

to the number of operators who failed the requalification exams

administered during the third cycle of 1989. As a result of

.t

eW

this reduction, the Unit 1 outage placed additional strain and

increased overtime obligations on the operations staff.

Although no operational events occurred as a result of operator

overtime, the licensee's overtime policy remains a concern,

i

Corporate management is developing a Nuclear Operations-

Directive to establish a uniform overtime policy governing

safety-related work in accordance with guidelines in Generic

,

Letters (GL) GL 82-12 and GL 83-14.

Full implementation'is

expected by April 30, 1990.

'

-Numerous station-management personnel changes were made during

this assessment period without significant impact on day-to-day

. operations. -Team work is encouraged by the new station

management to improve' communication between departments,

,

improve station personnel attitudes and promote ownership of

',

identified problems and corrective actions. The new station

management appears to be striving to resolve many operational

problems through the implementation of an intense problem

identification program entitled Performance Improvement Plan

',

(PIP). The licensee has identified a list of 300 action items

and.has aggressively taken actions for resolution of the 60

highest priorities.

(The PIP is discussed in more detail in-

Section IV.G.,oSafety Assessment / Quality Verification). Also,

to increase management involvement in operations and daily

,

_

plant activities, station management is required through PIP

'

,

. to routinely . tour- the plant.

The licensee's approach to the resolution of technical issues

from a safety standpoint was inadequate in some cases. This was

evidenced by the untimeliness in addressing self-identified

potential safety concerns, and in poor job planning within

the operations department and with other departments for the

performance of routine operational tasks. Operations management

demonstrated a lack of timeliness in responding to concerns

-

raised by the technical staff when the flow path from the

motor-driven AFW pump to the steam generators (SG) was in

question. The lack of timely, aggressive action on the part of

the operating personnel resulted in exceeding the TS Action

Statement for establishing the operable flow paths. Operating

personnel demonstrated inadequate job planning on two occasions.

Y

'

During the first occasion, the licensee entered the containment

because of increasing PSV leakage.

However, because personnel

were not properly prepared or adequately briefed, both-PSVs were

inadvertently isolated.

Increasing PSV leakage has been a

recurring problem for Unit 2.

In the second occasion, involving an

unplanned gas release, the operations crew failed to recognize

the potential for a repeat gas release due to plant corditions

and demineralizers' status. This resulted in two unplanned gas

releases to occur within two days.

9

..

.

-

y

,

,

.

g y w :.

W

j

'

.

C'

p'

T

i

2.

< Performance Rating

. _

.

.

.

The licensee's performance is rated Category 2 in this area.

sl' y

The licensee's performance was rated Category 2 in the previous

',

assessment period.

3.

-Recommendations

.

'None,

,

n

[

B.

. Radiological Controls

,

g _

1.

Analysis

Evaluation of this functional area un, based on the results of

.

seven inspections performed by regional inspectors and

observations made by resident inspectors.

t

' Enforcement-history in this area remained about the same as that

q

of the previous assessment period. One Severity Level V and

I

r

four Severity Level IV violations were identified during this

. period, compared with two Severity Level- IV violations and two

. violations awaiting severity level classification identified'

i

during the SALP 7 assessment period. - The-four Severity Level

j

IV violations, regarding failures to meet' Department of

j

Transportation regulations for two radioactive material

shipments, do not represent a'significant. programmatic-problem

<

since they had different root-causes and were isolated. incidents.

Staffing levels and-qualifications were adequate to' implement-

the. routine- chemistry 'and radiation protection (RP)' programs.

'

The reorganization of the Rad / Chem-Department-into separate

Chemistry and RP departments, each with its own supervisor,

was designed to provide greater oversight of each area and

'

,

increased specialization,

l

u

Management support of RP and chemistry. programs was mixed.

'

Support of RP outage needs was generally good, with sufficient

!

augmentation by contractor RP technicians (RPTs), good

1

contractor RPT training,-and facility changes to enhance

outage activities. However, management control weaknesses were

noted regarding:

the timeliness and thoro ~ughness of reviews

and corrective actions for problems identified by the Radiation

Occurrence Reporting system; the lack of adequate procedures,

-

instrumentation, and pre-job planning for fuel transfer canal

i

work; and high radiation area entry and 1 Rad door key control.

Good primary and secondary water quality, monitoring

-

instrumentation, and process system upgrades resulted from

continuing management support for the chemistry program.

E

However, the quality of the chemistry technician performance

testing program, which was well-implemented early in the

assessment period, declined somewhat in the latter part of the

period.

10

a.

LV

'1-

-

-

y~,

-

f;

N

.;

N gy :+

'

i

l'

[?-

._

lThe licensee's responsiveness to NRC: initiatives was generally-

4

g

,

.

2,-

W~

good,with some exceptions. .The licensee improved'the chemistry'

i

's

~ e

and Quality. Assurance / Quality Control (QA/QC) program,

<

y

-implemented prompt and thorough corrective action in-response-

'

F

to v.iolations, and improved the radioactive material control

program. .In contrast, although concerns regarding the process-

j

i

and ef fluent- radiation monitoring- systems' have persisted for:

..t

several years, the~ licensee has not adequately resolved the

issues. The monitors were frequently inoperable due in part to

L

unreliable equipment, antiquated:and incompatible. systems.and-

j

.

h

- components, and failure to aggressively pursue and resolve-

.

operability problems. The unreliability of the monitors has

placed a significant burden on the operations, maintenance,

,

'

system engineering, radiation protection,-and chemistry staffs..

The.-licensee's approach to resolution-of-technical. issues from.

'

-

a safety standpoint was mixed.

Examples of good performance.

j

included:- improvement of reactor head work through the:Use-of:

'

advanced robotic and video technology; special, well-monitored

m

temporary outage access control facilities; effective use of

portable ventilation systems; and performance-based QA

"

surveillances of solid radwaste/ dewatering activities.

Examples-

of poor performance included:

personnel errors and lack of

adequate procedures that led to' the radioactive' material shipping

, , '

violations; poor work-planning and: document controls that led'

l

- tocunnecessary work in the fuel transfer ' canal resulting in -

j

r1

added personnel exposure;:and-unplanned gaseous releases.due to-

'

inadequate job planning and' poor interdepartmentalicommunication.

i

The personnel: radiation exposure in 1988 was about <1260

'

person-rem, which was high.

It-is recognized that the licensee

incurred much of the exposure on unanticipated outage work.

Nevertheless_, work planning and-As-Low-As-Reasonably-Achievable

(ALARA) program deficiencies appear to-have contributed to the

]j

high annual dose. Gaseous and liquid radioactive-releases and-

<!

the solid radwaste volume continued to be low.- No radwaste

l

shipping' violations were identified by the waste burial

facilities.

.i

The results of the nonradiological confirmatory measurements

1

were very good, with_34 agreements in 36 analyses.

However,

some of the agreements with high biases were achieved because

of poor measurement precision.

The results in the corporate

i

interlaboratory comparison program declined somewhat over this

j

'

assessment period.

The quality of radiological- confirmatory

l

9

measurements declined during the period, with 89 agreements in

'

b

100 comparisons. A pervasive negative bias was noted in all

j

media analyzed. -The Radiological Environmental Monitoring

Program, conducted under the auspices of the corporate office,

appeared to comply with regulatory requirements.

{

p

i

11

M

-

+ +_

.-

-

L.

y

.

.

i

..

2.

Performance Rating-

_

The licensee's performance is rated Category 2 in this area.

3

.

The . licensee's performance was rated Category 2 in the previous

i

[

assessment period.

l

'

.3.

Recommendations

i

t

i

None.

'

C.

' Maintenance / Surveillance-

1.

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

. routine inspections performed by the resident inspectors, three

routine-inspections by regional inspectors, and a Maintenance-

Team Inspection (MTI). Maintenance and Surveillance were

separate functional areas in the previous assessment period, but

have been combined as one fun:tional area for this assessment.

F

The enforcement history was acceptable.

The most significant

violations issued involved failures to comply with maintenance

1

procedures or with documented requirements and failures to

j

perform post-modification testing.

'

The majority of the events resulting in LERs were directly

attributable to maintenance and surveillance activities.

The

'

majority of these were caused by' errors made by plant personnel

during the execution of surveillance, maintenance, modification,

1

and troubleshooting activities.

Also contributory to'these errors

i

was the failure of plant personnel.to recognize or implement

l

TS requirements.

Personnel errors contributed to two reactor

l

trips and several non-trip ESF actuations during this-assessment

!

period.

}

,

!

Personnel errors and procedural inadequacies demonstrate a

!

weakness ia management involvement to assure quality. The errors

i

and problems involved were not limited to any one station

department, but were indicative of a lack of attention to detail.

Although management involvement was evident by-the work in

progress on assigned sections of the Conduct of Maintenance

programs, implementation of these programs appeared to be lagging.

Q

Because of the lack of or ineffectivenFss of interim mea'sures,

!

weaknesses such as incomplete work packages, inadequate procedures,

and inadequate post-maintenance testing have not yet been

3

corrected by the maintenance pilot programs at Zion.

Some

?

problems were noted in the proper categorization of nuclear

i

work requests, however no critical work appeared to be

'

inappropriately delayed.

The licensee addressed this issue by

re-evaluating the work request prioritizations that resulted

j

in significant changes.

Several instances were noted where

]j

waintenance personnel failed to follow procedures or maintenance

procedures were inadequate.

In one case, this resulted in a

i

miswired torque switch on an AFW pump turbine main steam inlet

valve that subsequently tripped on thermal overload.

l

12

y

-

?

,

n! :;. m

4

,

x

Late'in the assessment period, licensee management developed

and implemented the PIP to address these deficiencies.

Implementation of program elements was progressing at the end

-'of the assessment period;.however, the effectiveness of the-

. program has yet to be evaluated by the NRC. Also, on the

positive side, an increased sensitivity to identifying and

~

. correcting hardware deficiencies resulted in-a significant

'

improvement in~the material condition of the plant and is

directly attributable to management involvement.

- There usually was evidence of prior planning in maintenance,

surveillance, and Inservice.Inspec. tion (ISI) activities. The

Unit 1 outage that commenced on September 7, 1989, appeared to-

be well planned with no major-setbacks.

On the other hand, there

4

were instances of maintenance activities performed that were not

'

adequately-planned; for example, inadequate planning resulted in

a missed QC holdpoint and in another instance created a potential

release path to containment atmosphere through AFW and SG.

The licensee's approach to identification and resolution of

technical issues from a-safety standpoint needed improvement.-

For example, recurring failures of battery-to-bus circuit

,

breakers to close on the first attempt were not evaluated or

corrected for an extended period of time.

Also, more management

involvement and commitment was needed to correct recurring

problems with radiation monitors (RMs) due to excessive- failures

of aging RMs and a high degree of inoperability. On the. positive

side, the licensee took immediate action to establish correct

main steam safety valve (MSSV) setpoints when it was determined

that the calibration and adequacy of test e'quipment was adversely

4

affected by the surrounding temperature.

Staffing in maintenance was generally adequate.

One indication

j

- of this was the manageable size of the maintenance work request

"

backlog. The non-outage corrective maintenant:e work request

l

backlog was-approximately 1200. Although the station goal of

ld

850 pending work requests was. not met, the backlog was within-

-

the capabilities of the current staff. There was approximately-

eight weeks of work to eliminate the backlog. A review of the

corrective maintenance backlog in July 1989 did not identify any

j

work requests that had an impact of equipment operability.

The

l

,

-preventive maintenance (PM) backlog was Inanageable; however, the

[

lack of comprehensive and complete reviews of vendor equipment

l

manuals for inclusion of necessary or desirable PM activities

- i

brought into question the adequacy of the scope of the current

PM program.

For example, the overspeed trip for the turbine

.

driven AFW pump was not incorporated into the program although

the test was recommended by the vendor.

13

.-

.

-

gy

y,

k

.. .

n

i

.

h'

.

.

>

The ISI personnel were well qualified, appeared to be

i

knowledgeable'and conscientious in their work. Outside

l

consultants were utilized at an appropriate level with adequate

,

' '

oversight being provided.

-

licensee management was not always responsiv6 in dealing with

ii

problems ana weaknesses identified by NRC inspectors such as

work instruction adequacy, work p wkage preparatiot,

!

'

documentation of work activities, tnd repetitive equipment

i

k,

failures. A response to address those shorte.omings was made ~only

l'

. at the end of the assessment pericd, some four months after it

was requested.- The licensee's docketed written response

~ delineating corrective actions to weaknesses and violations-

l

identified during the MTI did not address the possible generic

implications of.the_ findings, but rather foc ned only.on the

,

,

'

specific violations identified.

However, subsequent discussions

'

with the licensee' revealed that elements of their PIP, wnen fully.

implemented, would address the generic weaknesses in their

maintenance program.

!

2.

Performanca Rating

-

,

The licensee's performance is rated Category 2 in this area.

The licensee's performance was rated Category 2 in Maintenance.

j

and Category 2 in Surveillance in the previous assessment

. period.

)

i

3,

Recommendations

,

None.

?

D.

Emergency Preparedness

i

1.

Analysis

Evaluation of this functional area was based on two exercise

evaluation; and two routine inspections conducted by regional

inspectors, and three int,pections conducted by the resident

staff.

,

,

Enforcement history emained good. No violations were identified

during this or the previous assessment period,

y,

Management involvement in ensuring quality was insufficient

L

dur'ng the early months of the assessment period, as indicated

by fuur weaknesses. identified during the September 1988 exercise.

The exercise scenario was very challenging, including systems

degradations sufficient to warrant a General Emergency

declaration and a simulatea transportation accident involving a

dry active waste shipment with multiple injured and/or

contaminated accident victims.

The licensee'; response to the

transportation accident was inadequate, requiring a remedial

a

b

14

i

I

k. - -

-

.

-

.

.

.

f

demonstration of response capabilities that was successful.

!

i

Weaknesses, not associated with the transportation accident

I

response, that were identified during the September 1988 exercise

,

included: en untimely Site Area Emergency reclassification

decision following loss of all feedwater, and the inability to-

,

keep State and simulated NRC officials adequately. informed of

some' degrading conditions associated with that loss. Another

example of insufficient management was ti.at an unsuccessful-

accountability drill was not redone entil after inspectors had

i

expressed their concern to Station Management.

4

The licensee's internal evaluation of the 1988 exercise

l

performance agreed closely with the NRC's evaluation. Both

h

exercise evaluations, together with a thorough self-assessment

'

of.the Zion Station's emergency preparedness program conducted by

corporate and other stations emergency planning staffs, resulted

i

'

L

in a notable increase in the level of management attention to the

-;

F

program by early.1989.

The effectiveness of remedial training

efforts and several procedure upgrades was evidenced by the

r

successful performance during the April 1989 remedial

transportation accident response and the improved performance

L

during the May 1989 exercise. All items identified during the

,

September 1988 exercise and many other previously-identified

,

r

items were closed before or during the May 1989 exercise

r

'

inspection. However, two problems were identified during the

1989 exercise. Contamination control provisions were

inadeque:h at the Operations Support Center.

The licensee also

t

had dif N ulty keeping State officials informed of shifting

wind conditions which could later have affected protective

'

action decision making,

j

The licensee's identification and resolution of technica1' issues

was adequate.

The emergency plan was activated correctly on

'

two occasions through February 1989.

State and NRC officials

'

'-

were initially notified in a timely and adequately detailed

.

manner following both emergency declarations.

Internal

evaluations of both declarations were adequately performed.

.

As part of the corrective actions for the inadequate response

to the transportation accident scenario, the licensee worked

with local officials to develop a procedure for responding to a

transportation accident involving radioactive materials within

the city of Zion, Illinois. The notification form used by State

officials to document information regarding such accidents was

finally proceduralized, after having been in the Emergency Plan

for several years. The licensee's self-assessment of the Zion

,

Station's emergency preparedness program was very tnorough and

expanded on procedural and training program concerns identified

during previous NRC inspections.

This self-assessment was

performed in addition to the adequate efforts of the QA

Department.

In early 1988, the licensee identified the need to

repair and periodically test the Emergency Operation Facility's

(EOF) emergency ventilation system and associated radiation

15

y

-

. - -

.

.

l

'

s

monitor.

Equipment repairs, testing, and calibration activities

,

had been completed by mid-1989. However, surveillance

procedures to prevent a possible recurrence of equipment

.

degradation had not been completed by May 1989, over one year

'

after the licensee initially identified the problem,

1

it

..

L

The licensee has been responsive to NRC initiatives.

The

p

licensee fulfilled a commitment, resulting from the.1987 Federal

Field Exercise, to upgrade the evacuation time estimate study

for the-10-mile Emergency Planning Zone. 'The upgraded study was

n

approved in 1989. The licensee adequately re-evaluated an

internal critique of a medical drill after being advised that

its initial critique was ineffective since it had dismissed a

number of significant concerns rather than acting upon them to

n.

L

improve performance. The licensee committed to the State of

E

Illinois to upgrade the training provided to RPTs who may assist

hospital personnel in dealing.with a contaminated / injured

victim.

The licensee conducted a successful accountability

drill in December 1988, after being advised that an earlier,

unsuccessful drill would not satisfy an Emergency Plan

commitment.

Staffing levels for the onsite Emergency Response Organization

(ERO) remained good during early,1989, despite the changes to

the normal station organization caused by implementation of the

,

L

INTROSPECT Program. Three to five persons were identified for

each key position in the onsite ERO, with no instance in which

an individual. was predesignated for multipie p sitions.

The

licensee has used semiannual, off-hours drills successfully

to demonstrate its capability to augment onshift personnel in a

timely manner.

The staffing levels of the offsite ERO, which

consist of EOF and corporate EOF personnel, remain excellent,

with at least ten persons identified from either the corporate

office or from another nuclear station for each management,

supervisory, or senior staff position.

l

In response to NRC and self-identified items, the licensee

expanded its onsite ERO's training program in late 1988.

Control Room staff and appropriate members of the Technical-

Support Center (TSC) staff completed a " Team Training / Accident

Management" training program that addressed emergency

classification, offsite notification requirements, protective

action decisionmaking, and Control Room /TSC interface.

In

addition, the licensee initiated quarterly tabletop drills,

scheduled through 1989, which involve key onsite ERO staff.

'

The onsite ER0's annual training requirements and training

materials were also upgraded during the third quarter of 1988.

2.

Performance Rating

The licensee's performance is rated Category 2 in this area.

The licensee's performance was rated Category 1 in the previous

assessment period.

,

16

f

e

l

7<g

n

H,.-

l

!-

L

e

.

..

3.

Recommendations

i

None,

p

E.

Security

,

1.

Analysis

t

Evaluation of this functional area was based on the results

I

(-

of seven inspections (three routine, three special and one

!

'

-

i

Regulatory Effectiveness Review (RER]) conducted by. regional

!

specialists and headquarters personnel assisted by members of

the U.S. Army Special Forces, and routine observation _of-

security activities-by the resident inspectors.

.

N

-;

Enforcement history declined during this assessment period.

!

L

One Severity Level III violation with a civil penalty.and five

j

Severity _ Level IV violations were identified,_ compared with'one

'

'.

Severity Level IV violation during the previous assessment

b

period. These violations involved inadequate vital' area barriers,

access control, and licensee event reporting.

These. violations

are representative of a decline in performance and programmatic

i-

(

weaknesses relating to management oversight.

Although-no

L

significant vulnerabilities were identified during the RER,

16 weaknesses in the security program were identified reflecting

generally poor performance.

,

Ouring most of this assessment period, the overall effectiveness

e"

of site and corporate security and plant management in assuring

q'

the quality of the security program was weak.

This was evidenced

by the repeated violation for degraded vital area'barr ers and

_

/.

the weaknesses discussed previously. The corrective action

3

'L

taken was not effective at the time in correcting the root-cause

of the problem.

In addition to the violations, inspectors

identified other deficiencies that demonstrated weak management

effectiveness. These weaknesses involved:

poor identification,

-prioritization, timeliness, and trending of the security work

_

orders; a decline in guard force performance demonstrated by

two instances in which guards were inattentive to duty; a need

for additional performance-oriented QA audits and increased QA

surveillances; and a general lack of management effectiveness

.

that was demonstrated by the various violations and weaknesses.

'

~

Toward the latter part of the assessment period, the licensee

assigned a corporate security representative to the facility to

assist in supporting site security management.

Preliminary

indications appear to show positive results from this action,

The individual recently contributed positively to the management

of a tampering review case.

l

17

-

2

m. s

J

'

.. o

.

,

,

i

.

The licensee's resolution and identification of technical- issues -

$

was mixed. The security evaluation conducted by a consultant-

-

appeared to be adequate and addressed the technical requirements

L

of a vital area barrier.

The licensee's actions to address the

h

barrier problems were m % ed. 'In some cases, the licensee took

.

L

adequate measures, but b another case the barrier was poorly

installed. Additionally, the licensee hired a security-

'

1-

consultant to prepare for the RER; however, the licensee did not

take adequate actions to correct identified problems. 'The

.i

I

reliability of the security computer system was considered a

k

strength.

.

s

I

The licensee's responsiveness to NRC initiatives was weak, as

L

evidenced by the less than adequate corrective actions that

'

resulted in a repeat violation.

The licensee was slow to

L

respond to NRC concerns when the issue initially was-identified.

The licensee took a less than conservative approach to reporting

security events, which resulted in a violation. Thezlicensee

tended to address findings narrowly, rather than review a broader

scope, when dealing with corrective actions.

-

'

Similarly, the licensee's actions to address the security

'

events related to construction activities onsite were weak.

This was clearly evidenced by the occurrence of the repeat

violation involving barriers degraded by construction

activities. The licensee's weak performance relative to the

construction project was further indicated by a lack of

,

consistent communications between construction and security-

l

organizations. This less than effective communication was

neither identified nor reviewed by corporate or QA organizations.

l

_

,

[

Security staffing levels were adequate to ensure a level of

performance that met regulatory requirements, but resources were

'

somewhat strained when additional responsibilities were placed

on the staff.

The licensee augmented the security staff at the

end of the assessment period.

Positions within the licensee

'

and contractor security organizations were properly identified

and defined.

The training program was adequt.te; however, its

-t

effectiveness was limited by available personnel resources.

-

The licensee augmented the training staff at the end of the

' assessment period.

This should provide An enhanced program,

j

2.

Performance Rating

a

The licensee's performance is rated Category 2, with a

declining trend in this area. The licensee's performance

was rated Category 1 in the previous assessment period.

3.

Recommendations

The NRC will increase inspection effort in this area in order

to increase management effectiveness,

18

_ _

-_.

.

,

__

- - - - _ _

w 4.

'

.

-

c

,

l

F.

Enoineering/ Technical Support

,

p

I.

Analysis

!

Evaluation of this functional area was based on the results

of four inspections conducted by regional inspector $, two

>

L

licensed operator examinations conducted by operator licensing,

a maintenance team inspection, routine inspections.by the

resident inspectors, and evaluations of licensee technical

p

submittals by NRR.

L

Enforcement history during the assessment period involved a

violation related to the purchase-requisitions for MSSV testing,

.

L

in which the licensee failed.to include requirements necessary to

L

ensure adequate testing, and a violation for failure to perform

,

'

'

10 CFR 50.59 safety evaluations for some temporary alterations.

..

Although these two Severity Level IV violations represent a

f

L

significant decrease in the number of violations from the

r

previous assessment period, they were both significant. Also,

an Environmental Qualification Category C violation with no

,

'

civil penalty was issued during this assessment period.

In the

,

former case, the consequences of this violation contributed to

the plant operating in an unanalyzed condition, while in the

L

latter case, the violation was a repeat violation from one issued

as a result of the NRC's Safety System Outage Modification

Inspection (SSOMI) inspection in 1988.

Both-issues are

discussed in more detail below. At the end of the assessment

i

period, a Confirmatory Action Letter (CAL-RIII-89021) was'

issued relating to the licensee's unsatisfactory requalification

program for licensed operator training. -That program resulted

in the failure of one of three operating crews tested during

NRC simulator evaluations' conducted in September 1989.

Two

additional operating crews were administered simulator

.

examinations to confirm continued safe plant operations.

F

These crews successfully passed the evaluations.

Management involvement to assure quality was mixed.

On the

-

positive side, adequate planning was evident in the fire

.

protection upgrade activities for emergency lighting.

In

addition, prompted by the previous assessment period concern of

deficient procedures, the licensee has continued to update

surveillance procedures such as the automatic fire protection

system, safety evaluations, temporary alteration program and

ESF actuation surveillance procedures.

However, this has not

always resulted in effective procedures.

For example, inadequate

surveillance procedures resulted in an actuation of Unit I

containment isolation valves.

Functional testing of logic

r

systems only verified relay actuation, not contact actuation,

and resulted in the surveillance test failing to detect the

unconnected secondary undervoltage wiring that would have

provided the signal to auto-close the Essential Service Breaker

.

No. 2484 in response to a degraded voltage event.

19

.

-.,

P

p

.

. . .x

{'

.

1

'

.

(

. .*

There were many examples of deficient operational conditions

L.

where engineering involvement was lacking.

These included the-

failure to involve system engineers in generic problem analysis,

e

post mM ntenance testing, and root-cause analysis, and there

was a general lack of communication with coordinators of generic

_

functions such as the vibration coordinator.

In addition,

'

engineering personnel were not sufficiently involved in the

interpretation of the TS made by operations management personnel

4

as discussed in Section IV.A., Plant Operations.

During the implementation of the requalification program,

management oversight was lacking in the exam preparation

proce s s .~

For example -the joint licensee /NRC exam-team

ndirected changes to the exam were not correctly or fully

incorporated, requiring numerous iterations to obtain an

acceptable exam. The facility operations representative was.

,

absent during the exam review.

In addition, there was a lack of

available simulator time.to perform the basic review of the exam

prior to administration.

Also,' insufficient management oversight contributed to the

L

licensee's failure to implement prompt corrective action for-

the. Severity Level IV equipment qualification violation

,

identified in a previous assessment period, which continues to

i

remain unresolved. Although the licensee had made procedural

improvements to the safety evaluation and temporary alteration

programs, these were only partially effective.

In the

performance of safety evaluations, the licensee applied a very

narrow focus that allowed' alterations to be performed to TS'

J

equipment or systems without evaluations. This was the root-

cause of one of the above violations, When performed, the-

quality of the safety evaluations was very good.

Management control of contracted services was insufficient

to assure prompt correction of cable-tray deficiencies or

adequate performance of MSSV tests.

In the case of the cable

trays, the contractor had performed an extensive detailed

walkdown inspection in response to the SSOMI findings, which

were identified in 1988, that had identified 58 examples where

electrical cable separation criteria had been violated.

However,

as of September 1989, only three of these examples had been

-

,

thoroughly evaluated by the licensee.

In the care of the MSSV

testing, the examples relate to both the 1988 testing and 1989

testing.

In 1988, the valves were sent to a contractor for

testing using nitrogen gas without specifying what were the

appropriate testing acceptance criteria,

Upon return, they were

installed. The licensee's failure to establish a correlation

between testing of MSSVs with steam versus bench testing with

,

other media represented a weakness that resulted in the plant

being operated outside of the design basis.

In the case of the

,

1989 MSSV testing, the results of the contracted test were

,!

!

20

e

i

p

'

>

L

j

.

.

.

1

h

,

'

affected by the methodology for test performance in that the

equipment was not calibrated for the temperatures at which it

i

was operated. As a result, 16 of the 20 MSSVs were declared

inoperable because their set points values exceeded the 1%

acceptance tolerance prescribed by TS.

Some of the licensee technical submittals and licensee / staff

j

interactions reflected poor quality engineering evaluations.

j

L

In particular, the staff identified a number of concerns with

i

the licensee's request for one-time relief from the TS for the

i

7-day limiting condition for operation of the shared "0" diesel

'

generator.

The initial amendment request was incomplete and

contained erroneous information in the licensee's analysis.

The

licensee's TMI Action Plan submittal, required by NUREG-0737

item II.D.1, is another example of poor quality engineering

i

evaluation with regard to performance testing of relief and

j

safety valves.

In contrast, the submittals for TS changes

,

regarding the boron injection tank and its associated components'

l

and the response letter to GL 82-33 " Requirements for Emergency

>

Response Capability," were considered adequate.

.

The licensee's approach to the resolution of technical issues

from a safety standpoint was poor. Systems engineers did not

adequately evaluate and correct generic problems such as failure

of battery-to-bus circuit breakers to close on the first attempt.

.

On mcre than one occasion, the technical staff and electrical

department appeared to accept the recurrent failures without

1

documenting their occurrence nor performing a root-cause

'

evaluation to correct the degraded condition. Also, in a

number of instances, vendor recommendations were neither

incorporated into maintenance procedures nor analyzed for

appropriateness. Some components requiring PM were not

identified in the PM program. Available industry information

and the licensee's self-assessments indicated a need for

periodic testing of the overspeed tria linkages for the AFW

turbine-driven pum). This condition aad remained untested for

over 13 years for Jnit 2.

A. test was conducted on the Unit 1

,

AFW pump in 1986.

'

Licensee responsiveness to NRC-identified initiatives was mixed.

Management controls of engineering evaluations appeared to be

improving at the time of the follow-up SSOMI. One example of a

good response was the licensee's thermal stress analysis of AFW

system piping as committed to in a Confirmatory Action Letter

(CAL-RIII-88-017) dealing with AFW system check valve

back-leakage.

The analysis adequately addressed the NRC's

concerns, although additional review effort by the resident

inspectors was necessary because some facets of the analysis

were not well-defined. On the negative side, in March of 1989

the licensee was six months behind in developing requalification

questions, and had developed none of the 15 required scenarios

and only 13 of the 75 required Job Performance Measures (JPMs).

Facility grading of written examinations failed to meet NRC

requirements.

21

.

- .

.

Also, the licensee failed to complete the design and

implementation of the Anticipated Transient Without a Scram

(ATWS) mitigation system actuation circuitry. Although the

licensee decided to revise their previously approved design,

the NRC staff was not notified of this decision until the start

of the Unit 1 September 1989 refueling outage. The modification

was implemented during the outage.

The staffing levels were generally adequate; however, there was

insufficient dedication of staff to the implementation of the-

requalification program and an excessive reliance on contractor

personnel. This first became apparent when the materials

developed for use required numerous modifications to meet the

,

standards.

The licensee's training and qualification program failed to

ensure a high degree of success in passing NRC-administered

operator requalification exams, alt 1ough the program did result

in a 100% passing rate for replacement exams. A total of five

individuals failed the requalification examination with

individual failures in each of the different evaluation areas

addressed by the examination (JPM, written examination, and

dynamicsimulator).

In addition, one operating crew failed the

simulator portion of the examination.

Facility JPM evaluators

demonstrated weaknesses in their techniques.

This raised NRC

concern over the training program for the facility evaluators.

The requalification exam failure rate resulted in the

determination that the Zion requalification program was

unsatisfactory. A Confirmatory Action Letter (CAL-RIII-89-021)

was issued on October 5, 1989, which specified accelerated

remedial training for those personnel who failed the examination

and enhanced training in the areas where training program

weaknesses were identified for those licensed individuals who

had not taken the NRC administered examination. All of the

corrective actions specified in the CAL are to ha completed by

March 31, 1990.

2.

Performance Rating

The licensee's performance is rated Category 3 in this area.

The licensee's performance was rated Category 3 in the previous

assessment period.

3.

Recommendations

The NRC will continue to conduct quarterly management meetings.

G.

Safety Assessment / Quality Verification

1.

Analysis

I

This functional area was evaluated on the results of nine

routine and two special inspections conducted by the

resident inspectors.

In addition, NRR's reviews of licensee

i

22

.

.

m

,

,

g,

,, . . . ..

.

submittals'and requests for amendments to the Operating Licenses

were considered. This is a new functional area and consequently

was not rated during previous SALP periods.

It contains similar

attributes, however, to the previous SALP functional area of

Quality Programs and Administrative Controls Affecting Quality.

The enforcement history in.this functional-area remains

'

unchanged.

Six Severity Level IV violations were issued.

Four involved failure to take. effective corrective action on

f-

deficiencies. Another involved an instance in.which the QC and

l-

QA departments signed off a hold point on the' wr ~g weld. The

last involved the failure of station personnel to initiate both

e

!

a discrepancy record and a deviation report' for MSSVs-that failed

to meet acceptance criteria.

During the previous assessment

'

period, six Severity Level IV violations and two Severity Level V

violations were issued in the related functional area of Quality

c

Programs and Administrative Controls Affecting Quality,

r

Management's efforts to reduce overall operational events was

t

. mixed. The overall number of events leading-to LERs remained

about the same as the previous assessment period as did the

.

percentage attributable to personnel errors. However, as

l

previously mentioned in Section IV.C., Maintenance / Surveillance,

the current assessment period experienced a marked increase in-

events caused by personnel errors while involved in maintenance

and surveillance activities.

i'

Management involvement to ensure quality was mixed. On the

.

,

positive side, late in the assessment period, the licensee

adopted a number of programs to improve the overall performance

at the station.

These include the initiation of the " Quality

'First" program at Zion to identify safety concerns, the

developement of a new Safety-Related Component List, and a

detailed clean-up to improve the plant's material condition

,

following the Unit 2 refueling outage. -Also, as mentioned in

r

Section IV.A., Plant Operations, the licensee has implemented

PIP with over three hundred improvement items identified.

In

. addition, the licensee's newly implemented HPES appears to be

effective in investigating the events caused by personnel error

in the area of plant operation; however, the program has not been-

>

effective in the area of surveillances.

Another positive aspect of the licensee's PIP was the

.

development of administrative measures requiring-key

management and department heads-to tour the facility in

'

multi-disciplined teams of two to identify safety issues in

need of prompt management attention. This program also served

l

to enhance communications between departments.

l

1

!

l

23

l

}

_

-

g

-

-

v

a.

..

.

r

Overall, the licensee's PIP appears to be an intense effort on

r

the part of licensee to identify new problems and correct

"~

existing problems. This program however, has just recently

been implemented and additional time will be needed to evaluate

,

i,

the program's effectiveness..

'

i

On the negative side, during this assessment period the licensee.

l

'

was slow in taking timely corrective action on previously

identified weaknesses and problems. 'In.one example, for several

-

,

[

years the licensee was aware of the need to perform a test on the

,

overspeed trip mechanism on the turbine-driven AFW pump. The

,

licensee was made aware of the need for this test through vendor

6

'information, an NRC Information Notice-(IN) and through other

(

licensee assessments. The testing was finally conducted in 1989

.

at the urging of the NRC.

t

h

Also, adverse trends in degraded equipment and increasing steam

i

generator tube leakage did not always result in early and

conservative corrective action by the licensee.

Efforts to take

is

prompt conservative corrective action improved following

L

heightened NRC attention.

j

,

The quality of QA audits conducted by the licensee was mixed.

l

,"

Some maintenance audits were not performance-based and were

i

-

narrowly scoped, addressing only small portions of maintenance

'

activities, Other QA audits appeared to provide good coverage

of PM in the mechanical and electrical disciplines and resulted

in the identification of several significant PM problems.

1

'

The licensee's . identification and resolution of technical issues

i

was mixed. The licensee's follow-up assessment of a safeguards

testing anomaly led to the discovery of the AFW anti pump problem.

The problem was resolved quickly and conservatively; the units

!

were brought to a safe condition, and a corrective modification

was_ implemented.

Self-assessment efforts were lacking in the

1

g

licensee's handling of out-of-tolerance Unit l'MSSys.

Following

[

determination of the as-found setpoints by a testing contractor,

the licensee failed to initiate a discrepancy record or deviation

report in a timely fashion, as required by procedure, and was

-

slow to recognize and evaluate the fact that Unit I had operated

,

in an-unanalyzed condition.

Although the safety significance of

the out-of-tolerance MSSVs was later determined to be minimal,

the issue demonstrated a need for improved coordination and

initiative among station departments involved in quality

verification activities.

p

Also, as noted in Section IV.A., Plant Operations, management at

times adopted narrow interpretations of the TS and Final Safety

Analysis Report (FSAR) commitments.

For example, shortly after

,

the close of this assessment period the NRC determined that the

'

licensee has been operating both units for several months with

each train of emergency AC power technically inoperable. This

p

occurred when the licensee failed closed the air crash dampers

L

i

24

,

l-

$

pg

n-

-

.

-

[: -

Q

.

. ,

s

y

'

.o

e

i

on the emergency diesel generator (EDG) room ventilation intakes.

by placing the EDG room ver ilation fans in pull-to-lock and

g

K

removing the air supply to the dampers. .The FSAR requires the

ventilation systems to automatically start on an ESF signal that

starts the EDGs. . The license conducted a 10 CFR 50.59 required

evaluation for changing the failure mode of the dampers, but

failed to recognize the effect that closing the dampers had

b,

on EDG operability in terms of the ability.to maintain the

F

EDG roem temperature below the FSAR specified limit of 115 'F

to protect room equipment.

The licensee's response to NRC initiatives was mixed. As noted

elsewhere,in this report, the station generally took effective

action to resolve issues, component operability questions, and

adverse equipment trends once they received attention by NRC .

inspectors end management.

The cable deficiency walkdown

,

[L

inspection conducted by the licensee in response to the NRC

SSOMI finding was effective; however, in most cases the

"

'

identified problems were not promptly evaluated or' properly

L

corrected.

!

One area of concern that developed during the assessment

period was the perception that control room operators

,

were reluctant to discuss safety concerns with NRC inspectors

for fear that they would be subject to criticism by licensee -

management,

Operations personnel met with Regional management

in Region III to discuss operations and inspectors interface .

during inspection activities.

The resident inspectors later met

with licensee management and operating crews to discuss the roles

t

and responsibilities of NRC inspectors.and how the NRC would deal

with licensee representatives.

Subsequently, control room

operator and NRC interface has, in general, improved.

The staff conducted substantial reviews of licensee submittals

during this assessment period.

The licensee's submittals in

support of license amendment requests were generally inadequate;

L

in most cases additional discussions and submittals were required

to resolve the staff's concerns.

Submittals requiring extensive

effort by both the staff and licensee were related to TS for the

common diesel, the reactor trip system, and-the containment purge

and vent system.

In some cases, the. licensee did not adequately

review submittals to ensure accuracy and consistency with the TS.

In one instance, the analysis provided by the licensee was

erroneous. The quality of the amendment requests and the

timeliness in responding to the staff's concerns require

considerable improvement in order to expedite the licensing

process. Additionally, the staff's review of a recent revision

of the FSAR revealed that the licensee had removed all

organization charts from the FSAR and replaced them with one page.

The organization charts are required by 10 CFR Part 50.34.

I

i

l

25

'

.l

""

'

'

~ -'

" ^

Wm

.

,

,

+.

v

.

g.

s

..

e .

. y. .

.

.

^ 4:> l0

,s ;

f.

U-

fp

.

.'{

,.

i

n-

. .

]

-

o , s.

.

.

.

..

.

- In general, the licensee's respor.se to Bulletins, IN and GLs

- was adequate.. However,; the licensee's response;to GL 83-37

' :

" Review of_ Technical Specifications to Determine-Consistency

'

'

. . . .

with Guidance in NUREG-0737" was: inadequate and the TS proposals

. !

eL

for several TMI action plan items have not beer, implemented.to-

- date..

b;

-

h; ,

r N

z2.

- PerformanceRhtinoi

-f

-

'

1

-r

,

The ~ 11censee's performance,is rated Category 2' in this area. -

j

> ;.

4

Because'this is a,new area, no rating is available'for the

]

.

,_

. previous assessment period.

. ,

-

,

< ,

- ;

3.

Recommendations

-

]a

V ,'

None.

'

tp

'

.

.i

'

I

'f

14

!

+

-t

k

.,

r

- ;

i

,

• h

.i

$

1

<

1

i

k,

+

!

..

I

i

1

.f

I

,

p

26

t-

L

' f

-.

. 6s -

, ,

, , , ,.

,-

,w

www w

.w

w

-

-

-* -~

-

w

-

p'

t-

l

6.

l

,

.,.

V.

SUPPORT DATA AND SUMMARIES

i

l

.

p~

f

A.

Licensee Activities

1..

Unit I

Zion Unit 1 began the assessment period operating routinely with

no significant power reductions or outages until late October'

1988, when it was shutdown for AFW pump repairs.

It continued

with these repairs and remained shutdown through early November

1988. During the first quarter of 1989, Unit 1 experienced a'

,

,

p

major outage to repair SG manway gasket . leaks and perform testing,

l

l

During the second quarter 1989.and most of'the third quarter 1989,

1

Unit 1 operated routinely with the-exception of a few short

!

4

'

outages necessitated by SG 1eaks. The unit ended the assessment'

period in a 70 day refueling outage.

!

E

Unit 1 experienced ten ESF actuations, and.three reactor trips

during the assessment period.

Two of the three reactor trips

.

-

,

occurred at greater than 15*4 power and one trip occurred at less

!

than 15*4 power.

Two of these trips were.the result of personnel

errors and one was the result of an equipment failure.

Significant outages and events that. occurred.during the

assessraent period are summarized below.

Unit 1 Significant Outages and Events

a.

During July 13-16, 1988, Unit 1 tripped on a low SG 1evel

with feed flow mismatch, and remained shutdown to repair

-

failed feedwater flow instrumentation.

b.

During July 23-26, 1988, Unit 1 tripped as a result of a

feedwater transient.

The unit remained shutdown to repair-

,

an extraction steam line weld overlay leak,

c.

During October 25-November 4, 1988, Unit I was shutdown

due to AFW pumps, component cooling pumps,.and service water

pumps auto-start failures.

Repairs were performed and

modifications to the ESF logic circuitry were made.

'

d.

During January 27-20, 1989, Unit I experienced a forced

turbine trip and related reactor trip during reactor

protection system (RPS) testing.

Repairs and adjustments

were made to RPS test lights.

e.

During February 6-March 3,1989, Unit I was shutdown to

,

replace a heater drain tank rupture disc and to repair

leaks on the 'IB' and '1C' SG primary manway gaskets.

27

m

..

.

e

f;

During March 8-9, 1989, Unit I was shutdown to replace the

transformer on a control rod individual position jurdiction

circuity that had burnt up.

g.

During August 21-23, 1989, Unit I was shutdown due to an

EHC fluid leak from a crack in the common supply line to

.

p

the No; 2 and No. 4 stop and governor valve,

h.

During August 27-31, 1989, Unit I was shutdown due to MSSVs.

being found outside the TS . limit.

[

'i.--

On September 7,1989, Unit I was shutdown for a scheduled

p

70 day refueling and maintenance outage; Activitics

L

included control room board changes as a result of

L

Detailed Control Room Design Review (DCRDR) modif.ications,

p

and EDG 'O' overhaul.

4

2.

Unit 2

F

"

Zion Unit.2 began the assessment period operating routinely ~with

no significant power reductions or outages.

During October 1988,

pl

Unit 2 engaged.in its scheduled cycle X-XI refueling and

L

maintenance outage and remained shutdown through December 1988..

During the first quarter of.1989, Unit 2 was shutdown for leak

repairs to SG '2A', and was back on-line by late April 1989.

.The unit operated routinely for the remainder of the assessment

period, with the exception of.short maintenance outages.

-Unit 2 experie. iced ESF actuations, and three reactor trips during

t

the assessment period. Two of the three reactor trips occurred

at greater than 15% power and one trip occurred at less than 15%

power.

Two of these trips were'the result of procedure

o

deficiencies and one was the result of personnel errors.

Significant outages and events that occurred during the

assessment period are summarized.

Unit 2 Significant Outages and Events

a.

During August 9-12, 1988, Unit 2 was shutdown to repair

SG 1eaks on '2A' and '2D' SG handholes, and performed

ultrasonic testing of essential service piping.

b.

During October 8-9, 1988, Unit 2 tripped due to a

negative flux rate caused by a control rod dropping into

the reactor, after a fuse was pulled in the rod control

power cabinet. Adjustments were made and unit was

returned to power.

!

28

e

.p.

_

+=:

x*

---

,

n

-

+'

4

,

,

n

'

'

c.

During October 12-13, 1988, Unit 2 experienced

turbine / reactor: trips due to a condenser low vacuum

'

signal that resulted from a faulty procedure. After

'

.

. adjustments were performed, the licensee. opted to remain

~

p.

shutdown to begin its_ refueling outage.-

d.

' During October =13-December 28, 1988,-Unit'2 was shutdown-

.

~.for. its Cycle XI refueling outage.

.

'

~

During January 15-February 1. 1989, Unit 2 was' shutdown'

e.

'

to perform '2A' SG primary to secondary leak repairs..

,

'

f.

During . February:20-22,1989, Unit 2.was shutdown to

>

- repair PSV packing leakage.

,

g.

During April 22-24, 1989, Unit 2 was taken off-line toz

perform repairs to packing leaks on the reactor coolant

! system loop '2D hot leg sample valves,

-

.

B.

Inspection Activities-

p.

g-

Thirty-nine inspection reports are discussed in this.SALP report

-

-

p

(June 1,1988 through September 31,1989) and.are listed in '

Paragraph 1 of this section, Inspection Data. Table I lists.the-

p

,

iL ,

violations by functional-area and severity levels.

Significant

b

inspection activities are listed in Paragraph '2 of this section,;

i-

.Special--Inspection Summary.

n

'1.

Inspection Data

y

a.

Unit 1

Docket No.:'50-295

Inspection Reports Nos.:

88013 through 88025, 89002

through 89008, 89011 through 89026, and 89029'through'

89032.

> .

b.

Unit 2

Docket No.: 50-304

4

.

Inspection Reports Nos.: 88014 through 88025, 89002

'

E

through 89008, 89011 through 89024. 89026 through 89028,

and 89030.

7

[

1

L

!

e

'

,

29

l

l

'

,

.

,

^

,=u

y

- .

.

..e

6

v

.. ,

a

g

, .

'

e

,

,

Table I

,

L

,

Number of Violations in Each Severity Level

+

'

Unit l'

Unit 2

Common

"j

Functional-Areas-

III IV

V

III

IV

V~~

III ~IV V

- A'.

Plant Operations-

T

2-

1

-1

-

-

-

-

B..

Radiological Controls ~

'

4

1.

-..

-

-

-

-

- -

-

C.

Maintenance / Surveillance

1

8

-

-

-

-

.

-

-

-

D.

Emergency Preparedness-

!

-

-

-

-

- -

-

- -

E.

Security-

.

.

.

1

5-

>

-

-

-

-

- -

F.

Engineering / Technical

Support-

1*

1

1-

1

-

-

--

-

G. . Safety Assessment /l

[

-

. Quality Verification

2

'

4-

-

-

-

-

-

-

t

Unit 1

Unit 2

Common

TOTALS.

III

IV V

III 'IV V

III

IV V

'

-

la

~4

3 :

TUI

'

-

-

= * Environmental; Qualification (EQ) Category C violation with no Civil Penalty

.

was issued during this SALP assessment period,

j

'2.

ispecial Inspection Summary

$

[

'a.

.During December 15-January 4, 1989; January 10-24,.1989;.

l

and February 26, 1989, special inspections were conducted

relating to transportation radiological controls and

i

'

<

s

safeguards' events (Inspection Report Nos. 295/89003;

304/89003, 295/89005; 304/89005, 295/89007; 304/89007

4

8.

and Enforcement Case No. EA-89-005).

.

b.

During April 20-May'5, 1989, an inspection of-the annual

4

,

emergency preparedness exercise was conducted. (Inspection

v

Report Nos. 295/89012; 304/89012).

c.

During--June 19-July 24, 1989,: a maintenance team

!

inspection was conducted.

Inadequate procedures, and

'

-

failure to take timely corrective actions on numerous

!

maintenance deficiencies were identified (Inspection

Report Nos. 295/89018; 304/89017).

t

4

C.

Escalated Enforcement Actions

i

1.

On June 27, 1988, the licensee paid a civil penalty in the

amount of $100,000. This action was based on inadequacies in

the licensee's program and controls for the testing of pressure

o

isolation valves (Enforcement Case No. EA-87-211, Enforcement

Notice No. EN-87-108A, Inspection Report Nos. 295/87032;

'

304/87033).

l

.

30

m

s-

r

pary

-

-

y D u,

i

6

<

2.

'A'N'otice of Violation for a EQ Category C violation was

"

issued on October 19, 1988.

This action was based on

weaknesses relating to EQ of safety equipment at Zion

i

'

,

Nuclear Power Station.

No civil penalty was issued

(EA-88-199).

'

3.

'A Severity Level.III violation and civil penalty in the-

t

amount of-575,000 was issued on September 21, 1989. 'This

action was. based on the July 18, 1989, event of

a degraded

.

vital, area barrier and' multiple examples of the failure to

@

iensure that vital area barriers were capable of deterring

1

intrusion. (Enforcement Case No.'EA-89-153, Enforcement

'

Notice No. EN-89-087, and Inspection Report Nos. 295/89022;

.

.

304/89020).'

.j

D.

Confirmatory Action Letters

.

.

,

,

1.

A Confirmatory Action Letter (No. CAL-RIII-88-017) was issued

June.30, 1988,,regarding the corrective actions to be taken

associated with the repairs to the AFW check valves.

'

.

2.

A~ Confirmatory Action Letter (No. CAL-RIII-89-021) was issued

'

+

,

October 6, 1989, relating to the failure of 5 of 12 operators

'

who took requalification examinations during the week of

,

September 11, 1989, the weaknesses of the licensee's training-

.i

program, and the need for corrective actions.

E.

Review of Licensee Event Reports' (LERs)

f

'

Unit I LER Nos.: 88011 through 88024, and 89001

through 89013.

,

Unit 2 LER Nos.: 88005 through 88018, and 89001

through'89008.

'

,

,

Collectively, 49 LERs were issued.during this assessment period, in

'

m

"

accordance with NUREG-1022 guidelines. These are addressed in the

t

SALP 8 Report.

!

c

TABLE 2

"

NUMBER OT1TRT8Y CAUSE

Cause Areas

Unit 1

Unit 2

Personnel Errors

12

13

'

Design Deficiencies

3

0

External

1

0

'

Procedure Inadequacies

3

3

d ..

Equipment / Component

7

4

Other/ Unknown

1

2

-

TOTALS

27

22

Table 3 below shows a cause code comparison of SALP 7 and

SALP 8.

.

31

,

.

>

m,

.

,

-

~-

-

- - - -

-

f; ,

.

>

p :n e .: :.

IS"

a*[

.

'

.

o<

,

b

TABLE'3

l

'

.

NUMBER OF LERs PER'CAUSE

.!

i

.

(18 MO)

(16 MO)

CAUSE AREAS

SALP

7-

SALP' 8

l

Fr~sennel Errors'

^23 (50.0%):

25TSTM)

!

Design. Problems

0 ( 0.0%)-

3 ( 6.1%):

)

'.

External Causes

1:(-2.2%)

1 ( 2.0%).

l

,

l-

~

-Equipment / Components.

9(19.6%)

11 22,5%)

Procedure Inadequaciesi

-12(26.1%)

6 12.3%)!

l

"-

-

Other/ Unknown-

4f( 2.2%)

1

-3'

6.1%)

( 100%)-

49(-f00%l.

l

TOTALS

-

-

q

FREQUENCY (LERs/MO)

2.56

3.06

q

. NOTE:

The above LER information was derived from a review of.

j

.

LERs: performed by.the NRC and may not completed coincide

1

,

p

with the licensee's cause code assignments,

j

I

'

31 -

t

+-

.

I

j

bc

1

[c

i

b

n

l-

si

!!o

'I

>

.,

V

s

l

-

,

I,

--

,

i

'

,m

Is

.i

L

-i

d

!

"

a

.q

i

L'

.

,

h

l

!-

ls

+

o

i

1

L

32

H

4

l

U

'