A97003, Responds to NRC Re Violations Noted in Insp Repts 50-295/96-20 & 50-304/96-20.Corrective Actions:Training Dept Will Include Discussion of Event in Licensed & non-licensed Operator Training Programs

Responds to NRC Re Violations Noted in Insp Repts 50-295/96-20 & 50-304/96-20.Corrective Actions:Training Dept Will Include Discussion of Event in Licensed & non-licensed Operator Training Programs

ML20138F966
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	04/30/1997
From:	Mueller J COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
50-295-96-20, 50-304-96-20, ZRA97003, NUDOCS 9705060113
Download: ML20138F966 (12)

Text

. - . . - - .~- . - - -. .-

. *^ .

i ' (bmmonweakh lidison Contpany Zital Generating 5tatinti '

. 101 Shiloh Hou!crard

. Zion,11. (*XN9-2*'9~7 9 rel F-Nt>2tw4 i

ZRA97003 April 30,1997 i

U. S. Nuclear Regulatory Commission i Washington, D.C. 20555 Attention: Document Control Desk l

Subject:

Commonwealth Edison Reply to Notices of Violation in NRC Inspection Report Number 50-295/96-20,50-304/96-20.;

^

Zion Nuclear Power Station Units 1 and 2; NRC Docket Numbers 50-295 and 50-304

Reference:

Letter to J. H. Mueller (Comed) from G. E. Grant (USNRC) dated March 24,1997 NRC Inspection Report 50-295/96-20,50-304/96-20 and Notice ofViolation Gentlemen:

I By letter dated March 24,1997, the NRC cited Commonwealth Edison (Comed) as being l in violation of regulatory requirements. This letter and its attaclanent constitutes ,

l Comed's reply to the referenced Noti::e of Violation in accordance with applicable l regulations. Per telecon of March 24,1997, with Mr. Marc Dapas, Branch Chief, Region  !

III, an additional week after the reauired 30 day re.sponse from the date of the reference 1

letter was granted.

1 Attachment A to this letter provides the reasons for the violation examples, the corrective l l

actions taken, and the dates when full compliance will be/was achieved.

l T

l I

hb /

I l

9705060113 970430 oDR ADOCK 05000295

.) PDR i

i l il I I

-- e--

. i I

ZRA 97003 I Page 2 of 2 3

I

Should you have any questions concerning this response, please contact Robert Godley of my staff at 847-746-2084 extension 2900.

l

)

1 qincerely,  ;

i h)bu <

l J. H. Mueller j Site Vice President Zion Nuclear Station 1

I I

i I

Attachments cc: Regional Administrator, USNRC - Region Ill Senior Project Manager, USNRC - NRR Project Directorate III-2 Senior Resident Inspector, Zion Nuclear Station Office of Nuclear Facility Safety - IDNS s

ATTACIIMENT A to ZRA97003 PagdIof8 Brply To Notice Of Vio.latian VIOLATION: 50-295(304)/96020-02 10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures and Drawings," requires that activities afecting quality be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures, or drawings Abnormal Operating Procedure 7..S. "Eugle 21 Rack Failure Actions," Revision 8, Section C.

Step 2, requires that if the pressuri:er pressure controlfmetion has an inoperable instrument channel, an operable instrument channel be selected.

Contrary to the abnve, on Jaauary 18, 1997, when the pressuri:er pressure contrclfunction instrument channel was inoperable, control room operators failed to select the operable instrument channel.

ADMISSION ORDINIAL TO THE VIOLATION Comed admits the violation.

REASON FOR THE_Y10LAILQN The reason for the violation was inadequate operator training with respect to tne transient type of failure that occurred. The Training Department had not covered this type of failure with operating personnel during operator training, as a result, operating personnel involved in the event stabilized the plant before entering Abnormal Operating Proceedure (AOP) 7.5 " Eagle

21. Rack Failure Actions" The reason why operator training was inadequate was information from the manufacturer indicated that a failure would occur in a manner that would cause the failed instrumentation to fail as is rather than in a transient manner.

Discussion:

On January 18,1997, at 1825 hours0.0211 days <br />0.507 hours <br />0.00302 weeks <br />6.944125e-4 months <br />, Unit 1 experienced a transient failure on Eagle 21 Rack Protection Set i. Based on information available from alarms, controllers and indication of plant

, parameters, the two control room operators deteimined that they had failed controllers. They acted to place the plant into a stable condition by placing the pressurizer pressure control into manual. Placing this controller into manual allowed the operators time to analyze their indications and accurately diagnose that they had an Eagle 21 Rack failure. When this diagnosis was made, the operators carried out the correct steps of AOP 7.5 Eagle Rack 21 Failure. The plant was restored to a stable status within six minutes.

In this event different alarms were received than would be expected on an Eagle 21 failure and this contributed to the need for prompt operator diagnosis. For example a " Channel Set Failure" annunciator is expected en this transient. Neither control room operator saw this alarm

.. - -- . . . - . - . . . - . - - - . ~ . - - -.~ - . ~.

1 1

. ATTACllMENT AtoZRA97003  ;

l- Pagd 2 cf 3 I i illuminated. The Unit Supervisor, however, thought he saw the alarm. The Eagle 21 memory j did not indicate that the " Channel Set Failure" alann occurred during the transient as expected. j

! l Based on a detailed review of events and alarms observed by the control room operators, the  !

initial operator diagnosis was predicated on reasonable judgment and the indications and speed  ;

of the transient. This was a reasonable course of action in thi circumstance and was based on i i the overall training and judgment of the operators.

I Post incident investigation established the sequence of events occurring in the control room

was as follows

i

• The transient failure occurred in a manner different from expectations and training  ;

1

. Operators observed numerous plant transient indications and alarms l i e Key controllers were placed in manual to stabilize plant based on initial judgment i

.

• Operators diagnosed problem, recognized Eagle 21 Fr.ilure 1 i . . Operators entered AOP 7.5 action and cornpleted it satisfactorily e Plant was restored to a stable condition within six minutes l

i CORRECTIVFdCI1ONS TAKEN AND_RESULTS ACHIEVED Procedure AOP 7.5 was revised to give additional guidance to the operators on how to take j manual control when the Eagle 21 system fails, i

j- CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS i This event will be covered with licensed operators in cominuing operator training sessions.

3 This training will review concerns associated with the failure modes of the Eagle 21 system, i recognition of Eagle 21 malfunctions including transient failures, and initial operator actions

! per Operations Department expectations. This training will be completed during operator j training cycle 7.

DATE WHEN FULL COMPLIANCE WILL BE AClilEYEQ Zion Station is currently in full compliance.

TTACHMENT A to ZRA97003

Page'3 of 8 f VIOLATION

50-295(304)/96020 03 1

t Technical Specification 6.2.1.a requires th'it written procedures be prepared, implemented, and maintainedfor procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, j February 1978.

Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, specifies equipment control, e.g., lock'ing and tagging, as an example ofan administrative procedure.

Zion Administrative Procedure (ZAP) 300-06, "Out-of-Service [00S) Process," Revision 9,

Appendix A, " Placing 005 Techniques," requires that when it is possible to add energy to equipment fiom more than one source, then out-of-service cards be pieced on all isolating  !

l devices, including valves. l

' l Contrary to the above, on January 14,1997, the licensee did not place isolation valvesfrom the {

refiteling water storage tank, a potential energy source, 00S in support ofIB containment spray i pump maintenance.

ADMISSION ORDENIAL TO THE VIOLATION

.i Comed adrnits to the violation.

i 4

l REASON FOR VIOLATION i

j The reason for the violation is both the preparer and the reviewer of the OOS incorrectly i determined that the head of water from the suction tank to the discharge piping was insufficient to cause pump rotation, and decided that tagging the suction and discharge flow path valves DOS

, was neither necessaq nor required. This was in direct violation of the OOS procedure which

requires OOS tag isolation of all sources of energy for components being worked on . The

incorrect decision was based on previous management direction to minimize the number of tags 1

used for an OOS.

A contributing cause to this violation was the previously accepted practice for tagouts to be developed and performed using operatorjudgment that some boundary tags were not needed due to plant configuration. As a result the preparer and reviewer also took credit for the motor operated valve downstream of the pump (IMOV-CS0004) being shut to justify not tagging cut the flow path. However, an electrical maintenance worker accidentally caused the IMOV-CS0004 to open which allowed water from the suction and discharge header.s to equalize through the pump and rotate it.

Another contributing cause to this violation was a failure of maintenance personnel to adequately walk the job down to ensure adequacy of the zone of protection in accordance with the Out Of Service procedure.

~

, ATTACllMENT A to ZRA97003 l Page 4 of 8 i

. 4 1

G)RRECTIVE ACTIONS TAKEN AND RESULTS AC1)JEyfR

.' The IMOV-CS004 valve was shut and the OOS was revised to include this valve in the OOS l boundary to preclude any further pump rotation.

l The Operatiorn Manager has reinforced the tag out expectations to isolate all sources of energy i and explicitly follow the Out Of Service procedure with his managers.

i The Operations Department personnel involved in the improper OOS were counseled.

I

The Mechanical Maintenance department conducted tailgate sessions to emphasize to their personnel the necessity to ensure the adequacy of equipment Out Of Services and why this tag  !

out was not adequate. l 1

l COkRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS 2 The Training Department will include a discussion of this event in their licensed and non-

licensed operator training programs. A discussion of this event will also be completed with i operations personnel involved in work control activities. This will be accomplished during  !

l trammg cycle 7. l LATE WIIEN FULL COMPLIANCE WILL BE ACHIEVED  :

} Zion Station is currently in full compliance.

l 2

i i

i j b

1 l

J

. ]

2 .

ATTACHMENT A to ZRA97003 i

Page'$ of 8 j VIOLATION

50-295(304)/96020-05

, 10 CFR Part 30, Appendix B, Criterion XVI, " Corrective Actions," requires that measures be f . established to assure that conditions adverse to quality are promptly identified and corrected, and in the case of sigmficant conditions adverse to quality, that measures he established to  ;

assure that the cause of the condition is determined and corrective actions taken to preclude ,

recurrence.

l j

Contrary to the above, from November 26,1996, through February 5,1997, the licensee did not determine the cause of the water intrusion in the 1A auxiliaryfeedwater pump turbine, inboard j i bearing oil reservoir, which was a sigmficant condition adverse to quality.

t

[ ADMISSION OR DENIAL TO THE VIOLATION i i I

Comed admits the violation.

I  ;

REASON FOR THE VIOLATJDff The reason for the violation is that the problem identification form that documented water was i found in the oil of the 1 A Auxiliary Feedwater (AFW) pump was not classified as a significant condition adverse to quality. The Event Screening Committee (ESC) that reviews and classifies

! each PIF classified this PIF as one only requiring an apparent cause investigation. As a result, l l the AFW system engineer identified the potential causes of the condition via an apparent cause  !

j mvestigatmn.  !

1 i The investigation by the AFW system engineer identified four possible sources of water in the t 1A AFW pump turbine inboard bearing oil sump, but could not isolate it to one specific root cause. The potential sources of water and disposition of each are as follows

l

• Leak from previous cooler replaced due to a modification in the Z1R14 refueling outage. l The cooler replaced during the Z1R14 refueling outage was unavailable for inspection.

• Leak from the existing installed cooler, i The installed I A AFW lube oil cooler was successfully leak tested and visually inspected.

• Improper draining of oil (from the higher elevation site glass vs. the lower elevation sump plug) which may have led to water accumulating in sump from condensation or accumulated leakage from replaced cooler.

TTACilMENT A to ZRA97003

, Page 6 of 8 This appears to be the most likely cause of water in the bearing oil sump. The AFW j l engineer had observed fuel handling personnel change oil from the site glass of the l AFW pump in the past, but had not performed interviews with personnel to confirm this practice because he was not performing a root cause investigation. j l

To disposition this determined potential source fuel handling management reinforced

with fuel handling personnel the proper location for draining oil on various pieces of l equipment that fuel handling personnel work on. Feedback given during the

reinforcement sessions confirmed that the fuel h;mdlers are now aware of the proper location of changing oil. .

I

. Water sprayed onto bearing from leakage from the connected turbine.

I Turbine operation was monitored and no excessive leakage or spraying was observed  !

that could lead to water intrusion into the bearing tube oil.

j A subsequent investigation (PIF #29520096 CAT 3-4524) to determine the root cause of failure of the AFW pump bearing as a result of improperly installed slinger rings concluded that a i thorough attempt had been made to evaluate and eliminate all potential sources of water to the ,

i oil reservoir. l

I There have been no indications of water intrusion into the AFW pumps since this event has  ;

occurred. In addition, the system engineer is currently monitoring the oil levels on all the I 2

AFW pumps, and will ensure that the oil on the 1A AFW pump is changed and inspected l approximately 6 months (to allow for several pump runs) after Unit 1 is back on hne.

. CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED l

. The Zion Administrative Procedure (ZAP 700-08 " Problem Identification Process") that  :

! describes the event screening committee process has been changed to revise the PIF  !

! significance screening criteria. This revision more clearly aids in identifying conditions adverse to quality.

i Senior Managers are now conducting a collegial review of PIFs to focus line management l attention quickly on signifhant conditions adverse to quality to ensure they receive a root cause analysis. Another function of this review is to approve the ESC's recommended significance level and action assignee for each PIF.

. 1 CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS The Senior Manager's collegial review of PIFs described above is currently being included in I a revision to ZAP 700-03. The revision will be approved by May 31,199'7. l DATE WHEN FULL COMPLIANCE WILL BE ACIllINED  ;

Zion Station is currently in full comphance.

TTACilMENT A to ZRA97003  !

Page 7 of 8 j VIOLATION: 50-295(304)/96020-08 ,

i 10 CFR Part 50, Appendix B, Criterion 111. " Design Control," requires that design control measures be applied to items such as maintenance and repair. l l

1 Zion Administrative Procedure 510-02, " Plant Afodification Program," Revision 6, establishes l requirementsfor assuring design control during the modification process. It defines a " design change" as any change in design that may affectfunctional requirements, operating conditions, or safety, regidatory, reliability, and American Society of Alechanical Engineers code-related requirements, and that would require that affected documentation be changed.

Contrary to the above, on November 22,1996, the licensee changed the spring tension on Unit 2 pressurizer power operated relief valves 2PCV-455C and 2PCV-456 during corrective l maintenance activities, which constituted a change to fimctional requirements, without usmg design control measures specified in ZA P 510-02.

ADMISSION OR DENIAL TO THE VLOLATION Comed admits the violation.

REASON.FOR VIOLATION The reason for the violation is that maintenance engineering does not have adequate controls in

. place for identifying and controlling plant design changes that may be directed to them for 4

engineering review in the area of mechanical maintenance activities. Some examples include air operated valve setpoints and work on plant valves that could go beyond normal maintenance, such as alternate material replacement. As a result engineering personnel

, inappropriately provided an engineering request for changing the PORVs air regulator setting and corresponding spring tension in support of a revision to a maintenance procedure P/M003-7N " Copes-Vulcan Air Operated Control Valves", and failed to recognize that this constituted a change to the safety function requirements of the component and should have been addressed via a design change process.

Contributing to this violation was an inadequate 10CFR50.59 safety evaluation screening performed in support of the procedure revision to P/M003-7N. The procedure change described above was instituted with a 10CFR 50.59 screening which failed to recognize that changing the air regulator setting and corresponding spring tension for the pressurizer PORVs constituted a change to a safety function of the component. The Engineering Request described above was considered by the individuals preparing and reviewing the 10CFR50.59 screening for the procedure revision as engineering approval of the procedure change. This belief contributed to a less than rigorous preparation and independent review of the procedure change in accordance with the requirements of 10CFR50.59.

hTTACllMENT A to ZRA97003

Page'8 of 8

, CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED

! The maintenance engineering personnel who performed the engineering request were

, counseled regarding documentation required for engineering requests that support procedure revisions that change design infonnation requirements.

The Mechanical Maintenance (MM) procedure coordinator and the MM procedure group approver who performed the inadequate 10CFR50.59 screening evaluations were counseled regarding changes to design information contained in procedures and proper independent review methods.

To ensure maintenance engineering personnel clearly understand what constitutes a design change and the design change processes that need to be followed, the circumstances l surrounding this violation were discussed in a maintenance engineering tailgate session. l f

CORRECTIVE ACTIONSIO BE TAKEN TO AVOID FURTHER VIOLATIONS Engineering will issue an approved document listing mechanical maintenance activities which could fall under a design change process. This document will be approved by May 31,1997.

Engineering will perform a review of mechanical maintenance procedures to identify those i procedures which have the potential to affect critical design parameters. The procedures containing critical design parameters will be flagged to require engineering review prior to l revision of those flagged items. This evsluation will be completed by October 31,1997.

The circumstances surrounding this violation will also be discussed as a lessons learned with non-engineering personnel qualified in performing evaluations pursuant to 10CFR50.59 by May 31,1997.

Engineering will perform a review of a sample of engineering requests that supported procedure revisions to IM and EM maintenance procedures to determine if these revisions constituted a change to the safety function requirements of the component and should have been addressed via a design change process. This will be completed by July 31,1997.

DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Zion Station will be in full compliance when the actuator pressure settings and corresponding i spring tensions on the Unit 2 pressurizer power operated relief valves 2PCV-455C and 2PCV-456 are reset to the applicable design settings. This will be accomplished prior to startup of Unit 2.

. ._ _ _ . -- . ~ . .- _ -. . . - .- . .

- 4 4

• ATTACHMENT B to ZRA97003

'Page1of2 g List of Commitments Identified in this Violation Response  ;

i The following table identifies those actions committed to by Comed in this document.  ;

Any other actions discussed is this submittal represent intended or planned actions by i

Comed. They are described to the NRC for the NRC's information and are not regulatory l l commitments. Please notify Mr. Robert Godley, Zion Station Regulatory Assurance

Manager, of any questions regarding this document or any associated regulatory commitments.

j Commitment Committed Date

or Outage The circumstances surrounding the Eagle 21 rack failure event will be During training covered with licensed operators in continuing training. This event will cycle 7 be reviewed in training concerning the failure modes of the Eagle 21 i system, recognition of Eagle 21 malfunctions including transient failures, and initial operator actions per operations department l

expectations.

l l The Training Department will include a discussion of this event in During trairr.ng

their licensed and non-licensed operator training programs. A cycle 7 j discussion of this event will also be completed with operations '

personnel involved in work control activities. This will be accomplished prior to Unit 2 startup. l l The senior managers collegial review of PIFs discussed in the Notice Of May 31,1997 1 l Violation response will be included in a revision to Zion Administrative Procedure (ZAP) 700-08. l Maintenance Engineering will issue an approved document listing May 31,1997 l maintenance activities which could fait under a design change process.  !

Engineering will perform a review of maintenance procedures to October 31,1997

identify those procedures which have the potential to affect critical

)

l design parameters. The procedures containing critical design i parameters will be flagged to require engineering review prior to l 3 revision of those flagged items. This evaluation will be completed by i October 31,1997.

Engineering will perform a review of a sample of engineering requests July 31,1997 that supported procedure revisions to IM and EM maintenance i procedures to determine if these revisions constituted a change to the j safety function requirements of the component and should l' ave been l addressed via a design change process. This will be completed by July 31,1997. 1 The circumstances surrounding this violation will also be discussed as May 31,1997 a lessons learned with non-engineering personnel qualified in performing evaluations pursuant to 10CFR50.59.

The oil on the 1 A AFW pump will be changed and inspected Six months approximately six months (to allow for several pump runs) following the following the return 1

4 j ,

. ATTACHMENT B to ZRA97003 Page 2 of 2

return of Unit I to service. of Unit I to service.

Zion Station will be in full compliance when the actuator pressure Prior to the startup I settings and corresponding spring tensions on the Unit 2 pressurizer of Unit 2 i power operated relief valves 2PCV-455C and 2PCV-456 are reset to the applicable design settings.

{ l 4

l i l

2 4

4 i

i i l 4

.I 9

i 1

i s

t l'i i

i

. _ _ _ __. _ _ .