CY-97-115, Responds to NRC Re Violations Noted in Insp Rept 50-213/97-03 on 970805.Corrective Actions:Star Process Will Be Emphasized in Special Seminar as Self Checking Tool to Reduce Personnel Errors
| ML20198T206 | |
| Person / Time | |
|---|---|
| Site: | Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png |
| Issue date: | 11/07/1997 |
| From: | Feigenbaum T CONNECTICUT YANKEE ATOMIC POWER CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-213-97-03, 50-213-97-3, CY-97-115, NUDOCS 9711140226 | |
| Download: ML20198T206 (11) | |
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CONNECTICUT YANKEE ATOMIC POWER COMPANY C
HADDAM NECK PLANT 362 INJUN HOLLOW ROAD e EAST HAMPTON, CT 06424-3099 November 7,1997 Docket No. 50 213 CY-97-115 Re: 10CFR2.201 U.S. Nuclear Regulatory Commission Attention: Document Control Desk Washington, D.C. 20555 Haddam Neck Plant Reply to a Notice of Violation (NOV)
NE'C Integrated Insoection Reoort No. 50-213/97-03 in a !etter dated October 9,1997,W the NRC staff transmitted a report documenting the esults of an NRC inspection which was completed on July 7,1997 at the Connecticut (ankee Atomic Power Company (CYAPCO), Haddam Neck Plant (HNP) and the results of a teleconference and final exit summary between CYAPCO and the NRC staff on August 5,1997. Areas reviewed by the NRC during this time period include engineering, maintenance, decommissioning activities, and operations.
As noted in the report, at the final exit meeting, CYAPCO was given the choice to discuss s
certain significant violations identified in this inspection at an enforcement conference.
Based upon the results of the inspection, the NRC Staff did not believe that an enforcement
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conference was necessary in order to reach an enforcement decision. CYAPCO concurred in this regard. In summary the violations wers:
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- 1. Failure to take timely corrective action from August 1996 to March 1997 on the potential for water hammer on the service water supply to the spent fuel pool cooling system.
(1)
H. J. Miller (NRC) to T. C. Feigenbaum (CYAPCO), 'NRC Integrated Inspection Report Ne 50-13/97-03, Notice of Violation and Exercise of Enforcement Discretion" dated October 9,1997.
9711140226 971107 POR ADOCK 05000213 0
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U. S. Nuclear Regulatory Commission CY-97-115/Page 2
- 2. Failure t'o take timely and adequate corrective actions on similar events in November 1996 and May 1997 involving repetitive procedural nonadherences for operating the turning gear on the emergency diesel generators.
- 3. Inadequate safety evaluation in June 1996 in which a dedicated operator was used to compensate for feedwater regulating valves that could not perform their intended design function under certain circumstances.
C'/APCO recognizes that these violations are additional examples of problems wich have previously been identified in a letter from the NRC to CYAPCO dated May 12, 1997*
namely, the failure to aggressively pursue problems and to identify and correct root causes.
In an effort to preclude these problems from recurring, CYAPCO has instituted an " overhaul" of the HNP corrective action program.
Problem resolution is being addressed by mhnagement through the implementation of trending reports using standardized causal factors coding which provides the necessary data to facilitate recognition of programmatic or recurring causes. The new Adverse Condition Report (ACR) process and new ACR database allow for the tracking and evaluation of the effectiveness of corrective actions by using key performance indicators (KPis) to monitor and trend corrective action. Training relative to this program was conducted site wde in June of this year. Of r.,ignificance, is the fact that a lower ACR threshold has been established, resulting in an increase in the number of ACRs generated, and a heightened awareness of adverse conditions among CY personnel. The new ACR program also lends guidance to the preparation of root cause evaluations, as required. Seminars were held for all site personnel on standards for strict procedure compliance.
Personnel " turnover" of records, information and specific task status wil! be controlled through the use of a new administrative procedure. This procedure formalizes a process presently used by some departments, implementation of this procedure ensures that those individuals " moving" from current positions, to other positions either inside or outside of the CY organization, properly and systematically " turnover" their respective work assignments to their relieft or supervisors. This will ensure the continuity of ongoing work assignments and that commitments are maintained.
Pureuant to the requirements of 10CFR2.201, Attachment 1, provides the CYAPCO response to the Notice of Violation (NOV) and presents the current implementation status of the corrective actions. It is noted that this attachment addresses violation number 1 which pertains to the issue of performing timely and adequate corrective actions to rectify water hammer concerns on the service water supply, and violation number 2 which pertains to the failure of taking timely and adequate ccrrective actions to address a personnel error and procedure nonadherence for operating the turning gear on the emergency diesel generators.
(2)
H. J. Miller (NRC) to B. D. Kenyon (CYAPCO), " Notice of Violation (NRC Inspection Reports Nos. 50-213/95-27, 96-06, 96-07, 96-08, 96-11, 96-80,96-201)," dated May 12,1997.
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t U. S. Nuct:;;r R:gulatory Commission CY-97-115/Page 3 The third violation concerns an inadequate safety evaluation which was performed to allow operator c'ompensatory actions for feedwater regulating valves. As stated in Reference 1, the NRC has decided not to issue a Notice of Violation or propose a civil penalty for this issue. The NRC rendered this decision because the violation was based upon events prior to the plant being shutdown, and the fact that significant enforcement action had already been imposed as documented in reference 2, for the techn, val and safety review program inadequacies that led to this and other violations.
CYAPCO acknowledges the issues surrounding violation number 3 and has revised the safety review program inadequacies that led to this violation.
The revised program incorporates many of the suggested improvements of NEl 96-07
" Guidelines for 10CFR50.59 Safety Evaluations" and draft NUREG-1606 " Proposed Regulatory Guidelines Related to implementation of 10CFR50.59."
A review the revised program was conductM by the NRC staff as noted in Inspection Report 50-213/97-03 and the program was' found to be acceptable.
CYAPCO considers these violations very serious and is committed to implement and complete the corrective actions to improve station performance. We will continue to keep the NRC Staff informed of our progress in these areas. presents CYAPCO's commitments made within this letter and the attachments. Other statements within this letter are provided for information only.
If there are any questions regarding this submittal, please contact Mr. G. P. van Noordennen at (860) 267-3939.
Very truly yours, CONNECTICUT YANKEE ATOMIC POWER COMPANY B
A A ellor s For T. C. Feigenbaum Executive Vice President and Chief Nuclear Officer Attachments cc:
H. J. Miller, NRC Region i Administntor M. B. Fairtile, NRC Senior Project Manager, Haddam Neck Plant W. J. Raymond, NRC Senior Resident inspector, Haddam Neck Plant D. Galloway, Acting Director, CT DEP Monitoring and Radiation Division l
Docket Number 50-213 CY 97-115 Haddam Neck Plant Reply to a Notice of Violation NRC Inspection Report No. 50-213/97-03 November 1997
U. S. Nucle:r Regul: tory Commission j
CY-97-115/ Attachment 1/Page 1 Restat'ement of Violation During NRC inspections conducted on April 8 - August 5,1997, violations of NRC requirements were identified. !n accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," (60 FP. 34381; June 30,1995) the violations are listed below.
10 CFR 50 Appendix B, Criterion XVI, " Corrective Actions," requires that measures be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.
- 1. Contrary to the above, from August 14,1996 to March 11,1997, the licensee did not assure that a significant condition adverse to quality was promptly corrected.
Specifically, the licensee was notified by a consulting engineering firm report TM-1788a, dated August 14,1996 that potential water hammer in the SW cooling lines to the SFP system could occur following a loss of normal power event, and that the operability of the SW supply lines, and thus the SFP cooling system, could not be assured contrary to Technical Specification 3.9.15. Licensee actions to address this issue were neither timely or effective until March 11,1997, when a design change was developed to correct the design discrepancy and the matter was reported to the NRC.
(01013)
- 2. Contrary to the above, as of May 21,1997, the lic9nsee did not assure that the cause of a significant condition adverse to quality was determined and that corrective actions precluded repetition. Specifically, on November 27,1996, an operator failed to follow procedure PMP 9.1-31 which resulted in the operation of emergency diesel EG-2B with the jacking tool installed but no engine damage resulted. The licensee response to this significant condition adverse to quality was neither timely nor thorough to resolve the cause and preclude repetition (personnel errors and/or procedure noncompliance). On May 21,1997, an operator again failed to follow procedure PMP 9.1-31, which resulted in the operation of emergency diesel EG-2A with the jacking tool installed and damage to the engine. (01023)
These violations have been categorized in the aggregate as a Severity Level Ill problem (Supplement I).
U. S. Nucle:r R:gul: tory Cominission CY-97-115/ Attachment 1/Page 2 Resisons For The Violation The SWS violation pertained to the discovery of a design discrepancy in the SWS, creating the potential for postulated water hammer events, which could have affected the operability of the cooling water supply to the spent fuel pool cocling system following certain design basis accidents.
This issue was identified in a technical report which was prepared by a Creare Inc. and issued in August 1996. The design engineering supervisor who received the Creare Inc.
report failed to initiate an Adverse Condition Report (ACR) documenting the required actions necessary to address the SWS operability concerns. In December 1996, the design engineering supervisor accepted a new position in the Northeast Utilities system.
Transfer of work assignments to another engineer could not be verified. An NRC inspection in March of 1997 brought the SWS concerns documented in the Creare Inc.
report forward. A design change was instituted in March of 1997.
The cause of this violation was a personnel error with respect to taking timely corrective actions to address the operability and reportabil?y aspects of this matter when the technical issue was first identified in August of 1996. A secondary cause was the failure of the cognizant engineer, prior to re-assignment, to properly inform the new engineering manager of the SWS issue The Emergency Diesel Generator (EDG) violation pertains to the operation of the EDG in May of 1997, with the jacking tool installed. This violation represents a repeat c' a similar incident which occurred in November of 1996. The cause of thie violation was the failure to take timely and adequate actions to address a personnel error and procedure nonadherence from the initial November 1996 event. The operator involved in the November 1996 event, had been distracted by a call which caused him to leave the generator during performance of this task. Management inappropriately accepted this as the cause and did not require a root cause investigation. Following the occurrence of the May 1997 event, a root cause investigation was conducted and as recommended in the associated report, a mechanical stop was added to the jacking tool to preclude closure of the diesel flywheel housing cover with the jacking tool installed.
Corrective Steps Thrt Have Been Teen And The Results Achieved Corrective actions which have been taken to address the HNP failure to aggressively pursue problem resolution and identify root causes in a timely and efficient manner are identified below. In addition, corrective actions to reduce human performance errors before and during decommissioning, and corrective actions taken to ensure the adequacy of ctaff " turnover" controls are also identified below.
l U. S. Nucle:r R:gul: tory Commission CY-97-115/ Attachment 1/Page 3 Strict Prqcedure ComplianG9 Site-wide and department standards have been issued that include strict procedure compliance and increased management standards. All site personnel attended meetings conducted by the Unit Director expressly fer the purpose of reiterating management's expectations relative to strict procedure compliance and error reduction.
All site personnel are held accountable for improving upon past procedure compliance shortfalls.
Re.ducing Human Performance Errors A trending and rnonitoring program has been implemented. Key Performance Indicators (KPis) are reviewed. Trends which include personnel errors and procedure adherence are monitored and reviewed by plant management on a weekly basis. Quarterly KPI and ACR's trend results are reviewed and analyzed for declining performance. After a second quarter trend report showed an increase in human performance errors, a common cause report was prepared.
This report recommended the following four actions to minimize personnel errors.
Lessens learned from the common cause analysis should be presented to all plant management with a special seminar to be held for all supervisors. It is noted that management has bun briefed with respect to the results documented in the common cause report.
The use of the STAR (Stop, Think, Act, Review) process should be emphasized as a self checking tool in the lessons teamed seminar to reduce personnel errors.
The common cause, lessons leamed should be used in the work observation program to look for, and potential)v prevent, personnel errors.
The common cause and contributing factors should be trended for the third and fourth quarters in order to monitor the effectiveness of the corrective action progmm.
Those corrective eteps that have already been implemented to address the issue of personnel errors have had a positive effect in reducing the total number of personnel errors as evidenced by third quarter trends which shows a decrease from the second quarter. Also the fact that a positive cultural change has emerged on site, i. e., people willing to self identify problems and share information and potential fixes, verses people who kept information as privileged, is also attributable to the current trend status.
U. S. Nucle:r Regul: tory Commission CY-97-115/ Attachment 1/Page 4 Tinielv Corrective Actions A new', more effective Adverse Condition Report (ACR) process and new ACR database have been developed and implemented. To ensure that adverse conditions are identified and captured in the ACR process, management has conducted all hands training which began in June of 1997. Through this training program, management expressed the need to initiate low threshold ACRs for plant problems. Since completion of the training, there has been a significant increase in the number of ACRs initiated by plan; personnel. This heightened awareness by CY personnel coupled with the corrective action program initiatives greatly enhances the probability of being aware of site issues requiring corredive action. The new ACR process is structured to facilitate data gathering activities in the following areas:
Tracking of corrective actions.
Evaluating effectiveness of corrective actions (monitoring and trending).
Providing guidance and training on initiation of adverse condition reports.
Using KPls to monitor and trend corrective action effectiveness.
The causal factor coding provides the mechanism by which data can be categorized and evaluated in order to facilitate recognition of programmatic or recurring causes and thereby readily allows for the assessment of the effectiveness of corrective actions.
Imoroved Staff Turnover Controls With respect to the issue of corrective actions taken to erisure the adequacy of staff
" turnover" controls, such that safety and quality issues are not compromised by being inadvertently " dropped" or not acted upon, it is noted that a CY administrative procedure has been issued to address this concern. This procedure formalizes a process presently used by some departments.
Implementation of this procedure ensures that those individuals " moving" from current positions, to other positions either inside or outside of the CY organization, properly and systematically " turnover" their respective work assignments to their relief's or supervisors in " face to face" meetings. This will ensure the continuity of ongoing work assignmeas and commitments are maintained. Turnover procedure, process effectiveness, will be assured by the Nuclear Oversight Group.
Corrective Steps That Will Be Taken To Avoid Further Violations The following corrective steps will be taken to avoid further violations.
Lessons teamed from the common cause analysis will be presented ta all plant management with a special seminar to be held for all supervisors. The supervisors seminar, conducted by management, addressing the results of the common cause report is scheduled for November 1997.
The STAR process will be emphasized in the special seminar as a self checking tool to reduce personnel errors.
U. S. Nuclear Regul: tory Commission CY-97-116/ Attachment 1/Page 5 The common cause lessons. learned will be integrated into the work observation program to look for, and potentially prevent, personnel errors. New work observation forms will be issued in November 1997, The common cause and contributing factors are trended each quarter in order to o
monitor the effectiveness of the corrective action program. Trending is performed in a manner consistent with that performed for the first three quarters.
A team is assembled under the direction of the CY Engineering D; rector to perform the common cause analysis. The total number of ACR's generated during the affected period are divided amongst the team members with each member initiating a causal factor evaluation for each ACR. After the causal factors are determined for each ACR, an analysis of the common contributing factor is made and corrective actions for the most prevalent contributing factors is recommended.
Date When Full Compliance Will Be Achieved The corrective action progrcm has been implemented as stated in letters from T. C. Feigenbaum to the NRC dated June 11,1997* and September 30,1997.W Effectiveness reviews are ongoing with results being communicated to management and staff. The administrative procedure pertaining to " turnover" control has been approved for use on-site. Management will conduct a " supervisors seminar" in November,1997 exprassly for the purpose of communicating the results of the common cause report.
New work observation forms will be issued in November 1997. The corrective actions will be completed by November 30,1997.
(3)
T. C. Feigenbaum letter to the U. S. Nuclear Regulatory Commission, " Reply to a Notice of Violation (NOV) Inspections 50-213/95-27, 96-06, 96-07, 96-08, 96-11, 96-80 & 96-201" dated June 11,1997.
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T. C. Feigenbaum lotter to the U. S. Nuclear Regulatory Commission,
" Commitment Update," dated September 30,1997.
f Qorhet Number 50-213 CY-97-115 Haddam Nech Plant T
- CYAPCO Commitments NRC Inspection Report No. 50-213/97-03 9
E T-November 1997 T
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U.S. Nuclacr R:gul: tory Commission CY-97-115/ Attachment 2/Page 1 The fo'llowing are CYAPCO's commitments made within this letter and attachments.
Other statements within this letter are provided for information only.
CY-97-115-01 L essons learned from the common cause analysis will be presented to plant man &gement with a special seminar to be held for all supervisors. The supervisors seminar is scheduled for November, 1997.
CY-97-115-02 The STAR process will be emphasized in the special seminar as a self checking tool to reduce personnel errors.
CY-97-115-03 The common cause, lessons learned will be integrated into the work observation program to look for, and potentially prevent, personnel errors.
CY-97-115-04 New work observation forms will be issued in November 1997.
CY-97-115-05 Turnover procedura process effectiveness will be assured by the Nuclear Oversight Group.
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