IR 05000155/1993015
| ML20059J844 | |
| Person / Time | |
|---|---|
| Site: | Big Rock Point File:Consumers Energy icon.png |
| Issue date: | 11/09/1993 |
| From: | Martin J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Hoffman D CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| Shared Package | |
| ML20059J847 | List: |
| References | |
| EA-93-233, NUDOCS 9311150075 | |
| Download: ML20059J844 (5) | |
Text
November 9, 1993
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY -
550,000 (INSPECTION REPORT 50-155/93015(DRP))
Dear Mr. Hoffman,
This refers to the special inspection conducted from August 24 through September 14, 1993 at your Big Rock Point facility.
The inspection reviewed circumstances surrounding two recent events, and identified several related violations.
The first event, which you identified and reported in Licensee Event Report (LER)93-002, was the existence of a primary containment breach-while changing modes from Cold Shutdown to Refueling.
The second event was a primary coolant system (PCS) hydrostatic pressure-test that inadvertently pressurized the PLS beyond the procedural limit, thus lifting a steam' safety relief valve.
The report documenting this inspection was sent to you by letter dated October 5, 1993.
On October 12, 1993, we held an enforcement conference in the Region III office with you and other Consumers Power Company representatives to discuss the apparent +jolations, their causes, and your corrective actions.
The enforcement conference summary was sent to you by letter dated October 15, 1993.
The violations in the eaclosed Notice of Violation and Proposed imposition of Civil Penalty (Notice) involve the loss of control over these two plant evolutions.
In the first case, containment integrity was breached on June 27, 1993 by performing a switching and tagging order.
The order, developed to drain the feedwater line, failed to convey its effect on~ containment integrity.
due to inadequata attention to detail both by the preparer and the subsequent reviewer, the shift supervisor.
The shift st.pervisor authorized implementing the order without determining its effect on plant conditions.
Tro days later, with containment integrity still breached, shift supervision approved performing a surveillance test that changed the plant operational'
mode from Cold Shutdown to Refueling, a change requiring containment CERTIFIED MAIL RETURN RECEIPT REQUESTED 9311150075 931109
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integrity. Only after completing this test wa's the cont'ainment' integrity
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breach identified.
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r A contributing cause to this event was your lack of effective corrective
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actions for past events.
The root cause analysis for a December 1991 containment integrity breach was narrowly focused.
Similarly, the corrective j
actions implemented for a 1992 inadequate switching and tagging order event were narrowly focused on the event specifics.
Your corrective actions for.
a these events failed to adequately address program weaknesses and plant
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configuration control weaknesses.
l The second evolution was a hydrostatic pressure test of the-PCS. During the test, your personnel lost control of the evolution and pressurized the'PCS to a level where one of the steam safety valves opened, rupturing four rupture discs.
Review of the event found inadequate job briefings, inadequate job
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planning, shif t supervision becoming overly involved in troubleshooting which caused a loss of focus on overall plant status, inadequate communications between the job site and control room, inadequate work practices during the
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test performance, and insufficient understanding of solid plant operations.
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The fundamental problem was a pervasive lack of sensitivity to the potential l
for a pressure excursion, which engendered a lax approach to conducting the
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test.
Related weaknesses found during review included problems with test
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configuration (no relief valve at the pump), inadequate maintenance of the public address system, and procedure weaknesses. Management expectations and i
policy regarding such an evolution were also not effectively understood. As a l
result, a test that was performed only once per outace and that involved an
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abnormal solid plant operating condition, was treated as " routine" and'
l implemented without sufficient preparation.
The enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) describes six violations.
These violations represent a breakdown in
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the controls essential for safe conduct of important activities. Although
this particular case had minor safety consequences, similar performance under
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other circumstances might have resulted in more significant consequences.
Furthermore, the disorganized manner in which the hydrostatic pressure test f
was conducted is unacceptable for nuclear pawer plant operations.
We are concerned that the underlying causes of this event are essentially identical
to the causes of a recent Palisades event, for which we' held a previous
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enforcement conference with you on August 10, 1993. After..the Palisades
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control rod withdrawal event, the lessons to be learned were published at Big Rock Point.
Given that the Palisades event occurred in June.1993, corrective
actions for Consumers Power should have been developed and implemented to
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preclude similar events at Big Rock Point. We are also concerned that neither
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your line management nor your Nuclear Performance Assessment Department (NPAD)
contributed significantly to ensuring that these types of events do not recur.
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Collectively, the violations in the enclosed Notice represent a potentially significant lack of attention toward licensed responsibilities. Therefore,.in
accordance with the " General Statement of Policy and Procedure for NRC
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r Consumers Power Company-3-Enforcement Actions" (Enforcement Policy), 10 CFR Part 2, Appendix.C, these violations are classified in the aggregate as a Severity Level Ill problem.
Your corrective actions included improving visual aids: for the containment isolatior valves; notifying operations procedure sponsors of the potential for breaching containment integrity and instructing them to add caution statements-in applicable procedures; improving administrative controls for containment isolation valve operations and mode switch manipulation; and improving the man-machine interface for future PCS pressure tests (by modifying the pressure test equipment and the containment paging system).
In addition, you specified '
generic corrective actions, including increased backshift management dur.ing abnormal evolutions (refueling outages, all reactivity events, infrequently.
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performed tests and evolutions, etc.); more staff training in human
"l performance evaluation methodology; and better guidance on using the.
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infrequently performed test and evolution process to identify other evolutions.
for which the process is mandatory.
To emphasize the need for increased management attention to licensed
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activities, I have been authorized, after consultation with the Director, t
Office of Enforcement and the Deputy Executive Director for Nuclear Reactor
Regulation, Regional Operations, and Research to issue the enclosed Notice-in
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the amount of $50,000 for the Severity Level III problem.
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The base value of a civil penalty for a Severity Level III problem is $50,000.
The adjustment factors in the Enforcement Policy were considered.
Partial.
j mitigation (25%) was warranted for your identification and reporting of the
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events.
You identified and correctly report'ed the loss of containment integrity event.
The hydrostatic pressure test event was self-disclosing.
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NRC initiative was required to identify the numerous other contributing
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violations.
In addition, full mitigation (50%) was warranted for your-l comprehensive corrective actions.
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Partial escalation (50%) was assessed for past performance based upon'your j
most recent Systematic Assessment of Licensee Performance (SALP) ratings, more l
recent inspection findings, and the sometimes narrow scope and ineffectiveness w
of previous corrective actions, Specifically, at a July 9, 1992 enforcement
conference, we discussed violations associated, in part, with inadequate
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configuration control during the implementation of a switching and tagging
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order. Additionally, for a 1991 LER involving a previous breach of'
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. containment integrity, your corrective actions were narrow in scope and-i insufficiently implemented.
Partial escalation (25%) was also warranted for i
the prior opportunity to identify, based on your ineffective short-term
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implementation of the lessons learned from the recent Palisades control rod j
event.
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The remaining factors in the Enforcement Policy were considered'and no further U
adjustments were considered appropriate.
Therefore, based on the above, the i
civil penalty remained unchanged.
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You are required to respond to this letter and should follow the instructions
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specified in_ the enclosed Notice of Violation (Notice) when preparing your
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response.
In your. response, you should' document th'e specific actions taken -
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results of future inspections, the NRC will determine whether further NRC
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requirements.
l In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
The responses directed by this letter and the enclosed Notice are not subject i
to the clearance procedures of the Office of Management and Budget as required
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by the Paperwork Reduction Act of 1980, Pub. L. No.96-511.
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Sincerely,
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[jdh A
y J
B. Martin,.
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Regional Administrator l
Enclosure:
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i cc w/ enclosure:
Patrick Donnelley, Plant Manager Big Rock Point Nuclear Plant j
OC/LFDCB Resident inspector, RIII
James R. Padgett, Michigan Public
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Service Commission
Michigan Department of j
Public Health
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SRI, Palisades l
L. Olshan, LPM, NRR i
B. Jorgensen, Rill
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W. Dean, PDill-1, NRR
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Consumers-Power Company
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' Distribution:
PDR SECY
.CA J. Tay1or, EDO.-
H. Thompson, DEDS
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J. Sniezek, DEDR fl/
J. Lieberman, OE l-
' L. Coblentz, OE
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'L. Chandler, OGC J. Goldberg, OGC-T. Murley, NRR
'J. Partlow, NRR.
Enforcement Coordinators
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RI, RII, RIV RV f. Ingram, GPA/PA
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D.~ Williams, 01G B. Hayes, 01 E. Jordan, AE00 State of Michigan
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J RAO:RIII SLO:RIII
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PAO:RIII IMS:RIII'
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