IR 05000237/1991035
| ML17174B026 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 11/29/1991 |
| From: | Burgess B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17174B025 | List: |
| References | |
| 50-237-91-35, 50-249-91-38, NUDOCS 9112110142 | |
| Download: ML17174B026 (14) | |
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U. S. NUCLEAR REGULATORY COMMISSION-REGION I I I Report No /91035(DRP); 50-249/91038(DRP)
Docket N6 ; 50~249 License No DPR-19; DPR-25 Licensee:
Commonwealth Edison Company Facility Name:
Dresden Nuclear Power Station, Units 2 and 3 Inspection At:
Dresden Site, Morris, Illinois Inspection Conducted:
September 1 through November 8; 1991'
Inspectors:
W. G. Rogers D. E. Hills M. s. Peck Approved By: kJ~.
-. _pv-.s. L. Burgess_, Chief Projects Section 18 Inspection Summary Date - '
Inspection from September 1 through November 8, 1991 (Repdrt Nos. 50-237/91035(DRP); 50-249/91038(DRP)).
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Areas Inspected:
Special unannounced safety inspection by the resident inspectors of the circumstances, including operational implications, surrounding the torus high temperature event of Septembet 1; 1991, the hydraulic control _unit (HCU) draining event of September 25, 1991, and _the out of sequence control rod scram ~vent of October 6~ 199 Results:
Four apparent violations were identifie Two of these apparent violations involved multipie examples of failing to follow administrative*
procedures during operation The third apparent violation involved.a failure to follow a surveillance procedure by control room operator The fourth apparent violation involved two examples of inadequate administrative procedures which failed to provide sufficient direction in the performance of operational activitie Operations These events were indicative of licensee management's failure, despite similar
~revious events and cotrective actions, to effectively deal with personnel
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_performance problem Licensee management's effectiveness to ensure:
1) adequate implementation of administrative requirements through effective communication of expectations; 2) aggressive attitudes toward problem
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resolutions; 3) thorough plant status overview; and--4) quality eommunications was clearly deficient. Although seniot management had repeatedly communicated 9112110142 911i29 PDR
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G PDR
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a* general operational methodology to personnel, these efforts were ineffective due to a lack of reinforcement and feedback at lower management levels regarding appropriate expectation All three of the ~vents reflected inadequate communications between shifts
.and/or within shift crews and a failure of personnel to follow established procedure Several inadequacies in operating and administrative procedures contributed to the events. Also, the torus heatup and out of sequence rod scram ~vents revealed management's failure to instill an aggressive approach toward problem resolution at the operator leve Safety Assessment/Quality Verification Various ~spects of these events were indicative of licensee management's continued failure, despite.similar previous events and-corrective actions, to effectively deal with personnel performance problem The event involving the scramming of the control rod out of sequence occurred after management had mandated strict procedure tompliante and communication feedback when performing an evolutio Inadequacies in operating and administrative procedures cbntributed to the toru~ high temperature and HCU draindown events. Previously, inadequate procedures was identified as a deficient area and a long term upgrade program was initiate Due to a lack of resources early in the program, the scheduled completion ~ate was extended. Appropriate resources appear to be applied to meet the current completion dat '*
- DETAILS Persons Contacted Commonwealth Edison.Company E. Eenigenburg, Station Manager
.*C. Schroeder, Incoming Station Manager**
- L. Gerner, Technical Superintendent J. Kotowski, Production Superintendent E. Mantel,. Services Director
- D. Van Pelt, Assistant Superintendent - Maintenance J. Athterberg, Assistant Superintendent - Work Planning
- G. Smith, Assistant Superintendent-Operations K. Pete*rman, Regulatory A.ssurance Supervisor M. Korchynsky, Operating Engineer
- B. Zank, Operating Engineer J. Williams, Operating Engineer R. Stobert, Operating Engineer *
T. Mohr, Operating Engineer *
- B. Viehl, Nuclear Engineering De~artment Site Supervisor M. Strait, Technical Staff Supervisor L. Cartwright, Q.C. Supervisor J. Mayer, Station Security* Admi ni.strator D, Morey, Chemistry Services ~upervisor.
D. Ambler, Radiation Protection Manager Kanwjsch~r, Services Superintendent *
- T. Gallaher, Nuclear Quality Programs Engineer K. Kociuba, Nuclear Quality P~~grams Superintendent
- R. Janecek, Offsite Nuclear Safety Senior Participant
- D. Lowenste.in, Regulatory Assurance Analyst
- K.. Yates, On-site Nucle~r Safety Administrator
- K. Deck, On-site. Nuclear Safety
. *J. Pa~zolt, Reactor Engineer
- Denotes those attending the exit interview conducted o~
November 8, 1991, and at other times throughout the inspection perio The inspectors also interviewed several other licensee employees including members of the technical and engineering staffs; reactor and auxiliary operators; shift engineers and foremen; electrical, mechanical, and
instrument maintenance personnel; and contract security personne.
Event Descriptions Torus Temperature Event On August 30~ 1991, during shift 3 (afternoons) the 11 HPCI Turbine Inlet Drain Pot High Level 11 alarm was received during a Unit 2 startu The utility nuclear station operator (NSO) responded to the ala~m and notified the shift superviso The station control
- room engineer (SCRE) and center desk NSO were not aware of the alar Neither the alarm nor the NSO action of cycling the drainpot bypass valve were documented in the Unit 2 lo Unit 2 scrammed later that night and no further attempt to remedy the problem was made prior to
.the subsequent restar During the Unit. 2 restart on shift 1 of September 1, 1991, the drain pot alarmed again on high level. Cycling the bypass valve hand switch failed to clear the* alar The NSO opened a drain path to the torus in accordance with the alarm response procedure and informed the SCRE of this actio Neither the alarm or the abnormal drainpot lineup were documented in the unit lo The alarm and abnormal alignment were discussed during shift turnover by the NSOs but not the SCRE Subsequently on shift 2, a torus high temperature alarm was received and immediately cleare The NSO promptly informed the shift'
engineer (SE) but did not log-the alarm recejp (The SE had relieved the SCRE for a short time.)
The SE was unawar~ of the abnormal HPCI drainpot alignmen The SE believed the cause of the alarm was normal ambient condition Upon return of the SCRE, the SE failed to turnover receipt of the alarm, nor was it mentioned by the NS Therefore, the SCRE was unaware of any torus temperature problems during the shif No actions were taken by that shift to initiate torus coolin The NSO did send a non-licen5ed operator to check associated valves but did not document this action in the unit lo The oncoming shift 3 SE and SCRE becam~ aware of the abnormal lineup while walking the panels for turnove Although the shift recognized the need for torus cooling,, low priority was placed on this actio The low pressure cooling injection (LPCI) system operating procedure required, containment cooling service water (CCSW) samples to be taken "if time permits" and LPCI venting to be performed "if other than an emergency condit1on" existe As the SE and SCRE were concerned with a possible radiological release or the potential for a waterhammer event, a substantial delay occurred while placing torus cabling into servic The shift supervisor checked the local drain pot equipment sine~ this was believed to be the source of the torus temperature increas However, other priorities caused a substantial delay in accomplishing this tas When torus temperature reached 95 degrees F, at 7:59 p.m., the NSO informed the SCRE that this was.a Technical Specification (TS) condition; however, the NSO*believed 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> was allo.wed to restore torus temperature to normal condition The SCRE was aware this was a TS limit but concluded that there was no obvious action statemen TS 3.0.A applicability was not identified by the shift. The SCRE and NSO realized that a Dresden Emergency Operating Procedures (DEOP) entry condition was entered and reviewed the DEOP The SCRE did not inform the SE upon reaching the 95 degrees F torus.temperature.limit, howe~er, it ~as documented in the unit-lo The log entry did not mention that 95 degrees F was a TS limi **
e-The shift supervi3or later examined the equipment locally and cleared the alarm by agitating the stuck level switc The HPCI drainpot system was returned to its normal alignmen These corrective actions andan attempt by the NSO to cycle the byp*ass valve hand switch were not mentioned in tbe unit lo When th~ SE later reviewed the unit log for turnover, he noted the torus temperature and referred to the DEOPs.* He did not officially enter the DEOPs because he did not deem it an
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emer~entY since the heat input had stopped and progress ~as being made toward establishing torus coolin The SE did not realize that 95 degrees F was a TS limi Therefore, he did not realize the applicability of TS 3. Est~blishment of torus cooling was delayed into the next shift because the assigned individual left on a personal emergericy.:
Upon turnover, the ontoming shift 1 SE, SCRE, and NSO were aware of the torus temperature conditio The shift.1 SE also did riot realiz~ 95 degrees F was a TS limi Although the SE referred to the DEOP~, they were not officially entered for the same reasons as befor Later into the shift, the SCRE and NSO started discussing possi~le TS problems and took considerable time reviewing applicable document Consequently, the SE was.informed about possible TS problems approximately two to three hours into the shift.. About the same time, toru~ cooling was established.and torus temperature was reduced to below 95 degrees The unit log mentioned these actions, but did not indicate that a TS LCO had been entere HCU Draining Event On September 23, 1991, an equipment attendant (EA) depressurized all the Unit 3 east side hydraulic control units (HCUs) to support placing the mode switch in shutdow Dresden Operating Procedure (DOP) 500-4, 11 Reactor Mode Switch to Shutdown When All Drives Are Fully Inserted, 11 Revision 0, was the writte.n direction for performing this ~~tivity. This procedure required closure of the (HCU) drain valves on each accumulator following discharg The EA, who was not utilizing the procedure, left the valves ope Additionally, the procedure limited HCU discharge to only one accumulator at a time on each bank while the EA discharge4 five accumulators at a tim A second EA, after receiving instruction from the first, discharged the west bank accumulator The second EA also discharged five accumulators simultaneously and left the drain valves in the full-open*
positio On September 25, 1991, with all fuel removed from the reactbr vessel, approximately 2,800 gallons of contaminated water were released from the Unit 3 east HCU bank to the reactor building floor and torus basemen The spill occurred when the control air supply to the scram pilot solenoid valves was i.solated in
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accordance with out-of-service instructions to facilitate the rebuilding of the scram pilot valve The out-of~service
instructions failed to include the HCU drain valves in the clearance boundary and tc:i verify them close Single rod scram On October 6, 1991, with Unit 2 at 35% power, operators commenced routine half-core scram testing at 3:10 Prior to beginning the evolution, two heightened leveJ awareness briefings were hel The evolution began with the control room NSO assumin9 the duties of directing the non-licensed equipment attendant (EA)
manipulation of control rod charging flow, manipulating the control rods except for th~ actual scramming of the control rod, and directing the scramming of the designated control ro The utility NSO was assigned to scram the rod when directed by the control room NSO and the SCRE was to verify that the utility NSO
. was scramming the selected rod. After the third control rod was scrammed, the SCRE directed that the center desk NSO perform the verification duties while the SCRE completed some paper work on the standby gas treatment syste The center desk NSO accomplished this task on the fourth rod scrammed (L-11).
After scramming control rod L-11, the control room NSO experienced considerable difficulties in moving control rod L-11 back to position 4 **
While the control room NSO was taking action to move the rod~ an accumulator alarm came in on a control rod not associated with the test and the utility NSO required a relief brea TheSCRE directed the center desk NSO to t,ake over as the de~ignated person to scram the control rods and the SCRE returned to his position as the verifier of the rod to be scramme Coincident with the personnel changes~ the EA was instructed to re~pond to th ~ccumulato~ alarm and to valve out the charging water flow to the next rod, P-1 A few minutes later, at approximately 3:24 a.m., the EA informed the control room NSO that the accumulator alarm had been resolved, the
. charging water had.been isolated to rod P-10 and the rod was ready for scrammin The NSO repeated back the non-licensed EA statemen When the center desk NSO, who was sitting at the center desk, overheard the conversation between the EA and the control room NSO, he assumed that P-10 was to be scramme He, with the SCRE, proceeded behind the control board to the back panel and scrammed p:10 at approximately 3:25 The control room NSO was unaware of the center desk NSO's actions and rod L-11 had yet to be returned to position 48 prior to scramming control rod P-1 The control room NSO immediately identified the inadvertent scramming and the test was terminate Subsequently, the shift engineer notified plant management, the
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senior resident inspector, and the on~call nuclear engineer.. The nuclear ~ngineer authorized return to the procedure sequenc This was accomplished at 3:50 a.m. in the mornin ** Event Reviews Torus Temperature Event (1)
Personnel Performance Inadequate cognizance of plant conditions by shift management and inadequate communications between shifts and within shift crews were-prime factors in this even As a result, ke~ operating personn~l were not always in a
- position to make completely informed decision During the startup on August 30, 1991, the drain pot level alarm was not noted as-a problem in the unit log such as to identify needed action to management; and the alarm conditio was ~ot resolv~d. The unit NSD and SCRE were-not made aware of the problem by the utility NSD or the shift superviso Due to an inadequate turnover, no mention of the alarm or abnormal lineu~ in the unit log, and inadequate panel walkdowns, the shift 2 September 1, 1991, shift engineer (SE) was unaware of the abnormal torus heat input when evaluating the high torus temperatur The SE was not informed by the shift 2 NSD during the evaluatio The shift 2 SCRE was not made aware of the abnormal torus heat input during shi~t turnover or during panel observance ~nd was not told a_bout the torus temperature alarm by the SE or NSD upon return from an interim relie (There existed no administrative guid~nce on performing interim relief turnovers.) Therefore, no actions were taken by Shift 2 to-establish torus cool~ng or resolve the drain pot problem beyond the actions taken by the NS Upon exceeding a torus temperature of 95 degrees F, the shift 3 September 1, 1991, SCRE did nrit inform the SE of*
reaching a known emergency procedure entry condition and TS LC Upon later 1earning that torus temperatu~e had reached 95 degrees F by reading the unit log, the SE was not informed- _
that this was a TS LCD by either the SCRE or NS The unit log did not indicate ~hat this was a TS LC Therefore, the SE did not evaluate possible action statement *
Although the shift -1 September 2, 1991, NSD and_ SCRE were concerned about TS implications, they conducted considerable review and discussiori before informing the SE of the~e concern As a result, the SE did not realize that TS action requirements applied until about the same time as the LCD termin~te Licensed operating personnel had received ~d~inistrative procedure training for turnovers and log keeping during requalification cycle 2 (March 4 - April 12, 1991) which consisted of re-iteration of procedural requirement It
was apparent that this training was ineffective as was management's oversight of ensuring adequat~ implementation of admintstrative requirements.*
The personnel performance deficienci~s.noted over the course of the event were contrary to several administrative procedure requirements including the following:
Operations Department Technical Specification Interpretation No. 2, 11TS 3.0.A Implementation, 11 dated *
July 14, 1988 required, in part, that if no action statement was specified then TS 3.0.A governed and that the shutdown would be initiated immediately with recirculation flo Dresden Administrative Procedure (OAP) 7'."'05, 110peratin Lo*gs and Records, 11.Revision 9, required, in part, the unit log to contain a list of all alarms and abnormal conditions found upon assuming the shift or occurring during the course of the shift except those denoting normal conditions, a brief narrative of unusual performance of the plant and any efforts made to determine the cause, and TS LCOs that occur during the shif OAP 7-01, 110perations Department Organization 11,
Revision 15, required, in part, the shift engin~er (SE)
to ensure a proper shift turnover is accomplished and OAP 7-02, 11Conduct of Operations*,
11 Revision 16,
~equired, in part, for the shift control.room engineer (SCRE) shift turnover to include a discussion of uni statu OAP 7-01, 110perations Department Organization,
Revision 15, required, in part, for the SCRE to assist the SE in interpreting and applying the requirements of Technical Specifications and to notify the SE _of any abnormal operating condition OAP 7-01, 110perations Department Organization, 11 Revision 15~ required, in part,.that the SE be responsible for direct observations of each unit by overview of the contra l b_oards in the contra l room and keeping informed of any off-normal conditions that may exist or occur during the shift and the SCRE to maintai~ an in-depth knowledge of plant and equipment statu OAP 7-02, 11 Conduct of Shift Operations, 11 Revision 16, required, in part, that on turnover the SE walk the unit panels and the SCRE to walk the unit panels, performing a thorough review of system configurations, alarms, and in~ications.
OAP 7-01, "Operations Department Organiz*ation,
Revision 15, required the NSO to notify the proper authorities regarding unusual conditions and the Shift Supervisor (Licensed) to ensure that the SE and the SCRE are properly informed of all conditions which could adversely affect plant operation The many failures ta adhere to these administrative procedures for conduct of operations during the event are considered to be examples of an apparent violation (50-237/91035-0l(DRP)) of 10 CFR 5G, Appendix 8, Criterion The low priority given to addressing the HPCI drain pot problem by operating personnel contributed to this even Higher priorities prevented the shift supervisor from checking local equipment on August 30, 1991;. arid, following the shutdown, th~
shift supervisor was otherwise occupie Although the HPCI drain pot was suspected to be the cause of the torus temperature problem by the shift 3 September 1, 1991, operating crew, higher priorities prevented the shift supervisor from checking equipment until approximately seven hours into the shif The abnormal lineup fo~ the HPCI drain pot syste~ was allowed to continue for approximately 17 hours1.967593e-4 days <br />0.00472 hours <br />2.810847e-5 weeks <br />6.4685e-6 months <br /> although it was clearly ineff~ctive in clearing the alar Operator perception of a history of continuing problems with drain pot system components without restilution resulted in untimely operator action to resolve the proble A review of HPCI drain pot system component work histories identified considerable torrective maintenance work in earlier year However, as a result of a HPCI maintenance analysis completed on April 21, 1988, a number of preventive maintenance activities had been or were in the process of being instit~ted on problem compcinents and correciive maintenance activities had decreased substantiall This
.operator mindset appeared to be reflective of historical maintenance practices and not of current practice with regard to the HPCI drain po Management had been ineffective in instilling an aggressive approach toward problem resolution in the operators despite the maintenance improvement Through interv1ews with operators, the inspectors ascertained a lack of communications regarding these initiatives to b~ ~ contributor to operator attitud (2) Operator Training The delay in rectifying the drain pot proble*m was a*lso contributed to by a failure of individual operating personnel to recognize either 95 degrees F ~s a TS LCD or that a
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corresponding action statement was applicabl Both TS 3;7.A.l(c) on maximum bulk torus water temperature and TS.3.0.A were covered in initial license training. Although the licensee indicated that TS 3.7.A.l(c) had never specifically been covered in requalification trai~ing, the inspecto~s *
verified that various TS items were frequently co~ered in other area The licensee*indicated thit TS *3.0.A was last covered in requalificat~on training in June 1987 in response to a previous even Although it appeared that the initial and requalification program met regulatory requirements in. the areas reviewed with respect to 10 CFR 55, TS areas applicabl~.
to this event had not been covered fn requalification training at all or recently enough to be effectiv The inspectors also noted that the licensed operator training lesson plan for primary containment dated May 1989 did no~ list knowledg~ of applicabl~ Technical*
Specifications as an enabling objective nor did it indicate any of the identified enabling objectives as terminal obj~ctives. The inspectors reviewed several other lesson plans including some from the same time frame and by the same author and determined this to be an isolated cas The inspectors noted that numerous personnel were aware that 95 degrees F torus temperature was an entry condition into the DEOPs and revi~w~d the DEOP~ in that regard, although they were never officially entere In this case personnel did not believe an emergency existed due to the torus temperature rate of change being slow, knowledge that applicable actions were already being taken, a perception that this was not a *priority condition since torus temperature can exceed that value for testing, and ~ strong belief of what was causing the heat input and later that this cause had been stoppe DEOP 010, "Guidelines For Use of Dresden Emergency Operating Procedures", Revision 5 indicated that 11the DEOPs are entered and exe.cuted if any of the stated entry co.nditions exis They are exited when instructed or it is *determined an emergency no longer exists.
Further review of licensee policy regarding entry into emergency operating procedures with respect to this event is *to be addressed in inspection report (50-237/91029(DRS):
50-249/91031{DRS)).
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(3) Procedure Adequacy Weaknesses in specific operating procedures were identifie The alarm response procedures for torus high temperature failed to indicite that a Technical Specification was applicabl The operating procedure for torus cooling indicated that samples were to be taken if time permits but
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~id not ~pecifically define applicable circumstance The procedure also indicated that if other than an emergency existed *then LPCI would*be vented first.. The procedure did not further define the term "emergency".
The operator
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training program did not compensate for the vagueness in the procedure The perfor~ance of the sampling and venting activities resulted in a long delay in establishing torus coolin The licensee has committed to clarify the operating procedure for torus cooling regarding when sampling an analysis are neede This will be reviewed further in a future inspectio Previously~ the licensee had recognized that aeneric procedural improvements were necessary and a long term procedure upgrade program ~as in progress. These procedures had not yet been upgraded through that progra The revised torus temperature alarm response procedure was in the review
- and verification cycle at the time of the event and did refer to the applicable Technical Specificatio Due to the lack of adequate resources early in the program, the upgrade schedule was extende Recognizirig this problem, licensee management had already taken action to ensure revised
- schedule dates would be met..
The alarm response pro~edure for the HPCI drain pot *high level failed to give a stuck.level switch as a probable cause and this was net identified as the cause when local drain pot valving was checked by anon-1icensed operator on shift 2 September 1, 199 In addition, this procedure did not indicate any expected time limits for the abnormal drain pot lineup~ Although, this procedure had already been through the procedure upgrade program, a maintenance history*
review did riot identify a stuck level switch as a recurring proble~. The inspectors therefore did not regard these as obvfous procedure u~grade item The licen~ee i~dicated that arrrvpriat<:: procedure changes would be made to address these areas. Therefore, the inspectors have no further concerns in this are *.Administrative procedures were also deficient in that no.
specific guidance was given as to implementation of interim turnovers as opposed to shift turnovers in genera Regulatory Guide 1.33 (Safety Guide 33), "Quality Assurance Requirements (Operations),
11 dated November 3, 1972, committed to in Comrr;onwealth Edison Company's Topical Report, CE-1-A, Revisibn 55, required written administrative procedures to cover shift and relief turnover activitie Regulato1~
Gui~E 1;33 also endorsed American National Stbndards Jr:stitute (ANSI) NlB.7-1972 (American Nuclear Society (ANS)-3.2), "Standard for Administrative Controls for Nuc.lea-r Power Plants~ II which required.\\tffittU1 iristructions.
dealing *ith job turnover and relie As indicated above,
an inadequate interim turhover caused the shift 2 September 1, 1991, SCRE to be unaware of torus temperature problem The failure of administrative procedures to
specifically address interim job turnover and relief requirements is considered to be an example of an apparent violation (50-237/91035~02a(DRP)) cif lo CFR 50~ Appendix 8, C~iterion * HCU Draining Event (1) Personnel Performance As exhibited in the torus temperature event, thts event was also indicative of inadequate communicati~ns within the shift crew and a deficiency in the licensee's management oversight in ensuring adequate implementation of administrative requiremehts~ The HCU drain pre-job briefing failed to effectively communicate the expectations of the
. jo The EA left the briefing only with the understanding that he was to drain the accumulator However, the shift supervisor's (SS) expectation was that only one accumulator was to be drained at a time and the drain valves were to be
~los~d on each accumulator after discharg The EA did not repeat back the directions given by the S The SS also failed to verify the work had been properly completed in the reactor buildi~g. although this was the first time the EAs had c~nducted this evolutio OAP 7-02, "Conduct of Shift Operation," Revision i6, *
- requires operations personnel to reference and follow the procedure for the ehtire evolution for complex or infrequently performed ev~lutions; Both EAs failed to take a copy of DOP 500-4 to the job site although neither had performed this particular evoluti6n previousl Failure to-reference and follow infrequently performed DOP 500-4 per the requirements of OAP 7-02 was considered an apparent violation (50-249/91038-0l(DRP)) *of 10 CFR 50, Appendix 8, Criterion *
(2)
Procedure Adequacy DOP 500-4 did not include any signoffs to document the required verification that the accumulator had been drained, the pressure had been reduced to approximately 600 psig, and the drain valve was closed on each HC This procedure had been through the procedure upgrade program, but that program did not require the addition of verification signoffs for individual s~eps. ANSI N18-7-1972 requires that complex procedures should have checkoff list Although the failure to incorporate verification signoffs into DOP 500-4 was considered a weakness, this was not regarded as a violation of NRC requirements as the procedure was not reasonably considered "complex".
- Out-of-~ervice (OOS) III-1306, which isolated the control air to the scram air header, fail~d to include the HCU drain valves within the clearance boundar OAP 3-05,
"Out-Of-Service and Personal Protection Cards", Revision 23, did not specify the boundary condi ti o_ns required to be controlled by the OOS check list. *The preparation and
. review of the OOS relied on memory that the drain. valves were in the 11 normal 11 configuratio The failure of administrative procedures to ensure adequate boundary scope
- for out-of-services is considered an example of an apparent violation (50-237/91035-02b(DRP)) of 10 CFR 50, Appendix B, Criterion * Out-of-Sequence Control Rod Scram (1)
(2)
(3)
( 4)
( 5)
On shift management did not aggressively oversee th~ scram testing evolutio The SCRE involved hims~lf in paper wcirk unne~essarily.. The center desk N~O, who was inexperienced at this activity and had never actually performed this test except in a training status, received no additional supervisory overview from the SCRE in the performance of the
. activit The center desk NSO did not use the r~peat-back process prior to performing a reactivity manipulation by scramming control ~od P-1 The NSO did not adhere to the test procedure and authorized the v~lving 6ut of charging water to rod P-10 prior to returning rod L-11 to it's original position, The HLA briefing was deficient in that relief breaks for personnel were not addressed to assure that the activity could be performed without interruptio Th~ material condition of the c6htrol rods w~re poor and had yet to be adequately addressed or identified as such ih the log Specifically, the first three rods took drive water pressures of over 250 pounds before moving the rods from position 0 Th~ f6urth rod, L-11, took drive water pressure in exces~ of 600 pound This was not considered ari abnormality by the operating cre.
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Scramming control rod P-10 and val~ing out charging wate~ to control rod P-10 prior to placing control rod L-11 at it's designaied position was inconsistent with the procedural requirements of NTS 300-2,. "Control Rod Drive Scram Testing and Scram Valve Timing Test."
These actions were two examples of licensed operators failing to follow established procedures and is considered an apparent violation (237/91035-03(DRP)) of 10 CFR 50, _Appendix B, Criterion j Safety Significance The safety significance of the events from a technical sense was no hig The TS Bases indicated that the torus temperature limit. for complete conden~ation of the reactor coolant du~ing accident*
conditions was 170 degrees FSAR analysis determined that there would be a 50 degrees rise in torus temperat~re as a. result of an acciden Therefore, a te~perature rise to 147 degr~~s F (97 degrees F + 50 degrees F) was well below the 170 degrees F condensation limi The HCU spill happened when ~11. the fuel was in the spent fuel poo The contamination resulting from the HCU draining event affected only limited areas on two levels of the reactor building.. The area was decontaminated with.one individual ex~ernally con~aminated during the cleanup activities.* Scramming control rod P-10 out of sequence did not invalidate the shutdown margin or cause core management concern However, when viewed in ~ggregate as to management effectivene~ these ev~rits clearly involved an overall management breakdown in license activitie.
Exit Interview Th~ inspectors met with licensee representatives (denoted in paragraph 1) during the inspection period and at th~ conclusion of the inspection period on November 8, 199 The inspectors summarized the scope and results of the inspection ana discussed the likely content of this inspection repor The licensee ackno~ledged the information and did not indicate that any of the information disclose~ during the inspection could be considered proprietary in natur '
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