IR 05000237/1991040
| ML17174B067 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 12/13/1991 |
| From: | Burgess B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17174B065 | List: |
| References | |
| 50-237-91-40-EC, 50-249-91-44, NUDOCS 9112270122 | |
| Download: ML17174B067 (53) | |
Text
- I U.S. NUCLEAR REGULATORY COt'.MISSION REGION I I I Reports No. 50-237/91040(DRP); 50-249/91044(DRP)
Docket Nos. 5C-237; 50-249 Licenses No~ DPR-19; DPR*25 Licensee:
ColTITionwealth Edison Company Opus West III 1400 Opus Place *
Downers Grove, IL 60515 Meeting Conducted:
December 10, 1991 Meeting At:
Holiday Inn, Glen Ellyn, Illinois_
Type of Meeting:
Enforcement Conferer:ice Facility Name:
Dr den Nuclear Power Station, Units 2 and 3 Me~ting Summary
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oaa
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Enforcement Conference on December 10, 1991 (Reports No. 50-237/91040; 50-249/91044)
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Areas Discussed: A review of the apparent violations and areas of concern identified dur1ng the inspections, and corrective a~tions taken or planned by the licensee. The. enforcement optio~s pertaining to the apparent violations were also discussed with the license PDR ADOCK 05000237 G
'. DETAILS Persons Present at the Conference Connnonwealth Edison Company D. Galle, Vice President~ BWR Operations K. Graesser, General Manager-BWR Operations C~ W. Schroeder, Station Manager-Dresden E. D. Eenigenburg, Departing Dresden Station Manager T. J. Kovach, Nuclear Licensing G. L. Smith, Assistant Superintendent of Operations-Dresden M. Vincent, Chemical Services-Radwaste R. Radtke, Nuclear Licensing
. P. Barnes, Compliance Supervisor~Nuclear licensing K. W. *Peterman, Regulatory Assurance Supervisor N. E. Dubry, Safety Assessment Engineer K. Deck, Onsite Nuclear Safety, Dresden S. L. Trubatch, Counselor L~ Piet, Nuclear Licensing Administrator-Dresden S. Lawson, Safety Systems Group Leader Tech Staff, Dresden W. E. Morgan, Corporate Nuclear Safety*
M. Gallaway, Dresden Mechanical Maintenance T. Dolan, Senior Work Analyst R. Scott, Statton Control Room Engineer *
B. Colebank, Maintenance Staff, Dresden R. Janecek, Offsite Review Senior Participant.*
M. Korchynsky, Unit 3 Operating Engineer-Dresden W. Johnson, Fuel Handler-Dresden
L. Ciuffini, Reactor Operator, Dresden M. Parcell, Shift Engineer, Dresden U.S. Nuclear Regulatory Commission A. B. Davis, Regional Administrator, Region III {Rill)
W. L.. Forney, Deputy Director, Divisfon of Reactor Projects (DRP), (RIII)*:.
B. Clayton, Chief, Branch 1, DRP, RIII W. Troskoski, Acting Director, Enforcement Investigation Coordination Staff, RI II B. L. Burgess, Chief, Section lB, DRP, Riil W. Rogers, Senior Resident Inspector-Dresden P. L. Pelke, Enforcement Specialist, RIII J. Luehman (via phone), Enforcement Specialist, Office of Enforcement M. Peck, Resident Inspector, Dresden R. M. Lerch, Project Engineer, DRP, RIII B. Siegel, Dresden Project Manager, NRR C. Mohrwinkel, Attorney, NRR W. Pegg, Reactor Inspector, NRR D. Liao, Reactor Engineer, DRP, Riil P. R. Rescheske, Reactor Inspector, DRS, RIII
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Illinois Department of Nuclear Safety R. Zuffa,.Resident Engineer, Diesdeh Enforcement Conference An enforcement conference was held in the Holiday Inn, Glen Ellyn, Illinois on December 10, 1991. This conference was conducted as a result of.the preliminary findings of inspectio.ns during which apparer1t violations of NRC regulations and license conditions were identified. Inspection findings are docu~ented ir1 Inspection Reports No. 50-249/91032(DRS) and 50-237/91035; 50-249/91038(DRP), transmitted to the licensee by letters*
~ated November 22, 1991 and November 29, 1991 respctiv~ly;
The purpose of this ccnference was to (1) discuss the apparent
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violations, causes, and the licensee's corrective actions; (2) discuss*
several areas of concern; (3) determine if there were any escalating or mitigating circumstances; arid (4) obtain any information which would.help determine the appropriate enforcement actio The NRC present~d the*
apparent violations and concerns in slides, copies of-which are *
Attachment 1 to this repor The 1icensee 1 s representativ*es ciid not contest any of the apparent *
violations and were in agreement with the NRC's understanding 6f the areas of concer The licensee'~ representatives described the events which lead to the violations, including root cause(s) and corrective..
action(s) take The litensee's presentatiori slides are Attachment 2 _
to this repor In summary, the corrective actions were both -broa.d _.-
based long-term ahd specific near-term actiohs as described in
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Attachme.nt *
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Jl.t the conclusion of the meeting, the licensee was informed that they would be.~otified in the near future of the final.enforcement*jcti6n. -
Attachments:
As ~tated
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ATTACHMENT 1
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DRESDEN ENFORCE1\\1ENT CONFERENCE DECEMBER 10. 1991 U. S. NUCLEAR REGULATORY. COM1\\flSSION REGION.ID
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CONFERENCE AGENDA OPENING REMARKS:
A. BERT DA VIS,
REGIONAL ADMINISTRATOR OVERVIEW OF CONCERNS:
W. L. FORNEY, *
DEPUTY DIRECTOR, DRP EVENTS AND VIOLATIONS:
WALT ROGERS SENIOR RESIDENT INSPECTO C01\\1M:ONWEALTH EDISON C01\\1PANY C01\\1M:ENTS
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CLOSING* REMARKS:
A. BERT DA VIS, ~T A j,
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'*.
THE EVENTS
- TORUS HEA TUP
- HCU DRAINDOWN.
- OUT-OF-SEQUENCE ROD SCRAM
- FUEL HANDLING
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AUGUST 30, 1991 GRAVEYARD SHIFT TORUS HEATUP
"HPCI TURBINE INLET DRAIN POT HIGH LEVEL" ALARM RECEIVED NOT ADEQUATELY RESOLVED
. REACTOR SCRAM LATER THAT SHIFT
SEPTEMBER 1. 1991 GRAVEYARD *SHIFT
ALARM IDENTIFIED AGAIN
ABNORMAL LINEUP ESTABLISHED (HEAT INPUT TO TORUS)
DAY SHIFT
"IDGH TORUS TEMPERATURE" ALARM RECEIVED INADEQUATE INTERIM TURNOVER SWING SHIFT
DECISION MADE TO PLACE TORUS COOLING INTO SERVICE
TORUS COOLING LOW PRIORITY TASK
TECH SPEC LIMIT (95 F) REACHED AT 7:59 *
MOTHERHOOD NOT RECOGNIZED
- SEYI'EMBER 2. 1991 *
GRAVEYARD SHIFT
TORUS COOLING PREPARATIONS CONTINUE
NSO AND SCRE QUESTION WHETHER TECHNICAL SPECIFICATIONS APPLICABLE
2 - 3 HOURS LATER, SE WAS INFORMED
TORUS COOLING IN-SERVICE TEMPERATURE LESS THAN 95 F
HCU DRAINDOWN SEPTEMBER 23, 1991
NON-ROUTINE DEPRESSURIZATION OF HCUs PERFORMED
ALL DRAIN VALVES LEFf OPEN
.e NO SUPERVISOR FOLWWUP SEPTEMBER 25, 1991
SCRAM HEADER TAKEN OUT-OF-SERVICE (OSS)
OSS TAGGING DID NOT INCLUDE PLACING DRAIN VALVES. IN CONTROLLED STATUS
2800 GALWNS OF RCS SPILLED FROM CONTROL ROD DRIVES
...
OUT-OF-SEQUENCE ROD SCRAM
OCTOBER 6, 1991 (GRAVEYARD SHIFT)
ROUTINE 112 CORE SCRAM TESTING
. THREE RODS SCRAMMED THEN SCRAM VERIFIER CHANGED
- FOURTH ROD SCRAMMED WITH SIGNIFICANT PROBJ,,EMS IN RETRACTING FROM 00
- * *
SCRAMMER AND SCRAM VERIFIER CHANGE *
F'IF"IH ROD'S CHARGING WATER VALVED OUT BEFORE FOURTH ROD RETURNED TO ORIGINAL POSITION
. F'IFTH ROD SCRAMMED BEFORE FOURTH ROD RE~
TO ORIGINAL POSfilON
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FUEL HANDLING
OCTOBER 18, 1991 (SWING SHIFT)
NON-CRITICAL PATH ACTIVITY - SPENT FUEL POOL REORGANIZATION
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GRAPPLE NOT RAISED HIGH ENOUGH AFfER DISCHARGING A FUEL BUNDLE
THREE FUEL BUNDLES DAMAGED
SUPERVISOR NOTIFIED
FUEL MOVEMENTS CONTINUED UNTIL ABNORMAL MAST NOISES HEARD
IMPACT WITH FUEL BUNDLE BAILS CONTRIBUTES TO SUBSEQUENT MAST FAILURE
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SHIFT ENGINEER/SENIOR MANAGEMENT NOT INFORMED UNTIL LATK NEXT SHIFf
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TORUS HEATUP INADEQUATE SUPERVISOR INVOLVEMENT INADEQUATE COMMUNICATIONS x
WORKING AROUND PROBLEMS x
INADEQUATE _PROCEDURES. x INATTENTION TO DETAIL x
TRAINING INADEQUACIES x
CAUSAL FACTORS HCU our-OF-SEQUENCE FUEL
.DRAINDOWN ROD SCRAM HANDLING X*
x x
x*
x x
x x
x x
x x
x
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PRELIMINARY REGULATORY CONCLUSIONS MANAGEMENT BREAKDOWN IN THE CONTROL OF LICENSED ACTIVITIES VIOLATIONS:
5 TOTAL = 1 ENFORCEMENT ACTION 10 CFR 50 APPENDIX B, CRITERION V TORUS HEATUP FAILURE TO FOLWW PROCEDURES (7 EXAMPL~)
10 CFR 50 APPENDIX B, CRITERION V.
. INADEQUATE PROCEDURFS (2 EXAMPL~)
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10 CFR 50 APPENDIX B CRITERION V
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HCU DRAINDOWN FAILURE TO FOLWW PROCEDURES (1 EXAMPLE) -
OUT-OF-SEQUENC TECHNICAL SPECIFICATION 6.2..
SCRAM FAILURE TO FOLLoW PROCEDURES (2 EXAMPL~).
TECHNICAL SPECIFICATION. 6~2..
FUEL HANDLING FAILURE TO FoLWW PROCEDURES (1 EXAMPLE)
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. DECEMBER 10, 1991 ATTACHMENT 2 DRESDEN ENFORCEMENT CONFERENCE MANAGEMENT CONTROLS AGENDA INTRODUCTION/OVERVIEW EVENT SIGNIFICANCE/SPECIFIC CORRECTIVE ACTIONS STATUS OF IMPROVEMENT PLANS CLOSING D. GALLE C. SCHROEDER C..SCHROEDER
. D. GALLE NOTE: *Attachments A, 8, C, and D contain the detailed chronology, causes, significance and corrective actions for the cited event *
~.Tr./\\,C~MENT A: HYDRAULIC CONTROL UNIT SPILL EVENT ATTACHMENT 8: OUT-OF-SEQUl::i"Cc AOD SCRAM EVENT ATTACHMENT C: TORUS HEAT-UP*EVENT-ATTACHMENT D: FUEL HANDLING ERROR EVENT znld/1376/1
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. INTRODUCTION/OVERVIEW
THE CITED VIOLATIONS WERE EXAMINED AS INDIVIDUAL EVENTS IN RELATION TO THE 5 CAUSAL FACTORS
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ADDRESSED AT THE 11/12191 MANAGEMENT MEETING
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WE AGREE THE VIOLATIONS OCCURRED
CECo TAKES THESE ISSUES SERIOUSLY AND SYSTEMATIC
- CORRECTIVE ACTION IS UNDERWAY. SPECIFIC EMPHASIS.. *
IS BEING PLACED ON:
MANAGEMENT EXPECTATIONS/PROCEDURE PROCEDURE QUALITY COMMUNICATIONS
MANAGEMENT RECOGNIZES THAT STRONG CORRECTIVE ACTION IS NEEDED, BUT ESCALATED ENFORCEMENT IS**.
NOT WARRANTED
WE RECOGNIZE THAT IMPORTANT IMPROVEMENTS IN THE WAY WE DO BUSINESS ARE NEEDED:
WE ARE COMMITTED TO MAKING CHANGES BROAD IMPROVEMENT ACTIONS ARE ALREADY UNDERWAY; SEVERAL HAVE BEEN IMPLEMENTED SUSTAINED STRONG MANAGEMENT ATTENTION WILL BE APPLIED znld/1376/2
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UNIT 3 HYDRAULIC CONTROL UNIT (HCU)ACCUMULATOR DRAIN POWN EVENT SIGNIFICANCE
THE NRC CONCLUDED THAT FROM A TECHNICAL PERSPECTIVE THE SAFETY SIGNIFICANCE IS NOT HIG * * *
SIGNIFICANCE IS MINIMAL BECAUSE THE DRAINAGE OCCURRED AT A SLOW RATE AND THE TOTAL AMOUNT OF INVENTORY LOST (APPROXIMATELY 1") HAD NO SIGNIFICANTEFFECT ON WATER LEVE KEY NEAR TERM EVENT SPECIFIC CORRECTIVE ACTIONS
CONTAMINATION WAS QUICKLY CLEANED UP. [COMPLETE]
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THE ASSiSTA.N'T SUPERiNTFi\\if>>ENT OF OPE:A.l\\T10N8 COUNSELED THE INDIVIDUALS INVOLVED IN THIS EVENT ON.
THE REQUIREMENTS OE A PRE-JOB BRIEFING-AND
_p~OCEDURAL ADHERENCE. [COMPLETE]
- THE OPERATIONS DEPARTMENT HAS ISSUED A POLICY PROVIDING WRITTEN GUIDANCE ON WHEN PROCEDURES MUST BE USED "IN-HAND". [COMPLETE]
THE OPERATIONS DEPARTMENT IS REVISING PERTINENT OPERATING PROCEDURES TO BETTER DELINEATE THE STEPS.
REQUIRED TO DISCHARGE THE HCU ACCUMULATORS. THE
- INDIVIDUALS INVOLVED IN THIS EVENT PARTICIPATED.IN THI PROCEDURE ENHANCEMENT PROCESS. (TO BE COMPLETED BY 3/31/92]
THE OPERATIONS DEPARTMENT IS REVIEVvlNG ITS POLICIES ON.
ESTABLl~HMENT OF OOS BOUNDARIES. (TO BE COMPLETED BY 3/31/92]
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UNIT 2 OUT-OE-SEQUENCE CONTAOLAOP SCRAM EVENT SIGNIFICANCE
THE NRC CONCLUDED THAT FROM A TECHNICAL PERSPECTIVE THE SAFETY SIGNIFICANCE IS NOT HIG *
SIGNIFICANCE IS MINIMAL BECAUSE SCRAMMING THE SINGLE CONTROL ROD (P-10) OUT-OF-SEQUENCE DID NOT INVALIDATE THE SHUTDOWN MARGIN OR CAUSE CORE MANAGEMENT CONCERN KEY NEAR TEAM EVENT SPECIFIC CORRECTIVE ACTIONS
AN IMMEDIATE MULTI-DISCIPLINED INVESTIGATION WAS
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CONDUCTED THAT UNDERSCORED MANAGEMENT EXPECTATIONS. (COMPLETE)
. THE ASSISTANT SUPERINTENDENT OE OPERATIONS MET ("\\LIS:: -N...:.. *- """T'. "T't 'E It.I\\/,...,,.. D,......... llr"t *** "' --
.;......... ;:.... '""'~ *..
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.. ~'trVL..v~
'"Lll'V!UU;o.L *.:::i 11J1Jt~\\.d.i;;:,...,,.
AND REINFORCE MANAGEMENT EXPECTATIONS. [COMPLETE]
. eROCEDURE DIS 300-2, "CONTROL ROD DRIVE SCRA¥..
. TESTING AND SCRAM VAL VE TIMING TEST", WAS REVISED.TO DELINEATE PERSONNEL ASSIGNMENTS.AND SPECIFIC RESPONSIBILITIES AND TO SPECIFY WHEN BRIEFINGS MUST TAKE PLACE. THIS WAS IMPLEMENTED PRIOR TO THE RESUMPTION OE SCRAM TESTING. [COMPLETE]' *
THE EFFECTIVENESS OF HEIGHTENED LEVEL OF AWARENESS (HLA) BRIEFINGS IS BEING MONITORED BY SENIOR MANAGEMENT TO IMPROVE THE ~FFECTIVENESS OE HLA BRIEFINGS AND DETERMINE IF FURTHER IMPROVEMENTS ARE WARRANTED. [ONGOING]
A CONTROL ROD DRIVE TASK FORCE HAS BEEN FORMED WITH.
GENERAL ELECTRIC TO EVALUATE PRIOR CORRECTIVE ACTIONS AND IDENTIFY FUTURE ENHANCEMENTS. [IN PROGRESS)
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UNIT 2 TORUS BULK WATER TEMPERATURE EXCEEDING TECHNICAL SPECIFICATION LIMIT EVENT.
- EVENT SIGNIFICANCE
THE NRC CONCLUDED THAT FROM A TECHNICAL PERSPECTIVE THE SAFETY SIGNIFICANCE IS NOT HIG *
. THE SIGNIFICANCE OF THIS EVENT WAS MINIMAL. THE MAXIMUM
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TORUS WATER TEMPERATURE OF 97 F WAS WELL BELOW THE*
120 F LEVEL NEEDED TO MAINTAIN ACCEPTABLE.
TEMPERATURES IN TH(: evENT OF A LOC KEY NEAR TERM EVENT SPECIFIC CORRECTIVE ACTIONS *
THE ASSISTANT SUPERINTENDENT OF OPERATIONS COU~SELEQ THE SHIFT PERSONNEL INVOLVED IN THIS EVENT ON THE NEED FOR AWARENESS OF TECHNICAL SPECIFICATION REQUIREMENTS, ON THE NEED FOR CLOSER ATTENTION TO-NNUNC'A.-nri Al ARt..1~ S::OR.., ~ __, SYST. -=**t"' a**o*o** -r-...~
A..
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. STATION POLICY WITH RESPECT TO TECHNICAL SPECIFICATION *
3.0.A. [COMPLETE]
DURING REQUALIFICATION TRAINING LICENSED OPERATORS REVIEWED TECHNICAL SPECIFICATION 3.0.A., TECHNICA SPECIFICATION SECTION 3.7, TECHNICAL SPECIFICATIO INTERPRETATION MEMOS AND THE MANAGEMENT EXPECTATION* *
TO DIRECTLY REFERENCE TECH SPECS.. THIS TRAINING.
- INCLUDED A DISCUSSION OF THE EVENT. [COMPLETE]..
PERTINENT OPERATING PROCEDURES WILL BE REVISED TO CLARIFY ALARM SETPOINT, SAMPLING REQUIREMENT,.PROBABLE CAUSES OF ALARMS, AND TO ADD THE PROPER TECH.NICAL SPECIFICATION REFERENCES. [TO BE COMPLETED 3/31/92] -.
SPECIFIC GUIDANCE ON INTERIM TURNOVERS IS BEING.
DEVELOPED AS PART OF THE ENHANCEMENT OF THE SHIFT TURNOVER PROCESS. [TO BE COMPLETED BY 1 /28/92]
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UNIT 3 FUEL POOL ASSEMBLY MISHANDLING EVENT SIGNIFICANCE
THE NRC CONCLUDED THE SAFETY SIGNIFICANCE WAS MINOR SINCE THE IMPACT OE THE GRAPPLE ON THE FUEL BUNDLES.
. DID NOT RESULT IN THE RELEASE OE RADIOACTIVE MATERIAL.
SIGNIFICANCE IS MINIMAL BECAUSE THE IMPACT OE THE GRAPPLE ON THE FUEL BUNDLES DID NOT DAMAGE THE FUEL RODS. FURTHER THE MAST FAILURE WOULD NOT HAV CAUSED A *DROPPED FUEL BUNDLE (CABLE INT ACT).
KEY NEAR TERM EVENT SPECIFIC CORRECTIVE ACTIONS
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. THE EXPECTATION TO COMMUNICATE HAS BEEN ADDRESSED
- .- flt=T-ii 1n A." i 'f
~ F~ ~L H 'i\\i"\\I iNG. Pi:RSr\\Nl\\l~I..,..H*--**G
.. ~ "' -. P.* _ _..... L-. H_. u._.. _A. ~w_,_.. _ * _,., *~*~ 1 Huu :lit, THE ISSUANCE OE AN OPERATING DEPARTMENT POLICY. THIS NEW POLICY WAS ISSUED TO EACH PERSON INDIVIDUALLY *.
_AND WAS REVIEWED DURING TAILGATE TRAINING. [COMPLETE]..
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THE TRAINING DEPARTMENT HAS PROVIDED TRAINING SESSIONS ADDRESSING THE SAFETY PERSPECTIVE OE THE EVENT, EMERGENCY CLASSIFICATION, REACTIVITY MANAGEMENT AND REPORTABILITY REQUIREMENT [COMPLETE]
THE FUEL HANDLING TRAINING PROGRAM IS BEING REVIEWED FOR FUTURE ENHANCEMENTS. [TO BE COMPLETE BY 3/31/92]
- PERTINENT FUEL HANDLING PROCEDURES AND ADMINISTRATIVE PROCEDURES HAVE eEEN REVISED, AS REQUIRED, PRIOR TO BEGINNING FUEL MOVES WITHIN THE SPENT FUEL POOL. (COMPLETE]
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LESSONS LEARNED
THE PRECEDING REVIEW OF THE RECENT EVENTS INDICATES THAT; DRESDEN VIEWED THE EVENTS AS A DEPARTURE FROM OUR PERFORMANCE OBJECTIVES
- THE EVENTS RECEIVED PROMPT ATTENTION AND _
SPECIFIC CORRECTIVE ACTION
WE HAVE REVIEWED THE EVENTS COLLECTIVELY FOR LESSONS LEARNED, AND REVIEWED THEM AGAINST THE FINDINGS OF THE DRESDEN SITUATIONAL REVIEW TEAM (DSRT).
- COLLECTIVELY THE EVENTS REVEAL SELECTED WEAKNESSES
---WiT,.. - -lJ~- *,.,,,..~.-. o- ---~io*~~- *~N-t '"f\\l\\rr~u-1LS
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f1IN (J n L.1-\\ 1 en\\)
t" MA!... --1'.. -.,, ----.... -._
MANAGEMENT CONTROLS AT DRESDEN STATION
__ _ PROVIDE MULTIPLE BARRIERS TO THE OCCUR ENCE OF A SIGNIFICANT EVENT. THESE CONTROLS INCLUDE; znld/1376/7
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MANAGEMENT EXPECTATIONS
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POLICIES
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COMMUNICATIONS & FEEDBACK
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PROCEDURES
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SUPERVISORY INVOLVEMENT AL THOUGH SOME MANAGEMENT CONTROLS WERE NOT FULLY EFFECTIVE AS EVIDENCED BY THE OCCURRENCE OF THE EVENTS, SUFFICIENT MANAGEMENT CONTROLS REMAINED TO HOLD THE EVENTS TO A LOW. LEVEL OF
- SAFETY SIGNIFICANC.... *'
LESSONS LEARNED (CONT'D)
WHEN VIEWED AGAINST THE DSRT FINDINGS, THE IDENTIFIE WEAKNESSES ARE FULLY CONSISTENT WITH OUR SELF-IDENTIFIED NEED TO STRENGTHEN MANAGEMENT CONTROL THE IMPLEMENTATION OF THE DRESDEN MANAGEMENT ACTION PLAN WILL PROVIDE THE ROBUST MANAGEMENT CONTROLS NEEDED TO PRECLUDE THE RECURRENCE OF SUCH EVENT znld/1376/8
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.. RECENT EVENTS ANALYSIS ROOT AND CONTRIBUTING CAUSES
- AN EVALUATION OF THESE FOUR EVENTS WAS PERFORMED. THE EVALUATION PROCESS INCLUDED:
ANALYSIS OF ROOT AND CONTRIBUTING CAUSES FOR EACH.
EVENT
COMPARISON OF CAUSES FOR THE FOUR EVENTS TO *
IDENTIFY COMMON THREADS
. COMPARISON OF CAUSES TO THOSE ADDRESSED DURING THE 11/12/91 MANAGEMENT MEETING
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OUR EVALUATION OF THE FOUR EVENTS CONCLUDED THAT THE APPARENT AND CONTRIBUTING CAUSES MATCHED FOUR OF THE FIVE CATEGOAlE;~ IDENTIFIED BY THE NRC DURING THE NOVEMBER 12, 199 MANAGEMENT MEETING:
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IMPLEMENTATION OF MANAGEMENT EXPECTATIONS *
COMMUNICATIONS
PRQCEDUREADHERENCE
PROCEPURE QUALITY
ENGINEERING AND LICENSING SUPPORT
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RECENT EVENTS ANALYSIS ROOT AND CONTRIBUTING CAUSES - CONT'D FURTHER, THESE FOUR CAUSES MATCH FOUR OF THE ISSUES IDENTIFIED BX THE DRESDEN ~ITUATIONAL REVIEW TEAM (DSRT).
IMPROVE DEFINITION AND IMPLEMENTATION OF THE STATION VISION/MISSION/STRATEGY/EXPECTATIONS (INCLUDES*
PROCEDURE ADHERENCE EXPE_CTATION)
IMPROVE THE TEAM
COMMUNICATIONS
EMPOWERMENT AND ACCOUNT ABILITY
PERFORMANCE APPRAISAL -
IMPROVE TASK MANAGEMENT
PRIORITIZATION AND RESOURCE MANAGEMENT
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PLANNING, SCHEDULING AND WORK CQNTROL-c~ __
PROCEDURES UPGRADE..
COMMITMENT MANAGEMENT **
RESOLUTION OF TECHNICAL ISSUES *
OTHER BACKLOGS
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- AT THE MANAGEMENT MEETING ON 11/12/91, THE SHORT TERM ACTiONS TO ADDRESS RECENT EVENTS - INCLUDING THOSE DISCUSSED TODAY -
WERE DESCRIBED, ALONG WITH OUR LONG TERM APPROACH:
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STATUS APPLICABLE NOVEMBER 12, 1991 SHORT TERM ACTIONS IMPLEMENTATION OF MANAGEMENT EXPECTATIONS
FOCUSED AND FREQUENT SENIOR MANAGEMENT PRESENCE IN THE PLAN ONGOING INCLUDES PRESENCE IN CONTROL ROOM, SHOPS,
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PRE-JOB BRIEFINGS, HLA BRIEFINGS, AND IN-PLANT LOCATIONS
- DAILY SENIOR MANAGEMENT MEETING TO REVIE OBSERVATIONS
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znld/1376/11 ONGOING DISCUSS OBSERVATIONS FROM WALK-THROUGH$ AND REQUIRED ACTIONS
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EXAMPLES OF ITEMS OBSERVED
HLA BRIEFING WAS GOOD TECHNICALLY, BUT DISTRACTIONS EXISTED. FOLLOW-UP COMMENTS WERE MADE TO THE SHIFT ENGINEER LEADING THE
.BRIEFING
CONTROL OF ACCESS TO THE CONTROL ROOM NEEDS IMPROVEMENT. OPERATING IS CONSIDERING ALTERNATIVE *.
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SHORT TERM ACTIONS IMPLEMENTATION OF MANAGEMENT EXPECTATIONS * - CONT'D
PERSONNEL ERROR INTERVIEWS BY SENIOR MANAGEMENT znld/1376/12
- ONGOING INTERVIEWS WILL BE HELD BY SENIOR MANAGERS WITH PERSONNEL COMMITTING ERRORS TO ENSURE THOSE PERSONNEL KNOW SPECIFICALLY WHAT MANAGEMENT EXPECTATIONS WERE NOT MET. THE DVRTHRESHOLD-
. IS USED TO DETERMINE WHEN THESE INTERVIEWS ARE NEEDE ONE PERSONNEL ERROR EVENT (11 /19/91) HAS BEEN IDENTIFIED SINCE THIS PROCESS WAS IMPLEMENTED.*
INVESTIGATION OE THE BUS 34/34-1 OOS PROBLEM IS.
CONCLUDING, AND WILL BE FOLLOWED BY APPROPRIATE SENIOR MANAGER INTERVIEWS.
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SHORT TERM ACTIONS IMPLEMENTATION OF MANAGEMENT EXPECTATIONS. - CONT'D
ASSISTANT SUPERINTENDENT OF OPERATIONS ONE-ON-QNE EXPECTATION MEETINGS znld/1376/13 IN PROGRESS ASSISTANT SUPERINTENDENT OF OPERATIONS MEETINGS ARE BEING HELD WITH ALL LICENSED OPERATORS TO REVIEW RESPONSIBILITIES AND COMMUNICATE EXPECTATIONS TO EACH INDIVIDUAL, ONE-ON-ONE. APPROXIMATELY ONE THIRD OF THESE MEETINGS HAVE NOW BEEN HEL ""v_ N_ *-rENT. n.:: n*~,-~, *s-~"1'-'~ *NCL t n"l~
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QUESTIONING ATTITUDE
CONSERVATIVE APPROACH TO OPERATIONS AND REGULATORY ITEMS
PROCEDURE ADHERENCE.
REACTIVITY MANAGEMENT
PROFESSIONALISM
ACCOUNT ABILITY
LOG KEEPING, SHIFT BRIEFINGS, AND CONDUCT OF SHIFT OPERATIONS
SHORT TERM ACTIONS IMPLEMENTATION OE MANAGEMENT EXPECTATIONS - CONT'D
- ASSISTANT SUPERINTENDENT OE OPERATIONS ONE-ON-ONE
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EXPECTATION MEETINGS-CONT' REACTION OE INDIVIDUALS INCLUDES
ACCEPTANCE AND UNDERSTANDING OE NEED FOR CHANGE
RECENT EMPHASIS ON QUIET HOURS HAS NOT YET BEEN EULL Y SUCCESSFUL
HAVE NOTICED INCREASED INTEREST IN CONTROL.
HOOM ACT:ViTIC:3
HAVE NOTICED CONCERTED EFFORT TO FIX EQUIPMENT PROBLEMS BEFORE UNiT 2 RESTART CONTROL ROOM OVERVIEWS - SE/OE OBSERVING CREW IN PROGRESS OPERATING ENGINEERS ARE EACH WEEK OBSERVING VARIOUS SHIFT CREWS TO ASSURE OPERATIONS DEPARTMENT EXPECTATIONS ARE BEING MET SHlfT ENGINEERS ARE EACH WEEK OBSERVING OTHER SHIFT CREWS THAN THEIR OWN. THIS PROVIDES NOT ONLY A SELE CRITICAL REVIEW OE ANOTHER CREW, BUT *
ALLOWS FOR GOOD IDEAS TO BE SHARED BETWEEN CREWS THE PROGRAM IS BEING EXPANDED TO PROVIDE FOR SCRE AND SHIFT SUPERVISORS TO ALSO OBSERVE OTHER CREWS znld/1376/14
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SHORT TERM ACTIONS IMPLEMENTATION OF MANAGEMENT EXPECTATIONS -. CONT'D
CONTROL ROOM OVERVIEWS - SE/OE OBSERVING CREW
. (CONT'D)
EXAMPLES OE RESULTS INCLUDE **
- * UTILIZATION OE PHONETIC ALPHABET IS MORE EULL Y ACCEPTED AND NOW GENERALLY OCCURRING
CONTROL ROOM IS CROWDED DURING CURRENT SHIFT aRIEFINGS (BUT WILL BE RECTIFIED WITH NEW SHIFT TURNOVER PROCESS)
- * ON THE SPOT CORRECTIVE MEASURES FOR HI RAD
- [1()f)R GHF-CKS EXPECT.i\\iiGNS *
CONTROL ROOM OVERVIEWS - SPECIAL NOP SRO ASSIST
_YJ$1TS znld/1376/15 IN PROGRESS PROGRAM REQUESTED BY STATION EACH WEEK OVER A PERIOD OF SEVEN WEEKS, NOP IS.
PROVIDING SRO's (FROM OTHER SITES AND CORPORATE) *
TO OBSERVE SHIFT OPERATIONS AND PROVID FEEDBACK TO SENIOR OPERATIONS MANAGEMEN THIS ASSESSMENT IS PROVIDING ADDITIONAL INFORMATION THAT WILL BE USED TO FURTHER ENHANCE THE OPERATIONS DEPARTMENT IN AREAS SUCH AS SHIFT BRIEFINGS, OPERATOR ROUNDS, CONTROL ROOM PROFESSIONALISM, AND PROCEDURE ADHERENC. **
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SHORT TERM ACTIONS IMPLEMENTATION OF MANAGEMENT EXPECTATIONS - CONT'D
CONTROL ROOM OVERVIEWS - SPECIAL NOP SRO ASSIST VISITS (CONT'D)
EXAMPLES OE FEEDBACK INCLUDES.
- . GOOD MANAGEMENT/UNION RELATIONSHIPS DEMONSTRATED IN CONTROL ROOM ACTIVITIES
A NEED FOR BETTER METHOD OF UPDATING STATU OF EQUIPMENT WAS IDENTIFIED.. THIS IS NOW BEING ADDRESSED BY NEW DAILY OPERATING UNIT AND RADWASTE STATUS SHEET ?OSH 1VE tiEAC1 iON TO EXTRA UA l SHli-' f ::>Hu ii~
.
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CONTROL ROOM PURING THE REFUELING OUTAGE
SHIFT CREW VISITS TO OTHER STATIONS*
znld/1376/16 IN PROGRESS
. DURING THE CURRENT TRAINING CYCLE, FOUR SHIFT
. CREWSARE VISITING OTHER CECo STATIONS PROVIDES INSIGHT INTO OTHER WAYS OF DOING BUSINESS
, AREAS IDENTIFIED FOR IMPROVEMENT
SHORT TERM ACTIONS IMPLEMENTATION OF MANAGEMENT EXPECTATIONS - CONT'D
SHIFT CREW VISITS TO OTHER STATIONS (CONT'D)
znld/1376/17 EXAMPLES OF RESULTS INCLUDE
GOOD CONTROL ROOM ACCESS CONTROL NOTED AT LASALLE
WORK PLANNING HAS STRONGER OPERATIONAL FOCUS AT BOTH LASALLE AND BRAIDWOOD..
SIGNIFICANT DIFFERENCES IN OOS PROCESS. DUE TO
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- -- i=MT -r i\\l 49\\ln NI.-
FP. <)j.'.:
\\..Ju 1 AuE Eu., Ori tMPLt:M ____ P., !0..* __ *. ____ MB... ~*..
OUTAGES REQUIRED AT BOTH LASALLE AND BRAIDWOOD
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SCRE HAS,FEWER ADMINISTRATIVE DUTIES AT BOTH LASALLE AND BRAIDWOOD
SHORT TERM ACTIONS PROCEDURE ADHERENCE
DEVELOP CLEAR, CONCISE STATEMENT OF PROCEDURE.
ADHERENCE EXPECTATIONS TO REINFORCE ADHERENCE COMPLETE
COMMUNICATE THE PROCEDURE ADHERENCE EXPECTATIONS TO ALL PERSONNEL THROUGH MULTIPLE METHODS IN PROGRESS DISTRIBUTED WITH SECURITY BADGES 12-06-91 *
TA1.LGP.TE Pf;~!'-".'-==* ~-~.~TFRiA.L FOR IHiS WEE;k "-~t*.
- QUARTERLY FOR 1992 TO BE INCLUDED IN DAILY UPDATE ON REGULAR BASIS
. THROUGH 1992
MONITOR IMPLEMENTATION OF ADHERENCE POLICY VIATHE SENIOR MANAGEMENT PLANT OBSERVATIONS
-
ONGOING znld/1376/18
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SHORT TERM ACTIONS PROCEDURE ADHERENCE - CONT'D
CONTINUE IMPLEMENTATION OF THE 10/10/91 OPERATIONS POLICY #30 ADDRESSING *1N-HAND* USE OF PROCEDURES
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FOR PROCEDURES, (I.E. OPERATING ABNORMAL PROCEDURES), ROUND BOOKS, OOS CHECKLISTS, AND TECHNICAL SPECIFICATION REFERENCES:
ADDED SINCE 11/12/91 MANAGEMENT MEETING ON GOING EXAMPLES OF RESULTS INCLUDE
USE OF PROCEDURES HAS INCREASED
INCREASED AWARENESS TO ASSIGN SPECIFIC RESPONSIBILITY FOR SPECIFIC ACTIONS IN THE
. PRbC.EDURES PROCEDURE QUALITY
. ASSIGN OVERALL PROCEDURE MANAGER FOR THE STATION znld/1376/19 COMPLETE ANNOUNCED 11/25/91 SHORT TERM, HIGH IMPACT POSITION TO EFFECT SIGNIFICANT CHANGES IN THE PROCEDURE CHANGE. *
PROCESS
SHORT TERM ACTIONS.
COMMUNICATIONS
IMPROVE SHIFT TURNOVER PROCESS IN PROGRESS REVIEWING BEST ATTRIBUTES FROM OTHER CECo STATIONS NEW PROGRAM WILL BE IMPLEMENTED.CONCURRENT WITH THE 1992 SHIFT CREW SCHEDULE ON 1/28/92
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NEW PROGRAM WILL ALSO ADDRESS INTERIM TURNOVER REQUIREMENTS
CONTINUE OPERATIONS IMPROVEMENT TEAM znld/1376/20 ONGOING PURPOSE: "TO IMPROVE THE OPERATIONS DEPARTMENT BY IDENTIFYING PROBLEMS AND PROMOTING CHANGE:S FROM WITHIN."
FORMED IN OCTOBER, 1991 WITH A CROSS SECTION OF THE OPERATIONS DEPARTMENT PERSONNEL TEAM TRAINING INITIATED
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SHORT TERM ACTIONS COMMUNICATIONS - CONT'D,:.
CONTINUE OPERATIONS IMPROVEMENT TEAM (CONT'D)
INITIALLY IDENTIFIED 13 SHORT TERM AND 6 LONG T:ERM
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TASKS TO BE CONSIDERED. TYPES OF TASKS INCLUDE
REVISE THE OOS BOARDS TO MINIMIZE CONFUSION IN HANGING MASTER OOS CARDS
DEVELOP METHOD TO INCREASE/ASSURE CONTROL ROOM PANEL AWARENESS
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INVOLVE INPLANT OPERATORS IN SOME SIMULATOR TRA!N!NG l'tii=iii\\iG THE 6 v\\!EEK TRAiN!NG GYC=LE
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_SJ~NIFICANT STATION EVENT COMMUNICATIONS IN PROGRESS INVOLVES RAPID (NEXT DAY) COMMUNICATION OF SIGNIFICANT DRESDEN EVENTS TO AJ,.L STATION PERSONNEL REGULATORY ASSURANCE DEPARTMENT IS DEVELOPING PROGRAM
CONTINUE AND ENHANCE HLA BRIEFINGS ONGOING HLA BRIEFINGS WERE INITIATED LAST SUMMER znld/1376/21
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- SHORT TERM ACTIONS COMMUNICATIONS - CONT'D OUR PROCESS INCORPORATED ENHANCEMENTS MADE.IN THE PROGRAM AT BRAIDWOOD
A HEIGHTENED LEVEL OF AWARENESS POLICY HAS BEEN ESTABLISHED. THIS POLICY PROVIDES A MEANS OF IDENTIFYING THOSE ACTIVITIES MERITING INCREASED ATTENTION PRIOR TO PERFORMANCE OF WORK.*
CONTINUE IMPLEMENTATION OF THE 10/10/91 OPERATIONS,
'POLICY #30 REGARDING USE OF REPEAT BACKS AND PHONETIC ALPHABET NEW ACTION ADDED SINCE 11/12191 ONGOING
. IMPLEMENTATION IS IMPROVING WITH PRACTICE znld/1376/22
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LONG TERM APPROACH - PROCESS
SITUATIONAL REVIEW PERFORMED WEEKS OF OCTOBER 28, 1991 AND NOVEMBER 11, 1991 PURPOSE: TO IDENTIFY ISSUES THAT NEGATIVELY IMPACT STATION PERFORMANCE ADDRESSES BROADER SCOPE'
OUTPUT IS STARTING POINT FOB DRESDEN STRATEGIES
ACTION PLANS TO BE PREPARED FOR EACH STRATEGY TO BE PREPARED BY MARCH 31, 1992
ACTION PLANS TO BE TRACKED/MONITORED LIKE ZMAP
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ONGOING 6 MONTH SITUATIONAL REVIEW TO REFOCUS *
LIVING PROCESS * SELF CORRECTING - ONGOING znld/1376/23
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LONG TERM APPROACH - PROCESS - CONrD
IMPROVE DEFINITION AND IMPLEMENTATION OF THE STATION VISION/MISSION/STRATEGY/EXPECTATIONS
IMPROVETHETEAM COMMUNICATIONS EMPOWERMENT AND ACCOUNT ABILITY
. PERFORMANCE APPRAISAL
IMPROVE TASK MANAGEMENT PRIORITIZATION AND RESOURCE MANAGEMENT PLANNING, SCHEDULING AND WORK CONTROL.
PROCEDURES UPGRADE.
COMMITMENT MANAGEMENT R.ESOLUTION OF TECHNICAL ISSUES OTHER BACKLOGS znld/1376/24
- LONG TERM APPROACH - STEPS TO ENSURE SUCCESSES
DRESDEN DMAP DIRECTOR
- STARTED WEEK OF DECEMBER 2, 1991
. TRACKING/MONITORING PROCESS SAME AS SUCCESSFUL ZION PROGRAM (ZMAP)
0.0. (ORGANIZATIONAL DEVELOPMENT) ASSISTANCE
. MANAGEMENT ANALYSIS CORPORATION ASSISTING IN STRATEGY/PROCESS FOR LONG TERM APPROACH*
GORPOH.ATE PROVff>ING.~.DDIT!ONAt i=iESOUi=\\CES *
STATION 0 & M $7 1/2 MILLION (1992)
ENC 0 & M $5 MILLION (1992)'
APPROPRIATE PERSONNEL
CORPORATE REVIEW GROUP.
znld/1376/25
ATTACHMENTS EVENT CHRONOLOGY, CAUSES, SIGNIFICANCE_:
AND CORRECTIVE ACTION
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ZNLD/1348/14
ATTACHMENT A SEPTEMBER 25, 1991UNIT3 HYDRAULIC CONTROL UNIT ACCUMULATOR DRAIN DOWN EVENT CHRONOLOGY On 9/23/91, shift 2, the Operations Department was preparing to perform an Operating Surveillance, and as part of the preparation an equipment attendant
!EA) was assigned to discharge all the east bank accumulators per DOP 500-4, Reactor Mode Switch to Shutdown when all Drives are Fully Inserted". A prejob briefing was held between the EA and the Unit Shift Supervisor to review the evolutio Steps*F.1.and F.2 of DOP 500-4 provided the following instructions:
1. Close the charging water stop isolation valve 2(3)-0301-2. Discharge each accumulator as follows: Discharge the water side by opening drain valve 2(3)-0305-107. *. When water stops flowing out the drain and accumulator pressure reads approx.. 600 psig, close the drain valve 2(3)-0305-107 on the accumulator being discharge * *
As part ot tho b!if?fi~u. tht:l Shift Supervi~~r t"'d ~h~ FA.:. *
1. Be sure to notifY. Radwaste before beginning the accumulator discharge because a significant amount of water would be going to the floor drain syste. Do not discharge more than*s accumulators at a*time so a~ not t().overflow the floor_c~rain ~y~t~ __..
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The EA notified Radwaste and proceeded Into the plant to perform the task. He did not take a copy of the procedure with him, though there was no requirement for *
him to do s.
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The EA was very cautious not to overflow the floor drain system* as he had been instructed. Contrary to DOP 500-4 the EA did not reclose the drain valves once the accumulator was discharge A second EA, after receiving instructions from the first EA, discharged the west bank accumulators and left the drain valves ope *
On 9/25/91 at approximately 00:45 the instrument air supply to the scram pilot solenoids was Isolated to allow work on the Control Rod Dnve system. The scram Inlet and outlet valves on all 1 n CRDs opened, as expected, on loss of instrument ai At 01 :00 the Unit 3 Shift Supervisor was notified of water collecting on the Reactor Building 517' elevation in the vicinity of the east accumulator ban *
ZNLD/1348/15
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An EA was immediately dispatched to identify and secure the leak. Upon arriva water was observed flowing through several accumulator drain hoses. Initial attempts were made to isolate the leaks by closing the accumulator dr~in valve All drainage was subsequently isolated at approx. 01 :05 by restoring air to the scram pilot s.olenoid valve *
An estimated 2800 gallons of reactor water was released. The primary source of this water was from the CRD under piston volumes through the scram inlet and accumulator drain valves. Overflow of the Reactor Building equipment floor drain resulted in the release of water to the Reactor Building 517' elevatio *
. ZNLD/1348/16
APPARE.NT CAUSES ROOT CAUSE The root cause of this event is personnel error on the part of the EA (on 9/23/91)
who did not correctly follow procedure DOP 500-4 which required 3-0305-1 07 valves to be reclosed after accumulator discharg CONTRIBUTING CAUSES Insufficient pre-job briefing in that the Shift Supervisor's directions were improperly received by the EA. There was also no repeat back by the EA of the actions to be*
accomplishe The OOS procedure did not provide direction on the type of boundary to be used or how the boundary was to be.established. Administrative controls were not established to prevent the flow of water through scram valves when the air supply was shut of There was no procedural requirement for the EA to take the procedure with him while performing the task,
AS~ESSMENT OF SAFETY SIGN!F!CANCE The significance is minimal because the HCU accumulator drain do~n occurred
..
when all the fuel was In the spent fuel pool. Drainage occurred at a-slow rate and the total amount of Inventory.lost (approximately 1 Inch) had no significant ~ffect on water _level. The contamination resulting from the HCU drain.down affeCted *
limited areas on two levels of the reactor building.*
ZNLD/1348/17
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CORRECTIVE ACTIONS:
1.
The Assistant Superintendent of Operations counseled the individuals involved in this event on the requirements of a pre-job briefing and procedural adherenc [COMPLETE] The Operations Department is revising procedure DOS 500-7 arid DOP*500-4 to better delineate the steps required to dischar~e the HCU accumulators. The individuals involved in this event participated m this procedure enhancement process. [TO BE COMPLETED BY.3/31/92) The Operations Department has issued a policy providing written guidance on when procedures must be used "in-hand". [COMPLETE]
.. The Operations Department is reviewing Its policies on establishment of OOS - *
boundaries. [TO BE COMPLETE 3/31/92]
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- The Regulatory Assurance Department will write a station tailgate on the event as
- another example of the value of self-checking. [TO BE COMPLETED BY 3/31 /92].
ZNLD/1348/18
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ATTACHMENT B OCTOBER 6, 1991 UNIT 2 MISPOSITIONED CONTROL ROD EVEN CHRONOLOGY On 10/6/91, preparations were made to perform half core scram* testing. The *
testing would be performed by following procedure DTS 300-2, "Control Rod Drive Scram Testing and Scram Valve Timing Test".
- At approximately 02:45, the SCRE conducted two Heightened Level of Awareness (HLA) briefings. The first HLA briefing was between the SCRE and the "B" Operators who would be. assisting in the scram testing while stationed at the control rod drive (CAD) accumulator *
The second HLA briefing was between the SCAE and the entire crew that would *
_be performing the CRD scram testing. During the briefing the decision was made to have a second verification of the correct switch prior to scramming the CAD from the scram test pane *
The Unit NSO was responsible for control rod position. The Utility NSO acted as a second checker for control rod position and operated the Scram test Switch. The SCRE acted as a verifier for the Utility NSO when selecting the proper scram switc fi1e.. 3., Operators were to close the iia'-Culiiuieai\\),- \\:ihc.arglr.g water vaive wnen instructed to do SO, move the comruter toggle switch to the on position on the CAD accumulator alarm/test pane and read the CAD accumulator pressure for each control rod that was to be scram teste *
The Tech Staff engineer was colleding. CAD timing information from the process computer, analyzing the data and reporting If the data was goo. *
By 03:23 four rods had been scram tested, however, the Unit NSO ~as having
difficulty withdrawing the fourth rod from position "00" to it~ original position of "48" (fullout).
- At this same time the Unit NSO was communicating via the radio with the "B" Operators. The "B" Operator informed the NSO that the valving had been
complete for the next control rod to be scram tested. The NSO acknowledged the *
"B" Operator while continuing to try to withdraw the fourth control rod to its fullout positio.
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While the NSO was attempting to withdraw the fourth control rod, the Utility NSO requested permission from the SCRE to take a break. The SCAE granted permission, and the Utility NSO transferred his scram testing duties to the Center Desk NSO, while the verification of the scram testing switch was now assumed by the SCA ZNLD/1348/19
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At approximately 03:30 the "B" Operator notified the NSO by radio that they were ready for the next rod to be scramme The Unit NSO acknowledged the radio call which was overheard by the Center Desk NSO and the SCR.
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Without confirming with the Unit NSO, who was still attempting to withdraw the fourth rod, the Center Desk NSO and the SCRE proceeded to the back panel and scrammed the next rod, P-1 Failure to achieve the correct alarm response was_ adequate indication that rod P-10 had been scrammed prematurel Scram testing was stopped, the Qualified Nuclear Engineer was contacted and procedure DOA 300-12, "Mispositioned Control Rod". was referred to for subsequent actio ZNLD/1348/20
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APPARENT CAUSES ROOT CAUSE The root cause of this event was the Center Desk NSO and SCRE failed to communicate with the Unit NSO, yet scrammed rod P-1 O based on overhearing a repeat back given over the radio from the Unit NSO to the "B" Operator at th9 CAD accumulator *
CONTRIBUTING CAUSES A personnel error by the Unit NSO was identified as a contributing cause. The Unit NSO allowed the "B" Operators stationed at the CAD accumulators to perform valving for rod P-10 prior to the previous control rod being fully withdraw,
The HLA briefing given by the SCRE did not conform to Station policy because the briefing did not establish an individual that would be designated as the Scram Test Coordinator and did not establish a chain of comman There was no formal turnover between the. Utility NSO and. the Center Desk NSO *
when the Utility NSO went on a break~ This is a case where duties changed
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between 2 people within 15 minutes. Also, when duties were transferred to the Center Desk NSO, the Center Desk NSO had other responsibilities and was not working as closely with the Unit NS Procedure DTS 300-2 does not delineate the various responsibilities of the
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per~~~l'l?! performing t~'3 !:Or!trt::'! ro~ ~~r~m ~!m!ng test act!vtt!ee. !t ~lso does r;ct requi1t:J a $t:.Co11u \\:;-,.,~~of tho controi rod or scram toggl& ~witch seiection whiie *
control rod scram timing is in progress..
ASSESSMENT OF SAFETY SIGNIFICANCE
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- The significance.Is minimal because scramming the single control rod (P-1 O)
out-of-sequence did not invalidate the shutdown margin or cause core management concern ZNLD/1348/21
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CORRECTIVE ACTIONS Half Core Scram Testing was stopped at the time.of the event, the Qualified Nuclear Engineer was contacted and apprised of the situation. [COMPLETE] The two control rocts (L-11 and P-10) were withdrawn to their pre scram core position following the instructions received from the Qualified Nuclear EngineeL
~~PLH~
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. An immediate multi-disciplined investigation was conducted that underscored.
management expectations. [COMPLETE]
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4: * The Assistant Superintendent of Operations met one-on-one with the involved individuals.to discuss and reinforce management's expectations. [COMPLETE] Station Procedure Temporary Change Requa.st number 91-260 was issued for procedure DTS 300-2, "Control Rod Drive Scram Testing and Scram Valve Timing.
Test". The following additions were made to procedure DTS 300-2. The Technical Staff Engineer will act as Test Coordinator and will ensure that equipment is ready, notify the Shift Supervisor prior to starting the test, and ensure. that a licensed operator is assigned to verify proper scram switch operation. The Technical Staff Engineer will ensure with shift supervision that the following personnel are
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assigned and responsible for the following tasks~ The Reactor Control Panel NSO will conduct all control rod movement, approves all Scram Test Panel toggle switch operation which will be done at the Reactor Control Panel using fac~-to-face communication; and direct all Control Rod Drive Accumulator valving. The Utility NSO wm *:erify aii Cornro! Rnd movement and sel~ctio11 by thA Rea.r.tnr*co*!"'tro!
Piiin~i Operator, ano wm opei&t" \\i*~ t)i'u~i tcdgle S'*l~Ch at the Scram Te:;t.Fana:
after receiving instructions to do so from the Reactor Control Panel NSO via
.*
face-to-face communications at the Reactor Control Panel. The Scram Test Switch Verifier will verify that the proper scram toggltt swttc;;h nas be~n selected by the Utility NSO at the Scram Test Panel. The operator at the Control Rod Drive.
. Accumurator will have in hand and follow a valving check list to ensure *
. *
coordination between the Reactor Control Panel Operator control rod movements and required valving. The Test Coordinator will.brief all personnel prior to the start of control rod scram testing at shift change and every person that may relieve.a member of the test team. This was implemented prior to resumption of scram *
testing. [COMPLETE]
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. Temporary Procedure Change number 91-260 will be incorporated into '*.
. permanent change to procedure DTS 300-2 after review by the Assistant
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Superintendent of Operations to ensure that TPC 91-260 Includes positive control and meets managements expectations of how control rod scram testing will be
penorme *
7. * The Assistant Superintendent has issued verbal instructions that when a HLA *
briefing is required that the person giving the briefing h.ave in hand Dresden Policy memo #39, "Heightened Level of Awareness Activities", and cover all listed lirie Items. The Operations Department will make this a requirement by revising memo
- 39 to require that it be in the hands of the person conducting the HLA briefing and that all items (Attachment B - Guidelines for Pre-HLA Activity Briefing) will be covered. [COMPLETE]
.. The Training Department will conduct training for all licensed operators to include reactivity management concerns and station procedure OAP 7-32, "Routine Plant Test Activities". This training is being penormed by the Training Department during Cycle 7. [COMPLETE]
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ZNLD/1348/22
- 9. * The effectiveness of HLA briefings is being monitored by Senior Management to. *
improve the effectiveness of HLA briefings and determine if further improvements *
are warranted. (ON GOING]
10. A control rod drive task force has been formed with General Electric to evaluate prior corrective actions and identify future enhancements. [IN PROGRESS]
ZNLD/1348/23
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ATTACHMENT C SEPTEMBER 1, 1991 UNIT 2 TORUS BULK WATER TEMPERATURE EXCEEDING TECHNICAL SPECIFICATION LIMIT EVENT CHRONOLOG On 9/1/91 (on shift 1) at approximately 05:00 the Unit NSO attempted to clear the HPCI turbine inlet drain pot high level alarm by opening valve A02-2301-3 Dresden Annunciator procedure DAN 902(3)-3 B11 for the HPCI turbine inlet drain pot high levei alarm specifies that if cycling the A02-2301-31 valve failed to clear the alarm, then drain the drain pot to the torus by opening the A02-2301-28 valv The alarm was due to a stuck level switch~ not determined until later that day (on shift 3). The alarm did not clear and steam from the HPCI steam line flowed to the torus and began heating the torus wate Intermittent torus water bulk temperature hi annunciator alarms began on shift 2 and in response the. Unit NSO checked the front and back panel temperature recorders, finding the temperature to be.between 90 and 92 deqrees F. The Unit NSO continued to monitor the torus water bulk temperature dunng the remainder.
of shift.
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At the time of turnover from shift 2 to shift 3 (approx.* 15:00) one of the high toru~
water bulk temperature alarms was now continuous. The shift 3 SE began rnrrQr.tzv*,,,.. 8cil'0.,.~ in rAC!l'V\\ncu:11 tn ti...-. +""" *e> +ii;i.-~r... +1 '"~ ~*--~ f'OllOWl'ng "'re.C!n:!:lln..
~-***-*lol'~-~ ~
- -.... *~--*-.-:'... -.-:~_.. Viw....... _.....,....... \\,;,,it,~*......... ~*'!='*.''::
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Cipt,1ai1.-~ P*W6*1un; uOP 1500-2,.., orus Water voonng Moae ot Low f-'ressur.:,
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Coolant Injection System." This procedure required the results of a.radiochemical analysis of LPCI water samples prior to starting the LPCI cooling water pump *
.The samples were taken at 16:35 and 16:45, with the radioche_mical analysis.oUhe
. samples. completed at 20:5 The Unit. NSO logged reaching a torus water temperature of 95 degrees F at 19:59 and notified the SCRE. Neither the SCRE nor SE recognized that 95 degrees F
was a Tech Spec limi.
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At approx. 22:*00 the Unit Shift Supervisor reported hearing steam flow In the line from the HPCI drain pot and suspected that the level switch was stuck. He tapped
. the level switch which cleared the alarm. The Unit NSO then closed the valves that had been providing a drain path to the torus. Computer point history data :
Indicates that the maximum torus water temperature during this event was approximately 97 degrees *
.
ZNLD/1348/24
- APPARENT CAUSES ROOT CAUSE The root cal!se of this event was attributed to personnel error by the shift 3 SE and SCRE in failing to recognize a torus bulk temperature of 95 degrees Fas a Tech Spec limi CONTRIBUTING CAUSES Failure of shift 2 personnel to investigate the HPCI drain pot alarm. Low priority.
was given to reporting and resolving this equipment problem. Had the HPCI drain *
pot alarm been investigated and corrected by shift 2 personnel, the Tech Spec limit would not have been exceede *
Procedure adequacy in that DAN 902(3)-3 B-11 failed to identify a stuck level switch as one of the probable causes of the alarm, and no time limit is given for the
. action of clearing the alarm by establishing a drain path to the torus. Also Dresden Operating Abnormal procedures (DOA 902-4 A-18 & C-18) failed to reference the
. Tech Spec limits on torus water bulk temperatur *
There was miscommunication between the shift 3 NSO and.SCRE. The NSO informed.the SCRE when that temperature was reached, but assumed the SCRE fti(;(,~nized a T&ch Spec !..CO h~ti hABn 1?.rrt~ri: Log keeping was contrary to admin procedure requirement The need for improvement In the requallfl.c_ation training program was also noted due to.lack of Tech Spec knowledge.. *
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Insufficient turnovers and oversite by SE and SCRE, and.lack of administrative guidance on Interim turnover ASSESSMENT OF SAFETY SIGNIFICANCE The safety signfficance of this event was minimal. The maximum torus water temperature of 97° F was well below the 120° F level required to maintain acceptable temperatures in the event of a LOCA.
ZNLD/1348/25
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CORRECTIVE ACTIONS 1.
The Assistant Superintendent of Operations counseled the shift personnel involved in this event on the need for awareness of Technical Specification requirements, on the need for closer attention to annunciator alarms for safety systems, and on the station policy with respect to Technical Specification 3.0.A. [COMPLETE].
During requalification training Licensed Operators reviewed Technical Specification *
3.0.A., Technical Specification Section 3.7, Technical Specification interpretation *
memos and the management expectation to directly reference Technical Specifications. This. training included a discussion of this event. [COMPLETE]
Procedure DAN 902(3)-3 B11 is being revised by the Operations Depa.rtment to add a stuck level switch as one of the probable causes of the alarm and to account for this cause in the required Operator Actions. The procedure revision is currently in On-Site Review [REVISED PROCEDURE SUBMITTED 12/5/91]
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.4.. Procedure DOA 902(3)-4 A19 and C-18 is being revised by.the Operations Department to clarify the alarm setpoint and to add the pr~per Technical
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Specification references. The procedure revisions are currently in On-Site Review
[REVISED PROCEDURE SUBMITTEDr
- Procedure* DOS 1500-8 has been reviewed by the Operations Department and
. was found to contain adequate guidance on LPCI water sampling/analyses requirements prior to initiating torus coolin ~
Beth H~~sed ::r.=- norH!deiiS<id operators 'V":i!I ~
tra!~~d nn Oper~.~!I'.:\\~~
Uepanmem eXJJt:n::iationstor communications, *inciuciin9 rt:rio1t:i11ci1~~ rii:=vant **.-ech Specs and procedures, and repeating back critical informatio.
.
- HPCI drain pot level switch, LSH2-2365, will be inspected, repaired or replaced as
- necess.a..ry,.under work request 03796. *
- The Regulatory Assurance Department will initiate a request to amend Technical
- Specification 3.7.A.1.c.(1) to add remedial action requirement.
Specific guidance on interim turnovers is bei~ developed. as part of the. '. *
. enhancement of the shift turnover process. [TO BE COMPLETED BY 1/28/91]
10.. The Training Department Is developing a module as part of Licensed. Operator 1tralnlng to address improved log keeping. [TO BE COMPLETED BY 4/30/92]
ZNLD/1348/26
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ATTACHMENT D OCTOBER 18-19, *1991 UNIT 3 FUEL HANDLING EVENT CHRONOLOGY CHRONOLOGY On 10/18/91 fuel was being moved within the spent fuel pool (SFP) to reorganize
.the fuel in preparation for Unit 3 core reload. The fuel handling crew consisted of a
"8" man operating the refueling bridge and moving fuel, and an "A" man observing and performing required verification. A supervisor was not required to be presen *,
Several fuel moves had been completed by this crew. At approximately 22:15 the
"B" man opened the grapf?le.hook and raised the grapple after setting down a fuel bundle. The "A" man venfied that the grapple hook was open and theri directed
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his attention to the next fuel move on the fuel move sheets..
The "8" man started to move the bridge forward and turned to look for the next move when a "BANG" was immediately heard. It was determined that the
- grapple/mast had not been raised high enough to clear the fuel bundle bail handl When the bridge was moved, the bail handle was bent and the grapple then impacted and bent the next fuel bundle bail handl Furthermore, the"8" man failed to verify that the fuel bundle had disengaged from the grapple. Standard procedure upon releasing a fuel bundle is to raise the grapple and rotate It side to side to be sure It is unlatched and clear of the fuel.
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The crew backed the bridge up to strai~hten the mast, then raised the grapple from the bail handles. The *A* Operator verified that no bubbles were coming from the damaged bundles and the only.damage was. obsel'\\fed at the.. ball handle At aJ)proximately 22:30 the "B" Operator contacted the Fuel Handling Supervisor,
who was In the fuel handling office, and Informed him that at least two fuel bails had been damaged. The Supervisor asked for the location of the bundles so they**_.
could be logged, however, no explicit instructions to discontinue fuel moves were provided by the Superviso Following the phone conversation the Supervisor remained in the fuel handling * *
office to research procedures to find information on what should be done next. He found no Information related to bent bail handles. The fuel handling supervisor was unaware of the reporting requirements regarding damage to nuclear materia The fuel handling crew exercised the grapple to evaluate any possible damage, and believing the grapple was operable, move.d three additional fuel bundles. Fuel movement was then discontinued because the grapple began making unusual
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noise *
The fuel handling crew then parked the grapple over an empty fuel rack location, left the refuel floor and went to the fuel handllrc~ office.
ZNLD/1348/27
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The fuel handling supervisor, arriving on the refuel floor with another "A" Operator, inspected the fuel bundle bails and the mast and grapple. The supervisor noted that two fuel bundle bails had a significant degree of bending. He also noted that the upper tie plates (other than the bails) appeared normal and that no unusual radiation conditions existed on the floo *
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The supervisor proceeded to check the grapple's operability and dfrected a fuel handler to move the grapple to the cask pad in order to pick up a test weight and conduct further inspections. In preparation for picking up the test weights, the uppermost telescoping square mast section separated from its retainer plate and thereby caused all sections to collapse to their limit on the internal cable. NOTE:
The cable supports the weight of the fuel assembly, the mast merely provides *
lateral rigidit *Fuel moves were suspended for the remair:tder of the shift: *
After the mast failed at approximately 23:00 the fuel handling supervisor called the senior fuel handling supervisor at home, who recommended that they wait until,
morning to facilitate repairs. He assumed that the on-shift supervisor had informed the operations shift engineer. At this time no one outside of the fuel h.andling staff knew of the event, including the contro1 room and station managemen Upper station manaqement was informe(t of the situation at 06:00 when the senior fuel handling supervisor arrived on site. At this time all of the appropriate notifications were made, including calling the nuclear engineers and the NRC. The.
Chemistry and Rad PfQtection Departments were notified at approximately 10:30.
to ta1<e rGcctt'r w::..~Ar ~~mples and vA.rify ~h.~rc.a w~.~ rior~'~!!ee ~t rn1!cectiv~:.,*.
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ZNLD/1348/28
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APPARENT CAUSES ROOT CAUSE The root cause of the event was personnel error on the part of the "8" Operator who did not verify, as per proc9.dure and training, that the grapple had cleared the bundle by rotating the mast to check for interference prior to initiating horizontal motion with the refueling bridg *
CONTRIBUTING CAUSES Continued. fuel moves after having damaged the fuel bundle bail were due to inappropriate judgment on the part of the fuel handlers and the lack of specific direction by the supervisor to stop all further wor *
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Management expectation that work should be stopped in the event of personnel error or unusual occurrence had not been clearly communicated to the individµals involved in the even *
The cause of the supervisor's failure to notify the control room management or thE!
NRC was a lack of training and a.lack of written procedures regarding response to unusual event *
Management expectations regarding responsibility and communication were not clear to the fuel handling supervisor. The supervisor did not understand the
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e!g~~!c~nce of the cvsr.t nor the pote~!~! ~?~eafy tmplication~. H~ ~1i9\\/1?'1 th~
event wa& lioi a reactivity (critically) co11.,;-:;m, and not a.tad!c!cgl~al concern ciue to no alarms. There was no written contingency plan for fuel handling events or abnormal conditions except for radioactivity release, high radiation, personnel Injury and loss of spent ~u~I pool l~vel. *
ASSESSMENT OF SAFETY SIGNIFICANCE The safety significance of the event was minor since the impact of the grapple on the fuel bundles did not damage the fuel rods. Further the mast failure would not have caused a dropped fuel bund_le (cable intact).
. CORRECTIVE ACTIONS See the response to the Confirmatory Action Letter attache ZNLD/1348/29