IR 05000237/1993027
| ML17179B122 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 09/27/1993 |
| From: | Beverly Clayton, Hiland P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17179B121 | List: |
| References | |
| 50-237-93-27-EC, 50-249-93-27, NUDOCS 9310050130 | |
| Download: ML17179B122 (36) | |
Text
- U. S. NUCLEAR REGULATORY COMMISSION REGION I I I Report N /249-93027 (DRP) -
Docket N ; 50-249 license No. DPR-19; DPR-25 licensee:
Commonwealth Edison Company Executive Towers West III 1400 Opus Place, Suite 300 06wners Grove, IL 60515 Meeting Conducted:
Meeting locatibn~
Type of Meeting:
. Ihspection Conducted:
Inspectors:
Reviewed** By:
Approved By:
September 16, 1993 Region III Office 799 Roosevelt Road Glen Ellyn, 1llinois 60137 Enforcement Conference Dresden Site Morris, Illinoi November 30 to December 4, 1992 P: Hiland F. Brush
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H. Peterson B. Siegel*
p J;.A )_ 1/ Patrick L. Hiland, Chief Reactor Projects Section lB
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Brent Cl aytOfl)hief * -
Reactor Projects Branch 1 9310050130 930928 PDR ADOCK 05000237 G
PDR I
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~/i.7/..PI Date
Meeting Summary:
Enforcement Conference on September 16, 1993, (Report No. 50-237/249-93027 (ORP))
Areas Discussed:
Apparent violations identified during the sp~cial team inspection were discussed, along with the corrective actions taken or planned by the license The enforcement options pertaining to the apparent
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violations were also discussed with the licensee. *The apparent violations concerned: (1) failures to take corrective actions for a previous control rod mispositioning event on April 10, 1992, contrary to 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," and (2) ~ailures to foll6w procedures during the rod mispositioning event on September 18, 1992, contrary to Dresden Technical Specification 6.2.. ~.. *
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DETAILS Persons Present at.the Conference Commonwealth Edison Company M. Lyster G. Spedl T. Rieck J. Kotowski M. Strait S. Reece-Koenig J. Shields G. Edgar
.p. Piet M. Falcone S. Lawson L. Ciuffini R. Johnson R. Mitzel N. Kauffman Site Vice President, Dresden Station Manager, Dresden Nuclear Fuel Services Manager Operations Manager System Engineer Supervisor Regulatory Performance Administrator Regulatory Assurance Supervisor, Dresden Attorney
Nuclear Licensing Administrator, Dresden Nuclear Operatioris Staff Operating Engineer Reactor Operator Operating Experience Administrator Shift Engineer Human Resources Supervisot U. S. Nuclear Regulatory Commission J. Mart_i n T. Martin P. Hiland M. Leach F. Brush M. Bielby M. Jordan C. Weil Regional Administrator, Rill Deputy Director, Division of Reactor Projects, Riii
- Chief, Reactor Projects Section lB, RIII Senior Resident Inspector~ Rill Resident Inspector, RIII Operator Examiner, RIII Chief, Operator Licensing Section 1, Riil Enforcement Specialist, Rill Enforcement Conference
.An enforcement conference was held in the NRC Region III office on September 16, 199 This conference was conducted as a result of the
- .preliminary findings of the inspection -conducted from November 30 to December 4, 1992, in which apparent violations of NRC regulations ~er~
identifie Inspection findings were documented in Inspection Report 50-237/249-93027 (DRP), transmitted to the licensee by letter dated September 9, 199 The purpose of this conference was to (1) discuss the apparent violations, their causes, and the licensee's corrective actions; (2)
determine if there were any escalating or mitigating circumstances; and (3) obtain any information which would help determine the appropriate enforcement actio ~. I'
Following an intioduction by the Regional Administrator, the apparent violations were presente The licensee's representatives provided additional information concerning the apparent violations.. The licensee's representatives. described the events which led to the apparent violations, including root causes and corrective actions take At the conclusion of the meeting, the licensee was informed that they would be notified in the near future of the final enforcement actio Attachments: NRC Preseritation Slides CECo Presentation Slides
Attachment 1 *
U.S. NUCLEAR REGULATORY COMMISSION
REGION III
ENFORCEMENT CONFERENCE COMMONWEALTH EDISON
- - DRESDEN ST A TI ON September 16,. 1993.
9:00 A.M. (CDT).
REPORT NUMBER 50-237 /249-92033 EA NUMBER 93-182 * *
REGION III OFFICE 799 ROOSEVELT ROAD, BUILDING 4 GLEN ELLYN, ILLINOIS
DRESDEN ST A TI ON ENFORCEMENT CONFERENCE AGENDA September 16, 1993 INTRODUCTION AND MEETING PURPOSE.
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- _-_ *J. Martin, Regional Administrator _
APPARENT VIOLATIONS SUMMARY P. *Hiland, Chief, Projects Section lB
- CONCERNS DISCUSSION T... Martin,-Deputy Director, DRP --
- LICENSEE PRESENTATION AND DISCUSSION NRC FOLLOWUP QUESTIONS _
CLOSING REMARKS -
J. Martin, Regional Administrator
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TWO APPARENT VIOLATIONS 1. 1 O_CFR 50, Appendix B, Criteria XVI, *
CORRECTl.VE ACTION April 10, 1992, investigation did not identify
Failure to insert control rod
Rod movement w/o SCRE-approval 2. September 18, 1992, Procedural Violations Failed to. second verify *
- Failed to insert control rod Failed to report or log
.S*ROs Failed to perform duties Failed to *implement reactivity management controls
NRC C.ONCERNS
CORRECTIVE ACTION PROGRAM FAILED TO IDENTIFY PROCEDURA VIOLATIONS DURING APRIL EVENT..
. PRECURSOR EVENT COULD HAVE PREVENTED SEPTEMBER EVENT
'MOST RECENT REOUALEXAM IDENTIFIED CONTINUING PROBLEMS WITH ROD MISPOSITIONS
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APPARENT ROOT CAUSE OF THE SEPTEMBER 1992 EVENT WAS DELIBERATE MISCONDUCT~*.
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. NO SECOND VERIFIER REACTIVITY MANAGEMENT RESPONSIBILITY SUPERVISORY OVERSIGHT (LNE)
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CHRONOLOGY OF EVENTS SEPTEMBER 18, 1992 07:15*
07:25 07:31-07:56 08:15-08:17 08:17 08:17-09:45 09:49 09:52*
09:53*
09:57-10:05 10:05:...10:13*
10:13-10:16 10:19-10:22 10:23 EVENT The lead nuclear engineer (LNE) directed the QNE to reduce the flow control line by inserting peripheral control rod *~he QNE, with two nuclear engineers in tr~ining (NEITs), proceeded to the control roo The QNE and NEITs entered the control roo * Control rod arrays 8Cl (4 rods) and 8C2.(4 rods)
- inserted from full-out notch position 48 to full in notch position 0 Four control rods from array 3 inserted to po~ition 12~
Control rod H-1 selected to clear rod block monitor alar.m Reactor power inqreased about 100 MWe using reactor recirculation flow.. QNE.filled out anothe~ control rbd SI sheet to insert array 80 The Unit 2 NSO inserted control rod H-*1 from position 4j to position 36 by mistake.. The Q~E instructed and the NSO inserted array 801 (4 rods).
The QNE informed t~e SCRE that the NSO had inserted a wrong ro The ~NE filled out an SI to insert contr~l* rod H-1, along with four other rods in array 5; to position 0 The NSO inserted five rods from array 5 to position 0 The SCRE, NSO, QNE, and NEITs held a discussion in the Unit 2 back panel are The NSO, 'at the direction of the QNE~ withdrew array 3 (4 rods) from position 12 to 4 The NSO, at the direction of the QNE, inserted array 802 (4 rods) to position o The NSO, at the direction of the QNE, withdrew two rods.fro~ ar~ay 5 to position 4.*.
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10:26 10:30*
10:34-10:36 10:38-10:42 11:25 The LNE entered the control room to provide guidance to the QNE concerning the number (too many) of peripheral control rods that had been inserte QNE filled out SI sheets to insert arrays lOAl and 10A2 from position ~8 to position 2 The NSO inserted arrays lOAl and 10A2 to position*
2 The NSO withdrew the remaining rods in array 5 to position 4 The LNE left the control roo NOVEMBER 23, 1992 DRESDEN FIRST LINE SUPERVISOR OVEJUIEARD REFERENCE TO CONTROL ROD MISPOSITION EVENT NOVEMBER 24, 1992 DRESDEN SENIOR SITE MANAGEMENT INFORMED RIII OF POTENTIAL FAILURE TO REPORT CONTROL ROD MISPOSITION EVENT T!
LISTING OF APPARENT VIOLATIONS
- CFR 50, Appendix B, Criteria XVI, "Corrective Action," states in part that measures shall be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetitio Contrary to the above, on April 10, 1992, a control rod niispositioning event occurred as documented in licensee Deviation Report (DVR) 12-2-92-64. The stated corrective action concentrated on the mechanical problem which caused the ci>ntrol rod mispositioning. The licensee's root cause investigation failed to identify or take corrective actions for personnel failures to follow the required response procedure Specifically: Dresden Operating Abnormal Procedure (DOA) 300-12, Revision 2, section D.2.a(l), stated that if a single control rod was inserted greater than one even notch from its in sequence p~sition, then continuously insert the mispositioned control rod to position 00. -
On April 10, 1992, Control Rod M-4 was mispositioned greater than one even notch from position 16 to position 10, and the nuclear station operator (NSO)
failed tq perform the required action. Control Rod M-4 was withdrawn back to position 1 Dresden Administrative Procedure (DAP) 07-01, "Operations Department
_ Organization," Revision 15, sections B.4.n and B.5.j, stated th responsibilities for directing the licensed activities of NSOs, i.e. reactivity management, was designated to the shift engineer (SE) and/or the station control room engineer (SCRE).
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On April 10, 1992, the qualified nuclear engineer (QNE) directed the NSO to withdraw Control Rod M-4 following its mispositioning, without approval of the SE or SCR._..,..I I Dresden Technical Specification 6.2.A. l states the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2 dated February 1978, shall be established, implemented, and maintained. Regulatory Guide 1.33 Appendix A. l.c included administrative procedures, general plant operating procedures, and procedures for startup, operation, and shutdown of safety related system Dresden Operating Procedure, (DOP) 0400-02, "Rod Worth Minimizer,"
b.* Revision 6, section F.6, and Dresden General Procedure, (DGP) 03-04,
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"Control Rod Movements," Revision 17, section D.3, required an independent verifier with the rod worth minimizer not available during control rod movemen Contrary to those requirements, on September 18, 1992, the Unit 2 NSO inserted Control Rod H-1 without the required second verifie DOA 300-12, "Mispositioned Control Rod," Revision 2, section C.2, immediate operator action, stated that if a control rod was found or moved greater than one even notch from its in~equence position, then discontinue all_
control rod movement. On September 18, 1992, the Unit 2 NSO mistakenly.
inserted Control Rod H-1 from position 48 to 36; a movement greater than.one even notc *Contrary to the above requirement, the Unit 2 NSO's immediate action (less than 50 sec.) was to insert a control rod array from position 48 to 0 DOA.300-12, section D.2.a.(1), subsequent operator actions, stated that if a single control rod was inserted greater than one even notch from its insequence position, then continuously insert the mispositioned control rod to position 0 Section D.4 stated "In conjunction with step D.5, contact the Unit Operating Engineer or the Operations Duty Supervisor." Section D.5 stated "Compare
. the current Off Gas radiation level to the Off Gas radiation level prior to the suspected time of the mispositioning." Section D.5.d stated "Record data in the Unit log book including location of mispositioned rod(s), time of discovery of mispositioning, actions taken, -and any other observations determined to be
- relevant."
Contrary to the above requirements, on September 18, 1992, the NSO failed to fully insert Con~rol Rod H-1 after it was identified as a mispositioned control rod; failed to contact the Unit Operating Engineer; failed to compare Off Gas radiation levels; and failed to record in the Unit log any data concerning a control rod mispositionin ~-"'.. '
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Dresden Administrative Procedures, (DAP) 07-29, "Reactivity Managemen Controls," Revision 0, section F.1.g required the station control room engineer (SCRE) to "Communicate to the NSO the. requirements for procedural adherence, conservative response to abnormal reactivity events, and proper attitude toward reactivity controls." Section F.1.h required that the NSO
"Ensure* that control room activities are conducted in a professional manner by complying with the following: Procedural adherence, conservative response to abnormal reactivity events, and proper attitude toward reactivity controls."
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Contrary to the above requirements, on September 18, 1992, as noted above, the SCRE and NSO failed to perform their duties and responsibilities during
- -the performance of reactivity changes. -
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-- *- * CFR Part 50.54, "Co.nditions oflicenses," item (1) requires the licensee to designate individuals to be responsible for directing the licensed activities of licensed operators. Further, these individuals shall be licensed as senior operators pursuant to 10 CFR Part 55. DAP 07-01, "Operations Department Organization," Revision 15, sections B.4.n and B.5.j, stated the responsibilities for directing the licensed activities of NSOs; i.e. reactivity management, was designated to the SE and/or the SCR )
Contrary to the above, on September 18, 1992, a QNE directed ari NSO, a licensed reactor operator, to insert an out of sequence control rod array. This action was directed by the QNE to the Unit 2 NSO without written or approved instructions from a senior reactor operator (SRO).
2)
Contrary to the above, on September 18, 1992, an increase in reactor recirculation flow was performed, resulting in an appreciable load increase of about 100 MWe, 1,2 % reactor power. Based on review of records and interviews, that load change was performed without prior *.
knowledge or approval by a licensed SRO. During interviews, the on duty SCRE and SE, stated that neither supervisor was aware of the load increase nor gave prior approva \\
, Attachment 2.
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COMMONVVEALTH EDISON CONTROL ROD MISPOSlllONING EVENT ENFORCEMENT CONFERENCE.. *
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AGENDA APPARENT VIOLATIONS II CHRONOLOGY DISCOVERY OF EVENTS IMMEDIATE RESPONSE CECO INVESTIGATION ROOT AND CONTRIBUTING CAUSES Ill SAFETY SIGNIFICANCE IV CORRECTIVE ACTIONS*
CORPORATE DRESDEN STATION OPERATION. SYSTEMS ENGINEERING V
APRIL 1 O~ 1992 EVENT VI CONCWSION PAGE 2 G.SPEDL G.SPEDL G.SPEDL T. RIECK T. RIECK T. RIECK T. RIECK J. KOTOWSKI J. KOTOWSKI.
- .* M. STRAIT M. STRAIT M. LYSTER
INJRODUCTION PURPOSE REVIEW.RESPONSE TO THE 9/18/92 AND 4110/92 EVENT PROVIDE SIGNIFICANT FACTS - DISCOVERED DURING CECO INVESTIGATION. *
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PROVIDE AN UNDERSTANDING OF ROOT CAUSE.
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PROVIDE AN UNDERSTANDING OF THE CORRECTIVE ACTIONS AND STATUS.
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PROVIDE CECO PERSPECTIVE ON SAFETY AND MANAGEMENT SIGNIFICANCE OF THE EVEN PACE 3
APPARENT VIOLATIONS - 9/18/92 EVENT FAIWRE TO FOLLOW PROCEDURES CONTRARY TO TECHNICAL SPECIFICATION 6.2A FAILURE TO -ESTABLISH THE REQUIRED SECOND VERIFICATION FOR CONTROL ROD MOVEMENTS WITH THE ROD WORTii MINIMIZER ROD BLOCKS OUT OF SERVICE. *
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FAIWRE TO *DISCONTINUE CONTROL ROD MOVEMENTS AND TO lNSERT THE MISPOSITIONED ROD TO. ITS FUU.-IN POSITION. *
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FAIWRE TO TAKE MmGATING ACTIONS IN ACCORDANCE WITH DOA 300-12 'MISPOSmONED CONTROL ROD", AND TO DOCUMENT ACTION IN THE UNIT LO FAIWRE TO ADEQUATELY IMPLEMENT OAP 7-29, 'REACTIVITY MANAGEMENT CONTROLS."
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DIRECTING LICENSED ACTIVITY BY * A NON-LICENSED
- INDMDUAL WITHOUT PRIOR SRO APPROVAL FOR
- * ROD MANIPULATION,
- LOAD CHANGES COMMONWEALTH EDISON POSmON ON THE APPARENT VIOLATION COMMONWEALTH EDISON CONCURS WITH THE FIRST FIVE EXAMPLES OF APPARENT VIOLATION THE FIFTH EXAMPLE, PART lWO (LOAD CHANGES), IS DEPENDENT ON THE RECOUECTION OF TWO INDIVIDUALS NOT CURRENTLY EMPLOYED AT COMMONWEALTH EDISON, THUS COMMONWEALTH EDISON IS NOT IN A POSITION TO CONCUR OR DISPUTE THAT RECOLLECTIO PAGE4
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- -* - *-* CHRONOl.OGv 9/18/92 EVENT
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DISCOVERY OF EVENT _;;;
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ON 11/23/92, DURING A NUCLEAR 'ENGINEERING GROUP DISCUSSION, A NUCLEAR-ENGINEER-IN-TRAINING MENTIONED
. THAT A PROBLEM IN SEPTEMBER WAS DUE TO A.MISTAKE B THE REACTOR OPERATOR..
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THE ASSISTANT LEAD NUCLEAR ENGINEER QUESTIONED THE INDMDUAL ABOUT THE COMMENT AND BEGAN GATHERING DOCUMENTATION OF CONTROL ROD MOVEMENTS PERFORMED
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ON 9/18/92..
MIDDAY ON 11/24192, THE TECHNICAL STAFF INFORMED SENIOR STATION MANAGEMENT THAT A CONTROL ROD MISPOSITIONING HAD PROBABLY OCCURRED ON 9/18/92, BUT HAD NOT BEEN REPORTED BY THE INDMDUALS INVOLVED IN THE EVENT..
TECHNICAL STAFF MANAGEMENT HAD REACHED THIS CONCWSION FOLLOWING. DISCUSSIONS WITH NUCLEAR
- ENGINEERS AND A PRELIMINARY.REVIEW OF DOCUMENTATION,
. INCWDING UNIT 2 ALARM TYPER DATA
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IMMEDIATE~RESPONSE 11124192 IMMEDIATELY UPON NOllRCATION OF THE EVENT, STATION MANAGEMENT OBTAINED PROCTORED.WRITTEN STATEMENTS FROMAVAILABLE.INDMDUALSASWEU.ASOTHERPOTENTIALL INVOLVED INDMDUAl..S, AND REMOVED.THE FIVE INDMDUALS DIRECTLY INVOLVED IN* THE 9/18192 EVENT FROM THEIR DUTIE BY EARLY AFTERNOON, AN NRC RESIDENT INSPECTOR WAS
. INFORMED OF THE EVENT~
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TECHNICAL STAFF MANAGEMENT INITIATED A PROBLEM IDENTIFICATION FORM TO DOCUMENT THE PROBLE THE GENERAL MANAGER OF BVVR NUCLEAR OPERATIONS ASSIGNED A SPECIAL TASK FORCE, HEADED BY THE MANAGER OF NUCLEAR FUEL SERVICES (NFS), TO INVESTIGATE* THE EVEN THE TASK FORGE INCWDED SENIOR CORPORATE PERSONNEL EXPERIENCED IN ROOT CAUSE INVESTIGATIONS.. *.
THE STATION MANAGER ISSUED A GATEHOUSE MEMORANDUM*,
REITERATING SENIOR STATION MANAGEMENT EXPECTATIONS TO TAKE APPROPRIATE ACTIONS, INCWDING FULL DISCLOSURE AND REPORTING, IF A MISTAKE IS MAD PACE 6
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11/24192
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MANAGEMENT BEGAN CONTINUOUS SHIFT OVERSIGHT PENDING COMPLETION OF THE INVESTIGATION WITH THE PURPOSE OF:
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COMMUNICATING INFORMATION. ON 'THE EVENT :TO A OPERATIONS PERSONNEL
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COMMUNICATING AND REINFORCING MANAGEMENT EXPECTATIONS AS THEY RELATE TO THIS EVEN DETERMINING IF A GENERIC CONCERN. EXISTED AS TO NON-REPORTING INAPPROPRIATE ACTION PACE 7
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1'1125192
_ THE INVESTIGATION T~K GROUP ARRIVED ON SITE AND BEGAN ITSWOR IN ADDITION TO THE GATEHOUSE --MEMORANDUM, SPECIAL
'TAILGATE MEETINGS WERE CONDUCTED WITH ALL STATION DEPARTMENTS WITH THE PURPOSE OF:
DESCRIBING THE EVEN COMMUNICATING THE SIGNIFICANCE' AND REINFORCING THE NEED FOR WORKERS* TO -RECORD AND REPORT PROBLEM REINFORCING MANAGEMENTS EXPECTATIONS OF -
PERSONAL INTEGRITY AND TRUSlWORTHINES NUCLEAR FUEL SERVICES (NFS), THE ORGANIZATION' WITH CORPORATE RESPONSIBILITY FOR NUCLEAR ENGINEERS
--. ACTIVITIES, BEGAN DIRECT OVERSIGHT OF QUALIFIED NUCLEAR
.ENGINEERS. (QNE)
PENDING COMPLETION OF THE INVESTIGATIO THIS CORPORATE OVERSIGHT INCWDED A REQUIREMENT THAT AN NFS REPRESENTATIVE BE PRESENT, WHENEVER A QNE WAS IN THE CONTROL ROOM FOR POWER CHANGES OR FOR CONTROL ROD MOVEMEN PACE 8.
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11125192 THE CORPORATE SAFElY. REVIEW-BOARD TRANSMITTED PRELIMINARY INFORMATION ON THE EVENT TO THE OTHER FIVE COMMONWEALTH EDISON NUCLEAR -POWER PLANTS VIA A LESSONS LEARNED INITlAL NOTIFICATION REPOR THE CECO CHIEF NUCLEAR OPERATING OFFICER PROVIDED
, INFORMATION *SUMMARIZING THE EVENT _AND IMMEDIATE
- RESPONSE IN A LEI IER TO THE -NRC REGION-Ill
- ADMINISTRATOR SITE PERSONNEL MADE AN ENS NOTIFICATION -AND-CECO CORPORATE COMMUNICATIONS SERVICES ISSUED A PRESS RE~E ON THE EVENT, INVESTIGATION,- AND IMMEDIATE RESPONSE.--
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CECO INVESTIGATION - S/18/92 EVENT CHRONOLOGY OF INVESTIGATION '-
ON *11/24192 THE GENERAL MANAGER OF BVVR NUCLEAR OPERATIONS APPOINTED A MULTl.UISCIPUNED TASK GROUP TO INVESTIGATE THE AUEGED.ROD MISPOSmONING EVENT AT DRESDEN STATION ON 9/18/93.
. THE TASK GROUP CONSISTED OF NON-DRESDEN PERSONNEL *
.* EXPERIENCED IN A VARIETY OF~
INCWDING OPERATIONS,*
NUCLEAR ENGINEERING AND ROOT CAUSE ANALYSI THE INVESTIGATION TASK G_ROUP BEGAN WORK ON 11/25/92 WITH A BRIEFING BY THE DRESDEN STATION MANAGER THE *
BRIEFING INCWDED THE CURRENTLY AVAIL.ABl.E INFORMATION ON THE EVENT AND THE STATION'S IMMEDIATE RESPONSE.
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. THE INVESTIGATION TASK GROUP DEVELOPED A PLAN OF ACTION WHICH INCWDED:
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INTERVIEWING PERSONNEL
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REVIEWING AVAIL.ABl.E DATA
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REVIEWING PROCEDURES IDENTIFYING REQUIREMENTS PERTAINING TO ROD MISPOSITIONING EVENTS
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CONSTRUCTING AN EVENT AND CAUSAL FACTOR CHART PAGE10
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CHRONOLOGY OF INVESTIGATION THE INVESTIGATION TASK GROUP CONCWSIONS JNCWDED:
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A MISPOSITIONED CONTROL ROD EVENT DID TAKE PLACE *
ON** 9/18/92 AND WAS NOT REPORTED OR LOGGED AS REQUIRED BY PROCEDUR.
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THERE WAS NO EVIDENCE THAT ANY OF THE FIVE INDMDUALS WHO WERE INVOLVED IN THE EVENT TAU<ED* *
TO ANY OTHER COMMONWEALTH *~EDISON EMPLOYEES ABOUT THE EVEN THERE WAS NO EVIDENCE THAT OTHER CONTROL RODS HAD BEEN MISPOSITIONED AND NOT* REPORTED IN THE LAST SIX MONTH.
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CONTROLS WERE * IN PLACE THAT SHOULD HAVE
. PREVENTED THE CONTROL ROD MISPOSITIONING EVEN THESE CONTROLS INCWDED:
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- THE SELF CHECK PROGRA *
SECOND VERIFIER PROCEDURAL REQUIREMENT PAGE 11
CHRONOLDG:Y OF INVESTIGATION CONCWSION~ CONTINUE.. **:('*...
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CONTROLS -WERE"-fN : ~PLACE THAT SHOULD HAVE PREVENTED THE FAIWRE TO REPORT THE EVEN THESE CONTROLS. JNCWDED:. : *.
USE OE. LOG BOOKS BY *BOTH NUCLEAR STATION.
OPERATOR AND THE QUALIFIED NUCLEAR ENGINEE..
- * THEDOA0300-12PROCEDURALREQUIREMENTTHAT THE UNIT OPERATING ENGINEER OR THE OPERATIONS DUTY SUPERVISOR BE CONTACTED AND APPUCABI E INFORMATION BE RECORDE * *. USE OF THE INTEGRATED REPORTING PROGRAM TO REPORT AND INVESTIGATE * A CONTROL ROD
_MISPOSITIONIN THE SHIFT CONTROL.ROOM.ENGINEER DID. NOT REPORT THE MISPOSITIONED CONTROL 'ROD EVENT TO HIGHER
. STATION MANAGEMENT FOR FURTHER EVALUATION AS
- REQUIRED BY THE ABNORMAL PROCEDUR UPON NOTIFICATION : OE. THE EVENT, STATION
. MANAGEMENrS ACTION WERE PROPER AND CONSISTENT WITH EXPECTATION * **
THE STATION. CONDUCTED ITS OWN INVESTIGATION WHICH CONTINUED AFTER THE INVESTIGATION TASK GROUP SUBIVllITED ITS REPOR THE INVESTIGATION RESULTS WERE SUMMARIZED IN A
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ROOT AND CONIRIBlfflNG CAUSES - 9/18/92 EVENT
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EAIWRE TO FOi I OW PROCEDURES
- THE CECO INVESTIGATION IDENTIFIED MULTIPLE EXAMPLES OE PROCEDURAi.. VIOIATIONS WHICH WERE *CONFIRMED BY THE
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NRC'S APPARENT VIOIATION ON EAIWRE TO FOU.OW PROCEDURE INATIENTION TO DETAIL Wlu.FUL PROCEDURAL VIOIATIONS-.
. CONTRIBUTING CAUSE.
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THE PROCESS OF SEU:CTING A * SECOND VERIFIER WAS *
UNCLEAR AND IACKED FORMALIT THE DIVISION OF RESPONSIBILITY AND INTERFACE BETWEEN
. THE QNE AND OPERATIONS PERSONNEL WAS UNCLEAR WITH RESPECT TO. ACTIONS FOU..OWING A
CONTROL* ROD MISPOSITIONING.
THE INVESTIGATION PROCESS IN *use DURING THE. 4110/92 MISPOSITIONING EVENT DID NOT ADDRESS THE DIVISION OF RESPONSIBILITY AND INTERFACE BETWEEN THE QNE AND OPERATIONS. PERSONNEL WITH RESPECT TO ACTIONS FOLLOWING A CONTROL ROD MISPOSITIONING. *
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SAFETY SIGNIFICANCE - 9/18/92 EVENT
. THE NUCLEAR SAFETY SIGNIFICANCE OF THE EVENT IS CONSIDERED MINIMAL
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NO NUCLEAR SAFETY LIMITS WERE APPROACHED OR
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HOWEVER, FROM A MANAGEMENT PERSPECTIVE, THE EVENT IS CONSIDERED EXTREMELY SIGNIFICAN.
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. CORRECTIVE ACTIONS - 9/18192 EVENT CORPORATE INFORMATION AND EXPECTATIONS -REIATED TO THIS EVENT WERE *coMMUNICATED THROUGH -THE NUCLEAR DMSION VIA:
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A LESSONS LEARNED INITIAL NOTIFICATION REPORT
- A SIGNIFICANT LESSONS LEARNED REPORT
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- . A CORPORATE POLICY REGARDING QNE RESPONSIBIUTIES,
.AUTHORITY, AND INTERFACE WITH NRC LICENSED OPERATING PERSONNEL WAS DEVELOPED AND ISSUE '
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LESSONS LEARNED FROM THIS EVENT WERE INCORPO.RATED INTO THE. QUALIFIED NUCLEAR ENGINEER TRAINING PROGRA THE NEW GENERAL EMPLOYEE* TRAINING PROGRAM WAS EVALUATED BY CORPORATE TRAINING WITH RESPECT TO. THIS EVENT AND WAS DETERMINED TO BE ADEQUAT u:ADERSHIP BEHAVIOR FUNDAMENTALS WERE UPDATED IN
. APRIL1993, THESE FUNDAMENTALS ADDRESS:
. -
ACCOUNTABILITY
~ ROLE CLARITY
-
DECISION MAKING
-
LEADERSHIP BEHAVIORS VISION. AND VALUES PHILOSOPHY. PRESENTATION WAS DEVELOPED AND IS BEING IMPLEMENTED..
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THE CENTRAL MESSAGE OF THE VALUES PRESENTATION FOCUSES ON ABSOLUTE INTEGRITY AND OVERA *QUALITY. THESE TWO ATTRIBUTES ARE THE FOUNDATION OF THE COMMONWEALTH EDISON NUCLEAR OPERATIONS DIVISION MISSIO.
PACE 15
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DRESDEN STATION DISCIPLINARY ACTIONS WERE TAKEN AGAINST THE FIVE (5)
INDMOUALS INVOLVED IN THE EVENT FOR FAIWRE TO REPORT THE CONTROL-ROD*MISPOSITIONING EVENT. -
THE STATION MANAGER PERSONALLY DISCUSSED THIS EVENT WITH AU.STATION PERSONNEL EMPHASIZING THE EXPECTATION
- . OF HIGH*PERSONAl WFEGRIT:Y~ :
.
THE STATION IMPLEMENTED AND TRAINED ON A NEW SEU:
CHECK PROGRAM. - * [STAR (Stop, Think, Ad, Revie~] - IN DECEMBER 1992. ** * THIS. PROGRAM WAS IMPLEMENTED TO REINFORCE AND REVITALIZE THE SEU: CHECK EXPECTATION:
PACE 16
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IN DECEMBER 1992, DRESDEN ENSURED THAT REQUESTS FOR AN NSO TO* PERFORM ROD MOVEMENTS AND FLOW CHANGES BE RECEIVED AND APPROVED BY A SHIFT SRO PRIOR TO.BEING PERFORMED. *
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THE CORPORATE**POlJC.Y**REGARDING QNE RESPONSIBILITIES, AUTHORITY, AND INTERFACE WITH NRC LICENSED OPERATING.
PERSONNEL HAS BEEN INCWDED IN:
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THE CURRENT LICENSED OPERATOR CONTINUING TRAINING-CYCLE..
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REQUIRED READING PACKAG THE INl11AL OPERATOR *LICENSE TRAINING PROGRA DOA 0300-12. (Mispositioned COlibol Rod)~ BEEN REVISED TO*
CLARIFY THE QNE DUTIES AND RESPONSIBILITIES IN RESPONSE.
TO MISPOSITIONED CONTROL RODS. *
.
.
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ALL LICENSED OPERATING PERSONNEL AND QNE'S HAVE BEEN TRAINED ON THE REVISED DOA 0300~1.
DRESDEN PROCEDURES HAVE INCORPORATED GUIDANCE WITH RESPECT TO THE APPROPRIATE RESPONSIBLE ORGANIZATION FOR PERFORMING.THE SECOND VERIFICATION OF CONTROL ROD MOVEMENT WHEN THE ROD WORTH * MINIMIZER IS UNA V All.ABL DRESDEN EVALUATED THE PROCEDURES FOR OPERATING LOG KEEPING AND CONFIRMED THAT THEY. MET MANAGEMENT_
EXPECTATION PAGE 17
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-.
.OPERATIONS OPERATING DEPARTMENT INITIATED AN OPERATIONS SELF-ASSESSMENT VVl1l-I RESPECT TO OPERATING DEPARlMENT HUMAN PERFORMANCE EVENT.
-
LED BY THE NSO UNION STEWARD.
. COMPRISED OF UNION PERSONNEL CURRENTLY ONLY ADDRESSES SPECIFIC EVENTS..
RECENT SCRAM
NOTCHING ERRORS I ROD MISPOSITIONING
POWER INC~E ON EXITING EGC
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RECOMMENDATIONS TO HELP AU.EVIATE THE POTENTIAL FOR ROD MISPOSITIONING AND NOTCHING ERRORS WHICH ARE BEING EVALUATED INCWDE:
PERFORM CRD EXERCISING. ON THE AFTER NOON SHIF..
.
IMPROVE CRD MATRIX LABELING...
IMPROVEMENTS TO MAKE DOA 0300-12 MORE USER FRIENDL A MORE COMPREHENSIVE SELF-ASSESSMENT PROCESS WILL BE IN PLACE.. BY NOVEMBER 199 PACE18
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SYSTEMS ENGINEERING A MORE RIGOROUS AND SYSTEMATIC QNE TRAINING PROGRAM HAS BEEN DEVELOPED AND IMPLEMENTE *...,
LESSONS *LEARNED *FROM THIS *EVENT AND. FOR CO~TDOWN*
OPERATION HAVE BEEN INCORPORATED INTO THE COMMONWEALTH EDISON QUALIFIED NUCLEAR ENGINEERING TRAINING.
. A DISCUSSION OF THIS EVENT HAS BEEN INCORPORATED INTO..
THE REACTIVITY MANAGEMENT SECTION OF THE COMMONWEALTH EDISON QUALIFIED NUCLEAR ENGINEERING CLASS. THIS CLASS IS MANDATORY FOR BECOMING A QUALIFIED NUCLEAR ENGINEER QUALIFIED NUCLEAR ENGINEERS AND NUCLEAR ENGINEERS IN TRAINING ARE INCWDED. IN LICENSED OPERATOR SIMULATOR.
TRAINING REACTIVITY MANAGEMENT SCENARIO PAGE19
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APPARENT VIOLATION - 4110/92 EVENT
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THE PROCEDURAL CORRECTIVE ACTIONS TO A CONTROL ROD.
- MISPOSITIONING EVENT THAT TOOK PLACE ON APRIL 10, 1992, WERE INADEQUAT COMMONWEALTH EDISON POSITION COMMONWEALTii EDISON CONCURS WITH THE APPARENT VIOLATION AS STATE ROOT CAUSE SUBSEQUENT REVIEW AS A
RESULT OF. THE 9/18/92 INVESTIGATION 'INDICATES THAT INSUFFICIENT CORRECTIVE.
ACTIONS FOR THIS*EVENT WERE THE RESULT OF A ROOT CAUSE INVESTIGATION THAT DID NOT FOCUS ON PROCEDURAL ISSUES...
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NO ELEMENTS OF WIUFUL VIOLATION WERE PRESENT.. *.
SAFETY SIGNIFICANCE THE NUCLEAR SAFETY SIGNIFICANCE OF THE EVENT IS CONSIDERED MINIMAL
-
NO NUCLEAR SAFETY LIMITS* WERE APPROACHED OR * *
EXCEEDED.*
.
HOWEVER, THE PROCEDURAL ISSUES FOR THE EVENT ARE CONSIDERED SIGNIFICAN.
PACE 20
CORRECTIVE ACTIONS - 4110192--E\\iENr_..:..::..:.._
THE 4110/92 EVENT WAS RE-EVALUATED. CORRECTIVE ACTIONS FOR THIS EVENT WERE ADDRESSED IN THE CORRECTIVE ACTIONS FOR THE 9/18/92 EVENT.
. THE IRP PROGRAM WAS IMPLEMENTED AND TRAINING PROVIDED IN AUGUST 199 VARIOUS TRAINING COURSES WERE INITIATED IN 1992 ADDRESSING ROOT CAUSE ANALYSIS TECHNIQUE THIS *
TRAINING IS ONGOING IN 199 PAGE 21
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. -.. **.. CONCWSIONS COMPANY CULTURE..
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THE CULTURE AT DRESDEN AND COMMONWEALTH EDISON DID NOT CONDONE-THE Wlu.FUL ACTIONS WHICH WERE TAKEN ON 9/18/9.
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THE CURRENT CULTURE DOES NOT CONDONE WIUFUL VIOLATIONS *OF ANY *ACTIVITIES., _. *
THE IRP * PROCESS IS USED TO IDENTIFY, * THOROUGHLY INVESTIGATE. AND-TRACK TO COMPLETION CORRECTIVE ACTIONS ASSOCIATED WITH EVENT **-.
.
WHILE. NUCLEAR SAFETY SIGNIFICANCE OF THE EVENT WAS MINIMAL,. COMMONWEALTH EDISON CONSIDERS '-IT VERY SIGNIFICANT FROM A MANAGEMENT PERSPECTIV THE' 9/18/92 EVENT WAS DISCOVERED BY PROACTIVE CECO
- MANAGEMENT ACTION AND PROMPTLY REPORTE.,**.
PREVIOUS EVENTS DID *NOT INVOLVE WIUFUL VIOLATIONS AND CORRECTIVE ACTIONS WOULD NOT HAVE PRECWDED WIUFUL.
.
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VIOLATIONS OF 9/18/9 STRONG CECO MANAGEMENT RESPONSE..
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AGGRESSIVE INITIAL ACTION COMPREHENSIVE LONG TERM CORRECTIVE ACTION PACE 22
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IMPLICATIONS OF THE~9/18/92'E\\IENT.ARE-SOUNDE ISOLATED TO FIVE INDMDUALS AND SENIOR STATION MANAGEMENT WAS NOT INVOLVE WHILE. IMPROVEMENTS FOR -CORRECTIVE ACTIONS AND MANAGEMENT CONTROLS WERE INDICATED, THERE WAS NOT A PROGRAMMATIC BREAKDOWN OR LACK OF MANAGEMENT OVERSIGH DISCIPLINARY ACTION -. WAS _FIRM; PROMPT _ AND APPROPRIATE. - -
NRC SHOULD EXERCISE ITS DISCRETION AND FOREGO ESCALATED ENFORCEMEN Wlu.FUL VIOLATIONS CANNOT AND WIU.. NOT BE TOLERATED BY COMMONWEALTH EDISO PAGE 23