IR 05000255/1993022

Forwards Enforcement Conference Rept 50-255/93-22 on 930810. Decision Re EA Will Be Sent in Separate Correspondence

ML18059A331
Person / Time
Site:	Palisades
Issue date:	08/20/1993
From:	Greenman E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:	Slade G CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
Shared Package
ML18059A332	List: IR 05000255/1993022
References
EA-93-178, NUDOCS 9308310061
Download: ML18059A331 (25)

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Docket No. 50-255 License No. DPR-20 EA 93-178 Consumers Power Company ATTN:

Gerald General Manager Palisades Nuclear Generating Plant 27780 Blue Star Memorial Highway Covert, MI 49043-9530

Dear Mr. Slade:

AUG 2 0 1993 This refers to an Enforcement Conference conducted by Mr. John B. Martin, Regional Administrator, and other members of the Region III staff on August 10, 1993.

The subject of this conference was the events at your Palisades Nuclear Plant that led to a failure to uncouple a control rod and the subsequent lifting of the reactor vessel head with one control rod still attached.

We have enclosed a report summarizing the discussion.

~ou will be notified by separate correspondence of our decision regarding the Enforcement Action based on the information presented and discussed at the Enforcement Conference.

No response is required until you are notified of the proposed Eriforcement Action.

. In accordance with 10 CFR 2.790 of the Commission's regulations, a*copy of this letter and enclosed inspection report will be placed in the NRC Public Document Room.

We will gladly discuss any questions you have concerning this Enforcemen~

Conference.

Enclosure:

Enforcement Conference Report No. 50-255/93022

• See Attached Distribution Edward G. Greenman, Director Division of Reactor -Projects es~

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Consumers Power Company Di stri but ion:

REGION 111 799 ROOSEVELT ROAO GLEN ELLYN, ILLINOIS 60137 Docket No. 50-255 License No. DPR-20 EA 93-178 Consumers Power Company

.ATTN:

Gerald General Manager Palisades Nuclear Generating Plant 27780 Blue Star Memorial Highway Covert, MI 49043-9530

Dear Mr. Slade:

AUG 2 a 1993 This refers to an Enforcement Conference conducted by Mr. John B. Martin, Regional Administrator, and other members of the Region III staff on August 10, 1993.

The subject of this conference was the eve~ts at your Palisades Nuclear Plant that led to a failure to uncouple a control rod and the subsequent lifting of the reactor vessel head with one control rod still attached.

We have enclosed*a report ~u~marizing the discussion.

You will be notified by separate correspondence of our decision regarding the Enforcement Action based on the information presented *and disc~ssed at the.

Enforcement Conference.

No response is required until* you are notifi~d of the proposed Enforcement Action.

In accordance with 10 CFR 2.790 of the Commission's regulations, a copy of this letter and enclosed inspection report will be placed in the NRC Public Document Room.

We will gladly discuss any questions you have conc~rning* this fnforcement Conference.

Enclosure:

Enforcement Conference Report No. 50-255/93022 See Attached Distribution

Sincerely, f~A-~

Edward G. Greenman, Director Division of Reactor Projects*

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Consumers Power Company Distribution:

REGION III==

Report No. 50-255/93022 Docket No. 50-255 License No. DPR-20 Licensee:

Consumers Power Company 212 West Michigan Avenue Jackson, MI 49201

.-Meeting Conducted:

August 10, 1993 Meeting At:

Region III Office, Glen Ellyn, Illinois Tjpe of Meeting:

Enforcement Conference Inspection Conducted:

Inspectors:

M. Parker Onsite at Palisade.s Nuclear Plant, June 15 through 2~, 1993 Senior Resident Inspector Reviewed 2A Approved By:

Meeting Summary

• Date Date Enforcement Conference on August 10, 1993, (Report No. 50-255/93022)

Areas Discussed:

The apparent violations and areas of concern identified during the inspection were reviewed, and corrective actions taken or planned by the licensee were discussed.

The enforcement options pertaining to the apparent violations were also discussed with the licensee.

9308310064 930820 ~

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DETAILS Persons Present at Conference M. G. Morris, Executive Vice President, Chief Operating Officer D. P. Hoffman, Vice President, Nuclear Operations G. B. Slade, Plant General Manager T. J. Palmisano, Operations Manager D. W. Rogers, Safety and Licensing Director J. L. Hanson, Operations Superintendent R. D. Orosz, Nuclear Engineering and Construction Manager R. M. Rice, Director, Nuclear Performance Assessment Department (NPAD)

M. A. Savage, Public Affairs Director

D. E. Aalderink, NPAD Palisades Assessor J. Schepers, NPAD Specialist R. Beeker, NPAD Administrator R. McCaleb, NPAD Performance Specialist T. A. Buczwinski, Engineering Programs Manager J. Kuemin~ Licensing Administrator P. Donnelly, Plant Manager, Big Rock Point U. S. Nuclear Regulatory Commission. Region III J. B. Martin, Regional Administrator, Riii W. L. Forney, Deputy Director, Division of Reactor Projects, Riii W. D. Shafer, Chief, Reactor Projects Branch 2, Riii

R. W. DeFayette, Director, Enforcement and Invest. Coard. Staff; Riii P. R. Pelke, Enforcement Specialist, Riii A. H. Hsia, Project Manager, NRR

M. E. Parker, Senior Resident Inspector, Palisades Nuclear Plant D. G. Passehl, Resident Inspector, Palisades Nuclear Plant C. N. Orsini, Reactor Engineer, Reactor Projects Section 2A, Riii B. A.

Berson~ Regional Consul, Riii Enforcement Conference An Enforcement Conferente was held in the NRC Region III office on August 10, 1993.

Thjs conference was conducted. as a result of.the preliminary findings of the inspection conducted on June 15 through 25~

1993, in which apparent violations of NRC regulations and license conditions were identified.

Inspection findings are documented in Inspection Report No. 50-255/93016, transmitted to the license~ by letter dated July 9, 1993.

The purpose of this conference was to (1) discuss the apparent violations, 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 action.

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The licensee's representatives did not contest any of the apparent violations and we~e in agreement with the NRC's understanding of the areas of concern, which are outlined in the NRC's handout provided at the conference (Attachment 1).

The licensee's repre~entatives described the events which led to the apparent violations, including root causes and corrective actions taken and planned.

A summary of the licensee's corrective actions is included in the attached handout that the licensee provided at the conference (Attachment 2).

Included among these were the immediate actions taken to address the lessons learned from the control rod uncoupling event.

Also included were longer-term actions in the following areas:

revision and communication of standards and expectations, development of a field monitoring program, eval~ation of NPAD effectiveness, and enhancement of the managerial skills development program~

At the conclusion of the meeting, the licensee was informed that they*

would be notified in the near future of the final enforcement action.

Attachments:

As Stated

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U.S. NUCLEAR REGULATORY COMMISSION

REGION III

ENFORCEMENT CONFERENCE CONSUMERS POWER COMPANY PALISADES August 10, 1993 11 :00 a.m. CDT REPORT NUMBER 50-255/93016 :

EA NUMBER 93-178

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REGION III OFFICE 799 ROOSEVELT ROAD BUILDING 4 GLEN ELLYN, ILLINOIS

PALISADES ENFORCEMENT CONFERENCE AGENDA August 10, 1993 INTRODUCTION AND OPENING REMARKS

• WILLIAM L. FORNEY, DEPUTY DIRECTOR, DIVISION OF REACTOR PROJECTS DISCUSSION OF NRC CONCERNS AND APPARENT VIOLATIONS SUMMARY DAVID G. PASSEHL, RESIDENT INSPECTOR, PALISADES LICENSEE PRESENTATION NRC FOLLOWUP QUESTIONS SUMMARY OF NRC'S EVALUATION WILLIAM L. FORNEY, DEPUTY DIRECTOR, DIVISION.

OF REACTOR PROJECTS CONCLUSION OF CONFERENCE *

JOHN B. MARTIN, REGION III ADMINISTRATOR

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CHRONOLOGY OF EVENTS

. JUNE 10, 1993 0945 OPERA TORS UNCOUPLED 44 OF 45 CONTROL RODS DURING REACTOR..

DISASSEMBLY FOR FUEL SHUFFLE 1110

. ALL CONTROL ROD DRIVE RACK EXTENSIONS ARE RAISED INTO THE REACTOR VESSEL HEAD AND CONTROL ROD.NO. 39 IS RAISED INTO THE UPPER GUIDE STRUCTURE

. JUNE 15, 1993 1250 REACTOR VESSEL HEAD IS LIFTED TO 7 FEET WHEN CONTROL ROD NO. 39-IS REPORTED TO BE ATTACHED 1825

. REACTOR VESSEL _HEAD IS LOWERED APPROXIMATELY 1 FOOT-TO.FULLY*-

ENGAGE THE ALIGNMENT* PINS AND

• PRECLUDE HEAD ROTATION

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CHRONOLOGY OF EVENTS (CONT)

JUNE 15, 1993 2255 REACTOR VESSEL HEAD IS AGAIN

• LOWERED TO APPROXIMATELY 2 FEET ABOVE THE VESSEL FLANGE* TO DECREASE DOSE RATES TO PERSONNEL

• 1N CONTAINMENT JUNE. 16, 1993 0130 HELD INFREQUENTLY PERFORMED EVOLUTION BRIEFING FOR RECOVERY OF CONTROL ROD DRIVE NO. 39 0420 REACTOR VESSEL HEAD IS SET ON 12 INCH SHIMS AND CONTROL ROD 39 IS* * *

RE-INSERTED INTO THE CORE

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CHRONOLOGY OF EVENTS (CONT)

JUNE 16, 1993 1125 ALL CONTROL ROD DRIVE RACK EXTENSIONS ARE LOWERED INTO THE UPPER GUIDE STRUCTURE

• 1250 THE SHIMS ARE REMOVED AND THE REACTOR VESSEL HEAD IS SET ON ITS FLANGE 1320 CONTROL ROD 39 IS UNCOUPLED AND ALL CONTROL ROD DRIVE RACK

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EXTENSIONS ARE RAISED 1830.

THE REACTOR HEAD LIFT IS SUCCESSFULLY PERFORMED

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NRC CONCERNS

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INADEQUATE PRE-JOB BRIEFING 2.

AUXILIARY OPERATORS FAILED TO PRACTICE UNCOUPLING CONTROL RODS PER PROCEDURE (ON MOCK-UP)

3.

COMMUNICATIONS AMONG THE OPERATORS WERE CONFLICTING AND NOT IN ACCORDANCE WITH PROCEDURES 4.

CONTROL ROD UNCOUPLING PROCEDURE WAS LOST 5. - OPERATOR RELATIONSHIP WITH SHIFT *

MANAGEMENT WAS STRAINED 6.

REACTOR VESSEL HEAD LIFT PROCEDURE WAS *.

INADEQUATE FOR DETECTING ATTACHED *..

CONTROL RODS

TECHNICAL SPECIFICATION (TS)

TS 6.8.lA.

REQUIRES WRITTEN PROCEDURES BE ESTABLISHED, *

IMPLEMENTED, AND MAINTAINED FOR APPLICABLE

• PROCEDURES LISTED IN APPENDIX A OF REGULATORY GUIDE 1.33 QUALITY ASSURANCE.

PROGRAM REQUIREMENTS. THREE OF THE APPLICABLE PROCEDURES' ARE: *

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. AUTHORITIES AND RESPONSIBILITIES FOR SA;FE.

OPEJµ TION AND SHUTDOWN (SECTION 1.B)

PREPARATION FOR REFUELING EQUIPMENT

• AND REFUELING* EQUIPMENT OPERATION (SECTION 2.K)

REMOVAL OF REACTOR HEAD (SECTION 9.D)

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APP ARENT VIOLA TIO NS CONTRARY TO TECHNICAL SPECIFICATIONS AND REG GUIDE 1.33:

1.

THE SHIFT SUPERVISOR FAILED TO ADEQUATELY HOLD A PRE-JOB BRIEFING FOR.

THE ENTIRE CREW THAT PERFORMED THE.

CONTROL ROD UNCOUPLING PROCEDURE (SEc;TION 1.B).

. 2.. THE AUXILIARY OPERATORS FAILED TO PERFORM A DRY RUN OF UNCOUPLING CONTROL RODS AT THE CRDM MOCK-UP (SECTION 2.K).

3.

THE CONTROL ROOM OPERATOR WAS NOT..

NOTIFIED AFTER EACH CONTROL ROD WAS

- UNCOUPLED (SECTION 2~K).

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APPARENT VIOLATIONS (CONT)

4.

A COMPLETED COPY OF THE CONTROL ROD UNCOUPLING PROCEDURE WAS NOT RETAINED FOR OFFICIAL PLANT RECORDS (SECTION 2.K).

5.

THE PROCEDURE FOR PERFORMING THE REACTOR VESSEL HEAD INSPECTION FOR ATTACHED CONTROL RODS WAS INADEQUATE (SECTION 9.D).

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SUMMARY OF NRC'S EVALUATION 1.

FAILURE TO FOLLOW PROCEDURES 2.

INEFFECTIVE PROCEDURES 3.

INEFFECTIVE MANAGEMENT INVOLVEMENT 4.

INADEQUATE CONTROL OF WORK PRACTICES 5. *POOR ORGANIZATION

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WEAK COMMUNICATIONS 7.

LACK OF DOCUMENT CONTROL

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DIFFICULT WORKING CONDITIONS

ENFORCEMENT CONFERENCE AGENDA PALISADES CONTROL ~OD UNCOUPLING EVENT I.

OVERVIEW OF AGENDA................. -.............. DP Hoffman 11.

OVERVIEW OF THE BROAD MANAGEMENT ISSUES.......... GB Slade Ill.

DISCUSSION OF THE PROPOSED VIOLATIONS AND DETAILS. TJ Palmisano IV.

PALISADES MANAGEMENT ACTIONS...................... GB Slade V.

NOD MANAGEMENT ISSUES, PROBLEMS AND ACTIONS *..... DP Hoffman VI.. CONCLUDING REMARKS.............................. DP Hoffman

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PALISADES NUCLEAR Pl.ANT

• PALISADES *

ENFORCEMENT CONFERENCE AUGUST 10, 1993

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ENFORCEMENT CONFERENCE AGENDA (

PALISADES CONTROL ROD UNCOUPLING EVENT I.

OVERVIEW OF AGENDA............................... DP Hoffman II.

OVERVIEW OF THE BROAD MANAGEMENT ISSUES.......... GB Slade Ill.

DISCUSSION OF THE PROPOSED VIOLATIONS AND DETAILS. TJ Palmisano IV.

PALISADES MANAGEMENT ACTIONS........................ GB Slade V.

NOD MANAGEMENT ISSUES, PROBLEMS AND. ACTIONS..... DP Hoffman VI.

CONCLUDING REMARKS........................... :. *. DP Hoffman

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L MANAGEMENT ISSUES IDENTIFIED AS A RESULT OF THESE EVENTS The culture of the organization is one that typically resists "contrary" opinions as a first response.

II.

• Our efforts to transition from a very autocratic management to a more -

participative style has been slow and inconsistent.

Ill. * Our "oversight".functions have not been entirely successful in preventing recurrence of performance problems - especially those related to human/

management performance.

. IV.

Our efforts to get all employees to appreciate the growing competitiveness of the electric utility business has, at least subconsciously,_ resulted in a conflict with the number one priority of our department - SAFETY.

V.. Our communication and follow-up on implementation of managem*ent expectations including expectations for contractors and CPCo workers has not

• been adequate.

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Our management expectations have not been communicated clearly and consistently across department lines.

VII. Our supervisory coaching skills are weak.

VIII. Our views of the likely outcomes are overly optimistic without preparing adequate contingencies for unfavorable outcomes:

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ACTIONS TAKEN I.

Memo to all" site supervisory personnel on lessons learned from the rod un-coupling event emphasizing:

A.

The need for appropriate pre-job briefings including coordination within the crew and between crews..

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The requirements for procedure and work order usage and compliance.

C.

The need to stop work if it is not going according to plan or the procedure needs to be changed.

D.

The need for super-Visor morii.toring of work in progress.

II.

Onsite senior management observers established as part of the Confirmatory Action Letter will continue to monitor plant activities until the plant returns to.

service.

Ill.

Instituted the use of a pre-job briefing checklist Uob aid) to provide guidance to supervisors and lead workers in making sure that briefs cover all* critical elements of the job.

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Operations Department specific actions include:

A.

Reviews and revisions were completed of refueling procedures to correct weaknesses similar to the uncoupling procedure.

8.

Communication of expectations to workers and supervisors were made by the Operations Manager and the Operations Superintendent.

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ACTIONS BEING DEVELOPED I.

Actions plans are being developed by the Plant Management team in the following areas:

A.

Monitoring - A field monitoring program, including routine observations by plant senior management, is being developed. The program includes team.

debriefs of monitoring activities to build consistency and provide follow through* on immediate issues and big picture trends.

B.

Standards and Expectations - Plant standards and expectations are being reviewed by the management team to ensure consistency in interpretation.

C.

Communications - A plan for further communicating the standards and expectations with all levels of the organization is being developed. This communication plan will be integrated with the monitoring program to ensure each worker and supervisor understands and complies with the *

expectations.

D.

-Managing Change

. E.

Perfonnance Recognition 11.

Actions plans are being developed by the Operations Department in the following.

areas:

A.

Climate Improvement - Emphasis on more two way communications; clarity on operator errors and discipline policy, shift realignments.

B.

. Supervisory Perfonnance - Emphasis on coaching and counselling with management observations* and a customized development plan foreach Shift Supervisor.

C.

Worker Perfonnance - Emphasis on clarity of expectations, more specific feedback on performance. and individual development plans as appropriate.

Ill.

NOD wide action plans are being developed in the following areas:

A.

NOD Management Inspection Program - Modification of the "inspection" program to focus more on human performance vs. facility material condition.

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NPAD Effectiveness - The Director of the Nuclear Performance Assessment Department will:

1.

Evaluate how assessments are conducted by his department.

2.

Identify "outside" expertise that can participate in both our on-site and off-site safety oversight functions.

C.

Skill Development and Enhancement The Training and Development Organization has been directed to accelerate the current NOD Business Plan's schedule for supervisory and management skills development.

1.

Training in support of management and supervisory work process observation program. Specific content will focus on observation of human performance to standards.

2.

Workshops and training aimed at improving supervisory and management skills based on immediate needs.

3.

Development and presentation of team skills training, to enhance the performance of teams at every level ofthe organization, including management teams.

IV.. The actions at each plant and for the department will be incorporated into our 4th quarter NOD Business Plan revisions.

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CONTRACTOR CONTROL I.

1992 Refueling Outage Performance Contractor control issues identified, particularly with Refueling Services:

Improper administrative practices in the course of implementing procedures.

Inadequate monitoring by CPCo.

Inadequate understanding of expectations on the part of the.contractor.

Inconsistent quality of pre-job briefs and training on procedures.

II.

Corrective Actions Following 1992 Refueling Outage Training on expectations.

Training on procedural usage.

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Staffing enhancements by contractor.

Revised procedures to increase CPCo control.

Ill.

1993 Refueling Outage Daily formal communications.

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Improved staffing by contractor.

Improved procedures.

Disappointing performance on procedure usage.

Work practices of refueling contractor.