IR 05000269/1996019
| ML15118A169 | |
| Person / Time | |
|---|---|
| Site: | Oconee  |
| Issue date: | 01/09/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML15118A168 | List: |
| References | |
| 50-269-96-19, 50-270-96-19, 50-287-96-19, NUDOCS 9701210464 | |
| Download: ML15118A169 (10) | |
Text
U.S. NUCLEAR REGULATORY COMMISSION
REGION II
Docket Nos:
50-269, 50-270, 50-287 License Nos:
DPR-38, DPR-47, DPR-55 Report Nos.:
50-269/96-19, 50-270/96-19, AND 50-287/96-19 Licensee:
Duke Power Company Facility:
Oconee Nuclear Station, Units 1, 2 and 3 Location:
422 South Church Street Charlotte, NC 28242 Dates:
December 9-10, 1996 Inspectors:
W. Stansberry, Safeguards Specialist Approved by:
P. Fredrickson, Chief, Special Inspection Branch Division of Reactor Safety ENCLOSURE 9701210464 970109 PDR ADOCK 05000269 G
EXECUTIVE SUMMARY Oconee Nuclear Station, Unit 1, 2 and 3 NRC Inspection Report 50-269/96-19, 50-270/96-19, and 50-287/96-19 On November 6,1996, at approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br />, Maintenance workers were in the process of reconnecting the Limitorque Valve Operator for a Unit 3 main steam valve (3MS-82). As they opened the limit switch compartment housing, they discovered approximately 4 ounces of an oily foreign substance. Because the compartment was expected to be clean and dry from the recent refurbishment, they stopped work and notified their supervisor. The supervisor initiated an analysis of the fluid, and maintenance was notified. On November 7, 1996, a Problem Investigation Process (PIP) Report was initiated and site management began reviewing the circumstances and cause for this foreign substance being in the limit switch compartment. Maintenance reviewed the relocation sequence of the valve operator for the refurbishment. Because a plausible explanation was not identified, maintenance and management began to suspect equipment tampering. On November 20, 1996, Maintenance received verification from an independent lab that the substance did not match the greases and cleaning fluids mainly used in Limitorque valve operator refurbishmen On November 21, 1996, at 1145 hours0.0133 days <br />0.318 hours <br />0.00189 weeks <br />4.356725e-4 months <br />, the Station Manager notified the Security Manager of these events and findings. Security conducted a review of information
.
known at that time. At 1530 hours0.0177 days <br />0.425 hours <br />0.00253 weeks <br />5.82165e-4 months <br />, a management decision was made that there was adequate information to suspect equipment tampering as described in 10 CFR 73.71. At 1605 hours0.0186 days <br />0.446 hours <br />0.00265 weeks <br />6.107025e-4 months <br />, the NRC was notified of the event via the Emergency Notification System (ENS).
A licensee investigation team was assembled at 1800 hours0.0208 days <br />0.5 hours <br />0.00298 weeks <br />6.849e-4 months <br /> on November 21, 1996, and an Investigation Charter was established. Additionally, site supervisors and managers were notified to be aware of the event and Security was notified to heighten their awareness to any unusual activitie A chronological Sequence of Events is documented in Attachment A to this repor The licensee cleaned and reinspected the subject operator valve and installed it as previously planne The licensee's response to the November 6, 1996 foreign substance event, was excellen The inspector concluded the following:
Site management appropriately pursued identification of the foreign substance and the individual or individuals who may have placed the foreign substance into the valve operato *
Following extensive interviews and reviews by the licensee, they determined that tampering occurred; however, to date no suspect has been identifie The licensee's investigative staff adequately reviewed the event and other previous events to ensure that any potential tampering events had been fully evaluate *
The foreign substance was most probably inserted as an act of vandalis *
The licensee adequately evaluated other systems for signs of tamperin.
There was no evidence of additional tamperin.
The licensee had adequately evaluated plant condition reports and other documentation of additional examples of potential tamperin *
The act of tampering with the Limitorque Valve Operator did not compromise security or the safe operation of plant systems. The foreign substance would not have interfered with the operability of the valve operator if it had not been discovere The licensee was in compliance with the Physical Security Plan with respect to fitness for duty, personnel access authorization, criminal history checks, and access control of protected and vital area REPORT DETAILS 1. Operations
Operational Status of Facilities and Equipment 0 Tampering event On November 6,1996, at approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br />, Maintenance workers were in the process of reconnecting the Limitorque Valve Operator (LVO) for a Unit 3 main steam valve (3MS-82). As they opened the limit switch compartment housing, they discovered approximately 4 ounces of an oily substance. The workers did not recognize the look, smell, color or consistency of the fluid. Because the compartment was expected to be clean and dry from the recent refurbishment, they stopped work and notified their supervisor. The supervisor initiated an analysis of the fluid, and maintenance was notified. On November 7, 1996, a Problem Investigation Report (PIP) was initiated and site management began reviewing the circumstances and cause for this foreign substance being in the limit switch compartmen.1.1 Evaluation and Correction Inspection Scope The inspector reviewed the licensee's evaluation of the foreign substance (FS) found in the LVO to determine if the as-found condition represented tampering and to verify that the contaminated LVO was replaced and operability had been satisfactorily demonstrate Observation and Findings The inspector reviewed the licensee's actions as a result of the FS tampering even The inspector noted that the licensee's investigation team concluded that there were no apparent safety implications from the tampering act. Five factors were considered in determining the probability of a malevolent act:
The FS was discovered during the routine installation of the LVO. There was low probability that the FS would not have been discovered during the activit The FS was covering the interior to the LVO, indicating that it was present long before the installation. A thorough search of the interior of the affected LVO in the maintenance area did not disclose evidence of deliberate manipulation of any parts of this LVO or other LVOs in the are *
There was no communicated threat received toward the plant or plant
equipmen *
There were no other events of this natur The event involved a low level of sophistication. The FS appeared to be related or consistent with other fluids in the area that were readily availabl There was no force used. The FS could have been easily poured directly into the LV *
The target selected indicated two conflicting profiles of the individual or individuals committing the tampering ac *
The FS would not have interfered in the operability of the LV Conclusion The act of tampering with the LVO did not compromise security or the safe operation of plant system.1.2 Evaluation of Plant Systems and Previous PIPs for Evidence of Additional Tampering Inspection Scope The inspector reviewed the licensee's evaluation of plant systems to verify that plant safety systems have been sufficiently inspected for potential tampering to assure they could perform their intended function Observation and Findings In response to the LVO being tampered with, the licensee performed an inspection of other LVOs and additional systems, including safety related systems and non-safety related systems that could have an impact on the safe operation of the plant, to assure that the systems were intact, with no signs of potential tamperin The licensee reviewed the PIPs in an effort to determine if any other suspected issues existed that had the potential to have been caused by tamperin Conclusion Based on independent review of the documentation of the licensee's inspections, the inspector concluded that there did not appear to be any other examples of tampering related to the LVO even.1.3 Site Management's Response to the Event Inspection Scope The inspector reviewed the actions taken by site management in responding to the tampering with the LVO to determine if management's response was appropriate for the circumstance Observation and Findings The inspector reviewed the licensee's actions to investigate the event. Prompt action was taken to investigate the event and a investigation charter/plan was quickly initiated. The investigation plan included the following:
Establish the whereabouts of the LVO and the identity of those who had contact with it from the time it was refurbished until the foreign substance was discovere *
Determine if there were any pertinent issues regarding behavior, performance, relationships, etc. of individuals involve *
Determine the source of the foreign substance found in the housin *
Determine if there have been other events which may not have been recognized as resulting from deliberate tampering and, if found, any relationship to the even *
Determine the potential consequences of the foreign substance in the housing if not discovered, and determine if any action need to be taken to ensure reliable operation of similar component *
Search available information for any similar event *
Determine if appropriate and timely actions were taken upon the discovery of the foreign substanc Management initiated the following immediate measures:
(1) Compensatory maintenance and security measures to prevent any further acts of tamperin (2) Detailed inspections to ensure there was no evidence of tampering with plant equipmen (3) An independent investigation to determine who may have tampered with the LVO and the extent of any tamperin Management met frequently with plant personnel to discuss the status of the investigative effort. In addition, management kept NRC (site personnel and Regional and NRR management) informed of the actions being taken and the status of the investigation pla *
_4 Conclusion The inspector concluded that site management appropriately pursued identification of the individual or individuals who tampered with the LVO and sought identification of any additional potential tampering with plant equipmen The inspector concluded that tampering with the LVO had occurred and that the most likely individual or individuals involved had authorized access to the protected are IV. Plant Support SI Conduct of Security and Safeguards Activities S Safeguards Contingency Plan Implementation and Security Investigation of the Event Inspection Scope (81601)
The inspector reviewed appropriate chapters of the licensee's Duke Power Company Nuclear Security and Contingency Plan (S/CP), Revision 04, dated April 18, 1996 and the Nuclear Security Training and Qualification Plan, Revision 02, dated April 18, 1996 to determine if Security implemented appropriate actions according to the security plans and if the investigative team adequately reviewed the even Observations and Findings Review of the security plans verified that the licensee was in compliance with the commitments of the plan The investigation team was assembled on November 21, 1996, to determine independently when and how the oil was deposited into the LVO. The investigative team used personnel from the Employee Assistance Program, Organizational Effectiveness and Securit The investigative team researched files to determine if any workers were recently at other sites where tampering events had occurred, obtained a list of outage workers terminated after November 6, 1996, obtained a list of personnel within the protected area since 11:00 p.m., on November 5,1996, crossed-referenced the list of personnel within the protected area against those in the protected area during the LVO reinstallation, and interviewed selected personnel who had access to the LV A preliminary onsite analysis of the foreign substance did not provided identificatio On November 8, 1996, a sample was sent to an independent lab for analysis, along with samples of the grease and cleaners used on Limitorque valve operators. The independent lab did not identify a match from the samples analyzed. The foreign substance sample appeared to be a degraded, oxidized, mix of various sources of fuel, solvent, and lubricant. A field review identified a possible matching source in a
Rigid Threading Machine reservoir, located in the back of the Welding Shop. A sample of this was sent to the lab for a comparative analysis on November 25, 199 The lab report indicated the sample was similar to the foreign substance, but could not confirm them to be identical. No other sources had been foun Conclusions The inspector concluded that the licensee was in compliance with the security plans with respect to fitness for duty, personnel access authorization, criminal history checks, and access control of the protected area. The inspector also concluded that the licensee's investigative team thoroughly reviewed the event and that an unknown individual or individuals had deposited a foreign substance into the LVO. The inspector determined that the licensee response to the tampering event was thorough and complet V. Management Meeting X1 Exit Meeting Summary The inspector presented the inspection results to licensee management at the conclusion of the inspection on December 10, 1996. The licensee acknowledged the findings presented. Although reviewed during this inspection, proprietary information is not contained in this report. Dissenting comments were not received from the license PARTIAL LIST OF PERSONS CONTACTED Licensee E. Burchfield, Manager, Regulatory Compliance, Oconee Nuclear Station (ONS)
D. Durham, Security Specialist, ONS J. Hampton, Site Vice President, ONS D. Hubbard, Superintendent, Maintenance, ONS T. King, Manager, Security, ONS C. Little, Manager, Electrical Engineering, ONS T. McQuarrie, Operational Effectiveness Specialist, ONS J. Smith, Specialist, Regulatory Compliance, ONS NRC G. Humphrey, Resident Inspector INSPECTION PROCEDURES USED IP 71701:
Plant Operations IP 81601:
Safeguards Contingency Plan Implementation IP 81700:
Physical Security Program for Power Reactors
CHRONOLOGICAL SEQUENCE OF EVENTS DATE APPROX. TIME EVENT 10/29/96 Removed Limitorque Valve Operator (LVO) and move to MOV sho /5/96 11:25 LVO refurbished and bench test complete :30 MOV shop front door locke /6/96 6:30 MOV shop front door unlocke :00 LVO transported to Turbine Bldg. and hoisted to scaffoldin :00 Lunch break, LVO left attende :00 noon LVO was mounted on stem and reconnect work bega Limit Switch compartment opened and foreign substance foun :00 Supervisor notified and work stopped. Issue turned over to the oncoming cre :00 Foreign substance collecte :30 Cleaning of the LVO begin :30 Cleaning completed and LVO reinstalle /7/96 Functional and Valve Stroke test completed without problem PIP 3-096-2293 initiate :00 NRC Resident Inspector notifie /8/96 Foreign substance is overnight expressed to la /12/96 Two samples of grease and cleaning fluids used in LVO overnight expressed for comparative analysi /19/96 Verbal notification from lab indicating no match with comparative samples. Samples looked like waste oi /20/96 Written analysis received from lab on first sample ATTAC
DATE APPROX. TIME EVENT Fluid sample from Rigid Threader in Welding Shop collecte /21/96 11:45 Security notifie :00 noon Security staff starts revie :30 Management decides that enough evidence indicated component tampering and 73.71 reportability require :05 ENS notification to NRC mad :00 Investigation Team assemble /21/96 Site supervisors and managers notified of the Heightened Awareness situatio /22/96 9:30 Greenville FBI office called and a notification message requesting a return call is lef :00 Conference call with site management and NRC (Region and NRR) concerning event and action :30 FBI returns cal /25/96 Rigid Threader Machine sample sent to the la /27/96 Conference call with NRC (Region and NRR).
Verbal notification from lab that Rigid Threader Machine sample has high correlation to LVO foreign substanc /02/96 Written report from lab indicated that Rigid Threader Machine sample is similar to foreign substance, but not identica /05/96 Questionnaire prepared and distributed to employees onsite on the events of November 5 and 6,199 /06/96 Site management briefed by the investigation team on findings and recommendation ATTACHMENT