IR 05000272/1994080
| ML18101A186 | |
| Person / Time | |
|---|---|
| Site: | Salem  |
| Issue date: | 08/16/1994 |
| From: | Wiggins J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Miltenber S Public Service Enterprise Group |
| References | |
| EA-94-112, NUDOCS 9408240046 | |
| Download: ML18101A186 (41) | |
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EA No.94-112 Docket Nos. 50-272 50-311 Mr. Steven AUG I 6 1994 Vice President and Chief Nuclear Officer Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, NJ 08038
Dear Mr. Miltenberger:
SUBJECT:
MEETING REPORT NOS. 50-272/94-80 AND 50-311/94-80 (ENFORCEMENT CONFERENCE)
This letter refers to the Enforcement Conference held at the NRC Region I office, King* of Prussia, Pennsylvania, on July 28, 1994, arising from the Augmented Inspection Team (AIT)
inspection conducted from April 8 through April 26, 1994.
The Enforcement Conference was held to discuss the NRC's inspection findings regarding the event that occurred at Salem Unit 1 on April 7, 1994, related to the automatic reactor trip and two subsequent safety injection actuations. The enforcement conference was attended by you and other members of your staff. A list of attendees is enclosed (Enclosure 1). The following matters were discussed during the Conference: the event and its cause, and the facts surrounding the event; the safety significance of the event; your short and long-term corrective actions; the resultant apparent violations; and the NRC's Enforcement Policy (10 CFR Part 2, Appendix C). In addition, a summary of your root cause analysis of the event was discussed. The conference was open to the public in accordance with the Commission's trial program as published in the Federal Register, July 10, 1992. The conference was recorded and the tapes placed in the NRC's Public Docket Room.
The enclosed material (Enclosure 2) was presented by you and your staff at the conference and provides additional details regarding the event and your subsequent corrective actions.
No reply to this letter is required. You will be notified of our decision regarding enforcement action at a future date.
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AUG l 6 1994 Mr. Steven Your cooperation with us in this matter is appreciated.
Enclosures: As stated cc w/encl:
Sincerely, James T. Wiggins, Director Division* of Reactor Safety J. J. Hagan, Vice President-Operations/General Manager-Salem Operations S. LaBruna, Vice President - Engineering and Plant Betterment C. Schaefer, External Operations - Nuclear, Delmarva Power & Light Co.
P. J. Curham, Manager, Joint Generation Department, Atlantic Electric Company R. Hovey, General Manager - Hope Creek Operations F. Thomson, Manager - Licensing and Regulation J. T. Robb, Director, Joint Owner Affairs A. C. Tapert, Program Administrator A. Giardino, Acting Manager, Quality Assurance B. Hall, Acting Manager, Nuclear Safety Review R. Fryling, Jr., Esquire M. J. Wetterhahn, Esquire Consumer Advocate, Office of Consumer Advocate William Conklin, Public Safety Consultant, Lower Alloways Creek Township K. Abraham, PAO (2)
Public Document Room (PDR)
Local Public Document Room (LPDR)
Nuclear Safety Information Center (NSIC)
NRC Resident Inspector State of New Jersey State of Delaware
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AUG 1 6 1994 Mr. Steven bee w/encl:
Region I Docket Room (with concurrences)
K. Gallagher J. Lieberman, OE DRS File (2)
W. Dean, OEDO J. Stone, NRR M. Thadani, Acting PDI-2, NRR M. Shannon, ILPB M. Callahan, OCA
Mr. Steven os1f t94 RI:OE H°:Iif osliOOi AUG l 6 1994
OFFICIAL RECORD COPY A:SALEM.MTG
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ENCLOSURE 2 Ps~G Public Service
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Electric and Gas Company NRC ENFORCEMENT CONFERENCE JULY 28, 1994
SALEM GENERATING STATION
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE INTRODUCTION APRIL 7, 1994 EVENT Event Analysis Independent Assessment Event Significance AGENDA POTENTIAL VIOLATIONS Failure to take corrective actions Loss of configuration control Command and Control E-Plan Communications Procedural Adequacy Request for Discretionary Enforcement REGULATORY ASSESSMENT SALEM IMPROVE:MENT FOCUS Equipment Procedures People SUMMARY S. MILTENBERGER J.HAGAN C.LAMBERT L. CATALFOMO F.mOMSON F.mOMSON S. MILTENBERGER S. MILTENBERGER
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. SALEM GENERATING STATION NRC ENFORCEMENT. CONFERENCE EVENTS ANALYSIS Initial load reduction to reactor trip
- Circulating water pumps tripping due to marsh grass
- Dedicated team at circulating water structure experiences difficulty due to quantity of grass
- Operators make decision to take Unit off-line
- Shift supervisor directs transfer of electrical busses
- Operator has primary temperature trending down but does not communicate this to shift supervisor
- Control rods manually withdrawn to restore primary temperature; results in an automatic reactor trip
- Automatic plant protection systems function as designed to trip the reactor Root cause
- Control rods withdrawn farther than required
- Inadequate command and control 94EC24
SALEM GENERATING STATION NRC ENFORCEMENT* CONFERENCE EVENTS ANALYSIS First Safety Injection
- Immediately following the reactor trip a safety injection occurs
- Main turbine stop valve closure generates a pressure pulse in the main steam lines
- Main steam flow transmitters respond to the short duration pressure pulse
- Operators enter the emergency operating procedures
- Operators recognize only Train A actuation
- Single train actuation results in additional component verification and positioning per procedures
- Pressurizer goes solid, PORVs operate as designed to control primary system pressure
- Operators verify plant conditions and reset safety injection allowing the securing of Emergency Core Cooling System equipment
- Primary system temperature increases due to residual heat Root cause
- Operator error allowed a low primary system temperature. This, coincident with a false short duration high steam flow signal, generated the safety injection.
- The false high steam flow signal was due to a steam flow transmitter design vulnerability.
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SALEM GENERATING STATION NRC ENFORCEMENT*CONFERENCE EVENTS ANALYSIS Second safety injection
- Primary system temperature increase results in secondary system pressure increase
- Operators do not adequately communicate this with each other
- Atmospheric Relief Valves (MS-10) do not open at their setpoint
- Operator does not take manual control as trained
- Steam generator safety valve operates to control secondary system pressure
- Second safety injection results from low pressurizer pressure
- Pressurizer PORVs operate as designed to control primary system pressure
- Press~rizer relief tank rupture disc functions as designed Root cause 94EC2-7
- Personnel performance
- Less than adequate crew communications (primary system temperature increase and effect on secondary system)
- Operator not taking manual control of MS-10
- Inadequate design of the MS-10 automatic control system
SALEM GENERATING STATION NRC ENFORCEMENT* CONFERENCE INDEPENDENT ASSESSl\\IBNT OF EVENT Three independent assessments
- Post trip review
- Salem Operations & Technical Departments
- Significant Event Response Team
- Multi-disciplined team convened by station manager
- Specific charter
- NRC Augmented Inspection Team
- Dedicated team formed by NRC to assess significant industry events
- Specific charter Conclusions of the three independent assessment efforts are similar 94EC2-9
- 94EC2-37 SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE EVENT SIGNIFICANCE
- Inadequate management direction and inappropriate operator actions resulted in unnecessary challenges to protection equipment
- Non-conservative operational decisions during the transient resulted in inappropriate focus on secondary plant recovery with degrading RCS conditions
- Operator errors and supervisors' failure to maintain command and control complicated transient response
- Crew communications and teamwork were below performance expectations
- Long term tolerance of hardware issues led to RCS pressure boundary challenge
- Contingency actions not adequately addressed for control room response based on circulating water problems
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS Summary of Potential Violation (B)
Contrary to 10CFR50, Appendix B~ Criterion XVI, PSE&G failed to identify and take corrective actions for conditions adverse to quality
- Spurious high steam flow signals leading to unnecessary safety injection
- Main Steam Atmospheric Relief Valve (MSlO) reset/windup condition PSE&G Position We agree with the finding Spurious high steam flow signals 94EC2-SO
- PSE&G did not recognize that rapid closure of turbine stop valves caused a pressure wave to reflect back and forth initiating the high steam flow signal
- Computer analysis was required to confirm that rapid turbine stop valve closure initiated a reflective pressure wave resulting in subsequent high steam flow signals
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS MSlO Reset Windup
- Since 1977, issue had been addressed via operator intervention and training
- Elimination of reset/windup was included in scope of Digital Feedwater System design change initiated in 1991. Implementation scheduled for Spring 1995 Outage Root Cause
- Management failure to take appropriate and.
timely corrective actions 94EC2-SOa
SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE POTENTIAL VIOLATIONS Corrective Actions Taken Generic Corrective Actions
- Reinforcement that individuals are expected to identify and participate in the correction of identified problems
- Line management owns the problem and the permanent solutions
- Monitoring effectiveness of corrective action Spurious High Steam Flow Signals
- Steam Hammer Hydraulic Analysis performed to determine effect on pressure sensing lines resulting from rapid stop valve closure
- Modifications implemented for Salem Units 1 and 2 to. reduce transmitter sensitivity to high steam flow spikes
- Root Cause Analysis Procedure being developed to provide guidance from low level problems up to and including highly significant issues 94EC2-50b
SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE POTENTIAL VIOLATIONS MSlO Reset/Windup
- Modifications implemented for Salem Units 1 and 2 to correct response of MSlOs
- Verification of modification adequacy confirmed on Salem simulator and through post modification testing
- Systematic review of work-arounds completed with prioritization of followup actions in process
- All work lists being integrated and priorities being evaluated by station management Safety significance Combination of these deficiences unnecessarily challenged operators and automatic safety systems and complicated recovery from the event 94EC2-SOc
SALEM GENERATING STATION NRC ENFORCEl\\IBNT CONFERENCE POTENTIAL VIOLATIONS Summary of potential violation (E)
Contrary to 10CFR50, Appendix B, Criterion VIII, identification and control of materials, parts, and components, requires in part, that measures be established for the identification and control of parts and components
- Unit 2 Power Operated Relief Valve (PORV)
internals made of 17-4PH stainless steel (original design material) were installed in valves 2PR1 and 2PR2, in lieu of internals __ _
made of type 420 stainless steel
- Installed Unit 1 summator module for the high steam flow setpoint did not have the proper identification and contained an incorrect electronic part PSE&G Position We agree with the finding. Our review determined these examples to be isolated occurrences. These occurrences were self identified
SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE POTENTIAL VIOLATIONS Root Cause
- PORV internals
- The primary causal factor is that the work order planning process for DCPs, with shared installation activities, did not assure the proper parts are installed
- Installation and Test Engineer (l&TE) and the station planner did not perform adequate comparisons between the work order and the DCP
- I&TE did not follow through with station personnel involved in the valve work
- Upon completion of field activities the work package review by several groups was inadequate due to a lack of attention to detail
- Late issuance of the DCP
- Summator module
- Installation of the wrong module by the I&C technician was personnel error
- SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE POTENTIAL VIOLATIONS Corrective actions taken
- PORV internals
- Safety evaluation on 17-4 PH SS justified continued operation with this material until the 8th refueling outage
- All other joint 2R7 (E&PB/Maintenance) installation DCP projects were reviewed to assure no other similar occurrences. Similar DCPs for lRl 1 are being reviewed.
- Major DCPs SORC approved six months prior to outage start
- An independent root cause investigation is complete and under review by management. Corrective actions include:
A The E&PB planning procedure will be modified to assure the proper review of the work order parts list against the DCP BOM.
A E&PB will prestage all material for DCPs where joint installation responsibilities are agreed upon.
A A project directive will be issued to reinforce project expectations relative to scope of responsibilities and attention to detail as delineated in the Root Cause Report.
A Investigation results rolled down to project personnel
SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE POTENTIAL VIOLATIONS
- Summator module
- All Unit 1 "special 11 modules were removed and checked for the correct electronic configuration
- All Unit 2 modules were verified based on external ID on the case. All Unit 2 11 special" modules will be removed and checked for the correct electronic configuration during the 2R8 outage
- A configuration upgrade to provide a sketch for each special application is in process
- I&C Techs were briefed by supervision on this error and management expectations Safety Significance
- PORV Material
- The 17-4 PH SS is an acceptable alternative material.
The PORVs are capable of performing as required and did not contribute to the April 7 Event as this was a Salem Unit 2 issue
- Summator Module
- Steam flow summator replacement did not contribute to the April 7th Event and resulted in a conservative SI actuation setpoint bounded by the Accident Analysis.
- These are isolated occurrences 94EC2-Sld
SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS Summary of potential violation (A)
Contrary to Technical Specification* 6.1.2 and its implementing procedure NC.NA-AP.ZZ-0002(Q),
Command and Control was not properly exercised on April 7, 1994 PSE&G position We agree with the finding that there was inadequate command and control demonstrated on April 7, 1994
- Delay in decision to trip turbine
- Utilization of resources Root Cause Management did not provide adequate guidance specific to the recurring grass intrusion problems which resulted in rapid down transients Poor judgment on the part of shift supervisor
SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS Corrective Actions Taken Personnel/Training
- Individuals whose performance was less than expected have been provided additional training and evaluation
- Additional simulator training sessions have been conducted for all operating crews to reinforce
- Low power/low temperature operation issues
- Rapid down power transients
- Importance of team interaction within the crew
- Information Directive issued to all shift personnel to reinforce and clarify management expectations
- Command, control and communications
- Proper resource management Safety significance Inadequate command and control resulted in unnecessary challenges to the plant protection systems
SALEM GENERATING-STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS Summary of apparent violation (C)
Contrary to 10CFR50.57 and PSE&G's implementing procedure, Event Classification Guide Attachment 8, PSE&G failed to communicate within the prescribed time frame all required information, specific
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- SI logic train disagreement and subsequent failure of certain plant equipment to align as expected
- Exact cause of the reactor trip
- Effect of event on the plant
- Operator plan to recover from solid plant condition 94EC2-48a
SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE POTENTIAL VIOLATIONS PSE&G position We agree with the finding. Event information was not fully communicated and documented on the NRC Data Sheet
- Information provided was inappropriately judged to be adequate based on Emergency Coordinator assessment of plant conditions and expected plant response Root Cause Failure to provide adequate training to the Emergency Coordinator on the information needs of the NRC Operations Center 94EC2-S2a
- sALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS Corrective Actions
- ECG Attachment 8 procedure has been revised to address maintaining open line with NRC Operations Center if requested
- NRC Data Sheet will be revised to direct Emergency Response Data System (ERDS)
requests at Initial Notification
- Additional guidance has been provided to all Emergency Coordinators discussing NRC data requirements
- Emergency Coordinator training program to be revised to include additional guidance on filling out NRC Data Sheet Safety Significance NRC must have adequate information relative to plant events in order to properly exercise its emergency response procedures
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS Summary of potential violation (Dl Contrary to the requirements of T. S. 6. 8.1 and R. G.
1. 33 Appendix A, inadequate or nonexistent procedural guidance existed relative to:
- Recovery of RCS temperature from below minimum temperature for criticality
- Rapid power reduction due to grass intrusion
- Recognition of and response to SI train logic disagreement
- Recovery from solid plant conditions
SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS PSE&G position On April 7 existing procedures met the requirements of Reg. Guide 1.33 and TS 6.8.1
- Recovery of RCS temperature
- Alarm response procedure
- Rapid Power Reduction
- Integrated Operating Procedure
- IOP-4 Power Operation
- Abnormal Operating Procedure
- AB. CW-0001 Loss of Circulating Water
- AB.COND-0001 Loss of Condenser Vacuum
- SI Train Logic Disagreement
- Emergency Operating Procedures
- EOP. TRIP-0001 Reactor Trip or Safety Injection
- Solid Plant Conditions
- Emergency Operating Procedure
- EOP-FRCI-0001 Response to High Pressurizer Level
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS PSE&G position (cont'd)
Procedures exist to address a broad *spectrum of events and conditions but cannot be expected to address every possible event scenario
- Simulator training scenarios are established to supplement procedural guidance
- Events are evaluated for lessons learned and enhancements to procedures and training programs
- Past experience with rapid down power transients did not result in similar problems.
This was an isolated problem due to inappropriate control of RCS temperature
- Existing procedures met Reg. Guide 1.33 requirements and combined with training (classroom and simulator) provided the required guidance Lessons learned
- Procedure enhancements and training improvements implemented
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS Summary of Potential Violation (F)
- Failure to meet Technical Specification 3.0.3 requirements to bring the plant to hot shutdown within six hours PSE&G Position We believe discretionary enforcement was appropriate and could not have been reasonably anticipated
- Both trains of SI declared inoperable after second safety injection was reset due to block of auto actuation capability
- EOPs structured around SI being blocked after reset. Operating procedures call for reset in Mode 5 only
- Decision made to utilize Tech. Spec. while in EOPs
- Per TS 3.0.3 plant was required to be in Hot Shutdown in six hours
- Additional time was needed prior to initiating a plant cooldown 94EC2-S3A
- Operator made prudent decision to re-establish a bubble in the pressurizer to assure a well controlled plant cooldown
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE POTENTIAL VIOLATIONS PSE&G Position (cont'd)
- Request for discretionary enforcement was consistent with intent of NRC policy
- Literal compliance with the Technical Specification was not in the best interest of the Public Health and Safety
- Additional action statement time allowed cooldown at a lower rate thus minimizing unnecessary challenges to the plant
- Seeking a license amendment was impractical due to short time period involved PSE&G could not reasonably have predicted the exact sequence of events on April 7, 1994 nor the need for enforcement discretion
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SALEM GENERATING.STATION NRCENFORCEMENTCONFERENCE REGULATORY ASSESSMENT Based on the prior discussion of the* potential violations, the following mitigating factors apply
- Comprehensive corrective actions taken
- Event consequences bounded by updated Final Safety Analysis Report (UFSAR) Condition II accident analysis criteria
- No safety limits exceeded
- Plant safety equipment performed as designed
- Comprehensive investigation of the event
- The health and safety of the public was not affected 94EC'2-35a
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE SALEM IMPROVEMENT FOCUS Equipment 1990 Assessment 94EC2-40
- Materiel condition below the industry average
- Reliability of plant systems below acceptable levels
- Service water piping leaks
- Repetitive equipment failures
- CM backlog at 1600 work orders (priority A,B, 1,2)
- PM/CM ratio of 29.3%
- Total plant leaks 760
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SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE SALEM IMPROVEMENT FOCUS Equipment Progress To Date 94EC2-42
- 300 Million dollars spent to date addressing equipment and materiel condition concerns
- 307 Discrete areas identified for ongoing materiel condition evaluation
- Rating system established with overall goal of 2.80
- Present station rating is 2.14 and improving
- CM backlog reduced to approximately 350 (Priority A, B, 1, 2) work orders per unit
- PM/CM ratio increased to 57.1 % as of June 1994
- Total plant leaks reduced to 97 as of May 1994
- Completed Reliability Centered Maintenance review of 34 key systems
SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE SALEM IMPROVE:MENT FOCUS Equipment
94EC2-41 Tactical Plans
- Approximately 150 million dollars in projected expenditures to complete presently defined scope of work
- Improvements in Maintenance Program as implementation of NRC Maintenance Rule progresses
- Prioritization using PSA
- Improved trending to assess long term corrective action effectiveness
- Continued management emphasis on improving plant material condition and overall equipment reliability
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SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE SALEM IMPROVEMENT FOCUS Procedures 1990 Assessment
- Recognized weakness of implementing procedures
- Lack of detail *
- Generic procedures not adequate for specific applications
- Lack of detailed acceptance criteria
- Nonexistent criteria
- Poorly organized in procedure
- Procedures not user friendly
- Initiated Procedure Upgrade Project
- Overall objective to provide improved procedures of consistently high quality in terms of format, content, level of detail, technical accuracy and ease of use
SALEM GENERATING STATION NRC ENFORCEMENT CONFERENCE SALEM IMPROVEMENT FOCUS Procedures Progress To Date
- Procedure Upgrade Project completed
- 3500 Procedures reviewed, developed and upgraded
- Developed computerized procedure control system
- PSE&G commitments annotated in procedures 94EC2-44
- Reduction in number of procedure related LER's
- Procedures recognized as state of the art
SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE SALEM IMPROVEMENT FOCUS Procedures 94EC2-4S Tactical Plans
- Ongoing procedure maintenance to assure high quality is maintained
- Continue to emphasize procedural adherence through work standards, training, and supervisory oversight
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE SALEM IMPROVEMENT FOCUS People 1990 Assessment
- Developing a Vision Statement with an emphasis on people
- Initiating cultural changes to focus personnel on
- Ownership
- Attention to detail
- Performance standards 94EC2-38
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SALEM GENERATING STATION NRCENFORCEMENTCONFERENCE SALEM IMPROVEMENT FOCUS People Progress To Date
- While improvements have been noted, personnel performance still does not meet our expectations
- Clearly communicating our performance expectations
- Salem reorganization/unitization being implemented
- Many personnel having to re-bid their existing positions
- Emphasis on putting best qualified people in all positions
- Poor performers identified and appropriate action taken
- Emphasis on compliance with established work standards
- Increased supervisory oversight in the field 94EC2-38a
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- J SALEM GENERATING. STATION NRC ENFORCEMENT CONFERENCE SALEM IMPROVEMENT FOCUS People Tactical Plans
- Complete Reorganization/Unitization
- Personnel Performance Improvement is considered an ongoing process with the following key elements
- Clear Expectations
- Regular Reinforcement
- Accountability
- Feedback
- Improved Work Environment
- Fully incorporate work standards into culture
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SALEM GENERATING STATION NRC ENFORCEMENT* CONFERENCE COMPREHENSIVE PERFORMANCE ASSESSMEN 94EC2-12b
- Multi-disciplinary team review of incidents over last few years
- Comprehensive action plan developed
- Integral part of Nuclear Department Business Plan
- Senior Management monitoring of Action Plan progress
- Multiple performance indicators to continually assess effectiveness
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SALEM GENERATING STATION NRC ENFORCEMENT *CONFERENCE SU1\\1MARY April 7, 1994 event was significant.
- Unnecessary challenges to plant protection system
- Inappropriate operational decisions
- Inadequate Command and Control complicated event response
- Failure to address hardware problems with MS-10 controls resulted in challenge to RCS Pressure Boundary Integrity
- Crew response and interaction was below expectations
- Extensive corrective actions have been taken to address the root causes PSE&G acknowledges our need for performance improvement and is focusing on personnel performance improvement.