IR 05000275/1995017

Summarizes 960112 Predecisional Enforcement Conference Held to Discuss Violations Identified in Insp Repts 50-275/95-17 & 50-323/95-17.Licensee Evaluation Noted Lack of Mgt Control Over Installation & Removal of Ground Buggies

ML16342D193
Person / Time
Site:	Diablo Canyon
Issue date:	01/29/1996
From:	Dyer J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Rueger G PACIFIC GAS & ELECTRIC CO.
References
EA-95-279, NUDOCS 9602010142
Download: ML16342D193 (92)

Text

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aO UNITEDSTATES NUCLEAR REGULATORY COMMISSION

REGION IV

611 RYAN PLAZADRIVE, SUITE 400 ARLINGTON,TEXAS 76011.8064 JAN 29 l996 EA Number:

95-279 Pacific Gas and Electric Company Nuclear Power Generation, B14A ATTN:

Gregory H. Rueger, Senior Vice President and General Hanager Nuclear Power Generation Bus. Unit 77 Beale Street, Room 1451 P.O.

Box 770000 San Francisco, California 94177 SUBJECT:

PREDECISIONAL ENFORCBIENT CONFERENCE - JANUARY 12, 1996 On January 12, 1996, representatives of Pacific Gas

& Electric Company (PG&E)

for the Diablo Canyon facility met with NRC personnel in the Region IV office located in Arlington, Texas, to discuss the apparent violations identified in NRC Inspection Report 50-275/95-17; 50-323/95-17.

The conference was held at the request of Region IV, The licensee presented a summary of the causes for the apparent violations and their corrective actions, The discussion included the immediate and long-term corrective actions.

The licensee agreed with the findings in the inspection report and the potential violations.

The licensee noted that their root cause evaluation tended to focus on the overall lack of management control over the installation and removal of ground buggies rather than the personnel failures to follow procedures.

The licensee also noted that, as a result of dissemination of this event to plant personnel, they have become aware of other situations in which ground buggies or other grounding devices have been left installed when they should have been removed.

The attendance list and the licensee's presentation are enclosed with this summary (Enclosures 1 and 2).

In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice,"

a copy of this summary and its enclosures will be placed in the NRC Public Document Room.

Sincerely, 9602010L42 960129 PDR ADQCK 05000275

PDR J.

ED Dyer, Director Division of Reactor Projects

Pacific Gas and Electric Company Enclosures:

1.

Attendance List 2.

Licensee Presentation Dockets:

50-275 50-323 Licenses:

DPR-80 DPR-82 cc w/enclosures:

Sierra Club California ATTN:

Dr. Richard Ferguson Energy Chair 1100 11th Street, Suite 311 Sacramento, California 95814 San Luis Obispo Mothers for Peace ATTN:

Hs.

Nancy Culver P.O.

Box 164 Pismo Beach, California 93448 Ms, Jacquelyn C. Wheeler P.O.

Box 164 Pismo Beach, California 93448 The County Telegram Tribune ATTN:

Managing Editor 1321 Johnson Avenue P.O.

Box 112 San Luis Obispo, California 93406 San Luis Obispo County Board of Supervisors ATTN:

Chairman Room 370 County Government Center San Luis Obispo, California 93408 California Public Utilities Commission ATTN:

Mr. Truman Burns(Hr.

Robert Kinosian 505 Van Ness, Rm.

4102 San Francisco, California 94102 Diablo Canyon Independent Safety Committee Attn:

Robert R. Wellington, Esq.

Legal Counsel 857 Cass Street, Suite D

Monterey, California 93940

Pacific Gas and Electric Company Radiologic Health Branch State Department of Health Services ATTN:

Hr. Steve Hsu P.O.

Box 942732 Sacramento, California 94234 State of California ATTN:

Hr. Peter H. Kaufman Deputy Attorney General 110 West A'Street, Suite 700 San Diego, California 92101 Pacific Gas and Electric Company ATTN:

Christopher J.

Warner, Esq.

P.O.

Box 7442 San Francisco, California 94120 Pacific Gas and Electric Company Diablo Canyon Power Plant ATTN:

Warren H. Fujimoto, Vice President and Plant Manager P,O.

Box 56 Avila Beach, California 93424

Pacific Gas and Electric Company Resident Inspector MIS System Senior Project Inspector (DRP/E, WCFO)

Branch Chief (DRP/TSS)

Leah Tremper (OC/LFDCB, MS:

TWFN 9E10)

W. L. Brown, Regional Counsel S.

Bloom, NRR E-Mail report to D. Nelson (DJN)

E-Mail report to NRR Event Tracking System (IPAS)

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bcc distrib.

by RIV:

L. J. Callan DRS-PSB Branch Chief (DRP/E, WCFO)

RIV File M.

Hammond (PAO, WCFO)

G.

F. Sanborn, EO OE:EA File (MS: 7-H-5)

To receive copy of doclnant, indicate inborn C

~ Copy without enclosures

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~ Copy with enclosures "ii ~ No copy RIV:C:DRP/E HJWong df*

1/17/96 D:WCFO KEPerkins*

1/17/96 D:DRP JEDyer 1/

/96

• previous y concurre OFFICIAL RECORD COPY

Pacific Gas and Electric Company E-Hail report to D. Nelson (DJN)

E-Mail report to NRR Event Tracking System (IPAS)

bcc to DMB (IE45)

bcc distrib.

by RIV:

L. J. Callan DRS-PSB Branch Chief (DRP/E, WCFO)

RIV File M.

Hammond (PAO, WCFO)

G.

F. Sanborn, EO OE:EA File (MS: 7;H-5)

Resident Inspector HIS System Senior Project Inspector (DRP/E, WCFO)

Branch Chief (DRP/TSS)

Leah Tremper (OC/LFDCB, MS:

TWFN 9E10)

W. L. Brown, Regional Counsel S.

Bloom, NRR To receive copy ef docrsnent, indicate in box "C" ~ Copy without enclosures

"E" ~ Copy with encfosures "N" I No copy RIV:C:DRP/E HJWong;df*

1/17/96 D:WCFO KEPerkins*

1/17/96 D:DRP JEDyer 1/

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"previous y concurre OFFICIAL RECORD COPY

ENCLOSURE

ATTENDANCE LIST PREDECISIONAL ENFORCEMENT CONFERENCE JANUARY 12, 1996 Pacific Gas and Electric Com an J. Shiffer, Executive Vice President G. Rueger, Senior Vice President, Nuclear W. Fujimoto, Vice President Diablo Canyon Operations L. Womack, Vice President Nuclear Technical Services R.

Powers, Manager of Operations Services D. Miklush, Manager of Engineering Services T. Grebel, Director of Regulatory Services C. Harbor, NRC Interface C. Warner, Attorney NRC L. Callan, Regional Administrator J.

Dyer, Director, Division of Reactor Projects K. Perkins, Director, Walnut Creek Field Office T.

Gwynn, Director, Division of Reactor Safety C. VanDenburgh, Chief, Engineering Branch H. Wong, Chief, Reactor Projects Branch E

D. Acker, Senior Project Inspector M. Tschiltz, Senior Resident Inspector S.

Boynton, Resident Inspector T. McKernon, Reactor Engineer, Operations Branch G. Sanborn, Enforcement Officer G, Vasquez, Enforcement Specialist W. Brown, Regional Counsel B. Henderson, Public Affairs WE Bateman, Project Director, Project Directorate IV-2, NRR (by phone)

S.

Bloom, Project Manager, NRR (by phone)

AUXILIARYTRANSFORMER

~ Introduction - G. Rueger

~ Event description and root cause - R. Powers

~ Immediate corrective actions - D. Miklush

~ Long term corrective actions:

- G. Rueger

- W. Fujirnoto

- L. Womack

~ Safety significance - L. Womack

~ Summary - G. Rueger

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0" EVENTOESCRIPTIION AND ROOT CAUSES

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AuxiliaryTransformer 1-1 Event Res onse

~ Fire extinguished in approximately 30 minutes

~ Deluge system worked well and prevented fire from spreading

~ Fire brigade responded quickly and effectively

~ Hazmat response prevented oil discharge to ocean

~ Allthree EDGs performed satisfactorily

~ Offsite power restored when startup transformer returned to service at 1:29 am, 10/22/95

Damage Assessment

~ Heavy damage to AuxiliaryTransformer 1-1 and associated buswork

~ Minor external damage to AuxiliaryTransformer 1-2 and main transformers

~ 12 kV bus D and E no damage

Root Causes

~ Procedures did not effectively control grounding devices Division of Operations/Maintenance responsibilities unclear Clearance/work order processes inadequate to ensure grounding devices removed GB labels inadequate

~ Procedures/work instructions were not followed

~ Transformer failed faster than protective relays could operate

~ Past corrective actions were ineffective

Contributory Causes

~ Failure to document problems

~ Work schedule of foreman

~ Training for temporary supervisors

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OOT.CAUSE ¹1 (,ORRECTIVE ACTIONS procedures did not effectively control grounding devices

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Immediate Corrective Actions

~ Grounding device installation restricted pending additional instructions

~ All installed grounding devices identified

~ Interim grounding device controls implemented

~ Training conducted on interim controls

Improved Grounding Device Controls

~ Final GB administrative procedures issued

~ Clearance process now used to control GB installation and removal

~ New grounding device lamacoidsllabels

~ Prior to energizing equipment:

TM Foreman performs'

documented walkdown Operations walkdown of bus and follows

"Place in Service" procedures

~ Bottom line: Operations owns plant configuration

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Actions to Review Other Processes

~ Electrical team formed to brainstorm potential electrical safety issues Review DCPP processes Benchmark other utilityelectrical processes

~ Review for effectiveness of past corrective actions

~ Town Hall meetings All DCPP Part of error reduction process

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ROOT CAUSE 52 CORRECTIVE ACTIONS Procedures/work instructions were not followed

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Immediate Corrective Actions

~. Personnel counseled

~ SVP letter issued on event and procedure adherence

~ EIT findings presented at "all hands" meetings

~ Event video prepared and presented to NPG

~ Town Hall meetings performed

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Procedure Adherence Ke Com onents

~ Expectations & Culture Expectations must be clear and well communicated Personnel must understand and accept Consequences for non-adherence must be fair 8 consistent

~ Training must reinforce messages and methods

~ Change Process must facilitate necessary changes

~ Usability & Quality must encourage use

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0'rror Reduction Process ERROR FREE ENVIRONMENT QUALITY ERROR-FREE ENVIRONMENT REVIEW/RE-FOCUS 0/ORK PROCESSES TRAINING/QUALIFICATION DIRECTOR FOCUS AREAS SELF-ASSESSMENT MONITORING ACCOUNTABILITY EXPECTATIONS/STANDARDS YEARLYREVIEW BY MANAGEMENTTEAM HPES FACILITATION

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Error Reduction Process

~ Work the plans, track, and adjust over the year Managers provide oversight

~ Repeat annually

~ Build the success of error reduction into NPG's 1996 goals

~ Hold all accountable

Procedure Adherence Summary

~ Key issue for DCPP and the industry

~ Si nificant DCPP resources expended to date

~ Some improvement noted

~ Changing culture from meeting intent to adherence

~ Continuing management oversight required Directors error reduction process True accountabili y

ROOT. CAUSE 53 CORRECTIVE ACTIONS Transformer failed faster than protective relays could operate

~ Evaluated transformer "withstand" capability with assistance of outside contractor

~ Transformers have low withstand capability

~ Investigating phase to phase capability

~ Withstand to single phase to ground faults appears adequate based on experience (e.g., 1R7 RCP ground)

~ Actions under review

Fire Protection

~ Corrective actions taken:

Combustibles removed from transformer area Control of combustibles in area proceduralized

~ Enhancements being evaluated

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'orrective Action Effectiveness

~ NCR on corrective action program

~ Chaired by VPs Engineering and Operations

~ Reviewed for effectiveness of corrective actions:

Post 1990 NCRs and QEs 1994 and 1995 NOV corrective actions INPO items 1R7 lessons learned

CONTRIBUTORYCAUSE gg CORRECTIVE ACTION Failure to document problems

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CONTRIBUTORYCAUSE 52 CORRECTIVE ACTION Outage work schedules

Work Schedule Impact on Transformer Event

~ Contributor to event but not a primary cause

~ Fatigue identified as contributor to one broken barrier

~ Management expectations regarding use of overtime were not met

Work Schedule Corrective Actions

~ No overtime exceeding 6 days w/o VP approval

~ Directive to plan 2R7 with a six day work schedule

~ NCR on overtime practices

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Temporary Maintenance Superwsor Qualification Guide

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Communication 8 Leadership Tailboards/coaching Procedure use 8 methods to revise procedures

~ Work Control Process Checking work qualification matrix/assigning

. work Clearances 8 tag outs Design basis configuration control

~ Implemented for 2R7

Safety Significance

Fire Protection Safety Significance

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Deluge system promptly extinguished fire

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Containment separated by 3 hr barrier

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Turbine Building separated by 2 hr barrier

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Pavement slope designed to divert spilled oil

Loss of Offsite Power Safety Si nificance

~ Outage safety plan ensured three EDGs available

~ All EDGs operated properly during event

~ Residual heat removal No appreciable temperature increase Time to boiling was approx. 100 min.

~ Spent fuel cooling Temperature increased from 92F to 112F High temperature alarm setpoint is 130F Alternate water supplies were available Fully restored within 8 hrs

Safety Significance Conclusion The health and safety of the public was not adversely affected based on fire protection response and the outage safety plan

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CONCLVSIONS

~ pGg,E performed a thorough and comprehensive investigation which self-identified root cause and contributing

~ Initial corrective actions were effective and timely

~ Comprehensive long term corrective actions

~ The health and safety of the public was not adversely affected

Corrective Actions Taken

~ Established EIT to determine root cause

~ Implemented interim and final GB controls

~ Counseled personnel involved

~ Sr. VP issued letter on event and procedure compliance

~ All hands meetings

~ Town Hall meetings

Additional Corrective Actions

~ Procedure adherence Accountability throughout the organization Director error reduction process NPG focus area for 1996

~ Evaluate hardware

~ Enhance corrective action program Review of NCRs Correct other identified process deficiencies

~ Temporary niaintenance supervisor training

~ Restrictions on overtime

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