IR 05000285/1993012
| ML20057C517 | |
| Person / Time | |
|---|---|
| Site: | Fort Calhoun  |
| Issue date: | 09/15/1993 |
| From: | Beach A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | Tira Patterson OMAHA PUBLIC POWER DISTRICT |
| References | |
| NUDOCS 9309290061 | |
| Download: ML20057C517 (4) | |
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REGION IV
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SEP 151993
Docket:
50-285 License:
DPR-40 Omaha Public Power District ATTN:
T. L. Patterson, Division Manager Nuclear Operations Fort Calhoun Station FC-2-4 Adm.
P.O. Box 399, Hwy. 75 - North of Fort Calhoun Fort Calhoun, Nebraska 68023-0399 SUBJECT: NRC INSPECTION REPORT N0. 50-285/93-12
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Thank you for your letter of September 3,1993, in response to our letter and Notice of Violation dated August 4, 1993. We have reviewed your reply and find it responsive to the concerns raised in our Notice of Violation. We will review the implementation of your corrective actions during a future inspection to determine that full compliance has been achieved and will be maintained.
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Sincerely,
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A. Bill Beach, Dir ctor Division of Rea t r P/o'ects cc:
LeBoeuf, Lamb, Leiby & MacRae ATTN: Mr. Michael F. McBride 1875 Connecticut Avenue, NW Washington, D.C.
20009-5728 Washington County Board of Supervisors ATTN: Jack Jensen, Chairman Blair, Nebraska 68008
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ATTN:
Charles B. Brinkman, Manager Washington Nuclear Operations 12300 Twinbrook Parkway, Suite 330 Rockville, Maryland 20852
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Nebraska Department of Health ATTN: Harold Borchert, Director
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Division of Radiological Health 301 Centennial Mall, South l
P.O. Box 95007 Lincoln, Nebraska 68509-5007
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Fort Calhoun Station ATTN: James W. Chase, Manager P.O. Box 399 Fort Calhoun, Nebraska 68023
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September 3,1993 Omaha. Nebraska 68102-2247 402/636-2000 LIC-93-0231 U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Mail Station PI-137 Washington, DC 20555 References: 1.
Docket No. 50-285 2.
Letter from NRC (A. B. Beach) to OPPD (T. L. Patterson) dated August 4, 1993 Gentlemen:
SUBJECT:
NRC Inspection Report No. 50-285/93-12 Reply to a Notice of Violation (NOV)
The subject report transmitted a NOV resulting from an NRC inspection conducted June 24 through July 16, 1993 at the Fort Calhoun Station. Attached is the Omaha Public Power District (OPPD) response to this NOV.
OPPD is concerned about the significance of this event and has completed a comprehensive Root Cause Analysis and a Human Performance Enhancement System evaluation to fully understand the implications of this event. The corrective actions taken in response to this event should prevent its recurrence.
If you should have any questions, please contact. me.
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Sincerely, p./1. h WP-T W. G. Gates Vice President
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WGG/grc Attachment c:
LeBoeuf, Lamb, Leiby & MacRae J. L. Milhoan, NRC Regional Administrator, Region IV S. D. Bloom, NRC Project Manager R. P. Mullikin, NRC Senior Resident Inspector
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Attachment LIC-93-0231 Page 1 REPLY TO A NOTICE OF VIOLATION During an NRC inspection conducted on June 24 through July 16, 1993, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, the violations are listed below:
A.
10 CFR Part 50, Appendix B, Criterion V, and the Fort Calhoun Quality Assurance Plan, Revision 3, Section 2.1, Paragraph 4.2.1, state, in part, that activities affecting quality shall be prescribed by documented instructions or procedures and shall be accomplished in accordance with these instructions or procedures.
Nuclear Operations Division Quality Procedure N0D-QP-36, " Control of Switchyard Activities at Fort Calhoun Station," Section 7.1.1, states, in part, that to schedule work activities in the Fort Calhoun Station switchyard, the Production Operations Division system operator and plant shift supervisor shall be contacted to determine plant conditions and whether the proposed scheduled work activities can be adequately accomplished.
Contrary to the above, on June 24, 1993, two different work crews were performing work in the switchyard and the Production Operations Division system operator was not informed on either activity.
In addition, the shift supervisor was informed of only one activity.
B.
Standing Order 50-0-1, " Conduct of Operations," Section 10.1.3.E(19)
states, in part, that log entries into the official control room log shall be made to document access for all Fort Calhoun Station switchyard activities pursuant to Procedure N0D-QP-36.
Contrary to the above, on June 24, 1993, two different work crews accessed the switchyard and only one access was entered into the control room log.
C.
Standing Order 50-0-20, " Equipment Tagging Procedure," Section 3, states, in part, that personnel requesting the tagout, personnel constructing the tagout sheet, personnel involved in implementing the tagout, and the personnel involved in performing the maintenance activity, all have the responsibility to verify that the component tagout is adequate to ensure that it is safe for maintenance to proceed.
Contrary to the above, on June 27, 1993, the equipment tagout for Feedwater Heater FW-15A was inadequate and unsafe due to the failure to isolate the extraction steam supply to the heater while replacing a relief valve on the condensate side. This failure to isolate steam resulted in the condensate, which was left in the heater, turning into steam and blowing out of the relief valve's open connection.
This is a Severity Level IV violation. (Supplement I) (285/9312-01)
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Attachment i
LIC-93-0231 Page 2 Note:
Violation 285/9312-01 consists of three parts; A, B and C.
Since the subject matter of Parts A and B were related, Omaha Public Power District (0 PPD)
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addressed them together. The response to this violation addresses Part C l
separately from Parts A and B.
i OPPD RESPONSE TO PARTS A AND B P
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The Reason for the Violations
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experienced a reactor trip i
On June 24, 1993, Fort Calhoun Station (FCS)bine trip was caused by 0 PPD due to a loss-of-load turbine trip. The tur
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Electric Operations Division personnel (non-plant) working. in the FCS switchyard.
In response to this event, OPPD completed a comprehensive l
(RCA and a Human Performance Enhancement System
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Based)on the investigations performed in response to Root Cause Analysis (HPES) evaluation.
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this event, OPPD determined that Parts A and B of the violation resulted
from an inadequate implementation of N00-QP-36, " Control of Switchyard Activities at Fort Calhoun Station."
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Additionally, two contributing causes to these violations have been
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identified:
1) inadequate communications between the Control Room and
Electric Operations Division personnel, and 2 lack of a formal decision l
making process for determining risk associated)with switchyard activities.
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2.
Corrective Steps That Have Been Taken and the Results Achieved On June 28, 1993, the Supervisor - Operations issued a memorandum to all
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Operations personnel highlighting the need to evaluate risks associated '
with switchyard work and emphasizing the requirements of Procedure N0D-QP-t 36.
On-shift training on Procedure N00-QP-36 was provided to all
Operating Crews.
j On June 28, 1993 Electric Operations Division management completed
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briefing appropriate personnel on the requirements of N0D-QP-36. On July 8,1993, the Section Manager - Electric Operations issued a memorandum
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which highlighted management expectations related to switchyard access and
the control of work.
The purpose of the memorandum was to augment the existing N00-QP-36 until it was revised.
Procedure N0D-QP-36 has been revised to better define the type of work
that can be completed on-line and to clarify the type of work that has a
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high risk of affecting plant operations.
As required by the revised l
procedure, the Duty Supervisor will make daily tours of the switchyard i
(Monday through Friday) when activities are occurring. Additionally, the i
revision has enhanced and formalized the communication and work planning / review process between the two divisions.
A checklist now assists personnel in assessing the work scope and associated risks along
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with assuring that switchyard issues are properly addressed.
As an interim measure a required reading " Hotline" has been issued to various groups and selected individuals within FCS and selected Electric
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Operations Division personnel that are affected by the change.
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Attachment LIC-93-0231 Page 3 Corrective Steps That Have Been Taken and the Results Achieved (Cont'd)
After this incident, the switchyard entry gates were chained and locked to ensure positive control over switchyard activities.
Security maintains possession of the keys for entry with Operations maintaining responsibility for authorizing access.
Pre-planned " Switchyard Activities" are now included on the Fort Calhoun Plan-Of-The-Day and indicate whether they have been approved Station (FCS)lan-Of-The-Day items are discussed at the morning planning for work.
P meeting. This will further heighten awareness of switchyard activities by station personnel.
On August 3,1993, the Supervisor - Operations issued a memorandum to all Licensed Personnel outlining management expectations for documenting access for all FCS switchyard activities pursuant to N00-QP-36 and Standing Order 0-1.
have been Procedure N00-QP-36 and Standing Order 0-1 (Step 10.1.3.E(19)) This will included in the Quality Assurance Audit / Surveillance Program.
provide a mechanism to verify that switchyard activities are logged in the Control Room.
3.
Corrective Steps That Will Be Taken to Avoid Further Violations 1.
A key card reader, with an associated alarm, has been installed to restrict entry into the switchyard.
The system will not be placed into service until affected Electric Operations Division personnel have been trained on the revised N00-QP-36. This will be completed by September 15, 1993.
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A training program has been established for Electric Operations
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Division and other applicable personnel on the requirements of Procedure N00-QP-36. Key card access will not be authorized for an individual until the individual has completed this training.
This will be completed by September 15, 1993.
3.
A training program will be established for FCS Operations personnel on switchyard equipment and relaying.
This will enhance their ability to evaluate risks associated with switchyard activities.
The program will be developed by September 15, 1993. The training will be completed by November 15, 1993.
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Date When Full Compliance Will Be Achieved 0 PPD is presently in full compliance based on the completed actions listed abov.
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Attachment LIC-93-0231 Page 4 OPPD RESPONSE TO PART C 1.
The Reason for the Violation OPPD completed a comprehensive RCA of the tag-out of FW-15A and the failure to isolate the extraction steam supply. OPPD determined that this incident resulted from personnel oversight. The individual preparing the tag-out did not anticipate the impact bringing steam on-line would have on the isolated feedwater heaters.
In the past, operations personnel have performed work on FW-15A while on-line with extraction steam cut in with
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no problems since any residual moisture had already boiled off.
The introduction of extraction steam into the partially drained heaters resulted in a phenomena that had not been experienced before.
Additionally, two contributing causes to this incident were identified:
1) the lack of hold-points, within applicable procedures, requiring review of existing tag-outs for adequacy prior to making significant plant condition changes, and 2) the lack of a guideline document which could be referenced during tag-out preparation.
2.
Corrective Steps That Have Been Taken and the Results Achieved The Manager - FCS issued a memorandum to plant personnel emphasizing management expectations with respect to equipment tagging. Areas stressed included accountability, safety, proper communications and attention to detail.
A Senior Reactor Operator has been dedicated to tagging of equipment.
This individual will have lead responsibility for resolving tagging issues and review of previously prepared tag-outs.
In the process of tag-out preparation, this individual will interface with maintenance to gain a better understanding of the work to be performed.
This assignment will enhance consistency in the preparation of tag-outs.
Station Tagging Procedure Standing Order 0-20 has been reviewed and revised. In addition to the changes, the procedure was renamed G-20A. As opposed to being labeled an Operations procedure, the "G" signifies that it is a plant procedure. Therefore, plant personnel other than Operations are also responsible for ensuring that when tagging is undertaken, it is successfully completed.
Other areas enhanced included clearly defining department responsibilities and accountabilities; formalizing the verification process performed by both Operations and the Crafts; establishes the qualified requestor which ensures that personnel requesting a tag-out are trained on the process and ahilosophy of the tagging procedure; clarifying guidance associated witi removing danger tagged components from systems; and limiting / restricting the use of temporary and testing clearances.
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Attachment LIC-93-0231 Page 5 3.
Corrective Steos That Will Be Taken to Avoid Further Violations 1.
Power / Mode ascension procedures will be revised to require a review of tag-outs for adequacy prior to planned power changes and significant plant condition / equipment changes.
This will be completed by September 25, 1993.
2.
Appropriate procedures will be revised to require plant-wide announcements prior to making significant plant changes that could affect workers in the field.
This will be completed by September 25, 1993.
3.
Training for personnel tasked with tag-out preparation will be revised to emphasize protection of personnel and equipment safety.
This training will be completed by September 25, 1993.
4.
The FCS Training Department will develop and administer training for
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maintenance personnel that will emphasize adequate tag-out boundary be developed and training 25,1993.g will This trainin identification.
provided by September 5.
A dedicated work area for tag-out preparation / review will be established to help facilitate safe effective equipment tagging.
This will by completed by September 25, 1993.
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A tag-out preparation guideline or checklist will be developed for reference during tag-out preparation.
This will help ensure that various plant configurations are considered prior to generating the tag-out. This will be completed by September 25, 1993.
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Practical factors training on the revised Standing Order G-20A will
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be completed by November 15, 1993.
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Date When Full Compliance Will Be Achieved OPPD is presently in full compliance based on the completed actions listed above.
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