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Insp Rept 50-312/88-41 on 881214-890103.No Violations Noted. Major Areas Inspected:Onsite Followup of Event of 881212 & Associated Mgt Meetings on 881219 & 890103.Weaknesses Observed Re Decision to Operate Plant in Degraded State
	ML20235T244
Person / Time
Site:	Rancho Seco
Issue date:	02/13/1989
From:	Dangelo T, Jensen W, Johnston G, Miller L; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:	;
Shared Package
ML20235T235	List: IR 05000312/1988041; ML20235T232;
References
	50-312-88-41, NUDOCS 8903080207
	Download: ML20235T244 (86)
	v • d • e

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REGION V

Report No :- 50-312/88-41

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' License No. OPR-54.

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' ~,' l % 1 "M 4 Et i J w.414 Inspection at: Herald, Californta (Rancho $eco Site) , .j Inspection conducted: December 14-January 3,;1989 ' 1 - 1. ! ' o !- ' # >' "l' ; ' i '; -Inspectors:- , _ __,,,,, ' ' ', * ' " ' .,,. y* f/ i' L. - F., M111er dr., Chief, RP5 II,, ; - 'iDate Signed ' ? '

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Summary:. , 's " ru ' ' - jii jf]l[ ' - ll rjp .Inspectio_n_between December 14. 1988 andJanuary3i,1989',.ji,;fT i ' ' j g.f l"' ReporE l g.

50-312/88-4U "! ,' ' . , s . . , This special. routine ins'pection involved the onsita' followup. h @ @' W yyp,ggj.;AreasInspected: pe . 12. 1988 and. associated managment meetings on e"c l ' 4 ' t " ' ' and January 3.1989. During this inspection, Inspection"d * ' Ir ? .9 t of the event of December hr,0,7,gjDecember-.19,1988bjL b., Procedures 93702 and 30702 were u I4 * d '- ' - i ' -' " ' * ' ' ' ,! > '

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i Report No : 50-312/88-41 Docket No. 50-312 License No. DPR-54 Licensee: Sacramento Municipal Utility District P. O. Box 15830 Sacramento, California 95813 Facility Name: Rancho Seco Unit 1 Inspection at: Herald, California (Rancho Seco Site) Inspection conducte - Dece 4 Ja ry 3, 1989-Inspectors: _h 2-/OM -, LA.. Mille dr' Date Signed

l'., C ief, RPS II abb9 l - ior Litense Examiner "Dhtp Signed.

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Reactor ProJTcts Section II , " -Sunrnary: ,. Inspection between December 14, 1988 and January 3, 1989 - , , < Report 50-312/88-41) r.

, Areas Inspected: This special routine inspection involved the onsite followup e of the event of December 12, 1988 and associated management meetings on December 19, 1988 and January 3, 1989. During this inspection, Inspection Procedures 93702 and 30702 were used.

Results: Observed weaknesses were the decision to attempt to operate the plant for approximately three hours with the Auxiliary Steam System in a degraded state, poor communications among senior licensee managers of plant status as the event developed, and weak operational control of the degraded Auxiliary Steam System. Observed strengths were the licensee's investigation ___

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' of the root and. contributory causes for this event, and their development of a clear " Post Restart Corrective Action Sumary" to ensure all corrective actions arising from the investigation are completed.

No violations or deviations from regulatory requirements were observed.

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.- . _ _ _ _ - _ - _ _ - _ - _ _ _ _ _ _ _ - _ - _. _ 'q r (s-e ,, DETAILS ' , , a

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Persons' Contacted i . i

' Licensee Personnel

.) J. F. Firlit, Chief Executive Officer, Nuclear J.'Vinquist, Assistant General Manager (AGM), ' Quality and Industrial Safety B..Croley, AGM, Technical Services W.-E. Kemper, Manager, Operations . . ,D. R. Keuter, AGM, Nuclear Power Production j "W. F. Peabody, Manager, Nuclear Engineering -%. S. Crunk,'. Manager, Nuclear Licensing

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.f e: y y $, ,as y t i~ .J.;B.fM rtinJRegional Administrator ? ' 41 i ' 'B. H. Faulkenberry, Deputy Regional Administrator

w A'.t E.: Chaffee.fActing Director, Division of Reactor b.

r, 4 '& _ :. c .+ D . Safety an'd Projects.

c yu .D /F. Kirsch, Chief, Reactor Safety Branch wN . '- W'1 ,? . , . Ti"D'Angelok Senior Resident-Inspector i - % 9 w7 m ! L{ F.7 Miller;Jr., Chief, Reactor Projects Section II. Ncfl mq y

e , Er v/, f#;4 Other. licensee emhloyees contacted included operators, supervisors, a Nby p.]/ < ' y tschnician.s.- . e w - _El *j i* Attended the Management Meetings on December 19, 1988 and on January 3, 1989.

e , m H,, t .2.f 10nsite Followup of Event of December 12, 1988 (93702) On December 12,.1988 at 2:33 p.m., while conducting a plant startup with the. reactor at 12 percent power,.the Rancho Seco reactor was manually

tripped by control room operators after significant feedwater flow fluctuations resulted in the automatic initiation of the Emergency-

-Feedwater Initiation and Control System. Subsequent to the trip, the H reactor coolant' system cooled'down 13 degrees F more than anticipated,- l but in other respects the~ post trip response was normal.

Id . A' description of the event chronology and an overview of some of the licensee's corrective actions were previously reported in Inspection . Report 50-312/88-40. As discussed there, the event developed after two y separate automatic control stations in series _in the auxiliary steam L system malfunctioned over a period of a few hours. Licensee management - decided to manually regulate pressure at each station using an operator f 'until'another steam supply for the main feedwater pump could be arranged.

L E The auxiliary steam supplied through these stations was the sole supply L for the 'B' main feedwater pump which was supplying feedwater to the . steam generators. A rapid decrease in steam pressure developed (probably

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as a result of uncoordinated actions between the operators manually controlling steam pressure), and feedwater flow rapidly decreased, < ' producing a rapid decrease in steam generator level. Steam generator level rapidly reached the automatic initiation setpoint for the Emergency Feedwater Initiation and Control (EFIC) System, and that system initiated.

The reactor operators tripped the plant as required upon the initiation of EFIC. Subsequent to the trip, the 'B' Once-Through Steam Generator (OTSG) continued to cooldown due to the continued steam load to the-fourth point feedwater heater. In response to this cooldown, the operators isolated auxiliary feedwater flow to the 'B' OTSG, and allowed it to empty. After the feedwater heater steam load was isolated, the cooldown stopped, and the 'B' OTSG was refilled at 50 gallons per minute.

On December 14, 1988 a four person special inspection team was assigned by Region V to review the circumstances of the event, and to ensure that the licensee's investigation of the event was adequate in scope and depth.

The team members interviewed the licensed and nonlicensed operators-involved-in the event,,the managers who had participated in the decision to continue operations after the pressure reducing station failures, and their superiors. The' Emergency Operating Procedures (E0Ps) were reviewed for clarity and compared for accuracy with the Babcock and Wilcox ,

Technical Basis Document for the E0Ps. The recorded instrumentation data was.revieked to confirm that the parametric history of the event was

, ' consistent with the scenario outlined above.

OnDle'cember 16, 1988 the team met with licensee representatives to , discuss their observations. The team concluded that: a.. The licensee, including the Operations Manager, Shift Supervisor, Operation Superintendent, Maintenance Manager, and Plant . Performance Manager, were not sufficiently cautious in plannirg the ~_ recovery from the-failure of the auxiliary steam reducing valve (PV-36014A) and the main feedwater pump steam reducing valve (PV-30702).

b.

The Operations Manager, Plant Manager, and Chief Executive Officer, Nuclear did not communicate clearly among themselves the significance of the degraded condition of the auxiliary steam system prior to the reactor trip, nor the subsequent emptying of the 'B' OTSG.

c.

Operators attempted to control the malfunctioned steam stations with inadequate communications with the control room.

The licensee acknowledged the team's observations and stated their intention to conduct a thorough and probing investigation of the event.

No violations or deviations from regulatory requirements were identified.

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Management Meetings (30702) A management meeting was conducted in Region V on December 19, 1988 (Enclosure 2). At this meeting the licensee discussed the sequence of events, an evaluation of the steam generator's operability, and the corrective actions identified to that point.

A final management meeting was conducted in Region V on January 3,1989 (Enclosure 3). At this meeting, the licensee presented its root cause investigation, post trip report, and detailed commitments for corrective action (both pre-and-post-restart) was held on January 3,1989 (Enclosure 3). The presentation was complete and addressed all NRC concerns which had been identified as well as many others identified only by the licensee. Twenty six pre-restart and 35 post-restart actions were identified. The principal SMUD commitments were: a.

Revision of the Emergency Operating Procedures to isolate unneeded steam loads after a reactor trip, to clarify " overcooling" responses for different degrees of reactor coolant system overcooling, to reduce the likelihood of unnecessarily emptying an OTSG, and to improve the guidance for refilling an empty 0TSG.

b.

Identification of the foreign material (a guide pin from valve MSS-032) which had jammed the main-feedwater pump steam supply > reduccr, PV-30702.

c.

Confirmation by the NSSS supplier, Babcock and Wilcox, that the 'B' OTSG had not been damaged by being emptied.

, d.

Improvement of communications and decisionmaking among senior managers regarding plant status, and development of a communications standard for manual control of plant equipment in high noise areas.

e.

Reevaluation of the auxiliary steam system design to improve its

reliability when failures of reducing stations occur.

The NRC representatives concluded that the licensee's investigation was consistent with the team inspection's observations and the corrective action commitments.for the December 12, 1988 auxiliary steam reactor trip event were satisfactory, No violations or diviations from regulatory requirements were identified.

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. MANAGEMENT SYSTEMS PLAN ASSESSMENT OF DECEMBER 12.-1988, RANCHO SECO SHUTDOHN Revision 1.. L.

/k ) / v - Jpj6ph &. Firl'it .

-

chief Executive Officer, Nuclear /A&&, iNr9 /Boti G. Croley / . Assistant General Mary (ger, Nuclear Technical Services b $ der / i / / '9 R. Keuter ssistant General Manager, Nuclear Power Production / /bYh?- .# J41ffes R. Shetler (ssistant General Manager, Nuclear Support Services '~ ..,, n.i t - t - 89 l John)V. Vinquistu m.

Director. Quality & Industrial Safety ,

, , - . Y' }. . ? . _ _ _ _. ___________._.__.______m____._______m-

.. ,. . _ __ _ -___ _ __ _ _ ______-__-_ - _ - _- _ - ___ _ - _ _ -. o; .a.

PURPOSE - The. purpose'of this report is $o identify and' summarize the actions being' ' taken to address the management concerns,resulting from the December 12, 1988, Rancho Seco plant shutdown.

This Management Systems Plan will also serve as.a

guide for the programmatic improvements currently being implemented by the Rancho Seco organization. Attachment 1 to this document identifies, by name, those individuals responsible for carrying out these important management systems' enhancements.

, SCOPE The December 12, 1988, plant shutdown at Rancho Seco led the CEO-Nuclear.to critically review the~in-place management controls and/or management systems relative to their effectiveness during routine day-to-day' operations-and off-normal plant events.

A~ number of in-depth reviews were conducted as a means of identifying the management components in'need of strengthening.

Internal reports completed include the Operations Trip Report and the~ Root Cause Analysis. Additionally, the CEO-Nuclear conducted personal interviews.

with Operation Shift Supervisors and. Operations Department Superintendents.

Over and above the internal reviews, several outside independent assessments were conducted, including: o Management' Control System Reviews, conducted by Dan Whitney (Chairman of the Rancho Seco Management Safety Review Connittee) o Ins' titute of Nuclear Power Ooerations Review, conducted by an evaluation team the week of December 12, 1988.

o Nuclear Advisory Committee (NAC) Review, conducted by members of the 'NAC and other independent advisors to address the leadership issues'. I'

. ' , h h ' ~ , . ' > _ _ _. _ _ _. _ _ _ _ _. _ _ _ _. _ _ _ _ _

- _ _ _ _ _ - .-- t .o ' ' METHODOLOGY Due to thi nature o'f the plant shutdown, th'e initia1' management system reviews- ' involved interviews. conducted with Department Managers, Operations Supervisors, and plant personnel who we.re directly involved in the decision > -making process' surrounding the event.

Participants in the initial assessments-t also independently reviewed'the Operations Trip Report and draft-Root Cause ! . Reports ~during the " fact finding" phases'. ' . ' - A; number of key concerns were addressed as a means of leading to a clear ~ understanding'of.the issues surrounding this shutdown.

o o LEADERSHIE: Determine the effectiveness of organizational Lleadership through the establishing and communications of performance expectations and standards by Senior ~ Management.. o -COMMUNICATIONS: Determine what processes.and procedures are in place to govern management notification, and awareness of plant operating status and' equipment condition.

Determine the timeliness and quality of information provided from on-shift Operations _ personnel to plant and Senior Management during the course of the event.

o DECISION MAKING: Determine the effectiveness of the problem solving process relative to how complex, off-normal plant situations are managed and. resolved.

,

L - . A .. ) -2- + Jc,

9 . -

- _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _____ ________ _______ _-_-_ _________ __ __- _ ____________________ - ___-__- _______ CONCLUSIONS 1.

In addressing the " leadership" issue, it is clear that the CEO, Nuclear is relying upon Senior Management (Assistant General Hanagers and Director, Nuclear Quality) to implement his published performance standards and expectations down through the chain of command.

With the establishment of Rancho-Seco goals, objectives, and performance indicators, the mechanism for holding Senior Mangaement and Department Managers accountable for work < performance is in-place. All levels of mangagement must continue to provide leadership by example in response to degrading performance trends, l including those that correlate to potentially degraded plant conditions.

l All levels of manaaement are held accountable for orovidina strong leadershio that results in solid work performance.

Through discussions with staff and Operations personnel, it is clear that the Rancho Seco priorities of Safety / Quality / Schedule are understood and have been adopted.

2.

In addressing the " communications" issue, as it pertains to the specific ' shutdown, upward communication of plant problems and status changes were not provided on a timely and thorough basis.

The CEO, Nuclear, was not aware that an OTSG had boiled dry until so informed by the NRC.

In addition, although some plant status information relating to the two steam pressure regulators had been passed to the AGH, Nuclear Power Production, its correlation and potential significance had not been communicated to , him and in turn to the CEO, Nuclear.

, 3.

In addressing the " decision making" issue, it was determined that a decision making process was consciously applied during the event.

However, all alternatives were not considered.

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-ir ~ Attachment 11 < . MANAGEMENT SYSTEMS PLAN' lIn. response to the~ December 12. 1988, Reactor Shutdown and subsequent self ' aissessment, the.~following specific actions have been initiated in the ' Management; Systems area: , 1. - LEADERSHIP.

. Action- . ' Action Due-Items-Task By; Date ! . 1.01 Develop, implement and' communicate. Firlit '01/31/89 a Nuclear Policy reestablishing CEO. Nuclear expectations:in the areas of Safety / Quality / Schedule.

This policy will also address leadership, communications and the decision ' making process.

1.02 Establish lessons learned, meetings .Keuter-01/31/89 .. with appropriate personnel.

1.03 Initiate a formal Senior Management .Shetler 01/31/89 monthly review process for key ' indicators and performance trends.

- 1.04 Review the organization structure to Shetler 01/15/89-determine if.there is a need for Assistant Positions'for the CEO, Nuclear and.the AGMs.- - 1.05 Identify, prioritize and streamline - Shetler < ongoing . processes.. 1.06 Reestablish the performance Keuter/Croley 01/31/89 expectations-for management- -of the following groups: Maintenance ' Operations 4 - System Engineering Engineering .. -1- ,. ..,

_-_ ________- ____ - - ___ a .

_ _ _ _ _ _ _ _ _ _ _ _ 2. -COMMUNICATIONS

Action Action Due " ' Items-Task.

By Date '2.01 . Review appropriate procedures'and Shetler-01/31/89 program to assure Senior Management involvement ~in' transitional or complex situations.

NOTE:- Formal notification procedure OAP-0064 has been revised.

2.02' Conduct CEO, Nuclear meetings with Firlit Complete shift operating crews.

3.

DECISION MAKING Action Action Due . Items Task' By Date 3.01 Complete revision, review / approval, .Shetler 01/31/89 , training, and implementation _of AP.28, Post Trip Assessment and Coordination.

3.02 Conduct CEO, Nuclear meetings with Firlit Complete Operations Shift Supervisors.

3,03 Evaluate ' Red Flag' program at SONGS Yelliott 03/30/89 for applicability at Rancho Seco.

3.04 Establish a program for training Shetler 03/01/89 in formal decision making.

3.05 Assura Senior Management involvement Shetler 02/28/89 directly in the review / approval process for.significant evolutions.

., ~2- , f e 9' _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ }}

v t e Inspection Report - Rancho Seco - 1988041
80 \| 81 \| 82 \| 83 \| 84 \| 85 \| 86 \| 87 \| 88 \| 89 \| 90 \| 91 \| 92 \| 93 \| 94 \| 95 \| 96 \| 97 \| 98 \| 99 00 \| 01 \| 02 \| 03 \| 04 \| 05 \| 06 \| 07 \| 08 \| 09 \| 10 \| 11 \| 12 \| 13 \| 14 \| 15 \| 16 \| 17 \| 18 \| 19 \| 20 \| 21 \| 22 \| 23 \| 24 \| 25 \|
1988 Quarterly Integrated 1Q (0) 2Q (0) 3Q (0) 4Q (0) Assessments Mid Cycle End of Cycle 7(0) 8(0) 9(0) 11(0) 12(0) 13(0) 14(0) 15(0) 16(0) 17(0) 19(0) 20(0) 21(0) 22(0) 23(0) 24(0) 25(0) 26(0) 27(0) 30(0) 32(0) 33(0) 35(0) 39(0) 40(0) 41(0) 42(0) Security Operator Exams Emergency Planning Other

IR 05000312/1988041

Text

REGION V

REGION V

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