IR 05000320/1988009

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-320/88-09

ML20207M255
Person / Time
Site:	Three Mile Island
Issue date:	10/06/1988
From:	Bellamy R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Standerfer F GENERAL PUBLIC UTILITIES CORP.
References
NUDOCS 8810180198
Download: ML20207M255 (2)

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OCT 0 61983 Docket No. 50-320 GPU Nuclear Corporatic ,

ATTN: Mr. F. Standerft c Director of TMI-2 P. O. Box 480 Middletown, Pennsylvania 17057 Gentlemen:

Subject: Inspection No. 50-320/88-09

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This refers to your letter dated August 5,1988, in response to our letter dated July 8, 1988.

Thank you for informing us of the corrective and preventive actions documented iti your letter. These actions will be examined during a future inspection of your iicensed program.

Your cooperation with us is appreciated.

Sincerely,

.a Ty:

gl. L 1: ;J/

Ronald R. Bellamy, Chief Facilities Radiological Safety and Safeguards Branch cc w/ encl:

T. F. Demmitt, Deputy Director, TMI-2 R. E. Rogan, Licensing and Nuclear Safety Director J. J. Byrne, Manager, THI-2 Licensing S. Levin, Defueling Director J. B. Lieberman, Esquire A. Miller, Manager, Plant Operations Ernest L. Blake, Jr. , Esquire G. A. Kuehn, TMI-2 Operations Director TMI-Alert (TMIA)

Susquehanna Valley Alliance (SVA)

Public Document Room (PDR)

local Public Documtet Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector Commonwealth of Pennsylvania 0FFICIAL RECORD COPY RL TMI2 - 0001.0.0 .. ,

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0310180198 881006 2 U88 PDR ADOCK 050003:0 r P],

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GPU Nuclear Corporation 2 OCT 0 61988 bec w/ encl:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

DRP Section Chief S. Lewis, OGC Michael Masnik, PM, THI-2 Robert J. Bores, DRSS l I l I l

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SS R!:0RSS RI:0RSS g

RI:DRSS Sherbini Shanbafy Bellamy

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09////88 09/23/88 Q(#/S/88 0FFICiAL RECORD COPY RI. THI2 - 0002.0.0 09/21/88

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GPU Nuclear Corporation g g7 Post Of fice Box 480 Route 441 South Middletown, Pennsylvania 17057 0191 717 944 7621 TELEX 84 2386 Writer's Direct Olal Number:

(717) 948-8461 August 5 ,1988 l 4410-88-L-0125/0407P 1'

l US Nuclear Regulatory Comission Attn: Document Control Desk ..

t:asnington, DC 20555

Dear Sirs:

inree Mile Island Nuclear Station, Unit 2 (TMI-2)

) Operating License No. OPR-73 l l Docket No. 50-320 Inspection Report 88-09 The subjes 'nspection Report identified two (2) violations: 1) a violation of 10 CFR Dl(b) as a result of initiation of work in a radiologically controlled , .a witrout the appropriate radiation survey; and 2) a violation of a reauirenent of THI-2 Special Operating Procedure 4730-3255-88-R670 resulting in an accidental personnel contamination. Pursuant to the l provisions of 10 CFR 2.201, the attactrent provides the GPU Nuclear response to the NRC Notice of Violation.

In addition, the NRC letter forwarding Inspection Report 88-09 noted a concern tith GPU Nuclear's management control system for assuring adherence to l procedures. The corrective ae:tions taken to impruve performance in *.his area are also discussed in the attactment.

Finally, Sections 2.1 and 2.2 of Inspection Report 88-09 expressed a conccm  ;

cith the root cause de'.eMnation process applied by GPU Nuclear and its

efrectiveness; r 4 - ,.

!s also addressed in the attactment.

Sincerely,

/s/ T. F. Demmitt for F. R. Standerfer Director, THI-2 h~ ~~ ~ ,

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AttactTrents , C6~~

ec: Senior.Repet Insrector, TM1.- R. J. Conte l f Ragtesak Ameseetretw.Heg& css.1 ..Wv T. Russell Director, Plant Directorate IV - J. F. Stolz Systems Ergineer, THI Site - L. H. Thonus GPU Nudear Corporation is a subsidiary of the General Public Utilltles Corperation

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APPENDIX B

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4410-88-L-0125 Page 1 of 1 P W1 Nuclear Memorandum Sub;e:t PROCEDURE COMP 1.IANCE Date July 27, 1988 From Director, TMI-2 - F. R. Standerfer Lccation. THI-2 4000-S8-5-213 To All Personnel Working at 7EI-2 .

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In previous cessages I have informed you of the requirement to strictly adhere to procedures while perforcing work at TMI-2. The CPU Nuclear Corporate Policy 1 on procedures states in part:

"It is the policy of the CPU System to operate and maintain its nuclear plants in accordance with written approved procedures i formally issued f or use." l

"Co=p1hnce with this policy is an essential ele =ent of management whi:- assures that this co pany has the needed control of operations and is able to de=onstrate it. Every violation harms the co=pany."

There are three key points management would like to impart to each e=ployee at TM1-2. These points are:

1. Strict procedural co=pliance 1.; an integral part of every job. Employees and their managers are responsible to know or learn which procedures apply t.o their job and to f ollow them. Other pressures, such as schedules and budgetse are not justif ication f or noncompliance.

2. CPUN management understands that once work is etarted, taking action to chanse an incorrect procedure bef ore continuing with work can cause delays in a particular task. Focused attention is needed to help ensore that procedures are correct before a job is started--known problems or deficien-cies should be fixed in advance. However, if a procedure deficiency is found during a job, work shculd be stopped while needed changes are made.

Avoiding delay is not at. exr.use for f ailing to comply with procedure require =ents. Such delays must be accepted. It is manage =ent 's posit ion that taking time to correct procedures will, in the long run, have a beneficial impact on performance, schedules, and budgets.

3. Ynowing or negligent noncompliance with procedures <C1 result it.

,; progressive disciplinary actiocs.

-.* Please incorporate procedural coegiance into your workday activities.

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ATTACHMENT 4410-88-L-0125 A. NOTICE OF VIOLATION 10 CFR 20,201(b) reouires that each licensee make such surveys as may be necessary to comply with all sections cf Part 20. A defined in 10 CFR 20,201(b), "survey" means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presence of radioactive materials or other sources of radiation urder a specific set of conditions.

Contrary to the above, on April 4,1988, grinding of the highly contaminated block wall in the basement of the reactor building was started without performing an assessrrent of the effects of that process on the level of airborne activity in the contairrnent building.

This is a Severity Level IV violation.

GP'J NUCLEAR RESPONSE '

GPU Nuclear concurs in this finding as presented in the Notice of Violation.

The THI-2 Incident / Event Report (IER 88-023) stated that the cause of the event was "pomer grinding on the Reactor Building basement block wall without adecuate control of airborne radioactivity generated by this activity. Job planning and communication were contributi% causes.d Power grinding was used because other methods to cut /Dunch a hole in the block wall proved unsatisfactory. Attempts to contact the cognizant Radiological Engineer respensible for the ALARA review, as requested by Radiological Controls Field Operations, to obtain concurrence to proceed with this alternate activity were unsuccessful. Decontamination Operations determinM that neither the Unit Work Instruction, i.e. , UNI D-631, nor the existing ALARA review prohibited use of the grinoer on the block wall and that such activity was within the scope and intent of the UWI. When grinding was initiated, airborne activity levels in the Reactor Building increased significantly and resulted in three (3) individuals being exposed to airoome activity in excess of 5 WC-hrs.

The personnel were removed from the Reactor Building and bioassayed. Prior to resuming work, discussions were held between Radiological Controls and Decontamination Operations personnel and it was agreed that the ALARA review should be revised to reouire Radiological Controls notification if the specific alternative course of action was not bounded by the current review, art to reovire a pre-job briefing by Radiolcgical Controls Field Operations before the commencement of any additional work on the block wall. Using a mockup, drilling was determined to be the preferred method; the holes in the block wall were successfully drilled without further incident by June 2,1988.

Additional review of this incident resulted in the conclusion that the following root causes led to the event:

1. Inadeouate procedure: Step 180 of the UWI was ambiguous with regard to limits imposed on the use of alternate tools and courses of action.

2. Inadeouate ALARA review: The review was based on an understarding that use of the "air hanrner" was intended based on satisfactory mock-up !

performa/ce. The review failed to note the limited scope of applicability and did not address the opportunity irtplicit in the UWI to use altemate tools which could result in markadly different radiological conditions.

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ATTACH)ENT 4410-88-L-0129 3. A determination by the cognizant supervisor to proceed under the

"loophole" provided by UWI Step 180, notwithstanding the caution by Radiological Conf.rols Field Operationr.to discuss the applicability of the existing ALARA review with the cognizant Radiological Engineer, coupled with an apparent disregard of the "intent" of the UWI (i.e., to punch holes in the block wall with an air hammer).

1 Elimination of any one of the above noted root causes would have resulted in j

precluding this occurrence.

i Long-tem corrective actions to prevent recurrence were to counsel the responsible Decontamination Operations Supervisor for failing to perfom the task in a manner consistent with the intent of the UWI and radiological assessment and for failing to communicate effectively with the Radiological Controls r>ersonnel. Further, all of the Decontamination Operations Supervisors were counselled concerning the need to recognize and comply with '

the intent of procedures and the imortance of analyzing work operations before proceeding with alternative courses of action, out-of-secuence events, or urplanned steps to ensure proposed work is bc.unded by the existing AuARA review. The Radiological Engineers were sensitized to ils situation via a memorardin that emphasized the need for specificity in procedures and ALARA i reviews to avoid ambiguity concerning applicability.

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Further actions to prevent recurrence include a memorandum to all UWI writers, i

t task leaders, and engineers stressing the need for appropriate specificity in defining tasks es a means of enhancing procedure compliance and highlighting i

the importance of definition of work scope during planning and adequate i consideration of the impact of a work scope change on personnel and l radiological conditions. A formal meeting will be arranged for the Site l Operations Director to discuss the recent incidents with Decontamination personnel and to eftphasize the need for Radiological Controls approval before

! changing methods of operation. Finally, the Radiological Controls Field i

Operations technicians will be instructed to be clear in consnunicating "stop cork" orders.

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Full compliance is expected to be achieved through the above corrective l actions by mid-August 1988.

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i B. MC NOTICE OF VIOLATION

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Vechnical Specification 6.8, "Procedures," reouires, in part, that procedures i be established, implemented, and maintained for Recovery Operations and l Radiation Protection Plan iglementation.

l Procedure 50P 4730-3255-88-R670 states, in part, that all personnel shall be i

tied of f wnen working adjacent to any unguarded opening in the Shielded Work j Platform over the reactor vessel in the Unit 2 containnent building.

j Contrary to the above, on May 23, 1988, a worker worked on the Shielded Work

Platform at an unguarded opening in the platform without being tied off and

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fell into the Reactor Vessel.

This is a Severity Level IV violation. '

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l ATTACHPENT 4410-88-L-0125 l l GPU N'JCLEAR . RESPONSE

, GPU Nuclear concurs in this finding as presented in the Notice of Violation.

The root cause of this event was a charge of job scope without adequate pre-planning. Specifically, the relocation of long-handled tools was

undertaken during a lull in planned activities. This resulted in the individual working in proximity to an unguarded , open slot in the work platform without a safety line attached. The inrnediate corrective action was to extricate the individual from the Reactor Vessel, escort him from the

Reactor Building, and decontaminate the affected portions of his body. A contributing factor in this event was the absence or a temporary plywood fall protection device (i.e., cover) designeo for this specific opening in the

clatform. The cover had been removed from the building during past

hf,asekeeping efforts. Another temporary plywood plug was fabricated and is I 3dily available under the South platform. ,

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Long term corrective actions to prevent recurrence include the following:

1. fhe Manager of Defueling Support has issued a memorandm to all Defueling Support personnel snecifically prohibiting anyone from working on the Shielded Work Platform without being tied off, when any shield plugs are removed.

2. Defueling Support Supervisors have been counselled concerning the need to

', explicitly follow procedures with particular emphasis to be directed to personnel safety issues. Further, they have been enjoined by memorands to think work operations through carefully before proceeding with out-of-secuence or unplanned events.

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3. Briefings have been conducted for entry personnel concerning proper

, technioues for rescue of persons f rom the Reactor Vessel in the unlikely

event that a worker should fall between the rails of the slots on the j Shielded Work Platform.

Full compliance has been achieved through the above corrective actions.

C. NRC CONCERN

! Tne Inspection Report 88-09 cover letter noted: "We are concerned about your I management control system that allowed frecuent incidents to occur that were

) caused at least in part by lack of adherence to procedures."

l GPU NUCLEAR RESPONSE GPU Nuclear acknowledges that procedural adnerence is an essential element of

safe and successful nuclear power plant operations, regardless of plant i

operating mode. To that end, GPU Nuclear management has repeatedly stressed j the importance of procedural compliance (Appendices A and B). The TMI-2 Safety Review Group (SRG) conducts incident / event report trend analyses as

, part of its function. The 1987 analysis, completed in February 1988, i identified personnel error as the most frecuent root cause. Further special trend analyses conducted by SRG indicated tnat procedure non-conpliance and procedural inadecuacies were primary contributing factors not only in the iso?

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ATTACHMENT 4410-88-L-0125 events, but ir. the events occurring in the first half of 1988 as well. To address this situation, the Director of THI-2 held briefings for all managers '

and supervisors (11 briefings involving 191 of 192 designated personnel during Jane 30-July 19, 1988), discussed the problem with the management of our DIlmary craf t subcontractors (July 5,1988), directed that a Human Performarce Evaluation System (HPES) Qualified person assist in future IER critioves as a facilitator in the root cause analysis, as appropriate, and issued a

"Procedure Compliance" memorandum to all personnel working at THI-2. A program to simplify TMI-2 procedures, enha ce safety, and reduce personnel error is currently under development.  !

l THI-2 management is emphasiring three (3) key points: l I

1. Strict procedural compliance shall be a part of every job, 2. Focused attention is needed to help ensure that procedures are correct before a job is started (i.e., known problems or deficiencies should be )

fixed in advarce). If a procedure deficiency is fourd during a joo, work I should be stoppec while needed changes are made; and l 3. Knowing or negligent noncompliance with procedures will resulc in j progressive disciplinary actions.

GPU Nuclear believes that these measures are sufficient to reverse this personnel error trend. Horever, as GPU Nuclear management continues to monitor plant activities, we will consider additional measures ard take apprc7tiate action, as appropriate.

D. NRC CONCG N Section 2.1 of tne Insoection Report concernin;, the block wall event noted,

"The licensee's critique focused on two items as the rost cause for the incident: poor job planning and cormiunications, and higher than anticipated airborne radioactivity as a result of grinding. A review of the above data indicated that the critioJe was less than adeouate. It did not address the important lapses in the proper procedure to perform jobs on site. These lapses included: change in job Scope that was contrary to the UWI and invalidated the ALARA reviewt failure to notify the cognizant radiological cngineer of change; and failure to notify radiological controls prior to starting the job. The critioue's conclusion that the incident was caused by higher than anticipated airborne radioactivity was misleading and inappropriate since it is not a root cause; rather it is the result of a series of f ailures that are themselves the root cause's of the incident. The critique was conducted by the field operations supervisor who was in charge of the cutting operation at the time of the incident. This practice was poor because it may cause a bias in the analysis of causes arc may produce inappropriate conclusions, as it did in this instance. This scakness in identifying root causes of incidents during criticaes had been identified in previous NRC inspections, and will be reviewed during future inspections."

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AT'ACHMENT 4410-88-L-0125 Section 2.2 of the Inspection Report concerning the individual that fell into the Reactor Vessel states, "Tne criticue that was held to analyze tne incident did not consider any procedural violations but concentrated on providing a temporary plug for future use and on training personnel on rescue operations of future falls in the vessel. This weakness in arriving at root causes of incidents and not considering the problem of procedural violations is a recurring problem at THI-l and THI-2 (see paragraph 2 of this report). This area will be reviewed during future inspections."

GPU NUCt. EAR RESPONSE The purposes of the THI-2 critique program are to gather infomation regarcing the incident, allow attendees (including management and safety review j personnel) to ask ouestions of the personnel involved in the incident, direct 1 further infomation gathering, propose long-term corrective actions, and j assist in a preliminary root cause determination. An SRG engineer is assigned to further investigate the event, arrive at the final root cause based on all available input and proven root cause analysis technioues, and determine ccrrective/prevsntive actions.

C:e recognize the NRC concern regarding the leadership of the crit toue. THI-2 is in the process of adopting HDES technioues. A dedicated individual,

! currently undergoing formal FPES training, will assist in future THI-2 criticues and root cause analyses. However, the existing THI-2 Administrative Procedure 4000-ADM-J020.01, "THI-2 Incident / Event Repolts," states that the

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appropriate Section Manager shall promptly hold a critique to determine l

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corrective action. This procedure also states that the assigned SRG Engineer shall perform additional critiques, interviews, observations, and field trips I as necessary to co W ete the Incident / Event Report. GPU Nuclear believes that i reaviring the appropriate Section Manager to conduct the initial critiave is

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necessary to ensure that manegemen'. personnel having direct experience, authority, and responsibility are available and participate in the immediate fact finding. GPU Nuclear recognjzes that this procedure is in conflict with the Human Performance Evaluation System recommendations and is currently evaluating wnether a revision to the above Administrative Procedure is necessary.

The SRG-determined cause of the block wall event, i.e. , higher than normal airborne radiation levels in the Reactor Building, was "power grinding on the Reactor Building block wall wittout adequate control of airborne radioactivity generated by this activity. Job planning and comunication were contributing causes." Further, inoJiry into the matter resulted in a determination that the root cause(s), as previously noted, can De sumarized as: (1) an inadeouate procedure in that scope of alternative activities permitted was unduly broad and (2) the radiological survey was not bounding (i.e., applied to primary activity only without noting inapplicability to other alternatives imolicit in Step 180 of the UWI). Prevention of these root causes would have eliminated this event. ' re the UWI allowed flexibility in the type of tool used in this operation, ask supervisor erred in not considering the potential for a sitenifica 7 y different radiological condition in airborne radioactivity potentially to be generated by use of the alternate grinding activity and in not notifying Radiological Engineering. There was a

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ATTACHMENT 4410-88-L-0125 l j l misunderstanding (i.e., poor communication) between Decontamination personnel and Radiological Engineering personnel regarding the methods available and the i reouired job start notification. These contributing causes also have been resolved as discussed in the above response to Notice of Violation No. A.

$ With regards to the worker falling into the vessel, the critique clearly focused on corrective actions, not root cause analysis. Subsevent inouiry resulted in the conclusion that the absence of a safety harness pennitted the Andividual to fall partway into the reactor vessel (contributory cause).

l However, it was the change in job scope which reovireo the worker to unfasten the harness and perform a job task in pro imity to an unguarded opening that

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was the root cause. The change in scope of work was not well conceived and planned regardless of hen well intentioned. This incident occurred, in part, i due to a failure to follow sound industrial safety practices as outlined in THI-2 IER 88-042. The Defueling Support personnel have been counselled to be

! nore diligent in their safe work performance and to pay closer attention to detail. Further, discussion of the root causes of this event and the corrective actions taken are containeo in CPU Nuclear response to NRC Notice  ;

. of Violation No. B. Long-term corrective action to ensure procedural

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compliarce has been addressed in the GPU Nuclear response to 2 0 Concern No. C. ,

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APPENDIX A 4410 00-L-0125 Page 1 of 2 Nuclear Memorandum Sue;ect Date PROCEDURE COMPLIANCE July 15, 1988 Frem President - P. R. Clari L caten MCC 11 1000-88-2665 To Chairman, GORBs - 1. R. Finfrock Comptroller - D. W. Myers Corporate Secretary - W. f. Sayers Director, Administration - F. F. Manganaro Director, Comunications - C. Clawson q Director, Maintenance, Constructinn & Facilities - R. W. Heward Director, Oyster Creek - E. E. Fitzpatrick Director, Planning & huclear Safety - R. L. Long l

Director, Quality & Training - P. B. Fiedler Director, Radiological & Environmental Controls - M. B. Roche 1 1 Director, Technical Functions - R. F. Wilson Director, TMI-l - H. D. Hukill

, Director, TMI-2 - F. R. Standerfer l

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l GPU huclear Corporate Policy on procedure use was established by my I mesorandum of March 7, 1980, which states in part:

i "It is the policy of the GPU System to operate and maintain its l nuclear plants in accordance witt. written approved procedures formally issued for use."

"Compliance with this policy is an essential element of management which assures that this company has the needed control of operations and is able to demonstrate it. Every violation harms the company."

This requirement is captured in Corporate Policy 1218.01, which specifically requires compliance, but also allows for clearly marked non-mandatory steps in procedures and includes provisions for "quick change mechanisms" for handling obvious and minor administrative changes which do not impact safety or technical aspects.

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4410-88-L- 0125 Page 2 of 2 This matter has been the subject of continued emphasis and discussions.

However, internal and external reviews continue to show that we are not uniformly following procedures. Noncompliance is still the major cause of Quality Assurance QDRs. One problem appears to be an unwillingness to expend the time and effort it takes to change an incorrect procedure prior to or during its use.

Additional effort on our part is needed to promote proceuural  ;

compliance. Therefore, I am asking that you reaffirm to your employees and then you and your managers meet with the employees in y0ur Division, either individually or in groups, to discuss the following points:

1. L Ict procedural compliance is an integral part of every job. ,

Employees and their managers are responsible to know or learn which procedures apply to their job and to follow them. Other pressures, tuch as schedules and budgets, are not justification for noncompliance. -

2. GPUN management understands that once work is started taking action ,

to change an incorrect procedure before continuing with work can *

cause delays in a particular task. Focused attention is needed to help ensure that procedures are correct before a job is '

started--kr.own problems or deficiencies should be fixed in advance.

Howe"er, if e procedure deficiency is found during a job, work should be stopped while needed changes are made. Avoiding delay is not an .

cxcuse for failing to comply with procedure requirements. Such r delays r..ust be accepted. It is m procedures will, in the long run,yhave belief that taking a beneficial time on impact to correct ,

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performance, schedules, and budgets.

l 3. Knowing or negligent noncompliance with procedures will result in I progressive disciplinary actions.

Please issue this reaffirmation by August 1, 1988, arrange to complete these discussions by October 1, 1988, and confirm to me when your action it complete.

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u P. R. Clark

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. t cc: Exec nive Vice President . E. E. Kintner CAR!RS '

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