IR 05000322/1993002

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-322/93-02

ML20056F378
Person / Time
Site:	Shoreham File:Long Island Lighting Company icon.png
Issue date:	08/16/1993
From:	Durr J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Leslie Hill LONG ISLAND POWER AUTHORITY
References
NUDOCS 9308270079
Download: ML20056F378 (5)

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AUG 1 G 1993 Docket No. 50-322 Mr. Leslie Resident Manager Imng Island Power Authority Shoreham Nuclear Power Station P. O. Box 628, North Country Road Wading River, New York 11792

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Dear Mr. Hill:

SUBJECT: INSPECTION REPORT NO. 50-322/93-02 This refers to your July 16, 1993, correspondence, in response to our June 16, 1993, letter.

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

Your cooperation with us is appreciated.

Sincerely, l

Jacque P. Durr, Chief Operations Branch Division of Reactor Safety I

OFFICIAL RECORD COPY G:50322.932

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9308270079 930816 ' '

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gDR ADOCK 05000322 '

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AUG 16 FJ93

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l Mr. Lebie .

cc:

C. Giacomazzo, President of Shoreham Decommission Project (LIPA)

J. Brons, Executive Vice President - Shoreham Project (LIPA)

S. Schoenwiesner, Manager, Licensing / Regulatory Compliance Department (LIPA)

A. Bortz, Manager, Operations & Maintenance Department (LIPA)

R. Patch, Manager, QA Department (LIPA) [

J. Leonard, Vice President, Office of Corporate Services & Nuclear (LILCo)

Director, Energy & Water Division, Department of Public Service, State of New York .

State of New York, Department of 12w  !

Shoreham Hearing Service List

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Public Document Room (PDR)

Local Public Document Room (LPDR) ,

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Nuclear Safety Information Center (NSIC) -

K. Abraham, PAO (2) (w/ copy of letter dtd. July 16, 1993)

R. Nimitz, Project Manager, RI State of New York (w/ copy of letter dtd. July 16, 1993) ,

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Region I Docket Room (with concurrences)

J. Joyner, DRSS S. Weiss, NRR L. Bell, NMSS V. McCree, OEDO j R. Fonner, OGC L. Pittiglio, NMSS l

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(VIA E-MAIL AND NO ATTACIIMENT):

J. Durr, DRS -

E. Gray, DRS ,

J. Carrasco, DRS i

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DRS File

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R]:DRS RI:DRS R E Cagascoldmg Gra Durr  !

kdN 07/27/93 b" 07/5/93

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OFFICIAL RECORD COPY G:50322.932 i

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SHOREHAM SERVICE LIST ADDRESSEES

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W. Taylor Reveley, III, Esq. James P. McGranery, Jr., Esq.

Dow, Lohnes & Albertson Hunton & Williams Riverfront Plaza, East Tower 1255 23rd Street, NW, Suite 500 951 East Byrd Street Washington, DC 20037 Richmond, VA 23219-4074 Nicholas S. Reynolds, Esq. Gerald C. Goldstein, Esq.

David A. Repka, Esq. Office of the General Counsel Winston & Strawn New York Power Authority 1400 L Street, NW 1633 Broadway Washington, DC 20005 New York, New York 10019 Stanley B. Klimberg, Esq. Office of the Secretary President of Shoreham Gas Conversion ATrN: Docketing and Service Project and Special Counsel to the U. S. Nuclear Regulatory Commission Chairman Washington, DC 20555 Long Island Power Authority 200 Garden City Plaza, Suite 201 Garden City, NY 11530 Carl R. Schenker, Jr., Esq.

Charlie Donaldson Asst. Attorney General O'Melveny & Meyers 55513th Street, NW Department of Law State of New York Washington, DC 20004 120 Broadway New York, New York 10271

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SHOREHAM SERVICE LIST ADDRESSEES '

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Mr. John D. Leonard, Jr. Mr. John C. Brons l Vice President - Of0ce of Executive Vice President of Shoreham Project

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Corporate Services and New York Power Authority

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Office of Nuclear 123 Main Street Long Island Lighting Company White Plains, New York 10601 P. O. Box 628, North Country Road ,

i Shoreham Nuclear Power Station Wading River, New York 11792  ;

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Mr. S. Schoenweisner, Manager Licensing / Regulatory Compliance Dept. State of New York i Long Island Power Authority Department of Law Shoreham Nuclear Power Station ATTN: Charlie Donaldson, Esq.  ;

Box 628, North Country Road 120 Broadway j

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Wading River, New York 11792 New York, New York 10271  ;

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Mr. R. Patch, Manager Department of Public Service l QA Department Director, Energy & Water Division l Long Island Power Authority Three Empire State Plaza Shoreham Nuclear Power Station Albany, New York 12223 P.O. Box 628, North Country Road Wading River, New York 11792

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Richard Bonnifield, Esquire Mr. Leslie ;

General Counsel Shoreham, Resident Manager 4 Long Island Power Authority Long Island Power Authority 200 Garden City Plaza, Suite 201 Shoreham Nuclear Power Station Garden City, NY 11530 P.O. Box 628, North Country Road Wading River, New York 17792 i

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i SHOREHAM SERVICE LIST ADDRESSEES

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Mr. A. Bortz, Manager Mr. C. Giacomazzo, President !

Operations & Maintenance Department of the Shoreham Decommission Project l Long Island Power Authority Long Island Power Authority -l'

Shoreham Nuclear Power Station 200 Garden City Plaza, Suite 201 P. O. Box 628, North Country Road Garden City, NY 11530  :

Wading River, New York 11792 l

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Mr. Richard M. Kessel Ms. Donna Ross  ;

Chairman and Executive Director New York State Energy Office l

.New York State Consumer Agency Building 2 Protection Board Empire State Plaza 250 Broadway Albany, New York 12223 New York, New York 10007  ;

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Herbert M. Leiman, Esq. Commissioner James T. McFarland i Assistant General Counsel New York Public Sersice Commission j Long Island Lighting Company 814 Ellicott Building j 175 East Old County Road 295 Main Street i Hicksville, New York 11801 Buffalo, New York 14203  ;

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Samuel A. Cherniak, Esq.

NYS Department of Law -

Bureau of Consumer Frauds and'

Protection 120 Broadway New York, New York 10271

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LSNRC-2092 k

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U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D.C. 20555  !

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Reply to a Notice of Violation  ;

Inspection Report 50-322/93-02  !

Shoreham Nuclear Power Station - Unit 1  !

Docket No. 50-322 j Ref: (1) USNRC letter dated June 1, 1993 to L. from Richard W. Cooper, II; subject: Inspection Report No. ,

50-322/93-02. l (2) USNRC letter dated June 16, 1993 to L. from Richard W. Cooper, II; subject: Notice of Violation. {

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(3) LIPA letter dated June 8, 1993, LSNRC-2080, to Richard W. cooper, II from L.M. Hill; subject: Roet Cause Analysis for April 29, 1993 Jib Crane Incident. j i

Ladies and Gentlemen:  !

The attached information (Attachment I) is in response to your

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letter (Reference 2). This attachment addresses the subject Notice of Violation in accordance with NRC instructions. .

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Should you have any questions or require additional information, l please do not hesitate to contact my office. j i

Very truly yours, j l

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. Resident Manager l

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DYF/ab ,

Attachment .

cc: L. Bell )

C. L. Pittiglio '

j T.cT.sMartin i

R. Nimitz J. Joyner J. Carrasco .

l R.W. Cooper, II )

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Attachment I '

LSNRC-2092 Page 1 of 15

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RESPONSE TO NOTICE OF VIOLATION j The following section is a citation from Reference 2 which I

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describes the violations:

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" Violation During an NRC inspection conducted on May 6-7, 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 III, requires that measures shall be established for the selection and review for i suitability of parts, equipment, and processes that are -

essential to the safety-related functions of the structures, systems and components.

Shoreham's Defueled Safety Analysis Report (DSAR), Section 17.2.3, titled Design Control, states, in part, that the Long '

Island Power Authority (LIPA) quality assurance (QA) program requires that design control measures assure that adequate design is incorporated into the procedures and the hardware.

LIPA QA Manual, Section 3, titled Design Control, requires i

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that design control be formulated and implemented for design activities such as the selection of essential parts and {

equipment, and that reviews to verify their suitability for i their intended applications are conducted. Additionally, i design change control measures are to be provided to ensure l that non safety-related structures, systems, components will I continue to be accorded the safety significance given to them in the DSAR. ,

Contrary to the above, on April 29, 1993, measures were not established to assure that the design of the lifting device for the Refueling Jib Crane (RJC) with added counterweight and related rigging was adequate and properly translated into ,

instructions in the form of sketches and drawings. j Specifically, a documented calculation to obtain the center of i gravity of the RJC for its lifting / rigging was not available, and engineering drawings, along with analytical data and explicit instructions on how to obtain the center of gravity, also were not available.

This is a Severity Level IV violation (Supplement 1).

B. 10 CFR Part 50, Appendix B, Criterion V, requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of the type appropriate to the circumstances and be accomplished in accordance with l these instructions, procedures, or drawings. Instructions, l

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procedures, or drawings are to include appropriate quantitative or qualitative acceptance criteria for ;

determining that important activities have been satisfactorily l accomplished. l Shoreham's DSAR, Section 17.2.5, states, in part, that the LIPA QA Program establishes provisions for activities affecting the quality of safety related structures, systems and components during decommissioning to be accomplished and controlled in accordance with instructions and procedures.

LIPA Quality Assurance Manual, Section 5, requires that instructions, and procedures invoke appropriate controls and quantitative or qualitative acceptance criteria. These criteria require appropriate documented evidence that i activities have been satisfactorily completed. Furthermore, I I

the QA Department is required to verify, by means of review, l

audit, surveillance and/or inspection, that organizations '

within their scopes of activities adequately provide and implement instructions and procedures for their quality-  ;

affecting activities.  ;

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Contrary to the above, on April 29, 1993, a procedure for an ,

activity affecting quality, namely, Procedure No. 35X001.01,

" Handling of Heavy Loads with Reactor Building Polar Crane i 1T31/CRN-002,"was neither appropriate to the circumstances nor contained quantitative or qualitative acceptance criteria for j determining satisfactory accomplishment of an important activity, namely the handling and transportation of the Refueling Jib Crane. Specifically, 1. Instructional drawings for the heavy load lif t of the RJC explaining and giving specific instructions were not provided as part of the procedure, nor had this procedure specified the need for a pre-job briefing. The procedure did not prescribe an engineering walkdown of the load path as a part of the pre-planning nor was an actual engineering walkdown performed before the execution of the lifting and rigging of the RJC. After the lifting and transportation of the jib crane to its parking location, it was found that the alignment pins in the mast baseplate were 90 degrees out of line with the holes in the floor.

2. Section 8.3 of Procedure No. 35X001.01, titled Fuel Handling Jib Crane, did not provide guidance on how to locate the precise center of gravity to obtain a proper balance during the lifting.

This is a Severity Level IV violation (Supplement I)."

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Attachm2nt I LSNRC-2092 Page 3 of 15

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Background The above violations are both associated with a single incident, i.e., the dropping of the RJC from the polar crane auxiliary hoist on April 29, 1993. LIPA's root cause analysis (Ref. 3) of this ,

incident was submitted to the NRC on June 8, 1993. This analysis shows that there were two primary causes, four contributing causes, and two weaknesses in LIPA programs that were involved in the event. The primary causes, which relate most directly to Violation ;

A, were design / fabrication inadequacy of the RJC lifting ;

attachment, and failure to perform an adequate review of the '

lifting attachment against NUREG-0612 guidelines. The remaining contributing causes are most directly related to Violation B, and are discussed under that heading.

The initial design review of the lifting attachment during plant !

design and construction, was performed prior to issuance of NUREG- t

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0612, and evaluated the jib crane specification requirements at the time of procurement, and no deficiencies were identified. Upon issuance of NUREG-0612, design basis reviews for Shoreham heavy ,

loads were initiated. However, unknown to LIPA during its '

preparations for movement of the RJC, the previous NUREG-0612 l review of the RJC only addressed the une of the RJC as a lifting device and had inadvertently overlooked consideration of the RJC as a heavy load during location changes. Consequently, the novement of the Refueling Jib Crane from one mounting location to the other,

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by an approved station procedure, was considered a routine plant activity. ,

LIPA had insufficient reason to question the design adequacy of the ;

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lifting attachment since this was an existing plant component, previously qualified for this activity, and it was assumed by LIPA to have been adequately reviewed in the past. As such, an ,

engineering review of the design basis documents would not be warranted unless a design modification to the crane was being considered. No modification of the RJC was planned, rather, only movement and maintenance was to be performed. >

The lifting eye assembly was considered as an interfacing lift i point of the Refueling Jib Crane. The position of the lifting eye ,

assembly was established during the initial fabrication and ;

erection of the jib crane and hoisting trolley in accordance with -

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the purchase specification (SH1-303) . The procedure addressing the

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movement of the jib crane never intended that the lifting eye assembly would be moved after the original position was established and set during construction. The procedure (SP35X001.01, Rev. 8) l required that the Polar Crane auxiliary hook be positioned over the f jib crane lifting eye (Step 8.3.1) and that the trolley be set at

, the predetermined position for proper balance (Step 8.3.4). The

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movement of the lifting eye assembly and the addition of the !

counterweight was not within the scope of the procedure. A design ,

review of the lifting eye movement and counterweight addition was ;

therefore not performed since these activities were not anticipated and not authorized by the procedure.

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Attachment I LSNRC-2092 ,

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VIOLATION A  !

The Reason for Violation A A significant factor that contributed to Violation A (above) is the j

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fact that movement of the lifting attachment (i.e., a modification ]

of the equipment) , which in turn necessitated the addition of a ,

j counterweight to balance the load, was not anticipated when the i procedure revision for movement of the RJC was prepared and i reviewed by LIPA. These actions were taken based on decisions made l in the field, and did not receive the appropriate review and l

! incorporation into the procedure. The failure to identify the need to move the lifting attachment prior to the preparation of the i procedure stems, in turn, from an inadequate field walkdown that l' was performed. LIPA has determined that the design of the lifting eye assembly with added counterweight and related rigging was

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inadequate. However, we believe that the design was poor

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irrespective of the addition of the counterweight. The assembly's i l extreme sensitivity to fabrication tolerances and a lack of

detailed installation instructions contributed to the assembly i being unforgiving to installation alignment. See Reference 3 for ,

further details regarding this design inadequacy.

In addition, LIPA concluded that an appropriate NUREG 0612 )

evaluation of the lifting eye assembly had never been performed. :

LIPA feels that an adequate evaluation of the lifting eye assembly l j for NUREG-0612 compliance would have revealed this deficiency which '

would have resulted in a redesign of the lifting eye assembly and j thus might have prevented this incident and associated violations.

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The corrective steps That Have Been Taken And The Results Achieved j for Violation A

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1 The following actions were taken by LIPA in order to prevent

recurrence of this or similar incidents during future heavy load lifts at Shoreham.

1. Correction of Desinn/ Fabrication Inadequacies Associated with Jib Crane Lifting Attachments (Primarv Root Cause No. 1)

A) Corrective Action Commitment (Ref. 3): .

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"All jib cranes at Shoreham will be examined to determine those which are equipped with a lifting attachment similar to the one that failed on April 29, 1993."

Results: Decommissioning Crane Y, prior to being modified for decommissioning activities, was identical to Jib Crane 1T31-CRN-008A. Immediately following the Jib Crane drop, Decommissioning Crane Y was identified as having a lifting eye identical to that which had failed.

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I Attachment I LSNRC-2092 Page 5 of 15

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Shortly af ter, Fuel Channel Handling Crane 1F11- I CRN-074, also located on the refueling floor, was identified as having a lifting eye similar to that of Jib Crane 1T31-CRN-008A.

As of June 30, 1993 all jib cranes at Shoreham had f been inspected to determine if they were equipped '

with lifting attachments identical or similar to j that which had failed. It has been found that no other cranes than those previously cited are  !

equipped with such lifting attachments.  ;

B) Corrective Action Commitment (Ref. 3):

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"Any jib cranes equipped with a lif ting attachment similar to the one that failed on April 29, 1993, shall have these lifting devices removed." ,

Results: On May 4, 1993, via correspondence C&FE(N)93-017, l direction to remove the lifting eye assembly from .

Decommissioning Crane Y was given. Since then the l

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crane has been disassembled and removed from the Reactor Building and will be used as replacement ,

parts for the repair of Jib Crane 1T31-CRN-008A. ;

On May 12 ., 1993, via correspondence LDD-NED-93- l I

0335, direction to remove the lifting eye assembly from Fuel Channel Handling Crane 1F11-CRN-074 was given. The lifting eye assembly for the crane has been disconnected and removed from the Reactor Building. Engineering Change Report (ECR) T-00280 has been issued to document the permanent removal of the lifting attachment.

C) Corrective Action Commitment (Ref. 3):

"Any jib cranes which are to be lifted over or in the vicinity of the SFSP shall be moved either by use of NUREG-0612 qualified rigging, or by use of a new lifting device which meets the following criteria:

(1) Any jib crane lifting device will be designed to meet the guidelines of NUREG-0612, " Control of Heavy Loads," for factors of safety and/or redundancy, and will provide adequate protection against slippage in light of fabrication tolermmes and installation alignment; and (ii) One or more load tests of a jib crane lifting device will be conducted away from the Spent Fuel Storage Pool to confirm that the device is capable of safely lifting the weight of the jib crane and to confirm the required slippage resistance characteristics and load balancing.

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! Attachment I LSNRC-2092 Page 6 of 15 Item 1.C above will be specified as a prerequisite in station procedure SP35X001.01. This prerequisite will specify that items 1.C (i) and (ii) be performed for any new jib crane i lifting device prior to first use."

l Results: The lifting attachment for Jib Crane 1T31-CRN-008A has been redesigned in compliance with the l requirements of NUREG-0612 and addressed in the ECR T-00267 series. The lifting attachment is designed to be welded to the boom of the jib crane thus

, eliminating any possibility of slippage.

1 1 The new lifting attachment has been welded to the boom of the refueling jib crane at the designated location to ensure proper load balancing and has been successfully load tested. Nondestructive examin. tion of the welded lifting attachment has been per 'ed prior to and after the load test.

In the event the Channel Handling Crane IF11-CRN-074 requires relocation from its present location, standard rigging hardware (i.e., slings, shackles, etc.), conforming to the requirements of Station Procedure SP 35X001.01 will be used for its  ;

removal. [ Note: The Channel Handling Crane is less than the weight of a heavy load.] .

l 2. Assurance of Adequate NUREG-0612 Desian Compliance for Future Heavy Load Lifts (Primary Root Cause No. 2)

Corrective Action Commitment (Ref. 3):

l "Conformance with all current commitments to NUREG-0612 guidelines, l l e.g., use of safe load paths, use of procedures, crane operator ;

i qualification, crane and sling inspection and maintenance, etc., 4 i

will continue to be maintained at Shoreham in accordance with approved station programs and procedures. In addition, prior to performing any heavy load lifts over or in the vicinity of the l

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SFSP, LIPA will ensure that the following reviews are performed to assure compliance of the lifts with current NUREG-0612 commitments ( in order to ensure the safety of irradiated fuel in the Spent Fuel Storage Pool (SFSP).

(A) For beavy loads to be lifted over or in the vicinity of the SFSP involvina movement of oriainally installed clant eauipment, LIPA vill:

(i) Reconfirm that a safe load path and appropriate instructions )

are specified for the load in SP35X001.01; and (ii) Reconfirm that Shoreham licensing correspondence and/or engineering doc.imentation have addressed NUREG-0612 considerations for tre subject loads, specifically addressing the safety of irradiated fuel in the SFSP. This review will include a verification that the planned load is consistent with the parameters of the earlier review:

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LSNRC-2092 Page 7 of 15 ,

(a) Where safety factors, equipment redundancy, and/or compensatory measures were credited as the basis for NUREG-0612 compliance, LIPA will verify that the safety factors, i equipment redundancy and compensatory measures continue to

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satisfy NUREG-0612 guidelines. This will include verification

! of safety factors, redundancy and compensatory measures for cranes, special lifting devices, rigging and load attachment points; or (b) Where load drop consequences were previously assessed and found to be acceptable, LIPA will verify that a drop of the planned load remains bounded by the earlier analysis, e.g.,

load path is the same and plant conditions are the same as or less limiting than in the earlier analysis; or (c) Where it is determined that neither a bounding load drop evaluation was performed nor NUREG-0612 qualified safety factors and/or redundancy are present, either a new analysis :

will be performed demonstrating no adverse impact on safe fuel storage in the event of a load drop, or another NUREG-0612 ,

qualified approach will be developed to conduct the lift.

(B) For all heavy load lifts over or in the vicinity of the SFSP involvino ecuipment not previously considered in cast NUREG-0612 reviews at Shoreham, e.o., for new eauipment used in decommissionina or fuel disposition activities, LIPA will:

1 (i) Ensure that a safe load path and appropriate instructions are specified in SP35X001.01; and (ii) Ensure that either an analysis is performed demonstrating no )

adverse impact on safe fuel storage in the event of a load j drop, or that all cranes, special lifting devices, rigging and i load attachment points meet NUREG-0612 guidelines for equipment safety factors, redundancy, and/or compensatory measures.

(C) Although Actions 2.B(i) and 2.B(ii) have been routinely implemented throughout Shoreham Decommissioning, LIPA will revise station procedure SP 35X001.01 to more clearly identify l these actions as prerequisites. Lastly, all heavy load lifts i across the Refuel Floor will be subject to design approval by l the Nuclear Engineering Division (NED), including NED approval and/or preparation of any rigging sketches that may be necessary. Verification of design compliance with current NUREG-0612 commitments will be specifically documented with the NED approval of Refuel Floor heavy load lifts. The NED's approval responsibilities will also be clarified in order to ensure a thorough NUREG-0612 evaluation is performed.

The above items, i.e., 2.A, 2.B, and 2.C will be specified as a prerequisite in station procedure SP35X001.01 no later than June 30, 1993. Conforming changes to other station programs l

and procedures will be made as appropriate by June 30, 1993."

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Attachment I LSNRC-2092 i Page 8 of 15 :

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Results for Items 2A, 2B, and 2C:

Revision 12 of Station Procedure SP 35X001.01

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(effective: June 30, 1993) has incorporated the prerequisites to ensure safe load paths and ,

appropriate instructions are specified (Steps 5.14,  ;

5.18, and 5.19) and to ensure NED has performed a ,

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critical load evaluation (Step 5.17) prior to auxiliary hook use. In addition, prerequisites (Steps 5.20 and 5.21) of Station Procedure SP 35X001.01, revision 12 (effective: June 30, 1993) '

clearly identify actions to ensure that all crane l special lifting devices, rigging and load ;

attachment points for existing and new equipment t

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meet NUREG-0612 guidelines.

Revision 3 of Decommissioning Department Procedure DD SX05, " Processing of Engineering and Design  !

(E&D) Sketches and Interim Changes to E&D Sketches" 6 (effective: June 30, 1993) addresses the requirement for NED evaluation and approval of sketches for rigging of heavy loads that will be handled / lifted above elevation 175'-9" of the ,

Reactor Building to ensure NUREG-0612 compliance.  ;

These procedures ensure that a cognizant NED representative is an active participant for all l heavy load lifts over or in the vicinity of the i SFSP. The cognizant NED representative is !

required, by DD SXOS, to verify and document design  ;

compliance with current NUREG-0612 commitments to ensure a thorough NUREG-0612 evaluation is ,

performed for these lifts. 1 VIOLATION B i

The Reason for Violation B l

The reasons that the steps in station procedure SP35X001.01 for l movement of the jib crane were inappropriate, and therefore j contributed to the incident, are as follows:  ;

There was a failure of supervisory personnel to recognize that l required actions which were not authorized in the procedure  ;

warranted stoppage of the work in order to ensure the i performance of appropriate reviews. I; t

There was a failure of supervisory personnel to recognize that  ;

it was their responsibility to monitor the conduct of work to ensure it was in strict compliance with the procedure.

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The field walkdowns that were performed occurred too far in  !

advance of the actual lift to account for changed conditions l on the Refueling Floor and failed to include engineering.

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LSNRC-2092 j Page 9 of 15 i

The walkdowns failed to identify a need to move the lifting attachment to achieve vertical alignment with the polar crane ;

auxiliary hook or that the alignment pins would not line up )

when the crane was relocated. '

There was no clear requirement to conduct a pre-job briefing or instructions regarding the contents of such briefings.

l As a consequence of the above, the procedure did not contain pre- l reviewed and approved steps which reflected the complete actions !

taken in the field, and the responsible management also failed to stop work and initiate a procedure change when work could not be l performed as described in the written procedure. Additional '

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procedural instruction was not obtained as described in Station l Procedures, General Employee Training, and in special work control '

fundamentals training. These failures resulted in the consequent failure to reevaluate the adequacy of the lifting eye, to evaluate movement of the lifting eye assembly (including a calculation to ,

obtain the center of gravity of the RJC) , and to evaluate the ;

effect of adding a counterweight to the load.

The Corrective Steps That Have Been Taken end the Results Achieved for violation B >

1. Procedure and Other Work Control Adherence (Contributina Cause l No. 1)

Corrective Action Commitment (Ref. 3):

"The following actions have been or will be taken to prevent the recurrence of incidents similar to this one where activities were performed that were beyond the authorization provided in the applicable procedure:

A) Corrective Action Commitment (Ref. 3):

" Appropriate disciplinary actions have been taken against the supervisory personnel who are responsible for the failure to follow the procedure in this case. The contractor supervisor who was directly in charge of the rigging activities for the jib crane has been permanently removed from the Shoreham project. The Refuel Floor Coordinator in charge of cverall coordination of activities on the Refuel Floor was suspended without pay for a period of one week."

Results: The contractor's supervisors have a heightened sensitivity to the importance of procedural compliance and have an increased appreciation for LIPA's commitment to this compliance issue. The Refuel Floor Coordinator has been counseled on this issue (as well as receiving time off without pay),

and acknowledges the actions taken by station management were appropriate. His morale has not been negatively affected, and he has indicated a heightened commitment to performing to LIPA's expectations.

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Attachment I LSMRC-2092 Page 10 of 15 1 i

B) Corrective Action Commitment (Ref. 3):

"All Refuel Floor Coordinators and Senior Certified Fuel Handling Operators with Refuel Floor responsibilities will receive special indoctrination from the Resident Manager focusing on the need to closely monitor compliance with work control fundamentals, including review of specific work i control fundamental requirements, their bases, their ;

application in actual field situations, and how to recognize non-compliances. In addition, formal position descriptions will be developed and approved by the Resident Manager for the Refuel Floor Coordinator and Senior Certified Fuel Handling Operator positions. Such position descriptions will identify the work control fundamentals and supervisory responsibilities ,

associated with these positions." '

Results: Formal position descriptions for the Refuel Floor Coordinators and Senior Certified Fuel Handling Operators were developed, approved and issued on June 30, 1993. Additionally, two new key refuel floor supervisory position descriptions have been .

approved and issed on June 30, 1993: Fuels !

Engineer, and UE&C Catalytic Refuel Floor Superintendent. All four position descriptions outline the dutics of each position and their reporting authorities.

The Resident Manager met with all individuals assigned to these positions for a special indoctrination session which addressed all the ;

issues identified above. These personnel have I indicated a clear understanding of, and have a l commitment to, LIPA's expectations. j

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C) Corrective Action Commitment (Ref. 3):

"This event will be discussed with all Shoreham station personnel through department focus meetings as well as through

"all hands" meetings conducted by the Resident Manager. The ,

detail of how work control fundamentals were violated in this I case will be examined. Also, renewed emphasis in general will be placed on work control fundamentals such as the importance of having procedures to control work activities; the importance of procedural adherence; the need for attention to details in work planning to ensure an adequate procedure is developed; maintenance of a questioning attitude; and the need to recognize, stop work, and obtain appropriate formal procedural clarification when confronted with situations not adequately addressed in a procedure. These actions will be completed no later than June 30, 1993."

Results: All departments at Shoreham held focus meetings to discuss the importance of work control fundamentals, procedural adherence, attention to detail, attitude, and the need to stop work and ,

obtain procedural clarification when needed. In l

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Page 11 of 15 addition, the Resident Manager held "all hands" ,

meetings on June 29 and June 30, 1993 for all Station personnel, to emphasize the need for ,

procedure compliance and overall nuclear !

excellence. One of the "all hands" sessions was i videotaped for presentation to personnel not on <

site on those two days. i l

D) Corrective Action Commitment (Ref. 3):

" Lessons learned from this event, including the work control fundamentals emphasis described above, will be incorporated in General Employee Training (G.E.T.) given to all new employees at Shoreham, and will also be included in the annual G.E.T.

requalification lesson plan for existing employees. The lessons learned will also be added to other applicable programs such as Polar Crane Operator Training and Certified Fuel Handling Operator Training. Revisions to the lesson plans for these training programs will be completed by June 30, 1993."

Results: The initial G.E.T. Lesson Plan as well as the G.E.T. Requalification Lesson Plan have both been revised and were approved on July 1, 1993. On June 30, 1993, the Maintenance Engineer (Section Head) '

met with the qualified Reactor Building Polar Crane operators from both LIPA and UE&C Catalytic and provided them supplemental training. The training '

included: 1) Review of the Jib Crane incident, ,

reemphasis of the importance of procedure j compliance; 2) review of the issues identified in l the June 9, 1993, NRC Enforcement Conference, as j well as the LIPA commitments made to the NRC at the l conference; and, 3) review of the revisions made l to Station Procedure 35X001.01. Also, on June 30, 1993, the Certified Fuel Handling Operator Training ,

Program was updated to acknowledge the Jib Crane I incident and incorporate lessons learned.

E) Corrective Action Commitment (Ref. 3): i I

"In addition to the requirements incorporated as outlined l above, LIPA will give greater management attention and '

visibility to compliance with work control fundamentals in the field. Department and division managers will conduct and document reviews and tours to be performed to assess work ;

control fundamentals implementation. Each department manager I will be required to develop and submit to the Resident Manager a plan for ongoing monitoring and documenting of work control fundamentals compliance within the areas of their responsibility. Initial Resident Manager approval of all such plans will be obtisined no later than July 31, 1993 and periodic review of plan effectiveness will be conducted every three months thereafter."

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Page 12 of 15 Results: To give more attention and visibility to the compliance with work control fundamentals, LIPA has ;

created an interdepartmental task force. This task force includes two department managers and is responsible to develop a plan for monitoring the work control fundamentals at the plant. This plan will be reviewed and endorsed by all department managers, and will be submitted to the Resident Manager and approved no later than July 31, 1993.

A periodic review of the plan will be conducted at ,

a frequency of at least every three months '

thereafter.

2. Improvements In work Plannina Practices (contributina cause

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No. 2)

"The following improvements in heavy load work planning practices will be implemented in order to ensure that all logistical considerations in the field are translated into appropriately developed work instructions:

A) Corrective Action Commitment (Ref. 3):

Field walkdowns for Refuel Floor heavy load movements will include, but not be limited to, the author of the procedure and a cognizant representative of the NED."

Results: Station Procedure SP 35X001.01, Rev.12 (effective:

June 30, 1993) includes a prerequisite (Step 5.16)

to ensure that a field walkdown will be performed with a team of personnel including but not limited >

to a cognizant NED representative, the job leadman, and the originator (if possible or his supervisor)

of the procedure addressing the lift.

B) Corrective Action Commitment (Ref. 3): i

" Field walkdowns which are performed more than two days before the actual lift will be repeated on the day of the lift, including participation of a cognizant NED representative.

This will be done to ensure that any changes in field conditions which could affect the lift are identified prior to commencement of the actual lift."

i Results: Station Procedure SP 35X001.03, Rev.12 (effective:

June 30, 1993) includes a prerequisite (Step 5.16)

that will verify that a field walkdown of the heavy load movement has been performed within forty-eight i i hours prior to the move. This item was also added as step 5.16 to Appendix 32.5, " Pre-Requisite

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Checklist." The Pre-Requisite Checklist will be completed prior to moving any heavy load on the Refuel Floor with the Reactor Building Polar Crane.

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C) Corrective Action Commitment (Ref. 3):

" Formal pre-job briefings in accordance with station

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procedures will be required for all Refuel Floor heavy load lifts. Instructions to determine the applicability and content of formal pre-job briefings will be developed."

Results: Station Procedure SP 35X001.01, Rev.12 (effective:

June 30, 1993) includes a prerequisite (Step 5.6)

that will ensure that a formal pre-job br!.efing has been held prior to handling any heavy load with the polar crane. An Appendix " Heavy Load Handling Pre-Job Briefing Instructions" has been added to SP 35X001.01 to address: how the pre-job briefing will be conducted; who will attend; that an overview will be given by the responsible Section Head or :

his designee; that radiological requirements will be thoroughly discussed; that safety or design related concerns may be discussed; that the work crew will confirm understanding and clarity with specific procedural steps; and that attendance will be taken. The Pre-Requisite Checklist, Appendix .

12.5 of SP 35%001.01 includes step 5.6 to verify that a pre-job briefing has been conducted per Appendix 12.3, " Heavy Load Handling Pre-Job Briefing Instructions," and an attendance list has been attached.

3. Clarification of Field Supervisory Responsibilities ,

(Contributina cause No. 3)  !

Corrective Action Commitment (Ref. 3):

"As discussed in 1.B above, the position of Refuel Floor I

Coordinator will be defined in an appropriate position description which delineates the authorities and responsibilities associated with this position. The program description [ Note: Ref. 3 inadvertently referred to program description when a position description was meant] will specifically identify that personnel in this position are required to include monitoring for compliance with work control fundamentals as part of their daily responsibilities. The position description for Senior Certified Fuel Handling Operator will be developed to ensure that it clearly identifies these responsibilities as well.

Regarding the errors in judgement made by the supervisory personnel

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involved in the jib crane drop of April 29, 1993, please refer to item no. I above, " Procedure and Other Work Control Adherence" for actions which will address how to better make such judgements in the future."

Results: Position Specifications for the Refuel Floor Coordinator, as well as for the Senior Certified Fuel Handling Operator, Fuels Engineer, and UE&C Catalytic Refuel Floor Superintendent have been entered into the Training and Qualification System and designated personnel have been formally assigned to those positions. These Position

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Descriptions have been formally added to the *

Shoreham Administrative Manual.

4. Procedure Adequacy for Heavy load Lifts (Contributino Cause No. 4)

Corrective Action Commitment (Ref. 3):

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" Station Procedure SP35X001.01 will be reviewed based on the lessons learned from this incident and the associated root cause analysis to determine if the heavy load lift instructions are clear and adequate to perform the tasks described."

Results: Station Procedure SP 35X001.01, Rev.12, (effective date: June 30, 1993), Section 8.0, was reviewed by both users and by management personnel in detail to insure that the instructions for each specified lift were clear and accurate to perform the lift -

described. The procedure was revised in some areas to enhance the procedure's clarity. After review and revision, Section 8.0 of the procedure provides a clear step list to perform each lift.

Procrammatic Weaknesses The following actions were also taken by LIPA in order to enhance programs which were identified as being weak.

Weakness 1 Response - Enhance procedural guidance for ,

implementing critical load determination ;

l Corrective Action Commitment (Ref. 3): I

" Procedural guidance will be developed which will address l responsibilities for performing a critical load evaluation, including what types of compensatory measures should be considered (i.e., dynamometer tie downs, additional spotters) when performing ;

the evaluation. The guideline will also require that the Nuclear i

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Engineering Division review and or develop each critical load evaluation, and require that critical load evaluation be reviewed l by the SRC.

Station Procedure 35X001.01 wil.1 be revised to require as a  ;

prerequisite that a critical load evaluation has been performed for i the handling of heavy loads with the auxiliary hook." l Results: SP 35X001.01, Rev. 12, requires that if a critical load is handled with the polar crane auxiliary hook, the lift will be evaluated for the potential of load hang-up or binding. If the load has the potential to hang-up or bind, compensatory measures will be specified by Engineering due to the absence of a load limiting device in the polar crane auxiliary hoist circuitry. Tha caly currently allowable compensatory measures indicated in SP35X001.01, Rev. 12 include the use of a I l l-

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Page 15 of 15 dynamometer and/or spotters. When appropriate compensatory measures cannot be established for critical load lifts using the auxiliary hook, the polar crane main hook (with its load lifting device operable) may be used.

Station Procedure SP 35X001.01 has been revised as

' Revision 12 (effective date: June 30, 1993) to include a prerequisite (step 5.17) to verify that NED has performed a critical load evaluation for the load to be lifted, and that the critical load evaluation has been reviewed by the SRC.

Weakness 2 Response - Enhance pre-job briefing effectiveness Corrective Action Commitment (Ref. 3):

" Formal pre-job briefings will be described in a suitable work t instruction. The instruction will provide guidance on what groups should attend pre-job briefings and what types of activities will require utilizing the pre-job briefing instruction. This instruction will identify the subject areas to be addressed during a pre-job briefing. Examples of subject areas are as follows:

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Authorities and responsibilities

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Training, indoctrination, qualification

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Work authorization / permits / tags

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Plant condition requirements

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Safety considerations

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Posting and alarms

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Equipment / materials

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Procedures

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Quality control

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Radiological controls

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Radiological waste and contamination control

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Cleanliness control The requirements to hold a pre-job briefing in accordance with the developed instruction discussed above will be incorporated into Station Procedure SP 35X001.01."

Results: Appendix 12.3, " Heavy Load Handling Pre-Job Briefing Instructions." has been added to Station Procedure SP 35X001.01, Rev. 12 (effective: June 30, 1993). For a complete explanation refer to Section 2C above.

The corrective Steps That Will Be Taken to Avoid Further Violations and The Date When Full Compliance Will Be Achieved Full compliance was achieved on June 30, 1993 for all items

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required by the June 30, 1993 commitment date. One commitment (item 1E above), where a plan for ongoing monitoring and documenting of work control fundamentals compliance is to be approved by the Resident Manager, remains open and is scheduled for completion by its July 31, 1993 due date. Full compliance for this item will be achieved no later than July 31, 1993.

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