IR 05000324/1990029
| ML20058K242 | |
| Person / Time | |
|---|---|
| Site: | Brunswick  |
| Issue date: | 11/30/1990 |
| From: | Ebneter S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Eury L CAROLINA POWER & LIGHT CO. |
| Shared Package | |
| ML20058K245 | List: |
| References | |
| NUDOCS 9012170047 | |
| Download: ML20058K242 (5) | |
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NOV a o u l
i Docket Nos.
50-325 and 50-324 License Nos. DPR-71 and DPb 62 EA 90-154 1j
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Carolina Power and Light Company.
ATTN: Mr. Lynn W. Eury i
Executive Vice President
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Power. Supply Post Office' Box-1551
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Raleigh, North Carolina 27602
Gentlemen:
i SUBJECT:
NOTICE OF VIOLATION (INSPECTION REPORT'NOS.- 50-325/90-29lAND 50-324/90-29, AND AUGMENTED.
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INSPECTION TEAM REPORT NOS. 50-325/90,36AND-50-324/90-36)-
l This refers to the Nuclear Regulatory Commission (NRC) inspection conducted on -
i August 1-September 7, 1990, and-the special. inspection-conducted by the NRC-Augmented Inspection Team (AIT) on August 21-25, 1990, at the Brunswick i
facility. The AIT inspection, which was formally chartered on August 21, 1990,
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included the> review'and evaluation ~ of events that led to a reactor-scram.on i
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August 19 1990, and the-subsequent plant shutdown.
The August 1-September 7, 1990 inspection included a review of' activities authorized 1forithe: Brunswick facility as well as aL follow-up'of issues identified during-the AIT inspection.-
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I The reports documenting these inspections were sent :to you by letter dated September 17, 1990,- and September-19, 1990,'respectively. As a result of these
inspections, a significant failure to comply with NRCiregulatory requirements was identified. An Enforcement Conference was held"on October:16, 1990 in the.
1" Region 11 Office to discuss the: violations, their cause, anu your;correc,tive-
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action to preclude their recurrence.
The letter summarizing this conference was
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sent to you by letter dated November 1, 1990.
Violation A described in the enclosed Notice of Violation (Noticc). involved' the failure.to follow procedures and the subsequent inaccurate completion of proce-
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dural requirements associated with.a maintenance surveillance" test. On-August 19, 1990, Brunswick Steam Electric. Plant-(BSEP) Unit 42'was' operating at-
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- 100 percent power.
At approximately' 9:00 'p.m., Instrumentation and Control" (I&C)techniciansweregivenpermission;bytheSenior..ControlOperato'-(SCO)'
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to commence maintenance surveillanceLtest 2MST-PCIS24M, Primary Containment:
Isolation' System (PCIS)- High' Condenser Pressure Trip Unit Channel Calibration.
During.the-test all four channels are trip-tested individually. lThis mainte-nance surveillance test may be performed' by one 'techniciandexcept. for certain critical steps that require independent: verification. LHowever, established B3EP-work practices dictate that two I&C technicians perform'the testiin its entipty.
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lesting had been successfully. completed on PCIS Channels:Al and _Bl.. Testing a as
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performed on Channel A2; however, the technician failed to haveithe Control Rcom Operator reset the A2 channel'before testing the B2 channel.' Coasequently, as
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NOV 3 0 E0
Carolina Power and Light Company
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testing cmnenced on Channel B2, a full Group 1 isolation signal resulted. The Group 1 i a tion signal caused the unit to scram and various equipment sub-sequently :. lfunctioned during scram recovery.
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Your Site Incident Investigation Team revealed (as later confirmed by NRC inspection), that one I&C: technician intentionally performed the test without the required second technician present to independently verify that~ each channel had been reset' prior to proceeding to:the next sequential channel test.
It was also determined that this I&C technician had inadvertently skipped
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certain procedural steps in his haste to complete the surveillance test, and
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that he subsequently initialed those procedural steps as having been completed when, in fact, they had not been performed.
In addition, immediately after the unit scram, this technician convinced a second I&C technician, who was not present during the test, to initial-off procedural steps that indicated that
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independent verification had been performed, when, in fact, the second technician knew that he had not performed the required independer '.arification.
The seriousness of this event cannot be overstated._ A significant series if.
inappropriate actions on the part of the technician performing the test resulted in an unnecessary challenge to plant safety systems and related equipment.
In-addition, this individual influenced the actions of another individual, such that the second technician knowingly falsified the maintainance surveillance test. Although an unintentional failure to follow procedures or the inadvertent creation of an inaccurate document might normally be categorized at: Severity-
-Level IV, the severity level in this case is being adjusted because of the l
willful aspects of this event.
Specifically, the first technician knowingly.
failed to follow the procedure, with respect to the requirement _for independent verification, and the second technician knowingly falsified.the' maintenance
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suricillance test procedure, with respect to those steps indicating independent verification. Therefore, this vielation has beea categorized at Severity
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Level III.
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l In accordance with the " General Statement cf Policy and Procedure for NRC I
Enforcement Actions," (Enforcement Policy) 10 CFR Part 2, Appendix C-(1990), a
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civil penalty is considered for a Severity Level-III violation.. However, the NRC wants to encourage and support licensee initiative;forself-identification and correction of-problems. Therefore, after consultation with the Director, l
Office of Enforcement, and the-Deputy Executive Director for Nuclear Reactor i
Regulation, Regional Operations and Research, I have decided that a civil l_
penalty will not be proposed in this case because of your tenacious efforts _in identifying the willful failure to follow' procedures and the falsification of
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I the procedural record during the Site Incident Investigation Team's investiga-
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tion and because of your prompt and extensive corrective. action, that included
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l the termination of employment at BSEP for the two: technicians involved in the event, and the initiation of'appropritate actions' to inform and train plant
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staff on the importance of strict adberence to procedures and work control, l
l Violations B through D described in the' Notice involved various issues dealing l
with ' inadequate procedures, failure' to follow procedures,-and failure to'make I
required notifications. Although each of these violations have been indivi-I
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dually categorized at Severity Level IV, the NRC gave serious consideration as
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Carolina Power and Light Company-3=
NOV 3 0 8)
te whether or not those violations involving failures to follow procedures (B.1',
B.2, C, and D), collectively represented a significant regulatory concern justi-fying aggregating them to a Severity Level III problem.
Specifically, these violations reflect weaknesses in operator-protocol and indicate that additional work is required in the training area.
The event of August 19,1990, further revealed significant weaknesses in operator interface and formal communication i
with other work groups.
In this-particular event, the operator should have been
aware of plant status with regard to the test being conducted.
Two annunciators wh:ch were present just prior to the trip clearly indicated that Channel A2 was in a trip condition and that testing was underway on Channel B2. This should have alerted the operator to stop the testing.
In addition, when the operator confronted the technician concerning the status of the half-trip condition, communication between the individuals was imprecise and lacking formality.
The NRC is concerned that the operators " trusted" the technicians rather than demon-strating full control and knowledge of activities that affect their unit.
In addition, the NRC is concerned that your feilures to follow procedures in ade-
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quately classifying and reporting events delayed decisions requiring collective cooperation and coordination.
Specifically, with respect to Violation D,
although your Plant Emergency Procedure (PEP) wculd have. required that an-
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unusual event be initiated when five nuclear steam system safety relief valves (SRVs) failed to lift when their pressure setpoints were exceeded, the Operations Manager deferred the declaration pending further review by your technical staff.
In accordance with the Enforcement Policy, this violation alone could be cate-gorized at Severity Level III (Supplement VIII. example C.2).
However, we recognize that, but for your procedures, this event would not be classified as an unusual event and that you have since revised your emergency action levels
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such that it is no longer classified as-an unusual' event.
In addition, we note that your Shift Technical Advisor (STA) properly characterized this' event and that the Operations Manager is no longer in this position.
The staff recognizes.
that much is being done to address the specific problems; however, management
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should become more aggressively involved in correcting the pressing problem of procedural compliance.
Although not cited, but discussed in the Enforcement Conference, were additional weaknesses demonstrated by the training and engineering organizations. The trim of the Startup Level Control Valve was chenged in 1988 resulting in different flow characteristics for the valve.
This enange, which.was accomplished as a direct replacement rather than a modification, was not reviewed by the training organization.
Consequently, the simulator was not upgraded to reflect this change and the operators were not trained in its actual operation.
The simulator also did not model the five second hold requirement for re-latching-the Reactor Core Isolation Cooling trip and throttle valve.
These items may
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reflect a broader problem involving the lack of effective interaction between groups.
l You are required to respond to this letter ano should follow the instructions
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l specified in the enclosed Notice when preparing your response.
In your l
response, you should document the specific actions taken and any additional l
actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future I
inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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Carolina Power and Light Company-4-In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a-copy'of this letter and its enclosure will be placed in the NRC Public Document Room.
The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office.of Management and Budget as required
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by the Paperwork Reduction Act of 1980, Pub. L. No.-96.511.
Should you have any questions concerning this letter, please contact us.
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Sincerely
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2tbc! Rmed By:
4mrr.rt D. Ebneter Stewart:D. Ebneter Regional Administrator Enclosure:
Notice of Violation cc w/ encl:
R. B. Starkey, Jr.
Vice President Brunswick Nuclear Project Box 10429 Southport 'lC 28461 J. L. Harness Plant General Manager.
Brunswick Steam Electric Plant P. O. Box 10429
Southport, NC 28461 l
l R. E. Jones, General Counsel l
Carolina Power & Light Company l
P. O. Box 1551 l
Raleigh, NC 27602
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Ms. Frankie Rabon Board of Commissioners-l P. 0.' Box 249 Bolivia, NC 28422 o
Chrys Bagget-l State Clearinghouse
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Budget and Management 116 West Jones Street
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Raleigh, NC 27603
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cc w/ encl cont'd: See page 5 e
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Carolina Power and Light Company-5-
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cc w/ encl Cont'd H. A. Cole.
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Special. Deputy Attorney General State of North Carolina.
P. O. Box 629 Raleigh, NC 27602 l
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Robert P. Gruber-F Executive Director
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Pui411c Staff - NCVC n'w
'P. O. Box 29520 Raleigh, NC 27626-0520
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State of North Carolina
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Distribution:
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JGoldberg, 00C Enforcement Coordinators
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