IR 05000324/1991001

Forwards Enforcement Conference Summary Held on 910226 Re Insp Repts 50-324/91-01 & 50-325/91-01.List of Attendees & Licensee Handout Encl

ML20217B781
Person / Time
Site:	Brunswick
Issue date:	02/28/1991
From:	Reyes L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:	Eury L CAROLINA POWER & LIGHT CO.
References
EA-91-023, EA-91-23, NUDOCS 9103120226
Download: ML20217B781 (25)

Text

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FEB 2 81991

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Docket Nos. 50-325, 50-324 License Nos. DPR-71, DPR-62 ,

EA 91-023 =

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Carolina Power and Light Company ATTN: Mr. Lynn W. Eury Executive Vice President Power Supply P. O. Box 1551 Raleigh, NC 27602 Gentlemen:

SUBJECT: ENFORCEMENT CONFERENCE SUMMARY (NRC INSPECTION REPORT NOS. 50-325/91-01 AND 50-324/91-01 This letter refers to the Enforcement Conference held at our request on February 26, 199 This meeting concerned activities authorized for your Brunswick facility. The issues discussed at this conference related to: (1)

the series of breakdowns in Brunswick's work control process which resulted in the Unit 2 reactor scram on January 25, 1991, and (2) the failure of previously implemented corrective actions to prevent recurrence of such work control related events. A list of attendees and a copy of your handout are enclose We are continuing our review of these issues to determine the appropriate enforcement actio In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Rco Should you have any questions concerning this matter, please contact u

Sincerely,

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(Original signed by EMerschoff/for)

, Luis A. Reyes, Director Division of Reactor Projects

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Enclosures: List of Attendees Licensee Handout

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cc w/encls: (Seepage 2)

9103120226 910228 'i PDR ADOCK 05000324 \

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Carolina Power and Light Company 2 FEB 2 81991 cc w/encis:

R. B. Starkey, J Vice President Brunswick Nuclear Project P. O. Box 10429 Southport, NC 2B461 J. L. Harness Plant General Manager Brunswick Steam Electric Plant P. O. Box 10429 Southport, NC 28461 R. E. Jones, General Counsel Carolina Power & Light Company P. O. Box 1551 Raleigh, NC 27602 Ms. Frankie Rabon Board of Commissioners P. O. Box 249 Bolivia, NC 28422 Chrys Baggett State Clearinghouse Budget and Management 116 West Jones Street g Raleigh, NC 27603 Dayne H. Brown, Director Division of Radiation Protection N. C. Department of Environmental, Conmerce & Natural Resources P. O. Box 27687 Raleigh, NC 27611-7687 H. A. Cole Special Deputy Attorney General State of North Carolina P. O. Box 629 Raleigh, NC 27602 Robert P. Gruber Executive Director Public Staff - NCUC P. O. Box 29520 Raleigh, NC 27626-0520 bec w/encis: (See page 3)

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Carolina Power and Light Company 3 FEB 2 81991 bec w/encis:

J. Lieberman, OE G. R. Jenkins, EICS H. Christensen, Ril J.Le,NRR Document Control Desk NRC Resident inspector U.S. Nuclear Regulatory Commission Star Rte. 1, Box 208 Southport, NC 28461 Ril: RP Ril:DRP Ril : 0f,P R P RIl

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arroll HChristensen DVerrelli E bc6ff GJ 02/g7 /91 02/,17/91 2

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/91 02/pg 1 02/7/91

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ENCLOSURE 1 LIST OF ATTENDEES

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Carolina Power and Light Compay R. A. Watson, Senior Vice President, Nuclear Operations K. R. Karr, Special Assistant to Senior Vice President, Nuclear Operations R. B. Starkey, Vice President, Brunswick Nuclear Project J. W. Spencer, General Manager, Brunswick Nuclear Project K. B. Altman, Manager, Regulatory Compliance S. D. Floyd, Manager, Nuclear Licensing R. D. Tart, Manager, Unit 2 Operations K. T. Chism, Shift Foreman, Operations H. N. Wheeler, Foreman, Instrumentation and Control (180)

K. Scott, Maintenance Planner M. McPherson, 1&C Technician Nuclear Regulatory Commission S. D. Ebneter, Regional Administrator, Region !! (Rll)

J. L. Milhoan, Deputy Regior,a1 Administrator, RII L. A. Reyes, Director, Division of Reactor Projects (DRP), Ril A. F. Gibson, Director, Division of Reactor Safety, RIl E. W. Merschoff, Deputy Director, DRP, RII G. R. Jenkins, Director, Enforcement and Investigation Coordination Staff (EICS),Rll E. G. Adensam, Director, Project Directorate 11-1, Office of Nuclear ReactorRegulation(NRR)

D. M. Verre111, Chief, Reactor Projects Branch 1, DRP, Ril H. O. Christensen, Chief, Reactor Projects Section-1A, DRP, Ril R. : E. Carroll, Project Engineer, DRP., RIl R. L. Prevatte, Senior Resident inspector - Brunswick, DRP, Rll B. Uryc, Senior Enforcement Specialist, EICS, Ril N. B. Le, Project Manager, NRR

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p{ CLOSURE 2 BRUNSWICK NUCLEAR PROJECT

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ENFORCEMENT CONFERENCE I JANUARY 25, 1991 UNIT 2 REACTOR TRIP

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FEBRUARY 26, 1991 l

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ENFORCEMENT CONFERENCE FEBRUARY 26, 1991 AGENDA I INTRODUCTIONS

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REGULATORY OVERVIEW FAILURE TO FOLLOW PROCEDURE

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EVENT CONSEQUENCE SUMMARY

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ROOT CAUSES IMMEDIATE CORRECTIVE ACTIONS ON-GOING CORRECTIVE ACTIONS AND RESULTS -

SUMMARY CLOSING REMARKS I

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ENFORCEMENT CONFERENCE REG #LATORY OVERVIEW EVENT SUMMARY (1/25/91)

t 0 PREVENTIVE MAINTENANCE PROCEDURE

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WAS NOT FOLLOWED l

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0 UNPLANNED REACTOR TRIP l

0 WORK CONTROL WEAKNESS IDENTIFIED l ,

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ENFORCEMENT. CONFERENCE REGULATORY OVERVIEW (CONT'D)

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IDH IIFICATION AND REPORTING 0 SELF IDENTIFIED 0 PROMPTLY AND COMPLETELY REPORTED L 0 IMEDIATE CORRECTIVE ACTIONS TAKEN CAUSAL FACTORS AND ROOT CAUSE O CAUSAL FACTORS IDENTIFIED 0 ROOT CAUSES DETERMINED AND UNDERSTOOD

CORRECTIVE ACTIONS TO PRECLUDE RECURRENCE O PROMPT -

0 COMPREHENSIVE O SELF INITIATED 0 APPLIED SITE-WIDE 0 APPLIED CORPORATE-WIDE (AS APPROPRIATE)

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ENFORCEMENT CONFERENCE REGULATORY OVERVIEW (CONT'D)-

PAST PERFORMANCE AND DURATION

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1 0 BROADER ISSUE RESOLUTION BEING TENACIOUSLY PURSUED  ;

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REASONABLY EXPECTED TO SUCCEED

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' QUALIFIED, TRAINED, EXPERIENCED 0 FIRST FAILURE OF SWFCG TO IDENTIFY

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A " PLANT STATUS-TO-WORK"  :

SCRAM-GENERATING MISMATCH

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SWFCG IN PLACE SINCE 6/86

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1 ENFORCEMENT CONFERENCE REGULATORY OVERVIEW (CONT'D1

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PRIOR NOTICE OF SIMILAR EVENTS

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l 0 NONE SPECIFIC TO THIS PARTICULAR EVENT 0 BROADER ISSUE RESOLUTION BEING TENACIOUSLY PURSUED

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B&INTENANCE - RELATED CAUSE I

O WAS A FAILURE TO COMPLY WITH ESTABLISHED WORK CONTROLS 0 NOT A FAILURE TO PERFORM MAINTENANCE

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ENFORCEMENT CONFERENCE REGULATORY OVERVIEW (CONT'D)

SAFETY SIGNIFICANCE  !

0 NO DIRECT NUCLEAR SAFETY SIGNIFICANCE

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SAFETY SYSTEMS FUNCTIONED AS DESIGNED 0 BRUNSWICK PLANT ALWAYS WELL WITHIN ANALYZED CONDITION

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O NO ENVIRONMENTAL CONSEQUENCES

0 NO THREAT TO THE PUBLIC I

0 NO RADIOLOGICAL DOSE LIMITS EXCEEDED

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0 DID NOT INVOLVE CARELESS DISREGARD, DECEPTION, OR OTHER INDICATIONS OF

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ENFORCEMENT CONFERENCE FAILURE TO FOLLOW PROCEDURE SEQUENCE I

MAY 5, 1988 PROCEDURE WRITER

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AS A TECHNICAL UPGRADE, ATTACHMENTS 13 AND 14 (COMPUTER POINT CALIBRATIONS A1713, A1714)

WERE PREPARED FOR ADDITION TO OPIC-CPU 001 MAY 12, 1988 TECHNICAL REVIEWERS (2)

DID NOT IDENTIFY DISCREPANCY BETWEEN ATTACHMENT 13 PROCEDURE PREREQUISITES AND SUMERY SHEET

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j MAY 13, 1988 PROCEDURE REVISION ISSUED AND PREVENTIVE MAINTENANCE (PM) ROUTE ESTABLISHED i

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ENFORCEMENT CONFERENCE Attachment 13 Page 1 of 4

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DATA SHEET 1(2) COMP, PT A1713 (8022)

I UNIT WR/JO N SYSTEM Feedvater WNCTION Feedwater Flow Res. 1 0.26 mVdc

.IDCATION H12 P612 REQUIRED ACCURACY Comp. PT. t 0.03 M1b/hr CIASS ,V 2.0 -REFERENCES 2. Technical Specifications 4.1.1.b, 4.1.2.a.

7 j 4.1.3.2.a. 4.2.1.b 4.2.1, 4.2.2, 4.2.3.1, 4.2.3.2.a, and 4.9.10. l 2. SD 32.2, Feedwater Control System

3.0 PREREQUISITES-k ' PERMISSION WAS RECEIVED FROM THE SHIFT FOREMAN TO PERF0PM PROCEDUR *

SICNATURE DATE

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3. The unit will have to be in cold shutdown or refuel condition, to perform this test, due to the interlocks and controls of this loop (feedwater and recirculation) .

' PRECAUTIONS AND LIMITATIONS 4.1 This instrument is identified in the single point failure-analysi .0 TOO1.S AND EQUIPMENT 5. Ronan X85 calibrator or equivalent 5. Fluke 8600A or equivalent OPIC CPU 001 4 Rev. 9 I

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ENFORCEMENT CONFERENCE Attachment 13A Summary Sheet Page 1 of 1 Date Unit PROCESS INSTRUMENT CALIBRATION SUMMARY SHEET 1(2) COMP. PT. A1713 (B022)

NOTE: This Summary Sheet is provided as an aid to the Shift Foreman and shall not be substituted for the existing l

prerequisites and precautions stated in the procedur ,

PROCEDURE DESCRIPTION This procedure calibrates Process Computer Point COMP. PT. A1713 (8022).

REQUIRED PLANT CONDITIONS None ALTERi? IONS TO PIANT SYSTEMS The internal lead will be lifted from Terminal DD 84 in Panel H12.P612. This will in op Reactor W A Flow Process Computer Point COMP. PT. A1713 (B022).

The internal lead will be lifted from Terminal CC 83 in Panel H12 P612. This will in op Reactor W A Flow Process ERFIS Computer Point C32FA01 ANNUNCIATORS AND AFFECTED INDICATIONS Process Computer Point .RX W A Flow COMP. PT. A1713 (B022).

ERFIS Computer Point C32FA019 POSSIBLE TECHNICAL SPECIFICATION LCO Non !

OPIC. CPU 001 8 Rev. 7

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ENFORCEMENT CONFERENCE FAILURE TO FOLLOW PROCEDURE (CONT'D)

SEQUENCE C0ill'Q l

NOVEMBER 4, 1990 MAINTENANCE PLANNER PULLED AND ISSUED PM ROUTES TO MAINTENANCE _ FOREMAN

o OPIC-CPU 001 ATTACHMENTS 13 AND 14 HAVE A PERFORMANCE FREQUENCY OF 18 MONTH I o THESE PM ROUTES WERE PERFORMED THREE TIMES IN THE PAST DURING PLANT SHUTDOWNS; THEREFORE, THE DISCREPANCY WAS -

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o THE CYCLE FOR THESE PM ROUTES BEGAW ON DECE M R 24, I 1990, WITH AN 01/ERDUE DATE OF MAY 9,199 I JAN. 7, 1991 MAINTENANCE FOREMAN

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REVIEWED UPCOMING PM ROUTES BASED ON

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PROCEDURE REQUIREMENTS, PLANT STATUS, AND

! WORK LOAD BUT MISSED PROCEDURE-TO-SUMMARY ,

SHEET MISMATCH ON ATTACHMENT 13 AND PLANT c "?4TUS NOTES ON 2 OTHER-ATTACHMENT SUBMITTED SCHEDULE WITH 6 COMPUTER POINT PM ROUTES TO SWFC t

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ENFORCEMENT CONFERENCE FAILURE TO FOLLOW PROCEDURE (CONT'D)

SEQUENCE CONT'D JANUARY 14 MCG REVIEWED REQUEST BASED ON OTHER WORK BEING

, PERFORMED AND OPERATIONAL CONSIDERATION QUESTIONED ABILITY TO PERFORM THESE PM ROUTES DURING PLANT OPERATION, RETURNED PM ROUTES

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TO MAINTENANCE SPECIALIST FOR FURTHER REVIE JANUARY 'A MAINTENANCE SPECIALIST ri'IEWED PM ROUTE SUMMARY SHEETS AND IDt.NTIFIED TWO WHICH CCULD NOT BE PERFORMED q ON LINE. DELETED THESE TWO, AND RETURNED F- REMAINING PM ROUTES TO MAINTENANCE FOREMAN

FOR ADDITIONAL REVIE i JANUARY 14 MAINTENANCE FOREMAN I

RE-REVIEWED PROPOSED WORK, BUT AGAIN MISSED ATTACHMENT 13 SUMMARY SHEET ERRO RESUBMITTED SCHEDULE WITH 4 PM ROUTES TO SWFC JANUARY 15 iW._E.CS ACCEPTED RETURNED SCHEDULED BASED ON SECOND REVIEW AND FORWARDED DETAILED WORK PACKAGES TO NIGHT SHIFT SENIOR REACTOR OPERATOR (SRO) .

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g ENFORCEMENT CONFERENCE FAILURE TO FOLLOW PROCEDURE (CONT'D)

SEQUENCE CONT'D

, JANUARY 23 NIGHT SHIFT (SRO)

REVIEWED SUBMITTED PACKAGER, LEAVING ONE QUESTION (UNRELATED TO PL/AT STATUS) FOR FOLLOW-UP WITH DAY SHIFT SRO. QUESTION SUBSEQUENTLY RESOLVED BY DAY SHIFT SR JANUARY 25 MAINTENANCE FOREMAN / TECHNICIANS PREBRIEF PM ROUTE DISC'!LSED AS " ROUTINE" ACTIVIT i PROCEDURE PT.dREQUISITES WERE NOT COVERED DURING PREBRIE I JANUARY 25 TECHNICIANS SEEK 1.ND RECEIVE OPERATIONS SHIFT FOREMAN (SF) APPROVAL SF REVIEWED PROCEDURE SUMMARY SHEE SF AND I SENIOR SF SIGNED WR/JO TO AUTHORIZE WORK STAR TECHNICIAN SIGNED " PERMISSION RECEIVED" STEP IN PROCEDUR JANUARY 25 TECHNICIANS BEGAN TEST (08:10)

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ENFORCEMENT CONFERENCE EVENT CONSEQUENCE SUMMARY 0 FEEDWATER TRANSIENT RESULTING IN CHALLENGE TO SAFETY SYSTEMS-j 0 19 MINUTES AFTER THE SCRAM -- REACTOR WATER LEVEL WAS BEING CONTROLLED WITH NORMAL SYSTEMS 0 SAFETY SYSTEMS RESPONDED AS DESIGNED i

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ENFORCEMENT CONFERENCE ROOT CAUSES 0 PROCEDURE SUtNARY SHEET ERROR i

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ENFORCEMENT CONFERENCE IMMEDIATE CORRECTIVE ACTIONS

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SEQUENCE JANUARY 25 0 CAPTURED AND STOPPED RELATED WORK JANUARY 25 0 CONVENED SITE INCIDENT INVESTIGATION I- TEAM (SIIT)

I JARUARY 25 0 SUSPENDED SHIFT FOREMAN RELIANCE ON SUMMARY SHEETS i

JANUARY 28 0 INITIATED VALIDATION OF SUMMARY SHEETS JANUARY 28 0 REASSIGNED MAINTENANCE FOREMAN COMPLETED BY 0 INVESTIGATED AND CORRECTED EQUIPMENT JANUARY 30 PROBLEMS EXPERIENCED AFTER TRIP FEBRUARY 4 0 CHARTERED A WORKING LEVEL TASK TEAM COMPLETED BY 0 BRIEFED PLANT PERSONNEL ON EVENT FEBRUARY 11 l

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ENFORCEMENT CONFERENCE

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ON-GOING CORRECTIVE ACTIONS AND RESULTS 0 ISSUED BSP-43 TO FORMALIZE SWFCG GUIDELINES

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O CONTINUING EMPHASIS ON IN-PLACE ACTIONS i l 1 0 "PLEASE LISTEN" PROGRAM i ,

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0 AL WATSON "MAKE IT HAPPEN" BRIEFINGS 0 MANAGEMENT EMPHASIS

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ENFORCEMENT CONFERENCE SUMMARY 5 WHYS

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1) WHY DID THIS EVENT OCCUR?

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SUMMARY SHEET ERROR

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2) WHY WAS SUMMARY SHEET IN ERROR?

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INADEQUATE REVIEW

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3) WHY WERE PROCEDURES NOT FOLLOWED?

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WORK CHARACTERIZATION DURING PRE-BRIEF

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4) WHY IS THE EVENT A WORK CONTROL RATHER THAN A GLOBAL PROGRAMMATIC ISSUE?

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MULTIPLE PROGRAMMATIC BARRIERS EXIST

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BROADER ISSUE CORRECTIVE ACTIONS HAVE AND WILL CONTINUE TO REDUCE REOCCURRENCE i PROBABILITY

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5) WHY D0 WE CONSIDER RESPONSE ADEQUATE?

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NO PUBLIC OR NUCLEAR SAFETY IMPACT

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SELF IDENTIFIED

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PROMPTLY AND CONSERVATIVELY REPORTED

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a VERY EXTENSIVE a BROAD SCOPE a TIHELY

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ENFORCEMENT CONFERENCE WORK ASSIGNMENT ROUTINE COMPIACENCY >

INFORMATION INADEQUACIES >

PRESSURE >

DISTRACTIONS >

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ATTITUDE >

! v VORK PERSONNEL ERROR SATISFACTORILY COMPLETED INATTENTION TO

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