IR 05000324/1991001
| 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) | |
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FEB 2 81991
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Docket Nos. 50-325, 50-324 License Nos. DPR-71, DPR-62
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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, 1991.
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 enclosed.
We are continuing our review of these issues to determine the appropriate enforcement action.
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 Rcom.
Should you have any questions concerning this matter, please contact us.
Sincerely, (Original signed by EMerschoff/for)
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Luis A. Reyes, Director
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Division of Reactor Projects
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Enclosures:
1.
List of Attendees 2.
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
FEB 2 81991 cc w/encis:
R. B. Starkey, Jr.
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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FEB 2 81991 Carolina Power and Light Company
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
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02/g7 /91 02/,17/91 02/7/91
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/91 02/pg 1
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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
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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 ROOT CAUSES
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IMMEDIATE CORRECTIVE ACTIONS ON-GOING CORRECTIVE ACTIONS AND RESULTS
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SUMMARY CLOSING REMARKS I
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ENFORCEMENT CONFERENCE REG #LATORY OVERVIEW EVENT SUMMARY (1/25/91)
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PREVENTIVE MAINTENANCE PROCEDURE WAS NOT FOLLOWED
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UNPLANNED REACTOR TRIP
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WORK CONTROL WEAKNESS IDENTIFIED l
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ENFORCEMENT. CONFERENCE REGULATORY OVERVIEW (CONT'D)
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IDH IIFICATION AND REPORTING
SELF IDENTIFIED
PROMPTLY AND COMPLETELY REPORTED L
IMEDIATE CORRECTIVE ACTIONS TAKEN CAUSAL FACTORS AND ROOT CAUSE O
CAUSAL FACTORS IDENTIFIED
ROOT CAUSES DETERMINED AND UNDERSTOOD
CORRECTIVE ACTIONS TO PRECLUDE RECURRENCE O
PROMPT
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COMPREHENSIVE O
SELF INITIATED
APPLIED SITE-WIDE
APPLIED CORPORATE-WIDE (AS APPROPRIATE)
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ENFORCEMENT CONFERENCE REGULATORY OVERVIEW (CONT'D)-
PAST PERFORMANCE AND DURATION
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0 BROADER ISSUE RESOLUTION BEING TENACIOUSLY PURSUED REASONABLY EXPECTED TO SUCCEED
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APPLICABLE FOREMAN AND TECHNICIANS QUALIFIED, TRAINED, EXPERIENCED
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FIRST FAILURE OF SWFCG TO IDENTIFY A " PLANT STATUS-TO-WORK"
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SCRAM-GENERATING MISMATCH SWFCG IN PLACE SINCE 6/86
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~30,000 TASKS REVIEWED
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SWFCG = SITE WORK FORCE CONTROL GROUP f
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ENFORCEMENT CONFERENCE REGULATORY OVERVIEW (CONT'D1
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PRIOR NOTICE OF SIMILAR EVENTS
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NONE SPECIFIC TO THIS PARTICULAR EVENT
BROADER ISSUE RESOLUTION BEING TENACIOUSLY PURSUED B&INTENANCE - RELATED CAUSE
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WAS A FAILURE TO COMPLY WITH ESTABLISHED WORK CONTROLS
NOT A FAILURE TO PERFORM MAINTENANCE
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NOT A FAILURE OF MAINTENANCE PROGRAM
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ENFORCEMENT CONFERENCE REGULATORY OVERVIEW (CONT'D)
SAFETY SIGNIFICANCE
NO DIRECT NUCLEAR SAFETY SIGNIFICANCE SAFETY SYSTEMS FUNCTIONED AS DESIGNED
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BRUNSWICK PLANT ALWAYS WELL WITHIN ANALYZED CONDITION
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O NO ENVIRONMENTAL CONSEQUENCES
NO THREAT TO THE PUBLIC I
NO RADIOLOGICAL DOSE LIMITS EXCEEDED I
DID NOT INVOLVE CARELESS DISREGARD,
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DECEPTION, OR OTHER INDICATIONS OF WILLFULNESS
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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
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Attachment 13 Page 1 of 4
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DATA SHEET 1(2) COMP, PT A1713 (8022)
I UNIT WR/JO NO.
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 2.1.1 Technical Specifications 4.1.1.b, 4.1.2.a.
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 4.9.10.1.c.
l 2.1.2 SD 32.2, Feedwater Control System
3.0 PREREQUISITES-k
'3.1 PERMISSION WAS RECEIVED FROM THE SHIFT FOREMAN TO PERF0PM PROCEDURE.
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3.2.1 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).
'4.0 PRECAUTIONS AND LIMITATIONS 4.1 This instrument is identified in the single point failure-analysis.
5.0 TOO1.S AND EQUIPMENT 5.1.1 Ronan X85 calibrator or equivalent 5.1.2 Fluke 8600A or equivalent OPIC CPU 001
Rev. 9 I
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ENFORCEMENT CONFERENCE
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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 procedure.
PROCEDURE DESCRIPTION
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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 C32FA019.
ANNUNCIATORS AND AFFECTED INDICATIONS Process Computer Point.RX W A Flow COMP. PT. A1713 (B022).
ERFIS Computer Point C32FA019 POSSIBLE TECHNICAL SPECIFICATION LCO None.
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OPIC. CPU 001
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 MONTHS.
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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,
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I JAN. 7, 1991 MAINTENANCE FOREMAN
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REVIEWED UPCOMING PM ROUTES BASED ON PROCEDURE REQUIREMENTS, PLANT STATUS, AND
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WORK LOAD BUT MISSED PROCEDURE-TO-SUMMARY
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SHEET MISMATCH ON ATTACHMENT 13 AND PLANT
"?4TUS NOTES ON 2 OTHER-ATTACHMENTS.
c SUBMITTED SCHEDULE WITH 6 COMPUTER POINT PM ROUTES TO SWFCG.
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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 CONSIDERATIONS.
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QUESTIONED ABILITY TO PERFORM THESE PM ROUTES DURING PLANT OPERATION, RETURNED PM ROUTES TO MAINTENANCE SPECIALIST FOR FURTHER REVIEW.
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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 REVIEW.
i JANUARY 14 MAINTENANCE FOREMAN I
RE-REVIEWED PROPOSED WORK, BUT AGAIN MISSED ATTACHMENT 13 SUMMARY SHEET ERROR.
RESUBMITTED SCHEDULE WITH 4 PM ROUTES TO SWFCG.
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)
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REVIEWED SUBMITTED PACKAGER, LEAVING ONE QUESTION (UNRELATED TO PL/AT STATUS) FOR FOLLOW-UP WITH DAY SHIFT SRO.
QUESTION SUBSEQUENTLY RESOLVED BY DAY SHIFT SRO.
JANUARY 25 MAINTENANCE FOREMAN / TECHNICIANS PREBRIEF PM ROUTE DISC'!LSED AS " ROUTINE" ACTIVITY.
i PROCEDURE PT.dREQUISITES WERE NOT COVERED DURING PREBRIEF.
I JANUARY 25 TECHNICIANS SEEK 1.ND RECEIVE OPERATIONS SHIFT FOREMAN (SF) APPROVAL SF REVIEWED PROCEDURE SUMMARY SHEET.
SF AND I
SENIOR SF SIGNED WR/JO TO AUTHORIZE WORK START.
TECHNICIAN SIGNED " PERMISSION RECEIVED" STEP IN PROCEDURE.
JANUARY 25 TECHNICIANS BEGAN TEST (08:10)
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ENFORCEMENT CONFERENCE EVENT CONSEQUENCE SUMMARY
FEEDWATER TRANSIENT RESULTING IN CHALLENGE TO SAFETY SYSTEMS-j
19 MINUTES AFTER THE SCRAM -- REACTOR WATER LEVEL WAS BEING CONTROLLED WITH NORMAL SYSTEMS
SAFETY SYSTEMS RESPONDED AS DESIGNED i
OPERATOR PERFORMANCE WAS PROPER AND IN
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ACCORDANCE WITH PROCEDURES AND TRAINING
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ENFORCEMENT CONFERENCE ROOT CAUSES
PROCEDURE SUtNARY SHEET ERROR i
O INCOMPLETE PROCEDURE REVIEW AND
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OVER-RELIANCE ON SUMMARY SHEET
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ENFORCEMENT CONFERENCE IMMEDIATE CORRECTIVE ACTIONS SEQUENCE JANUARY 25
CAPTURED AND STOPPED RELATED WORK JANUARY 25
CONVENED SITE INCIDENT INVESTIGATION I-TEAM (SIIT)
I JARUARY 25
SUSPENDED SHIFT FOREMAN RELIANCE ON SUMMARY SHEETS i
JANUARY 28
INITIATED VALIDATION OF SUMMARY SHEETS JANUARY 28
REASSIGNED MAINTENANCE FOREMAN COMPLETED BY
INVESTIGATED AND CORRECTED EQUIPMENT JANUARY 30 PROBLEMS EXPERIENCED AFTER TRIP FEBRUARY 4
CHARTERED A WORKING LEVEL TASK TEAM COMPLETED BY
BRIEFED PLANT PERSONNEL ON EVENT FEBRUARY 11 l
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ENFORCEMENT CONFERENCE
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ON-GOING CORRECTIVE ACTIONS AND RESULTS
ISSUED BSP-43 TO FORMALIZE SWFCG GUIDELINES
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REQUIRES LIMITED USE OF SUMMARY SHEET
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REQUIRES MORE THAN ONE METHOD TO VERIFY
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CONTINUING EMPHASIS ON IN-PLACE ACTIONS
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"PLEASE LISTEN" PROGRAM i
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AL WATSON "MAKE IT HAPPEN" BRIEFINGS
MANAGEMENT EMPHASIS
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ENFORCEMENT CONFERENCE SUMMARY 5 WHYS
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WHY DID THIS EVENT OCCUR?
SUMMARY SHEET ERROR
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ESTABLISHED PROCEDURES NOT FOLLOWED
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2)
WHY WAS SUMMARY SHEET IN ERROR?
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INADEQUATE REVIEW
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WORK PROCESS ESTABLISHED
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(PLANNING FUNCTION AND PROCESS REVIEW)
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3)
WHY WERE PROCEDURES NOT FOLLOWED?
OVER-RELIANCE ON SUMMARY SHEET
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REPETITIVE NATURE OF WORK
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SEVERAL SIMILAR ITEMS RECENTLY PERFORMED
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WORK CHARACTERIZATION DURING PRE-BRIEF I
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l MANAGEMENT EXPECTATIONS NOT INTEGRATED
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INTO SPECIFIC TASKS
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4)
WHY IS THE EVENT A WORK CONTROL RATHER THAN
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A GLOBAL PROGRAMMATIC ISSUE?
INDIVIDUALS' BEHAVIOR WAS NOT
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PREDICTABLE AND-BASED ON TRAINING-SHOULD NOT HAVE OCCURRED MULTIPLE PROGRAMMATIC BARRIERS EXIST
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BROADER ISSUE CORRECTIVE ACTIONS HAVE
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AND WILL CONTINUE TO REDUCE REOCCURRENCE i
PROBABILITY
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s ENFORCEMENT CONFERENCE SUMMARY (CONT'D)
5)
WHY D0 WE CONSIDER RESPONSE ADEQUATE?
NO PUBLIC OR NUCLEAR SAFETY IMPACT
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SELF IDENTIFIED
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PROMPTLY AND CONSERVATIVELY REPORTED
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CORRECTIVE ACTIONS
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VERY EXTENSIVE
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a BROAD SCOPE a
TIHELY
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ENFORCEMENT CONFERENCE WORK ASSIGNMENT ROUTINE COMPIACENCY
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INFORMATION INADEQUACIES
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PRESSURE
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DISTRACTIONS
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ATTITUDE
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v VORK PERSONNEL ERROR SATISFACTORILY COMPLETED INATTENTION TO
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DETAIL
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