IR 05000331/1993013
| ML20046D093 | |
| Person / Time | |
|---|---|
| Site: | Duane Arnold  |
| Issue date: | 08/06/1993 |
| From: | Lanksbury R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20046D083 | List: |
| References | |
| 50-331-93-13-EC, EA-93-187, NUDOCS 9308160122 | |
| Download: ML20046D093 (41) | |
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U. S. NUCLEAR REGULATORY COMMISSION
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REGION I.11 i
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Report No.
50-331/93013(DRP)
EA 93-187'
Docket No. 50-331 License No. DPR-49
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i Licensee:
lowa Electric Light and Power Company
IE Towers
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P. O. Box 351 Cedar Rapids, IA 52406 Meeting Conducted:
July 29,1993 i
Meeting Location:
Region III Office
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799 Roosevelt Road Glen Ellyn, IL 60137 t
Type of Meeting:
Enforcement Conference Inspection Conducted: Duane Arnold Energy Center
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May 22 through July 7,1993, and l
July 22, 1993
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Inspectors:
M. Parker C. Miller i
S. Ray
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Approved By:
%d 8-6-f3 R. D. Lanksb'ury, Chief Date Reactor Projects Section 3B Meetina Summary Enforcement Conference on July 29. 1993 (Report No. 50-331/93013(DRP)
Areas Discussed: Two apparent violations identified during the inspection were discussed along with the corrective actions taken or planned by the licensee. Based on the information presented in the Enforcement Conference.
and further. review by the NRC, two Severity Level IV violations were identified.
The first violation involved the
"A" standby diesel generator being inoperable for a time significantly in excess of that allowed by technical specifications.
The second violation consisted of two examples of failure to follow procedures by control room operators.
In the first example, a control room operator incorrectly performed a step in a surveillance test procedure.
Due to this 9308160122 930806
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{DR ADDCK 05000332 PDR
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failure to follow procedures, control room operators were unaware of the.
status of an important emergency core cooling system component for about 14 hours1.62037e-4 days <br />0.00389 hours <br />2.314815e-5 weeks <br />5.327e-6 months <br /> even though the condition was indicated on the "B" core spray mimic
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panel in the control room.
In the second example, 'on July 22, 1993, an operator omitted a portion of a step in a surveillance test procedure.
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missed portion of the step required the circuit breaker for the "B" core spray, inboard isolation valve to be taken to the "off" position to prevent the valve-from opening during subsequent portions of the surveillance test procedure.
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The step was correctly performed only after the error was pointed out by the'
NRC inspector who witnessed the surveillance test.
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DETAILS l
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Persons Present at the Enforcement Conference f
Iowa Electric Liaht and Power Company
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J. Franz, Jr., Vice President, Nuclear D. Wilson, Plant Superintendent, Nuclear
M. McDermott, Manager, Engineering
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K. Peveler, Manager, Corporate Quality Assurance
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K. Young, Manager, Nuclear Licensing G. Van Middlesworth, Assistant Plant Superintendent, Operations and
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R. Anderson, Supervisor, Operations i
P. Bessette, Supervisor, Regulatory Communications j
D. Blair, Supervisor, Quality Assurance Assessment
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G. Hawkins, Diesel System Engineer D. Robinson, Regulatory Communications
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T. Subbert, Reactor Operator l
U. S. Nuclear Reaulatory ' Commission
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J. Martin, Regional Administrator, Region III E. Greenman, Director, Division of Reactor Projects, Region III J. Hannon, Director, Project Directorate III-3, Nuclear Reactor Regulation (NRR)
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R. DeFayette, Director, Enforcement and' Investigation Coordination j
Staff, Region III
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L. Greger, Chief, Reactor Projects Branch 3, Region III j
B. Berson, Regional Counsel, Region III
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R. Lanksbury, Chief, Reactor Projects Section 3B, Region III R. Pulsifer, Project Manager, NRR C. Miller, Resident Inspector, RIII E. Duncan, Reactor Engineer, Region III Members of the Public R. Brown, Nuclear Services Engineer, General Electric 2.
Enforcement Conference An enforcement conference was held in the NRC Region III Office' on July 29,1993. This conference was conducted as a result of the
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findings of an inspection conducted from May 22 through July 7, 1993, and of an event which occurred on July 22, 1993, in which two apparent violations of NRC regulations were identified.
Inspection report (IR)
50-331/93009(DRP), dated July 23, 1993, documented the results of the inspection conducted from May 22 through July 7, 1993, and section 3 below documents the event which occurred on July 22, 1993.
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The purpose of.this conference was to discuss the apparent violations,
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root causes, contributing factors, and the licensee's corrective actions.
During the enforcement conference, the. licensee presented the event investigation, safety significance, causes, and corrective actions.
The licensee's presentation contained no significant additions to the i
description of the event documented in IR 50-331/93009(DRP).
In addition to the corrective actions documented in IR 50-
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331/93009(DRP), the licensee's presentation indicated that the following
additional corrective actions had been taken following the control room-operator's failure to properly check the status of the
"B" core spray inboard isolation valve as required by Surveillance Test Procedure (STP)~
BS-5, " Control Room Panel Shift Check List:"
Through a records review, the licensee verified the operability of
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redundant emergency core cooling system equipment during the time j
valve M0-2137 was deenergized.
The licensee verified that no other omissions had been made on the
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BS-5 checklist.
The licensee issued a letter to the involved crews which stated
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their performance was unacceptable for this event.
i Interim guidance on the conduct of operations, including shift
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briefings and turnovers, was issued.
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Human factors improvements to the BS-5 checklist were
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accomplished.
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In addition to the corrective actions documented in IR 50-331/93009(DRP), the licensee's presentation indicated that the following i
additional corrective actions were planned or under' consideration following the "A" standby diesel generator (SBDG) being inoperable for a
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time significantly in excess of that allowed by technical specifications and the control room operator's failure to properly perform STP BS-5:
Evaluate the need to notify other nuclear power plants with
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Fairbanks Horse diesel generators of the details of the "A".SBDG failure to start.
(On August 2, 1993, the licensee sent letters to the other nuclear power plants with Fairbanks Morse diesel generators of the details of the
"A" SBDG failure to start.)
Permanent revisions to the shift turnover procedure
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Operator visits to other plants to improve crew' performance
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A copy of the licensee's and NRC's presentations are attached to this report.
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Surveillance Observation On July 22, 1993, during the performance of STP 45A007, " Core Spray System Simulated Automatic Actuation," an operator omitted a portion of Step 7.2.18 and completed Step 7.2.19 before step 7.2.18 was. completed.
Step 7.2.18 had two required actions. The first action verified that valve M0-2137, the "B" core spray inboard isolation. valve, indicated closed on panel 1003 in the main control room. That was performed and the step was " signed off" by the control room operator.
The control room operator then directed the local operator to perform step 7.2.19.
The NRC inspector identified the error to the control room operator and the Operating Shift Supervisor, a licensed senior reactor operator witnessing the STP.
The local operator was stopped before the step was performed and step 7.2.18 was correctly completed.
The second action of the step 7.2.18 required that an operator locally place the circuit breaker for valve M0-2137 in the "off" position.
The purpose of the-second portion of the step was to prevent the valve from opening during subsequent portions of the surveillance test procedure.
Attachments: As stated i
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U.S. NRC REGION lli
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DUANE ARNOLD r
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ENFORCEMENT CONFERENCE July 29,1993
9:00 A.M. (CDT)
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EA 93-187 REPORT NUMBER 50-331/93009
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REGION lli OFFICE 799 ROOSEVELT ROAD, BUILDING 4 GLEN ELLYN, ILLINOIS
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DUANE ARNOLD
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ENFORCEMENT CONFERENCE
Agenda INTRODUCTION AND OPENING REMARKS:
Edward G. Greenman, Director, Division of Reactor Projects DISCUSSION OF ENFORCEMENT POLICY Robert DeFayette, Director, Enforcement and investigation Coordination Staff NRC OVERVIEW:
Edward G. Greenman, Director, Division of Reactor Projects SUMMARY OF EVENTS:
Chris Miller, Resident inspector, Duane Arnold 1.
Diesel Generator inoperability 2.
Crew Performance Weaknesses SUMMARY OF APPARENT VIOLATIONS:
Chris Miller, Resident inspector, Duane Arnold LICENSEE PRESENTATION AND DISCUSSION:
lowa Electric Light and Power Company NRC FOLLOWUP QUESTIONS CLOSING REMARKS:
John Martin, Region ill Administrator PUBLIC QUESTIONS
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SBDG Time-line
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WEDNESDAY, MAY 12 1400 STP completed for the A SBDG, fuel rack reset Overspeed annunciator cleared FRIDAY, JUNE 11
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0844 A SBDG handswitch to " start" for STP, engine rolled a.
few seconds, then trips with overspeed annunciated Engine did not reach actual overspeed conditions e
0917 Operators declare A SBDG inoperable
1215 Completed visual inspection through viewing port i
Trip and reset operations tested 1400 Overspeed reset, STP run sat, A SBDG.available
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Management briefing called for increased
inspections and a root cause evaluation team
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2130 B SBDG operability verified using STP SATURDAY, JUNE 12-1 1400 Diesel manufacturer representative on-site
.i Completed inspection using remote camera Latch, reset and trip assemblies appear intact
,l 1401 A SBDG reset and declared operable ll
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APPARENT VIOLATION 1.
Technical Specification 3.5.G.1 requires, in part, that'during any period when one diesel generator is inoperable, continued reactor operation is permissible only during the succeeding 7 days unless that diesel generator is made operable sooner, if
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this requirement cannot be met, an orderly shutdown shall be initiated and the reactor shall be in at least hot shutdown within the next 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> and in cold shutdown within the following 24
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hours.
CONTRARY TO THE ABOVE I
On or about May 12,1993, the "A" diesel generator became
inoperable, was not restored to operable status within 7 days, and the reactor was not taken to hot shutdown within-the next 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />, or cold shutdown within the following 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
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The apparent violations discussed in this enforcement conference are subject to further review and may be subject to change prior to any resulting enforcement action.
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" Conduct of Opei~ations" Considerations Missed Breaker during STP and Panel Walkdowns
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Inappropriate Annunciators
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Shift Briefing Problems
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Recent Events
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"B" Core Spray Injection isolation Valve Time-line-Tuesday June 29,1993 (Times are approximate)
1700 Tactical drill starts (intruder)
Operations informed.
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1710 Drill players near breaker 1718 Guard inadvertantly opens breaker for valve Green control panel light goes out Containment isolation Monitoring System (CIMS)-
indicates no power to MO2137-- prints out on CIMS printer.
2230 Evening / midnight shift turnover. Severe weather, no other unusual problems. Shift supervisors and panel operators informally walked panels.
2300 BS-5 shift walkdown performed early in shift (as usual) to get detailed panel status. Operator incorrectly documented MO2137 as close.-
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Wednesday. June 30.1993
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0000-Midnight-shift operators performed several other panel walkdowns 0630
0630 Midnight-day shift turnover, informal panel walkdowns occurred.
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0705 BS-5 panel walkdown performed, MO2137 problem
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0706 Operator sent to motor controller for MO2137 at 1B44, l
found it in the off position; restored it to the on position.
CIMS printout indicates power restored.
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APPARENT VIOLATION
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Technical Specification 6.8.1 requires, in part, that written procedures covering normal startup, operation, and shutdown
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of systems and components of the facility be implemented.
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Surveillance Test Procedure (STP) BS-5, a written procedure covering operation of the facility, requires that a control room l
operator check and record the status of plant equipment, and
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indicate those components not in their desired position.
CONTRARY TO THE ABOVE i
On June 29,1993, the midnight shift control room operator failed to properly check and record the status of the "B" core spray inboard isolation valve, and did not indicate that the circuit breaker for the valve was not in the desired position during performance of and as required by STP BS-5.
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The apparent violations discussed in this enforcement conference are subject to further review and may be subject to change prior to any resulting enforcement action.
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DUANE ARNOLD ENERGY CE3TER
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AGENDA
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e OPENING REMARKS JOHN FRANZ VICE PRESIDENT, hTCLEAR
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e DIESEL GENERATOR FAILURE TO START
MICHAEL MCDERMOTT MANAGER, ENGINEERING e CORE SPRAY VALTT
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SUPERVISOR, OPERATIONS
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GARY VAN MIDDLESWORTH
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ASST. PLANT SUPERINTENDENT, OPERATIONS AND MAINTENANCE e CLOSINGREMARKS DAVID WILSON PLANT SUPERINTEhTENT
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DUANE ARNOLD ESERGY CENTER
JOHN FRANZ
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DUANE ARNOLD ESERGY CElNTER ATIENDEES JOHN FRANZ VICE PRESIDENT, NUCLEAR DAVE WILSON PLANT SUPERINTENDENT
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MICHAEL MCDERMOTT MANAGER, ENGINEERING KEN PEVELER MANAGER, CORPORATE QA KEITH YOUNG MANAGER, NUCLEAR LICENSING GARY VAN MIDDLESWORTH ASST. PLANT SUPERINTENDENT OPERATIONS AND MAINTENANCE
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RICHARD ANDERSON SUPERVISOR, OPERATIONS GARY HAWKINS SYSTEM ENGINEER, EDG DEBORAH ROBINSON REGULATORY COMMUNICATIONS PAUL BESSBITE SUPERVISOR, LICENSING DOUG BLAIR SUPERVISOR, QA ASSESSMENT
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TERYLSUBBERT NSOE REACTOR OPERATOR i-
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DUAXE ARN OLD EFERGY CEbTER MICHAEL MCDERMOTT u
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DUASE ARNOLD ESERGY CESTER A CHRONOLOGY OF EVENTS A ROOT CAUSE A CORRECTIVE ACTIONS
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DLASE ARNOLD ENERGY CENTER CHRONOLOGY OF "A" EDG TRIP / TROUBLESHOOTING JUNE 11,1993 A "A" EDG SURVFIT T ANCEIN PROGRESS A "A" EDG HANDSWITCH TO START (0844:45)
i A "A" EDG TRIPPED (0844:48)
A SYSTEMSENGINEERING/ MECHANICAL MAINTENANCE TROUBLESHOOTING
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A "A"EDG DECLARED INOP A MANAGEhENTMEE11NG-PREPARE FOR MORE DETATIFn EXAMINATION-REMAININ LCO-RESTORE TO AVAILABLE STATUS A "B" EDG SURVRTI.T ANCE COMPLETED SUCCESSFULLY JUNE 12,1993 A "A" EDG REMOVED FROM SERVICE A VENDOR REPRESENTATIVE INSPECTION CAMERAINSPECIION A DECLARED "A" EDG OPERABLE A PROVIDED ENHANCED OPERATOR GUIDANCE
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IN RESETTING THE TRIP MECHANISM
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DUASE ARNOLD EXERGY CESTER H
CORRECTIVE AC110NS t
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DUANE ARNOLD ENERGY CENTER EMERGENCYDIESEL GENERATOR AVAILABILITY 3 YEAR DISTRIBUTION (3/90- 3/93)
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PERCENTAVERAGEAVAILABILITY y,gg
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DUANE ARNOLD ENERGY CEbTER l-i t
SUMMARY A ALL INDICATIONS WERE DG PROPERLY RESET
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A PROMPT AND EXTENSIVE MANAGEMENT
INVOLVEMENT A COMPREHENSIVE ROOT CAUSE ANALYSIS A NO PRIOR NOTICE
A EXCELIRNTOPERATINGHISTORY
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A CORRECTIVE ACTIONS
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DUANE ARNOLD ESERGY CESTER SAFETY SIGSIFICANCE
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A DISCOVERED BY SCHEDULED SURVEILLANCE
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A REQUIREMENTS FOR CONTINUED OPERATION
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A OPERATOR ACTION TO RESTORE TO SERVICE A IMPACT ON DAEC PROBABILISTIC RISK ASSESSMENT
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DUANE ARb OLD ENERGY CEbTER RICHARD ANDERSON OPERATIONS, SUPERVISOR
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DUANE ARNOLD ENERGY CENTER l
i TOPICS TO BE COVERED:
A CHRONOLOGY OF THE EVENT i
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SAFETY SIGNIFICANCE a
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A CORRECnVE ACTIONS IMMEDIATE CORRECTIVE ACTIONS-ADDITIONAL CORREC11VE ACTIONS CORRECTIVE ACTIONSIN PROGRESS
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EXPECTATIONS FOR CREW PERFORMANCE'
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DUANE ARNOLD ENERGY CEbTER
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CHRONOLOGY OF EVENTS JUNE 29,1993 A 1700 - SECURITY DRILLIN PROGRESS
A 1718 -BREAKER INADVERTANTLY DEENERGIZED A 2300 - SHIFI' TURNOVER AND SHIFILY PANEL l
CHECKLIST PERFORMED i
JUNE 30,1993 i
A 0700 - SHIFI' TURNOVER A 0705 - POSITIONINDICATION IDEN11FIED
A 0706 - BREAKER ENERGIZED
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DEASE ARNOLD ESERGY CENTER SAFETY SIGNIFICANCE
A REDUNDANTSYSTEMS ALL OPERABLE A OPERATOR RESPONSE TO VALID INITIATION SIGNAL i
A BASIC RISK RATE FOR OPERATIONS UNCHANGED
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g UP TO SEVEN DAY LCO A NO MEANINGFUL CONTRIBUTION TO CORE MELT FREQUENCY CONFIRMED BY DAEC ANALYSIS GROUP
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A MINOR SAFETY SIGNIFICANCE, THE REALISSUEIS CREW PERFORMANCE
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DUAbE ARNOLD EFERGY CENTER IMMEDIATE CORRECnVE ACTIONS A REENER.GIZED BREAKER A VERIFIED OPERABILITY OF REDUNDANT EQUIPMENT
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A VERIFIED NO OTHER OMISSIONS MADE ON SHIFILY PANEL CHECKLIST
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DEANE ARNOLD ENERGY CENTER ADDITIONAL CORRECnVE ACTIONS COMPLETED A LETTERISSUED TO INVOLVED CREWS A PERSONNEL ACCOUNTABILITY FOR INCORRECTLY PERFORMED SURVEILLANCE A INTERIM GUIDANCE ON CONDUCT OF OPERATIONS INCLUDING SHIFT TURNOVER j
^ ROOT CAUSE REVIEW A HUMAN FACTOR IMPROVEMENTS TO ShlFILY PANEL CHECKLIST A MANAGEMENT MEETING WITH OPERATING CREWS I
CORRECTIVE ACTIONS IN PROGRESS A PERMANENTREVISIONS TO SHIFTTURNOVER PROCEDURE
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A BARRIERS CONSTRUCTED A OPERATOR PLANT VISITS
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DUANE ARNOLD ENERGY CENTER SUMMARY
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A MINOR SAFETY SIGNIFICANCE-BASIC RISK FOR OPERATION UNCHANGED A PROMPT AND THOROUGH CORRECTIVE ACTIONS A SELFIDEN11HED AND REPORTED A GOOD PAST PERFORMANCE
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DUANE ARNOLD ENERGY CENTER PROFESSIONAL OPERATOR J
CODE OF ETHICS
...IN PURSUIT OF EXCELLENCE WE SHALLACTIVELY STRIVE TO:
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e MAINTAIN AHIGH PERSONAL STANDARD OF HONESTY, INTEGRITY AND PROFESSIONALISM.
e OPERATE SAFELY BY ADHERING TO
ESTABLISHED PROCEDURES AND
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OPERATING PRACTICES.
- CONTINUE TO IMPROVE AND MAINTAIN A HIGH LEVEL OF KNOWLEDGE AND SKILLS
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THROUGH TRAINING, SELF STUDY AND l
PERSONAL EXPERIENCE.
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e BE OBSERVANT ON DUTY AND e
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AGGRESSIVELYMONITOR AND RESPOND TO PLANT CONDITIONS.
e PROVIDE A SAFE, RELIABLE AhT
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EFFICIENT SOURCE OF ELECTRICITYTO
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THE PUBLIC, o PROMOTE AN A1in ODE OF
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TEAMWORK, RESPECT AND COOPERATION AMONG ALLPERSONNEL.
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a DUASE ARNOLD ESERGY CESTER
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GARY VAS MIDDLESWORTH
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ASST. PIAST SUPERI:5TE:SDE:ST OPERATIONS ASD MAI:NTE:SANCE q
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DUANE ARNOLD ENERGY CENTER STANDARDS AND EXPECTATIONS FOR
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OPERATIONS
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DUANE ARNOLD ENERGY CENTER A IMPROVING CAPACITY FACTOR A DECREASING FORCED OUTAGE RATE A TRENDSINPERFORMANCE I
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DLANE ARNOLD ENERGY CENTER FEEDBACK ON PERFORMANCE A SELF ASSESSME:ST i
A QA A INDUSTRY PARTICIPATION A:SRC A PEER EVALUATIONS
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DUANE ARNOLD ENERGY CE:5TER FEEDBACK ON PERFORMANCE A MANAGEMENT
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DEANE ARNOLD ENERGY CEhTER
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DAVE WILSON
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I PLAST SUPERI:NTENDEST
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