IR 05000346/1984015
| ML20132C605 | |
| Person / Time | |
|---|---|
| Site: | 05000000, Davis Besse |
| Issue date: | 12/26/1984 |
| From: | Taylor J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | Williams J TOLEDO EDISON CO. |
| Shared Package | |
| ML20132B273 | List:
|
| References | |
| EA-84-095, EA-84-95, NUDOCS 8501030255 | |
| Download: ML20132C605 (1) | |
Text
{{#Wiki_filter:5 ' . . . . . DEC 2 61984 ' Docket No. 50-346 EA 84-95 - Toledo Edison Company ATTN: Mr. John P. Williamson . Chairman and Chief Executive Officer Edison Plaza 300 Madison Avenue Toledo, Ohio 43652 Gentlemen: Pursuant to your request for an extension of the response due date for alleged violations identified in Inspection Report No. 50-346/84-15, and based on the circumstances detailed in your letter of Cecember 10, 1984 (Serial No.
1-485), we hereby grant the extension as you requested. The new response due date is January 15, 1985.
Sincerely, M James M. Taylor, Director - Office of Inspection and Enforcement Nrad h i 12/21/84 1/)l/84 /pf84 [A m ur _;p - ySeJS3% D rs
' . . Docket No. 50-346 TOLEoD EDISON License No. NPF-3 , RC uac P Caoust Serial No. 1-485 .y.
mems mt Decembe r 10, 1984 Mr. James M. Taylor, Deputy Director Office of Inspection and Enforcement United States Nuclear Regulatory Commission Washington, D.C.
20555
Dear Mr. Taylor:
By letter dated November 21, 1984, (l.og No. 1-1062) the NRC transmitted to the Toledo Edison Company a Notice of Violation and Proposed Imposition of Civil Penalties for alleged violations identified in Inspection Report No. 50-346/84-15(DRP).
Pursuant to the provisions of 10 CFR Part 2.201, Toledo Edison is required to submit a written response to the Notice of Violation under oath or affirmation by December 21, 1984 for the Davis-Besse Nuclear Power Station Unit No. 1.
In order to provide a complete and detailed response to the Notice of Violation, Toledo Edison hereby respectfully requests an extension of the response due date to January 15, 1985 based on the following circumstances: , 1.
Tctedo Edison is preparing its response (due mid December 1984) to the NRC Performance Appraisal Inspection Report.
2.
Toledo Edison is preparing for a December 20, 1984 meeting designed to discuss the upcoming NRC Systematic Assessment of Licensee Perform-ance Inspection Report.
3.
Davis-Besse Nuclear Power Station is nearing the end of its current refueling outage and, therefore, Toledo Edison's manpower leval requirements are extensive.
The outage is scheduled to end in late December to ensure adequate power requirements are available during the Winter season.
Therefore, based on the above, Toledo Edison requests an extension of the response due date to January 15, 1985.
Very truly yours, RPC:MOR: CAB:lah cc: Regional Administrator DB-1 NRC Resident Inspector THE TCLECO ECISCtJ CCMPANY ECiSCtd PLAZA 300 MAC!SCtJ AVENUE TCLLCO. CHiO 43652 gM 2.L %LySd P-DEC 2 41984
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NOV 21 leg 4 . . Docket No. 50-346 ! EA 84-95
Toledo Edison Company ATTN: Mr. John P. Williamson Chairman and Chief Executive Officer Edison Plaza 300 Madison Avenue Toledo, OH 43652 Gentlemen: This refers to the safety inspection conducted by Messrs. W. G. Rogers and D. C. Kosloff of the Region III staff during the period June 11 through July 27, 1984 of activities at the Davis-Besse Nuclear Power Station authorized by Operating License No. NPF-3.
The results of the inspection , were discussed on July 13, 1984 during an Enforcement Conference held in the ' Region III office between Mr. R. P. Crouse and others of your staff and Mr. C. E. Norelius and other members of ti e NRC staff and on October 2,1984 during a meeting between Mr. W. A. Johnson and others of your staff and Messrs. R. C. DeYoung and J. G. Keppler of the NRC.
The following violations were identified during the inspection.
- , On May 7, 1984, both Control Room Emergency Ventilation System (EVS) chiller control switches were discovered in the "off" position.
This rendered both Control Room EVS trains inoperable.
Your program failed to recognize the technical specification requirements for the operability of the equipment and your program failed to ensure that procedures were followed to verify the operability of the equipment.
. On November 1,1983, one of the two ventilation fans for the Number One Emergency I Diesel Generator was removed from service.
You failed to recognize that removal of this ventilation fan from service represented a change in the facility as described in the Updated Safety Analysis Repurt (USAR).
This change affected the ' design basis requirements for equipment operability.
In addition, the required , review in accordance with 10 CFR 50.59 was not conducted.
l On December 19, 1982, you initiated a Facility Change Request that was implemented i on May 24, 1983 that changed the position cf the suction valve to the startup . feed pump to the open position instead of closed as required by the design basis analysis for flood protection.
On May 14, 1984, you determined one auxiliary ' feedwater pump was inoperable as this valve was open contrary to USAR requirements.
You immediately closed the suction valve and modified procedures to control the opening and closing of this valve.
During recovery activities following a unit trip on June 25, 1984, the suction valve was routinely used for unit startup.
On July 1, 1984, you again discovered the suction valve was open rather than , CERTIFIED MAIL i l RETURN RECEIPT REQUESTED , f*f.#d. MhN hg ' ,. - _. ...- -_ - -. - . _ _ - - -.- . -. . -
' ' . . NOV 21 1334 Toledo Edison Company
closed.
A review of these occurrences determined that an adequate 10 CFR 50.59 review was not conducted, that approved procedures for operating the system were not followed, and that operators failed to implement the corrective actions you initiated following the discovery of this problem on May 14, 1984.
In addition, a recent Performance Appraisal Inspection identified additional deficiencies with regard to the conduct of reviews in accordance with the requirements of 10 CFR 50.59.
This inspection also identified two examples when on March 8, 1984 and May 4, 1984, lead shielding was hung on decay heat piping and no safety evaluations in accordance with 10 CFR 50.59 were performed.
These events indicate the need for significant improvement in your ability: 1) to recognize the design basis and technical specification requirements for equipment operability and to ensure that these requirements are met when equipment is removed from service and 2) to ensure that procedures which define requirements for equipment operability are f611 owed.
These events also indicate the need to ensure that adequate corrective actions are taken to preclude repetition of identified deficiencies.
During the September 23, 1982, Systematic Assessment of Licensee Performance (SALP), we identified a weakness in your ability to recognize design basis requirements for equipment operability.
The NRC Region III staff restated this concern during an Enforcement Conference on March 9, 1983 and again during the October 28, 1983 SALP.
As a result of the March 9, 1983 Enforcement Conference, you committed to implement a Comprehensive Corrective Action Program to address these and other concerns.
You also assured us that other administrative measures were being implemented to deal with these problems.
However, your _ corrective actions have been ineffective as evidenced by your failures to recognize design basis requirements for safety-related equipment / systems.
j To emphasize the need for the licensee: (1) to recognize the importance of ! design basis and technical specification requirements for equipment operability and to ensure that these requirements are met when equipment is removed from service, (2) J ensure that procedures which define the requirements for equipment , ' operability z e followed, (3) to ensure that appropriate reviews are conducted in accordance ith the requirements of 10 CFR 50.59, and (4) to ensure that l adequate corn tive actions are taken to preclude repetition of identified problems, ....e been authorized, after consultation with the Deputy Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation
and Proposed Imposition of Civil Penalties in the cumulative amount of Ninety Thousand Dollars (590,000) for the violations described in the enclosed Notice.
The violations have been categorized in tne aggregate as two Severity Level III ' problems in accordance with the General Policy and Procedure for Enforcement Actions, 10 CFR Part 2, Appendix C, and the Policy as revised, 49 FR 8583 (March 8, 1984).
The base civil penalty for Item I is $50,000.
The base civil penalty for Item II is $40,000 because two of the violations identified occurred prior to the revisions to the recent Enforcement Policy.
i !
., _ _- . .. . ' . t Toledo Edison Company
NOV 211934 You are required to respond to the enclosed Notice and you should follow the instructions specified therein when preparing your response.
Your response should specifically address the corrective actions you will take to increase management involvement and oversight and to reduce personnel errors.
Your reply to this letter and the results of future inspections will be considered in determining whether further enforcement action is warranted.
In accordance with 10 CFR 2.790, " Rules of Practice," a copy of this letter and the enclosure will be placed in the NRC Public Document Room.
The responses directed by this letter and the accompanying Notice are not subject to the clearance procedure of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
Sincerely, 2.;Q,-/)J . s, I e ames G. Keppl ,, Regional Administrator
Enclosures:
1.
Notice of Violation and l Proposed Imposition of Civil Penalties
2.
Inspection Report No.
. 50-346/84-15(DP9)
REGION III== . Report No. 50-346/84-15(DRP) _ Docket No. 50-346 License No. NPF-3 Licensee: Toledo Edison Company Edison Plaza, 300 Madison Avenue Toledo, Ohio 43652
Facility Name: Davis-Besse 1 Inspection At: Oak Harbor, OH
Inspection Conducted: June 11 through July 27, 1984 Inspectors: W. Rogers I ! D. Kosloff f.,/cjL/ ' %W / G< r Approved By: 1. N. Ja iw, Chief ! Project / Section 2B Date -
Inspection Summary ' Inspection on June 11 through July 27, 1984 (Report No. 50-346/84-15(ORP)) Areas Inspected: Special inspection of the circumstances surrounding three < i events: the discovery of both control room emergency ventilation systems being incapable of performing their air conditioning function; removal of an emergency diesel generator ventilation fan from service without declaring the diesel inoperable; and inoperable auxiliary feed pump due to an open startup feed pump,uction valve.
The inspection involved 30 inspector-hours onsite by two NRC inspectors including 4 inspector-hours onsite during off-shifts.
j Results: Five items of noncompliance were identified (both trains of the control room emergency ventilation system made inoperable; emergency diesel ventilation supply fan taken out-of-service rendering the diesel generator inoperable; one auxiliary feedwater pump inoperable due to an open startup feed pump suction valve; procedures for startup feed pump and shift turnover not adhered to; improper 10 CFR 50.59 determination that changing the position of a SUFP valve , ! did not constitute a change in the facility).
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. _ . . DETAILS 1.
Persons Contacted - T. Murray, Station Superintendent - B. Beyer, Assistant Station Superintendent S. Quennoz, Assistant Station Superintendent D. Miller, Operations Engineer L. Simon, Operations Supervisor J. Faris, Administrative Coordinator The inspectors also interviewed other licensee employees, including members of the technical, operations, maintenance, I&C, training and health physics staff.
Enforcement Conference on July 13, 1984 Toledo Edison personnel R. P. Crouse, Vice President, Nuclear Mission T. D. Murray, Station Superintendent J. Helle, Engineering Division Director , i T. Myers, Nuclear Services Director J. Lingenfelter, Technical Engineer R. Peters, Nuclear Licensing Manager NRC Personnel - - C. E. Norelius, Director, Division of Reactor Projects W. D. Shafer, Chief, Projects Branch 2 I. N. Jackiw, Chief, Projects Section 2B W. G. Rogers, Senior Resident Inspector D. C. Kosloff, Resident Inspector 2.
Control Room Emergency Ventilation System Inoperable a.
Background Information Davis-Besse Technical Specification Limiting Condition for , Operation 3.7.6.1 requires two independent control room emergency ' ventilation systems (CREVS) to be operable in Modes 1, 2, 3 and 4.
' Both independent systems are the same with redundant 100% capacity capable of performing the two safety functions associated with a CREVS.
The two safety functions are: (1) Maintain the ambient air temperature below the maximum allowable temperature for continuous duty rating for the equipment and instrumentation cooled . by this system and (2) Maintain the control room habitable for ' operations personnel during and following all credible accident conditions.
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. . A CREVS is composed of three subsystems.
The first subsystem circu-lates air through the control room via a 3300 cfm centrifugal fan and associated ventilation ducting.
The second subsystem cools the air passing through the first subsystem by a cooling coil located in the ductwork of the first subsystem.
The cooling medium is freon R-12 which is supplied to the cooling coil via a compressor and associated piping.
The third subsystem cools the freon in the second subsystem.
This is accomplished by either an air-cooled condensing unit or a service water cooled heat exchanger, depending upon the outside temperature conditions, b.
Event At 0930 on May 7, 1984, the licensee was preparing to perform the 15 minute flow test required every 31 days by Technical Specification surveillance requirement 4.7.6.1.b.
The licensee's procedure for this test is ST 5076.01, Control Room Emergency Ventilation Monthly Test.
The first prerequisite in ST 5076.01 is to verify that the "on-off" switch powering the freon compressor on the second subsystem is in the "on" position.
The operator performing the prerequisite observed the switch to be in the "off" position.
The operator also observed that the control switch to the other freon compressor was also in the "off" position.
The operator immediately notified the shift supervisor of the situation.
The shift supervisor directed that the switches be repositioned to the "on" position and ST 5076.01 be. performed on both independent CREVSs.
The shift supervisor then logged that Technical Specification 3.0.3 was invoked for two inoperable CREVSs.
ST 5076.01 was successfully completed on both ventilation systems, the systems declared operable ~ and the unit removed from Technical Specification 3.0.3 requirements within an hour.
Technical Specification 3.7.6.1, Control Room Emergency Ventilation System, requires that two independent control room emergency ventilation systems be operable in Modes 1, 2, 3 and 4.
Technical Specification 6.8.1.a requires that procedures be established, implemented and maintained covering the applicable procedures recom-mended in Appendix "A" of Regulatory Guide 1.33, November 1972.
Administrative procedures delineating responsibilities for plant operation and shutdown are listed in Appendix "A" of Regulatory Guide 1.33.
The licensee's Administrative Procedure AD 1839.00.9, Station Operations, requires that during removal from service of a system or component, the operability of redundant safety-related equipment shall be verified by inspection and an evaluation be made of Technical Specification Action Statements.
Between April 23, 1984 and May 7, 1984, the air conditioning portions of both trains of the Control Room Emergency Ventilation System (CREV) were removed from service without complying with AD 1839.00.9.
This resulted in both trains of the Control Room Emergency Ventilation System being inoperable.
Failure to follow procedures and ensure operability of both CREVs is a violation (346/84-15-01A).
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. c.
Licensee Followup of the Event A deviation report was written on this event and an investigation into the event was initiated.
The deviation report is the ' licensee's mechanism for reporting conditions adverse to quality under Criterion XVI of 10 CFR 50 Appendix B.
The licensee issued LER 84-005 on June 6, 1984 documenting the event and the~results of the investigation.
The LER attributed the apparent cause of the occurrence to personnel not returning the switches to the "on" position following preventive maintenance on the systems.
The switches were being positioned to the "off" position and then back to the "on" position to check proper freon compressor per-formance under the statement " Check pump down system" on the instructions for performing preventative maintenance attached to the maintenance work order.
d.
NRC Followup Upon notification the inspector began an inspection into the circumstances surrounding the event.
Following a review of the system drawings the inspector requested that the licensee perform a safety analysis assuming both CREVSs were incapable of performing their air-conditioning function to determine the safety significance associated with this condition.
This request was made on June 7, 1984, during an exit interview for IE Report 84-06.
The inspector continued the review of the event based on the information supplied in LER 84-005.
The inspector interviewed the personnel involved with the ventilation system preventative . maintenance program.
Based upon those discussions and record review of when preventative maintenance and surveillance testing were accomplished it became apparent that the positioning of both control switches to the "off" position could not have been done under the approved preventative maintenance program.
The last preventative maintenance performed on a CREVS was on April 4, 1984.
ST 5076.01 had since been performed for CREVS #1 on April 9, 1984 and on April 23, 1984 for CREVS #2.
The inspector found no indica-tion that the switches were in the "off" position during those tests.
Therefore, the switches were repositioned sometime between April 23, 1984, and May 7, 1984.
The inspector reviewed maintenance work orders assigned to the CREVS startup system number for that time period and could not find any maintenance work that would account for the control switches being in the "off" position.
The licensee was informed of the inaccuracy of attributing the event to the pre-ventative maintenance personnel and is revising the LER.
This is considered an open item (346/84-15-02) until the LER is revised.
During the review of the preventative maintenance program the inspector noted that during the quarterly preventative maintenance activities the CREVSs were not being declared inoperable even though the air-conditioning portion of the CREVSs were being disabled.
. . The licensee had established administrative controls in AD 1844.00, Maintenance, to keep this from occurring. These controls were accomplished by the completion of an attachment to the maintenance work order entitled " Tech Spec Equipment Operability Checkoff List" by the maintenance staff.
This checkoff list required a written determination as to whether the maintenance activity authorized by the maintenance wor.k order affected operability of any Technical Specification equipment.
The maintenance work order and the checkoff list was then reviewed by the shift supervisor for concurrence of the maintenance staff's opera-bility determination.
The operability determination associated with the quarterly preventative maintenance on the CREVSs was being made by the maintenance staff and concurred with by the shift supervisor as not affecting system operability on the Tech Spec Equipment Operability Checkoff List.
The inspector also noted that the only formalized training require-ments, as delineated in the AD 1828 series on training of the - maintenance staff, was General Orientation Training.
This training did not cover Technical Specifications and the Updated Safety Analysis Report operability requirements of safety systems.
e.
Safety Significance Assessment The analysis requested by the inspector (reference 2.d above) and discussed in the July 13, 1984, enforcement conference was presented to the inspector in a meeting with the Engineering Division Director on July 19, 1984.
The analysis stated "...it is felt that if a situation were to occur where the emergency ventilation system was _ ' inoperable' due to the compressors not functioning, it would be recoverable in sufficient time so as not to affect the operability of control / monitoring equipment and/or the safety of the plant."
' The inspector reviewed the licensee's analysis against the two safety functions assigned in the bases of Technical Specifications for CREVS.
The inspector concluded that the safety function of the habilitability of the control room for all creditable accident functions was not affected by the loss of the freon compressors since the isolation of outside air to the control room was not affected.
Based on the licensee's "after the fact" analysis, the inspector concluded that the safety function of maintaining the control room temperature below maximum instrumentation / equipment ratings, though degraded, would have been minimized through reasonable operator action.
3.
Emergency Diesel Generator Ventilation Fan Taken Out of Service While reviewing the licensee's safety tag log and the jumper / lifted wire log on November 1, 1983, the inspector observed that an emergency diesel generator (EDG) #1 ventilation supply fan had been taken out of service at 0600 and returned to service at 1055.
The inspector determined that
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. this maintenance activity made the diesel generator inoperable based on a review of Section 9.4.2.1.2 and Table 9.4-4 of the Update Safety Analysis Report (USAR).
The USAR states that the two supply fans associated with one EDG are each 50% capacity fans.
The unit was in Mode 1 for all of November 1, 1983.
Technical Specification 3.8.1.1 requires two operable EDGs.in-Mode 1, 2, 3 and 4.
If an EDG becomes inoperable the action statement requires the licensee to demonstrate the operability of the offsite power sources by performing a breaker alignment and power availability check, and demonstrate the operability of the unaffected EDG.
These actions are required to be performed within one hour of the EDG being declared inoperable.
Since the maintenance staff and shift supervisor had determined that the EDG would be operable during the maintenance activity, the affected EDG was not declared inoperable.
The failure to recognize that the maintenance activity made the EDG inoperable is considered an example of an item of noncompliance against Technical Specifications 3.8.1.1 (346/84-15-Olb).
After the event was brought to the licensee's attention by the inspector an analysis of the EDG ventilation requirements was performed.
The analysis concluded that only one of the two supply fans was required , if the ambient outside temperature was less than 68 F.
During the time the supply fan was out of service the highest ambient outside temperature was 59'F.
A 10 CFR 50.59 review was not conducted to determine the acceptability of this analysis.
This is considered an open item (346/84-15-03).
The licensee requested general ventilation requirements for equipment _ operability from their architect-engineer after this event occurred.
The architect-engineer provided a list to the shift supervisors identifying general ventilation systems required for operability of safety related equipment.
In addition, licensee management developed administrative controls requiring their concurrence prior to placing these systems in an abnormal configuration.
The inspector reviewed procedure, SP 1107.11 Emergency Diesel Generator Operating Procedure and noted that the procedure did not reflect the requirement for two ventilation supply fans to be operable. Also, a licensee review of the procedure was conducted on August 26 and October 17, 1983 without identifying this deficiency.
The inspector ascertained that the cognizant individual responsible for the above review was not aware of the Updated Safety Analysis Report (USAR) require-ment.
In the response to IE Report 83-01 the licensee committed to increase emphasis on design assumptions by providing procedure reviews with the related USAR sections for their use during annual procedure reviews.
Selection of the USAR sections was to be by a computer program that correlates USAR sections to inputted keywords.
The keyword computer index utilized by the licensee did not reference the ventilation USAR section when the "EDG" keyword was inputted.
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. . . 4.
Auxiliary Feed Pump Inoperable a.
Background Information _.
The Startup Feed Pump (SUFP) system is a system which provides secondary cooling during plant startup and shutdown.
The system is composed of discharge piping, a pump, suction piping and manual valves.
The discharge piping connects to the common main feedwater piping upstream of where the main feedwater piping splits to each of the steam generators.
The pump is electric driven and its maximum heat removal capacity is 1-2% reactor power.
The suction piping for the SUFP goes through the two auxiliary feed pump rooms to two water sources, the deaerator storage tank and the condensate storage tank.
On May 14, 1984, the licensee determined that one auxiliary feedwater pump (AFWP) was inoperable because Figure 10.4-12 of the Updated Safety Analysis Report (USAR) was not being complied with.
This USAR requires the startup feedwater pump (SUFP) suction isolation valves from the deaerator tank (FW 32) and from the condensate storage tank (FS 91) to be closed to prevent flooding of the auxiliary feedwater pump rooms during a medium energy pipe break.
One suction valve (FW 32) to the startup feed pump mentioned in the USAR was being maintained open per the Startup Feed Pump Operating Procedure SP1106.27, and the Turbine Plant Cooling Water Operating Procedure SP 1104.39.
Therefore, the auxiliary feedwater pumps were not being protected from flooding in the event of a medium energy pipe break.
. To ensure operability of the AFWP and to ensure compliance to Figure 10.4-12 of the USAR, the licensee closed the valve in question, removed the fuses for the SUFP breaker and wrote temporary modifica-tions (T-Mods) to all affected procedures to maintain the valve closed except when the startup feed pump was in service.
In addition, on June 14, 1984 the licensee determined that the , original Safety Analysis Report did not encompass all the break spectrums associated with the startup feedpump piping.
The licensee had not taken into account a high energy break of the discharge piping.
The licensee shut the discharge valve and changed applicable procedures to reflect this condition.
b.
Event On June 24, 1984, the plant tripped during surveillance testing of the control rod drive trip breakers due to a personnel error.
During the recovery from the reactor trip the licensee placed the startup feedwater pump (SUFP) in service.
The SUFP was shut down following plant startup activities on June 25, 1984, however, the SUFP's suction valve (FW 32) was again left open.
The valve was found open by an equipment operator on July 1, 1984.
This rendered an
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. . auxiliary feed pump inoperable from June 25 to July 1,1984 in excess of the 78. hours allowed by the Technical Specifications for Mode 1.
The plant was in Mode 1 during the June 25 to July 1, 1984 time period.
This is considered an item of noncompliance for failure to meet a Limiting Condition for Operation (346/84-15-01C).
' c.
Followup of Event . The inspector interviewed the investigating personnel and the personnel involved in the startup and shutdown of the startup feed pump.
Based on these inputs the inspector ascertained that the Startup Feedwater Operating Procedure was not properly used to start the pump and the procedure was not used to shut the pump down.
Evidently, when it came time to shut down the SUFP the assistant shift supervisor provided the equipment operator with a list of valves he wished repositioned after shutting down the pump.
One of the valves on the piece of paper was FW32, the SUFP suction valve.
The equipment operator repositioned all the valves except FW32.
Prior to the repositioning of this valve the equipment operator was called away to the switchyard.
The shift supervisor was informed that the valve had not been repositioned.
The need to close FW32 was lost during the next shift turnover. This is considered an example of an item of noncompliance (346/84-15-1C) for failure to conduct an adequate turnover.
During the next shift, the shift supervisor directed an operator to check some of the startup feed valves for proper position.
The operator reported that all valves were properly positioned and erroneously identified normally closed valve FW 33 as FW 32.
- The inspector performed a record review of applicable logs and procedures.
The results of that review were: (1) Sections of SP 1105.27 and 1106.27 (startup and shutdown of the SUFP) were not signed off for starting and shutting down the SUFP as required.
Prerequisites, action steps and valve checklist steps were not signed.
(2) Trip Recovery Procedure PP 1102.03 step 4.2.2. as amended by T-cod 8048, was initialed annotating that the SUFP was started per SP 1106.27.
(3) Plant Startup Procedure PP 1102.2, step 8.1.4, as amended by T-Mod 8047, was initialed annotating that the SUFP had been stopped per SP 1106.27.
(4) Temporary Modifications (T-Mods) for Procedures PP 1102.03 and SP 1106.27 were still attached even though other more recent T-Mods had deleted these T-Mods.
This is normal practice on T-Mods that have been authorized for use but had not been approved by the onsite safety review committee.
. . . . (5) Temporary modification 8057 as written was inadequate to start the SUFP and assure proper operation.
One step in the procedure instructs the operator to start the SUFP even before the installation of the power fuses to the pump's_ breaker.
Other steps in the procedure are not referenced as required to be performed after the pump is started.
' (6) Completion of PP 1102.02 section 3, Zero to 25% Power Operations, was not signed off.
' (7) Tne reactor operator's log for June 24, 1984, does not reflect when the SUFP was put in service.
(8) The procedures for restoring the startup feed pump's suction and discharge valves, the startup feed pump's lube oil cooling and the startup feed pump's pump seal cooling did not require independent verification.
Items (1), (2), (3), (6), (7) and (8) are examples of an item of noncompliance for failure to properly implement procedures (346/84-15-01C).
Item (5) is considered an example of an item of noncompliance for failure to maintain an adequate procedure (346/84-15-01C).
The inspector performed a historical review of revisions and reviews of SP 1106.27, Startup Feed Pump Operating Procedure.
The results of that review were: (1) Since the beginning of plant operation, SP 1106.27 required that valve FW 32 be open.
- (2) SP 1106.27 had an annual review on July 7, 1983 by a co-op student and on November 23, 1983, by a shift supervisor.
the Technical Section provided an USAR review package for SP 1106.27 which did not include any of USAR section 3.6.
requirements for the position of the suction valve.
(3) USAR section 3.6, Protection Against Dynamic and Environmental Effects Associated with Postulated Rupture of Piping, was not keyworded in the licensee's computer data bank.
(4) On December 19, 1982, the station operations department initiated Facility Change Request (FCR) 82-176 requesting valve FW 32 be shown open instead of closed on design document, P&ID M-006B.
The FCR was implemented on May 24, 1983.
The licensee's engineering staff determined that this FCR did not constitute a change to the facility as described in the Safety Analysis Report even though Figure 10.4-12 of that report showed valve FW 32 closed.
As a result, the licensee did not perform an adequate 10 CFR 50.59(b) safety evaluation.
Changing _.
. . the position of valve FW 32 constituted an unreviewed safety question requiring prior NRC approval before implementation.
Had the licensee realized the safety significance, it is reasonable to conclude that the licensee would have directed closure of FW 32 at that time.
Item (4) is considered an example of an item of noncompliance for s failure to perform an adequate 10 CFR 50.59 review (346/84-15-1D).
5.
Enforcement Conference . On July 13, 1984, an Enforcement Conference was held at the NRC regional office to discuss the circumstances surrounding the mispositioning of the freon compressor control switches.
Licensee representatives in attendance are denoted in paragraph 1.
The meeting started with opening remarks from the NRC and a presentation of past events leading to and continuing to be a concern of the NRC in the area of the licensee's inability to recognize design basis requirements for operability of safety-related equipment.
The licensee made a presentation on their short term corrective action of requiring a senior reactor operator to review maintenance work orders for operability requirements before submission to the shift supervisor.
Potential long term corrective action was also presented dealing with key senior experienced licensee personnel reviewing the design basis of all safety-related equipment and identifying all components necessary for operability.
A general discussion then took place as to whether previous corrective actions in this area should have prevented the event.
The discussion then centered on the safety significance associated with the freon control switches being in the "off" position.
The licensee indicated that 20 to - 30 minutes would be available to the operator to take corrective action and that this time frame was adequate to determine the mispositioning of the switches and reposition them.
A discussion then ensued as to the CREVS function and its impact on station operations.
The licensee stated that the reason for the switches being placed in the "off" position was still under investigation.
The meeting concluded with the NRC stating that further internal discussion would have to be pursued to: (1) determine if the safety significance of the event would constitute escalated enforcement for violation of a Limiting Condition for Operation based on review of the licensee's analysis and (2) determine if the event occurred due to lack of adequate management controls in an area where inadequacies had been previously identified and corrective actions implemented.
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. November 15, 1984 EN 84-66 0FFICE OF INSPECTION AND ENFORCEMENT ~ NOTIFICATION OF SIGNIFICANT ENFORCEMENT ACTION _ Licensee: Toledo Edison Company Davis-Besse Nuclear Power Station Docket No. 50-346 Subject: PROPOSED IMPOSfTION OF CIVIL PENALTY - $90,000 This is to inform the Commission that a Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Ninety Thousand Dollars will be issued to Toledo Edison Company on or about November 21, 1984.
This action is based upon two violations which are categorized as two Severity Level III problems. The violations relate to the licensee's inability to recognize design basis and technical specification requirements for equipment operability, to ensure that procedures which define equipment operability are followed, and to ensure that appropriate reviews are conducted in accordance with the requirements of 10 CFR 50.59. The violations involving equipment operability also relate to the licensee's failure to take effective corrective actions once problems have been identified.
It should be noted that the licensee has not been specifically informed of the enforcement action. The Regional Administrator has been authorized by the Deputy Director, Office of Inspection and Enforcement to sign this action. The _ schedule of issuance and notification is: Mailing of Notice November 21, 1984 Telephone Notification of Licensee November 21, 1984 A news release has been prepared and will be issued about the time the licensee receives the Notice. The State of Ohio will be notified.
The licensee has thirty days from the date of the Notice in which to respond.
Following NRC evaluation of the response, the civil penalty.may be remitted, mitigated, or imposed by Order.
Contact: B. Beach, 'E 24766 J. Axelrad. IE 24909 Distribution: - H Street ?> 27 MNBB 3 2V Phillips EW Willste S/ 'd'- " Chairman FaTTadino EDO NRR IE NMSS Comm. Roberts DED/ROGR OIA RES Comm. Asselstine PA
Comn. Bernthal ELO AE00 Comm. Zech RM ACRS . SECY Air Rights f ' a'L1 Regional Offices MAIL CA SP RI 3.'?RIV ADM: Doc. Mgt. Br.
PE RII '5. V5 RV POR RIII PRELIMINARY INFORMATION - NOT FOR PUBLIC DISCLOSURE UNTIL NOVEMBER 21, 1984 -~ ~ c_ t )
_ _ _ _ _ , . _. _ ._ . . . _.... __. _ __ - _. -.. - . , ' DRAFT .. , . l Regulatory Performance History
! ' ' ' -Davis-B' esse April 1979 Enforcement Conference to discuss administrative and operating regulatory performance of Davis-Besse.
I j~ First of a series of management meetings to address i major concerns (1) unfavorable trend in number of ' noncompliances; (2) increase and significance of . personnel errors; (3) increase in repetitive equipment problems not resolved in timely manner; (4) breakdown in management system to grasp and address technical j ano administrative problems in timely fashion.
it
. l May 1979 Second in series of meetings to discuss actions taken i by TECO to address Region III concerns.
TEC0' outlined a program of improvement in management ,
control, staffing, training and correction of equip-ment problems.
. July 1979 TECO outlined action details in following areas: . Third Management 1.
Training - 22 openings and 3 filled to dete.
Meeting-2.
Procedures group developed to centralize the preparation :nd. maintenance of procedures.
. .- -r-r. v _ _,. --w.
. -.,,, _,,, ... . .m.-,. ,.,,,, .-~ -,. --y__.
,,,.-._.r._,, y.,,--, ,p-,. _,,, - - .
. DRAFT - . 3.
Management Control - management meetings with plant personnel'tIo continue.
4.
Maintenance - contractor to assist in implementing Facility Change Request program.
Also, improve preventative program.
September 1979 Discussions on following matters: Fourth Management 1.
Difficulty in filling vacancies (changes made in Meeting salary structure and hiring policies); (+ Positive Trend) 2.
LERs in area of personnel errors declined in past . 6 months; 3.
Nuclear Services Group to handle support activities (audits, FCRs, outage planning, training, etc.)
established.
4.
Training programs being implemented.
.
February 1980 Discussion on following matters: Fifth Management 1.
Training and experience level of nonlicensed Meeting operating personnel.
Letter to TECO V.F.
expressing concerns relating to safe operation of plant.
Commitments made to strengthen training area.
2.
Security inspection identified nine items.
June 4 1980 Licensee reported on the status of their program to Sixth Managv. :nt imprcve management controls and operations at Meeting Cavis-Sesse.
RIII ackncaledged significant progress
,
-. ._- , . _.
- . - - .-.. - DRAFT
i .
s (+ Positive Trend) made in ten areas to improve management controls of ' _ the operations of Dav'is-Besse.
Problems in implemen-tation of the security program and the overexposure i have detracted from improvements in other areas.
, -
SALP 2 General observation that there appears to be a lack (November 1980-of initiative in taking aggressive action before items March 1982) become regulatory issues.
Procurement, maintenance, fire protection and drawing control failed to show significant evidence of self identification of problems
- I and aggressive corrective actions.
Weakness in capability to recognize design basis requirements for equipment e operability (removal ECCS room coolers w/o declaring train inoperable; heating BWST over design assumptions for LOCA analysis; removal of both diesel generators tornado missle s'hielding w/o declaring diesels inoperable).
, i
i i January 1982 Discuss conserns in the area of drawing. controls,
' (Management nonconformance reports and increase in personnel Meeting) errors.
t
. t March 9, 1983 Continued RIII concern over licensee's inability to (Enforcement understand cperability requirements.
Other concerns: Conference) (1) Maintenance - failure to identify causes of equip- , ment malfunctions, evaluation of ea1 functions inadequate; ' . ! >
I . . _ _ _ _ _ _ _ _. -. _ _. _. _ _. _ _. _. _, _ _ _
r l . ' DRAFT
. , (2) Drawing control - failure to update and control drawings, (3) Nonconfo'rmance program - nonconforming , conditions not tracked or identified to proper organizations.
R. Crouse attended.
Action plan prepared to address NRC concerns of March 9, 1983 Enforcement Conference.
. 't April 7, 1983 Comprehensive Corrective Action Program initiated by TECO to address concerns including proper determination of equipment operability requirements.
_ July 1983 Improvements noted in confirmatory measurements and (SALP 3 procurement areas.
Maintenance continued at a CAT 3 April 1982-level.
While overall performance was good in Plant March 1983) Operations, personnel errors and operator cognizance of design /FSAR issumptions was still a concern.
. July 25-29, 1983 Appendix R Team Inspection Exit Meeting held 7/29/83.
R. P. Crouse did not attend.
August 16, 1983 Special meeting held in NRC HQ to discuss Appendix R findings and actions requiring completion before plant startup.
R. P. Crouse was present.
September 7-9, Followup inspection on Appendix R commitments made 1983 in August.
Exit on September 9, 1983.
R. P. Crouse did not attend.
T. Murray did.
. . . . . ._ DRAFT - . . . November 4, 1983 Appendix R program status meeting with NRR.
R. Peters , , was highest level TECO representative.
November 1983 Recommendation for a Regulatory Improvement Program (RIP).
(Management Mr. Davis gave some examples of areas which should be ' Meeting) considered by the licensee for inclusion in the RIP.
These examples were: Evaluation of personnel practices to assure they are adequate to identify and maintain staff j quality and quantity in each department to operate the
plant and perform the licensing functions; evaluation of , corporate / plant managers and' supervisors to determine if their workloads are manageable and realistic, work location is appropriate and the proper time is being , devoted to plant activities; evaluation of the technical specifications and final and updated safety analysis , report.to deter'mine operability limits on safety-related j systers, and improve management's systems and personnel l capability to ensure a more thorough evaluation of LERs,
i corrective actions and resolution of commitments.
He also ! stated that the Commissioner's concerns and the open commitments of the comprehensive corrective action program l should be included in the RIP.
'. At the end of this discussion, Mr. Crouse stated that a full diagnostic evaluation would be performed _over.the Nuclear Mission tc determine -eak areas and define the RIP.
Mr. Jchnson also attended this meeting.
l
h , -_ _ .- .. - --- ,- - - _,, -,,. - -,, - _ -,. ., - -. _. - .. .,,.,
_ _ _ _ _. _ . . - - - -- . -- . . DRAFT i . - December 1, 1983 Enforcement Meeting on Appendix'R.
Johnson and Crouse attended.
i ! December 14, 1983 First working meeting on RIP.
Licensee was reluctant to ~ ! give handouts that described program.
No interim measures proposed to minimize the impact of those safety issues already identified and placed into the RIP for long-term ' solution.
Memo sent to R. Crouse on 12/23/83 from C. Norelius to clarify the general structure of the RIPS ! January 10, 1984 TECO described status of their interim measures to _ minimize the impact of weaknesses on safe plant , operations.
Licensee defines scope of their Perfor-
mance Enhancement Program (PEP).
R. Crouse attended.
i January 29, 1984 Second Appendix,h Status Meeting.
i ? l February 2, 1994 Meeting in RIII to' discuss development of RIP.
R. Crouse attended.
, l l- ! April 1984 Working meeting at site to discuss'the status of RIP.
R. Crouse attended.
C. Norelius discussed concerns identified during March 3, 1984 incident.
Concerns i i related to improper maintenance on stuck safety relief f valve and licensee's concern to resume plant operation before completing a thorough review of all issues.
-,_ --. - .-_ ,. - -.. . - - _ _. - _ _. _ - -. -. _, -. - . -, -.
- -_ _ _ .._ _ . _ _ ., , DRAFT .
March 21, 1984 Third Appendix R Status Meeting.
R. Peters was highest .. TECO representative.
March 23, 1984 Emergency Preparedness NRC report re, commended EP program i be included in RIP.
Licensee rejected.
Report sent to , R. Crouse.
! I April-May 1984 Eight items of noncompliance were identified.
Inspection (RIII QA Inspec-concluded that even though noncompliances were identified, tion) Davis-Besse has an acceptable quality assurance program.
. _ ' , f i April 1984 A diagnostic of the Davis-Besse training organization and programs was issued in final by MAC (consultant in i this area).
The major problem identified -as the lack
of staff to implement the program.
The root cause of i . this problem was the Company's wage and salary structure.
A total of 21 positions were budgeted, only 13 had been filled (in last month this is up to 18).
The licensee had a draft copy of the diagnostic in December 1983.
July 2, 1984 was the first indication that management was acting on the diagnostic recommendations to hire additional personnel.
P ' June 7-8, 1984 Followup inspection on Appendix R commitments.
No top level management present for exit.
i f i
, l
_ . _ _....., _ _ _, _ _ _ _ _ _ _ _ _- . ~. - - - - -. ~-
. ._ -. _ .. .- . - ___- -. - . .
-
- DRAFT - . June 12, 1984 Fourth Appendix R Status Meeting.
R. Crouse in
attendance.
. t ..
l July 1984-Discuss recent events that indicate a breakdown in , (Enforcement management control systems.
Inability of TECO to . . Conference) recognize design basis requirements for equipment operability and failure to-take effective corrective actions when a problem nas been identified.
R. Crouse attended.
. , l . ' i - Examples: (1) Control Room Emergency Ventilation
system made inoperable due to personnel error; I (2) Emergency Diesel Generator (EDG) ventilation , i supply fan taken out of service without declaring i EDG inoperable and not performing the required-surveillances;[3)StartupFeedPumpsuctionvalve
left "open" and rendered an auxiliary feedwater pump inoperable.
After corrective actions were taken by TECO, the valve was again left "open" approximately i a month later.
. l July 20, 1984 NRC receives first unofficial copy of PEP program.
! July-August 1984 Ten areas inspected by eight inspectors.
Crouse and (PAS inspection Johnson attended.
Twenty-one potential enforcement 7 CAT 2 and findings were identified as follows: 3 CAT 3) 1.
Failure of SRV to revie procedure modification.
.. ., - . ,_ _ _ -. -..- _ _.
.,-, - __- -. - ,,- -,,..- ---... - - ,-.
_ .. . ... _ _.. _ o .. , DRAFT , . . . ? 2.
Failure of CNRB to review a deficiency in the (1980 PAS inspec-design of the high pressure injection system.
j tion 3.
Failure to include observations of maintenance 7 aver, 1 good, and operations activities in the QA audit program.
1 poor) 4.
Failure to provide adequate management represen-
{ tation at QA post audits.
t i < September 14, 1984 Licensee PEP docketed.
,
. September 1984 RIII - Proposed Escalated Enforcement Action based on . items discussed during July Enforcement Conference.
,
Inability of TECO to recognize design basis require-ments of equipment operability and failure to ensure , i ! adequate corrective actions to preclude repetition !' of identified problems.
Enforcement report sent to J. Williamson No'vember 21, 1984.
,
l October 1984 Keppler-DeYoung meeting with Johnson and Crouse.
l l October 11, 1984 Emergency Preparedness Meeting to discuss weaknesses in exercise and program.
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' EliCLOSURE 4 (Vol. 2) , Attachnent Supporting Q-22 '
- _
, ,, 1985 01/02/85 MEMO: J. Asselstine - W. Dircks: Iraining Program at Davis-Besse Nuclear Plant Training as Category 3, Susgest Staff Monitor Closely (2 pgs.)
02/r4/85 LETTER: TECo - J. Keppler: Response-to-SALP Report. ~ Low ratings came as a shock, not argue with assessments, devote energy to a program of improvement.
(3 pgs.)
01/04/85 Speech Outline from SALP Meeting.
(3 pgs.)
01/09/85 MEMO: J. Keppler - W. Dircks: Inform of Regulatory Performance.
Chronology of performance, starting in 1979.
(2 pgs.)
01/17/85 LETTER: J. Keppler - TECo: Refers to meeting 12/28/84.
Discussing regulatory concerns.
Previous letter 10/30/84 attached.
(3 pgs.)
01/31/85 MEMO: H. Thompson - H. Denton: Training Program at Davis-Besse.
Proposes training review. Memos of 01/30/85 (Draft?) and 12/12/85 attached.
(3 pgs.)
01/31/85 LETTER: TECo - J. Keppler: Response to PAT Report 84-19 item on general employee training. Will revise.
(1 pg.)
02/08/85 MEMO: J. Keppler - W. Dircks, H. Denton, J. Taylor: Davis-Besse SALP Response: Transmits TECo response to SALP.
Believe have attention and commitment of top licensee management.
TECo response attached.
(19 pgs.)
02/19/85 MEMO: J. Keppler - C. Norelius: Training Program at Davis-Besse Nuclear Plant. Memo from W. Dircks to Commissioner Asselstine (02/12/85) attached.
Please factor commitments into master inspection plan.
(4 pgs.)
02/26/85 MEMO: W. Shafer - C. Norelius: Trip Report - Davis-Besse: ' Meeting 02/07-08/85 to discuss licensee's performance enhancement , program. 55 action plans to meet with licensee first Thursday of each month. Action plans attached.
(59 pgs.)
03/04/85 OUTLINE: Management Assessment Team: Objectives, proposed plan, team members, schedules, (Draft) TECo organization charts attached.
(6 pgs.)
03/04/85 LETTER: TECo - J. Keppler: Supplemental information to response to SALP report requested by phone call 02/19/85.
Supplemental information attached.
(31 pgs.)
03/06/85 LETTER: J. Axelrad - TEco: Acknowledge letter of 01/14/85 and check of $90,000.
Letter of 01/14/85 and attachments.
(15 pgs.)
i
L
V-03/06/85 OUTLINE: Toledo Edison SALP Presentation, Region III 03/06/85.
(43 pgs.)
03/08/85 LETTER: W. Little - TEco: Transmiis' Report 85-01, Followup on Findings in PAT Report 84-09.
Report 85-01 attached.
(13 pgs.)
03/13/85 LETTER: J. Partlow - TECo: Responsa_po_ PAT Inspection: Pleased to receive response, disappointed response only addressed identified I specific details. Region III closely monitoring.
No further response requested.
(1 pg.)
03/15/85 MEMO: A. Davis - J. Keppler: Visit to' Davis-Besse on March 15, 1985: Discussions with operators, their suggestions.
(1 pg.)
'" 03/18/85 LETTER: R. Spessard - TECo: Transmits Report 85-05(DRS). First in a planned series to provide in-depth review and evaluation of corrective program and its implementation.
Program acceptable, increased management attention needed. Report attached.
(11 pgs.)
03/25/85 MEMO: E. Brach - W. Rogers: Mgant. Visit to Davis-Besse.
03/28/85 PRINTOUT: PEP Implementation Tracking System.
(5 pgs.)
04/02/85 LETTER: TECo - J. Keppler: MenIlons 03/06/85 meet ing.
Provides charter and membership of SALP improvement task force.
Attachments.
(11 pgs.)
04/23/85 LETTER: Transmits SALP Report.
Discusses overall view of , corrective actions proposed. Continued management needed.
SALP Report 84-11 attached.
(58 pgs.)
05/14/85 LETTER: R. Spessard - TECo: Transmits Inspection Report No. 85007(DRS) (2 pgs.)
05/15/85 Draft Notes on Plant Status s 05/16/85 LETTER: R. Spessard - TEco: Transmits Inspection Report (attached) No. 85012(DRS) (10 pgs.)
05/24/85 Meeting Notes for Enforcement Conference on 05/24/85 (Draft Notice of Violation included) (10 pgs.)
06/05/85 MEMO: J. Keppler - W. Dircks: Status of Regulatory Performance at Davis-Besse Nuclear Plant.
06/11/85 MEMO: J. Keppler - W. Dircks: Status of Regulatory Performance at Davis-Besse Nuclear Plant.
06/18/85 MEMO: W. Schultz - J. Axelrad: TECo - Davis-Basse Proposed Civil Penal-ies.
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