IR 05000373/1993028

Insp Repts 50-373/93-28 & 50-374/93-28 on 930923-25. Violations Noted.Major Areas Inspected:Selective Exam of Circumstances Surrounding Mispositioning of Spent Fuel Bundle in Unit 2 Spent Fuel Pool on 930913

ML20059D981
Person / Time
Site:	LaSalle
Issue date:	10/26/1993
From:	Clayton H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20059D939	List: IR 05000373/1993028 ML20059D936 ML20059D959
References
50-373-93-28, 50-374-93-28, NUDOCS 9311030056
Download: ML20059D981 (9)

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U.S. NUCLEAR REGULATORY COMMISSION REGION Ill Report Ho /93028(DRP); 50-374/93028(DRP)

Docket Ho ; 50-374 License Nos. NPF-ll; NPF-18 Licensee: Commonwealth Edison Company Executive Towers West 111 1400 Opus Place Suite 300 Downers Grove, IL 60515 Facility Name: LaSalle County Station, Units 1 and 2 l Inspection At: LaSalle Site, Marseilles, Illinois f Inspection Conducted: September 23 through September 25, 1993

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inspectors: S. Parsons M. Bielby D. Hills R. Hague  ;

Approved By: .,s4 00T 2 61993 ,.

IOVyIFn, Chie f Date Reactor Projects Branch 1  !

Inspection Summary *

Inspection from Septerber 23 through September 25. 1993 (Reports No. 50- l 373/93028(ORP): 50-374/93028(DRP)).

I Areas inspected: A special inspection was conducted to determine the  !

circumstances surrounding the mispositioning of a spent fuel bundle in the l Unit 2 spent fuel pool on September 13, 1993, and why corrective actions from a similar event in May 1993, were ineffective in preventing recurrenc .

Results: Two violations were identified. One involved a failure to follow !

procedures with regard to mispositioning a spent fuel assembly in the Unit 2 '

spent fuel pool (paragraph 3). The second involved inadequate corrective actions to prevent recurrence for a similar event in May,1993, (paragraph 4.c.).

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9311030056 931026 1 PDR ADOCK 05000373 i G PDRi d

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t Plant Doerations  ;

Performance in this area demonstrated a lack of team work on the refueling bridge, a-lack of a questioning attitude on the part of fuel handlers, and inadequate training regarding the spent fuel rack misalignment,  ;

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Enaineerino and Technical Support  !

Performance in this area demonstrated an ineffective root cause'and corrective action program, a modification procedure that does not address.necessary .

training and procedural changes if changes are made to the scope of a  ;

modification during installation, and a self assessment program that does not *

receive adequate management suppor '

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DETAILS-

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1 Persons Contacted

• J. Schmeltz, Operations Manager . ,

• J. Atchley, Assistant Superintendent Operations;  !!

• J. McIntyre, SQV Superintendent H

• J. Lockwood, Regulatory Assurance Superviso .

• T. Shaffer, Executive Assistant to Site VP- -t

• S. Harmon, Training Supervisor 1

• G. McCallum, Nuclear Engineer  ;

• W. Sly, Acting Operations Engineer .

• D. Carlson, NRC Coordinator . i J. Miller, Station Suaport' Supervisor- l T. Nauman, Master Meclanic

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• Denotes those attending the inspection exit meetin The inspector also talked with and interviewed several other licensee-employees during the course of- the inspectio !

' Backaround The NRC became concerned with the mispositioning of a spent fuel bundle in the Unit 2 spent fuel pool when it was determined that the mispositioning was at least partially due to a. misalignment. between the spent fuel racks and the refueling bridge. This misalignment had also caused an earlier event in May 1993, when fuel handlers moved an  ;

incorrect fuel bundle because they positioned the refueling bridge over !

the wrong location. Corrective actions for. this earlier event were too ,

narrow in scope to prevent the mispositioning~ event of September 13, ~i 199 '

The licensee replaced the original Unit 2 spent fuel racks in .1989 with r high density racks to increase spent fuel storage capacity. In.the !

original racks, spacing between adjacent cells was about one inch'in-the ;

east-west direction and about six inches in the north-south directio The spacing in the new high density racks is less'than an inch,in both directions. The new racks consist of 20 free standing modules each containing between 180 and 240 individual storage cells and were  ;

designed to be in alignment with the refueling' bridg However,.during :

installation, a change in seismic requirements necessitated the addition of spacers between the modules. With the spacers installed, the final ;

module configuration.resulted in a misalignment with the refueling .

bridge of four or more inches as the bridge is moved from west to eas :

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On the west edge of tne pool, there are 64 columns with letter

, designators from A through UUU. Because the pool is not rectangular, the east edge has columns F through MMM (see' attachment). The north-south rows are designated numerically 1 through 75. .The Unit 2 reactor sits immediately north of the pool requiring the concave shape of that sid . Event Description

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On September 13, 1993, while performing step 71 of the Nuclear Component Transfer List for Unit 2 Cycle 5 Core Unload, fuel bundle YJ0483 wa '

removed from the Unit 2 reactor and was to be placed in position FFF-38-of the Unit 2 spent fuel poo Instead, the bundle was actually placed ,

in position GGG-38 which is the adjacent cell immediately north of FFF- i 38 and the Fuel Handling Supervisor verified the step as being properly completed by initialing step 71 in the Nuclear Component Transfer Lis LaSalle Fuel Procedure (LFP)-100-2, " Administrative Control of Transfer-of Fuel or Special Nuclear Material Between or. Within the Spent Fuel Pool (s) or Vaults", step F.3., states "As the steps on the Nuclear ;

Component Transfer List are completed, they will be VERIFIED, initialed _

and dated by the Fuel Handling Supervisor." Failure to verify that the fuel bundle was placed in the correct location as required by LFP-100-2 ;

is considered a violation of technical specification 6.2.A.a (50-374/93028-01 (DRP)).

4. Event Evaluation

The team looked at several aspects of this even Besides interviewing -I all of the individuals on the refueling bridge at the time of the mispositioning, the team reviewed training and procedural adequacy, licensee root cause and corrective actions as a result of' previous ;

events, Quality Assurance Organization Involvement, and human factors-issue j 1 Interviews At the time of the fuel bundle mispositioning, there were five people on the refueling bridge; two fully licensed Senior Reactor Operators (SRO), a limited SR0 being reactivated, a non-licensed fuel handler, and a phone talker in communications with the control room. Limited SR0s usually function as Fuel Handling Supervisors but because of the period of time between refueling'

outages they have to be reactivated by standing an eight hour shift under the direct supervision of a fully licensed SRO. One fully licensed SR0 was on the bridge to relieve the other and waited for the completion of ' step 71 to accomplish the turnove The results of the interviews indicated that only the non-licensed fuel handler was aware of the misalignment between the bridge and the spent fuel racks. This notwithstanding, the fuel handler would routinely change the position of a bundle on orders from the

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Fuel Handling Supervisor without question. The best estimate of how often this occurred was about once in every 100 moves. There was not one uniform method used by the .SR0s to verify fuel bundle position. Methods employed included: sighting along the columns -

and rows with binoculars; counting. the number of cells from some reference position, either the edge of a module or a previously placed fuel bundle; or some combination of these.two methods. -The non-licensed fuel handler employed only the pointers on the bridge to determine his position over the spent fuel rack The SR0s do not believe that the turnover was a contributing factor in the mispositioning because although the relieving SRO came onto the bridge as the bundle was being removed from the core, he waited until the completion of the step and verification prior to assuming the responsibilities of Fuel Handling Superviso All individuals interviewed believed that a better method to identify and verify spent fuel pool positions could be devise Suggestions included; a removable template-placed around the i designated off-load area, indexing via the use of lasers, or- ;

requiring an additional verification step in the procedure. They

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also agreed that the present numbering on the_ bridge was confusing. The row identification numbers for the reactor positions are stenciled large black numbers. The row identification numbers for the spent fuel pool are hand written with a black felt tip pen directly above the reactor _ number The fuel handler stated that with the mast-positioned over one spent fuel pool location, he could place the fuel bundle'into any of the adjacent locations without moving the bridge, by applying pressure to the mast with his foo This was_later demonstrated with a dummy fuel bundle in the spent fuel pool. All present fuel handlers have held that position since the installation of the high density racks and were familiar with the misalignment proble b. Trainina / Procedures The team reviewed the training lesson plans for fuel handlers and limited SR0s and the applicable fuel handling procedures and found no references to the Unit 2 spent fuel pool storage rack misalignment with the bridge. Also neither " Master Refuel Procedure", LFP-100-1, revision 22, or " Fuel Movements Within The Reactor And Spent Fuel Storage Pools", LPF-400-1, revision 14,-

formalize or give guidance on how the fuel handler and the Fuel Handling Supervisor are to perform initial and secondary verification that a fuel bundle is in the correct spent fuel pool'

storage rack location, nor is this guidance covered in initial or requalification training for fuel handlers or fuel Handling Supervisor _ .- .

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A review of'the modification package used for installation of the-l high density-fuel storage racks indicated on a check-off list, which is completed prior to the actual installation of the '

modification, that no additional training or procedural changes:

would be required as a result of this modificatio Because the misalignment was introduced during the installation and' there is no mechanism in the modification procedure to verify after the'

modification is completed that there is still no need for additional training or procedural changes, the package was signed off as complet Corrective Actions The team reviewed the adequacy of corrective actions for a similar event which occurred in May 199 In that event, fuel handlers were directed to retrieve a fuel bundle from a specified location in the Unit 2 spent fuel pool and place it in a stand for inspection. The fuel handlers went to the wrong location and therefore retrieved the wrong bundle for inspection. There were

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no safety implications and in fact, because the wrong bundle was from the same cycle, it was inspected in lieu of the designated bundle. Moving the wrong bundle was classified as a severity '

level V violation in Inspection Report 50-374/93013 (DRP). The inspection report highlighted the NRC's concern over continued ;

personnel errors involving fuel handling activities and advised that " additional management attention was warranted in this area". *

Because this event occurred in the far eastern part of the pool where the misalignment is the most pronounced, corrective action for this violation included tailgating fuel handlers on the event and administrative controls to prevent fuel movement on the far ;

east side of the pool until appropriate markings 'could be i installed. Specifically, step E.8 was added to the " Limitations' !

and Actions" section of LPF-400-1 to prohibit any fuel activities '

east of row 54. During a demonstration on September 25, 1993, the team determined that the misalignment at row'51 was approximately i 4 inches and at row 38, where the latest mispositioning took I place, the misalignment was approximately 3 inches. This misalignment, absent any formal training or procedural 1 precautions, contributed to the most recent mispositioning even j The corrective actions for the May 1993, event where too narrow in '

scope and were ineffective in preventing recurrenc Failure to take measures to assure that the cause of the condition is determined and corrective action taken to preclude repetition is a violation of 10 CFR 50, Appendix B, Criterion XVI (50-374/93028-02(DRP)). i

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d. Quality Assurance Involvement 4)> The team reviewed previous Station Quality Verification (SQV)

activities including Independent Safety Engineering Group (ISEG)

functions to ascertain their degree of fuel handling activity oversight. Numerous surveillance observations of fuel handling activities at LaSalle were documented, including a fuel handling comparative audit of all Ceco plants conducted in early 1992. No problems at LaSalle were noted during these observations. Recent fuel handling events had been reviewed by the ISEG which issued lessons learned initial notifications (LLIN) on these events to other CECO plant Concerns regarding the licensee's root cause analysis program were discussed in the most recent NRC Systematic Assessment of Licensee Performance (SALP) report (50-373/93001; 50-374/93001) for LaSalle dated July 21, 1993. Due to adverse findings during an NRC emergency operating procedure inspection in April, 1993, the licensee conducted an independent commitment management audi The corresponding audit report was dated July 1, 1993. This report and an SQV audit completed in the same time frame both indicated corrective actions were frequently ineffective and too narrowly focused. At the time of this inspection, the licensee still had not determined actions needed to address these concerns and improve the root cause analysis and corrective action proces This was despite previous NRC discussions with licensee management, including the SALP meeting of August 20, 1993, in which the importance and apparent slowness in addressing the issue were emphasize SQV response to this event was lacking in view of the previous history of fuel handling errors and ineffective corrective action problems at LaSalle. Prior to the NRC inspection, the ISEG portion of SQV determined the event did not warrant an LLIN and planned to review the plant staff investigation finding There was no conscious, coordinated effort of SQV to perform a timely independent investigation to determine the reason for recurrenc Despite previous adverse SQV findings regarding an ineffective corrective action program, SQV had been unable to influence a timely plant staff response to the concerns, nor was this latest event being used as a focal point to prompt this actio e. Human Factors The team's human factors specialist provided the following insights which could enhance performance during spent fuel pool operations (these items are provided for licensee consideration and should not be construed to be regulatory requirements): All of the labeling for reactor cavity and spent fuel pool indexing should be standardized and permanen _. - _ _ . _- . -

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Additional, user triendly, labeling of the spent fuel pool :

high density: racks should be installed prior to the next :

Unit 2 refuelin j 4 Indexing point?rs should be placed as close'to the- _ _

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characters as possible to minimize the parallaxfwhen viewed !

from various position i

' The operator aid map of the spent fuel pool should be blown-up and highlighted designating the area being used for th ;

off-loa . Training describing the best method for locating and l verifying spent fuel pool locations should be provided to all fuel handlers and Fuel Handling Supervisor ; Fuel handling procedures for activities in the Unit 2 spent i fuel pool should include precautions addressing the- '

misalignment of the spent fuel rack ;

5. Exit Interview  :

The team met with licensee representatives (denoted in Paragraph 1) !

during.the inspection period and at the conclusion of the inspection :

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period on September _ 25, 1993. The team summarized the scope.and results of the -inspection and discussed.the likely content of this inspection ;

repor The licensee acknowledged the information and did not indicate

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that any of the information disclosed during_the' inspection could be !

considered proprietary in nature, j l

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ATTACHMENT

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