IR 05000397/1993027
| ML17290A524 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 07/08/1993 |
| From: | Johnson P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17290A523 | List: |
| References | |
| 50-397-93-27-EC, NUDOCS 9307260016 | |
| Download: ML17290A524 (27) | |
Text
U.S.
NUCLEAR REGULATORY COMMISSION REGION Y Report No:
Docket No:
License No:
Licensee:
Facility Name:
Meeting at:
Date of Meeting:
Prepared by:
50-397/93-27 50-397 NPF-21 Washington Public Power Supply System P. 0.
Box 968 Richland, WA 99352 Washington Nuclear Project No.
(WNP-2)
Region Y Office, Walnut Creek, California June 29, 1993 D.
E. Corporandy, Project Inspector Approved by:
P.
H. J hnson, Chief React Projects Section
7'8gp Date Signed Enforcement Conference on June
993 Re ort No. 50-397 93-27 An enforcement conference was held on June 29, 1993, with the Washington Public Power Supply System (Supply System) to discuss (1) the March 31, 1993, plant event that resulted in exceeding Technical Specification limits for drywell-to-suppression chamber bypass leakage and (2) circumstances associated with the falsification of fire tour logs.
After the enforcement conference, the licensee..also briefly discussed the 1993 Refueling Outage.
A copy of information-provided by the licensee at the conference is included as Enclosure 3.
93072b001b 930709 PDR ADOCK 05000397
DETAILS Heetin Partici ants Nuc1ear Re viator Commission B. H.
K. E.
C. Z.
F.
R.
W. H.
H. B.
C. A.
P.
H.
J.
W.
W. P.
K. E.
R.
C.
D. L.
D.
E.
Faulkenberry, Regional Administrator Perkins, Director, Division of Reactor Safety and Projects (DRSP)
Serpan, Acting Deputy Director, DRSP Huey, Enforcement Officer Troskoski, Enforcement Specialist, Office of Enforcement (via Telephone)
Blume, Regional Attorney VanDenburgh, Chief, Reactor Projects Branch Johnson, Chief, Reactor ProjectsSection I Clifford, Project. Hanager, NRR Ang, Chief, Engineering Section Johnston, Project Inspector Barr, Senior Resident Inspector Proulx, Resident Inspector Corporandy, Project Inspector Washin ton Public Power Su
S ste J.
V. Parrish, Assistant Hanaging Director for Operations G.
C. Sorensen, Regulatory Programs Hanager M. D. Shaeffer, Hanager, Operations H. J.
Davidson, Staff Attorney J. J. Huth, Principal Engineer, Operating Event Analyses and Resolution (DEAR)
J.
M. Massey, Principal Engineer, OEAR Back round This enforcement conference addressed two issues.
The first issue discussed, EA 93-135, concerned the falsification of fire tour logs, as reported in Licensee Event Report (LER) No. 50-397/92-023-01, dated August 6, 1992.
This LER stated that WNP-2 management had experienced problems. that involved plant equipment 'operators (EOs) falsifying log entries- (e.g.,
logging actions as having been completed, which were not actually performed).
The LER reported that 20 of 39 EOs were determined to have falsified log records.
The second issue, EA 93-134, concerned a Harch 31, 1993, event in which the Supply System exceeded the requirements of Technical Specification 3.6.2.l.b, drywell-to-suppression chamber bypass leakage.
According to LER 93-016, during the performance of Plant Procedure (PPH) 7.4.6.6.1.3C,
"Hydrogen Recombiner lA Flow Instrumentation,"
a plant control room operator noticed that containment atmosphere control (CAC) system inboard primary containment isolation valves CAC-V-4 and CAC-V-6 were open.
Further review disclosed that outboard isolation valves CAC-FCV-lA and CAC-FCV-4A were also open.
Mhen contacted, the system engineer noted that this condition opened a flow path from the drywell to the wetwe11 vapor space through the CAC "A" recombiner skid.
As a result, the
-2-Technical Specifications limits for containment drywell-to-suppression chamber bypass leakage were exceeded.
The direct cause of the event was installation of a jumper (as directed by procedure)
which allowed the energization of relays associated with containment isolation valve control power, causing valves CAC-V-4 and CAC-V-6 to open automatically.
The apparent root cause was ineffective implementation and followup of corrective actions initiated in response to a previous, similar occurrence for which the NRC issued a Notice of Violation.
An enforcement conference was held with the licensee on June 29, 1993 to discuss the apparent violations.
Enforcement Conference The enforcement conference convened at 9:00 a.m.
Mr. Faulkenberry opened the conference by stating.its purpose, to discuss and to understand the sa e y signi icance f t 'f'ce and circumstances associated with the falsification of the fire tour logs and the March 31, l993, plant event that resu e
in exceeding Technical Specifications limits for drywell-to-suppression chamber bypass leakage.
The licensee presented their view of the safety significance and circumstances associated with the two apparent violations as outlined in their presentation slides
{Enclosure 3).
Highlights of the conference follow.
Falsification of'ire Tour Lo s Mr. Huey summarized the issue involving falsified fire tour logs as an apparent violation of 10 CFR Part 50.9 requirements to maintain complete and accurate records of required information.
Mr. Huey added that the individual violations were considered Severity Level IV, but that the violation would be considered Severity Level III if it were determined that the falsifications involved willful actions.
Mr. Huey noted that
of 39 EOs had falsified fire tour logs during the period covered by the licensee's review, October 1991 through March I992.
Mr. Parrish stated that, in response to an industry initiative, Supply System management had initiated the review of WNP-2 EO fire tour logs.
This review uncovered instances of fire tour log falsification, and details'-of the findings were provided in LER 92-023.
Mr. Shaeffer explained that initially, Supply System management had felt that fir watch EOs were capable of filling out fire tour logs without further guidance.
Consequently, supervisor guidance was inconsistent, and minimal in most cases.
Mr. Shaeffer explained that corrective actions involved disciplining of the EOs found to have falsified fire tour logs and training by legal and technical staff personnel of all personnel involved in fire tours.
Mr. Shaeffer stated that no instances of fire tour log falsifications have occurred since implementation of these corrective actions.
It was noted that of the 128 instances of log falsification, 112 involved claims by the responsible EO that the absence of any fire was verified by checking with a person exiting the room to be toured.
A check of security card access logs verified that persons did exit the rooms at the
times claimed.
In each of these cases, the tour logs and security card access information also provided evidence that the adjacent rooms had been toured by the responsible EOs.
According to the two individuals responsible for the other 16 instances of log falsification, they verified that no fire existed by observing no smoke exiting from room vents or by feeling the doors for heat.
According to the licensee, none of these 16 instances involved rooms with Appendix R Thermo-Lag fire retardant material.
Hr. Sorensen summarized by stating that the fire tour log discrepancies were not a violation of. licensee procedures, since procedures did not at that time specifically address the conduct of fire tours.
He also stated that the Supply System recognized the importance of procedures for fire tours and now has such procedures in place.
The licensee emphasized that they considered the root cause of the fire tour log discrepancies to be a
lack of cleat guidance and not a willful falsification.
Violation of Technical S ecifications Limits on B
ass Leaka e
Mr. Johnson summarized the March 31, 1993, plant event that exceeded Technical Specification 3.6.2. 1 drywell-to-suppression chamber bypass leakage limits as an apparent violation of 10 CFR Part 50, Appendix B, Criterion XVI requirements.
Contrary to Criterion XVI, the licensee failed to provide adequate corrective actions to preclude repetition of a previous violation {Notice of Violation transmitted with Inspection Report No. 50-397/92-03),
wherein a procedure was approved which, if per-formed, would have resulted in exceeding Technical Specification 3.6.2.I drywell-to-suppression chamber bypass leakage limits.
Hr. Perkins added that, although the event was of minor, safety significance, he was concerned with the licensee's continued inadequate attention to the CAC system and the inadequacy of their corrective actions for a previous similar occurrence.
Hr. Parrish expressed his disappointment with the Supply System's performance on their Technical Specification/procedure improvement effort.
He stated that it had been the Supply System's intention to review all procedures associated with the CAC system that could potentially lead to bypass of the pressure suppression function of the wetwell..
Mr. Parrish attributed the Harch 31, 1993, event to the failure to review faulty surveillance procedures in sufficient detail in this case, the failure to review associated electrical drawings.
He added, however, that the discovery of this noncomplying condition could be credited to the questioning attitude of a control room operator.
Hr. Barr noted that the licensee had missed opportunities to identify problems with the faulty procedure when it had been performed on earlier occasions.
He also noted that the control room staff did not recognize, at the time, that the Technical Specification bypass leakage limit for the drywell-to-suppression chamber had been exceeded.
Messrs.
Parrish and Shaeffer responded that management's communication of higher expec-tations, personal accountability, and the need for a more questioning attitude could be credited, to an extent, for finding the problem this time.
However, they agreed that operator training in this area warranted improvemen Mr. Faulkenberry concluded the discussion on the enforcement issues by thanking the Supply System for their participation and by stating that the information presented would be considered during review of the enforcement issues.
4.
Discussion on the 1993 Refuelin Outa e
Mr. Parrish summarized the l993 refueling outage, identifying successes and areas for improved performance as follows:
regs for Im roved Performance
~
Radiation exposure was high, approximately 375 man-rem.
Freezing future outage schedules in October would allow time for development of sufficient detail to avoid repetitive work (e.g., scaffolding)
and avoid work crews getting in each others'ay (e.g.,
competing for power receptacles).
Mr. Perkins emphasized the importance of teamwork and coordination among departments.
~
System cleanliness was better than in recent outages, but still needs improvement.
~
Mistakes were made during the refueling process.
Jet pump cleaning did not go according to plan.
The cleaning tool did not perform well, because the conditions under which it was pretested failed to adequately simulate the conditions at WP-2.
~
Teamwork among design engineers, plant operators, and system engineers was not always optimal.
Successes
~
The safety/relief valve rebuilds were completed without any problems.
Modifications were made to the reactor vessel level indicating system, so that a continuous backfill line can be installed in the future.
The final containment cleanup resulted in a much cleaner containment than in past outages.
/
~
Safety improved.
Lost time injuries were significantly reduced.
~
Management was far more involved than in past outages.
~
The 53-day refueling outage was the shortest in HNP-2 history, but the licensee is working to compare work accomplished versus that of previous outages.
The meeting adjourned at 11:30 WASHINGTON PUBLIC POWER SUPPLY SYSTEM ENFORCEMENT CONFERENCE JUNE 29, 1993 AGENDA I.
INTRODUCTIONS VIC PA52USH II.
OVERVIEWOF SUPPLY SYSTEM PERSPECTIVES VICPABMSH III.
DISCUSSION OF ALLEGEDVIOLATIONS A.
CONTAINMENTATMOSPHERE CONTROL SYSTEM BYPASS LEAICAGEVIC PARIUSH B.
FIRE TOUR LOG ENTRIES BILLSHAEFFER IV.
CONCLUDINGREMARKS VIC PARISH
APPARENT VIOLATIONNO. 1 NR TATEMENTOF APPARENT VI LATI N
"[VFJhen surveillance procedure PPM 7.4.6.6.1.3C was performed on March 31, 1993, the [drywell-to-suppression-chamber bypass leakage]
limitof TS 3.6.2.1.b was exceeded.
This is an apparent violation of 10 CFR 50, Appendix B, Criterion 16, 'Corrective Action,'or failure to implement adequate corrective actions in response to previous concerns."
(Apparent Violation 50-397/93-20-01)
TE HNI AL PE IFICATION3.6.2.1.b
"The suppression chamber shall be OPERABLE with:
b.
Drywell-to-Suppression chamber b
ass leakage less than or equal to 10% of the acceptable 2/ k design value of0.05 ft~."
RELATED NRC C N ERNS
~
Weaknesses In Procedure Review, Verification And Validation Programs
~
Continuing Indications OfPoor Quality Procedures, Particularly Surveillance Procedures Operator Training Training Materials Did Not Address Suppression Pool Bypass Leakage Potential In Relation To CAC System 1-1
APPARENT VIOLATIONNO. 1 BACK R UND
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IAC Technicians Properly Followed TS Surveillance Procedure For Testing Of Hydrogen Recombiner Flow Indicators
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TS Surveillance Procedure Was Inadequate In That It Resulted In CAC System Misalignment and Violation of Suppression Pool Bypass Leakage LimitTS
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Primary Containment Bypass Not Involved (CAC Is Closed System-Extension Of Primary Containment)
Corrective Actions Originally Identified Following Previous Discovery Of Similar Condition involving Test Procedure) Not Fully Implemented Primarily As a Result Of Miscommunication/Misunderstanding
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Condition Self-Identified By Attentive Operator; Suppression Pool Bypass Leakage Path Was Corrected Within Time Period Specified in TS 3.0.3
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Corrective Actions For This Event Were Prompt and Extensive; Event Properly Reported to NRC
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NRC Staff Found Internal Review Board Actions "Timely, Thorough, And Critical" 1-2
APPARENT VIOLATIONNO. 3.
UPPLY Y TEM P SITION RE ARDIN APPARENT VI LATI N
~
Supply System Acknowledges Incomplete Implementation Of Previously Identified Corrective Actions Not Indicative Of Significant Program Breakdown, Rather A Result of Lack Of Communication/Coordination Among Plant Organizations Event Reflects Area Of Recognized Weakness In Implementation Of Corrective Action Program - Program Improvements Ongoing Supply System Acknowledges Exceeding TS 3.6.2.1.b LimitFor Drywell-To-Suppression-Chamber Bypass Leakage Surveillance Procedure Did Not Identify Effect Of Jumpers On Valves At Issue IAC Technicians Adhered To Surveillance Test Procedure Which Had Been Approved, In Relevant Part, At Time of Original Plant Start-Up REGARDIN RELATED NRC NCERN
~
Related NRC Concerns Also Being Addressed Verification And Validation Process Review Of Procedures, Including Surveillance Procedures Operator Training Regarding Bypass Leakage 1-3
APPARENT VIOLATIONNO. 1 AFETY E ULAT RY I NIFI. AN E MINIMAL AFETY I NIFICANCE
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No Adverse Effect On Public Health And Safety
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No Risk To Personnel
~ 'o Primary Containment Bypass (CAC System Is Extension Of Primary Containment)
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Design LimitWas Not Exceeded (Bounding Calculation Determiried That Suppression Pool Bypass Leakage During Postulated LOCA Would Have Been Approximately Half Of Design Limit)
~ ~
Suppression Pool Bypass Leakage Path Was Corrected Within The Time
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~
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Period Established In TS 3.0.3 t
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Condition Was Identified And Promptly Addressed By Attentive Operators
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CAC System Remained Operable During Surveillance MINIMALREGULATORYSI NIFICANCE
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Inadequate Corrective Actions Resulted From Lack Of Adequate Communication/Coordination, Rather Than From Failure To Properly Identify Root Cause And Formulate Response
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After Initial Procedure Approval Opportunity To Identify Effect Of Jumpers Limited Because Only Drawing Comparison Or Direct Observation Of Jumper Effect (As Occurred) Would Have Identified
t
APPARENT VIOLATIONNO. I R
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Prior Corrective Actions (As Recommended in NCR 292-0288) Not Effectively Carried Through Process (Ultimate Corrective Actions More Focused)
Inadequate Communication/Coordination Among Individuals/Organizations During Corrective Action Implementation Corrective Action Process Did Not Designate Ultimate Responsibility For Assuring Adequacy Of Corrective Actions As Implemented
~
Initial Review And Periodic Revision Did Not Identify Opening Of Isolation Valves As A Result of Using Jumpers Procedure Verification Process Did Not Result In Reviewers Referring To AllApplicable Plant Drawings To Verify Component Operation Procedure Validation Did Not Provide Sufficient Technician Or Operator Involvement To Identify Potential For Improper Component Operation/System Configuration During Performance Of Surveillance
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Other Contributing Factors Identified in NCR 293-0346 1-5
APPARENT VIOLATIONNO. 1 C RRECTIVE ACTI N IMAWDIATECORRECTIVE ACTIONS
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Performed A CAC System Operability Assessment, Including A Physical Examination, To Ensure. That CAC Would Adequately Perform Its Safety Function.
Status: Completed 4/2/93.
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Suspended AllCAC Surveillance And Testing Until Procedures That Could Involve Bypass Leakage Had Been Reviewed And Verified.
Status: Completed 4/I/93.
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Surveillance procedures With Greater Than Six-Month Performance Frequency And Scheduled To Be Performed Prior To R-8 Ref'ueling Outage Were Reviewed To Assure That They Can Be Performed During Operational Modes I, 2, and 3.
Status: Completed 4/4/93.
'I
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Licensing Paper Was Submitted To Document Supply System's Review Of The Use Of TS 3.0.3 In Response To This Event.
Status: Completed 4/2/93.
CORRECTIVE ACTIONS TO PREVENT RECURRENCE
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Corrective Action Program To Be Revised (Measures Already Underway At Time Of Event)
- Changes Will Include Verification That Corrective Actions Have Been Completed And Are Responsive To Initial Concern
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Procedural Verification And Validation Process Improvements (Previously Initiated)
APPARENT VIOLATIONNO. 1 CORRECTIVE ACTI Ns RRECTIVE ACTI N T PREVENT RECURRENCE (continued)
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Technical Specification Surveillance Improvement Program, Already Underway, Accelerated WillInclude Drawing Comparison Will Address Direct Observation Of Performance Effects
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Operators Provided Guidance And Will Be Provided Training Regarding Suppression Pool Bypass Leakage
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Modified SMS To Provide A Consistent Method For Designating Plant Conditions
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Other Specific Corrective Actions Reflected In NCR 293-0346 1-7
APPARENT VIOLATIONNO. 1 ENF RCEMENT CONCLV I N APPARENT VI LATION Low Severity Level Appropriate Minimal Safety Significance Programmatic
.Weakness Acknowledged, But Not A Significant Breakdown In Performance Of Licensed Activities Insufficient Final Corrective Actions Resulted
. From Lack Of Communication/Coordination In Implementation Of Originally Identified Corrective Actions (Concern Already Identified And Being Addressed)
THER N IDERATI N If Escalated Enforcement Action Considered, Mitigation (Or No Escalation)
Appropriate:
Self-Identified By Attentive Operator
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Prompt And Very Extensive Corrective Actions
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Discovery By Operator Indicative Of Questioning Attitude
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Prior Opportunity To Identify Limited Because Effect Of Jumpers Not Readily Apparent
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Single Occurrence During Inspection Period
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Limited Duration Of Plant Condition Outside Technical Specifications 1-8
APPARENT VIOLATIONNO. 2 TATEMENT F APPARENT VI LATI N
"P]nstances in which fire tours were not properly performed may have involved willful violation of the requirements of Technical Specification 6.8.1, regarding the Supply System's implementation of their fireprotection program."
(Apparent. Violation 50-397/93-20-02)
"Written procedures shall be established, implemented, and maintained covering the activities referenced below:
g.
Fire Protection Program implementation" 2-1
APPARENT VIOLATIONNO. 2 BA K R UND
'I
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Self-Initiated Management Review Of Plant Equipment Operator (EO) Log Data
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Review OfFire Tour Logs Revealed Discrepancies Between Recorded Data And Security Computer Records Of Room Entries
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Supply System-Initiated Investigation Of These Discrepancies Determined That The Fire Log Discrepancies Resulted From Inappropriate Personnel Fire Tour Practices
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No Violation Of Procedures/Guidance, Or Training Occurred
"Falsification" Of Fire Tour Logs Did Not Occur Direction/Expectations For Performance Of Fire Tours Not Explicit, Provided Through Minimal Guidance To Fire Tour Personnel Reliance on Skill/Experience Of Fire Tour Personnel (EOs)
2-2
APPARENT VIOLATIONNO. 2 PLY V TEN P ITI N
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Supply System Acknowledges That Self-Identified Fire Tour Log Discrepancies Reflect Insufficient Direction and Training Which Resulted In Inappropriate Personnel Practices In Performing Fire Tours
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No Indication That Personnel Falsified Fire Tour Logs Or Knowingly Or WillfullyViolated Fire Requirements
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Supply System Views Recordkeeping Failures As Very Significant, And Has Addressed These Deficiencies To Prevent Recurrence 2-3
APPARENT VlOLATIONNO. 2 AFEYV/RE ULATORV I NIFI ANCE MINIMAL AFETY I NIFICAN E
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Discrepancies Between Fire Tour Data And Plant Security Computer Records Reflect Improper Fire Tour Practices Rather Than Missed/Falsified Surveillances
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Fire Tour Data Discrepancies Did Not Involve Failure To Record Any Abnormal Conditions; Improper Tour Practices Did Not Result In Any Failure To Observe Abnormal Conditions
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In Most Cases, Abnormal Conditions During Periods Of Missing Data Entries Could Have Been Detected By Subsequent Or Prior Tours, Other Plant Personnel, And/Or Sensing Or Suppression Systems MINIMALRE ULAT RV I NIFICAN E
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Identification and Resolution of Concern Resulted From Self-Initiated Review and Corrective Actions
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Improper Practices Resulted From Lack of Clear Guidance And Training Rather Than Personnel Disregard For Procedures Or Requirements
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Guidance For Proper Conduct Of Fire Tours Has Been Developed And Implemented 2-4
APPARENT VIOLATIONNO. 2 RO T CAUS@ DE'rERMINATION
~
Insufficient Procedural Guidance and Training Personnel Performing Fire Tours Did Not Personally Verify Each Data Point EOs Unaware Such Fire Tour Practices Were Unacceptable No Explicit Contrary Procedural Direction Or Training 2-5
APPARENT VIOLATIONNO. 2 CORRECTIVE ACTIONS
.
Ih&IEDIATE ORRECTIVE ACTION
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Internal Review Was Conducted To Determine Cause Of Discrepancy Between Fire Tour Log Entries and Plant Security Computer Records
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Similar Recordkeeping Investigations Were Conducted In Chemistry, Health
Physics, Maintenance, Security, and Quality Control
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These Subsequent Investigations Resulted In No Findings Of Regulatory Significance C RRECTIVE ACTI NS T PREVENT RECURRENCE
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Management Expectations Regarding Conduct of Tours and Recording Of Information Were Communicated To Appropriate Plant Personnel
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EOs Responsible For Fire Tour Data Entry Discrepancies Were Interviewed and Performance Below Expectations Addressed
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Periodic Surveillance Has Been Developed To Assess Log Keeping Performance Of Various Departments
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Guidance And Training Have Been Revised To Clarify Expectations For Performing Fire Tours and Log Entries Subsequent NRC Inspection (IR 92-31)
Found Current Process Appropriate 2-6
APPARENT VIOLATIONNO. 2 ENFORCEMENT C NCLU I N
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No Violation of Existing Procedures/Guidance Or Training
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If Consideration Of TS 6.8.1 Violation, At Most Severity Level V Appropriate Supply System Acknowledges Detail Could Have Been Provided in Procedures And Training Regarding Fire Tours And Log Entries Minor Safety/Regulatory Significance Log Data Entries Do Not Refiect Falsification Of Records, No Indication That Personnel Knowingly Or WillfullyViolated Fire Tour Requirements Or Procedures
~
Discretion Not To Issue Severity Level V Appropriate Inadequate Practices Discovered During Self-Initiated Reviews Not Related To Previous Findings And/Or Corrective Actions Procedures And Training Have Been Revised To Bring Fire Tour Practices In Line With Supply System Management Expectations Personnel Involved Have Been Counseled And Appropriately Trained To Prevent Recurrence No WillfulViolation Involved 2-7