IR 05000397/1995034
| ML17291A787 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 05/08/1995 |
| From: | Beach A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | Parrish J WASHINGTON PUBLIC POWER SUPPLY SYSTEM |
| References | |
| EA-95-036, EA-95-36, NUDOCS 9505120057 | |
| Download: ML17291A787 (45) | |
Text
PRIDRIT'Y Z REGULATORg itME5QIIMRESiifA!99STYON SYSTEM (RYDS)
'~l ACCESSION NBR:9505120057 DOC.DATE: 95/05/08 NOTARIZED: NO FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe AUTHOR AFFILIATION EACH,A.B.
Region 4 (Post 820201)
RECIP.NAME RECIPIENT AFFILIATION'ARRISH,J.V.
Washington Public Power Supply System 950407 SUBJECT:
Forwards summary of enforcement conference d
t d con uc e
on
,to discuss apparent violations identified in NRC insp 50-397/95-34.List of attendees
& brifing matls encl.
DISTRIBUTION CODE:
IE01D COPIES RECEIVED:LTR ENCL SIZE:
TITLE: General (50 Dkt)-Insp Rept/Notice of Vio ation Response NOTES:
DOCKET I 05000397 RECIPIENT ID CODE/NAME PD4-2 PD INTERNAL: ACRS AEOD/SPD/RAB DEDRO NRR/DISP/PIPB-NRR/DRCH/HHFB OE DIR RGN4 FILE
COPIES LTTR ENCL
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NUDOCS-ABSTRACT OGC/HDS3 COPIES LTTR ENCL
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1 RNAL: LITCO BRYCE,J H
NRC PDR
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1 NOAC
1 VOTE TO ALL"RIDS" RECIPIENTS:
PLE 'LSE HELP US TO REDUCE O'ASTE! COYTACTTHE DOCL'ifEXTCONTROL DESK. ROOM PI.37 (EXT. 504-2083
) TO ELI!IifliNATEYOUR iNAiifEFROif DIS'I'RIB!.'TIOY.LISTS I'OR DOCL:!CLIENTS YOL'Oi "I'iEED!
TOTAL NUMBER OF COPIES REQUIRED:
LTTR
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UNITED STATES NUCLEAR REGULATORY COMMISSION
REGION IV
611 RYAN PLAZA DRIVE, SUITE 400 ARLINGTON,TEXAS 76011 6064 MAY 8 Bg5 EA 95-036 Washington Public Power Supply System ATTN:
J.
V. Parrish, Vice President Nuclear Operations 3000 George Washington Way P.O.
Box 968, MD 1023 Richland, Washington 99352 SUBJECT:
SUMMARY OF ENFORCEMENT CONFERENCE ON APRIL 7, 1995 This refers to the enforcement conference conducted on April 7, 1995, at the Region IV office in Arlington, Texas, regarding apparent violations identified in NRC Inspection Report Number 50-397/94-34.
The conference was held at the request of Region IV.
Attendees at the meeting are listed in Enclosure l.
Your briefing materials, which are included as Enclosure 2 to this summary, provided Region IV personnel a summary of the causes for the apparent violations and your corrective actions.
During the enforcement conference, you and your staff expressed agreement with the apparent violations as described in the inspection report.
In particular, you expressed that you had reported the Technical Specification violations in Licensee Event Reports prior to the conduct of the inspection.
You also indicated that the inspection report contained no significant factual errors.
However, you did provide a
5 page list of items, which is included as Enclosure 3 to this summary, for which you provided a response or clarification.
While we agree with your assessment that these items did not appear to represent any significant disagreements with the factual information in the inspection report, your position on these items will be considered in our enforcement deliberations.
In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice,"
a copy of this letter and the enclosures will be placed in the NRC Public Document Room.
Should you have any questions concerning this matter, we will be pleased to discuss them with you.
Sincerely, A. Bill Beach, Director Division of Reactor Projects 9505i20057 950508 PDR ADQCK 05000397
Washington Public Power Supply System Docket:
50-397 License:
NPF-21 Enclosures:
1.
Attendance List 2.
Licensee Briefing Materials 3.
Licensee List cc w/attachments:
Washington Public Power Supply System ATTN:
J.
H. Swailes, WNP-2 Plant Manager P.O.
Box 968, HD 927M Richland, Washington 99352-0968 Washington Public Power Supply System ATTN:
G.
E.
C.
Doupe, Esq.
3000 George Washington Way P.O.
Box 968, HD 396 Richland, Washington 99352-0968 Energy Facility Site Evaluation Council ATTN:
Frederick S. Adair, Chairman P.O.
Box 43172 Olympia, Washington 98504-3172 Washington Public Power Supply System ATTN:
D. A. Swank, WNP-2 Licensing Manager P.O.
Box 968 (Mail Drop PE20)
Richland, Washington 99352-0968 Washington Public Power Supply System ATTN:
P.
R.
Bemis, Regulatory Programs Manager P.O.
Box 968 (Hail Drop PE20)
Richland, Washington 99352-0968 Benton County Board of Commissioners ATTN:
Chairman P.O.
Box 190 Prosser, Washington 99350-0190 Winston 8 Strawn ATTN:
H.
H. Philips, Esq.
1400 L Street, N.W.
Washington, D.C.
20005-3502
Washington Public Power Supply System MN Q ice; E-Nail report to D. Sullivan (DJS)
bcc to DMB ( IEOl)
bcc distrib.
by RIV:
L. J. Callan DRSS-FIPB Branch Chief (DRP/E)
RIV Senior Project Inspector (DRP/E, WCFO)
Leah Tremper (OC/LFDCB, HS:
TWFN 9E10)
Senior Resident Inspector HIS System File Branch Chief (DRP/TSS)
B. Henderson (PAO, WCFO)
DOCUMENT NAME:
U: iDRSPiPSliW2~tWN031495. RPT To receive copy of document, indicate in boxt "C" i Copy without enclosures
"E" Copy with enclosures "N" ~ No copy RIV: PE DECorpo y
C:DRP/E C
D:WCFO DDC e lain KEPer D'P 5/
/95 5/
/95 5/
/95 CO COP 5/
/95
Washington Public Power Supply System Mh'(
rr,:aq E-Hail report to D. Sullivan (DJS)
bcc to DMB (IE01)
bcc distrib.
by RIV:
L. J. Callan DRSS-F IPB Branch Chief (DRP/E)
RIV Senior Project Inspector (DRP/E, WCFO)
Leah Tremper (OC/LFDCB, HS:
TWFN 9E10)
Senior Resident Inspector HIS System File Branch Chief (DRP/TSS)
B. Henderson (PAO, WCFO)
DOCUMENT NAME:
U;iDRSP~tPSIttW2tI,WN031495.RPT To receive copy of document, indicate in box: "C" ~ Copy without enclosures
"E" ~ Copy with enclosures "N" ~ No copy RIV: PE DECorpo y
C:DRP/E C
D:WCFO DDC e lain KEPer D'P 5/
/95 5/
/95 5/
/95
C
0 5/
/95
Enclosure
Attendance List for Enforcement Conference of April 7, 1995 Licensee Attendees:
J.
V. Parrish, Vice President P.
R.
Bemis, Regulatory Programs Manager J.
H. Swailes, WNP-2 Plant Manager G.
L.
M.
C. J.
J.
T.
Gelhaus, Manager, WNP2 Projects Hatcher, Attorney Schwarz, WNP2 Operations Manager Irish, Program 'Analyst, Bonneville Power Admin.
NRC Attendees:
L. J. Callan, Regional Administrator A.
B. Beach, Director, Division of Reactor Projects W.
H. Bateman, Director, Project Directorate, NRR J.
E. Dyer, Deputy Director, Division of Reactor Projects S. J. Collins, Director, Division of Radiation Safety and Safeguards K.
E. Perkins, Director, Region IV Walnut Creek Field Office D.
D. Chamberlain, Chief, Reactor Projects Branch E
J.
W. Clifford, Senior Project Manager, NRR R.
C. Barr, Senior Resident Inspector, WNP2 J.
L. Pellet, Branch Chief, Division of Reactor Safety W.
D. Johnson, Branch Chief, Division of Reactor Projects S. J.
Campbell, Resident Inspector, ANO T. X. Reis, Project Engineer, Branch C
D.
Korosec, Inspector, Slovenian Nuclear Safety Administration H.
Dawson, NRC Intern W. L. Brown, Regional Counsel J.
Beall, Senior Enforcement Specialist, OE W.
B. Jones, Enforcement Specialist, RIV
Enclosure
PRESENTATION BY WASHINGTON PUBLIC PONfER SUPPLY SYSTEM TO THE NUCLEAR REGULATORY COMMISSION APRIL 7, 1995 ENFORCEMENT CONFERENCE EA 96-036 INSPECTION REPORT No. 50-397/94-34)
AGENDA INTRODUCTION V PARRISH DISCUSSION OF EVENTS C. SCHWARZ USE OF 50.59 PROCESS DURING MODIFICATIONS G. GELHAUS PLANT MANAGER'
PERSPECTIVE J. SWAILES REGULATORY IMPLICATIONS P. BEMIS CLOSING REMARKS V. PARRISH
~
~
~
~
3-30-94 3-31-94 Leak Identified on Deluge Isolation Valve WO 1683 Priority 3
Filter Unit Discovered Leaking Water Discovered during Technical Specification Surveillance
I ~
~
4-5-94 4-26-94 6-27-94 WR 94001798 Door 4 Gasket 51B R-9 Outage Begins Door 4 Gasket 51B, Status 55 (Shift Manager Review Complete)
~
~ ~
o 6-24-94 6-27-94 WR 94003344 Door 6 Gasket 51B System Engineer Assessment
I ~
~
6-24-94 6-27-94 10-26-94 11-2-94 11-4-94 WR 94003344 System 51B Door 3 Gasket WR 94006022 51B Door 6 Door 6 Gasket Engineer Removed Door 3 Gasket Status 55 51B Assessment 51B 11-21-94 11-23-94 LER 94-19 Door 3 Gasket Discovery Date 51B, Status 55
WQ CR70 Authorizes ASD Penetration/
Cabling Work Holes Cut in Penetration (5016)
'
ER 94-02
~
51B Door, 3 Gaskets Status 55, (SM Review Complete)
Performed Operability Test for Associated 54B Fan. Fan Fails Test Evaluation Determined Holes Precluded Successful Test.
After Plugging Holes, Test Successfully Reperformed.
Further Evaluation Showed A8 B Trains lnop. KS 3. SUMIVlARYOF CONCLUSIONS COMMON THEMES
~
TRAINING OPERATIONS PERSONNEL WERE NOT S UFF IC IENTLY TRAINED TO EVALUATE D EG RADED CONDITIONS ASSOCIATED WITH THE CONTROL ROOM PRESSURIZATION ENVELOPE
~
WHEN FACED WITH OUT-OF-NORMAL SITUATIONS, A QUESTIONING ATTITUDE WAS NOT USED
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THE WORK ORDER SYSTEM RELIES TOO MUCH ON ONE INDIVIDUALTO MAKE DECISIONS ON OPERABILITY ADDITIONALFACTORS
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SUPPLY SYSTEM AGREES WITH THE BASIC FACTS OF THE VIOLATIONS
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THE TECHNICAL SPECIFICATION MATTERS WERE APPROPRIATELY REPORTED IN LERs
~
MINIMALACTUALSAFETY SIGNIFICANCE
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CONTROL ROOM WAS ALWAYS ABLE TO BE PRESSURIZED, EVEN THOUGH THE PRESSURIZATION LEVEL DID NOT MEET THE TECHNICAL SPECIFICATION REQUIREMENT
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THE ISSUES IDENTIFIED IN NRC's INSPECTION REPORT ARE CONSISTENT WITH THOSE IDENTIFIED IN THE SUPPLY SYSTEM's MID-CYCLE ASSESSMENT
SUMMARY OF FOLLOW ON ACTIONS MAINCONTROL ROOM DAYSHIFTSUPPLEMENTED WITH EXTRA SRO TO REDUCE ADMINISTRATIVE BURDEN
~
SRO ASSIGNED TO CLEARANCE ORDER REVIEW COMMITTEETO PROVIDE ADDITIONALOVERSIGHT
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CONDUCT UPGRADE OF TRAINING ON CONTROL ROOM PRESSURIZATION ENVELOPE FOR ALL OPERATORS
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CONDUCT TRAINING FOR IVIAINTENANCE PERSONNEL TO UPGRADE UNDERSTANDING OF CLASS 1 VERSUS CLASS 2 SYSTEMS
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ON-SHIFT SRO TO PERFORM PRELIMINARY SCREENING OF WORK REQUESTS PRIOR TO ROUTING TO WORK CONTROL
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WORK REQUEST REVIEW PROCESS NOW CONSISTS OF A MULTI-DISCIPLINARYTEAM TO ASSESS AND PRIORITIZE RESOLUTION OF PLANT PROBLEMS OR DEFICIENCIES
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IMPLElVIENTED PROGRAM TO TRACK PROBLEMS WITH S U RVEILLANCES AND TO TRACK INDIVIDUAL CREWS HAVING PROBLEMS FOR INDIVIDUALACCOUNTABILITY
SUIVIMARYOF FOLLOW ON ACTIONS (continued}
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REIN FO RC E EXPECTATIONS FOR ALL SITE PERSONNEL TO ENSURE
-
CONTROL ROOM PERMISSION IS OBTAINED PRIOR TO PERFORMING WORK
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LABEL DOORS TO AIR HANDLING UNITS TO ASSURE AWARENESS OF CONTROL ROOM BOUNDARY IIVIPLICATIONS
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INCREASE FORMALITY OF TROUBLE SHOOTING PROCEDURE
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CONTINUE EFFORTS ON IlVIPLEMENTATION OF SUPERVISORY OVERSIGHT PROGRAM AND PEER EVALUATIONPROGRAIVIS
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CONTINUE TO REINFORCE WITH OPERATIONS PERSONNEL NEED TO MAINTAINA QUESTIONING ATTITUDE WHEN CONDITIONS ARE OFF NORMAL
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BRING IN CONGER AND ELSEA TO PERFORM ROOT CAUSE ANALYSIS, FOR RECENT TECHNICAL SPECIFICATION RELATED ISSUES
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CONTINUE OPERATIONS DEPARTMENT STEP UP PLAN TO ADDRESS CULTURAL CHANGE, LEADERSHIP, PERFORMANCE, COMMUNICATION AND TEAM WORK
US E 0 F 50. 59 PROCESS DURING MODIFICATIONS NRC ISSUES WEAKNESS IN DESIGN MODIFICATION IMPLEMENTATION AND INTERFACE WITH MAINTENANCEAND OPERATIONS
~
50.59 REVIEW FOR INSTALLATION OF CONTROL ROOM PENETRATION WAS NARROWLY FOCUSED
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IMPROVED 50.59 PROCESS WAS NOT APPLIED RETROACTIVELYTO IN-PROCESS WORK
BACKGROUND ON 50.59 PROCESS PREVIOUS PRE-10 94
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SEPARATE 50.59 COVERING DESIGN.,:
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INSTALLATIONAND TESTING COVERED IN SECOND 50.59
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IN-PROCESS WORK ALLOWED TO CONTINUE CURRENT POST-10 94
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SINGLE 50. 59 ENCOMPASSING DESIGN, INSTALLATIONAND TESTING
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INPUTS FROM OPERATIONS, SYSTEM ENGINEER, INTERFACING SYSTEM ENGINEER(s),
DESIGN ENG INEER(s), PRO J ECT ENG INEER AND OTHERS
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OVERVIEW OF PROCESS IWlPROVEMENTS
~
PROJECT ENGINEER HAS RESPONSIBILITY FOR ASSURING WORK ORDER TASKS ARE PREPARED (INCLUDES SIGNATURE BY SUPERVISOR)
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SYSTEM ENGINEER WRITES OR REVIEWS POST-MODIFICATION TESTS
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ENHANCED "CHECKLIST" TO DOCUMENT THAT ACTIVITIES HAVE BEEN COMPLETED PRIOR TO TURNOVER TO OPERATIONS (e. g., FCNs)
~
PRO JECT ENGINEER REVIEWS INSTALLATION WITH OPERATIONS MANAGER PRIOR TO TURNOVER
~
PROJECT ENG IN EERI NG IS THE SINGLE POINT OF RESPONSIBILITY FOR MINOR MOD I F ICATIONS
SUPPLY SYSTEM's UNDERSTANDING OF KEY CONCERNS IN OPERATIONS CONCERNS RAISED BY NRC
~
TEAMWORK BETWEEN DEPARTMENTS IS LACKING
~
OPERATIONS IS NOT CHALLENGING OTHER ORGANIZATIONS AND, RATHER, IS SERVING TOO MUCH AS A LINE SERVICE ORGANIZATION
~
TEAMWORK IN THE OPERATIONS ORGANIZATION IS INCONSISTENT THE CRS IS UNABLE TO DEVOTE HIS FULL ATTENTION TO OVERSIGHT FUNCTIONS
~
ATTENTION-TO-DETAIL, SELF-CHECKING, AND INDEPENDENT VERIFICATION ALL NEED SIGNIFICANT IMPROVEMENT THE CLEARANCE ORDER PROCESS NEEDS IMMEDIATEIMPROVEMENT
~
SCHEDULE PRESSURE MAY HAVE CONTRIBUTED TO CERTAIN EVENTS WORK CONTROL PROCESS DOES NOT PROPERLY SUPPORT OPERATIONS
SUPPLY SYSTEM'S PERSPECTIVE
~
THE SUPPLY SYSTEM AGREES WITH THE NRC AND THESE ITEMS ARE CONSISTENT WITH OUR OWN FORMAL SELF-ASSESSMENT
~
AN ADDITIONAL COMPLICATING ISSUE RECOGNIZED DURING OUR ASSESSMENT OF THESE MATTERS IS THAT WE HAVE BEEN UNNECESSARILY CHALLENGING OPERATIONS STAFF
SUPPLY SYSTEIVI's SYSTEMATIC APPROACH TO RESOLVING LONG-STANDING PROBLEMS
~
REVIEWING AND AS SU RING THAT EXPECTATIONS HAVE BEEN ESTABLISHED AND CLEARLY COMMUNICATED FOR OWNERS H I P, R E S PO N S I B I LIT Y AND QUESTIONING ATTITUDE IN ALL PERSONNEL
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ESTABLISH MULTIPLE LAYERS OF DEFENSE AND PUSH ORGANIZATIONSTO EFFECTIVELY SURFACE PROBLEMS
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PROMPTLY CORRECT SURFACING PROBLEMS TO PREVENT UNDUE RELIANCE ON LAST LAYER OF DEFENSE TYPICALLYOPERATIONS
ACTIONS THAT ARE BEING TAKEN MANAGEMENTAREA
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SET HIGH STANDARDS AND EFFECTIVELY COMMUNICATETHEM
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DEVELOP AN ORGANIZATION THAT ACHIEVES EXCELLENCE IN WORK PROCESSES AND MODIFICATIONS
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IMPROVE TEAMWORK AND INTER-ORGANIZATIONAL COMMUNICATION (e.g.,
ECKERD COLLEGE, SUPERVISOR TRAINING, "BOSS TALKS," etc.)
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ELI lVI I NATE EXCESSIVE CHALLENGES TO OPERATIONS
~
ENSURE THAT OPERATIONS IS WELL EQUIPPED TO MEET REASONABLE CHALLENGES
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OPERATIONS MUST TAKE OWNERSHIP AND AGG RESS IVELY CHALLENG E THE REMAINDER OF THE PLANT
ACTlONS THAT ARE BElNG TAKEN {cont'd)
SYSTEMS ENGINEERING AREA
~
SYSTEM ENGINEER RESPONSI BILITIES AND PRIORITIES HAVE BEEN CLEARLY DOCUMENTED
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INCREASING 'UALITY AND QUANTITY OF SYSTEMS ENGINEERS (i.e., FEWER SYSTEMS PER ENGINEER)
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INCREASING IN-FIELDTIMEAND DAILYREVIEW OF CORRECTIVE ACTION WORK ORDER TASKS
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DETAILED SYSTEM WALKDOWNS IDENTIFYING AREAS FOR ENHANCEMENT
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'RANSFERRED NON-SYSTEMS ENGINEERING FUNCTIONS TO OTHER ORGANIZATIONS (e.g.,
MINOR MODIFICATIONS)
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CRITERIA DEVELOPED TO QUESTION CONTROL ROOM VENTILATIONOPERABILITY
ACTIONS THAT ARE BEING TAKEN (cont'd)
MAINTENANCEAREA
~
INCREASED USE OF
"PERSON IN CHARGE" IN COORDINATION AND PROBLEM RESOLUTION OF WORK
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REDUCED BACKLOG OF PREVENTIVE AND CORRECTIVE MAINTENANCE
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IVIAINTENANCEFUNCTIONAL TEAMS HAVE BEEN ASSIGNED AND TRAINED TO RESOI VE KNOWN LONG-TERM PROBLEMS (e.g., HVAC 5. REFUELING FLOOR)
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ROTATING EXPERIENCED CRAFT SUPERVISORS AND SYSTEM ENGINEERS INTO SCHEDULING AND PLANNING
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SHIFT TECHNICAL ADVISORS ATTEND DAlLY MAINTENANCESTATUS MEETINGS
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RE-ENGINEERING WORK CONTROL PROCESS
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MAINTENANCEMANAGEREMPHASIZED TO STAFF THAT PERSONNEL MUST GET ENGINEERING APPROVAL BEFORE MAKING CON FIGURATION CHANGES
sulVlMARY AREAS REQUIRING FURTHER ATTENTION
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GET BROAD INTERACTION ON FRONT END GENERATION OF OPERABILITY ASSESSMENTS AND SINGLE POINT OF REVIEW TO ENSURE CONSISTENCY FOR FINAL APPROVAL OF OPERABII ITY ASSESSMENTS
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CONTINUED EMPHASIS ON HUMAN PERFORMANCE IMPROVEMENT INITIATIVES INCREASED EMPHASIS ON PROBLEM RESOLUTION THROUGH DESIGN BASIS UNDERSTANDING IN TRAINING
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EXTEND SU PERVISORY AND PEER-TO-PEER ON-THE-JOB EVALUATIONOF FIELD WORK ACTIVITIES FROM OPERATIONS TO OTHER ORGANIZATIONS
~
POST MODIFICATION/MAINTENANCETESTING
REGULATORY IlVlPLICATIONS I
SUPPLY SYSTEM AGREES THAT TECHNICAL SPECIFICATION VIOLATIONS OCCURRED ACTUALSAFETY SIGNIFICANCE WAS MINIMAL SYSTEM OUT-OF-SERVICE TIMES MET LCO REQUIREMENT ONCE IDENTIFIED SYSTEM WAS ABLE TO PRESSURIZE CONTROL ROOM LOW DOSES WOULD HAVE RESULTED UNDER ACCIDENT CONDITIONS
~
SUPPLY SYSTEM RECOGNIZES THE REGULATORY SIGNIFICANCE OF THE MATTERS THEY DO NOT HOWEVER REPRESENT A SYSTEMIC FAILURE OF PLANT ACTIVITIES, INCLUDING THE CORRECTI VE ACTIONS PROCESS
~
MITIGATINGCIRCUMSTANCES KNOWLEDGE/TRAINING DEFICIENCY EXACERBATED PROBLEM SELF-IDENTIFICATION OF PRINCIPAL CONCERNS COMPREHENS!VE CORRECTIVE ACTIONS, INCLUDINGLONG-TERIVI INTEGRATED EFFORTS MAJORITY OF ISSUES WERE PREVIOUSLY RECOGNIZED BY THE SUPPLY SYSTEM AS PART OF ITS MID CYCLE LICENSEE ASSESSMENT TECH SPEC VIOLATIONS WERE REPORTED IN A TIMELY MANNER
APPENDIX A LER CORRECTIVE ACTIONS LER 94-012 IMMEDIATE
~
~
~
INSPECT AND CLEAN FILTER UNIT.
~
REPLACE LEAKYVALVE.
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TEST AND REPLACE CHARCOAL FILTER BED.
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REPLACE OTHER FILTERS ASSOCIATED WITH FILTER UNIT.
FOLLOW ON
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INSPECT REDUNDANT EMERGENCY FILTER UNIT, INSPECT NON-SAFETY RELATED FILTER UNIT.
~
ONE-ON-ONE DISCUSSION WITH OPERATOR AND SHIFT SUPPORT SUPERVISOR.
EMPHASIZE LESSONS LEARNED. ISSUED NIGHT ORDERS TO OPERATIONS STAFF TO EMPHASIZE MISSED OPPORTUNITY FOR EARLIER DETECTI0 N.
~
SYSTEM ENGINEER MANAGEMENT DISCUSS LESSONS LEARNED WITH SYSTEM ENGINEER.
~
REVISE CONFIGURATION OF SYSTEM AND SIMILARSYSTEMS TO PREVENT RECURRENCE.
~
INCLUDE LER IN OPERATIONS AND ENGINEERING TRAINING PROGRAM.
ALSO INCLUDE WORK CONTROL STAFF.
EMPHASIZE NEED TO ASSESS IMPACT OF LOW PRIORITY WORK ON SAFETY RELATED EQUIPMEN LER 94-019 IMMEDIATE
~
SEAL DOOR. RE-PERFORM 7.4.7.2.8 TO CONFIRM MEETING SURVEILLANCE REQUIREMENT.
FOLLOW ON MAINTENANCE MANAGER MECHANICAL MAINTENANCE COUNSELED MECHANICALMAINTENANCE SUPERVISOR ON NEED FOR PROPER WORK AUTHORIZATION,DESIGN REVIEWS, AND CONTROLS PRIOR TO STARTING WORK.
MAINTENANCE MANAGER EMPHASIZED EXPECTATIONS TO HAVE SUPERVISORS IDENTIFY AND DOCUMENT PLANT PROBLEMS.
~
MAINTENANCEMANAGER DISCUSSED WITH ALL MAINTENANCESHOPS:
IDENTIFYAND DOCUMENT PROMPTLY PLANT PROBLEMS INCLUDING WHAT WAS DONE TO CORRECT PROBLEMS AND NOTATIONS OF OBSERVATIONS.
REQUIREMENT TO OBTAIN APPROVAL PRIOR TO CHANGING PLANT CONFIGURATION.
IMPORTANCE OF CONTROL ROOM PRESSURIZATION BOUNDARIE LER 94-021 IMMEDIATE
~
IDENTIFY AND REPAIR HOLES, VERIFY CONTROL ROOM PRESSURIZATION.
~.
WALK DOWN OTHER CONTROL ROOM FLOOR PENETRATIQNS.
t
~
STOP ALL PENETRATION WORK OR BARRIER WORK AFFECTING CONTROL ROOM, SECONDARY CONTAINMENT, TECHNICAL SPECIFICATION AND EMERGENCY OPERATIONS FACILITYBOUNDARYPENDING RE-EVALUATION OF EACH TASK.
FURTHER
~
REVIEW PPM 15.4.5 TQ EXPLAIN MEANING OF SEAL REQUIREMENTS.
~
REVISE PPM 1.3.7.0 TO HELP PLANNERS RECOGNIZE THAT A CREDITED FUNCTION COULD BE AFFECTED BY PLANNED WORK.
~
OPERATIONS TRAINING ON BARRIERS PRESENTED TO INCLUDE OPERATIONS'ESPONSIBILITY FOR MANAGING-IMPAIRMENTS AND ASSOCIATED PROCEDURE CHANGES.
~
REVISE PPM 1.3.57 TO INCLUDE CR ENVELOPE AS PART OF BARRIER IMPAIRMENTEVALUATIONCRITERIA.
REVISE PPM 1.3.10, 10.25.57 TO REFERENCE REVISED 1.3.57.
TRAIN ENGINEERING, MAINTENANCE,OPERATIONS, WORK PLANNING, QA ASSESSMENT, AND PLANT CONTRACTOR ON PROCEDURE REVISIONS.
NIGHT ORDERS ISSUED TO OPERATIONS CREW ON IMPACT OF CUTTING HOLES.
EMPHASIZED THAT TECHNICAL SERVICES ENGINEER SHOULD BE CONTACTED ON SEAL REMOVAL AND BARRIER PENETRATIONS PENDING IMPLEMENTATIONOF CORRECTIVE ACTIONS.
~
ENGINEERING STAFF AND WORK PLANNING PERSONNEL TRAINED IN APPLICABILITYOF 1.3.5 r 6-24-0 6-24-94 Leak Identified WO 1683 WR 94001798 on Deluge Priority 3 Door 4 Gasket Isolation Valve 51B 6-27-94 6-27-94 6-27-94 11-2-94 11-4-94 11-21-94 R-9 Outage Filter Unit Water Discovered Begins Discovered during Technical LeaKing Specification Surveillance WR 94003344 Door 6 Gasket 51B WR 94003344 Door 6 Gasket 51B 11-23-94 Door 4 Gasket 51B, Status 55 (Shift Manager Review Complete)
System EngineerAssessment System EngineerAssessment WR 94006022 51B Door 6 LER 94 19 Door 3 Gasket Door 3 Gasket Status 55 Discovery Date 51B, Status 55 51B 11-22-94 11-23-94 WO CR70 Authorizes ASD Penetration/
Cabling Work Holes Cut in Penetration (5016)
LER 94-021 51B Door, 3 Gaskets Status 55, (SM Review Complete)
Performed Operability Test for Associated 54B Fan. Fan Fails Test Evaluation Determined Holes Precluded Successful Test. After Plugging Holes, Test Successfully Reperformed.
Further Evaluation Showed A 8 B Trains Inop. TS 30 MAINCONTROL ROOM EMERGENCY FILTER UNITWMA-FU.54B FILTER UNIT BOTTOM DRAIN LINES WITH SPRING LOADED CHECK VALVES DEEP WATER SEAL TRAP TRAP F(LL VALVE RESTRICTING ORIFICE FP-V-WMA/54B 3/4" TO DRAIN SYSTEM STRAINER TO DRAIN SYSTEM FP-V-WMA/21 FP-V-WMA/23 FROM DELUGE SPRAY SUPPLY TO DRAIN SYSTEM MAINCONTROL ROOM EMERGENCY FILTER UNIT WMA-FU-S4B DELUGE SYSTEM - ALIGNMENT AT TIME OF EVENT
OVTSIDE ASl NTAKE EHO SICDIVI 1848 AADClOSES AD.SIA.IAHD TRIPS WEAmat REMOTE DITAKE
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$4AI M
5481 EMEAG FILTER
$ 18 OIV2 AE
$28 A
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$18.1 FAN 548 M
AUTO START-0 ON FAZ H
TYPICAL M
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$10 FO 520 FO FAN SSA PURGE EXHAUST 150 CFM FAN 528 FO "E NE FO FAN $1 TAN0 N FAN 54A (8) START 7$0 CFM EXHAUST CONTROL ROOM HVAC NORMALLINE UP
OUTSIE ATIINTAKE.
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WMA.FD-7 52A 54A 51A 51B 54B 52B Cable Chase Control Room WMA-DPI.7 Cable Spreading Room Remote Shutdown Room Cable Spreading Room Pressurization Event
Enclosure
REFERENCES/CONCERNS Page 4, Paragraph 5:
"but did not assign a date to perform repairs."
"Only after wetted charcoal was identified.... was valve repaired."
Page 5, Paragraph 2:
"the emergency filtration system was unable to perform its design function" Page 7, Paragraph 5:
"FP-V-WMA/21 is only closed isolation..."
Page 8, Paragraph 2:
"the leak rate from the telltale drain was low (approximately I drop per second)"
Page 8, Paragraph 3:
"The orifice was intended to be a telltale indication of a leakage problem and the licensee did not recognize that the leakage could possibly render the charcoal filters inoperable".
Page 8, Paragraph 5:
"The EO, who had not received training on the design of this system."
RESPONSE We initiated a WO and initiallyscheduled work on a 12-week rolling maintenance window schedule (as reported by LER 94-012).
The design function, pursuant to the requirements of GDC 19, is to limitexposure to control room personnel.
This is accomplished through pressurization of the control room to a positive pressure.
The system was capable of performing its design function throughout these events.
This fact is stated in paragraph 1 on page 6 of the inspection report and in LER 94-019.
At the time of the event, this was the only closed isolation valve.
As documented in LER 94-012, both isolation valves are now closed and have been since the summer of 1994.
The EO found a 3-4" diameter puddle on the fioor. There was no quantifiable leak rate at that time.
The telltale drain was installed, after plant startup, because of the recognized potential for water intrusion into the charcoal units.
The EO in question was both trained and qualified on this system.
Page 9, Paragraph 2:
"the SRO did not recognize that the leaking valve potentially impacted the operability of the charcoal filter."
Page 10, Paragraph 6:
""a system engineer noted" The SRO clearly understood the function of the deluge system and potential to impact the charcoal.
The decision to work the valve during the normal 12-week rolling schedule was based on the limited leakage observed.
This should be "an EO noted", not a system enginee REFERENCES/CONCERNS Page 10, Paragraph 3:
"The licensee did not perform any calculation or assessment to determine the amount of time prior to May 31, 1994 that the unit was inoperable."
Page 10, Paragraph 4:
"From some undetermined time after March 31, 1994."
Page 12, Paragraph 4:
"the control room logs did not contain acceptance criteria for minimum differential pressure indication."
Page 13, Paragraph 4:
"The WOT did not provide instructions to operate the emergency filtration system at the higher pressure of the emergency mode.'age 13, Paragraph 4:
"The PMT was inadequate to identify that the emergency filtration system was inoperable with the Door 3 also missing as discussed in Section 3.4 below."
RESPONSE In accordance the NRC guidance provided in NUREG-1022, the condition was assumed to have occurred when found the first time on May 31, 1994.
The leakage found and identified prior'o this time, March 31, 1994, would not have rendered the charcoal unit inoperable.
This assessment was performed by the licensee as part of the development of LER 94-012.
Contrary to NRC guidance in NUREG-1022 as discussed above.
The date of occurrence was May 31, 1994 when the condition was first found.
This is true.
The implIcation that acceptance criteria are required is not correct.
This is not a surveillance procedure or a Technical Specification requirement.
The system operates in various modes (lineups) and therefore no single acceptance criteria can be applied.
However, guidance will be added to help the operators better understand the condition of the system based on the reading.
PMT testing does not necessary have to be performed at emergency conditions, and in fact for many systems post accident conditions cannot be simulated.
A "reasonable assurance" of operability must be provided, as was provided by the testing performed.
This is confirmed by control room logs taken after the installation of the gasket.
In this case, the pressure at the gasket does not change.
The PMT performed is to verify that the component worked on is returned to an operable status.
There is no requirement to perform a complete system test as a PMT, and in fact this generally is not done.
Surveillance testing is performed, at the required Technical Specification periodicity, to verify system operabilit REFERENCES/CONCERNS Page 15, Paragraph 3:
"Inspector concluded that the air handling unit was apparently inoperable for an indeterminate period with door 3 open."
RESPONSE Although this is not an incorrect statement, it could be somewhat misleading due to the absence of reporting results of interviews conducted by the resident inspector concerning performance of a surveillan'ce near the aff'ected unit one night prior to removing the gasket.
During this interview, Supply System personnel stated that they did not see the door open.
Page 17, Paragraph 5:
"The operators lacked a questioning attitude about operability of the emergency filtration system and did not verify operability of the redundant train."
Page 18, Paragraph 5:
"The planner also initiated a barrier impairment log sheet identifying the impairments, per Procedure 1.3.57. Revision 2, 'Barrier Impairment'"
Page 19, Paragraph 2:
"The individual who performed the evaluation noted that the installation process for the modification would not place the plant in an unsafe or unevaluated condition."
It is believed that the door may have been opened by one of the two maintenance crews working on the unit during the time period it was found open, and then found by the other crew.
The redundant train had successfully passed the same 18-month test the day before.
It was reasonable and prudent, given this fact, for the operators to conclude that the redundant train remained operable and that the condition they were seeing was single train only.
PPM 1.3.10 was used by the planner.
The system engineering supervisor used 1.3.57 when the breaches were identified.
As noted in Paragraph 1 on the same page of the inspection report, a design engineer noted on the seal control form the fire barrier and the air fiow seal requirements.
Therefore, since adequate air barrier control should have been put in place, and no unreviewed safety question should have been expected and the 50.59 evaluation was corre t.
Page 19, Paragraph 3:
"Procedure 1.4.1. 'Plant Modifications.'id not include guidance on installation, testing, and operational considerations."
This procedure does include this guidanc REFHKNCES/CONCERNS Page 24, Paragraph 2:
"the licensee did not research operability of Train A" Page 24, Paragraph 2:
"the licensee did not convene an IRB to discuss the leaking deluge valve event."
Page 24, Paragraph 2:
"the PER analysis did not discuss the operability of the redundant Train A of the CRVS during the period."
Page 24, Paragraph 3:
"LER 94-19 did not address the apparent ineffectiveness of this corrective action~
94-12 CA emphasizing importance of low priority deficiencies on SR equipment]."
Page 26, Paragraph 6:
"Therefore, the licensee concluded that a significant" RESPONSE The RCA analyst did this research as part of the PER evaluation.
For completeness, this information could have been included in the LER. The statement in the LER that "A redundant emergency filter unit is also installed to provide the control room with redundant filtering capability" was correct.
This was not one of the features credited in the conclusion paragraph of the LER safety significance section.
IRBs are used to gather information immediately following an event.
Since it was clear that the deluge valve had been leaking for some time prior to discovery on June 23, 1994, there was no need for an IRB for this event.
The root cause investigation was the appropriate investigative tool.
The PER did review this.
As reported in LER 94-019, and as discussed with the inspector, the SRO reviewer did not recognize there was a problem.
The SRO believed that the missing gasket was a long standing problem that had previously not impacted surveillance testing.
A more questioning attitude is desired, however.
The licensee did
~n conclude that a
"significant" dose could have been received.
The calculation was performed, at the request of the inspector, for a condition that did not exist (charcoal filter inoperable with the plant at 100% power).
The postulated versus actual conditions used for the calculation were discussed with the inspectors on several occasions.
Since this calculation was performed for a condition that did not exist, it was n'ot a formalized calculation.
Even ifan accident had occurred at power with an inoperable filter, a significant dose would not have been receive s
REFHMNCES/CONCERNS Page 27, Paragraph 1:
"the inspectors were provided no conclusions by the licensee on the potential thyroid dose based on the ninth refueling outage local rate data or based on a design basis leak rate.
RESPONSE The one calculation performed was performed at the request of the inspector for a condition that did not exist at %NP-2 (charcoal filter inoperable with the plant at 100% power).
No additional calculations were requested.
The R9 calculated doses for control room personnel increased to 9.61 rem thyroid, and 0.006 rem whole body.
The primary and secondary containment leakage rates assume a single failure on each penetration, along with other conservatisms, that make the calculation very conservative overall.
Since the known leakage rates are available, there is no reason to use the "allowable" design basis leakage value a e 0