IR 05000458/1992032

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-458/92-32 on 921210

ML20127N106
Person / Time
Site:	River Bend
Issue date:	01/22/1993
From:	Beach A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Graham P GULF STATES UTILITIES CO.
References
NUDOCS 9301290087
Download: ML20127N106 (4)

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,f Ig NUCLEAR REGULATORY COMMISSION

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't j REGloN IV 611 RYAN PLAZA DRIVE, SUITE 400

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JAN 2 21993 Docket No. 50-458 License No. NPF-47 Gulf States Utilities ATTN: P. D. Graham Vice President (RBNG)

P.O. Box 220 St. Francisville, Louisiana 70775 Gentlemen:

SUJECT: NRC INSPECTION REPORT NO. 50-458/92-32 (NOTICE OF VIOLATION)

Thank you for your letter of January 11, 1993, in response to our letter and Notice of Violation dated December 10, 199 We have reviewed your reply and find'it responsive to the concerns raised in our Notice of Violation. We will review the implementation of your corrective actions during a future inspection to determine that full compliance has been achieved and will be maintaine

Sincerely, l

. Bill Beach, Director Division of Reactor Projects cc:

Gulf States Utilities ATTN: J. E. Booker, Manager-Nuclear Industry Relations P.O. Box 2951 Beaumont, Texas 77704 Winston & Strawn ATTN: Mark J. Wetterhahn, Es L Street, Washington, b 9301290087 930122 PDR ADOCK 05000458 G PDR I

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Gulf States Utilities -2-Gulf States Utilities ATTN: Les England, Director Nuclear Licensing P.O. Box 220 St. Francisville, Louisiana 70775 Mr. J. David McNeill,111 William G. Davis, Es Department of Justice Attorney General's Office P.O. Box 94095 . - -

Baton Rouge, Louisiana 70804-9095 H. Anne Plettinger 3456 Villa Rose Drive Baton Rouge, Louisiana 70806 President of West Feliciana Police Jury P.O. Box 1921 St. Francisville, Louisiana 70775 Cajun Electric Power Coop. In ATTN: Philip G. Harris 10719 Airline Highway P.O. Box 15540 Baton Rouge, Louisiana 70895 Hall Bohlinger, Administrator -

Radiation Protection Division

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P.O. Box 82135 Baton Rouge, Louisiana 70884-2135

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Gulf States Utilities -3- JAN 2 21993 bcc to DMB (IE01)

bcc distrib. by RIV:

J. L. Milhoan Resident Inspector DRP Section Chie' (DRP/C)

Lisa Shea, RM/ALF, MS: MNBB 4503 MIS System DRSS-FIPS RSTS Operator RIV File Section Chief (DRP/TSS)

DRS Senior Resident Inspector, Cooper _

Senior Resident Inspector, Fort Calhoun

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Gulf States Utilities -3- JAN 2 21933 bec t'a DMB - (IE01)'

bcc distrib, by RIV:

J. L. Milhoan Resident Inspector DRP Section Chief (DRP/C)

Lisa Shea, RM/ALF, MS: MNBB 4503 MIS System DRSS-FIPS RSTS Operator RIV File Section Chief (DRP/TSS)

DRS Senior Resident Inspector, Cooper Senior Resident Inspector, Fort Calhoun

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GULF STATES UTELITIES we em s w;c,. ww wra sa,, w e a m asn a m s.A.,A m n AEk & CDCf 's04 635 f;O94 345 titMI January 11, 1993 RBG- 37976 File Nos. G9.5, G15. .i [! Is [2 0 W [$ ~.'

U.S. Nuclear Regulatory Commission g jlf'~~~ ~j ,

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Washington, D.C. 20555 L

I Gentlemen: REGiONIV

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River Bend Station - Unit 1 Docket No. 50-458/92-32 Pursuant to 10CFR2.201, this letter provides Gulf States Utilities Company's (GSU) response to the Notice of Violation for NRC Inspection Report No. 50-458/92-32. The inspection was conducted by Mr. W.F. Smith on September 27 through November 7,1992, of activities authorized by NRC Operating License NPF-47 for River Bend Station - Unit 1 (RBS). GSU's replies to the violations are provided in the attachment Should you have any questions, please contact Mr. L.A. England at (504) 381-414

Sincerely,

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!. i W.H. Odell Manager - Oversight River Bend Nuclear Group 1t>

JPS C/JWC/kvm Enclosure cc: U.S. Nuclear Regulatory Commission 611 Ryan Plaza Drive, Suite 400 Arlington, TX 77011 ,

NRC Resident Inspector b 7 /) Y O, WlA V'/ "

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P.O. Box 1051 St. Francisville, LA 70775 _gFFO

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ATTACIIMENT 1 REPLY TO NOTICE OF VIOLATION 50-458/9232-01 LEVEL IV REFERENCE Notice of Violation - Letter from A.B. Beach to P.D. Graham, dated December 10, 1992 VIOLATION A: FAILURE TO FOLLOW A SYSTF31 OPERATING PROCEDURF Technical Specification 6.8.1 requires, in part, that written procedures shall be established, _

implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 197 Regulatory Guide 1.33, Appendix A, recommends, in part, that instmetions for stanup, shutdown, and changing modes of opemtion should be papared for the containment ventilation syste System Operating Procedure SOP-0059, which was issued to satisfy the above provisions of Regulatory Guide 1.33, Appendix A, requires, in Section 5.4, that both trains of standby gas treatment must be operable to use standby gas treatment in the containment purge mod Contrary to the above, on September 24,1992, both trains of standby gas treatment were not operable when standby gas treatment was in the containment purge mode. Control room operators initiated a containment purge utilizing Standby Gas Treatment Train A in the containment purge mode for approximately 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />, with Train B inoperabl ,

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REASON FOR TIIE VIOLATION On September 24,1992 at 0005, the 'A' standby gas treatment (SBGT) filter train was staned and aligned for a containment high volume purge per SOP-0059, " CONTAINMENT IIVAC SYSTEM", section 5.4. The 'B' SBGT filter train was out-of-senice for maintenance at this tim The SBGT filter train was started by an operator to support a reactor water cleanup filter /

demineralizer backwash in accordance with SOP-0090, " REACTOR WATER CLEANUP SYSTEM". The shift supervisor was not directly involved with this evon:, ion. On September 24,1992 at 2345 the shift supervisor realized via conversation with crew members and a review of the control room log that the evolution had taken place and was not in accordance with procedural requirement The root cause of this event was failure to comply with procedural requirements. Contributing factors were 1) the lack qf communication between the crew and the more experienced shift supervisor and 2) the less than optimum placement of the procedure CAUTION in SOP-005 I of 2

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CORRECTIVE STEPS WIllCII IIAVE IlEEN TAKEN AND TIIE RESULTS ACIIIEVED Upon discovery of the incident and after the initialinvestigation the Shift Supervisor reviewed the procedures and the Technical SpeciGcation with the Contml Operating Foreman and the reactor operator System Operating Procedure SOP-0059 section 5.4 was changed to add a sirp to verify both trains of SBGT are OPERABLE prior to initiating containment purg The licensed operators on crew were counseled concerning procedure use, closed loop

. communication and reviewing Technical Specification _

CDJm.ECTIVE STEIN WIIICII WILL !!E TAKEN TO AVOID FURTIIER FINDINGS Training will be given to all licensed operators on this incident during annual Licensed Operator Requal Trainin A concentrated effort by Operations management to stress the concepts of closed loop communications and self checking at the individual and crew level is ongoin DATE WilEN FUIJ, COMPLIANCE WILtdlE Af]]IEVED Tmining will be completed by April 15, 199 *

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ATTACIIMENT 2 REPLY TO NOTICE OF VIOLATION 50-458/9232-02 LEVEL IV REFERENCE Notice of Violation - Letter from A.B. Beach to P.D. Graham, dated December 10,1992 VIOLATION B: FAILURE TO VERIFY OFFSITE POWER SUPPLY OPERABILITY

] Techniel Specification 3.8.1.1, Action b, requires, with either Diesel Generator I A or IB inoperable, that the operability of the required AC offsite sources to be demonstrated by performing Surveillance Requirement 4.8.1.1.1.a within I hour and at least once per 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> thereafte Technical Specification Surveillance Requirement 4.8.1.1.1.a requires, in pan, that each of the required independent circuits between the offsite transmission network and the onsite Class IE distribution system shall be determined operable by verifying correct breaker align:nents and indicated pwer availabilit Contrary to the above, on October 9,1992, between the hours of 1:43 p.m. and 3:01 p.m.,

while Diesel Generator l A was inoperable (in the maintenance mode), each required independent circuit between the offsite transmission network and the onsite Class lE distribution system was not determined to be operable within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> by verifying correct breaker alignments and power availabilit REASON FOR TIIE VIOLATION While performing the prestart checks for Diesel Generator l A, a task which is usually perfomied within one hour, it was noted that the Itat air system was out-of-service due to a plant modification. The rear air system supplies the motive force to the barring device, which is required to b< used as part of the prestart checks. The Shift Supervisor (SS) and Control Operating Foreman (COF) determined that the operator could realign the barring device supply to the forward air system to allow for the completion of the prestart checks. This additional work resulted in the diesel generator being in the maintenance mode for longer than one hou The operations crew failed to realize that the diesel genemtor had been in the maintenance mode for greater than one hour and therefore did not perform the required surveillanc Funher investigation into this event revealed three other instances whereby a diesel generator was placed in the maintenance mode for greater then one hour and surveillance 4.8.1.1.1.a was not performed. These occurred on October 6,1991, April 18,1992 and May 16,1992. In each of these cases, the diesel generator was undergoing prestart check The root cause of the event was personnel error in that a problem occurred during the performance of a routine task and the operations crew failed to realize that sufficient time had passed to necessitate the performance of this additional surveillance requiremen of 2

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CORRECTIVE STEPS WIIICIIIIAVE BEEN TAKEN AND TIIE RESULTS ACIIIEVED The corrective action identified to preclude this event from happening in the future include the:

-addition of a caution statement to applicable * operating and surveillance test procedures that require placing a diesel generator in the maintenance mode. This caution will make the operator

aware that surveillance requirement 4.8.1.1.1.a is required if the diesel generator is placed i the maintenance mode for one hour or longe With the exception of refueling outan procedures, the applicable procedures have been revised. The refueling outage procedures will be revised prior to the fifth refueling outag As a minimum, the operations crew will note in the control room log the entrance or exit into a Technical Specification Limiting Condition for Operation,_ whenever a diesel generator is placed in or removed from the maintenance mode, respectivel CORRECTIVE STEPS WIIICII WILL BE TAKEN TO AVOID FURTIIFR FINDINGS'

Tmining will be given to all licensed operators on this incident. This training will be conducted -

during License Operator I'c., qual Trainin Operations. policy for " Active Limiting Conditions of Operation" was revised (December 1, 1992) to reinforce management expectations when entry into a Limiting Condition of Operation -

is require DATE WIIEN FULL CONIPLIANCE WILL BF, ACIIIEVED '

l Training will be completed by April 30,1993.

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ATTACIIMENT 3 REPLY TO NOTICE OF VIOLATION 50-458/9232-03 LEVEL IV BEFERENCE Notice of Violation - Letter from A.B. Beach to P.D. Graham, dated December 10,1992 VIOLATION C: FAILURE TO CONTROL SAFETY-RELATED MAINTENANCE Technical Specification 6.8.1 requires, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures mcommended in Appendix A of Regulatory Guide 1.33, Revision 2, Febmary 197 Regulatory Guide 1.33, Appendix A, states " maintenance that can affect the performance of safety-related equipment should be properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances."

Contrary to the above, on July 8,1992, maintenance that affected the performance of the Division I emergency diesel generator, safety-related equipment, was not properly preplanned and was not performed in accordance with procedures appropriate to the circumstances in that the work instmetions did not specify backing down the adjusting screws when rocker valve arms were reinstalled. This resulted in major damage to the valve train of Cylinder 5 and in three additional bent push rod REASON FOR TIIE VIOLATION Following scheduled disassembly and maintenance and while setting the valves on the Division I diesel engine, the engine failed to turn using a pneumatic barring device. A valve train inspection was conducted and it was noted that the Cylinder 5 rear intake valve adjusting screw was installed further into the rocker arm assembly then all the other adjusting screws. The barring device was configured to turn the engine in the reverse direction and the adjusting screw was loosened. The engine was then rotated in the normal direction with no interference. It was concluded that valve train binding thereby prevented the engine from being rotated with the barring device. Subsequent inspection revealed valve train component damag The primary reason that no specific instruction was given to back out the lash adjusting screws when reinstalling the rocker arms is that there was nothing in the combined experience of the engine manufacturer (Enterprise) and GSU to suggest that failure to include such a step could lead to damage of the equipment. In fact, the manufacturer's instruction manuals, from which GSU-developed maintenance instmetions are derived, contain no such specific instruction In discussions at the time of the incident, Enterprise engineers did not believe that misadjustment of the lash adjusters could cause a mechanical interference or potential damage to the engin They were also of the opinion that the barring device could not exert enough force to cause damage to parts, and that a mechanical interference, if present due to another cause, would 1 of 3

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• e prevent rotation by the barring device. Before this July 1992 incident, GSU had received no report from other utilities of engine damage from barring it against a mechanical interferenc Had GSU been aware that there was a possibility of engine damage occurring from misadjustment of the lash adjusters, steps requiring conservative actions or inspections would have been included in the maintenance work order. They were not included because there was no knowledge or anticipation of such a possibilit Both the Division I and II valve trains have undergone similar disassembly or rocker arm assembly replacements during previous refueling outages. Installation of a new rocker arm assembly should include backing out the lash adjusters, as these screws are not factory-installe The contractor-generated, GSU appmved work procedures were, in these cases, the same in technical content and job steps as the procedum used in July 1992. No diesel maintenance job plan had ever specifically requir:d backing out the screws before installing rocker arms; yet this work has always been done without error, including on the Division II engine during refueling outage numlkr four. Only the Division I diesel has been adversely affected and only during refueling outage number four. This maintenance record indicates that while the lack of a specific step to back out the screws may be a causal factor, personnel errors also appear to have -

contributed to the caus CORRECTIVE STVPS WHICIIII AVE BEEN TAKEN AND TIIE RESULTS ACIIIEVED It is important to note that at no time during this course of events was the Division I dien1 declared operable, or required to be operable, under the Technical Specihcations, nor was it returned to service in degraded conditio The corrective actions taken to date include a detailed inspection of the entire Division I diesel valve train to locate any parts which were damaged or potentially degraded. Engineering evaluations by GSU and Enterprise had eliminated the possibility of damage to the large engine components, such as the pistons, connecting rods and crankshaft, based on a comparison to normal operating loads. The inspection resulted in the replacement of several push rods, valve spring retainer rings, valve stem wipers, cylinder head sub-covers, and one valv When events on the Division I diesel revealed that it is possible to bar the engine over through minor interferences, bending push rods without necessarily detecting it, the Division II diesel, which was the operable unit at that time, was taken out of service so that an inspection for bent push rods could be performed. As required under the Technical Specifications, all fuel handling activities were halted for the duration of time that the diesel was unavailable. The inspection found no bent push rods on the Division II diesel, and it was returned to service in less than one hou Enterprise has revised the outage work procedure in question, "RFO-454", and submitted it to GSU. The revision added a caution statement and a step to ensure the valve lash adjusting screws are backed out sufficiently to preclude damage, before rocker arm assemblies are installed on the engin .

Prior to this submittal, it was necessary to replace one of the cylinder heads on Divisioni, due to a jacket water leak whose cause is unrelated to the July 1992 events. To prevent a recurrence ,

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of these events during the head replacement, the rework instmetions issued by Engineering -

--(Condition Report '92-0842) included cautions and steps requiring backing out of the lash--

, - adjusters. These instructions were carried out, and the incident was not n peate GIRRsE. CTIVE STEPS WIllCII WILL BE TAKEN TO AVOID FURTIIER FINDINGS GSU will issue an addendum to the instmetion manuals for the Division I and II diesels including the instructions in the revised RFO-454. This will make the required information

available to anyone planning valve train work on these diesels, i

GSU has reported this event to INPO through the NPRDS database, making the infonnation i available to other utilitie I Condition Report 92-0551, which describes in detail the course of events, along with providing -

the inspection and rework instmetions, will be required reading for all maintenance planner GSU will continue to use System Engineering oversight on key contracts in refueling outages to improve performanc .l 1 DATE WIIEN FULL COMPLIANCE WII4 BE ACHIEVED Full compliance, including necessary training, will be achieved by July 1,1993.

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