IR 05000483/1992021
| ML20125C813 | |
| Person / Time | |
|---|---|
| Site: | Callaway  |
| Issue date: | 12/03/1992 |
| From: | Jackiw I NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20125C799 | List: |
| References | |
| 50-483-92-21-EC, NUDOCS 9212140087 | |
| Download: ML20125C813 (32) | |
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U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Report No. 50-483/92021(DRP)
Docket No. 50-483 License No. NPF-30 Licensee: Union Electric Company Post Office Box 149 - Mail Cod 100 St. Louis, M0 63166 Meeting Conducted: November 24, 1992 Meeting At:
Region Ill Office, Glen Ellyn, Illinois Type of Meeting:
Enforcement Conference Inspection Conducted: October 26-30, 1992 Inspectors:
B. L. Bartlett D. R. Calhoun
/# d -fz Approved By:
ac J' N. Japkiw, Chief Date ReactofProjects,Section3A Meetina Summary Enforcement Conference on November 24. 1992. (Report No. 50-483/92021(DRP))
brear Discussed:
A. review of the apparent violation and areas of concern identified during the inspection, and corrective actions taken or planned by the licensee. The enforcement options pertaining to the apparent violation were also discussed with the licensee.
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9212140087 921204 ADOCK0500g3 PDR
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DETA1LS 1.
Eersons Present at_Q)g._(pnferenct Mai0lLElectriglg;m Any D. r. Ichnell, Sento, Vice President, Nuclear G. L,.'twiolph, Vice President, Nuclear Operations W. R. Ccmpbell, Manager, Callaway Plant J. V Laux, Manager, Quality Assurance LS. NuclJiar Rt.gulatory Commission A. B. Davis, Regional Adn.inistrator Rill W. L. Forney, Deputy Director, Division of Reactor Projects, Rll!
L. R. Gregor, Chief, Reactor Projects, Branch 3, Rll!
1. N. Jackiw, Chief, Reactor Frojects, Section 3A, Rlli
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i B. L. Bartlett, Senior Resident inspector, Callaway, R!ll a
P. R. Pelke, Enforcement Specialist, Rill B. A. Berson, Regional Counsel, Rill J. W. McCormick-Barger, Chief, EP & NPR Sa: tion, Rill i
J. N. Hannon, Director, Project Directorate !!!-3, NRR
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L. R. Wharton, licensing Project Manager, NRR/PDill-3
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[.nfonement Conferegg An enforcen.ent conference was held in the NRC Region ill office on November 24, 1992.
This c.onference was conducted as a result of the preliminary findings of the inspection conducted on October 26-30, 1992, in which an apparent violation of NRC regulations and license conditions was identified.
Tne findings related to the loss of annunciator event on October 17, 1992, and the failure to declare an Alert in accordance with the Callaway Emergencv N an !mplementing Procedure, inspection findings were documented ii
- Inspection Report No. 50 483/92020, transmitted to the licenset letter dated November 18, 1992.
The purpose of this conference was to:
(1) discuss the apparent violation, causes, and the licensee's corrective actions; (2) discuss several areas of concern; (3) determine if t'
- were any escalating or mitigating circumstances; ar.d (4) obtain any.../ormation which would help determine the appropriate enforcement action.
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The licensee's representatives did not contest the apparent violation and were in agreement with the NRC's understanding nf the areas of t
concern.
The licensee discussed the results of their internal in n stigation of the event 1 11uding the following root causes:
inadequate knowledge of the annunciator system, poor teamwork and communications, less than adaquate work control practices, and lack of a questioning attitude.
They also discussed the safety significance of the event, presenn d event specific and generic corrective actions, and a
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i provided an evaluation of provinus loss of annunciator events.
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summary, the corrective actlons included:
(1) improving the training i
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program for licensed operators, instrument and control technicians, and i
engineering personnel; (2) developing off-normal and system
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troubleshooting procedures; (3) providing additional work controls to i
i address retest guidance, prejob briefings, and su>ervisory presence; (4)
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modifying the annunciator system to improve reliaallity, and provide
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direct indication of a degraded system status; and (5) revising
j emergency action level criteria to conform with NUMARC guidelines.
i.opies of the licensee's and NRC's presentation material are included as
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Attachments A and B, respectively, to this report.
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At the conclusion of the conference, the licensee was it. formed that they
wouid t,e notified in the near future of the final enforcement action.
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i NRC ENFORCEMENT CONFERENCE NOVEMBER 24, 'I992 LOSS OF ANNUNCIATOR EVENT
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Agenda for NRC Enforcement Conference
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November 24,1992
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Loss of Annunciator Event
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Callaway Plant I
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Results of Union Electric W. R. Campbell
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Investigation
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Event - Specific W. R. Campbell A.
Event - Specific Corrective Actions 1.
Training
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Compensatory Actions /
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Guidance 3.
Work Controls
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System Design
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5.
EAL Classification Criteria
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B.
Event Significance
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(continued)
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Generic Corrective Actions
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Important Non Safety Systems
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Management Controls C.
Procedural Adherence
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D.
Teamwork / Communications
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Evaluation of Previous Events
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Evaluation of Previous Events i
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Actions to improve Corrective Action Program i
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Summary G. L. Randolph f
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RESULTS OF UNION ELECTRIC
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INVESTIGATION
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PRINCIPLE ROOT CAUSE:
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i Knowledge of the Annunciator System
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l SECONDARY ROOT CAUSES:
j Teamwork and Communications
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no prejob brief
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inadequate questioning or followup on
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pieces of knowledge held by individuals (
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fully utilized
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l, Secondary Root Causes (continued)
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Work Control Practices
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confusion as to who was responsible for
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job supervision
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Engineer and technicians did not review the
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work package inadequate documentation of work
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completion inadequate retest specified following fuse
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replacement for the field power supplies Questioning Attitude
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l assumption of operability was based on
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previous practice or experience knowledge gap not clearly identified and
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resolved (continued)
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i Secondary Root Causes (continued)
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i System Design
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interdependence of power supplies
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potential for undetectable failures
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i EVENT SPECIFIC CORRECTIVE ACTIONS J.
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TRAINING i
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General Training:
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General Training for Nuclear l
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Division Personnel
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i Video 3/1/93
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I Licensed Operator Training:
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l Requal Training for Operations
Personnel ls
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Requal training on system
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and 10/1-7/92 event 1/1/93
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)o Initial Training of Licensed-
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Systems training for 4/1/93
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annunciator system (/esson plan)
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t Off-normal procedure 7/1/93-i'
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I simulator and classroom
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Training (continued)
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Team Skills Training for
Licensed Operators Modify to incorporate 7/1/93
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lessons learned
//esson plan)
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Instrumentation and Control Technicians Initial and Requalification
Training Upgrade to address 4/1/93
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troubleshooting
//esson plan)
Revised Job Task
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i Analysis for initial and requalification training Cornplete Engineering Personnel Incorporate into Engineer 4/1/93
Industry Events Retraining
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EVENT SPECIFIC CORRECTIVE ACTIONS i'
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COMPENSA TORY ACTIONS t
AND G_UJ. DANCE
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Develop Off-normal Complete
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Develop System Trouble-12/15/92
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shooting Procedure i
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I EVENT SPECIFIC CORRECTIVE ACTIONS WORK CONTROM l
Retest Guidance
Planning notes in the Complete
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Callaway Equipment List Generic guidance for Complete
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power supply replacements Prejob Briefings
Issue guidance for conduct 12/1/92
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and content
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Supervisory Presence
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Issue guidance for when 12/1/92
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direct supervision is required Clarify role of supervisor 12/1/92
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versus engineering support
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(continued)
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Work Contro/s (continued)
Preplanned Work Packages for
Annunciator Power Supply Replacement
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Field power supplies Complete
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Logic power supplies 2/1/93
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EVENT SPECIFIC CORRECTIVE ACTIONS
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.SXSIE.M. DESIGN i
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l Improve Reliability of Power Supplies
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Provide Direct Indication to
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Reduce Potential for Undetectable
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l Failures
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Issue design change package 1/1/93
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Implementation
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interim week.ly PM implemented
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EAL CLASSIFICATION CRITEBM h'
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Provide additional guidance in Complete l
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is off-normal procedure i
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i, Review EALs to identify those 1/1/93
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requiring additional guidance
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Submit revision of EALs to 7/1/93 i
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EVENT SIGNIElCANGE l
Not considered in any plant's Safety Analysis
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Automatic Safety Systems available
Comperratory alarms and non-alarming
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indications available ESF status panels
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DRPI, power range instruments, control
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rod group position
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Partial trip status panel
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Permissive / interlock status panel
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RRIS and RM-11 system
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Main Control Board instruments and indications
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Plant computer CRT displays and
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alarrn typers (2836 inputs)
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Conclusion: No threbt to public or plant safety
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GENERIC CORRECTIVE ACTIONS
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lMEORTANT NON-SAEETY SYSTEMS i
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Identify 2/1/93 l
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Evaluate need for off-normal 4/1/93
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4/1/94
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(implementation)
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i Knowledge / Training 4/1/93 i-
(identify needs)
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1/1/95
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(implementation)
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Plant Computer
l Upgrade off-normal 2/1/93
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procedures Single failure design 4/1/93
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review
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GENERIC CORRECTIVE ACT!ONS
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MANAGEMENT CONTROLS l
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Clarify Emergency Duty Officer Complete
(EDO) notification criteria
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Expand self-checking program 7/1/93-
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GENERIC CORRECTIVE ACTIONS 2BDDEDURAL ADHEBEMM Reinforce Management Expectations 1/1/93
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Evaluate Levels of Procedural 1/1/93
Adherence Procedure Revalidation 4/1/93
(actl3n plan /
priorities)
1/1/97 (completion)
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Revise and Simplify 1/1/93
Procedure Structure faction plan /
priorities)
1/1/97 (completion)
Nuclear Division Objective
for 1993
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GENERIC CORRECTIVE ACTIONS i
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IEAMWORK/COMMUNICA TIONS i
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Simulator Scenarios Designed 7/1/93
l, to Evaluate Team Ski lls, (implementation)
l Communications and Decision Making
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Licensed Operator Survey 2/1/93
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I Revised EDO Coverage /
Completed Prior
Qualifications to Event
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Licenses / Certification 1/1/97 l
for Key Positions
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Nuclear Division Objective -
1/1/93
Communications faction plan developed)
i Nuclear Division Objective -
1/1/93
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EVALUATION OF PREVIOUS EVENTS Operations Responses - did not recognize full
scope of affected annunciators
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Engineering Responses - focused only on the
equipment reliability aspects of the events
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Emergency Planning - prepared a response to
the 1991 event, but did not recommend any changes in EAL classification criteria
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Root Cause of Fallure to Previously identify l
Independent, uncoordinated responses with
no overview i
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Lack of system knowledge
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Incomplete responses
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ACTIONS TO IMPROVE I
CORRECTIVE ACTION PROGRAM l
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i Improve Screening of SOSs 1/1/93 i.
- Selected for ORC Review
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critical non-safety systems j
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utilize priority threshold
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Strengthen Management Review 1/1/93
i of SOS Responses i
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selected EDO/ Manager review
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SUMMARY
" Eye-Opening Event" for Callaway
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Event Specific Corrective Actions
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Generic Corrective Actions
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WORK REQUEST RESULTS i
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EXAMPLES
,
Questioning Attitude:
Loose parts monitoring alarm
-
,
.i Condensate pump seal water return
-
line small leak
,
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MOVATS result on EF-HV-66
-
PK ground on 'B' main feed pump
-
trip solenoid Heater drain pump cooling water line
-
,
fatigue crack NN12 voltage fluctuations / noise
-
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Attachment B
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,
NUCLEA_R REGULATORY COMMISSION i
ENFORCEMENT CONFERENCE NOVEMBER 24.1992
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UNION ELECTRIC COMPANY CALLAWAY PLANT
<
LOSS OF ANNUNCIATOR EVENT DB
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_O_CTOBER 17. 1932
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AGENDA l
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OPENING REMARKS A. B. DAVIS
- INTRODUCTIONS
- PUR. POSE NRC PRESENTATION
- SEQUENCE OF EVENTS B.L. BARTLETT j
- PROPOSED VIOLATION
- OVERVIEW / CONCERNS W. L. FORNEY
'
LICENSEE PRESENTATION UNION ELECTRIC
- ROOT CAUSES / CONTRIBUTING FACTORS
- CORRECTIVE ACTIONS
l CLOSING REMARKS A. B. DAVIS
.
. _ _ _ _
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SEQIlENCE OF EVENTS i
6:40 PM OCTOBER 16,1992 POWER SUPPLY NUMBER 2 FAILS RESULTING IN " NUMEROUS" (40 - 50) ANNUNCIATORS LIGHTS BEING LIT.
I2:58 AM OCTOBER _17,1992 FIELD CONTACT POWER SUPPLY NUMBER 2 REPLACED AND
'
ANNUNCIATOR LIGHTS RE]I.'RNED TO NORMAL.
1:00 AM ACCIDENTAL SHORT OCCURS RESULTING IN APPROXIMATELY ONE HALF 0F:
THE ANNUNCIATORS BEING LIT AND ALL OF THE ANNUNCIATORS BEING INOPERABLE.
1:56 AM ALL FOUR FIELD CONTACT POWER S'UPPLY FUSES REPLACED. ANNUNCIATORS t
RETURN TO THEIR " NORMAL" STATUS WITH A
'
COUPLE OF APPARENT EXCEPTIONS.129 ANNUNCIATORS REMAIN INOPERABLE.
[
7:37 :PM ALL FAILED-AN.NUNCIATOR FUSES REPLACED AND THE ANNUNCIATOR SYSTEM li RESTORED OPERAB'LE.
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PROPOSED VIOLATION
.
10 CFR 50.54(q) states that a licensee authorized to possess and operate a nuclear power reactor shall follow and maintain in effect emergency plans.
'
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Callaway Plant Radiological Emergency Response Plan (RERP), Revision 15, issued June 4,1992, Section 3.2, states that the Emergency Plan Implementing Procedures provide
,
detailed action steps, in procedure format, necessary to be performed in order to implement the commitments /
requirements as stated in the RERP.
The Callaway Emergency Plan Implementing Procedure EIP-7Z-00101,
" Classification of Emergencies," Revision 12, dated June 4,1992, Section 4.0, requires in part, that when
,
abnormal or emergency conditions (real or potential) occur, the Shift Supervisor shall, using the indications available and Attachment 1 (Emergency Action Levels), determine the appropriate emergency classification and declare the emergency classification that is listed.
Attachment 1 to EIP-
'
ZZ-00101 Group 3, " Safety System Functions," Item K, lists an emergency classification of Alert for a loss of most or all alarms (ennunciators) during all modes,
Contrary to the above, on October 17,1992, from 1:00 a.m.
to 1:56 a.m., a loss of all annunciators occurred and the Shift
'
Supervisor did not declare an Alert.
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NRC____ CONCERNS
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A.
IN^DEQUATE KNOWLEDGE OF THE
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ANNUNCIATOR SYSTEM
!
l B.
LACK OF A
QUESTIONING ATI'ITUDE
/
COMPLACENCY
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'
C.
.L E S S T"AN ADEQUATE WORK
PERFGhid. ' "7
.
.
D.
POC'F
-
UJNICATIONS AND LACK OF
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TEAlY '
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!
E.
FAILURE TO LEARN FROM PREVIOUS
!
OCCURRENCES
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