ML051520197
| ML051520197 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 06/01/2004 |
| From: | Paul Krohn NRC Region 1 |
| To: | Higgins P, Louden P NRC/RGN-III |
| References | |
| FOIA/PA-2004-0282 | |
| Download: ML051520197 (7) | |
Text
I PaulKrohnrvafwrit1ip.wpd Paul Krohn X...Page . va t.up..pd 1 Rill VALUE ADDED FINDING VAF NUMBER: SITE: RPT NUMBER: ISSUE DATE:
Point Beach Failure to Provide An Adequate Vent Path During Nozzle Dam Installation And Failure To Adhere To Prudent Industrial Safety Practices During Nozzle Dam Installation Using IP 71111.20, the inspectors identified that the licensee failed to provide an adequate Reactor Coolant System( RCS) vent path during Nozzle Dam installation as scheduled in the ongoing plant refueling outage. The inspectors also identified that prudent industrial safety practices were not followed in that multiple air hose disconnects occurred during this activity resulting in two workers being cut out of their bubble hoods and a personnel contamination.
In the early morning hours of April 9,2004, the R.C.S. level was at mid-nozzle to allow the steam generator primary and secondary manways to be removed and nozzle dams to be installed in both the hot and cold legs in preparation for flood-up and steam generator inspections. This activity is safety significant since the time to boil is short in this configuration and , accordingly, the plant in an orange risk path during mid-nozzle operation. The inspectors observed numerous actions which appeared to be inconsistent with prudent personnel safety practices and called these to the attention of the project lead as they occurred. These included numerous loss of air events as well as questionable manway entry and exit techniques. In addition, the inspectors noted that significant confusion occurred as to whether or not an adequate RCS vent path was present prior to installation of the final hot leg dam (the outage schedule logic required that the pressurizer manway be removed prior to installation of the nozzle dams). This confusion resulted in a work stoppage of the nozzle dam installation until this concern could be resolved. Following the stoppage of work on this activity, the inspectors , after consultation with appropriate regional personnel, reported their concerns to senior plant management personnel. Senior plant management was not aware of the vent path issue or of the extent of the personnel safety issues.
Later in the morning of April 9,2004, the licensee formed an incident response team to investigate the vent path issue and the personnel safety issues. Over the next several days, this team concluded that the plant management erroneously determined that it was acceptable to break the outage schedule logic ties and allow the installation of the hot leg nozzle dams in parallel with the removal of the pressurizer manway. The team also concluded that the personnel safety issues related to loss of air (as well as other issues) , were not brought to the attention of the appropriate plant management by plant personnel. The licensee thus concurred with all the inspectors conclusions and concerns, and identified other concerns during the coarse of their investigations.
The licensee took immediate corrective actions action to address all these concerns.
This VAF demonstrates the importance of having NRC inspections personnel onsite during critical plant evolutions to observe the behaviors of plant workers and management personnel during these activities, as such behaviors relate to nuclear and personnel safety. It also demonstrates the importance of following up concerns with senior plant management to assure that senior plant management is receiving a timely NRC inspector perspective on safety issues such that, if warranted, prompt corrective action results.
Distribution: J. Caldwell, G. Grant, M. Dapas, DRPIII, DRSIII, R. Blough, D. Chamberlain, A. Howell, D. Weaver, S. Richards, W. Lanning, C. Casto, V. McCree
Paul TV Krohn.- VAF C~omments .. Paul Krohn ... VAF Comme. Page1 1 From: Paul Krohn To: Higgins, Patrick; Louden, Patrick Date: 6/1/04 2:12PM
Subject:
VAF Comments Pat and Pat, Attached are my comments to the nozzle dam/safety practice VAF. Most changes are editorial. I added some words to emphasize that 4 SROs in key outage positions missed the relevance of the logic sequence in the schedule. Also, added some words to discuss the extent to which the bowl jumpers went to facilitate access. Other than that, changed everything to past tense.
Great inspection Pat H., I read the Harden report this afternoon and it amazes me that this actually occurred. A compare version of my comments to Pat's version is included for your information.
Paul Krohn CC: Kunowski, Michael; Morris, R. Michael
I Paul Krohn - VAF Compare pgkhiggins.wpd ... -P'age il II.
Rill VALUE ADDED FINDING VAF NUMBER: SITE: llRPT NUMBER: ll ISSUE DATE:
IF Point Beach 1 2004-003
Paul Krohn - VAF Compare pgk higgins.wpd r rr Page 2 Failure to Provide An Adequate Vent Path During Nozzle Dam Installation And Failure To Adhere To Prudent Industrial Safety Practices During Nozzle Dam Installation Using IP 71111.20-, the inspectors identified that the licensee- failed to provide an adequate Reactor Coolant System (-RCS) vent path during Nozzle Dam installation as scheduled induring the engoing plafUUnit I U1R28 refueling outage. The inspectors also identified that prudent industrial safety practices were not followed in that- multiple air hose disconnects occurred during this activity resulting in two workers being cut out of their bubble hoods and a personnel contamination event.
In the early morning hours of -April 9, 2004, the R.G.S. oeveIRCS inventory was at-mid-noez2Iereduced to allow the steam generator primary and secondary manways to be removed and nozzle dams to be installed in both the hot and cold legs in preparation for reactor cavity flood-up and steam generator inspections. This activity Jewas safety significant since the time-to-
-boil i6was short in this configuration(-38 minutes) and, accordingly, the plaRnt inhad been designated as an orange risk pathdu ing mid nozzle operantkecondition. The inspectors observed numerous actions which appeared to be inconsistent with prudent personnel safety practices and called these to the attention of the project lead as they occurred. These included numerous loss of air events as well as questionable manway entry and exit techniques including lubricating individuals to facilitate manway passage and physical assistance during access attempts. In addition, the inspectors noted that significant confusion occurred as to whether or not an adequate RCS vent path was present prior to installation of the final hot leg dam -(the outage schedule logic required that the pressurizer manway be removed prior to installation of the nozzle dams). This confusion resulted in a work stoppage of the nozzle dam installation until this concern could be resolved. Following the work stoppage ofwork o-n this-actMiv, the inspectors-,
after consultation with appropriate regional personnel, reported their concerns to senior plant management peFsOnneo.. Senior plant management was not aware of the vent path issue or of the extent of the personnel safety issues.
Later in the morning of April 9, 2004, the licensee formed an incident response team to investigate the vent path iswue-and4h4 personnel safety issues. Over the next several days, thise team concluded that the plantmanagawnenShift Outage Manager, OCC Operations Representative, WCC Supervisor, and Shift Manager (all SRO qualified) had erroneously determined that it was acceptable to break the outage schedule logic ties and allow the installation of the hot leg nozzle dams in parallel with the removal of the pressurizer manway.
The team also concluded that the personnel safety issues related to loss of air -(as well as other issues), were not brought to the attention of the appropriate plant management by plant personnel. The licensee-thus concurred with-al the inspectors conclusions and concerns, and identified other concerns during the coarse of their investigations. The licensee took immediate corrective actions action to address all the6e concems.
This VAF demonstrates the importance of having NRC -inspeGtiORS-personnel onsite during critical plant evolutions to observe the behaviors of plant workers and management personnel-during these-aatiVities, as such behaviors relate to nuclear and personnel safety. It also demonstrates the importance of following up concerns with senior plant management to assure that senior plant management is receiving a-timely NRC inspector perspectives on safety issues such that, if warranted, prompt corrective action results. -
For more information on this issue contact Pat Higgins (Kewuanee) or Mike Morris at the Point Beach Resident Office.
Distribution: J. Caldwell, G. Grant, M. Dapas, DRPIII, DRSIII, R. Blough, D. Chamberlain, A. Howell, D. Weaver, S. Richards, W. Lanning, C. Casto, V. McCree
Paul Krohn - vafwrituppgk comments.wpd Page i RiII VALUE ADDED FINDING VAF NUMBER: SITE: RTNUMBER: SSUE DATE L Point Beach L 2004-003 l Failure to Provide An Adequate Vent Path During Nozzle Dam Installation And Failure To Adhere To Prudent Industrial Safety Practices During Nozzle Dam Installation Using IP 71111.20, the inspectors identified that the licensee failed to provide an adequate Reactor Coolant System (RCS) vent path during Nozzle Dam installation as scheduled during the Unit 1 Ul R28 refueling outage. The inspectors also identified that prudent industrial safety practices were not followed in that multiple air hose disconnects occurred during this activity resulting in two workers being cut out of their bubble hoods and a personnel contamination event.
In the early morning hours of April 9, 2004, the RCS inventory was reduced to allow the steam generator primary and secondary manways to be removed and nozzle dams to be installed in both the hot and cold legs in preparation for reactor cavity flood-up and steam generator inspections. This activity was safety significant since the time-to-boil was short (-38 minutes) and had been designated as an orange risk condition. The inspectors observed numerous actions which appeared to be inconsistent with prudent personnel safety practices and called these to the attention of the project lead as they occurred. These included numerous loss of air events as well as questionable manway entry and exit techniques including lubricating individuals to facilitate manway passage and physical assistance during access attempts. In addition, the inspectors noted that significant confusion occurred as to whether or not an adequate RCS vent path was present prior to installation of the final hot leg dam (the outage schedule logic required that the pressurizer manway be removed prior to installation of the nozzle dams). This confusion resulted in a work stoppage of the nozzle dam installation until this concern could be resolved. Following the work stoppage, the inspectors, after consultation with appropriate regional personnel, reported their concerns to senior plant management. Senior plant management was not aware of the vent path issue or of the extent of the personnel safety issues.
Later in the morning of April 9, 2004, the licensee formed an incident response team to investigate the vent path and personnel safety Issues. Over the next several days, the team concluded that the Shift Outage Manager, OCC Operations Representative, WCC Supervisor, and Shift Manager (all SRO qualified) had erroneously determined that it was acceptable to break the outage schedule logic ties and allow the Installation of the hot leg nozzle dams in parallel with the removal of the pressurizer manway. The team also concluded that the personnel safety issues related to loss of air (as well as other issues), were not brought to the attention of the appropriate plant management by plant personnel. The licensee concurred with the inspectors conclusions and concerns, and identified other concerns during the coarse of their investigations.
The licensee took immediate corrective actions action to address all concerns.
This VAF demonstrates the Importance of having NRC personnel onsite during critical plant evolutions to observe the behaviors of plant workers and management personnel, as such behaviors relate to nuclear and personnel safety. It also demonstrates the importance of following up concerns with senior plant management to assure that senior plant management is receiving timely NRC inspector perspectives on safety issues such that, if warranted, prompt corrective action result. For more information on this issue contact Pat Higgins (Kewuanee) or Mike Morris at the Point Beach Resident Office.
Paul Krohn - vafwrituppgk comrents.wpd -. Page r 2 I.
Distribution: J. Caldwell, G. Grant, M. Dapas, DRPIII, DRSIII, R. Blough, D. Chamberlain, A. Howell, D. Weaver, S. Richards, W. Lanning, C. Casto, V. McCree
- a. r Paul Krohn - Re: VAF Comments Page1 From: Patrick Louden To: Paul Krohn Date: 6/1/04 2:24PM
Subject:
Re: VAF Comments okthanks
>>> Paul Krohn 06/01/04 02:12PM >>>
Pat and Pat, Attached are my comments to the nozzle dam/safety practice VAF. Most changes are editorial. I added some words to emphasize that 4 SROs in key outage positions missed the relevance of the logic sequence in the schedule. Also, added some words to discuss the extent to which the bowl jumpers went to facilitate access. Other than that, changed everything to past tense.
Great inspection Pat H., I read the Harden report this afternoon and it amazes me that this actually occurred. A compare version of my comments to Pat's version is included for your information.