ML14181A633
| ML14181A633 | |
| Person / Time | |
|---|---|
| Site: | Robinson  |
| Issue date: | 10/28/1994 |
| From: | Boger B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Hinnant C CAROLINA POWER & LIGHT CO. |
| References | |
| EA-94-205, NUDOCS 9411290071 | |
| Download: ML14181A633 (36) | |
Text
October 28, 1994 EA 94-205 Carolina Power and Light Company ATTN:
Mr. C. S. Hinnant Vice President H. B. Robinson Steam Electric Plant Unit 2 P. 0. Box 790 Hartsville, SC 29550-0790
SUBJECT:
ENFORCEMENT CONFERENCE
SUMMARY
(NRC INSPECTION REPORT NO. 50-261/94-23)
This letter refers to the Enforcement Conference held at our request on October 17, 1994. The purpose of the conference was to discuss the apparent violations involving a pressurizer cooldown rate which exceeded the Technical Specification limit, and the mispositioned steam line drain valves. A list of attendees and a copy of your slides are enclosed. We are continuing our review of these issues to determine the appropriate enforcement action.
During the enforcement conference, the in-plant SRO provided amplifying information regarding the circumstances surrounding his signing of Step 16 of GP-005. As described by the in-plant SRO, he understood that the downstream drain valves were to be shut for RCS temperature control.
He observed AOs closing the downstream valves and verified that steam was not issuing from the drain line discharge pipe following the valve positioning. Approximately three hours later, he incorrectly initialled GP-005 to reflect that all 15 valves were shut. The in-plant SRO stated that he failed to note that the root isolation valves were included in this step of GP-005. He also noted that the fact that the 15 valves were spread across two pages of GP-005 may have contributed to his not recognizing that he was signing for more valves than were repositioned.
Finally, he stated that he did not recognize the communications failure between the SRO and himself while he was initialling GP-005 coincident with shift turnover.
In accordance with Section 2.790 of the NRC's Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.
Should you have any questions concerning this letter, please contact us.
Sincerely, Bruce A. B ger, Ating Director Division of Reactor Projects Docket No.: 50-261 License No.:
Enclosures:
(See page 2) 9411290071 941028 PDR ADOCK 05000261 G
CP&L 2
Enclosures:
- 1. List of Attendees
- 2. Licensee Slides cc w/encls: Dale E. Young Plant Manager H. B. Robinson Steam Electric Plant P. 0. Box 790 Hartsville, SC 29550-0790 H. W. Habermeyer, Jr.
Vice President Nuclear Services Department Carolina Power & Light Company P. 0. Box 1551 Mail OHS7 Raleigh, NC 27602 R. Krich, Manager Regulatory Compliance H. B. Robinson Steam Electric Plant P. 0. Box 790 Hartsville, SC 29550 Max Batavia, Chief Bureau of Radiological Health Dept. of Health and Environmental Control 2600 Bull Street Columbia, SC 29201 Dayne H. Brown, Director Division of Radiation Protection N. C. Department of Environmental Commerce & Natural Resources P. 0. Box 27687 Raleigh, NC 27611-7687 H. Ray Starling Manager -
Legal Department Carolina Power and Light Co.
P. 0. Box 1551 Raleigh, NC 27602 Karen E. Long Assistant Attorney General State of North Carolina P. 0. Box 629 Raleigh, NC 27602 cc w/encls: (cont'd - See page 3)
CP&L 3
cc w/encls: (cont'd)
Robert P. Gruber Executive Director Public Staff - NCUC P. 0. Box 29520 Raleigh, NC 27626-0520 Public Service Commission State of South Carolina P. 0. Box 11649 Columbia, SC 29211 The Honorable Hugh Wells, Chairman North Carolina Utilities Commission P. 0. Box 29510 Raleigh, NC 27626-0510 Hartsville Memorial Library 147 W. College Hartsville, SC 29550 Distribution w/encls:
H. Christensen, RII B. Mozafari, NRR G. A.
Hallstrom, RH PUBLIC NRC Resident Inspector U. S. Nuclear Regulatory Commission 2112 Old Camden Road Hartsville, SC 29550 SEND OFC RII:DRP RII:DRP RII:DRP NAME JStarefos W~rders HChristensen PDR?
DATE 10/ 4
/94 10/N
/94 10/
94
//94
/
94 Yes No COPY?
Yes No Yes No No Yes No Yes No OFFICIAL RECORD COPY DOCUMENT NAME:
P:\\ROBI e.
LIST OF ATTENDEES Nuclear Regulatory Commission:
S. D. Ebneter, Regional Administrator, Region II (RH)
B. A. Boger, Acting Director, Division of Reactor Projects (DRP), RH A. F. Gibson, Director, Division of Reactor Safety (DRS), RH B. Uryc, Director, Enforcement and Investigation Coordination Staff (EICS),
RH H. 0. Christensen, Acting Chief, Reactor Projects Branch 1, DRP, RII C. F. Evans, Regional Counsel, RH L. J. Watson, Enforcement Specialist, EICS, RH J. E. Beall, Senior Enforcement Specialist, Office of Enforcement, Nuclear Reactor Regulation T. A. Peebles, Chief, Operations Branch, DRS, RII L. L. Lawyer, Chief, Operator Licensing Section, DRS, RH W. T. Orders, Senior Resident Inspector - Robinson, DRP, RII Licensee Attendees:
W. Orser, Executive Vice President, Nuclear Generation Group C. Hinnant, Vice President, Robinson G. Miller, Manager, Robinson Engineering Support Services R. Rogan, Manager, Nuclear Licensing, CP&L D. Young, Plant General Manager, Robinson B. Meyer, Manager, Operations, Robinson C. Fletcher, Senior Reactor Operator, Robinson D. Blakeney, Shift Supervisor, Robinson ENCLOSURE 1
CAROLINA POWER & LIGHT COMPANY H. B. ROBINSON STEAM ELECTRIC PLANT, UNIT NO. 2 NRC ENFORCEMENT CONFERENCE October 17, 1994 Atlanta, Georgia CP&L ENCLOSURE 2
NRC Enforcement Conference October 17, 1994 Agenda Introduction.
.s.......
ScottylHinnant Mispositioned Containment Isolation Valves Background / Event Summary....................................
Clark Fletcher Safety Significance....................................
Garry Miller Causes / Corrective Actions......................................
Bruce Meyer Conclusion...................................................
Bruce Meyer Excessive Pressurizer Cooldown Background / Event Summary...................................... Garry Miller Safety Significance.............................................Garry M iller Causes / Corrective Actions Dale Young Conclusion.........................................................
Dale Young Summary / Conclusions.............................
Scotty Hinnant CP&L Page 2
Introduction Both Apparent Violations Deal With Operator Performance Issues Mispositioned Containment Isolation Valves Resulted From An Individual Operator Not Meeting Expectations Operator Had No Prior Instances Of Poor Performance Pressurizer Cooldown Issue Reflects A Failure To Properly Monitor Pressurizer Technical Specifications (TS) Requirements By Operations Personnel These Issues Will Be Discussed In The Context Of Recent Previous Operator Errors October 12, 1994, Meeting Provided Basis For Actions Being Taken To Improve Operator Performance CP&L Page 3
Mispositioned Containment Isolation Valves Statement Of Apparent Violation From August 6, 1994 Until August 29, 1994, With The Reactor At 100% Power, Containment Integrity Required By TS Was Not Properly Established, In That, The Main Steam Isolation Valve (MSIV) Above And Below Seat Drain Isolation Valves Were Open Instead Of Closed CP&L Page 4
Mispositioned Containment Isolation Valves NRC Enforcement Conference October 17, 1994 Agenda Introduction....................................
Scotty Hinnant Mispositioned Containment Isolation Valves Background / Event Summary.
.. Clark Fletcher Safety Significance..
Garry Miller Causes / Corrective Actions.............................
Bruce Meyer Conclusion...............................................
Bruce Meyer Excessive Pressurizer Cooldown Background / Event Summary...................................... Garry Miller Safety Significance............................................ Garry M iller Causes / Corrective Actions........................................ Dale Young Conclusion.................................................. D ale Young Summary / Conclusions Scotty Hinnant CP&L Page 5
Mispositioned Containment Isolation Valves
Background
Professional Background of Senior Reactor Operator (SRO)
Valves In Question Are Containment Isolation Valves On Secondary Side Of Steam Generators (i.e., A Closed System Inside Containment)
These Containment Isolation Valves Are On MSIV Drain Lines Containment Isolation Valves Are Opened For Reactor Coolant System (RCS) Temperature Control During Hot Shutdown Conditions Non Safety-Related Valves Downstream Of These Containment Isolation Valves Are Throttled For RCS Temperature Control CP&L Page 6
Mispositioned Containment Isolation Valves Background (Continued)
Containment Isolation Valves Are Closed By Procedure During Plant Start-up Applicable TS Requirements TS 3.6.1 -
The Containment Integrity (as Defined In TS 1.7) Shall Not Be Violated Unless The Reactor Is In The Cold Shutdown Condition TS 1.7 -
Containment Integrity Is Defined To Exist When:
- a.
All Non-Automatic (e.g., Manual) Containment Isolation Valves Not Required For Normal Operation Are Closed...
Since Containment Isolation Valves Are Used For RCS Temperature Control, Administrative Controls Are Applied During Throttling Operations CP&L Page 7
Mispositioned Containment Isolation Valves MAIN STEAM LINE (TYPICAL)
I e-A TOTO An #O TO AT IMO TO A I1O TO 1
e-
-A eV-"
10o-*TI RVI-f 314
,--73 15 76 MS-VI-3A pe-2614 ISOL II CP&L
Mispositioned Containment Isolation Valves Event Summary Control Rbom SRO Directed Field SRO To Close MSIV Above And Below Seat Drain Valves, Including Containment Isolation Valves, In Preparation For Plant Start-Up Field SRO Understood That Downstream Valves Were To Be Closed For RCS Temperature Control Field SRO Observed Auxiliary Operators Close Downstream Valves And Verified That Drain Lines Were Not "Steaming" Approximately Three Hours Later, Field SRO Incorrectly Initialed Procedural Steps That All Drain Valves, Including Containment Isolation Valves, Were Closed CP&L Page 9
Mispositioned Containment Isolation Valves NRC Enforcement Conference October 17, 1994 Agenda Introduction....................................
Scotty Hinnant Mispositioned Containment Isolation Valves Background /Event Summary....................................Clark Fletcher Safety Significance Garry Miller Causes / Corrective Actions......................................
Bruce Meyer Conclusion........
Bruce Meyer Excessive Pressurizer Cooldown Background / Event Summary...........................................
Garry Miller Safety Significance.............................................
Garry M iller Causes / Corrective Actions........................................
Dale Young Conclusion.......
Dale Young Summary / Conclusions Scotty Hinnant CP&L Page 10
Mispositioned Containment Isolation Valves Safety Significance Analysis Of Non Safety-Related Valves And Piping Shows That Integrity Would Be Maintained During A Design Basis Seismic Event Consequences Of Failure Of Non-Seismic Portion Of One-Inch Drain Lines Bounded By Other Inadvertent Valve Opening Events Analyzed In Updated Final Safety Analysis Report CP&L Page 11
Mispositioned Containment Isolation Valves NRC Enforcement Conference October 17, 1994 Agenda Introduction....................................
Scotty Hinnant Mispositioned Containment Isolation Valves Background / Event Summary.......
Clark Fletcher Safety Significance.....
Garry Miller Causes / Corrective Actions
.. Bruce Meyer Conclusion Bruce 1Meyer Excessive Pressurizer Cooldown Background / Event Summary...........................................
Garry Miller Safety Significance...................................................
Garry Miller Causes / Corrective Actions........................................
Dale Young Conclusion.....................................................
Dale Young Summary / Conclusions Scotty Hinnant CP&L Page 12
Mispositioned Containment Isolation Valves Root Cause Management Expectations With Respect To Procedure Signoff Not Met Lack Of Attention To Detail By Field SRO When Reviewing / Initialing Procedure Steps Event Not Characteristic Of Performance Of This SRO o
SRO Fully Understood Responsibility / Accountability Associated With Initialing Procedure Steps CP&L Page 13
Mispositioned Containment Isolation Valves Contributing Factors Inadequate Communications Lack Of Programmatic / Procedural Barriers Design Basis Document (DBD) That Identified These Valves As Containment Isolation Not Properly Reviewed Nor Consistently Implemented By Plant Management Independent Verification Of Valve Position Not Performed o
Operating Procedure Requiring Independent Verification Of Manual Containment Isolation Valves Had Not Yet Been Revised To Reflect DBD Information Page 14
Mispositioned Containment Isolation Valves Context Individual Accountabilities Have Not Been Consistently Enforced Previously, Operator Performance Trends Were Not Effectively Identified, Analyzed, And Communicated CP&L Page 15
Mispositioned Containment Isolation Valves Immediate Corrective Actions Mispositioned Valves Were Closed Operator Involved Was Counseled Safety Evaluation Of Current Configuration Of Manual Containment Isolation Valves Performed On September 3, 1994 - No Adverse Conditions Were Identified Operating Crews Notified That Valves' Function Is Containment Isolation CP&L Page 16
Mispositioned Containment Isolation Valves Corrective Actions To Prevent Recurrence A "Lessoiis Learned" Review Concerning Communications, Procedure Adherence, And Attention To Detail, Is In Progress For Operations Personnel Operators And Supervisors Will Be Held Accountable For Their Actions A Professional Human Performance Consultant Will Be Utilized To Improve Our Process For Minimizing Personnel Errors And Dealing Positively With Personnel Performance Issues CP&L Page 17
Mispositioned Containment Isolation Valves Corrective Actions To Prevent Recurrence (Continued)
By December 9, 1994:
RCS Temperature Control Practices During Hot Shutdown Conditions Will Be Evaluated Containment Isolation DBD Will Be Reviewed By Plant Staff And Appropriate Plant Procedure Changes Will Be Performed Process For Accepting DBDs Will Be Reviewed And Strengthened As Necessary CP&L Page 18
Mispositioned Containment Isolation Valves Conclusions Safety Significance Of Valve Mispositioning Was Low Event Was Self-Identified Event Was Due To Inattention To Detail On The Part Of This SRO Accountability For Attention To Detail And Clear Communications AT ALL TIMES Is Recognized By Operators And Will Be Continually Enforced CP&L Page 19
NRC Enforcement Conference October 17, 1994 Agenda Introduction Scotty Hinnant Mispositioned Containment Isolation Valves Background / Event Summary......................................Clark Fletcher Safety Significance..........
Garry Miller Causes / Corrective Actions......
Bruce Meyer Conclusion..................................................
Bruce Meyer Excessive Pressurizer Cooldown Background / Event Summary...............
Garry Miller Safety Significance....
Garry Miller Causes / Corrective Actions.......................................
Dale Young Conclusion
................................................. Dale Young Summary / Conclusions Scotty Hinnant CP&L 20 Page 2
Excessive Pressurizer Cooldown Statement Of Apparent Violation On February 26, 1994, Pressurizer Cooldown Exceeded Technical Specifications Limit Of 200 Degrees Fahrenheit Per Hour When Operators Were Collapsing Pressurizer Bubble CP &.
Page 21
Excessive Pressurizer Cooldown Background / Event Summary This Condition Was Discovered As A Result Of An NRC Corrective Action /
Operating Experience Program Inspection Pressurizer Cooldown In Excess Of TS Limit On February 26, 1994, Resulted From Insurge Of Cooler Reactor Coolant Into Pressurizer While The Bubble Was Being Collapsed In Pressurizer At RCS Temperatures Less Than 200 Degrees Pressurizer Cooldown Was Not Recorded In The Past Based On Assumption By The Plant Staff That It Was Bounded By Reactor Vessel Cooldown CP&L Page 22
Excessive Pressurizer Cooldown Background / Event Summary (Continued)
Prior to 1980, Pressurizer Bubble Was Collapsed With RCS Temperature
> 200 Degrees Potential For Exceediug The Pressurizer TS Limits Under These Conditions Was Minimal 13 Cooldowns Since 1980 Were Analyzed During Which Conditions Could Have Resulted In Exceeding TS Cooldown Limits CP&L Page 23
Excessive Pressurizer Cooldown Safety Significance Westinghouse Evaluated Previous Cooldowns Plant Data For Pressurizer Transients Were Reviewed Two Enveloping Transients Were Developed Stress, Fracture, And Fatigue Analyses Were Performed All Design Transients Considered, Including Stratification CP&LP Page 24
Excessive Pressurizer Cooldown Safety Significance (Continued)
Actual Transients Have Not Impacted Pressurizer Integrity From A Stress, Fracture, Or Fatigue Standpoint Large Tolerance For Flaws In Pressurizer Bottom Head Fatigue Usage Is Acceptable For 40 Of Each Enveloping Transient Actual Cooldowns Translate Into A Maximum Of 25 Transients Structural Integrity Of Pressurizer Not Affected By Actual Transients Evaluation Determined That February 26, 1994, Event Did Not Adversely Affect Structural Integrity of Pressurizer CP&L Page 25
NRC Enforcement Conference October 17, 1994 Agenda Introduction....................................
Scotty Hinnant Mispositioned Containment Isolation Valves Background / Event Summary.
Clark Fletcher Safety Significance.............................................
Garry Miller Causes / Corrective Actions.....................................
. Bruce Meyer Conclusion.................................................
Bruce Meyer Excessive Pressurizer Cooldown Background / Event Summary Garry Miller Safety Significance..
Garry Miller Causes / Corrective Actions.
Dale Young Conclusion Dale Young Summary / Conclusions............................
Scotty Hinnant CP&L Page 26
Excessive Pressurizer Cooldown Causes Based On Incorrect Technical Assumptions, Procedural Guidance To Ensure Compliance With TS Was Inadequate Lack Of Questioning AttitLde By Plant Staff Carolina Power & Light Operating Experience Information Was Available To Alert Plant Staff To This Issue CP&L Page 27
Excessive Pressurizer Cooldown Corrective Actions Operating, Procedures Have Been Revised To Specifically Monitor Pressurizer Cooldowns To Ensure TS Compliance Training Will Be Conducted On This Event And Revised Procedural Guidance TS Have Been Reviewed To Determine If There Are Any Other TS Section 3 Limits That Are Not Adequately Addressed In Procedures - No Similar Instances Were Identified During Review CP&L Page 28
Excessive Pressurizer Cooldown Corrective Actions (Continued)
Operating' Crews Have Been Counseled On The Need To Question Past Understandings And Practices Regarding TS Compliance Selected Internal Operating Experience Information From 1988 To Present Will Be Reviewed For Applicability Prior To The Next Refueling Outage Additional Evaluations Will Be Performed As Appropriate CP&L Page 29
Excessive Pressurizer Cooldown Conclusion Failure To Comply With TS Limits Resulted From Lack Of Pressurizer Temperature Monitoring Due To Incorrect Assumption Pressurizer Integrity Was Not Affected No Additional Operational Constraints Resulted From Previous Pressurizer Cycles CP&L Page 30
NRC Enforcement Conference October 17, 1994 Agenda Introduction Scotty Hinnant Mispositioned Containment Isolation Valves Background / Event Summary..
Clark Fletcher Safety Significance........................
Garry Miller Causes / Corrective Actions......................................
Bruce Meyer Conclusion..................................................
Bruce Meyer Excessive Pressurizer Cooldown Background / Event Summary...........................................Garry Miller Safety Significance...................................................Garry Miller Causes / Corrective Actions.........................................Dale Young Conclusion...................................................
D ale Young Summary /Conclusions
.. Scotty Hinnant CP&L Page 31
Summary / Conclusion While These Issues Are Significant, There Were No Safety Consequences To The Plant Or Public Both Issues Reflect Weaknesses In Operations Practices And Operator Performance Corrective Actions Will Strengthen Practices And Performances Management Understands The Operations Issues And Is Implementing Higher Standards Operators Are Beginning To Personally Accept The Performance Trend And Recognize Their Role In Improving Performance Escalated Enforcement Is Not Necessary To Bring Proper Attention To These Issues CP&L Page 32