ML17179B080
| ML17179B080 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 09/07/1993 |
| From: | Beverly Clayton, Hiland P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17179B079 | List: |
| References | |
| 50-237-92-33, 50-249-92-33, NUDOCS 9309200076 | |
| Download: ML17179B080 (20) | |
See also: IR 05000237/1992033
Text
SPECIAL INSPECTION TEAM REPORT
- .*:*****:****:-****:***:*.***:-: ... * .*.*::;;.:-:-*
DRESDEN CONTROL ROD MISPOSITIONING EVENT
SEPTEMBER 18, 1992
INSPECTION REPORT NO'S. 50-237/92033(DRP); 50-249/92033(DRP)
9309200076 930909 I
ADOCK 05000237
G
TABLE OF CONTENTS
Table of Contents ..........*........*...........*..**..*...... i
Executive Summary ......**.......*..*......................... ii
Inspection Report Sumrnary .*.....**.*...*..*......*.......*.. iii
1. 0
Introduction .................................................. 1
I . I
Event Su11UTiary . .*..**...***....*..*..**........................ I
1.2
Team Formation **.*...**....*.................................... 2
. 1.3
Team Char.ter .................................................. 2
2 .. 0
Sequence of Events ............................................ 2
3.0
Special Inspection Team Review .*.............................. 4
3.1
Cause of the Rod Mispositioning Event .......*.....*..........* 4
3.2
Initial Licensee Response .......*.....*....................... 4
3.3
Event Safety Significance ...........*................*........ 5
3.4
Adequacy of Control Rod Movement Procedures ................... 5
3.5
Management Involvement in the Event .......................... L5
3.6
Review of Procedural Compliance ............................... 6
3.7
Previous Events ...*.......*..*.*.............................. 8
3.8
Reportability in accordance with 10 CFR 50.72/73 .**........... 9
3.9
Station Personnel Attitude and External Pressures ......*...... 9
3.10
Licensee Investigation of Control Rod Mispositioning Event ... 11
3.11
Crew Briefings and Corrective Action ..*...................... 11
3.12
Personnel Qualifications and Shift Staffing Levels ........... 12
3.13
Licensee's Long Term Corrective Action ....................... 13
4.0
Conclusions ..*.**.**......*...*..... ~ ........................ 13
5. 0
Exit . ........................................................ 14
Team Charter ....*.*........*.............*........ Attachment 1
November 25, 1992, CECo Letter to NRC ............. Attachment 2
December 3, 1992, CECo Letter to NRC ........*...... Attachment 3
Personnel Contacted *.*... ~ ***..................... Attachment 4
i
EXECUTIVE SUMMARY .
A special inspection team was assigned to support the NRC Office of
Investigations (01) in response to the Dresden Unit 2 control rod
mispositioning event which occurred on September 18, 1992.
The team conducted
a technical review of the circumstances surrounding the event. The inspection
concentrated on the adequacy of the licensee's procedures,. operator actions,
management involvement, corrective actions, and the safety significance of the
event.
No nuclear safety limits were approached or exceeded and no deviations
were identified in the areas inspected.
Two apparent violations with multiple
examples were identified.
The two apparent violations included:
Inadequate corrective action for a previous event
Failure to follow procedures (five examples} *
The initial cause for the September 18, 1992, control rod misposition event
was a personnel error during a routine maneuver.
While no safety limits were
approached, the event is a concern because the subsequent failure to follow
programmatic controls was apparently due to deliberate misconduct by the
individuals involved.
None of the five individuals (a licensed reactor
operator, a licensed senior reactor operator, and three non-licensed
i ndi vi dua 1 s) reported the error as prescribed_ by station procedure$. . The
event was discovered when a licensee first line supervisor overheard reference
to a control rod mispositioning during a conversation on November 23, 1992.
ii
U. S. NUCLEAR REGULATORY COMMISSION
REGION III
Report No. 50-237/92033(DRP); 50-249/92033(DRP)
Docket No. 50-237; 50-249
Licensee:
Commonwealth Edison Company
1400 Opus Place
Downers Grove, IL 60515
Facility Name:
Dresden Nuclear Generating Station, Unit 2 and 3
Inspection At:
Dresden Site, Morri~, IL
Inspection Conducted:
November 30 - December 4, 1992
Inspectors: F.
H.
B.
L. Brush, Rill, Clinton Resident Inspector
Peterson, RIII, Operator Licensing Examiner
Siegel, NRR, Project Manag r, Division of Reactor Projects
Approved By:
Approved By:
~ )_ t.U
Patrick L. Hiland
Team Leader
TnspP.ction Summary
Branch 1
. qh/13
~
Inspection on November 30 - December 4, 1992 {Report No. 50-237/92033(DRP);
50-249/92033(0RP))
Areas Inspected: Special team inspection conducted in response to a Dresden
Unit 2 control rod mispositioning which occurred on September 18, 1992, and
the failure to promptly report that event. The inspectors reviewed the
sequence of events, the safety significance of the event, the licensee's
investigation, the qualifications of the personnel involved, the licensee's
corrective actions, the licensee's corrective action program with respect to
identifying other .incidents of not reporting operational problems, and the
technical adequacy of applicable procedures.
Results:
Two apparent violations with multiple examples were identified.
No
nuclear safety limits were approached or exceeded and no deviations were
identified in the areas inspected. The special inspection team concluded the
following:
iii
1.
The licensee's corrective actions- to-a control rod mispositioning event
that took place on April 10, 1992, were inadequate.
The qualified
nuclear engineer (QNE) involved in the September 18 event was also
involved in procedural violations during the April 10 event when a
control rod was mispositioned due to mechanical_ problems.
The licensee
took corrective actions to deal with the mechanical problem; however,
the licensee failed to take corrective actions toward~ personnel failure
to take required procedural mitigating actions in accordance with
station procedures. This was an apparent violation of 10 CFR Part 50,
Appendix B, Criterion XVI, "Corrective Action."
2.
The station control room engineer (SCRE), nuclear station operator
(NSO), and QNE failed to follow numerous Dresden Station procedure
requirements.
The most significant of these we~e: failure to take
mitigating actions in accordance with Dre~den Operating Abriormal
-Procedure (DOA) 300-12,* "Misp~sitioned Control Rod," including the
failure to immediately stop all rod movements, and the failure to take
corrective action"to insert the mispositioned rod to its full-in
position; failure to establish the required second verification for
control rod movements with the rod worth minimizer (RWM) rod blocks out
of service; failure to obtain prior approvals from a senior reactor
operator (SRO) for rod manipulatfori and .load change; and the intentional
failure to record and notify the appropriate personnel of the event.
This was an apparent violation of Dresden Technical Specification (TS)
6.2.A.1 which requires implementation of plant operating procedures.
1.0
Introduction
On November 24, 1992, Dresden senior.site management informed the NRC
Region III office of a potential failure to report a control rod
misposition event that had occurred on September 18, 1992.
Initial
information from the licensee indicated that five employees, both*
licensed and non-licensed, had knowledge of a control rod misposition
event at the time of occurrence, but failed to report the event in
accordance with site procedures.
In response to the initial
information, Region III management directed the Region III Operator
Licensing Branch Chief to conduct a preliminary _on-site assessment of
the known facts the evening of November 24. That. initial assessment*
concluded that the information provided by the licensee was reasonably
accurate and that an unreported control rod misposition event had
occurred on September 18. Several apparent violations of site
procedures, 10 CFR Part*so, ahd/or plant technical specifications were
identified.
On November 25, 1992, Commonwealth Edison's Chief Nuclear Operating
Officer, Mr. M. J. Wallace, in a letter to Mr.
A~ B. Davis, Regional
Administrator, Region III, described the licensee's immediate actions
upon receipt of information that a control rod misposition event was
intentionally not reported. That letter also described the licensee's
planned follow up actions, which included senior management oversight
and a special investigative task force.
1.1
Event Summary
On September 18, 1992, control rod movements were being performed to
reduce the flow control line {FCL).
At the time of the event, reactor
power was about 85 percent and the FCL was at 103.7 percent. That
~ombination resulted in high average power range monitor {APRM) alarms.
In order to clear the high APRM alarms, the FCL was to be lowered by
inserting control rods. Control rod insertion was being performed in
accordance with"Special Instructions" {SI) prepared by a qualified QNE
and approved by a licensed SRO.
During the control rod movement
sequence, a wrong control .rod was: inserted from its "full out" notch
position 48 to notch position 36, a distance of about three feet of the
twelve foot control rod length.
Contrary to procedural requirements, control rods continued to be
inserted before taking corrective action for the mispositioned rod.
The
mispositioned rod was event~ally restored to its "full out" position
under the direction of the QNE.
Five individuals were aware of the
sequence of e~ents concerning the mispositioned control rod; the station
control room engineer {licensed SRO), the qualified nuclear engineer,
the Unit .2 nuclear station operator {licensed reactor operator {RO)),.
and two nuclear engineers in-training. None of the five knowledgeable
persons reported the control rod movement error as required by~station
procedures.
1
On November 23, 1992, a licensee first line supervisor overheard
reference.to a control rod misposition event during a conversation.
Additional questioning and review of available records indicated to
licensee first line supervision that a potential intentional failure.to
.follow station reporting requirements had occurred. That information
was reported to licensee senior management on the morning of November
24.
'
1.2
Special Inspection Team Formation
Subsequent to the notification of this event, the NRC Office of
.*
Investigation (01) concluded that an immediate investigative effort was
appropriate. The 01 investigative report i~ an internal NRC document
separate from this inspection report. Region III management determined
that a special inspection team was warranted to support that
investigation. The p~rpose of the team was to provide technical
assistance to the investigative effort due to the seriousness of the
apparent withholding of information concerning the September 18 control
rod mispositioning event.
On Friday, November 27, 1992, the special
inspection team was formed consisting of the following personnel:
Team Members:
P. Hiland, R-111, Chief, DRP Section 18
B. Siegel, NRR, Project Manager
H. Peterson, R-111, Operator License Examiner
F. Brush, R-111, Clinton Resident Inspector
Th~ team arrived on site November 30, 1992.
1.3
Special Inspection Team Charter
A*charter was formulated for the special inspection team and transmitted
from E. G. Greenman, to P. L. Hiland on November 30, 1992, with .copies
to appropriate EDO, 01, NRR, AEOD, and Riii personnel (Attachment 1).
The special .inspection team was terminated on December 31, 1992.
2.0
Sequent~ of Events (Charter Item 1)
A chronology of actions related to the ~od mispositioning event on
September 18, 1992~ was assembled by the licensee. That chronology was
- used along with information from interviews, computer alarm typer
printouts, and the control rod SI sheets*to develop the following*
chronology of events:
NOTE:
All *times are in Central Standard Time (a.m.).
Asterisked times are approximate.
Initial Pl.ant Conditions
Unit 2
Unit 3
699 MWe
762 MWe
2
TIME
07:I5*
07:25
07:3I-07:56
OS: I5-0S: 17
OS: I7
OS: I 7-09: 45 .
09:49
09:52*
09:53*
09:57-I0:05
l0:05-IO:I3*
IO:I3-IO:I6
IO:I9-I0:22
I0:23
I0:26
I0:30*
EVENT
The lead nuclear engineer (LNE) directed the QNE to reduce
the flow control line by inserting peripheral control rods.
The QNE, with two nuclear engineers in training (NEITs),
proceeded to the control room.
The QNE and NEITs entered the control room.
Control rod arrays SCI (4 rods) and SC2 (4 rods) inserted
from full-out notch position 4S to full in notch
position 00.
Four control rods_ from array 3 inserted to position I2.
Control rod H-I selected to clear rod block monitor alarms.
Reactor po~er increased about IOO MWe using reactor
recirculation flow.
QNE filled out another control rod SI
sheet to insert array SDI.
The Unit 2 NSO inserted control rod H-I from position 4S to
position 36 by mistake.
The QNE instructed and the NSO
inserted array SDI (4 rods).
The QNE informed the SCRE that the NSO had inserted a wrong
- rod.
The QNE filled out an SI to insert control rod H-I, along_
with four other rods in array 5, to position 00.
The NSO inserted five rods from array 5 to position 00.
The SCRE, NSO, QNE, and NEITs held a discussion in the
Unit 2 back panel area.
The NSO, at the direction of .the QNE, withdrew array 3
(4 rods) from position I2 to 4S.
The NSO, at the direction of the QNE, inserted array SD2
{4 rods) to position 00.
The NSO, at the direction of the QNE, withdrew two rods from
array 5 to position 4S.
The LNE entered the control room to provide guidance to the
QNE concerning the number (too many) of peripheral cohtrol
rods that had been inserted.
QNE filled out SI sheets to insert arrays IOAI and IOA2 from
position 4S to position 20.
3
10:34-10:36
10:38-10:42
The NSO inserted arrays lOAl and 10A2 to position 20.
The NSO withdrew the remaining rods in array 5 to position
48.
11 :25
The LNE left the control room.
NOTE: The inspectors concluded that at least one of the SI sheets was signed
by the SCRE subsequent to the rod adjustments. It was also concluded
that the QNE made changes to at least one SI sheet without the SCRE's
knowledge.
3.0
Special Inspection Team Review
3.1
Cause of the Rod Mispositioning Event .
- The September 18, 1992, rod mispositioning event was caused by personnel
error on the part of the NSO and QNE.
The initial mistakes were made by
not following approved plant procedures; however, the subsequent actions
to not report the event exhibited a lack of integrity from individuals
knowledgeable of the event occurrence (SCRE, NSO, and QNE).
The lack of
management oversight by the Shift Engineer (SE), SCRE, and the LNE was
also a contributing factor.
3.2 * Initial Licensee Response
Upon becoming aware of the potential for an intentional failure to
report the September 18 corttrol rod mispositioning*event, licensee
management initiated steps to perform an investigation.
In addition,
the NRC Region III office was verbally informed of the event on
November 24, 1992.
On November 25, 1992, the licensee.provided a letter
(Attachment 2) from Commonwealth Edison's Chief Nuclear Operating
Officer to the Region III Regi~nal Administrator detailing both the
immediate and' planned actions in response to the event.
As detailed in
that correspondence, the licensee suspended the individuals involved
while a licensee investigation was conducted.
Licensee senior
management initiated coverage on all shifts to communicate the event to
all operations personnel, communicate and enforce management
expectations, 'and provide oversight of the qualified nuclear engineers'
activities. The li.censee's speci.al task force was provided a charter by
the General Manager of BWR-Nuclear Operations, and directed to perform
an investigation into the September 18 control rod mispositioning event.
On December 3, 1992, the licensee provided a letter (Attachment 3) from
Commonwealth Edison's Chief Nuclear Operating Officer to the Region III
Regional Administrator summarizing the investigation into the control
rod. misposition event. The licensee concluded that inappropriate
actions had been taken by five individuals in response to the
September 18, 1992, control rod mispositioning event.
As a result of
that conclusion, one individual was suspended, and four other
individuals were released from employment with Commonwealth Edison.
4
3.3
Event Safety Significance {Charter Item 2)
The inspectors conducted a detailed review of the data produced by the
Powerplex computer system on September 18, 1992.
The Powerplex computer
system calculated the core thermal parameters a~ part of its function to
monitor the fuel. A revi~w of the reactor coolant and off gas
radiological activity data for the month ~f September was also
conducted. There were no fuel thermal limit violations, and no
increases in radioactivity. The inspectors concluded that the September
18 control rod mispositioning event and subsequent rod manipulations did
not cause nuclear safety limits to be approached.
3.4
Adequacy of Control Rod Movement Procedures {Charter Item 2)
The inspectors conducted a detailed review of the following control rod
movement procedures: . Dresden* General Procedure (DGP) 03-04,
Revision 17, "Contrdl Rod Movements"; Dresden Administrative Procedure
(OAP) 14-14, Revision 0, "Control Rod Sequences"; Dresden Operating
Abnormal Procedure (DOA) 300-12, Revision 02, "Mispositioned Control Rod
(W-2, W-3)"; and Dresden Technical Surveillance Procedure (DTS) 8231;
Revision 02, "Returning Mispositioned Control Rod(s) To Their In-
Sequence Position." The inspectors concluded that these procedures were
technically adequate.
The inspectors also reviewed the flow control line instruction (FCLI)
and SI sheets (OAP 14-14, forms 14.;.148,14-14C, and 14-14D) that were
used to document the rod movements before and after the rod
mispositioning event.
The sheets delineating the control rod moves
prior to the event were technically adequate; however, the SI sheets
following the event did not reflect the movements that took place. The
QNE filled in some of the SI sheets after the control rods had been
moved, rather than obtaining prior approval by a licensed SRO as
required by procedure. A review of the process computer alarm typer
printouts confirmed that the rod* movements on various SI sheets were not
accomplished sequentially .. Moreover, the control rod in question (rod
H-1) was not delineated as a mispositioned rod on any of the FCLI or SI -
sheets.
3.5
Management Involvement in the September 18. 1992. Event (Charter Item 5)
Five individuals were directly involved with the rod mispositioning
event, and the subsequent failure to report the incident. The
individuals included the SCRE, the Unit 2 NSO, the QNE, and two NEITs.
The SCRE (a licensed SRO) was the senior licensee manager directly
involved with the event.
Other licensee management, either directly or indirectly involved were
the shift engineer (SE) and the lead nuclear engineer (LNE).
Both of
these individuals had responsibility to monitor and direct performances
of their subordinates. The LNE was directly involved with identifying
the incorrect operations by the QNE for a similar incident on April 10,
1992.
The QNE was reprimanded for improper rod manipulations following
5
the April 10 event. During the September 18 event the LNE identified
that too many peripheral rods were inserted, and entered the control
room to counsel the QNE.
The LNE failed to bring this situation to
upper management attention. The SE, who had the overall responsibility
of the day shift on September 18, was unaware of the acti*ons taken
regarding control rod movements .. The SE was present in the control room
during the time of the September 18 event; however, the SE was unaware .
of activities being performed. This indicated a lack of management
oversight to ensure proper performance and adherence to station
procedures, and to assure safe plant operations.
3.6
Review of Procedural Compliance (Charter Item 3)
On September 18, 1992, the control room midnight shift was experiencing
high average power range monitor (APRM) alarms due to the existing flow
control line (FCL).
The midnight shift SCRE obtained verbal control rod
adjustment instructions from the lead nuclear engineer (LNE) to insert
several peripheral ~ontrol rods in an attempt t~ reduce the FCL.
Those
rod adjustments were made; however, the APRM alarms did not clear.
At about 7:15 a.m. on September 18, the LNE instructed the qualified
nuclear engineer (QNE) to perform additional FCL rod adjustments.
The
QNE then proceeded to the control room with two NEITs and prepared a set
of "Special Instructions," forms14-14C and 14-140 from Dresden
Administrative Procedure {OAP) 14-14, "Flow Control Line Instructions."
The initial set of special instructions (SI) were approved by the day-
shift SCRE.
At about 7:30 a.m., with the approval of the SCRE, the
Unit 2 day shift NSO initiated FCL rod adjustments in accordance with
QNE instructions. During the initial rod manipulation, the utility
reactor operator was utilized as a "second verifier." At the time of
control rod manipulations, the rod worth minimizer (RWM) rod blocks were
bypassed. Therefore, a second verifier for rod movement was required in
accordance with Dresden Gene~al Procedur~ (DGP) 03-04, "Control Rod.
Movements," and Dresden Operating Procedure (DOP) 0400-02, "Rod Worth
Minimizer.".
At 8:17 a.m. the Unit 2 NSO stopped rod insertion after
partially completing one page in a series of Sis, and the second
verifier left the Unit 2 control panel area.
The Unit 2 NSO selected *
edge control rod H-1 to bypass the rod.block monitor (RBM) inputs; this
was a station routine practice.
At 9:49 a.m. the NSO recommenced rod insertions and mistakenly inserted
control rod H-1 from full-out notch position 48 to.notch position 36.
Control rod H-1 was not included in.the original approved Sis. The NSO
inserted the incorrect rod (H-1) without an approved or written rod
insertion instruction, and without.a second verifier for rod
manipulations as required by Dresden General Procedure {DGP) 03-04,
"Control Rod Movements," and Dresden Operating Procedure, DOP 0400-02,
"Rod Worth Minimizer." *Dresden Technical Specifications 6.2~A~l states
the applicable procedures recommended in Appendix A of Regulatory Guide
1.33, Revision 2 dated February 1978, shall be established, implemented,
and maintained. Regulatory Guide 1.33 Appendix A.Le. included
6
administrative procedures, general plant operating procedures*, and
procedures for startup, operation, and shutdown of safety related
systems.
Failure of the NSO and the QNE to adequately perform the
required second verification was an example of an apparent violation of
approved procedures (92033-0la/50-237, 249 (DRP)).
At the time of initial event occurrence, the QNE recognized the error
and informed the NSO.
It was apparent from the action taken to stop rod
insertion that the NSO also recognized the error.
Upon recognition of
the control rod mispositioning, the NSO was required to take mitigating
actions in accordance with Dresden Operating Abnormal Procedure (DOA)
300-12, "Mispositioned Control Rod."
DOA 300-12 section C.2, immediate
operator actions, required that the NSO discontinue all control rod
movement and recirculation flow increase.s. Subsequent corrective action
was delineated in DOA 300-12, section D.2.a.(1); "lE a single control
rod is inserted greater.than one even notch from its in-sequence
position, THEN continuously insert the mispositioned control rod to
position 00. " The NSO failed to ta~e the required corrective * a*ct ion and
took unapproved directions from the QNE to insert two additional arrays
of control rods in an attempt to recover the correct rod sequence. _
Failure of the NSO to discontinue control rod movements and insert the
mispositioned control rod to its fully inserted position was an example
of an apparent violation of approved procedures (92033-0lb/50-237, 249
(DRP)).
The NSO failed to adequately perform any portion of the abnormal
procedure for a mispositioned control rod, DOA 300-12. Additional
required operator actions.that were not performed by the NSO included,
notifying supervisors, logging the event in the NSO operating logs,*and
monitoring Off-Gas release for possible fuel damage.* The NSO and QNE
. continued.to correct the rod configuration, and by 12:00 noon the NSO
indicated in the operating log that FCL adj~stments were completed.
There was no.mention of any problems associated with the rod
manipulations, a significant load increase, or the existence of a
mispositioned control rod in the NSO log.
Failure to take additional .
required corrective action per*ooA 300-12 and the failure of the NSO to
properly document required Unit log entries was an example of an
apparent violation of approved procedures (92033-0lc/50-237,249* (DRP))*.
After the initial rod mispo.sitioning, the NSO took immediate action
(within less than fifty seconds) and inserted control rod array 801. from
position 48 to 06, contrary to the required immediate action to stop all
rod motion.
This array of rods was apparently part of the approved Sis;
however, it was performed out of sequence from the original FCL plan.
It was not part of the same SI which was partially completed at
8:17 a.m .* The NSO and QNE proceeded to further manipulate the control
rod configuration to c*orrect the Unit 2 rod sequence without prior SCRE
approval.
The SCRE and the NSO failed to adequately perform their
duties and responsibilities in accordance with OAP 07-29,. "Reactivity
Management Controls." This was an example of an apparent violation of
approved procedures (92033-0ld/50-237, 249 (DRP)) *
. 1
The QNE directed the NSO to insert a second array (array 5) of five
control rods from position 48 to 00, this included the initially
mispositioned rod H-1 being inserted from position 36 to 00. This
action was directed by the QNE to the Unit 2 NSO without written or
approved instructions from a licensed SRO.
The QNE did not develop or
have the SCRE review and approve this rod sequehce change SI until after
the rod manipulation had been completed.
The rod manipulation, a
liCensed activity, was not directed by the SE or the SCRE as required by
OAP 07-01, "Operations Department Organization." Directing licensed
activity by a non-licensed individual, i.e. the QNE, without prior SRO
approval was an example of an apparent violation of approved procedures
(1) (92033-0lel/50-237, 24.9 (DRP)).
The inspectors noted that an increase in reactor recirculation flow ~as
performed between 8:30 and 10:40 a.m .. The flow increase resulted in a
load increase of about 100 Mwe, 12% reactor power.
As stated during
.
interviews, the on-duty SCRE and SE were unaware of this load increase.
The inspectors concluded that this load change was performed without
prior knowledge or approval by an SRO licensed individual. This was an
example of an apparent violation of approved procedures
(92033-0le2/50-237, 249 (DRP)).
Following the completion of the rod sequence manipulation, the SCRE
reprimanded the individuals involved, this included the NSO, QNE, and
two NEITs.
During discussions with these individuals, the SCRE
empha~ized the need to slow down, reduce levity in the control room,
prevent personnel from getting into trouble, and stated this event was
not going to leave the control room.
3.7
Previous Events {Charter Item 13) *
The inspectors ~eviewed* information on*past events of a similar nature
to that of the September 18 event .. Two previous events, April 10 and
May 12~ 1992, were noted as potential concerns.
Both events were
identified and reported in accordance with the licensee's deviation
report program (DVR).
The May 12 event occurred*on Unit 3 during a.planned reactor shutdown.
Control rods were being.inserted in accordance with unit shutdown
procedures and the control rod sequence package.
The Unit 3 NSO
incorrectly inserted control rod C-5 from position 12 to position 8.
This rod was inserted out of sequence, and the appropriate control rod
was G-5. * A mispositioned control rod was identified and procedure DOA
300-12 was implemented.
The NSO immediately stopped all rod movements,
entered DOA 300-12, and performed the required subsequent action by
inserting the mispositi-0ned control rod to position 00. After a review
of thi.s event, the inspectors*concluded that appropriate corrective
actions were taken.
8
The April 10, 1992, event occurred on Unit 2 during a control rod
sequence adjustment to increase the FCL.
Control Rod M-4 was being
inserted from position 16 to position 14, when the rod "triple-notched"
and inserted to positi-0n 10.
Under the QNE's direction, the NSO
continued to insert control rods (rod M-12) and_ then withdrew Control
Rod M-4 from position 10 to position 14. Subsequently, the rod sequence
configuration was corrected.
The licensee identified that Control Rod M-4 was mispositioned; however,
corrective actions described in Deviation Report (DVR) 12-2-92-64
concentrated on the mechanical problem associated with the root cause of
the control rod triple-notch. Although the control rod drive hydraulic
(CRDH) drive water pressure w~s normal (280 psi over reactor pressure),
there was a mechanical problem in the insert speed control valve (valve
123) causing drive speed to be too fast.
The inspectors concluded the
licensee took corrective actions for the mechanical problem; however,
the immediate actions and operator response to the mispositioned control
rod were not in accordance with approved plant procedures.
The operators did not take the mitigating actions in accordance with DOA
300-12, "Mispositioned Control Rod." Control Rod M-4 was mispositioned
greater than one even notch, and the procedure required subsequent
action to insert the affected rod to position 00.
The NSO failed to
perform the required action and withdrew the rod to position 14. This*
was an example of an apparent violation of approved procedure (92033-
02a/50-237, 249 (DRP)).
In addition, the QNE directed the NSO to withdraw the mispositioned rod
without SRO approval.
The SE and/or SCRE were designated to direct
licensed activities as required by OAP 07-01, "Operations Department
Organization." Directing control rod movement without a senior
operating license was an example of an apparent violation of approval
procedures (92033-02b/50-237, 249 (DRP)).
For the April 10 event, *the licensee identified the abnormal plant
condition (mispositioned control rod), but.did not identify the failure
to implement required procedural corrective actions.* The licensee
concentrated.on the mechanical problem with the CRD system, and failed
to implement-corrective actions to assure response to future
mispositioned control rods was in accordance with plant procedures.
This was an apparent violation of 10 CFR 50 Appendix B, Criteria XVI,
"Corrective Action," (92033-02/50-237, 249 (DRP)).
3.8
Reportability Requirements of 10 CFR 50.72 and 50.73 (Charter Item 4l
After reviewing the requirements of 10 CFR 50.72 and 50.73, the
inspectors determined *that the September 18, 1992, control rod
mispositioning event was not reportable to the NRC.
9
3.9
Station Personnel Attitude and External Pressure
(Charter Items 7. 11. & 13)
The inspection team interviewed over thirty station personnel.
The -
spectrum of personnel interviewed included nuclear engineers, mechanics,
quality control inspectors, senior reactor- operators, reactor operators,-
nuclear engineers in-training, first line supervisors, training
supervisors, unit operating engineers, technical staff engineers,
equipment operators, and radiation protection technicians.
The following observations were made by the inspection team:
Although there was not a specific training module to emphasize
reporting of errors or deficiencies, it appeared that it was -
emphasized during tailgate (informal work group discussions)
sessions on past events- and during the normal course of performing
duties by first line management.
The impression obtained from the interviews was that management
was not stressing operations over safety, and that personnel
believed management expected errors and deficiencies to be
promptly reported.
.There was a _concern among workers that additional layoffs could
occur, or the Dresden Station could be shut down in response to
company financial concerns.
The performance of marginal workers was believed to have improved
because* of the fear of layoffs, and that performance, not
seniority, would be the basis for retention.
Although Dresden.Station had a disciplinary policy, there was a
concern among workers that it was not applied in a consistent
manner~
Communication between workers in different disciplines was
believed to be improved over the past year. -
Although general training wa~ held on the use of the new problem
identification form {PIF), which was part-of a new integrated
reporting program, some workers thought more specific follow up
- training was needed for everyone to be comfortable with its use.
Some workers interviewed had not received PIF training.
Most personnel thought the PIF was a significant improvement over
the old system, Deviation Report {DVR), and it was simpler and
worked reasonably well, considering it had only been in effect 3
months.
Those that had used the PIF were encouraged by the fact that
prompt responses were received, and corrective actions were
initiated if the issue was approved.
10
Most of those interviewed believed Dresden's performance over the
past twelve months had imp roved, but that it still had a long way
to go.
Some individuals believed there were still a small number of
employees that had an "attitude problem."
From interviews and general observation, it was apparent that a feeling
of apprehension had influenced Dresden personnel in the performance of
their duties. Plant management had distributed memorandums and
conducted presentations to inform plant personnel that making a mistake *
did not result in employment termination; however, some negative
impressions remained following management corrective action to the
September 18 event.
-
There was external pressure on Dresden station employees, both staff and
management.
Although the external pressures had increased {Commonwealth
Edison Corporate and the.NRC) due to Dresden's performance, it was not
perceived as necessarily excessive. The added attention by the NRC was
believed appropriate for declining performance.
3.10 Licensee Investigation of September 18. 1992. Event (Charter Item 8)
Based on the inspection team's review of the licensee's investigation,
the licensee's report required more detail. That report did not include
specifics associated with the violations of plant procedures, technical
specifications, or 10 CFR regulations. The licensee did identify
incorrect actions which were taken by the individuals involved. in the
event; however, the actions were only identified as "inappropriate
actions." Undoubtedly, these inappropriate ~ctions were the failure to
follow existtng plant procedures.
The report failed to elevate the
significance of this event, rather it.appeared to minimize the
deliberate lack of following station procedures {abnormal, general, and
operating), and the deliberate misconduct of operators to*conceal their
error.
The* personnel actions to conceal the event exhibited a lack of
integrity.
- . The 1 i censee' s root cause determination of the inappropriate actions *
were stipulated as "personnel errors." It was true that personnel error
initiated the event; however, the lack of management oversight by the
SE, SCRE, and LNE was also a contributing factor.
3.11 Crew Briefings and* Corrective Action (Charter Items 9 & 10)
During the interviews discussed in Paragraph 3.9, licensee personnel
were questioned regarding the extent they were briefed or informed of
.the September 18, 1992, rod mispositioning event.
In general, personnel
interviewed were aware of the event. All of the employees present at
Dresden the week of November 23 were informed through tailgate sessions
and/or the station manager's November 24 "Urgent Noti~e." Because of
11
the Thanksgiving holiday; many employees were not at the site the latter
part of the week and did not find out about the event until Monday,
November 30, 1992.
Those employees found out through a combination of
tailgate sessions, the station manager's "Urgent Notice," and/or word of
mouth upon return to work.
Following completion of licensee's special task group investigation on
December 2, 1992, a follow up letter from the Station Manager to Dresden
workers, dated December 2, 1992, was distributed to all employees
entering or leaving that day after 2:00 p.m.
This letter contained a
summary of the licensee's task group findings and the actions taken
against the five individuals involved.
In addition, the Station Manager
personally conducted a series of meetings with station employees.
One
member of the inspection team observed a meeting on December 2 which was
attended primarily by the operations staff. The Station Manager's
presentation was an expansion of the December 2 letter. It emphasized
the reason for dismissal was not for the control rod mispositioning
error, but was due to the lack of ethics and integrity.
Employees were
asked for their comments following the formal presentation, and several
candid questions were asked related to the personnel actions taken and
disciplinary actions related to mispositioning control rod errors in
general. The Assistant Superintendent for Operations also gave a short
presentation emphasizing the need to continue with the work at hand.
The inspection team concluded that not only operating crews, but all
station employees, had been and were being adequately informed about
this event through a combination of meetings, tailgate sessions, and
station management lectures.
3.12 Personnel Qualifications and Shift Staffing Levels (Charter Items 6 &
ill
.
The inspectors reviewed the training records for the lead nuclear
engineer and the qualified nuclear engineer on duty September 18, 1992.
The records were found to be complete; however, the nuclear engineer
training program was not*definitive in all of its requirements.which
permitted some interpretation by the person performing the training.
The inspectors interviewed several Dresden station qualified nuclear
engineers on December 4,
1992~ The purpose of the interviews was to
evaluate the technical knowledge of the qualified nuclear engineers.
Based on the response to a prepared set of technical questions, the
inspectors concluded that the individuals were knowledgeable of the
field of nuclear engineering as it.would pertain to the duties of a
station nuclear engineer.
The involvement of engineering in the
training of qualified nuclear engineers appeared adequate.
The
inspectors noted_that the nuclear engineer's qualification program
implementing procedures were under revision at the time of the
inspection.
12
On September 18, 1992, the Dresden operating shift staffing was
adequately maintained and no overtime guidelines were exceeded.
The
inspection team noted that numerous operators routinely worked overtime
hours, but did not exceed any of the overtime limits, i.e. 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> in a
24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period, 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in a 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> period, or 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in a seven day
period. At Dresden, the operating crews consisted of.four SRO licensed*
operators (SE, SCRE, Unit 2 Shift Supervisor, and Unit 3 Shift
Supervisor) and four RO licensed operators (Unit 2 NSO, Unit 3 NSO,
Center Desk RO, and Utility RO).
The NRC Operator Licensing Section
evaluated qualifications of the Dresden licensed operators on a periodic
basis. The evaluations were made ~tilizing both the initial license and
the requalification examination processes. Through these examinations
the competency of licensed operators and adequacy of the licensee's
training program was determined.
Based on two previous requalification
examinations, the Dresden training program and its licensed operators
were evaluated to be adequate~ However, there were several identified
weaknesses, including plant communications, Emergency Operating
Procedure utilization, and operator knowledge of administrative topics.
The latter concern was addressed during the July 1992 license operator
exam, when the licensee initially indicated to the NRC that
administrative topics were not crucial, and that referencing procedures
was expected.
The licensee initially challenged the NRC on several exam questions
related to administrative topics. After some conversation and
correspondence with the licensee, the Dresden Station management
acknowledged that *"In order for operators to perform their job in a safe
and error free manner, knowledge of Dresden Administrative Procedures
(OAPs) is a necessary requirement,""(ref. licensee letter from T. J.
Kovach to USNRC dated September 30, 1992).
The licensee indicated that
training was to be provided to enhance overall awareness of
administrative procedures to the members of the operating department.
3.13 Licensee's Long Term Corrective Action {Charter Item 9)
On December 10, 1992, the licensee discussed with Region III management
the intended long term action pl an for the *September 18 control rod
mispositioning event. That action plan included the following
attributes: Communicate the details of the event to all nuclear stati.on
employees; develop a clear interface between the qualified nuclear
engineers and li~ensed operators; evaluite the nuclear engineer training
program; develop a corporate policy on expectations for integrity;
initiate action to reduce further control rod mispositioning events;
evaluate the general employee training program with regard to the
subject event; and define responsibility for independent verification of
control rod movement.
13 '
4.0
Conclusions
After completing the charter, the team was able to make the following
conclusions:
The control rod positioning error did not cause any nuclear safety
limit to be approached.
The control rod mispositioning itself was not reportable to the
NRC; however, it was required to be reported to licensee's upper
management in accordance with station procedures.
There was apparent deliberate.misconduct by the individuals
involved.
Several apparent violations of station approved procedures and NRC
requirements were identified.
Licensee short term corre~tive action for this event appears
adequate; however, long term corrective actions will require
further assessment as it is implemented.
5.0
Exit Interview
The team met with licensee representatives (denoted in Attachment 4} in
an exit meeting on August 26, 1993, and summarized the purpose, Special
Inspection Team charter items, and findings of the inspection. The team
discussed the likely informational content of the inspection report with
regard to documents*or processes reviewed by the team during the
inspection.
The licensee did not identify any such documents or
processes as proprietary.
14
ATTACHMENT 4
Personnel Contacted
Commonwealth Edison Company CCECol
- M. Lyster, Site Vice President
- G. Spedl, Dresden Station Manager
- * C. W. Schroeder, Former Dresden Station Manager
G. Smith, Assistant Superintendent Operation
D. Elias, Safety Review and Analysis Manager
- T. Rieck, Nuclear Fuel Servi~es Manager
R. Flessner, Safety Programs Director - SR&A
M. Healy, counsel to CECo, Newman & Holtzinger
J. Gutierrez, counsel to CECo, NeWll1an & Holtzinger
- D. Ambler, Executive Assistant to the Site Vice President
- L. Ciuffini, Reactor Operator
- A. D'Antonio, Site Quality Verification Supervisor
- M. Falcone, Nuclear Operations Staff
- R. Flahive, Technical Services Superintendent
- B. Gurley, NRC Coordinator
- N. Kauffman, Human Resource Supervisor
- J. Kotowski, Operations Manager
- S. Lawson, Operating Engineer
- R. Mitzel, Shift Engineer
- J. Paczolt, Dresden Reactor Operator
- K. Peterman, Work Planning
- G. Piccard, Dresden System Engineer
- P. Piet, Licensing Administrator
- s. Reece-Koenig, Performance Assistant Administrator
- J. Shields, Regulatory Assurance Supervisor
- R. Weidner, Dresden Training Supervisor
Nuclear Regulatory Commission CNRC)
- J. Martin, Regional Administrator, Riii *
- T. Martin, Deputy Director, Division of Reactor Projects, Rill
- P. Hiland, Chief, Reactor Projects Section lB, Rill
- F. Brush, Resident Inspector, Clinton
- H. Peterson, Senior Resident Inspector, Byron
- M~ Leach, Senior Resident Inspector, Dresden
R. Anderson, Investigator, Office of Investigation NRC Region III
. J. Ulie, Investigat~r, Offic~ of.Investigation NRC Region Ill
B. Clayton, Branch Chief, Division of Reactor Projects Branch 1
W. Rogers, Senior Resident Inspector, Dresden Station
M. Peck, Resident Inspector, Dresden Station
- A. Stone, Resident Inspector, Dresden Station
Illinois Department of Nuclear Safety
- R. Zuffa, Resident Engineer, IONS
- Indicated persons at the exit interview on August 26, 1993.