ML17229A797

Responds to NRC Ltr Re Violations Noted in Insp Repts 50-335/98-06 & 50/389/98-06.Corrective Actions:Reactor Coolant Pump Clearance Discrepancy Noted as Clearance Was Being Released.Equipment Order Not Revised

ML17229A797
Person / Time
Site:	Saint Lucie
Issue date:	07/08/1998
From:	Plunkett T FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
50-335-98-06, 50-335-98-6, 50-389-98-06, 50-389-98-6, NUDOCS 9807140213
Download: ML17229A797 (12)

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~ CATEGORY 1 ~

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

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CESSION NBR:9807140213 DOC.DATE: 98/07/08 NOTARIZED: NO DOCKET ACIL:50-335 St.'Lucie Plant, Unit 1, Florida Power &. Light Co. 05000335 50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 AUTH. NAME AUTHOR AFFILIATION PLUNKETT,T.F. Florida Power 5 Light Co.

RECIP.NAME RECIPIENT AFFILIATION Records Management Branch (Document Control Desk)

SUBJECT:

Responds 50-335/98-06 to NRC 6

ltr re violations noted in insp repts 50/389/98-06.Corrective actions:reactor coolant pump clearance discrepancy noted as clearance was being released. Equipment order not revised. h DISTRIBUTION CODE: IE01D COPIES RECEIVED:LTR ENCL SIZE:

TITLE: General (50 Dkt)-Insp Rept/Notice of Vio ation Response E NOTES:

RECIPIENT COPIES RECIPIENT COPIES 0 ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-3 PD 1 1 GLEAVES,W 1 1 INTERNAL: ACR S 2 2 AEOD/SPD/RAB 1 1 AEOIQgTC 1" 1 DEDRO 1 FILE CENTE 1 1 NRR/DRCH/HOHB 1 1 R/DM'ECB 1 1 NRR/DRPM/PERB 1 1 NUDOCS-ABSTRACT 1 1 OE DIR 1 1 OGC/HDS3 1 1 RGN2 FILE 01 1 1 I

TERNAL: LITCO BRYCE,J H 1 1 NOAC 1 1 D NRC PDR 1 1 NUDOCS FULLTEXT 1 1 0

E N

NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE. TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DZSTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD) ON EXTENSION 415-2083 TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19

h Florida Power & Light Company, 6351 S. Ocean Drive, Jensen Beach, FL 34957 July 8, 1998 L-98-168 10 CFR $ 2.201 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Re: St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to a Notice of Violation NRC Ins ection Re ort 98-06 Florida Power and Light Company (FPL) has reviewed the subject Notice of Violation and, pursuant to 10 CFR $ 2.201, the responses to the violations are attached.

As you are aware, we have identified the implementation of equipment clearance orders and corrective action as two of the primary challenges to St. Lucie Plant in 1998. Since the clearance order administrative process is the same at Turkey Point and St. Lucie, and since we have not encountered similar clearance order problems at Turkey Point, we have concluded that human performance errors predominate'as the cause of equipment clearance order problems at St. Lucie.

St. Lucie Plant has augmented the staffing of the clearance center and reconfigured the work area in order to minimize personnel error precursors. We expect to see significant improvement in clearance orders.

With regard to corrective action, we have formed a cross-functional team to determine what weaknesses exist in the plant's processes and personnel training that resulted in the NRC violation and Quality Assurance findings on corrective action. The team has identified insufficient administrative controls resulting in untimely corrective action and insufficient management involvement in the corrective action process as the cause'or cor'rective action performance problems. We are. in the process of addressing these important issues in order to improve St.

Lucie's implementation of the Condition Report process, which has been proven to be a robust process at Turkey Point.

Please contact us with questions on the enclosed violation response.

Very truly yours, Thomas F. Plunkett President Nuclear Division 9807i 402i3 980708 PDR ADGCK 05000335 8 PDR an FPL Group company

TFP/JAS/EJW Attachment cc: Regional Administrator, USNRC, Region II Senior Resident Inspector, USNRC, St. Lucie Plant

L-98-168 Attachment P~ae 1 Violation A Technical Specification 6.8.1 requires the licensee to establish, implement, and maintain the applicable procedures recommended in Appendix A of Regulatory Guide 1.33. Appendix A recommends procedures for equipment control (e.g., tagging and locking).

Procedures for equipment'control were contained in ADM-09.04, Revision 3, "In-Plant.

Equipment Clearance Orders." ADM-09.04, Section 3.8.3, required Electrical Department Personnel to "Verify that any grounding device is documented on the Equipment Clearance Order Form as a step with no tag."

ADM-09.04; Section 6.8.4.A, required the Nuclear Plant Supervisor, Assistant Nuclear Plant Supervisor, the Work Control Center-Assistant Nuclear Plant Supervisor, or the Nuclear Watch Engineer to "verify... the adequacy of the information contained in the Request section of the Equipment Clearance Order Control Form."

ADM-09.04, Section 6.9.2.C, required the Reactor Control Operator to "Verify [the] boundary using controlled documents...."

ADM-09.04, Section 6.11.1.A, required the Nuclear Plant Supervisor, Assistant Nuclear Plant Supervisor, the Work Control Center-Assistant Nuclear Plant Supervisor, the Nuclear Watch Engineer, or other Senior Reactor Operator to "Verifythe specified Equipment Clearance Order

. boundary satisfies the requirements specified in the Equipment Clearance Order request."

ADM-09.04, Section 6.12.20.A, required the Equipment Clearance Order Controller to sign the Equipment Clearance Order Control Form indicating they find the Equipment Clearance Order acceptable. Section 6.12.20.B stated "Signing the Acceptance Block on the Equipment Clearance Order Form (Figure 1) indicates concurrence that the Equipment Clearance Order boundary is adequate for the work to be performed."

ADM-09.04, Section 6.12.23.A, required the workers to perform a "verification of the Equipment Clearance Order boundary utilizing available reference materials."

L-98-168 Attachment P~ee 2 Contrary to the above:

On February 17, 1998, the licensee issued Equipment Clearance Order 1-98-01-202S to isolate the 1B1 Reactor Coolant Pump safely.

a. The Reactor Control Operator failed to verify adequately the boundary prior to issuance.

b. The Work Control Center-Assistant Nuclear Plant Supervisor failed to verify that the Equipment Clearance Order satisfied the requirements for the Clearance request.

c. The Equipment Clearance Order Controller failed to verify the adequacy of the Equipment Clearance Order boundary for the work to be performed.

d. Multiple maintenance workers failed to verify the Equipment Clearance Boundary prior to beginning work.

On March 30, 1998, the licensee issued Equipment Clearance Order 2-98-03-005 to isolate the 2C Intake Cooling Water pump. Electrical Maintenance personnel failed to verify that the grounding device installed was documented in the clearance order prior to starting the work.

On March 31, 1998, the licensee issued Equipment Clearance Order 2-98-03-.058 to allow routine maintenance of the 2B Waste Gas Compressor.

a. The Work Control Center-Assistant Nuclear Plant Supervisor failed to verify the adequacy of the clearance request.

b. 'he Reactor Control Operator failed to verify adequately the boundary of the Equipment Clearance Order prior to issuance.

The Equipment Clearance Order Controller failed to verify the adequacy of the Equipment Clearance Order boundary for the work to be performed.

The Maintenance workers failed to verify the Equipment Clearance Boundary prior to beginning work.

This is a Severity Level IV violation (Supplement I) applicable to both Units.

L-98-168 Attachment P~ee 3 R~es once

1. FPL concurs with the violation.

REASON FOR VIOLATION The reason for the violation was cognitive personnel error. in that the clearance procedure was not complied with during development and implementation of the clearances for the 1B1 reactor coolant pump, 2C intake cooling water pump, and 2B waste gas compressor.

The clearance procedure has various barriers in place to preclude errors of this type by providing several levels of verification of the adequacy of a clearance. However, certain clearance procedure barriers were ine6ective in preventing the clearance boundary problems because the procedure was not followed. For example, the 2B waste gas compressor clearance request submitted to Operations did not list the boundaries needed or the work to be performed. Both the 1B1 reactor coolant pump and 2B waste gas compressor clearances were incorrectly developed, and subsequent Operations and Maintenance supervisory and line personnel independent verifications were inadequately performed. The 2C intake cooling water pump clearance did not document the grounding device because the electricians did not inform Operations that the grounding device had been installed, as required by the clearance procedure.

Along with the failed barriers, other contributing factors to the violation were inadequate checks in the Electrical Department grounding procedure, and the inadequate identification of preventive maintenance that requires a system be mechanically open.

3.'ORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. As documented in Condition Report (CR) 98-0297, the 1B1 reactor coolant pump clearance discrepancy was noted as the clearance was being released, therefore the equipment clearance order was not revised.

B. As documented in CR 98-0561, the 2C intake cooling water pump clearance was revised on discovery to include the grounding device on March 30, 1998.

C. As documented in CR 98-0570, the 2B waste gas compressor clearance was revised on discovery to include the mechanical isolation valves on March 31, 1998.

D. Individuals involved with these events were counseled in accordance with plant policy.

4 L-98-168 Attachment P~ee 4

'. CORRECTIVE STEPS TO AVOIDFURTHER VIOLATIONS A. Standdown meetings for Operations were completed by June 15, 1998, to discuss compliance with the clearance procedure and the use of questioning attitudes when developing clearance boundaries.

B. The barrier analysis identified that a significant portion of the missed clearance procedure barriers occur during the initial development and verification of clearance requests. St. Lucie has reconfigured the Clearance Center in order to segregate personnel researching and writing clearances from distractions that may detract from their ability to focus on the task at hand. This human factors improvement is intended to minimize the likelihood of inadequate clearance development.

C. Barring extenuating circumstances,'the normal staffing level of the Clearance Center has been increased. This human factors improvement, along with corrective action 4.B above, will allow increased attention to each individual clearance and is intended to minimize the likelihood of inadequate clearance development.

D. An operator aid was created to assist in the development of clearances by listing the vital aspects of the preparation and implementation of clearances.

E. The Electrical Maintenance Guidelines EMG-53.08, Revision 2, "Safety Requirement for Grounding of High Voltage (4.16 or 6.9 KV) Switchgear Buses t

for Maintenance," and EMG-53'-07, Revision 3, "Grounding or Testing of High Voltag'e (4.16 or 6.9 KV) Loads," were implemented on May 7, 1998, to require a sign-off verifying that Operations was notified of the installation of grounding devices.

St. Lucie is evaluating master clearances for preventive maintenance and lubrication preventive maintenance to identify and modify those clearances that require the system to be open. This activity will be completed by September 30, 1998.

In order to reinforce management expectations and equipment clearance procedural requirements, Job Performance Measure (JPM) 1321090P, "VerifyIn-Plant Eq'uipment Clearance," will be revised to ensure that Maintenance personnel are required to evaluate the adequacy of equipment clearance order boundaries, in accordance with procedural requirements, as part of the JPM. This JPM will be revised by July 17, 1998.

L-98-168 Attachment P~ae 5

5. Full compliance was achieved on March 31, 1998, with the completion of action items 3.A, 3.B, and 3.C above.

L-98-168 Attachment P~ae 6 Violation B 10 CFR 50 Appendix B, Criterion XVI, Corrective Action, requires that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to appropriate levels of management.

Contrary to the above:

1. Corrective action was not completed in a timely manner for 1996 Condition. Reports (CRs) that identified 29 procedure revisions needed to correct deficiencies. Plant Manager Action Items had been opened in 1996 to make these procedure revisions and were still open in April 1998.

Corrective action taken for a significant condition adverse to quality, that was identified in February 1997 in Quality Assurance Audit QSL-CA-96-20 and documented in CR 97-282, was not adequate to prevent repetition. CR 97-282 documented that multiple CRs contained assigned corrective actions that did not adequately address the deficient conditions. A followup audit in December 1997, Quality Report 97-2271, found that five out of 29 Condition Reports again contained assigned corrective actions that did not adequately address the deficient conditions.

s e

Corrective action root cause evaluations required by procedure AP-0006130, Revisions 7-12, "Condition Reports," were not performed for issues identified in Condition Report 98-0112. This was similar to findings identified in Quality Assurance Audit QSL-CA-96-20.

This is a Severity Level IV violation (Supplement I) applicable to both Units.

R~es oese

1. FPL concurs with the violation.

2. REASON FOR VIOLATION A cross functional plant team was formed to investigate the causes of the subject violation.

The issues noted in the inspection report were determined to be the result of a number of

Qi L-98-168 Attachment

'~ae 7 causal factors. Implementation of the corrective action process for significant conditions has been less than adequate due to:

a) Insufficient administrative controls resulting in untimely corrective action and the development of a backlog of outstanding corrective actions (Example 1).

b) Insufficient Management involvement in the corrective action process (Example 2).

Management involvement in both the up-front prioritization of Condition Reports and the back end review of significant CR dispositions was inadequate to prevent recurrence.

Additionally, the procedural requirements for the assignment of root cause per AP-0006130, Revisions 7-12, "Condition Reports," did not reflect the Plant General Manager's role in determining ifa formal root cause analysis was required (Example 3).

CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. A more rigorous Plant Manager Action Item (PMM) system would have prevented example 1 of this violation. PMAIs related to procedure changes were not given due dates, but were assigned a priority code to indicate the relative importance and need for the planned procedure revision in relation to other pending procedure changes. The procedure related PMAI priority system was eliminated, and all procedure related PMAIs will be given due dates. This action will be completed by, July 31, 1998. Of the 29 overdue procedure revisions in example one of this violation, 16 have been dispositioned, and the remaining procedure revisions were reviewed and'valuated and new due dates assigned. It should be noted that several of the pending procedure changes cited in example 1 are associated with on going upgrade programs on emergency operating procedures and annunciator response procedures made by previous commitments.

B. As noted in the inspection report, the five CRs in example 2 of this violation that did not adequately address the deficient conditions were adequately dispositioned and corrective actions are complete.

L-98-168 Attachment P~ae 8 C. AP0006130, "Condition Reports," has been revised to eliminate ambiguity regarding the assignment of root cause analysis for CRs. The procedure now clearly states that the Plant General Manager will indicate whether a root cause analysis is required. An appendix to this procedure provides guidance on making this determination. This corrective action is complete.

4. CORRECTIVE STEPS TO AVOIDFURTHER VIOLATIONS A. Methods will be established to ensure that senior plant managers review significant CRs for proper departmental assignment and root cause level at the management meeting each day. These methods will be outlined in Corrective Action Group Guidelines that will be developed by July 10, 1998.

The role, of the Facility Review Group (FRG) as it relates to the review of CRs will be expanded. AP0010520 "Facility Review Group" will be revised to ensure that the FRG reviews the resolution of CRs for which root cause analysis has been assigned. The procedure change will be developed by July 10, 1998.

e AP0006129, "Plant Manager Action Item (PMAI) Corrective Action Tracking Program," willbe revised to provide additional controls on the extension of PMAI due dates; Controls will be established so that PMAIs do not receive due date extensions without Plant Manager approval.

PMAIs requiring changes to plant procedures will receive specific due dates, consistent with the prioritization efforts of the ongoing procedure upgrade program.

These changes to AP0006129, "Plant Manager Action Item (PMAI) Corrective Action Tracking Program," will be completed by July 10, 1998.

5. Full compliance willbe achieved on July 31, 1998, with the completion of corrective action 3.A above.