ML17261A969

Responds to Violations Noted in Insp Rept 50-244/89-16. Corrective Actions:Operations & Maint Personnel Received a Procedure Training That Highlights A-1408, Independent Verification, Requirements

ML17261A969
Person / Time
Site:	Ginna
Issue date:	02/23/1990
From:	Mecredy R ROCHESTER GAS & ELECTRIC CORP.
To:	Russell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
References
NUDOCS 9003020138
Download: ML17261A969 (18)

Text

AO;ELERATED DISHUBUTION DEMONSHWTION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ESSION NBR:9003020138 DOC.DATE: 90/02/23 NOTARIZED: NO DOCKET ACIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH. NAME . AUTHOR AFFILIATION MECREDY,R.C. Rochester Gas & Electric Corp.

RECIP.NAME RECIPIENT AFFILIATION RUSSELL,W.T. Region 1, Ofc of the Director

SUBJECT:

Responds to violations noted in Insp Rept 50-244/89-16.

DISTRIBUTION CODE IE01D COPIES RECEIVED:LTR ENCL SIZE:

TITLE: General (50 Dkt)-Insp Rept/Notice of VqoIation Response NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72). '05000244 E

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RECIPIENT COPIES RECIPIENT COPIES 1,

ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD1-3 PD 1 1 JOHNSON,A 1 1 D

INTERNAL: AEOD 1 1 AEOD/DEIIB 1 1 AEOD/TPAD 1 1 DEDRO 1 D NRR SHANKMAN,S 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA DIR 11 1 1 NRR/DREP/PEPB9 D 1 1 S NRR/DREP/PRPB11 2 .2 NRR/DRIS/DIR 1 1 NRR/DST/DIR 8E2 1 1 NRR/PMAS/ILRB12 1 1 NUDOCS-ABSTRACT 1 1 0 N,J 1 1 OGC/HDS2 1 1 1 1 RES MORISSEAU,D 1 1 RGN1 FILE 01 1 1 RNAL: LPDR 1 1 NRC PDR 1 1 NSIC 1 1 R

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D NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTETH CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELMINATEYOUR NAME FROM DISTRIBUTION LISIS FOR DOCUMENTS YOU DON'T NEEDl TAL NUMBER OF COPIES REQUIRED: LTTR 24 ENCL 24

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I , %0%l5 55A55 ROCHESTER GAS AND ELECTRIC CORPORATION ~ 89 EAST AVENUE, ROCHESTER, N.Y. 14649-0001 T C 5. E P H O N C A@CA CODE VI55 546-2700 February 23, 1990 Mr. William T. Russell Regional Administrator U.S. Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia, PA 19406

Subject:

Response to Inspection Report 50-244/89-16 Notice of Violation R. E. Ginna Nuclear Power Plant Docket No. 50-244

Dear Mr. Russell:

The enclosed response to the Notice of Violation contains our response to Violation 89-16-01 from the inspection at the R. E. Ginna Nuclear Power Plant from November 7 through December 11, 1989. The attached response includes Human Performance Evaluation System (HPES) investigation information and our corrective actions. Our long-term corrective actions have been determined to address the repetitive nature of these concerns, and the need for increased management attention.

Very truly yours, Robert C. Mecredy Division Manager Nuclear Production xc: U.S. Nuclear Regulatory Commission (original)

Document Control Desk Washington, DC 20555 Ginna NRC Senior Resident Inspector

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A'i'OC.I; 0.000:44 PDC

I RESPONSE TO NRC INSPECTION REPORT 50-244/89-16 Routine Inspection Report 50-244/89-16, Appendix A, stated in part:

" During an inspection at the R.E. Ginna Nuclear Power Plant from November 7 through December 11, 1989, the following violation was identified in accordance with the NRC Enforcement Policy (10 CFR 2, Appendix C).

Technical Specification 6.8.1 requires in part that written procedures shall be 'established, implemented, and -maintained .

covering activities referenced in Appendix A of Regulatory Guide 1.33, November 1972. Activities referenced'n Appendix A include maintenance and equipment control.

Calibration Procedure (CP)-410A, Calibration and/or Main-

'tenance of Saturation Temperature Monitor System "B" Loop, requires restoration of the test switch to the original position. In addition, Administrative Procedure (A)-1408,.

Independent Verification, and Procedure A-52.4, Control of Limiting Conditions For Operating Equipment, require in-dependent verification, by observation of proper indication or response, following alignment and restoration of equipment required by technical specifications.

Contrary to the above, on November 17, 1989, following maintenance on the 'B'oop saturation temperature monitor required by TS 3.5.3 using CP-410A, the test switch was not restored .to the original position and did not receive independent verification of instrument response or switch position."

Rochester Gas and Electric concurs with the above violation as described.

J

1. Reason for Violation A Human Performance Evaluation System (HPES) investigation was conducted on this event. A Causal Factors Chart has been prepared and is attached. The concept of barriers and defense in'depth to ensure safe operation and maintenance of the plant was challenged by this event. The HPES investigation identified numerous Specific Barriers that were meant to ensure correct performance of CP-410A, but in varying degrees were ineffective in preventing this event.

. Our analysis of this and other similar events points to three Primary Root Causes. iI Inadequate procedural direction Ineffective statement of station policies, co-mmunication, and follow-up of these policies Lapse .in the "good work practices" of some individuals 20 Corrective Actions Taken and Results Achieved A. While performing Main Control Room channel checks, the operators discovered the 1B subcooling monitor indicator pegged high. Instrument and Control Technicians were called in for troubleshooting and found the test switch not in the recpxired position. The test switch was repositioned, the monitor's restoration and indication was verified and the monitor was returned to service.

B. Operations and Maintenance personnel have received "A" procedure training that highlights A-1408, "Independent Verification" requirements and A-503, "Procedure Ad-herence".

C. Meetings were held with each operating shift, selected discipline and Administrative groups. The HPES in-vestigation was discussed with each group in detail, using the Causal Factor Chart as a presentation aid.

These discussions focused on:

• Barriers and defense in depth

• Work group interfaces

• Management communication of policies, and follow-up for effective implementation

• Importance of the independent verification Process in daily plant operation

• Corrective -Action Plan and specific roles for each work group

Management conducted a group meeting with the three Operators and the three I&C Technicians that were involved in this event. This meeting addressed What, Why, and Under What Conditions events occurred from the perspective of each participant. The focus was on understanding the event and establishing' basis for Corrective Action to prevent recurrence.

A memo to all Maintenenance personnel, dated February 06,1990, provides instructions to ensure that the latest revision of the implementing procedure is in the work package and that. the procedure has been marked up for independent verification of restoration steps as applic-able. A read and acknowledgement sheet was included with the memo, to en'sure the. memo was understood.

Good work practices have been re-emphasized in Section, Foreman, planning, and Shift Supervisor meetings.

Also, as noted in the RGGE response to Inspection Report 89-15, directions have been provided to Operations personnel concerning improved on-shift attention to detail, improved in-depth communications and acknowledg-ement of responsibilities for return of equipment to service.

CP-410A and CP-409A have been deleted to prevent use of these deficient procedures. The new Procedure Upgrade Program (PUP) procedures for calibration of the Saturation Temperature Monitor System are in draft form, ready for review, and will be available prior to next scheduled use. This upgrade corrects multiple action steps, lack of independent verification, inadequate technical content, lack of proper warnings, cautions, and notes and improves on overall procedure format and performance.

Label requests were initiated and completed for test switches TS-410A-1 and TS-409A-l. ,Also, a Drawing Change Request was initiated to revise Foxboro's drawings CD-11 and CD-21 to clearly identify the test switches. Other protective system rack drawings were reviewed for test switch installations similar to TS-409A-1 and TS-410A-1 and none were found.

Corrective Ste s Which Will Be Taken To Avoid Future Violations A. The Procedure Upgrade Program (PUP), for calibration procedures is ,in progress and on schedule for a 1990 completion. The remaining maintenance procedures to be upgraded are scheduled to be completed in 1992. This upgrade program address industry recognized procedure good practices in terms of'content, format, and process.

A Task Force will be formed to focus on problems as-sociated with procedure adherence,= system alignments, independent verificaton, and their repetitive nature.

The Task Force goal will be to eliminate these conditions.

This task force will report to the Plant Manager.

C. A request for a Training Effectiveness Evaluation on "A" Procedure training was generated by the Plant Superinten-dents. This evaluation iscurrently being performed by the Training Evaluation Group, and will be completed by March 02, 1990. The Request focused on the following areas:

How effective were the Station personnel in communicating plant needs to the training groups?

2 How effective is the training process as applied to training on "A" procedures?

it was This evaluation will assist the Task Force 'in assessing the effectiveness of Plant and. Training Organization interfaces. This will provide information for potential changes in the training process and the training programs that address procedure adherence and independent verific-ation.

D. A Training Change Request (TCR) was submitted requesting training for I&C personnel concerning the Saturation Temperature Monitor System interrelationships.

E. As noted in the RG&E Response to Inspection Report 89-15 "Administative Procedure A-52.4 "Control of Limiting Conditions for Operation" has been changed to further delineate expected actions of personnel for return to service of previously inoperable equipment. Specific examples are utilized within the body of the procedure to reinforce these requirements."

This procedure change is currently awaiting PORC approval following comment resolution. This approval will be completed by March 09, 1990.

i'

F. Utilize the Quality Performance Organization to aid management by providing a special assessment as feedback on the effectiveness of procedure adherence and indepen-dent verification procedures and activities.

4. The Date When Full Com liance Will Be Achieved Full compliance was achieved November 17, 1989, when the test switch was repositioned, the monitor's restoration and indication was verified, and the monitor was returned to service.

RGEE recognizes the need for increased management attention, due to the repetitive nature of problems associated with procedure adherence, system alignments and independent verification. Our goals are to eliminate incorrect system alignments, and assure independent verification whenever specified. We have made progress toward achieving this goal, and are continuing to reinforce our corrective actions on an urgent basis. Any future inadequacies in procedure adherence, system alignments, or independent verifications will be dealt with on a case-by-case basis and will be thoroughly investigated. Any necessary follow up actions including procedure corrections, policy clarifications, or individual counseling will be taken.

Training on A- lant Procedure HPES 90-01 "CP-410A Test Smite Returned" Adhcreacc Requirements" snd work CAR 1990 group discussion of 6/29/89 memo referring to ncw requirement on double NRC Inspection Report 60-244/89-16 signoff was not effective. Violation 01 Proccdurc dcsignt Training on A-1408 "Indcpcndent Vcrilication"was not cffectivc. (Note:

12/15/80letter to NRCcommincd RG&E Test switch is not called out.

to perform vnilication of correct performance. Ia step 5.6.7, thrcc actions arc uircdi Maasttancnt communication and follow-up ~ isconncct equipment on A-303 and A-1408 did not occur. ~ Rcstorc module to operation

~ Restore test switch Maintcnancc memo of 6/29/89 follow.up mcaiags with shops aot held. 5.6.7 is on the bottom of a page. Turn thc page for 5.6.8, which may bc out of Double signroff steps should have been sequence-or not rcquircd?

identilied in planning, but werc not.

The same function pnformcd in second "and" of $.6.7.

I i. JOB START fT, I2, Tech IandTech2tookout 2. ThC 2 add Tech 2 had a 4. Calibratioa steps corn P letcd 5. Tech I begins step 5.6.7 g. Tech 1 cominues step 5.6.7 t

. ccdhdioaadat

-52.4, "Control of Limiting problem understanding step ~~dIustments not required which contains three'steps t>i.m~dCT'~~ro Condrtrons for Opcraung 5.6. Unclear directions for L'~.Cs ibration ok. nncctcd by two "ands": ~drcstore module to " normal tep 5.6.3'f ihc procedure. operation aad rcstorc.

topped and discussed. Disconnca all calibration uipmcnt and rcstorc.

" Rcconnccts leads thea cvicwcd logic snd agreed to tdq indcpendenily verify tightness of! .

cch I dtseoaneas test all tcrminah.

g rocecd ast5.6.3.

'2 "w"~rr'~~~ ' ul meat .i Friday, November 17, 1989 I2t tep 5.6$ is rcdundart of middle J rtion of ste 5.6.7 (above).

drdxl$ w i(

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i Q9 pp hours 0"f>

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CP, adtddWTT IQ 17 hours1.967593e-4 days <br />0.00472 hours <br />2.810847e-5 weeks <br />6.4685e-6 months <br /> - atp~~@IIcqhtac fha ihi After Iulleh ":-* ': " ", ~ id ~ %$ 'k<R~e55'iN~hrv~M!Nw~:s fa I'<<Pare "+I0@ v rI O"'P For steps 5.6.0-5.6 6, Tech I During thc course of thc day' To "restore module" r cans to 409A and CP 410A arc done only once a year. was in Relay Room and Tech 2 work, Tech 2split his time rcconnca leads. Takes 3 I min.

in the Control Room? bctwcen tbc Relay Room and Checks tightncss of taminals.

CP 410A was originally schcdulcd for thc Control Room. Tech I Moves on to step 5.6.8 top of a spent thc entire day in thc new page. 5.6.8 stata "Connea Tcehs A & B, but they werc called away leads to pair terminals from Relay Room.

on another job. Tech I and Tech 2 took which they werc remcved.

over thc cart at approx. 09:00 hrs. Check tightncss of all terminals."

Ncithcr Tech I nor Tech 2 had done Wonders: Is 5.6.8 pate of "rcsiorc CPr4IOA before. g'ceh 2had done module to normal opemtion . It CPr409A ss part of 1989 Outage.) is possible to rcconrc.". and test Tcchs and plannns wnc trained on

'.6.3 "Hold thc voltage constant tiahtness of leads, sad skip ihe across pair terminal rrl third "and" of 5.6.7.

Foxboro Spec 200 rnodulcs by thc vendor. (approx. 4.5 VDC) snd incrcssc the voltage across pair terminal //3 until thc alarm The l&C Planner was not in that dsy.

actuates. Thc abrm is d low A backup planner handled thc p! arming. differential temp. alarm snd actuates when thc difference Brokea Intact t No "tsilgstcscssion" (discussion betwccn thc 2 voltages is Td 1.0 barrier barrier bctwcen pbnncr snd crew) wss held.

a volt =. I volt."

I 0

Switch func t called oui Switch was installed in I9S5 as patt of a modification for thc R&T for monthly HPES 90-01: "CP-410A Test Switch Not Retu in training. I&Ctraining stops at thc Spec 200 Icvcl. dNo training to reactor uip breaker testing.

'- conducted address thc unique RG&E herc NRC Inspection Report 50>>244/89-16 fcaturcs, such as the tnt switch, Switch is called diffcrcnt names by different d>>4J Violation Ol

'or how thcsc modilications affect plant groups..

thc'plani operation. a Test switch is not fail-safe.

System training for I&Ccovering T SAT (temperature differential Test switch is located near thc bottom of the I system) to include function of the rack-aot near thc equipment being scrviccd test switch was not done.

Test switch is noi considcrcd part of thc Spec 200 module for I&Cpurposes. ~Test switch lf Test switch is not direaly labeled. Of up to 20 modules in this rack, this is thc Procedure A-52;4 as written and as only loop with a test switch. practiced may bc unclear and open to imcrprmauon Thcrc are only 3 switches of this type in thc Switch is a unique Ginna Station entire plant. There are approximately 200 . Issues:

fcaturc. similar modules in the plant. Two tcchs arc rcquircd to sign ~ Who is rcsponsiblc?

THIS IS AN EXCEPTION. off thc A-52.4. ~ What is evcryonc rcsponsiblc for?

.,7, last part of step 5.6.7: Continued proccdurc through ~9. Tech 1: I calls I&CShoP. )>II.A 52.4 also signed off by: Ncw shift docs 8, 1 0, Tech S~tcp 5.95, a logical stopping ~3~eg i proccdurc 0.6.13.

>','" andrestoretestswitchto 9

wg:po>>t. >.'-.Oeans up job site. >. I,-jTceh 3 takes call. Hc goes -,"v>"Head Control Operator '

-g:. original position." i. - '.~a.'tothcControl Room and "-. '+Control Room Foreman Loop IB subcooling

,"; '+ signs off thc A-52.4. 4 indication pegged high.

j ga 'OT PERFORhIED!

~ dr~>>Tech 2 leaves for doctor' ~@~.'Returns to shop.

'= =~ Shift Supervisor aji iatmcnt.

off thc A-52.4. i '~NZIeclarcd A.~>.I "Ginna Station j~

.>>",>cGocs to Control Room to ,'. Tech I signs opcrablc at 15:00

~:::: ~I clear thc A-52.4 "Contro lof

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Possible intcrruptioa Tech 2 Tech 2 had been in and out of thc Tech 2 gone to doctor and A-52.4, step 3.9 for Good work practice not followed. I&CPlanner was contamcd returns to Relay Room? Control Room during thc day. unavailablc to sign off the verification of operabihty, at home. Hc knew about ihc A-52.4. was not pcrformcd correctly. Operations did not'check instru- test switch and surmised that

'ech I was ia thc Relay Room. f (Procedure statesi "if mentation in thc Control Room. it was the problem.

Procedure CPA IOA, step 5.6.7" ~nd rcstorc test operabihty of cquipmeat is Eatirc proccdme was not complctcd. not dcmonstratcd by switch to original position" was not pcrformcd. performing a PT, an operator Friday afternoon 3:00 p m.

Tech 2 was in thc Control Room willveriEy thc valve l>>c up, durino 5.7.4? Not sure. Howcvcr, switch and brcakcr position. ) Going into a wcckead.

Double vcriTication "with a hc de not check instrumentation double check to bc performed relating to steps in 5.6. Coming up on a shift change.

by Ihc person(s) performing Good work practice not the proccdurc" was not done. Tech 2did not do a walk@own Eol!owed.

inspection or check thc Coauol Step 5.6.7 was not slashed in Room instrumentation prior to I&Cdid not check instrumen-planning process per m<<mo leaving for his doctor's appointment.

'he tation in thc Control Room.

to indicate that double sigaeff is ncccssary. Good practices, (instrumentation check, walkdown, noting 'as Broken I Intact found'ad Tcchs werc not aware of this 'as is'onditions) were not barrier barrier d speciTic (double veri Iicatioa) followed.

suuation for step 5.6.7.

'