ML17299B199
| ML17299B199 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 03/25/1986 |
| From: | Van Brunt E ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR |
| To: | Chaffee A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| Shared Package | |
| ML17299B198 | List: |
| References | |
| ANPP-35699-EEVB, NUDOCS 8604210101 | |
| Download: ML17299B199 (19) | |
Text
RECclggq Arizona Nuclear Power Project P.O. BOX 52034
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PHOENIX, ARIZONA85072-2034 6+ mac Qgpg pt t
~<patch 25, 1986
'AIPP~I3$699-EEVB/JYM Mr. A. E. Chaffee U.S. Nuclear Regulatory Commission Region V
1450 Maria Lane, Suite 210 Walnut Creek, CA 94596-5638
Subject:
Palo Verde Nuclear Generating Station (PVNGS)
Units 1 and 2
Docket Nos.,STN 50-528 (License No. NPF&1)
STN 50-529 (License No. NPF-46)
Notice of Violation, 50-529/86-02&1 File:
86-019-026 '6-056-026 Re ferences.
a)
Letter from A.
E.
- Chaffee, NRC, to E.
E.
Van Brunt, Jr.,
- ANPP, dated February 21, 1986.
Subject:
NRC Inspection Report 56-528/86-02; 50-529/86-02.
b)
Letter from E.
E.
Van Brunt, Jr./JYM, ANPP, to J.
B. Martin,
- NRC, dated March 3,
- 1986, ANPP-35365.
Subject:
Notice of Violation, 50-528/85-43-01, 50-528/85-43-03.
c)
Letter from J.
B. Martin, NRC, to E. E.
Van Brunt, Jr.,
- ANPP, dated January 30, 1986.
Subject:
NRC Inspection Report 50-528/85-43; 50-529/85-44.
d)
Letter from E.
E.
Van
- Brunt, Jr./SGB,
- ANPP, to NRC dated February 10,
- 1986, ANPP-34971.
Subject:
Licensee Event Report Supplement 85-002&01.
Dear Mr. Chaffee:
This letter is provided in response to the inspection, conducted by Messrs'.
Zimmerman, C.
Bosted and G. Fiorelli of the NRC staff on December 27,
- 1985, through February 2,
1986, of activities authorized by NRC Licenses No.
NPF-41 and NPF-46, Reference a).
Based on the results of the inspection, an Instrument and Control testing error violation was identified by NRC.,
The violation is discussed in Appendix A of Reference a) which is provided herein as Attachment 1.
The ANPP response to this violation is submitted herein as Attachment 2.
Attachment 2
also addresses similar Instrument and Control testing concerns identified in Reference c).
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Mr. A. E. Chaffee Notice of Violation, 50-529/86-02-01 ANPP-35699
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Should you have any questions concerning this matter, please contact me.
Very truly yours, E. E.
Van Brunt, Jr.
Executive Vice President Project Director EEVB/JYH/dk Attachments cc.
A. C. Gehr (all w/a)
R. P.
Zimmerman E. A. Licitra
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ATTACHMENT 1 APPENDIX A NOTlCE OF VIOLATION Arizona Nuclear Power Project Post Office Box 21666 Phoenix, Arizona 85036 Docket No. 50-529 License No. NPF-46 As a result of the inspection conducted on December 27, 1985 - February 2,
- 1986, and in accordance with NRC Enforcement Policy, 10 CFR Part 2, Appendix C, the following violation was identified:
10 CFR 50, Appendix B, Criterion XVI, Corrective Action states in part "Measures shall be established to assure that conditions adverse to quality.... 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.
Technical Specification 6.8.1 requires in part, that written procedures be established, implemented and maintained covering the activities referenced in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.
Paragraph 9.(e) of this guide includes general procedures for the conduct of operations in the list of typical safety related activities that should be covered by wiitten procedures.
PVNGS procedure 36ST-9SQ01 Revision 2, dated April 27, 1985, contains an instruction in paragraph 8.2.1.2 which requires the monitor under test to be bypassed prior to testing.
Contrary to the above on January 24, 1986, the containment purge radiation detection monitor RU-37 was tested while the channel was in an unbypassed mode resulting in an inadvertent actuation of the Containment Purge Isolation System and a cross trip of the Cont'rol Room Emergency Ventilation System.
The test actually called for the fuel building radiation detector monitor RU-31 to be tested.
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Effective corrective actions to preclude repetition of such errors was not implemented as this represents a similar incident as those documented in 'lRC inspection report 529/85-44.
This is a Severity level IV Violation (Supplement I)
Pursuant to the provisions of 10 CFR 2.201, Arizona Public Service Company is hereby required to submit to this office within thirty days of the date of this Notice, a written statement or explanation in reply, including: (1) the corrective steps which have been taken and the results achieved; (2) corrective steps which will be taken to avoid further items of noncompliance; and (3) the date when full compliance will achieved.
Consideration may be given to extending your response time for o
cause FE8 2i. ]986 Dated F. Miller Jr.,
ief eactor Proj ec ion No.
2
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ATTACHMENT 2
RESPONSE
TO VIOLATION 50-529/86-02-01 CLARIFICATION OF FACTS Contrary to PVNGS procedure, radiation monitor RU-37 was tested while the channel was not in the bypassed mode.
As further described in NRC inspection report 50-528/86-02; 50-529/86-02, an Instrument
& Control (I&C) Technician inadvertently tested the containment purge radiation detection monitor RU-37 function'nstead of the fuel building radiation detection monitor RU-31 function.
Since, the control room staff had been advised that the test would involve RU-31 and the related channel had been
- bypassed, the inadvertent testing of RU-37 caused an actuation of the containment purge isolation system and a cross trip of the control room emergency ventilation system.
Reference c) discusses six incidents (one from Unit 1 and five from Unit 2, provided in Attachment
- 3) involving instrumentation and control maintenance and testing.
ANPP concurs
- that, from a general programmatic perspective of the need for corrective action to preclude repetition of personnel
- errors, five of the six incidents are similar to the violation.
- However, the Unit 2 incident, item 5) of Attachment 3,
was the result of equipment malfunction as discussed in reference d).
In addition, the incident occurred on December 13,
- 1985, as opposed to the November 19, 1985, date mentioned in the 50-528/85-43; 50-529/85-44 inspection report.
Also, following the 50-528/85-43; 50-529/85-44 and 50-528/86-02; 50-529/86-02 reporting period, troubleshooting commenced on the Unit 1 Pressurizer Relief Valve Monitoring System without the proper work document to authorize the work. It was requested, during an NRC Exit Meeting on March ll, 1986, that ANPP address this incident.
ANPP concurs that this incident is similar to the violation and the five incidents discussed in Attachment 3.
The following corrective steps are intended to address these concerns.
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ATTACHMENT 2 CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND RESULTS ACHIEVED Personnel errors of any kind are undesirable.
Industry data,
- however, shows that they do occur and that I&C personnel typically account for approximately 13X of human performance problems.
Due to the numbers of I&C technicians (150) onsite, first of a kind plant, and complexity of I&C equipment, ANPP I&C management anticipated that personnel errors would occur and in September,
- 1985, implemented a Quality Improvement Report (QIR) process.
The functions of the QIR process are to document and communicate improvements/corrective actions to prevent occurrence or recurrence of undesirable events/activities.
The Quality Improvement Reports contain the following information:
(1) description of undesirable event/activity; (2) the cause both direct and contributory; (3) improvements/corrective actions to prevent occurrence or recurrence; (4) designation of the individual(s) tasked with responsibility to implement the improvement/corrective action and the corresponding date the implemen'tation is due; (5) designation of the individual(s) responsible to verify implementation of the improvements/corrective actions.
A conscious effort has been made to ensure the lessons learned in one unit (i.e.,
Unit 1,
2, or 3) are incorporated site~ide through the improvements/corrective actions delineated in the QIRs.
I.
Generic Issues Eleven QIRs were issued during the time period from the commencement of the program in September,
- 1985, to December 31, 1985.
Five QIRs have been issued during the time period from January 1, 1986, to March 5, 1986.
Although this is an ongoing
- process, examples of the resolutions of individual QIRs are as follows:
Surveillance test procedure enhancements:
1 a)
The specificity of the independent verification instructions and signmff steps for restoration of instrument valves was increased.
I b)
The method for documentation of measuring and test equipment utilization was improved.
c)
A tabular listing of calibration source strengths and certification dates for radiation monitor calibrations has been implemented.
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ATTACHMENT 2 2)
Corrective and preventive maintenance work order enhancements:
a)
The work order instructions for capping of instrument lines has been made more specific.
b)
A more detailed checklist 'for review of completed work has been developed.
c)
An improved method for documentation of measuring and test equipment utilization has been developed.
d)
A specific sign-off instruction step for verification of equipment/instrument number prior to commencement of work has been added.
e)
The specificity of the independent verification instructions and sign-off steps for restoration of instrument valves was increased.
3)
Additional enhancements made were:
a)
Counseling of each technician involved in the unexpected event.
b)
Training of I&C technicians on the specifics of the unexpected event.
II.
S ecific Violation Relative to corrective steps and results achieved concerning the specific incident noted in the notice of violation, 529/862-01, the I&C technician involved in the incident on January 24,
- 1986, had previously been involved in a similar incident.
As a result of the January 24,
- 1986, incident, the I&C technician has been temporarily restricted to non~uality related work and disciplinary action has been administered.
ATTACHMENT 2 CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FURTHER ITEMS OF NONCOMPLIANCE I.
Generic Issues The personnel error incidents were previously evaluated individually.
In addition to the individual evaluation, each unexpected incident and QIR was evaluated collectively to identify commonalities.
The findings from this evaluation were:
The personnel errors were made by both utility and contract I&C technicians with no particular relationship to the technician's
- training, experience or job performance
- level, working schedule/shift, or familiarity with the specific test/work performed.
2)
The content of the procedure or work order instructions was adequately detailed to facilitate safe and correct job perf ormance.
- However, as s ta ted
- above, enhancements to provide additional detail or precautionary instructions were recognized and implemented.
3)
In most incidents, the technicians were attempting to perform their work activity in an expedited manner.
The technicians were not being pressured to work expediently by supervision but rather were aware of the importance of their work completion towards Pro ject goals and were sincerely motivated to accomplish their work to illustrate their technical capabilities.
A QIR (ICQIR 86-01) was issued to specifically address the importance of correct and concise performance as opposed to expedient performance.
In addition to the QIR process:
The I&C Maintenance Superintendent conducted presentations during the last week in February, to each I&C work group, stressing the importance of safe and quality performance of work performed at ANPP.
Additionally, a
memorandum was issued to each technician emphasizing management's direction to perform work with meticulous attention to detail and, if unsure of any action, to stop and resolve the concern and then commence work.
2)
Specific corrective actions delineated in QIRs have been communicated by memorandum to the site Training Department.
Many of the corrective actions are baaed upon implementing technical work practices/concepts.
Inclusion of these work practices/
concepts into I&C training
- courses, when appropriate, should provide substantial benefits towards the objective of preventing personnel errors.
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ATTACHMENT 2
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3)
Development and implementation of a prework assignment checklist.
The checklist will be utilized by the work group supervisor and the I&C technician to ensure a thorough work document review and gob briefing are performed by the supervisor and technician immediately prior to commencement of work.
ATTACHMENT 2
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DATE FULL COMPLIANCE WILL BE ACHIEVED Full compliance, to address the specific violation, the five generic errors identified in the Inspection Report 50-528/85-43; 50-529/85-44 including the incident discussed in the NRC exit meeting, was achieved on March 5,
- 1986, through
- 1) the QIR process,
- 2) presentations to I&C work group stressing the importance of safe and quality performance of all work performed at ANPP, and 3) a memorandum to each technician emphasizing management 's direction to perform work with meticulous attention to detail.
The following additional actions are intended to enhance the I&C Maintenance Program:
(a)
Development and implementation of the prework assignment checklist.
Implementation of the checklist will be completed by March 31, 1986.
The checklist will be evaluated, as to its effectiveness, and a
subsequent decision to maintain, revise, or delete the checklist will be made by no later than July 1, 1986; (b) Incorporate into the I&C training program the appropriate lessons learned from the specific violation, the five generic errors identified in the Inspection Report 50-528/85-43; 50-529/85%4 and the incident discussed in the NRC exit meeting into the I&C Training Program.
Completion date for this item is August 31, 1986.
ATTACHMENT 3 INSTRUMENTATION AND CONTROL ACTIVITIES UNITS 1 AND 2 Unit 1 On December 13, at approximately 4:20 P.M.,'n inadvertent safety injection and containment isolation initiation occurred at Unit 1.
Based on the inspector's preliminary
- review, this resulted when an I&C technician apparently did not follow the procedure in performing 36ST-9SB02, "Plant Protective System Functional Test" and had two channels in test simultaneously.
Unit 2 During the inspection period, five errors were committed at Unit 2 during the execution of I&C maintenance.
The first four occurred prior to the issuance of the Unit 2 operating license and involved:
- 1) the actuation of the Control Room Emergency Filtration System when an I&C technician inadvertently allowed a jumper lead to contact the terminal board of the "B" train Balance of Plant Engineered Safety Features Actuation System (BOP ESFAS) causing the system to operate on November 20, 1985; 2) the release of residual C02 from the C02 fire system line when a technician failed to close a local valve required by the procedure prior to testing a fire protection panel in the "A" Vital Switchgear Room on November 25, 1985;
- 3) a technician inadvertently worked on an emergency diesel switch different from the one identified on his work order causing an alarm in the Control Room on November 25, 1985; 4) a technician caused the actuation of the "B" train Control Room Emergency Filtration Actuation Signal (CREFAS) when contrary to procedure, work was initiated on the control unit prior to placing it in bypass on November 23, 1985; and 5)
The fifth error which occurred following the issuance of the Unit 2 license involved the actuation of the "B" train CREFAS on November 19,
- 1985, when an I&C technician began 'troubleshooting the system prior to having it placed in bypass.
The troubleshooting was started prior to the issuance of the work request authorizing the work and which contained an instruction to bypass the unit.
The root
- causes, which resulted in the above errors committed during I&C maintenance and testing, will receive further inspection and are considered an unresolved item pending completion of the inspector's review (529/85-44-01).