ML17305A698
| ML17305A698 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 04/06/1990 |
| From: | Cillis M, Wenslawski F NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17305A696 | List: |
| References | |
| 50-528-90-18-EC, 50-529-90-18, 50-530-90-18, NUDOCS 9004230624 | |
| Download: ML17305A698 (24) | |
See also: IR 05000528/1990018
Text
U.
S.
NUCLEAR REGULATORY COMMISSION
REGION V
Report
Nos.
50-528/90-18,
50-529/90-18
and 50-530/90-18
License
Nos.
and
Licensee:
Arizona Nuclear
Power Project
P.
0.
Box 52034
Phoenix,
85072-2034
Facility Name
Palo Verde Nuclear Generating Station Units 1,
2 and
3
Meeting Location
Prepared
by:
NRC Region
V Office, Walnut Creek, California
>s,
en>or
a
>a
>on
pec>a is
a
e
cygne
Approved by:
ens
awsk>,
ef
Facilities Radiological Protection Section
Da
e
signed
An enforcement
conference
was held with ANPP management
personnel
(listed in
paragraph
1) to discuss
the apparent violations
as set forth in the Notice of
Violation, enclosed
herewith as Appendix A.
The violations included several
examples
of failure to control locked high radiation areas
and
one violation
involving the failure to follow locked high radiation area
key control
procedures.
The licensee's
assessment
of the violations and corrective
actions
taken to prevent
a recurrence
of the apparent violations described
in
Region
V Inspection
Reports
50-528/90-04
and 50-528/90-13,
were discussed
by
both the
NRC and licensee
(see
paragraphs
2 and 3).
Inspection procedure
30702
was addressed.
9004230624
90040r.
ADQCK C)5000528
G
DETAILS
Meetin
Partici ants
J.
B. Hartin, Regional Administrator
R.
A. Scarano,
Director, Division of Radiation Safety
and Safeguards
R.
P.
Zimmerman, Director, Division of Reactor Safety
and Projects
G.
P.
Yuhas,
Chief,
Emergency
Preparedness
and Radiological Protection
Branch
R.
G. Harsh, Director, Office of Investigations,
RV
S.
A. Richards,
Chief, Reactor Projects
Branch
A. 0. Johnson,
Enforcement Officer
F.
A. Wenslawski,
Chief, Facilities Radiological Protection Section
H. J.
Mong, Chief, Reactor Projects
Section II
T.
L. Chan, Project Manager,
NRR/P05
S.
R. Peterson,
Project Manager,
NRR/DRSP
0.
L. Solorio, General
Engineer,
NRR/DRIS
D.
Coe,
Palo Verde Senior Resident
Inspector
H. Cillis, Senior Radiation Specialist
0.
M. Kunihiro, State Liaison Officer
G.
N.
Cook, Public Affairs Officer
J.
Sloan,
Palo Verde Resident
Inspector
Arizona Nuclear
Power Pro'ect
M.
F.
Conway,
Executive Vice President
J.
H. Levine, Vice President,
Nuclear Production
J.
W. Bailey, Vice President,'uclear
Safety
and Licensing
P.
W.
Hughes,
General
Manager,
Radiation Protection
J.
S.
Summy,
I8C
EED Supervisor
M.
L. Hypse,
Lead Electrical
Engineer
Introduction
An enforcement
conference
was held on March 30,
1990, at the
NRC Region
V
office in Walnut Creek, California.
The purpose of the enforcement
conference
was to discuss
the facts
and circumstances
involving three
recent events at Palo Verde,
each of which appear
to be significant
violations of NRC requirements.
Three events
discussed
were the
unlocked,
unoccupied
and unguarded
(LHRA)
gates
in Unit 3 on November 6, 1989, in Unit 1 on November 9,
1989 and in
Unit 3 on February
22,
1990.
The third event discussed
also involved the
loss of LHRA key control which appeared
to be the root cause for the
opened
LHRA found at 10:05 p.m.,
MST,
on
February
22,
1990,
event at
Unit 3.
A summary of the discussion
for each event is provided below.
Control of Locked Hi
h Radiation Areas
Hr. Hartin opened
the discussions
by stating that it appeared
that Palo
Verde was having repetitive problems associated
with the control of very
Hr. Hartin added that corrective actions for a
similar occurrence
in September
of 1988,
and from two recent
occurrences
reported in November
1989 did not appear to be timely or effective in
preventing the events
described
in Inspection
Reports
50-528/90-04
and
50-528/90-13.
Mr. Wenslawski
then
summarized
the apparent violations that are described
in Appendix A, Notice of Violation.
The violations included
two unlocked
and unguarded
high radiation area (i.e.,
2000 mrem/hr at 18") events that
occurred in Unit 3 on November 6,
1989,
and in Unit 1 on November 9,1989.
Hr Wenslawski
added that these
two violations might have
been
avoided
with the timely implementation of corrective actions that were committed
to from a similar event that occurred in Unit 3 on September
8,
1988.
Also summarized
was another
unlocked
and unguarded
(i.e.,
2200 mrem/hr) that was
found in Unit 3 on February
22,
1990,
in
which the licensee's
radiation protection staff failed to follow locked
key control procedures.
Hr. Wenslawski
stated that
the February
22,
19900,
event
may have also
been avoided
had the
corrective actions resultinq from the November
1989 events
been
effectively implemented.
L>censee
representatives
indicated that they
had
no disagreement
that the violations occurred
as stated.
Both Hr.
Martin and Scarano
stated that Palo Verde's
performance for controlling
access
was unacceptable
and
was in need of
immediate
improvement.
The discussion
then continued to focus
on the question of timeliness;
in
that, the commitment of December
29,
1988, associated
with the
installation of new locksets
and pick plates
on gates/doors
providing
access
to locked high radiation areas (i.e., greater
than
1000 mrem/hr at
18") had not been completed
as of February
9,
1990.
The repair of
radiation monitoring system,
RR-29, multi-point chart recorders
was
another
example involving timeliness that was discussed,
whereby actions
to repair the
same recorders
in all three Units was not timely in that it
had taken over one year to perform the repairs.
The question related to
the adequacy of communications
and the establishment
of priorities for
accomplishing
long outstanding
work was also discussed.
The licensee's
presentation
described
ANPP's assessment
of the problems
and the planned corrective actions
as described
in their handout,
Attachment
2.
The Vice President,
Nuclear Production,
acknowledged
the
apparent violations that were
summarized
by Hr. Wenslawski.
He indicated
that the root cause for the
two events
reported in November of 1989,
were
probable
unauthorized
forced entries
and the root cause
for the February
22,
1990,
event
was failure of personnel
to follow approved
locked high
radiation area
key control procedures.
The Vice President,
Nuclear
Production,
stated that corrective actions following the November
1989
events
included:
A.
Prompt installation of chains
and padlocks
on all
gates/doors.
B.
Improved control procedures
(e.g.,
dual verification of LHRA
door closure).
C.
Special
locking mechanism modification was expedited (i.e.,
installation of new locksets
and pickplates) for all
LHRA gates
and doors).
Licensee
Event Report
(LER) 1-90-002-00 indicated
that the
new locking mechanism modifications
had been installed
on
33
of 35 gates/doors
in Units 1,
2 and
3 (by Narch
26,1990),
that were being controlled
as
LHRA's.
The Vice President
(VP) stated that the November
1989 events
could have
probably been
avoided with the timely installation of the locking
mechanisms
and pick plates if it had been
done promptly as
was committed
to following the
LHRA event of September
8,
1988.
The
VP indicated that
the February
22,
1990,
event
was clearly attributed to errors in
personnel
performance
and the the existence
of improved hardware
was
irrelevant to this event.
The licensee
stated that this event did
highlight the need to readdress
personnel
performance
in connection with
maintaining the integrity of LHRA's.
This was
done promptly with the
implementation of the following short term and long term corrective
actions:
A.
Additional instruction in key control requirements
was provided
to the radiation protection staff in all three Units.
B.
Appropriate disciplinary action
was taken.
C.
Procedures
for key control will be further enhanced.
This will
be accomplished
by April 15,
1990.
The licensee's
assessment
included
a comparison of the
LHRA events 'that
had been identified to date.
It was determined that the February
22,
1990, event was similar to the September
8, 1988,
event to the extent
that personnel,
either in disregard of, or based
on a misunderstanding
of
the requirements
violated administrative controls for LHRA.
The adequacy of the hardware
was evaluated
as
an extra measure
of
precaution against
inadvertent or unauthorized
entry after
the September
8, 1988,
event.
Installation of the improved hardware
on
gates/doors
did not appear
to be
a priority item until after the November
1989 events.
The hardware
improvements
were not tied into the February
22,
1990, event.
In conclusion,
the
VP stated that the
common thread
among the events
appears
to indicate that there
was
an inadequate
respect for the
administrative controls associated
with LHRA access
and control.
Based
on this evaluation,
ANPP has taken and/or will take the following
additional corrective actions:
A.
The site Radiation Protection
Manager
(RPH) has delineated
management's
expectations
to radiation protection personnel
regarding
work practices that control
access
to LHRA's.
B.
Each Unit RPN has instructed their respective
personnel
on
these
management
expectations.
C.
General
employee training will be evaluated
to ensure specific
emphasis
is placed
on the potential
hazards
and necessity for
control of radiation areas.
D.
An article will published within the site wide distributed
"New Era" in the May 1990 issue detailing the potential
hazards
and necessity
for control of radiation areas.
E.
A videotape will be produced to reenforce
management
expectations
and the potential
hazards
and necessity for
control of radiation areas.
This video will be required
viewing by May 1990, for all personnel
having access
to
radiologically controlled areas.
The next subject
addressed
was the sequence
of events
involving the
repair of the multi-point recorders.
The
VP stated that the reason for
the untimely repair of the recorders
was strict'ly a communication
problem.
The engineering evaluation report
(EER) requesting that the
recorders
be repaired
and subsequently
replaced with new recorders
did
not make it clear that the recorders
were in need of immediate repair.
Additionally, no emphasis
was placed
on repairing the recorders
since it
was
known that the minicomputer provided information similar to that
provided by the multi-point recorders.
The
VP stated that action was
taken to improve the communication
problem.
Actions taken included the
assignment
of a
new Engineering Vice President
and
an enhancement
of the
EER processing
procedures.
In addition
a design engineering
group is now
on site.
Action has
been taken to examine
and prioritize engineering
,items
and plant restart
items.
Each item is being carefully examined
as
to its importance.
The
VP added that the liaison between
the Nuclear
Engineering
Department
and Engineering Evaluation Department
had already
started to show
some signs of improvements.
Mr. Martin summarized
by indicating that there appeared
to be
no basic
disagreement
over the facts
and then closed the meeting
by reemphasizing
that
ANPP needed
to thoroughly assess
all aspects
of the events to ensure
that corrective actions
are timely, effective
and will eliminate
any
similar occurrences.
ENCLOSURE
/33
ATTACHMENT 2
NRC
ENFORCEMENT
CONFERENCE
WALNUT CREEK,
CA
MARCH 30,
1990
LOCKED HIGH RADIATION AREA (LHRA) EVENTS
RECENT
EVENTS
A.
LHRA GATES
FOUND
OPEN
AND UNGUARDED
(11/89)
1.
ROOT
CAUSE
PROBABLE UNAUTHORIZED FORCED
ENTRIES
2.
CORRECTIVE ACTION
A.
PROMPT INSTAI LATION OF CHAINS,
PADLOCKS,
AND PICKPLATES
e.
IMPROVED CONTROL PROCEDURES
(E.G.
DUAL VERIFICATION OF
DOOR
CLOSURE)
c.
SPECIAL LOCKING MECHANISM
MODIFICATION WAS EXPEDITED
B.
LHRA GATE
FOUND OPEN
AND UNGUARDED
(2/90)
1.
ROOT
CAUSE
FAILURE TO
FOLLOW APPROVED
LHRA KEY
CONTROL PROCEDURES
03/30/90
JML-1
LOCKED HIGH RADIATION AREA (LHRA) EVENTS
(CONTINUED)
RECENT
EVENTS
(CONTINUED)
2.
CORRECTIVE ACTIONS
A.
PROCEDURES
FOR
KEY CONTROL ARE
BEING FURTHER
ENHANCED (APRIL
15,
1990)
B.
ADDITIONAL INSTRUCTION IN KEY
CONTROL REQUIREMENTS
WAS
PROVIDED
c.
DISCIPLINARY ACTION
II.
SUMMARY OF
NOVEMBER 1989
AND FEBRUARY 1990
RECENT
EVENTS
A.
IN THE 11/89
EVENTS,
THE OPPORTUNITY
FOR
UNAUTHORIZED ENTRY MAY HAVE BEEN
MINIMIZED THROUGH HARDWARE IMPROVEMENTS
(THIS WAS DONE PROMPTLY)
B.
THE 2/90
EVENT IS CLEARLY ATTRIBUTED TO
ERRORS
IN PERSONNEL
PERFORMANCE.
THE
EXISTENCE OF
IMPROVED HARDWARE IS
IRRELEVANT TO THIS EVENT
C.
THE EVENT DID HIGHLIGHT THE NEED TO RE-
ADDRESS
PERSONNEL
PERFORMANCE IN
CONNECTION WITH MAINTAINING INTEGRITY Of
LHRA'S AND THIS WAS DONE PROMPTLY
03/30/90
JML-2
LOCKED HIGH RADIATION AREA (LHRA) EVENTS
(CONTINUED)
III.
RELATIONSHIP TO 9/88
EVENT
A.
B.
THE 2/90
EVENT IS SIMILAR TO THE 9/88
EVENT TO THE EXTENT THAT PERSONNEL,
EITHER IN DISREGARD OF,
OR BASED
ON
MISUNDERSTANDING OF REQUIREMENTS,
VIOLATED ADMINISTRATIVE CONTROLS
FOR
LHRA.
THE PRINCIPAL APS
RESPONSE
WAS
ENHANCED
TRAINING AND INSTRUCTION IN ADHERING TO
PROCEDURES.
THE ADEQUACY OF
HARDWARE WAS EVALUATED
AS AN EXTRA MEASURE OF PRECAUTION
AGAINST INADVERTENT OR UNAUTHORIZED
ENTRY AFTER THE 9/88
EVENT
THE HARDWARE DID NOT APPEAR TO
BE A
PRIORITY ITEM UNTIL THE 11/89
EVENTS,
AFTER WHICH IT WAS ADDRESSED IN TIMELY
FASHION.
THE HARDWARE IMPROVEMENTS WERE IN
NO WAY
TIED TO THE ESSENTIAL CAUSE
OF THE 2/90
EVENT.
03/30/90
JML-3
LOCKED HIGH RADIATION AREA (LHRA) EVENTS
(CONTINUED)
IV.
SUMMARY OF CORRECTIVE ACTIONS
IF THERE IS A COMMON THREAD AMONG THE
EVENTS,
APS BELIEVES THAT THESE
EVENTS
INDICATE AN INADEQUATE RESPECT
FOR THE
ADMINISTRATIVE CONTROLS ASSOCIATED WITH
LHRA ACCESS
AND CONTROL.
BASED
ON THIS BELIEF,
HAS TAKEN OR
WILL TAKE THE FOLLOWING ADDITIONAL
ACTIONS:
THE SITE
MANAGER HAS DELINEATED
MANAGEMENT'S EXPECTATIONS TO
PERSONNEL
REGARDING WORK PRACTICES
THAT CONTROL ACCESS
TO LHRA'S
EACH UNIT RP
MANAGER HAS INSTRUCTED
THEIR RESPECTIVE
PERSONNEL
ON
THESE
MANAGEMENT EXPECTATIONS
GENERAL EMPI OYEE TRAINING WILL BE
EVALUATED TO
ENSURE SPECIFIC
EMPHASIS IS PLACED
ON THE POTENTIAL
HAZARDS AND NECESSITY
FOR
CONTROL OF
RADIATION AREAS
03/30/90
LOCKED HIGH RADIATION AREA (LHRA) EVENTS
(CONTINUED)
IV.
SUMMARY OF CORRECTIVE ACTIONS (CONTINUED)
AN ARTICLE WILL BE WRITTEN AND
PUBLISHED WITHIN THE SITE WIDE
DISTRIBUTED "NEW ERA" IN THE MAY,
1990
ISSUE DETAILING THE POTENTIAL
HAZARDS AND NECESSITY
FOR
CONTROL OF
RADIATION AREAS
A VIDEOTAPE WILL BE
PRODUCED
TO RE-
ENFORCE
MANAGEMENT EXPECTATIONS AND
THE POTENTIAL HAZARDS AND NECESSITY
FOR
CONTROL OF RADIATION AREAS.
THIS VIDEO WILL BE REQUIRED VIEWING
BY MAY, 1990
FOR ALL PERSONNEL
HAVING ACCESS
TO THE
03/30/90
JML-5
MULTI-POINT RECORDER
SEQUENCE
OF ACTIONS
APRIL 1989 -
EER WRITTEN IDENTIFYING PROBLEM
IN OBTAINING SPARE
PARTS
JUNE 1989 -
EED UNSUCCESSFUL IN OBTAINING
REPLACEMENT PARTS
FROM
RMS SUPPLIER (ASI).
EER TRANSFERRED
TO NED WITH RECOMMENDATION
TO REPLACE
RECORDERS VIA DESIGN
CHANGE
PROCESS
DECEMBER 1989 -
NED
CONCURRED WITH EED
RECOMMENDATION AND REQUESTED THAT EED SUBMIT
DESIGN
CHANGE REQUEST
FOR
NEW RECORDER.
DESIGN
CHANGE REQUEST SUBMITTED
JANUARY 1990 -
EED
CONTACTED THE RECORDER
MANUFACTURER (ESTERLINE)
AND DISCOVERED
REBUILD/UPGRADE KIT WAS AVAILABLE.
RECORDERS
RETURNED TO ESTERLINE
FOR
REBUILD/UPGRADE.
DESIGN
CHANGE REQUEST
FOR
NEW. RECORDER
APPROVED
BY PMC
CONCURRENT WITH REBUILD/UPGRADE,
EVALUATION
AND QUALIFICATION OF
UPGRADED
RECORDERS
PERFORMED
FEBRUARY 1990 -
RECORDERS
RETURNED TO PVNGS.
RECORDER
INSTALLED IN UNIT 3.
RECORDERS
TO
BE INSTALLED IN UNITS 1 AND 2 AS
SOON
PRACTICAL DURING REFUELING OUTAGE
03/30/90
JNB-1
MULTI-POINT RECORDER
(CONTINUED)
II.
TIMELINESS OF ACTIONS
EER DID NOT MAKE IT CLEAR THAT RECORDERS
WERE IN NEED
OF IMMEDIATE REPAIR
WHEN RECORDERS
ARE INOPERABLE,
THE RADIATION
MONITORS ARE NOT AFFECTED AND THE ASSOCIATED
MINI-COMPUTER PROVIDED INFORMATION SIMILAR
TO THE RECORDERS
INITIALLYEED DID NOT REALIZE THAT RECORDERS
WERE INOPERABLE
INADEQUATE COMMUNICATION BETWEEN
EED AND NED
REGARDING RECORDER OPERABILITY CAUSED TIME
LAG
BASED
ON THE ABOVE,
EER WRITTEN IN APRIL,
1989
WAS ASSIGNED "NORMAL" PRIORITY
FOLLOWING DISCOVERY THAT REBUILD/UPGRADE
KITS WERE AVAILABLE, TIMELY ACTIONS WERE
TAKEN TO
RETURN
RECORDERS
TO SERVICE
03/30/90
JNB-2
I
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