ML17306A784

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Forwards AIT Insp Rept 50-530/92-19 on 920508-14.Lists Three Points in Work Process Identified as Missed Opportunities to Prevent Loss of Plant Annunciator & Alarm Sys Event at Facility
ML17306A784
Person / Time
Site: Palo Verde Arizona Public Service icon.png
Issue date: 06/05/1992
From: Martin J
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To: Conway W
ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
Shared Package
ML17306A786 List:
References
NUDOCS 9206230124
Download: ML17306A784 (26)


See also: IR 05000530/1992019

Text

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Docket No. 50-530

License

No.

NPF-74

UNITED STATES

NUCLEAR REGULATORYCOMMISSION

REGION V

1450 MARIALANE

WALNUTCREEK, CAUFORNIA94596-5368

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Arizona Public Service

Comoany

P.O.

Box 53999, Station 9012

Phoenix, Arizona

85072-3999

Attention:

SUBJECT:

Nr.

W.

F.

Conway

Executive Vice President,

Nuclear

NRC INSPECTION REPORT 50-530/92-19

On Hay 8 - 14, 1992,

an

NRC Region

V Augmented Inspection

Team (AIT) conducted

an inspection at the Palo Verde Nucleat

Generating Station, Unit 3.

The AIT

examined activities authorized

by

NRC License

NPF-74.

At the conclusion of

the inspection,

on Hay .I4, the inspI.c.'rs

held

e discuss"'on of their findings

with you and members of your staff.ji identified in the en-:.;sod report.

Areas examin

d Outing the inspection

are identified in the report.

Within

these

areas,

the inspection consisted

of selective

examinations of procedures

and representative

records,

interviews with personnel,

and observations

by the

inspectors.

The AIT found that the event, the loss of plant annunciator

and alarm

systems

at Unit 3, could have been avoided.

Three points in the

work process

were identified as missed opportunities to prevent the

event:

1.

The work planner failed to review archived documents

as required

prior to issuing the work order.

As a result, the planner failed to

notice that the circuit breaker continuity check that initiated the

event

had been previously performed,

and that a repeat of the check

was not necessary.

2.

The work planner modified Engineering Department instructions,

which

originally asked for continuity checks

on spare breakers

only, to

require performing continuity checks

on active breakers,

without

obtaining Engineering review and concurrence for the instruction

modification.

3.

The electricians

implementing the work order disconnected

a lead,

an

action not specifically required by the work order.

The team observed that the programs

and procedures

governing non-safety

related maintenance

work apply equally to safety-related

maintenance.

The

team, therefore,

concluded that the findings noted

above could also

be

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applicable to safety-related

maintenance.

The team further concluded that

a

lack of intrusive supervisory

involvement in the initiation and performance of

routine, balance-of-plant electrical

work was

an underlying root cause of the

event,

common to each missed opportunity.

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In addition, the AIT found that the electricians failed to implement necessary

safety precautions for preventing accidental

equipment

damage.

Inadvertent

contact of the electrical

lead w>th. other. circuits would have been avoided

by

either (1) installing rubber or canvas

blankets

over the nearby 480 vac

electrical

bus work, or (2) exerting. positive controls to capture

and restrain.

the electrical

lead

upon di'sconnectson

from the terminal board.

The AIT found this failure to take adequate

safety precautions

to be of

particular note,

because

the resultant short circuit and ensuing

event. (1)

significantly degraded

-the Control

Room operators'bility to monitor plant

parameters

(2) impacted plant computer capabi,lity for automatic calculation

of plant safety limits, invoking license, requirements for reducing plant

power,

and (3) called. 1nto question the operability of the optical isolation

system,

which segregates

safety-related

and non-safety-related

devices.

Recent events at your faci.l.ity have occurred which,, at least partially, were

the result of poor practices in controlling work at Palo Verde.

These

include reactor trip breaker

maintenance

problems,

the lack of Senior Reactor

Operator coverage

during core alteratio>>:- at Uni.t 2,, and ",.'e Unit 3,

switchyard crane incj4~-than~-';,"erat'ed in a partial loss of offs.'.

p".'ver.

these events,

combined with the findings of this,AIT, raise serious

questions

regarding

the. effectiveness

of your programs for defining, performing,

and

controlling work with the potential for impact on plant safety.

Any enforcement action resulting from this inspection will be the topic of

separate

correspondence.

In accordance with 10 CFR Part 2.790 of the HRC's "Rules of Practice,"

a copy

of this letter and the enclosures will be placed in the

NRC Public Document

Room..

Should you have any questions

concerning this inspection,

we will be glad to

discuss

them with you.

Sincerely,

l

p~

a

Regional

Adminis

Encl osure:

Inspecti on Report 50-530/92-19

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II

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il

cc w/enclosure:

0. Hark DeMichele,

APS

J.

H. Levine,

APS

R. Stevens,

APS

.

S. Guthrie,

APS

E.

C.

Simpson,

APS

R.

W.

Page,

APS

T.

R. Bradish,

APS

J.

A. Boeletto,

Esq., Assistant Council, Southern California Edison

Company,

Rosemead,

CA

C.

B. Brinkman,

Combustion Engineering,

Inc.

C.

L. Hoskins,

El Paso Electric Company,

Phoenix,

AZ.

R.

P.

Lessey, Jr., Esq., Akin, Gump, Strauss,

Hauer,

and Feld

S. Olea, Chief Engineer,

Arizona Corporation

Commission

Al Gutterman,

Newman & Holtzinqer

S.

H. Olea, Chief Engineer,

ARszona Corporation

Commission

B.

M. Jones,

Esq., Akin, Gump, Strauss,

Haver,, and Feld

N.

C. Loftin Esq.,

Corporate Secretary

& Corporate

Counsel,

APS

J.

R.

Newman, Esq.,

Newman & Holtzinger P. C., Washington,

DC

M. A. Wright, Interim Acting Director

Arizona Radiation

Regulatory Agency (ARRA), Phoenix,

AZ.

Chairman,

Haricopa County Boar

fgupervisors,

Phoenix,

AZ

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Docket No.

50-530

License

No.

NPF-74

Arizona Public Service

Company

P.O.

Box 53999, Station

9012

Phoenix,

Arizona

85072-3999

Attention:

Mr. 'M.

F.

Conway

Executive Yice President,

'Nuclear

SUBJECT:

NRC INSPECTION

REPORT 50-530/92-19

On May 8 - 14',

1992,

an

NRC Region

Y Augmented Inspection

Team (AIT) conducted

an inspection at the Palo Yerde Nuclear Generating Station, Unit 3.

The AIT

examined activities authorized

by NRC 'License

NPF-74.

At the conclusion of

the inspection,

on May 14, the inspectors

held

a discussion

of our findings

with you and members of your staff identified in the enclosed

report.

Areas

examined during the inspection

are identified in the report.

Within

these

areas,

the inspection consisted of selective

examinations

of procedures

and representative

records,

interviews with personnel,

and observations

by the

inspectors.

The AIT found that the event,

the loss of plant annunciator

and alarm

systems at Unit 3, could have

been avoided.

Three points in the

work process

were identified as missed opportunities to have avoided the

event:

1.

The work planner failed to review archived

documents

as required

prior to issuing the work order.

As a result,

the .planner failed to

notice that the circuit breaker continuity check that initiated the

event

had been previously performed,

and that

a repeat

of. the check

was not necessary.

2.

The work planner modified Engineering

Department instructions,

which

originally asked for continu>ty checks

on spare

breakers .only, to

require performing continuity checks

on active breakers,

without

obtaining Engineering

review and concurrence for the instruction

modification.

3.

The electricians

implementing the work order disconnected

a lead,

an

action not specifically requ>red

by the work order.

The team concluded that

a lack of intrusive supervisory

involvement in the

initiation and performance of routine, balance-of-plant electrical

work was

an

underlying root cause of the event,

common to each missed opportunity.

In addition, the AIT found that the electricians failed to implement necessary

safety precautions

for preventinq accidental

equipment

damage.

Inadvertent

contact of the electrical

lead w>th other circuits would have

been avoided

by

II

ia.

0'

either

(1) installing rubber or canvas

blankets

over the nearby

480 vac

electrical

bus work, or (2) exertinq positive controls to capture

and restrain

the electrical

lead

upon disconnection

from the terminal board.

The AIT found this fai lure to take adequate

safety precautions

to be of

particular

note,

because

the resultant short circuit and ensuing event (1)

significantly degraded

the Control

Room operators'bility to monitor plant

parameters,

(2) impacted plant computer capability for automatic calculation

of plant safety limits, invoking license

requirements

for reducing plant

power,

and (3) called into question the operability of the optical isolation

system,

which segregates

safety-related

and non-safety-related

devices.

Recent events at your facility have occurred which, at least partially, were

the result of poor practices

in controlling work at Palo Verde.

These

include reactor trip breaker maintenance

problems,

the lack of Senior Reactor

Operator

coverage

during core alterations

at Unit 2,

and the Unit 3

switchyard crane incident that resulted in a partial loss of offsite power.

These events,

combined with the findings of this AIT, raise serious

questions

regarding the effectiveness

of your programs for defining, performing,

and

controlling work with the potential for impact on plant safety.

Any enforcement action resulting from this inspection will be the topic of

separate

correspondence.

In accordance

with 10 CFR Part 2.790 of the

NRC's "Rules of Practice,"

a copy

of this letter

and the enclosures will be placed in the

NRC Public Document

Room.

Should you have

any questions

concerning this inspection,

we will be glad to

discuss

them with you.

Sincerely,

J.

B. Martin

Regional Administrator

Enclosure:

Inspection

Report 50-530/92-19

bcc w/o enclosure:

LFMB (Licensee

Fee

Management

Branch)

bcc w/enclosure:

Region

V

J.

B. Martin, Regional Administrator

B. Faulkenberry,

Deputy Regional Administrator

M. Smith, Secretary,

Regional Administrator

G.

Cook, Regional

Public Affairs Officer

R.

Zimmerman, Director, Div. Radiation Safety

8 Projects

R. Scarano,

Director, Div. Radiation Safety

and Safeguards

S.

Richards,

Chief, Reactor Projects

Branch

L. Miller, Chief, Reactor Projects

Branch

0

~

i

0

cc w/enclosure:

0.

Mark DeMichele,

APS

J.

M. Levine,

APS

R. Stevens,

APS

S. Guthrie,

APS

E.

C. 'Simpson,

APS

R.

W.

Page,

APS

T.

R. Bradish,

APS

J.

A. Boeletto,

Esq., Assistant Council, Southern Cal.ifornia Edison

Company,

Rosemead,

CA

C.

B. Brinkman,

Combustion Engineering,

Inc.

C.

L. Hoskins,

El Paso Electric Company,

Phoenix,

AZ.

R.

P.

Lessey, Jr.,

Esq., Akin, Gump, .Strauss,

Hauer,

and Feld

S.

Olea, Chief Engineer,

Arizona Corporation

Commission

Al Gutterman,

Newman

8 Holtzinqer

S.

M. Olea, Chief Engineer,

ARizona Corporation

Commission

B.

W. Jones,

Esq., Akin, Gump, Strauss,

Hauer,

and

Feld'.

C. Loftin Esq.,

Corporate Secretary

8 Corporate

Counsel,

APS

J.

R.

Newman,

Esq.,

Newman

8 Holtzinger P. C., Washington,

DC

W; A. Wright, Interim Acting Director

Arizona Radiation

Regulatory

Agency (ARRA),. Phoenix,

AZ.

Chairman,

Maricopa County Board of Supervisors,

Phoenix,

AZ

il

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H. Mong, Chief, Projects

Section II, Div. Reactor Projects

B. Olson,

Palo Verde Project Inspector

Docket file

Resident

Inspector (4)

bcc w/enclosure:

James Taylor, Executive Director of Operations,

EDO

James

H. Sniezek,

Deputy Executive Director Nuclear Reactor Regulation,

Regional

Operations

8 Research,

OEDO

C. Calvo,

Region

V Contact,

OEDO

David A. Ward, Chairman,

Advisory Committee

on Reactor

Safeguards

(ACRS)

The Commissioners:

Ivan Selin,

Chairman

James

R. Curtiss

E. Gail

de Planque

Forrest J.

Remick

Kenneth

C.

Rogers

Charles Trammell,'II, Project Manager,

NRR

Alfred E. Chaffee,

Chief, Events

Assessment

Branch,

Div. Operational

Events

Assessment,

NRR

Document Control

Desk (Office of Information Resources

Management),

NRR

Thomas

E. Murley, Director,

NRR

F. J. Miraglia, Deputy Director,

NRR

J.

G. Partlow, Associate Director for Projects,

NRR

B.

A. Boger, Director, Div. Reactor

Projects--Regions III, IV, and V,

NRR

M. T. Russell,

Associate Director for Inspection

8 Technical

Assessment,

NRR

C.

E. Rossi, Director, Div. of Operational

Events

Assessment,

NRR

B.

K. Grimes,

Div. of Reactor Inspection

8 Safeguards,

NRR

J.

M.

Roe, Div. of Licensee

Performance

8 Quality Evaluation,

NRR

A.

C. Thadani,

Div. of Systems

Technology,

NRR

M. J. Virgilio, Assistant Director, Regions

IV 8

V Reactors,

NRR

J.

E. Richardson,

Director, Div. of Engineering Technology,

NRR

T.

R.

Quay, Director, Project Directorate

V,

NRR

Edward

L. Jordan,

Director,

AEOD

Denwood

F.

Ross,

Deputy Director,

AEOD

Director,

DRP, RI, II, III, IV

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bcc w/enclosure:

James

M. Taylor, Executive Director or Operations,

EDO

James

H. Sniezek,

Deputy Executive Director Nuclear Reactor Regulation,

Regional

Operations

8t Research,

OEDO

C. Calvo,

Region

V Contact,

OEDO

David A. Ward,

Chairman,

Advisory Committee

on Reactor

Safeguards

(ACRS)

The Commissioners:

Ivan Selin,

Chairman

James

R. Curtiss

E. Gail

de Planque

Forrest J.

Remick

Kenneth

C. Rogers

bcc w/enclosure:

Charles

Trammell, III, Project Hanager,

NRR

Alfred E. Chaffee,

Chief,

Events

Assessment

Branch, Div. Operational

Events Assessment,

NRR

Document Control

Desk (Office of Information Resources

Hanagement),

NRR

Thomas

E. Hurley, Director,

NRR

F. J. Hiraglia,

Deputy Director,

NRR

J..G.

Partlow, Associate Director for Projects,

NRR

B. A. Boger, Director, Div. Reactor Projects Regions III, IV, and V,

NRR

W. T. Russell,

Associate Director for Inspection

8 Technical

Assessment,

NRR

C.

E. Rossi, Director, Div. of Operational

Events

Assessment,

NRR

B. K. Grimes,

Div. of Reactor Inspection

8 Safeguards,

NRR

J.

W.

Roe, Div. of Licensee

Performance

8 guality Evaluation,

NRR

A. C. Thadani,

Div. of Systems

Technology,

NRR

H. J. Virgillo, Assistant Director,

Regions

IV 8

V Reactors,

NRR

J.

E. Richardson,

Director, Div. of Engineering Technology,

NRR

T.

R. quay, Director, Project Directorate

V,

NRR

Edward L. Jordan,

Director,

AEOD

Denwood

F.

Ross,

Dep t

Director,

AEOD

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bcc w/enclosure:

James

H. Taylor, Executive Director or Operations,

EDO

James

H. Sniezek,

Deputy Executive Director Nuclear Reactor Regulation,

Regional

Operations

& Research,

OEDO

C. Calvo,

Region

V Contact,

OEDO

David A. Ward,

Chairman,

Advisory Committee

on Reactor Safeguards

(ACRS)

The Commissioners:

Ivan Selin,

Chairman

James

R. Curtiss

E. Gail de Planque

Forrest J.

Remick

Kenneth

C. Rogers

bcc w/enclosure:

Charles

Trammell, III, Project Hanager,

NRR

Alfred E. Chaffee,

Chief,

Events

Assessment

.Branch,

Div. Operational

Events

Assessment,

NRR

Document Control

Desk (Office of Information Resources

Hanagement),

NRR

Thomas

E. Hurley, Director,

NRR

F. J. Hiraglia, Deputy Director,

NRR

J.

G. Partlow, Associate Director for Projects,

NRR

B. A. Boger, Director, Div. Reactor Projects Regions III, IV, and V,

NRR

W. T. Russell,

Associate Director for Inspection

8 Technical

Assessment,

NRR

C.

E. Rossi, Director, Div. of Operational

Events Assessment,

NRR

B. K. Grimes, Div. of Reactor Inspection

8 Safeguards,

NRR

J.

W.

Roe, Div. of Licensee

Performance

8 Quality Evaluation,

NRR

A. C. Thadani,

Div. of Systems

Technology,

NRR

H. J. Virgillo, Assistant Director, Regions

IV 8

V Reactors,

NRR

J.

E. Richardson,

Director, Div. of Engineering Technology,

NRR

T.

R.

Quay, Director, Project Directorate

V,

NRR

Edward L. Jordan,

Director,

AEOD

Denwood

F.

Ross,

Deputy Director,

AEOD

DKirsch

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bcc w/enclosure:

James

M. Taylor, Executive Director or Operations,

EDO

James

H. Sniezek,

Deputy Executive Director Nuclear Reactor Regulation,

Regional

Operations

5 Research,

OEDO

C. Calvo,

Region

Y Contact,

OEDO

David A. ward,

Chairman,

Advisory Committee

on Reactor

Safeguadds

(ACRS)

The Comm1ssioners:

Ivan Selin,

Chairman

James

R. Curtiss

E. Gail de Planque

Forrest J.

Remick

Kenneth

C. Rogers

bcc v/enclosure

Charles

Trammell, III, Progect

Manager,

NRR

Alfred E. Chaffee,

Chief, Events

Assessment

Branch, Div. Operational

Events Assessment,

NRR

Document Control Desk (Office of Information Resources

Management),

NRR

Thomas

E. Murley, Director,

NRR

F. J. Miraglia, Deputy Director,

NRR

J.

G. Partlow, Associate Director for Prospects,

NRR

B. A. Boger, Director, Div. Reactor .Pro]ects-Regions III, IV, and V,

NRR

M. T. Russell,

Associate Director for Inspection

8 Technical

Assessment,

HRR

C.

E, Rossi, Director, Div. of Operat1onal

Events .Assessment,

NRR

B. K. Grimes, Oiv. of Reactor -Inspection

8 Safeguards,

NRR

J ~

M. Roe

Div. of Licensee

Performance

5, Qual,ity Evaluation,

NRR

A. C, Thadani,

Div, of Systems

Technology,

NRR

M. J. Yirgillo, Assistant Director,

Regions

IY 5

'Y -Reactors,

NRR

J.

E, Richardson,

Director, Div. of Engineering Technology,

NRR

T.

R. Quay, D1rector, Project Directorate

Y,

NRR

.

Edward L. Jordan,

Director,

AEOD

Denwood

F. Ross,

Deputy Director,

AEOD

DKirsch

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bcc w/enclosure:

James

H. Taylor, Executive Director or Operations,

EDO

I

James

H, Sniezek,

Deputy Executive Director Nuclear Reactor Regulat1on,.

Regional

Operations

K Research,

OEDO

C. Calvo, Region

V Contact,

OEOO

David A. Mard, Chairman, Advisory Committee

on Reactor

Safeguards

(ACRS)

The Comoissioners:

Ivan Selin,

Chairman

James

R. Curtiss

E. Gail de Planque

Forrest J,

Remick

Kenneth

C, Rogers

bcc w/enclosure:

Charles

Trammell, III, Project Hanager,

NRR

Alfred E. Chaffee, Chief, Events Assessment

Branch, Div. Operational

Events Assessment,

NRR

Document Control Desk (Office of Information Resources

Hanagement),

NRR

Thomas

E, Hurley, Director,

NRR

F. J. Hiraglia, Deputy Director,

NRR

J.

G. Partlow, Associate Director for Projects,

NRR

B. A. Boger, Director, Div. Reactor Projects Regions Ill, IV, and

V,

NRR

M. T. Russell,

Associate Director for Inspection

5 Technical

Assessment,

NRR

C.

E. Rossi, Director, Div. of Operational

Events Assessment,

NRR

B. K. Grimes, Div. of Reactor Inspection

5 Safeguards,

NRR

J.

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Technology,

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T. R. quay, Director, Project Directorate

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Edward L. Jordan, Director,

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