ML17309A458
| ML17309A458 | |
| Person / Time | |
|---|---|
| Site: | Ginna  |
| Issue date: | 03/08/1991 |
| From: | Mecredy R ROCHESTER GAS & ELECTRIC CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9103210167 | |
| Download: ML17309A458 (23) | |
Text
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t i REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
SSION NBR:9103210167 DOC.DATE: 91/03/08 NOTARIZED: YES DOCKET CIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH. NAME AUTHOR AFFILIATION MECREDY,R.C.
RECIP.NAME Rochester Gas l'lectric RECIPIENT AFFILIATION Corp.
Document Control Branch (Document Control Desk)
SUBJECT:
Responds to NRC 910208 ltr re violations noted in Insp,Rept
,50-244/90=31 on 901213-910103.Corrective a'ctions:dc distribution panel switch labels revised to clarify switch load/function & addi checklists will be developed.
DISTRIBUTION CODE: IEOID COPIES RECEIVED:LTR ENCL / SIZE: /3 TITLE: General (50 Dkt)-Insp Rept/Notice of Vio ation Response /
NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72). 05000244 RECIPIENT COPIES RECIPIENT COPIES D 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/TPAB 1 1 DEDRO 1 1 NRR MORISSEAU,D 1 1 NRR SHANKMAN,S 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1 NRR/DREP/PEPB9D 1 1 NRR/DRIS/DIR 1 1 NRR/DST/DIR 8E2 1 1 NRR/PMAS/ILRB12 1 1 NUDOCS-ABSTRACT 1 1 1 1 OGC/HDS1 1 1 RG FIL 02 1 1 RGN1 FILE 01 1 1 EXTERNAL: EGGG/BRYCE, J. H. 1 1 NRC PDR 1 1 NSIC 1 1 D
A D
D NOTE TO ALL "RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!
TOTAL NUMBER OF COPIES REQUIRED: LTTR 22 ENCL 22
I ROCHESTER GAS AND ELECTRIC CORPORATION ~ 89 EAST AVENUE, ROCHESTER N. Y. 14649-0001 ROBERT C MECREDY TELEPHONE Vice Precidenr AREA COOE 71B 646 2700 Cinna Nuclear Producrion March 8, 1991 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555
Subject:
Reply to a Notice of Violation NRC Inspection Report No. 50-244/90-31 R.E. Ginna Nuclear Power Plant NRC Docket No. 50-244
Dear Sir:
This letter is in response to the February 8, 1991 letter from Thomas T. Martin, Regional Administrator, to Robert E. Smith, Senior Vice President, Production and Engineering, which transmitted Notice of Violation from Inspection Report 90-31. In that letter, Violations A and B were identified. This letter provides the reply to the Notice of Violation, pursuant to 10 CFR 2.201.
RESTATEMENT OF VIOLATIONS:
During an NRC inspection conducted between December 13, 1990 and January 3, 1991, violations of NRC requirements were identified.
In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, (1990),
the particular violations are set forth below:
A. 10 CFR Part 50, Appendix B, Criterion VI, "Document Control,"
states in part, that measures shall be established to control the issuance of documents, such as procedures, including changes thereto, which prescribe all activities affecting quality. These measures shall assure that documents, including changes, are reviewed for adequacy.
9103210167 910308 PDR ADOCK 05000244
~~ j,Hi l.e ap U PDR
Contrary to the above, in March 1989, a procedure affecting quality, namely, Procedure M-48.14, "Isolation of Bus 14 Undervoltage System for Maintenance, Troubleshooting, Rework and Testing," was changed without an adequate review being performed. The specific change involved inclusion of a step in the procedure which allowed the disabling of Engineered Safety Feature Actuation System (ESFAS) instrumentation while the reactor was in any mode of operation,'ncluding power. The licensee's organizational measures for review, approval, and issuance of this procedure change, including the review by the Plant Operations Review Committee, did not assure that the change was adequately reviewed in that did not identify that implementation of the procedure change it in a mode other than cold shutdown condition would place the plant in a condition that was prohibited by Technical Specification 3.5.2.
B. Technical Specification 6.8.1 requires establishment of the applicable procedures recommended in Appendix "A" of Regulatory Guide 1.33, November 1972, (Safety Guide 33)
Appendix A,Section I, specifies that maintenance which can affect the performance of safety-related equipment should be properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances.
Contrary to the above, on December 12, 1990, the licensee failed to adequately preplan and perform corrective maintenance on the A emergency diesel generator undervoltage circuit card. Specifically, maintenance procedure M-48.14, "Isolation of Bus 14 Undervoltage System for Maintenance, Troubleshooting, Rework and Testing," was used to perform the corrective maintenance while the reactor was at 3 percent power during startup. Step 5.5.1 directed personnel to open DC circuit breakers for the A and B safeguards logic trains which disabled the automatic and manual (push button) sequencing of safeguards equipment. This step was both unnecessary to perform the required work and inappropriate for the circumstances as it disabled the safeguards sequencing function at a time prohibited by plant technical specifications. Additionally, use of M-48.14 proceeded despite indications that the procedure was inappropriate.
Those indications included labels on the DC breaker panels warning of the possible safety injection consequences and the initiation of alarm annunciator L-31, "Safeguards DC Bus Failure."
Violations A and B are classified in the aggregate at Severity Level III. (Supplement 1)
REPLY TO VIOLATION A:
THE REASONS FOR THE VIOLATION Rochester Gas and Electric (RG&E) concurs that the stated violation occurred. Procedure M-48.14 was changed in March 1989, without an adequate review being performed. There were two weaknesses in Ginna's procedure development and change policy, which resulted in a technically incorrect procedure being approved. As discussed by RG&E at the Enforcement Conference on January 29, 1991, these weaknesses occurred at the level of the "Responsible Manager" (RM) review, and in the lack of a multi-disciplinary review of the proposed change. In March 1989, the procedure development and change policy did not provide adequate guidance to an RM for . determining the operational impact of the proposed change. Consequently, the RM (using existing policy guidance) concluded that the proposed change was "minor" and did not have any operational impact, since the proposed change added a step that was deleted during the last revision.
Therefore, the RM did not require a multi-disciplinary review. The Plant Operations Review Committee (PORC),
acting on the recommendation of the RM, did not pursue this classification in sufficient detail and recommended approval of the proposed change.
- 2. THE CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED RG&E personnel, with active participation by senior management, performed a thorough investigation of the event, and promptly initiated extensive and comprehensive corrective actions. The Senior Vice President conducted a .series of meetings, with PORC members, procedure RMs and all operating shifts to communicate management expectations for maintaining a questioning attitude and the need for attention to detail.
All plant procedures were screened for their impact on operability of safeguards equipment, resulting in numerous procedures being placed in a restricted status, such that
.the procedure could not be used without further review (quarantined). The procedure development and change policy was revised to require an operational review of ALL proposed procedure changes, and a structured procedure review checklist was developed for this 'review. PORC and senior management reviewed the adequacy of these short term corrective actions, and Quality Performance department personnel performed an independent assessment of these actions. These actions were completed prior to startup of the plant.
A detailed list of short term corrective actions (all of which have been completed) is at Attachment 1.'umerous corrective actions that are considered long term have also been completed. These completed long term corrective actions are at Attachment 2.
Results of these actions assure a high level of detail and consistency during the performance of safety reviews. The need for a questioning attitude at all times has also been reinforced. A total of approximately 275 procedures were quarantined, and these procedures will remain unavailable for use until a thorough review for their operational impact has been performed. These actions have strengthened existing barriers (or created new barriers) within the procedure development and change policy, to assure that procedure changes are adequately reviewed.
THE CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS RG&E personnel have established a detailed corrective action plan to strengthen the procedure development and change policy. Personnel will be trained on the lessons learned from this event. There will be periodic assessments of the adequacy of the proposed corrective actions, and of their continuing effectiveness. Ongoing evaluations will provide opportunities for changes to or reinforcement of these actions. The role of the RM in the procedure review process will be clarified. See LER 90-017 and NRC Inspection Report 90-31 for additional discussions of these long term actions.
A detailed list of these proposed corrective actions, including the current scheduled completion date, is at .
THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance with 10 CFR Part 50, Appendix B, Criterion VI was achieved prior to December 20, 1990. By that date, procedure quarantine had been completed, and the procedure development and change policy had been formally changed to require an operational. review of all -proposed procedure changes.
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REPLY TO VIOLATION B.
- 1. THE REASONS FOR THE VIOLATION Rochester Gas and Electric .concurs that the stated violation
'occurred. A Human Performance Enhancement System (HPES) evaluation determined that the following were co'ntributing causes for the violation:
A. There was a lack of a formalized process for the operational review of work order packages.
B. Procedure M-48.14 was a PORC approved procedure and was considered correct by the Planner, Scheduler, and Control Room Foreman.
C. Procedure M-48.14 had been previously used by the Planner to successfully implement corrective maintenance.
(However, the plant was at cold shutdown in that instance.)
D. Confidence in the validity of the PORC approved M-48.14 and the Planner's stated previous experience implementing M-48.14 outweighed the Control Room Foreman's questioning attitude in his decision making to follow the procedure instructions.
In addition, other indications were inadequate in informing the operators that use of M-48.14 was inappropriate under these circumstances:
A. Switch labelling within the DC distribution panels lacked adequate information in describing the switch/load function.
B. Required Actions in Alarm Response Procedure AR-L-31, (Safeguards DC Bus Failure) were not comprehensive.
l THE CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED The following corrective steps have been taken to address the contributing causes:
A. RG&E has developed and implemented a detailed work package review requirement for Safety Re'lated and Safety Significant work. This includes work package reviews for technical adequacy, proper isolation/holds, operational impact, adequate testing, conformance to technical specifications and quality concerns. The Technical (Discipline) and Operational Reviews are performed utilizing a . detailed checklist to ensure consistency in the reviews.
B. Rochester Gas and Electric Senior Management has communicated ,their expectations for maintaining' questioning attitude and attention to detail to Operations Personnel, PORC Members, and Station "planning staffs.
C. Selected plant procedure groups were screened for their impact on operability of safeguards equipment. Those requiring changes or additional information were quarantined from use until the changes are completed.
A total of approximately 275 plant procedures were quarantined.
D. DC Distribution Panel switch labels were revised to clarify switch load/function.
E. Procedure AR-L-31 (Safeguards DC Bus Failure) was revised to incorporate enhanced Required Actions.
F. Operations management issued formal guidance to the operators, stating management expectations for work package review prior to release of equipment to maintenance.
A detailed list of short term corrective actions (all of which, have been completed) is at Attachment 1. Numerous corrective actions that are considered long term have also been completed. These completed long term corrective actions are at Attachment 2.
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3 ~ THE CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS Corrective steps that will be taken to avoid further violations are oriented toward strengthening barriers and a more formalized work package review and approval process.
Additional checklists will be developed for work package reviews performed by non-Maintenance personnel. A detailed list of these proposed corrective actions, including the current scheduled completion date, is at Attachment 3.
4 ~ THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance with Technical Specification 6.8.1 and Appendix "A" of Regulatory Guide 1.33, November 1972 occurred on December 20, 1991 with the implementation of the additional reviews for Safety Related and Safety Significant work packages.
Very truly yours, Robert C. Mec dy RCM dp Subscribed and sworn to before me Attach. (3) on this 8th day of March, 1991 xc: Mr. Thomas T. Martin Regional Administrator Region 1 475 Allendale Road King of Prussia, PA 19406 v'AMES C. McGUIRE NTAAYPUBUC, Stats of Nsat Yctft Thomas Moslak OuaFOIinhheos Carly MfCNtatfaahn Expha Osc.2tt, $ 9+4 USNRC Senior Resident Inspector Ginna Station 1503 Lake Road Ontario, NY 14519
Page No.'TTACHMENT 1 LIST OF SHORT TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)
ITEM DESCRIPTION OF THE ACTION, WHICH NUMBER WAS COMPLETED IN 1990.
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01 Senior Management to meet with all operating shifts (prior to startup except for one shift) to communicate management expectations for questioning attitude and attention to detail.
02 , Management to meet with the maintenance planning staff to communicate management expectations for questioning attitude and attention to detail.
03 Management to meet with PORC members and procedure "Responsible Managers" to communicate management expectations for questioning attitude and attention to detail.
04 Prepare and issue a more detailed operations policy on the importance of following through on procedure concerns.
05 Prepare and issue a policy for station planners on the importance of identifying operational consequences for planned activities involving safeguards equipment.
06 Involve the Operations shift in the development of corrective actions for the HPES on crew performance.
07 Perform preliminary HPES evaluation for the issue of crew performance.
08 Perform screening of all plant procedure categories, to determine which categories require review for quarantine.
09 Identify all current "M", "EM", and "CP" procedures that could involve safeguards manipulation, Tech. Spec.'concerns, or A-52.4 concerns.
10 Identify all other current plant procedures that could involve safeguards manipulation, Tech. Spec. concerns, or A-52.4 concerns.
Based on the results of screening performed, quarantine any proce'dures that meet for quarantining. the'riteria 12 Independent check of the identification of procedures for quarantining.
Establish interim policy for the review of infrequently used procedures as part of the work package planning process.
i4 Determine the previous uses of M-48.13 and M-48;14, and identify any other times they were used inappropriately.
15 Review AR procedures to ensure the appropriate level of significance is imparted, and the appropriate response to the annunciator is clearly stated.
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ATTACHMENT 1 LIST OF SHORT TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)
ITEM DESCRIPTION OF THE ACTION, WHICH NUMBER WAS COMPLETED IN 1990.
16 Revise those AR procedures that have significant deficiencies.
17 Upgrade labelling of the two DC distribution panels and two individual DC switches in the Main Control Board.
18 Determine any other AC or DC distribution panels in the Control Room that require operator / training awareness, and/or upgraded labelling.
19 Perform immediate read and acknowledge training on the functions of all DC switches, including SI-A1 and SI-B1, in, the 1A and 1B DC Distribution Panels.
20 Provide improved direction or additional requirements for operational and pre-PORC review of changes to procedures.
Review the specific training histories and operating experience of those operators directly involved in this event.
22 PORC review of the adequacy of short term corrective actions, and evaluation of readiness for plant startup.
23 Perform a senior management review of the adequacy of short term actions completed, prior to plant startup.
24 Initiate TCR for training on DC distribution panels in the Main Control Board.
25 Initiate TCR for long term training requirements.
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ATTACHMENT 2, LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990 AND ALREADY COMPLETED)
DESCRIPTION OF THE ACTION, WHICH ACTUAL HAS ALREADY BEEN COMPLETED COMPLETION DATE Evaluate the safety significance on accident 02/22/91 analyses, for both trains of SI initiation being disabled.
Perform complete HPES evaluation on the issue '01/28/91 of crew performance, and identify recommended
'corrective actions.
Determine the priority and schedule for the 02/04/91 corrective actions resulting from the HPES evaluation of crew performance.
Management to meet with any remaining 03/05/91 licensed operators, training staff, etc., as needed, to communicate management expectations for questioning attitude and attention to detail.
Conduct training on the planner policy 03/08/91 regarding the importance of identifying operational consequences for planned activities involving safeguards equipment.
Provide training on Operations policy 02/15/91 regarding Importance of following through on procedure concerns, and provide feedback to Operations management.
Perform Root Cause Analysis of the approval 01/28/91 and use of M-48.14 (the PCN process), and identify any failed barriers. Recommend corrective actions.
Perform Barrier Analysis on the work planning 01/28/91 process, and identify any failed barriers.
Recommend corrective actions.
Review recommended corrective actions from 02/04/91 the HPES evaluations, and develop a long term action plan to improve the process.
Review results of actions .taken, HPES 02/12/91 evaluations, and commitments from LERs90-015, 90-016, and 90-017, and add actions
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to this plan.
Prepare a detailed action plan for the review 02/04/91 and release of procedures from quarantine.
Notify the industry via NUCLEAR NETWORK of 01/11/91 this event.
Initiate long term improvements in the 01/16/91 requirements for review of Maintenance Work Order packages.
NSARB to review the adequacy of the long term 03/05/91 Corrective Action Plan.
Issue formal guidance to the operators for 01/29/91 management expectations for release of equipment to maintenance.
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ATTACHMENT 3 LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT-YET COMPLETED)
DESCRIPTION OF THE ACTION GROUP SCHEDULED ASSIGNED 'OMPLETION DATE Evaluate the impact of use of MAINT 05/01/91 M-48.13/.14 during power operations, for other Technical Specification concerns.
Establish a working group to OPER 06/30/91 perform task identification of infrequently performed operational activities.
Develop training for lessons TRN-SYSTEM 09/01/91 learned from this event.
For each Ginna "pre-PORC" group, SGP 07/01/91 establish a pre-PORC review checklist or review criteria'or review of procedures. (This should similar to the review criteria
-'e developed for the Operations.
group.)
Revise remaining AR procedures that OPER 03/31/91 have deficiencies.
Assess the adequacy of the OPER 12/01/91 administrative controls established as a result of the event..
Evaluate the training conducted for TRN-SYSTEM 10/14/91 changes to A-503 (Procedure Adherence), for possible weaknesses in that training.
Notify the NRC of RGRE's policy for PM-MGMT 04/01/91 declaration of an event, and of the requirement to notify the NRC, and to subsequently evaluate the need to notify the state and counties.
Evaluate the guidance in the GMNP-EP 05/01/91 Emergency Plan and EPIP's, for declaration of an event and/or notification to the NRC and state
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and counties, after the condit'ions for the event no longer exist.
Curriculum Committees to review the TRN-GINNA 07/01/91 LER's, HPES evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.
Curriculum Committees to review the TRN-MAINT 07/01/91 LER's, HPES evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.
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ATTACHMENT 3 LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDUL'ED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED
'DESCRIPTION OF THE ACTION GROUP SCHEDULED ASSIGNED COMPLETION DATE Curriculum Committees to review the TRN-SYSTEM 07/01/91 LER's, HPES evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.
Clarify the role of the Responsible SGP 04/01/91 Managers in the procedure review process,,to ensure that the distinction between "major" and "minor" changes is and that 10CFR50.59 consistently'pplied, "consequential" changes are properly evaluated.
Clarify the role of the Responsible SGP 04/01/91 Managers in the procedure review process, to ensure that accountability for the adequacy and accuracy of procedures is designated.
Revise procedure A-601 to clarify SGP 07/01/91 the role of the Responsible Managers, and provide reinforcement of management expectations to Responsible Managers and other appropriate personnel.
Consult with other utilities, to PM-MGMT 06/01/91 obtain information on how they accomplish similar activities.
Provide a plan to assure the GMNP-MGMT 04/01/91 of the long term 'dequacy corrective actions.
Perform a review of policies issued QC-ADMIN 05/01/91 (or procedures changed) as a result of this event, to ensure they are consistent with previously existing policies and/or procedures.
Incorporate the policies for long MAINT 05/01/91 term improvements in the Maintenance Work Order process into formal administrative controls.
Ensure formal guidance is OPER 07/01/91 incorporated into administrative procedures.
Ensure appropriate training is TRN-GINNA 09/01/91 conducted on the formal guidance incorporated into procedures.
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ATTACHMENT 3 LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED)
DESCRIPTION OF THE ACTION GROUP SCHEDULED ASSIGNED COMPLETION DATE Implement training to all TRN-GINNA 12/01/91 applicable portions of the nuclear organization.
Implement training to all TRN-MAINT 12/01/91 applicable portions of the nuclear organization.
Develop a policy for, the use or OPER 09/01/91 reference to procedures to respond to Annunciator alarms.
Conduct follow up evaluations on PM-MGMT 06/30/91 the effectiveness of the short term corrective actions.
Conduct effectiveness reviews of OAC 12/01/91 the long term corrective actions.
Determine the need for added PM-MGMT 01/01/92 reinforcement of the short term corrective actions.
NSARB to review the preliminary GMNP-MGMT 06/15/91 results of effectiveness reviews.
NSARB to review the final results GMNP-MGMT 01/01/92 of effectiveness reviews.
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