ML17310B448
| ML17310B448 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 07/15/1994 |
| From: | Beach A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | Stewart W ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR |
| References | |
| NUDOCS 9407250035 | |
| Download: ML17310B448 (23) | |
Text
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~(NUDOCS OFFSITE FACILITY)
REGULARLY INFORMATION DISTRIBUTI~SYSTEM
( RIDS )
DOCKET 05000528 05000529 05000530 ACCESSION NBR:9407250035 DOC.DATE: 94/07/15 NOTARIZED:
NO FACIL:STN-50-528 Palo Verde Nuclear Station, Unit 1, Arizona Publi STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona Publi STN-50-530 Palo Verde Nuclear Station, Unit 3, Arizona Publi AUTH.NAME AUTHOR AFFILIATION BEACH,A.B.
Region 4 (Post 820201)
RECIP.NAME RECIPIENT AFFILIATION STEWART,W.L.
Arizona Public Service Co. (formerly Arizona Nuclear Power P
R 05000528 05000529 05000530 NOTES:STANDARDIZED PLANT Standardized plant.
Standardized plant.
SUBJECT:
Summarizes 940708 mgt meeting w/util.in Arlington,TX re activities authorized by NRC licenses NPF-41,NPF-51 6 NPF-74 for plant. List of attendees encl.
DISTRIBUTION CODE:
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TITLE: Summary of Significant Meeting with Licensee (Part 50)
RECIPIENT ID CODE/NAME HOLIAN, B INTERNAL: AEOD/DSP/TPAB NRR/PMAS/ILRB NUDOCS-ABSTRACT IL 02 RG 4
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U NOTE TO ALL"RIDS" RECIPIENTS:
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UNITEDSTATES NUCLEAR REGULATORY COMMISS REGION IV 611 RYAN PLAZADRIVE, SUITE 400 ARLINGTON,TEXAS 76011.6064 JII 5 l994 Dockets:
50-528 50-529 50-530 Licenses:
NPF-41 NPF-51 NPF-74 Arizona Publ ic Servi ce Company ATTN:
William L. Stewart Executive Vice President, Nuclear P.O.
Box 53999
- Phoenix, Arizona 85072-3999
SUBJECT:
PUBLIC MEETING WITH ARIZONA PUBLIC SERVICE COMPANY (APS)
This refers to the management
- meeting, open to public observation, conducted on July 8, 1994, at the Region IV office in Arlington, Texas, concerning activities authorized by NRC Licenses NPF 41, NPF 51, and NPF 74 for the Palo Verde Nuclear Generating Station.
Attendees at the meeting are listed in Attachment,l to this letter.
The purpose of this meeting was to discuss the APS assessment of the reactor trip event which occurred in Palo Verde Unit 2 on Nay 28, 1994.
The reactor trip occurred after APS workers removed a relay in the wrong train of the engineered safety features actuation system and caused a valve to inadvertently open.
This allowed approximately 7000 gallons of borated water from the refueling water tank to flow into containment.
The water caused a
fault in an electrical penetration for a reactor coolant pump and a subsequent reactor trip.
This event was of concern to the NRC because of the personnel errors which led to removing the wrong relay and because of the time that it took the reactor operators to identify the source of the water.
In the meeting, your staff described the details of the event and the failures which occurred during the event.
Your staff's evaluation of the event appeared to be thorough and comprehensive.
Your staff's presentation of the information was beneficial for the NRC to obtain a more complete understanding the event.
The personnel weaknesses in communications, self-verification, teamwork practices, and the prejob briefing were discussed.
In addition, the management weaknesses in the corrective actions for the adverse trend in human performance, the lack of a communications
- standard, and the inconsistent understanding of the Sensitive Issues Manual were highlighted.
Your immediate and longer-term corrective actions as a result of this event appear to be appropriate.
It is notable that in this event a series of failures occurred, any one of which had it not occurred could have stopped the event from continuing.
The slides presented during the meeting are provided as Attachment 2 to 'this letter.
9407250035 940715 PDR ADOCK 05000528 P
Arizona Publ ic Servi ce Company Your staff also described the actions being taken to resolve the performance problems with the feedwater and steam bypass control valves which were evident during this event.
We encourage your staff to continue their efforts to complete the design work and implementation of the changes to reduce the number of operator actions which may be required during plant transients.
In accordance with 10 CfR 2.790 of the NRC's "Rules of Practice,"
a copy of this letter will be placed in the NRC's Public Document Room.
Should you have any questions concerning this matter, we will be pleased to discuss then with you.
Sincerely, Attachments:
1.
Attendance List 2.
Licensee Presentation A. Bill Beach, Director Division of Reactor Projects cc:
Arizona Corporation Commission ATTN:
Nr. Steve Olea 1200 W. Washington Street
- Phoenix, Arizona 85007 Southern California Edison Company ATTN:
T.
E. Oubre, Esq.
P.O.
Box 800
- Rosemead, California 91770 ABB Combustion Engineering Nuclear Power ATTN:
Charles B. Brinkman, Nanager Washington Nuclear Operations 12300 Twinbrook Parkway, Suite 330 Rockville, maryland 20852 Arizona Radiation Regulatory Agency ATTN:
Aubrey V. Godwin, Director 4814 South 40 Street
- Phoenix, Arizona 85040
Arizona Publ ic Servi ce Company Naricopa County Board of Supervisors ATTN:
Chairman 111 South Third Avenue
- Phoenix, Arizona 85003 Newman
- 8. Holtzinger, P.C.
ATTN:
Jack R.
- Newman, Esq.
1615 L Street, N.W., Suite 1000 Washington, D.C.
20036 Palo Verde Services ATTN:
Curtis Hoskins, Executive Vice President and Chief Operating Officer 2025 N. 3rd Street, Suite 220
- Phoenix, Arizona 85004 Akin, Gump, Strauss, Hauer and Feld El Paso Electric Company ATTN:
Roy P.
Lessey, Jr.,
Esq.
1333 New Hampshire Avenue, Suite 400 Washington, D.C.
20036 Arizona Public Service Company ATTN:
Angela K. Krainik, Nanager Nuclear Licensing P.O.
Box 52034
- Phoenix, Arizona 85072-2034
Arizona Publ ic Servi ce Company bcc to DUB (IE45) bcc distrib.
by RIV:
L. J. Callan DRSS-FIPB Branch Chief (DRP/F, WCFO)
RIV File Leah Tremper, OC/LFDCB, NS:
Resident Inspector HIS System Project Inspector (DRP/F, WCFO)
Branch Chief (DRP/TSS)
NNBB 4503 PI:DRP/F*
BJOlson df 7/
/94 "previous y concurre C:DRP/F*
HJWong 7/
/94 D:WCFO*
KEPerkins 7/
/94 D
RP A
ach 7/)5/94
Arizona Publ ic Service Company JUL 15 l994
'Jcc"to"DNB;(IE45) bcc distrib.
by RIV:
L. J. Callan DRSS-FIPB Branch Chief (DRP/F, WCFO)
RIV File Leah Tremper, OC/LFDCB, NS:
Resident Inspector NIS System Project Inspector (DRP/F, WCFO)
Branch Chief (DRP/TSS)
NNBB 4503 PI: DRP/F*
BJOlson;df 7/
/94
- pr evsous y concurre C: DRP/F*
HJWong 7/
/94 D:WCFO*
KEPerkins 7/
/94 D
RP A
ach 7/15/94
ATTACHNENT I ATTENDANCE LIST Arizona Publ ic Servi ce Com an J.
Levine, Vice President, Nuclear Production G. Overbeck, Assistant to Vice President, Nuclear Production D. Garchow, Director, Site Technical Support P. Wiley, Nanager, Unit 2 Operations A. Krainik, Nanager, Nuclear Licensing R. Huffman, Team Leader, Instrumentation and Controls G. Anderson, System Engineer, Instrumentation and Controls NRC Re ion IV J. Callan, Regional, Administrator B. Beach, Director, Division of Reactor Projects (DRP)
H. Wong, Chief, Project Branch F,
DRP A. HacDougall, Resident Inspector, DRP S. NcCrory, Licensing Examiner, Division of Reactor Safety NRC NRR L. Tran, Project Nanager Others F.
Gowers, Site Representative, El Paso Electric R. Henry, Site Representative, Salt River Project
ATTACHMENT 2 NRC - APS Management Meeting Unit 2 Containment Spray Event of May 28, 1994 July 8, 1994
Palo Verde Uriit2 May 28, 1994 Reactor Trip Event Timeline and Barrier Analysis Designation nn IKO. that this is for Train
'A'?tN ork0nlc planned
& reviewed 9?TN Pdority3 scheduled for 7tltN SFAS relay phcement was added to weekend byl&C Foreman tkie to unrehted problems iith RTSG, nenthly hst dehyed.
SCteam rcess cd lyork w'as pulled ahead duc to signiFicant..
narum ofcomponent
~
SC Tech 2 obtahcd test equip. &setup bench test in Shop for rehy WD. included Train 'B",
retest Iromfff SC Tcch1 reviewed W.O.
Oeveloped mmdset that workwas h Train"8'S
&CRS Mead withSC Tcch1 Mpamlcly Tain'A'& 'B'n same keyring ESFAS keys for both Train'A'
'8'are obtahedby SCTech1 Tcchs proceed to Train
'8'anel to begin work.
Kff1rcmwcd iran Tram '8 ESFAS cabinet SC Tcch1 lifted power leads to relay &chcckcd in the control room forany unusual response jvhual only) aLJ 9'Shtftremet
&tneei
,:,BFAS'::.
'workout.
- -
- paNd:::::::
schedule;:
CRS'obb'unsiSS.'"..
appil}vaf-;:.i-."
7 Discussed riced lo
- mhrimize adios
- statement Train
'A'IACNV2 sendceby la@ IP'R~bs assmeStA4V672
-"';:-:: w'asOOS;"::.'.:-;
SS &STA
- .on'%8-:::
- Valve position
- hrcfcatesopen
~.ueenerLrat"-'":-'-.,:
ekidbyOPS;=
-;=:&Ãbeou}-:-,
- ryarttjteedht}
- -.
- -ittaiintCSv Procedural steps to verifyproper tah &equipment (Removed h 2I94 revision)
PAGE 1 OF 2 Sensitive issues
.'tanual ret imposed by:
Maintenance Inadequate P~;
brief for signiTeance ofjob Tearmrork Practices Communkations Repeat backs betrieeu SC Tacks &Ops Sem checking vcnficatton Sensitive issues Ltanuat:
Communications ret imposedby Operations
. Repeat back between SC Tech d Ops Access contml ning individual keys forcachlrain S8 chechng verTieation CommunMions No verbal communicate n between SC Tech &Ops
f
Paio Verde Unit 2 May 28. 1994 Reactor Trip Event Timeiine and Barrier Analysis 0944 N4T 0952 1006 1007 k
abrmresprmse h cchm srrmp Arms',
1010 1016 102T 1035 10451104 1108 1109 1115 1130 1131 rr)
I O
CQ
~Q
~Cfmefch k Oeebbrcs plepbribg hl CCctbimet errtry
.S.G. sensing e
. f'mesfor faire STA not awaaof ESFAS vrorfrinprogress SS &STA COrtlollreL SSastsif as/bod//
tooted at spray't SS rfieds
'tC
&WC srrltrrtbbts cbectbd for tenfdecmasa crabrombt atevo CRS eries RP&~
ofirtecth mbteacoe-mmebt request hr tCO
- Oats COltrctiob 4 trebrmg Cn RCS& crrtmnt pbrbmetelb(humility tepntm sump levets) ERHA0$ used
.trCTfevef,,
Cpel6xs pribblfhcus is nab orrdorru as mort lhbffsorlce
~ PZff fevef
~ fiCS temp.
. $$ orltbdrd 4 hformed ottwlscfsrtyxt needs
~ Steam ft feed lfowmismatch
~ Charging ktdown flowmismrdch;
-BfS afams fbi'ctivity
-SESS Rexhropelbhr bttemptshfoci'rrtbmbt tgtting pbbef on plirrts
\\
l5xto RdNhg CRS rebabs hcoctmt ruomfcr sbhsof frat
~:-.
'SC,a-:
colbms!
frvet btrrm Erstit sump pNp h
riibW"
'frrm:;
CRS reported cntmnt spay isolated bbldotlb to ttS gbrrr 'll.
SESS lfrobba'oof so pfef Lbhrebtrrm rboerlbd.
- ttbst"
'vb tnw!
Arm" Q:.
cK RCP tSee
~.ffvehj4 y, rrerbrie:,':%steer
~,ove!
/
CO ED crs Commie'atiions.
SS intlpreted:
CRS response to.
mean cntmnt spray.
vlas mvestfrfated "
Ouestloning attrhde SS and STA t(W control board.'
'veview became Lloisture enters NELtA4pmwlathn endosure via unseafedbolt hole Page 2 of:2
~,,
II...;'
100 G d
L tlI\\ P 00 Grade Levei
Termination Enclosure Source ofWater Intrusion Ground Wire to Hub Connection
,A~W
~ rVJl+V
~
0
~
p Ground Wire Electrical Penetration Assembly Conductor Termination (Typ.) I g
)
5 0
0 Typical for 2E-NAN-Z441 and 2E-NAN-Z451
ause of Plant Tri
~ Moisture entered into the termination enclosure (attached to the RCP 1B electrical penetration) causing a phase to ground fault which resulted in loss of a RCP and a plant trip on DNBR
Root ause of the Event
~ Cognitive personnel error due to work performed on the wrong train
Weaknesses Personnel weaknesses
~ Communication practices
~ Self-verification practices
~ Teamwork practices
~ Pre-job briefing Management weaknesses
~ Corrective actions for adverse trend in human performance ineffective
~ Communication standards not formalized outside Ops
~ Inconsistent application of Sensitive Issues Manual
Corrective Actions Completed Actions
~ Management briefing on human performance and regulatory trends
~ Maintenance, Operations, and STA briefing
~ Formalized cross-discipline communication standard
~ Work control evaluation by cross-discipline task force
~ Key separated
~ Control of work training for leaders Ongoing Actions
~ Management follow-up with frontline
~ Industry events training briefing
Post Trip Issues
~ Termination enclosure damage
~ Equipment exposed to borated water
~ CEASES rod bottom light
~ Feedwater economizer valve
~ Steam bypass control valves