ML17333A027
| ML17333A027 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 07/08/1998 |
| From: | Sampson J INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-315-98-08, 50-315-98-8, 50-316-98-08, 50-316-98-8, AEP:NRC:1285A, NUDOCS 9807150022 | |
| Download: ML17333A027 (16) | |
Text
CATEGORY REGUL ORY INFORMATION DISTRIBUTIO SYSTEM (RIDS)
ACCESSION NBR:9807150022 DOC.DATE: 98/07/08 NOTARIZED: YES
., DOCKET FACIL:50-315 Donald C.
Cook Nuclear Power Plant, Unit 1, Indiana M
05000315 50-,316 Donald C. Cook Nuclear Power Plant, Unit 2, Indiana M
05000316 AUTH.NAME AUTHOR AFFILIATION SAMPSON,J.R.
(formerly Indiana
&, Michigan Ele RECIP.NAME RECIPIENT AFFILIATION Records Management Branch (Document Control Desk)
SUBJECT:
Forwards response to violations noted in insp repts 50-315/98-08 5 50-316/98-08.Corrective actions:1 CD EDG bolts retorcgxed 6 jam nuts installed 6
1 AB & 2 CD EDG exhaust manifold support brackets inspected.
DISTRIBUTION CODE:
IE01D COPIES RECEIVED:LTR ENCL SIZE:
TITLE: General (50 Dkt)-Insp Rept/Notice of Violation Response NOTES:
E INTERNAL:
RECIPIENT ID CODE/NAME PD3-3 PD AEOD/SPD/RAB DEDRO NRR/DRCH/HOHB NRR/DRPM/PERB OE DIR RGN3 FILE 01 COPIES LTTR ENCL 1
1 1
1 1
1 1
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1 1
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1 RECIPIENT ID CODE/NAME STANG, J AEOD LE CENT R NRR DRPM PECB NUDOCS-ABSTRACT OGC/HDS3 COPIES LTTR ENCL 1
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0 EXTERNAL: LITCO BRYCE,J H NRC PDR 1
'1 1
1 NOAC NUDOCS FULLTEXT 1
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NOTE TO ALL "RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE. TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD)
ON EXTENSION 415-2083 TOTAL NUMBER OF COPIES REQUIRED:
LTTR 17 ENCL 17
4, Qr
indiana Michlga~-
Power Companylgg 500 Circle Drive Buchanan, Mi 49107,1395 INDIANA NICHICAN POWER July 8, 1998 AEP:NRC: 1285A Docket Nos.:
50-315 50-316 U.
S. Nuclear Regulatory Commission ATTN: Document Control Desk Mail Stop 0-Pl-17 Washington, D.C. 20555-0001 Gentlemen:
Donald C.
Cook Nucleax Plant Units 1 and 2
RESPONSE
TO NOTICE OF VIOLATION NRC INSPECTION REPORT NOS. 50-315/98008 (DRP)
AND 50-316/98008 (DRP)
This letter is in response to a letter from John A. Grobe, dated May 28,
- 1998, that forwarded a notice of violations.
The violations of NRC requirements were identified during a routine resident inspection concluded on April 27, 1998.
An extension for the submittal of this information to July 9,
- 1998, was previously granted.
The first violation involved a failure to follow procedure by contract maintenance workers.
The second violation involved inadequate root cause determination regarding the missing jam nuts.
The third violation involved the failure of the unit 2 operators to use a pxocedure designated as "continuous use" at the job site.
Our reply to these violations is provided in the attachment to this letter.
Sincerely, John R.
Sampson Site Vice President SWORN TO AND SUBSCRIBED BEFORE ME THIS~ DAY OF 1998 dLQ Notary Public My Commission Expires 4L lO
/vlb Attachment g~o'i 9807150022 980708 PDR ADGCK 05000315 8
U.S. Nuclear Regulatory Commission Page 2
AEP: NRC: 128 5A J. A. Abramson NDEQ -
DN fc RPD NRC Resident Inspector CD J. Paperiello
ATTACHMENT TO AEP:NRC: 1285A
RESPONSE
TO NOTICE OF VIOLATION NRC INSPECTION REPORT NOS. 50-315/98008 (DRP)
AND 50-316/98008 (DRP)
Attachment to AEP:NRC:1285A Page 1
During an NRC inspection conducted from March 13,
- 1998, to April 27,
- 1998, three violations of NRC requirements were identified.
In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions",
NUREG-1600, the violations are listed below.
NRC Violation No.
1 "Technical Specification 6.8.1
- requires, in part, that written procedures shall be established, implemented and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide (RG) 1.33, Revision 2, February 1978.
Regulatory, Guide 1.33, "Quality Assurance Program Requirements (Operation)," Revision 2, February 1978, Appendix A, recommended, in part, that maintenance that can affect the performance of safety-related equipment should be properly pre-planned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances.
Job Order C18424 was written in accordance with RG 1.33 to provide instructions for installing minor modification (MM) -438 on the 1 CD emergency diesel generator.
Contrary to the above, on April 24, 1998, the inspectors determined that in March 1997, contract workers failed to properly implement a maintenance procedure for safety-related equipment in that they installed MM-438 on the 1
CD emergency diesel generator and improperly reinstalled the exhaust manifold bracket without the jam nuts as required by Job Order C18424.
This is a Severity Level IV violation (Supplement I)
.'es onse to NRC Violation No.
1 A mission or Deni l f Alle ed Violation 2.
Indiana Michigan Power Company admits to a violation of the requirements of 10 CFR 50, Appendix B, as discussed below.
R a n
r Violatio The cause for this violation is an inadequate procedure, in this case a job order activity (JOA).
Investigation into this violation determined that the bolts and jam nuts were properly installed and verified by quality control (QC) when the exhaust manifold bracket was installed under MM-438.
Documentation from the QC inspection supports this conclusion, as do interviews with personnel involved in the installation of the minor modification.
The installation of the bracket was completed by one shift of
- workers, and the job turned over to the oncoming shift to reinstall the insulation cover.
The JOA used by the first shift was written to provide only general instructions on how to install the exhaust manifold bracket.
It provided QC hold points to verify'orque on the bolts for the bracket, and the final installed configuration of the bracket.
After QC verified the final installed configuration, the only additional directions the job order
Attachment to AEP:NRC:1285A Page 2
configuration, the only additional directions the job order provided were related to welding end plates on the insulation cover.
No direction was given pertinent to reinstallation of the cover itself.
This cover will only slide into place if the exhaust manifold support bracket bolts are oriented in a specific manner.
The bolts and jam nuts were apparently removed and reoriented to allow for installation of the cover.
Zt is thought that because no specific directions appeared in the JOA for reinstallation of the cover, and the relieving shift was not present when the bolts were torqued and the QC inspections took place, the cover was reinstalled after the bolts were reoriented, without the jam nuts being installed, and without a request for QC verification.
3.
Corrective Actions Taken and Results Achieved The 1
CD EDG bolts were retorqued and jam nuts were installed.
The 1 AB and 2
CD EDG exhaust manifold support brackets were inspected and it was verified that the jam nuts were installed.
The problem with the 1
CD EDG was originally discovered due to the failure of the exhaust manifold bracket on the 2 AB EDG on October 19, 1997.
A new, heavier duty bracket was installed on 2 AB EDG under DCP-861 on.October 28, 1997.
4.
Corrective Actions To Avoid Further Violations The job order package for the installation of the exhaust manifold bracket was prepared in 1994 and the work was actually performed in 1997.
Since the time that the JOA was
- prepared, the installation services (IS) department planning section has developed a guideline, ZSPG.001, "Installation Services Planning Guideline", for the preparation of JOAs.
The guideline
- contains, in part, direction that each JOA contain any pertinent cautions and limitations, and specific steps for any unique requirements to document data or'nformation.
This violation will be discussed with the ZS planners as a specific example emphasizing the need to have required information in the job order package.
This discussion will be completed by July 14, 1998.
5.
Dt en 11Cml n
Wi'1BeA ived Full compliance was achieved when the 1
CD EDG exhaust manifold bracket bolts and jam nuts were properly installed and QC verified on October 23, 1997.
Vi1 i o2
<10 CFR Pazt 50, Appondix B, Criterion XVZ, requires, in part, that measures shall be established to assure that conditions adverse to quality are promptly identified and corrected, and that 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.
The identification of the significant condition adverse to
- quality, the cause of the
Attachment to ABP:NRC:1285A Page 3
condition, and the corrective action taken shall be documented and reported to appropriate levels of 'management.
Contrary to the above, on April 24, 1998, the inspectors identified that the licensee's final investigation report of the missing jam nuts on the 1
CD emergency diesel generator, a significant condition adverse to quality, did not document the cause of the missing jam nuts.
This is a Severity Level IV violation (Supplement I)."
Res onse to NRC Violation No.
2 Admission or Denial of Alle ed Violation Indiana Michigan Power Company admits to the violation as cited in the NRC notice of violation.
2 ~
Reason for Violation The root cause of this event was poor work practices, resulting in a failure to follow the procedure governing the performance of root cause investigations 12-PMP 7030.INV.001, "Condition Investigations and Approvals".
This event illustrates a failure to fully implement the procedural requirement to determine a root cause and provide preventive actions that would preclude recurrence of the identified condition. The evaluator of the original condition did not pursue the investigation to the depth necessary to determine a root cause because of a lack of information.
Several potential root causes were identified, but information was not available to definitely support any one of the causes and rule out the others.
The supervisor and evaluator chose to address the issues for which a definitive conclusion could be reached.
As a result, a cause was chosen that was actually an effect rather than a root cause.
During the review and approval
- process, the evaluator's supervisor failed to ensure that the investigation was sufficient to determine the root cause.
- Thus, supervisory methods contributed to a
failure to meet procedural requirements.
Because neither the evaluation or the review defined the root cause, preventive actions for the root cause were never established.
3.
Corre tive Actions Taken and Re ults Achieved The root cause of the missing jam nuts was determined.
The results of that. investigation have been provided in our response to notice of violation" no.
1 of this inspection
- report, as have the corrective and preventive actions.
In addition to the corrective
- actions, a review will be performed of a sample of investigations from the responsible chain of command that received the same level of review and approval to determine if a trend exists.
If a trend is found to exist, appropriate actions will be taken.
This review will be performed by September 30, 1998.
Attachment to AEP:NRC:1285A Page 4
Corrective Actions Taken To Avoid Further Violations A lessons learned memo will be transmitted to investigators and individuals with approval authority within the nuclear organization.
The memo will describe the failure modes associated with the original investigation, why the barriers broke down, and the resultant impact on the organization.
Zt will stress the requirement of the corrective action program for development of preventive actions for significant conditions adverse to quality.
This memo will be issued by August 31, 1998.
A revised standard will be developed for performance of root cause analysis that will define the quality attributes associated with efficient and effective condition report investigations, corrective actions, and preventive actions.
Those standards will be communicated to condition report investigators and approval authorities.
Performance indicators will be developed to gauge the quality of those condition report attributes by December 31, 1998.
5.
Date When Full Com liance Will Be Achieved Full compliance was achieved on June 23,
- 1998, when the condition report investigation for the missing jam nuts, with root cause and appropriate preventive actions, was approved by the plant nuclear safety review committee.
NRC Violation No.
3 "Technical Specification 6.8.1
- requires, in part, that written procedures shall be established, implemented and maintained covering the applicable procedures recommended in Appendix A of RG 1.33, Revision 2, February 1978.
Regulatory Guide
- 1. 33,
"{}uality Assurance Program Requirements (Operation)," Revision 2, February 1978, Appendix A, recommended, in
- part, that administrative procedures covering procedure adherence be written.
Plant Manager's Instruction (PMZ)
- 2011, Revision 4,
"Procedure Use and Adherence,"
was written in accordance with RG 1.33.
Step 4.1.3 of PMZ-2011, required that for procedures designated as "Continuous Use," the procedure shall be in use at the job site.
Contrary to the above, on April 26, 1998, the inspectors determined that the Unit 2 Operations Head Procedure 4021.001.001, Revision 20, ~Plant Heatup From Cold Shutdown to Hot Standby," designated as "Continuous Use,"
was being used to maintain the plant in Cold
- Shutdown, but tho procoduro was not in use at the job site as required by PMI-2011, Revision 4, "Procedure Use and Adherence,"
stop 4.1.3.
This is a Severity Level IV violation (Supplement I)."
0
Attachment to ABP:NRC:1285A Page 5
Res onse to NRC Violation No.
3 Admission or Denial of Alle ed Violation Zndiana Michigan Power Company admits to the violation as cited in the NRC notice of violation.
Reason for Violation The investigation revealed that procedure 02-OHP 4021. 001. 001, "Plant Heatup From Cold Shutdown to Hot Standby,"
was originally entered on December 29,
- 1997, with the last signoff "for a
step performed made on December 30, 1997.
At the time a
mode 4 entry date of January 3,
- 1998, had been established for unit 1, and for unit 2 a mode 4 entry date of January 11, 1998.
Containment closeout tours had been scheduled for January 3,
1998.
- However, in early January several new issues arose that ultimately delayed startup further.
OHZ-4012, "Conduct of Operations (Shift Turnover) ",
establishes the shift turnover checklist log as a primary tool in the turnover for shift supervisor, assistant shift supervisors, unit supervisors, shift technical advisors, and reactor operators.
The log provides a
header entry for "procedures in progress", -under which the heatup procedure would be noted upon entry into the procedure.
A search of the files maintained for this log show that the heatup procedure was added to the log sheet on December 29,
- 1997, although it was entered under "unit load conditions", rather than "procedures in progress".
This entry was maintained on the log until late January.
A random check of log sheets was made for the period between the last entry and the early hours of April 27,
- 1998, when the inspectors questioned the unit 2 control room personnel.
The entry did not appear on those log sheets, which were checked.
It could not be determined why the entry was not maintained on the log sheet.
Failure to maintain the entry is attributable to ineffective written communication.
The heatup procedure is a
"continuous use" procedure, required to be in use in accordance with the requirements of PMI-2011, "Procedure Use and Adherence."
At some point after January 29,
- 1998, the heatup procedure was removed from the work surface of the unit supervisor's desk and placed in a file folder on the back of the desk.
Zt could not be determined on what date this occurred or why the procedure was placed in the file folder.
The unexpected delay in startup coupled with emphasis on good housekeeping practices could have provided the motivation for its removal.
Failure to maintain the procedure in accordance with the requirements of PMZ-2011 is attributable to poor work practices.
Zt is the responsibility of the shift managers and assistant shift supervisors to ensure that turnover responsibilities are properly performed and that turnovers are thorough and complete.
Both are required to review the turnover sheets on a shiftly basis.
However, the omission of the continuous use heatup procedure was not noted.
Failure to ensure that the turnover log sheet was correct is attributable to lack of adequate supervisory oversight.
0
+4
Attachment to AEP:NRC:1285A Page 6
3:
Corrective Actions Taken and Results Achieved
'nit 2
was verified to be in compliance with the current version. of 02-OHP 4021.001.001.
As 'the procedure was no longer needed to address current plant conditions, the working copy of the procedure was completed and closed out.
The cooldown procedure, 02-OHP 4021.001.004, was subsequently entered and the procedure was properly entered on the shift turnover checklist log.
Corrective Actions Taken to Avoid Further Violations Administrative controls will be enhanced to formalize a
checklist of reviews to be
- made, and other actions to be taken by the oncoming shift as part of the shift turnover process. 'he action to make changes to written guidance and incorporate this checklist is part of the operations department restart readiness review, and will be completed by September 1,
1998.
Formal training on this.violation will be provided to licensed operators by September 30, 1998.
The training will include the following aspects.
~
Procedures in progress or open. are to be listed on the shift turnover checklist log.
This includes general operating procedures, such as plant heatup and cooldown procedures.
~
Requirements for "continuous use" will be reviewed as related to this specific violation.
The need for strengthened supervisory oversight will be discussed by the operations manager or operations assistant manager in upcoming shift manager meetings.
This will be completed by September 1,
1998.
Date When Full Com liance Will Be Achieved Full compliance was achieved on April 27,
- 1998, with the verification of unit status in relation to 02-OHP 4021.001.001, "Plant He tup From Cold Shutdown to Hot Standby," the closeout of that procedure, and the initiation of the cooldown procedure, 02-OHP 4021.001.004, "Plant Cooldown from Hot Standby to Cold Shutdown".