ML17342A972

LER 87-024-00:on 870913,nonlicensed Person Manipulated Reactor Controls Under Supervision of Licensed Operator. Caused by Personnel Error.Personnel Counseled & Memo Explaining 10CFR50.54 Requirements issued.W/871013 Ltr

ML17342A972
Person / Time
Site:	Turkey Point
Issue date:	10/13/1987
From:	Salamon G, Woody C FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
L-87-411, LER-87-024, LER-87-24, NUDOCS 8710160316
Download: ML17342A972 (7)

Text

REGUi ATORY 'RM*TlQN DISTRIBUTION SYS I (BIDS)

• CCESSION NBR: 8710160316.: DOC. DATE: 87/10/13 NOTARIZED: NO DOCKET N FACIL: 50-250 Tur keg Point Planti Unit Si Florida Power and Light C 05000250 AUTH. NAME AUTHOR AFFILIATION SALAMONi G. Florida Power 5 Light Co.

MOODY'. O. Florida Poeer 5 Light Co.

RECIP. NAME REC IP IENT AFFILIATION

SUBJECT:

LER 87-024-00: on 870913. non licensed person manipulated reactor controls under supervision of licensed operator.

Caused,bg personnel error. Personnel counseled 5 memo explaining 10CFR50. 54 requirements issued. W/871013 itr.

DISTRIBUTION CODE: IE22D COPIES RECEIVED: LTR ENCL SIZE:

TITLE: 50. 73 Licensee Event Report (LER)i Incident Rpti etc.

NOTES:

RECIPIENT COf IES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1 1 McDONAl Di D 1 INTERNAL: *CRS MI CHELSON 1 1 ACRS MOELLER AEOD/DOA 1 *EOD/DSP/NAS 1 AEOD/DSP/ROAH 2 2 AEOD/DSP/TPAB 1 1 ARM/DCTS/DAH DEDRO 1 NRR/DEST/ADS 1- 0 NRR/DEST/CEB 1 1 NRR/DEST/ELB 1 NRR/DEST/ I CSB 1

'1 NRR/DEST/MEH 1 1 NRR/DEST/MTB 1 NRR/DEST/PSH 1 1 NRR/DEST/RSB 1 NRR/DEBT/SGH 1 NRR/DLPG/HFB 1 1 NRR/DLPG/GAB 1 NRR/DOE*/EAB 1 NRR/DREP/RAB 1 1 NRR/DREP/RPB 2 2

/SIB 1 1 NRR/PMAS/ILRB 1 1 R G I 02 1 1 RES DEPY GI 1 1 ELFORDi J 1 1 RES/DE/EIB 1 1 RGN2 F I LE 01 1 1 EXTERNAL: EGKG GRQHi M H ST LOBBY WARD 1 1 LPDR 1 NRC PDR 1 1 NSIC HARRIS' 1 NSIC MAYST G 1 TOTAL NUMBER OF COPIES REQUIRED: LTTR 45 ENCL 44

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NRB Form 355 U.S. NUCLEAR REOULATORY COMMISSION I()03)

APPROVED OMS NO. 3)EOO(04 EXPIRES: 5/3(/SS LICENSEE EVENT REPORT {LERI FACILITY NAME (I) DOCKET NUMBER (2) PA Turkey Point Unit 3 o s o o o 250 1 OF04 eac or on ro s anipu a e y a on- icense erson n er e grec upervssion of a Licensed Operator .

EVENT DATE (5) LER NUMBER (5) REPORT DATE (7) OTHER FACILITIES INVOLVED (SI MONTH OAY YEAR YEAR g~e SSQVENTIAL N'j OAY YEAR FAC(LITY NAMES DOCKET NUMBER(SI iiS> NUMSSrt NVMSStt MONTH N/A 0 5 0 0 0 0 9 1 3 7 8 7 024 0 0 1 0 1 3 8 7 0 5 0 0 0 OPERATINO THIS REPORT IS SUBMITTED PURSUANT TO THE REOUIREMENTS OF 10 CFR (I: (Cnecc one or more of me follorvinp/ (11)

MODE (Sl 20A02(rr I 73.71(II I 20AOS(cl 50.73(el (21 (iv)

POWER 20AOSI ~ )(I III) 50.35(c) III 50.734) 121(vl 73.71(el LEYEL 0 3 0 20AOSI ~ ) ill(SI 50.35(c) (2 I 50.73(el(2)(vS) OTHER /Spec/fy in Aptrrect rrefow end in Tent, Hire form 20.405( ~ ) I) l(i(ll 50.73(e) (2)D) 50.73(e) (2) IN(I)IAI 3BBAI 20.4054) II I(rv) 50,73(eH2)(S) 50.73(el(2) Iv(5) (Sl Voluntary Report 20.4051 ~ l(1) (vl 50.73(e I (21(lrl) 50.73(e I (2)(c)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE Gabe Salamon, Compliance Engineer -

3 0 2 4 6 6 5 6 0 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE OESCRI ~ ED IN THIS REPORT (13)

MANVFAC. REPORTABLE MANUFAC. EPORTABLE CAUSE SYSTEM COMPONENT TO NPROS s~A)~pj)~j~~)I@ CAUSE SYSTEM COMPONENT TURER TVRER TO NoROS NaÃMgk.~XI(r%%

SUPPLEMENTAL REPORT EXPECTED (14I MONTH OAY vEAR EXPECTED SUBMISSION DATE (15)

YES fifyer, comp/ere EXPECTED SVBM/$$ /ON OATEI X NO ABSTRACT (Limir IO tcor) rpetet, I e., epprpeimerery fifteen tinpie rpeCe rypevrrrrmn iieet/ (I ~ I On September '13, 1987, at 0300, with Unit 3 at 30X power, a non-licensed person under the direct supervision of a Reactor Control Operator (RCO), turned the Reactor Control Hake-up Switch to Start on two occasions.

This resulted in a 30 gallon, then a 20 gallon dilution of the Reactor Coolant System (RCS). At this time, a flux map was being run.

Negative reactivity was being added due to Xenon buildup. In order to minimize flux distortion,. control rod motion was being minimized, and to counter the negative reactivity addition, the RCS was being diluted.

The RCO directly supervised both dilutions. No other manipulations were made by the non-licensed person. The cause of the non-licensed person manipulating a control was personnel error, in that the RCO failed to comply with the requirements of 10CFR50.54(i) and 10CFR55.3.

Contributing to the event were inadequate procedures and training on the requirements of 10CFR50.54(i) and 10CFR55.3. The Plant Supervisor-Nuclear (PSN) counseled the RCO and the non-licensed person. The PSN discussed the event at the shift turnover meeting. A memo explaining the requirements of 10CFR50.54(i) was issued. All license'd'perators have been required to read and sign the memo prior to assuming shift responsibility. Additional corrective actions will be taken upon evaluation of the results of ongoing investigations.

8710),60316 870000+50 PDR ADOCK 0 PDR 8

NRC Form 355 (9 53)

NRC Form 3$ SA 1043) US. NUCLEAR REGULATORY COMMISSION LICENSEE EVEN EPORT ILER) TEXT CONTINUATION APPROVED OMS NO 3)50M)04 EXPIAESI S/31/ES FACILITV NAME (I)

DOCKET NUMSER (3)

LER NUMBER (S) PAGE (3)

VEAR :+~~< SEQUENTIAL I4 REVISION ISR/I NUMSER .re NVMSER Turkey Point Unit TEXT ///more aoecele n /rr/rerL Iree 3

/I/orrr/IVRCForrrr JS//A3/()T) o 6 o o o .50 024 0 0 2 OF 0 4 On September 13 1987, at approximately 0300, with Unit 3 at 30X power, a person under the direct supervision of a licensed operator, turned 'on-licensed the Reactor Control Make-up Switch to Start on two occasions in close succession.

The first occasion resulted in" a 30 gallon dilution of the Reactor Coolant System (RCS), and the second occasion resulted in a 20 gallon dilution. At the time of the event, a 30X power flux map was being run. As a result of Xenon buildup, negative reactivity was being added. In order to minimize flux distortion, control rod motion was being minimized, and to counter the negative reactivity addition, boron was being removed by diluting the RCS. The dilution was being performed by adding preset quantities of water to the RCS'eriodically. During this event, the Reactor Control Operator (RCO) preset the water quantity to 30 gallons, then permitted a non-licensed person to turn the Reactor Control Make-up Switch to the Start position. The system response to the 30 gallon dilution was not sufficient, and the above evolution was repeated with the water quantity preset by the RCO to 20 gallons. The RCO directly supervised both dilutions. No other manipulations were made by the non-licensed person.

CAUSE OF EUENT A thorough investigation was performed independently by both the plant Quality Assurance department and the Operations department. The investigations were performed. by personnel interviews, review of documents, personnel statements, notes, and reports of management personnel who had been on shift. The investigations had the following main goals:

a) review the timeliness of management actions b) determine if this was an isolated event c) review for potential reportability d) determine existing procedural requirements addressing this event e) determine training performed on this 10CFR50.54(i) and 10CFR55.3 requirement The investigations concluded that the cause of the non-licensed person manipulating con ro which directly affected the reactivity of the reactor was personnel a control error, in that the RCO failed to comply with the requirements of 10CFR50.54(i) an d 10CFR55.3.. Contributing to the absence of a full understanding of regulatory requirements were the following:

1) p lant an procedures pr c and training did not detail the requirements of 10CFR50.54(i) and 10CFR55.3,

2) plant procedures were not revised to address the revision of 10CFR55.3 which became effective in May, 1987

3) no training which addressed the revisions of 10CFR55.3 was performed.

NRC FORM 30OA

'S@3)

US. NUCLEAR REGULATORY COMMISSION NRC Form 36EA (93) LICFNSEE EVEN EPORT HLER) TEXT CONTINUATION APPROVFO OMB NO, 3)SOM104 EXPIRES: 8/31/88 OOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

FACILITY NAME (I)

YEAR SQdr SEQUENTIAL 8'EVISION NUMSER ?riQ NUMSER 0 2 0 3 oF 0 4 Turkey Point Unit 3 o s o o o TEXT ///moro d/IOOO /d drrrr'OrE ooo od/r//O'O/ro///RC Forrrr 388AB/ (IT)

ANALYSIS OF EVENT While the manipulation of controls, as defined in 10CFR50.54(i) and 10CFR55.3, were performed by a non-licensed person under the direct supervision of the RCO, this action did not result in any operation of the unit outside of normal parameters.

The evolutions performed by the non-licensed person were controlled and directly supervised by the RCO. Even though as a result of this event there were no safety consequences, the event represents a violation of regulatory requirements. This event is not a reportable event under either 10CFR50.?2 or 10CFR50.73. However, Florida Power and Light is voluntarily submitting this Licensee Event Report because of the generic concerns and lessons to be learned, in addition to the safety significance of this'vent.

CORRECTIVE ACTIONS Turkey Point has in place a Management on Shift program, the aim of which is to observe and improve Turkey Point s operation. 'he manipulation cited in this event was observed by the management on shift at that time. The Operations Supervisor was. notified of this event the following morning (September 14), and the Operations Superintendent and Plant Manager were notified at 1830 on September 14. The following immediate corrective actions were taken:

1) At 0001 on September 15, the Plant Supervisor-Nuclear (PSN} counseled the RCO and the non-licensed person involved in the event regarding the restrictions on manipulating controls.

2) The PSN discussed manipulation of controls by a non-licensed person and the requirements. of 10CFR50.54(i) and 10CFR55.3,at the shift turnover meeting.

The Operations Superintendent decided to investigate this event further. Since this event had already been determined not to be reportable under 10CFR50.72 the investigation s purpose was to establish the facts of the event in order to be able to take long term corrective actions to preclude recurrence. The investigation did not start until September 21, as the Operations Supervisor the, subject RCO, and the Operations Superintendent were offsite on September 15, 16, and 17, and the subject RCO did not report to work on September 18 and 19 due to sickness.

On September 22, the Operations Supervisor issued a memo. explaining the requirements of 10CFR50.54(i} and 10CFR55.3. All licensed operators have been required to read and sign the memo prior to assuming shift responsibility.

The Quality Assurance Superintendent, upon the request of the Vice President of Turkey Point Nuclear, initiated an independent investigation on September 23.

The Uice President of Turkey Point Nu'clear issued a letter to all site personnel on September 24 describing the event and emphasizing compliance with the iegulations. A second letter was issued on October 2, emphasizing the safety significance of the event.

NRC FORM 386A (94)3)

r'ICENSEE NRC Form 3ddA

(&$3 EVENT EPORT HLER) TEXT CONTINUATION U.S. NUCLEAR REGULATORY COMMISSION APPROVEO OMS NO, 3)SOW104 EXPIRES: 8/3)/88 FACILITY NAME n) OOCKET NUMBER (3) LER NUMBER (dl PAGE (3)

YEAR SEQUENTIAL REVrdIO N

@r. NUMEErl NUMSER Turkey Point Unit 3 o s o o o 2 5 0 7 0 2 00 04 DF0 4 TEXT /// moro o/>>co /o r)or)inR/, ooo or/I/r)/or>>/HRC iromr 3SSA 8/ (17)

The incident was discussed by management with over 600 FPGL employees at special meetings held on Saturday, September 26.

The RCO was relieved of licensed duties 'on September 26.

The Vice President of Turkey Point Nuclear held meetings with each crew of operators to discuss this event.

The following long term corrective actions are being taken:

1) Development of a training module detailing the requirements of 10CFR50.54 and 10CFR55.

2) Development of a procedure to incorporate changes to 10CFR into plant documents and training. A formal review of future 10CFR revisions to determine applicability to Turkey Point will be initiated. The FPSL commitment tracking will be accomplished.

system, CTRAC, will be utilized to assure that these reviews

3) Revise procedures as required in order to incorporate the requirements of 10CFR50.54(i) and 10CFR55.3.

ADDITIONAL INFORMATION Similar occurrences: none.

NRC fORM dddA (883)

P. O. BOX 1, JUNO BEACH, F L 33408.0420 USNRC-DS ill ll A Ia:02 OCI OCTOBER 1 3 19tl7 L7-4 I I U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:

Re: Turkey Point Unit 3 Docket No. 50-250 Reportable Event: 87-24 (Voluntary Report)

Date of Event: September l3, l987 Reactor Controls Manipulated by a Non-Licensed Person Under the Direct Su ervision of a Licensed 0 erator The attached Licensee Event Report is being submitted voluntarily due to generic concerns and lessons to be learned, in addition to the safety significance of this event.

Very truly yours,

~p'.

O. Woo Group Vice President Nuclear Energy COW/SDF/gp Attachment cc: Dr. J. Nelson Grace, Regional Administrator, Region II, USNRC

=

Senior Resident Inspector, USNRC, Turkey Point Plant an FPL Group company SDF I /067/ I