ML17347A831

Notice of Violation from Insp on 880425-0603.Violation Noted:Closure of Valve Caused Both Emergency Diesel Generators to Be Outside Design Basis as Described in FSAR

ML17347A831
Person / Time
Site:	Turkey Point
Issue date:	08/03/1988
From:	Grace J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML17347A830	List: IR 05000250/1988011 ML17347A831
References
50-250-88-11, 50-251-88-11, NUDOCS 8808150391
Download: ML17347A831 (50)

Text

ENCLOSURE 1

NOTICE OF VIOLATION Florida Power and Light Turkey Point Docket Nos. 50-250, 50-251 License Nos.

DPR-31, DPR-41 During the Nuclear Regulatory Commission (NRC) inspection conducted on April 25

- June 3,

1988, a violation of NRC requirements was identified.

The violation involved the failure to meet Technical Specification (TS) 6.8.1 requirements.

In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988),

the violation is listed below:

Technical Specification (TS) 6.8. 1 requires that written procedures and administrative policies be established, implemented and maintained that meet or exceed the requirements and recommendations of sections 5.1 and 5.3 of ANSI N18.7-1972 and Appendix A of USNRC Regulatory Guide 1.33.

ANSI N18.7-1972, section

5. 1.2 requires that procedures shall be followed.

Appendix A of Regulatory Guide 1.33, section 8.q., requires that specific procedures for surveillances of the Emergency Diesel Generators should be written.

Nuclear Chemistry Procedure NC-103, entitled Diesel Fuel Oil Inventory, Receiving Shipments and Periodic Sampling, revision dated April 14, 1988, section 8.3.4, outlines instructions for'ampling the Diesel Fuel Oil Tank (through the transfer line).

These instructions include opening valve 004 to obtain the diesel fuel oil sample and then reclosing and locking this valve after filling the sample container.

Contrary to the above, on May 29, 1988, after obtaining a sample from the Diesel Fuel Oil Tank, a chemistry technician locked closed valve 003, the suction valve for the Fuel Oil Transfer Pumps.

Closure of valve 003 caused both Emergency Diesel Generators to be outside the design basis as described in the Final Safety Analysis Report (FSAR).

FSAR, Section 8.2.3, states that transfer of fuel oil from the storage tank to the day tanks to maintain level is accomplished automatically.

With valve 003

closed, manual operator action would be required to restore the day tank fuel oil level.

This is a Severity Level IV violation (Supplement I).

~

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Pursuant to the provisions of 10 CFR 2.201, Florida Power and Light Company is hereby required to submit a written statement or explanation to the Nuclear Regulatory Commission, ATTN:

Document Control

Desk, Washington, DC

20555, with a copy to the Regional Administrator, Region II, and a copy to the NRC Resident Inspector, Turkey Point, within 30 days of the date of the letter 880815039i 880803 PDR ADQCK 05000250 PNU

Florida Power and Light Turkey Point Docket Nos. 50-250, 50-251 License Nos.

DPR-31, DPR-41 transmitting this Notice.

This reply should be clearly marked as a "Reply to a

Notice of Yiolation" and should include [for each violationj:

( 1) admission or denial of the violation, (2) the reason for the violation if admitted, (3) the corrective steps which have been taken and the results

achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved.

Where good cause is

shown, consideration will be given to extending the response time.

If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken.

FOR THE NUCLEAR REGULATORY COMMISSION Dated at Atlanta, Georgia this 3rd day of Q ~1988 C

J.

Nelson Grace Regional Administrator

ENCLOSURE 2

ENFORCEMENT CONFERENCE

SUMMARY

An Enforcement Conference was held on July 13, 1988, to discuss the potential violation described in Inspection Report No. 50/250, 251/88-11.

The licensee did not provide any information during the enforcement conference which would require correction to the information in the inspection report.

The licensee did provide details of a test run of a mockup fuel oil (FO) transfer pump to demonstrate the ability of the pump to run for an extended period of time with its suction valve shut.

The pump was run for two hours without damage.

Additionally, pump casing temperatures were monitored indicating relatively little rise in temperature over the two hour test period.

Overall, the licensee's presentation provided assurances that the diesel generator day tanks would not have run dry before the control room would have been alerted (day tank low level alarm) to the miss-positioned suction valve and the transfer pump would not have suffered damage while running with its suction valve shut during this period of time.

While addressing the root cause, the licensee proposed extensive corrective actions were directed at the broad scope appropriately involving valve alignment errors over the past year.

The licensee's program for minimizing the errors covers all plant personnel who may be required to operate valves or switches.

e ENCLOSURE 3 LIST OF ATTENDEES Enforcement Conference Licensee:

Florida Power and Light Facility:

Turkey Point Location:

Atlanta, Georgia Position/Title Name M. L. Ernst C.

W. Hehl G.

R. Jenkins M. B. Shymlock B. A. Wilson R.

V. Crlenjak G. A. Schnebli B. Uryc M. Lewis W. F.

Conway J.

S.

Odom J.

E. Cross P. L. Pace J. Arias R.

G.

Mende F.

H. Southworth D. J.

Lee Conference Tele hone G. Edison J.

Luehman DRA Deputy Director, DRP

Director, EICS Section Chief, Ops.

Branch Chief, Projects Branch 2

Chief, Project Section 2B Resident Inspector Sr.

Enforcement Specialist Project Engineer Sr. Vice President Site Vice President Plant Manager Licensing Supervisor Regulation and Compliance Sup.

Operations Sup.

Technical Staff Supt.

Nuclear Chemistry Tech.

PM, Turkey Point Enforcement Coordinator Or anization NRC/RII NRC/RII NRC/RII NRC/RII NRC/RII NRC/RII NRC/RII NRC/RII NRC/RII FPL FPL FPL FPL FPL FPL FPL FPL NRC/NRR NRC/OE

4

ENCLOSURE 4

PRIOR VALVE MISPOSITIONINGS

+<FHS.002:Id(djnn: 88

EVALUATION The methodology employed in the evaluation of the Diesel Fuel Isolation has been applied to the valve misalignments which have occurred since March 1987.

This evaluation revealed that the corrective actions for the prior occurences were developed incrementally on a case lay case basis and did not include management accountability.

- Broad based countermeasures to address:

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Repeated mispositionings involved AFW backup nitrogen Repeated mispositionings involved non-seismic pressure gauges in seismic systems

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Repeated changes to the same procedures

~/f1lS 002/d]/7/11/88

AI)I)I'I'IONAI.COICRI;C'I'IVI:AC'I'IONS Engineering willbe directed to evaluate a simplified redesign ofAFWBackup Nitrogen.

Seismic pressure gauges have been installed on the AFW Backup Nitrogen System and Boric Acid Transfer Pumps.

Non-seismic gauges installed in other seismic safety systems willbe further evaluated.

Engineering has been directed to provide only seismic gauges for future seismic installations.

Management willwalk down procedures l,hat affect AFW Backup Nitrogen and ensure they are clear and workable.

Management is and willcontinue to stress accountability and broad base root cause analysis.

~/F H5 002/8>/7/1 i/88

4

Prior Mis ositionin s

Date 5/28/87-6/3/87 Event Loss ofBoration Flow Path Root Cause Operators Valve Manipulations without procedure or Independent Verifications Corrective Actions Procedures Independent Verification, Training 7I15/87 Two ofThree AFW Np Backup Bottles Isolated 1/6/88 2/5/88 2/11/88, 2/17/88, 3/3/88 One ofThree AFW Np Backup Bottles Isolated ICW b,P Gauge Bypass Valve Found Isolated - Caution Tag Said "Do Not Close" 4B Boric AcidPump Discharge Pressure Gauge Left Unisolated After Temporary Clearance Lift 10/25/87 Accumulator Vent

(*-937) Closed Procedure Not Followed by Operators Inadvertent valve misposition, mislabeled, valve not on drawing Procedure not followed, IVnot required Procedure not followed Inadequate Administrative Controls Training Brief Discipline, Labeling Procedure Improvements Remove Valve, Policy Letter, Inspected for Similar Valves Discipline, Upgrade Procedures

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Operators meetings on work controls

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Policy Letters

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Discussed in Safety Meetings Reviewing Temporary LiftProcess 2/23/88 AFW N~ Backup Gauge Vent Valve Wired Open Versus Closed Personnel Error Operations meetings 3/20/88 3/28/88 CCW Heat Exchangers Valve Not Fully Opened AFW N~ Backup Gauge Sealed Open Versus Closed Personnel Error Same as 2/23/88 Inadequate Method of Procedure Changed IV

• iFHS-002/Id

NVCLEARSAFETY CONSIDERATIONS

~PHS402/Idtdy7/11,'88

FUEL OILTANKCAPACITIES ANDSETPOINT 65,000 gallon - capacity Fuel Oil Tank 40,000 gallon - Tech Spec

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Fuel Transfer Pump Day Tank 4,000 gal 3,614 gal - Fuel Transfer Pump stop 3,056 gal - Fuel Transfer Pump start 2,968 gal - Low Level Alarm - Control Room Interim Tech Spec Proc min level 2000 gal Skid 220 gal - valve closed from Day Tank 100 gal - gravity fillfrom Day Tank

15-20 gal - low level alarm

~/FHS 002'Id/dj/7/11/88

DIESEL FUEL OIL DAY TANK TRANSFER PUMP START DAY TANK LOW LEVEL ALARM 2.5 1.5 0.5 DAY TANK LEVEL FROM BOTTOM (FEET)

DIESEL DAY TANK LEVEL DURING NORMAL OPS 1.5 0.5 TIME OF DIESEL OPERATION (hours)

EDG DAY TANK LEVEL WITH DOTP ISOLATED 3.5 2.5 1.5 0.5 10 TIME OF DIESEL OPERATION (hours) 12

Test ofDiesel Fuel Transfer Pum (Jul 2-5 1988

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48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> Break-in

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1 hr suction isolated

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1 1/2 hr normal alignment

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2 hr suction isolated

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Normal Alignment Run

~IFH5402ndfd~njl li88

DIESEL FUEL OIL TRANSFER PUMP TEST OPERATION WITH THE SUCTION YLY ISOLATEO 0.9 0.8 z0 QZ 0

Q 0.7 0.6 0.5 0.4.

0.5 0.2 0.1 PRETEST 1

HR TEST POST 1

HR TEST 2 HR TEST POST 2 HR TEST

50 DIESEL FUEL OIL TRANSFER PUMP TEST OPERATION VflTH THE SUCTION VLV ISOLATED 40 30 20

+

TWO HOUR TEST 0

ONE HOUR TEST 0

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120 MINUTES

0

DIESEL FUEL OIL TRANSFER PUMP TEST OPERATION WITH THE SUCTION VLV ISOLATED 14 13 12 10 0

PRETER 1 HR TEST POST 1

MR TEST 2 HR TEST POST 2 HR TEST

DIESEL FUEL Oli TRANSFER PUMP TEST OPERATION SlTH THE SUCTION VLV ISOLATED 20 18'0

)6 ta 14 12 E

8 Q

PREPS'I HR TEST POST 1 HR TEST 2 HR TEST POST 2 HR TEST

SAFETY SIGNIFICANCE OF THIS EVENT

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Each diesel willrun at fullload 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> on day tank and skid tank Control Room alarm on low level on day tank will actuate after approximately 1/2 to 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> ifmain diesel fuel tank makeup is not occurring.

The diesel will have suAicient fuel to operate 10 to 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> after low alarm received.

A pump identical to the diesel oil transfer pump was tested and operated 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> with the suction valve closed.

Data from test indicates it would operate many additional hours without loss offunction.

The significance of this event is decreased by inherent system design which permits several hours for manual operator action to take place before system function is lost.

~/FH5-002ildfdj/7" 1/88

FLORIDAPOWER & LIGHTCOMPANY EMERGENCY DIESEL GENERATOR FUEL SUPPLY VALVEMISPOSITIONING JULY 13, 1988

Introduction AGENDA NRC Emergency Diesel Generator Fuel Supply Valve Mispositioning-A.

Opening Remarks B.

Description ofEvent C.

Root Cause D.

Corrective Actions E.

Safety Significance F.

Previous Valve Mispositionings G.

Summary/Questions FPI

%. F. Conway J. E. Cross J. E. Cross J. E. Cross F. H. Southworth J.E. Cross J. E. Cross III.

Closing Remarks FPL/J. S. Odom NRC

/I l

I I

L.S.70-002 70-031 EDG Oil Storage Tank "A"Day Tank 7Q-Q03 L.O..

CV Ls.

I Low level

~ alarmat

~A Control Room Alternate Fill L.C.70-004 I

D I

l Low level starts transfer I

I "A"EDG Oil Transfer Pump Low level opens Solenoid to allow

s gravity feed 5

I l

0

~iBtr EDG Oil Transfer Pump Identical for "B"EDG Skid Tank I

I l

"A"EDG I

Ii ~a I

I Generator Trouble Alarm at Control Room ADDITlONALDATA SET POINTS

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Day Tanks TANKCAPACITIES

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EDG Oil Storage Tank (1)

TS limit 65,000 gallons 40,000 gallons

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Day Tanks (2) 4,000 gallons each

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Skid Tanks (2) 275 gallons each SKIDTANK "A"refills at 70 gallons -44 minutes after EDG start "B"refillsat 120 gallons -35 minutes after EDG start NOTE:

These are based on normal tank fulllevels (A - 215 gallons, B - 235 gallons)

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Control Room Alarms

- Day Tank Low Level (2968 gallons)

- Generator Trouble and Ready to start light-19" from top of skid tank Transfer pump start - 3056 gallons Low level alarm - 2968 gallons NOTE:

This occurs at approximately 35 minutes to 3-,'ours depending on Day Tank initial levels.

EVENT CHRONOLOGY A.

May 22, 1988 (1715)

Valve verified locked open by

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Operations double verification.

B.

May 24, 1988 (0106)

Valve verified locked open through Management walkdown.

C.

May 28, 1988 Chemistry Technician discusses sample technique with supervisor.

D.

May 29, 1988 (1700)

Diesel Oil Storage Tank sampled by Chemistry.

E.

May 31, 1988 (1445)

Diesel Oil Transfer System Test inadequate discharge pressure noted on "A"pump. Operations investigated and found valve locked shut.

F.

May 31, 1988 (1452)

Valve 70-003 repositioned and locked open.

G.

May 31, 1988 (1600)

Operation event investigation begins.

Safety systems lock placed on valve 70-003.

H.

June 1, 1988 (0800)

Event analysis team formed (members).

I.

June 1, 1988 (1115)

Determined that a Chemistry Technician without procedural guidance manipulated the 70-003 valve and left it closed and locked.

• 01:I-md 07/09/88

THOUGHT PATTERNS 1.

5/28 First Technician discussed with Supervisor his concern over sampling.

Technician's concern was that a problem had recently been encountered on this system concerning the proper techniques for drawing the right samples.

Technician was also concerned over locating the current valve on the diesel day tank. Supervisor told the Technician that his shift partner had performed task the previous week and could help ifneeded.

2.

5/29 First Technician read the procedure and several samples ofdifferent quantities and locations were required.

He was still concerned over his abilityto perform the procedure correctly.

3.

5/29 First Technician asked second Technician to help him obtain sample.

Second Technician reviews procedure.

4.

5/29 Both Technicians went to sample location.

• 01:1-md 07i09/88 4

THOUGHT PATTERNS (Continued) 0 5.

5/29 Second Technician prepared to draw sample.

First Technician thought he must open the 003 valve to help second Technician. Second Technician busy doing sampling, didn't notice.

6.

5/29 Both Technicians worked together to perform the 5 gallon flush and obtain sample.

?.

5/29 Second Technician started removing test rig and closing and locking 004 valve while firstTechnician closed and locked 003 valve. (Under the impression it was originally shut). {Noverbal communications)

• 01:l-md07/OS/88

THOU6 HT PATTERNS (Continued) 8.

5/29 Both Technicians retrieved equipment and proceeded to next sample point.

(Day Tanks) 9.

6/1 First Technician came forward and stated that he had manipulated the va Ive 70-003.

• 01:I.md 07/08/88 ROOT CAUSE Chemistry Technician failed to followprocedure 4

Discussion of ROOT CAUSE

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Work performed without a procedure in hand - (procedure was reviewed prior to conducting).

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VaIve manipulation did not require si'gnoff or verification.

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Chemistry supervision did not completely understand and enforce the application of work controls.

• 01:I-md 07/09/88 4

INADEQUATEBARRIERS

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Chemistry Department Supervision did not ensure theTechnician was knowledgeable to perform this task.

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Locking system did not provide the desired level of error prevention.

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Consequences of actions not understood by Technician due to level of system knowledge.

SUMMARY

t

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Chemistry Supervision did not provide adequate guidance and controls which in turn allowed a Chemistry Technician to misalign valve 70-003.

,0

• 01:1-md 07/09/88 a

(

INTERlM:

')

1)

Performed walkdowns of all safety systems to verify proper alignment.

2)

Information bulletin of work controls issued to Department Heads for discussion with employees.

3)

Supervisor conducted meeting withChemistry Department on work controls.

4)

Completed evaluation and corrective action for safety system flow path locks.

5)

Employee notification of event via plant news network.

6)

Require signoffs for valve manipulations in safety related sampling procedures.

LONG TERM:

1)

Chemistry supervision checking documentation and compliance with work controls and spot checking field work.

2)

Completed evaluation on effects of chemistry sampling on equipment operability and changes are being processed.

3)

Signoffs willbe added to chemistry procedures when valves are manipulated.

4)

Training on work controls willbe implemented in New Employee Training and General Employee Training (GET).

5)

Work control training willbe part of continuing training.

6)

Work control training willbe expanded in initialtraining programs.

7)

Administrative procedure issued for Chemistry Department addressing procedure usage and compliance.

• 01:1-md 07/09/SS 8)

System training willbe provided to chemistry technicians. (Additional Staffing)