ML18059A439
| ML18059A439 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 10/13/1993 |
| From: | Slade G CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9310190303 | |
| Download: ML18059A439 (12) | |
Text
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consumers Power PDWERINli MICHlliAN'S PRDliRESS Palisades Nuclear Plant:
27780 Blue Star Memorial Highway, Covert *. Ml 49043 October 13, 1993 Nuclear Regulatory Commission.
Document Control Desk Washington, DC 20555 GB Slade General Manager DOCKET 50-255 - LICENSE DPR PALISADES PLANT - REPLY TO NOTICE OF VIOLATION; NRC INSPECTION REPORT No. 93016 NRC Inspection Report No. 93016, dated September 14, 1993 forwarded the results of a special inspection of the circumstances surrounding the failure
. to uncouple one control rod prior to the removal of the reactor vessel head.
The i~spection report identified an apparent violation of NRC requ1rements with ~espect to procedural compliance and record retention.
By letter dated June 19, 1993 we informed the NRC of the results of our init~al investigation of the potential causes and contributors to the failure to uncouple one control rod.
The failure to uncouple a control rod was the subject of an Enforcement Conference h~ld at ~egion I.II headquarters on.
August 10, 1993.
At the Enforcement Conference, we discussed our action taken to assess the situation and to develop a comprehensive action pla~. Our action plan contained both short term and long term actions to address the*
issues the NRC has raised and.those we have found during our assessment.
Our reply to ~he Notice of Violation 93016 addres~~s the importance o~
- management assessment, *observation and monitoring of activities to enable quick and ~ccurate feedback to our personnel on their performance.
We recognize that this quick and accurate feedback is essential to correct human behavior and to improve our human performance.
Our det~iled response is provided in Attachment 1 to this letter. Attachment 2 provides an update to*
those actions previously detailed in our June 19, 1993 letter.
Gerald B Slade General Manager CC Administrator, Region III, USNRC NRC Resident Inspector - Palisades Attachments 10nn~
9310190303 931013 PDR ADOCK 05000255 O
PDR 1-
~*
. I A CM5 ENCRGY COMPANY.
CONSUMERS POWER COMPANY To* the best of my.knowledge, information and belief, the contents of this submittal.are truthful and complete~
.By~c\\)c?
David P Hoffman, Vi Nuclear Operatio Sworn and subscribed to.before me thfs 13th day of October 1993.
LeAnn Morse, Notary Public Berrien County, Michigan Acting in Van Buren Countyi Michigan My commis.sion expires February*4, 1997
- [SEAL]
ATTACHMENT 1 Consumers Power Company Palisades Plant Docket 5.0-255 REPLY-TO NOTICE OF VIOLATION NRC INSPECTION REPORT No. 93016 October 13, 1993 4 Pages
REPLY TO.NOTICE OF VIOLATION Violation Technical Specification 6.8.1.a requires, in part, that written procedures be established, implemented and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2. (February
- 1978), Quality Assurance Program Requirements, as endorsed by CPC-2A,.Quality 1
Program Description.
.The Quality Program Description in CPC-2A endorses, among other things, the fo77owing applicable procedures listed in Appendix A of Regulatory Guide 1.33:
Authorities and Responsibilities for Safe Operation and Shutdown (Section 1.b); Record Retention (Section 1.h); Preparation for Refueling and Refue}ing Equipment Operation (Section 2.k); and Removal of the Reactor Head (Section*
9.d(6)).
A.
Administrative Procedure 4.00, "Operations Organization, Responsibilities, and Conduct," Revision 10, Step 4.4.1.h, established to implement the procedure listed in Regulatory Guide 1.33, Appendix A, Section. 1.b, requires, in part, that the Shift Supervisor explain plans,**
procedures and safety precautions to shift operating personnel prior to unusual or infrequent operations.
Contrary to the above, on June 10, 1993, the Shift Supervisor failed to explain plans, procedures, and safetiprecautioil$ to the auxiliary operators
- . assigned to perform the control rod drive mechanism uncoupling evolution, an infrequent operation.
s:
- Special Operating Procedure CRD0-:-1, "Disconnecting Control Rods from CRDMS," Revision 8, Step 3.4, established to implement the procedure listed in Regulatory Guide 1.33, Appendix A, Section 2.k, requires that*
persons performing this activity compl~te a dry run of this procedure using the control rod drive mechanism disconnecting mock-up.
Contrary to the above, on June 10, 1993, the auxiliary. operators performing control rod drive mechanism uncoupling had not completed a dry run of Procedure CRD0-1 using the control rod drive mechanism disconnecting mock-up.
- C.
Special Operating Procedure CRD0-1, "Disconnecting Control Rods from CRDMS," Revision 8, Step 5.1.3, establi.shed to implement the procedure listed in Regulatory Guide 1.33, Appendix A, Section 9.d(6}, requires the notification of the control room to record on Attachment 1 the control rod drive mechanism which has been disconnected.
Contrary to the above, on June 10, 1993, during the uncoupling of control rod drive mechanisms, operators repeatedly failed to notify the control room after each control rod drive mechanism was disconnected, but only notified the control room after groups of control rod drive mechani'sms were disconnected.
D.
Special Operating Procedure CRD0-1 ' "Disconnecting Control Rods from CRDMS,"- Revision 8, Step 7.2.3, established to implement the procequre listed in Regulatory Guide 1.33, Appendix A,Section I.h, requires that the control room working copy of this procedure be retained.
Contrary to the above, after completion of the control rod drive mechanism
- uncoupling evolution on June 10, 1993, the control room working copy of the procedure was not retained.
E.
Regulatory Guide 1.33, Appendix A, Section 9, as*endorsed by CPC~2A~
Quality Program Description, requires, in part, that mairitenance be properly performed in accordance with written.procedures appropriate to the circumstances.
Contrary to the above, as of June 15, 1993, Maintenance,Procedure* RVG-M-2, "Removal of the Reactor Vessel Head," Revision 24, a portion of which serves to verify that a77 rack extensions are uncoupled, was inappropriate to the circumstances in that Steps 5.20.18 through 5.20.20 were [10t adequate*to verify that a71 rack extensions were w:icoupled..
- Reason for the Violation 2
CPCo agrees wtth the violation as stated: The-details of the reasons for the*
violation and our inune*diate corrective action. were provided ~n our June 19, 1993 letter and are updated.in At~achment 2.
Corrective Actions and Results Achieved Our i mmed i a'te corrective actions were pr.Qvi ded in our: June' 19 I 1993 1 etter 'an'd are updated in Attachment 2. Additional actions we have taken include the '
following:
1 *. A memo has been sent to all site supervis9ry personnel*on lessons learned form the rod uncoupling event emphasizing:
A.
The need for appropriate pre-job briefings including ~oordination within the crew and between crews.
B.
The requirements for procedure. and work order usage and compliance.
C.
The need to stop work if it is not going according to plan*or.the procedure needs to be changed.
D.
The need for supervisor monitoring of work in progress.
- 2. A.pre-job briefing checklist (job aid) has been instituted to provide guidance to supervisors and lead workers.in making sure that briefs cover all critical elements of the job.
- 3. The Operations Manager and the Operations Superintendent conununicated their expectations to the Operations Department workers and supervisors.
' 4.
3 A multi-disciplined root cause analysis team completed a review of the rod uncoupling event and the results of that evaluation were distributed to all managers and supervisors. All managers and supervisors were requested to review those recommendations and factor them into their departments *. In particular, the Operations Department is factoring those comments into their actions to improve their climate and their supervisory and w6rker performance~
s.* We have reviewed the loss of the documentation of this occurrence and have determined it to be *an isolated case. All Operation and Document Control supervisory personnel have been informed of the loss of documentation.
We will continue to monitor the documentation and take additional actions if n'ecessary.
- 6.
We have reviewed and revised the.refueling procedures to correct weaknesses similar to those identified in the control rod uncoupling procedure.
Corrective Action to Avoid Future Non-Compliance Action plans are being developed by CPCo_to establish a wo~k climate in the Nuclear Operations Department, the Palisades Plant, and the Operations Department that is conducive to.eliminating human errors which result in potentially serious consequences.
The areas to be addressed are listed below for each area.
Nuclear Operations Department:
1 *. The NOD Managem~nt Inspection Program will be modified to focus more on human performance in addition to facility material condition *.
- 2.
The effectiveness of NPAD will be reviewed to evaluate how assessments are conducted and whether additional "outside" expertise should be used.
- 3. The planned supervisory and management skills development training has been accelerated. This training will include the following:
- a. Management and supervisory work process observation with specific content to focus on observation of human performance to standards.
- b.
Workshops aimed at improving supervisory and management skills based on immediate needs.
c~ Team skills training to enhance the performance of teams at. every level of the organization, including management teams.
These training courses will be available to the plant beginning in the fourth quarter of 1993.
The training will be delivered as requested by the individual plant departments.
- 4.
An independent consultant will be used to perform an assessment of NOD managements approach to the challenges we face.
The effectiveness of our management process and proposed actions will be presented to corporate management p_rior to returning the plant to service.
4
- 5.
All 1993 human performance related corrective action documents will be reviewed to determine if there are any coR111on causal factors :that have not been addressed *. The results of this review w11 l, be preserited to the Pl ant Review Conuni ttee and _NOD sen1 or management prior to startup.
Palisades Plant:.
- 1. A field monitoring pro.gram has been developed and includes *routine observations of human performance by plant senior management.
- 2.
The management team will review plant staridards _and expectations to ensure consistency in interpretation. Action plans will be developed to correct any unclear standards or expectations.
- 3. A conununications plan. is being developed to conununicate the standards and expectations to all levels of the organization.
4~ The management team-is developing a program to assist employees and.
sµpervisors on how to deal with and manage change.
Operations Department:
- 1. Operations management has contracted. a management* consultant to work with all levels of th~ department with a goal of improving the climate within the organization. Team-work and two way conununications are to be emphasized.
- 2. A plan for improved *supervisory performance with an emphasis on management observations, coaching ind counseling is being developed.
- 3. A plan for improved worker performance with emphasis on more specific feedback on performance is being developed.
The specific completion dates for the above general actions will be incorporated into the fourth quarter update of the NOD Business Plan.
Date of Full Compliance Full compliance has been achieved.
ATTACHMENT 2 Consumers Power Company Palisades Plant Docket 5.0-255 REPLY TO.NOTICE OF* VIOLATION..
NRC INSPECTION REPORT No. 93016 October 13, 1993 4 Pages
UPDATE TO JUNE 19, 1993 SUBMITTAL J1 Reason for the Violation Consumers Power Company agrees with the violation a~ stated.
A review of th~ circumstances that led to the failure to uncouple the control rod provided several lessons learned:
1
- 1.
The crew of operators who performed the uncoupling evolution were not
~ell organized for the evolution despite the.control operators having had mock-up training prior to performing the job.
In addition, the auxiliary operators were not involved in the dry run using the mock-up.
Performing the job with two teams (the same as February *1992) increased
.the level of coordination required to perform the job.
The pre-job brief could have been more thorough and emphas~zed the complications o~
two crews working together.
Improved preparation on the part of the crew could have reduced the coordination issu~s associated with the evolution.and improved th~ performance of the crew..
2..
T~e operators performing the rod uncoupling appareritly felt pre~sure to complete the evolution quickly, even though they stated they were *not
- under pressure. This led to a missed opportunity to take the time t~
correct several problems that they discovered at the start of the.
evolution, such as only having one pen and*one copy of the procedure for the two teams performing the work.
. 3. **. Although a.Shift Supervisor was present for the majority of. the evolutioQ and directed the operators to correct some of the problems that they had not corrected themselves, he failed to recognize the overall shortcomings of the process.
If he had recognized the
. inad~quacy of the process and ensured the operators were adequately
- documenting their work as it progressed, the failure to uncouple the cuntrol rod may not have.happened.
- 4.
The communications between the operators on the reactor vessel head and the control room were not in accordance with the procedure in that they did not report each control rod* uncoupled as it was completed.
Instead they maintained th.e record at.the work site. The means by which they maintained this record was not well defined and the ~rocedure did not provide gorid documentation of the completion of the evolution. This contributed to the failure to uncou~le the control rod.. *
- 5.
The Control Rod Uncoupling Procedure also did not provide the level of verification necessary to ensure that all of the control rods had been uncoupled.
Over several years, this procedure had undergone a series of
modifications to improve the process_ and reduc~ the radiation exposure*
received performing this job. Through this series of revisions the level of verifi~ation and its effectiveness wa~ reduced.
2
- 6.
The completed control rod uncoupling procedure was reviewed and signed
- by the Shift Supervisor. on the following shift as being complete at 111'0 hours0 days <br />0 hours <br />0 weeks <br />0 months <br /> on June 10, 1993.
Performance of this procedure is clearly
- doc~mented in the Shift Supervisor log book on pages dated June 10, 199j. His review of the completed procedure showed that all of the control rods had been marked off as being uncoupled. After signing the procedure, he placed the procedure in the out-basket for forwarding to document control.. Five days later, on June 15, when it was discovered that Rod No. 39 was not uncoupled, an attempt was made to review the completed uncoupling procedure; however, the procedure could not be*
found,.indicating a breakdown in the control of documentation.
- 7.
One other lesson learned in this event involved the head lift procedure.*
In that procedure there are provisions for vi~ually checking.that all the control rods are clear of the reactor vessel head after the head has been raised 8 to 12 in'ches off the vessel flange.
This check failed to*
identify that Rod No. 39 was st i 11 connected to the head and was ~eiiig Withdrawn from the upper g~ide structure.as the vessel head was being raised. After the inspection was ~erformed in accordance. with th~
procedure, the reactor vessel head was raised to approxi~ately 7 feet above the reactor vessel flange.
It was at this time that Rod No. 39 was discovered suspended from the ~eactor vessel head.
In reviewing this aspect of the event, it appears that a visual inspection*at the height specified in the procedure is not adequate to detect a coupled rod due to other-interferences, poor visibility, and adverse radiological conditions;*
Corrective Actions and Results Achieved B~sed on our review of the failure to*uncouple a *control rod, we identified and completed the following corrective actions:
- 1.
The Upper Guide Structure Lift had previously been classified as an Infrequently Performed evolution to provide additional management attention.
The pre-job briefing for the* Upper Guide Structure lift included the specific lessons learned from the rod uncoupling event and the Reactor Head lift. Proper procedural usage, the need to eff~cti~ely coordinate activities, and proper communications.with.the Control Room were discussed. Plant Management was directly involved in this briefing.
- 2.
Operations Department personnel were briefed on lessons le~rned from this control rod uncoupling event prior to involvement in fuel movements.
)
3
- a.
Control Operator and Auxiliary Operator briefings were conducted to
-1 emphasize the need to effectively coordinate activities, proper procedural usage, proper communications with the Control Room, and proper documentation of fuel movement.
The operators were reminded that if concerns arise, the evolution should be stopped and the concerns resolved prior to continuing.
- b.
Operations supervisory personnel briefings the need to perform thorough pre-job briefings, the need to effectively coordinate activities, proper procedura 1 usage, proper communi cat i ans with the Contra l Rooin, p.roper control of documentation, and the appropriate amount of supervisory and management i nvo 1 vement in. activities. Particular empha*s is was p 1 ac*ed on *.
the supervisory and management r~spons i bil ity to resolve concerns *
-\\
regarding the evolution.
- 3.
Management monitoring of core alteration activitie~ was provided ~n a 1
- periodic basis by Operations Department management personnel, Outage Shift Management personne 1, and independent man itori ng was pe.rformed by
. **I*
Nuclear Plant Assessment Department (NPAD) personnel. -
- 4.
Other* plant supervisory personnel were hriefed on the les_sons lea.rned from the* control rod uncoupling event.* The purpos~ of these briefings was to emphasize* pre-job briefings, procedural usage,, and* supervisory :
involvement in monitoring activities. *
- 5.
The Upper Guide Structure Lift Procedure w~s revi~wed and confirmed to contain adequate instructions for documentation and verificition of
- critical activities.
- 6.
The two. refueliMg proced~res ~sed bY the Operations Department were :
reviewed and confirmed to contain adequate: verification *instructions.
. I 7.. *The Control Rod Coupling Procedure was reviewed and revised prior to its 1*
use in the 1993 Refueling.Outage.
Particular.attention wa~:given to the documentation requirements and the verification of pr6per control rod*
The above actions were intended tci ensure that the lessons learned fro~ the control rod uncoupling event were i~corporated into our buta~e activities prior to core alteration activities. *These actions were also intended to provide feedback to personnel involved in other outage activities to help prevent similar problems.
... A
Corrective Action to Avoid Future Non-Compliance The following corrective actions are yet.to be completed.
- 1.
The Control Rod Uncoupling Procedure will be revised prior to its next use in the 19.94 Refueling Outage to ensure it contains adequate instructions for verification and documentation of proper control rod uncoupling.
- 2.
The Reactor Head Lift Procedure will be reviewed ~~ior to use in the 1994 Refueling Outage t6 determine the adequacy of inspection for coupled control rods~
Date of Full Compliance Full compliance has been achieved.
4