ML18065B153
| ML18065B153 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 01/26/1998 |
| From: | Thomas J. Palmisano CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-255-97-11, NUDOCS 9802030158 | |
| Download: ML18065B153 (6) | |
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Consumers Energy"">
A CMS Energy Comoany January 26, 1998 U.S. Nuclear Regulatory Commission ATIN: Document Control Desk Washington, DC 20555 Palisades Nuclear Plant 21180 Blue Star Memorial Hignway Covert, Ml 49043 DOCKET 50-255 - LICENSE DPR PALISADES PLANT Te/- 616 164 2296 Fax.* 616164 2425
'11otm* J. l'aladuao Site Vice President REPLY TO NOTICE OF VIOLATION 50-255/97011 INAPPROPRIATE PERMANENT MAINTENANCE PROCEDURE RESULTS IN PERSONAL CONTAMINATION NRC Inspection Report No. 50-255/97011 (DRP) dated December 19, 1997, contained a Notice of Violation for a Severity Level IV violation concerning the loss of equipment control due to an inappropriate maintenance procedure. The inappropriate procedure resulted in venting the waste gas surge tank to the Auxiliary Building atmosphere, resulting in the contamination of the maintenance crew. The response to the violation was required to be submitted within 30 days from the date of the letter transmitting the violation.
Discussion with Bruce Burgess at Region Ill on December 29, 1997, confirmed that the 30-day requested response could be provided within 30 days of receipt of the letter, which was December 26, 1997.
SUMMARY
OF COMMITMENTS This letter contains one new commitment as follows.
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Permanent Maintenance Procedure WGS-M-2 will be revised to eliminate the need to gag the discharge relief valve in order to perform the component checkout test.
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Thomas J. Palmisano Site Vice-President-- -- -- * ---
CC Administrator, Region Ill, USNRC Project Manager, NRR, USNRC NRC Resident Inspector - Palisades Attachment
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ATTACHMENT CONSUMERS ENERGY COMPANY PALISADES PLANT DOCKET 50-255 REPl Y TO NOTICE OF VIOLATION 50-255/97011-01 INAPPROPRIATE PERMANENT MAINTENANCE PROCEDURE RESULTS IN PERSONAL CONTAMINATION.
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. NRC VIOLATION 1 O CFR 50, Appendix B, Criterion V, states, "Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings."
1 Palisades Nuclear Plant Administrative Procedure 7.02, ALARA Program, Revision 8, dated June 6, 1997, Section 6.3, "Control of Radioactive Contamination': states, in part, that the plant objective is to maintain the extent of contamination areas ALARA. Control of radioactive contamination can be accomplished by minimizing the potential for release of radioactivity to the working environment, minimizing contamination of personnel and utilizing good radiological work practices to limit the spread of contamination.
Contrary to the above, Permanent Maintenance Procedure WGS-M-2, "Inspection and Repair of Waste Gas Compressor C-50A and C-508", Revision 4, dated September 19, 1995, was inappropriate to the circumstances in that it allowed gagging of relief valve RV-1114, which resulted in venting the waste gas surge tank to the auxiliary building, resulting in the contamination of five individuals on August 12, 1997.
This is a Severity Level IV violation (Supplement I).
CONSUMERS ENERGY COMPANY RESPONSE BACKGROUND During maintenance on Waste Gas Compressor C-SOA, control room personnel noted an increasing radiation level on stack gas monitor, RIA-2326, and shortly afterwards received an alarm on area monitor, RIA-1809, associated with the Waste Gas Compressor Room.
Subsequent investigation for the cause of the radiation led to the discovery that radioactive gases were leaking from the Waste Gas System header as a result of the gag that was installed on relief valve RV-1114. The method for gagging the relief valve resulted in the waste gas surge tank header and tank being open to the atmosphere through the gagging device, resulting in contamination of the maintenance crew.
REASON -F-OR-THE VIOLATION The root causes for this violation are as follows:
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Deficiencies in the Waste Gas System Procedure WGS-M-2 The step to gag RV-1114 was added in Revision 3 of WGS-M-2 to prevent lifting the relief valve when operating the waste gas compressor at shutoff head during compressor post maintenance testing. The compressor discharge pressure is controlled by a pressure limiting device factory set between 114 and 120 psig. Since RV-1114 is set at 114 psig, the RV will lift if the compressor is operated at shutoff head. Consequently, RV-1114 is gagged during the pressure test because the compressor is operated at shutoff head.
Revision 4 of WGS-M-2 added the specific description of the gagging device as a two-inch long, Y:z inch -20 bolt. The RV gagging device was used solely to seat the RV for upstream system integrity; that is, to maintain pressure boundary for post maintenance compressor testing. Although the specified gagging device, when installed, provided a barrier against release, procedural guidance for downstream system integrity was less than adequate in that a gas release could still have occurred during installation or removal of the specified gagging device. WGS-M-2, Revision 4, did not provide prerequisites or contingencies associated with breaching an active radioactive gas system, through installing the gagging device, to maintain dose ALARA. The failure of maintenance procedure WGS-M-2 to adequately notify Operations and the repair workers that the Waste Gas System is breached during compressor testing is a root cause of this event.
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Plant Personnel Failing To Follow WGS-M-2 Instructions Conversation with two of the repair crew members, including the lead repair worker, confirmed that Permanent Maintenance Procedure WGS-M-2 was at the job site and being used. However, the instruction to gag RV-1114 with a Y:z inch -20, two inch long bolt during the testing phase was not followed. The repair workers noted that they did not have the required bolt at the job site and one was not available in the Mechanical Maintenance Tool Room. It was clearly important to get C-SOA operational, as quickly as possible, because the other Waste Gas Compressor, C-508, was also out of service. Repair crew members were confident the original problem had been found and resolved, and all that remained.
was to test the compressor before it could be declared operable. Subsequently, the repair workers decided it was acceptable to use a fluted tap in place of the bolt, since the intent of the procedure step was only to gag the RV. The repair workers did not notify the responsible supervisor of that decision, but went ahead and used the tap to gag RV-1114.
The fluted tap aggravated both the* potential for release, and in his case the dose received, owing to the* poor sealing characteristics of the tap. Failure to follow WGS-M-2 or the process-to-change the procedure is a root cause for this event.
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED Remedial Corrective Action The tap was removed and the gag screw installed to stop the gas leakage. Subsequently, C-50A has been repaired and successfully tested.
CORRECTIVE STEPS TAKEN TO AVOID FURTHER VIOLATIONS Actions Taken To Prevent Recurrence 3
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The repair workers involved with the events led discussions on the expectations for procedural compliance with all Maintenance Department personnel. The discussions focused on, a) procedural compliance and the fact that innocent looking creative solutions can appear to resolve an issue, but may in fact create a new unexpected problem, and b) the need for all personnel to be sensitive to system inter-relationships, especially those systems where relief valves do not discharge to the atmosphere or a floor drain.
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Seven relief valves without bellows, (RV-2082, RV-2090, RV-2096, RV-2098, RV-2102, RV-2104, and RV-0401 ), were identified as discharging to an active system other than the Waste Gas Surge Tank. A review of associated operating, maintenance and technical specifications procedures was conducted and it was
. determined that gagging these relief valves is not specified in the procedures and not performed during normal evolutions. In addition, system hydrostatic tests are no longer performed and thus no likelihood exists for gagging the relief valves under these special conditions.
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The tagging process has been enhanced to require that relief valves that discharge to an active system and have an actuation device, are tagged as part of the associated system tag outs. Plant Administrative procedure 4.10, "Personnel Protective Tagging" has a new section added to address tagging of relief valves. The procedure also provides for the circumstance where the relief valve may be excluded from the tag out if appropriate reviews and approvals are documented. The procedure describes the acceptable level of review and documentation required for waiving the taggingrequirement. ---- -~
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- Additional Actions Planned to Prevent Recurrence Permanent Maintenance Procedure WGS-M-2 will be revised to eliminate the need to gag discharge relief valve RV-1114 in order to perform the component checkout test.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance was achieved when the work on the system was completed and the gag removed from the relief valve.
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