ML18068A347

Provides Response to Violations Noted in Insp Rept 50-255/97-14.Corrective Actions:Operations Superintendent Briefed All Operating Crews on Expectations for Effective Shift Communications & Emergent Work Planning

ML18068A347
Person / Time
Site:	Palisades
Issue date:	05/04/1998
From:	Thomas J. Palmisano CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:	NRC OFFICE OF ENFORCEMENT (OE)
References
50-255-97-14, NUDOCS 9805150059
Download: ML18068A347 (22)

Text

.c A CMS Energy Company May 4, 1998 Director, Office of Enforcement US Nuclear Regulatory Commission One White Flint North 11555 Rockville Pike Rockville, MD 20852-2738 Palisades Nuclear Plant 21180 Blue Star Memorial Highway Covert. Ml 49043 DOCKET 50-255 - LICENSE DPR PALISADES PLANT Tei>> 616 164 2296 Fax 616164 2425 J'l'lolms J.,,.lmlpno Site Vice President REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN NRC SPECIAL INSPECTION REPORT 50-255/97-014(DRS)

NRC Inspection Report 97-014 dated April 2, 1998, identified six violations associated with an event on October 17, 1997. This letter provides the Consumers Energy Company response to those violations.

The circumstances surrounding the event and the event's management implications have been discussed previously in voluntary Licensee Event Report 97-012 and in the Predecisional Enforcement Conference held on December 19, 1997. For completeness, a copy of the Licensee Event Report is provided as Attachment 2.

In this event normal drive power was removed from all control rods simultaneously without recognition that this condition placed the plant into a Technical Specifications shutdown action statement. This was a very significant occurrence because operators failed to understand the Technical Specifications implications of thei'r actions, and because multiple barriers within Operations and Maintenance failed to prevent it. In addition, plant management initially failed to step back and recognize the event's broader implications.

While the Palisades management team was extremely disappointed with the weaknesses revealed by this event, we are using it as a learning opportunity. As we discussed during the Predecisional Enforcement Conference, one of the most significant lessons learned was the need for an immediate; aggressive plant management response to potentially significant plant occurrences. This event underscored the urgency of promptly gathering all relevant facts so that management

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can quickly understand their implications and initiate remedial actions even before the

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9805150059 980504 PDR ADOCK 05000255 G

PDR

full root-calise evaluation is completed. To this end, Palisades has incorporated an Incident Response Team concept into the Corrective Action process. Since January, 1998, Incident Response Teams have been employed successfully on three separate occasions for immediate investigations of plant events.

2 Our analysis of this event revealed that the causes were similar to performance weaknesses that had been observed previously. Specific personnel performance problems in this event related to the conduct of work and the performance of control room activities. Previous corrective actions for weaknesses in these areas had not been fully effective. The management team had not fully articulated and reinforced standards in the areas of communication, job preparation, procedure compliance, and conduct of work; and had not effectively used the corrective action and self-assessment processes to evaluate and resolve some human performance issues. To address these underlying issues we have embarked on a series of activities to improve human performance and to make plant assessment processes more effective. provides responses to the six violations identified in the Inspection Report.

In addition to the specific causes and corrective steps for each violation, some actions are also included which address the underlying management issues discussed above.

SUMMARY

OF COMMITMENTS This letter contains no new commitments and no revisions to existing commitments.

~~

Thomas J. Palmisano Site Vice President CC Administrator, Region Ill, USNRC Project Manager, NRR, USNRC NRC Resident Inspector - Palisades Attachment

CONSUMERS ENERGY COMPANY To the best of my knowledge, the contents of this document entitled "Reply to Notice of Violation for Six Violations Identified in NRC Special Inspection Report 50-255/97-014(DRS)", are truthful and complete.

~~~

By Thomas J. Palmisano Site Vice President Sworn and subscribed to before me this,If- #7 day of 'Z2ia.f I 1998.

~"~z Berrien County, Michigan (Acting in Van Buren County, Michigan)

My commission expires February 16, 2000

~--- -----

[SEAL]

ATTACHMENT 1 CONSUMERS ENERGY COMPANY PALISADES PLANT DOCKET 50-255 Reply to Notice of Violation for Six Violations Identified in NRC Special Inspection Report 50-255/97-014(DRS) 10 Pages

ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN NRC SPECIAL INSPECTION REPORT 50-255/97-014(DRS)

. NRC NOTICE OF VIOLATION 1 Administrative Procedure 4.00 (Revision.20.- 7118197), "Operations Organization, Responsibilities and Conduct," a procedure required by Section 1.b of RG 1.33, at Step 4.2.3.b.6, required that the Control Room Supervisor shall keep the Shift Supervisor informed of plant and equipment status.

Contrary to the above, on October 17, 1997, the Control Room Supervisor failed to properly implement Administrative Procedure 4.00 in that the Shift Supervisor was not kept informed that power would be removed from all of the control rod drive motors in order to facilitate maintenance on control rod 38. (01013)

CONSUMERS ENERGY COMPANY REPLY TO VIOLATION 1 Consumers Energy agrees with this violation. While additional fact finding is still ongoing, we concur that the Shift Supervisor was either not kept informed or did not maintain sufficient involvement in associated control room activities.

Reasons for Violation There was inadequate communication between the Shift Supervisor and the Control Room Supervisor.

Corrective Steps Taken and Result~ Achieved

1.

Plant management reviewed the event and suspended the "A" shift licensed operators from licensed duties until remedial activities were completed and documented. Remedial actions included reinforcement of expectations for keeping the Shift Supervisor informed of plant and equipment status.

2.

The Operations Superintendent briefed all operating crews on the expectations for effective shift communications, emergent work planning, and verification of proper Technical Specifications implementation.

3.

The Operations Department developed a lessons learned package which was.

used by each Shift Supervisor to brief his crew. The package covered the event in 1

ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN NRC SPECIAL INSPECTION REPORT 50-255197-014(DRS) detail, identifying each point at which an opportunity to avoid problems using already established procedures was missed. Subjects discussed included the leadership role which must be assumed by the Shift Supervisor for emergent maintenance activities.

4.

A strategy was developed in the Palisades Five Year Plan to manage a human performance improvement initiative. Stand-down meetings have been conducted by all departments to train on human behaviors which will promote improved performance. The strategy includes continuing training and reinforcement on this subject in the future. This action addresses the underlying root causes relating to the need for improving human performance and questioning behaviors.

As a result of actions taken, crews have become more consistent in keeping the Shift Supervisor informed and involved with Technical Specification issues. Occasionally, however, situations continue to be observed which indicate that furthe~ improvements in crew communications with the Shift Supervisor are warranted. Action is ongoing to reinforce management expectations for Shift Supervisor involvement in the resolution of important issues.

Corrective Actions Remaining to Avoid Further Violations Each of the described actions has been completed.

Date by Which Full Compliance Will Be Achieved The plant is currently in full compliance.

NRC NOTICE OF VIOLATION 2 Administrative Procedure 4. 10 (Revision 6 - 4130197), "Personnel Protective Tagging," a procedure required by Section 1.c of RG 1.33, at Step 7.2.2 required that the Shift Supervisor shall ensure that equipment may be removed from service by ensuring that the Technical Specification requirements, including the Limiting Conditions for Operations and Action Statem.ents, are met.

Palisades Nuclear Power Plant Technical Specification 3.10.4.b, Amendment 169, states, in part, that a control rod is considered inoperable if it cannot be moved by its operator and if more than one control rod becomes inoperable then the reactor shall be placed in hot shutdown within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />.

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ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN

-~NRC SPECIAL INSPECTION REPORT 50-255/97-014(DRS)

Contrary to the above, on October 17, 1997, the Shift Supervisor (and the Control Room Supervisor, Shift Engineer (all licensed senior reactor operators)) failed to ensure that equipment could be removed from service by failing to ensure that Technical Specification requirements, including the Limiting Condition for Operation and Action Statements, were met prior to removing all the control rods from service. Specifically, power was removed from all the rods and the licensed operator failed to realize that removing power from more than one control rod required entry into a 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> action to shut down the plant. (01023)

CONSUMERS ENERGY COMPANY REPLY TO VIOLATION 2 Consumers Energy agrees with this violation as written.

Reasons for Violation There was inadequate understanding by the operating crew of Technical Specification 3.10. This inadequacy led to the failure to understand the implications of the emergent work so it could be appropriately prioritized and controlled.

Corrective Steps Taken and Results Achieved

1.

Plant management reviewed the event and suspended the "A" shift licensed operators from licensed duties until remedial activities were completed and documented. The remedial action included training on the specific requirements of Technical Specification 3.10.

2.

The Operations Superintendent briefed all operating crews on the expectations for effective shift communications, emergent work planning, and verification of proper Technical Specifications implementation.

3.

The Operations Department developed a lessons learned package which was used by each Shift Supervisor to brief his crew. The package covered the event in detail, identifying each point at which an opportunity to avoid problems using already established procedures was missed. Subjects discussed included clarification of the requirements of Technical Specification 3. 10.

4.

A strategy was developed in the Palisades Five Year Plan to manage a human performance improvement initiative. Stand-down meetings have been conducted by all departments to train on human behaviors which will promote improved performance. The strategy includes continuing training and reinforcement on this 3

ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN

,-NRC-'SPECIAL INSPECTION REPORT 50-255/97-014(DRS) subject in the future. This action addresses the underlying root cause relating to the need for improving questioning behavior.

As a result of actions taken, the questioning behaviors that were deficient in this event are being displayed more frequently in the Operations Department. As a result of this improved behavior, procedural adequacy and Technical Specification interpretations, including some long standing traditional interpretations, are being challenged at a greater rate. The crews have become more consistent in involving engineering, management, and licensing resources to resolve identified questions; but occasional weaknesses are still observed. Expectations for displaying questioning behaviors continue to be reinforced on an ongoing basis.

Corrective Actions Remaining to Avoid Further Violations Each of the described actions has been completed.

Date by Which Full Compliance Will Be Achieved The plant is currently in full compliance.

NRC NOTICE OF VIOLATION 3 Administrative Procedure 4.02 (Revision 15 - 6127197) "Control of Equipment, 11 a procedure required by Section 1.c of RG 1.33, at the NOTE before step 1 of Attachment 8, "Safety Assessment for Removal of Plant Equipment (SSCs) From Service, 11 required that Attachment 8, or an equivalent risk-based assessment, be completed for maintenance activities that met all of the following conditions:

a) entry into unplanned maintenance outages b) involved high safety significant systems identified in Attachment 10 c) would render the system incapable of perfonning its Maintenance Rule function d) did not occur with the equipment positioned in its designed safety position prior to removing its power source.

Contrary to the above, on October 17, 1997, the licensee failed to complete Administrative Procedure 4. 02, Attachment 8, or perfonn an equivalent risk-based assessment for the maintenance on control rod 38. Specifically, this maintenance activity: (1) was an unplanned maintenance outage because the corrective maintenance on control rod 38 was emergent work; (2) involved the control rod drive 4

ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN NRC SPECIAL INSPECTIONcREPORT 50-255/97-014(DRS) system which was a high safety significant system identified in Attachment 1 O; (3) rendered the control rod drive system incapable of performing its maintenance rule function of manual operation; and (4) did not occur with control rod 38 positioned in its designed safety position of fully inserted prior to removing its power source. (01033)

CONSUMERS ENERGY COMPANY REPLY TO VIOLATION 3 Consumers Energy agrees with this violation as written.

Reasons for Violation The expectation for performing risk-based safety assessments was not clearly understood and implemented. The failure to consistently use risk assessment had not previously been.highlighted as a performance weakness requiring corrective action.

Corrective Steps Taken and Results Achieved

1.

The Operations Department developed a lessons learned package which was used.by each Shift Supervisor to brief his crew. The package covered the event in.

detail, identifying each point at which an opportunity to avoid problems using already established procedures was missed. Subjects discussed included Maintenance Rule requirements (including use of risk assessment).

2.

An improvement plan has been initiated to strengthen the self-assessment process, to improve line management ownership of the process, and to provide more assessments which focus on human behaviors.

As a resulrof actions taken, the expectation for performing risk assessments is now

. understood and is being appropriately performed. Sponsorship of the self-assessment process has specifically been assigned to a line manager.

Corrective Actions Remaining to Avoid Further Violations Each of the described actions, except implementation of the improvement plan for self-assessment, has been completed.

Date by Which Eull Compliance Will Be Achieved The plant is currently in full compliance.

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ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN NRC SPECIAL INSPECTION REPORT 50-255/97-014(DRS)

NRC NOTICE OF VIOLATION 4 MaintenanceProcedure CRD-E-32 (Revision 7 - 2121195), "CRD [Control Rod Drive Motor] Control Relays Cleaning and Inspection," a procedure required by Section 9.a of RG 1.33, at Step 3.4.2.e, required during plant operation with rods withdrawn and the clutch power supply energized that only one relay set and its related fuses be removed from service at a time.

Contrary to the above, on October 17, 1997, during implementation of work order 24714120, maintenance on control rod 38, licensee personnel failed to properly implement Maintenance Procedure CRD-E-32 in that more than one control rod relay set and its related fuses were simultaneously removed from service and inspected.

(01043)

CONSUMERS ENERGY COMPANY REPLY TO VIOLATION 4 Consumers Energy agrees with this violation as written.

Reasons for Violation There was inadequate questioning by maintenance personnel of the requirements of this maintenance procedure prerequisite. This led to a failure of repair workers* to recognize its applicability and significance.

There was inadequate communication between Maintenance and Operations. Better communication between the groups would have resulted in the requirement being met.

Corrective Steps Taken and Resµlts Achieved

1.

The Maintenance and Construction Manager reviewed this event with all Maintenance repair workers and supervisors in a series of stand down meetings.

Among other topics, these meetings discussed the need for good communications

, and questioning among all cooperating work groups.

2.

Shift Supervisor sign offs have been added to permanent Maintenance procedures that have prerequisites for a specific plant configuration.

3.

Standards for procedure use and compliance, communications, pre-job

• preparation and briefings, control of work scope and documentation, and response to unexpected conditions have been established or clarified in the Maintenance 6

ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN NRC SPECIAL INSPECTION REPORT 50-255197-014(DRS)

Department. A monitoring program against these standards has been implemented.

As a result of actions take.n, Operations personnel reviews for specific operational requirements embedded in maintenance procedures have ensured that those requirements are being met. This barrier has been strengthened by the clarification of expectations and standards for communications between work groups.

Corrective Actions Remaining to Avoid Further Violations Each of the described actions has been completed.

Date by Which Eull Compliance Will Be Achieved The plant is currently in full compliance.

NRC NOTICE OF VIOLATION 5 Administrative Procedure 5.01(Revision21 - 5112197), "Processing Worl<

Requests/VVorl< Orders, n a procedure required by Section 9. e of RG 1. 33, Attachment 2, "Worl< Order Scheduling, Performance, and Completion," at Step 2.3.c, required the Assigned Supervisor to review scheduled worl< orders to determine the worl< could be performed as scheduled, and if not notify the Shift Supervisor ("scheduledn includes both the time of occurrence and manner of conduct). Step 6. 1 of Attachment 2, required the worl< order to be replanned, per the requirements of this procedure, if the Assigned Supervisor determined that the worl< required to correct the problem was not adequately described in the worl< order job plan. Step 5. 11.b required the repairperson to document the "as found" conditions and the repairs/adjustment made.

Contrary to the above, on October 17, 1997, during implementation of worl< order 24714120, maintenance on control rod 38, licensee personnel failed to properly implement Administrative Procedure 5. 01 in that three additional control rod drive relay contactors for control rods 3, 40, and an unidentified Group Ill control rod were removed, inspected, and reinstalled. This represented a condition not allowed by the worl< procedure and was an unplanned and undocumented expansion of the approved worl< scope without the required notification to the Shift Supervisor. (01053)

CONSUMERS ENERGY COMPANY REPLY TO VIOLATION 5 Consumers Energy agrees with this violation as written.

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ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN

. ____ _ __

• _ NRC SPECIAL INSPECTION REPORT 50-255/97-014(DRS)

Reasons for Violation Workers failed to recognize that proposed additional work was outside the authorized work scope. Established procedural actions for identifying and changing maintenance work scope, followed by proper documentation of work performed, were, therefore, not performed.

Corrective Steps Taken and Results Achieved

1.

The Maintenance and Construction Manager reviewed this event with all maintenance repair workers and supervisors in a series of stand down meetings.

While these meetings addressed several topics pertinent to this event, they concentrated on compliance with procedures, repair worker responsibility for working within the approved job scope, the difference between non-intrusive inspections and inspections which require formal work controls and post-maintenance testing, and the need for good communications among all cooperating work groups.

2.

Maintenance has revised and redistributed to each repair worker a standards handbook which establishes clear performance expectations for procedure compliance, scope control, and communications with other groups.

As a result of the coaching and reinforcement of expectations 'for working within approved work scope and for documenting work, performance has improved in these areas. To verify the effectiveness of its actions, Maintenance plans to perform additional self-assessments in the areas of work scope control and adherence to standards during maintenance.

Corrective Actions Remaining to Avoid Further Violations Each of the described actions has been completed.

Date by Which Full Compliance Will Be Achieved

/

The plant is currently in full compliance.

NRC NOTICE OF VIOLATION 6 Administrative Procedure 5.19 (Revision 6 - 4115197), "Post Maintenance Testing," a procedure required by Section 9.e of RG 1.33, at Step 5.2.e, required the Operations

• Manager to ensure that Post Maintenance Testing was properly performed prior to 8

ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN NRC SPECIAL INSPECTION REPORT 50-255/97-014(DRS) declaring the equipment operable. Step 5.4.c required the Maintenance Supervisor to ensure that the specified post maintenance testing was revised, as necessary, if the scope of maintenance performed was changed after initial planning.

Administrative Procedure 4. 02 (Revision 15 - 6127197), "Control of Equipment," a procedure required by Section 1.c of RG 1.33, at Step 9.3.b, required operability testing to be performed on safety-related equipment following any maintenance* activity which had the potential to affect the equipment's operability.

Contrary to the above, following implementation of work order 24714120, maintenance on control rod 38, on October 17, 1997, licensee personnel failed to properly implement Administrative Procedures 5.19 and 4.02. Specifically, more than one control rod relay set and its related fuses were removed from.service and inspected which represented a change in the scope of maintenance after initial planning. However, the specified post maintenance testing was not revised as necessary. Consequently, appropriate Post Maintenance Testing was not identified or pe"rformed. (01063)

CONSUMERS ENERGY COMPANY REPLY TO VIOLATION 6 Consumers Energy agrees with this violation as written.

Reasons for Violation An inadequate understanding of maintenance standards led the repairman to conclude incorrectly that intrusive inspection activity was not maintenance that exceeded the authorized scope of the work order and warranted post-maintenance testing. As a result appropriate post-maintenance testing was not performed.

Corrective Steps Taken and Results Achieved

1.

Post-maintenance testing was subsequently performed on October 20, 1997, to verify operability of all affected control rods.

2.

The Maintenance and Construction Manager reviewed this event with all maintenance repair workers and supervisors in a series.of stand down meetings.

A number of topics relevant to this event were discussed, including repair worker responsibility for working within the defined job scope, the difference between non-intrusive inspections and inspections which require formal work controls and post-maintenance testing, and the need for good communications among cooperating work groups.

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ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION FOR SIX VIOLATIONS IDENTIFIED IN NRC SPECIAL INSPECTION REPORT 50-255/97-014(DRS)

3.

Standards for procedure use and compliance, communications, pre-job preparation and briefings, control of work scope and documentation, and responses to unexpected conditions have been established or clarified in the Maintenance Department. A monitoring program against these standards has

• been implemented.

4.

The Operations Department developed a lessons learned package which was used by each Shift Supervisor to brief his crew. The package reviewed the event in detail, identifying each point at which an opportunity to avoid problems using already established procedures was missed. They also reviewed several important behavior topics including the criteria for determining the need for post maintenance testing.

As a result of actions taken, planning personnel and operating crews are more consistent and aggressive in their consideration of post maintenance testing needs, and the resulting performance of appropriate testing has improved.

Corrective Actions Remaining to Avoid Further Violations Each of the described actions has been completed.

Date by Which Eull Compliance Will Be Achieved The plant is currently in full compliance.

10

ATTACHMENT 2 CONSUMERS ENERGY COMPANY PALISADES PLANT DOCKET 50-255 LICENSEE EVENT REPORT 97-012 Control Rods Deenergized While in Power Operation 7 Pages

NRC FORM 366 U.S. NUCLEAR REGULA TORY COMMISSION APPROVED BY OMB NO. 31~104 (4/95)

EXPIRES 4130/98 LICENSEE EVENT REPORT (LER)

ESTIMATED BURDEN PER RESPONSE TO COUP!. Y WITH THIS MANDA TORY IN'ORlolf< TION COl.LECT10N ~:

50.0 HRS. REPOR"TED l£SSONS I.EARNED AAS!.

INCORPORATED INTO THE UCEHSlHG PROCESS ANll FED BACK TO INDUSTRY.

FORWARD COMMENTS REGARllfNG BURDEN ESTIMATE TO THE INFORMA T10N ANO

{See reverse for required number of digits/characters for each block)

RECORDS MANAGEMENT BRANCH (T-4 1'33). U.S. NUCLEAR REGULA TORY COWllSSION, WASHINGTON. DC 20555-0001, ANO TO THE PAPER'NORK REDUCTION PRO.ECT (3150-0104, OFFICE OF MANAGEMENT ANll BUOGET, WASHINGTON, DC 20503

• ,..._.~ FACIUTYNAME{1). CONSUMERS ENERGY COMPANY DOCKET NUMBER (2)

Page (3)

PALISADES NUCLEAR PLANT 05000255 1of7 TITLE (4) CONTROL RODS DEENERGIZED WHILE IN POWER OPERATION EVENT DATE (5)

LER NUMBER (6)

REPORT DATE (7)

OTHER FACILITIES INVOLVED (8)

MONTH DAY

. YEAR YEAR I SEQUENTIAL REVISION MONTH DAY YEAR FACILITY NAME DOCKET NUMBER NUMBER NUMBER 05000 10 17 97 97 012 00 01 26 98 FACILITY NAME DOCKET NUMBER 05000 OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR§: {Check one or more) (11)

-DE (9)

N 20.2201{b) 20.2203(a)(2)(v) 50.73(a)(2)(1) 50.73(a)(2)(iii) 20.2203(a)(1) 20.2203(8)(3)(1)

50. 73(a)(2)(ii) 50.73(a)(2)(x)

L (10) 080 20.2203(8)(2)(1) 20.2203(a)(3)(ii)

50. 73(a)(2)(iii) 73.71 I****************

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20.2203(a)(2)(ii) 20.2203(a)(4)

50. 73(8)(2)(iv) x OTHER 20.2203(8)(2)(iii) 50.36(c)(1)

50. 73(8)(2)(v)

Voluntary Report

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20.2203l8lC2)(ivl

• 50.36{c){2l

50. 73{a)(2){vii)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER (Include Area Code}

Charles S. Kozup (616) 764-2241 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE

AUSE.

SYSTEM COMPONENT MANUFACTURER REPORTABLE TONPRDS TONPRDS AA CNTR A160 N

SUPPLEMENTAL REPORT EXPECTED (14)

MONTH DAY YEAR YES x I NO EXPECTED If yes, COMPLETE EXPECTED COMPLETION DATE SUBMISSION DATE (15)

ABSTRACT At 2102 hours0.0243 days <br />0.584 hours <br />0.00348 weeks <br />7.99811e-4 months <br /> on October 16, 1997, during power escalation to 85% power, it was noted that control rod #38 did not move as expected. The plant power escalation was ceased and the power*

level was held at 80% until the repairs to control rod #38 and repairs to a secondary side pump were completed. For personnel safety during the repair, the control room personn.el elected to remove rod drive power from all control rod drive mechanisms, thus rendering the control rods immovable from the control room. However, the ability to trip the control rods was retained. The control room personnel did not question the appropriateness of disabling a reactivity control system, did not recognize it was a procedure violation, and failed to realize that they had entered a Technical Specification LCO action statement. In addition, maintenance procedures were violated and the authorized scope of the maintenance work order was exceeded. Plant management did not initially identify the significance of this event. Later in the event, management initiated a multidisciplinary root cause analysis. The regulatory significance of this event stems from the simultaneous failure of multiple barriers, any one of which should have prevented this event. A multidiscipline root cause analysis team identified the causes for the event. Corrective actions are underway.

NRC FORM 366a 4/95 U.S. NUCLEAR REGULA TORY COMMISSION LICENSEE EVENT REPORT (LER)

-- - -EAClllTY NAME 1 CONSUMERS ENERGY COMPANY PALISADES NUCLEAR PLANT TEXT CONTINUATION DOCKET 2 05000255 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

EVENT DESCRIPTION LER NUMBER 6 g SEQUENTIAL REVISION 11 ____ __._ __

N_UM_B_ER __

..._N_U_MB_E_R~

]

012 00 YEAR 97 At 2102 hours0.0243 days <br />0.584 hours <br />0.00348 weeks <br />7.99811e-4 months <br /> on October 16, 1997, during power escalation to 85% power, it was noted that control rod #38 did not move as expected. When a withdrawal signal was applied to the group of control rods, control rod #38 moved into the core approximately one inch. The control rod was declared inoperable and the power escalation was ceased. The power level was held at 80% until the repairs to the control rod drive contactor and repairs to a secondary side* pump could be completed.

Engineering management,' a maintenance planner, an electrical repairman and the system engineer reported to the site to support the maintenance planning. The Operations Superintendent was contacted by telephone and the plans were discussed with him.. The next shift continued to support the work to repair control rod #38. The "A" shift (0000-0800 hours, Friday, October 17, 1997) control room supervisor, the system engineer and the electrical repairman questioned the adequacy of the workman's protective tag out recommended by the previous shift because it did not remove all power to the electrical contactor for control rod #38 which had been identified as the deficient component..

This discussion led to a decision to expand the tag out to include electrical panel C15 which would emove all power from the electrical contactor for control rod #38. This action also removed rod drive ower from all 45 control rods.

The "A" shift control room supervisor, the shift engineer and the three nuclear control operators discussed actions to be taken in the event of a plant transient. The control rods remained capable of being tripped arid the operators recognized that for certain transients a plant trip would be required.

At 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br />, October 17, 1997, the control rod drive power for all control rods was tagged out and the work to clean the contactor for control rod #38 was started. As the electrical repairman finished the maintenance on the electrical contactor, he and the system engineer decided to remove another contactor (for control rod #3), to determine if it needed cleaning. The system engineer and the electrical repairman made a recommendation to the control room supervisor that additional contactors needed to be worked. The control room supervisor discussed this recommendation with the shift supervisor. The shift supervisor came to the job site to examine the situation. To demonstrate the need for the additional contactor work, the electrical repairman removed two additional contactors to show the shift supervisor. At this time, the shift supervisor recognized that all rod drive power to the control rods was deenergized.

The shift supervisor returned to the control room to discuss the status of the control rod drive system with the control room supervisor, shift engineer and the nuclear control operators. The shift supervisor reviewed Technical Specification 3.10.4.b, and determined that a twelve hour action statement had unknowingly been entered. At 0457 hours0.00529 days <br />0.127 hours <br />7.556217e-4 weeks <br />1.738885e-4 months <br />, the control rod drive power was returned to service. At 0620 hours0.00718 days <br />0.172 hours <br />0.00103 weeks <br />2.3591e-4 months <br />, the post maintenance testing of control rod #38 was completed and control rod #38 was declared operable. At 0730 hours0.00845 days <br />0.203 hours <br />0.00121 weeks <br />2.77765e-4 months <br />, the shift supervisor initiated a condition report to investigate the ack of recognition that a Technical Specification twelve hour action statement had been entered.

NRC FORM 366a U.S. NUCLEAR REGULA TORY COMMISSION 4/95 LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION

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-FACILITY NAME l1 l DOCKETl2l LER NUMBER Sl PAGE CONSUMERS ENERGY COMPANY YEAR I SEQUENTIAL REVISION NUMBER NUMBER PALISADES NUCLEAR PLANT 05000255 30F7 97 012 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

Following plant management review of the incident on 8 shift (0800-1600 hours), Friday, October 17, 1997, the "A" shift licensed operating crew*was relieved of shift duties until remediation activities were completed.

On Monday, October 20, 1997, during a management interview with the electrical repairman who performed the work on control rod #38, it was recognized that three additional contactors had been removed and reinstalled on October 17, 1997. At 1520 hours0.0176 days <br />0.422 hours <br />0.00251 weeks <br />5.7836e-4 months <br />, a condition report was initiated to investigate why activities outside the authorized work scope had been performed. At 1550 hours0.0179 days <br />0.431 hours <br />0.00256 weeks <br />5.89775e-4 months <br />, an operability determination was completed and the three control rods which had their contactors

• removed early Friday morning, October 17, 1997, were found to be operable. At 1734 hours0.0201 days <br />0.482 hours <br />0.00287 weeks <br />6.59787e-4 months <br />, control rod exercising was completed to confirm the operability of these three control rods.

On October 31, 1997, the shift supervisor initiated a condition report to investigate why the three control rods were declared operable on October 20, 1997; before completion of their post-maintenance testing.

On November 25, 1997, during a formal management review of the initial evaluation of the condition report on the lack of recognition that a Technical Specification twelve hour action statement had been entered, it was concluded that additional investigation of the event was warranted. This resulted in a multidiscipline team being assigned to further investigate the event and search for its causes.

ANALYSIS OF THE EVENT Our analysis of the event determined that several barriers incorporated into our work processes failed during the planning, execution and post job revie~ of this control rod drive repair effort. These failed barriers manifested themselves as procedural violations because the barriers are contained in procedures.

During maintenance planning, control room personnel elected to remove power from the control rod drive mechanisms, rendering the control rods immovable from the control room operator's control switch. Although the ability to trip the control rods was retained, control room personnel did not question the appropriateness of disabling a reactivity control system and failed to realize that they had entered a Technical Specification LCO action statement. Procedures were violated in that 1) a procedure prerequisite stating that only one control rod could be deenergized was signed attesting that the prerequisite had been met, and 2) the safety significance of removing power to the control rods was*not evaluated by a risk-based assessment prior to performing work.

0 NRC FORM 366a 4/95 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)

• FACILITY NAME 1 CONSUMERS ENERGY COMPANY PALISADES NUCLEAR PLANT TEXT CONTINUATION DOCKET2 05000255 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

LERNUMBER 6 PAGE YEAR SEQUENTIAL REVISION

• 1 ___ __.__N_uM_e_ER_..__N_u_MB_E_R -4* 4 OF 7 97 012 00 During maintenance troubleshooting, operations and maintenance personnel failed to realize that the approved work order scope had been exceeded by removing, inspecting and reinstalling the three additional control rod drive relay contactors. Procedures were violated since the approved work order scope only allowed work to be performed on control rod drive #38. In addition, procedures were violated when the disassembly and inspection of the three additional contactors went undocumented in the work order summary.

During the post maintenance phase, testing of the three additional contactors after their removal, inspection and cleaning was not performed as required by procedures prior to declaring the control rods operable. In addition, at 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br /> on October 20, 1997, when the failure to perform a post maintenance test was discovered, the control rods should have been declared inoperable pending

. completion of the post maintenance test, even though it was believed that the contactors would function. Declaring the control rods inoperable and entering the TS 3.10.4.b action statement would have been prudent until the control rod status could be confirmed.

uring the initial oversight of these activities, management did not identify the significance of this vent. Based upon subsequent management reviews, a multidiscipline root cause* analysis team was formed to further evaluate the event. The evaluation identified the causes for failure of barriers to have prevented inadequate performance. Corrective actions have been developed to preclude similar events and to strengthen the barriers which assure safe plant operation.

SAFETY SIGNIFICANCE A reactivity control system was disabled without appropriate questioning and planning by the control room personnel. This event has regulatory significance in that multiple barriers which provide defense-in-depth failed to prevent this event from occurring. The plant evaluation of this event focused on why these barriers failed and what could be done to assure repetitive failures do not occur.

The actual nuclear safety significance of this event was low because of the following:

1.

Removing control rod power did not affect reactor trip eapability. The ability to trip all control rods was retained throughout the event.

2.

Palisades design takes no safety credit for normal control rod drive capability to respond to events.

3.

The crew clearly recognized the impact on the plant of removing control rod power and was prepared to respond to any transient condition.

NRC FORM 366a 4/95 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)

FACILITY NAME 1 CONSUMERS ENERGY COMPANY PALISADES NUCLEAR PLANT TEXT CONTINUATION DOCKET 2 05000255 TEXT (If more space is required, use additional copies of NRC Fonn 366A) (17)

YEAR LER NUMBER 6 g SEQUENTIAL REVISION n-~__._~N-UM_B_ER~..._N_U_MB_E_R~

?

97 012 00

4.

The plant remained in compliance with the operating license since all control rods were returned to service within eight hours and Technical Specification 3.10.4.b requires the reactor be placed in Hot Shutdown within twelve hours if more than one control rod becomes inoperable.

5.

Testing proved that the control rods which had been returned to service without a post maintenance test would have functioned throughout this period, and the Technical Specification had not been violated.

CAUSE OF THE EVENT Our evaluation identified causes which contributed to the failure of individual barriers to prevent inadequate performance. We also identified the underlying root cause contributing to the failure of multiple barriers.

Contributing causes:

Inadequate understanding of Technical Specifications and plant equipment status.

This inadequacy led to the failure to understand, prioritize and control emergent work.

2.

Failure to maintain procedural compliance and work order conditions.

This failure led to inadequate risk assessment, verification and documentation of emergent work.

3.

Inadequate communication within and between working groups. This inadequacy led to a reduction in our depth of defenses and relinquished opportunity to effectively question our work plans.

Underlying Root Cause:

Plant standards and management expectations which failed to promote consistent high quality performance. Some plant standards do not provide sufficient guidance or were not used to achieve expected performance. All departments involved in this event engaged in work activity without performance expectations explicitly conveyed.

~.

NRC FORM 366a 4/95 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)

_ FACILITY NAME 1 CONSUMERS ENERGY COMPANY PALISADES NUCLEAR PLANT TEXT CONTINUATION DOCKET 2 05000255 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

CORRECTIVE ACTIONS COMPLETED LER NUMBER 6 g SEQUENTIAL REVISION 11 ____ _._ __

N_UM_B_ER __..._N_U_MB_E_R_

?

012 00 YEAR 97 A number of remedial actions have been taken to improve procedural compliance, communications among work groups, management of emergent work, and the understanding of technical specifications and plant equipment status. These actions include:

1.

Plant Management reviewed the event and suspended the "A" shift licensed operators from licensed duties 1.mtil remedial activities were completed and documented.

2.

Post-maintenance testing was performed to verify the operability of all control rods suspected of being involved. *

3.

The Operations Superintendent briefed all operating crews on the shift communications, emergent work planning and Technical Specifications which were specific to this event; and the plant expectations for effective shift communications, emergent work planning, and Technical Specification interpretation and compliance.

An internal review was performed by Electrical Maintenance, and the incident was reviewed with the electrical repairman involved. The event was reviewed with all Maintenance repair workers in a series.of stand down meetings. The Maintenance and Construction Manager held follow up meetings with all Maintenance groups.

In addition, a memorandum was issued by the Maintenance Manager to department staff to clarify expectations for signing procedure prerequisites.

5.

A System Engineering Department staod down meeting was conducted where the following management expectations were reviewed: 1) understanding Technical Specifications,

2) conducting work order and procedure reviews prior to commencing work in the field, and

3) performing pre-job briefs before starting multiple department tasks or significant emergent work.

CORRECTIVE ACTIONS TO BE COMPLETED.

Corrective actions which will be completed include:

1.

Establish or clarify and communicate fundamental standards in the areas of: procedure use and compliance_, pre-job preparation and briefings, communications, control of work scope, documentation of work, response to unexpected and unanticipated conditions, Technical Specification knowledge.

2.

Improve the mechanism for managing emergent work and extend the outage management support until the normal thirteen week schedule activities resume following an outage.

• NRC FORM 366a 4/95 U.S. NUCLEAR REGULA TORY COMMISSION LICENSEE EVENT REPORT (LER)

FACILITY NAME 1 CONSUMERS ENERGY COMPANY PALISADES NUCLEAR PLANT TEXT CONTINUATION DOCKET 2 05000255 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

LER NUMBER 6 g SEQUENTIAL REVISION it-~--'...._N_U_M_BE_R~.._N_U_MB_E_R--1

]

012 00 YEAR 97

3.

Implement more effective management involvement within the corrective action and self-assessment programs to identify performance trends and implement actions which prevent the recurrence of inadequate performance.

4.

Perform a future self-assessment to evaluate the effectiveness of these corrective actions.