ML18101A446
| ML18101A446 | |
| Person / Time | |
|---|---|
| Site: | Salem  |
| Issue date: | 12/23/1994 |
| From: | Hagan J Public Service Enterprise Group |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NLR-N94228, NUDOCS 9501050483 | |
| Download: ML18101A446 (16) | |
Text
Public Service Electric and Gas Company Joseph J. Hagan Public Service Electric and Gas Company
- P.O. Box 236, Hancocks Bridge, NJ 08038 609-339-1200 Vice President - Nuclear Operations DEC 2 31994 NLR-N94228 United States ~uclear Regulatory Commission Document Control Desk Washington, DC 20555 Gentlemen:
RESPONSE TO NRC'S NOTICE OF VIOLATION INSPECTION REPORT 50-272/94-24; 50-311/94-24 DOCKET NOS. 50-272; 50-311 Public Service Electric and Gas (PSE&G) has received the NRC Inspection Report 50-272/94-24, 50-311/94-24, dated November 28, 1994.
Within the scope of this report, four violations of NRC regulations were identified.
Accordingly, in Attachment I to this letter, PSE&G submits its respons~ to the identified violations.
Attachment II contains PSE&G's assessment and response to the inadvertent cut of the 4160V cable.
Should you have any questions regarding this transmittal, please do not hesitate to contact me.
Sincerely, 9501050483 941223
~DR ADOCK 05000272 PDR A'*f/D\\ i
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I
Document Control Desk NLR-N94228 Attachments (2) 2 C
Mr. L. N. Olshan, Licensing Project Manager U.S. Nuclear Regulatory Commission One White Flint North 11555 Rockville Pike Rockville, MD 20852 Mr. c. s. Marschall (S09)
USNRC Senior Resident *Inspector Mr. T. T. Martin, Administrator - Region I U.S. Nuclear Regulatory Commission 475 Allendale Road King of Prussia, PA 19406 Mr. Kent Tosch, Manager, VI New Jersey Department of Environmental Protection Division of Environmental Quality Bureau of Nuclear Engineering CN 415 Trenton, NJ 08625 OEC 231994 95-4933
OEC 2 31994 REF:
NLR-N94228 STATE OF NEW JERSEY SS.
COUNTY OF SALEM J. J. Hagan, *being duly sworn according to law deposes and says:
I am Vice President - Nuclear Operations of Public Service
- Electric and Gas Company, and as such, I find the matters set forth in the above referenced letter, concerning the Salem Generating Station, Unit Nos. 1 and 2, are true to the best of my knowledge, information and belief.
Subscribed before me this J..3 1994 BARBARA A. POWELL
'NOTARY PUBUC Of NEW JERSEY My Commission expires on MytumrissionE1piresDec.2. 1998
~~~~---'~-----it~o+1~21M&~o3~21--~~~-
RESPONSE TO NRC'S NOTICE OF VIOLATION INSPECTION REPORT 50-272/94-24; 50-311/94-24 DOCKET NOS. 50-272; 50-311 NLR-N94228 ATTACHMENT I V:IOLAT:ION A 10 CFR 50, Appendix B, Criterion XVI requires, in part, that licensees establish measures to assure that conditions adverse to quality are promptly identified and corrected.
The facility Operating License for Salem Nuclear Generating station, Unit No. 2, requires that PSE&G operate the facility at steady state reactor core power levels not in excess of 3411 megawatts (thermal).
Contrary to the above, from July 23, 1993 until January 19, 1994, the licensee failed to promptly identify and correct sustained periods of steady state reactor core power levels of up to 3499 megawatts (thermal).
THE REASON FOR THE V:IOLAT:ION PSE&G does not dispute the violation.
In the Fall of 1992 PSE&G noticed a slight increase in generator electrical output.
Salem station management requested the Technical Department to investigate the apparent increase in megawatt electrical (MWe) output to ensure that thermal power was not exceeded.
Technical Department investigation concluded that thermal power was not being exceeded, and that the observed increased electric output was due to increases in secondary side efficiency.
This conclusion was reached based upon a comparison of specific plant operational data from cycles 5 and 6 to cycle 7.
Additionally, plant modifications performed during cycle 6 were reviewed with the appropriate vendors and it was concluded that the increase in MWe output was within the expected efficiency gain due to the modifications.
Late in the Fall of 1993, another MWe increase was noted, and plant management limited generator output to 1180 MWe.
Early in 1994, a full investigation was undertaken which eventually led to the conclusion that Unit 2 was operated above its rated thermal power.
ATTACHMENT I NLR-N94228 2 -
The root cause of this event has been attributed to an error in f eedwater flow rate indication due to erosion (bypass flow) of the feedwater flow noz:!:les.
Failure to track statepoint data, and failure to properly review industry experience were identified contributing causal factors.
Further information is documented in Licensee Event Report (LER) 311/94-002 dated 02/17/94 and supplements dated March 9 and 30, June 29, and August 12, 1994.
CORRECTIVE STEPS THAT HAVE BEEN TAKEN Power and protection setpoints were reduced to ensure plant operation would remain within licensed limits.
Flow measurements using a Caldon Leading Edge Test ultrasonic flow meter were performed in Unit 2 to determine actual feedwater flow.
Once installed, this equipment continued to monitor feedwater flow for the remainder of the cycle.
A*tracking and trending program was established for statepoint and calorimetric data.
The program's primary focus is to ensure that plant parameters remain within acceptable design limits.
The feedwater flow nozzles have been replaced during the unit's eighth refueling outage.
Safety analyses were performed which documented acceptable consequences, for past plant operation, at power levels up to 104.5 percent of rated thermal power.
Therefore, the safety significance of the overpower condition was determined to be minimal.
PSE&G is evaluating this event for Part 21 applicability.
CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS The feedwater nozzles were removed during the unit's eighth refueling outage.
An evaluation/analysis of these components is being performed and PSE&G will provide the NRC with the results by the end of February 1995.
Any additional corrective actions stemming from this evaluation will be assessed at that time.
DATE WHEN FOLL COMPLIANCE WILL BE ACHIEVED PSE&G is in full compliance.
ATTACHMENT I NLR-N94228 VIOLATION B 3 -
Technical Specification 4.3.1.1.1 for Salem Unit 2 requires that each reactor trip system instrumentation channel shall be demonstrated operable by the performance of the channel calibration as shown in Table 4.3-1.
Table 4.3-1 specifies that the power range neutron flux functional unit shall be calibrated by heat balance daily for power operation above 15%.
Technical Specification 1.13 defines daily as at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
Technical Specification 4.0.2 requires that each surveillance requirement shall be performed within the specified interval with a maximum allowable extension not to exceed 25% of the specified surveillance interval.
Contrary to the above, with the reactor power above 15%, on October 12, the licensee failed to perform the required daily calorimetric of the NIS within the variance allowed by the Technical Specification.
THE REASON FOR THE VIOLATION PSE&G does not dispute the violation
- At the time of the event a controlled unit shutdown was in progress in preparation for the unit's scheduled refueling outage.
Consequently, the operating crew erroneously assumed that the calorimetric would not be required because the unit would be in a non-applicable mode (less than 15% rated thermal power (RTP)) at the end of the 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
The operating crew assumption that the calorimetric did not have to be performed was based on the belief that "every 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />" meant or was equivalent to "daily".
The root cause of this event has been attributed to personnel error.
Personnel involved failed to follow and adhere to procedural requirements and supervision failed to properly review the shift routines.
Additionally, less than adequate training was identified as a contributing causal factor.
CORRECTIVE STEPS THAT HAVE BEEN TAKEN Operations management reviewed all other 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or less required surveillances to ensure Technical Specification (T.S.)
compliance.
The review did not identify any other violations.
The shift routine procedure (SC.OP-DD.ZZ-OD40(Z)) was revised to clarify the surveillance frequency.
On November 8, 1994, a Night Order Book (NOB) entry was made which described the.
procedure change and required all Senior Supervisors to review the change with th~ir licensed operators.
ATTACHMENT I NLR-N94228 4 -
An Operations clarification (NOB entry) to the meaning of the surveillance requirement frequency was issued on October 26, 1994.
Licensed personnel involved in this event have been counseled concerning their actions and management's expectations regarding procedural compliance.
A Licensee Event Report (LER) 311/94-012 was issued on November 14, 1994.
CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS All licensed operators will receive training specific to this event and T.S. surveillance frequency requirements.
Additionally, the training center will review its initial licensing training to ensure proper focus is placed on T.S.
surveillance frequency requirements.
Operations management will revise SC.OP-DD.ZZ-OD40(Z) to separate T.S. required surveillances from routine non-T.S. requirements.
This will be accomplished by 2/28/95.
This event will be reviewed with all licensed operators and selected personnel from Technical Department (Reactor Engineering Group) to ensure proper understanding of the T.S. surveillance frequency requirements.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED PSE&G is in full compliance.
ATTACHMENT I NLR-N94228 VIOLATION C 5 -
Technical Specification 3.9.4 for Salem Unit 2 requires that during core alterations or movement of irradiated fuel within the containment, the containment building penetrations, providing direct access from the containment atmosphere to the outside atmosphere, shall be either (1) closed by an isolation valve, blind flange, or manual valve, or (2) be capable of being closed by an operable automatic containment isolation valve.
Contrary to the above, the licensee moved irradiated fuel from 11:38 p.m. on October 24, 1994, to 1:10 a.m. on October 25, 1994, with a release pathway from open service water vent valves in containment to open service water drain valves outside of contain~ent.
THE REASON FOR THE VIOLATION PSE&G does not dispute the violation.
As stated above, Technical Specification (T.S.) 3.9.4 for Salem Unit 2 requires, in part, that during core alterations or movement of irradiated fuel within the containment, the containment building penetrations, providing direct access from the containment atmosphere to the outside atmosphere, shall be either (1) closed by an isolation valve, blind flange, or manual valve, or (2) be capable of being closed by an operable automatic containment isolation valve.
Between 11:38 p.m. on October 24, 1994, and 1:10 a.m. on October 25, 1994, PSE&G moved fuel in containment without having all penetrations closed. (Service water vent valves were open in containment and servica water drain valves were open outside containment, in the auxiliary building, elevation 78 Ft).
The potential release pathway (described above) did not provide a direct access from the containment atmosphere to the outside atmosphere.
During the period specified above, the auxiliary building exhaust filtration system was in service in its normal configuration with the Roughing and HEPA filter train in service, and the Charcoal filter train in standby.
Additionally, the plant vent radiation monitors (particulate, gas, iodine) were in service and capable of detecting and isolating the plant vent if required.*
ATTACHMENT I NLR-N94228 6 -
NUREG 0800 (Standard Review Plan) Section 15.7.4 (Radiological Consequences of Fuel Handling Accidents) Acceptance Criteria (part II Nos.1 and 5, Pg. 15.7.4-3)) states, in part:
"The plant site and dose mitigating ESF systems are acceptable * *
- if the calculated whole-body and thyroid doses at the exclusion area *.
- are well within the exposure guidelines of 10 CFR Part 100 * *
"The containment design is acceptable with respect to a postulated fuel handling accident if it possesses the capability from prompt radiation detection by use of redundant radiation monitors and automatic isolation, if fuel handling operations inside containment occur when the containment is open to the outside atmosphere (i.e., with a containment purge exhaust system). An acceptable alternative approach is containment venting through an ESF atmosphere cleanup system or containment isolation during fuel handling operations."
NUREG-0800 finds an acceptable containment design for postulated fuel handling accidents, a containment which is capable of being isolated or one that filters the releases through an ESF-type filtration system.
As discussed above, the potential release path was being filtered, monitored, and capable of being isolated.
However, PSE&G recognizes that it had not provided adequate guidance and training to ensure that the filtration system would be in service, and consequently does not dispute the violation.
The reason for the violation has been attributed to personnel error.
The SRO failed to conduct an adequate review of the off-normal and tagged components prior to commencing fuel movement.
A contributing *factor to this event was less-than-adequate outage planning and scheduling associated with the service water work and the required containment closure for fuel movement.
CORRECTIVE STEPS THAT HAVE BEEN TAKEN Fuel movement was stopped.
The open drain valves outside containment were closed and the piping integrity between these valves and the containment was verified.
The Off-Normal and Off-Normal Tagged component lists were reviewed. This review did not indicate any additional discrepancies.
ATTACHMENT I NLR-N94228 7 -
Procedure S2. OP-S~. CAN*-0007 (Q) "Refueling Operations -
Containment Isolation" was revised.
The revision moved the requirement to review the Component Off-normal and the Off-normal Tagged lists from the Prerequisite" section to the implementing steps to give this requirement more focus.
This revision was performed on October 25, 1994.
An information directive was issued.to reiterate management expectations associated with review of the Component Off-normal/Tagged lists.
A Licensee Event Report (LER) 311/94-013 was issued on December 7, 1994.
CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS Outage management will perform a review of its outage planning and scheduling process.
The focus of this review is to identify appropriate controls that can be put in place to prevent conflicting activities that could affect containment closure.
This event will be included in the next scheduled segment of Salem licensed operator requalification training.
Additionally, this event will be shared with Hope Creek operations for lessons learned.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED PSE&G is in full compliance.
ATTACHMENT I NLR-N94228 VIOLATION D 8 -
The NRC-approved Artificial Island Security plan section 5.6 requires measures to insure control of access to vital areas at Salem Unit 2.
Post orders to control access to the Salem Unit 2 No. 2C Emergency Diesel Generator (EDG) requires that the security guard verify that persons entering the EDG room had proper authorization prior to granting access.
Contrary to the above, on October 24, a security guard permitted two persons to enter the Salem Unit 2 No. 2C EOG room without verifying proper authorization prior to granting access.
THE REASON FOR THE VIOLATION PSE&G does not dispute the violation.
Because the individuals entering the area (NRC inspectors) were authorized for the area, the Security Force Member (SFM) did not check/verify the authorization list for the individual's name.
The violation has been attributed to personnel error.
The SFM failed to follow the direction provided in the applicable Post Order Compensatory Post 2 (PO CP2).
CORRECTIVE STEPS THAT HAVE BEEN TAKEN The SFM was immediately relieved from duty and replaced with another SFM.
The SFM involved was retrained and certified in performance of Artificial Island Security Training & Qualification Plan Task 4 -
Control Access in an Emergency or on a Compensatory Post.
This incident was discussed with Security force personnel during shift briefings.
Particular emphasis was placed on the importance of following post orders, regardless of the identity or perceived status of the person involved.
Appropriate disciplinary action was taken with the involved SFM.
Follow-up random self-assessment surveys and subsequent performance indicate that the measures taken were effective.
All personnel surveyed were aware of this incident and were cognizant of the requirement to follow post orders explicitly
- ATTACHMENT I NLR-N94228 9 -
CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS PSE&G believes that no additional actions than that described above are necessary to prevent recurrence.
DATE WHEN FOLL COMPLIANCE WILL BE ACHIEVED PSE&G is in full compliance
- RESPONSE TO NRC'S INSPECTION REPORT 50-272/94-24; 50-311/94-24 DOCKET NOS. 50-272; 50-311 NLR-N94228 ATTACHMENT II PSE&G ASSESSMENT OF THE INADVERTENT CUT OF 4160V CABLE BACKGROUND AND ROOT CAUSE Design Change Package (DCP) lSC-2269, Package 7, provided a new power source to the Unit 2 circulators via switchyard modifications.
The specific work activity involved routing new cables from the new switchyard power source, in the existing cable tray, and splicing these to the old cables.
In Qrder to perform the splice, the.old cable in the cable tray had to be cut and, due to cable fill, a section of that cable had to be removed.
On October 29, 1994, a tagged out and de-energized 4160V (4KV) cable was incorrectly cut during demolition activities associated with removing the old cable.
An immediate work standdown was initiated to prevent recurrence of a similar event, while an extensive investigation into the root cause was undertaken.
Because of the seriousness of this event, it was treated as a "fatality," even though no personnel injuries occurred.
The investigation consisted of three independent and parallel efforts.
These were: (1) The responsible organization (Salem
.Projects) conducted its own assessment to identify "failed barriers" which could have prevented the event; (2) An independent review of the event was performed by the manager of Hope Creek Projects; and (3), because the event involved potential issues of inadequate human performance, a Human Performance Enhancement System (HPES) investigation was initiated.
That investigation is on-going.
The root cause of this event has been attributed to personnel error.
Before starting the work, the crew was instructed to use a hand-over-hand method to positively identify the cables to be cut.
The electrician performing this work correctly identified and made a first cut of the cable to be removed.
- However, because of interference in pulling the cable through the cable tray, the electrician visually traced the cable through the congested area and incorrectly cut a (different) de-energized cable.
This second cut was done inside the tray, instead of cutting outside the cable tray (as instructed).
A ~ominant causal factor identified during this investigation was a collective failure to appropriately identify the demolition of the 4KV cable as a "complex or critical activity" requiring increased, focused attention.
The critical and complex evolution was thought to be the initial identification of the cables to be cut.
That activity was clearly specified and well-controlled.
ATTACHMENT II NLR-N94228 2 -
However, once the original identification and initial cable cut were performed, the remaining demolition was not deemed to be "critical and complex" and was not given the amount of attention that it deserved.
A number of "causal factors" and "failed barriers" have been identified.
These included contractor supervisory oversight, PSE&G installation oversight, adequate pre-job briefing, and the work package instructions.
The increased contractor supervisory oversight was concentrated on the cable being installed in the control and relay rooms.
The contract supervisor and the Installation & Test Engineer did not observe any significant portion of the cable demolition.
Other activities that had been determined "critical and complex" occurring in the relay rooms took priority over this evolution.
The DCP, package No. 7, contained all the necessary information and cautions, including the requirement to positively identify the cable, to remove 4 to 5 feet of cable from the cable tray, to cut the cable outside the tray, and a caution regarding energized cables.
The (field) work package, prepared by the project team, lacked the requirement to cut the cable outside the tray and the caution regarding energized cables.
Several other contributing factors were identified.
These are:
less-than-adequate communication between the job foreman and the craft electrician, inadequate self-checking on the part of the craft electrician, less-than-adequate task-specific training, and less-than-adequate planning and identification of specific work conditions.
PSE&G has compared this event to one that occurred during lRll, in which an electrician inadvertently cut through an energized 125Vdc cable (NRC Inspection Report 50-272/93-23 and 50-311/93-23).
Although similar, these two events are not related.
The corrective actions taken for the lRll event were effective with respect to taking unsigned work packages into the field, and improved tagging practices. It should be noted that, in the event described herein, both the craft electrician and the supervisor walked down the job to ensure that the cables identified for removal were properly tagged.
However, corrective actions with regard to communicating PSE&G expectations on procedural adherence and work standards were not effective in preventing this event.
ATTACHMENT II NLR-N94228 CORRECTIVE ACTIONS TAKEN 3 -
Immediate corrective actions taken were:
Imposed a standdown of all cable demolition and electrical work Initiated an HPES evaluation Performed a focused-review of the event with contract craft and supervisors Implemented short-term corrective actions which included:
No work was conducted in the field while supervision was involved in turnov2r meetings.
Activities such as general housekeeping of the area, job walkdowns, and training were allowed.
Current and planned modifications for this outage (2R8) were reviewed to insure key work standards were inpluded in the field work packages.
Established the following requirements for power cable work -
Any cutting, splicing, demolition or termination will be double-verified.
In addition, prior to cable cutting, the person performing the cut and a non-manual supervisor must verify the cut and record the cut on the Cable Cutting Checklist.
Supervisors providing second verification must be on the approved tagging list.
Cable trays will be walked down prior to the start of work to verify that all cables installed in the tray adjacent to the cable to be removed have been identified, and (if possible) tagged out.
Pre-job briefings will be held before the start of work and a mid-shift review is conducted and recorded in the Communications Checklist after each lunch and dinner break.
Prior to the start of remaining demolition activities, reviews were conducted to insure that these short-term corrective actions were incorporated in work packages.
IJ ATTACHMENT II NLR-N94228 4 -
CORRECTIVE ACTIONS TAKEN TO PREVENT RECURRENCE The current training (Phase A and B) for contractors will be re-assessed to consider the testing of personnel to assure a minimum level of knowledge, understanding, and cognizance of PSE&G expectations.
The procedure "Installations, Salem Generating station" (SC.DE-TS. ZZ-2034 (Q)) will be revised to incorporate appropriate short-term corrective actions.
Lessons learned from this event and short-* and long-term corrective actions are being evaluated for applicability to other departments such as Station Maintenance and Site Maintenance.
The process to assess or identify complex and critical activities will be re-evaluated.