ML18152A548

Responds to NRC 951019-1122 Ltr Re Violations Noted in Insp Repts 50-280/95-20 & 50-281/95-20 on Stated Date.Corrective Actions:Immediate Actions Initiated to Restore & Maintain RCS Inventory & to Ensure Outage Activities Controlled

ML18152A548
Person / Time
Site:	Surry
Issue date:	12/22/1995
From:	Ohanlon J VIRGINIA POWER (VIRGINIA ELECTRIC & POWER CO.)
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
95-624, NUDOCS 9512290048
Download: ML18152A548 (14)

Text

VIRGINIA ELECTRIC AND POWEB. COMPANY

• RICHMOND, VIRGINIA 23261 December 22, 1995 United States Nuclear Regulatory Commission Serial No.95-624 Attention: Document Control Desk

• SPS/BCB/GDM RS' Washington, D. C. 20555 Docket Nos. 50-280 50-281 License Nos. DPR-32 DPR-37 Gentlemen:

VIRGINIA ELECTRIC AND POWER COMPANY SURRY POWER STATION UNITS 1 AND 2 REPLY TO A NOTICE OF VIOLATION NRC INSPECTION REPORT NOS. 50-280/95-20 AND 50-281/95-20 We have reviewed Inspection Report Nos. 50-280/95-20 and 50-281/95-20 dated October 19, 1995 and your November 22, 1995 letter and enclosed Notice of Violation for Surry Unit 1. While the violations were not individually safety significant, we recognize their collective and potential implications and understand that they did not meet our standards for unit operations or regulatory compliance.

We have taken extensive actions to identify the underlying causes of the events leading to the violations and to implement actions to prevent recurrence of similar events. The most significant issue associated with these violations was the failure of operations personnel to comply with established standards for supervisory control, communications, configuration control, and procedural usage. We have taken action to ensure that these standards are clearly understood and implemented by station operations personnel. Disciplinary action, including the removal of an individual from licensed duties, was taken to reinforce the need for compliance with the established standards.

Additional corrective actions and enhancements are discussed in the attached violation response. We are confident that these actions and our continued monitoring of operations activities will prevent recurrence of similar events.

We have no objection to this letter being made a part of the public record. Please contact us if you have any questions or require additional information.

Very truly yours, James P. O'Hanlon

• • . Senior Vice President - Nuclear 9512290048 951222 PDR ADOCK 05000280 G PDR

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• Attachment cc: U.S. Nuclear Regulatory Commission Region II 101 Marietta Street, N.W.

Atlanta, Georgia 30323 Mr. M. W. Branch NRC Senior Resident Inspector Surry Power Station

• REPLY TO A NOTICE OF VIOLATION NRC INSPECTION CONDUCTED SEPTEMBER 14 - OCTOBER 4, 1995 SURRY POWER STATION UNITS 1 AND 2 INSPECTION REPORT NOS. 50-280/95-20 AND 50-281195-20 NRC COMMENT:

"During an NRC inspection conducted on September 14 through October 4, 1995, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the violations are listed below: '

A. 10 CFR 50, Appendix B, Criterion V, as implemented by the Surry Operational Quality Assurance Program Topical Report (VEP-1-5A), Section 17.2.5, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality be prescribed by and accomplished in accordance with documented procedures of a type appropriate to the circumstances.

For operational activities affecting quality these requirements are implemented, in part, by Virginia Power Administrative Procedure (VPAP)-1401, Conduct of Operations, Revision (Rev.) 1; Operations Department Administrative Procedure (OPAP)-0005, Shift Relief and Turnover, Rev. 4; and OPAP-0002, Operations Department Procedures, Rev. 3.

VPAP-1401, Section 6.1.12.b.1, requires that the Shift Supervisor and the Unit Senior Reactor Operator maintain, as a matter of highest priority, the broadest perspective of operational conditions affecting the facility.

VPAP-1401, Section 6.1.12.c.2, requires that all shift team members be aware of station status at all times and that supervisory personnel monitor the performance of shift personnel who could affect station safety.

OPAP-0005, Section 6.1.4, requires that the departing shift make checks and remarks on the required shift relief checklist in a way that informs the relieving shift of information including significant or important inoperable equipment inc;:luding instrumentation. Section 6.1.5 also requires that the departing and relieving personnel discuss important items affecting plant operations.

OPAP-0002, Section 5.3.5, states that the Shift Supervisor and Unit Senior Reactor Operator are responsible for enforcing compliance with procedures as written .

• NRC COMMENT (Continued):

Contrary to the above, on September 13, 1995, activities affecting quality were not accomplished in accordance with documented procedures as evidenced by the following examples:

1. The Shift Supervisor and the Unit Senior Reactor Operator failed to maintain a broad perspective of operational conditions affecting the facility, in that, reactor coolant system inventory was reduced by approximately 4,500 gallons over an approximate five hour period without knowledge of the activity and its effect on unit safety.

2. Not all shift team members were aware of station status, in that, a unit control room operator unknowingly lowered reactor vessel water level when he conducted letdown operations to maintain standpipe level indication. Additionally, shift supervision did not properly monitor the operator performing this evolution which could have affected station safety.

3. The departing day shift failed to make remarks on the required shift relief checklist to inform the oncoming shift of important inoperable equipment.

Specifically, the isolation of the reactor coolant head vent which rendered the only means of reactor v~ssel level indication inoperable was not recorded on the shift relief checklist. Additionally, members of the departing and relieving shifts failed to discuss this important issue affecting plant operations.

4. The Shift Supervisor and Unit Senior Reactor Operator failed to enforce compliance with procedure 1-0P-RC-011, Pressurizer Relief Tank Operations, Rev. 1, for venting the Pressurizer Relief Tank as described in Violation C below.

8. Technical Specification 6.4 requires, in part, that detailed written procedures be provided for corrective maintenance activities which would have an effect on nuclear safety and that they be followed.

VPAP-2002, Work Request and Work Order Task, Rev. 5, partially implements these requirements for maintenance activities.

VPAP-2002, Section 5.7.1, requires that the Shift Supervisor review and approve work orders on permanent plant structures, equipment, and components.

• VPAP-2002, Section 5.7.2, requires that the Shift Supervisor align plant systems, as required, to support work order task activities .

• NRC COMMENT (Continued):

VPAP-2002, Section 5.7.4, requires that equipment be prepared for maintenance prior to approval of a work order.

Contrary to the above, on September 13, 1995, the Shift Supervisor who approved Work Order 00316472, Retract/Install Flux Thimbles, failed to ensure

• that the appropriate plant system was aligned to support the work order task requirements and failed to ensure that the appropriate equipment was prepared for maintenance prior to approval of the work order. Specifically, the Shift Supervisor failed to ensure that the reactor coolant system was depressurized.

C. Technical Specification 6.4 requires, in part, that detailed written procedures be provided for activities which would have an effect on nuclear safety and that they be followed.

Procedure 1-0P-RC-011, Pressurizer Relief Tank Operations, Rev. 1, Section 5.5, establishes the method for venting the pressurizer relief tank to the Vent Vent System. Steps 5.5.4, 5.5.5, and 5.5.6.a require that a Gaseous Group Release Permit be obtained for venting the pressurizer relief tank to the Vent Vent System; a poly hose be connected from valve 1-RC-ICV-5025 to the nearest containment purge exhaust; and, valve 1-RC-HCV-1549, PRT Vent, be closed, respectively.

Contrary to the above, on September 13, 1995, approved detailed written procedures were not followed to perform venting of the Unit 1 pressurizer relief tank as evidenced by the following:

1. No Gaseous Group Release Permit was obtained for venting the pressurizer relief tank to the Vent Vent System.

2. A poly hose was not connected from valve 1-RC-ICV-5025 to the nearest containment purge exhaust.

3. 1-RC-HCV-1549, PRT Vent, was not closed.

These violations represent a Severity Level Ill problem (Supplement I). This violation is applicable to Unit 1 only."

• REPL V TO A NOTICE OF VIOLATION NRC INSPECTION CONDUCTED SEPTEMBER 14 - OCTOBER 4, 1995 SURRY POWER STATION UNITS 1 AND 2 INSPECTION REPORT NOS. 50-280/95-20 AND 50-281/95-20 Violation A

1. Reason for the Violation, or, if Contested, the Basis for Disputing the Violation The examples of activities not accomplished in accordance with procedures are correct as stated.

1. The Shift Supervisor and unit Senior Reactor Operator (SRO) did not maintain a sufficiently broad perspective of operational conditions, as required by VPAP-1401, Conduct of Operations. The Shift Supervisor and unit SRO were monitoring operational evolutions that were in progress, but failed to recognize the gradual reduction in Reactor Coolant System (RCS) inventory. Other members of the shift team failed to communicate information concerning the RCS inventory changes that would have alerted the SRO to the need to more closely monitor that evolution .

• 2. The unit Reactor Operators (RO) tasked with controlling reactor vessel water level focused on maintaining the correct reactor vessel level standpipe indication since they believed that it was correctly indicating vessel level. As a result, they failed to identify that the RCS inventory was slowly being reduced.

• The ROs responsible for maintaining reactor vessel level were experienced and had performed this task during previous refueling outages. The task was not considered to be unusual or complex. The ROs believed that the reactor vessel level standpipe indication was accurate and did not understand that the standpipe would become inoperable when the reactor vessel head vent was closed. This lack of knowledge regarding standpipe operability is discussed further in our response to example No. 3 below.

The ROs also failed to exhibit a questioning attitude, mistakenly believing that the gradual increase in reactor vessel standpipe level (due to pressurizer relief tank venting) was the result of water being released from the steam generator tubes. To compensate for the increasing standpipe indication, the Letdown System was used to reduce the perceived increase in RCS inventory .

• 3. The significance of the reactor vessel head vent being isolated was not fully understood by the Operations team. The prevailing belief was that the indicated reactor vessel standpipe level would remain accurate for a short period of time (since off-gassing and temperature changes would be limited) provided no significant RCS inventory changes were made.

As a result, the isolation of the reactor vessel head vent was not entered in the control room logs and proper emphasis was not placed on returning the head vent to service.

The shift turnover checklist is typically developed, in part, based on the control room fogs. Since the isolation of the reactor vessel head vent was not included in the control room logs and the effect on the reactor vessel standpipe was not recognized, it was not included on the shift turnover checklist.

Although the day shift Desk SRO discussed the status of the reactor vessel head vent with the night shift Desk SRO during the shift turnover, the information was not discussed with other shift members.

4. The Supervisor Shift Operations, who was a qualified licensed SRO, requested and received permission from the Shift Supervisor to coordinate the pressurizer relief tank (PRT) venting evolution. The Shift Supervisor, Desk SRO, and unit SRO believed that this evolution would be conducted in accordance with operating procedure 1-0P-RC-011, Pressurizer Relief Tank Operations, but did not verify that procedural compliance was being maintained.

2. Corrective Steps Which Have Been Taken and the Results Achieved To address the examples discussed in Section No. 1 above, the following corrective actions were implemented.

Immediate actions were initiated to restore and maintain RCS inventory and to ensure outage activities were properly controlled:

• RCS level was promptly restored when the reduction in RCS inventory was identified. Abnormal procedure 1-AP-27, Loss of Decay Heat Removal Capability, was initiated .

The reactor vessel head vent and level standpipe were tagged to their in-service positions and the configuration of important safety systems was confirmed.

Work activities potentially affecting RCS inventory were halted until they could be reviewed by station management.

Station management initiated an interdepartmental Root Cause Evaluation (RCE) Team investigation to determine the cause of the undetected loss of RCS inventory and to recommend corrective actions. Senior management also assembled a management team to oversee the RCE investigation and to assess the event for broader implications. The results of the RCE and the management oversight assessment were discussed with the NRC at the November 6, 1995 Predecisional Enforcement Conference.

Additional corrective actions continued during the outage:

• Management oversight of the outage was strengthened. SRO qualified engineers, who had been briefed by management, were assigned to monitor night shift outage activities.

• Station management conducted meetings with Operations personnel and Shift Technical Advisors to clarify and reinforce expectations. These meetings addressed the need for maintaining a broad perspective of operational activities and discussed the responsibilities related to the Nuclear Safety Policy, command and control, monitoring of critical plant parameters, shift turnover, and configuration control.

• A fuel on-load assessment was performed to verify equipment status and to confirm the completion of corrective actions designed to improve RCS inventory controls. Station Manager approval was required before fuel on-load could begin.

• Training was conducted for Operations Personnel and Shift Technical

• Advisors.

- Operations standards and management expectations were reinforced.

The discussion emphasized the importance of:

• .monitoring critical plant parameters

• clear and effective communications

• making control room log entries

• preparing shift turnover checklists

• performing effective shift turnovers

• effectively using the operations command and control structure

• - The interrelationship between the reactor vessel head vent and level standpipe was clarified.

• The training described in detail the effects of changing plant conditions on reactor vessel standpipe indication when the reactor vessel head vents are closed. The training also defined the configuration required for the reactor vessel level standpipe to be considered operable.

- RCS inventory controls were reviewed.

- The procedural requirements associated with the performance of an RCS inventory balance were discussed.

• Operations Periodic Test procedure 1-0PT-10.2, Reactor Coolant System Cold Shutdown Inventory Balance, was revised to provide additional controls for tracking RCS inventory at Cold Shutdown/Refueling Shutdown.

• Operating procedure 1-0P-RC-013, Reactor Head Vent and Standpipe Operation, was developed to provide instructions for placing/removing the reactor vessel head vent and standpipe in/from service.

• The outage schedule was revised to reduce concurrent activities that affected RCS inventory. A change was also made to unisolate the reactor coolant loops only when the RCS level was greater than a pressurizer level of five percent.

An SRO and RO, who were involved in these events, met with each operations shift team to assess the three violations and discuss the lessons learned.

Operations personnel that were directly involved with the supervision and oversight of the activities discussed in Violation A were disciplined.

The Unit 1 refueling outage and a subsequent Unit 2 maintenance outage were completed with no similar events.

Nonessential station activities were halted for the day on December 7, 1995 to heighten station personnel's awareness of human performance issues. This "Human Performance Day" provided a special opportunity, through group discussions, for station personnel and management to focus on human performance problems and solutions.

The three violations were used as a case study for Technical Staff and Manager Continuing Training. This training emphasized the underlying causes and focused on the need for proper control and oversight of plant activities .

• 3. Corrective Steps Which Will be Taken to Avoid Further Violations The corrective actions discussed in Section 2 are sufficient to avoid further violations. However, the additional enhancements outlined below are planned to eliminate the weaknesses identified by our investigation.

enhancements will be completed by April 1996.

These

• Additional, more detailed, operations standards are being implemented to better define specific management expectations. These standards will be communicated and. reinforced through initial and continuing Operations training programs. To ensure the standards are being met, Operations personnel performance will be monitored through simulator evaluations and observation of in-plant activities.

• An assessment of operations configuration control will be completed.

• Outage related controlling procedures will be enhanced to integrate and better control outage activities.

• Refueling outage preparatory training will be developed to ensure shift teams are better prepared to implement the outage schedule.

• The continuing training programs for Operations personnel and Shift Technical Advisors are being revised to:

- reinforce the need to maintain a questioning attitude, the need to self check when making RCS inventory changes, and the need to maintain a broad perspective of unit activities

- enhance the discussion of the reactor vessel head vent and level standpipe interrelationship

- emphasize STA responsibilities during outages

- include simulator training on RCS draindown evolutions

4. The Date When Full Compliance Will be Achieved Full compliance was achieved on September 27, 1995 when the training discussed in Section 2 was completed .

• Violation B

1. Reason for the Violation, or, if Contested, the Basis for Disputing the Violation The violation is correct as stated and resulted from a personnel error in that plant conditions were not verified, as required by VPAP-2002, Work Request and Work Order Task, before Work Order 00316472, Retract/Install Flux Thimbles, was approved for implementation.

The Desk SRO verified RCS pressure was atmospheric at the beginning of the

. day shift on September 13, 1995. This verification created a mind-set that RCS pressure was atmospheric when the subject work order was approved for

. implementation. This mind-set was further reinforced by a request from the Chemistry Department to change a procedure to allow the pressurize*r vapor space to be sampled using a vacuum pump, since a driving head did not exist.

During the course of the shift, the RCS was drained down to ,a level of 18 feet.

To ensure a vacuum would not be created during the draindown evolution, the RCS was pressurized to 11 psig with nitrogen gas. To perform the subject work order, the reactor vessel level must be maintained at 18 feet and the RCS must be at atmospheric pressure.

Before the work order* was released for implementation, the Operations Maintenance Advisor conferred with the Desk SRO to discuss the boundaries and unit conditions required to support the activity. Both agreed that appropriate protection was provided by a tagout that de-energized the incore drive system and isolated the reactor vessel level indication system from the, RCS seal table. Due to the previously established mind-set, however, neither the Desk SRO nor Operations Maintenance Advisor verified that RCS pressure was atmospheric before the Operations Maintenance Advisor released the work order for implementation.

2. Corrective Steps Which Have Been Taken and the Results Achieved The implementation of the subject work order was immediately suspended by the Desk SRO when it was determined that the RCS was pressurized. The Desk SRO also stopped the release of a work order that had been initiated to remove the pressurizer safety valves. These work activities were resumed following verification of plant conditions and station management review.

Station management counseled the Operations personnel involved with Violation B to reinforce the need for verifying plant conditions prior to the release of work. The individuals involved with this event were disciplined .

.j

• 3.

The actions identified in our response to Violation A represent the collective corrective actions taken to address both Violations A and B.

Corrective Steps Which Will be Taken to Avoid Further Violations Although adequate procedural controls exist, an assessment of operations configuration control is being performed as discussed in Section 3 of our response to Violation A. This assessment will review existing control methods to ensure that activities affecting the RCS are carefully controlled.

The corrective actions discussed in Section 2 are sufficient to avoid further violations. The enhancements described in Section 3 of the response to Violation A are also applicable to Violation B.

• 4. The Date When Full Compliance Will be Achieved Full compliance was achieved on September 19, 1995 when the management

• meetings discussed in Section 2 were completed .

• Violation C

1. Reason for the Violation, or, if Contested, the Basis for Disputing the Violation The violation is correct as stated and is the result of an individual not adhering to procedures.

The Supervisor Shift Operations was responsible for coordinating the pressurizer relief tank (PRT) venting to the Vent Vent system in accordance with operating procedure 1-0P-RC-011, Pressurizer Relief Tank Operations.

Although the procedure was available, the Supervisor Shift Operations independently decided not to perform the steps in the procedure identified as examples in the violation in an effort to increase the rate of the PRT venting.

One of the unit ROs became aware that the PRT venting was not being performed in full compliance with 1-0P-RC-011, but failed to communicate this problem to the unit SRO. Had the Shift Supervisor, desk SRO, or unit SRO been aware of this noncompliance, the evolution would have been stopped consistent with our standards for verbatim compliance with procedures.

2. Corrective Steps Which Have Been Taken and the Results Achieved A Deviation Report was submitted to identify that a Gaseous Ground Level Release Permit was not issued before the PRT was vented.

Management investigated this event to determine why procedure 1-0P-RC-011 had not been properly implemented. The investigation concluded that inappropriate personnel performance on the part of the Supervisor Shift Operations was the cause. As a result, the Supervisor Shift Operations was relieved of licensed duties.

The RO involved in this incident was counseled. Station management conducted meetings with Operations personnel to clarify and reinforce expectations. These meetings addressed Operations responsibilities related to the Nuclear Safety Policy, compliance with operations standards, and the importance of procedural adherence. Station management directed Operations personnel to communicate to the appropriate level of management any observed noncompliance.

3. Corrective Steps Which Will be Taken to Avoid Further Violations The corrective actions discussed in Section 2 are sufficient to avoid further violations .

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• 4. The Date When Full Compliance Will be Achieved Full compliance was achieved on September 21, 1995.

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