ML19023A033

Southern California Edison Company; San Onofre Nuclear Generating Station, Pre-Decisional Enforcement Conference Slides

ML19023A033
Person / Time
Site:	San Onofre
Issue date:	01/24/2019
From:	Southern California Edison Co
To:	NRC Region 4
References
Download: ML19023A033 (75)

Text

Pre-Decisional Enforcement Conference January 24, 2019 1

Participants

• Doug Bauder - Vice President of Decommissioning and Chief Nuclear Officer

• Tom Palmisano - Vice President of External Engagement

• Lou Bosch - Plant Manager

• Al Bates - Manager, Nuclear Regulatory Affairs and Nuclear Oversight

• Jerry Stephenson - Manager, Engineering

• Jim Peattie - General Manager of Decommissioning Oversight

• Mark Morgan - Regulatory Affairs 2

Agenda

• Introduction

• August 3rd Download Event

- Description of event

- Safety Significance

- Causal Analysis

- Corrective Actions

• Reportability

- Timeline

- Causal Analysis

- Corrective Actions

• Regulatory Considerations

• Conclusions/Questions 3

INTRODUCTION Doug Bauder, Vice President of Decommissioning and Chief Nuclear Officer

Safety Perspective The incident on August 3, when the redundant safety functions of our lifting system were not maintained, is a serious matter which we should not have allowed to happen.

Southern California Edison (SCE) accepts the proposed violations of regulatory requirements.

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Safety Perspective

• Immediately following the event, SONGS placed the affected canister in a safe condition and suspended Fuel Transfer Operations (FTO)

• We have analyzed the incident and developed corrective actions with the utmost rigor, depth, and thoroughness

• We have utilized top industry expertise to verify our conclusions and actions

• We now know with full confidence, that in the unlikely event of a load drop on August 3, the canister would not have been breached, and there would have been no radiological hazard to our employees or to members of the public 6

Safety Perspective

• There were significant organizational and programmatic lessons learned

• Weve established comprehensive and rigorous criteria prior to re-starting FTO

- Demonstration of effective corrective actions and equipment operations to the NRC

- Multiple independent reviews

- Full satisfaction by SCE that our actions are complete and sustainable

• Planned post-restart actions to further ensure sustainability 7

Focus Areas of Improvement 8

AUGUST 3RD EVENT Lou Bosch, Plant Manager

Canister Downloading Event What Happened

• On Aug. 3, 2018, as a loaded Multi-Purpose-Canister (MPC) was being downloaded into its storage vault, it became lodged on the shield ring For less than an hour, the MPC remained lodged and was not suspended by the rigging Significance

• Although unlikely, the canister could have fallen 18 feet to the bottom of the Cavity Enclosure Container (CEC)

• Canisters have been analyzed to be able to withstand drops of up to 25 feet with a substantial margin of safety

• During the event there was no radiological risk to employees or the public; however, this is still an unacceptable incident 10 10

Canister Download Evolution

• Animation deleted due to file size 11

Description of Event

- Multi-Purpose Canister (MPC) lodged on shield ring

- Shield ring is 2 thick; welded in place 12

SAFETY SIGNIFICANCE Jerry Stephenson, Manager of Engineering

Safety Significance of a Load Drop

• Shield ring is located in the CEC

• Shield ring performs dose reduction function

• Tight clearance required for effective shielding

• Shield ring is 2 thick and welded to divider shell

• Reinforced with 8 gussets

• Fully capable of supporting canister without damage 14

Safety Significance of the Incident

• Actual consequences

- No breach of the canister

- No release of radioactive material

- With the canister resting on the shield ring with slack slings, it was exposed to a possible 18 drop into the CEC for less than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />

- Contact with the shield ring may have caused minor scratches to the side of the canister, which have been evaluated to be acceptable, and will be evaluated in the Inspection and Maintenance Program to be implemented in 2020 15

Safety Significance of a Load Drop

• Probability of a canister drop

- No release of radioactive material even if it had dropped

- Lowering the canister onto the shield ring resulted in the ductile baseplate locally conforming to the shape of the ring

- Significant force required to dislodge the canister from the shield ring (such as a seismic event)

- The canister was in this condition for less than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />

- The probability of a seismic event large enough to dislodge the canister during a 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> period at SONGS is very low.

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Safety Significance of a Load Drop

• Load drop evaluation

- Deterministic load drop evaluation was performed with very conservative assumptions

• We analyzed 25 drop vs. actual height of 18

• Assumed 1/2 wall thickness vs actual thickness of 5/8

• Analyzed no friction, and an infinitely rigid bottom

• Used a conservative strain limit of .55 in/in

• The calculation used NRC approved code (LS-DYNA) 17

Safety Significance of a Load Drop Load drop analysis (continued)

• Calculated maximum strain was well below the conservative calculational limit of .55 in/in. The canister would not have been breached

• This result affirmed that there would be no canister breach and therefore no release of radioactive material 18

Safety Significance of a Load Drop

• A fuel damage evaluation was performed for a postulated canister drop of 25

- Conservative because the potential fall was only 18

- Some fuel damage would have occurred

- However, as previously shown, there would be no canister breach and no release of radioactive material

- No increase in local or offsite dose rates 19

Safety Significance of a Load Drop

• No significant effect on cooling as a result of a postulated 25 drop

- Helium cooling medium is maintainedno canister breach

- Fuel bundles remain in their individual cells

- No significant change in heat transfer

• External cooling of the canister was also reviewed

- Cooling is maintained per design with air flow past the canister

- Approximately 6 clearance would be maintained between canister and divider shell

- Minor changes to external dimensions would not affect overall cooling 20

Safety Significance of a Load Drop

• Conclusion

- The possibility of a canister drop was very low

- Even if it had dropped, there would have been no breach

- Without a breach, there would have been no release of radioactive material

- There would have been no change in local or offsite dose rates

- The canister would have remained cool and safe in the CEC 21

CAUSAL ANALYSIS Jim Peattie, General Manager of Decommissioning Oversight

Root and Apparent Cause Evaluations

• Root Cause Evaluation to examine the causes for loss of redundant drop protection features during the download of the loaded spent fuel canister

• Apparent Cause Evaluation to examine ineffectiveness of SCEs oversight of the fuel transfer process, which may have prevented the event 23

Root Cause Evaluation

• Root Cause: Management failed to recognize the complexity and risks associated with a long duration fuel transfer campaign while using a relatively new system design 24

Root Cause Evaluation

• Root Cause Evaluation of MPC Downloading Event at SONGS

- Contributing Causes

• Design review of the shield ring did not capture unintended consequences

• Inadequate procedure content

• Training Program did not capture uniqueness of UMAX system and challenges of a long-term project

• Continuous Learning Environment not established for use of operating experience and lessons learned

• Communication protocols for canister movement not well defined 25

Apparent Cause Evaluation

• Apparent Cause Evaluation of Oversight

- Apparent Cause

• Failure to establish rigorous oversight process

- Contributing Causes

• Project management observations not routinely performed

• Low threshold for Corrective Action Program (CAP) entries not enforced 26

Corrective Actions 27

Corrective Actions 28

Corrective Action Operating Procedures

• Fuel Transfer operating procedures have been revised to identify critical steps, required qualifications, load limits, and use of new equipment

- HPP 2464 100 MPC Pre Operational Inspections

- HPP 2464 200 MPC Loading at SONGS

- HPP 2464 300 MPC Sealing at SONGS

- HPP 2464 400 MPC Transfer

- HPP 2464 500 MPC Unloading

- HPP 2464 600 Abnormal Conditions 29

Corrective Action Oversight Procedures

• Oversight procedures revised to improve:

- Review and acceptance of contractor procedures and training programs

- Field performance of fuel transfer oversight through use of task guides 30

Corrective Actions 31

Corrective Action Training

• Developed a new SONGS-specific training program and procedure using systems approach to training and trained FTO personnel

• Trained oversight specialists on oversight procedure changes and process fundamentals

• Added a subject matter expert with training experience into oversight organization 32

Corrective Actions 33

Corrective Action Equipment

• Load Monitoring Shackles installed with remote indication and alarms

• Cameras and monitors installed to observe downloading remotely

• Tag-line indicator installed on MPC for physical verification of downloading 34

Corrective Actions 35

Corrective Action CAP

• SCE Corrective Action Program is now being used for all problem identification and resolution associated with the fuel transfer project

• Training conducted on Lessons Learned from Aug 3rd event, July 22nd pre-cursor event, and updated CAP training for FTO and oversight personnel 36

Corrective Actions 37

Corrective Action Oversight

• Procedures revised to include rigorous review of contractor procedures and training programs

• Procedures revised to include improved task guides, risk management, and direction on intervention

• Implemented a Senior Management observation program for fuel transfer project and oversight activities

• Enhanced oversight organization with additional fuel-transfer-experienced personnel 38

Cause/Action Correlation Cause Summary Actions Taken Status Root Cause Evaluation

• CAPR-1 Revised Holtec procedure Complete (RCE) Root Cause 1 - for Project Risk Management Complexity of long-term project with relatively new

• CAPR-2 Evaluated Executive Complete design not fully understood Oversight Board charter to improve effectiveness 39

Cause/Action Correlation Cause Summary Actions Taken Status RCE Contributing

• Revised Holtec Writers Guide Complete Cause 1 - Inadequate procedure procedure content

• Revised Holtec Operating Complete procedures to include responsibilities, qualifications, critical steps and engineering features

• Revised scripted pre-job briefs for Complete critical lifts (high risk)

• Revised all Job Hazard Analyses Complete (JHA) 40

Cause/Action Correlation Cause Summary Actions Taken Status RCE Contributing Cause 2

• Revised Holtec design review Complete

- Design review did not procedure to enhance review capture unintended process including use of an consequences additional independent challenge team RCE Contributing Cause 3

• Developed and conducted training Complete

- Communication on communication protocols Protocols not well defined including 3-way communication, command and control, and responsibilities 41

Cause/Action Correlation Cause Summary Actions Taken Status RCE Contributing Cause 4

• Revised Holtec Project Manager Complete

- Continuous Learning procedure to include section on use Environment not of OE from various sources established for use of

• Revised Holtec Field Condition Complete Operating Experience Report procedure to provide additional clarification on the threshold for initiation of FCRs including any abnormal or unexpected condition 42

Cause/Action Correlation Cause Summary Actions Taken Status RCE Contributing

• Developed SONGS site specific Complete Cause 5 - Training training program using elements of Program did not capture Systems Approach to Training uniqueness of challenges (SAT) from UMAX system and

• Developed SONGS site specific Complete long-term project training procedure that includes minimum training and qualification by position

• Revised Chapter 9 of Final Safety Complete Analysis Report (FSAR) to increase rigor of load handling activities 43

Cause/Action Correlation Cause Summary Actions Taken Status RCE

• Perform assessments to verify Due: 60 days Effectiveness Reviews effectiveness of the CAPRs and a after restart CAs

• Perform oversight through a Due: After 5 surveillance using an independent to 10 canister evaluator on the first two downloads downloads after restart plus three of the following 10 downloads

• Perform an assessment of Holtecs Due: 60 days Cask Loading personnel including after restart but not limited to the CLS, RIC, JLG operator, and VCT Operator to ensure proficiency 44

Cause/Action Correlation Cause Summary Actions Taken Status Apparent Cause

• Revised Holtec Operating procedures to Complete Evaluation (ACE) Apparent require load monitoring, stop criteria for Cause 1 - Failure to safety limit, critical steps, and lessons learned establish rigorous

• Revised SCE Oversight procedure to Complete oversight process include rigorous review of contractor procedures and training programs

• Revised SCE Oversight procedures to Complete include improved task guides, risk management, and guidance

• Reviewed and revised Holtec/SCE Complete training materials and provide training to SCE Oversight Specialists 45

Cause/Action Correlation Cause Summary Actions Taken Status ACE Contributing

• Revised SCE Oversight guide for Complete Cause 1 - Project Pool to Pad work to include paired Management Observations observations by peers and not routinely performed management ACE Contributing

• Developed and conduct Lessons Complete Cause 2 - Low Threshold Learned Case Study Aug 3rd event, for CAP entries not July 22nd pre-cursor event, and enforced updated CAP refresher training

• Developed and conduct SCE oversight training to reinforce Complete observation documentation and identification of trends 46

Cause/Action Correlation Cause Summary Actions Taken Status ACE

• Qualitative assessment of Due: Prior to Effectiveness Reviews implementation of corrective actions dual unit based programmatic changes operations implemented and management observation comments as they apply to effectiveness of training, effectiveness of task guides, responses to observer questions

• Training SME perform observations Due: Prior to of pre-job briefs and OE delivery. dual unit Participate in evaluation of operations qualification and readiness review of Holtec Training 47

Revised Download Process

• Video deleted due to file size 48

Corrective Actions Conclusions

• SONGS took immediate action to:

- Place in-process canisters in safe condition and

- Suspended all fuel movement activities

• SONGS has performed thorough cause evaluations and implemented extensive corrective actions

• SONGS will ensure sustainability of our corrective actions 49

REPORTABILITY Lou Bosch, Plant Manager

Problem Statement

• On August 3, 2018, during the download of a canister, the canister became lodged which led to the rigging becoming slack. This disabled an Important-To-Safety (ITS) load control function while no other supporting function was available.

This condition was reportable to the NRC within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in accordance with 10 CFR 72.75(d)(1) 51

Reporting Timeline

- Event on Friday August 3rd at approximately 1250 PDT

- Saturday and Sunday (8/4 and 8/5) the station considers reportability for unanalyzed condition [10 CFR 50.72(b)(3)(ii)]

• Not appropriately assessed by the station for Part 72 reportability

- Monday, August 6 at 0500 PDT - time period for compliant reporting expires - extension allowed per 10 CFR 72.75(d)(2).

- Discussions throughout Monday, August 6

• Courtesy call to Region at approximately 1500 PDT

- Tuesday, August 7 - Conference call with NRC - questioned reportability

- September 10 Special Inspection - Apparent Violation discussed during debrief

- Friday, September 14 - Late formal report filed 52

Root and Contributing Causes

• Root Cause

- Management failed to recognize the transition to fuel transfer operations as requiring the integration, familiarization, and application of 10 CFR 72.75 reporting requirements into plant processes

• Contributing Causes

- (CC1) There was lack of guidance to facilitate understanding the wording in 10 CFR 72.75(d)(1)

- (CC2) Management did not encourage, and the organization did not demonstrate, a conservative bias for reporting 53

Extent Of Condition

• Extent of Condition

- SCEs review of the extent-of-condition of this event identified two additional issues associated with the HI-PORT, spent fuel transfer vehicle

• Lateral clearance to fixed objects

• Height of center of gravity

- These issues were reported on December 20, 2018 to the NRC and have been corrected 54

Extent of Cause

• Failure to conduct training on ISFSI reporting regulations prior to the start of initial fuel movements in early 2018

• Failure to conduct training on other decommissioning reporting regulations 55

Immediate Corrective Actions

• Immediate Corrective Actions Completed

- Trained Shift Managers and regulatory personnel on this event and the 10 CFR 72.75(d) notification requirements

- Revised our reporting procedure 56

Corrective Actions

• Provide enhanced 10 CFR 72.75 training that includes:

- Identifying accident and design basis events

- Identifying analytical limits

- Identifying ITS components

- Identifying potential failures

• Establish a biennial refresher training requirement for reportability to ensure sustainability 57

Corrective Actions

• Enhance reportability procedure with additional reporting guidance

• Conduct and document an assessment of other decommissioning activities that also have reportability requirements 58

Corrective Actions

• Effectiveness review

- After the required training is complete, Shift Managers, Plant Manager, Operations Manager, regulatory personnel, and Engineering Manager will be given a real time reporting exercise once a month and success will be based on three consecutive months with no incorrect reportability calls

- Appoint a skeptic at reportability conference meetings 59

Cause/Action Correlation Cause Summary Actions Taken Status Immediate Actions

• Revised procedures to Complete include references to NRC guidance, voluntary reporting, and bias for reportability; also created conference call with management for reportability issues

• Trained shift managers Complete on 8/3/18 event and Part 72 reporting requirements 60

Cause/Action Correlation Cause Summary Actions Taken Status Root Cause - CAPR1: Develop and Due February 19, 2019 Management failed to provide training (including recognize the transition re-training) for decision to fuel transfer makers that identifies operations as requiring ISFSI related accidents, the integration, design basis events, and familiarization, and safety functions specific to application of 10 CFR 72.75 reporting 10CFR72.75 reporting requirements to determine requirements into plant correct reportability processes 61

Cause/Action Correlation Cause Summary Actions Taken Status Root Cause - CAPR2: Establish a Due February 19, 2019 Management failed to biennial refresher training recognize the transition requirement for to fuel transfer reportability training operations as requiring the integration, familiarization, and application of 10 CFR 72.75 reporting requirements into plant processes 62

Cause/Action Correlation Cause Summary Actions Taken Status Root Cause - CAPR-3 (for Root Cause and Due February 4, 2019 Management failed to Contributing Cause 1) - Revise recognize the SO123-0-A7 to include guidance transition to fuel for 72.75 reporting that:

transfer operations as

• disabling a function that requiring the prevents an accident is integration, equivalent to a function that familiarization, and mitigates an accident application of

• there are two aspects of 10CFR72.75 reporting; the requirement and reporting the time.

requirements into

• Management meeting including plant processes participation by the SM 63

Cause/Action Correlation Cause Summary Actions Taken Status Contributing Cause 1 Addressed by CAPR-3, above Due February 4, 2019

- Lack of procedural guidance to facilitate understanding of the wording in 72.75(d) 64

Cause/Action Correlation Cause Summary Actions Taken Status Contributing Cause 2

• Revise procedure to include Due February 4, 2019

- Management did guidance for 72.75 reporting not encourage, and and maintaining a bias for the organization did reporting not demonstrate, a

• Assign responsibility for Due February 4, 2019 conservative bias for reporting to shift manager reporting

• Conduct an event review with Due March 14, 2019 decision makers on reportability aspects of August 3rd download event

• CNO to conduct All-Leaders Due March 14, 2019 and All-Hands briefings that addresses bias for reportability 65

Cause/Action Correlation Cause Summary Actions Taken Status Root Cause -

• Effectiveness Review - 1: After Due July 25, 2019 Management failed to training, SCE Shift Managers ,

recognize the Plant Manager, Operations transition to fuel Manager, NRA personnel, and transfer operations as Engineering Manager will be given requiring the a real time reporting exercise once integration, a month and success will be familiarization, and based on three consecutive application of months with no incorrect 10CFR72.75 reportability determinations reporting requirements into plant processes 66

Cause/Action Correlation Cause Summary Actions Taken Status Root Cause -

• Effectiveness Review - 2: Appoint a Due July 25, Management failed to skeptic at reportability call meetings. 2019 recognize the Skeptic attends the first 3 transition to fuel reportability call meetings to transfer operations as determine that; using a conservative requiring the reporting bias is mentioned, integration, dissenting opinions are encouraged, familiarization, and the Shift Manager (SM) is requested application of to make the call, the SM is not 10CFR72.75 influenced to not report by other reporting management members requirements into plant processes

• After three observations, conduct and document a qualitative assessment of observations 67

Corrective Actions Conclusion

• SONGS has taken immediate actions:

- Trained Shift Managers and regulatory personnel on this event

- Revised our reporting procedure

• SONGS has performed a thorough cause evaluation and has taken extensive corrective actions 68

REGULATORY CONSIDERATIONS Al Bates, Manager of Nuclear Regulatory Affairs and Oversight

Regulatory Considerations Violation Severity Level

• Loss of Redundant Load Protection

- No actual safety consequences

- Vulnerability lasted for a short period of time (less than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />)

- If the canister had dropped

• No radiological release

• No harm to the health and safety of the public

- A canister drop is unacceptable, and we have taken strong corrective actions

- We ask that the NRC consider these factors in determining the final severity level of this violation 70

Regulatory Considerations Violation Severity Level

• Reportability

- Considerations include impact on ability of NRC to perform its regulatory oversight function, and willfulness

• NRC notified informally and thoroughly briefed

• NRC performed a Special Inspection as a result of the event

• SCE maintained frequent and transparent communication with NRC following event

- We ask that the NRC consider these factors in determining final severity level of this violation 71

Regulatory Considerations

• Redundant Load Drop Protection

- Enforcement History - No escalated enforcement within 2 years

- Identification - Self-Revealing

- Corrective Actions - Timely and Effective

• Reportability

- Enforcement History - No escalated enforcement within 2 years

- Identification - NRC-identified

- Corrective Actions - Timely and Effective 72

Civil Penalty Escalation/Mitigation From NRC Enforcement Policy 73

CONCLUSIONS Doug Bauder, Vice President of Decommissioning and Chief Nuclear Officer

Conclusion

- SCE takes this incident and these violations seriously

- We have performed extensive cause evaluations and implemented timely and effective corrective actions

- We will be demonstrating the effectiveness of our corrective actions to the NRC during upcoming inspections

- This incident did not create, nor have the potential to create, a radiological hazard to the public or employees 75