ML19208B036
| ML19208B036 | |
| Person / Time | |
|---|---|
| Site: | Arkansas Nuclear  |
| Issue date: | 07/11/1979 |
| From: | Johnson W, Westerman T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML19208B033 | List: |
| References | |
| 50-313-79-19, NUDOCS 7909180537 | |
| Download: ML19208B036 (21) | |
See also: IR 05000313/1979019
Text
U. S. NUCLEAR REGULATORY C0&lISSION
OFFICE OF INSPECTION AND ENFORCEMENT
REGION IV
Report No.
50-313/79-11
Docket No.
50-313
License No. DPR-51
Licensee:
Arkansas Power and Light Company
P.O. Box 551
Little Rock, Arkansas
72203
Facility Name: Arkansas Nuclear One (ANO), Unit 1
Inspection At: ANO Site, Russellville, Arkansas
Inspection
Conducted:
June 2-14, 1979
Inspector:
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e
Y.'D.Jgson,ResidentReactorInspector
Date
Approved by:
2 [< #
7[N/79
T. F. Westerman, Chief, Reactor Projects
'Da t'e
Section
Inspection Summary
,
Inspection conducted during period of June 2-14, 1979
(Report No. 50-313/79-11)
Areas Inspected:
Special, announced inspection of the circumstances
surrounding the operational occurrance at Arkansas Nuclear One Unit 1
on the morning of June 2, 1979. The inspection involved 191 inspector-
hours on-site by two (2) NRC inspectors and two (2) NRC investigators.
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2.
Results: Within the areas inspected, two items of noncompliance were
identified (infractions - failure to adhere to procedures, paragraph 5, and
failure to adhere to Technical Specification requirement for procedure
change, paragraph 2).
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3.
DETAILS SECTION
1.
Persons Contacted
Ackansas Power & Light Company Employees,
J. P. O'llanlon, ANO Plant t!anager
G. H. t! iller, Engineering & Technical Support Pfanager
B. A. Baker, Operations Superintendent
T. N. Cogburn, Nuclear Engineer
E. C. Ewing, Production Startup Supervisor
B. A. Terwilliger, Operations and flaintenance Pfanager
J. Robertson, ANO-1 Operations Supervisor
F. Foster, Plant Administrative Flanager
R. Elder, I&C Supervisor
R. Tucker, Electrical Engineer
J. FicWilliams, Planning & Scheduling Supervisor
J. Vandergrift, Training Supervisor
T. Green, Training Coordinator
D. Trimble, Licensing Flanager
W. Cavanaugh, Vice President, Generation and Construction
D. Sikes, Director, Generation Operations
11. Bishop, Offices- Services Supervisor
The inspectors and investigators also contacted other plant personnel,
including operators, shif t supervisors', technicians and administrative
personnel.
2.
Inspector Observations
At 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br /> on June 2, 1979, when the plant was"in a hot shutdown
condition (RCS temperature greater than 525 F), the inspector observed
that the emergency feedwater system was not capable of being started
automatically due to the following observed conditions:
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llandswitch (HS) 2617 for CV-2617 and HS-2667 for CV-2667 were
in the " normal close" position. For automatic operation of
CV-2617 and CV-2667, the steam supply valves to the steam
driven emergency feedwater pump (P7A) from steam generator B
and A, respectively, these handswitches must be in the
"open auto" position.
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4.
HS-2621 and HS-2671 were in the " lock close" position. For
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automatic operation of CV-2620 and CV-2670, the supply valves to
steam generators B and A, respectively, from the emergency feed-
water pumps, these handswitches must be in the " normal" position.
The handswitch for the electric motor driven emergency feedwater
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pump (P7B) was in the " pull to lock" position. For automatic
operation of this pump, this handswitch must be in the " normal
after stop" position.
The inspector informed the Assistant Operations Superintendent of these
discrepancies.
He immediately corrected them and pointed out that step
6.4.42 of OP 1102.02, Plant Startup, requires that the handswitches for
the steam supplies for P7A be placed in "open auto" and that the handswitch
for P7B be placed in " normal af ter stop" af ter the auxiliary feedwater pump
is started. This pump had been started at 0107 hours0.00124 days <br />0.0297 hours <br />1.76918e-4 weeks <br />4.07135e-5 months <br /> on June 2, 1979. This
step had been signed off by the operator. The inspector later learned
that the automatic initiation of emergency feedwater was defeated at about
0715 hours0.00828 days <br />0.199 hours <br />0.00118 weeks <br />2.720575e-4 months <br /> prior to performance of Supplement II of OP 1102.02. This
supplement performs a seating test of the main feedwater check valves, FW-7A
and FW-7B.
Since this procedure required that the auxiliary feedwater
pump be turned off, and this would result in an autostart signal to the
emergency feedwater system, the operator defeated the autostart features of
the emergency feedwater system. The procedure did not include steps for
defeating automatic initiation of EFW, any caution statements to warn the
operator that EFW would autostart unless defeated, or any steps to
reinstate EFW autostart capability after the test.
Due to problems
in reading the feedwater header pressure at a local gauge temporarily installed
at FW-1042, the test was discontinued while the pressure gauge was being
relocated.
It was during this period of discontinuance of the check valve
seating test that the inspector made the above ob,servations at 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br />.
The licensee's failure to follow the Technical Specification requirements
of Section 6.8.3 concerning changes to procedures is an apparent item of
noncompliance.
As discussed in other parts of this report, the licensee has taken (and
the inspector has verified) corrective action and action to prevent further
noncompliance. Therefore no written response to this item is required.
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5.
3.
NRC Order of June 2, 1979
By Order dated June 2, 1979, the NRC directed the licensee te pro-
ceed to, and remain in, a cold shutdown condition, and to not re-
start until the Acting Director, Office of Inspection and Enforce-
ment, has confirmed in writing, that the following actions have
been satisfactorily accomplished:
a.
the licensee shall evaluate and modify as appropriate
its methods for the development, review and approval
of procedures for all modes of plant operation;
b.
the licensee shall evaluate existing procedures to
assure that such procedures include all actions
necessary for safety; and,
c.
the licensee shall take appropriate steps to assure
that all plant personnel adhere to approved procedures
and do not add unauthorized steps to any procedures.
The inspector verified that the unit was in a cold shutdown con-
dition on June 3, 1979.
4.
Inspector Followup on Items of June 2, 1979 Order
a.
Order Item 1 - Development, Review and Approval of Procedures
Quality Control Procedure (QCP) 1004.21, Handling of
Procedures, specifice the licensee's method of development,
review, and approval of procedures required by Section
6.8.1 of the Technical Specifications. The major steps
of this procedures relating to development, review, and
approval of procedures were summarized in a letter to
Mr. Victor Stello, Jr. (NRC) from Mr. Willia'm Cavanaugh III
(AP&L) dated June 12, 1979.
Af ter the procedure writer is satisfied with the typed draft,
the procedure is reviewed independently by a knowledgeable
member of the plant staff.
Upon incorporation of any changes
requested by the reviewer, the procedure is reviewed by the
group supervisor. The supervisor ensures that the proce-
dure is in compliance with the FSAR and the Technical Spec-
ifications and that a written safety evaluation is attached
when required.
When the supervisor is satisfied with the
procedure, the Plant Safety Committee (PSC) reviews the
procedure. When all PSC required changes and corrections
are made to the procedure, the PSC recommends approval of
the procedure.
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6.
Quality Control Procedures are then reviewed by the Manager
of Quality Assurance. The Safety Review Committee (SRC) reviews
the procedureg if reqaeste4 by the PSC or SRC or required by the
Technical Specifications.
When all reviews are complete and all
comments are resolved, the plant General Manager approves the
procedure.
The licensee's method for development, review and approval of
procedures meets the requirements of Section 5.2.15 of American
National Standard ANS - 3.2 (ANSI N18.7-1976), Administr_ative
Controls and Quality Assurance for the Operational Phase of
Nuclear Power Plants. On June 11, 1979, the licensee issued
Standing Order Number 39, Revision 1, entitled Adherence to
Procedures. The policy guidance in this Standing Order concern-
ing the degree of required adherence to procedures and thus the
degree of detail necessary to be in procedures should decrease
the possibility of a defective procedure being issued in the future.
b.
Order Item 2 - Existing Procedure Evaluation
In response to this item, the PSC formed a procedure review group to
perform the required procedure evaluation.
Procedures selected for
review incl'uded 2eneral plant operating procedures, system operating
procedures including surveillance procedures, procedures having a
similiarity to the incident of June 2, and procedures which might
need revision to reflect philosophy or design changes. The review
group was provided with the following guidelines:
A step for all required actions.
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Single evolution per step.
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Verify prerequisites are explicit and satisfy the condition
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necessary to perform the evolution (i.e., step, supplement
or surveillance).
Verify no other safety systems are overridden or bypassed
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by the performance of that procedure except for the system
involved.
Incorporate proposed Technical Specifications.
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Of the approximately 30 procedures reviewed, all but one were revised
The changes were mostly editorial in nature, with additional guidance
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being inserted in appropriate places to aid the cperator.
The inspectors
reviewed a sample of the revised procedures and had no significant
findings. While the requirement of the Order of June 2, 1979, has
been met, the licensee has agreed to extend the procedure review to
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include the few remaining safety-related procedures for Unit 1
and to initiate a similar review for Unit 2 procedures.
As a part of the procedure review process described above, licensee
operations personnel walked through the revised procedures. After
the revised procedures were approved, training sessions were conducted
for Unit I shift operating personnel.
c.
Order Item 3 - Procedure Adherence
On June 11, 1979, the licensee issued Standing Order Number 39,
Revision 1, entitled Adherence to Procedures. This standing
order provides guidance for the proper usage of written procedures
and specifies the degree of adherence required for various
types of procedures. The categories of procedures covered
in this standing order are listed below:
(1) Operating Procedures
a.
Plant Operating Procedures
b.
Auxiliary Plant Operating Procedures
c.
Setpoints and Limits and Precautions Procedures
d.
Electrical Lineup Procedures
c.
Work Plans
f.
Valve Checklists
(2) Emergency ond Abnormal Procedures
(3) Refueling Procedures
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(4) Response to Alarm Procedures
(5) Surveillance Procedures
(6) Chemistry Procedures
(7) Health Physics Procedures
(8) Maintenance Procedures
Plant maintenance personnel and Unit I shift operating personnel have
attended training sessions in which this new standing order was
explaineu.
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5.
Valve Lineups
The inspectors reviewed the valve / breaker lineup sheets for the
plant heatup conducted on June 1st and 2nd.
These lineup sheets
are, in general, attachments to system operating procedures.
OP 1102.01, Plant Preheatup and Precritical Checklist, and
OP 1102.02, Plant Startup, require that specified systems be lined
up in accordance with referenced system operating procedures.
The inspectors observed many discrepancies on the completed valve /
breaker alignment checklists. The most common types of discrepancies
were:
No position noted for component
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Component noted to be in a position other than the desired
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position specified by the procedure without explanation.
.The checklists for the Decay Heat Removal System were completely
blank.
Other systems with discrepancies included:
OP 1102.01','Attachmeat F, Category E Valve Checklist
OP 1104.02, Attachment A, Makeup and Purification System
OP 1104.03, Attachment F, Chemical Addition
OP 1104.05, Attachment A, Reactor Building Spray
OP 1104.24, Attachment A, Instrument Air
OP 1104.25, Attachment A, Service Air
OP 1103.28, Attachment A, Intermediate Cooling Water
OP 1104.29, Attachment A, Service Water
OP 1106.06, Attachment A, Emergency Feedwate,r
OP 1107.01, Checklist H, Electrical System
The Arkansas Power and Light Company Quality Assurance Topical
Report (APL-TOP-1A), " Quality Assurance Manual - Operations "
policy statement states, in part:
"It is the policy of the Arkansas Power & Light Company (AP&L)
from the highest level of corporate management, that its
Quality Assurance Program for Operation shall meet the re-
quirements of the Code of Federal Regulations, 10 CFR 50,
Appendix B, with respect to operation, maintenance, refueling,
repair and modifications, and inservice inspection of AP&L
Nuclear Plants. The program shall, in addition, comply with
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WASH 1283, 5/24/74; WASH 1284, 10/26/73; and WASH 1309, 5/10/74;
and be responsive to Industrial Standards and Codes which pertain
to the structure of the Program and the implementation of its
procedures."
WASH 1284 (10/26/73) states in part:
" Regulatory Guide 1.33 (Safety Guide 33) endorsed the re-
quirements and recommendations included in proposed Standard
ANS-3.2 (subsequently designated N18.7) and N45.2-1971 as being
generally acceptable in providing an adequate basis for complying
with the quality assurance program requirements of Appendix
B to 10 CFR Part 50."
Section 5.3.1 of ANSI N18.7-1972 includes the following require-
ments:
"(1) Prerequisites.
Startup procedures shall include
determination that prerequisites have been met, in-
cluding confirmation that necessary instruments are
operable and properly set; valves are properly aligned;
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necessary systems procedures, test and calibrations have
been comp!cted; and required approvals have been obtained.
Check-off lists should be used for this purpose."
The licensee's startup procedures had incorporated the above require-
ments, but these procedures had been inadequately implemented. This is
an apparent item of noncompliance with Technical Specification 6.8.1
which requires the establishment and implementation of procedures.
Since the inspector was concerned that the existing valve / breaker
lineups gave inadequate assurance of proper system alignment, he
requested that the licensee complete the required corrective action
prior to plant startup.
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The licensee issued Standing Order Number 3, Revision 1, entitled
Valve Line-ups, on June 11, 1979. This standing order gives
guidance on the desired method of conducting valve / breaker lineups.
It establishes a Master Valve / Breaker Lineup Book which is
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maintained in the Control Room and which contains the most recent
valve / breaker lineup sheets for each system. The standing order also
establishes Valve / Breaker Lineup Exception Sheets. These sheets are
used to document exceptions to the valve / breaker lineup sheets and their
reasons, and are to be filed in the Master Valve / Breaker Lineup Book.
The standing order also specifies that:
" Valve / Breakers will be aligned per their respective lineup
sheets. The operator performing the lineup will initial in
ink for each valve / breaker as each valve / breaker is verified.
"Each person who places his initials on a lineup sheet shall
also sign his name on the top or bottom of that sheet and
date the sheet. Each valve / breaker on the lineup sheet
shall have its position verified."
The licensee implemented the requirements of Standing Order Number
3, Revision 1, prior to plant startup.
Since corrective action
was achieved prior to the end of this inspection, no written
response is required for this item.
6.
Plant / System Status Information and Shift Turnover
As discussed in Attachment A, Summary of Inquiry, the inspectors con-
cluded that the plant / system status information available for the
operating crew is inadequate and administrative controls governing
shift turnover are insufficient to assure that all significant inform-
ation is passed on to the shift coming on duty.
The licensee also had identified these problems and took corrective
action during the period of this inspection.
Standing Order Number 40, entitled "Use of Safety System and Plant
Status Boards," was issued on June 13, 1979. This standing order
provides for the use of two status boards in each Control Room. A
plant status board is used to note specific off-normal conditions
of various non-safety systems. A safety system status board is used
to note any inoperability or degradation of safety systems or components.
The standing order also provides guidelines for status board usage.
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The inspector verified that the status boards were in use before.the
end of this inspection period.
Standing Order Number 41, entitled "Use of Shift Relief Sheets During
Shift Turnover," was issued on June 14, 1979. This standing order pro-
vides guidlines for shift relief and establishes the requirement for use
of the Shift Relief Sheet. These sheets are used to document oncoming
shift review of various aspects of plant status listed below:
Plant Annunciator (All Alarms)
Station Log
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Hold Card Log
Caution Card Log
Jumper and Bypass Log
Key Log
Plant Status Board
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Safety System Status Board
Weekly Surveillance Schedule
Evolutions in Progress
Evolutions Scheduled
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New Instructions, Standing or Special Orders, Memos
Major Alterations of Plant Operating Procedures Received During
Shift.
The requirements of this standing order were implemented prior the end of
this inspection period.
7.
Emergency Feedwater System Design Changes
The inspectors reviewed design change numbers 1-79-34; 1-79-34A, 1-79-34B;
1-79-34C, which added or deleted relay logic in the ICS to perform the
following:
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12.
a.
Start the emergency feedwater pumps P7A and P7B whenever OTSG
1evel is less than 18" as indicated on the startup range level
instrumentation.
b.
Added a bypass below 5% reactor power such that a trip of
both main feedwater pumps will not start P7A and P7B.
c.
Remove all contact sense inputs from the auxiliary feedwater
pump P75 to the P7A and P7B start circuits and to the EFW
MOV's automatic control circuits.
d.
Install an alarm on control room panel K08 indicating that
the 5% reactor power bypass is in effect.
The job orders implementing and testing the circuits of the above design
changes were also reviewed. The inspectors had no adverse findings in
these areas.
8.
Gas ~eous Radwaste System
Attachment A includes concerns about the licensee's operation of the
Gaseous Radwaste Systems. For details of the followup action on
these concerns, refer to NRC Inspection Report 50-313/79-14 which
documents an inspection performed on June 7 and 8, 1979, and which
was transmitted to the licensee by letter dated June 20, 1979.
9.
NRC Order of June 14, 1979
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After determination by the Director, Office of Inspection and Enforcement,
that the licensee had satisfactorily accomplished the conditions re-
quired by the June 2, 1979 Order, the NRC issued an order authorizing
resumption of operation on June 14, 1979.
10.
Exit Interview
The inspectors and investigators met with the plant General Manager
and other members of the AP&L staff at various times during this
inspection period.
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UNITED STATES
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NUCLEAR REGULATORY COMMISSION
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REGION 11
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101 M ARIETTA ST., N.W., SulT E 3100
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SUrfMARY OF INQUIRY
Subj ect:
Arkansas Power and Light Company
Arkansas Nuclear One, Unit 1
Docket No. 50-313
Failure to follow procedures regarding Emergency Feedwater
System during plant startup.
Dates of Inquiry:
June 4-6, 1979
Performed by:
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C. E
lderson
Date
Regional Investigator
Office of the Director
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D. R. FicGuire
Date
Regional Investigator
Office of the Director
Reviewed by:
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A F. J. Long L W /
' Ifate
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Acting Deputy Director
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Office of the Director
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I.
INTRODUCTION
On June 2, 1979, the Director, Region IV, contacted the Director, Region II,
and requested investigative assistance to determine the circumstances
surrounding an apparent procedural violation committed by an NRC licensed
operator on June 2,1979, at Arkansas Power and Light Company's Arkansas
Nuclear One, Unit 1 (ANO-1).
Based on instructions received from the
Director, Region II, a Region II Investigator contacted the Director,
Region IV and the Resident Inspector at ANO on the evening of June 2.
The investigator was informed that during a tour of the ANO-Unit 1 control
room on the morning of June 2 the Resident Inspector had observed that
the controls for the Emergency Feedwater system had been placed in manual
and/or pull-to-lock positions, thus defeating the automatic start features
of this system. The Director, Region IV requested investigative assistance
to determine (1) the circumstances leading to this apparent procedural
violation and (2) whether procedural violations of this type were common
practice at this site.
The inquiry at the ANO site commenced on June 4 with the Region II investi-
gators meeting uith the Resident Inspector and with representatives of
the Operator Licensing Branch and the Division of Systems Safety, both of
the Office of Nuclear Reactor Regulation. During the peridd June 4-6,
the investigators interviewed eleven individuals currently employed by
AP&L. The on-site inquiry was conluded on June 6, 1979, with a meeting
between the investigators, the Resident Inspector, the ANO Plant Manager
and members of his staf f during which the Resident Inspector outlined the
preliminary results of the inquiry to the licensee.
This inquiry was conducted under the authority provided by Section 1.64
of Title 10, Code of Federal Regulations, and required a total of 87
man-hours of investigative effort by two Investigators (58 man-hours) and
the Resident Inspector (29 man-hours).
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II.
DETAILS OF INQUIRY
A.
Meeting of NRC Personnel
On the morning of June 4, 1979, the following individuals met at the
ANO site to discuss the information then available regarding the
apparent procedural violation which had occurred on June 2 and to
establish the objectives and the procedures for conducting the
inquiry:
W. Johnson, NRC Resident Inspector
D. McGuire, Regional Investigator, Region II
C. Alderson, Regional Investigator, Region II
B. Boger, Operator Licensing Branch, NRR
G. Mazetis, Division of Systems Safety, NRR
During this meeting the Resident Inspector stated that he had entered
the control room at approximately 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br /> on June 2 and observed
that the switch for the electrically-driven Emergency Feedwater
Pump, P-7B was in the " pull-to-lock" position and the switches for
the steam supply valves to the turbine-driven Emergency Feedwater
Pump, P-7A were in the " manual-close" position. This defeated the
automatic start feature of the Emergency Feedwater System.
The Resident Inspector stated that he brought this to the attention
of the Assistant Operations Superintendent (AOS) for Unit I who was
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in the control rcom at the time. The AOS, after reviewing the Plant
Startup procedure and Station Log, placed the switches in the proper
positions for automatic initiation. The AOS and other operating
personnel in the control room were unable to explain why the switches
had been positioned improperly.
The Resident Inspector explained that later in the day on June 2 he
was notified by plant management that they had determined that the
switches had been placed in the manual / pull-to-lock positions during
testing of the main feedwater check valves.
Problems had been
encountered during the test and it had not been completed at the time
the Resident Inspector observed the switch misalignment.
Following this briefing, a list of objectives was developed by the
NRC personnel present.
It was determined that the following should
be accomplished:
1.
Ascertain the factual details surrounding the event.
2.
Determine if divergence from procedures was common practice at
ANO and review administrative procedures for controlling proce-
dural deviations.
3.
Evaluate the adequacy of shift turnover and plant status
informa tion.
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4.
Eva!uate licensee actions in response to Part III of the Order
issued to Arkansas Power and Light by the NRC on January 2,
1979.
After establishing the above objectives, it was agreed that the
Resident Inspector and the investigators would work jointly in
obtaining objectives 1-3, while Region IV and NRR personnel would
pursue objective 4.
B.
Meeting with AP&L Management
The NRC personnel identified in Paragraph A above, met with the
following representatives of Arkansas Power and Light to inform them
of the inquiry and its purposes:
AP&L Corporate Personnel
W. Cavanaugh, Vice President, Generation and Construction
D. Sikes, Director, Generation Operations
ANO Site Personnel
J. O'Hanlon, Plant Manager
H. Miller, Manager Engineering and Technical Support
T. Cogburn, Plant Analysis Superintendent
B. Baker, Operations Superintendent
M. Bishop, Office Services Supervisor
During this meeting the Plant Manager provided the NRC representatives
with copies of the minutes of the meeting of the Plant Safety Cannittee
which was conducted on June 2, 1979 to review the occurrence. The
Plant Manager also
- ribed the information that the licensee had
obtained regarding tne occurrence.
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C.
Apparent Procedural Violation
On June 5 and 6, 1979, the investigators and Resident Inspector
interviewed two shift supervisors, one plant operator, two assistant
plant operators and an auxiliary operator who had been on shift at
the time of the occurrence.
The Assistant Operating Superintendent
for Unit I was also interviewed. As a result of these interviews
and a review of the Station Log and the Plant Startup Procedure,
OP 1102.02 which was in progress on June 2, the following sequence
of events was developed:
As a result of NRC actions taken following the Three Mile
Island incident, an automatic start feature was added to the
electrically-driven Emergency Feedwater Pump, P-7B.
This
modification was completed on May 16, 1979.
In addition, a
procedure change to OP 1102.02 was initiated on May 19, 1979,
y (3)
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and approved on May 22, 1979, which required that the hana
switches for the steam supply valves to the turbine-driven
Emergency Feedwater Pump P-7A be placed in the OPEN-AUTO-
position and the hand switch for P-7B be placed in the NORMAL-
AFTER-STOP position.
Placing the switches in these positions
arms the system for automatic initiation.
At approximately 0100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br /> on June 2, plant heatup had pro-
gressed to the point where the Auxiliary Feedwater Pump was
required.
The Station Log indicates that 'this pump was started
at 0107 hours0.00124 days <br />0.0297 hours <br />1.76918e-4 weeks <br />4.07135e-5 months <br />. The Assistant Plant Operator stated that he
armed the Emergency Feedwater system as required by Step 6.4.42
of OP 1102.02 immediately thereafter.
The Assistant Plant Operator further stated that at approximately
0715 hours0.00828 days <br />0.199 hours <br />0.00118 weeks <br />2.720575e-4 months <br />, he initiated Step 6.4.57 of OP 1102.02.
This step
requires that Supplement II of the procedure ~ be ccmpleted. The
supplement provides the procedural steps for performing the
seating test on the main feedwater check valves, FW-7A and
FW-7B.
Step 2.1 of Supplement II required that the Auxiliary
Feedwater Pump be stopped.
The Assistant Plant Operator stated
that he realized that stopping the Auxiliary Feedwater Pump
would cause automatic start of the Emergency Feedwater system
and result in an undesired cooldown.
To prevent this, be
placed.the hand switch for P-76 in PULL-TO-LOCK and the hand
switches for the steam inlet valves to P-7A in the MANUAL CLOSE
position. These actions are not specified in the procedure.
After placing the Emergency Feedwater system in the manual
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mode, +.ne operator stopped the Auxiliary Feedwater Pump and h a
the Aoxiliary Operator take the data for the check valve test.'
The interviewees estimated that this took approximately iise
minutes.
The Auxiliary Operator informed the Assistant Platt
Operator that one of the check valves had failed the test ic
that no differential pressure was observed across the vrlve.
The Assistant Plant Operater stated that he then restarted the
Auxiliary Feedwater Pump, but did not return the Emergency
Feedwater system to the automatic mode because the check valves
test had not been completed.
The Shift Supervisor ind the Assistant Plant Operator both
stated that they disc. ssed the problem with the check valves,
but that the Shif t Supervisor was not aware that the. Emerges:y
Feedwater system had been placed in the manual modt
The
interviewees also stated that the Plant Operator was involved'
in other activities and was not immediately involved in the.
test.
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A shift change occurred between 0730 and 0800 hours0.00926 days <br />0.222 hours <br />0.00132 weeks <br />3.044e-4 months <br /> and all
interviewees stated that while information regarding the check
valve test failure was relayed to the oncoming shift, the
status of the Emergency Feedwater system was not documented nor
was it brought to the attention of the oncoming shift.
.
The Plant Operator who had been on the 0001-0800 shift worked
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over at the Plant Operator on the next shif t.
The Shift Super-
visor and the Assistant Plant Operator were relieved by oncoming
personnel.
At approximately 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br />, the Resident Inspector entered the
control room and observed the switch misalignment.
He brought
this to the attention of the Assistant Operations Superintendent
for Unit i who was in the control room. The AOS reviewed the
,
Plant Startup Procedure and determined that Step 6.4.42 had
been signed off indicating that the Emergency Feedwater system
was in the autcmatic mode. The AOS then placed the switches in
the automatic positions without discussing his actions with the
operating crew.
The minutes of the Plant Safety Committee
meeting on June 2 indicate that the AOS was unaware of the
complete situation at that time.
The FRC Resident Inspector then notified his Regional office of
thls-apparent violation of procedures and ANO management set
about trying to determine the reason the valves were in the
position indicated.
Some interviewees stated that it was
initially-telieved that the valves had not been properly
positioned at the time Step 6.4.42 of the procedure had been
signed off.
A meetiag of the Plant Safety Committee was held on the afternoon
of June 2; to review the occurrence and a meeting of the Corporate
Nucleaf Review Committee was he?4 on June 3,1979 for the same
purpose.
Based on the interview , it appears that the licensee is in noncom-
pliance with Technical Specification 6.8 in that steps were added to
,
Supplement II of OP 5102.02 without a temporary 3r permanent change
being initiated and approved in accordance with Administrative
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Procedure 1004.21, " Handling of Procedures." The licensee may al's
be in noncompliance with Technical Specification 3.4.1 which required
that both Emergency Feedwater Pumps be operable when the reactor is
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heated above 280 F. -It should be noted that various members of the
licensee's staff'believe that system to be " operable" even though
the system is in the v.aaaal mode. To support this position, the
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licensee points but the.t prior to May 1979 the system was operate d
lin the manual mode.
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The investigators were also concerned regarding the actions of the
AOS in manipulating plant controls without the knowledge of the
operating crew.
D.
Divergence From Procedures
The individuals identified in Paragraph C were asked if they had
other occasions to add or delete steps from procedures. One
additional shift supervisor and two assistant plant operators were
also interviewed in this respect.
The Manager, Operations and
Maintenance was interviewed to determine previous management
philosophy with regard to procedure adherence.
The investigators
also reviewed the Plant Startup Procedure, OP 1102.02 and various
valve alignment sheets which had ceen completed during the most
recent plant heatup.
Many of the interviewees including the Manager, Operations and
Maintenance, stated that procedures for " safety" systems were
adhered to, but that procedures for "non-safety" systems were viewed
as guidance and were not strictly followed. When asked for examples
of procedures which were not followed, the majority of the inter-
viewees stated that the Vacunn Degasifier had operated intermittently
for several months and that procedural steps affecting that system
could not be accomplished.
The interviewees stated that the Vacuum
Degasifier was bypassed and Hiat reactor coolant would be routed
directly to the Clean Waste neceiver Tanks without degasification.
One of the interviewees stated that the Caseous Waste Decay Tanks
had also been bypassed with all radioactive gases being routed
directly to the plant vent without holdup.
The investigators briefly reviewed the system operating descriptions
for this equipment in Chapter 11 of the Final Safety Analysis Report
and it appears that the systees are not being operated in accordance
with these descriptions. This matter was beyond the scope of the
inquiry and after discussion with Region IV management it was
determined that Region IV personnel would follow up to determine
whether or not the licensee is in compliance with his technical
specifications and 10 CFR 50.59.
During the review of the Plant Startup Procedure and valve alignment
sheets the investigators noted many exanples chere valves were not
signed off as being in the required positio and no explanation was
provided on the alignment sheet.
The corresponding steps in the
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Plant Startup Procedure were found to be signed off or marked "N/A"
without identification or explanation of the valve alignment
discrepancies. Specific examples include:
OP 1102.02
Step No.
System - Operating Procedure
6.2.2
Service Water System - OP 1104.29
6.2.4
Instrument Air System - OP 1104.24
6.2.5
Service Air System - OP 1104.25
6.2.7
Clean Waste System - OP 1104.20
6.2.8
Gaseous Radwaste System - OP 1104.20
6.2.22
Vacuum Degasifier - OP 1104.16
6.2.25
Reactor Building Spray System - OP 1104.05
6.3.11
Makeup and Purification System - OP 1104.02
Failure to complete valve alignments as specified in the procedures
and/or document the reasons for non-completion or different align-
ments appears to be in noncompliance with Technical Specification 6.8
which requires that procedures be developed, implemented and maintained
and establishes requirements for making temporary or permanent
changes to procedures.
The licensee issued Standing Order No. 39 on June 3, 1979 which
addresses procedure adherence.
E.
Adequacy of Shift Turnover and Plant Status 'Information
During the interviews individuals were asked how they passed on
information to personnel relieving them and how they knew the status
of the plant. All individuals asked these questions stated that
they kept a " rough log."
They then described what essentially was
pieces of scratch paper on which they made notes.
They explained
that these notes were given to the Shif t Supervisor who extracted
information for the Station Log.
These notes were also passed on to
the incoming shift.
Some interviewees were asked if they specifically discussed the
causes of activated alarms with the individual who was relieving
them. No interviewee indicated that all activated annunciators were
discussed with the person relieving them and only two or three
stated that they discussed "significant" alarms during shift turnover.
The interviewees also stated that shift turnover on weekday mornings,
especially during an outage, was hectic because maintenance personnel
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were in the control room and Shift Supervisors' office to obtain
sig. natures on job orders or to get keys from the shif t supervisor.
The licensee is aware of this problem and is considering changing
shift times to resolve this problem.
Based on the interviews, it appears that plant / system status informa-
tion available for the operating crew is inadequate and admin ~strative
conceols governing shift turnover are it. sufficient to assure that
all significant information is passed on to the shift coming on
duty.
F.
Exit Interview
The Resident Inspector and the investigators met with the following
personnel at the conclusion of the inquiry on June 6, 1979. The
Resident Inspector outlined the preliminary results of the inquiry
as described above during this meeting.
J. O'Hanlon, Plant Manager
B. Terwilliger, Manager, Operations and Maintenance
B. Baker, Operations Superintendent
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