ML19351A280
| ML19351A280 | |
| Person / Time | |
|---|---|
| Site: | Trojan File:Portland General Electric icon.png |
| Issue date: | 10/12/1989 |
| From: | Cockfield D PORTLAND GENERAL ELECTRIC CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 8910190200 | |
| Download: ML19351A280 (15) | |
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MM David W. CockfWd Vice President, Nuclear October 12, 1989 Trojan Nuclear Plant Docket 50-344 1.icense NPF-1 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington DC 20555 Dear Sir Reply to a Notice of Violation h
Your letter of September 12, 1989 transmitted a Nntice of Violation associated with Nuclear Regulatory Comission (K2C) Inspection Report. 50-344/89-17. Attachment 1 is our response to that Dotice of Violation.
Sincerely, i
I Attachment c
Mr. John B. Martin gg Regional Administrator, Region V Nwo U.S. Nuclear Regulatory Commission 58'
'A9, Mr. David Stewart-Smit.h v.io State of Oregon og Department of Energy l
bO oc Mr. R. C. Barr C. $4 NRC Resident Inspector
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Trojan Nuclear Plant Document Control Desk l
Docket 50-344 October 12, 1989 License NPF-1 Page 1 of 14 REPLY TO A NOTICE OP VIOLATION i
VIOLATION A Title 10 to the Code of Federal Regulations, Part 50 (10 CFR 50),
Appendix B, Criterion XVI, provides, in part, that " measures shall be established to assure that conditions afterse to quality such as... nonconformances are promptly i&mtified and corrected".
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Nuclear Quality Assurance Program, PGE-8010, Section 16.2.1., states in part, that "Any PGE employee has the authority and responsibility to report a nonconforming activity (NCAR) to their manager or supervisor who i
will assure that the nonconforming activity is or has been documented on en NCAR unless it has been previously documented".
i contrary to the above, on July 14, 1989, while conducting steam generator crevice flushing per Operating Instruction (01)-T-61 " Steam Generator Crevice Flushing" Revision 0, dated July 11, 1989 Licensee employees identified boiling in the residual heat removal / component cooling water l
RHR/CCW heat exchangers, but did not promptly docunent the boiling as a nonconforming activity.
This is a Severity Level IV violation (Supplement I).
gegponse portland General Electric (FCE) acknowledges the violation.
i 1.
Reason for the Violation:
The reason for the violation was personnel error, failure to comply with the procedure.
2.
Corrective Steps That Have Been Taken and The Results Achieved r
Event Report (ER)89-105, " Void formed in Component Cooling Water (CCW) Side of the RHR Heat Exchanger", was initiated July 17, 1989.
The ER evaluation has been completed and is under6oing review by the performance Monitoring and Event Analysis (PM/EA) Dranch of pCE.
All operating crews were lectured on the nved to follow and comply with procedures.
Supervision involved in this event were counceled i
on the need to recognize and document nonconforming activities.
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Trojan T,uclear Plant Document Control De;k Docket 50-344 October 12. 1989 License NPF-1 l
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Page 2 of 14 3.
The Corrective Stepa That Will Bn Taken to Avoid Further Violations Procedural compliance has been emphasized by all levels of supervision and management.
These levels include the Branch Manager of Operations through the Vice President. Nuclear. 1he issue of procedural compliance will continue to receive high levels of attention to ensure that the proper use of } rocedures becomes a standard for PCE performance., Management has also been counseled on the need to provide oversight of significent Plant activities.
4.
The Date When Full Compliance Will Be Achieved:
Full compliance was achieved following the issuance of Event Report 89-105 on July 17, 1989.
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,.,,m Trojan Nuclear plant Document Control Desk I
Docket 50-344 Oc t.ober 12, 1989 License NPr-1 page 3 of 14 y]QL& TION B.3 10 CrR part 50 Appendix B, Criterion V, states, in part, that
" Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures or drawings".
Contrary to the above, Maintenance Instruction (NE) 89-1538 did not provide appropriate work instructions specifying that the calibration of the first stage impulse pressure lead-lag module, LY-505-E, could only be calibrated while shut down. Because the procedure was used with the reactor at 100 percent power on March 4, 1989, a steam generator water-level transient occurred.
This is a severity Level IV violation.
Response
pCE acknowledges the violation.
1.
Reasons for the Violations a.
The work instructions for calibrating modules in the Hagan instrumentation racks were inadequate. They did not provide clear instructions for designating which modules could be calibrated with the plant operating at power. The FR was generic in nature, and did not contain specific instructions concerning the methods to be used for calibrating individual modules.
b.
The Instrument and Control (16C) Craft Supervisor did not provide an adequate pre-job briefing to the technicians. He did not explain the use of a list attached to the KR and markings on the folders which contain the calibration data sheets for the modules. The list with the KR contained only modules which can be calibrated at power.
Specific folders are annotated with an asterisk to indicate that some of the module calibration data sheets contained within cannot be completed at power. However, neither the list contained within each folder nor the individual calibration data sheets indicated which modules could not be calibrated at power.
c.
A contr3buting cause was the Work Croup Supervisor did not follow approved procedures in that he did not perform a second pre-job briefing when the work originally planned for Saturday, March 4, 1939, was deferred and other work was substituted.
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- Trojan Nuclear Plant Document control De:k i
j Docket 50-344 October 12, 1989
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License NPF-1 page 4 of 14 i
2.
Corrective Steps Taken and Results Achieved:
a.
An additional job position for a Supervisor I&C Maintenance, i
has been provided.
This will provide improved supervision of i
I&C technicienc.
I b.
The use of generic MRs f or calibrating HaSan instrt).hentation modules has been discontinued.
MRs must clearly in$1cate the specific modules to be calibrated.
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c.
The folders for associated Hagan instrumentation modules have been reorganized so there is a clear distinction between modules which can be calibrated at power and those that cannot.
d.
The calibration data sheets for Hagan instrumentation modules which cannot be calibrated at power have been clearly marked.
e.
This event was critiqued with all of the I&C technicians in a i
training session led by the two technicisna that committed the error. The requirements for adequate work instructions, l
thorough pre-job briefings, and the need for reporting back to I
the supervisor when faced with uncertainty, were all strussed.
3.
Corrective Steps That Will Be Taken to Avoid Further Violations:
Detailed proceduren for calibrating Hagan instrumentation models are j
bein5 developed. Additional resources are being applied to this task.
4.
Date When Full Compliance Will Be Achievedt Detailed module calibration instructions will be included in the appropriate Plant I&C Test procedur9s. This will be completed by September 30, 1990.
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r, Trojan Nuclear plant Do!.ument Control De:k L
Docket 50-344 October 12, 1989 License NPF-1 Page 5 of 14 i
VIOLATION B.2 i
10 CFR part 50, Appendix B, criterion V, states, in part, that
" Activities affecting quality shall be prescribed by documented l'
instructions, procedures, or drawings, of a type appropriate to the circunstances and shall be accomplished in accordance with these instructions, procedures or drawings".
l Contrary to the above. Tamporary Operating Instruction OI-T-61, " Steam Generator Crevice Flushing", Revision 0, dated July 11, 1989, was not appropriate for the circumstances in that the procedure required closing the CCW supply valves to the RHR heat exchanger with 315'F reactor coolant flowing through the heat exchanger, which resulted in the shell side of the RHR/CCW heat exchanger exceeding its design analyzed temperature by approximately 105'F on July 14, 1989.
This is a Severity Level IV violation.
Response
pCE acknowledges the violation.
1.
Reason for the Violation:
The reason for the violation was personnel error in not performing an adequato safety evaluation and technical review, which resulted in an inadequate procedure.
2.
Corrective Steps That Have Been Taken and the Results Achieved:
The temporary instruction written to perforn this evolution was deviated to allow throttling of RHR heat exchanger outlet and bypass valves.
A walkdown of the RHR heat exchangers and associated CCW piping was performed to ensure damage had not occurred. The design bases of the RHR heat exchangers and associated piping were reviewed to ensure design limits for this equipment were not exceeded. A
" lessons learned" information notice on this event was written and distributed to PGE Nuclear Division employees. The incident was reviewed and discussed with the crew involved, and the individuals that conducted the original safety evaluation were counseled on the significance of the safety evaluation error.
plant Operating Manual (p0M) procedures C01-4 (plant Shutdown From Hot Standby to Cold Shutdown) and 01-4-1 (Residual Heat Removal) were revised to prevent the CCW side of the RHR heat exchanger from exceeding 200*F and to require that CCW flow always be maintained to the RHR heat exchanger during Mode 4 when R9R is in service.
I Trojan Nuclear Plant Do:ument Control De;k l
Docket 50-344 October 12, 1989 l.
License NPF-1 Page 6 of 14 Procedure 0I-7-61
" Steam Generator Crevice Flushing", has been deletedifrom the Plant Operating Manual.
3.
Corrective Steps That Will Be Taken to Avoid Further Violations:
A Request for Design Change (RDC) to replace the RNR heat exchanger valves (RDC 88-17) was reviewed by management and the priority for implementation was raised to the highest priority (Level 1) in the capital plan.
Engineering for this RDC ic scheduled for 1990.
Installation is scheduled for 1991.
This RDC will allow the RHR valves to throttle RHR flow effettively, thereby eliminating the need to throttle the CCW flow to the heat exchangers.
4.
Date When Full Compliance Will Be Achieved Full compliance was achieved on July 15, 1989 when the temporary instruction. OI-T-61, was deviated to a110w performance of the evolution.
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Troj00 Nuclear Plant Document Control Desk Dockct 50-344 October 12, 1989 License NFF-1 Page 7 of 14 s
c VIOLATION BJ Administrative Order (AO) 4-2, "Use of Procedures" defines the requirements for the use of Plant procedures contained in the Plant Operating Manual (POM).
'Section 4.2.3.a of the POM requires, in part, that persorinel are not to blindly follow procedures. Rather, if the POM or lower-tier procedures cannot or should not be performed as written, procedures are to be revised or deviated in accordance with A0 4-4 or appropriate Lower-Tier Administrative Procedures.
Contrary to the above, on July 14, 1989, while conducting crevice flushing of steam generators per Procedure 01-T-61, " Steam Generator Crevice Flushing", Revision 0, dated July 11, 1989, 01-T-61 could not be performed as written, but was performed differently than written in that Valves MO-3210A&B were alternately opened and closed where the procedure specified the valves be closed, even though the procedure for conducting the evolution was not revised or deviated.
This is a Severity Level IV violation (Supplement 1).
Response
PGE acknowledges the violation.
1.
keason For The Violation:
The reason for the violation was personnel error, failure to comply with the procedure.
2.
Corrective Steps That Have Been Taken and The Results Achieved:
Procedure OI-T-61 was deviated in accordance with A0 4-4, " Procedure Additions. Revisions Deletions, Deviations and Corrections", on July 15, 1989. The individuals involved with the procedural non-compliance were counseled concerning their responsibility to l
follow procedures.
3.
The Corrective Steps That Will Be Taken to Avoid Further Violations:
PGE has reemphasized the importance of procedural compliance in a meeting conducted by the Vice President, Nuclear, to all station personnel on September 15, 1989.
This issue will continue to receive high levels of attention to ensure procedural compliance hecomes standard performance.
4.
Date When Full Compliance Will Be Achieved:
Full compliance was achieved on July 15, 1989 when procedure OI-T-61 was deviated.
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i Trojan Nu21 ear Plant Document Control Da;k Docket 50-344 October 12, 1989 License WPF-1 i
page 8 of 14 i
VIOLATION B.4 Administrative Order 3-9
" Maintenance Requests",. establishec the controls for initiating, pisuning, performing and documenting work i
performed in response to Maintenance Requests (MRs).
Section 4.9.1 of this order states that " Changes in MR work instructions, 9
made after approval by the Cognizant Work Group Supervisor, shall be submitted for supervisor approval prior to implementation".
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Contrary to the above, on April 28, 1989, the work instructions of MR 89-1770 did not include instructions for pulling wires from Containment penetration St03; even though MR 89-1770 had been approved by L
the Cognizant Work Group, wires were pulled out of the penetration module without changing the work instructionc or obtaining appropriate supervisor approval to conduct the wire pulling.
This is a Severity Level IV violation, i
Response
i PGE acknowledges the violation.
1.
Reason for the Violation:
During replacement of seals to the penetration modules, an engineer in charge of the replacement project incurrectly authorized an l
electrician to perform work not specified in the MR by having the l
electrician pull-test wires in the module to check for tightness.
This engineer also instructed his relief engineer to pull test wires in modules, again without supervisor approval of the revised MR work instructions.
Although the engineerp in question believed, at the time o.f the incident, that their actions were allowable using l
engineering judgment, they had not complied with procedure A0-3-9, I
Section 4.9.1, "MR packago Revisions".
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2.
Corrective Steps That Have Been Taken and the Results Achieved:
The incident was discussed with the plant System Engineering Department. The engineers were instructed to the; requirements of AO-3-9, in particular the need to obtain permission to deviate from KR 'sork instructions on May 2, 1989.
3.
Corrective Steps That Will Be Taken to Avoid Further Violations:
Guidance is being developed to specify the activities that can be performed by designers and engineers during equipment walkdowns and incpections.
This Guidance will be developed by January 31, 1990.
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Trojan Nuclear Plant Document Control De;k l.-
Docket 50-344 October 12, 1989 l
License NFF-1 Pa6e 9 of 14 s
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4.
Date When Full Compliance Will Be Achieved I-1 i
Full compliance will be achieved by January 31. 1990 following the development of guidance for engineering walkdowns.
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b Trojan Nuclear Plant Document Control De:k i
i Docket 50-344 October 12, 1989 e
. License NPF-1 Page 10 of 14 l
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V10LAT!op B.5 Administrative Order A0 5-5, " Request for Evaluation", establishes the process for requestint, documenting and tracking a Request For Evaluation i
(RFE).
t Section 3.4.1 of A0 5-5 states, in part, that:
"The assigned evaluator shall revicw the situation described in Part 1 of the kFE and the assigned RFK priority.
If the i
evaluator determines it is not possible to completely resolve the RFE within the date implied by the assigned priority, the evaluator shall:
a.
Perform an evaluation in sufficient detail to determine what, actions need to be taken to resolve the RFE and complete an Initial RFE Response.
Contrary to the above procedure, the below are examples of RFEs which were l"
not responded to within the date specified by the priority:
Evaluation SfFEA PI[orji_I Date Loned Date
_ Days Lat e.__
6825 30 Dsy 06/12/89 07/28/89 16 Days 6787 7 Day 06/05/89 06/21/89 9 Days 6722 7 Day 05/19/89
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No Evidence Performed 6699 7 Day 05/17/89 06/29/89 37 Days 6581 7 Day 04/27/89 05/16/89 12 Days This is a Severity Level IV violation.
Response
PGE acknowledges the violation.
1.
Reason For The Violation:
The reason for the violation is personnel error, failure by the assigned individuals to comply with the requirements of procedure A0 5-5.
2.
Corrective Steps That Have Been Taken and the Results Achieved:
l Each RFE associated with the violation was evaluated prior to August 15, 1989. No operability concerns existed.
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uo Trojan Nuclear plant Document Control Desk j
Docket 50-344 October 12, 1989 License NPF-1 page 11 of 14 i
To ensure an immediate proper assignment of priority to RFEs, a priority field has been included on the Trojan E%gineering Work Tracking System (TEWTS). This priority field will inform the l
supervisor of the cognizant system engineer of the initial response i
due date.
l 3.
Corrective Steps That Will Be Taken to Avoid Further Violations:
s To ensure management awarenesh of the status of the RFE program, the RFE backlog will be included on the plant System Engineering Quarterly progress Raport.
l An action plan will be developed by October 15, 1989 to improve the n
RFE process.
i On June 29, 1989, the plant Systems Engineering (pSE) Branch Manager began implementing a plan for reducing the RFE backlog.
This backlog reduction plan will review all open RFEs in order to reprioritize and develop a plan f or resolution by December 1,1989.
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Date When Full Compliance Will Be Achieved:
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tull compliance will be achieved when the backlog reduction i
resolution plan is completed on December 1, 1989.
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Trojan Nuc1:ar Plant Document Control De k Docket 50-344 October 12, 1989 i-License NPF-1 I
page 12 of 14 l
VIOLATION B.6 l
Administrative Order 10-1, " Plant Housekeeping", defines the responsibilities for maintaining the Plant in a clean and orderly condition.
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Section B., A0 10-1' states, in part, that:
"Each employee will perform the following at the i
termination of each assignment or at the end of the day if the assignment is not yet completed:
- 1) Wipe up minor oil spills; pick up rags, papers and other foreign material.
All solvent waste, oily rags and other flammable alquids shall be kept in fire-resistant covered containers and are to be emptied at reasonable intervals as the work progresses and upon completion of the work".
Contrary to the above, at the end of the work days specified below, the following conditions existed:
a.
On June 18, 1989, oily rags and tubing were on the diesel-driven auxiliary feedwater (AFW) pump, b.
On June 28, 1989, oily rags were on both main feodwater (MFW) purps and insulation was lying near the pumps. Also, approximately 2.5 gallons of oil in an open buchet was next to the south MFW pump and a half coffee can of linseed oil was next to the north MFW pump.
This is a Severity Level IV violation.
Response
PGE acknowledges the violation.
1.
Reasons for the Violation, s.
The cause of this violation was personnel error in that there was a basic misunderstanding of the instructions of the Administrative Order.
The criteria for housekeeping at the end of each shift was misinterTreted. The rags and parts lying on the diesel-driven APW pump were being stored until additional parts could be obtained to complete the task. The parts were laid out around the pump baso aiid rags were used to cover the open flanges from which piping had i
been removed. However, the parts and rags were in such a fashion l
that it war not apparent that these items were purposely placed I
there. Care was not taken to ensure that these items were being controlled.
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Trojan Nuc1:ar plant Document Control De:k Docket 50-344 October 12, 1989 License NPF-1.
Attachment I t'
page 13 of 14 i
i The lack of control of material (oily rags, oil in buckets and insulation) around the Main Feedeater (MrW) pumps was the result i
l of several different work groups, each one apparently assuming l
that another group would take care of the debris.
The bucket of oil came from an unknown source as the oil was not from any l
activit'/ associated with the inspection of the MrW pump that was in progress at the time.
b.
Another contributing cause for this incident was the supervisors of the work crews involved did not tour the work sites frequently to ensure cleanliness requirements were being met.
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Corrective Steps Taken and Results Achieved:
a.
All maintenance personnel were instructed to use wooaan closures on open piping when components were removed. They were further instructed to tape all temporary closures using the rags so that these closures can be immediately identified as a controlled closure.
l b.
Maintenance personnel were instructed to clean their work areas regardless of the source.
Emphasis was placed on completing cleanup at the end of the shift regardless of whether or not the task had been completed.
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Maintenance personnel were inutructed to assure that parts and l~
s equipment removed during the disassembly of any equipment are laid t
l out in order and isolated to paevent inadvertent scattering of l
equipment or loss of the parts.
3.
Corrective Steps That Will Be Taken to Avoid Further Violatione:
During large repair tasks, supervisors will be assigned direct a.
field responsibilities to oversee the work to ensure the supervisor is in contact with the fleid work and is able to provide the necessary guidance to ensure cleanliness requirements I
are being met.
b.
A revision to AO-10-1 and Kp-3-5 will be completed to reflect the i
requirements to use temporary closures or tape closure materials.
l These revisions will be completed by November 31, 1989.
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Trejan Nucic0r plant Document Control Desk Docket 50-344 October 12, 1989 4
License NPF-1 Page 14 of 14 c.
PCE will evaluate a change to the responsibility of the maintenance supervisors.
It will be considered to have job analysts do a complete document review of the work package.
This Practice will allow the supervisor to focus on maintenance work closeout, ensuring circle Q, circle I holdpoints and housekeeping requirements are not. This evaluation will be completed by December 31, 1989.
4.
Date When Full Compliance Will Be Achieved:
Full compliance was achieved following cleanup and restoration of the area scound the diesel-driven auxiliary feedwater purp and the main feedwater pumps.
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