ML20024J242
| ML20024J242 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 10/03/1994 |
| From: | Creed J, Madeda T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20024J237 | List: |
| References | |
| 50-254-94-24-EC, NUDOCS 9410130047 | |
| Download: ML20024J242 (9) | |
See also: IR 05000254/1994024
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U.S. NUCLEAR REGULATORY COMMISSION
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REGION III
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Reports No. 50-254/94024(DRSS); 50-265/94024(DRSS)
Docket Nos. 50-254; 50-265
Licensee: Commonwealth Edison Company
Opus West III
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1400 Opus Place
Downers Grove, IL 60515
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Facility Name: Quad Cities Nuclear Generating Station, Units I and 2
Meeting Conducted:
September 23, 1994, 12:30 p.m.
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Meeting At: NRC Region III Office, Lisle, Illinois
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Type of Meeting:
Enforcement Conference (Fitness-For-Duty Event)
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Inspector:
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trry J. Madeda
hysical Security Inspector
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Approved By:
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mes R. Creed, Chief-
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~ afeguards & IR Section
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Meetina Summary
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Enforcement Conference on Seotember 23. 1994 (Reports No. 50-254/94024(DRSS):
50-265/94024(DRSS))
Areas Inspected:
Enforcement conference to include a review and discussion of
the circumstances involved, and corrective action taken in response to a self-
disclosing event pertaining to two apparent failures to adequately implement
the facility's fitness-for-duty program.
Results: The licensee did not contest the apparent violations. Corrective
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actions were adequate.
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9410130047 941003
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ADOCK 05000.754
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1.
Key Persons Present at the Conference
Commonwealth Edison Company
J. Perry, Senior Vice President, BWR Operations, Comed
E. Kraft, Site Vice President, Quad Cities
J. Morris, Executive Assistant, Site Vice President
G. Campbell, Site Manager, Quad Cities
J. Kudaus, Site Services Director
K. Leech, Site Security Administrator
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D. Winchester, Director, Site Quality Verificatien
N. Chrissotimos, Supervisor, Regulatory Assurance
R. Baumer, NRC Coordinator, Regulatory Assurance
L. Tucker, Technical Superintendent
P. Welsh, FFD Assistant Program Administrator
U.S. Nuclear Reaulatory Commission
J. Martin, Regional Administrator, Region III
W. Axelson, Director, Division of Radiation Safety & Safeguards,
Region III
R. Capra, Director, Project Division III-2, NRR
C. Pederson, Chief, Reactor Support Programs Branch, Region III
J. Creed, Chief, Safeguards and IR Section, Region III
P. Hiland, Section Chief, Reactor Projects, Section IB, Region III
C. Miller, Senior Resident Inspector, Quad Cities, Region III
T. Madeda, Physical Security Inspector, Region III
P. Pelke, Enforcement Specialist, Region III
2.
Enforcement Conference
An Enforcement Conference was held in the NRC Region III office on
September 23, 1994, at 12:30 p.m..
The conference was conducted to
address two apparent violations pertaining to the inadequate
implementation of the Quad Cities Fitness-For-Duty Program. Our
inspection findings were documented in Inspection Reports No. 50-
254/94018(DRSS); 50-265/94018(DRSS) which were transmitted to the
licensee by letter dated September 7, 1994.
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The purpose of the conference was to:
(1) discuss the apparent
violations, causes, and the licensee's corrective actions; (2) determine
if there were any escalating or mitigating factors; (3) obtain
information which would help determine the appropriate enforcement
action; and (4) provide any additional information deveioped subsequent
to the inspection noted above.
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Regional representatives presented a brief description of the pertinent
facts that led to the apparent violations, the regulatory requirements,
and potential safety significance of the event.
Licensee's representatives provided a description of the sequence of
events, the apparent violations, their safety significance, root cause
analysis and corrective actions.
The licensee concluded that the two
apparent violations discussed in our inspection report occurred because
of a failure to follow Quad Cities Fitness-For-Duty Procedures. The
following contributing factors were identified:
(1) limited review of
the appropriate procedure during the event; (2) site senior management
was misled by the Acting Operations Manager; (3) weak assessment of the
Acting Operations Manager's condition; and (4) operating activities that
had distracted the Shift Engineer from the fitness-for-duty issue.
Corrective actions were taken to address each referred are of failure.
Your agenda for the conference is attached as an enclosurt
, this
report.
Prior to the meeting, the licensee's review of Inspection Reports No.
50-254/94018 and 50-265/94018, dated September 7, 1994, identified on
pages 4 and 7 that the phrase "about 1:00 a.m." should be changed to
"12:30 a.m."
They also indicated that on page 8, paragraph 2, item 1,
the report incorrectly identified that a specific site procedure failed
to identify a time frame to conduct a for-cause test. We agreed that
the referenced section should have read that the specific site procedure
did not clearly denote the specific time period to conduct a for-cause
test.
The above changes were acknowledged.
Licensee representatives discussed mitigating factors which included
their self-identification of the event and apparent violations, prompt
corrective action and that the event had a minimal impact on plant
safety.
The licensee also concluded that the event was an isolated
occurrence and did not represent an overall breakdown of their fitness
for-duty program.
At the conclusion of the conference, the licensee representatives were
informed that they would be notified in the near future of final
enforcement actions.
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SEPTEMBER 23, 1994
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QUAD CITIES ENFORC1' MENT CONFERENCE
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FITNESS-FOR-DUTY EVENT
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AGENDA
1.
INTRODUCTORY REMARKS
. E. Kraft
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II.
SEQUENCE OF EVENTS AND APPARENT VIOLATIONS
. ... K. Leech
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SAFETY SIGNIFICANCE
. . G. Campbell
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IV.
CAUSES AND CORRECTIVE ACTIONS
. . . . . . . . . G. Campbell
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V.
CONCLUSIONS . .
. .G. Campbell
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FITNESS-FOR-DUTY
I. INTRODUCTORY REMARKS
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Agenda
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Initial Perspectives
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Immediate Site Vice President involvement and initiation of extensive
investigation by Corporate Security.
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Conduct of Operations Manager was unacceptable.
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Actions of Shift Engineer did not meet management expectations or procedure
requirements.
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Quad Cities Station and Nuclear Operations Division have taken aggressive
corrective and preventive actions.
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FITNESS-FOR-DUTY
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II. SEQUENCE OF EVENTS
7:52 PM
The Shift Engineer called the Operations Manager to inform him of a problem
with the Unit 2 main transformer. The Unit 2 transformer suffered a complete
loss of its cooling fans, and when the cooling fans could not be restored within
a half hour, a rapid load drop was initiated to remove the transformer from
service.
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8:30 PM
The (acting) Operations Manager called the Shift Engineer for further
discussion and an update on the transformer problem. The Operations Manager
infonned the Shift Engineer that he is coming into the station to provide
assistance. (The Shift Engineer did not request that the Operations Manager
come to the plant.)
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9:03 PM
The Operations Manager arrived at the station and entered
the protected area.
9:09 PM
The Operations Manager entered the control room.
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The Operations Manager came in contact with the Unit Supervisors, the Shift
10:10
Engineer, and the unit nuclear station operator and these individuals smelled
alcohol on the breath of the Operations Manager.
9:31
The emergency telephone rang in the control room informing them of a man
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down in the toms. An ambulance was called to the plant.
9:50 PM
The Unit Supervisors approached the Shift Engineer about
the smell of alcohol on the Operations Manager's breath.
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10:10-
The Shift Engineer and the on<oming Shift Engineer worked on the shift
10:30
turnover in the Shift Engineer's Office.
10:30 PM The Shift Engineer confronted the Operad9ns Manager in
the Shift Engineer's office (outside the control room) about
this matter. The Operations Manager admitted to having a
beer.
10:44
The Operations Manager re-entered the control room.
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FITNESS-FOR-DUTY
II. SEQUENCE OF EVENTS (Continued)
10:52 PM The Shift Engineer reviewed the for-cause-test
determination guidelines in the applicable procedure and
called the Station Manager. The Station Manager agreed
that a "for-cause" test needed to be done.
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11:04
The Operations Manager exited the control room and proceeded to his office
with the Shift Engineer. They discussed the for-cause test that needed to be
completed. The Operations Manager indicated that he wanted to complete
some tasks.
I1:20
The Shift Engineer returned to his office to discuss the main transformer
problem with the relief Shift Engineer and to complete shift logs.
12:00-
The on-coming Shift Engineer discussed the transformer fix with the
12:15
Operations Manager in the Operations Manager's office.
12:30
The Station Manager called in to see what the status of the "for-cause" test
was. The test had not been performed yet. The Station Manager told the Shift
Engineer to get the test done.
1:08
The Shift Engineer and Operations Manager exited the protected area to have
the test conducted.
1:15 AM
The "for-cause" testing began.
2:01 AM
The "for-cause" testing was completed.
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2:05
The Security Supervisor notified the Security Administrator of the test results.
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FITNESS-FOR-DUTY
II. APPARENT VIOLATIONS
1)
Licensee did not test-for-cause as soon as possible in accordance with 10 CFR 26.24.a.3 after receiving credible information that an individual is abusing alcohol.
Comed acknowledges that the test was not conducted within the one hour
period set forth in station procedures. The determination to test-for-cause was
made within the one hour period set forth in station procedures.
2)
Impaired workers, or those whose fitness may be questionable, shall be removed from
activities within the scope of 10 CFR 26.27.b.1, and may be returned only after the
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individual is determined to be fit to safely and competently perfonn activities.
Comed acknowledges that the Operations Manager was not removed from
activities prior to testing. The Shift Engineer had observed no aberrant
behavior and had been told by the Operations Manager thtt he had consumed
only one beer. As a result, the Shift Engineer did not believe that the
Operations Manager was a threat to plant safety.
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FITNESS-FOR-DUTY
III. SAFETY SIGNIFICA.NCE
Plant activities were properly controlled by licensed personnel throughout the event.
Although the Operations Manager was in the protected area unescorted throughout the
event, he did not direct actions affecting plant conditions, and by observation and the
information available at the time to the Shift Engineer, the Shift Engineer determined
that the Operations Manager posed no threat to the safety of the Station.
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Although the desired result was achieved in identifying and dispositioning the FFD
issue, failure to follow procedures concerning timeliness of testing, and candor and
judgement of Operations Manager are issues of significant management concern.
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FITNESS-FOR-DUTY
IV. CAUSES
APPARENT ROOT CAUSE OF BOTH VIOLATIONS IS:
A failure to follow the Quad Cities Station Fitness-for-Duty procedure.
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CONTRIBUTING FACTORS
Shift Engineer did not consult the entire procedure during the event.
Shift Engineer was misled by Operations Manager in that he stated that he only had
pm beer.
Shift Engineer's assessment that the Operations Manager was not a threat to plant
safety was based upon observations and misleading statements provided by the
Operations Manager.
Operational conditions and events created distractions for the Shift Engineer,
including a Unit 2 transformer transient and recovery; a medical emergency,
including the possible declaration of an Unusual Event based on the medical
emergency; and the need to provide a thorough shift turnover to the oncoming shift
(based on the events of the evening and current plant conditions).
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FITNESS-FOR-DUTY
IV. CORRECTIVE ACTION
1)
Immediate and Near Term Actions included:
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Operations Manager:
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immediately denied site access;
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removed from position, and following confirmation of test results;
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the individual resigned from Comed.
Quad Cities personnel, including licensed shift personnel, received
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supplemental FFD training from Site V.P. and/or Station Manager on all
aspects of the FFD program, with emphasis on:
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for-cause test determinations
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response to odor of alcohol
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escort requirements
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time requirements for testing
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instruction for reporting to work
Shift Engineer was counselled by Station Manager. The Shift Engineer
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subsequently reviewed the FFD Policy and Lessons-Learned from the event
with all other Shift Engineers.
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Programmatic and LAng Term Actions:
FFD training has been reviewed for adequacy and was determined to be
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satisfactory.
Chief Nuclear Officer has communicated this event in writing to all Nuclear
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Division Employees, with emphasis on FFD expectations. This
communication and expectations has been incorporated into our training.
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FITNESS-FOR-DUTY
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V. CONCLUSIONS
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The event was identified, reported in a timely manner, and comprehensively
investigated and corrected by Quad Cities Station.
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Although FFD Program procedural requirements were not implemented in a timely
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fashion, an overall FFD Program breakdown did not occur.
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The determination of the need for testing was timely.
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Testing was completed and unfitness for duty was properly determined.
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At all times, plant activities were properly controlled during the event, and
overall actions by Operations personnel were reasonable in real time,
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Aggressive management action was taken to correct the conditions which led to the
event and to prevent recurrence.
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