ML20034E972
| ML20034E972 | |
| Person / Time | |
|---|---|
| Site: | Sequoyah  |
| Issue date: | 02/17/1993 |
| From: | Merschoff E NRC Office of Inspection & Enforcement (IE Region II) |
| To: | Medford M Tennessee Valley Authority |
| References | |
| EA-92-257, NUDOCS 9303020146 | |
| Download: ML20034E972 (33) | |
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V MN Esg FEB l 71993
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Docket Nos. 50-327, 50-328 License Nos. DPR-77, DPR-79
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EA 92-257 Tennessee Valley Authority ATTN: Dr. Mark 0. Medford, Vice President Nuclear Assurance, Licensing and Fuels 3B Lookout Place 1101 Market Street Chattanooga, Tennessee 37402-2801 Gentlemen:
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SUBJECT:
ENFORCEMENT CONFERENCE
SUMMARY
(NRC INSPECTION REPORT NOS. 50-327/92-36,38, 50-328/92-36,38)
This letter refers to the Enforcement Conference held at our request on February 5, 1993. This meeting concerned activities authorized at your Sequoyah facility. The issues discussed at this conference concerned the mispositioning of throttle valves in the essential raw water cooling system (ERCW) and the cooldown of the refueling water storage tank (RWST) below technical specifications limits. A list of attendees and a copy of your handout are enclosed. We are continuing our review of these issues to determine the appropriate enforcement action.
In accordance with Sec'. ion 2.790 of the NRC's " Rules of Practice," Part 2, Title 10 Code of Fec'eral Pegulations, 2. copy of this letter and its enclosures g
will be placed in the NRC Public Document Room.
Should you have any questions concerning this letter, please contact us.
Sincerely, Original signed by E. Merschoff)
Ellis W. Merschoff, Director Division of Reactor Projects
Enclosures:
- 1. List of Attendees
- 2. ERCW/CCS Tnrottle Valve /
RWST Cooldown Presentation Notes cc w/encls:
(See page 2) 3 I
9303020146 930217 PDR ADOCK 05000327 O
PDR g
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.Q FEB I 7 F993
-4 Tennessee Valley Authority 2
cc w/encls:
Mr. John B. Waters, Director Mr. M. J. Burzynski, Manager Tennessee Valley Authority Nuclear Licensing and ET 12A Regulatory Affairs 400 West Summit Hill Drive Tennessee Valley Authority Knoxville, TN 37902 58 Lookout Place Chattanooga, Tennessee 37402-2801 TVA Representative Tennessae Valley Authority Rockville Office Mr. Michael H. Mobley, Director 11921 Rockville Pike Division of Radiological Health Suite 402 T.E.R.R. A. Building 6th Floor Rockville, MD 20852 150 9th Avenue North Nashville, TN 37219-5404 Tennessee Valley Author 1!.y County Judge ET 11H Hamilton County Courthouse 400 West Summit Hill Drive Chattanooga, TN 37402 Knoxville, TN 37902 bcc w/encls:
(See page 3)
Mr. J. R. Bynum, Vice President Nuclear Operations Tennessee Valley Authority 3B Lookout Place 101 Market Street i
Chattanooga, TN 37402-2801 Ms. Marci Cooper, Site Licensing Manager Sequoyah Nuclear Plant Tennessee V-lley Authority P. O. Box te':J Soddy-Daisy, TN 37379 Mr. Robert Fenech, Vice I"e;ident Sequoyah Nuclear Plant Tennessee Valley Authority P. O. Box 2000 Soddy-Daisy, TN 37379
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1-FEB I 7 ggg3 Tennessee Valley Authority 3
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'bec w/encls:
J. R. Johnson, RII G. C. Lainas, NRR F. J. Hebdon, NRR P. J. Kellogg, RII D. E. Labarge, NRR NRC Senior Resident Inspector U.S. Nuclear Regulatory Commission 2600 Igou Ferry Soddy-Daisy, TN.37379 NRC Document Control Desk
- For previous concurrence - See atached page.
DRP/RII DRP/RII EICS/RII DRP/RII
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9 ENCLOSURE 1 LIST OF ATTENDEES NRC S. D. Ebneter, Regional Administrator, Region II, (RII)
E. W. Merschoff, Director, Division of Reactor Projects (DRP), RII A. F. Gibson, Director, Division of Reactor Safety (DRS), RII l
G. C. Lainas, Associate Director, RII Reactors, Office of Nuclear Reactor Regulation (NRR)
F. J. Hebdon, Director, Project Directorate 11-4, NRR G. R. Jenkins, Director, Enforcement and Investigation Coordination Staff i
(EICS), RII W. E. Holland, Senior Resident' Inspector, RII S. M. Shaeffer, Resident Inspector, RII P. J. Kellogg, Chief, Reactor Projects Section 4A, DRP, RII D. E. LaBarge, Senior Project Manager, NRR l
B. Uryc, Senior Enforcement Specialist, EICS, RII W. M. Troskoski, Enforcement Specialist, Office of Enforcement (by telephone)
M. T. Markley, Operations Engineer, NRR t
M. Mizuno, RII Assignee from Japan j
TVA l
J. R. Bynum, Vice President, Nuclear O. rations-t M. 0. Medford, Vice President, Nuclear Assurance, Licensing and fuels R. A. Fenech, Vice President, Sequoyah R. J. Beecken, Plant Manager J. S. Baumstark, Operations Manager i
M. A. Cooper,- Site Licensing Manager i
J. P. Maciejewski, Quality Assurance Manager j
T. A. Flippo, Site Quality Manager P. G. Trudel, Engineering Manager J. R. Walker, Operations Program Manager J. P. Maciejewski, Manager Quality Assurance M. J. Burzynski, Corporate Licensing Manager J. K. Gates, Outage Manager D. L. Lundy, Technical Support Manager R. R. Thompson, Compliance / Licensing Manager, Sequoyah j
D. F. Webb, Shift Operations Supervisor D. P. Stewart, Assistant Shift Operating Supervisor i
M. L. Roeser, Assistant Unit Operator j
W. T. Leary, Assistant Unit Operator j
J. D. Camden, Unit Operator l
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-t ENCLOSURE 2 j
Of TENNESSEE VALLEY AUTHORITY j
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-i ERCW/ CSS THROTTLE VALVE RWST OVERCOOLING ENFORCEMENT CONFERENCE j
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l FEBRUARY 5,1993 i
NRC REGION 11 OFFICE i
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PRESENTATION AGENDA i
i introduction / Summary of Presentation R. Fenech Discussion of ERCW/CCS Event, Chronology J. Baumstark Discussion of issues, Root Cause J. Baumstark Immediate Corrective Actions &
J. Baumstark Event-Specific Long-Term Corrective Actions Safety Significance M. Cooper Licensing Perspectives M. Cooper Discussion of RWST Event, Chronology J. Baumstark Discussion of Issues, Root Cause J. Baumstark Immediate Corrective Actions &
Event-Specific Long-Term Corrective Actions J. Baumstark l
Safety Significance M. Cooper Licensing Perspectives M. Cooper Overall Control of Configuration R. Beecken Operations Performance R. Beecken Broad Perspective / Closing Remarks R. Fenech
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SUMMARY
OF PRESENTATION
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TVA RECOGN!ZES THE UNACCEPTABLE PERFORMANCE THAT LED TO RECENT EVENTS ALTHOUGH DIFFERING SITUATIONS AND CAUSES, COMMON THREAD IS OPERATIONS PERFORMANCE SON PROGRAMS ARE BEING STRENGTHENED, BUT ARE BASICALLY SOUND TVA CONSIDERS ITS USE OF "N/As" TO BE APPROPRIATE PAST OPERATIONS PERFORMANCE IMPROVEMENT EFFORTS HAVE NOT BEEN s
FULLY EFFECTIVE -- FOLLOW-THROUGH HAS BEEN LACKING MANAGEMENT ACTIONS ARE BEING TAKEN TO ENSURE COMPREHENSIVENESS OF CORRECTIVE ACTIONS, BUY-IN (AT ALL LEVELS), PERFORMANCE MONITORING, FEEDBACK, AND ACCOUNTABILITY LONG-TERM AND CONTINUlNG SENIOR MANAGEMENT FOCUS THROUGH OVERALL SITE IMPROVEMENT PLAN m
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APPARENT VIOLATION 1 ERCW/CCS EVENT NJ TECHNICAL SPECIFICATION 6.8.1, REQUIRES, IN PART, THAT WRITTEN PROCEDURES BE ESTABLISHED, IMPLEMENTED AND MAINTAINED. THIS INCLUDES PROCEDURES FOR CONTROL AND OPERATION OF SAFETY-RELATED SYSTEMS.
ACCORDING TO THE NRC, CONTRARY TO TMIS REQUIREMENT, TVA DID NOT ESTABLISH ADEQUATE PROCEDURES IN THAT:
EXAMPLE 1:
GUIDANCE PROVIDED IN PROCEDURES SI-OPS-067-682.M, "ERCW FLOW BALANCE VALVE POSITION VERIFICATION" AND 2-St-OPS-070-032.A,
" COMPONENT COOLING WATER VALVES POSITION VERIFICATION, TRAIN A, REVISION 1" DID NOT PROVIDE AN APPROPRIATE METHOD TO ALLOW FOR FREEPLAY IN THE VALVES. THIS DEFICIENCY RESULTED IN THE MISPOSITIONING OF:
THE UNIT 1,1B CONTAINMENT SPRAY HEAT EXCHANGER ERCW THROTTLE VALVES (1-67-537 A & B) FROM NOVEMBER 30,1991 THROUGH DECEMBER 16 AND DECEMBER 18,1992 RESPECTIVELY, AND V
THE UNIT 2, 2A RESIDUAL HEAT REMOVAL HEAT EXCHANGER CCS THROTTLE VALVE (2-70-546A) FROM APPROXIMATELY MARCH 1,1989 THROUGH DECEMBER 19,1992.
EXAMPLE 2:
SI-566, "ERCW FLOW VERIFICATION TEST, UNITS 0,1, AND 2, REVISION 22" DID NOT PROVIDE POSITIVE ADMINISTRATIVE CONTROL TO ASSURE COMPLETION OF THE REQUIRED UPDATING ACTIVITIES.
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CHRONOLOGY FOR ERCW/CCS EVENT l
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ERCW Valves 11/30/91 During the U1C5 Outage restoration, SI-682M, "ERCW Flow Balance Valve f
Position Verification," was performed. Per procedure records, Valve 1 !
537A (throttle valve) was position-checked and set at 22 3/4 turns from full-open position with Seal No. 21405 in place; and Valve 1-67-537B (throttle valve) was position-checked and set at 221/2 turns from full open position i
I with Seal No. 21217 in place.
12/12/92 SI 682M performed. Seal Nos. 21217 and 21405 verified in position.
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i 12/16/92 SI-566, "ERCW Flow Verification Test" determines that the as-found flow-i rate on the 1B heat exchanger is approximately 1788 gpm.
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The as-found position on valve 1-67-537B is deiermined to be 26 3/4 turns from full open. Seal No. 21217 verified to be in position. Valve position corrected to 221/2 turns, flow-rate verified to be 4560 gpm, and new seal
.l is applied.
12/17/92 SI-566 completed on ERCW Trains A and B; verified that acceptance criteria met.
12/17/92 10 C.F.R. 50.72 call (1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />) made (potentially outside design basis).
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12/18/92 Position of valve 1-67-537A checked due to SI-566 flow rates being only slightly above acceptance criteria. Seal 21405 verified in place.
As-found position of valve is 23 3/8 turns from full open position rather than l
22 3/4 turns specified in SI-566. Valve position corrected to 22 3/4 turns l
from full open and new seal applied.
12/18-19/92 Extent of condition evaluation performed on both units. All safety-related ERCW and CCS throttle valve positions confirmed. It is determined that the problem involves only large (18") Pratt butterfly valves, and is due to slack in the valve positioner and how that slack is counted.
l 12/28/92 10 C.F.R. 50.72 call revoked after it is determined that condition is inside the design basis.
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1/17/93 Re-performed SI-566 to verify proper system performance following extensive manipulations dorie to establish the extent of the condition noted
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above for both units (ERCW).
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F CHRONOLOGY FOR ERCW/CCS EVENT (CONT *D)
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CCS Valve 3/24/89 Valve 2-70-546A set at 19 3/4 turns after performance of PMT-82; Seal No.
21326 installed.
12/19/92 Valve 2-70-546A found at 23 turns from full-open position with Seal No.
21326 in place.
Valve repositioned to 19 3/4 turns from full open and sealed.
10 C.F.R. 50.72 (1 hour) call made (potentially outside design basis).
12/28/92 10 C.F.R. 50.72 call revoked after determination that condition was not outside the design basis.
Failure to Revise SI-682
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6/15/91 SI-566 completed on ERCW Train A.
7/21/91 SI-566 completed on ERCW Train B.
11/91 SI-682 revised to reflect new valve positions, but only included Train B valve position changes.
12/17/92 SI-566 completed.
12/21-12/25/92 SI-682M performed and seven valves that have positions different than what is required by SI-566 are identified. Flowrates in affected systems verified to be adequate.
12/21/92 Revisions of SI-682M initiated to correctly reflect valve positions. Effort complete.
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4 TVA POSITION REGARDING APPARENT VIOLATION 1 ERCW/CCS EVENT oOi!
TVA AGREES WITH VIOLATION 1 AND NOTES THE FOLLOWING CAUSE{S):
SUMM ARY OF VIOLATION 1. EX AMPLE 1:
PROCEDURES DID NOT PROVIDE AN ADEQUATE METHOD FOR HOW TO POSITION THROTTLE VALVES.
ROOT CAUSE:
CONFLICTING AND AMBIGUOUS PROCEDURAL GUIDANCE ON HOW TO COUNT THE NUMBER OF TURNS FROM FULL OPEN POSITION AND THE INABILITY TO CONSISTENTLY DETERMINE THE AMOUNT OF VALVE OPERATOR SLACK.
CONTRIBUTING CAUSE:
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PAST OPERATOR TRAINING ON THROTTLE VALVE POSITIONING WAS INCONSISTENT WITH PRESENT (CORRECT) PROCEDURAL GUIDANCE.
SUMMARY
OF VIOLATION 1 EXAMPLE 2:
FAILURE TO UPDATE PROCEDURES AS REQUIRED.
ROOT CAUSE:
t INADEQUATE PROCEDURAL CONTROL IN PLACE TO REQUIRE THE REVISION OF 0-SI-OPS-067-682.M FOLLOWING THE PERFORMANCE OF SI-566.
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SIGNIFICANT IMMEDIATE CORRECTIVE ACTIONS
'vli ERCW/CCS EVENT CORRECTED VALVE POSITIONS PERFORMED EXTENT OF CONDITION REVIEW CONCLUDED THAT CONDITION LIMITED TO 18" PRATT BUTTERFLY VALVES OUT OF 8 VALVES, A TOTAL OF THREE PRATT VALVES WERE FOUND OUT OF POSITION TO SOME DEGREE APPARENT COMPENSATION FOR " SLACK" IN EACH CASE INITIATED REVIEW OF OPERATIONS PROCEDURES REGARDING THE PROPER METHOD OF COUNTING TURNS ON THROTTLED VALVES OPERATORS ARE RECEIVING TRAINING ON THE PROPER METHOD OF COUNTING VALVE TURNS ON THROTTLED VALVES A VIDEO TAPE IS BEING USED TO TRAIN OPERATORS ON STANDARDIZED METHODS OF CONFIGURATION CONTROL REVISED SI-566 TC INCLUDE SIGN-OFF CONFIRMING REVISION OF 0-SI-OPS-067-682.M TO INCLUDE NEW VALVE POSITIONS AND TO PLACE THE AFFECTED PROCEDURE ON ADMINISTRATIVE HOLD UNTil VALVE POSITIONS ARE CHANGED RE-PERFORMED SI-566 TO VERIFY CURRENT ERCW FLOW BALANCE STATUS EVALUATED OTHER POTENTIAL CAUSES OF THROTTLE VALVE MISPOSITIONING CLARIFIED MANAGEMENT EXPECTATIONS j
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SIGN!FICANT LONG-TERM CORRECTIVE ACTIONS IN RESPONSE TO ERCW/CCS EVENT
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DEVELOP JOB PERFORMANCE MEASURES TO CONFIRM THAT PERSONNEL KNOW AND ARE PROPERLY TRAINED REGARDING THE PROPER METHOD FOR THROTTLING VALVES DEVELOP AND PERFORM A PERIODIC FLOW BALANCE PROCEDURE FOR THE COMPONENT COOLING WATER SYSTEM CORRECTIVE ACTIONS WILL ENABLE REPEATABLE VALVE POSITIONING cbf 8
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LICENSING PERSPECTIVES' ERCW/CCS EVENT i
TVA IDENTIFIED CONDITION AND ASSOCIATED ISSUES MINIMUM ACTUAL SAFETY SIGNIFICANCE - POTENTIAL SIGNIFICANCE RECOGNIZED PROMPT, EXTENSIVE ACTIONS TO BOUND EXTENT OF CONDITION AND ESTABLISH APPROPRIATE POSITIVE CONTROLS i
PROBLEM OUTSIDE SCOPE OF PREVIOUS CONFIGURATION CONTROL I
CORRECTIVE ACTIONS 1
FACTORED INTO BROAD CONFIGURATION CONTROL REVIEW
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FOCUS ON BROADENING SCOPE OF CONFIGURATION CONTROL IMPROVEMENTS PREVENTING NEW TYPES OF PROBLEMS BEYOND CURRENTLY IDENTIFIED SCOPE i
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APPARENT VIOLATION 2 RWST EVENT TECHNICAL SPECIFICATION 3.5.5.c REQUIRES, IN PART, THAT THE REFUELING WATER STORAGE TANK (RWST) SHALL BE OPERABLE WITH A MINIMUM SOLUTION TEMPERATURE OF 60 DEGREES F.
ACCORDING TO THE NRC, CONTRARY TO THIS REQUIREMENT, TVA FAILED TO MAINTAIN THE UNIT 2 RWST SOLUTION TEMPERATURE AT OR ABOVE 60 DEGREES F DURING MODE 1 OPERATION FOR APPROXIMATELY 25 HOURS.
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a APPARENT VIOLATION 3 RWST EVENT O.
TECHNICAL SPECIFICATION 6.8.1, REQUIRES, IN PART, THAT WRITTEN PROCEDURES BE ESTABLISHED, IMPLEMENTED AND MAINTAINED. THIS INCLUDES PROCEDURES FOR CONTROL AND OPERATION OF SAFETY-RELATED SYSTEMS. ACCORDING.TO i
THE NRC, CONTRARY TO THIS REQUIREMENT, THE FOLLOWING PROCEDURES WERE EITHER INADEQUATE TO ACCOMPLISH THE TASK, OR WERE NOT FOLLOWED:
EXAMPLE 1 SI-SXP-072-001.A AND.B, " CONTAINMENT SPRAY PUMP 2A-A & 2B-B QUARTERLY l
OPERABILITY TEST" WERE NOT ADEQUATE WITH REGARD TO THE MANNER IN WHICH THEY WERE USED (THE PROCEDURES CONTAINED SEVERAL STEPS WHICH WERE "N/A" IN ACCORDANCE WITH SSP-8.1; HOWEVER, NO PROCEDURE CHANGE WAS PROCESSED TO ADDRESS THE NEW PURPOSE OF THE PROCEDURE).
EXAMPLE 2:
SSP 8.1, " CONDUCT OF TESTING" WAS INADEQUATE IN THAT IT AUTHORIZED A PROCESS CONTRARY TO SSP-2.3 AND TECHNICAL SPECIFICATION 6.5.1 A FOR
.i MAKING CHANGES TO SAFETY-RELATED PROCEDURES (THE SSP ALLOWED J
PERSONNEL TO "N/A" STEPS IN PROCEDURE 2-SI-SXP-072-001.A &.B TO THE
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EXTENT THAT THE INTENT OF THE PROCEDURE WAS MODIFIED).
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EXAMPLE 3 SSP-12.1, " CONDUCT OF OPERATIONS, REVISION 2" WAS NOT FOLLOWED IN THAT l
OPERATORS DID NOT MAINTAIN CONTROL OF EQUIPMENT AND SYSTEM STATUS, AND COGNIZANCE OF OPERATIONAL STATUS OF EQUIPMENT AND SYSTEMS WITH REGARD TO UNIT 2 RWST SOLUTION TEMPERATURE REQUIREMENTS.
EXAMPLE 4:
SSP 2.3, " ADMINISTRATION OF SITE PROCEDURES," WAS NOT FOLLOWED IN THAT CHANGES TO SURVEILLANCE INSTRUCTIONS 2-SI-SXP-072-001.A AND 2-SI-SXP-072-l 001.B WERE MADE WITHOUT FOLLOWING THE PROCESS DESCRIBED IN THE l
PROCEDURE.
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APPARENT VIOLATION 4 RWST EVENT TECHNICAL SPECIFICATION 6.5.1 A REQUIRES, IN PART, THAT PROCEDURES REQUIRED BY SPECIFICATION 6.8.1 AND CHANGES THERETO, SHALL BE REVIEWED BY A QUALIFIED INDIVIDUAL OTHER THAN THE INDIVIDUAL WHO PREPARED THE PROCEDURE OR CHANGE; APPROVED BY THE APPROPRIATE RESPONSIBLE MANAGER DESIGNATED IN WRITING BY THE PLANT MANAGER; REVIEWED TO DETERMINE WHETHER OR NOT ADDITIONAL, CROSS-DISCIPLINARY REVIEW IS NECESSARY; AND REVIEWED TO DETERMINE WHETHER OR NOT AN UNREVIEWED SAFETY QUESTION IS INVOLVED PURSUANT TO 10 C.F.R. 50.59.
ACCORDING TO THE NRC, CONTRARY TO THIS REQUIREMENT, SURVEILLANCE INSTRUCTIONS 2-SI-SXP-072-001.A &.B WERE CHANGED PRIOR TO THElR PERFORMANCES ON DECEMBE" 22 AND 23,1992 WITHOUT REVIEW AS REQUIRED BY TECHNICAL SPECIFICATION 6.5.1 A.
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1 CHRONOLOGY FOR RWST COOLDOWN EVENT 12/22/92-2312 12/24/92 0730: ERCW flow maintained on 2B Containment Spray Heat Exchanger per.
2-SI-SXI-067-001.B.
i 12/23/92 0300: RWST temperature recorded as 71 and 70 degrees per 2-SI-OPS-000-003.D.
12/23/92 0510: 2B Containment Spray Pump started on recirculation flow.
12/23/92 0618: RWST temperature estimated to drop below technical specification j
limits.
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12/23/92 0741: 28 Containment Spray Pump secured from recirculation flow, 12/24/92 0350: RWST temperature identified by Operators as 60 and 58 degrees t
which is below the technical specification limit.
12/24/92 0749: RWST temperature restored to 2. 60 degrees.
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TVA POSITIONS REGARDING RWST COOLDOWN EVENT
'N TVA AGREES WITH APPARENT VIOLATION 2 & VIOLATION 3, EXAMPLE 3 TVA DOES NOT AGREE WITH APPARENT VIOLATION 3, EXAlviPLES 1,2 & 4, AND APPARENT VIOLATION 4 (TO BE DISCUSSED LATER) i t
SUMMARY
OF VIOLATION 2:
TVA FAILED TO MAINTAIN THE UNIT 2 RWST SOLUTION TEMPERATURE AT OR ABOVE 60 DEGREES F DURING MODE 1 OPERATION FOR APPROXIMATELY 25 HOURS l
SUMM ARY OF VIOLATION 3. EX AMPLE 3 OPERATORS DID NOT MAINTAIN CONTROL OF EQUIPMENT AND SYSTEM STATUS, AND COGNIZANCE OF OPERATIONAL STATUS OF EQUIPMENT AND SYSTEMS WITH REGARD TO UNIT 2 RWST SOLUTION TEMPERATURE REQUIREMENTS.
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CAUSES - RWST COOLDOWN EVENT
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CAUSES RELATED TO SYSTEM INTERACTION INADEQUATE COORDINATION AND REVIEW OF WORK ACTIVITIES CAUSED BY:
(1)
FAILURE BY SYSTEMS ENGINEERING / TECHNICAL SUPPORT TO ADEQUATELY EVALUATE POTENTIAL PROBLEMS ASSOCIATED WITH SIMULTANEOUS PERFORMANCE OF INDIVIDUAL TEST PROCEDURES, AND (2)
INADEQUATE OPERATOR REVIEW OF TEST ACTIVITIES (i.e., SHOULD HAVE RECOGNIZED SYSTEM INTERACTIONS)
(3)
LACK OF OPERATOR AWARENESS WHEN CS PUMP STARTED i
CONTRIBUTING CAUSES (1)
SECTION XI PUMP PERFORMANCE TESTS DID NOT VERIFY ABSENCE OF SHELL SIDE FLOW b
(2)
OPERATIONS PERSONNEL DID NOT MEET EXPECTATIONS RELATIVE TO PERFORMANCE (i.e., SYSTEM STATUS, LOG KEEPING, BOARD MONITORING, AND SHIFT TURNOVER) THAT CONTRIBUTED TO THE DURATION OF EVENT v
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SIGNIFICANT IMMEDI ATE CORRECTIVE ACTIONS - RWST COOLDOWN EVENT
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'G PUMPS PLACED ON RECIRC TO BRING RWST TEMPERATURE WITHIN TECHNICAL SPECIFICATION REQUIREMENTS CONDUCTED MANAGEMENT COUNSELING WITH INDIVIDUALS INVOLVED OPERATIONS PERSONNEL INVOLVED IN THE EVENT WILL REVIEW THE EVENT WITH OPERATIONS SHIFT PERSONNEL AND DISCUSS MANAGEMENT EXPECTATIONS i
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t SIGNIFICANT LONG-TERM CORRECTIVE ACTIONS - RWST COOLDOWN EVENT
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(_) i STRENGTHEN PROCESS FOR OPERATIONS MANAGEMENT TO MONITOR LICENSED OPERATOR PERFORMANCE REGARDING CONTROL BOARD MONITORING, LOG KEEP!NG, SHIFT RELIEF, TO ENSURE THAT MANAGEMENT EXPECTATIONS ARE SATISFIED REVISE PROCEDURES TO ENSURE THAT COOLING WATER FLOW TO THE CONTAINMENT SPRAY HEAT EXCHANGER IS ISOLATED PRIOR TO OPERATION THE CONTAINMENT SPRAY PUMP TECHNICAL SUPPORT MANAGEMENT WILL DISCUSS LESSONS LEARNED FROM
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THIS EVENT WITH OTHER SITE MANAGERS
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i SUMM ARY OF APPARENT VIOLATIONS REGARDING "N/A" ISSUE
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SUMMARY
OF APPARENT VIOLATION 3l' EXAMPLE 1-SI-SXP-072-001.A AND.B WERE NOT PROPERLY USED IN THAT STEPS WERE "N/A'd" f
WITHOUT PROCESSING A PROCEDURE CHANGE TO ADDRESS THE NEW PURPOSE t
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SUMMARY
OF APPARENT VIOLATION 3. EXAMPLE 2:
I SSP 8.1 WAS INADEQUATE IN THAT IT AUTHORIZED A PROCEDURE CHANGE PROCESS THAT IS INCONSISTENT WITH TECHNICAL SPECIFICATION REQUIREMENTS l
SUMM ARY OF APPARENT VIOLATION 3. EXAMPLE 4:
CHANGES TO SURVEILLANCE INSTRUCTIONS 2-SI-SXP-072-001.A AND 2-SI-SXP-072-l 001.B WERE MADE WITHOUT FOLLOWING THE PROCESS DESCRIBED IN THE APPROPRIATE PROCEDURE
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SUMMARY
OF APPARENT VIOLATION 4:
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SURVElLLANCE INSTRUCTIONS 2-SI-SXP-072-001.A &.B WERE CHANGED AND IMPLEMENTED WITHOUT TECHNICAL SPECIFICATION REQUIRED REVIEWS i
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TVA ASSESSMENT OF "N/A" ISSUE
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BACKGROUND
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6 ASSOCIATED PROCEDURES:
SI-SXI-072-001.B - CS PRESSURE TEST - THE ACTIVITY REQUIRING PERFORMANCE SI-SXP-072-001.8 - CS PUMP TEST - PRESSURIZES SYSTEM TO SUPPORT PRESSURE TEST SSP-8.1 - CONDUCT OF TESTING - PROVIDES PROCESS FOR USE OF N/A'S IN TESTING INCLUDING INTENT AND REQUIRED DOCUMENTATION AND APPROVALS SSP-2.3 - ADMINISTRATION OF PROCEDURES - PROVIDES PROCESS FOR CHANGING PROCEDURES 9h CONDITION:
PRESSURE TESTS NECESSARY DUE TO DISCOVERY THAT THEY WERE NOT PERFORMED DURING SECOND PERIOD CS QUARTERLY PUMP TEST USED TO SUPPORT CSS PRESSURE TEST FOR PURPOSE OF PRESSURIZING SYSTEM - PUMP TEST NOT DUE WHEN NEED FOR PRESSURE TEST DISCOVERED FULL INSTRUMENTATION INSTALLATION FOR PURPOSE OF CS PUMP TEST UNNECESSARY FOR PERFORMING PRESSURE TEST STEPS IN CS PUMP TEST PROCEDURE REGARDING INSTALLATION /
REMOVAL OF UNNECESSARY INSTRUMENTATION WERE "N/A'd" WITH REQUIRED DISPOSITION AND APPROVALS v
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1 TVA ASSESSMENT OF "N/A" ISSUE (CONT'D)
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SUMMARY
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- ALL FOUR EXAMPLES ARE DIFFERENT FORMS OF THE SAME ISSUE f
METHOD USED FOR NOT REQUIRING FULL INSTRUMENTATION INSTALLATION HAD NO BEARING ON RWST EVENT OR CAUSES OF 7
EVENT ISSUE NOT TIED IN ANY WAY TO INTERACTION OF 3
SEPARATE ERCW PRESSURE TEST ALREADY UNDERWAY. AND THE 2
CSS TESTING PROCEDURES UNDER DISCUSSION ALTERNATE METHODS (i.e., PROCEDURE REVISION) WOULD HAVE ONLY ADDRESSED CS TESTING PROCEDURES l
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APPLICATION OF N/A'S FOR THIS CASE DID NOT CONSTITUTE A k
CHANGE IN PROCEDURES OR A CHANGE IN INTENT / PURPOSE OF THE l
PRESSURE TEST ACTIVITY BEING PERFORMED NOT ALREADY j
CONSIDERED / APPROVED j
B Y
SON PROCESS FOR USING N/A'S CONSISTENT WITH INDUSTRY DESIRED IMPROVEMENTS WILL FURTHER CLARIFY APPLICATION AND ENSURE CONSISTENCY l
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TVA ASSESSMENT OF "N/A" ISSUE (CONT'D)
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BASES FOR POSITIONS:
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CONTAINMENT SPRAY PRESSURE TEST DESCRIBED INTENT OF PUMP TEST PROCEDURE RELATIVE TO PRESSURE TEST j
ACTIVITY:
LEAKAGE DETECTION WHILE SYSTEM PRESSURIZED FOR
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PERFORMANCE OF PUMP TEST; ASSUMES CONCURRENT l
SCHEDULED PERFORMANCE OF PROCEDURES j
PUMP TEST ALIGNMENT PRESSURIZES COMPONENTS WITHIN TEST f
BOUNDARY
-f NOTED THAT PUMP TEST ACCEPTANCE CRITERIA NOT RELEVANT-TO PRESSURE TEST t
NOTED THAT PUMP TEST ONLY PROVIDED SYSTEM ALIGNMENT,-
i REALIGNMENT AND CONFIGURATION CONTROL FOR PRESSURE TEST PUMP TEST PROCEDURE ALLOWED USE FOR OTHER PURPOSES ALTHOUGH IT DID NOT SPECIFICALLY REFERENCE PERFORMANCE FOR PRESSURE TEST; HOWEVER IT WOULD BE IMPRACTICAL TO ALWAYS REFERENCE IN STAND-ALONE PROCEDURES ALL POSSIBLE SUPPORTING ROLE USES OF THOSE PROCEDURES i
i PERSONNEL INVOLVED CLEARLY UNDERSTOOD THAT PUMP TEST PROCEDURE WAS NOT BEING USED FOR QUARTERLY SECTION XI TEST AND INTENT / PURPOSE OF PUMP TEST RELATIVE TO PRESSURE TEST j
TEST DIRECTOR LOG STATED BASIS FOR ACCEPTABILITY, i
REITERATING (NOT CHANGING) INTENT / PURPOSE OF PUMP TEST FOR THE SUBJECT PRESSURE TEST PERFORMANCE -
APPROPRIATE REVIEWS AND. APPROVALS WERE PERFORMED A PERMANENT CHANGE TO EITHER PROCEDURE WAS NOT DESIRED OR NECESSARY
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BASES FOR POSITIONS (CONT'D):
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.t BASED ON INDUSTRY SURVbY, SON PROCESS IS CONSISTENT WITH INDUSTRY USE OF N/A'S l
DEFINE CONDITIONS AND APPROVALS TO CONCLUDE ACCEPTABLE WITHOUT PROCEDURE REVISION PREDETERMINED CONDITIONS THAT WILL NOT CONSTITUTE FURTHER CHANGE (S) BEYOND THOSE APPROVED THROUGH THE ADMINISTRATIVE AND TECHNICAL PROCEDURES l
l TVA CONS!DERS THAT WHILE APPLICATION IN THIS CASE WAS j
4 APPROPRIATE ENHANCEMENTS CAN BE MADE TO ENSURL j
APPROPRIATE / CONSISTENT APPLICATION i
CONCLUSION:
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NO VIOLATION OCCURRED
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SEQUOYAH NUCLEAR PLANT 1
14me Lise inr I:l=93=099 12/22/02 12/24/02 2312 0730 ERCW Flow Maintained on 2B CS HX Per 2-SI-SXI-067-001.B t
12/23/02 12/23/02 t
0510 0741 k
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2B Cont. Spray Pmp Operated on Rec!ro. Flow Per 2:SL-BXf10'I2:00.1.11 02 0350
-12/23/02 su0300 g
RWST Temp identitled k
g4 to tio Below T.S. Umit 12/24/02 HWST Temp PW f'
By2 M EBdQQa03R
. T,p 0749 Recorded As 70'F On
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2:al:QER:000dD3R RWST Temp flestored to h.io'F.
-s e-e--
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w-w--++.-
s-,w.
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>= wene w w-,w~v,,m..
- -,*ww--
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r w
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- m
+~<3
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LICENSING PERSPECTIVES - RWST COOLDOWN EVENT fh i
APPARENT VIOLATIONS 2. 3. AND 4 g
I TVA IDENTIFIED CONDITION AND ASSOCIATED ISSUES r
MINIMAL ACTUAL SAFETY SIGNIFICANLE - SIGNIFICANCE OF PERFORMANCE RECOGNIZED L
PROMPT IMMEDIATE AND LONG-TERM CORRECTIVE ACTIONS TAKEN -
FACTORED INTO BROAD CONFIGURATION CONTROL REVIEW 1
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27
REVIEW OF OVERALL CONFIGURATION CONTROL O,'
SHORT-TERM ACTIONS TO VERIFY CONFIGURATION:
RE-TRAINED OPERATORS ON PROPER THROTTLE VALVE POSITIONING TECHNIQUES VEPIFIED THROTTLE VALVE POSITION ON ERCW/CCS LOOKED FOR OTHER CONFUSING VERIFICATION TECHNIQUES VERIFIED MCR SWITCH POSITIONS PERFORMED SAMPLING OF COMPONENT CONFIGURATION ON SAFETY-l RELATED SYSTEMS BROADER CONFIGURATION CONTROL ACTIONS:
LOOKED BACK AT 1992 CONFIGURATION CONTROL ISSUES-CATEGORIZED ISSUES O,
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DETERMINED WEAKNESSES j
i DETERMINED TRENDS CORRECTIVE ACTIONS s-VERIFYING PROCEDURE CONSISTENCY TO DESIGN _
i REASSESSING SCOPE OF CONFIGURATION CONTROL f
REINFORCING WORKING WITHIN PROCESSES i
SIMPLIFYING VERIFICATION PROCESS l
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N O) 28 l
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i OPERATIONS PERFORMANCE (BIG PICTURE) i U
l TVA HAS MADE SOME PROGRESS CON O ROOM PROFS IONALISM REQUALIFICATION OPERATIONS CONTROL CENTER (OCC)
STANDARDS OF PERFORMANCE HAVE NOT ACHIEVED DESIRED LEVEL l
QA TOLD OPERATIONS THAT SEVERAL' AREAS WERE AACINT PERFORMANCE INDICATORS GAVE SIGNS COMMON VISION OF APPROPRIATE STANDARDS WAS NOT 7
ESTABLISHED WITH ALL OF OPERATIONS MANAGEMENT j
ATTEMPTED TO PROVIDE PERSONNEL WITH UNDERSTANDING OF PERFORMANCE EXPECTATIONS -- MARGINAL SUCCESS i
s/
NOW SON HAS A TEAM WITH APPROPRIATE STANDARDS
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CONTINUOUS COACHING OF CREWS WILL PROVIDE CONSTANT I
REINFORCEMENT q
USE OF OPERATIONS PERFORMANCE MODULES j
i STRENGTHENING OF AUO PERFORMANCE QA FOLLOW-UP ON PERFORMANCE ASSESSMENT f
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29 i
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CONCLUSIONS O
1 TVA RESPONSE TO RECENT EVENTS AND EVALUATION OF PERFORMANCE HAS i
FOCUSED ON WHAT THE EVENTS INDICATE FROM A BROADER PERSPECTIVE-SON PROGRAMS ARE BEING STRENGTHENED, BUT ARE BASICALLY SOUND i
i TVA CONSIDERS ITS USE OF "N/As" TO BE APPROPRIATE l
t BEYOND INITIAL ACTIONS TO ENSURE CURRENT ACCEPTABILITY SON IS i
FOCUSING ON THE LONG TERM IMPLICATIONS j
i TVA HAS INITIATED BROAD CORRECTIVE ACTIONS IN THE PAST, BUT FOLLOW-t THROUGH HAS BEEN LACKING O
i FOLLOW-THROUGH WILL OCCUR i
MORE EXTENSIVE USE OF PERFORMANCE MONITORING AND INDICATORS i
MORE EXTENSIVE MID-COURSE EVALUATIONS OF CORRECTIVE ACTION l
EFFORTS MANAGERS WILL BE HELD ACCOUNTABLE REGARDING IMPROVEMENTS l
AND ADEQUACY OF CORRECTIVE ACTION PROGRAMS TO PREVENT RECURRENCE CONTINUED FOCUS THROUGH IMPLEMENTATION OF THE OVERALL SITE IMPROVEMENT PLAN i
SENIOR SITE MANAGEMENT WILL REMAIN INVOLVED IN ENSURING THAT THERE IS ACTUAL PROGRESS AND APPROPRIATE FEEDBACK 30
...