ML20035A412
| ML20035A412 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 03/19/1993 |
| From: | Linville J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Boulette E BOSTON EDISON CO. |
| References | |
| NUDOCS 9303260027 | |
| Download: ML20035A412 (3) | |
See also: IR 05000293/1992028
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MAR 191933
Docket No. 50-293
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E. Thomas Boulette, PhD
Senior Vice President - Nuclear
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Boston Edison Company
Pilgrim Nuclear Power Station
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RFD #1 Rocky Hill Road
Plymouth, Massachusetts 02360
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Dear Dr. Boulette:
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SUBJECT: PILGRIM INSPECTION 92-28
This letter refers to your February 26 response to our January 28, 1993 letter that cited a
procedure violation associated with setting of the main steamline high radiation monitor alarm
on two occasions.
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We acknowledge the corrective and preventive actions related to procedure improvement and the
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sensitization of personnel to the event. However, it doesn't appear that the causes stop at the
I&C supervisor level.
Additional management review, including the post-trip and event
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critiques, failed to prevent subsequent startup with an incorrectly set alarm. These actions will
be examined during a future inspection of your licensed program.
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Your cooperation with us is appreciated.
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Sincerely,
CrigM! Signed B
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Jema C. Unvi!le'c
James Linville, Chief
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Projects Branch No. 3
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Division of Reactor Projects
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9303260027 930319
ADOCK 05000293
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OFFICIAL RECORD COPY
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MAR 101993
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E. Thomas Boulette, PhD
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cc:
E. Kraft, Acting Vice President, Nuclear Operations and Station Director
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L. Schmeling, Plant Manager
V. Oheim, Manager, Regulatory Affairs and Emergency Planning Department
D. Tarantino, Nuclear Information Manager
N. Desmond, Compliance Division Manager
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R. Hallisey, Department of Public Health, Commonwealth of Massachusetts (w/cy of Licensee's
Response Ixtter)
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R. Adams, Department of 12bor and Industries, Commonwealth of Massachusetts (w/cy of
Licensee's Response Ixtter)
The Honorable Edward M. Kennedy (w/cy of Licensee's Response letter)
The Honorable John F. Kerry (w/cy of Licensee's Response Ixtter)
The Honorable Edward J. Markey (w/cy of Licensee's Response Letter)
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The Honorable Terese Murray (w/cy of Licensee's Response 12tter)
The Honorab!e Peter V. Forman (w/cy of Licensee's Response 12tter)
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B. McIntyre, Chairman, Department of Public Utilities (w/cy of Licensee's Response Ixtter)
Chairman, Plymouth Board of Selectmen (w/cy of Licensee's Response Ixtier)
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Chairman, Duxbury Board of Selectmen (w/cy of Licensee's Response Letter)
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Plymouth Civil Defense Director (w/cy of License:'s Response Letter)
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Paul W. Gromer, Massachusetts Secretary of Energy Resources (w/cy of Licensee's Response
letter)
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Sarah Woodhouse, Ixgislative Assistant (w/cy of Licensee's Response Ixtter)
A. Nogee, MASSPIRG (w/cy of Licensee's Response Letter)
Regional Administrator, FEMA (w/cy of Licensee's Response Letter)
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Office of the Commissioner, Massachusetts Department of Environmental Quality Engineering
(w/cy of Licensee's Response letter)
Office of the Attorney General, Commonwealth of Massachusetts (w/cy of Licensee's Response
Letter)
T. Rapone, Massachusetts Executive Office of Public Safety (w/cy of Licensee's Response
Letter)
Chairman, Citizens Urging Responsible Energy (w/cy of Licensee's Response Ixtter)
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Public Document Room (PDR) (w/cy of Licensee's Response Letter)
Local Public Document Room (LPDR) (w/cy of Licensee's Response Ixtter)
Nuclear Safety Information Center (NSIC) (w/cy of Licensee's Response Letter)
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NRC Resident Inspector (w/cy of Licensee's Response Ixtter)
Commonwealth of Massachusetts, SLO Designee (w/cy of Licensee's Response letter)
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OFFICIAL RECORD COPY
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MAR 19 M3
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E. Thomas Boulette, PhD
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bec w/cy of Licensee's Response Letter:
Region I Docket Room (with concurrences)
DRS/EB SALP Coordinator
J. Linville, DRP
E. Kelly, DRP
J. Macdonald, SRI - Pilgrim (with concurrences)
W. Butler, NRR
R. Eaton, NRR
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OFFICIAL RECORD COPY
A: REP 9228.MEO
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BOSTON EOISON
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Pngom Nacies' Fonet stat <on
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Plymouth, I.*8553Chut,0ft$ C226c
February 26, 1993
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BEco Ltr. 93- 026
E. T. Boulette. PhD
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Semor vce President - Nuclei,r
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U.S. Nuclear Regulatory Commission
Attn:
Document Control Desk
Washington, D.C. 20555
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Docket No. 50-293
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License No. DPR-35
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REPLY TO A NOTICE OF VIOLATION (REFERENCE NRC RECION I INSPECTION !
SUBJECT:
REPORT NO. 50-293/92-28)
Dear. Sir:
Enclosed is Boston Edison Company's reply to the Notice of Violation contained in
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the subject inspection report.
Please do not hesitate to contact me if there are any questions regarding the
enclosed reply.
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E. T. Boulette
DWE/bal
Enclosure: Reply to the Notice of Violation
cc:
Mr. Thomas T. Martin
Regional Administrator, Region I
U.S. Nuclear Regulatory Commission
475 Allendale Rd.
King of Prussia, PA 19406
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Mr. R. B. Eaton
Div. of Reactor Projects I/II
Office of HRR - USNRC
One White Flint North - Mail Stop 34D1
11555 Rockville Pike
Rockville, MD 20852
Sr. NRC Resident Inspector - Pilgrim Station
Standard BECo Distribution
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ENCLOSURE
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REPLY TO THE NOTICE OF VIOLATION
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Boston Edison Company
Docket No. 50-293
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Pilgrim Nuclear Power Station
License No. DPR-35
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As a result of the inspection conducted at Pilgrim Station from November 24, 1992 to
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December 31, 1992, and in accordance with the NRC Enforcement Policy (10 CFR Part 2,
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Appendix C), the following violation was identified:
Technical Specification 6.8. A requires the proper implementation of procedures
recommended in Appendix A of USNRC Regulatory Guide 1.33.
Appendix A, Section 4
recommends establishment of procedures for startup, operation, and shutdown of
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safety-related systems including the Reactor Protective System (RPS).
Procedure
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3 M.2-7.6, "NUMAC Log Radiation Monitor Setpoint Change Procedure", provides
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instruction for the adjustment of protective instrument setpoints associated with
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the RPS system.
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Contrary to the above, on two occasions, the licensee f ailed to properly implement
procedure 3.M.2-7.6 in that technicians established incorrect RPS protective
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setpoints and management reviews failed to identify the associated discrepancies.
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Specifically, on December 20, 1992, following an automatic reactor trip (which
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resulted from incorrectly established RPS setpoints) technicians failed to reset the
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MSL high radiation alarm setpoints as required by procedure 3.M.2-7.6.
Further, the
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required management review of the completed procedure failed to identify the
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discrepancies. Additionally, on December 23, 1992, following reactor startup,
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procedurally-specified review of the setpoint changes again failed to identify the
incorrect as-found MSt. high radiation alarm setpoints. During the period of time
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between December 20-23, 1992, while the MSL-trip setpoints had been correctly
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established, the above licensee failures resulted in the MSL high radiation alarms
being unavailable to perform their intended function.
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lois is a Severity Level IV violation (Supplement IV).
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REASON FOR THE VIOLATTON
The reason for the 1&C technicians failing to reset the Main Steam Radiation
Recorder Alarm after the plant trip on December 20, 1992, was miscommunication
between the Instrumentation and Control (l&C) Supervisor and Technicians.
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technicians were instructed to reset the trip settings of the Main Steam Radiation
Monitors.
No instruction was given to reset the alarm settings of the Main Steam
Radiation Recorder.
The reason the discrepancies were not identified was I&C.
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Supervisor error. The same 1&C Supervisor reviewed the results of procedure
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3.M.2-7.6 (Rev. 2) conducted on December 20, 1992, and December 23, 1992 (3.M.3-7.6
Rev. 3). The Supervisor was aware of the cause of the plant trip on
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December 20, 1992, and knew that corrective actions were initiated and applicable
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corrective action would be taken prior to the subsequent restart. The trip settings
of the Main Steam Radiation Monitors were correctly reset to reflect radiation
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background levels anticipated for operation without hydrogen injection.
The alarm
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settings for the Main Steam Radiation Recorder should have been reset but were not.
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Instead, the procedure step was not performed and "N/P" was entered. The entry of~
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"H/P" is procedurally allowed if the alarm setting is not being changed.
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Boston Edison Company
Docket No. 50-293
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P-ilgrim Nuclear Power Station
License fio. DPR-35
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The provision for entering "N/P" is included in the procedure because several
different instruments can be adjusted using the same procedure. The instruments
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consist of the Main Steam Radiation Monitors and Recorder, and Steam Jet Air Ejector
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Radiation Monitors.
Procedure 3.M.2-76, Attachment 1, is used for documenting
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adjustments to these devices and provides blank spaces for identifying the device
being adjusted. Therefore, * he entry of "N/P" is procedurally allowed when the
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adjustment of a device is not opplicable (e.g., adjusting the Main Steam Radiation
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Monitors and Recorder but not the Steam Jet Air Ejector Radiation Monitors).
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Attachment 1 Step [2] includes spaces for entering the required settings of these
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different devices and also allows the entry of "N/P" when the setting of the
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applicable device is not being changed.
The trip and alarm settings were correctly
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identified in Step [2] when the setpoints of the Main Steam Radiation Monitors-and
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Recorder were to be reset after the plant trip on December 20, 1992.
The trip
settings of the Main Steam Radiation Monitors were reset on December 20, 1992, for
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background radiation levels expected during operation without hydrogen injection.
The alarm settings of the Main Steam Radiation Recorder was not adjusted on
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December 20, 1992, and "N/P" was entered by the 1&C Technicians because the
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technicians were not instructed to reset the alarm settings. The I&C supervisor did
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not question the entry of "N/P" in Step [27] that would have reset the alarm
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settings of the Main Steam Radiation Recorder.
Procedure 3.M.2-7.6 (Rev. 2) was revised as a result of the plant trip on
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December 20, 1992.
The revision was issued on December 20, 1992, and included
clarifications in several sections of the procedure. The acceptance criteria
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section was changed to verify the required settings listed in Step [2] agree with
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the as-left settings in Step [21].
Several steps in the implementation portion of
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the procedure were also strengthened.
The entry spaces for the required settings,
identified in Step [2], were changed to identify the required settings in scientific
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notation format.
Step [15] was changed to refer to Step [2] when programming (i.e.,
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entering) the settings.
Step [21] was changed to record the as-left downscale trip,
hi trip, and hihi trip settings in scientific notation format.
Step [22] was
changed to specify a comparison of as-left settings in Step [21] to the required
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settings identified in Step [2]. Step [27] was similarly changed to compare and
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verify the as-left recorder alarm setting to the setting identified in Step [2].
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new additional Step [30] was added for an independent verification by a utility
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licensed operator that the as-left settings agree with the settings identified in
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Step [2].
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The trip settings of the Main Steam Radiation Monitors were reset (i.e., increased)
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in accordance with procedure 3.M.2-7.6 (Rev. 3) on December 23, 1992.
The
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subsequent injection of hydrogen occurred without incident. The Main Steam
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Radiation Recorder alarm settings were checked during the performance of the
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procedure on December 23, 1992, and no adjustment was necessary because the as-found
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settings were correct for operation with hydrogen injection. Therefore, the alarm
settings for hydrogen injection established on December 19, 1992, and not reset on
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December 20, 1992, were the as-found and as-left alarm settings on
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December 23, 1992.
The I&C Supervisor reviewed the procedure and verified the as-
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lef t settings were correct prior to signing the completed procedure for IEC
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management on December 23, 1992. The supervisor did not identify the as-found and
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as-left settings as a discrepancy because the as-left alarm settings were correct
for operation with hydrogen injection.
The Main Steam Radiation alarm function is
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not safety-related.
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Boston Edison Company
Docket No. 50-293
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Pilgrim Nuclear Power Station
-License No DPR-35-
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CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED
The I&C Supervisor who reviewed the completed procedure performed on
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December 20, 1992 (procedure 3.M.2-7.6 Rev. 2), and December 23, 1992 (procedure
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3.M.2-7.6 Rev.- 3), and did not identify the discrepancies received progressive
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discipline.
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Problem Report 93.9006 was written by the 1&C Division Manager to document the Main
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Steam Radiation Recorder alarm setting discrepancies during December 20 - 23, 1992.
The circumstances of the incorrect settings of the Main Steam Radiation Monitors and
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radiation recorder were discussed during a IEC workshop meeting on January 8, 1993,
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Review of procedure 3.M.2-7.6 completed in the previous 18 months revealed no other
discrepancies.
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The I&C Supervisors received training for I&C Supervisor review of completed
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surveillance procedures.
The training, conducted on February .1,1993, focused on
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1&C Supervisor responsibilities and management expectations ~ regarding completed
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surveillance procedures.
Essentially, the 1&C Supervisor is responsible for
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ensuring a completed surveillance procedure has been properly conducted prior to
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review / signature by the senior utility shift licensed operator (NWE).
Included in
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this I&C Supervisor responsibility are checks that inlude information/ data entry
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where required, comparison of data entered to identified tolerances, appropriateness
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when a step is not performed, legibility, and explanation of notes or discrepancies
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in the proper location.
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The effectiveness of the 1&C Supervisor training is being assessed.
Initially, 1&C
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Supervisors will complete a yes-no type checklist containing key elements directly
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related to the training conducted. The checklist also includes the date, procedure
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number and attachment (when applicable), I&C Supervisor name, and a comments
section.
Each I&C Supervisor is completing this checklist for the first 12
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surveillance procedures completed after February 1,1993. The completed checklists
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are being forwarded to the I&C Division Manager for review. This initial action is
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providing 1&C Supervisor /I&C Division Manager feedback to determine the
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effectiveness of the training conducted. As of the date when this response was
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prepared, the feedback indicated the training was effective.
These actions will
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be complete when the 1&C Supervisors have each completed a checklist for the first
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12 surveillance procedures completed by the I&C Technicians for whom the Supervisors
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are responsible.
Due to the variation in the frequency of the surveillance
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procedures that are scheduled in accordance with the Master Surveillance Tracking
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Program, the date when these actions will be completed will vary by the individual
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IEC Supervisor.
The completion date for all current I&C Supervisors is expected to
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be September 1, 1993.
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The longer term effectiveness of the training conducted will also be assessed via a
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periodic sample of completed surveillance procedures. The sampling has been
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established by the creation of a new Preventive Maintenance Program node
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(P 0487035). The node functions to notify the 1&C Division Manager that the
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sampling is to be conducted.
The initial sampling frequency is once per six months.
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Based on the results of the sampling conducted, the frequency may be increased,
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decreased, or eliminated. The initial sample is scheduled to be reviewed by the end
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of July 1993.
These actions will be complete when two consecutive samples of
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completed surveillance procedures have been reviewed with acceptable results by the
I&C Division Manager.
Based on the initial sampling frequency of once per six
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months, the earliest completion date would be the end of January 1994.
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Boston Edison Company
Docket No. 50-293
Pilgrim Nuclear Power Station
License No. DPR-35
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CORRECTIVE ACTION TO PRECLUDE RECURRENCE
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Procedure 3.M.2-7.6 (currently Rev. 3) is being evaluated for further improvement.
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When this response was prepared, the focus for improvement was the possible removal
of the Steam Jet Air Ejector Radiation Monitors from the scope of Attachment I to a
new attachment or other procedure.
This would eliminate the need for the
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procedurally-allowed ability to enter "N/P".
Other improvements may be identified
as a result of the evaluation.
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The circumstances of the incorrect settings of the Main Steam Radiation Monitors
that resulted in the plant trip on December 20, 1992, and the incorrect alarm
settings of the Main Steam Radiation Recorder after the plant trip and prior to the
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resumption of hydrogen injection on December 23, 1992, were discussed during a
Maintenance manager meeting with Maintenance Supervisors on February 22, 1993. The
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supervisors were from the 1&C, Electrical Maintenance, and Mechanical Maintenance
Divisions.
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The Maintenance Training Program includes general indoctrination and Maintenance
Supervisor training. The Maintenance Supervisor Training Program includes
orientation by the Maintenance Manager. The training includes the manager's
expectations (i.e., philosophy and perspectives) in several topical areas that
include the conduct of maintenance and work control, the conduct of operations, and
administrative requirements. Maintenance Supervisor training will be strengthened
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by including key elements of the training provided to the I&C Supervisors on
February 1, 1993.
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The plant trip on December 20, 1992, was reported in LER 92-018-00.
The event and
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response to this violation will be included in the continuing Plant Status Update
training for 1&C Supervisors and Technicians. The training will be completed by
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December 31, 1993.
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The evaluation of procedure 3.M.2-7.6 (currently Rev. 3) is expected to be completed
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by March 1, 1993. The procedure improvements will be initiated by March 31, 1993,
with an estimated completion date of May 30, 1993.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED
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Full compliance for the Main Steam Radiation Recorder alarm settings was achieved
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when the alarm settings were checked and verified to be correct on
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December 23, 1992.
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Full compliance for the Main Steam Radiation Recorder alarm setting discrepancies
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was achieved when Problem Report 93.9006 was written on January 7,1993.
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