ML20035G269
| ML20035G269 | |
| Person / Time | |
|---|---|
| Site: | South Texas  |
| Issue date: | 04/19/1993 |
| From: | Milhoan J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | Cottle W HOUSTON LIGHTING & POWER CO. |
| Shared Package | |
| ML20035G270 | List: |
| References | |
| EA-93-023, EA-93-23, NUDOCS 9304270064 | |
| Download: ML20035G269 (6) | |
Text
pR Pico UNITE D STATES 3
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?g NUCLEAR REGULATORY COMMISSION Ipj REGION IV I{II
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611 RY AN PLAZA DRIVE. Suf7E 400 AR LINGT ON, T EXAS 76011-8064
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APR I 91993 Dockets:
50-498; 50-499 Licenses:
NPF-76; NPF-80 EA 93-023 Houston Lighting & Power Company ATTN: William T. Cottle, Group Vice President, Nuclear P.O. Box 1700 Houston, Texas 77251
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSilION OF civil PENALTY -
$25,000 (NRC INSPECTION REPORTS 92-29, 92-32 AND 93-03)
This is in reference to NRC inspections conducted between September 13, 1992, and February 1, 1993.
These inspections reviewed eight instances in which South Texas Project Electric Generating Station (STP) personnel failed to follow procedures requiring self-verification.
Each of these was discovered by Houston Lighting & Power Company (HL&P) and described in a written Station Problem Report. The inspection reports describing the events that resulted in these apparent violations were issued on November 25, 1992; January 19, 1993; and February 18, 1993.
These apparent violations were discussed with you and other HL&P representatives at an enforcement conference in the NRC's Arlington. Texas office on March 8,1993.
The violations in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) include eight examples of f ailures of STP personnel to adhere to procedural requirements regarding self-verification.
STP Procedure OPGP03-ZA-0010, " Plant Procedure Adherence and Implementation and Independent Verification," requires plant personnel to follow a seven-step self-verification process in performing any procedure that requires the-manipulation of plant equipment.
The seven steps are:
- 1) stop and think about the task; 2) locate the device to be operated; 3) touch the device:
- 4) verify the correctness of the device; 5) anticipate the expected and unexpected responses and the actions to be taken; 6) manipulate the component; and 7) observe for expected and unexpected responses.
Step 9 of the self-verification process requires individuals to ensure they are on the correct unit, correct train and correct device.
The eight violations of this procedural requirement occurred between September 28, 1992, and January 9, 1993, and primarily involved the failure to verify the correct unit, correct train or correct device before conducting testing or maintenance activities.
The specific examples are described in more detail in the inspection reports and included:
- 1) maintenance work beguri on the wrong condenser waterbox before the error was discovered; 2) maintenance performed on the wrong pipe support in the Essential Cooling Water
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9304270064 930419 PDR ADDCK 05000498 O
4
. Houston Lighting & Power Company M i 91993 system; 3) operational test performed on the wrong reactor cooling pump underfrequency trip actuating device; 4) local leak rate test performed on the wrong containment isolation valves; 5) lifting of wrong leads during the performance of accumulator pressure surveillance test; 6) maintenance performed on the Qualified Display Parameter system in the wrong unit;
- 7) service request written for the wrong feedwater heater drain valve (although work was performed on the correct valve); and 8) _high neutron flux trip setpoint set incorrectly.
The NRC acknowledges that these particular errors did not result in any operational events and did not have any immediate impact on the safety of the plant or plant personnel.
The NRC's concerns about these errors, and similar i
errors HL&P identified subsequent to the issuance of the inspection reports i
t include:
- 1) the potential for errors of this type to result in plant transients or cause injury to personnel; 2) the recurring nature of personnel errors at STP despite the NRC's having expressed concern about such errors on f
numerous occasions and despite plant management's efforts to correct previous,
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similar problems involving the failure of personnel to pay attention to detail; and 3) because a number of these errors involved contract personnel, i
the extent to which contract employees are being trained in procedural
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adherence requirements. When viewed collectively, these violations represent-l a significant regulatory concern in the area of personnel performance and more specifically attention to detail. Therefore, in accordance with the " General l
Statement of Policy and Procedure for NRC Enforcement Actions," (Enforcement a
Policy) 10 CFR Part 2, Appendix C, these violations are classified in the aggregate as a Severity Level III problem.
j In its presentation at the enforcement conference, HL&P presented additional j
examples of the issues discussed above and identified two broad causes of'all I'
of these recent errors: 1) personal accountability and responsibility, which HL&P said encompassed both the failure of individuals to perform the self-verification procedure and a lack of attention to detail; and
- 2) organizational / programmatic support, which HL&P said encompassed a lack of clear written instructions, poor oral briefings / instructions, inadequate equipment design / labeling, and the repetitive nature of some tasks. While HL&P has developed a long list of short-term and long-term corrective actions j
to address these root causes, the likely effectiveness of these actions is j
difficult to gauge at this time since many of the more important actions-are planned but have not been implemented or completed.
The NRC notes that four additional examples of individuals failing to follow self-identification
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procedures or pay attention to detail were reviewed during an inspection J
completed on April 12, 1993.
These examples, which will be discussed in Inspection Report 93-ll, indicate that HLSP's efforts to correct these i
problems have not yet been effective.
i HL&P's completed corrective actions to address these problems include:
meeting with plant personnel to discuss these errors, management expectations and lessons learned; issuing a plant bulletin on " Attention to Detail;"
conducting additional training on the self-verification process; and modifying m
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3, 3 993
- Houston Lighting & Power Company '
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k work packages and service requests to minimize the opportunity for error.
Ongoing and planned corrective actions include, but are not limited to:
increasing oversight of field activities by _ supervisors; discussing self-verification and attention to detail in routine meetings; simplifying the self-verification process and enhancing self-verification training; rotating personnel to avoid desensitization; initiating a plant manager's-forum to i
discuss human performance expectations and employee-identified problems; i
augmenting work controls for critical plant equipment; upgrading labeling of plant components; and evaluating the results of an ongoing organizational.
l interface assessment for issues which affect human performance.
To emphasize the importance of attention to detail, i.e., doing the job right l
the first time, and the need for HL&P to be aggressive in implementing i
corrective actions of a larting nature, I have been authorized to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) i in the amount of $25,000 for the Severity Level III problem described above j
and in the Notice.
The base value of a civil penalty for a Severity Level III problem _is $50,000.
l The civil penalty adjustment factors in the Enforcement Policy were considered and resulted in a 50-percent decrease in the base value.
In assessing these i
factors, the NRC considered HL&P's identification and documentation of these i
errors worthy of a decrease equivalent to 50 percent of the base value.
The other adjustment factors in the Policy were considered and no further adjustment to the base civil penalty was considered appropriate.
You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response.
In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this i
Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is i
necessary to ensure compliance with NRC regulatory requirements.
j In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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Houston Lighting & Power Company ~
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4 The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No.96-511.
f Sincerely, u
j i
e L.?R L ames L. Milhoan 3
-u l
f egional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enclosure:
Houston Lighting & Power Company ATIN:
William J. Jump, Manager Nuclear Licensing i
j P.O. Box 289 l
Wadsworth, Texas 77483 City of Austin Electric Utility Department 1
ATTN:
J. C. Lanier/M. B. Lee P.O. Box 1088
]
Austin, Texas 78767 City Public Service Board 3
ATTN:
R. J. Costello/M. T. Hardt l
P.O. Box 1771 a
San Antonio, Texas 78296 i
i Newman & Holtzinger, P. C.
ATTN: Jack R. Newman, Esq.
1615 L Street, NW j
Washington, D.C.
20036 Central Power and Light Company l
ATTN:
D. E. Ward /T. M. Puckett P.O. Box 2121 Corpus Christi, Texas 78403 l
INPO l
Records Center i-1100 Circle 75 Parkway j
Atlanta, Georgia 30339-3064 l
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- Houston Lighting & Power Company !
i APR 1 9 1993 J
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Mr. Joseph M. Hendrie l
50 Bellport Lane j
4 Bellport, New York 11713 Bureau of Radiation Control State of Texas i
1101 West 49th Street Austin, Texas 78756 i
Judge, Matagorda County Matagorda County Courthouse
[
i 1700 Seventh Street l
Bay City, Texas 77414 l
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Licensing Representative l
Houston Lighting & Power Company j
Suite 610 i
Three Metro Center Bethesda, Maryland 20814 j
i Houston Lighting & Power Company i
ATTN:
Rufus S. Scott, Associate General Counsel P.O. Box 61867 j
Houston, Texas 77208 j
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Houston Lighting & Power Company
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