ML20035G293
| ML20035G293 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 04/19/1993 |
| From: | Beach A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | Withers B WOLF CREEK NUCLEAR OPERATING CORP. |
| References | |
| NUDOCS 9304270087 | |
| Download: ML20035G293 (4) | |
See also: IR 05000482/1993001
Text
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WUCLEAR REGULATORY COMMISSION
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AR LINGTON. T E X AS 760118064
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Docket:
STN 50-482
License: NPF-42
Wolf Creek Nuclear Operating Corporation
ATTN:
Bart D. Withers
President and Chief Executive Officer
P.O. Box 411
Burlington, Kansas 66839
SUBJECT: NRC INSPECTION REPORT 50-482/93-01
.
Thank you for your letter dated April 7,1993, in response to our letter
and Notice of Violation dated March 9, 1993.
We have reviewed your reply and
find it responsive to the conerns raised in our Notice of Violation.
We will
review the implementation of your corrective actions during a future inspection
to determine that full compliance has been achieved and will be maintained.
Sincerely,
v/
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$lete
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[A.BillBeach, Dire Prohs
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Division of React
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CC:
Wolf Creek Nuclear Operating Corp.
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ATTN: Otto Maynard, Director
Plant Operations
P.O. Box 411
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Burlington, Kansas 66839
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Shaw, Pittman, Potts & Trowbridge
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ATTN: Jay Silberg, Esq.
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2300 M Street, NW
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Washington, D.C.
20037
,
Public Service Commission
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ATTN:
C. John Renken
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Policy & Federal Department
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P.O. Box 360
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Jefferson City, Missouri
65102
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9304270087 930419
ADOCK 05000482
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Solf Creek Nuclear Operating
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Corporation
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U.S. Nuclear Regulatory Commission
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ATIN:
Regional Administrator, Region Ill
799 Roosevelt Road
Glen Ellyn, Illinois 60137
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Wolf Creek Nuclear Operating Corp.
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ATTN:
Kevin J. Moles
Manager Regulatory Services
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P.O. Box 411
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Burlington, Kansas 66839
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Kansas Corporation Commission
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ATIN:
Robert Elliot, Chief Engineer
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Utilities Division
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1500 SW Arrowhead Rd.
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Topeka, Kansas 66604-4027
Office of the Governor
State of Kansas
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Topeka, Kansas 666i2
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Attorney General
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Ist Floor - The Statehouse
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Topeka, Kansas 66612
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Chairman, Coffey County Commission
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Coffey County Courthouse
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Burlington, Kansas 66839-1798
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Kansas Department of Health
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and Environment
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Bureau of Air Quality & Radiation
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ATTN:
Gerald Allen, Public
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Health Physicist
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Division of Environment
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Forbes Field Building 321
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Topeka, Kansas 66620
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Kansas Department of Health and Environment
ATTH:
Robert Eye, General Counsel
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LSOB, 9th Floor
900-SW Jackson-
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Topeka, Kansas 66612
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Bart D Withers
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President and
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Chef Execut#ve Omcer
April 7 1993
U.S. Nuclear Regulatory Commission
ATTN: Document Control Desk
Mail Station Pl-137
Washington, D. C. 20555
Reference:
Letter dated March 9,
1993, from A.
B.
Beach, NRC to
B.
D. Withers, WCNOC
Subject:
Docket No. 50-482: Reply to Notices of Violation
482/9301-01 and 482/9301-03
Gentlemen:
Attached is Wolf Creek Nuclear Operating Corporation's- (WCNOC) " Reply to
Notices of Violation" 482/9301-01, and -03 which were documented in the
Peference
(NRC Inspection Report
50-482/93-01).
Violation
482/9301-01
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concerns two examples of failures to follow procedures in that the incorrect
Protection Set comparator trip bistables were inad*'ertently placed in test and
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the failure to open the Fuel Building to Auxiliary Building dampers when the
Fuel Building Exhaust Train was secured.
Violation 482/9301-03 concerned an
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inadvertent reduction of the Refueling Water Storage Tank level as a result of
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inadequate procedures.
The NRC identified both violations as Severity Level
IV contrary tc the requirements of Technical Specification 6.8.1.a.
If you have any questions concerning this matter, please contact me at (316)
364-8831 ext. 4000 or Mr.
K.
J. Moles of my staff at ext. 4565.
Very truly yours,
.
Bart D. Withers
President and
Chief Executive Officer
BDW/jan
Attachment
cc:
W.
D.
Johnson (NRC), w/a
G. A.
Pick (NRC), w/a
J.
L. Milhoan (NRC), w/a
W.
D. Reckley (NRC), w/a
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PO Box 411 ! Burhngton, KS 66839 / Phone. (316) 364-8831
An Ecua! Opportunny Empeyer M'FHCVET
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Attachment to WM 93-0050
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Page 1 of 7
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Reply to Notices of Violation 482/9301-01 and 482/9301-03
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Violation 482/9301-01:
Failure to Follow Procedures:
Incorrect
,
Pressurizer Protection Set comparator trip
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bistables inadvertently placed in test and
failure to open the Fuel Building to Auxiliary
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Building dampers when the Fuel Building Exhaust'
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Train was recured.
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Findings:
" Technical Specification 6.8.1.a states that written procedures shall be
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established,
implemented,
and raintained
covering
the
applicable
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procedures recommended in Appendix A of Regulatory Guide 1.33, Revision
j
2,
dated February 1978.
Two examples of violations of this requirement
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are stated below.
1.
Regulatory Guide 1.33, Appendix A, Item 8.b.
(1) (1), requires
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specific
procedures
for
reactor
protection
system
tests
and
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calibrations.
75 ?,s is accomplished, in part, by Procedure STS IC-203A,
" Analog Chennel Operational Test of TAVG,.dT and Pressurizer Pressnre
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Protection Set III, " Revision O.
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Step 5.3.1.14 of Procedure STS IC-203A requires personnel to' place
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Prorection Set III comparator trip bistables in test.
Contrary to the above, on January 25, 1993, instrumentation and-
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control technicians determined they had inadvertently placed Protection
Set IV bistables in test instead of Protection Set III bistables.
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2.
Regulatory Guide 1.33, Appendix A,
Item 3,. requires procedures
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for startup, operation, and shutdown of safety-related systens.
This is
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accomplished, in part, for the fuel building . ventilation syst'em by
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Procedure SYS GG-200,
" Fuel Building Emergency Exhaust ~ Operations,"
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Revision 4.
,
Step 4.3.6 of Procedure SYS GG-200 requires personnel to open the
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fuel building to auxiliary building dampers, Dampers GG HZ-42 and GG HZ-
,
62 {GL HZ-42), when securing a fuel building exhaust. train.
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contrary to the above, on January 14,'1993, with the fuel building
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exhaust train secured,_ licensee personnel deterndned that Dampers GG HZ-
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62 and GG HZ-42 (GL HZ-42) were closed and Step 4.3.6 incorrectly marked
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"not
applicable."
This could have resulted in an unmonitored,
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unfiltered release of air."
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Reason for Violation.
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1.
The reason for this violation was inattention to detail by tuo non-
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licensed licensee technicians during the performance lof Technical
Specification surveillance test procedure STS IC-203A, " Analog Channel
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Operational Test of TAVG, dT, and Pressurizer Pressure Protection set
III",
Rev.
O,
on January 25, 1993.
Two Instrument and Control (I&C)
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Technicians signed on to the authorization cover sheet lor STS IC-203A
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and returned to the area of the protection sets to begin the-test.
One
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technician was very familiar with the performance of the procedure, but
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Attachment to WM 93-0050
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Page 2 of 7
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the other only had
limited familiarity.
Both technicians were
qualified.
One technician assumed the responsibility of reading the
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procedure steps
aloud and performing the checkoffs,
annotations,
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initialing,
etc.
On this particular day there was a piece of
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maintenance and test equipment (M&TE)
1.e.,
strip chart recorder located
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on the floor in front of and connected to a circuit in Protection Set
IV.
An additional circumstance existed in that Annunciator B093, "PCS
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Cabinet Door Open," which alerts operators to the fact that a protection
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set door is open, was locked in alarm because the Protection Set IV
doors were slightly ajar to allow test leads to enter from the M&TE
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strip chart recorder.
Finally, given the fact that the plant was in a
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reduced power configuration and a Control Room annunciator power failure
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delayed performance of the procedure for about four hours, this could
have contributed to a subconscious sense of urgency to complete the
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procedure.
These factors in all likelihood contributed to the mental
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error involved.
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It should also be noted that the access cabinets for the Pressurizer
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Pressure Protection Sets are color coded.
Protection Set III is color
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" blue" and IV is color " yellow".
This fact is also annotated in steps
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5.2 and 5.3 of STS IC-203A.
Had the technicians checked the color code
on the Protectirn Set IV process instrument cabinet doors prior to
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performance of
.his ' procedure, they would have realized they were
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entering the wrong access cabinet.
The first technician moved the mobile test cabinet into position.
Due
to inattentien to detail, the technician positioned the test cabinet in
front of Protection Set III and opened the door to Protection Set IV.
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The second technician was preoccupied with an annotation to step 5.2.2
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of the procedure, which uas due to the alarm for the protection set door
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already locked in.
W'en the second technician was ready to commence
subsequent steps, th t Protection Set- IV door was already open and
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performance commenced
6 tith step
5.3.1,
which is the switch "line-up"
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prerequisites section.
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During the performance of this preliminary section, the performance of
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step 5.3.1.14 became impossible because there was no SS-2 Comparator
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Trip Switch in location 03-842, since this is located in Protection Set
III.
At the same time Control Poem Operators noticed that Channel IV
bistable partial trip status lights illuminated instead of the Channel
III lights on SB069 step 5.3.1.15 of the procedure.
At this point the
I&C Technicians, as well as a Control Room Operator on the scene,
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rea]ized the error, stopped all acti; ?ies and exited the procedure.
2.
The reason for this violation was inadequate self-checking during
performance of procedure SYS GG-200, " Fuel Building Emergency Exhaust
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operations". During the performance of SYS GG-200, Operators closed the
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Fuel Building to Auxiliary Buildir.g dampn a GG HZ-42 and GL HZ-62 per
step
4.1.4.
However, when the restoration section of SYS GG-200 was
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done, step 4.3.6 to open dampers GG HZ-42 and GL HZ-62 was incorrectly
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marked
"N/A".
The individual performing the procedure read the steps
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too quickly and believed step 4 . 3. 5,
which required closure of the
supply dampers, pertained to Train "A" and step 4.3.6 pertained to Train
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"B".
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Attachment to WM 93-0050
Page 3 of 7.
Corrective Steps That Have'Been Taken and Results Achieved:
1.
Upon realization of the error,
I&C Technicians restored all
equipment to its normal operating configuration'as established prior to
procedure performance.
Once the initial condit?ons were - properly
established, performance of the procedure was restarted and continued to
completion.
A Periormance Improvement Request (PIR # TS 93-0051) was
initiated to investigate the actions leading to ' the event and human
factors which contributed to the inattention to detail during the-
performance of STS IC-203A.
The I&C Technicians involved reviewed their
actions and determined that PIR # TS 93-0051 should be discussed in
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detail for departmental review.
The I&C Technicians involved were
counseled and the IEC Manager reiterated to I&C personnel the importance
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of good communications and sound use of self-checking techniques.
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2.
Once the Control Room was notified of excess pressure in the Fuel
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Building, an Operator investigated and discovered dampers GG HZ-42 and
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GL HZ-62 were closed.
The Operator opened the dampers'per SYS GG-200
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step 4.3.6 and the pressure returned to normal.
Corrective Steps That Will Be Taken to Avoid Further Violations:
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1.
PIR # TS 93-0051 has been routed as required reading to I&C
personnel to reiterate the importance of attention to detail.
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2.
In February 1993, operations Senior Management initiated the " STAR"
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(Stop,
Think,
Act,
Review) ~ Self-Checking
Program to
provide
an
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environment.that encourages personnel to carry out their work activities
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in a thoughtful, deliberate manner.
The program uses self-verification
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techniques to prevent or minimize the potential for human error.
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In response to this event, the individual involved in _ the event will'
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make presentations to the operating Crews and to WCNOC management
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emphasiring the STAR program and explain how self-checking techniques
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could have been used during this event.
The presentation will stress
'
that before a work practice is consciously and deliberately initiated by
an individual,
they should identify the correct unit,
train,- or
component, review the intended action and expected response, verify the
adequacy and configurat3cn
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test equipment,
compare the actual
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response to the expected respt..ts e and resolve any dif f erences before
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proceeding. The presentation will also review the correct usage _of "not
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applicable" (N/A).
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Actual or Potential ~Consecuences of this Violation
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1.
The potential for an inadvertent reactor trip to occur was very
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remote. The time that the equipment was in a configuration not allowed
by the procedure was approximately ' two minutes.
All equipment was
promptly restored without adverse consequences to either the_ equipment
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or plant status.
Procedure STS IC-203A is properly written as it
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exists.
Thus, there was never any risk to public health and safety or
plant safety.
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The potential for an inadvertent release of radioactivity to the
public was very remote, as all the required safety equipment was
operable during the time the dampers were closed.
Should there have
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been an event of radiological consequence, a Fuel Building Isolation
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Signal would have actuated.
Thus, there was never any risk to public
health and safety or plant safety.
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Date When Full' Compliance Will Be Achieved:
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1.
Full compliance was achieved on February 10, 1993, with the
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completion of PIR f) TS 93-0051 actions.
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2.
Full compliance will be achieved by June 15, 1953 with the
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presentation.
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Attachment to WM-93-0050
Page.5 of 7
Violation -462/9301-03:
Inadequate Procedure:
Inadvertent reduction of
the Refueling Water Storage Tank level as a
result of inadequate procedures.
Findings:
" Technical Specification 6.8.1.a states that written procedures shall be
established,
implemented,
and maintained
covering
the . applicable-
i
procedures recommended in Appendix A of Regulatory Guide 1 33, Revision
2,
dated February 1978.
Appendix
B,
Criterion
V,
" Instructions,
Procedures and Drawings,"
requires,
in
part,
that
activities affecting quality shall be prescribed by procedures of a type
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eppropriate to the circumstances.
Regulatory Guide 1.33, Appendix A,
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Item
8.b.
(1)
(j), requires procedures for performing emergency core
!
cooling system tests.
This is accomplished, in part, by Procedure STS
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EJ-100A, "RHR System Inservice Pump A Test," Revision 10.
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contrary to the above,
on February
4,
1993,
licensee . personnel
determined that, while Step 5.1.16 of Procedure STS EJ-100A directs the
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operator to open or verify open Valve BN V004, safety injection test
header to refueling water storage tank isolation, the procedure did not
.i
require closing Valve BN V004.
This resulted in an inadvertent
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reduction of the refueling water storage tank level."
Reason for Violation:
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The Refueling Water Storage Tank (RWST) was on cleanup recirculation via
the Fuel Fool Cooling and Cleanup demineralizers, with RWST valve BN
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V004 closed and Safety Injection System valve EM V120 open due to Safety
Injection discharge header problems.
Turnover instructions were to
depressurize the Safety Injection header at approximately 800 psig. The
path for depressurization has been via EM HVB835, EM HVB871, EM VB964,
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EM V120 to the online Recycle Hold-up Tank (RHUT).
Valve _BN V004 is a
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normally open valve, but had been closed to avoid diluting th e - RWST .
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Valve EM V120 was left open and the air-operated valves were operated
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from the control Room as needed to depressurize the Safety Injection
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on February 3,
1993, at 2300 CST operations personnel made the lineup
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for procedure STS EJ-100A, "RHR System Inservice Pump A Test," Revision
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10, which opens or verifies open valve BN V004.
Since this had been a
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normal open valve, proce&are STS EJ-100A does not restore the valve to
the closed position.
(STS EJ-100A was written from a normal lineup
,
point
of
view,
but the RWST was
on
recirculation through the
!
demineralizers and the checklist procedure, CKL BN-120, " Refueling Water
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Storage System Lineup," Revision. 7, had been changed allowing valves BN
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V004 and EM V120 to be open or closed.)
)
At step 5.1.16 of STS EJ-100A, when the operator opened valve BN V004,
a
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path was provided from the discharge of the Fuel Pool Cooling and
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Cleanup pumps via valve BN V002 through normal open valve BN V004 to
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valve EM V120 and then to the on-line RHUT to drain the RWST.
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On February 4, 1993, at 1252 CST, the Control Room received alarm 47E,
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"RWST Level Hi/Lo," because of low level, less that 99% in the RWST.
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Residual Heat Removal (RHR) train B pressure indicated 340 psig.
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Attachment to WM 93-0050
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Page 6 of 7
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Operators responded to the level-decrease.
As the RHR
"A"
relief valve
has been known to lift-early, the' relief valve was investigated.
The-
Operators commenced makeup to the RWST at 1615 CST, adding 2700 gallons
of borated water to the RWST.
However, the FWST level continued to
y
decrease at about 240 gallons per hour.
To monitor flow, a controlatron
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was placed on the RHR
"A"
discharge relief valve.
It indicated a flow
,.
of 180-30C gallons per hour leading Operators to believe the problem wts
, '
the RHR relief valve.
Methods were pursued to keep the RWST level
within Technical Specifications limits with frequent additions and.
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sample recirculation times of 2-3 days,
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The Reactor Operator questioned the relief velve problem, as the RHR
header was high on
"B"
train and the trains are cross-connected.
At
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1930 CST on Eebruary
4,
1993, the previous day Auxiliary Building .
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Watchstander remembered opening BN V004 and that the procedure never
addressed re-closing
it.
At the same time the off-going Reactor
Operator called from home and reported he remembered this happening some
5
time in the past and to check BN V004.
This reason for this violation
,
is inadequate procedures which caused confusion as to whether BN V004
i
was to be open or closed.
.;
Corrective Steps That Have Been Taken and Results Achieved:
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Upon realization.that BN V004 was open, Operators closed the valve at
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1938 CST on February 4,
1993, and the RWST level stabilized.
FIR # OP
93-0084 was initiated on February 5,
1993, to assure a proper evaluation
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of this event, a thorough root cause determination would be done, and
)
. appropriate corrective actions implemented.
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STS EJ-100A and STS EJ-100B were revised on March 31, 1993, to include a
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check that BN V004 is closed and EM V120 is open.
Other applicable
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procedures were evaluated and revised on March 31, 1993, including, STS
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EM-100A, " Safety Injection Pump A Inservice Pump Test" Rev.-9, STS EM-
t
100B, " Safety Injection Pump B Inservice Pump Test," Rev.
5, and STS PE-
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19E, "RCS Isolation Check Valve Leak Test" Rev. 9.
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To avoid any other similar problems, Operations proceduralized Residual
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Heat Removal header (EJ) depressurization on March 23, 1993, and the
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Refueling Water Storage System Lineup Checklist, CKL BN-120, was revised
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on February 9, 1993, to identify a specific position for BN V004 instead
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of either open or closed.
To avoid confusion, the Safety Injection
{
System Lineup Checklist, CKL EM-120, was revised on February 12, 1993,
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to place EM V120 in a speci fic position instead of either open or
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closed, as this caused confusion,
)
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Corrective Steps That Will Be Taken to Avoid Further Violation:
}
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Operations
will make
Safety
Injection header
depressurization
permanent procedure requiring EMV120 to be checked open and BN V004 to
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be checked closed.
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Attachment to WM 93-0050
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Page 7 of 7
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A work request will be initiated by June 1,
1993, to evaluate' changing
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the corresponding plant drawings to reflect BN V004 as .normally closed
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and EM V120 as normally open.
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Training will 2ncorporate issues from this event into the Plant and
Industry Events section of the licensed operator requalification cycle
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(93-3) scheduled to begin approximately April
1,
1993, and into the
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nuclear station operator requalification cycle (93-4) scheduled to begin
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June 1,
1993.
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Actual or Potentia) Consequences of this violation
Technical Specification 3.5.S assures OPERABILITY of the RWST as part of
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the Emergency Core Cooling System (ECCS) so that a sufficient supply of
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borated water is available for ECCS injection in the event-of a Loss of
Coolant Accident (LOCA).
The limits on RWST minimum volume ensures
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sufficient water is available in Containment to permit recirculation
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cooling to the reactor core, consistent with the LOCA Safety Analysis.
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The Technical Specification required minimum volume of 394,000 gallons
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was raaintained throughout this event.
Thus, there was never a condition
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not assuring public health and safety
plant safety.
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Date When Full Compliance Will Be Achieved
Safety Injection header depressurization will be procedura112ed by May
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31, 1993.
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Operations will initiate a work request to evaluate changing the
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corresponding plant drawings to reflect valves BN V004 as normally
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closed and EM 120 as normally open by June 1,
1993.
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Training to incorporate new procedures and lessons learned from this
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event into licensed and non-licensed training by September 1, 1993.
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