ML20044G762
| ML20044G762 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 05/26/1993 |
| From: | Johnson W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20044G754 | List: |
| References | |
| 50-482-93-16, NUDOCS 9306040222 | |
| Download: ML20044G762 (9) | |
See also: IR 05000482/1993016
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APPENDIX
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U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
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NRC Inspection Report:
50-482/93-16
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Operating License No.:
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Docket No.:
50-482
Licensee: Wolf Creek Nuclear Operating Corporation-
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P. O. Box 411
Burlington, Kansas 66839
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Facility Name: Wolf Creek Generating Station
Inspection At:
Coffey County, Burlington, Kansas
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Inspection Conducted: May 10-13, 1993
Inspectors:
S. J. Campbell, Resident Inspector
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G. A. Pick, Senior Resident Inspector
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Approved: /A//)
f/M/93
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WilliamDp7 Johnson, Chief, Prof-'SectionA.
Date'
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Inspection Summary
Areas Inspected: A special inspection was conducted to. determine the events
surrounding entry into Mode 3 with both motor-driven auxiliary'feedwater' pumps
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Results:
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Six apparent violations were identified:
(1)
The first apparent violation involved the failure.to satisfy the
requirements.of Technical Specification 3.0.4.
On May 8, 1993,
the reactor was taken into Mode 3 without the Technical
Specification required motor-driven ' auxiliary feedwater pumps
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being operable (Section 2.1).
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(2)
The second apparent violation involved the failure to take:the
appropriate acticn of Technical Specification _3.7.1.2, with two
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motor-driven auxiliary feedwater pumps inoperable (Section 2.1).
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(3)
Four other apparent violations involved failures to follow
procedures in accordance with the requirements of Technical
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9306040222 930526
ADOCK 05000482
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Specification 6.8.1.a.
Control room operators failed to perform a portion of
Procedure GEN 00-002 prior to entering Mode 3
(Section 2.2.1).
Control room operators did not perform adequate shift
turnover briefings and main control board walkdowns and, as
a result, did not note that both motor-driven auxiliary
feedwater pumps were inoperable (Section 2.2.2).
Control room operators did not perform thorough main control
board .;alkdowns during shift operations and, as a result,
did not note that both motor-driven auxiliary feedwater
pumps were inoperable (Section 2.2.2).
Control room operators did not use the equipment out-of-
service log to track the inoperable motor-driven auxiliary
feedwater pumps (Section 2.2.3).
Summary of Inspection Findings:
Apparent Violation 482/9316-01 was opened (Section 2.1).
Apparent Violation 482/9316-02 was opened (Section 2.1).
Apparent Violation 482/9316-03 was opened (Section 2.2.1).
Apparent Violation 482/9316-04 was opened (Section 2.2.2).
Apparent Violation 482/9316-05 was opened (Section 2.2.2).
Apparent Violation 482/9316-06 was opened (Section 2.2.3).
Attachment:
Attachment - Persons Contacted and Exit Meeting
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DETAILS
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1 SEQUENCE OF EVENTS
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On May 8,1993, at 6:21 p.m. (CDT), a plant mode change was initiated from
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Mode 4 to Mode 3, with Mode 3 being entered at 6:38 p.m. when the reactor
coolant temperature exceeded 350oF. After a shift turnover briefing was
performed and the control room shift turnover log was completed, the oncoming
night shift assumed their respective duties at 7:14 p.m.
The night shift
performed numerous tasks, which included completing nine surveillance tests,
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in preparation for Mode 2 entry.
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On May 9, 1993, at 7:16 a.m., following shift turnover, the night shift was
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relieved by the day shift. At 7:53 a.m.,
the motor-driven auxiliary feedwater.
pump control room handswitches, which were discovered by a balance-of-plant
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operator in the pull-to-lock position, were placed in the normal position to
comply with the requirements of Technical Specification 3.7.1.2.
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2 DETAILED INSPECTION FINDINGS
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2.1 Mode Change Conducted Without Technical Specification Reauired Eauipment
Between 6:38 p.m. on May 8 and-7:53 a.m. on May 9, 1993, the
motor-driven auxiliary feedwater pump handswitches were misaligned to the
pull-to-lock position after an entry into Mode 3 was performed. The
handswitches were required to be in the normal position to permit automatic
starting of the pumps in order to perform their safety-related function of
supplying auxiliary feedwater to the steam generators to remove decay heat
from the reactor.
Placing the handswitches in the pull-to-lock position
rendered the motor-driven auxiliary feedwater pumps inoperable.
Technical Specification 3.0.4 states, in part, that entry into an operational
mode shall not be made unless the conditions for the Limiting Condition for
Operation are met without reliance on provisions contained in the action'
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requirements. Technical Specification 3.7.1.2.a requires that in Mode 3 two
motor-driven auxiliary feedwater pumps be operable. The entry into Mode 3
with both motor-driven auxiliary feedwater pumps inoperable was an apparent
violation of Technical Specification 3.0.4 (482/9316-01).
Technical Specification 3.7.1.2, Action b, states that in Modes 1-3, with two
auxiliary feedwater pumps inoperable, the reactor must be piaced in Hot
Standby (Mode 3) within 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and Hot Shutdown (Mode 4) within the following
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6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />. The reactor had been placed in Mode 3 on May 8, 1993, at 6:38 p.m.
With the handswitches for both the motor-operated auxiliary feedwater pumps in
the pull-to-lock position, the Technical Specification required the reactor to
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be placed in Mode 4 within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> following the entry'into M:de 3, or
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'6:38 a.m., May 9, 1993. The failure to take the action required by Technical Specification 3.7.1.2, Action b, with two auxiliary feedwater pumps inoperable
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was an apparent violation (482/9316-02).
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2.2
Inadeauate Performance of Licensed Activities
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2.2.1
Failure to Follow Procedures
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The inspectors conducted a review of actions performed during the shift
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briefings and turnovers, in addition to interviewing the control room-
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personnel, in order to determine the causes for the unauthorized mode change
from Mode 4 to Mode 3.
Procedure GEN 00-002, Revision 25, " Cold Shutdown to Hot Standby," was the
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governing procedure that provided direction to the operators during the mode
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change evolution.
Step 5.31 of Procedure GEN 00-002 directed operators to
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continue with the mode change provided that the required portions of
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Attachment GEN 00-002-1B, " Mode 4 to Mode 3 Checklist," were completed. The
inspectors determined that Attachment GEN 00-002-1B, which provided specific
instructions to place the motor-driven auxiliary feedwater pump handswitches
in the normal position, was not completed; however, Step 5.31 of GEN 00-002
indicating completion of Attachment GEN 00-002-1B had been initialed.
The
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failure to perform Attachment GEN 00-002-1B was an apparent violation of
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Technical Specification 6.8.1.a'(482/9316-03).
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The inspectors determined, through interviews conducted with shift operators,
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that Step 5.31 of Procedure GEN 00-002 had been incorrectly initialed as
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complete.
A surveillance checklist titled, " Mode' Change Checklist Mode 4 -to
Mode 3," which had been completed earlier, had been confused with the
similarly titled Attachment GEN 00-002-18. The operators had worked
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extensively on the surveillance checklist throughout the day and mistakenly
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concluded that they had completed the correct checklist.
Interviews with shift operators indicated that they felt real or imagined
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pressure tc meet a schedule goal and enter Mode 3 before the end of the day
shift. This schedule pressure caused operators to rush the preparations for
Mode 3 entry ad to perform less thorough than desired reviews of plant
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conditions, associated documentation, and open items prior to making the mode
change.
The rushed reviews contributed to the failure to complete the mode
change checklist. A management inquiry to the shift supervisor about whether
the mode change would be accomplished prior to shift turnover may have
resulted in the shift supervisor establishing a goal of entering Mode 3 before-
the end of his shift.
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2.2.2
Inattention to Detail
Procedure GEN 00-002 made no provisions for placing the motor-driven auxiliary
feedwater pump handswitches in the pull-to-lock position.
Based on interviews
with licensed operators, the inspectors determined that it was common practice
for the handswitches to be placed in the pull-to-lock position during outage
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periods, in order to preclude automatic starts resulting from inadvertent
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engineered safety feature actuation signals.
Since the handswitches remained
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in pull-to-lock throughout most of the refueling outage (Modes 4-6), the
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operators became inattentive regarding the status of the handswitches during
the shifts and during shift turnovers.
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Step 7.6 of Procedure ADM 02-010, Revision 18, " Shift Relief and Turnover,"
requires that the oncoming and off-going reactor operators and supervising
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operators walk down the control boards to verify checklist items and to
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discuss the status of safety-related systems, inoperable equipment and
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limiting conditions for operation, and the reasons for annunciator alarms.
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Step 7.7 of Procedure ADM 02-010 requires the shift supervisor to walk down-
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the control boards after assuming the shift.
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From the review of-this event,~the inspectors determined that there were
multiple opportunities during two shift turnovers to identify and take action
on the improper position of the handswitches which had rendered the motor-
driven auxiliary feedwater pumps inoperable. The inspectors considered the
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control board walkdowns during shift turnover by operators and supervisors to
have been inadequately performed because two shifts failed to identify the
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improper position of the handswitches. The inadequate performance of
Procedure ADM 02-010 was an apparent violation of Technical
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Specification 6.8.1.a (482/9316-04).
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Step 4.4 of Procedure ADM 02-040, Revision 9, "Conductlof.On Duty Operations
Personnel," requires that operators ' tour their respective assigned areas to
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maintain cognizance of plant equipment status. The procedure also requires-
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that a control board walkdown be performed to- ensure a complete and accurate
turnover of equipment status and problem areas. Because the operators failed
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to recognize the handswitches in the pull-to-lock position following control
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board walkdowns, they were not cognizant of the status of plant equipment.
Inadequate performance of Procedure ADM 02-040 was an apparent violation of
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Technical Specification 6.8.1 (482/9316-05).
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2.2.3
Use of the Equipment Out-of-Service Log
The equipment out-of-service log was not utilized as a method for tracking
safety-related equipment declared inoperable. The motor-driven auxiliary
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feedwater pumps, which were inoperable prior to and after entering Mode 3,
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should have been included in Procedure ADM 02-105, Revision 8, " Equipment Out
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of Service Log," as stated in Step 1.4.1.
The intended purposelof the-log'was
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to aid the operators in tracking the status of inoperable' equipment required
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to be operable by Technical Specifications. Step 4.1.2 required that
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Technical Specification items be included in the log regardless of the plant
mode. The operators' failure to utilize the equipment out-of-service log as a-
tool for tracking inoperable equipment was an apparent violation of Technical Specification 6.8.1 (482/9316-06).
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3 LICENSEE'S CORRECTIVE ACTIONS
Immediate corrective action taken by the licensee consisted of placing the-
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handswitches in the normal position following the discovery of the improper
switch alignment.
Reportability Evaluation Request 93-030 and Performance
Improvement Request 93-0429 were subsequently initiated to provide further
' investigation
Interoffice correspondence dated May 11, 1993, was written by
the operat'.ns mai. qer addressing the thoroughness of shift turnovers, the
requiremerr.s for being aware of the status of safety-related equipment, the
prioriti'.ing of problems and concerns regarding safety-related equipment, and
ensuring that evolutions were not hurried.
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The licensee developed further proposed corrective actions which included the
following:
Developing a checklist to identify Technical Specification requirements
for safety-related equipment when entering each mode. GEN 00-002 will
be revised to initiate a crew brief addressing Technical Specification
requirements prior to mode changes;
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Reviewing all required.open items and documentation prior to a mode
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change. The review will be conducted by the operations manager or his
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designee;
Incorporating improved outage planning to permit operations to complete
required tasks prior to mode changes;
Moving specific steps within the checklist to the body of the procedure
in order to streamline procedures;
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Removing ambiguities between the surveillance checklist and the heatup
procedure checklist by changing a title;
Considering not rendering safety-related equipment inoperable by placing
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the handswitches in the pull-to-lock position, unless directed by
procedures; and
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Minimizing control room activity and distractions during shift
turnovers.
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ATTACHMENT
1 PERSONS CONTACTED
1.1
Licensee Personnel
M. E. Dingler, Nuclear Plant Engineering Support Manager
W. M. Lindsay, Quality Assurance Manager
0. L. Maynard, Vice President of Plant Operations
K. J. Moles, Regulatory Services Manager
J. A. Tarr, Regulatory Compliance Engineer
J. D. Weeks, Operations Manager
S. G. Wideman, Licensing Supervisor
B. D. Withers, President and CEO
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NRC Personnel
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S. J. Campbell, Resident Inspector
G. A. Pick, Senior Resident Inspector
A. T. Howell, Deputy Director, Division of Reactor Safety
The personnel listed above attended the exit meeting.
In addition to these
personnel, the inspectors contacted other personnel during this inspection
period.
2 EXIT MEETING
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An exit meeting was conducted on May 13, 1993. During this meeting, the
inspectors reviewed the scope and findings of the report. The licensee did
not identify as proprietary any information provided to, or reviewed by, the
inspectors.
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ENCLOSURE 2.
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30762
Federal Register / Vol. 57. No.133 / Friday. July 10.1982 /. Notices
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a naaweewe- Sea,; . ........rts 9.. . u
Secretary of the Pnmmtaminn !
,
Nuclear Reg.datory e- -"--~'
T
T
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m
Washmgton.DC 20555. ATIN:
Conferences;Poucy Statement
ung
Brad
Hand deliver comments to:One White
Anency: Nuclear Regulatory
Flint North.11555 Rockvdle Pike.
Comm2asion.
Rockville MD between 7:45 a.m. to 4:15
ACT10cc Policy statement.
p.m Federalworkdays.
Copies of ccmments may be erammed
sueensAny:ne Nuclear Regulatory
at the NRC Public Document Room. 21:'O
Commission (NRC) is issumg this policy
L Street. NW. (Lower Level).
statement on the implementation of a
Washmgton. DC
two-year trial program to allow selected
FOR N NTION COctTACT:
enforcement conferences to be open to
lames Lieberman. Director. Office of
attendance by all members of the
Enforcement. U.S. Nuclear Regulatory
general public. This policy statement
Comm2suon. Washmgton.DC 20555
descnbes the two-year tnal program
(301-504-2741).
and informs the public of how to get
informanon on upcoming open
suressameNTARY fMPORIsaTION:
enforcement conferences.
Back M
pates:This trial program is effective on
July 10.1992, while comments on the
b NRC's m #p
g
g
program are being received. Submit.
Seenon V of the latest revision to the
mmments on or before the completion
of the trial program scheduled for July
.[. *"'ral Statement of Pohey and
11.1992. Comments received after this
""*, ". for Enforcement Actions,,
data wiH be considered ifit is practical
(Enforcement Policy)10 Cm part 2.
to do so, but the nmm-ion is able to
appendix C that was published on
e
assure consideration only for comments
Febmary 18.1992 (57 FM).The
received on or before this date.
Enforcement Policy states that.
" enforcement conferences will not
normally be open to the public."
However the Commis, ion has decided
to implement a trialprt. gram to
determme whether to mamtain the
current pohey with regard to
enforcement conferences or to adopt a
new policy that would cllow most
enforcement conferences to be open to
attendance by all members of the public.
Policy Statement
Position
- Ihe NRC is implementmg a two-year
trial program to allow pubhc
observanon of selected enforcement
conferences.De NRC will momtor the
program and determme whether to
establish a permanent policy for
conduenng open enforament
conferences based on an assessment of
the followmg cnteria:
(1) Whether the fact that the
conference was openimpacted the
NRC's ability to mndnct a mesmnefid
conference and/or implement the NRC's
enforcement program:
(2) Whether the open conference
impacted the licensee's participation in
the conference:
(3) Whether the NRC expended a
sigmficant amount of resources in
makmg the conference public; and
(4)The extent of publicinterest in
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Federal Reprter / Vol. 57, No.133 / Friday. July 10, 1992 / Notices
30783
L Critaria for Selocams Open
three categones of t*- wdl be
subpect to persemunni sam ===mm. that
Edoecensmat Confesennes
0-.-sr.ial operstmg reactors.
signs, bammers, poossus. etc.not larger
.
Enforcement conferen
at be
hospatcla and other he-n=an which
than 18" be perantled, and that
en=
Pat g
g
mllermnat of the r mamma types of
disruptive perooms may be reinoved.
ucemees.
Each ,eg
a d s . d _ _ io
acuan beeg comtemplated- '
(1) Would be taken agamst an
IL Au-~
-3Open Em,-m
A.
condmet the edarn=====8 h
-. M;_.i
Individual.or af the action. though not
Conferencee
p
g __
taken agamet an mdividual. turns on
p
p r_=
whether an indmdt.a1 has """""
As soon as itis determmed that an
mil cartunee tobe a aseenag between
Wm""d*""
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enforcement conferenca mil be cpen to the NRC and the brum==e. While the
(2) Involves =Wmt perenn'i
public observation. the NRC wdl orally
drcement condecenceis open for
nody the hcensee that b edorrw ent public observanon.it la not open for
failures where the NRC has requested
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that the individualis)involven be
conference will be open to public
pubhc pamczpanos.
observation as part of the agency's trial
persons attendmg open c ;.I - ;nt
present at the conference-
(3)Is based an the findmgs of an NRC program and send the licensee a copy of confereaces are rennaded that (1) the
this Federal Reipster notice that outunes apparent violationediscussed at open
Office of Invesaga nons (OI) report or
the p Ucensees mil be asked to
(4) Invosves safeguards info =nanon.
d-Me mWe
estimate the munber of parue: pants it
funbar review and may be suMeet to
Pnyscy Actinformanon.or other .
,
wdl brms to the enforcement confennee
informanen which could be constnerea
change pnar to any resulting
so that the NRC can sclodule an
enforcement acnon and (2)the
Propnetary,
appropnately sized conference room.
Enforcement conferences involving
statements of views or expr==amna of
medical misadmmistrations or
ne NRC wul also nonfy appropnate
opinion made by NRC employees at
State liaison officers that an
open enforcement conferences or the
overexposures wd! be open assummg
edorcement coderence has been
the conference can be conducted
WM w Med to
scheduled and that it is opan to pubhc
mthout disclonmg the exposed
observanon.
represent final determmations or behefs.
The NRCintends to announce open
In addition to pnmding comments on
individual a name. In addition.
enforcement conterences to the punhc
de agency's tnal pmgram m accordance
enforcement conferences mil not be
open to the public rf the conference will normally at least to workmg days m
with the pdance in this notice, persons
be conducted by telephone or the
advance of the enforcement conference
attending open enforc= ment =f-aane's
conference wdl be conducted at a
wdlbe
'ded
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thmugh the followmg m-
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submit
en ccEYan"onymously
relauvely smalllicensee s facdity.
(1) Notices posted in the Pubhc
"
Finally. with the approvalof the
Document Rue
g g g g g n ,,, m e,
Execunve Director for Operstions.
(2) Toti-free telephone ma===nes: sad mil subsequently be forwarded to the
enforcement conferences mll not be
(3) Toll-free electrcmc bulletm board
Director of the Office of Enforcement for
open to the pubbein special cases
review and consideration.
messages.
where good cause has been shown after
Pendmg establishment of the toll-free
Dated at Rockvska.MD. this 7th day eOuly
balancmg the benefit of public
messaee systems. the public may call
N-
observanon aenmar the potennalimpact (301) 492-4732 to obtam a awuug of
For the Nuclear Regn.saary &=====
on the agency's enforcement scuca m a upcommg open enfomement
Samuel 5. r Mtk,
parucular case.
conferences. The NRC mil ierne another Secmoryofde Co-~
ne NRC wdl stnve to conduct open
Federal Registernonce after be toll-free (FR Doc. 92-18223 Filed T-9-92; 8A5 a.m.)
enforcement conferences dunna the
messaee erstems are established.
.
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two. year snal program m accorcance
To assist the NRCin makiug
with tha followmg three goals:
appmpnate arrangements to 6upport
(1) Approxunately 25 percent of all
public observaton of enforcement
eligible eniorcement coderences
conferences. indmduals mterested m
concucted by the NRC wdl be open for
attenomg a parucular enforcement
public observanon:
conference should nonfy the mamdur)
(2) At least one open enforcement
ident:fied1n the meetmg notice
conference wdl be cwed in each of announcmg the open enforcement
the remonal offices: and
confennce no later than five bus.ncas
(3) Open enforcement conferences
days pnor to the enforcement
i
wdl te conoucted with a vanety of the
conference,
i
o av
po nal bias in the
III. Conduct of Open Enforcement
selecnon process and to attempt to meet Confemices
the three sosis stated above.every
In accordance with current prectice.
fourm ehriole enforcement conference
enforcement conferences wdl coutmue
involyms one of three categones of
to nonnaily be held at the NRC renonal
l
r
licensees mil normally be open to the
offices. Members of the public wdl be
public donna the tnal program,
allowed access to the NRC respocal
I
However, m cases where there is an
offices to attend open enserr+mme
ongoms adrudicatory pmMug mth
conferences m accordance wrth the
one or more mtervenera, enforcement
"Stancard Operanng 6.a f or
conferences mvotymg tasues related to
L. Ag Secomy Strpport forNRC
the subiect matter of the ongnmo
Heannas And Meetmas" published
adiudicanon msy also be opened.For
Novemoer 1.1971 (56 FR 58251L Re.se
the purposes of thia analprogram, the
proceoures prm,de that visitors may be
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