ML20045C440
| ML20045C440 | |
| Person / Time | |
|---|---|
| Site: | Shoreham File:Long Island Lighting Company icon.png |
| Issue date: | 06/15/1993 |
| From: | Carrasco J, Gray E, Nimitz R, Pasciak W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20045C428 | List: |
| References | |
| 50-322-93-02-EC, 50-322-93-2-EC, NUDOCS 9306230119 | |
| Download: ML20045C440 (29) | |
See also: IR 05000322/1993002
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U.S. NUCLEAR REGULATORY COMMISSION
REGION I
Enforcement Conference Report No. 50-322/93-02
Docket No.
50-322
Licensee No. NPF-82
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Licensee:
Lone Island Power Authority
Post Office Box 284
North County Road
Wading River. N.Y.11792
Facility Name:
Shoreham Nuclear Power Station
Conference At:
Kine of Pmssia. Pennsylvania
Conference Conducted:
June 9.1993
Prepared By: 0
W
M
b ' I4 -~ D
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J.E. Carrasco, Reactor Engineer,
date
Materials and Processes Section, EB,DRS
RLMu~ct
c, 14N3
R.L. Nimitz, Sr. Health 4hysics,
date
Facilities Radiation Protection Section
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Approved by:
@D
E
b 'I9 O 3
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E. H. Gray, Chief, Materials
date
EB,DRS
0-
6-9 c~-
C - IS-U
W5J. Pasci , Chief
date
Facilities
diation Protection Section
,
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Conference Summary: The Enforcement Conference was held to discuss the findings of NRC
Inspection No. 50-322/93-02, which was conducted in response to an April 29,1993, event
where a 10,000 pound Refueling Jib Crane (RJC) fell from the polar crane auxiliary hook onto
the refueling floor. The following additioral matters were discussed'during the enforcement
conference: the event, its safety significance, and the facts associated with the event; the
appropriateness of the apparent violations relative to criteria outlined in the NRC's Enforcement
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Policy (10 CFR Part 2, Appendix C); their safety significance; the possible basis for exercising
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.9306230119 930616
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ADOCK 05000322.
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discretion in accordance with Section VII of the Enforcement Policy; short and long term
corrective actions; and factors that NRC considers when it detennines the amount of a civil
penalty that may be assessed in accordance with Section VI.B.2 of the Enforcement Policy. In
addition, a summary of the licensee's root cause analysis of the event was discussed. The
conference was attended by representatives of Long Island Power Authority (IJPA) and
members of NRC management and staff. The conference lasted about four hours.
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DETAILS
1.0
Licensee and NRC Personnel in Attendance
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Attachment 1 to this conference repon identifies licensee and NRC personnel in
attendance.
2.0
Pumose of Conference
The pmpose of the Enforcement Conference was to discuss the safety significance and
licensee assessment of an April 29, 1993, event where a 10,000 pound Refueling Jib
Crane (RJC) fell fmm the polar crane auxiliary hook onto the refueling floor.
Also discussed were the apparent violations identified in NRC Inspection No. 50-322/93-
02 as well as the licensee's evaluations of the apparent violations, the appropriateness
of the apparent violations relative to criteria outlined in the NRC's Enforcement Policy
(10 CFR Pan 2, Appendix C), their safety significance, the possible basis for exercising
discretion in accordance with Section VII of the Enforcement Policy, shon and long term
corrective actions, and factors that NRC considers when it determines the amount of a
civil penalty that may be assessed in accordance with Section VI.B.2 of the Enforcement
Policy. In addition, a summary of the licensee's root cause analysis of the event was
discussed.
3.0
NRC Comments
NRC management opened the conference by identifying the purpose of the conference.
4.0
Licensee Comments
The licensee's representatives discussed the following topics:
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event description
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LIPA root cause evaluation
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root cause analysis findings, including primary root causes and contributing root
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causes
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corrective actio'is
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LIPA review of NRC Inspection Report No. 50-322/93-02
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LIPA evaluation of the event against the NRC Enfon:ement Policy
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Corrective action status
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The licensee indicated that the inspection report was generally factual. However, contrary
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to the comment in the inspection report that indicated that management control and
oversight were not evident during the transport of the RJC, the licensee indicated that at
the time of the event a supervisor and member of management (i.e., Area Coordinator)
were present.
The licensee also provided additional details regarding apparent violation No. 3 contained
in NRC Inspection Report 50-322/93-02. In addition to other information provided, the
licensee's representatives indicated that there were 83 surveillances of heavy load
activities on the refueling floor, including 22 surveillances of such activities in or around
the spent fuel pool; a Station Review Committee (SRC) procedure was being used to
provide guidance for the lifting activities; and that there was an absence of any previous
problems with moving this cane known to management. The licensee's representatives
indicated that the information known about heavy lifting activities gave reasonable
assurance to the Quality Assumnce group that the activity could be accomplished in a
satisfactory manner.
Attachment 2 of this report is the hand-out provided by the licensee at the enforcement
conference.
The licensee also provided, at the conference, a copy of the two volume root cause-
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analysis, dated June 8,1993 (LSNRC-2080). The document included, among other
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information, data collection, root cause determination techniques, and root cause analysis
results. The document was placed in the NRC Public Document Room and is available
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for public review. Attachment 3 of this report is a copy of the Root Cause Analysis
taken from the June 8,1993, document. Attachment 4 of this report is a copy of the
Actions to Prevent Recurrence taken from the same document.
5.0
Concluding Remarks
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NRC management acknowledged the information provided by the licensee and indicated
that the apparent violations were subject to change and that the licensee would be
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informed of decisions regarding any enforcement actions in separate conespondence.
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Attachment 1
List of Attendees at June 9.1993. Enforcement Conference
Lone Island Power Authority
C. Giacomazzo, President, Shoreham Decommissioning Project
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L. Hill, Resident Manager
S. Schoenwiesner, Licensing / Regulatory Compliance Department Manager
R. Patch, Nuclear Quality Assurance Department Manger
R. Bonnifield, General Counsel
,
Nuclear Regulatory Commission
S. Shankmm, Deputy Director, Division of Radiation Safety and Safeguards
E. Imbro, Deputy Director, Division of Reactor Safety
K. Smith, Regicnal Counsel
W. Pasciak, Chief, Facilities Radiation Safety Section
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J. Carmsco, Reactor Engineer
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R. Nimitz, Senior Radiation Specialist
C. Pittiglio, NRC Project Manager
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N. Wagner, Reactor Systems Engineer
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ATTACliMENT 2
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LIPA/NRC ENFORCEMENT CONFERENCE
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June 9,1993
P
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Refueling Jib Crane incident of April 29,1993
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-(NRC Inspection No. 50-322/93-02)
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INTRODUCTION
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PURPOSE OF MEETING
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RESPOND TO NRC INSPECTION FINDINGS DOCUMENTED IN
REPORT NO. 50-322/93-02.
PROPOSED AGENDA
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EVENT DESCRIPTION
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LIPA ROOT CAUSE ANALYSIS
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ROOT CAUSE ANALYSIS FINDINGS
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CORRECTIVE ACTIONS
LIPA REVIEW OF INSPECTION REPORT NO. 50-322/93-02
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LIPA
EVALUATION
OF
INCIDENT
AGAINST
NRC
CORRECTIVE ACTION STATUS
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EVENT DESCRIPTION
DATE AND TIME OF INCIDENT
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APRIL 29,1993,11:55 AM
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REFUELING JIB CRANE (RJC) INITIALLY LOCATED IN NORMAL
OPERATING POSITION ALONG SOUTHWEST CORNER OF FUEL
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POOL.
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RJC SUPPLIED AS A TRANSPORTABLE CRANE WITH SIX
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POSSIBLE LOCATIONS OR SOCKETS LOCATED ON REFUEL
FLOOR.
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LIPA PLAN WAS TO TEMPORARILY RELOCATE THE RJC TO
AN ALTERNATE SOCKET DISTANT FROM THE FUEL POOL IN
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ORDER TO PERFORM RJC MAINTENANCE AND REPAIR
ACTIVITIES.
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RJC RIGGING AND HANDLING ADDRESSED BY PROCEDURE
SP35X001.01 (HANDLING OF HEAVY LOADS WITH REACTOR
BUILDING POLAR CRANE).
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RJC RIGGING AND HANDLING WAS FIRST ADDED TO
SP35X001.01 DURING 1984.
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SP35X001.01 REVISED DURING APRIL,1993 TO REFLECT
ADDITIONAL RIGGING AND HANDLING CONTROLS.
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RJC TO BE LIFTED USING AN EXISTING MOVEABLE LUG
FURNISHED
BY
THE
RJC
SUPPLIER,
SPECIFIED-
IN
SP35X001.01.
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LIFTING LUG RELOCATED AWAY FROM RJC CENTER OF
GRAVITY BY WORK CREW, PRIOR TO PERFORMING LIFT, TO
PROVIDE FOR ADDITIONAL AUX HOIST CLEARANCE. (LUG
RELOCATION NOT IN SP35X001.01)-
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PLASMA ARC POWER SUPPLY SUSPENDED FROM RJC BY
WORK CREW TO ENHANCE ' CONTROL OF LOAD, l.E.
ESTABLISH CENTER OF GRAVITY BENEATH RELOCATED
LUG. (ALSO NOT IN SP35X001.01)
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RJC LIFTED (ALONG WITH PLASMA ARC MACHINE) AND
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TRANSPORTED
ALONG
SAFE
LOAD
PATH
SPECIFIED
IN
SP35X001.01 TO DESIGNATED CRANE SOCKET.
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PHYSICAL INTERFERENCE PREVENTED USE OF DESIGNATED
SOCKET.
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WORK CREW DECISION TO LOCATE RJC.TO ALTERNATE
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LOCATION TO REORIENT' BOOM' AZIMUTH TO ELIMINATE
INTERFERENCE.
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RJC LIFT LUG FAILED AT THIS ALTERNATE LOCATION BEFORE
-ENERGlZING THE RJC TO REORIENT THE BOOM.
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RJC FELL IN THE SOUTHWEST DIRECTION (AWAY FROM FUEL
POOL) IMMEDIATELY ADJACENT TO THE REFUEL FLOOR MAIN
HATCHWAY.
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RJC MAST FELL, STRIKING THE PLUG COVERING AN EMPTY
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NEW. FUEL STORAGE VAULT PLUG.
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PLASMA ARC POWER SUPPLY SWUNG IN DIRECTION OF
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FALL, STRIKING AND TRAPPING A MEMBER OF THE WORK
CREW (RECEIVED MINOR BRUISES AND WAS ABLE TO
WALK FROM THE AREA).
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IMMEDIATE LIPA RESPONSE
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PROMPT NOTIFICATION OF NRC REGION i VIA TELEPHONE
CONVERSATION.
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IMMEDIATE HALT OF ADDITIONAL REFUELING FLOOR
HEAVY
LOAD
RIGGING
AND
HANDLING
PENDING
IMPLEMENTATION OF INTERIM CORRECTIVE ACTIONS.
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SECURED RJC IN PLACE.
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INTERIM CORRECTIVE ACTIONS IMPLEMENTED FOR ALL REFUEL
FLOOR HEAVY LOAD LIFTS, PENDING COMPLETION OF ROOT
CAUSE ANALYSIS.
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FORMAL PRE-JOB BRIEFINGS.
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NOA, NED AND RESPONSIBLE SECTION HEAD PRESENT FOR
EACH LIFT.
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NED DEVELOPMENT AND/OR REVIEW AND APPROVAL OF
HEAVY LOAD RIGGING CONFIGURATIONS.
IMMEDIATE
PLANS
TO
CONDUCT
FOCUS
MEETINGS
TO
ADDRESS PROCEDURE COMPLIANCE AWARENESS.
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PROMPT NOTIFICATION (MAY 5,1993) OF OTHER UTILITIES VIA
NUCLEAR NETWORK.
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PROMPT NOTIFICATION OF IRP AND DISCUSSION OF RJC
INCIDENT WITH IRP MEMBER AT SHOREHAM SITE.
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LIPA COURSE OF ACTION ALTERED TO REFLECT REQUIREMENTS
DIRECTED IN NRC CONFIRMATORY ACTION LETTER NO.1-93-
006.
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ROOT CAUSE ANALYSIS
PROMPT PREPARATION (APRIL 30) OF A WRITTEN PLAN TO
THOROUGHLY EVALUATE THE RJC INCIDENT.
NQA REQUESTED TO COORDINATE THE ROOT CAUSE ANALYSIS
(RCA) IN ACCORDANCE WITH THE SHOREHAM ROOT CAUSE
DETERMINATION AND CORRECTIVE ACTION GUIDE.
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THE RCA PERFORMED FOR THIS INCIDENT RELIED ON A
NUMBER
OF
DATA
GATHERING
AND
EVALUATION
TECHNIQUES.
EXTENSIVE STATION INVOLVEMENT IN THE RCA PROCESS
THROUGHOUT ALL LEVELS OF STATION MANAGEMENT AND
PHYSICAL WORKERS.
IN
EXCESS
OF
2,000
JOB
HOURS
EXPENDED
IN
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PERFORMING THE RCA.
RCA COMPLETED AND SUBMITTED TO THE NRC ON JUNE 9,
1993 AS DIRECTED BY CONFIRMATORY ACTION LETTER.
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ROOT CAUSE ANALYSIS FINDINGS
- PRIMARY ROOT CAUSE(S) -
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DESIGN / FABRICATION INADEQUACIES - THE PRINCIPAL CAUSE
FOR THE FAILURE RELATES TO INADEQUACIES ASSOCIATED
WITH THE DESIGN OF THE LIFTING EYE ASSEMBLY.
THE
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ASSEMBLY'S
EXTREME
SENSITIVITY
TO
FABRICATION
TOLERANCES AND A LACK OF DETAILED
INSTALLATION
INSTRUCTIONS
CONTRIBUTED
TO THE ASSEMBLY
BEING
UNFORGIVING TO INSTALLATION ALIGNMENT.
INADEQUATE OR NO NUREG-0612 (HEAVY LOADS) EVALUATION-
AS IDENTIFIED IN THE FAILURE ANALYSIS REPORT, THE LIFTING
EYE ASSEMBLY DOES NOT HAVE A REDUNDANT OR DUAL LIFT
POINT SYSTEM, SAFETY FACTORS FOR . STRESSES DUE TO
COMBINED STATIC AND DYNAMIC LOADS AT ANY POINT IN THE
ASSEMBLY SHALL NOT BE LESS THAN 10 AGAINST ULTIMATE
TENSILE STRENGTHS OF THE MATERIAL.
SAFETY FACTORS
FOUND FROM THE STRUCTURAL EVALUATION FOR THE LIFTING
EYE ASSEMBLY WERE LESS THAN 10.
AN ADEQUATE EVALUATION OF THE LIFTING EYE ASSEMBLY
FOR
COMPLIANCE WOULD
HAVE
REQUIRED
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REDESIGN OF THE LIFTING EYE ASSEMBLY THUS PREVENTING
THIS INCIDENT.
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ROOT CAUSE ANALYSIS FINDINGS
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- CONTRIBUTING CAUSES -
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FAILURE TO FOLLOW PROCEDURES - THERE WERE SEVERAL
EXAMPLES IDENTIFIED WHERE ACTIVITIES WERE PERFORMED
BEYOND THE AUTHORIZATION OF STATION PROCEDURES. THE
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WORK ACTIVITY COULD NOT BE PERFORMED AS DESCRIBED IN
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THE WORK INSTRUCTIONS.
THE STATIONS WORK CONTROL
FUNDAMENTALS AS DESCRIBED IN STATION PROCEDURES,
GENERAL EMPLOYEE TRAINING AND IN SPECIALWORK CONTROL
FUNDAMENTAL TRAINING REQUIRED THAT THE WORK BE
STOPPED AND ADDITIONAL PROCEDURAL GUIDANCEOBTAINED.
ALTERING THE LIFT LUG LOCATION OR INSTALLATION OF THE
940#
COUNTER
WEIGHT
WOULD
HAVE
REQUIRED
AN
ENGINEERING
EVALUATION
OF
THE
LIFTING
EYE
FOR
ADEQUACY.
INADEQUATE WORK PLANNING - THE NEED FOR MOVING THE
LIFTING EYE ASSEMBLY WAS NOT IDENTIFIED DURING FIELD
WALK DOWNS AND NOT TRANSMITTED TO THE PROCEDURE
WRITER.
THIS
PREVENTED
ANY
PREPLANNING
AND
PROCEDURAL DIRECTION FOR HOW TO REESTABLISH THE
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BALANCE FOR THIS LIFT.
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POOR SUPERVISORY JUDGEMENT - FAILURE TO STOP THE WORK
WHEN WORK COULD NOT BE PERFORMED WITHIN THE BOUNDS
OF THE PROCEDURE. PLANS TO ENERGlZE THE JIB CRANE AND
ROTATE THE BASE 90
WHILE CRANE WAS STILL SUSPENDED
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ON THE HOOK.
MOVING THE CRANE IN AN UNANALYZED
CONDITION (940# COUNTER WElGHT ATTACHED TO THE
TROLLEY).
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INADEQUATE PROCEDURE - THE PROCEDURE (SPCN 93XO200)
THAT WAS APPROVED BY THE SRC AND UTILIZED TO START
THE MOVEMENT OF THE JIB CRANE WAS NOT ADEQUATE TO
MOVE THE CRANE TO IT'S PREDETERMINED LOCATION. THIS
WOULD NOT HAVE CONTRIBUTED TO THIS INCIDENT IF WORK
HAD BEEN STOPPED BY THE RESPONSIBLE MANAGEMENT
PERSONNEL AND A PROCEDURE CHANGE INITIATED.
DURING
THE WORK PLANNING STAGE THE NEED TO MOVE THE LIFTING
EYE WAS NOT IDENTIFIED, THUS THE PROCEDURE GUIDANCE
FOR HOW TO ADEQUATELY BALANCE THE LOAD WAS NOT
PROVIDED.
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ROOT CAUSE ANALYSIS FINDINGS
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- PROGRAM WEAKNESSES -
LACK OF PROCEDURAL GUIDANCE FOR IMPLEMENTING CRITICAL
LOAD DETERMINATION - STATION PROCEDURE 35X001.01 REV.
8, PARA. 4.3, IDENTIFIES THE NEED TO TAKE " APPROPRIATE
COMPENSATORY MEASURES" WHEN HANDLING A CRITICAL
LOAD THAT HAS THE POTENTIAL OF BINDING OR HANGING UP.
CURRENTLY
THERE
IS
NO
PROCEDURAL
GUIDANCE
DIRECTION TO IDENTIFY WHO IS RESPONSIBLE AND WHAT IS
REQUIRED FOR " APPROPRIATE COMPENSATORY MEASURES."
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INADEQUATE PRE-JOB BRIEFINGS - THE EFFECTIVENESS OF THE
PRE-JOB BRIEFING WAS LACKING.
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CORRECTIVE ACTIONS
- PRIMARY ROOT CAUSE(S) -
CORRECTION
OF
DESIGN / FABRICATION
INADEQUACIES
ASSOCIATED WITH JIB CRANE LIFTING ATTACHMENTS.
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ALL JIB CRANES AT SHOREHAM WILL BE EXAMINED TO
DETERMINE IF THEY ARE EQUIPPED WITH LIFT LUGS
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SIMILAR TO THE RJC.
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ANY JIB CRANES EQUIPPED WITH THIS TYPE OF LIFTING
ATTACHMENT SHALL HAVE THESE LUGS REMOVED.
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ANY JIB CRANES WHICH ARE TO BE LIFTED ACROSS THE
REFUEL FLOOR SHALL BE MOVED WITH NUREG-0612
QUALIFIED RIGGING OR A NEW LIFTING ATTACHMENT
WHICH MEETS NUREG-0612 CRITERIA.
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ASSURANCE OF ADEQUATE NUREG-0612 COMPLIANCE FOR
FUTURE HEAVY LOAD LIFTS.
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RECONFIRM
SAFE
LOAD
PATHS
AND
COMPLIANCE FOR ALL HEAVY LOADS TO BE LIFTE.'
ACROSS THE REFUEL FLOOR INVOLVING MOVEMENT OF
ORIGINALLY INSTALLED PLANT EQUIPMENT (1. E.
PRE-
EXISTING EQUIPMENT INCLUDED IN SP35X001.01).
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SP35X001.01 ENHANCEMENTS TO MORE CLEARLY DEFINE
ACTIVITIES AND CONTROLS TO ENSURE NUREG-0612
COMPLIANCE FOR ALL HEAVY LOAD LIFTS ACROSS THE
REFUEL FLOOR INVOLVING EQUIPMENT NOT PREVIOUSLY
CONSIDERED IN PAST NUREG-0612 REVIEWS (E.G.: NEW-
EQUIPMENT
USED
IN
DECOMMISSIONING
FUEL
DISPOSITION ACTIVITIES).
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PROGRAM ENHANCEMENTS TO MORE CLEARLY DEFINE
NED NUREG-0612 RESPONSIBILITIES.
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CORRECTIVE ACTIONS
- CONTRIBUTING CAUSES -
MEASURES TO
ENSURE
PROCEDURE AND
OTHER WORK
CONTROL ADHERENCE.
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APPROPRIATE DISCIPLINARY ACTIONS HAVE BEEN TAKEN
AGAINST SUPERVISORY PERSONNEL RESPONSIBLE FOR
PROCEDURE DEVIATIONS.
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REFUEL FLOOR SUPERVISORY PERSONNEL (REFUEL FLOOR
COORDINATORS AND SENIOR CERTIFIED FUEL HANDLING
OPERATORS) TO RECEIVE SPECIAL INDOCTRINATION FROM
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RESIDENT MANAGER.
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FOCUS
MEETINGS
AT
ALL
LEVELS
OF
SHOREHAM
MANAGEMENT,
AND
INCLUDING
ENTIRE
SHOREHAM
PROJECT TEAM TO DIRECT AND EMPHASIZE PROCEDURE
AND WORK CONTROL COMPLIANCE.
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INCORPORATION OF RJC LESSONS LEARNED INTO GET AND
OTHER
APPLICABLE
TRAINING
AND
QUAllFICATION
PROGRAMS.
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DEVELOPMENT OF FEEDBACK PLAN TO ENSURE THAT
CORRECTIVE ACTIONS ARE MADE AND SUSTAINED ON A
LONG TERM / CONTINUOUS BASIS.
IMPROVEMENTS
IN
HEAVY
LOAD
LIFT WORK
PLANNING
PRACTICES.
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SP35X001.01 TO REQUIRE FIELD WALKDOWNS OF HEAVY
LOAD MOVEMENTS AS PART OF THE PLANNING PROCESS;
WALKDOWNS
ARE
TO
INCLUDE
A
COGNIZANT
REPRESENTATIVE OF THE NED.
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FORMAL PRE-JOB BRIEFINGS WILL BE REQUIRED FOR ALL
REFUEL FLOOR HEAVY LOAD LIFTS.
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CLARIFICATION
OF
REFUEL
FLOOR
FIELD
SUPERVISORY
RESPONSIBILITIES.
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POSITIONS OF " REFUEL FLOOR COORDINATOR" AND
" SENIOR CERTIFIED FUEL HANDLING OPERATOR" WILL BE
FORMALLY DEFINED.
SP35X001.01 WILL BE REVIEWED IN ITS ENTIRETY BASED ON
LESSONS
LEARNED
FROM
THE
RJC
INCIDENT;
SPECIAL
ATTENTION WILL BE DEVOTED TO THE CLARITY AND ADEQUACY
OF THE INSTRUCTIONS PROVIDED IN SP35X001.01.
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CORRECTIVE ACTIONS
- PROGRAM WEAKNESSES -
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CLARIFY SP35X001.01 REQUIREMENTS RELATED TO CRITICAL
LOAD DETERMINATION.
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ESTABLISH
OWNERSHIP
OF
CRITICAL
LOAD
" COMPENSATORY ACTION" TECHNICAL REVIEWS.
ENHANCE PRE-JOB BRIEFING EFFECTIVENESS.
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SCOPE OF HEAVY LOAD LIFT PRE-JOB BRIEFINGS WILL BE
FORMALLY DEFINED.
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Review of NRC Inspection Report 93-02
Apparent Violation 1
LIPA agrees that there was a design control deficiency (see
primary cause No. 1) however,LIPA believes that this deficiency
is related to the inadequacy of the original lifting eye assembly
design.
The failure to perform calculations to obtain the center
of gravity with the lifting eye assembly moved out and the
counter weight (plasma arc machine) added was caused by the
responsible individuals on the work crew failing to follow
approved station procedure. (See contributing cause No. 1)
Apparent Violation 2
LIPA agrees that procedure 35X001.01 " Handling of Heavy Loads
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with Reactor Building Polar Crane IT 31-CRN-002", was inadequate
to ensure the proper handling of the refuel jib crane once the
lifting eye was moved and the counterweight was added.
LIPA
management had not intended that these actions be taken, however,
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and did not approve these actions. (See contributing cause No.
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4). This would not have contributed to this incident if work had
been stopped by the responsible supervisory personnel and a
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procedure change initiated.
LIPA agrees that the work planning was inadequate.
The need for
moving the lifting eye assembly was not identified during field
walk downs and was not transmitted to the procedure writer.
This
prevented any preplanning and procedural direction for how to
reestablish the balance for this lift.
The adequacy of the pre-
job briefing was identified as a program weakness (See weakness
No. 2) while the absence of an effective pre-job briefing.did not
directly contribute to this incident it was apparent that an
effective pre-job briefing should have been preformed.
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Apparent violation 3
LIPA has identified that the judgement utilized by the
supervision responsible for this work activity was poor.
The
supervision failed to stop the work when it could not be
performed within the bounds of the procedure. The plan to
energize the jib crane and rotate the base 90 degrees while the
crane was still suspended on the hook was unacceptable.
The need
for additional supervision was unnecessary if the supervision
would have performed their responsibilities in accordance with
the station procedures and extensive training in work control
fundamentals.
With regard to the NQAD's oversight and involvement, the
maintenance work request for this activity was reviewed by NQAD
and based on the following a decision was made not to monitor
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this activity:
Simplicity of the rigging design
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The absence of any previous problems with
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moving this jib crane known to management
The jib crane was designed to be moved around
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six (6) different locations provided
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A written SRC approved procedure existed for
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performing the task
As a measure of the NQAD's level of oversight, LIPA respectfully
points to 83 surveillances of heavy load activities on the refuel
floor, including
twenty two (22) surveillances of heavy load
activities in or.around the spent fuel storage pool and twelve
(12) detailed inspections were performed for the various-refuel
floor cranes that were performed over the previous' fourteen
months.
The results of these surveillances provided NQAD with
reasonable assurance that this activity could be accomplished in
a satisfactory manner.
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LIPA EVALUATION OF INCIDENT
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AGAINST NRC ENFORCEMENT POLICY
CLOSEST POTENTIALLY APPLICABLE AREAS OF ACTIVITY
INCLUDE REACTOR OPERATION AND FACILITY CONSTRUCTION
NO WILLFUL VIOLATIONS INVOLVED
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SIGNIFICANCE OF DESIGN ISSUE SUGGESTS A " BORDERLINE"
SEVERITY LEVEL IV OR lli VIOLATION, CONSIDERING FUEL POOL
PROXIMITY BUT LACK OF ACTUAL IMPACT TO FUEL OR FUEL
POOL.
SIGNIFICANCE OF PROCEDURE ADEQUACY AND ADHERENCE
PROBLEMS SUGGESTS ONE OR MORE SEVERITY LEVEL IV
VIOLATIONS.
IF ANY ISSUE IS DETERMINED TO BE SEVERITY LEVEL lli, LIPA
BELIEVES THE FOLLOWING. MITIGATING FACTORS WARRANT
CONSIDERATION:
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INITIATIVE IN IDENTIFYING VIOLATION ROOT CAUSES
FOLLOWING A SELF-DISCLOSING EVENT (25%)
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PROMPT AND EXTENSIVE CORRECTIVE ACTIONS (50%)
l
LIPA BELIEVES THAT THERE ARE NO ESCALATION FACTORS
WHICH WOULD APPLY,
SPECIAL CIRCUMSTANCES MAY APPLY AS BASIS FOR EXERCISE
OF DISCRETION:
,
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PLANT IS NO LONGER OPERATING (BASE PENALTY MAY
NOT BE APPROPRIATE)
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IN EXCESS OF $250,000 EXPENDED IN RESPONSE TO THIS
INCIDENT (JIB CRANE REPAIRS, ROOT CAUSE ANALYSIS)
.
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CORRECTIVE ACTION STATUS
e
SHOREHAM PROJECT TEAM HAS INITIATED ACTIONS TO
IMPLEMENT CORRECTIVE ACTIONS DESCRIBED HEREIN.
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MANY PROBLEM AREAS WERE IDENTIFIED EARLY IN THE
RCA PROCESS ALLOWING TIMELY FORMULATION AND
IMPLEMENTATION
OF
SOME
CORRECTIVE
ACTION
ELEMENTS.
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ALL CORRECTIVE ACTIONS WITH ONE EXCEPTION TO BE TAKEN
NO LATER THAN JUNE 30,1993.
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DEVELOPMENT OF MANAGEMENT FEEDBACK PLAN TO BE
COMPLETED NO LATER THAN JULY 31,1993.
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CORRECTIVE ACTIONS TO BE INDEPENDENTLY VERIFIED USING
EXTERNAL RESOURCES.
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CORRECTIVE ACTIONS TO BE COMPREHENSIVELY REVIEWED
-
WITH THE IRP AT UPCOMING JULY 8,1993 MEETING.
e
PROCEDURE FOR CLOSURE OF CONFIRMATORY ACTION LETTER
NEEDS TO BE DISCUSSED WITH THE NRC.
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ATTACHMENT 3
,
Root Cause Analysis Results
Primary Root Cause
1.
Design / Fabrication Inadequacies - The principal cause for the
failure relates to inadequacies associated with the design of
the lif ting eye assembly.
The assembly's extreme sensitivity
to f abrication tolerances and a lack of detailed installation
instructions contributed to the assembly being unforgiving to
installation alignment.
2.
Inadequate or No NUREG-0612 (Heavy Loads) Evaluation - As
identified in the failure analysis report the lifting eye
assembly does not have a redundant or dual lift point system,
safety factors for stresses due to combined static and dynamic
loads at any point in the assembly shall not be less than lo
against ultimate tensile strengths of the material.
Safety
factors found from the structural evaluation for the lifting
eye assembly were less than 10.
It is felt that an adequate evaluation of the lifting eye
assembly
for
compliance
would
have
required
redesign of the lifting eye assembly thus preventing this
incident.
Contributing Causes
1.
Fail"~a to Follow Procedures - There were several examples
identitAnd
where
activities
were
performed
beyond
the
auth .rit stion of station procedures.
The work activity could
not be preformed as described in the work instructions.
The
stations work control fundamentals as described in station
procedures, general employee training and in special work
control fundamental training required that the work be stopped
and additional procedural guidance obtained.
Altering the
lift lug location or installation of the 940/ counter weight
would have required an engineering evaluation of the lifting
eye for adequacy.
2.
Inadequate Work Planning - The need for moving the lif ting eye
assembly was not identified during field walk downs and not
transmitted to the procedure writer.
This prevented any
preplanning and procedural direction for how to reestablish
the balance for this lift.
Failure to stop the work when
3.
Poor Supervisory Judgement
-
work could
not be
performed within the
bounds
of
the
procedure.
Plans to energize the jib crane and rotate the
base 90' while crane was still suspended on the hook.
Moving
the crane in an unanalyzed condition (940/ counter weight
attached to the trolley).
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4.
Inadequate Procedure - The procedure _(SPCN 93X0200) that was
approved by the SRC and utilized to start the movement of the
jib crane was not adequate to move the crane to
it's
predetermined location.
This would not have contributed to
i
this incident if work had been stopped by the responsible
management personnel and a procedure change initiate.
During
,
the work planning stage the need to move the lifting eye was
not identified,
thus the procedure guidance for how to
adequately balance the load was not provided.
In addition to the Root and Contributing Causes associated with
this incident, other program weaknesses (not directly contributing
to the incident) were identified.
1.
Lack of Procedural Guidance for Implementing' critical Load
Determination -
Station Procedure 35X001.01 Rev. 8, Para. 4.3, identifies the
need to take " Appropriate Compensatory Measures" when handling
a critical load that has the potential of binding or hanging
up,
currently there is no procedur,al guidance or direction to
identify
who
is
responsible
and
what' is
required
for
" Appropriate Compensatory Measures."
,
2.
Inadequate. Pre-job Briefings - The effectiveness of the
pre-job briefing was lacking.
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ATTACHMENT 4
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ACTIONS TO PREVENT RECURRENCE
The following actions will be taken by LIPA in order to prevent
recurrence of this or similar incidents during future heavy load
lifts at Shoreham.
These actions are intended to directly address
the primary root causes and contributing causes which were involved
in the. dropping of the refueling jib crane on April 29, 1993.
1.
Correction of Desian/ Fabrication Inadecuacies Associated With
Jib Crane Liftina Attachments (Primary Root Cause No. 1)
<
A)
All jib cranes at Shoreham will be examined to determine those
which are equipped with a lifting attachment similar to the
one that failed on April 29, 1993.
B)
Any jib cranes equipped with a lifting attachment similar to
the one that failed on April 29,
1993,
shall have these
lifting devices removed no later than June 30, 1993.
C)
Any jib cranes which are to be lifted across the Refuel Floor
shall be moved either by use of NUREG-0612 qualified rigging,
or by use of a new lifting device which meets the following
criteria :
(1)
Any jib crane lif ting device will be designed to meet the
guidelines of NUREG-0612,
" Control of Heavy Loads," for
factors of safety and/or redundancy, and will provide adequate
protection against slippage in light of fabrication tolerances
and installation alignment; and
(ii)
One'or more load tests of a jib crane lifting device
will be conducted away from the Spent Fuel Storage Pool to
confirm that the device is capable of safely lifting the
weight of the jib crane and to confirm the required slippage
resistance characteristics and load balancing.
Item 1.C above will be specified as a prerequisite in station
procedure SP35X0.01.01 no later than June 30,
1993.
This
prerequisite will specify that items 1.C (i) and (ii) be
performed for any new jib crane lifting device prior to first
use.
.
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2.
Assurance of Adecuate NUREG-0612 Desian Compliance For Futur ;
Heavy Load Lifts (Primary Root Cause No. 2)
Conformance with all current commitments to NUREG-0612 guidelines,
e.g.,
use of safe load paths, use of procedures, crane operator
qualification, crane and sling inspection and maintenance, etc.,
will continue to be maintained at Shoreham in accordance with
approved station programs and procedures.
In addition, prior to
performing any heavy load lifts across the Refuel Floor, LIPA will
ensure
that
the
following
reviews
are
performed
to
assure
compliance of the lifts with current NUREG-0612 commitments in
order to ensure the safety of irradiated fuel in the Spent Fuel
Storage Pool (SFSP).
A)
For heavy loads to be lifted across the Refuel Floor involvina
movement of oriainally installed clant eauipment. LTPA will:
(1)
Reconfirm that a safe load path and appropriate instructions
are specified for the load in SP35X001.01; and
(ii) Reconfirm
that
Shoreham
licensing
correspondence
and/or
engineering
documentation
have
addressed
considerations for the subject loads, specifically addressing
the safety of irradiated fuel in the SFSP.
This review will
include a verification that the planned load is consistent
with the parameters of the earlier review:
(a)
Where safety factors,
equipment redundancy,
and/or
compensatory measures were credited as the basis for NUREG-
0612 compliance, LIPA will verify that the safety factors,
equipment redundancy and compensatory measures continue to
satisfy NUREG-0612 guidelines. This will include verification
of safety factors, redundancy and compensatory measures for
cranes, special lifting devices, rigging and load attachment
points; or-
(b) Where load drop consequences were previously assessed and
found to be acceptable, LIPA will verify that a drop of'the
planned load remains bounded by the earlier analysis,
e.g.,
load path is the same and plant conditions are the same as or
less limiting than in the earlier analysis; or
(c)
Where it is determined that neither a bounding load drop
evaluation was performed nor NUREG-0612 qualified safety
factors and/or redundancy are present, either a new analysis
will be performed demonstrating no adverse impact on safe fuel
storage in the event of a load drop, or'another NUREG-0612
qualified approach will be developed to conduct the lift.
(B)
For all heavy load lifts across the Refuel Floor involvina
cauipment not oreviousiv considered in east NUREG-0612 reviews
at Shoreham,
e.a.,
for new eauioment used in decommissionina
l
or fuel disoosition activities, LIPA will:
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(i)
Ensure that a safe load path and appropriate instructions are
specified in SP35X001.01; and
(ii) Ensure that either an analysis is performed demonstrating no
adverse impact on safe fuel storage in the event of a load
drop, or that all cranes, special lifting devices, rigging and
load
attachment
points
meet
guidelines
for
equipment safety factors,
redundancy,
and/or compensatory
measures.
(C)
Although Actions 2.B(i)
and 2.B(ii)
have been routinely
implemented throughout Shoreham Decommissioning, LIPA will
revise station procedure SP 35X001.01 to more clearly identify
these actions as prerequisites.
Lastly, all heavy load lifts
across the Refuel Floor will be subject to design approval by
the
Nuclear
Engineering
Division
(NED),
including
NED
preparation and/or approval of any rigging sketches that may
be necessary.
Verification of design compliance with current
NUREG-0612 commitments will be specifically documented with
the NED approval of Refuel Floor heavy load lifts.
The NED's
review and approval responsibilities will also be clarified in
order to ensure a thorough NUREG-0612 evaluation is performed.
The above items,
i.e.,
2.A, 2.B, and 2.C will be specified as
a prerequisite in station procedure SP35X001.01 no later than
June 30, 1993.
Conforming changes to other station programs
and procedures will be made as appropriate by June 30, 1993.
3.
Procedure and Other Work Control Adherence (Contributino cause
No. 1)
The following actions have been or will be taken to prevent the
recurrence of incidents similar to this one where activities were
performed that , were beyond the authorization provided in the
applicable procedure:
A)
Appropriate disciplinary actions have been taken against the
supervisory personnel who were responsible for the failure to
follow the procedure in this case.
The contractor supervisor
who was directly in charge of the rigging activities for the
jib crane has been permanently removed from the Shoreham
project.
The Refuel Floor Coordinator in charge of overall
coordination of activities on the Refuel Floor was suspended
without pay for a period of one week.
B)
All Refuel
Floor Coordinators and . Senior Certified Fuel
H,andling Operators with Refuel Floor responsibilities will
receive special indoctrination from the Resident Manager
focusing on the need to closely monitor compliance with work
control
fundamentals,
including review of
specific work
control
fundamental
requirements,
their
bases,
their
application in actual field situations, and how to recognize
non-compliances.
In addition, formal position descriptions
will be developed and approved by the Resident Manager for the
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Refuel Floor Coordinator and Senior Certified Fuel Handling
Operator positions.
Such position descriptions will identify
the work control fundamentals and supervisory responsibilities
associated with these positions.
These actions will be
completed no later than June 30, 1993.
C)
This event will be discussed with all Shoreham station
personnel through department focus meetings as well as through
"all hands" meetings conducted by the Resident Manager.
The
details of how work control fundamentals were violated in this
case will be examined. Also, renewed emphasis in general will
be placed on work control fundamentals such as the importance
of
having
procedures
to
control
work
activities;
the
importance of procedural adherence; the need for attention to
details in work planning to ensure an adequate procedure is
developed; maintenance of a questioning attitude; and the need
to recognize,
stop work,
and obtain appropriate
formal
procedural clarification when confronted with situations not
adequately addressed in a procedure.
These actions will be
completed no later than June 30, 1993.
D)
Lessons learned from this event, including the work control
fundamentals emphasis described above, will be incorporated in
General Employee Training (GET) given to any new employees at
Shoreham,
and will also be included in the annual GET
requalification lesson plan for existing employees.
The
lessons learned will also be added to other applicable
programs such as Polar Crane Operator Training and Certified
Fuel Handling Operator Training.
Revisions to the lesson
plans for these training programs will be completed no later
than June 30, 1993.
E)
Greater management attention and visibility will be given to
!
compliance with work control fundamentals in the field.
Department:and. division managers will conduct and document
reviews andb tours to be performed to assess work control
fundamentals implementation.
Each department manager will be
,
'
required to develop and submit to the Resident Manager a plan
for ongoing monitoring and
documenting of
work
control
fundamentals
compliance
within
the
areas
of
their
responsibility. Initial Resident Manager approval of all such
plans will be obtained no later than July 31,
1993 and
j
periodic review of plan effectiveness will be conducted every
sthree months thereafter.
4.
Improvements In Work Plannina Practices (Cgr '.ributina Cause
No. 2)
,
The following improvements in heavy load work planning practices
will be implemented
in order to ensure that all
logistical
considerations in the field are translated into appropriately
developed work instructions:
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A)
Field walkdowns for Refuel Floor heavy load movements will
include, but not be limited to, the author of the procedure
and a cognizant representative of the NED.
B)
Field walkdowns which are performed more than two days before
the actual lift will be repeated on the day of the lift,
including participation of a cognizant NED representative.
This will be done to ensure that any changes in field
-
conditions which could affect the lif t are identified prior to
commencement of the actual lift.
C)
Formal pre-job briefings in accordance with station procedures
will be required for all Refuel Floor heavy load lifts.
Instructions to determine the applicability and content of
formal pre-job briefings will be developed.
The above requirements will be incorporated in the appropriate
procedures no later than June 30, 1993.
5.
Clarification
of
Field
Supervisorv
Responsibilities
(Contributina Cause No. 3)
As discussed in item 3.B above, the position of Refuel Floor
Coordinator will be defined in an appropriate position description
which delineates the authorities and responsibilities associated
with this position.
The program description will specifically
identify that personnel in this position are required to include
monitoring for compliance with work control fundamentals as part of
their daily responsibilities.
The position description for Senior
Certified Fuel Handling Operator will be developed to ensure that
it clearly identifies these responsibilities as well.
These
position descriptions will be . effective no later than June 30,
1993.
Regarding the errors in judgment made by the supervisory personnel
involved in the jib' crane drop of April 29, 1993, please refer to
item no. 3 above, " Procedure and Other Work Control Adherence" for
'
actions which will address how to better make such judgments in the
future.
6.
Procedure Adecuacy For Heavy Load Lifts (Contributina cause
No. 4)
Station procedure SP35X001.01 will be reviewed based on the lessons
learned from this incident and the associated root cause analysis
to determine if the heavy load lift instructions are clear and
adequate to perform the tasks described.
This review will be
completed no later than June 30, 1993.
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PROGRAM ENHANCEMENTS
The following actions will be taken by LIPA in order to enhance
programs which were indentified as being weak.
Weakness 1 response - Enhance procedural guidance for
implementing critical load determination
Procedural guidance will be developed which will address
responsibilities for performing a critical load
evaluation, including what types of compensatory measures should
be considered (ie dynamometer tie downs, additional spotters)
when performing the evaluation.
The guideline will also require
that the Nuclear Engineering Division review and or develop each
critical load evaluation, and require that critical load
evaluation be reviewed by the SRC.
Station procedure 35X001.01 will be revised no later than June
30, 1993, to require as a prerequisite that a critical load
evaluation has been performed for the handling of leavy loads
with the auxiliary hook.
Weakness 2 response - Enhance pre-job briefing effectiveness
Formal pre-job briefings will be described in a suitable work
instruction.
The instruction will provide guidance on what
groups should attend pre-job briefings and what types of
activities will require utilizing the pre-job briefing
instruction.
This instruction will identify the subject areas to
be addressed during a pre-job briefing.
Examples of subject
areas are as follows:
Authorities and responsibilities
.
Training, indoctrination, qualifications
.
Work authorization / permits / tags
.
Plant condition requirements
.
Safety considerations
.
Posting and alarms
.
Equipment / materials
.
Procedures
.
Quality control
.
Radiological controls
.
Radiological waste and contanination control
.
Cleanliness control
.
The requirements to hold a pre-job briefing in accordance with
the developed instruction discussed above will be incorporated
into station procedure SP 35X001.01 no later than June 30, 1993.
6-6