ML20046A282
| ML20046A282 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 07/21/1993 |
| From: | Rhodes F WOLF CREEK NUCLEAR OPERATING CORP. |
| To: | NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| EA-93-129, ET-93-0087, ET-93-87, NUDOCS 9307270185 | |
| Download: ML20046A282 (7) | |
Text
.
l i
W8 FCREEK 1
NUCLEAR OPERATING CORPORATION I
i Forrest T. Rhodes Vice Premden? Engineering July 21, 1993 g
ET 93-0087 Director, Office of Enforcement U.
S.
Nuclear Pegulatory Commission
{
f ATTN:
Document Control Desk Mail Station P1-137
[
Washington, D.
C.
20555 Peference:
Letter dated June 25, 1993 from James L. Milhoan, j
NRC to B.
D. Withers, WCNOC
Subject:
Docket No. 50-482:
Reply to Notices of Violation 482/9316 Gentlemen:
i Attached is Wolf Creek Nuclear Operating Corporation's. (WCNOC) " Reply to I
a Notice of Violation" which was documented in the Reference (NRC Enforcement Action EA 93-129).
Violation 482/9316 concerns WCNOC's discovery on May. ', 1993 that the plant had been placed in Mode 3 with the motor-driven auxiliary feedwater pumps in the
" pull-to-lock" position. The two cited violations in the aggregate are considered to be a Severity I,evel III problem.
A civil penalty of $50,000 was assessed in this incident.
The funds were i
electronically transforred to the Treasurer of the United States on July i
16, 1993.
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, n
f t
,a r
Forrest T.
Rhodes Vice President Engineering Attachment NSC/jan ec:
W.
D.
Johnson (NRC), w/a J.
L. Milhoan (N RC ), w/a i
G. A.
Pick (NRC), w/a i
W.
D. Reck. ley (NRC), w/a
'l h.3 l
m n n n.
f..
Pf) Box 411/ Burlington. KS 66839 / Phone: (316) 364-8831
=
9307270185 930721 k
gn eq,.41 Opportunity Employer WF/HC/ VET PDR ADDCK 05000482 t/
G PDR S
W ' 4 tk m 4.AW.
m.
i l
- l Attachment to ET 93-0087 i
Page 1 of 6
. 1 Reply to Notice of Violation and Proposed Imposition of Civil Penalty EA 93-129 Findinas:
A.
Technical Specification 3.0.4 requires 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 requirements.
Technical Specification 3.7.1.2.b Limiting Condition for Operation requires that for Mode 3 operation, two motor-driven auxiliary feedwater pumps be operable.
Contrary to the above, on May 8, 1993, the reactor entered Mode 3
with both the motor-driven auxiliary feedwater pumps inoperable due to the pump controller handswitches being in the pull-to-lock position.
B.
Technical Specification 6.8.la requires, in part, that written procedures be established, implemented, and maintained covering the activities referenced in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.
Section 2.a.
of Appendix A of Regulatory Guide 1.33, Revision 2,
February 1978, requires safety-related activities to be covered by written procedures, which includes administrative procedures to govern mode changes from cold shutdown to - hot standby.
Procedure GEN 00-002, Revision 25,
" Cold Shutdown to Hot Standby.* states, in part, that when the required portions of Checklist GEN-00-002-1B (Mode 4 to Mode 3 Checklist) have been j
completed, continue with the RCS Heatup and Pressurization.
Checklist GEN-00-002-1B requires, in part, that the motor-driven auxiliary f eedwater pump handswitches be placed in the normal position.
Contra ry to the above, at 6:38 p.m.
on May 8,
1993, licensed operators placed the plant in Mode 3 ond continued the RCS Heatup and Pressurization without assuring that the required portions of Checklist GEN-00-002-1B had been completed.
This resulted in the reactor being placed in Mode 3 with the motor-driven auxiliary feedwater pump handswitches in the pull-to-lock position, which is not the normal position.
The handswitches remained in that condition until 7:53 a.m.
on May 9,
1993.
1
~ -
.. - l
-1 Attachment to ET 93-0087 Page 2 of 6 Egacon for violation:
'{
On May 8,
1993, Wolf Creek Generating Station (WCGS) was in Mode ascension following the sixth refueling outage.
The goal of the ' day i
shift Operating Crew was to clear the final restraints and make the Mode 4 to 3 transition per General Operating Procedure GEN 00-032,
" Cold Shutdown to Hot Standby,"
Revision 25.
The level of plant Mode ascension / restart activity was high and the Mode change effort was critical path.
Technical Specification 3.7.1.2 requires at least three independent Steam Generator Auxiliary Feedwater Pumps and associated flow paths to be OPERABLE in Modes 1,
2, and 3.
The Motor Driven Auxiliary Feedwater Pump (MDAFWP) handswitches had been in " pull-to-lock" (manually blocked from starting by pulling and turning the Control Room handswitch) throughout most of the refueling outage to prevent spurious actuations.
The handswitches should have been returned to NORMAL just prior to the Mode change as directed in " Checklist GEN 00-002-1B, (Mode 4 to Mode 3 CKL). "
A second checklist, " Surveillance Mode 4 to 3 Checklist," had been worked on extensively during the shift.
Its completion was verified by the Shift Supervisor who then signed-off GEN 00-002, step 5.30.1.
Step 5.31 of procedure GEN 00-002 directs continuation of the heatup following verification of " Checklist GEN 00-002-1B."
The Supervising Operator initialed step 5.31 without referring to and completing the required actions of " Checklist GEN 00-002-1B, (Mode 4 to Mode 3 CKL). "
The Mode change was made at 1838 CDT on May 8, 1993, with both MDAFWP's INOPERABLE in violation of Technical Specification 3.0.4.
This situation remained uncorrected until May 9,
1993, at 0753 CDT, when the handswitches were returned to NORMAL to comply with Technical Specification 3.7.1.2.
Administrative Procedures ADM 02-010
" Shift Relief and Turnover,"
Revision 18, steps 7.6 and 7.7, and ADM 02-040 " Conduct of On Duty Operations Personnel," Revision 9,
step 4.4, deal with control board walkdowns and shift turnovers.
The intent of these steps were not met as two shift changes occurred without adequate discussion of the requirements for this safety-related equipment.
Both Control Room Operating Crews were aware of the availability of the MDAFWP's.
They had recently performed various Auxiliary Feedwater System Surveillances and had run the MDAFWP's at various times during the outage to prcvide makeup water to the Steam Generators.
All personnel involved knew that the handswitches were in " pull-to-lock" from their control board walkdowns and turnovers, but failed to recognize that this condition was prohibited in Mode 3.
l The direct root cause of this event was failure of the Operating Crews to allocate sufficient time to thoroughly review the applicable Technical Specificatjons for Mode 3 and to completely understand the impact of the status of safety-related equipment required to be operable.
The major
=
l Attachment to ET 93-0087 Page 3 of 6 contributing factor to the root cause was failure of the Operating' Crews to adequately control plant work activity in the Control Room just prior to and during the decision to transition from Mode 4 to Mode 3.
While all personnel were aware of physical plant status (i.e.,
that the-handswitches were in
" pull-to-lock"),
the broader procedural and Technical Specification context was not adequately considered.
1 Therefore, the necessary level of awareness of these requirements relative to plant status and the impending Mode 4 to 3 transition was neither maintained nor brought out in shift turnover discussions.
Contributing factors to this event include:
Procedural confusion created by existence of two checklists (GEN 00-002-1B and the Survrillance Mode 4 to 3 Checklist) caused the Supervising Opere" to initial step 5.31 thinking " Checklist GEN 00-002-1B" had been completed when it had not.
The Shift Supervisor's signing off of the " Surveillance Mode 4 to Mode 3 Checklist" instead of allowing the Supervising Operator to do it may have contributed to the Supervising Operator's oversight.
There was a desire on the part of the crew and management to complete the mode transition prior to shift turnover since the oncoming operating crew had been off for two days.
Corrective Stens That Have Been Taken and The Results Achieved:
A memo from the Manager Operations to Licensed Operators, issued on May 11, 1993, emphasized taking the necessary time for thorough turnovers and properly prioritizing concerns dealing with saf ety-related equipment and Technical Specification requirements.
The Vice President Plant Operations issued three memos on May 13, 1993, that addressed:
1 Restricting activities which may distract from proper Control Room turnovers
(" quiet time")
- The requirements for Shift Supervisors to maintain Control Room professionalism, formality, and work controls.
Communications from various managers with the Control Room must be carefully worded and avoid unrealistic expectations.
The memo also i
discussed personnel performance expectations.
In order to prevent a similar occurrence during the Mode 2 transition, a procedure change was issued on May 14,
- 1993, to General Operating Procedure GEN 00-003, " Hot Standby to Minimum Load, " Revision 29.
This change requires either the Manager Operations or the Supervisor 4
Operations to review the Equipment-Out-of-Service
- Log, Clearance Order
- Log, Work Request
- Log, and Surveillance Mode Change Checklist prior to entering Mode 2.
The Manager Operations also discussed applicable Technical Specification items for the Mode 3 to Mode 2 clange with the Operating Crew.
-Attachment to ET 93-0087-Page 4 of 6
.l Two other memos were issued by the Manager Operations on May 24, 1993 and June 4, 1993 respectively.
The first delineated his expectations of the Operating Crews in regard to turnovers and controlling the number of plant work activities allowed to proceed at once.
The second directed that only the ' Supervising Operator sign steps in the General Operating Procedures (with certain exceptions).
The individuals involved in this event were counseled by Operations Management concerning control of the plant and maintaining. awareness of.
safety-related equipment status.
In addition, the Supervising Operator made a presenuation (positive discipline) to peers and to management of the errors made and how proper self-checking, i.e.,
" STAR" (Stop,. Think Act, Review) could have prevented this incident.
Operations personnel have re-evaluated the use of " pull-to-lock" on Main Control Board handswitches, and the need for formal procedural control-when this is done.
Operations Standing Order 24/B was issued including guidance for this practice.
" Pull-to-lock" may be used for personnel or equipment safety, but a clearance order should be initiated as soonLas possible.
Handswitches may also be placed in " pull-to-lock" when directed by procedure, Procedure ALM 02-010, has been reviewed with all Licensed Operators. in Licensed Operator Requalification Training (Training ID# LR 10 108 38).
The Manager Operations has been performing periodic observations of Control Room activities and turnovers to assure the effectiveness of these corrective actions.
To avoid the confusion generated by two checklists, Revision 26 of-GEN-00-002 was issued July 1,
1993 which deleted GEN 00-002-1B and GEN 00-002-1A,
" Mode 5 to Mode 6 CKL" checklists.
" Perform" steps ' from the checklists were moved to the body of the procedure.
The Manager Operations or his designee is required to review plant-status and procedural requirements prior to Mode changes.
" Attachments" have been added which delineate the Technical Specifications which become effective in the new Mode.
The Shift Supervisor will review the appropriate list with the operating crew prior to a Mode change.
f i
The Equipment Out of Service Log (EOL) was not used to track the status of the MDAFWPs.
The EOL was not intended to be used in this manner as its usefulness would be diminished with the large number of entries during an outage, and GEN 00-002 did include steps to ensure all surveillances were current and MDAFWP handswitches were in Normal prior to the Mode 3 transition.
However, due to the ambiguities contained in the procedure, ADM 02-105, " Equipment Out Of Service Log (E.O.L.),"
has been revised to clearly identify when the log is ta be used.
Specifically, Technical Specification equipment need only be entered while operating in Modes 1 and 2.
I Attachment to ET 93-0087 Page 5 of 6 To date, the establishment of quiet time and the emphasis on shift relief and watchstander responsibilities have resulted in more thorough and effective Control Room turnovers and panel walkdowns.
Personnel are more professional and formal in their approach to performing these activities, and plant awareness has been heightened.
Operations management continues to question operating crew personnel regarding equipment ' status and key recent events to ensure continued improvement in shift performance.
Corrective Stecs That Will Be Taken to Avoid Further Violations:
The other General Operating Procedures are being reviewed for similar problema.
The itemization of Technical Specifications which become effective when Mode changes are made will be incorporated wherever appropriate.
The changes to General Operating Procedures, including a discussion of this event, will be presented in Licensed Operator Requalification Training (Training ID# LR 00 102 02).
The routine Quality Assurance surveillances of Control Room activities will also verify adherence to these corrective actions.
At the request of the Manager Operations, Quality Assurance will perform special evaluation of Operating Crew turnovers and board walkdowns.
a An independent " Performance Assessment of Operations" was requested by the Vice President Plant Operations and is ongoing.
The purpose of this Assessment is to identify any areas for further improvement.
Specific areas of assessment include Operations management effectiveness, outage training and preparation, cultural
- issues, on-shift organizational structure and frequency, type and trends of errors within Operations.
The Assessment will be performed by personnel from both within and i
outside of WCNOC.
Date When Full Com11 a n y Will Be Achieved:
WCNOC took prompt action for this event to restore compliance with plant Technical Specifications.
The comprehensive corrective actions taken to date have and will continue to ensure the applicable requirements are effectively fulfilled.
Longer-term actions to ensure continuous performance improvements in this area are in progress as noted.
I All General Operating Procedures will be revised by September 30, 1993.
I Just prior to the seventh refueling outage additional training will be I
conducted on the General Operating Procedures to reemphasize their use.
I
,.,m,.-
~
Attachment to ET 93-0087 Page 6 of 6 The special Quality Assurance evaluation is in progress.
Feedback will-be provided to the Manager Operations during the evaluation with a final report by August 20, 1993.
The report from the " Performance Assessment of Operations" is due by August 31, 1993.
Actual or Potential Consecuences of This Violation:
At the time of the event, surveillance test procedure STS AL-003,
" Auxiliary Feedwater System Valve Etatus Verification" Revision 6,
had been performed ensuring proper Auxiliary Feedwater System valve alignment.
The 200% capacity Turbine-Driven Auxiliary Feedwater Pump (TDAFWP) was functional at the existing 350 degrees F,
and would have auto-started as designed providing in excess of 600 gpm flow.
This flow is more than would have been required to remove the decay heat of a new reactor core.
Additionally, the MDAFWP's were available for manual actuation.
Operators would have been directed to verify Auxiliary Feedwater flow early in any of the Emergency Operating Procedures (EMGs), and at that time could have taken the MDAFWP's out of " pull-to-lock."
The pumps would then have been fully capable of performing their intended safety function.
As the plant was coming out of the sixth refueling outage, the decay heat load was minimal and the heatup was being accomplished using the 14 MWTh heat input of the Reactor Coolant Pumps (RCPs).
With a constant steaming.
rate of 200 gpm maintaining the Reactor Coolant System (RCS) at 450 degrees, it would have taken approximately 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> to reach a steam generater low-low level alarm or B hours to dry out the generators.
By stopping three of the RCPs, these times could have been extended to 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br /> respectively.
If needed, actions could have been taken to cool down and depressurize the RCS and re-align Residual Heat Removal System cooling within 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.
Based on the low reactor heat load, the functional TDAFWP, the manual actuation availability of the MDAFWP's, and the fact that no loss of offsite power or loss of Main Feedwater System flow occurred, there were no adverse consequences to the plant.
Plant safety and public health and safety were assured throughout the event.
WCNOC acknowledges that although the immediate safety significance of this event was mitigated as discussed above, the same mistake under other circunstances could have had more serious safety implications.
Compliance with the appropriate (Technical Specification or otherwise) prerequisites for plant mode changes han broad safety significance as well as regulatory significance.
The very purpose of ensuring the operability of such equipment prior to mode changes is to assure that equipment important to safety is available to operate as assumed in the design and anal)-is bases of the facility.
Plant Operators are licensed.
to ensure such activities are completed effectively and are responsible for attention to detail in such matters.