ML20055J447

Responds to NRC Re Violations Noted in Insp Repts 50-295/90-03 & 50-304/90-03.Corrective Actions:Training Rev Request Initiated & Personnel Counseled

ML20055J447
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	04/26/1990
From:	Kovach T COMMONWEALTH EDISON CO.
To:	Davis A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
References
NUDOCS 9008020272
Download: ML20055J447 (6)

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C:mmon';;ealth Edis:n e

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- 1400 Opus Placs

( v~') Downers Grove, Illinois 60515 QCb

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April 26, 1990 Mr. A. Bert Davis Regional Administrator i

U.S. Nuclear' Regulatory Commission Region III i

799 Roosevelt' Road Glen Ellyn, IL 60137 f

Subject:

Zion Nuclear Power Station, Units 1 and 2 License Nos. DPR-39 and DPR-48

-Response to Notice'of Violation Inspection Report No. 50-295/90003 and 50-304/90003 NRO Docket No. 50-295 and 50-304_

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Reference:

March 28, 1990 letter from W.D. Shafer to Cordell Re'd.

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Dear Mr. Davis:

The letter referenced above.provided the results of a routine safety inspe.ction conducted by Messrs. J.D. Smith, R.J. Leeman, R.B. Landsman,_and P.B.-Moore and Ms. A.M. Bongiovanni of your office during Jan'iary 16, 1990-through March 10, 1990 of activities at Zion Station.

During the course of this inspection, certain activities appeared to be in violation of NRC requirements. The response to'the violation is provided in the Attachment to.

this' letter.

Please direct any questions that you may have regarding this matter

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to this office.

Very truly-yours, fp Sm/

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vach l-Nuclear censing Manager TJK/RC/Imw cc:

C. Patel - NRR Senior Resident Inspection - Zion f' \\

9008020272 900426 PDR ADOCK 05000'295 18580 0

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fa ATTACIMENT A N

As a result of the inspection conducted January 16, 1990.through March 10, 1990 and in accordance with 10 CFR rart 2. Appendix C - General Statement of Policy and Procedure for NRC Enforcement Actions (1990), the following violation was identified.

10 CFR 50, Appendix B,-Criterion V, as described in Section 5 of Topical Report CE-IA, Revision 55..and as implemented by the Z*on Quality Assurance Manual. Section 5, requires'that. activities affecting quality be prescribed by documented instructions, procedures and drawings, and that those' activities be j

accomplished in accordance'with those instructions, procedures and-drawings.

t Technical Specifications 6.2.1 states. in'part, that written procedures shall be prepared, impicmented and maintained for normal startup, operation and shutdown of the reactor and other systems and components involving nuclear safety of the facility.

Contrary to the above:

a.

Surveillance procedure, PT-7, " Auxiliary Feedwater Checks and Tests,"

was inadequate and could not be used for the operation-of the auxiliary feedwater system (AFW) during plant. conditions (Mode 7) that existed on January 16, 1990.

The use of PT-7 resulted in the cavitation of and damage-to the 1A AFW pump when both the discharge and recire valves were closed at the same time. (50-295/90003-01a (DRP)).

b.

On January 23, 1990, the IB AFW pump wac inoperable for approximately five hours due to a valve that was' improperly aligned by an. operator and improperly verified by the shift foreman.

The individuals failed to follow Zion administrative procedure, ZAP 5-51-3A. which. requires varifying the position of valves by attempting -to move them in the L

closed dirtetion (50-295/90003-Olb (DRP))

c.

On February 13, 1990, operations' personnel failed to follow surveillance test PT-7A, " Starting Procedure for Auxiliary Feedwater Pump Lube Oil Pumps," and inadvertently started the IB AFW pump (50-295/90003-01c(DRP)).

d.

On February 13, 1990, maintenance personnel-failed to follow Zion Administration Procedure, ZAP 14-51-2, and general practices on manipulating equipment. The worker isolated the DC c.atrol power and removed the key from the key-lock switch-making the 2B emergency diesel generator inoperable for approximately seven minutes (50-304/90003-01(DRP)).

This la a Severity Level IV violation (Supplement'1).

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The 1A AFW pump was disassembled and the impeller replaced.

The discharge piping and supports were walked down and inspected for damage. No damage was found.

j A formal Human Performance Evaluation System (HPES) investigation was-conducted, and found the cause to be personnel error compounded by

_ procedural deficiency.

i Periodic Test-(PT-7) " Auxiliary Feedwater System checks and Tests" has been' revised to include a sign-off that a flow path for the pump.

exista during the performance of the test.

It has been stressed to all operations personnel that if serious doubts or concerns exist about the consequences of an evolution, the evolution shall not continue until all doubts and concerns are addressed to the fullest extent possible.

Also, the Operating Department has implemented a program whereby pre-job briefings are held for evolutions considered to be significant in nature. These pre-job briefings are-intended to ensure that all persons involved in the job are well informed as to the purpose, mechanics, and desired results of the evolution.

Zion also performed a documentation search to determine whether q

previous occurrences of a-similar nature had occurred and lessons learned f rom those events could have prevented this incident. ~ No previous events of a similar nature were found.

Other procedures related to pumps have been reviewed to ensure the maintenance of a flow path exists where appropriate. No procedures were found where a flow path would be isolated.

b.

The immediate corrective actions taken when the misalignment was discovered consisted of opening the 1FW0038 valve, and restoring the-t pump to operable status.

Additionally, selected systems were walked down to verify the

-position of the valves:and the operability of the associated systems; no discrepancies were found.

A procedure change to System Operating Instruction (S01-10)

" Auxiliary Feedwater" was made to include a section detailing the actions to be taken for restoring the AFW pumps to their normal' l

at-power alignment.

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A training revision request was initiated to review the training department's lesseo plans to ensure that valve' position is verified in accordance with existing administrative procedures.

Both the operator and the licensed shif t supervisor conducted briefings to the five operating crews, and discussed the event and the lessons that could be learned to prevent future events like this from occurring.

In addition, both the operator and the licensed shif t supervisor were counseled.on the importance of checking valves by attempting to close'them to verify valve position, and not to rely on valve stem position as the only method of valve position indication.

Zion Station has reviewed previous events and operating experience to determine whether stated corrective actions could have prevented this event. This review found one Deviation Report (DVR) and one significant Operating Experience Report.(SOER);.

DVR 22-2-82-80 documents a turbine driven AFW pump-running with-its discharge valve closed and the crosstle valves open. No action taken as a result of that DVR would have prevented this event.

SOER 85-2 titled " Valve Mispositioning Events Involving Human Errors" does address this type of event.- This'SOER details 10 recommendations of which Zion was requested to respond to nine of-the items. A review of the recommendations indicate that i

these items have been addressed.

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L The action taken in response to this'DVR coupled'with the continued implementation of the INP0 recommendations should prevent future' personnel errors of this type..

l c.

An equipment attendaut (B-Man) at the Remote Shutdown Panel'(RSP) inadvertently started the IB~ Auxiliary Feed. Water pump.

He immediately recognized his error and stopped-the pump. A formal Human Performance: Evaluation System (HPES) investigation.was conducted and found the cause of this event was personnel error compounded by poor _ human factors design-of the panel, i

To prevent recurrence, a-protective-plastic cover was added to the auxiliary feedwater pump switch at the. Remote Shutdown Panel.

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.t Caution cards were hung from all three auxiliary feedwater pump switches at the RSP. These corrective actions were carried out for both units.

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4 Additionally..a standing order was issued'that requires a Licensed l

Shift Supervisor to attend all local operator actions concerning.t!e auxiliary.feedwater system.

This standing order will remain in

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effect until all appropriate operations personnel-have been t

re-trained on the Auxiliary Feed Water system.-

d.

Periodic Test (PT) Diesel Generator Loading Test" was performed on.2B EDG after DC control power had been restored to ensure operability.

The'"A" Mechanic involved in the incident was disciplined according to' station policy.

Carrective Actiona_to be Take.n to Prevent _, Recurrence a.

A review of pump operating characteristics, including this event, shall be included in licensed operator. retraining.

,b.

Zion Station believes that corrective actions taken will prevent recurrence of misaligned valves.

c.

The RSP. layout and labeling will be investigated by a Human Factors Engineer for current standards.. RSP modifications will be-implemented if deemed appropriate.

Periodic Test, PT-7A, will be revised to add a caution statement warning the operator that light position indication will bedifferent than expected.

Drawings of.the RSP utilized by the training department:~will be reviewed to ensure they are consistent with as-built conditions.

Drawing revisions will be initiated as necessary..

d.

Zion Station is in full compliance at this time.

Date When Corrective Actiona Will Be Completed Licensed Operator training on pump operating characteristics will be completed by December 31, 1990.

The Human Factors review of the RSP layout will be completed by.

December 31, 1990.

Periodic Test PT-7A will be. revised by July 1,19'90.

The RSP drawing review in the Training Department will be completed by

'l December 31, 1990.

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• ZlOD_fttation's_CDMnitment to Exce11enne -

The above. mentioned corrective actions will prevent recurrence of these specific examples of violation. However, Zion Station recognizes that personnel errors, including failure to follow procedures, are unacceptable.

As a commitment to excellence, Zion has included in it's Performance I

Improvement Plan (PIP) actions to reduce personnel errors. Reduction of personnel errors is one of the top three PIP actions plans at Zion for 1990.

To facilitate these action plans Zion held an all station " stand-down" in January of 1990. All non-essential work was stopped for approximately 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />.

while each department discussed recent personnel errors at Zion as well-as throughout the industry. The importance of procedure adherence was part-of those discussions.

To ensure that complete and accurate root cause determinations are made, events at Zion where personnel error is' suspected,-are investigated utilizing the Human Performance Enhancement System (HPES) or Zion's Personnel Error

-J Review Program.

.l The result of those investigations has led to the development of Zion Station's "Self-Check" campaign. This campaign consists.of presentations to all work groups which emphasizes the importance of an individual "Self-Check" i

program and how utilizing its concepts can significantly reduce personnel error events.

It is planned that.all station personnel will be formally introduced to this program by June 1,1990.

Zion Station is committed to excellence in all phases of Nuclear Operations.

Development of the PIP, close monitoring of the results, and effective communication of Zion's expectations to all employees -will demonstrate that excellence can be achieved.

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