ML20058D542

Responds to Violations Noted in Insp Repts 50-346/90-09, 50-346/90-12 & 50-346/90-13.Corrective Actions:Max Value Will Be Established for Core Support Assembly Lifts W/ Provisions for Verifying Clearances Between Obstructions

ML20058D542
Person / Time
Site:	Davis Besse
Issue date:	10/29/1990
From:	Shelton D CENTERIOR ENERGY
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
1-934, NUDOCS 9011060153
Download: ML20058D542 (14)

Text

_v

. %.{

.c_

q J.

-mu Donald C. Shehon 300 Madison Avenue Vce President Nuclear Toledo, OH 43652&X)1 DavbBesse.

(419)249 2300 Docket Number 50-346 License Number llPF-3 Serial Number 1-934 October 29, 1990 a

' United States Nuclear Regulatory Commission Document Control Desk

, Washington, D. C.

20555 Subject Response-to Notice of Violation (NRC Inspection Reports No. 50-346/90009 (DRP): 50-346/90012 (DRSS): and 50-346/90013 (DRP)

' Gentlemen Toledo Edison received the subject Notice of Violation (Log 1-2363) which includes the referenced NRC-Inspection Reports and provides the attached reply.

Additionally,.a synopsis of the Toledo Edison management actions initiated in response to the' operational' events described has been provided herewith.

If you have any questions regarding this matter, please contact Mr. R. W.

..Scn G"dar, Manager'- Nuclear Licensing, at (419) 249-2366.

Very truly yo;rs.

Q RWG/mmb cci P. M. Byron, DB-1 NRC Senior Resident Inspector A

B. Davis, Regional Administrator, NRC Region III M. D. Lynch, DB-l'NRC Senior Project Manager

. Utility Radiological Safety Board 9011060153 901029 DR ADOCK 0500034.6 dhi PDC f~'

0

' Operating Companies.-

Cleveland Electre Illuminating Toledu E0: son

~

~' f

1* Docket Number 50 346 L.icense Number HPF-3

-Serial Number 1-934'

' Attachment 1

Page 1 RESPONSE TO NOTICE OF VIOLATION (NRC INSPECTION REPORT NUMBER.50-346/90009 (DRP))

(NRC-INSPECTION REPORT NUMBER 50-346/90012 (DRSS))

(NRC INSPECTION REPORT NUMBER 50-346/90013-(DRP))

FOR DAVIS-BESSE NUCLEAR POWER STATION-n

' UNIT NO. 2

' Attached 'is Toledo.Eriison's response to the Notice of Violation as issued by

1etter dated September. 26,-1990.- This response is submitted pursuant to 10'CPR 2.201.

1 i

I i

l-m

u. _,

By

'M D. C. Sh41 ton. Vice President - Nuclear Sworn and subscribed before me this 29th day of October,1990, btlt Al Notary Pun 11c, State of.0hio EVEl.YN L DRESS NOTARY PUCUC. STATE OFOH10 MyConnui:nEntr::aMyE13H L-_.

--____________i_____________._--.-__

. Docket Number 50-346

.,bicense Humber NPF-3 1

Serial Number 1-934 Y

CAttachment 2 Page 1 SYNOPSIS OF TOLEDO EDISON HANAGEMENT ACTIONS Thel series of events discussed in the subject Notice of Violation occurred during the recently completed refueling outage which' began on January. 26, 1990 and ended on July 4, 1990.

On April 25, 1990, several workers received an unanticipated radiation dose during a transfer of the reactor core support assembly (CSA). Although no personnel exposure limits were exceeded during the event, the significance of the occurrence received prompt attention by Toledo Edison management personnel. A critique of the event was held soon after the appropriate

'immediate actions were carried out.

The results of-the critique were incerporated into's Radiological-Awareness Report-(RAR) and subsequently-elevated to a Potential Condition Adverse to Quality Report (PCAQR). An ad hoc committee was assembled at-the Plant Manager's request to evaluate the facts surrounding this event.

Additionally, the Independent Safety Engineering Group.

(ISEG) was tasked with' performing an assessment of the radiological significance of the'CSA event.

The conclusions reached from these evaluations and.the resulting corrective actions were acknowledged in NRC Inspt an Report No.-

,50-346/90014 (DRP). On May 1, 1990, the reactor vessel was unintentionally drained to;approximately 18-inches below the desired level during-a refueling canal drain down.

This event was attributed to the failure by Operations

-personnel' to recogr.ize~ the ef fect of an indexing' fixture which was placed on top

of theLreactor vessel flange.; A detailed critique performed after the. drain down' event also pointed out the need to perform pre-evolution walkdowns and j

. pre-job briefings for infrequently performed evolutions.

These recommendations t

were. incorporated into the corrective-actions for-this event. -The corrective

-actions were' presented at the June 1, 1990 Enforcement Conference held at the NRC. Region III office and again acknowledged in NRC Inspection Report'No..

50-346/90014L(DRP).-

i

~Between the dates ei Hay 10 to Hay 27, 1990~, several additional events occurred.

These. included an' Emergency Core Cooling System (ECCS) injection 1(May 18, 1990),

a Steam Generator overfil'l event (Hay 24, 1990) and two Decay Heat (DH) system 1

valve ~ misalignments.(Hay 122, 1990 and May 27, 1990).

[

On May 30, 1990, after an incident. involving,a secondary system valve misalignment, Toledo Edison management imposed.a qualified stop work / testing

order.

This action was bellered necessary due to the accumulation of incidents-which hadfoccurred over the previous month, Individually these incidents were-

'of minimal safety significance.. However, as the incidents continued,. Toledo Edison management became concerned of the collective significance and-therefore took! actions culminating in the work stoppage.

These actions included I

implementing a "go-slow" work philosophy, initiating Senior Operations management coverage earlier than planned,'and re-emphasizing to Operations ipersonnel their responsibilities for activities that could potentially affect plant operations..

i

e

,Dockst Numb;r 50-346l

. bicense Numb;r NPF-3:

s S?tial'Humber 1-934 Pag 2 On Hay 31, 1990,-the Davis-Besse Operations Superintendent met with all Operating Shift personnel to re-emphasize their responsibilities for evolutions that affect plant operations.

The Operations Superintendent explained that the quellfled stop work / testing had been imposed because there appeared to be a lack of control over plant activities. The job descriptions for the Shif t Supervisora Reactor Operator, and Equipment Operator-were reviewed and the responsibilities that accompany these jobs were emphasized.

The operations Superintendent also presented a set of rules (later issued as an Operations Section Policy - June 6, 1990) for all shif ts to follow.

The rules address the cognizance. required and the chain of command that should be followed prior to the performance of evolutions.

Specific rules were provided for special evolutions (defined as large, unusual, infrequent or otherwise determined task that have a designated lead).

Two additional incidents occurred during the month of June 1990.

The first

. involved an inadvettent Decay. Heat System pressurization (June 16, 1990) and the: second incident resulted f rom shutting down the urong Hakeup (HU) pump

[

during testing (June 21, 1990).

Both events were attributed to personnel errors.

l0n Junef22, 1990 Toledo Edison informed the NRC Region III staff of its' decision.to delay restart due to several problems encountered during startup.

.Plantreooldown'was-initiated to resolve hardware problems and operational

. concerns.

1 An operations review was performed to assess and_ develop corrective actions to

. address'the. continued trend of operational incidents.

This included an

. independent review performed by senior plant operations management personnel from other utilities. Additional startup training was provided to operating

shift personnel and several short term improvement suggestions were implemented.

The short1 term improvements included overview training with procedure walk 1

throughsLfor. plant' operations in Modes 5 through 1.

Problem areas encountered during this startup and past startups were reviewed I

and subsequently-described in documented findings,by the Institute of Nuclear' Power Operations-(INPO). Toledo Edison QA personnel, and representetives from.

j other, Toledo Edison' organizations.

The aggregate of these findings', including-i

'thoseJidentified by.the NRC, was-reviewed to identify corrective actions and i

enhancements required to address common identified deficiencies.

Expectations,7 performance, and ownership will be stressed as the foundat!on for actions taken in response to the findings.

The expectations, performance.,and

-l ownership theme wil1~be pursued through a program which emphasizes management expectations,. monitors personnel adherence to-these expectations, and applies emphasis as necessary.

! Actions beingctaken under this program: include Management-Action Response JChecklist'(HARC) and assertiveness training for Operations supervisors to M

.. provide:them'with= skills in. coaching, counseling,.and supervising represented

personnel, The program stresses increased overnight by line supervisors to ensure expectations are being met and establishes review requirements for work activities to identify performance weaknesses and foster improvements.

~

Additional details are' included.in the response to Violation C.

j r

e r

5 o

I LD;ck t Numbsr 50 346:

[7SarialNumb9r1934 Licinst Numb 2r NPF-3 i

1 Attachmen-Page 3-y RESPONSE TO NOTICE OF VIOLATION Violation As

'10 CFR 20.201(b) requires that each licensee make or cause to be made such surveys as (1) may be necessary to comply with the regulations in this part, and (2) are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present.

10 CFR 20.201(a) defines a survey as an evaluation of the radiation hazards incident to the production, use, release, disposal or presence of radioactive materials or other sources of radiation under a specific set of conditions.

Contrary to the above, on April 25, 1990, the licensee transferred the reactor core support assembly from temporary storage and installed it in the reactor vessel.

However, the licensee failed to make an adequate survey, which was reasonable under the circumstances, to evaluate the extent of radiation hazards that may be present. As a result, several-workers received unplanned radiation doses."

(90012-01)

Acceptance of De:Jal of the Alleged Violation Toledo Edison acknowledges the violation as stated.

Reasoo for-the Violation

'On April'25, 1990 the reactor core suppoct assembly (CSA), which had been temporarily stored inLthe deep end of the= refueling canal,,was being lifted and

transferred to the reactor vessel in. preparation for core refueling.. During the lift,'the contracted. lift' specialist perceived a need to raise the CSA higher s

acut of the water than in a previous move. 'This was to assure that he had-adequate. clearance between the. lower end'of the CSA and obstructions whichtwere-

present

in:the shallow end of_the refueling' canal.

Prior: to performing the' CSA move, the work area had been walked down by1the j

i operations-Superintendent and a senior representative lfrom the contractor organization providing :the lif t specialist.

The obstructions which were present

'q in i shallow end offthe refueling canal were noted at that times however, it was m cermined that the obstructions would.not-pose a problem during the CSA

= move..The lift specialist was not present'for the walkdown.

The lift specialistiaiso did not attend a pre-job briefing and a subsequent ALARA t

briefing which were conducted on April 25, 1990, prior to the.CSA move.

1 U

7

. Additionally, Radiological Controls Group personnel had expeated a CSA position

.of'8> feet out of the water to be the maximum value for the 12ft for the. purpose' of' controlling radiation exposure.

However, the 8 foot position was not viewed

as;an-absolute limit by the lift specialist.

The primary concern of.the lift sapecialist was to complete the movement without damaging the CSA..JBased on hisi i

background, experience and'visualLobservation, the lift specialist felt it

'necessary to raise the CSA high enough to ensure adequate' clearance between the Ebottom of the CSA.and the shallow end of tha refueling canal. Althorgh the

. valueL of-8 feet out of the water was consf iered a limit, no special markings or measurements were available to determine ti-actual height of the CSA above the refuelingicanal water level-or the CP. psition relative to the refueling canal

floor.

j k

l

-D;ck]t Numb;r 50-346-

'Lic:nse-Humb2r NPF-3

_Strrial Numb;r 1-934 o

p Attachment Zu Page 4 i

Additional contributing factors to this event include the lack of. adequate management participation by TE personnel and insufficient detail on the Radiation Work Permit (RWP) used for the job.

j i

Corrective Actions Taken and Results Achieved l

Several assessments of the CSA lift incident were initiated in response to the l

event to determine the underlying causal factors. Actions taken as a result of i

' findings from these assessments are as follows:

i o

Other open RWP's were reviewed to determine whether common j

deficiencies existed.

Inadequate RWP's were canceled where appropriate.

o The administrative procedures governing RWP's (DB-HP-01901) and ALARA-job reviews (DB-HP-01800) were revised to' require separate RWP's for tasks with varying job requirements, c

Guidance was issued to TE management to ensure oversight and control

[

of majrr_ evolutions.

J o

The requirements.for pte-job'and ALARA briefings were reemphasized for applicable station' personnel.

l I

m o..

Responsibility for'the control of contractor activities has been' proceduralized.

,j Actions-to Avoid Further Violations j

U

.The'following additional corrective actions are to be taken:

01 Positive ' indication of. equipment position will be provided when moving j

2-equipment in the refueling canal using the polar crane.

j o

A maximum value will be established for CSA lifts with= provisions estab1'ished for verifying clearances between the CSA and refueling canal-floor / obstructions.

i The' commitment to complete the corrective actions listed'above was previously i

50~346/90014 (DRP).

{

, acknowledged in NRC Inspection' Report g

i Date When Full Compliance Will Be Achieved i

A modification'to provide position indication for the polar crane will~be

completed during the next scheduled refueling outage.

Specific controls for CSA.

.]

' lifts will be-in place prior to the next scheduled CSA movement.

j j

l 3

4

!)

1 u

' Dock 0t Numb?r 50-346

'Lic ns? Numbar NPF-3 s

Sericl? Number 1-934

-Page 5 Violation B:

10 CFR Part 50, Appendix B, Criterion V, as implemented by P

Section V of the licensee's Nuclear Quality Assurance Manual, requires that activities affecting quality be prescribed by documented instructions _ procedures, or drawings of a type appropriate to the circumstances and shall be accomplished in accordance with these_ instructions, procedures, or drawings.

Contrary to the above, examples of the licensee's failure to have procedures appropriate to the circumstances are listed below:

1.

Documented instructions in Procedure DB-0P-06023

" Fill, Drain, and Purification of the Refueling Canal," were not appropriate to the circumstances in that they neither addressed draining of the refueling _ canal with the indexing fixture in place not contained precautions about the potential loss of decay heat cooling from a partially filled reactor coolant system.

As a result, on May 1, 1990 reactor coolant -level in the reactor vessel was inadvertently lowered while draining the refueling canal.

(90012-03) 2.

Procedure DB-PF-10100, " Steam Generator 1 Hydrostatic Test,"

was not appropriete the o!rcumstances in that it did not i

evaluate the 'ef fe' 1

co ec+ing the steam generator level 11;u and did not require diverse, a

tap to the:contair.t_

=

level indicators or the monitoring of open vents. As a result, steam generator 1 was Geerfilled on May-23,.1990..

l-(90009-06)

Respon'se to Violation B.1 (90012-03):

Acceptance or' Denial of the Alleged Violation 4

Toledo Edison acknowledges : the violation cited in Part - B.1: above with the '

'following clarification.

Toledo Edison agrees that Procedure DB-0P-06023 was-deficient in:that'it did not address-the presence of the indexing fixture.

.i However, precautions for potential loss of' decay heat' cooling'from a partially Lfilled reactor coolant system 1(RCS) in Procedure DB-OP-06023 were not-considered appropriate.. Precautions _regarding the potential for a loss of decay heat

~

coolinB during reduced kCS. inventory conditions _are included in Procedures DB-OP 06002, " Draining and Nitrogen Blanketing of the RCS"siDB-0P-02527, " Loss 7

~

1 of~ Decay Heat Removal": and DB-OP-06012

" Decay Heat and Low Pressure. Injection I

Operating Procedure"._ Procedure DB-0P-06023, " Fill, Drain, and Purification of the_ Refueling Canal" is utilized for routine post-refueling drain down'of the.

refuelire mal.

This evolution'would not normally involve a potential for r'educti i RCS inventory.

The presence of-the indexing fixture in the

instance

e.ribed above represents an abnormal condition. Addressing this abnormal condition incthe draindown instructions would have precluded the need-m.

for consideration of precautions concerning the loss of decay heat' removal.

t

~Dockst Numb 2r 50-346'

~

,'Liccnsa Numb 2r NPF-3 S] rial Humbir 1-934

. Attachment 2 Page 6

' Reason for the Violation on' April 30, 1990, Operations personnel were performing a post refueling drain down of. the refueling canal.

The upper plenum assembly was installed inside the reactor vessel. The indexing fixture, used to align the upper plenum assembly during installation, remained seated on the reactor vessel flange.

When 11nstalled, the cylindrical indexing fixture extends approximately 6 feet above the, reactor vessel flange. A drain path for the evolution had been established from the RCS hot leg, through Decay Heat (DH) Pump 1-1 to the Borated Water Storage Tank (BWST).

The target level for the drain down was an elevation of-578'6' which is about 6 inches above the floor of the refueling canal and the 31

.incore tank.

A Reactor Operator (RO) had been aosigned the sole function of

~

jdraining the refueling canal.

The RO monitored the. refueling canal level i

' indicator, the BWST level indicator and the reactor vessel level indicator in-the Control Room, during the evolution.

The Shift Supervisor (SS) had requested

-the Containment Coordinator to monitor refueling canal level locally. An Equipment Operator.(EO) was assigned to go into containment when the refueling canal level-decreased to about 5 feet to observe the final portion of the refueling canal drain, ti The RO assigned to perform the drain down used the refueling canal level

-indication as the primtry level indicator.

The RO determined that refueling

. canal level had'been,decrecsing about 1 foot every 10 minutes after:the drain down began.

Some time later, the RO noticed that the reactor vessel level was continuing to decrease while the refueling canal level indicator remained 3

relatively: constant.

The RO then reduced _the drain rate by about two-thirds.

At~about the same time, the Containment Coordinator called the Control Room and 3

notified crsecond RO who was on shift, that he had visually observed,the indications just reported by the other R0.

The Containment Coordinator also t

mentioned the, presence of the indexing fixture over the reactor vessel.

The RO

~

performing the drain down thought that the inderE.g fixture was 1n'its stored position at the north end of the refueling canal.

The Containment Coordinator notified'the. Control Room'that they were starting.to-uncover-the plenum. :The RO draining'the canal stopped DH Pump 1-1~and secured the draining evolution.

LTlie Shif t Supervisor (SS) instructed the RO's to commence a gravity fill!of.the

' reactor vessel from the EWST to restore refueling canal level.

The SS laterthad

-the!1ndexing' fixture removed and'the draining of the refueling canal resumed 1

without further incident.

!The Radiological Controls (RC) Foreman in containment directed ~personne1Lto immediately leave the area when he noticed that the plenum was partially uncove re r'..

It-was'later determined that no increased personnel radiation exposure,resulted from'tl.e event.

The pritaary.cause for this event was attributed to the failure by operations t

personneleto recognize the effect'of the indexing fixture on the drain down j

concurrent with the. failure-to remain cognizant of the indexing fixture status.

Although this evolution-had beenl discussed among various shift personnel no tformal pre-evolution briefing or pre-evolution walkdown was performed.

During the investigation of this event it was also noted that the confusion concerning-

,the indexing fixture status was partially attributable to misinterpreted-1 information obtained from an outage short-interval overview schedule.

D:ck0t' Numb r=50-346

'LicGnss Huxber NPF-3

, Serial Numbsr 1-934 Page 7 t

Corrective Action Taken and'Results Achieved The Operations Sitperintendent issued an Operations Policy Hemorandum which provided guidance on responsibility and leaderstip of the Shift Supervisor to underscore existing policies and philosophy. Auditionally, this event was discussed with licensed operators with emphasis placed on the importance of pre-evolution walkdowns.

Actions to Avoid Further Violations The corrective actions listed below will be implemented to preclude similar incidents:

o Procedure'DB-CP-06023 " Fill, Drain, and Purification of the Refueling Canal" will be revised to state that when the indexing fixture is installed, only a partial drain of the refueling canal can be performed, o

The revision to DB-0P-06023 will also include a requirement that an operator be in containment to monitor draining of the refueling canal.

o Outage Hanagement personnel will ensure that changes to outage schedules are routed to Operations for-concurrence and approval.

l Date When Full Compliance Will Be Achieved i

The referenced changes to procedure DB-OP-06023 will be completed by LNovember"30, 1990'~ Administrative controle for ensuring that changes to outage schedules are reviewed and approved by.0perations will be in place by December 31, 1990.

Response to Violation B.2 (90009-06'):

sAcceptance'or Denial of-the Alleged Violation j

-Toledo Edison' acknowledges the violation as. stated.

Reason for the-Violation l

e 0'n May 23, 1990,- Steam Generator (SG) 1-1 was being. filled using the Motor Driven Feedwater Pump (HDFP) in preparation-for a secondary-side hydrostatic o

test' Performance Engineering Procedure DB-PF-10100, " Hydrostatic. Test of SGL1-1"- contained the instructions.for filling the SG and perfonnance of the ihydrostatic-test. 'the procedure instructions' required the SG to be filled to a' i

level of 610" and maintained at that level to increase the SG shell temperature l

tofabout 180 degrees F.

DB-PF-10100 also required-the reference leg for the SG ivide range indication to be lined up to the containment vent header.

The wide 4

l range indicator'was being utilized in conjunction with contact pyrometers and SG shell thermocouples to provide SG 1evel indication.

Procedure DB-PF-10100 did-not. require monitoring of vent paths prior to reaching 620".

i a

I r

Docket'Humb2r.50-346

• bicensh Number NPF-3

?.

' Serial;Humbir 1-934 Page.8 JThe water level in the SG stopped increasing at approximately 590".

It was later. determined that a positive back pressure of about 4 psi in the reference leg vent path was causing the indicated level in the SG to read lower than

' actual.

An obstruction in the vent line also caused pressure to build up in both the'SG and the vent line.

This resulted in water eventually being forced out through the' main steam line header.

The overfilling of the SG occurred due to the failure to identify and evaluate the effects of the pressure in the containment vent header.

Corrective Actions.Taken and Results Achieved i

Procedure DB-PF-10100 was revised to address the problem with the level 4

Indication and the hydrostatic test was satisfactorily completed on May 25 1990.

The Operations procedures for filling the secondary side of the SG and filling and venting the Reactor Coolant System (RCS) were also reviewed to determine whether a similar condition existed.

No additional problems were identifiedc i

Actions to Avoid Further Violations The, corrective action taken to resolve the procedure deficiency will be incorporated into the SG hydrostatic test for the second 10 year Inservice Test.

~DatelWhen Full Compliance Will Be Achieved Full. compliance with required corrective action was achieved upon sucr.easful completion of the hydrostatic test ~on.May 25. 1990.

4 ii f

. i,

" Technical Specification 6.8.1-requires that-written procedures

[

Violation Cai lue' implemented for activities listed in Regulatory Guide 1.33..

Appendix A.

Regulatory Guide 1,33, Appendix A lists among other things, the following activities:

(1) preparation for' refueling and refueling equipment-operation:'(2) authorities and responsibilities-for safe operation and shutdown (3), performing maintenance:-(4) equipment controls (5) shutdown cooling systems (6) cold shutdown to hot standby operating procedures -and (7) loss of component cooling system and' cooling to individual q

components.

l T

k 1

4 y

j

Docket-Number 50-346

' License Number NPF-3

e-Serial 4 Humber 1-934

'Page 9 Contrary to the above, examples of the licensee's failure to

-implement procedure described in Appendix A or Regulatory Guide 1.33, are shown belows' 1.-

Procedure DB-MN-00006, " Control of Lifting and Handling Equipment', Sections 6.1.8 and 6.1.9 require that detailed handling.'nstructions or procedures be prepared for items that require special handling.

The licensee neither issued special instructions nor were they contained in Procedure DB-HM-09092. " Reactor Vessel Internals Removal and Installation," which described a method for determining the clearance between the bottom of the core support assembly (CSA) and the top of objects in the refueling canal for the installation of the CSA on April 25, 1990.

As a result while transferring the CSA, a lift specialist unnecessarily raised the CSA thereby creating higher than expected radiation dose rates and unplanned radiation exposures.

(90012-02) 2, Procedure DB-OP-00000

" Conduct of Operations," Section 6.7.6, requires that prior to the performance of critical, complicated, unusual, or infrequent operations a procedure review be performed and briefings be conducted by the individual in charge of the solution.

However, the licensee did not identify during the' pre-evolution briefing that the indexing fixture was in place for the draining of the refuelingLcanal (an infrequent operation) on April 30, 1990.

Further, on June 21,'1990, the, licensee failed to hold a pre-evolution briefing prior to performance of DB-0P-06900, 6

" Leak Check of DH76 and DH77', (another infrequent operation).

(90012-04) 3.

Procedure DB-SC-04053, "4160 System. Transfer and Lockout Test Buses C1 and C2 " Step'4.2.10 requires that the licensee isolate only regulated rectifier-YRF3.

However, on May 18, 1990,. the licensee failed to-follow this procedure and isolated both inverter YV3 and regulated rectifier YRF3.

(90009-02) 4.

.Proceduce DB-0P-06012, " Decay Heat and Low Pressure Injection Operation Procedure," Section 14.2.3.a requires that, unless otherwise directed by the shif t supervisor, valve verifice.clon list.B-1 18 to be perforred.if Decay Heat Pump 1-1 will be used for recirculation.

Valve verification list B-1, Sheet 3, requires DH33'to be closed.

However, on May 22, 1990, while decay heat pump 1-1 was used for recirculation, the licensee found DH33 open and the shift supervisor had not directed otherwise.

(90009-03)

l Docket.Humb3r 50-346

'*Lic ns Number NPF-3

--7.x

-

• S3 rial-Humbar 1-934

' Attachment 2' Page 10 5.

Procedure DB-0P-06012

" Recirculation of BWST with a Decay i

Heat Pump " Section 14.1.1, requires that the Decay Heat (DH) Pump Suction Valves from the Reactor Coolant System (RCS) be closed before opening testa flow valves to the BWST if DH11 and DH12 are open.

Specifically, it requires that suction valves DH1517 and DH10 be closeu'before test valves DH66 and DH68 are opened.

However, on May 27, 1990, while DH11 and DH12 were open, the licensee opened test valves DH66 and DH68 while suction valve DH1517 was open.

(90009-04) 6.

Procedure DB-0P-06900, Attachment 16

" Leak Check of DH76 and DH77,* Step 5.0 requires that valve DH1B be closed before opening valve CF1B.

However 'n June 21, 1990, while-o performing a leak check of valves DH76 and DH77, the l

licensee failed to close valve DH1B before opening. valve CF1B.

(90013-2A) 7.

P roced;.e DB-0P-02512, " Loss of RCS Hakeup," Step 4.1.9.a.1, r' quires seal injection flow to be restored by slevly opening HU19 to achieve a 5 GPM rise every 2 minutes until i

normal flow of 36 GPM is reached.

However, on June-21, 7990, the licensee inadvertently shut off Makeup Pump No. I which interrupted seal injection flow and then immediately restarted the pump which caused full seal injection flow to be-restored immediately.

(90013-2B)

Acceptance or Denial of~the Alleged Violation

-Toledo' Edison acknowledges the violation as stated.

f Reason-For The Violation The examples included above illustrate: weaknesses in the areas of procedure

' adherence and attention to detail..Though each of the events described above "had minimal' safety significance by its own' merit; the-collective significance of

'the events' combine wita the frequency of the occurrences resulted -in-

~"'

progressively escalated actions by TE management which were described.

previous 4y.

These actions culminated with.the plant cooldown to Mode 5 on June 3l

21. 1990.'

j

)

J r

1 i

.i l

1 i

Docket Number 50-346

' License Humber HPF-3

~ Serial Number 1-934 Page 11 Corrective Actions Taken and Results Achieved Prior to resuming plant operations following the cooldown, several assessments of the. Operations department were performed by both TE and other utility management personnel. The results of these assessments included recommendations / suggestions for long-term and short term improvements to enhance the performance of Operations personnel.

The short-term recommendations were

- implemented prior to the resumption of plant startup on June 30, 1990.

These actions included a review of the causes and circumstances for the events described in the violations A, B and C above, overview training for plant

=

operations in Modes 5 through 1 with procedure walkthroughs and discussions with Operations personnel to emphasize Operations policies.

Specific corrective actions for_the examples detailed in Violatio. C vere briefly discussed during

- an enforcement conference on June 1, 1990 and a subsequent telephone enforcement conference conducted on July '17, 1990. The corrective actions include procedure revisions. and enhancements in addition to the-overall corrective actions stated previously.

Required Actions to Avoid Further Violations L~

To address the areas of weakness which wera identified in Violation C, a program was initiated by Operation Section Management personnel to improve the teamwork and performance of Operations personnel. As stated previously in the " Synopsis of Toledo Edison Management Actions", this program was also intended to address Z

similar weaknesses identified by INPO, peer utility groups, and TE personnel.

Emphasis will be increased on Operations manager, superintendent, and first-line supervisor oversight of performance issues as part of the improvement program.

Performance issues will include radiological control practices, procedural compliance, communications.-and safety. Additionally, Operations first-line 1 supervisors will be responsible.for the root cause analysis of Potential

==

Con'ditions' Adverse to Quality (PCAQ) issues and.for'the development of corrective action to prevent recurrence on issues that affect their work groups.

LShiftiSupervisors-andAssistantShiftSupervisors.will'completeManagement

' Actiori Response Checklist (MARC) and Assertiveness training by March,.1991.

1 1

.This; training focuses on methods to correct and coach subordinates. - Observation training will be provided for first-line. supervisors.to. improve their techniques for observing-personnel performance.

In the interim, Operations-supervisors will employ the philosophy and concept of Management by Walking:Around-(MBWA) to-

. assess the following personnel related issues:

o Consistent application of component status verification 0

Procedure compliance o

Communications

(

=0 Radiological control work practices

o

Safety

.o Material condition jg-g

-=

ns

j Dock;t.Humb2r 50-346

' bic%nsa Numb:r MPF-3

~

Sari:1;Humb;r 1-934

- Attachment 2-Page'12 A' peer review program will be im,_3mented by January, 1991 to provide monitoring of Operations activities by other station personnel-(e.g., Maintenance, Quality s

Assurance, and Engineering).

Strengths, weaknesses and suggestions for improvement will be identified through the peer reviews and implemented, as applicable by the operations section.

Operational events will be trended by Operationo management personnel to identify problem areas and provide feedback cto operators.

Dste When Full Compliance Will be Achieved Various target dates'have been established for implementing facets of the

-overall Operations improvement program.

This program will be periodically ansessed by the TE Quality Assurance organization to determine the progress and.

l effectiveness of the program.

' Itfis expected that meteurable progress in achieving the objectives of the

-l Operations Improvement Program can be demonstrated by March 29, 1991.

?

4 as e

5 N.

~

s I

s b'h 1

4 Y

r T

l