ML20058H950

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Discusses 931202 Enforcement Conference in Region IV Ofc Re Apparent Violations Identified in Insp Repts 50-445/93-41 & 50-446/93-41
ML20058H950
Person / Time
Site: Comanche Peak  Luminant icon.png
Issue date: 12/06/1993
From: Beach A
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To: William Cahill
TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC)
References
NUDOCS 9312130287
Download: ML20058H950 (42)
v • d • e


See also: IR 05000445/1993041

Text

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d NUCLEAR REGULATORY COMMISSION N

' f -) E REGION IV . f 611 RY AN PLAZA DRIVE, SUIT E 400 <, AR LINGTON, T E X AS 76011 8064

DEC - 61933 Dockets: 50-445 50-446 , Licenses: NPF-87 NPF-89 TU Electric ATTN: W. J. Cahill, Jr., Group Vice President Nuclear Engineering and Operations Skyway Tower 400 North Olive Street, L.B. 81 Dallas, Texas 75201 SUBJECT: MINUTES OF ENFORCEMENT CONFERENCE HELD DECEMBER 2, 1993 r This refers to the enforcement conference conducted at NRC's request in the Region IV office on December 2, 1993. This enforcement conference related to the apparent violations identified in NRC Inspection Report 50-445/93-41; 50-446/93-41, dated November 24, 1993, and was attended by those on the attached Attendance List. The subjects discussed in the meeting included a review of the events, your initial and long-term corrective actions, the nuclear safety significance of , the events, generic implications, the effectiveness of past corrective actions, and your clarifications related to the inspection report. We found the discussions beneficial and believe that they provided us with a better understanding of the events and the circumstances surrounding them. This information will be factored into our final decisions regarding this enforcement matter. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, , Title 10, Code of Federal Regulations, a copy of this letter will be placed in the NRC's Public Document Room. Should you have any questions concerning this matter, we will be pleased to discuss them with you. Sincerely,

1000?u u ,ab A. Bill Beach, Director Division of Reactor Projects ] Attachments: , 1. Attendance List ) 2. Licensee Presentation (NRC distribution only) i [l/j h I 93 2130287 931206 6 i ! I PDR ADOCK 05000445 O PDR t/ .. , , _ . .

. ' ' % TU Electric -2- l cc w/ Attachment 1:

TU Electric ATTN: Roger D. Walker, Manager of Regulatory Affairs for Nuclear i Engineering Organization

Skyway Tower 400 North Olive Street, L.B. 81 l Dallas, Texas 75201 } Juanita Ellis president - CASE

1426 South Polk Street Dallas, Texas 75224 i GDS Associates, Inc. Suite 720 1850 Parkway Place , Marietta, Georgia 30067-8237 TU Electric Bethesda Licensing i 3 Metro Center, Suite 610 Bethesda, Maryland i0814 Jorden, Schulte, and Burchette ', ATTN: William A. Burchette, Esq. . Counsel for Tex-La Electric Cooperative of Texas 1025 Thomas Jefferson St., N.W. Washington, D.C. 20007 , Newman & Holtzinger, P.C. ATTN: Jack R. Newman, Esq. 1615 L. Street, N.W. Suite 1000 Washington, D.C. 20036 Texas Department of Licensing & Regulation

ATTN: G. R. Bynog, Program Manager / f Chief Inspector Boiler Division , l P.O. Box 12157, Capt 'Statit

Austin, Texas 78711 i Honorable Dale McPherson , County Judge P.O. Box 851 i Glen Rose, Texas 76043 i i ! s - -

. . . _ ___. _ _ _ _ ._ _ . . . 3. . TU Electric -3- Texas Radiation Control Program Director 1100 West 49th Street Austin, Texas 78756

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DEC - 6 MB3 TU Electric -4- i i bec to DMB (IE45) ! bcc distrib. by RIV- J. L. Milhoan Resident Inspector (2) i Section Chief (DRP/B) Lisa Shea, RM/ALF, MS: MNBB 4503 , MIS System DRSS-FIPS , ! RIV File Project Engineer (DRP/B) Section Chief (DRP/TSS) i i > ! !

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- ._ __ ' ATTACHMENT 1 . I $NFORCEMENT CONFERENCE ATTENDANCE ' . . LICENSEE / FACILITY TU Electric ' TIME /DATE December 2, 1993, 1 p.m. l MEETING LOCATION Region IV Training Conference Room EA NUMBER EA 93-275 NAME (PLEASE PRINT) ORGANIZATION TITLE

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ENFORCEMENT CONFERENCE ATTENDANCE . . LICENSEE / FACILITY TU Electric

TIME /DATE December 2, 1993, 1 p.m. l MEETING LOCATION Region IV Training Conference Room EA NUMBER EA 93-275 i i-

NAME (PLEASE PRINT) ORGANIZATION TITLE r6c2 M.GL uhs $ base sh 4 dasesh sec& e % s - e . 's 00hh& W &. Y9691 &fpgjg](, JU){N i i , i . h , i 1 1 ! ' i ! ! l ? l - d

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7 --- "- .= = TUELECTRIC CPSES-9317950 c. u nce Terry November 30,1993 % irr Persostent TO: Managers & Supervisors SUBJECT: Management Use of the Seven Steps of Self Verification Over the last two years we have placed significant emphasis on our expectations ' for use of the Seven Steps of Self Verification by our personnel. Although the majority of this emphasis was directed to individuals performing hands-on work in the field or in the shop, many of you have interpreted your expectations for personnel doing non-manual work. Personnel error trend rates indicate that our efforts are providing positive results. Although we have not eliminated personnel errors, we have achieved a steadily decreasing number of total personnel errors, and an even more pronounced decrease in significant personnel errors. Those trends are encouraging, and are attributable in large part to your emphasis on your expectations, reinforced by your presence in the field to assure those expectations are understood and properly implemented. We need to continue this emphasis on procedural compliance and self verification by our people, assuring that our people do the ' job right. Several ev,ents which have occurred during 1RF03, however, indicate that we need to take another step to improve our total performance. We need to better j understand how to perform self verification to enhance cur role as managers. Self verification for managers and supervisors is different, because our role is different. We expect our personnel to follow procedures and to routinely practice self verification, i.e., "we want our personnel to do things right". Doing things right will normally prevent us from making significant mistakes; BUT NOT ALWAYS. Another key factor to ensure success is "doing the right thing". We, as managers and supervisors, play a key role in achieving this factor. Our major . function is to think about how to put our personnel into position to perform activities properly, and how to avoid putting our personnel into situations i which could challenge plant or personnel safety. We need to ensure that we are doing the right thing before our people can consistently do things right. If we do both, we have a very high probability of success. . P.O Box K02 Glen Rose.Tetas 7(043 i

. 4 . . CPSES-9317950 November 30,1993 Page 2 i What do i mean by "doing the right thing"? The Seven Steps are somewhat different for management. Our actions should proceed along these lines:

, STCP AND THINK What activity is scheduled? Is there a procedure that addresses the activity? What are the plant conditions? Are the plant conditions such that the procedure can safely be used? , VERIFY READINESS Who will be doing the task? Does the individual have the procedure? Does ! the individual have the required tools? Has the individual been trained on the i task? Has it been done before? How long ago? Is a briefing necessary?

ANTICIPATE THIS IS ONE OF YOUR M 3ST IMPORTANT FUNCTIONS. Can the procedure be used with the existing p' ant conditions? What problems could result? Is there other work that might 3e affected? Am I protecting the plant? Am I protecting the employee? AM i DOING THE RIGHT THINGS? What do I expect to see? What should be monitored? What contingency plans do I need to , prepare to take? i MANIPUL' ATE , Brief the people who will be doing the job. Are the right people available? Who's ! in charge? Have I properly communicated my expectations and precautions? 1 Do affected personnel know what plant conditions are, and how they can affect, ' or be affected by, the planned activity? Do personnel performing the activity have

the procedure and required tools available? Do personnel understand what l potential problems might occur, what to monitor, and what action to take should problems occur? Have proper communications been established, and are people in place to take required corrective action if potential consequences warrant? . i . k ! e . - .

. - . .. _- .. -- . .- . . - . .- . , ., . . ,

CPSES-9317950 November 30,1993 l Page 3 , < . ' OBSERVE Monitor the performance of the task. Be ready to immediately implement

' contingency actions if necessary. If your planning was right -if you are doing the right thing - then your people should be able to do things right and get the ' < expected results. , . We have achieved good success by implementation of our Seven Steps of Self Verification. I encourage each of you to discuss these management , ' responsibilities'amongst yourselves, and implement those actions necessary_ to continue our improvement. , i ! ! / L N ! - C. L. Terry E01 l ! CLT/seg ! cc: CCS E06 [ t ! , O d .i .; , - i , l . ! i 'l

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COMANCHE PEAK STEAM ELECTRIC STATION (CPSES) i i NRC ENFORCEMENT CONFERENCE ON UNIT 1 REFUELING CAVITY DRAIN EVENTS 9 i

- 1 DECEMBER 2, 1993

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',.*l ~ . .' A_GENDA OPENING REMARKS LANCE TERRY 1. BACKGROUND LANCE TERRY 2. SYSTEM DESCRIPTION J0E DONAHUE 3. DESCRIPTION OF EVENTS J0E DONAHUE ' 4. IMMEDIATE CORRECTIVE ACTIONS J0E DONAHUE 5. NUCLEAR SAFETY SIGNIFICANCE J0E DONAHUE OF BOTH EVENTS 6. ISSUES J0E DONAHUE 7. PREVENTIVE ACTIONS J0E DONAHUE i 8. GENERIC IMPLICATIONS JOE DONAHUE 9. EVALUATIONS OF INDUSTRY DOUG DAVIS EXPERIENCE 10. EFFECTIVENESS OF PAST LANCE TERRY CORRECTIVE ACTIONS 11. CONCLUSIONS LANCE TERRY 12. CLARIFICATIONS RELATED TO NRC ROGER WALKER .i INSPECTION REPORT 2

. .. . . . 4 . i 1. BACKGROUND o UNIT 1 IN REFUELING OUTAGE (1RF03) , o ENTIRE CORE OFFLOADED PER TU ELECTRIC PRACTICE o FUEL BUILDING ISOLATED FROM CONTAINMENT .

, o NO FUEL OR IRRADIATED COMPONENTS IN REFUELING CAVITY, TRANSFER TUBE, OR TRANSFER CANAL o REFUELING CAVITY LIFT GATE USED TO PERMIT MAINTENANCE WITHOUT DRAINING AND DECONTAMINATING ENTIRE CAVITY o AT THE TIME OF EVENTS, LIFT GATE WAS NOT PERFORMING ANY NUCLEAR SAFETY FUNCTION

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'. ' - . , . 2. SYSTEM DESCRIPTION o LIFT GATE WITH INFLATABLE SEAL SEPARATES THE REFUELING CAVITY INTO WO AREAS o LIFT GATE PERMITS DRAINDOWN OF EITHER AREA 0F REFUELING CAVITY FOR MAINTENANCE, WHILE MAINTAINING WATER LEVEL IN OTHER AREA o REFUELING CAVITY FUEL TRANSFER AREA IS SEPARATED FROM THE FUEL BUILDING TRANSFER CANAL BY FUEL TRANSFER TUBE GATE VALVE o TRANSFER CANAL IS SEPARATED FROM SPENT FUEL POOLS (SFP) BY SWING GATES WITH INFLATABLE SEALS o N0 GATE FAILURE WILL RESULT IN UNCOVERING STORED FUEL o REFUELING CAVITY LIFT GATE SEAL CAN BE PRESSURIZED WITH N, BOTTLES OR INSTRUMENT AIR o SERVICE AIR CONNECTION IS ALSO AVAILABLE IN ) CONTAINHENT BUT NOT AUTHORIZED BY SOP-506 4 - - - - - - - - - - - - - - - - - - -

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, . . 3. DESCRIPTION OF EVENTS !

o OCTOBER 23 i 1 INITIAL CONDITIONS: REFUELING CAVITY AND - REACTOR COOLANT SYSTEM (RCS) FLOODED, CORE OFFLOADED INTO SFP #1 WITH SWING GATE CLOSED-, TRANSFER TUBE GATE VALVE CLOSED, REFUELING CAVITY LIFT GATE INSTALLED, AND PRESSURIZED- WITH N2 INITIAL LEAK IDENTIFIED, FITTING CHANGED, AND - LEAK APPEARED TO HAVE STOPPED. DRAINING OF REACTOR VESSEL AREA COMMENCES - LEAK IN SEAL IDENTIFIED AND WORK REQUEST ISSUED - TO LOCATE SPECIFIC LOCATION OF LEAK SEAL DETERMINED TO BE FUNCTIONAL BECAUSE - PRESSURE SUPPLY COMPENSATES-FOR LEAK o OCTOBER 24 SHIFT SUPERVISOR (SS) AND DUTY MANAGER (DM) - DISCUSS-TRANSFER FROM N, TO SERVICE AIR BECAUSE OF N, UTILIZATION RATE -- THEY DID NOT REALIZE THAT SOP-506 REQUIRED USE OF INSTRUMENT AIR OR N, 5

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! -- RECOGNIZED PLAN REQUIRED ISOLATING SERVICE AIR FOR LOCAL LEAK RATE TESTING (LLRT) IN THE NEAR TERM, BUT UNDERSTOOD THAT THE LLRT WOULD BE RESCHEDULED DURING TRANSFER, PERSONNEL RESTRICTED FLOW FROM - PRESSURE SUPPLY HOSE TO PREVENT PRESSURE LOSS BECAUSE NO BACKFLOW PREVENTION DEVICE WAS PROVIDED. THEY DID NOT PERCEIVE THIS AS A PROSLEM . o OCTOBER 25 STEAM GENERATOR (S/G) MANWAYS ARE OPENED AFTER - DRAIN DOWN OF REACTOR VESSEL AREA WAS COMPLETED THE POTENTIAL FOR WATER DRAINING PAST THE SEAL - INTO THE REFUELING CAVITY WAS NOT RECOGNIZED BY MANAGEMENT OR THOSE RESPONSIBLE FOR THE S/G WORK o OCTOBER 26 - FIRST EVENT SS DIRECTS THE FIELD SUPPORT SUPERVISOR (FSS) - IN THE CONTAINMENT TO TRANSFER FROM SERVICE AIR TO N, TO PERMIT LLRT, AS ORIGINALLY PLANNED FSS NOT AWARE OF REACTOR CAVITY LIFT GATE - PROVISIONS IN S0P-506, AND WAS NOT FAMILIAR WITH THE TASK . 6

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FSS RECOGNIZES WATER LEAKING PAST THE GATE AND - RESTORES SERVICE AIR, STOPPING FURTHER WATER LOSS o OCTOBER 26 - SECOND EVENT DRAIN DOWN OF REFUELING CAVITY FUEL TRANSFER - AREA IS PLANNED USING PROCEDURES AND DRAWINGS AS PART OF CORRECTIVE ACTION FOR FIRST EVENT FOR DRAIN D0WN, SOP-110A STATES THAT ONE OR - BOTH VALVES 1SF-0026 AND 1SF-0025 ARE TO BE OPENED i UNIT SUPERVISOR (US) AND REACTOR OPERATOR (RO) - INCORRECTLY MARK-UP DRAWINGS AND PROCEDURES - PER MARKED UP DRAWINGS AND PROCEDURES, BOTH VALVES OPENED, RESULTING IN OPEN SLUICE PATH i WATER RE-ENTERS REACTOR VESSEL AREA - WATER FLOW STOPPED BY CLOSING THE DRAIN VALVES - 7 . - - - -

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. 4. IMMEDIATE CORRECTIVE ACTIONS , o CLEAN-UP AND DECONTAMINATION o RESTRICTION OF RCS AND CAVITY WATER MOVEMENT o ENHANCED PROCEDURES FOR FUEL BUILDING GATES o PROVIDE ADDITIONAL TRAINING FOR FUEL BUILDING GATES o CONSISTENT WITH PAST PRACTICE, REVISED PROCEDURES TO PRECLUDE STORAGE OF SPENT FUEL OR IRRADIATED COMPONENTS IN REFUELING CAVITY WHEN ONE SIDE IS DRAINED o INCREASED MONITORING OF FUEL BUILDING GATES o REVIEWED OTHER REFUELING EQUIPMENT PRIOR TO USE i FOR RELOAD TO CONFIRM ADEQUATE PMs o ASSIGNED SYSTEM ENGINEER FOR REFUELING GATES AND SEALS o ISEG RECONFIRMED ADEQUACY OF SHUTDOWN ANALYSIS FOR OTHER REFUELING ACTIVITIES o CPSES HAS FILLED TRANSFER CANAL AND PARTIALLY j FILLED #2 SFP AS ADDED PRECAUTION ! o ESTABLISHED TASK TEAM l 8

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u )/, gbh r / \\ \\ .t i a.\\, e . ,' / w - l - 1 /,' / . . u,, f*'n'"wt"'*E f 5 C /. ' / \\ v uw g aj i < NfI @.j , l'J l AFi,k 4 ,:*:, ca:/,": . m x n - -.. .- r , . x,; w. . n. u c,s q ~- - y, g .e,:;.r.m. = y - } . _ _ps e r . / U .i ~ ~ l y , __ U ? ,_ ..[thi hh !",,*"j *, * J @g}' 4 o 6 , -

\\ I .- . ,,t= o m .. / . % ,,'..,4 , ,, > \\. , ,, , < ,, N ' t ' .5 (y} . l u . ~,. . gja m= " ' ' * * * .y , l - Pt AN AT EL 860'-0* . . FUEL HANDLING AND STORAGE LIFT GATES AND SWING GATES . . f - - __ . . . . . - . . - u m-.u .-. m m--. -- m mm- aw em = .*.,4-a e=w e mem.am--se ma*wey.ee1w-e,4r.. wsgmerrg.-ve m& =%=use w w15gM*=e-*4frw*4sw5-1 re e 99.-* + - mew =mre.-eP

-

.. . . . . 5. NUCLEAR SAFETY SIGNIFICANCE OF BOTH EVENTS o REFUELING CAVITY WAS ISOLATED FROM FUEL BUILDINS o LIFT GATE WAS NOT PERFORMING A NUCLEAR SAFETY FUNCTION i ' o MINOR SHOE AND EQUIPMENT CONTAMINATIONS o POTENTIAL CONSEQUENCES WERE LIMITED BY PROCEDURES WHICH PROHIBIT OPENING OF FUEL TRANSFER TUBE VALVE WHEN REFUELING CAVITY IS DRAINED DOWN o ASSESSMENT OF OTHER POTENTIAL SCENARIOS IF IRRADIATED COMPONENTS OR SPENT FUEL WERE - STORED IN REFUELING CAVITY FUEL TRANSFER AREA ) DURING THE EVENTS THEN: ADEQUATE COOLING AVAILABLE FOR ANY SPENT -- FUEL ADEQUATE SHIELDING AVAILABLE -- DOSE RATE -- ' WOULD BE LESS THAN 2.5 MREM /HR AT EL. 860' 4 , 9

"; e , . 6. ISSUES o MATERIAL CONDITION MECHANICALLY INDUCED DAMAGE IS THE CAUSE OF - LEAK i LEAK IN SEAL SET THE STAGE FOR POTENTIAL LOSS - OF SEAL PRESSURE DUE TO NEED TO CHANGE PRESSURE i SOURCE (EVENT PRECURSOR) - EVALUATION OF THE LEAK LEAK PERCEIVED TO BE SMALL AND PRESSURE TO -- SEAL WAS BEING ADEQUATELY MAINTAINED WORK REQUEST WRITTEN AS A CORRECTIVE ACTION -- DOCUMENT, CONSISTENT WITH PROCEDURES PREVENTIVE MAINTENANCE ISSUES - o PERSONNEL PERFORMANCE PERSONNEL DID NOT FULLY APPRECIATE THE - POTENTIAL FOR FAILURE OF THE GATE, AND THE ASSOCIATED HIGH FLOW RATES AND IMPACTS OF THESE ACTIVITIES ON PERSONNEL SAFETY i SS DID NOT TELL FSS TO USE S0P-506, AND FSS WAS - NOT AWARE OF SOP-506 AND DID NOT PREVENT DEFLATION 10

'

, _ . , IMPRECISE COMMUNICATION REGARDING AUTHORIZATION - FOR TRANSFER ON OCTOBER 24, 1993 - USE OF SERVICE AIR NOT CONSISTENT WITH S0P-506 US AND R0 INCORRECTLY MARKED DRAWINGS AND - PROCEDURES o CONFIGURATION CONTROL PERSONNEL MODIFIED PRE-STAGED H0SE - INSTRUMENT AIR MORE THAN 100 FEET FROM LIFT - GATE . DOCUMENTATION - DESIGN BASIS DOCUMENTS (DBDs) DID NOT -- ADDRESS GATES AND SEALS i TECHNICAL INFORMATION/ VENDOR RELATED ISSUES < -- o PROCEDURES SOP-506 DID NOT CONTAIN SUFFICIENT GUIDANCE - S0P-110A DID NOT CONTAIN CAUTION TO WARN OF - POTENTIAL FOR SLUICE PATH 11 - - .

~ .; .:

. ! 7. PREVENTIVE ACTIONS l l 0 MATERIAL CONDITION ! REPLACE UNIT 1 REACTOR CAVITY LIFT GATE SEAL - ESTABLISH PREVENTIVE MAINTENANCE PROGRAM FOR j - SEALS WHICH CONSIDERS VENDOR MANUAL AND

INDUSTRY. PRACTICE l

EVALUATE DESIGN MODIFICATION TO PROTECT SEAL - l FROM POSSIBLE DAMAGE ' , LESSONS LEARNED FROM EVALUATION OF LEAK

- o PERSONNEL PERFORMANCE i RE-EMPHASIZE NEED FOR MANAGEMENT TO EVALUATE - PLANNED ACTIVITIES FOR POTENTIAL ADVERSE l IMPACTS RE-EVALUATE SCOPE OF OUTAGE TRAINING -

i

LESSONS LEARNED ON EFFECTIVE COMMUNICATIONS

- s LESSON LEARNED ON PERSONNEL SAFETY - . l RE-EMPHASIZE THAT THE SCOPE OF PLANNING AND - - SCHEDULING INCLUDES PERSONNEL SAFETY , 12 . g- .=g y - --ww. 9- - - - n. - g

.; .: . ENHANCE OPERATIONS PROCEDURES TO REQUIRE - CONTINGENCY PLANS FOR POSTULATED SEAL LOSS o CONFIGURATION CONTROL INCLUDE PROVISIONS IN PROCEDURES TO CONTROL - REFUELING PRE-STAGED HOSES \\ EVALUATE DESIGN CHANGE TO RELOCATE INSTRUMENT - AIR OR PROVIDE FILTER FOR NEARBY SERVICE AIR CONNECTION REVISE DBDs TO ADDRESS GATES AND SEALS - . EVALUATE AMENDMENT TO FSAR TO PROHIBIT STORAGE - OF SPENT FUEL OR IRRADIATED COMPONENTS IN ' REFUELING CAVITY FUEL TRANSFER AREA UNLESS REFUELING CAYITY IS FULLY FLOODED EVALUATE ALTERNATIVE SEAL CONFIGURATIONS FOR - FUTURE USE o PROCEDURES - PROVIDE ADDITIONAL GUIDANCE ON INSTALLATION AND USE OF GATE AND TRANSFER OF PRESSURE SUPPLY - ADD CAUTION STATEMENT TO S0P-110A 13

. ..

. . 8. GENERIC IMPLICATIONS o MATERIAL CONDITION - CALCULATION DEMONSTRATES TRANSFER CANAL AND REFUELING CAVITY LIFT GATE SEALS RADIATION DOSES WELL BELOW SPECIFICATION - CUMULATIVE RADIATION EXPOSURE OF NUMBER ONE POOL SWING GATE SEAL IS WITHIN SPECIFIED RADIATION LIFE - NEED FOR REPLACEMENT OF SEALS WILL BE EVALUATED CONTROLS HAVE BEEN ESTABLISHED PREVENTING -- RELIANCE UPON SEALS PENDING EVALUATION RESULTS - SPENT FUEL P0OL GATE SEALS ARE ABLE TO PERFORM THEIR FUNCTION PERIODIC CHECKS HAVE CONTINUED TO CONFIRM -- SEAL INTEGRITY VENDOR INSPECTIONS AND DESTRUCTIVE -- EXAMINATIONS OF LIFT GATE SEAL IDENTIFIED OVER TOROVING OF SEAL STEM EUT THAT OTHERWISE SEAL IS CAPABLE OF PERFORMING ITS FUNCTION ! 14 i t

. . __ _ _ _ . - _ . . _. . _ _ _ _. __ . 'c

.

.. ' l - REVIEWS-0F SCOPE OF PM PROGRAM ! OUR REVIEW INDICATES THAT ITEMS TAGGED- -- PRIOR TO 1989 WERE ADEQUATELY REVIEWED FOR l INCLUSION IN PM PROGRAM - ' GATES AND SEALS WERE NOT TAGGED PRIOR TO -- 1989 . ! REVIEWS WERE PERFORMED BY. SYSTEM ENGINEERS -- - TO IDENTIFY ANY OM ER UNTAGGED EQUIPMENT; ! REFUELING EQUIPNENT WAS IDENTIFIED..AS- UNTAGGED

REVIEW 0F PMs AND IMPLEMENTATION.FOR l -- REFUELING EQUIPMENT (UNIT 1 AND COMMON) SHOWED ONLY MINOR DISCREPANCIES WHICH DID NOT IMPACT FUNCTION OF EQUIPMENT EVALUATE TAG NUMBERS ADDED SINCE 1989 TO -- ASSURE INCLUSION IN PM PROGRAM , -- WILL REQUIRE PR0 GRAMMATICALLY THAT NEW TAG . NUMBERS ADDED BE REVIEWED FOR PMs . o PERSONNEL PERFORMANCE l , - OBSERVATIONS INDICATE THAT PERSONNEL ARE AWARE OF AND USE PROCEDURES , ! - ONE FORMS INDICATE THAT PERSONNEL ARE REPORTING PROBLEMS IN THE FIELD , , 15- . , , , ,, e.-. - , . - - - , ,c-

.; .: . . . - PERFORMANCE ENHANCEMENT PROGRAM (PEP) DATA INDICATE THAT OVERALL PERFORMANCE HAS BEEN IMPROVING - PROCEDURES REQUIRE CONSIDERATION OF PERSONNEL SAFETY FOR PLANT CONDITIONS 0 CONFIGURATION CONTROL - WE HAVE ADEQUATE CONTROLS ON OTHER PRE-STAGED EQUIPMENT - REVIEWS HAVE DEMONSTRATED ADEQUACY OF DBDs i ' o PROCEDURES l - EXISTING PROCEDURE REQUIRES PERSONNEL TO REPORT PROCEDURE CONCERNS PRIOR TO IMPLEMENTATION - RE-EVALUATE REFUELING ACTIVITIES TO CONFIRM THAT ADEQUATE PROCEDURES EXIST ) l 4 16

. . .- .v . . - . f , . I 9. EVALUATIONS OF INDUSTRY

' EXPERIENCE 0 PREVIOUS INDUSTRY EVENTS INVOLVED: - SPENT FUEL POOL GATE SEALS - REACTOR CAVITY SEALS THAT ARE FUNDAMENTALLY DIFFERENT FROM CPSES SEALS o LESSONS LFARNED FROM INDUSTRY EVENTS - INFLATABLE REACTOR VESSEL SEALS ARE VULNERABLE TO FAILURE j - AIR SUPPLIES MAY NOT BE RELIABLE - PLANNED COMPENSATORY ACTIONS FOR SEAL FAILURES i MAY NEED ENHANCEMENT , - SEAL MATERIAL INTEGRITY WAS NOT AN ISSUE IN PREVIOUS EVENTS o CPSES PERFORMED EVALUATIONS OF FUEL BUILDING GATES WHICH FOCU3ED ON: - SINGLE AIR SOURCE RELIABILITY - AIR SUPPLY PATH VULNERABILITY 17

.: . . - . . - ACCEPTABILITY OF COMPENSATORY ACTIONS o EVALUATIONS VERIFIED EXISTENCE OF APPROPRIATE PROTECTIVE ACTIONS FOR FUEL BUILDING GATES - PROCEDURES FOR ESTABLISHING THE SPENT FUEL POOL SYSTEM GATE SEALS - DOUBLE INDEPENDENT SEALS ON SWING GATES - POPPET VALVES RETAIN SEAL PRESSURE WHEN PRESSURE SUPPLY HOSE IS DISCONNECTED - PRESSURE SUPPLY CONNECTED ONLY TO ONE OF TWO SWING GATE SEALS TO PROTECT AGAINST SINGLE FAILURE OF PRESSURE SUPPLY - BACKUP PRESSURE SUPPLY AVAILABLE - SHIFTLY CHECKS OF PRESSURE AND LEAKAGE - PROCEDURES FOR LOSS OF SEAL PRESSURE OR PRESSURE SUPPLY 1 - LEVEL, TEMPERATURE AND RADIATION ALARMS FOR DETECTING GROSS SEAL LEAKAGE ) o EVALUATIONS HAD SOME ERRORS AND DID NOT FULLY CONSIDER REACTOR CAVITY LIFT GATES 0 EVALUATIONS ARE BEING CORRECTED 18 ]

. - .

. ., . . . . . ! . o INTERNAL AND INDEPENDENT REVIEWS HAVE CONCLUDED

THAT CPSES OPERATING EXPERIENCE PROGRAM HAS BEEN

l EFFECTIVE o-A SUBSET OF PREVIOUS EVALUATIONS OF INFORMATION ' NOTICES WILL BE REVIEWED TO CONFIRM THEIR ADEQUACY ! ! l t I i 19 4 -a u w

. . - _ . .- _ . . . ..

y . - . . . .: ? - 1 ' 10. EFFECTIVENESS OF PAST CORRECTIVE ACTIONS

L <. o CORRECTIVE ACTIONS FOR PREVIOUS EVENTS .

- PERSONNEL ERRORS HAVE BEEN DECREASING f -- TU ELECTRIC HAS TAKEN EXTENSIVE ACTIONS TO l IMPROVE PERSONNEL PERFORMANCE i -- MEETING GOALS FOR BOTH PERSONNEL ERRORS AND

SIGNIFICANT PERSONNEL ERRORS THROUGH FIRST THREE QUARTERS OF 1993

-- SIGNIFICANT PERSONNEL ERROR RATIO IS ONE

l

HALF 0F 1991-1992 - EXTENSIVE TRAINING PROVIDED IN PREPARATION FOR THE OUTAGE, INCLUDING REVIEW 0F PAST SIGNIFICANT .! - CPSES EVENTS AND INDUSTRY EVENTS WITH OPERATIONS

PERSONNEL o REVIEWED PIRs SINCE SPRING 1992 TO IDENTIFY ANY RECURRING FACTORS q - ROOM FOR IMPROVEMENT IN SUPERVISION i - ACTIONS TAKEN INCLUDE THE FOLLOWING: ) -- SELF-VERIFICATION FOR SUPERVISORS- 20 .. -.

. _ _ _ _ _ ., . . - . . l ! RE-EMPHASIZE THAT ROLE OF SUPERVISORS IS- i -- l DIRECTING AND OVERVIEWING, NOT-PERFORMING RE-EMPHASIZE NEED FOR MANAGEMENT TO EVALUATE ) -- PLANNED ACTIVITIES FOR POTENTIAL ADVERSE IMPACTS i 21 . -_

^

- - 4 y .. . . - . . ' . Total Personnel Error Rates From 1/4/92 -11/20/93

Based on a Holling 26 Week Ratio of ONE Forms with Construction and Startup Data Removed t , 2 000 -- i 4 i800 - ' t600 _ f 400 ' 1 ' 1200 2 t.000 Final 0 Comptetion and {o800 tenup of Unit RFO2 RF03 0 800 0 400 C200 !

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n s r r ! o6 a n l 2n i a . l rr - E go H i nt lei c + 9_ . l nl u H o - n r + s ort s H s ano R . re n P oC + h H - - t _ nd + t a ei 4 3 s w H c . a i f B + in H g 4 iS H - - ! ! ! s H - l , l . l i H+H s . + . 4 _ . H _ = - _ - o 0 _ - 0 0 0 o m s 0 _ 0 5 0 5 o 0 _ i 3 2 2 1 0 0 0 0 o o o _ _ - 3g { _ 1 _ - - 1l l. li l\\ !I

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.

, i . OUTAGE ISSUE WEEKLY TREND . . 8 ERAGE DTE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _1 R_F_01_A_V_ _ _ _ _ _ _ _ _ _________________________ , 7 Issues tracked: Status Control ' Clearance Issues O ! Work Order- Admin Work Order - Implementation ' RI' Issues 35 Spilla/ releases

Material Control si4 1 Jg2_ AVE GE RATE _ _ _ H ________________________ a: _ __ ____________ w . Q. 3 ! W _ d IR,F03_A_VERAGE RA_ _ __ ______ ___ ___ ________ 2 ._________________ ,. ,

1RFO2. 1RFO3 3 I t I I I e I i 1 I t t i f f f 9 3 5 4 5 5 I 1 I 5 5 5 5 3 5 5 5 5 () ' e' ' s E 8- A 3 s x e M- M . .- - - N - - e - - o . - -- o - . - DATE - - . _ ~ . . . . . . . _, , __ - ..____._..__.______.___._.__:__.__,___ -

. , . . .- . . .' 11. CONCLUSIONS o EVENTS DID NOT AFFECT PLANT NUCLEAR SAFETY o PERSONNEL DID NOT FULLY APPRECIATE IMPLICATIONS FOR PERSONNEL SAFETY o TU ELECTRIC IS TAKING CORRECTIVE ACTIONS FOR ROOT CAUSES AND GENERIC IMPLICATIONS o PERSONNEL ERROR RATES ARE CONTINUING TO IMPROVE , 22

. , . . .

. 12. CLARIFICATIONS RELATED TO NRC INSPECTION REPORT o MINCR MODIFICATION (MM) 92-0250 (9341-03) - SCOPE OF HM 92-0250 PERTAINED TO SERVICE AIR ALARM - MODIFICATION OF DRAWING / TAG FOR SERVICE AIR CONNECTION NOT WITHIN SCOPE OF MM 92-0250 - DCN NO. 4437 REY. 0 WHICH IS PART OF MM 92-0250 INDICATES THE DESIRABILITY TO MAINTAIN FLEXIBILITY BY MAINTAINING SERVICE AIR AS AN ALTERNATIVE HENCE THE RETENTION OF THE CURRENT DRAWING / TAG DESCRIPTION o ONE FORM FOR OCTOBER 24, 1993 TRANSFER (9341-08) - NEAR HISS REQUIREMENTS OF PROCEDURE STA-421 G0 1 ' BEYOND THE REQUIREMENTS OF APPENDIX B - NEAR HISS DEFINITION IS SUBJECTIVE AND IS INTERPRETIVE TO SITUATION - PERSONNEL PERFORMING TRANSFER DID NOT BELIEVE CIRCUMSTANCES INVOLVING THE TRANSFER CONSTIRITED A NEAR HISS HENCE NO ONE FORM WAS REQUIRED IN THEIR MIND 23

. , . . , y . - , . . I o WORK REQUEST (WR) FOR SEAL LEAK (9341-09) l - SOURCE OF LEAK NOT CLEARLY IDENTIFIED ON OCTOBER- 23,. 1993 l

.. - PER STA-606, WR INITIATED TO IDENTIFY LEAK '! SOURCE l - WORK REQUESTS ARE SUBJECT TO CORRECTIVE ACTION, AND TRENDING i ! ' 1 l . ! I 24 . A,_, s . i - - - - , - . - - , , . - . .m - -~ e }}

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