ML20059A455
| ML20059A455 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 10/21/1993 |
| From: | Farrar D COMMONWEALTH EDISON CO. |
| To: | NRC OFFICE OF ENFORCEMENT (OE), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9310260336 | |
| Download: ML20059A455 (11) | |
Text
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Commonwxith Edis::n
- JZ_,
1400 Opus Place I
Downers Grove, Ilkros 60515 October 21,1993 Director, Oflice of Enforcement i
U. S. Nuclear Regulatory Commission j
Washington, D. C. 20555 j
i Attn: Document Control Desk
Subject:
Quad Cities Power Station Units 1 and 2; NRC Docket Number 50-254 and 50-265; NRC Inspection Report Numbers 50-254(265)/93017 J.B. Mart n letter to M. J. Wallace dated September 21,1993, i
Reference:
transmitting Notice of Violation and Proposed Imposition of Civil Penalty - $125,000 Enclosed is Commonwealth Edison's response to the Notice of Violation (NOV) transmitted with the referenced letter. The NOV cited four violations:
Failure to correct deficiencies with the HPCI turbine steam inlet and exhaust level switches despite recurring work requests, industry notifications, a HPCI reliability centered maintenance (RCM) report recommendation, and a Site Quality Verification (SQV) audit; Failure to make personnel near the HPCI turbine aware of an impending test and the potential for leding steam; Failure to conduct a briefing prior to a test; And an inadequate procedure for draining moisture from the HPCI turbine inlet steam line.
These violations have been classifled in the aggregate as a Severity Level III problem, and assessed a civil penalty of $125,000. CECO's response and payment of the civil penalty is attached.
Your letter identified the root cause of the event to be station manar,ement's failure to properly control activities associated with the safety related HPUI system. The most significant failure was that engineering 1,ersonnel'did r ot fully understand the systems design and vulnerabilities, and did not insist that steam drain system problems be aggressively addressed.
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Director, Ofc. of Enf. October 21,1993 CECO provided a discussion of the detailed assessment of Quad Cities' station performance in a letter to the NRC dated September 3,1993. This assessment was completed following the HPCI event by our Business Development Team (BDT). This self assessment identified the need to further improve our system engineering program and management involvement and follow through in the timely resolution of equipment deficiencies. As a result, additional actions have been established and were incorporated into the 1993 Management Action Plan which will resolve the BDT findings and the concerns you have identified.
These actions are being aggressively implemented.
To improve the system engineering program, actions are proceeding to support the development of the system manager concept through implementation of the Corporate Maintenance Strategy. As part of this development process, the System Engineering Supervisor is being temporarily assigned to the Monticello plant to learn first hand how they achieved a well recognized system engineering program. In addition, the system engineers' mentoring program has been strengthened with the addition of an experienced individual from outside the company to help coach and improve the knowledge ofinexperienced engineers in identifying deficiencies during walkdowns and observations of equipment. The use of multi-disciplined teams to assist the syste.m engineer in understanding system design and vulnerabilities to deficiencies has been started with the piloting of a readiness review of HPCI. These reviews will become a vital part of the system management function and include other safety and non-safety related systems.
Management involvement and follow-up to resolve equipment deficiencies i
and system performance issues have been improved through implementation of j
the integrated reporting program to ensure problems are identified and the correct j
root cause found. In addition, many long standing equipment deficiencies including those observed by the Diagnostic Evaluation Team have been scheduled for resolution in upcoming outages or the refueling outages scheduled in 1994. To ensure that identified deficiencies obtain management attention and timely correction, a Site Planning Group has been established to coordinate resolution of problems and establish a planning cycle to achieve sustained performance improvement.
Commonwealth Edison recognizes the significance of the June 9,1993 High Pressure Coolant Injection Turbine Exhaust Diaphragm rupture when five individuals received steam burns. Any time personnel receive injuries at CECO it is a matter of great concern. CECO needs and wants to take appropriate actions to prevent injuries to personnel. CECO believes the corrective actions taken and described in this response will prevent events of a similar nature from recurring.
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Director, Ofc. of Enf.
. October 21,1993 If your staff has any questions or comments concerning this matter, please refer them to Marcia Jackson, Regulatory Performance Administrator at (708) 663-7287.
Very truly yours,
+ =-
VW Dennis Farrar, Manager Regulatory Services cc:
J. B. Martin, Regional Administrator, RIII C. Patel, Project Manager, NRR T. Taylor, Senior Resident, Quad Cities h:rpa:entcon:q.2ad:ca93210:3
ATTACHMENT A NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Violation: 254(265)/93-017 01A A.
10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action," requires, in part, that measures be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action shall be documented and reported to the appropriate levels of management.
Contrary to the above:
1.
As of June 9,1993, recurring significant conditions adverse to quality existed with the High Pressure Coolant Injection (HPCI) turbine steam inlet drain level high alarm as documented in eight work requests dated between April 17,1986, and September 18,1992,and the cause of the condition was not determined and corrective action was not taken to preclude repetition.
2.
As of June 9,1993, the licensee failed to promptly correct an identified condition adverse to quality. Specifically, the licensee received a General Electric Service Information Letter (SIL) No. 531, "HPCI and Reactor Core Isolation Cooling (RCIC) Magnetrol Level Switches," which was issued on February 7,1991. The SIL recommended the installation of an improved level switch in high temperature applications. Although the SIL directly applied to the 4
HPCI and RCIC system drain level switches, the licensee took no action regarding the recommendations.
3.
As of June 9,1993, the licensee failed to promptly correct an identified condition adverse to quality. Specifically, the final report of the HPCI system reliability centered maintenance study dated j
December 31,1991, recommended calibration and functional testmg of the HPCI turbine inlet and exhaust drain pot high level switches at 18 month intervals. The licensee did not include this activity in its preventative maintenance program. Furthermore, Site Quality Verification Audit No. 04-93-01 dated March 10,1993, identified that the torus high level switches had not been tested as recommended by the reliability centered maintenance study, and concluded that the station did not adequately review the reliability centered maintenance report.
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ATI'ACHMENT A NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Reason for the Violation:
CECO acknowledges the violation. Several factors have contributed to it. Some are examples of the broader concerns which Quad Cities is currently addressing i
actively. Of those, the ones which were particularly evident here were inconsistencies in management oversight, the completeness of root cause analyses and the corresponding effectiveness of corrective actions, and the quality of some work processes.
Other contributors are more specific. System engineers do not always appropriately divide their time between resolving day-to-day problems and developing long term strategies for improvement. Backlogs have been permitted to grow in certain activity areas including procedure changes and work requests.
Maintenance on the Magnetrol level switches had not been implemented as broadly or as timely as we now realize would have been appropriate.
Corrective Steps Taken and Results Achieved Short term actions have focused on ensuring that the equipment issues have been resolved. These actions have not been limited to the HPCI but have also been applied to the RCIC, as appropriate, in order to ensure that all similar rupture discs have been addressed. Functional testing of all HPCI and RCIC drain switches has been performed. Repair of all malfunctioning drain switches was completed as necessary.
All steam exhaust rupture discs in the HPCI and RCIC systems for both Unit 1 and Unit 2 were replaced. The HPCI rupture discs are now included in the l
Inservice Testing Program and will be replaced on a five year interval. The RCIC rupture discs are in the preventative maintenance program and will be replaced every third refueling outage.
Corrective Steps Taken to Avoid Further Violations:
Quad Cities views this event as particularly serious not only because it involved personnel injury but also because it graphically illustrated the potential for significant consequences due to degraded program pcrformance. Consistent with this appreciation for the message implied by the occurrence of this event, Quad Cities is taking a broad based approach in its response. Several specific actions related to the event itself, broader equipment concerns, system related programs and support programs are described below.
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ATTACHMENT A NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY In addition, Quad Cities is using the event as a reference point for its overall response to the concerns which either the station or the NRC have identified in recent performance reviews, including the diagnostic evaluation. Many of the program enhancements currently in progress will address the weaknesses which led to this event. Therefore, in determining the details for implementing these program enhancements, the preventability of this kind of event is implicitly factored into individuals' thinking, even if not explicitly addressed as a programming criterion. This underlying recognition of the need to avoid recurrence of this type of event gives Quad Cities confidence that the event specific and broader generic responses will be successful in that regard.
HPCI Specific Actions SIL 531 has been reviewed and the appropriate Magnetrol switches will be replaced with the recommended switches during the next refueling outages (Q1R13; Spring 1994 and Q2R13; Fall 1994).
Procedures will be developed to functionally test the HPCI inlet and exhaust drain pote, the associated level switches and alarms on a refueling cycle frequency.
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These procedures will be completed by February 28,1994, prior to the next j
refueling outage.
107 of 140 tasks identified by the HPCI Reliability Centered Maintenance (RCM) study have been entered into the General Surveillance tracidng program or are a part of an existing station procedure. Work requests have been initiated for two of the tasks. CECO has evaluated the remaining 31 tasks, and has determined that these will not be implemented at this time.
Broader Equipment Actions An action plan has been developed which identified the scope of GE SILs to be reviewed. Implementation of the action plan has begun with the review of 72 SILs.
Additionally a re-review of SIL responses will begin in January 1994. This re-review will evaluate SIL responses. Unclear or marginal responses will be reissued to the appropriate departments for additional response.
Procedures will be developed to functionally test the RCIC drain pot level switches i
on a refueling cycle frequency. These procedures will be completed by February 28,1994, prior to the next refueling outage.
The third interval of the Quad Cities Inservice Testing program requires that HPCI rupture diaphragms to be replaced on a 5 year interval. The RCIC rupture diaphragms are in the prevent.ative maintenance program and will be replaced every third refuel outage. The next scheduled replacement is during the Q1R16 and Q2R16 refuel outages.
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ATTACIIMENT A NOTICE OF VIOLATION i
AND PROPOSED IMPOSITION OF CIVIL PENALTY 1
System Program Actions A task force was assembled to review all RCM recommendations both opened and closed. Members of the task force were from System Engineering and Maintenance Staff and a licensed individual. The review has been completed and some items are waiting for outages for implementation.
System Readiness Reviews have been initiated with HPCI selected as the pilot system for review. This review focuses on system history of such items as work requests, discrepancy reports, engineering reports, industry experience, etc. A multi-disciplined team has been chartered to improve short term performance of safety systems and provide the necessary support to the system engineer to maintain system performance improvement over the long term.
Support Program Actions CECO will Implement the Zion Integrated Quality Effort (IQE) as part of the Quad Cities' ongoing self assessment program. IQE data from September,1993 will be used to establish a performance monitoring meeting and report. IQE will be used by station management as a tool to assure improved safety system performance.
Additionally, an initiative of the Quad Cities Management Plan focuses on the implementation of the Integrated Reporting Program and Corrective Action Program improvements. The process will include program trending and assessment requirements to evaluate the thoroughness ofinvestigations and corrective actions.
Date When Full Compliance Will be Achieved:
Full compliance will be achieved on February 28,1994 when the HPCI and RCIC functional test procedures will be issued.
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ATTACHMENT A NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY i
i Violation: 254(265)/93-017 01B j
B.
10 CFR 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," states that activities affecting quality shall 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.
t 1.
Procedure QCOS 2300-5, Roit in 3, dated December 11,1992,
" Quarterly HPCI Pump Ope..ihF ty Test," Step F.4, requires ensuring that personnel near the HPCI turbine are aware of the impending test and the potential for steam leaking around the turbine.
Contrary to the above, on June 9,1993, personnel near the HPCI turbine were not made aware of the impending test and the potential 1
for steam leaking around the turbine.
2.
Procedure QAP 300-2, Revision 36, dated May 1993, " Conduct of Operations," Step C.13.j, " Responsibilities of all Operating Department personnel licensed by the Nuclear Regulatory Commission as Reactor Operators or Senior Reactor Operators,"
requires that briefings be conducted by cognizant personnel for individuals involved in an evolution that is to be performed. The detail of the briefing is dependent on the degree of complexity, routineness, logistics, or number of people involved.
Step C.14.j, " Responsibilities of all Operating Department personnel licensed by the ' uclear R.egulatory Commission as S_enior Reactor N
Operators." requires that briefings be conducted by the Shift Engineer, or his designee, for individuals involved in an evolution that is to be performed. The detail of the briefing is dependent on the degree of complexity, routines, logistics, or number of people involved.
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-i ATTACHMENT A NOTICE OF VIOLATION AND l
PROPOSED IMPOSITION OF CIVIL PENALTY The individual who is to perform the activity is responsible to adequately review the procedure, to fully understand what he is doing, and to be cognizant of all limitations, precautions, and requirements.
j Evolutions involving many individuals, especially from two or more departments or disciplines, may require large formal briefings or i
preplanning sessions. If the evolution is complex and involves close coordination, the briefing session shall be coordinated by the Operating Engineer or his designee and should include:
(1) a review of the appropriate section of the procedure by key i
- parties, i
(2) examination of each individual's specific involvement and responsibility; (3) discussion of expected results or performance; review of limitations, hold prints, emergency action to be taken if contingencies arise; and (4) assurance that everyone understands the interface and communications required.
Contrary to the above, on June 9,1993, Operating Department personnel licensed by the NRC did not conduct a briefing prior to performance of the Quarterly HPCI Pump Operability Test, an evolution involving many individuals drawn from two or mort departments and requiring close coordination among the parti ipants.
3.
Procedure QCOS 2300-5, Revision 3, dated December 11,1992,
" Quarterly HPCI Pump Operability Test," Step 1.22, for draining moisture from the HPCI inlet steam line specified a time limit of 10 seconds as the criterion for closing drain valves AO 1(2)-2301-64 a'id AO 1(2)-2301-65.
Contrary to the above, as of June 9,1993, Procedure QCOS 2300-5, Revision 3 was determined to be inappropriate for the circumstances because Step I.22 should have specified the observation of steam from the sump as the criterion for closing the drain valves in order to ensure that all moisture had been properly drained.
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ATTACHMENT A
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NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Reason for the Violation:
CECO acknowledges the violation. Prior to starting the HPCI system, an announcement was not made on the public address system because clear instructions had not been provided on who was responsible for ensuring that personnel near the HPCI turbine would be made aware of an impending test.
i A contributing factor was that a pre-job briefing was not held The briefing was not held because the applicability of the pre-job briefing procedure to this activity was not clearly understood by the individuals responsible for conducting such briefings.
Procedure QCOS 2300-5 was inadequate because the procedure erroneously adopted an inappropriate way to determine when all moisture had been properly drained.
Corrective Steps Taken and Results Achieved:
Personnel Protection Clear assignments of responsibility have been given to the individuals who are expected to make the required announcements whenever an impending test requiring such an announcement is initiated. An Operating Department Standing Order was issued which lists the major pieces of equipment that require extra precautions. These precautions deal with the concern for personnel to be away from the vicinity of the equipment during initial equipment start up.
Management will review that list with tae responsible individuals.
Pre-Test Briefings Clearer instructions regarding the need for pre-job briefings have been provided for tests comparable in importance to the HPCI test involved in the event.
Precautions requiring a pre-job briefing for all involved personnel have been added to the following Quad Cities Operating Surveillances (QCOS): 2300-1 for the Periodic HPCI Operability Test,2300-5 for the Quarterly HPCI Pump Operability Test,1300-1 for the Periodic RCIC Pump Operability Test, and 1300-5 for the Quarterly Pump Operability Test.
l Appropriate Procedures The specific inappropriate procedures have been modified to include the effective method for determining that all moisture has been drained. Quad Cities Operating Surveillances (QCOS) 2300-1 Periodic HPCI Operability Test and QCOS 2300-5 Quarterly HPCI Pump Operability Test, have been revised to require that the air operated valves 2301-64 and 65 be opened until the steam is observed in the sump.
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1 ATTACHMENT A NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Corrective Steps Taken to Avoid Further Violations Personnel Protection Positive controls to ensure against the potential for a repetition of this event have been adopted.
Quad Cities Operating Surveillance (QCOS) 2300-5, " Quarterly HPCI Pump Operability Test" has been revised to require: (1) that all personnel are outside of the HPCI room prior to rolling of the HPCI turbine; (2) that communication is i
established between the control room and the operator outside of the HPCI room, prior to rolling of the HPCI turbine; (3) that the impending turbine roll will also be announced on the public address system. The individuals responsible for ensuring that these instructions are implemented will be trained on the importance of these actions. In addition, other operating surveillances will be reviewed to determine if similar precautions should be added to them.
Pre-Test Briefings In addition, all other routine surveillances for other major systems were reviewed to identify the need for pre-job briefings prior to the performance of surveillances.
That review focused on whether those surveillances were complex enough to require pre-job briefings. Revision ofidentified procedures will be completed by December 31,1993.
Clearer instructions regarding the activities which require pre-job briefings will be provided. Quad Cities Administrative Procedure QAP 300-2 " Conduct of Operations", will be revised to clearly define management's expectations regarding the performance of pre-job briefings. This revision will be completed by October 31,1993. Personnel responsible for implementing this procedure will be trained on it.
Date When Full Compliance will be Achieved:
1 Full compliance will be achieved October 31,1993. When procedure QOS 300-2
" Conduct of Operations" will be revised to define management's expectations for pre-job briefings.
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