ML20059C899
| ML20059C899 | |
| Person / Time | |
|---|---|
| Site: | Diablo Canyon  |
| Issue date: | 08/21/1993 |
| From: | AFFILIATION NOT ASSIGNED |
| To: | |
| References | |
| OLA-2-I-MFP-109, NUDOCS 9401060193 | |
| Download: ML20059C899 (29) | |
Text
. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N f Y N hl{ l 60 - 2 7 5 3 2 3 - 0u1 - '
g/2ijga inwag y 1-w h o9 NCR DC2-91-TN-N102 Rev. 02 2/
3 November 18, 1992
.g g gg p r 17 MANAGEMENT
SUMMARY
During the period of October 12 1991, through October 21, 1991, several cases of loose debris in containment were identified.
A verification is required to insure that all loose debris are removed from containment after each containment entry. These verifications are required by Technical Specification 4.5.2.c.
Four people were identified as not having filled out an M-45B data sheet certifying that they performed a visual inspection for loose debris when containment integrity had been established.
On this basis, TS 4.5.2.c had not been met and therefore this event is reportable.
' During 1RS, while conducting a walkdown of the containment,
~
the NRC found loose debris (paper) and material unnatended in containment and considered a Notice of Violation.
The root cause of this event was determined to be a lack of a comprehensive program for control of loose debris and materials when containment integrity is established during high intensity work periods (i.e. outages).
As a corrective action to prevent recurrence, the current procedures for administrative control of containment integrity during high intensity work periods (i.e. outages) will be enhanced to address the following items: (1) During outages in modes 4 to 1,
containment integrity will be the responsibility of the OCC, to be transitioned to Operatione i
at an agreed upon time; (2) OPEG special instructions for materials in containment will be captured in a procedure attachment; (3) All containment work orders will contain guidance on the proper practices to maintain containment cleanliness; (4) Appropriate personnel will be trained on the extent of the program revisions through the procedure revision training process.
l To address concerns expressed by the NRC during 1R5 and possible Notice of Violation to be issued due to debris left i
in containment during the IRS outage, the TRG reconvened on November 18, 1992 to enhance the corrective actions already taken and determine if additional actions were needed.
NPAP C-10S6 and STP M-45A, B and C will be reviewed for additional enhancement based on the events during 1RS.
91NCRWP\\91TNN102.PGD Page 1
of 29 9401060193 930821 PDR ADOCK 05000275 C
4 NCR DC2-91-TN-N102 Rev. 02
~
November 18, 1992 i
I.
Plant Conditions Unit 2 was in Mode 3 (Hot Standby) at 0 percent pc.er.
1 II.
Description of Event A.
Event:
Summary:
On October 16, 1991, Quality Control (QC) initiated a surveillance of the containment at the request of Radiation Protection.
During the period of October 16, through October 21, 1991, that QC surveillance identified several instances of debris left in containment.
A review of the containment entry records found perstanel making containment entries without filling an inspection l
verification (STP M-45B) data sheet upon leaving the containment.
At the urging of QC, the Outage Control Center (OCC) performed a clean-up of the containment. The surveillance identified tools and paperwork unattended inside containment after containment integrity had been established.
On g,P October 21, 1991, outage management performed U
ns another containment clean-up.
N v
\\ h fn
Background:
G \\'li e4 i-JJ !
Technical Specification (TS) 4.5.2.c.
requires W
'g C1 - '
i cv l that a visual inspection of containment be uy j
)
performed to verify that no loose debris is in i
s j
E l5 a
b, containment that could clog the recirctlation sump l
-8 gM [
~
Iprior to and after establishing containment
@f
- s s
L Integrity.
E i
, k I'ly Surveillance Test Procedure j
4 i
i (STP) M-45A,
. f ^Uk[N" Containment Inspection Prior to Establishing
- s 3j
(
D DJ
]@
Containment Integrity," satisfies the requirement
[N of TS 4.5.2.c.(1).
~u 6C
{g I
\\g
,'<{ '3j,g4 TS 4.5.2.c.(2) requires that a visual inspection i
t of containment be performed to verify that no i
7 loose debris is in containment that could clog the
{
1 o _.
- recirculation sump after each containment entry.
i i
91NCRWP\\91TNN102.PGD Page 2
of 29
NCR DC2-91-TN-N102 Rev. 02 November IP 1992 STP M-45B, " Containment Inspection When Containment Integrity is Established," satisfies the requirements of TS 4.5.2.c(2) and requires that an inspection data sheet be completed to certify that a visual inspection has been performed to satisfy the TS requirements.
Chronoloov and Discussion:
On October 12, 1991, at 2340 PST, the performance of STP M-45A was verified and containment integrity was established.
During the period of October 12, 1991, through October 21, 1991, the Unit 2 outage control center requested several clean-ups of containment.
In spite of the clean ups, RP continued to remove abandoned tools and debris frem all elevations of containment.
As a result of_the clean-ups, QC initiated surveillance 91-0098 to investigate the problem.
The QC surveillance identified several instances of debris in containment. The location of the debris was documented, and photographs taken.
QC also found several entries in containment with no STP M-45B data sheet completed to verify that all inspections were completed as required.
The impact of the documented debris on the operability of the recirculation sump was evaluated by NECS.
NECS concluded that only the material (small plastic bag, wipealls, tool cag, i
water jug and tool bin) left in the Unit 2 containment recirculation sump were postulated to migrate to the suro under LOCA conditions. NECS determined tha+
_w if the material left in containment m irate to the sump, there was enough available frei wre to support the RHR system flow requirements c
.ag a Loss Of Coolant Accident (LOCA).
Because the RHR pumps could draw adequate reactor coolant from the containment recirculation sump with the material postulated to be partially blocking the sump screen, the ECCS would be I
91NCRWP\\91TNN102.PGD Page 3
of 29
4 NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 Although the program has improved over the last outage, during 1R5, while conducting a walkdown of i
the containment with DCPP QC inspectors, the NRC inspectors found loose debris and material left unnatended in containment.
An Notice of Violation is being considered.
Additional Investication:
Another problem was identified during the investigation of debris in containment. Several departments stated that they did not always perform STP M-45B after containment entries.
STP M-45B defines the " completion of a containment entry" as " completion of work at a specific job site".
STP M-45B clarifies that this "shall not be construed to allow tools and material to be left unattended longer than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />".
The procedure requires that a visual inspection of containment be performed and that loose debris be removed.
A review of the control room logs identified that between October 12, 1991, and October 17, 1991, STP M-45B data sheets filled out and inspections performed successfully approximately 29 times.
QC performed subsequent investigations to document occurrences when STP M-45B data sheets had been filled out after a containment entry. These investigations found that out of 1,041 entries by 346 individuals, approximately indiviauals could not be traced to an existing M-45B data sheet. Of these ten individuals were interviewed and four specifically stated that they were not aware of the requirement and did not complete an M-45B data sheet, resulting in a violation of Tech Spec 4.5.2.c.(2)
B.
Inoperable Structures, Components, or Systems that Contributed to the Event:
None.
4 91NCRWP\\91TNN102.PGD Page 4
of 29
..n
. _. ~. - - -.
NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 C.
Dates and Approximate Times for Major Occurrences:
1.
October 12, 1991, at 2340 PST:
Containment integrity was established in preparation to enter Mode 4.
2.
October 17, 1991:
Discovery date Loose ruaterial and paperwork were identified unattended in containment.
3.
February 4, 1991:
The TRG agrees that this event is a violation of TS 4.5.2.c and is reportable.
D.
Other Systems or Secondary Functions Affected:
None.
E.
Method of Discovery:
Utility personnel, identified the problem as a result of investigation performed after a routine walkdown.
p F.
Operators Actions:
None.
G.
Safety System Responses:
None.
III.
Cause of the Event A.
Immediate Cause:
Loose debris were left unattended in containment due to inadequate housekeeping and work controls, 91NCRWP\\91TNN102.PGD Page 5
of 29 1
,-,n
.--n-
=,. - - -., -. - -
...--...-,,,m.-
1 1
NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 B.
Determination of Cause:
1.
Human Factors:
a.
Communications:
Was a tailboard conducted with the individuals performing the containment inspection, ac required by STP M-45A and B?
Tailboards are being conducted by Operations during Modes 1-4.
But tailboard was not required during the Mode 5 to 4.
Is the work control proct,;s adequately communicated to the planc staff?
No, enhanced loose debris control requirements will be communicated by the new supplement to NPAP C-10.
b.
Procedures:
Do adequate controls exist to assure that all tools and other equipment not being installed leave containment?
No, the new supplement of NPAP C-10 needs to be issued to give additional guidance.
Was STP M-45B performed after every l
containment entry?
See details in the description of event of this NCR under additional investigations.
c.
Training:
Have individuals working in i
containment been adequately trained on the requirements to remove debris from containment, and to not leave debris 91NCRWP\\91TNN102.PGD Page 6
of 29
t NCR DC2-91-TN-N102 Pa".
02 November 18, 1992 in containment unattended for more than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />?
The TRG discussed this issue and agreed that there is a concern in this area.
This concern will be addressed in the new supplement of NPAP C-10, by having the containment clerk remind indivicm 1s working in containment of the requirements.
I d.
Human Factors:
N/A e.
Management system:
N/A 2.
Equipment / Material:
Because this problem-is an administrative problem, and not related to material or equipment, this section is not applicable.
C.
Root Cause:
Lack of a comprehensive program for control of loose debris and material when containment integrity is established during high intensity work periods (i.e. outages).
l D.
Contributory Causes:
The lack of understanding of the housekeeping and work controls requirements by some individuals i
contributed to the cause of this event.
IV.
Analysis of the Event j
A.
Safety Analysis:
The ECCS is required to provide adequate cooling of the core to prevent core damage during a loss of coolant accident (LOCA).
The containment recirculation sump is the source of makeup reactor coolant during the cold leg and hot leg recirculation phases of a LOCA recovery.
91NCRWP\\91TNN102.PGD Page 7
of 29
i NCR DC2-91-TN-N102 Rev. 02 November 18, 1992
{
The containment recirculation sump is aligned to the suction of the residual heat removal (RHR) pumps after the refueling water storage tank (RWST) has been injected into the reactor coolant system (RCS).
The inlet of the suction piping is surrounded by a screen to prevent loose debris and insulation from being sucked into the RHR pumps and causing damage.
If too much debris collects on the screens, the flow through the screens will be inadequate to supply the RHR pumps.
An NECS evaluation (reference # 9) reviewed the amount of debris identified in containment, and determined that enough loose debris would not be transported to the containment recirculation camp during a design basis accident to prevent adequate flow through the screens to the suction of the RHR pumps to prevent it from fulfilling its safety related function.
Since the RHR pumps would be capable of drawing sufficient reactor coolant from the containment recirculation sump, the ECCS system was not inoperable as a result of the loose debris in containment, and the health and safety of the public were not affected by this event.
B.
Reportability:
1.
Reviewed under QAP-15.B and "etermineu to be non-conforming in accordance with Section 2.1.2.
2.
Reviewed under 10 CFR 50.72 and 10 CFR 50.73 per NUREG 1022 and determined to be reportable.
During the investigations it was found that at least four individuals fail to fill an M-45B data sheet certifying that a visual inspection was performed and no loose debris were present in containment as required by Tech Spec 4.5.2.c.
Therefore since there-was a violation of the Tech Spec 4.5.2.c, this event is reportable as a missed Technical Specification surveillance.
i j
LER 2-91-012 was submitted on March 5, 1992.
91NCRWP\\91TNN102.PGD Page 8
of 29
NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 3.
This problem does not require a 10 CFR 21 report.
The problem does not involve a material deficiency.
4.
This problem does not require reporting via an INPO Nuclear Network entry.
5.
Reviewed under 10 CFR 50.9 and reportability in accordance with 10 CFR 50.9 this event is reportable under 10 CF 50.73.
6.
Reviewed under the criteria of AP C-29 requiring the issue and approval of an OE and determined that no OE is required.
V.
Corrective Actions A.
Immediate Corrective Actions:
Containment was inspected, and all loose debris were removed.
B.
Investigative Actions:
1.
Review STP M-45A and STP M-45B to determine if they adequately implement the requirements of Technical Specification 4.5.2.c.
i I
RESPONSIBILITY:
M.
Hug DEPARTMENT: Regulatory Compliance Tracking AR:
A0253144, AE #01 STATUS:
COMPLETE.
2.
Evaluate impact of loose materials on recirculation sump.
AR A0248662 and A0248925 identify uncontrolled items inside containment during Modes 1 through 4.
Please evaluate the l
impact on the recirculation sump.
Polaroid pictures and more specific references can be provided by M.
Cherubini.
RESPONSIBILITY:
H.J.
Hodges DEPARTMENT:
Quality Control Tracking AR:
A0248925, AE # 02.
STATUS:
COMPLETE.
91NCRWP\\91TNN102.PGD Page 9
of 29
.~,.
l NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 3.
Determine the appropriate work controls for activities in containment.
The review should include maximum duration for leaving items unattended in containment, acceptable quantities, locations, and types of material left in containment, and methods for implementation of the work controls.
RESPONSIBILITY:
E.
Chaloupka DEPARTMENT:
Plant Engineering Tracking AR:
A0253144, AE #02 STATUS:
COMPLETE.
4.
Review the FMEA procedere and possible modifications that can be implemented as l
corrective actions.
RESPONSIBILITY:
T.
McKnight DEPARTMENT:
Quality Control Tracking AR:
A0253144, AE #03 STATUS:
COMPLETE.
5.
Compare containment entry records to documented STP M-45B performances to determine if any containment entries were made without a corresponding STP M-45B.
i RESPONSIBILITY:
D.
Snodgrass/M. Cherubini l
DEPARTMENT:
System Engineering Quality Control Tracking AR:
A0253144, AE #04 J
STATUS:
COMPLETE C.
Corrective Actions to Prevent Recurrence :
1.
Create a new NPAP C-10 supplement that includes enhanced housekeeping requirements for Modes 1 through 4 when a unit is being restarted after an outage and covers periods of high intensity or multiple work loads in containment.
Develop the new supplement with assistance with NECS.
RESPONSIBILITY: John McIntyre DEPARTMENT:
Mechanical Maintenance.
Tracking AR:
A0253144, AE # 5.
Outage Related? Yes, before 1R5 91NCRWP\\91TNN102.PGD Page 10 of 29
~
- - ~ -.--
NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 OE Related?
No NRC Commitment? Yes CMD Commitment? No STATUS:
COMPLETE 2.
Upgrade STP M-45B to be consistent with the new administrative program. Capture NECS waiver activities.
RESPONSIBILITY:
K. Wallace L.
Cossette DEPARTMENT :
Plant Engineering.
Tracking AR:
A0253144 AE #
7.
STATUS.
RETURN 3.
Disposition all the Action Requests (AR's) associated with 1R5 locse debris in containment.
l a
RESPONSIBILITY: John MacIntyre DEPARTMENT:
Mechanical Maintenance Tracking AR:
A0253144, AE # 08 Outage Related? No OE Related?
No NRC Commitment? No CMD Commitment? No STATUS:
RETURN 4.
Mechanical Maintenance (John MacIntyre) to meet with the containments coordinators and Quality Control Inspectors to determine the J
revisions to be made in the new NPAP C-1"
+
supplement and M-45A, B,
and C based on lessons learned during 1R5.
i RESPONSIBILITY: John MacIntyre DEPARTMENT:
Mechanical Maintenance.
Tracking AR:
A0253144, AE # 09 Outage Related? No i
OE Related?
No NRC Commitment? No CMD Commitment? No STATUS:
RETURN i
I 91NCRWP\\91TNN102.PGD Page 11 of 29
.. ~ -
NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 D.
Prudent Actions (not required for NCR closure) 1.
Support the development of a new NPAP C-10 supplement appendix (NECS appendix to NPAP C-
- 10) to be created to contain the provisions for approval of storage in containment in modes 1 through 4 at the end of the outage.
RESPONSIBILITY:
H.
J.
Hodges DEPARTMENT:
NECS/OPEG Tracking AR:
A0257696 STATUS:
RETURN 2.
Request the development and installation of a door sign near containment to inform personnel of the establishment of containment integrity and requirements for debris and loose material control.
RESPONSIBILITY:
. John MacIntyre ECD: 07/15/92 DEPARTMENT:
Mechanical Maintenance.
Tracking AR:
A0267792 STATUS:
VI.
Additional Information A.
Failed Components:
None.
B.
Previous Similar Events:
NCR DCO-89-EN-N025 Containment Recirculation Sump This NCR addressed several problems with the containment recirculation sump, including debris left in the sump following a refueling outage.
The corrective action for the problem included development of STP M-45 A and B.
STP M-45 had been used for all containment inspections prior to the development of STP M-45A and B.
These procedures included details on inspections of the containment sump.
91NCRWP\\91TNN102.PGD Page 12 of 29
4 l
l l
l NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 Additional actions included the revision of appropriate procedures to assure application of Foreign Materials Exclusions Area (FMEA) controls None of the corrective actions for the sump.
addressed control of materials in other areas of containment.
A problem had not been identified with control of materials in other areas of containment.
Operating Experience Review:
C.
1.
NPRDS:
~
Not applicable.
2.
NRC Information Notices, Bulletins, Generic Letters:
IE Notice 88-28 Potential for Loss of Post-LOCA Recirculation Capability due to Insulation Debris Blockage This notice addressed concerns with insulation ECCS damaged during a LOCA nigrating to the sump, and blocking the screens.
The blockage could reduce the net positive suction head at the screen and cause cavitation.
The response to this notice did not address work related materials i.nside containment.
A problem with STP M-45 had not been identified at that time.
Generic Letter 85-22 Potential for Loss of Post-LOCA Recirculation Capability due to Insulation Debris Blockage This Generic Letter addressed the same concerns as IE Notice 88-25, 3.
None.
D.
Trend Code:
91NCRWP\\91TNN102.PGD Page 13 of 29
NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 Responsible department TN, and cause code A4 (Programmatic Deficiency).
E.
Corrective Action Tracking:
1.
The tracking action request is A0253144.
F.
Footnotes and Special Comments:
The training of personnel on the changes to the containment integrity program controls will be accomplished during the procedures preparation and revision processes.
Appropriate tailboards for the preparation of the supplement to NPAP C-10 and the revision of STP M-45B will be required before the outage.
G.
References:
1.
Action Request (AR) h0248925 2.
AR A0248662 3.
STP M-45B, Rev 1 4.
STP M-45A, Rev 2 5.
Technical Specification 3/4.5.2 6.
Shift Foreman Logs dated 10/12/91 - 10/17/91 7.
Surveillance Report QCS 91-0098 8.
Agenda of 12/17/91 TRG.
9.
Response to AR A0248925, AE 2 by NECS Onsite project Engineering group.
- 10. DCL 90-018.
- 11. Recirculation Sump sketch.
- 12. Draft of AP C-10 Supplement.
- 13. Root cause analysis.
- 14. Surveillance Report.
15.
E. Mail from M. Coleman to R.
Waltos.
- 16. LER 2-91012 H.
TRG Meeting Minutes:
1.
On December 10, 1991, the TRG convened and considered the following:
Review of the work control process for work in containment.
An investigative action was assigned to review the work control process for work in containment.
Discussion on operability of the containment recirculation sump during a design basis accident.
NECS was assigned an action item to determine the probability of the debris 91NCRWP\\91TNN102.PGD Page 14 of 29 l
1
i NCR DC2-91-TN-N102 Rev. 02 November 18, 1992 identified being transported to the containment recirculation sump, and blocking the screens Review of the adequacy of the implementation of TS 4.5.2.c.
Regulatory Compliance was (1 signed an investigative action to review STP M-45A and STP M-45B against TS 4.5.2.c.
TRG to reconvene on 12/17/91 to discuss the results of the investigative actions.
2.
On December 17, 1991 the TRG reconvened and considered the following:
Review if this event is reportable.
Reportability was discussed and the voting l
members of the TRG voted in favor of reporting this event.
The reasons were that the TS 4.5.2 (c) had been violated in regard to loose materials left unattended in the containment.
Loose material had been left abandoned or unattended for more than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />. The reason for the violation of the Technical Specification is due to inadequate performance of the STP.
Also, it is not clear if an STP M-45B was performed for every job which would have required it to be performed.
\\
An LER needs to be written to address the reportability.
Review the results of the investication.
i a.
Reviewed the findings and actions ficr. the task force led by Plant Engineering. The task force needs to reconvene and do more work before making any recommendation on i
root cause or corrective actions.
i However, the task force made the following recommendations:
o Periodic walkdown by containment j
coordinators.
Approved containers at work sites.
o
~
91NCRWP\\91TNN102.PGD Page 15 of 29
~
e
6 NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 o
Identify areas for enhanced control.
i b.
Reviewed the written report from NECS Onsite Project Engineering in response to A/R A0248925, AE # 2 regarding blockage of the RHR recirculating sump by loose material.
NECS concluded that the function of the RHR recirculation sump was not jeopardized by loose material.
Reviewed recommended chances to M-45B in AR A0251889.
STP M-45B needs to be reviewed and maybe revised in light of the Technical Specification. The Technical Specification does not address material unattended for no a than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />, although this is a PSRC interpretation of the Technical Specification.
Reviewed possible root cause using the following actual or potential barriers.
Training which leads to an understanding a.
of the concern about loose debris and requirements to control work.
Training on loose debris is deficient. A training representative will be invited to the next TRG.
b.
Work orders need to be more specific, c.
There may be a need to acuress the lose debris program in the radiation worker
- training, d.
Work documents shall require control and removal of all tools and materials.
e.
Tailboards shall review the concern.
Workers shall be sensitized.
f.
Containment coordinators or others shall have the responsibility for control of tools and material in the containment, g.
Define what kind of items, floatable compared to movable items. Possible FEMA. h.
Provide approved storage enclosures.
91NCPWP\\91TNN102.PGD Page 16 of 29 s
ci--
,y.
4.,_-
.-_m
)
l l
NCR DC2-91-TN-N102 Rev. 01 I
November 18, 1992 i
i i.
Responsibility for administration and enforcement of the STP M-45B program and containment condition need better definition.
j.
Impediments to prompt removal maybe contribute to the problem.
Bins may need to be used.
k.
STP M-45B assigned personnel to be responsible for workers following STP M-45B and for containment condition. This was perceived as a good idea.
1.
STP M-45B should be as clear and useable as possible.
m.
Other tool control requirements (e.g.,
AP D-55) may help.
n.
Volume of work needs to be controllable from STP M-45B viewpoint.
STP M-45B needs improvements.
TRG to reconvene on Wednesday January 15, 1992.
3.
On January 15, 1992 the TRG reconvened and considered the following:
1 An Agenda of the meeting was established to cover the following subjects:
a.
Reportability.
b.
Subcommittee recommendations.
c.
How D-55 fit in this NCR.
d.
Corrective actions and how to close this NCR.
e.
Reconvene date.
Reportability.
l Marty Hug discussed the reportability issue.
He indicated that Paul Dahan had prepared the LER.
He indicated that the first TRG chairman was Steve Banton.
It was then decided that NECS would perform an evaluation of procedure M-45 and determine the consequences of loose debris that could be entrained to the sump.
91NCRWP\\91TNN102.PGD Page 17 of 29
NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 NECS has since concluded that only the loose debris on the 91 foot elevation could be entrained to the sump.
All the material found on the 91 foot elevation was covered by an M-45B except one small plastic bag. This bag was not large enough to cause any significant restriction to the sump flow. On this basis, management felt that this event was not reportable.
During further discussion, some sections representatives said that they never completed an M-45B data sheet for routine inspections l
and walk downs. Some TRG members felt that a PSRC interpretation was required to determine if the routine inspections and walkdowns not being done resulted in Technical Specification not being met.
A vote was taken on reportability and the TRG was split 2 to 2.
Therefore, the issue will be referred to the Plant manager and Vice President, John Townsend and the QA Manager, Jim Sexton for a decision.
A review nf the new procedure on floatable material in containment needs to be done.
RP prepared one M-45B for all the work conducted in centainment.
Review the exceptions of all groups using M-45B.
QC/QA TRG representatives to discuss with their management the reportability issue.
Training.
Maintenance and administrative procedures training. Determine what departments need the training.
Get the information out.
The TRG proposed to the training department that this training be included as part of the General Employee Training (GET).
Training on NPAP C-10 Supplement:
91NCRWP\\91TNN102.PGD Page 18 of 29
i l
l
\\
NCR DC2-91-TN-N102 Rev. 01 November 18, 199e Action #1:
Training to evaluate what changes to the Rad worker training are necessary.
ECD: End of January.
Action #2:
Create new supplement to NPAP C-10 by March 15, 1992.
David 'ampert.
A barrier analysis to be included in this NCR.
i A copy of a draft supplement to NPAP C-10 (control of floatable material in containment) was reviewed by the TRG. This new procedure will be placed into a supplement to NPAP C-10
" Housekeeping". (To be replaced by STP M-4 5C).
The following prudent actions have been determined:
Upgrade M-45B to be consistent with the a.
recommendations of QC. ECD: 03/15/92 b.
A supplement to NPAP C-10 is to be developed to contain the provisions of the enhanced housekeeping requirements in containment during mode 1 through 4.
All procedure revisions to be completed by 03/15/92.
TRG to reconvene by January 28, 1992.
4.
On January 23, 1992, the TRG reconvened and discussed the following:
The TRG discussed Training's recommendations.
Training has included STP M-45B in a recommendation list for subjects to be discussed in a human performance video that will be included in general employee training.
Training also stated that it would be useless to include a discussion of the event in general employee training as it would not be remembered.
The Manager, Technical Services discussed his position on reportability.
He stated that no 91NCRWP\\91TNN102.PGD Page 19 of 29 i
~'
~.
i NCR DC2-91-TN-N102 Rev. 01 November 18,.1992 documented evidence exists that equipment.left in containment would have caused inoperability of the containment sump.
He also stated that if documented evidence could be produced that identified containment entries that were not covered by an STP M-45B, the event would be reportable.
System Engineering and QC were assigned an investigative action to determine if 4
containment entries had been made that were not covered by an STP M-45B.
The TRG. discussed methods to implement stricter control of material in containment.
An investigative action was assigned to review changes that would be required to the FMEA procedure to make it applicable to containment.
TRG to reconvene on January 31 1992, to discuss the results of the investigative actions.
5.
On January 31, 1992 the TRG reconvened and considered the following:
I A search of all containment entries against STP-M45B was reviewed. From 10/15/91 to 10/21/91, their were 1,041 entries concerning 346 individuals. Forty potential M-45B violations were identified as possible.
Departments that could be involved are Engineering; QC; Mechanical Maintenance; GC Civil; Safety; Operations.
Half dozen examples of people in containment who did not complete an STP M-45B were noted.
The question of M-45B's not being filled out during normal operation is not a concern. The i
shift foremen run tailboards before the i
entries.
Review of the Root Cause Analysis.
Draft of NPAP C-10 supplement was reviewed and numerous comments were made such as:
91NCRWP\\91TNN102.PGD Page 20 of 29 d
1
a NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 a.
discussion on work areas left unattended; 1
b.
cleaning of areas; c.
Area to be secure as the worker is leaving; d.
need to address what to do in the event of an evacuation; e.
D-55 needs to be revised to address taking out material brought in containment; f.
D-55 requires to take everything out when leaving; g.
under paragraph 1.4.1, c.
add loose debris and tagged under D-55; (under D-55 tagging is complied with, somebody needs to evaluate).
h.
2 types of containers to be approved by OPEG. One of them to be permanently mounted.
i.
Modify paragraph 1.4.3 to show the type of containers that need to be approved.
j.
Should say what you bring, you take out.
John MacIntyre and Denis Burton to discuss the new FEMA procedure.
l 4
Discussion on who can go into containment.
Everybody to be trained on the new NPAP C-10 supplement.
Recommendations to add in the NPAP C-10 supplement:
a.
a definition of containment entries.
b.
the words "the shift foreman or his I
delegate have authority to review M-45B
)
data sheets."
i TRG to reconvene on Tuesday February 4, 1992 at 9:00 AM to discuss reportability and review the concrete evidence of M-45B violations.
6.
On February 4, 1992 the TRG reconvened and considered the following:
Discussion on reportability.
91NCRWP\\91TNN102.PGD Page 21 of 29 1
i m,,,,
l e
i NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 Review of 1,041 entries into containment by 346 individuals.
i QC was to find out how many people entered the containment without completing a M-45B form QC interviewed a total of 10 individuals which included operators and other QC personnel. The results of these interviews were as follows:
i; t-a.
A number of operators had filled out the M-45B data sheets.
However, two of.the i
operators were aware of the requirement, i
but did not feel that they had to fill the j
j data sheets.
b.
Of 'he QC personnel interviewed, CC QC was j'
aware of the STP M-45B requirements and l
knew that it was for the job they were l
covering.
One QC inspector was not aware j
of the M-45B requirement, the other QC j
inspector was aware of the requirement, j
but did not fill out the M-45B data sheet.
t c.
A system engineer coordinator interviewed
}
did not fill an M-45B data sheet for j
himself, but the person he was with did.
1 j
One QC personnel and two operators knew of the j
requirement, but did not think the M-45B requirements applied to them.
They thought that they were under the Radiation Protection umbrella.
In summary, four out of ten people interviewed did not fill STP M-45B data sheets which require visual inspection of the containment for loose debris when containment integrity is established.
Therefore, the requirement of TS 4.6.2.c has not been met, making this event reportable.
Write an LER and let management decide if they want to go through with it.
The TRG will reconvene, if management is under the opinion that this event is not reportable.
91NCRWP\\91TNN102.PGD Page 22 of 29
NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 I
Write the root cause as lack of comprehensive l
program for control of material after I
containment integrity is established.
Coirective Action to Prevent Recurrence written as fo) lows:
Develop a new STP M-45C that includes enhanced hcusekeeping regr' ements for Modes 1 through 4 when a unit is being restarted after an outage.
Develop the new supplement with assistance from NECS.
Two prudent actions written as follows:
Upgrade STP M-45B to be consistent with a.
the new administrative program, b.
Support the development of a new STP M-45C to contain the provisions for approval of storage in containment in modes 1 through 4 at the end of the outage.
TRG not to reconvene.
Summary of Actions:
Regulatory Compliance to prepare and a.
submit an LER for this event.
(See,LER 91-012).
b.
Obtain PSRC review and approval of th:
NCR.
d.
Close this NCR.
On April 8, 1992 this NCR was rejected by the PSRC for inconsistency between'the root cause and corrective actions.
Subsequently, several discussions were held with the Manager of Maintenance services and the Manager of Technical services.
On May 14, a meeting was held between D.
- Miklush, Mana@er of Operation Services, Christopher Groff, TRG chairman and Paul Dahan, Regulatory Compliance.
]
91NCRWP\\91TNN102.PGD Page 23 of 29 l
e NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 A review was made of the implementation of STP M-45A which covers the containment inspections prior to establishing containment integrity and STP M-45B which cover inspections when containment integrity has been established with respect to TS 4.5.2.c.2 to prevent tools or other materials from being transported to the containment recirculation sump during any specific job in containment, mainly during outages in Modes 4 through 2.
Based on this review and recommendations made.by i
other utilities regarding control of loose debris in containment, it was decided that a new STP M-45C shall be developed to establish the rules for control of material and loose parts in containment during outages, modes 4 through 2, before and during containment integrity.
These controls will minimize the paperwork to be filled out by temporary personnel during outages, thus eliminating the requirement to complete an
)
STP M-45B data sheet for each entry.
Therefore, the responsibility will be shifted to the containment coordinators which will be the watchdogs for every job being conducted in containment (during modes 4 through 2) to ensure that the containment integrity is maintained.
They will ensure that personnel performing jobs in l
containment during outages will clean up before
)
leaving the containment.
However the containment log will be maintained and personnel will have to sign when going in and out of containment.
This new method will streamline the process and help maintain the containment integrity during outages.
The corrective actions to prevent recurrence will
{
be revised to read as follows:
Create a new STP M-45C to establish administrative controls, to include enhanced housekeeping requirements for Modes 4 through 1 and placing the responsibility to maintain containment integrity (during mode 4 through 2 when a unit is being restarted after an outagc) on the Maintenance Department (containment coordinators).
91NCRWP\\91TNN102.PGD Page. 24 of 29 l
4
m NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 The containment coordinators will verify that the areas in containment have been cleaned of any loose debris after each job has been completed.
A containment log will continue to be maintained for all personnel to sign when entering or leaving the containment.
To expedite the resolution and approval of this NCR.
Rather to reconvene the TRG, this NCR will be circulated to all TRG voting members for concurrence and will then be resubmitted to the PSRC for review and approval.
Management recommended that the TRG reconvene to review the PSRC concerns.
7.
On May 28, 1992 tollowing management recommendation the TRG reconvened and considered the following:
Reviewed the description of the events.
Discussed the philosophy on responsibilities for containment integrity.
Reviewed the purpose of the applicable procedures.
STP M-45A:
Establishes containment integrity.
STP M-45B:
Maintains containment integrity at power and during high intensity work periods.
NPAP C-10:
Housekeeping program.
AP C-10S6:
Control containment integrity during outage.
It was agreed that the recommendation to create a new NPAP C-10 supplement is correct.
It was decided to discard the idea to create a new STP M-45C and instead to revise STP M-45B.
l Appropriate personnel need to be trained on the new procedure NPAP C-10S6.
l The control for this whole program should rest with the maintenance department.
The responsibility for the corrective actions will 91NCRWP\\91TNN102.PGD Page 25 of 29 l
-..=
4 NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 be shifted from Outage Management to the maintenance coordinator.
I Discussed enhancement of the work orders described in the new procedure.
Work packages should address containment integrity during high intensity and non-outage jobs.
The revision to STP H-45B should capture NECS waiver activities.
Shift the following action from prudent action to corrective action to prevent recurrence and revise it to read:
Upgrade STP M-45B to be consistent with the new administrative program. Capturo NECS waiver activities.
Prudent action assigned to mechanical maintenance to:
Request the development and installation of a door sign near containment to inform personnel of the establishment of containment integrity and the requirements for debris and loose material control.
The training of personnel on the changes to the containment integrity program controls will be accomplished during the procedures preparation and revision processes.
Appropriate tailboards for the preparation or the supplement to NPAP C-10 and the revision of STP M-45B will be required before the outage.
NCR CLOSURE:
ECD: 09/01/92 THIS NCR NEEDS TO BE APPROVED AT THE NEXT PSRC ON JUNE 0,__1992.
Based on concerns expressed by the NRC during 1R5 and possible Notice of Violation to be issued due to debris left in containment during the outage, the TRG reconvened on November 18, 1992 to enhance the corrective actions already taken and determine if additional actions were needed.
i 91NCRWP\\91TNN102.PGD Page 26 of 29 F
P
~-
r
--m..
o NCR DC2-91-TN-N102 Rev. 01 November 18, 190; The agenda was:
a.
Lessons learned from 1RS.
b.
Plan for STP M-45A/B/C for 2RS.
Review of lessons learned during 1RS.
During 1R5 an NRC insocctor (Brad Olson) performed a walkdown in containment with two QC inspectors and found an area near the sump which had materials left unattended.
Also, material was left unattended in the fan coolers area and the Radiation Protection (RP) off pad.
RP claimed that they received some guidance from NECS Engineering.
Two incidents on the 91 foot ele /ation were noted.
One of which involved a rag tied around a balancing pipe.
Discussion whether to tag or not to tag materials in containment.
Although the procedure states that materials should be tagged nobody implemented this requirement.
Maybe the procedure should be changed using the words shall instead of should.
Recap of work during 1R5 refueling outage; a.
Personnel logged in and out.
b.
Personnel were dressed in yellow.
c.
The tool clerks did a good job.
I d.
A sign was posted in containment to call the containment coordinator if anybody had any question. The sign was removed by D. Lampert because he did not to sit by the phone.
e.
1300 entries were made in modes 3 and 4.
The NRC expressed the following concerns:
a.
Nine pieces of paper which included OVID sheets were left unattended in containment.
b.
Equipments were left unattended in the fan cooler hydro pump area.
c.
All equipments were not tied.
91NCRWP\\91TNN102.PGD Page 27 of 29
NCR DC2-91-TN-N102 Rev. 01 November 18, 1992 These incidents were noted by the NRC while the personnel were taking a break. This personnel knew that they should not leave material unattended in containment while they were gone.
However, it was noted that the program now in place has improved since last outage.
Question whether PG&E personnel need additional training, since most of the incidents in containment involved PG&E personnel.
PG&E personnel in general know the requirements.
It was agreed that RP had hardly anybody in containment.
Does RP need all this equipment in containment?
Five AR's were written regarding loose material in containment during the outage.
They are:
A-0285190; A0284897; A0285405; A0284998; A0284818.
There is a need to look at each AR and determine the extend of the problem.
Should M-45A be detailed enough to look for wipe-all, black tape?
On the 91 foot level outside the bio-shield, there j
should be a thorough search.
The NRC is looking at the effectiveness of the i
program.
i Baseline the procedure supplement ma require the containment coordinator to inspect as soon as j
possible the various areas in containment.
Use of the approved containers.
Need to write down what is expected from the personnel in containment during Modes 3 and 4.
4 Two corrective actions to prevent recurrence were established:
1.
Mechanical Maintenance (John MacIntyre) to i
disposition all-the Action Requests (AR's) associated with 1R5 loose debris in containment.
91NCRWP\\91TNN102.PGD Page 28 of 29 I
.~ ~ ~ -
~
J
NCR DC2-91-TN-N102 Rev. 01 1
November 18, 1992 l
2.
Mechanical Maintenance (John MacIntyre) to meet with the containments coordinators and Quality Control Inspectors to determine the revisions to be made in the new NPAP C-10 supplement and M-45A, B,
and C based on lessons learned during 1RS.
j i
Need to determine after the November 20, 1992 meeting with the NRC if the TRG needs to reconvene.
I.
Remarks:
None.
J.
Attachment (s):
l l
l l
91NCRWP\\91TNN102.PGD Page 29 of 29 i
-