ML20059G965
| ML20059G965 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 11/03/1993 |
| From: | Maynard O WOLF CREEK NUCLEAR OPERATING CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| WO-93-0184, WO-93-184, NUDOCS 9311090213 | |
| Download: ML20059G965 (13) | |
Text
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i W8LF CREEK
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' NUCLEAR OPERATING CORPORATION Otto L Maynard November 3, 1993 Vee Presdent Plant operatons WO 93-0184 U.
S. Nucleer Re9dlatory Commission ATTN: Docurient Control Desk
-Mail Statici.51-137 Washington, D.
C. 20555
Reference:
Letter dated October 4, 1993 from S.
J.
- Collins, NRC, to N. S. Carns, WCNOC
Subject:
Docket No. 50-482: Reply to Notices of Violation 482/9321-02, 482/9321-03 and 482/9321-05 Gentlemen:
Attached is Wolf Creek Nuclear Operating Corporation's (WCNOC) " Reply to Notices of Violation 482/9321-02, 482/9321-03 and 482/9321-05 which were documented in the Reference (NRC Inspection Report 50-482/93-21).
Violation 482/9321-02 concerned three examples of failure to -implement corrective action for known significant conditions adverse to quality.
Violation 482/9321-03 concerned a failure to generate a corrective work request, for a known condition adverse to quality, - as required by work instructions.
Violation 482/9321-05 concerned a failure to correctly position Valve EF-V0263 " Essential Service Water Screen "1B" Warming Header Upstream Isolation" in accordance with procedural requirements.
The NRC identified each of these incidents as Severity Level IV violations.
If you have any questions concerning this matter, please contact ' me at (316) 364-8831 ext. 4000 or Mr. K. J. Moles at ext. 4565.
Very truly ours,
.f' YdffM
/
Otto L. Maynard Vice' President
. Plant Operations OLM/ RAM /jra Attachment cc:
J. L. Milhoan (NRC), w/a G. A.
Pick -(NRC), w/a W. D.
Reckley (NRC), w/a M. A.
Satorius (NRC), w/a P. C. Wagner (NRC), w/a L. A.
Yandell (NRC), w/a
/,
9311090213 931103 8 m i Bens n.
3
% (316 m a31 1 }.
PDR ADOCK 05000482 An Ewal oppoqanny Emplorer M WC' VET G
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Attachment to WO 93-0184 I
Page 1 of 12
' Reply to Notices of Violation 482/9321-02, 482/9321-03 and 482/9321-05 Violation 482/9321-02:
Inadequate / failure to implement corrective actions:
I Three examples of known failure to implement i
corrective actions for known significant conditions
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adverse to quality.
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t Criterion XVI, Corrective Action, of Appendix B to 10 CFR Part 50 states that
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- measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and' corrected.
In the cases of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined to preclude repetition.
.g The identification of the significant condition adverse to quality, the cause-
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of the condition, and the corrective action taken shall be documented and I
reported to appropriate levels of managemen*
1 Contrary to the above, the following 'aolations of those corrective action' l
provisions were identified:
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- 1. There had been seven failures of the bellows in Residual Heat Removr1 Relief Valves EJ8856A and -B since 1984.
The licensee failed to promp*
resolve these repetitive failures and had failed to perform a thor l
evaluation of the causes of the problem.
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- 2. The licensee failed to determine the correct model number for component i
cooling water flow transmitters in a timely manner.
The drawing discrepancy for the reactor coolant pump thermal' carrier cooler flow transmitters was identified on August 1,
1992, but -no action had been 3
i initiated until the time of this inspection.
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1 3.
Performance Improvement Request 91-0398 indicated that bends in
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safety-related tubing installed in the plant could not be verified to meet
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ovality requirements of the applicable American Society of Mechanical
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Engineers Code.
This condition was reported on July 10,
- 1991, and i
t evaluated to be significant on September 23, 1991.
There was no additional effort to determine,
- plan, or initiate corrective action-until
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Jun; 3, 1993.
Admissien of Violatirn:
u Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that i'
a violation of Criterion XVI, " Corrective Action", of Appendix B to 10 CFR 50, occurred when WCNOC failed to implement prompt and effective corrective actions to correct and prevent recurrence of the problems stated above.
Reason for Vicistion:
WCNOC recognizes its responsibility to thoroughly evaluate the consequences of non-conforming conditions, including an evaluation of both the specific and
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generic effects on the ability of safety-related equipment to perform their 1
intended design basis function (s).
Generic aspects of WCNOC's failure to correctly implement its corrective action program included:
j-f f
a-
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i Attachment to WO 93-0184
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Page 2 of 12 z
Inadequate communication of management's expectations contributed to the poor quality of documentation.
During August, 1993, Engineering conducted a self assessment of the engineering dispositions performed during the Sixth Refueling Outage, (second quarter 1993).
One weakness discovered during this self assessment was the inconsistent quality of the disposition documentation.
All of the dispositions were found to be technically correct, however the i
documentation packages were inconsistent across different engineering groups, l
both in terms of format and content.
Engineering Department procedures
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provide general guidance on the content of dispositions, but the guidance is l
not specific enough to ensure consistent content and format across different j
groups and across the different tynes of disposition documents.
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- Also, WCNOC's failure to promptly resolve corrective action issues was exacerbated by the growth of the engineering backlog over a seven year period, from 1985 through 1992.
With the development of this backlog it was necessary-l to prioritize the work and work to a defined plan. The Engineering Department I
is currently one year through a two year backlog reduction effort.
Since August, 1992, the backlog of work has not increased, and in fact has decreased in the areas of procurement, Industry Technical Information Program (ITIP)
Reports (WCNOC's Operating Experience Program),
Performance Improvement
_j Requests, Hardware Failure Analysis Requests, Work Requests and Engineering Evaluation Requests.
As will be described later in this response, this-backlog reduction plan includes key strategies for reducing the quantity of l
cpen work and managing the open work until the backlog is effectively eliminated.
Examole 1:
I I
The direct root cause for the inadequate evaluation of the cracked relief valve bellows was insufficient personal awareness on the part of field personnel discovering hardware problems. WCNOC personnel failed to retain the evidence in the form of the cracked 1ellows.
WCNOC discovered and replaced -
the failed relief valve during the Fifth Refueling Outage, in the fourth' quartei of 1991.
Although a Hardware Failure Analysis Request (HFAR) was initiated to investigate the repetitive bellows failures, the failed relief valve could not be located after the refueling outage.
Engineering incorrectly assumed that, without failure evidence, they could not perform an adequate root cause investigation.
Engineering should have perforned other investigative activities to compensate for the lack of direct
- evidence, including work history searches, coordination with the valve supplier, and a thorough research of industry experience.
Such actions would.
have resulted in the definition of credible failure scenarios in lieu of'a specific root cause, and subsequent implementation of corrective actions to envelope all of the credible failure scenarios in a much more timely fashion.
Under HFAR MA 92-004, a preliminary evaluation of the problem for valves EJ8856A and B indicated the cause of the bellows failure to be high cycle fatigue.
Due to check valve leakage from the Reactor Coolant and Safety Injection Systems, the Residual Heat Removal System pressurizes and causes the relief valves to cycle.
Inspection of the relief valves concluded that.the relief valves would. function and open within tolerances for the required set pressure. The final root cause will be determined by November 30, 1993.
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Attachment to WO 93-0184 Page 3 of 12 Due to the lack of physical evidence this preliminary root cause was based, in part, on the results of HFAR. MA 92-003, which evaluated a similar bellows f ailure on a relief valve in the Chemical and Volume Control System.
HFAR I
MA 92-003 was performed to determine the root cause of the failure of Pressure Relief Valve BG811B on the discharge side of the Positive Displacement Pump.
i Relief Valve BGB118 is of similar design to Relief Valves EJ8856A and B.
In this case, a problem was first noticed when leakage was discovered coming from a crack in the valve inlet piping flange weld.
Investigation into the failure j
scenario, root cause and conclusions showed that the bellows is made of 316L (low carbon content) Stainless Steel.
This material can only be hardened by
" cold work" that can be the result of thermal or mechanical cycling of tPe valve.
The bellows failure mechanism was due to high cycle fatigue.
This as noted above is the same failure mechanism as suspected for Valves EJB856A and B.
Failure occurred where the valve stem connected to the bellows.
The l
bellows suffered sixteen fatigue cycles after crack initiation prior to l
failure.
The source of this failure is due to system pressures exceeding the 1
set pressure of the valve and resultant valve flutter.
However, it should be noted that inspection of the relief valves concluded that they would function and open within the tolerance for the required set pressure and would have t
provided their protective function.
P Example 2:
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Work Request 03909-92 was initiated in August, 1992., by WCNOC, to identify and resolve a model number discrepancy between a vendor manual and a vendor j
drawing for the Reactor Coolant Pump Thermal Barrier Component Cooling Water Flow Transmitters.
The model number for these transmitters was changed in 1983 from 1153-B series to 1153-D series.
All documentation was updated at that time to reflect this change, except the subject vendor drawing j
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(J-301-00062).
Because of the extensive work backlog in Engineering and the j
low safety significance (a condition not adverse to quality) of this drawing
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discrepancy, the work request was assigned a low priority. Actions to correct this drawing discrepancy were completed in October, 1993 with the issuance of f
Configuration Change Package (CCP) #CC00729.
l Examole 3:
The root causu for this violation was a breakdown in internal communications within the Maintenance and Modifications Division.
This breakdown occurred between August 22, 1991, when the tubing ovality concern was determined through preliminary research to have no basis, and September 23, 1991, when i
the Performance Improvement Request (PIR) was identified as significant.
The breakdcwn led to an impasse in that the individual assigned to resolve this concern was required to perf orm a formal root cause on an issue which had previously been determined to have no basis. This led to a lack of urgency to 3
process the PIR through approval to completion.
The resolution of the PIR defaulted to a low priority, resulting in the long delay in closure.
I Corrective Stecs Taken and Results Achieved:
Generic aspects of WCNOC's failure to correctly implement its corrective i
action program:
l The Engineering backlog reduction plan includes the following key strategies for reducing the quantity cf open work in Engineering, as well as managing the open work until the backlog is effectively eliminated:
l Attachment to WO 93-0184
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Page 4 of 12 l
tnsure that work is screened and prioritized based on safety significance f
per procedure ADM 01-02BA *Prioritization of Wolf Creek Activities," which l
l vas issued for use on May 17, 1993.
Prior to May, 1993, and since
- December, 1991, Engineering work had been prioritized per procedure i
KPN-J-308 and WCNOC-079, which formed the basis for ADM 01-28A.
All incoming work documents are screened at initiation to a company-wide l
prioritization scheme based upon safety significance.
Work that potentially affects operability of plant equipment is addressed immediately I
as emergent and urgent.
All other work is scheduled based upon resources.
and opportunity to accomplish in plant work.
Management also ensures that j
the backlog is periodically reviewed to reassess any changes in priorities j
over time, due to cumulative experience.
A significant reallocation of engineering resources started in August, 1992 to shift the focus from plant modifications work to the backlog of procurement and corrective action work, while maintaining appropriate l
resources for emergent issues.
Needed design modifications to support j
plant enhancements are temporarily being completed by contract Architect
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J Engineers. This level of resource focus will continue until the backlog is effectively eliminated.
- The WCNOC design evaluation / change process was streamlined, so that management expectations were defined more directly and so that problems are j
solved through more efficient use of engineering resources.
These enhancements have improved production by allowing the level of disposition work effort to match the complexity and safety significance of the problem.
Additional enhancements to the
- process, to be completed by Decenber 31, 1993, will improve the ability to match the level of effort I
with safety significance.
- To ensure that Engineering resources remain focused on. the important issues, WCNOC implemented a screening process for all "non-corrective action" requests for Engineering evaluation.
Beginning with the formation of System Engineering, System Engineers screen Engineering Evaluation Requests for significance and relative benefit to plant performance.
The j
evaluation requests of a discretionary nature are then evaluated by management in the Operations Department, who then select a running list of i
the top ten requests for Engineering to resolve.
This process is enabling Engineering to complete important plant enhancements while dedicating significant resources towards backlog reduction.
The above actions have reduced the overall Engineering backlog by 60%, from 2632 documents in August,
- 1992, to a
level of 1024 documents in-Mid-October, 1993.
The backlog of work in Engineering will be effectively l
eliminated and will be at a normal level of
- active, open work by i
Decenber 31, 1994.
A quarterly review of the backlog will be conducted during this period to ensure there is no change in safety significance.
Example 1:
Since the time of the bellows crack during the Fif th Refueling Outage, WCNOC has recognized the recurring nature of its failure to retain evidence and the impact this f ailure has had on the quality of its root cause investigations i
into hardware failures.
To ensure that hardware failure evidence is retained for evaluation, WCNOC implemented the following actions:
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Attachment to WO 93-01B4 Page 5 of 12 txisting corrective action procedures (e.g.,
KGP-1212, " Hardware Failure
- a Analysis") were revised in October, 1992, to assign responsibilities for evidence retention and to provide better expectatiens for maintaining i
post-failure control of the physical evidence.
This has been reinforced with appropriate Maintenance personnel.
- The System Engineering organization was formed during,the third quarter, t
1992.
System Engineering was formed, in part, to provide immediate engineering involvement in day-to-day operational activities.
System Engineering is heavily involved in emergent plant issues, including investigation of potentially significant hardware failures.
System Engineering also works closely with field personnel to retain appropriate physical evidence.
Since implementation of the above actions, evidence retention has been satisfactory, improved, which has contributed to an improvement in both the quality and timeliness of hardware failure analyses.
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To address the previously incorrect perceptions within Engineering, the Vice President Engineering has emphasized his expectations for thorough root cause investigations of potentially significant hardware failures with Engineering management.
These expectations included the development of credible. f ailure j -
scenarios and implementation of enveloping corrective actions for instances where the direct root cause may not be able to be determined in a timely manner; e.g.,
due to a prior loss of evidence.
Based on the preliminary evaluation results the corrective actions under evaluation for the bellows failures may include:
Repair of the leaking check valves and/or minimizing the effects of leaking check valves on these relief valves.
Inspection of the relief valves to assure the correct " nozzle ring" settings to prevent valve chatter or flutter once it has lifted.
- The installation of a gauge to monitor system pressure at the relief valve.
Based on the information provided by the gauges, operations personnel will be able to take manual actions, when needed, to relieve system pressure.by venting the system.
Vendor training for appropriate site personnel.
Given the preliminary root cause of high cycle fatigue, it is apparent that the cycling of relief valves needs to be avoided whenever possible The root cause of relief valve EJBB56B's failure is still being studied and there is no 3
i basis at this time to conclude that the rest of WCGS's relief valves are j
subject to bellows failure.
The conclusions associated with the valve's j
failure will be stated in HFAR MA 92-004.
l WCNOC is presently working on a comprehensive relief valve program that will i
make all design criteria and necessary information for each relief valve easily available.
Training of the engineers and craft workers will educate and strengthen the abilities of key personnel who work with relief valves.
This program, integrated with WCNOC's Maintenance personnel will provide additional assurance that each relief valve will be able to perform its design-function.
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Attachment to WO 93-0184
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P Page 6 of 12 l
f Exafnnle 2 :
i The following actions have been taken to correct this drawing discrepancy:
The subject vendor drawing (J-301-00062) was updated.by Configuration Change Package #CC00729 in October, 1993.
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f An on-going backlog reduction effort in Engineering (which has been discussed on previous occasions with the Nuclear Regulatory Commission) has effectively eliminated the backlog of drawing discrepancies..
i All corrective actions for this example have been completed.
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Example 3:
j Recent administrative changes to the organization and personnel within 'in l
Maintenance and Modifications have greatly improved communications within the i
organization.
Work Request 03834-93 was issued on June 3,
1993, to obtain Engineering's
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j evaluation and disposition of the safety related tubing ovality concern identified on Performance Improvement Request 91-0398.
Nuclear Engineering determined that construction ovality checking for instrument tubing was not considered to be required by the ASME code of record for WCGS in accordance with section on Article NC-3642.1(b)
No significant technical risk exists despite the intent of the 1992 code requirement, which has clarified the 1974 code.
The testing performed under the above work request provided sufficient confidence (97%) that tubing bends meet the 8% ovality.
Therefore no change.
in current practice for tubing installation is required.
All corrective actions for this example have been completed.
Correct ive Steos That Will Be Taken to Avoid Further Violations:
Generic aspects of WCNOC's failure to correctly implement its corrective action program to improve the quality of Engineering dispositions and associated documentation:
- WCNOC is currently developing disposition guidelines to define the
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appropriate level of documentation.
These guidelines will provide the j
required content for dispositions, given the type of disposition and the j
safety significance of the issue, and will be applicable to such corrective
- j action documents' as Performance Improvement Requests, Corrective Work j
Requests and ITIP.
The engineering guidelines for corrective. action
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documents will be completed by December 31, 1993 l
Examole 1:
j The final root cause of the relief valve bellows failure will be determined by November 30, 1993.
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j Attachment to WO 93-0184
-Page 7 of 12
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To
'further address the previously incorrect perceptions within Engineering,(Due Engineer's incorrect assumption that, -without failure evidence,-they could not perform an adequate root cause evaluation.) the.Vice President Engineering has also Instructed Engineering to re-review past hardware failure investigations to ensure that~ safety related failures were evaluated for root cause, despite the potential lack of evidence - retention.
This action will be completed by December 31, 1993.
Date When Full Comoliance Will Be Achieved:
All corrective actions necessary for compliance by WCNOC will be completed and WCNOC will be in full compliance by December 31, 1993.
Additional actions discussed above that are to be completed beyond this date are considered-enhancements to the process used.
Actual or Potential Consecuences of This violation:
WCNOC recognizes that the primary concern in this matter is WCNOC's failure to j
implement required corrective actions in a timely and effective manner.
This j
failure allowed the affected equipment to be returned to service without the root cause of the problem being identified and corrected.
WCNOC's efforts to implement corrective actions in accordance with regulatory requirements were slowed by an excessive work backlog. Actions have been implemented to resolve the adverse effects of the current backlog.
These actions should be effective in preventing recurrence of the above noted corrective action program concerns.
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Attachment to WO 93-0184 Page 8 of 12
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, Violation 482/9321-03: Failure to generate a-corrective work request, for a i
known condition adverse to quality, as required by l
work instructions.
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" Technical Specification 6.8.1.a states that written procedures shall be-j established, implemented, and maintained covering the app]icable procedures recommend in Appendix A of Regulatory Guide 1.33, Revision 2, dated February l
1978.
Regulatory Guide 1.33, Appendix A,
Item 9a, recommends, -in part, that I
maintenance that can affect the performance of safety-related equipment should l
be properly pre-planned and performed in accordance with written procedures appropriate to the circumstances.
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Contrary to the above, on July 23, 1993, maintenance workers failed to generate a corrective work request as required by Step 2.4 of Work Request 4595-93, after critical tolerances measured internal to Valve EF-V046'were not within the acceptance criteria."
i Admission of Violation:
1 WCNOC agrees that a violation of Technical Specification 6.8.1.a occurred when f
Maintenance personnel failed to generate a corrective ' work request, upon identification of tolerance measurements outside of acceptable limits, as
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required by Step 2.4 of Work Request 04594-93.
1 Reason for Violation:
The root cause for the failure to perform work instructions as written was that the responsible craft personnel did not have a clear understanding of the scope of the assigned work activity.
This misunderstanding has been attributed to the lack of attention ta detail during the review of work instructions, misleading work instruction, and the absence of a questioning-l attitude.
1 Corrective Steos Taken and ReFults Achieved:
The work instructions utilized to inspect Valve EF-V046 were revised to ensure that the work task is appropriately identified.
This revision included the addition of informational notes and enhanced illustrations.
The Supervisor of Mechanical Maintenance and the Supervisor of Planning for Mechanical Maintenance discussed:
- 1. The root cause investigation results for this violation with the Maintenance Engineering Group.
This discussion stressed the importance'of ensuring that work instructions are clear and concise, and that independent review of work instructions (prior to.use) are performed - to minimize potential craft interpretation errors.
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- 2. The importance of Pre-Jcb Briefings with Craf t personnel.
This discussion j
l stressed the importance of Pre-Job Briefings to ensure all personnel.
involved with a job understand the work scope, of questioning situations that do not seem appropriate to the circumstance, and the need for self-checking with the additional use of independent review.
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. Attachment to WO 93 'J184
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Page 9 of 12 1
Coriective Stecs That' Will Be Taken to Avoid Further Violations:
The corrective acts.ons described above are-considered appropriate and sufficient to avoid further violations. Therefore, all corrective actions are complete.
f Date When Full Comoliance Will Be Achieved:
All corrective actions were completed by October 22, 1993.
Actual or Potential Consecuences of This Violation:
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WCNOC recognizes that the primary concern.in this matter is the. failure of WCNOC personnel to correctly verify the operability of Valve EF-V046 and upon
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the identification of a potential significant condition adverse to quality,.
the failure of the personnel to generate the appropriate corrective action
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vehicle.
Both of these errors are viewed as breakdowns in the implementation.
of the work control process
-However, subsequent inspections of the valve i
showed the critical tolerances were within the allowed'11mits.
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- l Attachment to WO 93-0184
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Page-10 of 12 i
Violation 482/9321-05:
Failure to correctly position Valve EF-V0263 j
" Essential Service Water Screen "1B" Warming Header i
Upstream Isolation" in accordance with procedural i
requirements.
l Technical Specification 6.B.I.a states that written procedures shall be established, imple nented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, dated February l
1978.
j Regulatory Guide 1.33, Appendix A, Item 3.m, requires procedures for startup,
. I cperation, and shutdown of safety-related systems. ~This is accomplished, in part, by Procedure STN GP-001,
" Plant Winterization," Revision 9,
which is l
0 F for one implemented when the outside temperature has remained less than 35 week or as directed by the operations manager.
Procedure STN GP-001, Step
-l 5.6.4.1 directs operators to open Essential Service Water Warming Line Valve EF-V263 [EF-V0263]
Procedure STN GP-001, Step 6.3.3.1 subsequently directs 0 F for one week, the that when the outside temperature remains greater than 40 system be restored by closing Valve EF-V0263.
Contrary to the above, on November 10, 1991, and November 28, 1992, operators failed to open Valve EF-V0263 as required by Step 5.6.4.1 of-Procedure I
STN GP-001; and on April 13, 1992, and April 29, 1993, operators failed to shut Valve EF-V0263 as required by Step 6.3.3.1 of Procedure STN GP-001, Operators failed to properly position Valve EF-V0263 because the valve actuator was damaged and manipulation of the manual operator did not change j
the position of the valve, even though the actuator's indication of valve l
position did change.
.(The failure of the valve mechanism was documented on April 30, 1991.)
F i
Admiscion of Violation:
a WCNOC agrees that a violation of Technical Specification 6.8.1.a occurred
~ i since Maintenance personnel failed to transfer the problem description from Work Request 01656-91, which was used to troubleshoot the valve's operational
. l problems, to Corrective Work Request 01658-91.
This failure on the part of l
Maintenance personnel to transfer the problem statement to the open work j
request misled the Operations personnel into believing the valve had been repaired and was functioning correctly.
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Reason for Vic1ation:
i Troubleshooting work instructions were written for Work Request 01656-91lto determine if the problem existed in the actuator or in the valve itself.
- i After troubleshooting was completed, the workman identified t?at no problem i
existed inside of the valve actuator and that the valve was stuck internally.
The group leader closed Work Request 01656-91 in troubleshooting and
. i identified on this work request that the valve would 'be reworked per Corrective Work Request 01658-91.
Work Request 0165B-91 identified the valve j
i required excessive force to operate. Once troubleshooting identified that'the problem existed in the valve it was determined that the scope of Work Request 01658-91 was the same and Work Request 01656-91 was closed in. troubleshooting
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without transferring the problem description.
There are no procedural requirements for transferring information from one work request to another when it is being closed in process or closed in troubleshooting.
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Attachment to WO 93-0184 Page 11 of 12 Additional troubleshooting per Work Request 05134-93 identified that the actuator shaft was broken in an area close to the valve shaft coupling.
The actuator shaft was apparently broken after the initial troubleshooting was performed, but was not identified per the Corrective Work Request.
Also, with this sheared shaft, the operator could be turned without actually positioning the valve disc.
Initially the valve operator was not easily.
turned with the sheared shaft due to the uneven surface of the sheared area on the stem.
Over a period of time the sheared area on the stem wore down making the valve operator easier to turn.
This lead the Operators to believe that the valve was operating normally due to the resistance of the' rubbing surfaces of the sheared area of the stem.
The valve actuator appeared to be operating similar to other large butterfly valves in the plant.
The other three valves j
were known to cperate hard and they believed this valve may have been worked on.
Valve EF-V263 is in series with Valve EF-V265 and this valve operated to the cpen and closed position, when performing STN GP-001.
This allowed the warming line to be placed in service in the fall and removed from service in l
the spring.
Valve EF-V263 is a Jamesbury Butterfly Valve Model 8026-EX with a manual operator.
There is valve position indication on the manual operator and the valve stem.
Currently the manual cperator indicates shut while the stem indicates half open.
After reviewing the vendor manual, it is believed that the stem position indication is accurate and the valve is half open.
3 Operations checked the valve and stated that it was closed.
The root cause was that Maintenance personnel failed to consider the need to transfer necessary and pertinent information from the work request used to j
troubleshoot the valve, wnich was being closed, to the work request in place to perform the work; i.e.,
fix the prtblem.
Contributing Factors:
WCNOC Administrative Procedure, ADM 01-057, " Work Request", did not provide guidance to the user for when information and what types of information must be transferred from a work request being closed-in-process to the work request which will perform the work activity.
1 Nuclear Station Operators were unf amiliar with the stem position indication I
available on the Jamesbury Model 8026-EX butterfly valves (valve EF-V263).
Although 2nformation on this stem indication had recently been. incorporated into Initial Lesson Plan NOO1020301, " Valves and Valve Actuators", for Nuclear Station Operators, the information had not yet been incorporated into the Requalification Lesson Plans for Nuclear Station Operators, nor were the previously qualified Nuclear Station Operators made aware of the available stem position indicators on the Jamesbury Model 8026-EX butterfly valves.
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ttachment to WO 93-0184 j
Page ?,2 of 12 i
Corrective Sters Taken and Results Achieved:
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Procedure ADM 01-057 was revised to provide clear guidance on when and what l
types of information must be transferred from a work request being i
closed-in-process to a work request which will be used to perform the work activity.
This action eliminates the burden on. the craf t personnel to
't determine when and what type of information must be transferred.
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Performance Improvement Request # OP 93-0941 was placed in Operations Required Reading (#93-202) to inform the cperators of the valve stem position indicator and to re-emphasize the importance of effectively performing STAR when conducting activities that can affect safety.
f Corrective Steps That Will Be Taken to Avoid Further Violations:
[
Nuclear Station Operator Lesson Plan NOl636009, " Plant and Industry Events, "
will be revised.
This revision will address:
l The valve stem position indicator and its uses.
f t
- The problem caused by the failure to identify the existence. of and the i~'
failure to use the valve stem position indicator when manipulating - Valve EF-V263.
1 This activity will be completed and all Nuclear Station Operators presently j
qualified will be trained by December 23, 1993.
Date When Full Compliance Will Be Achieved:
Corrective actions necessary for WCNOC to be in full compliance 'been completed.
The additional training is an appropriate enhancement and will be completed by December 23, 1993.
Actual or Potential Consecuences of This Violation:
WCNOC recognizes that the primary concern in this matter is the ' f ailure of l
WCNOC personnel to correctly transfer the necessary information from the work l
request being closed-in-process.
This failure to transfer necessary and l
pertinent information led the Operations staff to believe the valve had been I
repaired and was functioning correctly.
Therefore, they were hampered in their ability to identify and correct a condition adverse to quality.
WCNOC Engineering has performed a systems evaluation and has determined that adequate flow was available to maintain the pump suction bays at the ' correct temperature for the plant design parameters. Therefore, adequate warming flow was provided when required and was adequately isolated when required by a-redundant system isolation valve.
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