ML20059M550
| ML20059M550 | |
| Person / Time | |
|---|---|
| Site: | Diablo Canyon  |
| Issue date: | 08/19/1993 |
| From: | Rueger G PACIFIC GAS & ELECTRIC CO. |
| To: | |
| References | |
| OLA-2-A-024, OLA-2-A-24, NUDOCS 9311190160 | |
| Download: ML20059M550 (10) | |
Text
l- M - 2 75[3 2,3 -OL A - 1 N' 2Y y/9[.3 F u ;T u - Ft N A u - C Pacific Gas and Dectric Company 77 Bm S!:nt . a: ; Gregar, , R4;u l Sriiuncisco CAST 106L Suo % t President and 41W3 4Go4 Geierni Mm;r.:
i Nuclear Pones Ger.vator.
July 20, 1992 ~93 OCT 28 P 6 :)2 PG&E Letter No. DCL-92-161 g p-U.S. Nuclear Regulatory Commission :a-ATTN: Document Control Desk .
Washington, D.C. 20555 Re: Docket No. 50-275, OL-DPR-80 Docket No. 50-323, OL-DPR-82 Diablo Canyon Units 1 and 2
- Reply to Notice of Violation in NRC Inspection Report 50-275/92-17
- and 50-323/92-17 Gentlemen
i .NRC Inspection Report 50-275/92-17 and 50-323/92-17, dated '
June 19, 1992, contained a Notice of Violation citing three Severity Level IV violations regarding (1) work order instructions that were not implemented for maintenance of containment fan cooler units (CFCUs),
(2) an inspection of Unit 2 CFCUs that was conducted without appropriate procedures, and (3) untimely corrective action taken on a CFCU reverse rotation condition. PG&E's response.to the Notice of Violation is
. enclosed.
I As discussed in meetings between NRC and PG&E on April 2 cnd May 19, 1992, PG&E considers these issues regarding improper CFCU maintenance to be significant and has implemented an extensive 1
corrective action program to address them. PG&E is committed to aggressive, comprehensive, and timely resolution of maintenance problems that may indicate conditions adverse to quality or safety. 'Our corrective action program is intended to clearly communicate I
management's expectation that all employees will adhere to this commitment.
i Sincerely, _
- n) /.y Greg)ry H. Rueger ACTS LIBRARY ohn B. ar n LOG # hhD Philip J. Morrill Harry Rood CROSS R ION REF # D'IUlOI -
CPUC p l L9l'c)(-
Diablo Distribution - '
Enclosure 5828S/85K/DDS/2237*
9311190160 930819' PDR ADOCK 05000275 0 PDR_
. \
PG&E Letter No. DCL-92-161 -
ENCLOSURE REPLY TO NOTICE OF VIOLATION IN NRC INSPECTION REPORT 50-275/92-17 AND 50-323/92-17 On June 19, 1992, as part of NRC Inspection Report 50-275/92-17 and 50-323/92-17, NRC Region V issued a Notice of Violation citing three Severity Level IV violations for Diablo Canyon Power Plant (DCPP) Units 1 and 2. The statements of violation and PG&E's responses follow.
STATEMENT OF VIOLATION A Section 6.8.1 of the Diablo t.anyon Technical Specifications requires the licensee to establish and implement procedures for the activities recommended in Appendix A of Regulatory Guide 1.33, Revision 2, 1978.
Section 9.a of Appendix A to Regulatory Guide 1.33, Revision 2, states that appropriate procedures or instructions should be provided for maintenance activities that can affect the performance of safety-related equipment.
Work Orders R0063770, R0064110, R0064103, R0063296, and R0063768 provided instructions to inspect, clean, and lubricate Unit I containment fan cooler units (CFCU) in february and March 1991. The work orders referenced American Warming and Ventilation drawings SHW-D-9098, Revision F, and 9099, Revision B (DCPP Drawings 663079-38/38), for proper assembly details for containment fan cooler unit (CFCU) backdraft dampers.
Contrary to the above, the work order instructions were not implemented for maintenance of CFCUs as follows:
- Counterweights were installed without su'ficient clearance for free movement in a slotted ho?e in the -
lever arm (all Unit 1 CFCus).
- Damper linkage bars were assembled in a reverse configuration (CFCU 1-5).
- The linkage bar was placed on the wrong side of the linkage arms, causing binding of the damper (CFCUs 1-1 and 1-5).
Washers were used although none were specified in design drawings (CFCU 1-2). i i
This is a Severity Level IV violation (Supplement 1),
applicable to Unit 1.
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58285/85K REASON FOR THE VIOLATIO1 PG&E agrees with the violation.
PG&E has thoroughly investigated this event. The investigative team included personnel from plant operations; system, maintenance, and design engineering; as well as the quality organizations. Vendor information was also considered.
In addition, as discussed in meetings with the NRC on this subject, senior management has been extensively involved because it considers the improper CFCU maintenance to be significant and has directed that a' thorough investigative and corrective action program be implemented.
The investigation team determined that the cause of the improperly assembled CFCU backdraft dampers was that management and the maintenance organization underestimated the importance of the backdraft damper to the overall safety function of the CFCUs, and therefore did not provide for adequate maintenance.
This resulted in inadequate: (1) planning of CFCU backdraft damper work; (2) work instructions; (3) job turnover; (4) Quality Control (QC) involvement in inspection of CFCU backdraft damper work; and (5) system engineer involvement.
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED All ten Unit 1 and Unit 2 CFCUs have been thoroughly reinspected and all identified deficiencies have been repaired or evaluated by design and maintenance engineering and accepted. The CFCUs have been tested to thoroughly demonstrate backdraft damper operability. Surveillance Test Procedure (STP) H-51A, " Routine Surveillance of Ccntainment Fan Cooler Units for Reverse Rotation," is being performed on a monthly basis until all ten units are completely overhauled during the upcoming refueling outages IR5 and 2R5.
To correct the inadequacies noted above, PG&E has formed a CFCU High Impact Team (HIT) to assure adequate planning and coordination of maintenance activities and identification of spare parts associated with backdraft d&mper overhaul planned for 1R5 and 2RS. A nonconformance report (NCR DCO-92-MM-N007) was issued to determine the root cause and corrective actions necessary to resolve the immediate and long-term concerns. A multi-disciplinary Integrated Problem Response Team (IPRT) was formed to investigate the conditions and to determine if the problem is symptomatic of larger problems.
Also, to ensure that CFCU backdraft damper maintenance is conducted properly, post-maintenance testing procedure PHI 23.06, " Test of CFCU Backdraf t Dampers," has been developed to specifically confirm CFCU backdraft damper operability. As part of the review of this event, PG&E is surveying plant maintenance, operations, and technical support personnel to determine if there are other safety-related systems or components where appropriate practices, quality and/or understanding of the functions have not been clarified.
CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS STP M-93A, "CFCU Test," for backdraft dampers will be revised to adequately verify backdraf t damper operability following CFCU maintenance. Maintenance Procedure (MP) M-23.8 is being developed to provide more specific instructions for CFCU backdraft damper maintenance. Maintenance personnel assigned to 58285/85K
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perform backdraft damper maintenance will be trained on this new mainte... ace procedure utilizing a model of a portion of a backdraft damper. '
For further corrective actions addressing QC and system engineer involvement, refer to the response to Violation C.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED -
PG&E is presently in full compliance with the regulations. .STP M-93A will be !
revised by August 31, 1992. MP M-23.8 is being developed and~ appropriate >
personnel will be trained prior to initiation of CFCU backdraft damper >
maintenance activities in 1R5 and 2R5.
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i STATEMENT OF VIOLATION B i
Section 6.8.1 of the Diablo Canyon Technical Specifications requires the licensee to establish and implement procedures for the activities recommended in Appendix A of Regulatory Guide 1.33, Revision 2, 1978.
Section 8.b of Appendix A to Regulatory Guide 1.33, Revision 2, states that appropriate procedures or instructions should be provided for the performance of inspections that can affect the performance of safety-relatad equipment.
Contrary to the above, the licensee's inspection of Unit 2 CFCus on March 7 and 8, 1992 was conducted without appropriate procedures, and incorrectly concluded that CFCUs 2-2 and 2-5 were assembled correctly.
This is a Severity Level IV violation (Supplement I),
applicable to Unit 2.
REASON FOR THE VIOLATION -
PG&E agrees with the violation.
PG&E's investigation of this issue included:
e Interviews with the involved individuals by the Senior Mechanical Maintenance Engineer, Director - Mechanical Maintenance, Manager - Maintenance Services, and Senior Vice President and General ,
Manager - Nuclear Power Generation !
e Interviews with other involved supervisors and craft per;cnnel e A formal Human Performance Evaluation System evaluation PG&E's investigation concluded that although the inspection instructions were oral, the engineers understood the inspection assignment and did, in fact, write down the results of their inspection activities following the '
inspection. The root cause of the deficient' inspections was determined to be poor individual performance in that the inspections were not thorough, erroneous assumptions were made, results of previous inspections were not made readily available, and the inspections lacked objectivity and professionalism.
A contributing causal factor was the lack of a detailed inspection checklist to be filled out during the inspection activities.
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED The individuals performing the inspection have been formally disciplined in accordance with the PG&E Positive Discipline Program which includes a formal letter to file and follow up evaluations of performance.
To further emphr. size management's expectations, a letter was issued to all employees within Nuclear. Power Generation on May 18, 1992, by the Senior Vice President and General Manager - Nuclear Power Generation, which reemphasized 58285/85K expectations regarding individuals paying attention to details on assignments and ensuring top-quality = performance. The letter also stated-that personnel who intentionally fail to meet these expectations will be subject to disciplinary action. This issue was also discussed with Maintenance Services !
supervisors by the Manager - Maintenance Services.
l CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS. _
A maintenance policy will be distributed to all Maintenance-Services employees- J regarding the importance of timely closure.of work orders to assure'that information, such as results of previous inspections, is made promptly -
available to personnel.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED l PG&E is in full compliance. The maintenance. policy will be distributed _by- l August 31, 1992. !
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STATEMENT OF VIOLATION C 10 CFR Part 50, Appendix B, Criterion XVI, requires that measures be established to assure that conditions adverse to quality, such as defective equipment, are corrected.
Contrary to the above, on March 27, 1991 until February 22, 1992, the licensee failed to correct a condition involving reverse rotation of '
CFCU 1-5, a condition adverse to quality. Correction of this problem could have led to the discovery of similar problems with the backdraft dampers associated with three other containment fan cooler units.
. This is a Severity Level IV violation (Supplement I), applicable to Q Unit 1.-
REASON FOR THE VIOLATION PG&E agrees with the violation.
PG&E believes that the cause of the untimely response to the identified CFCU reverse rotation problem was that management and the maintenance organization underestimated the importance ef the backdraft dampers to the overall safety function of the CFCUs. Contributing to this were: (1) inadequate training of plant personnel regarding the identification and resolution of such problems, and (2) inadequate definition of problem resolution and oversight responsibility. Inadequate system engineering staffing levels also resulted in system engineering personnel being overburdened with other responsibilities. These inadequate staffing levels resulted in missed
. opportunities to learn from prior problems and observations relative to backdraft damper design and maintenance.
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED A multi-disciplinary Integrated Problem Response Team (IPRT) was formed to !
evaluate the organizational effectiveness in responding to the emerging CFCU issues in January through March 1992 (Task I of the IPRT Report, dated June 3,1992), and to evaluate the containment HVAC system to determine if 4
there is an underlying root cause that has contributed to the history of ~'
identified CFCU problems (Task 2 of the IPRT Report, dated June 3,1992).
The IPRT concluded in Task 1 that the initial organizational response could have been more comprehensive and timely; however, the backdraft damper problems were pursued aggressively to resolution. The.IPRT concluded in Task 2 that there is no underlying physical root cause for the identified HVAC problems. The IPRT concluded that the HVAC problems were attributable to inadequate design and maintenance. A nonconformance report (NCR DCO-92-MM- 1 N022) had been previously initiated to focus on maintenance practices, procedures, and methods associated with safety-related HVAC equipment. The IPRT provided their recommendations to the Technical Review Group for their consideration in developing the final corrective actions for NCR DCO-92-MM-N007.
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The Senior Vice President and General Manager - Nuclear Power Generation-directed the Vice President - Nuclear Technical Services-(VP-NTS) to review-the overall organizational issues related to'this event. -After extensive discussion with members of the key organizations (maintenance, system, design and reliability engineering), the VP-NTS concluded that the system engineers were not receiving sufficientdsupport and that' clearer delineation of the responsibilities of the respective organizations was required. These. issues are discussed below.
To ensure that identified problems are-elevated to upper management for attention, plant system and design system engineers have been advised that they have immediate access to Plant Vice President Staff Meetings'and Nuclear.
Technical Services (NTS) Emerging Issues Meetings.to present important issues affecting their systems.
Also, a discussion was held with maintenance supervisors on the importance of questioning plant equipment problems.. System and maintenance engineer interface working group meetings are being conducted to further define system and maintenance engineering responsibilities.
CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS To improve definitions of roles, a Program Directive will be issued describing :
the responsibilities of system, design, maintenance, and. reliability engineers.
Reliability engineering will provide relevant' component failure trending data i to system and maintenance engineers. The trend results.will be included.and
. evaluated in the quarterly system status reports that are jointly' prepared ~ by the plant system and design system engineers according to. Administrative-Procedure (AP) A-350,~" Plant System-Engineering. Program," paragraph'4.2.1.c.,
" Interface With NECS Design System Engineers." These quarterly. system' status.
reports identify immediate and long-term priorities .and address repetitive problems. QC inspection selection criteria will be-improved through use'ofs equipment failure trending, and will incorporate lessca: learned from the CFCU backdraft damper issue.
u The System Engineering staff will be increased by six positions,'and existing vacancies will be expeditiously filled. ' .
face-to-face communication among system, design, maintenance,'and reliability engineers (including supervisors) will be re-emphasized' to ensure that' critical information on plant problems is understood'by:all involved orgainzations.
o The scope of work order review for inspection activities performed by-non-quality organizations will be reassessed to assure proper inspection-planning, clarity, and acceptance criteria.- ManagementLexpectations for QA/QC-to aggressively question responses in plant problem reports will be-re-emphasized, and QC Department reviewers will be trained on.the requirements for thorough documentation. Management will also re-emphasize expectations for QA/QC personnel to maintain an' independent perspective, to continually consider the broader issues involved, and to rapidly: identify substantive' concerns directly to management. Periodic QA audits will be- performed on the' effectiveness.of system engineering programs. .
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To provide additional-guidance in enhancing the quality, completeness, and consistency of engineering evaluations of degraded plant conditions, PG&E will r i
i revise Nuclear Plant Administrative Procedure (NPAP) C-29/ Nuclear Power Generation 7.10. " Operability Evaluation." . Training will be provided for-engineers, supervisors, and licensed operations personnel in evaluating j degraded plant conditions. '
i DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED i
- PG&E is in full compliance with Appendix B Criterion XVI.
Corrective actions to be taken will be completed.as follows: ,
- 1. A Program Directive describing the responsiblities of the various engineering disciplines will be issued by December 31, 1992. .
- 2. QC inspection selection criteria will be revised by December 31, 1992.
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- 3. QC Department training'on the requirement for thorough. documentation wili- i j be completed by August 31, 1992. ,
- 4. The six additional system engineering positions are scheduled to be j staffed by December 31, 1992.
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} 5. HPAP C-29/NPG' 7.10 will be revised by August 31, 1992.
ji 6. Training regarding degraded plant conditions will.be completed by'
- August 31, 1992 ,
- 7. The scope of work order review for -inspection activities will be j- reassessed by August 31, 1992.
- 8. Re-emphasis of management expectations of QA/QC will beLeompleted by i
August 31, 1992. ' '
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