ML20073G181
| ML20073G181 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 04/26/1991 |
| From: | Kovach T COMMONWEALTH EDISON CO. |
| To: | Lieberman J NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| ID886:1, NUDOCS 9105030161 | |
| Download: ML20073G181 (9) | |
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April 26,1991 Mr. J. Lieberman, Director Office of Enforcement U.S. Nuclear Regulatory Comniission Washington, D.C. 20555 Attn: Document Control Desk
Subject:
Quad Cities Nuclear Power Station Unit 1 Notice of Violation and Proposed imposition of Civil Penalty (50 254/91006)
Response to Concern (50 254/90025 & 50 265/90025)
NBC.DockeLNumbetS0 254A50 205.
References:
(a)
A. Bert Davis letter to Cordell Reed dated March 27,1991, transmitting Notice of Violation and Proposed Irnposition of Civil Penalty (b)
H.J. Miller letter to Cordell Reed dated March 5,1991, transmitting inspection Report 254/91009 (c)
H.J. Miller letter to Cordell Reed dated February 14,1991, transmitting Inspection Report 254/91006 (d)
H.J. Miller letter to Cordell Reed dated February 25,1991 transmitting Inspection Report 50 254/90025 and 50 265/90025 (e)
T.J. Kovach letter to A. Bert Davis dated March 22,1991 transmitting commitment on response to Inspectiott Repor150 254/90025 and 50-265/90025 Dear Mr. Lieberman This letter provides Commonwealth Edison Company's (CECO) response to the Notice of Violation and Proposed Imposition of Civil Penalty, as transmitted in reference (a). An Enforcement Conference was held on February 21,1991 to discuss the results of the NRC's Inspection of the January 24,1991 loss of primary system inventory which were transmitted in reference (b),
Commonwealth Edison recognizes the significance of the violations set forth in the Notice and, as described at the February 21,1991 enforcement conference, has taken and continues to implement extensive corrective and preventive actions in response to them. These actions are summarized in the Response to the Notice of Violation (Attachment A), and reflect a dedication to fully incorporating the lessons learned from the events that led to the violations into its operational culture, hh Ni
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016036
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Mr. J. Lisb:rman 2-April 24,1991 1
1 i
The cover letter transmitting Reference (a) specified that CECO should Indicate when the operational staff at each of our nuclear plants would be aware of current expectations on operations. Attachment B provides a discussion on communication of expectations.
Reference (d) transmitted NRC Inspection 50 254(265)/90025 which
- provided the results of a routine resident inspector's report in this report, a concern was identified which related to a personnel error assoc ated with an out of service activity. In the transmittalletter for the Inspection report your staff indicated that a response to that concern could be included in our response to the reference (a) letter.
The response to this concern is, therefore, also provided in Attachment A.
Finally, we are concerned with the basis for escalatlon of the fine for prior 1
notice. In light of (a) the limited time available between the October Braidwood event 1
(and December Enforcement Conference) and the January Quad Cities event, (b) the time required to address operational Issues and Implement effective solutions and the fact that during a substantial portion of the period, Quad Cities was developin i:
actions in response to the October IRM Scram event, CECO believes that only with hindsight can it be concluded that the Braldwood situation should have prompted greater short term actions at Quad Cities. -We acknowledge that the escalation of a l
1ine is discretionary and, in order to maintain our focus and emphasis on actions to improve our performance, the proposed penalty will be paid.
Pursuant to 10 CFR 2.205, enclosed is a check for the full amount of the penalty to close this matter out.
If there are any questions or comments regarding this response, please contact Mr. P. Barnes at (708) 515 7278.
Very truly yours, e.
ovach Nuclear l$ censing Manager
Enclosure:
Check #01607224
$112,500.00 e
cc:- A. Bert Davls Rill L.N. Olshan NRR T.E. Taylor-Ouad Cities
. ID886:2
ATTACHMENT.A RESPONSE TO NOTICE OF VIOLATION 2
NRC INSPECTION REPORT i
50 254/91006 This attachment first outlines the violation as cited by the NRC. Following is our response to the violation including the corrective actions we have taken and those i
underway.
VJolation 1.
Technical Specifications 6.2.A.1 and 6.2.A.6 require adherence to detailed written procedures for normal operations and preventive and corrective maintenance activities which could have an effect on the safety of the facility.
I a.
OEMP 6001," Electrical Maintenance of Safety Related and Non Safety j
Related Motor Operated Valves," Section D.3 requires that permission be obtained from the Operating Department before moving a valve off of an open or closed seat.
Contrary to the above, on January 24,1991, Electrical Maintenance personnel failed to obtain permission from the Operating Department prior to moving the 4
shutdown cooling pum a suction valve, 1 100143D, a motor operated valve, off the closed seat, wh le performing an electrical maintenance activity on the
- valve, b.
OAP 3001, ' Operations Department Or nization," Section 0.10.q requires that the Nuclear Station Operator (NSO shall inillate " holds" during plant evolutions that are required to ensure it at the evolution does not threaten the L
stability of the unit. result in damage to equipment, or violate administrative controls. The NSO is also required to notify proper authorities regarding l
- unusual conditions.
Contrary to the above, on January 24,1991, the Shift 3 Unit 1 NSO failed to place a hold on the electrical maintenance testing of shutdown cooling 3 ump suction valves and ensure that a re3orted out of sequence valve operaling error did not threaten the stability o f the unit. The NSO also failed to notify the oroper authorities, shift supervision, of the reported valve operating error or lhe report of water in the reactor building sump in a timely manner, c.
CAP 3001, ' Operations Department Organization," Section C.10.p requires that the NSO shall be alert and attentive to his panels at all times. Attentive to panels means the control board indicators are monitored frequently enough to detect adverse trends before problem situations occur.
Contrary to the above, on January 24,1991, the Shift 3 Unit 1 NSO failed to be attentive to the control board Indicators after being informed of water accumulation in the reactor building sump. Specifically, the NSO failed to check reactor vessellevelindication and RHR pressure orlor to cycling the -
shutdown cooling isolation valve in an attempt to relieve a perceived high pressure in the RHR system.
1D886 3
ATIACHMENLA.(continued) d.
CAP 300 2, ' Conduct of Shift Operations,: Section C.14.1, requires that a briefing session shall be coordinated by tho Operating Engineer or designee for evolutions which are complex and involve close coordination.
Contrary to the above, on January 24,1991, the Operating Engineer or designee f ailed to hold a briefing session for the ccheduled shutdown cooling system valve stroke testing. The evolution was complex and required close coordination in that it involved the partiallift of an out of service tagout and realignment of a portion of the RHR system by the Operations Department arlor to performance of the post maintenance valve stroke test by the Maintenance Department, e.
OAP 300 2," Conduct of Shift Operation,: Section C.28.c requires that the Station Control Room Engineer (SCRE) shall have the responsibility of controlling control room activltles to assure safe plant operation.
Contrary to the above, on January 24,1991, the Shift 3 SCRE failed to control control room activities to assure safe plant operation by not maintaining cognizance of the status of the Unit i reactor. Specifically, the SCRE was unaware of the valve stroking evolution during the January 24,1991 event, that the Shift 3 Unit 1 Nuclear Station Operator secured shutdown cooling, ion 1
and that the Nuclear Station Operator operated the shutdown cooling suct isolation valve to relieve perceived high residual heat removal system discharge pressure.
2.
10 CFR Part 50, A 3pendix B, Criteria V, requires that activities affecting quality shall be prescribec by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Contrary to the above, as of January 24,1991, procedure OAP 30014,
- Equipment Out of Service", Revision 26, was not of a type appropriate to the circumstances for controlling ;he process for the temporary lift of out of service tagouts on fluid systems because it does not provide appropriate guidance for the 3 reparation and verification of system alignments to ensure appropriate Isolation aoundaries. Specifically, the arocedure failed to ensure that all active out-of service tagouts are rev ewed to determine existing system configuration such as the position of vent and drain valves.
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ATTACHMENT. A (continued) flesponse Commonwealth Edison acknowledges the violations stated above. The violations involved the f ailure of personnel to adhere to various administrative and electrical maintenance procedures during post maintenance testing of shutdown cooling pump suction valves and the subsequent response to the initial loss of inventory.
Commonwealth Edison's review of the event determined that from the standpoint of the health and safety of the public, the event had minimal safety significance.
Commonwealth Edison, however, reviewed this event in conjunction with other events including the October 27,1990 IRM scram, as well as, recent assessments of station performance and the October 4,1990 Braidwood loss of reactor coolant Inventory event. That comprehensive and thorough review revealed the need to address broader root causes. The corrective actions which were developed are appilcable to the specific violations, and c, included in the discussion below.
Conective_ActionslakenAndResultsAchieved 1.
Eersonnet/EIoceduralActions a.
The Senior "A" Electrician and Nuclear Station Operator (NSO) were removed from their duties. Appropriate disciplinary action was taken and additional training provided prior to resuming their duties, b.
Changes to the out of service procedure OAP 30014 were approved on March 26, and April 26,1991 to clearly specify actions of responsible individuals and to provide more specific requirements for tem aorary lifts.
Appropriate training on the April 26 revision will be conductoc.
c.
Inspection Report 50 254/90025 and 50 265/90025 cited a concern regarding a failure to properly prepare and verify adequacy of a Unit 1 out of service.
Due to the 'mproper out of service an unplanned partial Group Two isolation occurred. This involved errors by the out of service preparer and reviewer.
The Quad Cities Human Performance Enhancement System Coordinator conducted an investigation of this event and determined that the events causal f actors were similar to those associated with the January 24,1991 out of service deficiencies. The corrective actions cited under 1.a above and under 1.a for Corrective Action to Avoid Further Violation encompass and address the event.
d.
Procedure OEMP 6001, Electrical Maintenance of... Motor Operated Valves", was revised on February 15,1991 to relocate the step notifying the Control Room immediately before the movement of a valve.
Similar procedural guidance has been provided for incorporation to the procedure rewrite project and periodic review program.
e.
Procedure OAP 300-13 " Caution Cards" was changed on February 15,1991 to specify caution cards are to be hung at local control points. All caution card installations have been reviewed to ensure that caution cards are hung at local control points when appropriate.
ID886:5
ATTACHMENTA(continu:d) 2.
Operating Department Actions a.
The operatin0 shift organization was revised on an interim basis to provido additional support to the Control Room. For outa00 periods a SRO was added to assist the Station Control Room En0 ncor (SCRE) with out of service i
activities and a SRO was added for 1 ten hour day shift to overview the outa00 unit activities. Also, a SRO was added to the Communications Centor for two shifts por day to assist in the many administrativo dulles such as l
out of sorvice preparation.
For non outage periodri a SRO was added to assist the SCRE and a SRO was added to the Communications Center to superviso the many administrativo duties such as out-of service preparation.
i An ongoing review by both Station and Corporate Management will bo conducted of the effectiveness of those organizationalchanges. Appropriato changes will be made based on this evaluation, j
b.
Changes have boon made to the operating department shift briefing / turnover process. These include:
Specific guidance on the content and form of the shift briefing was issued via a Operating Momo.
The shift briefing was moved out of the Control Room by requiring shift aersonnel to report one half hour early for the briefing. This was dono to mprovo upon identification and discussion of critical activitios comin during the shift and enhance the interdepartmental briefing process,g up c.
A Quad Cities Heightened Levol of Awareness (HLA) Program was initiated.
This program builds upon the Braidwood Station program to (1) Identify critical tasks and incorporato them into the planning process, (d for critical tasks and
- 2) onsuro that appropriate briefings and control measures are require (3) provides for operating management involvement, d.
An Operating En0 neer Overview of the Control Room was imptomonted on l
February 15,1991. A guldeline with specific review critoria is used to overview activities such as communications, proceduto usage, attention to aanels and the OOS process. The continuation of this overview function will 3e evaluated by June 15,1991, e.
A three phase program has been implemented to strengthen conduct of operations and communicate standards. Phase one includes face to f ace communication of standards from the Plant Manager down to the operating crew. Phase two consists of observational training provided by a consultant to operating department management. Phase three consists of continuing foodback on performance.
ID886:6
ATIAC11MENLA(continued) 3.
Management PlogramActions a.
A senior management overview of plant activities has been initiated to 4
promptly reinforce managements' standards to alllevels of personnel. An assessment of the continuation of these overview activities will be performed by June 15,1991.
b.
Operations and maintenance personnel are being trained and coached in observation and monitoring techniques by senior industry peers.
c.
A formal Standards Document has been developed that includes twelve Station Management fundamentals and incorporates station department Codes of Ethics. This document has been mailed to each station employee and was reviewed during all station meetings on March 5,1991.
d.
A Self Check Program focusing on a person's attention to detail has been implemented.
GottectlyeAcilons_toAvoldfurther.Ylolatlon 1.
Personnel / Procedural Actions a.
A task analysis will be performed by the Quad Cities Station Training Department to determine specific training / qualification requirements needed to perform out of service activities. This analysis is expected to be completed by August 31,1991.
outage scheduling of critical tasks. prior to the next refuel outage to spec b.'
A station procedure will be written 2.
ManagementfrogramActions a.
A Station Communication Training Program action plan has been developed.
Training will be provided to ap3ropriate personnel on ccmmunications and is expected to be completed by July 17,1991.
i b.
An independent review team is being utilized to' integrate all corrective actions identified and to assess their effectiveness. The review team, consisting of industry experts from a consulting firm, arrived at Quad Cities Station on i
March 25,1991, and is currently assessing the corrective action program.
Date..WhenfulLCompilance_WillbeAchieved The corrective actions in response to the violation will be completed by August 31,
- 1991, ID886:7 '
ATTACHMENT.B COMMUNICATION OEEXPECIATIONS IR 50 295/91006; 50 304/91006 Reference (a) requested that Commonwea!!h Edison (CECO) indicate when we expect that the operational staff at each of our plants will be aware of our current expectation on operations, so that in the future the lack of awareness of management expectations will not be the cause of violation >. The following provides our response to your request.
CECO management expectations concerning safe plant operations are contained in various administrative and operating procedures which have been derived from corporate guidance documents such as Nuclear Operations Policies and Directives. These procedures are typically philosophical in nature and more represent Company policies rather than prescriptive instructional procedures. These procedures are authorized for use by the Station Managers after a thorough review and approval by the appropriate mana0ement personnel as set forth by the Station's Technical Specifications Through these procedures, the Gtation's oaerational philosophy and expectations are communicated to the plant staff. The plant sta"f gains awareness and knowledge of these procedures through regular and s aecial training, periodic departmental meetin0s, reading packages, qualificiation cards anc on the job use of arocedures. The implementation of these procedures, however, require personal dedica; ion and awareness of the basis for these philosophies. In essence, the 1 allure to follow those procedures represents the individual's performance weaknesses in executing his/her duties or could represent a lack of full understanding of the policy.
We are concerned with the NRC's statement "As you are the operator of twelve licensed reactors, it is our view that you should be able to clearly and forcefully communicate your management expectations to all your facilities and initiate appropriate steps to enforce your expectations " We believe that we have communicated our expectations in an overall effective manner in light of the industry's continulng efforts to promote stringent professional two of our f acilities (Byron and Braldwood) have received Category 1 standards. Currently,ich reflects our effectiveness in communicating expectations. Thr ratings from INPO wh our f acilities (Dresden, LaSalle and Byron) have received SALP 1 ratings in the Operations area. Commonwealth Edison considers these evaluations as Indicative of our continuing efforts toward achieving excellence in nuclear plant performance.
We share the NRC's philosophy that management has a duty and obligation to foster the development of a
- safety culture" at each f acility and to provide a professional working environment throughout the facility that assures safe operation. We recognize that our managers must provide the leadership that perpetuates the safety culture. Consistent with that piilosophy, when such events occur at our facilities (i.e., EA 90 203, EA 90 208 and EA 91018) we believe it is essential that a critical evaluation of management performance be conducted. In that spirit, we are obligaN to share the rersensiblhty in the shortf alls of our employee's performance. The intent 01 me February 21,1'991 Enforcement Conference presentation was not to imply that we have not adequately communicated our expectations or failed to enforce them but rather to address how we could potentially have created a more effective barriers in avoiding such events due to poor personnel performance.
ID886:8
ATTACHMENT B (continued)
Commonwealth Edison continues its efforts in strengthening the safety culture which we believe has been established at all of our facilities. The Stations continue to implement various established, as well as now and innovative, programs focussed at improving communications, teamwork, critical thinking and questioning attitude skills. While the programs differ between stations, some examples include Corporate Oversight Committee aresentations, the use of station newsletters, routine department meeting, the "Self Check" Program and the heightened level of awareness programs, in conclusion, Commonwealth Edicon's organization consists of dedicated personnel whose first objective is safo operation of the plant. Commonwealth Edison has adequately communicated our expectations at all of our plants and has enforced those expectations through various management techniques, e.g., personnel performance evaluations and management observations of plant activities, While we recognize that we have not yet ach!eved excellence at each of our nuclear plants, we are in the process of implomonting effective measures to achieve excellence at each of our plants.
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