ML20076B364
| ML20076B364 | |
| Person / Time | |
|---|---|
| Site: | Brunswick  |
| Issue date: | 07/01/1991 |
| From: | Watson R CAROLINA POWER & LIGHT CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| EA-91-045, EA-91-45, NLS-91-160, NUDOCS 9107110181 | |
| Download: ML20076B364 (10) | |
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CD&L Carolina Power & Light Company P o Box 1551
- Ratesgh, N C. U602 "JUL 011991 SERIAL: NLS 91-160 R. A. WATSON Sena Vre Presdu.it Nuclear Genershon United States Nuclear Regulatory Commission ATTENTION: Document Control Desk Washington, DC 20555 BRUNSWICK STEAM ELECTRIC PLANT, UNIT NOS.1 AND 2 DOCKET NOS. 50-325 & 50-324/ LICENSE NOS DPR-71 & DPR 62 REPLY TO NOTICE OF VIOLATION (EA 91-045)
Gentlemen:
On May 31,1991, the Nuclear Regulatory Commission issued a Uotice of Violation (EA 91-045) for issues at the Brunswick Steam Electric Plant, Units 1 and 2. Details of the NRC inspections are provided in Inspection Report Nos. 50-325/91-06 and 50 324/91-06 dated May 31,1991.
Carolina Power & Light Company hereby responds to the Notice of Violation. The enclosure to this letter provides CP&L's reply to the Notice of Violation in recordance with the provisions of 10 CFR 2.201. Also enclosed is a check payable to the Treasurer of the United States in the amount of Eighty Seven Thousand Five Hundred Dollars ($87,500.00).
In the Cammission's May 31,1991 Notice of Violation, recognition of the limited safety impact of the individual violations was acknowledged. The Company continues to believe that management initiatives implemented shortly before these violations will effect the necessary human performance improvements.
Please refer any questions regarding this submittal to Mr. S. D. Floyd at (919) 546-6901.
Yours very truly, O g?(
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R. A. Watson WRM/wrm nwp\\ea91045.wpf)
Enclosure cc:
Mr. S. D. Ebneter Mr. N. B. Le 7g7[
Mr. R. L. Prevatte 4
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Document Control Desk NLS-91-160 / Page 2 R. A. Watson, having been first duly sworn, did depose and say that the information contained herein is true and correct to the best of his information, knowledge and belief; and the sources of his information are officers, employees, contractors, and agents of Carolina Power & Light Company.
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ENCLOSURE BRUNSWICK STEAM ELECTRIC PLANT, UNITS 1 AND 2 NRC DOCKET NOS. 50 325 & 50 324 OPERATING LICENSE NOS. DPR 71 & DPR 62 REPLY TO NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF civil PENALTY VIOLATION A:
Technical Specification 6.8.1.a requires that written procedures be established, implemented and maintained for applicable procedures recommended in Appendix A, Regulatory Guide 1.33, Quality Assurance Program Requirements, November 1972. Appendix A to Regulatory Guide 1.33 requires that administrative procedures be established detailing procedure adherence requirements.
'OMM-001 Maintenance: Conduct of Operations, Revision 14, Section 5.2.2, requires that each procedure shall be accomplished in the sequence written and initialed upon completion.
Contrary to the above:
(1)
During performance of OPIC-DPT007, Calibration of Rosemount Model 1151 Square Root Differential Pressure Transmitter, for Standby Liquid Control System pump discharge test flow transmitter C41 FT-5512 on March 15,1991, instrumentation and Control (l&C) technicians failed to independently verify the torque of the high and low pressure vent plugs as required by steps 7.1.12 and 7.1.13. Additionally, the documentation of the y
return-to-service required by steps 7.4.6 through 7.4.11 was performed out of sequence in that the second l&C technician performed the independent verification prior to the first l&C technician Jocumenting the restoration steps being completed.
(2)
During performance of OPIC-Ul004, Calibration of Action Model V560 Indicators, for the 2
Standby Liquid Control System local flow indicator C41-FI 5512 on March 15,1991, the same technicians failed to document completion of prerequisite step 3.1 for obtaining permission from Operations to initiate the calibration procedure,' and step 7.1.1 for opening l'
a terminal box and lifting an electrical lead. The I&C technicians also failed to perform and
' document an independent verification required by step 7.4.2 prior to completion of the j
procedure.
l This violation applies to Unit 1 only.
RESPONSE TO VIOLATION A:
- Admission or Denial of Violation:
CP&L admits to this violation.
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Reason for the Violation:
The I&C Technicians that were involved with both procedure non-conformances, performed the physical work as required by the procedure, but failed to maintain the administrative requirements by not initialing the steps as performed.
Corrective Stens Which Have Deen Taken and Results Achieved:
The work on the affected equipment was stopped until the extent of the non-conformances could be determined. The work was restarted once the previously performed steps and sign-offs were brought up to date. The work was completed without any adverse results.
Meetings were held by Maintenance supervision with I&C/ Electrical and Mechanical crafts-persons, The topic was the expectation for total procedural compliance with special emphasis on attention to detail, sign-offs, independent verification, and keeping all paperwork up to date and current.
This was completed by April 15,1991.
The two individuals involved in the event have received appropriate disciplinary action.
Corrective Stoos Which Will Be Taken to Avoid I urther Violations:
The "Please Listen" training, which is currently being given, stresses quality communications and self-checking techniques. This training will re-enforce the meetings held by Maintenance supervision. Brunswick Nuclear Project personnel and long term contractors are expected to complete this training by September 27,1991.
To assess and reduce non-conformances, supervisors are being required to increase their time in the field. Also, Qua..ty Control (OC) and Nuclear Assessment Department (NAD) surveillances have been increased on work activities, i
Periodic meetings have been established between the Vice President (Brunswick Nuclear Project) and his supervisors, on expectations, performance standards and employee coaching that will help avoid further violations.
Date When Full Comoliance Will Be Achieved:
l CP&L is in full compliance.
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ViQL ATION B:
Technical Specificetion 6.8.1.a requires that written procedures be established, implemented, and maintained for applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Quality Assurance Program Requirements, November 1972. Appendix A to Regulatory Guido 1.33 requires that maintenance which can affect the performance of safety-related equipment be performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances.
OMM 001 Maintenance; Conduct of Operations, Revision 14, dated January 24,1991 Section 5.1, states that all maintenance will be performed under the guidance of approved plant procedures or specific instructions on a work request / job order.
Contrary to the above, on March 26 and 27,1991, while performing maintenance under WR/JO AFXP1 on safety-related Oiesel Generator No.1 for investigation of metallic particles in the lube oil strainer, maintenance personnel conducted activities that were not specified on the work request / job order or a approved plant procedure. Specifica!I,, adjacent camshaf t bearings were removed and the diesel was barred over.
This violation applies to Units 1 and 2.
RESPQNSE TO VIOLATION B:
Mimission or Denial of Violatioq:
CP&L admits to this violation.
Reason for the Violat[pn:
The instructions in the Work Request / Job Order (WR/JO) depended upon the technical representative providing the necessary guidance and precautions to ensure the investigation and repair activities related to the potential sources of metal particles found in Diesel Generator No.1 were performed correctly. A maintenance procedure had not been developed since the technical manual did not cover the required work scope, the technical representative was the best source of, information. end he was on-site to oversee the repairs. Although the WR/JO was written relying on the technical representat ve to provide direction and work control, these responsibilities were i
not adequately communicated. As a result the technical representative did not take an active role in overseeing the repair activities and primarily provided advice when questions were raised.
When an interference was encountered which prevented removal of the #9 bearing by normal means, maintenance personnel sought direction from the technical representative on how to proceed since the WR/JO did not provide direction. He recommended the #8 bearing cap be emoved so the cam shaf t would drop slightly, allowing more clearance between the #9 bearing and its upper housing. This is the normal practice used by the technical representative for this El-3
l bearing. The restriction in the WR/JO ir.structions to remove eveiy other bearing was not enforced because the WR/JO said to work in accordance with the direction from tN technical representative. He recommended pulling adjacent bearings but indicatet, concerns or a need to reinstall one of the adjacent beariags prior to procetding. When the technical representative recommended removing the adjacent bearing caps, he was not aware of the presence of the magnetic pickup unit on the camsha8t gear housing at,it is normally located on the main shaf t flywheel. When #8 bearing was removed, the cam shaft came to rest on the magnede pickup unit and the night shif t mechanics, without a technical representative covering the shif t, proceeded to rotate the shaf t for cleaning pu the next step of the WRIJO, This resulted n.,,...nages to the camthaft.
The root causes for this event ato:
1.
The technical representative was not adequately briefed as to his expected role of providing job direction nor did the we k organitation/ planning proces; p. -ide for his proper presence at the work site.
2.
The technical representative did not communicate the risks and n recautions associated with perfurming the work he directed.
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Work proceeded without revising the WR/JO instructions, thus bypassing the plantiing process.
Carmlive Sters.fitsttJinthen_Tf en and Results AcWved' k
followinD the camshaf t damage, repair activities vvete susp,inded until a repair procedure was prepared and approved. The damage was then repaired and Diesel Generator iJo 1 returned to service.
The Communications, Command and Cuntrol M mual (13SP-bO) war. issued in April 991. This manual further estebt:shes uniformity in the execution of comr and anu control process and requires that appropriate individual work scthity wi" bo under '5e enttmand and contrni of a designved individual and involved parties will undetstand who is tha; cesignated hdtvidual. Thir individua' establish " Control,* meaninq he will veril( " hat tvc ything occur i in anformity with an adopted plan, with approved ins'.ructens, ano ;n rcordance with establisi.c1 principles. He will ensure Site Work Force Control Group (SWNG) criteria have been rut by ensuring plant ccnditions necessary to perform the evolut on exi::t and that 1 briefing oi +he particmarits has been conducted i
to discuss the expected paransatov changes and plausible cionificant consequencen of error.
Corrective Stoos Which Will 13e_Taken tp_A_yrdQjgr,{gy,jplajigp3:
1.
Maintenance will review and revise applicable procedures as oceded to reflect lessmis learned during the diesel generator work (such as not rotating the enDine with a magnetic El-4
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1 pickup insta ed and the #9 camshaft boa,' 4., cn the same bank removed). This action is expected to be completed by September t..,1991.
2.
Maintentece and Technical Support will assess the need for better controls on the use of
-l technical representatives (and other contractors) in providing direction and control (or other critical activities) over work on 0 list equipment, if a contractor is going to be used for this type of activity, the scope of his authority and responsibilities should be agreed to in advance and documented in writing as needed. Other important personnelin job planning and execution need to be made aware of this agreed upon scope. This action is expected
' to be completed by September 27,1991.
3.
This ev2nt and the lessons learned will be reviewed by the appropriate Maintenanco and Technical Support personnel. This action is expected to be completed by October 31, 1991.
Date Wher. Full Compjance Will Be Achieved:
CP&L is in full compliance.
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.l Technical Suocification 0.0.1.a requires that written procedures be established, implemented, and maintaineri for applicable procedures recommended in Apprindix A of Regulatory Guide 1.33, L
Ouality Assurance Program Requirements, November 1972. Appendix /, to Regulatory Guide 1.33 reacires administrative procedures for equipment control.
Administrative Instruction Al 58 Equipment Clearatice procedure, Revision 34, Section 5.3.8, requires that double vr.rification be performed for removal from service of systems / components j
important to safety as designJted in '.he Operating Manual Administrative Procedure AP: Volume I, l
Revision 130, Table 11.7.1, which includes the Emergency Diesel Generator System. Double l-
- verification is clefined to mean that each operator will independently identify the component be8 ore L
manipulation of the component.
p 1.ocal Clearance 2 91-0201 was approved on March 30,1991, to allow removal of Diesel Generator No. 4 froin service. Tag No.1 of the local cioarance required that the Diesel Generator L
No. 4 control power breaker be placed in the of f position.
Contrary to the above, on March 30,1991, when instructed to remove Diesel Generator No 4 I
from service, one auxiliary operator erroneously tagged and opened the control power breaker for switchgear 54, and the second auxiliary operator did not verify that the control power brecker for Diesel Generator No. 4 had been identified before the control power breaker was opened, ihis violation arf es to Unit 2.
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Admission or Dcnial of Viola.lign:
i CP&L admits to the victation.
Reason for t!tq Violation:
The clearance required opening the Diesel Generator No. 4 output breaker, its control power (both located in the Switchgear E4 cubical) and, the Diesel generator No. 4 DC control power (located by the Diesti Generator No. 4 on a lower clovation of the diesel generator building). The Senior Auxiliary Operator (AO) developed an incorrect mindset and prepared to open the Switchocar E4 control power breaker which is also located in the Diesel generator No. 4 output breakee cubical.
The Senior AO and the assisting AO both checked the htended action as required by double verification, but neither compared the breaker label with the component or the location specified in the clearance. Failu*e to correctly perform double verification, resulted in the clearance tag being hung on switchgear E4 DC control power breaker versus the Diesel Generator No. 4 DC control power breaker.
Corrective Steos Which Have Begptlpken and ReipJts Aqbiqv d:
a The control room became aware that the wrong breaker had been turned off and called the Entem Engineer for assistance in assessing the effect of turning this breal<9r off. The incorrectly hung clearance tag was removed and the switchgear E4 DC contiv power was re energized without incident.
The two individuals involved in the event have received appropriate disciplinary action.
COLre.q1 Lye Steos Which Will Be Taken to Avoid Further Violations:
1.
Operations Shif t Supervisors are conducting briefings with ewh crew to include the following:
Review requirements 01 Al 53, Equipment Clearance Procedure with added emphasis on specific steps for performance of independent c.nd doublo verification.
Attention to details.
Consequences of tagging errors.
Review of plant events involving improper performance of independent and double verifications.
Each operations persor,is responsible for their individual actions.
This action is expected to be completed by July 31,1991.
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Provide additional Electrical Distribution Systems training for AOs who are responsible for placing electrical clearances. This ar: tion is expected to be completed by December 20,
- 1991, Date When Puff Comoliance Will Be Achieved:
- CP&L is now in full compliance.
31LMMARX:
Our review of the events related to those violations indicates they represent residual symptoms of problems with personnel fully adhering to the expected standards of performance that have been established by management. The events contain simi;ar behavior issues which were recognized during the on golog assessment of previous events where octions have been Initiatodi Some of these actions have been completed and others are just now beginning to provido payback.
The Company believes that there was not sufficient time between the January 26,1991 Unit 2 reactor scram (EA 91023) response and the subsequent March events for the long term corrective actions to be fully effective. However, we believe that those actions remain adequate to alleviate i
concerns with the work control process at the Brunswick Plant for the long term.
Long term corrective actions involved are:
1.
Site Communications, Command and Control Manual (BSP 50) established the guidance needed to ensure uniformity of oral communications and the execution of command and control. This includes requuements for pre-job briefings and establishing leadership responsibilities. This procedure was approved April 8,1991.
2.
During the months of November and December 1990, site personnel attended a training class entitleJ " Reducing Human Error." As a follow up to this training, a "Please Listen" program was implemented to make personnel aware of the importance of good communications and to enhance self checking in the work place. This training began in April 1991. Brunswick Nuclear Project personnel and long term contractors are expected to complete this training by September 27,1991.
3.
In April 1991, periodic meetings were established between the Vice President - BNP and supervision on expectations, performance standards, and employee coaching.
4.
Along with the increased time supervisors are expected to spend in the field, increased surveillance of work activities by OC and NAD were initiated. This action was initiated in Apr!I 1991.
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Additional focus has been placed on emphasizing rnanagement expectations for, first and second line supervisor roles, and individual accountabilities. These expectations are being reinforced by increased attention in exercising consequence management. Along with initiating standardized disciplinary practices to dist ' rage inappropriate behavior a program has been initiated to recognize winning behav;or.
These actions willlead to increased attention to detail by personnel, increased follow through to produce the desired personnel behavior, and sustained improved performance.
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