ML20077D941
| ML20077D941 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 05/30/1991 |
| From: | Kovach T COMMONWEALTH EDISON CO. |
| To: | Lieberman J NRC OFFICE OF ENFORCEMENT (OE), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9106050285 | |
| Download: ML20077D941 (7) | |
Text
Commonwrith Edison
) 1400 opus Pitc3 Down:rs Gron, Illinois 60515 May 30,1991 Mr. J. Lieberman, Director Office of Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Attn: Dncument Control Desk
Subject:
Quad Cities Nuclear Power Station Notice of Violation & Proposed Imposition of Civil Penalty (50 254/91000)
NRC Docket Number 50 254
Reference:
(a)
T.J. Kovach to J. Lieberman letter dated April 26,1991 transmitting CECO's response to the Notice of Violation and Proposed imposition of Civil Penalty (b)
A.B. Davis to Cordell Reed letter dated March 27,1991 transmitting Notice of Viol 8 tion and Proposed imposition of Civil Penalty
Dear Mr. Lloberman,
The purpose of this letter is to clarify the Information which we orovided in reference (a), as well as to provide an update of our Lessons Learnec initiatives. We believe that our corrective actions at Quad Cities represent a concerted effort to resolve the issues identified in the subject enforcement action, and that our lessons learned program encompasses a proactive approach to the challenges and opportunities of communicating improvement initiatives throughout a multi-site operation. I hope the information provided in this letter clarifies our continuing strong commhment to comprehensively addressing enforcement issues and associated NRC l
concerns.
l R spectfully, f nuu
,p r,nr Thomas.
.sach Nuclear Licensing Manager Attachments: (A) Clarification of Attachment B to the April 26,1991 Letter (B) Lessons Learned Synopsis of the Quad Cities Event cc:
A. Bert Davis - Region ill L.N. Olshan - NRR T.E. Taylor - Quad Cities
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Att: chm:nt A Clcnficition of Att: chm:nt B to tha April 26,1991 Lctt:r In reference (b), the NRC requested that the Company,"... Indicate when you expect that the operational staff at each of your plants will be aware of your current expectations on operations so that the lack of awareness of management expectations will not be the cause of violations..." Our response provided by reference (a), included as its Attachment B, an overview of the range of communication systems In use, as J
well as the scope of communication performance measures available in total, these systems and performance measures provide our basis for concluding that adequate communication by management to our operations personnel does occur. We co not however, wish to diminis 1 the importance we attach to the weaknesses in management communication and reinforcement as they applied to the Ouad Cities event. In the February 21,1991 Enforcement Conference, we presented the following conclusions of our Quad-Cities event investigation;
- 1. Management standards have not been effectively communicated / reinforced.
- 2. Administrative controls of some work activities were not adequate.
- 3. Personnel errors.
Our assessment of the Quad Cities event remains that the management must be more effectively involved in the communication of standards. Through such communication and reinforcement, management provides a vital barrier the propagation of an event from other causes. Given this, we undertook comprehensive corrective actions that focussed on clearly defining station standards and on increasing management involvement observing personnel, developing forums for communication and creating situations in which immediate feedback to personnel could be provided.
We will continue our efforts to improve plant performance through more effective management systems and management involvement.
Although there have been individual instsnces of communication weaknesses at other Company facilities, when we reviewed a wide range of communication performance measures, we could not conclude that the cause of the recent Quad Cities events is indicative of the performance at all our stations. However, as part of our continuing attention to this issue, our Lessons Learned Program is forcefully and effectively communicating the Quad Cities enforcement conference issues to all of our operating staffs. The Lessons Learned Review Committee, which Includes senior managerwnt representation from all of our nuclear stations, has conducted a detailed review of the Quad Citles event, and elevated the subject to a Significant lessons Learned notice to each of our Station Managers. A coay of the Lessons Learned synopsis of the Quad Cities event that was transmitted to all of our stations on N arch 14,1991, is provided in Attachment B to this letter. Our Lessons Learned Program tasks each of our stations with the action to review the identified lessons learned, and to take appropriate action to reduce the potential for recurrence. Through our On-Site Safety Groups, the lessons learned followup actions of each station are monitored, consistent with our Operating Experience Program quality and performance assessment personnel will periodically (OPEX). Also, our audit Individual station effectiveness in learning from internal Commonwealth Edison experiences disseminated via the Lessons Learned Program. Cor, sideration :s being given to developing a performance measure for eacT1 station which will provide a quarterly assessment of station effectiveness in learning from internal corporate experiences. A 3erformance measure already exists for external utility experiences utilizing OPEX nformation as its input. Taken together, these actions provide confidence that we are agressively and effectively pursuing resolution of the root causes of the Quad-Cities event.
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Attachment B Lessons Learned Synopsis of the Quad Cities Event
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SIGNIFICANT LESSONS LEARNED INFORMATION FOR STATION / DEPARTMENT MANAGER'S ATTENTION (Significant Lessons Learned Document 91-2)
March 14, 1991 To:
R. Bax K. Kofron C. Sargent G. Diederich R. Pleniewicz R. Flessner E. Eenigenburg J. Leider T. Joyce
Subject:
Quad-Cities Unit 1 Inadvertent Loss of Reactor Vessel Inventory During RHR Valve Testing Activities The attached Lessons Learned information, relative to the subject event, has been reviewed by the Lessons Learned Review Committee (LLRC) and deemed significant enough to warrant the Station / Department Manager's attention.
j A one page synopsis of the event is followed by a list of Lessons Learned that were evaluated at the LLRC meeting on February 27, 1991.
The status of Iessons Learned items will be tracked via the NTS system.
No additional written response is required.
<_ O N J U.3/.1 y l9i Lessons Learneli Group Safety Assessment Department Attachments:
A 7-91 P.F. Manning letter regarding equipment 00S cicarance B 30-91 Galle/Wallace letters regarding valve stroking G - Braidwood Station NLA cc C. Reed M. Turbak D. Farrar-D. Galle J. Bowers K. Brennan M. Wallace M. Willoughby P. Rescek L. De1Leorge ONSG Administrators (6)
D. Brown
-R. Querio P. Manning K. Graesser N. Kalivianakis Sta. Tech. Supts (6)
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SYNOPSIS INUTES.GE111L011 On January 24, 1991 "B" train Ri!R System (non-operating) MOV post-modification testing van scheduled. The Operating Department temporarily lifted 00S cards with the MOV circuit breakers in the "off" position.
By 1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br /> the Electrical Maintenance Department (EMD) completed energizing, cycling, and testing the RllR torus suction MOVs.
Prior to cycling the RIIR reactor vessel suction MOVs, EMD was supposed to notify the Unit 1 NSO to allow temporary shutdown and isolation of the Ri!R system in the shutdown cooling mode.
EMD did not notify Operating and cycled the RIIR reactor vessel suction MOVs.
When Operating had temporarily lifted 00S cards on the "B" RilR system, the vents and drains were omitted based on the belief that the RilR system would be shutdown and completely isolated from the Reactor vessel.
EMD vrive cycling resulted in the loss of approximately 2800 gallons of water from the reactor vessel and 1400 gallons from the EllR piping.
l'IsminenL CREJ B fEIrllLEnnLJAu1Ligatira.RefrLtl
- Management standards were not adequately communicated
- Inadequate administrative controls Lack of a questioning attitude
- Personnel error Orntilhuling_Cann ( f rom Event Inveatigatip1LRepar.tl Inadequate communication to the control room and between the NSO and the SCRE The fact the NSO did not recognice the loss of the water from the reactor vessel (in a timely manner)
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1 PINAL LESSONS LEARNED QUAD CITIES UNIT 1 INADVERTENT LOSS OF REACTOR VES3EL INVENTORY DURING Rl!R VALVE TESTING ACTIVITIES 4
1)
Rtat19nH_nh0Mid_fYElDAtLminimizinn the r91tt.ine_yge of temp _liita. The large number i
of temp lifts increases the probability for operating errors.
The endividual station evaluations should be coordinated by the Nuclear Operationt :caff.
If temp lifts are needed for special testing they should be limited to one ahift (consistent with INp0 Good Practice OP-203).
QA/NS should continue their plans to revise Q.P.
3-52 regarding 00S clearance; however, the 2-7-91 P.F. Mannir A me'no to the HQP Superintendents (attachment A) regarding equipment 00S clea:aner ?tates that at the completion of the physical work an outage may be cleared prior t-signing the work request by Quality Control. This QA manual clarification should allow stations to minimize the use of temp lifts, provided sufficient administrative controls exist to ensure all work requests which affect operability are completed prior to declaration of operability.
l Target Completion Date 10-1-91 Track Status Under NTS # 909-247-00201 (Cta., NOD, Action) 2)
SladonLDILGRl.d review adginistrative egntrols that_ dAfine responsibil_111es for all indlyldnala_1 hat _EIcPAIf_33td veri fy._QDjl argurncro.
The review should ensure administrative contr01st a) include all experience, training and qualification requirements, b) provfde standards for guidance on items of ccncern when performing OOS/ temp. lift reviews, and c) provide standards on the le*S1 of detail required for temp. lift verifications.
Target completion date 10-1-91 Track Status under NTS # 909-247-91-00202 (Sta. Action) 3a) Stations. nhould reriew their maintenance valve strokiDr vroegdures to eneure ppnAljnLngrapnnel are alwAys in control of the af tivity and ayere of the yely_g nquitign/staina. This maintenance procedure review should verify adequate precautions are included in the proper steps of the procedure.
3b) EAclt_EtAlign should rgylew its current policy for electrical _ breaker maniculations and enoure the manipulations are limited to Operat[pna Department personngl.
Items 3a and 3b above should be accomplished consistent with the direction provided to station managers by:
The 1-30-91 Galle/Wallace letter regarding valve stroking guidelines and circuit breaker control, and the 1-30-91 Galle/Wallace followup letter.regarding valve stroking (attachment B)
Target completion date 6-1-91 Track Status under NTS # 909-247-91-00203 (Sta. Action)
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- 4) EnttLatationah9xid_rtricy its c9mmunicat19na_m931ry_httvern_the Optrat19na_and Maintacnth_1!LafLucpts. and_the_c9munical19na_vithin_the_.0nntat19nu,laintu nda Irrit,Jr a f f nenia,__Jn_Adstli19n,. a policy _nhuuld_he_catah11shrLtbaLicquitea fonlin1LQgs coytmunirg1]on betvtrn_ygtjtingplions whenJ.ullip]r_y.91)Lylteg_gre in191 red.
(For example, see item 3 of the Zion Station MOV Maintenance Work practices, included in Attachment B) Although communication concern was addressed as a part of Significant Lessons Learned Document 91-1 (Quad-Cities Inadvertent Criticality and Subsequent IRM 111111 SCRAM) item 7 (NTS # 909-247-91-00107),
additional recommendations are being provided to emphasize the importance of proper communications.
Shift Engineers should perform evaluations of operating shift crews to ensure (at a minimum) that a) The SCRE is informed of the starting and stopping of evolutions, b) Information being communicated to the control room is sufficiently complete to allow the HSO to be aware of the status of plant equipment (for -xample had the EM's communicated the fact water flow was heard while cycling the MOV, the HSO may have been able to identify decreasing reactor vessel inventory).
Target Completion Date 10-1-91 In addition the QP&A performance Assessment Department vill perform a special communications assessment based on station communication expectations.
Target Completion date 4-1-92 Track Status under NTS # 909-247-91-00204.
(STA/ PAD Action)
- 5) Katahlish_a_atAL19n_n911Ey_gimilar_19JraidVAndjllAAtitchment C (nov tcrmtd inficqUcnt. Evolutlpaly_atencas for Conttel_Roon Activitfra)_.thatrKplainn_h9v critical _ tank:Litanks renuirina_aptain1_ntecaulions or continnencical_are_ident111cd And..Apsfific1LthC_picIAUliDER_to be gganidtrgda Develop and proceduralize critical task list using lessons learned.
Establish a station policy which requires a multi-disciplinary review of critical tasks to be coordinated by the station planning department.
Target Completion date 10-1-91 Track Status under IGS # 909-247-91-00205 (STA Action)
- 6) All_s ta tiorm_nh9 ulite rity_their_admJ nintratlic_ntacndu rs_ trna rslina_ca utirn_ca rcitts sneutc_thnLalLnnints of_ control _are_identiflsti_AnLcarArda Target Completion date 10-1-91 Track Status under NTS # 909 247-91-00206 (STA Action)
- 7) All_gtit19na_gbould condutt_R911catiYn_.hriffinan (includinA_mannacment_And haTAainina_At939pa_patticlRRt.iDLinact1Y.i.tlea)_for taska_istenij fied by_thq_at.at193tg irti.trmJ.
Target Completion date 10-1-91 Track Status under IGS #909-247-91-00207 (STA Action)
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