ML20078G620
| ML20078G620 | |
| Person / Time | |
|---|---|
| Site: | Limerick  |
| Issue date: | 11/07/1994 |
| From: | Helwig D PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9411160104 | |
| Download: ML20078G620 (5) | |
Text
..
David Ft. Helwig Vice Prwdent a
A L#mero Genera!.ng StaSon
_a 7
PECO ENERGY nco%c-Leerd Gene ra ng St#0n PO Bax 2300 Sanatoga, PA 19%4 &J20 6?O 3271200, E et 3000 10 CFR 2.201 November 7,1994 Docket No. 50-353 Ucense No. NPF-85 l
U.S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555
SUBJECT:
Limerick Generating Station, Unit 2 Reply to a Notice of Violation NRC Combined Inspection Report Nos. 50-352/94-21 and 50-353/94-21 Attached is the PECO Energy Company reply to a Notice of Violation for Umerick Generating Station, Unit 2, that was contained in your letter dated October 7,1994.
The cited violation involved the failure of a nonlicensed operator to align and tag components in the sequence specified on the clearance while applying a master clearance to emergency diesel generator D21. The attachment to this letter provides a restatement of the violation followed by our reply.
If you have any questions or require additional information, please contact us.
Very truly yours, l/
~
D RBW Attachment cc:
T. T. Martin, Administrator, Region I, USNRC w/ attachment N. S. Perry, USNRC Senior Resident inspector, LGS 9411160104 941107 PDR ADOCK 05000353 D
PDR O\\
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Attachment Docket No. 50-353 November 7,1994 Page 1 of 4 Beoly to a Notice of Violation Ecstatement of the Violation During NRC inspection conducted on August 16,1994 through September 26,1994 a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, the violation is listed below:
Technical Specification (TS), Section 6.8.1, states in part, written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.
Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, recommends the establishment of administrative procedures hcluding procedures covering equipment control (e.g., locking and tagging).
The Clearance and Tagging Manual, the administrative control for clearance and tagging, Stop 12.3., written to comply with TS 6.8.1, states, in part, the Clearance Applier shall align and tag components in the sequence specified on the Clearance.
Contrary to the above, on August 28,1994, the Unit 2 plant operator did not align and tag components in the sequence specified on the Clearance. Specifically, he installed a standard safety ground at the wrong location, and also pulled incorrect fuses, while applying a master Clearance to the emergency diesel generator D-21.
This is a Severity Level IV Violation (Supplement 1).
RESPONSE
Mmiasion_QL1he Violation PECO Enorgy Company acknowledges the violation.
Ecason_foilhe_Wolation On August 28,1994, the D21 Emergency Diesel Generator (EDG) Master Clearance was given to a Unit 2 non-licensed plant operator (NLO) for application to support the D21 five year overhaul inspection. During application of the clearance, a floor supervisor joined the NLO in the D214Kv Switchgear Room to observe the rest of the clearance application. The
Attachment Docket No. 50-353 November 7,1994 Page 2 of 4 axt few steps of the clearance involved applying standard safety grounds (SSGs) to the 4Kv bus. After reviewing the clearance, the NLO placed the clearance down and left the area to obtain the proper equipment for application of the SSGs. Upon returning to the 4Kv switchgear room, the NLO proceeded to the rear of the D21 switchgear panel, and applied the SSGs without incident. The NLO returned to the front of the D21 switchgear panel and retrieved the clearanca. The next few steps in the clearance involved removing the D21 EDG primary potential transformer metering and relaying fuses. The clearance was reviewed, and the fuses were removed at the D21 switchgear panel. This action resulted in the actuation of several main control room (MCR) alarms, and tripping of the 2A Turbine Enclosure Equipment Compartment Exhaust Fan.
The MCR called the Unit 2 NLO to review his actions. The NLO reported that he had pulled fuses in the D214Kv switchgear room. The NLO re-installed the fuses at the direction of the MCR supervisor.
Once the NLO retui..ad to the MCR, the MCR supervisor reviewed the clearance and determined that the clearance was accurate as written. However, this review revealed that, as specified by the clearance, installation of tne SSGs and removal of the metering and relaying fuses should have been performed in the D21 Diesel Generator Room instead of the D214Kv switchgear room. The clearance was then re-applied without further incident by another operator.
The cause of this event was the failure of the NLO to comply with the clearance as written.
The factors that contributed to this event are described below.
The NLO used ineffective self checking for the installation of the SSGs and removal of the fuses. The NLO did not verify that he was in the correct room, and therefore, on the correct component, by comparing the clearance task description with the field labeling. The NLO relied on his recollection of SSG installation and fuse removal for this activity rather than paying specific attention to the clearance. The SSG installations and fuse removals are typically performed at the same location as the breaker removal. The breaker is located in the D214Kv switchgear room. However, in this case, the SSG installations and fuse removals were specified to be performed in the D21 Diesel Generator Room. The NLO failed to follow management expectations regarding comparing the clearance description with the label description.
The floor supervisor which observed this activity inadequately enforced the expectation of comparing the clearance description with the field labeling. The floor supervisor was observing this activity to obtain field experience and this may have contributed to why he did not enforce management expectations.
Clearance human factoring and location information was insufficient. The last text step on page four of the clearance specified where the tasks on the follo,"ing pages regarding the SSG installation and fuse removals were to occur. Similar to proc)dures, it is an appropriate
Attachment Docket No. 50-353 November 7,1994 Page 3 of 4 human factoring technique to include notes on the page to which the notes apply. In addition, each clearance step for the SSG installation and the fuse removals did not include i
specific location information. The component record list that was used for preparation of the clearance does not have locations for these components. However, the panel number was provided in the description field, and this does provide the location for the activity.
Correctlye Actions Taken and Results Achieved j
l The NLO was disciplined regarding proper use of self checking practices. In addition, the i
NLO was placed in an ongoing performance remedial program. The floor supervisor was counseled on the need to enforce management expectations concerning self check practices.
As an interim measure, a supervisor has been directed to be present during fuse removals.
In addition, operations personnel have been notified to ensure that the SSG installation is in accordance with the respective work documentation. There have been no additional events related to the removal of an incorrect fuse or incorrect installation of SSGs by an NLO since this action.
C.omechvo Ar'jons to Avoid Future Non-comoliance As stated in your transmittal letter for Combined Inspection Report Nos. 50-352/94-21 and 50-353/94-21, "this violation is of concern because there have been two similar instances where incorrect fuses were inadvertently pulled within the last eight months."
The two previous events have been captured in the Performance Enhancement Program (PEP), i.e., our in-house event investigation program. PEP contains expectations for the consideration of previous similar events when investigating new events. Therefore, the previous two events were considered during the investigation of this most recent fuse pulling event and during the development of the corrective actions. The corrective actions to avoid these type of events in the future are described below.
The clearance and tagging manual will be revised by December 15,1994, to include expectations for including text steps on the page to which they apply and to require the sign-off of all text steps.
Additional training on the proper location to install SSGs and the reason for the location will l
be provided to shift operations personnel by December 31,1994.
A new operations management oversight guide on self checking was generated and was issued on September 30,1994. This guide will help focus management attention to enforce the practice of self checking. In addition, existing observation guides, " Electrical Safework Practices" and " Clearance and Tagging" will be revised by November 17,1994, to include specific queries regarding field labeling versus the clearance or work documentation.
Attachm6nt Docket No. 50-353 November 7,1994 Page 4 of 4 1
Date When Full Compliance was Achieved Full compliance was achieved on August 28,1994, when the incorrect fuses were reinstalled, the incorrectly installed SSGs were removed, and the clearance was successfully applied by another nonlicensed plant operator.
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