ML20078S191
| ML20078S191 | |
| Person / Time | |
|---|---|
| Site: | Peach Bottom  |
| Issue date: | 12/21/1994 |
| From: | Danni Smith PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC |
| To: | NRC OFFICE OF ENFORCEMENT (OE), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9412280143 | |
| Download: ML20078S191 (10) | |
Text
m
'f D6ckinson C. Seuilth I
Senior Vice Przsidrnt and -
, Chief Nuclear Offictr Y.
l O ENRGY ecCo en..<Compant Nuclear Generation Group
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965 Chesterbrook Blvd.,63C-3 i
Wayne, FA 19087-5691 l
610 640 6600 i
Fax 610 640 6611 10CFR 2.201 10CFR 2.205 December 21,1994 Docket Nos. 50-277 50-278 i
Ucense Nos. DPR-44 DPR-56 g
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Director, Office of Enforcement U. S. Nuclear Regulatory Commission Attn: Document Control Desk l
Washington, DC 20555 4
Subject:
Peach Bottom Atomic Power Station Units 2 & 3 Reply to Notice of Violation and Proposed imposition of a Civil Penalty NRC Inspection Report Nos 50-277/94-24; 50-278/94-24 Gentlemen In response to your letter dated November 21,1994, which transmitted the Notice of Violation (NOV) and Proposed Civil Penalty, PECO Energy Company submits the attached reply. The NOV was identified in a special safety 1
inspection (94-24/24) that evaluated activities performed August 3,1634, that placed the Emergency Service Water (ESW) system in an unanalyzed configuration for approximately 50 minutes.
l A check in payment of the civil penalty made payable to the Treasurer of the l
United States was transmitted separately by PECO Energy letter to the Director, i
Office of Enforcement dated December 21,1994.
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if you have any questions or desire further information, please do not hesitate
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to contact us.
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'7 G7ooT7 9412280143 941221
' g PDR ADOCK 05000277 i
G PDR I
December 21,1994 Page 2 Attachment and Affidavit cc:
R. A. Burricelli, Public Service Electric & Gas R. R. Janati, Commonwealth of Pennsylvania T. T. Martin, USNRC, Administrator, Region I W. L Schmidt, USNRC, Senior Resident inspector H. C. Schwemm, VP - Atlantic Electric R. l. McLean, State of Maryland l
A. F. )Grby ill, DelMarVa Power l
COMMONWEALTH OF PENNSYLVANIA :
ss.
COUf JIY OF CHESTER D. M. Smith, being first duly sworn, deposes and says:
That he is Senior Vice President and Chief Nuclear Officer of PECO Energy Company; that he has read the attached reply to Notice of Violation and Proposed imposition of a Civil Penalty NRC Inspection Report No. 94-24, for Peach Bottom Atomic Power Station Facility Operating Ucenses DPR-44 and i
DPR-56 and knows the contents thereof; and that the statements and matters set forth therein are true and correct to the best of his knowledge, information and belief.
Senior Vice President and Chief Nuclear Officer j
Subscribed and s orn to before me th day of 1994.
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"Notafv Public '
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RESPONSE TO NOTICE OF VIOLATION 94-24-01 Restatement of the Volation A.
.10 CFR 50, Appendix B, Criterion lil, requires, in part, that measures shall be established to assure that applicable regulatory requirements and the design basis are correctly translated into procedures and instructions.
Contrary to the above, on August 3,1994, the iconsee conducted a j
testing activity on the emergency service water (ESW) system that placed the system in a configuration that was not within the design basis described in the Updated Safety Analysis Report. Specifically, ESW system valve MO-498, the system's normal retum to the ultimate heat sink (UHS), was shut and left unattended. As a result, the ESW system i
flow to safety-related components was reduced to the extent that adequate cooling was not available in the event that the design basis accident occurred at the design basis UHS maximum temperature.
I (01013)
B.
10 CFR Part 50, Appendix B, Criterion V, requires, in part, that activities 2
affecting quality shall be prescribed by documented instructions and
. l procedures of a type appropriats to tha circumstances and shall be accomplished in accordance with those procedures and instructions.
j Contrary to the above, on August 3,1994, the licensee tested ESW System Valve MO-498, an activity affecting quality, in a manner that was not prescribed by documented instructions and procedures of a type appropriate to the circumstances. Valve MO-498, the ESW system normal return to the ultimate heat sink and important to maintaining adequate cooling water flow to safety-related components, was shut and i
procedures were not in place to require personnel to remain at the valve l
and immediately open the valve if needed in the event of an accident.
As a result of the inadequate procedure, after shutting the valve, maintenance personnel left the valve unattended and in the shut position for approximatcly 50 minutes. (01023)
This is a Severity Level lli problem (Supplement 1).
i Admission or Denial of Alleaed Violation i
The PECO Energy Company acknowledges the violation.
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Background
On August 3,1994, at approximately 12:21 PM a clearance was applied to l
Motor Operated Valve MO-0-33-498 to allow diagnostic testing of the valve.
This valve controls ESW discharge flow to the Susquehanna River. Testing was performed ir accordance with Maintenance Procedure M-511-130, " Procedure for Diagnostic Testing of Limitorque Motor Operated Valves using Uberty Technologies ' Votes' Method." This procedure dealt with the mechanics of performing the test and did not address system operability issues that could
- arise, The MO-498 breaker was blocked and locked in the open condition. A Special Condition Tag was hung on the breaker to allow Maintenance technicians to operate the breaker and the valve during the VOTES test. Maintenance technicians received the key to unlock the breaker as part of the clearance.
With the valve breaker in the open position, control room indication of valve position became unavailable.
At 6:27 PM two Maintenance technicians entered the Control Room to obtain
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permission to begin VOTES testing of another ESW valve, MO-0 33 841, the Emergency Cooling Water Pump Discharge Valve. Approximately 10 minutes later, two other Maintenance technicians entered the Control Room to obtain 1
permission to VOTES test MO-498. While both groups were in the Control i
Room they each received permission to begin testing from the Work Control Supervisor. In addition, the MO-498 work crew received permission to begin work from the Unit 2 Reactor Operator.
The Unit 2 Reactor Operator had reservations about allowing work to be done i
on MO-498 and expressed his concerns to the Control Room Shift Supervisor.
The Control Room Shift Supervisor addressed these concems by questioning one of the Maintenance technicians who he thought was working on MO-498.
Through this questioning he confirmed that the testing would not mechanically disable the valve, that the valve would be immediately available to the operator if needed, and that the technicians had a radio so that they could be immediately contacted by the Control Room. Satisfied that operators would be able to take control of the valve imrnediately if necessary, the Control Room Shift Supervisor informed the Unit 2 Reactor operator that valve testing was permissible. In reality, however, the Control Room Shift Supervisor had questioned the lead technician working on MO-841.
At approximately 7:07 PM testing began on MO-498. The testing required' the -
Maintenance technicians to close the valve breaker and operate the valve locally from its breaker in the E-4 diesel bay. During this testing'the Maintenance technicians did not notify the Control Room when the valve's position was changed. They believed that the operator signoff in their test procedure which granted permission to perform VOTES testing also constituted the operator's permission to change valve position as needed without prior control room notification.
At 10:22 PM the Maintenance technicians temporarily stopped work and left the i
work area. At that time, they left MO-498 in the closed position, roopened the valve breaker and locked it. The key for the valve breaker lock remained with the Maintenance technicians who did not notify the Control Room operators 4
that they had left the valve area or that the valve was in the closed position.
With MO-498 closed, service water which is normally supplied to ECCS cooing l
loads was discharged to the Emergency Cooling Tower instead of the river. The j
technicians believed that they were leaving the valve in a safe condition. The work package did not provide any information on a preferred valve position nor did it prohibit the valve from being left unattended.
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Sometime after MO-498 was closed the emergency cooling tower high/ low level alarm was received in the Control Room. Operators confirmed that tower level
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was high using a control room level indcator. They attributed the level increase
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to rain. Per the alarm response card, the appropriate action was to reduce tower level using the Emergency Cooling Water pump and MO-841. Typically this condition does not require an immediate response and with MO-841 under j
test, an immediate pump down of the tower was not undertaken.
At 11:09 PM the Maintenance technicians returned to MO-498. At about the j
same time, the afternoon and night shift Unit 2 Reactor Operators had completed their turnover and the oncoming Reactor Operator began to think i
about possible reasons for the emergency cooling tower high level alarm. He was skeptical that the alarm was caused by rain. At 11:15 PM Just before the l
Reactor Operator recognized the connection between the emergency cooling.
l tower high level alarm and the work on MO-498, a security guard notified the Control Room that water was overflowing the Emergency Cooling Tower basin.
The Reactor Operator immediately informed the Control Room Shift Supervisor that the overflow was probably caused by the work on MO-498.
The Control Room Shift Supervisor contacted the Maintenance technicians informing them of the Emergency Cooling Tower overflow and the need to open MO-498 and MO-841 to allow the cooling tower to drain down. The two valves were opened and the restoration of the cooling tower level to normal was completed. Once the MO-498 was stroked to the open position, the ESW system was returned to an analyzed condition.
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Following identification of this problem by the NRC, calculations by PECO Engineering determined that ESW flow would have been reduced by L
approximately 40E Additional calculations were pedormed using this reduced flow rate to determine the operability of emergency diesel generators and ECCS equipment assuming the worst case plant licensing event, a loss of coolant accident with a loss of offsite power. These cahdations showed that l
with the river and air temperatures that existed on the day of the event, all L
ECCS room coolers and equipment coolers would have performed their design '
function throughout the event. In addition, the required number of emergency l
i diesel generators would have remained operable during the first ten minutes without operator action. The diesels would have remained operable following the first ten minutes if diesel loads were balanced to below their continuous rating of 2600 kw. Analysis also showed, howeve,r, that the reduced ESW flow l
would have prevented the diesels from performing their safety function had the design basis accident occurred with river water at its design maximum temperature of 90 degrees F. Actual river temperature on the day of the event was 81 degrees F.
l Reason for the Violation 1
l Administrative controls to ensure that MO-498 would remain operable during VOTES testing were not clearly established as part of the planning for this activity. Ukewise the impact of closing MO-498 on emergency cooling tower l
level and the ESW system were not addressed in the work package.
Continued operability of MO-498 during VOTES testing came to depend solely l
on the controls the Operators put in place at the start of the job. The challenges encountered during this event could have been avoided had adequate planning taken place before the work request reached the Control Room.
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During the planning process it was decided that MO-498 could remain operable during VOTES testing, however, the operability impact associated with this decision was not carefully evaluated or managed. Enhanced work controis to limit the chance of an undetected inoperable condition should have been written into the work package to supplement any verbal controls imposed by Operations. Although written instructions had been successfully used in the past to control work activities, an expectation that such instructions be consistently included in work packages involving operable safety related equipment had not been established. As a result, no one was responsible to verify that it was included in the work package and the absence of enhanced guidance and control was not questioned.
1 Diagnostic MOV testing had been conducted for several years with no adverse consequences. As a result, VOTES testing was perceived to be a low risk operation with little cause for concern. This perception caused some personnel to be less sensitive to the potential for a problem during the testing of MO-498.
Personnel interviewed had a very general understanding of the VOTES testing
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l process and thought the process simply involved the momentary stroking of a i
valve to obtain test data from installed sensors. There were no previous problems that would have caused this concept of VOTES testing to be 7::^-7ed or compelling reasons to research the actual details of the testing procedure. This lack of knowledge about the details of the VOTES test reduced the likelihood that personnel who understood the design and operation of the ESW system would foresee the impact on Emergency Cooling Tower level and restrict the time that the valve could be left closed. Such a restriction may have prevented the maintenance technicians from leaving the valve in the closed position.
1 Extensive reviews had been previously conducted to determine if equipment operability could be maintained during testing. Tests where equipment could remain operable were reviewed to ensure that appropriate controls were established and written into procedures. This review was restricted to
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surveillance and routine testing. VOTES testing is a preventative maintenance task which does not fall into either category, therefore it was never thoroughly evaluated.
The request to conduct VOTES testing on MO-498 should have initiated the imposition of enhanced test controls and increased mMtoring of the condition of the valve by Operations. Several opportunities to establish these controls existed, but were not effectively achieved. The first opportunity came when Maintenance requested permission from the work control supervisor to initiate work. The work control supervisor recalled being concerned about simultaneous work on MO-498 and MO-841, but did not establish any special controls. Secondly, concern was expressed by the Unit 2 Reactor Operator when he was asked to grant permission to allow testing on MO-498. His '
concerns were directed to the Control Room Shift Supervisor who resolved the concerns to their mutual satisfaction. Although these individuals recognized that MO-498 was a safety significant valve, the. degree of monitoring and control established over the testing of MO-498 was inadequate in view of its safety significance.
The Control Room Shift Supervisor tried to affirm the acceptability of working on the MO-498 valve by questioning one of the maintenance technicians who was in the Control Room seeking permission to perform VOTES testing. The technician questioned, however, was actually working on MO-841. The questions asked by the Shift Supervisor were appropriate, but were general in nature so that neither party realized that they were talking about different valves. As a result, the Maintenance Technicians working on MO-498 never heard the Shift Supervisor's questions and had no awarenoss of the RO's concerns.
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D Interaction between the Maintenance Crew and Control Room Operators _ during MO-498 testing was less than adequate. The Clearance and Tagging Manual requires that Shift Manayamont permission be obtained immediately prior to each Special Condition Tag (SCT) component manipulation. However, the manual also provides an exception to this requirement stating that at the discretion of Shift Management, permission may extend through a series of.
manipulations not to exceed the shift of the individual granting the penit:':-a.
During the event the Maintenanca technicians did not notify Shift Management immediately prior to each manipulation of the valve. The technicians interpreted the Work Control Supervisor signoff in their test procedure granting permission j
to perform the test as also granting the exemption from mt., king the notifications. In the mind of the Maintenance Technician, the permission to conduct VOTES testing automatically included permission to stroke the valve and apply the exception for SCT component manipulation notification. Previous experience and the absence of any contrary' direction from Operations validated these assumptions.
When the Maintenance technicians left the work area, they left MO-498 in the closed, deenergized position thinking that this was a safe configuration that did not adversely impact plant safety.. They did not understand the function of the i
valve in relation to the ESW system and therefore made an incorrect decision.
Had the technicians been clearly informed of the function of the valve and its safety significance by a pre-job briefing, this event may have been averted. This information, however, was not provided to the technicians before they went to the Control Room to get permission to initiate testing. It also was not provided by any of the Operations personnel who had contact with the technicians.
Corrective Stoos That Have Been Taken and The Results Achieved A Performance Enhancement Program (PEP) investigation (PEP-10002629) was initiated September 7,1994, to determine the causal factors of placing the ESW system in an unanalyzed configuration and to develop appropriate corrective actions to prevent recurrence.
Appropriate counselling and disciplinary actions were administered commensurate with individual's level of responsibility.
This event was reviewed with Maintenance and Operations and Planning personnel.
Required reading packages were developed and communicated to Operations 1
i personnel on September 12 & 13,1994. Operations personnel were instructed to consider Motor Operated Valves inoperable during VOTES testing and were given specific instruction to consider systems inoperable with components being worked under action requests, minor maintenance, SCT, or *Fix it Now" (FIN) team work unless othenuise determined by a licensed operator.
L MO-498 was information tagged indicating that it shall only be operated using PORC approved procedures that specifically address MO-498. The VOTES test i
procedure is an example of a procedure that does not meet this criteria.
i OW=5s for manipulation of compaonts covered under an SCT were j
m issued to Maintenance and Operations personnel stating that effective communication must occur between Shift Management and Maintenance prior i
to component manipulation. Additionally, the terms " Shift Management" and J
"immediately prior to" were clearly defined.
i The work planning and Operations Service Group have been reorganized to facilitate improved planning and work coordination. Evpar*=%ns for improved planning and conrdination of work activities, especially those performed on operable equipment, have been communicated to personnel in the planning i
organization. This includes the expectation that appropriate information and i
controls related to equipment operability be documented in the work packages.
q Corrective Stoos that Will be Taken To Avoid Further Volations
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An Operations improvement Plant was developed December 13,1994, to reinforce proper standards and expectations to improve overall performance.
This plan will be implemented through 1995 to ensure clear understanding of roles and responsibilities of Operations personnel, involvement of upper level management when operating limits could be unnecessarily challenged, and the I
need to continually maintain a healthy skepticism and questioning attitude during work evolutions. This plan also includes reinforcement of management expectations regarding the conduct of pre-job briefings, verbal communication standards, and the need for heightened operator awareness and control during the conduct of work activities involving operable equipment.
Enhanced controls are being added to the VOTES test procedure.
Maintenance Procedure M-511-130, " Procedure for Diagnostic Testing of Umitorque Motor Operated Valves using Liberty Technologies ' VOTES' Method" will be revised to clearly delineate a section where Operations can document restrictions or controls on the performance of VOTES testing. This revision will j
be completed by January 31,1995.
j Procedures governing releases of equipment for maintenance cre being enhanced to provide clear guidance regarding equipment operability and control requirements. This item will be completed by March 31,1995.
The Date When Full Comoliance Was Achieved Full compliance was achieved August 3,1994, when MO-498 was re-opened and the ESW system was returned to an analyzed condition.
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