ML20080B934
| ML20080B934 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry  |
| Issue date: | 12/02/1994 |
| From: | Machon R TENNESSEE VALLEY AUTHORITY |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9412070046 | |
| Download: ML20080B934 (15) | |
Text
s.
W l
Tomm va +myp w o neav pacc oca r me a a ycyn coa R. D. (P ck) Machon
'Ju numient aws rwo meu pwn DEC 0 21994 U. S. Nuclear Regulatory Commission 10 CFR 2 ATTN: Document Control Desk Appendix C Washington, D.C. 20555 Gentleman:
In the Matter of ) Docket Nos. 50-259 Tennessee Valley Authority ) 50-260 50-296 BROWNS FERRY NUCLEAR PLANT (BFN) - NRC INSPECTION REPORT 50-259, 260, 296/94 REPLY TO NOTICE OF VIOLATIONS (NOVs)
This letter provides our reply to the three NOVs transmitted by letter from Mark S. Lesser, NRC, to O. D. Kingsley Jr.,
TVA, dated November 2, 1994. These NOVs concerned: (1) noncompliance with Technical Specification requirements for the Intermediate Range Monitors (IRMs) ; (2) four examples regarding lack of procedural adherence; and (3) improper ;
maintenance activities involving a clearance boundary. We ,
admit to each violation.
While each NOV reflects areas that require needed attention, I particularly share your concerns regarding our continuing problems in the area of procedural adherence. As indicated in our response to NOV 94-09, an Incident Investigation (II) team was assembled to review recent procedural adherence problems, identify the underlying causes, and recommend corrective actions for long-term improvement. The examples ;
that led to NOV 94-09 occurred primarily in the area of Maintenance. However, the events that led to the NOVs in ,
this inspection report were, for the most part, operational l related. The Operations Manager personally discussed these issues with the licensed Senior Reactor Operators and stressed the rieed for greater attention to procedural detail.
9412070046 941202 PDR ADOCK 05000259
/ b l
l l U.S. N'u clear Regulatory Commission
.Page 2 DEC 0 21994 In addition to the examples addressed in this inspection report, several subsequent operational errors have occurred (e.g., loss of shutdown cooling during a diesel generator load acceptance test, reactor water level decrease during a preventive maintenance test, half scram due to a mispositioned switch during reactor startup) that warrant additional corrective actions in this area. Thus, we have assembled an II team, separate and distinct from the one on procedural adherence, to review recent operational error events and develop long-term corrective actions. The results of this II will be compared to the II on procedural adherence to ensure our root causes and corrective actions are fully enveloped. The results of this will be provided to you by February 02, 1995.
The preliminary results of the II team on procedural adherence were discussed with NRC at the "mid-SALP" presentation on September 9, 1994, I believe it is important to further summarize the conclusions of the II team.
The II team consisted of personnel from multiple disciplines including BFN front-line and management personnel. Over 200 personnel, from various organizations were interviewed to identify specific causal factors, areas of concern, and corrective action recommendations. As a result, we have identified the following root causes:
- Perceived schedule pressure, inappropriate priority, or production pressure;
- Ambiguous / unclear or complex procedures and programs;
- Work order / procedure inconsistencies and redundancies;
- Training deficiencies;
- supervisory Skills High Impact Teams, consisting of front line personnel and supported by independent facilitators, have been assigned to each of the causal factor areas to review the findings and develop corrective actions. We expect to start implementing ,
corrective actions from these teams beginning next year. )
Meanwhile, a briefing paper on the results of the II was I developed. The Plant Manager directed that this briefing paper be used by front line managers to ensure that their personnel receive a clear and consistent message as to the findings from the II.
. _. ~ -_ - .
l U.S. Nuclear Regulatory Commission Page 3 DEC 0 21994 I further recognize that our actions toward improving and sustaining procedural adherence cannot be a short-term fix.
Thus, I have requested that the Plant Manager and the Nuclear Assurance and Licensing (NA&L) Manager conduct a follow-up evaluation within approximately six months after the complation of the II to assess our improvements in this area.
We expect to complete this evaluation by May 30, 1995. This follow-up evaluation will determine the effectiveness of our corrective actions or if further actions are warranted.
Finally, as discussed at our mid-SALP presentation, we are still showing a " red window" in the area of procedural adherence in our quality trend report. The red color indicates that the area is receiving increased management oversight. The window was created by TVA management based on our self critical review of procedural errors. The NA&L Manager has responsibility for this window and it requires >
his personal concurrence to change it. This trend report receives wide visibility and demonstrates the seriousness with which I take this issue.
Enclosures 1 through 3 provides TVA's " Reply to the Notice of Violation" (10 CFR 2.201). Enclosure 4 contains commitments ,
made in the reply.
If you have any questions regarding this reply, please feel free to call me at extension 729-3675.
Sincerely, R. D. Machon Site Vice President Enclosures cc: see page 4
- A U.S. Nuclear Regulatorf Commission Page 4 DEC 0 21994 Enclosures cc (Enclosures):
Mr. Mark S. Lesser, Section Chief U.S. Nuclear Regulatory Commission Region II 101 Marietta Street, NW, Suite 2900 ,
Atlanta, Georgia 30323 NRC Resident Inspector Browns Ferry Nuclear Plant Route 12, Box 637 Athens, Alabama 35611 Mr. J. F. Williams, Project Manager U.S. Nuclear Regulatory Commission One White Flint, North 11555 Rockville Pike Rockville, Maryland 20352
ENCLOSURE 1 TENNESSEE VALLEY AUTHORITY BROWNS FERRY NUCLEAR PLANT (BFN) 1 Units 1, 2, and 3 l REPLY TO NOTICE OF VIOLATION (NOV)
VIOLATION A l
INSPECTION REPORT NUMBER l 50-259, 260, 296/94-24 RESTATEMENT OF VIOLATION
" Technical Specification 4.1.A requires that the intermediate range monitor high flux trip circuitry shall be functionally tested once/ week during refueling and before each startup.
Technical Specification 1.0.D defines " prior to startup" as prior to withdrawing the first control rod for the purpose of making the reactor critical.
This is a Severity Level IV Violation (Supplement I)."
TVA's REPLY TO VIOLATION
- 1. Reason For Violation As noted in Licensee Event Report (LER) 260/94009, the root cause of this event was a misunderstanding of the Technical Specification (TS) resulting in inadequate procedures. TS Table 4.1.A requires that the frequency for the Intermediate Range Monitor (IRM) instrumentation functional tests be performed before each startup and once a week during refueling. However, the General Operating Instructions (GOIs) for unit startup did not require the IRM functional tests to be performed before each startup because it was believed that they met the TS requirements. It was believed that the tests were only needed to be performed once every seven days (Note: as discussed in the referenced LER, this discrepancy also applied to the Average Power Range Monitors (APRM)). Additionally, the Surveillance Instruction (SI) for the IRM functional test did not specify the correct frequency.
- 2. Corrective Steps Taken And Results Achieved TVA has revised the GOIs for unit startup to require the IRM and APRM instrumentation to be tested before each startup.
The SI for the IRM functional test was also revised to require IRM testing before each startup. Additionally, TVA has trained licensed operators on this event.
'TVA reviewed other TS conditional procedures related to startup and did not find any other GOIs and sis for nuclear instrumentation with an incorrect testing frequency.
Additionally, TVA plans to submit a TS change to revise the 1 frequency for the IRM and APRM instrumentation functional '
tests to be consistent with utandard TS requirements. ;
- 3. Corrective Steps That IHave Been orl Will Be Taken To Prevent Recurrence No other actions are required to prevent recurrence.
- 4. Date When Full Compliance Will be Achieved Full compliance has been achieved.
- 5. Other NRC Concern on IRM Functional Test During Refueling Mode In Inspection Report (IR) 94-24, the NRC questioned the operability of the IRMs after entering the refueling mode of operation. Specifically, the NRC expressed a concern that the IRM high flux trip functional test was not performed until three days after entering the shutdown mode of operation.
The IR does note that the TS requirements for inoperable IRMs were met during the period that the IRMs had not been tested. Thus, this was not considered as an additional example of this NOV. TVA has reviewed this issue, and has taken action to further assure the operability of the IRMs ,
following shutdown in the future. The applicable procedures have been revised to require the IRM high flux trip test to be performed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of taking the mode switch out of the RUN position.
El-2
ENCLOSURE 2
. TENNESSEE VALLEY AUTHORITY BROWNS PERRY NUCLEAR PLANT (BFN)
UNITS 1, 2, AND 3 REPLY TO NOTICE OF VIOLATION (NOV)
VIOLATION B INSPECTION REPORT NUMBER 50-259, 260, 296/94-24 RESTATEMENT OF VIOLATION
"... Technical Specification 6.8.1.1.a requires that 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. Paragraph 2 of Appendix A recommends operating procedures for hot standby to cold shutdown. Paragraph 8 of Appendix A recommends procedures for surveillance testing of the standby gas treatment system.
Paragraph 5 recommends procedures for safety related alarm annunciators.
Contrary to the above, written procedures were not implemented as evidenced by the following examples:..."
EXAMPLE 1 OF THE NOV
'" ...On October 1, 1994, during a reactor plant cooldown, reactor water level indication monitoring required by Step 5.45 of Procedure 2-GOI-100-12A: Unit Shutdown From Power Operations to Cold Shutdown and Reduction in Power During Power Operations was not performed. The condition existed for at least 30 minutes and was corrected after questioning by an NRC Inspector...."
Introductory ReSDonse to the NOV This NOV concerns several examples involving operational errors.
As a result of the errors and others that occurred during the Unit 2 Cycle 7 refueling outage, TVA has commissioned an II team to evaluate this issue. The purpose of the II team is to assess commonalities and identify necessary corrective actions. The results of this I1 will be compared to the II on procedural-adherence to ensure the appropriate root causes and corrective actions have been identified. The results of this effort will be provided to NRC.
l TVA's Reply to Violation B Example 1
- 1. Eeason For Example 1 l
The reason for this event was a failure to follow procedure. l The screen of the integrated computer system had been used to retrieve temperature data missed in Example 2 of the NOV and should have been changed back for monitoring of reactor water level data.
- 2. Corrective Steps Taken and Results Achieved This event was discussed in a monthly Shift Operations Supervisor (SOS) meeting. The General Operating Instruction (GOI) was revised to delete the requirement (i. e.-
step 5.45). The monitoring requirement is no longer needed upon the completion of a reactor vessel level instracentation' modification that provides backfill from the Control Rod Drive (CRD) system to the instrumentation reference leg.
- 3. Corrective Steps That Ihave been orl Will Be Taken To Prevent Recurrenca No further corrective actions are deemed necessary.
- 4. Date When Full Compliance Will Be Achieved Full compliance has been achieved with the specific example of the NOV.
EXAMPLE 2 OF THE NOV
"...On October 1, 1994, during a plant cooldown, temperature monitoring required by Procedure 2-SI-4.6.A.1: Reactor Heatup and Cooldown Rate Monitoring, was not performed in that the "B" reactor recirculation loop temperature was not recorded at 15 minute intervals. This temperature was not monitored or recorded on the 2-SI-4.6.A.1 data sheet for a period of approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />...."
TVA's Reply to Violation B Example 2 -
- 1. Reason for Example 2 The reason for this event was a failure to follow procedure. l Specifically, on September 27, 1994, Surveillance l Instruction (SI) 2-SI-4.6.A.1 was revised in that instrument unique identification numbers were changed to allow ,
l E2-2
operators to monitor the suction temperature during this .
'cooldown because the discharge temperature indicator was not j in service. However, the Assistant Unit Operators (AUOs) were not properly briefed on the revision to 2-SI-4.6.A.1.
On October 1, 1994, an AUO initiated the cooldown log. The i AUO realized that the indicator for the loop B reactor recirculation pump discharge temperature had failed. The AUO discussed the problem with the Unit Operators and an Assistant Shift Operations Supervisor. Since the loop B discharge temperature had always been recorded, Operations personnel incorrectly assumed that both instrument unique identification numbers that were noted on the cooldown rate monitoring log were for the discharge temperature indicator.
Consequently, the AUO did not document required data on the cooldown log for two hours.
- 2. Corrective Steps Taken and Results Achieved The required data was retrieved from the loop B suction temperature indicator utilizing the Integrated computer System. Additionally, appropriate temperatures for the remainder of the shift were successfully logged. This event was discussed at an SOS monthly meeting held on October 19, 1994.
- 3. Corrective Steps That thave been orl will be taken to Avoid Further Violations In order co further heighten Operators' awareness, this event will be reviewed by Operators as part of their Operations Training Program.
- 4. Date when Full Compliance Will Be Achieved Full compliance has been achieved with the specific example of the NOV.
EXAMPLE ? OF THE NOV
"...On deptember 30, 1994, the Unit 2 reactor zone to standby gas treatrent system dampers were not placed in the normal (open) position as required by step 7.27 of Procedure 0-SI-4.7.C.1:
Comb.tned Zone Secondary Containment Integrity Test. This condition existed for approximately one hour before an NRC inspector identified the issue...."
l l
E2-3 !
l l
1
l TVA's Reply to Violation B Example 3 !
l
- 1. Reason For Example 3 The reason for this event wa.s a failuro to !clltw tha l procedural requirements of 0-SI-4.7.C... Seer '.27 of this procedure requires the individual respons. .- .or the performance of the SI to notify Operations that. the Standby Gas Treatment (SBGT) system can be realigned ia accordance !
with the present plant configuration. Operaters are then required to realign the system in accordance with the applicable Operating Instructions. In this case, operators did not follow the procedure instructions concerning alignment of the SBGT dampers.
- 2. Corrective Steps Taken and Results Achieved The SBGT dampers were closed. This event was discussed during a monthly SOS meeting.
- 3. Corrective _g_teps That Ihave been orl Will Be Taken To Prevent Rektrience As an enhancement, TVA is reviewing non-Operations sis to i evaluate whether additional system restoration guidance is necessary. Since this SI has been successfully performed in the past, this action is not essential to ensure compliance with this violation.
- 4. Date When Full Compliance Will Be Achieved Full compliance with the specific example of the NOV was ,
achieved when the SBGT dampers were returned to their correct position.
EXAMPLE 4 OF THE NOV
" ...On September 23, 1994, the actions required by Alarm Response Procedure 2-ARP-9-3 for annunciator number 33 on panel 2-XA-55-3F: High Pressure Coolant Injection Turbine Exhaust Drain Pot Level High, were not completed. Approximately 2.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> after the annunciator had cleared, an NRC inspector identified that the handswitch for valve 2-73-8 had not been '
returned to the "close/ auto" position...."
TVA's Reply to Violation B Example 4
- 1. Reason for Example 4 The reason for thic event was failure to follow procedure.
Operations personnel are expected to provide an expeditious follow-up on any activity that requires some time to transpire between the initial action and a final action.
Specifically, the Alar.n Response Procedure step for the High E2-4
Pressure Cooling Injection Turbine Exhaust Drain Pot Level
'High alarm allows 5 to 15 minutes for the clearing of the alarm. Normally, the switch is placed in an open position to allow the drain pot to drain; however, it is expected of the Operator to follow-up on the initial action and to reposition the switch in the appropriate time frame.
- 2. Corrective Steps Taken and Results Achieved-The switch was placed in the correct position '
("close/ auto"). The Operator was made aware of the need to perform follow-up actions. This event was discussed in a monthly SOS meeting to heighten shift supervisors of significant events that happen on other shifts. Soss ;
discussed this event with their respective shift members.
- 3. Corrective Steps That thave been orl will be taken to Avoid Further Violations No further corrective actions are deemed necessary.
- 4. Date when Full Compliance Will Be Achieved Full compliance with the specific example of the NOV has been achieved.
l E2-5
l
- i ENCLOSURE 3 '
TENNESSEE VALLEY AUTHORITY BROWNS FERRY NUCLEAR PLANT (BFN) )
UNITS 1, 2, AND 3 REPLY TO NOTICE OF VIOLATION (NOV)
VIOLATION C l INSPECTION REPORT NUMBER .;
50-259, 260, 296/94-24 ;
T RESTATEMENT OF VIOLATION
" Technical specification 6.8.1.1.a requires that 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. Paragraph 1.c ;
of Appendix A requires administrative procedures for equipment ;
control. 1 Site-Standard Practice (SSP)-2.1, Site Procedures Program, Section 3.2, states that employees are responsible for following ,
current procedures as written. SSP-12.3, Equipment Clearance Procedure, step 3.1.2, states that work shall not be allowed to '
proceed on any piece of equipment that is part of a clearance boundary, unless the work is evaluated by the Shift Operations Supervisor (SOS) SOS / SOS Representative and clearance holders to ,
ensure a safe boundary remains intact and that personnel safety ,
and protection of equipment is not compromised.
Contrary to the above, procedures were not implemented on >
October 9, 1994, when maintenance personnel removed the Unit 2 .;
drywell differential pressure air compressor aftercooler with a clearance tag attached to its vent valve. i This is a Severity Level IV Violation (Supplement I)." ,
-1 TVA's Repiv to the Violation
- 1. Reason for Violation C [
This violation resulted from a failure to follow procedure !
concerning the requirements of SSP-12.3, " Equipment Clearance Procedure." This procedure requires that when !
establishing a clearance boundary, the clearance holder (in :
this case, the maintenance foreman) shall perform a walkdown 1 of the clearance to ensure proper tag placement. Had this walkdown been properly performed it would have been detected that the heat exchanger, including the drain valve, could ,
not be removed without modifying the clearance boundary.
n -
o n. .. , .
l Additionally, SSP-12.3 states that personnel working around
' equipment that is involved in a clearance shall be j responsible for understanding and recognizing the boundaries I established by protective tags and shall not violate the l boundary and conditions of the clearance. ;
In this event, the personnel involved did not recognize that a drain valve attached to the heat exchanger was part of the clearance and that it would be removed from the system at I the same time the heat exchanger was disassembled. The individuals involved should have notified operations prior to removing the shell side of the heat exchanger with the boundary tag attached to the Reactor Cooling Water system drain valve.
- 2. Corrective Steps Taken and Results Achieved Upon discovery of the event the work on the heat exchanger was terminated. After a review of the work by the SOS and the individuals involved, the clearance boundary was modified to place the drain valve in the drain and vent section of the Form SSP-139 and the boundary tag removed from the valve.
Additionally, the SOS talked with the personnel involved emphasizing to them that equipment cannot be operated or moved if a clearance tag is attached to it. After modifying i the clearance and the discussions with the personnel involved in the maintenance activity, the work was resumed.
To document the condition of noncompliance with SSP-12.3, a Problem Evaluation Report was initiated in accordance with the TVA Corrective Action Program.
- 3. Corrective Steps That thave been orl Will be Taken Prevent Recurrence This event and the reason for the event were discussed with the Maintenance personnel, including the foreman, that were directly involved in the event. To further heighten personnel awareness of the significance of working on equipment under a clearance, the Maintenance and Modifications Manager issued a memorandum to the appropriate personnel reemphasizing his expectations in the area of working inside a clearance. The memorandum stressed that no equipment shall be operated or moved if a clearance tag is attached. Additionally, the memorandum stated that if a clearance tag prohibits the work task from being performed, operations should be contacted prior to beginning the work and the clearance changed to allow necessary work.
E3-2
~~
. t
+ l
'To prevent recurrence of this event, TVA will add a summary of this' event to the required reading for the appropriate ,
maintenance personnel. The summary will become part of the annual training for maintenance personnel.(both TVA and contractor) personnel.
-4. Date When Full Compliance Will Be Achieved Full compliance with the NOV has been achieved. The actions necessary to prevent recurrence will be completed by February 15, 1995.
I i
t 1
l
)
1 l
E3-3
l
, i j ' ENCLOSURE 4 4
TENNESSEE VALLEY AUTHORITY BROWNS PERRY NUCLEAR PLANT (BFN) (
UNITS 1, 2, and 3 REPLY TO NOTICE OF VIOLATION (NOV) ;
LIST OF COMMITNENTS INSPECTION REPORT NUMBER 50-259,260,296/94-24 ,
i
+
COVER LETTER
- 1. An II team has been assembled to evaluate the recent i operational errors that led to the second NOV on the !
Inspection Report as well as other similar errors that occurred during the Unit 2 Cycle 7 outage and subsequent '
startup. The results of this II will be compared to the II t on procedural adherence to ensure our root causes and ;
corrective actions are fully enveloped. The results of this ;
effort will be provided to NRC by February 2, 1995. !
- 2. The Plant Manager and the Nuclear Assurance and Licensing -
Manager will conduct a follow-up evaluation within approximately six months after the completion of.the II regarding procedural adherence to assess our improvements in '
this area. We expect to complete this evaluation by i May 30, 1995. !
s ENCLOSURE 1
{
None ENCLOSURE 2 In order to further heighten Operators' awareness, Example 2 of 1 this NOV will be reviewed by Operators as part of their Operations Training program. This action will be completed by )
January 30, 1995.
ENCLOSURE 3 ,
l
~
TVA will add a summary of this event to the required reading for the appropriate maintenance personnel. The summary will become '
part of the annual training for both TVA and contractor personnel. The required reading will be completed by February 15, 1995.
.. -