ML20080C976

Responds to NRC Re Violations Noted in IE Insp Rept 50-267/83-18.Corrective Actions:Health Physics Dept Operator Reminded of Importance of Following Procedures. Future Clearance Will Be Normally Tagged & Cleared

ML20080C976
Person / Time
Site:	Fort Saint Vrain
Issue date:	08/19/1983
From:	Warembourg D PUBLIC SERVICE CO. OF COLORADO
To:	Jay Collins NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
References
P-83285, NUDOCS 8308290409
Download: ML20080C976 (60)

Text

{{#Wiki_filter:- 7 PLII) lie NI*Vice coniii>,iiiv e ocan1rado 16805 WCR 19 1/2, Platteville, Colorado 80651 August 19, 1983 Fort St. Vrain Unit No. 1 P-83285 Mr. John T. Collins, Regional Administrator

0 i Alf> 2 21983 b!

U. S. Nuclear Regulatory Commission i 611 Ryan Plaza Dr., Suite 1000 UI.- - ~ Arlington, TX 76011 _ _)

SUBJECT:

I & E Inspection Report 83-18

REFERENCE:

NRC Letter dated July 21, 1983

Dear Mr. Collins:

This letter is in response to the Notice of Violation received as a result of inspections conducted at Fort St. Vrain during the period June 1-30, 1983. The following response to the items contained in the Notice of Violatipn is hereby submitted: 1. Technical Specification 7.4.a, " Procedures, Administrative Controls," states, in part,

that, written procedures shall be established, implemented, and maintained...."

Administrative Procedure P-2, " Equipment Clearances and Operation Deviations," dated April 20, 1983, Section 3.0,

states, "3.5 If the clearance is being issued to Results or Health Physics personnel and requires manipulation of valves normally operated by Results or Health i

Physics personnel, the valve manipulation required and the hanging of tags is to be performed by a Results or Health Physics person other than the person asking for the clearance." 00$ f 8308290409 830819 8 l PDR ADOCK 05000267 l C PDR

% 1 Equipment Clearance Tag 4985, issued June 2,1983, line 3, "Special Instructions," states, " Verify V-93444 is open to l insure flow to ME-9306 and ME-9307." Technical Specification LC0 4.4.5, " Analytical System 1 Primary Coolant Moisture Instrumentation Limiting Condition for Operation," states, "If both of the monitors become inoperable, during the above mentioned power increase, the reactor shall be shut down immediately." Contrary to the above, on June 8, 1983, the NRC inspector determined that the valve tagging operation normally done by Health Physics personnel was performed by Operations personnel, and that V-93444 was not opened as required resulting in reactor operation between 5 percent power and shutdown without operable analytical moisture monitors and the reactor was not placed in a shutdown condition as required in accordance with LC0 4.4.5. l This i s a Severity Level IV Violation. (Supplement I.D.) (50-267/8318-01) I (1) The corrective steps which have been taken and the results achieved: The clearance was reviewed and verified to be correct. In the future the clearance will normally be tagged and cleared by the Health Physics Department. The operator involved was reminded of the importance of following procedures and was given a formal verbal reprimand. No further violations have occurred. The clearance form has been revised to specifically state that Health Physics is responsible for tagging this system. (2) Corrective steps which will be taken to avoid further violations: t The clearance will be handled by Health Physics personnel who are more familiar with this system. No further corrective action is anticipated at this time. (3) The date when full compliance will be achieved: Full compliance was achieved prior to August 1,1983. 1 -e---- -v e,, 3-y ,e -pg n -mw+- iw s-,y1- -.o -*-+*--t -cr,-ur-rv-r --9,% sg -e,79.- g--.w g, .,.eg--scw eww ew -.9--- v

1

2.

Technical Specification 7.4.a, " Procedures, Administrative Controls,"

states, in part,

that, written procedures shall be established, implemented, and maintained...."

a. Surveillance SR 5.8.1cd-Q, " Radioactive Gaseous 4 Effluent System Calibratior.," Issue 33, effective date March 28, 1983, Steps 5.2.2, 5.3.2, 5.4.2, 5.5.3, and 5.6.3 state in part, I " Notify Reactor Operator that RIS ... bypassed status noted in the Reactor and verify Operators Log." Steps 5.2.39, 5.3.38, 5.4.38, and 5.5.27 state in

part, i

" Notify Reactor Operator that RIS ... returned to NORMAL and verify. . status is noted in the Reactor Operators Log." Contrary to the above, on June 14, 1983, the NRC inspector determined from a review of the operations logs that the instrument technician performing this surveillance had not verified the noting of the i radiation monitor status in the reactor operator log since not all the required entries had been made. i (1) The corrective steps which have been taken and the results achieved: Surveillance Test SR 5.8.1cd-Q has been revised in a manner such j that the Reactor Operator must verify the status of the radiation monitors in his log and veri fy this in the i - Surveillance. (2) Corrective steps which will be taken to avoid further violations: 4 Personnel were reminded that Administrative Procedure P-4 states that surveillance test must be performed as written unless changed by an approved Procedure Deviation Report. Surveillance Test SR 5.8.1cd-Q has been revised per (1) above. i ,,,.,,-.--.--.--.r,.r_.. ,-,---,,-~.m-w.--.%, ,-v.,ww--.. y....,,-m,--,,,, ....r,rm --~,--.,.-.,.....,-,--...m-.-_

O i f (3) The date when full compliance will be achieved: l 7-22-83. b. Administrative Procedure P-2, " Equipment Clearances and Operation Deviations," Issue 6, dated April 20, 1983, states, in part, " REACTOR OPERATOR 12. Directs required operations to return the system to the normal condition. 13. Removes Operation Deviation Sheet from the " Systems Abnor-malities Book" and initials the form to indicate the system is in its normal condition." Contrary to the above, on June 28, 1983, the NRC inspector determined that on two separate occasions for Operation Deviations 2912 and 2681, issued on June 7 and June 27, 1983, respectively, for work during performance of SR 5.8.1cd-Q, the system had been returned to normal overnight without the reactor operator removing the operation deviation sheet and initialing as required. (1) The corrective steps which have been taken and the results i achieved: The rewriting of SR 5.8.1cd-Q requires operator signature that the system has been returned to normal. This assures notification. All Operations personnel have been notified by memo (attached) that future documented failure to follow procedure violations will result in disciplinary action. (2) Corrective steps which will be taken to avoid further j violations: I The rewriting of subject surveillance will insure that future violations will be avoided. (3) The date when full compliance will be achieved: l 8 August 1983, i t I i

. c. Administrative Procedure P-4, " Surveillance Testing Program," Issue 3, dated October 26, 1981, Section 4.2.3 states, in part, "e) If a Surveillance Test cannot be run in normal sequence or changes must be made to the procedure, a Procedure Deviation Report must be filled out. Changes to the procedure, which do not change the intent of the original procedure, may be made with the concurrence of two members of the Plant Management Staff, at least one of whom holds a senior reactor operator license prior to running the revised test." Contra ry to the above, on June 8, 1983, the NRC inspector determined that two steps in Surveillance SR 5.8.1cd-Q had been bypassed without completing a procedure deviation report. This is a Severity Level V Violation. (Supplement I.E.) (50-267/8318-03) (1) The corrective steps which have been taken and the results achieved: Administrative Procedure P-4, " Surveillance Testing Program," Issue 3, dated October 26, 1981, Section 4.1.4

states, "The person (s) assigned to conduct the Surveillance Test (Test Conductor (s)) are responsible for:"

"f) Performing the

test, in a functionally sequential

order, and filling in the appropriate blanks provided upon step completion."

i . 1 j Administrative Procedure P-4, " Surveillance Testing Program," Issue 3, dated October 26, 1981, Section 4.2.3 also states, in part: 1 } "e) If a Surveillance Test cannot be run in normal I sequence or changes must be made to the procedure, a Procedure Deviation Report must be filled out. Changes to the procedure, which do not change the intent of the original procedure, may be made with the concurrence of s two members of the Plant Management Staff, at least one of whom holds a senior reactor l operator license prior to running the revised test." } The Administrative Procedure P-4 would therefore allow either method in the conduct of a Surveillance Test. If a Surveillance Test is written such that the numerical steps can be completed in a sequenc.' that is more functional for the plant condition or 1 l test condition, the Administrative Procedure P-4 is intended to provide the latitude. It is therefore our belief that the i sequence taken during the performance of SR 5.8.1cd-Q, Issue 33, involving the two bypassed steps does not constitute a violation i as either method was acceptable per Administrative Procedure P-4. 4 i (2) Corrective steps which will be taken to avoid further i violations: Administrative Procedure P-4 was deleted on 7-27-83 and replaced by the Station Manager Administrative Procedure 1 (SMAP-1), " Surveillance Testing Program," also effective that date. Conflicting portions of the earlier procedure were removed in this new procedure. 4 (3) The date when full compliance will be achieved: 7-27-83 A i In addition to our response to notices of violation your letter of i July 21, 1983 requested an additional response describing those j actions taken or planned to improve the effectiveness of management I Control. 1 I i

4 4 As I indicated to you in my letter of December 20, 1982 (P-82550) which resulted from our last SALP review, we are concerned about personnel errors and failure to follow procedures events. I indicated in that letter several things that we were doing to improve the effectiveness of our programs, and that we would continue to 4 evaluate this matter further. I indicated to you that we were having a very difficult time assessing the situation due to our higher than average exposure to i plant transients and the resulting start-ups, shutdowns and other l personnel challenges. As a result we did begin an overall trending [ program that could be utilized by management to provide a better t feedback vehicle and/or management tool for assessing the problem. I j am attaching that program for your information and review. i Basically the objective of the program was to develop a system that i would track, on a monthly basis, various items that resulted in NRC l violations and Reportable Occurrences. We developed the system within the frame work of the SALP reports and the Reportable Occurrences utilizing a classification system that addresses five (5) i areas (Failure to Follow Procedures / Personnel

Error, 2

Design / Manufacturing Deficiency, Inadequate Procedure, Component ] Failure, and other). Each of these five (5) areas is plotted for each month beginning in 1980 and proceeding through July 1983 for i Reportable Occurrences and June 1983 for NRC Violations. We were only able to look at the first half of 1983, but based on the historical data the first half of the year is fairly representative, in terms of numbers, with the last half of the year. From the summarized table there is an overall downward trend in terms 1 of the total number of occurrences which indicates that some r improvement is being realized although the improvement is not as significant as we would like. I } 1 i I 2 l .-. _ -._.--- _ _ _ - - - -,___ _,_ _._,...~. _ _ -,_ __.,_ _ _..-.-_. _

. As a follow-up to the summary table we determined through INPO the industry averages for the five (5) areas for reportable occurrences so we could have some type of comparison data. We determined from this effort that industry wide the reportable occurrences are as follows: Industry Avg. FSV Aug. 80 thru 82 Personnel Error / Failure to Follow Procedures 17.4% 11.39% Design / Manufacturing / Installation 12.19% 4.95% Inadequate Procedures 5.78% 1.98% Component Failure 50.03% 44.06% Other 13.08% 37.62% Based on these percentages FSV compares favorably with the industry averages. We have not as yet been able to compile a comparable list for NRC violations. We are continuing our efforts to evaluate this data further with respect to plant operations. Although we have not as yet been able to reach any definite conclusions there does appear to be a definite trend and/or relationship of personnel error / failure to follow procedures with plant operations. For your information we have enclosed tne Operating History of Fort Saint Vrain for each year from 1980 to the present. In evaluating the operating history versus the number of violations for failure to follow procedures there appears to be some definite correlation of increased number of violations during periods when we are attempting to get the plant back in service especially after an extended outage. We are, however, in the very preliminary stages of this data comparison, and we are not in the position at this time to draw any conclusions. We are still of the opinion the operational status of FSV and the associated challenges of the operators are definitely contributing factors. We have not, as yet, determined the root cause or remedies for the situation. Please be assured that we are continuing our evaluation in an attempt to determine areas that need more concentrated attention.

t i i l i f Recognizing that this has been a time consuming process and will continue to be somewhat time consuming in the future before we can develop definite solutions, we have taken some interim actions in an ] attempt to reduce failure to follow procedure type events. On t August 1, 1983 the operating staff was put on notice about our concern for the number of failure to follow procedures events (see PPC-83-1923~ attached). Subsequently the subject was reiterated at my staff meeting on August 17 1983, where in management's position on failure to follow procedure type events (see memo PPC-83-1979 attached) was presented to nuclear production supervisors, 2 i It is obviously much too early to assess the effect of these interim actions. I believe, however, that based on the above activities that you will agree that management is making a strong effort to define the root cause of the problem, cavelop management tools for continuing assessment of the problem as well as attempting to take some interim actions to correct the problem. I j We recognize that the above plans are not as definitive as we would like them to be, but we are working toward a more definitive program which must necessarily be based on our continuing evaluation. l Should you have any further questions, please contact j Mr. L. Milton McBride, (303) 571-7436, ext. 201. i Very truly yours, ((StJkk l on W. Warembourg l Manager, Nuclear Production Fort St. Vrain Nuclear Generating Station DWW/djc Attachments 1 1 1 i i -, -,. -.. -,, ~.,... - -..,. -, - - _. _ ~ _..,. _. _. - - -,... _ -..,,, -. -,, - - -. - _ _., -

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%8 g; E !? u 8 %8 eeE 88 5% v2 8 v s u. No. No. No. No. No.- I 4 80 23 19 83% 1 4% 3 13% 0 0% 0 0% 81 29 26 90% 0 0% 1 3% 1 3% 1 3% o 3 82 19 19 100% 0 0% 0 0% 0 0% 0 0% e o 5

• 83 8

7 88% 0 0% 1 12% 0 0% 0 0% 0 84 I 80 76 6 9% 7 9% 1 1% 33 43% 29 38% E g 81 72 9 12% 3 4% 0 0% 31 43% 29 40% t 82 54 8 15% 0 0% 3 6% 25 46% 18 33% o

• 83 22 5

23% 1 4% 1 4% 9 41% 6 27% a l T g

• • 83 23 6

26% 1 4% 1 4% 9 39% 6 26% E 84

• 1983 is for the first half only, through June 1983.
  • 1983 is data that reflects through July 1983.

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l -. 2 o co w. tco - q ? to N ( 1980 NRC Violations Fai ture to Foi tow Procedure g 4 l 40 i i,..lTotal for Year I i 35 R Total for 12 Months Ending I' 2 @] Total for Month 30 g 3 o Total number of Nr<C Violet ons for 1980 - 23 2$ a O ( t. g > 20 u_o 1 n l n T x 15 i.u i i! i m I r .j l l I I 2 10 3 4 'j f d i m. u i ~ 5--.< .3 __ _ _ -n. f. p: 7-pn.i. : -t : p i! i. ,i. g 6 n i <.i n p 1; j n; e i i t i i JAN FEE MAR APR MAY JUN JUL A'JG SEP OCT NOV DEC + 1 j MONTH i \\ i 9/tt et3 i i 1 4 a i I i 1 } i vr g y- ]

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77:' m CO d em N l-1981 NRC Vionations q'- Failure to Follow Procedure t 1_ o' 40 R Total for Year r 9 Total for 12 Months Ending 35 j' te2] Total for Month 30 LO Total n urnbe r of ISC Violat 'ons for 1901 - 29 -o m E 25 '~ y _a l o 'I .r ll 1! 13 -i g. m

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\\ c q 1981 NRC Violations Component Fai lure G c. ( 40 y Total for Year /' > Total for 12 Months Ending e s Total for Month m 30 Tot.: moder .4 rec viot.t on. <.r isst - 2s Q 25 a S > 20 u. O \\ g 15 Ea 4 10 5 0 non JAN FEB MAR APR MAY JUN JUL AUG SEP GCT NOV DEC I MONTH I '11/01 1

(. i ( i: q. = ~; 4 m t- ' co ?;, - _- 9., N !g', tD- ? (o i. 'N q 1982 NRC Viotations Failure to Follow Procedure .1. r,3 - 4, .:C ( i9 40 F -jTotal for Y ear f 4 7 ear Total for 12 Months Ending 5 35 E.ed Total for Month 30 g Total number of NRC Violet ons for 1962 - 19 8 q W j $ 25 J II O I' 'i F .I l' s 4 > 20 w C x 15 5 w ~ 59 i o 3 10 I I' L 4, t o MN,d I., M 2 u ( I. l ri n rt n i n R h B i O re - n I i 4 l I JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH 4 9/11/93 4

( i ( .a. ( ( 1982 NRC Violations lO g Component Faifure q c (~ ( 1. 40 l :.; { To t a l for Year ( ( 38;9 Total for 12 Months Ending 35 ~ ( 4 - Total for Month 30 e y, Tot. number ofesc viet.t ou <r tss2 - ts Q 25 a S > 20 u. ( o = 15 g r 3 10 ar = 5 5 g m m re m m n ri r1 n e m i a i i JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH I/11/03 4

( e, 1982 NRC Violations b Other f I'- 40 [ g Total for Year ,g' Total for 12 Months Ending ~a Total for Month m 30 Tot t number of enc vion.t ons for 1982 - is Q 25 s > 20 a O ~ m 15 E ( r ,2 10 5 g m n n n n n m rn 6 i i JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH e?was 4

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gr Total for 12 Months Ending i 35 mus Total for Month 2 0 C l 3 Total n ut.t,e r of NRC Violet 'ons for 1983 - 8 s l $ 25 I ao ( H ( > 20 w I o ( i e 15 i w f r i cn E q E 4 10 ( l e I M-5 ? l I i. s i! 1 ~ ,5 e D 72 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC I l MONTH t (. t/11/93 L f l l l

4 1 I 8 g n i 3 d 8 n 9 1 E r o s f h s t n C n o o h E t r M t D a a n l o e 2 o i Y 1 M V V .i O C N r r r N o o o t f f f fo T l l l C r a a a e D t t t b m o o o u T T T n P E E] t S ] a a u t t a p p L o e l [ T s r G n u U o d A i e t c a o L l r U o H P J T i V N e O t n N M Ca n U R u J Nq e 3 n Y d 8 a n 9 n t 1 I n R n P n A RM F B E F NA J 0 5 0 5 0 5 0 5 g 4 3 3 2 2 1 1 u20 Q s > uQ gmI3 j ( ( 7 C' C C ( t' ( r t r ~ c .L f$i t

q (.. (j / v [ R.,. D ) N~ 1980 r Cause Code A n Personnel Error l 2 0 M.. 40-i /+ b - l Total for Year p. ' ' 'i- -~ 3 ew Total for 12 Months Ending* C w Total for Month 6 30 l m N$ Totiil nebt r of RC 's for 1969 - 76. a 25 ma U a 20 it o e 15 w ? 3 10 ,g t 5 ( Il fl g n n n n n n n n n n JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH IData for " Total for 12 Months End.ng" not incluoed. 9/11/63

Q e P C p j p C G 1980 Cause Code B q Design. Manufacturing. Construction / Installation c i: 40 I,,1 Total for Year c f. 35 +wo Total for 12 Months Ending8 b;': Total for Month g 3g Lij w Totu t numtn r of PC 's for 1969 - M. a 25 a O !$20 u.o x 15 w ( E @ 10 5 Il O fl Un U g m n n n n JAN FEB MAR APR MAY JUN JUL AUCr SEP OCT NOV DEC MONTH EData for " Total for 12 tio n t h s E n d ; n g" n o t included. 9/it/t3

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5 ( c 1 h ~ C C 1980 Cause Code D t_ 4 Defective Procedure r 4 h, 40 l-l Total for Year 35 R Total for 12 t1onths Endings m 30 y Total for Month W w Totot nebt r of RC 's for 1962 - 76 a 25 aao {$20 t uo a 15 w 3 10 ( 5 g_ nmn mn i t JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC t10 NTH EData for " Total for 12 Months Ending" not encluded. S/11/93 4

k + i 0, 'f. ( t' 4 e ~a i .4.- c. ( ey 1980 g Cause Code E p+v] Total for Year Q Component Failure r r je:c, Total for 12 Months Endinga q 0:' 48 4, P< Total for Month ( 35 " ' - - ' e a' ar - < ~ "** - 7 6 v ?.,-,... m 30 ua s W O m 25 t, x r-oou r, - ~ o 20 u. o ( m 15 w 3 10 ,c i i C 5-( I fl. R R R R R l l e R JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC T10 NTH IData for " Total for 12 Honths Ending** not i n c l u de d. 1 t/st/93 / + I m

y{ 7 h C: ( l'380 r Cause Code X 1 - c Other l- :l Total for Year 40-- em Total for 12 t1onths Endings ( Total for tiOnth A& (_ rotal numfu r of PC *s for 1988 - 76 m 30 m ~ 8 $ 25 l 1ao a 20 y i e 15 N ~ r 3 10 5 ( F ~ 0 Un R R R n g JAN FEB MAR APR MAY JUN JUL AUCr SEP OCT f40V DEC MONTH IData for " Total for 12 Honths Ending" not included. 9/11/03 Is

.J - i :: (.. = V e 0 .n..e, c.+ ( 4 's 4.. s ' f g in's ~ > : n:,. 40 A Total for Year z 35 y g Total for 12 Months Ending , 3p g Total for Month .tij i To titt numbs r of RC *s for 1981 - 72 a 25 eD O E! 20 (. O x 15 21e s., 1 I 3 r I'. i, O bn g n i n n JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH 9/11/93 ( l +

E... r e (- ,e l if O g [ '; - 1981 Cause Code C h e' d External Cause C 40 l.-. -;] Total for Year c 35 e Total for 12 Months Ending a g 9 Total for Month m 30 r w ' *"' " " " ' ' ' " # "C ' ' *'**-72 25 8 t a 20 Ei ( x 15 U ( 1 CQZ @ 10 k (' 5 '( 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH 9/11/03 (

{ e g 7.g. .y; y. G ( 1981 Cause Code D g~ Defective Procedure 40 [, d Total for Year 35 .q~ Total for 12 Months Ending u) 30 Q Total for Month ( w r w Totot nunibt r of RC *s for 1961 - 72 a 25 xau a 20 u. o e 15 W r @ 10 5 0 m n n n n n m r1 m u i i i i e JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH 6'11/ B3

C ( c p' e d 1981 v.i Cause Code E y Total for Year -1 Component Fa,i t ure I: g Total for 12 Months Ending g ",t{"j:;i[ 40 Totat for Month 0 Total number of RO's for 1981 - 72 35 f.., r ( I u) 30 i w i N U w a 25 e t x i D i U

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i U ll 4 I o 20 i P L o ll i tt x 15 e w c l co r G 10 f i V 7 i l l 7 c 5 i i a h I i l lh .s L p ) v F I ~ 0 l JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH iwis 4

(d ( c c x., K.F,?. ff%^ C q 1 <381 L.i Cause Code X 3 Other y Total for Year L a,- 40 g@ Total for 12 Months Ending gp-C3 Total for Month ( 35 Total Number i-( PO's for 1981 - 72 L - r s p g l i to 3 0 f ( w _l n M e IE 25 f x 1 U l o i l " a 20 d u. 4 a l s x 15 l w i en l I g gg 3 , \\- i q d t c' 5 i c l ll [l i R ll nll R Fi l I. 1 i e l rtil l h ~ 0 JAN FEB MAR APR MAY JIN JUL AUG SEP OCT NOV DEC MONTH 9/11/93 (" e, s 4

( (, 6 g .( ( I e g n i dn E 4 5 s h 2 t 8 n 9 C 1 o h E r M t r n D o a n f e 2 o Y 1 M 's V O C r r r R n N o o o f f f f o T r l l l 1

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n O a a a t m t t t u o o o n T T T P l l 4 a l E { t S f o m T p m G U r A o Ar r e L d E L U H 2 o J T t 8Ce N 9 n O 1 e N M n s [ U o u J s a r Ce Y P [ A n M R P o A RA e M l B I i E E F N A J 0 5 0 5 0 5 0 5 p 4 3 3 2 2 1 1 ewNwaaaoE b awmI3 l 3 9/ 1 1/ 9 t c' e-C c I ( i v I [ !t; . 'w.

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DU ( o 20 1.L O e 15 c w CQE t. 3 10 5 I 3 0 1 ri ri JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH B/11/03 l i

.( c t c g n i dn E 4s s h 2 t e n 9 C 2 o h E r M t r D o a n f e 2 o Y 1 M V O C r r r N o o o f f f T l l l C a a a b' O t t t o o o T T T I E P H S l 1 l 9 i M H s l I G U e A Cs u ea L dC U H 2 o J T 8Cl N 9 a O 1 en N M sr d U ue J at CxE YAM R PA RAM B E F NA J e 0 5 0 5 0 5 0 5 0 4 3 3 2 2 1 1 ow Ex o e xgr3 t 3 9 / 1 1 / B c e c c n c. f I_

J C (* u-r n L c.q m 37 6-O u 1982 k~ Cause Code D [ Defective Procedure I ~ 40 r, Fr I t, { Total for Year l C 35 43 Total for 12 Months Ending 1:. ' O P ~3( Total f C r Ilo n t h C wo Tot <il numbi r of RC 's for 1962 - 54 ( x 25 xa U E!20 LL o e 15 W ( car 3 10 ( C-5 OblU UU UU lilU 1 g i i i JAN FEB MAP APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH siwn cis o

F. V(bi, ( ( y ( N ~ . h.. ',:. c C 1982 m t. Cause Code E c Component Failure C C 4O } - > ,w e M Total for Year 7, 35 g,. gg To t a l for 12 Months Ending O s Total for Month a in 30 w N Totiit numbt r of RC 's for 1982 - 54 wa 25 R l m l j U 0 1-O i, I n ,s 's y li i i o 20 Q; - o Y LL ( t. O l l I x 15 e' LLJ j l 5 r N l I q d E i i, i d ti i g

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c. Other 6 r' 40 r b,f-R Total for Year C 35 eg Total for 12 tionths Ending

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C 6 l Q Total for Month m 30 i~ W ( w Total numba r of RC *s for 1982 - 54 x 25 C r xD I 'I O i i e' 20 a ( i o x 15 g r i l R 10 8 a \\ d I (y ) t-5 l,. i ll l L i 3 ,y n n O ! O ! I Il 1 n i g m

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f. ( w< y.. p g 1983 y Cause Coce A g / Personnel Error . - Total for Year C-( 4g y Total for 12 Months Ending .s, (. ca Total for Month ( 35 Total 14 umber of PO*s for 1983 - 23 g u) 30 wW Oie 25 eau a 20 u. o x 15 W i mr 3 10 i I t I. c n ~ 5 r i l } ir 5 + i t t t i f n Il n n ts. I t r c n t g I a a a i JAN FEB MAR APR MAY JUN JUL AUG SEP DCT NOV DEC MONTH 9/15'93 ( e

c. d r c ? h* C C A:.' f 1983 Cause Code B p.. g T Design, Manufacturing. Construction / Installation r-Q 40 1 7l Total for Year C-C. 35 Total for 12 Months Ending w- $ IOtal for Month g wW$ Total numti r of PC *s for 1983 - 23 m 25 eao a 20 w e o x 15 -- w 5 10 5 g nrin nn ra n nn on en i i i i i JAN FEB MAR APR MAY JUN JUL AUG SEP OCT T40V DEC Mot 4TH B,'1% B3 i t 4

G c C g g g 1llll g n i dn E 3 2 s h 3 t 8 n 9 C 1 o h E r M t r D o a n e 2 o Y 1 M s V O C r r r F N o o o f f f f o T r l l l e C a a a b O m t t t u o o e n T T T P t i 9 a E l 4. l to S 6 T 6 l 0 1 G U e A Cs u ea L dC U H 3 o J T 8Cl 4 9 a f 1 en N 0 M sr U ue J at Cx E YAM R PA R t B E F N A J 0 5 0 5 0 5 0 5 0 4 3 3 2 2 1 1 mw w &DO! LC 1W 3 L E 3 9 /5 1/ 8 (. f b ,LL Iif f kjli !Il I

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h'- ( r..' g.. l_ C J' 1983 Cause Code D c Defective Procedure 40 le :l Total for Year O C 59; Total for 12 Months Ending .- j g

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B/it'93 ( g (

W. b-W:t C ${ 'N ( ( 4, Lse qs A. J c ( @.4$t i983 7;h'g. Cause Code E g 's Component Fai t ure c C 40 ~ 8 Total for Year C c 35 + Total for 12 Months Ending . ~.., C. C Q Total for Month g 30 W T**"" 'a' 2ses - 23 !E 25 ea U Oo 20 l u. p o e 15 ( tu c a2r 2' 10 ~ e 5 ~ ~ C r n: o "} k I p p-w 3 n e n g i JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH iesus ( 4

.' (. ( ( ".;:. u;. g < e.e 1983 -y;.' - g Cause Code X Other s 40 .j..f.j l2 >{ Total for Year 35 Total for 12 Months Ending c; ( g Total for Month to 3 0 ( w ( w Tota, t twb a r of RC *s for 1983 - 23 (. x 25 o 8 c a 20 1 C-( o x 15 r-w c caI j t. i ( (? ~ ~

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( = f U ) 0 m n e n n JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTH t/1Vt3 (+ L

REACTOR POWER % y w ro w c-u es --a co 'o o o o o o O O o O o O O g-4 Shutdown to recover from scram m Replace "B" circulator (ruptured static seal) ym 7 Turbine Over Speed Tests [ Scram due to cool-ine tower line l rupture r Instru-ment eroble=s loss of vacuum E Icop Shutdowns n H urbine off due to loop shutdowns T 1 1 1 i g M l l 4 5* _= ~ g Loop shut-o down stayed down due to ke c %utdown due to hydraulic oil leak and fire l cao3 4 Planned shutdown for =aintenance/ surveillance testing a Turbine Of1' Line S Reactor scram l due to loop shutdown during g: surveillance testing _x Turbine taken off ? line for HRH drain line e repair ste gen at o lea D Repair FW trin valve I Reactor Scra= During Startu; Shutdown for turbine generator intercept valve

1 ) Thermal Power % 1. Continued turbine reheat valve shutdown. 2. Power reduction for moisture. 3. Shutdown for feedwater leak. 4. Power reduction for moisture. 5. Hot reheat scram. 6. Loop 2 sample valves installed. 7. Power reduction for fluctuation testing, RT-500K. 8. Turbine trip during PMD-4-w. 9. Shutdown due to excessive purified helium leakage following recovery from turbine trip. 10. Shutdown for excessive purified helium leakage. 11. Start up with purified helium system modification. 12. ARS Scram due to RMCC1 loss. 13. Scram recovery and return to power. 14. HRH Scram due to 1D circulator trip. 15. Loop II trip and recovery. 16. HRH Scram due to 1A circulator trip. 17. Turbine off line for Control Circuit modification.

18. High vibration trip on turbine generator. Start of refueling outage on 5-21-81.

19. Sliutdown for refueling. 20. Startup following refueling. 21. "A" circulator out of service for SV-2105 repair. 22. Turbine trip and reactor scram during attempted repair of SV-2105. Also cable repair after construction fire in cable tray. 23. Turbine off line for isolation of #5 feedwater heater leak. 24. Reactor scram on two-loop-trouble, turbine trip. l l .-n 1

_2 25. Loop 2 trip and recovery 26. Turbine off line, reactor <2.0% of power for excessive purified helium leak from B.2.3 5/6 penetration. 27. Shutdown for loop-split modification. s 9 O l 3 3 / t t ./

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's, c -l C 5 e " y i* g m l s - +.- ,.s, ,..s 1982 s a T. 'l 1 THERMAL PCMER % r, 2,

1.'

Continued loop-split modification. s 2. Investigation of system 46 leakage, and CRD-19 replacement. s 3. Reduction of power due to primary coolant oxidants. 1 4. Loop 1 shutdown.tollowed b'y manual scram. 5. Reactor scram and re[dvery. 6. Turbinageyaatortripandreedvery. 4 7. Loop 1 stutdown'follovad by a reactor scram. 8. Continuation of shutdown (#7) for internal reactor and secondary l maintenance. 9. Steam Generator modale B-2-3 leak repair. y g s k b '"x M.6 & QM ) , x n q g t = 1 sn., \\ m 1 3- .\\ ~;~-~~r~

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1983 THERMAL POWER (%) 1. Reactor scram due to a moisture ingress to the PCRV following a helium circulator system upset. 2. Manual reactor scram and turbine-generator trip upon loss of "B" instrument power inverter. Continued shutdown due to high primary coolant impurity levels. 3. Reactor scram from high moisture. Remained shutdown for maintenance to "D" helium circulator. 4. Reactor manually scrammed for maintenance to the circulating water system.

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+ INTER-DEPARTMENT MEMO 'PUBLIC SERVICE COMPANY OF COLORADO NC 61 1 PPC-83-1923 / i DATE: August 1, 1983 TO: Operations Personnel FROM: William J. Franek, Superintendent of Operations ATTN: L. Milton McBride, Station Manager SUBJ: FAILURE TO FOLLOW PROCEDURES We have recently received the listed Notices of Violation for failure to follow procedures: 1. Failure to remove Operations Deviations when a system returned to normal, ~ 2. Failure to follow a Clearance procedure. 3. Failure to review start-up book prior to increasing power from 1.5% near 2% power. Reactor Operator was unaware of the start-up status or location. 4. Failure to have sealed and critical valves properly sealed. 5. Violation of liquid nitrogen storage--tank-level requirements. (Outside dewars capacity can not be added to satisfy Technical Specification requirements.) 6. Failure to note a Technical Specification grace period on the ACM as required by the Technical Specification Compliance Log. In addition to the above listed occurrences, plant Operations has five (5) other failure to follow procedure violations. These are known violations which are documented by the resident inspector. The systematic assessment of License Performance (SALP) Review Panel and the INPO audit of Operations consistently gives Operations' low marks for professionalism, following procedures, and job performance. Procedure violations will no longer be tolerated. Personnel involved in a documented failure to follow procedure violation in the future will have disciplinary action noted and documented. The mechanism for changing procedures exists and is functioning. 1 ?

August 1, 1983 2 PPC-83-1923 I l If you have any questions or constructive suggestions please contact me. l I I I WiIliam J.~ Frane V WJF/dje l l Y 9 4 e m l l 9 1 t 4

INTER-DEPARTMENT MEMO - PUBLIC SERVICE COMPANY OF COLORADO 1 PPC-83-1979 DATE: August 17, 1983 i { TO: All FSV Supervisors I FROM: Charles H. Fuller, Technical / Administrative Services Manager, FSV l Frederick J. Borst, Radiation Protection Manager, FSV L. Milton McBride, Station Manager, FSV 1 ATTN: Messrs. Lee, Brey, and Gahm SUBJ: In 1980, the NRC issued Fort St. Vrain 23 Notices of Violation Of i these, 19 were for Failure to Follow Procedure. In 1981, 29 Violations were identified, with 26 of these for Failure to Follow l Procedure. In 1982, all 19 Violations which Fort St. Vrain received were for Failure to Follow Procedure. Finally, in 1983, seven of eight Violations have been for Failure to Follow Procedure. We, the Plant Managers, are deeply concerned with the lack of progress in correcting the rate of personnel errors and failure to i follow procedure violations as reflected in the above statistics. We 1 are of the opinion that these violations are in large part due to i negligence and not due to honest mistakes. Attached are examples of NRC Notices of Violation and Reportable Occurrences for 1980 to 1983, j and the 1983 PRP trend analysis tables for your information and review. The data exemplifies Management's concern. Management does not condone, nor can we tolerate, continued violations due to negligence. Therefore, stronger actions are required by all of us. l All Fort St. Vrain supervisors are instructed to hold a departmental meeting upon receipt of this memo, and: 1. Provide a copy of this memo to each employee present. j 2. Read the memo in its entirety to all personnel present. { 3. Document in writing the personnel in attendance. For those individuals not in attendance, repeat steps 1-3 above as soon as possible, ensuring that each individual in your unit receives i the information. All documentation as required above is to be forwarded to your manager. All Fort St. Vrain personnel are instructed to: 1. Open, read, and use procedures at all times other than when immediate actions are required in an emergency situation. If this requires you to take a procedure book into the plant, then you are expected to do so-and to return the book to its proper location when you are finished with it.

August 17, 1983 2 PPC-83-1979 i i i 2. Correct erroneous or deficient procedures in accordance with APM G-2 and G-3 (i.e., write a PDR and DCCF upon discovery of an incorrect / unworkable procedure.) Under no circumstances other than an emergency should you continue on until you complete the appropriate paperwork. If you know of procedure problems, get them corrected prior to running the test, surveillance, SOP, etc. j 3. Initiate new procedures for those situations in which a i procedure does not exist but for which you feel one is warranted. Follow APM G-3 for PCAR's. Delete, with management approval, those procedures which are no longer necessary. if t 4. Resolve questions with the Shift Supervisor or your supervisor in those cases where you are unsure of your actions in the normal course of performing your job. There are times when personnel errors can be mitigated by various circumstances, but in many of our recent personnel error problems it is extremely difficult to support the action taken by some mitigating circumstance. Perhaps the term negligence is somewhat strong, but it is used here to indicate a broad spectrum of problems such as lack of 3 attention, short-cuts, not taking the time to determine procedural I requirements, etc. We have made various attempts to reduce personnel errors especially in the f&ilure-to-follow procedure area, but these attempts have not j brought about satisfactory results. Personnel errors are costly not only in terms of Nuclear Regulatory Commission citations, but in terms of unit outages or equipment damage. We have in the past taken some disciplinary action for personnel errors, but we have not a generally applied the progressive discipline guidelines. In the future, we will be looking at and evaluating personnel errors in more detail and disciplinary action will be taken where deemed i appropriate. It is not the intent of this memo to threaten personnel with disciplinary action. We expect people to make mistakes. We do l not, however, expect people to make mistakes out of negligence. l We recognize that most FSV employees are dedicated individuals who conduct themselves in a professional manner. It is not our intent to penalize you for the errors of a few. Therefore, be assured that an honest mistake will not result in disciplinary action.

Further, plant-management will formally recognize, in writing, those I

situations in which you perform above and beyond the call of duty. l This information will be utilized in your future performance reviews. I It is unfortunate that it has become necessary to take a harder look at violations in regard to personnel errors and failure to follow procedures. We think that you will agree, however, that there is really no excuse for many of these problems. We are also confident i that you share in our belief that in order to ensure the continued safe operation of Fort St. Vrain, these steps must be taken now. 4 . ~.

August 17, 1983 3 PPC-83-1979 If you have any questions concerning this memo, please refer chem to your supervisor. If your supervisor can not provide ycu with an explanation, then he is hereby directed to refer the question to his manager. This memo is effective immediately. T)]bW A '7],A *Cx f 'kSC k ptG( L. MiYton McBride' Wrederick J. Bdrst L /f Lh $ b. Charles H. Fuller Approved: S JV WLAca $ w o Don W. Warembourg i i l l l l t l i}}