ML20082E284
| ML20082E284 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 04/03/1995 |
| From: | Boulette E BOSTON EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| BECO-LTR-#95-04, BECO-LTR-#95-4, NUDOCS 9504110176 | |
| Download: ML20082E284 (12) | |
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10 CFR 2.201 O .
., Boston Edhoon Pilgrirn Nuclear Power Station Rocky Hill Road .
Plyrnouth, Massachusetts 02360 April 3 ,1995-E. T. Boulette, PhD BECo Ltr. #95-041 '
Senior Vice President-Nuclear 3
- U.S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 License No. DPR-35 Docket No. 50-293 i
Subject:
RESPONSE TO NOTICE OF VIOLATION
Reference:
(1) NRC INSPECTION REPORT NO. 94-26 (2) NRC NOTICE OF VIOLATION, EA95-010, DATED MARCH 3,1995 1
Please find enclosed the response to the Notice of Violation. Enclosures 1 and 2 provide the i rcsponse to the violation parts I and il, respectively. ,
I Boston Edison Company believes the management attention to and emphasis on the corrective actions taken and planned are commensurate with the violation.
Please feel free to contact me if there are any questions regarding this response.
& h ot.u l t Q E.T. Boulette, PhD Enclosures '
DWE/ lam /9457 Then personally appeared before me, E. T. Boulette, who being duly sworn, did state that he is Senior Vice President - Nuclear of Boston Edison Com aany and that he is duly authorized to execute cnd file the submittal contained herein in the name anc on behalf of Boston Edison Company and ,
that the statements in said submittal are true to the st of his knowledge and belief.
My commission expires: Ocd-dt48f5' DATE /
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[Page 2 Ltr. #95- 041 -
cc: Mr. ThomasT. Martin .
Regio'nal Administrator, Region I
. U.Sl Nuclear Regulatory Commission
- 475 Allendale Road :
King of Prussia, PA 19406 Mr. R.B. Eaton .
Division of Reactor Projects I/II Office of NRR - USNRC One White Flint North- Mail Stop 14D1 11555 Rockville Pike .
Rockville, MD 20852 Senior Resident inspector L
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Bzton Edis:n C:mp:ny Docket N2. 50-293 Pilgrim Nuclear Power Station License No. DPR-35 N ENCLOSURE 1 NOTICE OF VIOLATION During an NRC inspection conducted between December 7,1994 and January 17, 1995, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, the violations are set forth below:
- 1. Technical Specification (TS) 3.7.A.2.a requires, in part, that primary containment integrity be maintained at all times when the reactor is critical. Primary containment integrity means, in part, that the drywell and pressure suppression chamber (torus) are intact and that all manual containment isolation valves on lines connected to the reactor coolant system or containment which are not required to be open during accident conditions are closed.
TS 3.7.A.6 provides that if TS 3.7.A.1 through 3.7.A.5 cannot be met, an orderly shutdown shall be initiated and the reactor shall be in Cold Shutdown condition within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
Contrary to the above, from November 29,1994 to December 28,1994, while the reactor was critical and primary containment integrity was required, primary containment integrity was not maintained in that a pathway existed from the torus air space to the reactor building (or secondary containment) atmosphere through a low pressure side port on the valve manifold of drywell-to-torus differential pressure transmitter PTD-5021. The pathway existed because a pipe plag that establishes the primary containment isolation boundary was not reinstalled in the open port following a monthly calibration of the transmitter that was performed on November 22,1994. The reactor operated in this condition from 7:00 AM on November 29,1994, until 4:46 PM on December 28,1994, without an orderly shutdown being initiated and the reactor being placed in Cold Shutdown. (01013)
REASON FOR THE VIOLATION A plant shutdown was not initiated and the reactor was not placed in cold shutdown i within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> because the uninstalled plug was not detected until l December 28,1994, when the Drywell-Torus atmosphere differential pressure
! transmitters including PTD-5021 were being calibrated. The plug was not re-installed l
as part of a calibration of PTD-5021 on November 22,1994. The reason for the test ,
plug not being re-installed is discussed in the response to Part 11 of the violation.
l The Drywell atmosphere-to-Reactor Building atmosphere differential pressure is sensed by transmitter PTD-5067A. The Torus atmosphere-to-Reactor Building atmosphere differential pressure is sensed by transmitter PTD-50678. The Drywell atmosphere-to-Torus atmosphere differential pressure is sensed by transmitter i PTD-5021. Transmitters PTD-5067A/B and PTD-5021 are located in the Reactor i Building at Panel C-88.
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Bo:t:n Ediscn C:mp:ny D:cket No. 50-293 !
Pilgrim Nuclear Power Station License No. DPR-35 ENCLOSURE 1 (Cont'd)
These transmitters operate on the force-balance principle. In operation, a difference in pressure between the high pressure side and low pressure side of the transmitter is sensed and converted to a signal sent to a pressure indicating instrument (e.g., PID-5021). The sensing cell is mounted in the transmitter's manifold that is equipped with ,
high and low pressure connections, vent and drain plugs. For PTD-5021, the Drywell atmosphere is connected to the high pressure side of the transmitter, and the Torus atmosphere is connected to the low pressure side of the transmitter. For PTD-5067A, the Drywell atmosphere is connected to the high pressure side of the transmitter, and the Reactor Building atmosphere is introduced into the low pressure side of the transmitter. For PTD-50678, the Torus atmosphere is connected to the high pressure side of the transmitter and the Reactor Building atmosphere is introduced into the low i pressure side of the transmitter. i i
instruments PID-5067A (from PTD-5067A), PID-5067B (from PTD-50678), and PID-5021 (from PTD-5021) provide indication in the Main Control Room, provide no automatic control function, and are governed by Technical Specification 3/4.2.F (surveillance instrumentation). Table 4.2.F specifies these instrurnent channels be checked once per shift and calibrated once per 6 (six) months. The instrument checks j are performed via procedure 2.1.15, " Daily Surveillance Log" The instrument calibrations are performed via procedure 8.M.2-6.2, "Drywell and Torus Pressure / Temperature Readout" Transmitter PTD-5021 is located on Panel C-88 approximately 18"-24" above floor level. The low pressure side of PTD-5021 has two test plugs one of which is removed '
for a calibration. The plug that is removed for a calibration is located on the bottom surface of the transmitter's manifold and, as such, is not readily visible without crouching or significant body adjustment. -
Transmitters PTD-5067A and PTD-5067B are also located on Panel C-88.
Transmitters PTD-5067A and PTD-50678, however, are located side-by-side and approximately five feet above floor level. Moreover, since these transmitters measure Drywell atmosphere pressure and Torus atmosphere pressure relative to Reactor '
Building atmosphere pressure, one of the low pressure side plugs on PTD-5067A and one of the low pressure side plugs on PTD-50678 are not installed during operation. >
This configuration is different from that of PTD-5021 which requires both low pressure side (Torus atmosphere) plugs to be installed during operation.
Transmitter PTD-5021 did not have calibration valves consistent with most other transmitters and pressure switches installed in other applications. 7 Transmitter PTD-5021 was not included in Procedure 8.M.1-33, " Instrument ,
Walkdown", which is performed to verify instruments are properly aligned prior to startup from extended outages. Procedure 8.M.1-33 was performed prior to startup (i.e., after November 22,1994).
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1 Bo: tan Edirn C;mp:ny Docket No. 50-293 l Pilgrim Nuclear Power Station License No. DPR-35 1 ENCLOSURE 1 (Cont'd)
The uninstalled test plug was not detected by instrumentation readings during the l November 29,1994 to December 28,1994 timeframe due to the fact the Torus '
atmosphere pressure is maintained at approximately Reactor Building atmospheric pressure. The instrument checks that compared PID-5067A and PID-5067B differential readings and PID-5021 readings were within specification even though the low pressure side of PTD-5021 was sensing the Reactor Building atmosphere pressure, instead of the Torus atmosphere pressure, because of the uninstalled test plug.
Moreover, the uninstalled test plug was not detected during plant tours because the plug was not readily visible due to its location. ,
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED Upon discovery, at approximately 1040 hours0.012 days <br />0.289 hours <br />0.00172 weeks <br />3.9572e-4 months <br /> on December 28,1994, of the uninstalled test plug on PTD-5021, the shift utility non-licensed I&C Supervisor was notified and a temporary, non-qualified, plug was installed. The I&C Supervisor notified the shift senior utility licensed operator (NWE) of the discovery, initiated a work document for replacement of the temporary plug, and wrote a Corrective Action Program document (PR94.9568) to document the discovery. Meanwhile, the NWE initiated a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Technical Specification 3.7.A.2.a/3.7.A.6 Limiting Condition for Operation (LCO) pending replacement of the temporary plug. Walkdowns of other similar instruments were initiated.
By 1646 hours0.0191 days <br />0.457 hours <br />0.00272 weeks <br />6.26303e-4 months <br /> on December 28,1994, the temporary plug was replaced with a qualified plug and the LCO was terminated. By 0300 hours0.00347 days <br />0.0833 hours <br />4.960317e-4 weeks <br />1.1415e-4 months <br /> on December 29,1994, the walkdowns of 12 similar instruments and 37 additional instruments were completed with no discrepancies identified.
Based on the results of preliminary calculations, the NRC Operations Center was ,
notified at 1756 hours0.0203 days <br />0.488 hours <br />0.0029 weeks <br />6.68158e-4 months <br /> on December 28,1994. Licensee Event Report 94-007-00 was 1 submitted to the NRC in accordance with 10CFR50.73 on January 27,1994.
Transmitters PTD-5021 and PTD-5067A/B were modified on February 2-3,1995. The modification included the installation of additional tubing, fittings, and valves to the drain / calibration ports of transmitters PTD-5021 and PTD-5067A/B. Procedure 8.M.2-6.3 was revised to address the modification.
Procedure 8.M.1-33 was revised (to Rev. 8) and issued on February 2,1995. The revision included the addition of a new attachment that included PTD-5021 and PTD-5067A/B. The revision included specific steps to verify the instruments' valves are in the normal (correct) position, similar to the revision of Procedure 8.M.2-6.2.
The response to Part 11 of the violation contains the related corrective steps taken and results achieved.
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Boston Edison Company D:cket No. 50-293 Pilgrim Nuclear Power Station License No. DPR-35 ENCLOSURE 1 (Cont'd)
CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS Eight other instruments having a primary containment pressure boundary that are required to be opened and/or closed for calibration purposes were identified for
- modification similar to the modification for PTD-5021 and PTD-5067A/B. The instruments are: PSH-5016, PS-5030, PISD-5040A/B, PS-5045, PT-9016, PT-9017 -
and PT-9046. The modification of these instruments is being tracked via LER 94-007- !
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The response to Part ll of the violation contains the related corrective steps that will be ;
taken to avoid further violations. .
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED l Full compliance was achieved by 1646 hours0.0191 days <br />0.457 hours <br />0.00272 weeks <br />6.26303e-4 months <br /> on December 28,1994, when the 24-hour LCO was terminated following replacement of the non-qualified test plug with a i qualified test plug.
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Bost:n Edison C:mp;ny Docket No. 50-293 l Pilgrim Nuclear Power Station License No. DPR-35 ENCLOSURE 2 ,
1 NOTICE OF VIOLATION l During an NRC inspection conducted between December 7,1994 and January 17, 1995, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, the violations are set forth below:
II. TS 6.8.A requires the proper implementation of procedures recommended in Appendix A to Rc;ulatory Guide (RG) 1.33.Section I.d of Appendix A to RG 1.33 recommends establishment of procedures for procedural adherence.
Procedure 1.5.17, " Conduct of Maintenance", Section 6.9 (Adherence to Procedures) states, in part, " approved written procedures and instructions shall be strictly adhered to" Procedure 8.M.2-6.2, "Drywell and Torus Pressure / Temperature Readout Field Transmitters", Attachment 2, Step 4.e.2, states, in part, that the transmitter must be restored following calibration by reinstalling the test plugs and that a double verification that the plug had been properly installed, must be performed.
Contrary to the above, on November 22,1994, instrument and Control technicians failed to follow Procedure 8.M.2-6.2, in that:
A. The test plug for drywell to torus differential pressure transmitter, PTD-5021, was not replaced following calibration.
B. The I&C technician failed to perform the required double verification following restoration of the transmitter PTD-5021. (01023)
This is a Severity Level ill problem (Supplement I).
REASON FOR THE VIOLATION The reason for the violation was inattention to detail on November 22,1994, when PTD-5021 was calibrated and when the calibration procedure was reviewed and signed. Specifically, the re-installation of a low pressure test plug on PTD-5021 was not completed properly, a procedure step for double verification that the plug was re-installed was missed, a supervisor review of the completed calibration procedure did not detect or identify the missing double verification, and a shift utility licensed operator (Nuclear Watch Engineer) review of the completed procedure did not detect or identify the discrepancy.
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Scnon Edison Comp:ny Docket N2. 50-293 Pilgrim Nuclear Power Station License No. DPR-35 ENCLOSURE 2 (Cont'd)
Procedure 8.M.2-6.2 (Rev. 21) Attachment 2, "Drywell and Torus Pressure Readout l Field Transmitters," step contained steps for isolating PTD-5021, connecting test equiament, calibrating P -5021, removing the test equipment, and returning PTD-502' to service. The procedure was used to calibrate PTD-5021 on November 22, 1994. As peMf returning PTD-5021 to service, the test plugs that are removed from the manifold d PTD-5021 for the calibration were to be re-installed at substep (e)(2).
This step contains spaces for initials of the I&C Technician performing the step and the initials of another I&C Technician verifyir g the performance of the step. Based on investigation following discovery on December 28,1994, one of the low pressure side test plugs (i.e., the tost plug found not installed) of PTD-5021 was not re-installed at '
substep (e)(2). The double verification space for substep (e)(2) was not initialed. The I&C Supervisor who reviewed the completed procedure did not detect or identify the missing initials in the double verification space. The I&C Technicians and Supervisor indicated there was no sense of urgency or distractions that influenced their work. To his best recollection, the Technician who initiated substep (e)(2) recalled the re-installation of the plug. To his best recollection, the other Technician who did not initial the double verification space for the substep recalled the re-installation of the plug.
Panel C-88 vibration was considered and eliminated as a potential cause because it experiences negligible vibration. The uninstalled plug was not found in the vicinity of or on Panel C-88 during a search conducted following the discovery of the uninstalled plug. The re-installation of the plug could not be proved or disproved during the investigation. The I&C Supervisor focus during review of the calibration procedure was on the numerical values recorded during the calibration. The absence of initials in the double verificatior. srace was not detected or noticed by the Supervisor during the review, in part, bema of the focus. The utility licensed operator (Nuclear Watch Engineer) did not sect the discrepancy during review of the completed procedure because the sp9ce provided for identifying discrepancies, and located on the signature /signofi page for Attachment 2, indicated "none" Procedural deficiencies contributed to the plug not being re-installed during the calibration of PTD-5021 on November 22,1994. The calibration arocedure did not include specific information cautioning the I&C Technicians that t 7e test plug was a primary containment pressure boundary. The procedure substep (e)(2) for returning the transmittet to service was worded, " Install test plugs on transmitter", which required two actions to be performed in the same step. The space for the initials of the Technician who was to double verify the re-installation of the test plugs was located at the bottom of the procedure page and immediately above the area containing the procedure number, page number and revision number, where it could easily be overlooked.
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED Audits were conducied of completed surveillance procedures or surveillance type procedures performed by the I&C, Electrical Maintenance, Mechanical Maintenance, Operations, Radwaste, and Chemistry organizations. The audits were performed by personnel from the Quality Assurence Department and/or personnel in the noted organizations. The audits were completed and no discrepancies were identified that would have negatively affected operability or configuration control.
Bo t:n Ediscn C:mp:ny D:ck;t N150-293 Pilgrim Nuclear Power Station License No. DPR-35 i
ENCLOSURE 2 (Cont'd)
The Station Director and Plant Manager interviewed the two l&C Technicians who performed the calibration and the I&C Supervisor who reviewed the completed calibration procedure performed on November 22,1994. The other l&C Supervisors were also interviewed. The purpose of the interviews was to obtain the perspective of these, personnel regarding management expectations and barriers that may exist that could lead to events such as the uninstalled test plug. The information obtained revealed the method in place to identify and correct documentation errors at the worker level did not meet management expectations.
The Station Director, Plant Manager, and Maintenance Manager met with the I&C, Electrical, and Mechanical Divisions in the Maintenance section. At these meetings, the Maintenance Manager provided to each person a document clearly outlining the manager's expectations for maintenance personnel during their daily work. Moreover, at these meetings the Station Director and Plant Manager discussed .in detail the events that led to the uninstalled plug. The meetings included a lengthy discussion of the uninstalled plug and an open discussion with them regarding management expectations and accountability.
The l&C Technicians who performed the calibration, the I&C Supervisor and Nuclear Watch Engineer who reviewed the calibration of PTD-5021 on November 22,1994, received disciplinary action.
The frequency and extent of Maintenance I&C Division self-assessment type audits of completed I&C procedures was increased from once per six months to 100 percent per week. The results of these audits have been and are being reviewed at the weekly meetings of the I&C Technicians and Supervisors. The results-to-date indicate the -
corrective actions taken have been and are effective. The frequency and extent may be modifad as performance indicates.
An Operations Section standing order was issued requiring the Nuclear Watch Engineer (NWE) to perform a line by line verification of all steps of procedures requiring NWE signature. This order is an interim measure until revision of Procedure 1.3.34, " Conduct of Operations", and discussed in the next section, is approved.
A Maintenance Section standing order was issued requiring a Maintenance Supervisor to perform a pre-evolution briefing that includes a discussion of configuration control when a component has to be configured from its normal configuration. l Primary containment pressure boundary related instruments including PTD-5021 and PTD-5067A/B that, if breached, would not be detected by normal means of monitoring were tagged. This action was completed in January 1995.
Procedure 8.M.2-6.2 was revised (to Rev. 23) and issued on January 26,1995. The i focus of the revision was to add cautions regarding the re-installation of test plugs of PTC-5021 and importance relative to primary containment. The revision also ;
strengthened the steps for returning PTD-5021 to service. The revision included !
similar strengthening for PTD 5067A and PTD-50678. The procedure was performed 1 with satisfactory results on January 26,1995. l l
Boston Edison Company Docket No. 50-293 Pilgrim Nuclear Power Station License No. DPR-35
, ENCLOSURE 2 (Cont'd)
Procedure 8.M.2-6.2 was revised (to Rev. 24) and approved on February 2,1995. The focus of the revision was the modification of PTD-5021 and PTD-5067A/B that is discussed in the response to Part I of the modification.
Procedure 1.5.17 " Conduct of Maintenance", was revised (to Rev. 2) and approved on February 7,1995. The focus of the revision was to strengthen the requirements for adherence to procedures relative to surveillance procedure signatures, initiating, verification and independent verification.
Procedure 1.3.34, "Conduc.i of Operations", was revised (to Rev. 43) and approved on March 29,1995. The focus of the revision was to strengthen pre-evolution briefs by including a discussion for ensuring proper component configuration following a surveillance activity.
Procedure 8.M.2-6.2 was revised (to Rev. 25). The focus of the revision was to require independent verification (versus double verification) for component system restoration.
The revision is expected to be approved in early April 1995.
CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS Procedure 1.5.18 (currently Rev. 0), " Maintenance Section Performance Assessment Program" will be revised. The focus of the revision is to provide the flexibility to perform self-assessments in any program area at any time. The revision is expected to be approved in April 1995.
The calibration procedures of the 47 instruments that communicate with the primary containment atmosphere were evaluated. The focus of the evaluation was to determine if independent verification (versus double verification) should be performed when restoring the component / system to service. Based on the evaluation, eight procedures are being revised. The revisions are currently expected to be approved by the end of the 1995 Refueling Outage.
Longer term corrective actions resulted from the overall assessment of a violation in NRC Inspection Report 92-28 and related Quality Assurance Department findings, the portions of NRC Inspection Report 94-18 3ertaining to maintenance, and the Quality Assurance Department findings describec in NRC Inspection Report 94-26. These actions are in addition to the corrective actions related to the uninstalled test plug of PTD-5021. These actions include:
A matrix type monitoring system is being developed to monitor the performance of Maintenance Section craftsmen and supervisors. The matrix is expected to be in place by mid-April 1995. The system enables the effectiveness of the corrective actions to be monitored, provide feedback to these personnel, and adjustment as necessary.
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- Boston Edison Company Docket No; 50-293 .
Pilgrim Nuclear Power Station: License No. DPR 4 ENCLOSURE 2 (Cont'd) q
~ Peer reviews by su*rvisors have been initiated of 100 percent of surveillance procecures performed by the Maintenance l&C, Electrical, .
w and Mechanical Divisions. -The focus of the reviews is to provide i additional assurance the completed surveillance :rocedure contains the -l applicable data entries, check marks, initials, anc signatures prior to R
, . licensed operator review for signoff. These reviews will provide input into 1 the matrix tracking system. Based on experience, the peer reviews may . j be modified or eliminated as performance indicates.
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A Maintenance improvement Plan was developed and is being ;i implemented. The plan is broadl !
The plan includes the following: y focused and performance oriented. a 1
A multi-disciplined team was formed to design and implement a '
new work control process. The process is being designed to be - i more efficient, timely, and allows the supervisor to have more time r in the field The new process will be implemented following the i 1995 refueling outage. ;
Another team, the " Work It Now" (WIN) team, was formed. This
. team is multi-disciplined and assigned to selected emergent !
maintenance items and enhances the ability to complete work on - l schedule. The team began its function in March 1995. !
A INPO Supervisor Observation Training assist visit was completed on December 12-14,1995. The visit provided Maintenance i Section supervisors with enhanced observction techniques and ;j included the importance of observation at work locations. The visit j was one of a series of assist visits planned through 1995. These '
visits may continue thereafter as experience indicates. l
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The Station Director and Plant Manager have begun a mentoring program with the Maintenance Supervisors and in the Operations .
Section. This program will continue as experience indicates. ;
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A annual worker requalification process for maintenance - !
technicians and supervisors has been established. Annually, each j worker will be tested on base knowledge and the ability to use !
procedures at work locations. The process may be modified as expenence indicates 5
New Maintenance Performance Indicators were developed. The ~!
PMnt Manager and Maintenance Manager meet weekly to review 1 the indicatos and make adjustments if necessary. The frequency l of these meetings will be adjusted as experience indicates. !
A Peer Exchange Program is being developed. The program '!
provides for the exchange of personnel to/from other selected i o
power plants and from Pilgrim Station. These exchanges will be l implemented as experience indicates. '
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Boston Edison Company Docket No. 50-293 Pilgrim Nuclear Power Station License No. DPR-35
. ENCLOSURE 2 (Cont'd)
, r The closecut of all Quality Assurance Department deficiency reports will be reviewed during meetings with the Senior Vice President - Nuclear and the Quality Assurance Manager.
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' Monthly audits of 33 surveillance procedures perfo,rmed by the ,
Maintesnance I&C, Electrical, and Mechanical Divisions were initiated and
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are being performed. These audits are being performed by Senior ;
Nuclear Organization Managers. Based on experience, these audits may be modified or eliminated as performance indicates. ,
in summary, the Maintenance improvement Plan includes actions taken, actions being taken, and actions that may be modified or eliminated as experience or performance i indicates.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED As described in the response to Part I of the violation, full compliance was achieved on December 28,1994, when the qualified test alug was installed on the Drywell i atmosphere-to-Torus atmosphere differentia pressure transmitter PTD-5021. ,
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