ML20083B982
| ML20083B982 | |
| Person / Time | |
|---|---|
| Site: | Dresden, 05000349  |
| Issue date: | 05/05/1995 |
| From: | Joyce T COMMONWEALTH EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| TPJLTR-95-0052, TPJLTR-95-52, NUDOCS 9505150042 | |
| Download: ML20083B982 (15) | |
Text
,-
4.
' Commonwealth idison Company Drcuk n Generating $tation 6MM North Drexten lload Morris, IL 60450 Tel H15-912-2920 1
.i l
i May 5,1995 i
TPJLTR 95-0052 4
U.S. Nuclear Regulatory Commission Washington, D. C. 20555 Attention: Document Control Desk
Subject:
Dresden Nuclear Power Station Units 2 and 3 Responses to Notices of Violation; Inspection Report 237/95004; 249/95004 NRC Docket Numbers 50-237 and $0-249
Reference:
John B. Martin letter to Michael J. Wallace, dated April 5,1995 transmitting Notice of Violation and Proposed Imposition of Civil Penalty; NRC Inspection Report 50-237/95004; 249/95004.
E. G. Greenman letter to J. S. Perry, dated February 27,1995, transmitting Inspection Report 50-237/95004; 249/95004.
E. G. Greenman letter to J. S. Perry, dated February 2,1995, transmitting Inspection Report 50-010/94019; 50-237/94019; 50-249/94019.
Enclosed as Attachment 1 is Comed's response to the Notice of Violation regarding violation of Technical Specifications and Procedures, which was transmitted with Dresden Station - Units 2 and 3 Notice of Violation and Propud Imposition of Civil Penalty - (NRC Inspection Report Nos. 50-237/249/95004(DRP)). We do not contest your action to classify this matter as a Severity level III problem or the proposed civil penalty. Accordingly, enclosed is a check in full payment of the proposed penalty.
Adherence to procedures and other requirements is a strong area of focus and challenge at Dresden Station. Our performance in this matter was unacceptable.
1ECO.O he g 000 g,) OM ' fp #h, Ig[/k s
9505150042 950505 '
r PDR ADOCK 05000237 m95m2.95 G
PDR p
F
- r U.S.- Nuclear Regulatory Commission Page 2 As noted in your letter and detailed in Attachment 1, we are taking vigorous action in i
response to this matter. We continue to reinforce our expectations in this area' with our. workers in the field Reinforcement of procedure adherence expectations is also being demonstrated by immediate and thorough response to instances of deviation l
from requirements, and through our 1995 Focus Area action plans to improve.
Procedure Adherence. These efforts include steps to upgrade procedures by revising them when discrepancies or areas of vagueness are identified. We will continue reviewing our performance and improve formality of our oversight activities to completely correct this problem.
The requested response to Inspection Report 50-010/94019; 50-237/94019; 50-249/94019, associated with procedural adherence is included in Attachment 1, item 3.
If your staff has any questions concerning this letter, please refer them to Peter Holland,'Dresden Station Regulatory Assurance Supervisor, at (815) 942-2920, extension 2714.
Sincerely, l
f.
W Thomas.Jo ce Site Vice President l
TPJ/CM:pt 3
i Attachments: As described
{
cc:
J. Martin, Regional Administrator, Region III i
J. F. Stang, Project Manager, NRR (Unit 2/3) i P. B. Erickson, Project Manager, NRR (Unit 1)
M. N.12ach, Senior Resident Inspector, Dresden j
File: NRC Inspection Report 50-010(237)(249)/94019 NRC Inspection Report 50-237(249)/95004 l
l l
l f
TPJ95WOS2.95
ATTACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 VIOLATION: (50-237/249-95004) 1.
Technical Specification (TS) 3.7.A.2 requires that primary containment be maintained at all times when the reactor is critical. TS 3.7.A.2.b(2)(a) requires that when primary containment integrity is required, primary containment leakage rates be limited to a combined leakage rate of less than or equal to 60 percent of L, for all testable penetrations and isolation valves subject to Type B and C tests.
Contrary to the above, between January 6 and February 3,1995, with the Unit 3 reactor critical, primary containment integrity was not maintained. The primary containment boundaries on valves 3-1601-31 A & B were broken for surveillance testing on January 6 and local leak rate testing was not performed. When the boundaries were tested on February 3, the licensee determined that the combined leakage rate exceeded 60 percent of L, for all testable penetrations and isolation valves subject to Type B and C tests. (01013)
REASON FOR VIOLATION:
An investigation of this event revealed that a previous method for testing (DOS 1600-13 rev 2) the 3-1601-31 A(B) vacuum breaker, a split body style tilting disk check valve made by Crane / Chapman, involves use of a removable arm (Special Rotating Tool) to manually operate the valve. Prior to manual operation, a flange is removed allowing the removable arm to be inserted into the hinge pin. After cycling the check valve did the arm is removed and the flange replaced and bolting tightened down.
This flange ieeps leakage from around the hinge pin contained. This flange is part of primary comainment.
In 1987, an On-Site review of a procedure revision (rev 3) to Dresden Operating Surveillance (DOS) 1600-13, Suppression Chamber To Reactor Building Vacuum Breaker Full Stroke Exercise Test For 2(3)-1601-31 A and B, concluded that the hinge pin flanges were not part of primary containment and as such no LLRT was required as part of the surveillance.
During an investigation into Torus to Reactor Building vacuum breaker LLRTs (February 1990) it was concluded that the 1987 On-Site Review had been incorrect in their determination that the flange was not part of primary L:\\B360\\8301\\NRC\\RESIONSB950N
i.
A'ITACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
REASON FOR VIOLATION:(continued) containment. In addition, DOS 1600-13 did not contain adequate instructions to verify proper installation of the flange. As a result, DOS 1600-13 was revised to use the vacuum breaker's maintenance access ports, which are upstream of the check valve and allow access to the valve disk, to perform the operability surveillance. This eliminated the need for the LLRT.
However, DOS 1600-13 (rev 8) (Note: revision 8 to DOS 1600-13 was for minor typographical changes) instructs the user to remove the inspection plate upstream of the vacuum breaker 3-1601-31 A(B). The terminology used in the procedure conflicts with labeling in the field. The field labeling of the port is " access door for check i
valve". In addition, the hinge pin flange (shaft cover) could be mistaken for being upstream of 3-1601-31A(B) and DOS 1600-13 does not state how far the inspection plate is upstream of the vacuum breaker. The surveillance procedure gives no descriptive details about either the Special Rotating Tool (old tool) or the Special Extension Tool (new tool). These names are vague enough to allow either name to be assigned to the removable arm.
i The Operations Scheduler gave the Unit 3 Field Supervisor the Special Rotating Tool (old tool). The Field Supervisor then gave the tool to the B operator. No information l
provided in the procedure would have alerted the B Operator to this error. Based on j
the B Operator's experience of performing this surveillance using the previous method and being provided the old tool, he read and performed the procedure using the previous method, which does not obviously conflict with DOS 1600-13 under revision
- 8. In order to perform DOS 1600-13 using the new method, an individual would have to be familiar with the new methodology of testing to know what the non-descriptive terms in the procedure mean. Neither the Operations Scheduler, Field Supervisor, or the B Operator had received training on the new method.
Previous surveillances were conducted with or by the IST Engineer who was familiar with the changes made to DOS 1600-13 and the new method used for testing. The access port is outside of primary containment and allows for cycling of the vacuum breaker valve disk with a wooden " broom handle" (Special Extension Tool). In addition, no LLRT was performed because it was not recognized by the B Operator that he had disturbed primary containment and e.e DOS 1600-13 documentation would not have alerted the performer or reviewer that the wrong access port was opened, thereby violating the primary containment.
L:\\8360'8301\\NRCRESPONSIE950M
ATTACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
REASON FOR VIOLATION:(continued)
The root cause of this event is the use of an inadequate surveillance procedure. A contributing cause was the lack of training given to Operations Department personnel following the procedure revision.
1 CORRECTIVE STEPS TAKEN AND RESULTS ACIIIEVED:
In order to verify that the inboard Torus to Reactor Building Vacuum Breaker Butterfly Valves 3-1601-20A and 3-1601-20B were still performing their functions as Primary Containment Isolation Valves, the valves were challenged with an LLRT.
The LLRT yielded acceptable leakage rates.
Dresden Operating Surveillance (DOS) 1600-13, Suppression Chamber To Reactor Building Vacuum Breaker Full Stroke Exercise Test For 2(3)-1601-31 A and B, was then performed to demonstrate operability of the tilting disk check valve vacuum breakers.
i CORRECTIVE STEPS TAKEN TO AVOID FURTIIER VIOLATION:
DOS 1600-13 has been revised to improve procedure clarity.
l Training concerning these procedural changes will be given to Operations Department personnel during continuous training.
Field labeling has been modified to be consistent with the procedure enhancements.
All Operating Department IST Surveillances have been reviewed to ensure the procedure steps are clear and appropriate. The procedures will be revised as necessary to ensure any special equipment or support is clearly delineated. These revisions will be completed by July 31,1995.
LA8360\\830hNRC\\R13PONSD950fM
l,"
ATTACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
C_ORRECTIVE STEPS TAKEN TO AVOID FURTIIER VIOLATION:(continued)
The process for determining which Operations Department procedure revisions are included as continuous training topics will be evaluated and strengthened where appropriate. This action will be completed by July 31,1995.
i This incident was tailgated to station personnel.
DATE WIIEN FULL COMPLIANCE WILL BE ACIIIEVED:
{
Dresden Station is currently in compliance with the referenced Technical Specification.
Corrective actions to prevent recurrence continue and are scheduled to be completed by July 31,1995.
i 12\\83(28301\\NRC\\RIEPONSm95004 t.
ATTACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
VIOLATION: (50-237/249-95004) 2.
TS 3.6.H.5 requires that an idle recirculation pump shall not be started unless the temperature differential between the reactor vessel steam space coolant and the bottom head drain line coolant is less than or equal to 145'F. TS 4.6.H.5 requires that this differential be determined to be within the limits within 15 minutes prior to startup of an idle recirculation loop.
Contrary to the above, on January 10,1995, the 2B recirculation pump was started in an idle loop without determining within 15 minutes prior to startup that the temperature differential between the reactor vessel steam space coolant and the bottom head drain line coolant was less than or equal to 145'F. (01023)
REASON FOR VIOLATION:
An investigation of the 2B recirculation pump event identified the following issues:
A knowledge deficiency existed in that the licensed operators who participated in this event believed that the requirements of the technical specification were being met.
The preliminary G.E. analysis concluded that the 145 degree F temperature difference i
was not exceeded. However, the operators had no way of definitively measuring the temperature of the bottom head drain line coolant prior to starting the recirculation pump.
Acceptance of low station standards in procedural / technical specifications quality, adherence and change implementation resulted in procedures that could not be followed as written, vague procedural guidance which allows non-compliance with procedures under certain conditions, and at least one procedure that does not satisfy technical specifications requirements. Training on procedural changes consisted primarily of a required reading program of questionable effectiveness.
The operations team decision to restart the 2B pump was non-conservative. The crew recognized that the Technical Specification, applicable procedures, and plant i
1 L:\\t360t830lWRGRI5PONSC\\950(4
A'ITACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
REASON FOR VIOLATION:(continued) configuration were not in agreement, but used poor judgement in continuing with the restart of the 2B recirculation pump using alternate methods and without pursuing additional guidance.
The reactor vessel drain line is clogged, and has been for many years.
The engineering review of the procedure change which allowed the use of the reactor bottom head metal temperature to meet the requirements of G.E. SIL 251 (the document discussing idle recirculation pump start issues) when the drain line became unavailable was inadequate.
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED:
The Shift Operations Supervisor informed operating team members via the Operations Orders that the units will be shut down if a recirculation pump trip occurs until there is consistent documentation to support restart of an idle recirculation pump.
The Unit 2 Operations Manager discussed the event with the Operations Management Team involved and coached them on conservative decision making. The team now understands that the decision to restart the 2B recirculation pump under these circumstances was non-conservative.
Each Shift Manager and Unit Supervisor has signed a statement that they understand that literal compliance with Technical Specifications is required except under emergency situations defined by 10CFR 50.54(x).
An Operations Standing Order has been issued to prohibit restarting an idle recirculation pump while operating.
Dresden has evaluated short-term actions for the plugged bottom head drain lines.
Because of the high cost and high radiation exposures expected, Dresden has dec! -d not to pursue unplugging the drain line on Unit 2 in D2R14. Dresden is evaluating long-term alternatives, including alternative idle recirculation pump starting criteria and improved bottom head drain line cleaning methods.
l 1A8360.8301\\NRCMWSPONSD9hX4 1
.~
ATTACHMENT 1 EESPONSE TO NOTICE OF VIOL ATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
CORRECTIVE STEPS TAKEN TO AVOID FURTIIER VIOLATION:
A team has been assembled to review the technical specifications and procedures involving technical specifications with the intent of determining other inconsistencies similar to those existing in this event. In addition, the team will review training i
conducted on recent technical specification amendments to determine what additional operator training is necessary. These actions will be completed by September 14, 1995.
An engineering evaluation was completed which determined that Technical Specification 3.6.H.5 cannot be complied with when the reactor vessel bottom head drain line is clogged. Another engineering evaluation is underway to determine alternative idle recirculation pump start criteria with a clogged drain line. The findings of this evaluation will be utilized to determine subsequent actions. This evaluation will be completed by July 1,1995.
Senior station management has reinforced to the Shift Managers that their primary roles are the overview of plant operations, ensuring compliance with safety requirements and operational standards, and reinforcing the importance of conservative decision making. The Shift Managers have been trained on these roles by senior station management and their effectiveness in meeting these expectations will be continuously evaluated.
The Operations Department Core Team will continue to evaluate and improve operational standards, with emphasis on the importance of conservative decision making.
The Technical Specification amendment review and implementation process will be revised to include an operational readiness review to ensure that the proposed amendment is operationally feasible. Formal training will be provided prior to technical specification implementation.
Conservative Decision Making Seminars have been conducted for all Licensed Operators. These seminars provided the definition of conservative decision making and the importance of the issue in light of selected operational experience reports, especially SOER 94-01.
L:\\Ufe.001\\NRCNRr5PONSE950N
ATTACHMENT 1 RESPONSE TO NOTICE OF VIOLATION i-NRC INSPECTION REPORT 50-237(249)/95004 1
(Continued)
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Dresden Station is currently in compliance with the referenced Technical Specification.
Corrective actions to prevent recurrence continue and are scheduled to be completed by September 14, 1995.
L:\\83Mh830hNRC'JtESPONSEi95004
A'ITACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
VIOLATION: (50-237/249-95004) 3.
10 CFR 50, Appendix B, Criterion V, "Instruaions, hxedures, and Drawings,"
requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
a.
Contrary to the above, as of January 6,1995, Dresden Operating Surveillance (DOS) 1600-13, " Suppression Chamber to Reactor Building Vacuum Breaker Full Stroke Exercise Test," Revision 7, approved September 24,1992, an activity affecting quality, was not appropriate to the circumstances.
Specifically, Steps I.2.b and I.2.d were not sufficient for an operator to locate and remove the access plate outside the primary containment boundary prior to cycling check valves 3-1601-31 A & B. (01033) b.
Dresden Operating Abnormal (DOA) 0202-01, " Recirculation Pump Trip - One or Both Pumps," Revision 10, approved December 20,1994, Step D.12 states, "If idle loop starts are not planned within one hour, then isolate seal purge flow to the idle loop per DOP 0202-11." This is an activity affecting quality.
Contrary to the above, on January 10,1995, the 2B recirculation pump tripped and was restarted 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 22 minutes later without isolating seal purge flow to the idle loop. The start of the idle loop was not planned within one hour of the 2B recirculation pump trip. (01043) c.
Contrary to the above, as of January 10, 1995, Dresden Operating Procedure (DOP) 0202-01, " Unit 2 Reactor Recirculation System Startup," Revision 14, approved December 22,1994, Step G.10, an activity affecting quality, was not appropriate to the circumstances in that it did not accurately reflect the requirements of TS 3.6.H.5 and 4.6.H.5. TS 3.6.H.5 and 4.6.H.5 require a determination within 15 minutes prior to starting a second recirculation pump that the temperature differential between the reactor vessel steam space coolant and the bottom head drain line coolant is less than or equal to 145*F.
However, Step G.10 of DOP 0202-01 required, in part, that if starting a second recirculation pump, then within 15 minutes of starting the pump verify that the bottom head thermocouple temperature is within 145 degrees of the steam space temperature. (01053)
L\\l560\\8301\\NRCNRESPONSE\\93004
k.
A'ITACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
REASON FOR VIOLATION:
3.a,b&c Dresden Station has experienced errors and events as a result of inadequate procedure adherence. The three instances of procedure problems cited in the Notice of Violation are examples of a general site wide issue that requires attention. Analysis of procedure non-compliance events over the last two years indicates the expectation for literal procedure compliance has not been effectively communicated and reinforced. This has resulted due to varying degrees from perceived schedule pressures, contradictory administrative guidance, some inaccurate procedures, a cumbersome procedure change process, material condition weaknesses, and the failure of supervisors to correct poor procedure compliance decisions.
In order to be effective in correcting this problem throughout the entire site, a project team was assembled consisting of numerous department personnel at all levels of management and union. The team evaluated previous studies, investigations, findings, violations and corrective actions in addition to interviewing nearly forty workers to be able to clearly assess the cause of the inadequate procedure adherence culture at Dresden. The analysis of SQV's Field Monitoring Report (FMR) data, Discrepancy Reports, and PIF data over the last two years indicated that sixty percent of the occurrences are caused by
" Rule-Based Errors". These are errors where individuals make intentional decisions due to habit, previous acceptance, or interpretations of intent. The project team reviewed a number of other nuclear site programs for procedure process enhancements and adherence improvement corrective actions.
Past corrective actions have addressed symptoms of procedure non-adherence, and not the underlying causes. This approach has led to fixing the process (i.e., Procedure Upgrade Program ), but failed to engage the workforce on the importance of the issue and the need for change. This issue was fostered by inadequate management communication and reinforcement of expectations to workers The result was an ineffectiveness at improving performance / behavior standards of our workforce, which had not significantly changed in several years.
F 138360\\8301\\NRCR13PONSih95008 1
l ATTACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
CORRECTIVE STEPS TAKEN AND RESULTS ACIIIEVED:
A station standdown was initiated in February, stopping work to discuss with employees the importance of adhering to procedures. Specific recent examples of procedure non-compliance were highlighted during these sessions for personnel to understand the breadth of the issue.
Site Quality Verification analyzed 1994 procedure adherence data and identified that 60% of these problems were due to personnel believing tha', procedure adherence meant meeting the " intent" of the procedure. This information was provided to the Procedure Core Team.
A Procedure Core Team consisting of all levels of workers and departments was assembled to identify and take near term actions to address the problem.
The results of this team set the groundwork for the actions taken for the site regarding procedure adherence.
A new procedure DAP 09-15, ' Interim Procedure and Revision Processing, has been developed and implemented which provides the ability to change procedures in a quicker fashion. This removes a barrier to fixing and utilizing proper procedures at all times.
The Operat ons Manager provided specific guidance to the Shift Managers and Operating crews on determining when a procedure is necessary.
Conservative Decision Making Seminars have also been conducted by the Comed BWR VP for all Station Senior Management, r.nd a similar seminar has i
been provided to licensed operators.
I 1.:\\B360\\8301\\NRCiRESPON5th95(K4 1
i 5
ATTACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued) i CORRECTIVE STEPS TAKEN AND RESULTS ACillEVED:(continued)
Simulator Training has been conducted for all Licensed Operators emphasizing Single Loop Operations and utilizing SOER 94-01 recommendations for conservative decision making.
)
Regulatory Training emphasizing technical specifications, reportability, 10CFR50.54(x) and other pert nent regulatory issues will be provided to all Licensed Operators during an upcoming training cycle. This training is scheduled to be completed by June 9,1995.
CORRECTIVE STEPS TAKEN TO AVOID FURTIIER VIOLATION:
To clearly and concisely set the standard for procedural adherence, DAP 09-of M.}tocedure Use and Adherence' has been revised to provide a descri 13,'I hagement's expectations for procedural compliance. Definitions, explanations, and examples of proper adherence, strict requirements, and a detailed explanation have been added.
To en:ure employees understanding of the new standard for procedure
{
adherence, training was conducted for all employees. This training was j
accomplished in a unique manner in that the material was cascaded from the top down -- senior managers were trained, the senior managers then trained the department heads, contractor supervisors, and shift managers, who train their supervisory personnel, and their individual workers. Training in this manner demonstrates their supervisor's commitment to procedure adherence at all levels.
L:\\t%D\\B301\\NRO RCSPONSIB930l4
i i
ATTACHMENT 1 RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 50-237(249)/95004 (Continued)
CORRECTIVE STEPS TAKEN TO AVOID FURTHER VIOLATION:(continued)
Procedural Adherence has been added as one of Dresden Station's Focus Areas. Use of Focus Areas has been an effective means for the station to improve certain areas by maintaining a high level of intensity to improve.
Action plans have been written to address the identified weaknesses regarding procedure adherence. Performance indicators are tracked and reviewed by senior management routinely.
Senir,r Management engages the work force in the plant on a daily basis. They
[
now report th& findings regarding procedure adherence. This process of l
engag'cg the work force has shown good results in ensuring the workers know that procedure adherence is an absolute expectation.
Dresden has initiated a station policy which records procedure adherence violations in the personnel file of the worker. Depending on the nature and circumstances of the violation, appropriate discipline is then applied.
l t
DATE WIIEN FULL COMPLIANCE WILL BE ACIIIEVED:
Dresden Station has corrected the identified violations and the affected items are currently in compliance. Corrective actions to prevent recurrence are continuing.
An effectiveness review of these corrective actions will be completed by October 31,1995, to determine the appropriateness of the actions in preventing recurrence.
The Station will keep the NRC Resident Inspector informed of the corrective action progress.
L:\\836(h8301\\NRC',RESPONSD950N