ML20086F575
| ML20086F575 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 11/27/1991 |
| From: | Kovach T COMMONWEALTH EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9112030290 | |
| Download: ML20086F575 (4) | |
Text
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- 4) 1400 Opus Place nowners Grove, Illinois 60515 November 27, 1991 U.S. Nuclear Regulatory Commission Attn:
Document Control Desk Hashington, DC 20555
Subject:
Quad Cities Nuclear Power Station Units 1 and 2 Response to Notice of Violation Inspection Report Nos. 50-254/910h ; 50-265/91016 NRC Docket Numbers 50-254 and 50-265
Reference:
E. Greenman letter to C. Reed dated November 1st transmitting NRC Inspection Report 50-254/91020; 50-265/91016 Enclosed is Commonwealth Edison Company's (CECO) response to the Notice of Violation (NOV) which was transmitted with the reference letter and Inspection Rep t.
The NOV cited one Severity Level IV violation.
The violation regm ds the effectiveness of previous corrective actions.
CECO's response is provided in the attachment.
If your staff has any questions or comments concerning this letter, please refer them to Denise Saccomando, Compliance Engineer at (708) 515-7285.
Very truly your,
/
/-
/
T Vach Nuclear LicpdIing Manager Attachment cc:
A. Bert Davis, NRC Regional Administrator - RIII L. 01shan, Project Manager - NRR T. Taylor, Senior Resident Inspector - Quad Cities 3 [ f$ kk N N Q4 l
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ZNLD/1339/4 ll /
RESE0NSLIO NOIICLOLYl0LA110N 50-254/91020; 50-265/91016 Y10Lal10N~
10 CFR 50, Appendix 8. Criterion XVI states, in part, that in the case of significant conditions adverse to quality, measures shall be established to e
assure that the cause of the condition is determined and' corrective action taken to preclude repetition, Contrary to the above, the licensee failed to assure that some of the causes of an October 27, 1990, unplanned reactor scram and a January 24, 1991, loss of reactor vessel 1nventory events, significant conditions adverse to quality, were determined and corrective action taken to preclude repetition.
Specifically, on September 18, 1991, a Nuclear Station Operator (NS0) again failed to be attentive to control panel indications and the Shift Control Room Engineer again failed to be cognizant of plant conditions and NSO activities as. required by procedures.
The Unit 2 "B" inboard main steam isolation valve had failed closed and the effects on key plant parameters went unnoticed for about 3-1/2 hours.
REASON 10RlI0LAUON On September 18, 1991 the normal shift 3 operating crew was augmented by four license trainees.
Early in the shift, the Unit 2 Nuclear Station Operator (NS0) was conducting an on-the-job evaluation (0]E) of a trainee.
At 1805, the inboard "B" main steam isolation valve steam separated from the main disc, thereby, allowing the main. disc to drop and restricting the flow in the "B"
This restriction resulted in the sudden increase in reactor pressure from 984 psig to 1018 psig.
Reactor power spiked causing the Average Power Range Monitor (APRM) to momentarily increase, the turbine throttle pressure control valves momentarily closed and the main steam line flow indication for the "B" line decreased to almost 0 mlbs/hr, The transient did not result in any parameter reaching an alarm setpoint, therefore no alarms were received.
At the time of the event the-Unit 2 NSO was conducting OJE of a trainee.
At 1906 the Unit 2 Diesel Generator was declared inoperable and Limiting Condition for Operation 3.9 E.1 was.enterea which required the initiation of several surveillances involving, the 1/2 Diesel Generator, the low pressure cor. i.coling system and loops of the-containment cooling modes of the Residual Neac Removal system associated with the operable diesel generator.
The surveillance of the 1/2 Diesel Generator-was assigned to the extra NSO and the' core spray and RHR surveillances were assigned to the Unit 2 NSO.
At 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> the surveillance commenced.
The trainee's performance of the surveillances were overviewed by the NS0s. At 2115 the extra NSO was reassigned to Unit 2 tc support performance of instrumentation surveillance at
- which time he observed the spi.kes on the APRM recorders.
Ine cause of the spike was investigated through the review of drawings and control room indications.
At 2i45 the cause of the APRM spike was determined to be a problem with the "B" Main Steam Line.
The investigation revealed that the delay in the identification of the event was due to ineffective monitoring of Control Room parameters by the NSO and the Operating crew.
The NSO may have focused too much attention on the-activities of the-trainees, although at tho time believed that he was properly monitoring plant parameters. Additionally, minimum acceptable standards which define the appropriate frequency and critical parameters to be monitored on the control room panels had not been formally established.
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- CQRREflIVE_SIEESlHALBAVLBEELTAKENELulE_RESULISlCRI EYE 0 After determining that the APRM spike was due to a problem with the "B" Main Steam Isolation Valve, the station initiated a reactor shutdown.
The 28 MSIV was closed at_0000 hours on September 19th to ensure the "B".'MSIV was isolated per Technical Specification requirements.
The process of determining the cause of the HSIV failure began _after cold shutdown was achieved.
An investigation team reviewed not only the technical failure bm also the performance of the operating crew.
As a result of'that investigation Quad Cities station has taken corrective actions which incit 9 outlining minimal acceptable standards for panel attentiveness and management's expectation for control room supervision.
On September 28, 1991 Operating Memo 91-5, " Guide for Control Room Panel Attentiveness" was issued.
It details the frequency of panel observation and the minimum plant Indicators which should be checked during routine operation, shutdown conditions and start up/ shutdown conditions.
Panel attentiveness after panel manipulation and during OJT/0JE is also addressed.
Additionally, Operating Memo 91-6, " Guide for Control Room Supervision" was issued.
This memo clearly outline's expectations for the supervision and control of work in the control room.
The Senior Control Room Engineer (SCREs) supervisory responsibilities, guidance on OJT/0]E, along with turnover protocol are among the-issues addressed, To ensure that all operating crews were aware of management's expectations
- training was provided to all operating personnel on this event and the associated memo before the startup of Unit 2.
CORRECIIYLSIEESlHAIJI LL D LIAKELT0_AV0lD_EURIllERE0LAIION S i
As a result of the September 18, 1991 event the station recognized the need to further gain additional feedback on operator's performance in the control
. room.
The operating department overview program was enhanced with interim
. augmented control room overviews.
The first phase of the augmented program consists of two 10 hour1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> daily overviews conducted for-14 days by senior station and operating-management. Overviewers concentrated their observations on NSO panel awareness and the SCRE's control of activities.
They ensured
. compliance with Operating Memos 91-5 and 91-6 while soliciting input for future revised improvements of the memos.
Feedback to the observed crew was given immediately and deficiencies were corrected.
The overview results were l~
documented and reviewed for common trends.
In mid-October, the second phase (two 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> daily overviews) of the augmented program began and continued for 6 additional weeks.
Initial feedback from those conducting the reviews indicate that operating personnel are meeting management's expectations and-are aware and-complying with the operating memos.
Additionally, the overviews
-have been beneficial because the immediate feedback provided to the individual acted as a catalyst for additional communication between management and operating personnel. A comprehensive-review of the overview programs results is expected to be completed before-January 1,'1992.
The results of this review will be incorporated into a revision of Operating Memo 91-1 which is expected to be completed by January 1. 1992.
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CGRB ECILV E_SIEELT H AIJ!AV E_D E EILIAKM _AND_lB ele SU LIS_AC H I EV E QlCon tin u ing l After reviewing the preliminary results of the augmented overview program findings, senior operating management realized the need to incorporate the existing overview program into an ongoing Coaching / Monitoring Program.
This program, to be detailed in the Operating Memo 91-1 revision 3, will encourage immediate feedback to personnel and open discussion between operating personnel and the individual performing the monitoring.
Guidance will be provided to management on the frequency of control room overviews.
Documented observations will be summarized and reviewed monthly by the Assistant Superintendent of Operating.
Based upon the results of the observations, the program will be enhanced as necessary.
lhis program is expected to commence with the isoiance of the revision to the operating memo.
All licenseo, nonlicensed operators and operating management are currently attending Monitoring / Coaching training.
This training reinforces management's expectations of procedural adherence, compliance with safety and radiation protection policies along with panel attentiveness and control room decorum.
Students receive instruction on the station's self check process along with an explanation of the intent of the operating department's Coaching / Monitoring Program.
This training is expected to be completed by January 1, 1992.
Starting the week of September 30th offsite Nuclear Quality Programs (NQP)
Conducted a weekly 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> overview of control room personnel for eight weeks.
Feedback was provided to the Assistant Superintendent of Operating during weekly debriefs and generally indicated that control room panel attentiveness has improved and personnel were in compliance with the issued operating
- memos, Results of NQPs overview will be locorporated into operation's Coaching / Monitoring program.
RAIE_WREtLERL L_CQMP LI ANC L HI L L 6L ACH I EV ED Full compliance was achieved with the issuance of operating memos 91-5 and 91-6 on September 28, 1991.
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