ML20086P988
| ML20086P988 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 12/18/1991 |
| From: | Shelton D CENTERIOR ENERGY |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 1-968, NUDOCS 9112270309 | |
| Download: ML20086P988 (10) | |
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Y DoneW C. Demon ll00 Madson Avenue VceP W Nxleaf W2, OH NW i
i Davis Beste NW Docket Number 50-346 License Number NPF-3 Serial Number 1-968 December 18, 1991 P
United States Nuclear Regulatory Commission Document Control Desk Vashington, D. C.
20555 Sul'j ec t :
Response to Inspection Report Number 50-346/91017 i
Centlement Toledo Edison (TE) has received Inspection Report 91017 (Log Number 1-2559) and provides the following response. The due date for this esponse was extended to December 18, 1991 per discussions with the Senior Resit*ent Inspector and the Region III-staff on December 4', 1991.
Requirement Technical Specification 6.8.1 requires that written procedures:be developed and implemented for activities listed in Regulatory Guide 1.33 -Appendix A.
Regulatory l
Guide 1.33, Appendix A lists among other. things, activities such as refueling operations and surveillance
- testing, Contrary-to the above, examples of the licensee's' failure to develop or implement procedures described in Appendix A of Regulatory Guide 1.33 are shown belovt Violation:
91017-OlAt Procedure DB-0P-06023 Revision 1, " Pill, Drain, and Purification'of the Refueling Canal," Attachment 3, Step 6.D requires that.DH93 be shut. This procedural requirement was not implemented on September 20, 1991, vhen refilling _the refueling canal and incore instrument tank in_that DH93 was open.
Responset Acceptance or Denial of the Alleged Violation 1.
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- Toledo Edison acknowledges the alleged violation.
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This violation resulted fron personnel error.
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Valve DH43, Incore Instrument Tank Drain Valve to the Nermal Sump, was out of its normal position (cloced) for aproximately six hours on September 20, 1991. The prinary reason fur DH93 being out-of-position was failure of personnel to properly verify valve position.
Existing procedures and policies, if followed, contain the necessary safeguards to preclude such an eveut.
i On September 17, 1991, the refueling canal and incore instr" men
- tank vas being filled in preparation for refur!!ng.
- 1uring this evolution,. seal leakage from the reactor vessel head flange was noted.
Between September 17 to Saptember 20, valve DH93 was opened and closed a number of times to fill and drain the incore instrument tank as part of the troubleshooting effort to repair the reactor vessel flange seal.
During this time patriod, the status of valve DH93 was not adequately updated in the Control Room system statue file.
At approximately O L acurs on September 20, 1991, Control Room personnel noted that the status of certain valves was questionable bared vpon a review of tha system statua file. The Shi f t ?npervisor directed an Asristant Shift Supervisor
.o perform valve position
. valves (which included DH93) in veritication of t <
preparation for filling the refueling canal and incore ins t rt. ment tank. The SSA proceeded to perform this task.
by applying force to the manual valve operator for DB93 in the closed direction.
He did not check the valve position indicator for DH93 and reported completion of the task to the Control Room personnel.
At 1005 hours0.0116 days <br />0.279 hours <br />0.00166 weeks <br />3.824025e-4 months <br />, after shift turnoser, filling of the refuelisg canal and incure instrument tank began.
Control Room personnel noted an increase in containment normal suttp level, which is indicative oC refueling canal leakage. N t:ontrol Room Senior Reactor Operator (SRO) contacted a Reactor Operator in containment, and directed him to again verify DH93 closed.
The Reactor Operator reported back to the Control Room within mirutes, stating that DH93 had been open but was now closed.
The SSA responsible for verifying that DH93 was closed erred. Valve DH93 is ruanurlly operated with a T-handle that extends above a deek grating; position indication is provided under the da k grating. The SSA applied what he
- Docket Number 50-346 License Number NPF-3 Scrial Number 1-968
'Page 3 considered appropriate force in the closed direction to the correct valve T-handle, but failed to experience valve movement from the valve backseat.
The SSA also did not check the valve position indicator.
This SSA had never operated DH93 before.
A Mgnificant contributing f actor to this violation was tv failure of operations personnel to properly maintain anc utilize the_ system status file.
Documentation of Dil93 valve position from September 17 to September 20, 1991, was inadequate.
The SSA involved in this event incorrectly thought that DH93 vas initially closedi he therefore did not expect to get valve movement in the closed direction during position verification. Valve position could have been ascertained by correctly maintaining and using the system. status file.
Corrective Actions Taken and Results Achieved Valve D!i93 vas closed at 1042 September 20, 1991. Normal sump level was monitored and no other indications of leakage from the refueling canal were evident.
Individuals involved in the event were counseled regarding the importance of proper valve position verification and systet tatus-file maintenance and use.
As a result of a number of operational o.ccurrences dur the sixth refueling outage in 1990, TE implemented a program to improve the performance.of-the Davis-Besse-Operations Department. The objectives of this program are to effecti 21y. c mtunicate and reinforce manarment expectations, promote teamwork among operating crews and wit'.iin the depa tment, and strive for error free plant operations. A set of performance -indi :ators was leveloped to measure the effectiveness of the program and l
to provide timely feedback to TE management. Three of ~
these indicators, Identification'of Precursors to
-Conditions A herse to Quality, Ability to Implement Lessons Leatned for Past Errors c.ud Problems, and Improper Equipment Operations, deal with the-effectiveness of--TE's efforts to reduce personnel errors.
These indicators show that the number of events attributable to operator errors have decreased since the sixth refueling outage.
Toledo Edison vill continue to i
stress the obiectives of the program and. monitor the performance L dicators to minimize the number of events caused by personnel errors.
Corrcetive Actions to Prevent Recurrence 1
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On-shift operations supervisory personnel will be made aware of their responsibilities concerning maintaining j
L the system status file.
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Docket Number 50-346 License Number NPF-3 Serial Number 1-968
'Page 4 Oper..tions, vill be enhanced to provide more precise instructions for the use and maintenance of the system status file. This vill be completed by February 28, 1992.
This event vill be reviewed with Operations personnel with emphasis placed upon adherence to existing procedures, policies and practices relating to this event.
This will be completed by February 28, 1952.
This event vill be reviewed as part of the critique of the seventh refueling outage and lessons learned vill be assessed for tossible implementation during future outages.
Operations pre-outage requalification training vill be conducted and vill specifically address this event.
Training vill be completed prior to the eighth refueling outage.
The importance of adherence to procedures _and policies will be stressed to site personnel through discussion of this event in a future Veekly Operating Experience Report, compiled by Davis-Besse Ferformance Engineering.
This vill be completed by February 28, 1992.
Date When Full Compliance Vill Be Achieved-Full compliance was achieved on September 20, 1991 when valve DH93 was closed.
The corrective actions to prevent recurrence noted=above vill be implemented prior to the eighth refueling outage.
Violation 91-017-01B:
-Froce. dure DB-HI-09044, Revision 1, " Refueling /Pover Operation Locations For RE-2005, Containment Radiation Safety Features Actuation System (SFAS) Channel 2" provides inst _octions for testing RE-2005. This procedure was_ inadequate in.that it did not provide the necessary precautions or limitations to preclude testing while another SFAS channel was da-energized.
Acce'rence or Denial of the Alleged' Violation
Response
p Toleda. Edison acknowledges the alleged violation.
Reason for the Violation On September 8, 1991, an inadvertent Safety Feature Actuation Systems Level 1 actuation occurred.vith the plant in Mode 5 for the seventh refueling outage.
SFAS Channel 4 had been deenergized in order to perform l
Shutdown Bypass Hodification 90-0006.
Subsequently, with
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Docket Number 50-346' License Number NPF-3 Serial Number 1-968
'Page 5 SFAS Channel 2 in Test Trip Bypans-(TTB), Cen*ainment Radiation High Trip Bistable RSHH2005 on SFAS Channel 2 vas intentionally tripped per DB-HI-09044,
" Refueling / Power Operation Locations for RE2005, Containment Radiation SFAS Channel 2".
The function of the TTB is to allow testing.to be performed in an SFAS channel without the trip signals generated by the testJng to be seen in the other three channels.
The TTB does not prevent the channel being tested from trJpping.
Installation of the modification and performance of DB-HI-09044 on complementary SFAS channels (Channels 2 and 4) resulted in the inadvertent SFAS Level 1 actuation.
This event was reported in accordance with 10CFR50.73(a)(2)(iv) in License Event Report (LER)91-003 on October 8, 1991.
In the schedule for the seventh refueling outage _that was-in place prior to the start of the outage, these two-evolutions vere scheduled to be performed in sequence.
Toledo Edison outage management concluded, based upon a review of the SFAS plant status by systems engineering, maintenance, and operations, that the two evolutions could be performed simultaneously.
The cause of this event vas attributed-to inattention to detail on the part of the parsonnel from systems engineering, maintenance, and operations.in their review of the abnormal status-of the SFAS for performance of procedure DB-MI-09044.
Personnel involved in the reviav-of.the schedule change mistakenly concluded that perfo--ing the.tvo evolutions on complementary SFAS channels (i.e., channels 2 and 4) vould not result in an SFAS actuation.
A contributing factor was that DB-MI-09044 did not contain an. explicit prerequisite l
prohibiting performance of the calibrailun of RE2005'vith' the complementary SFAS channel deenergized.
The reason for the procedure deficiency ves that it was not anticipated that the calibration vould be performed in the abnormal condition with the -complementary: SFAS-channel deenergized.
DB-MI-09044_ included a prerequisite that no other testing could be performed on.SFAS Channel 2 and required that a check bs made of'the other-three SFAS channels to ensure they are not in a tripped condition. These procedural steps were followed.
However, because SFAS Channel 4 was deenergized'for
' installation of the modification the trip indications for Channel 4 vere also deenergized,: indicating the' channel was not tripped, i
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Docket Number 50-346 License Number NPF-3 Serial Number 1-968
'Page 6 Corrective Action Taken and Results Achieved The personnel involved with the incident vere counseled with regard to tripping a SFAS channel in TTB concurrent with a deenergized complementary SFAS channel vill satisfy the logie for a SFAS actuation.
Maintaining a questioning attitude while performing routine plant evolutions during abnormal plant conditions was also emphasized.
Corrective Actions To prevent Recurrence Refueling outage maintenance procedures used for calibration of the affected SFAS radiation elements (DB-HI-09043, DB-HI-09044, DB-HI-09045, DB-MI-09046) vill be revised prior to their next scheduled use Juring the eighth refueling outage.
License Event Report (LER)91-003 was issued to 4
Operations, Maintenance, Systems Engineering personnel for required reading.
Required reading vill be completed on December 31, 1991.
This event will be reviewed as part of the critique of the seventh refueling outage and the lessons learned will be included in-TE's outage management scheduling guidelines. These guidelines will be implemented prior to the start of the eighth refueling outage.
This event, including the lessons learned, vill be-included in Operations pre-outage requalification training. ' Training vill be completed prior to:the eighth refueling outage.
The importance of attention to detail and maintaining a questioning attitude at all levels of'the organization' vill be stressed to site personnel through discussion of this event in a future'Veekly Operating Experience Report, complied by Davis-Besse Performance Engineeting.
This vill be completed:by February 28, 1992.
-Date When Full Compliance Vill Be Achieved r
Full compliance vill be achieved when procedures DB-HI-09043, DB-HI-09044, DB-M1-09045,- and DB-MI-09046-are revised prior to their next scheduled-use during the eighth refueling outage.
l The corrective actions to prevent recurrence noted above.
vill be implemented prior to_the eighth refueling outage.
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Docket Number 50-346 License Number NPF-3 Serial Number 1-968
' Page 7 Violation 90-17-0?:
10CFR Part 50 Appendix B, Criterion XVI, as implemented by Section 14 of the licensee's Nuclear Quality Assurance Hanual, requires that measures be established to assure that conditions adverse to quality are promptly identified and corrective action tsken to preclude repetition. The licensee implemented corrective actions to prevent the repetition of overfloving the steam generator _vhich occurred on May 23, 1990.
Contrary to the above, on October 15. 1991, when filling Steam Gene-stor #2 in accordance with SP 1106.08 Revision 12, Steam Generator Secondary Side Fill, Drain and Layup Procedure, the generator was overfilled.
The corrective actions taken to preclude this event which vere not implemented resulted from the May 23, 1990, event.
Responset Acceptance Or Denial Of'The Alleged Violation Toledo Edison acknowledges the alleged violation.
Corrective actions resulting from the May 23, 1990, event-included procedure enhancement and policy revisions.
However, the corrective actions were not properly followed in.this case, resulting in a similar event.
Reason For The Violation This violation occurred because procedures and policy statements governing system filling and~ draining vere not followed._ These procedures and policies, if followed, contain_the safeguards necessary.to preclude such an event.
The primary-reason for.the violation was failure to propetly follow procedure DD-OP-06230, Steam. Generator Secondary Side Fill, Drain and Layup Procedure.
l In accordance with Section 8 of DB-0P-06230, completion of the prerequisites necessary for steam generator (SG) fill began during the evening of October 13, 1991. The procedure. requires two vent paths during SG fill; one via the,SG upper tap and the other via a main steam'line vent.
Step 8.1.6.2.a of DB-0P-06230 requiresLthe SG upper tap (MS 756) to be opened.
The Senior-Reactor Operator (SRO) in charge of performing the prerequisites determined that Step 8.1.6.2.a was not applicable and,.
accordingly, initialed and marked the step N/A.
Procedure DB-0P-00000, Conduct of_0perations, allows such an action when specific conditions are set forth or when plant conditions do not allow a_ procedural step to be pqrformed.
However,-in this situation, the SR0's action was inappropriate.
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Docket Number 50-346 License Number NPF-3 Serial Number 1-968 Page 8 As indicated by notes next to Step 8.1.6.2.a. tFe SRO's decision to leave valve MS 756 closed was based on two incorrect assumptions:
(1) only a partial fill of SG #2 was being performed and, (2) as such, only one vent path was sufficient to pecform a partial fill. The open vent path was'via a main steam line vent (MS 877) which was properly opened per DB-0P-06230.. The SRO's decision to leave valve MS 756 closed was also influenced by a concern of the potential for a spill in a high contamination area inside containment which would be created by opening MS 756.
Operations policies provide detailed mee.sures to be taken during the filling and venting of l1".d systems.
"u a annel are expected to estimate flow rate, quantity of
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f]uld to be transferred and duration of transfer; these esti 'tes should be periodically verified during the evo.
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A local vatch stander is also called for, in order, monitor for overflow.
Implementation of these sound operating practices, detailed in the form of an Operations Section Policy, vould have prevented this violation, A contribut 7g factor to this event was the failure of both the de, and night shifts to adequately review the.
.i progress of the SG fill procedures during: shift ternover.
Pretcquisites were completed and filling of SG #2 began at 1335 on 0ctober 14, 1991.vith discovery of the overfill condition occurring at 0226 on October 15, 1991.
The night shift nLpervisor and secondary RO vere avare of y
the open SG vent path through MS 877.
As a result of MS-756 being left closed, an erroneous main steam line vater level indication was introduced.
l Without vent.ing-the' upper-portion of'the SG'through MS 756, SG vater level indication does not accurately reflect the actual water level in the main: steam header i
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.due to a pressure difference between the SG and the main steam line At the time r :he occurrence,cthe secondary.
R0 was observing the trend recorder for SG level and also the level indicatior.
Thc SG 1evel indication did not suggest that the SG vas to the point of overflowing. The secondary RO noticed a decreasing fill rate ~ indicated by SG full range-level indication and attributed the decrease to tlw increasing head of water.in the SG.
The shift super"isor alsA noted the decrease in indicated fill rate but did not equate the decrease with a problem.
At 0226 on 0ctober 15, 1991. a call was received from a security guard who reperted. vater spilling onto the floor in main steam line room #2.
Operators secured filling of i
SG'#2 and closed MS 877.
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Docket Number 50-346 License Number NPF-3 Serial Number 1-968
'Page 9 The spill occurred through MS 877, which was properly opened per DB-0P-06230.
A review of plant data indicates that the duration of the spill was approximately 70 minutes with a flow rate of approximately 13 gpm; resulting in a total release of approximately 910 gallons.
Effluent from the main steam line roon floor drains is directed to the station storm sever d ain system and monitored by radiation monitor RE468f prior to release to the training center pond which is l'. side the ovner controlled area.
As a result of the spill, lov levels of radioactivity were released to the training center pond. Based on grab samples, it is estimated that the total activity released was 7.5 uCi in 910 gallons of Specific isotopic concentrations were estimated water.
to be 6.83E-07 u i/c( of Cs 134 and 1.4?E-06 uCi/cc of Cs-137. This release is within Technical Specification effluent release limits ard will be reported in the next Semiannual Effluent Report, scheduled to be issued by April 1, 1992. The quai.tity of hydrazine released was also analyzed and estimated to be approximately.67 pounds, less than the reportable quantity for hydrazine of one pound as specified in 40CFR302..This event vns of minor safety significance.
Corrective Actions Taken And Results Achieved The individuals involved in-this event were counseled regarding-the importance of properly following procedures and reviewing the progress of major evolutions to ensure that performance standards match inanagement expectations.
Corrective Actions To Prevent Recurrence This event, including lessons learned and Operations Policy 3 G, vill be reviewed with Operations personnel.
This vill be completed by February 29, 1992.
The requalification lesson plan for DB-0P-00000, Conduct of Operations, will be revised to stress the importance of completing all required prerequisite steps. This.
specific event vill be used as an example of improperly declaring a procedural step not applicable and the resultant consequences.
Operations pre-outage requalification training vill be
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conducted and vill specifically address this event, including an explanation of the relationship between SG level, SG pressure, and main steam line vent flovpaths.
Training vill be completed prior to the eighth refueling outate.
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Docket Number 50-346 License Number NPF-3 Serial Number 1-968
'Page 10 This event vill be reviewed as part of the critique of the seventh refueling outage and the lessons learned vill be assessed for possible implementation during future
- outages, l
The importance of adherence to procedures vill be j
stressed through discussion of this event in a future
' eekly Operating Experience Report, complied by Davis-Besse Performance Engineering. This vill be completed by February 28, 1992.
Date Vhen Full Compliance Vill Be Achieved The corrective actions to prevent recurrence noted above vill be implemented and full compliance achieved by the start of the eignth refueling outage.
should you have any questions or require additional information. please contact Mr. Robert V. Schrauder, Manager - Nuclear Licensing, at (419) 249-2366.
1 Very tr ly yours, Q
NEP/dlm cc:
A. B. Davis, Regional Administrator, URC Region III J. B. Hopkins, NRC Senior Project Manager V. Levis, DB-1 NRC Senior Resident-Inspector Utility Radiological Safety Board 1
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