ML20090J591
| ML20090J591 | |
| Person / Time | |
|---|---|
| Site: | Waterford  |
| Issue date: | 03/11/1992 |
| From: | Burski R ENTERGY OPERATIONS, INC. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| W3F1-92-0125, W3F1-92-125, NUDOCS 9203170327 | |
| Download: ML20090J591 (6) | |
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R. F. Burski i
W3 F1 0125 A4.0S QA March 11, 1992 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk -
- Washington, D,C. 20555 Subject :
hatcrford 3 SES Docket No. 50-382 License No NPF-33 NRC Inspection Report 92-01 Reply to Notice of Violation Gentlemesi:
In accordance witti 10CF22.201, Enter gy Operations, Inc. hereby roubmits in Attachinent 1 the response to the violation.s identified in Appendix A of the subject inspection Report.
If you huvo any questions concerning this response, please contact T.W. Gates at (504) 739-GG97.
Very truly yours,
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-RFB/TWG/ssf Attachment ec:'
R.D. Martin, NRC Region IV D.L. Wigginton, NRC-NRR R.B. McGehee -
N.S. Reynolds NRC Resident Inspectors Office 4
I 9203170327 920311 hi n
PDR.ADOCK 05000382
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Attuch:nent to W3F1-92-0125 Page 1 of 5 ATTACllMlWT1 ENTERGY OPEil ATIONS, INC. RESPONSE TO Till: VIO!.ATIONS,lDENTIFIED IN ApFENDIX A.0F INSPECTION IEPolg_92-01 VIOLATION NO. 9201,01 Criterion VI of Appendix B et 10 CFP. Part 50 tund the licensee's approved Quality Assurance Program require that measures be ectablished to control the issutnice of iocuinents, such as instructions, procedures, and drawings, and changes therett,, which prescribt all activities affecting quality.
Contrary to the above, the licensee failed to control the changes to Drawing LOU-15tk1-G167, Sheet I, " Flow Diagram - Safety injection," in that the invised drawing was posted in the contrd room without transferring the tags indicating that a safety-related temporary alteration (modification) af fected the drawing.
RESPONSE
(1)
Reason for the Violation Entargy Operations, Inc. admits this violation and believes that the root cause of the event is that Admh istrative Procedutu UNT-005-001,
"'l emporary Alteration Control," is inadequate in that it does not include measures for designating offected drawings so that other interested parties are aware of the temporary alteration. In practice, this means that a
personnel posting revised drawings in the control room do not know
'Nhether a particular drawing is affCeled by a temporary alteration unleSS they observe a temporary alteration -ticker on the drawing they are replacing.
The control roem con.ains three sets of drawings-one hard copy set and two sets on apwrture cards. Discussions with the individual typically assir:ned to update iho control room drawings ind:cated that th9 usual practice was to cross-check the three sets of drawings to ensure that each of the sets reflected the same temporary alteration status. In this instance, a discrepac.cy was noted. The individual attempte.1 to resolve the discrepancy by checking the status of temporary alteration 91-060 in the temporary alteration lag. Unfortunately, he inadvertently checked the 9
caution tag-out log and, base.d on (caution tag-out) log number 91-050 being clnsed, incorrectly concluded that the temporary alteration had been removed. As a result, the revised drawings were posted in the control room without the stickers indicating that a temporary altenation wr3 installed.
(2)
Corrective Steps That llave Been Taken and the Resuite Achieved The affected control room drawing-LOU-15G4-G167. Sheet 1. " Flow a
Diagram Safety Injaction," was apdatad to properly indicate the installation of a terrporary alteration.
Secondly, control room drawings were audited to verify the proper placement of temporary alteration tags. No discrepancies were noted.
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Attachment to W3F1-92-0125 Page 2 of 5 Thirdly, Plant luigineering generated a list of all controlled drawings af fected by the installation of temporary alterations. The list will be updated each tLne a temporary alteration la installed or removed, in the Fhort term, this will ensure that personnel charged with posting revised
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drawings to the control room know wideh drawings should indleato the installation of a temporary alteration.
Finally, this event was discussed at the Plant Engineering daily status meeting to highlight the importance of propar implen entation of the Corrective Action Program. Il the root cause of a similar problem noted during the third cluarter,1991 temporary alteration audit had been fully evaluated, this event may have been prevented.
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I (3)
Corceetive Steps Which Will lie Taken to Avoid F..rther Violationa ca Aciministrative Procedure UNT-005-001, "'Iemporr.ry Alteration Control,"
6 wlU be rovised to include guidance on the administrative aspects of temporary alteration control.
(4)
Dam When Full Comglance Will lie Achieved Adininistrative Procadura UNT-005-004 wit.1 be revised by. lune 4,1992.
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Attachment to W3F1-92-0125 page 3 of 5 VIOLATION h'O. 9201-02 Criterion 111 of Appendix fl of 10 CFil Part 50 and the liccusee's appro' sed Quality Assurtwee Program require that design changes, !neluding field changes, shall be (subject to desipra control measures] commensurate with those applied to the original design and be approved by the organization that performed the original design unless the upplicant designates another responalble organization.
Contrary to the abova, the Ucensee, during the performance of Work Authorization WA-9000040G on April 16, 1991, made an apparent field dealgn change without the required res few and approval. One conductor of safety-related electrical Cable 30588C-SMB was terminated at a different point than specified in tlm work authorization. The individual lined out, initialed, and Ated the presevibed termination point and then substituted a different termination point. This termination was independently verified and the entiro design change package reviewed and closed. Ilowever, the field change process was not implemented und the affected drawing (LOU-1561-ll42 ?, Sheet 588S) was not changed to reflect the as-built configuration.
ItESPONSE (1)
Henson for t_he Violatioil Entergy Operations, Inc. admits this violation. While the root cause of this event can not be determh'ed conclusively, it is likely that the event resulted from a combination of an incomplete work package and an undetectable error by the electrician in the field.
First, review of Work Authorization (WA) S900040G Indicates that an approved change to Design Change Package (DCP) 3260, " Removal of Shutdown Cooling Auto-Closure Interlock," was not f ully incorporated into the work package. The reasons for this are not clear but it appears that i
the change to the DCP-Document Revision Notice (DRN) 1910l?13-was incorporated into the termination / determination sheets in the package while the drawing associated with the DRN was not. This was not neceasarily lucorrect but it did contribute to the violation because, without the drawing, an error made in the termination / determination sheets was not easily detectable.
The error in the package involved a wire termination at Auxiliary Isolatior.
Panel M Terminal Board TBC point C5. In accordance with the DRN, two wires were t.o be terminated at this point in order to connect pressurizer pressure isolation relay G3X4 to point A-23 in Piant Protection System PAC Cabinet CP 2G. In the termination / determination sheets however, only one wire was terminated at point C5, The other wire was terminated at the adjacent point on the same terminal board, point C4.
This error was recognized by the technician during the installation in the field. The technleian was familiar with the intent of the DRN and recognized that both wires needed to be terminated at the same point on the terminal board. Although the technical basis for his decision is unclear, the electrician believed that technical documentation existed to support
Attachment to W3F1-92-0125 Page 4 of 5 r
cha.iging the termination point and proceeded to terminam the cables at point C4. No documentation has been found to support that deelslon. In any case, j
the wiring was satisfactory from an electrical utandoolut but was not in l
accordarae with the latest DRN.
I Again, the far t that the drawing ussociated with DRN 0101213 was apparently not in the pack 9gu played a role. Electricians are normally authorized to correct typographical errors on terminat'on/ determination sheets as long as the withig is ultimately installed in accordance with the latest DRN. In this case, one of the wire terminations was obviously incorreet; either puint C4 or C5 would have been acceptable (electrically) as long as both wires were terminated at the same point. 'rhe electrician may have selected terminal
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board point C4 because it had been used in the or'f;8nal design; in any event, the proper termination point could not be determined without reference to the design authority which, at the time, was DRN 9101213. Although he was fully aware of the overall wiring plan and perfornad the withig in a satisfactory manner from an electrical standpoint, the electrician may have unknowingly referenced an improper or superseded design source to justify the selection l
of termination point C4.
A number of so-called " barriers" failed to prevent this ever.t. The most significant of these is that the field wiring was subjected to and passed a I
point 'o point wiring check. It appears that this check was performed using a combinntion of the orig!ual DRN and the termination /determinafwn sheets.
l A review of Maintenance Proceduro ME-007-001, " Cable Insulation Resistance and Continuity Testing," indicates that the procedt.re provides very little l
guidance on the documentation that should be used to conduct point-to point checks.
(2)
- Corrective Steps That llave Been Token and the ResultsJehieved j
t Because the wiring of pressurizer pressure isolation relay 63X4 between
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- Auxiliary Isolation Panel 2 and CP-26 was saticfactory from an electrieu!
standpoint, DRNs 19200324 and 19200325 were issued to update the eriected controlled drawings, i
In addition, the_ Electrica! Maintenance Department has implemented new
_ guidance with respect to he peeparetion of terminadon/ determination sheets.
To avoid confusion, the peactice of uaing line-outs and initials to update the sheets when a DRN is issued has been discontinued.
Rather, standard practice in the future wl'1 he for the work plannor to start from a " clean-l sheet" and, to the eotent possible, rewrite the ent. ire sequence of operations l
i necessary to implement a change. _ This change should _ encourage a moro logical thought process, simplify the review process _and, _ by extension, reduce the likelihood of errors when incorporating changes to the termination / determination sheots.
Third, it la now standard practice that Maintenance Department planning Supervisors recieve a controlled copy of a DRN if the DRN impacts an assigned -
DCP. - This should ;"close the loop" to a certain extent by ensuring that the -
Maintenance Department gets every DRN as soon as it is distributed. This practice is less dependent on personal interaction between the Maintenance Department and Design Engineering and should ensure that issued DRNs L
' reach the planners and are included in the work packages.
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Attachment to W'A F1 0125 Pago 5 of 5 Finally, the Maint muneo Superintendent reviewed t:ds event with the technician who inirformed the 1: eld work and his supervisor. The discussion stressed the preembience of controlled drawings over other documentatinn in the perf ormance of field work.
(3)
Corrective StegWhich Will lin Taken to Avoid Further Violations Weterford 3 will perform n comprehensive review of the pimeess of coordinating and communicating changes to approved Design Change Packages between Design Engineering and the implementing organizations.
Although the exact nature of the review has no; been decided, it is expected to luelude representatives from Maintenamu, Modification Control, Document Contrm, and Design Engineering, annong others.
Secondly, this event will be discusved with Maintenance Department personnel in the regular shop meetings. The importance of controlled drawings as the principio design authority wiil be stressed. For the niectrical and 1&C disciplinos, the importance of point-to-point with.g checks and independent verification in accordance with the latest DitN will be emphasized.
Finally, Maintenance Precedure ME-007-001, " Cable Insulation Itesistance and Continuity Testing," will be revised such that it requires the use of the latest DitN when conducting point-to point withig checks.
(4)
Date When Full Compthince Will lie Achieved, Waterford 3 will complete the procedure revision, hold the shop meetings, and conduct the process review described above before the start of the fifth refueling outage which is expected to begin September 19, 1992.
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