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Responds to NRC Re Notice of Violation & Proposed Imposition of Civil Penalty Noted in Insp Repts 50-413/91-27 & 50-414/91-27.Corrective Actions:Breaker 1EKPG 22 Closed & Proper Use of Tagout Sys for Components Emphasized
	ML20090M772
Person / Time
Site:	Catawba
Issue date:	03/16/1992
From:	Tuckman M; DUKE POWER CO.
To:	; NRC OFFICE OF ENFORCEMENT (OE), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
	NUDOCS 9203250223
	Download: ML20090M772 (57)
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DIIKE POWER.

March 16, 1992 Director, Office of' Enforcement

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S.

Nuclear Regulatory Commission ATTN:

Document Control Desk Washington, DC 20555

Subject:

Catawba Nuclear Station Docket Nos. 50-413'and 50-414 NRC Inspection Report Noa. 50-413/91-27 and 50-414/91-27 Reply to a Notice of Violation Attached is Duke Power's response to the Level IV violation concerning configuration control problems cited in the Notice of Vjulation and Proposed Imposition of Civil Fenalty dated February i s,: -1992.

Duke admits the violation occurred and submitted the payment of the civil penalty on March 12, 1992 Also Lattached.is Duke's response'to two aaditional examples ci configuration control problems that' ere documented in_ NHC J nspecticn Report Nos. 50-413 /91-28 and 50-414 /91-28 dated February 5,'1992.

Attacnment 1.contains col 5ies of tko-~LERs regarding breakers'1ERPG

22 and 2EXPH #22, Attachment 2 contains letters from Operations man 4genent to Operations personnel on' component mispositionings and valve-positioning; basics, 'and. Attachment 3 contains information pertnining.to the Component Positioning Team.

03' requested in the Notice of Violation, Attachment 4-contains Cuke'Pcwor's' corporate directive.on independent verification, and W.auba's plans for implementaticn of the' directive.

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S. Nuclear Regulatory Commission March 16, 1992 page-2 Catawba is very concerned about tr.i "ond that hau developed with respect to mispositioning events.

We are dedicating considerablo management attention towards the goal of reversing this trend.

Duke Power is currently implementing a company-wide program which is centered on achieving excellence in the way we do businests.

The implementation of this program comes at an opportune time to assist us in solving our component positioning problem.

We will be using the program of " managing for excellence" as our approach in dealing with,this problem. describes this program and provides the direction we are taking towards achieving excellence.

Very truly yours, p

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Tuckman RKS/ VIOL 91.27 Attachments xc:

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Ebneter Regional Administrator, Region II R. E.. Martin, ONRR W.-T.

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DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-27 Technical Specification C.8.1 requires that written procedures be established, implemented and maintained covering the operation of the control room area ventilation system, maintaining containment integrity and performing sur millance tests on safety-related equipment.

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Contrary to the abeve, procedures were not adaquately implemented as evidenced by the following examples:

A)

H m _k_er_JEKPG #22 On September 13, 1991, at approximate?y S:00 a.m.,

operators failed to follow Operations Management Procedure OMP 2-18, "Tagout Removal and Rostoration (R&R)," when R&R 01-2764 was imp h.mo nt ed on breaker 1EKPG-21 as vpposed to the intended breaker 1EKPG-22. This resulted in both trains of the Control Room Ventilation (VC) System being inoperable for a period of approximately one and a half hours.

B) 2NI-11.8_A & 2NI-150B On tiovember 17, 1991. at approximately 4:00 a.m.,

an operator failed to follow procedure PT/1(2)/A/4200/13H, "NI/NV Check Valve Movement Test," when he wns aligning valves to support system testing and signed-of f two valves 2NI-118A and 2NI-150B as being closed when they were actually open.

This resulted in the Train "A"

Cafety In]ection (NI)

Pump experiencing runout f]ow on startup for the test.

C).

LSV-6C on November 16, 1991, a non-licensed operator, when completing performance test PT/2/A/4200/02E, " Verification of Refueling Containment Integrity," verified with a sign-off that valve 2SV-66, a 28 steam generator power operated rollef valve (PORV) drain line valve, was closed when it was accually open.

D)

RSM-10J On November 18, 1991, a non-licensed operator, when completing perfcrmance test PT/2/A/4200/02E, " Verification of Refueling Containment Integrity," verified with a sign-off that valve 2SM-103, a 2C steam generator outlet header drain valvc was closed when it was actually open.

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i DUKE PCWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-27 E)

EqntAirp_gn.t Isglation VerifieqLL2D On November 18, 1991, operations personnel verif. icd that the "inside" containment iso)ation linettp was correct inntead of the "outside" containment isolation lineup as required by the j

operations support workshoot, The following two examples of configuration centrol problems are documented in Inspection Report 50-413/91-28 and 50-414/01-28.

However, they are being addressed in this response as requested in the subject Inspection Reports (91-27 and 91-20).

F)

Es Pumo_pJt On December 10, 1991 with Unit 2 in Mode 5,

Cold Shutdown, Performance Department technicians were in the prococa of conducting inservice testing (IST) of the Train B Containment Spray (NG) pemp.

Due to an improper valve alignment, the pump was started Without a

suction

source, and ran for approximately 4-5 minutes before being secured.

G)

UnitLfrin_TMd;ing On December 16, 1991, at approximately 7:35 a.m.,

Unit 2 was in Mode 4 in the process of starting up from the 2EOC4 refueling outage.

Instrumentation and Electrical (I AE) personnel were performing post-modification testing of a new main turbino control system installed during the outage when an inadvertent main turbine roll occurred.

This is a Severity Level IV Violation (Supplement I).

RDAR95LD L-1.

Mai_NAARIL.9r __DeDia) of ylolation Duke-Power admits the violation.

2.-

Reappp J or Viglg.i.lon A)

Brea_her 1E5fS_f22 This incident is attributed to <s lack of attontion to detail by the operator when tagout 01-2764 was prepared.

The operator failed to correctly i mpl eue.at -

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DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-27

.information given in Technical Memorandum 21-07 when he listed the wrong breaker on this tagout.

This incident is described in LER 413/S'.-20.

A copy of this LER can be found in Attachment 1.

B) 2HI-11M. & 2RL-150B This incident is attributed to a lack of attention to detail in that the operator inappropriately signed-off the two valves as being closed when in fact they were open.

In addition, there were two other factors that contributed to thic incident.

One facter was procedural complexity and lack of clarity.

The second factor involved miscommunicr.tlon between the test coordinator and the operator.

The operator was given two valve checklists which we'e part-of the test procedure.

The operatc; did not understand that the two checklists were tc bc. implemented separately.

As a result, the operator discovered. that the checklists contained conflicting valve positions.

This misundarstanding added confusion and contributed to the operator's mistake of signing off the valve positions incorrectly.

C) 2SV-66 This incident was caused by a poor work practice and a lack of attention to detail by the operator involved.

Tha operator failed to follow the required practice of

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signing of f valves individually as they are verified.

In lthis instance, the operator veri' fed the position of several valves and then signed thea off.

- D)

.1SM-103 This incident occurred. because the operator failed to 1

~ check the two tags hung on the valve.

Both of these tags indicated that the valve was open.

This crror is also attributed ~.to a management deficiency.

Operations management did not c1carly define their expectations to the operators with respect to valve verifications involving red tags.

Operations management expected that an operator would use both red tags-and manual manipulation to verify valve posit'io'n.

The operator believed that the verification was to be carried out without any dependence on the red tags. The operator did l

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try to close the valve to verify its position.

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DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-27 the operator assumed the valve was closed because he could not move it in the closed direction.

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.Qp_n_t;3qipment, Isp.J ation Veri fication I

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This incident is attributed to an inappropriate action

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taken by the on-shift Control Room SRO.

The shift was instructed by the worklist to document "outside" containment isolation when performing PT/2/A/4200/02E.

Instead, the on-< shift Control Room SRO chose to document f

"insidc" containment isolation.

He failed to recognize that this created a

conflict with the required penetration alignment for scheduled maintenance work.

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F) liS PUMP 2B This incident is attributed to inappropriate actions taken during the implementation of the procedure.

The procedure available for use had not been written for the enist.ing plant condition (i.e. Mode S). The Control Room supervision N/A'd the procedure alignment requirement without recognizing the need to ensure a suction sourco via other means.

In addition, the balan(.e of plant operator who started the puup failed to self-verify that the expected discharge flow was achieved or that a 4

suction / discharge path existed.

G) linitQ Ma1D Turbing m

This incident is attributed-to inadequate scheduling and

planning during preparations for the turbine control systen test.

A change in plant conditions (i.e., Main Steam isolation valves opened) was not recognized when testing resumed.

In

addition, inadequate group communications was a contributing factor.

The Control Rcom operators were not fully aware of the extent of the testing and this limited t; heir ability to evaluate the potential impact on plant operations.

3.

Co2rrective ActJons-Taken aad. Regu_Jts Achieved A) lireqker.LEEPG #T2 q

The corrective actions taken in response to the incident involving breaker 1EKPG #22 are listed in LER 413/91-20 which is given in Att.achment 1.

Subsequent to this 4

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DUKE-POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-ll7

event, another mispositioning event occurred which involved breaker 2EKPH #22.

This breaker is related to 1EKPG #22 in that it performs the same function but on l-the opposite train.

This incident was reported in LER 413/92-02.

A copy of this LER can be found in Attachment 1 and it covers the corrective actions taken in responso to this <3 vent.

The follow.ing items given in LERs 9]-20 and 92-02 as a planned action have been completed:

1)

Planning han added a note to predefined work orders for 1(2)CR-AHU-1 and 1(2)CRA-PFT-1 identifying the need for a tagout for IEXPG #22 ( 2 EKPli #22) when working in these componento.

This provides further asuurance of proper configuration control.

2)

Operations has revised Operations Management Procedure (OMP) 2-5 te strengthen the management controls over the process of using Technical Memorandums.

,B)

?JiL-11EA & 2NI-110J1 The following actions were taken in response to the incident involving 2NI-118A and 2NI-1508:

1)

The 2A NI Pump was secured after 20 seconds of

.aperation.

2) 2NI-118A and 2NI-150B were closed following verification of their proper position.

3)

The individual involved received appropriate correctivo discipline per DPC Management Procedure 101.05.

4)

Performance conducted an IWP test on 2A NI Pump on December 14, 1991.

Pump performance was verified to be unaffected by this occurrence.

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DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-27 c) 2H1-01 The following actions were taken in responso to the incident involving 2SV-66; 1)

Core alterations were immediately halted by the Shif t Superviror upon discovery of the discrepancy.

2) 2SV-66 was closed following verification of its proper position.

3)

All Containment refueling activitics were sunpended for two days while a double verification of each containment penetration was performed.

This verification identified no other alignment errors.

4)

An individual was designated to coordinate and monitor the status of containment integrity for the remainder of the refueling outage.

No other

~instancos occurred during the remainder of the outage.

S)

The individual involved received appropriato corrective discipline per DPC Management proceduro 101.05, 6)

The Shift Operations Manager (SOM) provided verbal and written guidance. on component mispositioning and position verification to each shift on the following dates:

A Shift - 11/20/91 B Shift - 11/22/91 C Shift - 11/20/91 D Shift - 11/27/91 E_ Shift 11/?l/91' A copy of this written guidance is given-l'n..

7)

A lotter from the Shift Operating Manager on management's expcotations with respect to Valve Positioning Basics. was issued to each shift on November 25, 1991.

A copy of this letter is given in Attachment 2.

6

DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-27

)

8)

The continuous Improvement Action Team reviewed this and other valve related component mispositionir,g incidents.

Basic methods and expectatione concerning operator manipulation of valves were developed.

These basics were reiterated to each shift in person by the Shift Operations Manager.

Those basics have been incorporated into OMP 2-33, Valve and Breaker i

Pcsition Verification and Valve Operation.

D) 2f11-103 The following actions were taken in response to the 4

incident involving ?SM-103:

1)

Core alterations were immediately halted by the Shif t Supervisor upon discovery of the discrepancy.

2)

Operations verified and documented that proper containment integrity was already in place for this penetration using an alternate isolation alignment.

J 3)

All Containment refueling activities were suspended for two days while a double verification of each containment penetration was performed.

This verification identified no other alignment errors.

4)

An individual was designated to coordinate and monitor the status or containment integrity for the remainder of the refueling outage.

No other instances occurred during the remainder of-the i

outage.

5)

The individual _ involved received appiopriate corrective discipline per DPC Management procedure 101.05 concerning his failure to use a.1 the information available (i.e., tags) to determire the position of the valve he was verifying, i

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l DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-27 6)

The Shift Operationu lenager (SNi) provided verbal and written guidance on component minpositioning and position verification to each shift on the following dates:

A Shift - 11/20/91 B Shift - 11/22/91 C Shift - 11/20/91 D Shift - 11/27/91 E Shift - 13/21/91 A

copy of this written guidance in given in s

7)

A letter from the Shift Operating Manager on management's expectations with respect to Valve Positioning Danica wan issued to each shift on November 25, 1991.

A copy of this letter is given in Attachment 2.

8)'

The continuous Improvement Action Team reviewed thin and other valve related component r

mispositioning incidents.

Basic methods and expectations concerning operator manipulation of valves were developed.

These basica were reiterated to each shift in person by the shift Operations Manager.

These basics have boen incorporated into OMP 2-33, Valvo and Dreaker Position Verification and Valve Operation.

E)

Q9AtainDCht_IEllAt19n_YfT.itlqAt1911 The following actionn were taken in response to the in'cident involving.the verification of containment isolation:

1)

Core alterations. were immediately halted by the Shif t Supervisor upon discovery of the discrepancy.

2)

Proper containment integrity was verified to exist.

It was determined that "outside" containment isolation was maintained during

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F DUKE POWER COMPANY REPLY TG NOTICE OF VIOLATION 413, 414/91-27 3)

A review of Westinghouse as-built drawings for both Units' steam generators was performed to deternine if any secondary side access holes were omitted from the Containment Closure Verification pts.

No discrepancies were found on Unit 1.

We discovered 1

that two 2.5 inch access holes were omitted from the procedures for each steam generator on Unit 2.

Procedure changes were initiated to add these holas to the containment integrity checklists for the SM (Main Steam) piping and the CA (Auxiliary Feedwater) piping for which both holes are isolation boundaries.

In addition, the steam generatot water level required to take credit for these holes being 11osed was raised from 15% wide range to 60% wide range.

It should be noted that these items on Unit 2 never caused an integrity problem.

They were found as a rebult of our investigation into potential problems.

l F)

NS Pyro 2B The following actions were taken in response to the incident involving Containment-Spray (NS) Pump 2B:

1)

NS Pump 2B was secured after about four to five minutes of operation.

2)

NS Pump 2B was properly aligned to its suction j

source and successfully tested for operability.

3)

The involved personnel were - counseled on their actions and judgements.

G)

Unit 2 Main Turbine The following actions. were taken in response to the incident involving the inadvertent roll of the Unit 2 Turbine:

1)

When the operators recognized the transient, they immediately tripped the Unit 2 Turbine.

2)

All Turbine testing was immediately suspended and a proper isolation boundary was established.

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DUKE POWER COMPANY REPLY TO NOTICE OF VICLATION 413, 414/91-27 4-991f.op_(lyo_ hoti.pns to bo IAkeD_tR_ Aloi.5L EMI.ther_V_io1Rii9fl8 A)

Iirnker_1EEPG #22 The following actions will be taken in response to the incident involving IERPG #22:

1)

Operations management will emphasize the need for proper use of the tagout system for all components, and 'the need for attention to detail while preparing tagouts.

This information will be communicated to the appropriate personnel by June 1,

1992.

2)

A Nuclear Stat.on Modification (NSM) to climinate the requirement of opening 1EKPG #22 (2 EKPli #22) during work on 1(2)CR-AliU-2 and 1(2)CRA-PFT-1 will be implemented following approval of a proposed Technical Specification change submitted to the NRC on August 12, 1991.

3)

Station management, in conjunction with the Continuous Improvement-Action Team (CIA),

established the Component Positioning Team (CPT),

with representatives from Operations and other station groups with responsibilities for component operation.

This team will-study component mispositioning events at Catawba and will make recommendations to prevent these types of incidents.

See Attachment 3 for additional details on-CPT activities.

This-attachment describes the mission and work of the

CPT, a

copy of the conclusions and recommendations made by this team, and a summary of the minutes from past meetings.

4)

The Component Positioning Team will review the need for a method to identify the correct positions of low voltago breakers within panelboards in the plant so that, when working in a panel, it is apparent which breakers are required to be open or closed.

This review will oc completed by June 1, 1992.

As mentioned earlier, PIR 92-02 involved a nimilar incident to that discussed abovn. The investigation into this incident resulted in further actions being proposed

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DUKl: POWER COMPANY REPLY TO NOTICE OF VIOLhTION 413, 414/91-27 to provent reoccurrence.

'1he following actions will be tahn in response to this incident:

5)

This incident will be discussed with Operations shift personnel during requalification training.

This will be accomplished by June 1, 1992.

6).

A programming change will be made to the Operations red tag computer program so that Special Instructions will appear on the screen.

This will be accomplished by October 1, 1992.

B) 2 N I-11 {}A_and_2141-150!i The following actions will be taken in respense to the incident involving 2NI-118A and 2NI-150B:

1)

Operations management will make clear to the Unit Supervisors its expectations concerning the information that should be obtained prior to allowing work to begin on the unit.

This information will be communicated to the appropriate personnel by June 1,

1992.

2)

Enhancements to the NI and NV Check Valve procedure will be mado prior to its use during the Unit 1 EOC6 outage.

C)

ZSV-66

.The following actions will be taken in response to the incident-involving 2sv-66:

1)

The Continuous Improvement Action Team is reviewing the nothod for controlling-Containment Closure / Integrity status and its interface with tagouts-for maintenance.

Based on-the results of this review, corrective actions will be taken.

Changes will be implemented for the Unit 1 EOC6 i

ueling outage.

2)

The-Component Positioning Team has publicized the concern for co.nponent positioning.

Employees have L

been encouraged to report all component mispositions through the lower tier problem reporting and resolution process.

Component p

Position Team members are on call, through a duty 11 l

1 I

DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION

~

413, 414/91-27 rotation, to investigate events as soon as they have been identified to the Shift Manager.

Root Causa determinations will be

mado, corrective actions will be taken and tracking / trending analysis will be used to determino appropriate process / generic corrective actions.

D) im&-101 The following actions will be taken in response to the

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incident involving 2SM-103:

1)

The Continuous Improvement Action Team is reviewing the method for controlling Containment Closure / Integrity status and its interface with tagouts for maintenance.

Based on the results of this review, correctivo actions will be taken.

Changes will be implemented for the Unit 1 EOC6 refueling outage.

2)

The Component Positioning Team has publicized the concern for component positioning.

Employees have boon encouraged to report all component mispositions through the lower tier problem reporting and resolution process.

Component Position Team members are on call, through a duty rotation, to investigate events as soon as they have been identified to the Shift Manager.

Root Cause determinations will be

made, corrective actions will

-be-taken and tracking / trending analysis will be _ used to datormino appropriato process /gencric corrective actions.

E)

Contginnqnt Inq131tLQp Verifint1GD The f ollowing actions will be taken in response to the incident involving the verification-of containment I

isolation:

1)

The Continuous Improvement Action Team is reviewing the method for controlling Containment closure / Integrity status and its interface with

. ugouts for maintenance.

Based on the results of this review, _ corrective actions will be taken.

L Changes will be implemented for the Unit 1 EOC6 refueling outage.

12 i

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DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/91-27 2)

The Component Positioning Team has publicized the concern for component positioning.

Employees have been encouraged to report all component mispositions through the lower tier problem reporting and resolution

procosa, Component Position Team members are on call, through a duty rotation, to investigato events as soon as they have been identiflod to the Shift Manager.

Root Cause determinations will be

nade, corrective actions will be taken and tracking / trending analysis will be used to determine appropriate procons/ generic corrective actions.

F)

HS PumlL23 The need for additional procedural guidance will_ be evaluated, and if dntermined necessary, will be implemented for the Unit 1 EOC6 refueling outage.

G)

.j) nit 2_JialILTntbJnq A procedure for each unit will be written to -- provide guidance on testing and troubleshooting the Main Turbine Control System.

This will take the place of the general troubleshooting procedure used during this_ incident. The Unit 1 procedure will be validated during the Unit 1 EOC6 refueling outage and will be approved by October _1, 1992.

The Unit 2: procedure will be written from the Unit 1 procedure and will be approved by November 1, 1992.

5.

p_afe of_ Full _qolnplialtp.c

-Duke Power is now in full complianco.

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t' DUKE POWER December 12, l')91 Lacument Control Desk U. S. Nucicar Regulatory Commission Washington, D.

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20555

Subject:

Catawba Nuclear Station Docket No. 50-413 LER 413/91-20 Gentlemen:

Attached is Licensee Event Report 413/91-20, concerning TECHNICAL SPECIFICATION 3.0.3 ENTRY DUE TO TWO INOPERABLE TRAINS OF THE CONTROL ROOM VENTILATION SYSTEM.

This event was considered to be of no significance with r2spect to the health and satety of the public.

Very truly yours, W. R. McCollura /

Station Manager ken:LER-NRC. GM xc:

Mr. S. D. Ebneter M & M N clear Insurera Regional Administrator, Region II 1221 Avenues of the Aner icas U. S. Nuclear Regulatory Cormnission New York, NY 10020 101 Marietta Street, h"<i, Suite 2900 Atlanta, GA 30323 P, E. Martin IMPO Records Center U. S. Nuclear Regulatory Cormniasion Saite 1500 Office of Nuclear Reactor Regulation 1100 Circle 75 Parkway Washington, D. C.

20555 Atlanta, GA 30335 Mr. W. T. Orders NRC Resident Inapector Catawba Nucleer Station h."$CDh

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1991, at 1300 hours0.015 days 0.361 hours 0.00215 weeks 4.9465e-4 months , with Unit 1 in Mode 1, Power Operation, at 93 percent power and Unit 2 in Mode 5, Cold Shutdown. Operations attempted to awap to Train A of the Control 'rtoom Area Ventilation and Chilled Water (VC/YC) System. During this activity, it was discover 9d that breaker IEKPG ir22, Train A VC/YC System Controls, was open. The breaker was last functionally demonstru ed to be closed on September 11 at 2210 hours0.0256 days 0.614 hours 0.00365 weeks 8.40905e-4 months . A Leview of all activities between Septerbor 11 at 2210 hours0.0256 days 0.614 hours 0.00365 weeks 8.40905e-4 months , and September 15 at 1300 hours0.015 days 0.361 hours 0.00215 weeks 4.9465e-4 months did not clearly reveal how/when IEKPG #22 was opened.

However, it is_connidered most pecbable that lEKPC v22 was opened between 0930 and 1520 hours0.0176 days 0.422 hours 0.00251 weeks 5.7836e-4 months on september 13.

Train A VC/YC had been declared inoperable on September 13 from 0455 hours0.00527 days 0.126 hours 7.523148e-4 weeks 1.731275e-4 months to 2340 hours0.0271 days 0.65 hours 0.00387 weeks 8.9037e-4 months for work on various Train A components.

Prior to this work. a tigout was placed to open IEKpG #21 lastead j

of #22.

It is considered probable that Technical Specification 3.0.J was entered on Septmber 13 from O'310 to 0930 hours0.0108 days 0.258 hours 0.00154 weeks 3.53865e-4 months becauso neither train of VC/YC would have been capable of adequately pressuricing the Control Room.

This incident is attributed to Irappropriate Actim s.

Correctivo actions include formation of a task force to study component mii. positioning events and discussion of t.his incident with Operations personnel.

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The Control Room Area Ventilation (EIIS:UCl (VC) and Chilled Water (EIIS:UEl (YC) Systems combine to form one system which is designed to maintain a suitable environment in the follow 2ng plant necas at all tim : Control room (C/R), Cable Room, Ba+. tory [E1IS:DTRY) Rooms, Switchgear Roon s, Motor fEIIS:M0] Control Center (MCC) Rooms, and the Electrical Penetration Rcoms at elevetion SH + 0.

The VC/YC System is shared between both Units and cot.sists of two 100% redundant trains of equipment. Each is capable of being powered by Unit 1 or Unit 2 Essential Auxiliary Power, but under normal conditions both trains are aligned to Unit 1 Two Diesel Generat. ors (Ells: GEN] (D/Gs) are provided per U,-it to energize the Essential Auxiliary Power buses during emergency conditions.

The portion of the VC/YC System serving the C/R includes two 100% capacity air handling units (ICR-AHU-1 for Tra!n A and 2CR-AHU-1 for Train B), two '.00%

capacity emcke purgo fans [EIIS:BLO), and two 100% capanity outsido air pressurizing filter [EIIS:FLT] trains (ICRA-PFT-1 for Train A and 2CRA-PFT-1 for Train B).

Broakers (EIIS:BRK] 1EKPG N22 (Train A) and 2EKPH #22 (Train B) provido control power for permissivea tu VC/YC System components including CR-AHUs, CRA-PFTs, and system dampers. With either of these bruakers open, the recpective train related components would be un/1ble to start /aliga in response to a safety injection signal.

Operations Technical Memorandum 21-07 states that in the event that a C/R AHU or Pressurizing Filter Train is taken out of service, the pressurization of the C/R may be degraded unless certain steps are taken. With no action taken, the darpers on the ou* of service train will allga upon receipt of a safety injaction signal but the associated fans will not start due to their being out of service. This results in the in service train recirculating ai-through the out of service train which may degrade the pressure in the C/R, In order to preveat this from happening, the out of service train dampors must remain f

in place to prevent the air from recirculating. This can be accomplished by removing the control power to the permissives for the dampers and fans on the out of servica train. Therefore, the Techr.lcal Memorandum requires that becaker IEKPG #22 be taggad opened when taking AC3-AHU-1 or ICRA-pFT-1 (Train A) out of serv 1ce, and that 2EKPH #22 be tagged oroned when taking 2CR-AHU-1 or 2CRA-PFT-1 (Train B) out of service. These actions would not allow the train related dampers to reposition upon receipt of a safety injection aignal, thus maintaining npposito train C/R pressurization capability.

Technical Specification (T/S) 3.7.6 specities that two independent trains of VC YC shall be operable during all operat.Wnal (nodes.

If one train becomes inoperable while either Unit is in Mode 4, Hot Shutdown, or above, the inoperaule train must be restored to operability within seven days or be in at

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=ar m.,.m least Mode 3, Hot Standby, within the next six hours and in Mode 5, Cold l

Shutdown, within the following 30 hours3.472222e-4 days 0.00833 hours 4.960317e-5 weeks 1.1415e-5 months .

Sutve111ance 4.7.6.e.3 requires that i

at least once per-18 months the sys*em demonstrates the ability to maintain the C/R at a positive pressure of greater than or equal to 1/8 in we relative to adjacent areas.

T/s 3.0.3 is required to be entered when the Unit is operating in a condition prohibited by T/Ss.

M s condition exists when a Li.miting Condition for i

Operation (LCO) is not met except as provided in the associated Action Requirements.

It requP3s that within one hour action shall be initiated to I

place the Unit in a Mt & n which the specification does not apply by placing it, as applicable, int a)

At least Hot Standby in the next 6 hours6.944444e-5 days 0.00167 hours 9.920635e-6 weeks 2.283e-6 months , b)

At least Hot Shutdown within the following 6 hours6.944444e-5 days 0.00167 hours 9.920635e-6 weeks 2.283e-6 months , and c) at least cold shutdown within the subsequent 24 hours2.777778e-4 days 0.00667 hours 3.968254e-5 weeks 9.132e-6 months .

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T/S 3.0.4 states that entry into an Operational Mode shall not be made when the conditions for the LCO are not inet and tho associat+3 action rquires a i

shutdown if they are not net within a specified time interval.

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i EVENT DESCRIPTION on September 7, 1991, at 0105 hours0.00122 days 0.0292 hours 1.736111e-4 weeks 3.99525e-5 months , VC/YC Train B was placed in service = per OP/0/A/6450/11, Control Room Area Ve!.tilation/ Chilled Water System.

i On 5tptember 11, at 0855 hours0.0099 days 0.238 hours 0.00141 weeks 3.253275e-4 months , with-both Units in Mode 1, powe: Speration, VC/YC Train A was declared inoperable for Maintenance to investipto and repair a Freon leak on YC Chiller A.

VC/YC Train B remained in service. Work I

was completed on the YC chiller and at approximately 2210 hours0.0256 days 0.614 hours 0.00365 weeks 8.40905e-4 months VC/YC Train A was placed in service to verify operability of breaker 1 ETA'.7, which had been opened during maintenance work. -The Train A chiller started normally and the breaker passed the operability test. At this time, due to the successful start of the chiller, breaker 1EKpG #22 wt.s known to be closed. Following the startup/shtdown of Train A, VC/YC Train B was placed back in service at approximately 2235 hours0.0259 days 0.621 hours 0.0037 weeks 8.504175e-4 months . At this time, per OP/0/A/6450/11 Enclosure 4.7, breaker 2EKPH #22 was verified closed,-and step 2.1.16 of the procedure _was NA'd.

(Step 2.1.16 indicates that if ICR-AAU-1 or 1CRA PFT-1 is taken out of service, 1EXPG #22 is-required to be opened and tagged.)

On September 13, at 0022 hours2.546296e-4 days 0.00611 hours 3.637566e-5 weeks 8.371e-6 months , Unit i entered Mode 2 and at 0038 hours4.398148e-4 days 0.0106 hours 6.283069e-5 weeks 1.4459e-5 months , entered Mode 1.

on September 13. at 0455 hours0.00527 days 0.126 hours 7.523148e-4 weeks 1.731275e-4 months . VC/YC Train A was declared inoperable for Preventive Maintenance (PM) on several Train A components. This included PMa ~

on the ControlPoom (ICR AHU-1) and Control Ronm Area (1CRA-AHU-1) air handling units.- The worklist from the Operations Unit Manager group noted 9.

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At approximately 0500 hours0.00579 days 0.139 hours 8.267196e-4 weeks 1.9025e-4 months tagout nurrber 01-2764 was issued and placed breaker IEKpG #21 (instead of IEKpG s??)

in the OFLN position.

As noted in the Techt.ical Specification Action Item L39 (TSAIL) and on the tagoul t.heet, this tagout was placed to maintain VC'YC Train B operability.

Independent Verification (IV) of the tagout for IEKpG

21 was performed by s operations Unit Superviso.

Also at approximately 0500 hours0.00579 days 0.139 hours 8.267196e-4 weeks 1.9025e-4 months , tagouts were placed on the Control Room and Control Room Area Air Handling Unit breaktrs, as well as the Switchgear /WU breakers.

On September 13, at 0010 hours1.157407e-4 days 0.00278 hours 1.653439e-5 weeks 3.805e-6 months , Maintenance performed the " correct component verification" on ICR-AHU-1 prior to beginning the pH per Work order Task 91072720 m Following this verification, the required pH was performed on this anit This included removal of the ICR-AHU-1 access doors.

The pH results indicated that the filter, drive belts, and other required inspections were satisfactoty; therefore, no corrective maintenance was performed. At 0930 hours0.0108 days 0.258 hours 0.00154 weeks 3.53865e-4 months , the red tag stubs were signed by Maintenance and returned to operations, indicating all work was complete on ICR-AHU-1.

On Septerr.ber 13, at 1520 hours0.0176 days 0.422 hours 0.00251 weeks 5.7836e-4 months , the correct component verification was performed on ICRA-PTT-1 prior to obtaining a carbon sarnple por Work order Task 91071711-01 (which did nct specif y the use of red tags). The Work Order was stamped " Consult Cor. trol Room SRO prior to Starting Work".

The Bahnson personnel involved recalled contacting the C/R as required. The access panel was then removed and the carbon sample was taken. At 1600 hours0.0185 days 0.444 hours 0.00265 weeks 6.088e-4 months , the Job Supervisor signed the Work Order indicating the task was completed.

On Septerber 13, at approximately 2340 hours0.0271 days 0.65 hours 0.00387 weeks 8.9037e-4 months , the tagout placed on IEKPG #21 was removed and the breaker was closed.

Subsequently, VC/YC Train A was declared operable and removed from TSt.IL.

On September 15, at 1300 hours0.015 days 0.361 hours 0.00215 weeks 4.9465e-4 months , Operations attempted to swap VC/YC from Train D to Train A per op/0/A/6450/11. At this time, breaker IEKPG #22 wan found open. Operations immediately began investigati1g why the breaker was open.

At approximately 1310 hours0.0152 days 0.364 hours 0.00217 weeks 4.98455e-4 months , tagout 01-2764 wau found to bo in err'r (IEKpG

21 tagged instead of IEKpG N22).

At this time breaker 1EKPG N22.,as closed.

CONCLUSION When this incident was initially documented and reviewed as a problem on September 15 and 16, no reportable concerns were identified as a result cf finding 1EKpG #22 open.

Subsequent investigation did conclude that a reportable event had occurred.

On Septerter 15, at 1300 hours0.015 days 0.361 hours 0.00215 weeks 4.9465e-4 months , breakim 1EKpG #22 was found open when VC/YC Train A was thought to be operable.

With this breaker open, Train A is inoperable because the train will not run or start in response to a safety

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,w a wwenoa. ms,mn 41gns1. On September 11, at 2210 hours0.0256 days 0.614 hours 0.00365 weeks 8.40905e-4 months , 1EKPG #22 was known to be closed due to the successful startup of the Train A chiller when verifying operability of broaker 1 ETA-17 All activitier between these two timer that could have involved manipulation of IEKpG #22 were reviewed.

Duri'ig the investigation, the Unit Supervisor that performed the IV on tagout 01-2764 for IEKpG #21 indicated that he is confident that IEKpG #22 was c27 sed at that time (Saptember 13 at C300 hours).

Extensive interviews with Operations p0rsonnel did not reveal any recollection of a request to open IEKpG #22 or any action taken to open the breaker.

Discussions with the day shift on September 13 also did nut reveal any actions taken to open 1EKpG #22. Bahnson personnel that obtained the carbon cample from 1CRA-PTT-1 did not know of the need to open 1EKpG #22 when working in the filter train.

No conclusive evidence was found that would indicate when 1EKpG #22 was opened. Therefore, the work activities during the time period in question were reviewed in an offort to determine the most probable point at which the

-breaker was opened.

The conclusion drawn is that IEKpG #22 was probably opened on September 13 just prior to the carbon sample being taken f rom ICPA-ppt-1 to prevent startup of the component during this activity.

With this conclusion, breaker 1EKpG #22 would have been closed on September 13 from 0810 hours0.00938 days 0.225 hours 0.00134 weeks 3.08205e-4 months to 0930 hours0.0108 days 0.258 hours 0.00154 weeks 3.53865e-4 months during the time the access doors were removed from ICR-AHU-1.

If an SI signal would have been received during this time, VC/YC would not have been able to pressurigo the Control Room to 1/8 in we an required by T/S due to the resulting Train A damper realignment and air flow escape path through the open access doors. Therefore, during this time both trains of VC/YC would have been rendered inoperable requiring entry into T/S 3.0.3.

Normally, thin concern.ls eliminated by tagging out (opening) 1EKpG

22 per Technical Memorandum 21-07.

However, this tagout was improperly prepared and was placed on 1EKpG #21 instead. Another concern associated with IEKPG #22 being opened at this time is that VC/YC Train A would have been inoperable during a period when it was thought to have been operable, specifically from September 13 at approximately 2340 hours0.0271 days 0.65 hours 0.00387 weeks 8.9037e-4 months until the breaker was closed on September 15 at 1310 hours0.0152 days 0.364 hours 0.00217 weeks 4.98455e-4 months . During this time Train B was operable and the T/S Action Statement for T/s 3.7.6 (one train inoperable for less than seven days) was met.

The most conservative assumption (with respect to length of time) is that 2

1EKpG #22 was opened just after September 11 at 2210 hours0.0256 days 0.614 hours 0.00365 weeks 8.40905e-4 months when it was functionally demonstrated to be closed. With this assumption, a concarn weald exist in that Unit 1 changed operating Modes on September 13 at 0022 hours2.546296e-4 days 0.00611 hours 3.637566e-5 weeks 8.371e-6 months (entered Mode 2) and 0038 hours4.398148e-4 days 0.0106 hours 6.283069e-5 weeks 1.4459e-5 months (entered Mode 1) with one VC/YC Train inoperable.

In this case, the requirements of T/S 3.0.4 would not have been met.

Another evncern would exist in that from September 11 at 2210 hours0.0256 days 0.614 hours 0.00365 weeks 8.40905e-4 months to September 13 at 0455 hours0.00527 days 0.126 hours 7.523148e-4 weeks 1.731275e-4 months , and again from September 13 at approximately 2340 hocrs to September 15 at 1310 hours0.0152 days 0.364 hours 0.00217 weeks 4.98455e-4 months , Train A would nave been inoperable when uo ma,o.,

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it was thought to have been oporable.

During these porlods Train B was operable and the T/S Action Staternent wan mot.

The concern 'issociated with the inability to pressurice the Control Room to 1/8 in we with the access doors for ICR-AHU-1 off would not exist since IEKpG #22 would have been open (as required) at this time.

Thic incident is attributed to Inappropriate Actjons. An Inappropriate Action, failure to adhere to policies, directiveo, or management procedures, occurred when breaker 1EKpG #22 was apparently opened without the proper use of an Operations tagout (RER).

The person (s) or work group responsible could net be datermined. Another Inappropriate Action, action taken was incorrect due to lack of attention to detail, c:: curred when tagout 01-27fa4 was prepared litting breaker 1EKPG #21 instead of IEl*pG #22 as required by Technical Memorandum 21-07.

If this tagout had been properly prepared, the concern at:sociated with the inabi Alty to pressurize the Control Room to 1/8 in we with the ICR-AHU-l access doors off would not exist.

Component mispositio4 og events are a recurring problem at Catawba.

Station Management has forined t task force, with representatives from Operations e d other station groups with responsibilities for component operation, to study this problem and mako recommendations to reouce/eilminate these types of incidents.

CORRECTIVE ACTIONS SUBSEQUENT 1)

Breaker 1EKpG #22 was closed.

2)

Station Management has estchlished a task force, with representatives from Operations and other station groups with responsibilitien for component oporation. This task force will study component mispositioning events at Catawba.

This group will make recommendations to reduce /eliminst.e these typeu of incidentr,.

3)

OP/0/A/6450/11 Enclosure 4.7 has been revised to clarify that IEKpG #22 (2EKPH #22) is required to be tagged open.< hon 1(2)CR-AHU-1 and 1(2)CRA-PFT-1 is rendaritd " inoperable" rather than "taken out of service",

s PLANNED 1)

Operations management will emphasize the need for proper use of the Operations tagout system for all components, and the need for attention to detail while preparing Operations togouts.

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The need for a Nuclear Station Modification (HSM) to eliminate the requirement of opening IEKPG #22 (2EXPH #22) during work on 1(2)CR-AHU 1 and 1(2)CRA-PTT-1 will be evaluated.

3)

The component mispositi'aning overits task group will review the i

need for a method to identify the currect positions of low voltage breakers within panelboarda in the plant so that, when working in a panel, it is apparent which breakers are required to be open/ closed.

4)

Planning will add a note to Predefined Work orders for 1(2)CR-AHU-1 and 1(2)CRA-PFT-1 identifying the need for a tagout for 1EF.PG

22 (2EKPH #22) when working in there components.

SAFETY kNAkYSIS Assuming that breaker 1EXPG N22 was opened at the mowt probable time, the safety significance of this condition can be assessed as follows.

Both Trains A & B of VC/YC were operable during the Mode che.nges early in the morning of Septerrier 13.

During the time period from 0010 to 0930, Train A had baun declared inoperable

~out not fully removed from service because Breaker s22 was (most ptobably) still closed.

Dampers associated uth frain A would have re-positioned in response to a safety signal.

For this period of tiano ICR-AHU-l Ja assumed to be open f or filter PMs.

In this alignment it is unlikely the Conta l Room would ba pressurizud to greater than 1/d in we even with the Pressurizing Filter Train able to run due to the amount of flow escaping through the open AHU doors. Therefore, VC/YC is unknowingly in T/S 3.0.3 due to two inoperable trains of VC/YC.

However, the time period for this T/S 3.0.3 is less than the amount allowed in the ACTION for T/S 3.0.3 which allows for one hour to fix the protlem then six t6 shutdown.

Per Operations Technical Memorandum, VC/YC Train A would be recot sithin one hour. Note that this time f rame is a conservatise bounding of the time period that ICR-AHU-1 was breached.

It includes any. time opent exiting the RCA, time the paperwork spent in getting written up by the craft i

people, and time spent waiting for the work crew supervisor review.

Due to the construction of the Control Room at Catawba it.is not likely that being pressurized to less than 1/6 in we would algnificantly af fect Operstor l

Dose. The 1/8 in we is required to compensate for wind and thornal effucta l

along the Control Room pressure boundary which could locally affect inleakage, At Catawba only a small section of the Control Room west wall is exposed to t.he wind and thic is solid concrete with no penetrations. Therefore, wind is l

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..,on an insignificant contributor to Control Room inleakage.

Furtherw ro, of the areas adjacent to the Control Room all the areas receivo some sort of HVAC and therefore are not thermally stratified to any significant degrou because of the mixing action of the HVAC systems.

Additionally, because of the relatively small height of the Coatrol Reom, thermi column ef fects will be minimal.

An analysis of Control Roon pressur a do ~ w acident shows that a positive pressure of approximately 0.015 in :.U2 w.

respect tu t.11 adjacent i

areas except those across the Auxil.'tv %i W dall (OAC Room, Servico Building and oatside).

The Control k w..[

w viary lightly negativo (approyimately.007 in wc) with respect tu veso areas.

This wall and the two doors in it by nature of their construction nre very low teakage. Due to the low differential pressure across this wall

.1, appners t. rat the upper 11mit of 10 cfm unfiltered.in'.cakage into the control Roca. would still be satisfied and Control Room Operator doses would not exceed those stated in the FSAR Dono Ar.alysis.

Per Operations Technical Mamorandum, VC/YC Train A would be rosot within one hour, thus restoring Control koom preusuriration capabillt'/ and eliminating the minor leakage across the "AA" wall.

Prior to September 13 at 1520 hours0.0176 days 0.422 hours 0.00251 weeks 5.7836e-4 months , ureaker N22 is presumec to have been opened, isolating power to the Train A dampers.

Thus, when the A Pressurizing Filter Train (ITT) unit cover was opened f rom 1520 to 1600 hours0.0185 days 0.444 hours 0.00265 weeks 6.088e-4 months to obtain a carbon sample, no impact on Train 8 operabilit( existed.

If, on the other hand, Breaker #22 is 4:ssumed to have been opened shortly af ter it was last confirtned closed (at 2210 hours0.0256 days 0.614 hours 0.00365 weeks 8.40905e-4 months on September 11), the safety significance changes.

In this scenario, the opening of Breaker (22 renders Train A of VC/yc inoperable, but for a length of time within the neven day limit permit.ted by T/Us. Train A would have been unknowingly inoperable when Unit 1 changed modes early on the morning of Iopts:mber 13.

Thus, T/S 3.0.4 was unknowingly violated. Train B war fully operable and capable of fulfilling the required safety function.

During the two maintenanco periods cn September 13, from 0810 to 0930 and f rom 1520 to 1600 hours0.0185 days 0.444 hours 0.00265 weeks 6.088e-4 months , Train A was proporly removed f rom service with Breaker N22 open. Thus, those maintenance activities had no iapact on the operablo VC/YC Train B.

The health and safety of the public were net af fected by thiu inc.ident.

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CVKF POWEk C0!iPAfW/CATAWDA NUCLEAR STATION PIR 0-C'J1-0344/LER 413/91-020 Page 9 ENCLOSURE 8.1

[afety Feview Group Signat9ros Prepared by:

G. T. Ford, Dato:

December 6, 1991 bhlI b,

Date:

i1 Reviewed By:

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a EliCLOSURE U.2 Q ting of Enclonuros Title 8.1 Safety Review Group Signatures 3.2 Listing of Enclosures 8.3 Cause Code Assignments 8.4 CorrectAve Action Schedule 8.5 References B,6 Potontial Problem / Activity Areas 8.7 Safety Review Group connidoration of Part 2.1 Reportability 0.8 Personnel Referenced

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DUY2 POWER COMPANY / CATAWBA !&C1. EAR STATION

.PIR 0-C91 0344/LER 413/91-020 l

Page 10 l

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i FNCLOSURE B.3 i

Caann code Assionnonts I

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Pailure to adhore to poAlcies, directives, or management l

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A3b6 Actica taken was incorrect due to lack of attention to detail i

Contributing cause i

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ENCLOSURE U.4 Corrective-Actiny Schedule l

i 1

. Corrective Actlon Assignod To Due Date.

1 Operations

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2-System Engineering.

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Safety Review 4/1/92 4

Planning /Op9tations 4/1/92 i

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DUFI POWER COMitNY/ CATAWBA N9CLElJ< STATION PIR 0-C91-0344/ TAR 413/91-0:0 Page 11 ENCLOSURif 0.5 Re f o rentyg a

D OP/0/A/6450/11, control Room Area Ventilation / chilled Water System TSAIL Work Order Tasks 91071711 01, 91072720 01, 91072729 01, 91073875 01 Operations Tagout Numbern 01-2764, 01-2744, 11-2569, 01-2757 VC/YC System Description Technical Spccifications C4 ntrol Room logbooka ENCLOSURE 8.6 Potenttal Problog/ Activity Arnas Description 20 Valve / Breaker Micpo itioning 1

. ~ _. _ _. _ _ _ _ _ _.

DUKE ICWE4 COMPANY / CATAWBA NUCLEAR STATION p1R 0+C91 0344/LER 413/91-020 Nga 12 ENCLOSURE 8,7 Safoty Review Group considerat ton of Par t 21 Report ability M No I.

Has a "Defoet" or " Deviation" been Identified in a "Baule X

Component"?

i IT.

Is the "Dofect" or "l' aviation" present in a "Danic component", that is a plant structure, system, ccmponont or part thereof necessary to ensuro:

The' integrity of the reactor coolant boundary?

X 2.

The capability to shutdown reactor and maintain it in a safo shutdown condition?

X 6

3.

Tr.e capability to prevent or initigato the i

consequences of sccidents which could result in potential of f rile exposure cotepar@le to

.those reforred to'in 10CFR100.117 X

Including dealgn, inspection, testing, or consulting

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In the "Bar.ic Component" ope that has been accopted for ownership or instal.'.od, for use.or operation?

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if'a yes in I, 11 and III above, could defect create a

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a' safety limit as.definej in Tech Spoes?

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M S r.W 45 OUNCPOWER fob 4u.ary 13,1992 Document Control Desk U. S. Nuclear Regulatory Cminignion Washington, D.C.

20555 Subjwet:

Catawivi Nuclear Station Dockot No. 50-413 LER 413/92-002 centlemon Attached is Licenseo Evert Report 413/92-002 concerning TECHNICAL SPECIPICATION 3.0.3 ENTRY tXIE TO TWO INOpERAIUI TRA1HS OF THE CONTROL POOM VENTILATION SYSTEM.

This event n a considered to be of no significance with respect t o th a he/ilth and safety of the public.

Very truly yours,

,hf d'

E R. McCollum

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Station Manager

/lho Attachwnt xct Mr. S. D. Ebneter M E M Nuclear Inauroro Regional Administrator, Region II 1221 Avenues of the Americas L D. Nuclear 9egulatory Consnission Now York, NY 10020 101 Marietta Street, NW, Suite 2900 Atlanta, GA 30323 R. E. Martin INPO Records Center U. S. Nuclear Regulatory Ccranionion Duite 1500 Otfice of R,2 clear Hencto' Regulation 1100 Circle 75 Parkway Washington, D.C.

20555 At?.anta, GA 30339 Mr. W. 7. Orders HRC Resident Inspector Catawba Huclear Station

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t On January 16, lW, at 20J0 nouca, with Unita 1 and 2 in flodo 1, lower Operation, Operationa personnel were reviewing activitina associated with startup of the Train 3 Control Wom Area Ventilation and Chilled Water (VC/YC)

System following maintenance.

It was discovered that breaker JEKril #22, Train B VC/YC System Controls, had not been eponed during preceding maintenance activitios as required by Operations Technical Memorandumn. VC/YC Train B had been inoparable on January if, f rom 0353 to 1725 hours0.02 days 0.479 hours 0.00285 weeks 6.563625e-4 months .

During this time, t ht.

Train B Cont rol Pnom Air 11andling Unit was removed f rom acrvice and annociated i

accecs doors were opened to allow for equipment incroctions.

With those accoas panels cpen and 2EKPH #22 closed, VC/YC Train B dampers would havo repositioned upon recolpt of a cafety signal, thus allowing air t' low to escapo through the openings in the syntom.

VC/YC Train A. which was oporable and in service, would not have been ca.7able of adequately pressurizing the Control Room. Tberefore, both VC/YC Trains were Inoperable wh'.le the access panels were open and Technical Specification 3.0.3 was unknow.ingly entered.

This incident is at.t ributed to Inappropriate Act ions, Control Room Operators did not recognize the need to open 2EKPH #22.

Correctivo actione include red tag computer program enhar :orrent s and a Technical Memorandum program review.

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,o...m.,sec,,n w,on liACKGROUND Tho Cont rol Reum Area Ventilat ion l Ells:UC) (VC) and Ch t11od Wat er l Ells:Ur.)

(YC) Systov, combine to form ano syst em which la dealqned t o maintain a nultable envirota nt in the following plant arcan at all limos: Control Room (C/R), Cat le Room, ILt tery l EIIS;BTHY) Rooms, Swit chgear Rooran, Hoto

[EIIS:MO) Control Contor (MCC) Hooma, and th9 Elect rical Penetration Roomn at elovatior S94 6 0.

The VC/YC System in sharno between noth Units and conninta of t wo 1401 re+2ndant trains of equipment.

Each la capable of being powered by Unit 1 or Unit 2 Eonontial Auxiliary Power, but under normal conditionn both trnins are aligned to Unit 1.

Two Diesel Ovnerators [ Ells: GEN) (D/Gn) are pro /ided por Unit to onorgine the Escontial Auxilla y Power buseo during emorgency conditlona.

The portion of tho VC/YC System serving the C/R includon two 100t enpacity air handling units (ICR-AHU-1 for Train A and 2cR-AHU-l for Train B), two 100t capacity smoke purgo f ans (Ells: lit.0), and two 100% capacity outside air pressurizing filter { Ells:F1.T) traint4 (1CRA-PFT*1 for Train A and 2CRA-PFT-1 f or Train ')).

Breakers lEllS:bRK; 1EMPG #22 (Train A) and 2EF"H #22 (Trnin B) provide control power for permicalves to VC/YC System enmponents including CR-/dlun, CRA-PF'Is, and syntem dampora. With eitnor of thoso breakorn open, the respective train related components wou)A be unable to start / align in responce to a safoty injection signal.

Operationo Technical Memorandums (T/Mn) 11 05 (Unit 3) and 21 07 (Unit 2) statov that in the event that a C/R AHU or Pror.surizing riit or Train in tAen out of netvice, the pror,curization of the C'R ruy be degraded untono ce;tein ottpa are t aken. W th no action takon, the dampers on the out of nervice train will tuign upon recolpt of a safoty injectioi. nignal but the anaociated fans-will not ctart due to their being out of servico.

This results in tho in nervice train recirculetAng air through the cut of service train which may degrado the prosnura in the C/R.

In order te provent thia from happening, the out of service tra)n damporn must remitu in place to prevent the air from recirculating.

This can be ac:omplished by removing the cor. trol power to the permissivos for the dampers and f ans on the out of service t rain.

Thorofore, the T/Ms require that breakor 1EKPG N22 bo tagged opened when taking ICk-AllU-l or ICRA-PFT-1 (Train A) out of nervico, and that 2EKPH #22 bn taggod opened when taking 2CR-AHU-l or 2CFiA-PPT 1 (Train D) out of service. Those actions would not allow the train related dampors to reretition upon recoipt of a cafaty injection signal, thus maintaining opp % ito train C/R prosaurization capability.

The T/M program, an specifled in oporstiona Managemont Procedure (CMP) 2-S, la uued by operations (OPS) to provide rahancemonts to en existing proceduro or provide temporary inatructions in the obsence of a Proceaure; however, they j

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0[ q 2 Oj o 0l 3 of 0jF Catawba Nuclear Statian, Unit i Op l 0 l o gglj 912 t e o m.,. u.m.

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,.ne a-w,4.. m thall not conflict with or be aned no a permanont replacernent for oreratira proceaarea.

7, T/M mual not prevont an existing procedure f rom being lollowd, and when being used no a cupplement to a procedure, it must not t'e in the non-conservat've directton. T/Ms are terrpurery in naturo a.id shall have an expiration dato assigned.

The Operationu Unit Managor tu normally responalble for writing and issuing Y/Ms, and reviewirg them to ensure they are deleted or ruinsued prior to the expiration dato.

OMP 2-22, Shif t furnover, requires Shil e Supervisora, Control Room Senior Reactor couratort (C/ R SRO), Acnist ant Shif t Supervisoro, operator at the Controls (OATC), Balance of plant (DOP) Operators, and Non-Licensed Opurators (M/0) to review the T/F bgbook during each shif t chango.

Op/0/ A/6450/11, Control Room A ea Vont 11ntion/ Chilled Water System, Encionure 0.7, Shifting the 7peratinq vc/YC Train, is used whr. switching frorn one VC/YC Train to the other.

Procedure steps 2.1.17/2.2.17 require IEKPG #22/2c.KPH #22 to be tagged OFF when tagging out 1(2)CR-AHU-l and/or 1(2)CRA-PFT-1.

Technical Speeltication (T/b) 3.7.6 specifies that two independent trains of VC/YC Jhall b1 opo"able during all operational modes.

If one train becOmos inopo.ablo while olthtr Unit is la Mode 4, Hot Shutdcen, or above, the

.inope rable train must be rostored to operability wJ thin boven days or be in at Inas; Hode 3, Hot Stendby, within the next a]x hours and.in Mode 5, Colti Shutd>wn, within t he follewing 30 hours3.472222e-4 days 0.00833 hours 4.960317e-5 weeks 1.1415e-5 months .

Survoillance 4.7.6.o.3 roTaires that at loaTt cnce per 18 monthn the ystem demoastrates the ability to maintain the C/R st a positive pressure of greater than or equal to 1/8 in wc relative to adjacent areas.

T/S 3.0.3 is required to be ontored when the Unit is operating in a condition prohibited by T/Ss.

This condition :sxia*.s when i Limiting Condition f or Operation (LCO) in not mot except as provided in the associated Action Requirementa.

It requirvia that ulthin ono hour action shall bo initiated to place the '"4t in a Mode in wnich the specification does not apply by placing J

j it, as applicable, in:

a)

At loat,t Hot Standby in the next 6 hourn, b)

At least Hot Shutdown within the following b hours, and c)

At loaut Cold Shutdown within tho subscquent 24 tours.

EVEN DESCkipTION un January 3.,

1992, at 0239 hours0.00277 days 0.0664 hours 3.95172e-4 weeks 9.09395e-5 months , VC/YC Tra' A was placed in service por l

OP.10/A/6450/11 On'Jenuary 15, 1992, the Operations Unit Manac;er group generated a worklist item for night shift to make and hang tags for seson Work Orders (W/Oa) on VC/yC Train B.

Included in these W/Os were 92001717-01, p-eventive

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A.,m n Maint enance ( hi) on 2CA-AHU-1, and 920017 3 3-01, inspection ot ;'CR D-4 ( ?Ck AllU-l dischargo dampor).

Both of these W/Ou required 2EMXH-FC7B, 2CH-AHU-l power nupply, t o bo tagged open during each respect ive work act ivit y.

On January 15, IW2 during night cht!t, tho work Control Center (WCC) Senior

!=

Reactor Operator (890) reviewed the VC/YC Train H wot klint item and all associated W/09.

He then gave them to Nuclear Operation Specialist (NOR) A to prepare the required togoats.

From approximately 2200 to 2230 hours0.0258 days 0.619 hours 0.00369 weeks 8.48515e-4 months , NOS h preparod the tagoute uaing the correct proplanned tagouta in place on the Operations red tag computer program.

Tagauts02-11b and 22-61 were prepared for W/Os 920017 D-01 and 9200D 34-01, roupect ively.

Each tagout required only 2EMXH-F07B to bo tagged opon; therefore, no taes were inaued for 2LKPH N22.

Tho work package was then ferwarood to Annistant Shif t Supervisor A for review. After his review, he signed the "tagout ordered by" sec'.lon of the tagout shoot.

On January 16, at 0353 houro, with Unita 1 and 2 in Mode 1, lower Operu lon, tha C/R SRO reviewed the work packago and VC/YC Train H wau declared inoperablo.

Sinco VC/YC Train A was operable and already in nervico, Vc/YC a

Trains did not heve to be nwapped por GP/0/A/6450/ll, Encionuro 4.7.

This enclosure contalnu guidarmo on opening breaker 2EKPH #22 (lFEpG #27) to encuro opposite train operability is maintained.

The work package was aubsequently taken to the "horseshoo" area of the C/R.

Unit I and 2 Nuclear Control Operators (NCOs) A and B reviewed ar.d initialed the " Control Foom Acknowledge" section of tageuta 02-115 and 22-61.

At 0425 houru, NCO C opened 2EMXH-F07H and placed both rod tagn on thu breaker.

NOS B performed Independent VerificatAon of thin action.

On January 16, at 0300 houra, the Correct Component Verit ication was perf ormed on 2CR-AHO-1 por W/0 92001737-01.

The AHU accean panels were then removed t o irapoet the condition of the unit'n iliters and boite and other PM requirements.

The results of the inspection indicated all Items were sc.tisfactory; thereforo, no replacements woro neceauary and no work war.

perf ormed. Maintenanco pornonnel involved indicated that the total timo tho accens panels were removed was loss than five minuten.

At 0845 hourn, the "Taak Completion Comments" section of the W/0 was completed iridicating all inspections were satisfoctory.

At 0900 hours0.0104 days 0.25 hours 0.00149 weeks 3.4245e-4 months , the " placement Veri! led By" section was signed on the red tag for tagout 22-61 prior to tr.spection of damper ?cR-D-4 per W/0 92001733-01.

Bahnson personnel than ontored the duct to perform the insp9ctton. The resulto of the inspection woro satisf actory, and the personnel then exited t he dactwork. Dahnnen porconnel indicated t hat the tot al t ime t he accet.n door wan open was lous than three minutec.

At 0915 houra, the red taq ntub was signed indicat ing work wan completo, m

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=*c u. e On Janitary 16, at 1640 hours0.019 days 0.456 hours 0.00271 weeks 6.2402e-4 months , red tugn f or tagouts 02-11') and 22-61 were romoved from 2ERXH4 07B and the breaker was closed. VC/YC was t.absequently

.;Wdpped [ rom Train A to Train B por OP/0/A/6450/11, Enclosure 4.7.

At 1725 i

haurs, VC/YC Train b was declared operable.

At 2000 hours0.0231 days 0.556 hours 0.00331 weeks 7.61e-4 months , while reviewing l

activities associated with startup of VC/YC Train B, Assintant Shift Supervisor A discovered that breaker 2EXPH #27 was not Lnggoa open as required while 2CR-NIU-1 wan tagged out.

l CONCLUSION This incident is attributed to Inappropriate Actions, CRos did not recognize the need to open breaker 2EKPH #22 per T/Ms 11-05 and 21-07 when 2CR-NIU-1 was removed from service. During preparationa to tag out 2CH-NIO-1 (breaker 2EMXH-F078), Assistant Shift Supervicor A,-the C/R SRO, and NCOs A and B reviewed tagouts02-115 and 22-61 but did not identify the need to open 2EKPH 922.

Each operator had reviewed the T/M logbook during shift turnovor, and during subcoquent interviews ench operator indicated that he was aware of t he requirements of the T/Ms. This incident was discusseo with all Operations porconnel involved, and wau discussed during the noy.t Snift Supervisor's mooting.

In addition, this incident will be discussed with all shift personnel during upcoming shift meetings.

The 600V power supply breakers for 1(2)CR-NiU-1 and 1(2)CRA-PFT-1 have had whito Removal and Restoration (RGR) tags placed with the breakers ON.

Before those breakers can be opened, the whito Pt.R tags must be cleared which toquires GRO approval, This will provido the SRO with another opport 2nity to ensure IEKpG #22 (2EKPH #22) is opened when required. This action was taken no that a physical barrior would bo in place prior to opening the 600V breaker.

The OPS red tag computer program is used by operatore to initiato and print tagout sheets and rad / white tags. An enhancement had been made to the program ao that when the 600V breakers for 1(2)CR-NIU-1 or 1(2)CPJs-PFT-1 are tagged out, a prompt automatically apposrs to allow the operator to also print a red tag for IEKPG #22 (2EKPH #22).

In addition, a note has been added to the "Special Instructions" coction identifying the need to cron IEKPG #22 (2EKPH

22) when removing 1(2)CR-AHU-1 or 1(2)CRA-PFT-1 frort servico.

This note will automatically print out on the tagout nheet at the lino item for each required 600V breaker. A further enhancement will be made in the program with respect

- to Special Instructions. During interviews, operators expressed concerns that Special Instructions do no always appear on the computer screen level from which tagout sheets are printed. Thorofore, the operator preparing the tagout may not soo the Special Instructions on the screen. To provide e.nother level of defense to provent further incicents from occurring, the red tag computer program will be enhanced so that Special Instructions appear at the screen level from which togouts are printed.

In addition, a change has been made to the Technical Specification Action Item bogbook (TSAIL) computer program so

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,=.,ues.,mu,mn that when either VC/YC train is declared inoperablo, a special noto is automatically placed in TSAIL referencing 1EKPG #22 (2EKPli 422) and this Problem Investigation Repott (PJR).

Preplanned W/Os fer 1(2)CR-AHU-1 and 1(2)CRA PFT-1 hTvo hed notes eided in the Special Instructions section identifying the need to open IEKIG #22 (2EMPd

22) when working on these components.

This action was taker, on January 14, 1992 in response to LER 413/91-020, Technical Specificetion 3.0.3 Entry Due To Two Inoperablo Trains of the Control Room Ventilation System.

However, the W/Os ur:ed on January 16 woro printed before this dato and did not contain the Special Instructions.

Future W/Os for these components will have the notes autcoatically printed on them, pcoviding another means to alert operators af the need to open 1EKPG N22 (2EXPH #22).

Incidents involving missed T/M requirements are recurring at Catawba, LER 413/91-020 involved a T/S 3.0.3 entry because 1EKPG #22 was not properly tagged out during Train A VC/yC work.

Corrective action was taken after this incident to clarify in OP/0/A/6450/11, Enclosuro 4.7 when lEKPG c22 (2EKPH

22) is required to be open. The correctivo action did not address situationa in which the procedure was not needed.

LER 413/92-001 involved a T/S violation due to an irlproporly performed T/S surveillance becausw an action was not taken per a T/M. OPS managomont will roview OMP 2-5 and make revisions to otrongthen the management controls over the process of using T/Ha. Proposed changsa includo plans to reduce tho overall number of T/Ma, atrict requirements for setting expiration datos, and higher levels of management approval for extension of expiration dates.

This plannod corrective action is also documented in LER 413/92-001.

CORRECTIVE ACTION SUBSEQUENT 1)

The 600V power supply broakors for 1(2)CR-AllU-1 and 1(2)CRA-PFT-1 have boon white tagged "0N".

2)

Enhancements have been mado to the OPS red tag computer program so that when a tagout is made for the 600V breakers for 1(2)CR-AHU-1 and 1(2)CRA-PFT-1, a prorrpt appears allowing tho operator to also print a red tag for IEKPG #22 (2EKPH N22).

3)

A note was added to the "Special Instructiona" nection of the OPS red tag computer program identifyang the need to open 1EKPG #22 (2EKPH #22) when tagging out the 600V breakers for 1(2)CR-AHU-1 and 1(2)CRA-PPT-1.

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4) wi+ h this event.

A change has been made to the TSAIL computer program no that when a crecia*. note is 5) either VC//C train is declared inoperablo, automatical y placed in TSAIL referencing llWpG #22 (2EKPH #22) and this Plk.

PLAtmED This incident will be discussed with OPS shift personnel.

1)

An enhancement will be made to the OPS red tag computer progra.m so 2) that Special Instructions will appear on the screen level f rom which tagouta are printed.

will review CMP 2-b and make revisions to OPS management strengthen the management controls over the process of using T/Ms.

3)

SAFETY _ ANALYSIS During VC/YC Train B was inoperable on January 16 f rom 03S3 to l'/25 hours.However, 2CR-AHU-1 this timo period, 2CRA-PFT-1 was not removed from service.

was removed from service and air flow eucape paths were present when its During PM activities por W/0 92001717-associated access panclu were removed.

01, the Correct Component Verification was performed at 0600 hours0.00694 days 0.167 hours 9.920635e-4 weeks 2.283e-4 months prior to The W/0 " Task Completion Comments" were recorded at 0845 beginning work.The PM results were documented as satisfactory, and no filters or Maintenance personnel involved ostimated the total hours.

belts were changed out.

During the time the access panels were removed was less than five minutes.the " Placement Verified By" 92001733-01, 2CR-D-4 dampor insp2ction per N/O section of the red tag was signed at 0900 hours0.0104 days 0.25 hours 0.00149 weeks 3.4245e-4 months prior to beginning work.

in order to perform the inspection, the duct Dahnson personnel indicated that, access door is opened, a person enters the ductwork, the access door is closed, the inspection is performed, then the access door is opened to allow Involved personnel estimated the total time the person to exit the ductwork.

At 0915 hours0.0106 days 0.254 hours 0.00151 weeks 3.481575e-4 months , the the access door was opened to be less than three minutes.

red tag stubs were signed indicating work was complete.

it is During the time periods that tbo Train B access panels were open, unlikely the C/R would be pressurized to greater than 1/6 in we by VC/YC Train A even with the Pressurizing Filter Train able to run due to the amount of With 2EKPH #22 closed, dampers flow escaping the system through access doors.B would have repositioned in response to a associated with Tra.

Therefore, VL/YC was unknowingly in T/S 3.0.3 during two short time f

signal.

intervals due to two inoperable trains (unable to pressurize the C/R).

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.,nn Howover, the timo period for thin T/S 3.0.3 is less than the amount allowed in the ACTION for T/3 3.0.3 which allows for one hoar to fix the problem thon six to shutdown.

por Operat ionn Technical Memm andum, VC/YC Train B would be roset within one hour.

Duo to the construction of the cont rol Room at Catawba it la not 11koly that being pressurized to loan than 1/8 in we would significantly of fcct Operator Dose. Tho 1/8 in we is required to compentutte f or wind and thorn.al ef tectn alor.g the Control Room pressure boundary which could local'y affoct iniaakage.

At Catawba only a small section of thn Control Room west wall in expcnod to the wind and this in solid concrete with no penetrationn. Therefoto, wind in an insignificant contribittor to control Room inloakage, furthermore, af the areas adjacent to the Control Roorr all the arcan recolvo como sort of HVAC and therefore are not thormally stratified to any significant degree because of the mixing action of t he ilVAC systems. Additicnally, because of the relatively small height of the control Bonm, thermal column offoetu will be n.i nimal.

An analysis of Control Room pressuren during a postulated accident noows that a positivo pressure of approximctely 0.015 in we will exist with r.npoet to all adjacent areas except th e actocs the Auxiliary Building "Ah" wall (OAC Room, Servico Building and outside). The Control Room will be 9ery slightly negativo (approximately.007 in sc) with respect to thoso arena.

Thin wall and the two doorn in it by nature of their construction are very low leakage.

Duo to the low differnntial pressure across this wall it appoern that the upper limit of 10 cfm unfiltered iulnakago into the Control koom would utill bo satisflod and Control Room Operatnr doses would not excood those stated in the FSAR Doce Analysia.

Per Operations Tochnical Memorandum, VC/YC Train B would be reset within one hour, thus routoring Control Poom pronourizatien capability and eliminating tho ininor leakago acresa the "AA" wall.

It has been concluded thut, although the T/S required 1/8 in sic prennurization

.requiremont may rot ha.vo boon achieved under all conditions, the consequencon to C/R habitability and Oporator Doso wculd not be significant.

'!he health and safety of the puhlle v. ore not af fected by thin incident.

4

DUKE WWEP coMPANV/ CATAWBA NUC15.AK STAT 1014 PIR 0-c92-0013/LER 413/92-002 Pago 9 ENCLOSURE H.1 P.afety imview Group signat uren Prepared By:

G. T. Ford Date:

February i 199?

Reviewed By:

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Approved-By:

Chairman, SRG ENCLOSURE 8.2 1.inting of Enclosures W

Title 0.1 Safety Review Group Signatures 8.2 Listing of Enclosures 8.3 Cause Code Ascignments 8.4 Corrective Action Schedulo 8.5 References 3.6 Safety Review Group Consideration of Part 21 Reportability 8.7-Personnel Reforenced

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DUKl* POWER COMPANY / CATAWBA NUCLEAll STATION I

PIR 0-C92-0013/LEH 413/92 002 l' age 10 I

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ENCLOSURE 6.3 caune Code Anstanment n f

t Root Caunes l

A3a1 Inappropriate Action, no action taken when required bec="So j

the nood was not recognized i

-Contributing Caumon None-t ENCLOSURE 8.4 CorrectIvo Action Schedule i

l Correctivo Action N Assigned To Duo Dato 1

op1rrations 4/30/92 2

Operations 7/31/92

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Operations 4/1/92 (This C/A also appears on LER 413/92-001)

EHCLOSURE 5.5' 1

Refereness.

I-CNSD 1211.00-06

[

OP/0/A/6450/11, control Room Area Ventilation / Chilled Water System

.OMP.2-5, Opetations Work List:and Technical Memorandums

+

.OMP'2-22, Shitt Turnover l-

. Catawba Technical Specifications p

= Operations Technical Memorandums 11-05, 21-07 TSAIL

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_. _. _ _. ~. - _. _ _ - _ _

s DUXY, KCER COMPA!iY/CATAWitA 110 CLEAR STAT 101, PIR 0 C92-0013/LER 413/92-002 Page 11 FliCLOSURE B.6 r.af o,ty koview Group considerat ion of Part 21 Pcj>ortability Icn !!2_

I.18as a " Defect" or " Deviation" been identified in a "llanic X

Component."?

II. la the "Dofoct" or "Doviation" prouent in a "11asic Component", that is a plant structuro, system, component or part thereof necessary to ensuro 3.

Tho intocrity of the reactor coolant boundary?

X 2.

The capability to shutdown roactor and maintain it in a safe shutdown condition?

X 3.

The capability to provent or mitigato the consequences of accidents which could resul.t in potential off-site exposure comparable to those referrod to in 10CFR100,117

_X_

Including design, inspection, testing, or consulting services rotated thoroto, III, Is the "llasic Componont" one that han boon accepted for ownership or installed for use or operation?

X If a yes in I,11 and III above, could def ect create a cubstantial safety hazard or contribute to exceeding of X

a safety liinit. an defined in Tech Specs?

. Comments 2//d[?4 Propared Ilyi bmt+

Date:

Saf9ty Roview Group O//2/U

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Date:

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COMPONENT'MISPOSITIONINGS We have recently had several events to occur in the plant involving component sispositionings. Two incidents involved 2SM-103 and 2SV-66 which were signed off as " CLOSED" in the containment integrity PT but were actually "0 PEN" (one was red tagged open on the backseat, the Other was white tagged open).

We also had a problem with 2tN-291 being signed of f in the lineup as " LOCKED CLOSED" when it was actually partially open causing the run out, of the !N pump during testing.

2NV-291 had been backseated on an R&R and van very hard to operate.

2HI-118 and 2NI-150 were signed off in the control room as being " CLOSED" when they were actually "0 PEN" resulting in N1 pump runout.

The containment integrity problems caused a significant delay in the refueling activities as we rechecked our PT's and the NI and !W incidents could have resulted in pump damage.

The NRC has been very concerned about these incidents.

Tuesday nignt an emergency meeting of the CIAT (Continuous Improvement Action Team) was called and they recommended a two-phase approacht A.

Establish a

Component Hispositioning Tasm to

evaluate, investigate, and trend component mispositionings.

This teap would consist of personnel from OPS, IAE, Maint., Performance, Chemistry, HPET (Human Parformance Excellence Team),

and other,s as appropriate.

B.

Short-term suggestfons:

1.

Establish a containment Integrity coordinator (Parallel position to Containment Closure RO) 2.

Caution people on backseated and hard to operate valves, n.

Define backseat and proper way to open valves b.

Ask for help on valve positioning (to break frca or double verify) 1.

Keep a list of problem valves for NLO use 2.

Be careful with valva vranches (personnel safety and valve damage) r the remainder of the outage list the position of all 3.

t valvos that are backseated as "BACKSEATED" on the Red (or White) tag and R&R.

4.

As a part of verifying valve position (especially closure / integrity), read and evaluate all tags on valves.

(This sounds like a simple item but is definitely an aid in determining final valve position).

In our jobs we must take thu time to do it right the first time" while working efficiently co return the unit to service.

' lou have done an excellent job this outage processing a tremondous amount of work correctly - let's learn from cur mista:tes and continue to get i

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If you have items you would like to be considered by the component Hispositioning Team, please submit them to your shift CIA team member.

N A pac hob Ferguson Shift operation Manager

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SH!ri OPERATIOM PRIACERS BRIE f DG *******

Novcaber 25, 1991 To All operations Shift Personnel

SUBJECT:

Valva Positioning Basics In the process of looking into our recont incidents it was suggested that V8 may need to vrite down a basic process for properly verifying valve position.

We do have a broad spectrum of experience levels across operations and this may be more useful to some than othern, but at least we can be assured that he are all performing this tack consistently.

This process is intended to apply to alignir.g valves per a valve checklist in a procedure or by an R&R.

j 1)

Maintain the checklist, procedure, R&R (or a copy) in your possession at all times.

I 2)

Locate the valve to ha aligned or verified - use the valve

book, R&R computer, tag

stubs, or procedure checklist to obtain the coordinates and elevation of the valve.

3)

Self-verify (or allow the IV'er if required) to verify thac the valve number in the controlling document matches the label on the valve - Unit - System - Valve Number -

Train.

4)

Read and evaluate any red or white tags hanging on a valve - Don't assume a tag on a valve means it is open or closed - read the tag - look out for backseated valves!

(referencing other R&R's in the affected procedures will help here too).

5)

Place your " hands 2n" the valve and Nova it toward the required position.

Be sure to self-varity heral If you believs the valve is in the desired position - still attempt to move it in the open or closed ditaction to ensure its position is correct. (Note this does not apply to valves in the " throttled" position).

If you opened a valve and you hear flow, is this expected? If not, close the valve and notify your supervor.

6)

If a valve is too hard for you co turn or you naed a second opinion, ask for help! - don't hesitate to ask for help.

Other.s are more than villing to help you out, and l

chances are you'll be able to return the favor someday.

l 7) once you have positioned a valve or verified its position sign its position off on the controlling document l

(checklist, procodure or RER in your ' possession) immediately.

Self-verify that you are signing off the valve you have just manipulated.

De sure to sign them off gne at a time.

Do not rely on memory to sign several valves of f at once.

This is a dangerous practice and has caused many errors in the past.

8)

If IV is required have the IV'er repeat these steps to i

verify tho velvo prioition and th0n sign of f tho valvo position for that vaiva (again signing than off one at a time).

As with any successful team, the ones that really excel are those who executs the basic elements of a gar.e or job the most effectively.

Let's make these basic steps a pset of our everyday routint unen verifying valvo positions (note that the sa:ne principles can be applied to electrica* breakar positions).

By practicing these steps we will take operations a step closer to l

becoming the excellent team we all are striving to baconi.

/$o$ h- -

Bob Ferguson Shift operations Manager

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E. M. Gaddie Ops Section Managers E

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ATTACllM1:!JT 3 P

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. w-l DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413,414/91-027 ATTACHMENT 3 COMPONENT POSITIONING TEAM -_ACTIVITI Q AND PESULTj i

Station managetrent, in conjunction with the ontinuous improvement Action Team established the Component Positioning Team (CPT) with representatives from Operations, Performance, Chemistry, Inst ument and Electrical (IAE), Training, Safety Review,-and the Human Performance Excellence Team. - The mission of the CPT is to help achieve a goal of maintaining all components in their correct position at all times.

In carrying out its mission, the CPT is accountable for accomplishing the'following objectives..

l.

To apply a broad perspective that encompasses all work groups involved in achieving the goal.

is r

2.

To work.with all a.fected work groups, communicating and involving them in the CPT's activities, to forge a cons 9nsus action plan.

3.

To encourage and support employees in candid reporting o' component mispcsitioning events.

4.

To analyce.past and present component mispositioning events to determine j

root causen and contributing factors.

'-5.

, To evaluate' alternative courses of action and recommend the best for implementation.

16.

To develop a method for mearuring progress towcrd the stated goal, i

Significant progressfhas been made toward accompliching these objectives. A charter for the CPT has-been establishad and'is attached. The team meets weekly as well as. devoting haditional-time tar the investigation and analysis of mispositioning' events.

-T!.e CPT members are being assigned to investigate all mjsoositioning evants at Catawba. -All team members have received training in Roo-Cause Analysis! techniques. A duty rotation and call-out process has been(established to support investigations outside normal work hours. A list of mispositior.ing evert attributes 1or categories has been established to help-focus analysis and promote thorough, consistent evaluations.

~Since implementction of. Catawba's Lower Tier Event Reporting Program on October 1, 1991, 38~mispoaltioning events have-been reported.- This high number of reported events is both expected and encouraged, for unless problems

-are identif3ed and reported they cannot'be corrected. Thirty (30) past and current.mispositioning' events nave already been analyzed in detail.

Investigations are' continuing into recent events.

Considerable effort-is being expended to communicate with site staff and employees.

It is clearly understood that unless every person working at Catawba accepts accountability for correctly positioning every component they work with, achievement'of our goal will not occur. The significance of.this problem and the need for-improved performance has been discussed in the Site m

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JVice-President's " Team Notes" on-soveral occasions. The Station Manager

<iasuod a-iotter to:all'employons explaining the insuo and their rolo in

'rosolving it.

Thia lotter was covered _by dupervinors witn all employoen.

An Earticle has appeared in the site Newsletter.

Tho CPT in preparing manthly summary reports and issuhg weekly bulletina to keep employees abronut of mispositioninja events.

i n

lIn the miopositioning uvents analyzed to date, six recurring problem aroan/ issues havo boon identified.

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+

inadequato; verification of methodu inadequato or doficient procedures poor work practicos outage-activity planning / scheduling eventa-involving equipment removal and restoration events involving hardware / equipment problems-

-With: respect to the first problem area, inadequato verification methods, six out of 1s inluponitioning events could have laen provented by thorough "oeli-verification" by the individual (n) involved.

This problem area, and the associated events, was discuaned by CPT members with the plant staff during a broad (but unstructured [~nurvoy.

Feedback from the staff confirmed the Pnportance of self-verification as, the first line of def onse against emispoaltioning ovents.

(The team aloo reco1ved_ considerable foodback on the subfoet of-Independent Verificat16n which the team providod-to station

-management.. See_ Attachment /.)

The CPT han initiated an offort to emphas;zo and promoto-good self-vorifi_, tlon.by all employcos. Tho CPT will work with station managomont to continue this effort.

Withiroupect to the second problem area,. inadequate or deficient procedures, the team concluded that 8 outLof 14 ovents-woro directly attributable to deficient proceduros being used, and that 6 of these events' involved procedures-with missing _or incomplete work.quidanco.

Based on-its broad

experience, the CPT concluded that como procedure deficiencies have gono

_ uncorrected ~because the effort required was' perceived to be too great oritoo

' lengthy. The CPT has recommended that the procedure _ chango procosa, within

n11 work groupa, be. examined and wherover ponsiblo_mado simpler, moro-responnivo,: and not burdonsome on the person who :1dentifies the need for a

= procedure change. The_CPT.haa also recommended a clone working partnership-betwoon procedure users and procedure writers.

Finally. the CPT han

+

frocommended that an effective'proceduro validation and verification procosa be-l established within all work groups.

1

The Component positioning Tee._is continuing to work'diligentlv to help achievo_the_. goal of "zero minpositioningo".

Son Attached CPT Conclusions and

-Recommendations! dated March 31, 1992. A'aignificant-amount of offort has boon iexpended wIth tangible-results thusLfar; however, much remains to bo dono.

-MoroLmlopositioning eventa will to investigated. Additional data will be

. compiled and analyzed. Additional recurring problema/insuoc will likely bc

-foundfond further recommendations' developed. A measurom nt. tool!will be developed..And most; importantly, ongoing discussion and ommunication of the CPT's activitica and results will take piaco.

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CATAWBA COMPONENT POSITIONING TEAM 4

CPARTER

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. Ws are ct mmitted to operating our plant safely and 4

of ficiently with all cotaponents correctly positioned at all

timoa,

?

t IMISS10Hi The Component Posit: ion Team (CPT) has been est ablished to help achieve tha -Anvu goal by communicating-the immrtance p

of this goal, by identifying barriers or obstacles to its achievement,. by recommending effative means to overcomo

[

obstacles and barriora, and by establishing a means to measure progress toward this goal.

OBJECTIVES:

In carry}ng out its mission, the CPT is accountable for accomplishing the.following objectiven.

1)

To apply a broad perspective t hat encompesses all work

[

groups involved in achieving this goal.

N

~ 2)

To work with all affected groups, communicating and

[

-involving them 1.n tho CPT's activities, to forge a

~

L consensus action plan, j;

. 3)

To encourage and support employees in car.did reporting

- of component mispositioning events.

' 4) ~

To analyze past:and present component-mispositioning events to determino root causes and contributing factors.

4

(

.-5)-

i To evaluate alternative courses of-action-and recommend the best for implementation.

-6)

- To develop a method for measuring progress--toward the stated goal.

COMPOSITION:

Tho' team will be composed of members of the sito plaff and management representing the principla work groups who.

position components.. Members of the team will be appointed by site management with Lheir commitment to making sufficient timo available for toom members-to actively

. p uticipate, i

-.. DURATION:

Tho CPT will remain in existence until its mission and objectives are achieved.

P Management may continue'the CPT in an ongoing' role to measure progrens toward the goal. The CPT may be tasked to assess _the effectiveness of implemented solutions.

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t It'is expected that the CPT will, over time, evolve into an olement of the Finaging for Excellenco effort with the responsibility of pursuing continuous,improygmont in component position activities.

PROCESS:

The CPT, and various sub-committees as noodod, will meet regularly to carryout'their work. Team memborn will carryout assignments between meetings. Support from outsido the' team wil1 be used as needed.

Minutos of team meetings will be distributed promptly.

Site management will-be kept advised of the team'a prc9rens throtgh mcathly briefings.

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fComponent. Poaltionind! Tenm

Conclusion 1and Reconanon"ationn March 11, 1992 l

CONCIA!SION information end -insight gained f rom analyzing old mispositioning evont PIRu is minimal due to rilssing information; too many anounpt ions had to be made to f111' In tho anps. _ Therefory, the CPT will concentruo current and f uture j

ovonts.

_ Cf1NCL11S f 0N -

It Aa-important to inventigato mispoultioning events quickly after they occur, before Anformation IP forgotton,- or - the peoplc involved "over-nnEWze" t heir

actiohal CONCillSION Based en detailed analyals of 14 recent eventa and Ib_ older eventn, tho

. following:recorring-prohlom aroaa/lasues.havo been Adontiflod.

Each area will-be dnhlyzed further.

-inadequate verif$ cation methoda

'Anadequato'or deficient procedureu poor' work practicea

=-

g outage actAvity-planning /ucheduling Dr.R diccrepanclea hardwaro:problema?

CONCLilS10NS t-E!nadequate-Wirlficat ton - Methods CA.

Inoffeetivo self-verlfication. won a contrit>uting factor in 6 out of 14' covents.

Effectivo self-verification:-could have provented 411 6=eventn.

B.

Ef f ect ivo' self-verificat tort by all employcos;1a the first-line of-defense ogAinnt mispositioning eventai -Solf-vorifAcation'in a vory-Timportant' elernent of verification, as.J!.mportant to sofo oporation na

~.~ double or separste verifIcatjon.

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Emphaals en nelf-verification reinforces' employee ownerahlp; egohoalu oni n

EI/V can.dlluteLow,orship.

.D.

' Basod-on (teedback f rom unployee.9,; relf-verificaticM is not widely.

understood, nor widely practiced. - 11any personnel havo not heard of "solta hocking".

"PIJASEtLISTEN" 'as n-calf-seck concept han f ailed; 11:

c is scen an,too complex /cumbersemo. ' Classroom training alone wan i

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insufficient =toLJngrainethe concept in employenu.-

E.

1 Achieving ef fectivo, wide spread self-verification will require l eh_gvlor l

-rnod1Qeation much note than skill _devoltveent.

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$FCOMMRNDATIONS - Rhlt-Verification A.

- Thtf effort to build.uolf-verif icatica should stay'out of the clausrocm, j

1t? shohld be toght, coachecs, and promoted _ by managemant 'and

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sapetvision, l

1 B.

Tho "PTAH" concept (stop,.think, act, review) should be incorporated in plarC of "? LEASE. IJSTEN" e j

.C, _

Employeas should _ hear about the con equences of' not. using unif-verification, 1.o., what can happen. Tho. CPT will be ccennicating nilspositioning evento that involvo poor self-vorification.

r D.

Jelf-Vorification should be covered in crow tallgate mootings as another element of the expected Hork evolution.

CONCLUSTONS - Inder>endent Verification Policy i

A.

The enrient Indepsndant Verificatlon (1/V) policy is inconciatently imphamentod betweten-station work groups. There is little common Q

understanding of either the philosophy of.or method of verit.ication.

B!

. Varying interpretation of. 1/V require'ments and expectations by static.c groups has led to inconsistent ~.implesnentation and confusion among

' personnel 4

.C.

Contiinious c,mpmnication of the intent of and uxpnctat.lona for I/V has

- not take" plhce.

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RECOMMEt4DM' TUNS

- I/V Policy

Ac A'revjsed Catawba Situ 7./V policy uhould be in place by 6/1/92.

B..

.-Mnnagamoot should establich atiJ!/V)Jmpleacntation 'Toam by "1/15/92-with

, representatives 'lrosa all utation work gro6pa11ndolved i4 T.*V,- includinf Operations, _ 'A;.stru wnt. and Fiectrical;, _ Che'nist ry< System Engineering; Training fiervices, and Mechanical daintenanco. The CPT abould be a

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repressentsd_ on the team. The I/V team rhoui.d be charged-With developing

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_ _a Dplea,entut; ion' plan. lyy -$/1/92 and. carrying -1_t out.

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C.7 The Catawb61/V policy should bu consistent!with thu tec%nical.jaidance

- do.t-.forth'in the Doparuwit Directivo. -

Cathba policy nhouldAlways call for calf-vorific.t ion but only 3mposo'

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DV?relSV/ubesngrquirb ; by mgulation or satety significance.

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E, Ttu team 'should deteririne Me mout-of fcctive way to'.. train on; the I

techniquea Lot "senannt9" and " double" verification. - inchding classe".mm,

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l task'.1ista,- qalification 'statidards, ute, i P.

L ThuRcplementation ply shauid susurm canalutency in when, where, and now CV and OV n's perferred at ' Catawba,. doth within-work. groups and l4 between work gr.mps.

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C; The 1/V team should determine how SV and DV will bo implemented in

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procedures and shculd includo representativo procedure writers and j

users, n

l-CONCLUSIONS - Prohlom Awarenen l

A During the survey, very feu people were aware of misposit.loning eventu occurring; however, many said that they wanted tr hear <ux>ut the events F

'in~a conciae manner.

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.B.

Many vark groups. believed chat th did not have a problem with j#

mispositioning events, they believed that oth sork groups had n problem.

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=REf*OMMENDAT1H - Problem Awawnoun i,

.CPT will continuo to emphani e br.ad awareness within the plant staff of the

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significance of this problem and the occurrence of miipositioning ovento.

-tmagement and supervialen sho ild reinnna this eff ort at omry cpportaulty.

4 CONCLUSIO,NS -=Proceduto Deficlancien 4

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A.

Eight (8) out of 14 events involved a ptoceduro de;iciency.

Six (6)

>f the 8 had N.vaing' guidance /.information.

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B.

- Previou.ly Identifiod proceduro'def10ter.c'er have gono uncorrected becauao the change procesa in perceivod i. Le too burdonr2 cme on Lue init3ator, take Loo,,, joy;g, and ofte1 at,,,effoctivo.

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.C.

Procedure ; validation and veriff t% tion is cot wHely imple: rented but

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could. help-identify and elimitnta _ the type J proceduto deficiencies J

. that. lead to mispositiorinj omnta,

..o., lua co minnina Inf1rmation.

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REC 0FF.ENDAT ONS - Proceduro-D^ticle.icles l

=A.

Tho procedura <thsnge pecus, within all wonc croupsi abould bo effective.- it shoald: encourage reparting of deficiencies and should l

promptly respond to reportvi pr,blems.

B.

A formal procedu'.c ond procodure chang.) validation and ierification i

iprocess should La widely and coaalch ntly implemar ed, C.

Strong; partnerships shad 14.M entablished between procedure wri',ers 'and users.

I D.-

ProcedLre probbms '.dentified in mispultioning events thould'be l-assigned priority for resolution before the ; rocedure is used next.

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- The following' t ecomendations result f rom tre CPT'n inves' igetions' of

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I recent-events and ad lress the imediato and broader implications of t

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. Revia).the Performance NI and NV check valve test procedures to i

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improvn Alarity aL3 ruiu:e complexity in the valve alignments.

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Ot).ar procedures that include multiple but asntlicting valve alignments should also be reviewed and improved au needed.

l 2.

Revise the operations procedure for re-alignment of the Cation Bed dominerajizer to include needed guidance.

3.

Revise the IAE procedure which calls for closur of 2StH 4 to specifically include confirmat ion f rom the exocation group (operations) that the valve is closed.

Review other, similar prorocurea tc identify where action in needed by other work groups to accomplish a step so that positive confirmation of the step in obtained.

1.

Develop procedural guidance t'or ensuring proper ayatum alignnent

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when operating the NS pump in Mcdes 5 and 6.

Review other, similar procedures to ensure that adequate guidance la provide.3 for system / equipment operation for all plant

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colditions in which it occurs.

5.

Develop appropriate procedure guidance to ensure opening of EXPH and SKPG bceaker #22 as needed during maintenance on VC Nius.

6.

Revisu Containment Isolation proceer es to include tho Onit 2 S/G accessways.

7.

Revise the chemistry procedure for BB domineraLim r to include guidance for hopper removal and flange installation.

Evaluate the need fm; and incorporate ac needed individual procedure n+.ep aignot f s in chemistry pn.cedures, s

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SUMMARY

OF PAST MEETINGS December 2:

Discussed tenma mission, list of customers, those involved inmispcsiting events:

doers, tellers, inadvertent doors, etc.

Faur objectives defined:

increased awareness of the problem, develop y

measurement tool, analyze mispositioning events, both past and present.

December 12:

Discussed ccmmanication/ awareness efforts - develop letter over station manager's signature; discuss issue with each shift manager.

OcVeloped definition of Component Mispositioning".

Schedules team training.

Established investigation duty rotation.

January 15, 1992 Noted several recent mispositioning avents:

turbine roll, NS pump start, 2SV-66., 2SM-103, breaker IEKPH 22, SG accessway, N1 pump runout.

Charged Investigation sub-committee with analyzing these events.

Established purpose of Investigation and Analysic sub-committees.

Distribute new department IV directive for review.

January 22:

ROADMAP problem solving training.

January 27, 28:

Root Cause Analysis training, i

February 3 (all day):

Investigation and Analysis subcommitteca met to complete event packages.

February 4 (all day):

Full team met to review and analyze 14 recent events and 16 older events.

February 5 (all day):

team met to identify recurring problems /lasues from 30 cvents.

Idantified 6 recurring issues:

poor work practices, verification 2nadequacies, procedure deff dencies, outat related events, R&R events, hardware problems.

Team membert diapersed to survey plant staff on conclusions.

February 6 (al? day):

Discussed results of survey, captured feedback.

Evaluated results and developed conclusions on " Ineffective verification" issue.

Developed conclusions und recommendations on department directive on IV.

February ll:

Discussed pros and cons of measuring mispositioningc vs correct positionings.

Defined success as Zero Mirpositionings.

Discussed

" Procedure deficiencies" issue and developed conclusionn and t

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recommendations-

'l February 19:

Discussed and refintd recommendations for self-verification

_j promotion campaign and IV implementation.

February 26:

Discussed IV ?.mplementation plan milestones.

Discussed ways to disseminate information o mispositioning events.

March 4:

Team viewed video tape of NRC management meeting at Otonec.

Reviewed draft "CPT Activities and Pesults" and "CPT Conclusions and Recommundations" to-date.

5-March 11:

Discussed daily toview of PIP log and assigned work groups to CPT members.

Discussed and refined recom2uendations on " Procedure Deficienc.les".

Heard nanagement's request for CPT to lead IV implementation effort.

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NPTACitMENT 4 m

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DUKE POWER COMPANY REPLY TC NOTICE OF VIOLATION 413,414/91-027 ATTACHMENT 4 IllELEtiENIATION OF REVJJJiQ,lHDEPXt{DJE_VERLEICAT10tLE_QLLCY The Nuclear Generation Depar' ment has recently issued i:ew c

quidance for performing.indepandent Verification (I/V) at all three Duke Power Company nuclear stations.

(Sco attached Department Directivo.)

Implementation of this guidance at Catawba is the responsibility of the I/V Implementation Team r

created by station management.

The objectives of the team are to define and carry out an offective plan that maximizen clari.y, consistency, understanding, and offcctiveness across the Catawba site.

Adherence to the provisions of the Deparctment Directive is to be ensured as well.

As a result of its investigations into recent mispositioning events and diccussions with many employees, the Component Positioning Team (CPT) has made the following recommendations to station managotuent:

REC.QMMERDA110NS,_ftpl,f-VSIlligation

=

A.

The offort to build self-verification should stay out of the classroom.

It should be taught, coached, and promoted by management and supervision.

B.

The " STAR" concept (stop, think, act, review) should be incorporated in place of "PLEASE LISTEN".

O.

Employees should hear about the consequeaces of not using self-verification, i.e.,

what can happen.

The CPT will be communicating mispositioning events that involve poor self-vorification.

L.

Self-verifl::ation should be covered in crew tailgate meetings as another element of the expected work evolution.

Pf&QHtiEEDATIONS - ILV_.P911sy A.

A revised Catawba Site I/V policy should be in place by l

6/1/92.

B.

Management should establish an 1/V Implementation Team by 3/15/92 with representatives from all station work groups involved in I/V, including Operations, Instrument and Electrical, Chemistry, System Engineering, Training Services, and Mechanical Maintenance.

The CPT should be i

- _ - - _ - _ _ - - _ _ _ - _ _ _ - - _ - _ _ - _ - _ _ _ _ - - _ _ - _ _ _ _ _ _ - _ - __ _ _ _ _- - - _ - _ - - _ _ _ - _ _ - _ _ _ _ _ - _ _ _ _ _ - _ _ _ _ _ ~

- represented on the team._

The I/V team should be charged with developing a implementation plan by S/1/92 and carrying it out.

C.

The Catawba I/V policy should be consistent witn the j

technical guidanco set forth in the Department Dir ectivo.

D.:

Catawba _ policy should gly.qyg call for self-verification _but only impose DV or SV ylmn regulf.qd by regulation or safety significanco.

i E.

-The team should determine the most effective way to tralri on

- the-techniques of "separato" and "doublo" verification, t

including classroom, task lists, qualification standards, etc.

4

- F.

The-implementetion plan should ensure consistency in when,-

where, and.how SV and DV are performed at Catawba, both within work groups and between work groups.

G.

The I/V team should determina how SV and DV will be implemented __in procedures and should include representative procedure writers an!) users.

A2ti20._Taken on Re.G2%DRDdati.QGH Catawba Nuclear Station management nas accepted these recommendations and has established an implementation date of 6 /:1/ 92.

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Nuclear Generation Department Directive 3.1.l(0)

Revision 6

Date 17/19/91 i

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nn Apr'oved: \\3 4. H.k General Manager, Nuclear Services DUKE POWER COMPANY NUCLEAR GENFRATION DEPAR'. MENT INDEPENDENT VERIFICATION 1.0 Purpose 4-To provide instructions for the use of Independent verification (IV) at Duke Pcuer Company nuclear stations in establishing a consistent verification program. Independent Verification r,Jcogniaes the human olament of component operation; that is, any individual, no matter how proficient and conscientious, can make a mistake. Self-checking techniques should be pro.noted to ensure an ingrained work ethic where a worker independently and ponitively identifies the correct unit, train, and/or component, reviews the intended action and expected response before performing the task, and then, verifies the action performed was correct. Independent Verification will help reduce numan error by ensuring thatt (1)

An applicable system or component being Ramoved From or

, Returned To operability is the coerect one and is in the position or condition required by the procedure or work order.

(2)

An applicable system or component being positicned or verified per station procedure or work order is the correct one and is in the correct position or condition.

2.0 References 2.1 INPO Good Practice OP-214, Independent Verit.ication Rev 2 2.2 IE Inferration Notice B4-51, Independent verification 3.0 Definirlons 1

3.1 Independent verification In general, the Independent verification process is a documented check by a second person which helps to ensure the correct condition or pos',ticia of plant components.

Included in the Independent verification process are the following two techniques t-4 1

1 l

J Page 2 3.1.1 separate verification A verification process which requires some time interval between tha actions of the ' Doer' and the verification process of the ' Verifier'.The l

time interval ensures individuals act separately and independently. The ' Doer' performs specific actions per station procedures and the

'Veritter' checks the actions of the ' Door'and verifies the actions were correct.

3.1.2 Double verification A verification process in which the ' Doer' and

' Verifier' must indspendently decide that an action is correct prior to the ' Doer' performing any action. Once an agreement is reached that the action is proper and that it is to be done, the ' Doer' performs the specific action per station procedures. The deeirions reached independently concur that s te)

The correct component in identified.

(b)

The action to be taken is correct.

(c)

The action performed was correct.

3.2 Self Verification An ingrained work practice where a worker independently and positively identifies the correct unit, train, and/or component, reviews the intended action and expected response before performing che task, and then, verifies the action pecforned was correct.

3.3 operable A sybtem, subsystem, trair, component or device shall be considered OPERABLE when it is capable of perforning its inton.ed functions.

3.4 Supervicor Individual directing the work activicy. May include the followings (1) Crew supervisor / relief supervisor (2) Responsible - ayatem/ component engineer or engineer with specific assignment (3) Technician temporarily working in a supervisory position.

4.C Responstbilities 4.1 station Manager 4.1.1 Provides overall direction of the Indapendent Verification Program.

i

Page 3 4.2 Superintendents and Managers 4.2.1 Have overall responsibility for determining those systems and/or components requiring separate or Double Verification.

4.242 Have final responsibility for determination of procedure steps requiring separate or Double verification.

4.3 Supervision 4.3.1 Ensure that only qualified personnel perform Independent Verification as per Section 8.0, 4.3.2 Authorize deviations from normal verification practices as per Section 10.0.

4.3.3 Convey the importance of using self checking techniques. Feriodically monitor personnel to ensure that self checking techniques are being

/

practiced.

4.3.4 Resolve any discrepancies discovered in component status or alignment and onsure that the af f ected components are properly atigned or in the proper otate.

4.3.5 Establish and provide training as necessary to plant and vendor personnel engaged in o

Independent Verification activities.

4.4 Tra ini ng 4.4.1 Develop and conduct training of plant and vendor personnel engaged in Indeper.dont Verification activities under the guidance supplied from the Group Superintendents / Managers.

4.5 Individuals 4.5.1 Recognize the importance of the Independent Verification program and accept tha responsibilities associated with performing Independent Verification.

4.5.2 Utilize self checking techniques in performing their Independent Verification tasks.

4.5.3 Properly maintain any required documentation of Independent Verification activities 4.5.4 Identify and repott labeling and/or procedural and/or component status discrepancies.

5.0 Applicability 5.1 All breakers, valves, Snd other components which meet the criteria established in Section 5.2 will be indepandantly verified to be in the correct position / condition utiliaing Separate or Double verification techniques as described in Sectiors 5.3 and 5.4.

Page 4 5.2 Independent Verification applies to the following (1)

Removal from and restoration to operability of all systema or components which af fect the ability of a system to perforn a safety related function.

I (2)

Systems and equipment which if improperly aligned, could result in the releast of radioactive liyutds or gases from the site.

(3)

Valves, breakers, and other components in fire protection system major flow paths, including fire fighting water supply and storage, halon and carbon dioxide storage oystems, fire detection cyntems, and componente necessary for the system to function and supply the extinguishing media to the fire.

5.3 The followirg are suggest ions as to when Separate Vertftcation should be used. Actual practice mas vary depending upon Site Management discretion.

(1)

Initial system lineaps conducted following an outage where the system status was not maintained in the normal operattny lineup. Specific lists of applicable systems should be developed.

(2)

Normal system lineup periodic checke during operating conditions. In this case, the individual pertorming the check of the original lineup is considered to be the Separate verifi3r and a single chock of valve position is sufficiert.

(3)

Supervision, or in the case of NSMs the responsible Engineer, may choose to use separate Verification techniques when personnel are not available to perform c Double Verification. This decision will bes (a)

Documented in the affected prncedure or work order.

(b)

Approved by a supervisor, temporary supervisor, or higher.

5.4 The following are suggestions as to when Doubia Verification should be used. Actual practice may vary depending upon Site Management discretion.

(1)

If the system or component is being removed from service for the placement of safety tage.

(2)

If the system or component is being returned to eervice o: restored to a standby-lineup, and safety tags are being removed.

(3)

To ensure the correct installation and removal of temporary modifications to systems and components.

(4)

Whenever locked valves and breakers are manipulated.

(5)

When directed by specific procedures.

1

l Paga 5 (6)

Prior to the operation, removal, or installation of wires, jumpers, switches,or other connections or components.

(7)

Prior to the oporation of valves, breakers, and other components where the inappropriate posttioning coulds (a)

Adversely affect system operation or containment integrity.

(b)

Result in an uncontrolled radioactive material release to the envircument.

(8)

On removal or restoration actions performed as an intagral part of the-follawing procedures (a)

Chemistr,-

(b)

Radiation trotection (c)

Operating (d)

Instrument and Electrieni (e)

Mechanical Maintenance (f)

Periodic Tests (g)

Removal and Restoration (h)

Power Delivery Department (i)

All Temporary Procedures (TO, TN, TM, TI, etc.)

(9)

Removal or restoration actions perf ormed on applicable equipment using a station work order where this method is chosen to document the perfot-mance of the Independont Verification process.

(10)

Planned releases of radioactive liquids or gases.

5.5 Independent verific.itior. is not required if work is performed while the component (s) are toolated (not capable of causing adverse plant conditions) and functionally vertfied prior to restoration.

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Page 6 6.0 Verification Process 6.1 Self Verification In performing Independent Verifications utilizing etther Separate or Double Verification, Self Checking Techniques 1

(i.e. PLEASE) shall be utilized as necessary. The techniques consist off (1)

P repare Have all materiale needed to locate the equipment. Take ti.Te to pause and consider the intended action. Be aggressively eusptetous.

(2)

L ocate Identify the correct component / t rain / unit using visual, audible, and tactile senses.

(3)

E xamine Touch, or in the case of energized electrical wires or circuits, point l

to the component / train / unit, but do not operate. Reconfirm the components identity.

(4)

A nticipate Consider the expected responsen from the actions about to be taken (e.g.,

indications, alarms, noise, heat, vibration, etc.). Consider what actions to take if the expected responses are not received.

(5)

S tart Lift the electrical wire, place the j

jumper, mantpulate the component, etc.

(6)

E valuate Ensure that the action taken has resulted in the expected response.

Be ready to react to unexpected results.

6.2 Separate Verification - Requires some time interval between the actions of the ' Doer' and the verification process of the ' Verifier'. Refer to step 3.1.1 for complete definition.

The following are correct ways of performing Separate verification.

6.2.1 After identifying the correct component, the

' Door' checks the component position locally and, as necessary, places the component an the required position. The ' Verifier' then checks the component position locally and verifies the action of the ' Doer' was correct.

6.2.2 After identifying the correct component, the i

' Doer' checks the component position locally and, ae necessary, places the component in the required position. The ' Verifier' then checks a remote indication and verifies the action of the

' Doer' was correct.

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pago 7 6.2.3 After identifying the correct component, the

' Door' checks the component position using remote indication and, as necessary, places the component in the required posttion. The

' Verifier' then checks the remoto (or local)

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indication and verifies the 4ction of the ' Door' was correct.

5.3 Doubla verification - The ' Door' and the ' Verifier' must decide and agree that an actic n is correct prior to the

'Dcer' performing any manipulations, Refer to step 3.1.2 for complete definition.

6.3.1 If the ' Door' and ' Verifier' are unable to reach an agreement, then they will stop at that point and request assistance from their supervisor.

6.3.2 After agreement has been reached identifying the the correct component AND that the action about to be taken is correct, the ' Doer' checks the component anc positions as required while the

' Verifier' watches (or helpo if the component is hard to operate) and verifies tna actions of the

' Doer' are correct.

6.4 When performing Indepencent verification using either separate or Double Verificetion techniques, the ' Verifier' should use a hands on approach where appropriate to verify the action taken by the ' Doer' was correct.

6.5 For procedure steps requiring documented Independent Verification, the affected portions of the procedure are to be in the possescion of the individuals while performing or observing the actions. In special cases, it may be neccseary for a copy of the affected portiens of the procedure to be in the posession of the individual with the signature copy residing elsewhere as dicussed in section 9.4 (2).

6.6 If a discrepancy is discovered while verifying a condition, the individual discovering the discrepancy will immediately contact hin/her supervisor for resolution.

J 6.7 During the performance of verifications, positionings, and Independeet verifications, all components will be :hecked to ensure the component identification label is attached properly and in good condition. The individual discovering a labeling deficiency will initiate actions to correct the condition in accordance 91th labeling direettves.

- -- -.~.- -

=-

Page 8 1.0 Implementation The following guidelines should be taken into consideration when performing Independent vertfications:

7.2 When Double Verification of a component / condition is required and the two indtviduals perf orming the task must physically work together, the thought process of the ' Doer' and 'Verifter' must be completely separate and independent.

The individual performing the ' verificat ion' n.u st not rely upon the observed actions of the other individual to determine tne correct component identification, posttion, or condition. Verifier independence must be maintained to ensure the integrity or the Independent verification process by not relying on the actions or statements of eacn other.

7.2 When a Separate Verification is required, the time interval should be less than one shif t to reduce the possibility of component miapositiontng errors and facilitate the smooth transf6r of plant status during shift turnover.

7.3 When using remote indicators to determine component status, station personnel must ensure through n eans, such as periodic testing, that the device being used provides a positive and definite indication of the component's status and functional ability.

(i.e., Performance and/or I&E testing proves indications are correct within normal limitu.)

7,4 If a system operating condition prohibits closing a throttled ccaponent to verify its positton and the act of fully opening the component would not unduly upset the system, the number of turns throttled closed from full open may be used ia lieu of the normal method of counting the turns open from fully closed-7.5 When the operation of a throttled component is necessary to determine its position, having a verifier observe the initial component operator's action is preferable to having both persons individually operate the component. This second component operation would effectively nullify the first and would therefore serve no purpose.

7.6 If a system operating condition prohibits moving a component to verify its position, the operating system parametcre may be used to perform the verification. Care must be exercised when using process parameters as a second check of a component's pcsition due to possible alternate flow paths or other conditions that could make this method unreliable.

7.7 The Technical Specification requirements relating to the required open or closed positions of certain components must be considered on all component manipulations. If the act of verifying the position of a component violates the Technical i

spectfu.ation's designated position for the plant operating condition, positive control of the operability of the component must be maintained at all times during the component manipulation. Technical Specification requirements should be reviewed for applicability prior to component manipulation.

l l

Page 9 7.8 Alternate verification techniques may be used it specified by approved procedures or approved by supervisory personnel.

Examples include the following and are subject to normal limitations and precautions:

I (1)

Use of process parameters (i.e.,

flow, pressure, flow vibrations, currer.t, voltage, potential lamps, etc.)

(2)

Observation of an acceptably marked valve stem te aid in the determination of valve position.

(3)

Authorized scribe marks on valve stems, properly labeled with the throttled position.

(4) runctional mechanical position indicators.

7.9 Verification techniques for valve position will vary depending on the particular valve type, make, or model.

(1)

The position o.nany valves cannot be determined visually and may require movement of the valve to verif y position.

(2)

Valve orientation must be considered when visually l

establishing the position of the valve.

(3)

Butterfly valves cay requir6 the use of position indication in conyanction with the physical repo61tton to ensure that it has not moved past the neat.

(4)

Observation of the relative height of a valve stem will NOT be used as the sole determinant of a valve's pcm itToli.

(5)

Position indicators are subject to equipment failures that could result in display of the incorrect status of a valvo or breaker.

(a)

If possible, one check should be performed locally at the component to avoid common failure problomm.

(b)

The use of remote position indicators is acceptable for both verifications because periodic testing proves the remote indicators are accurate.

(c)

If remote position indicators are used, personnel should agree to use different remote indicaters if available.

(6)

If remote position indi:ation is being used to verify the position of one or more valves, the position will be verified prior to deenergizing the control power or motor power because of the possible loss of remote position indication when deenergised.

____ _ - - - - -__- _ - _ _--__ = ______ ____ - ______ - - ____-________ ____________ ______________

l Page 10 7.10 Veri'ication of Unlocked valves.

(1)

Valves verified open will be manipulated in the closed direction only as necessary to remove any slack from the operating mechanism and verify valve stem movement. The valve will then be fully opened, subject to normal precautions on backseating valves.

(2)

Valves verified closed should be manipulated in the closed directica only. If necessary, to verify the valve is fully closed and not binding cr difficult to cperate, open directica may be used. Care must be exercised to avoid overtorquing the valve operator and damaging the valve seat. If any doubt exists, supervision should be contacted for resolution.

(3)

Valves verified in a throttled position normally will be manipulated in the closed direction, with the operator counting the numbec of turns required to fully cloes the valve. The operator will then reopen the valve to its properly throttled position.

7.11 Verification of locked valves uill ts performed as in Section 7.10 (Unlocked Valves). In add 4 tion the following guidan:o is provided (1)

Locking mechanisms are to be removed if necessary to determine the position of the vaivf. Perform an Independent Verification of the re-installation of the locking device.

(2)

On initial valve lir. supa t cc locking device will be installed proporly a;c decurented on the appropriate locked valve adt - liut in.accordance with the locked valve /breakst prcgrLm.. Perform an Independent Verificattor, s

the installation of the locking device.

7.12 Electrical switches and breakers of ten have several pcsitions. Assuu that t*t specified position has been obtained.

7.13 When deactivating a power source, a thorough review to determine all equipment that will be affected must be perforced.

7.14 Statian sp2citic componaats that require special attent ton to determine the operational status because at design or 13;tallation factors should be identified to station p<'nonnel through training or within applicable procedures.

Retverse acting valve attuatora ata one example of this type component.

7.15 Many compcnente will require special attention when using visual means to determine status. Precautiunary instructions and appropriate training are to be given to station personnel for these instances.

Page 11 7.16 Circuit breaker verifications will incluoc a local inspection of the breaker, control power switches or f uses, and other equipment a3 outlined balcw.

(1)

To verify a breaker is removed from service, the operator wills i

(a)

Ensure the control power is isolated, if required, by inspecting the appropriate switches at.d fusas or fuse blocks.

(b)

Ensure the breaker is fully racked out, as applicable.

I (2)

To verify a freaker is restored to service the operator wil?.:

(a)

Ensure the cor*

power is energized by inspecting the appropriate switches, indicating lights, and fuses or fuse blocks.

(b)

Ensure the breaker is fully racked in.

(c)

Ensure the closing springs charged and the recharging motor on, as applicable.

(d)

Ensure the cubicle door is in good condition with all fastiners tight.

7.17 Locked circuit breakers will be verified indwoendently by inspection of the 'ceking device for proper installation.

The position will be documented on the appropriate locked breakor list in accordance with the Locked Breaker Program.

7.18 Removal and Restoration procedures snall:

(1)

Give consideration to the sequence of required actions so as to I,reclude ur. desirable effects during the process.

b (2)

Clearly: indicate the affected valves that require Independent Verification.

7.19 The following are additional general methods to help'in identifying component s while performing IV:

(1)

Comparison of equipteent identification name/ number on a work order with that on the equipment.

(2)

Key control, issuance and return, where tne key la spectfic to a unit and to a system.

-(3)

Use caution in the use of plant drawings and valve location ecoks. Ali plant drawings do NOT ehow the physical layout of the syqtem.

i-(4)

Comparison of unit, train, or component designations to the designations in the applicable procedure.

4-4.

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Eage 12 i

8.0 Personnel 8.1 For the purposos of this directive, c qualified indtvidual ta one who possesses the knowledge to determinut (1)

The correct system or component is properly identifted and properly tamoved from operability according to approved procedures, 93 (2)

The system or component.is properly aligned for the desired operating a4 ode according to approved procecures.

E.2 Indopendent verification (IV) must be performed by individuals who tre qualified to perform IV. These individuals may be from the same work group or another section who have completed approved Independent Verification training (ETQS or other means).

(1)

In addition to IV Qualification, thw ' Doer' munt be qualifted, or in the cane of training, be under the direction of an individual qualified on the job task / component / system.

(2)

The ' Verifier' will be IV Qualified but may or may not be qualified on the job task / component / system.

9.0 Procedures 9.1 Written procedures or documentation oheets are required when conducting ectivittom where Independent Verification is applied.

9.2 The requirement for a procedure step (s), procedure valve checklist or other procedure attachments, and work orders to receive Independent Verification must be clearly ident ified in the af fected document by means such ass (1)

Provisions for double sign off of the affected procedure steps, procedure attachments, or work orders. The step may be identiflod by the use of "SV" for separate Verification or a "DV" for Double Verification.

\\

(2)

Supplementing valve checkilsts which are labelwd "Verificat.an Checklist". In most cases this would indicate Separate Verification was to be used.

(3)

Appropriate footnoting of procedure steps or npecific valves within a checkt.wst whic~n receive Independent Verification.

9.3 Station specific directives are to clearly define the methods utilized to all portonnel using the procedures or work orders.

Page 13 9.4 Personnel signing the documentation for Independent Verificaticn must havos 4

(1)

Either performed or verified the action required by the specific procedure step, valve check;tsts, or work re qu e st.

9.B (2)

Been designateo by station management to sign the documentation in the absence of the individual actually performing or observing the action.(e.g., A Control Room Operator (CRO) may sign a procedure step upon receiving the status of the effected component verbally from a Non-Licensed Operator (NLO) who is 4

performing or observing the action at a remote location).

When this method is used to document Independent Verification, both of the individuais are to be indicated in the dignature. For the above example, this would be accomplished in a manner such as NLO by CRO, NLO/CRO, or other appropriate means. Station specific directives are to clearly define the acceptable alternatives to all personnel signing the 4

Independent Verification document.

10.0 Exceptions Independent Verification may be waived under any of the following i

situations with appropriate supervisory approval and documentation:

(1)

If it would result in a significant personnel radiation 4

exposure as defined belows (a)

Individual radiation exposure of greater than 10 mrem for a single Independent Verification.

(b)

Access to an area with a dose rate equal to or greater than 1 rem / hour.

(c)

Procedures containing several single Independent verification steps, each with high exposures but less than the above exposure limits should be considered for being waived.if exposure from Independent verification would exceed 100 mrem per week.

(2)

In situations that presant a significant personnel safety risk. Station management is to evaluate and determine these situations.

(3)

If valves perform a safety function which receive an automatic signal to move to their proper safety position, unless these. valves are removed from operability in a manner that would prevent automatic actuation.

(4)

On general vent and drain valves which would NOT prevent a safety related system fec~m performing its safety function.

(5)

Under emergency conditions.

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ML20090M772

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