ML20091K421

Forwards Response to NRC Re Violation Noted in Insp Rept 50-327/95-15.Corrective Actions:Personnel Involved Received Appropriate Disciplinary Action

ML20091K421
Person / Time
Site:	Sequoyah
Issue date:	08/18/1995
From:	Adney R TENNESSEE VALLEY AUTHORITY
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9508250394
Download: ML20091K421 (5)

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I Tenreeseee Vaney Authority Post Offce Box' 2000, Soddy-Daisy, Tennessee 37379-2000

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R.J. Adney ' .

t Site Vce President .

Sequoyah Nuclear Plant

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I i August'18r 1995 .!

r U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D.C. 20555 [

L Gentlemen: f i ' In the Matter of- ) Docket No. 50-327

[ . Tennessee Valley Authority )

SEQUOYAH NUCLEAR PLANT (SON) - NRC INSPECTION REPORT NOS. 50-327, 328/95 REPLY TO NOTICE OF VIOLATION (NOV) 50-327/95-15-01  ;

Enclosed is TVA's reply to Ellis W. Merschoff's letter to Oliver D. Kingsley, Jr., dated }

' July 25,1995, which transmitted the subject NOV. The violation is associated with .

the failure to implement adequate corrective actions for operator errors that result in reactor 1.ips.

TVA is concerned that previous corrective actions have not been fully effective in preventing the recurrence of this type of event. Corrective actions for this event  ;

include an emphasis on individual accountability for the use of self-checking techniques. Previous corrective actions included training on self-checking tecnniques i and management's expectations for using those techniques. However, the lack of accountability demonstrated by management for previous events where self-checking  ;

was not used resulted in personnel applying self-checking techniques inconsistently. >

' The inconsistent application of self-checking resulted in this reactor trip. The ,

' corrective actions for this event have demonstrated that management will hold.

employees accountable for the use of self-checking techniques. Management has also

reemphasized that individuals will be held accountable during any future occurrences .

. of the failure to use self-checking. .

The enclosure contains TVA's response to the violations.

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l U.S. Nuclear Regulatory Commission l Page 2.  !

August 18, 1995  ;

P if you have any questions concerning this submittal, please telephone S. D. Gilley at (615)843-7427.

Sincerely, .  !

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R. J. Adney Enclosure-cc (Enclosure):

Mr. D. E. LaBarge, Project Manager Nuclear Regulatory Commission i

One White Flint, North 11555 Rockville Pike Rockville, Maryland 20852-2739

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NRC Resident inspector l Sequoyah Nuclear Plant 2600 Igou Ferry Road Soddy-Daisy, Tennessee 37379-3624 .

' Regional Administretor U.S. Nuclear Regulatory Commission Region 11 101 Marietta Street, NW, Suite 2900

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Atlanta, Georgia 30323-2711 1

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• _ ENCLOSURE 1 RESPONSE TO NRC INSPECTION REPORT NOS. 50-327,328/95-15 ,

ELLIS W. MERSCHOFF'S LETTER TO OLIVER D. KINGSLEY, JR. j DATED JULY 25,1995 VIOLATION 50-327/95-15-01 l

"10 CFR 50, Appendix B, Criterion XVI, requires, in part, that for significant conditions adverse to quality, the cause of the condition is determined and corrective l action taken to preclude repetition. ,

"LER 50-327/94008, dated May 25,1994, detailed corrective action for a Unit 1 i

automatic reactor trip on May 1,1994. The root cause of the trip was personnel error. Corrective actions included site management's continued reinforcement of the i self-check process. ,

"The licensee's response to violation 50-327/94-18-02, dated September 14,1994, and LER 50 327/94011, dated August 12,1994, discuss details regarding a Unit 1  !

reactor trip on July 15,1994. The violation response stated that the cause of the trip was personnel error; failure to self-check. Corrective actions included steps taken to reemphasize work standards, including the proper application of self-checking.

Reinforcement of the self-check process was continuing through training, supervisory ,

observation, and coaching in the field.

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" Contrary to the above, corrective actions were not adequate to preclude repetition, in

' that on June 23,1995, a Unit 1 reactor trip occurred due to failure to use established ,

i self-checking techniques. l 4

"This is a severity level IV violation (Supplement 1)."

Reason for the Violation

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- This violation is associated with personnel error in the establishment of a clearance that resulted in a reactor trip. The reason for this violation was that prior corrective '

-actions were not fully effective in preventing this type of error, and as a result, the '

l self-checking process known as STAR (Stop-Think-Act-Review)was not followed. A contributing factor for this event was that the personnel involved did not consider this l

to be a significant activity since the intent was to remove power from a radiation monitor. The clearance should have tagged out two essential raw cooling water (ERCW) radiation monitors and was believed to be a routine manipulation. Instead of I

l tagging the breaker to remove power from the radiation monitors, the breaker that

was tagged removed power from 1R3 Process Protection Set 1. Several barriers were l in place that could have prevented this error' The individual placing the clearance

. l entered 125-V Vital Battery Board Room I, instead of 125-V Vital Battery Board p

' Room 11. Once inside the room, the panel was misread. The panel where the tag was hung was 125-V AC VitalInstrument Power Board 1-l: it should have been placed in

' 125 V AC Vital Instrument Power Board 1-11. Breaker No. 48, which was the breaker number listed on the clearance, wa's located. However, both of the panels' mentioned

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! .- 4 have a breaker No. 48. The nomenclature tag was not read to verify that the proper -  ;

breaker No.' 48 was being tagged. The breaker that was opened was '1R3 Process Protection Set l'; the correct breaker nomenclature would have read 'ERCW Radiation i Monitor 0-RE-90-134 & 0-RE-90-141.' Another barrier that might have prevented this event was the color coding associated with process protection set channels. The ,

breaker that was opened had a red label (Channel 1), and the correct breaker had a i

black label (Channel II). .

Corrective Actions That Have Been Taken and the Results Achieved J

i The persennel involved in this event received the appropriate disciplinary action.  !

4 An additional barrier has been instituted temporarily for any manipulation involving ,

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electrical components in pulling or inserting fuses, opening or closing breakers, and l lifting or landing leads. This additional barrier requires the use of concurrent j

verification. Concurrent verification is the process where an agreement must be i

reached between the performer and the verifier that the activity / manipulation to be

performed is understood prior to initiation. The need for this additional barrier will be i

reevaluated in the future and may be deleted if conditions warrant, j 3 e i' This event has been communicated to the Operations department in a series of meetings which emphasized that the trip could have been avoided if the STAR process of self-checking had been used. This event was also used to illustrate the point that i the STAR process cannot be selectively applied to only those activities that are  !

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believed to have potentially serious consequences because any activity that is not

• j performed correctly has the potential for serious unforeseen consequences. The meetings also introduced the new Sensitive Activities Manual which has been developed to assist personnel with the appropriate precautions to use when dealing i with sensitive equipment. f

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Through this event, management has reemphasized that personnel will be held l

accountable for preventable errors. .

Operations management has performed evaluations'of Operations personnel to assess 4- .'the implementation of management's expectations. Severalindividuals were restricted i from performing shift activities as a result of the evaluations. These individuals are undergoing personalized instruction that focuses on the identified deficiencies. They  :

will be reevaluated in the future to determine whether they will be returned to shift j duty. Additionally, the evaluations indicated that several other individuals in the  ;

. Operations department needed additional instruction, but did not indicate a need to

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remove these individuals from shift activities. Corrective actions will be established [

l for the deficiencies identified for these individuals. l E

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The following actions were not initiated as a direct result of this event but will have a 4

positive effect on preventing events of this type in the future Measures have been ,

taken to improve communications within the Operations department, including a change in shift tumover meetings to a routine in line with industry norms. As a result  !

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,. 3- t of rotational development initiatives,10 positions in Operations have been filled with j

new managers or front-line supervisors. Site Training personnel will observe in-plant i

Operations activities using the man-model that Operations' managers developed based on critical performance criteria. Deficiencies observed will be reported to management for correction and incorporation into revised training activities.

The Corrective Steos That Will be Taken to Avoid Future Violations Corrective actions to prevent future violations are stated above.

Date When Full Comoliance Will be Achieved The completed corrective actions stated above bring TVA into full compliance.

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