ML20091L463
| ML20091L463 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 01/22/1992 |
| From: | Broughton T GENERAL PUBLIC UTILITIES CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| C311-92-2013, NUDOCS 9201280064 | |
| Download: ML20091L463 (8) | |
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GPU Nut. lear Corporation
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Route 441 South Middletown, Pennsylvania 17057 0191 717 944 7621 TELEX 84 2386 Wnter's Direct Dial Number:
(717) 948-8005 January 22, 1992 C311-92-2013 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C.
20555 Gentlemen:
Subject:
Three Mile Island Nuclear Station, Unit I (TMI-1)
Operating License No. DPR-50 Docket No. 50-289 Response to Notices of Violation in Inspection Report 91-23
.In accordance with 10 CFR 2.201 this letter transmits the GPU Nuclear response to the Notices of Violation included in Appendix t to Inspection Report 91-23.
.The Inspection Report required that GPUN also provide a perspective on the apparent. negative trend in procedural controls when performing critical evolutions, particularly those performed on an infrequent basis, three examples of which are identified in violation B of the Notice of Violation.
GPUN compared the events-(both cited and non-cited) resulting from infrequently performed evolutions during the 9R refueling outage-to those occurring during the BR outage (1/5/90 thru 3/4/90) and 7R outage (6/1//88 thru 8/16/0?) and identified no negative trend.
The types of problems experienced in 9R (e.g., inadvertent 'ctuation-of safety systems, reactor trip and violation of Technical Specificas o.
LCOs) have also. occurred in past outages at a similar frequency. However, none of the specific events occurring in past outages have recurred and there have been no loss of decay heat. removal events since the 7R outage. This indicates that the corrective actions taken in response to the specific events were effective.
However, the GPUN expectation that fewer problems related to complex or infrequently perfec.wd evolutions would be experienced during'the 9R outage was not real u.r d Based on the review of events from th e outages, GPUN considers PT0r2 9201280064 920122 i
PDR ADOCK 05000289 I
GPU Nut e r Ccirporat:on is a subscary of General Pubhc Utses Corporatior
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i C311-92-2013 Ja6uary 22, 1991 t
Page 2 of 2 that broader based "ograms to address human performance and procedure quality are warranted. As a result, GPUN has undertaken actions to strengthen the procedures for infrequently perforn.ed evolutions and to reduce human errors through a "self-check" program and training which emphasizes supervisory responsibility to ensure complex and infrequent evolutions are understood before they are begun.
This is addressed further in the response to violation B.
Sincerely, b
T. G. Brougiton Vice President & Director. TMI-l WGil:
Attachment cc: Administrator, Region I TMl-1 Senior Project Manager THI-l Senior Resident Inspector 1
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j METROPOLITAN EDISON COMPANY JERSEY CENTRAL POWER AND LIGitT COMPANY PENNSYLVANIA ELECTRIC COMPANY GENERAL PUBLIC UTILITIES NUCLEAR COPP0 RATION Three Mile Island Nuclear Station, Unit-1 (TMI-1)
Operating License No. OPR-50 Dockt.t No. 50-289 8
Response to the Notice of Violation in Inspection Report 91-23
.his letter is submitted in response to the Notice of Violation in Inspection Report 91-23, Routine Monthly Inspection for the period September 22 throu9h November 16, 1991 for THI-I dated December 23, 1991.. All statements contained in this res3onse have been reviewed, and_al' such statements made and matter set forth tierein are true and correct to the best of my knowledge.
WYm'Or I
g T. G. Broughton Vice President and Director, TMI-l P
Signed:and sworn before'me this 22nd day of-Ja nua rv
, 1992.
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Attachment C311-92-2013 Page 1 of 5
.:otice of Vielation A Technical Specification 6.8.1.a requires that written procedures shall be established and implemented for applicable procedures recommended in Appendix "A" of Rcgulatory Guide 1.22, revision 2, February 1978.
Regulatory Guide
-1.33, Appendix A, Section 9.a requires that maintenance that can affect the performance of safety-related equipment be performed in accordance with written procedures.
Contrary to the above, the licensee failed to establish adequate maintenance procedures to lubricate motor-operated valves witn threaded yokn bushings prior to 1989.
In addition, upon establishing the program with revision 17 to Preventive Maintenance Procedure E-13 in May 1989, the licensee failed to adequately implement the procedure. This led to the eventual failure of high i
pressure injection discharge isolation valve MU-V16A, and the degradation of MU-V-168, C and D.
-This is a Severity Level IV violation (Supplement I).
GPUN Response GPUN agrees in principle with this violation. However the text of the Inspection Report appears to reflect a misunderstanding on the part of the NRC with respect to the history of valve maintenance programs at THI-l and specifically the MOV program.
IMckaround The vendor recommended yoke bushing lubrication was not performed due to a
-lack of understanding that a sub-set of MOVs requit ing special action with respect to lubrication existed.
The valves at issue have rotating, rising stems and are unique in that the load bearing member for valve closure is the yoke bushhg external to the valve motor operator and not the stem nut inter.1al to the valve motor operator. Although the specific sub-set of 19 Rockwell design M0Vs was not identified until October 1991, GPUN had been performing stem lubrication as a part of its valve maintenance activities.
Since THI-l began operations, the plant has had corrective and preve? ~ve valve maintenance programs and procedures in place for manual and motor operated valves (MOVs). Maintenance of MOVs is primarily preventive in nature, weighted heavily toward the motor operator and performed in accordance with PM procedure E-13.
The procedure was established in December 1975 and predates by approximately 10 years the industry guidance promulgated on the subject of M0Vs (IE Bulletin 85-03 and Generic Letter 89-10). Significant M0V training provided to maintenance supervisors and technicians since implementation of the procedure, well established PM tasks, and the early implementation of M0 VATS testing are examples of the typical proactive approach to quality maintenance employed at TMI.
Attachment C311-92-2013 Page 2 of 5 n
M0VA1S testing was initiated in 1985.
Test results on soma MOVs indicated higher than desired running leads. The possible contributors to the high MOV running loads were reviewed, the need for a well lubricated yoke bushing was identified and valves exhibiting higher running loads during testing were lubricated.
In 1989, details addressing stem and yoke bushing lubrication
-were added to PM procedure E-13 to assure proper performance of the maintenance task.
This proactive change was prompted by the M0 VATS test
- results, Since there had been no failures related to lubrication problems and no significant concerns relative to tne higher running loads, a situation requiring immediate lubrication of ali valves effected by the new lubrication guidance war act coiisidered to exist. A schedule for performing E-13 lubrication requirements on all Limitorque MOVs in the plant was established taking into consideration each valve's function, location / environment, frequency of operation and maintenance history.
The schedule was seen as well conceived and appropriate for accomplishing the numerous preventive maintenanca actions in PM procedure E-13, including lubrication, in an appropriate sequence.
The MOVATS data revealed no gradual degradation of MU-V16A.
Prior to the MU-V16A yoke bushing failure, GPUN expected that MOVA1S testing would provide an indication of degradation and potential failure such as that which led to the failure of MU-V16A. Since that was not the case, the first indicaticn of severe degradation causeu by lack of adequate lubrication was the failure of MU-V16A.
A grease residue was found on the valve stem of Mb-V16A at the time of the yoke bushing failure. The residue resulted from previous lubrication of the motor operator internals and stem to motor operator interface; some lubricant inevitably travels down the stem of a vertically mounted valve from the motor i
aperator internals. Those motor operator internals are lubricated routinely in accordance with PM E-13.
Corrective Actions Taken and Resu].ts Achieved The schedule initiating the performance of preventive maintenance on all MOVS in 1975 and recently revised as described above is considered an element of the corrective. action. For the rusons previously stated, there was no effort mada to complete the PM schedule in advance of the established cycle.
Preventive Maintenance procedure E-13 was revised in 1989 to include specific steps to lubricate the yoke bushing. The scheduling of. E-13 PM with the added lubrication requirements for all plant MOVs assures iubrication of all valve stems.
Preventive maintenance was completed in accordar.co with the revised procedure on 13 of the 19 valves in the sub-set similar to MU-V16A prior to the September 1991 failure of the MU-V16A yoke bnhing.
Preventive maintenance on the remaining six M0Vs was completed during the 9R refueling outage as scheduled by the plant computerized PM scheduling system. During the 9R outage, a proactive and.thoroagh review of the MU-V16A failure
Attachmeac C3h-92-2013 Page i of 5 implications was performed. Tne review included a multi-disciplined root cause analysis. During investigation of the failure mode, the stem on MU-V16A was found to be slightly bent.
An engineering evaluation concluded that MU-V16A with a new lubricated bushing will remain operable with the bent stem until the 10R outage, at which time the stem will be replaced.
Correctiy.e Actions to Avoid further Violations The corrective steps required to avoid further violations of this type were identified and accomplished as a re. ult of the root cause analysis of the MU-V16A failure performed in October 1991. Actions consisted of identifying all safety-related manual and motor-operated valves with the pohnlial to exhibit wear or degradation similar to that experienced on MU-V16A and verification
.that each is included in tha preventive maintenance program such that appropriate, periodic lubrication is assured. GPUN engineering and maintenance personnel are also considering other MOV testing methods which exhibit a potential to provide earlier and more reliable valve condition information.
Although in hindsight,- the process used proved untimely-in that damage to the MU-V16A bushing occurred prior to its lubrication, GPUN considers the process of evaluation used to determine the method and schedule for implementation of this change to be appropriate.
This process will continue to be used in other backfit situations.
Date of Full ComE lanca GPUN considers that full compliance has been achieved as of this date for those actions considered necessary to address the cited deficiency.
The concern was isolated to 3 particular sub-set of valves that were inspected
.and repaired as~necessary.
Future MOV lubrication activities 4111 be accomp1'shed in accordance with the established procedures and schedult.
((otice of Violation B Technical Specificati>n 6.8.1.b requires t bt written procedures shall be established and implemented for surveillance-and test activities of equipment that affects nuclear safety.
Contrary to the above, the licensee failed to adequately imolement surteillance procedures as evidenced by the following examples:
> /,; r M."_ Attach' ment.
C311-92-2013:
Pago 4 of;SL a.
OnLSeptember 28,1991, the111 censee failed to implement _ Surveillance --
rocedure 1303-11.10 rev._25l
Engineered Safeguards-System Emergency Sequence and Power Transfer Test," properly, performing procedure steps out of the order specified. This procedural nonconformance led to the disabling of_ Makeup Pump IC (HU-P-10),
b.
On November 12 jl991, the licensee failed to adequately implement
-Surveillance-Procedure 1303-4.1, rey-72, " Reactor Protection System," step-8.7.4.1.- The step requires'the technician to obtain permission from the Shift Supervisor prior to testing the reactor coolant system pre:s'ure
- channel. Due to poor communications, step 8.7.4.1 was..mt adequately implemented which resulted in the inadvertent lifting of the pressurizer power operated. relief valve.
i c.:.On November 13, 1991,_the licensee failed to adequately establish l
-Surveillance' Procedure 1303-11.39A rev 7,'"HSPS-EFW-Auto Initiation," by notispecifying initial plant conditions required for the test.
This led 3:
to'an_ improper restoration from the test resultinJ in an inadvertent
- auto-start of-the motor driven emergency feed pumps.
Thisiis.a Severity Lev 61 IV violation (Supplement -1).
_ g GPUN Response
' GPUN agrees with the violation as written. The causes of the violation were:
(1) a failure of trained persenrel to prnperly implement the approved
. procedures and;(2) a failure to provide adequate procedures.
- fpfrective Actions Taken-and1Results Achieved As a result of,the th.ee incidents GPUN performed the following corrective-actions:E h:
a)' Rclevant plant incident reports were reviewed by all of the Operations
^ department-.personnelsas1 required by Administrati_ve Procedure 1029:" Conduct of Operations."
-b)iA procedure change request _(PCR) was_ submitted to Procedura 1303-11.10-to; clarify the appropriate: procedural steps, thereby eliminating _ potential:
- operator confusion caused by the or ginal wording in performance of:the j
surveillance procedure.
1 c)!The. Plant _ Operations Director discussed each of the incidents in-detai!
=with.the:parsonnel affacted. The discussions included the need for personnel accountability, the responsibility to understand the: details of 1
tasks'to be' performed, and the expected outcome and potentially adverse affects of actions 1taken or to be taken when physical manipulations are l performed during infrequently accomplished or complex tasks.
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e Atiachment C311-92-2013 Page 5 of 5
,r As a result of these corrective actions there is a renewed awareness on the part of all operators that additional attention to detail, plannir;g, and communications must be observed when performing surveillances that are performed infrequently or are comp 1icated in nature.
[qrrective Actions to Avoid further ViolatioD1 GPUN has taken the following actions to pa event further violations of a similar nature:
a) Surveillance procedures which are infrequently performed and which could result in potentially significant adverse consequences will be identified and reviewed as a special task.
Each selected procedure will be reviewed by a team including: an individual knowledgeable in the technical area, an individual from the group which nerforms the test, and an individual knowledgeable in the area of human factors / procedure writing techniques. The selected procedures will be revised as necessary based on the committee review.
Procedure revisions identified by these reviews will be ;ompleted prior to the next refueling outage scheduled for tember, 1993.
b) INP0 SOER 91-01 which deals with infregaently performed tests or evolutions will be reviewed and discussed with each licensed operatcr during training cycle 92-01 (the training c;cle currently in progress),
c) Managoinent has committed to emphasize personnel accountability.
-Personnel must be more aware of all on-going plant activities and, in particular, the effect.their actions have on overall plant conditions and those activitles. All personnel need to be alert to indications of a potential problem or misunderstanding, and the importance of being able to respond to them as they are identified, i.e., to esk the right questions and receive meaningful-and appropriate responses.
Supervisors will be reminded of their responsibility to (1) ensure proper preparation of personnel and understanding of the plann5d evolution prior to its commencement, and (2) provide increased oversight during the performance of complex or infrequently performed tasks. The management of the TMI-l Operatior.s and Plant Materiel departments will counsel all their personnel on the importance of checking their actions just prior to the performance
- of a physical manipulation.
With repeated use of this "self checking" concept, this characteristic is expected to become a standard practice at L
THI-1.
Date of Full Comoliance Full compliance will be achieved with the issuance of revisions for procedures 1303-11.10 and 1303-ll.39A identified by the Notice of Violation.
Procedure revision. will be completed prior to the next retuoling outage scheduled for September, 1993 via the team process described above. The September, 1993 implementation date is suitable, since the procedures are appropriate as is, for operating plant conditions.