ML20091S193
| ML20091S193 | |
| Person / Time | |
|---|---|
| Site: | Cooper  |
| Issue date: | 08/31/1995 |
| From: | Mueller J NEBRASKA PUBLIC POWER DISTRICT |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NLS950170, NUDOCS 9509080028 | |
| Download: ML20091S193 (8) | |
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.e, COOPER NUCLEAR STATION P.O.90x es.BROWNVILLE, NEBRASKA 98321 Nebraska Public Power District
" T 4 5:2 ""
NLS950170 August 31, 1995 Director, Office of Enforcement U. S. Nuclear Regulatory Commission Attention: Document Control Desk Washington, D.C. 20555 Gentlemen:
Subject:
Reply to a Notice of Violation; NRC Inspection Report No. 50-298/95-08; Cooper Nuclear Station, NRC Docket 50-298, DPR-46
Reference:
Letter from Mr. J. E. Dyer (USNRC) to Mr.
G.
R. Horn (NPPD), dated July.25, 1995, NRC Inspection Report 50-298/95-08 and Notice of Violation.
This letter, including Attachments 1 and 2, constitutes Nebraska Public Power District's (the District) reply to the referenced Notice of Violation (NOV) in accordance with 10 CFR 2.201.
Inspection Report 50-298/95-08 documented the results of an NRC inspection conducted from April 16 through May 27, 1995, and consisted of selected examinations of procedures and representative records, L
interviews with personnel, and observation of activities in progress.
In addition to replying to the specific violations, the District was also requested to address four other questions regarding the control and use of procedures.
These issues are answered in Attachment 1,
under ADDITIONAL DISCUSSION.
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discussed with with Mr. P. H. Harrell, the submittal date for this response was extended to August 31, 1995.
In summary, the District admits nonfulfillment of the NRC requirements cited in violation A (298/9508-01) and has completed all corrective actions that are necessary to return Cooper Nuclear Station (CNS) to full compliance with regard to the cited examples of this violation.
Should you have any questions concerning this matter, please contact my office.
H. Mueller Site Manager j
l Attachment cct-Regional Administrator USNRC Region IV NRC NRR Project Manager USNRC
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NRC Resident Inspector i
Cooper Nuclear Station lj n
9509080028 950831 NPG Distribution PDR ADDCK 05000298 i
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i to NLS950170 Page 2 of 7 REPLY TO JULY 25, 1995, NOTICE OF VIOLATION COOPER NUCLEAR STATION NRC DOCKET NO. 50-298, LICENSE DPR-46 During NRC inspection activities conducted from April 16 through May 27, 1995, a violation of NRC requirements was identified. The particular violation and the District's reply is set forth below:
Violation A violation A contained in the referenced inspection report cites the following:
" Criterion V of Appcndix D to 10 CFR Part 50,
- Ins tructions, Procedures, and Drawings, " a t a tea, in part, that activities aficcting quality shall be prescribed by documented instructions, proccdures, or drawings of a type appropriate to the circwnatances and shall be accomplished in accordance with these instructions, procedurea, or drawinga.
1.
Contrary to the above, Dnergency procedure 5.2.5.1,
- Loos of all AC, " was not appropriate to the circumstances in that the procedure did not provide inatructiona for occuring the high pressure coolant [ injection] cystem turbine af ter 10 minutes into a station blackout scenario.
2.
Step 8. 6.3 of Procedure 1.9, Tontrol and Retention of Records, " required that record copies of documenta be transferred to the Records Control Center within 90 daya.
Con trazy to the above, permanent record copica of: (1) Revision 0 of Procedure 0.31,
- Equipment Sta tus Con tro1 *; (2) replacement component evalua tions; ano (3) motor-operated valve diagnostic traces were not forwarded CO the Records Control Center within 90 days.
3.
Step 2.6 oE Procedure 3.25,
- Replaccment Component Evaluation, " Revialon 3,
s ta ted, in part, that a completion checklist be included to ensure pertinent controlled documents are updated to reflect the replacement.
Contrary to the above, the completion checklist for Replacement Component Evaluation 9A-071, which evaluated the replacement of Valve CS-MOV-MOSA, was not corppleted (a blank form with no entries was found in the package)
- and, ao a reaul t, the valve limit swi tch setpoint values for the replacement valve were not updated in the appropriate procedure.
4.
Procedure
- 7. 3. 36,
- Limit and Torque Switch Checkout and Adjustment for Rising Sten Limitorque Motor Operated Valves, " dated November 8,
- 1994, s ta ted, in part, that valve position shall be expressed in the number of handwheel turns and, when counting handwheel turns, do nat include the turna required to engage the stem or take up gear alack.
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Contrary to the above, on December 19, 1994, an operator act the limit awitch for Valve CS-MOV-MOSA without accounting for engaging the stem or taking up gear alack, which resulted in the limit owitch being adjusted incorrectly and caused the valve to not indicate that it was fully shut during perfazmance of a curveillance test on May 5, 1995."
Adminnion or Denial to Violation The District admits the violation.
The discussion of the overall violation is presented below.
The individual examples are discussed in Attachment 2.
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to NLS950170 Page 3 of 7 Reasons for violation The cited examples in this violation underscore a major challenge at CNS with regard to procedure quality and adherence. The District believes that these two elements are closely linked to each other.
The adherence issues corroborated a I.
recognized adverse trend for which investigations had already been initiated.
A Condition Report (CR) was generated to determine the root cause of this adverse trend and to recommend corrective actions to prevent recurrence.
The Condition Review Team conducted extensive interviews with management and first line workers from numerous departments. Additionally, various CRs which concerned inadequate procedural adherence were examined.
The conclusion was reached that CNS management had failed to develop and foster an environment in which procedure use and adherence is an absolute requirement.
Key elements of such an environment were found to be lacking in various degrees.
Specifically:
1)
Management had not been clear on their meaning and understanding of procedure use and adherence.
While there was the expectation that procedures are to be followed, there was not a consistent understanding on what this means.
2)
The General Orientation Training program for site access discussed procedure compliance with regard to " Work Procedures" but did not address the expectations for adherence to administrative type procedures.
3)
The procedure change process and length of time to revise a procedure is a barrier to procedure use and adherence.
Additionally, the process requires the originator to be accountable for all changes in a particular revision including those changes made by several people.
These two obstacles predisposed employees to live with a procedure deficiency rather than submit a Procedure Change Notice (PCN).
4)
The lack of high quality procedures and the past culture at CNS has led to a perception that it is acceptable not to follow the procedure as long as the work meets the procedure's intent.
Corrective fceps Taken and the Results Achieved To address the broad-based chal2enge of procedure adherence at CNS, Senior Managers have cted meetings with their departmental personnel to emphasize the importance ct this issue and to stress the need to revise the procedures within each work area that need improvement. Additionally, the Site Manager has discussed this at all-hands meetings characterizing procedural adherence as one of his foremost concerns.
The District believes that these actions have succeeded in sensitizing site personnel to this issue.
Station management and supervision have also stressed the District's expectation of procedural adherence by promulgating a recent CNS Directive and through enhanced site orientation training on the subject.
The District has initiated a Phase 3 Performance Improvement Plan to address the area of procedure use and adherence.
The objective of the plan is to develop a comprehensive approach to procedure use and adherence that clearly defines I
management expectations, promotes individual accountability and ownership, and facilitates the development and maintenance of quality procedures that support the safe, efficient, and consistent operation of the plant.
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'* Attachment 1 to NLS950170 l
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. Corrective Steos That Will Be Taken to Avoid Further Violations j
4 As stated previously, the District has inaugurated a Phase 3 Performance 1
Improvement Plan to enhance procedure use and adherence. The key activities of this plan as currently constituted include-l
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i Development of management's expectations concerning procedure use and i
adherence.
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Revising the procedure change process to facilitate the timely improvement l
2 of procedures.
i Development and implementation of a procedure system that results in high l
quality procedures that support the safe, efficient, and consistent operation of the plant.
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r To avoid further violations of Criterion V of 10 CFR 50 Appendix B, the District will follow through to completion the Phase 3 Performance Improvement Plan for procedure use and adherence, i
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Date When Full Como11ance Will Be Achieved
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l The District is in full compliance with the requirements of 10 CFR 50 Appendix I
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i B Criterion V with respect to the examples cited in this Violation.
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1 ADDITIONAL DISCUSSION 4
what actiona will be taken to resolve why the incue related to a station blackout l
conunitment was not identified during the 1994 review and what actions have been I
taken to ensure that all other station blackout commitmenta have been met?
l To determine why a previous 1994 SBO commitment review did not note Violation 4
Example A.1, this issue was included within the scope of Condition Report (CR) r 95-0551.
The CR process has satisfactorily resolved why this occurred (the cause was attributed to personnel error on the part of the reviewing engineer and an j
inadequate review by his supervisor). As discussed in Attachment 2, the District will perform a detailed reevaluation of the NRC submittals associated with l
Station Blackout using the requirements of Procedure 0.42, "NRC Correspondence Control Procedure", to ensure the licensing basis assumptions have been properly 4
1 translated into the appropriate CNS documents.
what actions will be taken to [ provide] assurance that the version of a procedure approved by the Station Operation Review Committee la actually the version that la laaued?
j The Technical Support Group's practice of maintaining multiple hardcopies of the pre-SORC procedure changes in order to facilitate expeditious distribution has i
been discontinued. Previously, after final SORC comments were incorporated and the revision was approved, any changed pages were reprinted and then inserted by 2
hand into the other copies. This practice provided an unacceptable potential for human error.
Because all controlled copies are now reproduced from the single j
SORC-approved document, the version approved by SORC will be the one issued.
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to MLS950170 Page 5 of 7 l
' What actions will be taken to [ ensure] when it la identified that a procedure I
requirea revialon, iasuance of the revialon io a timely manner [occura] in lieu of continuing to use an inadequate procedure to perform safety-related activi ties?
The District understands that this question stems from page 12 of the Inspection Report where it was observed that Revision 0 of Procedure 7.3.50.5 was issued a few days after the replacement of CS-MOV-MOSA.
As discussed in Attachment 2, Example 3,
the District recognizes that the Replacement Component Evaluation (RCE) process has a weakness in that it does not cause certain required document changes prior to returning the equipment to operability.
Example 3 further discusses the actions taken and the commitment made to fix this weakness.
Additionally, as discussed in corrective Steos Taken and the Results Achieved, Management has taken steps to sensitize CNS personnel to the issue of procedural adherence (including the expectation that deficient procedures will be corrected prior to the resumption of the activity).
s What actions will be taken to (provide) assurance that the reason for changes being made to procedures la fully documented?
The PCN package provides the quality record that documents what the changes are and why they are being made.
The package includes the PCN forms which describe in detail the reason for the procedure change and the annotated copy of the procedure. To document PCN reviewer comments (which may not be reflected in the PCN forms), Comment / Resolution sheets have been used as a tool to properly address them.
The District has recently instituted a policy of including the
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i Comment / Resolution sheets with the final PCN package for microfilming.
Proceduralization of the use of the Comment / Resolution sheets has been included in the upcoming revision to the PCN procedure. With respect to the observation that there was an inappropriate level of documentation for a procedure change l
that incorporated a Station Operation Review Committee (SORC) comment, the SORC l
Administrator is using the Comment / Resolution sheets as a vehicle for capturing and dispositioning SORC comments, supplemented by direct annotation on the original SORC PCN.
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to NLS950170 Page 6 of 7
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DISCUSSION OF SPECIFIC EXAMPLES The specific examples of this violation have been closely examined via the CNS Corrective Action Program.
The following summaries describe the causes, completed corrective actions, and future steps that will be taken with regard to each issue.
Examnle 1 This example resulted from the failure to ensure in 1991 that the licensing basis assumptions for the use of HPCI during a Station Blackout (SBO) event were clearly identified and properly reconciled with the SBO Emergency Procedure.
This procedure has been changed to correct this cited example.
It now assures that during the licensing basis SBO, HPCI will be promptly secured after one cycle of operation. Additionally, a review was performed of the SBO calculations that were affected by the use of HPCI. This review has validated that associated calculation assumptions were supported by operator actions as directed by plant procedures. The District will verify that the other licensing basis assumptions associated with the SBO submittals have been properly translated into the appropriate CNS documents using the action item identification process of Procedure 0.42.
Based on the results of this verification, a decision will be made as to a broader inquiry and further corrective action.
Examnle 2 In addition to the broader concern for procedural adherence, the items described in this example indicate that there is a lack of understanding among some employees as to what a quality document is and the appropriate storage requirements for them.
Specific corrective actions have been taken for each issue:
The original PCN for Revision 0 of Procedure 0.31 (as well as several other PCNs in routing) were reclaimed and sent to the CNS Records Center for microfilming.
The requirements of Procedure 1.9,
" Control and Retention of Records", with respect to this issue have been reiterated to the Technical Support Group clerks.
The RCEs were relocated to a qualified fire-proof cabinet as allowed by Procedure 1.9.
The RCE procedure was changed to reflect this requirement.
Additionally, the cognizant Engineering Clerk was advised of the requirements for storage of quality documents.
The results of MOV diagnostic traces were added to the parent MOV Maintenance Work Request (MWR) packages per procedure 7.3.35.5.
The MWR packages are stored in fire-proof cabinets which meet the requirements of Procedure 1.9.
Test data that had been maintained on computer floppy disks has been transferred to optical disks which are also now stored in fire proof cabinets.
Actions that have been taken to address the concern for CNS document control practices include:
Establishing the Site Services Manager as the program owner for Document Control.
Providing to CNS managers and supervisors a definition of terms to clarify and promote awareness of correct document control practices.
Commencing an intensive review of CNS document control practices to determine weaknesses relative to the rest of the industry.
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to NLS950170 Page 7 of 7 Examnle 3 In investigating this issue, the System Engineer was found to have in fact filled out the Completion Report on February 22, 1995 (as required by Procedure 3.25,
" Replacement Component Evalua tion"), but did not provide this to the Plant Engineering Clerk who maintained the open RCE records (which were the files reviewed by the inspectors and which still indicated a " blank" Completion Report).
Although this completion report did not identify the need to revise Procedure 7,3,50.5 (which controlled the CS-MOV-MO5A limit switch settings) this issue underscores a weakness in the RCE process in that Procedure 3.25 does not require document revisions until after RCE implementation is accomplished in the field.
Documents that are more appropriately revised prior to (or coincident with) installation of the replacement part rely on that particular document's programmatic change process and the expertise of the RCE originator in recognizing the needed change, rather than by specific prompting in the RCE procedure.
To correct this weakness, Procedure 3.25 has been placed in a restricted use status with administrative compensatory measures pending the incorporation of guidance that addresses this weakness.
The RCE process will be changed to ensure that plant documents which will need revision are identified, and revised if necessary to support operability, prior to declaring the af fected component operable.
Examnle 4 In an effort to curtail valve mispositioning events, Operations personnel had been directed to manipulate components that were tagged out for Maintenance under approved Clearance Orders.
Although Maintenance Procedure 7.3.36 contained a precaution on the proper counting of MOV handwheel turns, the Maintenance personnel overseeing the completion of the procedure step failed to ensure the precaution was clearly communicated to the operator, who was not specifically familiar with this procedure. As described in Attachment 1, CNS management has stressed the requirements for procedure adherence, including training sessions at the working group level.
This has succeeded in sensitizing CNS personnel to this challenge. Additionally, the recurrence of this specific type of event has been precluded by revising the previously mentioned policy so that qualified Maintenance personnel can perform manipulations on equipment that has been tagged out and turned over to the Maintenance Department.
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LIST OF NRC COMMITMENTS ATTACHMENT 3 Correspondence No:NLS950170 The following table identifies those actions committed to by the District in this document.
Any other actions discussed in the submittal represent intended or planned actions by the District.
They are described to the NRC for the NRC's information and are not regulatory commitments.
Please notify the Licensing Manager at Cooper Nuclear Station of any questions regarding this document or any associated regulatory commitments.
COMMITMENT COMMITTED DATE OR OUTAGE The other licensing basis assumptions associated with the 9/30/95 SBO submittals will be verified to have been properly translated into the appropriate CNS documents using the action item identification process of Procedure 0.42.
Based on the results of this [SBO submittal]
None verification, a decision will be made as to a broader inquiry and further corrective action.
The District will follow through to completion the Phase None 3 Performance Improvement Plan for procedure use and adherence.
The RCE process will be changed to ensure that plant 9/30/95 documents which will need revision are identified, and revised if necessary to support operability, prior to declaring the affected component operable.
PROCEDURE NUMBER 0.42 REVISION NUMBER 0 PAGE 12 OF 16