ML20096F298
| ML20096F298 | |
| Person / Time | |
|---|---|
| Site: | McGuire, Mcguire  |
| Issue date: | 05/13/1992 |
| From: | Mcmeekin T DUKE POWER CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9205210008 | |
| Download: ML20096F298 (9) | |
Text
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AkGuire Nntrar Crwatuut 1%sartment nce Presidret
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DUKEPOWCR May 13,1992 U. S. Nuclear Regulatory Commission Attendon: Document Control Desk Washington, DC 20555;
Subject:
McGuire Nuclear Station Docket Nos E0-369. -370.
Inspection Report No. 50 369 -370/92-08 Gentlemen:
Pursuant to 10 CFR 2.201, please find attached Duke Power Companya response to Violations 369/92-08-01, and 369, 370/92 08-03 for McGuire Nuclear Station.
Should there be any) questions concerning this matter, contact-Larry Kunka at (704 875-4032.
Very truly yours, 7th 4.,
T. C McMeckin Attachment.
xc:
Mr. S. D. Ebneter -
Administrator, Region 11:
U. S. Nuclear Regulatory Commission 101. Marietta St., NW,- Suite 2900 -
Atlanta, Ga. 30323
.Mr. Tim Reed U. S. Nuclear Regulatory Commission-Office of Nuclear Reactor Regulation -
- Washington.1DCJ 20555 L Mr. P. K. Van Doorn :
NRC. Resident Inspector; McGuire Nuclear Stauen 2u n _,m J
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4 Document Control Desk Page 2 l
May 13, 1992 bxc:
A.V. Carr-(PB05E)
E. M. Kuhr R. C. Futroll (CNS)
R. L. Gill t
P. R. Herran M. E. Patrick (ONS)
R. O. Sharpe D. R. Bradshaw M.
A. Mullen i
T. L. Pederson T.
S. Barr QA Tech.-Services NRC Coordinator (EC12A)
M.F.
1.2.1.
File 015.01
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a McQ111RE NHCLEARJTATION RESPONSE TO VIOLATION 30PS2-pj-Q1 VIOLATlON 3.6952-08-01 10 CF A 50 Appendix B Cdorion XVI and the licensee's accepted Quality Assurance Program (Duke-t-A) Section 17.2.16 collectively require that measures be established to assure that conditions adverse to quality are promptly identified and corrected, i
Contrary to the above, although measures were established, they were not e!!octively imp!0mented.
On February 26,1992, while conducting daily rounds, a non licensod operator reported to the Unit Supervisor that the 1 A diesel generator fuel oli tank level was low. This ccndition was not corrected until February 28,1992. During this time, the 1/, diesel generator fusi oil tank level was 38,000 gallons which was below the 39,500 gallon minimum level ruquired by Technical Specification 3 81.1.1 This is a Severity Level IV (Supplement 1) violation and applies to Unit 1 only.
T. tie REASON FOR THE VIOLATION On February 26, 1992, during sampling of the Unit 1 Fuel Oil Storage Tanks (FOST's), Chemist 6'y techniciant, inadvertently left two valves on the recirculation pump suction of the 1 A FOST open while recirculating the 1B FOST. Thorofore, during the four hcur recirculation period for the 18 FOST, the recirculation pump was taking suction on bcth 1 A and 18 FOST but was discharging only to the 18 FOST.
This caused the love! In the 1 A FOST to be 'owered below the Technical Spocification (TS) limit.
Later that evWng, an Operations (OPS) non-licensed operator (NLO) was performing the first night shift inspection of the Service Building and Outside Equipment per OMP 2-8, He observed the 1 A FOST level was 38,000 gallons and noted this value in the appropriate block on Attachment 3 nf OMP 2-8. The rounds standard instructions in OMP 2-8 specifies for any out of norrral value or value parameter that is noted on she onclosure, the person oerforming the rounds inspection shall write "E1' in thJ parameter space along with the parameter val r. The roovired value listed on the rounds shoet was " greater than 40,0M
- gallons. The NLO did not flag the out of nt mal value. The NLO did inform the Assistant Shift bupervisor of the 1 A FOST lovel. The assistant shift Supervisor acknowledged the level and stated he would look into it. He believed the level was within the TS limits, when the 1S limit is actually 39,500 gallons. Another Senior Reactor Operator (SRO) was given the rounds shoots to review. The normal practico for SRO review of rounds sheets is to focus primarily on values that are flagged as out of normal Since the NLO had not flagged the FOST value as out of normal, the low value was not datocted during i
the SHO's review and no action was taken.
The next day, an NLO m the day shift noted the value of the 1 A FOST as 37,500 gallons, but again due to attention to detail, the value was not noted as out of normal and the subsequent SRO review did not detect tha low value. There'oro, once again no action was taken to increase the low level in the t A FOST.
When the night shift returned, the NLO recorded 37.500 gallons in the 1 A FOST. Since he had informed the Assistant Shift Supervisor of the low level on the previous shift, he saw no reason for concern and once again did not flag the value as out of normal. When the SRO reviewed the round sheets, once again the low value was not detected and no action was taken to raise tne level in F.41 A F0ST.
During the day shitt on February 28, the NLO assigned to perform the rounds nohd 37,500 gallons as ine e
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i I A FOST level but again the value was not flagged as out of normal. The rounct theets were O ven for l
j revies to a shift supervisor who had not performed this review recently and was not as familiar with the i
rounds sheet review. Therefore, h0 was very thorough in looking at the data. During this review the Shift Supervisor realized that the 1 A FOST was outside of TS limits and actions were taken to inetease the level to within TS limits.
Therefore, the low level on the 1 A FOST was not immediately corrected due to inattention to detall by various OPS personnel while performing Nd reviewing the rounds sheets.
T!iLQQRRECTIVE STEPS TAKEN AND RESULT!LA_CHIEVEQ 1.
1 A FOST valves were closed and locked by Chemistry personnel.
2.
OPS personnet returned 5,000 gallons of fuel oil from 18 FOST to 1 A FOST which raised the 1 A FOST level atme the TS limit.
THE CORRFS.T._L E STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS V
1.
OPS managernent personnel will evaluate the current NLO rounds turnover policy and initiate changes to the policy as necessary.
2.
The importance of NLO rounds sheets, management's expectations of how to complete rounds sheets, proper rounds turnover, and proper rounds techniques will be re-emphasized in NLO training.
3.
OPS g ?onnel will revise rounds sheets to highlight TS related items.
4.
OPS personnel will evaluate how out of normal values ard flagged on rounds sheets and make changes as necr$sary, 5.
OPS management will devise an Equipment Training and Qualification Standard (ETOS) that incorperhtes having an OPS supervisor accompany each NLO and Reactor Operator during rounds activities at least once every two years.
Q_ ale WHEN FULL COMPLIANCE WILT. BE. ACHIEVED McGuire is in full compliance.
WOUIRE NUCLEAR STATION RESPONSE TO VIOLATlON 369. 370S2-08-03 1
VIOLATION 369. 370'92-08-02 Technical Specification 6.8.1 requires that written procedures bn established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guido 1.33, Reveion 2, February,1978, which include; the operation of safety related systems, maintaining containment integrity, and performing survell!ance tests on safety rotated equipment.
Contrary to the above, procedures were not adequately implemented to maintain configuration control as evidenced by the following examples:
1.
On August 12,1991, the licensee discovered valves 1SA-40 and 1SA-39, the above and below set.t drains for the auxiliary feedwater turbine stop valve, open. Licensoo procedure, OP/1/A/6250/02, Auxiliary Feedwater System, requires that these valves be closed.
2.
On September 30,1991, the licensos discovered valve 1 RN-951, Containment Spray (NS)
System Pump 1 A Air Handling Unit Outlet Contro!, in the Nuclear Service Water system shut. This tesulted in the "A" train of NS being inoperable for an indeterminate period of time. During the period when the system was inoperable, the unit was in a retueling outage when NS was not required to be opersble. This valve is required to be maintained in a partially open configuration by procedure OP/1/A/6100/22, Unit 1 Data Book.-
3.
On February 28,1992, the Ilcensee discovered that the suction valves to the recirculation lines between the 1 A and 1B diesel generator fuel oil storapt tanks were ' oft open.
Licensee procedure CP/1/A/8600/411 Chemistry Procedure foi Sampling of Oils in Unit 1, requires that the valves be closed followhg the completion of fuel oil recirculation which was performod on February 26,1992.
4.
On January 30,1992, while attempting to terminate a containment atmosphere Sample l
on Unit 2, the Radiation Protection technicians isolated the EMF supply valve and the EMF sample inlet valves, rwdering the EMF's inoperable for approxl.nately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />. The valves intended to be isciated were the sample inlet and outlet vcives, as required by HP/0/B/1003/39, VD/VP/incore Release Procedure. This occurred while the unit was in a refueling outage.
l 5.
On April 1,1992, pressure transmitter 2NSPT5390 was discovered with its isolation valve closed by Operations personnel. With the transmitter isolation yalve in the closed positict',
the Containment Pressure Control System (CPCS) for the Containment Air Rc9tn i
Exchange and Hydrogen Skimmer (VX) system Train 2A is inoperable.
This example wal glven in inspection Report 369,370/9%-10.
This is a Severity 1.ovel IV (Supplement 1) violation.
REASON FOR THE VIOLATION The reason for each of the five examples of canfiguration control problems will be addressed separately.
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The rounds non licensed operator (NLO) opened the valves as instructed by the rounds sheet.
He then went into the RN Pumo Strainer Room to continue his rounds with the intention of returning to the pump room to close the valves. This is a common practice. While in the RN Strainer Room, he was distracted by a radio call directing him to another location in the plant.
The NLO left te respond to the call, leaving the valves open. Later he resumed his round but forgot to reclose the valves.
The NLO was distracted by o'her activities after opening the valves but befora reciosing them. No guidance was given in the proccdure to ensure the operator does not have concurrent duties while cycling these valves. The cause was determined to be an inadequate procedure that did not specify the valves should be opened and shut without concurrent duties and the NLO not having sufficient attention to detail.
2.
On September 30,1991, valve 1 RN-951, Containment Spray (NS) System Pump 1 A Air Handling Unit Outlet Contiol, was found mispositioned in the closed position during maintanance activities.
The misposition of 1RN-951 was brought to the attention of Operations Control Room personnel during discussion of the misposition of valve 1RN-949, Residual Heat Removal (ND) System Pump 1 A Air Handling Unit Outlet Control, which was discovered on October 4,1991.
Valve 1RN-951 had been in the incorrect porltion for an unknown period of time after September 4,1991, when the air handling unit had betn operated 'vith no abnormal temperatures noted.
This resulted in Train 1 A of the NS system Ming inoperable for an unknown period between Sepiember 4,1991 and October 4,1991. The NS system had been required to be operable September 4 through September 21,1991, until Unit 1 entered Mode 5. No definite or orobable cause could be found for the incorrect positioning of 1RN-951, 3.
On February 26,1992 Chemistry technicians were assigned the task of obtaining samples from the Unit 1 and 2 Diesel Generator (DG) Fuel Oil Storage Tanks (FOST). Prior to sampling the fuel oil inside each FOST must be recirculated at least four hours. The technicians proceeded to the Unit i FOST location, and placed the 1 A FOST in recirculation mode. This required the unlocking and opening of four vah t Approximate!y four hours later, the technicians obtained the sample from the 1 A FOST and p.oced the 18 FOST in rec'rculation mode for the required four hours.
The technicians did not realize that the two valves for the 1 A FOST In the suction header of tN, recirculation pump were not closed. The precedure being used did not specify an individual sign off for the valve position. Therefore, du,-ing the four hour recirculation period for the 18 FOST, l
the recirculation pump was taking suctiori on both 1 A and 1B FOST but was discharging only to l
the 1B FOST. This caused the level in the 1A FOST to be lowered below the Technical Specification limit of 39,500 gallons.
4.
On January 30,1902,2 EMF 38,39, and 40, Containment Particulate, Gas and lodine monitor was taken out of service to perform monthly maintenance. Unit 2 Containment Purge (VP) system operation was secured during the maintenance.' The VP system was to be restarted on the day shift. Radiation Protection (RP) day shift personnel started a sample at 0800 to measure ar,d account for any changes n containment airborne activity levels. Aftar retuming to the RP shift lab, the personnel realized the VP system had not been restarted and the sample was not required. At 0907, the VP purge was restarted. At approximately 0930, the RP personnel stopped
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the sample. At approximately 1130, RP personnel working on the EMF noticed thc EMF sample supply valve and the EMF supply valve were both closed.
Both of the RP personnel involved with the securing of the sample believed that they were the ones who performed the Inoependent Veiification when the sample was secured. Neliher could remGnber actually cperating the valves but both were confident they had IV'ed the valves. Since neither of the individuals could semember operating the valves, they could nc! have been in the
correc' position when they were IV'ed. The cause of this event is f ailure to follow the procedure for the EMF Sampling (HP/0/B/1003/39) and inattention to the details o' the task at hand.
5.
On April 1,1992. Operations (OPS) personnel noticed the handle on the is0!allon valve for CPCS transmitter 2NSPT5390 was not fully extended in the open direction. Trie OPS personnel attempted to move the transmitter isolation valve m the close ' r.trection and found the valve closed. With the transmitter isolation valve to the closod porition, the CPCS for Containment Air Return Exchange and Hydrogen Skimmer ', stem 2A was inoperable. No reason as to how, why or when the transmitter isolation was clossd could be determined.
CORRECTIVE STEPS TAKEN AND RESULTS AQHIEVED For all of the above configuration control events, the appropriate plant personnel were informed and the niispositioned con ponent was returned to its correct position.
Other corcoctive actiens will be listed for the individual events.
1.
The rounds sheet has been changed to require the NLO to stand by the valves while they are being cyclen.
2.
A.
The remaining Unit i ND and NS pump air handling unit outlet throttle valves were' verified by OPS personnel to be in the correct pooltion.
B.
Performance personnel ensured that the valve stem lock nuts were ll htened on all Unit 0
1 and 2 throttled RN system flow balance related valves.
C.
OPS personnel revised Station Directive 3.1.5, Activities Affecting Station Operations or Operating indications to add a requirement for station personnel to rotify the Conto Room SRO 11 a plant device S ' and mispositioned or misaligned.
3, A.
Procedures CP/1(2)/8600/41, CHM Procedure for Sampling of Oils on Unh 1 and Unit 2, were revised to require sign offs for Individual valve alignments.
B.
Chemistry (CHM) management personnel discussed this everit with h chemistry technicians involved.
4.
A.
Discussions were held with the two llP specialists involved in tha event.
B.
Discussions were held with cJl RP shift personnel reinforcing the requirements of the RP IV responsibilities covered in RP Manual Section 8.6, the necessity to follow the procedure in the field, and the need to not switch from the performer to the IVer within the same step of a procedure.
5.
A.
Instrument and electrical (IAE) personnel verified all CPCS transmitter isolation valves were open on Units 1 and 2.
B.
Iso!ation valves were verified positioned properly on the following system for instruments without continuous indication:
Auxiliary Feedwater Residual Heat Removal Chemical and Volume Control Nuclear Service Water Containment Air Addition and Release Liquid Waste
l CORRECTIVE STEPS TO_BE TAKEN ~p AVOID FURTHER VIOLATIONS The correctlve steps to be taken will be addressed for each example with generic corrective steps listed at the end.
s 1.
The change to the rounds sheet and the reason for the change will be communicated to all rounds NLOs.
2.
Maintenance management will cover thi9 event with all maintenance technicians. The importance of notifying OPS Control Room personnel it a plant device is found mispot,ltioned or misaligned will be stressed.
3.
A.
( PS and CHM personnel will evaluate the interface process for operation of plant equipment which is under the dual control of OPS and CHM and enhance current practices as appropriate.
B.
CHM management will cover this event with appropriate CHM personnel.
C.
CHM personnel will review all procedures under their control that are directly involved with state, federal or NRC regulations and assure that component configuration control is adequately addressed.
D.
CHM personnel will evaluate the practice of locking open valved during tank recirculation activities and rene this policy as appropriate.
E.
CHM management will revise the task of obtaining fuel oil samples dudg routine monthPt sampling of FbSTs so ihat Train A tanks will be sampled on a different day than Train d tanks.
F.
Procadures CP/1(2)/A/8600/41 will be revised by CHM Staff to require notification of the l
duty SRO prior to FOST recirculation and sampling activities.
l 4.
A.
Procedure HP/0/8/1003/39 will be changed so that only the stepc that require IV are I
identified in bold so they will not be confuseo with steps that do not require IV.
B.
When other shift RP procedures are due for review or are updated, the IV requirements l
will be reviewed and placed in bold type.
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The corrective action to be taken for example 5 will also. address the configuration control concerns I
generically.
5.
The Component Mispositioning Working Group (CMWG) has been formed to use the Human Performance Enhancement System methodologies to find the root or probable causes of the -
component mispositioning events and upon determining the causes, recommend effective means to prevent recurrence of mispositioning events. The team will be composed of members of the site staff aad management representing the principle work groups w'n position components.
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This working group will make recommendations. to management on an tingoing basis.
Management will evaluate the recommendations for implemsntation.
s Additionally, since many component mispositionings are due to procedure adherence, the excellence group formed to look at procedure adherence in response to the violation given in inspection Report 91-22 will also server to address component mispositioning.
DATE WHEN FUt L COMPLIANCE W1L BE ACHIEVED McGuire is in full compliance.
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