ML20099H340
| ML20099H340 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 08/13/1992 |
| From: | William Cahill, Woodlan D TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| TXX-92358, NUDOCS 9208180260 | |
| Download: ML20099H340 (8) | |
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5 Log # TXU 92358 7UELECTRIC File # 10130 (IR 92-16)
Ref. # 10CFR2.201 William J. Cahlli, Jr.
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August 13. 1992 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555
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SUBJECT:
COMANCHE PEAK STEAM ELECTRIC STAT 10f; (CPSES)
DOCKET N05, 50 445 AND 50-446 NRC INSPECTION REPORT NOS. 50 445/92-16: 50-446/92-16 REPLY T0 A NOTICE OF VIOLATION Gentlemen:
I TU Electric has revieved the NRC's letter dated July 14, 1992, concerning the inspection of Messrs. D. N. Graves and R. M. Latta during the period May 3 through June 13, 1992, of. activities authorized for the Comanche Peak Steam Clectric Station, Units 1 and 2.
A Notice of Violation was attached in.the July 14, 1992 letter.
TV Electric's response to the Notice of Violation is attached.
The-letter also requested that TV Electric advise the NRC when the review of potentially reportable deficiencies (SNs), identified between January 1988 and June 1990, would be complete and provide your staff an opportunity to review the results.
The subject-review will be completed bef ore October 1, 1992.
Documentation of the review will be available for your staff at that time..
i Sincerely.
William J. Cahill, Jr.
By:
d D. R. Woodlan L.
Dock 8.icensing Manager TLH/ds e - Mr. J. L. Milhoan,- Region IV Resident inspectors. CPSES (2) i Mr. T.
A.. Bergman. NRR Mr. B. E. Holian, NRR 9208100260 920813 h-PDR ADOCK 05000445 G:
PDR yl1 400 N. Ohve Street LB 81 Dallas Texas 75201
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Attachment to TXX+92358 Page 1 of 7 11rm A (445/9216 01)
CPSES, Unit 1. Facility Operating License, Paragrapn 2H. states, in part,
'TU Electric shall fully implement ana maintain in effect all provisions of the physical security plan...previously approved by the Commission...
CPSEE Physical Security Plan, paragraph 6.2.3.1 requires that all licensee designated vehicles must be locked or secured when not in use within the protected area, Contrary to the above, on June 9. 1992, at approximately 11:40 a.m..
the inspector identified an uasecured licensee designated vehicle within the protected area which was unattended with the motor running while not in use.
Retoonse to Item A (445/9216-01)
TV Electric accepts the violation and the requested information follows:
1)
Reason for Violation The reason for-the violation was less than adequate comprehension of the procedural requirement on_the part of the vehicle operators.
While preparing to unload a temporary structure f rom a tractor trailer within the protectod area, the vehicle operator and his assistant left tne cab to-inspect the proposed laydown area.
Contrary to the above requirement the operators positioned themselves away^from the Licensee Designated-Vehicle (LDV) at a distance from which control could not be assured 2 )-
Corrective Steos Taken and Results Achieved The vehicle. operator's assistant returned to the immediate _ vicinity of the cab to maintain control of the LOV. The vehicle operator, the-assistant, and their supervisor were counseled by the Administrative Security Supervisor as to the proper implementation of' the control of LOV's.
The cccurrence was entered in the Security Log.
All individuals who control LOV's were contacted and informed ci the nature of the violation.
Contractor craft personnel working within the protteted area were informed _ byLtheir management of the details of the violation and the p~rocedural requirements which govern the proper steps to be taken when an.LUV is not in use.
i 3) forrective Actions-Taken to Preclude Recurrence
'A memorandum detailing the requirements for the control of LDV*s and management's expectations for cor pliance with these requirements has l1
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4 Attachment to TXX-92358 Page 2 of 7 been issued to applicable site personnel.
Additionaliy, guidelines for controlling LDV's are now distributed to individuals who request use of an LDV.
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Elte When Full ComDliance Will_[e Achieved Full compliance has been achieved, item B (446/9216-02)
Criterion V-of Appendix B to 10 CFR 50 as implemented by Section 5,0 of the
.lu Electric Quality Assurance Manual, states, in part, ' Activities.ffecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appror
- ' e to the circumstances.'
Station Administration Procedure STA 806, ' Construction Work Requests and Work Orders.' Revision _16, Steps 6.3.8 and 6,3,9. states, in part, that.the
- Unit _2 work control center will ensure all permits and cleartices have been included and that the-Unit 2 shift supervisor or his desig,ee shall sign for work start approval following review and approval of all necessary documents.
Contrary to the above, Construction Work Document ETP 1191, including Startup Work Authorization 82903, was not appropriate to the circumstances in that it was approved, authorized for work, and released to the field for performance on battery room exnaust fan CP2VAFNID10, which was energized from a temporary power source, without adequate provisions for ensuring personnel safety and equipment protection, Response to Item B
-(446/9216-02)
TV Electric accepts the violation and the requested information follows:
1.
Reason for-Violatinn i
On' April. 28,- 1992, a construction electrician attempted to work on a l
Battery Roon Exhaust-Fan which was energized by temporary power.
The electrician was unaware of.the energized condition.
The electrician
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first removed,the fan motor terminal cover for general inspection. As L
-the coser was removed and-thv electrician began straighten-ing the wires, i
a faulty wire gr ounded inside the _ fan niotor housing causing arcing and-1-
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Attachment to TXX-92358 Page 3 of 7 a brief fire.
The i' ire self-extinguished and the fan motor was de-energized.
The electrician was not injured.
The electrician was attempting to rework a deficiency dif ferent from the ore which started the fire.
The deficiency which started the fire had not been previously identified.
The electrician was fully compliant with procedures and authorized to perform the work.
At the tima, it was believed that the administrative controls, including work sequencing, authorizations and tagging, were adequate to preclude work on energized i
equipment.
Tht root causes for this incident are discussed below.
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inedequate communication of the Battery Room Exhaust Fan work sequencing, and lack of designated overall responsibility for work sequencing, led to inappropriate approval of a Startup Work Authorization (SWA).
This allowed work in a compon?nt that had temporary power (under the Startup Temporary Modification (TM) process) supplied to it.
The electrician implementing the SWA was unaware of the temporary power condition wher, he removed the component's cover for an authorized work activity inspection, o
The electrician was not familiar with temporary..dification tags and the associated potential safety hazards.
This led to a field situation where, despite a conservative approach to TM tag coverage and despite reference to the TM on the Unit 2 Impact Sheet.in the work package, the assigned electrician was still not alerted to the temporary power condition.
Several contributing factors pertinent to the overall work planning and implementation processes were also identified and are discussed below.
o The original planning effort for the Battery Room Exhaust Fan work was not implemented as scheduled.
This_ created the need for additional planning-and temporary modification to the Battery Room Exhaust Fan: motors.
After a defined scope of electrical work associated with the_ fan relays had been planned and completed under a clearance, construction work en other priorities delayed completion of the I&C and Mechanical packages ossociated with the same clearance.
This delay prevented closure of_the clearance,-
thus creating interferences for additional work a:tivities.
o Some packages-were worked outside of the intended work sindow.
' Construction work packages were prepared in advance, with clearances and work release authorizations issued prior to the actual intended work window.
This practice complicated the
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Attachment to TXX+92358 Page 4 of 7 Startup Test Engineer's (STE) task of mainteining cognizance of overall system status and specific work activities that could impact one another.
o Construction craft personnel and others involved in the package preparation process geratally f elt that they were still working in a construction environment versus a testing / operations-type enviror, ment, which necessitates more detailed work planning and sequencing, o
Interface impact reviews between TMs and clearances were not effective enough to find and correct all potential personnel safety hazards.
Work packages or TMs/ clearances that may have had a personnel safety impact on each other could have been approved for field implementation concurrently.
O Construction craft / supervision's implementation of the Common Area Checklist, pre job briefings, and Total Saf ety Task Instructions (TSTI), prolui ineffective in detecting and calling craftsman's attention to the potential safety hazard.
The craftsman felt that-no out-of the ordinary precautions were needed for the job, o
There was lack ~of clarity in this specific work package concerning the exact scope of= intended work.
As a result, package reviewers (STF and Work Control Center) were hindered from performing effective TM/ clearance safety impact reviews.
o There was a general lack of information exchange within Construction and with the STE. _As a result. specific sequencing notes or precautions were not-brought to craft *s attention.
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Corrective Steos faken and Results Achieved A TUE Form was wr'tten to identify and disposition deficient Battery
. Room Fan No.10.
The f an has been replaced.
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- Another TVE Form was written to document the incident involving work on the energized fan..Because of the "near miss' nature of the incident, it was considered both serious _ and significant.
Therefore, management's review of the-UIE Form resulted in formation o; e multi disciplined Task Team. 'The Team was organized tr identi<
root cause(s) and contributing factors; perform a safety-analysis and personnel performance evaluation; and recommend-corrective actions and actions to preclude recurrence l
which would be-consistent with and which would resolve the causes and contributing factors.. The Team's evaluation also included an investigation of another:similar-incident involving authorized work in an energized chill water' system control panel.
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Attachment to TXX 92358 Page 5 of 7 The team's conclusions and recommendations were documented in a report approved en June 5, 1992.
This report generated a number of subsequent actions which were finalized on July 20, 1992.
The causes and corrective actions specified in this letter are consistent with the Team's conclusions and report and are intended to oreclude conditions that existed prior to both investigated incidents.
3.
Corrective Steos Taben to Preclude Recurrence I
The Task Team-provided a number recommendations fnr corrective actions.
The recommendations were forwarded to Project Management for evaluation and implementation.
Identification and status of those actions is explained below.
On May 13, 1992, the Startup Manager wrote a memo entitled 'Startup Test Engineer (STE)-Responsibilities,'
Besides identifying the STE as the focal point for maintaining cognizance, cot ? Jination and control of systems turned over to Startup, the memc requested full support to ensure work activity coordination with the appropriate STE.
As a result a second team was organized to evaluate how best tc implement enhanced work activity coordination.
Based on the recommendations of the initial Task Team and further work by the second team, the following actions have been accomplished.
o STEs are currently coordinating Startup SWAs and Startup Work Permits'(SWPs)-in Startup by daily coordination and sequencing through the Startup Support Group over which they have direct control.
In addition, tne System Custody Hatrix was updated to identify primary -and backup STEs.
A listing of these STEs is being procedurally distributed to Unit 2 organizations.
All Startup Test Group Supervisors have been informed to contact the primary or backup system STE if they have qucstions about system
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Startup and Construction conducted a review of auth3rized Construction SWAs (approximately 670) and either pulled the packages from the field for revision or adjusted the work windows as necessary to ensure-proper work sequencing.
- onstruction, through their Work Document Tracking Proup.-controls all Construction SWA packages to be sent to the field and establishes c
I work windows based upon published Startup Plan of-the-Day l
-schedules or communications with the appropriate Construction Engineer and STE.
Work windows consideration: include proper sequencing, personnel safety, and need dates.
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Attachment to TXX 92358 Page 6 of 7 o
The responsibilities and duties of the STE and Shift Supervisor regarding their impact reviews associated with Temporary Hodifications (TMs) and clearances were procedurelized.
The Unit 2 Work Control Center enhanced the processes to ensu.'e that the TH log is thoroughly reviewed f or impact on new clearances or TMs.
This process was also communicated via verbal guidance from Operations Management.
o Unit 2 Operations will develop and implement clearances to support a specific work package without further modifying t:* cicarance scope unless specifically authorized by the appropriate STE.
As more systems are turned over to Operations, the Project will transition towards this method for developing and implementing clearances.
o Construction management met with craft supervision to review femmon Area Checklists, pre job briefings and the TSTI program to c-luate the need for changes.
In general, the TSTI program and the pre-job briefings were considered effective.
However, use of the Common Area Checklists was determined to be inconsistent and in some respects duplicative of the TSTI and pre-job briefing, in addition, other controls including use of dedicated crews in the common area, training, enhnnced interfaces and increased emphasis on personnel and equipment safety indicated that the Common Area Checklist was not needed.
Therefore the program has been discontinued, o
Construction anr: Startup Hanagement reviewew work package preparation practices.for needed improvements.
A number of actions were implemented, Construction Engineers (CE) involved with the package preparation were trained concerning the level of detail in various document description blocks, the need to provide work information that is ' user-friendly' to the craftsmen, and the need to properly reference associated documentation.
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- addition, a number of human f actors changes to field packages sucn as bold printing, highlighting and the 'seven steps for self-l verification
- were implemented.
o A inemorandum titled ' Sensitivity to Changing Work Conditions
- was approved _on J.ne 17, 1992. by;the Unit 2 Project Manager, Manager of Startup and Unit 2 Operations Manager.
This memorandum stressed the need for ai? Project personnel to be sensitive to changing plant conditions. changes to custoJy of systems and safety now that Unit 2 has transitioned from a bulk construction mode _to a test /preoperational mode.
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i Attachment to TXX-92358 Page 7 of 7 l
0 Sooa after this incident. Construction's craft personnel were given a training bulletin describing a Temporary Modification (TM) tag and its potential for indicating a hazardous situation.
o Unit 2 Project Training developed and implemented an enhanced training module on site tag familiarization entitled ' Safe Work fractices.'
This training includes the potentially hazardous conditions that each type of tag may indicate.
It also. reiterates t
the need for self verification methods to improve attention to I
detail and the need to implement work-within approved Startup work i
windows.
4.
Date of Full Comoliance i
Full compliance has been achieved.
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