ML20113B380
| ML20113B380 | |
| Person / Time | |
|---|---|
| Site: | Braidwood  |
| Issue date: | 06/14/1996 |
| From: | Stanley H COMMONWEALTH EDISON CO. |
| To: | Lieberman J NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| NUDOCS 9606270072 | |
| Download: ML20113B380 (13) | |
Text
Commonwealth 1:dimn Company firaidw om! Generating Station Route *I, llox N 6 lirzces ille,11. Un07%I 9 Tel HI44584801 June 14,1996 1
Mr. James Lieberman i
Director, Office of Enforcement U.S. Nuclear Regulatory Commission One White Flint North 11555 Rockville Pike Rockville, MD 20852-2738
Subject:
Braidwood Station Units 1 and 2 Reply to a Notice of Violation and Proposed imposition of Civil Penalty NRC Docket Numbers 50-456 and 50-457
References:
- 1) L. F. Miller letter to K. Kaup dated April 5,1996, transmitting NRC Inspection Report Number 50-456/457/96005
- 2) W.L. Axelson letter to K. Kaup dated May 14, 1996, transmitting NRC Enforcement Conference Report Number 50-456/457/96010
- 3) H.J. Miller letter to T.J. Maiman dated May 16,1996, transmitting Notice of Violation and Proposed Imposition of Civil Penalty from NRC Inspection Report 50-456/457/96005 Reference I provided the results of a special investigation conducted on January 23 through March 21,1996. This report included five apparent violations which were identified to be considered for escalated enforcement action. These apparent violations involved failure to i
properly control the configuration vf safety-related systems, and to correct weaknesses that were identified in our methods for configuration control. The Reference 2 report addressed the Predecisional Enforcement Conference that took place on April 26,1996. Finally, Reference 3 contained the Notice of Violation and Proposed Imposition of Civil Penalty associated with the
)j Enforcement Conference.
1 Enclosed is Commonwealth Edison's (Comed) response to the Notice of Violation and Proposed imposition of Civil Penalty transmitted in Reference 3. The attachment focuses on the actions taken by Braidwood Station for each individual violation listed. Also, please find enclosed a check in the amount of $100,000.00 made payable to the Treasurer of the United States.
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Braidwood Station recognizes the collective significance of the cited violations. Every effort is l
being made to implement our licensed responsibilities in the most safe and effective manner.
When a performance deficien.:y does occur, prompt action is taken to correct that deficiency.
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Nuclear Regulatory Commission June 14,1996 However, in the case of the cited violations, it is rmagaimi that these efforts could have been substantially better.
Since the time the problems associated with configuration control and the OOS process were identified, many changes have been implemented to improve Station performance. For example, Operations has continually emphasized the importance of following established standards, including the need for questioning attitudes.
This information is regularly communicated to Operators during shift meetings, training cycles, and reinforcement sessions.
OOS process changes have resulted in additional management oversight with the expectation that the added involvement will prevent repeated personnel errors. The Station recognizes Outage planning as another area requiring enhancements. Changes in this area include appointing a full time Operations planner and the commitment to meet outage planning mil ~*aa~
Finally, in order to improve root cause investigations, the size of the Station's Root Cause Team has been increased and Senior Manager sponsors are assigned to Level III Nuclear Tracking System (NTS) items to ensure appropriate attention is dedicated to resolve identified concerns.
To further improve performance, significant resources have been expended to conduct assessments of Station performance. An internal assessment done by Braidwood personnel and an external assessment done by Comed personnel who were assisted by industry consultants have been completed. From the analysis of these assessments, four key areas have been identified for improvement; (1) human performance, (2) materiel condition, (3) outage aptimi=*iaa, and (4) corrective actions. In these four areas, thirteen action plans have been developed to drive improvement. Seven of the action plans are targeted for implementation during the balance of 1996. De others are planned for implementation as part of the 1997-1998 business planning process. These action plan initiatives are geared toward achieving high performance levels and are supplemental to those actions necessary to ensure fulfillment of the Station's licensed responsibilities.
We are excited to move ahead and, as a result of these initiatives, we will achieve dramatic performance improvements. The results of our assessments and our action plans have been shared with the NRC Resident Inspectors at Braidwood. We will continue to appraise the la=a~ *ars on the results of our efforts.
The following commitments were made in response to this siolation:
The licensed operator initial and requalification training will be revised to include all phases of hydrogen monitor operation, normal lineup, and access control for the monitor. His information will be provided in Cycle 4 of 1996 to be completed by July 12,19%,
De Station will implement an enhanced OOS procedure by July 15, 1996. This will include appropriate training for necessary personnel.
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Nuclear Regulatory Commission June 14,1996 Operators will be assigned to the OOS group on a rotating basis to maintain proficiency in the OOS process. 'Ihis change will be implemented on June 17,1996.
Also, the OOS group will be relocated near the Maintenance staff to optimize communication between the workers. The relocation will take place by July 8,1996.
j Should you have any questions related to the attached, please contact Mr. Terrence Simpkin, Regulatory Assurance Supervisor, Braidwood Station at (815) 453-2801, extension 2980.
l Respectfully, 1
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Site Vice President Attachment l
cc:
H. J. Miller, NRC Regional Administrator - Rill R. R. Assa, Project Manager - NRR j
C. J. Phillips, Senior Resident hupector F. Niziolek, Division of Engineering, Office of Nuclear Safety - IDNS Document Control Desk l
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TTACHMENTI l
REPLY TO NOTICE OF VIOLATION During a NRC inspection conducted on January 23 through March 21, 1996, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC
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Enforcement Actions," NUREG-1600, the Nuclear Regulatory Commission proposes to impose a civil l
penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act),42 U.S.C. 2282, and 10 CFR 2.205.
In addition to the specified violations, this attachment contains the reasons for the Siolations, the corrective l
actions that have been taken and the results achieved, the corrective actions that will be tr. ken to avoid l
further violations, and the date when full compliance will be achieved.
1.
10 CFR 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," requires that l
activities affecting quality shall be prescribed by documented instructions, procedures, or l
drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with l
these instructions, procedures, or drawings.
A.
Braidwood Administrative Procedure, BwAP 330-1, Revision 17El, Step c.2.a, requires if j
points of isolation required are different from a standard (normal) isolation, marked-up l
prints or a separate list shall be submitted showing the required isolation points. If the out l
cf senice is done on the computer, the prints / list will be sent to the SE office or out of l
service planning office, with adequate information identifying the associated out of senice.
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j Contrary to the above, as of March 1,1996, the cognizant work planner did not submit j
marked-up prints or a separate list to the SE office or out of service planning office l
showing required isolation points for out of senice #960001992 for the 2B safety injection l
pump. He out of service was performed on computer and the required isolation points were different from a standard isolation.
REASON FOR THE VIOLATION:
Management's expectation regarding the preparation of out of services is that the Work Ar'alysts are responsible for providing to the OOS preparers detailed information and communicating this information on a level sufficient to ensure work is adequately bounded. The method prescribed by BwAP 330-1,
' Station Equipment Out-of-Senice Procedure,"to convey this expectation was too prescriptive. Also, the Work Analyst's understandmg of the procedural requirements was not sufYicient to ensure the procedure was followed. Finally, the Work Analyst did not meet management's expectations with respect to providing sufficient information to the OOS preparer.
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CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
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He Work Analysts involved were counseled by their supenision and expectations related to procedure knowledge and adherence were reinforced.
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TTACHMENTI REPLY TO NOTICE OF VIOLATION I
CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED (continued):
BwAP 330-1 has been revised to better reflect management's expectations associated with the need for sufficient detail being provided to OOS preparers Management's expectations and the revised procedaral requirements have been communicated to Work Analysts.
CORRECTIVE ACTIONS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATION:
ne Station is establishing a Work Execution Center (WEC) to redirect the responsibility for administrative i
tasks associated with work executien from the Control Room. His will allow the Control Room staff to l
focus on their primary responsibihties. This Work Execution Center will be directed by a licensed individual who will be responsible for overall coordination and execution of work activities, configuration control, OOS, and maintaining appropriate communications with the Control Room. Included in these communicaten responsibilities is the requirement to keep the Unit Supenisors abreast of current plant activities. This Work Execution Center was manned on June 10, 1996, and full implementation is scheduled for June 24,1996.
1 The OOS group will be relocated near the Maintenance staff to optimize communication between the workers. The relocation will take place by July 8,1996.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance was achieved upon completion ofindividual counseling and training.
B.
Braidwood Administrative Procedure, BwAP 330-1, Revision 17El, Step c.2 requires, in part, that the designated Nuclear Station Operator (NSO) reviews the out of senice for completion and information and determines the isolation points as necessary to meet the method ofisolation requested by the requester. For out of senices requiring independent verification, the out of senice isolation points, sequencing, and positions are reviewed by a second qualified individual. The Unit Supenisor (designee) reviews the out of senice, and independently verifies isolation points to assure opposite train operability.
Contrary to the above:
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On Febmary 23, 1996, the on shift NSO who prepared out of senice
- 960001992, and a second NSO who performed an independent verification, did not adequately determine the isolation points as necessary to meet the method of isolation requested by the requester.
2.
On March 1,1996, the on shift Senior Reactor Operator did not independently verify all isolation points to assure opposite train operability for out of senice
- %0001992, an out of service requiring independent verification.
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ETTACHMENTI REPLY TO NOTICE OF VIOLATION REASON FOR THE VIOLATION:
Due to personnel errors in the preparation, verification, and approval of the OOS, inadequate isolation boundaries were identified to cover the scope of work on the 2B SI pump discharge flange. The Operators were unaware that the system boundary was going to be breached because sufficient work scope details were not provided by the Work Analyst when requesting the OOS.
CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
The affected work activity was stopped and system integrity was restored.
l Current OOSs were checked to verify adequate isolation points were included. Also, selected outage OOSs were rechecked to ensure the inclusion of appropriate isolation points.
SROs reviewed OOSs with non-licensed operators before OOSs were hung following the event. Reviewing OOSs prior to having them hung has become a continued practice.
Instructions to Work Analysts on the level of detail required in the additional information section of the OOS request were clarified.
The Operations Manager discussed the event with the licensed operators involved and reinforced management expectations. Written management expectations regarding OOSs were distributed to licensed Operators.
CORRECTIVE ACTIONS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATION:
Details of this and similar events were discussed with Station personnel during a March 15, 1996, reinforcement session. Additional discussions were held with Operations and Maintenance personnel during a more recent reinforcement session held on May 17,1996.
The Station will implement an enhanced OOS procedure by July 15,1996. His will include appropriate training for necessary personnel.
As previously discussed, the establishment of the Work Execution Center is expected to be effective in preventing recurrence of this violation.
Operators will be assigned to the OOS group on a periodic basis to maintain proficiency in the OOS process. This change will be implemented on June 17, 1996. He OOS group will be relocated near the Maintenance staff to optimize communication between the workers. The relocation will take place by July 8,1996. Also, an expectation is being established that the primary authors of out of >crsices are to be the OOS group. Generation of OOSs by Control Room personnel is expected to occur only in exceptional cases.
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1 ETTACHMENTI REPLY TO NOTICE OF VIOLATION i
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance was achieved when the drainage path from the RWST via the 2A train of SI was isolated, and SI work was stopped until the OOS was corrected.
I.
10 CFR 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
C.
Contrary to the above, on January 23 and 24,1996, operators manipulated valves V-4 and V-5 on the 2A and 2B hydrogen monitors, without using instructions or procedures, an activity affecting quality.
REASON FOR THE VIOLATION:
'Ihe manner in which the Operator verified the valve position is consistent with Station administrative i
requirements and operator training. Due to the limited range of motion on the valve stroke, the operator
' inadvertently moved the valve without recognizing that this occurred. The Operator lacked specific component knowledge and was unaware of the ser.sitivity of the valve. As a result, when he went to verify the valve position, the valve was inadvertently closed.
CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
The Operations Manager reinforced with Operators the expectations of performing 4 elf-checking".
Operations personnel were briefed on the expectation that prior to any valve manipulation, the required valve position should be known.
Signs were posted outside the hydrogen monitor panel indicating that permission was required from the Shift Engineer prior to entering the panel. Signs were also posted inside the cabinet warning that the V-4 and V-5 throttle valves affect operability and permission is required from the Shift Engineer prior to operation.
CORRECTIVE ACTIONS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATION:
The surveillance requiring access to the hydrogen monitor panel interior has been removed from Operations procedure 1/2BwOS 6.3.3-8 and is now incorporated in Instrument Maintenance procedure BwlS 6.4.1-201. Restricting the access to the monitor cabinets as discussed above and allowing only one work group to perform manipulations inside the hydrogen monitor panel has been effective in ensuring that valves are not inadvertently mispositioned.
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ATr.ACHMENT I REPLY TO NOTICE OF VIOLATION l
CORRECTIVE ACTIONS THAT W!LL BE TAKEN TO AVOID FURTHER VIOLATION (continuedt "Ihe licensed operator initial and requalification training will be revised to include all phases of hydrogen monitor operation, normal lineup, and access control for the monitor. This information will be provided in Cycle 4 of 1996 to be completed by 7/12/96.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance has been achieved. Surveillances on the hydrogen monitor requiring routine access to the cabinets are no longer performed by Operators. Instead, these suncillances are done by Instrument Maintenance workers and access into the hydrogen monitor cabinets is limited to specific personnel.
II.
10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action," requires, in part, that measures be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is deternuned and corrective action taken to preclude reoctition. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to the appropriate levels of management.
A.
Contrary to the above, as of January 24,1996, the licensee failed to promptly correct a condition adverse to quality.' Specifically, on December 3,1994, an event occurred where l
thronle valve V-5 was inadvertently closed on a hydrogen monitor during a surveillance.
On Febaary 16,1995, Engineering Request ER9500287 was initiated to replace the V-5 throttle valv: on each of the four hydrogen monitors with a valve having a finer throttling control because it was barely cracked open and any bumping of the valve would cause a flow problem. However, as of January 23, 1996, the licensee had not replaced throttle valve V-5 on each of the four hydrogen monitors nor implemented administrative controls i
to prevent two similar events from occurring on January 23 and 24,1996.
REASON FOR THE VIOLATION:
An Engineering Request (ER) provides a method of requesting engineering assistance and evaluations.
Engineering Requests may be submitted by any individual requiring engineering or technical assistance.
Although an Engineering Request was written to evaluate the V-5 throttle valve, this request was not dispositioned in a timely manner because it was considered a low priority issue and the cognizant Engineer l
suspected that the problem was associated with operator error, not the valve.
Engineering Request 9500287 had been responded to by the System Engineer for the hydrogen monitor in August,1995. He considered the root cause of the hydrogen monitor problems to be associated with the manipulations of the V-5 valve by Operations. However, due to the sensitivity of the valve, informal actions were pursued to address the problem by System Engineering, including working with Instrument Mamtenance to test alternative valve types and posting signs on the monitor. These actions were not effective in preventing the cited violations.
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TTACHMENTI REPLY TO NOTICE OF VIOLATION
' CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
As previously dW=i additional controls have been established on the hydrogen monitor cabinets to control access to muunuze the possibility of valve mispositxxungs These actions have been effective in ensuring that valve pienitmie do not occur.
CORRECTIVE ACTIONS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATION:
The closure of the V-5 valve resulted in an unplanned entry into an Action Statement. Had the December 4,1994, event occurred under the current program requirements, the PIF documenting this problem would be categorized as a Level III. As such, a Senior Station Manage:r ent Sponsor would be assigned to the PIF, action items would be assigned completion dates, and Station Manager approval would be required to revise these completion dates. Additionally, these actions are required to be tracked via the NTS system, and they can no longer be closed to other tracking mechanisms, such as the ER system. Therefore, an ER generated under these circumstances will be appropriately tracked to a timely resolution.
A design change has been mitiated to replace the V-5 valve.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance has been achieved. Surveillances on the hydrogen monitor are no longer performed by Operators. Instead, these surveillances are done by Instrument Maintenance workers and access into the hydrogen monitor cabinets is limited to specific personnel.
II.
10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action," requires, in part, that measures be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significam conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to the appropriate levels of management.
B.
Contrary to the above, as of March 21,1996, the licensee failed to promptly identify and correct recurrent problems in the area of plant configuration control and out of services, a significant condition adverse to quality. Specifically:
1.
' Site Quality Verification Reports QVL 20-95-106, QVL 20-95-110, and QVL 20-
%-004, for the months of October, November, and December 1995, respectively, identified problems in the areas of plant configuration control and out of services.
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ATTACHMENT I l
REPLY TO NOTICE OF VIOLATION i
l VIOLATION II.B (continuedh l
2.
On November 20,1995, the licensee documented a potential adverse trend in the l
area of plant configuration control (Trend 95-018).
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3.
Subsequent trend investigations identified there had been numerous plant configuration control and out of service problems throughout 1995.
However, as a result of these problems not being promptly identified and corrected, a i
number of subsequent events occurred including uncontrolled valve manipulations which l
rendered both trains of the Unit 2 hydrogen monitoring system inoperable on January 24, l
19%; an inappropriate out of service rendering both trains of Unit 2 safety injection inoperable on March 4,1996; an auxiliary building ventilation supply fan was approved for operation on March 12, 1996, following maintenance even though it was still disassembled; uncoupling a Unit I containment chilled water pump without proper authorization on March 13, 1996; and inadvertently generating a low pressurizer level i
signal while de-energizing two panels to hang out of senice cards on March I8,1996.
EEASON FOR THE VIOLATION:
A detailed investigation was conducted on the problems associated with the Station's Corrective Action l
Program. Several deficiencies on the structure and implementation of this Program were identified.
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l Causes of deficiencies in this area are attributed to inadequate resource management and insufficient i
management oversight.
l CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
In addition to event specific corrective actions to restore proper plant configuration, the following additional actions were taken:
Operations initially performed 26 walkdowns which resulted in the identification and correction of numerous documentation in mechanical and electrical lineup sheets. In a limited number of cases, actual valve position anomalies were identified and corrected.
Operations has continued performing walkdowns and developed a plan to reperform electrical and mechanical lineups. This plan prioritizes the sequence oflineups based on safety significance and opportunity to perform the lineups.
A process change has been instituted to require workers to report to the shift office prior to beginning work. This will afford shift personnel an additional opportunity to review imminent work activities in light of current plant configuration and other ongoing work.
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. 1TTACHMENTI REPLY TO NOTICE OF VIOLATION CORRECTIVE ACTIONS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATION:
Based on results from the root cause investigation on the Corrective Actions Program, the following actions have been taken.
l The Root Cause Team size has been increased to five individuals.
j All Level III and above investigations are being assigned to Senior Managers.
Completion dates are required for all Level III and above corrective action items and extensions of these dates will require approval from the Station Manager. Also, these items will be tracked via the Nuclear Tracking System (NTS) and will not be closed to alternative tracking systems.
An effectiveness review process will be implemented by July 1,1996 for all Level ill and above corrective action items. Effectiveness reviews will be done on all Level 11 and above corrective action items. At least 25% of all Level Ill items will be subjected to effectiveness reviews within one year of completion.
Trend PIFs are assigned to Senior Managers who are responsible to ensure the investigations are completed as required. This will ensure the appropriate level of management attetion is afforded to the resolution of these trends. Updates on trend investigations are omviod weekly at -
Braidwood Leadership Meetings (BLM).
An indaaaadaat review of the Corrective Actions Program, assisted by FPI International, was conducted at the Station. The conclusions from this assessment were consistent with the findings of the root cause investigation discussed above.
The following additional actions will enhance the Station's ability to maintain proper plant configuration control:
i Lineups are to be done and a schedule is to be developed to periodically reverify the lineups. These actions are to be completed by December 31,1996.
A full time Operations planner has been assigned to improve outage planning.
Lineups are being performed inside OOS boundaries upon return to sersice.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance has been achieved.
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W ETTACHMENTI REPLY TO NOTICE OF VIOLATION i
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REPLY TO NOTICE OF VICLATION (EXTRA INFORMATION: Probably will not be incorporated in response)
An independent investigation of Braidwood's Corrective Actions Program was done.
Operations developed a plan to reperform electrical and mechanical lineups. This plan prioritizes the sequence oflineups based on safety significance and opportunity to perfonn the lineups. System lineups will continue to be done by Operations on a periodic basis.
1 Operations performed 28 walkdowns and identified numerous errors in mechanical and electricallineup sheets.
Lineups will be performed inside OOS boundaries upon return to service (system to be in I
place by 7/31/96).
A schedule is to be developed to maintain lineups current. This schedule is to be completed by 12/31/96.
Prior to beginning work, workers must check in with the shift (in place since 4/18/96).
Allplanned temporary hfts and partial clear requests must be turned in by 10 AM (in place 4/18/96).
LLRT valves are now labeled to prevent conflict with other evolutions.
Loopfill evolutions are now coordinated by afield supervisor.
Guidelines will be provided related to Action Requests which may be bundled to OOSs (to be completed 9/30/96).
Guidance will be developed to limit orfree:e the scope of work covered under 00Ss (by 9/30/96).
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