ML20115H316
| ML20115H316 | |
| Person / Time | |
|---|---|
| Site: | Crystal River  |
| Issue date: | 03/25/1996 |
| From: | Morris B AFFILIATION NOT ASSIGNED |
| To: | Gibson A, Landis K NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| Shared Package | |
| ML20115H310 | List: |
| References | |
| NUDOCS 9607230051 | |
| Download: ML20115H316 (91) | |
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.... 3 Is EXHfBIT 1rINESTONE c, MORRIS hcR.g
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e ee meeseam.vues e. _ - :m AnANTA. oRomoIA Do3Se e,uase ; _-_-:
=essees.eese
===. s 6 eassem es...emme March 25, 1996 or aesons eee Mr. Kerry D. Landis, chief Reactor Projects Branch 3 Division of Reactor Projects United states Nuclear magulatory Commission Region II 101 Marietta Street, N.W.
Suite 2900 j
Atlanta, Georgia 30323-0199 Mr. Albert F. Gibson United States Nuclear Regulatory e - 4maion Region II 101 Marietta Street, N.W.
Suite 2900 Atlanta, Georgia 30323-0199
SUBJECT:
Predecisional Enforcement Conferences Mark E. Van Sicklen Jack D. Stewart, Jr.
christine M. Smith James T. Atkinson
Dear Messrs. Landis and Gibson:
Mark E. Van Sicklen, Jack D. Stewart, Jr., Christine M. Smith and James T.
- Atkinson, through their undersigned
- counsel, respectfully substit this written presentation to be included in the record of the Predecisional Enforcement Conference to be held on April 4,
1996.
The purpose of this presentation is to provide infornation regarding the licensed activities of these Florida 1
Power CorpoTration ("FPC") employees at the Crysta.1 River Nuclear Plant relating to the reactor coolant system makeup tank.
This viitten submission is' offered in response to notice of an apparent violation that is being considered by the NRC for escal.nted enforcement action.
It is respectfully st*mmitted that no e.nforcement action is necessary or appropriate after consideration of the information provided below.
9607230051 960710 PDR ADOCK 05000302 G
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Nuclear operators at Crystal River became aware of serious safety concerns regarding the directives FPC management issued for i
maintaining critical nuclear reamr support and emergency systems.
i The "A" shift took the lead in identifying and reporting the safey i
ooneerns to management and engineering.
The "A" shift operators j
eentrally involved with these safety concerns included the Shift Supervisor, D&VID A. FIELDS (" FIELDS"); Assistant Shift Supervisor ROBERT P. WEISS (" WEISS"); chief Nuclear Operator, MMtK VAN SICKLIN
(" VAN SICKLEN"); Chief Nuclear Operator, JACK STENMtf ("STENMt?");
Reacter Operator CERISTINE SMITE ("SMITN"); and Nuclear Operator j
JAMES ATKINSON ("ATKINSON").
f MMtK VAN SICKLEN was born February 17, 1962 in New York state.
j one of seven children, he was raised by his mother and his father, i
who was a truck driver.
After graduating from high school MhEE joined the United States Navy in 1980 as a Nuclear Machinist Nata.
He served in the Navy for six years obtaining an honorable discharge in February of 1987.
During his Navy career he received four Letters of Commendation, two Letters of Appreciation, a Good conduct Medal and, a Sea Service Ribbon for four strategic deterrent patrols on two ballistic missile submarines.
1 Immediately after his d4=ah=7e MARK began his career with 3
i Florida Power Cw.yEation in March of 1987.
He earned his Reactor j
operator's License in 1990.
From the date of his employment i
through July 20, 1995, he operated the controls of the Crystal I
River Nuclear Plant and while performing his duties received j
excellent yearly evaluations, having been rated by his supervisors i
as " Exceeds Most Standards".
l NARK has been married for 13 years and has two children ages 6 and 8.
His wife is a substitute school teacher.
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CHRISTINE M. SMITE is 30 years old and was born and raised in j
northern Ohio.
Following high school and a. period of employment j
in the photographic fis1d she relocated to Florida and was hired by Florida Power Corporation in November of '1987 as a temporary l
employee. Her status was upgraded,to permanent employment in March l
of 1988.
In September of 1988 CHRISTINE was promoted to Assistant i
Turbine Building Operator at Crystal River.
Over the next five years she progressed to Turbine Building operator, Auxiliary i
Building Operator and successfully completed licensed operator j
training. She received a Reactor Operator License from the Mac and j
since 1993 has been working the control board at Crystal River as
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a licensed operator.
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CHRISTINE attends Central Florida Community College currently working toward a college degree in Engineering.
She is an active member of the First Christian Church in Dunne11on, Florida.
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JAMES ~ T. ATKINSON was born on January 2, 1957 in Morris, i
While attending high school he enlisted in the United I
States Navy under the " CAGE" program.
Immediately fallowing high I
school graduation he entered Navy Boot Camp training initially as a bull tar *nician and was later accepted as a Builder in the Sumares.
Be received an honorable d4=*= v in September of 1979 i
with the rank of E-5.
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JIM has been married since May of 1988. While he and his' wife have no children of their own, they have raised their nephew'since j
he was abandoned by his mother in 1989.
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JIM began his employment with Florida Power C.r.sation in i
August of 1988.
Be has been with the -
for almost ten years and has worked his way up from an Ass nuclear Auxiliary j
operator to a Licensed Chief Nuclear operstar.
JAM D.
- STINART, JR.
is 40 years old and a native of Cincinnati, Ohio.
Raised in Doylestown, Pennsylvania, upon his
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I graduation from high school he enlisted in the United States Navy serving a six year enlistment, two of which ware in the Nuclear Division.
He was honorably die *==ged with the rank of E-5 as a j
Machinist Mate.
JA M has been married to his wife Carol Jo since 1989.
Carol j
Jo is a former Florida Power Cw.,Gration employee now working in j
her own craft business.
JA G began his career with Florida Power C esation in June of 1983.
He obtained his NRC operator's License in October of 1986.
From June 1983 until August 23, 1995, JAS was employed by FPC as a nuclear operator at FPC's nuclear power plant located at Crystal River, Florida.
While employed by FPC, JA M'S duties and responsibilities involved working his entire omroer operating the i
nuclear reactor and its.
rgt systems which culminated in being i
a chief reactor operator for the last six (6) years.
Currently, l
JA3 is employed by FPC as a " scheduling coordinator".
At all times material hereto,iTAN SICKLEN, SMITE, ATKINSON and STEWART were licensed by the United States Nuclear kegulatory Commission ("NRC") as reactor operators pursuant to C.F.R. 555.1 et seg.
In' accordance with their NRC license, each was charged i
with operating the nuclear reactor in such a manner as to protect the health and safety of the public and to minimise the danger to life or pse,
.i.f.
Each has always taken this responsibility very seriously.
While on duty at Crystal River, each was a member of l
the crew "A" shift which controlled the apparatus and mechanisms i
for operating the nuclear reactor and its associated systems.
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j ZZ.
RMMqmoHED:
River,peration of the Raaster coolant system at O
Crystr,1 Pierida during mermal and emergency j
operations.
1 A critical component in the operation of the FPC nuclear i
reactor is the Makeup system ("MU system").
The MU system is j
composed of various components, including a 600 cubic foot (4,43s i
gallon) Makeup Tank ("MDT").
See ihrhihit 1 attached hereto, i
l During normal operation, the MD System supports the Reactor j
coolant. system ("RcS") by providing the===== to purify and place additives into the reactor coolant fluid.
One of the additives is i
hydrogen gas, which is pua# into tho' MUT under pressure.
The i
hydrogen gas miwan with the coolant solution in the MUT in a j
process similar to carbon dioxish being added to soft drink i
beverages.
As the coolant solut1M passes through the high radiation fields in the reactor core, the ;.d wan acts as a i
scavenger to remove dissolved oxygen in the 3CS..During normal
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operation, the MUT level is maintained between 55 inches and 86 j
inches (1,694 to 2,649 gallons).
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During normal operations, a single pump operates to inject the i
mixed coolant solution from the MUT into the RCS.
This pump is commonly referred to as the " normal duty pump."
During emergency operations, the MU Syst.am and RCS automatically switch from their normal operating modes into specialized roles which serve integral functions within the Righ Pressure Injection' ("HPI") system.
The HPI system is a crucial element of the emergency core cooling system required to safely c
shut down and cool the reactor in case of an accident.
At all times, the nuclear fuel must be covered and cooled.
In the event l
of an accident, such as a decrease in RCS pressure due to a leak, the HPI system is activated to force large quantities of water into the reactor vessel by specialized HPI pumps.
In order to avoid fmilures during emergency operations, the NRC mandates that EPI system components, especially the HPI pumps, meet special. design and operational requirements.
Among the most critical components of the HPI system are three HPI pumps, which are exceptionally complicated and specialised.
The pumps are designed to inject up to 540 gallons of water per minute, per pump, into the reactor vessel.
If these pumps fall in an emergency, the amount of fluid reaching the reactor vessel may be insufficient to cover and cool the nuclear fuel, and a catastrophe could ensue.
Therefore, it is imperative that the nuclear operators ensure that the coolant system operates in such a manner that the HPI pumps will operate as designed when called rpon.
When the HPI system is activated in an emergency, the normal duty pump goes into its HPI mode, drawing fluid from the MUT.
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i second HPI pump is activated to inject water into the reactor j
vessel directly from the Borsted Water Storage Tank ("BNST").
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There is no way to isolate the HPI system from the normal duty i
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pump, the MU System, and the MUT.
When the crystal River reactor l
was first built, a valve designated MOV-64 was inc-esrated into I
the system to isolate the MUT from the EPI system.
Since previous I
fmilures with this valve caused BPI pump fmilure during,past surveillance operations, the valve was chained open and.its i
actuator deactivated.
..The EFI system was maMfied so that waan the ' fluid level in 4
the MUT teak was drawn down to a point where hydrogen over-j pressure in the MUT equalized with the static head (pressure) in j
the BWST, all fluid to the EFI pumps would then come from the BNST.
j This is commonly referred to as the cross-over point.
If MUT pressure were maintained within correct limits, sufficient fluid j
would remain in the MU System and gas would not enter the EPI pump.
i If hydrogen pressure in the MUT was excessive, disaster could j
very well result.
Excessive hyaW. pressure in the MUT would cause the water level in the MUT to be pushed lower than the fluid level in the BNST.
Consequently, the MUT would empty before water from the BWST entered the MU System.
Rydrogen gas from the MUT would then enter the suction of the EFI pump.
The hydrogen would cause the EPI pump to immediately lose suction, begin to cavitate, overheat,.and lead to rapid catastrophic failure. Similar EFI pump failures have been verified several times.
III. TER MUT ISSUE: Managensat's direstives to ineresse hydrogen pressurisaties in the MUT and the resulting esmoeras raised by the operaters.
Prior to April 1993, MUT hydrogen pressure was limited to 12 psig. In April 1993, FPC's Engineering department at crystal River issued a calculation which provided for a variable and increased hydrogen pressure to be maintained in..the MUT.
This new calculation was incorporated in Plant Operating Procedure OP-1033 and designated curve #s.
Curve #8 of OP-1033 is attached hereto as Exhibit 2.
curve #8 was presented to the operators as an administrative curve and was alleged to have been derived from a calculated system response. curve #8 depicts the maximum allowable variation between hydrogen over pressure (left side) and the water level in the MUr (botton) and how the MUT would. predictably respond during a draindown evolution.
For example, an over-pressure reading of 20 psig and an indicated water level of 75 inches would be acceptable.
If the MUT is at this level when emergency procedures are initiated, curve is predicts how the system should respond as the water / pressure ratio in the MUT tank decreases as the tank empties.
This decrease should continue until hydrogen over-pressure in the 5
MUT equalized with the static head (pressure) in the BWST. At this point, the source of fluid to the BPI pumps should cross over to the BNST.
If the MU System operated in accordance with engineering's calculations, sufficient water would remain in the MUT when the cross-over to the BNST occurred.
On the other hand, if an unacceptable ratio were maintainid in the MUT, such as a pressure reading of 20.psig and an indinated water level of 65 inches, pump fmilure would predictably result.
In this example, the MUT tank would have too much hydrogen pressure, causing the water level in the MUT to be lower than the static head (pressure) in the BNST.
EPI. pump suction would empty the MUT tank befare cross-over occurred. Bydrogen would enter the BPI pump, resulting in rapid cata.6 -yhic failure.
To avoid possible HPI pump failure in' the middle of the crucial evolution of flooding the reactor vessel in an emergency, nuclear shift operators considered it critical to safe operations to avoid operating the MUT tank with excessive hye iiian pressure.
l In April 1993, oP-1038 and Curve #8 were instituted and presented to the operators without elaboration. System performanam or Operating / Administrative curves include a margin of error,.
j commonly referred to as being " conservative".
Unbeknownst to the nuclear reactor operators, Curve #8 was a dagian hasia e ra that t
l was non-conservative and included no margin for error.
Only after the evolution performed by "A" shift did FPC inform its nuclear I
operators that curve #8 was not a system po j
gEKY.R but was in fact a damian basiE M ER.p ormance or comratina 1
i With the introduction of OP-1033 and curve #S, FPC management j
instructed the nuclear operators to maintain the MUT pressure equal to the maximum pressure allowed by Curve #S.
Accordingly, management, as approved by engineering, instructed the operators that Curve #8 was an operatina sgExa.
The increased hydrogen pressure required to maintain MUT pressurization in accordanam with Curve #s greatly concerned *the "A" shift operators, and other I
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, licensed operators in the operations department. Because awa masive j
MUT pressurization was hazardous, the operators were extremely 8
uncomfortable with the new requirements.
Furthermore, there I
appeared to be no specific operational necessity to raise the l
hydrogen pressure in the MUT.
i The operators' prevailing concern with excessive MUT l
pressurization was the possibility for hydrogen entrainment and f
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IFPC's failure to correctly identify and translate Curve #8 as j
a design basis curve has been identified as a violation of NRC i
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procedures.
333 NRC Investigative Report 95-13, Paragraph 4 i
(Exhibit 21), and NRC Investigative Report 95-22, Paragraph 7
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(Exhibit 23), and NRC office of Investigators Report 2-94-0365.
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fmilure of the normal duty Pump when it shifted into its HPI mode during emergency activation.
A second **anamen was how to get e
i concentrated boric acid solution into the MUT for emergency boration of the RCS.
Boric acid in the RCS solution absorbs i
neutrons in the reactor core and acts to slow any ongoing nuclear i
chain reaction.
A third concern was that during a fire, the hydrogen isolation valve would fail open, over pressurizing the
'MUT.
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"A" shift operators initially raised their concerns verbally l
with engineering personnel and with FPC's. manager of nuclear i
operations, Mr. Greg mainan.
Shift supervisar David FIELDS and Assistant Shift supervisor Robert WEISS namenrrred and' supported those concerns.
Two "A" shift reacter operators, VAN SICKLEN and Mr. Bruce Willas, were the most vocal in raising concerns with management's directive that the MUT be operated with high hydrogen 3
pressure as depicted in curve #8.
As a result, concerns with the i
3 MUT issue became associated primarily with "A" shitt.
The other i
five nuclear operations shifts relied upon "A" shift to address and i
resolve the MUT issue with engineering and management.
1 Initially, engineering verbally responded to "A"
shift's i
concerns about the MUT. With regard to hya.-yan entrainment of the HPI pump, engineering simply gave verbal assurances that the pump i
would not become hydrogen-bound during emergency activation.
With regard to emergency boration, engineering said that the BWST was the primary source of borated water and the MUT would not interfere with adding more boric acid.
Engineering di==immad the fire i
concern outright as not being a plausible accident scenario.
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The operators were dissatisfied with engineering's response i
to their concerns and the lack of credible information and basis to assure the operators that their concerns were not valid.
The operators were not in a position to disputa engineering.
- Instead, j
"A" shift and other operators responded by operating the MUT exactly as they had hetare by keeping ai.,.
imately 10 peig j
pressure in the tank, well below that. required by curve #8 and management's directives.
On May 10, 1994, during Refueling Outage nine
("RF-9") a 4
scheduled test known as SP-630 wa's performed to ensure that the l
HPI system would operate as designed during an accident.
SP-630 was a full flow functional test of the EPI system.
FIELDS, WEISS j
and "A" shift were on duty and performed this test.
Because of j
their previous concerns with the MUT and curve #8, the operators j
paid special. attention to how the.JEUT level and pressure responded j
during the actual draining of the MUT under emergency conditions.
i The operators noted that a discrepancy seemed to appear between how 1
the MUT reacted during the test and the way it was calculated to i
partora as depicted in curve #8.
The test began with MUT pressure i
in the acceptable region.
As the MUT began to drain, the actual data plots reflected that the pressure / level in the MUT was not 3,
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res y ina as predicted by curve #4.
Instead of the actual MUT pressure / level paralleling curve
- 8 as predicted, the pressure / level appeared to be moving in a direction that would cross over curve #8 into the unacceptable region.
Many problems with the HPI system were noted during the test and were written up in Problem Report 94-0149 ("PR94-0149").
A Problem Report is the official mechanism that dar== ants problems and tracks the corrective action until resolution.
A copy of PR 94-0149 is attached hereto as Eskihit 3. to PR 94-0149 is the " Procedure Discrapsney Report Parm" completed by VAN sICELEN, which reported the discrepancy between the MUT performance and Curve #8 and included the actual plotted data obtained during SP-630.
In PR 94-0149, Part 3 Section A (3c) entitled
- Contributing Factor (s)", the report notes "A" shift 8s comparison and states that "The concern is: If the==w4==
allowable pressure had been used would the actual plotted curve have entered into the unacceptable region.
Based on this canamen, the subject curve has been revisited."
PR-0149 Part 3 - Section B is the corrective action plan for the problems discovered during SP-630.
Item 7 directs engineering to evaluate the acceptability of Curve #8.
Attactament 2 to PR-0149 issued June 14, 1994 is the result of engineering's.arevisita of curve #8. states that in enginameing's opinion, the " decreasing change" between the plotted curve noted by the operators during the actual test and the prediction set forth in curve #8, " appears to be mainly due to the fact that both curves are converging on. sero psig.
emmad on this evolution, engineering concluded that "it does not appear the plotted curve would have,
entered into the unacceptable region of Curve #8."
Furthermore, engineering stated that "there is conservatism built into curve #8 to ensure that instrument error, for example, could not create an excessive over-pressure condition."
For a second time, engineering rejected the operators' concerns and again reached the conclusion that curve #4 is conservative, accurate and acceptable.
The demonstrated response of,,the MUT in an actual HPI full flow test cast serious doubts in the minds of the operators on "A" shift about the accuracy of Curve #8 and engineering's assurances.
l The prevailing concern of "A" shift and their supervisors remained; whether in an emergency, excessive MUT hydrogen pressure could cause the HPI pumps to become hydrogen-bound and fail when the MUT j
was completely drained prior to altsT cross-over.
In June 1994, the MUT issue was intensified following the restart of nuclear power generation after RF-9.
FPC management insisted that the nuclear operators keep the =mwi== NUT hydrogen i
j pressure allowed by Curve #8.
Specifically, management directed j
that the MUT hydrogen pressure be kept "at the top of allowable
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bands" and began to instruct the crews on ways to do so.
A June l
27, 1994 electronic mail ("e-mail") message from management to the i
nuclear operators, attached hereto as Eskihit 4,
demonstrates j
management's urgency to maintain the MUT with high hydrogen pressure.
In addition, management was advising the operators that j
RCS hydrogen concentration was being traoked closely and plotted i
j (hourly) by chemistry.
see Exhibit 4.
In other words, management was tracking how each and every crew operated the MUT to ider;tify i
those who were not operating the MUT with the mawi=2= allowable pressure.
Management issued this directive despite the 2act that PR 9409149 had not been resolved to the satistaction of.the operators. Management appea. red unresponsive to the safety twmaarns voiced by the operators with regard to maintaining the MUT with j
what they considered to be excessive hydrogen levels.
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Management gave no explanation or reason for maintaining the MUT with such excessive hydrogen pressure. When hydrogen di==alves in the reactor coolant, it soavenges oxygen from the system.
0xygen can cause corrosion to build-up in the RCS. Maintaining i
approximately 10 psig of pressure in the MUT results in a hydrogen j
concentration of approximately 20 cc/kg (cubic centimeters per i
kilogram). Previously, the nuclear reactor system at Crystal River i
had never been known to have a ' problem with oxygen in,the RCS.
Operating the MUT exactly on curve #8 would now result a 25 cc/kg hydrogen concentration, which was management's goal on July 25, 1994, an e-mail message from Greg Halnon observed i
that not all shifts were operating the MUT in accordance with the demands of management.
In addition, this e-mail provided the j
operators with a method to increase hydrogen concentration in the i
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- The 25 cc/kg ration was actually established by the Institute of Nuclear Power Operations ("INP0").
INPO is a nuclear i h ky support group created after the Three Mile Island nuclear accident i
in 1979. INPO acts as an industry watchdog to audit and assist l
nuclear power plants all over the -uky.
.INPO rates the plants, j
and its highest rating, INPO-1, rates a plant in the top one-third 4
of nuclear power plants in the country. Dr. P.M. Beard, FPC Senior l
VIce President for Nuclear Power'was formerly a vios president of j
INPO betare being hired by FPC to head its nuclear program.
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nuclear power plant at Crystal River has never been rated INPO-1; j
historically,,
it has been INPO-3, or at best, IMPO-2.
FPC 1
management no doubt desired to achieve the highest rating possible
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4 for Crystal River.
It is well known in the nuclear power ihky l
that NRC and..INPO ratings influence bond and credit ratings.
Dr.
Board was the driving force behind management's efforts to most the industry guideline of 25 cc/kg.
Bowever, the INPO goal of 25 8
cc/kg was for Westinghouse nuclear reactor plant designs and not for the Babcock & Wilcox designed reactor at Crystal River.
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Therefore, the increased hydrogen pressure did not have the desired
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effect at Crystal River.
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MUT.
First the MUT water level was lowered, then hydrogen was added up to the curve.
Then more water was added to raise the level and " press the hydrogen" bubble.
on July 27, 1994, Mr. Dave Jones, Mr. Balnon's assistant, sent another e-mail to the operators which provided further clarification on "MUT hydrogen overpressure operations" he had been doing with another shift supervisor, Mr.
Garrett Babb. The reterenced July 1994 e-mails are attached hereto as meh4 hit 3.
At this time, Dr. Board also began to question his operaitions managers daily regarding whether or not. the.MUT tank was being.
maintained as proscribed by curve #3..At one annagement meeting, Dr. Beard instructed Mr. Halnon to "get up there and get those operators straightened out."
The nuclear operators, particularly "A" shift, continued to voice concerns and objections to being forced to operate the MUT with what they considered to be excessive and unsafe hydrogen j
pressure / levels.
The operators sought assistance primarily from Mr. Halnon. Mr. Halnon assigned his assistant, Mr. carl Bergstrom, Support shift Manager, to work on the MUT issue.
In addition, Mr.
Steve. Roe, Operations Technical Advisor, and Mr. Pat Minman, MU System Engineer, were astrad to independently validate Curve #3 of OP-1035.
It is unknown whether Mr.
Roe and Mr.
Hinman's independent evaluations were ever performed.
On August 9,
- 1994, Mr. Halnen acknowledged the operators' continued nanneens, and advised them that engineering was again revisiting the issue.
Mr.
i Halnon's August 9, 1994 e-mail is attached hereto as Rubibit 7.
Unknown to the operators, argineering had previously identified the exact same concern that FIEIDS, WEISS, and "A" shift were raising.
In a memorandum dated October 15, 1992, Mr. Rinman addressed the subject of " actions required to implement the new make-up tank hydrogen cover gas pressure limits such that a 25cc/kg hydrogen concentration can be maintained in the RcS." Mr. Hinman's October 15, 1992 memorandum is attached hereto as m ihit 8.
Mr.
Hinman8s study acknowledges the existence of "two separate issues concerning the potential damage from make-up. gas pressure."
The first concern was with hydrogen gas ming out of solution and collecting in the pipes - this gas could then be transferred to the HPI pumps.
The second concern states:
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At some poin); during a LOCA will the BNST head pressure be overcome by make-up tank head pressure?
This eendition eenld petaattally eesar as the BEST and make-up tank investeries are depleted to a
peint eventually allowing make-up taak cover gas te enter the EFI pump susties esamea to the make-up taat. (emphasis added) 10
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i Furthermore, Mr. Hinman's memorandum specifically addresses
" actions required" as a result of the concern with hydrogen gas entering the RPI pumps as later envisioned by the operators.
This action included a review of the basic system calculations and a revision to OP-1038 (Curve is).
In subparagraph "d.", Mr. Winnan addresses tho data required to produos a new Curve #8 required to maintain the 25 oc/kg ratio.
In order to reach this figure, Mr.
Hinman calculated that the MUT high pressure alarm be raised to a j
new ' set point "ah.imately 3 PSIG hi j
value for required cover gas pressure." gher than a conservative Mr. Rinnan concludes:
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. Because the make-up tank is part of a dynamic system, there may be short periods of time when the operating pressure will ensees the tank pressure vs level surve and times when suffisient hydrogen is not present.
&t this point in the evaluation phase, we believe this should be j
asseptable.
(esphasis added.)
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Thus, engineering not only identified the problem but considered i
it " acceptable" to operate for short periods of time in excess of j
the curve.
This information was never provided to the operators.
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By August 1994, VAN SICELEN was so concerned with the MUT l
issue that on four separate occasions he spoke to NRC Resident i
Inspector Mr. Todd c s;-E to solicit his help with and involvement in the MUT issue.
After their fourth conversation, VAN SICELEN reported to his supervisor David FI'tLDS that Mr. Cooper suggested that if they were still dissatisfied with annagement's reluctance i
to resolve this safsty concern, they could suhait a farmal allegation to the NRC. Rather than initiating a formal allegation, "A" shift and their supervisors falt that the problem should and could be resolved within the FPC structure.
On September 2, 1994, the MUT issue came to a crisis point.
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Mr. Bergstrom met with FIELDS and showed him a draft letter fros l
Mr.
Jerry Campbell, Manager Nuclear Plant Technical Support l
(engineering), to Mr. Bruce Hickle, Director of. Nuclear Plant l
Operations.
The September 2, 1994 letter is attached hereto as i
Exhibit 9.
The letter references an August 5, 1994 meeting to 8
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" determine what was required to increase overpressure so desired RCS hydrogen concentration could be maintained with minimal j
Operator burden."
The letter addressed different options to j
increase hydrogen overpressure which would not require changes to l
OP-103B, curve #8.
The letter specifically states.that:
l angineering believes this serve (curve pe) is mesurate i
and reaseaably eenservative to protest the EPZ pumps from j
hydrogen intrusion in the verst ease Larne armak Lock.
i The September 2,
1994 letter concluded that engineering had i
evaluated the MUT issue raised by the operators and PR-0149, and determined that the situation was safe and that the issue would 11 i
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As stated by engineering, "it is acceptable to raise i
the hydrogep overpressure to the curve at any indicated Make-up j
tank level.
Mr. Campbell's letter does not mention that curve #8 is actually a dagign haala gngra.
On the co..kary, Mr. Camphyll refers to Curve is as being " reasonably conservative."
Curve is was represented to be an Aquinistrative/comratins EME23 Toothe i
operators, this. indicates that a sufficient margin of err built into the curve to avoid exceeding a design limitation.y.was Bad i
FIELDS or the other members of "A" shift known that Curve #8 was a danign haais Agggga, they would not have' operated 'on the curve and i
allowed MUT pressure / levels to cross into the unacceptable region.
IV.
une avrw3"From passa==en nr was swese car e-m----
4th &
AIEL verifiention that curve #8 was isoerrest and unsafe.
l Mr. Bergstrom presented FIEIDS with Mr. Campbell's. letter j
(mmhihit 9) and anved if there was anything FIELDS wanted to do in response, because the MUT issue was being closed out.
FIELDS knew that Mr. Bergstrom represented Mr. Balaen and management and was in etfact urging him to take some action to resolve or extend the i
i MUT issue if FIELDS' concern remained.
J Because of the potential for cata.L@, the safety concerns of FIELDS and "A" shift remained.
Collectively, they decided to respond as Mr. Bergstrom had invited a response.
On September 4, 1994 during their shift, they d4=====d what would be the appropriate response.
They decided that in accordance with
}
authorized pwcedure OP-402, the MUT could be filled up to 86 1
inches and pressurized to the top of the band, exactly at the pressure point depicted in curve #8. The MUT would then be allowed to drain into a holding tank, in accordance with OP-402, to a level of 55 inches, the lower and of the operating range.
During this evolution, the actual system level and pressure response could be plotted. This simple, safe and authorized evolution would simulate the manner in which the MUT would respond during actual EPI activation and the data verifying actual system response could be collected and then compared with Curve #8.
Basically, the 3The M)tc subsequently found that engineering fmiled to i
properly respond to PR-0149 and missed identifying errors in the calculation upon which curve #8 was based.
Such failure has been i
i cited as an apparent violation of-NRC rules and regulations.
Ana j
NRC Inspection Report 95-22, Paragraph 3.
'For example, the new curve #8 modified by engineering as a I
result of "A" shifts' etforts and attached hereto as Eskihit 84, clearly depicts the " restricted region" between the alarm curve and
{
the design linic curve.
4 e
i I
)
i
6 i
l evolution entailed placing the system in the position directed by j
management and approved by enginearing.
Then "A" shift would observe and document system response as water was drained from the e
MUT.
To "A" shift, this appeared to be the best way to check the j
validity of the predicted system response, as represented by curve j
- 8, with the actual MUT response.
If Curve #8 were accurate, the 4
I system would simply follow the curve and the MUT would never. cross over the curve as predicted by engineering and reiterated in Campbell's' september 2, 1994 letter.
However, if curve #8 were inaccurate,.then the actual system response would cross over curve
- S. In performing this evolution, "A" shift was doing exactly what
{
management directed by placing the MUT at the " top of allowable hand" in accordance with curve #8, and then letting the tank drain as provided in OP-402.
"A" shift 's n==- rviser nime=d. reviewed and authorized this evolution.
FIELDS, as the nuclear shift supervisor, insisted that the evolution be performed in accordance with' existing operational procedures.
All
===haes of "A" shift. were well aware that manipulations of a nuclear power plant are strictly required to be performed only in accordance with approved guidelines and i
procedures.
The r M e w to add hydrogen and drain the MUT are routine operations performed regularly by all operators and covered j
by OP-402.
See Exhibit 8.
l OP-402, Section 4.5, provides the guidelines for adding water j
to the MUT.
Steps 4.19.8 and 4.19.9 provide guidance for addisq j
hydrogen gas to the MUT.
These two steps refer the operator to curve #8 for the maximum hydrogen pressure allowed.
"A" shift followed the authorized procedures and added hydrogen until a point j
exactly on Curve #8 was reached at 86 inches.
OP-402, Section 4.4, provides the guidance for reducing the water level in the MUT.
"A" shift believed that OP-402 was an i
authorized procedure to reduce the MUT level from 86 inches to 55 inches.
This very same procedure to lower the MUT level is
}
performed routinely in the control room, and all operators are j
thoroughly familiar with this simple evolution.
l If.the MUT pressure / level moved to the left of curve #8, an 4
annunciator," MAKEUP TANK PRESSURE HIGH" would activate, alerting j
the operator that the MUT pressure was too high for the given level j
of water. A procedure entitled Annunciator Response 403("AR-403")
i describes this condition and instructs the operator what actions j
may be taken for a valid alarm.
A copy of AR-403 is attached j
hereto as Exhibit 10.
AR-403 provides guidance for the Control i
Room Operator to dispatch the Aux Building Operator to vent the i
MUT.
As a precautionary measure, prior to initiating the i
evolution, the Aux operator was notified to be standing by in case j
the MUT required venting during the evolution.
i l
f
,--_-__---_-,-------------a--
w wwr s
w w-
' - ~
1 4
a&"inistrative Instruction, AI-500, Conduct of operations, I
provides guidance and policy for answering annunciator alarms. AI-l 500, Section 4.3.2.2 is attached hereto as Exhibit 11.
This j
,.he states that " Annunciator response p.44es shall be i
used to diagnose alarms not expected (ones not directly related tp i
intentional manipulation of plant controls), and for any alarm that i
the operators are not explicitly familiar with."
Nothing in this i
procedure directs that the operators take immediate action to i
silence the annunciator alarm light. There was no requirement that directed immediata action to clear an annunciator response which was actually expected to occur as a result of authorised* plant 4
j manipulations.
"A" shift was prepared to make the appropriate response even before the annunciator light came on.
l After reviewing the authorised procedures, FIELDS and "A"
shift felt comfortable that they'had explicit procedural guidanam to perform the desired evolution, especially since enginaaring had assured them repeatedly that the system would respond by staying l
within the acceptable operating region.
In addition, management 4
had urged them to respond to the September 2, 1994 letter if they had continued concerns.
- Further, "A"
shift operators aan=nited l
with their supervisors, FIELDS and WEISS for guidance and were assured that the proposed evolution was authorised.
In accordance with his NRC license as a senior reactor operator and his position as shift supervisor, FIEEDS had a duty to gather the necessary data to resolve an issue of serious safety concern.
He advised "A" shift operators that the evolution to be performed was safe, approved by swinting procedures, did not risk public safety or jeopardise the operation of the reactor or its
' safety systems, and was within FIELDS' authority and responsibility to perf arm.
"A" shift operators reasonably relied upon their supervisor's assurances.
.As senior reactor operators, FIELDS and WEISS were part of managementandbelievedbythe"A"syftoperators.tobeempowered by FPC to perform the MUT evolution.
"In the fall of 1993, FPC required all plant supervisors at Crystal River to attend a one-week seminar on empowerment and management's, expectations. During the seminar, FPC representatives explained that the utility industry was facing competitive challenges which required FPC's employees to make decisions and take actions to streamline the organisation's effectiveness.
Dr.
Beard and Mr. Gary Boldt, Vice President for Nuclear Production, presented their expectations to FIELDS, WEISS, and the other supervisors. Attached hereto as artaihit 12 is a handout from their-presentation entitled " CHALLENGE THE PROCESS."
" Pat & Gary's Expectation's" included:
14
FIELDS and WEISS ande clear to the operators that based upon their duty to the pubic, guidance provided by senior FPC management, and Mr. Bergstron's request, FIEIDS and WEISS believed that performing an authorized evolution to verify a critical safety issue was exactly what was espected of them as nuclear operators and shift supervisors.
i on September 4,1994, FIEIDS, WEISS and "A" shitt held a ' pre-job hriefing to discuss the evolution and make assignments. FIELDS would continue his duties as shift supervisor. WEISS would oversee the evolution, and STIN&RT would operate the control board to perform the evolution.
VAN SICELEN had no specific assignment.
SMITs, the Reactor operator, was assigned to monitor the routine plant operation while the evolution was in progress.
In accordance with 07-402, the MUT was filled and pressurised as directed by Curve #8, to approziantaly 86 inches.
Water from the MUT was than drained to a holding tank. The annunciator light, AR-403, activated almost immediately.
In accordanam with AR-403, the Aux. Building operator, who had been previously alerted, was standing by and available to vent the MUT if maa== mary.
The MUT draining was secured at a level of a y.
imately 55 inches.
Water r
was added to the MUT and the annuncjator light alarm was cleared.
'.'here was never say need to vent the byerogen from the MUT or take other precautions other than what had already been performed.
1 The~ real time data collected was determined by WEISS to be inconclusive and a smooth, definitive trace of the actual system response was not obtained.
The data could not be used to verify actual MUT response.
Because the setting was so fine, the data read outs fluctuated up and down.
In addition, the time _ sequence between the strip chart and the computer varied and had to be taken into effect.
As a result, the real time data record was inconclusive and may not have accurately reflected actual system response.
Although the data was inconclusive, VAN SICELEN remained concerned and went to the plant library to obtain a copy of the engineering calculation used to develop curve ps, 190-0024 Rev. 5.
In accordance with standard operating pzhures, the Reactor De an innovator mad initiator of needed ohange -
a.
avoid getting trapped by buremueratio policy and the status goo; b.
It's o.E. to question any "remairement" (Laoluding regulations and oompany policy) that doesn't make sense. Rigid and blind obedience is not in the best interest of analear safety.
15
Operator logged the draining and retilling of the MUT in her official Log Book.
FIELDS did not consider the evolution significant enough to merit inclusion in the Shift Supervisor's Log Book, because it was based upon a routine i.r i e and no results were obtained.
On September 5, 1994, when "A" phift returned to duty, there were no plans to conduct another evolution.
During the shift, WEISS'and VAN SICKLEN had the -yr-amity to review the engineering calculations obtained from the library.
The "A" shift operators also suspected that the. previous night's inconclusive data may have, i
been caused. by the addition of cold hydrogen which did not have j
sufficient time to stabilise with the solution in the tank.
j WEISS and VAN SIcKLEN noted that the calculation stated that it was only good th. 4 Refuel 8.
As di -===d above, RF-9 had been completed months prior.
In addition, the calculation used an outdated accident mitigation plan based upon the Reactor Building flood level and not the current plan based upon the BNST level, j
It was apparent that the curve #8 calculation had not been seriously reviewed, because the whole strategy for accident mitigation had changed since the calculation had been written.
l These' errors indicated that curve #8 may not have been correct but l
did not demonstrate it was wrong.
Furthermore, all information j
available to "A"
shift indicated that curve
- 8 was an j
Administrative /Onerating gggg.
Nothing indicated Curve #8 was a i
ASEigD hasis curYm.
I This infornation increased the concerns of FIELDS, WEISS and l
the "A" shift operators. Numerous oral and written !===4 vies about
{
curve #8 and management's directives had been made tn.
$. proper j
channels. Now, engineering was presenting its conclusive response i
in the September 2, 1994 letter.
The discovery that the design i
assumptions for curve #8 were erroneous and based upon assumptions that were out of date and changed by plant modifications indicated j
what "A" shift considered to be a legitimate safety concern.
FIELDS and "A" shitt could not understand how engineering could i
have written the September 2,1994 letter when the calculations and assumptions curve #8 were based upon were questionable.
In light l
of this new information, engineering'.s statement that curve #8 was j
" accurate and reasonably conservative" appeared inc
..ct.
The not l
effect bolstered FIELDS' and "A" shift's concerns about Curve #8.
i l
After iaking tasse discoveries during their September 5,1994 shift, FIELDS and "A"
shift considered what to do.
Previously, they had raised their concerns verbally and in a written problem report and received unsatisfactory responses.
They continued to i
complain and now were being placed on notice that their safety
{
concerns with excessive hya,. pressure in the NUT were being.
i closed out unless they had something more to offer.
It appeared to "A" shift that nothing short of conclusive data would convince management arid engineering that the safety concerns were 16
)
b i
?
.--,m
.m=.
legitimate.
2 FIELDS then approved "A" shift to perform a second evolution.
l This time after w ing the hydrogen gas, they would let the gas stabilise approximately 30 minutec prior to draining the MUT.
As j
an additional precaution, the Aux Bul? ding Operator would dress out J
in anti-cone==4pation clothing in ame0 he was needed to vent the i
MUT.
Prior to the evolution, appropric*.e procedures were again
{
reviewed.
Attached hereto as Exhibit is is a time line of the evolution performed on september 5, 1994.
. The entire avs.lut' ion lasted ey,.aimately 2 1/2 hours. The i
annunciator light vna activated for a total of 37 minutes.
For at I
least the last fifteen minutes the annunniator light was on, the operators were responding by stabilizing the system and adding j
water until the light alarm cleared.
As provided by the p - ures, the MUT was vented after this evolution.
This time the actual system response data recorded on the i
REDhs computer was transferred to a disk.
The data was then delogged and compared to a computer-generated Curve #8.
The i
results were as*=4=h4==.
The actual system response did not l
follow the predicted curve #s.
Instead, the system responded by i
moving into the unacceptable region and continued to exceed curve j
- 8 by an increasing amount as the tank anytied.
on September 7, 1994, upon learning this infornation, FIELDS and "A" shift initiated Problem Report 94-0267 ("PR 94-0267").
A
)
copy of PR 94-0267 is attached hereto as EEkihit 14 and includes j
a graph that compares actual system response during the September j
5, 1994 evolution with Curve #8.
In PR 94-0267, Problem 1 addressed the apparent incorrect assumptions in the calculation upon which Curve #8 was based.
Problem 2 addressed the observed j
variance between actual system re conse and curve #8.
4 l
j On September 7, 1994, PR 94-0267 was reviewed by Mr. Larry j
Moffitt, the Shift Manager on Duty, who considered the report to i
be very significant. Most importantly, the data revealed that when
{
the tank reached 55 inches, the system response reflected an error j
in curve #8 of about 1.7 psig above the predicted response.
This 1
error equates to a water column'of 3.9 feet, which is much more
{
than the 2
feet of assumed column predicted by curve #4.
j Therefore,,1f the MUT were maintained on or near curve #8, as j
mandated by management, and the HPI system were activated, hydrogen j
would have entered the suction piping of one of the two EPI pumps, resulting in rapid catastrophic., failure.
l The concerns of "A"
shitt and their superiors were
]
conclusively demonstrated to be valid and accurate.
Curve #8 was i
incorrect.
In essence, to operate the MUT on or near Curve #s, as 1
l demanded by Dr. Board, would have resulted in half of the HPI i
system being rendered inoperable in the middle of an emergency.-
17 1
i I
J b
i
The demands of management were a. setup for violating design basis.
The evolutions perfarmed by FIELDS and "A" shift validated their legitimate safsty concerns Curve
- 8 was wrong and non-conservative. A serious safety problem was conclusi without jeopardizing the public health and safety.,vely identified Aside from fulfilling their duties, FIELDS, weiss and thi *'A' shift operators had nothing to gain by W a % the evolyt4cas of. september 4 and 5, 1994.
Because of the safety concerns and potential hazardous conditions, they were obligated to verity MUT response and the assumptions of curve ps.
By following an authorised procedure, they felt their % oculd be demonstrated safely, effectively and within their authority.
"A" shift placed the system in a alegal" position as demanded by management and approved by engineering, and it was the svetam remnanna that fell outside the design limits.
The actions of "As shift on September 5, 1994 consisted of a
- simple, routine evolution to plot actual system response to approximate what would happen during a major loss of coolant accident.
Each operator believed that supervisors had authorised the evolution and that no p---
^
s were violated.
OP-402 was used throughout the evolution and the appropriate steps.to respond to the annunciator light were anticipated and followed to clear the light alarm.
"A" shitt fallowed procedures they were assured were correct and authorized by management.
PA 94-0267 included only the data from the september 5, 1994 evolution. Because the september 4,1994 data was inconclusive and served no purpose, it was not d 4=====d.
At no time did the
===hars of "A" shift attempt to withhold infornation regarding the september 4 1994 evolution.
They assumed that it would be discussed when engineering researched and resolved PR 94-0267, as required by the administrative instructions for the resolution of problem reports. In addition, the events of both September 4th and 5th were discussed with senior Licensing Engineer Paul Fleming and Systems Engineers on or about sep==hae 6,
1994.
Incredibly, although FIMLDs met with Paul Flanung, senior Licensing Engineer, members of dA" shift were never contacted, questioned, consulted or invited to discuss the events of september 4th or 5th by anyone i
in FPC.
Engineering never talked with "A"
shift operators to i
reconstruct the evolutions or validate the data obtained.
'The BGtC confiras that "aparation on curve 8 of OP-1033 resulted in operation outside the design basis of the plant."
As a direct result, the NRC has cited FPC for an apparent violation for its fmilure to properly translate detinitions into specifications, drawings, procedures, and instructions.
A33 NRC Inspection Report 95-13, Paragraph 3 (Exhibit 21) and NRC Inspection Report 95-22, Paragraph 7 (Brhibit 23).
18
I i
on the morning of September 8, 1994, "A" shift's last day on i
midnight shift, Mr. Bruce Hickle, Director of Nuclear Plant operations (Plant Manager) came to weiss and congratulated him for j
being tenacious and ab-Alonging engineer's calculations which established curve #8.
)!
The sense of outrage and azooption that engineering personnel
{
would take to the "L" shift operators' challenge to engineering's i
ability to present a sate and accurate curve was unexpected.
Mr.
j Balnon assigned Mr. Walt Neuman, operations Technical Advisor,, to i
represent operations in the resolution of.FR. 94-0287.
Mr. Neuman
}
has stated that Mr. Saltaman and Mr. Minman were completely opposed j
to considering the data presented by "A" shift as being relevant l
and refused to admit that curve #8 was incorrect.
However, Mr.
Neuman convinced engineering that its response was unacceptable to operations.
i
{
on september 9,1994, Mr. Neuman issued short Term Instruction
("sTI")94-019, which instructed the operators to operate the MUT 2.0 psig below Curve #8.
On september 14, 1994, STI 94-021 was i
issued and further reduced the pressure level operators should l
maintain in the MUT to 2.5 poig below Curve #8.
===haes of "A"
shitt had no knowledne that curve
- 8 represented the design basis limits for operating the MUT.
FPC's engineering department had consistently represenced to the operators that curve #8 was an administrative / operating curve.
Despite weiss', FIELDS' and "A" shift's concern that Curve #8 may have been incorrect, they had no. idea that it was a design basis curve and that an authorized 4.. would result in a design basis violation. Had they known curve #8 was a design basis curve, they would not have performed the september 4 and 5,
1994 evolutions, and would have refused to operate the MUT with the pressure levels demanded by management.
Instead, the "A"
shift operators would have pressed on with their efforts to resolvp their concerns "in-house", hetare going to the NRC if paa====ry Management,
' based on engineering's calculations and recommendations, had instructed the operators to maintain and operate the MUT in excess of its. design basis limitations.
As demonstrated by "A" shift and admi~tted by engineering, Curve #8 was 7Engineering has now made significant revisions to Curve #8.
The new Curve #8 includes an explanation page which defines the terms and expected operating conditions and regions. The new Curve
- 8 clearly depicts the 4a3173 limit curve, a restricted area between the design limit curve and the annunciator alarm curve and a third computer alarm curve.
Furthermore, the new Curve #5 identifies the " preferred region" for operation of the MUT, which is lower than the level previously set by management under the old Curve #8.
The new Curve #8 is attached hereto as urhihit 34, 19
l I
4 incorrect.
If not for the actions of "A" Shift, this error would I
have continued unnoticed until a potentially catastrophic fmilure occurred during a nuclear emergency.
subsequently, FIELDS was directed to generate y Mure or work instructions for a 3Rrf overpressure test.
on september 19, 4
1994, FIELDS submitted the new procedure, which was subsequently approved by management and instituted as Test Procedure 94-2p7, entitled " Makeup Tank Pressure Limit Curve verification" and is attached hereto as ashibit 15.
The approval of this procedure indicates that the. evolutions performed by "As shift on September 4
and
'5, 1994 were safe, effective and now sanctioned by management.
On September 18, 1994, Mr. Malmm ingged a meagrandum, via e-mail to all nuclear operators, regarding the 3RPF issue.
In that e-mail he c-nts on the actions of FIEEDS, weiss and "A" shift.
The questioning attitude we ask you to eukibit was essellent.
The thought processes and safety culture for this issue were essellent.
The philosophy of not amoepting an insemplete, unsatisfastery answer was eseellent.
The data obtained was azoellent.
Mr. Halnon admitted that he and management could have handled the MUT issue better had they known more and aggressively pursued the issue.
Furthermore, Mr. Balnon's memorandum encouraged the other operators to talk to FIELDS and NEISS, and it compliments them on their professionalism.
A copy of Mr. Balnan g ggpgggggg s
is, 1994 e-mail is attached hereto as ashibit 1s.
on November 16,
- 1994, engineering issued an interoffice correspondence that concluded curve #8 was, in fact, a design basis curve.
The memorandum also acknowledged that curve #8 was "non-conservative due to 1-- sect assumptions in the calculation which developed the curve," and that " operation on or to the left of the OP-103B curve (Curve #8) at the onset of a LBIDCA (Large Break Loss of Coolant Accident) or core flood line IDCA (Loss of Coolant Accident) would have resulted - in HPI pump damage.
This is considered operation outside the design basis of the plant per NRC regulations."
A copy of the Novesbar 16, 1994 interoffice correspondence is attached hereto as amhthit 17.
V.
MRC NOTIFIC&TICE OF & REs m Y TIDL&TIONI ERC investigatisa and FFC's, reactions.
operation outside of a design basis limitation is a violation of NRC regulation 10CFR50.72(b)(1)(ii)(B) and requires a report to be made to the NRC's Operations Center within one hour. After the November 16, 1994 interoffice w - -W - + vas received in the Control Room, FPC issued its one-hour report to the NRC Operations 20
4 i
t 1
center, even *hmt the (PParent violation had actually taken place l
l some two months hetore.
{
on November 22, 1994, personnel from the NRC's Region II office met with FPC officials.
It has been reyed that the j
meeting began with Mr.
Stewart Ebneter, NRC's Regional II administrator, expressing his " great concern over the unauthorised j
test performed on the NU System" and the fact that he was
" extremely unhappy that it had occurred." In addition, Mr. Ehn,eter
]
expressed concerns with Management oversight and the time taken by FPC to address the technical issues involved.
Apparently,.the.
initial concerns of FIEEDS, WEISS and the "A" shift operators were never communicated to the NRC or addressed.
In addition, FPC r
apparently did not reveal "A"
shift's prior actions to resolve their concerns.
NRC regulations require a Licensee Event Report ("LER") to be made within thirty days after the initial notion of violation. The i
LER requires the event in question to be analysed as to makse,
{
corrective actions taken, time frame for when the plant will be in full compliance, and a statement as to why the violation would l
never occur again.
Despite these requirements, FPC never involved j
"A" shift in its initial investigation.
LER 94-009 was submitted to the NRC with Dr. Reard's permanni review and approval.
LER 94-009 downplays the significanos of operating the MUT in accordance with CURVE #8.
Nevertheless, FPC l
admitted:
l l
The cause of the continued operation of the MUT at or above the design basis was a requirement to maintain hydrogen concentration of the reactor coolant system within specification.
This required operators to place pressure level points on or near the curve as a routine evolution.
Each time the operating point was deduced to be on or near the curve as indicated by the main control board instrument, the MUT may have been operating outside the design basis.
{
FPC acknowledged that its directives were the source of the design i
basis violations.
Following Ebneter's visit, FPC advised FIEIDS that the NRC's office of Investigation ("OI") would conduct interviews the next 2
day with him and the other members of "A" shift.
FIELDS and WEISS l
i
" Inspection Rep 95-22, Paragraph 2.5, Ewhihit 23 concludes that FPC made the one hour report promptly after discovering the outside of design basis condition. Clearly, this establishes that i
FPC did not recognise Curve #8 as a design basis curve until at 1
least November 16, 1994.
l 1
21
were informed that one purpose of the NRC investigation was to determine whether the September 5, 1994 evolution constituted a willful violation of gE+hal requirements. Mr. Gerald Williams, FPC's farmer corporate counsel, held a telephone confarance with FIEIDS in the the NRC investigation. presence of Mr. Een Wilson and dise n==ad Mr. Williams instructed FIELDS to answer the l
questions but not to volunteer any information.
' Prior to the OI intervimas, FIEIDS and WEISS met with Mr.
Williams and Mr. Balnon. Mr. Williams again instructed FIELDS and WEIBS not to volunteer any information.
On Daa==ahae 5, 1994, VAN SICKLIN and EMITE were briefed, by Balnen in preparation for their OI interviews.
In discussing the events of September 5th the operators told Balnon that the september 5th evolution was not the first such evolution perfarmed.
Mr. Halnen stated that 'he was only aanaanimi about the events of September 5th.
In addition, Mr. Williams met with the other "A"
shitt operators and advised them also to answer questions asked but not to volunteer any infornation to the stC investigators.
During the NRC's investigation, all members of "A" shift were interviewed.
Each answered truthfully all the questions the investigators posed.
No questions were asked about any other evolutions, and nothing was discussed about the September 4, 1994 evolution.
OI interviews {.M. Balnen was asked by the operators to observe the In an e-mail to the other operators at Crystal River, Mr. Halnon stated that the responses of the operators and the others were " professional and complete."
A copy of Mr.
Halnon's e-mail message is attached hereto as Exhibit 1s.
Thereafter, FPC transferred FIELDS to an administrative position within operations.
weiss was transferred to a position as an emergency operating procedure coordinator in accordance with a prior arrangement.
FPC split up the four other licensed nuclear operators on "A" shift and removed them to different shifts.
"A" shift ceased to exist.
On March 1, 1995, unbeknownst to the operators, NRC personnel met with FPC officials.
During the meeting, the NRC expressed
" concerns with management oversight and commitment to program
)
implementation."
Apparently, the NRC remained uninforag of the j
real purpose behind the September 5,
1994 evolution.
As a 4
i
'Except for VAN SICKLEN, who was accompanied by Mr. Bruce Willas.
18 Although Mr. Halnen was aware of the September 4th evolution from discussions with VAN SICKLEN and SMITE on December 5th, 1994 and with VAN SICKLEN in January and March, 1995, apparently FPC failed to notify the NRC of the September 4th evolution until 7/95.
22 1
1 4
i 1
i i
result, the NRC remained concerned with what it perceived as an j
" unauthorized test" and FPC's actions to discipline the operators j
vho had committed such acts.
il i
on May 5, 1995, Dr. Beard provided a letter to the NRC as
" additional information from our cone 4=ti==
review of MUT operation."
A copy of Dr. Beard's May 5, 1995 letter is attached hereto as Eskihit 19.
The letter refers to the NRC's investigations which " focused" on whether "A" shift had committed l
a " willful violation of g4 al requirements." Dr. Beard stated that FPC had reviewed the events of september 5, 1994, "from the
{
perspective of whether a willful violation ooourred."
Dr. Beard i
concluded that FPC did not "believe that the individuals' action i
aroes to the level of deliberate mimaand**at" and admitted that j
"they were motivated by a desire to obtain data to support a i
legitimate technical concern with the validity of the MUT operating j
curve."
Furthermore, FPC admitted that as a result of the evolution, " engineering confirmed that the operating curve was inaccurate and nonconservative" and that FIEEDS and WEISS "did not l
realize that the operating curve was a design basis limit."
- However, the letter ch Ated the reasons why "A"
shift originally perfarmed the aw,1stion.
In addition, the letter minimised the data obtained by "A" shift and characterised the legitimate safety concern expressed by FIELDS and "A"
shift as merely "a technical concern."
Furthermore, Dr. Board stated that
" operation in the unacceptable region of the curve constituted operation outside the design basis of the system." This statement misleads the NRC and ignores the fact that the data collected by "A" shift demonstrated that operation of the MUT on or near curve
- 8, as demanded by management and approved by engineering, was actually operating the plant outaide its design basis.
l Engineering's original November 16, 1994 =amarandum, Eskihit 17, j
previously confirmed this. As a result of management's directives, all the other shifts at Crystal River had unknowingly operated the a
j WT outside its design basis limits numerous times.
)
l Indeed, the operators were directed to. maintain MUT pressure 1
on a curve that was clearly wrong and outside the equipment's
]
design basis.
Any belief that "A" shift " drove" the plant outside j
its design basis is totally incorrect.
As demonstrated by the actual events on september 4 and 5, 1994, the system was already 1
outside its, design basis.
The actions by "A" shift did not drive the system at all.
The evolutions merely demonstrated the actual system response when the MUT was drained after being positioned in accordance with management's directives and engineering's approval.
on May 23, 1995, FIELDS sent a letter to Mr. Ebneter,.a copy of which is attached hereto as Eskihit St.
As set forth therein, 1
FIELDS explained the operators' perspective behind the MUT issue i
and their perception that management had not resolved a legitimate j
safety issue.
In addition, FIELDS takes personal responsibility i
23 I
!j I
i 4
1 9
i j
for any F+ mt errors by "A"
shift in conducting the nor evolutions.
s
]
On July 7, 1995, the NRC advised FIELDS, WEISS, STEMERT, VAN i
SICELEN, SMITE and ATEINSON that a, *r A isional enforcement j
conference" would be held on July 21, 1995 "to obtain infornation i
regarding an apparent violation of plant Technical SpecificatiBas and operating procedures related to licensed activities atis the i
Crystal River Nuclear Plant on September 5, 1994."
The alleged j
" intentional acts" the NRC complained of were that "A"
shift j
apparently:
.)-
(1) p1manad and conducted en evolution that. allowed the make-i up tank pressure to exceed the acceptable operating region of j
CP-1033, Curve 8 for appradamtaly 35 minutes, and a
(2) delayed the response to the annunciator for the makeup i
tank overpressure condition.
I i
significantly, the NRC acknowledged that the data obtained by 4
"A" shitt " confirmed that the procedural curve differed from the actual curve."
Thus, the NRC validated the fact "A"
shift conclusively demonstrated a legitimate safety e anaam.
J j
The actual regulatory violation the NRC accused FIEIAS, WEISS, j
STEWAP.T and VAN SICKLEN of was " deliberate minnandurt."
- STENhET, 4
SMITH, ATKINSON and VAN SICKLEN categorically denied the allegation j
of " deliberate misconduct."
t i
on July 7, 1995, the NRC also cited FPC for four apparent i,
violations identified as:
,(1)
Deliberate operation of the MUT outside the acceptable operating region; (2)
Operating curves for'the MUT were,outside design basis and the fmilure to take adequate corrective actions for i
significant conditions adverse to quality; i
(3)
Inadequate design assuuIptions for BNST swapover level; fmilure to take adequate corrective actions for l
significant conditions adverse to quality; and failure to adequately translate design basis requirements for j
available stored fire protection water into procedures; l
and
~
l (4)
Inadequate not positive suction head to an Engineered Safeguard pumps during accident conditions.
4 i
In addition, the NRC notified FPC that a " closed predecisional j
enforcement conference" would be held on July 25, 1995, at which 24 i
I l
4
. -.~. -
k I
j time FPC could respond. More importantly, enclosure 2 to the July j
7, 1995 letter details the NRC's 4aWon conducted between September 5, 1994 and July 5, 1995.
The enclosure provides a detailed report of each violation and identifies the regulations and technical parameters allegedly violated.
All the alleged Mac violations against FPC directly resulted from the. conditions identified by "A"
shift or their acts which validated their j
legitimate safety concerns.
l Although it was"not listed as a violation, the NRC's Ju'ly 7, t
1995 letter noted that "these appazent violations indicata.
l significant
h
in management control of the review and resolution of significant conditions adverse to qualitp." The NRC noted the fallowing wa=w==es by management in the control of the j
review and resolution of significant conditions adverse to quality:
i (1) the fmilure to adequately review operstar concea ns on gas entrainment in the high pressure injection pumps which had been identified in several problem reports and i
correspondence between operations and engineering; l
(2) inadequate engineering reviews of the design assusytions l
2or the pressere/ level operating curve of the makeup tank; (3) failure to implement timely corrective actions for indications of deficiencies in the design assumptions far various safety-related tank levels.
l Each area of weakness directly resulted from management's i
fmilure to thoroughly acknowledge and react to the legitimate safety concerns expressed by "A" shift.
On or about August 22, 1995, FPC concluded its own in-house investigation and determined that the members of "A" shift should be punished. STEMMtT and VAN SICKLEN were stripped of their NRC licenses and reassigned to other departments outside of operations.
i SMITH received a written - reprimand, which she has challenged through the union grievance process..ATKINSON received a verbal reprimand.
4 l
In August 1995, shortly after he was terminated, WEISS j
obtained copies of information recorded by the REDh5 computer of j
critical plant systems, including MUT level and pressure.
WEISS j
i dologged the information and graphed a three-month history of MUT J
l evolutions from June 1, 1994 to september 7, 1994.
Amazingly, on j
63 separate occasions, OP-103, Curve #8 had been violated by the
{
operating crews.
Many of the events produced traces very similar
{
to the curves generated by FIELDS and WEISS on September 4 and 5, l
1994.
This information was presented to the NRC in the form of an Allegation in mid September 1995 and is attached hereto as Exhibit j
22.
i t
25 I
4 a
4 i
4 5
The significanoe of this new information cannot be over emphasized.
All of the other operating shifts considered Curve #s i
to be an Onaratins gg33 No one r w ized it was a damian hagig 2
ggIn nor did they consider it a sanctity which could not be bromohed.
Some of the traces indicate a significant disregard for curve #8 and the annunciator alarm response required. For example, i
the information reveals that other shifts left the MUT Sigh
)
Pressure Alarm "in" for up to four hours.
The information provided by WEISS includes evolutions that were performed between July 21 and July 23, 1994 by another shift.
Apparently, these evolutions relate to work reported by Mr. mainen and Mr. Jones in their July 1994 e-mail messages, which references j
methods the operator could use to increase the hydrogen pressure i
in the MUT.
See EEhlh1LA.
This indicates that the July 1994 MUT evolutions were performed with the participation of management and i
l utilized OP-402 as the procedural guidance for addirq hydrogen to meet Mr. Board's demands.
This procedural guidance was exactly I
what FIELDS, WEISS and "A" shift operators used to perfora the i
september evolutions.
A comparison of the July 1994 curves with j
the September 1994 curves (see ashibit 33), reveals that the curves are nearly identical.
In h*,
1995 the NRC conducted a
"special team investigation" of crystal River.
The NRC aandneted extensive i
interviews with management and engineering personnel.
t h
On February 5, 1996, the NRC issued Inspection Report 95-22, I
which is attached hereto as Eskihit 23.
As set forth therein, the NRC cites FPC with four apparent violations with each violation j
having numerous examples.
The four apparent violations were j
identified as:
1 (1) Nine examples of operation of the makeup tank outside the 4
l acceptable operating region (Curve #8) while adding hydrogen; (2)
Two examples of conducting an unauthorized test or experiment without a written safety evaluation containing the bases for the determination that an unr,eviewed safety question did not j
exist; i
(3) Three examples of inadequate corrective action concerning i
l inadequate revisions to curve #s; (4) Four examples of inadequate design control concerning the j
incorrect design information contained in curve da, which allowed j
the plant to be operated outside its design basis, incorrect i
swapover point for the BWsT, inadequate not positive suction for
}
the low pressure satety injaction pumps during swapover to the Reactor Building sump, and minimum volume requirement for the fire water storage tank not being met.
26 f
I i
i
l In addition, the stC noted weaknesses including " human factors 4
aspects of infornation provided to operators for control o* Mtrf level and pressure;" ineffective ocumunications between oper+. dons and engineering and within both depu
.is;" and vague guidance i
provided to operators in r 4-es for when ga+t - e are adequat:e for evolutions being perfarmed, 2or alarm response times, and 2or determining when evolutions constitute a
tesy or experiment."
i In 95-22, paragraph 2, the IGtc di=====d.the NUT operation.,
i The NRC noted that in its previous review, 95-13, it was determined j
that curve #8 constituted a design basis curve. Therefore, the NRC.
)
i concluded that the examples cited included not only 2milures to 1
follow g==i
-s but operations outside of a design basis.
The NRC iaW selected eleven oconsions it deemed significant when the anmine intor alarm was in for more than thirty (30) minutes and i
curve #8 was awaamdad by more than 0.5 peig.
As noted by the NRC, j
the cited examples included 30 different licensed operators and j
approximately 100% of all licensed operators at Crystal River.
4 With regard to the September 4 and 5,
1994 evolutions performed by "A" shift, the actions the NRC complained of in its l
July 7, 1995 notice of apparent violation, = - M4=lr curve #8 and j
not responding to the annunciator alarm, were essentially the sans as all the other crews.
- However, "A" shift's actions were of less duration and differed materially in that "A"
shift was merely j
observing system response while being prepared to react should further actions be paa==== 7 The other shifts actually i-manipulated plant conditions to achieve the results sought by i
management and then failed to react when the aanditions set off the j
annunciator alarm.
i l
The NRC therafore characterized "A"
shift 8s evolution as a i
" test or experiment."
Significantly, in 95-22, paragraph 4, the NRC found that in FPC's procedures manuals:
}
No guidamos was present to assist in determining if an i
evolution being osaduated was a test er infrequent i
evolution.
Furthermore, the liosasse (FFC) did not j
define what activities constituted a test er experiment.
1 i
and "A" shift did not violate any existing g M ure that defined
{.
operators to consult.
Based upon his authority as a licensed and prohibi'ted such a " test".
No documentation existed for the senior reactor operator, the Sr L -stions of management, and existing procedures, FIELDS was believed by "A"
shift to be f
authorized to perform the evolutions.
In fact, FPC told MRC inspectors that it " relied on the shift supervisor's experience and d
licensed operator training" when new gc-+ Mas would be developed.
j NRC Inspection Report 95-22 validates the concerns of FIIIDS, 4
I 27 3
i 1
1 i
j 1
1
wrIss and "A" shift, and appropriately criticizes engineering and management for their fallures to discover the errors pointed out by "A" shift and others.
VI.
REE70MBE TO RFR& RENT E GL122M In 9=iq= f roe dated March 3,
1996, the NRC noted an apparent violation described as follows:
"':he apparent violation occurred when you conducted tests without written safsty evaluations as required by 10 CFR 50.59 and when you failed to follow crystal River plant l
procedures for control of makeup tank pressure and level.
Procedural limits for makeup tank pressure and level were hM and subsequent analysis has shown that the plant was operated outside of its design basis "
i i
The applicable procedures cited were AI-500, Rev. 32, Step 4.3.1.1 I
and W oiw 27, Item 6; OP-402, Rev. 75, Step 4.19.9; OP-1033,
{
Curve 8, Rev.12; and AR-403, Rev. 21, Item E-04-06.
i The operators of "A" shift, ATEINSON, EMITE, STEMART and VAN I
SICKLEN respectfully show that during the evolutions performed ce
{
September 4th and 5th, 1994, they believed that their actions were
{
consistent with all applicable Crystal River plant y.-- +h-s.
i l
With regard to procedure AI-10L the. operators were aware of i
their responsibility for **4ag timely and proper actions to ensure the safe operation of the plant.
See section 3.3.2.15.
In fulfilling their responsibility to ensure safety, "A" shift raised legitimate questions of safety with their supervisors and managers through the proper channels.
On September 2, 1994 the operators j
were notified that their safety concerns were to be closed-out unless additional information was provided.
"A" shift operators would have been derelict in their duties had they allowed a i
critically important safety issue to remain' unresolved to their i
satistaction.
Consistent with their responsibilities under AI-500 they consulted their shift supervisor for direction regarding l
an evolution to be conducted to confirm their safety concerns.
Under 'the direction of their shift supervisor, the written l
policies and procedures of Unit 3 were consulted and reviewed. The shift supervisor concluded and advised that the planned evolution was authorized by existing procedures.
As such, AI-500 section 4.2.35.1 was complied with.
It was not only reasonable for the operators to rely upon and follow the guidance of their shift supervisor, it was procedurally f
j imperative.
AI-500 section 4.3.2.3.2a provides that
" shift 4'
j 28 i
i l
I
i i
i 1
i supervision" is charged with determining which r cc4 ural l
reiguirie are applicable.
The shift supervisor determined that the contemplated evolution was within the guid=M of existing l
plant procedures for control of makeup tank pressure and level.
J In discussing the evolution, the operators considered the possibility that the annuneistor alarm might be activated.
They
)
consulted AI-500 s. action 4.3.2.2.4 and AR-403 for guidance.
As i
this was to be a controlled evolution, the response r -cedures of i
AI-500 section 4.3.2.2.4.1 did not require that the annunciator response procedure he utilised. No further guidanne on timeliness in responding to alarms or implementing alarm response operator i
actions is provided in AI-500.
Ristorically, FPC practice was to 1
accept that no action was required in response to the annunciator alarm during plant operations.
(333 stC Inspection Report No. 95-i 22, paragraph 2.4, page 15 (Euhibit 23), where it is noted that j
virtually 100% of all licensed operators at CR-3 had taken no action in response to extended alarm activation, in the presence of senior management.)
Thus, the operators did not violate plant i
procedures by allowing the alarm to rammin activated during the j
evolution.
OP-402 provides guidance with regard to the operation of the l
makeup and purification system including MUT hydrogen gas addition j
and water level changes.
OP-402 was referenced by "A" shift and fallowed throughout the evolutions.
No guidance for MUT pressure limit was.given in procedure OP-402 for lowering and raising MUT water level.
Therefore, it was the shift supervisor's judgment to i
determine if new or additional.r c ^..1 guidanna was required.
Shift supervisor David Fields determined that no additional guidance was necessary to conduct the evolutions.
The operators believed that the shift supervisor's decision authorized their actions.
I
'On September 4th and 5th, 1994, "A" shift operators believed that. the evolution entailed placing the system in the position directed by management and approved by engineering.. Then "A" shift would observe and document system responses as water was drained from the MUT.
At no time did "A" shift belihva that crossing OP-103B, Curve a constituted a violation of plant procedures or design bases.
At j
the time of,the evolutions curve a did not include an explanation j
page or define the terms and expected operating conditions and i
regions.
Members of "A"
shift had no knowledge that Curve a represented.the design basis limits for operating the MUT.
FPC's i
engineering department had consistently z r:r-e A to the plant operators that curve a was an Administrative / Operating curve.
No guidance for MUT pressure limit was given in pi-cedure OP-402 including lowering and raising MUT water level.
Further, OP-402 did not provide emphasis on maintaining MUT pressure within the limits of OP-1305, curve s.
As a consequence, the operators i
)
29 4
4 l
l k
d 3
--.,_,m_
--4
l i
holieved that the evolution was within the parameters of plant j
procedure as interpreted by their shift supervisor.
1 i
Regarding the apparent violation of 10 CFR 50-59. no written i
safety evaluation was sought because neither the "A"
shift j
operators nor their supervisors r m ined the planned evolutions as " tests or experiments".
At the time of the evolutions, FPC Mad 1
no procedural guidance to determine whether existing procedures were adequate or if new procedures were necessary. No guidance was t
available to assist in de+= -inia? if an evolution being conducted was a " test" or infrequent " evolution".
Neither 10 CFR 50.59 nor FPC defined what activities constituted a test or experiment.
It was therefore left to the shift supervisor's judgment as to whether or not new or additional procedural guidanna was required.
The i
shift supervisor determined that the planned evolutions did not constitute " tests" or " experiments" and therefore no written safety evaluation was required.
"A" shift operators had no reason to doubt their supervisor's decision and were authorised to rely upon it.
6.
TII.
e i-* -
VAN SICKLEN, STENART, SMITE and ATKINSON acted reasonably and responsibly in their efforts to resolve a legitimate safety l
They acted with the full knowledge and approval of their concern.
i shift supervisors.
At all times they believed their actions were l
consistent with their responsibilities as licensed nuclear i
operators.
i l
These evolutions conclusively validated their concerns and avnted a significant potential safety hazard.
Regretfully, as a result of incorrect information provided by engineering, the concern was worse than anticipated and resulted in an unintentional f
violation of a design basis limitation.
However, public safety and the operation of the reactor and its support systems were never jeopardized by their actions.
Despite their good intentions the i
members of "A" shift were punished by FPC..As a direct result of l
FPC's disciplinary actions, VAN SICKLEN, SMITE, ATKINSON and STEWART and their
- families, have suffered damage to their professional
- careers, loss of. income, attendant employment j
benefits, incurred public humiliation, and auffered immeasurably.
f
~
VAN SICKLEN and STEWART were stripped of their operator's license.
Both were removed from the Operations Department. Their nampensation was reduced by apprarinately $25,000 per year.
The attendant pension benefits were diminished. Both suffered the loss
{
of their union membership and privileges.
i
{
SMITH and ATKINSON received written and verbal reprimands,
{
respectively. Their otherwise unblemished records are now suspect.
i i
30
.i i
Each of the "A" shift operators, VAN SICKLEN, SMITH, ATKINSON and STENMtT respectfully requests that the NRC find that they acted in conformity with the duties and responsibilities of their license, and that they be spared further punishment for the good i
faith actions they performed in attempting to bring to the i
attention of their management their legitimate safety concerns.
,i j
mespectfully submitted, 1
FINESTONE & MORRIS Attorneys for Mark Van Sicklen, Jack D. Stewart, James T. Atkinson, j
and christine M. Smith j
By:
i Bruce R. Morris i
i aux /$$
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a esas ese as asese sua tsies tenesstes artse p=ess mess as M esWeste GB sere le me 4 er ese ese afr=e8 sans tsue team la se um gasseesa some es SSR seressegue of pt, sam.88 has e eseeer tismeten es esses eyese es seguemst eues of asssestan. as se seus EstS emete es eness arts es peepseman lose.e sense eM to seese esmeest oss es e ese, M esses penas IM ftse Gees tatso meureme ama e me eWI. ausmuur, en een efespues en es eusse esotese af M es Omettetty eles 58 te ehemse h as peggess iem.ee to e tottense artse ens eenma espessamme er 96 as e#essantes eramese aps moetense e asse e ones ear-e een assemesseet, F sees, ets es amnes e ano entseese es.1 temet aus euer pumuse, me est test pumme se es sewe et p.43e ser nr tt me tens 6 mass e es me. en a possummse lem.o sense sessee of air =es to spectesMs y ease en ta
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esses e ets resser enn les see er a atmus atense enen se F pass EP ese des aus esse as estas es ene esse of S i
etMeesee, se prenanstler se meet etenese een emettestem of seemessa to amatenes easy aten. as tem. mass en sure 1 I
I see 3, est.e evennetty etenes ese me F pas a penas esser e>ts sus mesunse amuset tems.
3 la enese e sewe e poeta es ame mies see me es tastests aus eteem es eum se tense as she tessusta, one e es emotetes any S. SUen t.o. me asse essor me eurtesumes of 59 e38. Des tueussten emaeuses ese me asurent emetten et mm.ee is emme se o elastse se es gese does as escase, 96e omte ensure eles entremens tan reed seeresas en este=o est emot mas e h ammmenry ammesete tems, te een a asumuseas sumsumme setes enremes termer essemesse me deemsmen, en enestes e emme summum merentes pesareas ese ep.m esemaeus er essesses artse se sette sp.ta es On serveen, ese et eens unumsmed g
g assistem mee esoneness. per emesses, pumm one assesums A.
j es esmesses en ens esemary emme somete, em suped eup to Geog see launt setsh ammeses se as saws of me ter ett en ame me pes-e. e..
seus ennew asus to e assunt emmeten, enseur, tasas e e esuurteen meer er emuseos sessumt er es asent sup e entres see tenet e as umstem asase sua ear.penswer eyes sp.tm apus e, et asumeses mas e eram sassoas ese s
me meet een eneses openas amase as summassesse supean er arms a es emesse est taunt ensus game seamens spumm staaresemy esmre, aseammen m. asensen ens passem eres des sus amar me amammesses septen, me enestet our.pem mates ensammte summee has tem was sunse as esent anseems seus ese esass emmese, es sehen eye tas amen seweesses. ese aa-t er es sundes er een esoneseems.
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j eso este enrosse tot enes=e saa teses se asumuseus esp to et te, WIe teSeeneumuss M j
tes fees.
N tamed as senet stas een esseseus eyess M Ger DE emetenes W ese WWNW Bism suo pruemose eastemeten sense amarves eman sp=u ene to espotes.
H. M esos asemanus M M Destessee one asetal Ashrt est leet auf emusesonger9 eeS edde W JIEW W E Nat 90 sele searvus erese N teaspaese 99 cm.m. true S to assagenste.
M, m tues amusessum S m propte,umes.uutedent emes tur e W sursuer spesa emeldertse WW SWs.% Wet meessume mes susu6 ans w ips test se eser presase ser as pse h das Dam. new a.
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ATTACII W I fogeIof4 ptM 8849 Part 36. Secondary Causes testiased:
wtth IRIP lA at apprestastely 0100 en Ilay it.19M.1he'second pug tasted uns IslP.18 shish started at apprestaately 4D0. Isp.lC testtag started at apprestaately ell. Alp.lA and 18 ett1tand the 'A' WIf seIply Itas. IIN.73 is the taelatten valve la the 'A' SMBT sepply Itas. Cheek valve Istv.72 ts testal)ed Just emastrean of 1W5 73. IWP.It attitsed the *P M57 supply Itas. IEN.501s the tastatten vaise la the "B" agply lies. theek valve l
1815 4 0 ts lastalled Just done stress of IWF.IS.
?
l Whos IID 1A uns first started. WP.lA uns la servies restreelattag the MIT at i
i apprestostely 3000 SPIT. The MIT 1evel as aprestostely 19.5 ft. the total new ashleved darles SP.830 to the samen 14
'A' BIET sepply lies ens i
apprestastely 3480 4 pit. As fles uns betag taeressed ta'159-14 to 400 Wil. Igr.
j IA ses decreased by le to 25. OperetteesJersonnel suspected that W.lA uns t
carttattag and tamediately itsered Igr IA nom. 591A uns sesered and SP.830 l
coattamed. IslP.1A flew uns taeressed to the regetred SP.430 fleu of IIS WIL.
Aeps runstand steady and SP 838 as esspleted sat.as IRS.1A,.
c As stated aheve. SP-430 en 5p.1B started at apprestaately 8D0 ett1tateg the j
sans MIT supply itse ('A' side) as used for IIIP.1A. Ils prehless sure identifled and the SP was comp 1sted sat. Both Decay liest pumps eure essered 1
j dertag the IIIP.18 run.
SP-830 started at apprestaately 515 for Elt. Fler uns tecrossed to testely 500 8p18. After appresteetely three steates et See a step la ER.11evel from 3P to 39' esaurred and Tlsa la each Irl leep dropped. free aserestostely 135 ERI to ISO 1heOperelar teametately tripped IWp.lC; thes Wrigt ses first spened the W P sostles i
header to the 55T. the Operster meted flew from the plebe to the WET.
It was later discovered tant check valve IRIV 40 did set.tattially snees.
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Diseesste@valmtlen:
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i rat after'the"3P.00.for a.IA are as N11es,s:M, iess i
1 suspected the deep la Mr.1A corrent was.the reselt of earttetten.
unre sensorsed with 19511 avetlable to IRIP.1A telle Sr.lA ens la servles rectrealatlas the 'Af5T'at 3000 spIL. Isp.1A and WF.1A more shertog the 'A' ell 5T supply Itas.
mMERn II.. 0 1.
er e ens issus to a. dress evanWie to Itake-Up pumps derta0 fell ECCS fles eundittens.1 hts ca1selatten has ehme that meegeste NPSIl ts ovatiable for liehe4 peeps below e leveksf 35 ft ti the 3 157 provided sely ese Ilete.gp pasp W5T sepply 19ee is aparettani the j
analysts conservativel assimas the fel) mestem Ettt*fles'estst la both i
of the 14' k sT lleasi 471 fles of SFIt. ESP flew of 2000 Spil and j
IIP 1 n ew of 570 total flew rate of 5420 SML. The em reestruments 4
for a IInke.Ilp peep at 579 SHI is 40 ft. An Irl flew of 570 GHI is used is the
(
analysts for tastrument error esasiderettees. Based en the mostmas fion of l4ft GFIl and a reducties in 5115T level to 5 ft (124 ft ele.), it ces he shown j
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_ _ _.._ _._.~ _
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Dese 2 of 4 that greater than 45 ft of 1r311 ts still avattele to a Rahe up peep operettag in a staple BMIT sepply lies.
l The actaal IFR avallele dortag the mp.lA portten of Sp.830 is as $11eus:
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with the SW5T 1evel at esprestaately 19.5 ft and a enstaan flew rate la the i
cameen 14' Itae of 3450 Spu. the INEN evallele to IEp.lA uns greater than $1 i
ft. la additten, entti the Rake-Up taak and MIT reach centithrim, the Ir5N available is actaally higher as a reesit of the lettlal Nake up task level and i
overpressure. At the potet of aest1thrten, the decrease la WRI ts dependent en the rate of dec1tas of the RIET.
~
In s of the 3 5-0042 saiculatten, esseral tafernal and tedspeedsat head calce attens more performed by site Emptsiser,tes.*1he reesits of these head
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caissiatten are very seeststest with the reesits obtaland in 5 5 sest.
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E9-11 Pa== heat g
i asses en see aben analysts, the Npg avst1dle to Wp IA dortaa th perferunace of Sp 830 ans more them adeemste to provost serftstica.eMe speratten of NS 1A only asemented for elaer head lesses. Resever, this does not explain the drop la the Nake-Up peep ester earrant observed prior to-sacertag MS IA. The aest logical emplanatten for the serrent drop is that atr
)
ens present la the s' 'A' W5T espply lies to IRp 1A. As flew uns betag i
i lacreased to SP 830 reestrements, flew uns1d inttially eene frun the Ashe up tank. As flew appreeshed 450 Sm. flee frem the WST uns hetes establiehad.
i i
Air to the 8' RET espply Itas uns then pelled lete the pulp. It is asemand that saly a small porttah of the fler uns dielhead 3F tbs off. As*a paeslt i
the peoptag 1ead and vessit aster leaWeerrent useld hose deeressed. De 1
appearance of air hates' dress threagh the pump useld be oestwhleet to i
cavitattee. It is assened the air prosest la the itse uns renound by 1
1 before BIF-IA uns esserad.
g,-
j prior to the perferusass of Sp-830. IAfD0105 spened and taspected check valve IEN.M. The seWeet WET llas uns dreland for this laspecties.1here 4
there was as ty for air to ester this NET espp)y Itaa. Because o I
the long 1 of pipe betones IEN N and theilEF header a fill and west of i
this Itae most have esserved. Ilesev3P.~ tt 1s esdhfDst,est all of the air uns removed. There is a secties 1pf this t' itse upstress of IRpft and IIN 73 that cannot be total); vealed des to the lack of veut valves usesvar tt does met appear that satstenaaeruns perferunel in lifts portten of the system to allow air to enter this eeWhntable settlene Berlag*the IIN 72 taspectles. IEN-73 rematand closed.
-i.
tb abese analysts. Estlesere 9 uns added to Op-402, ter. 75.
This Ensiesure addresses vesttap the eeWest *A* RET espply liens to Igr IA.
prior to this rettstes, the blyn potet vest (IIN 85Tues not addressed ta a venting secties of Sp-4N. la addittaa *ah REA has been generated te regnest I
the addttles of a vest vaise to this 8 RST itas etch cannot serrently be completely wanted.
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W.13 P - _. :
There sere as senseres identifled ductag Sp.830 for stip 15. He tant as completed utthest any problems. he 'A' WIT sepply Itae std not samtata att i
because the air sas removed by Itap 1A.
l 12 tammaren ratsed after Sp 830 for IRS 1C are as fellems: Fles uns teeressed to i
testely ISI SfR. After apprestestely three elastas a step la Eff.
I evel asserved and ehertly mereafter flew to seek WI 1eep from i
apprestestely 125 Efil te les Spit. Sees agata it appeared that earttatten had escurred. then IRft 58 uns first egemed me EF settles to the i
WIT the Operstar estad fles entsted free task to the M. It uns later dissevered that check valve IIft 40 did est tattiatly slees.
11able. dort the first of Sp.830 for W 3C. uns for all practical s acut alent to the run utth the emospttaa of einer differesses la and Nake-Up task levels. la additten, durtag this res where certtatten appeared to be present, both Besar Esat peups sure secured. The esta difference with the first W-IC pig run and the first 187 IA run uns IIft 80 ans stuck open. As stated ahese, thes Efp 88 uns first owned, flee ses estabitshed from the nahe D task to the 35T. Da ten tints ratees ts: Could the flew to the MBT enabland with the IEF-3C heen such that essassive hand lesses more crestad to the e' Ashe up task disaharge Itas? Cas14 a sofftetest reducties is WW hese ensarved due to lies leases caustag certtatten? la
, to evalesta uts emnettles. MBW dets ter nahe-Up level and ;.
and WBT 1asel uns attiland. Curves produced frem this esta ses he seen la Attachemet St. hfortenstely, se WI flew pelats sure active to RED 45 dortag Sp SIO.
...L Based en the RIIM5 data, at the pelat IEF 1C uns tripped des to edist appeared to be cavitatten, partial flew from the WIT had 41reet been established. See Attachenst f4 for details. His teplies that the fls1195 gpa tedicated flew uns not totally betag provided be the Rats up test. Rusever, for esmeervattaa the fellestag evalestten will assues the Rake Up tank provided get ga.
As taferuel head saisalatkan "was! ' ermed to deterstee WM avellable to IIlp.
3C assestag a get go flew from nahe up task esistad. A Ilske 8p task level of It* and everpressere of 3.5 patg ens used la this eveleettaa. Based en this calculaties, the W511 available was 38 ft. Rahe Op task Itas leases sure calculated te he prestar then 28 ft. Dese Itaa lesses are incorporated la the,
38 ft W511 avallatie. As stated abers, this is a senservative assemptten because RIBR$ data ladicates the WET uns la fact prortelag a portten of the fles. Based sa the IEF-lC peep curve, the WIN ragstred ta provost sovitatten at 500 is apprestestely IS ft. Assenta reestred is apprestaately 33 ft. g a esasersetteeinstrummut error, the Taarefore..eems the mest severe head.
1ess candittens that cos14 have aristad dartagJp-538r.WW uns not a probles and cavitatten should met have accurred.
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i tased as the above analysts, the IWW available te leip.lC during the performance of 5p.630 was adeguate to prevent cavitattaa. lieuever, this does set aplata.uhr the four 191 leap flew indicator dropped fres 125 ges to 100 gps. The most i tsal eslanatten for the flew reducties is that str ses
. present to the 8
- t' WIT sepply Itae to Itlp.lC. As the str reached the pump sectten both motor survent and fles useld have decreased hecesse the pcey i
fles and meter 1eed were disrepted. The effects westd appear the same as if
,i j
the pup was savitattag.
After soeurtag IRip IC. the pump and assestated ptplag.uas vestad. Ihree engtaaertag persesnel more present een the venttag at.IEN.805 asserred. The ceaseases among Engineertog uns a larger amount of att uns vestad via IIN.386.
154 286 is the high potat vast on the s' 'B' MIST supp. y lies.
1 j
l Operattens aise reported that three sleutes passed before the fler redactten l
escurred. Yhts saa he esplained as fellous: tihen IEN.58 uns first speasd IEN.
88 did act tattially slese. the resultant fles from the IIshe-Op task to the WST esped the air back toward the W5T.1 hts would have samed a delar la the 4
air reachtaa the pup settles. It is alas assemed that the str la ths Itas disrupted the attitty of estar to flew from the OM5T further delaytag the str.
This could alan expiata the steep drop is the IIshe up tank issel. If secties effects en the W5T sure suppressed due to the air the task uns1d tend to sountar act these effects by esattestas to be the preferred secties supply rossittag ta a higher flem rata free the IInte up task. g l
l j
l tb aheve analysts. Eac) 8 uns
.Rev.il.
Yhts Easlesure addresses vaattag the *B' WIT supply Itas to IEr.IC. prier to i
this rettstes, the high potat vest (IEN.335) was act addressed la a vesttag secties of OP.402. la addities, as 35A has been generated to regnest the addttten of a vest vaise la the s' W5T lies uhtsh ceanet surrently be completely vaated.
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a Addittanal Evaluattaa haantredt'. -
y.e n
During the above sealustles. a formai talculat. ten uns est liinst 6'tihtch.
~**
supported the current l' WIT.susp.ever point referenced la'EOp.08, ter 1.
Step 3.35. Based of the.IDp dotatis.:a tatal Etts flew of 7488 gpa ess1d arist uhen the M571evel is.5' or 1ess. Based en a.prellotnary stalestten, starting the seap-over at l' st this fler rata any not: provide adagnetaates ta perform the susp ever.
This issue trill he further evelented and tf. deemed necessary a formal calculatten will he produced to dotarstes an adeguate SuST map ever potet.
This eve)eattes wlll tensider vertertersmacerns and the ttee regelred to aske the susp.ever. Corrective Actles f8 stil track this issus.
m
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ATTACIOWir 1 l
PEN 0143 page I gr 3 i
part as - teatributlag Fasters sentlausd the tutent of the fe11setas discussten is to provide the bases for thes developeest of the Mantam Nake up Tank everpressure serve to SP.1838..This discuesten will aise address how the hohe-up taak will response dortag the j
uorst case scenarie seed to the Op ISIB surve 8 evaluattes:
4
}
Carve #8 of Op less uns produced Celestatten I-gS-ant. Ints salutatten 1 -
uns perfereed to produes en n
- 1. Itstt for the i
fs11 tadicated level of the salesfatten seestdered the aest severe W57 dree deus eartog full fles essettless. The salemistles evansated the differmettet pressere ter) betuses me WBT and the Nehe Ep task i
i at the point dere the Nehe Up tant piplag Jetas the Rats-up pump austles header. The eksective of the amairsts uns to emeure that pressere from the WBT at this tie te petst useld alunps he grestar than the Mats up tank hydrogen overpressure. This sesid ensure a solum of unter util alugps entst en the nake up taak side.te provost todrogen gas from asterlag the oestles 1
f header. The actual level of unter estatatand as the Nahn Op task side useld be directly sat en the W5T level. actual ECC8 fler rats and resultant Itas lesses in 14' and 6' WIT supply Itses.
As topiled abeve, the level asistaland en the Nake up tant side will very dependtag en the actasi essettiene to the WBT dartog a dree deus at mastes EECS fleus, the y ptsta L. For esegle, tank 35" Law Las louel alars seuld assur at a 357 level of apprestentait ft tf enh one Rebe Ep pup per W57 supply Itas is ts.servies. As WIT levet decremens, the lesel.as the Rake-up tank will evestes11s ge off scale leu. As the W5T level asuttenes to decrease the NEtf% tank will septy. In thst; if tEt 8 ft MIT sulp eser -
petst was reached and fell IECS fleus still artsted, a eehen of unter greater than 6 ft ses14 still entst to the Itehe up tank stptag prevaattag gas from entertag the settles header. At this point, the itydrogen everpressure useld have spanded te less then. I pets.
R8345 data collected free the recent perforenace of SP Est esii sempered to the 61culatten deserthed above uklah produce OP 1835. Curw s.The hydrogen everpressure apaastes seen durtag Sp 830 ses for the anst part osaststest with this evaluattes. There are soms staar differences.that teamet he felig assistand at this stas. The decreastag ohnaps hetuosa tin pletted curve and SP 1838 Curve 8 appears to be estely den ts.the fact that both surves are converstag en tore pets, based as this evalastion tt does est appear the pletted curve mesid.have esterer the anaeseptable regten of Carve 4. la additten, there is senservettaa hetit late Curve 8 to assers that lastruunat Also,,the M57 dras deus as a shale is cesservative. error for esemp Addittanal tvaluattaa taastrada As tadicated la Attachuset 1, the 5' WIT susp-over point currently provided ta 50P 08 will he further evaluated. Rake.gp tank overpressers will as taciudad is this evaluetten. See corrective actles it.
' ~ -
.. u. yi.- g Pac.r. I ec Z FR 9 4 -Ol+*l PtoffDURf D11(efe4Ncv RfPORf FOM Use this fers ta report discrepancies and seppesttens related to operatten's i
proceevres (these for uhtch feePO is Interpretatica Centact)
Forward this fers to: MARTT WOLF er 04VE JONES 1838
/OI b atV!sim:
I 9'-
PacCtcunt m: ap.
[] RED.MAKED COPf' ATTAtut0.
I M & N L/P / bast /kssts/Af.
DISCRIPANCT/ SUGGESTION:
reA4e y 4 1 e n.
/ktMssws et.tse ve c, ret rur,o us rM'- 13100 dest 7"' Ar-to" /a
- IJh%/
l.,at e. L b 2 M i n s /2 Txe W 1' d.
n tvenhLeMost e., net f er *= N Md'M-Ste !.
'ThD uenr* &
Get V &&"eise.
92'*
wtr MMLv uAs A m2 = ; 'TNC.C' Cedn 25' reWnnee w s s. A f.v. ' %
"'Y DISCittPAllCT FOWS Bf:
~
((Plant operetten3ssulater, rwtes, etc...)
Infit: Oh D JL.Je te. d BEtt:
S"' /8"Y SUPERVISOR: - fC d
titt:
Ibb94
[] Correcties to be taplemented with mest revisten. Liettatten, if any. of appitcabtitty are ilsted holes.
l [ here taformatten as Ilsted below is.needed.
Discrepancy /suppestles act appitcable as deserthed beles.
I,,,L lasertag tapet is needed en this concers. See attached correspondence.
(see helw).
Reviewed by:
Date:
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To: DFIEI,DS I
From: DJONES
Subject:
MOT TOPICS Date: 06-27-94 Time:
3:ISP To: *S500 THE FOLIDWING ARE SOME OF TODAYS, MONDAY 6/27,
" MOT TOPICS":
- RCS M2 CONCENTRATION => TO MAXIMIEE RCS N2 00NCENTRATION INSURE MUT LEVEL AND PRESSURE ARE BEING MAINTAINED AT TOP OF mmm
- SANDS 11....
PARAMETERS ARE BEING TRACKED CIASELY AND FIDTTED (NOURLY DATA POINTS) FROM REDAS DATA BY CHEMISTRY.
COPY OF 1ATEST PLOT WAS GIVEN TO THE 8800 (FIELDS).
I REQUESTED CRIMISTRY TO OBTAIN A PURITY SAMPLE PRIOR TO NEET WEEKS VENT OF THE MUT TO SEE IF INCREASED ~ VENTING FREQUENCY IS CALLED FOR.
- BACK TO RACK LION ADDS TO TME RCS ARE PROJECTED TO CONTINUE tRITIL AT LEAST 6/30.
DISCUSSIONS WITH EEVERAL PPC'S INDICATES THAT NOT EVERY AUX BUILDING OPERATOR IS AWARE OF THE NEED TO AVOID DEEAYS T* TME TEE PROCESS OF ADDING LION TO THE RCS.
IF AN ADD IS READY AT TURNOVa.s TIME CONSIDER NOLDING DVER A PPO TO CONTINUE TME PROCESS.
TME TARGET IS AT LEAST 4 ADDS PER DAY AND IS BEING TRACKED AS WILL.
- INPO IS HERE FOR AN " ASSIST VISIT" TMIS WEEK AT 3RUCE MICKLES REQUEST.
THEY ARE LOOKING AT HUMAN PERFORMANCE ERRORS AND THE PROCESS FOR CORRECTINC MISTAKES.
EDDIE MCLEOD IS THE CONTACT FOR.0PERATIONS IN THIS AREA AND WIL1 RE WORKING WITH INPC MGST OF THIS WEEK.
PLEASE SE OPEN AND FRANK WHEN-ASKED QUESTIONS, WE ARE PAYING INPO " BIG BUCES" FOR THEIR ASSISTANCE.
I EXPECT THEN TO OBSERVE HOW WE PERFORN MANIPUIATIO!!S AND CONTROL EQUIPMENT CONFIGURATION.
- REQUIRED READING IS DUE.
- BRUCE H. ASKED MAINTENANCE SUPERVISION TO IDENTIFY BY NAME ANYONE OBSERVEI BREMCING SAFETY RULES / PRACTICES AND FORMARD TO TMAT PERSONS SUPERVISOR.
THE SUPERVISOR CAN DECIDE WHAT PROGRESSIVE ACTION IS APPROPRIATE.
OPERATIONS DEPT WAS NOT ADDRESSED DIRECTLY BECAUSE OPERATORS OBSERVED WERE IN COMPLIANCE WITH EXPECTATIONS.
O m___
To: DPIELDS Prest GIIAIJ8088 amIr$ests.Nirt E2 Centrol Date: 07-2 P94 Times 12:00p originated by senauloll o7 22-94 4:02p To: *S800 i
wp This meessee is free work Dave Jones did with carrett, iets all try and maintain E2 maammatration in the seemptable region, here is a. method te carrect it if necessary.
Presently, Et is just under the sin of 25 oc eres.eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee e.e l
TO Grr ECS E215 SPEC BAD namuTT ImWER NOT 1ETEL TO 85* AIID PUT IN E2 AND PRESS Tits BUBBLE BY RAISIIIG IEUT LETEL UP.
IIEEN EDT PRESSURE M&S It&DITAIND SIIEATER TEAN 20# FOR 24 ERS TEEN CC/ES WEll? UP TO 28.9 CC/ER.
25 TEE PacCESS WE USED 4# OF E2 80 BAD TO EEPEAT TEE PROCESS TER IIEET Dht. OIICE i
TEE E2 IS AT NElf EgtIALIBRItal USMIE B500I8 DROP.
TEE OTEER FActet IS j
p IntLESS OPERATICIES RAISES IIUT LETEL CIICE A D&Y TO TOP OF BAllD TERIE PRIESUltZ j
WILL DECAY 19 BEEDIf 20# AllD. III WILL 00 OUT OF SPEC.
SAEltETT AGREED TO Do THIS SUT WEEN AIIOTEER SEIFT COIEES Cet IT SERES LIEE TEE PROCESS STARTS ALL
- OTER AGAIN.
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To: DFIELDS Fros: D30NES
Subject:
NUT H2 DVERPRESSURE l
Date: 07-27-94 Time:
7:28p To: *SSOD UPDATE ON NOT N2 DVERPRESSURE OPERATICIts.......
FIRST SONE ma
, gy TEE PAST TWO NEERS OPERATICIls NAS SNONN TMAT IF TEE NUT OVERPRESSURE IS l
MAINTAINED ABOVE 10f TEEN RCS N2 CC/EG WILL BE MAENTAINED IN TEE DESIRED i
BAND.
McWEVER, TO ACCOMPLISH TEIS OPERATICIts EAD TO EITRER s (1) 1AnfER I
NUT LEVEL, INCREASE.52 OVERPRESSURE (WITEIN THE attmauer BAND) AND FINALLY, RAISE LEVEL TO TEE UPPER END OF TEE LEVEL BAND TO "SOUEEEE" TEE BUBBLE.
OR (2)
' BYPASS TEE E2 RESULATOR PER OP=402, TO GET PRESSCtE l
UP TO ABOUT 25# WITE LEVEL NEAR TEE UPPER END OF TEE BASED.
NOW TEAT WE MAVE SNOWN TEAT THE REQUIRED RCS N2 CONCENTRATION CAN BE ACRIEVID BRUCE MICELE MAS DIRECTED TIBAT IIIGINEERIIIG, (PAT IIIstAN), ADDRESS ISSUES 30 W.
j CAN USE TEE E2 RESU1ATOR TO ACitIEVE TEE DESIRED E2 PRESSURE (WITEIN TEE i
av.vmantF VALUES OF TIEE EDT CURVE) WITMOUT PERPOIIMING TEE EVOLUT!cIIS t
DESCRIBED ABOVE.
PAT IS WORKIIBG OIf TEIS ISSUE, BUT IN TEE MEAIITIIEE THE FOLWWING ACTIONS WILL IIAXIMIZE N2 OVERPRESSURE WHILE CONTIt0LIIIC TIRE NUT IN A NORMAL MANNER:
THE DAYSHIFT SMIFT SUPERVISOR SMOULD DAILY ADD E2 VIA THE RESU1ATOR AND THEN MAKE AN EQUALIBIRt3t ADDITICII TO TME MUT TO RAISE LEVEL TO TEE UPPER l
ElfD OF TEE LEVEL BAND TO MAIItTAIN A MIGIEER AVERAGE ItDT OVERPRESSURE WHILE l
COMPLYING WITH TITE ItUT CustVE LIMITS.
i ONCE A WEEE CIIIMISTRY SAMPLES TEE ItDT.
OPERATICIf5 SIIOULD TitEN REP 1 ACE l
THE N2 LOST TO SAMPLING AllD N2 LOST SY AS50ItPT100t IIETO Tite ItCS.
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I OP.401 1
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FLORIDL POW S CORPORATI M 1
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i NRKEUP A S PURIFICATION SYST M t
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TNIS PROCDWE A00 ESSES SAPETY RELATED COWOIWifS i
TNIS PROCDURE ADORESSES ENIROIBWNALLY ODALIFIB (80) COWOINITS J
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APPROVED M: QterpretattenCantact j-
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(5i RE N FILE)
M"kV DATE:
1 IIITERPRETAfts COEACT: Superviser. Ilmelear Operattens Aestatstrative Rift i
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4.4 II1TBI RLER ACTIONS DETAILS 9
upm Cheness la perificaties line ups dile en Decay Nettsten effect vessel level and the operetten of the Desay Nest system.
4.4.1 Select '9 LED M*
e _ RCST-3A selector outsch to desired a _ EST-38 4
E Bleed Tank e _ RCET-3C M Pull Mandle Up
/
1mittal/Date 4.4.2 Select M -112 Centrol switch to SLHD
/
laittal/Date 4.4.3 M ptif decreases to leu level alans.
3 desired letdeus is i
completed.
select M 112 to In,tttal/Date 4.4.4 Place 'SLHD MODE' selector switch in the pushed in posities
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laittal/ Data s
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op-est new. 7s page 35
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ACT1 tug DETAILS NBft: Changes ta portfiestlan lies ops iM1e en Bossy Nest een effect vessel level and the operetten of the testy heet
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SFstema s
1 1
4.5.1 Detemtne required amount
- e. Refer to OP.304 i
of Feed 1
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lattnal/D.
- 1 4
4 4.5.2 All9n Satch Centre 11er 1.
Select ' Start / Step' evitch to i
STOP 4
l Repress ' Clear' pushbetten f
A cest ' Batch Stas' theshowitch to desired flew AC=
P=.hutee.'
theshowitch to destred 2.
presheteous setestat 5 elect ' Start / Step' arttch to l
START I
/
4 latt141/Date 4.5.3 Select *FEID MODE' selector evitch te desired feed Source AE Pull Handle up
/
Intt1al/Date 4.5.4 E. selected feed'searce is e
a 8457, e.,,,.,, START CAP.1A llER Open discharte valve E
a W start an CAP o _ ITART CAP.18 i'
/
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latttal/Date I
4.5.5 Place both postfilters in e Open postfilter tselatten i
service valves 1
, M -90
,,, M -91 l-
_ M.97 M.95 4
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Insttal/Date i
t op.4st nov. 75 P.,e x I
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{ (.5.6 purtftcatten Feed POV i
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e 4.5.7 Adjust flew rate estag l
VALVE LOAD 1115 Colml0L on J
the tatch Centre 11er to i
desired fleu 4,3.3 1833 Nff 1pel essches t
j oestred level.
M CLOSE MN 103 1
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57 was opened, 4.5.9 i
CLOSE CAV 57 i
STOP renning CAP i
i 4.5.10 Place the ' FEED M*
i selector suttch in the pushed ta postttee j
4.5.n nesters postfttter linew I
l as desired i
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= mae maatties g,gg j
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J 4.10.1 festrod s
80 TO Step 4.19.8 sentinue with mest step went Isif to WEDT j
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i 4.19.2 Essere as other dratatag er venttag operettens are to progress ta the easte las system 3'
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Select tilf 1A OR desired 4.19.3 Waste las Decay Tent as directed by Chem. Dept.
l 4.19.4 perfore Valve Alignment for vaattag flif l
4.19.5 Vent 1817 I
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4.19.8 1RER apprestaately 1 l
To estas have elapsed.
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1 4.13 m.1Birtus aim tas AIBITI M (Cent'd)
ACTIONS DETAILS 4.19.7 Reseve Waste Sas Decay e P1 selector evitch ta fant se)ected in IK Stop 4.19.3 from service
's ace desired tank in service Y Ened WasteSasDe$kaak.!ser
/
Anitial/94 I 4.19.8 g}i ssere a
- 1. _
er to Curve 3 of OP 1938
- 1. -
M
. El Centrol se, =.
- 3. _ M ER M is at desired the fellestag:
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&a151al/ Data 4.19.9 E
addities with the
- 1. _ Determine mestaus M rPed tut'fi;:!
- 1. _.f Aer "'" " '
5t WA Loca11 seen M -492, Open M 1 N ES
- 3. _ Add desired
- 4. _ mit it'"l of
.e 5eN M.4
- C 1
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lattial/Date 4.19.10 overpressure i
- 1. _ Determine anstema M Nerothe NOE 4.CO.esiredN
'WA of gs -
1: = g ;; ;;s:;;='stih?".i!H i i
lattial/D4Le OP-402 Rev. 75 Page 78
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To: DTIILDS 1
From: GNA1AION j
subject: Journal Date 0s-09-94 Time:
2: opp i
To: *.700RNAL i
j There have been some questions regarding the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> rule.
It is still alive and well and takes the DNPO approval to exceed 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.
Euomeding 1
i 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> will be considered if no viable alternative can be found.
I j
instructed clint to attempt to schedula such that we do not aseeed 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> for a 7 day period.
If in doing this, it will require scheduling a person i
to work hours that he/she would normally be sleeping (ie the fatigue factor i
would be high) to attempt an overtime deviation authorisation.
The point i
is it is better to keep someone werking.a set schedule one extra day-or a j
fow extra hours than to take someone who would normally he sleeping on that day and ask him/her to work.
When attempting to sobedule around the 72 l
hours, all attempts will be made to get the concurrence of the personnel j
involved.
It is not the point to limit the total number of hours, since it i
will probably wash out as either premium time or overtime anyway.
The j
point is to not ask our personnel to work more than 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in a seven day a
period because that is where we set the limit on where we are willing to i
push the human body.
Admittingly, some peop1s can handle the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> and f
more and some get more fatigued.
Rather than try and label our personnel.
as to their physical / mental agility after 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, we set the standard.
j 1
We will be making a change in the clerk's shifts.
Andrew will rotate onto l!
days and Marlene onto mids.
This change will be effective this weekend.
The reasons behind the schedule change are several but suffice it to say it I
will provide some cross training.rr. duhities, help put some emphasis on department trends, and help to alleviate some issues that will work out for the best for operations as a whole.
Andrew will start lee.ning the schedule which Marlene has built into an exos11ent tool for our people.
3 Marlene will perform the duties of the mid shift and all tnat is necessary to maintain department records and plant status.
She will also help me I
perfora some detailed trending of key indicators in ops.
I hope ovaryone i
can make this transition a smooth one and give both your best support.
There is an ongoing discussion on the issue of 52 pressure in the NUT.
I have talked to Mark V. and understand the concerns.
I discussed this with Bruce and.7erry campbell and will be working.to resolve the questions.
It i
is important, and Bruce has asked, if anyone has a concern, please write it down and send it to me.
Even if it is not now, I need to get all perspectives of this issue so we can address the right areas.
It appears what has been addressed has not satisfied the concerns to date, so I need l
to be absolutely clear on the questions.
Bob Murray has volunteered to look, in detail, at the deleted computer i
i alarm summary.
The purpose is to do away with unr=aa==mey alarus so that j
the real ones are not diluted beyond recognition.
He will need same j
support in being I asked him to get at least a second opinion before ha 4
goes to Barry Baumgardner to get the points deleted.
I also asked that I j
be kept informed, not as an approval, just so I can keep aprised of the progress.
Its a good project and I command those who questioned the need j
and are taking action to correct it.
4
]
I A concerted effort will be undertaken to do away with " operator j
work-arounds".
I need your input.
Please send me any and all comments on
- 4. ~..~. - 4 w...~.a
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Gd subject:
Summary of actions required to implement the new make-up tank hydrogen cover gas pressure limits (Ref Calc. I-90-0024) such that a 25cc/kg hydrogen concentration can he maintained in the RCS.
NOTE: There are two separate issues concerning the potentialv damage to make-up pumpe resulting from an increase in make-up oever gas pressure. These ocnoerns are as follows:
1.
During normal operations, will raising the make-up tank cover gas pressure to the limit specified in calculation I 0024, cause hydrogen gas to osse out of solution in the make-up pump suction piping and collect in the high point of the static portions of thLs piping. The aaaamm is, if a buildup of gas occurs in the BNST piping common to the normally running aske-up pump, upon an NPI actuation this gas would be transferred to either pump in the common section header and potentially cause pump damage (Ref: IN 88-023 including Supplements 1 and 3).
- 2. At some point during a IACA will tho BMST head ure he overcome by make-up tank head pressure. This tion could potentially occur as the suST and make-up tank inventories are depleted to a point eventually allowing maka-up tank cover gas to enter the NPI pump suction piping common to the make-up taak (Ref: IN 88-023 Supplement f 2).
Actions required for item 1 above:
a.
Per the Nuclear Operations Engineering response to NRC IN 8s-23, including supplements 1 and 3, the potential for hydrogen gas to collect in the static piping of the non-running make-up pump may exist at CR3.
Per an NPSE walk-down of the make-up pump suction piping, high points do exists in the BNST piping that can trap gas. NPSE will view the high point sections of piping with an infrared scope to determine if any. gas is currently i
present.
If this method of ~ ges detection is deemed reliable, it will be used to monitor these high points en a routine bases following the implementation of the new make-up tank cover gas pressure limits. If this method is not considered reliable, than semples will be taken from high point vents. Chemistry and NPSE will develop a method to quantifying the trapped gas. Routine sampling will then be performed until it is determined that a problem exists.
If a gas buildup is occurring, routine venting of the high point vents will be required.
NPSE will perform the infrared analysis on 10/27/92.
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Actions required for iten 2 above:
1 a.
Complete the review of GC calculations 1-90-0024. The
)
Nuclear Operations Technical Advisors are performing a j
final review of the subject calculation. Per conversatio9 j
with Rill stephenson, this review will be completed 'by J
October 23, 1992.
ss
)
b.
Following the above review and subsequent acceptance by 1
the NOTA's, a revision to 07-1035 -(ourve GS) is required.
I curve #8 is the maximum make-up tank pressure vs. indirstad
}
water level curve.
i c.
calculation I-92-0034 recommends that only one of the two make-up pumps normally lined up to the make-up tank, i.e.
1 NUP-1A or 15, be operating during a IAch when the i
piggyback mode must be established. When this analysis was performed, all three pumps could be operating at this i
switch over point;
- however, recent changes to the j
Engineered safeguards Actuation procedure (AP-380 now requires that only two of the three pumps are run)ning.
i l
Operations should review AP-380 considering the. make-up j
tank pressure concerns for any additional changes required.
d.
calculation I-92-0024 provides the data required to produce a new make-up tank level vs sever gas pressure curve. The curve will represents seceptable normal plant operations that do not endanger make-up pump This ourv(EFI) operation in the event of a lock.
e does not address the hydrogen cover gas pressure required to maintain the 25 cc/kg RCs sencontration. A calculations j
currently being performed by Rocky Thompson will determine the actual make-up tank hydrogen cover gas pressure required to reach 25 cc/kg. Dale Mc collough is working with Rocky on specific plant data needed for this calculation. Based on the results of this calculation, a l
MAR will be required to raise the make-up tank high l
pressure clara set point.
Per conversation with Operations, raising this set point is anooptable and should not produce any operating ooneerns. The new alarm l
set point will likely be approximately 3 PSIG higher then j
a conservative value for required sever gas pressure.
i Because the make-up tank is part of a dynamis systen, j
there any be short periods of time when the operating j
pressure will exooed the-tank pressure vs level curve and times when sufficient hydrogen is not present. At this point in the evaluation phase, we believe this should be acceptable.
I An REA will be written to request a MAR to change the high j
pressure alarm set point however, the cover gas pressure j
requirement must first be determined. Also, operations 1
i j
i
i must by into the proposed set point change. The plan is to write the REA by October 28, 1992.
e.
A revision to OP-402 will be required to incorporate the proposed new make-up tank set point and any details required by operations to incorporate the new higher operating tank pressure.
f.
A revision to AR-403 will be required to incorporate the j
new higher make-up tank set point.
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- INTEROFFICE CORRESPONDENCE h t h k n e w :nyft(x b O M Nuclear flant Technical, Sussert Matt fan. san arties au:
neisamm
$vtesobtj.h.tc SUSsECT: Make Up Tank Hydrogen Overpressure G
w h g. :.iu 't.
T0: B.J. Hickle DATE: ' september 2, 1994 NHS 94-0429 On August 5th,1994, a meeting wtth Operations, Chemistry, SNES, EE and WT5 was
~
held to discuss current Make Up tank everpressure condittens. The purpose of the meeting was to determine what was required to increase everpressere se desired RCS hydrogen concentratten could be maintained with minimal Operator burden. The options discussed are provided below. It should be noted that none of these options will reconnend changes to Op-1938, Curve 98. Engineering believes this curve is accurate and reasonably conservative to protect the Migh pressure. Injection pumps from hydrogen gas intrusion in the worst case Larne treak LotA. In additten, corrective action #8 of pR 94-149 is currently is. progress to preytde technical bases for the gWST swap over point. During this analysis, Make-Up tank everpressure per Curve #8 will be re-evaluated. This action is scheduled to be completed by September 30,
~1994.
~
tackaround:
There are two conditions which limit the amount of hydrogen ever maintained in the Make-Up tank. These conditions are as follows: pressure being 1.
The first limiting condition is based on the LOCA analysis. In this analysis, the differential pressure between the Make-Up tank and W5T was evaluated during maximum ECCS flows at various Make-Up tank overpressures. The object was to determine the maximum allowable tank everpressure such that gas free the Make-Up tank would not enta? the Make-Up pump suction header. This condition must exist down to the point where ECCS pump section is transferred from the SW57 to the RB sump due to a low BWST level. Np! pump operation after the. transfer would require an Lp!
piggyback line-up. In the piggyback mode, gas intrusion into the Make-Up pump suction header is not a concern due te Lpl discharge pressere.
This analysis resulted in a revision'to the Make-Up tank level vs. pressure curve, (Curve it of Op-1038). The curve is based en the expaasten of a known volume of hydrogen for an increasing or decreasing Make-Up tank level. Therefore, for the LOCA analysis it is acceptable to raise the hydrogen overpressure to the curve at any indicated Make-Up tank level.
- 2) The sedond limittag conditten f$r hydrogen everpressure is based on section.
111.J of 10CFR50 Appendix R and the Appendix R fire study.Section III.J states that operator action cannet occur for eight hours to achieve safe shut down unless emergency lighting is provided for the required action. The study postulates a fire in the Auxiliary building which causes fRN-143 (Make-Up tank hyd supply valve) to fail open. In addition, a plant trip is postulated to occur.
cannot take credit for operator action to manually isolate the Make Up tank hydrogen supply because there is no emergency Itghting to the isolation valves (ftN-4g3 or 494) on the 119 ft Auxiliary Building. Also, the fire any prevent access to these valves.
Ther.. fore, the current setpoint of MUV-491 (hydrogen supply regulator) is limited t the ight hour period. Following the trip, make-up to the RCS is required
1 j
page 2
{
September 1, 1994 j
upflg4-0429 for inventory control during plant cooldown. With IEN 143 failed open, hydrogen i
ovespressure on the Make-Up tank will remain at the setpoint of ftft 4pl while the l
Make Up tant level decreases. The analysis evaluates Make-Up tank level with respect j
to bd5T level during cooldown while maintaining Make Up tank overpressure at the regulator setpoint. The regulator setpoint ensures that hydrogen gas will not enter the Make-Up pump section header within the eight hour limit. Operator action would
]
be required to isolate hydrogen to the tank after eight hours. In this Appendix R j
scenario, Curve #8 of Op-1938 will be violated. However, because Curve #8 is for i
LOCA considerations.and an Appendt R fire is not assumed to occur concurrent with a l
LOCA, the violation of Curve #8 is acceptable.
j' Oetions ta increase.hydromen overnrassurg; Option 1: Based on a review of the current MUV-431 setpoint and the analysis I
performed to establish this setpoint, sees of the conservative facters used in the analysis can be relaxed. The current 20 psig setpoint would allow apprezimately 14.2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> before operator action would be required to prevent pas intrusion.
If the time frame is lowered to the miniemm 8 hour9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> period, the setpoint can be j
increased by approximately 1.2 psig. In addition,' the setting of fGN 491 per the Refuel 9 MAR funtional test can be revised to allow the regulater setting to be based on indicated tank pressure. The Refuel e MAR functional test set the regulator at a conservative 13.5 psig at a Make Up tank level of 70 inches. However. the i
actual tank pressure was 17.7 psig. This difference is due to lasses in the hydrogen supply line between the tank and the regulator and due to a drastic reduction of gas i
l flow to the tank as pressure approaches setpoint. If both the above changes are made, the new regulator setpoint would be approximately 23 psig. This would provide the ability to increase tank pressure from the Centrol Ross to the curve at approximately 74 inches without annipulating Make-Up tank level. At present, pressure can be increased to the curve at approximately $3 inches but then the Make-Up tank level must be increased to increase pressure to achieve 25 cc/kg.
4 Although this option is relatively easy to implement and it will improve the ability 2
to add hydrogen to the hake-Up such that the 25 cc/kg RCS hydrogen concentration can be maintained, the overall improvement is marginal.
Option ti The hydrogen addition regulator setpoint could be raised if a redundant isolation valve was added to the supply line. This valve could be operated from the j
Control Room providin MUV-143 to fail open.g its power is'.reuted independent of the fire zone which caus l
The addition 'of a manual valve with emergency Itghting could i
also be added and. accessed free outside the fire zone. If the setpoint of IGN-491 is i
raised to 24 psig, the redundant valve would have to be isolated within
}
approxinhtely one hour. The kst location for a redundant valve appears to be on the i
119 ft elevatten of the Turbine Building. The hydrogen supply line is routed l
approximately 10 feet above the 113 ft Turbine Building floor, This option will also improve the ability to add hydrogen to the Make-Up tank and i
maintain the 25 cc/kg concentration. However, like Option 1, the taprovement is marginal. Also, the legistics of installing a new valve in the hydrogen supply line i
at power could be camp ex. Temporary hydrogen supplies to both th: generator and
{
Make-Up tank would be required.
i Opt *in 3: The restoration of MUV 64 with a chain operator would allow the Make-Up
{
t? he :. n11) inists:
!a",dy eveil tia te -t "oV 6ain *N ntnt of a fire. Because erergency lighting is el es t
the igetet4ea eevis eeeve v4+h4. ok. m h+
haae i
l 1
i.
Page 3 i
september 1, 1994 i
IFT5M-0429 3
i stedy assumes a fire on the 119 ft of the Auriliary Building could cause M 143 to fall gen. In this scenario, the 95 ft elevation of the Austliary Sullding remains
}
acce sible. M-64 is on the 95 ft elevation. If the fire exists on the 95 ft l
Assiliary Butiding then 9g4143 would be unaffected.
1 i
Based on preliminary IIDE analysis, M 64 would have to be isolated within approminately 15 minutes of a fire if W following conditions entsts: A fire on the lit ft Auxiliary Building, a Reactor trip, and either the loss of Make-Up' tank indications or a high tank pressure alars occurs due to M-143 failing open. The isolation of M-64 in the 15 minute period is based on the nake-Up tank being able t
to supply an average of 140 gem for 15 minutes even if the tank level is initially-55 inches (Iow level). Once the pug suction header is aligned to the BW5T and i
IRW-64 is isolated, the pas binding concern no longer exists. Also, the hydrogen
{
regulator setpoint (M-491) would no longer be an issue.
l The isolation of M-64 could be restored to the Control Room and a protected control board switch could be installed. However, the restoration of power and air i
would be complex and very costly. The valve would have to be protected free spurious j
closure in the event of a fire.
i la addition to installing the chain operator, a MAR would be required to raise the j
setpoint of M-491 to ensure operations can maintain a minimum ef.25 cc/kg hydrogen concentration in the RCS without Operator work around. The installation of the chain operator and setpoint change would fall into the category of a minor MAR.
i Canclusient Based on preliminary evaluations. Engineering prefers insta11 tag a chain operator per option three. The chain would be locked to the wall to prevent unauthorized 3
i valve operation. This would require a revision to SP-381 (Locked /5ealed Va),e Check l
List procedure). Also, AP-800 (Fire Protection procedure) would have to be revised l
to incorporate the isolation of M-64 in the event the conditions described above j
occur during a fire.
ff_
= -
4 J.P. Hinman, Nuclear Project Engineer j
nuclear Plant Technical Support
.V. Campbell, Manager j
nuclear Plant-Technical support
+
i jph i
l sc:
- 5. K. Balliet s
C. W. Bergstrom i
E. H. Malnen j
J. R. Masada i
P. E. Saltsman i
K. D. Vogel
}
P.ecord: P.anagement 1
1 i
i l
?
OBSOLETE
(
Rev. 21 M!f/
[ffective Date i
4 s
i s'
ANNUNCIATOR RESPON$t i
i i
AR 403 4
f, FLOR!DR POWER CORPORATIOt CRYSTAL RIVER W IT 3
.i PSA N ANNUNCIATOR RESPONSE t
i 1
TNIS PROCIBEE ASBEESSES SAFETY RELATW CENPOISITS i
i i
4 APPtottD BY: late rotatt tact 1.-
+
3%fWFILE) 4/h/N oRTt:
INTERPRETATION Cal 1ACT: Itenecer Nuclear Plant Operations
~
l
-+
i
}
)
thttostar i i
(Pete 121 of IH) 3 l
P54 7 ANNUNCIA10R RESPONSE P5A.T.04 06 N.04 06 I
l 4
MAKEUPTN PRE 55 MIGH/ LOW j
j l
s EVDIT POIllT 1062 i
I IWitATED CONDITION:
f l
e MAKEUP TANK PRE 55URE > THE CVERPsE55URE VALUE CALCULATED BY THE PLANT l
COMPUTER.
i i
l REDUW4fff IMICAT10Il WHICH WILL vtRIFT ALARM:
o sal. slo.LIR1, palf LEVEL / PRES $URE REEORDER.
e COMPUTER POINT 5 1359 Am 1401.
OPERATOR ACTIONS FOR A VALID ALA M:
1 o ENSURE IGN.141, InfV.143 CLOSED 1
o REDUCE PRES 5URE WITHIN LIMITS OF MKEUP TANK PRES $URE/ LEVEL CURVE j
OF OP.1038.
l 4
f DISCUSSION:
THE VALUES OF THE COMPUTER POINTS ARE INPUT TO A CALCULATION WIOl ACTUATE 5 THIS EVENT POINT 1891 IRif LEVEL / PRESSURE Comin4TI0li ARE SEllIE
)
OPERATED IN THE UNACCEPTABLE REGleR OF CURVE S OP.1938.
{
s I
l
'REFERDICES: DRAWIIIG 208 041.IIU.47.
SEN5tIIG ELEsIENT: CSIPUTER POINT 13H Ale I481 e
i i
j AR 403 new. 21 Page !!3 I
i i
i
i AttOchment 9 1
3 4.3.2.2 Annuncistar Alam Reseense fAR) Procedures i
4.3.2.2.1 The purpose of the Annunciater alare system is to warn the Operater of any abnemal canditions in aanttered systems.
1 4.3.2.2.2 Operattens permnel shall know the reason each tiluminated i
annunctator 1r their area of responsiblitty is in alam.
1 i
- 4. 3.2.2.3 The Centrol Board operators should'announce recetyt er clearing of j
annunctater alarms.
l 4.3.2.2.4 Annunctstor Response precedures (AR's) shall he attilzad as follows:
4 i
1.
Annunciator response procedures shall be used to diagnose alares I
not espected (not directly related to intentional manipulatten of plant controls). and for any alars that the operators are not l
espitettly fantitar with.
2.
The Centrol Board Operators shall interpret and verify that annunctater alam signals are consistant with plant condittens.
i l
4.3.2.3 General praettees for precedure lanlementatian 4.3.2.3.1 AI-400A, Description and General Adstatstratten of Plant Precedures.
Section 4.1 Requirements for Approved Written precedures, must be utt11 ed to determine if a precedure is required for an E10uff!ON.
4.3.2.3.2 Written procedures are also nee' ed for those EVoufTIONS that umuld d
affect a change in the system fleupath or operating parameters.
e The boundary betusen an *Evouffler and a ' TASK' eay not al be clear and, as such. It is espected that plant operators encounter situatiens uhers the adequacy of eststing procedures may be guesttened
- a. In these instances, ' shift supervisten will make the deterstaatten as to uhat procedural requirements are app 11 cable.
4.3.2.3 3 For procedures perfemed by Plant Operattens. the Shift Superviser 3
er his designes shall ensure the principles of Enclosure 19, pre-Job Briefing Checklist, are ast.
Using his judgement h regard to plant safety, the $300 may
' e elect to formally complete Enclosure 13. pre-Job triefing Checklist, for the appitcable procedure Al-500 Rev. 85 page 45
i l
Pat & Gary's Expectations
(
1 CHALLENGE THE PROCESS 1
1 LHe is never stsac: strive to cormnuously irnprove how Nuclear Operatio$s does l
e busmess as a team and how your job is done individually.
3 i;
I Develop the ability to criticas your own work and have the courage to face e
l facts even those whsch may be " unpopular".
i Develop the capacity to learn from esperience yours and others. This reevires i
e j
objectivity and a withngness to admit mistakes so that costly or unsafe errors are not repeated.
4 4
j Seek to MDggggg[ the reason (s) why things are done in a certain way - the e
j reason (s) may no longer be valid.
i e
Be an annovator and initistor of needed cnange - svoid gettmg trapped by j
i bureaucretac pohey and the status quo.
e it's 0.K. to guesuon any *.,.i...... " (including reguistions and company I
pokcy) that doesn't make sense. Regid and bilnd obedience is not in the best I
interest of nuclear safety.
I Avoitthe traps of *bissed thinking
- and
- pre-established value systems".
e They will rob you of the ability to see things clearly and achieve results.
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I i
l 4
t f
o.
e Espectations 1
1 a
a i
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j l
TDdE LDE - EEFIEMBER 5.19N MUT DRAWDOWN EVOLUTION i
4 l
i TJat AGEIGR i
4 0400 Imel raised m 83*. Pnamare insnaamd a curve limit.
0425 Imel raised e 86".
0447 Imel documme manad - psessere escames lindt.
0501 Inval dennese smopped at 55*.
0518 Imel acrease maned.
0522 Pressme is back widda limit as level is incimanad-Imel is 59".
0533 Imel acrease is stopped at 80*.
0648 MUT pressee is vexed from 27 pounds to 21 pounds at 81" level.
Total Tune MUT pressme exceeds limit = 37 minnes E
V a
J.
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1 1
i PR0BLEM R E'P O R T PR 94 0267 m
{
PART 4: Ewausar3ON of CAU5E. CAP. Age CBNPtssams r av TIIE OuaLITY Pe0385 s--
- ^'__ m r-j tu Cmments4 i
i Based on a review of the Cause Analysis described in Part 3 Section A and a discussion with involved personnel, the Corrective Act1on Plan described in Part 3 8 is considered acceptable.
t 3
Please forward documentation of the completion of each of the Corrective Plan Items I
to Quality Programs.
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EELOSIRE 2 nassan eenE ceRPout2m gmL21Y Assa mCE RICORB Traum YvaL I
ATT Bff1 M s RECDEDE MANASDENT SECTim j
CEVITAL RIVR WIT M. 3 hecalent Nerieaf ketotd for neWM e accants TamenTita:
PA l'/ 2C 7 - TP- / Alske ks IN. lttH uh* E'in!>V *
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The Osality Assurance Records Itsted above are herehr transmitted for l
inclusten is the Plant Quality Flie.
i These records are esselete and in asupilance with the requirement of Florida 4
l Power Carporatten's taality Progrus.
DATE /
RECE!FT amum rnerurwT ST:
1 P.
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DATE II II ON Manager. Nuclear leforestten Gesaurtss/Destgese RmIRE RETDITim 0F TIESE RECORDE 15 THE RESPME!BILITT OF BECOME NMIASDENT.
AI-Ines Rer. 25 Papa 79 (LAST PASQ e
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i ew_ =uy premsun Tm an tvottrtfan curert in Answer the fs11 ewing pleas ta deterates if this. procedure describes an infreemently H.Te. __ test er eveletten.
I H mahle to asks a deterutsatten following complettes ef this checklist, M censult the INFO for flaal deciates.
1.
Does this precedure cmate a situaties that can affect the cars, reactivity centrol, or the reacter protection systant
@ NO E the answer is as, this checklist is complete and it is El to be nc uded to the procedure package.
l Yt3 2 tha assuer is yes, RER SOER 9141, Camdect of Infreemently perfereed Tests or Evolutions (available from the tiens Technical Advisers), should be reviewed to he p assere adequate controis are ta place for the optistzatten of'reacter
- safety, A E contians on with this checklist.
2.
Does this precedure create an evolutten met covered by an eststieg moraal er abnormal operating procedurst am
=
3.
Does this precedure create an evolution that will soldes be performed, even though it is covered by an existing morual er sheernal operattas precedurst m
m 4.
Does this procedure create an infrequently performed surveillance test that tavelves campiteated segnanctag, or placing the plant ja an unusual configurattenf l
l 5.
Does this procedure reestred the use of a seccial test precedure in conjunction with existing operating er testing procedurest m
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Rev. 0 Effective Date d'
o TEST Penrms PR
- 94-267 71 FLORIDA PONER CORPORATION CRYSTAL RIVER UNIT 3 MAKEUP TANK PRESSURE LIMIT CURVE VERIFICATION
{
THIS PROCEDURE ADDRESSES SAFETY RELATED CIBRBIE
-9 APPROVED RY: INTERPRETATION CONTACT DATE:
INTERPRETATION CONTACT: Manager, Nuclear Plant Operation
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TART 1 Of CONIEN15 O
f.Eni, 1.s MatRE..........................................................
1 i
2.o arrrermert.......................................................
I 2.1
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1 2.2 C 6a K.. fi TM Tii s li%...............................
1 2.0 P88er"""I m 1ET1ou.........................................
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2 2
40 imi=ElioN1..................................................... p3 5.0 FfR I N tlp ACT' m.......................................
3 5.1 c m
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4-PR 94 267 TP.1 new, o p.,,
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1.D PURPOSE The purpose of this test is to verify the accuracy of OP 1038, i
Curve 8. *Mastaus Makeup Tank Overpressure". This procedureSull) provide "after the fact
- documentation, review, and approval of the testing previously performed, which served as the basis of
.probles Report 94 167.
F.e amaswrt 2.1 DFLDerTIME REFEREEES 2.1.1 OP.402 Makeup and Purification System 2.1.2 OP-1038. Plant Operating Curves 2.2 DEVELOPMENTAL REFERENCES 2.2.1 CALC i 190 0024 Rev. 5 2.2.2 Probles Report # 94-149 2.2.3 Problem Report 8 94-267 I
3.s ri u i tr-- inimafien 3.1 DEstRIPT10N 3.1.1 Maximum Makeup Tank overpressure must be limited to prevent hydrogen entrainment in the suction ~ef the Makeup Pumps during a LOCA. The martaus overpressure allowed at a MUT 1evel of 55" is derived in Calculation 190-0024 Rev. 5. The methodology used includes calculating the MUT press conditions which would result in ine worst case LOCA flow olumn of water in the MUT outlet line. This safe press 2
1 w line is then compressed to a level of 55" in the MUT utt the ideal Eas Law.
OP 103bCurve 8 is generated by expanding and compressing this safe 55' pressure over a O to 100 inch range utilizing the Ideal Gas Law.
PR 94 267 TP 1 Rev. O Page 1
f 3.1.2 Data. collected during SP.630 and documented in PRf M-149 suggests i
that OP 1038 Curve B is noncenservative. If the fllf gas space j
behavior can be described by the ideal Gas Law, which is an v assumptten of the calculattens, then the felf pressure response to 1
{
a level decrease should parallel the limit curve. The actual pressure responst curve converges en the Itatt curve uhun pressure is in the acceptable region and level is decreased.
1 3.1.3 1
This test will initially fill the IllT to a.. level of 86".
Itif j
pessnare will then be increased to the curve 4 Itatt. The systen will be allowed to stablitze for approxiestely 30 minutes.
The j
Inff level will then be bled to a level of 55".
r, The IRif will then be reft 11ed to normal operating level, and fElf pressure vested if necessary to remain within the Cerve 8 Ilmit. Durtag the test, l
the A n tilary tutidtag operator shall be stattened in the AB prepared to vent the falf if pressere is above the limit and a LOCA Data will be collected utt11 stag.the REDAS system.
occurs.
4 3.2 LIMITS AND PRECAUT15t$
3.2.1 If during the performance of this test,1817 pressere is above the limit.of 071038 Curve 8 and indicattens of increased RC3 leakage occur. immediately terstaate the test and went the IElf to return MUT pressure to within the lietts of OP-1038 Curve 8.
3.2.2 For work located in Radiation Centrolled Areas, due considerstles aust be given to the ALARA program. This any result in a determination that special preparations and/or precautions are necessary.
, 3.3 ACCEPTANCE CRITERIA 3.3.1 Actual IllT pressere is less than er equal to the pressere Itait of OP.1038 Curve 8 at all lerels within the test range.
3.4 PREREGU151TES 3.4.1, The At operator shall be stationed in the Aust11ary tutiding prepared to vent the filT if nottfled by the Control Room.
PR 94-267 1P-1 Aev. O Page 2 e
r
4 M,
le i d itous 4.1 Il at any time during the performance of this test indicattens of increased RCS leakage are present, ITER tamediately terutnate the test and went the MllT if necessary to return 187T pressere to within the limits of OP-1038 Curve 8.
4.2 Ratse M level to 86* per OP-402 Section 4.5.
4.3 Raise MLN N, pressere to the limit of OP-1038 Curve'8 per 0P-402 Section 4.13.
c.
4.4 Allow the system to staht11re for appremiantely 30 minutes.
4.5 Lower MLIT level to 55' per OP-402 Section 4.4.
4.6 Raise Mlli level to normal operattng level per'0P 402 Section 4.5.
4.7
/ Mlli pressure is above the liett of OP-1038 Curve 8, vent.the MllT per OP 402 Section 4.19.
4.8 Collect REDAS data on camputer potats X-389 (MLif Level) and X-401 (191T Pressure) on a one minute frequency for the period of the test.
4.9 Utilizing Excel, preFort an "X Y" plot of the collected data to evaluate acceptability.
5.6 FatInu.up AcT1out 5.1 CONT 1HEENCIES 5.1
$NJi a Problem Report should be generated.I the Acceptan a
PR 94 267 TP.I hv. O Page 3 l
4
l 4
}
To: DFIELDS From: GRALNON j
subject: Journal t/18 Date: 09 18-94 Time:
4:21p
}
To: ' JOURNAL Bruce will he coming to discuss the events over the last week in reference to the MUT pressure curve.
Everyone knows some details
,of what happened. so to dispell any rumors, here are some details.
t
. First, A-shift is not "in trouble".
We, as a department, were brought into the lime-light by an ' action to raise attention of a potential satety issue. The methods to raise this attention brought up a philisephical issue we must all be clear of the expectations.
When I say
- all",
I as != m== of all of CR-3 annagement and j
workers, not just operations.
The philosophy is in how we deal with operating curves and limits.
First, when given an operating curve, we will comply with it at all times.
Becant, we must give j
to operations curves we CAN comply with and when complied with assure the safety of the plant.
Without both of these, we, as a 1
plant, let ourselves down in attempting to comply with our Code of f
Ethics.
The safety of the plant is utmost, unfortunately drastic measures are felt required to bring ' safety subjects to a head.
j Also unfortunately, in bringing the BErr issue to a head, we passed into an unknown region of compliance, into clearly unacceptable j
regions of a curve which was already thought to be non-conservative.
The questioning attitude we ask you to exhibit was excellent. The thought processes and satety culture for this issue '
were excellent. The controls put on the evolution were escallent.
The philosophy of not accepting an 4= m lete, unsatisfactory answer was excellent.
The data obtained was excellent.
The one place we felt we could have done better was to have a pre approved procedure, one that without a shadow of a doubt, showed no unreviewed safety questions for crossing over the curve.
I feel our management team could have done better if I more agressively pursued the completion of the issue.
Whether it be my background l
or that I thought I fully understood the issue, I do not know.
I do know the three days I agent with the subject, almost non stop, taught me a lot about the issue I did not.know and should have. In closing,. Bruce will discuss with each of us his expectations on operating conservatively. 21 ease do not take offease by surmising that he thinks you are not.
By clearly stating expectations, it will open up ' discussions where, once again, we will learn more aboup nuclear power.
The and did not justify the means, even though in the big picture, it will bring the issue to closure.
I encourage you to talk to Dave or Rob about the issue.
They both handled the questions extremely well and professional.
Bruce commented on this and felt their attitude contributed a lot to our i
learning process and brought the issue to the right people the quickest.
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j (osesidsed as hamnmadines husek shut, the hisudsen ass he $ds IDcA is apid easedt e peopt symma to aspend as Ilmy wasM in a IMDCA. Theredes, suodse piphs hand iscus
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to g;t moro c;n31ctent en how wa label equipment.
Input from th3 chop 3 eill be necessary but wa will take the lead in ctandardizing guidance end looks for plant labels.
It is to our advantage to ensure labels in the plant (including the control room) are the best we can get them.
The reactor building offers a unique challenge with the radiant heat.
The waterfront and barn have weather to contend with.
All of these concerns need to be pulled together to make a good program.
Please get back to me if you are interested in owning this program.
The anrr issue has blossomed into an arena of entornement.
I will be glad to speak to any questions about this issue. Suffice it to say that Dave, Rob, Jim, and Jack responded to questions from the NRC Office of Investigation in a very professional and complete manner.
I sat in on all.
of the interviews and was very pleased with their.. responses and the'Nac questions. The overriding issue remains violating the operating curve and the reasons behind it.
Lets all ensure we understand the operating envelopes we are tasked to operated this plant in and bring in the proper resources to help us do our jobs if any aballenges occur.
....**........................................................ee........
............e I will be going to Atlanta next week to talk to the Kerry Landis, my counterpart in the region NRC office.
He is very interested in CR-3 and hopefully we will have a good discussion on the event s of the past year.
.e........................................................................o Good Luck and Thanks for your hard work.. Hope your holiday plans go smoothly and safely.
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V.S. mesleer Regulatory Ceemssten 101 Marietts Street. N.W.. Suite 8900 Attenta, Georgia 38883
Reference:
A.
IAC to FPC 1etter. 3R1194 St. dated Nevester 4.1994 j
B.
PPC to uRC 1etter 3F1836-ee, sasse December 8. Seet
$skjoct:
thweea1wed f tam es ft.81. Nahmen Tank Baarattaa j
Deer Mr. Ihneter:
Thts letter segelassets sur letter of Desaster 2.1994 (Referstes 5)lvedby i
j providtataddittenal inforgottee from ser teettestes revise of eersee 3
ites 96 u.81, sekeep tant (ftlf) sporetten. This attittees) tafermetion incledes FPC's serrective actions to resolve the 1sses and further l
disetelinary action taken spetest the ressenettle Shift legerviser and 1
Assistant 3Dift Supervleer.
l As you kasu this astter has been the sehject of an tevestigatten by the j
NRC's Office of levestigattens (0!). The focus of that investigattes. as we
'l understand it, is ehether the acttens of as FPC eseraties shift et Crystal Elver Unit 3. la senducting se unasthertsed evolutten en the INT se September 5.1994, constituted a villfh) vtalette of precedural reestressets. FPC takes any K teaters in this regard
'serteenly.
We have therefore retteund the events of September 5. 1994, the perspective of shether a otlift1 vtalettee escarne.
As salained in eers deta11 telm. PFC in as say condense the acttens of the
, Shift S e erviser and Assistant Shift legerviser. FPC has tahan appropriate disciolinery attica with regatt to the responsitte.tnetotemals, ameh me believe to M adesusta in It
.everall perferennes reeeres.ght of all the stremotences, tastedtog their Based sees sur Portes, hemover se es est
' believe that the tedividuals' estions rose to the level e/ deltherste elecenduct. They were mettveted kr a destre to attain esta to support a legitteste tschetcal concers with the voitetty of the Intr eserettog serve.
Moreover, they did met understand at the tlas that the curve reflected design basis Itstts.
MMK SW ASWrWests testEARWlasseeW.5WW,ams A esses 2*d
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Under these stremoteases. FPC does not believe that ser porpose useld be served by W esformasset tattee agatest the instetemals.
We are aise s
j eensereed with the necesse that seen se esttee might sand. PM esmagesset has unrhed hard to testill e essett attttede seems the workfwee at Crystal River. Further estles agatest I tavelves emeld hevo the metatended effect of disenerettet others perseteg.1stitta te sensores.
additiana} tarpeettue settama la addities to the stees doesrthed in ser Besenhor t.1994 letter. FPC has tatse the fellestag eorreettve estteest i
j 1.
The Shift Superviser and the Aeststemt Shift taperviser esse renewed fres 1teensed estles and reasstsees artthis the apsrettees teserteest. Thetr 3
surrent enties lessive precedsres developeset and other operettsaal i
seppert areas ears their 800 esporteese is helpfel. FFC hee no totest
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te_ place the tedividuals best en attft at this ties. FM will acessit wita the K befers reterates either tedividual to ehtft dettes.
q 2.
rm has established a estalled felles se esties pies to resolve, to a-i semproteestve fachten. the seules tschetal 1seems assestated with l
"Jewei.
task escretten and the hereted ester. storage l"=*'ttee of.eildt.ag
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= est pies w iede f = r,e p.m,
terve 8. to eneers the correst operettog resten and alare values.
l If any FK lissened perseasel had willfully vielsted operettag preesdores, i
FPC emeld not besttste to tehe even strenger settee. tesluttes disoberge of l
the persons resposethis. ter forther rettee of this estter has seeftreed eer seertsttee that altheegh the Shift's estless la esadestieg se essetterised evolettee were coasseptable and marrested strong disstelles. the todtviduals j
did est espage te deltherste etssendest.
Ca.teluntans ensardine antiharate M4eematet The facts serveneding the uneetherited sveletten se the Itif are seemertaed te our December t.1994, letter and the K's leepesttee hosers (Referases A).
We prettes here a essery of the festers that reflest the state of sted of I
the tedivtemals involved. If the est is seere of eRF evideses of eroepfel l
tateet,pisasemettfyFPCse;thatusseetakeappropriateaattee.
!e brief, se lief 10.1994,dort the refseltog estege at CR.3, the Shtft i
Superviser med Assisteet Shift ser were to sharge of the operetteg grew that eerformed Servet11eees (SP).438. s full flee test for i
e the Nigh Pressere lejecties peeps and sheek valves. tertie perfemolog SP 630 the operetere sheerves a mettesekte sesroese to see not level.
tedtsattes a peastble stusk-enhece selve. 41 with savstettee of ftfP.1C. This sonetties'ues in Probles (pt) 94 8848 dated May it. 1994. PR M.0140 ested that. hoses as sosporteses by j
opersttens perassee) of the estesi drop to INT 1evel with the emetene een overpressere serve to SP 1938 (Cerve 8), a serve pletted with the esteal 1
j data potets treated teserd the emessestehle regtes of Curve 8. Pt M.
3 014g further noted that this esserred eyes thesgh the tettial IEff ever-1 pressere leve) dertog SP 830 was holes the aestmo allessele pressure ser l
Cerve 8.
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3P9006 13 Pase 3 The servestive settees for et 94.elet testuded evelsattag the IEfr 1,The vel 2
e that esserved to esterstes emetter terve a ses semestelers eva settes perfetued g11essSystes legtesertog [Nesleer Plant Teekstee Support)seeslededas l
l The decreastes caenge henseem the plotted serve and OP.1938. terve j
8 esessrs te he estely due to the feet that both serves are essvergtet se sore gets. Stees se this evalesttee. It dose est j
espear the pletted serve useld have senerer (sic] the seassestehle restem of Cerve 8.
le edittism. 84ere is esseerystfaa herit fase j
Chrve a to sneers that teatruest error, for sessple. seald est ersete se essessive overpressure essetttes. [esphastsadded]
4 Thee esselestems were alas desseented to a esserename fium emetser Plant Tesisties) Support, ested Septemer 1,1994. A cost of the seneresene use provided to the Shift Superrteer and Aseteteet $htft Supervleer, fhr the pertese of deterw6eing dother they het any additteest sensores or i
l
~"'~f.'~ ~ "" e 1"";,t p
,ser h.v. t.dt.et.d that f
they did est have enough taferesties to hees meether they still shoeld j
he sensereed with the fElf overpressere/ level serve. Assereleg1E en September 5.1994 essensted the evolettee (deserttes to res's letter of Dossumer I.1 te gather edittlesa) data by messertog the system ressesse as fart see lesered.
to carrytes set this evolettee, the Shift Seserviser and Assisteet Shift Superrteer have tedicated that they felleend the operaties precedere for the Inf testem i
(OP.eSt) een tattially 31eeed the system se the sperating cares Itatt (1.s. est te violattee of the serve). 1 hey enigssly eastead est to tehe the stif level holes the slastly stated les level liett of Ig testes, j
As the felt level ses reduced. ther teen data en the system ressesse.
Sese after the evolettee tegen, the overpressere ertfted late the j
enacceptele eserettes rests with respost to left level. The cres failed I<
to terstests tas evolettes at that potet er otherwise take essrspriate that settee. The evolettes etd. henever. lead to engteseries omftretag#ift i
the operettes earve.ses teesserste sad sensesservative.
The reported this distressesy to their senagesent and tattisted a Prehise i
i Report (pt M.OBSF).
4 The m's Enforteneet Poltty.10 C.F.R. Part 2. Appendix C. Sestten VI!!.
states that esforceenet settees tegelvtag tedividuals ers *stgetftceat l
personeel esttees whist will be ties 01F sentrolled and juditiessly applied.'
Asserttag to secties VI!! et the teforcement pelley esferessent esttees l
' easiest se testylesal are reserved for *(ejere eartees stelattees. tesluttes l
these tavelvtag the tatsgrtty of as todttfees) (e.g.1ytag to the E).
- Appliestion of this peitty. is reflected to t$e fellestag cases teve),tes eneathertsed actices by eehrsters, enere the K has teessed testv$ deaf j
esforseaset seesttees: 3g envid tano uqa. IA M.e6 (1934) (K probittted SM free eagestag to iteseses estivities for three years fellentes seither:ta i
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U.5.beslearAnge1MeyCastasten N0895 13 Page e
- -- : t. et = _ 2 _._ gA 96 cover es of sisposttiemed sentrol red testdest)Ctttes nuclear Pouer Statten.
31 (1990) EA 30 31 (1990 (lee tassed (guedereers seepensing itsease of fe ans e
- seinea ca.
Ustt 1).
head 11eg se and esetfytag the Itsense for tend ctttes unem sne individsalonsaged ta eastgelettens te nahe up for an error in the planensst ani ens an, emen. (tlyster Creet mesleer of a feel assemely)84 A. ga m.33a esa ese. m ma L senerettneStatten).
i
'(IgGB) (NK isamed vtalattene to gett llelease ans centret rees operator for sperator's celtherste.anstreetten of elem tape deemmentine safety 1tett I
vtelattes): seen e-(passe Osttee Atests Poser Statten). Ek m. age (1994)
(EC costioned lleensee that future deltbarste violettens of presseeres govemtes entry inte high restattaa erees useld tegelt to enfersement aatten l
agatest both Itannees and tedividuele tevolved).
I Neusser, ta cases set tevolvies delfterste totest to violate regolettens or precedures the IK hea feud forseft1 diestplieery setten by the itsemese to j
he sofficient. and has est gereced esferessest setten egetast the l
tedividuals involved.
2--
^ v"- Man, r-- tam (Vernset Tankee Nestear Pouer Stettes. IA N M 13 5 ) (11eensee removed fun licensed estles the senter sentrol roes opera (ter and shift superviser en j
when a testateten samond vio1stion of te reestrtag sesentary eestatesmet sortag sevement of irrestated feel to spent feel peells unne ca- (N.B. Ashtases plast): fA M.13 (1996) (11eenees pay a licenses seerster and shift forenen she fatted to felles pneedores for vert la 91gh restattes area).
l tataamattaa paetmen j
l Al tho' Shift's acttens to esaducties the evolettee withest aether y were clearly teoppropetees. tus entseesttag fasters shes acted. First, the eyeletten uns esadested fer the peresse of gathertog dela ta detemine whether a testettal toneers with Carve 8 outsted. This uns not a saae of a fallers to felles precedores settvated by teoreper er wrongfel intest. Seesat. the Shtft Superviser and Assistant Shift Superviser die est realise tast the eserattee corse uns a deetp heats Itstt. They believed i
that the serve effeettvely established adotetstrettve 1tatts as had been todtested in the Septsamer 1.1936, esserendes in uhtch testesertag_ had asecluded that Curve 8 mes 'asserete and vesseeably seatervative.' la fact.
sely after further design beats evelsatten did FPC centlade that operetten to l
the enacceptable rettee of the-serve seestttsted operetten outstes the destga I
basts of the system (see Attasteest 8 of our Gesenhor 1.1996 letter).
, Tnts uns aise est a sees where an operster haastagly fatted te ' feller an ~
espiteit presederal stee or other reestrement er disregarded the aertes of other centrol room persemel that his setten was inesasteteet with erecedures. The Shift Superviser and Amsteteet $btft legervtsorteferred te
- OP.408 and estatataed the stif level withts the mores 1 esorettag itetts of as to N tasmas. la addtttes, t have eles indicated that they more est sure that Curve 8 (of OP 105) ted dortog this evolettes since it is esty,
referenced in the portten 40t goverstag vesting and additten (sestian 4.30). These fasters de met eassee the W.
allere to act to a steely smner once the system reopense ertfted tote the enesesotable reage of Cerve 4.
Neuever, this saae shoeld be diettagetshed from one there operators task affiruettve setten that violated an emp1tatt proceeerst
egstrement.
E'd das %er) - und gru udspree as, se.au
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l 370886 13 i
Page 5 l
i ammma lie retterate that FPC ta se ser esadenes the acttens of the ad l
condesttap en moutherteed evelettes en the IRR.
Base es acSten is tassapettele with good operating priestples and management's essertattees.
2 IIeuertheless. FPC resetas concerned wim the meesttee tesect of further W enfersement sametteam apatast the tadtvides) hift Seperviser and Assistant htft Sueerviser to the aheemse of seltbarste steesseest and ta. view of FPC 4
prier disciplisery settens. Desed.ones the feats of this sese..therefers, FFE does act bellege esfergement matten asetest the lativideal eserstars is t
surrested (e.e.. for a vielstles of the m's delttersta mtseenduct rule in le C.F.R. I 56.5).
steuerely.
&b P. M. b ed. Jr.
Senter Vice President Ilus1 ear Operettens l
FIGeff l
est Desument testowl Desk Office of Investi tems 4
Otef. Braset 2 en !!
lenter testeent Inspector j
W Project Manager 4
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.ms vari-ww ru warise as. so -w