ML20115H487
| ML20115H487 | |
| Person / Time | |
|---|---|
| Site: | Crystal River  |
| Issue date: | 05/23/1995 |
| From: | Fields D FLORIDA POWER CORP. |
| To: | Ebneter S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| Shared Package | |
| ML20115H310 | List: |
| References | |
| NUDOCS 9607230151 | |
| Download: ML20115H487 (7) | |
Text
i May 23, 1995 Mr. Stewart Ebneter Regional administrator, Region II U. S. Nuclear Regulatory Ceemission 101 Marietta street, N.W., Suite 2900' Atlanta, GA 30323 Referanos:
A. FPC to NRC letter, 3F0595-13, dated May 5, 1995 B. Manager,0perations ' Journal' to Operations May 19, 1994 subjects tinresolved Item 94-22-01, Makeup Tank Operation
Dear Mr. Ebneter:
The purpose of this lottar is to provide my perspective of events and proposals presented to you in FPC to MRC letter, dated May 5, 1995 (Reference A).
My name is ' David A. Fields and I was the Nuclear shift supervisor on duty September 5,1994 'when an evolution was. performed and data taken en the makeup tank operating characteristics.
This information was presented in Problem Report 94-0267, MUT Pressure Limit curve Inadequate.
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'believe my input into the discussion is important. These are my j
comments, they should have no negative effect upon the 3
individuals who worked for as on shift.
2 I strongly disagree with the tone and content of FPC's letter of May 5.
I do, however, believe that Dr. P. M. Beard is sincere in his desire to limit or avoid MRC individual enforcement estians against the operaters who actually performed the evolution.
Let as provida you with a very short summary of why I felt authorised i
to partora the evolution and why I continue to believe that the evolution was not a ' test'. This is not an effort to say that
' mistakes' were not ande.
I personally made judgmental arrers j
which have made this situation more damaging to FPC and to the people who worked for as and are now under scrutiny.
I will discuss these errors and I will take full responsibility for 1
them.
Rydrogen over pressure in the MUr was first identified as a concern in IE Nation 88-23.
FPC's response was slow and not without centroversy partly.due to the fast that calculations were being performed by Gilbert' Associates sad comments beak and forth between site, St. Petersburg engineering, and 841 in Reading, PA.
were time consuming and there was no clear project manager. At that time, the MUr was administreively limited, by OP1033, Curve 8, to 12psig. In April 1993 a no.' Curve 8 was introduced, a variable curve based upon level in the Mgr.
The increased over pressure was desired to maximize dissolved hydrogen in the reactor coolant system.
The nur': ear operator en my shift had manamens at this time about taa.. 411ty to emergency berate and 9607230151 960710 PDR ADOCK 050003 2 0
system response in the event of a fire.
The concerns were not adequately addressed to his satisfaction.
During Refuel 9, my shift performed SP-430, MPI Full Flow Test, and serious problems were encountered.
The primary cause was determined to be incomplete venting of the pamp's suction piping.
A secondary concern identified and included in the Probles Report (PRS 4-149) was the MUF pressure response during drawdown and the 2act that it appeared to be converging and would cross curve 8.
Nearly all of the issues and resolutions w ing PRS 4-149 were routed
', thzeegh my nucinar operator.
Es had many,, conversations, letters, and meetings over the various 4===a= with engineering and management.
He kept me up to data and informed, but I did not play an active role in the issue and resolution.
At this same time, following restart from RF 9, there was increased attention to Res hydrogen concentration. Management demanded that operating shifts operate high in pressure and on the curve (curves).
On september 2, Engineering sent a letter to the Director, Plant Operations saying that FRS4-149 issues had been resolved and curve a was conservative.
The draft of this letter was brought to me by operations management and I was asked if there was anything my shift wanted to do or respond to beesume the issue was going to be closed.
our response was to perform the MUT drewdown evolution on septer.ber 5, -1994.
We had calculation 190-0024 Rev 5, which we could see had several incorrect assumptions.
The calculation assumed that the hydrogen over pressure was an ' ideal' gas.
The calculation, used pump suction pressures based upon an assumption that MUT to Bust swapover would essur at an RB level instead of a
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WNST level.
We sould also see that the omloulation sensladed that with two MPI pumps operating off of a single sucties heedrr, that a celuan of water 2.27 feet above the pump suctien ~ eald w
result if a worst case Iack break size oosurred.
We ats a shift asked ourselves 12 we could legally perform the avoixion. We l
reviewed OP-402 and concluded that we had approved guidance for lowering the MUT from as" to 55*.
One member of the shift questioned whether we.should drain below $58 and the ANSS said
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no, that to go outside the precedure would he a ' test'.
No procedure Limits or Precautions would be violated. We reviewed the Annunciator Alarm ps-r ^ Ee and determined that at the conclusies of t.he evolution, we would take actions to restare the tank and clear the alarm.
Sinos we understood that the surve was a n-aaamm in the event of a large break Iach and with an equipment malfunction which resultad in two MFI pumps operating off of a single suction header, we decided to. station the Auxiliary Building operators in a position to be ah?3 to immediately v et the pressure from the WF.
All of this was discussed at d. pre-$ob briefing. We fully expected to get the i
MUT Pressure High Alarm.
We fully empeoted to drew a systea response tr.n was above curve s.
A third licensed oper*.nr was
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stationed in the control room to plot MUT level and pressuro on curve a so we would know exactly where we were at all times and could abort the evolution if something unexpected happenad.
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i OP-1033, Curve 8, is a systaa response curve.
We did not violate this curve, we placed the MUT at es" with hydrogen over pressure exactly on the curve.
Using an approved, routine procedure we i
lowered the level to 55".
Actual system response, the data we i
took, drew the real and correct curve 3.
We did not violate curve 8, we. proved that the engineering assumptions used to a
derive the published orarve were incorrect.
The smooth curve that we included.in Problem Report 94-0267 was in fact the real Curve
- s. The published surve was incorrect because it was based upon j
poor engineering assumptions.
l The data we collected showed an error of 1.7 peig at 55".
This number is significant in that the 2.27 foot solumn assured in the 4
calculation was inadequate, and hydrogen entrainment of EFI pumps was truly a concern.
Lost in this entire issue is the fact that t
we were right.
We had a safety coneers which was not addressed by Management or Engineering and we proved that it was valid.
On September 9 operation was administratively restricted to 2.0 peig 3
below curve a and this was inormased to 2.5 peig on september 14.
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Engineering retustantly agreed that op-toss, curve a was met l
correct.
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For 35 minutes.on September 5, my shift operated in a regies that later turned out to be outside of the EFI System Design Basis.
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That is 35 minutes with extra people stationed and briefed for l
actions to take in case of an emergency.
- h11' other timas that j
the NUT was operated 'on' Curve 8, CR-3 was.outside of the same design basis.
The plant operated outside of design basis for j
months in cycle 9 and fallowing restart irem Refual 9.
Our efforts have had a direct positive affect upon the safe operation of the plant.
Engineering is senducting a complete evaluaties of 2
l this complex issue.
Two additional one hour design basis reports have been made and a twenty six iten MUT Action Flan has been l
developed to validate system assumptions and calculations and I
EDP procedure guidanam.
l We initiated PR94-267 on September 7'.
Within days, the sub$est i
of ' design basis' and 'unauthorised test
- was raised.
Neither I j
nor anyone on my crew know that curve 8 was a design basis limit.
i Ne one in Management kasw it was a design basis or they mem14 not have insisted; demanded that we operate on the surve.
IAny weald i
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Engineering provide us with a surve and an annunciator alaan that indicated a one hour NRC report was dus, if they understand that j
it was a design basis curve 7 la fast, Engineering could not detinitively deside that a design basis had been violated until November is when the one leper report was made.
It is FD e not totally elear, in my opinion, whether a ' test' was notasally i
performed.
There is ne slaar policy or g.idelines in CR=3 4
Administretive Procedures of what consti :t':cs a test.
I use as a
' rule of thuah' that if an evoluties is cotered Dy an approved procedure, then a test precedure is not required.
If I thought 1
j that the evolution that we performed on the MUT was a ' test', I
.ould not have authorised it's performa..?
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i Dr. Board's letter of May 5 presents Management's view that my
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shift performed an unauthorized test and violated the epi systen j
design basis.
He is asking you, the NRC, to not take individual i
enferoament action against me and my assistant for our achiens.
j I agree with his senclusion that neither of us willfully er j
knowingly violated any NRC requirement.
I do not agree With his j
assessment that management has fully understood this issue and j
has taken appropriate disciplinary action against us.
Their l
actions appear to me to be a reaction to what they 'think' the l
NRC will de or what they 'think* the NRC expects management to i
do.
Fellowing the Management Review Committee investigation of,
j ny shift's actions concerning the Mtrf evolution, my supervisor, the Manager Nuclear Plant Operaticas, presented his view of the i
NEPF evolution and lessons learned in his e-mail Journal to all j
operations Department personnel (Reference B, attached).
This was the most balanced and insightful discussion of the isees that I have seen.
It is clear to as that management expostations had not been established prior to this event, but were being stated j
in his journal.
Additional disciplinary actions were not taken against me er my assistant, until after the Offios of Investigation manaannand its arrival on site to perfora an investigaties.
I was working the j
mid-night shift and was called at home and told not to same into i
work, that I was 'off shift'.
The Assistant shift superviser was j
already off shift because he had been asked, prior to September 5, to cons off shift and be the Energeasy operating Procedure j
(ESP) Caerdinator.
Dr Beard's letter aise states that the l
oempany has no intention of restering either of us to Licensed duties. He has told as that I will never go beak on shift. Eis 4
letter was the first time, however, that my assistant has ever i
been notified that he was administrative 1y removed fraa TAa===ad l
activities. After the Management Review Committee completed its investigation, there were no restrictions, and no disciplinary actions taken against us.
Dr. Beard assured both of us personally that FPC had'1ooked at the issue and felt that i
appropriate action had been taken and the issue was closed. Why has FPC changed their position?.No new information has surfaced.
Region II and O&I interest and involvement seems to be the only reason these additional actions were taken.
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,4 I do not understand the purpose of Dr. Board's letter. The j
- politics
- between FPC and the NBC is completely foreign to me.
j Every licensed person on ry shift answered all O&I questions j
truthfully.
I believe that their report will contain no i
intornation or allegation of any willtul wrong doing.
Any
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l actions which.the office of Enforomaant misent take against as l
seem to pale in comparison to the actions which my company has already taken.
My career and reputation..have been ruined over j
this; issue.
It new appears that my assistant's career is also being harmed by these unilateral actions.
After Dr. Beard showed as his letter and I expressed my j
disappointment, he accused me of not being willing to amospt any,
i responsibility.
I as responsible for every thing that happens on 1
l ay shift.
I authorised the m evolution and take all 1
responsibility for any errors which were made. No individuals 3
reporting to me, including my assistant, should be considered 2or any individual enforcement.
I was their superviser and I made the decisions... period.
it The fallowing discussion is my perspective of areas where I could have made better decisions.
1.
The Nuclear Operator en my shift took the lead on the W and the concerns the operations department had with operattag with elevated pressures.
Following Sp-430, he worked tirelessly with engineering to help resolve the problems identified.
I kasu that i
the O&I report will show his dedication and frustration with the i
issue.
I should have gottaa more personally involved and helped him with his concerns and got his questions raised to the appropriate levels.
I let his down.
If I had been a ases aggressive, effective supervisor, this entire issue oosad have been avoided.
l 3.
I as the one person on shift who abould have c j-M that curve 8 was more than an operating surve.
No had the calculation, and we could see that the surve provided was the assumed system response to a m drawdown. This informatism should have alerted me that no conservatism was included.
I.am a degreed engineer, I spent five years as an officer in the 55 Navy nuclear program, I worked as an engineer ior Duke Power ier three years, and I worked for FPC.as an engineer for seven years prior to becoming a shift supervisor eight years ago.
I as the only person on shift who could have been expected to roooghise curve 8
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as a-design basis.
If I had made that distiastion, then I womad i
not have perfarmed the evoluties.
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I did r::. notify er sensait with the STh/ Shift Manager i
prior to tah:.r.; data en the M.
That was a serious mistake in
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judgement.
I mistakenly did not pleos the proper importamos en j
the evoluticr. we were goiaq to perform.
I do not think the STh j
would have *.S ' se any objectioner however, that is an opinion and ny action.
j does not ext..-
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We were not a group of frustrated operators bent on proving a point and taking inappropriate action to embarrass engineering or i
annagement.
I honestly believed that I was taking appropriate actions as a shift supervisor to address the concerns of W I
operators within my W. The data was taken on the mid-l night shift only beu. w we were on the mid-night shift. "our intent was only to take data we thought would keep a safety concern open.
I hope this letter has given you a different perspective en the MUT issue than the one provided'Dy Dr. Board.
I helieve the OEI l
report will come to the anmelusion that there was no willful
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misconduct associated with any aspost of the event.
I as disappointed that FPC has abasen to say our actions were taken i
because we had ' technical' amaamens with curve 8.
I believe this i
wording trivialises a valid safety comoors.
I an disappointed that FPC has taken punitive actions against me and my assistant over an issue as important and sensitive as this.
Ny assistant is the finest Assistant shift Superviser that I have over worked with.
His ability, integrity, and moral principles are
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outstanding.
It is wrong and inappropriate that he should auffer because of my mistakes or the mistakes of our management.
If l
nothing else comes of this discussion, I would like~to see hia removed from any threat of individual enforcement.
l My position and FPC's position on this issue are clearly not in agreement.
I would like to be included in any further discussion i
of this unresolved item.
I weleene the opportunity to attend any i
Enfornament Conierence.
I consider my Mmmonsion of this event I
as a protected activity defined and governed by 10 CFR St.7.
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i sincerely,
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i David A. Fields
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Nuclear Shift Supervisor 1
Nuclear Operations l
t oc F. N. Beard Office of Investigation chief, Branch 2, Region II l
Senior Resident Inspector 3GIR Project Manager attachment 9
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To: DFIELDS attachment, Reference B From: GMAIJION subject: Journal 8/18 j
Date: 09-18-94 Time:
4:21p i
Tot *3OURHAL l
eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee Bruce will be coming to discuss the, events over the last week in reference to the NUT pressure curve.
Everyone knows same dotsils i.
of what happened, so to dispell any rumors, here are some details.
First, A-shift is not "in-tsouble".
We, as a departamat,' were brought into the line-light by an action to raise attention of a i
potential satety issue. The methods to raise this attention brought l
up a philisophical issue we must all be clear of the expoetations.
When I say "all",
I as talking of all of CR-3 management and workers, not just operations.
The philosophy is in how we deal j
with operating curves and limits.
First, when given an operating curve, we will comply with it at all times.
seoord, we must give 4
i to operations curves we CAN comply with and when complied with 1
assure the safety of the plant.
Without both of these, we, as a plant, let ourselves down in attempting to comply with our code of i
Ethics. The safety of the plant is utmost, unfortunately drastic asasures are felt required to bring safety subjects to a head.
Also unfortunately, in bringing the NUT issue to a head, we passed into an unknown region of complianos, into clearly unnooeptable i
regions of a curve which was already thought to be non-conservative. The questioning attitude we.ask you to exhibit was j
excellent. The thought pr-- and safwty omiture for this issue were excellent. The controls put. on the evolution were====11=nt.
j The philosophy of not aosepting an incomplete, unsatisfactory I
answer was excellent.
The data obtained was esos11ent.
The one place we felt we could have done better was to have a pro-opproved 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 sempletion of the issue.
Whether it he my beakground i
j or that I thought I ' fully understood the issue, I do not know.
I do know the three days I spent with the subject, almost nea-stop, taught as a-let about the issue I did not know and should have. In
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closing, treme will discuss with each of us his expectations on operating conservatively.
please do not take offense by auraising that he thinks you are not.
By clearly stating expostations, it wilf open up discussions where, ones again, we will learn more about nuclear power.
The and did not justify the means, even though in the big picture, it will bring the issue to sleeurs.
I encourage you to talk to Dave or Rob about the issue.
They both handled the guestions extrasely well and professional.
Bruce v
commented on this and felt their attitude cent.ikneted a lot to our l
1 earning process and brought the issue to the right people the j
quickest.
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g NUCLEAR COMbMSSION nemens I
101 MARIffTA stagr. M.w egnem ATheeftA, gm m
\\.1 July 7, 1995 EA 95-125 Nr. P. M. Beard Jr.
Senior Vice. President. Nuclear Operations ATTN: Manager. Nuclear Operations Licensing, NARI 4
Florida Power Corporation
. 15750 West Pouer Line Street Crystal River FL 34428-5708 SWJECT:
E OFFICE OF INVESTISATION5 REPORT 2-94-035 i
K INSPECTitNI REPORT W. 50-302/95-13
Dear Mr. Beard:
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This refers to an investigation by the Nuclear. Regulatory Commssion (MC)
Office of Investigations (01) completed on May 24. 1995, and inspoctions
. conducted by Mr. Ross Sutcher of this office between September 5. 1994 and July 5.1995 and documented in IRC Inspection Report No 50-302/95-13. This i
special inspection report also summarizes related findings discussed la NRC Inspection Reports 50-302/94-11, 95-01, 95-07, 95-08 and 95-09. Durtag these i
reviews, the NRC examined the facts and circumstances surrounding a September 5.1994 event involving pressure contre) of the reactor coolant j
system makeup tanks and reviewed the adaspaaey of design control and corrective actions that affected operability of emergency core cooling system pu ps. The subject inspection report and the synopsis of the O! investigatten are i
enclosed. At the conclusten of the inspecties, the findings were discussed j
with those members of your staff identified in the enclosed report.
I Based on the results of our inspections and the 0! investigt.tton. four apparent violations have been identified and are beine considered for I
escalated enforcement action in accordance with.the " General Statement of Policy and Precedure for NRC Enforcement Actions" (Enforcement Policy),10 CFR Part 2. Appendix C.
la addition, enforcement action is being considered j
against the licensed operators involved in the September 5, 1994 event.
j In regard to the first apparent violaties, on September 5,'1994, licensed j
operators planned and conducted an evolutten that alloued the makeup task i
pressure to escoed the acceptable operating region of OP-1038, Curve 8 for approximately 35 minutes. In addittoa, the operators delayed their ressesse to the annonciator for the askeup tank overpressere conditica while they i
continued to drain the makeup tank, causing the tank overpressure to diverte i
further into the unacceptable regten of curve 8.
These apparest intentional l
acts resulted in a violaties of. Technical Specificaties 5.5.1.1 which requires taplementation of procedures Al-500, Conduct of Operationst OP-403. Mahoup and l
Purification System OP-1038 Plant Operating Curvest sad AR-403, PER N 1
Annunciator Response. Had an Engineered Safeguards acteatten occurred while i
in this condition, cavitation and subsequent inoperability of one of the high j
pressure injection pumps could have resulted.
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FPC 2
The 01 investigatten concluded that the shift superviser, assistant shift sneerviser, and two chief operators deliberately violated Crystal River s
Nuclear Plant precedures. 10 CFR 50.5 (a) Deliberate flisconduct, in part, j
ershibits licensee employees from espaging in deltherste misconduct that causes a licensee to he in violatten of a conditten of any license issued by 1
the Commission. Deliberate miseenduct is defined by 10 CFR 50.5(c) as an intentional act er emissten that the person kasus constitutes a violation of a j
j requirement, procedure, instructies or policy of a Itcenses.
l The record in this case reflects that licassed operators planned and conducted j
an evolution that they fully espected would neult in exameding the makeup task overpressure limits specified in procedures. The record aise reflects that the licensed operators latentiemally delayed implementaties of the reemirements of the annunciator reopease precedure in order to gather adettional data en the overpressure conditten. Apparently, the licensed operators involved were aware of the precedural requirements and inteettenelly violated the procesures. The IRC censiders these apparent intentional acts.te constitute an apparvat violation of 10 CFR 50.5(a). We an aise concerned that appropriate annagement eversight and centrol mes not esercised to preclude intentional violation of plant procedures.
The remaining apparent violations involved failures to meet the reesirements of 10 CFR 50. Appendix B, Criterien III. Design Centrol ta that the design basis.was not correctly translated inte drastags, precedures, and i
instructions, for: (1) operation of the askamp taak; (2) operation of the manual suas ever of the ECCS pu ps' secties from the herated water sternes l
tank to the reacter butiding suses and (3) estatatatag adeguate teventory in the reacter building sump to provide adequate met positive section head to one I
low pressure injection pump with the high pressure injection (IFI) pump l
suction crosstie valve open and supplying tuo operating HPI pumps. Tuo of these violations aise involved apparent violations of 10 CFR 50, Appendix B.
i Criterion XVI, Corrective Action, in that once the design deficiencias were j
identified they were not adequately corrected in a timely mammer.
These apparent violattens indicate sigstficant weaknesses in management j
control of the revies and resoluttaa of significant conditions adverse to i
quality. Operator centerns about pas entratament in the high pressere j
injection pumps, identified in problem reports and correspondence betmeen i
operations and engineering, were not adequately resolved ever a significast j
period of time. Subsequent to identificattaa of the design deficienstes ta makeup task overpressure 11stts, engineering reviens of the design assumpttens j
for the pressure / level operating curve of the makeup tank were not thereuph.
1 The curve issued by engineering contained errors and was nea-conservative.
The revised curves issued by engtasering aise contained errors and were non-conservative. The curves permitted the plant to be operated entside the design basis. Indications of deficiencies in the destga assumptions for l
various tank levels in other safety related tasks aise were not appressively pursued.
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No Notice of Violatten is presently being issued for these taspecties 1
findtags. The number and characterisatten of the apparent violattens
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described in the enciesed inspection report may cheaps as a rossit of further IRC revies.
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FPC 3
A closed predecisional enforcement conference to discuss these apparent violations has been scheduled for July 15. 1995 at 10:00 a.s. in the NRC's Region !! office in Atlanta, Georgia. In addition, as discussed with you en July 5, 1995, we are aise schedultng prodocistanal enforcement cesferences with each of the licensed operators inve>1ved in the September 5,1994 event.
The decision to held conferences wtth you and the licensed operators ddes not mean that the INIC has 6:t::Naed that the violattens have occurred or that enforcement action will. be taken. The purposes of therse confersecas are to discuss the apparent vielstions, their causes and safety significance to provide you the opportonity to point out say errors ta sur inspecties reports and to provide sa appertuotty for you te present your corrective actions. la' your discussion, you shesid specifically address the concerns described above with regard to management oversight and contre) of licensed activities and include any mitigating considerations not previously identified. In addition, this is an opportunity for you to provide any informaties concerning your perspectives en 1) the severity of the violattens, 2) the applicaties of the factors that the NRC considers when it determines the enount of a civil penalty that may be assessed in accordance with Section VI.B.2 of the Enforcement Policy, and 3)..any other application of the Enforcement Policy to this case, including the exercise of discretten in accordance with Section VII.
Please note that the NRC Enforcement Policy was revised and became effective with its publication in the fosferal Aspfster (60 FR 34381, June 30,1995)
(Enclosure 3). Secause the apparent violations in this case were under review before the effective date of the revised Policy, the K will utilize whichever version of the Policy accrues to the honefit of the licensee.
During the conference, you will be provided as appertanity te address say application of the revised Enforcement Policy to this case. You will be advised by separate corresponeence of the results of our deliberations en this matter. No response regarding 1,ne apparent violattens is reedired at this ttaa.
Pursuant to 10 CFR 1.790 of the INIC's " Rules of Practica", a copy of this letter and its enclosures will.be placed in the IAC Public Document Room.
Should you have any questions concerning this letter, please contact us.
, 51 ly i
lis W.
iracter Division of Projects Docket No. 50-301 License No. OPR-72 EA 95-115
Enclosures:
1.
Synopsis of NRC Office Of Investigations Report 1-94-038 2.
NRC Inspection Report 50-302/95-13 3.
Revised Enforcement Policy cc w/encis: (See next page)
I ij FPC 4
i ec w/encis:
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Gary L. Boldt, Vice President B111 Passetti Nuclear Production (SAIC). FPC Office of Radiation Control
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15740 West Power Line Street Department of Health and Crystal River FL 34423-570s Rehabilitative services 1317 Wineused Soulevard
- 8. J. Nickle, Director Tallahassee, FL 32399-0700 J
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Nuclear Plant Operations (NAtC)
Florida Power Corporation Joe Myers, Director j
15750 West Power Line street Divisten of Emergency Preparedness 1
Crystal River FL 34433-5708 Departmast of Cemessity Affairs 1740 Centerview Drive L. C. Kelley, Director (N4t!)
Tallahassee, FL 32399-1100 Nuclear Operations sita support. FPC 15760 West Pouer Line street Chairman Crystal River, FL 34428 6708 Board of County Commissioners Citrus County Gerald A. Williams 110 N. Apopta Avenue Corporate Counsel Inverness FL 35250 l
Florida Power Corporation l'
f NAC - AEA Robert B. Borsus j
P. 0. Bos 14042 B&W Nuclear Technololies j
I St. Peterstnrrg, FL 33733 1700 Rockville Pike, Suite 525 4
I Rockville, 2 20052-1631 Attorney General l
Department of Legal Affairs The Capitol l
Tallahassee, FL 32304 2
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Dn Novemoer ll.1994. :na U.S. Nuclear Reguistory Ccssission. Region !!
office of Invest 1gations initiated this investigation to setermine ti'tertain 4
reactor entrators at Florica Power Corporation's Crystal River Nuclear Plant (CIDIP) teitberately violates CRNP procesures oy consucting an unauthdrited j
evolution involving the relationship between the water level versus pressure in the anseus' tant.
The investigation oisclosed that on"Sestamber 5.1994, tne Oserstions midnig 1
snift se)iberate)y allowes the makaus tant water level to decrease. within allousele limits, without aajasting the maasus tant overpressure to prevent i
entering a scenibites area of overpressure.
This pronibited area was i
j nascribes by a CRNP proceeural docesant which displayeo a slet (curve) of j
permisstole tant leve) versus pressure response.
The purpose for the conduct
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of this eve)ution by the operators was to notain actual tant level versus cressure ressonse cata for causarison to the orcesoural curve. This curve I
sescrioen sne perm 1ssiale operating region.
j when the overpressure entereo into the unaccentatie coerating regten.
annunciators act1vates. and the operators knowingly continues to attata data i
without taking any action to alleviate the overpressure and allones the i
j unaccostatie overpressure conettien to exist for 35 minutes. The data i
gatherto by the operators confirimod that the procesural curve differes fres the actual cune.
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Basso uoon the evidence developed in this investigation. it is concluded that the sntft supervisor. assistant shift supervisor, and two chief operetars
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caliberately violates CRNP procedures by exceeding the allomaale makeup tank oversressure, ano delaying taking appropriato action to reeuce makeup tant 3
overpressure.
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4 C m No. 2-94-034 1
Enclosum 1
/ *%
IJINTS STATgs
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g
~ NUCLEAR REGULATORY C04mmBSON Rosene i
1el asadugTTA sTRWr. N.w sWft 3 i
ATLANTA. eminea m tg.
Report No.: 50-302/95-13.
Licensee: Florida Power Corporation 3201 34th-Street. South St. Peterstnerg, FL 33733 Decket h : 50-302 Lt.conse No.: Opt-72 4.
Facility Name: Crystal River 3 1
Inspection conducted:
September 5, 1994 through July 5, 1995 Inspector:
M [ [_'
!cf R. Ek%cher. Senior Resident inspector D#te 61gneo i
j Accompanying Inspectors:
l T. Cooper Resident Inspector s
L. Mellen. Reactor Inspector. RI!
j R. Schin.- Project Engineer. RII 7
pr Approved by:
j X. undis. section Chief Date dignes Division of Reactor Projects, 1
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j Scope:
3 This special inspection report dae====ts inspections conducted by the NRC between September 5,1994 and July 5.'1995 and summarites the related findings of NRC Inspection Reports 50-302/94-22. 95-02, 95-07, 95-08 and 95-09. These inspections included reviews of: -
The unesthorized evolution by licensed operators regarding the operation of the makeup tank outside of procedural operating limits.
Operation of the makeup taak per approved operating instractions that resulted in operation outside the design basis of the makeup and purification system.
re ncer 2 Of ffp6W
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j Emergency operati procedures that directed the manual swapover of the l
Emergency Core co ing System (ECCS) pumps suction from the Borated l.
Water Storage Tank (IMIT) to the reactor building sump at a SW5T water j
level that could have resulted in the loss of the ECCS pumps, and Energency operating procedures that directed the alignment of one Low i
Pressure Injection (LPI) pump to supply two operating High Pressure Injection pumps that could have ress; ted in the loss of the only j
Rasults:
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Four apparent violations were identified:
j Apparent violation 50-302/95-13-01: Deliberate operation of makeup tank outside the s ceptable operating region. (paragraph 2) 4
]
Apparent' violation 50-302/95-13-02. Examples 1. 2 and 3: Operating j
curves for makeup tank outside design basis and failures to take j
adequate corrective actions for significant canditions adverse to j
guality. (paragraphs 3 and 4)
Apparent violation 50-302/95-13-03, Examples 1. 2 and 3: Inadequate design assumptions for borated water storage tank suopover level:
failure to take adequate corrective actions for significant condittens j
adverse to quality; and failure to adequately translate design basis requirements for available stored fire protection water into precedures.
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(paragraphs 5 and 6)
Apparent violation 50 101/95-13-04: Inadequato not positive section j
head to an Engineered isfoguards pump during accident conditions.
j (paragraph 7) j These issues were previously being folloued up as URI 50 302/94-22-01, f
Makeup tank operation outside the acceptable operating region, and URI 50-302/95 08-04 Discrepancies in the implementation of the fire service water tank level versus volume calculations. These unresolved 1
items are closed.
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REPDRT DETAILS 1.
Persons Contacted Licensee Employees
- P. Board, Senior Vice President Nuclear Operations
- G. Becker. Manager-In-Training, site Nuclear Engineering Services
- R. Davis, Manager, Nuclear Plant Maintenance
- P. Fleming, Senior Nuclear Licensing Engineer
- t. Gutherman, Nuclear Engineering supervisor
- G. Halmon, Manager. Nuclear Plant Operations
- S.-Nickle, Director, Nuclear Plant Operations
- M. Jacobs, Corporate Communications
- L. Kelly, Director, Nuclear Operations Site Support
- J. Masada. Manager Design Engineering
- P. McRae. Director. Quality Programs
- P. Tampuay, Director, Nuclear Engineering and Projects
- G. Wil.iana. Legal Council
- K. Wilson. Manager, Nuclear Licensing Other licensee employees contacted included office, operations, engineering, maintenance, chemistry / radiation, and corporate personnel.
Nuclear Regulatory Commission
- R. Butcher. Senior Resident Inspector
- T. Cooper. Resident Inspector
- C. Evans. Regional Council, RI!
- K. Landis. Chief, Reactor Projects tranch 2. Region !! (RII)
- E. Marschoff. Director, DRP, RII
- T. Peebles. Chief, Operator Licensing Branch R!!
- L. Raghaven. Licensing Project Manager. Office of Nuclear Reactor Regulation (NRR)
- R. Schin, Project Engineer RII
- L. Watson. Senior Enforcement Specialist, RII
- G. West Engineering Psychologist. Human Factors tranch NRR
- Attended exit interview
- Participated in exit intervien via telephone Acronyms and initialisms used throughout this report are listed in the last paragraph.
2.
Fellowup of Apparent Operator Misconduct During September 5, Igg 4 Event (g2g01)
On September 7, igm a PR.was issued regarding the adequacy of the MIT hydrogen overpressure curve in OP-1038, Plant Operating Curves.
PR g4-0267 MUT Pressure Limit Curve Technical Basis inadesusta, listed operator concerns regarding the engineering calcelatten (1g0-0024 Revision 5) that the operating limits curve was derived free. The need to maintain He overpressure as high as possible was to address RCS
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chemistry control. The industry guideline for RCS N concentration is i
all ec/KG. ' At CR 3. the operators annually manipulate the M level to attain the maximum N overpressure by lowering M 1evel, increasing j
He pressure to the maximum allound value per the curve. and then Mising l
the MUT 1evel to increase H pressure. RCI He concentration will stabilize at t 25 cc/Eg. Operators were instructed by management to estatain hydrogen overpressure as high as possible due to RC5 bydrogen concentration concerns. The ll55/All55 shift relief checklist dated July 11. 1994 under ra====ts/Special Instructions, directed the j
operators to keep IRIT pressure as high as pessible. OP-1038. Plant f
Operating Curves. Curve 8. Maximum Makeup Tank Overpressure, p1sts M' i
alleuable everpressure (psig) versus M indicated water level (ta.).
l The purpose-of OP-1038 is to provide operattenal infessation for plant startup, shutdeun, and other plant operattens and evolutions. The j
operators are to use this curve to determine that the IllT is in en l
acceptable operating region.
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Recently, the operators expressed concern that the engineering t
calculations regarding the acceptable H overpressure sa the Itif were non-conservative. Operators had observed the HUT pressure versus level j
variance from the curve during operation and were convinced that curve 8 i
was neither accurate nor conservative. This observation had been j
doceented in PR 94-0149. left-80 Stuck Open, which resulted in an unexpected drop in the MUT level. On September 5.1994 in order to verify actual MUT pressure versus level differed from that shown on curve 8. the operators adjusted MUT pressure to fall on the curve at a MUT 1evel of 88 inches (MUT high level setpoint). The system was allowed to stabilize and then the MUT 1evel was bled down to the lou level setpoint of 55 inches. Operating precedure OP-402. Maksep and Purification System, paragraph 4.1.15 directs operators to maintain the NT 1evel between 55 ane 88 inches. As noted earlier, curve 8 in i
j Op-1038 tr then used to maintain the tRif allowahle overpressure (in psig) versus indicated water level (in inches). When the operators allowed the MUT to bleed doun, the MUT pressure entered the unacceptable region and the difference between the curve and actual pressure increased throughcut the entire level decrease. At a IRIT lower level of 55 inches. ftlT pressure was approximately 1.7 psig above the curve.
PR 94-0287 stated that the 1.7 psig equates to approximately 3.9 feet of i
water. Calculation 190-0024. Revision 5. only ensures a eslumn of water in the IslT line 1.27 feet high and therefers the errer in curve 8 is j
larger than the margin provided by the calculation.
i II 5.6.1.1 requires precedures be established, implemented, and maintained covering activities as rem in Regulatory Suide 1.33.
Rev. 2. Appendix A. February 1978. Regulatory Guide 1.33. Appendia A recommends precedures for startup, operation. and shutdown of the j
reactor coolant system. Precedure Al 500. Conduct of Operations.
paragraph 4.3.1. Precedural Compliance, states it is the duty ef.every 3
member of the Crystal River Plant work force to comply with precedures.
Procedure OP-401. Makeup and Purification System, steps 4.19.8 and 4.19.9 required operators to refer to curve 8 of OP-1038 for anxioun ftlf 4
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overpressure. Precedure OP-1038. Plant Operating Curves. Curve 8.
j Maxime Makaus Tank Overpressure, defines the allowable makaus tank pressure versus level operating region during operation. AR-403, j
PSA H Annunciator Response, annunciator M PRE 55 HIGH/ LOW. requires operators to take action to reduce IRIT pressure to within the limits of 4
l OP 1035. curve 8, when a valid alam is received.
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However, on September 5.1994, operators allound the makeup tank j
pressure versus level to exceed the acceptable operating region of t
OP.(1938, curve 8.
The operstars then delayed actions to comply with
{j AR-403 when the makaus tank high pressure alam annunciated. Exceeding the acceptable region of curve 8 of OP-1938 and delaying the annunciator response is an apparent violation of the reestrements of Technical l
Specification 5.5.1.1 which requires implementation of plant precedures i
Al 500. Conduct of Operationst OP-402, Makeup and Purification Systems OP-1038, Plant Operating Curves; and. AR-403 PSA H Annunciator l
Response.
An investigation of the apparent deliberate failure to follow plast precedures was comeneted by 01. The investigation was completed on May 14. 1995. The 0! investigation concluded that the shift supervisor, assistant shift supervisor, and two chief operstars deliberately violated Crystal River Nuclear Plant precedures by exceeding the a11emable makeup taak overpressure and delaying taking appropriate
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action to reduce makamp tank overpressure. 10 CFR 50.5, (Deliberate i
misconduct), paragraph (a), in part, prohibits licensee employees from j
engaging in deliberate misconduct that causes a licenses to be in violation of a condition of any license issued by the Commission.
j Deliberate misconduct is defined by 10 CFR 50.5(c) as an intentional act or emission that the person kness constitutes a violation of a
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reoutrement, precedure, instruction or policy of a licensee. The licensed operators involved apparently were amare of the procedural recuirements and intentionally violated the procedures. The NRC considers these intentional acts to constitute an apparent violation of j
10 CFR 50.5(a). Management oversight and control of control roon j
operations is discussed in paragraph 8.
The apparent violation of plant i
precedures and 10 CFR 50.5 is identified as apparent violation j
50-302/95-13-01.
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3.
Review of Design Basis of IEff Operattag Limits (g2903) l F5AR Section 6.1 ECCS, states in part that upon a valid actuation i
signal, the Makaus and Purification System is automatically suttched j
from its normal operating made to the emergency operating made (High Pressure Injection) to deliver water from the SW5T into the reacter a
vessel. Unstated in the FSAR is the design feature which reestres the i
hydrogen everpressure in the IllT be limited to prevent the leff from
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being emptied which could allow hydrogen gas to enter the section of the HP! pe gs (which aise function as the makamp pumps in the Makamp and j
3 Purification System) and result in desage to the pulps.
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Based on the continuing operator concerns. licensee management initiated a comprehensive reviou of the falf H overpressure issue. An engineering evaluation was completed on November IE. 1994 that concluded that j
operation on or to the left of the OP-1038 curve at the enset of a' LBLOCA or core flood line LOCA would have resulted in MP! pump demoge.
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This means that operation on curve 8 of Op-1038 resulted in operation i
outside.the design basis of the plant.
l Subsequently, the licensee recognized that they normally operate with the two trains of HPI isolated from each other on the suction side of ths HOPS. One train is aligned with its suction from the Itif (and also the SMST after an E5 signal), while the other train section is moren11y l
isolated from the first train and is aligned to the Bust after an Es signal through a separate pipe from the tusT. In this case, escass j
hydrogen pressure in the fRif during the enset of a LOCA could cause gas binding in one of the two Et selected HPI pumes. The other Et selected i
HPI pumo would not be affected since its suction'is aligned directly to j
the sWsi.
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Houever, one LOCA scenario, a postulated break in a core flood line in j
conjunction with the potential gas binding of high pressure injection pump due to a high overpressure in the makeup tank, could lead to the e
j loss of the safety function as explained below. In this scenario LPI j
cooling water enters into the reactor vessel through the core flood itses. Any cooling water from LPI in the train containing the break 1
usuid not reach the vessel. A single failure in the other train. i.e.,
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loss of the B emergency diesel generator, would result in less of the i
other train of LP! and loss of one train of HPI. The remaining train of i
HP! cooling water would then be required to attigate this event. The i
core flood line nozzles have inserts which limit the break size to 0.44 senare feet which is considered an intermediate break size. The blowdown rate for this LOCA is rapid enough to promet systems to respond as they would in a large breas LOCA. Therefore, the falT pressure limit j
curve constitutas a design basis limit for this event because a high overpressure in the makeup tank could result in emptying the makeup tank 4
i prior to switchover to the BW5T resulting in gas binding of the i
remaining HP! pump and loss of the safety function. Conseguently, a l
pipe break in the A core flood line concorrent with a LOOP, and a start i
failure of the B emergency diesel generator could result in a reactor coolant system bloudoun and unavailability of both trains of LPI and one
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train of HPI, as well as loss of the second train of HPI due to hydrogen j
gas binding. It should be noted that with operator action the A LPI
- 1nme could be manually aligned to the SW5T and used for injection of cooling water.
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'10 CFR 50, Appendix 8. Criterion III Desipa Centrol, requires that l
asasures be established to assure that app,1 cable rege_1 story requirements and the Design Basis, as defined in 10 CFR 50.1, j
Definitions, and as specified in the license application, are correctly 4
translated inse specifications, drawings, procedures, and instructions.
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The failure to translate the design basis to ensure proper operation of c
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5 the Makeup and Pudfication System such that the system is autsmatically switched from its normal operating mode to the emergency operating mode (Mich Pressure Injection) and is capable of delivering water from the BWE" ints the reactor vessel is an apparent violation of 10 CFR 50 Appendix 8. CriteNon !!!. This is identified as example 1 of apparent violatten 50-303/95-13-02.
4.
Review of Revised Operating Curves for fRff (93903)
On September 9.1994, short ters instruction (STI)'94-019 was issued resu1Has operators to maintain fart pressure approximately 2 esig below the limit shown en OP 1038. carve 8.
On September 14,1994. STI 94-021 was issued stating that engineeHng had identified that the caltslated 4
l errer was greater than 2 psig and therefore, operators were directed to j
maintain 187T pressure approximately 1.5 psig below the limit shoun en OP-1038. curve 8.
The pernement revision. Revision 13 to OP-1938, was issued on January 30, 1995. and contained two new curves to replace the i
existing curve 8 titled. Maximas Maheup Tank Overpressure.
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On January 31. 1995, the licensee reported the operation outside their design basis to the NRC. The licensee deterizined that the short ters j
instructions issued on September 9 and September 14, 1994, and the new pressure versus level operating curves for the Itif (curves SA and SB in
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0P-1038. Plant operating Curves), issued on Jassary 30. 1995, were non-conservative. The ST!s and the new curves were based on design assumstions that did not correspond to current EDP reemirements.
Specifically. E0P-08. LOCA Caeldsun, step 3.35 and 3.83, and EDP-47 Inadeonate Core cooling, step 3.9. require realigning ECC5 pump section to the R8 sume and aligning for piggy back operation of the fars when the BW57 reaches an indicated leve..of a 5 feet. The calcolation used to support the STIs and generate the new 0P-1038 curves assumed the swap over to the R8 sums and piggy back alignment was completed prior to reaching 5 feet in the BWST. The STIs issued on September 9 and September 14. 1994 and the curves issued on January 30, 1995 did not prov1de adequate margin to ensure that hydrogen entratament in the high pressure makeup pumps was prevented duNng design basis events when the makeup tank was operated within the specified pressure and level limits; and. therefore. the interim curves alloued operation,of the makeup tank outside of'the design basis pf the plant.
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The licensee's immediate action was to issus a short ters instraction with the following guidance to operations:
(1)
Due to inconsistencies between the design assumptions used to te OP-1038. Rev.13. Curves SA and 88, and EDP-8 LOCA idown. maintain falT pressure a minimum of 7 and a maximum of 11 psig less than the limit given in 0P-1938. Rev.13 Curves SA and 88.
(1)
When transferring LPI section from the SW5T to the RS suo and establishing HPI suction from LPI (EDP-8. steps 3.35 and 3.53 and E0P-7. Inadequate Core Coeltag, steps 3.9 and 3.10) valve D
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alignments need to be perfomed in a timely manner. While j-performing the numbered detail steps in ereer, both A and 8 train j
valves listed within the step should be streked simultaneously.
(3)
Due to the location of the transmitter, indicated SW5T 1evel will 1
j not decrease below 2.33 feet.
l (4)
The STI was not to be altered or rescinded without DNPO approval.
f 10 CFR 50, Appendix B, CHteHes III, Desipa Centrol, requires that i
measures be established to assure that app,1ceble regulatory reesirements and the Design Basis, as defined in 10 CFR 50.1, j
Definitions, and as specified in the license.applicaties, are correctly transisted inte specifications, drawings, precedures, and instrections.
FSAR Section 6.1. ECCS, states in part that the upon a valid actuation signal, the Makeup and Purification System is automatically switched from its normal operating mode to the emergency operating mada (High Pressure Injection) to deliver water from the berated water storege tank into the reactor vessel.
OP-1038. Plant Operating Curves, Curve 8. Maximus Makaus Tank Overpressure, defined operating limits for centre) of the reactor 3
coelaat system makeup tank pressure versus level. Operators were instructed by management to maintain the sakaup tank pressure versus level close to the limit defined by Curve 8 to anzimize hydrogen overpressure.
10 CFR 50, Appendix 5. CHterica XVI Carrective Acties, states, in
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part, that measures shall be established to assure that conditions adverse to cuality, such as nonconfermances, are promptly identified j
and corrected. In the case of significant conditions adverse to j
quality, measures shall assure that the cause of the condition is j
determined and corrective action takaa to preclude repetities.
.As discussed aheve, the design basis for the ECC5 was not correctly translated into drawings, procedures, and. instructions for the emergency operating mode (High Pressure Injection) ef.the Makeup and Purification System. The STis isssed on September e and September 14, Igg 4 and Revisten 13 to 0p-1038, Plant Operating Curves, which replaced Curve 8 Mexisme Makaus Tank Overpressure, with new Curves SA and 85, Mexiana Mekamp Tank Operating Pressure Versus Level en January 30, Igg 5 all alleued operaties outside the plant design basts.. An Engineered safeguards actuation while operating en the new curves, could have resulted in cavitation and. subsequent inoperability of at least see of the high pressure injectica pues and, for a given scenarie as descHbd in paragraph 3, without operator interventica, could have reselted in the loss of all MPI pues. Thorsfere, the corrective actions for the previously identified problem with the curves were inadequate to prevent operaties outside of the design basis. Failure to meet the requirements of 10 CFR 50. Appendix B, CriteMen III and XVI for the interia curves
7 and the curves issued in Revision 13 to OP 1035 are identified as examples 1 and 3 of apparent violation 50-302/95 13-02.
5.
Review of Design Assumptions for torated Water Storage Tank Swepower Level (92903) l On February 2. 1995, the residents nuestioned the licensee regarding 1
their desi to the RB'gn assumptions for the SWIT 1evel for swap over from the SW5T sump. The inspectors identified the following addittenal concerns:
The indicated BWET in the control room reeds from 0 to 50 feet.
The accuracy of the SWST level instrumentation contains more than 0.5 feet of uncertainty.
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The top of the 14 inch line from the IMIT to the Es pumps is J
located at apprezimately the two feet level in the BW5T.
Vertaxing of the borated water in the W5T was not accounted for.
1 The BWIT contates a vertex breaker, housver, the licensee has been i
unable to iscate any of the calculations for this devica. The-l licensee's preliminary calculations indicate that even with the i
vertex bresher, vertering would be likely to occur between 3.5 and l
4 feet of BW5T level.
t Operators could ;-.."..
the IWIT to RB sume transfer function in j
accordance with procedures at anyttas the SW5T 1evel became less
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than 5 feet.
l At the maximum flow rates, the drew doun of the IW5T approaches 1
one foot per minute.
1 On February 2. 1995 the licensee made a report to the NRC regarding their finding that manual swap over of the Es passes from the BW5T to the R8 suas may not occur in ties to prevent vertering in the BW5T.
Preliminary calculations indicated that a staisum of 4 feet is reesired in the SW5T te prevent wortexing and therefore ensure adequate NPSN.
Engineering calculation M95-0005 dated February 5. IM concluded that vertexing in the SW5T has the potential to begin at 8' 5' in the tank.
Taktag level instrument error and calibration tolerances inte j
pensideration increases the level required by I' 2* and the suspever to the RB sump suction should be complete before an indicated level of 7 feet is reached in the SW5T.
l 1he licensee's analysis i$itcated that after disposittening these j
considerations. it was acceptable to raise the SW5T suas ever to the i
15 feet level.
The E0ps have been revised to reflect that the suopover i
should occur starting at 15 feet and be completed by 7 feet.
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The swapover from the WST to the RB suas is a manual operation and has j
been designated over the years as follows:
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(1) 5/75 to 5/79 2.5 feet in the Bust os 1
(2) 5/79 to 6/83 3 feet 9 inches in the SW5T 3
i (3) 5/83 to 6/90 2.5 feet in the SMST.
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(4) 6/90 to 4/93 2.2 feet in the R5 i
(5) 4/93 to 2/95 s 5 ' feet in the SWET i
The licensee is conducting a more rigorous analysis of the swepover 4
level. There are vortex and NpSH considerations for the peups taking suction fram the reacter building sume. Addittenelly, there are Trisodium Phosphate baskets for pH control in the RB louer basement areas. The calculations for their placement assues a certata volume of water in the sume and a certain flew rate. Both the volume and flew rate of SW5T water into the suas area will change if the suas over level in the BWST changes. These changes will result in a different rate of Trisodium Phosphate dissolution.
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10 CFR 50 Appendit B Criterion !!!, Desipa Centrol, receiros that l
asasures be established to assare that app.icable regulatory i
reentraments and the design basis, as defined in 10 CFR 50.2.
Definitions, and as specified in the license application, are correctly j
translated inte specificattens, drawings, procedures, and instructions.
i FIAR Section 6.1.2.1.2. LPI. states that when the WST level reaches an elevation of 5 feet, the operator will take action to sees the LPI system suction valves from the RB emergency simo, permitting i
recirculation of the spilled reactor coolant and injected mater from the R5 sump.
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EOP E0P-08 LOCA Coeldown, revision 2. steps 3.35 and 3.83, and E0P-07, Inadegrate Core Cooling, step 3.9, revisten 1, require realignias the LP! puns suction from the WST to the R5 sump and aljgning for piggyback j
operatim of the Make Up Pueps (9 tips) when the SW5T reaches an indicated 1evel of less than er equal to five feet.
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<As discussed above, the design basis for the ECCI was not correctly j
translated inte drawings, procedures, and instructions for operation of j
the manual swap over of the ECCS pumps suction from the IW5T to the RS 3
sump in that on February 1,1995 an engineering evaluatten identified that initiation of suas ever of ECC5 pump section from the W57 to the RB sumo should be completed prior to an indicated level of seven feet to prevent wortering and resultaat disab11ag of the ECCI pues. Stace 1975 t
(except for the time period of June 1990 through April 1993) plant procedures have required the mensal swepower from the tusT to the RB suo at a level of five feet or less in the SW5T which is tasefficient j
to assure that all of the ECCI pumps would not be damaged by vertering.
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1 This is an apparent violation of 10 CFR 50, Appendix 8, CHteHon III, j
Design Control and is identified as example 1 of apparent violation 50-l 302/95-13-03.
6.
Follow-up of Licensee Event Report 92-003.. Personnel Error and Lack of Technical Review in Past Procedure Revision Process Leads to incorrect Proceeures Resulting in Violation of Technical specification and Design i
Basis (92903) j 1
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On August 1,19g1, the licensee identified a potential problem conceratag a calculatten to support the basis for assuHas EDS fuel' oil storage volumes were maintained as required by 75 and design basis. On j
April 15,19g1, the licensee deterartand that two precedures for i
documenting the volume of fuel stored in the EDS fuel oil stareos task i
had been erroneously revised, resulting in see occurrence of fasture to meet the minimum volume of feel assmed in the design basis and i
14 occurrences of failure to meet T5 regatrements for minimum fuel volume. The cause of the problem was attributed to a failure to recognize that due to suction locations, some of the volume in the l
storage tanks would be unusable and cos1d not be taken credit for.
As part of the corrective actions, the licensee stated that the relationship of suction point to task level for other tanks havtag a T5 required minimum volume would be vedfied. A corrective acties plan, i
which pHoHtized the vaHous taats, uns developed. Originally, the various tanks were scheduled to be completed by December 1994, with the j
highest priority tanks being scheduled for completion by December 1993.
The prioHty 1 tanks included the CST, the Bust, the EEDG fuel oil day 4
j tanks, the SASTs, and the CFTs.
On September 19,19M the corrective action plan was revised, as none of the steps for recalculating the volumes had been completed. The new completion dates called for the project to be completed by ApH11997, and the priority 1 tanks were scheduled to be completed by March 1995.
This delay has an impact on the concerns en the SWST discussed in i
previous paragraphs. The calculation of the SW5T volume concerns has a i
direct impact on the BWST issues. This issue was a previous opportunity for the licensee to identify and correct the problems with OW5T section.
A recent NRC review of the fire water storage tanks F5T-1A and F57-15 tank calculations M93-0028, revealed a discrepast condition'hetmeen the i
FPP and the EDSD requirements. The FPP required that 345,000 gallons of I
water be contained in each fire water storage task. The EMI regnited a statsum capacity of 300,000 gallees of water be available from each tant to the fire pumps. However; the capacity of the F5Ts is less then 345,000 gallons of ganhlt water in either tank. When full the tasks each contain appreztmately 318,000 gallons of gaggg water. The 1
requirement in the FPP for each tank to contain 34a,000 gallons does not i
appear to correspond to the design basis requirement of 300,000 gallons.
1 The licensee's volume calculattens of the tanks concluded that when L
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197,000 gallons of EIAbla water are in the tanks.
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The surveillance precedure. Sp 300. Operating Daily Surveillance Leg, requires that each tank be verified to castain greater than 35 feet of water by level indicaters FS-1-LI and F5-2 LI. These indicators are read on a 0 to 37 feet scale in the control room. The 37 feet level corressends to approximately 315.500 salleas of B15411 water. The 4
35 foot requirement specified in, Sp-300 correspenas to approximately j
195.000 gallens of 333g13 meter. The precedural requiremmat does not appear to account for instrement talerances, wht:h betueen the l
transmitter and the indicator, are nearly 14 inches. This worse case i
candition, considering the instrument tolerance and a level of 35 foot i
in the tank, would en ly ensure a value of approximately 183.000 gallons of E04kl1 water in the tank. This value is outside of the design basis.
The iconsee has stated that they norus11y aparate above the 35 foot level, since there is an alare eight inches above this level. The alars is calibrated to assure that approxiestely 302.000 gallonsofMIakl1 water are available in the tank. Housver, the level switch has sa allowable talarance of four inches. meaning that the alars, set within the talerance, could correspond to only apprezimately 199.000 gallons of water, which is outside of the design basis.
When made aware of the inspectors caecerns, the operators increased i
FST levels to the maximus the tana can held, to assure that there was enough water available to guarantee that the design basis calculated l
mininds' requirements were met. This placed the F3T gagglg water above the levels where concerns exist. Operaters were informee of this issue by a note in the shift supervisers' leg.
The Crystal River Facility Operating License No. DPR-72, paragraph i
2.C.(9). Fire protection, requires that fire protection measures be implemented. FSAR Section 9.8 states that the fire protection program I
has been formulated in accordance with specific fire protection I
governing documents listed in FSAR Table.918. Table 9-18 includes the i
FPP.
The FPP required that 345.000 gallens of water be sg&&1ggg in i
each fire water sterage tank. To impletant this requirement, the EDE j
required a minimum' capacity of 300.000 gallonsofwaterbeAttilakli j
free each tank to the fire pumps.
10 CFR 50. Appendix 8. Criterien XVI. Carrective Action, states. in i
' part, that measures shall be estabitshed to assure that conditions i
adverse to quality, sech as neoconfermances, are promptly identified and corrected. In the case of significant candittens adverse to quality, measures shall assure that the cause ef the condities is deteretned and corrective action taken to preclude ret.dtities. Failure to implement timely corrective acties to reviou potential sigstficant j
condittens adverse to quality involving safety related tanks. including the BMST and F5T. is a violation of the requirements of 10 CFR 50 Appendix B. Criterien XVI and is identified as avample 2 of apparent i
violation 50-302/g5 13-03.
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11 10 CFR 50. Appendix t. Criterion III. Design control, requires that measures be established to assure that applicable regolatory reeuttsants and the design basis, as defined in 10 CFR 50.2.
i Definitions, and as specified in the license applicaties, are correctly translated into specifications, drawings, procedures, and instructions.
4 Failure to translate the design basts reentrenants of the F5T into operating procedures is a violation of 10 CFR 50. Appendix 5., Criterion 4
III and 1s identified as exemple 3 of apparent violation of 50-302/95-13-03. This issue was previously follound up under URI'50-302/95-08-04. This unresolved item is new' closed.
7.
Operation With One LPI Pump and Two MPI Pamps While in the Piggy tack i
Mode (92901)
On March 22.1995, at 5:07 p.m. the licensee made a 10 CPR 50.72(b)(1)(ii)(3) report regarding the finding of inadequate post LOCA i
RS water inventary to support the current E0P requirement to aliga one
- i operating LPI pump with two operating HPI pumps. Durinp a follosup engineering investigatten of previously identified proh.eas ir.217tc operation of the fRIT outside of the design basis (See LER 94-003.
Personnel Errors in Determining paff Level / Hydrogen Pressure. BMST j
Vertexing and RB Suas Level Parameters Rasult in Potential for Operation outside Design Basis, and URI 50-302/94-22-01 addressed in Its 50-302/94e22, 95-02, and 95-07) the licensee identified a condition specified in E0P 08. LOCA Cooldown, revision 1. steps 3.39 and 3.57, and E0P-07, Inadequate Core Coolinp, revision 1, step 3.10 that directs the
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operator to accompitsh the fo1 owing:
If only 1 LPI peup is operating,1hglLensure IRIP section cross tie valves are open;
- fGN-69 This created a syates alipament where one LPI pump could be subjected to two HPI pumps. gpa nomina, to the RV 540 jam to the section of each ofA rec supplying 2200 j
and 100 gpa recirculation f" ow.
calculation (Meo-0021) shows that insoffittent water inventory would exist in the RB to provide adequate llPSH to the single LPI pump at the noted flow rates. This lineup could result in the loss of the only operable LPI pump.
As immediate corrective action, the HPI pues' sectica cross tie valves were caution tagged to the 5512. STI 95-0022 was issued en March 22. 1995, to provide operators with addittenal guidanca. The STI is required reading for all operators and it advised operators of the reason for the revtsed calculation and to alert them to the tagging order on the HPI suction cross tie valves. The STI aise alerted the operators that E0P-07 and E0P-08 were affected. The STI had a 10 CFR 50.59 safety evaluaties, an 1% revieu, a PRC revieu, and 011P0 approval. The centrol copy of the affected E0Ps in the controi 4
room were marked wtch a red pen at the appropriate steps to remind the i
12 operators that @a STI affecting that step had been issued. The formal change to the E s is scheduled to be accomplished within ten days. The inspectors verified that the E0Ps had been marked as specified and that the STI was in the centrol room.
10 CFR 50. Appendix 5. Criterien III Design Centrol, requires that asasures be established to assure that app,1 cable regulatory reestrements and the design basis, as defined in 10 CFR 50.2 Definitions, and as specified in the license application, are correctly translated in to specifications, drawings, precedures, and instructions.
FSAR 5ection 5.1.1, which describes the design basis of the ECCS states, in part, that the ECCS has been designed to perform its functions if a si le active failure occurs and that one of the design functions of the E
is to provide long term cooling by recirculation of injection water j
from the reactor building same to the cwe through LPI.
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E0P-05, steps 3.39 and 3.57, and EOP-07,' step 3.10. direct the eseraters to open the HPI pumps' cross tie valves is the event only one LPI pump i
These procedural directions have existed since April B. 1993.
is available to supply suction when in the piggy-back mode of operation.
i Neuever, engineering calculation M30-0011, revision 5. dated March 22. 1995, determined that during post LOCA operation there was inadequate inventary in the RB sus to provide adequate NPSI to a LPI l
peup, with the HPI pume suction crosstie valve open, supplying two i
operating HPI pumps. This. lineup could result in the less of the only operable LPI pump. This is an apparent violation of 10 CFR 50 Appendix 5. Criterien !!!. Design Centrol, and is identified as apparent violation 50-301/95-13-04.
f 8.
Review of Management Oversight and Centrol of Licensed Activities In regard to the actions of the licensed operators on September 5.1994 1
the lutC is concerned that appropriate management eversight and centrol j
was not exercised to preclude the apparent intentional violatten of plant procedures. In the licensee's letter to the NRC dated May 5.1995, the licensee characteriges the operaser's concerns about
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the makeup tank operating curve ~as a legitimate technical concern, yet l
the record reflects that engineering famed the curve to be edessate and j
proposed that the issue be closed. It is not clear that managemast was J
, properly involved in resolution ef these differing technical spinions.
l In addition, operators did not seek approval of management in conducting i
the evolution to evaluate response of the system. This reises questions i
as to the adeemacy of communications betusen management and the licensed eperating staff including whether management has clearly conveyed its l
expoetations in regard to procedural adherence and the need to use established review mechanisms for planned activities that are outside i
routine operation.
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As stated in the cover letter, these apparent violattens aise indicate significant weaknesses in the management control of the revies and al i
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resolutica of significant conditions adverse to cuality. These weaknesses include (1) the failure to adequately review operater concerns en gas entesinnent in the high pmssure injection pumps which had been identified in several problem reports and correspondence between operations and engineering; (2) inadeonata engineering revious l
of the design assumptions for the pressure / level operating curve of the i
makeup tant; and (3) failure to implement timely corrective actions for 4
indications of deficiencies in the design assumptions for various safety-related tank levels. The rest casse of these issues appears to be a lack of managensat oversight of the review process. The IK has previessly expressed concerns with management eversight and cemettment 4
to program implementation in meetings with licensee management es j
llevanter 22, 1994 and liarch 1,1995.
9.
Exit Intervios i
The inspection scope and findings were summarized on July 5,1995, with i
these persons indicated in paragraph 1.
The inspectors described the areas inspected and discussed in detail the inspection results Itsted l
below. Proprietary inforestien is met contained in this report.
4 J.XRt h h Descristion and Reference EEI 95-13-01 Open Deliberate operation of makeep tank i
operation entside of acceptable operating j
regten. (paragraph 2)
EEI 95-13-02 Open Operating curves for makeup tank estside design basis and failure to take adagnate corrective actions. Three examples.
(paragraphs 3 ane 4)
EEI 95-13-03 open Inadequate design assumptions for berated water storage tank swapever level, inadequate corrective actions, and inadequate stored' fire protection unter.
(paragraphs 5 and 6)
EEI 95-13-04 open Inadegasta Ilot positive section lleed to an Engineered safeguards pump during accident canditions. (paragraph 7)
URI M-12 01 Closed liekamp tank operation outside the acceptable operating region.
(paragraphs 1, 3, and 4)
URI 95-08-04 Closed Discrepancies in the implementation of the fire service water tank level versus volume calculations. (paragraph 6)
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IXRR M Status Descrintion and Reference 1
LER 91-003 open Personnel Error and Lack of Technical i
Revies in Past Procedure Revision $ Process l
Leads to Incorrect Procedures Resulting in i
Violation of Technical SpecificaYion and Design Basis. (paragraph 6)
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i 10.
A w and Abbreviations 1
I AI
- Administrative Instruction j
AND
- Auxiliary Nuclear Operator i
ANES - Assistant Nuclear shift Superviser 35P
- tutiding spray Pump seu
- Babcect a v11cez l
W5T - Borstad Water Storage Tank i
CCHE - Castrol Complex Habitability Envelope CFM
- Cubic Feet per Minuta
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- Certificate af Complianca CF
- Campliance Procesare i
CW - Castrel Red Drive Mechanism i
CREV5 - Castrel Room Emergency Ventilation System j
CVT
- Constaat Voltage Transformer DCP
- Decay Heat Closed Cycle Coeling Pump 4
- Decay Heat Closed Cycle Cooling Valve j
- Decay Heat Pump j
OHV
- Decay Heat Valve DNPO - Director Nuclear Plant Operations
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ECCI - Emergency Care Cooling Systan(s) t EDEFI - Electrical Distribution system Functional Inspection
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EGDG - Emergency Diesel Generator i
- Emergency Operating Procedure ESF
- Engineered safeguards Feature ESA5 - Engineered safeguards Actuation System F
- Fahrenheit FCN
- Field Chans Notice FLUR - First Love Undervoltage Relay FPC
- Florida Power Corporation 4
FSAR - Final safety Analysis Report NEPA - High-efficiency Particulata Air i
- High Pressere Injection IR
- Inspection Report LCO
- Limiting Candition for Operation LER
- Licensee Event Report LOCA - Less of Coolant Accident LPI
- Les Pressure Injectiton MAR
- Modification Approval Record MP
- Matatenance Procedure Mur
- nakeas Puno M
- Makeup Tank M
- Makeup Valve NCV
- Non-ettad Violation
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15 NOTIS Nuclear Operations Tracking & Information System i
- Notice of Violation NPSH - Not Positive section Head NPT5 - Nuclear Plant Technical support 185 5
- Nuclear shift Supervisor 3RREG - NRC technical report designation 01
- Imc ' Office of Investigations i
OP
-~ Operating Precedure PM.
- Preventive Maintenance
- i pes
- parts per million PR
- Problem Report i
- Plant Review Committee i
psi
- pounds per square inch psig - pounds per sgears inch gauge f
OC
- Quality Centroi 04
- Quality Assurance i
RS
- Reacter Building l
- Reactor Building Spray RCA
- Radiation Castrel Ares j
- Reactor Coelant Pump RCI
- Reactor Coelant System RP5
- Reactor Protection System RV
- Reactor Vessel RW
- Raw Water RWP
- Raw Water Ping i
RWV
- Raw Water valve j
SCRA - Self Costained treathing Assaratus SL1R - Second Level Underveltage Relay j
- Surveillance Precuhrre SR
- Surveillance Requirement
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- Staneard Review Plan i
5512 - Shift Supervisor on Duty i
- Short Ters Instruction SWP
- Service Water Pump TDP Training Department Procedure TIS
- Training Information system i
T5
- Technical specification T51
- Technical Specification Interpretation l
- Unresolved Ites
=
- Violation WR
- Work Request V
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ma nne E M E"conamsmaa g%
.. _se,s. g a. : -
,,,,,)
,ebre.r,..i
,,.#CL+
y Mid.2,ft.-A ha gg e
2 CA 95 116 fGCEVEP' 4/"
nr. P. M. sord Jr.
ACT10N DY: ## #*% -
soster vice pr. n d.et, n ior e,e,eu.
e Eda 22ce"r,"J*eE.""" """',gs sifflisI! Ilfhllitill i
i 187m West power Lies Street l
Crystal River. FL 34438-4700 I
SUBJECT:
NAC IIIBptCTim RD0tf W. 56 30t/95-22 I
Dear Mr. Seard:
I85358l$15 3g331 This refers to a special tese tospectten conducted se Decesher 1118.1916 at the Crystal River factitty. The perpees of the tospecties ses to deterates uhether operettee of Crystal Rieer ustt 3 ses safe and'Is accordance utt4 EK reentressets. At the conclasten of the toepeetten the fledlags were discussee with those easters of peer staff identified to the enclosed report.
t Areas essetned dortog the taspecties are identifled to the report.
Ethie these areas, the loopsction tecluded selective esentsattees of precedsres and records and interviews with persessel concerates the facts and circemetences pertaistas to control of pressere and level to the reacter coolest system i
enkeep task.
Based on the results of this tespeettee, and the results of the toepecties described in leepectise Report 96 388/95 83, lated enforceanet a fear apparest violettees were identified and are betes considered for esca A
accordance with the 'lemeral Stetsenet of pelley and precedere for M Enforceaset Actions * (teformannet pelley). IRMt.1800. In addities, i
enforcement actice is hetag caseldered agatest the Itcensed operators teseleed le the esparent vtelattens se September 4 and 5.1994. which are doesrthed belos.
4 A synopsis of na IK teveettgsttaa of activities related to the
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september 5.1994, apparest vtelattees ses prov$ded te krserletterof l
July 7. 1995. Ao levestigette of estivities se 4.1994, is la progress and a synopsis of that tesesttestles will provided to pas ebes the tesestigettes is coepiste.
With regard to the first' esperest.vtelattee deserthed to the enslosed report, eine examples of operators esteedtog the eastsee overpressure corse for the make up task while adding hydrepen were identified. Additismally la the eine examplas reviewed by the NE, the action regelred by the alare res,sesse procedere was not carried est for perteds of time ranging free 3 etestes to 1M stastas.
The seemed apparest violettes esteeres tus evoiettees of Septeater 4 and 5, 19p4. These evoluttees were slee violettees of the easteen overpressure curve. Stess these eso attees were est reestree by plass candittees at the ties. het were testead tattiated by operatore for the p +aR R &
f t
FM porpose of gathering data relative to the astems tank curve, they are l
Performance of tests or coasteered to have been tests or espertasets.
experteents without a urttten safety evaluatten which provides the bases for
.i the determinatten that as unreviernd safety guestten is not tave)ved ts a violattee of it CFR 50.59.
The teled apparent vtalatten, with three examples, levolved fattures to east 1
i 10 CFR. Part st. Appendia S. Criterten IV1. Carrective Action, la that enes l
destge defieleetles more identified by year staff, they were met adegastely i
corrected in a timely meaner.
3 1
l The fourth apparent violatten, with fear esemples, tevolved failures to aset the requirements of IS CFK. Part 56. Appeedt 8. Criteries III. Destga i
Centrol, to that the design basis was set correctly treastated inte drawings.
l precedures, er tastructions, for: (1) eperettee of the makeup tasks (2) operatten of the mensal suas over of the Emergency care Castlag Spetes pumps suction free the berated unter storage task to the reacter bet 18teg
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sumet (3) metattutag adeguate teventary in tM reactee hetidtag seg to j
proelds adessoa yt positive sectten head to see low pressere tajecties pump with the high preaure tajectica (NPI)laaestten peeps and (4) antsta j
sopiths tus operating Nigh Pressere seequate unter asentity la the fire water storage tank.
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No hettce of Violatten is presently bites inmed for these inspection i
la aedtttes please be adeloch that the musher and characterttatise findtags.
of the apparent vtelattens deserthed to the enclosed inspecties report may change as a result of further SAC reelow. A predecistaael enfersement l
cesference to discuss these apparest violattens will be scheduled at a later date. No response to these apparent violattens is reestred at this teen.
In accordance with le CFR 1.790 of the IKs
- tules of Practice'. a copy of
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this letter and its enclosures will be placed la the IRC Peelic Document Rees, h
'5hould you have any questtens concerates this lettar, please coatect us.
f 54 1{.
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- f. 4thasa, b -
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Otvisten of teacter Safety 3
Decket No.: 50 302 l
Ltcasse No.: DPR-72 j
Enclosure:
HRC Inspection Report 5M01/95 t!
1 (ccw/ enc): (See peps 3) l 4
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FPL 3
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cc w/enci l
Gary L. Goldt. Vice President Nuclear Pro 6uction (5 ARC)
Florida Power Corporatten j
Crysta) River Emery Comples 15750 West Power'Line Street l
Crystal River. FL 34488 6708 j
j
- l. J. Nickle. Director Nuclear Plant Operettens (natC) l Florida Pouer Corporetten Crystal River taergy Complex 15)Se West Peuer Line Street Crystal River. FL 34488 6708 L. C. Kelley, Director (5ntA)
Nuclear Operattees 5tte Support Florida Power Corneretten Crystal River Energy Comples j
15760 West Power Line Street j
i Crystal River. FL 34428-6708 g
l Corporate Counsel Florida Pouer Corporatten MAC - ASA P. D. Ses 14042 l
St. Petersburg, FL 33733 Atteraey Geners)
Department of Lapal Affairs The Capital Tallahassee. FL 33304
.(cc w/enci cost'd See page 4) i 9
1 s=o l
1 4
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1; i
4 i
FEL i
I (ccefeati cent'd)
Sl119essetti j
office of Radiatina Centrol Degertueet of Health and i
hhabilitative services 139 Wheemoed.Seulevard i
TaHahasses. FL 32399-0700 1
l Joe fWrs. Meester Diststem of Emew Preparedness Desertment of Commently Affairs j
275 Centerview Drive i
TaMatessee. FL 12399 1100 Chstrema j
leerd of Ceesty Ceamissteners j
Citrus Cemety las E. Apopka Avenus i
Innereess. FL 34450 4245 l
1 I
R6ert S. Bersus E5 huslear Technolog$stte 125 ies IIIe ser.tv111e Pike, Astkville.19 20811-1631 0
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me n sva m esWOLSAR haputA1eRY 000stsiesgost asume f
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- M"eendEe'n"e's"
\\,...../
e Report No.: 50-301/95 22 Licensee:
Florida Peuer tem 3303 34th Street St. Petersburg, F133733 Dechet No.: 50 302 License No.: OfR41 Factitty Nome: Crystal River liuslaar Plant Unit 3
- 7ggggf gg Accompanytag Inspectors:
C. Ross, Ramster laspector R. Schte. Reester laspector hlb Approved by:
I natens o. cartstenses, sater sete signes l
Metatemence trench Divisten of tereter Safety 538WIRf Scope:
An inspectien was conducted to deteretas if ;afmeet provided adequate guidanca, trataing, precedures, and other sept MT, necessary to meet annagement's espectattens for operetten of the Make-se fast System. De inspecties reviewed Make up, Tant data to determine if the system ses operated in accertance with approved precedores and if appropriate acttees unre taken for est of specificatten condittens.
" hessits:
,Four apparent, violattens were identified:
Apparent vtalatten 50 301/95 22 01: Nine esame)es of operattaa of the enkse tank entside the acceptable operating regten while adding hydrogen.
Apparent violetten 56-303/95 11 02: Too esemples of conducting en unesthorized test er esperteset withest a urttten safety evaleotten containing the bases for the deterutsatten that se enrettesed safety Wien did est estet.
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Apparent violatten 50 302/95 12 03: Three examples of inadessate corrective i
actten conceratag taedequate revistees to Curve 8, Mastaun Rake up lank j
Overpresseret inadequate review of Problem Report M.149; and inadegeste 1
corrective actten for reestred tant velemes.
j j
Apparent violatten 50 302/H It N: Fear examples of inadoesste design control conceratag the incorrect design informatten costaland in Curve S which 4
2
' allowed the plant to be operated setstes of its destge basis, taaervest suspever point for the berated water storage taat, landecente not peettive 3
I sectten head for the les pressere safety in,teettaa pumps derlag seapover ts j
the teacter tutidtag semp. and afstaus volane regelressat for the fire water j
storage tank met betag set-i tieaknesses were identified ta the human facters espects of taformatten provided to operators for centrol of ashoop tank lege) and pressure. lack of tracking out of calibesties data, the fallere to place the asheep tank level / pressure alara in a restine calibretten progras, taaffective communicattens between eserattens and engtasertag and withte both departasats, vague guidance provided te operatirs la precedures for thaa precedures are adeguate for evolutions betag performed, for alors response times, and for deterstalag when evolettees constitute a test er espertaast,
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l REfgET OCTAILS i
1.
Persons Centacted i
Licensee Personnel
- K..Saker. Manager Nuclear Configuratten Centrol G. Becker. Iloclear Plant Operattens Evaluator
- G. Belt. Vice president Nuclear Production
- R. Bright Nec) ear Prtactple Liceastag Eastaser J. canetell. nsanger Nuclear feuer Techatcal support
- R. Cuts. Matstoneses Neanger
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- 0. deNeofert. Nuclear Operattens lastructor
- N. Seneven. Superviser Nuclear Power Teshattal Support
- R. Enflager. Senter Licenstes Eastseer j
P., Fleastag. Senter Nuclear Licenstag Eastaser
'A. Friend. Nuclear Principle Lisaastag Eastseer
- t. Gathermen. Nuclear Licenstag Manager
- t. Malaan. Manager teclear Plant Operettens V. Hermaneet, Senter Nuclear Employee Caseura 5pecialist
- l. Miakie. Directer. Nuclear Poser Operettees
- L. Kelly. Director. Reclear Operettees Sita support
- W. Kinner.Jr.. Senter Nuclear Schedule Caerdinator j
- K. Lancaster. Nuclear Manager
'J. Ltad. Manager Nuclear taas Tratstag
- t. Langheeser, Nec ear Security
- J. Raseda. Romager leer Eastaaertag Design
- R. McLaughlte. Nuclear Regelstery Specialist B. Meere. Meneger tiert Centrols I
- s. Rehtases. Nameser Nuclear Seality Asserence J. Smith. 5eserviser Operstar Tratatag
- 0. Stanger. Attermey
- P. Tangeay. Otracter Nuclear Engineering and Projects i
- 5. Wataberg. Attorney R. Wide 11, Neelear Operattens Trataing Other Itcensee employees contacted included engineers, techstetaas.
operators and office pereennel.
NRC Personne)
- t. Butcher. Senter Restdent laspector
- T. Ceeper, besident.nsposter
- P. Kellogg!. Senter Project Manager. Otvision of Anector Sa Regten !
- K. Landis. Branch Chief. Olvistes of Reacter Projects. Reglas !!
'C. same. Reester Inspector
- t. Schin. Reacter Inspector
- Attended Eatt laterview.
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Operation of the Makaup Tank l
The taspectt'en documented ta NRC laspecties Report (IR) 50 302/W13 i
l reviewed the strcumstances sorroundlag the septoneer 5.199s event l
levolving pressure contre) of the reacter coolant systes makeup taat.
J Dotatis of the retten of the September 5.1994 event are decomested la paragraph ! ef IR 80 302/95-13. Apparent violatten 80308/9813-01was teentifled as a result of that rettes. After forther rettes, the IRC i
has concluded that, en tus essastems se Septesher d and 8.1994, est
!j' enly did operators fail to felles precedures, het M CFR 98.M uns aise j
v6 elated to that the manipulations more est rewired by plant condittens and es approved precedere esisted for the conduct of tas tests. This i
l apparent vf.elatten is discussed la dotatl la sectten 1.1 of tkts report and identified as apparset violettes 50 30t/9642-08. Apparaat violattes 56 303/95 13 81 ts adelaistratteely cleted and the fatture to j
follow procedures en Septester 5.1994 identified to $8 388/9513-81 ts 4
l incorporated late asample 1 ef apparent vietattaa N 382/95-II St.
Paragraph 1 of It M.308/95413 hts the K rettee of k hip i
hasts of itK operatteg 16atts. Bertag this review it uns deterstand
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that the esR pressure llett curve seastttutes a desten bests itset.
Apparent violattes $0 302/582 41 deurthed is detall holes therefore l
represents esemples set only of a failure to fe11su preenderes. het aise examples of the failure to operste withis the design tests Italt.
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1.1 Makeup Tank Data The taspectors revisued enhe-up task data for the stas pried I
.1ume 1.1994, through Septesher 7,1994, to deterstee tee number of ttans Curve 8 Itatts as sehe-up taak pressors and level had 1he tospectors aise shserved the sake.tp tant f
been awaadad.
pressere and leve) lastrusatatten in the control rues, reviewed drawings and calthrottaa reeeres for that tastrumentatten, retteued the design calcelatten that supported Curve 8. rettaued 4
hperater legs, ens disenssed the tastemastattes destge and f
operattes uttk engineers sad getrt1gfs.
lastrementatten in the centrol fees for enke-up tank level and pressure included a high pressure alars, computer potets, and a chart recorder. Durtog the time perted.lume 1,1994, threeph September 7.1994. the alars was drives by the campster eash tha uhasever the cesputer valse for make-up tank pressure escoeded the curve a tiett for the esisting mate ep tank levs1, tkt a)ers would ;
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be activated. ilhos the pressure was equal to or below Carve 8.
the alarm would be dt. activated (there uns as propressed dead 6eersters seeld dispity the asapeter potets for make.up band).
tank level and pressere sa vndes screens above the esta centre) heard er en the rtpht stes of the costrel heard. The seester data was saved nr the plant sempster every stoute and uns available for the taspector to rettee. Joe shart recorder uns 1ecated on the vertical sostion of the esta sentre) heard a
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displayed aske up tank level and pressure en one strip chart. The 4
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chart records were saved by the itcensee and captes were available 4
for the inspector to regten.
Plant computer records of make.sp* tant pressure and level l
tadteated that Cerve 8 Itatts had been escoeded, and the related i
central roes alare had been valtdly activated, en numereas l
different occastems deptes the ties period in geestica. The tespectors selected the eleven most digatftsamt essastems for J
further nvtes. When the alare had been to centlemeesty for more-i than 30 stestas and Corn 8 had been exceeded by more than 0.5 i
psig. These escastems were:
t Duratten Maatama pressere j
bang 11 3 (minutasi over Cerve a faste) 11 7/13/94 12:13 14:14 112 1.es
!)
7/25/94 18:27.-11:14 44 0.48
]
3) 7/t7/94 14:44 16:01 78 8.65 4) 7/20/94 14:36 17:29 184 1.10 5) 7/30/94 09:28.!!:38 ISO 0.73 6) 8/6/M 00 H.12:15 141 0.82 7) 8/8/94 18:08 11:14 67 1.54 8) 8/24/M 13:34 14:50 87 8.51 i
- 9). 9/4/94 04:34-05:06 43 1.35 10) 9/4/94, 15:21 16:46 as 2.87 11) 9/5/94 04:45 05:21 37 1.T!
l On the first essasten (ht3/94) level to sheet 53 the computer data tadicated that oserstars reduced make.ep task
, added regen to tacrease pressere from 55 inch les 1ew1 Itatt)4 pstg ( hes about 11 pstg to about 1 theCurve8Itstt),thes lacreased level to about St.5 inc As level was increased.
aske up tank pressure tacreased to apeut'29 psig. The tempster data indicated that tM Cerve 8 alars would have been activated dortag the hydrogen additten. reestned ta threagh the level Secrease, and them stayed ta for thout another 95 minutes as pressure gradeally decreased to bales the alaru potet Chart recereer esta testaated appremiestely t.e same hieher level (54 inches and 85.5 taches) and apprestestely 8.8 te 1.8 psig louer pressors (11.5 psts and 27.5 este) then the campster esta.
cattbratten and assuracy of these instruments an addressed later
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in this report. When pletted en Curve 8. chart recorder data indicated that mata-g tank pressure escoeded Cerve 8 dertog the l
hydrogen additten, crossed to the acceptable retten af Cerve 8 durtag the level increase. and then rematand in the f.cceptabia region. Operator legs incleted bleedtag 585 gallons from the GCS
.te the 'C' RCST. then feedteg 335 gallens from the 'C' EST to the l
i ES. There were as other leg entrtes conseretag this eselaties.
l As assessanat of operater legheestag is addressed later la this report.
The inspectors assessed whether operater actions dortag the l
7/t3/94 evolutten were ta asserdance with operettne preenderes' precedere Op-402. Makeup and Partficetten System, hav. 75. ste i
4.4.3. directed operators to step reductag aske up task level l
'uhes een decreases to les level alaru'. State the preesdure i
directed operators to step redettag level after getti the M.
l-inch les level alare and the data taficated that the tant level was increased, withis apprestostely 11 stestes, to 55 i
insbes, the taspectors.ceecluded that operaters did not vtalate I
I the precedere when they decreased sehe w tant level holes a taches. Neuever, the inspectors acted that engtasertag ca)culatten 190-0034 free etch Curve 8 uns dortved, assened that the ante-up tank useld timers he operated at as tedicated 1 sus 1 of j
greater than er ogeal to 55 inches. The taspectors esesledad that j
the operettag precedere and 1se 1svol alars setpetat Lat 5 inches) were weak ta supporttag the septseertas calcohottes. The inspectors aise concluded that operators violated presadores denne seheequest parts of this assistion. Operators did est fe11em op-det instructions for addies bedregen.1he aspitentle step to Op-402 spectftcally stated ' refer to Curve 8 of GP M5 for easiasm IRR everpressere'. Neuever, operators esensded Cerve i
8 during hydrogen addities. Operators aise exceeded the administrative liatts of Op lO38. Cerve h. flestaan Naksep lack Overpressure for en estended perled of time (abest att atestes).
Eastaaertas calculattaa 1998004 assemed that the ante se task weeld sisars he operated at as indicated pressers of less thes er egual to Curve 8.
In addities, proceders AR-483. Asamectater Response, regelred.that, for a valid alars, operators take acties to reduce pressers. to withis the lietts of Op-1838. Carte 8.
Neuever, during tails evoletten, operators did met tabs tienly acties in response to the "IgIEF TAIK pCIE IllEll' teauntleter.
Operators stated that vesttag the make-ep taak to redens pressert would take apprestostely tem staates hacesse of the reestred ausillary operater actions. The austitary operator actions included selecting a weste gas decay taaf., deastag asti.
contaminatten c1statag and entertag a contaminated area. clostag one meaual valve and opentes another. entti the contentested area, and starttag a unste gas copresser.
es this emeletten, lastead of radettag pressure ta respeans.te the alors, aparators tecreased level (and pressure) le the eekens task and then twA the alars la for apprestostely as addtttemal 98 stastes althmet taktag action to reduce pressere. 1Antle the campster/alars and
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1 chart recorder data differed, all tastrumsats sore operattenal and
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tedicattens from all should have base consteered valid. Operettes l
with a valid pressure indicatten entside of values allound by procedures, as tedicated by the alars. constituted a vtelattaa of i
the precedures. Te re)y en the chart recorder tedicatthh and 1
disregard the alare and computer data utthest havtag tha i
alarwcompeter tedicatten checked by estatenense persammel and i
preven to be lavalid, use14.be enestdered esaconsorsattee and i
esecceptable. As discussed later, to tMs testance the chart recorder tedicatten was apparently toescerate and eenceaservatta.
l 1he fattere of operators to fel)eu precedores by violattag the j
lietts of Op 408 while adetag bedregen en 7/11/94 is identtfled as l
an example of apparent violatten 58 38t/9511-41.
i On the second occasion (7/25/94), campeter data tadicated that i
operators reduced aske up tank level to apprestestely 58.5 taches
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(pressere went to aheet 15 ssig).' then tecreased level to l
approximately 83 taches eht)e pressere lacreased to apprestattely j
19 psig. The data tadicated the Curve 8 alars useld have been activated ehen level was decreased to 58.5 taches, reestand in 4
l throegt mest of the level tecrease, and then deactivated en level lacreased aheve 79 inches. Chart recorder data tedicated that pressure mest free a les of apprestaately 15.5 palg to a htsk of
{
approxiestely 28 psig while level uset from a 1er of sheet 59 inches to a algh of about 84 taches. lana pletted en Curve 8, the chart recorder data todtested that enha-op tank pressere uns se er below Cerve 8 throughout this evoletten. Operater legs testeded hiesding 400 sallens to the 'C' RCET, then feedias 600 gallens from the 'C' RCST and 100 gallens from the 'A' RCST to reise hydrogen pressure to 17 psts. There were as other leg astries for this evoletica. The iaspectors concluded that operators vtelated procedures during this evoletten. Operators esteeded the atsialstrative 1tatts of Op-1638. Carve S. Marteen Mahmuy Tank PArpressors, for an extended parted of time (abest 48 stestes).
'an additten. operators did not take tieely actten la response to the ' MAKEUP TAIK ptESS NIGN' aaneettater. lastsad of redactag i
pressere in ressense to the alare as regetred by the amanactater response precedere. eperators tatreased level (and presserelta i
the makeup tank. 'This is na example of apparent violattaa es.
308/pl tt-01.
Ga the third occastem (7/I7/94), cespeter data indicated that operators started at a enke ep tank level of apprestaately FI inches and a pressure of appreminately 19.5 pstg, added hydrogea to increase pressure to aheet 21.5 psig, then lacreened level to pressure went to aheet 15 pais). Ihm data.
atest 77.5 inches (Curve 8 alars use14 have activated d i
ledicated that the hydrepen addities, remataed la darteg the level tecrease. then stayed la for abest amether 78 miestes as pressere graduaHF decreased ta below the alare petet. Chart reewder data tedicated that inttle) aske-ep task level uns ehest 73 techos enestetttal peessere was atest 19 psts, pressere was secreased to thest 21 e
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i psig, then level was increased to abeet 78 taches (pressere uset to aheek 24 pste). laten pletted en Carve 8. the chart resorter 1
i data tedtasted that ashe up tank pressere was below Curve e throughest this evolutten. Operater legs tecluded feedtog ISO i
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.gallees free the "C" RCST and 30 ga11 ens of deelneraltaed unter te the make up task. There were ao other les estries for this event.
i The tespectors seesledad that operators vtalated preesdures dortag this evoluttaa. Dersters dtd est feller Op 4R testreettenz for addleg todregne by asses 11y hypasslag the 15 reguister. Tes applicable step ta Op.408 j
- Deterates enstaus IIR everpressere usteg Corse 8 et legt. Add j
desired assuet of hydrogen editie essertag IGN pressure 1tett is not enesaded.* lieuever. eseraters essented Curve 8 durteg Operators aise esteeded the adelaistrettve J
hydrogen addities.
ltatte of Sp 1838. Cerve 8. for an estended perted of time (did abset 78 stestas). -la addittaa. dettag tats evolutten. operaters not take steely action in response to the "MESP TAK ptES$ NIGN' annunctater.. lastead of redaclag pressors in respesae 46 the alers as regetred. opersters tecreased level (and pressere) la the l-askaus task and then left the alare la for thout as additiesal 7 stastas without taktsg acties to redues pressors. Tbts is an esaapia of apparent v$elettaa 50-30t/96-22 81.
On the fearth escastem (7/t8/94), cesputer data tedicated that operators started with a ashe up task level of about F3.5 taches te lacrease and a pressere of thest 16.5 pstg. andaJ pressere to ahest 24 pets, then tacreased eve to ahest a taches i
(pressere seat to shout 38.5 pste). The data tedicated that the l
Cerve 8 alare vesid have activated when the hydrogas ses added, e
i remained la through the level insrease, thee stayed to frr about as pressure gradeally decreased to holes the j
183 stastes 1 recorder data indicated that the latttal ashe-alars pelat, op tant level was atest 74 taches and pressure was atest N pets, pressure uns increased to about IS psig, then level uns leeressed te sheet M taches (pressers went to thest it pste). Iges pletted l
se Curve 8. the shert recorder datt tedicated that ashe g task 4
pressure was en er holes Curve 8 throughout this suelettee.
Operator legs tecleded aditag hydrogen to the enha ap task to the maalaus for the curve, feedtag 47 gallees free the 'A' MIT and 283 gallens free the 't' RCET. thes addtog 40 gallens of domineraliaed water to the make ep task. Thera more es other les The inspectors samsleted that entries for this eve)stles.
operators vielated procedores daring this evelstles. Operatorsby did not fs11sw Op-441 lastrucitons "er addtag le step in hypnastas the-15 psis hydrogen regulater. The appl Op-402 specifically required *ensertog itR pressure Italt is est exceeded.' lissever, operators escoeded the Curve 8 IIK pressors Itatt durtag bedregen addities. Operaters aise mamandad the for an esemported adotatstrettve lletts of Op.1938. Ceres 8, durtag shis assigtsas,
'.s addttten, of time (about 184 slantes).
operators did est taba Steely actten to respeese to the 'INENP Instead of reductog pressere in TAE PRESS 518t* aneuectater.
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ressesse to the alare es reestred, operaters increased level (and i
pressere} ta the atheep task ese them left the alats la for abset i
en additiesa) 180 atestes withest taktag action ta reeste c l
This is an esample of apparent violatten pressors.
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50 302/95 22 01.
j On the fife occasion (7/34/94) coepeter data indicated that l
eperators started at a aske ep task level of sheet 74.5 lashes and j
a pressere of thest 19.8 pstg. added bygreges ta leerseas pressere to shout 23.5 este tekee'the alars esttested). then~ehest les f
ainstes 1 ster tacesased level to abant St.5 taches (pressere east to aheet 28 pstg). The data tedicated that the Carve 8 alare weeld have estivated thee hydrogen oss added and reestead te setti it cleared then level uns subsagesatly raised.. Chart recorder i
data tedicated that the lattial ashe ep task level uns meet 76 1sches and pressers was abget 14.5 pstg. pressere ses lacreased to atest 23 psis, then level uns tecreened to atest 84 tastes (pressere sent to abast 25.5 petg). tihen plotted en Cerve 8. the chart recorder data tedicated that make up tank pressure roasteed below Cerve 8 threecheet this eseletten. Operster legs tecluded feedtag 45 galleas from the 'A' EST and 255 gellens free the '8' RCBT ta the make-up task. There were as ether. ieg astries for this evoluttaa. The taspectors sencluded that operators veelated precedores dartag this suelettes. Operators did est felles N 402 teatructtens for addine by senmally hppasstag the 15 pstg hydrepes regulater. tee appt le step in Op 448 spectflently regetred "easertse IIK liett is met ascended.' Nasser.
l operators esseedal the 8 Ist pressure Itett additten. Operators alas amenmand the adotatstrettve 1 ts Op-1938. Cerve 8. for an estended perted of ties (ehest 190 la addities, dortog this evoletter, operators did set staates).
take stanly action la response to the 'suempp TmE pMIS Eler annenstater. lastaed of redse pressere to response to the alars as regetred, aparaters as action for ehest 190 stestas, them increased level (and pressere) in the mateep task to clear the alars. This is an esemple of apparent violattes 50-38t/95-It-01.
On the sixth ocessian (4/E/94), competer data tadicated that operators iacroased enke up-task level to aheet 81 leches pressere to about 27.5 pois. The, then Edded hy (pressors went to abast at pale) data tedicated that the cerve 8 alars seeld have activates ehes the hydrogen uns added, thee stayed in for abast 141.alestes as pressure grades 11y decreased to belos the alars poist. Chart recorder data tedicated that the nazimen pressere cas about 26.5 pets at abest 82 insens. has pletted on terve S. the chart recorder data tadicated that enke up this sueletten.
taak pressure reestand holes Cerve 8 thaJC' jet to the Operater 1ess tasteded edelag ist galleen Theremore se other les estries for Ahts eseletten.
enke-up tank.
The inspectors cessteded that aparators vielstedjessednes daring this evoletten. Operators did est feller Op-44t destreettoes for e
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8 aditag hydresen by annually bypastles the Il psig hydroges.
The applicable sw tu 0P.482 specifteally rueelred repelstor.
Neuever, aparators
- ensuring IER pressere Ilott is est onceeded.'
enconded the Curve 818K pressure 1tatt dortag hydrogen additten.
Operators alas exceeded the edetatstrattve Ilmits of Op 15, la Curve 8. for an extended perted of time (abest 141 staates).
additten, during this ovelettes, aparators did set take tteoly acties la response to the 'IgEElf la pqE55 N!st* aanmutater.
lastead of redactag pressere la reepsess to the.alars as recotred, l
operators left the alors to for atest 141 stestes. Yhts 1s as esemple of apparent vietattes 16 30t/95 It 81.
ca the seventh occasien (8/8/94), cespeter data indicated that eperators started with a este up task level of abset 79 tashes and a pressure of shoot 30 pstg, then added hydrogen to tasroese l
pressure te shout 27.5 psig. The data indicated that the Curve 8 4
was added, then l
alarm would have hoes acttrated ehes the 11y deeressed to stared in for sheet 67 ainetes as pressere i
helse the alars point.. Chart recorder data tedicated that the i
assimum pressure was aheet 25 t at a level of shoot 80 lashes.
recorder esta tedicated that I
When pletted en Cerve 8. thesure roastead as or holes Ceres 8 t ashe-up tank were se operster leg entries for this seeletten.
evolutten.
The inspectors teocluded that operators vietated precedores daring Operators did est follou ep.40s instreettoms for this evoluttaa.
adding hydrogen by unmen11y typeestes the 15 pstg hydrogen Tae apolicable step to GP-402 spectftoally regoired regulater.
e-ring an prus= itsis is at sees.w.
ne =r, ap=tm l
gettsuttJant.LilFJme.L'=!*.teriaL8**'**=? ??.Paa-i Cerve 8. for an estended perted of time (ekset 47 elastes). la l
additten, dertog this evelation, ters did not take timely
!aNond'efrediscUng*$
MAEJRREE M s.
l operators left the alass ta for atest 87 stestes. This is as i
asample of apparent violaties 16 30t/95 II-41.
sperators started at a ante up test seves er esse 6'se nadath 4 l
pressure of about 18 pst, teoreased level to shout 81.5 lechos pmartr&u then i stiAJta t tti_Wdrars.**.'==*se d
alars would have been trated eben hydrogen was added, then j
stayed in for about 87 ainetes as pressere grados11y decreased to below the alaru point. Chart recorder data indicated that the f
maalaus pressure was abast 27 psig at abast 88.5 taches. lesse i
pletted on Curve 8. the chart recorder data tedicated that ashe up i
tank pressure remained belee Curve 8 threaghout this eseletten.
j There were as operater. leg astries for this evolettaa.. The taspectors concluded that operators violated precedores darles s
eparatore did not fe#1em eP 401.testeesttees for
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this evolutten.
nedtog hydrogen bp ammes11y tapesstes the 15 pate kreregen f
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e regulater. The applicable step ta Op det spectftcally reestred
'essertep IUT pressere limit is met esseeded.' heur"er. operstars esteeded the Curve S 9tN pressure limit dortag hydrogen additten.
Operators aise exceeded tDe adotaistrative Itetts of Op lam.
Cerve 8. for an estended perted of time (eheut 87 stantes), la addities, dettag this evoluttes, operators did set taha'tteoly acties is response to the *nKElr TK FRE55 Mler assenstater.
i laslead of ndestas sere la ressesse to the alars at rentred.
eperaters 1 eft the a are la for shout SF stautes.1kts is as l
example of apparent vtalatten 56-30t/96 23 01.
l De the ninth occasten (5/4/94). coupster data tedicated that operators started at thout as taches and S pstg in the ente up i
tank, tecreased level to shout SE taches (pressure uset to atest 16 patal, added hydrogen to tacrease pressure te sheet 31 pets j
(due he alars activated). reduced level to aheet 51.5 tethes (pressere uset to about 14.5 este), tecreased level to aheet 79 taches~(pressere unst to aheut il psig), then vented the este up tank to stest 30 pelg. ' The data tastsated that the $$ tash i
stataes level was esteeded dortog the suelettes. Also, the Carve 8 alare unald have been activated free the Stee that hydrogen was added at the bestantas of the eyelettes estil the sehe.ep task uns i
vented at the end of the evolutten. The data aise tedicated that.
as 1evel uns redened from atest 85 tashes to aheet 51.5 lashes, der I
pressere easeded Curve 8 by as tecreastag assent. Chart recor l
data tadicated that pressure west free a nigh of atest 25.5 psig at a level of shout 85 taches to a les of stest 34.5 at a i
level of shout R taches, then to a high of sheet 5 at a l
1evel of shest N inches. tAma pletted sa Cerve 8, recorder dets indicated that nahe up task pressere went absse Cerve 8 as level was bsing decreased be1eu about te taches.
remained above Curve 8 durias the level decrease, then returned holes Cerve 8 darias the level tacrease. Operator legs tasteded feedine Ill.gallens from the 't' RCST: adding repens bleedles 924 gallees to the 88* ACST: and feedles 120 ans true the *A*
Rcsf. 380 gallons from the 'C' atBT. and 380 allees from the 'C' It3T. There were as other leg entries for th s evoluttes. The l
taspectors concluded that operators violated precederse dortag this evelation. Operstars did est feller ep set lastrusttees for star app s
ca regelred r
'easartog Itif pressure Itatt is act sesseded." neuever, apareters escoeded the Cerve 8 IGN pressure Itatt dortag hydrogen additten.
Opersters aise escoedsd the administrative inatts of W-1838 Curve 4. for an estanded parted of tlas (about 43 utestas). la additles, eartog this eve)stten. eparators did est take Steely actlen la response to the 'HAKEW TM ptE55 N191' anseestater.
Lastead of redesteg pressere to c1 ear the siers as reestved.
operators redr.J.Sevel (and pressers) uhtch caused teatterne 8
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Itatts to be esseeded by an tearnestas sammet. Operstars left the alare la for ehest as minutes hefers vestsee the sehe-ep tsk to I
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g regulater. The applicable step ta op.det specifically reertred
- ensartep Illt pressure limit is not sesseded.' ileur?ar, apareters exceeded the Cerve 8 Itif pressure llett dortet 7drogen edNtten.
k Geersters site exceeded the adotatstrative Itatts of Op. LOR, Cerve 8. for sa estended perted of time (about 87 stautes). la addities. dertog this evoluttes, operators did set tabe~tteely action te response to the 'IIRKEllP TAIK PRS 51815' aamunstater.
leslead of Ndestag peestere la response to the alars as regirg(,
d speraters 1 eft the altre la for about SF stantes. This is an I
i saanple of apparent vtalatten 50 30t/35 II 01.
i en the sisth escasles (9/4/94) computer data tedicated that operators started at thout 80 taches and D psig in the sehe ep tank. Sacreased level to about 95 taches (pressure went to about l
15 pste), added twdrogen to increase preneure to atest SI psig F
(when ha 6)are activated) reduced level to aheet 51.5 teshes i
j (presesre west to about 14.5 pste), tacreased level to atest 79 taches~(pressere uset to about 26 pstg), then vented the sehe up J
task to aheet to peig. ' The data indtsated that the 58 tech i
the Curve statens level was exceeded during the evolettes. Also,drogen w 8 alava useld have been activated from the ties that hy addes at the bestastas of the evoluttes es411 the sete.ep task uns vested at the sad of the evolutten. The data aise tedicated that, as level ens reduced from about 85 teshes to ahoot $1.
pressere sneesded Curve 8 by na tecreastag assent. Chart recor l
data tedicated that presours west fres a eigh of atest 25.5 psts i
at a level of shout 85 taches, to a les of atest 14.5 at a level of shout R inches, then to a high of about 28 as at a level of absst SO inches. See plotted en Cerve S. the recorder data indicated that aske.up tant pressere meet absse l
Cerve 8 as level was being decreased below shoot te teshes, reestmed above Curve 8 durtag the level decrease, then returned holes Cerve 8 dertas the level tetrease. Operator legs testudad j
feedine Ill.gallens from the "t* RC8in addlag regens bleeding' g24 gallens to ths *B' RCET and feedles its ses from the 'A RCst 380 gallens from the 'C' EST. amt 388 liens from the 'C' i
RCET. There were no other leg astries for this evoluttes..The i
taspectors concluded that operators violated precedores dertag l
this evoletten. Operaters did est felles sp 401 lastreettens for regulater. The appitcab)le step laadstes hydemona tw man 15 asse hydrsele spectPleaily reestrud
'ensartog Itif pressure limit is not exceeded.' lieusver, apareters escoeded the Cerve 8 IETT pressure 11stt during hydrogen edittien.
Operaters aise escoeded the adelaistrative lietts of W-1838 i
Cerve 8. for an extended parted of time (about 43 eleutes). la addities, during this evoletten. eparaters did est tehe Steely actten la response to the *llAIEW TAIK.ptE55 91181' ensumeister.
Lastead of redactos pressere to clear tan alors as reestved.
e,ersters redeced.5evel (med pressure) insch caused thseterve s lletta to be esseeded by as lacreesfag smaaet. Operaters left the a)ars la for about 43 minutes before vestieg the sehe-up task to
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i clear the alars. (volsttees. not required by plant cemettleas.
I conducted to tellect data constitute a test er esporteest.
I 10 CFR 50.59 requires -ta part that tests er suportomets that are l
conducted nest costate a urttten safety evaluatten that prerldes the bases for why as metertened safety guestten does not entst.
The evoluttee conducted sa g/4/g4 without a written safety evaluattes is identified as esseple 1 of apparaat violettsa 50-303/g5 22 01.
l On the tenth occastes (t/(rg4), computer data tedicated that l
eperators started with a ashe-up task level of about 31.5 sechos and pressere about 20.5 pots, added hydrogen to tecrones pressure 4
l to aheet 30 pste, then atest 85 stastes later a differset shift of l
emerators vestal the make.ep tank to reduce eresare to about 1g pstg. The data tedicated that the Curve 8 alare useld hose been i
i activated from tha time that hydrogen was added sett? the Sten that the make.up task uns vented. Chart recorder dets tedicated a nestaun pressere of shout 28.5 pstg at a level of abset SB taches.
lAien pletted se Cerve 8, the chart recorder data tedicated that 3
aske.up tank pressure reenteed en er helev Curve 8 daring this evolutten. Operater legs tecluded venttag the ashe ep task at the and of this evolettet. There were se other les estries for this evoluttes. The tespectors concluded that opersters vloisted I
precedures dortag this ovelstlen. Opersters did est felles Op.401 instructions for edites hydrogen by massally bypasstag the 15 pstg hydrogen regulater. The aspitcable step in Op 408 spostfleally reestred 'essertas M pressors 1tatt is set essended.' assover.
I sperators exceeded the Curre 8 ItfT pressere 1tett dartes lydrogen adststen. Operators slee neceeded the administrative ilmets of Op-1838. Curve 8. For an entended perted of time (about N sinutes). In addities, durtag this evolutteer. epersters did not take steely estles is ressense to the '9tWEup TAE eMR5 ESf" annunctater. Operators left the alars in for ahest 85 elastes before they vested the enke-up tank to reduce pressure. Ihts is i
an example of apparent violatten 56 308/g5-32-01.
On the eleventh occasle' (t/5/94), computer data tedicated that s
eperstars started with a enke up taak level of abest 88 taches and l
a pressere of about it psts,lors activated), tacreased lesel toadde l
to sheet 30 pstg (w(then the alars cleared at a pressere of shou hom the a about 86.5 taches l
a 32 psis), decreased leret to sheet 53.5 inches (pressere uset to about 14 pstg), then tecreased level to about 81 lashes (pressure went to about 17 psig). The data indicated that the Cerve 8 alarm f
~
would have beesr activated for shout 15 etautes free the ties hydrogen was added until the level was increased to abast 85.5 inches and the alare cleared. Then the alars wee)d base been activated for atest 37 elastes free the tima the leest desrease was begun until the alare cleared certog the subsegeset lesel tacrease. The data ales ledtasted as level uns desposeed followtag the alare, preneurs M S ny en teoreesteg i
amount. Chart recorder data tedicated a mestaan pressors of shout
. - -.. -. -. ~. -..
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30 pstg at a level of shout 86 tsches and a statmos pressure of about 14 psig at a level of about 54 taches. When pletted se Curve 8. the chart recesder data tedicated that make-up4ank i
pressure uset above Curve 8 shout eldney during the level decrease j
and returned te en er helen turve 8 during the subsageent level tecrossa. Operater legs taciudad feettag 185 gallens fma the 't' RCRT: addlag bleedtap 955 sallons to the 'B' RCST: then i
feedtag 120 lens from the 'A' RCST: 300 galleas.from the 'C' RCBTi and gallens from the *g* Est. 1here were no other leg astries for this evoluttes. The taspassers concluded that aseraters violated erecedures earles this oveletten. Operators did not fo11em Op 401 lastrustless for addtag hydrogen by sensally bypasstag the 15 pste hydrogen repelater. The appilcable step te i
Op-402 spectftcally regetred "ensartag fait pressure itett is set eaceeded.' Neusvar, operators eussaded the curve 8 InfT pressure 1tatt dortag hydrogen addttten. Operators aise escoeded the administrattve liatts of Op 1838. Carve 8. for an'estended period ef time (about 37 stantes dartag the level decrease and subsegeant level tacrease). la addities, dortat this evelstlen eseraters l
did not take timely actice la roepsmee to the *NAEEMP TANK ptE55 HIEN* annunctater. lastead of redactes pressure to clear the i
alars as regr,tred. operators cleared the flest alam by tesmeslag level (and pmssure). Een the alaru came in while operaters were redactag level (and pressure). eperstars continued to reduce level which caused the Curve 8 Itatts to be esteedeG by an increastag amount. Operators subsequently cleared the alars after 37 staates by tecreasing level Land eressure) to the make-up tank.
1 Evelettens, met regovred by plant senditions, conducted to sellect data constitute a test er espertaaet. le CF8 56.59 requires la part that tests er esperiments that are conducted must castata a j
vrittaa safety evaluettee that provides the bases for why as unreviemed safety questles does not entst. This evoluttee was conducted without a writtaa safety evaluation and is ideettfied as t
esemple 2 of apparent violattaa 50 30R/95 82-01.
'Of the 11 accastens revieued, the inspectors noted that tuo of them, the stath and eleventh occastees, differed la sees estartal respects frea.the other atas. Da nine of the occasions, operators were taking acti6es to tecrease enke up tank hydrepea pressure (as recausended for ICS chemistry centrol) when sesseded Curve 8 Itatts. However, en tus of the escasiens (9/4 a.m. and 9/5/94 sperators esseeded Curve 8 limits while reductag make-up a.m.) level (and pressure) and while performing an evoletten tha tank was not required to support RCS chemistry contre). On aine of the eccastems, operators teek delayed action (or as action) fellewing the alars to reduce the amesat by which sake-up tank pressure.
exceeded the alleusble regten of Carve 4.
Neuever, en tus of the occastems (9/4/94 a.m. and 9/5/94 a.a.)lare to farther operators took' mencenservative actions fellestag the a the amount by which aske up task pressere aseneded.the alleushie regten of Curve 8. Also, the Itcassee stated that esNun of the occastens (g/4/94 a.s. and 9/5/94 a.a.) operators pleased the w
.e
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evoletteac to challenge the accuracy of Carve 8 and task dets dortag the evolutions, la additten, se 9/5/94 a.a. operators I
stattened an austitary operater hy the make up tank veut to take l
action if a plant event occurred while the make-ep tank pressure exceeded Carve 8.
The inspectors esecluded that uhtle aparators violated precedures, and the des 19s basts Itatts established by the Itif pressure 1tatt curve, en each of the 11 escastems rettsued. available taformatten taticated that the latest of-the esersters dortag the tuo escastems (9/4/94 and trl/94) dttfered from the other stas essastems. Mose annetherland aantpalettens of the plant en 9/4/94 and 9/5/95 to additten te violettes the precedores Op.402. Op.103B. and AR.403 shile addleg hydrogas, also violatad it CPR 50.59 in that the asetpelattens unre est reestred by plant candittens and me approved precedure entsted for the connect of the tests. As deserthed pretteusly, these tue unautiertred tests are identified as esemples 1 and 2 of apparent violattee 50 301/95 31 02.
mile reviewing the competer and chart recorder data, the inspectors noted that many substaattal changes la aske ep task level had been made where Carve 8 uns est neceeded. The l'.censee's analysts of this tsses found that, durtog the ties perted.lume I ta September 30 1994, there unre 500 mentoulattens of task level er pressures teclettag $10 level reducttens or lesel tecreases. 48 hydrogen addittees, and 10 vents of the task. The Itcenses farther stated that !! of these annipulattens (only 3.35) resulted in the competer tenerated annunctater for aska.up tank pressure betog to the alare cemettien. His indicated that, en most ashe.up task lesel or pressere senipelations, operators did act eaceed the pressure Itatts of Curve 8.
la seemary, the insposters sencluded that operaters esseeded Carve 8 Itaits and violated operating precedures en at least 11 escastens during the ttee perted.lume 1.1994, through Septesher 7,19M. Two of these essastens were unauthertred tests or experissets not required by plant condtttens.
2.2 llenas facters and> Centre) Reen Instrumentatten The tospector assessed the human facters aspects of the eastrel rees tastruments for make-up tank pressure and level. The campster data for pressere and level were clearly displayed digitally. Pressure was dispinyed to the nearest one4mmeredth of a psig and leveLwas displayed to the searest one4endredth of an lect. The chart recorder was such aere difficult to read.
pressere could he read to apprestastely the nearest ene4 elf patt and level could he read to apprestaately the nearest task. Stase the Carve 8 calculatten (190-8034) prertded saly sus feet of unter (sheut e.8 pets) as protecties for the Npt pump.:the tospector -
considered that the readebtitty of the chart recorder ses set soffletent to support operettag the seks-up 4ank en er meer d
13 Curve 8.
Operattaa en er near Curve 4 was alleued by precedures and was enesereged by Itcenser. management to mestatte the concentratten $n the reacter toelant system. Atee. there no display in the contre) reos for praatuity to Curve 8. Topake a i
esteentnatten of prestetty to the 1tatt of Corw 8. esereters 1
usuid have to seassily p1st make up tank pressere and level en a i
copy of Curve 8. The lack of such a etspley. shtet assid have l
been'provided by the
, made it very difflealt.Ser sperators to ta.vease
-en tent pressure class to Come a j
without enesedtog Cerve 8.
Ine taspectors costledad that the j
henna facters aspects of the IER lafemattes displayed in the centrol roes more seek is sepperttag operetten eser Curse 4.
4 l
1.3 Calibretten and Asseracy of Isakeup Tank Instrements l
The inspector assessed the calthrattaa sad acesrety of the i
instruesats. Mate ep tank pressure tapets to the competer and j
chart recorder were free the same pressure treassitter and electrical beffer. Maistenance procedure 80' 105 4 celthrottes records fres Octsher 27,1994, tedicated that the chart recorder 1
pressure string read abset 0.7 pelg law (at 25 pste). (no aske-l ep tank pressere ses esmally centrolled heteese apprestestely 15 i
withta the 1).11 psis eastam tastresset erver assuost byThe tespe and 30 pstg.
i j
Calculaties 196 00t4, dated August 28 1988, free ettet Curse 8 was derived. The inspectors acted that the alwrt recorder read i
lem (by about 1.0 to 4.0 pale) and est of talarsses, at pressures aheve 25 esig (i.e.. at 30, FS. and 100 pstgh a tus essessettve calibretient. Revenber 27.1998 and Octsher yT,1944. to eseh i
escasten, it had been recalibreted and left reading asserstely.
Neuover, the Itceasse had no trending progres to idestify (and l
taittate corrective acties) when en lastrument, that ses calibrated by a matetenance precedure and possibly tapertant to safety was repeatedly fasad to indicate inaccurately entside of i
the a1Ismed toleresca. From the as feend calibraties data, the l
Insposter seeld ses detenstae whether the eiurt recorder preesere l
would have read eithis the 1.12 psig assumes eastees testament l
error, at a ante sp, task pressure-of 29 or 30 peig, darter the perted Joly three$ legtecter.1994. IAma infomed of these chart recorder errors, the incessee promptly checked the celthrotten of
[
the chart recorder for enke-up tank pressere and feed it to be within the a11suchle talarenes. The toepectors identified the i
lack of instrument est of calibratten tracking (and corrective I.
action) as a usanness la the licensas's maintenance program.
1 The inspectors noted that the cemester aske se task pressere and the Curve 8 altro som not checked by calibraties precedoms. By compartsen of the cesputer data with the chart recareer data, the inspectors feed that the coopster pateranyitedteste$,Ingber -
psettape than the thirt retarder kr abset t.l ta 15 esta'about 29 pstg and by aheet 6.1 pate et about 17 pstg.- the 4espostare foemd that aatten takse to complete MAR 93 es-es41A. dated,
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14 1
July it.1993 which had testalled the cesputer pressere pelat and terve 8 alars. had failed te rettse procedures to assers that the lastruments useld be calibrated ta the future. Th. M4 feastlesal test had tested the Curve 8 alars setpoints in July 1993. Tae i
inspectors ested that calibretten procedures meeld have reestred the instrussets to he taltheated every tus years, and that less 1
than tus years had transpired stace the teatrussets som tastal)ed. Therefore, tbs safett sigatftcence of the missed precedure rettstems was steer. The taspectors.tdantified $4ts fatture of the toplementattee of IWht D-06-06 01A to appropriately revise procedores as a usethess in the lleenaae's endiftrattee process.
Level inputs to tipi comester and chart recorder were from tue etPferent level transmitters and electrical buffers. Threagh a selector switch en the vertical section of the esta centrol heard.
centre) rees operators could select either transattler to the chart recorder. The sea selected transmitter veeld then supply the' computer. There were se records of the sultch posities. thers j
uns as indicated preferred swP.sh gesitten, and operators stated that they occastenally had changed the switch positten.
t Calibrattaa of level transaltter LTE en December 8,1988, per surveillance pescedere IP-lGet. Easlesure 1. found that the short i
ledicated thest 10 taches high at 88 and recorder level string (The sake ep teak level was sereally i
90 taches of level.
i The potet l
centrolled hetmeen about Il and se taches.) f level uns not checked at that ttaa. Calibrstten o tter LT1 en March 18 1994, per Sp-IsK. Inclosure 1. fasad that the I
chart neerder level string tadicated atest 1.5 tastes high at E0 inches of level and ekset 1.0 taches high at 90 tashes of level. That calibretten aise checked the computer potet and fasad that it ladicated abast 1.8 taches high at 60 and 90 taches of level. On hath dates, the as.fesed condittees were generally within alleueble tolerances, and the instruments were recalibrated and left with apprestattely sere error. By rettes of the aste ep tank level calibratten data strip charts. and computer dets, the inspectors deterstand that chart recorder mereally read higher than the computer by aheet BJ to 1.0 inches. The taspectors concluded that the 1.0 and 1.5 tack errors fesad deries calibratten were within the 8.y taches mestemm fastrunnet erver assumed by Calculatten 1958084, uhtch derived Curve 8.
In summary, the inspectors identified tus Itcoasse *=
ene usanness in related te make-up Lank lastresset calibratten:
the Itcensee's estatenance program to that out of calibrettaa tracking and corrective actten was lacktag for instrussets that were rolled spee te support a safety related calculatten. and one weakness la the Itsensee's modification process to that a RAR that installed instruments did est revise precednes to ragstre e#
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Il f
pertedic calibratten of these lastruents. The inspectors l
centledad that overall, the make up tant instressatatten (alars.
semester, and chart recorder) uns suffittent to seppert operetten sf the make.ep tank withta the authertsed regten of Carve 3, l
1.4 Operaters Legs In rettesing operator legs, the taspectors feend that the teformatten la the legs did not therweghly or seeststeetly the tespectors centledad that desament the evolettees. llenoverInte Itsesses regattements for the state of the less did est vie i
The legheeping, as the licensee's requirensets were vague.
tespectors aise meted that eseraters se shift dertog all er part of the eleven evolettens tecluded as differest Itcassed operators.
apprestastely 1005 of all Itcensed operators se shift at Crystal 4
(The operaters were sa -a sta. shift rotattes, and each tiver 3.
shift leciedad five licensed operators, to SAbs and three 80s.)
3 Alse..the 1aspectors seted that there were skift tersevers, during three of the elevee essastems, when the enke up task high pressure alare useld have been ta. The shift assagers were supposed to attend the shift tarnevers, and them.Jsesid have had the i
esportsatty to becce emere that the enha-sp task high pressors i
alart uns te.
The inspectors concluded that most of the Itcassed operators at Crystal River 3 were involved is the mies esemples of apparest vielstien 50 302/95-22 01. Alse licenses samassenet had ample i
speertmity to identify the apparaat violetten.
2.5 asportablitty The inspectors rettened the tiselteens of tha Itteness's reporttag of the operetten of the enke ep task eatside the destga hosts, with eseessive hydrogen overtressors. The aparater evolettens4 that challenged the acevracy of Carve 8 eteerred as and 5. 1934. Probles Report PR 94.e387. IER pressere Techetcal Basis Inndequate, uns dated Septesher 7,1994. Licensee docaests and statements tedicated that engtasering deterstand en hovember 15, 1994 that Cerve 8 was aseteeservettve med estelde the The licensee further detersteed that operetten en design basis.
or absve Cerve 8 useld poteuttally alles enha.g tant igdreges to ester and damage a make.ap (IF1) pump dartes a eartstr event, a core fleed line break cetecident with a fetters of ese eastgency The itecasse made the reestred see.heer le CFR diesel generater.
5g.72 roport et th55 en lievenhor 15 Igg 4 and sabettled th regatred LER en December 1g.1994.
the Itcassee made the ane-heer report promptly after diesevertas the entside of destga basis canditten. The LER uns sekoitted late, aat was proviessly identified as VIS $8 38t/94-87.et.
9
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3.
Engineering Support l
The taspectors assessed emptasertag support to operattens. They reviewed probles reports and engineering departoont correspondence
)
re)ated to tae Curve 8 prehisest revteund the engtasertag calculatten free whIch Curve 8 was derivedi and discussed the isseet vtik systes J
engtaaers. design engtasers, and operators to assess the adequacy of enstaaertag support for this tasse.
i 3.1 Accuracy of Curve 8. Nestama Maksep Tank Overpressere Carve l
The operstars stated that the pergoes of the evolettees se September 4.1994 and en September 5.1994. mes to confire their perceptian that Curve 4 was losarrect. The tempectors restened l
eagtaaertag seppert te operations daring June Septesher 1994; specifically, the issue regarding the assuracy of Curve 8. The 8
taspectors reviamed Problen Reports M 93 0014 Peteattally landeemste Me ep Peep IIPgN. dated January 30. 1993 R M 0149, IRN-se iteck opea. dated may le.1984 and m M easf. Its 1
Pressure Cerve Technical Basts landequets, dated Septanter F.
The taspectors aise reviamed reisted RfA 948F47 esseers l
1994.
air heias draun late the aske-up puuge dortag the perferesses of Sp 830 (felp poll Fles Testtag). dated Jane y.1994 and W M1305. casserstag operater burden la este up pump sperability dortag accident scenaries, dated
- 1. 1984. Is l
additten, the inspectors revleued eastseertas Calcolattes ISD-0024. dated 28.19R. from ubich Curve 8 was dertved IglR l
93-06-06 01A.
ist Changes to IRE Duerpressere. Lew W Level,and1815 t and a related safety evaluatten dated July 15.
1993. The taspectors alte retteund captes of wartees related laternal engtasertag anaerenda and competer esti sessages and discussed the issue regardtag the accuracy of Cerve 8 utth systas i
engtaaers and destga sagtseers.
l Based on this review, the i sencieded that the operesars' l
saecern with the escaracy 8f Iuns'identifiedas8 centrthutteg faster to Prahlem Assert M 94-0149 dated fler 18, t
1994, and was alse identitled mere clearly la m M aggF (after the Septesher 4 tad 5 twelettene). A Jane 14. 1994 urftees
/
as the ensuracy seglasertag evaleatten of a stated cessers 40, caesseded that of Curve 8. ehish had been reported'ta'R the data supplied did not ledicate an arver la Carve 8.1he envianering evaluatten identified as errors la calculattee 190 0024. that derived Cerve 8.
Sehseguest 1tcoasse review of Curve 8. after-September 5.1994, itsettfled several errors related to the calculatten of Cerve 8. These errors included the entssion of the effects of gas ahoorption. temperature ebenges.
Internal menereeds.
and the partiti pressure of water v engtseers tedtested that PR electreetc messages, ind statenests unre discussed senoral M 0149 corrective tattm (and Cerve )tesledtag at asettage en tiens hetmans engteatre met operaters, July it.1994, and en Asinr4 5.1994. la additten, engtseers unre
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17 aware that at least see operator was act satisfied with the 4
responses free engtseerlag and made attempts to get the operator's conceras more clearly decesanted. Emptneertag managers (and operettens managers) did not get proactively tavolved ta*the precians with resolving operator's concerns utth the agoracy of Curve 8. The inspectors concluded that the fallere of he engineerine evaluatten ta ressense to Pt 94 0149 to teestify errors ta Calculattee 190-0084 with respect to the slope of Curve 8 consttteted taedequate corrective actica. His inadeguate corrective actten ts identtfted as assepte 1 of esperent vtelattes 56 30t/95 32 83. Additteen) esmsples ~ef failure to take adessate corrective acttens sore identified as apparent violattens to It 58 302/95 13. As deserthed ta Section 7 of this report, these examples are i tate esseples I and 3 of apparest violatten 5g.
22 03.
laternal licensee docesamts alas indicated that engineers and operators discussed the mothed ett113ed by operaters to estetste adequate hydrogen overpressere in the feli to achieve 25 cc/kg of dissolved hydrogen to the EE. Alas, a esmerandes free a syster engteese en August 8,1994, to one SM and ens M (apparently in response to questtees from them) edytsed the esersters to ese the computer potets for enho.up test pressure and level when ashteg addittens staes they useld give mere accurate tedicatten chart recorder. De same further stated that the alors teak precedence over the recorder indicattees. This teforms) response to a queetten uns set dissentaated to other operators by engtasering er by operettoes. The taspectors noted that the reopense aise was met coaststent with a cesservative operettag presttee that any valid indleattene (t.a. alars, eseputer and recorder) he kept set of the mascceptable operaties restems. This was emether indicaties of a meakness is communicattens betusse operattens and engtaaering and also within operattent.
Records available to the tosposters indicated that the calibratten/ accuracy of the aske-up taak pressors and level instruments (alors, sospeter, chart, recorder) were est sha11essed by operators or engtaaers. Metatenance records revealed that the aske-up tank pressere ladicaters had met been calltrated betones hovember 1991 and Octsher 1994 and then ta etteber 1994 the chart recorder pressors tedicotten ens foemd to be eresseems and noncenservattva. (1he tastruments were scheduled for roettes calthration every tus years). No corrective action was takes ta preclude recurrence of this prehlen.
The inspectors conciedad that engineering ressended to prob)ess or essettens that sero clearly stated to Pts and REAs. Nemover the ges11ty and tieeltmens of these reopeases varted. tentle the above roepenses were taamplete and untiaaly ethers appeared to be therseek. La one emepla. sagineers identifted.sts cases of aske-es peep cavttetten identitled to pt 94 8149 to beatrapeshots left after asisteneste la certata sections of ptplag qthey then l
l a
is laittated modifications and precedere cheapes to assure that, the sections of piping were vested after metatanones. In anotaer
. (
esamle. REA 941308. engtaaers performed a detailed Keener.irspee 0
ik escisten anklap analysts of various poteattal corrective actions to reesta er e totaats operater turden ta ensartag make up pese opereht11ty dettag en acetdent. As snagle of another issue whers operators uste dissatisfied with corrective action tavolved the foodnoter cost?ol systes, where operators had to rest ly place the RFU pass ta manus) esacre) and reduse the fleurates dortog treastests. His action ute'reestred la the E0Ps and sessessfelly praettend sa the staulater but uns ceashored by operators to be en saaecessary herden. Mts operater burden was i Itseasee's Itst of *cperator workarounds* for which E
et
.tive aattoes were betag appropriately purseed by plaat k ement.
While revientag Calculettes 196 0034. dated August 28, 1988. from shtch Curve 8 was derived, the tempectors acted a discrepancy betseen a calculatten asaustion and itseasee prosedures. The calesistten assumed that, dortog a LOCA the switchover of BCC5 peeps' suction from the adsf to the reacter betidles susp useld assur by praemene at as RB saap level that useld egosta to a BW5T level of obest 14 ft. The calsslattaa assestten stated that the vales for SUBT switchover level useld be valid through refuel S.
shich had occurred to 1983. Neuever, Itsessee emergency operating precedures te effect ilmes Septsster 1994 reupstres eseraters to hagia the est at a BuBT 1evel of 5 ft. Tbs tospectors found that a 15R to rates the lasel of certate l
testruments to the reester belletag (for l'1eed plane ceaneros) had been tastalle6 la 1938. The IIR tegicated that the energesty s
eserattag precedures were to be changed but did met tedicate that Calculattaa 196 0024 mes affected. Fellestep the IWE. the esorgency operattaa precedures had been changed to require the euttshower et a OuBT 1evel of 5 ft. The Itconsee ehemed the en laternal imeertas samerandum dated Ilarch 24, l that the 5 ft sultchsver leve 1
sitt en evaluatten mes appropriate. Ubtle the 14 level was based on too ruestag NPI (sabe-up) peeps ta one trots. the 5 ft level mas bened en only one re ntet IIPI pue per trata and thus less fles and less pressure loss from the MIST to the ist pumps. The taspector rettened the evaluattaa la the esserends and settledad that it i
uns a logical and reassaable esteesten of Calestattes 19p 8084
.1 n
with roepect to ensurlag the ashe up task hedrepea ses kept out of the HP! pumps. However, it overleeked poteattal verteslag in the j p
)
EMET and tetroducties of air tate all ECCS pumps. Alas, it h
overlashed the Tact that the ERP startad settehaver at 5 ft ta the p
gulf and that there usand be stes (and GM5T 1ess) decrease) h I
calculattaa Ibthe euttsbever. Further, both the meme end.ov lave) sed dort Y
level alloued to to beise sese, coerators ese14.hase se tedicattes of edegaste enke-ep que 1994 and as a result coald deedde to step the affected p a p. De taspectar verified that the saargemey Il
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1 eperatine precedures ineleded a rageiroment for operators to
~
essere that as more than one 191 peep per trate was reesteg shoe Bust level decreased below 25 ft. The laternal r.itesertse asserends was signed by a soster nuclear engineer and a esclear engineertag aspervtser. Itemover. as formal change was ande to the l
offtetal calcolatten. The foreal change to the caisslatten, a goality record, alpht have tenettfled the discrepeactes eith the cancelatten and seeid hees reestred ladspondest vertftcettaa by a i
seemed goaltfted meer to addities to the supervisers 1.
i i
The taspectors that prehles report pt M-Step. dated 10.
1994, had ideettfled the need for a formal calcolatten to espport 1
i the 5 ft OuBT seapever petst. The engineertag schedsle for coepletten of that analysis uns September 30. 1994. Also, probles report pt 94 4357 dated Septesher 7.1994. Identified the esed to j
sedate calculattaa 190 0ge4.
l The inspectors concleded that the itemmame's fallere to to a ase official caissistian er revise the calculattaa i ta Iterch 1993 was an apparest violatten of 10 CFR 58. Appendis 8.
l tritertes 118 regetressets for destga esatal tastedtag tadopendent vertricettee of desten cales14tteaa. This tendessata des control stil be tacinead In esmote t of appermet v6elatten l
B-21 04. Apparest violettes 95 13 01 esseple 1.
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peregraph 5 of IR 50 308/95 13 deserthed as apparest violattaa of 10 Era St. Appendis B. Cetternes !!I. Design Centrol for taedequate doeten assesyttens for hereted water storage task j
suepover level. Yhts apparest vtalatten is adelaistrettsely cleted and taeorporated tote apparent violattes 86 308/N 82 04 2
i eseeple t.
l Addittenal les of inadegeste doet centre) ears idsstified as apparent attens ta It 56 308/95 3. As described ta 4
Secties T of this report. these eseeples are 1 take eseeples 1. 3 and 4 ef apparest violettaa 50 21 5.
1 3.1. Revies of Operability Centern Resoluttaa (valuatten tapart 1
i As part of the revise of the J.mewes' new operability eusleetten process. the taspectors revissed the operabtitty evaleotten cesseratag en easecured secties of RB same grottog testalled ever the ECC5 peep secties pit. Mlle testalled antaly fer geresseel protecties, this trating was credited to the FSAR for pressettag objects larger then 1.5 taches fres estarias the ECCS pas section pit.
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Te deterstee if the easecured M seep grattag cos)d affect the esereht11ty of the ECCI peeps, the Itcasses calcolated the pressere en the graties created by the verst casa.fleersta est of the sucties pit and late the 5 sup and coepareddthetete the fores necessary to lift the grottes. Baeed en this talei$etten.
the Itcensee come?oded the moret case fleerste cassed tesoffitteet forms to itft the grattaa. The Itseases ales considered the fores
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es the grattag resulting free speatng the M drog Inna with the reacter at pressare. This actica was directed by precedere te protect the W pumps from fallere in the event the til peeps had heen esersted at law flew for se estended perted of ties. The licenses dismissed this as a poteattal cause estag ' engineering
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,ledgement" based en the calculated flew rate necessary to amort a force soffletest to lift the grattag. Ustag the same methodelegy for calculattes the forse from sectten pit selfles. the Itenesse i
i calculated that greater thes 3.000.000 gym useld be reestred to j
inft the grating. Itasemer, ledependent caleslattees by the laspectors, estas the Itseasee's anthodelegy, found that en)y 134.000 sps uns required ts lift the grottag. Becaese of the significant difference hetuses the tue values. the lampacters i
enesttened how the weise of 3.000.000 gpo mes calculated. The Itconses stated the vales was calculated by structorsi eestasertag and not by aschaatsal engtesering. Structeral empteartas fatted to recogatze that fler varied as a functies of the rasere rest of d
l the differential pressure and had performed as taappropriate i
estrapolatten. Forthermore, stractoral sagtaaering did act caemusicate this vales to mechanical enstasertag for vertes. The Itcensee said the value ses geesttened by anchanical as I
after the opereht11ty resslettaa uns issued. het as les j
entsted to amend the vales.
i The taspectors questioned the effect of steauvuster taptagneest sa i
the grattag due to spettag the M drop Itse with the reester at pressure. The inspectors regtound the procedural goldenes orovided by the Itsenses. Prior to directice to span the M drop i
i Itas, acttens unre tahan to reduce IES temperaters to less thas l
200*F. Forthermore, the M drop Itse was reestred to be spened sely if M peep operetten at les fleurate useld seemed ten hours.
tased on the preceder:1 actions to reduce RCS toeparatore below l
200'F and the artended time perted hefers this actien useld be i
reeutred, the inspectors concluded there was ne potential for l
staanvuater taptagement en the grottes.
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The taspectors concluded that, shile there was ne tenedtate
, operahtitty concers, the operability concere reseletten prosess lacked adeguate retteus to ensure that senservattve operettitty l
deterstaattees were ende. Furtheeuere, the fact that plant assagement had accepted the rese)sttaa tedicates that tesofficient management attention uns given te this particular rese)stles and a j
willtegness by management to accept, withest reytes, engtesering evaluattens that rossited la continued plant operettaa. The j
Iallere of the sig i...) englasertag group ts, commanicate the value to the nachaatta) espineering group for reyter is asether example of weak commestcatoons hetmeen plant orgent2sttees.
l la summary, the inspectors identifled tus apparent vie)attees and tus weaknesses la the area of engtaaering support to operetteas.
The fa11ere of the engiamartog evalgettaa ta response to R M 801414 1
identify errors to Cales1atten 130 0034 with respect to the esmeracy of j
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i 11 Curve 5 constttuted inadequate corrective actton. The fa11ere to generate a new or revised efftstal calculatten for Curve 8 ta merch 1993. Le support the revise ( eserating precedure 1euertag SIET witchever tevel to 5 ft. cinstituted inadeemste oestfn centrol j
including a lack of independent vertficatten. The infomal communicattens between engineering and operattens 7egarding operater use I
of aska-up tank instrumsats and last of suca communtcattens utthta j
operattens' indicated a weakness ta tetra and interdeperimental i
communicatteam. Alse.the incorrect calculatten and lack of-commentsattens withis the eaglesertas department, with respect to an -
evaluatten of an ensecerad sectica of M asse grottag, Indicated a usakness to the licensee's operability evaluatten process.
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4.
precedures The inspectors reviewed the precedures that were is effect dertog the perted June 1 to September 5,1994. Particular emphasis uns placed on the adeouacy of guidance available to operators for the conduct af plaat evolutions, rescendtas to plant alarms. and determistag when an evolutten was covered by entsttag plant procedores.
AI 800, Ceedact af Operattens revisten 75. provided general geldence en operater respensthiittles and procedure usage. Al 500 secties 3.3.2.15 stated that operators were responsible for taktag Steely and 4
actlens to essere safe operatten of the plant. Forthermore.
sostion 4.3.2.2.4 stated that annunetator reopense presederen shall be used to diagnose alarms met directly related to latentteest sentpolattes of plant centrois and for any alars the operators were est espitettly familiar with, he further goldenee en timeltaess ta respeedlag to alarus er implementing alars ressense operator actions uns proridad in f
A1 500.
A1500 sectten 4.1.35.1 stated that it was the duty of every neeber of the Crystal River Unit 3 workforce'to strictly share to j
written peitetes and to comply with procedores urttten for Crystal River llatt 3. lissever. AI 800 sectten 4.3.3.3.1.a stated that een the adeenacy of existine precedores was guestioned, shift supervistaa would I
enke the detarstaatlen as to which precedere1 regetrements mars l
appitcable, s
N00-11. lentementatten of Teeketcal specificatten, revisten 3 provided a j
mechanistic process ta dettaine when precedures more regelred for conducting activities covered tr Techetta) Speciftettles A.S.t.1. Yhts i
process did not provide guidases for deterstateg when precedores mers poteattally inadegeste er when en activity was. net covered it entsting l
precedures. Precedure N0011 was an upper. tier proceders and was implemented by AI.4004..Descripties and General Adelaistrattaa of Plant l
Precedures. Procedure Al 4004. revisten 8, gave directies en the generation for new precedures tecluding any revlees that more reestred.
, no getdance en uten mer precedures should be generated una present.
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22 Precedure AI-400E, Performance and Transetttal of Precedures, provided a checklist to assist ta deterstalag if a procedere coastlisted a test er tafreguest e;alutten. Housver, this checklist only weeld be used if a new precedura had been generated and set to deterstne if an evoletten betag conducted using asisttag precedures was a test er an infregeest evolution. No puidance uns present to assist la determining if as evoletten botas conducted was a test er tafrequent evoluttes.
Furthermore, the Itceases did met define uhat activities constilstad a test'or esperteemt.
The inspectors discussed with the licenses the issues concerateg eben new procedures would be devoleped. The itsenses said there uns se spectfic guidance and it seald have been the shift seerrisors' judgement to determine if new or addittenal precedersi guldence ses required. The inspectors asked if the shift supervleers received any trelatag that mos1d assist them ta mettag this deterstaatten. The itecasse stated they retted on the aktft supervisers' esortense and licensed operater tratelag.
. 9perided Procedure A!.48tB, Procedere Writtag (Escept for E0P/AP/VP)Specific directies for the centest and format of plant the guidance for eserattag precedures stated parameters.that ser jeopardize egetpoest safety if exceeded steeld he tecladed in the Instts and precautions secties of the precedure. precedere Op ROM Ceres 8 uns a limit estabitshed for the purpose of protecttag the high pressure ta$ecttaa pumps from hydrogen gas tetrusten. Centeery to the goldeses of Al 40tt, ne referenes to Curve 8 uns present ta the lletts and precasttees rectten of precedere W-det. Ilakeup and Portftsatten Systes.
rettsten 75. AI 40tB did est prertde geidence en ese of plast anwes referenced within precedures.
Precedure op 4pt rettsten Fl.
tastrections for norus) aparetten of the makeup and purificatten tacledtog MR hydrogen gas additten j
and water level changes. This precedure uns presented to a sectiemal format to alles for operator flestbtitty by taplemsstieg sely tes appitcable sectten er settless. Itsuever, a pressuties er Itsttatten 3
fiven ta ese eastian did est apply to other sections of the pesdadore.
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The only precautions and Itsttattens that more applicable threaghest the entire precedure were these elves is the procesttens and liettettees secties. The precautten er llettatten for 855 pressere uns presented only ta the sectten for hydrogen gas addities. Se farther setenes for ISR pressure 1tatt was given ta procedure Op.4et taciuttag louerlag and raising itR water level.
e Precedure AR 403. PSA N Annunciater Responsa, rettsten 11. provides i
gutaance for operator. response to a IRR high pressure alarm. Ike alare was driven by a compartsen of laK 1evel and pressure to a esecuter algertthe that apprestaated the IER pressure limit (Curve 3). Ike gendance for a valid alars was to ensure 181W.141 and 185-143 une closed and to reduce pressere withis the IgR pressure listt (Curve 454. Be getdanes for tiaaliness to taittate aparator actions er the melhed for reducing ISR pressere uns gissa.
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21 Precedure OP.1038. Plant Operattag Curves, provided the adotaistrative operating Italts for normal slant operations. This precedure did est provide guidance en mersal plastocrattens or en the applicahtitty of ahtalstrative seerattag Italtn. In fact, precedure OP.103B ass'e'esed only to provide revision / contre! uhen administrative operettag,1tatts were revtsed.
Procedural guidance was met prerleed to aastst the shift superviser ta deterstateg when entsttog precedures were edeemate er if mer preesdures Furtherners. the tampacters concluded tha_t preesdure were necessary.
OP 442 did met provide suffittest enghests en matstatalag IW_ T pressers withts the 1tatts of preceders GP-10N Curve 8. Additionally,as specific guidance for timeltaess of response to plant alerus was present.
The inspectors concluded that operating procedures, as urttten, were adeguate for operattens withts the authertsed reglen of Curve 8. All 3
atae of the examples of apparent violatta 95 81 01 tavelved hydrogen i
addities, for which procedures were clear ta invektet Cerve 8 Ilotts.
I Mesever there were usaknesses te written directicas to operators ragardlag appitcability and ese of precedures.
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Trafatag I
l The inspectors reviamed the Itceased operator initial and retraaltftcatten tratatag programs to deterates if adequate tretetag j
satsted.
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l The licensed operator regnalificatten program una presented seer a tus-year perted. Neuever, set all precedures or systems were covered withis that tus. year perted. The inspectors deterstmed that th AI dN sortes j
precedures were last covered la lett and the Makeup tes portftcuttaa operating procedure was last cerered to 1998. Proceders AI.980 aos covered dortag the iteensed operater regnalificatten cycle prter to Septamher 6. 1994.
The Itcessee supplemented the itsensed operator regnaltfleetles progras with the Itcensed operster regetred reedtag progres. This progres uns 2
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used te keep operators amers of precederal changes. goldence for the licensed eserater reestred reedles propres coaststed of a process for developtog the reestres reestas liet and presenstag of sign off sheets.
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Neuever, as formal directten as the totest of the regelred feedtog l
program was present. Furtherners, precedures that the operators esed reettnely were not always included as reestred reading.,
4t Trateing on plant curves and adstatstrative lleits was i...W durtag l
taitta) Itcense trataing. Reettne pleet operattens, such as IIR hydrapea addities or water level changes, were not specifically included during Itcensed operator regualifttetten trataing. The itemese empletand that covert roottaa plast operattees una not seasidered e effective use of trat ressurens because the operstars sure familiar with such operattoma.
Ilficattes tratales tastaad aghastand estag i
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4 tt the ahnerms) and emergency plant precedores to respond to plaat treastents. Evalsettees of operater performance were conducted during ehserved re61.ttee stealater tratates. The Itcenses was estag mets 1921. Operater Licenstag Isantner Standards, as the evalAttve standard for acceptable operater performance. leats 1821 was used ey Nec esastners to deterstne if as tedivideal demonstrated suffletent kassiedge and aht11ttes to reestve er malatate as operater's Itcense.
IRMER tatt eve) mated operater perfemance te a vertety of areas teclettag precedere use and adherence alars response, and cespitance with adotatstrettee lloits.
The taspectors concluded the itseased tratalag program was adeesta.
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6.
taplayee Cancera Prograa h inspector reviewed the ECF to deterates the adeseacy of the program.
l N inspector retteund 100 flaenal Procedere MS.M. hertsten 5. dated 12/11/94 to deterstes the content and parpose of the progres. The porpose of the progres is to call attenties to the CPR regetrements wh6ch prohlhtt discristaatten by FPC. Its centracters, or sah.
centracters seatest an employee for emeestas to eartain protected activstles. This includes providtag tWest taformatten abast possible violattens of regrtrements tapened by the Ateste Energy Act er the i
j Energy Rearpentsattaa Act. It esseres that esplayees have a presses to espress sceneras or enha suggesttees withest fear of retrihettre er disertateatten. The progres estehlishes a prosess for deceasetteg.
inestigating, and resolvtag the conceras. Adittlensily, the progren i
asesres that enttlag employees have an opportsatty to identify senseres.
The progres costates a sentidsstiality provisten to protect the identity i
cf the tedividual prortetag the consore. This protecties is est l
shseluta la that thets are some stremstances seder stich the seestity could be revealed. These teclude as order of the coort, board or statiar legal entity. Also, as tedivident is considered to i
watved the right to ceafidenttality if he/she acts is a asemer reasonably espected to disclose his/her tenettty.
The program regetres settficattee of the ladtvident of the reseletion of to his/her cancern. The program sise allees the todtvides1 the i
attens j
appeal the reseletten of the esacers to the Director, haclear Sita support for revies of the concese and reseletten te deterstas if 4
l forther tavastigative actica is escassary or desired.
r The inseector discussed the program with the ICL and revleued the records of the progren tativetag several conseras that were sempleted and others that were still active. This revtes tedicated that la tue past year, the programireceived as to 48 conceras. Is j
this decrease la activity with, plant==t-'
and the ER and i{
concluded that the reassa for tats decreams ses the toplementatten of I
the precurser card system. 1 hts system ses toplemented to eller the licasses to teentify concerns prior to their rtstag to the level store a j
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25 probles report was reestred to be generated. The preterser cards are i
reviewed at the daily plan of the day asettag and are assigned to i
individuals for action. The cards are then tracked to closure. Both the 1tteesee and the inspector concluded that tais program was ani enhancement of their corrective acties program and that its wt ed d
iaplementatien should have redeced the mueber ef employee The inspector concluded that the closed concerns had received proper attention and that the open conceres sore atti) active with long ters corrective acttees in progress.
The tespector revleued audits N 'tk WP esaducted in Decesher INB and July 1994. The audit rossits lad;caiad that tratatag of persessel en i
the ECP was effective. Seventy five persent of the individeals serveyed tadtested the espected degree of feelltertty with the program. Elpty a-percent of the indiviesels surveyed indicated an adequate anderstandtag of annagement's sapectattaa as to when an ECP fers should be sateltted.
In general, the servey taticated that employees panorally were p)essed 3
with the propres and management's commitment to saa progren. The i
inspector randomly laterviewed personnel while anstte and arrived at l
l essentially the same conclestems as the audit reports.
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7.
. Dispositten of Apparent Violattees identtfled ta MC laspostles esport 50 308/95 13 1
l The inspecties docesastad in NBC It 50-30t/96-13 identtfled apperust violattens inve)ving the adagnacy of destga control and corrective actions.
s Apparent vtelatten 86 38t/95-13 Ot. esemple 1. described to pareproph 3 l
ef IR 50-302/9513 levolved the fat)ere to transiste the destes best:
te ensure proper sporstles of the Mateup and Purtftsattaa Systas, seet that the system is aetaastically switched fyse its meres) eparettep made j
to the emergency operettag ende Littgh Pressert IWetties) and is capable of delivertoe water free the Ourf late the reacter vessel, as as i
apparest violatten of it CFR 58. Appendia 8. Cettertes !!!. This i
apparent violattaa is adoleistratively closed and incorporated late
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apparent vtalatten $6-308/95-81-04, esemple 1.
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Apparent violattes 9511-01. examples I and 3. deserthed la peregraph 4 of IR 50 302/9513. tavelved the fallers to meet the reestressets of 10 CFR 50. Appendia 8. Criterien !!! and IV! for the laterte serves and the curves issued in Anytsten 13 to f91838. This apparaat ytelettaa is administratively closed and tacerpeCed inte apparent vietatten 50 302/95 12-03, example 2.
i Apparent violatten 9513-03, esamIple1.descrthedin 5 of IR 56 301/95 13 involved the annual smapever from the to the RB sump at a level of five feet er less in the SW5T. which is toestfletant to assure that all of the EtCS peeps usand not he damaged by vertastag.
This is an apparent violattaa of 18 CFR 58. Appendia S. Crtterten III.
Design Centrol for taadessate destga assumpttens for hereted unter
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25 storate task swapever level. This apparent vielatien is aestatstratively closed and incorporated into apparent violation
$0 302/95 tt 04, esanele 2.
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Apparent violatten 95 13 03. example 2. descrlhed in paragraph 5 of It 50 302/95 13. levolved the fallere to topleaset timely corrective acties to revies poteattal significant canditless adverse to'esality 4
tavelving safety reisted tanks. laciedtag the MBT and F5T. unich is a i
violatten of the reestrements of 10 CFR 50. Appeedts E. Cetterten Itt'.
This apparent violatten is adotatstratively cleted and locarporated into apparent vtalatten 50 302/95 31 03, esseple 3.
Apparept violatten 95 13-08. esseple 3. descrthed la peregrach 6 ef it 50 301/95 13 levolved the fallere to tresslate the destga hosts requirements of the FST tate operattep!precedores uhtch is a vtalattes of le CFR 50. Appendia B. Criterien !
. This apparent vtalatten is adelaistratively closed and incorporated into apparent violatten
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I 50 303/95-12 04, eseeple.d.
Apparent vietatten. 95 13 04, described in paragraph 7 of IR 50 303/95-
- 13. lavolved leadegoate destga centrol to essere adeguate investery in the 5 soap te prettee adegoate WM to a LP! pimp, with the 191 gesp section crosstle valve open. sepp 1rtog too sporetteg IIP! peeps. uts linese could rossit in the less of the only operable LP! peep. This was identified as an apparent violattaa of 10 CFR 88. Appendia R.
Criterten 111. Design Centes). This apparest vtalation is administratively closed and incorporated late apparent vietatten 50-38t/95 12-04, example 3.
i B.
Exit laterview The iaspectien scope and fiattogs were sammertaed as December 15.19p5 with these persons indicated in paragraph 1. The taspectors described the areas inspected and discossed in detail the inspection results Itsted belen. Proprietary informatten is est costaland ta this report.
Igg Iten llusher 2 3131 Desertatiam and Reference EE!
95-It 01 Open ~
Illes esemples of operatten of the enheep task setside of acceptable operattag regten.(paragraph 1.1)
IE1 95 11 02 open Two examples of enasthertzed tests /
esperiments duttag which the plant was operated to a mensenservettve manner t
setside the acceptable operating ret en withest a safety evaluatten. (paragraph 1.1)
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EE1 95 !! 43 Open Three esamples of inadeouste corrective actten concerning inadeouste revtsten to curve 8. Inadessate rettews. inadegoate tank volumes. (paragraph 3.1) eel 95 12 04 Open Fear esamples of inadequate desten control conceratag Cerve 8 varteus setpoints, and tank velames. (paragraph 3.1)
Etl 95 13 81 Cleaed Item closed by incorporating the smaaple-tote 95 32 St.
EE1 95 13 82 Closed Itse closed by incorporattag the esemples late 95 It 83 and M.
eel, 95 13 83 Closed Itse closed by int.wperating the examples inte 95 12 03 and 94.
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95 13 e4 Closed Itas closed by tacorporating the asample tete 95 11 04.
8.
Acronyms and lattialises SNET terated Water Storage Tank, ON Becay Heat t4 ECCS Energency Core Coeling system ECP Employee Concern Program ECR Employee concern Represostative EFW Energency Feeduator EOP Energency Operating Precedere FPC Florida Power Corporation FSAR Final Safety Analysis Report Hp!
Nigh Pressure injectica LOCA Less Of Coolant Ari1 dest MAR Nadtficatten Actlen Roguest 14fP Make up Pune Illi Make up Tank IG Nuclear Operations Departeent WPSH liet Positive Secties Need PR Probles Report R8 Reacter Building RC87 Reacter Coelant 81eed Tank RCs teacter Coelant System RfA Roguest for Engineering Assistance R0 Reacter Operator SRO 5 enter Reactor Operster 4
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Lurve uA. as, st.
Page 4 of 4 4
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CistVE SA, as 1.8C OPDATIONAL CRITRIA
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The BE51E LIMIT curve is based on Engineering Calculaties W6-0053, now. 2.
e he BEstm UNIT curve is based on instrument error fee pressure and level as read i
from W LtRI.
o h IARCCEPTABLI. il315 is se er above the DESIM L EIT curve. Operatten in the j
WACCEPTABLE REB 10h shall remire an evaluattaa la accordanes with CP-111
'lattiation and Processtag of Precursor Cards and Problem Asports'.
e The AISERICIATOR AlJWI is a variable alars based ea'a' press.%.1eus relationship for the,anheep taak and tattiates at 3 psi helen the destga 1 hit carve at a level of M inches.
e De COINTER ALAMI is a variable alare based en a Pressure / Volume relattenshis for i
the ankaup tank and tattiates at 4 psi below the desiga limit carve at a level of B taches.
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De ActIFTABLE REEIN is below the AIOReturet ALAM above 'O' psig and m a==== the PREFERRM RER!aN. It is bounded by the Les and 8tigh Level alarus j
that the ana)eup tank pressure is approaching the amanesister alars.The ColWTR (55' & 100* respectively.
t Eacneding the computer alara does not require any immediate acties.
I Exceeding the AIERBICIATOR ALAM will require operator actica to asserdance with the i
aapropriata Annunciator Anspense Procedure. This area is considered a MSTENTM M M.
The PREFERRED RERIGIl is an area below and to the right of the COINTER ALAtil and t
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equal to er greater than 16 psig. This region should provide adeguate Iqydrogen concentration (tE5 cc/kg) ja the RC5 if askeup tant pressures are consistantly asistained in this area.
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o Operation evtside the PREFERED RER1011 is acceptable during plant maneuvertag; j
however, under steady state conditions, efforts should be neds to operate in the PREFERD REG 1011.
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Makeup Tank Pressure should be maintataed above 0' psig durieg sermal operating j
eenditions, and during venting evolutions. This will prevent damage to the IRIT
. during a drau-deun from a.destga basis accident.
I Exceeding the IRIT MIM and LON LEVEL alars 'setpoints (100*, M*) will reoutre o
acties in accordance with the apprspriate Alare Response precedure(s). These areas are RESTRICT 5 AE810118.
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Op-1038 Rev. 15 Page 34 i
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