ML20116E822
| ML20116E822 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 07/31/1996 |
| From: | Carns N WOLF CREEK NUCLEAR OPERATING CORP. |
| To: | Lieberman J NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| EA-96-124, WM-96-0081, WM-96-81, NUDOCS 9608060134 | |
| Download: ML20116E822 (26) | |
Text
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g W$LF CREEK
~-
l NUCLEAR OPERATING CORPORATION I
July 31, 1996 l
Neil S. " Buzz" Carns I
Chairman, President and CNef Executive Officer WM 96-0081 l
Mr. James Lieberman Director, Office of Enforcement U. S. Nuclear Regulatory Commission One White Flint North, l
11555 Rockville Pike, Rockville, MD 20852-2738 l
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Reference :
Letter dated May 25, 1996, from T.
P. Gwynn, NRC,
[
co N.
S. Carns, WCNOC
Subject:
Docket No 50-482: Response to Enforcement Action EA 96-124 j.
Gentlemen:
l This letter transmits Wolf Creek Nuclear Operating Corporation's (WCNOC) l response to the above enforcement action.
Attachment I of this letter l
addresses the violations associcted with WCNOC's engineering group.
l Attachment II of this letter addresses the violations associated with WCNOC's operations group.
Attachment III of this letter addresses the violations associated with WCNOC's maintenance group.
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5 WCNOC's response to the violations is in the attachments to,this letter.
As I
part of WCNOC's commitment to excellence, refinements may be made, as deemed appropriate, to the corrective actions discussed in the attachments to this letter.
If you have any questions regarding this response, please contact me at (316) 364-8831, extension 4100, or Mr. Terry S. Morrill at extension 8707 i
A civil penalty of $300,000.00 was assessed in the enforcement action.
Enclosed is a check in the amount of $300,000.00 made payable to the Treasurer of the United States.
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Very truly yours, e
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9608060134 960731 l
PDR ADOCK 05000482 Neil S.
Carns G
PDR i
1 NSC/jad
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Attachments (3) i 4ff cc:
L.
J. Callan (NRC), w/a W.
D. Johnson (NRC), w/a i
J.
F. Ringwald (NRC), w/a l
J. C. Stone (NRC), w/a Document Control Desk (NRC), w/a Enforcement Officer, Region IV (NRC), w/a PO Box 411/ Burhngton, KS 66839 / Phone. (316) 364-8831 l
An Equal Opportunity Employer M/F/HC/ VET f
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l-l I
l STATE OF KANSAS
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SS l
COUNTY OF COFFEY
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L.
l Neil S. Carns, of lawful age, being first duly sworn upon oath says that he is President and Chief Executive Officer of Wolf Creek Nuclear Operating Corporation; that he has read the foregoing document and knows the content l
.thereof; that he has executed that same for and on behalf of said Corporation
. with full power and authority to do so; and that the facts therein stated are i
l true and correct to the best of his knowledge, information and belief.
D Os/ [h LINDA M. OHMIE '
By Notary Putsc. State elKansas Neil [STCarfE:
(
i e Appt. Empires T.3/ C/8 ;
President and f
Chief Executive Officer s
SUBSCRIBED and sworn to before me this d f ~ day of del &}
, 1996.
hch; W7. (Chudo No ary Public
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Expiration Date l
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l Attachment I
l WCNOC's Response to 4
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Enforcement Action EA 96-124 Notice of Violations I.A and II.A
l-Attachment I to WM 96-0081 Page 1 of 5 p
Violation I.A:
Several missed opportunities to identify and correct the i
design bases of the essential service water (ESW) system specifically related to warming line flow.
t
" Appendix B,
Criterion XVI, states that measures shall be established to assure that conditions adverse to quality, such as failures and malfunctions, are promptly identified and corrected.
l Contrary to the above, as of January 30, 1996, the condition of inadequate essential service water system warming line flow (a condition adverse to quality) was not promptly identified and corrected.
There were several opportunities to have identified and corrected the design bases of the system l'
specifically related to warming line flow:
(1) during the evaluation performed in 1993 related to warming line valve only capable of being 50 percent open; (2) while evaluating whether a frazil icing event at another l
l plant in 1993 could occur at Wolf Creek; (3) while answering an internal l
question in 1991 directly related to a concern for frazil icing; and (4) while j
reviewing a 1978 NRC Circular related to icing conditions (frazil ice was specifically considered by the licensee's architect-engineer). (01013)"
i Adalission of violatient Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that l
a violation of 10 CFR 50, Appendix B, Criterion XVI occurred when WCNOC failed to identify and correct design errors in the ESW system warming line calculations.
Reason for Violation:
]
Root Cause:
The root cause of this violation has been determined to be managemert's failure to: 1) provide consistent and demonstrated management expectations; and 2) to establish and implement effective personnel accountability tools / processes.
The failure to implement these items has resulted in I
multiple examples of inadequate engineering rigor, inadequate documentation of
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engineering work / judgment, and the lack of a sufficient questioning attitude.
Corrective Steps Taken and Results Achieved:
To effectively communicate and reinforce the required standards of performance l
in the above mentioned areas, to enable our engineering staff to achieve these i
l standards, and to measure the effectiveness of the corrective action program, two new tools were developed. They are:
- 1. An enhanced personnel evaluation process.
This process provides for a supervisor rating of engineers' work products against a focused set of performance dimensions.
Inadequate performance in these dimensions has been found to contribute to the weak engineering performance that has been observed at Wolf Creek Generating Station (WCGS). The results of these work product evaluations will form the primary basis for salary and career development and progression for Engineering personnel at WCGS.
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Attachment I to WM 96-0081 Page 2 of 5
- 2. An improved process for evaluating, targeting, prioritizing, scheduling, and tracking of tasks assigned to the 3ngineering staff. This process will allow the engineers to better focus their attention / efforts on issues which are potentially safety / operationally significant with sufficient time and resources.
Both of the above interim tools will be tested by the Engineering Department as part of our daily activities throughout the remainder of 1996.
Also, these tools will be tested as part of the auxiliary feedwater system functional assessment discussed below.
Improvements will be made as warranted.
WCNOC has reviewed all outstanding safety-related action requests (greater than six months old) to determine if any additional examples of long term potentially safety / operational significant concerns remain unidentified and unresolved. No new safety significant concerns were identified as a result of this review. The results of this re. view were presented to and reviewed by the Plant Safety Review Committee (PSRC).
WCNOC will continue to reevaluate all outstanding safety-related action requests (greater than six months old) and to report the results of these evaluations to the PSRC to assure safety i
significant concerns are not being allowed to remain unresolved for unacceptably long periods of time.
Correct.ive stens That will Be Taken and the Date when Full Crweliance will Be Achieved:
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i Full compliance has been achieved. The above discussed corrective actions are considered adequate to prevent recurrence of this violation.
The following l
system functional assessments are being implemented.
These assessments will also be used as a methodology of testing the effectiveness of the above mentioned corrective actions and to assure that no additional potentially safety / operational significant design concerns exist:
- 1. Auxiliary Feedwater System - Targeted completion date 12/31/96 2.
Essential Service Water System - Targeted completion date 6/30/97 3., Component Cooling Water System - Targeted completion date 12/31/97 4.
Residual Heat Removal System - Targeted completion date 4/30/98 These self assessments will evaluate the following:
- a. Design and licensing assumptions,
- b. Incorporation of lessons learned into the design bases, l
- c. Agreement of the USAR with the design bases,
- d. Agreement of Unreviewed Safety Question Determinations, operations l
Information Requests and Technical Specification Clarifications with l
licensing and design assumptions, and, l
- e. Effectiveness of testing to verify safety functions.
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As these assessments progress, management will continuously evaluate the above scope and schedule and make adjustments if warranted.
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r Attachment I to WM 96-0081 Page 3 of 5 l
Violation II.A:
Design measures failed to assure that the ESW design bases were appropriately translated into specifications and drawings.
Criterion III, states that measures shall be established to assure that applicable regulatory requirements and design bases for those structures, systems, and components to which this appendix applies are correctly translated into specifications,
- drawings, procedures, and l
instructions.
Contrary to the above, as of January 30, 1996, design measures failed to l
assure that the essential service water system design bases (protection against natural phenomena) were appropriately translated into specifications and drawings in that design errors were r le which caused the essential service water system not to be freeze prwected.
Specifically, incorrect l
assumptions regarding warming line temperatures and flow rates (35'F and full l
pipe flow) resulted in significant degradation in the freeze protection capability provided by the warming line.
(04013)"
l ad=4maion of violations WCNOC acknowledges and agrees that a violation of 10 CFR 50, Appendix B,
Criterion III occurred when WCNOC f ailed to assure that the ESW system was adequately designed and to translate the design bases for freeze protection into specifications, drawings, procedures, or instructions.
Reason for Violationt Root Cause:
Due to the historical nature of this event, the-exact root cause is indeterminate. However, the apparent root cause is the inadequate design of
-the ESW system to operate in an environment that could lead to frazil ice formation.
Given the existing ESW return line temperature, there was insufficient warming line flow to prevent the accumulation of frazil ice on the intake trash racks.
The most probable root cause was human error, in that the architect engineers (A/E) and responsible WCNOC interface personnel failed to assure all design assumptions were adequately questioned and/or verified.
During the original design, the potential for frazil ice formation was recognized, but was thought to be addressed adequately by the design of the ESW system warming lines and the spacing of the trash rack bars. During April and May of 1976, the A/E performed an evaluation on the potential for frazil ice formation at the WCGS ESW pumphouse. As a result of this evaluation, the A/E changed the location of the warming lines to position them directly in front of the trash racks.
A design calculation performed during this evaluation assumed an ESW warming line temperature of 3 5'F.
With this l
assumption, the calculation determined a flow of 4000 gpm was required.
Later, a design calculation determined that actual flow would be 4800 gpm with i
the additional assumption that the pipes would be full of water.
The above assumptions were incorrect.
The warming line temperature on the morning of
Attachment I to hN 96-0081 Page 4 of 5 January 30, 1996, was approximately 33*F.
It was subsequently discovered that the warming line and the ESW to Ultimate Heat Sink (UHS) return line piping diameters and elevations are such that portions of these lines operated with partial pipe flows.
This condition was apparently not foreseen by the piping designer, and made the calculation methodology used for sizing the warming line invalid with resulting non-conservative errors.
Actual flows were not able to be accurately measured, but all estimates of flow indicated insufficient heat addition to prevent frazil ice.
Corrective Steps Talran and Results Achieved (T - diate Short Term Actions)t Immediate short term corrective actions included: the erection of a temporary shelter over the external bays to minimize heat losses; the procurement and installation, on an interim basis, of portable space heaters and heater blowers to. warm the air in the ESW pumphouse and suction bays; and the procurement and installation of portable air compressors, an air-bubbler l
system, and portable water boilers to inject air and warm water into the outside ' bays of the ESW pump to aid in the agitating / breakup and removal of the frazil ice.
After briefing and training a team of individuals, WCNOC established a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> watch to verify continuous operation of the temporary equipment installed at the ESW pumphouse and bays and to inform the control room of any equipment degradation.
With the knowledge gained from the investigation, the incident investigation team (IIT) recommended additional compensatory enhancements to ensure frazil ice blockage of the ESW intake trash racks did not occur until a permanent design solution could be implemented.
Incorporation of these enhancements provided additional interim assurance for frazil ice mitigation at the ESW pumphouse:
- 1. Verify proper valve and system lineup to maximize warming flow to the ESW bays whenever ESW pumps are running.
2.
Install temporary heating equipment in the ESW screen bay area to reduce the likelihood of ice formation on the traveling screens.
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- 3. Provide a means to clean the front of the ESW trash racks, by installing temporary air sparging in each bay to " broom" the front of the trash rack.
- 4. To provide early detection of active frazil ice formation while the ESW pump are running, immerse a metal chain several feet into the trash rack bay water and monitor for ice accumulation.
5.
Install tents over the grating of the' bay to provide wind protection for personnel assigned to. monitor ESW bay conditions and to help prevent surface ice formation.
This individual will:
- 1) monitor the sparging air compressors,. 2) monitor the tents, and 3) watch for formation of ice on the traveling screens, screen wash discharge, and trash racks.
l Notification of the control room will occur immediately upon compressor failure, tent degradation or detection of ice formation.
7.
Install high intensity lights for use in observing and cleanirs of trash racks and traveling screens.
Attachment I to WM E6-0081 l
Page 5 of 5 1
l Recommendations 1 through 7 were incorporated, with implementing details, into a " Contingency Plan For Ice Prevention Measures At The ESW Intake,"
dated February 24, 1996.
Appropriate details of the contingency plan were subsequently incorporated in to Procedure STN GP-001, " Plant Winterization."
From the experience gained during the icing event, performance of these measures provided assurance that these temporary measures were adequate compensation until the design deficiency could be corrected.
l Corrective Steps That Will Be Taken and the Date When Full C - liance Will Bg Achieved (Lona Term Actione)r Design Change Packages were developed and are being implemented to ensure adequate warming line flow.
The hydraulics of the ESW discharge to the UHS and the warming line to the ESW pamphouse were changed to distribute the proper amount of flow to the ESW suction bay.
Additional actions being taken as enhancements are l
l Installation of vent lines on the ESW warming lines.
Incorporation of lake water temperature, ESW pump suction temperature and warming line temperature indication into the WCNOC design basis.
The potential for frazil ice is significant when bulk lake water temperature is at 33*F and decreasing.
Very small changes in temperature when the water is in the 32*F range can trigger frazil ice production.
Proceduralize the use of an air-bubbler and frazil ice detection system in a stand alone procedure.
This will aid the operators in the detection of frazil ice and provide a means of ice removal if a warming line became inoperable.
i These enhancements to the WCNOC plant winterization program will be completed on or before October 1, 1996.
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Attachment II WCNOC's Response to l
Enforcement Action 3
l EA 96-124 l
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Notice of Violations I.B, II.B, and II.C i
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1 Attachment II to WM 96-0081 Page 1 of 8 i
Violation I.B:
Failure To Follow Alarm Response Procedure.
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" Technical Specifications Section 6.8.1 states that written procedures shall be established, implemented, and maintained covering the activities recommended in Appendix A,
of Regulatory Guide 1.33, Revision 2,
February 1978.
Appendix A of Regulatory Guide 1.33, Revision 2, specifies procedures for abnormal, offnormal, or alarm conditions.
The licensee's alarm response Procedure ALR 00-008B, " SERV WTR PRESS HI LO,"
Revision 8,
directs the operator to establish operation of the essential service water system (ESW) using Procedure SYS EF-200, " Operation of the ESW System."
Procedure SYS EF-200 requires that ESW Valves EF HV-37 and -38 be opened, and EF HV-39,
-40,
-41, and -42 be closed.
Contrary to the above, on January 30, 1996, a control room operator, while aligning the ESW system as directed by alarm response Procedure ALR 00-008B, failed to use system Procedure SYS EF-200, and consequently the control room operator closed Valves EF HV-37 and -38 (to throttled positions), and opened Valves EF HV-39,
-40,
-41, and -42 which was not in accordance with Procedure SYS EF-200. (02013)"
Admission of Violations WCNOC acknowledges and agrees that a violation of Technical Specification 6.8.1 occurred on January 30, 1996, when control room personnel failed to align the ESW system as required by the alarm response procedure (ALR).
Reason for Violation:
Root Cause of this violation was that ALR 00-008B, " Service Water Pressure Hi Lo," referred to another procedure for short term actions and the control room operators failed to obtain and follow the procedure (SYS EF-200, " Operation of the ESW System").
Contributing Factor:
Control room operators upon completion of their initial alignment of the ESW system failed to perform the necessary follow-up actions.
The operators failed to obtain SYS EF-200 and verify the ESW system was correctly aligned.
The use of teamwork, proper communications, proper self checking techniques, j
questioning attitude, and strong command and control techniques were not 1
adequately demonstrated by the operators.
The shift supervisor incorrectly assumed, based on personal knowledge and l
working experience, that the control room operator would take the required I
actions, in accordance with plant procedures.
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Attachment II to WM 96-0081 l
Page 2 of 8 l
t Corrective Stens Taken and Results Achieved:
Administrative Procedure (AP) 15C-002, " Procedure Use and Adherence," has been revised regarding follow-up activities to be taken when the shif t supervisor or supervising operator directs operating personnel to take expedient actions I
that minimize the possibility for personal injury or damage to equipment. The following actions will be implemented for this unusual circumstance.
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- 1. Return the equipment / system to an approved lineup or initiate appropriate procedure changes, as soon as practical.
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- 2. Conduct an engineering evaluation of the effects of any abnormal j
equipment / system operation, -as soon as practical.
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- 3. Use magnetic lamacoid " follow-up buttons" which have been provided in the l
control room for the operating crews to identify items for which a follow-I up review is required.
4.
This action will be documented in the shift supervisor log or control room l
log.
operations management has reinforced procedure use expectations with each of l
the operating crews.
The meetings discussed the following expectations from l
" Procedure Use and Adherence," and AP 21-001,
" Operations Watchstanding Practices:"
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- 1. Continuous use versus reference use requirements OUP 15C-002; paragraphs 6.1, 6.2)
Jan of "not applicable," (N/A) (AP 15C-002, paragraph 6.6)
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alft rea,.uf and turnover (AP 21-001, paragraph 6.1) 5.
Conduct of operations personnel UU?21-001, paragraph 6.4) 6.
Commt.nications (AP 21-001, paragraph 6.4.2)
- 7. Main control board walkdowns (AP 21-001, paragraph 6.4.5) 8.
Control room board awareness (AP 21-001, paragraph 6.4.6) 9.
Supervisory monitoring and coaching (AP 21-001, paragraph 6.4.8) 10.WCNOC's self checking program (Stop Think Act Review (STAR)] (AP 21-001, paragraph 6.4.9)
These meetings also addressed the issues of communications and teamwork with augmented crews.
In addition, management reinforced the use of operations' divisional standards (STAR, safety, communications, questioning attitude, attention to detail, and housekeeping).
A seventh operations division standard, follow-up, has been added.
These operating principles will be periodically reinforced.
To further strengthen communications, a " codeword" was developed for use by any operator.
When implemented, an operator who states the codeword, will immediately become the focus of attention for the control room.
At that time, the operator will state the concern.
An evaluation of that concern will be
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made by shift supervision, and appropriate follow-up actions put in place.
The " follow-up buttons" previously mentioned will be utilized to identify items which cannot be. immediately addressed.
The use of the
- codeword" concept will be reviewed in September 1996, to determine its effectiveness.
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Q Attachment II to WM 96-0081 Page 3 of 8 Training was provided to the operating crews to reinforce current management expectations (operations watchstation practices, procedure use and adherence, and divisional standards), and to reinforce the use of the " follow-up button" l
and " codeword" concepts.
WCNOC has developed a pilot program to establish a protocol of behavior that recognizes and appropriately responds to the unexpected.
This involves the interjection of some pre-planned inappropriate
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l action or verbal response by a crew member.
The intent is to develop skills that recognize the inappropriate action or response (poison-pill),
and subsequently gain control of the situation with the correct verbal and procedural response.
This pilot program will complement the " training for j
l success" concept of our systematic approach to training, with a " training for failures" theme which will also help assure that proper actions are taken.
l Additionally, simulator scenarios have been developed to provide an increased l
stress environment for the operators.
These scenarios involve complex multiple casualty situations with increased plant paging and control room phone call activity to distract the operators.
At a predetermined time, the l
scenario will be stopped. The purpose of stopping the scenario is to evaluate the effectiveness of the crew communication, after each crew member has had an l
opportunity to focus on individual issues.
These scenarios begin with an event in progress (not steady state).
Simulator training in this manner is expected to. allow the operations personnel to practice communication skills l
within the crew (making sure that each crew member is kept apprised of the l
others' activities and priorities), practice use of the " codeword," utilize the " follow-up button" and stress the value of complete, precise turnovers.
i The use of these techniques will be reviewed in September 1996, to determine their effectiveness.
Management guidance has been provided to all operating crews to ensure there is no misunderstanding of the expectation that safety-related systems are not to be aligned to merely support the operation of non-safety-related systems.
Plant and industry events training for all operators was conducted as part of the requalification training to discuss this event and the lessons learned.
In addition, the management expectations regarding operation of safety-related systems were thoroughly discussed and will receive periodic emphasis with all operators.
The following enhancement has been developed as a tool to aid management in the control room operator selection process.
On July 9,
- 1996, operations management implemented a personnel
" Attribute" matrix.
This matrix will assist management in identifying personnel who have strong skills in communication (both verbal and written), judgment, coaching, accountability, and leadership.
This matrix will be used by operations management to evaluate personnel in the control room and on the simulator.
Additionally, this matrix will be used to aid in the evaluation of crew interaction to enhance crew manning for the optimum mix of personalities and abilities.
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Attachment II to WM 96-0081 Page 4 of 8 l
Corrective stags That Will Be Taken and the Date When Full Comoliance Will Be Achieved:
Full compliance has been achieved. The above discussed corrective actions are considered adequate to prevent recurrence of this violation.
As part of WCNOC's commitment to excellence the control room ALns are being upgraded.
This action will be completed on October 1, 1996.
The goal of this review was to identify and revise, as necessary, all ALRs which referred to l
other procedures for specific instructions on how to align systems.
- ALRs, which required short term operator actions important
- o aligning the system l
promptly, are being revised to include the specific actions or steps required.
The reference to SYS Procedures was resequenced within existing ALRs to l
provide for long-term system operation and monitoring.
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Attachment II to WM 96-0081 Page 5 of 8 Violation II.B:
Essential control room procedures were missing or incorrectly filed.
" Technical Specification 6.8.1 states that written procedures shall be established, implemented, and maintained covering the activities recommended in Appendix A, of Regulatory Guide 1.33, Revision 2, February 1978.
Appendix A of Regulatory Guide 1.33, Revision 2,
specifies procedures for abnormal, offnormal, or alarm conditions.
Operations Procedure ADM 02-014, " Control of Operations Documents, Revision 5, Section 6.9.3 states that,
" Procedures will be filed in the appropriate Procedure File Drawers, Procedural Manuals or field areas as applicable."
Contrary to the above, on January 30 and March 22,
- 1996, control room procedures were not filed in the appropriate location.
Specifically:
- 1. On January 30, 1996, when needed during the transition from Emergency Procedure EMG E-0,
" Response to Reactor Trip or Safety Injection," to Emergency Procedure EMG ES-02,
" Reactor Trip Response," EMG ES-02 was determined not to be filed in any of the four emergency operating procedure sets in the control room as required.
- 2. On March 22,
- 1996, an NRC inspector determined that alarm response procedure ALR 00-110, "SL41 Bus Trouble," was not located in the control room after it had been identified as missing during an earlier licensee audit of procedures. (05014)"
Anim4 salon of Violation:
WCNOC acknowledges and agrees that a violation of Technical Specification 6.8.1 occurred January 30, 1996, when WCNOC failed to have the required copies of procedures within the control room and was not satisfactorily corrected until March 22, 1996.
l Egason for Violatient Root Cause:
The root cause of the initial error has been determined to be personnel error (inattention-to-detail).
The shift clerk, who performed the emergency j
operating procedure update activity, failed to adequately verify she was upgrading the correct procedure.
1 The root cause of WCNOC's failure to correct the problem has been determined to be personnel error.
The WCNOC document services personnel performing the corrective actions (the conduct of a 100% audit of all control room procedures) for the initial error and the interfacing control room shift clerks failed to conduct adequate face-to-face communications.
This failure to adequately communicate resulted in each group assuming the other would implement the corrective actions.
The responsible individuals failed to obtain agreement on who would implement the required corrective actions and no one re-verified that the corrections were properly made.
Attachment II to WM 96-0081 Page 6 of 8 Contributing Factors:
The shift clerks were not adequately trained.
The importance of inserting procedure changes and the need for attention to detail were not clearly communicated to the clerks.
The established programmatic controls for procedure revision and replacement did not provide adequate tools to assure critical control room procedures were correctly replaced.
Further, no checks and balances were provided to insure personnel performed these tasks in an acceptable manner.
Corrective Stans Taken and Results Achieved:
All missing control room procedures were replaced.
The shift clerks have been trained on the importance of inserting procedure changes, the need for attention to detail, and the established program requirements.
Ongoing verification of the procedure posting performed on the previous shift indicates the maintenance and accuracy of control room procedures has been improved.
In addition, periodic audits of all critical control room procedures (these procedures utilized by the operators for normal and off-normal plant operations) are being performed in accordance with procedure AI 15A-002, " Procedure Audit."
Corrective Stans That Will Be Taken and the Date when Full h liance Will Be Achieved Full compliance has been achieved. The above discussed corrective actions are considered adequate to prevent recurrence of this violation.
1 Attachment II to WM 96-0081 Page 7 of 8 l
i Violation II.C:
Failure to cooldc"an the plant within the time limits specified in Te':hnical Specification Action Statement 3.7.2.b.
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" Technical Specification Limiting Condition for Operation Action Statement l
5.7.2.b specifies that in Mode 1,
2, and 3,
"With two. auxiliary feedwater.
l pumps inoperable, be in at least HOT STANDBY within 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in HOT SHUTDOWN within the following 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />."
Contrary to the above, on January 30, 1996, when in Mode 3 (Hot Standby) and with two auxiliary feedwater pumps inoperable, hot shutdown was not achieved as specified-in Technical Specification Action Statement 3.7.2.b.
The second auxiliary feedwater pump (A Train) became inoperable at 7:47 a.m.
on January 30,.1996.
Hot shutdown, which should have been achieved by 1:47 p.m.,
was not achieved until 3:31 p.m. on January 30, 1996. (06014)"
i ad=4mmion of violations l
WCNOC acknowledges and agrees that a violation of Technical. Specification l'
Action Statement 3.7.1.2.b occurred on January 30, 1996, when the control room personnel failed to cooldown the plant within the six hour time limit.
l Reason for Violationt-
Background:
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WCGS. entered Technical Specification 3.7.1.2 Action Statement "b,"
which l
requires the plant to be in Hot Shutdown (MODE 4) within six hours of being in Hot Standby (MODE 3) when two of. the three auxiliary _ feedwater pumps are l
inoperable.. At approximately 2.25 hours2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br /> in to the six hour actions statement the Manager Operations was informed that the sir. hour Limiting Condition for Operation (LCO) might be exceeded.
The Vice President of Operations and NRC Resident Inspector were notified shortly thereafter.
The Operators were cautioned by the Manager Operations to reach MODE 4 safely and in a timely manner, and not rush to try and meet the LCO time requirement.
The plant entered MODE 4 approximately 1.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> late, i
l Root Cause:
I cause of this violation has been determined to be a combination of l
The root l
inadequate procedure guidance and inadequate training. General Operating
. Procedure (GEN) 005, " Minimum Level To Hot Standby," and GEN 006, " Hot Standby I
To Cold Shutdown," did not.specify which steps were required to be completed in series and.which could be completed in - parallel.
Also, the operator training program had not required crews to complete a six hour "real-time" i
plant cooldown.
l Contributing Factor:
The supervising operator (SO) incorrectly believed he was required to complete
' GEN 005 prior to entering GEN 006.
Attachment II to WM 96-0081 Page 8 of 8 Corrective steps Taken and Results Achievedt l
i GEN 005 was revised.
This revision provides clear indication of which steps must be completed prior to entering GEN 006.
All other general operating l
procedures have been reviewed.
No generic implications which could cause similar problems were identified.
Operations management reinforced its procedure use expectations with the operating crews.
The meetings discussed the following expectations from AP i
" Procedure Use and Adherence,"
and AP 21-001,
" Operations Watchstanding Practices "
Shift relief and turnover (AP 21-001, paragraph 6.1) 5.
Conduct of operations personnel (AP 21-001, paragraph 6.4)
- 6. Communications (AP 21-001, paragraph 6.4.2) 7.
Main control board walkdowns (AP 21-001, paragraph 6.4.5) 8.
Control room board awareness (AP 21-001, paragraph 6.4.6)
- 9. Supervisory monitoring and coaching (AP 21-001, paragraph 6.4.8) 10.WCNOC's self checking program (Stop Think Act Review (STAR)] (AP 21-001, paragraph 6.4.9)
These meetings also addressed the issues of communications and teamwork with augmented crews.
In addition, management reinforced the use of operations' r
divisional standards (STAR, safety, communications, questioning attitude, I
attention to detail, and housekeeping).
A seventh operations division standard, follow-up, has been added.
Simulator training for accelerated plant shutdown /cooldown was conducted for each operating crew.
This training provided the operating crews with an opportunity to respond to plant conditions which required the performance of an accelerated plant cooldown.
Correctiva stens That Will Be Taken and the Data When Full Caneliance Will Be Achieved:
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Full compliance has been achieved. The above discussed corrective actions are considered adequate to prevent recurrence of this violation.
The following program enhancement is being implemented and will aid in the prevention of this event:
WCNOC is in the process of converting the current WCNOC Technical Specifications to the improved standard technical specifications. Based upon the use of completion times in the improved Technical Specification 3.7.5, 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> would have been allowed to achieve hot shutdown and the j
current technical specifications' requirements of six hours would not t
have been violated.
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Attachment III I
l WCNOC's Response to l
Enforcement Action l
EA 96-124 i
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Notice of Violations I.C, II.D, and II.E I
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Attachment III to t'M 95-0081 Page 1 of 8 violation I.C:
An aggregated violation with inadequate work instructions and ineffective corrective actions associated with work performed on the Turbine Drive Auxiliary Feedwater Pumps (TDAFWP).
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Criterion V,
states that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances.
Contrary to the above, on January 25 and 30, 1996, work instructions provided for packing the turbine-driven auxiliary feedwater (TDAFW) pump l
(an activity af fecting quality) for WP 108952, Task 6, and WP 109087, Task 2,
were not appropriate to the circumstances in that not all i
pertinent packing information in Component Change Package 05767, which i
was contained in the TDAFW pump vendor
- manual, was included.
Specifically, neither WP 108952, Task 6, or WP 109087, Task 2, provided adequate instructions concerning:
(1) the proper tightening of the packing gland follower nuts, (2) guidance on proper installation of the-packing gland follower into the pump stuf fing box, and (3) directions on the pump's post maintenance run time required to obtain proper packing leakoff.
(03013) l 2 10 CFR Part 50, Appendix B, Criterion XVI, specifies that measures shall be established to assure that conditions adverse to quality, such as
- failures, malfunctions, deficiencies, or deviations are promptly j
identified and corrected.
In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is i
determined and corrective action taken to preclude recurrence.
Centrary to the above, as of January 30, 1996, a significant condition adverse to quality - improper adjustment of packing on the safety-related TDAFW pump - was identified, but actions were not ' taken to determine and correct the cause of the deficient condition.
i Specifically, Performance Improvement Request (PIR) 94-1918 was issued on October 30, 1994 to address the improper adjustment of packing.on the TDAFW pump.
However, the PIR was closed on the basis of repacking the pump without determining and correcting the cause of the packing installation problem.
(03023)"
W amion of violations f
WCNOC acknowledges and' agrees that a violations of both 10 CFR 50 Appendix B, Criterion V and XVI occurred on January 25, 1996, when maintenance personnel failed to develop and implement adequate work instructions for the performance of maintenance associated with the TDAFWP and when they failed to correct a known condition adverse to quality i
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9 Attachment III to WM 96-0081 Page 2 of 8 l
Reason'for violation:
Root Causet l^
The root cause of example #1 was inadequate and-inconsistent work planning t
l resalting in poor packing installation and adjustment practices.
1 The root cause of example #2 was that a sound engineering evaluation was not l
conducted to determine the cause for the packing failure.
The responsible l
engineer failed to properly determine the cause of the packing failure due to l
not being involved in the problem resolution process.
l Contributino factors includer l
Example #1:
The responsible maintenance planning personnel failed to incorporate revised vendor manual technical information (Configuration Change Package (CCP) 05767], into work package instructions.
Maintenance planning and engineering personnel failed to address adequately corrective action issues on previous PIRs.
Mechanical maintenance personnel who implemented the activity failed to follow the work instructions correctly and adequately.
l Maintenance personnel failed to apply the rudiments of the CCP 05767 change to technical manual M-021-0061 in their maintenance continuing training.
l Mechanical maintenance personnel lacked a questioning attitude at the work location.
Example #2:
The responsible personnel failed to demonstrate a questioning attitude and accepted the apparent cause rather than assessing all the different aspects of the job which could have been cause for the component failure.
Corrective Steps Taken and Results Achieved:
Example #1:
The questionable inboard packing for the TDAFWP was immediately repacked under WP. 109087.
The appropriate post maintenance testing and operability surveillances were performed.
Auxiliary feedwater pump work instructions were revised to include updated packing instructions and post maintenance testing instructions which fully l
implemented CCP 05767 instructions.
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l-Attachment III to WM 96-0081 Page 3 of 8 l
I PIRs 96-0269 and 96-0217, developed from IIT 96-001, "TDAFW Pump Trip Throttle l
Valve (FC-HV-0312) Retest Failure & TDAFW Pump Inboard Packing Failure,"
l findings, have been provided to maintenance planners both as required reading l
and as continuing training topics to promote uniform awareness of the planning i
concerns associated with this issue and insure long term incorporation of lessons learned into maintenance planning activities.
The effectiveness of this training will be examined during the followup to the two significant PIRs in question.
A critique training session was conducted with all planners concerning the lessons learned from PIRs 96-0269 and 96-0217.
This training reviewed the revised packing and maintenance run-in work instructions.
i A new preventive maintenance task to inspect the three auxiliary feedwater pumps (PALO2, PALO1A, and PALO1B) sleeve nuts and to tighten them, if necessary, was developed and implemented.
As of July 30, 1996, all three pumps have been inspected once with no concerns identified.
The second performance of this preventive maintenance task will be completed in the third quarter of 1996.
l Additionally, the surveillance frequency and run-time duration for all auxiliary feedwater pumps has been increased to provide more data history to demonstrate long-term wear characteristics of this packing and to document its continued satisfactory performance. All pumps are performing in an acceptable manner.
In addition, outstanding corrective maintenance on the TDAFWP was reviewed by the system engineer to ensure outstanding system issues were addressed.
The Manager Maintenance issued letter MD 96-0012, dated March 11,
- 1996, placing into effect a requirement that a separate and knowledgeable individual responsible for oversight be assigned for unscheduled corrective maintenance activities on the TDAFWP and the emergency diesel generators (EDG).
This has been directed for the purpose of providing extra vigilance to assure the i
correctness of maintenance activities and equipment reliability.
This action also provides added oversight on adherence to work instructions, use of STAR at the work location, and the use of questioning attitudes.
The effectiveness of this oversight and the need to continue will be evaluated during the fourth quarter 1996.
PIRs 96-0269 and 96-0217 and corrected technical manual information were added to maintenance continuing training.
Example #2:
The Manager Maintenance on January 31, 1996, reemphasized his expectations on l
the importance of using self-critical evaluations by all concerned when I
significant problems occur.
Additionally, he emphasized the requirement for maintenance personnel to solicit the involvement of system engineers in resolving significant maintenance corrective actions.
Separately, tha corrective action procedures were revised to require independent reviewers or the individuals who perform the root cause analysis to be trained in root cause techniques.
To monitor the involvement of system engineering in daily
Attachment III to WM 96-0081 i
Page 4 of 8 I
maintenance, the Plant Manager, the Manager Maintenance, and the Manager System Engineering review current maintenance issues for the degree of specific agenda item in their weekly meeting.
From involvement as a observations to date. marked improvements have been noted in the system
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engineers involvement in maintenance, and communications among work groups and engineers are frequent, routine and effective.
For example the responsible system engineer was noted to be in the plant monitoring the performance of the auxiliary feedwater pumps immediately following the June 6, l
1996, reactor trip.
To measure the specific effectiveness of this improved i
involvement, maintenance and system engineering will conduct a self-assessment I
in the third quarter of 1996.
I System engineering is now working directly for the Chief Operating Officer to emphasize the importance that the Chief Operating Officer places on system engineering involvement.
This enhancement will focus the key WCNOC personnel on resolution of plant material concerns.
Additionally, a supervisor in system engineering has been assigned sole responsibility for all auxiliary j
feedwater issues to ensure proper regard for the unique significance of the system for safe plant operation.
Corrective Stans That Will Be Taken and the Date When Full Cn=mliance Will Be Achieved!
Full compliance has been achieved. The above discussed corrective actions are considered adequate to prevent recurrence of this violation.
The below noted additional actions will be completed by September 1, 1996.
These actions are being implemented to further enhance the actions discussed above.
Additional pump packing training will be provided to planners and mechanics.
This training will also be offered to system engineers.
The appropriate post maintenance testing methodology relative to maintenance activities will be developed.
Attachment III to WM 96-0081 page 5 of 8 Violation II.D:
Incorrect closure of a work request without action being implemented to address the identified concern.
Criterion XVI, specifies that measures shall be established to assure that conditions adverse to quality, such as. failures, malfunctions, deficiencies, or deviations are promptly identified and corrected.
In the case of significant conditions adverse to quality, the measures shall j
assure that the cause of the condition is determined and corrective action taken to preclude recurrence.
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f Contrary to the above, as of January 30, 1996, a significant condition adverse to quality was identified, but actions were not taken to correct the deficiency or to determine the cause of the condition.
Specifically, Work Request 60242-94 was issued on October 20, 1994, to correct the TDAFW pump inboard packing gland follower nuts which had insufficient thread engagement; however, the Work Request was closed without further action on the basis that a non-conformance report did not specify full thread engagement was acceptable.
(07014)"
1A=4maion of violations WCNOC acknowledges and agrees that a violation of 10 CFR 50, Appendix B, Criterion XVI occurred on January 25, 1996, when maintenance personnel failed to correctly disposition Work Request 5933-94 (Work Request Number 60242-94 is an incorrect number).
Reason for Violations Root Cause:
The root cause of this violation was that a sound engineering evaluation was not conducted to evaluate the identified concern. The responsible engineer failed to properly determine the cause of the concern due to not being involved in the problem resolution process.
Contributing Factor:
The. responsible mechanical maintenance and engineering personnel failed to demonstrate a questioning attitude.
They accepted the apparent cause concerning thread engagement, rather than assessing all aspects of the job which should have determined the cause for the existing packing gland condition and the potential this represented for packing degradation.
Corrective Steps Taken and Results Achieved The corrective actions documented in WCNOC's response to Violation 9603 I.C, Example 2, have been reviewed and determined to be adequate to correct and prevent recurrence of this violation. No further actions are warranted.
Corrective Steps That Will Be Taken and the Date when Full Cn=pliance Will Be Achievedt Full compliance has been achieved.
The above discussed corrective actions - are considered adequate to prevent recurrence of this violation.
Attachment III to WM 96-0081 Page 6 of 8 Violation II.E:
Failure to follow established procedures in the implementation of work on the TDAFWP.
" Technical Specification Section 6.8.1 states that written procedures shall be established, implemented, and maintained covering the activities recommended in Appendix A, of Regulatory Guide 1.33, Revision 2, February 1978.
Appendix A of Regulatory Guide 1.33, Revision 2,
specifies that maintenance that can affect the performance of safety related equipment should be properly preplanned and performed in accordance with written procedures.
Maintenance Procedure 16C-002,
" Work Controls," Revision 2,
Step 6.6 7.5 states, " Perform work in accordance with work instructions and referenced documents," Task 2,
step 5.4 of work order WP 108952 specified that the packing gland follower nuts be tightened " snug."
Contrary to the above, on January 25, 1996, maintenance personnel failed to follow established procedures in the implementa. tion of work on the TDAFW pump.
Specifically, maintenance personnel tightened the nuts only " finger tight,"
instead of " snug."
(08014)"
id=a4asion of Violationi WCNOC acknowledges and agrees that a violation of Technical Specification 6.8.1 occurred on January 25, 1996, when maintenance personnel failed to follow the established procedures when tightening the packing gland follower nuts.
Reason for Violation Root Cause:
A mechanic failed to follow procedures while performing work instructions.
The root cause of this violation is that the responsible individual applied his 'own interpretation to the work instructions, rather than to seek supervisory clarification.
Contributing Factors:
The work - instructions were inadequate, in that. they did not provide the mechanic with sufficient detail.
The mechanic was unable to reconcile apparent differences between the work instructions and his previously received training.
Additionally, there is a precautionary note just above the work instructions warning the mechanic not to over-tighten the packing to prevent excessively reducing gland leak off.
Thus the mechanics were of the " finger tight" mind set and not the " snug tight" mind set.
This mind set resulted in the incorrect tightening of the nut.
4 Attachment III to WM 96-0081 Page 7 of 8 Corrective stens Taken and Results Achieved Training was conducted with all mechanics and supervisors to reemphasize the necessity to follow procedures and to seek supervisory guidance if the work instructions are not in agreement with their knowledge of the job.
The work instructions for repacking the TDAFWP were rewritten and all mechanics were trained.
The Manager Maintenance expectations, issued on January 31,
- 1996, were reviewed with all maintenance personnel by the Manager Maintenance and Maintenance superintendents.
These prescribe the expectations that all workers will seek supervisory clarification if they have difficulty in understanding or carrying out planner work instructions.
Training was conducted with all first line supervisors to review what is required to:
establish minimum standards for work practices of craft personnel.
check that work performance in the field satisfies work instructions.
change the work package so that it results in acceptable work performance.
The specific first line supervisor who followed this work in the field was counseled on his responsibility to ensure that the work adheres to established work practices upon which the mechanics have been trained and that the specific attributes for success of the work have been met.
j The Manager Maintenance reinforced the significance of the TDAFWP and the emergency diesel generators for safe shutdown of the pliant, and whenever work is being performed on this equipment, due regard must be made to th2ir unique importance to reliable plant operation.
Bi-weekly evaluations of work in progress are conducted to determine: work package quality, maintenance personnel adherence to standard work practices and the effectiveness of maintenance supervisors in the field.
The effectiveness of this effort will be measured by a self-assessment conducted in the fourth quarter of 1996.
All maintenance supervisors were counseled by the Manager Maintenance, the Plant Manager, and the Chief Operating Officer on their responsibilities to be accountable for the quality for work performed by the craft and the quality of the work packages they accept for field use.
A new Superintendent Maintenance Planning was assigned from the Operations Department to provide more of an operational focus to the planning process.
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Attachment III to WM 96-0081 Page 8 of 8 Corrective Stens That Will Be Taken and the Date When Full Compliance Will Be Achieved:
Full compliance has been achieved. The above discussed corrective actions are considered adequate to prevent recurrence of this violation.
To further enhance these actions, the following action will be implemented:
The mechanical maintenance continuing training program has been revised to include the requirement for each mechanic to repack a mock-up packing gland using the new instructions.
This training is ongoing and will be completed in mid-August.
As part of WCNOC's self critical evaluation program and to measure the effectiveness of the above training, a self-assessment will be conducted j
in the third quarter of 1996, to determine the adequacy of work packages
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in the field.
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