ML20117F572
| ML20117F572 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 08/29/1996 |
| From: | Jeffery Wood CENTERIOR ENERGY |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9609040135 | |
| Download: ML20117F572 (5) | |
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'N - CENTEmon M
ENERGY C200 00k free Boulevard uod Aasess independence 0H PO Box 94661 7
216 447 3100 Cteveiona OH 4410b4661 Docket Number 50-346 License Number NPF-3 Serial Number 1-1108 August 29, 1996 United States Nuclear Regulatory Commission Document Control Desk Washington, D.C.
20555
Subject:
Response to Inspection Report 50-346/96003 Ladies and Gentlemen:
Toledo Edison has received Inspection Report 96003 (Log Number 1-3721) and the enclosed Notice of Violation; the response to which is provided below.
Reply to a Notice of Violation (346/96003-01 and 02)
Alleoed Violation During an NRC inspection conducted on April 10 through June 11, 1996, a violation of NRC requirements was identified.
In accordance with the
" General Statement of Policy and Procedure for NRC Enforcement Action,"
NUREG-1600, the violation is listed below:
10 CFR Part 50, Appendix B, Criterion V, states, in part, that
" Activities affecting quality shall be prescribed by documented instructions, procedures, or dr sings of a type appropriate to the circumstances and shall be accc a inhed in accordance with these instructions, procedures, or d)
>< q a.
Davis-Besse system operatia procedure DB-OP-06316 (Revision 01)
" Diesel Generator Operating Procedure" included specific steps to adequately perform an emergency shutdown of Emergency Diesel l
Generator (EDG) 2 and then place it in a standby condition.
Specifically, the procedure included Section 5.8,
" Emergency l
Shutdown or Operation Following an Automatic Trip of EDG 2".
Step 5.8.9 required Section 3.10, " Stopping EDG 2",
be performed l
if the EDG was to remain shut down.
Contrary to the above, on May 15, 1996, operators performed an emergency shutdown of EDG 2, and placed it in a standby condition j
without completing all steps of Section 5.8 nor entering Section 3.10 of DB-OP-06316.
(50-346/96003-01) 9609040135 960029 y,-
I DR ADOCK 050 6
Operating Componies.
Cleveland Electne inuminating Toledo Ed son
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Docket Number 50-346 License Number NPF-3 Serial Number 1-1108 Page 2 l
b.
Licensee procedure DB-OP-06012, Decay Heat Removal System Operation precaution 2.1.5 stated, in part, "Whenever the DH cross-over line is used (Valves DH 830 & DH 831), the auction valve to the disabled pump must be closed to prevent over pressurization of the DH pump suction line and lifting (relief valve) PSV (DH) 1508 or PSV (DH) 1509."
Contrary to the above, on May 22, 1996, operations personnel opened DH 830 without shutting the suction valve to the disabled pump, causing DH 1508 to lift, transferring about 200 gallons of Reactor Coolant to the Reactor Coolant Drain Tank.
(50-346/96003-02)
This is a Severity Level IV violation (Supplement I).
Igledo Edison Response
- 1. Reason for the Violation a.
The reason for the violation involving failure to complete procedure DB-OP-06316 for the EDG was personnel error. The system operating procedure was not properly utilized to place the EDG in standby following an inadvertent start which
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occurred while preparing for EDG testing. The Operations administrative procedure Conduct of Operations (DB-OP-00000) defines proper procedural usage and adherence requirements.
Deviation from the Management expectatione delineated in this procedure occurred, although thu correct procedure for the restoration was being used, because there was a failure to adequately document the performance of the procedure by signing off the steps. The supervisor incorrectly determined that the performance of this activity was a " routine evolution" which does not require procedure sign-offs.
During conduct of the procedure, the operator also identified a confusing routing step. The supervisor made the decision that the procedure step was not required based on the testing configuration and therefore did not route to and complete Section 3.10 for the restoration. Although the correct actions were subsequently taken to place the equipment in a standby condition, the method by which this was performed and the process used to deal with the confusing procedural step was inappropriate because a procedure clarification should have
a i
Docket Number 50-346 License Number NPF-3 Serial Number 1-1108 Page 3 been obtained. This event occurred due to a supervisory individual's failure to adhere to Management expectations with regard to procedural compliance, b.
The reason for the violation involving failure to follow procedure precaution 2.1.5 of DB-OP-06012 for DH 830 was personnel error. During the Tenth Refueling Outage activities of DH system restoration, the Shift Supervisor and Control Room Senior Reactor Operator (SRO) were aware of the need to crack open DH 830 prior to returning it to electrical control, due to it being manually seated for a tagging boundary in accordance with DB-OP-00015, Safety Tagging. These two SROs had determined that DH 830 would not be opened at that time due to the potential for loss of Reactor Coolant System (RCS) inventory.
i However, another SRO on shift directed an operator to perform j
the task of manuall.y unseating DH 830. When the valve DH 830 i
was manually unseated, the intent of procedure DB-OP-06012, j
precaution 2.1.5, was violated. Opening DH 830 was not performed in accordance with DB-OP-06012 and could have been prevented if the activity had been properly evaluated or communicated to the Control Room Staff prior to taking action.
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- 2. Corrective Action Taken and Results Achieved a.
The EDG was test started and responded normally, after the inadvertent start, to verify that the EDG was in the correct configuration for the testing in progress when the inadvertent start occurred. The Operator who decided not to document completion of the procedure later realized his error and completed the appropriate documents. The EDG was placed in standby following completion of testing.
b.
After DH 830 was manually unseated, the Control Room Operator closed the valve due to loss of inventory from the RCS.
The Supervisor who directed the activity to manually unseat DH 830 was counseled on his failure to properly evaluate the evolution and communicate his decision to the Control Room prior to initiating the activity. The operator involved was counseled regarding the need to be attentive to plant conditions and Management's expectations regarding observation of system operating procedure requirements when operating all plant equipment. An evaluation was performed concerning the potential overpressure condition caused by manually opening DH 830.
This evaluation determined that the piping was not
i Docket Number 50-346 License Number NPF-3 Serial Number 1-1108 Page 4 pressurized beyond the evaluated maximum pressure. A walkdown of piping was performed and no abnormal leakage or piping damage was identified.
- 3. Corrective Actions to Prevent Recurrence Within the time period prior to and during the Tenth Refueling Outage, Operations Management took a proactive approach to espouse the procedural use and adherence philosophy contained in the Conduct of Operations procedure. Management expectations were clearly communicated to emphasize the critical issue. Also, the subject of inadvertent water transfers in the past, and areas where this potential existed were reviewed by Operations Management during preoutage training.
It was clearly communicated that any manipulation of valves on systems interconnected to the RCS required a thorough review and extreme caution to assess the potential impact.
Both of these events demonstrate the need to periodically emphasize procedural compliance and proper communication.
To provide this emphasia, these events were reviewed with all cperators and licensed vrsonnel during the operator requalifi-cation training cycle completed on July 6, 1996.
The events, lessons learned, and Management's expectations for procedure compliance were emphasized by the Operations Superintendent.
The importance of communications and having procedures in hand and followed has been clearly communicated to all operators.
In addition, procedure DB-OP-06316 for the EDG was modified to clarify the routing step that was misinterpreted by the operator.
4.
Date When Full Compliance Will Be Achieved Full compliance with the Diesel Generator Operating Procedure, (DB-OP-06316), was achieved when the documentation for EDG shutdown was completed on May 16, 1996.
Compliance with the intent of DB-OP-06012, precaution 2.1.5 with regard to DH 830 was achieved when the Control Room Operator reclosed DH 830 after discovering the change in RCS inventory on May 22, 1996.
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Docket Number 50-346 License Number NPP-3 Serial Number 1-1108
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Page 5 Should you have any questions or require additional information, please I
contact Mr. James L. Freels, Manager - Regulatory Affairs, at (419) 321-8466.
Very truly yours, i
K. Wood-Vice President - Nuclear Davis-Besse Nuclear Power Station DLMatam l..
l cc: L. L. Gundrum, NRC Project Manager l
A. B. Beach, Regional Administrator, NRC Region III l
S. Stasek, DB-1 NRC Senior Resident Inspector l
Utility Radiological Safety Board 1
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