ML20134D252
| ML20134D252 | |
| Person / Time | |
|---|---|
| Site: | Oconee  |
| Issue date: | 06/04/1991 |
| From: | Ebneter S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Tuckman M DUKE POWER CO. |
| Shared Package | |
| ML20134D255 | List: |
| References | |
| EA-91-049, EA-91-49, NUDOCS 9610210046 | |
| Download: ML20134D252 (4) | |
See also: IR 05000269/1991008
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UNITED STATES
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NUCLEAR REGULATORY COMMISSION
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R EGION 11
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101 MARIETTA STREET. N.W.
AT LANTA, GEORGI A 3G323
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JUN 0 41991
Docket Nos. 50-269, 50-270, 50-287
License Nos. OPR-38, OPR-47, DPR-55
EA 91-049
Duke Power Company
ATTN: Mr. M. S. Tuckman, Vice President
Nuclear Operations
P. 0. Box 1007
Charlotte, NC 28201-1007
Gentlemen:
SUBJECT: NOTICE OF VIOLATION
(INSPECTION REPORT N05. 50-269/91-08, 50-270/91-08 AND 50-287/91-08)
This refers to the Nuclear Regulatory Commission (NRC) Augmented Inspection
Team (AIT) special inspection conducted on March 12-15, 1991, at the Oconee
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Nuclear Station.
The AIT was chartered on March 11, 1991, and directed to
review the loss of reactor coolant inventory event of March 8,1991.
The
report documenting this inspection was sent to you by letter dated April 15,
1991.
As a result of this inspection, violations of NRC requirements were
identified.
An Enforcement Conference was held on May 7,1991, in the NRC
Region II office to discuss the violations, their cause, and your corrective
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action to preclude their recurrence.
The letter summarizing this conference
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was sent to you by letter dated May 15, 1991.
On March 8,1991, while Unit 3 was in cold shutdown for refueling, the Decay
Heat Removal system was lost for approximately 18 minutes due to cavitation of
the operating Low Pressure Injection (LPI) pump caused by a rapid primary
system water loss.
Approximately 9.750 gallons of water were drained from the
Reactor Coolant System into containment.
Another 4,500 gallons were drained
from the Borated Water Storage Tank (BWST) into containment for a total of
approximately 14,000 gallons of water.
The control room operators took prompt
action to stop the water loss, refilled the primary system from the BWST to
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allow for LPI pump operation and subsequently restarted the pump.
The sequence of activities that lead to this event are fully discussed in the
AIT special inspection report.
In addition, the report addressed several
significant human performance implications that contributed to the event. Most
significant were the improper use of a schematic drawing by a maintenance
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supervisor and his subsequent incorrect verbal instructions to maintenance
technicians who, as a result of those instructions and mislabeled piping,
mistakenly installed a blank flange on the emergency sump suction line piping
for valve 3LP-20 instead of valve 3tP-19.
Other human performance aspects
which contributed to this event included: (1) additional independent
verifications which did not detect the error in the initial flange placement,
(2) maintenance and operations personnel who failed to report the reliance on a
non-standard label, and (3) miscomunications which occurred between control
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room operators and maintenance personnel.
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9610210046 910604
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ADOCK 05000269
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Duke Power Company
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M N 1991
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Violation A described in the enclosed Notice of Violation (Notice) involved the
installation of a flange on the wrong valve which occurred because of improper
instructions from the supervisor to the maintenance technicians who performed
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the installation ano their subsequent reliance on those instructior.s as well as
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a non-standard label which incorrectly identified valve 3LP-20 as 3LP-19.
Violation B described in the enclosed Notice involved the failure of independent
verification activities in that verification that valve 3LP-19 could be manually
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opened was mistakenly verified because the flange had actually been installed on
valve 3LP-20. Violation C described in the enclosed Notice involved the
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failure to have an adequate procedure for labeling plant equipment, resulting
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in a handwritten label erroneously identifying valve 3LP-20 as valve 3LP-19.
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These violations must be evaluated collectively as they represent a significant
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example of singular minor events compounding to produce the potential for
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serious safety consequences. Vulnerability for routine evolutions to rapidly
expand into non-routine events is inherently increased during shutdown
operation. . The NRC recognizes that the safety consequences of the event were
minimal since LPI pump 3A and train B were available for use and plant systems
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required for these conditions were functional.
In addition, no Technical
Specification required safety limits for these conditions were exceeded. Never-
theless, the event is considered significant since it reflects a lack of plant
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status awareness by control room operators, and consisted of numerous personnel
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errors, poor communications, and procedural problems, all of which contributed
to the event which is of importance not only during power operation but also
during outage conditions. Therefore, the violations are classified in the
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aggregate as a Severity Level III problem.
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In accordance with the " General Statement of Policy and Procedure for NRC
Enforcement Actions," (Enforcement Policy) 10 CFR Part 2, Appendix C (1991), a
civil penalty is considered for a Severity Level III problem. However, after
consultation with the Director, Office of Enforcement, and the Deputy Executive
Director for Nuclear Reactor Regulation, Regional Operations and Research, I
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have decided that a civil penalty will not be proposed in this case because
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mitigation was warranted for your prompt and extensive reporting and
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identification of other problems related to this event. Mitigation was also
warranted for your immediate corrective action to address procedural, labeling
and communications deficiencies and your proposed long term corrective actions,
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specifically your connitment to complete all corrective actions prior to the
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next scheduled refueling outage in August 1991.
Finally, additional partial
mitigation was warranted for your good _past performance. No other factors
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warranted further adjustment of the civil penalty.
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You are required to respond to this letter and should follow th'e instructions
specified in the enclosed Notice when preparing your response. In your
response, you should document the specific actions taken and any additional
actions you plan to prevent recurrence. After reviewing your response to this
Notice, including your proposed corrective actions and the results of future
inspections, the NRC will determine whether further NRC enforcement action is
necessary to ensure compliance with NRC regulatory requirements.
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Duke Power Company
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JUN 0 41991
In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of
this letter and its enclosures will be placed in the NRC Public Document Room.
The responses directed by this letter and the enclosed Notice are not subject
to the clearance procedures of the Office of Management and Budget as required
by the Paperwork Reduction Act of 1980, Pub. L. No. 96.511.
Sincerely,
Stewart D. Ebneter
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Regional Administrator
Enclosure:
cc w/ encl:
H. B. Barron
Station Manager
Oconee Nuclear Station
P. O. Box 1439
Seneca, SC 29679
A. V. Carr, Esq
Duke Power Company
422 South Church Street
Charlotte, NC 28242-0001
County Supervisor of Oconee County
Walhalla, SC 29621
Robert B. Borsum
Babcock and Wilcox Company
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Nuclear Power Generation Division
Suite 525,1700 Rockville Pike
Rockville, MD 20852
J. Michael McGarry, III, Esq.
Bishop, Cook, Purcell and Reynolds
1400 L Street, NW
-Washington, D. C.
20005
Office of Intergovernmental Relations
116 West Jones Street
Raleigh, NC 27603
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Duke Power Company
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JUN 041991
cc w/enci cont'd:
Heyward G. Shealy, Chief
Bureau of Radiological Health
South Carolina Department of Health
and Environmental Control
2600 Bull Street
Columbia, SC 29201
Manager, LIS
NUS Corporation
2650 McConnick Drive
Clearwater, FL 34619-1035
Stephen Benesole
Duke Power Company
P. O. Box 1007
Charlotte, NC 28201-1007
R. L. Gill
Nuclear Production Department
Duke Power Company
P. O. Box 1007
Charlotte, NC 28201-1007
Karen E. Long
Assistant Attorney General
N. C. Department of Justice
P. O. Box 629
Raleigh, NC 27602
H. B. Tucker
Senior Vice President-Nuclear
Duke Power Company
P. O. Box 1007
Charlotte, NC 28201-1007
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UNITED STATES
NUCLEAR REGULATORY COMMisslON
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REGION ll
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101 MARIETTA STREET. N.W.
ATLANTA, GEORGIA 30323
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. APR 151991
Docket Nos. 50-269, 50-270, 50-287
License Nos. DPR-38, DPR-47, DPR-55
Duke Power Company
ATTN: Mr. M. S. Tuckman, Vice President
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Nuclear Operations
P. O. Box 1007
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- Charlotte, NC 28201-1007
Gentlemen:
SUBJECT:
NRC INSPECTION REPORT NOS.:
50-269/91-08, 50-270/91-08, AND
50-287/91-08
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This refers to the special inspection conducted by the Nuclear Regulatory
Commission (NRC) Augmented Inspection Team (AIT) at your Oconee facility during
the period March 12-15, 1991. The inspection included a review of events that
lead to the March 8, 1991, Loss of Decay Heat Removal. At the conclusion of
the inspection, the findings were discussed with those members of your staff
identified in the enclosed report.
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The enclosed copy of the AIT report identifies the areas examined during this
inspection. Within these areas, the inspection consisted of selective
examinations of procedures and representative records, interviews with
personnel and observation of activities in progress.
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The AIT concluded that the event was caused by a combination of factors
including incorrect labeling, poor verification of flange installation, poor
communication between operations and technical personnel, procedural
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inadequacies and incorrectly using plant' drawings.
Each of these fcctors taken
singularly are relatively minor; however, taken in total, emphasizes the need
for continued management attention to routine evolutions.
In addition, events
of this nature, although not resulting in serious consequences, provide a
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basis for changing routine activities when the event and its causal factors
receive in-dept analysis. Our report shows there were multiple causal factors,
- many of them related to human factor deficiencies. Certainly a more detailed
and comprehensive event analysis by the Duke staff could have provided
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additional lessons learned.
This event further reinforces the need for more management attention to the
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serious consequences of errors committed during shutdown operation. Risk
management with consideration for contingency plans could have received more
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attention at Oconee particularly with regard to the total disablement of the
radiation monitoring equipment in the containment.
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Within^the s pe of this inspection, n violations
eviations were - m \\ _
identifibd'
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APR 151931
Duke Power Company
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In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2
Title 10, Code of Federal _ Regulations, a copy of this letter and its enclosure
will be placed in the NRC Public Document Room,
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We appreciate your cooperation during our team inspection and subsequent
evaluation of this event.
Your open discussion of your findings and
evaluations were very beneficial.
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Should you have any questions concerning this letter, please contact us.
Sincerely,
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Stewart D. Ebneter
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Regional Administrator
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Enclosure:
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NRC Inspection Report
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cc w/ encl:
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H. B. Barron
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Station Manager
Oconee Nuclear Station
P. O. Box 1439
Seneca, SC 29679
A. V. Carr, Esq
Duke Power Company
422 South Church Street
Charlotte, NC 28242-0001
County Supervisor of Oconee County
Walhalla, SC _29621
Robert B. Borsum
Babcock and Wilcox Company
Nuclear Power Generation Division
Suite 525, 1700 Rockville Pike
Rockville, MD 20852
J. Michael McGarry, III, Esq.
Bishop, Cook, Purcell and Reynolds
1400 L Street, NW
Washington, D. C.
20005
(cc w/enci cont'd - see page 3)
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Duke Power Company
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cc w/ encl:
(Continued)
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Office of Intergovernmental Relations
116 West Jones Street
Raleigh, NC 27603
Heyward G. Shealy, Chief
Bureau of Radiological Health
South Carolina Department of Health
and Environmental Control
2600 Bull Street
Columbia, SC 29201
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Manager, LIS
NUS Corporation
2650 McCormick Drive
Clearwater, FL 34619-1035
Stephen Benesole
Duke Power Company
P. O. Box 1007
Charlotte, NC 28201-1007
R. L. Gill
Nuclear Production Department
Duke Power Company
P. O. Box 1007
Charlotte, NC 28201-1007
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Karen E. Long
Assistant Attorney General
N. C. Department of Justice
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P. O. Box 629
Raleigh, NC 27602
H. B. Tucker
Senior Vice President-Nuclear
Duke Power Company
P. O. Box 1007
Charlotte, NC 28201-1007
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