ML20134D252

Forwards Insp Repts 50-269/91-08,50-270/91-08 & 50-287/91-08 on 910312-15 & Notice of Violation

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: IR 05000269/1991008 ML20134D252 ML20134D258
References
EA-91-049, EA-91-49, NUDOCS 9610210046
Download: ML20134D252 (4)

See also: IR 05000269/1991008

Text

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UNITED STATES

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p NUCLEAR REGULATORY COMMISSION

R EGION 11

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g j 101 MARIETTA STREET. N.W.

• * AT LANTA, GEORGI A 3G323 ,

%,*...*/ JUN 0 41991

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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

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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 ,

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 l

action to preclude their recurrence. The letter summarizing this conference I

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 l

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 l

significant were the improper use of a schematic drawing by a maintenance  ;

supervisor and his subsequent incorrect verbal instructions to maintenance l

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 tk

room operators and maintenance personnel.

9610210046 910604 I

PDR ADOCK 05000269  !

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, Duke Power Company -2- 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

a non-standard label which incorrectly identified valve 3LP-20 as 3LP-19.

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Violation B described in the enclosed Notice involved the failure of independent

verification activities in that verification that valve 3LP-19 could be manually

opened was mistakenly verified because the flange had actually been installed on

valve 3LP-20. Violation C described in the enclosed Notice involved the

! failure to have an adequate procedure for labeling plant equipment, resulting

{ 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

example of singular minor events compounding to produce the potential for

i 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

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minimal since LPI pump 3A and train B were available for use and plant systems

i required for these conditions were functional. In addition, no Technical

Specification required safety limits for these conditions were exceeded. Never-

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theless, the event is considered significant since it reflects a lack of plant

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

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during outage conditions. Therefore, the violations are classified in the

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aggregate as a Severity Level III problem.

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

! mitigation was warranted for your prompt and extensive reporting and

i identification of other problems related to this event. Mitigation was also

warranted for your immediate corrective action to address procedural, labeling

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and communications deficiencies and your proposed long term corrective actions,

specifically your connitment to complete all corrective actions prior to the

j next scheduled refueling outage in August 1991. Finally, additional partial

s mitigation was warranted for your good _past performance. No other factors

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 -3 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:

Notice of Violation

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 .

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 -4- 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

/p2 KiCoq'o NUCLEAR REGULATORY COMMisslON

"

y"- n REGION ll

3 j 101 MARIETTA STREET. N.W.

• * ATLANTA, GEORGIA 30323

$,

...** . 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

_

Nuclear Operations

P. O. Box 1007

i - 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

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identified in the enclosed report.

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.

l 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

inadequacies and incorrectly using plant' drawings. Each of these fcctors taken

singularly are relatively minor; however, taken in total, emphasizes the need

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for continued management attention to routine evolutions. In addition, events

of this nature, although not resulting in serious consequences, provide a

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

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

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management with consideration for contingency plans could have received more

attention at Oconee particularly with regard to the total disablement of the

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radiation monitoring equipment in the containment.

Within^the s pe of this inspection, n violations

identifibd' .

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eviations were - m \ _

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APR 151931

Duke Power Company 2

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

j Enclosure:

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NRC Inspection Report -

cc w/ encl:

l H. B. Barron

l Station Manager

Oconee Nuclear Station

P. O. Box 1439  !

Seneca, SC 29679 l

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 3

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cc w/ encl: (Continued) -

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

-

Manager, LIS

NUS Corporation

2650 McCormick Drive

Clearwater, FL 34619-1035

Stephen Benesole

Duke Power Company

P. O. Box 1007

Charlotte, NC 28201-1007

l

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 -

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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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