ML20134M395

Submits Results of NRC Insps at Facility on 961004.Util Will Be Advised by Separate Correspondence of Results of NRC Deliberations on Manner

ML20134M395
Person / Time
Site:	Clinton
Issue date:	11/19/1996
From:	Beach A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:	Jackie Cook ILLINOIS POWER CO.
Shared Package
ML20134M383	List: ML20134M381 ML20134M395
References
FACA, NUDOCS 9611250075
Download: ML20134M395 (5)

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l l November 19, 1996 John G. Cook l Senior Vice President Illinois Power Company 500 South 27th Street j Decatur, IL 62525

( Dear Mr. Cooks i

On October 4, 1996, the NRC completed two inspections at your Clinton facility: a Special Inspection into the circumstances surrounding the September 5, 1996, recirculation pump seal

package failure and an independently chartered operational Safety Team Inspection (OSTI) which was initiated as a result of operator performance in the recirculation pump seal package l failure event. The enclosures to this letter present the results of those inspections.

As will be discussed below, on September 5, 1996, the operations l

department put in motion a sequence of events which revealed significant deficiencies throughout the organization at the Clinton facility. These deficiencies included procedural l adequacy and adherence problems, lack of rigor in conducting plant operations, and weak engineering support to operations.

And, most significantly, the deficiencies included serious lapses in safety focus by both plant management and staff. It appears that plant management and staff made decisions which placed plant production ahead of plant operational safety. This matter is the subject of an ongoing Office of Investigations review.

Our review of the activities associated with the September 5, event, and additional confirmatory findings from the OSTI, identified a number of actions and practices which are inconsistent with procedural and programmatic controls for assuring safe operation of a nuclear power plant. These actions and practices were also evident in the April reactor scram when station management decided to maintain the unit in a hot standby condition, thereby minimizing down time. This decision resulted in degraded safety relief valves. In both events, actions necessary to place the unit in the safest, most stable condition were not taken. Further, the decision to maintain the unit in z hot standby following the June reactor scram resulted in a lost

@ @ opportunity to address the degrading "B" recirculation pump seal

.O package.

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• E8 Specifically during the September 5, event, operators were pgj attempting to place the unit in single loop operation to allow gw[e n 1 the continued "B" reactor unit operation by isolating recirculation a reactor pump shaft coolant While seal package. leak in

, g [ attempting to isolate the loop, seal pressure, temperature, and

( $gg@iunit leakoperation.

rate were notTodecreasing increase the quickly pump enough to ensure shaft seal's coolcontinued down rate i

and reduce leakage, shift supervision directed actions which were

( inconsistent with both Clinton procedures and vendor l recommendations for isolating the seal package. After this l

, 'procddural noncomplitnco,--scal leakage increased to greater than 5.0 gallons-per-minute, the technical specification (TS) allowable leakage rate. The shift crew entered the emergency plan, declared a Notice of Unusual Event, and made appropriate notifications.

The plant'was now in a TS limiting condition for operation (LCO) which required reducing the leakage within four hours or shutting the plant down. Based on the four-hour limitation, additional.

procedural steps were not followed in another attempt to reduce the leakage to less than the TS limit to allow for continued unit operation. These activities exacerbated ~the seal condition resulting in a seal failure and leakage exceeding the installed instrumentation's ability to accurately monitor the leakage. The crew, although recognizing the seal failure, did not recognize the instrumentation's limitations. It was not until a relief Shift Technical Advisor arrived that leakage rates were properly calculated. Even though shift management was aware that these actions would further degrade the seals and was aware that a previous seal failure had resulted in leakage in excess of the criteria for declaring an Alert under the emergency plan, an Alert was not declared following all of the obvious indications that a seal failure had occurred.

After the seal package failed, shift supervision continued to delay commencing the reactor shutdown, maximizing the operating time and fully expecting the leakage to drop below the TS limit so that single loop operation could be maintained. Finally, four hours after the seal package failed (two hours after the LCO expired), with a leakage rate still greater than twice the TS 4 limit, a briefing was held for the planned orderly shutdown of )

the unit. Plant shutdown continued to be inappropriately J protracted with plant operation continuing to within 46 minutes of the_12-hour shutdown requirement being exceeded.

l Throughout the event, operators' actions were complicated by {

preexisting equipment deficiencies. The originally installed  !

leakage rate instrumentation has been a continuing problem at  :

Clinton. A modification installed to provide similar information had.its indication capped at 8 gallons-per-minute, well below the actual leakage achieved during the September 5 event. While providing leakage rates, the modification did not support i continued leakage' rate information or emergency classification j assessments when most needed. Safety relief valves, cycled 85 '

times in the April event discussed earlier, were leaking and contributed to operators diverting their attention from the plant shutdown to enter an Emergency Operating Procedure to reduce suppression pool level.

Even after the unit was placed in a shutdown condition, the operations department still appeared to be driven by schedule pressures rather than conservative operating practices. For example, while placing the feedwater system in a cleanup mode, the' operations department determined there was a need to expedite

,the cleanup rate and again operated equipment / components outside .

of procedural controls. This procedural non-compliance resulted )

in the spinning of the feedwater pump without oil to the bearings which could have caused serious damage to the pump.

Following the event, our observations indicated that the Clinton

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,'otaff balicvad that tho actions taken during the event were l appropriate. The failures to follow procedures, inadequate l

procedures, operator performance issues, and inadequate management involvement were not promptly identified nor

understood. It was not until the NRC had extensively intervened, i through a number of calls with senior plant management over a period of several days that-action was taken'to initiate a '

thorough and comprehensive assessment. This commitment was formalized in our Confirmatory Action Letter dated l September 11, 1996.- The initial assessment, while drawing l appropriate overall conclusions, did not provide a solid basis

for some of the conclusions. For example, while the initial i assessment concluded that procedures were not followed, the i

i detailed report indicated that procedural steps were followed, or a procedure deficiency existed, when in fact the problem was that i procedural steps were not followed. Following subsequent i discussions with the NRC, the Clinton staff's revised assessment corrected these issues.

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In summary, our assessment of the recirculation pump seal package

failure event identified three significant concerns. First, the j operations department lacked an appropriate safety focus as exhibited by: (1) the failure to follow procedures in an i extraordinary attempt to keep the unit in an operating condition, f and (2) the protracted unit shutdown. Secondly, the failure to correct known material condition deficiencies that complicated

! operators' actions and responses indicated a lack of management i sensitivity and priority to the removal of barriers affecting i operator performance. Finally, the engineering department's

! support to operations was weak as exhibited by poor corrective

! actions for the original leakage instrumentation problems and the l deficient compensatory modification.

While the examples differed, the same issues were independently

.. confirmed during the OSTI. A number of problems with procedure j adequacy and adherence were identified. Two cases of L preconditioning for a diesel generator surveillance and an inadequate local leak rate test procedure were identified. The preconditioning is of concern because this could mask materiel

! condition issues affecting the operability of the diesel

( generators. Problems with procedure adherence were further

! exemplified by operators failing to follow the procedure for i isolating spent fuel pool cooling and thereby allowing a 1000

! gallon per day leak. In addition, when an operator was asked why j they (operators) were having difficulty with a specific i procedura, he responded that they were trying to do_this the l right way because the NRC was watching. This statement 2

demonstrates a poor attitude toward and understanding the l importance of procedure adherence.

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The OSTI identified, through control room observations, a lack of

management oversight and a full appreciation for the

{ responsibilities held by licensed operators. At one point the

! "at the controls" operator left the designated control area i without obtaining a relief. Short term relief turnovers were

? weak, and variations in crew communications and formality were i observed. That these activities would occur during a major NRC l team inspection, with inspectors in the control room, indicates j to us that these problems may be more widespread.

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Engineering support to operations was weak and the engineers exhibited a weak safety focus. Engineering and operatiors on occasion conducted tests on-facility systems with the reactor at power to identify potential impacts on safety systems. For oexample, cycled condensate was isolated from the residual heat removal system to determine the potential impact. This test resulted in the residual heat removal system being declared inoperable. These special tests did not receive the required safety evaluations (10 CFR 50.59) or site reviews for  ;

acceptability. Further, engineers indicated it was acceptable to perform actions by combining steps from disparate procedures without further review. Conducting unreviewed, unauthorized tests demonstrates a lack of a safety focus by engineers and licensed operators.

The OSTI also noted that often engineers seemed focused on finding a way to. justify system operability rather than L

perfonning an in-depth evaluation and analysis demonstrating system operability and compliance with the FSAR. The operability evaluation program was poor with the process for operability evaluations not fully described. The Clinton staff did not know how many c: what operational evaluations were in-place. Further, the staCI had no mechanism of tracking evaluations. This is of significant concern to us because degraded plant equipment needs to be promptly evaluated to ensure appropriate safety margins are maintained, l Most of these significant issues described in this report i

including asvecal apparent violations with multiple examples, were identified by the NRC, including: 12 examples of failing to follow procedures, 8 examples of inadequate / inappropriate l procedures, 4 examples.of failure to perform safety evaluations

! (10 CFR 50.59), two examples of inadequate corrective actions, an example of an operator leaving the " control" area without' relief, and an example of operations management not performing l appropriate administrative activities. The failure of the l

Clinton staff to recognize the significance of the issues identified and to promptly and appropriately respond to the them ,

shows a lack of appreciation for the importance of adherence to l l NRC requirements. l

, Based on the results from the inspections and as noted above, I

several apparent violations of NRC requirements were identified and are being considered for escalated enforcement action in accordance with the " General Statement of Policy and Procedure  !

for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600.

No Notice of violation is presently being issued for these inspection findings. In addition, the number and j characterization of apparent violations described in the enclosed j inspection reports may change as a result of further NRC review. i A pre-decisional enforcement conference to discuss these apparent violations will be scheduled. The decision to hold a pre-decisional enforcement conference does not mean that the NRC has

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determined that a violation has occurred or that enforcement action will be taken. The conference will be held to obtain information to enable the NRC to make an enforcement decision,

! including a common understanding of the facts and circumstances j

surrounding the violations, their root causes, your' opportunities to identify the apparent violations sooner, your corrective actions, and the significance of the issues.

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-In addition, this is an opportunity for you to point out any j errors in our inspection reports and for you to provide any I information concerning your perspectives on 1) the severity of  !

the violations; 2) the application of the factors that the NRC considers when it determines the amount of a civil penalty-that may be assessed in accordance with Section VI.B.2 of the Enforcement Policy; and 3) any other application of'the Enforcament Policy to this case, including the exercise of discretion in accordance with Section VII.  ;

You will be advised by separate correspondence of the results of I

our deliberations on this manner. No response regarding these l l apparent violations is required at this time. i i

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! In accordance with 10 CFR 2.790 of the NRC's ' Rules of Practice,' I a copy of this letter and its enclosures will be placed in the l l NRC Public Document Room (PDR).

1 sincerely,

/s/A. Bill Beach A. Bill Beach  ;

Regional Administrator Docket No. 50-461 l

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