ML20134M841
| ML20134M841 | |
| 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 | |
| ML20134M845 | List: |
| References | |
| NUDOCS 9611260057 | |
| Download: ML20134M841 (6) | |
See also: IR 05000461/1996010
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Noveuber 19, 1996
John G. Cook
Senior Vice President
Illinois Power Company
500 South 27th Street
Decatur,IL 62525
Dear Mr. Cook:
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 11
Team inspection (OSTI) which was initiated as a result of operator performance in the' I
recirculation pump seal package failure event. The enclosures to this letter present the
results of those inspections.
As will be discussed below, on September 5,1996, the operations department put in
motion a sequence of events which revealed sigoificant deficiencies throughout the
organization at the Clinton facility. These deficiencies included procedural 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 i
confirmatory findings from the OSTI, identified a number of actions and practices which 1
are inconsistent with procedural and pr'ogrammatic controls for assuring safe operation of l
a nuclear power plant. These actions and practices were also evident in the April reactor l
scram when station management decided to maintain the unit in a hot standby condition, 4
.thereby minimizing down time. This decision resulted in degraded safety relief valves. In l
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 hot standby following the June
r_eactor ccram resulted in a lost opportunity to address the degrading "B" recirculation
pump seal package.
~ Specifically during the September 5, event, operators were attempting to place the unit in
single loop operation to allow continued unit operation by isolating a reactor coolant leak in
the "B" reactor recirculation pump shaft seal package. While attempting to isolate the
loop, seal pressure, temperature, and leak rate were not decreasing quickly enough to
ensure continued unit operation. To increase the pump shaft seal's cool down rate and
reduce leakage, shift supervision directed actions which were inconsistent with both
Clinton procedures and vendor recommendations for isolating the seal package. After this
procedural noncompliance, sealleakage increased to greater than 5.0 gallons-per-minute,
the technical specificaticn (TS) allowable leakage rate. The shift crew entered the
emergency plan, declared a Notice of Unusual Event, and made appropriate notifications. f
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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 furthe: 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 dxlared
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
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seal package failed (two hours after the LCO expired), with a leakage rate still greater than
twice the TS limit, a briefing was held for the planned orderly shutdown of the unit. Plant
shutdown continued to be inappropriately protracted with plant operation continuing to
within 46 minutes of the 12-hour shutdown requirement being exceeded.
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
continued leakage rate information or emergency classification 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 poollevel.
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.
l Following the event, our observations indicated that the Clinton staff believed that the i actions taken during the event were appropriate. The failures to follow procedures,
inadequate procedures, operator performance issues, and inadequate management
involvement were not promptly identified nor understood. it was not until the NRC had
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extensively intervened, 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
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September 11,1996. The initial assessment, while drawing appropriate overall
conclusions, did not provide a solid basis for some of the conclusions. For example, while
the initial assessment concluded that procedures were not followed, the detailed report
indicated that procedural steps were followed, or a procedure deficiency existed, when in
fact the problem was that procedural steps were not followed. Following subsequent
discussions with the NRC, the Clinton staff's revised assessment corrected these issues.
In summary, our assessment of the recirculation pump seal package failure event identified
three significant concerns. First, the operations department lacked an appropriate safety
focus as exhibited by: (1) the failure to follow procedures in an extraordinary attempt to
keep the unit in an operating condition, and (2) the protracted unit shutdown. Secondly, l
the failure to correct known material condition deficiencies that complicated operators' i
actions and responses indicated a lack of management sensitivity and priority to the
removal of barriers affecting 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 deficient compensatory modification.
While the examples differed, the same issues were independently confirmed during the
l' OSTl. A number of problems with procedure adequacy and adherence were identified.
' Two cases of 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 isolating spent fuel pool cooling and thereby allowing a 1000 gallon per
- day leak. In addition, when an operator was asked why they (operators) were having
difficulty with a specific procedure, he responded that they were trying to do this the right
way because the NRC was watching. This statement demonstrates a poor attitude toward
and understanding the importance of procedure adherence.
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 without obtaining a relief. Short
term relief turnovers were weak, and variations in crew communications and formality
were observed. That these activities would occur during a major NRC team inspection,
with inspectors in the. control room, indicates to us that these problems may be more
widespread.
Engineering support to operations was weak and the engineers exhibited a weak safety
. focus. Engineering and operations on occasion conducted tests on facility systems with
i the reactor at power to identify potential impacts on safety systems. For example, cyc%d l condensate was isolated from the residual heat removal system to determine the potential l impact. This test resulted in the residual heat removal system being declared inoperable. 1- 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
l unreviewed, unauthorized tests demonstrate'.s a lack of a safety focus by engineers and [ licensed operators. L ! \
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J. Cook -4-
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The OSTI also noted that often engineers seemed focused on finding a way to justify
system operability rather than performing 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 or what operational evaluations were
in-place. Further, the staff 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.
Most of these significant issues described in this report including several apparent
l violations with multiple examples, were identified by the NRC, including: 12 examples of l failing to follow procedures,8 examples of inadequate / inappropriate procedures,4 l 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 appropriate
administrative activities. The failure of the Clinton staff to recognize the significance of ,
the issues identified and to promptly and appropriately respond to the them shows a lack l
of appreciation for the importance of adherence to NRC requirements. l
l Based on the results from the inspections and as noted above, several apparent violations l of NRC requirements were identified and are being considered for escalated enforcement l 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 characterization of apparent violations described in the enclosed inspection
reports may change as a result of further NRC review.
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 determined that a violation has occurred or that enforcement action will
I 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
surrounding the violations, their root causes, your opportunities to identify the apparent
violations sooner, your corrective actions, and the significance of the issues.
l l In addition, this is an opportunity for you to point out any errors in our inspection reports l and for you to provide any information concerning your perspectives on 1) the severity of l the violations: 2) the application of the factors that the NRC considers when it determines l the amount of a civil penalty that may be assessed in accordance with Section VI.B.2 of I the Enforcement Policy; and 3) any other application of the Enforcement Policy to this
case, including the exercise of discretion in accordance with Section Vll.
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You will be advised by separate correspondence of the results of our deliberations on this
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manner. No response regarding these apparent violations is required at this time.
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J. Cook -5-
- Docket No. 50-461
l l cc w/ encl: Mr. Wilfred Connell, Vice President l l P. Yocum, Plant Manager l
Clinton Power Station
j R. Phares, Manager-Nuclear Assessment !
P. J. Telthorst, Director - Licensing
l
Nathan Schloss, Economist
Office of the Attorney General
l K. K. Berry, Licensing Services Manager l General Electric Company
Chairman, DeWitt County Board
State Liaison Officer
Chairman, Illinois Commerce Commission
.
Office of Enforcement (3)
J. Goldberg, OGC
G. Marcus, NRR
i i l
l
Distribution:
!
! Docket File w/ encl DRP w/enci
OC/LFDCB w/ encl y ;PUBLIC IE-01 w/enci
l SRI Clinton, Dresden, Rill PRR w/ encl
LaSalle, Quad Cities CAA1 w/enci (E-mail)
l Project Manager, NRR w/ encl A. B. Beach, w/enci l B. L. Burgess, w/enci W. L. Axelson, w/ encl
B. McCabe, OEDO
-
Document: R: INSPRPTS\ CLIN \CLl96010; 96011
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NAME Mrkt/LeTd Granth Bu M /01
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Axelson/ Beach
- DATE 11//f[96 11/)h/96 11/5/96 11/\,/;/96 11/ /96
0FFICIAL RICORD COPY
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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 (PDR).
Sincerely,
/s/A. Bill Beach l
A. Bill Beach I
Regional Administrator
l
Docket No. 50-461 l
cc w/ encl: Mr. Wilfred Connell, Vice President
P. Yocum, Plant Manager
Clinton Power Station l
R. Phares, Manager-Nuclear Assessment
P. J. Telthorst, Director - Licensing
Nathan Schloss, Economist
Office of the Attorney General
K. K. Berry, Licensing Services Manager
General Electric Company
Chairman, DeWitt County Board
State Liaison Officer
Chairman, Illinois Commerce Commission
Office of Enforcement (3)
J. Goldberg, OGC
G. Marcus, NRR
Distribution.
Docket File w/ encl DRP w/enci
OC/LFDCB w/enci PUBLIC IE-01 w/enci
SRI Clinton, Dresden, Rill PRR w/enci
LaSalle, Quad Cities CAA1 w/enci (E-mail)
Project Manager, NRR w/enct A. B. Beach, w/ encl
B. L. Burgess, w/ encl W. L. Axelson, w/ encl
B. McCabe, OEDO
See orevious concurrence
Document: R: INSPRPTS\ CLIN \CLl96010; 96011
-i . iwi.. 4. en. n.. c - c.,, -itu .it.cnf.ui c - c.,r itm .st. nf.=i n-
g gi.. . . , .e ini.
0FFICE RIII RIII RIII RIII RIfif
l NAME Wright / Leach Grant Burgess /0I Caldwell Axkl3n/ Beach j DATE 11/ /96 11/ /96 11/ /96 11/ /96 11/M/96
0FFICIAL RECORD COPY l
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