ML20135C443
| ML20135C443 | |
| Person / Time | |
|---|---|
| Site: | FitzPatrick  |
| Issue date: | 02/24/1997 |
| From: | Cowgill C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Michael Colomb POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK |
| References | |
| NUDOCS 9703040048 | |
| Download: ML20135C443 (3) | |
See also: IR 05000333/1996007
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February 24, 1997
Mr. Michael J. Colomb
Plant Manager
New York Power Authority
James A. FitzPatrick Nuclear Power Plant
Post Office Box 41
Lycoming, NY 13093
Dear Mr. Colomb:
Subject:
NRC Inspection Report No. 50-333/96-07 and Notice of Violation
This letter refers to your January 17,1997 correspondence, in response to our
December 13,1996 letter.
Thank you for informing us of the corrective and preventive actions documented in your
letter. These actions will be examined during a future inspection of your licensed program.
Our review of your response noted that the performance factors that were determined to
be the cause of violation C did not appear to be addressed by the corrective actions listed.
In addition, your response to violation D does not seem to address the extent of the
problem with design document identified deviations / deficiencies as discussed in the
inspection report nor discuss the failure of other opportunities (i.e. the Instrument Drift
Analysis Study and the TS 4.1 Basis statement changed in TS Amendment 233) to
question the transmitter test frequency noted in the violation. We will review these issues
during the course of a future inspection, although you may provide additional information in
this matter either verbally or in writing for clarification prior to that time if desired.
Your cooperation with us is appreciated.
Sincerely,
Original Signed by:
Richard S. Barkley for
Curtis J. Cowgill, Chief
Projects Branch 2
Division of Reactor Projects
Docket No. 50-333
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0FFICIAL RECORD COPY
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Michael J. Colomb
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cc:
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C. D. Rappleyea, Chairman and Chief E.<ecutive Officer
R. Schoenberger, President and Chief Operating Officer
J. Knubel, Chief Nuclear Officer
H. P. Salmon, Jr., Vice President of Nuclear Operations
W. Josiger, Vice President - Engineering and Project Management
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J. Kelly, Vice President - Regulatory Affairs and Special Projects
T. Dougherty, Vice President - Nuclear Engineering
R. Deasy, Vice President - Appraisal and Compliance Services
R. Patch, Director - Quality Assurance
G. C. Goldstein, Assistant General Counsel
C. D. Faison, Director, Nuclear Licensing, NYPA
T. Morra, Executive Chair, Four County Nuclear Safety Committee
cc w/ copy of Licensee's Response Letter:
Supervisor, Town of Scriba
C. Donaldson, Esquire, Assistant Attorney General, New York Department of Law
P. Eddy, Director, Electric Division, Department of Public Service, State
of New York
G. T. Goering, Consultant, New York Power Authority
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J. E. Gagliardo, Consultant, New York Power Authority
E. S. Beckjord, Consultant, New York Power Authority
F. William Valentino, President, New York State Energy Research
and Development Authority
J. Spath, Program Director, New York State Energy Research
and Development Authority
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Michael J. Colomb
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Distribution w/ copy of Licensee's Response Letter:
D. Screnci, PAO
W. Dean, OEDO (WMD)
K. Cotton, NRR
D. Hood, NRR
R. Correia, NRR
R. Frahm, Jr., NRR
L. Cunningham, NRR
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D. Barss, NRR
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Nuclear Safety information Center (NSIC)
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PUBLIC
NRC Resident inspector
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Region I Docket Room (with concurrences)
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Inspection Program Branch, NRR (IPAS)
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R. Barkley, DRP
R. Junod, DRP
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DOCUMENT NAME: G:\\ BRANCH 2\\RL9607.FTZ
To receive a copy of this document, indicate in the box: "C" = Copy without attachment / enclosure
"E" =
Copy with attachment /Mclosure
"N" = Nf)cfy
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Jim:0 A Fit 2 Patrick
Nucutr P:wsr Fitnt
PO Ben 41
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Lycom> rig New York 13093
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315 342 3840
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tv Authority
manmeneser
January 17,1997
U.S. Nuclear Regulatory Commission
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ATTN: Document Control Desk
Mail Station P1-137
Washington, D.C. 20555
SUBJECT:
James A. FNPatrick Nuclear Power Plant
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Docket No. 50-333
Reply to Notice of Violation
NRC Insoection Report 50-333/96-07
Gentlemen:
In accordance with the provisions of 10 CFR 2.201, Notice of Violation. the Authority
submits a response to the notice transmitted by your letter dated December 13,1996.
Your letter refers to the results of the integrated inspection conducted from September 29,
1996 through November 16,1996 at the James A. FitzPatrick Nuclear Power Plant.
Attachment I provides the description of the violations, reason for the violations, the
corrective actions that have been taken and the results achieved, corrective actions to be
taken to avoid further violations, and the date of full compliance.
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in addition to the corrective actions described in the attachment, in an effort to continue
improvement in all aspects of operation at the James A. FitzPatrick Nuclear Power Plant, a
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team of line personnel was formed to evaluate human performance related events at the
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site. Corrective actions developed by the team will be implemented to ensure continued
performance improvement.
To address the lack of rigor and weaknesses in engineering activities, an improvement plan
is being developed. Both of these efforts are part of the Business Plan.
There are no commitments contained in this submittal.
If you have any question, please contact Mr. Arthur Zaremba at (315) 349-6365.
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Very truly yours,
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Wh-
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MICHAEL J. COLOMB
STATE OF NEW YORK
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COUNTY OF OSWEGO
Subscribed and swom to before me
this
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day of 3An/una.1997
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MJC:GB:las
yTAFLY/ PUBLICS
NANCY B. CZEROW
cc:
next page
Notary Public, State of NewYork
Oustifled in Oswego County #4864611
commission Expires / d4 -9 7
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cc:
RIgional Administrator
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U.S. Nuclear Regulatory Commission
475 Allendale Road
King of Prussia, PA 19406
Office of the Resident Inspector
U.S. Nuclear Regulatory Commission
P.O. Box 136
Lycoming, NY 13093
Ms. K. Cotton, Acting Project Manager
Project Directorate 1-1
Division of Reactor Pro l acts l/II
U.S. Nuclear Regulatory Commission
Mail Stop 14 B2
Washington, DC 20555
Attachments:
1.
Reply to Notice of Violation
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Attachm:nt 1
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Renly to Notice of Violation 96-07
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Violation A
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Technical Specification 6.8.(A) requires that written procedures and administrative policies
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shall be established, implemented and maintained that meet or exceed the requirements
and recommendations of Section 5 of American National Standards Institute (ANSI) 18.7-
1972 * Facility Administrative Policies and Procedures.' Section 5.1.2 of ANSI 18.7-1972
states in part, that procedures shall be followed, and the requirements for use of
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procedures shallbe prescribedin writing. MP-004.03, CRO Removaland Replacement,
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describes remnval and replacement of control rod drives (Crus). The procedure requires
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that all CROs to be removed are accurately located and readily identified (marked) prior to
removal.
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Contrary to the above, on November 11,1996, during the work preparation phase, CRDs
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to be removed were not accurately located prior to removal which resulted in the incorrect
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removalof three Crus.
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This is a Severity I.evelIV Violation (Supplement 1).
Admission or Denial of the Allened Violation
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The Authority agrees with this violation.
Reasons for the Violation
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The cause for this violation was personnel error. The performance factors leading to these
errors were:
inadequate training and qualification. The contract supervisor assigned the duties
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associated with Control Rod Drive (CRD) replacement at FitzPatrick during the
plant's Refuel Outage 12 did not have the proper training or experience to
accurately locate and identify the correct CRDs prior to removal.
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ineffective worker practices. The contract supervisors overseeing the CRD
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removallreplacement activities did not effectively utilize self-checking or second
verification techniques to ensure the CRDs were correctly labeled. Additionally,
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numerous opportunities arose during the CRD work evolution where work should
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have been stopped by both the contractor and the Power Authority because of
abnormal or unexpected conditions.
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Poor supervisory oversight and methods. The Authority did not provide an
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appropriate level of management or supervisory oversight of the job.
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Atttchm:nt I
Realv to Notice of Violation 96-07
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Poor written procedures anti %cuments. The written procedure provided by the
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Authority to the contractor was inadequate and did not contain steps for
verification of crucial work evolutions (i.e., selection of the correct CRD).
Additionally, the core map was not part of the work procedure. The core map
could have contained additional reference points such as nuclear instruments.
Corrective Actions That Have Been Taken
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The Authority revoked the contract supervisor's task qualification certification.
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The Authority assigned Senior Nuclear Managers to oversee the remainder of the
CRD mechanism changeout once work was stopped.
immediately following this event, a memorandum titled "NYPA Responsibilities For
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Contractors" was issued by the Plant Manager to all departments re-emphasizing
obligations when using contract personnel at FitzPatrick. The accountability and
responsibility for the quality of work performed by contract personnel belongs to
the Authority. Expectations including work oversight, quality, questioning attitude,
and open communication was stressed.
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A case study was completed to review and identify opportunities during the CRD
replacement evolution where personnel directly involved could have, but failed to
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take a questioning attitude and stop work. The case study was enhanced with
management expectations at each opportunity. The case study was then presented
to the appropriate plant staff.
Results Achieved
The Authority believes the corrective actions taken were effective in preventing
recurrence. A heightened awareness of the issues relating to the causes for this violation
has been achieved. The Authority will continue to reinforce the importance of maintaining
a questioning attitude, performing self verification and applying the appropriate level of
management oversight.
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Corrective Actions To Be Taken
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Maintenance Procedure MP-OO4.03, "CRD Removal and Replacement" will be
revised to incorporate a map with reference points and verification steps to ensure
that the correct CRD unit is initially identified and assure the correct CRD unit is
identified during ensuing steps when opportunities for selecting the wrong drive
exists. (Scheduled Completion Date - 06/30/97)
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Realv to Notice of Violation 96-07
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Administrative Procedure AP-10.05, " Outage Management", the program used at
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FitzPatrick to manage outages, will be revised to include "NYPA Responsibility For
Contractors" expectations. (Scheduled Completion Date - 02/27/97)
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Date When Full Comoliance Will Be Achieved
Full compliance was achieved on 11/15/96 following issuance of the Plant Manager's
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memorandum affirming the Authority's responsibility for the quality of all work performed
at FitzPatrick.
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Reniv to Notice of Violation 96-07
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Violation B
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10 CFR Part 50, Appendix B, Criterion lit, ' Design Control,' requires that the design basis
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shall be correctly translated into specifications, drawings, procedures, and instructions;
that the adequacy of the design be verified; and that design changes be subject to design
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controlmeasures.
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Contrary to the above, on and before October 25,1996, the design basis was not
correctly translatedinto procedures, the adequacy of design was not verified, and design
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changes were not subjected to design control measures, as evidenced by the following
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examples:
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Unverified engineering judgement regarding design calculations JAF-CALC-ELEC-
00426 and JAF-CALC-ELEC-00427 erroneously equated spare battery capacity
with voltage at safety-related components.
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(2)
Electricalload added to safety-related station battery calculations JAF-CALC-ELEC-
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01417 and JAF-CALC-ELEC-0141G was not consistent with the load specified in
Modification F1-89-158.
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(3)
Unverified engineering judgement concerning calculation JAF-CALC-HPCI-00840
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was used to conclude that air injection would not affect high pressure coolant
injection pump operability.
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An incorrect assumption was made in calculation JAF-CALC-DHR-03445 that a
non-safety related component could be assumed as a limiting single failure.
(5)
An unverified assumption was made in calculation JAF-CAL DHR-02380 that a
plate heat exchanger could be modeled as a shell and tube heat exchanger.
This is a Severity levelIV violation (Supplement II.
Admission or Denial of the Alleged Violation
The Authority agrees with the violation. However, after review of pertinent data for cited
example 2, the Authority determined that battery calculations JAF-CALC-ELEC-01417 and
JAF-CALC-ELEC-01418 are consistent with the final calculations for modification F189-
158 and that no deviation exists.
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Attachm:nt i
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Reply to Notice of Violation 96 07
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Reasons for the Violation
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The cause for the violation was personnel error. The performance factors contributing to
this were:
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inadequate training. For example 1, personnel assigned responsibilities for
preparation and review of the battery calculations (JAF-CALC-ELEC-00426 and
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JAF-CALC-ELEC-00427) did not exhibit rigor in verifying the assumption that
equated spare battery capacity with voltage. For example 4, personnel assigned
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responsibilities for preparation and review of the flooding analysis (calculation JAF-
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CALC-DHR-03445) demonstrated inadequate understanding of the application of
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single failure criteria.
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Weak supervisor / managerial methods. For examples 3 and 5, the expectations for
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documenting engineering judgement and unverified assumptions had not been
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adequately communicated to the individuals responsible for preparing the
calculations.
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Corrective Actions That Have Been Taken
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An operability assessment was performed to review the adequacy of the unverified
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judgement against station batteries A and B. The assessment confirmed that A and
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B station batteries were operable. New calculations were prepared which properly
documented the basis for the station battery modified performance test. As a
conservative measure to assure adequate capacity exists for the long term,
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Modification M1-96-078, Revision 1, was implemented which added two cells to
each station battery.
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Calculation JAF-CALC-HPCI-00840 was revised to state that NUREG-0897,
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Revision 1, " Containment Emergency Sump Performance" was used as a basis for
vortex limit determination. The revised calculation also included the discussion with
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the pump vendor which confirmed the use of the NUREG 0897 vortex limit is
appropriate.
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A review of calculation JAF CALC-DHR-03445 was performed to confirm that no
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safety-related components were affected as a direct consequence of the postulated
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piping failure.
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Calculation JAF-RPT-DHR-02535, Revision 0, was developed and approved on
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10/24/96. This calculation validated the use of the GOTHIC code used for the
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specific Decay Heat Removal System application. The use of the GOTHIC
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simulation of a shell and tube heat exchanger in place of a plate heat exchanger as
evaluated in calculation JAF-CALC-DHR-02380 was found to be acceptable.
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This violation, its causes, lessons learned, and management expectations were
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discussed with Design Engineering personnel at a departmental tailgate meeting.
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Recly to Notice of Violation 96-07
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Results Achieved
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The Authority believes the above corrective actions were successfulin resolution of the
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conditions identified in the violation and will be effective in preventing recurrences.
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Corrective Actions To Be Taken
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Design Engineering Action Plan JDED-APL-96-018 was developed to track
additional improvements with the DC systems' design calculations and surveillance
tests. (Scheduled Completion Date - 06/30/97)
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Engineering Procedure DCM-2, " Preparation and Control of Manual Calculations and
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Analysis" will be reviewed, and revised if necessary, to assure appropriate design
controls and processes related to rigor, verification and engineering judgement are
included. Treining will be conducted with Design Engineering to reinforce and
ensure management expectations regarding documentation of engineering
judgement are clearly understood. (Scheduled Completion Date - 04/30/97)
Training on the requirements of DCM-14, " Preparation and Control of Computer
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Generatsd Calculations" will be performed to increase staff sensitivity to the
process for utilizing and controlling computer generated calculations and analysis.
(Scheduled Completion Date - 03/31/97)
This violation will be entered into the Engineering Support Personnel (ESP) Training
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Program to provide Technical Support staff with lessons learned from this event.
(Scheduled Completion Date 03/01/97)
Calculation JAF-CALC-OHR-03445 will be revised to correct the application of
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single failure criteria. (Scheduled Completion Date 03/01/97)
Date When Full Comoliance Will Be Achieved
The Authority has been in compliance with 10 CFR 50, Appendix B, Criterion til since the
identification, review and verification of the above conditions found no inadequacies in
plant design. This conclusion is based on: for example 1, when the new calculation was
prepared which properly documented the basis for the A and B station battery modified
performance test; for example 3, the revision to the calculation and confirmation by the
pump manufacturer that the vortex information in calculation JAF-CALC-HPCI-00840 is
acceptable; for example 4, the review of calculation JAF-CALC-DHR-03445 confirmed that
no safety-related components are affected by the postulated piping failure; and for
example 5, calculation JAF-CALC-DHR-02380 being performed and validating that the
GOTHIC code used was acceptable.
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Attachm:nt I
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Renly to Notice of Violation 96-07
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Violation C
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10 CFR Part 50, Appendix B, Criterion XI, " Test Control,' requires written test procedures
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which incorporate acceptance limits contained in applicable design documents.
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Contrary to the above, on and before October 25,1996, surveillance procedures did not
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incorporate the acceptance limits containedin applicable design documents, as exemplified
by the following:
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(1)
Instructions in Work Request 9442935-00, dated April 21,1994, did not contain
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sufficient guidance to ensure that voit meters of appropriate accuracy and precision
were used to measure voltage between the reactor protection system electrical
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protection assemblies and their respective power panels.
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(2)
Acceptance criteria in surveillance procedure ST-2X, "RHR Service Water Flow
Rate, " did not incorporate acceptance limits contained in applicable design
documents by not accounting for instrument error associated with measuring
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required flow to the residual heat removal system heat exchangers.
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(3)
Acceptance criteria in station battery service test procedures MST-071.24, Revision
2 and MST-071.26, Revision 0, ' Modified Station Battery Performance / Service
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Test," did not reflect the minimum battery terminal voltages for acceptable
operation of safety-related equipment specifiedin design calculations JAF-CALC-
ELEC-00426, Revision 1, dated October 16,1992 and JAF-CALC-ELEC-00427,
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Revision 0, dated June 4,1992, respectively.
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This is a Severity LevelIV violation (Supplement I).
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Adm! Men or Denial of the Alleaed Violation
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The Authority agrees with the violation.
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Attchment I
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Renly to Notice of Violation 96-07
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Reasons for the Violation
The cause for this violation was personnel error. The performance factors leading to the
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three cited examples of design document acceptance limits not incorporated into written
test procedures were:
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Inadequate training. The individual responsible for preparing the work instructions
for Work Request 94-02935-00 did not have an adequate knowledge of the test
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equipment requirements to assure the correct volt meters were identified in the
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work package and that their accuracy was properly considered. The individuals
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responsible for preparing the calculations used to establish the acceptance critena
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used in station battery service test procedures MST-071.24 and MST-071.26 did
not assure that the results of their calculations were accurately translated to the
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test procedure. Contributing to this was the lack of written guidance for translation
of the calculation to the test procedure and a lack of a questioning attitude by the
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preparer of the test procedure in establishing the basis for the acceptance criteria.
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ineffective worker practices. The individuals assigned responsibility for the
preparation and inclusion of acceptance criteria into surveillance test procedure
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"RHR Service Water Flow Rate" did not maintain a questioning attitude. The
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procedure reflected an acceptance limit value contained in the Technical
Specifications (T.S.). He assumed the T.S. value accounted for instrument error.
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The basis for this assumption had not been documented. Contributing to this error
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was the ineffective corrective actions taken in 1994 when this condition was first
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identified.
Corrschs Actions That Have Been Taken
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An operability review was completed for the Reactor Protection System (RPS)
electneal protection assembly (EPA) calibration period. The review determined that
RPS was operable. In addition, new voltage measurements between the RPS
electrical protection assemblies and their respective power panels have been
completed.
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Calculations were prepared and surveillance test procedure ST-2X, "RHR Service
Water Flow Rate" was revised to accurately account for instrument error during
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test measurement evolutions. Additionally, a review was completed of other similar
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T.S. surveillance procedures which utilize installed instrumentation to measure test
data. The review determined that these surveillance test procedures did not require
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change.
New calculations were prepared to determine the acceptance criteria for the station
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battery service tests. Test procedures MST-071.24 ar,d MST-071.26 were revised
to include the acceptance criteria.
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Attachment I
Realv to Notice of Violation 96-07
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An evaluation of other Technical Specifications was performed to confirm that an
adequate basis existed for the Technical Specification requirements.
This violation, its causes, lessons learned, and expectations were discussed with
Design Engineering personnel at a departmental tailgate meeting.
Results Achieved
The above listed corrective actions were successful in resolving the deficiencies identified
in the violation. The Authority believes the corrective actions taken will provide increased
awareness of the issues and the causes identified in this violation.
Corrective Actions To Be Taken
This violation will be entered into the Engineering Support Personnel (ESP) Training
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Program to provide Technical Support staff lessons learned from this event.
(Scheduled Completion Date - 03/01/97)
Test standards are being developed to assist engineers in selecting proper test
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methods. These standards will contain guidance on the proper consideration of
measurement instrument accuracy. (Scheduled Completion Date - 08/01/97)
The Authority is currently engaged in an improved Technical Specifications Project.
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The project will ensure that instrument accuracy is considered when specifying the
requirements of the Technical Specifications.
(Scheduled Completion Date - 12/31/97)
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The calculation for the RPS/ EPA calibration period will be revised using new
measured voltages. (Scheduled Comp!stion Date - 03/01/97)
Date When Full Comoliance Will Be Achieved
Full compliance was achieved on 01/16/97 following: (1) the operability assessment and
completion of new RPS/ EPA voltage measurements; (2) the revision to surveillance
procedure ST-2X: and (3) the revisions to the modified Battery Performance / Service Tests.
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Violation D
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10 CFR Part 50, Appendix B, Criterion XVI, ' Corrective Action," requires conditions
adverse to quality such as failures, malfunctions, deficiencies, deviations, defective
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materialand equipment, and non-conformance be promptly identified and corrected.
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Contrary to the above, on and before October 25,1996, conditions adverse to quality
were not promptly identified and corrected, in that:
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(1)
Approximately 54 deviations and deficiencies associated with the Final Safety
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Analysis Report, calculations, and procedures pertaining to the residual heat
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removal system, identifiedin the design basis documentation verification program
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(D80-10) in 1994 were not evaluated for corrective action.
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(2)
Appropriate corrective action related to the calibration frequency was not taken to
correct recurring APRM flow bias flow transmitter calibration failures.
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This is a Severity LevelIV violation (Supplement I).
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AdmisMon or Denial of the Alleaed Violation
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The Authority agrees with this violation.
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Reasona for the Violation
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The cause for this violation was personnel error. The performance factor leading to these
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errors was:
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Poor supervisory methods. Following compilation of the 54 Residual Heat Removal
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(RHR) System DBD identified deviationsideficiencies, adequate controls and
oversight were not in place to assure that the deviations were reviewed and
resolved in a timely manner.
Programs and/or processes did not require prompt resolution to questions involving
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transmitter performance history and instrument calibration failures that had been
identified during instrument calibration in 1994.
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Att:: chm:nt I
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Reclv to Notice of Violation 96-07
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Corrective Actions That Have Beenlakan
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The Authority has completed evaluations and system operability reviews of the 54
identified conditions found during the RHR System DBD review. No operability
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concems were identified. The evaluation determined that 24 issues had been
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corrected and subsequently closed. The remaining issues have been prioritized and
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entered into management's corrective action tracking system for resolution.
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Responsible design engineers have been assigned to DBDs, as owners, to ensure
accountability for proper maintenance and validity of DBDs.
I&C engineering has reviewed the performance history of the Flow Bias Transmitter.
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The instrument calibration frequency for the transmitter has been reduced to 12
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month intervals.
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This violation, its causes, lessons learned, and management expectations were
discussed with Design Engineering personnel at a departmental tailgate meeting.
Results Achieved
The completed corrective actions were effective in resolving the conditions identified in the
violation. The Authority believes the corrective actions being taken will be an
enhancement to the corrective action program.
Corrective Actions To Be Taken
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A Nuclear Engineering Administrative Procedure NEAP-38, " Design Basis Document
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Validation Procedure" has been developed and is in the review and approval
process. This NEAP defines responsibilities and interfaces for the conduct of DBD
validations. These responsibilities include closure of open items.
(Scheduled Completion Date - 04/04/97)
The flow bias transmitter parameters will be reviewed to determine the cause(s) for
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and corrective action (s) to be taken to resolve instrument drift.
(Scheduled Completion Date - 04/01/97)
Administrative Procedure AP 19.01, " Surveillance Testing Program" will be
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reviewed to determine the adequacy of the guidance contained in Corrective Action
section of the program.
(Scheduled Completion Date - 03/17/97)
This violation will be entered into the Engineering Support Personnel (ESP) Training
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Program to provide Technical Support staff with lessons learned from this event.
(Scheduled Completion Date - 03/01/97)
Page 11 of 18
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Att chm:nt i
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Roolv to Notice of Violation 96-07
Date When Full Cemoliance Will Be Achieved
Full compliance was achieved 10/18/96 following completion of the operability
determination for the open DBD items and following calibration frequency change to the
flow bias transmitters to a 12 month cycle to assure instrument reliability.
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Page 12 of 18
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Realv to Notice of Violation 96-07
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Violation E
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10 CFR 50.59, ' Changes, tests, and experiments ' permits licensees to make changes to
the facility, as described in the Safety Analysis Report, without prior Commission
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approval, provided that the proposed changes do not involve a change in the technical
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specifications or involve an unreviewed safety question. Records of these changes must
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include a written safety evaluation which provides the bases for the determination that the
change does not involve an unreviewed safety question.
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Section 4.10.3 of the FitzPatrick Final Safety Analysis Report (FSAR) describes the
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utilization of the equipment area temperature monitoring sy< tem to detect reactor coolant
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pressurc bcundary leakage outside of the primary containment. Area temperature sensors
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are calibrated with the station in operation with normal ventilation patterns and ambient
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temperature levels to detect a seven gallon per minute leak. The residual heat removal
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(RHR) system equipment area temperature detectoris shown in FSAR Table 4.10-1,
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'Summty of Isolation / Alarm of System Monitored and the Leak Detection Methods Used. '
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Contrary to the above, on or about August 12,1996, a temporary high efficiency
particulate air (HEPA) filter and blower, which could have altered the accuracy of the area
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temperature monitoring system, were installedin the 'A ' RHR heat exchanger room, and
no safety evaluation was performed and documented to provide the bases for the
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determination that the change did not involve an unreviewed safety question.
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This is a Severity LevelIV violation (Supplement I).
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Admi--Ian or Denial of the Alleaed Violation
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The Authority agrees with the violation.
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R===ans for the Violation
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The cause for this violation was personnel error. The performance factor leading to this
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eaor was:
inadequate implementation of a change process. The individual assigned the task
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of reviewing the temporary HEPA filter / blower installation for inclusion into the
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Temporary Modification process, failed to consider all parameters impacted by the
temporary HEPA exhaust installation in the "A" Residual Heat Removal (RHR)
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System Heat Exchanger Room, specifically, the potential effect on the design of the
Steam Leak Detection System (SLDS). This error lead to the decision of not
categorizing the HEPA installation as a Temporary Modification. Subsequently, the
10 CFR 50.59 safety evaluation review process was not invoked.
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Att:chment i
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Realv to Notice of Violation 96-07
Corrective Actions That Have Been Taken
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The Technical Services Department Manager reviewed this event with die
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responsible engineer and the engineer's supervisor. Discussed were factors leading
to the determination that a Temporary Modification was not required, and potential
program weaknesses which may have lead to this conclusion,
A Procedure Change Request was initiated to revise Administrative Procedure
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AP-05.02, " Control of Temporary Modifications", Section 2.0, APPLICABILITY. to
include changes which could add or remove heat, or affect the air exchange rate to
plant areas with a potential effect on area equipment design requirements.
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An abstract of this violation was included in the weekly Department Tailgate
meetings to provided personnel a sum >
y of the event and to increase their
sensitivity on the use of portable ventit.non and its potential effects on plant
desi n.
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RES Department Procedure RP-RESP-02.15, " Portable Ventilation Systems" has
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been revised to include a prerequisite that all portable ventilation systems installed
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in SLDS areas will require initiation of a Temporary Modification and a precaution
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statement that removing air from areas monitored by SLDS may render the SLDS
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Results Achieved
Actions taken have increased awareness, sensitivity and understanding of the potential
affects that temporary ventilation may have on plant design.
Corrective Act ons To Be Taken
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p3te When Full Comoliance Will Be Achieved
Fun compliance was achieved immediately following removal of the temporary HEPA
filter / blower from the "A" RHR System Heat Exchanger Room.
Page 14 of 18
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Realv to Notice of Violation 91-91
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Violation F
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Technical Specification 6.11 requires, in part, that each entry into a posted locked high
radiation ares shall be under the control of a radiation work permit (RWP) and that a
radiation monitoring device which continuously integrates the radiation dose rate in the
area and alarms when a preset integrated dose is received be utilize. RWP 96-0411 issued
for work in the drywellrequires that each worker wear an alarm dosimeter.
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Contrary to the above, on October 30,1996, a contractor entered and workedin the
drywell under RWP 96-0411, a postedlocked high radiation area, for three hours with his
alarming dosimeter tumed off.
This is a Severity LevelIV violation (Supplement IV).
Adn=l==lan or Denial of the Alleaed Violation
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The Authority agrees with the violation.
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R---na for the violation
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The cause for the violation was personnel error. The performance factor leading to this
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error was ineffective worker practices. The contracted maintenance worker did not follow
procedures, did not utilize protective equipment prop 6rly, and did not utilize self-checking
to verify that the equipment was operating correctly.
Corrective Actions That Have Been Taken
immediately following the event, a critique was conducted by the Radiological and
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Environmental Services (RES) Department with the responsible individual and
Maintenance Department supervisors to review the circumstances surrounding this
event. The individual's employment was subsequently terminated.
Lessons learned from this event were included in all department tailgate meetings.
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Personnel were provided a summary of the circumstances surrounding this event
including the necessity to spend sufficient time to assure compliance with
procedures, maintaining a questioning attitude, take the time needed to perform
Radiation Worker practices properly, and reaffirming that self verification practices
also include frequent checks of personal dosimetry.
Page 15 of 18
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Atta:hment l
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Realv to Notice of Violation 96-07
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Additional changes to the Radiation Protection program included: (1) an
enhancement to the Radiological Controlled Area (RCA) access control computer
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program which eliminated the need to turn alarming dosimeters off at satellite
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control points when individuals change from one Radiation Work Permit to another:
(2) during the recently completed Refuel Outage, Radiation Protection technicians
verified that each individuals dosimetry was on prior to entry into the Drywell; and
(3) RCA entry briefing rooms were limited to one crew at a time to reduce noise
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and confusion, and provide a better atmosphere for technician / radiation worker
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interface.
Results Achieved
The Authority believes the corrective actions taken were effective in preventing
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recurrence. A review of Radiation Worker events following FitzPatrick's recently completed
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Refuel Outage provided assurance that the causes for this event were satisfactorily
addressed and resolved.
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Corrective Actions To Be Taken
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None.
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Date When Full Comoliance Will Be Achieved
Full compliance was achieved on October 30,1996 when the maintenance worker exited
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the Drywell.
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Att: hment 1
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Roolv to Notice of Violation 96-07
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Violatio.D_R
Title 10, Code of FederalRegulations. Part 71.12 (10 CFR 71.12) states, in part, that
shippers oflicensed materials are generally licensed for shipment utilizing packages for
which the Commission has issued a certificate of compliance, provided that the licensee
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have in place a quality assurance program meeting the requirements contained in sections
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71.101 through 71.137. 10 CFR 71.133 requires, in part, that the licensee establish
means to assure that conditions adverse to quality, such as deviations, are promptly
identified and corrected.
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Contrary to the above, on October 22,1996, the licensee shipped licensed radioactive
materialin an NRC-approved package (Certificate of Compliance No. USA /9094/A) without
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promptly implementing corrective actions for a prior violation of an applicable shipping
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procedure (involving the lack of current certification of technicians relative to the
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applicable computer code used to classify the shipment) as previously identified by the
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licensee's deviation event report (DER 96-1188).
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This is a severity levelIV violation (Supplement V).
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Admission or Denial of the Alleaed Violation
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The Authority agrees with the violation.
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Reasons for the Violation
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The cause for this violation was poor managerial methods. The RES Department
management failed to be rigorous in its implementation of corrective actions to an
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identified problem. RES procedure RW SHP-104, " Radioactive Waste Data Base Control
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Program" had been revised and was in the approval cycle. RES Department management
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did not ensure the changes were approved before the waste shipment was made.
Corrective Actions That Have Been TalMD
RES management has been counseled by the General Manager of Support Services
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on the importance of thoroughness of corrective actions, and stringent procedure
ccmpliance.
RES Department procedure RW SHP-104, was revised and approved for use on
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10/24/96.
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Results Achieved
The Power Authority believes the correction actions taken have been and will continue to
be effective in preventing recurrence.
Page 17 of 18
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Attachment 1
Reniv to Notice of Violation 96-07
Corrective Actions To Be Taken
None.
Date When Full Comoliance Will Be Achieved
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Full compliance was achieved on 10/25/96 following revision to procedure RW-SHP 104.
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Page 18 of 18