ML20136E546

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Forwards File Submitted to Kerry on 961024 Re PIM-like Summary of Events from 92-93
ML20136E546
Person / Time
Site: Saint Lucie  NextEra Energy icon.png
Issue date: 11/14/1996
From: Mark Miller
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To: Julian C
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
Shared Package
ML17229A261 List: ... further results
References
FOIA-96-485 NUDOCS 9703130231
Download: ML20136E546 (9)
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From: Mark Miller /[2f!L ,

To: CAJ (, 'To I i 4 N ETF "

Date: 11/14/96 6:34am

Subject:

Rssponses to Stew's Request on St. Lucie Self-Assessment Here's the file I sent Kerry on 10/24. Addtitionally, theres a file with a PIM-like sumthary of events from '92 '93 that helped form the basis of what I said, 9

9703130231 970306 PDR FOIA BINDER 96-485 PDR us ,

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The followin'g table was assembled from NRC Inspection Reports for a period from late 1991 )

until early 1993. Only the more significant items are repeated, not all events that occurred have been captured here, l 1

inspect 1on. Description NRC Response Report -

IR 91-22 Over 1000 gallons of service water accidentally Vio_SL;lV introduced into the Rx cavity.

IR 92-03 Containment cooling system relief dampers IFI dispositioned inoperable. Unit l's dampers were painted shut. into no violations IR 92-04 Unattended combustible material found in cable Vio SL IV spreading room.

IR 92-04 Third radiation monitor reportable event in 4 flone months, This time the Unit 1 containment particulate and gaseous monitors were isolated.

IR.92-04 Inspector noted that several packing retaining nuts None f were fully unthreaded on several drain valves that were in service.

IR 92-05 Required quarterly code-tests not performed on ICW Vio SL IV equipment for over 2 years.

IR 92-05 Valves MV-21-2 and MV-21-3 described in FSAR as Cited as Deviation qualified for submersible service. No positive from commitment documentation and no maintenance performed.

i IR 92 07 "C" containment pressure transmitter 0.0.S for at V10 SL IV least one cycle. Also during this time period another channel was bypassed for approximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />. -

IR 92-07 Unit 2 turbine failed to trip automatically after None manual Rx trip or manually from the control board.

IR 92-07 "B" train 4KV circuit breaker for the generator aux None transformer failed to close due to trash jamming the 1 circuit breaker. ,

IR 92-07 Operator closed incorrect switch during a test on 1A None transformer. Licensee stated that it was a procedural / human fac. tors problem.-  !

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c O-2 IR 92-07 The 28 EDG required rework when the procedure did None not explicitly require all 3 fan belt drive' hubs to be aligned.

IR 92-07 Gages used to set MS Safeties were not accurate Vio SL IV enough to satisfy the intent of the procedure.

IR 92-07 The 2A HPSI pump failed to start due to breaker None failure, Failure attributed to frequent use of HPSI pump to fill two weeping SITS.

IR 92-07 Rad Gaseous Effluent Mcnitoring Instrumentation for NCV fuel handling buildir; 0.0.S. for about 23 hours2.662037e-4 days <br />0.00639 hours <br />3.80291e-5 weeks <br />8.7515e-6 months <br /> due to parsonnel error.

IR 92-07 Containment Atmosphere fartt.ulate and Gaseous Rad NCV Monitors 0.0.S. due to pers,onnel error.

IR 92-08 Several safety related pump emergency load sequencer URI that was relay thumbwheels were set differently than determined tu be no expected. investigation revealed thumbwheels violation inadvertently moved by contractor cleaning electrical buses.

IR 92-08 Both 2A and 28 EDGs inadvertently wetted down with a IFl that was water hose by cleaning crew.' determined to have no effect on system.

IR 92-11 Safety grade conduit not reattached to its seismic Vio SL IV support after' maintenance IR 92-11 lechnical loss of boration flow path for 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br />. NCV 1R 92-11 Cold leg RTD temperature transmitters to RRS and NCV DDPS control systems incorrectly calibrated due to procedural and personnel errors.

IR 92-11 Unit 2 Rx trip from 100% due to momentary loss of None turbine load signal generated while testing. This was caused by an inadequate understanding of newly

. installed and designed components.

IR 92 11 The 1A EDG tripped on high jacket water temperature NCV due to loose spare screws in the temperaturc switches.

IR 92-16 One of 4 starting air compressor pressure cutoff None switches stuck causing 2B2 air receiver relief to lift repeatedly.

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1R 92-16 The 282 travelling screens failed due to inadequate None maintenance, IR 92-16 Unit 1 CCW pump motor bearing temperatures are None ,

, elevated due to particulate plume caused by sand

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, IR 92-18 Increased ICW pump noise due to mismatched upper None bearings having been installed. ,

2 1R 92 18 .EPs had to be changed when Hurricane And,rew IFl later closed

, threatened. EP classifications were inconsistent i

and did not represent a logical progression of I- degraded safety conditions.

IR 92 18- Operator mistakenly de-energized a 480 V load center None instead of operating an adjacent EDG governor. '

control. switch

! j IR 92 18 Unit I snutdown due to leaking pressurizer safety. None-  ;

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IR 92-18 Unit 2 CCW flow indication erratic. Known to be None erratic for a long time with no repair. ,

j. IR 92-18 Poor wiring prae.tices caused a fire to occur in the None i 2C condensate pump IR 92-21 Inadvertent operation of CS pump 2B due to operator None I g , error, n IR 92-21 During replacement of U2 NFW RTDs, all RTDs replaced URI later determined 2

were reading high. Actual CTP was about 101.6%. not to be a i I- '

violation l IR 92-24 Quench tank rupture disk ruptured in' Unit 2 due to None personnel error while cooling the quench tank and -

due to prenurizer safety leakage.

-l 1R 92 24 The 2B AFW Pump failed to start on Auto start signal None due to misaligned contacts.

. IR 92-24 Turbine manually tripped during S/U due to abnormal None i

noise. Noise caused by loose studs on main turbine shaft coupling. .

IR 92 24 Main turbine tripped manu' ally due to high condenser None pressure caused by a fouled waterbox and personnel 4

error.

IR 92 24 RCGVS pilot operated valves'werezinstalled with the None ,

pilot disk reversed. :This contributed to leakage.

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IR 93-02 The 2Al RCP v1bration and leakage caused about a 1 None month unplanned shutdown to repair.

IR 93-02 Licensee determined that a 15 required surveillance LER later closed to determine abnormal ECCS exhaust fan operation had -

not been performed adequately since Unit 1 -

construction. This was caused by inadequate ,

understanding of the system.

IR 93 02 Partial Unit 1 ESFAS actuation due to a relay LER later closed

_ failure. No pumps started and no water was injected.

IR 93 02 Startup strainer found in CCW pump 28. Licensee URI later closed unable to determine when the strainer was installed. .

but could have been since construction.

IR 93 05 Failure to follow procedure during Rx cooldown None resulted in injection of some of the SIT volume.

IR 93-07 Inadvertent start of IB EDG by electrician while None

. installing test gear for safeguards test.

IR 93-08 Three of 4 steam space instruments on Unit 2 Vio SL IV pressurizer replaced due to leakage. Repair performed not IAW ASME code.

IR 93-12 The IB LPSI pump failed due to inadequate Vio SL IV lubrication to the bearings due to poor maintenance practices. .

IR 93 12 Seven CEAs in unit 2 were dropped. Apparent cause None was a ground in the. electrical system.

1R 93-15 Upon restart.of Unit 1, it was discovered that a None dual unit CEA was not latched, IR 93 15 Since plant had to enter mode 5 to investigate CEA None problem, the IA2 RCP seal replaced due to leakage.

IR 93 15 Turbine startup aborted when a tear was discovered None in IB condenser boot; .

IR 93 15 F1ve more attempts to bring-the generator on line None .

were unsuccessful due to several minor secondary problems.

IR 93-18 Approximately 55,000 gallons of water leaked from None the Unit.1 RWT.into the surrounding soil.

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6 IR 93-18 Failure to follow a na1ntenance procedure caused.an - NCV AFW M0V to fail.

, IR 93-19 Unit 2 S/D due to condenser tube leakage. None

. IR 9319 The 1A EDG tripped on a spurious.high Jacket water None

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temperature signal during a routine load run.

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IR 93 Unit I taken off-line twice ard Unit 2 power reduced None k once due to jelly fish intrusion. .  :

i IR 93-22 Unit 2 power reduced due to unidentifiable chloride. None  :

intrusion into the 2A SG.  :

IR 93-22 Unit 1 power. reduced due to high linear. heat rate None alarms, it was later determined that the alarm setpoints were reduced during the last jelly fish '

intrusion and never reset.

IR 93-22, Power. reduced on Unit 1.to effect repairs on a MFP. None IR 93-22 Power reduced on Unit 2 due to a rupture in the None screen wash system.

IR 93-22 Unidentified leak rate on Unit 1 exceeded 1.0 gpm. None Eventually determined that the cause was misaligned ,

l sample' valves.

IR 93-22 Written procedures were not implemented to install Vio SL IV temporary air to, UHS valves, IR 93-22 Licensee made changes to the facility as described V10 SL IV in the FSAR without performing a safety analysis.

IR 93 23 Unit 2 manually tripped due to high main generator None H2 temperature caused by a faulty TCW temperature control valve.

1R 93-24 Spent resin tank pressure exceeded allowable. Vio SL IV pressure.during resin transfer due to not using procedure. I 1R 93 24 Unit 2 power reduced due to condenser tube rupture. None 9

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Responses to RA Questions Regarding St. Lucie Self-Assessment ,

I. 1 Specific Answers

a. Is the assessment correct?

e Yes. The assessment addresses areas which we have identified formally as problems (corrective actions, programs / processes / procedures), areas which we have discussed informally (complacency, change management, communications),  ;

and areas we have not identified (training, self-assessm.ent, accountability).

b. Did the NRC identify via inspections and/or SALP any indicators that should have prompted us to potential problems? -

Yes. The NRC began to have concerns about St. Lucie's performance as early as Spring / Summer 1994, when an increase in the munber of reactor trips (6 in 6 months) was noted. In April,1994, the Site Integration Matrix was developed to attempt to identify the problems at St. Lucie. In June 1994, St. Lucie was removed from the NRC list of good performers. The following assessments were made:

Plant Status Report, June 1994 Reactor trips not seen as related, but additional attention to the adequacy of procedures was recommended. Weakness in review cited. Weaknesses in corrective actions discussed. Operations was assessed as continuing to .  !

be strong. Other functional area discussions indicated strong performance.

Plant Status Report, August 1994 '

Fundamentally the same assessment as June,1994, although potential problems in vendor technical manuals noted in the maintenance area.

Plant Status ReportfrPPR, October 1994 PSR concluded that performance remained strong in all functional areas, however, SRI notes for the TPPR indicating a difficulty in identifying common causes for deficiencies identified through inspection. SRI's assessment was that some complacency existed, management standards .

were not firmly set and communicated, and too many people (in EPL) didn't believe that a real problem existed. ,

Plant Status Report /PPR, March 1995 Sharp decreas'e in the number of reactor trips cited. Weaknesses pointed l l

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out in annunciator response procedures, corrective actions, logkeeping, and some aspects of FRG activities (reviews), however, Ops rated as ,

strong overall. Some maintenance weaknesses were identified (VTMs, ,

IVs, welding), but, overall, maintenance was seen as superior. Other functional areas were seen as continuing at superior levels.

  • August,1995 Regional personnel perform a root cause analysis'for indications of organizational and programmatic deficiencies, based on SIM' data for 12

. months. The predominant root cause for events observed at the plant was insufficient detail and scope in site programs and precedures. Deficiencies were noted in job skills, work practices, decisionmaking, interface among organizations, and unclear organizational responsibility and

. accountability. These weakness areas conform well to the licensee-identified limiting weaknesses in training, accountability, programs / processes / procedures, and communications management.

Plant Status Report /PPR, September 1995 Increase in personnel errors noted in Operations, including failures to follow procedure, inattention to detail, an.d failures to maintain awareness I of equipment status. Overall, Operations' performance was seen as having I declined. Maintenance perfomiance was similarly seen as having declined. with procedural quality and adherence and attention to detail I

cited as problem areas. Engineering and Plant Support were seen as continuing to perform strongly.

1 A review ofinspection report findings from 1992-93 indicates that, primarily in the areas of equipment reliability and procedural adherence, problems existed. A cursory review indicates that opportunities for enforcement may have been missed in some c'ases. However, the SALP report covering the period indicates that only minor problems (operator attention-to-detail and mainten' ance procedure ,

adherence) were identified and does not categorize problems into specific areas in i a manner sufficient to conclude that declines in performance levels were occurring.

c. Did we pursue any of the indicators? If yes, how? If no, why not? .

Prior to August,1995, when significant plant events (e.g. containment spraydown, RCP seal failure) indicated a clear decline in performance, no specific inspection efforts were targeted at t i - perceived weaknesses outside of the core inspection effort. A review ofInspection Reports from mid 1994 through the end of 1995 indicate that the only departures fro'm the core inspection l program were for allegation related issues. l 4

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.0 Miller's. Assessment (Opinion) l The failure of the NRC to act more proactively in applying inspection effort to St. Lucie  ;

stemmed from several factors: ,

j A long history of superior performance leading to reduced inspection effort and a subsequent reduction in the number of findings i i

A failure to act on the negative findings which were developed, as they tended to be -

masked by a large number of positive findings '

A failure to take advantage of the opinions of DRS and other visiting inspectors who, overwhelmingly, felt the plant was overrated 1

A lack of a clear discriminator as to when negative findings warrant amplification over a larger number of positive findings l

I Additionally, the plant is now undergoing what has been described in several documents in that, with added inspection effort come more findings and more enforcement which tends to appear as a decline in performance when, in fact, conditions which had persisted for some time are only now being realized. The percived decline then invites additional inspection, which turns up more

' problems, and the cycle repeats.

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