ML20137L252
Text
- _ . . . _- .. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ^ ~ ~~
^
c i
i 5
j MEMORANDUM : David R. McGuire, Chief Safeguards Section e
I
\h Nuclear Materials Safety and Safeguards Branch g\ Division of Radiation Safety and Safeguards FROM: Orysia M. Masnyk, Safeguards Specialist, DRSS t
i
SUBJECT:
SAFEGUARDS REVIEW REPORT, REVISION 38 TO THE ST) i LUCIE PHYSICAL SECURITY PLAN, CASE CONTROL NUMBER i
N5S65VA50033593 i
1 i
I BACKGROUND: By letter dated September 8, 1993, Florida Power and Light company submitted revision 38 to the St. Lucie Physical
{ Security Plan under the provisions of 10 CFR 50.54(p).
! EVALUATION:
changes The enclosed represents an accurate summary of the i
made. The revisions do not appear to lessen the j
j offectiveness of the previously approved plan and are, therefore, cceeptable for inclusion in the plan.
l 1
l py m ykw l Orysia M. Masnyk I Safeguards Jpecialist 4
)
Enclosure:
Summary of Changes cc: Region II Licensing File (65VA) 50-335 l
i i
i
~ ,
i O l'
! 0 9
- i 4
} 9704070181 970325 PDR FOIA BINDER 96-485 PDR
, ~.,
\ C SALP INPUT FEEDER FORM ST. LUCIE ISSUE EXAMPLES DATE REFEREN NRC ASSESSMENT CE CONTACT
- 1. 5fCtmlf t Secur. ty weapons qualification was observed in odottlan 3/27-31/95 93-06.?c Tobin The training program was consis*ently f retning & Qualificetten to " shoot don't shoot
- course. Records of treined ef f ect i ve . Seevetty personnel were officers were reviewed and were acevrete sad detailed ded$ceted eM =ctivated F. SECtmlTV There ==re no violettons of regulatory requirements 2/?-11/94 94-07.2a illimen Secertty, Tralning and Quait f tcetten Security Plans & Procedures Adherence tdrettf ted during this assessment period _ and Contingency Plens end twelementing precedures =*re edetsate 3 $ECts!1Y Review of invissentation of a fully operational hand 9/F6-30/94 94-21 te Tobin The personnel access control /bedging Access Controf e geonetry system thet occurred utd Dece=6er 1994. Ow 2/7-11/94 94 - 02.fc it ilmen program was consistently effecttee and non-cited eloistion in the area of posttag concensatory reliable.
seesures within regulatory tieefrane for access control to vital areas was noted.
- 4. $fCimlf f This area was not inspected dvrtng this ! ALP period. 9/A N/A N/A W/A Access Authert rat ton
+
H.
_ _ _ . _ . ______.__.._..____.._m.__..m - - - _ _ - _ _ _ . _ _ _ _ . . _ _ _ _ . _ _ . _ - _ . _ . _ .
nut, m, SALP INPUT FEEDER FORM ISSUE EIAMPLES DATE REFERENCE NRC ASSESSMENT CONTACT
- 5. Sitte t TY This eree was not inspected during this 5 ALP period. W/A N/A W/A R/A F t tness Foe Dut y
- 6. SECURITY This gree was not inspected chteing this 5 ALP perted. 9/A N/A W/A R/A 5ef aguards f efoemet ha Controt
- 7. 5tCtstTV There has been seven plan changes during the cou*se of this a/A h/A N/A Changes were timely and Plan Changes assessmeet period. epprepet et e.
- 8. SEttS!TP Internet Audit Pregese found three fladings in the areas of 2/7-11/94 94-02 to Ti t imen Internet audits wre teceough.
Audits & Coerective Actions security plan change drawings, egutpaent testing, and Itght ceaylete, ed effective.
meter cettbrotton and control. Quellty assurance peevides 9/76-30/94 94 -21. Fb Tobin Corrective actlen to finding was thorough sad accurate audits. ttsely and appropriate.
Stu !*ternal Aucttts conducted by 5ecurity Ceppliance specieltst; no discrepenties idantified
- 9. SEtta!TV Portions of tte perimeter has redundant detection etes. 3/27-31/95 95-08.Fe & b Tobin Barriers, elems. Ilghts cleted 5cevrity Systems Improved tituetnetton distributton noted, ctreelt ceneres, canaunteet tons. .
Closed circuit television essessment found to be ence11ent; 9/F6-30/94 94-21.?c Tobin powee supply, eiere stations e d very good vital eres eterm and barriers. Sone system the testing, motetenance and felleres in the beginntag of the SALP period due to 2/7-11/94 94 -Ot . Fb. c , Tilleen repair support were good, teclement weather. Alere stations were more then adeguately d.e. E f equipped, c:remunicotton egelsment and the secondary power suppl y system operated es required
i J !3r 9 C.
'Date PRELIMINARY 3NSPEus2CREsud SUNLRRY:OEIINSEEu.;.uu!RESULTS i
l Plant:Inspe[ctati & LwE gepoz = .Nos/Datles:
46-oi I
. Inspeercr:fi)&--Hand-
- d. 5e e m % .e(#"<- -
l l
Otherts);.:
< . hw w ls u s 0h ow ht' W- '
E %M (/2 WA'i dw -%g f \k31 Safety-Obj ect-Lver: IPrevide a brief statement of the saferv
) coiettive of this insDectient cmi s .d N bit- 7= uxim 4 %t Pre. rrca e,5 c. Lv e , e u w s--- t.
o fxA% t u vT c a kr'wT e~ F- \ \ n \ e, G l 1
1 v 1 Ramnitr- (Violations. Deviations. Unresolved rtoms. TFT's.
Streneths se Weaknesses. Others) i
~ t% bo w A ,- V ei h cer
.- pst Cohm A< V madout / c ww Lw Asn % shw up ( cr#' h -
8 o a c-22. ,s N u a e 4 s c r.
a
&E. %----w ex bau e e we-r WA ,e Nm o t (
bh w r- x AM hwa %w:- 0w.a N Exri%iA M-D
- 7) / l .
n r/ r J (w
Discr_-hution:
InspectordsrSect:icn:. Chief Inspec:=rdsrBranr h -Chief n ef:Date InspecterdsmDiv454 nn-nirector Pr:3ecc: Sect:Lon-rm4ef 1}
Regzn-m radm4"*?trator _
e -
l ST. LUCIE ONSITE EVENT FOLLOWUP INSPECTION OVERDILUTION EVENT of 1/22/96 (Exit was at 10:00 a.m. on 1/30/96) j inspectors: R. Schin, S. Sandin, B. Desal l
, Summary of draft nreliminary findinas: '
- 1. Magnitude of power and temperature excursion i
- a. Reactor power l Peak reactor power was approximately 101.18%
100% power was exceeded for approximately 70 minutes 101% power was exceeded for approximately 4 minutes The event was within.the accident analysis The guidelines of the Jordan memo were not exceeded l
- b. Cold leg temperature Peak Tc was approximately 549.9 degrees F !
3 TS limit of 549 was exceeded for approximately 50 minutes i l -
TS 2-hr. action statement was properly entered and was not l
j exceeded i
! 2. Concern with operator attentiveness - Potential / Apparent VIO of procedures (Enforcement panel form completed on this issue):
! a. Operators faued to stop dHution when the proper amount had been i added.
- b. There was inadequate watch turnover for the operator at the controls j during dilution.
- c. Operators faHed to follow the Conduct of Operations procedure in l , performing the dHution procedure.
J d. Operators faHed to adequately report the event to licensee
- management.
j
- 3. Concern with control room command and control- Weakness 4'
- a. The SRO in the control room was not aware of the dHution in i progress.
)
- b. The board operator did not inform the SRO of dHution .this was a j general practice at the site and not required by procedures.
i 4
l
- - ~ - -- -
1 2
- c. The watchstander board was not maintained (on Saturday).
i
- d.
i The SRO in the control room was allowed to be in the ANPS office for unlimited time, out of sight of control room activities and out of
! hearing range of almost all control room activities except annunciator j alarms (not applicable during this event).
l 4. Weaknesses in procedures 1
- a. The Unit 2 dHution procedure had been changed, but not the Unit 1 procedure, to more accurately describe dHution the way the operators j
had performed it for years (in manual and direct to the charging
! pumps). During the event, manual dHution could not be accomplished j by using the Unit 1 procedure in compliance with the Conduct of
- Operations.
l b. Procedures and practices for dHution (before and during the event) did
! not support the FSAR accident analysis assumptions on how dBution was performed. The FSAR assumed dNution in automatic and to the j VCT.
i
- c. Procedures for duution (before and during the event) did not require the operator at the controls to remain by the dBution controls a0d to j closely monitor the dNution during a manual dNution with no automatic
! shutoff.
i
! 5. Weaknesses in corrective action i
j , s. Potential VIO of 10 CFR 50.59: Revised procedure (after the event) j did not support the FSAR Chapter 15 accident analysis assumptions 1 on how dHution was performed. The FSAR assumed dNution in j automatic and to the VCT.
i e
- b. The revised procedure for manual dHution (after the event) did not l require the operator at the controls to remain by the dRution coctrols
- and to closely monitor the dRution during a manual duution with no automatic shutoff.
4
! c. The licensee initial investigation of the event was not thorough in that !
l It concluded that maximum reactor power was 100.2%. Subsequent review by the NRC and licenses found that maximum reactor power
, was approximately 101.18%.
1 i
i I
e
1 -
i l 2
- 6. Weakness in Operational Experience Feedback I i
4
- a. In response to SOER 94-02, dated September 1994, which described i a similar Turkey Point overdilution event and severalinadvertent i duution events at other utilities, the licensee reviewed the St. Lucie i operating procedures related to dilution and concluded that no j
changes were needed. This was a missed opportunity to strengthen i
operating procedures to prevent the 1/22/96 overduution event.
l 7. Other comments i I
- a. There was no clearly noticeable indication of dilution in progress. The j
dRution clicker was quiet (might not be heard from the desk area) and
- j. sounded identical to the nearby clickers that routinely made noise.
i b. Operators routinely did not log reactivity additions; however, the j licensee's Conduct of Operations procedure' stated that operators
! should log reactivity changes.
i 1 i
f
} LICENSEE DISSENTING COMMENTS j 1. The licensee had dissenting comments on item 5.a. above, the potential !
violation of 10 CFR 50.59. The inspectors told the licensee at the exit that i those dissenting womments would be included in the inspection report, for ;
i further review by NRC management. The dissenting comments, from the '
j engineering manager (Dan Denver) and the licensing manager (Ed Weinkam),
i included:
l a. The previous procedure allowed diluting in manual and directly to the suction of the charging pumps, and that had been the practice for j many years. Therefore, the temporary change on 1/23/96 (after the j eventi did not change the method of dilution, but only clarified a
] previously existing procedure and made it conform to " verbatim compliance" rules. The inspectors did not disagree. In fact, further i review, as requested by the inspectors, found that the first time the
} dilution procedure was changed to allow opening of valve 2525 l (directly to the suction of the charging pumps) was in a change to j rev. 2 of the procedure,in 1976, before the operating license was i
issued.
)
1
- b. The design of the plant (piping, talves) always was such that dilution j in manual and directly to the suct.Nn of the charging pumps was j possible. The inspectors did not disagree.
i i
i
I . ~. . . _ ..
}.
j c. The accident analysis assumed a worst case dNution event with domineralized water going directly to the suction of the charging l
pumps and three charging pumps running. That would be three times ;
j the flowrate of this event and therefore that analysis bounds this i event. The inspectors did not disagree. ,
i
- d. The FSAR Chapter 9 description of the Chemical and Volume Control i System did not prohibit duution in manual and directly to the suction of the charging pumps. The. Inspectors did not disagree.
l e. The automatic mode of dBution is less safe than the manual mode, in i
that there is more opportunity for a malfunction that could result in a J maximum flowrote approaching the design limit. The inspectors did i j not comment on that position.
I
- f. The procedure change that first allowed dilution directly to the su'ction
] of the charging pumps was made before the operating license was i lasued, therefore 10 CFR 50.59 did not apply to that change. The j inspectors did not comment on that position.
1
! g. Since the operating procedure that was in effect at the time the j
operating license was issued allowed d8etion in manual and directly to the suction of the charging pumps, that method was included in the L
originallicensing basis of the plant. The inspectors did not agree with !
l that position.
i ll
- h. After receiving these licensee comments, the inspectors' concern l remained unchanged: The Temporary Change of 1/23/96 (after the event) described procedure steps for dBution in manual and directly to the suction of the charging pumps. That procedure was different ;
' from the one described in the FSAR. The licensee's procedure '
differed from the FSAR in that it allowed a faster rate of reactivity l addition and without an automatic shutoff. The licensee had not i performed a safety analysis of this difference and had not revised the l procedure and/or FSAR to make them agree.
j 2. The licensee also had a dissenting comment on item 5.c. above, the i
weakness in the licensee'c initial investigation. The dissenting comment, j from the Plant Manager (Jim Scarola), was:
I a. The initial investigation, for the in-House Event Summary, was done by the STA. Timeliness was more important than quality at that time.
l Subsequent more thorough review would be performed by the
} licensee. The inspectors acknowledged the licensee's comment.
a-
]
I
, 1 i __ _ _ _. -
r l
t f
ESCALATED ENFORCEMENT PANEL QUESTIONNAIRE' i INFORMATION REOUIRED TO BE AVAILABLE FOR ENFORCEMENT PANEL l PREPARED BY: S. Sandin NOTE: The Section Chief is responsible for preparation of this questionnaire and its distribution to attendees prior to an Enforcement Panel. (This information will be used by EICS to l prepare the enforcement letter and Notice, as well as the ,
transmittal memo to the Office of Enforcement explaining and i justifying the Region's proposed escalated enforcement action.)
. i
- 1. - Facili ty: St. Lucie Nuclear Power P1 ant ;
Uni t (s) : 1 i l
Docket Nos: 50-335 License Nos: DPR-67 Inspection Dates: 1/26-1/30/96 Lead Inspector: R. Schin
- 2. Check appropriate boxes:
X A Notice of Violation (without "boilerpla te") which includes the recommended severicy 1evel for the violation is enclosed.
[] This Notice has 'been reviewed by the Branch Chief or Division Director and each violation includes the i appropriate level of specificity as to how and when the l requirement was violated. i 1
[] Copies of applicable Technical Specifications or \
license conditions cited in the Notice are enclosed. l
- 3. Identify the reference to the Enforcement Policy Supplement (s) that best fits the violation (s) (e . g. ,
Supplement I.C.2) }
SupF i 'unt I. C. 3
- THIS DOCUMENT CONTAINS PREDECISIONAL INFORMATION--
IT CAN NOT BE DISCicSED OUTSIDE NRC WITHOUT THE APPROVAL OF THE REGIONAL ADMINISTRATOR
. . - -- .- = ~ -. .. .. - . .- - - - - . _ _ . -. .
ESCALATED ENFORCEMENT PANEL OUESTIONNAIRE
- 4. What is the apparent rgot cause of the violation or problem?
Operator inattentiveness to reactivity addition.
i
- 5. State the message that should be given to the licensee (and }
industry) through this enforcement action. l Operators must recognize and treat Boration/ Dilution as i seriously as rod manipulations. Unusual operations events ;
must be transmitted promptly to management. l 1
\
6.
Factual information related to the following civil penalty 1 escalation or mitigation factors (see attached matrix and
- 10 CFR Part 2, Appendix C, Section VI.B.2. )
, a. IDENTIFICATION: (Who identified the violation? What were the facts and circumstances related to the discovery of the violation? Was it' self-disclosing?
Was it identified as .a result of a generic
, notification ?)
Licensee. See attached information.
i
- b. CORRECTIVE ACTION: Although we expect to learn more
- information regarding corrective action at the en forcement conference, describe preliminary 1 information obtained during the inspection and exit in terview.
J One Licensed Operator removed from licensed duties. An i In-House Event was initiated including a STAR. Night Orders issued and management conducted operator
, briefings.
- What were the immediate corrective actions taken upon discovery of the violation, the development and implementation of long-term corrective action and the timeliness of corrective actions?
Operators restored Tc. Operator relieved. Procedures changed.
What was the degree of licensee initiative to address the violation and the adequacy of root cause analysis?
Slow to recognize - Notify management 4
- THIS DOCUMENT CONTAINS PREDECISIONAL INFORMATION+=
IT CAN NOT BE DISCLOSED OtTTSIDE NRC WITHOtTT THE APPROVAL OF THE REGIONAL ADMINISTRATOR 2
ESCALATED ENFORCEMENT PANEL OUESTIONNAIRE
- c. LICENSEE PERFORMANCE: This factor takes into account the last two years or the period within the last two inspections, whichever is longer.
List past violations that may be related to the current i violation (include specific requirement cited and the date issued):
- 1. VIO 335/94-22-02, " Improper Modification of Control Room Logs", November 25, 1994
- 2. NCV 335/95-07-01, " Failure to Follow Shutdown Cooling Operating Procedures", April 19, 1995
I
- 5. VIO 335/95-15-03, " Failure to Follow Procedure and Document abnormal valve position in the Valve Switch Deviation Log", October 16, 1995
- 6. VIO 335/95-15-04, " Failure to Follow Procedures during Alignment of Shutdown Cooling System",
October 16, 1995 i
- 7. VIO 389/95-18-01, " Failure to Follow Procedures ,
and Maintain Current and Valid Log Entries in the i Rack Key Log and Valve Switch Deviation Log", l November 27, 1995
- 8. VIO 389/95 32, "Fai1ure to Fol1ow the Equipment Clearance Order Procedure and Require Independent Verification of a TS Related Component", December 8, 1995 All of the above VIO/NCVs involved licensed operators with a licensee corrective action commitment to strict adherence to procedures.
i 1
-THIS DOCUMENT CONTAINS PREDBCISIONAL INFORMATION--
IT CAN NOT BE DISCLOSED OtJTSIDE NRC WITHotTT THE APPROVAL OF THE REGIONAL ADMINISTRATOR 3
]
i l
ESCALATED ENFORCEMENT PANEL OUESTIONNAIRE Identify the applicable SALP category, the rating for this category and the overall rating for the last two SALP periods, as well as any trend indicated:
OPS - 2 (Predecisional), 1 previously Declining performance since August 95.
- d. PRIOR OPPORTUNITY TO IDENTIFY: Were there opportunities for the licensee to discover tne
, violation sooner such as through normal surveillances,
- audits, QA activities, specific NRC or industry
, notification, or reports by employees?
- No ,
a 1
^
- e. MULTIPLE OCCURRENCES: Were there multiple examples of the violation identified during this inspection? If there were, identify the number of examples and brief1y describe each one.
Yes (4)
.All were failures to follcw procedures, i.e.
(1) Did not monitor totalizer and secure dilution (2) Did not follow dilution procedure verbatim l (3) Did not notify Ops management of unplanned
- reactivity change t
(4) Did not perform proper interim watchstander turnover E
- f. DURATION: How long did the violation exist?
! Activities took place over about a 10 minute period.
1 i
ADDITIONAL COMMENTS / NOTES:
See attached NOV, General Description of Event, and Detailed Sequence of Events l
4 1
--THIS DOCUMENT CotrTAINS PRRDECISIONAL INFORMATION--
IT CAN NOT BE DISC 14 SED OUTSIDE NRC WITHOUT THE APPROVAL OF THE REGIONAL ADMINISTRATOR, N
, .~ . _ - .
'4 ESCALATION AND MITICATION FA'" TORS (57 FP 5791. February le. 1992)
IDENTIFICATION CDRRECTIVE LICENSEE PRIOR MULTIPLE DURATION ACTION PERFORMANCE OPPORTUNITY TO OCCURRENCES IDENTIFY
+/* 504 + /- son + /- 2 00% + 100% + 100% + 1004 Licensee Timeliness of current Licenses should Multiple Used for identified (M) corrective violation is an have identified examples of significant (To be app 1 led action (M) isolated violation violation regulatory even if (Did NRC have failure that as sooner as a identified message to licensee could to intervene to inconsistent result of prior during licensee. (E) have accomplish with licensee's opport unitie s inspection identified the satisfactory good such as audits (only for SL I, violation short-term or performance (M) (E) II or III sooner) remedial action violations) (E)
(E))
NRC adentafied Promptly Violation as opportunities DTHEP CONSIDEPATION9 (E) developed reflective of available to schedule for licensee's poor discover 1. Legal aspects and potential long term or declining violatton such litigation risks corrective performance (El as through action (M) prior 2. Negligence, careless dio-notafication regard, w111 fulness and (El management involvement self- Degree of Prior Ease of earlier 3. Economic, personal or disclosing licensee performance and discovery (El corporate gaan (M 264 af instantive (M) effectiveness there was (To develop of previous 4. Any cther regulatory f rame-initiatava to corrective corrective work factors that need to be identify root actions and action for consideredi pending action cause) root cause) eimilar with regard to licensing, violations commission meeting, or press conference.
Licensee Adequacy of the SALP , Period of time identified as root cause Considers between $. What is the antanded message a result of analysis for SALP 1 - (M) violation and for the licensee and the generic the vnolation SALP 2 - (o) notification industry?
notification (M) SALP 3 - (E) received by (m) licensee (E) ...... ... NOTES ** -------
Comprehensive Prior similaraty corrective enforcement between the action to history violation and prevent including notification occurrence of escalated and (El similar non-escalated violation (M) enforcement Immediate Level of corrective management action not review the taken to notifiestion restore safety received (s) and compliance (E)
M MM M . nz. .. . . . . ==. : = . . . .
SAFETY SIGNIFICANCE: In determining the safety significance of a violation in conjunction with the enforcement process, the evaluation should consider the technical safety significance of the vnolation as well as the regulatory significance. Consideretton should be given to the matter as a whole an light of the circumstances surrounding the violation. There may be cases in which the technical safety significance of the matter is low while the process control f ailure(s) may be esgnificant, and, therefore, the severity level determination should be based more on the process control failure (s) than on the technical safety assue. The following factors should also be cons &dered: 1) Did the violation actually or potentially impact public health and safety? 2) What was the root cause of the violation?
- 3) Is the violation an isolated incident or is it Indicative of a programmatic breakdosn? 4) Was mannaement aware of or involved in the violation? El Did the violatton involve w111 fulness?
l l
l l
ESCALATED ENFORCEMENT PANEL OUESTIONNAIRE PROPOSED VIOLATION Technical Specification 6.8.1.a required that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33. Rev 2. February 1978. Appendix A includes operating procedures for the chemical and volume control system and
. administrative procedures for relief turnover, procedural adherence, and authorities and responsibilities for safe operation.
Operating Procedure No. 1-0250020. Boron Concentration Control - Normal Control. Rev. 35, step 8.5.14 required that operators monitor the water flow totalizer and close valve V2525 after the desired volume was added during a boron concentration dilution using the direct path to the charging pump suction. ,
I 1
Administrative Procedure No. 0010120. Conduct of Operations. Rev 79. Appendix l D. Crew Relief / Shift Turnover, required that, for short term watchstander relief, a turnover be conducted including: general watchstation status. Off- l normal conditions, and tests in progress.
^
Administrative Procedure No. 0010120. Appendix M. Procedural Compliance and l Implementation, required that controlled procedures be implemented and complied with in accordance with the instructions provided in 01 5-PR/PSL-1. l Procedure 01 5-PR/PSL-1. Preparation. Revision. Review / Approval of. Procedures.
Rev 67. Section 5.13.2. stated that all procedures shall be strictly adhered to and identified that Operating Procedure 1-0250020 was not considered " skill of the trade" and was not to be performed from memory without referring to the procedure.
Administrative Procedure No. 0010120.. Appendix E. Notification of Operations Supervisor /FPL Management required prompt verbal notification of the
- Operations Supervisor for unplanned reactivity changes.
Contrary to the above:
- 1. On January 22. 1996, at approximately 2:30 a.m. Unit 1 operators failed to close valve V2525 after the desired volume was added during a boron concentration dilution using the direct path to the .harging pump.
Operators had desired to add between 25 and 40 gallons of primary makeup water, but failed to stop the dilution until approximately 400 gallons were added. During this time, the temporary relief operator at the controls was unaware that a boron concentration dilution was in progress, which resulted in an unmonitored reactivity addition. The SRO
! and other operators in the control room were also unaware that a reactivity addition was in progres's.
4
--THIS DOCUMENT CONTAINS PREDSOISIONA*. INFORMATION--
a IT CAN NOT BE DISCLOSED OttfSIDS NRC WITHOtff THE APPROVAL OF THE REGIONAL ADMINISTRATOR b
l e
ESCALATED ENFORCEMENT PANEL OUESTIONNAIRE
- 2. On January 22. 1996, at ap)roximately 2:30 a.m., the Unit 1 operator at the controls conducted a slort term watchstandar relief with an inadequate turnover in that it failed to include general watchstation status and conditions including that a boron concentration dilution was in progress. As a result, the relief operator at the controls was unaware that a boron concentration dilution was in progress and failed to adequately renitor and control the dilution. I 1
- 3. On January 22, 1996. at approximately 2:30 a.m.. operators performed Operating Procedure 1-0250020 from memory, without referring to the procedure, and without strictly adhering to the procedure. At the time, the procedure was written such that the boron concentration dilution that was performed could not have been performed by strictly adhering to the procedure.
4 On January 22, 1996. between 2:30 a.m. and 7:20 a.m. . operators failed to give prompt verbal notification to the Operations Supervisor for l I
unplanned reactivity changes that had occurred.
i l
General Descriotion of the Event At approximately 0225 on January 22. 1996, the Unit 1 control board Reactor Controls Operator (RC0) began a manual dilution to the RCS by aligning primary makeup water (demineralized water) directly to the suction of the IB Charging Pump. Moments after beginning the dilution, the board RCO responded to a secondary plant annunciator and then saw the desk RCO return from the kitchen. He requested that the desk RCO relieve him so that he could prepare his lunch. During the turnover, there was no discussion of the dilution in progress. Following the turnover, the relief operator at the controls and the Nuclear Plant Supervisor (NPS), who was at the desk RC0 station, were not aware that a dilution was in progress. The original board RC0 returned between 5-10 minutes later and immediately recognized his error. He informed the 1
other RCO of the overdilution, which was overheard by the NPS, and '
stopped the dilution. The NPS directed the ANPS take charge and begin a manual boration. Unit 1 entered 2-hour TS LCO Action Statement 3.2.5 for T cgreater than 549*F. The maximumcT obtained was 549.9 F and the maximum reactor power was 101.18%. eT was above the TS limit of 549 F for approximately 50 minutes and reactor power was above 100% for approximately 70 minutes. The TS LC0 Action Statement for Tc was not exceeded and the guidance of the Jordan memorandum on maximum reactor power was not exceeded. The operators did not verbally notify plant management or the NRC of this event. -
--THIS DOCUMElfr CONTAINS PREDECISIONAL INFORMATION.-
IT CAN NOT BE DISCLOSED OUTSIDE NRC WITHOUT THE APPROVAL OF THE BEGIONAL ADMINISTPATOR 7
)
..,..-r. _.. ~ .
1 I
J ESCALATED ENFORCEMENT PANEL OUESTIONNAIRE Detailed Seauence of Events (Note that the times for the sequence of events are approximate and only relevant events are mentioned) 1/21/96 j
11:00 p.m. Incoming mid shift assumed Unit I responsibility with the !
Unit at 100% power. 870 MWe, Tavg at 575 degrees F. Thot at J
600 degrees F. Tcold at 548.9 degrees F. RCS Boron 1 concentration at 376 ppm. Xe worth at -2722 pcm, all CEAs >
fully withdrawn and manual, and no Technical Specification )
action statements in effect. Major evolution planned for the shift was to place the waste gas system in service.
Further there was an annunciator alarm E-9 associated with circulating water pump lube water supply strainer delta P high that was intermittently coming in due to a failed pressure switch.
11:45 p.m. Board RCO reset to zero the primary water (to VCT or charging pump) flow totalizer in preparation for inventory balance (RCS leak rate calculation) 11:00 p.m.- i 2:00 a.m The board RC0 recalled performing at least two dilutions of approximately 35 gallons each between 11:00 p.m. and 2:20 a.m. without resetting the totalizer.
1/22/96 xx:xx a.m NPS arrived in Unit 1 control room to gather data for morning report meeting and sat near desk behind control boards. STA was also present near NPS !
xx:xx a.m. ANPS turned over control room senior reactor operator responsibility to NPS and proceeded to the kitchen to prepare breakfast xx:xx a.m. Desk RC0 left control room to go to the kitchen 2:20 a.m. Nor'aal continued fuel burnup resulted in indicated Tc of 548.7 degrees F on RTGB-104 (digital meter). At this point the board RCO decided to restore Tc to maximum allowable program value of 549.0 degrees F.
xx:xx a.m. Desk RCO arrived in the control room with his meal
--TMIS DOCUMEIC CONTAINS PREDECISIONAL INPORMATION--
IT CAN NOT BE DISCLOSED QUTSIDE NRC WITHot11' THE APPROVAL OF TH8 REGIONAL ADMINISTRATOR O
n
- ESCALATED ENFORCEMENT PANEL OUESTIONNAxg5 2:25 a.m. The board operator began a manual dilution by aligning primary water to the suction of the charging pumps by opening FCV-2210X and A0V-2525. The flow rate was approximately 44 gpm.
2:26 a.m. Annunciator E-9 associated with circulating water lube water sup]ly strainer high delta P was received. The board RCO walced to the panel and acknowledged the annunciator.
2:27 a.m. After acknowledging the annunciator the board operator 1 decided to proceed to the kitchen to prepare his meal. The board operator conveyed this to the desk operator and ]
requested that he take over the board operator responsibilities. However. he did not mention the ongoing dilution. The desk operator got up and proceed to the board in the vicinity of panel 103. The original board operator proceeded to the kitchen and started preparing his' meal on a skillet that had been kept warm. At this time the NPS and the STA were in the control room at the desk area. The NWE had been in and out of the control room throughout the shift. The relief operator at the controls, NPS. STA. and NWE were not aware of the ongoing dilution.
2:35 a.m. The original board operator returned from the kitchen with his meal. Upon approaching the board he realized that he j had left the control room with an angoing manual dilution.
He exclaimed that he had overdiluted and immediately began securing the dilution. The desk operator questioned how much water was added and the board operator noted from the totalizer that approximately 400 gallons was added.
2:35 a.m. Soon after, annunciator M-16 associated with RCP controlled bleedoff pressure high was received. At this point the Tc was noted by the desk operator to be 549.6 degrees F. Entry into two hour action statement associated with Technical Specification 3.2.5. DNB paramenters was recognized and later logged.
2:36 a.m. The desk operator directed the board operator to initiate I boration to restore Tc to program. The NWE calculated the amount of borated water to be added to the RCS. The NPS asked the desk operator to notify the unit ANPS to come to l the control room.
x:xx a.m. ANPS walked into the control room. '
i
- THIS DOCUMENT CONTAINS PREDECISIONAL INFORf% TION--
i IT CAN NOT BE DISCLOSED OUTSIDE NRC WITHOUT THE APPROVAL OF THE REGIONAL ADMINISTRATOR 9 1
I
, _ ~ _ . _ _ . . . _ _ _ _ _ _ _ . _ _ .
ESCALATED ENFORCEMENT PANEL OUESTIONNAIRE 2:41 a.m. Tc reached the highest noted value of 549.9 degrees F. MWe i reached 875 and indicated reactor power was approximately 101.2%
x:xx a.m. Operator secured boration.
3:14 a.m. Tc noted below 549.0 degrees F. Technical Specification action statement was exited.
- x
- xx a.m. STA initiated an In-House Event Report and notified HPES l personnel by telephone.
5:45 a.m.-
6:00 a.m. Shift turnover occurred. It appears that the dilution event was not discussed with the oncoming shift.
6:25 a.m. In-House Event Report was E-mailed to standard distribution.
i which included plant management. by the STA.
6:30 a.m. The Operations Manager toured the control room but was not informed of the over dilution event.
7:20 a.m. The Operations Manager read the control room logs (in his office by computer) and questioned the log entry associated
- with the overdilution event. -
7:30 a.m. Licensee initiated a detailed investigation associated with
, the event.
7:45 a.m. Senior Plant management was notified of the event during the morning meeting.
. 10:00 a.m. NRC resident inspector was given the event report that was initiated associated with the event.
)
l
- THIS DOCUMENT CONTAINS PREDECISIONAL INFORMATION.- j IT CAN NOT BE DISCLOSED OUTSIDE NRC WITHOUT THE APPROVAL OF THE REGIONAL ADMINISTRATOR 20 4
C' ST LUCIE ENFORCEMENT PANEL
SUMMARY
2/7/96
- 1. General DeScriotion of the Event At approximately 2:25 a.m. on January 22, 1996, the Unit I control board
< Reactor Controls Operator (RCO) began a manual dilution to the RCS by aligning primary makeup water (demineralized water) directly to the suction of the IB Charging Pump. Moments after beginning the dilution, the board RCO responded to a secondary plant annunciator and then saw the desk RCO return from the kitchen. He requested that the desk RCO relieve him so that he could prepare his lunch. During the turnover, there was no discussion of the dilution in progress. Following the
'~ turnover, the relief operator at the controls and the Nuclear Plant Supervisor dilution was(NPS), who was at the desk RCO station, were not aware that a in progress. The original board RCO returned between 5-10 minutes later and immediately recognized his error. He informed the 4
other RCO of the overdilution, which was overheard by the NPS, and f stopped the dilution. The NPS directed the ANPS take charge and begin a manual boration. Unit 1 entered 2-hour TS LC0 Action Statement 3.2.5 for T, greater than 549*F. The maximum T, obtained was 549.9'F and the
- maximum reactor power was 101.18%. T, was above the TS limit of 549'F for approximately 50 minutes and reactor power was above 100% for approximately 70 minutes. The TS LCO Action Statement for T, was not exceeded and the guidance of the Jordan memorandum on maximum reactor power was not exceeded. The operators did not verbally notify plant management or the NRC of this event.
- 2. Enforcement Panel Preliminary Conclus s I Part 50 Licensee: One SLIII Problem, with three violations - Supplement I.C.7: A breakdown in the control of licensed activities involving a
- number of violations that are related that collectively represent a significant lack of attention or carelessness toward licensed responsibilities. The NRC will hold a closed predecisional enforcement ;
conference with the licensee. i The three violations are: I
- a. Operators failed to follow procedures, four examples:
- 1) Operators failed to stop dilution when the proper amount had been added.
l
- 2) There was inadequate watch turnover for the operator at the controls during dilution.
- 3) ' Operators failed to follow the Conduct of Operations procedure in performing the dilution procedure (lack of l' strict / verbatim compliance).
- 4) Operators failed to adequately report the event to licensee management.
p\C L
s
\
m 4 .'
y/
f 2
- b. Inadequate design control, in that Unit 1 procedures for adding a mixture of demineralized water and boric acid to the reactor coolant system (in manual and directly to the suction of the charging pumps) did not implement the procedure as' stated in the FSAR, Chapter 15, (in automatic and to the VCT) and had not done so since before Unit I was licensed.
- c. Inadequate 10 CFR 50.59 evaluation, in that the licensee made a change to the Unit I dilution procedure on January 23, 1996 the event), to allow adding pure demineralized water in manua(after l and directly to the suction of the charging pumps, that was different from the procedure as stated in the FSAR, Chapter 15 (in automatic and to the VCT) without a 10 CFR 50.59 safety evaluation.
Part 55 Licensees: No official enforcement action, but the NRC will ask the licensee to bring three licensed operators from the event (the NPS, board R0, and desk R0) to the enforcement conference with the utility.
Also, the staff is considering sending letters to the three operators expressing NRC concern with their actions.
- 3. Special Insoection and FSAR Review Region II was notified of this event at approximately 10:00 a.m. on Monday, January 22, when the licensee delivered a copy of the In-House Event Report to the NRC resident inspector. At the time, RII had an ongoing corrective action program inspection at the site including region based inspectors R. Schin, M. Thomas, and L. Moore. On Thursday, January 25, RII management organized a special event followup inspection to begin on Friday, January 26, and continue through the weekend until completed. The special inspection included lead inspector R. Schin plus Turkey Point resident inspector B. Desai and St. Lucie acting resident inspector S. Sandin. The special inspection exit interview was conducted at 10:00 a.m. on Tuesday, January 30.
The inspectors included FSAR review in the inspection plan, and B, Desai's review of the F"AR identified that the licensee's operating procedures for boron dilution were not consistent with the FSAR Chapter 15 accident analysis procedure for boron dilution. Further review of this issue resulted in proposed violations b. and c. above. At the exit interview, the licensee had seven dissenting comments to this finding.
P