ML20137M021

Responds to NRC 850927 Notice of Violation & Proposed Imposition of Civil Penalty Noted in Insp Repts 50-373/85-23 & 50-374/85-18.Corrective Actions:Eccs Switch Tripped & Secondary Containment Integrity Reestablished.Fee Paid

ML20137M021
Person / Time
Site:	LaSalle
Issue date:	11/26/1985
From:	Reed C COMMONWEALTH EDISON CO.
To:	Taylor J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE)
References
0764K, 764K, EA-85-095, EA-85-95, NUDOCS 8512030583
Download: ML20137M021 (15)

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2 -[. q [f Commonwealth Edison y5 l One First National Plaza. Chicage llano 4*

h,9h l Address Reply to Post Office Box 767 l Chicago. Ilhnois 60690 l

November 26, 1985 Mr. James M. Taylor, Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555

Subject:

LaSalle County Station Units 1 and 2 Response to Notice of Violation and Proposed Imposition of Civil Penalty Inspection Report Nos. 50-373/85-023 and 50-374/85-018 (EA 85-95)

Reference:

J. G. Keppler letter to J. J. O'Connor dated September 27, 1985.

Dear dr. Taylor:

This is Commonwealth Edison Company's (Edison) response to the above referenced Nuclear Regulatory Commission's (NRC) Notice of Violation, Proposed Imposition of Civil Penalties and accompanying inspection report.

As we agreed, this response has been submitted within 60 days of the Notice rather than within the 30 days originally provided. We appreciate the opportunity that this extension of time has given us to explain in detail Edison's comprehensive program for addressing the matters at issue here.

Because Edison does not protest the fine, this letter is accompanied by a check as payment in full of the $125,000.00 penalty.

Edison appreciates the significance of the deficiencies identified-in the Notice. Our program to ensure the safe operation of our nuclear facilities depends in part on ensuring the correct implementation of plant modifications. Edison acknowledges that the events which gave rise to these deficiencies were unacceptable. To ensure that similar incidents will not recur. Edison has initiated the extensive corrective action discussed below for boh the Station and the General Office.

The attachment to this letter describes the wide range of measures, both Immediate and long term, which have been instituted by the LaSalle County Nuclear Power Station and General Office management. The immediate measures: (1) ensured that the violations were corrected; (2) determined that no similar violations had gone undetected; and (3) instituted new procedures to prevent a recurrence of similar events. Among the significant longer term measures are the establishment of a committee which, for a trial period, will review post-modification tests for their ability to determine the operability of the modified equipment and the development of a checklist for helping to choose appropriate tests for modified equipment.

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l J. M. Taylor November 26, 1985 l

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These measures demonstrate Edison's continuing commitment to the operational safety of its nuclear stations. Edison believes that such safety i L will be enhanced by the corrective actions described in this letter and its i

attachment and, therefore, that the LaSalle County Nuclear Power Station will continue to operate in a manner that fully ensures public health and safety.

Very truly yours, ,

C,dOk 09a Cordell Reed Vice-President im Attachment cc: J. G. Keppler - Region III ,

LaSalle Resident Inspector SUBSCRIBED AND SWORN to before me this M _ day of9)lNnh to , 1985 sl50h&&w Notary Public i

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i ATTACHMENT RESPONSE TO NOTICE OF VIOLATION 1A. Technical Specification 3.3.3.b requires that with one or more Emergency Core Ccoling System (ECCS) actuation instrumentation channels inoperable take the action required by Table 3.3.3.1.

Table 3.3.3.1 in Action 30 requires that when the number of operable channels is less than the required minimum of two, place the inoperable channel in the tripped condition within one hour or declare the associated system inoperable.

Contrary to the above, from 3:30 a.m. on June 5, 1985 until 12:10 p.m. on June 10, 1985 when the number of operable channels was less than the required minimum of two, the inoperable ECCS actuation instrumentation channel was not placed in the tripped condition within one hour and the associated system was not declared inoperable.

ADMISSION OR DENIAL OF TFE ALLEGED VIOLATION Commonwealth Edison admits the violation.

REASON FOR THE VIOLATION This violation resulted from our reliance on post-modification tests which did not accurately determine the cperability of the modified Division 1 Low Reactor Water Level Switches.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED

1. Initial Responses As soon as it was discovered that the instruments were inoperable, one of the switches was placed in the tripped condition as required by Action 30 of Table 3.3.3.1 of Technical Specification 3.3.3.b.

l Appropriate Station Personnel and General Office Management were also informed of the event. Shortly thereafter, the errors were corrected and an investigation was initiated into the causes of the events. The results of these investigations provided bases for

! additional actions intended to prevent recurrence of similar events.

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2. Further Actions To ensure that no other problems of this type had been missed, several broader actions were taken.

All safety-related modifications made during the Unit 2 outage were reviewed by either the Commonwealth Edison Station Nuclear Engineering Department (SNED) or the architect-engineer. No serious discrepancies requiring further physical changes were discovered. Also, either SNED, the station or the architect-engineer walked down all accessible '

safety-related modifications made during the Unit 2 outage. The architect-engineer also reviewed for completeness the results of our walkdowns. As a result of these walkdowns, only minor discrepancies between the design documents and as-built configurations were discovered. Only one, a labeling deficiency, required correction in the field. For the others, we have corrected the appropriate documents.

Moreover, a Quality Control Inspector independently walked down one hundred twenty-four of tne instruments modified during the outage.

All of the test requirements specified in the safety-related work requests and modifications performed during the outage were reviewed completely. Also, it was verified, prior to restart, that all modified instruments would perform as designed.

3. Training All departments involved conducted informal documented training sessions to discuss the event, its causes, and the corrective actions being ta':en to prevent its recurrence. This training was accomplished in two steps. First, prior to startup, appropriate personnel in the instrument maintenance, electrical maintenance, and operating departments were trained. After startup, relevant personnel in construction, maintenance, technical staff, and quality control, as well as contractor personnel were also trained. At each of these sessions the significance of the events and their unacceptability were emphasized.

We believe that these training sessions have strengthened post-modification testing procedures by increasing awareness of the need to ensure that testing accomplishes its intended function.

CORRECTIVE ACTION TAKEN TO AVOID FURTHER VIOLATION

1. Revised Modification Procedures Our analysis of these events led us to change significantly the station's procedures governing the types of actions involved here.

These chances in procedure substantially strenothen the orocess for ensuring that post-modification tests are adequate.

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The Station's administrative procedure for plant modifications, LAP 1300-2, has been revised as follows:

a. The procedure now explicitly requires the preparation of post-modification tests in accordance with the newly established

" Guidelines for Development of Tests for Modifications" LTP 800-9. These guidelines provide methods for developing tests to ensure that system and component operability are adequately demonstrated after modification. Our confidence in these guidelines is based, in part, on the following new approach incorporated in them. Instead of focusing testing on only modified equipment, testing, where warranted, will now be extended to unmodified parts of a system. By varying input signals at those points in the system and observing the corresponding responses in the modified part of the system we will be better able to verify the operability of the modification. In particular, this procedure would have helped to ensure the proper installation of instrument piping to pressure differential DP type instrumentation.

b. These incidents have also led us to realize the importance of developing in one persun an attitude of responsibility for all aspects of a modification. Accordingly, the procedures now require the cognizant modification engineer to be more involved with the installation and testing of modifications. This greater involvement includes maintaining overall knowledge of a modification's design and status, assuring that design intent is implemented in the modification as installed and monitoring progress on the design, installation and testing of a modification.

2. Checklists These incidents have also demonstrated the limited effectiveness of checklists used to determine system operability. Such checklists were developed after April,1985 in response to an incident involving inoperability of a train of the Standby Gas Treatment System. Although it was believed that such checklists would be adequate, there was only a limited period of time in which to assess the adequacy of those checklists before the June,1985 events occurred. Because experience has now shown that checklists limited to system inoperability are not always adequate, the maintenance and operating departments have developed additional checklists which go beyond previous lists by now requiring some testing at the component level. This consideration of finer levels of detail should aid in the selection of testing requirements adequate to demonstrate operability after either maintenance or. modification. Accordingly, it is believed that these new lists will help to prevent recurrence of these types of events.

3. Review Committee To further ensure the adequacy of tests of safety-related modifications, an additional level of review of post-modification tests for their ability to determine the operability of modified equipment has been established. This review will be conducted by a committee which will include the Technical Staff Supervisor, an Operating Engineer or an Assistant Superintendent, and the cognizant Modification Engineer. This committee will review the adequacy of any modified equipment before it is declared operable.

DATE WHEN FULL COWLIANCE WILL BE ACHIEVED Full Compliance has been achieved. The effectiveness of the Review Committee will be _ evaluated by March,1986 to determine whether the committee should become a permanent part of the post-modification review process.

18. Technical Specification 3.5.2 requires at least two Emergency Core Cooling Systems (ECCS) to be operable in the shutdown condition.

With both of the required subsystems / systems inoperable, one subsystem must be restored to operable status within four hours or secondary containment integrity be established within the next eight hours.

Contrary to the above, with the three ECCS Divisions inoperable on June 5, 1985, secondary containment integrity was not established within eight hours.

ADMISSION OR DENIAL OF THE ALLEGED VIOLATION Commonwealth Edison admits the violation.

REASON FOR THE VIOLATION Same as in Item 1A.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED Secondary Containment integrity had been reestablished before it was discovered that the Division I ECCS Systems were inoperable. No further corrective action was nece sary.

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CORRECTIVE ACTION TAKEN TO AVOID FURTHER VIOLATION Refer to Item 1A.-

' DATE WHEN FLLL COWLIANCE WILL BE ACHIEVED Full' Compliance has been achieved.

IC. 10 CFR Part 50, Appendix B, Criterion VI, as implemented by the

. Commonwealth Edison Company's Quality Assurance Manual, Quality Requirement 6.1, requires that a document control system be used to assure that documents such as drawin's be distributed to and used at the locations where the prescribed activity is performed.

Contrary to the above, Field Change Request 85-123 dated April 4, 1985 was issued to' correct an error in Modification M-1-2-84-136; however, it was not distributed to and used at the location where the prescribed activity was performed. As a result, piping for two switches was installed backwards rendering Division I of the Unit 2 Emergency Core Cooling Systems inoperable.

. ADMISSION OR DENIAL OF TIE ALLEED VIOLATION Commonwealth Edison admits the violation.

REASON FOR THE VIOLATION This violation' resulted from an inadequate document control procedure.

The Station's procedure for controlling Field Change Requests (FCR) did not require the FCR's to list contractor drawings. Therefore, FCR 85-123.did not list all of the drawings for revisions to the instal-lation details for 22 instruments. For 20 of those instruments, the installation details had been revised on the contractor's drawings. For i the remaining two instruments, the contractor's production drawings reflected only the original designs because the drawings had not been

-modified in accordance with the FCR. The FCR had not indicated that those drawings would be affected.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED

.The installation of the two instruments was corrected and tested to demonstrate the proper. reinstallation. To ensure that similar problems had not been missed, all other FCR's nenerated durina the outage were 7

reviewed, and found not to contain any further errors.

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r CORRECTIVE ACTION TAKEN TO AVOID FURTFER VIOLATION To prevent a recurrence of this type of error, we have added mandatory cross-references to the Stations' procedures. Station Administrative Procedure LAP 1300-5 " Field Change Requests" has been revised to require an FCR to include a list of all affected documents / drawings, including contractor production drawings. In addition, both the mechanical and the electrical contractors have prepared and implemented procedures to formalize the control of FCR's and requirements for Quality Control field inspection. These procedures require checks to ensure that FCRs are properly posted to all affected drawings.

DATE WHEN FULL COM3LIANCE WILL BE ACHIEVED Full compliance his been achieved.

10. 10 CFR Part 50, Appendix B, Criterion X, as implemented by the Commonwealth Edison Company Quality Assurance Manual, Quality Requirement 10.1, requires that Quality Assurance inspections be conducted at the site during modification activities to verify conformance to applicable drawings.

Contrary to the above, Quality Assurance inspections were not conducted at the site during Modification M-1-2-84-136 to verify conformance to the applicable drawing (FCR 85-123).

ADMISSION OR DENIAL OF THE ALLEGED VIOLATION Connonwealth Edison admits the violation.

REASON FOR THE VIOLATION This violation resulted from a failure to specify adequate hold points in the instructions for installing modifications.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED All accessible elements of the modifications performed during the outage were completely walked down . To ensure an independent review, this walkdown was conducted by persons who had not been involved with the installations. Moreover, the results of these walkdowns were documented.

It was found that all final installations were in acenrd with the approved final designs.

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• s CORRECTIVE ACTION TAKEN TO AVOID FURTHER VIOLATION Station procedures have been substantially modified to ensure that inspections will be conducted during modification activities. LaSalle has developed and implemented an administrative procedure LAP 1700-3,

" Guidelines for Quality Control Hold Points". This procedure provides guidance to Station Quality Control and Contractor Quality Control personnel in establishing hold points. That guioance requires mandatory hold points for field inspections to verify that safety related modifications have been installed in accordance with approved drawings and specifications.

DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full Compliance has been achieved.

IE. 10 CFR Part 50, Appendix B, Criterion XI, as implemented by the Commonwealth Edison Company Quality Assurance Manual, Quality Requirement 11.1, requires that the test program include those tests necessary to demonstrate that systems will perform satisfactorily in service following plant maintenance or modifications.

Contrary to the above, Operational Test LIS-N8-204 performed following U1e completion of Modification M-1-2-84-136 did not adequately demonstrate system operability in that the test only verified the instrument and electrical connections. The piping configuration of the reactor pressure vessel water level reference and variable legs was not verified.

ADMISSION OR DENIAL OF THE ALLEGED VIOLATION Commonwealth Edison admits the violation.

REASON FOR THE VIOLATION This violation resulted from an inadequate post modification test which was improperly limited to testing the instrument and its electrical connections.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED l To ensure that similar problems in other equipment had not been l overlooked, all safety-related instrumporation m,dified durinn tha outage was retested. The retests verified correct instrument response to varying process parameters. All installation errors identified were corrected and retested to verify that the final "as installed" plant condition reflected the "as designed" condition.

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l' CORRECTIVE ACTION TAKEN TO AVOID FURTE R VIOLATION We believe that the new procedures discussed above in Item I.D will prevent a recurrence of this event. Those procedures, especially the new guidelines for identifying adequate post-modification tests and, in the interim, the committee review of those tests for adequacy, should ensure that all relevant parameters are tested and verified.

DATE WHEN FULL COW LIANCE WILL BE ACHIEVED Full Compliance has been achieved.

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2A. Technical Specification 3.3.2 requires the isolation actuation instrumentation channels shown in Table 3.3.2-1 to be operable with their trip setpoints set consistent with the values shown in Table 3.3.2-2. The Residual Heat Removal (RHR) shutdown cooling pump suction high flow instrumentation is included for Operating Conditions 1, 2, and 3. Technical Specification 3.3.2.c. requires that with the number of operable channels less than the minimum operable channels per trip system required for both trip systems, place at least one trip system in the tripped condition within one hour and take the action required by Table 3.3.2-1. Action Item 25 of Table 3.3.2-1 requires the isolation valves to be closed and locked for the RHR shutdown cooling mode and the system to be Jeclared inoperable.

Contrary to the above, from April 7, 1985 until July 12, 1985, while the plant was in Operating Conditions 1, 2, and 3, the Unit 1 RHR shutdown cooling pump suction high flow sensors would not have met the designated isolation setpoint in that the isolation actuation instrumentation channels were inoperable. With the channels inoperable, the actions required by Action Item 25 of Table 3.3.2.1 were not taken. The isolation valves were not closed and locked for the RHR shutdown cooling mode and the system was not declared inoperable.

ADMISSION OR DENIAL OF THE ALLEGED VIOLATION Commonwealth Edison admits the violation.

REASON FOR THE VIOLATION This violation resulted fran our reliance on post-modification tests which did not accurately determine the operability of the RHR Shutdown Cooling High Flow isolation switches.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED The discovery of the inoperable switches was made when the plant was in an Operational Condition which did not require those switches to be operable. Accordingly, no immediate action was required. Before entering an Operational Condition in which those switches were required to be operational, the piping errors were corrected, and it was verified that the switches could perform their isolation functions, rn4RfrTTvF Ar*TinN TAL'FM TO AVOIO FURTHER VIOLATION Refer to Item 1A.

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DATE WHEN FlLL C0bPLIANCE WILL BE ACHIEVED Full Compliance has been achieved.

2P. 10 CFR Part 50, Appendix B, Criterion VI, as implemented by the Commonwealth Edison Company's Quality Assurance Manual, Quality Requirement 6.1, requires that a document control system be used to assure tha*. documents such as drawings, be distributed to and used at the locations where the prescribed activity is performed.

Contrary to the above, Drawing Change Request 7383, issued to document a piping change to Modification M-1-1-82-054, was not distributed to and used in the development of Modification M-1-1-84-091. As a result, the Unit 1 Regenerative Heat Removal shutdown (RHR) pump cooling suction flow isolation channels were inoperable during power operations from April 7, 1985 until the unit was shutdown on July 12, 1985.

ADMISSION OR DENIAL OF THE ALLE ED VIOLATION Commonwealth Edison admits the violation.

REASON FOR THE VIOLATION This violation resulted from the failure to ensure that changes to the plant were reflected on current plant drawings. The violation occurred as described below.

On May 10, 1982 it had been discovered that the original flow switches lE31-N012A and lE31-N0128 were piped backwards due to the High and Low Process Lines being reversed inside the Suppression Pool. Accordingly, WR #L15576 and modification #M-1-1-82-054 were issued to correct the piping and (in addition) install pressure snubbers. Snubbers were added and the repiping was performed by reversing the tubing locally at the instrument rack. Upon satisfactory resolution of M-1-1-82-054, Drawing Change Request #73-83 was submitted to reflect: (1) The inclusion of pressure snubbers, and (2) the changes to the process line, root valve, and Excess Flow Check Valve numbers associated with lE31-N012A and B (with the Drywell Penetration Numbers remaining the same). Based on their request for more information with regard to the snubber installa-tion, the Architect Engineer (A/E) rejected DCR 73-83. OCR 73-83 (which included the revised drawing #M-2096-5) was inadvertently closed out without the appropriate changes being made. Therefore, when lE31-N012A and R warp rpmnvad and later rpnlanaq hy IFT1 uni?an/DA/Aa/RA, their process inputs (High vs Low) became crossed, due to drawing #M-2096-5 having never been revised.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED Our investigation of the situation revealed that it had resulted from a failure to properly complete action on a Drawing Change Request (DCR).

To ensure that similar problems had not been overlooked, the Station's, the Architect Engineer's (A/E), and the Station Nuclear Engineering Department's (SNED), Drawing Change Request logs were reviewed to identify DCRs which had been rejected or cancelled. All rejected, open or cancelled DCR's were verified to reflect properly on the critical drawings and/o' r the appropriate drawing aperture cards. No further discrepancies were found. The DCR for Modification M-1-1-84-91 reflected the previously rejected drawing change request.

CORRECTIVE ACTION TAKEN TO AVOID FURTHER VIOLATION This incident alerted us to a procedural deficiency in our handling of DCR's. On that basis, SNED initiated a review of its procedure for control of DCR's. This review indicated that SNED had revised its DCR procedure in August 1984 to provide a specific procedure for handling DCRs rejected or cancelled by the A/E. This procedure was not in effect at the time this incident occurred. It is believed that the current procedure will prevent the recurrence of a similar problem.

DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance has been achieved.

< 2C. 10 CFR Part 50, Appendix B, Criterion XI, as implemented by the Commonwealth Edison Company Quality Assurance Manual, Quality Requirement 11.1, requires that the test program include those tests necessary to demonstrate that systems will perform satisfactorily in service following plant maintenance or modifications.

Contrary to the above, the post-installation testing performed following the completion of Modification M-1-1-84-091 did not adequately demonstrate system operability in that the test did not detect that the Regenerative Heat Removal pump suction high flow

. isolation switches were piped backwards prior to returning the instruments to service.

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' ADMISSION OR DENIAL OF THE ALLEED VIOLATION Commonwealth Edison admits the violation.

REASON FOR THE-VIOLATION See Item 2A.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED See Item 2A.

CORRECTIVE ACTION TAKEN TO AVOID FURTHER VIOLATION Refer to Item 1A.

DATE WHEN FULL COWLIANCE WILL BE ACHIEVED Full Compliance has been achieved.

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3. '10 CFR Part 50, Appendix B, Criterion XI, as implemented by the Commonwealth Edison Company Quality Assurance Manual, Quality Requirement 11.1, requires that the test program include those tests necessary to demonstrate that systems will perform satisfactorily in service following plant maintenance or modifications.

Contrary to the above, during this inspection period, the operability test for two Unit 2 shutdown cooling high flow isolation switches was not performed correctly. Specifically, walkdown of the piping

'to these switches identified no problems although the piping to the switches was installed backwards. This error was discovered by an alternate test that was not specified for proof of operability testing.

, ADMISSION OR DENIAL OF THE ALLEGED VIOLATION Commonwealth Edison admits the violation.

REASON FOR THE VIOLATION As a result of previously identified installation errors a system

. walkdown was designated in June, 1985 as corrective action to verify that all piping was installed in accordance with design drawings modified during the outage. A Technical Staff Engineer was assigned to perform.a walkdown of the RHR Shutdown Cooling pump suction high flow isolation switches. The Engineer who performed the walkdown had traced the piping to a wall penetration and when he went to the other side of the wall he reoriented himself with informal markings on the piping which were reversed. The remainder of the inspection was performed utilizing the reversed reference.

CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED Our investigation to determine the cause of the walkdown error identified the problems that could have contributed to it. As a result, a second walkdown of all process instrumentation piping which penetrated walls was conducted by two Technical Staff personnel, one on either side of the wall. Moreover, all differential pressure instrumentation was verified by performing a second test by varying the process which the .

instrumentation measured. The piping was corrected and it was verified that the installation was correct by conducting a retest which measured flow in the system.

CORRECTIVE ACTION TAKEN TO AVOID FURTHER VIOLATION Refer to Item 1A.

-OATE WEu r:1L com LInwrc wits _ w Am IEyEO Full Compliance has been achieved.

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