ML20137P391

NRC Closed Predecisional Enforcement Conference,St Lucie Nuclear Plant

ML20137P391
Person / Time
Site:	Saint Lucie
Issue date:	12/10/1996
From:	NRC
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ML20137P228	List: ML20137P226 ML20137P236 ML20137P391 ML20137P440 ML20137P509 ML20137P533 ML20137P565 ML20137P589 ML20137P595 ML20137P609 ML20137P624 ML20137P631 ML20137P647 ML20137P675 ML20137P686 ML20137P700 ML20137P714 ML20137P719
References
FOIA-96-485 NUDOCS 9704090243
Download: ML20137P391 (65)

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{{#Wiki_filter:' r,. J ? i NRC. CLOSED PREDECISIONAL ENFORCEMENT CONFERENCE-ST. LUCIE NUCLEAR PLANT 1 1 DECEMBER.10, 1996 i J 9704090243 970407 P PDR FOIA BINDER 96-40S PDR ,.a

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l l OPENING REMARKS AND INTRODUCTIONS (S. Ebneter) Good morning. I am Stew Ebneter. Regional Administrator for the Nuclear Regulatory Commission's Region II Office. This morning we will conduct a predecisional enforcement conference between the NRC and St. Lucie which is CLOSED to public observation. The agenda for the predecisional enforcement conference is shown in the viewgraph. Following my brief opening remarks. Mr. Bruno Uryc the Director of the Region II Enforcement Staff, will discuss the Agency's Enforcement Policy. I will then provide introductory remarks concerning my perspective on the events to be addressed today. Mr. Albert Gibson. Director of the Division of Reactor Safety, will then discuss the apparent violations. You will then be given an opportunity to respond to the apparent violations. In this regard. I wish to reiterate to you that the decision to hold this conference does not mean that the NRC has determined that a violation has occurred or r that enforcement action will be taken. This conference is an important step in arriving at that decision. L.

Following each presentation. I plan to take about a 10-minute break so that the NRC can briefly review what it has heard and determine if we have follow-up questions. Lastly. I will provide concluding remarks. At this point. I would like to have the NRC staff introduce themselves and then ask you to introduce your participants. j [ INTRODUCTIONS] Thank you. Mr. Uryc will now discuss the Agency's Enforcement Policy. ) 4 l

l l NRC ENFORCEMENT POLICY I will provide some background information on the enforcement process for those who might not be familiar with the process. The NRC Enforcement Program is governed by the Commission's Enforcement Policy. (NUREG 1600). For those who desire, we have copies of the Enforcement Policy available on'the table behind me. Following an inspection. the inspector's findings are reviewed and if a determination is made that the findings constitute an apparent violation, the apparent violation is initially categorized into one of four severity levels based on safety and regulatory significance. For cases where there is a potential for escalated enforcement action, that is, where the severity level of the apparent violation may be at a severity level I. II, or III. a predecisional enforcement conference is normally held. Copies of the inspection report for the issues to be discussed today are also provided on the table. f l

2 A predecisional enforcement conference is essentially the last step of the inspection process before the staff makes an enforcement decision. The purpose of a predecisional enforcement conference is not to negotiate a sanction. Our purpose bere today is to obtain information that will assist us in determining the appropriate enforcement action, such as: (1) a common understanding of the facts, root causes and missed opportunities associated with the violations. (2) a common understanding of corrective action taken or planned. and (3) a common understanding of the significance of issues and the need for lasting comprehensive action. At the predecisional enforcement conference stage of the process, we want to be sure the licensee understands the significance of the issues and is taking effective corrective action. We are seeking information that may be relevant 1 to either mitigation or escalation of any resulting sanction, as well as determining the licensee's position on the findings in the inspection report. which was provided in advance of the conference. We are interested in whether the licensee is challenging the factual findings in the report or the apparent violations and if so, the basis for any such disagreement. Licensees are encouraged to provide any information they believe is relevant to an enforcement decision. The appt W. violations discussed at the conference are subject to further reviee. > ine NRC. They are subject to change prior to any resulting enforcement action. It is 1mportant to note that the decision to conduct the conference does not mean that NRC has determined that a violation has occurred 1 j or that enforcement action will be taken. I should also note that statements l ) l

3 or opinions made by NRC staff'at the conference, or silence in response to a licensee statement. should not be taken as an NRC position. There are three primary enforcement sanctions available to the NRC and they are Notices of Violation, civil penalties, and orders. Notices of Violation and civil penalties are issued based on identified violations. Orders may be issued for violations, or, in the absence of a violation, because of a significant public health or safety issue. Following this conference, the Regional Administrator in coordination with the NRC Office of Enforcement and other Headquarter's offices will reach an enforcement decision. This process normally takes four weeks to accomplish. Finally, if the final enforcement action involves a proposed civil penalty or an order. the NRC will issue a press release 24 hours after the enforcement action is issued.

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SUMMARY

OF THE ISSUES (S. Ebneter) This enforcement conference is to address apparent violations in three functional areas, i.e., security, emergency response organization and engineering. Each.of the apparent violations represents an issue with which we have significant regulatory concern. For the security issues, your Access Control Program has resulted in a failure to prevent unauthorized individuals from gaining access into the St. Lucie facility. Upon discovery of the deficiencies, you failed to report the unauthorized access into the protected area within one hour and log related events. As a consequence, one unauthorized individual entered the protected area, and had the potential to ~ enter the vital areas, and five other unauthorized individuals could have had access to both the protected and/or vital areas. It appears that human resources and plant supervisors failure to follow procedures and notify security when personnel were terminated largely contributed to the above i deficiencies. With regard to your emergency preparedness organization we are concerned that the_ issues under consideration represent a breakdown in management control of the emergency preparedness program for the St. Lucie Plant. We are further concerned that you missed opportunities to take corrective actions for many of the findings from this inspection as these issues were identified to you by members of your staff during the past two years. Regarding the engineering issue, you installed a modification to the nuclear instrumentation system that was not thoroughly reviewed by an independent party. As a result, the modification resulted in cross-wiring of the system.

... = -.. = 2 Lack.of independent review of modifications could lead to a loss of design basis configuration. ~ Further, you did not properly conduct an independent v' rification of a new computer code used for core monitoring. Again, e independent verification' is essential in assuring that the plant is configured consistent with your license. 9 At this point I will turn over the discussions to Al Gibson who will discuss each of these issues in detail. We will proceed with the security issue first, complete it and then move on to the emergency preparedness issue and the engineering issue. I

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STATEMENT OF CONCERNS / APPARENT VIOLATIONS (A. Gibson) This is a predecisional enforcement conference to discuss three apparent violations. The first issue is associated with the failure of your Access Control Program to prevent unauthorized individuals gaining access into the St. Lucie facility. As a result of that failure, one unauthorized individual did gain access to the protected area, and also had potential to enter vital -areas. Additionally, five other unauthorized individuals could have gained access to both protected and vital areas. The apparent violations were identified during an inspection performed between October 21 and 25.19%. In addition io the violations, we are concerned that corrective action for a St. Lucie Cc.dition Report issued on August 19. 1996. which identified access control problems, did not identify the extent of the problem and prevent further deficiencies from occurring. We are also concerned that your failure to report the event in one hour is a repeat of a previous reportability violation, which was identified in Inspection Report 96-16. Our inspection findings are documented in Inspection Report 96-19 which was transmitted to you on November 15, 1996. At this conference we are affording you the opportunity to provide inforretion relative to: --- Any errors in the inspection report --- The severity of the violations --- Any escalation or mitigation considerations --- Any other application of the Enforcement Policy relevant to this issue. 9

APPARENT VIOLATIONS PREDECISIONAL VIOLATION A 10 CFR 73.55(7) requires that licensee's shall establish an access authoFization system to limit unescorted access to vital areas during non-emergency conditions to individuals who require access in order to perform their duties. The licensee's Physical Security Plan (PSP). Revision 48. dated 2/23/96 states. "Only those individuals with identified need for access and having appropriate authorization, shall te granted unescorted Vital Area access." ~ From July 28. 1996 to September 19. 1996 an individual whose employment terminated on July 28, 1996, had unescorted access to protected and vital areas without appropriate authorization. In addition, on August 7: August 9: and August 15. 1996, that individual entered the protected area and had access to vital areas. Also. five other individuals had unescorted access to the protected and vital areas after they were terminated from the period of July 27 to September 19, 1996. without appropriate authorization. However, those individuals did not access the protected or vital areas. NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision. i

4 APPARENT VIOLATIONS PRE 0ECISIONAL VIOLATION B 10 CFR 73. Appendix G. states that an actual entry of an unauthorized person into a protected area or vital _ area be reported within one hour of discovery. 10 CFR 73. Appendix G. states that any failure, degradation, or discovered vulnerability in a safeguards system that could have allowed unauthorized or undetected access to a protected area or a vital' area had compensatory measures not been established, be recorded within 24 hours of discovery in the safeguards event log. On October 9.1996. the licensee discovered that an individual had been terminated on July 28.1996. and had entered the protected area on five different occasions. yet failed to make a report within the one hour timeframe. In addition, on September 19, 1996, the licensee discovered three individuals who had previously been terminated on July 27. July 28. and August

24. 1996 that had access to the protected area and failed to report that discovery in the safeguards event 109 NOTE: The apparent violation discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision.

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STATEMENTOFCONCERNS/APPARENiVIOLATIONS (A. Gibson) The second predecisional enforcement conference concerns three apparent violations and a related apparent deviation in the area of emergency preparedness. The three apparent violations involve (1) failure to adequately maintain the capability for timely augmentation of your Emergency Response Organization during off-hours. (2) failure to establish and maintain adequate orocedures for the. implementation of certain requirements contained in the ladiological Emergency Plan, and (3) failure to adequately implement multiple aspects of your training program for Emergency Response Organization personnel. The apparent deviation involves the failure to relocate the requirements formerly found in TS 6.8.1.d and 6.8.1.e to the Security Plan or Emergency Plan. as applicable, in accordance with a written commitment to the NRC. Dur inspection findings are documented in Inspection Report 96-18, which was l transmitted to you on November 26. 1996. At this conference we are affording you the opportunity to provide information relative to: --- Any errors in the inspection report --- The severity of the violations --- Any escalation or mitigation considerations --- Any other application of the Enforcement Policy relevant to this issue.

l - APPARENT VIOLATION A. PREDECISIONAL 10 CFR 50.54(q) requires that nuclear power plant ~ licensees follow and maintain in effect emergency plans which meet the planning standards of 10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR Part 50. Section 2.4 of. the licensee's Radiological Emergency Plan (REP). Revision 31. states that activation of the Technical Support Center (TSC) and the Operational Support Center (OSC) will be initiated by the Emergency Coordinator in the event of an Alert. Site Area Emergency. or General Emergency. and that arrangements have been made to staff the TSC and OSC in a timely manner. Also specified is that activation of the Emergency Operations Facility (E0F) is required for a Site Area Emergency or General Emergency, and i that' arrangements have been made to activate the EOF in a timely manner. The REP requirements delineated above are implemented in part by Emergency Plan Implementing. Procedure (EPIP) 3100023E. "On-Site Emergency Organization and Call. Directory". Revision 72. The instruction in Section 8.2 of that procedure states that, upon the declaration of an emergency classification. "the Duty Call Supervisor will initiate staff augmentation" using the " Emergency Recall System or Appendix A. Duty Call Supervisor Call Directory to noti fy persons... " l From approximately July 22 to October 3.1996.-arrangements were not available to staff or activate the TSC. OSC. or EOF in a timely manner because the licensee did not have the capability to adequately implement either the primary method (using the Emergency Recall System) or the backup method (using the Duty Call Supervisor Call Directory) for notifying its personnel during off-hours to staff and activate the TSC. OSC, and EOF. NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision. l I

3 APPARENT VIOLATION B PREDECISIONAL As of August 19. 1996. Technical Specification (TS) 6.8.1.e required that written procedures be established, implemented, and maintained covering Emergency Plan implementation. (The subject TS was deleted with NRC approval effective August 20. 1996. but these examples of inadequate EPIPs existed in the same form prior to August 20. 1996 as when identified during the inspection.) Procedures covering Emergency Plan implementation were not adequately established. implemented, and maintained with respect to the following aspects of the Emergency Plan; a. recovery activities, as discussed conceptually in REP Section 5.4 b. description and delineation of the licensee's emergency response organization (ERO) and the detailed means for notifying ERO members in an emergency, as discussed generally in REP Section 2.2 I relocation of the OSC if required by radiological or other adverse c. conditions during an emergency, as referenced in REP Section 2.4.4-NOTE: The apparent violations discussed.in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision. i t i i l 6

APPARENT VIOLATION C PREDECISIONAL 10 CFR 50.54(g) requires that nuclear power plant licensees follow and maintain in effect emergency plans which meet the planning standards of 10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR Part 50. REP Section 7.2.1. " Objectives". stated the following: "The primary objectives i of emergency response training are as follows: 1. Familiarize appropriate individuals with Emergency Plan and related implementing procedures. 2. Instruct individuals in their specific duties to ensure effective and expeditious action during an emergency.

3. Periodically present significant changes in the scope or content of the Emergency Plan.

4. Provide refresher training to ensure that personnel are familiar with their duties and responsibilities." REP Section 7.2.2. " Training of On-Site Emergency Response Organization [ER0] Personnel". states. "The training program for members of i

the on-site emergency response organization will include practical drills as appropriate and participation in exercises, in which each individual demonstrates an ability to perform assigned emergency functions... For employees with specific assignments or authorities as members of emeraency teams, initial training and annual retraining 3rograms will be provided. Training must be current to be maintained on tie site Emergency Team Roster." REP Section 7.3.2 states. "The Plant Training Manager will ensure that on-site Emergency Response Organization personnel are informed of relevant changes in the Emergency Plan and Emergency Plan Implementing Procedures (EPIPs]." i a. In 1994, the licensee failed to provide initial training or annual retraining for 17 positions (approximately 92 individuals) identified as part of the on-site response organization. In 1995, the licensee failed to provide initial training or annual retraining for 8 positions (approximately 54 individuals) identified as part of the on-site response organization. i b. The licensee's training program failed to include initial training or annual retraining on all procedures required to be implemented by ERO personnel in several identified positions. Examples: EPIP 3100027E. "Re-entry" - En=rgency Coordinator Radiation Team Leader. OSC Supervisor. Re-entry Team Supervisor, Re-entry Team Member. OSC Status Board Keeper, and OSC Dose Recorder. EPIP 3100026E. " Criteria for and Conduct of Evacuation" - Emergency Coordinator. Assembly Area Supervisor, and TSC Security Supervisor. EPIP 3100035E. "Off-site Radiation Monitoring" - Radiation Team Leader and TSC Supervisor. The Plant' Training Manager failed to ensure that ERO personnel in several identified positions were informed of relevant changes in procedures. Example: EPIP 3100026E. " Criteria for and Conduct of Evacuations" c. For the calendar year 1995, the licensee failed to remove from the emergency response organization two individuals who had not completed retraining as required. and whose qualifications had expired in 1994. The licensee also failed to remove six individuals from the emergency team roster effective October 6.1996, who hsd not remained qualified to fill response team requirements as a result of allowing their respirator qualifications to lapse.

APPARENT DEVIATION PREDECISIONAL Amendment Nos. 147 and 86 to the operating licenses for Units 1 and 2. respectively, were approved by the NRC on August 20. 1996, and consisted of changes to the TS in response to the licensee's application dated August 16. 1995. Among numerous changes in these amendments were the deletion (for both Units 1 and 2) of the previous TS 6.8.1.d and TS 6.8.1.e. which formerly specified that " Written procedures shall be established. implemented and maintained" to cover " Security Plan implementation" and " Emergency Plan implementation", respectively. In Attachment 2. " Safety Analysis", to the August 15, 1995 application, the licensee stated (in the introduction to the section addressing modifications to TS 6.5.1.6.1. 6.5.1.6.J. 6.8.1.d. and 6.8.1.e) that the " selected Technical Specifications are being relocated to the Emergency Plan or Security Plan as appropriate. Relocating these requirements to the appropriate plan will ensure the control of future changes are under the requirements of 10 CFR 50.54, 10 CFR 73.55 and 10 CFR 73.56." The NRC's referenced approval of the subject application stated that the " licensee proposes to reiocate these review requirements and their implementing procedures to the St. Lucie Security and Emergency Plans..." The licensee failed to relocate the requirements formerly found in TS 6.8.1.d and 6.8.1.e to the Security Plan or Emergency Plan, as applicable in accordance with the comitment to the NRC contained in the licensee's application dated August 16, 1995. NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision. f' l L i

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STATEMENT OF CONCERNS / APPARENT VIOLATIONS (A. Gibson) The third predecisional enforcement conference concerns apparent violations regarding installation of a modification to your nuclear instrumentation system. Upon reaching 100% power your staff identified conditions inconsistent with expected parameters. Further investigation revealed that the modification was incorrectly designed such that electrical drawers which process the nuclear instrumentation signals were cross-wired. We are concerned about the failure of your design control process and about the potential impact of this failure implies on other design products. We are also concerned that the miswiring and calibration errors were not identified earlier based upon questions raised by control room operators. With regard to the third violation, we are concerned that a Condition Report was not written when the marking discrepancy was discovered and about the potential impact on quality if Condition Reports have not been written as required for other discrepant conditions. Our inspection findings are documented in Inspection Report 96-22 which was transmitted to you on November 26. 1996. At this conference we are affording you the opportunity to provide information relative to: --- Any errors in the inspection report --- The severity of the violations --- Any escalation or mitigation considerations --- Any other application of the Enforcement Policy relevant to this issue. 1

APPARENT VIOLATIONS PREDECISIONAL VIOLATION A 10 CFR 50. Appendix 8. Criterion III. Design Control, requires, in part. that measures be established to ensure that the design basis is correctly translated into drawings and that design control measures provide for verifying the adequacy of the design by individuals other than those who performed the original design. FPL Topical Quality Assurance Report. TOR 3.0. Revision 11. " Design Control." Section 3.2.4. " Design Verification." stated. in part. " Design control measures shall be established to independently verify design input... Design verification shall be performed by technically qualified individuals or groups other than those who performed the design.~ Engineering Quality Instructions (01) 1.7. Design Input / Verification, dated July 5.1995, states, in part that " Design verification is the process whereby a competent individual, who has remained independent of the design process, reviews the design inputs.... and design output to verify design adequacy. This independent review is provided to minimize the likelihood of design errors in items that are important to nuclear safety." 1) On July 30. 1996. it was discovered that a design change (PC/M 009-195) to install new nuclear instrumentation system drawers did not receive an independent design verification by a competent individual inde)endent of the design process. Lesign change PC/M 009-195 was completed ay a lead designer and a lead engineer. This design change was independently verified by a second designer who had no s)ecial knowledge of the design. The design was then approved by t1e lead engineer whom was not independent of the design process. 2) On July 30, 1996, it was discovered that an independent design review was not conducted for the installation of a new core flux monitoring computer code BEACON. During initial operation of BEACON it was found that the code did not compensate for a core mid-plane offset created by a previous core modification. The engineer who prepared the design was not aware of the core mid-plane offset and the lack of an independent review of the new BEACON code did not provide the opportunity to identify this omission. NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision.

-l VIOLATION B PREDECISIONAL Technical Specification 6.8. Procedures and Programs, paragraph 6.8.1 requires. in part that written procedures recomended in Appendix A of Regulatory Guide 1.33 revision 2. February 1978, shall be established and implemented. Engineering Quality Instruction (01) 3.7. Com) uter Software Control. Revision

1. Section 5.4. requires that 50A1 software s1all be validated and verified (V&V'ed) in accordance with Section 5.6 of 01 3.7.

Section 5.6 states that new software shall.be V&V*ed prior to use. The V&V process includes the use of test cases to ensure the new software produces correct results. Item 4 of Section 5.6 states that technical adequacy.shall be determined by comparing the test case to results from alternative methods such as functionally equivalent and previously validated software. During the Unit 1 Cycle 14 outage. BEACON core monitoring system was placed into service on Unit I without any benchmarking against IMPAX. the on-line core performance monitoring code BEACON was replacing. Instead. BEACON was installed on Unit 2 and benchmarked against CECORE, the core monitoring system installed on Unit 2. which did not require any modifications to accomodate the core midplane offset. NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision.

VIOLATION C PREDECISIONAL Technical Specification 6.8. Procedures and Programs. paragraph 6.8.1. requires in part that written procedures recommended in Appendix A of Regulatory Guide 1.33 revision 2. February 1978, shall be established and implemented. Administrative Procedure No. 0006130. Condition Repnrts. Revision 4. dated March 22,1996. Par. 8.1.1. A states in part that "Any individual who becomes aware of a problem or discrepant condition... should initiate a CR. If doubt exists. a CR form should be initiated". On July 30. 1996. Instrument and Control technicians installing Modification PC/M 009-195 did not initiate a Condition Report when they became aware of a discrepant condition when markings for electrical terminal connectors differed from existing cable markings. The failure to resolve the discrepant condition resulted in incorrectly installing two excore nuclear instrumentation system detectors. NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision. l 1 l

ENFORCEMENT ACTION WORKSHEET INFORMATION REQUIRED TO BE AVAILABLE FOR ENFORCEMENT PANEL ST. LUCIE UNAUTHORIZED ACCESS PREPARED BY: Lori Stratton DATE: 10/30/96 NOTE: The Section Chief of the responsible Division is responsible for preparation of this questionnaire and its distribution to attendees prior to an Enforcement Panel. The Section Chief shall also be responsible for providing the meeting location and tele) hone bridge number to attendees via e-mail [ENF.GRP. CFE. OEMAIL. JXL. JRG. SiL. LFD: appropriate RII DRP. DRS: appropriate NRR. NMSS]. A Notice of Violation (without "boilerplate") which includes the recommended severity level for the violation is required. Copies of applicable Technical Specifications or license conditions cited in the Notice or other reference material needed to evaluate the proposed enforcement action are required to be enclosed. This Notice has been reviewed by the Branch Chief or Division Director and each violation includes the appropriate level of specificity as to how and when the requirement was violated. Signature 1. Facility: St. Lucie Unit (s): 1 and 2 Docket Nos: 50-335. 50-389 License Nos: DPR-67. NPE-16 Inspection Report No: 96-19 Inspection Dates: 10/21 - 10/25/98 Lead Inspector: L. Stratton 1. Brief Summary of Inspection Findings: A. 10 CFR 73.55(7) requires that licensee's shall establish an access authorization system to limit unescorted access to vital areas during non-emergency conditions to individuals who require access in order to perform their duties. The licensee's Physical Security Plan (PSP). Revision 48, dated 2/23/96 states. "Only those individuals with identified need for access and having appropriate authorization shall be granted unescorted Vital Area access." Contrary to the above, from July 28. 1996 to September 19, 1996 an individual whose employment terminated on July 28, 1996. had unescorted access to protected and vital areas without appropriate authorization. In addition, on August 7: August 9: and August 15, 1996, that individual entered the protected area and had access to vital areas. PREDECIsIONAL ENFORcEENT INFORMATION NOT FOR PL2LIC RELEASE WO APPROVAL OF DIRECTDR. OE

ENFORCEMENT ACTION 2-1 i WORKSIEET g

Also, other individuals had unescorted access to the protec and vital areas after they were terminated from the period of July 27 'to September 19. 1996.'without appropriate authorization. However, those individuals did not access the protected or vital areas.

B. 10 CFR 73. Appendix G. states that an actual entry of an unauthorized person into a protected area or vital area be i . reported within one hour of discovery. 10 CFR 73. Appendix G.. states that any failure, degradation, or discovered vulnerability in a safeguards system that could have allowed unauthorized or undetected access to a protected area or a . vital area had compensatory measures not been established, be recorded within 24 hours of discovery in the safeguards event 109 Contrary to the above on October 9. 1996, the licensee discovered that an individual had been terminated on July 28, 1996, and had entered the protected area on five different occasions, yet failed to make a report within the one hour timeframe. In addition, on September 19. 1996. the licensee discovered three individuals who had previously been terminated on July 27. July 28. and August 24, 1996 that had access to the protected area and failed to report that discovery in the safeguards event 109 2. Analysis of Root Cause: Violation A: Responsible organizations failure to adhere to Administrative Procedure (AP) 0010509. " Personnel and Haterial Control." Revision 18. dated 9/30/96 and notify security when individuals were terminated.

Also, those organizations' inadequate review of the 31 day vital area access lists.

Violation B: i Security's failure to implement Security Procedure (SP) 0006125. " Report of Safeguards Events." Revision 10. dated 10/9/96. 'i 3. Basis for Severity Level (Safety Significance): [ Include example from the supplements, aggregation. repetitiveness, willfulness, etc.] Violation A:< Supplement III. SL III The NRC' Enforcement Policy states as example. "A failure or inability to control access through established systems or procedures. such that an unauthorized individual (i.e., not authorized unescorted access to the protected area) could easily gain undetected access into a vital area .from outside the protected area." i PREDECISIONAL ENRRcDENT INF0DETION

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i l ENFORCEENT ACTION 3-WORKSHEET Violation 8: Supplement III. SL III Th NRC Enforcement Policy states in Section 7.10. "The severity level assigned to the licensee's failure to submit a required, acceptable, and timely report on a violation that occurred at the licensee's facility is normally the same as would be assigned to the violation that should have been reported. However, the severity level for submitting a late report may be reduced, depending on the individual circumstances. NOTL-This is a first repeat of this violation with respect to failure to n.ake a one hour report. 4. Identify Previous Escalated Action.Within 2 Years or 2 Inspections? [by EA# Supplement, and Identification date.] 95-180: PORVs Inoperable Due To Personnel Error. SL III 96-040: Dilution Event: SL III i 96-249: Multiple Examples of Inadequate 50.59 Reviews: SL III 5. Identification Credit? [ Enter Yes or No]: No Consider following and discuss if applicable below: a Licensee-identified a Revealed through event a NRC-identified a Mixed identification a Missed opportunities Violation A: Security immediately removed the. individuals' access when discovered. However. The licensee missed an opportunity to evaluate their access program on 8/19/96, when Condition Raport (CR) 96-2041 was issued. This CR identified that an individual was presented a FPL severance package and his access was still valid 12 days later. In addition, although Security did remove the individuals' access authorization, they missed an opportunity to validate that those individuals did not use their unauthorized access from the date of their respective terminations. Violation B: Several missed opportunities with respect to reportability occurred at St. Lucie. (a) The security access coordinator on September 19 failed to notify any other personnel when he discovered three individuals had unauthorized access. Therefore, the event was not logged in the safeguards event log. (b) When the security access coordinator learned on October 9 that one of the individuals he had earlier identified as having unauthorized access actually entered the protected area, he did notify his supervisor. However, the event was neither one hour reported nor logged in the safeguard event log. (3) When the Security Manager learned of the event of October 11. a deturmination was made to put the event in the safeguards event log rather traen make a one hour report. The event was eventually reported on October 16. PREDECIsIONAL ENFORCD M INFORMATION. NOT FOR PUBLIC RELEASE W/0 APPRoWAL OF DIRECTOR OE

ENFORCEENT ACTION ,4-WORKSHEET A possibility exists that if the individual did not apply for a position at Turkey Point and had his processing.for that position conducted by the St. Lucie staff for convenience purposes the problem would not have been identified. '(See attached chronology for more specific details). Enter date Licensee was aware of issues requiring corrective action: Violations A and B: September 19.19% 6.- Corrective Action Credit? [ Enter Yes or No): No. Brief summary of-corrective actions: Violation A: Security imediately removed the individuals' unescorted access to the protected and vital areas. FP&L inter-office correspondence dated October 25 to all responsible organizations that by COB 10/30/96, an access review and certification that all individuals listed on the attached access lis,ts are valid. A comparison of a listing of 594 terminated individuals to the security computer to. verify that unescorted access was correct, which was started October 17 and completed October 31. Out of those 594. three more individuals were identified. Two individuals were identified for Turkey Point and one individual was identified with unauthorized access to both facilities. However, an inadequate assessment of CR 96-2041 which resulted in 'no specific corrective action could have identified to the licensee a problem existed as early as 8/19/96. Also.again on 9/19/96. when the access coordinator discovered the three individuals who had unauthorized access. Finally on October 9 when the licensee discovered an individual had entered the 3rotected area after termination, the licensee once again should lave identified a problem existed with respect to terminations and unescorted access. Not until the period of October 16, when the event was called to the NRC to October 25..when CR 96-2496 was generated, did the licensee recognize a significant problem existed. Violation B: The' licensee did eventually determine a one hour report was warranted. No other corrective action had been initiated. The corrective. action generated by the violation cited in IR 96-16 was partially complete when the events ' occurred and fully completed prior to the PREDEcISIONAL ENFORcDefT INFONMT10N NOT FOR PLSLIC RELEASE WO APPROVAL OF DIRECTOR OE

ENFORCEMENT ACTION ' WORKSHEET finish of the inspection. However, the corrective action for IR 96-16 was to change the procedure to include tampering events. whereas the cause of these violations was adherence to the procedure itself. 7. Candidate For Discretion? [See attached list] [ Enter Yes or No]: Indeterminate. The licensee's failure to report th'e event within one hour is a repeat violation. 8. Is A Predecisional Enforcement Conference Necessary? [ Enter Yes or No]: Yes. Why: To facilitate a better understanding of root cause and missed opportunities. If yes, should OE or 0GC attend? [ Enter Yes or No): Yes Should conference be closed? [ Enter Yes or No): No 9. Non-Routine Issues / Additional Information: See attached chronology. 10. This Action is Consistent With the Following Action (or Enforcement Guidance) Previously Issued: [EICS to provide] [If inconsistent. include:] Basis for Inconsistency With Previously Issued Actions (Guidance) 11. Regulatory Message: Encouragement of prompt identification and prompt comprehensive corrective action. 12. Recommended Enforcement Action: Severity Level III and Severity Level IV violation. 13. This Case Meets the Criteria for a Delegated Case. [EICS - Enter Yes or No] No 14. Should This Action Be Sent to OE For Full Review? [EICS - Enter Yes or No] No If yes why: PREDECISIONAL ENFORCEENT INFORPMTION NOT FOR PUBLIC RELEASE WO APPROVAL OF DIRECTOR OE

ENFORCEENT ACTION ' WORKSHEET 15. Regional Counsel Review [EICS] At the panel. No Legal Objection Dated: 16. Exempt from Timeliness: [EICS) No. Basis for Exemption: Enforcement Coordinator: DATE: f i l l l PREDECISIONAL ENFORCDENT INFORMATION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR, OE t.

ENFORCEENT ACTION - 7-WORKSHEET ' ISSUES TO CONSIDER FOR DISCRETION o Problems categorized at Severity Level I or II. o Case involves overexposure or relee of radiological material in excess of NRC requirements. o-Case involves particularly poor licensee performance. o Case-(may) involve willfulness. Infonnation should be included to address whether or not the region has had discussions with OI regarding the case, whether or not the matter has been fonnally referred to 01, and whether or not OI intends to initiate an investigation. A description.. as applicable of the facts and circumstances that address the aspects of negligence, careless disregard. willfulness and/or management involvement should also be included. O Current violation is directly repetitive of an earlier violation, Excessive durat'on of a problem resulted in a substantial increase in i o risk. o Licensee made a conscious decision to be in noncompliance in order to obtain an economic benefit. O Cases involves the loss of a source. (Note whether the licensee self-identified and reported the loss to the NRC.) l a Licensee's sustained performance has been particularly good. o Discretion should be' exercised by escalating or mitigating to ensure that the proposed civil penalty reflects the NRC's concern regarding the j violation at issue and that it conveys the appropriate message to the licensee. Explain. 1 l l E i PREDECISIONAL ENFORCEMENT INF0mMTION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR.'0E

1 i CMONOLOGY i UNAUTHORIZED INDIVIDUAL ENTERING THE PA AFTER TERMINATION e 7/28/% Employee terminated, j 9/19/96 PSL Access Coordinator identifies employee terminated and removes the individual's access (along with 2 others). but fails to notify. Security. 10/7/96 TPN contacts PSL Access Coordinator ~to process this individual for. TPN access. 4 10/9/% During the processing of this individual. the PSL Access Coordinator notices that-the employee's last badge use date is i after his termination date. Further review reveals the individual had entered the PA on 5 occasions (3 different days). Upon interview of the individual, the licensee learns he returned for [ an interview on one occasion. However, on the other occasions, came back to talk to other people in general. The Access Coordinator notifies the security supervisor, who determines the event as non-reportable. 10/11/96-The Security Manager learns of the situation and logs the event in the licensee's SEL. CR is generated. 10/16/96 The licensee. determines the event to be one hour reportable. Call made to R d on II (Stratton) and OPS Center. PROBLEMS: p 1. Procedure does not provide a form / checklist for termination. 2. Procedure denotes responsibility to the individual. their supervisor, and human resources to notify secu:'ity upon termination. All three individuals failed to do so. 3. No-training on the procedure. Limited distribution of the procedure. .however, the procedure-is available to anyone. 3. Access Coordinator's failure to notify security and recognize the seriousness of the situation and failure to log the event in the . licensee's SEL. 4. Security's failure to one hour report-the event after learning the individual had entered the protected area. IR %-16 (tampering event report) also identified a violation for failure to report. 5.' The licensee's missed an opportunity to investigate / correct the problem when, on 8/19/96. CR 96-20411dentified an individual having access to. the_ site 12 days after termination. The corrective action did not 5 m m

4 identify the excenit of the access control problem. 6. If the individual had not processed in at PSL. the problem may not have been identified, and the licensee would still not know an unauthorized individual had entered the PA. 7. Corporate QA had responsibility to ensure compliance with this procedure. No evidence that was ever initiated. 8. This problem is FPL wide. PTN also has identified individuals who had ) ) access after they.were terminated. No other individuals who had access after termination entered either site. Responsible organizations who failed to notify Security included Engineering. MIS. Human Resources. I&C. and QA. 9. Nunerous severance packages are being offered in conjunction with many terminations at FPL. 10. Security's inadequate. investigation of the event in that, the two people identified by the individual es being visited on the days when the individual accessed the site were interviewed. That's all that was done as far as Security's investigation. Upon independent inspection. this ins >ector learned that the two individuals spent approximately 2 hours wit 1 the individual. 1.5 hours on 8/15 and 15 minutes on 8/7. According to access records. the employee was in the protected area as follows: 8/7/96 12:02 - 12:45 (43 minutes) 8/7/96 12:59 - 14:20 -(30 minutes) 8/7/96 14:37 - 17:15 (2 hours 38 minutes) 8/9/96 10:07 - 15.37 (3 hours 30 minutes) 8/15/96 12:47 - 17:37 (4 hours 50 minutes) Approximately 10 hours inside the protected area are unaccounted for. 11. Individual had PA and VA access. Did not enter any VAs during the times noted above. i i' l

ENFORCEMENT ACTION WORKSHEET INADEQUATE DESIGN C WTROL PREPARED BY: John W. York DATE: October 28. 1996 NOTE: The Section Chief of the responsible Division is responsible for preparation of this EAW and its distribution to attendees prior to an Enforcement Panel. The Section Chief shall also be responsible for providino the meeting location and telephone bridr,e number to attendees via e- - mail [ENF.GRP CFE. 00%IL. JXL. JRG. SHL. LFD: appropriate RIl DRP. DRS: appropriate NRR.- WISS). A Notice of Violation (without "boilerplate") which includes the recomended severity level for the violation is required. Copies of applicable Technical Specifications or license conditions - cited in the Notice or other reference matertal needed to evaluate the proposed enforcement action are required to be enclosed. This Notice' has been reviewed by' the Branch Chief or Division Director and each violation includes the appropriate level of specificity as to how and

when the requirement was violated.

Signature Facility: St. Lucie Unit (s): 1 and 2 Docket Nos: 50 335. 389 i License Nos: DPR 67 NPF-16 Inspection Report No: 96 17 Inspection Dates: 10/7 11. and 10/15 18, 1996 Lead Inspector: John York 1. Brief Summary of Inspect' ion Findings: [Always include a short statement of the regulatory concern / violation. Reference and attach draft NOV. Then, either summarize the Inspection findings in this section or reference and attach sections of the inspection report, inspectors are encouraged to utilize the Noncompliance Information Checklist provided in Enclosure 4 to ensJre that the information gathered to support the violation t is complete.] in The licensee replaced some safety related nuclear instrumentation drawers during the Unit 1 Outage. The drawers were wired backwards because of incorrect drawings. Part of the root cause identified the lack of a proper independent verification as a potential cause. This is a violation of 10 CFR 50 Appendix B Criterion III. In examining the safety aspects of this event, one additional example of inadequate design verification was identified for BEACON on line core performance monitoring system. In. addition to the wiring problem for the drawers, the maintenance group s connected the field cables for an NI backwards because the 'ings on the connectors were different than'on the previous detectors. An NOV was written for failure to write a Condition Report (discrepai y report) and resolve this problem prior to installation of the detector. See attached IR feeder and proposed NOV for details. PROPOSED ENFORCEMENT ACTION - NOT FOR PUSUC DISCLOSURE WITHOUT THE APPROVAL OP THE DIRECTOR, OE ) s

\\ i ENFORCEENT ACTICH w=====r 2. Analysis of Root Cause: i Lack of control and procedural adherence in the licensee's program for . preparing and implementing Plant Change / Modifications (PC/Ms). 3. Basis for Severity' Level (Safety Significance): CInclude example from the - supplements, aggregation. repetitiveness. w111 fulness. etc.] Aggregation of examples and application of Supplement.I. C.7. a breakdown in the control of licensed activities involving two violations '4 that are related that collectively represent a potentially significant lack of attention toward licensed activities. The safety significance of reversing the detector inputs to the NIS drawers substantially reduced the safety margin between the TM/LP trip setpoint.and the analysis limit even considering the increased TM/LP. margin to the trip setpoint due to actual core operating conditions. 4. Identify Previous Escalated Action Within 2 Years or 2 Inspections? [by EM Supplement, and Identification date.] EA 96-249 - Inadequate 50.59 did not identify US0. 7/12/96 EA 96-040 - Boron Overdilution Event. Supplement 1. 1/22/96 EA 95-180 - Inoperable PORVs due to Inadequate PMT. Supplement 1. 8/4/95 l 5. Identification Credit? No The miswired NI drawers were identified through an event (the failure to i have the system respond properly), i. e. the analysis of the data by Reactor Engineering discovered the miswiring of the NI drawers but the error in the drawing should have been discovered in the design control process. j The design. error associated with BEACON was identified through routine comparisons of actual plant data with predicted data. This error could have been discovered in the design control process. Enter date Licensee was aware of issues requiring corrective action: 7/30/96 i 6. Corrective Action Credit? Yes Brief sumary of corrective actions: In response to the issue, the licensee adopted corrective actions which included:- For imediate action the licensee prepared a change request for o the modification package and channels A.C. and D were reconnected and testing was performed to verify proper NI response. A root cause/self assessment and training meeting for the e Engineering Department emphasizing importance of proper design PROPOSED ENFORCEMENT ACTION - NOT FOR PUBUC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR, OE

ElrFORCBIErf ACTIQat e 3-wommanueT verification and importance of questioning attitude. Tape was produced of this meeting-for future engineering training. Procedures (Engineering Quality Instructions) were revised to (1) require all critical aspects be verified during the PC/M. (2) emphasize that-the same level of verification is required for. i PC/Ms duplicated for the second unit and (3) reinforce the verification requirements for safety related drawings. Walkdowns will be conducted (linear NIs) to revise any design documentation and tagging. ASI targets will be established for future trending of ASI during e power ascension. e Require cross-disciplinary reviews of design inputs Better documentation of assumptions in core design inputs and e codes Explain application of corrective action credit: Corrective action appears to be of appropriate scope. 7. Candidate For Discretion? NO Explain basis for discretion consideration: Since actual power conditions did not exceed trip setpoints, no escalation is warranted. Several examples of licensee's declining performance in engineering does not warrant mitigation. 8. Is A Predecisional Enforcement Conference Necessary? Yes Why: To determine adequacy of licensee's proposed long-term corrective actions regarding backward looks at modifications performed prior to the Unit 1 outage. This included discussions of other modifications that may not have been independently verified. If yes should OE or 0GC attend? [ Enter Yes or No): Should conference be closed? [ Enter Yes or No]: 9. Non Routine Issues / Additional Information: PROPOSED ENFORCEMENT ACTION - NOT FOR PUBUC DISCLOSURE MRTHOUT THE APPROVAL OF THE DIRECTOR, OE

arroacmaarr Acrzou -4 WORKSEIRT 10. This Action is Consistent With the Following Action (or Enforcement Guidance) Previously Issued: [EICS to provide) (If inconsistent include:] Basis for Inconsistency With Previously Issued Actions (Guidance) 11. Regulatory Message: Positive cont.ol must be established and maintained over the design process, with particular emphasis on properly performing independent design verification. 12. Recommended Enforcement Action: SL III 13. This Case Meets the Criteria for a Delegated Case. [EICS Enter Yes or No] 14. Should This Action Be Sent to OE For Full Review? [EICS - Enter Yes or No] If yes why: 15. Regional Counsel Review [EICS to obtain) No Legal Objection Dated: 16. Exempt from Timeliness: EEICS) Basis for Exemption: Enforcement Coordinator: DATE: PROPOSED ENFORCEMENT ACTION NOT FOR PUSUC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR, OE

ENFORCEENT ACTION WORKSHEET ISSUES TO CONSIDER FOR DISCRETION a Problems categorized at Severity Level I or II. a Case involves overexposure or release of radiological material in excess of NRC requirements. o Case involves particularly poor licensee performance. a Case (may) involve willfulness. Information should be included to address whether or not the region has had discussions with 01 regarding the case, whether or not the matter has been formally referred to 0I. and whether or not 01 intends to initiate an investigation. A description, as applicable, of the facts and circumstances that address the aspects of negligence. careless disregard willfulness, and/or management involvement should also be included, a Current violation is directly repetitive of an earlier violation. o Excessive duration of a problem resulted in a substantial increase in risk. o Licensee made a conscious decision to be in noncompliance in order to obtain an economic benefit. o Cases involves the loss of a source. (Note whether the licensee self-identified and reported the loss to the NRC.) o Licensee's sustained performance has been particularly good. o Discretion should be exercised by escalating or mitigating to ensure that the proposed civil penalty reflects the NRC's concern regarding the violation at issue and that it conveys the appropriate message to the licensee. Explain. . PROPOSED ENFORCEMENT ACTION - NOT FOR PUBUC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR, OE

REFERENCE DOCUMENT CHECKLIST [] NRC Inspection Report or other documentation of the case: NRC Inspection Report Nos.: [] Licensee reports: [] Applicable Tech Specs along with bases: ' [] Applicable license conditions [] Applicable licensee procedures or extracts [] Copy of discrepant licensee documentation referred to in citations such as NRC. inspection record, or test results [] ' Extracts of pertinent FSAR or Updated FSAR sections for citations involving 10 CFR 50.59 or systems operability [] Referenced ORDERS or Confirmation of Action Letters [] Current SALP report summary anc applicable report sections [] Other miscellaneous documents (List): ] I 9 9 mm, i PROPOSED ENFORCEMENT ACTION - NOT FOR PUBUC DISCLOSURE WITHOUT THE APPROVAL OF THE DNIECTOR, OE

j. p-NI INSPECTION ST. LUCIE-October.7-18. 1996 l On July'30.1996. 'St. Lucie Unit 1 was operating at approximately 100 % 1 i power when reactor. engineering was analyzing the' data taken during power ascension and noted an anomaly in the results. The data indicated three of the four excore linear detectors measured core power moving to the top of the core during power ascension.. This was an unexpected. )henomena and did not agree with the trend of the power moving to the )ottom of the core indicated by RPS Channel B Linear Range Detector. F Control Channel #9 Linear Range Detector, and the BEACON Core Power Distribution Monitoring System. Evaluation of the data collected L indicated that RPS Channels.A.C.and D could have reversed (rolled) leads l of the top and bottom chambers input to the RPS. drawers. The modification performed during the outage associated with this L problem was No. PC/M 009-195. During the outage. the licensee replaced 'the power range NI drawers for the Reactor Protection System (RPS) with new Gamma Metrics drawers. This modification combined the linear power range input to.the RPS and the logarithmic wide range channel into a 4 single drawer i.e. reduced the number of drawers on Unit 1 from eight i to four. This modification increased the limits of the instruments ' range and replaced aging equipment. j Engineering.Verif1 cation-Root Cause A design error was responsible for the reverse connection (rolled leads) on four NI safety related drawers on Unit 1. The Controlled Wiring Diagram (CWD). no. JPN-009-195-001/002 depicted the upper uncompensated Ion Chamber (UIC) connected to the lower UIC input at the NI drawer. The root cause noted that the designer and the lead engineer interpreted conflicting informatiot. on the' existing CWDs and made an assumption. [ The independent verification may have' caught this error had the process i been properly performed. The drawings were prepared by the lead designer with input from the lead engineer. The drawings were then i checked by a second designer who had no special knowledge of the NI i design. This check was essentially a drafting check..The drawings were 1 e then reviewed by the lead designer and then by the engineering supervisor. U Engineering Quality Instructions (01) 1.7. Design Input / Verification. L dated July 5.1995. states in part that " Design verification is the process whereby a competent. individual, who has remained independent of the design process. reviews the design inputs.... and design output to L verify design adequacy. This independent review is provided to minimize the likelihood of design errors in items-that are-important to nuclear ~ safety." _ Contrary to this requirement the first reviewer could not be e considered as competent because he was not an engineer as required by PROPOSED ENFORCER 4ENT ACTION - NOT FOR PUBUC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR, OE y

4 2 l 01 1.7 and the lead engineer as the third reviewer could not be considered to have remained independent of this design project. O v of the action items to prevent recurrence was to check all the-I&C am electrical PC/M to see if all the drawing approval signatures could qualify as independent verifiers. The licensee found three out of eight open modifications where this was a potential problem. two of these modifications were electrical and one was I&C. This therefore is not an isolated case. This failure to perform independent verification according to procedure is identified as example one of violation 50-335/96:17-XX. Failure to Control the Design Process According to the 1 Requirements of 10 CFR 50. Appendix B. Criterion III. BEACON Core Power Distribution Monitoring System i The licensee had installed BEACON during this refueling outage to replace the older IMPAX code used for in-core flux monitoring. BEACON provided several significant improvements over IMPAX one being real-time flux profile monitoring. This improvement permitted reactor engineering to identify the NIS problem quickly and initiate prompt corrective 4 actions. 1 During power operations, reactor engineering used BEACON to obtain the actual in-core flux profile. The actual in-core flux profile was then used to verify compliance with Technical Specifications and provide calibration information for the excore NIS drawers. As part of these routine surveillances, reactor engineering compares actual in-core flux profile to the in-core flux profile predicted by the core design code. Reactor engineering noted larger than normal errors between actual and predicted in-core flux profile. Because BEACON used the same neutronics l engine as used in the core design code. reactor engineering could not ] explain the error and notified the corporate core design engineers. As part of the process to resolve these errors, it was discovered that a simplifying assumption. used to overcome limitations of the IMPAX. was not accounted for in the original design of BEACON. This simplifying assumption was used because the licensee had changed the fuel design to incorporate a longer end cap to prevent debris induced fuel failures. This longer end cap raised the overall core height by 2.64" causing an offset between detector midplane and actual core midplane. The IMPAX code assumed detector midplane was along core midplane and could not accommodate the 2.64" offset. Therefore, the licensee, after discussion with the fuel vendor (Siemans), used this simplifying assumption to essentially lower the core midplane by 2.64" so that final design output would be referenced to detector midplane: not core midplane.

However, the engineer preparing the design input for BEACON was not aware of this simplifying assumption consequently BEACON was referenced to core midplane resulting in an increased error between the core design predicted in-core flux profile and actual in-core flux profile.

PROPOSED ENFORCEMENT ACTION NOT FOR PUBLIC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR, OE

3 i p The licensee *s root cause evaluation identified lack ~of cross-discipline review as the-significant contributor to this design error. The i inspector concurred with the licensee's. evaluation. Engineering Quality Instructions (01) 1.7. Design Input / Verification. dated July 5.1995. y states in part that " Design verification is the process whereby a i competent individual, who has remained independent of the design l process.-reviews the design inputs.... and design output'to: verify design-adequacy. This independent review is provided to. minimize the likelihood of design errors in items that are important to nuclear safety." Contrary to this requirement. the design inputs were not-adequately reviewed by a competent individual in that-the core midplane i; ' offset was not identified as a design input.for BEACON. 'This failure to i perform an adequate independent design review for the BEACON system is ~ identified as example two of violation 50-335/%-17-XX. Failure to Control the Design Process According to the Requirements of 10 CFR 50. Appendix B. Criterion III. i' - The safety significance of reversing the detector inputs to the NIS drawers substantially reduced the safety margin between the TM/LP trip setpoint and the analysis limit even considering the increased TM/LP margin to the trip; set)oint due to actual core operating conditions. The safety impact of t1e-failure to identify the core and detector midplane offset on TM/LP or LPD safety limits was minimal. CONNECTOR SWAPS AT DETECTOR 6-CHANNEL'B All four of the RPS Linear Range Detectors had the connectors reversed as previously discussed but the B channel unlike the other three channels was giving the correct data. At the same time that the drawers t were being replaced on Unit 1. the detector for channel B (detector no.

6) was being replaced as a maintenance activity.

During connection of the field cables, the connections were reversed for the upper and' lower detection chambers, thereby causing the B channel to record properly. The root cause for the swap of the cables was that the new detector had different labeling than the existing cables. The existing cables were labeled TOP SIG and BOT SIG. and the new detector had A and B. The t inspectors discussed this-maintenance job with the I&C supervision who had supervised the latter part of this maintenance project. Several opportunities were ) resented to the maintenance personnel one when the Ldetectors were checced out in the warehouse and a second time when this condition was noted in the field. Maintenance personnel should have resolved the labeling problem by writing a Condition Report:(CR) and having a formal resolution. Administrative Procedure No. 0006130. Condition Reports, rev. 4. dated March 22..1996. Par. 8.1.1.A states in part that "Any individual who becomes aware of a problem or discrepant condition....should initiate a PROPOSED ENFORCEMENT ACTION - NOT FOR PUSUC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR, OE

4 CR. If doubt exists. a CR form should be. initiated". This failure to comply with the requirements of the administrative procedure is identified as violation 50-335/96-17-YY. Failure to Initiate a Condition Report for Labeling on Safety Related Decectors. e l l PROPOSED ENFORCEMENT ACTION - NOT FOR PUBUC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR, OE

Violation 1 with two examples. 10 CFR 50 Appendix B. " Quality Assurance Criteria for Nuclear Power Plants and Fuel Reprocessing Plants." Criterion III requires, in aart. that... design control measures shall provide for verifying or clecking the adequacy of design, such as the aerformance of design reviews...The verifying or checking process shall De performed by individuals or groups other than those who performed the original design, but who may be from the same organization. FPL Topical Quality Assurance Report. TOR 3.0. revision 11. " Design Control." Section 3.2.4. " Design verification." stated, in part. " Design control measures shall be established to independently verify design input... Design verification shall be performed by technically qualified individuals or groups other than those who performed the design. Engineering Quality Instructions 1.7 " Design Input / verification." rev.1. dated July 5.1995, states in part. " Design verification is the process whereby. a competent individual, who has remained independent of the design process, reviews the design inputs.... and design output to verify design adequacy. Contrary to the above: 1. Contrary to the above. on July 30. 1996. it was discovered that a design change (PC/M 009-195) was completed without an independent design verification by a competent individual. Design change PC/M 009-195 to install new Gama Metrics Nuclear Instrumentation drawers was completed by a lead designer and a lead engineer. This design change was independently verified by a second designer who had no special knowledge of the design. A engineering supervisor approved the design. Neither the second designer or engineering supervisor had remained independent of the design process. 2. Contrary to the above on July 30, 1996, it was discovered that an independent design review was not conducted for the installation of a new core flux monitoring computer code BEACON. During initial operation of BEACON it was found that the code did not compensate for a core mid-plane offset created by a previous core modification. The engineer who prepared the design was not aware of the core mid-plane offset and the independent review of the new BEACON code ld not identify this omission. . Violation 2 Technical Specification 6.8. Procedures and Programs, paragraph 6.8.1 requires in part that written procedures recomended in Appendix A of Regulatory Guide 1.33 revision 2. February 1978. shall be established. implemented... PROPOSED ENFORCEMENT ACTION NOT FOR PUBUC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR, OE w w r +- m-

2 ~ Administrative Procedure No. 0006130. Condition Reports. revision 4 dated March 22.19%. Paragraph 8.1.1. A states in part that "Any 1 individual who becomes aware of a problem or discrepant condition... should initiate a CR. If doubt exists, a CR form should be initiated". 1 Contrary to the above, on July 30.19%. Instrument and Control technicians installing a plant design change (PC/M 009-15) did not initiate a coridition report when they became aware of a discrepant condition concerning incorrectly marked cables. They continued to install the modification and an error was made that resulted in cross-wiring of the nuclear instrumentation system. i PROPOSED ENFORCEMENT ACTION - NOT FOR PUSUC DISCLOSURE WITHOUT THE APPROVAL OF THE DIRECTOR. OE

4 ENFORCEMENT ACTION WORKSHEET BREAKDOWN IN MANAGEENT CONTROL OF THE ST. LUCIE EMERGENCY PREPAREDNESS PROGRAM PREPARED BY: James L. Kreh DATE: November 7,19% This Notice has been reviewed by the Branch Chief or Division Director and each violation includes the appropriate level of specificity as to how and when the requirement was violated. M gnature Facility: St. Lucie Plant Units: 1&2 Docket Nos.: 50 335. 50 389 License Nos.: DPR 67. NPF 16 l Inspection Report No.: % 18 Inspection Dates: October 718 and October 28 November 1.19% Lead Inspector: J. L. Kreh 1. Brief Summary of Inspection Findings: Violation A 4 On the evening of October 3. 1996, the licensee conducted a test of its automated system known as the FPL Emergency Recall System (informally called " autodialer") for notifying the emergency response organization (ERO) in the event of an off-hour emergency requiring augmentation of the on-shift crew for staffing and activation of emergency response facilities (v12.. Technical Support Center [TSC). Operational Support Center [05C]. and Emergency Operations Facility [ EOF)). The autodialer did not operate, and no individuals received notifications during the test. A failure assessment by the licensee disclosed that the autodialer had been in an inoperable configuration for a period which apparently began on July 22. 1996. In addition, the inspection identified the licensee's failure to adequately maintain the manual backup system (a " call tree") for ERO call-out over an indeterminate period (at least the last several years). These concurrent deficiencies represent a failure (during the period July 22-October 3.1996 at minimum) to maintain the capability to execute the provisions of the REP and its implementing procedures in a timely manner with respect to mobilization of the ERO during off-hours. PREDECISIONAL ENFORCDert INFOMMTION NOT FOR PtBLIC RELEASE W/0 APPROVAL OF DIRECTOR. OE

i I ENFORCDENT ACTION 2-

7 W3tKSEET Violation B The licensee *s training program for ERO personnel has not been adequately implemented since at. least 1994.

This violation includes failure to provide opportunities for most personnel to participate in exercises and/or drills.. failure to provide annual retraining to certain designated 1 wrsonnel in 1994 and 1995 - failure to provide any training.for certain ERO positions with respect to selected implementing procedures, and. failure to remove individuals from the ERO roster when their respirator . ualifications had lapsed. q 2. Analysis of Root Cause: ^ The root cause of both violations is failure of licensee management to (a)' provide an appropriate level of oversight of the emergency preparedness program as required by the REP..' and (b) ensure the implementation of timely and effective corrective actions for identified findings and deficiencies in emergency preparedness. 3. Basis for Severity Level (Safety Significance): For both violations: Suoolement VIII - Emeraency Preoaredness. SL III Section C.3 of Supplement VIII presents as an example, " Violations involving... a breakdown in the. control of licensed activities involving a number of violations that are related... that collectively represent a potentially significant lack of attention or carelessness toward licensed responsibilities. Section IV.A of the Enforcement Policy states that "a group of Severity Level IV violations may be evaluated in the aggregate and assigned a single. increased severity level, thereby resulting in a Severity Level III problem. if the violations have the same underlying cause or programatic deficiencies, or the violations contributed to or were unavoidable consequences of the underlying problem." 4. Identify All Previous Escalated Actions Within 2 Years or 2 Inspections 95-180: PORVs Inoperable Due To Personnel Error: SL III 96-040: Dilution Event: SL III

• 96-249:

Multiple Examples of Inadequate 50.59 Reviews: SL III 5. Identification Credit? Yes Violation A ~ Date licensee was aware of issues requiring corrective action: October 3. 1996. This identification credit /date applies only to the autodialer inoperability portion of the violation. The problem with the manual call-out system was NRC/CI-identified. PREDECISIONAL ENFORCDGIT IWOMETION. NOT RR PLBLIC RELEASE 61/0 APPRDWAL OF DIRECTER, OE

ENFORCEENT ACTION 3-s WORKSHEET Explain application of identified credit, who and had identified and consideration of missed opportunities: The inoperability of the autodialer was identified by the licensee on 10/3/%. but could have been identified much earlier if periodic functional tests (e.g., weekly) had been perfonned. With appropriate administrative controls in place (as had been recommended by a'n EP Coordinator as early as April 1996), autodialer inoperability would have almost certainly have been precluded. An autodialer problem (limited in scope--not a complete system failure) also occurred during the NRC-evaluated June 1993 exercise, but corrective action for that problem was clearly not sufficiently comprehensive. Violation B Date when the licensee was aware of issues requiring corrective action: January 19%. Explain application of identification credit, who and how identified and consideration of missed opportunities: Many of the identified failures in the licensees training program were-self-identified in a self-assessment that was performed in January 19%. However, some of the identified failures were not self-identifwd. but should have been through existing licensee program controls. 6. Corrective Action Credit? No Violation A Administrative controls have been implemented for the autodialer under Protective Services Department Guideline No. PSG-015. " Maintenance and Testing of the Emergency Recall System".' Revision 0 dated 10/29/96. For the manual call-out system. individuals required to maintain a copy of the procedure were added to the controlled distribution list. and a drill was conducted on October 10, 1996 with reasonably successful results. Application of corrective action credit: (1) No credit for autodialer issue because identified by licensee EP Coordinator in early 1996 and no action taken: (2) Credit for correction of manual call-out problem after identification to licensee on 10/7/96. Violation B The licensee has initiated action items to evaluate and determine corrective actions for self-identified issues. The licensee is currently completing a mass training effort for all emergency response organization positions necessitated by recent changes in responsibilities from Corporate staff assianments to Plant staff assignments. Application of corrective action credit: No credit because the licensee has not yet fully determined or implemented programmatic changes to resolve identified issues. PREDECISIOML ENFORCDENT INFORMATION NOT FOR PUBLIC RD. EASE W/0 APPROVAL 0F DIRECTOR OE

ENFORCEENT ACTION 4-i N 7. Candidate For Discretion? -No Licensee *s perfonnance in emergency preparedness is now recognized to have been particularly poor during the past several years. 8. Is A Predecisional Enforcement Conference Necessary? Yes Why? To determine whether the subject violations represent a progrannatic breakdown in emergency preparedness. -If yes, should OE or OGC attend? Yes Should conference be closed? No 9. Non Routine Issues / Additional Information: OTHER FINDINGS FROM THE OCTOBER 19% EP PROGRAM INSPECTION i Violation i Failure to establish an Emergency Plan Implementing Procedure (EPIP), or to have an adequate EPIP. with appropriate implementing details to address certain aspects of the Radiological Emergency Plan as follows: a. the transfer of OSC functions to an alternate location in the event that evacuation of the primary OSC is required (EPIP-3100032E. "On-site Support Centers". contains no implementing details for the statement in Radiological Emergency Plan Section 2.4.4 that "In the event that the OSC becomes untenable, the Emergency Coordinator will designateanalternatelocation."){inadequateprocedure}.and b. recovery activities upon reaching a stable plant condition following an emergency (Radiological Emergency Plan Section 5.4) (no procedure}. Emeraency Preoaredness Procram Weaknesses i 1. Inadequate program of drills to ensure availability of sufficient ERO personnel and timeliness of ERF staffing 2. Management failure to ensure the implementation of timely corrective actions for certain emergency preparedness deficiencies and weaknesses. Examples are: ] a. failure to address concerns regarding the audibility of the Gaitronics .(or plant public-address system) formally identified in late 1994 and still being tracked as an open i l L item by the licensee's corrective action system. b. failure to provide adequate corrective action to address a questionable capability for notification of the State of Florida within 15 minutes of an emergency declaration (identified by an NRC inspection in February 1995). and PREDECISIONAL ENFORCDelT IWGOMTION - NOT FOR PtBLIC RELEASE WO APPRDWAL OF DIRECTR OE

ENFORCEENT ACTION 5-WORKSHEET -c. failure to implement timely-corrective actions for deficiencies and recommendations identified by the critique of the Hurricane Erin response in August 1995 (examples of issues: identify hurricane-safe structures onsite and a plan for positioning personnel in those structures; designate an onsite individual to monitor the hurricane path: establish consistent staffing policies) 10. This Action is Consistent With the Following Action (or Enforcement Guidance) Previously Issued: Supplement VIII. Section C.3 \\ 1 PREDECISIONAL ENFtRCD ett INFONWiTION NOT FOR PUBLIC RELEASE WO APPROVAL OF DIRECTUR. OE \\

ENFORCEENT ACTION 6-WORKSHEET t 11. Regulatory Message: Management must provide strong and consistent oversight and support for emergency preparedness activities in order to ensure a viable emergency response capability at all times. 12. Recommended Enforcement Action: Two SL IV violations evaluated in the aggregate as a SL III problem 13. Should This Action Be Sent to OE For Full Review? No j 14. Exempt from Time 11.iess: No Basis for Exemption: N/A Enforcement Coordinator: DATE: PREDECISIONAL ENFORCDENT INFORETION NOT FOR PlBLIC RELEASE W/0 APPhoVAL OF DIRECTOR. OE

ENFORCEENT ACTION ' DRAFT NOTICE OF VIOLATION St. Lucie Plant Inspection Report Nos. 50-335. 50-389/%-18 A. 10 CFR 50.54(q) requires that nuclear power plant licensees follow and maintain in effect emergency plans which meet the planning standards of 10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR Part 50. Section 2.4 of the licensee's Radiological Emergency Plan (REP). Revision 31 states that activation of the Technical Support Center (TSC) and the Operational Support Center (OSC) will be initiated by the Emergency Coordinator in the event of an Alert. Sitt Area Emergency, or General Emergency. and that arrangements have been made to staff the TSC and OSC in a timely manner. Also specified is that activation of the Emergency Operations Facility (EOF) is required for a Site Area Emergency or General Emergency, and that arrangements have been made to activate the EOF in a timely manner. The REP requirements delineated above are implemented by procedure EPIP-3100023E. "On-Site Emergency Organization and Call Directory". Revision 72. The instruction in Section 8.2 of that procedure states that upon the declaration of an emergency classification. "the Duty Call Supervisor will initiate staff augmentation" using the " Emergency Recall System or Appendix A. Duty Call Supervisor Call Directory to notify persons..." Contrary to the above, from approximately July 22 to October 3.1996. arrangements were not available to staff or activate the TSC. OSC or EOF in a timely manner because the licensee did not have the capability to implement either the primary method (using the Emergency Recall System) or the backup method (using the Duty Call Supervisor Call Directory) for notifying its )ersonnel to report to the plant during off-hours to staff and activate tie TSC. OSC, and EOF. B. 10 CFR 50.54(q) requires that nuclear power plant licensees follow and maintain in effect emergency plans which meet the planning standards of 10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR Part 50. REP Section 7.2.2. " Training of On-Site Emergency Response Organization Personnel", states. "The training program for members of the on-site emergency response organization will include practical drills as appropriate and participation in exercises. in which each individual demonstrates an ability to perform assigned emergency functions." The licensee's Plan further states. "For employees with specific assignments or authorities as members of emergency teams. initial training and annual retraining programs will be provided. Training must be current to be maintained on the site Emergency Team Roster." Contrary to the above. the licensee failed to provide a program which included an opportunity for each individual assigned to the on-site emergency response organization to participate in a drill or exercise, as follows: PREDECISIONAL ENFORCDOT INFORMATION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTDR. OE

ENFORCEENT ACTION WORKSEET 1. In 1994. the licensee failed to provide training for 17 positions (approximately 92 individuals) identified as part of the on-site i response organization. In 1995, the licensee failed to provide training for 8 positions (approximately 54 individuals) identified as part of the on-site response organization. l 2. The licensee's trair11ng program failed to include initial, periodic retraining, or information on revisions w;th respect to certain procedures required to be implemented by several identified positions. These procedures included EPIP 3100026E.. Criteria for 2 Conduct of Evacuation: EPIP 3100027E. Re-entry: and EPIP 3100035E. Offsite Radiological Monitoring. 3. For the calendar year 1995, the licensee failed to remove from the emergency response organization 4 individuals who had not completed retraining as required. and their training qualifications had expire in 1994. The licensee ~ failed to remove 6 individuals from the i emergency response organization effective October 6. 1996, who had not remained qualified to fill response team requirements as a result of allowing their respirator qualifications to lapse. b< 1 i i 1 i I i l f MtEDECISIONAL DIFORCDert IlfGWRTION NOT RR PLBLIC RELEASE W/0 APMIDWAL OF DIRECTGt. OE

i Iq FPL k ST. LUCIE PLANT RADIOLOGICAL EMERGENCY PLAN REVISION 31 l i l Approved by: 6P Date / / /3 / // President, Nuclear Division b 1 f____,____.__________._____________.

2. ORGANZATION. FAC1LITIES. AND SUPPORT SERVICES (continued) 2.4 2. Technical Support Center (TSC) The company maintains an on site Technmal Support Center to provide i the Control Room with in-depth diagnostic and engineering assistanos i wkhout adding to congestion wkhin the Control Room. The TSC intertsons with the EOF regarding thoes diagnostic and engineering decisions. This assistance can help determine the operadonal decisions that would be appropriate to best control and mitigate the consequences of the emergency. The TSC is located adjacent to the Unit 1 Control j Room. 4 i Activation of the Technical Support Center will be initiated by the Emergency Coordinator in the event of an Alert, Site Area Emergency or General Emergency. Arrangements have been made to staff the TSC in l a timely manner. i The Technical Support Center contains pertinent records and drawngs. i j The Technical Support Center has an emergency communications i network similar to the Control Rooms. The TSC also has the NRC FTS i Emergency Telecommunications System. See secuo14.6 for a more detailed t- -d-A-i of the FTS system. 3. Operational Support Center (OSC) ( The company maintains an on-site Operational Support Center (OSC) to serve as an assembly poet for auxiliary operators, health physics l technicians, maintenance personnel, and other plant personnel available to support the emergency response. Required staff wi!! be assigned to appropriate activities by t'io Emergency Coordinator or his/her designee. Equipment that can be used by personnel dispatched from the OSd is stored in the Service Building. Table 2-4 indicctes the types of material and equipment stored there. { Activation of tra OSC will be initiated by the Emergency Coordinator. The OSC will be activated and in operation for an Alert, Site Area l Emergency or General Emergency. Arrangements have been made to l staff the OSC in a timely manner. The OSC is maintained in the second floor large conference room in the l North Service Building. Telephone communications are maintained between t% OSC and the Technical Support Center. l }- EPS:4 2 32 et. Luule. Rev. 31

2.~ ORGANIZATION. FACILITIES. AND SUPPORT SERVICES (continued) 2.4 4. Allemate Operational Support Center in the event that the OSC becomes untenable, me Emergency Coordinator will designate an allemale location. 5. Emergency Operations Facility (EOF) The company maintains an Emergency Operations Facility from which evaluation and coordmation of FPL activities reisted to an emergency can be carried out and from which FPL can provide information to federal, state, and local authorities. The Emergency Operations Faciitty is located at the intersection of State l Route 712 (Midway Road) and I-95 approximately 101/2 miles west of 2 the St. Lucie Plant. The EOF has sufficient space to accommodate the Florida Power & Light Company response organization and designated i.pi::-Ma of the federal, state, and local authorities. Altemate temporary locations for the Emergency Operations Facility may be designated by the Recovery Manager if e 'atural disaster or other (non-radiological) extomal event significantly affects the operational capatnlity of the facility. /r i i 1 The Emergency Operations Facility has an emergency communications l network including but not limited to, Local Govemment Radio (LGR), j commercial telephone lines, Hot Ring Down (HRD) phone, NRC ENS, j NRC HPN, NRC counterpart links, ESATCOM, and various Florida Power & Light Co. maintained radio systems. Essential, prerehdated j emergency data and pertinent reports and drawings are readily avaliable. i Activation of the Emergency Operations Facility is the responsibility of i the Recovery Manager and is required for a Site Area Emergency or General Emergeng The RM should place the emergency response l staff on standby in me facility for an Alert. Arrangements have been l made to activate the EOF in a timely manner. / j 6. Emergency News Center (ENC) An Emergency News Center (ENC) is provided to allow the news media access to information from the Emergency Operations Facility. The Emergency information Manager will designate an individual to supervise the ENC. The ENC is co-located with the EOF (Midway Road /l-95 intersection). 3 i EP3:4 2 34 St. Lamin, Rev. 31 -. t _.____j

7. MAINTAINN(Q l EMERGENCY PREPAREDNESS (condnued) 7.2 Emergency Response Training 1. r"9- ;x The primary objectives of emergency response training are.as follows: 1. Famdiertze appropnets individuals with the Emergency Plan and related implementing procedures. 2. Instruct individuals in their specific duties to ensure effective and expeditious acion during an emergency. 3. Periodically present significant changes in the scope or content of the Emergency Plan. I 4. Provide refresher training to ensure that personnel are familiar with their duties and responsibilities. 5. Provide the various emergency organization groups with the req @ed training that will ensure an integrated and prompt respones l to an emergency situation. 2. Training of Ordsite Emergency Response Organization Personnel 1 Training programs have been established for personnel working at the plant site. The programs include initial indoctrination and subsequent retraining. The training program for members of the on-site emergency response organization will include practical drills, as appropriate and part% l in exercises, in which each individual demonstrates an ability to perform assigned emergency functions. l The St. Lucie Plant Training Manager is responsible for the conduct and documentation of initial training and annual retraining programs for on-site FPL Emergency Response Organization (ERO) personnel. l Emergency teams will receive specific training as specified in the following subsections. The Emergency Planning Coordinator is r:: 4W for the content and accuracy of the Emergency Planning Training. ' Each new employee permanently assigned to work at the St. Lucie Plant shall be given initial onentation training. For employees not assigned specific responsibility or authority under the Emergency l-Plan or Procedures, such training shall, at a minimum, provide information desenbing the action to be taken by an individual discovenng an emergency condition, the location of assembly areas, the identification of emergency alarms, and the action to be taken upon hearing those alarms. I f i EPS:4 78 St.1.assie, Rev. 31

i 7.' - MAINTAINING pngERGENCY PREPAREDNESS (continued) i s 7.2 2. Training of On-eles Emergency Response Organization Personnel (contmuod) j For i-k,::: with specinc =- *y. or authorities as members of ~ emomency teams. initial training and annual retraining programs will be provided. Training must be current to be maintained on the sits Emergency Team Roster. The site Emergency Team Roster is updated by the Plant Training Manager once each calendar month. Securky maintains training records for momenes of the security. mas The folloung provides a description of the training provided to personnel filling the indicated positions. l 1. Emergency Coordinator a. l r.;.T,,=: S i of plant and field data and how it relates to emergencies and their classification (i.e. emergency action level determinatiori per Chapter S). b. Prompt and effective notincation methods, including the types of communication systems. c. Method of activating the Florida Power & Light Company Emergency Response Organization (ERO). d. The methods used for estimating radiation doses and recommending off-site protective actions. e. Emergency Plan familiarization f. Emergency Plan implementing Procedures (EPlPs) familiarization g. Communications and record-keeping methods h. Accident assessment and cornective action (licensed operators only). Q EPS:4 78 St. Lusis, Rev. 31

L / Page 1 of 27 ~.. id FLORIDA POWER & LIGHT COMPANY _ r ST. LUCIE PLANT I% i- --Il 4 E-PLAN IMPLEMENTING PROCEDURE NO. 310002: EM i y' M '. REVISION 72 i .e-g gisk ~ ~ 1.0 M: u%Cr.uu& 4.g [ ON-SITE EMERGENCY ORGANIZATION AND CALL D! RECTORY 2.0 REVIEW AND APPROVAL: Rewowed' by Facility Review Group 7/2519Jj_ ' - Approved by K. N. Harris Plant General Manager 7/2919J.j_ Revision Z2_ Reviewed by F R G 9/1219.Rg_ { Approved by J. Scarola Plant General Manager 9/1219.Rg_ l THIS PROCEDURE HAS BEEN COMPLETELY REWRITTEN, PLEASE READ ENTIRE PROCEDURE BEFORE PROCEEDING. /R72 1 i 3,0 SCOPE: i 3.1 Purpose This procedure provides instructions and phone numbers necessary to activate the On-Site Ernergency Organization (see Figure 1) for shift augmentation in response to an emergency declaration. In the appendices are the names, phone numbers and altomates for company emergency personnel, as well as phone numbers of County, State ar.d Federal agencies. S OPS DATE DOCT PROCEDURE DOCN 210D023E SYS COMP COMPLETED fTM 72

Y ST. LUCIE PLANT E-PLAN IMPLEMENTING PROCEDURE NO. 3100023E, REVISION 72 ON-seim:""",MNCY ORGANIZATION AND CAII DiRNiORY

8.0 INSTRUCTipNS

8.1 Upon no85cedon by the Emergency Coordinator (EC), thei on-shift Emergency Respones Organization shall assemble and prepare to respond as necesenry to the emergency. 8.2 Upon nodhostion by the EC, the Duty Call Supervisor (DCS), will initiate staff augmentation in accordance with Figure 3, Staff Augmentation Call Trea. The DCS will use the (automated dialing) Emergency Recall System or Appendix A, Duty Call Supervisor Call D's4wiy, to notify persons to fill the positions of Recovery Manager lTS Pirih Supervipot', TSC Supervisor, Emergency Coordinato, CMg, TSC Chemistry j Supervisof, OSC Super.h and TSC Security Supervisor. Instructions for use of the Emergency Recall System are in the ANPS office in 8.3 either Control Room. 11 the_ system _ is i.at used contmue with the next step. 4 8.4 The DCS_will record the names of persons fillino nadians am well as the expected times of amval at the plant on a form similar to Figure 3. 8.5 The Recovery Manager shall determine the action to be taken by EOF Responders. 1. For an Alert, EOF Responders should be notified and placed in a standby status or mobilized to respond to the EOF. 2. The EOF shall be activated in a Site Area Emergency and/or General i Emergency. / 8.6 Persons filling the positions of TSC HP Supennser and TSC Chemistry l Supennsor will notify the appropriate number of individuals from their ( respective departments in accordance with Figure 3 (See Appendix B, TSC i \\ Health Physics Supervisor and TSC Chemistry Supennsor Call Directory). 8.7 The TSC Supervisor (altemate) shall call the necessary persons to establish the minimum staff per Figure 3. He may call additional persons, as necessary ( (See Appendix C, Technical Support Center Supervisor Call Directory). i l / 8.8 The OSC Supennsor (altemate) shall call the necessary persons to establish the minimum staff per Figure 3. He may call additional po'rsons, as necessary (see Appendix D, Operational Support Center Supennsor Call Directory). l i t i i

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l September 19,1996 Flonda Power and Light Company ATTN: Mr. T. F. Plunkett Ptosident - Nuclear Division P. O. Box 1*000 i Juno Beach, FL 33408-0420 4-

SUBJECT:

NRC SPECIAL INSPECTION REPOMT 50-335/96-16 AND 50-389/96-16 AND i NOTICE OF VIOLATION

Dear Mr. Plunkett:

On August 23,1996, the NRC completed a specialinspection involving component tampering events at your St. Lucie reactor facidies. The enclosed report presents the results of that inspection. i Overall, St. Lucie's response to the potentis1 and actual tampering events between May and August 1996 was satisfactory. Some respone deficiencies were identified and are discussed in the details of the report. Also, based on the results of this inspection, certain.of your activities appeared to be in violation of NRC requements, as specified in the enclosed Notice of Violation (Notice). In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of thic letter and its enclosures will ne placed in the NRC PuNic Document floom (PDR). Sincerely, ORIGINAL SIGNED B'l ALBERT F. GIBSON Albert F. Gibson, Director Division of Reactor Safety Docket Nos.: 50-335, 50-389 License Nos: DPR-67, NPF-19

Enclosures:

1. Notice of Violation

2. Inspection Report 50-335/96-16 and 50-389/96-16 i

cc w/encis: (See page 2) /

~ FP&L 2 cc w/encis: Jack Shreve, Public Counsel - J. A. Stall Office of the Public Counsel Site Vice President clo The Florida Legislature St. Lucie Nuclesr Plant 111 West Madison Avenue, Room 812 i P. O. Box 128 Tallahassee, FL 32399-1400 Ft. Pierce, FL 34954-0128 Joe Myers, Director H. N. Paduano, Manager Dnnsion of Emergency Preparedwss Licensing and Special Programs Department of Community Affairs Florida Power and Light Company 2740 Centerview Dnve P. O. Box 14000 Tallahassee, FL 32399-2100 Juno Beach, FL 334084420 Thomas R. L. Kindred J. Scarola County Administrator Plant General Manager St. Lucie County St. Lucie Nuclear Plant 2300 Virginia Avenue P. O. Box 128 Ft. Pierce, FL 34982 Ft. Pierce, FL 34954-0128 Charles B. Brinkman E. J. Weinkam Washington Nuclear Operations Plant Licensing Manager ABB Combustion Engineering, Inc. St. Lucie Nuclear Plant 12300 Twinbrook Parkway, Suite 3300 P. O. Box 128 Rockville, MD 20852 Ft. Pierce, FL 34954-0218 4 J. R. Newman, Esq. Morgan, Lewis & Bockius 1800 M Street, NW Washington, D. C. 20036 John T. Butler, Esq. Steel, Hector and Davis ) 4000 Southeast Financial Center Miami, FL 33131-2398 4 Bill Passetti Office of Radiation Control Department of Health and Rehabilitative Services l 1317 Winewood Boulevard Tailahassee, FL 32399-0700 l e l v w

4 - FP&L 2 cc w/encts: Jack Shreve, Public Counsel 'J A Stall Office of the Public Counsel Site Vice President clo The Flonda Legislature St. Luae Nuclear Plert 111 West Madison Avenue, Room 812 P. O. Box 128 Tallahassee, FL. 32399-1400 l Ft. Pierce, FL 34954-0128 Joe Myers, Dwector H. N. Paduano, Manager Division of Emergency Preparedness 4 Licenssng and Special Programs Department of Community Affairs Florida Power and Light Company 2740 Centennow Dnve i i P. O. Box 14000 Tallahassee, FL 32399-2100 4 Juno Beach, FL 33408-0420 Thomas R. L Kindred J. Scarola County Administrator Plant General Manager St. Lucie County i St. Lucie Nuclear Plant 2300 Virginia Avenue P. O. Box 128 Ft. Pierce, FL 34982 Ft. Pierce, FL 34954-0128 Charles B. Brinkman E. J. Weinkam Washington Nuclear Operations i Plant Licensing Manager ABB Combustion Engineering, Inc. St. Lucie Nuclear Plant 12300 Twinbrook Parkway, Suite 3300 P. O. Box 128 Rockville, MD 20B52 Ft. Pierce, FL 34954-0218 D!sittihuhortwlencl: i J. R. Newman, Esq. K. Landis, Ril Morgan, Lewis & Bockius J. Norris, NRR 1800 M Street, NW B. R. Crowley, Ril Washington, D. C. 20036 G. A. Hallstrom, Ril PUBLIC I John T. Butler, Esq. Steel, Hector and Davis NRC Resident inspector 4 4000 Southeast Financial Center U.S. Nuclear Regulatory Comm. Miami, FL 33131-2398 7585 South Highway A1A Jensen Beach, FL 34957-2010 Bill Passetti Office of Radiation Control Department of Health and Rehabilitative Services i. 1317 Winewood Boulevard Tallahassee, FL 32399-0700 1 OFFicF RnrMtB RetrMtB Rtt DNP Rtt NRR Rit-Dftp SiONATURE NAME searr DThomenon JMunemy LWeena KLanes DATE 12 1 1 98 12 1 l es 12 / 1 96 12 1 s es 12 1 1 96 12 1 t es COPY 7 YES NO YES NO YES NO YES NO YES NO YES NO UPNV AL. Mt;wMu u PT L= =ct-NT NAME; A;W515M1.IU15

1 NOTICE OF VIOLATION i Flonda Power and Light Company Docket Nos. 50-335, 50-389, St. Lucie Nuclear Plant License Nos. DPR47, NPF-13, During an NRC inspechon conducted on August 19-23,1996, violabons of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Achons," NUREG-1600, the violations are listed below: A. 10 CFR 73.71, Reporting of Safeguards Events, Appendix G, (a)(3) Reportable Safeguards Events, requires the licensee to report to the NRC within one hour of discovery, followed by a written report within 30 days, events which cause interruption of normal operations through tampering with controls including the security system. The licensee's Security Procedure, SP-0006125, Reporting of Safeguards Events, Revision 9, dated April 20,1995, Paragraph 8.2 (1) defines one of those specific events as being a " confirmed tampering of suspicious origin with safety or security equipment." Contrary to the above on July 29,1996, the licensee failed to follow their procedure and report the confirmed tampering with security equipment (locks) within one hour to the NRC. i This is a Severity Level IV violation (Supplement lii) B. Technical Specification 6.8.1.s requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of i Regulatory Guide 1.33, Revision 2, February 1978. Appendix A, paragraph 1.c l includes administrative procedures for equipment control. Administrative Procedure i No. 2-0010123, " Administrative Control Of Valves, Locks And Switches," Revision 73 implements this requirement with respect to administratively controlled keys. l Step 8.2.1 of this procedure states in part that cubicles containing critical controls in i remote locations shall be locked and the keys maintained under Administrative Control. i Contrary to the above, on August 19,1996, keys used for the control of Power Operated Relief Valves V1474 and V1475 located in the 2A and 2B electrical penetration rooms respectively, were located in the unlocked cubicles which house the 3 switches. This is a Severity Level IV violation (Supplement 1). I Pursuant to the provisions of 10 CFR 2.201, Florida Power and Light is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: 4 ' Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, Region ll, and a copy to the NRC Resident inspector at the facility that is the subject of this notice within 30 days of the date of the letter transmitting this Notice of Violation (Notice). This reply should be clearly marked as a " Reply to a Notice of Violation" and should include h/h kh

7-Notice of Violation 2 l 1 for each violation: (1) the reason for the violaton, or, if contested, the basis for disputing the violation, (2) the corrective steps that have been taken and the results achieved, (3) the corrective steps that will be taken to avoid further violations, and (4) the date when full 4 compliance will be achieved. Your response may reference or include previous docketed correspondence if the consspondence adequrtely addresses the required response. If an adequate reply is not received within the time specified in this Notice, an order or Demsnd for informaten may be issued as to why the license should not be modified, susper:ded, or revoked, or why such other action as may be pmper should not be taken. Where good cause is shown, consideration will be given to extending the response time. Because your response will be placed in the NRC Public Document Room (PDR), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction. If personal privacy or i proprietary information is necessary to provide an acceptable response, then please provide a bracketed copy of your response that identifies the information that should be protected and a redacted copy of your insponse that deletes such information. If you request withholding of such material, you must specifically identify the portions of your response that you seek to have withheld and provide in detail the bases for your claim of withholding (e.g., explain why the disclosure of information will create an unwarranted invasion of personal l privacy or provide the information required by 10 CFR 2.79C(b) to support a request for with-holding confidential commercial or financial information). If safeguards information is i necessary to provide an acceptable response, please provide the level of protection ] described in 10 CFR 73.21. Security or Safeguards Information should be submitted as an enclosure to facilitate withholding it from public disclosure as required by 10 CFR 2.790(d) or 10 CFR 73.21. ) Dated at Atlanta, Georgia this 19th day of September 1996

• *'ho

U.S. NUCLEAR REGULATORY COMMISSION REGION 11 Docket Nos: 50-335. 50-389 License Nos: DPR47, NPF-16 Report No: 50-335/96-16, 50-389/96-16 Licensee: Florida Power & Light Co. Facility: St. Lucie Nuclear Plant, Units 1 & 2 Location: 9250 West Flagler Street Miami, FL 33102 Date: August 23,1996 Inspectors: K. Barr, Team Leader 'J. Munday, Resident inspector L. Wens, Project Manager i D. Thompson, Security inspector Approved by; A. F. Gibson, Director Division of Reactor Safety ? i i i i t i 4 4 p,n dulM j _ y U:} W l Q*

1 TABLE OF CONTENTS 1 i ' EXECUTIVE

SUMMARY

5 REPORT DETAILS 5 021, May-June 19g6 Relief Valve Potential Tampering Events 02.1.1 Evaluation and Conective of Damaged Components 6 02.1.2 Evaluation of Plant System for Additional Tampering 7 8 02.1.3 Site Management's Response to the May 1996 Event 02.2 Summary of the July 1996 Lock Tampering Event 10 02.2.1 Evaluation and Conection of Damaged Components 11 02.2.2 Evaluation of Plant System for Additional Tampenng 11 02.2.3 Site Management's Response to July 26,1996 Tampering Event 12 02.2.4 Implementation of interim Action to Detect New Tampering 13 13 l ~ S1.2.5 Security investigation of the Event S1.2.7 Evaluation of Compliance with the Physical Security Plant 14 l 02.3 Summary of August 1996 Event'Concoming Damage to Hot l-Shutdown Panel Keylock Switches 14 02.3.1 Evaluation and Correction of Damaged Components 15 02.3.2 Evaluation of Plant System for Additional Tampering 15 l 02.3.3 Site Management's Resporise to the August 14 Tamper Event 19 02.3.4 Implementation of Interim Actions to Detect New Tampering 21 S1.3.5 Security investigation of Event 22 L 02.3.6 Plant Licensing Basis 23 S1.3.7 Evaluation of Compliance with Physical Security Plant 24 INSPECTION PROCEDURES USED 26 ITEMS OPENED, CLOSED, AND DISCUSSED 26 EXIT MEETING

SUMMARY

27 PARTIAL LIST OF PERSONS CONTACTED 28 LIST OF ACRONYMS USED 29, Attac.hment A: Chronological Sequence of Events A-1, Attachment B: Information Provided to Licensee By NRC On August 15,1996 B-1. Attachment C: Photographs Showing Valve Locations and Examples Of Damaged Locks and Key Lock Switches C-1, Attachment D: List of Licensee Documents Reviewed D-1

- ~.. - ll-l l j i* I EXECUTIVE

SUMMARY

i St. Lucie Nuclear Plant, Units 1 & 2 i NRC inspection Report 50-335/w6-16, 50-389/96-16 A' Chronological Sequence of Events was estabished by the inspection team. That listing is contained in Enclosure 2, Attachment A to this report. Overall, the licensee's response to the potential and actual tampering events between May i and August 1996 was satefactory. Some response deficiencies were identified and are ~ discussed in the details of the report. In addition, two violations of regulatory requirements were identified,for (1) failure to make a report to NRC under 10 CFR 73 concoming damaged locks and (2) failure to follow procedure concoming control of keys to critical controls. An unresolved item (URI) was identified concoming differences between the Updated Final Safety Analysis Report (UFSAR) hvuon of the Hot Shutdown Paimi (HSDP) for Unit 1 and the instmmentation actually installed. An inspector follow item (IFI) was identified for 'I _ follow up on final implementation of interim actions to detect new tampering in a more timely

manner, In May and June 1996, the licensee identified two pressure relief valves which, when tested, were found to have pressure setpoints 55 percent and 9 percent above their design values.

These valves were also found to have broken wire seals. The licensee's documented technical evaluation identified, as possible root causes, tampering or unauthorized work by plant personnel. Licensee management subsequently determined the valve anomalies were not due to tampering. l Through discussions with the licensee and documentation review, the inspectors concluded that the licensee's policy on the use of wire seals was inconsistent. There were no clear instructions to apply wire seals and, as a result, a number of valves did not have seals attached. l Based on independent review of the documented facts, observations of the installed valve configurations, and the effort required to access the valve spring tension mechanisms, the ) inspectors concluded that tampering, although it could not be conclusively ruled out, was not likely to have occurred in either of these specific cases. A person knowledgeable enough about relief valve operation to tamper with the valves could use an easier method to prevent y proper operation of the valve. The more likely cause for the misadjusted valve was poor maintenance practices. j L The inspectors verified through documentation review that the two valves were either replaced or repaired. The inspectors verified through documentation review, that the V2325 setpoint was adjusted, properly tested and the valve reinstalled in the system. The inspectors concluded that site management appropriately pursued identification of the cause for relief valve V3483 having a high setpoint. In addition, because of the broken wire valve seal, appropriate walkdowns were coriducted to determine the extent of possible valve tampering. Once the extant was established, management appropriately evaluated and dispositioned the deficiencies.

2 Since tampering with valves V2325 and V3483 could not be conclusively ruled out, management's decmion to alert Security of the tampering possibelsty was appropriate. However, due to a communications lapse, site Security was not notified. The inspectors also concluded that failure to follow.through on alerting Site Security precluded actions to enhance security force arwareness to other possible tampering events. The inspectors determined that the event would not have been required to be reported to the NRC. However, the Secunty Manager should have been informed of the' event because Security Procedure, Reportmg of Safeguards Events, SP-0006125, Paragraph 5.2 states that "the plant security supervisor is responsible for making report ability determination under 10 CFR Part 73.71." On July 26,1996, eleven examples of actual padlock and door lock tampering were identified Nine padlocks and two door locks were found to have been intentionally damaged by having foreign material injected into the lock cores. These locks controlled personnel access to various pieces of plant equipment. The damaged locks were repaired and verified operational. Although the licensee's response to the damaged locks was completed in a timely manner, the extent of condition evaluation did not identify keylock switches as other locking devices that needed to be checked for damage. Management's response to the July event was not thorough in that keylock switches were not checked for damage until August. Identification of tampering of components within the vital area of the plant demonstrated that l additional tampering could likely occur. Therefore, the licensee should have considered additional measures to detect new tampering of equipment at the site in addition to alerting the Security force. The Corporate investigative staff adequately reviewed the event. The licensee failed to follow their procedure and report the confirmed tampering with the secunty equipment (locks) to NRC within one hour. This is a violation of regulatory requirements. On August 14,1996, three additional examples of actual lock taapering were identified. The lock mechanisms of the two keylock switches on the Unit 2 HSDP and the keylock switch on the Unit 1 HSDP were found to be intentionally damaged by having foreign material injected into tne lock cores. These were the only keylock switches on the panels. The inoperable Unit 1 power operated relief valve (PORV) control switch and the Unit 2 "A" and "B" channel safety injection actuation system (SlAS) bypass switches were replaced and operability was adequately verife' d. Following extensive reviews done by the licensee and independent verifications by NRC, the i inspectors concluded there was no evidence of additional tampering. 'I.

4 3 - The inspectors identdied that keys to operations equipment'were not properiy maintained in accordance with procedural requirements. This represents a violation for failure to follow procedural requirements. Site management satsfactorily evaluated, consstent with the known examples of tampering, the operational capability of the plant safety systems to perform their intended safety functions. Site management satafactority evaluated plant areas for foreign matenal and abnormalities. Site management did not use all available plant documentation of equipment deficencies (e.g., plant work orders) in its search for additional examples of tampering. Site management should have been more proactive in establishing interim actions to detect new tampering in a more timely manner by using plant staff observers as well as Security force members. The interim actions subsequently identified by plant management, if properly implemented, should provide reasonable assurance that new tampering were be promptly detected. The security force implemented good preventative measures to detect or prevent new tempering with plant equipment. f The licensee took appropriate and extensive actions to determine the individual (s) involved in the lock tampering event (s). With one exception, the design and installation of the HSDPs for St. Lucie Units 1 and 2 were in accordance with the licensing basis of the plants. The FSAR description of the controis and instruments installed on the HSDP for St. Lucie Unit i did not match the installed equipment in that the FSAR description did not indicate the installed nuclear instruments. The failure of the FSAR to correctly describe the installed equipment is identified as an URI. j Control of access to the HSDP rooms of St. Lucie Unit 1 and 2 was in accordance with the approved PSP for the site. The licensee was in compliance with the site PSP regarding access controls, patrols, alarm i. station operations, fitness for duty and access authorization. I During this site inspection, the inspectors independently reviewed a large number of plant records of Condition Reports (CRs) and Nuclear Plant Work Orders (NPWOs) in an attempt to identify any previously unidentified tampering events. No new tampering events were identified by the team. !', Attachment B contains information provided to St. Lucie site management by NRC to assist in the site's response to the events. The attachment contains NRC Information l Notice 83-27 concoming deliberate acts directed against plant equipment and intamai NRC guidance for plant system checkout following suspected sabotage. + w

4 Attachment C contains illustrative photographs of the valves, padlocks and keylock switches that were the subject of this inspechon. i l l 1 ( l

] l 1 j 14 c. Conclusion The Corporate invesbgative staff adequately reviewed the event. S1.2.7 Ev=W of Comohance with the Physical Security Plan I a. Inspechon Scope Determee if the licensee was in comoliance with their PSP and Procedures. 10 CFR 73.71, Reporting of Safeguards Events, Appendix G, (3) Reportable Safeguards Events, requires the licensee to report to the NRC within one hour of discovery, followed by a written report within 30 days, events which cause interruption t I of normal operations through tampering with controls including the security system. i b. Observations and Findenas The licensee's Security Procedure, SP-0006125, Reporting of Safeguards Events, Revision 9, dated April 20,1995, Paragraph 8.2 (1) defines one of those events as being a " confirmed tampering of suspicious origin with safety or security equipment." On July 29,1996, the licensee failed to foreow their procedure and report the confirmed tampering with the security equipment (locks) within one hour to the NRC. This is a violation (VIO) of regulatory requirements (VIO 50-335/96-16-01, j 50-389/96-16-01, Failure to report an event to NRC within one hour). c. Conclusion 4 The licensee failed to comply with requirements for reporting the event to the NRC. O2.3 Summarv of Auaust 1996 Event _Qoncemina Damaae to Hot Shutdown Panel Keviock Switches On August 14,1996, during a monthly surveillan::e of the Unit 2 HSDP at about 10:00 a.m., a plant operator discovered two key switches could not be operated because foreign material precluded the insertion of the keys into their locks. These were the only key switches on the Unit 2 HSDP. Each St. Lucie unit has an HSDP that was designed to be used to shutdown the unit from outside the unit main control room. The two damaged key lock switches operated channels A and B, respectively, of the SIAS to block unwanted actuation of the Safety injection (SI) system during unit cool down. Upon identification of the damaged Unit 2 key lock switches, a check of the HSDP for Unit 1 was conducted. The Unit 1 HSDP contained only one key switch on the panel. Similar to Unit 2, that key lock switch could not be operated because of foreign matenal in the lock mechanism. The damaged key lock switch operated the pressurizer PORV which provides a backup means to control primary system pressure if auxiliary pressurizer spray becomes unavailable while bringing the unit to a controlled shutdown condition. 4

NNDIBER 15, 1996 i I i' EA 96-458 Flonda Power and Light Company ATTN: Mr. T. F. Plunkett i Preesdent - Nuclear Division P. O. Box 14000 Juno Beach, FL 33406 0420

SUBJECT:

NRC INSPECTION REPORT NOS. 50-334/96-19 AND 50-389/96-19

Dear Mr. Plunkett:

This refers to the inspection conducted on October 21 - 25,1996, at the St. Lucie facility. i The enclosed report presents the results of this inspection. Based on the results of this inspection, two apparent violations were identified and are being considered for escalated enforcement action in accordance with the " General Statement of i Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1800. The apparent violations pertain to your failure to limit unescorted access to protected and vital areas during non emergency conditions and your failure to report that event under the enteria specified in 10 CFR 73.71. Accordingly, no Notice of Vioistion is presently bemg issued for these inspection findings. In addition, please be advised that the number and characterization of apparent violations described in the enclosed inspection report may change as a result of further NRC review. A predecisional enforcement conference to discuss these apparent violations has been scheduled for December 10,1996. The decision to hold a predecisional enforcement conference does not mean that the NRC has determined that a violation has occurred or that enforcement action will be taken. This conference is being held to obtain informaten to enable the NRC to make an enforcement decision, such as a common understanding of the facts, root causes, missed opportunities to identify the apparent violations sooner, corrective actions, significance of the issues and the need for lasting and effective corrective action. In particular, we expect you to address the breakdown of your access control program within the Flonda Power and Light Company organization. In addition, this is an opportunity for you to point out any errors in our inspection report and for you to provide any information concoming your perspectives on 1) the severity of the violations,2) the apphcaten of the factors that the NRC considers when it determines the amount of a civil penalty that may be assessed in accordance with Section VI.B.2 of the Enforcement Policy, and 3) any other appbcaten of the Enforcement Policy to this case, including the exercise of discreten in accordance with Section Vll. i , o ff' ( h n L. .fj M blApylW/u v v I HW l

FP&L 2 This conference will be closed to public observation in accordance with the Commesson's contmuing trial program as discussed in Section V of the NRC Enforcement Policy, NUREG 1600 (Enclosure 2). You will be advised by separate correspondence of the results of our delibersbons on this matar. No response regarding these apparent violations is required at this time. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and its enclosures will be placed in the NRC Public Document Room. Sincerely, ORIGINAL SIGED BY AIEERP GIBSGI Albert F, Gibson, Director Division of Reactor Safety j Docket Nos. 50-335, 50-389 License Nos. DPR-67 NPF.

Enclosures:

1. Inspection Report 50-335, 389/96-19

2. NUREG 1600, Enforcement Policy ec w/ encl:

J. A. Stall Site Vice President St. Lucie Nuclear Plant P. O. Box 128 Ft. Pierce. FL 34954-0128 H. N. Paduano, Manager Licensing and Special Programs Florida Power and Light Company P. O. Box 14000 Juno Beach, FL 33408-0420 i J. Scarola i Plant General Manager St. Lucie Nuclear Plant P. O. Box 128 l Ft. Pierce, FL 34954-0128 (cc w/encis cont'd - See page 3) A b

FP&L 3 (cc w/encis cont'd) E. J. Wemkam Plant Licensing Manager St. Lucie Nuclear Plant P. O. Box 128 Ft. Pierce, FL 34954-0218 M. S. Ross, Attomey Florida Power & Light 11770 US Highway 1 North Palm Beacn, FL 33408 John T. Butler Esq. Steel, Hector and Davis 4000 Southeast Financial Center Miami. FL 33131-2398 Bill Passetti Office of Radiation Cantrol Department of Health and Rehabilitative Services 1317 Winewood Boulevard Tallahassee, FL 32399-0700 Joe Myers, Director Division of Emergency Preparednesc Department of Community Affairs 2740 Centerview Drive 4 Tallahassee, FL 32399-2100 Thomas R. L. Kindred County Administrator' St. Lucie County 2300 Virginia Avenue Ft. Pierce, FL 34982 Distribution w/enets. K. Landis, Ril J. Noms, NRR B. R. Crm%y, Ril G. Mepper, Ril C2. A. Hallstrom, Ril PUBLIC 4 Distnbution w/encis cont'd - See oaoe 4: L

FP&L 4 1 l DistnhubonWends. cont'd NRC Residen. ;rspector U.S. Nudear b ',guistory Comm. 7585 South Highway A1A Jensen Beach, FL 34957-2010 j 1 l 4 i are. r et, w .,1 . n .t g .tr.eres ett.ac .tv nas !! GNAT @! N l %AME .JC JULI W VFRRELLI r W. (VANS GIB W OATE 11/ '6k / M h M d / 96 11/h/96 7 4k / 96 11/II].16 11/k 96 3 ccPy? ( YES) NO MA7 YE5 g~l I"Yn ) W YES ( NO) 6ES/ NO vre aiA.muw ws m mn. 2n g voars. t - 1 i d 4 s l 1 1 i

U. S. NUCLEAR REGULATORY COMMISSION REGION 11 Docket Nos: 50-335, 50-389 License Nos: DPR-67, NPF-16 Report Nos: 50-335/96-19, 50-389/96-19 Licensee: Florida Power and Light Company Facility: St. Lucie Nuclear Plant Units 1 and 2 Location: - 9250 West Flagler Street Miami, FL 33102 Dates: October 21 - October 25,1996 Inspector L. Stratton, Safeguards inspector i Approved by: Paul E. Fredrickson, Chief Special Inspection Branch Division of Reactor Projects i l 4 4 ENCLOSURE 1

) EXECUTIVE

SUMMARY

St. Lucie Nuclear Plant Units 1 and 2 NRC inspechon Report 50-335/g6-1g, 50-38g/g6-1g-1 This rouhne announced inspechon was conducted in the area of plant support by a regonal i safeguards speashst. The spedk area evaluated was the Physcal Secunty Program for Power Reactors. Portens of the hcensee's Fitness for Duty program with respect to adulterated samples and the appeal process were reviewed and found to be in accordance whh requirements (10 CFR 26 (S1.3)). The hcensee's failure to prevent unauthorized unescorted access into the protected area and potental access into vital areas is an apparent violation of regulatory . requirements. (S2.1) The licensee's failure to log in the Safeguard Event Logs or make a one hour report within the required time with respect to the access control events described in Paragraph S2.1b is an apparent violation of regulatory requirements. (S4.1) The Training and Qualification Plan was reviewed with respect to conducting physical fitness tests of security personnel and found to meet the requirements. (S5.1) Through document review and interview of licensee representatives, the inspector determined that the portion of the audit program evaluated ww, adequate. i j l

I i REPORT PETAILS j 81 Conduct of Security and Safeguards Activities S1.3 Fitness for Duty a. Inspection Scope f81502) In accordance with 10 CFR 26.10(a), the licensee must provide reasonable assurance that nuclear power plant personnel will perform their tasks in a reliable and trustworthy manner and are not under the influence of any substance, legal or illegal, or mentally or physically impaired from any cause, which in any way could adversely affect their ability to safety and competently perform their duties. b. Obserystions and FindiDER On October 21,1996, at the Florida Power and Light (FP&L) Company corporate offices, the inspector reviewed ten randomly selected records to verify compliance with 10 CFR 26. The inspector noted that one record documented that an individual was given a chemical test on January 4,1996; however, the test result was j documented as a " refusal." Upon further discussion with licensee representatwes, the l inspector leamed that a confirmed adulterated sample was documented as a refusal ' by the licensee. On January 5,1996, the licensee's contract laboratory's report documented that the sample appeared to have a " soapy" presence. Upon request from the licensee's Medical Review Officer (MRO), the contract laboratcry sent the possible adulterated sample to another independent laboratory for review. That laboratory confirmed the presence of an anionic surfactant. The licensee determined this was a failure to cooperate with the testing requirements, therefore deemed the test results as a refusal. The individual was again tested by observation on January 5,1996, with the results being negative. l 10 CFR 26 requires that when an-individual's test results are confirmed positive, the licensee must offer an appeal process to that individual. Since the results of the individual's test discussed above was categorized as a refusal, the licensee did not offer an appeal under 10 CFR 26. However, the inspector noted that on June 24, 1995, the individual was given an appeal based on 10 CFR 73.56, access authorization requirements. The licensee informed the inspector that since the l sample was confirmed adulterated, the individual's trustworthiness and reliability were in quesbon. Therefore the suspension of his unescorted access was appealed, rather than the adulterated sample results. The appeal board suggested reversing the denial nf unescorted access based on the ] Individual's willingness to cooperate; the fact that FP&L's policy did not adequately t address adulteration; and the individual's second negative sample. The licensee is currently evaluating the case. i

1. i 2

L ) c. Conclusions i Through document review and discussen with licensee rep,-_::-- _^ ;x, the LA-concluded that the portens of 10 CFR 26 that were reviewed met reguietory requwements. There were no violetons of regulatory requirements noted. S2 Statue of Security Facilities and Equipment S2.1. Pertected and Vital Area Agcess Control i j a. Insoscten Scone (81700) l 10 CFR 73.55(d)(7) requires that licensee's shall establish an access authonzaten l system to limit unescorted access to vital areas dunng non-emergency conditions to 1 mdeduals who require access in order to perform their duties. l Tne licensee's Physical Secunty Plan (PSP), Revision 48, dated 2/23/96 states, "Only j those individuals with identified need for access and having appropnote authonzstan, l shall be granted unescorted Vital Area access." b. Observatens and Findinas The licensee documented on August 19,1996, in Condition Report (CR) 96-2041 that an individual was presented a FP&L severance package on July 17 and upon retuming to St. Lucie on August 14, leamed his badge was never deactivated. In response to the CR, the licensee determined an administrative error had occuned and i-this error was an isolated event. On September 19,1996, the licensee's access coordinator determened that three other former FP&L employees who were favorably terminated in July continued to have active badges to the St. Lucie facility. The access coordinator immediately removed the individuals' access from the secunty computer. On October 9,1996, the licensee discovered that one of the individuals determmed not to need access on September 19, had entered mto the protected area on five different occasions on August 7, August 9, and August 15,1996. The individual did not enter vital areas on these dates. Upon intervow, the licensee loamed the individual had retumed to the site for a job interview and to " generally talk to some people." In response to the discovery, the licensee initiated an audit on October 21,1996, for the penod of January 1,1996 to the present of individuals who had been terminated. The audit, which was completed October 31,.1996, encompassed checking 594 individuals' names /socal secunty numbers against active badges in the secunty 4 computer. Through this corrective action, the licensee discovered six additenal j individuals; two with access to St. Lucie; three with access to Turkey Point, and one ENCLOSURE 1 .w

.j 3 ' with access to both facilities. All six individuals subsequently identified had not accessed the protscled or vital areas after the date of their termmation. Upon discoverv, the licensee deactuated those individuals' badges. The inspector reviewed Administrative Procedure (AP) 10509, " Personnel and Malenal Control,". Revision 18, dated September 30,1996. The procedure clearly states the responsibility to notify secunty that an individual is terminated rests with (1) the individual to tum in his security badge; (2) department head and supennsors to notify secunty when unescorted access is no longer required; and (3) the Plant Resource Control Supervisor or Human Resources to notify secunty of personnel changes. However, all three avenues of the procedure failed to be implemented. The inspector did note that although the procedure clearly states responsability, a temunabon of access form /checidest was not provided, which could possibly ensure hardcopy I documentation in the event secunty was not notefied. c. Conclusions The licensee's failure to prevent unauthonzed unescorted access into the protected area and potential access into vital areas is noted as an apparent violation of regulatory requirements (10 CFR 73.55 (d)(7) and eel 50-335, 50-389/96-19 01). ~ j S4 Security and Safeguards Staff Knowledge and Performance S4.1 Records and Reoorts a. insoection Scone (81038) 3 10 CFR 73.71, states that an actual entry of an unauthonzad person into a protected area or vital area be reported within one hour of discovery. 10 CFR 73.71, states that any failure, degradation, or discovered vulnerability in a safeguards system that could have allowed unauthonzed or undetected access to a protected area or a vital ares had compensatory measures not been estabisshed, be recorded within 24 hours of discovery in the safeguards event log. b. Ooservations and Findinas Upon review of the access control event detailed in Paragraph S2.1b, the inspector reviewed Secunty Procedure (SP) 6125, " Reporting of Safeguards Events," Revision 10, dated October 9,1996. The procedure accurately outlines the provisions specified in 10 CFR 73.71, Appendix G. However, on September 19,1996, the licensee failed to document in the Safeguards Event Log (SEL) the possibility of three individuals having unescorted access to p,eeded and vital areas In addition, on October 9,1996, the licensee failed to make a one hour report when they discovered - that one of the individuals who maintained unescorted access after terminaten, actually entered the protected area on five occasons. Upon further review, the ENCLOSURE 1

i 4 liconese determmed that a one hour report was warranted. On Octo'bor 16,1996, the licensee made a one hour report to the NRC under the provisens of 10 CFR 73.71. c. Censlunkma The licensee's failure to log in the SEL or make a one hour report withm the reqused time with respect to the access contml events desenbod in Paragraph S2.1b is an apparent violation of regulatory requirements (eel 50-335,50-389/96-19-02). 3 l SS Security Safeguards Staff Training and Qualification j S5.1 Secunty Trainina and Qualification l a. lnscechon Scone (81700) l The mspector reviewed the secunty training and qualificaten (T&Q) pmgram to ensure that the criteria specified in the licensee's T&Q plan were being met in the l area of conductin( 1hysical fitress tests for security personnel. i b. Observations and Findinas l The inspector reviewed T&Q Plan implementmg instruction, Revisen 2, dated September 9,1996, to verify the licensee was conducting the physical fitness test for security personnel in accordance with the requirements of the T&Q Plan. The inspector noted that Attachment 3 had been added to the procedure, which is a 2 detailed instnsction on conducting the physcal fitness test. Prior to this revision, the procedure only documented what the test entailed and the time penod required to perform the test. Attachment 3 denotes specific matenal required and detailed L guidelines to ensure all physical fitness tests are performed consistently. The inspector noted the procedure specifies that if an individual fails to pass the required physical fitness test within 72 hours a second attempt may be made. However, on one occasion, an individual did fail both attempts to pass the physcal fitness test by not meeting the required time allowance, yet was allowed to make a third attempt. Further discussion with licensee representatives revealed that those two attempts at the physical fitness test were prior to the addition of Attachment 3 to the T&Q Plan implementing instruction. The licensee determined that those two tests ] may not have been conducted consistently, therefore allowmg an ermr in the actual timekeeping. However, since the test is now better standardized, the timekeepern margin of armr has been eliminated. The licensee considers this individual's second attempt as a re-test rather than a second try. i ENCLOSURE 1 l e Ye + 1 %r

k i 5 c. Condumans Through interwow of secunty personnel and procedural review, the inspector detomuned that the licensee was meeting the prowseons of the T&Q Plan with respect to physical fitness testing. 87 Quality Assurance in Secudty and Safeguards Activities 1 S7.1 Audits a.' inanechon Smaa (81700) Chapter 14. of the licensee's Physical Secunty Plan, Rewson 48, dated February 23, t 1996, denotes the security program shall be audited no less frequently than once evety 12 months. i b. Observations and Findinas - The it:spector reviswed a portion of the Security and Safeguards Information - Functional Area Audit QSL-OPS-96-03, dated April 22,1996 to verify that the required i elements of the security program were reviewed. The audit was performed by the Qtiality Assurance Department, located at FP&L's corporate offices. The audit report was fumished to site and corporate management as appropriate. Numerous strengths were noted in the areas of secunty's self-assessment program, trac 6ung and trendmg of personnel and hardware performance, and unannounced crucial tasking of secunty officers. Two technical recommendations were noted: (1) Land Utilization Procedure LU-Ql-11.0-20 be rowsed to include dimensional verification (to ensure the 96 square in limit is roet) of selected panels during safe-net inspections. j (2) Substitute the simulated crawl test (conducted with a sled and aluminum ball) with another method desenbed in Regulatory Guide 5.44. The inspector noted that the audit rerort covered AP-10509, " Personnel and Matonal Control;" however, no findings by the. auditors were documented. Further evaluation of the licensee's audit program for security will be rowewed in future inspections. c. Condustons Through document review and interview of licensee representatives, the inspector determmed that the portion of the audit program evaluated was adequate. ENCLOSUREi i

1 i 6 88 Miscellaneous Security and Safeguards issues i S8.1 Achon of Prevous insongpon Findmos (92904) (DISCUSSED) IFl 96010. This IFl will remain open pending the completon and future performance of the hcensee's FFD program. S8.2 Followun on Tamoenna Event in response to the recent tampering events that occurred at St. Lucie, the licensee had inihated additional measures as noted below: At the time of this inspection, twelve boxes in remote locations in various vital areas to house a camera and a VCR were in place. The licensee plans to i have a total of 19 locations. All locations will have a camera installed. Two VCRs with a backup battery capacity of 720 hours. These two VCRs will be rotated to two of the nineteen locations every 24 hours, with one VCR per unit. The licensee implemented mese additional measures beginning October 4,1996. The evening Security Shift Supervisor will be responsible for selecting the l location and ensuring the VCR is installed. All VCR boxes are locked with security controlled keys. i ) The inspector noted that temporary extension cords were currently Deing used to support the operation of the cameras and VCRs. The licensee informed the inspector they plan to run the cords through the existing cabling after an i engineenng study has been performed sometime in late November. The two extra patrols the licensee had in place are no longer being utilized. All nineteen locations have signs in the area waming personnel of the possibility of being observed by remote cameras. The tapes will be maintained for approximately two weeks, according.to the implementing procedure. The inspector and a secunty shift specialist performed a walkdown of vital areas to observe the boxes that were currently installed. Additionally, the inspector reviewed tapes of several locations to determine if the angle position of the cameras was adequate. All cameras captured ingress and egress points of particular vital equipment selected to be viewed I ENCLOSURE 1

') 7 EEGanoment Meetinos 4 X1 Exit Moebng Summary ' The inspedor presented the inspmxion results to hconsee management at the conciusion of I the inspechon on October 25,1996. The inspector noted and docussed two apparent woletions with respect to access control and reportability requsements. The hconoce acknowisdood the findmos presented. Although renewed dunng this inspechon, proprietary informsbon is not contained in this report. Desentme comments were not recorved from the hconsee. PARTIAL LIST OF PERSONS CONTACTED Licensee D. Bonthron, Access Program Supervisor, Florida Power and Light (FP&L) A. Cummmes, Fitness for Duty Coordinator, St. Lucie Nuclear (SLN) S. Plantz, Security Training, SLN J. Scarola, General Manager, SLN E. Weinkam, Licensmg Manager, SLN W. White, Secunty Manager, SLN NBC. ~ M. Miller, Senior Resident inspector INSPECTION PROCEDURES USED IP 81038: Reporting Requirements IP 81502: Fitness for Duty Program IP 81700: Physical Secunty Program for Power Reactors IP 92904: Achon on Previous inspection Findings ITEMS OPEN, CLOSED, AND DISCUSSED Opened 50-335, 50-389/96-19-01 eel Failure to limit unescorted access to protected and vital areas during non-emergency conditions to individuals who require access in ortier to perform their dubes. 50-335, 50-389/96-19-02 eel Failure to report an event under the criteria of 10 CFR 73.71 i Discussed 50-335, 50-389/96-10 IFl FFD Staff Reorganasten and Corrective Achons i ENCLOSURE 1 1 i

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~ ~ .~ _. _ _ _.~. - - -. - i uNrtED STATES

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NUCl. EAR REGut.ATORY N t ,s E 101 MAfutTTA STREET, N.w.. surTE 300 5 "M% W W EA 96-464 t Florida Power and Light Company ATTN: Mr. T. F. Plunkett President - Nucisar Division r P. O. Box 14000 L Juno Beach, FL 33408 0420 l

SUBJECT:

NRC INSPECTION REPORT NOS. 50-335/96-18 AND 50-389/96-18 4 Dear Mr. Plunkett. This refers to the inspechon conducted during the period October 7 - November 1,1996, at your St. Lucie facility. The enclosed report presents the results of this inspechon, as we,il as a summary of follow-up telephonic conferences conducted on November 14,25, and 26, 1996. Based on the results of this inspection, three apparent violations were identified and are being considered for escalated odorcement action in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions"(Enforcement Policy), L NUREG-1600. These apparent veistens were concemed with 1) failure to adequately maintain the capability for timely augmentation of your Emergency R:;-:-,ee Organizabon during off-hours,2) failure to establish and maintain adequate procedures for the ) implementaten of certain requirements containoa in the Radiological Emergency Plan, and 3) failure to adequately implement multiple aspects of your training program for Emergency Response Organization personnel. Accordingly, no Notice of Violation is presently being issued for these inspection findings. In addition, piense be advised that the ' number and characterization of apparent violations described in the enclosed inspecten j report may change as a result of further NRC review. A predecisional enforcement conference to discuss these apparert violations has been scheduled for December 10,1996. The decision to hold a predessional enforcement conference does not mean that the NRC has determined that a violation has occurred or that enforcement action will be taken. This conference is being held to obtain information to enable the NRC to make an enforcament decision, such as a common understanding of the facts, root causes, missed opportunities to identify the apparent violations sooner, conective actions, significance of the issues and the need for lasting and effective conective action. In addition, this'is an opportunity for you to point out any errors in our inspection report and for ,you to provide any information concoming your perspectives on 1) the severity of the - ~ ' violations,2) the appimation of the factors that the NRC considers when it determines the amount of a civil penalty that may be assessed in accordance with Section VI.B.2 of the Enforcement Policy, and 3) any other application of the Enforcement Policy to this case, including the exerene of discretion in accordance with Section Vll. We also bring to your attention the fact that an apparent deviation from commitments made to the NRC was identified during the inspection, and will be discussed during the conference. No Notice of Deviabon is presently being issued for this inspection finding. jj}hD ? h

) 4 J FP&L 2 \\ ^ You will be advised by separate correspondence of the results of our deliberstens on this matter. No response regarding these apparent violatons or deviabon is required at this time. in accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and ~ its enclosure will be placed in the NRC Public Document Room. 1 Sincerely, ORIGINAL SIGNED BY A. F. GIBSON l l Albert F. Gibson, Director J ] Drvision of Reactor Safety Docket Nos. 50-335, 50-389 l License Nos. DPR 67, NPF-16

Enclosure:

Inspection Report 50-335/96-18, 50-389/96-18 cc w/ encl: M. S. Ross, Attomey J. A. Stall Fionda Power & Light ]: Site Vice President 11770 US Highway 1 St. Lucie Nuclear Plant North Palm Beach, FL 33408 P. O. Box 128 Ft. Pierce, FL 34954-0128 John T. Butler, Esq. L Steel, Hector and Davis H. N. Padueno, Manager 4000 Southeast Financial Center Licensing and Special Programs Miami, FL 33131-2398 Florida Power and Light Company P. O. Box 14000 Bill Passetti Juno Beach, FL 33408-0420 Office of Radiation Control Department of Health and J. Scarola Rehabilitative Services Plant General Manager 1317 Winewood Boulevard St. Lecie Nuclear Plant Tallahassee, FL 32399-0700 [ P. O. Box 128 Ft. Pierce, FL 34954-0128 Joe Myers, Directoi Division of Emergency Preparedness E. J. Weinkam Department of Community Affairs Pla."t Licensing Manager 2740 Centerview Dnve St. Lacie Nuclear Plant Tallahassee, FL 32399-2100 P. O. Dox 128 Ft. Pierce, FL 34954-0218 Thomas R. L. Kindred County Administrator i St. Lucie County 2300 Vuginia Avenue Ft. Pierce, FL 34982 I ' ~

U.S. NUCLEAR REGULATORY COMMISSION REGION ll \\ Docket Nos.: 50-335, 50-389 License Nos: DPR 67, NPF-16 Report No: 50-335/96-18, 50-389/96-18 Licensee: Florida Power and Light Company Facility: St. Lucie Plant, Units 1 and 2 Location: 9250 West Flagler Street Miami, FL 33102 Dates: October 7-18 and October 28-November 1,1996 Inspectors: James L. Kroh, Radiation Specialist 4 Daniel M. Barss, Emergency Preparedness Specialist Approved by: Albert F. Gibson, Director Dnnsion of Reactor Safety l l l .-{f M 3-L{ D, g,p)9

L EXECUTIVE

SUMMARY

St. Luae Plant, Units 1 and 2 NRC inspechon Report Nos. 50-335/96-18, 50-389/96-18 l The purpose of this special inspechon was to review and evaluate the onsite emergency preparedness (EP) program. Significant negative findings were identified, including three apparent violations, one apparent deviation, one Unresolved item, and one EP Program Weakness. i Anoarent Violabons During the approximate period July 22-October 3,1996, the licensee failed to maintain the capability to execute the provisions of the Radiological Emergency Plan (REP) and the associated Emergency Plan implementing Procedures (EPIPs) in a timely manner with respect to mobilizabon of the Emergency Response Organization (ERO) dunng off-hours (Section P2.1). The EPIPs did not adequately implement the requirements of the REP in the following i f respects: (a) recovery achvibes, discussed conceptually in REP Section 5.4, were not J adequately addressed in EPIPs; (b) the EPIPs did not adequately describe and ) l delineate the licensee's ERO arsd the detailed means for notifying ERO members in an emergency; and (c) REP Section 2.4.4 regarding OSC relocation was not 1 n adequately implemented by the EPIPs (Section P3.2). The licensee failed to implement the training program for ERO personnel as specified in the REP and EPIPs since at least 1994, as evidenced by the: (a) failure to provide f annual retraining to certain designated personnel in 1994 and 1995, (b) failure to provide any training for certain ERO positions with respect to selected implementing procedures, and (c) failure to, remove individuals from the ERO roster when their qualifications had lapsed (Sections P5.1, P5.3, P5.4). Apparent Deviation The licensee failed to relocate the requirements formerly found in Technical Specifications 6.8.1.d and 6.8.1.e to the Security Plan and Emergency Plan, respectively, in accordance with wntten commitments to the NRC (Section P3.1). Unresolved item ' The ERO training program, described in REP Section 7.2.2, did not, as implemented, include a programmatic method to ensure that each ERO member demonstrated an ability to perform assigned emergency functions through participation in exercises ] and/or drills (Section P5.2). L 4 d Enclosure i'

..-._ ~ I Ememency Preparedrwss Pronram Weakness ) Management failed to ensure the impismentation of timely corrective actions for certain emergency preparedness defkzenoes and weaknesses. Examples include: (a) failure to resolve concerns regarding the audibility of the Gaitronics (or plant j pubic-address system) formally identified in late 1994; (b) failure to' provide timely i corrective action to address a questionable capability for notification of the State of Fionda within 15 minutes of an emergency declaraten; and (c) failure to implement timely corrective actions for deficsonoes and recommendations identified by the critique of the Hurricane Erin response in August 1995 (Section P7.1). 3-Positive Observations Good progress has been made in the last several months to develop and implement corrective actions to address the large number of open concems in the St. Lucie emergency preparedness program (Section P7.1). Significant improvements in the emergency preparedness training program have been initiated (Section F5.1). T R t, I i! i Enclosure i

__ ~ _ _ _ _ _. _ _.. _.. _ _ .4 REPORT DETAILS l P2 L Status of EP Facilities, Equipment, and Resources P2.1 Mobdmation of the Emernency Response Omanmatio7 s. Inspechon Scone (82701) 3 l The inspectors reviewed the licensee's strategy and provisens for notificaten and mobilmation of its personnel in the event of an off-hour emergency det.ieration ) requiring activation and staffing of emergency response facilities (ERFs). In addition l to the Control Room, the licensee's ERFs compneed an onsite Operational Support . Center (OSC) and Technical Support Center (TSC) and an offsite Emergency Operatens Facility (EOF). This review included evaluation of the adequacy and i implementation of the following Emergency Plan implementing Procedures (EPIPs): EPIP 3100021E, Duties and Responsitulities of the Emergency Coordinator, Revision 43, approved September 12,1996. EPIP 3100023E, On-Site Emergency Organization and Call Directory, Revision 72, approved September 12,1996. b. Observations and Findinos Section 2.4 of the Radiological Emergency Plan (REP) desenbod the licensee's' methodology for notification of the emergency response organization (ERO) in the . event of an emergency declaration at the Alert level or higher. In such a 5 - circumstance, timely staffing and activation of the TSC and OSC (and the EOF at a Site Area Emergency or General Emergency declaration) would be required, except possibly for situations in which the declaration is terminated rapidly following l resolution of the adverse initiating condition. l The implementing details for the ERO notification methodolcgy were located in EPIP 3100023E. Step 8.2 of the instructions in that procedure specified that on-shift 2 staff augmentation, when required, was initiated from the Control Room by means of either the automated system known as the Emergency Recall System (informally called " autodialer") or the manual backup system utilizing Appendix A, " Duty Call Supervisor (DCS) Call Directory", of the procedure. ] On the evening of October 3,1996, the licensee initiated a staff augmentation test 4 using the autodialer. The system did not operate, and no individuals received j L notifications during the test. No attempt was made at that time to conduct the test using the backup method. A failure assessment by the licensee disclosed that the autodialer had been in an inoperable configuration from about July 22 through October 3,1996. According to the licensee, this configuration resulted when the c autodialer computer was rebooted without first closing the database file that compiled j personnel information used in the notification scheme. The inoperability of the autodialer could have been identified much earlier than October 3 had periodic 1 Enclosure l 4 1 s~> ~ ~ ~e-~ v e w

2 . funcbonellests (e.g., wee 6Jy) been performed to verify that the system was in an l operable configuraten. With approprisia admrustratwo controls.in place, as had been { recommended by a member of the EP staff as earty as April 1996, together with teshng, extended penods of autodialer inoperability would almost certainly have been )wecluded. An earlier, limsted-scope autodmier problem occuned dunng the NRC evaluated Jurm 1993 exercise (see Exercise Weakness 50-335, 50-389/93-16 04: Failure to activate the EOF in a timely manner). Review d licensee ] documentaten also disclosed that an ERO augmentabon drill conducted on December 14,1994 ubiang the autodmier was ur-===ful because of technical. problems with the system. Conective actions for these previous problems were not sufficiently comprehensive to detect the recent system malfuncten. l The manual backup augmentation method was a " call-tree" strategy (displayed graphically in Figure 3 of EPIP 3100023E) which depended upon notificabon by the DCS of persons away from the plant site, with some of those persons sut::g= 4 responsible for notificatens of others. The inspectors reviewed the details of how, and by whom, the manual call-out process would be implemented. The inspectors interviewed 14 of the 17 persons whose names were listed in Appendix A of i l EPIP 3100023E as call-tree functionaries who would need to have the cunent version of that procedure available if contacted by the DCS during off-hours in order to notify others in the call tree. Three indivictuals listed in Appendix A for the position of TSC Chemistry Supervisor and one individual listed as OSC Supervisor ackncd:-t+1 that, prior to October 1,1996, they did not maintain a copy of EPIP 3100023E st home and were not fully cognizant of their assignments in the call-tree scheme. Most interviewees stated that they,sttempted to maintain a copy of EPIP 3100023E at home, but, without appropriate contrr>lled distributen, may not have had the up-to-date revision. Prior to October 10,1996, only 3 of the 17 referenced individuals were on the list for contmiled distribution of EPIP 3100023E, which was updated at least quarterly. The licerisee had not conducted drills or other specific training to confirm individual performance and to verify the overall function of the manual call-out system for at least the last three years. The inspectors concluded that staffing and activaten of ERFs using the manual process would not have been timely. As indicated by REP l Table 2-2A, " timely" staffing and activation of an ERF means within about 60 minutes of the emergency declaration warranting such activation. A drill conducted during off-hours on October 10,1996 was marginally successful in that it indicated staffing times of about one hour could have been achieved. However, this occurred only after wntten and oral instruction, procedure distribution, and announcement of the drill to l affected persons. Since no actual travel to the plant was involved, this drill did not constitute a highly accurate measure of the actual time required to staff and activate l the ERFs. c. Conclusions i The inspechon determined that the licensee failed to adequately maintain both the automated system for ERO call-out (from about July 22 to October 3,1996) and the manual backup system over an indeterminate period (at least the last several years). The concurrent deficencies in the automated and manual systems for ERO call-out represented a failure by the licensee, during the period July 22-October 3,1996, to Enclosure l l

h (,. i 3 mentain the capabihty to execute the provisions of the REP and its implementing pmcodures in a timely manner with respect to augmentabon of the ERO during off-hours. This failure to comply with the requwoment of 10 CFR 50.54(q) that nucisar power plant licensees follow and mentam in effect emergency plans which meet the pionrung standards of 10 CFR 50.47(b) and the requwements in Appendix E to 10 CFR Part 50 is identified as Escalated Enforcement item (EEI) 50-335, 50-389/96-18 01: ERO augmentabon scheme not mentained adequately, I P3 EP Procedures and Documentation ' P3.1 Radelonical Emeroency Plan s. Inacechon Scope f82701) j The inspectors selectively reviewed changes made to the REP since the NRC's l proveus program inspechon of this area (conducted in February 1995) to determme whether any of these changes had decreased the effechveness of the REP. i 4 i b. Observations and Findanas j l Since February 1995, the licensee had issued four revnions to the REP (Revnions 28-31). Revnion 30 (dated July 31,1996) and Revision 31 (dated . September 13,1996) were selechvely reviewed and diame==d with licensee i personnel, since those revosons had not been formally evaluated through the NRC's j license review process. Revision 30 primarily promulgated the modifications associated with the transfer of the Nuclear Division staff from the corporate office to the St. Lucie and Turkey Point sites. With respect to the EP program, this entailed the transfer of program management and oversight responsibilities from the Manager, Nuclear Emergency Preparedness (in i the corporate office) to the Site Services Manager (a position later renamed Services Manager, and which reports directly to the Site Vsco President), and the addition of a third Emergency Planning Coordinator to the St. Lucie EP staff. In addition, the Off-site Emergency Response Organization (which provided personnel for the EOF) became the Expanded Emergency Response Organizaten. The inspectors evaluated i these changes in detail and discussed them with cognizant licensee representatives, including the former Manager, Nuclear Emergency Preparedness, the Services Manager, and a Quality Assurance (QA) Senior Analyst. The inspectors determined that strong EP program oversight would be required from the Services Manager to ~ preclude further degradaten of the effectiveness of the licensee's EP program and to implement appropriate corrective actions for the findings of this inspection, and that such a level of oversight is defined and required by provisions of both the REP and procedure QI 1-PR/PSL-1, " Site Organization", Revision 30, dated September 1996. The changes made in Revision 31 were primarily concemed with the licensee's efforts to standardize the REPS for its two nuclear plants. 1 4 - Enclosure 4 p

q-4 E The inspectors ascertamed that the licensee had rece'ntly made changes to the 1 Technical Specmcations (TS) for the St. Lucie Plant which included implications for the REP, as well as the Security Plan. Amendment Nos.147 and 86 to the operatmg licenses for Unit 1 and 2, respectwely, were approved by the NRC on August 20,' 1996, and consisted of changes to the TS in response to the licensee's application dated August 16,1995. Among numerous changes in these amendments were the delsbon (for both Unit 1 and 2) of the previous TS 6.8.1.d and TS 6.8.1.e, which fonnerly specified that " Written procedures shall be established, implemented and maintamed" to cover " Security Plan implementation" and " Emergency Plan i implementation",' respectively. These changes were proposed by the licensee in response to NRC Generic Letter (GL) 9347, dated December 28,1993, which authonzed licensees to propose modifications to certain TS administrative control ] requirements for emergency and security plans. In Attachment 2, " Safety Analysis", to the August 15,1995 application, the licensee stated (in the introduchon to the section addressmg modifications to TS 6.5.1.6.1, 6.5.1.6.J. 6.8.1.d, and 6.8.1.e) that the " selected Technical Sped &.u,ns are bemg relocated to the Emergency Plan or Security Plan as appropriate. Reisc.,0w these requirements to the appropnate plan ] will ensure the control of future changes are under the requirements of 10 CFR 50.54, 10 CFR 73.55 and 10 CFR 73.56." The NRC's referenced approval stated that the " licensee proposes to relocate these review requirements and their implementmg procedures to the St. Lucie Security and Emergency Plans..." The licensee's application did not specifically state that TS 6.8.1.d and 6.8.1.e would be deleted without relocation to the Security Plan and Emergency Plan, as applicable, nor did it provide a justification for such an agivedi, which would be explicitly contrary to the detailed guidance on page 2 of Enclosure 2 to GL 93-07. As of the end date of the i current inspection, the licensee had not relocated the requirements formerly found in TS 6.8.1.d and 6.8.1.e to the Security Plan or Emergency Plan, as applicable. j Condition Report (CR) No. 96-2611 was written to identify the discrepancy discussed i here with respect to the REP, but corrective action was not expected to be completed until issuance of the next REP revision near the end of 1996. c. Conclusions j The inspectors concluded that the changes in REP Revision 30 associated with the licensee's August 1996 reorganization and the changes in Revision 31 did not decrease the effectiveness of the REP. The licensee's failure to relocate the requirements formerly found in TS 6.8.1.d and 6.8.1.e to the Security Plan or l Emergency Plan, as applicable, in accordance with a wntten licensee commitment, is identified as an apparent deviation (eel 50-335, 50-389/96-18-02): Deleted TS not relocated to Security Plan and REP. I L P3.2 Emeroency Plan implementino Procedures a. Inspechon Scope (82701) The mspectors reviewed the licensee's administration of selected REP requirements through evaluation of the adequacy of the implementing details contained in the EPIPs. L Enclosure i

'O 5 4 b. Observabons and Findmos l In accordance with regulatory requirements and guidance, the licensee m-2 cntens to be used to determme when, followng an accident, reentry and recovery acten could be initieted. As guidance for CVii and conducting recovery operations, the hcensee developed a document entitled, "Flonda Power & Light Company Nuclear Power Plant Recovery Plan"(Recovery Plan). This document was not controlled as part of the REP or EPIPs, though it was clearly an adjunct to the REP and interdependent with the EPIPs. There appeared to be no admmistrahve 2 guidance that controlled the development, distribubon, and periodic review of the Recovery Plan. The licensee had established, and followed, penode review requirements for the Emergency Plan and EPIPs. The Recovery Plan was not subject to such revows, and was last revised on May 31,1993. 1 Section IV.A, "Organizaton", of Appendix E to 10 CFR Part 50, concoming the content of the licensee's emergency plan, states the followmg: "The organization for copmg with radiologmal emergencies shall be desenbed, includmg definition of authonties, responsebehties, and duties of individuals assigned to the licensee's j emergency organization and the means for notificabon of such individuals in the event - of an emergency". in.Sechon 2.2 of the REP, a basic description of the normal and i emergency response organization was provided. Some addibonal details of the ERO r i structure were provided in EPIP 3100023E, "On-site Emergency Organization and Call Directory". This procedure generally addressed the personnel who respond to the site in an emergency. A review of EPIP 3100023E compared to the autodisier database disclosed that 21 of the positions identified in the autodialer database were not inc!uded in the EPlP 3100023E. A document entitled "St. Lucie Plant Emergency l Response Directory" provided more details of the licensee's ERO structure. This i directory generally addressed the personnel who would respond to offsite facilities, i such as the EOF, in an emergency. This directory was not controlled as part of the i FsEP and EPIPs, though it was clearly an adjunct to the Emergency Plan, and interdependent with the EPIPs. The only available listing of the 8icensee's complete l ERO was through the autodialer database. Neither the REP nor its associated implementing procedures provided a clear or complete descript6n of the licensee's organization for coping with emergencies. The same was true for the means used by the licensee to notify individuals in an emergency. No documents, other than the autodialer database were available which clearly described the means for notification of all ERO personnel. Section 2.4.4 of the REP stated, "In the event that the OSC becomes untenable, the 3 Emergency Coordinator will designate an altamate location." The procedure expected 4 to provide implementing details relative to this direction was EPIP 3100032E, "On-Site Support Centers", Revision 17, approved February 5,1996. The only applicable implementmg informahon in this procedure was contained in Step 8.7 of the " Instructions" sechon, which consisted of the following statement: "In the event that the OSC becomes untenable, the Emergency Coordinator shall designate an altemate location." As stated in Section 1.3 of the REP, the REP ltself "provides a conceptual basis for the development of the detailed procedures necessary to implement the plan." In repeating the " conceptual basis" found in the REP, EPIP 3100032E was Enclosure l ..I J -, -- ._ _. -., ~. - _..,.. ~

l' a 6 inadequate with respect to the prcidori of appropnate guidance for the Emergency Coonhnolor and other ERO personnel regardmg suitable altamate locatens for the I 1 OSC and actions that may be necessary to offect the transfer of OSC funcbons to that allemate locaten. i 1 c. Conclusions Several insdoquecies and discrepencies were identified with respect to the implementmg dotads provicted in the EPIPs. The inspectors concluded that the EPIPs did not adequately impionent the requirements of the REP in the followmg respects: i (1) recovery activities, discussed conceptually in REP Sechon 5.4, were not ="+=Cy addressed in EPIPs; (2) the EPIPs did not adequately desenbe and deimeste the imensee's ERO and the detailed means for notifymg ERO members in an emergency; and (3) REP Sechon 2.4.4, addressing OSC relocaten, was not adequately implemented by the EPIPs. Prior to August 20,1996, the hconsee's i TS 6.8.1.e specified that " Written procedures shall be estabbshed, implemented and maintained covering... Emergency Plan implementaten." The examples of inadequate EPIPs hated above were present in the same status prior to August 20, 1996, as when identified during the inspecten. These multiple examples of failure to establish and maintain adequate procedures to implement the REP are identl6ed as eel 50-335, 50-389/96-18-03: Inadequacies in certain Emergency Plan implementmg Procedures. i P5 Staff Training and Qualification in EP l i The inspectors conducted a review of the licensee's ERO training program compared to regulatory requirements. The following sections identify the specific areas reviewed and the results of those revews Three examples of apparent violations of REP requirements in the training program are discussed in Sections P5.1, P5.3, and P5.4, and are collectively identified as eel 50-335, 50-389/96-18-04: Training progra'm not adequately implemented. P5.1 initial Trainina and Annual Retrainina of Ememency Response Omanization Personnel a. Inspection Scope (82701) in order to determine the state of the licensee's training program for emergency response personnel, the inspectors reviewed the' records documenting completon of required training for the years 1994 and 1995. b. Observations and Findinos REP Secten 7.2.2,' Training of On-Site Emergency Response Organization Personnel", stated, "For employees with specific assignments or authorities at members of ememency teams, initial training and annual retraining programs will be 4 provuled. Training must be current to be maintained on the site Emergency Team Roster." The licensee's ERO training program was descnbod in detail in EPIP 3100034E, " Maintaining Emergency Preparedness - Emergency Response Plan Encdoeure

1 i i 4 } Traimng." in Seson 8.0,"Instruchons", of EPIP 3100'034E, some emergency F response poolbons and the annual training required for those positons were described. j A review of the licensee's training records for the year 1994 disclosed that not all of r the positions identified in the ERO were included in the annual retraining pmgram. Specillcelly, the followmg 17 positions were not included in the 1994 retraming j program: OSC Electrical Reentry Supervisor, OSC instrumentation and Contmis Reentry %+-ix, OSC Mechanical Reentry Supennsor, OSC Electncal Chief, OSC Supennsor, OSC Coordmator with TSC, Rotatmg Maintenance Shift Supennsor, Electricans, Mechanics, instrumentaten and Contmis Technicians, OSC Operatens 3-Support Testmg Staff, Dosimetry Technicians, Paramedic, Mechanical Foreman, OSC - i Nuclear Material Management Staff, OSC Fire Protechon, and OSC Administrative Technician / Log Keeper. Approximately 92 individuals who were included in the ERO with spedfle assignments were not retrained in the year 1994. 9 i In early February 1995, the licensee conducted a REP self-assessment, as a result of which the heenses determmed that sorne members of the ERO were not properly i requalified in 1994. The licensee took action to correct the deficences that were identified. The licensee also initiated programmate conechvo action to ensure that i training requirements were property maintained. Conective actons were documented In St. Lucie Acton Request (STAR) 950157, which was closed on May 5,1995. (The i STAR program was the predecessor to the current system.) The February 1995 l self-assessment did not identify the broader problem of the training program's failure l to include all ERO personnel; it was primarily focused on the delinquent qualificatens of those identified in the existing training program. The licensee's critique of the September 1994 accountability drill included a suggested l corrective action item to " Clarify training requirements for all TSC and OSC emergency response positions in conjunction with the annual review of the Emergency Plan and Emergency Plan implementing Procedures." On March 22,1995, the l licensee revised EPIP 3100034E to add several more of the posebons identified in the j ERO to those described in the procedure. A review of the licensee's training records L for the year 1995 revealed that not all of the positions identified in the emergency response organization were included in the annual retraining program. Specifically, i the following eight positions were not included in the 1995 retraining program: OSC I Electrical Chief, OSC Coordinator with TSC, Electncians, Mechanics, instrumentaten ] and Controis Technicians, Dosimetry Technicians, Paramedic, and Mechanical Foreman. Approximately 54 individuals who were included on the ERO with specific i i assignments were not retrained in the year 1995. Through discussions with cognizant j l licensee personnel, the inspectors datermined that for those positions which did not receive annual retraining, as specifed above, there was also no specific initial training provided. Existmg records also showed that no training was provided for these positions. L During the course of this inspection the licensee was conducting special training sessions intended to cover all personnel assigned to the ERO. The inspectors vasted three of the training sessions. This training was being provided because of recent h Enclosure 1 t

1 8. I l maior changes in the ERO as a result of reassignment of many funchons, responsibillhos, and personnel from the hoensee's corporate organambon to the site. This training was not part of the estabbshed training program. Through diam =amn with cognizant hoensee personnel the inspectors loamed that the licensee was in the process of evaluatmg the currently estabhshed emergency preparedness training program to identify areas that may need improvement. c. Conclusion 1 i The licensee failed to provide specific initial training or annual retraining for i 17 poestions (approximately 92 individuals) in 1994 and for 8 possbons (approximately j 54 individuals) in 1995. This is Example 1 of an apparent violation of the training j requirements found in Sechon 7 of the REP. P5.2 Exercise and Practice Orills j a. Inspechon Scone (82701) In order to determme the state of the licensee's training program for emergency I response personnel,' the inspectors interviewed selected individuals assigned to l various ERO positions. The inspectors also reviewed sign-in sheets for exercises conducted in 1994,1995, and 1996. l. b. Observations and Findinas ) I REP Sechon 7.2.2," Training of On-Site Emergency Response Organization j Personnel", stater, "'m training program for members of the on-site emergency response organization will include practical drills as appropriate and participation in l exercises, in which each individual demonstrates an ability to perform assigned emergency functions." The licensee's REP training program was described in detail in i EPIP 3100034E. This procedure mde no mention of the participation of individuals. in drills or exercises as part of the training program. No arrangements were provided to ensure that each individual participated in drills or exercises, either'during initial qualification or periodically thereafter, r i Through interviews with cognizant licensee personnel, the inspectors teamed that [ frequently the same individuals participated, in the same positions, from year to year, in both the annual exercise and practice drill (s) associated with the annual exercise. This practica excluded other individuals qualified for those positions from paiMpetsii in drills. - A review of selected names from exercise sign-in sheets for the years 1994, 1995, and 1996 indicated that the same individuals did often participate in the i L exercise while others did not. The sign-in sheets also indicated that these individuals tended to be responding to fill the same position each year. However, the sign-in sheet documentation was not sufficiently detailed to verify this in each of the instances . that were reviewed. i i

i 9 c. Conclusion 4 The boonses had not provided a programmatic method to ensure that each indudual, through portumpeten in.s drill or exerase, demonstrated an ability to perform assigned i emergency functions. Pendmg receipt and evaluston of additionalinformaten from the hconsee (see Secten X3), this matter is identified as Unresolved item (URI) 50-335, 50-389/96-18-05: ' ERO personnel not qualified through drill / exercise j participation. l-P5.3 Tramino of Ememency Response Omanizaten Personnel on Ememency Plan j j Implementma Procedures i a. Insoechon Scone (82701) [ In order to determine the state of the licensee's training program for emergency 1 l response personnel, the inspectors reviewed the hconsee's training records 1 documentmg completon of required training for 1994 and 1995. J b. Observations and Findings i REP Section 7.2.1, " Objectives", stated the folloung: "The primary objechves of j emergency response training are as follows: 1. Familiarize appropnate individuals with l l Emergency Plan and related implementing procedures. 2. Instruct individuals in their specific duties to ensure effechve and expeditious acten during an emergency. 3. l Periodically present significant changes in the scope or content of the Emergency i Plan. 4. Provide refresher training to ensure that personnel are familiar with their l. duties and responsibilities." l The licensee's REP training program was desenbod in detail in EPIP 3100034E. In Section 8.0, " Instructions", some emergency response positens arvj the annual training required for those positions were described. For most of the hated emergency L response positions, individuals were to receive " Emergency Plan familiarization through review of selected Emergency Plan implementing Procedures (EPIP)." The annual REP training packages used in 1994 and 1995 to accomplish required l training were reviewed. For both years only the five following EPIPs were identified as needing to be reviewed: EPIP 3100021E, "Dutes and Responsibilities of the Emergency Coordinator"; EPIP 3100022E,"Classificaten of Emergencies"; EPIP 3100023E, "On-site Emergency Organization and Call Directory"; EPIP 3100032E, "On-site Support Centers";_and EPIP 3100033E, "Off-site Dose Calculations". i As discussed in Section P5.1 above, not all personnel on the ERO received training l as was required. For those individuals who did receive training, the training consisted of an assignment to read only the previously hated five EPIPs. A review of assigned responsibilities and instructions in several selected EPIPs compared to the five EPIPs included in the annual training package revealed that many personnel were not receiving specific training on several of the procedures that they would be required to 1 Enclosure v- ,v. . m.,

.. -. - -... ~ .i 10 _ implement in performmg their assigned emergency response duties. The followng EPIPs, and mah ERO posihons that would impisment the EPIP, are specsfic 4 exampler: EPIP 3100027E, "Re entry" - Emergency Coordmator, Radiaton Team Leader, OSC Supervisor, Re entry Team Superwoor Re entry Team Member, OSC Status Board Keeper, and OSC Dose Recorder. L EPIP 3100026E, " Criteria for and Conduct of Evacuaten"- Emergency Coordmator, Assembly Area Superwoor, and TSC Security Supervisor. EPIP 3100035E, "Off-site Radiaten Monitonng" - Radiation Team Leader and TSC Supervisor. j in addition to not receiving initial or annual retraining on all applicable procedures for j a specific position, personnel were not informed of significant changes that were made t to procedures. For example, EPIP 3100026E was revised significantly in September 1994, and again in February 1995. No Jocumentation was available to indicate that e affected ERO personnel were informed of the changes made to the procedure. i c. Conplusion The licensee's training program failed to include initial training and annual retraining on all procedures required to be implemented by ERO personnel in several identified positions. The licensee also failed to ensure that ERO personnel in several identified positions were informed of relevant changes in EPIPs. This is Example 2 of an apparent violation of the training requirements found in Secten 7 of the REP. F P5.4 Mentenance and Control of Emeroency R==aanse Omanization Qualifications a. Insaar*ian Scone (82701) In order to determine the state of the licensee's training program for emergency response personnel, the inspectors reviewed the licensee's training records documenting completion of required training for 1994 and 1995. The inspectors also reviewed a copy of the Scenario Roster Listing Duty Roster (autodialer database), dated October 9,1996, the Radiation Exposure Monitoring & Access Control System (REMACS) Exposure Summary Report, dated October 11,1996; and the Emergency Team Roster, dated October 2,1990 b. Observatens and Findinos REP Secten 7.2.2,' Training of On-Site Emergency Response Organization Personnel", states in part, "For employees with specific assignments or authonties at members of ememency teams initial training and annual retraining programs will be provided. Training must be current to be maintained on the site Emergency Team Roster" The ERO training program was desenbed in detail in EPIP 3100034E. Sechon 5.4.3 stated that the Protecten Serwces Supervisor was responsible for:

- -.- - --..-.- -= -. - 1 11 4 l " Removing indeviduals who fail to maintain tra.ning qualificebons for EPIP 3100023E, "On-alle Emergency Organization end. Call Drectory" and the FPL Emergency Recall System (autodeler) database when notified by the appropnote department head or t the Training Department." in EPIP 3100034E, Sechon 5.7 stated: " Department heads responsible for personnel fillmg the followmg posthons shall ensure that these persons are currently Radishon Control Area Training (RCAT) and resperator qualified: (151) i OSC HP Tech,..., (161) OSC Electncian..."- t - A review'of the licensee's training records for the year 1994 revealed that two individuals filling the posthon of TSC S3curity Supervisor did not complete annual retraining in 1994.~ These two individuals remained on the On-site Emergency Organization and Call Dwectory for the year 1995 without having completed retraining as needed. 1 i In early February 1995, the licensee conducted an EP self-assessment. This self-assessment identified that no documentation could be found for the qualificebons of the two individuals filling the positen of TSC Security Supervisor. The licensee initiated programmatic correchve action to ensure that training requirements were property maintained. The licensee's correchve actions were docurnented in STAR 950157 which was closed on May 5,1995. The Emergency Preparedness Functional Area Audit conducted between March 27, l 1996 and August 14,1996, Audit No. QAS-EMP-96-1, faund that one individual filling an OSC position as a Mechanical Reentry Supervisor had not completed the annual requalification training as required. The administrative systems failed to remove this ' individual fmm the ERO upon expiration of training requirements. Corrective actions implemented by STAR 950157 were not successfulin preventing recurrence of the 3 deficiency. The Emergency Team Roster, dated October 2,1996, issued by the Training Department identified several individuals as not having current respirator qualifications. A review of the autodialer database, dated October 9,1996, compared to the REMACS Exposure Summary Report, dated October 11,1996, revealed that four individuals listed as (151) OSC HP Tech and two individuals listed as (161) OSC Electrician were not respirator-qualified as they were required to be for their i respective positions. The four individuals listed as OSC HP Tech were identified in the October 2,1996, Emergency Team Roster as not having current respirator qualification. The two individuals listed as OSC Electncian were not identified in the October 2,1996, Emergency Team Roster. Again the licensee's administrative systems failed to remove these individuals from the ERO upon expiration of training requirements. c. Conclusion For the calendar year 1995, the licensee failed to remove two individuals from the emergency response organization who had not completed retraining as required, and whose qualificehons had expired in 1994. The licensee also failed to remove six individuals from the emegency team roster effective October 6,1996, who had not Enclosure I ~n

1 .i 12 remained quahlied to fill response team requirements as a result of allowing their respwator 7" :eM e to impee. The boensee did not have an effectwo method of s)C-f:r; ensuring that individuals assigned to the ERO are current in required treinmg and 5" :e2-74. This is Example 3 of an apparent violation of the training requirements found in Section 7 of the REP, i j P7 Quality Assurance in EP Activities P7.1 Correctwo Action Pronram i i s. Inspection Scoon (82701) l The inspectors reviewed the licensee's program for identifymg and correcting j weaknesses and deficances in EP. This review included the evaluation of numerous + identified issues and their respectwo correctwo achons in the CR, Plant Manager Action item (PMAI), and EP Action systems. b.- Observations and Fmdmas i l-Critique items from a site accountability drill conducted in September 19M identified problems with the audibility of the site-wide public-address system (Gaitronics), and the need for the addition of an alert tone (alarm). The licensee initiated correctwo ,i' actions for the addition of a new alarm under STAR 94110314. A request for i i engineenng assistance (REA) 94-068-90 was issued to initiate the appropnate action i to result in installation of the new storm.' For unidentified reasons the REA was never completely in-:-x:nd, the item was not budgeted, and no actions were implemented. In early 1996, STAR 94110314 was closed and transferred to PM96-03-247 (in the PMAI system) for administrative reason due to discontinuance of the STAR program. e Subsequently, the licensee discovered that REA 94068-90 had not been implemented. A new REA (REA 96 084) was issued on September 16,1996 to ) initiate the necessary actions to resolve the issue and result in the installation of the new alarm. This item has been budgeted by Maintenance for 1997. i l The licensee initiated correctwe actions to verify the audibility of the Gaitronics system l under STAR 94110315. The licensee identified that this issue was simiter to a previously addressed issue identified in NRC Bulletin 79-18, concoming the audibihty j of alarms in high-noise areas. The licensee had responded to the NRC on September 21,1979, indicating that the site was then in comphance with Bulletin 79-18. In early 1996, STAR 94110315 was closed and transferred to PM96-l 02-423 for administrative reasons (i.e., discontinuance of the STAR program). As of 4 November 1,1996, the licensee had not completed action to resolve the issue of I sudibility of the Gaitronics system throughout the site. i in February 1995, an NRC inspection identified apparent petformance problems with respect to the 15-mmute requirement for notification of the State of Florida followng i . an emergency declaration (see Paragraph 5 of NRC inspection Report l Nos. 50-335/95-03 and 50-389/95-03). As documented in that report, the inspector observed two drills conducted in the Control Room simulator as part of the Licensed e F t. l t Enclosure j i i

e.....

,t.-- n r-r

~ ~ j i i 13 ) Operator Requalification (LOR) Training Program. The time penods required to begin the Stato notifications were 27 and 26 minutes, well beyond the 15-minute entenon. i. The report documented the hce7see's initiation of STAR 950172 to track appropnate follow-up and conective actions for this issue. Although the STAR was subsequently 3i, closed after modifications to EPIP 3100021E and the training in this area, problems with notiflcabons continued to be raised by bconses personnel during LOR training. The issue was formally identified again in CR 96-1465, which was initiated by a member of the Operations staff on June 19,1996. The inspector's review of this ] issue determined that the licensee's past prachce of conduchng most drills and exercises during normal working hours had precluded identification of a problem with Control Room staffing. Under such conditions, it was legitimate for an " extra" Nuclear Plant Supervisor (NPS) to appear in the Control Room immediately after the drill or exercise commenced to assume a posibon called NPS Communicator. This extra } NPS was not typico8y onsite during off-hours, and would not be readily available to l j serve as NPS Communicator. During the current inspechon, the licensee decided to train a pool of knowledgeable personnel in the Rotatmg Mamtenance Shift Supervisor i posebon to serve as offsite communicator following an emergency declarabon. Although it appeared that this approach was likely to be successful, it represented an instance of untimely root-cause klentification and ineffochve management oversight of i EP problem resolution. In late July and early August 1995, the St. Lucio site and adjacent areas were affected by Hurricane Erin. As a result of the hurricane, the licensee declared a Notification of Unusual Event in accordance with established procedures. Subsequent to the event, the licensee developed a draft critique of the site's response to Hurricane 4 Erin. A total of 50 recommendations for corrective schons were identNied in the draft critiq'ue, Some examplu of these corrective actions included the following: identifyng i hurricane-safe structuit. onsite and a plan for posiuoning personnel in those structures; designating an onsite individual to monitor the hurricane path; and establishing a consistent staffing policy. This draft critique was never finalized and issued by licensee management to assure that correchve actions were taken followmg i the event. Hunicane Bertha threatened the St. Lucie site in earty July 1996, after which the licensee again prepared a critique of its response actions. A total of 17 recommendations for corrective actions were identified in the draft critique for l Hurricane Bertha. On August 23,1996, the draft critiques for Hunicane Erin and Bertha were communicated by memorandum to the Vice President - St. Lucie Plant. As of November 1,1996, the licensee had initiated corrective actions for some nf the issues identified in the critiques. Licensee management acknowledged that necessary corrective actions deriving from the Hurricane Erin critique should reasonably have been completed by June 1,1996, which was the beginning of the 1996 hunicane

season, i

c. Conclusions ) The inspectors concluded that licensee management failed to ensure the l implementation of timely corrective actions for certain emergency preparedness j deficiencies and weaknesses. The significant examples identified were: (a) failure to address concoms in a timely manner regarding the audibility of the Gaitronics (or l i Enclosure

14 plant pubic eddress system) formally identsed in late 1994; (b) failure to provide timely correctwo schon to address a queshonable eeM for not$ cation of the Stats of Florida withm 15 mmutes of an emergency declarabon; and (c) failure to implement bmoly correctwo schons for deficiences and recommendabons identined by the erttique of the Hurricane Erin response in August 1995. These issues are collectively identified as an EP Program Weakness, and will be tracked as inspechon I Follow-up item (IFI) 50-335, 50-389/96-18-06: Unbmely correchve actions for some EP de6ceenaos 1 P7.2 dgga s. Inspectic,n Scone (82701) An independent audit of the emergency preparedness program was required to be i performed at least annually by REP Section 7.3.4 and 10 CFR 50.54(t). The followng L audit reports were reviewed and discussed with licensee representatives: Quality Assurance Audit Report QSL-OPS-94-06, dated June 6,1994 Quality Assurance Audit Report QSL-OPS-95-07, dated June 16,1995 Quality Assurance $udit Report QAS-EMP-96-1, dated August 16,1996 b. Observations and Findinas The audits were conducted annually as required and addressed applicable emergency preparedness program areas. The audits focused on verscation of compliance with NRC requirements and the REP. The incpectors revowed audit checklists and found thorn adequate. No significant findings were disclosed by the 1994 and 1995 QA a>Alia. The 1996 audit identified three findings, all of which were somstar to the violations or weaknesses documented in this report. The report summary stated that "The findings in this audit indicate a decline in St. Lucie readiness and Emergency Preparedness program effectiveness." ~ From discussions with licensee personnel and review of applicable documentation, the inspectors determined that the auditors had appropriate training and qualifications to perform EP audits. c. Conclusions The audit program met required frequencies, and the audits were adequate and performed in accordance with regulatory requirements. -,,w a -- a v- -

l 1 a 15 MANAGEMENT MEETINGS X1 Putdic Exit Meet 6ng Summary The inspectors presented the inspection results (substantially as delineated in the Executive Suminary) to members of the licecsee managernent rnd the public at the conclusion of the inspection on November 1,1*W6. The licensee acknowledged the l findings without dissenting comments. l X3 Follow-up Management Meetings via Teleconferene,e I On November 14,1996, a follow-up teleconference between Mr. J. Scarola, Plant Manager, and Mr. E. Merschoff, Director, Dmsion of Reactor Projects, NRC Region ll, was conducted to discuss the issue,regarding qualification of ERO personnel through drill and/or exercise participation (Paragraph P5.2). The licensee committed to provide additional wntten information relative to this matter by November 20, but this date was later changed to November 25,1996 at the licensee's request. The subject information was not factored into this report. l On November 25,1996, a follow-up teleconference between Mr. A. Stall, Vice President - St. Lucie Plant, and Mr. K. Barr, Chief, Plant Support Branch, NRC l Region ll, provided licensee management with tlie final categorization of inspechon j i findings as delineated in the Executive Summary of this report. The most significant change from the findings as presented during the exit meeting of November 1 was the addition of an apparent deviation. On November 26,1996, a follow-up teleconference between Mr. A. Stall, Vice President - St. Lucie Plant, and Mr. K. Barr, Chief, Plant Support Branch, NRC Region 11, informed licensee management that.an issue previously identified as an Unresolved item had been categorized as an apparent violation (Sectior) P3.2 of i l inspection report). 1 l Enclosure

l l 16 PARTIAL UST.0F PERSONS CONTACTED M. Allen, Training Manager G. Casto, Emergency Preparedness Supervisor R. Dawson, Protechon Services Supervisor D. Fadden, Serwces Manager D. Mothena, Manager, Plant Serwoes (Corporate) J. Scarola, Plant General Manager l A. Stall, Vice President - St. Lucie Plant E. Weinkam, Licensing Manager i l l l 1 i l j Enclosure

l i \\ 17 i i i i f INSPECTION PROCp!DURES IP 82701: Operational Status of the Emergency Preparedness Program ITEMS OPENED. CLOSED. AND DISCUSSED l Opened 50-335, 50-389/96-18-01 eel ERO augmentation scheme not maintained adequately (Section P2.1) 50-335, 50-389/96-18-02 eel Deleted TS not relocated to Security Plan and REP (Section P3.1) 50-335, 50-389/96-18-03 eel Inadequacies in certain Emergency Plan Implementing Procedures (Section P3.2) 1 50-335, 50-389/96-18-04 eel Training program not adequately implemented (Section PS) 50-335, 50-389/96-18-05 URI ERO personnel not qualified through drill / exercise participation (Section P5.2) ) 50-335, 50-389/96-18-06 IFl Untimely corrective actions for some EP deficiencies (Section P7.1) 4 i 1 Enclosure

.l ~ 18 i UST OF ABBREVIATIONS USED CFR Code of Federal Regulabons CR Condition Report 1 .DCS Duty Call Supennsor eel Escalated Enforcement item I EOF Emergency Operations Facility EP Emergency Preparedness EPlP Emergency Plan implementing Procedure ERF Emergency Response Facility ERO Emergency Response Organizabon FPL Fionda Power and Light Company GL Genenc Letter IFl inspection Follow-up item LOR Licensed Operator Requalificaten NPS Nuclear Plant Supervisor NRC Nuclear Regulatory Commission OSC Operatsonal Support Center i PMAI Plant Manager Acton item QA Quality Assurance RCAT Radiation Control Area Training REA Request for Engineenng Assistance REMACS Radiation Exposure Monitoring & Access Control System REP Radiological Emergency Plan STAR St. Lucie Achon Request TS Technical Specification TSC Technical Support Center URI Unresolved item i t L h i l Enclosure

4 J+ a* h OW N LJ M N N 4 9 9 N 1 4 1 1 l l {

l 4 L November 26,1996 EA 96-457 Florida Power & Light Company ATTN: T. F. Plunkett President - Nuclear Division P. O. Box 14000 i. Juno Besch, Florida 33408-0420

SUBJECT:

' NRC SPECIAL INSPECTION REPORT 50-335/96-22, 50-389/96-22

Dear Mr. Plunkett:

' On October 18,1996, the NRC completed a special inspection of engineering . activities at your St. Lucie 1 and 2 facilities. A final exit briefing was held via telephone with members of your staff on November 25,1996, to clarify the apparent violations identified during the inspection. The enclosed report presents the results of that inspection. Areas examined during the inspection are identified in the report. 1 Within these areas, the inspection consisted of selective examinations of procedures and representative records, plant drawings, and engineering evaluations. Based on the results of this inspection, three apparent violations were identified ano are being considered for escalated enforcement action in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600. The first apparent violation involved the failure to establish design control measures in accordance with 10 CFR 50, Appendix B, Criterion Ill. Specifically, a failure to 3~ translate design requirements into drawings and a failure to provide independent review for identification of this error resulted in miswiring of excore nuclear instrumentation. Similarly, a failure to compensate for a physical shift in the reactor core midplane in the software used for calibration of incore nuclear instrumentation i and a failure to provide independent review for identification of this error resulted in improperly calibrated, safety related instrumentation being placed in service. The second apparent violation involved your failure to verify and validate properly the software used for calibration of incore nuclear instrumentation as required by plant procedures. Specifically, results produced by new BEACON software were not compared with results from the functionally equivalent and previously validated IMPAX software. This comparison migh't have identified the design error conceming core midplan offset. a m e a-e .-~== -m-

l l i \\ FP&L 2 I I The third apparent violation involved the failure of your plant staff to prepare a Condition Report as required by plant procedures when markings for electrical terminal connectors on a replacement excore neutron detector were found to be different from existmg cable markings. The wires were connected incorrectly, and the miswired detector was placed in service before the error was identified. A Condition j Report on the marking error would have provided an independent review of this discrepancy and might have prevented the installation error. ) With regard to the first two apparent violations, we are concemed about the failure of your design control process and about the potential impact of this failure implies on other design products. We are also concemed that the miswiring and calibration i errors were not identified earlier based upon questions raised by control room operators. With regard to the third violation, we are concemed that a Condition j Report was not written when the marking discrepancy was discovered and about the ~ potential impact on quality if Condition Reports have not been wntten as required for other discrepant conditions. f A predecisional enforcement conference to discuss these apparent violations has i been scheduled for December 10,1996. The decision to hold a predecisional enforcement conference does not mean that the NRC has determined that a violation ] has occurred or that enforcement action will be taken. This conference is being held to obtain information to enable the NRC to make an enforcement decision, such as a common understanding of the facts, root causes, missed opportunities to identify the apparent violations sooner, corrective actions, significance of the issues and the need for lasting and effective corrective actions. In addition, this is an opportunity for you 4 to point out any errors in our inspection report and for you to provide any information 4 conceming your perspectives on 1) the severity of the violations,2) the application of the factors that the NRC considers when it determines the amount of a civil penalty that may be assessed in accordence with Section VI.B.2 of the Enforcement Policy, and 3) any other application of the Enforcement Policy to this case, including the j exercise of discretion in accordarce with Section Vll. You will be advised by separate correspondence of the results of our deliberations on this matter. No response regarding these apparent violations is required at this time. 4 d i -

. ~. _ _ FP&L 3 4 in accordance with 10 CFR 2.790 of the NRC's " Rules of Prachce," a copy of this letter and its enclosures will be placed in the NRC Public Document Roorn (PDR). Sincerely, ORIGINAL SIGNED BY ALBERT F. GIBSON FOR Albert F. Gibson, Director Division of Reactor Safety r Docket Nos. 50-335, 50-389 License Nos. DPR-67, NPF-16

Enclosure:

Inspection Report 50-335/96-22, 50-389/96-22 cc w/ encl: J.A. Stall Site Vice President i St. Lucie Nuclear Plant P. O. Box 128 Ft. Pierce, FL 34954-0128 H. N. Paduano, Manager Licensing and Special Programs Flr -ida Power and Light Company P. O. Box 14000 Juno Beach, FL 33408-0420 J. Scarola l Plant General Manager i St. Lucie Nuclear Plant P. O. Box 128 Ft. Pierce, FL 34954-0128 E. J. Weinkam Plant Licensing Manager St. Lucie Nuclear Plant P. O. Box 128 l Ft. Pierce, FL 34954-0218 4 ~ (cc w/enci cont'd - See page 4)

- ~. _ _. _ _ _. _. FP&L 4 (cc w/enci cont'd) 1 J. R. Newman, Esq. Morgan, Lews & Bockius 1800 M Street, NW Washington, D. C. 20036 John T. Butler, Esq. Steel, Hector and Davis 4000 Southeast Financial Center Miami, FL 33131-2398 i Bill Passetti Office of Radiation Control j Department of Health and Rehabilitative Services j - 1317 Winewood Boulevard Tallahassee, FL 32399-0700 3 Jack Shreve, Public Counsel Office of the Public Counsel clo The Florida Legislature 111 West Madison Avenue, Room 812 Tallahassee, FL 32399-1400 Joe Myers, Director j Division of Emergency Preparedness Department of Community Affairs 2740 Centerview Drive Tallahassee, FL 3P,399-2100 Thomas R. L. Kindred County Administrator St. Lucie County 2300 Virginia Avenue Ft. Pierce, FL 34982 (cc w/enci cont'd - See page 5)

FP&L 5 i (oc w/enci cont'd) Charles B. Brinkman Washington Nuclear Operations 4 ABB Combustion Engineering, Inc. j 12300 Twinbrook Parkway, Suite 3300 Rockville, MD 20852 i Distnbution w/ enc l: J. Lieberman, OE B. Summers, OE:EA file (2 LTRHD) C. A. Julian, Ril L. A. Wens, NRR B.' R. Crowley, Ril W. H. Rankin, Ril S. H. DuBose, Ril PUBLIC NRC Resident inspector U.S. Nuclear Regulatory Comm. 7585 South Highway A1A Jensen Beach, FL 34957-2010 s

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1 4 FP&L 4 / (cc w/ enc. wnt'd). / Jack Shreve, Public Counsel Distribution w/ encl: Omce of the Pubhc Counsel clo The Florida Legislature J. Lieberman, OE 111 West Madison Avenue, Room 812 B. Summers, OE;EA file (2 LTRHD) i Tallahassee, FL 32399-1400 C. A. Julian, Rir L. A. Wiens,,NRR _d I Joe Myers, Director B. R. Crowley, Ril ] - Division of Emergency Preparedness W. H. Rankin, Ril Department of Community Affairs S. H.,DuBose, Ril 2740 Centerview Drive-PUBJJC 4 I Tallahassee, FL 32399-2100 / j 41RC Resident inspector i Thomas R. L. Kindred U.S. Nuclear Regulatory Comm. County Administrator 7585 South Highway A1A St. Lucie County Jensen Beach, FL 34957-2010 ) l 2300 Virginia Avenue Ft. Pierce, FL 34982 l Charles B. Brinkman Washington Nuclear Operations ABB Combustion Engineering, Inc. [ 12300 Twinbrook Parkway, Suite 3300 i Rockville, MD 20852 l 0 l ce o@l* .,,a $1GNAtu.I LL k { ( h eWWE CCaste Ch mitier CJulian / 11/d/ 9 11 [/) 96 11 /D / % 11_/ 96 11./ / 96 DATE 11 /Y /% CD.Y?

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i U.S NUCLEAR REGULATORY COMMISSION l REGION ll Docket Nos: 50-335, 50-389 License Nos: DPR-67. NPF-16 Report No: 50-335/96-22, 50-389/96-22 Licensee: Florida Power & Light Co. Facuity: St. Lucie Nuclear Plant, Units 1 & 2 Location: 9250 West Flagler Street Miami, FL 33102 i i Date: November 26,1996 inspectors: J. York, Reactor inspector C. Rapp, Reactor Inspector M. Miller, Senior Resident inspector Approved by: C. Casto Chief, Engineering Branch Division of Reactor Safety Enciosure

EXECUTIVE

SUMMARY

St. Lucie Nucisar Plant, Units 1 & 2 NRC Ir.spection Report 50-335/96-22, 50-389/96 22 I This speaalinspechon'was conducted to evaluate the modification of the excore Linear Nuclear instrumentaten drawers which resulted in these drawers being cross wired because of design control problems. This condition was also complicated by reversing the leads on a i detector that was being replaced during a maintenance activity. While assessmg the safety significance of the event, another design control problem and a procedural compisance ~ ?' probiem were identified. This inspection resulted in identifrcaten of three apparent violabons: 1 The first apparent violation involved the failure to establish design control 1 i measures in accordance with 10 CFR 50, Appendix B, Criterion Ill.' Specifically, a failure to translate design requirements into drawmgs and a j l failure to provide independent review for identificaten of this error resulted in meswering of excore nuclear instrumerv.ation. Similarly, a failure to ce.i.per::^- for a physical shift in the reactor core midplane in the software used for calibration of incore nuclear instrumentation and a failure to provide l-independent review for identification of this error resulted in improperty ] calibrated, safety related instrumentation being placed in service. j (paragraphs E1.1.b.1 and E1.1.b.2). j The second apparent violation involved your failure to verify and validate properiy the software used for calibration of incore nuclear instrumentaten as required by plant procedures. Specifically, results produced by new BEACON software were not compared with results from the functionally equivalent and previously validated IMPAX software. This comparison might have identified the design error concoming core midplan offset. (paragraph E1.1.b.2). l The third apparent violation involved the failure of your plant staff to prepare a i Condition Report as required by plant procedures when markings for electncal terminal connectors on a repideement excore neutron detector were found to be different from existing cable markings. The wires were connected incorrectly, and the miswired detector was placed in service before the error i l was identified. A Condition Report on the marking error would have provided i an independent review of this discrepancy and might have prevented the installation error. (paragraph M1.1.b). O L 1

1 J Report Details 1 i E1 Conduct of Engineering (37550) j E1.1 Design Control of Nuclear instrumentation blodification a. Inspection Scone ) The inspectors reviewed activibes associated with the plant modification used to replace the Linear Nuclear Instrumentatum (NI) drawers located in the Unit 1 control room This modificat6on resulted in NI channels A, B, C, and D being cross wired due 4 j to a design error. This review included evaluations of the root causes, prior i opportunity and safety significance from a core physics point of view. !^ b. Observabons and Findmas The St. Lucie Unit 1 Nuclear instrumentation (NI) System is designed to employ a total of 10 detectors, all located extemal to the reactor vessel, as desenbed below: " Detector. Detector Types Channel Purpose Associated RPS Trips Numbers 1,2,3,4 Fission Chamber Wide Range High Rate of Change Logarithmic Detection 5, 6, 7, 8 Uncompensated Linear Safety Related Variable High Power lon Chamber Detection Thermal Margin / Low i. Pressure = Local Power Density l 9,10 Uncompensated Linear Non-Safety None lon Chamber Detection (control i channels) [ Detectors 5,6,7,8, 9, and 10, above, are designed with 2 axially distinct i4tectors each, forming single detector assemblies to allow for the detection of pow" 'ractions in the upper and lower axial halves of the core. The signals from the upps vid lower lealves of each of these detectors are summed to form a total power signalirom each detector. The upper and lower halves are also combined electronically to develop an Axial Shape index (ASI) signal consistent with the equation ASI = (Lower Detector Power - Unoer Detector Power) (Lower Detector Power + Upper Detector Power) ASI is used in the control of axial ccre power distribution by operators and to provide i i inputs to Thermal Margin / Low Pressure (TM/LP) and Local Power Density (LPD) Reactor Protection System (RPS) trips. Each of the 4 linear safety related detectors

j' f e 2 feeds an individual RPS chenrmi, and the RPS trips the reactor on a 2-out-of 4 j coincdonce for a given trip (e.g. TM/LP). The purposes of the TMILP trip are to prevent exceedmg Departure from Nucleate Boiling (DNB) limits and to provide a low pressure reactor trip in the event of a loss of cooient accident. - The trip setpomt itself is designed to be a reactor coolant system (RCS) pressure limit, set at the higher of 1750 pois or a pressure setpoint calculated by the core protection calculator based upon RCS temperature conditions, reactor power, and power distribution (expressed by the ASI signals generated by detectors 5, 6,7, and 8). The TM/LP trip is required per Technical Specifications (TS) Table 2.2-a 1, with setpoints adjusted to agree with Figures 2.2-3 and 2.2-4 of TS. TS Table 3.3-1 requwes that at least 3 operable RPS channels provide this trip function at or above 1% thermal power. I The purpose of the LPD trip is to prevent peak local power density in the fuel from - exceeding 21 kw/ft, thus assuring that the molting point of the fuel will not be reached during anticipated operational occurrences. The trip is designed to be initiated whenever axial power offset, as indicated by ASI, exceeds either a high or a low i calculated setpoint. The LPD trip is required per TS Table 2.2-1, with setpoints adjusted to agree with Figures 2.2-3 and 2.2 4 of TS. TS Table 3.3-1 requires that at least 3 operable RPS channels provide this trip function at or above 15% thermal i power. Each linear Ni detector assembly is cylindrical in design, with the two detectors located axially adjacent to one another. The signal cables for each detector assembly (which transmit output from both detectors) exit the assembly from one end of the cylinder. Each detector is installed in a cylindrical housing extemal to the reactor = vessel in positions spaced radially about the vessel to ensure that all quadrants of the core are monitored. l The signal cables for the detectors installed in Unit 1 had been labeled by the vendor as " TOP SIG" and " BOT SIG," indicating output for each detector. in the assembly. This labeling scheme assumed that each assembly was installed in its housing oriented such that the signal cables exited the top of the assembly. However, the St. Lucie design is such that the detector assemblies are installed with the signal cabling exiting the assemblies from the bottom, making the " TOP SIG" signal cable correspond to the detector monitoring the bottom half of the core, and vice versa. During the most recent Unit 1 outage, the licensee elected to replace their existmg NI circuitry with a new system developed cooperatively with Gamma-Metrics. The scope of the change included new Ni drawers for all four RPS channels and new wide range detectors. During the outage, unrelated to this modification, uncompensated ion chambers (UlCs) were replaced in RPS channel B (detector 6) and in the control l channel detector 9 kx:ation. 4 l On July 30,1996, St. Lucie Unit 1 was operating at approximately 100 % power when reactor engineering was analyzing the data taken during power ascensicn and noted an anomaly in the results. The data indicated three of the four excore linear detectors

P l 3 4 measured core power moving to the top of the core during power ascension. This was an unexpected phenomena and did not agree with the trend of the power movmg l to the bottom of the core indicated by RPS Channel B Linear Range Detector, Control Channel #9 Lineer Range Detector, and the BEACON Core Power Distribution Morutonng System. Evaluation of the data collected indicated that RPS Channels A,C,and D could have reversed (rolled) leads of the top and bottom chambers input to the RPS drawers. l At 1:00 p.m. the same day, Unit 1 operators were mformed of these conditions and immedetely declared the A, C, and O channels out-of-service (OOS), which placed the unit in TS 3.0.3 due to 3 of 4 RPS channels for TMLP and LPD being inoperable. The inspector responded to the control room and found that leads were being reversed on the A and C channels in an attempt to restore the channels to operability. Reactor Engineering support was available, with new NI gain values bemg calculated i in support of l&C as the leads for the affected channels were property aligned. At 1:50 and 2:00 p.m., work was completed on the A and C channels, respectively, and operators drove CEAs into the core to verify proper ASI response. The inspector verified that proper channel response occurred, and the A and C channels were j declared operable.st 2:00 p.m., leading to an exit from TS 3.0.3. c. Evaluation of Root Cause In reviewing the issue, the licensee determined that all four safr ty related Ni channels had been connected to the NI drawers in the RPS cabinets with the upper and lower detector inputs reversed. These field errors resulted from errors in the associated Control Wiring Diagrams (CWDs); that is, the detectors were connected at the NI drawers in conformance with approved engineering drawings. The drawings were prepared and approved with errors in the designation of connection points to the Ni t drawers. The errant drawings were a part of the Plant Change / Modification (PC/M) package which replaced the Ni drawers. In addition to the wiring errors described above, the licensee determined that N1 detectors 6 (assocated with RPS channel B) and 9 (one of two control channels) were miswired at the detector ends (in containment), which resulted in RPS NI channel B indicating correctly (as the error at the detector end cancelled out with the error at the Ni drawer) and the control channel indicating incorrectly. The miswiring at the detectors was the result of errors made by maintenance personnel during installation. As a resuit of the deficiencies described above, the licensee performed a root cause evaluation. The inspectors reviewed the evaluation, discussed the events with the licensee and performed independent revows of documentation assocated with the NI modification. The results of these activities are desenbod below. The licensee's root cause effort determined that, during the preparation of PC/M 96-009195, "RPS NI Drawer Replacement," a lack of available vendor information (in the form of approved technical manuais and drawmgs) forced design personnel to develop drawmgs based on assumpbons generally derived from a similar modification made to - Unit 2 during the most recent Unit 2 outage. As a result, CWDs JPN 009-195-002

l ) ( 4 (providmg wiring instruchons for RPS channel A), JPN-009-195-004 (providing winng metruchons for RPS channel B), JPN-009-195-006 (providing wmng instruchons for RPS channel C), and JPN-009-195-008 (providing wmng instruebons for RPS channel i i L D) were modified showng upper and lower detector cable connechons at each respective drawer which were in confiset with the intomal wmng of the drawers which l were to be installed (i.e. field cables for the upper d6tectors were fed to the drawers' lower inputs and vice versa). 4 Beyond the assumphon of similarity between units, the licensee found that the verificahon process for the drawi ps in quesbon contained weaknesses that resulted i in a failure to identify the condsbon. Specifically, the licensee found that the drawmps were prepared by a Lead Designer (draftsman) based on inputs from the Lead j Engineer (having responsibility for developing the modification package). The j drawngs were then checked by a second Designer, conshtutmg (essentially) a drafbng check. The drawmgs were then reviewed and approved by the Lead Engineer and approved by the Lead Engineer's Supervisor. l The licensee found that this process differed from the approva! process for the j , modsfication package, which was independentiy reviewed by a second engineer. t However, the licensee pointed out that the package review did not include a point-to-point winng check of the affected drawings. The licenses found that the method and sequence of verification described appeared to meet the requirements of Quality Instruction (Ql) 1.7, dated July 5,1995, " Design inputNorification," but that the j method revealed a weakness of the process, i While the subject drawings were approved without having approved vendor technical manuals (VTMs) available to support the review, the licensee had placed a hold on the PC/M completion pending receipt of the vendor documents. Upon receipt, the l~ VTM and other vendor documents were to be incorporated into the PC/M via Change Request Notification (CRN). However, when the documents were received, the licensee stated that they were not reviewed against other package drawings; thus, the wiring designation discrepancy was not identified. The licensee identified an additional weakness in the amount of time available to verifying engineers. Specifically, the licensee stated: i "The total U1 project man-hours through May 1996 was approximately 1150 [ man-hours. For scoping and scheduling puiposes on a entical complex project 30% of a projects [ sic) total man-hours should be allocated for verification activities. This should have accounted for a few hundred man-hours. The verifying Engineer on the Engineering Package charged a total of 40 man-hours to the project,15% were on overtime. The verifying Engineer i on the CRN charged a total of 6 hours to the project. This relatively small amount of time spent on verification is due to project delays due to supped;i@ unanticipated outages, the number of large projects being worked coincidendy . [ sic) in PEG l&C...and the available resources..." The inspectors reviewed these licensee-generated findings for conectness. --.L

t L .t 5 The inspector concluded that the licensee's review of the hours spent (or lack thereof) in the review of the subject modification showed thoroughness in the self-assessment process. However, the inspector found that, in focusing on "...the amount of time ava# awe [emphasas added] to the verifying Engineers to perform verifications..." the laconsee failed to identify the larger issue of ensuring that verificabons are not curtailed due to schedular constraints. The inspectors reviewed CWDs prepaisd with the PC/M package and found the licensee's conclusions on the reasons for the field mowiring to be correct. The j inspectors noted that the licensee's conclusion that the drawings had received an inadeounte independent verification was correct; however, the inspectors disagreed i with the conclusion that the verification process as performed met the requirements of the applicable Quality instruction (Ql). The inspectors concluded that the subject QI was of sufficient clarity to ensure an appropriate review. Specifically, the Ql, when taken as a whole, required that an engineer (not the designer) perform an independent review of design output documents (e.g. drawings) to ensure agreement with desegn inputs (in the case of the subject PC/M, the Gamma-Metrics VTM). Contrary to these requirements, the licensee chose to approve the subject CWDs when no approved design input document was available against which the output could be reviewed and allowed the l review to be performed without the required level of independence. Further, when the - approved design input was available, the licensee failed to perform necessary reviews i to ensure agreement between vendor-generated documents and existing licensee-1 generated drawings. Specifically, QI 1.7, Revision 1, " Design inputNerification," included the following: Section 5.3 stated that " Design verification is required for... approved design output documents..." Section 5.5 stated that " Design verification shall normally be performed by an engineer competent in the discipline / area of expertise, other than the originator i of the design. The design verifier shall have remained independent of the overall design process." l Contrary to this section, the verification for the subject CWDs were not performed by an engineer independent of the design process. Section 5.6(2) stated that " Design verification should normally be complete, commensurate with the state of design activity, prior to release of associated design output documents to the plant." Contrary to this section, the design verification process was never completed in that the VTM was never reviewed against the CWDs which delineated { (erroneously) NI wiring.

i I 6 Sechon 6.0 stated that " Records of design input and verification activities shall i be retained as QA records..." I ]. Contrary to this requirement, the licensee could not produce records of desegn inputs to the CWD revision process, stating that the design inputs would have l been the VTMs, which were not available in an approved form while the subpect CWDs were being approved. i One of the action items to prevent recurrence was to check all open l&C and electncal i PC/Ms to see if all the drawing approval signatures could qualify as independent verifiers. - The licensee found three out of eight open modifications where a lack of i independence existed. Two of these modifications were electrical and one was l&C. 10 CFR 50, Appendix B, Criterion lil, Design Control, requires, in part, that measures be established to ensure that the design basis is correctly translated into drawings p and that design control measures provide for verifying the adequacy of the design by individuals other than those who performed the original design. The inspectors concluded that the licensee's failure to implement the salient aspects of instruction QI l 1.7 adequately in this issue collectively represented a failure to satisfy Appendix B requirements and, as such, represented an example of an apparent violation (eel 50-r 335/g6-22-01, " Failure to Control Design Processes for Nuclear Instrumentation i Modifications"). d. Instellation of BEACON ComDuter Code L The licensee had installed a new in-core flux monitoring system (BEACON) during this refueling outage to replace the older in-core flux monitoring system (IMPAX). BEACON provided.several significant improvements over IMPAX, the most significant being reduced time to analyze SAF test dets. This improvement sided reactor engineenng in identifying the Ni problem and initiating prompt corrective actions. During power operations, reactor engineering used BEACON to obtain the actual in-l core flux profile. The actual in-core flux profile was then used to venfy compliance [ with Technical Specifications (TS) and provide calibration information for the excore NIS drawers. As part of this routine surveillance, reactor engineering compares actual in-core flux profile to the in-core flux profile predicted by the core design code. Reactor engineering noted larger than normal errors between actual and predicted in-l core flux profile. Because BEACON used the same neutronics engine as used in the core design code to generate in-core flux profiles, reactor engineering could not explain the error and notified the corporate core design engineers. As part of the process to resolve these errors, it was discovered that a simplifying assumption, used to overcome limitations of IMPAX, was not accounted for in the original design of BEACON.. This simplifying assumption was used because the licensee had changed the fuel design to incorporate a longer end cap to prevent debris induced fuel failures. This longer end cap raised the overall core height by 2.64" causing an offset between detector midplane and actual core midplem. IMPAX assumed detector midplane was g along core midplace and could not acconimodate the 2.64" offset. Therefore, the licensee after discussion with the fuel vendor (Siemans), used this simplifying

-- -.- ~. Y 7 assumption to lower the core midplane by 2.64" so that final desen output would be referenced to detector midplane; not core medplane. However, the engineer preparing F the design input for BEACON was not aware of this semphfymg assumption: consequently, BEACON was referenced to core midplane resulting in an increased j error between the core desen predicted in-core flux proflie and actualin core flux profile. J The licensee's foot cause evaluation concluded lack of cross-discipline review was the i segnificant contributor to this design error. The inspes reviewed the licensee's root cause evaluation and concurred with the licensee's conclusion. Engineering Quality instructsons wl) 1.7. Design input /Vertfication, dated July 5,1995, states in part that i "Desen verification is the process whereby a competent individual, who has remamed independent of the design process, reviews the design inputs,... and design output to verify design adequacy. This independent review is provided to minimize the q likelihood of desgn errors in items that are important to nuclear safety." Contrary to l this requirement, the design enouts were not adequately reviewed by an independent individual in that the core midplane offset was not identified as a necessary design input for BEACON. This failure to perform an adequate independent design review for the BEACON system is identified as example two of an apparent violation (eel 50-3 335/96-22-01, " Failure to Control the Design Process According to the Requirements of 10 CFR 50, Appendix B, Cdterion ill," EA 96457). I e. Evaluation of Safety Consecuences The safety significance of reversing the detector inputs to the NIS drawers substantially reduced the safety margin between the Thermal Margin / Low Pressure (TM/LP) trip setpoint and the analysis limit even considering the increased TM/LP margin to the trip setpoint due to actual core operating conditions. The safety impact of the failure to identify the core and detector midplane offset on TM/LP or Linear Power Density (LPD) safety limits was minimal. It was also identified that BEACON was placed into service on Unit 1 without any benchmarking against IMPAX, the on-line core performance monitoring code BEACON was replacing. Instead, BEACON was installed on Unit 2 and benchmarked against CECORE, which did not require any modifications to accommodate the core midplane offset. Technical Specification 6.8, Procedures and Programs, paragraph 6.8.1 requires in part that wntten procedures recommended in Appendix A of Regulatory Guide 1.33 revision 2. February 1978, shall be established and implemented. Engineering Quality instruction (Ql) 3.7, Computer Software Control, Revision 1, Section 5.4. requires that SQA1 software shall be validated and verified (V&Ved) in accordance with Section 5.6.. Section S.6 states that new software shall be V&Ved prior to use. The V&V process includes the use of test cases to ensure the new software produces correct results, item 4 of Section 5.6 states that technical adequacy shall be determined by comparing the test case to results from attemative methods such as functionally. equivalent and previously validated software. In the case of BEACON, IMPAX would have been functionally equivalent software. Benchmarking BEACON against IMPAX might have' identified the design error concoming core midplane offset because the two codes would not have yielded the f y-yr a

Y l 8 same results Contrary to this requirement, BEACON was placed into service on Unit 1 without benchmarking against IMPAX. This is identified as an apparent veisten (eel 50-335/96-22 02, " Failure to Follow Procedure According to Technical Speci5ceton Sec. 6.8 for Placmg the BEACON System in Service," EA 96457). i i E1.2 Prior Opportunities to identify a. Insoection Scope The inspectors reviewed the subject event and activities preceding its identification to determme whether the licensee had opportunities to identify the miswiring of NI i drawers sooner. i \\ 1 b. Observabons and Fmdenas The inspector reviewed QA Audit Report QSL-PM-96-17, July / August 1996, which included, in PMON 96-052, a review of the licensee's performance with respect to design control for the subject PC/M. The QA review concluded that the licensee's engineering, maintenance and QA organizations were not sufficiently sensitive to the woming signs of a breakdown of the quality program. Indicators of problems cited in the QA report included: I Vendor difficulties in meeting fabrication schedules Loss of the project's Lead Engineer four months prior to implementation Installation difficulties traceable to erroneous design information provided to the vendor from the licensee Loss of the instrument & Control (l&C) Supervisor responsible for 4 implementation midway through the installation process Numerous noise problems encountered in wide range Ni channels after installation j l At least two cases in which the new design provided improper output to the RPS A large volume of change paperwork written against the installation package (32 CRNs), a large number of scope changes to the installation work order (20), and a large number of deviations against the pre-operational test. procedure (46). The inspector reviewed the CRNs generated against the subject PC/M and found the j followng: 4 y w- ,m e< y m

t 9 i The CRNs addressed problems in the areas of structuralfmstallation, vendor recommendshons for performance enhancement, correchon of vendor document errors, desen errors, and field wmng difficulties. A large number of the CRNs addressed themselves to the instatisten of the wide range detectors and noise problems associated with system startup. A number of the CRNs clearty indicated inaccuracies in the new design, to include: Incorrect statements concoming the sizes of cables already installed in the plant which were to be employed with the new design Failures to change the ranges of control panel meters and strip chart recorders to accommodate the new range of the wide range detectors A failure to treat the RCS Low Flow trip within the modification package, which resulted in a constant trip signal from the RPS after installation The inspector also reviewed 13 Condition Reports (CRs) associated with the installaten of this modificaten. As in the case of the CRNs, the CRs covered a broad area and addressed both wide range and linear range installation issues. The inspector identified two CRs of particular note: CR 96-1358, written on June 11 by OA, reported a possible loss of desgn control in the installation. The CR reported that multiple problems had been encountered during the installation of the modification, including the loss of key personnel, a work package which had become " voluminous and unwieldy" with "13 work package scope changes... approx 40 ' deviations' to the Pre-Op procedure, and also numerous. changes to the Vendor Tech manual specifications." The CR Condition Description concluded that "...with so many changes to the Tech Manual and Pre-Op procedure and also the lack of personnel that are experienced in this particular modification, the possibelsty exists that the Design Control process could fail." The resolution to this CR, prepared by l&C and Engineering, concluded that a loss of design control had not occurred, as a review of all associated paperwork indicated that appropriate reviews had been performed and approvals for actions taken had been obtained correctly. CR 96-1818, wntten on July 23 by l&C, questioned the operability status of Ni detectors 6 (RPS channel B) and 9, given their installation during the outage and the need to have the reactor at power to calibrate them. The resolubon to the CR stated that the detectors were operable, but stated that a check for ASI d : agreement would be performed at 13% power to compare RPS channel B with A, C, and D. i i

b i ) 10 While indications of poor quality existed dunng the installation of the subject PC/M, the inspector concluded that the licensee could not reasonably been expected to l perform a complete re-nmow of the design package as a result of those indicabons. l The inspedor noted that the licensee's root cause evaluation identified that several 3 ) opportunities existed for identification of the miswired conditions during power ascension testmg. On July 25, with the reactor below 5%, operators noted channel B j to be indicabng more bottom-peaked than the other channels. This was explairmd by reactor engineenng as expected behavior and the B channel was calib.ated (forced to i agree with incore data, which resulted in B channel indicatmg similarly to channels A, C, and D. Later the same day, with the reactor at 5.5% and Control Eiement Assemblies (CEAs) being withdrawn from 90 to 103 inches, ASI on channels A, C, i and D were noted to trend toward the top of the core; however, channel B indicated j ASI movmg toward the bottom of the core. Operators quesboned the indication and i were told that B channel, being a new detector, would require calibration at a higher power level. On July 28, while increasing power from 70% to 98%, operators again questioned a mismatch between channels B and A and channels C and D. RE responded that ASI was within TS limits and that a shape annealing factor (SAF) test was being i performed on channel B, as the detector was new, to bring it into agreement with the balance of the channels. The disagreement was again identified on July 30 by operators. That same day, RE identified the miswiring while analyzing SAF data. The inspector concluded that there existed an opportunity to identify the miswered channels during power ascension testing. Operators were successful in identifymg l anomalous behavior days before the ultimate identification of the condition. While the licensee's root cause evaluation concluded that "[ prior) to significant power levels it is difficult to detect the discrepancies in RPS ASI trends..." operational experience. in this case indicated that the trend could have been (and was, although not in an integrated fashion) identified at relatively low power levels. l l The inspector further concluded that a failure to resolve the first indications of channel disagreement in a formal, technically defensible way (i.e. testing, performed specifically with the goal of establishing a basis for the channel-to-channel differences) delayed the identification. 1 p c. Conclusions on Conduct of Enaineerino j i As a result of this inspection two violations were identified for the engineering area. One violation had two examples of problems with the licensee's design control process. ' One example involved the failure to verify independently Controlled Winng Diagrams which were in error and resulted in wiring the Nl drawers backwards. Another example resulted in the core midplane offset not being identified as a design input to BEACON, the computer program used for real time flux profile monitonng. The second violation involved the failure to validate and verify a new computer program before placing it in use. 4

l 11 l l M1 Conduct of Maintenance M1.1 ; m___.. ... of No. 6 Nuclear instrumentation Detector a. Insoechon Scone The inspectors reviewed the maintenance activity for reple&g the No. 6 detector for 2 channel B of the Linear Range Detector. The maintenance achvity allowed reversal of ] J the field cables. i b. Observahons and Findinas i All four of the RPS Linear Range Detectors had the connectors reversed as previously discussed but the B channel unlike the other three channels was giving the correct data. At the same time that the drawers were being replaced on Unit 1, the detector for channel B (detector ric. 6) was being replaced as a maintenance activity. During connection of the field cables, the connections were reversed for the upper and lower detachon chambers, thereby causing the B channel to record property. ' The root cause for the swap of the cables was that the new detector had different labeling than the existing cables. The existing cables were labeled TOP SIG and BOT SIG, and the new detector had A and B. The inspectors discussed this maintenance job with the l&C supervision who had responsibility for the latter part of this maintenance project. Several opportunities were presented to the maintenance personnel, one when the detectors were checked out in the warehouse and a second time when this condition was noted in the field. Maintenance personnel should have resolved the labeling problem by writing a. Condition Report (CR) and having a formal resolution. Technical Specification 6.8, Procedures and Programs, paragraph 6.8.1, requires in part that wntten procedures recommended in Appendix A of Regulatory Guide 1.33 revision 2, February 1978, shall be established and implemented. Administrative Procedure No. 0006130, Condition Reports, Revision 4, dated March 22,1996, Par. 8.1.1.A states in part that "Any individual who becomes aware of a problem or discrepant condition... should initiate a CR. If doubt exists, a CR form should be initiated". This failure to comply with the requirements of the administrative procedure is identified as an apparent violation (eel 50-335/96-22-03, " Failure to initiate a Condition Report for Labeling on Safety Related Detectors in Accordance With Technical Specification Sec. 6.8," EA-457). c. Conclusions on the Conduct of Maintenance . The l&C maintenance personnel reversed the field cables for the no. 6 channel B detector. The cables were labeled differently than the existing ones and the maintenance personnel had two occasions to question this condition by initiating a Condition Report. An apparent violation for failure to conform to administrative procedure for writing a CR was identified.

3 m._. .___m.__.m. ...... ~.... _ _. _ _ _ _. - _. m -_.... _ _ _ _.-...-.___ _ - __ - 4 12 V. MANAGEMENT MEETINGS AND OTHER AREAS X.1 UFSAR Reang The inspectors reviewed the Unit 1 UFSAR for the areas covered in this report. The inspectors found that a past modification to the N1 circuitry disabled the rod drop / turbine runback feature at St. Lucie Unit 1. The FSAR was never updated to reflect this change. PCWI 009-195, Revision 0, paragraph 7.1.8 F, acknowledged this doishon of function, but did not rectdy the FSAR discrepancy in the section that updated the FSAR. This is another instance of weakness in the Engineering Review process, and will be included in Unresolved item 50-335,389/96-04-09, " Failure to 4 i Update UFSAR". i . The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection on October 18,1996, and during a telephone l conversaten on November 25,1996. The licensee acknowledged the findings-presented. Dissenting comments were not received from the licensee. The licensee did not identify any materials used during the inspection as propnetary information. PARTIAL LIST OF PERSONS CONTACTED i Licensee O. Lowens, Acting Site Quality Manager D. Denver, Site Engineering Manager [ J. Scarola, St. Lucie Plant General Manager J. Stall, Site Vice President i E. Weinkam, Licensing Manager Other licensee employees contacted included operations, engineering, maintenance, l and corporate personnel. l l!gPEGTION PROCEDURES USED IP 37550: Engineenng ITEMS OPENED. CLOSED. AND DISCUSSED Opened 50-335/93-22-01 eel Failure to Control the Design Process According to the Requirements of 10 CFR 50, Appendix B, Criterion Ill. 50-335/96-22-02 ~ eel ' Failure to Follow Procedure for Placing the BEACON System in Service. 1

i 13 i 50-335/96-22 03 eel Fadure to inibste a Condition Report for Labeling j on Safety Related Detectors. j 1 1 50-335/96-11-06 URI " Unit 1 NI Wiring Errors" b Discussed ) . 335,389/96-04-Og URI Tailure to Update UFSAR" j LIST OF ACRONYMS USED ATTN Attention CFR Code of Federal Regu'.ations ' CR Condrtion Report CRN Chantys Request Nohces - CWD Controlled 'Mring Diagram EA Enforcement Action eel Escalated Enforcement item . FPL The Florida Power & Light Company l&C Instrumentation and Controls IR [NAC) Inspection Report LPD Unear Peswer Density NI Nuclear instrumentation NIS Nuclear instrumentation System No. Number i NRC Nuclear Regulatory Commission NUREG Nuclear Regulatory (NRC Headquarters Publication) PC/M Plant Change / Modification PDR NRC Public Document Room QA Quality Assurance QI Quality instruction RE Reactor Engineering RO Reactor Operators RPS Reactor Protection System TM/LP Thermal Margin / Low Pressure TS Technical Specifmation UIC Uncompensated lon Chamber USNRCL United States Nuclear Regulatory Commission - V&V Validation and Verification 3 J V 1 m r

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~ EXPECTED ATTElWEES Florida Power and Licht Co. Art Stall. Vice President St. Lucie J. Scarola, Plant General Manager Tom Plunkett. President Nuclear Division D. Fadden. Services Manager Ed Weinkam. Licensing Manager NEC Stewart Ebneter. Regional Administrator. Region II (RII) Luis Reyes. Deputy Regional Administrator. RII Albert Gibson, Director. Division of Reactor Safety (DRS), RII Jon Johnson. Acting Director. Division of Reactor Projects (DRP) RII Bruno Uryc. Director. Enforcement and Investigation Coordination Staff (EICS). RII Charles Casto. Chief. Engineering Branch (EB). DRS. RII Carolyn Evans. Regional Counsel. RII Ken Barr, Chief. Plant Support Branch (PSB). DRS. RII Paul Fredrickson. Special Inspection Branch (SIB). DRS. RII Mark Miller. Senior Resident Inspector. St. Lucie Fred Hebdon. Project Director. PD II-3 Len Wiens. Project Manager. PD 11-3 ~

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) 4_ CLOSINGi REMMKS (S. Ebneter) In closing this predecisional enforcement conference. I remind the Licensee of two things: First. the apparent violations discussed at this closed predecisional enforcement conference are subject to further review and may be subject to change prior to any resulting enforcement action. Second, the statements of views or expressions of opinion made by NRC employees at this predecisional enforcement conference, or the lack thereof, are not intended to represent final agency determinations or beliefs, O e I l } 1 j

-i ENFORCEMENT ACTION WORKSHEET SREAKDOWN IN MANAGEMENT CONTROL OF THE ST. LUCIE EMERGENCY PREPAREDNESS PROGRAM PREPARED BY: James L. Kreh DATE: November 7. 1996 This Notice has been reviewed by the Branch Chief or Division Director and each violation includes the appropriate level of specificity as to how and when the requirement was violated. r egnat'ure Facility: St. Lucie Plant i Units: 1&2 Docket Nos.: 50 335, 50 389 License Nos.: DPR 67, NPF 16 Inspection Report No.: 96-18 Inspection Dates: October 7 18 and October 28 November 1, 1996 Lead Inspector: J. L. Kreh 1. Brief Summary of Inspection Findings: Violation A On the evening of October 3. 1996, the licensee conducted a test of its automated system known as the FPL Emergency Recall System (informally i called " autodialer") for notifying the emergency response organization (ERO) in the event of an off-hour emergency requiring augmentation of the on-shift crew for staffing and activation of emergency response facilities (viz. Technical Support Center [TSC). Operational Su) port Center [0SC). and Emergency Operations Facility [ EOF]). The autodia'er did not operate, i and no individuals received notifications during the test. A failure assessment by the licensee disclosed that the autodialer had been in an inoperable configuration for a period which apparently began on July 22. 1996. In addition. the inspection identified the licensee's failure to adequately maintain the manual backup system (a " call tree") for ERO call-out over an indeterminate period (at least the last several years). These concurrent deficiencies represent a failure (during the period July 22-October 3.1996 at minimum) to maintain the capability to execute the provisions of the REP and its implementing procedures in a timely manner with respect to mobilization of the ERO during off-hours. PREDECis!0NAL ENFORCEENT INFORMATION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR. OE

I d L ENFORCEMENT ACTION. 2-WORKSHEET yiolation B 4 The licensee *s training program for ERO personnel has not been adequately implemented since at least 1994. This violation includes failure to provide opportunities for most personnel to participate in exercises and/or drills, failure to provide annual retraining to certain designated Jersonnel in 1994 and 1995, failure to provide any training for certain ERO positions with respect to selected implementing procedures, and failure to remove individuals from the ERO roster when their respirator qual-ifications had lapsed. 2.. Analysis of Root Cause: The root cause of both violations is failure of licensee management to I (a) provide an appropriate level of oversight of the emergency preparedness program as required by tne REP, and (b) ensure the implementation of timely and effective corrective actions for identified findings and deficiencies in emergency preparedness. 3. Basis for Severity Level (Safety Significance): For both violations: Sucolement VIII - Emeraency Preoaredness. SL III Section C.3 of Supplement VIII presents as an exam)le. " Violations involving... a breakdown in the control of licensed activities involving a number of violations that are related... that collectively represent a potentially significant lack of attention or carelessness toward licensed responsibilities." Section IV.A of the Enforcement Policy states that "a group of Severity Level IV violations may be evaluated in the aggregate and assigned a single. increased severity level, thereby resulting in a Severity Level III problem, if the violations have the same underlying cause or programmatic deficiencies, or the violations contributed to or were unavoidable consequences of the underlying problem." 4. Identify All Previous Escalated Actions Within 2 Years or 2 Inspections > 95-180: PORVs Inoperable Due To Personnel Error: SL III > 96-040: Dilution Event: SL III > 96-249: Multiple Examples of Inadequate 50.59 Reviews: SL III 5. Identification Credit? Yes Violation A Date licensee was aware of issues requiring cc,rective action: October 3. 1996. This identification credit /date applies only to the autodialer inoperability portion of the violation. The problem with the manual call-out system was NRC/CI-identified. PREDECisIONAL ENFORCEENT INFORMATION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR, DE

O ENFORCEENT ACTION-3- WORKSHEET Explain application of identified credit, who and how identified and consideration of missed opportunities-The inoperability of the autodialer was identified by the licensee on 10/3/%. but could have-been identified much earlier if periodic functional tests (e.g., weekly) had been performed. With appropriate administrative controls in place- (as had been recommended by an EP Coordinator as early as April 1996), autodialer inoperability would have 4 almost certainly have been precluded. An autodialer problem (limited in scope--not a ' complete system failure) also occurred during the. NRC-evaluated June 1993 exercise, but corrective action for that problem was clearly not sufficiently comprehensive. Violation B Date when the licensee was aware of issues requiring corrective action: January 1996. Explain application of identification credit, who and how identified and consideration of missed opportunities: bany of the identified failures in the licensees training program were self-identified in a self-assessment that was performed in January 1996. However, some of the identified failures were not self-identified, but 3 should have been through existing licensee program controls. 6. Corrective Action Credit? No Violation A Administrative controls have' been implemented for the autodialer under Protective Services Department Guideline No. PSG-015 " Maintenance and Testing of the Emergency Recall System" Revision 0, dated 10/29/96. For the manual call-out system, individuals required to maintain a copy of the procedure were added to the controlled distribution list, and a drill was conducted on October 10. 1996 with reasonably successful results. Application of corrective action credit: (1) No credit for autodialer issue because identified by licensee EP Coordinator in early 1996 and no action taken: (2) Credit for correction of manual call-out problem after l identification to licensee on 10/7/96. Violation B The licensee has initiated action items to evaluate and determine corrective actions for self-identified issues. The licensee is currently completing a mass training effort for all emergency response organization positions necessitated by recent changes in responsibilities from Corporate staff assignments to Plant staff assignments. Application of corrective action credit: No credit because the licensee has not yet fully determined or implemented programmatic changes to resolve identified issues. PREDECISIONAL ENFORCEENT INFORMATION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR, OE

ENFORCEMENT ACTION 4-WORKSHEET 7. Candidate For Discretion? No Licensee's performance in emergency preparedness is now recognized to have been particularly poor during the past several years. 8. Is A Predecisional Enforcement Conference Necessary? Yes Why? To determine whether the subject violations represent a programmatic breakdown in emergency preparedness. If yes, should OE or OGC attend? Yes Should conference be closed? No 9. Non Routine Issues / Additional Information: OTHER FINDINGS FROM THE OCTOBER 1996 EP PROGRAM INSPECTION i Violation-Failure to establish an Emergency Plan Implementing Procedure (EPIP), or. to have an adequate EPIP. with appropriate implementing details to address certain aspects of the Radiological Emergency Plan as follows: a. the transfer of OSC functions to an alternate location in the event that evacuation of the primary OSC is required (EPIP-3100032E. "On-site Support Centers", contains no implementing details for the statement in Radiological Emergency Plan Section 2.4.4 that "In the event that the OSC becomes untenable. the Emergency Coordinator will designateanalternatelocation."){inadequateprocedure},and b. recovery activities upon reaching a stable plant condition following an emergency (Radiological Emergency Plan Section 5.4) {no procedure}. Emeroency Preoaredness Proaram Weaknesses 1. Inadequate program of drills to ensure availability of sufficient ERO personnel and timeliness of ERF staffing 2. Management failure to ensure the implementation of timely corrective actions for certain emergency preparedness deficiencies and weaknesses, Examples are: a. failure to address concerns regarding the audibility of the Gaitronics (or plant public-address system) formally identified in late 1994 and still being tracked as an open item by the licensee's corrective action system. b. failure to provide adequate corrective action to address a questionable capability for notification of the State of Florida within 15 minutes of an emergency declaration (identified by an NRC inspection in February 1995). and PREDECIsIONAL ENFORCEENT INFORMATION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR, OE-i

i i ENFORCEMENT ACTION .6-WORKSHEET 4 c. failure to implement timely corrective actions for deficiencies and recommendations identified by the critique of the Hurricane Erin respense in August 1995 -(examples of issues: identify hurricane-safe structures onsite and a plan.. for positioning personnel in those structures: designate an onsite individual to monitor the hurricane. path; establish consistent staffing policies) 4 10. This Action is Consistent With. the Following Action (or Enforcement Guidance) Previously Issued: Supplement VIII, Section C.3 1 a G l i J s i a ) 1 i 1 i ^ j 1 PREDECISIONAL ENFORCEENT INFORMATION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR, OE

ENFORCEMENT ACTION. WORKSHEET 11. Regulatory Message: l Management must provide strong and consistent oversight'and support for emergency preparedness activities in order to ensure a viable emergency response capa]ility at all times. 12. Recommended Enforcement Action: L ~Two SL IV vi.olations evaluated in the aggregate as a SL III problem 13. Should This Action Be Sent to OE For Full Review? No 14. Exempt from Timeliness: No Basis for Exemption: N/A Enforcement Coordinator: DATE: l l l 1 i a PAEDECISIONAL ENFORCEENT INFORMATION NOT FOR PUBLIC RELEASE W/0 APPROVAL 0F DIRECTOR, OE

ENFORCEMENT ACTION 7-WORKSHEET DRAFT NOTICE OF VIOLATION. St. Lucie Plant Inspection Report Nos. 50-335, 50-389/96-18 A. 10 CFR 50.54(q) requires that nuclear power plant licensees follow and maintain in effect emergency plans which meet the planning standards of 10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR Part 50. Section 2.4 of the licensee's Radiological Emergency Plan (REP). Revision 31. states that activation of the Technical Support Center (TSC) and the Operational Support Center (OSC) will be initiated by the Emergency Coordinator in the event of an Alert. Site Area Emergency, or General Emergency, and that arrangements have been made to staff the TSC and OSC in a timely manner. Also specified is that activation of the Emergency Operations Facility (EOF) is required for a Site Area Emergency or General Emergency, and that arrangements have been made to activate the E0F in a timely manner. The REP requirements delineated above are implemented by procedure EPIP-3100023E. "On-Site Emergency Organization and Call Directory". Revision 72. The instruction in Section 8.2 of that procedure states that, upon the declaration of an emergency classification. "the Duty Call Supervisor will initiate staff augmentation" using the " Emergency Recall System or Appendix A. Duty Call Supervisor Call Directory to notify persons.. " Contrary to the above. from approximately July 22 to October 3.1996. j arrangements were not available to staff or activate the TSC. OSC or E0F in a timely manner because the licensee did not have the ca] ability to implement either the primary method (using the Emergency Recall System) or the backup method (using the Duty Call Supervisor Call Directory) for notifying its aersonnel to report to the plant during off-hours to staff i and activate t1e TSC. OSC, and EOF. B. 10 CFR 50.54(q) requires that nuclear power plant licensees follow and maintain in effect emergency plans which meet the planning standards of 10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR Part 50. j REP Section 7.2.2. " Training of On-Site Emergency Response Organization Personnel". states "The training program for members of the on-site emergency response organization will include practical drills as appropriate and participation in exercises. in which each individual demonstrates an ability to perform assigned emergency functions." The licensee's Plan further states. "For employees with specific assignments i or authorities as members of emergency teams, initial training and annual retraining programs will be provided. Training must be current to be maintained on the site Emergency Team Roster." >ntrary to the above, the licensee failed to provide a program.nich included an opportunity for each individual assigned to the on-site emergency response organization to participate in a drill or exo cise, as follows: PREDECISIONAL ENFORCEMENT INFORMA110N NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR. OE

I ENFORCEMENT ACTION' 8-l WORKSHEET 1. In'1994, the licensee failed to provide training for 17 positions l' (approximately 92 individuals) identified as part of the on-site response organization. In 1995, the licensee failed 'o provide training for 8 positions (approximately 54 individualsi identified as part of the on-site response organization. 2. The licensee's training program failed to include initial, periodic retraining, or information on revisions with respect to certain procedures required to be implemented by several identified positions. These procedures included EPIP 3100026E. Criteria for Conduct of Evacuat on: EPIP 3100027E. Re-entry; and EPIP 3100035E. Offsite Radiological Monitoring. l 3. For the calendar year 1995, the licensee failed to remove from the emergency response organization 4 individuals who had not completed retraining as required, and their training qualifications had expire in 1994. The ' licensee failed to remove 6 individuals from the emergency response organization effective October 6, 1996, who had not remained qualified to fill response team requirements as a result of allowing their respirator qualifications to lapse. l l 1 i PREDECIs!0NAL ENFORcEENT INF0fdMTION NOT FOR PUBLIC RELEASE W/0 APPROVAL OF DIRECTOR OE-}}