ML20137R297

Responds to NRC Ltr Re Violations Noted in Insp Rept 50-355/96-03.Corrective Actions:Rcs Dilution Secured & RCS Temp & Reactor Power Restored to within Required Limits of 549 Degrees Fahrenheit & 100 Percent

ML20137R297
Person / Time
Site:	Saint Lucie
Issue date:	04/23/1996
From:	Plunkett F FLORIDA POWER & LIGHT CO.
To:	Lieberman J NRC OFFICE OF ENFORCEMENT (OE), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
Shared Package
ML20137R112	List: IR 05000335/1996003 ML20137R106 ML20137R236 ML20137R253 ML20137R297 ML20137R317 ML20137R468 ML20137R544 ML20137R556
References
FOIA-96-485 EA-96-040, EA-96-40, L-96-93, NUDOCS 9704140084
Download: ML20137R297 (9)

Text

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Merida Power & Light cessaav. P 0. ses Miss. Jose seese, FL ness 4ess j

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1 APR 2 31998 Ie-96-93 10 CFR 2.201 '

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Mr. James Lieberman y

Director,. Office of Enforcement U. S. Nuclear Regulatory Commission Documsnt Control-Desk Attn Washington, D. C. 20555 i Dear Sirt Re St. Lucla Unit 1 /'

i . Docket No. 50-335

! Inspection Report 96-03

'. maniv to Natiam of Violation EA 95-040 Florida Power - and' Light Company (FPL) has reviewed the subject

notice of violation. Pursuant to the provisions of 10 CFR 2.201 and section 182 of the Atomic Energy Act of 1954, as amended, the reply to the notice of violation is attached. FPL will remit payment of the civil penalty by electronic transfer on or before April 27, 1996.

Very truly yours, T. F. Plunkett President - Nuclear Division TFP/EJB ,

Attachment- f ces Stewart D. Ebneter, Regional Administrator, USNRC Region II ,

Senior Resident Inspector, USNRC, St. Lucie Plant

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Res 'Ct. Lucio Unit 1 Docket No. 50-335 Reply to Notice of Violation

j. Inamaction Renart 96-os

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STATE OF F14RIDA

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COUNTY OF PAIJE BEACH ) 1

] T. F. Plun\ett being first duly sworn, deposes and says:

That he is .?' resident, Nuclear Division of Florida Power & Light i company, the Licensee herein; l i

That he has executed the foregoing document; that the statements made in this focument are true and correct to the best of his knowledge, information and belief, end that he is authorised to execute the document on behalf of said Licensee. .

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& 4f T. F. Plunkett l

l' subscribed and sworn to before me this d4 day of , 19 k .

MM NK.< # 4:K EcoA>c/Hy 1

NOTARY PUBLIC, in and for he County of Pala-Beach, state of Floride say comanission expires i

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05-06 .Hea UsFt1 5L wcie hestoent Ottsce 407 461 4622 F.04 -

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• 4 st. Lucie Unit 1

! Docket No. 50-335 1 ' Haply to Notice of Violation i Inanection Renort 96-03 i VIOLATION As l

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Technical specification 6.s.l.a requires that written procedures

+ be established, implemented and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Bevision 2, February 1978. Appendix A includes operating 4

procedures for the chemical and volume control system and j administrative procedures for relief turnover, procedural i adherence, and authorities and responsibilities for safe

operation.

l Operating Procedure No. 1-0250020, soron concentration control -

1 Wormal control, Revision 35, step 8.5.14, requires, in part, that

when adding a blend of primary makeup water and boric acid to the reactor coolant system by using the manual mode of operation and

> a flow path directly to the charging pump suction, that operators

, monitor the water flow totaliser and close valve V2525 after the j desired volume was added. )

! Administrative Procedure No. 0010120, conduct of operations, Revision 79, Appendix D, Crew Relief / shift Turnover, requires, in

part, that, for short term watchstander relief, a turnover be

! conducted including: general watchstation status, off-normal conditions, and tests in progress.

I Administrative Procedure No. 0010120, Appendix M, Procedural compliance and Implementation, requires, in part, that controlled procedures be implemented and complied with in accordance with

, the instructions provided in QI 5-PR/PSL-1. Procedure QI 5-

PR/PSL-1, Preparation, Revision, Review / Approval of Procedures,

Revision 67,-section S.13.2, provides that all procedures be

strictly adhered to and identified that Operating Procedure 1- .

l 0250020 was not considered " skill of the trade" and was not to be l performed from memory without referring to the procedure. '

l Administrative Procedure No. 0010120, Appendix E, Notification of operatione supervisor /FPL Management, requires, in part, prompt j verbal notification of the operations supervisor for unplanned  !

! reactivity changes. l contrary to the above:

l

) 1. On January 22, 1996, at approximately 2:30 a.m., the  ;

licenees failed to implement the requirements of operating

Procedure No. 1-0250020 in that Unit 1 operators failec to j monitor the water flow totaliser and failed to close valve l

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I St. Lucle Unit i Docket No. 50-335 l i Reply to Notice of Violation l t Inanection Renart 96-02 additions of primary water were made to maintain 100 percent power . (Raference FPL . letter. L-96-61, . dated March. 6,-.13s&) .

i Contributing factors to the violation include the followings i

\

1) Coynitive personnel arror on the part of the licensed

ut;.lity operator who initiated the reactor coolant

system (acs) dilution resulted in the failure to pronarly oemplete the evolution. The operator i istitiated the Rcs dilution and then left the immediate at. a after responding to an unrelated control board 3

annunciator.

i

2) The administrative requirements of the conduct of operations Procedure regarding watchstander relief,

procedure use and saragement notification were not l fully understood or consistently applied by operations personnel.

3) st. Lucie Plant's Operating Experience Feedback program did not adequately respond to similar reactivity

! management events at other facilities. As a result, ,

FPL did not identify routine dilutions as an evolution j which required special attention.

3. CORRECTITE STEPS TRIEE 1ED TEE RESULTS 1CEIEVED i

A. The RCS dilution was secured and RCS temperature and reactor power were restored to within the required l limits of 549 degrees Fahrenheit and 100 percent, ,

! respectively (within approximately 50 minutes), upon i'

. discovery of the condition on January 22, 1996.

i .

B. The Operations Department Supervisor was informed of the event at approximately 0545 on January 22, 1996.

l 4. CQRRECTIYE .32222 TO AYOID FURTEER VIOLhTIDES l A. The operator who performed the subject boron dilution was removed from licensed operator duties.

E. FPL completed a performance assessment for the licensed operator involved in this event and developed a  ;

, remedial training plan to be successfully completed

prior to returning the individual to licensed duties.

i 3 l

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05-0a-1996 04:02ftt 5s Lucae Reaaorns 0+ tace . &i o1 -621 FU St. Lucie Unit 1 Docket No. 50-335 Reply to Notice of Violation tri====et ian mannet as-03

c. The operations supervisor discussed with each Nuclear Plant Supervisor (NPS) the purpose and threshold for  :

providing notification to plant management in accordance with the requirements of the conduct of.

operations Procedure, AP 0010120. j D. Operations Administrative procedure, AP 0010120, l Conduct of operations, was revised to provide clearer  ;

standards regarding operator attentiveness, l watchstation turnover, control room oversight and  ;

procedure adherence. These changes include the {

followings i

1. Additional watchstander relief requirements were {

added to specifically address short ters.  !

watchstander relief during reactivity changes.

2. Supervisory presence by the licensed senior Reactor operator with the control room commend function is now required during reactivity 4 changes.

3. Additional guidance was included which specifies that the Reactor control operator (RCO) is to remain in the immediate vicinity of the control l board during all reactivity changes.

4. The acceptable methodology for procedure adherence during boration or dilution activities was spec 12ied.

l E. Reactor operating fruidelines were revised to establish  !

i normal operation wath a reduced Reactor Coolant Systes cold leg temperature (T-cold) in order to increase the operating margin between the 100 percent T-cold value l and the Technical specification limit.

j F. Management conducted crew briefings with each operating

arew to emphasise conservative plant operation and review Institute of Nuclear Plant operations (INFO) t recommendations regarding reactivity management.

l G. Plant management issued a letter to each licensed

operator to re-emphasise personal responsibility for

- reactor safety and to stress the importance of i reactivity control and constant attention to detail. j 4

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St. Lucie Unit 1 Decket No. 50-335 Reply to Notice of Violation Inanaction manort 96-02 ,

H. FPL Quality Assurance is performing en evalwation of the adequacy and effectiveness of the St. Lucie Plant program for transferring lessons learned from industry

) events. This evaluation will be completed and i

recossendations forwarded to st. Lucie management by j April 30, 1996.

l S. Full compliance was achieved on January 22, 1996 with the oompletion of items 3A and 33 above.

VIOLATION 38 r I 10 CFR 50 Appendix B, Criterion III, Design Control, requires j that measures be established to assure that applicable regulatory 1 requirements and the design basis, as specified in the liosase j application, are correctly translated into procedures.

i Units 1 and 2 Technical specifications (TS) 6.8.2 requires that each procedure of Ts 6.s.1 be reviewed periodically as set forth j in administrative procedures. Ts 6.8.1 requires that written

procedures be maintained covering the activities recommended in 4 Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.

Appendix A included operating procedures for the chemical and volume control system. Procedure QI 5-PR/pSL-1; Preparation, t

Revision, Review / Approval of Procedures, Rev 41; required that all plant procedures shall be reviewed every 36 months.

section 15.2.4.1 of the Updated Final Safety Analysis Report (UFSAR) states, in part, that during normal operation, i concentrated boric acid is mixed with domineralised makeup

. water... and is automatically introduced into the volume control tank in response to a low water level signal from the volume i control. To effect boron dilution, the makeup controller mode selector switch must be set to " Dilute" and the desineraliser water batch quantity set to the desired quantity. When the specific amount has been injected, the domineralizar water

! controi valve is shut off automatically.

contrary to the above, from approximately January 24, 1976 (before the Unit 1 operating license was issued), through January i

4 23, 1996, the licensee failed to correctly translate the design basis, as specified in UFSAR Section 15.2.4.1, into procedures in that the UFSAR description of the method for adding a mixture of boric acid and domineralized water to the reactor coolant system was not incorporated into the operating Procedure No. 1-0250020, Boron Concentration control - Normal Control, Revision 35, for i

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l st. Lucie Unit i  !

Docket No. 50-335

! Reply to Notice of Violation ,

j Inanection manort es-os l 1

l I st. Lucie Unit 1. Specifically, rati Procedure No. 1- .

1 0250020 described a method for ad ng a ure of boric acid.and l domineralised water to the reactor coolant system (in manual and directly to the suotion of the charging pumpe) that was different from the method stated in the UFsAR (in automatic and to the i volume control tank). Further, the licenses- failed to conduct an 4

i adequate iodio review of operating Procedure No. f.-0250020 as  :

TS 6.8.2. Specifically, during periodic reviews, the l-required last of which was accomplished on July 11, 1995, the licensee

' failed to correct the difference between the procedure and the

! UrsAR. (01023)

RMsPOWs3 38

1. FFL concurs with the violation.

2. REhECE FOR TICLhTION The root cause for the violation was that an inadequate process existed for ensuring that UFSAR design requirements were translated into plant procedures during procedure development and periodic review.

s. ppnaqqyrva swarm ramma man run maanLes acuravan In accordance with 10 CFR 50.59, a safety evaluation was completed which reviewed St. Lucie Unit 1 and 2 UFSAR requirements regarding boron concentration control. The evaluation provhded changes to be included into the Unit 1 and Unit 2 UFsARs which more clearly describe the acceptable methods available for boron concentration control. The boron l concentration control operating procedures (1-0250020 and 2-0250020) are consistent with these methods. Additionally, the evaluation determined that operation of the Chemical volume and contrni systems (cycs) in accordence with these changes does not constitute an unreviewed safety question and is supported by the UFSAR accident analysis. This action i was completed on February 15, 1995. j i

4. canaESTIYE STEPS TO AYoID FURTEER Y20LhTIGES l A. The process for the development and periodic review of plant procedures was changed to improve referencing of applicable UFsAR and Technical specification (TS) 1 eeotions in the procedures. Documentation of UFsAR and 3 Ts sections reviewed has been included in the process.

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US r.as-asina O Wh 5% L.ucte seslocnt Ofince 1 47 01 622 E.'O a

St. Lucie Unit 1 Docket No. 50-335 Reply to Notice of Violation j Inspection Raport 94-04 l

B. A change was issued to update the Unit 1 and Unit 2 i'

UFSARs to clarify acceptable operation of the Chemical and Volume control System with regard to boron concentration changes.

C. FPL is reviewing the Unit 1 and Unit 2 UFSARs and plant procedures for mutual consistency. This review will be

, completed by December 31, 1996.

1 4

5. Full compliance was achieved on February 15, 1996, with the ,

! completion of item 3 above.

I

TZoIATICW Cs

! 10 CFR 50 59 allows the licensee to make changes to its i

procedures as described in the Safety Analysis report (SAR),

i without prior Commission approval, unless the change involves, in

, part, an unreviewed safety question. The licenses shall maintain j

records of changes in procedures made pursuant to this section,

• to the extent that they constitute changes in procedures as 1 described in the SAR. These records must include a written

safety evaluation which provides a basis for the determination j that the change does not involve an unreviewed safety question.

l Contrary to the above, on January 23, 1996, the licensee made

! Temporary Change 1-96-017 to operating procedure 1-0250020, Boron Concentration Control - Normal Operat,,on, Revision 35, a procedure described in the UFSAR, and failed to include a written safety evaluation which provided a basis for the determination i that the change did not involve an unreviewed safety question.

I specifically, the licensee added instructions for dilution in l manual and directly to the suction of the charging pumps which is contrary to the UF5AR, paragraph 15 2.4.1, which states that i boron dilution must be conducted in the " Dilute" mode (such that i when the specific amount has been injected, the desineralised

water control valve is shut automatically) and described a flowpath into the volume control tank. (01033) 5 RRSPOWs3 Os

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1. FPL concurs with the violation.

2. M FOR TIGEATION The root cause of the violation was cognitive personnel error by the shift technical advisor (STA) who performed the l

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st. Lucie Unit i Docket No. 50-335 Reply to Notice of Violation

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t 10 CFR 50.59 screening review for the temporary change to procedure 1-0250020, Doron concentration control - Normal operation. The review by the STA determined that the

tempor change did not represent a change to a procedure as deser in the UFSAR, and therefore that a safety evaluation was not required.

A contributing factor to the violation was a weakness in the wrocess for performing 10 CFR 50.59 screening evaluations.

The process did not require that the applicable UFSAR

meotione reviewed during the screening be documented. 1 3, cammenerva somma ymmmer nun 1.- r- des u-i..--

1 l

In accordance with 10 CFR 50.59, a safety evaluation was 1

completed which reviewed St. Lucie Unit 1 and 2 UFSAR i

requiremente regarding boron concentration control. The evaluation provided changes to be included into the Unit i and Unit 2 UFSAR periodic updates which more clearly '

dameribe the acceptable methods available for boron concentration control. The boron concentration control 4 operating precedures (1-0250020 and 2-0250020) are consistent with these methods. Additionally, the evaluation i

determined that operation of the chemical volume and control i

Systems (CVCS) in accordance with these changes does not constitute the accident ananalysis.

unreviewed safety question and is supported by j February 15, 1996.-

This action was completed on

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Additional STA training was conducted to address and clarify the requirements associated with screening j

procedure changes for 10 CFR 50.59 applicability.

, 5.

j As 3, discussed under the corrective actions for violation j the process for procedure development and periodic review was revised to improve referencing of applicable UFSAR and TS emotione in the plant procedurse.

c.

The process for performing 10 CFR 50.59 screening relative to procedure changes was revised to require  ;

documentation of the UF8AR and Technical specification  ;

sections reviewed during the screening process.  !

i 5.

Full compliance completion was3 achieved of item above. on February 15, 1996 with the 1

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4 TOTAL P.11

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101 MAnmTTA STReef N.W., SUITE EDO 5 ATLANTA, GeoMSA Empete

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%,***.* February 22, 1996 EA 96-04'0 3

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Florida' Power & Light Company ATTN:o J. Goldberg President - Maclear Division i P. O.' Box-14000' C '

Juno Beach, Florida 33408-0420

j. -

SUBJECT:

NRC INSPECTION REPORT NOS. 50-335/96-03 AND 50-389/96-03

Dear Mr. Gcidberg:

This refers'to .the special followup inspection of the January 22, 1996, Unit I

! overdilution event. The inspection was conducted on January 26-30, 1996, at-the St. Lucie facility. This matter was again discussed on February 8, 1996, 4

~1n a meeting in Atlanta. The' purpose of the inspection was to determine

! whether activities authorized by the license were conducted safely and in accordance with NRC requirements. At the conclusion of the inspection, the

. findings were discussed with you and those members of your staff identified in '

the enclosed report.

Areas examined during the inspection are identified in the report. Within these areas, the inspection consisted of selective examinations of procedures and: representative records, interviews with personnel, and observation of F activities in progress.

d

Based on the results of this' inspection, three apparent violations were identified and are being considered for escalated enforcement action in

.accordance with the " General Statement of Policy and Procedure for NRC

. Enforcement Actions" violation involves operator (Enforcement failures toPolicy), NUREG-1600.

follow procedures The firstcoolant for reactor apparent

system boron dilution, watch turnover, adherence to procedures, and prompt reporting of events. As a result of these errors, operators exceeded 100%

reactor power on January 22, 1996. The second apparent violation involves 4

inadequate design control in that the procedure for adding a mixture of domineralized water and boric acid to the reactor coolant system did not implement the method stated in the Final Safety Analysis Report (FSAR), and had not done'so since January 1976. The third apparent violation' involves a change that was made to the Unit I procedure for reactor coolant system boron dilution on January 23, 1996, that differed from the method stated in the FSAR, without performing a required safety evaluation.

No Notice of Violation is presently being issued for these inspection findings. In addition, please be advised that the number and characterization i

of,the apparent' violations described.in the enclosed inspection report may .

P . change as a result of further NRC review.

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LA predecisional enforcement conference to discuss these apparent violations

-has been scheduled for. March 8, 1996. Also, you have been requested to bring ENCLOSURE-1 i- $l' ', d k b b y,

t FPL 2 i

the three licensed operators who were involved in the overdilution event to I the enforcement conference. The decision to hold a predecisional. enforcement l 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 I held to obtain information to enable the NRC to make an enforcement-decision, l 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 addition, this is an opportunity for you to point out any errors in our i inspection report and for you to provide any information concerning 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 accordance with Section VI.B.2 of the Enforcement Policy, and 3) any other application of the Enforcement Policy to this case, including the exercise of discretion in accordance with Section VII.

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.

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.

]

Should you have any questions concerning this letter, please contact us. j Siricerel , (\

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]d

? Jc --

Albert F. Gibson, Director Division of Reactor Safety Docket Nos. 50-335, 50-389 License Nos. DPR-67, NPF-16

Enclosures:

1. Inspection Report

2. Enforcement Policy:

Section V, "Predecisional Enforcement Conferences" cc w/encls:

W. H. Bohlke Vice President St. Lucie Nuclear Plant P. O. Box 128 Ft. Pierce, FL 34954-0128 cc w/encls cont'd: See page 3

FPL 3

cc w/encls cont'd:

H. N. Paduano, Manager Licensing and Special Programs i Florida Power and Light Company P. O. Box 14000 Juno Beach, FL 33408-0420 J. Scarola  :

Plant General Manager St. Lucie Nuclear Plant P. O. Box 128 i Ft. Pierce, FL 34954-0128 E. J. Weinkam '

Plant Licensing Manager St. Lucie Nuclear Plant P. O. Box 128 Ft. Pierce, FL 34954-0218 ,

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 ,

Bill Passetti Office of Radiation Control Department of Health and Rehabilitative Services 1317 Winewood Boulevard Tallahassee, FL 32399-0700 Jack Shreve Public Counsel ,

Office of the Public Counsel l c/o The Florida Legislature 111 West Madison Avenue, Room 812 Tallahassee, FL 32399-1400 Joe Myers, Director Division of Emergency Preparedness Department of Community Affairs 2740 Centerview Drive Tallahassee, FL 32399-2100 i

cc w/encls cont'd: See page 4 '

1 I

i FPL 4 r cc w/encls cont'd*  !

Thomas R. L. Kindred l

' County Administrator '

St. Lucie County 2300 Virginia Avenue l'

- Ft.' Pierce, FL 34982 Charles 8. Brinkman Washington Nuclear Operations  :

- A88 Combustion Engineering, Inc.

12300 Twinbrook Parkway, Suite 3300 Rockville, MD 20852  :

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s/g UNITED STATER NUCLEAR REGULATORY COMMISSION RemoN u

.E o 101 MARIETTA STREET. N.W., SUffE 2500 C j- ATLANTA, GEORGIA 3035019

\...../ -

i Report Nos.: 50-335/96-03 and 50-389/96-03 Licensee: Florida Power & Light to 9250 West Flagler Street Miami, FL 33102 ,

Docket Nos.: 50-335 and 50-389 License'Nos.: DPR-67 and NPF-16 Facility Name: St. Lucie 1 and 2 Inspection Conducted: January 26-30, 1996 Lead inspector:

$ au 9L R. S'ch'in DWte Signed Reactor Inspector Accompanying Inspectors: B. Desai, Resident Inspector, Turkey Point M., Killer, Senior Resident Inspector, St. Lucie S./Sandin, Senior Operations Officer, AE00 7

Approved by: ft t[

C.'Casto, Chief Y~ O/EN6 ,

Date Signed '

Engineering Branch Division of Reactor Safety

SUMMARY

Scope:

This special inspection was conducted on site to review the Unit 1 overdilution event of January 22, 1996.

Inspections were performed during normal and backshift hours and on a weekend.

Results:

The inspectors identified concerns with licensee control of licensed activities and with licensed operator attentiveness. Three related apparent violations were identified:

a. Operators failed to follow procedures, with four examples:

1)- Operators failed to stop dilution of the reactor coolant systera when the proper amount of demineralized water had been added.

t 4

2

2) There was inadequate watch turnover for the operator at the controls during dilution.  !

3)- Operators performed the boron dilution procedure from memory, i without referring to the procedure, and without strictly adhering to the procedure.

4) Operators failed to promptly verbally report the event to licensee  :

management.

As a result of these errors, operators exceeded 100%, reactor power. This-event was bounded by the FSAR_ Chapter 15 accident analysis.

b.

Design control was inadequate, in that Unit 1 procedures for adding a I mixture of domineralized water and boric acid to the re, actor coolant system (in manual and directly to the suction of the charging pumps) did not implement the method stated in the Final Safety Analysis Report ,

(FSAR), Chapter 15 (in automatic and to the volume control tank), and had not done so since January 1976, before Unit I was licensed. i

c. 'A 10 CFR 50.59 evaluation was inadequate, in that the licensee made a cha'nge to the Unit 1 boron dilution procedure on January 23, 1996 (after the event), to allow adding domineralized water in " Manual" and directly  ;

to the suction of the charging pumps, that was different from the method stated in the FSAR, Chapter 15 (in " Dilute" and to the volume control tank) and without preparing a 10 CFR 50.59 safety evaluation.

In addition, a weakness in control room command and control was identified, with the following examples:

a. The senior reactor operator (SRO) in the control room was not aware of the boron dilution in progress.

b. The board operator did not inform the SRO of the boron dilution - this -

was a general practice at the site and not required by procedures.

4

c. r The watchstander Saturday, January 27).board in the Unit I control room was not maintained (on

d. The SR0 in the control room was allowed by procedures to be in the

Assistant Nuclear Plant Supervisor's (ANPS) office for unlimited time, "

out of sight of control room activities and out of hearing range of almost all control room activities except annunciator alarms. (During .

this event, the control room SR0 was at the control room desk operator's .;

area and in sight of control room activities.)

i Also, a weakness in procedures was identified, with the following examples:

a.

The procedure change process failed to address deficiencies in the Unit I

, procedure at the time the Unit 2 procedure was changed. During the i

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event, manual boron dilution as performed by operators could not be accomplished by strict compliance with the Unit I procedure. >

b. Procedures did not require the operator'at the controls to remain by the dilution controls during a manual boron dilution. o

There was also an identified weakness in corrective action, with the following

examples: l' 1

a. The licensee's initial investigation of the event was not thorough. i Spe'cifically, the initial investigation concluded that maximum reactor  ;

power was 100.2%, but subsequent review by the NRC and licensee found '

that maximum reactor power was approximately 101.18%. The licensee's ,

1 4

initial investigation also did not identify that the reactor operator who i started the boron dilution had left the control room with the dilution in  !

, progress and without telling other operators that a dilution was in j

progress.

l b. The revised procedure for manual boron dilution (after the event) did not i t

require the operator at the controls to remain by the dilution controls during a manual bo'ron dilution.  ;

Further, there was an identified weakness in operating experience feedback: l s

a.- In response to Significant Operating Events Report 94-02, dated September i

i 1994, which described a similar Turkey Point overdilution event, the

• licensee reviewed the St. Lucie operating procedures related to boron dilution and concluded that no changes were needed. This was a missed  !

opportuity to strengthen operating procedures to prevent the January 22; j 1996, werdilution vent, .

I l

The inspectors also had the following comments:

a.

! There was no clearly noticeable indication of boron dilution in progress. J The dilution clicker was quiet (and possibly inaudible from the desk i area) and sounded identical to other nearby clickers that routinely made noise. j

b. No alarms came in during this event to alert the operators that reactor coolant system cold leg temperature (Tc) and reactor power had exceeded )

c allowable values. The licensee had raised the Tc alarm setpoint so that i

it no longer served to alert operators that they had entered a Technical Specification two-hour action statement. Also, control room operators did not have comp'lete information available about the Digital Data Processing System computer alarms.

• 1: c. Operators routinely did not log re' activity additions; however, the licensee's Conduct of Operations procedure stated that operators should log significant reactivity changes.

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TABLE OF CONTENTS

1. Persons Contacted . . . . . . . . . . . . . . . . . . . . . . . . . 1

2. General Description of the Overdilution Event . . . . . . . . . . . 1

3. Detailed Sequence of Events . . . . . . . . . . . . . . . . . . . . 2 t

4. Shift Manning, Operator Qualifications, and Overtime . . . . . . . 4 4.1 Adequate Shift Manning . . . . . . . . . . . . . . . . . . . . 4 4.2 Adequate Operator Qualifications . . . . . . . . . . . . . . . 5 4

4.3 Adequate Overtime Use . . . . . . . . . . . . . . . . . . . . 5 4.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 6

5. Operating and Administrative Procedures . . . . . . . . . . . . . . 6 5.1 Inadequate Boron Dilution . . . . . . . . . . . . . . . . . . 6 5.2 Inadequate Watch Turnover . . . . . . . . . . . . . . . . . . 6  :

I 5 . 3' Inadequate Adherence to Procedures . . . . . . . . . . . . . . 7 5.4 Inadequate Prompt Notification . . . . . . . . . . . . . . . . 8 5.5 Weakness in Control Room Command and Control . . . . . . . . . 8 5.6 Weakness in Operating Procedures . . . . . . . . . . . . . . . 9 5.7 Other Comments . . . . . . . . . . . . . . . . . . . . . . . . 9 5.8 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 10

6. Updated Final Safety Analysis Report Review . . . . . . . . . . . 10 6.1 Inadequate Design Control . . . . . . . . . . . . . . . . . . 10 6.2 Inadequate 10 CFR 50.59 Evaluation . . . . . . . . . . . . . 12 6.3 Licensee Dissenting Comments . . . . . . . . . . . . . . . . 13 6.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 14

7. Human Factors and Equipment Condition . . . . . . . . . . . . . . 14 7.1 Control Room Arrangement . . . . . . . . . . . . . . . . . . 14 7.2 Water Flow Totalizer and Batch Integrator . . . . . . . . . . 14 7.3 Alarms . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

J 2

7.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 15 ,

8. Operating Experience Feedback . . . . . . . . . . . . . . . . . . 16 8.1 Turkey Point Overdilution Event . . . . . . . . . . . . . . . 16 8.2 St. Lucie Inadvertent Dilution Event . . . . . . . . . . . . 17 8.3 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 17

9. Management Expectations . . . . . . . . . . . . . . . . . . . . . 17 9.1 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 18 10.

Initial Corrective Actions . . . . . . . . . . . . . . . . . . . . 18 10.1 Weakness in Initial Event Investigation . . . . . . . . . . . 18 10.2 Corrective Actions . . . . . . . . . . . . . . . . . . . . . 18 10.3 Licensee Dissenting Comments . . . . . . . . . . . . . . . . 19 10 A Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 19 i

11.

Exit Interview . . . . . . . . . . . . . . . . . . . . . . . . . . 19

12. Abbreviations, Acronyms, and Initialisms . . . . . . . . . . . . . 19 l

i e

• j i

I

l.

.I REPORT DETAILS NOTE: Acronyms used in this report are defined in paragraph 12.

1. Persons Contacted Licensee Employees

• Bladow, W., Site Quality Manager

1. Bohlke, W., St. Lucie Plant Vice President

• Burton, C., Site Services Manager

• Dawson, R., Licensing Manager

• Denver, D... Site Engineering Manager

• Fincher, P., Training Manager

• Fulford, P., Operations Support and Testing Supervisor

• Marchese, J., Maintenance Manager

• Olson, R., Instrument and Control Maintenance Supervisor

1. Plunkett, T., incoming President - Nuclear Division

• Sager, D., St. Lucie Plant Vice President

• 1. Scarola, J., St. Lucie Plant General Manager

• 1. Weinkam, E., Licensing Manager

• West, J., Operations Manager

• Wood, C., Operations Supervisor Other licensee employees contacted included office, operations, engineering, maintenance, chemistry / radiation, and corporate personnel.

NRC Personnel l

l 1 C. Casto, Branch Chief, Division of Reactor Safety, RII

• B. Desai, Resident Inspector, Turkey Point i

1. K. Landis, Branch Chief, Division of Reactor Projects, RII

• M. Miller, Senior Resident Inspector, St. Lucie

• R. Musser, Resident Inspector, Browns Ferry

• S. Sandin, Senior Operations Officer, AEOD

• 1. R. Schin, Reactor Inspector

• Attended exit interview on January 30, 1996.

1. Attended exit interview on February 8, 1996.

2. General Description of the Overdilution Event (92700)

At approximately 2:25 a.m. on January 22, 1996, the Unit I control board RCO Degan a manual boron dilution of the RCS by aligning primary makeup water (demineralized water) directly to the suction of the IB Charging ,

Pump. Moments after beginning the dilution, the Board RCO responded to a l secondary plant annunciator and then saw the Desk RCO return from the  !

kit'chen. He requested that the Desk RCO relieve him so that he could I prepare his meal. During the turnover, there was no discussion of the  !

dilution in progress. Following the turnover, the relief operator at the '

controls and the NPS, who was at t,he Desk RCO station, were not aware '

that a dilution was in progress. The original Board RCO returned between i 5-10 minutes later and immediately recognized his error. He informed the l

2 other RCO of the overdilution, which was overheard by the NPS, and stopped the dilution. The NPS directed the ANPS to take charge and begin a manual boration. Unit 1 entered two-hour TS LCO Action Statement 3.2.5 for Tc greater than 549'F. The maximum Tc obtained was 549.9'F and the maximum reactor power was 101.18%. Tc was above the TS limit of 549'F for approximately 50 minutes and reactor power was above 100% for ,

approximately 70 minutes. The operators did not promptly verbally notify '

plant management or the NRC of this event. During this event, the TS LCO Action Statement for Tc was not exceeded and the guidance of the NRC memorandum from E. L. Jordan of August 22, 1980, on maximum reactor power was not exceeded. Also, this event was bounded by the FSAR Chapter 15 '

accident analysis.

3. Detailed Sequence of Events (92700)

See Attachment I for the Unit I control room arrangement and locations of

operators. Also, note that the times in the sequence of events are approximations and only relevant events are mentioned.

1/21/96 t 11:00 p.m. Incoming mid shift assumed Unit I responsibility with the Unit at 100% power, 870 MWe, Tavg at 575 degrees F, Th at 600 degrees F, Tc at 548.9 degrees F, RCS Boron concentration at 376 ppm, Xe worth at -2722 pcm, all CEAs I fully withdrawn and in manual, and no Technical Specification action statements in effect. Major l evolution planned for the shift was to place the waste gas system in service. Further, there was an annunciator alarm E-9 associated with circulating water pump lube water supply strainer delta P high that was intermittently coming in due to a failed pressure switch.

11(45 p.m. Board RCO reset to zero the primary water (to VCT or charging pump) flow totalizer in preparation for inventory 11:00 p.m.- balance (RCS leak rate calculation).

2:00 a.m. Board RCO recalled performing at least two RCS boron dilutions of approximately 35 gallons each between 11:00 p.m. and 2:20 a.m. without resetting the totalizer.

1/22/96 2:00 a.m. NPS arrived in Unit I control room to gather data for morning report meeting and sat near desk behind control boards. STA was also present, near NPS.

2:10 a.m. ANPS turned over control room senior reactor operator responsibility to NPS and proceeded to the kitchen to prepare meal.-

i* .. j 3

2:15 a.m. Desk RC0 left the control room to go to the kitchen.

2:20 a.m. Normal continued fuel burnup resulted in indicated Tc of I 548.7 degrees F on RTGB-104 (digital meter). At.this

+

i point, the Board RCO decided to restore Tc to maximum i allowable program value of 549.0 degrees F. .!

2:23 a.m.- s

. Desk RCO. arrived in.the control room with his meal. i e

2:25 a.m. Board RCO began a manual dilution by aligning primary i

water to the suction of the charging pumps, by opening i FCV-2210X and A0V-2525. The flow rate was approximately  !

44 9Pa. 'l, 2

26 a.m. Annunciator E-9' associated with circulating water pump. l lube water supply strainer high delta P was received. The Board RCO walked to the panel and acknowledged the  !

annunciator,

[ j 2:27 a.m. After acknowledging the annunciator, the Board RCO decided to proceed to the kitchen to prepare his meal. The Board l j

F RCO conveyed this to the Desk RCO and requested.that he take over the ' operator at the controls' responsibilities. l

' However, he did not mention the ongoing dilution. The 1 i Desk RCO got up and proceeded to the board in the vicinity J of RTGB 103. -The original Board RCO proceeded to the i

kitchen and started preparing his meal. At this time, the NPS and the STA were in the control room at the desk area.

' ' The NWE had been in and out of the control room throughout the shift. The relief operator at the controls, NPS, STA,

! and NWE were not aware of the ongoing dilution.

' 2:35 a.m. The original Board RCO returned from the kitchen with his meal. Upon approaching the board, he realized that he had left the control room with an ongoing manual dilution. He

! exclaimed that he had overdiluted and immediately began securing the dilution. The Desk RCO questioned how much

- water was added and the Board RCO noted from the totalizer that approximately 400 gallons was added.

I 2:35 a.m. Soon after, annunciator M-16 associated with RCP controlled bleedoff pressure high was received. At this point, the Tc was noted by the Desk RCO to be 549.6 i

degrees F. Entry into the two-hour action statement i 3

associated with TS 3.2.5,'DNB parameters, was recognized and later logged.

2:36 a.m.

Desk RCO directed the Board RCO to initiate boration to 1

restore Tc to program. The NWE calculated the amount of borated water to be added to the RCS. The NPS asked the

' Desk RCO to notify the unit ANPS to come to the control room.

f

r i'

4 2:40 a.m. ANPS walked into the control room. '

2:41 a.m. Tc reached the highest noted value of 549.9 ' degrees F.

MWe reached 875 and indicated reactor power was  ;

approximately 101.2% '

2:50 a.m. Operators secured boration. -

t 3:14 a.m. Tc noted below 549.0 degrees F. TS Action Statement was  ;

exited. '

3:45 a.m. STA initiated an In-House Event Report and notified HPES ,

personnel by telephone.

5:45 a.m. NPS informed Operations Supervisor of the overdilution during a routine morning phone call.

5:45 a.m.-

6:00 a.m. Shift turnover occurred. The dilution event was ,

apparently not discussed with the oncoming shift.  !

i 6:25 a.m. In-House Event Report was E-mailed to standard .

distribution, which included plant management, by the STA.  :

6:30 a.m. Operations Manager toured the control room but was not informed of the overdilution event.

7:20 a.m. Operations Manager read the control room logs (in his '

office by computer) and questioned the log entry

. associated with the overdilution event.

7:30 a.m. Licensee initiated a detailed investigation associated with the event.

~

7:4'5 a.m. Senior plant management discussed the event during the morning meeting.  :

' 10:00 a.m. NRC resident inspector was given the event report that was initiated associated with the event.

4. Shift Manning, Operator Qualifications, and Overtime (92700) ,

4.1 Adequate Shift Manning P

The inspectors reviewed actual shift manning as compared with TS requirements. TS Table 6.2-1 establishes the minimum shift crew composition for St. Lucie Unit 1. With both Unit I and Unit 2 operating in a mode 1 condition, a Unit SRO, two R0s, and two A0s are required for each unit. In addition, a Shift Supervisor (SRO) and an STA are required, who may be the same individuals for both units. Additionally, although not required by TS,- an NWE (SRO) was assigned to support both units. At any time, at least one R0 (at the controls) and one SRO W

w

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L* ..

L

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5

-(control room command function) are required to be in the Unit I control room.

l

~

i During the event, operators on shift included an NPS (SR0), who was at a

. desk in the Unit I control room (fulfilling the control room command  !

function); an ANPS i room until summonedto(SRO), who restoration supervise was in the kitchen of Unit near I reactor the Unit 1owerI control and ,

reactor coolant system cold leg temperature; a Board RC0 (RO) wie started j the boron dilution (while at the controls) and then went to the kitchen .

o after being relieved at the controls by the Desk RC0; a Desk RCO (RO) who  !

, relieved the Board RC0 at the controls; an NWE (SR0), who was in the NWE' i

, office in the Unit I control room; and an STA, who was in the Unit 1 i i control room near the NPS. The Unit I control room arrangement and i operator locations are shown in Attachment 1. The inspectors concluded '

that the TS requirements for shift manning and the minimum number of i operators in the control room were satisfied.  !

4.2 . Adequate Operator Qualifications 4 )

The inspectors reviewed the Unit I licensed shift crew qualifications, J

medical status, and experience. All licensed operators had a current  ;

license and medical certification on file. The dates of initial R0 and )

SRO licenses and most recent reque.lifications were as follows:

i l R0 (initial) SRO finitial) Reaualification s NPS March 1985 September 1988 November 1995 ANPS August 1984 September 1988 December 1995

. Board RCO November 1993 N.A. November 1995 Desk RCO May 1992 N.A. October 1995 NWE May 1987 November 1991 December 1995 The inspectors. concluded that the qualification status of the Unit 1 I

, licensed operators was current and that the operators had considerable operating experience.

4.3 Adequate Overtime Use The inspectors reviewed the operators' recent work history (including overtime) and alertness. St. Lucie shift crews worked a forward rotation schedule consisting of:

.e Seven Peak shifts (1500-2300) Monday through Sunday, I e, Seven Mid shifts (2300-0700) Wednesday through Tuesday, o Six Day shifts (0700-1500) Friday through Wednesday, followed by e Five Day shifts (0700-1500) in either.a relief capacity or in requalification training before beginning Peak shift the following  !

Monday.

);

On the. morning of January 22, the Unit I cre;r was working their sixth

-consecutive mid shift. The inspectors questioned the RCOs to determine whether~ fatigue may have affected their alertness. Both RCOs said they i

l 4

. ,,,__e ,---,; .- - _

l

p, ,

'l 6 l were alert and- rested. . The NWE and STA confirmed this. The inspector  !

reviewed.the Operations Overtime Tracker sheets which showed that the  ;

L licensee had been tracking overtime to. assure compliance with TS  !

, rsquiruments. During the week prior to the event, some Unit.1 shift crew 1 members'had stood a double shift (two consecutive eight-hour shifts plus. ,

7 one-half hour turnover, followed by seven and one-half hours off,-

followed by an eight-hour shift), but all Unit I shift crew members had

!- complied with the TS 6.2.2.f requirements for maximum working hours.- The i

~f inspectors concluded that'neither excessive overtime nor operator fatigue.  !

contributed to.this event. l t

4A Conclusions j l The inspectors concluded that TS requirements for shift manning and

' minimum number of operators in the control room were satisfied. Also, j i the qualification status of the Unit I licensed operators was current and i

those operators had considerable operating experience. In addition,  !

neither excessive overtime nor operator fatigue contributed to this  ;

1 event. >

l 5.. -Operating and Administrative Procedures (92700) .

! The inspectors reviewed operator actions related to this event and the  !

licensee's related operating and administrative procedures.

l l 5.I' Inadequate Baron Dilution  ;

I Operating Procedure No. 1-0250020, Boron Concentration Control - Normal I

, Control, Rev. 35, established a method to supply boric acid and makeup L' water to the RCS at a desired boron concentration and provided  !

a instructions for various modes of control. The Board RCO had used

!' procedure section 8.5, Manual Mode of Operation, to initiate the boron dilution. Procedure step 8.5.14 required that operators monitor the boric acid and water flow totalizers and, when the desired amounts had t i been added, close valve V2525 or V2512, as applicable, to stop the

addition of boric acid and primary makeup water. The Board RCO desired

to . add between 25 and 40 gallons of primary makeup water, but failed to stop' dilution until approximately 400 gallons were added. During this time, the temporary relief operator at the controls was unaware that a boron concentration dilution was in progress, which resulted in an

!l unmonitored reactivity addition. The SR0 and other operators in the  !

control room were also unaware that a reactivity addition was in progress. This failure to follow OP 1-0250020 requirements, to monitor and stop the dilution when the desired amount was added, is an example of

! apparent violation 50-335,389/96-03-01. ,

a '

i 5.2 Inadequate Watch Turnover .

l Administrative Procedure No. 0010120, Conduct of Operations, Rev 79,  ;

Appendix D, Crew Relief / Shift Turnover, required that, for short ters watchstander relief, a turnover be conducted that include: general

• _ _ _ _ _ . . _ _ . _ _ - ~ . _ _ _ _ _ _ _ _ _ _ _ - _ _ _.

4 4 1

watchstation status, off-normal conditions, and tests in progress.

However, the Unit 1 operator at the controls conducted a short term watchstander relief with an inadequate turnover.in that it failed to

)

include general watchstation status and conditions including that a boron concentration dilution was in progress. As a result, the relief operator at the controls was unaware that a boron concentration dilution was in j

. progress and failed to adequately monitor and control the dilution. This l failure to follow AP 0010120 requirements, for a short term watchstander relief, is a second example of apparent violation 50-335,389/96-03-01.

The inspectors questioned both RCOs as to how they typically conducted l short term watchstation turnovers and, more specifically, what occurred during this event. The Board RC0 said that he recalled responding to a I l recurring annunciator alarm E-9 moments after starting the dilution. . He moved from the charging station at RTGB-105 to RTGB-102. He did not ,

i recall how long he was at RTGB-102 before seeing the Desk RCO returning i

- from the kitchen. He left RTGB-102 by stating "I will be over the line.

I am going to get my food" i which the operator at the co(over the line refers to the boundary within ntrols must remain). The Desk RCO l

acknowledged, assumed operator at the controls responsibility, and moved  ;

i from behind the desk to a position in front of RTG8-103. None of the short term relief requirements were performed prior to notifying the NPS }

i of the watchstation turnover. The Board RCO stated that it was a general  ;

practice, and management's expectation, to inform his relief of any '

evolutions, maintenance, or work in progress. Typically, this would not involve a face-to-face board walkdown. In this particular event, the

" Board RCO felt he was distracted by the E-9 annunciator alarm; however, he had no explanation of why he lost track of the dilution. The Desk RCO l i

• confirmed the general practice and management's expectation regarding '

short term relief. He further said that he did not ask the Board RCO for the status of the watchstation based cni His past experience and expectation that the operator requesting

• relief would provide the information routinely, and a

- L His observation that the annunciators were " black board" and his knowledge that there was no maintenance or other activities

scheduled for that shift. .

1 The inspector discussed the Desk RCO's performance in short term shift '

relief with both the Operations Supervisor and Operations Manager and I concluded his performance was consistent with past practices and management's expectations. l i

5.3 Inadequate Adherence to Procedures Administrative Procedure No. 0010120, Appendix M, Procedural Compliance  !

and Implementation, stated: " Controlled procedures are available in both '

Control Rooms and shall be implemented and complied with in accordance

• with the_ instructions provided in QI 5-PR/PSL-1." Procedure QI 5-PR/PSL-1,1 Preparation, Revision,: Review / Approval of Procedures, Rev 67, Section l i

d 5.13.2, stated "A strict adherence to procedural requirement - Verbatim b

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)

Compliance - is the policy expected and required of all St. Lucie Plant  !

i personnel." AP-0010120,: Appendix M, also identified those tasks considered " skill of the trade" which were repetitive and routine.in.

! ' nature and may be performed from memory without referring to the i procedure.

Boron concentration control was not identified as one of these tasks. The inspectors determined during interviews.that both.RCOs, the NWE, and the Operations Supervisor mistakenly believed that . i OP.1-0250020,-Boron Concentration Control, was a " skill of the trade"  !

task. During this event, the Board RCO had started the boron dilution - i from memory without referring to the procedure.  !

! t OP'l-0250020, Section 8.5, provided steps for adding a blend of boric  ;

),

acid and primary water to the VCT or'directly to the suction of the i charging pumps. It did not describe adding primary water with no boric

, acid. It included steps for starting a boric acid makeup pump and '

opening the. boric acid makeup isolation valve and those steps were not  :

indicated as optional. During this event, the Board RC0 did not strictly adhere to OP 1-0250020 in that he added primary makeup water with no boric acid, did not start a boric acid makeup pump, and did not open the e

boric acid. makeup isolatit,n valve. Operator performance of OP l-0250020 ,

from memory, without referring to the procedure, and without strictly ,

e adhering to the procedure (as required by AP 0010120), is a third example  !

' of apparent violation 50-335,389/96-03-01.  :

i i

5.4 Inadequate Prompt Notification The inspectors noted that AP 0010120, Appendix E, Notification of Operations Supervisor /FPL Management, required prompt verbal notification

' ' to the Operations Supervisor of unplanned reactivity changes. However, on January 22, 1996, between 2:30 a.m. and 7:20 a.m., operators failed to

! give prompt verbal notification to the Operations Supervisor of unplanned reactivity changes that had occurred during the overdilution event. In addition, the Operations Manager toured the Unit I control room at i- 6:30 a.m., but control room operators did not inform him of the i overdilution event. It was not until about 7:30 a.m., when the l Operations Manager and the Plant General Manager read the operator logs on their office computers, that plant management became aware of the overdilution event. The failure of operators to follow requirements of AP 0010120, for prompt verbal notification to the Operations Supervisor l of unplanned reactivity changes, is a fourth example of apparent violation 50-335,389/96-03-01.

i>

5.5 Weakness in Control Room fmand ed Control During this evo ., the Board RCO did not inform the NPS that he was beginning a. boron dilution. Operators told the inspectors that not notifying the SRO about boron dilution was a general practice at the

-site. 'Also, licensee procedures did not require the Board RCO to notify the SRO about starting boron dilution. In addition, during this event t

the NPS was not aware that-a boron dilution was in progress. The inspectors identified that the Board RCO not telling the NPS about a boron dilution in progress and the NPS not being aware that a boron

~

p 9

dilution was.in progress were examples of a licensee weakness in control room command and control.

- A review of licensee procedures revealed that the control room SRO was ,

allowed to be to be in the ANPS office for an unlimited time, out of sight of control room activities and out of hearin i control- room activities except annunciator alarms.g The range of was SR0 almost not all in the ANPS office during this event and the inspectors did not identify py examples where the SRO spent excessive time in the ANPS office.

Nonetheless, the inspectors identified the fact that licensee procedures allowed the SRO to be in the ANPS office for an unlimited time as another

, example of a licensee weakness in control room command and control.-  !

While visiting the Unit 1. control room on Saturday, January 27, the  ;

~

inspectors noted that the watchstander board on the wall of the control  ;

' room was not maintained current. The watchstander names indicated on the i l

board were not those of the crew that was currently on watch. The

' inspecto.= identified this as another indication of a licensee weakness  :

in command and control. '

5.6 Wea'kness in Operating Procedures

< The Operations Manager and other licensed operators told the inspectors i that boron dilution by adding primary water with no boric acid, in manual >

and directly to the suction of the charging pumps, had been performed by t operators for many years and was the routinely used method. The inspectors inquired as to how operators could use OP l-0250020 to do this while followir.g the verbatim compliance policy. The Technical Operations

- Supervisor noted that this procedural deficiency had been identified on Unit 2 and corrected prior to restart in January 1996. He further said .

that usually when a deficiency of this nature is noted, the other Unit's procedures are reviewed and corrected, if applicable. However, in this case, he was surprised to see that it had not been done. The inspectors e - reviewed the Unit 2 procedure change and verified that it had failed to include changing the Unit 1 procedure. The inspectors identified this failure to address the Unit 1 procedure when the Unit 2 procedure was changed as an example of a weakness in licensee procedures. '

1 The inspectors noted that licensee procedures in effect during this event  ;

~

did not require the operator at the controls to remain by the dilution controls and to closely monitor the dilution during a manual dilution '

i i

with no automatic shutoff. Boron dilution added reactivity to the '

nuclear reactor, albeit slower than control rod movement, but was not administratively controlled in the same manner as was control rod  ;'

movement.

i The inspectors considered the lack of a requirement for the

> Board RCO to remain at the dilution controls during a boron dilution to  ;

constitute another example of a weakness in licensee procedures.

5.7 Other Comments The inspectors also noted that operators did not routinely log reactivity additions by boron dilution. However, AP 0010120, Appendix F, Log

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i Keeping, stated that RCO log entries should include significant changes i in plant conditions,-including reactivity changes.

5.8 Conclusions In conclusion, the inspectors identified an apparent violation for operator failures to follow procedures, with four examples: 1) Operators failed to stop dilution of the RCS when the proper amount of i domineralized water had been added; 2) There was inadequate watch

'- - turnover for the operator a. 'he contrcis during dilution; 3)~ Operators performed the boration dilution procedure from memory, without referring j i- to the procedure, and without strictly adhering to the procedure; and 4)

Operators failed to promptly verbally report the event to licensee management. As a result of these errors, operators exceeded 100% reactor power. j i

l The inspectors also identified four examples of a weaknees in licensee 4

i control room command and control: 1) The Board RCO did not tell the NPS i

about a boron dilution in progress; 2) The NPS was not aware that a boron 1 a.

dilution was in progress; 3) The SRO in the' control room was allowed to i be in the ANPS office for unlimited time, out of sight of control room i activities; and 4) The control room watchstander board was not maintained

, current. i i

In addition, the inspectors identified two examples of a weakness in

, licensee procedures: 1) The procedure change process had failed to '

address deficiencies in the Unit 1 procedure when the Unit 2 procedure was changed, and 2) Procedures did not require the Board RCO to remain at the dilution controls during a boron dilution. i The inspectors also had the following comment: Operators routinely did not log reactivity additions; however, the licensee's Conduct of Operations procedure stated that operators should log significant reactivity changes. i

6. Updated Final Safety Analysis Report Review (92700) i i A recent discovery of a licensee operating their facility in a manner contrary to the UFSAR description highlighted the need for a special focused review that compares plant practices, procedures, and/or parameters to the UFSAR description. The inspector reviewed applicable sections of the St.1.ucie UFSAR, including System Description, Chapter E 9.3.4, and Accident Analysis, Chapter 15.2.4, to verify current plant configuration, procedures, and operating practices conformed to UFSAR description and commitments as well as to determine significance of the i dilution event in reference to the assumptions in the accident analysis.

6.1 ~ Inadequate Design Control The inspector noted inconsistencies between the wording of the UFSAR and plant procedures. UFSAR Chapter 9.3.4.2.1, Chemical and Volume Control u -. + . a , s ,, , . . , . , . ,-m.~. -

~..

l.. ,

11 System Normal' Operation, Jdescribed the four modes of makeup to the RCS-affecting boron concentration: dilute, borate, manual, and automatic.

The UFSAR stated that in the dilute mode, a preset quantity of. reactor makeup water is added into the VCT at.a preset rate. It stated that the.

4' - manual mode is primarily used for makeup and filling the safety 1njection-

~

tanks and the refueling water tank.

4 UFSAR Chapter 15.2.4.1, Chem'ical and Volume Control System !1alfunction-l Boron Dilution Event, stated:

} . Boron dilution is conducted under strict administrative procedures which specify permissible limits on the rate and magnitude of any i required change in boron concentration. . . . During normal ')

operation, concentrated boric acid solution is mixed with i domineralized makeup water to the concentration required for proper l plant operation and is automatically introduced into the volume -

control tank in response to a low water level signal from the volume )

control To effect boron dilution, the makeup controller mode  :

selector switch must be set to " Dilute" and the domineralized water batch quantity selector set to the desired quantity. When the

,- specific aN -+ has been injected, the domineralized water control valve is shut adomatically. . . . . Because of the procedures L

involved and the numerous alarms and indications available to tue operator, the probability of a sustained or erroneous dilution is very low.

However, the inspectors noted that procedure OP l-0250020, Boron Concentration Control - Normal Control, Rev. 35, that was in effect during the event, allowed adding a mixture of boric acid and primary water in manual and directly to the suction of the charging pumps. It did not include boron dilution by adding primary water, with no boric acid, in the manual mode of operation.

The inspectors also noted that, during the event, no alarms came in to alert operators of the overdilution. Just after the Board RCO recognized the overdilution and initiated corrective actions, annunciator M-16 associated with RCP controlled bleedoff pressure high alarmed. That alarm, which was not mentioned in the UFSAR, came in because the RCP  ;

i bleedoff went to the VCT, where the pressure had increased due to the

increased level from primary water addition. The alarms that were I credited in the UFSAR did not come in during this event, in part, because the dilution path was directly to the suction of the charging pumps and not to the VCT.

Further review, as requested by the inspectors, found that the first time the' dilution procedure had been changed to allow adding a mixture of l primary water.and boric acid in manual and directly to the suction of the 3

. charging pumps was~in a change to rev. 2 of the procedure, dated January 24, 1976, before the Unit 1 operating license had been issued. i The UFSAR Chapter 15.2.4.1; description of the methods for adding a mixture of primary water and boric acid and for boron dilution, as stated above, was on UFSAR pages 15.2.4-1 and 15.2.4-2, which were original

(  !

)

l

)

J

g -  ;

a i

N ,, 1 12 a

pages - the words remained exactly as reviewed by the NRC, as part of the -!

design basis as specified in the license application, prior to Unit I  ;

licensing. 1The inspectors concluded that the licensee's procedures, for= l adding a mixture of boric acid and primary water to the RCS, differed R from the methods described in the UFSAR from January 24, 1976, through

January .23, 1996.

<- 10 CFR 50,. Appendix B, Design Control, requires that measures be' established to assure that applicable regulatory requirements and the 4

design basis, as specified in the license application, are correctly >l translated:into procedures. The inspectors concluded that the UFSAR  ;

description of methods for adding boric acid and primary water to the RCS

. had not been correctly translated into procedures. This is identified as '

2 apparent violation 50-335,389/96-03-02: FSAR Description of Methods of  ;

RCS Boron Dilution Not Correctly Translated into Procedures,

- j>

6.2 Inadequate.10 CFR 50.59 Evaluation  !

The inspectors reviewed TC 1-96-017, dated January 23, 1996, which revised OP l-0250020, Rev. 35, on the day after the overdilution' event.

The TC stated that the reason for the change was to add procedural-guidance for manual dilution and boration of the RCS, in the same format ,

, as the corresponding Unit 2 procedure. The inspectors noted that in the

- 10 CFR 50.59 screening that was performed for the TC, the question "Does i

' the change represent:a change to procedures as described in the SAR" was  ;

answered "No." Consequently, a 10 CFR 50.59 safety evaluation was not  ;

i performed. The contents of the change included a new two-page step by i

t step instruction on manual dilution and a new three-page instruction on manual boration. The new instruction on manual dilution allowed dilution ,

in manual and directly to the suction of the charging pumps. The '

inspectors concluded that the TC was a change to the procedure and that the method of dilution described in the TC (in " Manual" and direct to the suction of the charging pumps) was different from the method of dilution t  ;

described in the UFSAR (in " Dilute" and to the VCT).

10 CFR 50.59 states that the licensee may make changes in the procedures as described in the SAR, without prior Commission approval, unless the '

L proposed change involves an unreviewed safety question. A proposed 4

change shall be deemed to involve an unreviewed safety question if the 4

probability of occurrence of an accident evaluated in the SAR may be i increased. The licensee shall maintain records of changes in procedures  ;

i made pursuant to this section, to the extent that these changes '

constitute changes in procedures as described in-the SAR, and the records 4

must include a-written safety evaluation that provides the basis for the

• determination that the change does not involve an unreviewed safety  ;

question. -In this case, the licensee had no written safety evaluation.  !

The licensee's failure to perform an adequate 10 CFR 50.59 evaluation for  !

TC 1-96-017 is. identified as apparent violation 50-335,389/96-03-03; '

Change to Procedure as Described.in FSAR Without a Safety Evaluation. I 4

t 4  ?

1 r,  !

) 13 6.3- Lic'ensee Dissenting Comments -

)

! .The licensee had dissenting comments with regard to the apparent 10 CFR l

50.59 violation. The dissenting. comments, from the Engineering Manager and the Licensing Manager, were: {

1 2

la. l The previous procedure allowed diluting in manual and directly to i

the suction of the charging pumps, and that' had been the practice. .{

i for many years. Therefore, the TC on January 23, 1996 (after the j event) did..not change the method of dilution, but only clarified a l i

previously existing procedure and made it conform to " verbatim. l compliance" rules. I 1

b.

(

The design of the plant (piping, valves) always was such that dilution in manual and directly to the suction of the charging pumps j

(3 was possible. l l

c. The accident analysis assumed a worst case dilution event with domineralized water going directly to the suction of the charging i pumps and three charging pumps running. That would be three times ,

the flowrate of this event and therefore that analysis bounds this

{ event.

1 d.. The FSAR Chapter 9 description of the Chemical and Volume Control I

' System did not prohibit dilution in manual and directly to the suction of the charging pumps. .

e. The automatic mode of dilution is less safe than the manual mode, in L~~ ' that there is more opportunity for a malfunction that could result  !

in a maximum flowrate approaching the design limit. t

?

f. The procedure change that first allowed dilution directly to the suction of the charging pumps was made before the operating license was issued, therefore 10 CFR 50.59 did not apply to that change.

g. Since the operating procedure that was in effect at the time the '

operating license was issued allowed dilution in manual and directly to the suction of the charging pumps, that method was included in  ;

the original licensing basis of the plant.

Afte'r receiving these licensee comments, the inspectors' concern remained unchanged: TC 1-96-017 of January 23,1996 (after the event) described [

procedure steps for dilution in manual and directly to the suction of the charging pumps. That procedure was different from the one described in

! -the FSAR. The licensee's procedure differed from the FSAR in that it allowed a faster rate of reactivity addition and without an automatic  ;

shutoff. The licensee had.not performed a safety analysis of this  ;

difference'and had not revised the procedure and/or FSAR to make them agree. i t

E l'.

i

?

, ,# ._____________._M__

L.,

i i

14 . I 6.4.: Conclusions j7 The inspectors concluded that-licensee design control was inadequate, in  !

' that Unit 1 procedures for adding a mixture of domineralized water and i boric acid to the reactor coolant system (in manual and directly to-the '

suction of the r,crging pumps did not implement the procedure as stated

-in the FSAR, Chapter 15 (in au)tomatic and to the VCT) and had not done! i

, since January 1976, before Unit I was licensed.  !

The inspectors also concluded that a 10 CFR 50.59 ' evaluation was-  !

inadequate, in that the licensee made a change to'the Unit I dilution  !

procedure on January 23, 1996 (after the event), to allow adding pure I

domineralized-water in " Manual" and directly to the suction of the ,

charging pumps, that was different from the procedure as stated in the FSAR, Chapter 15 (in " Dilute" and to the .VCT) without a 10 CFR 50.59 i

, safety evaluation.

7. Human Factors & Equipment Condition (92700)  ;

i The inspectors reviewed control room layout including operator desks, 1

ANPS office, and kitchen location; as well as system and annunciator panels, controls, and indications to assess their potential-contribution to the overdilution event. A plan view of the Unit I control room layout is included as Attachment-1. The inspectors had the following l

observations in this area:

7.1 Control Room Arrangement I

4 The location of the operators' desks where the STA, NPS, and desk s

operator were seated were within visual and audible range of all significant alarms and indications and did not compromise the operators' ability to react to an abnormal condition or indication.

i i The location of the ANPS office (where it was acceptable for the ANPS to j

^

perform administrative tasks) was not within the visual range of the control room panels and indications but was within audible range of most annunciator alarms. This did not contribute to the overdilution event as the control room SRO responsibility was fulfilled by the NPS who was seated at a desk in the control room during the overdilution event.

i Further, the inspectors were informed by the licensee that the ANPS i routinely spends a majority of his/her time in the control room outside the office, i.e. in the controls area. The inspectors were informed that, after the overdilution event, the licensee was considering l

] relocating the ANPS work area / office to within the controls area of the l control room.

, 7.2 Water Flow Totalizer and Batch Integrator 4

~

The inspectors noted that there was no clearly noticeable indication in the control room of dilution in progress. The dilution water flow 4

totalizer clicker was quiet (and possibly inaudible from the desk area),  ;

a I

1

• 15 sounded identical to the nearby clickers from the waste gas and liquid  !

release totalizers that routinely made noise, and was masked by noise from the control room air conditioning units.

Operators stated that the makeup water batch integrator that was designed to enable automatic makeup had not been used in the last several years.

The inspectors noted that there was no open work request on the makeup water batch integrator.

7.3 ' Alarms The annunciator panel and DDPS (computer) alarm setpoints associated with Tc had been modified from 549 degrees F to 552 degrees F for the

- annunciator panel and 551 degrees F for DDPS. The inspector reviewed and discussed the modification with the licensee. The licensee operated the plant with Tc close to 549 degrees F for thermal efficiency purposes.

With the alarm set at 549 degrees F, the annunciator would often alarm, becoming a nuisance to the operators. Also, the alarm would at times remain locked in, thereby becoming unavailable for future use.

Therefore, the licensee raised the setpoint sufficiently so that the alarm would not routinely come in. The inspector concluded that, while '

the decision to raise the alarm setpoints might have seemed reasonable, ,

the alarms no longer functioned to alert the operators when they were '

exceeding the TS limit on Tc of 549 degrees F and entering a two-hour l action statement.

The inspectors asked if there were any other alarms or indications that  !

would alert the operator of an overdilution event, and the licensee  !

indicated that there was a delta T power alarm on the DDPS computer, set  !

at 101 percent power. Since 101 percent power had been exceeded during '

this event and that alarm had not come in, the inspectors asked the licensee to verify the alarm setpoint and functionality. Upon investigation, the licensee determined that the DDPS delta T power Unit 1 alarm setpoint was 101 percent and Unit 2 setpoint was 150 percent. l However, these alarms were not in use and were disabled. The inspectors concluded that control room operators and other licensee personnel did not have complete information available about DDPS computer alarms.

The licensee informed the inspectors that a feedwater high temperature alarm, set at 437 degrees F, would come in at approximately 102 percent power.

Also, the Tc alarms would have come in at 551 and 552 degrees F to alert the operators of a more severe transient than the one that occurred on January 22, 1996.

7.4 Conclusions l

The inspectors concluded that the control room arrangement did not contribute to the overdilution event. However, the location of the ANPS-office was previously addressed as an example of weakness in control room command and control.

l

i 16 The inspectors noted that there was no clearly noticeable indication of '

dilution'in progress. The dilution clicker was: quiet (and possibly ,

' inaudible from the desk area) and sounded identical to the nearby 4

, clickers that routinely made-noise. ,

i The inspectors also noted that no alarms came in during this event to alert the operators that Tc and reactor power had exceeded allowable j values. . The licens5.e had raised the Tc alarm setpoint so that it no '

. longer served to alert operators that they had entered a TS two-hour action statement. Also, control room operators did not have complete j information available about the DDPS computer alarms.

8. . Operating Experience Feedback (92700)  !

The inspectors reviewed previous industry events involving reactivity management to determine applicability and effectiveness of licensee '

j actions.

8.1 Turkey Point Overdilution Event i

i INPO SOER 94-02, Boron Dilution Events in Pressurized Water Reactors,  !

dated September 19, 1994, discussed a similar overdilution event at 4

Turkey Point and several inadvertent dilution events at other utilities. ,

The SOER made specific recommendations with regard to factors that could potentially affect reactivity as a result of a gradual boron dilution while at power, including: identification and training of those plant >

personnel who have the potential to affect reactor coolant system boron concentration, and conducting a systematic evaluation of their initial and continuing training programs to verify that lessons learned from

these events are addressed through classroom, simulator, and on-the job training where appropriate. Further, the SOER recommended reduction in I the risk of an inadvertent dilution through administrative controls, j i availability of appropriate monitoring of key parameters and/or alarm L functions, and minimization of operating crew distractions during  ;

j activities involving changes to boron concentration. '

The inspector reviewed licensee actions with regard to the specific recommendations of the SOER. The licensee had completed numerous actions 1

2 in the area affecting training, chemistry procedures involving CVCS ion 3 exchanger activity, Health Physics Procedures involving decontamination, l

! and Nuclear Materials Management involving Boric Acid purchase and '

storage. However, the licensee had concluded that operating procedures  ;

for boron dilution adequately addressed the recommendations involving administrative controls and availability of appropriate monitoring of key l

parameters and/or alarm functions. In response to the SOER, the licensee l

l made no changes to the operating procedures for boron dilution or the related administrative controls.

~

, The inspector. concluded that licensee response to the SOER was weak in 1

!' that it primarily focused on inadvertent dilution events and did not '  !

, . adequately address overdilution events, such as the one described in the l i

,.I' y -- ,- , , , .

7.- ,

4

, 17

, f i ' SOER that occurred at Turkey Point. The changes in administrative.

controls that the licensee made after the January 22, 1996, overdilution e

event were similar to changes in administrative controls that Turkey '

Point had made after their overdilution event. This SOER was a, missed ,

opportunity.to strengthen St. Lucie operating procedures to prevent the  ;

January 22, 1996, overdilution event. -

i 8.2 St. Lucie ' Inadvertent Dilution -

i The inspector also reviewed a minor inadvertent dilution event that 1 occurred at St. Lucie on January 11, 1996, during the valving in of a  ;

! CVCS ion exchanger.- During this event, the control room board operator ';

i had prematurely diverted, to the VCT, letdown flow through an ion-exchanger that had been aligned to the HUT, pending boron. sampling by

. chemistry. As a result, water with a very low boron concentration was i 4

added to the VCT. This event resulted in a slight increase to Tc that i was promptly detected and addressed through boration. Licensee  !

corrective actions included a change to procedure OP-0210020, to ensure '

t completion of a boron sample prior to placing ion exchanger in service.

L

' The inspector noted that the event was not logged in the control roon j operator logs; however, the Operctions Manager had.been made aware of the >

issue. The inspectors concluded that the licensee had missed another l

' opportunity following the January 11, 1996, inadvertent dilution event to  :

L . recognize, emphasize, and rectify a weakness in the conduct of operations l during evolutions affecting reactivity. l 8.3 Conclusions s

The inspectors concluded that the licensee's response to SOER 94-02, '

' dated September 1994, which described a similar Turkey Point overdilution event, was weak. This was a missed opportunity to strengthen operating procedures to prevent the January 22, 1996, overdilution event.

The inspectors also concluded that the St. Lucie inadvertent dilution event of January 11, 1996, was another missed opportunity to strengthen administrative controls for the conduct of operations during evolutions

~

affecting reactivity. ,

9. Management Expectations (92700) l n

The inspectors reviewed recent documented indications of management '

expectations; including a memo from the President - Nuclear Division to plant personnel emphasizing corporate policy on the responsibility and authority of.the Nuclear Plant Supervisor and the Shift Technical Advisor i on Shift; a memo from tne St. Lucie Plant Vice President to plant  !

personnel about procedure usage; various Operations Night Orders; and j i

inter-office correspondence. ,

3 s

l

s. ..

18 9.1" Conclusions '

i

. The inspectors concluded that some management expectations'had been  ;

recently documented and transmitted to plant personnel. Those management '

expectations had'specifically addressed adherence to procedures, but had not specifically addressed overdilution events or the other issues '

addressed in this report as apparent violations or weaknesses. '

10.

Initial Corrective Actions (92700)

The inspectors reviewed the timeliness and thoroughness of the licensee's initial corrective actions for the overdilution event. '

10.1 Weakness in Initial Event Investigation The licensee initiated an In-House Event Report summarizing the event and I began distribution of that report within about four hours after.the i event. The licensee's initial investigation, as documented in the In-House Event Report, was timely but was not~sufficiently thorough. The ,

In-House Event Report stated that maximum reactor power was 100.2%, .

however, subsequent review by the NRC and licensee found that maximue reactor power was approximately 101.18%. Also, the In-House Event Report did not identify that the reactor operator who had started the boron  !

dilution had left the control room with the dilution in progress and without telling other operators that a dilution was in progress. As a result.of the weakness in the In-House Event Report, licensee management did not promptly recognize the significance of the event and the ,

licensee's subsequent more thorough investigation was unduly delayed.

10.2 Corrective Actions Following the event, the licensee immediately removed the reactor  !

ope'rator who had initiated the event from' licensed duties, promptly i issued a Night Order and conducted training on the event with operators j i

on each shift; revised the Unit 1 procedure for dilution so that manual dilution could be performed by strict compliance to the procedure steps; i

revised the Conduct of Operations procedure to require the RO to get

I prior approval from the SRO for dilution /boration, to require the SRO to directly supervise dilution /boration, to require no RO or SRO turnover during dilution /boration, and to require RTG8 walkdown prior to R0 or SRO 1 i

i i

short term relief; and initiated further review of the event. '

The inspectors concluded that the licensee's initial corrective actions were reasonably prompt and comprehensive. However, the inspectors noted

' a weakness in-that the revised procedure for manual dilution (after the  !

event)'did not require the' operator at the controls to remain by the i

- dilution controls and to closely monitor the dilution during a manual dilution with no automatic shutoff.

3 I

4 i

i s

- *, .--- so-.i. . ~ - -- -- e . .e-- - --m --m. -rm-v- w

19  ?

l 10.3 Licensee Dissenting Comments '

The licensee had a dissenting comment on the inspector-identified weakness in the licensee's hitial investigation. The dissenting -!

comment,- from the Plant-General Manager, was i The initial investigation, for the In-House Event Summary, was done by.

the STA. Timeliness was more important than quality at that time. A '

subsequent more thorough review would be performed by the licensee.

10.4 Conclusions The inspectors concluded that the licensee's initial corrective actions were reasonably prompt and comprehensive. However, the licensee's f initial investigation was weak. The In-House Event Report significantly-understated the peak reactor power during the event and failed to state that the reactor operator who had started the boron dilution had left the control room with the dilution in progress and without telling other operators that a dilution was in progress. Also, the revised procedure. '

for manual dilution (after the event) did not require the operator at the controls to remain by the dilution controls and to closely monitor the i diTution during a manual dilution with no automatic shutoff.

11. Exit Interview The inspection scope and findings were summarized on January 30, 1996, and on February 8, 1996, with those persons indicated in paragraph 1.

The inspectors described the areas inspected and discussed in detail the inspection results listed below. Proprietary information is not contained in this report. There were numerous licensee dissenting

-comments, as documented in paragraphs 6.3 and 10.3.

hp.g Item Number Status Descriotion and Reference EEI 335,389/96-03-01 Open Operators failed to Follow Procedures for Boron Dilution, Watch Turnover, Procedure Adherence, and Event Reporting (paragraphs 5.1, 5.2, 5.3, and 5.4)

EEI 335,389/96-03-02 Open Inadequate Design Control of Reactor Coolant System Boron Dilution Procedure (paragraph 6.1)

EEI 335,389/96-03-03 Open Inadequate 10 CFR 50.59 Safety Evaluation of Change to Boron Dilution Procedure (paragraph 6.2)

]

12. Abbreviations, Acronyms, and Initialisms 1 AE00 Analysis and Evaluation of Operational Data, Office for (NRC)

, =A0 Auxiliary Operator-e,- n. _ -

1 .

i

. 1 20 i

A0V Air Operated Valve '

ANPS Assistant Nuclear Plant Supervisor l

. AP Administrative Procedure  ;

CEA Control Element Assembly CFR Code of Federal Regulations '

CVCS Chemical and Volume Control System l

DDPS Digital Data Processing System delta P Differential Pressure

)

DN8 -Departure from Nucleate. Boiling ,

1 DPR Demonstration Power Reactor (A type of operating license)

EEI Escalated Enforcement Item  ;

FCV Flow Control Valve FPL The Florida Power & Light Company FSAR . Final Safety Analysis Report

gpa gallons per minute J

HPES Human Performance Evaluation System 4

' HUT Hold-up Tank INPO Institute for Nuclear Power Operations -

IR [NRC] Inspection Report LCO TS Limiting Condition for Operation MWe Megawatts Electric N:A. Not Applicable NPS Nuclear Plant Supervisor .

NRC Nuclear Regulatory Commission i

NWE Nuclear Watch Engineer j

OP Operating Procedure pcm i percent milli (a measure of reactivity) ppm Part(s) per Million i QI Quality Instruction RCO Reactor Controls Operator RCP Reactor Coolant Pump RCS Reactor Coolant System Rev Revisio:t RII Region II - Atlanta, Georgia (NRC)

R0 Reactor Operator RTGB Reactor and Turbine Generator Board SAR Safety Analysis Report SOER Significant Operating Events Report SRO Senior Reactor Operator i

STA Shift Technical Advisor Tavg Reactor Coolant System Average Temperature TC Temporary Change 2

Tc Reactor Coolant System Cold Leg Temperature Th Reactor Coolant System Hot Leg Temperature 1 J

TS Technical Specification (s)

UFSAR Updated Final Safety Analysis Report Xe Xenon t

Page 91 of 174 ST. LUCIE PLANT ADMINISTRATIVE PROCEDURE NO. 0010120, REVISION 79 COr4 DUCT OF OPERATIONS FIGURE 3

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1 g February 22, 1996 J ,

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EA 96-040 r '

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~ Florida Power & Light Company i ~ ATTN: J. Goldberg President - Nuclear Division i

,. P. O. Box-14000

Juno Beach,. Florida. 33408-0420 i

4

SUBJECT:

NRC INSPECTION REPORT NOS. 50-335/96-03 AND 50-389/96 -

Dear Mr. Goldberg:

This refers to the-special followup inspection of the January 22, 1996, Unit l

overdilution event. i The inspection was conducted on January 26-30,~1996, at .

' .the St. Lucie facility. This matter was again discussed on February 8, 1996,  !

L in a meeting in Atlanta. The purpose of the inspection was to determine whether' activities authorized by the license were conducted safely and in 1 3

i accordance with NRC requirements. At the conclusion of the inspection,-the ,

findings were discussed with you and those members of your staff identified in

{ the enclosed report.

< e i

Areas examined during the inspection are identified in the report. Within  !

these areas, the inspection consisted of selective examinations of procedures  !

and representative records, interviews with personnel, and observation of -

{ ' activities in progress.

l Based on the results of this inspection, three apparent violations were i

},

identified and are.being considered for escalated enforcement action in i

i accordance with the " General Statement of Policy and Procedure for NRC '

Enforcement Actions" The first apparent e violation involves operator (Enforcement failures toPolicy),

follow proceduresNUREG-1600' for reactor coolant i i

i. system boron dilution, watch turnover, adherence to procedures, and prompt i reporting of events. As a result of these errors, operators exceeded 100% i I' reactor power on January 22, 1996. The second apparent violation involves  !

inadequate design control in that the procedure for adding a mixture of dominera11 zed water and boric acid to the reactor coolant system did not  !

L implement the method stated in the Final Safety Analysis Report (FSAR), and had not done so'since January 1976. .The third apparent violation involves a  :

i

' change that was made to the Unit 1 procedure for reactor coolant system boron  !

dilution on January 23, 1996, that differed from the method stated in the i FSAR, without performing a required safety evaluation.

No Notice of Violation ~is presently being issued for these inspection .

j findings'. In addition, please be advised that the number and characterization

' of the 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 March 8,1996. Also, you have been requested to bring ,

'I i: ,

l

. - i g _,._.s. '"~

i o .

FPL 2 the three licensed operators who were involved in the overdilution event to the enforcement conference. 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 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 concerning 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 accordance with Section VI.B.2 of the Enforcement Policy, and 3) any other application of the Enforcement Policy to this case, including the exercise of discretion in accordance with Section VII.

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.

In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this let'ter and its enclosure will be placed in the NRC Public Document Room.

Should you have any questions concerning this letter, please contact us.

Sincerely, Original signed by Albert F. Gibson Albert F. Gibson, Director Division of Reactor Safety Docket Nos. 50-335, 50-389 License Nos. DPR-67, NPF-16

Enclosures:

1. Inspection Report

2. Enforcement Policy:

Section V, "Predecisional l

Enforcement Conferences" cc w/encls:

W. H. Bohlke Vice President St. Lucie Nuclear Plant P. O. Box 128 Ft. Pierce, FL 34954-0128 cc w/encls cont'd: See page 3

3 ,

FPL 3 cc w/encls cont'd::

H. N. Paduano, Manager i Licensing and Special-Programs Florida Power and Light' Company-P. O. Box 14000 Juno Beach, FL 33408-0420 J. Scarola )

Plant General Manager i St. Lucie Nuclear Plant ,

P. O. Bdx 128 Ft. Pierce, FL 34954-0128 E. J. Weinkam-Plant ~ Licensing Manager St. Lucie Nuclear Plant P. O. Box 128 Ft. Pierce, FL 34954-0218 l

J. R. Newman, Esq.  :

Morgan, Lewis & Bockius 1800 M Street, NW Washington, D. C. 20036  :

John T. Butler, Esq.  !

Steel, Hector and Davis i 4000 Southeast Financial Center Miami, FL. 33131-2398 Bill Passetti Office of Radiation Control Department of Health and Rehabilitative Services 1317 Winewood Boulevard Tallahassee, FL 32399-0700 Jack Shreve Pubile Counsel Office of the Public Counsel c/o The Florida Legislature 111 West Madison Avenue, Room 812 Tallahassee, FL 32399-1400 Joe Myers, Director Division of Emergency Preparedness Department'of Comunity Affairs 2740 Centerview Drive t Tallahassee, FL 32399-2100 cc w/encls cont'd: See page 4 9

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FPL. ... 4 ccw/enclscont'd:'

Thomas R. L. Kindred- )

County Administrator- -

St...Lucie County.

2300 Virginia Avenue Ft. Pierce, FL 34982 Charles B. Brinkman Washington Nuclear Operations

, ABB Combustion Engineering, Inc. 1

.12300 Twinbrook Parkway, Suite 3300 t Rockville, MD 20852 >

Distribution w/encls: .)

i

.J. Lieberman, OE 1

! :J.~Beall,.OE

OE

EA (B. Summers)(2) i J. Norris, NRR  ;

E G. Hallstros, RII 1 PUBLIC NRC Resident Inspector n U.S. Nuclear Regulatory Comm.

4 7585 South Highway A1A Jensen Beach, FL- 34957-2010 9

i F-Maj] w/encls: a

M. Davis (nJ51), "I*B. NRR . g; i

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M L4641 i Mardi 6,1998 2

U. 8. Nuoleer Regulatory Commission Attre DocumentControlDests ,

j Washinglen, DC 20586 i Re: St. Lucie Units 1 and 2 -

1 Doolest Nos. 60436 and 60389 Enoses Duution of the Remotor Coolant System Due to Personnel Error Muninar Prnbiam Reoort 9p 008. Raylalon.1 As the result of an event involving the exosas dilution of the Reactor Coolant System at l St Lucie Unit 1 on January 22,1996, Florica Power & Ll9ht Company (FPL) initiated a aces 4unctional h.z!y " -, to determine root cause and corrective actions. On February

. 21, 1996, an interim Nuclear Problem Report (NP) 96006 was issued discussing

! preliminary conotusions.

The purpose of this letter is to forward to the NRC Revision i to NP 96008 which, in

adattien to presenting the results of the original cross-functional investigation concerning root cause and corrective actions, includes the event ansWs and conclusions of an j independent, non-FPL expert on nuclear plant operations and event analysis.

i

If you have questions on the attaened report, please contact us.

l l v truly yours, -

l . H.

, Vice President j St. Luole Plant Attachment WHBIEJW

]

! oc: Stewart D. Ebneter, Regional Administrator, Region 11, USNRC, Attenta, GA i Santor Reeldent inspector, USNRC, St. Lucie Plant t

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L0641 Mush 4,less

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ST.LUCIE PLANT  !

i NF.700 PROBLEM REPORT 76-008 I

L EVENT TTYLE

• Bessen D5utloo of the Reactor Coolant Systent Due to Personnel Brmr.

St.Lasie Unit 1 Event Dess: 22 January,1996 i

! E. INrrIAy{ ANTCQKDrt10NE

i j Unit I was at 100 percent power, steady state opwations.

l HL EVENTBEOUENCE i At appr*=W 0220 on January 22,1996 normal reactor fbei depletion resulted in sa

IndScoted reactor coolant cold leg temperature (T ) of 548.7F. The Board Reactor Control Operator (BRCO) commenced a dilution to the Rascror Coolant System (RCS) la order to restore T. to a tempensure of $48.9F. He began a manual dilution with Primary Maheup

Water (PMW) at approximately 38 gym directed to the auction of the IB Charging Pump at .

g, -- r:'y 0225. According to the BRCO, ahortly aner the dilution was commenced l l aamunciator E 9, %be Water Supply Strainer d/p Hi", was received. The BRCO at the

esserals ist the vialaity ofRTGB 105 (this is the location of the controls ihr the boration and i dBadon system) to acimowledge this alarm on RTGB 102. AAer ieg= '. to the slana, the

BRCO requested that the Desk RCO (DRCO) relieve him at the controls so he might go to the1%n 1hsDRCOmovedintothevicinhyofRTOB-103. Thedilutionin progresswas not -=Imad by the BRCO during the short term turnover process. The BRC0 then isA the "at the controls usa' and went to the kitchen to prepare his meal.

i Approximately 8vs minutes later, the BRCO returned to the control room and heard the PMW integrator 'sklig".1he BRCO realised the addition of primary makeup water to the

RCS was stb in progress and immediately took corrective actions to securs the dilution and j conunenced borating the RC5. The BRCO commenced boration to the auction of the IB Charging Pump fbr a total initial addition of approximately 26 gallons of borio acid and i intuned the DRCO and the Nuclear Plant Supervisor (NPS) of his actions. At si,jge '- fj i the man time the BRCO was taking corrective action, annunciator M-16 "RCP CONT BLDOFF FRB53 IBGH" alarmed, due to a higher than normal Volume Comrol Tank (VCT) pressurs kom the increase in VCT level and Pressurizar level as a result of the expansion of a RCS inwensory ham Tave increasing. The Assistant Nuclear Plant Supervisor (ANPS) was

! ====8 by the NPS to the control room Dom the kitchen to assist in actions to return the

plant to within nonnat operating parameters. T. was obaarved to be greater than 549F.

With the boration started, the NPS and STA reviewed the Technical SpeciScations and 1

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I tml Manh4,less Ansshans l novisis. I essered a two hour action statement to restore RCS T, to less than or equal to $4pF la sesordanos widiTechnical Sp-hia= Limidas Condition of Operation (LCO) 3.2.5, DNB Parasseters. At 0314, ladicated T. was returned to less than 549F, and the LCO Assies l Stelementweneuitos Atotherpermusemareadiednormatievelscone.arrently. Asweelster

' selsuissed, and condrmed by recorded plant indisselaas, the highest reador power and RCS ,

oeid les temperature during the event was 101.13 percent and $50.JE (single point

**""**)- f i

Betsu the creer left the site that morning, several reviews of sqk /

event began. Tbsereur sMt shpervision verbelly oounseled the BRCO for leaving his sostion while a dilutlos was in pseyssa. The ANPS also wrote a noddestion of the event in the fann ofDesa Shess (DS) i 7 (Operations Departmans Problem Report, Conduet ofOperesions procedwe) and anded a paper copy to the Operations Supervisor. The ANPS provided a verbal antiSession ofthe

! event to the Op-tx technical supervisor during his nonnal morning tour of the esmerol moms. The STA prepared a drat In House Event (DIE) summary 9600s to convey ths &sta of the event to the site managanet and to inishes a STAR lbr root esuse determination. The L STA also requested that the hann Partnnanos Evaluation System (HPBS) Coordinater be ented out to invesdgate the event. The HPES Coordinator arrived onsite at 0515, reviewed the dreA IRB and conducted interviews widt the personnel involved. At the 0740 a%

management phone call, the Operations Supervisor and the Plant General Manager wese provided with a oopy of the EE. On that mune day, the Operations *=ahaical supervisor

! begna an event review which included h==laaa with the relief crew, RCO chronologiosi review, the D3 7, training and perfbnnance appraisals related to the BRCO. At the and of

! the day, the 4 #= technical supervisor recommended to the Operadoes Supervisor that the BRCO be removed Rom watch standirg duties. He also noti 6ed the NRC Resident of the lavestigation status.

l

! On the fbilowing day Qanuary 23), the Operations technical supervisor conducted a Act Snding meeting with the crew and bergsining unit represamlative. Following that meeting, the i Operadons Supervisor conauned in the mispension of the BRCO Rom watch standing duties, j

The Operations technical supervisor provided the NRC resident with an update to the event.

i On January 26, the DE was updated by the HPES Coordinator to include at of the fhets lemmed about the evers during the weelt. At the direction of the Plant General Manager, os i

January 31,1996, a cross fianctional team was fbrmed to review the event and subsequent

plant stdrasponse.

)4 E ANALYBIE j The team identi6ed two primary pmblems for this event. They are discussed in detail below.

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1' A seassivhy evoludon was initiated without adequate comrols, '

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f Rsudne boson dilutions to maintain 100 porosat power are not tre Impostamos as other resativhy managemen malmesia 100 porosas power.

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1) Cogsidvs error on the put of the BRCO who initiated the d

as part of his monnal responsibiEties, recognised the need t ,

it was neoussey to iriest approximately 30 gallons of primary ma RCE. The FMW h(esdos rase was to be about 38 gnBons d per mi dhalos evabelonwasto have lasted less tha i

SS) and sulsesquently let the humediate ares.

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a. The opensor's knagrated performance was not :" ; +i evaluat

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Tbs BRCO's training and personnel records were reviewed fbr insi perfumanos, ne subject received an 'Unsatistatory" ranas in hi j ovaluadon (consrolboard operations) and was placed on the ope i Ator remediation and reevaluation, the subject reesived an indivi l 'Senadarginal Saasty SigniSonnt." Upon ibrlher remediance the su indivkh al rating of "Satisikstory" (6/2/95). The BRCO was ideaddedl l department memo (9/845) as a Historical Poor Performer due  !

! June 1995 and siendator pesformance exam in May 1995. In particul Other noted  ;

that he is "is too nanch of a hurry, and doesnt communicate well."

j observadons taken kom simulator evaluation summary fbrms and perfb l i

! - "need to work on somm*a+=ne.and 'should mark time / 1

! monhoring containsnent sump' . simuistor evaluation of 4/2954; J

• W to realias that pretsurizer sahty valve was open" - simulator evaluados of11/6/95; 4

1

• an to irnprove in this m' - pufm soview 11/1Wp4.

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! ladividual should have been more closely scrutinland by Operadons and Tralaing

! wansomment.

b. 'Bere was no supervisory involvement at the etert of the diknion, t

Neither the dikataa procedure, OF 10250020 ' Boron Consentration Control -

Nonnel Operation", nor the "Conduet of Operadone' procedure requim the SRCO to laamn the ANP5 or other watabstanders of the initiedom of eay boredom or dBudes evolutions. Berating or diluting the RC5 changes the roastivity of the reester eers'and

. should be considend a sigelSonat evoluunn. Glwen that there was as procedural aqubenesens er say type ofnotiscados et St. Lucie, the BRCO was not deSeiset la this

esen. Had this been a plant policy, the ANPS (or other wetshstanders) would have been

swest of the evolution and may have recognised and corrected the error ofthe ERCD. ,

j

2) Conduct ofOperations supectations are not Adly understood or oossimendy appued.

I The BRCO let the RTOB ares and went 'over the lias" to the kitchen. During this ,

taasition, he turned over the RTOB watch to the DRCO who wee rensning tom the kiesboa.

l Appendia D of the "Coeduct of Operations

• procedure provides instructions br providleg

a me ar er " shat tema muer which is de8and as les than two hours. Accosdag to the j procedure, minknues turnover requirements consist of providing: a general wetab station statue; of.noresal senditions; and tests in progrees. 0;zie --- ;n "i expoetetlen le ilus short tenn tumover is applied whenever a watchstander goes 'over the line' and is out ofans ofmight of the board. However, beesd on interview ofseven operators aRar the event, this espectation is not clearly understood by operators. A proper turnover may have prompted the BRCO to receu the dilution and take appropriate medon. Misunderstanding of such a Amdamasmal policy indicates a weakness in monitoring of tbs '_ y ^ ^'- of pousies and =-?+=^' r by n- ;

wonegaments apatadon of vwbatim" complianos to procedure does not aany recognise the quality of current procedures nor accountability for instances of non compiinnes.

Procedure OP 1 0250020 did not contain auf6Sont detail to permit ' verbatim" complianos, yet none of the operators identiSed the need fbr a procedure change. In thct most of the, operisere interviewed aner the event Seit that this evolution should not require a procedure.

'Dey feltit was "sidu of the oraA.' ,

3) Rooses plant events invoMng operator personnel enors have been previously identi8ed and sorreedve eselona have not been compio ely effbetive.

A WA asessement, Teobnieel Review Reg ort #1TR 95 023, performed at 'the request of the site Vlos President, reviewed abneen evaas that occuned sinos August 1995, Idansland that many of the events' corrective actions did not so ihr enough to address at potential enseal thstore. R concluded that many similar events had a medium to high probabuity be seenrennes.

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4) The plant's Operusing Experiones Fee 6ask prograin did not respond to similar reesdyky

memessemat evens at mSe sueleer piams.

1 Beaumes ofa number ofindustry events levolving remedvity amongament, INp0 issued a i signiscent Operating Bayerienee Rapon (SOBR) 94-2, wideh alerted the industry se de

] luponemos ofrensevity managuesa dahg nonnel opermies. This report M a dilmien  ;

event very eindlar to the St. Lucie event which oosurred at Turkey Polst in October 1993.

In respondkig to the report, the plant did not idestdy routine dilutions u an evoluties that j tequited special an==la=

i S) IJeansed Operator m ataMA Tkaising houses principally on abnonnal or energsmsy sisandons. -

I lasses plans and simulator experience deal almost ecolusively with abnormal or emergusy j slaastlema. As a result, routine evolutions, which are oAen the procursor of abnonnel or amargemey events, tend to have less signiSoanos.

! 6)The plant's Self Assessment Programs have not been Mly c5sceive in preventing

{ resumonos ofproldema. -

t

) As discussed eartier, the Quality Assurance organisation has identided operator

partnnanos shortoomings where conostive actions have not been Adly 5betive.

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lashade; j 1) Plant procedures do not specify the prefbrred method of making baration or duution

changea.

1 Operating Procedure OP 1 0150020 " Boron Concentration Control Normal operation' allows esveral Bowpaths for dilution. The procedure does not state which Bowpath is preewred ibt maldag boron concentradon changes. A note in sendon 8.1.7 states that 44almup Sosa the Baron conowaradon control system can be directed to either the VCT (br long tens adhots, la any mode ofoperados) or the Charging Pump suction (ibt short term

enhetsk in the MANUAL or BORATE mode of opersion.' Sandon 8.5 ' Manual Mode of Operaden" alkywe bisoding directly to the VCT or use of a direct path to the charging peep sumion. DGution via the Volume Control Tank provides a slower renativity response and in i

this insident may love answed Ibr rooovery pitor to power omentarian Dilutloaviathe VCT aise legehens the duration of the evokation. Operations nuast evaluate the various Sowpath l

options tr making baron concensration changes, idendfy the preferred methods and revise i ptooedutos assorgungly.

2) The pandes dbr operating at the Technicalra -incadaa limit for 7, provided no operating saggla.  !

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L4641 Munk6,less Ammemens Revisies t For PELUnk 1, the limit ibr DNB considerations lbr cold leg tempersart is less then er i egnet to 549F. ' Ins at. Lucie plant pressioe to operate ooid leg temperstmo at the Tedminal

&.una er-seer did nos parvise margin ear mier. chameing acs keen 1

enessammion is a normal plant opersdon, soapsnesting ihr long term reandvity ofRuts, sudt

as ami depiadas, asman imildup and doomy, piam stanups, dandowns, or changes in menor poser. As the cycle progresses, the RCOs are required to make more toquest ressewhy i seemipulations, usulting in a higher chance of occurrones of an enor due to lessened sense j etswerunnesorimportanos.

3) Lack of-=almiaa and indiostion during this evens.

A semdsol rossa alans responding to a dilution evolution in proyam annunciates only when the dhelos becomes anoassive. N only alarin to annunciate in the consrol roosa as a rosmit of this everwillution event was M 16, RCP CONT BLDOFF PRESS HION, which was l consed by rising Volume Control Tank (VCT) Presswo as reactor coolant imenery i l lasreased. An alarm for RCS high cold leg temperature is available, but to avoid malsamos i alerum (operator distraction), the alana setpoint is approximately 3F grooter than the j sppushes IJmidng r'aamian ihr Operation of 549F. Similarly, a Delta T Power alana (Peim j ID.742) on the plant DDPS computer is no longer maintained in a Amational status

4) The UFSAR has not been maintained current with regard to operating practices.

i l 75L.1 UFSAR 5ection 9.4.2.3 primardy discusses baration and dDution utiltalag the i

automatic mode oroperation. Little discussion is provided regarding the manual mode of j operation. No specific discussion regardlag dilution diready to the charging pump session

Is provided in this sostion of the UFSAR. St. Lucie operators have historicaEy made

mandvity danges via the nanual mode ofopemtion. Discapandes between the PSL UFSAR l and existing operating practices am a .Ef__ f problem at St. Lucia. A recent QA audit l Pindlag and an NRC deviation have provided examples of this issue. The UFSAR has been i maintained surrent with regard to physical plant change via the plant change'modiSostion

! (PC/M) prosses. The UFSAR has not always been maintained current with regard to

! descripdoes of operating Practices, procedures and d=Wmmtive details. The UFSAR has

} act been routinely referred to during the periodic review ofplant procedures or during the l procedure revision process to ensure continuing agrooment with plant operating practions.

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' Ins plant staffs rMion of this evoet's signiam was slow.

BaatCannet i

1 The root cause of this problem is lack of a well deined threshold for recognizing sailsty sipiBsenos. The opensing crew quiddy diagnosed the problem, took quick and appropriate

{

oorrective action prior to challenging any safbty systems and reported the event la that

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l L.e641 Masks,tses

• Residsmi l esatus. Managsmaat abould have swoogniand that In House Event Reports and MPES  !

latervenions hiestify issues of saasty signi6cence which should be blkrwed up mom e g ned wely. l l -  :

coatsthettas Fantarm i i

a i De Is,. house Event eenmary had inmmelant detall to gain management atesados and

! mensguesse did not aspond egyselvely so an unplaned remadvity changs event, sesenBum j etslydessoas. SpostuRy, the IEE dd not contain the inbruuden that the BBCO had Ist

a resetMay change unamandad Addhionally, bened on the observed indications efDighet 1 Data fsoemaing Sysese (DDPS) dishal display provided by the operadas erow and NPS to i

time STA, the DIE reported that the peak reactor power as 100.2 perooms. Sebsequest detaued analysis revoeled that roastor power pesied at 101.13 perosat. Subsequest to the event, Flest and Operadons management did not pursue details surrounding the dHutios ta

- a time Aame sensistus with the event's signiSonnes.

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At appseulesesty OMS, the Operations Supervisor made his rousins phone eat tous adBdes i to the eescot rooms br s unit status. The NPS related details about the event per this phone souveranden. The disemelon iaciudad correcdvs actions, the Technical Sp.4a- gro i essered and suited, the RCO Chronological log entry, individuals involved, initiation of as l DIE and DS 7. (Appendix E of the Conduct of Operations procedure requires the Shit

":;rf '= to make prompt verbal notincation ihr unexplained or unplanand roastMty i abanges.) Asindested above, the ANPS was prompt with compiados of the DS 7 beteo be went off shiA. Rsview of the DS 7 revealed that the speciSc detail related to the BRCO

lesving a reactMty changs unattended was not included la the report, e

i i e_- " =_._ u.= land dt.<'.c. the event rd . ; wt.Eh w nr hua C' ^'=

inihedK

1) The plant staffs inhial lavesdgadon of this event was less than adequate.

Dare were severslinidal lavestigadcas into this event, all of which were Et; W of j andi oder to a large deres. Prior to the end of the shiA Monday, several independat event j reviews took pines, ns opersdons crew shiR :;rP= evatusted the event as warrendas

. desummession to the Cp- '= Supervisor via a DS 7. The STA also weets na DIE to site

namessuem er the event. no HPa3 coordinator int = viewed de pasonast ievolved. on

runday, operadens a>puvlsion conducted a Act Anding meeting with the crew. On

. Wedasedey, Operations management conducted a review of the event. Nine days star the event, a cross ihnodonal team was brmed to review the event and aabsequent plant response.

4 Comertaming causes to the slow and independent e8brts included lack of site procedens br laeagrated event response kn2='=, root cause analysis, and self mam 4

Addlelematy, the level ofdessu la existing procedures and guidelines is inadequate la that:

$ - DS 7 does not contain requirements ibr a signi5 cant level of detall,

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- enm is ao pmoeshnet sundemos ca ciamissations of event severar and appmprime isvois

ef secourses requked ihr event invesdgaden. i 2 .

l; 2) De self ma- by the operedng crew was less then adequate. I 1

1 l j 1ha Cp ?-:-x crew shlA supervlaar verbety causealed the RCO br leaving his sesion l

whh a dilution in pogress, but did not kidade this level ofdeemi la the DS 7. A ilW self l - of the ment abould have been condueed by the crew prior to their leaving the elle on abs day c(the ment. Conatudng ceuess to this condblon were the absense of a deEshhe i

site esif- poiley and procedme and no continuing training provided to operosisms 3

personest es self- nad pereenmet enor analysis.

2

3) The treashr ofisseons learned tom a similar event as Turkey Point to St. Imsie weeless l l them adequate,

.t As previously dinamad a simBar event to this one has previously occuned at Turkey i Poks, with simlar coumannaamires appEed. .

D j L ANALYRIE OF FHYSICAL PLANT RESPONSE DURING EVENT

! The key safety parameter associated whh this event is departure kom nuciente boiEng (DNB). There wtre two piam opendas perunsters that were notably afibend by this meat,

[ reestor nooinst said leg temperature (T,) and reestor power. Per Technical spesiesstion l

3.2.5, T, is Emited to 5 549F and is nonanDy controlled at about 548.9F. Amesult of the aution, T.inerossed to a peak value of 549.7F (per ERDADS). Graphical data showed T, l

above 549F hr appresimetely 50 minutes, Reactor power is nonasty maintained et $ 100 l

pereers. From a review of ERDADS (Q power) and colorimetric power data, it een be l

ladstred that calorknetric power did not exceed 101.13 percent. Interpolation of the data j shows that reestor power was above 101 percent fbr spi,,s.4.ly fbut minutes and above 100 percenter si,,.i_-? 50 f minutes.

UFSAR section 15.2.4 provides an analysis of the design basis boron dilution evesta.

j Does ovsess assene the h(estion of unborated domineralized water into the RCS et ai l of 132 3 pas (3 oberging pumps x 44 gym / pump). The analysis notes that boros dution meets are reistively snow meres and that there are numerous indiccions and alama svetable to operatore (e.5., boronometer, VCr level, makeup Dow, VCT leolation). However, should dheios proceed without opernorlatervendon, the evoet would be tennlanted by the tid &P or venshie tip power trip. DNB redo (DNBR) Emits would not be escoeded in aash a case.

f i The out$ ant dilution oosurmd et a rete of 38 spm. '!%us, the evoet is oleesty esvaloped by th suisdag UFSAl analysis ihr a boroa dButica at power event. MM-: :"y, a core sua map gesorated tom DOF8 data polled at 0300 (aBer the event) and compared te. she desa tom j '

0300 (bette the event) ladiosted a monnal Sun distribution.

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! L4641 Musha,less i j Ammhmus needsa1 i

kt consknion, the baron duution snet affanuary 22,1996 was whhin the design basis and 4 amaWie ofthe plant and did act present a chauenge to plant asihty systems or pose a risk to i

. the hashb and assay orche putdie. The event was tennimated by operators prior to the onest

! of the slaams and automans protestive actions provided br auch aa svent. De Beanse g P'

condition of maahnuma '; m+ thennel power was not vloissed. A .

i R m ACHONS  ;

i l EMBROEd j

. 1. De BRCO was removed from licensed operator duties. Complete

2. Hanna Rasources and Training are developing an assessment and rapadiadaa plan dbr I 4

possbie return of the BRCO to licensed operator duties. Complate i

l 3. Lassoas learned tom this evus were reindbrood via swisi expectadoes

' aa=sanala==d to Shift Technical Advisors in the areas of! Sensitivity to plant events, In-House Evans summuy accuracy and completeness of suppordng data, and 10 CFR 50.59 l j tovisers. Complete

4. The Operations supervisor has discussed with sach NPS the purpose and thresholds of Appenex E, Conduct of Operadoes, and the necessary noti 6 cations. Complete -

5. The Conduct c(Operations Procedure was revised to include the following:

- Board walk down is now included as part of the 'Short Term Turnover' process,

- Direct supervision of reactivity changes is requ' red by a Senior Reactor Operator, i 1

4 Rasetor Contiel Operator is to remain at the controls during all reactivity changes whde in progresa, i

- Mvirf changes shall not be turned over while in progress.

Complete

6. Operations wiu revise the " Conduct of Operations' to clarify 'short term turnover",

l Buamples of when short term turnover

• is required wiu be included in the revision. This revision should be coenmunicated to Operation's personnel by Night Order and discussed i

with operating erows. Training should reinfbres these expectatless during trainlag i esosions and Mer;g,; r. should monitor ks efectiveness. Complete

~

9 I

l l

)

_ _ _ _.. _ . _. _. __ ____ .__.~ _- _. _ .__ _ _______ _ ___ _ _ _

j, JAN453 '98 RE 22s381D: . TE. ma mas 9 P12 A A i y a\

pf '

j L4641 d usuba,less .

Aanshusas assision1 i

l 7. Eaglsesring has perimmed a 50.59 evaluados to redest operation's preesise etusing the / 7 ,

• mesual" mode)W of diludon and boration. (Dis $0.59 win be included

'F** jf& din rg &fr N ?

$ 8. Enginsedng hee reonavened the IX8AR review team to complete abe reviour of the 2 WEARveras piess pscoedures. Sampling completed 2/29/96. Fuu soops and scheduls due by sou96. Den Denver i

i 9. Operadoes wB revise ths " Conduct of 0peradens' procedure to require a assiest level .

efdstat in DS 7 reports so management will have adequate indmnation ibr assessnest of j tho problent JetWest-Due 3/31/96 i

j 10. System and t'P Engineering is t; t'; an Event Response procedure. De i procedure will include or reference: Root Cause Analysis techniques, event severity

awh and resources required for aestysis. This procedure will also includa l

expectadoes Air the team to include cross imetional merabership flrom

SCE, C,-.f - .

Engineering, Maintenanes and QA. Turkey Point's Event Response Procedure is under j review Air incorporadon et St. Lucia. Chuck Wood - Due 3/15/96 ,

! \

! 11. De pmoedure upgrade process wEl lnclude UFSAR review to identify inconsistencies ibt oorrection. Compless

12. For the balance of plans orocedure not captured in the upgrade process, Inferumatica Services wiB ensus that the UFSAR is ouunined dudag the three year procedure review l prosses and that insensistencies are noted and sorrected Jim Holt - Due 3/15/96 l Emulpment Parbrmanne

! 13. De Piet Osnaral Manager has reemphasized the reduction of nuisance alarms to at line

[ organisations to support the " blackboard' concept for operations. Complete

14. ' B- the marras control roan amainciation for possible innprovunmits N

to help ibous awareness of reactivity changes Dan Denver - Due 3/31/96 l 15. OST will survey the industry on the use of automade and manual boration and IElution ooetrols to benchmark St. Lucie and detemdne best means of reactivity changes by ahemicalenacol. Complete i Tmining& Quality Ammarmana

. 16. At DS 7s, C, #-4 Events, wit be transmitted to the Training Departmen't ibt lessons f learned to be included in the training progreat Complete j i

17. QA should evaluate performing a pedbnennes based audit on the adequacy and 10 I

,-w aa ,a u..n sua ,w w, m ,-u 4

I L4641 Musha,less

• Raideal

. edhativeness of the corporate proyam er transordsg lessoas learned between thuissy i reint and st. Lusie er wesen widah oesur at de other she, ed er events which osser l la theindustry. Wes Bladow-Due 3/15/96 d

5 18. Operations wE review the corrent weahmandare er }amadeel Poor Personnense, and

assess need hr action. Complets

) 19. A Tralaing and Partnesana Raviour Board wl3 be lasthmed to oceduct a conseEdstad i review ofat perhrmance indicssor Air licensed operations personnel who are ideadSed i as sienorical Poor P tnana. The review wB amme de mal As shklamai senadel 1 tesesses and/or the runoval of the Histodcal Poor Perfbrmer Dom Ileensed dudas, i i Compisee )

20. h w han W = h for # ding N m b l .-& " ; and

• N 4= M s'i plicia and espectations ibr an plant

!  % ' s. (Standenis

=

Aaaaa==== Ouldeline by Management) Complete l l 21. A review wu undertaken to waluate the adequacy of the adsdag policy and guidance

! involving reecevity contrat Piant management win now reintbros expectations and the

impostance of remodvky control in a pasonal letter torn the Plam General Manager and she yke Pasident to ach aco and sao. compiate t

22. operanas crew brisense by operations supavision were held dhcussing the dikaion

event, Zach Fate's "The Control Room" and managemem's expectadoes with respect to l

ooeservethe plast operation. Operadoes Supervision also reindbrood espectatione in a

condam or operstican whh respax to ==*=d-i of opwadoes Managanet, los keeping, ibous on ruscovhy changen, and the abost tem turnover process. Complete l

i 23. Operations Mana$erners teviewed its expectadons dbr command and conwel using j labrmados obtained fem other sites including Turkey Point. 'lls impilastions ofthis j event wm also be reviewed by a team fbr applicability to other operstion's astMeles both

ladde and outside the control room. J. A. West STAR 960146B & C - Schedules due i

3/31/96

24. Nuclear Plant Supervisors have been directed to review an new In House Events at the

0740 meeting with Plant M - ^;- -- to help prioritias activkies. Complete l 25. In addition to specific corrective actions, plant management will self assess the operadon j of st. Lucie plan. This seit assessment will include, but is not limhed, to Conduct of

Opersticas, alarm seapoint poEcy, operadas experience bedback, training, procedures,

correadve madons, and seassement policia. This review win in portreed by plant penommi mammeed by operienced individuals som ofr. site. Recomra aaaa acaions wm L

i I 11 i

l

, - - - . - - - - - - . ,_ - -- ,.u.a,a w ---as. a. m ..,_.m ..m_. . -. mm. ,22e 4A- - m Mwa__,a.,4. w A, -.awt,.e.a.A . .m -- 4A-- Ers-*

h 4 ,

MklE usesimal Ammhmus be soviewed sad stamaned in the monddy indicator booit LW oversidt of this e- wE be provided vis the Compesy Husleer Review Board. Am seends -

Raportdus MI/ps l

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s .. UNITED STATEB

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NUCLEAR R8GULATORY N .i p 4 nemon n .

. .I

w. E tot MAnIE1TA STfWT. N.W., SUffE 'EDB -i I

'5 - ATLANTA GeonejAalmpetGB e um nO l

, ***** March 13, 1996 Florida Power and Light Company '. l

.*~ ATTN: Mr. T. Plunkett '

President - Nuclear Division-P. 0. Box 14000  :

Juno Beach, FL 33408-0420 1 1  ;

SUBJECT:

I MEETING St#9tARY - PREDECISIONAL' ENFORCEMENT CONFERENCE

.ST LUCIE - DOCKET NOS 50-335 AND 50-389 Gentlemeni

'This refers to the predecisional enforcement conference conducted at our request' at the NRC Region II office in Atlanta, Georgia, on March 8, .1995.

'The purpose of the meeting was to discuss apparent violations regarding a '

. _ January.22,-1996, event' involving excessive boron dilution on Unit 1. It is' j- our opinion that this meeting was beneficial. >

, A list of attendees is provided in Enclosure 1 and the material you presented is provided in Enclosure 2. .

! .In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2,- I

, Title 10 Code of. Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.

Should you have any questions concerning this letter, please contact us.  ;

Sincerel ,

f t /

kwlSl C arles A. Casto, Chief p b Engineering 3 ranch Division of Reactor Safety t

Docket Nos. 50-335, 50-389 License'Nos. DPR-67, NPF-16 ,

Enclosures:

1. List of Attendees 2.- FPL Presentation  !

cc w/encis: See page 2 j ,

e 900 I i

ENCLOSURE 3 j

p

. --96co3eiwit DYpp.

. =- .  !

• ' 4 i

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.-. t 2 .

i FPL 2 _-

i cc w/encis:

W. ~ H. Bohlke

, Vice-President- ,'

• St. Lucie Nuclear P1 ant. '

P. O. Box ^128-i; Ft. Pierce, FL 34954-0128 i

H.lN. Paduano, Manager

' Licensing and Special Programs ,

Florida Power and Light Company

-P. O. Box,14000- .'

l . Juno Beach, FL. 33408-0420 ,

i 1

J.'Scarola f

-Plant General. Manager-

,' ' St. Lucie Nuclear Plant 3

P. O. Box 128 '

1- Ft. Pierce, FL 34954-0128 E. J. Weinkan '

Plant Licensing Manager

St. Lucie Nuclear Plant 4

P. O. Box 128 ,

Ft. Pier,ce, FL 349F -0218 l 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 Bill Passetti .

Office of Radiation Control Department of Health and Rehabilitative Services I 1317 Winewood Boulevard

+

Tallahassee, FL 32399-0700

~ Jack Shreve Public Counsel t Office of the Public Counsel.

c/o The Florida Legisisture 111 West Madison Avenue, Room 812 Tallahassee', . FL 32399-1400 1 cc w/encls cont'd: See page 3 . I t I i'

. . . . . - . ._ . = _ . _ .- . - --.

i? ;

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FPL 3  !

^

cc w/encls cont'd:

Joe Myers, Director Division of Emergency Preparedness .*

,~ Department of Community Affairs "

2740 Centerview Drive Tallahassee, FL 32399-2100 Thomas ' R. L. K'indred

-County Administrator St. Lucie County .

2300 Virginia Avenue Ft. Pierce FL 34982 Charles B. Brinkman  ;

Washington Nuclear Operations i ABB Combustion Engineering, Inc.

12300 Twinbrook Parkway,. Suite 3300 Rockville, MD 20852 i

l l

l 1

i I

I 1

_____i

_ _. . _ - __ _._ _ . . . _ . . _ . _ . . _ . ... - _ _... . _. _ _ . _ _ _ . _ _ _ _ . ~ . _ . _ _ .

, , 4 g. 4 2 -

LISTOFATTiNDEES Florida Power and Licht Company' '

T.' Plunkett, President - Nuclear Division, FPL -

W. Bohlke, Vice President, St. Lucie Nuclear Plant 4

J. Scarola, Plant General Manager, St. Lucie

. D. Denver, Engineering Manager, St. Lucie E. Weinkam, Licensing Manager, St. Lucie .

. P. Honeysett, Nuclear Plant Supervisor, St. Lucie F. Cone, Reactor Controls Operator, St. Lucie H. Holzmacher, Reactor Controls Operator, St. Lucie  ;

4-Nuclear *Reculatory Commission S. Ebneter, Regional Administrator, Region II (RII)

A. Gibson, Director, Division of Reactor Safety (DRS), RII J. Johnson,-Deputy Director, Division of Reactor Projects (DRP), RII

- J. Beall, Enforcement Coordinator, Office of Enforcement (OE)

B. Uryc, Director, Enforcement and Investigation-Coordination Staff (EICS), r RII C. Casto, Chief. Engineering Branch, DRS, RII

- T. Peebles, Chief, Operations Branch, DRS, RII -

K. Landis, Reactor Projects Branch 3, DRP, RII J. Norris, Project Manager, NRR L. Watson, Senior Enforcement Specialist, EICS, RII 1

C. Evans, Regional Counsel, RII M. Miller, Senior Resident Inspector, St. Lucie, DRP, RII

R. Schin, Reactor Inspector, Engineering Branch, DRS, RII D. Lanyi, Project Engineer, DRP, RII i

a 1

I 4

4 4

4 A

ENCLOSURE 1

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!, PRE-DECISIONAL ENFORCEMENT

! CONFERENCE i .

l ST.LUCIE PLANT

\

i l '

NRC INSPECTION REPORT I

NOS. 50-335/96-03 AND 50-389/96-03 i

j MARCH 8,1996 l ATLANTA,GA Enclosure 2

i 1

l" UNIT 1 FLOOR PLAN RAB CONTROL ROOM ELEVATION 62.00 1

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i I OPS ERDADS ADMIN. COMPUTER OFFICE OFFICE [ { l l l lllll I

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(DEPTA.C9001SS!s Rt) i

UNIT 1 DILUTION EVENT

JANUARY 22,1996 l

BRCO RETURNS FROM KITCHEN .

4>

BRCO DILUTION LEAVES FOR b 4 EVENT KITCHEN TERMINATED 0200 0300 0314 E . .

UW . . E ,

Al Al ANANAl AN . AN tb d l ,

NPS ASSUMES BRCO F 4 ANPS T-COLD AND SENIOR RO BEGINS SUMMONED TO POWER i RESPONSIBILITY DILUTION CONTROL ROOM; STABILIZED; i (0225) ENTER LCO EXIT LCO (0314)

BRCO 9--

RESPONDS TO ALARM

,y E-9 qp i

DRCO DRCO LEAVES RETURNS FOR FROM KITCHEN KITCHEN t

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9 UNIT 1 DILUTION EVENT .

PROMPT ACTION JANUARY 22 JANUARY 23 A A

/ T ( T 0400 NOON MIDNIGIIT E E E Il ilIlllllil Il il Il Il il O O DS.7 OPS TECHNICAL COMPLETED SUPERVISOR BY ANPS RECOMMENDS ,

BRCO llPES 9- 4 OPSTECHNICAL SUSPENSION OPS TECHNICAL F l COORDINATOR SUPERVISOR SUPERVISOR HOLDS ON SITE BEGINS EVENT FACT RNDING (0515) REVIEW MEETING WITH CREW ,

AND BARGAINING UNIT I

NPS RELATES 9- -9 MANAGEMENT EVENT TO OPS PHONE CALL SUPERVISOR DISCUSSING EVENT t l DURING ROUTINE (0740)

( CALL FROM OFFSITE

-4 DRAFT lHE CPS SUPERVISOR 9-  !

i (0545) APPROVES OPS l DISTRIBUTED TO MANAGEMENT TECHNICAL SUPERVISOR (0630) RECOMMENDATION TO SUSPEND BRCO NPS FURTHER 9- -G ANPS NOTIFIES .

DISCUSSES OPS TECHNICAL '

EVENT WITH OPS SUPERVISOR ORALLY SUPERVISOR IN OFFICE; DELIVERS DRAFT IHE (0600) 3

.__ - _ -_-_--_--_ - -___ -- _ _ - --__- r - _-__-_- _ -_-_-_ _ __ _ _ _ - - _ - _ -._ . . . - -

Root Cause Evaluation .

PROBLEM 1:

A reactivity evolution was initiated without adequate controls.

Root Cause: Routine boron dilutions to maintain 100 percent power are not treated with the~same importance as other reactivity management evolutions. ,

PROBLEM 2: ,

l l The plant staffs recognition of this event's significance was slow.

l ,

Root Cause: The root cause of this problem is lack of a well defined threshold for recognizing safety significance.

i 4

~

PROBLEM 1  :

A reactivity evolution was initiated without adequate controls.

=

Corrective Actions ,

- Personnel

- Procedures / Documents / Policies .

- Equipment Performance

- Training and Quality Assurance 1

- Supervision and Management I

5

~

~

PROBLEM 2

~

The plant staffs recognition of this event's significance was slow. .

Corrective Actions

- Personnel

- Procedures / Documents / Policies -

- Equipment Performance .

l

- Training and Quality Assurance

- Supervision and Management

t Management Lessons Learned ]

1 Management's Operational Guidance to Maintain Tc at 549F l Adjustment of High Tc Alarm

. t Reinforcement of Expectations to the Operating Crews Concerning l l

Personal Accountability -

Operating Crew Communication with Plant Management 4

1 Personnel Lessons Learned  :

Operating Staff Has the Highest Levels of Honesty, Integrity, and:

Accountability Confirmation of Crew Members' Fitness to Perform Licensed . >

Duties n

Procedures and Policies Lessons Learned Senior Reactor Operator Direct Oversight of Reactivity

~

Manipulations Periodic Dilution of the Reactor Coolant System Is Not an Activity to Be Turned Over to Another Operator ,

Clarification of Short Term Turnover of Control Station Responsibility Implementation of Event Response Teams l

Equipment Lessons Learned Continued Focus on " Dark Board" Use of" Manual" Mode versus " Automatic" Mode of Control for ,

Boration and Dilution E m

c. - - . .

Training and Quality Assurance Lessons Learned Lessons Learned Need to be Included in Continuing Training .

f i

Effectiveness of Corrective Actions -

i t

i a

Safety Significance Reactor Power Peak at 101.13% -

~

Observed Cold Leg Temperature (Tc ) Maximum of 549.75F Technical Specification Limiting Condition for Operation ACTION Limit with Tc > 549F is 2 Hours; Tc Exceeded 549F for About 50 Minutes .

UFSAR Boron Dilution Event Licensing Basis Assumptions Bounds Subject Boron Over-Dilution Event Probabilistic Safety Assessment Evaluation Concluded That the Plant's Core Damage Frequency Was Unaffected by the Event l

17

l Apparent Violations B and C Apparent Violation B - Inadequate Design Control ~

- Review & Conclusions

- Corrective Actions Apparent Violation C - Inadequate 10 CFR 50.59 Evaluation .

- Review & Conclusions

- Corrective Actions 4

h 13

y. . _

. i Apparent Violation C (Cont'd) i

Conclusions:

- TC 1-96-01710 CFR 50.59 Screening Conclusions Are Not Supported by UFSAR Description

- UFSAR and 10 CFR 50.59 Screening Process Need Improving ,

I us._..__ _-__.m_ ____m____.____.._____m__ .__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Apparent Violation C (Cont'd)

Corrective Actions

• Improve 10 CFR 50.59 Screening Process -

- Improve Process by Documenting the UFSAR and Technical Specifications Sections Reviewed During Screening

- Conduct 10 CFR 50.59 Training for Departments Responsible for Procedure Changss with New Emphasis on the Definition of"... procedures as described in the safety analysis report" Clarify Screening Criteria ,

- Reference Applicable UFSAR Sections within Procedures

. Improve UFSAR Eliminate Procedure / UFSAR Inconsistencies to

t Impact of the Boron Dilution Event on St. Lucie Plant t

I

Management Expectations .

Programs and Procedures i

Training Personnel Performance Management Performance i i

to

p .p.

March 13, 1996 Florida Power and Light Company ,

~ ATTN: Mr. T. Plunkett President - Nuclear Division '

P. O. Box 14000 Juno Beach, FL 33408-0420

SUBJECT:

MEETING SUMARY - PREDECISIONAL ENFORCEMENT CONFERENCE ST LUCIE - DOCKET NOS 50-335 AND 50-389 Gentlemen:

This refers to the predecisional enforcement conference conducted at our i request at the NRC Region II office in Atlanta, Georgia, on March 8,1995.

The purpose of the meeting was to discuss apparent violations regarding a i January 22, 1996, event involving excessive boron dilution on Unit 1. It is '

our opinion that this meeting was beneficial.

A list of attendees is provided in Enclosure 1 and the material you presented is provided in Enclosure 2.

In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10 Code of Federal Regulations, a copy of this letter and its enclosures 1 will be placed in the NRC Public Document Room. l l

Should you have any questions concerning this letter, please contact us. l Sincerely, Original signed by Charles A. Casto Charles A. Casto, Chief Engineering Branch  ;

Division of Reactor Safety Docket Nos. 50-335, 50-389 .

License Nos. DPR-67, NPF-16 l

Enclosures:

1. List of Attendees

2. FPL Presentation cc w/ enc'1s: See page 2 t 4

~~ ^' ~ ~ ~

[. . . . ' ?.. _

~ .. 1 -, q FPL 2 .

O cc w/encis:.

.W. H. Bohlke 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 J. Scarola Plant General Manager ,

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 Ft. Pierce, FL 34954-0218 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, F,L 33131-2398 i

Bill Passetti Office of Radiation Control Department of Health and Rehabilitative Services 1317 Winewood Boulevard Tallahassee, FL 32399-0700 Jack Shreve Public Counsel Office.of the Public Counsel c/o'The Florida Legislature 111 West Madison Avenue, Room 812 '

Tallahassee, FL 3?399-1400 cc w/encls cont'd: See page 3 .

O 5

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FPL 3 - -

1 cc w/encls cont'd:

Joe Myecs, Director Division of Emergency Preparedness '

Department of Coimmunity Affairs ~

2740 Centerview Drive Tallahassee, FL 32399-2100 Thomas R. L. Kindred County Administrator St. Lucie County 2300 Virginia Avenue Ft. Pierce, FL 34982 Charles B. Brinkman Washington Nuclear Operations ABB Combustion Engineering, Inc.

12300 Twinbrook Parkway, Suite 3300 Rockville, MD 20852 ,

i Distribution w/ encl:

K. Landis, RII l J. Norris, NRR G. A. Hallstrom, RII PUBLIC NRC Resident Inspector U.S. Nuclear Regulatory Com.

7585 South Highway AIA Jensen Beach, FL 34957-2010 l

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PRE-DECISIONAL ENFORCEMENT CONFERENCE ST.LUCIE PLANT i

! NRC INSPECTION REPORT l

NOS. 50-335/96-03 AND 50-389/96-03 i

I l

MARCH 8,1996 .

l i,

l ATLANTA,GA l

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O UNIT 1 DILUTION EVENT JANUARY 22,1996 BRCO y, RETURNS .

FROM KITCHEN 0

BRCO D!LUTION s LEAVES FOR b 4 EVENT i KITCHEN TERMINATED 0200 0300 0314

E . .

M . . E s

'n a

nn n l s a a O o i NPS ASSUMES BRCO F 4 ANPS T-COLD AND -

SENIOR RO BEGINS SUMMONED TO POWER DILUTION CONTROL ROOM; STABluZED; RESPONSIBIUTY ENTER LCO EXIT LCO (0225)

BRCO 9-RESPONDS TO ALARM dp E-9 q, DRCO DRCO LEAVES RETURNS FOR FROM KITCHEN KITCHEN t

li puo m wswo 2

UNIT 1 DILUTION EVENT PROMPT ACTION t

JANUARY 22 JANUARY 23 A ,

A T T (

il 0400 NOON MIDNIGHT E E E

ll' E il h llillih it it E h 0

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DS-7 OPS TECHNIC .

COMPLETED SUPERVISOR BY ANPS RECOMMENDS BRCO 4 OPSTECHNICAL SUSPENSION OPS TECHNICAL #-

HPES 9- SUPERVISOR HOLDS COORDINATOR SUPERVISOR i BEGINS EVENT FACT FINOfNG ON SITE REVIEW MEETING WITH CREW (0515) AND BARGAINING UNIT i r

NPS RELATES 9- -9 MANAGEMENT EVENT TO OPS PHONE CALL SUPERVISOR DISCUSSING EVENT j DURING ROUTINE (0740) -i i CALL FROM OFFSITE OPS SUPERVISOR 9-(0545)

-9 DRAFTIHE i i APPROVES OPS DISTRIBUTED TO  !

MANAGEMENT TECHNICAL SUPERVISOR RECOMMENDATION (0630) TO SUSPENO BRCO NPS FURTHER 9- -9 ANP3 NOTIFIES DISCUSSES OFa TECHNICAL EVENT WITH OPS SUP' "IISOR ORALLY SUPERVISOR IN OFFICE; DELIVERS DRAFT IHE (0600) tavamemnan 3

Root Cause Evaluation PROBLEM 1:

A reactivity evolution was initiated without adequate controls.

Root Cause: Routine boron dilutions to maintain 100 percent power are not treated with the same importance as other reactivity management evolutions. .

PROBLEM 2:

s The plant staff's recognition of this event's significance was slow.

Root Cause: The root cause of this problem is lack of a well defined threshold for recognizing safety significance.

4

PROBLEM 1 A reactivity evolution was initiated without adequate controls.

Corrective Actions s

- Personnel

~

- Procedures / Documents / Policies

- Equipment Performance

- Training and Quality Assurance

- Supervision and Management 5

5 PROBLEM 2 .

The plant staffs recognition of this event's significance was slow. .

~

Corrective Actions J' Personnel Procedures / Documents / Policies .

1 Equipment Performance Training and Quality Assurance Supervision and Management e

6

..,_.m _.# . . -- . m _ - . . - -, _ _ , _ , , , . . , ,. ...x .- .,-.. .<,,, . -,. .. . ,

Management Lessons Learned  !

1 i

Management's Operational Guidance-to Maintain Tc at 549F v

3 Adjustment of High Tc Alarm -

Reinforcement of Expectations to the Operating Crews Concerning Personal Accountability

.l Operating Crew Communication with Plant Management l

i 7

Personnel Lessons Learned Operating Staff Has the Highest Levels of Honesty, Integrity, and Accountability -

Confirmation of Crew Members' Fitness to Perform Licensed '

Duties .

8

Procedures and Policies Lessons Learnetl 1 .

Senior Reactor Operator Direct Oversight of Reactivity ,

Manipulations .

Periodic Dilution of the Reactor Coolant System Is Not an Activity to Be Turned Over to Another Operator  ;

p Clarification of Short Term Turnover of Control Station Responsibility -!

Implementation of Event Response Teams h

Equipment Lessons Learned Continued Focus on " Dark Board" .

~ .

i Use of" Manual" Mode versus " Automatic" Mode of Control for Boration and Dilution I

l a

10

Training and Quality Assurance Lessons Learned Lessons Learned Need to be Included in Continuing Training '

a V A /y %W-F) f n P'  ;

Effectiveness of Corrective Actions ~ #

z w-I 11

Safety Significance ,

Reactor Power Peak at 101.13%

Observed Cold Leg Temperature (Tc) Maximum of 549.75F 1 ..

Technical Specification Limiting Condition for Operation  ;

ACTION Limit with Tc > 549F is 2 Hours; Tc Exceeded 549F for About 50 Minutes [4hbbTO . .,

61tW '

UFSAR Boron Dilution Event Licensing Basis Assum s y -

1 Bounds Subject Boron Over-Dilution Eveg a

Probabilistic Safety Assessment Evaluation Concluded That the Plant's Core Damage Frequency Was Unaffected by the Event Jp Aa yrF 12  :

- _ _ _ = - _ _ - - _ - _ _ - _ - - _ _ _ _ - _ _ _ _ - _

Apparent Violations B and C Apparent Violation B - Inadequate Design Control

- Review & Conclusions

- Corrective Actions Apparent Violation C - Inadequate 10 CFR 50.59 Evaluation

- Review & Conclusions

- Corrective Actions 13

. Apparent Violation B Proposed Violation: -

" Design control was inadequate, ... procedures for adding ... demineralized water and boric acid to the ... [RCS] (in manual and directly to the suction of the charging pumps) did not implement the method in... Chapter 15 (in automatic and to the volume control tank), ...since January 1976..."

Assessment:

FPL Concurs with the Apparent Violation

- UFSAR Describes Automatic Mode as Normal in Contrast to Plant Practice:

15.2.4: "During normal plant operation, concentrated boric acid solution is mixed with demineralized makeup water...and is automatically introduced into the

[VCT]..."

t 14

. Apparent Violation B (Cont'd>

. Conclusions qqOffd'f' 4

/ '

- Design as Described in the UFSAR Is not Consistently Translated into Procedures .

t

- UFSAR Inconsistencies with Plant Practices Need to Be Eliminated r

Safety Analysis Has Concluded No Unreviewed Safety Question W ,W;'p!

' Nt f 7r Corrective Actions k

- Review and Enhance UFSAR 7 ppm P[:*#4

- Assessment by Multi-Discipline Team (Covered ~ 1/3 UFSAR Content) p

- Complete Identification and Elimination ofInconsistencies N

- Unit I by mid-December 1996

- Unit 2 by September 30,1996

. Improve the Procedure Review Process to Include Feedback for UFSAR Update 15

Apparent Violation C Proposed Violation:

"A .. 50.59 evaluation was inadequate, ... the licensee made a change to the Unit I boron dilution procedure on January 23,1996 (after the event), to allow adding demineralized -

water in " Manual" and directly to the suction of the charging pumps, that was different v from the method stated in the UFSAR, Chapter 15 (in " Dilute" and to the volume control tank) and without preparing a .. 50.59 safety evaluation."

Assessment:

FPL Concurs with the Apparent Violation o UFSAR Description Is Not Consistent with Plant Practices 16

Apparent Violation C (Cont'd)

Conclusions:

L o TC 1-96-01710 CFR 50.59 Screening Conclusions Are Not Supported by UFSAR v Description i

o UFSAR and 10 CFR 50.59 Screening Process Ntxa Improving v

e 17  ;

-Apparent Violation C (Cont'd) .

j,p Corrective' Actions - / k o Improve 10 CFR 50.59 Screening Process

- Improve Process by Documenting the UFSAR and Technical Specifications Sections Reviewed During Screening Conduct 10 CFR 50.59 Training for Departments Responsible for Procedure Changes with

' New Emphasis on the Definition of"... procedures as described in the safety analysis ,

report" .

Clarify Screening Criteria ch Reference Applicable UFSAR Sections within Procedures 1 a Improve UFSAR Q' Y F Eliminate Procedure / UFSAR Inconsistencies a ;r fW 1R

i Impact of the Boron Dilution Event on St. Lucie Plant r

. Management Expectations #

$ t(j # cf a

f;5 i. ' neby Programs and Procedures Tram. .mg

,' .P r

9 o Personnel Performance

\

Management Performance h

. _ . .