ML20138A193
| ML20138A193 | |
| Person / Time | |
|---|---|
| Site: | LaSalle  |
| Issue date: | 04/21/1997 |
| From: | Subalusky W COMMONWEALTH EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9704280015 | |
| Download: ML20138A193 (12) | |
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Coninmowcaltli litiwn Company lealle Gener.iting $tation 2601 North list Road Marseilles, !!. 614 il T;7 Tel 814.457 6~61 April 21,1997 United States Nuclear Regulatory Commission Attention: Document Control Desk Washington, D.C. 20555
Subject:
NOTICE OF VIOLATION; NRC INSPECTION REPORT 50-373/374-96020
Reference:
M. N. Leach letter to W. T. Subalusky, dated March 26,1997, Transmitting NRC Inspection Report 373/374-96020 The enclosed attachment contains LaSalle County Station's response to the Notice of Violation, that was transmitted in the Reference letter.
If there are any questions or comments concerning this letter, please refer them to me at (815) 357-6761, extension 3600.
Respectfully, b
W. T. Subalusky Site Vice President LaSalle County ajo Enclosure T O' ' i I
cc:
A. B. Beach, NRC Region 111 Administrator M. P. Huber, NRC Senior Resident inspector - LaSalle D. M. Skay, Project Manager - NRR - LaSalle j
9704280015 970421 PDR ADOCK 05000373.
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ATTACHMENT RESPONSE TO NOTICE OF VIOLATION NRC INSPECTION REPORT 373/374-96020 VIOLATION: 373/374-96020-01 During an NRC inspection conducted on December 7,1996, through February 6,1997, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the l
violations are listed below:
1.
Technical Specification 6.2.A.a requires that applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, be established, implemented, and maintained.
1 Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, specifies proceduros forimplementation of a fire protection program and operation of onsite AC power and liquid radioactive waste systems.
Step F.15 of LaSalle Operating Procedure (LOP) AP-11, " Racking-out a 4160 Volt Motor Operated Air Circuit Breaker," Revision 8, requires that operators secure the t
breaker compartment door bolt by tightening the bolt at the top of the door when the l
associated Division 3 breaker is removed from service.
4 Step F.2.b of LaSalle Operating Surveillance (LOS) FP-M4, " Fire Protection Sprinkler and Deluge System Valve Lineup and Alarm Check," Revision 20, requires that operators open the inspector's test drain valve during the surveillance test.
Steps F.8.a through F.8.1 of LaSalle Operating Procedure LOP WX-06, " Establishing i
a Waste Sludge Tank Transfer Loop," Revision 10, requires that operators secure the transfer of the waste tank contents, close the waste tank outlet valves, and begin a flush of the transfer lines with " clean" cycled condensate water after transferring the desired amount of waste sludge from the tank for further processing and disposal.
Step B.4 of LaSalle Administrative Procedure LAP 900-16, " Fire Protection Equipment and Fire Barrier impairments," Revision 13, requires initiation of a fire protection impairment permit before any fire protection component or system is taken out-of-service or otherwise rendered inoperable.
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t Contrary to the above, applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, were not correctly implemented l
in the following instances:
a.
On January 21,1997, inspectors identified that the bolt at the top of the Division 3, Bus 143, Cubicle 3 compartment door was not secured. The bolt was hanging loose and not engaged with the switchgear frame, although the breaker was removed from service.
This is a Severity Level IV violation (Supplement 1). (50 373/96020-01; 50-374/96020-01).
REASON FOR VIOLATION: 373/374-96020-01a During inspections of the switchgear cubicle doors, it was identified that some doors were misaligned. As a result, during reinstallation, the threads on some bolts became damaged and would no longer engage. Also, Operations procedures for breaker operation did not include instructions to verify that fasteners are properly secured when closing up the j
switchgear cubicle. As a result, operators did not ensure that the switchgear cubicle door
.were appropriately secured.
CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
1.
Switchgear cubicle doors for all three divisions were walked down. Loose or missing bolts were identified. Electrical Maintenance ensured that fasteners were properly secured on all switchgear cubicle doors. Action Requests were initiated to replace j
damaged bolts and realign doors. This work has been completed.
2.
Training was provided to Operations and Electrical Maintenance per'sonnel by General Information Notice (GIN)97-003. The GIN covered the proper securing of switchgear access doors and panels.
CORRECTIVE ACTIONS TO BE TAKEN TO PREVENT FURTHER VIOLATIONS:
1.
Maintenance procedures associated with breaker operation were reviewed and verified to contain appropriate instructions to secure switchgear door fasteners.
Operations procedures LOP-AP-01, 03-05, 07-11, 20 and 22, associated with breaker operations, are being revised to include instructions for properly securing switchgear door fasteners. These procedures will be completed by July 31,1997.
(NTS No. 373-100-96-02001a.01) 2.
LaSalle County Station has an ongoing effort to improve human performance at the site. During a series of all-hands meetings conducted during February and March 1997, management conveyed their expectation for LaSalle's improvement 2
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and the necessary elements of each individual's contribution to this effort. These include strict procedural adherence, strong use of the self-checking program, a questioning attitude and a demand for rese!ution of issues As a result, we have seen a slow down in work as procedures are followed and an increase in the number of procedures being sent back for revision. This action is also applicable to violation examples 01b,01c and 01d.
DATE WHEN FULL.,0MPLIANCE WILL BE ACHIEVED:
Full compliance was achieved with the door realignment, bolt replacement, proper securing of cubicle doors and the GIN training of personnel.
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' VIOLATION: 373/374-96020-01b b.
On February 1,1997, while conducting a fire protection system surveillance test in accordance with LOS-FP-M4, a non-licensed operator opened the manual deluge valve for the Unit 1 auxiliary transformer instead of the inspector's test drain valve.
This is a Severity Level IV violation (Supplement 1). (50-373/96020-01; 50-374/96020-01).
J REASON FOR VIOLATION: 373/374-96020-01b i
Surveillance LOS-FP-M4 is used to verify the alignment of the deluge stations and alarm check valves and to perform a test to verify that the local and remote alarms are functioning in the event thosa fire protection systems are initiated. The alarm test for deluge stations is performed by taking water pressure from the system before the isolation valve to the pressure switch mounted at the deluge valve. Since the arrangements of the plant's deluge stations vary, the surveillance procedure provides generic instructions to perform the alarm test and alignment verification for both deluge and alarm check valves.
Three figures are included in the procedure for the operator to identify the specific deluge station or alarm check valve arrangements of which there are five types. Emergency trip valves or pul: devices for deluge valves are also located near each station for manual initiation if needed in the event of a fire on the component. The manualinitiation device for this transformer taps off the same line going to the alarm pressure switch and is inside a wall box mounted on the building wall,way from the deluge valve. The operator had used this manual initiation device inst %d of the three-way valve when he performed the alarm test.
The operator was performing this test for the first time. He had reviewed the surveillance procedure after receiving the assignment and believed that he understood how to do the test. The UAT deluge station was the first station tested. At the procedure step where the operator was to open the inspector's test drain valve, he mistakenly went to the manual initiation device and used that valve which resulted in deluging the transformer.
This was a kr;owledge-based error occurring during the first-time performance of a task.
The operator's knowledge of this equipment and of the task was inadequate even after his review of the procedure. The procedural guidance was adequate for the task. The manual deluge valve was appropriately labeled and inside a box. When the operator encountered differences between the procedure instruction and the actual components, he did not stop and seek guidance from another experienced operator or supervisor. He continued with the task, using a valve located sufficiently away from the equipment being tested and labeled as an initiation device that he had to leave the UAT deluge valve to operate it. This failure to stop in the case of uncertainty was an inadequate work practice on the part of the operator.
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' CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
1.
The operator and shift supervisors involved were counseled by senior operating management on the need for a strong questioning attitude and strict procedural adherence in all activities. Appropriate disciplinary action was taken.
2.
The fire protection deluge station test valves and devices have been properly 4
labeled and surveillance LOS-FP-M4 was successfully completed, 3.
LOS-FP M4 has been revised to incorporate lessons-learned from this event.
4.
As an interim measure, during pre-job briefs, operators are asked if they have
. performed the task before, if not, supervision will further evaluate the task and the j
performer prior to continuing.
CORRECTIVE ACTIONS TO BE TAKEN TO PREVENT FURTHER VIOLATIONS:
1.
Operating has established a pre-job briefing requirement to identify operators being l
assigned a task such as a first time evolution or tasks where the operator has no similar experience and to evaluate if the operator can perform the task safely and correctly.
2.
The Auxiliary Operator Certification Guide is being evaluated by Training and Operating personnel to identify and resolve any weaknesses. This evaluation will be completed by Maj a0,1997. (NTS No. 373-100-96-02001b.01) 3.
The Station's ongong effort to improve human performance, fully described in violation response 01a, is applicable to this violation.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance was achieved with the successful completion of LOS-FP-M4.
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VIOLATION: 373/374-96020-01c c.
On January 31,1997, during a waste tank transfer in accordance with LOP-WX-06, an operator did not secure the transfer of the waste tank contents, close the waste tank outlet valves, and begin a flush of the transfer lines with " clean" cycled condensate water per steps F.8.a through F.8.i.
This is a Severity Level IV violation (Supplement I). (50-373/96020-01; 50-374/96020-01).
REASON FOR VIOLATION: 373/374-96020-01c The Radwaste Solids Operator had established and monitored a waste sludge transfer j
loop earlier in the day on January 31,1997. He subsequently was attempting to flush and secure the waste sludge transfer loop per procedure LOP-WX-06. While tuming the page in the procedure, rather than going to page 5, the Operator accidentally turned two pages and was on page 6 of the procedure. The Operator continued on with the procedure resulting in missing some steps that were on page 5 of the procedure. As a result, the -
operator did not secure the transfer, close the waste tank outlet valves, and begin to flush the transfer lines with " clean" cycled condensate water as prescribed in the steps on page 5 of the procedure. When the operator reached the procedural step which directed him to close the cycled condensate flush valve to secure the transfer line flush, he noticed that the valve was already in the closed position. Assuming that he had missed the procedural step to open this valve, the operator opened the valve. The high level alarm enunciated and the Operator immediately secured flushing. A proper flush sequence was completed late on i
January 31,1997, following the appropriate settle time of the tank.
In reviewing the procedure with the Radwaste Shift Supervisor and Radwaste Solids t
Manager, the error of turning two pages was identified. The Operator's error resulted from l
a failure to self-check during the conduct of the procedure.
CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
The Radwaste Solids Operator was counseled by the Radwaste Solids Manager. Basic expectations of procedural adherence and self-checking wer9 reviewed. Appropriate disciplinary action was taken.
CORRECTIVE ACTIONS TO BE TAKEN TO PREVENT FURTHER VIOLATIONS:
The Station's ongoing effort to improve human performance, fully described in violation response 01a, is applicable to this violation.
s DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance was achieved when the proper flush sequence was completed on January 31,1997.
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l VIOLATION: 373/374-96020-01d d.
On January 11,1997, personnel in the Consolidated Facilities Maintenance Group did not obtain a fire impairment permit before disabling fire door 149.
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This is a Severity Level IV violation (Supplement I). (50-373/96020-01; 50-374/96020-01).
REASON FOR VIOLATION: 373/374-96020-01d in September 1996, Radiation Protection (RP) removed High Radiation Area access controls to the Unit 2 Low Pressure Heater Bay (LPHB) following Unit 2 reactor shutdown for a refuel outage in accordance with procedure LAP-1100-13, High Radiation Area Door Surveillance and Alarm Response. As directed by the station work control and scheduling team, Station Construction submitted the fire protection impairment permits to cover the opening of the Unit 2 LPHB doors. This was done as a matter of routine to support the work in the heater bay. The impairments stated the door would be blocked open with a wedge. The Consolidated Facilities Maintenance Team (CFM) reversed the latching plates for the routinely accessed doors to the Unit 2 LPHB. This was completed at the request of RP. This was done as a matter of routine to support the work in the heater bay and aid access by not requiring the workers to obtain a key to enter the area. This practice had i
been in place for the past three or four outages. It was instituted upon the removal of the station security card readers controlling access to the high radiation area doors as a means of providing individuals access.
On September 30,1996, the Unit 1 reactor was shutdown. RP removed High Radiation Area ac::ess controls to the Unit 1 LPHB following shutdown. CFM was requested to reverse the latching plate on door 149. On January 11,1997, while performing an inspection of areas in the turbine building, the System Engineer found fire door 149, Unit 1 Turbine Building 710, Service Air (SA) Compressor room to LPHB, closed but uniatched.
The latch plate had been reversed preventing the latching mechanism from functioning.
No fire impairment was found attached to this door.
On January 13,1997, the station Fire Marshall completed an inspection of all doors affected by recent down postings by RP. Three additional doors were found to have latch mechanisms impaired without having an adequate fire impairment in place.
This event resulted from inadequate procedural / process controls in place to temporarily remove a high rad door from a high rad status to allow for maintenance to be performed inside the specified room during outages. The changes made to the doors' latching mechanisms were completed under a blanket work request. A contributing factor was inadequate communications between the RP department and the team performing the requested work which resulted in no fire impairment being issued prior to work.
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' CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
1.
On January 14,1997, the door latch mechanisms were returned to the normal position for all doors securing the Unit 1 LPHB. The doors for the Unit 2 LPHB were retumed to normal operation and fire impairments were left in place for the doors necessary to support the unit outage.
2.
As an interim measure, the Maintenance Manager suupended all work on blanket woik requests by CFM, unless a specific Action Request is written for the work and appropriately screened by the Screening Committee.
3.
A review of the current practice of utilizing blanket work requests inside the power block and previous work done under blanket work requests were completed. As a result, all blanket work requests that involve power block work were deleted and replaced with pre-approved work requests. Pre-approved work requests contain specific instructions on what work is allowed under the document and also requires a 10CFR50.59 screening to ensure proper configuration control prior to issuance.
This change was effective February 5,1997. Any work that does not strictly adhere to the pre-approved work request document will be processed under the normal work request process, ensuring it is screened and controlled.
4.
Maintenance Department Work Analysts developed a pre-approved work packago for specific door maintenance which will contain all door activities allowed to be performed. This package has all necessary checklists, reviews, approvals and safety evaluations. Work outside of this work package will require a separate work request.
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This event was reviewed with the CFM Team at a tailgate meeting. The review included a discussion of the need to follow the appropriate procedures when making changes to plant components (i.e., temporary alterations, fire impairments, etc.).
CORRECTIVE ACTIONS TO BE TAKEN TO PREVENT FURTHER VIOLATIONS:
1.
Procedure LAP-110013 "High Radiation Area Door Surveiliance and Alarm Response" will be revised to ensure barriers identified as fire related have the fire j
impairment initiated prior to work and the appropriate tests are in place to verify the barriers operate properly upon return to service. This revision willinclude appropriate controls for the doors routinely down-posted and re-posted and controls to insure fire impairment reviews are performed and issued if necessary prior to work being performed. The procedure revision will be completed by August 30,1997. (NTS No. 373-100-96-02001d.01) 2.
By August 30,1997, a review will be performed of other Radiation Protection procedures that request support from other departments to ensure these requests comply with other station requirements (e.g., fire impairment, FSAR, etc.).
(NTS No. 373-100-96-02001d.02) 8
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'3 Training on this event was initiated by applicable departments on General Information Notice (GIN)97-014. The GIN reviews the event, the causal factors and corrective actions. (NTS No. 373-100-96-02001d.03) j 4.
The Station's ongoing effcrt to improve human performance, fully described in violation response 018, is applicable to this violation.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance was achieved on January 14,1997, when all doors were verified to have fire impairments assigned or were returned to normal operation.
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'VIOLNTION: 374-96020-03 10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures and Drawings,"
requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures, or drawings.
Contrary to the above, out-of-service (OOS) 960015064, dated October 11,1996, was not appropriate to the circumstances in that it did not contain sufficient instructions to ensure that operators removed the correct Unit 2, Division 2, battery charger circuit breaker from service.
This is a Severity Level IV violation (Supplement 1) (50-374/96020-03).
REASON FOR VIOLATION: 373/374-96020-03 in removing the Unit 2 Division 2 Battery Charger from service, the operators first transferred DC busses. The shutdown of the Battery Charger was the next required action.
The operators reviewed the OOS checklist to ensure they were on the right equipment and used LOP-DC-01 section F.3 to remove the charger from service. Step 3.d of this 4
procedure directs the operator to open the charger's DC supply breaker to DC bus or distribution panel. At this step, the operators thought that their previous action in opening a bus supply to the distribution panel during the bus transfer had accomplished this.
Therefore, they proceeded to step,3.e, completing the procedure. To perform step 3.d correctly, the operators should have opened the breaker at Bus 28. After the operators had completed shutdown of the charger, they prepared to hang the OOS. The first OOS card was hung at Bus 236X-3 on Cubicle B-5, the 480V supply to the charger. For the second card, the OOS identified the isolation point as, D-2125V Battery Charger DC Load.
There was no equipment location information such as with the first card but Ckt 2D was listed. The operators located the DC power switch, CD-2, on the battery charger. They incorrectly concluded that this was the breaker identified on the second card on the OOS checklist. However, the feed breaker at cubicle 2D of Bus 2B was the breaker identified on the checklist and was the correct breaker.
There are several contributing causes which resulted in tagging out the incorrect breaker.
The information included on the OOS checklist, in section 3 of LOP-DC-01 and through the equipment labels did not provide consistent and clear information to the operators. Using the OOS checklist, they concluded that the OOS card should be placed on the DC Power CB-2 switch at the battery charger although the checklist identified CKT 2. The intended isolation point provided on the checklist was the battery charger feed breaker at the 2B Bus. Five other information deficiencies were identified. These deficiencies occurred because the methods used to identify components in the plant and in EWCS were inadequate to ensure consistent nomenclature was used or to correct identified discrepancies.
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'The operators proceeded to hang the second OOS card at the battery charger, although they could not fully verify the component information available to them when placing the card. They performed a peer check and concluded they were correct in the placement of the card but did not request an independent or supervisor's opinion to resolve the discrepancies.
CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:
1.
The operators were counseled by shift supervision on the expectation to stop an activity when the information provided or their understanding of the information is unclear and then to obtain an independent check or verification before proceeding.
Appropriate disciplinary action has been taken for each operator.
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Operating Department Memo No.19 was reviewed to clarify and reinforce management's expectations for verification of labeling, l. e., exact match of EPN and technical match on description.
3.
LOP-DC-01 has been revised to provide clearer instruction for energizing or shutting down all battery chargers including specific identification and location of the associated AC and DC feed breakers.
CORRECTIVE ACTIONS TO BE TAKEN TO PREVENT FURTHER VIOLATIONS-1.
Labels were added at the Unit 2 Div. 2 Battery Charger, and the corresponding i
Unit 1 equipment, to identify the AC Input and DC Output switches, in addition, the Bus 2B panel identification label is back in place and Cubicle 2D has been relabeled l
to clearly identify it as the Unit 2 Div. 2 Battery Charger feed breaker and to correspond with the information in EWCS.
2.
Operating has established a Labeling Group to identify and correct discrepancies in component descriptions and labeling.
3.
Procedure LAP-100-30, independent Verification, will be revised by July 1,1997, to provide for " apart in time" independent verifications of OOSs.
(NTS No. 373-100-96-02003.01)
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
Full compliance was achieved with the personnel counseling and the corrected component labeling.
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