ML20138B814
| ML20138B814 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 04/23/1997 |
| From: | Muench R WOLF CREEK NUCLEAR OPERATING CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| ET-97-0044, ET-97-44, NUDOCS 9704290285 | |
| Download: ML20138B814 (15) | |
Text
= - - - _
~_.. _ - -
.. - ~. _... _ _. -. _
l l
i WQLF CREEK NUCLEAR OPERATING CORPORATION Richard A. Muench Vice President Engineenng April 23, 1997 ET 97-0044 U.
S. Nuclear Regulatory Commission ATTN:
Document Control Desk Mail Station P1-137 i
Washington, D.
C.
20555 l
Reference:
Letter dated March 10, 1997, from A. T.
- Howell, NRC, to O.
L. Mayncrd, WCNOC
Subject:
Docket No. 50-482:
Response to Notice of Violations 1
50-482/9704-01,
-02,
-03,-04, and -07 Gentlemen:
This letter transmits Wolf Creek Nuclear Operating Corporation's (WCNOC)
I response to Notice of Violations 50-482/9704-01,
-02,
-03,-
04, and
-07.
Violation 9704-01 concerns the failure of a Shift Supervisor to recognize conditions requiring entry into Technical Specification Action Statement 3.6.3, and failure to log that entry.
Violatton 9704-02 involved manipulation of a turbine-driven auxiliary feeowater pump governor valve while troubleshooting an inadvertent overspeed trip without correct work controls, and without correct authorization.
Violation 9704-03 concerns WCNOC's failure to establish procedure SYS AL-124 adequately to control the test activity.
Violation 9704-04 occurred when an operator failed to follow procedure direction when attempting to trip the turbine-driven auxiliary feedwater pump.
Violation 9704-07 occurred when a revision to a flow chart in the Emergency Elan inadvertently resulted in a decrease in the effectiveness of the plan, without prior NRC approval.
This response letter is being submitted after the 30 day due date with the concurrence of the Senior Resident Inspector as discussed at the 50-482/97-08 Inspection Exit Meeting.
WCNOC's response to these violations is in the attachment.
If you have any questions regarding this
- usponse, please contact me at (316) 364-8831, extension 4034, or Mr. Pic%rd D.
Flannigan at extension 4500.
Ve tru y yours, 9704290285 970423 PDR ADOCK 05000482 G
PDR Richard A. Muench RAM /jad
]h D f Attachment f
cc:
E.
W.
Merschoff (NRC), w/a l
W.
D.
Johnson (NRC), w/a f
J.
F. Ringwald (NRC), w/a J. C. Stone (NRC), w/a
,,, ; i 4
l C30021 l
PO Box 411/ Burhngton, KS 66839 / Phone- (316) 364-8831 An Equal Opportun ty Empk>yer M F HC, VET
m Attachment to ET 97-0044 Page 1 of 14 Violation 50-482/9704-01:
The Shift Supervisor did not recognize that a Containment Isolation Valve failure resulted in entry into Technical Specification Acti on Statement 3.6.3, and failed to log entry into Technical Specification Action Statement 3.6.3.
" Technical Specification 6.8.1.a
- states, in
- part, that written procedures shall be established and implemented covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2.
Regulatory Guide 1.33, Appendix A, Section 1.h, requires administrative procedures for log entries.
Administrative Procedure AP 21-001,
" Operations Watchstanding Practices," Revision 4,
Step 6.2.3.d, requires a log entry for entry into Technical Specification action statements due to equipment failure.
Contrary to the above, on July 28, 1996, at 5:15 p.m.,
the Shift Supervisor logged a failure of Containment Isolation Valve EF HV0034 to close on demand, but failed to recognize that this valve failure j
resulted in entry into Technical Specification Action Statement 3.6.3 and failed to log entry into Technical Specification Action Statement 3.6.3."
j l
Admission of Violation:
Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that a violation of Technical Specification 6.8.1 occurred when the Shift i
Supervisor failed to recognize that the EF HV0034 Containment Isolation Valve failure resulted in entry into Technical Specification Action Statement 3.6.3, and failed to log entry into Technical Specification Action Statement 3.6.3.
All Limiting Condition for Operations (LCO) actions were adequatelv addressed but not logged.
Reason for Violation:
Two concerns were identified during the evaluation of the items identified in Violation 9704-01.
- 1. The Shift Supervisor did not enter Technical Specification 3.6.3 on July 28, 1996.
He neglected to consider the containment isolation function of EF HV0034, instead he concentrated on the safeguards required position of the valve.
(EF HV0034 is a motor operated containment isolation valve located within the containment structure.)
The safeguards required position is "open".
The Shift Supervisor's concentration on the "open" safeguards position combined with:
- 1) Dual indication problems that occurred in the " closed" position; 2) Technical Specification Table 3.6-1 specifying "N/A" for the maximum EF HV0034 isolation time; and 3)
Subsequent stroking of the valve that did not result in problem recurrence, caused the Shift Supervisor to incorrectly determine that the containment isolation requirements of Technical Specification 3.6.3 did not apply.
The root cause for not entering Technical Specification 3.6.3 was personal error. The root cause of personal error by the Shift Supervisor appeared to be an isolated instance, not having generic implications; however, on March 6,
1997, two Performance Improvement Requests (PIR 97-0715 and PIR 97-0716) were issued.
Botn PIRs dealt with the failure to either properly enter, or to properly log the entry into, Technical Specification 3.6.3.
- 2. LER 96-010-00, which reported the failure of EF HV0034 to properly operate j
from March 10, 1996, through October 9, 1996, did not discuss operability
Attachment to ET 97-0044 Page 2 of 14 1
l of EF HV0034 in relation to Technical Specification 3.6.3.
LER 96-010-00 did discuss events surrounding the inoperability of EF HV0034, but stated the basis for reportability was Technical Specification 3.7.4, which states "At least two independent essential service water (ESW) loops shall be operable."
LER 96-010 did not consider noncompliance with Technical l
Specification 3.6.3, which pertains to containment isolation, and states:
"The containment isolation valves specified in Table 3.6-1 shall be OPERABLE with isolation times as shown in Table 3.6-1."
l The root cause for failing to identify in LER 96-010 that Technical Specification 3.6.3 was not properly entered was an incomplete investigation of Performance Improvement Request (PIR) 96-2528.
The root cause for this problem was inadequate interface among organizations.
This event, and the LER reporting it, were mainly evaluated by WCNOC Engineering
]
without sufficient participation by Operations.
J The failure of the PIR 96-2528 investigation to identify the failure to address Technical Specification 3.6.3 was determined to have generic j
implications.
The generic implications are that a PIR, such ae 96-2528, i
has multiple issues affecting various work groups.
In the specific case of j
PIR 96-2528, this PIR was evaluated by Engineering, and the issue of
)
Technical Specifications compliance was not given sufficient in-depth attention.
]
Corrective Steps Taken and Results Achieved:
Performance Improvement Request (PIR) 96-2528 served as the basis for information for the description, root cause, and corrective action for the event reported in Licensee Event Report (LER) 96-10-00.
The WCGS l
Corrective Action Review Board (CARB) was not in existence when the
)
evaluation for significant PIR 96-2528 was performed.
The CARB now provides upper level management and multi-discipline review of PIRs involving significant
- issues, prior to the PIR's closure.
The procedurally required review by the CARB is now a practice that will help ensure all applicable issues are evaluated when addressing significant PIRs.
Because LER content is based on significant PIR evaluation, CARB review will aid in preventing inaccurate or incomplete LERs from being issued.
Corrective Steps That Will Be Taken And The Date When Full Compliance Will Be Achieved:
Procedure AP 28A-001, Revision 6,
" Performance Improvement Request,"
will be revised by May 10, 1997, to provide guidance for when a multi-discipline team approach should be used to perform evaluations of l
significant PIRs.
This will ensure that knowledgeable organizations are l
given the opportunity to provide input into the evaluation process for significant issues.
- A revision to LER 96-010-00 will be issued by April 30, 1997, to correct the failure to identify entry into Technical Specification 3.6.3.
ADDITIONAL EVENTS IDENTIFIED:
On March 5, 1997, at 0900, the "B"
train Containment Cooler was isolated by Clearance Order (C/0) 97-0302-EF to support abbreviated Valve Operation Test and Evaluation System (VOTES) testing on EF HV0034.
Technical Specification 3.6.3 requires an action when specific containment isolation valves, such as EF HV0034, become inoperable.
EF HV0034 became inoperable during the abbreviated VOTES testing, when the valve's operator rotor cover was remcVed; i
I Attachment to ET 97-0044 Page 3 of 14 however, the Shift Supervisor did not enter Technical Specification 3.6.3, as required.
l A misunderstanding occurred concerning the work scope.
Interviews with the Shift Supervisor revealed that he understood that the limit switch l
compartment cover (rotor cover) would be removed, as is stated in the Maintenance Work Package Summary.
However, the Supervising Operator did not understana that the cover would be removed. Although the Shift Supervisor and Supervising Operator each had a different understanding of the work scope, neither identified the need to enter Technical Specification 3.6.3.
This is due to the following:
- 1. The Shift Superv.isor understood the cover was being removed as was stated in the Work Package Summary.
The Shift Supervisor did not enter Technical Specification 3.6.3 because Clearance Order 97-0302-EF closed the outside containment isolation valve (EF HV0032).
The Shift Supervisor understood that this met the action for Technical Specification 3.6.3, and therefore he thought it was not necessary to log entry of the Technical Specification into the Shift Supervisor log.
J l
i
- 2. The Supervising Operator misunderstood the scope of work and thought the cover would remain installed.
The Supervising Operator therefore had no reason to believe operability would be affected and he subsequently did not enter Technical Specification 3.6.3.
Based on the facts reviewed, the following were causes of the identified problems:
- 1. There was no clear expectation of Equipment Out-of-Service Log (EOL) or Control Room Log entries when a Clearance Order meets the Technical Specification action. The Shift Supervisor and Supervising Operator to believe that it was not necessary to log the Technical Specifications that are considered whenever a
Clearance Order satisfies the Technical Specification action statement. At that time, Operations did not log all Technical Specifications being considered when the Technical Specification action statement was met by a Clearance Order. This is part of the pre-job planning and satisfies the LCO.
The expectations for the future will be to log all Technical Specifications that apply and which are being considered; including those Technical Specifications in which the action statement is met by a Clearance Order.
Logging of all applicable and considered Technical Specifications will indicate that all appropriate Technical Specifications have been considered.
- 2. Verbal and written communication resulted in the misinterpretation of the j
words "non-intrusive" and " operability" used in the Work Package Task work scope.
Corrective Steps Taken to " ADDITIONAL EVENTS IDENTIFIED" and Results Achieved:
Control Room Log entries were amended.
1 PIR 97-0716, which documents the desc:iption, root cause, and corrective actions for this event, has been placed in Operations required reading.
Attachment to ET 97-0044 Page 4 of 14 Corrective Steps That Will Be Taken to " ADDITIONAL EVENTS IDENTIFIED" And The Date When Full Compliance Will Be Achieved:
Operations Management will issue a written expectation stating that, even when an action statement is met, reference needs to be made in both the contro) room logs, and in the EOL. This action will be completed by May 16, 1997.
Confusion surrounding the meaning of the words "non-intrusive" and
" operability" will be addressed in training.
This training will develop a consistent definition for each word that is acceptable to both Maintenance and Operations.
Training will alert personnel to the different connotations words can carry and that words can have multiple definitions based on the organizational perspective. Consideration to other words will also be given.
This training will be given to both Maintenance and Operations. Completion date for the training is July 5, 1997.
The Superintendent of Operations will discuss with the operating crews the importance of clear, concise and detailed communication with Maintenance personnel.
Operating crews will be reminded that different terms can have different meanings to various organizations. Clear communication ensures that the sender and receiver each have a common understanding.
These discussions will be completed by May 16, 1997 Procedure AP 21F- 001, " Equipment Out-Of-Service Control," shall be changed to reflect that if a Clearance Order meets the requirements of a Technical Specification action statement, the Equipment Out-of-Service Log (EOL) must state this, so it is understood that the Technical Specification is not being violated.
This revision will be completed by May 16, 1997.
l
Attachment to ET 97-0044 Page 5 of 14 Violation 50-482/9704-02:
A System Engineer manipulated the turbine-driven auxiliary feedwater pump governor valve FC FVO313 while troubleshooting an inadvertent overspeed trip without a work package task and without authorization from the Shift Supervisor, and control room operators manipulated the speed of the turbine-driven auxiliary feedwater pump to below 3850 rpm.
" Technical Specification 6.8.1.a
- states, in
- part, that written procedures shall be established and implemented covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2.
Regulatory Guide 1.33, Appendix A, Section 9,
requires procedures for performing maintenance that can affect the performance of safety-related equipment.
l Administrative Procedure AP 16C-002,
" Work Controls,"
Revision 4,
Attachment C,
Step C.2.1, requires workers to perform troubleshooting activities using a work package task with authorization from the Shift Supervisor.
System operating Procedure SYS AL-124,
" Venting the Turbine-Driven Auxiliary Feedwater Pump Oil System," Step 6.1.4, requires operators to open Valve FC HV0312, a turbine-driven auxiliary feedwater pump trip-throttle valve, until the turbine operates between 3850 and 3900 rpm, then slowly open the valve while verifying that the governor valve j
maintains control of the turbine.
Contrary to the above, on January 24, 1997, system engineers failed to comply with procedures for performing maintenance.
Specifically:
1.
The system engineer manipulated Valve FC
- FV0313, the turbine-driven auxiliary feedwater pump governor valve while troubleshooting an inadvertent overspeed trip without a work j
package task and without authorization from the Shift Supervisor.
2.
Under the direction of the system engineer, control room operators manipulated the speed of the turbine-driven auxiliary feedwater pump to below 3850 rpm."
Admission of violation:
Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that a violation of Technical Specification 6.8.1 occurred when a System Engineer failed to comply with procedures for performing maintenance by manipulating valve FC FV0313, without a work package task, and without authorization from the Shift Supervisor.
WCNOC also agrees that, under the direction of the system engineer, Control Room operators manipulated the speed of the turbine-driven auxiliary feedwater pump to below 3850 rpm.
\\
4 s
~-
Attachment to ET 97-0044 Page 6 of 14 l
l Reason for Violation 9704-02:
Two examples were identified for Violation 9704-02.
These two examples are addressed separately below.
Reason for Violation --- Example One 1
l The root cause for this inappropriate action by the system engineer was the I
system engineer's mindset to identify and resolve the Turoine Driven Auxiliary Feedwater Pump (TDAFWP) overspeed trip problem, at the expense of his duties l
as Team Leader.
The system engineer did not consider the procedural direction provided in AP16C-002,
" Work Controls,"
that defines the limits of investigation.
Following overspeed trip of the TDAFWP, the system engineer became fully engaged with resolving the trip.
The system engineer discussed concerns about the possible cause of the trip with the Shift Supervisor. The Shift Supervisor understood that the system engineer was planning to visually investigate the cause of the trip, but the Shift Supervisor was unaware that the system engineer would actuate components.
The system engineer's responsibility to identify the cause of the overspeed trip became his primary focus, and being aware of the need to check for Governor Control Valve (GVC) binding while the equipment was still warm, and the time constraint associated with the Limiting Condition For Operation (LCO), he acted inappropriately.
The system engineer felt that because the system was out of service, and he thought he had the Shift Supervisor's permission, no further controls were necessary.
The system engineer, being inexperienced in the area of troubleshooting, responded inappropriately by not stopping and considering the i
procedural requirements identified in AP16C-002 as they relate to troubleshooting.
Additional investigation, documented in PIR 97-0363, provides evidence that the problem at hand is not glcbal within the system i
engineering organization.
It was also identified that the Shift Supervisor delayed AR initiation later than the " Work Controls" procedure allows.
This conclusion is based on the interview with the Shift Supervisor which revealed that he was attempting to determine the cause for the trip for information prior to AR initiation.
The Shift Supervisor is knowledgeable of the work controls process, but did not know this level of activity is outside of the limits for investigation.
The Work Controls procedure is a " reference use" category procedure which requires it to be readily available, but not in hand.
The Shift Supervisor did not consult the procedure before making his decision.
Discussions with other Shift Supervisors have indicated that they would not have allowed this troubleshooting to occur without initiation of an AR and subsequent approval of a Work Package.
This provides evidence that this lack of understanding is not global to all Shift Supervisors.
The root cause for the inappropriate action by the Shift Supervisor was an error in judgment concerning the limits of investigation provided in AP16C-002, " Work Controls" Corrective Steps Taken and Results Achieved For Violation 9404-02 --- Example One Immediate corrective action resulted in appropriate counseling and l
discipline of System Engineering personnel by System Engineering management.
l l
Attacnment to ET 97-0044 Page 7 of 14 I
Following this event, the Superintendent of Operations met with all l
l cperating crews and re-corrrunicated the requirements identified in the work control process, emphasizing procedural compliance, the limitations of I
investigation, requirements for Shift Supervisor initiation, and the threshold of troubleshooting as defined in AP16C-002.
The Manager of System Engineering reviewed issues associated with procedures AP15C-002, " Procedure Use and Adherence," and AP16C-002, " Work Controls," and discussed issues related to this event with all System Engineers.
This action was completed on April 22, 1997 Corrective Steps That Will Be Taken and the Date When Full Compliance Will Be Achieved For Violation 9704-02---Example One:
The Manager System Engineering will develop a qualification standard to include specific training, as a minimum, on procedure AP15C-002, " Procedure l
Use and Adherence" and procedure AP16C-002 " Work Controls".
This standard will ensure the pertinent information of each procedure is understood as it applies to System Engineering responsibilities.
Training to this standard will be completed by July 1, 1997.
Additional interim corrective action requires the Manager System Engineering to review this event with other Engineering Managers for identification of information that relates to other engineering groups.
This review will determine the need for a qualification standard for other engineering groups.
This action will be complete by May 30,1997.
The Manager integrated Plant Scheduling (IPS) will collect information relative to Team Leader responsibilities and ensure that it is included in an existing procedure, or a new procedure.
Those persons acting as Team Leaders will be qualified only after meeting the requirements for these roles as specified in the procedure.
The Manager IPS will maintain and update the qualified list of personnel who can fulfill the role.
These actions are to be complete by May 30, 1997.
Reason for Violation 9704-02 --- Example Two The root cause of the second example was inadequate work practices in the use of procedure SYS AL-124.
The system engineer and the Supervising i
Operator made judgment errors in the use of the procedure.
Contributing causes included ineffective communications between the system engineer and the Shift Supervisor, failure to perform a second pre-job brief of the procedure, and a procedure that was inadequate to the task.
The system engineer had been involved with SYS AL-124 in the past.
The l
system engineer also thought that some operator intervention of lowering i
the speed control had taken place in past runs.
This condition has been substantiated during a previous run of SYS AL-124, in December of 1996.
The system engineer was also aware that what he recommended was not specifically in the procedure, but felt that the procedure was being followed.
The Operations group was responsible for performing SYS AL-124.
The i
Supervising Operator, when presented with the decision at completing step I
6.1.4.3, had two options:
continue with the procedure as written, possibly I
resulting in another overspeed trip, or halt the procedure and place the l
equipment in a safe condition.
The Supervising Operator chose to intervene by lowering the speed controller setpoint, avoiding another possible l
overspeed trip, rather than to halt the procedure and notify the Shift Supervisor.
l l
r
Attachment to ET 97-0044 Page 8 of 14 It is evident that both the system engineer and the Supervising Operator were cognizant of their procedural performance responsibilities.
They both knew that manipulation of the speeo controller was not specifically addressed by proceaure step 6.1.4.3.
They were aware of management expectations regarding procedure
- use, but aid not perform to this expect nion.
Corrective Steps Taken and Results Achieved For Violation 9404-02 --- Example Two Immediate corrective action resulted in appropriate counseling and discipline of Operations and System Engineering personnel by their management.
Eollowing this event, the Superintendent of Operations met with all operating crews and re-empnasized his expectations for procedural compliance. These meetings were completed by March 15, 1997 The Manager of System Engineering conducted a training session with the system engineers to emphasize the role of the Shift Supervisor in regards to direction and performance of work in the plan.
Special emphasis was placed on effective three-way communication between the requester and the Shift Supervisor, prior to the start of any activity.
This action was completed on April 22, 1997 Interim corrective action resulted in "On the Spot Change" (OTSC)97-024 to procedure SYS AL-124.
This procedure change was effective in preventing
)
recurrence of an cverspeed trip The Manager of Operations provided long-term corrective action by revising SYS AL-124, to provide an optimal way of regulating the TCAEWP control system.
This procedure change was completed April 22, 1997.
Corrective Steps That Will Be Taken And The Date When Full Compliance Will Be Achieved For Violation 9704-02---Example Two:
AP15C-002, Revision 8,
" Procedure Use and Adherence" will be revised to include a definition for literal compliance to better aid personnel in the field.
The PSRC Chairman (Manager IPS) is responsible for incorporating this definition into the procedure.
This action will be complete by May 8,
- 1997, i
-.~ -.. - = _. _ - - - - -.
Attachment to ET 97-0044 Page 9 of 14 l
I Violation 50-482/9704-03:
Personnel failed to properly establish procedure SYS AL-124.
Specifically the procedure failed to j
define low speed and oil pressure parareters, and l
failed to specify actions should those parameters be exceeded.
In addition, a change was made to SYS l
AL-124 that required operators to manually open the i
trip-throttle valve and control turbine speed at approximately 2500 rpm.
This could not be accomplished due to the design of the ramp generator circuit.
" Technical Specification 6.8.1.a
- states, in
- part, that written procedures shall be established and implemented covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2.
Regulatory Guide 1.33, Appendix A,
Section 9,
requires procedures for l
performing maintenance.
System operating Procedure SYS AL-124,
" Venting the Turbine-Driven Auxiliary Feedwater Pump Oil System," Revision 1, provides guidance for post maintenance testing of the turbine-driven auxiliary feedwater pump.
Contrary to the above, on January 24, 1997, licensee personnel failed to properly establish Procedure SYS AL-124.
Specifically:
1.
The procedure contained a precaution to closely monitor the bearing oil pressure when operating the turbine at low speeds, but failed to define low speeds and low oil pressure, and failed to specify what actions were to be taken when low oil pressure was reached.
l 2.
On-The-Spot Change 97-0023 to the procedure required operators to manually open the trip-throttle valve and control turbine speed at approximately 2500 rpm.
With the goverr.or controller set at the normal position of approximately 3850 rpm, this could not be accomplished due to the design of the ramp generator circuit that attempted to accelerate the turbine from approximately 1100 rpm to the normal setting of the controller, 3850 rpm."
Admission of Violation:
Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that a violation of Technical Specification 6.8.1 occurred when licensee personnel failed to properly establish procedure SYS AL-124 by failing to define low speed and oil pressure parameters, and failing to specify actions should those parameters be exceeded.
In addition, personnel incorrectly established and attempted to implement a change to SYS AL-124 that could not be accomplished due to the design of the equipment.
Reason for Violation:
The root cause of these two examples was failure to recognize the correlation between LIMIT SWITCH 6 (LS-6), TTV position, and the speed of the TDAFWP resulted in selection of an unachievable speed.
This resulted in additional idle speed operation, not anticipated by the procedure change, and subsequent normal low oil pressure (above the low pressure alarm) due to idle operation.
The Marager Operations placed a stop work order on future performances of SYS AL-124, to remove any perceived time constraint pressure associated with completion of the LCO.
A group, consisting of the Central Work Authority
9 Attachn.ent to ET 97-0044 Page 10 of 14 I
(CWA), Shift Supervisor, System Engineering Supervisor, Operations Procedures l
Writer, System Engineer, and I&C, was then tasked with changing the procedure.
A Control Room brief cf the changed procedure was then conducted by the system engineer.
The system engineer would be the local lead test performer with the Supervising Operator being the responsible lead with the procedure.
LS-6 actuation is at a throttle position above 3000 rpm.
Below this position, the control circuitry controls at idle speed of 1100 rpm.
The change thus caused longer operation at idle speed, because achieving 2500 rpm was not obtainable.
This resulted in subsequent idle speed oil pressure.
The OTSC would have been successful if LS-6 were located lower in the throttle position of the TTV.
This was not known by the group that changed the procedure, nor is this key information captured by any documentation.
Had the procedure change recognized the correlation of LS-6 and TTV position, prolonged idle speed operation would not have occurred.
The unanticipated prclonged idle speed gave the appearance that the oil pressure concern was not l
addressed.
The caution had no explicit speed for low oil pressure.
The j
procedure performers, conscious of the caution, took the appropriate action.
This operation time at idle had no adverse affect on the TDAEWP.
Corrective Steps Taken and Results Achieved:
Procedure SYS AL-124 was revised.
The procedure revision included l
l information detailing the actuation of LS-6 while manually opening the TTV, mixed with automatic GCV function.
The procedure revision also reviewed l
the oil pressure precautions as they relate to idle speed operation.
This revision was completed on April 22, 1997.
l l
Manager of System Engineering has supplemented the TDAEWP instruction I
l manual, I/M M-021-00086, via the Vendor Engineering Technical Information Program (VETIP), to clarify manual TTV operation, mixed with automatic GCV control of the TDAEWP.
i Review of the OTSC process identified the process to be prudent and appropriate.
No programmatic deficiencies were identified, therefore no additional corrective action is warranted.
Corrective Steps That Will Be Taken And The Date When Full Compliance Will Be Achieved:
Training, detailing the actuation of LS-6, while manually opening the TTV, mixed with automatic GCV function, will be included in the Operator Training Instructions.
This training will apply to both initial and re-qualifications and include both licensed and non-licensed operators. Re-qualification training will be completed by June 30, 1997 Initial
(
training will be completed by January 30, 1998.
l i
l
. - -. =..
Attachment to ET 97-0044 Page 11 of 14 Violation 50-482/9704-04:
An operater unsuccessfully attempted to trip the turbine-driven auxiliary feedwater pump by pulling on the trip linkage.
" Technical Specification 6.8.1.a states, in part, that written procedures shall be established and implemented covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2.
l Regulatory Guide 1.33, Appendix A,
Section 3.1, requires procedures for operation of the auxiliary feedwater system.
I l
System Operating Procedure SYS AL-124, " Venting the Turbine-Driven Auxiliary Feedwater Pump Oil System," Step 6.1.5, requires the I
operator to trip the turbine driven auxiliary feedwater pump using the manual trip lever.
Contrary to the above, on January 24,
- 1997, the operator unsuccessfully attempted to trip the turbine-driven auxiliary feedwater pump by pulling on the trip linkage, causing the turbine speed to increase."
Admission of Violation:
i Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that a violation of Technical Specification 6.8.1 occurred when an operator attempted to trip the turbine-driven auxiliary feedwater pump by pulling on J
l
'the mechanical overspeed connecting rod (trip linkage).
l Reason for Violation:
l On January 24, 1997, during the third performance of SYS AL-124, a decision l
was made to trip the TDAFWP. When the Shift Supervisor entered the pump room, I
he directed the Nuclear Station Operator (NSO) to trip the TDAFWP.
The NSO, controlling speed manually with the TTV, attempted to trip the TDAEWP by pulling on the mechanical overspeed connecting rod.
He chose this method based on his physical location in the room, and also due to congestion in the room.
This attempt was not successful.
A second NSO who was in the room, made his way to the manual trip push button, located on the other side of the pump, and tripped the TDAFWP.
Operators were taught to use the mechanical push button to trip the TDAFWP.
The method to utilize the connecting rod was used successfully in the past Evidence from interviews indicates that tripping the pump by the connecting rod method was informally introduced during field training.
The TDAFWP manual only discusses using the trip button, and does not instruct the user to pull on the connecting rod.
A review of old lesson plans did not identify
(
instruction for utilizing the connecting rod method. Subsequently, it was determined tnat the Electrical Trip / Reset on the FC219 panel was also an i
acceptable method for tripping the TDAFWP.
The root cause of this event was inappropriate field training that fostered the use of an ad hoc non proceduralized trip method, A contributing factor that fostered the use of the ad hoc method is the physical lay out of the room and the difficult access to the trip push button.
It was easier to utilize the ad hoc method than to climb over, around, and through the equipment in the room to access the mechanical trip push button.
2 l
Attachment to ET 97-0044 Page 12 of 14 Corrective Steps Taken and Results Achieved:
l
- The Shift Supervisors, Supervising Operators, as well as their operating crews, were immediately informed of the proper methods for tripping the TDAEWP.
Essential Reading was developed for Operating crews instructing that only the mechanical trip push button, or the electrical trip / reset button on the FC219 panel, are acceptable methods to be used to trip the TDAFWP.
This Essential Reading was initiated on April 10, 1997.
Corrective Steps That Will Be Taken And The Date When Full Compliance Will Be Achieved:
Additional communication to appropriate personnel that ad hoc operation is unacceptable, and that equipment is to be operated per procedures, or per design will be completed by June 30, 1997 l
t i
l
{
1 l
l l
l Attachment to ET 97-0044 l
Page 13 of 14 Violation ! -482/9704-07:
A change was made to the Emergency Plan, which resulted in a decrease in the effectiveness of the plan without prior NRC approval.
l "10 CFR 50. 54 (q) permits the licensee to make changes to the l
emergency plans without prior Commission approval only if the l
changes do not decrease the effectiveness of plans and meet the standards of 10 CFR 50.47(b).
l Contrary to the above, on February 23, 1996, the licensee changed the emergency plan, which resulted in a
decrease in the effectiveness of their plan without prior NRC approval in that an emergency action level form that would have previously classified l
a particular event as a site area emergercy was changed to classify it as an Alert."
i I
Admission of Violation:
j Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees l
that a violation of 10 CFR 50. 54 (q) occurred when an editorial error during a revision process inadvertently resulted in redirecting the flow path of one decision box to the potential declaration of an ALERT, instead of leading to the intended declaration of a SITE AREA EMERGENCY j
(SAE).
Reason for the violation:
This incident occurred because an error was made during a change to the i
" Safety System Failure or Malfunction" page of the Emergency Action l
Level (EAL) flow charts.
As part of this change, several decision boxes were re-sized and realigned.
During the process of reorganizing and changing this flow chart page, an editorial error inadvertently resulted in redirecting the flow path of one decision box from leading to a SAE to leading to an ALERT.
This error was not identified during the review and approval process.
Consequently, there was a reduction in the effectiveness of the Emergency Plan without prior NRC approval.
The results of subsequent evaluation and interviews identified the root cause to be inadequate reviews performed by the initiator and the qualified reviewer.
There were two contributing factors:
The guidance in AP 15C-004, Revision 9,
" Preparation, Review, and l
Approval of Documents,"
was unclear, and allowed for varicas interpretations.
This led to an inconsistent understanding and application of the expectations concerning the required level of detail to be applied to the document review process.
AP 15C-004 also did not provide clear guidance on how to perform a j
review of a flow chart.
Compounding this, there was no tool available which would allow the initiator, or other personnel reviewing the EALs, to verify that the logic for the blocks that led to each level of classification was correct, ana had not been inadvertently changed on any of the EAL flow charts.
Interviews indicated that individuals involved in this review process varied in their perception of procedural and management expectations
[
concerning the level of detail required.
The evaluation also determined j
that there was a disparity between the perceived expectations of l
l l
Attachment to ET 97-0044 Page 14 of 14 s
preparers and reviewers.
This is potentially a generic issue with the review process, extending beyond just the review of Emergency Planning Procedures.
The Inspection Report cover letter and " Observations and Findings" section of the inspection report did identify that the Shift Superviser was not notified in a timely manner.
The root cause of this failure to effect a timely notification of the Shift Supervisor was the incorrect I
belief by Emergency Planning personnel that other EAL emergency action classification trees would have caused the correct classification of this event scenario.
This belief was corrected in discussions with the Senior Reaident Inspector on January 21, 1997.
A demonstration of the effectiveness of corrective actions to this concern about timely notification was given on January 23, 1997, when another error in the EALs was identified.
The inspection report " Observations and Findings" section identified that immediate notification and corrective action occurred in this instance.
Corrective Steps Taken and Results Achieved The error in the " Safety System Failure or Malfunction" page of the Emergency Action Level (EAL) flow charts was corrected on January 22, 1997.
- A matrix detailing all possible logical flow paths was developed.
Each classification has every possible combination of blocks listed.
l This will allow a reviewer to ensure there are no undocumented I
changes which would alter an EAL classification.
This matrix was completed March 28, 1997.
- The initiator of the form revision and the qualified reviewer were given job performance counseling in accordance with the Management Action Response Checklist (MARC) program.
This action was completed on March 26, 1997.
i Corrective Steps That Will Be Taken And The Date When Full Compliance l
Will Be Achieved
identifying the EAL matrix discussed above.
The section will also direct that the matrix be used to perform the review of the flow i
chart in order to review each possible emergency classification.
These changes will be incorporated by April 30, 1997 Until the change is incorporated, the Manager Emergency Planning will assure that the matrix is used for any revisions to the EALs.
l Information on possible generic issues, including the disparity in l
perceptions of preparers and reviewers about procedural requirements l
and management expectations concerning the level of detail required in reviews, will be presented to the PSRC on April 23, 1997.
4 l
l l
l l