ML20141E411

Notice of Violation from Insp on 970304-13.Violation Noted: ST-20C Was Not Followed,In That CR That Was Not Fully Withdrawn to Position 48 Was Selected for Movement & Shift Manager Permission Was Not Obtained Prior to Performance

ML20141E411
Person / Time
Site:	FitzPatrick
Issue date:	06/23/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20141E372	List: ML20141E369 ML20141E411
References
50-333-97-03, 50-333-97-3, EA-97-118, NUDOCS 9707010052
Download: ML20141E411 (13)

Text

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ENCLOSURE 1 NOTICE OF VIOLATION 4

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New York Power Authority Docket No. 50-333 l

James A. Fitzpatrick Nuclear Power Plant License No. DRP-59 j

EA: 97-?18 i

i During an NRC inspection conducted from March 4 to 13,1997, NRC Inspection No. 50-333/97 03 a violation of NRC requirements was identified, in accordance with t

the " General Statement of Policy and Procedure for NRC Enforcement Actions,"

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NUREG-1600. The particular violation is set forth below-Technical Specification 6.8(A)2 requires that written procedures and administrative i

policies shall be established, implemented and maintained that are recommended la Appendix A of Regulatory Guide 1.33, November 1972. Appendis A n! Regulatory Guide 1.33 requires operating procedures governing the control roo envc Jystem and administrative procedures for safe operation. Operations Surveillance Test

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Procedure (ST-20C) governs testing to verify control rod drive systen! operability; paragraph 8.1.15, in particular, governs the performance of a control rod coupling integrity check. NYPA Administration Procedure (AP) 12.03, Adrt!nistration of Operations,' Revision 9 provides direction to plant personnel concerning general practices and philosophy for safe operations. Paragraph 7.2 requires that self-checking shall be practiced when operating plant equipment and paragraph 8.17, Reactivity Management, requires independent verification of correct control rod selection and motion.

Contrary to the above, on March 3,1997, ST-20C was not followed in that a control rod that was not fully withdrawn to position 48 was selected for movement and the shift manager's permission was not obtained prior to the performance of the evolution, in addition, self-checking and independent verification of correct control j

rod selection and motion was not accomplished during this control rod manipulation, resulting in a mispositioned control rod. The consequence of this error was an unplanned, but modest reactivity addition.

This is a severity Level IV violation (Supplement 1)

Pursuant to the provisions of 10 CFR 2.201, New York Power Authority (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the receipt of this Notice of Violation and Proposed imposition of Civil Penalty (Notice). This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation: -(1) admission or denial ~of the alleged violation, (2) the reasons for the violation if admitted, and if denied, the reasons why, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. Consideration may be given to extending the response time for good cause shown.

9707010052 970623 PDR ADOCK 05000333 G

PDR

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Because your response will be placed in the NRC Public Document Room (PDR), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction. If personal privacy or proprietary information is necessary to provide an acceptable response, then please provide a bracketed copy of your response that identifies the information that should be protected and a redacted copy of your response that deletes such information. If you request withholding of such material, you must specifically identify the portions of your response that you seek to have withheld and provide in detail the bases for your claim of withhold-ing (e.g., explain why the disclosure of information will create an unwarranted invasion of l

personal privacy or provide the information required by 10 CFR 2.790(b) to support a 4

request for withholding confidential commercial or financial information). If safeguards i

information is necessary to provide an acceptable response, please provide the level of protection described in 10 CFR 73.21.

Dated at King of Prussia, Pennsylvania this 23rd day of June 1997

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j MEETING BETWEEN NRC i

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AND JAMES A. FITZPATRICK NUCLEAR POWER PLANT i

NEW YORK POWER AUTHORITY l

DOCKET NO. 50-333 MAY 8,1997

i AGENDA i

L MAY 8,1997 i

Introduction......................

Mike Colomb I

Control Rod Mispositioning i

l Event.........................

Paul Brozenich i

l September '96 Scram Lessons l e a rn e d Paul Brozenich I

i Other Human Performance l

Events......................... Dennis Kieper j

i Human Performance Review i

e Analysis /Causes................ Dave Nacamuli e Corrective Actions Initiatives and Effectiveness......... Dave Topley i

j Analysis of the Event Charlene Faison i

Summary Mike Colomb

1. > NewWrkPbwer 1# Authority

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j CRD MISPOSITIONING EVENT i-l i

Introduction / Overview i

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Contributing Factors 1

o Evolution Not Treated and Controlled as a j

Reactivity Change i

l No independent Verification l

e inadequate Communication with Shift l

Manager l

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e inadequate Self-Checking e

No Written Policy on Manipulating Equipment for Training j

l C 224*'

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I CRD MISPOSITIONING EVENT CORRECTIVE ACTIONS i

SRO/RO Removed From Licensed l

Responsibilities l

Reinforcement of Expectations l

e Stand-Down Briefing l

e Defined Controls for Rod Manipulations l

e Established Policy for On-Shift Training l

e implemented Peer Checking l

Training Conducted on Appropriate Control l

Room Lessons Learned from Industry Events in the Areas of:

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Reactivity Management e

Operating Practices e

Teamwork e

Conservative Decision-Making Review and Revision of Reactivity Management Procedures Management Observation of Control Room Conduct Coaching and Reinforcement

1. > NewYorkPower tv Authority

j SEPTEMBER 16th SCRAM i

Challenging Transient i

e Residual Bus Transfer i

e Restoration of Balance of Plant Systems l

(i.e., instrument air, closed loop cocling, feedwater and condensate)

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e Restoration of UPS (i.e., plant page, control l

rod position, precess rad raonitors, control room graphic displays) i l

l Rupture Disc-Actuation t

Management Observation of Command and Control

1. > NewWrkPbwer

& Authority 1

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l, SEPTEMBER 16th SCRAM PERFORMANCE ISSUES l

l EOP-2 Vice EOP-3 Decision RPS Inadvertently De-Energized l

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EHC Pressure Setpoint Adjustment l

Corrective Actions Pre-Startup l

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Operator Training Event Review e

AOP-1 Changes i

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Additional Corrective Actions i

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Simulator Walk-Through of September 16 l

Event e

Operations Simulator Instructor Added to Post-Trip Review Team Summary h

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HUMAN PERFORMANCE EVENTS

.i-MAJOR CORRECTIVE ACTIONS i

Human Performance Events Performed Root Cause Analysis on Events i

i Work Planning and Scheduling improvements i

i Procedure Revisions l

Communicated Lessons Learned / Maintaining a j

Questioning Attitude i

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HUMAN PERFORMANCE REVIEW ANALYSIS /CAUSES 1

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l-Background and Charter l

e Cross Disciplinary Team e

Two Objectives j

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Methodology e

Use of Industry Guidance on Human l

i Performance Excellence l

e Reviewed Quarterly Trend Reports i

e Selected Plant Events and Compared l

Behavior Characteristics l

e Conducted Employee Interviews l

l Summary of Findings and Recommendations i

e Ownership i

e Coaching e

Self-Checking j

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Root Cause Team Composition l

Performance Enhancement Review l

Committee i

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1. > NewYorkPbwer l

4f Authority i

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CORRECTIVE ACTIONS I-INITIATIVES AND EFFECTIVENESS i

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Objective o

Zero Events Caused by Personnel Error l

How Are We Going to Get There l

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18 Month Error Rate Trend Decreasing e

Deeper Look at Recent Performance Reinforcement of Nuclear Professionalism e

Human Performance Team Presentations e

Management Seminar j

All-Hands Meetings e

l Initiatives e

Human Performance Team Assessment j

e Coaching and Mentoring j

e Peer Checking j

e Strengthened Management Observation i

Program l

e Performance Enhancement Review Committee l

e Focus on Critical Activities l

e Maintaining Priority and Focus on Human Performance t

1. > NewYorkPower l

& Authority i

4, CORRECTIVE ACTIONS l'

INITIATIVES AND EFFECTIVENESS l

Accomplishments to Date i

e Working Group Participation Questioning Attitude j

e Coach-of-the-Day, Coach-of-the-Week j

Affecting Change i

Measuring Effectiveness j

e Findings From Management Observation, j

Coaching Programs e

Coach-of-the-Day Presentations i

e Coach-of-the-Week Presentations e

Monthly Department Assessment of Personnel Errors 3

e Annual Human Performance Assessment M

i ify

i, ANALYSIS OF THE EVENT i

Identification s

Promptly Restored Control Rod to Correct Position Corrective Action l

l Intent i

4 Minimal Safety Significance e

Technical Specification Thermal Limits Not Exceeded Past Events l

1. > NewYorkPbwer er Authority u

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