ML20147B340

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NRC Enforcement Conference at Plant on 911020 Re Turbine Startup
ML20147B340
Person / Time
Site: Salem PSEG icon.png
Issue date: 02/04/1992
From:
Public Service Enterprise Group
To:
Shared Package
ML20147B009 List:
References
FOIA-96-351 NUDOCS 9701310153
Download: ML20147B340 (33)
v • d • e


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FEBRUARY 4, 1992 NRC ENFORCEMENT CONFERENCE 4

AGEN]A 1

INTRODUCTION S. E. MILTENBERGER

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YP G CHIEF NUCLEAR OFFICER NRC FINDINGS S MEETING S. LaBRUNA

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OBJECTIVES VP - NUCLEAR @ERATIONS OVERVIEW OF 11/9/91 C. A. VONDRA TURBINE / GENERATOR EVENT GN - SM MTIMS SOLENOID REPLACEMENT C. A. VONDRA COMMITMENT GN - SM MTIMS OCTOBER 20, 1991 TURBINE V. J. POLIZZI STARTUP WERATIONS MANAGER - SALEN BROADER ASSESSMENT C. A. VONDRA GN - SALEN OPERATIONS l

REGULATORY ASSESSMENT F. X. THOMSON MANAGER - LICENSING &

REGULATION CONCLUSION S. LaBRUNA YP - NUCLEAR OPERATIONS

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE i

NRC FINJ:: HGS i

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eAPPARENT VIOLATION OF TECH SPEC 6.8.1 IN THE i

AREA 0F PROCEDURAL COMPLIANCE

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e SPECIFICALLY:

- IOP-3 WAS SIGNED OFF AS COMPLETED AND TURBINE STARTUP CONTINUED WITHOUT THE EFFECTIVE COMPLETION OF THE OVERSPEED PROTECTION CIRCUIT (OPC)

TEST

-FAILURE TO IDENTIFY S IMPLEMENT CHANGES TO THE PROCEDURE TO CORRECT A PERCEIVED PROCEDURAL DEFICIENCY ADDITIONAL CONCERNS eINVOLVED FIVE LICENSED OPERATORS e MULTIPLE LEVELS OF OVERSIGHT G CONTROL DID NOT PREVENT THIS EVENT 92:C

-t' 2/4/92

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE MEETING OBJECT::VES i

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o SHARE PSEGG'S UNDERSTANDINGS & PERSPECTIVE OF j

THE OCTOBER 20TH STARTUP j

ePROVIDE INSIGHTS INTO PSESG'S CORRECTIVE ACTION PLANS l

ePROVIDE A STATUS OF PSEGG'S PERSONNEL PERFORMANCE IMPROVEMENT PROGRESS AND OUR j

ASSESSMENT OF OCTOBER 20TH AS AN ISOLATED i

OCCURRENCE i

eALTHOUGH PROCEDURE COMPLIANCE STANDARDS WERE i

NOT ADHERED TO WE EXPECT TO DEMONSTRATE THAT l

ESCALATED ENFORCEMENT IS NOT APPROPRIATE i

l eREINFORCE YOUR CONFIDENCE IN PSEGG'S ABILITY TO EFFECTIVELY ADDRESS THIS ISSUE AND PROVIDE i

CONTINUED SAFE OPERATION OF THE SALEM & HOPE CREEK GENERATING STATIONS i

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SALEM II OCT 20TH 3/U ENFORCEMENT CONFERENCE OVERVIEW OF TURB::hE/ GENERATOR EVENT NOVEMBER 9,

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eROUTINE 30 DAY TURBINE TEST IN-PROGRESS l

e TURBINE TRIP G REACTOR TRIP (ALL VALVES CLOSE) i o TURBINE VALVES BEGIN TO RE-OPEN & STEAM RE-ADMITTED e THREE SO' CNOID VALVES FAILED ALLOWING TURBINE OVERSPEED WHEN GENERATOR BREAKERS OPENED eTURBINE OVERSPEED OF 2700 - 2900 RPM DAMAGES

TURBINE, GENERATOR S CONDENSEFi eGENERATOR LEAKING HYDROGEN GAS AND SEAL OIL,
IGNITED, RESULTING IN FIRE i

eRAPID RESPONSE BY FIRE PROTECTION EXTINGUISHED FIRE e PLANT OPERATIONS COMMENCED G COMPLETED SAFE SHUTDOWN

  • ALL SAFETY SYSTEMS FUNCTIONED AS DESIGNED 92501-13 2/ 4, s2

SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE OVERVIEW OF "UR3INE/ GENERATOR EVENT NOVEMBER 9,

1991 l

i MISSED OPPORTUNITY l

eFAILURE TO REPLACE TURBINE SOUJNOID VALVES l

DURING THE MAY 1991 MAINTENANCE OUTAGE, AS COMMITTED TO IN AN LER RESPONSE l

eFAILURE TO IDENTIFY THE OPC SOLENOID FAILURES l

DURING THE OCTOBER 20TH TURBINE STARTUP, DUE j

TO:

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- MISINTERPRETATION OF TEST RESULTS

- PERCEIVED PROCEDURAL ERRORS

- PROCEDURAL NONCOMPLIANCE 325:.

3. - r

I SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE S0_EN0IJ RE3 _ACEMENT COMM::TMENT

  • SALEM UNIT I SEPTEMBER 1990 STARTUP IDENTIFIED OPC SOLENOID PROBLEM

- OPC 20-1 G OPC 20-2 SOLENOIDS REPLACED

- 20 ET SOLENOID REPLACED

- PM FOR SOLENOID VALVES ESTABLISHED eLER COMMITMENT

- ENTERED INTO ACTION TRACKING SYSTEM (ATS)

- UNIT II OPC S 20ET SOLENOID VALVES REPLACEMENT

- NEXT GUTAGE OF SUFFICIENT DURATION eWORK ORDER WRITTEN G ATS ITEM CLOSED

- WORK ORDER IDENTIFIED JOB AS LER COMMITMENT

- PLACED ON FORCED OUTAGE LIST

- PLACED ON UNIT II STH REFUELING OUTAGE LIST l

i 32501-1, 2, i el

5' SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE

{

SOLENOID REP _ACEMENT COMMITMEC

  • DISCRETIONARY MANAGEMENT SHUTDOWN TO COMPLETE SAFETY & RELIABILITY RELATED WORK i

i eDECISION MADE NOT TO INCLUDE IN MAY MAINTENANCE OUTAGE

- NOT IDENTIFIED AS LER COMMITMENT ON FORCED OUTAGE LIST

- NOT A KNOWN FAILURE

- SOLEN 0 IDS TESTED ON RETURN TO SERVICE

- CONNECTION TO SEPTEMBER 1990 SOLENOID FAILURES NOT MADE eCORRECTIVE ACTIONS

- NAP-30 ISSUED TO STRENGTHEN COMMITMENT MANAGEMENT PROCESS

- ATS ITEMS WILL ONLY BE CLOSED BY COMPLETION OF TASK

- COMMITMENT ITEMS WILL BE UNIQUELY IDENTIFIED ON WORK ORDERS & OUTAGE LISTS

- PERSONNEL INVOLVED APPROPRIATELY COUNSELED

- GM LETTER TO STATION MANAGEMENT PERSONNEL STRESSING THE SIGNIFICANCE OF THOROUGH COMMUNICATIONS nan-e

SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE j

SE_F IDENTIFICATION OF l

OCTOBER 20TH TEST DEFICIENCIES

}

e TEST DEFICIENCY CONCERNS PROACTIVELY IDENTIFIED

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FROM WITHIN THE OPERATIONS DEPARTMENT 1

e INVESTIGATION PROMPTLY INITIATED BY OPERATING ENGINEER i

eTHE DETERMINATION WAS MADE THAT A POTENTIAL TEST FAILURE EXISTED eINVESTIGATION IDENTIFIED PROCEDURAL COMPLIANCE ISSUES

  • PRELIMINARY FINDINGS WERE PROMPTLY COMMUNICATED TO THE NRC ON THE SAME DAY 32i;i e*

i SALEM II UCT 20TH S/lJ ENFORCEMENT CONFERENCE OCTOBER 20, 1991 l

TURB::NE STAR UP eDEFICIENT CONTROL ROOM PERFORMANCE eSEQUENCE OF EVENTS eOPERATOR UNDERSTANDING OF TEST e ASSESSMENT OF OPERATOR PERFORMANCE eCORRECTIVE ACTIONS eOPERATOR PERFORMANCE RECENT TRENDS

  • CONCLUSIONS e

j-SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE OCTOBER 20, 1991 i

TURBINE STARTUP.

1 i

{

DEFICIENT CONTROL ROOM PERFORMANCE e FAILURE TO FULLY UNDERSTAND & RESOLVE AN APPARENT OPC TEST DISCREPANCY eFAILURE TO INITIATE & COMPLETE A PROCEDURE REVISION PRIOR TO CONTINUING ROOT CAUSE:

oPERSONNEL ERROR, IN THAT PERSONNEL FAILED TO FOLLOW ESTABLISHED STANDARDS OF PROCEDURAL COMPLIANCE 32i. ; e-1.

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE OCTOBER 20, 1991 SEQUENCE OF EVENTS l

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l eTURBINE REMOVED FROM SERVICE 10/18/91

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- FOR CHLORIDE CLEANUP TO STAY WITHIN EPRI GUIDELINES

- REACTOR MAINTAINED CRITICAL IN MODE 2

- STEAM GENERATOR LEVEL CONTROL IN MANUAL e PLANT CONDITIONS (4X12 SHIFT, OCT 20, 1991)

- 10% REACTOR POWER

- TURBINE LATCHED 92ECi-1 2,4, 92

l j

SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE OCTOBER 20, 1991 SEQUENCE OF EVENTS l

l e IMPLEMENTING IOP-3 " HOT STANDBY TO MINIMUM l

LOAD"

- STEP 5.310F IOP-3 REFERS OPERATORS TO OP-III-1.3.1 " TURBINE GENERATOR OPERATION"

- STEP 5.1.13 0F OP-III-1.3.1 DIRECTS OPERATOR TO PERFORM OVERSPEED PROTECTION CIRCUIT l

(OPC)

TEST

- NO SPECIFIC SIGNOFF FOR COMPLETION OF STEPS IN OP-III-1.3.1

- OP-III-1.3.1:

CATEGORY II PROCEDURE THAT CONTAINED SOME DISCRETIONARY STEPS l

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IOP-3 i

5.31 Place turbine on line IAW i

j OP III-1.3.1, Turbine generator Operation.

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OP III-1.3.1 5.1.13 INSERT ke'y in the OPC (OVERSPEED PROTECTION

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CONTROLLER) key switch.

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TURN the key to the TEST position and a.

OBSERVE that the Interceptor Valves close rapidly.

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RETURN the switch to normal IN SERVICE Position.

j VERIFY that the Interceptor Valves reopen.

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OPC TEST ACTIVITIES & INTERACTIONS i

  • REACTOR OPERATOR #1

- PERFORMED OPC TEST

- 0BSERVED RESULTS

- R E Q U E S T E D A S S I S T A N C E.F R O M R E A C T O R OPERATOR #2

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eREACTOR OPERATOR #2

- PERFORMED TEST j

- 0BSERVED RESULTS o REACTOR OPERATORS #1 S #2

- DISCUSSED TEST WITH NUCLEAR SHIFT SUPERVISOR i

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1 32EC -2 2,4 s2

SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE 1

OCTOBER 20, 1991 J

SEQUENCE OF EVENTS i

I OPC TEST ACTIVITIES & INTERACTIONS (CONT) 4 j

eOPERATING ENGINEER i

- OVERHEARD DISCUSSION j

- 0FFERED INFORMATION CONCERNING PROPER KEY l

POSITION

- OFFERED THAT PROCEDURE UPGRADE WOULD ADDRESS PROCEDURAL ENHANCEMENTS

- CONTINUED WITH OTHER CONTROL ROOM AREA l

ACTIVITIES (IN G OUT OF AREA)

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e SENIOR NUCLEAR SHIFT SUPERVISOR (SNSS)

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- RETURNED FROM TURBINE DECK j

- 0VERHEARD THE END OF THE CONTROL ROOM DISCUSSION WITH THE OPERATING ENGINEER i

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- CONCLUDED THE PROBLEM TO BE PROCEDURAL G PREVIOUSLY IDENTIFIED

- ORDERED STARTUP TO CONTINUE j

eOPERATING ENGINEER

- CHECKED WITH SNSS CONCERNING OPC TEST (SNSS RESPONDED - NO) 4

- 0BSERVED TURBINE AT RATED SPEED

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- BELIEVED TEST TO BE DISCRETIONARY 1

I 92EC1-3 2/4/92

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE OCTOBER 20, 1991 l

OPERATOR UNDERSTANDING 0F TEST 1

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eSHIFT LICENSED PERSONNEL ASSUMED j

PREVIOUSLY IDENTIFIED PROCEDURAL PROBLEMS EXISTED G WERE BEING PROCESSED FOR CORRECTION i

j eNO LICENSED PERSONNEL UNDERSTOOD THE l

OPC FUNCTION TO BE INOPERABLE l

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e SENIOR NUCLEAR SHIFT SUPERVISOR AND j

OPERATING ENGINEER DID NOT REALIZE OPC l

TEST WAS ACTUALLY PERFORMED i

92EC1-4 2sde92

SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE ASSESSMENT OF OPERATOR PERFORMANCE OCTOBER 20TH OPERATOR PERFORMANCE eINCONSISTENT WITH ESTABLISHED STANDARDS eINCONSISTENT WITH DEMONSTRATED DEPARTMENT ADHERENCE TO STANDARDS e AREAS OF UNACCEPTABLE G INCONSISTENT PERFORMANCE

- PROCEDURAL COMPLIANCE

- COMMUNICATIONS

- ATTENTION TO DETAIL

- SUPERVISORY OVERSIGHT eROOT CAUSE l

- PERSONNEL ERROR IN THAT PERSONNEL FAILED TO i

FOLLOW ESTABLISHED STANDARDS OF PROCEDURAL

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COMPLIANCE a

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE j

CORRECTIVE ACTIONS i

i eMANAGEMENT CONSIDERATIONS FOR DISCIPLINARY j

ACTIONS

- TIMELINESS

- REFOCUS STAFF TO VALUES i

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- MAXIMIZE LESSONS LEARNED k

-INDIVIDUAL RESPONSIBILITY ACKNOWLEDGED AND ACCEPTED i

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- WELL RECEIVED BY ALL OPS PERSONNEL

- ASSURE CORRECTION OF BEHAVIORS WHICH COULD l

LEAD TO A SIMILAR OCCURRENCE l

eDISCIPLINARY ACTIONS i

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- REACTOR OPERATORS COUNSELLED f

- NSS, SNSS AND OPERATING ENGINEER DEVELOPED j

RERSONNEL CORRECTIVE ACTION PLANS (OPERATING j

ENGINEER CURRENTLY ASSIGNED OUTSIDE QPERATIONS DEPT) 1

(

- NSS AND SNSS DEVELOPED AND CONDUCTED LESSONS j

LEARNED TRAINING FOR ALL LICENSED PERSONNEL l,

AND TRAINING CENTER STAFF

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325C1-35 2, A u

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE CORRECTIVE ACTIONS

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I eLETTER ISSUED TO ALL OPS PERSONNEL ADDRESSING j

PROCEDURAL COMPLIANCE e VP NUCLEAR OPS / GENERAL MANAGER SHIFT MEETINGS f

COMPLETED l

- ROLES S RESPONSIBILITIES

-INDIVIDUAL & TEAM PERFORMANCE

- MANAGEMENT EXPECTATIONS

- LLSSONS LEARNED

- CONFIDENCE FOR THE FUTURE l

e TRAINING i

- LESSONS LEARNED

- EHC REVIEW

- ENHANCE SIMULATOR EFFECTIVENESS I

- CONDUCT OF OPERATIONS EXPANDED A LOG TAKING A WORK STANDARDS HANDBOOK l

A OPERATIONS DOCUMENTS eUPDATED ANNUAL LETTER FOR SHIFT MANAGEMENT RESPONSIBILITY FOR STATION OPERATION l

92EC1-13 2/4/92 k

3ALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE CORRECTIVE ACTIONS eUPGRADE OF TURBINE OPERATING G. TESTING PROCEDURES eCONTINUE THOROUGH ROOT CAUSE ANALYSIS WITH EFFECTIVE CORRECTIVE ACTION eCOMPLETE BALANCE OF INPO PERSONNEL ERROR AWARENESS ROLLDOWN e0PS MANAGER MEETINGS WITH EACH OPERATING SH!?T

- 1/2 DAY Df 92VSSION OF PHILOSOPHICAL &

PRACTICAL ISSUES OF PROCEDURAL COMPLIANCE e HPES EVALUATION OF OCT 20TH STARTUP eREGULAR VP NUCLEAR OPS / GENERAL MANAGER SHIFT MEETINGS eTEAM BUILDING TRAINING e ONE ON ONE OPS MANAGER S SENIOR SHIFT SUPERVISOR MEETINGS 92ECi-16 2/ 4< 92

SALEM II OCT 20TH S/IJ ENFORCEMENT CONFERENi.,E OPERATOR PERFORMANCE RECENT TRENDS IMPROVING TREND HAS BEEN REALIZED eMANAGEMENT ASSESSMENTS

- STRONG PROCEDURAL COMPLIANCE, COMMUNICATIONS l

G SUPERVISORY OVERSIGHT

- EVENT RESPONSE IS PROMPT AND CONSERVATIVE l

- ACTIVITIES ARE WELL PLANNED AND EXECUTED l

- PLANT SAFETY IS NOT COMPROMISED TO MEET SCHEDULE

- THOROUGH G EFFECTIVE INCIDENT IDENTIFICATION S FOLLOW THROUGH e GUALITY ASSURAtise REVIEWS

- DEDICATED TO SAFETY"

" ATTENTION TO DETAIL IS NOTEWORTHY"

",KNOWLEDGABLE ABOUT RESPONSIBILITIES" eINPO EVALUATIONS

- SIMULATOR PERFORMANCE

- OPERATOR PERFORMANCE oOPERATOR SURVEY eNRC INSPECTIONS

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE i

OPERATOR PERFORMANCE RECENT TRENDS i

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PERFORMANCE ON NOVEMBER 9, 1991 i

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eCONSISTENT WITH ESTABLISHED STANDARDS l

- DELIBERATE j

- ACCURATE

-IN ACCORDANCE WITH PROCEDURES i

eASSESSMENT OF THE OPERATORS i

- WELL TRAINED 1

1

- EFFECTIVELY FOLLOWED THE EMERGENCY OPERATING PROCEDURES

- CORRECTLY CLASSIFIED THE EVENT IN ACCORDANCE WITH THE ECG j

- ALL REQUIRED NOTIFICATIONS & REPORTS WERE MADE IN A TIMELY MANNER I

- ACTIONS TAKEN WERE PRUDENT & COMMENSURATE l

WITH INDICATIONS & PROCEDURES I

- NO INDICATION OF INCORRECT OR INAPPROPRIATE i

ACTIONS THAT INITIATED OR COMPLICATED THE EVENT i

92EC1-8 2/4/92 a

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE OCTOBER 20"H OPERATIONS CONC _US::0NS i

{

eMINIMAL SAFETY SIGNIFICANCE 4

- FAILURE TO COMPLETE OPC TEST PROPERLY WAS A j

MINIMAL CHALLENGE TO REACTOR SAFETY SYSTEMS

- DID NOT CAUSE TURBINE OVERSPEED

- IN THE AGGREGATE, OCTOBER 20TH PERFORMANCE WAS AN ANOMALY l

i ePROMPT EFFECTIVE CORRECTIVE ACTIONS HAVE BEEN TAKEN AND WILL REQUIRE CONTINUED REINFORCEMENT i

4 j

ePAST EFFORTS HAVE SHOWN SIGNIFICANT j

IMPROVEMENTS i

I 00PERhTIONS DEPARTMENT HAS LEARNED AND GROWN l

FROM THIS EVENT 1

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}

92EC1-29 2s4/s2 i

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SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE BROADER ASSESSMENT OF OCTOBER 20, 1991 l

e CANNOT FOCUS OUR ANALYSIS S CORRECTIVE ACTIONS ONLY ON OPERATIONS e PERSONNEL PERFORMANCE G WORK STANDARDS HAS BEEN l

G WILL CONTINUE TO BE A MAJOR FOCUS WITHIN

{

SALEM STATION S THE ENTIRE NUCLEAR DEPARTMENT eCORRECTIVE ACTIONS

- ROLLDOWN OF LESSONS LEARNED TO ALL PERSONNEL i

HAS BEEN COMPLETED l

- APPLY OPERATIONS CORRECTIVE ACTIONS TO HOPE CREEK OPERATIONS l

-INITIATED HPES INVESTIGATION INTO OCTOBER j

20TH STARTUP

- REVISION AND UPGRADE TO TURBINE TESTING PROCEDURES

- VP NUCLEAR OPS / GENERAL MANAGER MEETINGS WITH

'i MAINTENANCE PERSONNEL i

A PROCEDURAL COMPLIANCE

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A WORK STANDARDS ADHERENCE

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A VISION S VALUES i

- CONTINUE TO BUILD ON S REINFORCE ESTABLISHED j

IMPROVEMENT PROGRAMS 92EC1-24 2/4,92

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SALEM II OCT 20TH 3/U ENFORCEMENT CONFERENCE ONGOING IMPROVEMENT PROGRAMS o SNSS DAILY MEETING WITH PLANT MANAGERS j

ePROCEDURE UPGRADE PROJECT e VISION ROLLDOWN eWORK STANDARDS COMMUNICATIONS / MONITORING i

  • 0FF HOUR INSPECTIONS S HOUSEKEEPING TOURS eREWORK ACCOUNTABILITY eROOT CAUSE TRAINING eSALEM REVITALIZATION e DAILY ACCOUNTABILITY MEETINGS o PERSONNEL PERFORMANCE ENHANCEMENT PANELS (PEP) e HPES VOLUNTARY REPORTING S EVENT ANALYSIS eTEAMWORK AWARDS e INPO PERSONNEL ERROR AWARENESS ROLLDOWN 92EC1-23 2/.1,.42

~

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3ALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE PLANT PERSONNEL PERFORMANCE IMPROVEMENTS eMANAGEMENT ASSESSMENTS

- WORK STANDARDS MONITORING

- PERFORMANCE INDICATORS

- ACCOUNTABILITY MEETINGS eLICENSEE EVENT REPORTS ePLANT RELIABILITY IMPROVEMENTS eSCRAM RATE IMPROVEMENTS

  • PROCEDURE UPGRADE PROGRESS o EXPOSURE & CONTAMINATION EVENTS eINPO ASSESSMENTS 1

eNRC VIOLATIONS eNRC INSPECTIONS WE ARE ON A COURSE FOR HIGHER LEVELS OF EXCELLENCE 1'

32EC:-15

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i SALEM II UCT 20TH S/U ENFORCEMENT CONFERENCE i

PERSONNEL ERROR LER PROCEDURAL NON-COMPLIANCE i

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4 SALEM II OCT 20TH S/U ENFORCEMENT CONFERENCE REGULATORY ASSESSMENT l

NRC VIOLATION:

FAILURE TO FOLLOW ESTABLISHED PROCEURES ePSEGG DOES NOT DISPUTE THE VIOLATION

  • SEVERAL MITIGATING FACTORS APPLY:

- COMPREHENSIVE CORRECTIVE ACTIONS TAKEN/ UNDERWAY

- MINIMAL SAFETY SIGNIFICANCE

-IMPROVING TRENO IN PERSONNEL PERFORMANCE

-ISOLATED CASE OF DEFICIENT PERFORMANCE

- OPERATIONS DEPARTMENT SELF IDENTIFICATION OF l

ISSUE: GUESTIONING ATTITUDE DEMONSTRATES EXPECTED BEHAVIOR

- OPEN, PROACTIVE AND COMPREHENSIVE INVESTIGATION l

OF DEFICIENCY i

- PROMPT NOTIFICATION OF NRC oPAST PERFORMANCE ON IDENTIFICATION AND CORRECTIVE l

ACTIONS FOR DEFICIENCIES HAS BEEN PROACTIVE AND EFFECTIVE eBASED ON MITIGATING FACTORS PSEGG BELIEVES THAT l

ESCALATED ENFORCEMENT SHOULD NOT BE APPLIED TO THIS ISSUE saect-aa 2y, 33 4

/*"%g UNITED STATES

'g NUCLEAR REGULATORY COMMISSION i-E OFFICE OF PUBLIC AFFAIRS, REGION I

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475 Allendale Road, King of Prussia, Pa.19406 Tel. 215-337-5330 No.1-92-13 March 18,1992 Contacts: Diane Screnci Karl Abraham NRC STAFF CITES PSE&G FOR SALEM UNIT 2 NUCLEAR PLANT WORKERS NOT FOLLOWING l

PROCEDURES, CONTRIBUTING TO SEVERE DAMAGE OF THE TURBINE-GENERATOR KING OF PRUSSIA, PA--The Nuclear Regulatory Commission staff has cited Public Service Electric and Gas of New Jersey (PSE&G) for two violations of NRC-required procedures, saying that these violations, along with other factors. contributed to the catastrophic failure of the turbine-generator of Salem Unit 2 at Hancocks Bridge, NJ, on November 9,1991.

No one was injured in the fragmentation of the turbine and the ensuing nre in the electric generator.

The plant's reactor system was not involved. PSE&G has estimated it will cost S75 million to restore the plant to service.

The two violations are: (1) failure to follow procedures for turbine startup on October 20,1991, when a test disclosed the failure of certain key valves to operate properly. The operating crew continued with preparations for startup and neither the Unit 2 shift supervisor, the senior shift supervisor nor the operations engineer on that shift took action to assure that the appropriate procedure was followed. (The failure of thes valves led to the destruction of the turbine 3 weeks later); and, (2) failure to change the procedure in accordance with the applicable review and authorization process on October 20.1991, when the operating crew ran into difficulty using the procedure stipulated for the test of the valves.

In a letter to PSE&G, Thomas T. Martin, Regional Administrator of NRC Region I, said, "The NRC is... concerned with your failure to adhere to the commitment documented in Licensee Event Report No.90-030, dated October 9,1990, to replace the solenoid valves at Unit 2 during the next outage of suf6cient duration due to the problem identined at Unit 1 in September 1990. These valves were not replaced during the planned outage in May 1991, which was of suf6cient duration to accomplish the replacement. Weaknesses in your commitment tracking process contributed to the valves not being replaced during the May 1991 outage.

Mr. Martin also said, "The NRC recognizes that corrective actions have been taken or planned to prevent recurrence of such violations. These actions, which were described at the enforcement conference, as well as in a Licensee Event Report, included, but were not limited to: (1) development of a personal f

corrective action plan by each of the five involved licensed individuals; (2) enhanced training of operators I

relative to the expected conduct of operations; (3) issuance of a letter to all operations personnel regarding procedural compliance; (4) conduct of shift meetings by management with all staff regarding their roles and responsibilities; and (5) upgrade of procedures."

(more) 1

~ _. - - = -.

. -. - - He also informed the utility why no fine was being levied in this case. "In making this determination to mitigate the civil penalty, the NRC decided that: (1) since the violation was identified and reported to the NRC by your staff,25% mitigation of the base civil penalty for this factor is warranted; however, full l-mitigation is not warranted because this was a self-disclosing event; (2) your corrective actions, as described herein, were considered prompt and extensive, and therefore,50% mitigation of the base civil l

penalty on this factor is warranted; (3) your past performance in the operations area specifically, reduction l

in personnel errors and overall control room performance, warrants 50% mitigation of the civil penalty; and l

(4) although you had prior notice of potential problems with the mechanical binding of solenoid valves because of a similar problem at Unit 1 in September 1990, no adjustment of the civil penalty on this factor is warranted because the primary issue involved in this case is the performance of the operators rather than the maintenance of the equipmeitt (solenoids). The other escalation and mitigation factors were considered, and no adjustment based on these factors was warranted since the violation did not involve multiple examples nor exist for an extended duration," Mr. Martin's letter said.

PSE&G was given 30 days to respond to each of the violations, by giving "(1) the reason for the violation; or if contested, the basis for disputing the violation, (2) the corrective steps that have been *.aken and the results achieved, (3) the corrective steps that will be taken to avoid further violations, and (4) the date when full compliance will be achieved."

The State of New Jersey has been informed of this enforcement action.

d e

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_.___..____.__...._.m_

...._--_..____.m JOSEPH R BIDEN Ja

maaan, linited $tates $tnatt WASHINGTON. DC 20510-0802 April 2, 1992 Dr. Ivan Selin Chairman U.S. Nuclear Regulatory Cosmtission Washington, DC 20555

Dear Mr. Chairman:

I am stunned by the Nuclear Regulatory Cossaission's (NRC) decision not to impose penalties on the Sales nuclear plant as a result of the turbine generator destruction in

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November, 1991.

This decision appears to be based on a very restricted view of the turbine explosion, and can only i

reinforce the public's perception that the NRC fails to

,.emand the highest level of safety.

It is an understatement to call the turbine explosion a serious event.

Seventy-five million dollars in damage was incurred by the utility as a result of the explosion.

The 4

force of the explosion was strong enough to blast shards of turbine blades through the thick turbine casing and throw them up to three hundred yards away.

In addition, steam generator tubes were shredded and a fire developed.

While the specifics of the blast are serious, perhaps the most disconcerting aspect of the explosion was that it was preventable.

But your agency's decision to impose no penalties on Prblic Service Electric and Gas (PSE&G) appears to ignore this fact as well as many others.

A review of actions and inactions, as documented by your own review team, that led to the accident shows many serious shortcomings in the operation of the Salem plant.

First, the Augmented Inspection Team (AIT) sent to Salama after the accident found that "PSE&G missed valuable opportunities to prevent the Salem Unit 2 turbine generator failure.... Insufficient priority and importance was as, signed to the verification of operability and replacement of solenoid valve at Salem Unit 2."

In addition, the team found that the utility ignorsd i

earlier warnings of problems with the solenoid valves.

An information notice sent by the NRC " identified several solenoid valve problems, including applications in turbine trip control systems....The NRC found D9. indication that the licensee had directed m artention or priority to addressing f

the implications of this information... as of the date of this occurrence." (emphasis added)

)i DM9N 9F

1 i

Perhaps the most shocking aspect of the sequence of 4

l events is that the utility had found a similar problem at another reactor at the same facility, the Salem 1 reactor.

The utility initially took on the responsibility to prevent a i

problem at the Salem 2 reactor by promising the NRC to j

replace the valves in question during fuel outage scheduled for May, 1991.

[

However, the inspection team found that " work was deferred... due to management decision that may have been j

caused by a defician'cy in commitment tracking".

No further explanation was provided as to why management decided to put off replacing the valves, what factors went into that l'

decision, or why the NRC failed to detect that the valves i

were not replaced.

l Finally, the inspection team documented that test results from October 20, 1991 showing that the valves were not working properly were ignored by supervisory personnel.

1 This was not the decision of a single person, but rather i

several personnel, including " licensed operators, a shift i

supervisor, a senior shift supervisor, and a senior j

operations engineer."

l So, in summary, according to the inspection team sent in j

the aftermath of the accident, PSEEG 1) ignored warnings from the NRC that the solenoid valves were troublesome in other l

plants, 2) ignored the lessons of their own experience with the valves, 3) failed to follow through on commitments to replace the valves, and 4) ignored test results which showed that the valves in question were not working preperly.

With the findings of the inspection team's report, it is inconceivable that the NRC believes no penalty is justified.

jl The reasons provided for the absence of a penalty are not convincing.

l In deciding not to impose any penalties, your agency i

noted that " corrective actions have been taken or olanned to prevent recurrence of such violations." (emphasis added)

To l

be blunt, I see no basis for confidence in PSE&G's planned future actions in light of their failure to fulfill past commitments related to the valves.

In addition, the unstated amount of penalties was l

reduced to zero through a series of three "mitigations".

The first reduced the unknown penalty by 25 percent because the utility told the NRC, on its own, that a turbine on the roof i

of the building had exploded, showering the facility with j

i metal debris.

To suggest that a utility can receive credit for reporting an event that would be impossible to hide is a j

ludicrous policy.

1 i

l

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l Another mitigation reduced the unstated penalty by l

one-half because of "past performance in the operations area l

specifically, reduction in personnel errors and overall

)

control room performance...."

I cannot fathom the reasoning behind this reduction since personnel errors and operating procedure failures clearly contributed to the explosion.

And j

those errors were not the result of a single decision; they i

were a series of decisions spread out over several months.

l I would also note that this seems to represent a recurrence of a problem cited by the NRC years ago.

In a Systematic Assessment of Licensee Performance (SALP) report j

j on Salem's performance in 1988, the report specifically noted

)

"further improvement in attention to detail... is needed to i

reduce the frequency of... missed surveillance tests."

In addition, a 1989 SALP overview of the Salem's j.

operations found that " reduced management and supervisory 1

oversight of maintenance activities resulted in laxness in i

the implementation of the maintenance program....the j

long-standing nature of the (surveillance) problem and the j

inability to promptly correct the problem indicates a j

weakness in management attention to this issue."

l l

Based on the AIT report on last November's explosion, it appears this aspect of the plant's operation continued to be l

problematic.

Yet your agency elected to reduce the penalties l

based on these shortfalls to nothing.

i A third reason the penalty was zero was because j

"although you [ Salem) had prior notice of potential problems with the mechanical bi.. ding of solenoid valves because of a similar problem at Unit 1 in September, 1990, no adjustment i

to the civil penalty is warranted because the primary issue involved in this case is the performance of the operators, rather than the maintenance of the equipment."

Again, this reasoning is remarkable.

In effect, the NRC has said that because Salen kept the plant from disaster and put out the fire -- crucial goals to be sure -- the utility did its job.

But this completely ignores the point that the explosion and fire could have and should have been prevented by the utility in the first place.

Under the agency's reasoning, it is acceptable to court disaster, as long as the disaster does not actually occur.

With regard to nuclear energy in particular, this approach cannot improve weak public confidence in this already-troubled technology.

/

i But beyond the faulty reasoning, as I see it, used to

)

j reduce the penalty based on operations performance, I am at a loss to understand why your agency decided to ignore maintenance problems completely.

The NRC and PSEEG both knew

]

of problems with the valves.

A calculated risk was taken in

)

deferring replacement of the valves until the next scheduled shutdown, and a further risk was incurred when that replacement was pushed back to an even later scheduled shutdown.

And yet any penalty related to maintenance of the i

l plant's equipment is simply swept off the table.

I question whether PSE&G should'be so easily exonerated for their maintenance procedures in place leading up to the accident.

As you know, I have advocated an independent safety board for the NRC for years.

One reason I continue to j

advocate such a board is because of decisions like the 2

absence of any penalty after the Novesaber accident.

The J

inspection team process, already flawed in its structure, is

'1 turned into a complete sham when its findings are ignored and no changes are made in the plant or the utility.

That is l

what I fear has happened at Salem.

i In the aftermath of an accident at Salem in 1983, the NRC planned similar inactions, in effect throwing up their hands at any meaningful penalties.

I managed to convince the Commissioners at that time that their approach did not pass public muster.

After reconsidering their decision, the Commission instead got tough on the utility, imposing the largest fine at that time -- $850,000.

One result was a wake-up call to Salem's ma,nagement that procedures and attitudes had to change, and change they did.

A few years later, top management had been overhauled, and Salem's operating record had improved dramatically.

Unfortunately, it appears that problems have returned.

But the decision of the NRC to impose no penalty at all does nothing to force management to take another long, hard look at the operations of the plant.

The message of the NRC is that a turbine explosion is no big deal, at least not one big i

enough to rise to the level of penalties.

The turbine explosion and fire were the reHult of a breakdown of procedures, operations, training, and commitments at the Salem plant.

The NRC's decision to ignore the findings of its investigatory team is bad for residents around the Salem plant, and bodes poorly for meaningful follow-up to other accident investigations around the country.

i -

i One disaster has occurred.

It wan preventable.

I am very concerned that other disasters, also preventable, might be allowed to occur,,

I urge you to reconsider the NRC's actions to date with regard to Salem.

j Sinc el i

/N Jopeph R. Biden, Jr.

U ted States Senator

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1 e

t i

Q UNITED STATES s

NUCLEAR REGULATORY r.0MMlisION OFFICE OF NUCLEAR REACTOR r,EGULATION WASHINGTON, D.C.

20555 April 23, 1992 NRC INFORMATION NOTICE 92-30:

FALSIFICATION OF PLANT RECORDS Addressees All holders of operating licenses or construction permits for nuclear power reactors and all licensed operators and senior operators.

Purpose The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice to alert addressees to the NRC's concern that plant mechanics, technicians, and operators may have falsified plant logs at several nuclear power plants. The NRC is reminding plant mechanics, technicians, and operators (both licensed and non-licensed) of the penalties that could result from intentionally violating Federal regulatory requirements and criminal statutes.

The NRC is also reminding addressees that all personnel are subject to the requirements of 10 CFR 50.9(a) which states that information required by statute or by the Commission's regulations be complete and accurate in all material aspects.

It is expected that recipients will. review the information for applicability to their facilities and consider actions, as appropriate, to avoid similar problems.

However, suggestions contained in this information notice are not NRC requirements; therefore, no specific action or written response is required.

Description of Circumstances On March 1,1992, the shif t superintencent for the Public Service Company of New Hampshire's Seabrook Nuclear Station was conducting a surveillance, in accordance with a personnel performance monitoring program, to verify that operations department personnel were properly performing their assigned duties.

On this occasion, the shift superintendent reviewad the security department's computerized card key entry records against locations in which an auxiliary fa operator's (A0's) log entries had indicated that he had performed inspections.

>5 The shift superintendent found that the A0 had logged " SAT" (satisfactory) for some plant areas, indicating that he had performed the required periodic h3 inspections, although the computerized security data indicated that some of

$)

these areas had not been entered.

M The shift superintendent's findings prompted the licensee to establish an independent review team (IRT) to perform a comprehensive analysis of the root cause(s) and the generic implications of this occurrence.

The IRT interviewed the individuals involved and the management and supervisory staff and examined a wide range of historical records created or used since the issuance of the full power operating li. cense, ' including security logs, 4

-92041f01t3-

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IN 92-30 April 23, 1992 Page 2 of 3 I

operations logs and procedures, administrative program manuals, and training lesson plans. Discrepancies were found by the IRT, and some involved violations of technical specifications and some involved licensed operators.

In response to the findings at Seabrook, random checks were conducted at the i

Haddam Neck Plant and Millstone Nuclear Power Station.

Tc date, no dis-crepancies have been identified at Haddam Neck. At Millstone, the Northeast Nuclear Energy Company (the licensee) determined that several non-licensed plant equipment operators (PEOs) had not completed certain inspecti.o.n rounds as' represented 'in-their legs.

The Millstone licensee h'as since exparided it's evaluation tol verifying the accuracy of log entries recorded by all PE0s.

The manageme~nt at Millstone informed plant personnel of its findings and expectations for recording log entries. The Millstone licensee also established an IRT (with a representative from the Seabrook IRT acti-ng in an advisory status) to investigate its findings, to determine the extent of the problem, and to determine correcthe actions that should be taken.

At Oyster Creek, several non-licensed PE0s were involved with falsification of records associated with routine plant log taking rounds. None of the records involved were related to technical specifications.

The discovery of the falsified log entries was fro;., an ongoing random investigation comparing

~ security door entry records with operator rounds.

As a result of discrepancies found at Seabrook, Oyster Creek, and Millstone, at least one individual had his employment terminated, several individuals resigned, and several other individuals were suspended.

On January 28, 1992, two Instrumentation and Control technicians at the Vogtle Electric Generating Plant, Unit 1, performed a surveillance on a portion of the reactor trip system instrumentation. The Georgia Power Company (the licensee) informed the NRC that the technicians failed to properly follow the surveillance procedure and subsequently created the data that was erte W on the calibration data sheet.

NRC evaluation of each of these matters is continuing.

Discussion of Safety Significance Maintenance of shif t records, log sheets, and surveillance records, attention to detail, and work ethics are important factors which contribute to the safe operation of nuclear power plants. Complacency, by mechanics, technicians, or licensed or non-licensed operators, cannot be tolerated.

Similarly, manage-ment expectations and supervisory overview of rounds need to be clearly communicated and monitored. All personnel involved in NRC-regulated activities

' are responsible for complying with applicable NRC regulato y requirements and other Fed'eral laws.

Log keeping activities as well as surve.llances performed by licensed or non-licensed personnel are subject to the requirements of 10 CFR 50.9(a) regarding completeness and accuracy of information.

IN 92-30 April 23, 1992 Page 3 of 3 In addition, the administrative section of plant technical specifications requires that written procedures be implemented covering the applicable proce-dures in Appendix A of Regulatory Guide 1.33, Quality Assurance Program Requirements (Operation). Among the safety-related activities which Appendix A states should be covered by written procedures are surveillances and log entries.

Willful violations, committed by personnel at any level of a licensee's organization, are of regulatory concern because the NR.C must,have reasonable assurance 'that' licensed activities wil-1 be 'co'nducted in a manner that wfil protect the public health and safety.

Such reasonable assurance is prov'ided

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in large part by the integrity and conscientiousness of each individual performing licensed activities.

Deliberate violations concerning matters within_the scope of an individual's responsibilitics, including fal.sification of reccrds, will be considered for enforcement action against the individual as well as the facility licensee. As provided in 10 CFR 50.5, " Deliberate Misconduct by Unlicensed Persons," 56 Federal Register 40684, August 15, 1991, the NRC may take direct enforcement action against unlicensed personnel who deliberately cause a licensee to be in violation of the Commission's regulations or who provide false information to the licensee concerning licensed activities.

Addressees may wish to take actions as appropriate to ensure that plant personnel are properly performing their assigned duties. Addressees may also wish to distribute copies of this information notice to all their employees.

This information notice requires no specific action or written response.

If you have any questions about the information in this notice, please contact one of the technical contact (s) listed below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

Charles E. Rossi, Director Division of Operational Events Assessment Office of Nuclear Reactor Regulation Technical contact (s): David C. Fischer, NRR (301) 504-1154 Eugene M. Kelly, RI (215) 337-5183 James A. Prell, RI (215) 337-5108

Attachment:

List of Recently Issued NRC Information Notices

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IN 92,,

)

April 23,.1992 3

Page 3 of 3 i

i In addition, the administrative section of plant technical specifications requires that written procedures be implemented covering the applicable proce-dures in Appendix A of Regulatory Guide 1.33. Quality Assurance Program Requirements (Operation). Among the safety-related activities which Appendix A j

states should be covered by written procedures are surveillances and log entries.

i Willful violations, committed by personnel at any level of a licensee's organization, are of regulatory concern because the NRC must have reasonable j

assurance that licensed activities will be conducted in a manner that will protect the public health and safety.

Such reasonable assurance is provided in large part by the integrity and conscientiousness of each individual performing licensed activities. Deliberate violations concerning matters within the scope of an individual's responsibilities, including falsification of records, will be considered for enforcement action against the 1,ndividual as well as the facility licensee. As provided in 10 CFR 50.5, " Deliberate Misconduct by Unlicensed Persons," 56 Federal Register 40684, August 15, 1991, the NRC may take direct enforcement action against unlicensed personnel who deliberately cause a licensee to be in violation of the Commission's regulations or who provide false information to the licensee concerning licensed activities.

Addressees may wish to take actions as appropriate to ensure that plant personnel are properly perforraing their assigned duties. Addressees may also wish to distribute copies of this information notice to all their employees.

This information notice requires no specific action or written response.

If you have any questions about the information in this notice, please contact one of the technical contact (s) listed below ce the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

]

i Charles E. Rossi, Director Division of Operational Events Assessment Office of Nuclear Reactor Regulation Technical contact (s): David C. Fischer, NRR (301) 504-1154 Eugene M. Kelly, RI (215) 337-5183 James A. Prell, RI (215) 337-5108

Attachment:

List of Recently Issued NRC Information Notices Document Name:

IN/GUNDECK LOG CONCURRENCES --- SEE NEXT PAGE

_____.__.-._._.__.....________._m.

Attachment i

IN 92-30 e

April 23, 1992 Page 1 of 1 1

LIST OF RECENTLY ISSUED NRC INFORMATION NOTICES Information Date of Notice No.

Subject Issuance Issued to 92-21, Spent Fuel Pool Re-04/22/92 All holders of OLs or cps Supp. I activity Calculations for nuclear power reactors.

92-29 Potential Breaker Mis-04/17/92 All holders of OLs or cps coordination Caused by for nuclear power reactors.

Instantaneous Trip i

Circuitry 92-28 Inadequate Fire Suppres-04/08/92 All holders of OLs or cps sion System Testing for nuclear power reactors.

92-27 Thermally Induced Acceler-04/03/92 All holders of OLs or cps ated Aging and Failure of for nuclear power reactors.

ITE/G0ULD A.C. Relays Used in Safety-Related Applic-ations 92-26 Pressure Locking of Motor-04/02/92 All holders of OLs or cps Operated Flexible Wedge for nuclear power reactors.

Gate Valves 92-25 Potential Weakness in 03/31/92 All holders of OLs or cps Licensee Procedures for A for nuclear power reactors.

Loss of the Refueling Cavity Water 92-24 Distributor Modification to 03/30/92 All holders of OLs or cps Certain Commercial-Grade for nuclear power reactors.

Agastat Electrical Relays 92-23 Results of Validation Test-03/27/92 All holders of OLs or cps ing of Motor-Operated Valve for nuclear power reactors Diagnostic Equipment and all vendors of motor-operated valve (MOV) diag-nostic equipment.

OL = Operating License CP = Construction Permit

f. %

NOT PUBUCt.Y RELEASED

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POLICY ISSUE i

June 21, 1993 (InfOrmation)

SECY-93-173 I

i i

EQB:

The Commissioners a

fBQH:

James M. Taylor Executive Director for Operations l

SUBJECT:

PROPOSED NRC GENERIC LETTER TITLED, " ROD CONTROL SYSTEM j

FAILURE AND WITH0RAWAL OF R00 CONTROL CLUSTER ASSEMBLIES" i

I PURPOSE i

To inform the Commission, in accordance with the guidance in the December 20, 1991, memorandum from Samuel J. Chilk to James M. Taylor regarding SECY #

i 172, " Regulatory Impact Survey Report-Final," of the staff's intent to issue the subject generic letter. On May 27, 1993, operators at the Salem Nuclear 4

Generating Station, Unit 2, experienced problems with the rod control system i

that resulted in the withdrawal of a single rod control cluster assembly in response to an insert command. The NRC staff is requiring licensees to report on whether they meet their licensing basis for system response to a single l

failure in the rod control system in light of the information generated by the Salem event. A copy of the proposed generic letter is enclosed.

i DISCUSSION i

I The rod control system installed at Salem, Unit 2, is used at all Westinghouse-designed PWRs except Haddam Neck.

Initial assessments concluded that a single failure in the rod control system could result in unintended rod

]

withdrawal movements in multiple control rods. While the reactor protection

Contact:

Margaret Chatterton, NRR i

(301) 504-2889 NOTE:

TO BE MADE PUBLICLY AVAILABLE IN 10 WORKING DAYS FROM THE i

DATE OF THIS PAPER i

. V e emxegg g

n

l The Commissioners system is independent of the rod control system logic and, therefore, the scram fenction is not compromised, there remains a concern that a previously unanticipated single failure mechanism may exist in the control system which l

can init'. ate or aggravate reactivity excursions and result in fuel failure.

General Design Criterion (GDC) 25, " Protection system requirements for reactivity control malfunctions," specifies that acceptable fuel design limits not be exceeded for any single malfunction of the reactivity control systems.

L The PRC Standard Review Plan (N') REG-800), Sections 15.4.1, 15.4.2, and 15.4.3, discuss the specified acceptable fuel design limits for single failures in the reactivity control system (in this case the rod control system). One of these fuel design limits is that fuel rods do not violate the minimum departure from nucleate boiling ratio (DNBR) criterion. This proposed generic letter addresses the ccmpliance issue associated with plant-specific licensing bases l

in this regi.rd.

A notice of opportunity for public comment on the proposed generic letter was not published in the Federal Reaister because of the urgent nature of the generic letter. The proposed generic letter will be published in the Federal Reaister when it is issued.

The proposed generic letter was endorsed by the Comittee to Review Generic Requirements (CRGR) during its meeting on June 17, 1993. The staff has incorporated all comments provided by CRGR in that meeting.

The Office of the General Counsel reviewed this generic letter and has no legal objections.

The staff intends to issue this generic letter immediately.

/

s or

.xecutive irector for Operations

Enclosure:

Proposed Generic Letter, " Rod Control System Failure and Withdrawal of a Rod Control Cluster Assembly" DISTRIBUTION:

Commissioners Regional Offices OGC EDO OCAA ACRS OIG ASLBP OPA SECY OCA OPP

u%q A

+

UNITED STATES c

E i

NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20606 k... *,o8 l

+

i T0:

FOR ACTION - ALL HOLDERS OF OPERATING LICENSES OR CONSTRUCTION l

PERMITS FOR WESTINGHOUSE (W)-DESIGNED NUCLEAR POWER REACTORS EXCEPT HADDAM NECK FOR INFORMATION - ALL HOLDERS OF OPERATING LICENSES OR CONSTRUCTION PERMITS FOR COMBUSTION ENGINEERING (CE)-DESIGNED AND BABC0CK AND j

WILC0X (B&W)-DESIGNED NUCLEAR POWER REACTORS AND HADDAM NECK

SUBJECT:

R00 CONTROL SYSTEM FAILURE AND WITHDRAWAL OF R0D CONTROL CLUSTER ASSEMBLIES, 10 CFR 50.54(f) (GENERIC LETTER 93-XX)

Purcose The U.S. Nuclear Regulatory Commission (NRC) is issuing this generic letter (1) to notify addressees about a single failure vulnerability within the Westinghouse solid state rod control system that could cause an inadvertent withdrawal of control rods in a sequence resulting in' a power distribution not considered in the design basis analyses, and (2) to require, in accordance with Section 50.54(f) of Part 50 of Title 10 of the Code of Federal Reaulations (10 CFR 50.54(f)), that all action addressees provide the NRC with information describing their plant-specific findings related to this issue and actions taken. The NRC will use this information to assess licensee compliance with the plant-specific licensing basis regarding single failures in the rod control system.

Backaround The staff issued Information Notice 93-46, " Potential Proble'm With Westinghouse Rod Contrtl System and Inadvertent Withdrawal of a Single Rod Control Cluster Assembly," dated June 10, 1993, to alert licensees to the potential for an inadvertent withdrawal of one or more rod control cluster assemblies in Westinghouse plants in response to an insert signal.

Qescriotion of Circumstances On May 27, 1993, operators at the Salem Nuclear Generating Station, Unit 2, experienced problems with the rod contfoi system. During an attempt to withdraw Shutdown Bank A, the operator observed that the analog rod position indicator (ARPI) did not indicate that the control rods were being withdrawn.

The operator stopped attempting to withdraw rods at 20 steps as indicated on the group demand indicator.

At this time the ARPI indicated that all of the rods in Shutdown Bank A were at the O step position.

(The function of the group demand indicator is to provide the operator with information on the l

l

Generic Letter 93-XX June XX, 1993 position to which the rods should have moved on the basis of the demand from ti6e rod control system. The fu',ction of the ARPI is to show the actual position of each rod.) The operator then attempted to insert Shutdown Bank A.

However, one control rod (ISA3) withdrew to 8 steps as indicated by the ARPI while the group ' demand indicator counted down from 20 steps to 6 steps.

The

. operator continued to try to insert the Shutdown Bank A control rods until the group demand indicator showed a rod position of zero. The operator observed t%t the indicated position on the ARPI for control rod ISA3 was 15 steps.

Public Service Electric & Gas (the licensee) removed power from the rod by pulling fuses, and rod ISA3 dropped to the 0 step position as indicated by the ARPI.

The licensee initiated troubleshooting activities on the rod control system at Salem, Unit 2.

An.NRC augmented inspection team (AIT) was sent to Salem Unit 2 to evaluate this issue and observe the investigation of this event by the licensee.

The licensee, in response to NRC questions, has postulated that, for the event that occurred on May 27, 1993, a single failure in the rod control system caused a single rod to withdraw from the core 15 steps while the operator was applying a rod insertion signal. The failure of an integrated circuit on a slave cycler decoder card disrupted the normal sequence of pulses that the rod control system sends to the rods in the selected bank. Normally, on insert demand, the pulses are staggered in a sequence that leads to rod insertion.

With the failure, the rod control system periodically sent simultaneous pulses to the movable gripper coil, lift coil, and stationary coil for each of the rods in the selected bank. Under these conditions each rod in the bank may either remain where it is or withdraw from the core when a rod movement demand occurs.

When the rod control system is in the automatic mode of operation, a rod movement demand is generated automatically in response to changes in turbine load and changes in the average reactor coolant temperature. Rod movement then occurs without any operator action until the demand is satisfied. When the rod control system is in the manual mode of operation, a rod movement demand is generated only in response to operator manipulation of the IN-HOLD-OUT switch, 'given no failures in the demand circuit.

Discussiort The rod control system installed at Salem Unit 2 is used at all Westinghouse-designed pressurized-water reactors (PWRs) except Haddam Neck.

Initial assessments by Westinghouse showed that a single failure in the rod control system could result in unintended rod withdrawal movements in multiple control rods. Although the reactor protection system is independent of the rod control system logic and, therefore, the scram function is not compromised, there remains a concern that a previously unanticipated single-failure mechanism may exist in the control system that can initiate or aggravate reactivity excursions and result in fuel failure.

This is of particular importance since the frequency of demand on the rod control system for power adjustments is very high (daily in many plants).

Generic Letter 93-XX June XX, 1993 General Design Criterion (GDC) 25, " Protection system requirements for reactivity control malfunctions," of Appendix A to 10 CFR 50 specifies that acceptable fuel design limits not be exceeded for any single malfunction of the reactivity control systems.

The Standard Review Plan (NUREG-0800)

Sections 15.4.1, 15.4.2 and 15.4.3, discuss the specified acceptable fuel design limits for single failures in the reactivity control system (in this case the rod control system). One of these fuel design limits is that fuel rods do not violate the minimum departure from nucleate boiling ratio (DNBR) criterion.

The staff requested activation of the Westinghouse owners Group Regulatory Response Group (RRG) on June 8, 1993. The Westinghouse Owners Group RRG met with the staff on June 14, 1993, to discuss the RRG generic safety assessment of the Salem event.

The RRG concluded that the failure can produce a withdrawal signal if either a manual or automatic insert command is given to any rod control cluster assembly (RCCA) bank or overlapping banks.

The RRG also discussed analysis results showing that asymmetric RCCA withdrawal at power and from a subcritical condition are the limiting cases.

For both of these cases conservative bounding evaluations indicate that a small percentage (less than 5 percent) cf the fuel rods experience a calculated DNBR below the l

limit value.

The staff believes that the safety significance of this issue is 'not high based on the following information:

All automatic safety functions will perfonn as designed.

For the worst cases of single failures in the rod control system only a small number (or none) of the fuel rods will be below the DN8R limit.

Not all events will lead to fuel rods below the DNBR limit.

Furthermore these events do not provide a challenge to the reactor coolant system or the containment boundary. Although the staff believes that the safety significance of this issue is not high, it believes that compliance with plant-specific licensing bases is in question for all action addressees.

GDC 25 specifies that acceptable fuel design limits not be exceeded for any single malfu,nction of the reactivity control systems. The analyses discussed by the Westinghouse Owners Group indicated that fuel failures could result from single failures identified as a result of the Salem event.

Westinghouse issued a Nuclear Safety Advisory Letter (NSAL)93-007, dated June 11, 1993, recommending the following actions:

1.

Licensed operators should continue the normal process of verifying that rod motion is proper for required movement.

2.

Licensees should confirm the functionality of rod deviation alarms.

3.

Operators should review the advisory letter to ensure their understanding of the event.

Generic Letter 93-XX June XX, 1993 4.

The Westinghouse Owners Group (WOG) survey its members regarding rod misalignment events and provide a summary.

Implementation of the recommendations in the Westinghouse NSAL is judged by the NRC staff to be a prudent action.

The licensee for Salem is implementing several compensatory actions prior to the startup of either unit.

These actions include:

Enhanced rod control system surveillances prior to startup and during operation More frequent periodic surveillances of the rod control system Modification of the startup procedure to preclude an asymmetric rod withdrawal from the subcritical condition by first pulling control rods while still highly borated to the estimated critical position, then, deborating to criticality Classroom and simulator training addressing the effects of potential single failures in the rod control system Issuance of standing orders to heigh'en operator awareness of potential t

rod control system malfunctions Review of event response procedures to assure adequate guidance to operators in the event of a rod control system malfunction Reauired Resoonse Pursuant to Section 182a of the Atomic Energy Act of 1954, as amended, and 10 CFR 50.54(f), each action addressee is required to submit written information as follows:

1.

Within 4,5 days from the date of this generic letter:

(a)

Provide an assessment of whether or not the licensing basis for each facility is still satisfied with regard to the requirements for system response to a single failure in the rod control system and provide a supporting discussion for this assessment in light of the information generated as a result of the Salem event.

(b)

If the assessment in 1(a) indicates that the licensing basis is not satisfied provide an assessment of the impact of potential single failures in the rod control system on the licensing basis of the facility

Goneric Letter 93-XX June XX, 1993 describe any compensatory short-term actions taken or that will be taken to address any actual or potential degraded or nonconforming conditions (see Generic Letter 91-18, Reference 1) such as additional cautions or modifications to surveillance and preventive maintenance procedures additional administrative controls for plant startup and power operation additional instructions and training to heighten operator awareness of potential rod control system failures and to guide operator response in the event of a rod control system malfunction 2.

If the assessment in 1(a) indicates that the licensing basis is not satisfied, within 90 days from the date of this generic letter provide a i

plan and schedule for the long-term resolution of this issue.

Address the required written reports to the U.S. Nuclear Regulatory 1

Commission, ATTN:

Document Control Desk, Washington, D.C. 20555, under oath or affirmation under the provisions of Section 182a of the Atomic Energy Act of 1954, as amended, and 10 CFR 50.54(f).

In addition, submit a copy to the appropriate regional administrator.

This generic letter requires information that will enable the NRC to verify that the licensee is complying with its current licensing basis regarding single failure vulnerability within the rod control system. Accordingly, an evaluation justifying this information requirement is not necessary in accordance with 10 CFR 50.54(f).

Backfit Discussion This generic letter does not involve any backfitting.

It only requires (under the provisions of 10 CFR 50.54(f)) the submittal of information needed by the NRC staff to assess the compliance by the action addressees with existing NRC rules and regulations.

Although the, staff believes that the safety significance of the issue addressed by this generic letter is not high, there is an urgency to the information requirement involved based on the consideration that plants may be currently operating outside of their licensing bases and the information is needed promptly to allow the staff to assess this situation. Therefore, a notice of opportunity for public comment on this generic letter was not published in the Federal Reoister.

i l

Generic Letter 93-XX June XX 1993 i.

Paperwork Reduction Act Statement j

This generic letter contains information collection requirements that are subject to the Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.).

These requirements were approved by the Office of Manage ~ ment and Budget, j

Approval Number 3150-0011, which expires June 30, 1994.

The public reporting burden for this collection of information is estimated to' i

average 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, i

and completing and reviewing the collection of information.

Send comments i

regarding this burden estimate or any other aspect of this collection of information, including suggestions for further reducing reporting burden, to

}

the Information and Records Management Branch (MNBB-7714), U.S. Nuclear i

Regulatory Comission, Washington, D.C. 20555; and to the Desk Officer, Office of Information and Regulatory Affairs, NE08-3019, (3150-0011), Office of Management and Budget, Washington, D.C. 20503.

l Compliance with the request for the following information is purely voluntary.

j The information would assist the NRC in evaluating the cost of complying with this generic letter.

(1) the licensee staff time and costs to perform requested inspections, corrective actions, and associated testing (2) the licensee staff time and costs to prepare the requested reports and documentation (3) the additional short-term costs incurred as a result of the inspection i

findings such as the costs of the corrective actions or the costs of down time

}

(4) an estimate of the additional long-term costs that will be incurred in i

the future as a result of implementing commitments such as the estimated l

costs of conducting future inspections or increased maintenance i

The NRC is issuing this generic letter to the information addressees to alert them to a problem with the Westinghouse rod control system and inadvertent withdrawal of a control rod.

It is expected that recipients will review the l

information for applicability to their facilities and consider actions, as appropriate, to avoid similar problems. However, the requested actions and reporting requirements applicable to the action addressees are not applicable to the information addressees; therefore, no specific action or written response is required from them.

1 I

j r

~

r,

Generic Letter 93-XX June XX, 1993 If you have any questions about this matter, please contact one of the technical contacts listed below or the appropriate Office of Nuclear Reactor Regulation project manager.

4 James G. Partlow Associate Director for Projects i

Office of Nuclear Reactor Regulation v

Technical contacts: Margaret Chatterton, NRR

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(301) 504-2889 Timothy Collins, NRR (301) 504-2897 l

Lead project manager: Thomas Alexion, NRR (301) 504-1326

Reference:

Generic Letter 91-18 "Information to Licensees Regarding Two NRC Inspection Manual Sections on Resolution of Degraded and Nonconforming Conditions and on Operability," issued November 7, 1993 Attachments:

List of Recently Issued NRC Generic Letters e

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