ML20149J548

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 70-1257/94-06 on 941110

ML20149J548
Person / Time
Site:	Framatome ANP Richland
Issue date:	12/27/1994
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Maas L SIEMENS POWER CORP. (FORMERLY SIEMENS NUCLEAR POWER
References
NUDOCS 9501060014
Download: ML20149J548 (2)

Text

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+ -,g NUCLEAR REGULATORY COMMISSION E '_ o o REGION IV 611 RYAN PLAZA DRIVE, SUITE 400 *

$, ,/ AR LINGTON, TEXAS 760114064 DEC 27 lw4 Siemens Power Corporation ATTN: L. J. Maas, Manager Regulatory Compliance 2101 Horn Rapids Road P.O. Box 130 Richland, Washington 99352-0130 ,

SUBJECT:

NRC INSPECTION REPORT 70-1257/94-06 Thank you for your letter of December 16, 1994, in response to our letter and Notice of Violation dated November 10, 1994. We have reviewed your reply and find it responsive to the concerns raised in our Notice of Violation. We will review the implementation of your corrective actions during a future inspection to determine that full compliance has been achieved and will be maintained.

Sincerely, Samuel J. Collins, Director Division of Radiation Safety and Safeguards Docket: 70-1257 License: SNM-1227 cc:

State of Washington 9501060014 941227 PDR ADOCK 07001257 C PDR

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7/#croh WC 19 p December 16,1994 LJM:94:142 U.S. Nuclear Regulatory Commission ,

Attn: Document Control Desk Washington, DC 20555 Gentlemen:

Subject:

Reply to a Notice of Violation Ref: Letter, S.J. Collins to B.N. Femreite,"NPC INSPECTION REPORT 70-1257/94-06 (NOTICE OF VIOLATION)," dated November 10,1994 f

Below is Siemens-Power Corporation's (SPC's) reply to the notice of violation accompanying the referenced letter. Per a telephone conversation between F.A. Wenslawski, NRC Region IV, and myself on December 7,1994, SPC requested and was granted a delay from December 10 to December 16 for submittal of this response.

In addition, in the referenced letter you pointed out certain areas where, based on NRC's review of the September 18th powder spill, further improvement is warranted. As requested, SPC's views on these issues have been provided as a separate discussion attached to this letter.

Violation 1.A.

Item 8.1 of Section 8.0," Acceptance of Work Completed" of Procedure EMF-858, No.

1.13, " Engineering Change Notice (ECN)," Revision 13, dated December 22,1993, '

requires, prior to operation, the startup approval signatures must be obtained. The startup approval process on Page 2 of the ECN requires the operating supervisor to j make a determination that operator training has occurred and standard operating ,

procedures have been revised, or that these actions are not required before startup l approval is obtained. ]

1 Contrary to the above, following a modification to the powder preparation systems on February 14 and 18,1994, the licensee did not provide training to operators relative to the modification or evaluate the need to revise operating procedures prior to restarting these systems. Specifically, when the modification was completed, the engineering Siemens Power Corporation Nuclear Dms& Engineenng and Manufactunng Facihty Richland. WA 99352 0130 Tel (509) 375 8100 Fax. (509) 375-8402 2101 Horn Rapd Road, PO Box 130 220m -??

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department did not forward the applicable ECN to the operations department which circumvented these actions.

This is a Severity Level IV violation (Supplement VI).

SPC Response

1. Reason for the Violation. In order to understand the reason for this violation, some background on the events leading up to the powder spill itself must be presented.

The powder preparation lines contain inspection ports (nominal 2" diameter) which are used primarily to insert a vacuum wand for enrichment cleanouts.

These ports had been closed with a threaded plug until it became evident that the plug could vibrate loose. In some locations these plugs were replaced with threaded ball valves which served the same purpose but were expected to be -

more convenient, not requiring removal from the port, and not as subject to vibration. The administrative mechanism for replacing the plugs with ball valves is the Engineering Change Notice (ECN). In mid 1993 an ECN was prepared and approved to allow installation of the ball valves. The ball valves were not an optimal solution because, for some enrichment cleanouts, they had to be removed as part of the equipment disassembly and reinstalled afterwards and they were much larger than expected. After an enrichment cleanout prior to the spill, a plug, instead of the ball valve, was installed in the inspection port in the une 2 powder preparation chute upstream of the hammermill. The plug subsequently vibrated out, allowing UO, powder to escape the equipment and enter the surrounding hammermill area.

Because of the ball valve's being deemed early on as an inadequate solution to the problem of Inspection port plug vibration, the ECN was not closed out and the " ownership" of the inspection port was not formally retumed from Engineering to Operations. As a result the required operator training, which must be completed prior to startup and final acceptance of the completed work by Operations, was not completed. In addition, the operator who most likely installed the plug was receiving on-the-job training and was given less than adequate supervision.

2. Corrective Actions Taken. The immediate corrective actions taken were to shut down powder preparation Une 2 and Unos 1 and 3 to check the status of their inspection port installations. The ball valves were found in place in unes 1 and

3. A ball valve was reinstalled in Une 2 and the ball valves in all three lines, as well as an upper feed hopper plug on Une 2, were lockwired to preclude their loosening from vibration.

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' After the powder spill was cleaned up and the valves lockwired, with the concurrence of the Criticality Safety Specialist, the Chemical Area Supervisor, the Manager of Plant Operations, and the Richland Plant Manager, the powder preparation lines were restarted.

3. Corrective Actions to be Taken to Avoid Further Violations. The following actions have been or are being undertaken to avoid further violations:

a. Refresher training for the ECN procedure was initiated with the

! Manufacturing Engineering staff, Operations supervisors and Operations-l-

lead technicians beginning the week of October 10, The findings of the incident investigation Board (llB) report were also covered in these sessions. This training is complete.

b. Configuration Control training had been previously developed and was started for Operations and Maintenance craft personnel the week of September 26,1994. This training will be complete by January 31, 1995.

c. The Plant Manager met with line management and supervisors of Plant Engineering, Plant Operations, and Safety, Security & Ucensing to discuss expectations for (a) configuration control, (b) robust ECN and operating procedures, (c) effective handoff between Engineering and Operations, and (d) ownership of the process equipment, as well as to i

assess the effectiveness of corrective actions. In addition a memo discussing " ownership" of equipment and processes was sent out to all  :

Manufacturing personnel. This action is complete. l

d. An Operating Practices training course is being developed for i instructing new employees more specifically on configuration control, i

use of procedures, compliance with procedures, effective change control, and shift communications. The training course will be complete '

by April 30,1995 and the training itself by June 30,1995. Annual ,

refresher training will be provided for all applicable employees.

e. The Engineering Change Notice (ECN) procedure has been revised substantially since March 1993 to make the hand-off of completed engineering work more effective and robust.. Among the requirements of the current revision are operations training prior to approval for '

startup and completion of an ECN. As built requirements are clearly specified by the current procedure. This action is complete,

f. All ECNs in progress (80) or ready for execution at the time of the spill '

were reviewed and brought to the requirements of the current revision of the ECN procedure. In addition, all completed ECNs dating back to

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$ March 1993 (431) were reviewed to ass Jre proper Closure and that '

appropriate user training was conducted as now required by the current revision. These actions are complete.

g. All experienced conversion employees who take part in on-the-job 7 training for operators in-training have been re-instructed that they are ,

responsible for the work performed by the trainee under their direction.

This action is complete. s

h. Any confusion over " ownership" and expectations about effective shift turnover and operations were resolved by the Richland Plant Manager in his meetings with staff. This resolution was reinforced by the Managers of Plant Operations and Plant Engineering in a letter of October 13,1994 to their staffs and in subsequent meetings and training sessions. Additionally, a Maintenance Work Permit procedure is being implemented which requires permission from the applicable Plant '

Operations supervisor prior to the start of maintenance or modification work. Implementation is complete In the chemical conversion and UO, ceramic areas. .

4. Date When Full Comoliance Will be Achieved. Based on reviews and actions already completed, SPC now fully complies with the training and procedure review aspects of its ECN procedure.

' Violation 1.8.

Item 4.16 in Section 4.0," Radiological, industrial and Fire Safety," of Operating i

• Procedure EMF 22, No. P66,813, " Preparation of UO, [ uranium dioxide] Powder as i Press Feed, " Revision 23, dated August 12,1994, requires that prior to operating the powder preparation system, a checkoff list must be completed in accordance with '

Attachment C to verify that the system has been properly reassembled. One of the checkoff items for the powder preparation system on Attachment C, Powder Prep Start of Shift Checkoff Ust," requires verification that all hood doors are closed and i latched.

Contrary to the above, on September 18,1994, two bottom latches on a lower door of f the une 2 powder preparation hammermill hood were not verified to be latched before starting the powder preparation system. The failure to secure these latches allowed approximately 41 kilograms of low enriched uranium powder to spill from the hood door onto the floor outside of the hood, in conjunction with a larger spill inside the hood.

This is a Severity Level IV violation (Supplement VI).

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r December 16,1994 SPC Response

1. Reason for the Violation. The primary reason for this violation was a less than adequate design of the subject hood latches. The design of the latch is such that it is not visually obvious whether or not the latch is properly engaged when it is toggled shut. Failure to properly overcheck/ confirm adequate performance of the latching requirement also contributed to the violation.

2. Corrective Action Taken. The immediate corrective actions taken in response l to the powder spill are addressed in the response to Violation 1.A., above. The .

corrective actions taken to address the concerns relative to the hood latches '

are described below under " Corrective Actions Taken to Avoid Further-Violations."

3. Corrective Actions Taken to Avoid Further Violations. The following corrective actions have been or are being undertaken to avoid future occurrences.

a. Hood door latches are being replaced with ones that visually reveal latch open or closed status. This action will be complete by January  :

31,1995,

b. Procedural controls are being strengthened to provide enhanced assurance that all equipment startup tasks are properly conducted and overchecked. Specifically:

- The Moderation Control Observation Procedure has been revised to require the moderator watchperson, as part of his/her scheduled (every half hour) work area inspections, to speedically look for powder spills (inside and outside of equipment) and to ,

confirm that all doors and ports on powder preparation equipment are secure.

• Powder preparation procedures are currently under revision to require that a flashlight-sided inspection and completion of the '

powder preparation startup checkoff list be completed not only at start of shift but also at any time the equipment is restarted ,

after a shutdown of any sort.

• A new procedure, " Conversion Area Operating Practices" has ,

been written to cover generic issues, e.g. "all latches must be used as designed." This procedure brings together general 4

safety and operating practices, some of which were " boiler plate" in each operating procedure, into one procedure. This action i will facilitate proper emphasis of and training on these practices.

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c. As discussed under the corrective actions for Violation 1.A, all findings of the SPC incident investigation Board relative to the causee of this spill, including the fact that not all hood latches were secured, have 1 been reviewed via formal training sessions with appropriate Operations supervisors and lead technicians. This action is complete.

4. Date When Full Comoliance Will be Achieved. Based on training and -

procedural control enhancements already undertaken, SPC is now fully complying with the requirements for latching hood doors. Installation of more favorably designed latches should be completed by January 31,1995.

As you have noted, SPC has made significant programmatic improvements in a number of areas over the past two years, including operator training and qualification and engineering control. The changes SPC has made as a followup to the September 18,1994 powder spill will further strengthen an already sound engineering change management system.

if you have questions or require further information, please call me at 509-375-8537. ,

i Very,truly yours, O\db L J. Maas, Manager Regulatory Compliance LJM:pm cc: Nuclear Regulatory Commission Regional Administrator, Region IV Arlington, TX Nuclear Regulatory Commission Region IV Field Office ,

Walnut Creek, CA

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L ATTACHMENT Siemens Power Corooration's Discussion of Potential Procrammatic Weaknesses Revealed by the Sootember 18.1994 Hammermill Powder Soill =

' NRC Inspection Report 701257/94-06, in addition to identifying two violations relative to the '

subject powder spill, pointed out "certain areas where further improvement is warranted." As requested by the NRC, SPC's views on these issues are discussed ,

below.

Similarity of the September 18.1994 Powder Solil to the February 7,1993 Feed Hoooer Tube ERl!!

Based on its review of the September 18,1994 spill, the NRC perceives similarities to the  ;

February 7,1993 feed hopper tube spill in that both events:

• " illustrated operator confusion over system status which ultimately was rooted in poor judgement and less than rigorous procedural adherence by  ;

, engineering staff," and a " involved a lack of communication and system status awareness by operators and shift supervisors."  ;

SPC recognizes that both powder spills stemmed from shortcomings in SPC's efforts to effectively manage and communicate equipment modifications in its manufacturing facility.1 At SPC the administrative mechanism used to manage the installation of new, and the modification of existing, equipment and technology is the Engineering Change Notice (ECN) procedure. It follows then that both incidents involved shortcomings in the substance and implementation of the ECN process. The specific nature of the shortcomings in the ECN ,

process underlying these two events however are not synonymous. Therefore they have been, and are being, addressed by distinct corrective actions which, taken together, will j further strengthen an already well-developed change management program in SPC's  ;

manufacturing facility.  ;

The ECN process problem undertying the February 1993 spill was a weakness in the ECN procedure itself. The ECN procedure and companion Work Order (WO) p'rocedure in effect at the time that the powder feeder limit switches were installed permitted engineering judgement <

relative to ECN vs WO usage for " minor changes." The events leading to the installation of the powder feeder limit switches, and ultimately the purpose for their installation, were not straightforward. The latitude and ambiguities in the ECN and WO procedures in effect at that time led to a choice by the cognizant engineer (i.e. use of a WO rather than an ECN) that in hindsight was incorrect. This was in spite of the fact that the engineer was knowledgeable of  ;

the procedures and the criteria for choosing which option to use. The engineer's decision to

• utilize a WO rather than an ECN was an underlying reason for the lack of operator understanding of the purpose and importance of the limit switches.

SPC addressed the change management problems identified by the February 1993 incident with prompt and clearly defined improvements to the ECN/WO procedures. The procedures l were reviewed, revised, and re-issued in March 1993, clarifying the WO versus ECN i

i ATTACHMENT (Cont'd) Page 2 requirements and categorically disallowing the use of Work Orders for any modifications ;o fissile material-containing systems. Affected staff were thoroughly trained on the revised criteria and the procedures have been effectively implemented in that regard since that time.

An error in selecting the ECN versus the WO option was not a factor in the September 1994 hammermill powder spill. As will be discussed later, the ECN implementation problem .

associated with the September 1994 powder spill stemmed from a management decision that failed to assure that key aspects of a revision to the ECN procedure were imposed on ECNs in process at the time of the revision.

As indicated in the referenced NRC report, SPC's ECN procedurd has undergone additional revision since the previously discussed improvements in March 1993. Most notably, Revision 13 issued in December 1993 required that appropriate operator training and SOP revisions be completed prior to signoff for equipment startup. Prior to Revision 13, the ECN procedure required that these training and SOP requirements be fully addressed prior to final ECN acceptance / closure, but not necessarily prior to initial equipment startup for testing, process verification, etc.

At the time of the Revision 13 change, SPC management made a conscious decision not to

. recall / retrofit ECNs in process that had been issued under previous revisions to the ECN procedure. This decision directly affected the ECN in process for installation of the ball valves in the Line 2 hammermill bridge breaker assembly, an ECN that had been initiated in August 1993. Training provided to Engineering staff relative to Revision 13 implementation did indicate an intent to follow the Revision 13 requirements relative to operator training and SOP revisions for ECNs in process. In retrospect, however, the decision to not systematically recall / retrofit these ECNs was not fully consistent with SPC's prior and ongoing efforts at assuring a rigorous engineering change management system.

Corrective actions relative to effective and consistent implementation of the ECN procedure have been outlined in SPC's response to Violation 1.A. In addition to a number of-

• communication and training initiatives, the corrective actions involved a systematic review of all ECNs in progress (80) or ready for execution at the time of the September 18 spill to assure compliance with requirements of the current revision of the ECN procedure. In 4

addition, all completed ECNs dating back to March 1993 (431) were reviewed to assure proper closure and that operations training was conducted as required by the current ECN '

revision.

SPC concurs that in both cases (the February 1993 and September 1994 powder spills),

l ineffective implementation of the ECN process resulted in less-than-adequate training of operators relative to the modifications undertaken on the equipment. This in turn contributed to the confusion and lack of system status awareness by operators and shift supervisors.

i With respect to the ECN procedure itself, this issue was addressed in the December 1993 revision. A significant number of other communication, procedural, and training initiatives have been undertaken with operating personnel to address issues related to system status i awareness, shift turnover, and intra-shift communications. These actions are d!* mad in SPC's response to Violation 1.A and include procedures and training programs emphasizing configuration control, the ECN process and change management in general, the need for communication between technicians and supervisors with regard to unreviewed equipment i

ATTACHMENT (Cont'd) Page 3 changes or other unusual conditions, and the responsibility _of operators to be fully informed on the status of processes and equipment with which they work.

" . . . ouality of effort in this (SPC's) investication (that) was less than orevious reports."

There were two simultaneous and independent investigations undertaken as a result of this incident - one by the incident investigation board (IIB) and one by SPC management. The findings of these investigations have been reconciled. Although the timeliness of the reporting of the investigative results was not as good as for past investigations, SPC feels that the combined investigations were well done and thorough 3 in the strictest sense the conduct of this investigation probably did not match the quality of previous incident investigations. It was not, however, due to management inattention or to lack of effort. SPC's view as to the reason for the difficulties in the investigation is discussed below.

Historically in its investigation of incidents such as this one, SPC has included on the investigation team a member of the organization, Chemical Operations in this case, directly involved in the incident. Prior to his being formally named to the llB, the Supervisor of Chemical Operations began normal information gathering steps (interviews, es'.ablishment of an incident timeline, etc.). In this case, however, the makeup of the 118 was changed so as

,n_qi to include Chemical Operations. This change was made both in the interest of training new personnel in 118 procedures and also to maintain independence from th6 organization involved in the incident. As a result the supervisor stopped interviews. The _ interviews were restarted later as part of the SPC management review of the incident, discussed earlier. This _j interruption in the information gathering process however had a negative overall impact on . i the conduct and timeliness of the investigation. l The llB report did contain one technical error. The failure of the high differential pressure audible alarm was not a causal factor. While the audible alarm probably would have .

Indicated the presence of uncontained UO,in the hood (the visual alarm did operate, but wasn't noted), this is not its primary purpose. The primary purpose of the alarm is to indicate '

loading of the HEPA ventilation filter. The 118 wanted to be clear that the intermittent failure of this alarm is not an acceptable condition. A properly operating alarm could possibly have  !'

lessened the extent of the spill, but its failure should not have been viewed as a cause of the incident.

There were lessons learned from this investigation. As a result, the procedure for conducting  !

IIBs has been revised to include an appendix with guidelines for selecting team members,  !

personnel to be interviewed, and material to examine.

" , operators in trainino may not be receivino adeouate oversicht durino shift operations."

I SPC, in its investigation of the powder spill, also came to this conclusion. This was based on the finding that the operator who most likely misassembled the port closure was receiving on-i the-job training and apparently was given less than adequate supervision. As a result, a new l

j Plant Operations standard operating procedure (SOP) was written which emphasizes the importance of configuration control; reinforces the need for communication between t k

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l ATTACHMENT (Cont'dj Page 4 technicians and their supervisors with regard to unreviewed equipment changes or other l

unusual conditions; and emphasizes that the responsibility for work done by operators in training rests with the technicians conducting such training. Such technicians are, therefore, instructed to overcheck any work done by operators in training for correctness and i

completeness. This SOP and associated training will strength SPC's existing operator l

qualification program and willinstitutionalize much of the special emphasis training provided '

In a campaign fashion as a followup to this event.

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