ML20151W198
| ML20151W198 | |
| Person / Time | |
|---|---|
| Site: | River Bend  |
| Issue date: | 09/09/1998 |
| From: | Gwynn T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | Edington R ENTERGY OPERATIONS, INC. |
| References | |
| 50-458-98-12, NUDOCS 9809150213 | |
| Download: ML20151W198 (5) | |
See also: IR 05000458/1998012
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SEP -9 1998
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Randall K. Edington, Vice President - Operations
River Bend Station
Entergy Operations, Inc.
P.O. Box 220
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St. Francisville, Louisiana 70775
SUBJECT: NRC INSPECTION REPORT 50-458/98-12
Dear Mr. Edington:
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Thank you for your letter of August 27,1998, in response to our letter and Notice of
Violation dated July 29,1998. We have reviewed your reply and find it responsive to the
concerns raised in our Notice of Violation involving a breaker tagging error and a failure of most
of the emergency sirens following a software upgrade. 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,
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irector
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ivision of Reactor Projects
Docket Nc.:
50-458
License Nc.: NPF-47
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. Executive Vica President and
Chief Operating Officer
Entergy Operations, Inc.
P.O. Box 31995
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Jackson, Mississippi 39286-1995
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Entergy Operations, Inc.
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Vice President
Operations Support
- Entergy Operations, Inc.
P.O. Box 31995
- Jackson, Mississippi 39286-1995
General Manager
Plant Operations
River Bend Station
Entergy Operations, Inc.
P.O. Box 220
St. Francisville, Louisiana 70775
Director - Nuclear Safety
River Bend Station
Entergy Operations, Inc.
P.O. Box 220
St. Francisville, Louisiana 70775
Wise, Carter, Child & Caraway
P.O. Box 651
Jackson, Mississippi 39205
Mark J. Wetterhahn, Esq.
Winston & Strawn
- 1401 L Street, N.W.
Washington, D.C. 20005-3502
Manager - Licensing
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River Bend Station
Entergy Operations, Inc.
P.O. Box 220
St. Francisville, Louisiana 70775
The Honorable Richard P. leyoub
Attorney General
Department of Justice
State of Louisiana
~ P.O. Box 94005
Baton Rouge, Louisiana 70804-9005
H. Anne Plettinger
3456 Villa Rose Drive -
Baton Rouge, Louisiana 70806
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Entergy Operations, Inc.
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Pres' dent of West Feliciana
Police Jury
P.O. Box 1921
St. Francisville, Louisiana 70775
William H. Spell, Administrator
Louisiana Radiation Protection Division
P.O. Box 82135
Baton Rouge, Louisiana 70884-2135
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Rick J. King
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August 27,1998
U.S. Nuclear Regulatory Commission
ATTENTION: Document Control Desk, OP-17
Washington, D.C. 20555
Subject:
Reply to Notices of Violation in inspection Report 50-458/98-012
River Bend Station - Unit I
License No. NPF-47
Docket No. 50-458
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RBG- 44616
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RBF1-98- 0227
Ladies and Gentlemen:
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Pursuant to the provisions of 10CFR2.201, Attachment 'A' provides Entergy
Operations, Inc. (EOl) responses to the Notices of Violation 50-458/98012-01
and 50-458/98012-02. The commitments contained in this document are
identified on Attachment 'B'.
Should you have any questions regarding the attached information, please
contact Mr. David Lorfing of my staff at (225) 381-4157.
Sincerely,
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K/RLB
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Reply to Notice of Violation in 50-458/98-012
August 27,1998
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RBG-44616
RBF1-98-0227
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Page 2 of 2
cc:
Regional Administrator
U.S. Nuclear Regulatory Commission
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Region IV-
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611 Ryan Plaza Drive, Suite 400
Arlington, TX 76011
NRC Sr. Resident inspector
P.O. Box 1050
St. Francisville, LA 70775
David Wigginton
NRR Project Manager
U.S. Nuclear Regulatory Commission
M/S OWFN 13-H-3
Washington, DC 20555
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ATTACHMENT A
REPLY TO NOTICE OF VIOLATION 50-458/98012-01
Page 1 of 7
Violation:
Technical Specification 5.4.1 states, in part, " Written procedures shall be
established, implemented, and maintained covering the following activities: The
applicable procedures recommended in Regulatory Guide 1.33, Revision 2,
Appendix A, February 1978."
Regulatory Guide 1.33, Revision 2, Appendix A, February 1978 specifies,
in part, procedures for equipment control (locking and tagging).
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Procedure ADM-0027, " Protective Tagging," Revision 16, requires the
operator to, perform component positioning in the sequence shown.
The Clearance Order 98-0583 (Clearance Authorization / Installation /
Removal Sheet) specified, in part, that the 'C' Residual Heat Removal
Pump breaker be racked-in.
Procedure SOP-0046, "4.16 KV System," Revision 13, Attachment 5
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defines steps necessary for racking-out and racking-in 4.16 KV plant
breakers. As part of the racking-out process the procedure states,
"deenergize the breaker control power fuse block." This is accomplished
by pulling the breaker's control power fuses.
Contrary to the above, on June 1,1998, while accomplishing Clearance
Order 98-0583, the operator did not follow the sequence shown on the
clearance order while positioning components in that he manipulated the
Division 11 diesel generator output breaker (by pulling control power
fuses) instead of the C residual heat removal pump breaker, which was
the next component in sequence. The diesel generator output breaker
was not specified on the clearance order.
Reasons for the Violation:
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Following restoration of a clearance, which included the restoration of the 'C'
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Residual Heat Removal Pump Breaker, it was noticed in the Main Control Room
(MCR) that the breaker had no " control power available" indication. The Control
Room Supervisor instructed the Operator performing the restoration to remove
and re-install the control power fuses. The assumption was that the fuse
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ATTACHMENT A
REPLY TO NOTICE OF VIOLATION 50-458/98012-01
Page 2 of 7
contacts may not have made proper connection. The Operator performed this
action, and reported it to the MCR. This action did not correct the problem. The
Operator was instructed to rack out and reinstall the breaker believing that it was
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possible that the breaker stabs had not made a good connection. The Operator
then opened the cubicle door for the Division 11 Diesel Generator (DG) Output
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Breaker and removed the control power fuses. When alarms were received in
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the MCR, the Operator was contacted and instructed to immediately restore the
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Division 11 DG breaker control power fuses. Subsequently, 'C' Residual Heat
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Removal Pump breaker was racked out and then back into its cubicle, which
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alleviated the original problem.
A task analysis of the event revealed that the removal and subsequent
installation of the control power fuses was appropriately accomplished using
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Operator " tool box skills" acquired from training and plant experience. The
breaker racking evolution was performed in accordance with Station Operating
Procedures.
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A root cause investigation was conducted, and the primary cause identified was
failure to adequately self-check (more specifically, the need to re-verify the
correct component after breaking eye contact and prior to taking action).
River Bend Station's Operation Department Management recognized that this
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specific violation is a potential indicator of a more generic underlying issue
regarding human performance. River Bend Station, in order to proactively
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address the broader issues, sponsored an Adverse Trend Condition Report and
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resulting investigation. The investigation included a review of several condition
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reports for a period beginning September 1997 until July 1998. Notable during
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this review was the fact that the failures to self-check were primarily in the field
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and not in the Main Control Room. This analysis helped to identify the
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necessary corrective actions to address the trend and correct this specific
violation.
Major causes identified during the investigation:
Reinforcement of Expectations during activities external to the Main
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Control Room is less than adequate (both supervisory and peer
reinforcement)
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ATTACHMENT A
REPLY TO NOTICE OF VIOLATION 50-458/98012-01
Page 3 of 7
Contact with personnel during activities external to the Main Control
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Room is too infrequent to detect work habit / attitude changes
(supervisory methods)
Job performance and self-checking standards are not properly
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communicated during activities external to the Main Control Room
(supervisory methods)
Self-imposed Schedule Pressure during accomplishment of field
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activities external to the Control Room (usually self-driven, not
supervisory driven)
Failure to obtain Independent Verification or a peer check / Failure to
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Self-Check when performing activities external to the Control Room
Failed to Follow Procedure (also primarily applicable to field activities
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external to the Main Control Room (configuration control)
Actions to address this adverse trend and those that specifically address this
violation are seen as mutually inclusive and are provided without distinction.
Corrective Actions That Have Been Taken:
Counseled operator involved.
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A Condition Report was written to identify an adverse trend in Operation's
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human performance.
The adverse trend was discussed with the Operations Senior Management
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Team (OSMT) to raise Supervisory awareness of this negative trend.
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The Operations Superintendent / Designee provided a bi'efino to Operations
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and Operations Training personnel on these and other recent human
performance events, emphasizing STAR / Peer Checking, focusing on the task
at hand, reducing self-imposed schedule pressure, personal accountability,
and procedural compliance / ownership.
Self-checking Simulator (STAR) Trainer was presented at Operations non-
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licensed operator training.
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ATTACHMENT A
REPLY TO NOTICE OF VIOLATION 50-458/98012-01
Page 4 of 7
Operations Standards and Expectations (OS&E) on Peer Checking and Self
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Checking were revised to provide more specific guidelines.
Operations Shift Superintendents (OSSs) discussed the recent incidents with
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their crews, emphasizing the importance of using Peer Checks and Self
Checks.
Corrective Actions That Will Be Taken to Avoid Further Violations:
Evaluate past breaker racking failures to determine if the cause is
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mechanical, or due to mis-operation.
The STAR Trainer or Simulator Training will be provided to licensed operators
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during requalification with additional focus on coaching and management
observations.
The Operations Superintendent / Designee will discuss supervisory oversight
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expectations with each Operations Shift Supervisor / Control Supervisor in
one-on-one sessions.
As part of this discussion, include discussion on
improving field coaching / oversight from afar, minimizing work distracters
(non-productive tasks), use of effective pre-job /tailboard briefings, preventive
vs reactive oversight, and bahncing administrative vs supervisory functions.
Date When Full Compliance Will Be Achieved:
Adequate controls were in-place at the time of the violation and full compliance
was achieved immediately upon restoration of the Diesel Generator Breaker
Control Power Fuses on June 1,1998.
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ATTACHMENT A
REPLY TO NOTICE OF VIOLATION 50-458/98012-02
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Violation:
10 CFR 50.54q states, in part, "A licensee authorized to possess and operate a
nuclear power reactor shall follow and maintain in effect emergency plans which
meet the requirements in appendix E of this part."
10 CFR 50, Appendix E, Section D.3 states, in part,"The design objective
of the prompt public notification system shall be to have the capability to
essentially complete the initial notification of the public within the plume
exposure pathway EPZ [ emergency planning zone) within about 15
minutes.
Section 13.3.5.4.1.2.2 of the River Bend Emergency Plan states, in part:
1) "The prompt notification system for the 10-mile EPZ of the RBS [ River
Bend Station]... consists of high-powered electronic sirens and alert
monitoring radios which provide comprehensive coverage of the local
residential and transient population;" and 2)"RBS shall ensure that means
exist to notify and provide prompt emergency instructions to the
population in the plume exposure pathway EPZ."
Appendix 3 of NUREG-0654 states, in part,'Within the plume exposure
EPZ, the system shall provide an alerting signal. The minimum acceptable
design objectives for coverage by the system are: a) capability for
providing an alert signal to the population on an area wide basis
throughout the 10 mile EPZ, within 16 minutes . "
Contrary to the above, between May 14 and June 3,1998, the prompt
notification system was not capable of providing an alert signal to the
population on an area wide basis throughout the 10 mile EPZ within 15
minutes due to inadequate post-installation testing of system software.
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Reasons for the Violation:
During the monthly siren test on June 3,1998, only the first parish tested had
sirens sound. River Bend Station (RBS) Emergency Preparedness immediately
notified parish Emergency Operations Center (EOC) personnel of the failure and
advised them to use their alternate means to alert the public. RBS Emergency
Planning also notified state and federal agencies; and through the Control Room,
reported the incident to the NRC Staff. The site investigation concluded that
during the period of time from installation of the upgraded software until
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ATTACHMENT A
REPLY TO NOTICE OF VIOLATION 50-458/98012-02
Page 6 of 7
discovery (the period of May 14 to June 3,1998), if sounding had been
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sequenced through the parish EOCs, then only the sirens in the first parish
would have sounded. To sound other parishes would have inserted an added
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delay (as tested) of up to 18 minutes. The reason for this delay would have
been to allow rebooting of the computer and enable use of the previous version
of the software. This delay was not recognized until the problem was identified.
This delay may have affected the system's ability to assist state and local parish
officials in the alert of the public within the 10-mile Emergency Planning Zone.
NUREG-0654 " Criteria for Preparation and Evaluation of Radiological
Emergency Response Plans and Preparedness in Support of Nuclear Power
Plants" requires the system to be capable of being sounded within about 15
minutes after the decision to do so by the offsite authorities.
A root cause investigation was conducted with the following primary causes
identified:
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Did not use applicable procedures - i.e., Failure to enforce management
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systems / Communications of Standards, Policies, and Administrative Controls
An inadequate plan was used during post installation testing.
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Corrective Actions That Have Been Taken:
Reinstalled previous version of software.
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Tested the reinstalled version by sequencing silent activation through parish
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Conducted successful audio functional test
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Corrective Actions That Will Be Taken to Avoid Further Violations:
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Provide Computer Software QA requirements training to Emergency
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Preparedness personnel emphasizing proper system functional testing.
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Compile Computer Software QA Compliance Package for siren software, that
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will test all software functions prior to releasing software for use. Establish a
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test bed in which to test the siren system.
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ATTACHMENT A
REPLY TO NOTICE OF VIOLATION 50-458/98012-02
Page 7 of 7
Date When Full Compliance Will Be Achieved:
Adequate controls were in-place at the time of the violation and full compliance
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was' achieved on June 9,1998 following satisfactory performance testing of the
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system.
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ATTACHMENT B
COMMITMENT IDENTIFICATION FORM
Page 1 of 1
Violation 50/458/98012-01
COMMITMENT
ONE-TIME
CONTINUING
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ACTION
COMPL!ANCE
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Evaluate past breaker racking failures to determine if the
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cause is mechanical, or due to mis-operation.
The STAR Trainer or Simulator Training will be provided to
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licensed operators during requalification with additional
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focus on coaching and management observations.
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The Operations Superintendent / Designee will discuss
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supervisory oversight expectations with each Operations
Shift Supervisor / Control Room Supervisor in one-on-one
sessions. As part of this discussion, include discussion on
improving field coaching / oversight from afar, minimizing
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work distracters (non-productive tasks), use of effective
pre-job /tailboard briefings, preventive vs reactive
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oversight, and balancing administrative vs supervisory
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functions.
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Violation 50/458/98012-02
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COMMITMENT
ONE-TIME
CONTINUING
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ACTION
COMPLIANCE
Provide Computer Software QA requirements training to
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Emergency Preparedness personnel emphasizing proper
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system functional testing.
Compile Computer Software QA Compliance Package for
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siren software, that will test all software functions prior to
releasing software for use. Establish a test bed in which to
test the siren system.
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