IR 05000324/1988015
| ML20195J186 | |
| Person / Time | |
|---|---|
| Site: | Brunswick  |
| Issue date: | 06/17/1988 |
| From: | Grace J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Utley E CAROLINA POWER & LIGHT CO. |
| References | |
| EA-88-131, NUDOCS 8806290073 | |
| Download: ML20195J186 (56) | |
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g JUN 171988 i
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WY
. Docket Nos.- 50-325, 50-324 License Nos. DPR-71, DPR-62 EA 88-131- ^
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Carolina Power and Light Companyc ATTN: Mr. E.- E. Utley Senior Executive Vice President Power Supply and Engineering and Construction P. O. Box 1551-- '
_Raleigh, NC 27602 1 g Gentlemen:
SUBJECT: ENFORCEMENT CONFERENCE SUMMARY (NRC INSPECTION REPORT NOS. 50-325/88-15 AND 324/88-15)
i This letter refers to the Enforcement Conference held at our request on May 27, 198 This meeting concerned activities authorized.'or your Brunswick facility._ The issues discussed at this conference related to recent examples of operator error and less than adequate ' attention to detail in perfonning
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' shift duties. A conference summary, a list of attendees, and a copy of your handout are enclosed. We are continuing our review of these issues to deter-
,.mine the appropriate enforcement actio In -accordance with Section .2.790 - of the NRC's "Rules of Practice" Part 2,
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Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be'placed in the NRC Public Document Room.-
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Should you have any questions concerning this matter, please contact u ,
Sincerely,
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J. Nelson Grace
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Regional Administrator i
Enclosures:
l Enforcement Conference Summary
' List of Attendees Handout
REGION II M. L. Ernst, Deputy Regione.l Administrator L. A. Reyes, Director, Divis'on of Reactor Projects (DRP)
E. W. Merschoff, Deputy Direct,r, Division of Reactor Safety (DRS)
D. M. Verrelli, Chief, Branch 1, DRP R. Jenkins, Director, Enforcement arid Ir.vestigative Coordination Staft (EICS)
P. E. Fredrickson, Section Chief, DR.'
W. H. Ruland, Brunswick Senior Resident Inspector (DRP)
W. Levis, Brunswick Resident Inspector (DRP)
R. Schin, Reactor Engineer, DRS <
S. Schaeffer, Reactor Inspector, DRP L. Slack, Technical Assistant, EICS NRC-HEADQUARTERS E. G. Adensam, Director, Project Directorate 11-1, Office of Nuclear Reactor Regulation (NRR)
E. Sylvester, Brunswick Project Manager (NRR)
J. Stephano (By Telephone), Enforcement Specialist, Office of Enforcement l
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_EllCLOSURE 3, I l
ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 0 OPENING REMARKS C. R. DIETZ O OBJECTIVES
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C. R. DIETZ O MODE SWITCH EVENT DESCRIPTION R. M. POULK O SEQUENCE OF EVENTS O
MODE SWITCH EVENT FINDINGS AND RESPCNSE G. C. JOHNSON O PERFORMANCE FACTORS AND 0 CORRECTIVE ACTIONS D. T. PATE O HEATUP/ CONTROL ROD EVENTS R. M. POULK O EVENT DESCRIPTIONS AND ACTIONS
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O OPERATIONS ASSESSMENT C. R. DIETZ O CLOSING REPJdES C. R. DIETZ l
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 O OBJECTIVES O
TO REVIEW THE SEQUENCE OF EVENTS ASSOCIATED WITH AN IMPROPER MODE CHANGE AT BSEP ON 4/26/88 INCLUDING AN INACCURATE DETERMINATION OF RHR SYSTEM ALIGNMENT TO
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SUPPORT STARTUP OF UNIT O TO REVIEW ALL FACTORS AND VARIABLES THAT WERE CONTRIBUTIVE TO THE ERRORS NOTED ABOV O TO REVIEW OTHER EVENTS THAT MAY BE INDICATIVE OF AN ADVERSE TREND IN PLANT OPERATIONS PERFORMANCE.
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O TO REVIEW A BROAD SCOPE OF RELATED CORRECTIVE ACTIONS WHICH HAVE BEEN IMPLEMENTED AS A RESULT OF THESE i
i INVESTIGATIVE EFFORT O TO PRESENT CONCLUSIONS RELATED TO THESE EVENTS AND l OVERALL OPERATIONS PERFORMANCE.
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ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 SEQUENCE OF EVENTS 0435 (L) MODE SWITCH WAS PLACED IN THE STARTUP POSITION FOR THE PURPOSE OF PERFORMING THE ROD WOR'I3 MINIMIZER SURVEILLANCE TEST, PT-01.6.2- (C) SHIFT TURNOVER; PT-01.6.2-2 STILL IN FROGRES (L) PT-01.6.2-2 IS COMPLETED BY THE OPERA % (C) DECISION WAS MADE BY THE SHIFT FOREMAN (SRO) TO LEAVE "HE MODE SWITCH IN THE STARTUP POSITION AND TO IN'TIATE THE PERFORMANCE OF THE RO: SEQUENCE CONTRCL SYSTEM S'URVEILLANCE TEST, PT-C1. (P) PT-01.6.1 IS COMPLETED
- THIS TEST DID NOT PROVIDE GUIDANCE ON THE PLACEMENT OF THE MODE SWITCH FOLLOWING THE COMPLETION OF THE PROCEDURE.
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ENFORCEMI.NT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA ?OWER & LIGHT COMPANY MAY 27, 1988 SEQUENCE OF EVENTS FOOTNOTE FOR TECHNICAL SPECIFICATIONS 3.1.4.1 (3.1.4.2):
ENTRY INTO CONDITION 2 AND WITHDRAWAL OF SELECTED CONTROL RODS IS PERMITIED FOR THE PURPOSE OF DETERMINING THE OPERABILITY OF THE RWM (RSCS) PRIOR TO WITHDRAWAL OF CONTROL RODS FOR THE PURPOSE OF BRINGING THE REACTOR TO CRITICALITY.
l TYPICAL FOOTNOTE ALLOWING THE MODE SWITCH TO BE REPOSITIONED:
THE REACTOR MODE SWITCH MAY BE PLACED IN THE RUN OR ,,
STARTUP/ HOT STANDBY POSITION TO TEST THE SWITCH INTERLOCK l FUNCTIONS PROVIDED THAT THE CONTROL RODS ARE VERIFIED TO REMAIN FULLY INSERTED BY A SECOND LICENSED OPERATOR OR OTHER TECHNICALLY QUALIFIED MEMBER OF THE UNIT TECHNICAL STAFF.
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i LIMITING CONDITIONS NOT MET WHEN THE MODE SWITCH WAS PLACED IN STARTUP:
l 3.6. PRI CONTAINMENT INTEGRITY DW DOORS OPEN 3.6. PRI CONTAINMENT LEAKAGE DW DOORS OPEN l
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3.6. PRI CONTAINMENT AIR LOCK DW DOORS OPEN
, 3.5. LOW PRESSURE COOLANT INJECTION S/D COOLING
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ENFORCEMENT MEETING
$RUNSWICKSTEAMELECTRICPLANT CAROLINA POWER E LIGHT COMPANY -
MAY 27, 1988 SEQUENCE OF EVENTS 1219 (P)
TRACKING LCO T-2-88-0729 WAS CANCELE *THIS LCO WAS ESTABLISHED AT 2006 ON 4/25/88 TO TRACK THE OPENING OF BOTH DRYWELL AIRLOCK DOORS TO ALLOW THE RUNNING OF WELDING CABLES INTO THE DRYWEL (P)
INITIATED PROCEDURES FOR SECURING SHUTDOWN COOLING AND RESTORING THE LPCI SYSTEM TO THE STANDBY LINEU .
1406 (L) SHUTDOWN CO] LING SECURED ON THE "B" LOOP; "A" LOOP OF LPCI IS IN THE STANDBY LINEUP.
i *THE PROCEDURE (OP-17) WHICH CONTROLLED THIS EVOLUTION AND THE RESTORATION OF LPCI TO THE i
l STANDBY LINEUP IS STILL BEING PERFORMED.
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ENFORCEMENT MEETING NRUNSWICKSTEAMELECTRICPLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 SEQUENCE OF EVENTS 1419 (P) ACTIVE LCO ON THE SUPPRESSION POOL TO REACTOR
. BUILDING VACUUM BREAKERS IS CANCELE *THIS LCO WAS ESTABLISHED AT 0325 ON 4/25/88 DUE TO THE BACKUP N:TROGEN PNEUMATIC SOURCE BEING -
ISOLATED TO THE DRWELL FOR PERSONNEL SAFETY WHILE IN THE DRWEL .
1453 (L) "B" RECIRCULATICN PUMP IS STARTED AND NORMAL
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RECIRCULATION FLOW IN BOTH LOOPS IS ESTABLISHE (L) PRIMARY / SECONDARY CONTAINMENT IS ANNOUNCED AS
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BEING IN EFFECT IN PREPARATION FOR A UNIT START'J (P) GENERAL PROCEDURE (GP)-01, STARTUP CHECKLIST, IS SIGNED OFF AS CCMPLETE.
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- THE PROCEDURE "O RESTORE LPCI (OP-17) TO THE STANDBY LINEUP :S A PREREQUISITE TO SIGNING GP-01 ( (STEP 5.1.15). OP-17 WAS STILL BEING PERFORMED.
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ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 SEQUENCE OF EVENTS 1507 (L)
VESSEL SHELL TEMPERATURE IS VERIFIED TO BE WITHIN
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LIMITS ESTABLISHED BY TECHNICAL SPECIFICATION FIGURE 3.4.6.1-2 IN ACCORDANCE WITH GP-02, APPROACH TO CRITICALITY AND PRESSURIZATION OF THE REACTO (L)
COMMENCED REACTOR STARTUP WAS ANNOUNCED BY SHIFT
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FOREMA 'THE STARTUP SRO NOTIFIED THE SHIFT FOREMAN THAT THE LPCI SYSTEM HAD NOT BEEN RESTORED TO THE STANDBY LINP.UP PER OP-1 THE STARTUP WAS HALTED BY SHIFT FOREMAN PRIOR TO THE CONTROL ROD SELECT SYSTEM BEING ENERGIZED AND THE CCNTROL OPERATOR WAS NOTIFIED TO SECURE FROM THE STARTUP UNTIL DIRECTED BY THE SHIFT FOREMA r O
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ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 SEQUENCE OF EVENTS 1546 (P) OP-17 IS SIGNED OFF AS COMPLETE, THUS RESTCRING THE LPCI "B" LOOP TO ITS STANDBY LINEU (P) THE TIME FOR COMPLETION OF GP-01 IS CHANGED TO REFLECT A TIME OF 1600 VICE THE INITIAL ENTRY OF 150 * AT THIS TIME, THE STARTUP WAS RECOMMENDED IN
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ACCORDANCE WITH GP-0 (C) COM'4ENT (L) OPERATIONS LOG ENTRY (P) PROCEDURE ENTRY (*) INVESTIGATOR COMMENT
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA FOWEP G LIGHT COMPANY MAY 27, 1988 MODE SWITCH EVENT
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O MODE CHANGE FROM MODE 4 TO MODE 2, UNREALIZED 0 MODE SWITCH WAS IN STARTUP/ HOT STANDBY AT SHIFT TURNOVER FOR REQUIRED TESTIN .
O WE DID NOT CONSIDER REACTOR TO BE TN MODE O MODE CONSIDERED TO BE 4, COLD SHUTDOW O THIS IS LONG-TERM HISTORICAL PRACTIC .
O PROCEDURES WERE COMPATIBLE AND CONSISTENT WITH THIS INTERPPETATIO O ROD WORTH MINIMIZER TESTING IN PROGRESS AT SHIFT TURNOVE O WE WERE IN GP-01, STARTUP CHECKLIST; GP-02, APPROACH TO CRITICALITY AND PRESSURIZATION OF THE REACTOR, COh'1' ROLLED THE MODE CHANG O STATUS OF TESTING REQUIRING MODE SWITCH TO BE IN STARTUP RAD NOT BEEN DETERMINED TO BE COMPLET j
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ENFORCEMENT MEETING BRUNSW!CK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 MODE SWITCH EVENT O
MODE CHANGE FROM ?CDE 4 TO MODE 2, UNREALIZED O
B LOOP RHR WAS IN SHUTDOWN COOLING,
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MAINTAINING COOLANT TEMPERATURE LESS THAN O
212 F TO PRECLUDE ENTERING MODE 3, HOT SHLTDOWN .
O PRIMARY CONTAINMENT WAS NOT IN EFFECT;
. DRYWELL WAS STILL ACCESSE O CORRECTIVE ACTIONS TO ENSURE REACTOR MODE IS CONSISTENT BETWEEN TECHNICAL SPECIFICATIONS AND PROCEDURES O GP REVISION O CLASSROCM AND SIMULATOR TRAINING TO I! GROVE OPERATICNS CONTROL OF REACTOR MODE RELATIVE TO THIS EVENT (ROS AND SROS).
O DETAILED REVIEW OF GP VS. TECHNICAL SPECIFICATIONS REQUIREXENTS TO VERIFY FULL COMPLIANCE DURING MAJOR PM EVOLUTION _ - _ - _ - - - - - - - - - - -
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 MODE SWITCH EVENT O MODE CHANGE FROM MODE 4 TO MODE 2, UNREALIZED 0 B LOOP RHR WAS IN SHUTDOWN COOLING,
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MAINTAINING COOLANT TEMPERATURE LESS THAN
212 F TO PRECLUDE ENTERING MODE 3, HOT SHLTDOWN .
O PRIMARY CONTAINMENT WAS NOT IN EFFECT; DRYWELL WAS STILL ACCESSE .
O CORRECTIVE ACTIONS TO ENSURE REACTOR MODE IS CONSISTENT BETWEEN TECHNICAL SPECIFICATIONS AND PROCEDURES
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O GP REVISION O CLASSROCM AND SIMULATOR TRAINING TO IMPROVE l OPERATICNS CONTROL OF REACTOR MODE RELA"IVE TO THIS EVENT (ROS AND SROS).
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O DETAILED REVIEW OF GP VS. TECHNICAL SPECIFICATIONS REQUIREXENTS TO VERIFY FULL COMPLIANCE DURING l MAJOR P*.JST EVOLUTIONS.
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l ENFORCEMENT MNETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 MODE SWITCH EVENT O IMPRUDENT DECISION-MAKING O DECISION TO LEAVE MODE SWITCH IN STARTUP AFTER
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COMPLETION OF ROD WORTH MINIMIZER TESTIN O CONSIDERED REACTOR MODE TO BE CONDITION O PT-01.6.2-2, RWM TEST, REQUIRED A DECISION TO BE MADE--EITHER PLACE REACTOR MODE SWITCH TO SHUTDOWN OR VERIFY THE PREREQUISITES ARE MET -
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FOR LEAVING THE MODE SWITCH IN STARTUP
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PENDING REACTOR STARTU O CONSIDERING THE MODE TO BE CONDITION 4, THE ONLY LOGICAL DECISION WAS TO PLACE THE MODE
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SWITCH TO SHUTDOWN OR DO NOT.
l 0 SINCE RSCS TEST WAS REQUIRED, THE DECISION WAS MADE TO NOT PLA*E THE MODE SWITCH TO SHUTDOW O THIS DECISION WAS SUPPORTED BY THE STARTUP SR ._
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 MODE SWITCH EVENT O IMPRUDENT DECISION-MAKING
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O DECISION TO LEAVE MODE SWITCH IN STARTUP AFTER
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COMPLETION OF RSCS TESTIN O PT-01.6.1, RSCS OPERABILITY TEST, DID NOT REQUIRE A DECISION BE MADE AT TEST COMPLETION CONCERNING THE REACTOR MODE SWITC O CONSIDERED REACTOR TO STILL BE IN MODE O ROD WITHDRAWAL FOR THE PURPOSES OF MAKING THE REACTOR CRITICAL WAS THOUGHT TO BE IMMINEN .
O REMAINING STARTUP ITEMS WERE FIN AND STATUS WAS VIRTUALLY COMPLETE O HAD NOT VERIFIED THAT ALL REQUIREL TESTING WHICH REQUIRED THE MODE SWITCH TO BE IN STARTUP/ HOT STANDBY WAS COMPLETE O DID NOT DESIRE TO INSERT UNNECESSARY ACTUATION OF RPS LOGIC BY PLACING MODE SWITCH TO SHUTDOW .- .. . . _ , - , . .- - .-
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e ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA, POWER & LIGHT COMPANY MAY 27, 1988 MODE SWITCH EVENT O IMPRUDENT DECISICN-MAKING O DID NOT DESIRE TO SHOCK CRD SEALS BY AN
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UNNECESSARY DISCHARGE OF HCUS WITH RODS ALL FULL-I O CORRECTIVE ACTIONS TO IMPROVE DECISION-MAKING ABIL. TTY RELATIVE TO THE EVEN O REVISIONS TO GP-01, GP-02, AND PT O STANDING INSTRUCTION 88-04 O CLASSROO!! AND SIMULATOR TRAINING WITH EMPHASIS ON PROPER MODE SWITCH POSITIO ,
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPAb"!
MAY 27, 1988 MODE SWITCH EVENT O PREMATURE SIGN-OFF OF GP-01 (SHUTDOWN COOLING SECURED PER OP-17)
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O AMBIGUOUS WORDING OF STATEMENT IN GP-0 O NOT SPECIFIC ENOUGH--INCOMPLETE INTEN O PLACEMENT OF THIS STEP IN GP-01 NOT COMPATIBLE WITH THE NECESSITY TO ENTER MODE 2 TO COMPLETE ROD WORTH MINIMIZER AND RSCS PT .
O UNIT SRO INEXPERIENCED IN SRO ASPECTS OF SIGN-OFFS OF STEPS IN GP-0 O COUNTED ON RO'S STATEMENT, "SH'7")OWN COOLING SECURED," AS BENCHMARK TO INITIATE SIGN-CFF OF i PROCEDURAL STEP INSTEAD OF AFTER-THE-FACT REVIEW OF THE COMPLETED PROCEDURES OR CO LOG ENTRY OF ATTAINING STANDBY LPCI LINEU O UNIT SRO USED RTGB INDICATION TO VERIFY LPCI IN STANDBY--AN E LOWABLE. STEP IN FREVIOUS PORTION OF GP-01 FOR THE OTHER LOO ,
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 MODE SWITCH EVENT O PREMATJRE SIGN-OFF OF GP-01 (SHUTDOWN COOLING SECURED PER OP-17)
O GP-01, STARTUP CHECKLIST, WAS COMPLETED BASED ON THE RO R1' PORT AND THE SRO OBSERVANCE OF CONTROL ROOM
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INDICATIO O GP-0.?, SOS AND SHIP 1' FOREMAN PERMISSION SIGN-OFFS, WAS VIEWED AS THE CONTROLLING POINT FOR ENTERING MODE '
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O EXPLAIN CORRECTIVE ACTIONS, HOW THE ERROR WAS IDENTIFIED AND CORRECTED, AND ACTIONS TO PREVENT ROD l PULL, INCLUDING INFORMING SOS OF PLANT STATUS.
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 MODE SWITCH EVENT O FURTHER IMPROVEMENTS TO ENSURE TECHNICAL SPECIFICATION COMPLIANCE
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O ON-SHIFT TRAINING ON THIS EVEN O STREAMLINE GPS AND OTHER PERTINENT PROCEDURES TO IDENTIFY AMBIGUOUS STEPS, IMPROVE USABILITY, AND VERIFY FORMAT OF GPS IS CONSISTENT WITH REGULATION BUT NOT
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OVERLY RESTRICTIV O THE OPERATIONS STAFF AT BRUNSHICK IS INTENT ON ELIMINATING NRC CONCERNS ABOUT CUR ABILITY TO CONTROL OUR PLANT AND IS DEDICATED TO DOING ALL THAT IS NECESSARY TO ENSURE THAT THESE CCRRECTIVE ACTIONS ARE EFFECTIVELY IMPLEMENTE O EACH AND EVERY LICENSED OPERATOR ON OUR STAFF SIP.RES OUR DESIRE TO ENSURE REGULATORY REQUIREMENTS ARE MET, AND I THANK YOU FOR THIS OPPORTUNITY TO PRESENT THE FRONT-LINE TROOP'S REPORT ON THIS EVEN .
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ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 CONTROL ROD 10-39 WITHDRAWN WITH THE SHORTING LINK INSTALLED
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DESCRIPTION OF EVEN_T FROM 0350 HOURS TO 2052 HOURS ON MARCH 8, 1988, CONTROL ROD 10-39
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ON UNIT 2 WAS IN THE 3'ULLY WITHDRAWN POSITION WITH THE SHORTING
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LINKS INSTALLED IN VIOLATION OF TECHNICAL SPECIFICATION IT IS NOTED THAT THE "FULL-OUT" RED LIGHT FOR CONTROL ROD 10-39 WAS NOT WORKIN CONTROL ROD 10-39 WAS WITHDRAWN IN ACCORDANCE WITH PLANT
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SURVEILLANCE TESTING TO VERIFY OPERABILITI BET 4EEN 2025 HOURS ON
' ARCH 7 AND 0029 HOURS CN MARCH 8; HOdEVER, THE CONTROL ROD WAS
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NOT REINSERTED AS REQUIRED BY THE PROCELUR AT 0350 HOURS ON MARCH 3, THE SHORTING LINKS hERE INSTALLED, THUS PLACING THE PLANT IN VIOLATION OF TECHNICAL SPECIFICATION , ._- _ _ _ . _-. _ _ - - . - . - . . . _ . -
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ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT
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CAROLINA POWER & LIGHT COMPAlu MAY 27, 1988 ,
CONTROL ROD 10-39 WITHDRAWN WITH THE SHORTING LINK INSTALLED CHRONOLOGY MARCH 7 1930 OD-7 OPTION 2 VERIFIES ALL RODS AT "O."
2025 SHORTING LINKS REMOVED IN PREPARATION FOR ROD TESTIN CONTROL ROD TESTING IS INITIATE MARCH 8 0029 CONTROL ROD MOVEMENT IS SECURE .
0037 OD-7 OPTION 2 INDICATES ALL CONTROL RODS AT "0" FJCCEPT THAT THE POSITION FOR 10-39 IS BLAN THIS SAME.
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VERIFICATION WAS PERFORMED AT 0215, 0534, 0640, AND 0720 HOURS WITH THE SAME RESULT SHORTING LINKS WERE INSTALLE OUTAGE SRO QUESTIONS WHY ROD DRIFT A:. ARM ON CONTROL ROD l 10-3 THE ALARM IS RESET.
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0700 SHIFT TURNOVER.
l 0900 A CLEARANCE IS PLACED ON THE ROD WORTH MINIMIZER SYSTEM WHICH PREVENTS THE SELECTION OF ANY CONTROL ROD WITH THE RLD SELECT SYSTEM.
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ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT
CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 CONTROL ROD 10-39 WITHDRAWN WITH THE SHORTING LINK INSTALLED CHRONOLOGY (CONTD)
MARCH 8 (CONTD)
1900 SHIFT TURNOVER
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l948 THE CONTROL OPERATOR NOTICED THE BLANK INDICATION FOR CONTROL ROD 10-39 WHILE PERFORMING AN OD-7 OPTION HE NOTIFIES THE SRO THAT CONTROL ROD 10-39 APPEARS TO NOT BE FULLY INSERTE THE CONTROL OPERATOR PERFORMS AN OD-7 OPTION 3 AND CONFIRMS THAT CONTROL ROD 10-39 IS FULLY WITHDRAW CONTROL ROD 10-39 IS FULLY INSERTED BY IN:!VIDUALLY SCRAMMING THE RC FINDINGS / CONCLUSIONS PROCEDURE WAS NOT FOLLOWE THE TEST PROCEDURES BEING USED TO TEST THE OPERABILITY OF THE COh' TROL RODS REQUIRE THAT THE CO m OL RODS BE EITHER FULLY REINSERTED OR LEFT AT A POSI*' ION AS DIRECTED BY THE NUCLEAR ENGINEER IF THE TESTING IS PERFORMED DURING POWER OPERATION.
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ENFORCEMENT MEETING
$RUNSWICKSTEAMELECTRICPLANT
CAROLINA POWER & LIGHT COMPANY l MAY 27, 1988 I
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CONTROL ROD ' 0-39 WITHDRAWN WITH THE SHORTING LINK INSTALLED FINDINGS / CONCLUSIONS (CONTD) OPERATIONS STAFF WAS NOT NOTIFIED OR TRAINED ON THE PROGRAM CHANGE PERFORMED ON OD-7 OPTION .
PRIOR TO THE SOF'IWARE CHANGE ON OD-7 OPTION 2, THAT PROGRAM WOULD HAVE INDICATED ROD 10-39 AT "48." THE CHANGE REMOVED THE PRINTOUT FOR ANY ROD AT "43" AND LEPT A BLANK FOR THAT RO THIS WAS DONE TO MAKE THE PRINTOUT LESS CONGESTED DURING POWER OPERATION WHEN
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MANY RODS ARE LOCATED AT "48." FAILURE OF THE "FULL-OUT" RF.D LIGH .
THE "FULL-OUT" RED LIGH hAD FAILED AT SOME TIME PRIOR TO THIS EVENT AND WAS ON THE OUTAGE SCHEDULE FOR REPAI IN ADDITION, THE FAILURE OF THIS INDICATOR WAS BEING TRACKED BY AN LC HAD THE LIGHT BEEN OPERABLE, THE OPERATIONS STAFF WOULD HAVE READILY IDENTIFIED THAT CONTROL ROD 10-39 WAS FJLL OU l l
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ENFORCEMENT NEETING NRUNSWICKSTEAMELECTRICPLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 CONTROL ROD 10-39 WITHDRAWN WITH THE SHORTING LINK INSTALLED CORRECTIVE ACTIONS THE CONTROL ROD WAS FULLY INSERTE . INVOLVED PERSONNEL HAVE BEEN COUNSELE . STANDING INSTRUCTIONS WERE ISSUED IDENTIFYING THE SOPIMARE CHANGE TO OD-7 OPTION . THE PROCESS OF SOFTWARE MODIFICATIONS WILL BE REVIEWED TO EVALUATE Ah"i CHANGES NECESSARY TO ENSURE FCRMAL OPERATOR TRAINING REQUIREMENTS ARE IDENTIFIE . APPROPRIATE PROCEDURES ARE BEING REVISED TO REQUIRE VERIFICATION THAT CONTROL RODS ARE RESTORE: TO THEIR REQUIRED POSITION.
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ENFORCEMENT MEETIM
$RUNSWICK STEAM ELECTRIC PidWT CAROLINA POWER & LIGHT COMPhNY *
MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON JANUARY 25, 198R DESCRIPTION OF EVENT WHILE ATIEMPTING TO STABILIZE THE UNIT 1 REACTOR COOLANT TEMPERATURE IN COLD SHUTDOWN, REACTOR COOLANT TEMPERATURE INCREASED FROM 120 DEGREES AT 2130 HOURS ON 1/25/88 TO 210 DEGREES AT 0430 HOURS ON 1/26/8 .
DIFFICULTY HAD BEEN EXPERIENCED IN MAIPTAINING THE DESIRED TEMPERATURE WHILE IN SHUTDOWN COOLIN AS COOLANT TEMPERATURE CONTINUED TO DECREASE, THE BYPASS AROUND THE HEAT EXCHANGER WAS FULLY OPENED, FOLLOWED BY THE THROTILING OF THE RESIDUAL HEAT REMOVAL (RER) HEAT EXCHANGER OUTLET VALVE, E11-F00 LATER IN THE SHIPr, THE F003 INADVERTENTLY WENT SHUT, THUS REMOVING SHUTDOWN COOLING CAPABILIT THIS WAS NOT RECOGNIZED BY THE i OPERATIONS STAFF FOR APPROXIMATELY 1 HOUR AND 45 MINUTES.
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ENFORCEMENT MEETING NRUNSWICKSTEAMELECTRICPLANT CAROLINA POWER & LIGHT COMPANY *
MAY 27, 1988 ,
INTERRUPTION OF SHUTDOWN COOLING ON JANUARY 25, 1988 CHRONOLOGY JANUARY 23 REACTOR IS SHUT DOWN IN PREPARATIONS FOR A SCHEDULED APPENDIX R MODIFICATION OUTAG JANUARY 24 1623 COLD SHUTDOWN IS REACHED (REACTOR COOLANT TEMPERATURE IS LESS THAN 212 DEGREE .
JANUARY 25 -
2000 REACTOR COOLANT TEMPERATURE IS 130 DEGREES BUT NOT STABILIZED; THE HEAT EXCHANGER BYPASS VALVE IS ADJUSTED IN AN ATIEMPT TO STABILIZE THE COOLDOW AS THE TEMPERATURE DECREASES TO APPROXIMATELY 90 DEGREES WITH THE BYPASS VALVE FULLY OPEN, THE OPERATOR BECAME CONCERNED ABOUT COOLANT TEMPERATURE DECREASING TO THE NDT LIMIT AND THE F003 WAS THROTILE _ ~ _ _ _, . _ _ _ _ _ _ -
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT -
CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON JANUARY 25, 1988 CHRONOLOGY (CONTD)
2130 REACTOR COOLANT TEMPERATURE IS STABILIZED AT 120 DEGREES WITH THE BYPASS VALVE FULLY OPENED AND 'mE F003 THROTTLE THE F003 IS DESIGNED AS AN OPEN OR CLOSE VALV THE CONTROL SWITCH FOR THIS VALVE HAS A "DEAD BAND" BETWEEN THE "OPEN " AND "CLOSE" POSITION
.
WHICH WILL CAUSE THE VALVE TO STOP TRAVEL AS IS (THROTTLED). USE OF THIS METHOD OF VALVE CCNTROL WAS ALLOWED BY PROCEDURE UP TO JUNE 198 THIS METHODOLOGY OF VALVE CONTROL WAS DELETED AS A RESULT OF THE CONTROL ROOM HABITABILITY STUDY, WHICH IDENTIFIED THAT THE VALVE WAS NOT BE NG OPERATED AS DESIGNE ACCORDING TO TEMPERATURE RECORDER TRACES, REACTCR COOLANT TEMPERATURE BEGAN TO INCREASE, INDICATING THAT THE F003 VALVE HAD CLOSE THIS WAS NOT IDENT FIED BY THE OPERATIONS STAFF AT THIS TIM .
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ENFORCEMENT MEETING
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NRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON JANUARY 25, 1988
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CHRONOLOGY (CONTD)
0430 THE CONTROL OPERATOR NOTED THAT TEZ RECIRCULATION LOOP TEMPERATURE WAS 202 DEGREE HE I N IATELY CHECKED
.
THE SHUTDOWN COOLING LINEUP AND FOUND THE F003 SHU .
THE F003 WAS RECPENED AND SHUTDOWN COOLING WAS REESTABLISHE THE TEMPERATURE IS NOTED TO BE AT 170 DEGREES AND DECREASIN THE HIGHEST TEMPERATURE REACHED DURING
.
THIS EVENT WAS 210 DEGREE .
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EHFORCEMENT MEETING NRUNSWICKSTEAMELECTRICPLANT CAROLINA POWER & LIGHT COMPANY *
MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON JANUARY 25, 1988 FINDINGS / CONCLUSIONS PROCEDURE NOT FOLLOWE ,
THE OPERATING PROCEDURE FOR ESTABLISHING AND MAINTAINING SHUTDOWN COOLING DOES NOT ADDRESS (AFTER 6/82) THE THROTILING OF THE F003 VALVE FOR SHUTDOWN COOLING OPERATION THE PROCEDURE DIRECTS -' HAT -
FOLLOWING THE OPENING OF THE BYPASS VALVE, THE OPERATOR SHOULD REDUCE SERVICE WATER FLOW AND THEN REDUCE RHR
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(REACTOR COOLANT) FLO IF THE COOLDOWN IS STILL EXCESSIVE, THE PROCEDURE DIRECTS THAT THE F")03 BE SHU THE OPERATING PROCEDURE WAS NOT REVIEWED DURING THIS EVENT AS SHUTDOWN COOLING HAD BEEN ESTABLISEED USING THE GENERAL PROCEDURE FOR PLANT SHUTDOW IN ADDITION, BECAUSE THE THROTTLING OPERATION WAS CONSI:ERED TO BE A
"SIMPLE EVOLUTION," THIS STEP WOULD NOT NEED TO BE PROCEDURALIZED.
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ENFORCEMENT MEETING NRUNSWICK STEAM ELECTRIC PLANT
CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON JANUARY 25, 1988 FINDINGS / CONCLUSIONS (CONTD) F003 WAS IMPROPERLY UTILIZED AS A THROTILE VALV .
THE F003 CONTROL SWITCH IS AN "OPEN/CLOSE" SNAP SWITCH WHICH DOES NOT HAVE A THROTTLING CAPABILIT PREVIOUS OPERATOR EXPERIENCE HAD NOTED THAT THERE WAS A "DEAD" POSITION BETWEEN THE "OPEN" AND "CLOSE" SWITCH POSITIONS THAT WOULD STOP VALVE MOVEMENT WHEN THE SWITCH WAS PLACED IN THAT POSITIO THIS HAD BEEN THE
.
PROCEDURALIZED METHOD TO CONTROL COOLDOWN WHEN SHUTDOWN COOLING WAS LOWERING THE TEMPERATURE BELOW THE DESIRED TEMPERATURE BAND AND THE HEAT EXCHANGER BYPASS VALVE WAS FULLY OPE THIS ME'."HOD HAD BEEN DELETED IN JUNE 1987.
l l REACTOR COOLANT TEMPERATURE WAS NOT APPROPRIATELY MONITORED.
(
TEMPERATURE RECORDERS INDICATE THAT THE REACTOR COOLANT l
l TEMPERATURE BEGAN TO INCREASE AT APPROXIMATELY 0245; HOWEVER, IT WAS NOT IDENTIFIED UNTIL APPROXIMATELY 0430.
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ENFORCEMENT MEETING
$RUNSWICKSTEAMELECTRICPLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON JANUARY'25, 1988 CORRECTIVE ACTIONS APPROPRIATE DISCIPLINARY ACTION HAS BEEN COMPLETF ' ON-SHIFT TRAINING ON THIS EVENT WAS CONDUCTED WITH EACH SHIFT EMPHASIZING PROCEDURAL REQUIREMENT . MAKING THE F003 A THROTILE VALVE IS BEING EVALUATED TO PROVIDE BETTER COOLDOWN CONTRO *
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! ENHANCED MES.ODS OF MONITORING THE STATUS OF SHUTDOWN .
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COOLING ARE BEIt!G EVALUATED.
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ENFORCEMENT MEETING NRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON MAY 11, 1988 DESCRIPTION OF EVENT WHILE PERFORMING MAINTENANCE ON THE E11-F003 VALVE, REACTOR
_
COOLANT TEMPERATURE INCREASED FROM 165 DEGREES AT 1400 HOURS T
.
205 DEGREES AT 2100 HOUR UNIT 2 WAS IN COLD SHUTDOWN MAINTAINING REACTOR COOLANT TEMPERATURE BETWEEN 160 AND 185 DEGREES WITH THE "A" LOOP OF TRR RESIDUAL HEAT REMOVAL (RHR) SYSTEM IN ACCORDANCE WITH OP-17 (MINIMUM RHR AND SERVICE WATER FLOW, HEAT EXCHANGER BYPASS VALVE F'JLLY OPEN, AND TEMPERATURE BEING CONTROLLED BY OPENING AND CLOSING THE RHR HEAT EXCHANGER OUTLET VALVE F003). MAINTENANCE WORK WAS IN PROGRESS ON THE E11-F003A DUE TO AN IDENTIFIED PROBLEM WHICH PREVENTED OPENING THE VALVE FROM THE RTG DURING W IS MAINTENANCE, THE F003 WENT SHUT FROM THE THROTTLED POSITICN, CAUSING A LOSS OF SHUTDOWN COOLING AND THE NOTED REACTOR COOLAh TEMPERATURE INCREAS ___ _ _ . . . . _ . .- --- - - -
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O ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY .
MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON MAY 11, 1988 CHRONOLOGY MAY 11, 1988 1255 PROBLEM IDENTIFIED WITH THE F003 VALVE; THE VALVE WILL
.
CLOSE BUT WILL NOT OPEN FROM THE RTG WORK IS INITIATED BY MAINTENANCE TO TROUBLESHOOT AND -
REPAIR THE PROBLEM WITH THE F003 VALV REAC'IOR
.
COOLANT TEMPERATURE IS 165 DEGREE .
1545 OPERATIONS STAFF DECIDES TO MANUALLY THROTILE THE F003
,
AND OPEN THE BREAKER (TO PREVENT INADVERTENT AUTOMATIC l
VALVE TRAVEL) TO ENSURE CHUTDOWN COCLING IS MAINTAINED
AT AN APPROPRIATE LEVEL WHILE MAINTINANCE WAS BEING l
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PERFORME THE VALVE WAS INITIALLY THROTILED TO 25%
OPEN AND WAS FINALLY THROTILED TO 15% OPEN TO MATCH THE HEAT LOAD.
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NRUNSWICKSTEAMELECTRICPLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 ,
INTERRUPTION OF SHUTDOWN COOLING ON MAY 11, 1988 CHRONOLOGY (CONTD)
MAY 11, 1988 (CONTD)
1630 THE F003 VALV8 BREAKER IS CLOSED TO ALLOW MAINTENANCE
.
PERSONNEL WORKING ON THE VALVE TO TAKE ELECTRICAL READINGS AND THEN REOPENE CHART RECORDINGS INDICATE THAT THE F003 VALVE WENT CLOSED DURING THIS EVOLUTION; HOWEVER, THIS ACTION WAS NOT RECOGNIZED BY THE OPERATIONS STAFF, AS VALVE POSITION INDICATION IS LOST WHEN THE BREAKER IS OPE REACTOR COOLANT TEMPERATURE WAS 170 DEGREES AT THIS TIM THE CONTROL OPERATOR NOTICES THAT THE RHR HEAT EXCHANGER INLET TEMPERATURE IS LOWER THAN THE OUTLET TEMPERATURE AND NOTIFIES THE SR THE SRO DECIDES THAT THE HEAT EXCHANGER IS STILL STABILIZING AND INSTRUCTS THE CONTROL OPERATOR TO MONITOR THE INLET AND OU'.~LET TEMFERATURE SHIFT TURNOVER INCLUDES DISCUSSIONS ABOUT THE F003 PROBLEM AND THE UNUSUAL TEMPERATURE READING ON THE RECORDE I
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ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT CAROLIliA POWER & LIGHT COMPANY -
MAY 27, 1988 INTERRUPTION OF SIRJTDOWN COOLING ON MAY 11, 1988 CHRONOLOGY (CON'It)
MAY 11, 1988 (CONTD)
2000 THE NIGHT SHIFT NOTICES A DISCREPANCY BE'1VEEN THE
.
~ LOGGED REACTOR COOLANT TEMPERATURES AND THE INDICATED
-
RECIRCULATION LOOP AND REACTOR WATER CLEANUP TEMPERATURES, WHICH WERE HIGHE THE CONTROL OPERATOR OBSERVES THAT THE HEAT EXCHANGER OUTLET TEMPERATURE IS 205 DEGREES AND NOTIFIES THE SR THEY CONCLUDE THAT THE F003 VALVE MUST BE CLOSE AN OPERATOR IS SENT TO MANUALLY OPEN THE F003 VALV THE F003 VALVE IS OPENED 25% AND FLCW IS ESTABLISHED THROUGH THE HEAT EXCHANGER, THUS REESTABLISHING SHUTDOWN COOLIN .
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ENFORCEMENT MEETING
$RUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY -
MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON MAY 11, 1988 FINDINGS / CONCLUSIONS THE OPERATIONS STAFF WAS MAINTAINING THE REACTOR COOLANT TEMPERATURE IN ACCORDANCE WITH PLANT PROCEDURES WHEN A
.
COMPONENT PROBLEM PREVENTED F003 REMOTE OPERATIO ACTIONS TAKEN BY 'rHE OPERATIONS STAFF TO MAINTAIN REACTOR COOLANT TEMPERATURE (THROTTLE THE F003) WERE PRUDEN . THE OPERATIONS STAFF RECOGNIZED EARLY IN THE HEATUP THAT THE
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TEMPERATURES BEING MONITORED WERE NOT FOLLOWING THE EXPECTED TREN THESE TEMPERATURE TREND DEVIATIONS WERE MCNITORED AND INVESTIGATED BY THE OPERATIONS STAFF UNTIL THE CAUSE WAS t
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IDENTIFIED, AT WHICH TIME APPROPRIATE ACTION WAS TAKE CORRECTIVE ACTIONS THE F003 WAS MANUALLY THROTTLED APPROXIMATELY 25% OPEN, AND l THE REACTOR COOLANT TEMPERATURE WAS LOWERED AND MAINTAINED l AT 125 TO 150 DEGREES.
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ENFORCEMENT MEETING NRUNSWICKSTEAMELECTRICPLANT
CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 INTERRUPTION OF SHUTDOWN COOLING ON MAY 11, 1988
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CORRECTIVE ACTIONS (CONTD) THE PLANT IS REVIEWING THE POSSIBILITY OF MODIFYING THE F003 VALVE AND LOGIC TO ALLOW THROTTLE OPERATIO THIS FEATURE
.
IS NEEDED DURING TIMES OF LOW DECAY HEAT WHEN THE ONLY REMAINING CONTROL IS TO OPEN AND SHUT THE F003 FOR TEMPERATURE CONTRO . THE PROCEDURE FOR CONTROLLING SHUTDOWN COOLING OPERATION
.
(OP-17) IS BEING REVIEWED TO DETERMINE IF IT SHOULD BE REVISED TO ALLOW THRCfITLING DURING LOW HEAT LOAD CCNDITION IF REVISED, PROPER PRECAUTIONS AND CONTROLS WILL BE ESTABLISHED TO ENSURE SHUTDOWN COOLING IS MAINTAINE l
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ENFORCEMENT MEETING DRUNSWICK STEAM ELECTRIC PLANT -
CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 O OPERATIONS PERFORMANCE FACTORS O MANAGEMENT PROCESS O SCHEDULES AND RESOURCES O PROCEDURAL ADEQUACY ;
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O TRAINING O PERSONNEL 0 MOTIVATION AND COMMITMENT O DISCIPLINE OF OPERATIONS '
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O EQUIPMENT +-
O PERFORMANCE AND RELIABILITY O DESIGN ADEQUACY
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ENFORCEMENT MEETING BRUN3 WICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 0 OPERATIONS PERFORMANCE FACTORS O MANAGEMENT PROCESS O SCHEDULES AND RESOURCES
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O INITIATED AN INDEPENDENT ASSESSMENT OF THE ENP ROTATIONAL SCHEDULE (12-HOUR SHIFTS) TO DETERMINE POTENTIAL FATIGUE FACTO O TO BE COMPLETED BY NSSS PERSONNEL BY
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_ 8/8 O ASSESSED MANNING LEVELS TO EFFECTIVELY CARRY OUT ASSIGNED TASKS (INFORMAL).
O ACTION COMPLETE WITH NO RECOMMENDED CHANGES; UTILIZATION OF THE STARTUP SRO IS EFFECTIV s. k g,
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 O OPERATIONS PERFORMANCE FACTORS
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O MANAGEMENT PROCESS O SCHEDULES AND RESOURCES O ASSESSED SCHEDULED WORK ACTIVITIES TO ENSURE REALISM IN SCHEDULE DFEAND O ACTION IS COMPLETE WITH NO RECOMMENDED CHANGES; ONGOING EFFORT TO ENSURE THAT M NAGEMENT ATl'ITUDES DO NOT CREATE UNNECESSARY SCHEDULAR STRES O PROCEDURAL ADEQUACY
.
O INITIATED COMPLETE PEVIEW OF GP-01 THROUGH GP-07 TO CLARIFY THE SCOPE OF PF.OCEDURAL l
l ACTIONS, DOCUMENTATION OF PROCEDURAL SIGN-OFFS, AND IMPROVED SEQ'JENCE OF EVENTS.
I l 0 TO BE COMPLETE BY 9/88.
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 O OPERATIONS PERFORMANCE FACTORS O MANAGEMENT PROCESS O PROCEDURAL ADEQUACY O ISSUED MEMORANDUM OF INSTRUCTION RELATED TO MODE CHANGES; PROVIDED CLARIFICATION OF ALLOWABLE MODE SWITCH MANIPULATION TO SUPPORT RELATED SURVEILLANCE TESTIN .
O INTERIM ACTION IS COMPLET O PERF.ANENT ADMINISTRATIVE CHANGES TO BE COMPLETE BY 8/8 O TRAINING O INITIATED REAL-TIME TRAINING FOR ALL OPERATIONS SHIFTS COVERING MODE SWITCH CHANGES AND HEATUP EVENT O ACTION IS COMPLET .
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ENFORCEMENT MEETING n BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMJANY MAY 27, 1988 O OPERATIONS PERFORMANCE FACTORS O MANAGEMENT PROCESS O TRAINING
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O INITIATED REQUEST TO THE NUCLEAR TRAINING SECTION TO INCORPORATE LESSONS LEARNED FROM THESE EVENTS INTO INITIAL OPERATOR AND REQUALIFICATION TRAINING PROGRAM .
O TO BE COMPLETE BY 12/8 O INITIATED DEVELOPMENT OF AN INTERNAL TRAINING PROGRAM TO BE PROV:DED TO NEW SRO PERSONNEL FOCUSING ON THE ADDITIONAL MANAGEMENT RESPONSIBILITIES OF THAT LICENS O TO BE COMPLETE BY 11/8 . _ . . . _ _ -
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 O OPERATIONS PERFORMANCE FAC'IORS
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O PERSONNEL O MOTIVATION AND COMMI'IMENT
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O OPERATIONS PERSONNEL ARE TOTALLY COMMITIED TO ATIEMPTING TO DO THEIR ASSIGNED TASKS WITHOUT ERRO .
O EVIDENCE OF PRIDE IN THEIR JOBS AS MEASURED IN A VARIETY OF WAY O PERSONAL OPINION BASED UPON INTERACTION, OBSERVATION , 'AND EXPOSURE OVER THE PAST ,
SEVEN YEARS.
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY
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MAY 27, 1988 0 OPERATIONS PERFORMANCE FACTORS O EQUIPMENT O PERFORMANCE AND RELIABILITY / DESIGN
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O FACTORS AFFECTED THE UVENTS BUT WERE NOT SIGNIFICANT IN INFLUENCING THE CONCLUSIO O EQUIPMENT FAILURES PROVIDED SOME LEVEL OF MITIGATION TO THE SEQUENCE OF EVENTS BUT DO NOT COMPENSATE FOR THE LACK OF ATTEh"IIVENESS TO PLANT AND EQUIPMENT CONDITIONS.
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l O INITIATED AN ASSESSMENT OF DECAY HEAT REMOVAL
- PROCEDURES AND RELATED EQUIPMENT APPLICATIONS TO DETERMINE THE ADEQUACY OF PROCEDURAL i CONTROLS AND RECOMMENDED VALVE MANIPULATIONS.
l THIS EFFORT WILL ALSO INCLUDE DETERMINING THE NEED FOR PRIMARY COOLANT TEMPERATURE ALARMS WHEN OPERATING IN MODES FOUR AND FIV O TO BE COMPLETE BY 11/88.
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIO PLANT CAROLINA POWER & LIGHT COMPANY
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MAY 27, 1988 O OPERATIONS PERFORMANCE FAC'IORS O EQUIPMENT O PERFORMANCE AND RELIABILITY / DESIGN
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O FACTORS AFFECTED THE EVENTS BUT WERE NOT SIGNIFICANT IN INFLUENCING THE CONCLUSIO O EQUIPMENT FAILURES PROVIDED SOME LEVEL OF MITIGATION TO THE SEQUENCE OF EVEh7S BUT DO NOT COMPENSATE FOR THE LACK OF A'I'IENTIVENESS TO PLANT AND EQUIPMENT CONDITION O INITIATED AN ASSESSMENT OF DECAY EEAT REMOVAL PROCEDURES AND RELATED EQUIPMENT APPLICATIONS TO DETERMINE THE ADEQUACY OF PROCIDURAL l CONTROLS AND RECOMMENDED VALVE MANIPULATIONS.
l l THIS EFFORT WILL ALSO INCLUDE DETERMINING THE l
NEED FOR PRIMARY COOLANT TEMPERATJRE ALARMS WHEN OPERATING IN MODES FOUR AND FIV O TO BE COMPLETE BY 11/88.
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY MAY 27, 1988 L
O OPERATIONS PERFORMANCE FACTORS O PERSONNEL O DISCIPLINE OF OPERATIONS
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O SELF-INITIATED ACTION BY THE OPERATIONS
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"ON-Q" PROJECT QUALITY TEAM TO DEVELOP RECOMMENDATIONS THAT WILL MORE CLEARLY DEFINE
"SKILL OF THE CRAFT" RELATED TO ROUTINE -
EVOLUTIONS SUCH AS VALVE THRO'ITLIN '
O ACTION TO BE COMPLSTE BY 7/88.
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O INITIATED DEVELOPMENT OF TRAINING PROGRAM INSTRUCTIONS THAT WILL EMPRASIZE INCREASED ACCOUNTABILITY 'IO OBTAIN GUIDANCE FROM OPERATIONS MANAGEMENT IN APPROPRIATE INTERPRETATION OF PROCEDURAL INTEN THIS ACTION IS INTENDED TO MINIMIZE PERSONAL JUDGMEN ,
O ACTION TO BE COMPLETE BY 8/8 s-l
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY
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MAY 27, 1988 O ASSESSMENT OF BNP OPERATIONS O PRECURSORS O EVENTS INDIVIDUALLY DO NOT REPRESENT A SERIOUS CO$ PROMISE OF PLANT SAFETY OR EVIDENCE OF A DETERIORATING OPERATIONAL COMPETENC O EVENTS IN SUMMATION CREATE BASES FOR CONCERN THAT BNP IS DEVELOPING AN UNFAVORABLE PERFORMANCE TREN *
O INDEPENDENT AND INTERNAL ASSESSMENTS O QA/QC O INTERNAL PERFORMANCE ANALYSIS O INPO
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. ENFORCEMENT MEETING BR9.tSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COM?ANY
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MAY 27, 1988 O ASSESSMENT OF BNP OPERATICHS O QA ASSESSMENT OF OPERATIONS O REQUESTED BY THE PLANT GENERAL MANAGER AS A %ERJLT
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OF POTENTIAL DEVELOPMENT OF A NEGATIVE PERFORMANCE TREND INDICATIVE OF DETERIONATING OPERATIONAL COMPETENC ,
O FINDINGS: (MEMORANDUM: BNP/Qh/QC-88-139 JONES TO
DIETZ)
O "WE HAVE COMPLETED OUR OVERALT, ASSESSMENT OF !
THE OPERAT:CNS SUBUNIT AS REQUESTED. THIS ASSESS!*ENT INCLUDED:
-
REVIEW OF QA SURVEILLANCE REPORTS PERTA:NING TO OPERATIONS ACTIVITIE '
- REV7,D' OF NCRS , FIELD REPORTS, ITEMS CF CONCERN, QA AUDIT DEFICIENCIES, OERS, NRC V OLATIONS, m LER OPERACIONS PRACTICE THE REVIEW FOCUS WAS TO DETERMINE IF THERE IS AN APPARENT OR REAL TREND RELATIVE TO OPERATIONS-CAUSED ERROR WE CONCLUDE THERE IS INSUFFICIENT EVIDEHCE TO INDICATE THERE IS A TREND TO SUPPORT
' OPERATIONS IS WEAK.'" +
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY
MAY 27, 1988 O ASSESSMENT OF BNP OPERATIONS O INTERNAL PERFORMANCE ANALYSIS O ATIEMPTED TO IDENTIFY PERFORMANCE TREND BY
.
EXAMINING PREVIOUS PERSONNEL ERROR EXPERIENC FOUR CATEGORIES WERE UTILIZED AS FOLLOWS: INATIENTION TO DETAIL O ERROR PERFORMING TASKS DUE TO OVER-
CONFIDENCE, RUSHING, OR MENTAL LAPS I PROCEDURE NONCOMPLIANCE O PERFORMANCE OF TASKS GOVERNED BY PROCEDURE BUT SEQUENCE / INSTRUCTIONS WERE NOT FOLLOWE III. EXPERIENCE O ERRORS MADE BASED ON THE KNOWLEDGE OF THE INDIVIDUAL RELATED TO TIME IN POSITION AND PPEVIOUS WORK EXPERIENC I ACCEPTED PRACTICE IN PAST O ERRORS PERFORMING TASKS USING GUIDELINES OR PRACTICES ACCEPTED AS ADECUATE IN THE PAST WHICH HAVE BEEN IDENTIFIED TO BE INADEQUATE DUE TO CHANGING PHILOSOPH J
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4 ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY
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MAY 27, 1988 O ASSESSMENT OF BNP OPERATIONS O INPO O REVIEWED HISTORICAL DATA TO DETERMINE THE EXTENT OF PREVIOUS INPO FINDINGS AS ILLUSTRATED BY FIGURE O REVIEWED INPO EVALUATION RESULTS COMPLETED IN
'
DECEMBER 1987 RELATIVE TO PERFORMANCE OBJECTIVE:
OPERATIONS ORGANIZATION SHOULD ENSURE EFFEC C.*E IMPLEMENTATION AND CONTROL OF OPERATIONS ACTIVITIE . _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ _ -
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT
. CAROLINA POWER & LIGHT COMPANY
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MAY 27, 1988 O ASSESSMENT OF BNP OPERATIONS O INPO O INPO FINDING (OP.1-1)
"INITIATIVES TO PROMOTE EXCELLENCE IN OPERATIONS HAVE BEEN DEVELOPED USING OPERATOR INVOLVEMENT IN A WELL-FOCUSED MANMP FOR EXAMPLE, THE OPERATIONS MISSION STATEMENT, WHICH BROADLY DEFINES THE OPERATIONS DEPARTMENT'S GOAL FOR ACHIEVING EXCELLENCE, WAS THE PRODUCT OF AN OPERATIONS IMPROVEMENT WORKSHOP ATIENDED BY STATION SHIFr OPERATING SUPERVISORS AND FOREME , BREAKOUT SESSIONS WERE USED TO LAY THE GROUNDWORK FOR A COMPREHENSIVE ACTION PLAN FOR ACCOMPLISHING THE MISSION. IN ADDITION, THE "AWARD FOR EXCELLENCE IN OPERATIONS" WAS DEVELOPED BY
,
REPRESENTATIVES FROM ALL OPERATING CREWS. THE
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OBJECTIVE OF THIS AWARE IS TO PROMOTE ACHIEVEMENT I OF KEY GOALS DEFINED BY THE OPERATORS BY i
RECOGNIZING OUTSTANDING CREW PERFORMANC MEASURABLE OBJECTIVES SUCH AS PERSONNEL ERROR REDUCTION, SAFETY AWARENESS, AND REQUALIFICATION EXAM PERFORMANCE ARE USED TO MEASURE PROGRESS l TOWARD THE GOAL INDIVIDUAL CREW BRAINSTORMING l SESSIONS HELD DURING THE REQUALIFICATION TRAINING l
CYCLE ARE FOCUSED ON IDENTIFYING METHODS THAT EACH
! CREW WILL USE TO ACHIEVE THE GOALS."
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O?. 3RA?::0NS 33303 ASS 3SSEBXT mts
.-
EVENT.BY SOURCE TYPE dis M TR w UNIT i OUTAGE i i UNIT 2 OUTAGE _
5-4 .
EVENTS
" '
.--.,_.---..,- =, ' . .
. .
0 ,
TOTAL NUMBER OF EVENTS 6-.
,,
'
NO. OF *S
.. '3
EVENTS ....
'
2 2 2
R 87 M g
NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT j
'
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,
IXPO F:XJJG ?]3 CA .'3G03Y 1981-:.987
32- -
30 .
28 .
'
26 .
24--
'
l 22 .
l NO. OF 20 - /'//
' '//
FINDINGS 18 ./
16- -
$4" "r
/o/ m, ii i
' j'
12-
-! !! !
.i i i
,
i -
' ~
l 8--b l !,l l ../'
'
' ' ' ' YV V :-
l 6' '
7_4.'..l js 'V.V's/.7 s . i V*
x N N A ,^^N 4 .
-
/ /, /,/ /,'/ / /,/ , ' / 's
0
-
i i
-
,
-
i
,
-
- +>->>'+
i m
"
i 1981 1983 1984 1986 1987
'
O OSA B MAINT G TECH SUP g OPS [2] APSC O BG G OVAL
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ENFORCEMENT MEETING BRUNSWICK STEAM ELECTRIC PLANT CAROLINA POWER & LIGHT COMPANY
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MAY 27, 1988 O CONCLUSIONS O EVENTS DISCUSSED TODAY ARE CONSIDERED TO BE SIGNIFICANT DEFICIENCIES IN BNP OPERATIONS QUEST FOR EXCELLENC O NEITHER INTERNAL NOR INDEPENDENT ASSESSMENTS OF THESE EVENTS INTEGRATED WITH PREVIOUS YEARS' EXPERIENCE ,
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SUPPORTS A DETERMINATION THAT PLANT OPERATIONS HAVE INCURRED SIGNIFICANT DETERIORATIO O THE SEQUENCE OF EVENTS REFLECT OPERATIONAL DEFICIENCIES RELATED TO PROCEDURAL ADEQUACY, STRI'"r PROCEDURAL ADHERENCE, INATTENTIVENESSTODETAhL,ANDINADEQUATE TRAINING RELATED TO MODE SWITCH EVOLUTION O INVESTIGATIVE EFFORTS HAVE BEEN TIMELY AND AGGRESSIVE; OPERATIONS STAFF INPUT HAS BEEN SELF-CRITICAL WITHOUT DEFENSIVENES O CORRECTIVE ACTIONS TO PRECLUDE RECURRENCE HAVE BEEN OR ARE BEING PURSUED AGGRESS!'!ELY.