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Discusses 971202,pre-decisional Enforcement Conference in Arlington,Tx Re Circumstances Surrounding Two Incidents Involving Loss of Shutdown Cooling & Two Apparent Violations Identified in Insp Rept 50-458/97-15.Attendance List Encl
	ML20197G660
Person / Time
Site:	River Bend
Issue date:	12/24/1997
From:	Gwynn T; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Mcgaha J; ENTERGY OPERATIONS, INC.
References
	50-458-97-15, EA-97-497, NUDOCS 9712310084
	Download: ML20197G660 (71)
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John R. McGaha, Vice President - Operations

River Bend Station ;

Entergy Operations, inc;

P.O. Box 220

St. Francisville, Louisiana 70775

SUBJECT: PRE-DECISIONAL ENFORCEMENT CONFERENCE SUMMARY

Dear Mr. McGaha:

? On December 2,1997, a pre-decisional enforcement conference was held with representatives

of Entergy Operations Inc., River Bend Station in the Region IV Office - Arlington, Texas, to

discuss the circumstances surrounding two incidents involving the loss of shutdown cooling and

two apparent violations identified in NRC Inspection Report 50-458/97-15. This meeting was

held at the request of the NRC,

The licensee presented their perspective and circumstances surrounding the issues, long-term

corrective actions, and their enforcement perspective. The attendance list and the licensee's

presentation are enclosed with this summary.

In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this summary and

_

its' enclosures will be placed in the NRC Public Document Room,

Sincerely,

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, Division of Reactor Projects

Docket No.: 50-458

License No.: NPF-47

Enclosures:

1J Attendance List

2. Licensee's Presentation

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Executive Vice President and-

Chief Operating Officer.

Entergy Operations lInc.-

P.O. Box 31995

Jackson, Mississippi ;39286-1995

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? Vice President

Operations Support

Entergy Operations, Inc.

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' P.O. Box 31995

Jackson, Mississippi 39286-1995

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LGeneral Manager

( Plant Operations

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Entergy Operations,' inc.

P.O.' Box 220'

St. Francisville, Louisiana 70775.

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Director- Nuclear Safety

River Bend Station

. Entergy Operai;ons, Inc.

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P.O. Box 220

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' 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.

1 Washington,' D.C. : 20005-3502.

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- Manager - Licensing :

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River Bend Station

Entergy Operations, Inc,

- P.O. Box 220 (

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' St. Francisville, Louisiana -70775:

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"The Honorable Richard P. leyoub..

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Attorney General .

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i Piesident of West Feliciana

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LJoint Ownership Manager

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1 William H. Spell,' Administrator

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ENCLOSURE 1

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PREDECISIONAL ENFORCEMENT CONFERENCE ATTENDANCE

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- LICENSEE / FACILITY

ENTERGY OPERA flONS INC. RIVER BEND STATION

DATE/ TIME

DECEMBER 2,1997

1:00P.M. CST

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REGION IV OFFICE, ARLINGTON, TEXAS

CONFERENCE

LOCATION

EA NUMBER

97-497

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1:00P.M. CST

CONFERENCE

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ENCLOSURE 2

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Opening Remarks

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Introduction

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RF-7 Decay Heat Conditions

Agenda

Opening Remarks

John McGaha

Vice President, Operations

Introduction

Rick King

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Director, NS&RA

Management Overview

Joel Dimmette

General Plant Manager

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Inadvertent Mode Change

Dan Dormady

Manager, Plant Engineering

Loss of Shutdown Cooling

Bi!! O'Malley

Manager, Operations

Long-Term Corrective Actions

Joel Dimmette

General Plant Manager

Enforcement Perspective

Rick King

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Director, NS&RA

Closing Remarks

John McGaha

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Vice President, Operations

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Management Overview

Joel Dimmette

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General Plant Manager

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Barriers In Place

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- RHR Chemical Cleaning

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Barriers In Place

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Evolution and Presence in the Control

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Operations On-shift Briefing for Post

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Focus on Temperature Monitoring

Special Focus on Potential to Drain the

Vessel-

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Barriers In Place

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Meets NUMARC 91-06

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Outage Optimized Based on Risk Insights-

Monitoring Using Equipment Out-Of-

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Service (EOOS) Program

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Barriers In Place

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Accuracy

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Barriers In Place

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e Shutdown Operations Protection Plan in

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Place

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e Shutdown Cooling Protection Procedure

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o Extensive Bus Restoration Procedure in

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Place

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Where Barriers Failed

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Drive Timely Completion of the Post

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Modification Test Procedure

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Produce an Acceptable Procedure

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Assure Adequate Evaluation of

Temperature Monitoring and Coolant

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Where Barriers Failed

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Did:Not Question Time to Boil

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Did Not Sufficiently Question Validity of-

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Temperature Indications

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High Decay Heat

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Where Barriers Failed

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Qualitative Evaluation Was Weak

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During the Outage

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Modeling

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Where Barriers Failed

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Performing Test at This Point in the Outage

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Time to Boil

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Transition Time to ADHR From RHR

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Formal Use of Infrequently Performed Test

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or Evolution Procedure

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Formal inclusion of Alternate Temperature

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Monitoring in the Plant Management Team

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Where Shutdown Cooling

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Protection Barriers Failed

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Require Tagging of Breakers (Lack of

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Detail)

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Sufficient Attention to Detail

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Understand the Results of Each Action

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in the Restoration Process

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Inadvertent Mode Change

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Dan Dormady

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Plant Engineering

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Background / History

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o Design was initiated in 1994 for a

Suppression Pool Cleanup, Cooling and

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Alternate Decay Heat Removal system

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started in October 1995

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completed in June 1997

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July / August 1997

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Background / History

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Except

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Confirmation of Alternate Decay Heat

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Removal (ADHR) Flowrates

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Confirmation of Heat Exchanger Capability

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service August 9,1997

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improve accuracy of test results

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e PMT established test termination cnteria at 160 F.

.

reactor water bulk temperature

Operations established Reactor Water Cleanup

l

(RWCU) as temperature monitoring point

l

e Planned to use Station Operation Procedure to operate

the system

I

'

.

i

20

j

i

.

._.

-

l

Inadvertent Mode Change

l

(continued)

]

!

I

i

e Significant Event Response Team

L

i

!

Multi-disciplined Team

'

l

Reviewed all aspects of the event

1

Determined major contributing factors

through a structured root cause evaluation

>

p

process

i

1

'

!

21

1

.

-

- - - - - -

-.

- - -

- -

-

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-

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'

i:

I

-

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Root Causes

!

!

l

e Change Management

j

l

Operators misled by past experience with

!

.

l

RWCU monitoring of coolant temperature

,

l

Outage Risk Assessment did not consider

l

transitional periods (e.g., valve alignment)

)

!

i

I

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-

f

i

i

.

-

. .

.

-

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-

-_

.

,

'

,

Root Causes

.

(Continued)

'

I

,

o Knowledge-Based Decisions Without

Effective Oversight

Test procedure did not contain Precautions

j

and Limitations concerning time to boil

l

FRC review of test procedure did not

.

l

identify transitional period concerns (i.e.,

[

time to boil)

l

!

i

l

I

. .

_ . . .

. - . . .

.-.;

_

i

Root Causes

,

(continued)

i

.

o Use of Available Knowledge Resources

4

t

Operating Experience not used

[

Time to Boil Curves not reviewed

t

l

Reliance on a single temperature indication

c

l

'

>

'

f

,

24

-

.

. .

..,

__

._

_ _

_

.

. _

__ .. _

-

.

i

Short-Term Actions

1

v

l

e Prompt actions taken by operators to

,

reduce temperature

c

l

e Plant returned to Mode 4 when ADHR

l

flow maximized

o

.

l

o SERT formed to review event

,

l

e Heightened awareness to time to boil

.

i

I

'

I

!

2s

i

!

-- ----.:

.

.-_

_.

__

!

Short-Term Actions

[

(continued)

!

L

'

o Outage Shutdown Cooling activities reviewed

j

!

for remainder of outage

4

i

e Trained operators on temperature monitoring

'

limitations using RWCU

l

e Optimized procedure for placing ADHR into

l

service (e.g., reduceci valve re-alignment

l

time)

j

e Incorporated decay heat curves and heat-up

i

rate curves into plant procedures

26

!

L

--

-

- - .

-

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- - -

r

.

. - .

_

-

_.

_-

- _ _

_ _ _

-

!

-

l

t

!

i

I

Safety Significance

.

I

!

e Low safety significance

i

Less than 30 minutes > 200 F

<

l

Maximum average calculated reactor water

i

. temperature ~205 F

'

,

i

No bulk boiling

i

,

!

ADHR rapidly restored cooling

!

l

,

I

l

27'

i

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-

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--.--- ...---- - ------

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-

,

[

Safety Significance

,

!

i

,

i

e With no injection, calculations show:

-

l

Time to bulk boiling approximately 57

l

minutes, or 75 minutes with credit for

L

RWCU circulation

1

.

l

Time to uncover core - seven hours

!

No releases

No impact on public health and safety

j

l

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I

!

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Loss of Shutdown Cooling

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j

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Loss of Shutdown Cooling

(continued)

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Event Chronology:

Electrical Bus Fustoration in Progress

l

Operator Re-energized SDC Valve

j

i

Valve Stroked Closed Due to No Leak

c

Detection System Power

Shutdown Cooling Restored Within 17

,

l

Minutes, Temperature Rise 3.7oF

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(continued)

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e Root Causes:

-

l

Shutdown cooling protection administrative.

l

controls inadequate

!

Bus restoration procedure missing

information

,

j

Work Practice - over-reliance on process

e

and inadequate integration with other

outage activities

i

33

-

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-

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- .

. - -

-

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__

.

_

_ -

- - -

l

Loss of Shutdown Cooling

l

(continued)

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4

l

-

I

!

e Corrective Actions Completed:

Crew entered AOP-0051 for loss of SDC and

restored SDC rapidly

,

.r

[

Immediate Management reinforcement of

l-

standards and expectations.

!

-Operations meeting on event

!

-Investigation of event

t

l;

Knowledge assessed and immediate training

l

presented to Operators

j

i

'

!

34

i

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- .

- . .

- . - - ~ . . . +

. . -

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_ .

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1.

l

Loss of Shutdown Cooling

(continued)

!

-

l.

!

e Actions Completed (continued)

Bus outene procedure and SDC protection

'

i

procedure revised

j

4

[

Audited Administrative Controls Placed on SDC

[

Flowpath

l

-Independent audit of RHR "A" protection and

i

Management tour conducted resulting in

j

additional tagging

-Tagged a number of additional components

!

_

-

--

-

--.

-

. _

_

.

Loss of Shutdown Cooling

Safety Significance

Low safety significance

- 3 F rise

- 17 minute period

- Vessel level near flange, 97 F

'

- Relatively low decay heat

(after new fuel in vessel)

- Time to core uncovery with no operator

action:

~35 hours-

t

36

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t

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Immediate Actions

j

l

e SERT Was Formed immediately,

I

Before We Thought We Had Exceeded

l

200 Degrees

!

e Finding We Had Exceeded 200

'

Degrees Did Not Change Our Approach

i

To This issue

'

o Put Temporary Crutage Risk

l

Assessment Practices into Place

'

sa

j

,

- - - - -

- - ---

.. -. .--

. .-

!

-

.

s

'~

.

i

Long-Term Corrective Actions

j

i

l

'

9

o Quality Action Team Chartered to

l

Improve the Modification Process

l

Emphasis on Post Modification Testing

l

4

.

i

Better Use of Industry Operating

[

Experience

l

Review of Entire Process

j

t

l

'

.

!

i

39

I

- - - , - _ - . . . - . . . - .

. - - . . - - . . . . . - . - . - - . . . . - . . . . . -

. .

.

.-

-.

. -

. - .

-

. -

.

_

.-

.

h

1

!

[

Long-Term Corrective Actions

,

'

.

b

o Enhancing Management oversight of

,

)

complex processes

i

Emphasis on Operations Leadership

i

Operations Excellence Plan

j

.

'

Operations Challenging the Site

Application of fundamental knowledge

Addressed to Entire Team

.

Supervisors Workshops in December

l

Case Study of The Event - Train Entire Site

j

40

l

i

-

.

- - -

. -

_

.

_

'

,

I

l

'

4

!

Long-Term Corrective Actions

!

o There Will Be a Standing Team for Outage

e

L

Risk Oversight During Future Refueling

i

l

Outages

!

Temporary Measures Were Put in Place in RF7-

Daily Monitoring of Outage Risk

Evaluation of Schedule Changes and Transitions

e Additional Outage Risk Awareness Training for

i

Future Outages

,

41

i

.

-

.

- -

--

.

-

_

.

-

..

_ _ .

_

i

.

Long-Term Corrective Actions

j

.

i

!

e Facility Review Committee Has Been

Assessed

'

1

'

Fundamentals Are Sound

j

!

Too Much Remediation of Lower Quality

j

Packages

'

e Taking the Larger Strategic View

e Raised FRC Standards and

j

Expectations

1

,

.

42.

1

.

>

i

_

l

.

l

Long Term Corrective Actions

!

e Formalize Shutdown Cooling Procedure

j

to a Greater Degree of Detail

t

!

e Assessment of the Process by

EOl/ Industry Top Performers

e Collateral Position (Bus Coordinator)

l

Assignment for the Entire Cycle

e Clarifying Roles of Outage Positions

'

e Continued Refinement of Expectations

.

l

for Operators and Their Supervision

e

i

.

..

,

_

. . .

-

. . . _ _

. .

- .

.-

.

..

.-

-

_.

..

_ -.

_

t

Conclusions

.

i

e RBS Is Capable of Managing and Executing

Complex Processes -- These Two Events Do

Not Represent Our Normal Performance

j

o Major Modifications and Projects Have Been

L

Conducted With Success

>

i

ECCS Suction Strainer Modification

. Chemical Cleaning of Residual Heat

.

Removal Heat Exchanger

Instrument air system

4

.

,

-.

-

.

- .

.

..

_.

.

--

.

,

Conclusions

.;

'

,r

!

o RF-7 outage improvements

.

Outage exposure

Personnel safety

.

Human performance

j

c

l

Management involvement in outage

Fuel movement activities

'

i

,

l

L45

-.-- A

-

--

-

- - _

--

_

-

.

_

i

,

Conclusions

!

,

e Processes Were in Place to Prevent

1

Such an Event but They Need

l

Improvement

e Management Oversight Performance

.

!

Needs Improvement

-

Critical Questioning

i

'

Ensure All Facts / data / operating Experience

Is Employed

Raise the Standards

46

- -

. -

.

-

O

.-

.

-

.

..

_-.

.

'

Conclusions

q

,

!

o Need to Get Back on Steep

Improvement Curve

j

e Re-emphasize Fundamentals

Attention to Detail

. Planning

Communication

1

Quality Versus Quantity

.

Application of Fundamental Knowledge

j

!

.

e Clear D.O.R. and Accountability

,

.

--..

.

.-

.

_

-

_

__

-

. _

-__

_ -___ _ _

_.

.

s

.

Enforcement Perspective

.

i

Rick King

!

l

Director

'

-

Nuclear Safety & Regulatory Affairs

'

i

!

i

!

48

.

'

.

..

._m.

m..

.

_.u...

.

.........m

. . . - - - > .- . . . . . . . . .

w-.

.

-

.

'

j

Enforcement Perspective

1

i

!

e NRC Inspection Report Cites 2 Apparent

Violations:

Entering Mode 3 without satisfying

4

applicable Limiting Conditions of Operation

(TS 3.0.4.)

'

<

Inadequate Procedures (TS 5.4.1.a)

4

49

i

l

A

.

-

. .

.

. .

-

..

-

.\\

.

-

_

__

-

___

- -

.

Enforcement Perspective

]

Inadvertent Mode Change

,

.

o Safety Significance

.

No Actual Consequences

Negligible Potential Consequences

j

l

e Regulatory Significance

!

Isolated event

i

Met TS Action Statements time periods

'

!

Unintentional results (i.e., mode change)

e Severity Level

1

'

so

.

-

- - -

_

..

._

-

-.

.

Enforcement Perspective

,

l

Loss of Shutdown Cooling

q

i

l

i

r

,

i

e Safety Significance

i

No Actual Consequences

j

Negligible Potential Consequences

j

4

oRegulatory Significance

Met TS Action Statement time period

i

e Severity Level

j

i

51

.

. - .

. . , .

..

_

- -

-

--

.

..

.

Enforcement Perspective

Mitigation Factors

l

e Enforcement History {last 2 years}

!

No civil. penalty

!

Only one escalated enforcement

4

!

e Identification Credit

Although 9/13 transient self disclosing, an

engineering evaluation was necessary to confirm

j

inadvertent mode change; credit for thorough root

cause analysis

j

.

Loss of shutdown cooling self-disclosing; credit for

thorough root cause analysis

i

52

,

~ .

_

.

.-

.-.

._

.

_.

Enforcement Perspective

L

i

Mitigation Factors

j

i

l

' o Prompt Corrective Actions

j

I

immediate operator actions promptly

1

[

reduced temperature after inadvertent

t

l

mode change

i

Restored shutdown cooling in

j

approximately 17 minutes after loss of

shutdown cooling

Broad and Comprehensive Corrective

Actions for Both Conditions

I

53

l

't

..

-

_

-

.;_

L

.

'

Enforcement Perspective

,

Conclusion

1

.

l

e A reasonable basis exists for citing two.

).

Severity Level IV violations

e Alternatively,2 examples represent a

}

single Severity Level Ill violation

l

No civil penalty warranted based on

'

identification and corrective action credit

j

e Escalated enforcement not needed to

1

encourage improvements

'

N

l

-

.

-

.

-

..

.

-

_ _

_

_ _

.

,

Closing Remarks

.

i

John McGaha

I

!

Vice President,

4

.

k

l

Operations

i

!

'

!

,

f

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!

Post Modification Tests

.

SPC/ADHK Modification

i

e Verification of Control Circuitry Changes-

Completed 2/8/96

e

Pre-Operational Test SPC Filter /Demineralizer

Completed 7/7/97

e

Containment Isolation Valve Test (new RHS-valves)

'

Completed 8/2/97

I

e

Operation of Suppression Pool Cleanup System

Completed 9/12/97

'!

e

Service Water Flow Verification for ADHR Operation

Completed 9/12/97

e ADHR Flows and Heat Exchanger Capability Test

.

Rev 0 issued 7/24/97

Rev 1 issued 9/13/97

57

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2) VE5SELVIA RHR A AND RETURN TO LPCIC

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3) VESSEL VIA RHR S f.ND RETURNS TO LPQ C

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/Fr

E12-F08

4, =: ,

.-

SDC

'

,1.

.

-

SUCTION

r

_

I

l

U

TO RWCU

09

-

.

..

.

-

_

l

4-

.

Sequence of Events

o Plant shutdown for RF7 - 9/11/97

j

,

.

o 9/13/97 0730:

FRC meeting to review

!

PMTL

1

4

i

e Control room briefings on PMT

e RHR "A" shutdown in preparation for

j

aligning SPC system in ADHR mode

60

.

-

- - - _

-

._

..

1

!

Sequence of Events

i

!

o Entered TS LCO 3.4.10 Actions B.1/

B.2 for no operating RHR or Recire

pumps at 1147 (time zero}

o Started ADHR at 1324 (time 1 hr 37

min.}

e Temperature at ADHR heat exchanger

inlet reached 2' 0 F within minutes

61

i

-

.

--

.

-

.

I

-

.- -

--_

__.

-

, ,.

l

!

.

L

Sequence of Events

!

'

e Operator maximized ADHR and Service

i

Water cooling flows (in control)

!

e Temperature at ADHR heat exchanger inlet

!

less than 200 F at 1341

Temperature indicated above 20C F for 12

r

!

minutes

.

o Temperature at ADHR heat exchanger. inlet

reading 158 F at 1431

1

62

.

-.

- .

-

._ _.

_-_

_

. _

_ .

. , ,_-

!

Safety Significance

'

o Shutdown EOOS is an Improved Risk

'

Model (though transition times are not

included}

l

e Core Damage Frequency: 2.8E-

06/ reactor year

.

l

e Boiling Frequency: 2.1 E-03/ day

e Number of systems available for cooling

63

i

!

.

-

ML20197G660

Text

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