ML20198A503

Responds to NRC Re Violations Noted in Insp Rept 50-482/97-19.Corrective Actions:Rev 1 to EID-0003 Was Issued on 971103

ML20198A503
Person / Time
Site:	Wolf Creek
Issue date:	12/23/1997
From:	Maynard O WOLF CREEK NUCLEAR OPERATING CORP.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
50-482-97-19, WM-97-0151, WM-97-151, NUDOCS 9801050388
Download: ML20198A503 (10)

Text

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

4

• ; g W@lJLF CREEK NUCLEAR OPERATING CORPORATION Otto L. Maynard President and Chief Exeo tue Officer December 23. 1997 ..

WM 97-0151 U. S. Nuclear Regu}atory Cot.. mission '

ATTN: Document Control Desk' Mail Station P1-137 Washington, D. C. 20555

Reference:

Letter dated November 25, 1997, from W. D. Johnson, NRC, to O. L. Maynard, WCNOC

Subject:

Docket No. 50-482: Response to Notice of Violations 50-482/9719-01, 9719-02, 9719-03, 9719-04, and 9719-05

Gentlemen:

l This letter transmits Wolf Creek Nuclear Operating Corporati.cn's (WCNOC) response to Notice of Violations 50-482/9719-O', 9719-02, 9715-03, 9719-04, and 9719-05. Notice of Violation 9719-01 cites use of an operator aid without ,

the documented approval of tne Shift Supervisor. Notice of Violation 9719-02 cites examples of effecti'?eness follow-ops for corrective action documents not being performed as required by procedure. Notice of Violation 9719-03 cites an example of a maintenance worker working outside of procedural guidance which resulted in a r. inadvertent opening of an atmospheric relief valve.

Notice of Violation 9719-04 addresses a failure to reinstall an equipment hatch cover following the replacement of the associated filter cartridge.

Notice of Violation 9719-05 cites four examples of personnel failing to adhere to radiation protection procedures.

WCNOC's response to these violat.i ons is provided in the attachment. If you have - any questions regarding *his response, please cont:'t me at (316) 364- /,

8831, extension 4000, or Mr. Michael J. Angus at extension 4077 /.

Very truly yours, e!

l . fo rk f Otto I . Maynard # $0 OLM/jad Attachment l

cc:

!' W. D. Johnson (NRC), w/a E. W. Merschoff (NRC), w/a l~ J. F. Ringwald (NRC), w/a K. M. Thomas ( N RC) , w/a 9801050388 971223 lll i J

PDR g

ADOCK 05000482 pgg l0ll -

- e e a r

}l a .

i

],

a 3

}il a.

RO. Box 411/ Burhngton, KS 66839 / Phone: (316) 364 8831 An Equal Opporunity Emp4 oyer M F HCNET l

I , Attachment to Wti 97-0151 Page 1 of 9 c

Violation 50-482/9719-01:

" Criterion V of Appendix B to 10 CFR 50 requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, and drawings apornpriate to the circumstances, and shall be accomplished in accordance with tl.ese instructions, procedures, or drawings.

Procedure AP 21D-003, " Control of Information Tagging," Revision 1 Step 6.6.10 requires operatur aids to be approved and documented by the Shift Supervisor. p Contrary to the above, from October 8, to October 22, 1997, operators used markings on Drawing EID-0003 as an operator aid without documented approval of the shift supervisor.

This is a Severity Level IV violation (Supplement 1) (50-482/9719-01)."

heason for Violation:

Engineering Information Drawing (EID)-0003, " Refuel Level Indication," was referred to by Control Room operators between October 8, and Octooer 25, 1997.

The inspector noted that EID-0003 listed the levels in percent while the wide range cold pressurizer level was calibrated in inches. In order to provide a correlstion between the two, a calculation was performed and EID-0003 was marked-up with handwritten notes. EID-0003 and the handwritten noces should have been controlled as either an operator aid, or the notes should have been lacorporated as a revision to the drawing.

The reason for the violation is failure to follow procedures which resulted in use of information which had not been verirled and validated. AP 21D-003,

" Control of Information Tagging" was not followed when the hand written notes were added to the drawing, and therefore not verified, validated and approved for usage.

Corrective Steps Taken and Results Achiev,eg On November 3, 1997, Revision 1 to EID-0003 was issued. This revision removed all Callaway site specific information and verified the tygon tubing water level (feet).

Corrective Stopa That Will Be Taken:

The contributing cause and generic implications related to this event are being evaluated by PIR 97-0945 which was written in association with Self Assessment 97-017, " Evaluation of Desktops or c,the r Informal Instructions,"

which looks at the generic implication of site wide uncontrolled documentu.

The expected completion date is January 15, 1998.

The Superintendent Operations Support will meet with each operating crew and review -AP 21D-003, " Control of Information Tagging" in conjunction with Per f ormance Improvement Request (PIR) 97-3442, associated with this violation, to ensure thev understand the appropriate use of documents. This action will be completed by February 2, 1998.

s Each Operations Shift Supervisor and the Superintendents of Operations and Operations Support will meet with their direct reports and ensure all uncontrolled documents that could be used to make decisions in operating the plant are removed from the Operations office spaces and the Control Room.

These uncontrolled documents are then to be either destroyed or submitted for processing to become controlled documents. The expected completion date for these meetings is February 2, 1998.

_ _ _ _ _ - - 1

, 'Attcchm:nt to WM.97 0151 Paga 2-of 9 Cate When Full Compliance Will Be Achieved:

WCNOC is currently in full cornpliance. Compliance was achieveJ on October 25, 1997 when EID-0003 was removed from the Control Room.

'Attachmont t o !?M 97-0151 2 Paga 3 of 9-Violat' ion 50-482/9719-02:

Criterion V of Appendix B to 10 CFR Part 50 requires, in part, that activities ,

affecting quality shall be prescribed by documented instructions, procedures, and drawings appropriate to tha circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.

Administrative Procedure AP 28A-001, "Performaace Improvement Request,"

Revision 8, Step 6.1 1.1, requires that an effectiveness followup review be performed foi all Significance Level I and II performance improvement requests.

Contrary to the above, on October 22, 1997, effectiveness followup reviews were not performed for Performance Improvement Requests 96-2966 and -2989.

Both were Significance Level II perfctmance improvement requests.

o This !* e Ca"arity Level IV violation (Supplement 1)(60-482/9719-02).

Reason for the Violation Additional reviews by WCNOC personnel identified 35 Performance Improvement Requ7sts (PIRs) past their effectiveness follow-up review due dates. Twenty-seven of these were significant PIRs which are required to have an effectiveness follow-up review. Eight of the PIRs were non-significant which are not required to have an effectiveness follow-up revicw. Eight different groups had effectiveness follow-up reviews past due.

The reason for the violatien is that during initial development of the PIR ,

orogrem, mechanisms were not designad to provide management all of the tools to effectively monitor effectiveness follow-up reviews. Specifically, though the requirement was in place to perform effectiveness follow-up reviews, guidance for reporting and trending and the responsibility for performing these actions were not established, o Contributing Cause The controls to execute a computer search for effectiveness followup review dates were not user friendly and were different from the usual search techniques.

Corrective Steps Taken and Results Achieved Responsible managers were contacted to advise them of the concern and request they review their PIRs or re-schedule them to an appropriate time. Immediate actions included the. Operations department completing six effectiveness follow-upa and the Maintenance department re-scheduling four follow-ups and deleting one follow-up date that was assigned to a non-significant PIR. By October 29 1997, all the overdue effectiveness fol?ow-up reviews had been completed or re-scheduled.

On October 26, 1997, the PIR data base was modified to make the search for of tsct iveness follow-up review dates more user friendly. PIR Logkeepers were then interviewed and on-the-job training performed to ensure they know how to search for effectiveness follow-up review due dates and have adequate knowledge to find PIR due dates.

The Licensire and Corrective Action group began monitoring effectiveness follow-up review due datos on October 29, 1997 A 30-day "look ahead" report is now provided to managers to advise them of effectiveness follow-ap reviews coming due. This corrective action was implemented on December 19, 1997.

%ttachment to WM 97-0151 Page 4 of 9-A Corrective Stepr. That Will Be Taken The program for monitoring effectiveness follow-up reviews will be modified to assign PIR Coordinators the responsibility to monitor effectiveness follow-up review due dates. Procedure AP 28A-001, " Performance Improvement Request,"

will be revised by- December 31, 1997, to clearly state the PIR Coordinator responsibility for this monitoring function.

Licensing and Correction Action will develop performance indicators for tracking corrective action effectiveness follow-up reviews. These performance indicators will be developed by February 2, 1998.

PIR Coordinators will bc trained by December 31, 1997, to use the search functions in tca PIR data bace to find effectiveness follow-up review due dates.

Date When Full Compliance Will Be Achieved:

Full compliance was achieved on October 29, 1997, when the overdue effectivenuss follow-up reviews were either performed or reacheduled.

' Attachment to WM 97-0151 Page 5 of 9 Violation 50-482/9719-03:

" Technical Specification 6.8.1.a requires, in part, that written procedures be established, implemented, and maintained covering- the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.

Regulatorv Guide 1.33, Revision 2, Feb-uary 1978, Section 3.f., recommends, in part, that procedures be established for surveillance tests.

Surveillance Procedure FTS MT-008, " Main Steam Safety Valves Settings,"

Revision 8, Section 4.3, requires the test performer to not operate the root valves. indicated on Attachment C.

ntrary to the above, on September 30 ,1997, the test performers closed then opened Valve AB V0028, the instrument root valve indicated on Attachment C of Procedure STS MT-000, causing an inadvertent opening of valve AB PV0003, utmospheric relief valve for Steam Line C.

This is a Severity Level IV violation (Supplement 1) (50-482/9719-03)."

Russon for Violation:

The reason for t!.is violation is personnel error in that Maintenance personnel failed to comply with procedural requirements. The procedure, STS MT-008, did not contcin step for operating valve ABV0028, a root valve. It contained a caution note telling the worker not to operate the valve.

Contributing to the event were two additional causas:

1. There was inadequate communication between personnel olved in the work activities. There were missed opportunities to provide more specific direction, to confirm what was misunderstood or to call " time-out".

2. The pre-jnb briefing was incomplete in that there was a failure to cover specific responsibilities, procedural procautions, and procedure use requirements. The failure to covar these items in the pre-job briefing was a missed opportunity to make s .e everyono understood their roles and responsibilities.

Corrective Steps Taken and Results Achieved:

The Manager Maintenance met with Mechanical Maintenance personnel, tirst line Maintenance supervisors, and contractors on September 30, and October 1-2, 1997, to reinforce the limits and expectations for maintenance personnel operatiq plant equipment. Additionally, the expectation that the Control Room be contacted immediately upon recognizing a component or system manipulation error was reinforced.

Training for all Mechenical Maintenance personnel, reaffirming the requirements of procedure AP 15C-002, " Procedure Use and Adherence," was completed on October 2, 1997 The training also included instructions for use of three-way communication and the exoected elements of pre-job briefings.

Fact find! discussions and job counseling were done with those personnel involved. nese actions were completed on October 7, 1997.

E Procedute MTS MT-008 was revised on October 9, 1997, to correct valve misnomers,- idd caution notes and incorporate other human factor improvements.

"Communica' ion for Error Prevention" training was given to Maintenance craft personnel. This training was completed on December 22, 1997.

. Aitochmant to WM 97-0151 Page 6 of 9 4

Corrective Steps that will be Taken!

The lessons learned from this event will be shared with the other maintenance groups through review of Performance Improvement Request (PIR) 97-2959 during group s">fety meetings. This corrective action will be completed by February 27, 1998.

Date When rull Compliance Will Be Achieved:

WCHOC is current 4y in full compliance. Compliance was achieved on September 30 1997, when ABV0028 was opened.

. ' Attachment to WM 97-0151 Pag @ 7 of 9

' Violat$ ion 50-482/9719-04:

" Technical Specification 6.8.1.a requires, in part, that written precedures be established, implemented, and maintained covering the applicable procedure 3 recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.

Regulatory Guide 1,33, Revision 2, February 1978, Section 3.f., recommends, in part, that procedures be established for replacement of important filters."

Procedure MCM M7230-01, "NSSS Filter Changeout," Revision 9, Section 8.4, requires maintenance personnel to reinstall tne hatch cover over the equipment compartment as part of the restoration.

Contrary ta the above, on October 12, 1997, maintenance personnel signed for the ccmpletion of Procedure MCM M723Q-01 following the replacement of the

• filter cartridge without reinstalling the equipment hatch cover. The failure to replace the hatch cover resulted in tne area near the filter to be accessible as radiation levels increased to 3 Rem per hour 12 inches from the filter housing after operators returned the filter to service.

This is a severity Level IV violation (Supplement 1) (50-482/9719-04)

Response to Violation The reason for the above stated violation and the asscciated corrective actions were documented in WCNOC's response to violation 97-020-01, in letter WM 97-0133, dated December 12, 1997, which pertained to the same event.

i i

. ' Attachment to WM 97-0151 Page 8 of 9 Violation 50-482/9719-05:

" Technical Specification 6.11 requires, in part, that radiation workers adhere to procedures for personnel radiation protection consistent with. the requirements of 10 CFR Part 20.

Administrative Procedure AP 25A-100, " Radiation Protection Manual" Revision 2, Section 6.7.4, requires that access to the RCA [ radiologically controlled area} be controlled by an approved RWP tradiation work permit].

Contrary to the above:

a. On October 5, 1997, a mechanic accessed the radiologically controlled area using Radiation Work Permit 970009 and used an.

internally contaminated gauge while performing work in the radiologically controlled area, an activity prohibited by the radiation work permit.

b. On October 10, 1997, a radiation worker exited the radiologically controlled area and logged out of Radiation Work Permit 972601.

The wveker subsequently reentered the radiologically controlled area without logging onto a radic. tion work permit and without obtaining any dosimetry,

c. On October 26, 1997, a radiation worker entered containment without an alarming dosimeter as required by Radiation Work Permit 970034

d. On October 27, 1997, a radiation worker entered the radiologica.ly controlled area without the thermoluminescent dosimeter required by Radiation Work Permit 970009.

This is a Severity Level IV violation (Supplement IV) (50-482/9719-05)."

Reason for Violation:

As the above examples are similar in nature and pertain to violations of the radiation worker practices they were researched together to determine the root cause and appropriate corrective actions.

In the case of example b. it was concluded that the initial cause was a human error resulting from either a short-cut being taken or failure to implement rules learned in radiation worker training.

In the remaining examples it was determined that the radiation workers exhibited inattention to detail that caused them to violate radiation protection program requirements. The errors were unintentional and occurred either due to overconfidence on the part of the employee or due to an unplanned interruption that took the employees' attention away from the radiation protection program requirements, Corrective Steps Taken and Results Achieved:

Corrective actions for each example included these common actions:

• Each employee or contractor had their access to the radiologically controlled area (RCA) revoked.

• Employee retraining or counseling was performed which met the standards of management.

• Job performance counseling was performed.

• Each event was discussed during group or safety meetings to ensure lessons learned were shared.

, ' Attachment to WM 97-0151 Paga 9 of 9 Other actions implemented by the Health Physics organization included the establishment of the RCA access control area as a "No Talking Zone" to allow for greater concentration, and posting of a security officer at the RCA access door as an interim control during outage activities.

Corrective Steps That Will Be Takent Performance Improvement Request (PIR) 97-2389 was initiated by Health Physics on August 7, 1997, to identify general adverse trends regarding violations of the Radiation Protection Program. Short term corrective actions for tnis PIR were completed as of. October 2, 1997. Long term corrective actions including evaluation of changes to radiation worker training are due to be complete by January 30, 1998.

In an offort to improve human performance in the Access Control area, WCNOC Health Physics personnel will submit a proposed facility change to be evaluated using the design change process. This proposal will be submitted by January 1, 1998.

Date When Full Compliance Will Be Achieved:

WONOC is currently in full compliance. Full compliance was achieved on the date of occurrence of each event when the individuals involved were brought into compliance with WCNOC's radiation protection program requirements.

4

_ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ . _ _