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Insp Rept 50-382/97-26 on 971117-1205.No Violations Noted. Major Areas Inspected:Operator Activities Re Failure to Return Valve ACC-126A,auxiliary Component CWS Flow Control Valve,To Automatic Operation When Restoring CWS
	ML20198C887
Person / Time
Site:	Waterford
Issue date:	01/05/1998
From:	; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	;
Shared Package
ML20198C878	List: ML20198C872; ML20198C887;
References
	50-382-97-26, NUDOCS 9801080078
	Download: ML20198C887 (11)
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ENCLOSURE 1

. ,s U.S. NUCLEAR REGULATORY COMMISSION ,

REGION IV

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Docket No.: 50 382 ,

License No.: NPF 38 ,

Report No.: 50 382/97 26

Licensee: Entergy Operations, Inc._

Facility; Waterford Steam Electric Station, Unit 3

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Location: Hwy.18 _

Killona, Loulslana :

Datest - November 17 through December 5,1997

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Inspector: G. A. Pick, Senior Project Engineer -

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Accompanied By: J. C. 2dgerly, Resident inspector Trainee

Approved By: P. H. Harrell, Chief, Branch D

Division of Reactor Projects ,

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Attachment: Supplemental Information. ,

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EXECUTIVE SUMMARY !

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L Waterford Steam Electric Station, Unit 3 l

NRC Inspection Report 50 382/97 26 j

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-This special, announced inspection reviewed aspects of operator activities related to the :

failure to return Valve ACC 126A, auxillary component cooling water system flow control i

valve, to automatic operation when restoring the auxiliary component cooling water system i

to its normal standby lineup.

Onorations

An apparent violation resulted because AuFiliary Component Cooling 'Nater - l'

Trains A and B were inoperable at the sama time, a condition prohibited by

Technica Specification 3.7.3 (Section 04.1).

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Apparent violations occurred because of the failure of the operations staff to comply

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with the conduct of operations procedures. The five violations reflected deficiencies

in basic conduct of control room operations, including failure to maintain effective !

on shift operations supervision oversight of plant operations and the failure of the ,

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operations staff to follow procedures (Section 04.2).

Several of the root causes for the failure to place the controller for Valve ACC 126A !

in automatic were the same as the root causes identified by the licensee for the 4

configuration control problems identified in October 1996 (Section 08.1).

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Report Details ,

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Summarv of Plant Status !

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The plant operated at essentially 100 percent power during this inspection. s

LOperations

01 Conduct of Operations (71707)

01.1 Int oduction ,,

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Summarv of Event

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On h aber 9,1997, at 6:47 p.m. (CST), prior to the shif t meeting but following '

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shift toiover, the secondary nuclear plant operator initiated chemical mixing of the

Train A wet cooling tower basin in accordance with. plant procedures, utilizing

. Auxiliary Component Cooling Water Pump A. Operation of the auxiliary component 4

cooling water pump sweeps the piping and heat exchanger to ensure equal mixing of

the chemicals. Aftet about 34 minutes of operation, the operator secured Auxiliary

Component Cooling Water Purnp A, but inited to restore the manual / automatic

controller for Valve ACC 126A, auxiliary component cooling water system flow .

control valve, to the automatic position.- At 3 a.rn, on November 10, Auxiliary l

Component Cooling Water Train B was tagged out and removed from service to

perform routine maintenance. The operators appropriately ents..ed Technical

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Specifications 3.7.3 and 3.7.4 for having the Auxiliary Component Cooling Water

Train B out of service and for disabling a single train of the ultimate heat sink.

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At approximately 6 a.m. on November 10, the day shif t putormed a shift relief and

turnover from the night shift. At 10:25 a.m., during a mid dayshift relief, the '

relieving nuclear plant operator noted that the manual / automatic controller for

Valve ACC 126A was in manual and the valve closed. The operators recognized

that Auxiliary Coniponent Cooling Water Trains A and B were inoperable and ,

immediately entered Technicel Specification 3.0.3 and initiated Condition

Report 97 2565 to document the identified problem. Af ter researching possible

reasons for the controller for Valve ACC 126A being in manual, and not identifying a

need for the condition, operators restored the valve controller to an operable status

within 1 minute by placing the controller in automatic. As a result of having the ,

controller for Valve ACC 126A in manual, both trains of auxiliary component cooling

water were rendered inoperable for 7 hours8.101852e-5 days 0.00194 hours 1.157407e-5 weeks 2.6635e-6 months 25 minutes (the total time from removal

of Train B from service and retuin of Train A to wrvice), which resulted in operation

outside the Ilmits specified by the Technical Specifications.

Eystem Descrintion

~ The auxiliary component cooling wate. system operates in conjunction with the i

component cooling water system and the wet cooling tower basin to serve as the

ultimate heat sink. The component cooling water system is designed to remove

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60 percent of the accident heat load through the dry cooling towers. Depending on

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the beat load and the meteorological condi' ions, the auxiliary component coofing

water system !c designed to remove any additional heat load (up to 40 percent)

beyond the capability of the component cooling water system and transfers the heat

to the wet cooling towu basin. The auxiliary component cooling water system was

designed to supply 850 gpm to the essential chillers, which supply room cooling for

safety related equipment, and at least 4500 gpm to a heat exchanger for transfer of

the component cooling water he & load to the wet cooling tower basin. The

component cooling wates system supplies cooling water to components such as the

containment f an coolers, safety related pumps, and shutdown cooling heat

exchangers.

The auxiliary component cooling water flow through the component cooling water

heat axchangers is controlled by increasing or decreasing the flow, by opening or

closing Valves ACC 126A and 1268, to maintain the co>nponent cooling water

outlet temperature at a predetermined setpoint. With the valve controller in

automatic and upon receipt of a safety injection actuation signet the setpoint

automatically increases to 115'F in response to a process analog computer signal.

If the valve controller is in manual, signals from the process analog computer to the

valve are inhibited and the valve remains in the as is position.

04 Operator Knowledge and Performance

04.1 Mispositioned Manual / Automatic Controllet

a. Ecoco1929011

The inspectors evaluated the circumstances and f acts surrounding the

mispositioning of the manual / automatic controller for Valve ACC 126A. The

inspectors reviewed control room logs, the sequence nf events, debrief notes with

the operators involved, and discussed the event with licensed operators,

b. Ohittyations and Findinas

The inspectors concluded that operators inadvertently placed the plant in a condition

that should have required entry into Technicci Specification 3.0.3 at 3 a.m. on

November 10,1997, when both trains of auxiliary component cooling water were

out of service. Operators returned Train A to service at 10:25 a.m. on

November 10, which then made the requirements of Technical Specification 3.0.3

no longer applicable.

Technical Specification 3.7.3 identifics that two trains of auxiliary component cooling

water are required to be operable while in Modes 1,2,3, and 4. The f ailure to

maintain two trains of the auxiliary component cooling water system operable, as

required by Technical Specification 3,7.3, is an apparent violation (50 382/9726-01).

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c. Conclusions !

An apparent vi..ation resulted because both trains of the auxiliary component

cooiin0 water system were made inoperable. Upon recognizing that both trains

were inoperable, operators promptly restored one train to an operable status.

04.2 Reouirements Related to Ooerator Conduct

a. Scoon!929D11

The inspectors reviewed the regul. rnents and guidance provided to operators for

control room conduct, performance of control panel walkdowns, and shift turnover

to verify compliance with Technical Specification 6.8.1. This specification requires

that activities be performed in accordance with approved procedures that specify

the acceptable method for conducting safety related activities,

b. - Qbservations and Findin23

The inspectors reviewed the procedures that described responsibilities, expectations,

and requirements for conduct of control room pctsonnel, shif t turnovers, and

self checking Procedure OP 100-001, " Duties and Responsibilities of Operators on

Duty," Revision 12, specified, in part, that the responsibilities for the control room

supervisor were to: (1) monitor, direct, and evaluate the reactor operators during

plant evolutions and (2) direct the preparation and installation of danger tags,

verifying that Technical Specification requirements are observed. Responsibilities of

the nuclear plant operators include: (1) t.ontinuously monitor performance of plant

contrul systems and ' 'rumentation to verify operability, (2) operate plant systems

in accordance with plant procedures, and (3) verify that the redundant

system / component is operable prior to performing maintenance.

The intp0ctors noted that the secondary nuclear plant operator performed the

chemical mixing evolution following shif t turnover but prior to the shift meeting.

The secondary nuclear plant operator performed this routine, weekly repetitive task

in accordance with Work Autho lzation 01164142. The operator utilized

Procedure OP-002 001, " Auxiliary Component Cooling Water," Revision 11, to

perform the chemical mixing evolution. Procedure OP-GO2 001 provided instructions

to place the auxiliary component cooling water system in standby and one step

included placing the controller for Valve ACC 126A in automatic.

The operators perform shift relief and turnover at approximately 6 a.m. and 6 p.m.,

which includes review of the major activities performed, ongoing evolutions,

system / component status, shif t logs, and in addition, conduct a joint walkdown of

the control boards by the offgoing and oncoming nuclear plant operators.

Procedure OP 100 007, "Shif t Turnover," Revision 16, specified, in part, that the

shif t superintendent, control room supervisor, and both reactor operators shall

perform two control panel walkdowns with one walkdown per watchstander

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documented by signing the appropriate block on the turnover sheet. A control board

walkdown consisted of thoughtfully observing every light, indicator, switch, and

button. Further, the oncoming and offgoing reactor operators should walkdown the

control panels together discussing, as a minimum, safety system status, operating

equipment, and system alignments.

Based on the above discussion of pro dural requirements, the inspectors

concluded:

The control room supervisor did not adequately monitor the chemical mixing

evolution performed by the secondary nuclear plant operator, as he did not

verify that the auxiliary component cooling water system was returned to

standby. The f ailure of the control room supervisor to provide sufficient

oversight of the secondary nuclear plant operator's performance of the

chemical mixing evolution, as required by Procedure OPA00 001, is an

apparent violation of Technical Specification 6.8.1.a (50 382/9726-02).

When danger tags were installed on Auxiilary Component Cooling Water

Train B, the operators f ailed to verify operability of Auxiliary Component

Cooling Water Train A prior to removing Auxiliary Component Cooling Water

Train B from service, as required by Procedure OP 100-001. This is an

apparent violation of Technical Specification 6.8.1.a (50 382/9726-03).

A nuclear plant operator f ailed to closely monitor the indications available

when securing Auxiliary Component Cooling Water Pump A in that the

individual f ailed to recognize that the status indicator of the controller for

Valve ACC 126A indicated the valve was in manual. The primary nuclear

plant operaur, who performed the peer check, did not recognize that the

status indicator of the controller for Valve ACC 126A indicated the valve was

in manual. The f ailure of the control room supervisor and nuclear plant

, operators to recognize that the controller for Valve ACC-126A was in

manual, as required by Procedure OP 100-001, is an apparent violation of

Technical Specification 6.8.1.a (50-382/9726-04).

Procedure OP-002-001, Section 7, Step 6 provided instructions for operators

to verify that the temperature setpoint for the controller for Valve ACC-126A

is set s 95'F and to place the controller in automatic. The f ailure to return

the manual / automatic controller for Valve ACC 126A to r.utomatic is an

apparent violation of Technical Specification 6.8.1.a (50-382/9726-05).

From review of the control room logs and plant procedures, it was

determined that operators performed control room walkdowns (eight

opportunities during the night shif t and an additional three during chif t

turnover) to observe system alignments and the status of allindicators, but

f ailed to identify the mispositioned manual / automatic controller, as required

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by P:ocedure OP 100-007. This is an apparent violation of Technical

Specification 6.8.1.a (50-382/9726-06),

c. Conclusions

Apparent violations of Technical Specification 6.8.1.0, consisting of five examples -

of the f ailuro to comply with the conduct of operations procedure, were identified.

The eFamples reflected the failure of operations personnel to maintain appropriate

cognizance of ongoing plant activities and the f ailure to identify the inoperability of a

Technical Specification required system during control board walkdowns and shif t

turnovar.

08.1 Corrective Actions

a. S.09DR 192901)

The inspectors reviewed licensee actions implemented to evaluate the root causes

for leaviag the controller for Valve ACC 126A in manual and actions taken to

prevent recurrence. This review involved discussions with the operations

superintendent and review of the event debrief notes and other plaat

documentation,

b. Observations and Findinas ,

The licensee performed an event debrief in accordance with Operations Department

Policy No 13, " Improving Operator Performance," Revision 1. The event debrief

identified that: (1) the nuclear plant operators did not recall placing the controller

ior 'falve ACC 126A in automatic; (2) the primary nuclear plant operator, who

performed the peer check, only checked that the temperature setpoint was returned

to the required temperature and that the correct switch was being manipulated, not

the final switch posit!on; (3) although the secondary nuclear plant operator initiated

the chemical mixing to efficiently use the time until the shif t meeting, he indicated

that performing the task following the shif t meeting would have been more

apr toptlato; (4) the primary nuclear plant operator identified that he should have

become more f amiliar with the evolution; (5) the control room supervisor could have

briefed the evolution with the primary nuclear plant operator (since he was not

normally on shif t); and (6) the control room supervisor did not identify the

mispositioned switch during the control board walkdown following the shif t meeting.

. Following evaluation of this information, the operations superintendent modified

Procedure OP 002 001, Section 7, Step 6 to separate the action statements for

setting the temperature controller and for placing the controller for

Valves ACC 126A and _1268 in automatic, and formalized the peer check process

to address several of the above weaknesses. The operations superintendent

initiated Standing Instruction 97 07 to clarify and formalize his expectations related

to peer checking. Specifically, the individual performing the peer check is expected

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to be familiar with the task for the cc mponent/ train being manipulated, will verify

the correct component, and will ver'fy . the expected response is obtained.

Further, the operations superintandent modified Procedure UNT OO7-011 "Dubes

and Responsibilities of the Shif t Technical Advisor," Revision 6, to requile the shift

technical advisor to complete an assessment of the control panels in accordance

with the Technical Specification / Technical Requirements Manual Control Panel

We'kdown Checklitt. The Control Panel Walkdov,n Checklist was developed to help

identify out-of position control panel switches * hat render Technical

Specification / Technical Requirements Manual equipment inc wrable. The licensee

revised Procedure OP 100-OO7 to require control panel walkdcwns to verify the

proper position of switches, indicators, controllers, etc., to ensure components are

placed in the correct position following manipulations, and to verify that a redundant

system / component is operable by reviewing the control panel prior to removing any

rystem/ccmponent from service.

Operations personnel also reviewed a historicallisting of condition reports that

related to mispositioned components by operations personnel. The licensee noted

14 instances of mispositioned component 3 had occurred in the plant spaces since

the NRC identified a previous problem, which is discussed below. The licensee

indicated that corrective actions were being implemented to improve human

performance,

c. Previous Findinos

The inspectors evaluated previous findings because of past concerns with operator

entry into Technical Specification Limiting Conditions for Operation when placing

Valve ACC-126A into manual and with the configuration constrol of other systems,

As a result of this effort, it was noted that Section 3.1 of NRC Inspection

Heport 50 382/96-03, issued in February 1996, documented the placement of

Valve ACC-126A in manual and the subsequent determination that this action

resulted in inoperability of the system. The inspectors determined that the root

cause for this previous event resulted from e communication breakdown among

maintenance, operations, and engineering personnel. Engineering f ailed to widely

disseminate the information that placing Valves ACC-126A and -126B in manual

renders the valves inoperable. The report further stated that operators relied

substantially on procedure guidance instead of pursuing an answer to the potential

operability quection regarding maintaining Valves ACC-126A and -126B in manual.

Section 02.1 of NRC Inspection Report 50-382/96-13, issued in December 1996,

documented three instances of operators failing, in October 1996, to maintain

cognizance of the status of safety-related equipment. The instances were identified

as being contrary to plant procedures. The cited examples included f ailure to secure

the airborne radioactivity monitor for 19 days after securing containment purge,

f ailure to place a dry cooling tower fan switch to OFF instead of AUTO for 36 hours4.166667e-4 days 0.01 hours 5.952381e-5 weeks 1.3698e-5 months ,

and f ailure to close a safety injection system injection valve following inservice

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testing for 62 hours7.175926e-4 days 0.0172 hours 1.025132e-4 weeks 2.3591e-5 months . The corrective actions for the violation issued for this problem

Iincluded reinforcing expectations related to performing thorough control panel .

c walkdowns and monitoring of giant controls, increasing the formality of the control ;

board walkdowns by requiring two walkdowns per shift for each of the four licensed --

individuals,"and evaluating the shift turnover process.-

The licenseo attributed the root causes for the vioiation documented in NRC

inspection R.) port 50 382/96-13 to: (1) failure to follow procedure, (2) failure to ,

closely monitor equipment' status on the main control board, (3) poor shift turnovers,

and (4) poor on shift ooerations s.upervisory oversight of plant activities,

d. Conclusions

'The inspectors noted that several of the root causes for the current failure to place

the controller for Valve ACC-126A in automatic, as discusrid above, were the same

as the root causes_ identified by the licensee for the configuration control problems

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identified in October 1996.

V. Manaaement Meetinas

X1 Exit Meeting Summary

The inspectors presented the inspection results telephonically to members licensee

management on December 15,1997. The licensee acknowledged the findings

presented.

The inspectors indicated that some materials examined during the inspection were

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. considered proprietary but were returned to appropriate personnel.

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. ATTACHMENT -

- SUPPLEMENTAL INFORM ATION

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E , PARTIAL LIST OF PERSONS CONTACTED

hensee

G. Bruner, Manager, Planning and Scheduling

F. Drummond, Director Site Support

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C. Dugger, Vice-President, Operations

E. Ewing, Director Nuclear Safety & Regulatory Affairs

- C. Fugate, Operations Superintendent

T. Gaudet, Licensing Manager

J. Hoffpauir, Manager, Operations

,T. Leonard, General Manager, Plant Operations

G. Pierce, Director of Quality .

._C. Thomas, Corporate Communications

D. Vinci,' Superintendent, System Engineering ,

A. Wrape, Director, Design Engineering

NflC

-J. Keeton, Resident inspector

INSPECTION PROCEDURES USED

IP 71707: Plant Operations

IP 92901: Followup - Plant Operations

ITEMS OPENED, CLOSED, AND DISCUSSED

'Onened

50 382/9726-01 -APP Failure to meet the action requirements of Technical-

Specification 3.7.3 (Section 04.1).

50-382/9726-02 APP Failure to comply with Procedure OP 100 001 for monitoring

plant activities (Section 04.2).

50-382/9726-03 APP Failure to comply with Procedure OP-100-001 for installing

danger tags (Section 04.2).

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50 382/9726-04 APP Failure to comply with Procedure OP-100-001 for monitoring

/ - control board indications (Section 04.2).

50-382/9726-05 APP. Failure to follow Procedure OP 002-001 for operation of ACCW

system (Section 04.2).

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50 382/9726-06 APP Failure to follow Procedure OP 002 001 for control panet walkdowns

(Section 04.2).

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ML20198C887

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