ML20199D962
| ML20199D962 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 06/13/1986 |
| From: | Leblond P COMMONWEALTH EDISON CO. |
| To: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| References | |
| 1771K, NUDOCS 8606230145 | |
| Download: ML20199D962 (6) | |
Text
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_ N Commonwealth Edison
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i / 72 West Adams Street, Chicago, Illinois Address Reply to: Post Offica Box 767 Chicago, Illinois 60690-0767 June 13, 1986 n
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w Mr. James G. Keppler
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Regional Administrator j
U.S. Nuclear Regulatory Commission
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~199 Roosevelt Road E
Glen Ellyn, IL 6013~1 OL 9
Subject:
Zion Nuclear Power Station Units 1 and 2 Zion ABOD LER Report NRC Docket Nos. 50-295 and 50-304
Reference:
April 3, 1986 letter from C. E. Norelius to Cordell Reed.
Dear Mr. Keppler:
The referenced letter provided Commonwealth Edison with a copy of an assessment of Zion's LER quality that had been prepared by the NRC's Office for Analysis and Evaluation of Operational Data (ABOD). The referenced letter also requested that commonwealth Edison provide Region III with the actions taken to improve the overall quality of LERs at Zion Station. Our response to this request is in Attachment I to this letter.
In addition, the ABOD report contained a number of areas that require some clarification. These areas are delineated in Attachment 2 to this letter.
The referenced letter also expressed the NRC's concern regarding the number of people who are involved in the preparation of LERs at Zion Station. Zion Station recognizes the need to ensure that all personnel involved with the preparation of LERs are adequately trained. The difficulty of this task is increased by allowing a large number of people to be involved with LER preparation. However, this policy also contains some positive aspects.
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Mr. J. G. Keppler June 13, 1986 The Zion Technical Staff and Health Physics Department prepare the majority of LERs at the station. The specific system expert responsible for the systems involved is assigned to author the LER.
This policy enables engineers to develop their investigative / trouble-shooting and report writing
. skills while keeping them aware of events and corrective actions related to their assigned systems. These aspects are viewed as positive results of Zion's LER authoring policy.
Please direct any questions you may have regarding this matter, to this office.
Very truly yours, P. C. LeBlond Nuclear Licensing Administrator 1m Attachments cc:
Mr. J. A. Norris - NRR Zion Resident Inspector 1771K
r ATTRCISept 1 i
'Elon Station first became aware of the NRC Office for Analysis and Evaluation of Operational Data's (ABOD) assessment of our Licensee Event.
I Reports (LERs) in late October 1985 from the station's Senior NRC Resident Inspector. This information was closely followed by the stations receipt of NUREG 1022 supplemer;t 2.
I The station immediately developed and implemented an LER and immediate notification (red phone) reporting improvement program which included the following aspects:
Increared awareness of the requirements of 10CFR 50.73 by the LER authors and reviewers as well as Shift Supervisors.
Increased awareness of the requirements of 10CFR 50.72 by Shift Supervisors and Operating Engineers.
Increased attention to LER quality and timeliness by Department l
Heads, authors and reviewers.
Major revision to the station administrative procedures (zap's) 3 related to event reporting.
Implementation of a root cause determination flow chart based on the Management Overview Risk Tree (MORT) concept.
i Increased attention by the Regulatory Assurance Group to the j
quality of LERs.
Clarification of the term "ESF actuation" as it relates to 10CFR j
50.72 and 50.73 reporting.
i Increased attention by the Offsite Review of LER quality.
We feel that the above program has and will continue to improve the quality of Zion's Event Reports.
In summary, Zion Station recognized the need to improve the quality of LERS submitted by the station and had implemented an aggressive program to upgrade them upon first learning of the BG&G's assessment of Zion LERs performed for the NRC and NUREG 1022 Suppl. 2.
l The effort to improve the quality is a continuing process which i
will include continued review by the Regulatory Assurance Group and Offsite Review.
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ATTRCIBENT 2 4
Cosumonwealth Edison has recognized that Zion's LERs needed improvement in order to fully comply with NUREG 1022. However, our review of NUR80 1022 supplement 2 and ABOD's assessment of Zion's LERs revealed that some of the criteria used as the bases for assessment are in direct conflict with the information provided in 10 CFR 50.*13 and NURBG 1022. 10 CFR 50.72 and NURBG 1022 were the only guidance licensees had available until Suppl. 2 and the ABOD report were issued.
As a case-in point, NUREG 1022 item 4 " Title" states;
" Enter a concise description of the event which defines the principal problem or issue associated with the event (e.g., " Inoperable Diesel Generators", " Reactor Trip", " Failure of the Reactor Trip Breakers")."
e However, NUREG 1022 Suppl 2 pages 29 and 30 states in-part:
"The basic problem with many of the titles was that they focused too much on the result of the sequence of occurrences (i.e., the event) rather than presenting a description of the event as a whole.
For example, a title such as " Reactor Trip" does not represent an accurate description of an event. A reactor trip is the result (or at least one of the results) of a sequence of occurrences. It is recognized that the result, which is normally the reason the event was required to be reported, is an important aspect of the event; however, at least two other elements are necessary to forumlate a meaningful title. These i
elements are cause, and a principle link between the cause and the
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result. Just as a title " Reactor Trip" was considered inadequate, the title " Personnel Error Causes Reactor Trip" is considered lacking in that there could be innumerable ways in which a person could cause a reactor trip. The principal ~ link in this example would be the details necessary to explain how the error caused trip, (e.g., " Technician Inadvertently Injected Signal Resulting in a Reactor Trip"). The above title presents the reader with a better interpretation of the event; however, if a procedural error caused the technician to take the wrong i
action, a more appropriate title might be " Error in Procedure Leads to a Reactor Trip."
In this example the procedural inadequacy is the root cause rather than personnel error.
To summarize, a title should contain three elements that describe the event:
(a) a root cause, (B) a result, and (c) a link between the root cause and the result."
Similar comments are also made in the ABOD report.
. other commients regarding the ABOD report which are worthy of note are:
Page 3 Para. 2 regarding the number of authors of LERs.
zion Technical Staff and Health Physics prepare the majority of LERs at the station with the specific system expert being responsible for events related to his or her system. This policy enables engineers to develop their investigative / troubleshooting skills as well as their report writing skills while keeping them aware of events and corrective actions related to their assigned systems.
Page 4 Para. I and 2 regarding apparent contradictory statements in two similar LERs The two events although similar in that they involved tubing on a diesel generator are quite different in that the fuel line was 1/4" copper tubing being replaced with stainless steel tubing. The lube oil line was 1" steel tubing being replaced with carbon steel pipe, a common and reasonable corrective action.
Page 5 Para. 2 regarding plant conditions prior to the event.
This information is given in the coded fields and was assumed to satisfy the requirement prior to receiving NURBG 1022 Suppl. 2.
Page 0 Para 4 regarding personnel error indication.
Personnel errors are always indicated in the coded field Page 7 Para. 4 regarding previous event information:
NURBG 1022 Para. (b) states:
" Reference to any previous similar events at the same plant that are known to the licensee". It does not indicate that a statement to the effect that there are none is required.
Page 8 and 4 regarding the
Title:
See case-in-point made previously.
Table 4 Personnel error discussions:
When personnel error was identified as the root cause, the coded field indicated "A" as cause. Also see comment regarding Page 5 Para. 2.
. Operating Conditions prior to the event:
Power level and mode are always coded: Also see comment for Page 5 Para 2.
Previous Similar events:
See comments for Page 7 Para. 4.
Manufacturer and model number information:
See comment for Page 5 Para 2.
Text Ptesentation consistency:
NUREG 1022 stated there is no prescribed format, however Zion is adopting a standard format.
Abstracts:
The root cause, although it probably should be, is not required to be included in the abstract per NURBG 1022 page 26 item 16.
Coded Fields (a) Titles: See previous discussion.
(b) Position
Title:
10 CFR 50.73 (b) (6) states name and telephone number only are required, although NURBG 1022 Page 24 item 12'does state position title also.
(c) Component Failure:
Although the coded fields are ostensibly for failed components the blocks are useful for licensee trending of event by cause.
l ATTACHMENT A and B Several plants indicated in Attachment A as having no ESF actuations for the period JAN-JUN 1984 indicate a significant number of Reactor Trips in 1984 in Attachment B.
(2) (iv) indicates that the Reactor Protection System (RPS) is included in ESF actuations.
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