ML20199J727
| ML20199J727 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 11/21/1997 |
| From: | Jamila Perry COMMONWEALTH EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-010-97-13, 50-10-97-13, 50-237-97-13, 50-249-97-13, JSPLTR-97-0195, JSPLTR-97-195, NUDOCS 9711280210 | |
| Download: ML20199J727 (13) | |
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6500 Nnnh l>rrot ti lhol Mot rk, il f eu isu 101 Hl % 9 8 2-1920 November 21,1997 JSPLTR: 97-0195 U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D. C. 20555
Subject:
Dresden Nuclear Power Station Units 2 and 3 Reply to a Notice of Violation; Inspection Report 5010/237/249/97013.
MTJkchet Numbers50-010. 50 237. and 50-249
Reference:
GeofTrey E. Grant letter to J. S. Perry, dated October 24,1997, transmitting NRC Inspection Report 5010/237/249/97013 and Notice of Violation The purpose of this letter is to provide Comed's reply to the Notice of Violation transmitted by the above reference. Specifically, the violation resulted from the failure to take corrective action to prevent recurrence of previous events noted in the report, and a second violation for failure of an indiviiual to verify radiation areas prior to working in the area. The response to the Notice of Violation is found in the enclosure to this letter.
Your report noted several examples of operation department performance deficiencies.
Dresden Senior Management is conceined with the performance of all persornel but is extremely sensitive to operator performance The Operations department has taken steps to address overall department performance by the creation of a lluman Performance improvement Plan. The plan includes Performance Review Boards for each operating team.
TN Board reviews the past performance; of each operating team and overall department perfonnance and recommends areas for improvements.
The report a'so cites multiple examples ofinadequate corrective actions. Dresden has a number of systems in place to assure the quality of corrective actions. The Corrective Action Review Board (CARB) reviews and approves proposed corrective actions The Problem Identification Forms (PIFs) which identify problems at a low threshold are screened by Senior Managers 3 times per week. In addition, cfrectiveness reviews are required for most corrective actions in the months following the implementation.
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'USNRC November 21,1997 JSPLTR: #97 0195 Page 2 The following commitments are contained in the enclosure:
Each Shift Manager will brief members of their operating team on this event, which will include the importance of procedure adherence and maintaining high Operating Standards. (NTS # 237-200-97-04302A,B,C,D, E by each Shin Manager, due 12/05/97)
Radiation Protection will develop method to ensure surveys of power affected areas are e
performed after unit startup, and will consider establishing control through pre-define surveillance or equivalent method. Other major power transients or system operation changes that should trigger performance of new plant surveys will be considered. (NTS#
237-201-97-72401, duc 12/31/97) 0, erations will make presentation to Curriculum Review Committee (CRC) requesting training on event, expectations, and new Radiation Protection procedure or policy from NTS # 237 201-97 72401 A. (NTS # 237 201-97 72401 A-01, due 3/31/98)
Operations will pre review all Tech Spec surveillances with a frequency of quarterly or longer to ensure Tech Spec and DATR LCOs are pre identified (NTS # 237-180 97-01501, dec date 1/15/93)
All spare breakers will be stored in the breaker corral located in the reactor brilding thereby eliminating storage of the breakers near the 4 kv emergency buses. This will be added to the procedure (s) that control movement of these breakers- (NTS # 237-100 01301C 01, due January 31,1998.)
For other 4 kv areas, all breakers will be checked m,ce per week by Operations personnel e
during routine rounds. This will be added
- the procedure that contains Operator rot A (NTS # 237-10047-01301C-02, e e January 31,1998.)
The engineer will be coached regaiding engineering standards, (NTS 237-100.
Ol304 A due 12/15/97)
The Station has a requirement to conduct an annual llAZMAT drill, and the next one is planned for the first quarter 1998. (NTS 237-100-97-01308, due February 27,1998)
In addition to the Notice of Violation, the report described an Inspector Follow up Item 5010;237;249/97013 03 and two Unresolved items 5010,237;249/97013-04 and 50-10,237,249/97013-06.
USNRC November 21,1997 JSPLTR: 497 019$
Page 3 With respect to inspector Follow up Item 5010,237,249/97013-03 Ilydrogen Analyzer Area Temperature, the following actions have been taken:
- 1. The range of acceptable area air temperatures for the Off Gas liydrogen Analyzer has been changed on the Unit 2 and Unit 3 Operator rounds to 50 to 105 degrees F. which agrees with the range of area temperature found in the Technical hianual.
- 2. The operators are required to record the area temperature each shin on the Appendix F and Appendix G computer rounds.
- 3. The operating procedure for the Off Gas liydrogen Analyzer, DOP 540018 has been revised to include installation of the portable heaters in accordance with the Temporary Alteration Procedure DAP 05-08 if necessary,
- 4. The electrical load of radiant heaters was analyzed for the local welding outlets and found acceptable.
- 5. A Nuclear Station Work Procedure (NSWP A-11)is under development for us; at all Comed Nuclear Stations to control Temporary hiodifications. This procedure will make it clear that 480 VAC welding outMs are not designed for continuous loads and an engineering evaluation must be completed if continuous use is planned for any of those outlets.
Unresolved item 50-010/237/249/97013-04 described two instances wherein maintenance personnel actions created situations which challenged the operators. The first event led to a turbine trip when the 311 hicisture Separator Drain Tank (h1SDT) Emergency Drain Valve failed to open. An air line from the h1SDT emergency level conthi transmitter was found disconnected An Apparent Cause Evaluation (ACE) was performed which determined that the work was performed by contractor personnel hired to support the refuel outage work. A work instmetion step to reconnect the air line was signed off as complete. It was concluded that the work instructions were acceptable, but were not followed. The contractors were laid off at Dresden at the end of the outage and were not on site when the problem was discovered All other hiSDT control <
tre walked down and no additional problems were found.
In the second instance, Temporary Alteration in ' i.97 was incorrectly installed. The workers making the installation used we n tiens which included a sketch provided by Engineering. The sketch showed the '.cw we" connection to be on the right side of the transmitter The workers concluded (vy bspection of plant labeling which differed from the sketch) the right side of the level transmitter was the "high side" and proceeded to connect the Temporary Alteration, as directed by the work instru: tion steps to the " low side" as indicated by plant labeling. The workers were coached by department supenision because
USNRC Novemtwr 21,1997 JSPLTR: #97 0195 Page 4 they failed to meet department standards and expectations by proceeding with the installation in the face of uncertainty.
The engineer made the sketch based upon his walkdown of the instrument lines. The walkdown was performed under power operation following a request for the Temporary Alteration to prevent spurious tripping of the Unit 3 3D2 high pressure feedwater heater.
The engineer has been interviewed and agrees that his sketch should have provided clearer guidance. The engineer will be coached regarding engineering standards, NTf. 237100 Ol304 A (due 12/15/97).
URI 5010/237/249/97013 06 is open pending the inspectors review of the Updated Final Safety Analysis Review and revised battery calculation Ph1ED 898230-01. Revision 11 to calculation PhiED 898230 01 was completed in August 1997. The revision included operation ofliigh Pressure Coolant injection (llPCI) valves 2301-15,2301-48, and 2301-49 concurrently with the operation ofilPCI Auxiliary Oil Pump and hiOV 2301-3. In addition the battery aging factor was changed from 1.00 to 1.25 as recommended by Standard IEEE 485 "lEEE RECOhih1 ENDED PRACTICE FOR SIZING LARGE I. FAD STORAGE BATTERIES FOR GENERATING STATIONS AND SU13 STATIONS."
Section R4, Radiological Protection StalTKnowledge and Perfbrmance, discussed the use of
" warning flags" on radiation survey maps to signify that conditions may have changed since the survey was completed The report noted that an operator had entered an area for which a warning flag had been placed without verifying the dosse rates in the area. Furthermore two shifts of Radiation Protection personnel were not aware of the reason the warning Hag was posted. Radiation Protection hianagement reviewed the m of" warning Hags" following these events and concluded that " warning flags" would no loager be used to denote changes in radiological conditions. Radm/ ion Protection Policy Memo ti.IDM-/4 was approved on November 12.1997 to create consistent performance in documenting changes to conditions on the routine survey board Now when changes to radiological conditions are noted, Radiation Protection Supenision is to be notined to turnover the information to following shifts. In addition the RPT is te make red pen and ink changes on the survey map to denote the changes and initial and date the changes.
In Section S4 Security and Safeguards StafT Knowledge and Performance. The inspectors noted numerous deficiencies in the Station response to what was thought to be a potentially toxic plume approaching the Station. ' While there was never a threat from this event, it is clear that better preparation was needed should the Str. tion be confronted by a toxic plume in the future. The report stated,"The licensee planned to perform drills similar to the event to improve station personnel response." Beginning in 1998, the llazardous hiaterials (llAZh1AT) drills will be used to improve Station performance for this type scenario. The Station has a requirement to conduct an annual liAZh1AT drill, and the next one is planned for the first quarter 1998. (NTS 237100 97-01308, due February 27,1998)
4 USNRC November 21,1997 i
JSPLTR: #97 0195 Page$
This response contains no proprietary or safeguards information. If there are any questions concerning this letter, please refer them to Mr. Frank Spangenberg, Dresden Station Regulatory Assurance Manager, at (815) 942 2920 extension 3800.
Sincerely, wm
. ?tephentlitry fd-ite Vice Presi ent Dresden Statior Attachment cc:
A.11i11 lleach, Regional Administrator, Region ill C. Miller, Acting Branch Chief, Division of Reactor Projects, Region til J. F. Stang, Project Manager, NRR (Unit 2/3) j K. Riemer, Senior Resident inspector, Dresden Omce of Nuclear Facility Safety IDNS File: Numerical
NITACilMENT A REPLY TO A NOTICE OF VIOLATION Commonwealth Edison Company Docket Nos. 50-237;50 249 4
Dresden Nuclear Power Station, Units 2 and 3 License Nos. DPR 19; DPR 25 UNIT STAFFING BELOW TECilNICAL SPECIFICATION REQUIREMENTS VIO 50-237/97013 01 A(DRP); 50 249/97013-01 A(DRP)
VIOLATION Criterion XVI, " Corrective Action," of 10 Cl R Pan 50, Appendix B, states,in part, that measures shall be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.
Contrary to the above, corrective actions taken by the licensee were not adequate to preclude the repetition of an event involving inadequate stafling of the control room. Specifically, on August 17,1997, the Unit 2 unit supenisor lefl the contcol room without being relieved, reducing the control room stafrievel below specified levels. A similar event occurred on February 26,1997. This is a Severity Level IV violation (Supplement 1).
REASON FOR VIOLATION The primary cause was determined to be a co,nitive personnel performance error by the Shill i
Manager for his loss of focus of Unit Supervisor responsibilities during the interim turnover in the Control Room, resulting in his exit from th-Main Control Room prior to being relieved by the Unit 2 Unit Supenisor. llis action of exiting the Contial Room to return to his oflice resulted in non-compliance (o Technical Specification 6.2.B.2.
Contributing to the event was the inadequate interim turnover performance by the Shin Manager and the Unit Supervisor. Neither individual demonstrated a questioning attitude and practiced STAR. More importantly, because the Shif) Manager is ultimately responsible for Station compliance to the Technical Specifications, his action of exiting the Control Room without adequate manning is in non compliance with Department Standards. All operaior actions involving turnovers of command and control are required to be announced to the Operating Team. There was no announcement of the interim turnover between the Shif) Manager and Unit Supeniscr Announcement of turnovers in the Main Control Room communicates to everyone cognizance of who retr 4 ins command and control within the Main Control Room at all times The Page1of3
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- lack of adherence to the interim turnover requirements is in non compliance of DAP 07-02, Conduct of Shill Operations.
i Also a contributing factor was the failure to proceduralize placement of the clip on supervisor security badges when in command and control of the units. Though long term corrective actions were created from the February event, no documented interim actions were put into place until completion of the long term actions.
The corrective actions from the February 1997 LER were aimed at assuring Technical Speci6 cation manning compliance through Control Room access control. The decision to utilize J
such a complex control mechanism resulted in a delayed implementation date, in addition to event recurrence.
CORRECTIVE STEPS TAKEN AND RESULTS ACillEVED The Shill Manager and Unit Supervisor understand their responsibility to adequately self check their actions, the requirement fi>r procedural compliance, and understand how their actions resulted in non compliance to the Technical Speci6 cations. Operations has taken the appropriate j
discipliunry actions in accordance with station policy. (Complete) i CORRECTIVE STEPS TAKEN TO AVOID FURTIIER VIOLATION The Operations Department took immediate action to address the Technical Speci6 cation noncompliance by performing an Operations standdown with each o"the oncoming shifts. During this time, recent operational errors were discussed and reinforcement of Operations Standards for error free reactor operations was performed (Complete)
Operations has icvised DAP 07 02, Conduct of Shift Operations, amending the Shifl Manager's duties by not allowing him to perform routine interim relief to the Unit Supervisor, except under speci6c conditions This is intended to assure that the Shill Manager remains in his primary role and not routinely relieving the Unit Supervisor. DAP 07-02 was additicnally redsed to provide a more formal step-by-step turnover process, which inc!udes; announcement of all completed turnovers, logging of all turnovers and the requirement ihr usage of a security badge clip.
Implementatiou of the use of a badge clip indicates when a SRO is in command and control of a unit as well as providing a physical barrier which prevents their security badge from being placed into the card reader. (Complete)
Operations StalTsubmitted a supplemental LER to rescind the inappropriately selected corrective actions stated in LER 97-006/05000237 (Complete)
Page 2 of 3
DATE WilEN FULL COMPLI ANCE WILL llE AClllEVED Compliance with Criterion XVI,
- Corrective Actions" of 10 CFR part 50, Appendix B,in regards to Dresden's ' Control Room Stalling flelow Specified Levels" has been achieved, as all corrective actions have been completed.
Page 3 of 3
4 ATTACilMENT B REPLY TO A NOTICE OF VIOLATION Commonwealth Edison Company Docket Nos. 50 237;50-249 Dresden Nuclear Power Station, Units 2 and 3 License Nos. DPR 19; DPR-25 hilSSED UNIT 2 TECIINICAL SPECIFICATION REQUIREMENTS VIO 50 237/97013-01B(DRP); 50-249/97013-01B(DRP) -
VIOLATION Criterion XV.I " Corrective Action," of 10 CFR Part 50, Appendix B, states, in part, that
,neasures shall be established to assure that c iditions adverse to quality are promptly identified and corrected. In the case of significant cond,, ions adverse to quality, the r..easures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.
Contrary to the above, corrective actions taken by the licensee were not adequate to prec'ude repetition of an event involving the failure to enter the required actions statements of a Techni Specification. Specifically, on August 21,1997, ope:ators applied Technical Specification 3 instead of 3.2.A, which was more limiting. A similar event occurred on January 23,1997.
REASON FOR VJOLATION The primary cause for this event was a cognitive personnel performance error by the Unit Supervisor by not performing an ndequate review of DIS 1600-16 and subsequently not entering Technical Specification 31 A. The Unit 2 Unit Supersisor failed to utilize all available resources in his decision process as a result of exhibiting a high levd of confidence during task performance.
His performance was beneath Operations Standards and resulted in a shortcut during the review proCeas.
. A Contributing Cause was determined to be prc grammatic fa!!ure in the methodology for -
performance of peer checking ar,d review of LCO's. The Unit Sepervisor's review (peer check) of LCO's does not always entail an emire roccss revieve to determine if all LCO's have been identified for a givcn surveillance, but inste.d, is usually limited to concurrence that identified
'LCOs are correct.
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CORRECTIVE STEPS TAKEN AND RESULTS ACillEVED The Unit Supervisors involved understand their responsibility to adequately self check their actions, the requirement for procedural review, and understand how their actions resulted in non-compliance to the Technical Specifications. Operations has taken the appropriate disciplinary actions in accordance with station policy. (Complete)
CORRECTIVE STEPS TAKEN TO AVOID FUP. tiler VIOLATION Shill Managers held diseasions with the members of their teams to discuss recent events and how Operationt Standards were not upheld (Complete)
Operations will pre review all Tech Spec surveillances with a frequency o quarterly or longer to r
ensure Tech Spec and DATR LCOs are pre-identified. (NTS#2371809701501, due date 1/15/98)
Operations established a process where surveillances are reviewed for Tech Spec and DATR LCOs, starting from the E-5 work week. This review will be performed by the Operating Team responsible for the work execution week. Additionally, Operations implemented " apart in time" independent surveillance reviews, from which a compari on will be performed to assure the accuracv of the reviews. This action will replace the peer check methodology currently in place which only assures that the identified Tech Specs are correct, and fails to challenge whether all applicable Tech Specs have been identified. (Complete)
DATE WlIEN FULL COMPLIANCE WILL BE ACillEVED Compliance with Criterion XVI, " Corrective Actions" of 10 CFR part 50, Appendix B, in regards to Dresden's " Missed Unit 2 Technical Specification Requirements" will be achieved when all corrective actions have been completed. (due date 1/15/98) i t
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l A'ITACllM ENT C REPLY TO A NOTICE OF VIGLATION Commonwealth Edison Company Docket Nos. 50 237,50-249 Dresden Nuclear Power Station, Units 2 and 3 License Nos. DPR-19; DPR-25 UNSECURED 4-KV BREAKERS / PORTABLE EQUIPMENT VIO 50-237/97013-01C(DRP); 50-249/97013 01C(DRP)
VIOLATION Criterion XVI, " Corrective Action," of 10 CFR Part 50, Appendix B, states, in part, that measures shall be established to assure that cc.d:3 c- *erse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.
Contrary to the above, corrective actions taken by the licensee were not adequate to preclude repetition of an event involving an unrestrained 4-KV breaker. Specifically, from July 22,1997, when the inspectors informed the licensee that a 4-KV breaker near a safety-related bus was unrestrained, until approximately July 28,1997, the licensee did not correct the deficieut breaker condition. A similar event, for which a violation was issue:1, occurred on January 18,1996.
REASON FOR VIOLATION The cause of the unsecured 4 KV breakers / portable equipment is indeterminate.
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED The unsecured 4-kv breaker was properly secured.
CORRECTIVE STEPS TAKEN TO AVOID FURTHER VIOLATIO'.,
All spare breakers will be stored in the breaker corral located in the reactor building thereby elin3ating storage of the breakers near the 4-ky emergency buses. This will be added to the procedure (s) that refers to movement of these breakers. (NTS 237-100-97-01301C-01, due Januaiy 31,1998 )
o Page1of2
. For other 4 kv areas, all breakers will be checked once per week by Operations personnel during c
routine rounds. This will be added to the procedure that contains Operator rounds. (NTS 237-100-97-0i301C-02, due January 31,1998.)
DATE W}lEN FULL COMPLI ANCE WILL BE ACHIEVED Compliance with Criterion XVI, " Corrective Actions" of 10 CFR part 50, Appendix B, in regards to Dresden's "Unrecured 4 kv Breakers / Portable Equipment" will be achieved when all corrective actions have been comp!eted. (due date January 31,1998.)
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ATTACilSIENT D REPLY TO A NOTICE OF VIOLATION Commonwealth Edison Company Docket Nos. 50-237;50-249 Dresden Nuclear Power Station, Units 2 ai.a 3 License Nos. DPR-19; DPR-25 USE OF SURVEY MAPS: VIO 50-010/97013-02(DRP); 50-237/97013-02(DRP);
30-249/97013-02(DRP)
VIOLATION Dresden Station Technical Specification 6.8.a requites that written procedures be esiablished, implemented, and maintained covering the applicable 5.rocedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, references radiation protec',!an procedures, which include a radiation work permit system.
Dresden Administrative Procedure (DAP) 12-25, " Radiation Work Permit Program," Revision 06, Step F.1.f(3), requires that personnel, " Verify understanding of work area dose rates and contamination levels and locations oflow dose rate waiting areas."
Contrary to the above, on August 8,1997, personne; who performed turbine building equipment rounds did not read radiation protection survey maps or othenvise verify dose rates for the Unit 2 Turbine Building Elevation 601 general area prior to working in that area. The surwy map for the area had a warning posted over the map stating that radiological conditions had changed and that radiation protection personnel must be consulted for a curre
- survey.
This is a Severity Level IV violation (Supplement IV)
REASON FOR VIOLATION The cause of this event was determined to be Procedural Non-Compliance due to committed actions not being cat ried out (evoking snoi: cuts), due to complacency in the work place. The two operators were in procedural non-compliance for failure to review radiation surve maps j
prior to entry into the RPA. Plant workers need to know dose rates, contaminated areas and low dose areas in the plant Page1of2
.. CORRECTIVE STEPS TAKEN AND RESULTS AClllFVED The tv.o Operator:: involved were counseled in accordance with the MARC principles.-
l (NTS # 237-200-97-04301 A,0 - closed)
CORRECTIVE S TEPS TAKEN TO AVOID FURTifER VIOLATION
. Each Shin Manager will brief members of their operating team on this event, which willinclude the importance of procedure adherence and maintaining high Operating Standards. (NTS # 237-200-97-04302A,B,C,D, E by each Shif) Manager, due 12/05/97) r i
Radiation Protection will develop method to ensure surveys of power afrected areas are performed after unit startup, and will consider establishing control through pre-define
- surveillance or equivalent method. Other major power transients or system operation changes that shculd trigger performance of new plant surveys will be considered. (NTS# 237-20197-72401, due 12/31/97)
Radiation Protection Management reviewed the use of" warning flags" following these events and concluded that " warning flags" would no longer be used to denote changes in radiological conditions. Radiation Protection P<.!icyMemo MDM-H was approved on November 12,1997 to create consistent performance in documenting changes to conditions on the routine survey board.
Operations will make presentation to CRC requesting training on event, expectations, and new Radiation Protection procedure or policy from NTS # 237 201-97-72401 A. (NTS # 237-201 72401 A-01, due 3/31/98)
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Compliance with Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, in regards to Dresden's "Use Of Survey Maps" will be achieved when all corrective actions have been -
completed. (due date 3/31/98) 4 4
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