ML20199J876
| ML20199J876 | |
| Person / Time | |
|---|---|
| Site: | Peach Bottom  |
| Issue date: | 01/29/1998 |
| From: | Mitchell T PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-277-97-07, 50-277-97-7, 50-278-97-07, 50-278-97-7, NUDOCS 9802060055 | |
| Download: ML20199J876 (10) | |
Text
,
Thoma)N.Mitchell Vice rieskbnt F%ach Bottom Atomic Fbwer Station
- g-'
,PECO NUCLEAR g;g&~
A Unit of PECO Energy g,' tag 7p-9032 rex 717 456 4243 January 29, 1998 Docket Nos. 50-277 50-278 License Nos. DPR-44 DPR-56 U. S. Nuclear Regulatory Commission Attn.: Document Control Desk Washington, DC 20555
Subject:
Peach Bottom Atomic Power Station Units 2 & 3 Response to Notice of Violation (Combined Inspection Report No.
50-277/E7-07 & 50-278/97-07)
Gentlemen:
In response to your letter dated December 16,1997 which transmitted the Notice of Violation conceming the referenced inspection report, we submit the attached response. The subject report concerned a Residents' integrated Safety Inspection which was conducted September 21 through November 22,1997. An extension to the original required date of the response was requested via telephone on December 23,1997 by Ronald K. Smith, Peach Bottom Experience Assessment Gruup ano was granted by Clifford J. Anderson, Chief-Projects Branch 4, Division of Reactor Projects.
If you have any questions or desire additional information, do not hesitate to contact us.
Y$*bk/W Thomas N. Mitchell Vice President, Peach Bottom Atomic Power Station Attachments cc:
N. J. Sproul, Public Service Electric & Gas R. R. Janati, Commonwealth of Pennsylvania i
H. J. Miller, US NRC, Administrator, Region I (D I
- )
A. C. McMurtray, US NRC, PBAPS Senior Resident inspector T. M. Messick, Atlantic Electric R. l. McLean, State of Maryland A. F. Kirby ill, DelMarVa Power IlllIlll lifilli ll s
buUAV1 CCN #98-14006 9802060055 900129
~
PDR ADOCK 05000277' G
pgg
[_
j
~
RESPONSE TO NOTICE OF VIOLATION 97-07-02
' Restatement of Violation --
Technical specification 5.4.1 requires, in part, that written procedures be established, implemented, and maintained _ covering the applicable procedures recommended in Regulatory Guide 1.33, Appendix A, November 1972. The procedums listed in Regulatory Guide 1.33, Appen_ dix A, include those covering 3
procedure adherence, equipment maintenance, startup of DC electrical systems-and general plant scram recovery.
Contrary to the above, PECO did not properly implement written procedures on
- three separate occasions, specifically:
A.
- On multiple occasions between July and September 22,1997, personnel
' did not follow the instructions for work order C0174600,- resulting, in part, -
in electrically uncoupling the unblocked, safety-related 3B High Pressure :
. Service Water pump versus the non-safety-related Service Water pump,
as specified in the work order.
fB.
. On November 9,1997, an equipment operator did not follow system operating procedure SO 578.1;A-2, "125f250 Volt Station Battery Charger
~
- Startup" for starting the Unit 2A-2 safety related station battery charger,-
= which resulted ir s Unit 2 reactor scram.
= C.
From November 9,= 1997, to_ November 11,1997, while executing a' Unit 2-cooldown subsequent to a' scram,' licensee personnel failed to perform '
Section 3.0 of ST-O-0800-500-2," Recording and Monitoring Reactor Vessel Temperatures and Piescures;"in that they.did not complete nor document the required prerequisites before proceeding with subsequent
-. steps in the procedure as required.
This is a Severity Level IV violation.(Supplement I).
2
e-4 Backaround Information
_(Exampl6 A)
In July,1997, a walk-down to plan scaffolding for_ cable replacement on the 3B Service Water (SW) pump was performed by a contractor foreman and a foreman from Peach Bottom's SEAL (scaffolding,- erosion / corrosion /non-destructive examination preparation, asbestos abatement and lead shielding)
~
team. During this walk-down, the contractor foreman planning the work did not have paperwork for the job with him. Instead, he used his previous plant experiences as a guide in locating what he thought was the 3B SW pump. Since the contractor foreman did not have paperwork with him that indicated the
- appropriate pump numbers or names, he relied on his memory and took the l SEAL team foreman to the unit 3 HPSW pump bay and pointed cut the pumps toi be worked.- The SEA'. team foreman brought a dirgram of the pump structure
- with him during the walk-down and following the direction of the contractor foreman, circled the 3B HPSW pump. The diagram clearly identified the service
,l water pumps and HPSW pumps. In an interview following the event, the -
contracter foreman stated that he fully balieved the 3B HPSW pump was the 3B SW pump.
- During the week of September 15,'1997, a SEAL team crew was dispatched to erect scaffolding between the 3B and 3C SW pumps. -This team arrived at the appropriate work location with the work order package in-hand. When they-reviewed the pump circled on the pump structure diagram prepared during
- p!anning, they immediately noted a discrepancy between the number on the -
pump motor (the 3B HPSW pump) and the number listed on the work order (the 3B SW pump). The.3B HPSW pump motor number is 3BPO42 and the 3B SW l pump is 3BP004. Upon identifying the problem, they contacted the SEAL team planner for the job to find out what was wrong. The SEAL _ team planner contacted the contractor foreman with the discrepancy.. The contractor foreman
. told him thct the motor number was not the same as the pump number, and that they were indeed in the correct location. At this point, no correctioric were r, ade to the work order activity and the erection of scaffolding continued as planned.
- On the morning of September 22,1997, the contracter foreman walked down the cisarance for the 3B SW pump with Operations. This clearance consisted of--
removing the associated breaker on 116' turbine building and installing a ground truck. The clearance was verified to be installed on the correct breaker for the 3B SW pump. The 3B HPSW pump was not blocked. This walk-down was limited to 116' turbine building and did not include the pump structure. Following y
this walk-down, the contractor foreman assembled his crew for the 3B service
. water pump tr.otor de terming activity.
3 u.
The brew consisted of two electricians to de-term the law side voltage of the 3B SW pump transformer and two electricians to de-term the voltage of 3B SW pump motor. The contractor foreman took one of the two electricians assigned to de term the 3B SW pump motor into the HPSW bay and pointed to the 3B
]
HPSW pump indicating which junction boxes on the pump motor to work. The contractor foreman again did not have the work package with him during this walk-down with his team. The contractor foreman was stili under the belief that the 3B SW pump was located inside the HPSW pump bay. Following this walk-down, the electrician left the job site to obtain the tools necessary to perform the work.
Shortly following this work walk-down, the second electrician assigned to de-term the 3B SW pump motor arrived on the job site. He was instructed by the contractor foreman to begin removing the junction box covers on the "3B service water pump". Following the event, the electrician stated he was unsure as to whether he was pointed in the direction of the HPSW pump bay or if he jus + went to the pump vdth the scaffolding erected by it. in any event, he did not take part in a formal walk-down of the job site. Further, he stated he did not seek out the work order package to ensure he was working on the correct piece of equipment.
He stated he tsusted the judgment of his foreman and coworkers.
After obtaining the appropriate tools, the first electrician joined his crew member at the 3B HPSW pump. The two electricians proceeded in de-terminating the motor leads. The next step in the job was to verify the as-four,d phasing for the pump moter. At this point in tina, the low side cables on the 3B SW pump trarsformer had also been de-terminated. The two work crews began ringing out cach of the cab les. The contractor foreman was at the transformer during this evo!ution. The crew at the pump motor rad:ced the contractor foreman that they could not get the expected indict. tion on any of the cables at their end. The
- contractor foreman went to the HPSW pump bay to investigate the problem.
Upon looking in the junction box at the de-terminated cables, he noticed they were larger than the cabler at the transformer. As he began to look around, he noticed the safety-related scheme numbers on the conduit leading to the pump, and for the first time during the entire evolution, came to the realization that work was being performed on the 3B HPSW pump instead of the 3B service water pump. He immediately evacuated the HPSW pump bay and notified the control room and station management of the incident.
4
n
~
. On September 29,1997, at approximately 2:00 p.m., it was discovered that the 3B -
HPSW pump had mistakenly been electrically de-terminated for work instead of the 3B SW pump The 3B SW pump had been properly blocked prior to this discovery to support the replacement of 4ky power cables during the eleventh Unit j'
3 refuel outage (3R11). The 3B HPSW was not blocked out of service and could.
- have started anytime during this evolution.
[(Example D).
On November 9,1997, with unit 2 at 100 percent power, operations personnel-swapped the A reactor protection system (RPS) to the attemate power source and
- received the 2A battery trouble charger alarm. An equipment operator (EO) was -
dispatched to investigate this alarm. The EO reported that the fan failure light on the 2AD003 bat:ery charger was lit, although the fans inside the charger appeared to be operating properly. The EO's attempt to reset the fan failure alarm we,e -
unsuccessful and per ths alarm response card, the EO was directed to place the 2AD00 standby battery charger in service in accordance with system operating (SO) procedure SO-57.B.1.A-2, "125/250 Volt Station Battery Charger Startup",
During the performance of the SO,- the EO completed step 4.1.3 which placed
" Charger 1 (2) AC Input Switch" in "ON at the applicable battery charger._ A caution statement then requires the operator to wait 15 to 20 seconds for the
. charger to ramp-up before. closing the DC output switch to prevent blowing fuses in the Charger. Step 4.1.4 then requires verification that the DC Voltmeter on the ;
charger in service indicates at least 125 VDC prior to closing the "Chargar 1 (2)
- DO Output Switch". The EO failed to wait the appropriate time as noted in the caution and then closed the DC output switch prior to reaching tim required =
voltage of-125 VDC as stated in stap 4.1.4. As, a result of being below 125 VDC, a
- momentary _ loss.of DC power was sensed by the generation protection relay panel and the generator field and auxiliary panel logic that eventually resulted in a ?
- [. eratorlockout and turbine tnp.
- (Example C)-
On November 9,1997, following the unit 2 reactor scram, operations personnel 5 initiated ST-O-030-500-2," Recording and Monitoring Reactor Vessel g
Temperatures and Pressura" to ensure the cooldown rate of the vessel did not exceed the Technical Specification limit of 100 degrees F per hour. Personnel
- initiated this monitoring and data collection without completing two prerequisite steps which required <1ocumenting why the procedure _was being performed and a verification that the procedure was the current revision.
k'
Re6 son (s) For The Violation -
4 (Example A)
Reasons for this event and the subsequent violation were determined to be a -
reliance on previous plant P.nowledge in lieu of self-checking, inadequate pre-job -
briefings and walk-downs by contractor personnel, and industrial work practices which pre-conditioned contractor personnel to forego self-checking.
The foreman relied completely on past plant experience to identify the location g
- of the 3B SW pump and did not use the appropriate self-check techniques.
When the contractor foreman was assigned the task of planning the de-termination of the 3B SW pump motor, he thought he knew exactly where the pump was, He did not know why he identified the 3B HP6W pump as being the 3B SW pump, in lieu of the signs on the HPSW pump bay door and the pump r
p motor itself. No, equipment labeling deficiencies wore identified during this iraestigation.
During the planning walkdown'with the SEAL Team, the contractor foreman did not take any work package information which would indicate the equipment
- numbers ~ associated with the work. Since the job was only in the planning phase,- the SEAL team foreman did not yet have any information associated with the job and was relying on the contractor foreman. The contractor foreman stated that he did not consistent _ly take paperwork with' him during job
- walkdowns. It depended on whether he felt confident with his knowledge of the
, plant, es was the case in this' event.
The SEAL team's question about the correct location _of the pump prior to -
erecting the scaffolding was not properly evaluated due to the contractor
.. foreman's insistence that the pump identified during the initial walkdev.n was
= correct. As a result, a third party walkdown was not performed to resolve this
. discrepancy. The SEAL team crew proceeded with the erection of tho scaffolding even though the equipment number on the work order did eot match
- the equipment number in the field.
LThere _was no formal pre-job briefing or walkdown with the entire work crew and
- their foreman. The electricians assigned to perform the de-terming of the 3B service water pump motor and transformer were nct taken to the job site with their foreman to walk the entire job site down as a team. Although this is a standard practice for PECO maintenance teams, it is not consistently performed by contractor work teams.. This is due in part to the fact that many contractors hire their workforce as needed and do not maintain a constant work team.
6 l
l
'a The electricians involved in this event did not perform adequate w!f-checking prior to the start of work. Both electriciano assigned to work on the 3B HPSW -
pump motor did not walk down the job ';Ath the work order in-hand. The electricians indicated they knvy the expectations associated with walking the job down and self-checking with the work order activity in hand, but they placed their trust with the foreman that everything was satisfactory to work.
Subsequent interviews with the contractor work force revealed that it is standard practice at industrial work sites for the foreman to hold the paperwork and to direct their crews. Further, in non-nuclear environments, equipment labeling is often poor to non-existent. As a result, workers are not physically able to perform adequate self-checking regardless of whether they have access to the work package. This is why the craft work practices are aligned such that the foreman does all the preliminary walkdowns and equipment verifications. The foreman is expected to be fully cognizant of the work location and the workers implicitly trust their foremen. Although PECO strongly promotes and reinforces the use of the STAR principle during vendor initial training, contractor workers in this case put their trust in the foreman and did not perform adequate self-check or work package verification.
(Example B)
The reasen for the violation and unit 2 plant set was the result of the failure to -
properly follow and adhere to SO-57.B.1.A-2, "t 150 Volt Station Battery Charger Startup." The EO failed to wait the presv..aed ti:ae noted and did not verify voltage greater than 125 VDC as required in step 4.1.4. Although the EO had previoucly reviewed the steps of the procedure and had the procedure with him, he did not have the procedure in-hand to properly review and complete each
, step as required.
(Example C)
- The reason for the violation was inattention to detail in the initiation and performance of ST-O-080-500-2. The Reactor Operator who initiated the ST obtained the test from the " consumable" procedure book and initiated temperature readings on the data sheet, but did not take time to appropriately complete the prerequisites steps. Operations personnel focused their attention immediately on monitoring and recording vessel cooldown rate. As a result, Operations personne' failed to properly complete and document two administrative prerequisites prior to monitoring and recording vessel cooldown rate.
7
q As a result of investigation into this event, it was determined that daring some licensed operator training simulator exercises, the ST is used many times during the week. It appears that a practice may have developed where only the data sheets were used by Operations personnel to record and monitor simulated
- reactor vessel cooldown witnout completing appropriate prerequisite steps._ This
- practice may have carried over to plant and contributed to the focus on data -
- collection and the failure to complete the required prerequisite steps.
- Corrective Steos That Have Been Taken and the Results Achieved (Example A)
- Once the error was identified, the HPSW pump bay was evacuated and the control room and station management were notified of the incident. An administrative clearance was placed on the 3B HPSW pump to prevent either a
-manual or automatic start.
A safety stand down was held for contractor personnel involved with cable
- replacement activities and a briefing sheet with details of this event was
- developed for discussion with plant work force teams. The SEAL team also implemented a new lolicy of walking down scaffolding jobs independent of the -
work order planner. These actions have resulted in higher worker awareness of- -
the importance of proper self-check, having appropriate work packages in-hand "
and pre-job briefings.
-- An in-house svent investigation was initiated to determine the apparent cause(s)"
of this event. The results of this investigation were used to develop the violation response.
A_ pre-job check-off/self-check form was created and incorporated into
-Administrative Guideline _(AG)-126, Rev.1, " Oversight of Contractor Activities I
and Verification of Contractor Qualifications". This form will be used for work
- order ectivities which require a clearance. The form requires a pre-job briefing, a clearance walkdown with a crew member for verification, a walkdown of components in the job _ scope, and a sign-off indicating that personnel have
- performed self-check and are confident that work to be performed is safe.
(Example B)
' Appropriate actions were taken outside of the corrective action process to address the human performance aspects of this issue.
8
(Examples B & C)
The Senior Manager of Operations met with the Shift Supervisors and the Shift Managers on each shift team individually to reinforce the expectation around 7
procedure usage and the back to basics approach. The Senior Manager of Operations also met with each shift team during Licensed Operator Re-qualification training cycle 96-12 to reinforce these expectations. In addition, the Event Free Operations program strongly supports management expectations of proper procedure usage.
(Example C)
The prerequisite administrative steps were promptly completed when it was identified that the steps had not been properly completed prior to test initiation.
Training was notified of the practice of Operations personnelin the simulator where prerequisites steps were not being properly complated prior to initiating data collection and monitoring of simulated cooldown rate. Training continues to reinforce procedural adherence and the appropriate sequence of steps to initiate data collection of ST-O-80-500-2. Additionally, binders with the data sheets have been removed and personnel are required to obtain a new procedure with performance of prerequisite steps prior to data collection and monitoring Corrective Steos That Will Be Taken to Avoid Further Violations (Examples A, B and C)
On January 2,1998, Peach Bottom adopted a "back to basics" approach with a primary focus on three fundamental areas for 1998. These fundamental areas include safety culture, procedure use and work package use. This initiative was rolled-out to plant personnel in the way of briefing sheets on January 5,12 and 15, 1998. In addition, these focus improvement areas have also been discussed with employees and work teams by immediate supervisors and management.
To improve safety culture, the key messages to site personnel were to reco tize hazards, communicate clearly and effectively, employ conservative decision-making and a challenging and questioning attitude. An action plan improving safety culture has been developed and initiated as well as planned actions for follow-up assessment and communication of progress in this area.
To improve precedure use, the back to basics approach of the STAR principle (Stop, Think, Act, Review) when performing procedures was communicated to the site. Additionally, personnel were encouraged to think about procedure adherence and level of usage and to understand expected responses. An action plan foi improving proce:fure use has been developed and initiated as well as planned actions for fc!Iow-up assessment and communication of pmgress in this area.
9
4.
To improve work package usage, personnel were instructed to follow the work package and plan and to beware of work scope changes. With respect to work scope changes, personnel were encouraged to question or think about what else could change. In addition, it was communicated that personnel should perform effective pre and post-Job br'efings and ensure that documentation is concise complete and thorough. An action plan for improving work package use has been developed and initiated as well as planned actions for follow-up assessment and communication of p ogress in this area.
The NRC Senior Resident will be updated on a periodic basis of the status of these initiatives and any additional activities which may result.
(Example A)
This event will be incorporated into the Initial Vendor Treining Program 3
emphasizing the need for honest open dialog with supervision. This training enhancement will be incorporated by February 28,1998.
Date When Full Compliance Was Achieved (Example A)
Full compliance was achieved on September 29,1997, when it was self-identified that the 3B HPSW pump had been de-terminated instead of the 3B SW pump.
Work was stopped, the control room was notified and an administrative clearance was applied.
(Example B) _
Full compliance was achieved on November 9,1997, when the procedural compliance problem was identified and appropriate action was taken to address the unit 2 scram.
(Example C)
Full compliance was achieved on November 11,1997, when the failure to properly perform procedural prerequisites for obtaining reactor cooldown data was identified and corrected.
4 10
_ _ _ _