ML20212A241

Responds to Notice of Violation & Proposed Imposition of Civil Penalty of $50,000 Re Insp Rept 50-278/86-09. Three Personnel Suspended & One Reprimanded for Error Concerning Control Rod Positioning.Reduction Requested

ML20212A241
Person / Time
Site:	Peach Bottom
Issue date:	07/23/1986
From:	Daltroff S PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC
To:	Taylor J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE)
References
NUDOCS 8607280145
Download: ML20212A241 (11)

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PHILADELPHIA ELECTRIC COMPANY 2301 M ARKET STREET P.O. BOX 8699 PHILADELPHIA. PA.19101 SHIELDS L. DALTROFF rLecInic"ra$oS"c som July 23, 1986 Docket No. 50-278 Inspection Report No. 50-278/86-09 Mr. James M. Taylor, Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555

REFERENCE:

Letter, T. E. Murley, USNRC, to S. L. Daltroff, PECo, Dated June 9, 1986

Dear Sir:

The referenced letter transmitted a Notice of Violation and Proposed Imposition of Civil Penalties relative to Inspection Report No. 50-278/86-09 for Peach Bottom Atomic Power Station Unit 3. A base civil penalty of $50,000 for each of two violations was proposed with an increase of 100% for each penalty. The increase of 100% for each penalty was proposed "to emphasize the need for increased management involvement and attention in station activities to assure improved personnel performance".

Two items were identified in the Notice which do not appear to be in full compliance with Nuclear Regulatory Commission requirements. These items are restated below followed by Philadelphia Electric Company's response to the Notice in accordance with Section 2.201 of the Commission's regulations and the instructions in the Notice. Also included is the Company's answer, pursuant to 10 CFR Section 2.205, which seeks mitigation of the amount of the proposed civil penalties.

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4 Mr. James M. Taylor July 23, 1986 i Page 2 Restatement of Violations:

i I.A. Technical Specification 6.8.1 requires that written procedures shall be established, implemented, and maintained covering the activities of Appendix A of Regulatory Guide 1.33, November 1972. Appendix A of l Regulatory Guide 1.33 states in part that the activity I of " Hot. Standby to Minimum Load (nuclear Startup)"

requires procedures.

! Technical Specification 6.8.1 is implemented by the Peach Bottom General Procedure GP-2, Appendix 1, j Revision 3, "Startup Rod Withdrawal Sequence

Instructions." Step 13 of GP-2 requires the reactor operator to withdraw control rod 02-23.

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Contrary to the above, at 1:28 a.m. on March 18, 1986

) while at step 13 of GP-2, Appendix 1, the reactor

operator withdrew control rod 10-23 rather than rod

02-23 and incorrectly documented that rod 02-23 had i

been withdrawn.

i l B. Technical Specification Limiting Condition for

]~ Operation 3.3.B.3.b requires that whenever the reactor is in the startup or run mode below 25% rated power,

the Rod Worth Minimizer shall be operable or a second licensed operator shall verify that the operator at the reactor console is following the control rod i program.

4 Contrary to t he above, at 1:28 a.m. on March 18, 1986, I

> while the reactor was in the startup mode below 25%

j power and the Rod Worth Minimizer was inoperable, the

second licensed operator did not' verify adherence to-

the control rod program and identify that a wrong control rod (10-23) was withdrawn. The second

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l licensed operator also incorrectly documented that rod 02-23 had been withdrawn.

This is a Severity Level III problem (Supplen.ent I)..

! (Civil Penalty - $100,000 assessed equally among the j violations).

t II.A. Technical Specification Limiting Condition for Operation 3.3.B.3.a and 3.3.A.2.d require that

whenever the reactor is in the startup or run mode

below 21%_ rated power, the Rod Sequence Control System

(RSCS) shall be operable, and no position switches a shall be bypassed unless'the control rods are moved in sequence to their correct postion and the actual rod position is known.

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Mr. James M. Taylor July 23, 1986 Page 3 Contrary to the above, between 2:30 and 2:55 a.m. on March 18, 1986, when a Group 3 rod withdrawal was attempted while the reactor was in the startup mode below 21% rated power, a rod block occurred. The RSCS position switch for rod 02-23 was bypassed to the full-out position by the Shift Supervisor and the Shift Superintendent when in fact the rod was full-in.

B. Technical Specification Surveillance Requirement 4.3.A.2.d requires that a second licensed operator verify a control rod is in its correct position before the RSCS function is bypassed.

Contrary to the above, on March 18, 1986 when the RSCS function was bypassed for control rod 02-23, the second licensed operator failed to verify that control rod 02-23 was in the correct position.

This is a Severity Level III problem (Supplement I).

(Civil Penalty - $100,000, assessed equally among the violations).

Licensee's Section 2.201 Response to Notice of Violation and Proposed Imposition of Civil Penalties Admission of Alleged Violations:

Philadelphia Electric Company acknowledges the alleged violations as stated above.

Reasons for the Violations:

The violations were caused by a series of personnel errors involving failure of the reactor operator to withdraw the correct control rod, failure of a second operator to verify that the correct withdrawal sequence was being followed, and failure of a' Shift Supervisor and Shift Superintendent to verify the proper position of a control rod prior to bypassing the RSCS input for that rod.

Consequences of the Event:

The Philadelphia Electric Company Nuclear Fuel Management Section and GenerzL Electric (GE) Company have reviewed this e' rent and determit ed that the current Unit 3 reload analysis 2nd Drop Accident (RDA) results bound this event. The

Mr. James M. Taylor July 23, 1986 Page 4 various RDA scenarios associated with this event were identified during the review. The worst case RDA results of the scenarios show a peak enthalpy deposition of approximately 120 calories / gram compared to the RDA design criteria of 280 calories / gram. The 280 calories / gram design criteria value bounds all currently licensed fuel bundle exposure values. Therefore the Unit 3 reactor operated in a condition such that RDA consequences would not have exceeded the design criteria.

Corrective Actions Taken and Results Achieved:

The Operations Superintendent directed a manual scram of the reactor because that was the most prudent, conservative, and expeditious response to ensure compliance with the Technical Specifications.

The four individuals responsible for this event were disciplined. Disciplinary measures involved three suspensions and one written reprimand.

Detail Prior to discovery of the out-of-sequence control rod, the dayshift Shift Superintendent requested that the reactor engineer reset the process computer in an effort to return the RWM to service. Within 20 minutes the computer had been reset and the RWM was reinitialized. It then displayed an insert error for control rod 02-23. The Control Room Shift Supervisor checked the position of that control rod and found that it was full-in and that the RSCS input for that rod was bypassed to give the RSCS a full-out signal for that rod. He immediately returned the bypass switch to normal to comply with Technical Specification 3.3.A.2.d. The Shift Superintendent, the Shift Supervisor, and the Reactor Engineer discussed the Technical Specification implications of this situation and possible corrective actions. By 8:30 AM, the Shift Superintendent reported the rod position error to the Operations Engineer and Operations Superintendent. '

At 3:42 AM control rod insertion was begun to return the l reactor to a control rod pattern in accordance with the RSCS and RWM.

When the decision was made to manually scram, the NRC Site )

Inspector was informed and he reported to the Control Room 1 within a few minutes. The Plant Manager and the I Superintendent-Nuclear Generation, who were in Philadelphia I at the corporate headquarters, were immediately dispatched to the plant to investigate the matter.

Mr. James M. Taylor July 23, 1986 Page 5 An investigation was begun, and all of the operators who were involved were contacted immediately by a Shift Superintendent to develop the investigation report and determine the cause of the Technical Specification violations. On March 18, 1986, that investigation report was presented to station management and corrective actions were developed. Later that day the sequence of events and the corrective actions were presented to Philadelphia Electric Company Electric Production Department management and USNRC Region 1 personnel by conference call. The restart of the unit was delayed until this event was analyzed and appropriate corrective actions were developed and presented to Operations personnel, including the revision and PORC approval of procedures necessary to prevent recurrence.

Corrective Actions Taken to Prevent Recurrence:

To prevent recurrence, the following actions have been developed and implemented:

1. A letter was issued on March 18, 1986 from the 1

Operations Superintendent to all licensed personnel outlining the event and describing interim requirements for verification of proper rod positioning.

2. A procedural control has been implemented to use the plant process computer to generate a rod position map at the completion of withdrawal of specific rod groups if the RWM is out of service. The computer generated map will be compared to a rod position map which is attached to the operator's rod withdrawal sheet. The two maps will then be verified to be identical before proceeding to the next rod group.

3. Six procedures involving RWM and RSCS have been revised and PORC approved to enhance the procedural requirements. Included in these revisions is the RSCS bypass procedure which has been revised to require a Shift Supervision signature for proper verification of rod position prior to bypassing the RSCS input for any rod.

4. On March 24, 1986 the Plant Manager issued a letter to

, Shift Supervision to ensure that best efforts are made to place the RWM in service prior to commencing reactor startup. In accordance with this direction, the procedure for manual bypass of the RWM has been revised to require the permission of the Plant

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• i Mr. James M. Taylor July 23,'1986 Page~6 4

4 i Manager, Operations Superintendent, or Operations l Engineer as a prerequisite to such manual bypass.

! 5. When rod movements are being performed with the RWM bypassed, the RWM manual bypass procedure requires that the second licensed operator shall have no other duties and shall verify that the proper rod sequence i is being followed.

6. Plant. staff management meetings have been held with i all Operations Personnel to discuss the event and

individual responsibilities. I i

7. The four individuals responsible for this event were ,

disciplined. Disciplinary measures involved three  !

suspensions and one written reprimand.

J j Further, Philadelphia Electric has begun the process

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of implementing the Human Performance Evaluation System (HPES) at

both Peach Bottom and Limerick. The HPES has been developed i through a pilot program by the Institute of Nuclear Power ,

! Operations (INPO) and several nuclear utilities. HPES's i objective is to identify and correct situations that cause human j errors. The success of this program is' dependent on operating,

, maintenance and testing personnel reporting actual or potential

{ situations that can cause human errors so that they can be i

corrected before someone else is put into thelsame situation.

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Date When Full Compliance was Achieved:

Full compliance with the Technical Specifications which were l violated during this event was achieved on March 18, 1986

] when Unit 3 was manually scrammed at 0855 hours0.0099 days <br />0.238 hours <br />0.00141 weeks <br />3.253275e-4 months <br />. j t

i l Licensee's Answer Pursuant to 10 CFR Section'2.205 and Request i 1 for Mitigation of Amount of Proposed Civil Penalties  !

{ Concerning the imposition of civil penalties as l discussed in the referenced letter, Philadelphia Electric Company i believes that the additional increase of 100% for each of the two l penalties is excessive, unwarranted and fails to properly balance I the factors enumerated in Appendix-C to Part 2 in determining the j appropriate penalty level. Accordingly, Philadelphia Electric '

j Company requests that consideration be given to reducing the  ;

j proposed penalty of $200,000 to the base penalty of $100,000. q Your letter of June 9, 1986 additionally stated, "We view such problems as being indicative of a lack of management i

involvement in and attention to station activities to assure that l l

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Mr. James M. Taylor July 23, 1986 Page 7 the station personnel respect, understand the need for, and adhere to your policies and procedures for the safe operation of the facility."

Four specific instances were referenced in support of assessment that there is a continuing inattention to detail, failure to adhere to procedural requirements, and a generally complacent attitude of staff toward performance of their duties being indicative of a lack of management involvement and attention to station activities to assure improved personnel performance. These examples covered the time period of 1983 to the present. Four violations of containment integrity that resulted from the failure of non-licensed individuals to follow procedures in 1983 was the earliest event referenced. The second referenced violation occurred June 18, 1984 involving control room personnel errors including two instances when heat up rates were exceeded, and one instance when the reactor vessel was pressurized above limits. Indeed, the 1984 Civil Penalty associated with the violation was mitigated from $40,000 to

$30,000 because of our unusually prompt and extensive corrective actions taken. An unreferenced 1985 Civil Penalty was mitigated from $50,000 to $25,000 because of PECo's " comprehensive corrective actions". The third event cited involved a 1985 event concerning the apparent inattentiveness of a licensed operator while at the controls of the reactor, an event which resulted in removal of this individual from nuclear related work under our fitness for duty program for medical reasons. This event did not involve inattention to detail but fitness for duty.

The fourth event cited was the most recent one detailed in the report proposing these civil penalties. Our investigation determined that the cause was human error wherein ,

the operators believed they were following the procedures. The 1 error was one in which they failed to view the limit lights. The management does not condone this error, and dispensed prompt discipline, as described in Corrective Actions Taken and Results Achieved.

We can not agree that increased emphasis is required to improve management involvement in order to assure personnel performance, nor do we see a pattern of inattention to detail, failure to adhere to procedural requirements, and a general complacent attitude on the part of the staff. We do recognize unrelated occurrences resulting from human error. Our management and supervisors continually express the need to follow procedures and pay close attention when conducting operations.

We do not believe that our staff has a complacent attitude. It is not uncommon for our staff to propose alternative ways for conducting an activity. These proposals, although not always implemented, are directed toward betterment

Mr. James M. Taylor July 23, 1986 Page 8 of operations. We encourage this and view such proposals as indications of a healthy attitude, an attitude not expected of a complacent group.

On May 20, 1985, Philadelphia Electric reorganized the nuclear station management structure to provide for improved management attention to day-to-day activities by splitting the major station responsibilities between two Superintendents who report to a Station Manager. Further, we announced on March 27, 1986 the further strengthening of Nuclear Production Management by providing a Superintendent for Limerick 2 Construction and Startup and appointing an experienced Manager from Limerick to the position of Superintendent Nuclear Generation, the position to which the Plant Manager reports.

This appointment was made with the direction that close attention be paid to the activities at Peach Bottom with the aim of strengthening those weaknesses which had been identified by INPO and the NRC. The Superintendent - Nuclear Generation has been meeting frequently with the power plant staff to develop programs to eliminate these weaknesses. He reviews and assesses progress and has daily discussions with corporate

! management. While the full effect of these changes has yet to be seen, we believe that the initial favorable effects were observed by the recent NRC evaluation team during a two-week inspection of l Peach Bottom. Note that the planning of this action pre-dates the March 18 incident.

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In further support of the requested mitigation of the proposed penalties and as directed by the referenced letter, the 1 five factors contained in Section V.B of Appendix C to Part 2 are 1 addressed below.

1. Prompt Identification and Reporting (reduction of up to 50% of the base civil penalty may be given when a Licensee identifies the violation and promptly reports

the violation to NRC).

The Unit 3 reactor was operated with control rod 02-23 out-of-sequence for a relatively short period of time.

The error was identified by the control room operators, was promptly reported to the NRC Resident Inspector, and the NRC was kept fully advised of developments in this matter (See discussion, Corrective Actions Taken and Results Achieved).

Further, the unit was promptly shutdown. After discovery of the error, Philadelphia Electric Company is convinced that prompt and appropriate actions both relating to the reporting to the Commission and the recovery of the plant to a safe status were taken by i

management and shift personnel. Philadelphia Electric 4

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Mr. James M. Taylor July 23, 1986 Page 9 Company requests that the Commission consider the prompt managerial actions taken in recognition of this condition and consider this a factor to mitigate these penalties.

2. Corrective Action to Prevent Recurrence (reduction or increase by as much as 50% of the base civil penalty may be given depending upon the promptness and extensiveness of Corrective Actions and Actions Taken to Prevent Recurrence).

Philadelphia Electric Company believes it did take prompt and extensive corrective action to prevent recurrence. Technical and process oriented corrective action was promptly taken including prompt institution of an investigation to determine root cause.

Immediate cause was determined to be personnel error.

Management, after in-depth investigation of the error, determined that failure to follow approved procedures was the root cause. Disciplinary action, -

considered severe within the Philadelphia Electric Company, was taken against the operators and supervisors involved. While specific actions have been taken such as reviewing procedures and improving them where required, and holding meetings specific to this incident with all operating shifts, Philadelphia Electric believes that the basic failing was with certain individuals and, therefore, the NRC should give positive consideration to these comprehensive actions when analyzing this request for mitigation of the proposed penalties.

3. Past Performance (reduction or increase by as much as 100% of the base civil penalty may be given depending upon past performance in the general area of concern).

l Philadelphia Electric Company is convinced that the, root cause in this case is failure to follow its approved procedures. In this particular case the procedures were followed as to the technical aspects, except that human effort combining failure to observe j and proceeding on an untrue assumption permitted rod '

withdrawal out of sequence. Philadelphia Electric '

believes its past performance as a nuclear operating utility, as demonstrated by the lack of enforcement action in these areas, should support mitigation of the action doubling the proposed civil penalties.

4. Prior Notice of Similar Event (an increase of as much as 50% of the base civil penalty may be given if the Licensee had prior knowledge of a problem as a result l

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's of a Licensee audit, or specific NRC or industry

. notification, and had failed to take effective

/ preventive steps).

t This event occurred as a result of personnel errors in that personnel neglected to observe the actual rod position of rod 02-23. It was not the result of e

failure to consider prior notices of similar events.

5. kultipleOccurrences(anincreaseofasmuchas50%of the base civil penalty may be given where multiple examples of a particular violation are identified during the inspection period).

No similar violations were identified during the inspection period.

Based upon the foregoing, it is our belief that the Company has responded promptly and extensively in resolving the underlying causes of the violations which resulted in the Notice i

of Violation and Proposed Imposition of Civil Penalties. We believe that the Company has demonstrated a recognition of the seriousness of the occurrence and that we have taken strong and effective measures to prevent recurrence. It is our view that in determining the amount of a civil penalty, the NRC should consider our discussion of its concerns with management attention and should balance the positive factors, described more fully above, regarding prompt identification and reporting and  ;

corrective actions taken against the factors identified in the Notice of Violation as the bases for the 100% increase in the civil penalties. Accordingly, it is hereby requested that the proposed penalties be mitigated as described herein.

Should you have any questions or require additional information, please do not hesitate to contact us.

Very trul yours,

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cc: Dr. T. E. Murley, Administrator, Region I, USNRC Mr. T. P. Johnson, Resident Site Inspector l

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COMMONWEALTH OF PENNSYLVANIA : ,

ss.

COUNTY OF PHILADELPHIA  :

S. L. Daltroff, being first duly sworn, deposes and says:

That he is Vice President of Philadelphia Electric Company, that he has read the Company's foregoing Section 2.201 Response to Notice of Violation and Proposed Imposition of Civil Penalties concerning NRC Inspection Report No. 50-278/86-09 and the Company's answer, Pursuant to 10 CFR 2.205, and Request for Mitigation of Amount of Civil Penalties and knows the contents 1 thereof; and that the statements and matters set forth therein are true and correct to the best of his knowledge, information and belief.

n a L,7 J ll Subscribed and sworn to rcl before me this23 day of j , /fYb

//a/O / A

,, Notary Public MELANIE R. CAMPANELt.A Notary Public Phitadcl;:hia, Phifade?ph!a Co.

My Commission Empires February 12,19SQ

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