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Forwards Payment of Civil Penalty & Responds to NRC 861118 Notice of Violation from Insp on 860714-0811.Corrective Actions:Rept Documenting Nuclear Instrumentation Cable Interchange Written on 860712.NRC Operations Ctr Notified
	ML20212A603
Person / Time
Site:	Cook
Issue date:	12/18/1986
From:	Alexich M; INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:	Taylor J; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE)
References
	AEP:NRC:1009, NUDOCS 8612240264
	Download: ML20212A603 (10)
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INDIANA & MICHIGAN ELECTRIC COMPANY P.O. BOX 16631 COLUMBUS, OHlO 43216 December 18, 1986 AEP:NRC:1009 Donald C. Cook Nuclear Plant Unit Nos. 1 and 2 Docket Nos. 50-315 and 50-316 License Nos. DPR-58 and DPR-74 NRC REPORT NOS. 50-315/86029 and 50-316/86029 NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Mr. James M. Taylor, Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555

Dear Mr. Taylor:

This letter responds to the NRC Region III letter dated November 18, 1986, which refers to the subject Inspection Report of the special safety inspection conducted by the Region III staff at the Donald C. Cook Nuclear Plant during the period July 14 through August 11, 1986. This inspection reviewed the circumstances associated with the inoperability of two of four power-range excore nuclear instruments during a Unit 2 reactor start-up. The Notice of Violation and Proposed Imposition of Civil Penalty transmitted by the Region III letter proposed a civil penalty of $25,000 collectively for Violations I.A.1, I.A.2 and I.B. The Notice indicates that the $25,000 represents reduction of the base civil penalty by one-half because of our unusually prompt and extensive corrective actions. Violation II was not assessed a civil penalty.

Our response to these violations is presented in the attachment to this letter. In addition, we have enclosed a check in the amount of $25,000 in full payment of the imposed civil penalty.

Very truly your ,

8612240264 861218 PDR ADOCK 05000315 O PDR . P. lexich Vice President 31 Attachment cc: John E. Dolan W. G. Smith, Jr. - Bridgman R. C. Callen G. Bruchmann G. Charnoff NRC Resident Inspector - Bridgman J. G. Keppler - Region III 1\ /E: !Y l 1

Jamen M. Tcyler AEP:NRC:1009 STATE OF OHIO COUNTY OF FRANKLIN M. P. Alexich, being duly sworn, deposes and says that he is the Vice President of Licensee Indiana & Michigan Electric Company; that he has read the foregoing response to NRC Inspection Report 50-315/86029, 50-316/86029 and knows the contents thereof; and that said contents are true to the best of his knowledge and belief.

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Subscribed and sworn to before me this /# day of it/vrebt , 19 96.

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e Ju (Notary Public)

RUTH A. OHLINGER

01ARY PUBut SIAlt gF OHIO NCOMMISSION EAflRES.VM.1952~.

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Attachment to AEP:NRC:1009 NRC Inspection Report 50-315/86029; 50-316/86029 i

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AEP:NRC:1009 Attachm:nt Pags 1 NRC Violation No. I A. " Unit 2 Technical Specification 6.8.1 requires written procedures be implemented covering applicable procedures recommended in Appendix A of Regulatory Guide 1.33, November 1972, which includes administrative procedures cover - 3 procedural adherence.

Administrative Procedure PMI-20: 0, Plant Manager and Department Head Instructions, Procedures and Associated Indexes requires that instructions and procedures shall be adhered to by all plant personnel.

1. Administrative Procedure PMI-2140, Temporary Modifications, Revision 6 (in effect until July 1, 1986) required the use of Attachment 1, Lif ted Wire Form, unless wires were lifted one at a time and immediately relanded, as in troubleshooting.

Contrary to the above, on or about May 31, 1986, while performing Job Order No. 54516, two wires were lifted at the same time and crossed on power range nuclear instrument channel No. NI-41 without the use of the ' Lifted Wire Form.'

2. Administrative Procedure PMI-7030, Condition Reports and Plant Reporting, Paragraphs 5.2.b and 5.2.c, requires that a Condition Report must be submitted when print discrepancies are noted or when a suspected failure exists that could leave safety-related equipment inoperable or in a degraded mode.

Contrary to the above, on or about May 31, 1986, a Condition Report was not submitted when print discrepancies involving the wiring of power range nuclear instrument channels No. NI-41 and NI-42 w'ere noted. The discrepancies had the potential to render the equipment inoperable or degraded.

B. Unit 2 Technical Specification 2.2.1 requires that reactor trip system setpoints shall be consistent with the Trip Setpoint values of Table 2.2-1 when the respective instrumentation is required OPERABLE as shown in Table 3.3-1. Table 2.2-1 specifies two separate allowable power range neutron flux trip setpoints equal to or less than 26% and 110% of RATED THERMAL POWER. With a setpoint less conservative than that specified, the required ACTION is to declare the channel inoperable and apply the ACTION requirements of Technical Specification 3.3.1.1.

Technical Specification 3.3.1.1 requires that the reactor trip system instrumentation channels be OPERABLE as shown in Table 3.3-1.

For power range neutron flux instrumentation, Table 3.3-1 requires, while in MODES 1 or 2, or whenever the reactor trip system breakers are closed and the control rod drive system is capable of rod withdrawal, that with less than four channels OPERABLE, the inoperable channel must be placed in the tripped condition within one hour and the minimum channels OPERABLE requirement of three channels must be met.

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- AEP:NRC:1007 Attachmant Psgs 2 1

Technical Specification 3.0.3 specifies that when a Limiting Condition-for Operation is not met, except as provided in the associated ACTION requirements, action shall be initiated within one hour to place the unit'in a Mode in which the specification does

.not apply.

-Contrary to the above, from 4:22 p.m. on July 6,1986, until 1:57 a.m. on July 7, 1986, and from 6:09 a.m. on July 7, 1986, until 4:14 a.m. on July 11, 1986, while in Modes 1 or 2 or with the reactor trip system breakers closed and the control rod drive system capable of rod withdrawal, two of the four power range nuclear instrument channels, No. NI-41 and NI-42, were rendered inoperable and actions were not initiated within one hour to place the unit in a mode where the specification did not apply."

Resoonse to NRC Violation I

- Admission or Denial of the Alleged Violation Indiana & Michigan Electric Company admits to the violation. However, as described below, it should be noted that NI-42 was fulfilling its safety

. function during the time it was connected to the reactivity computer.

i Reasons for the Violation During the period of May 20 through May 31, 1986, while Unit 2 was in Mode 5 (Cold Shutdown) following refueling, Instrumentation and Control (I&C) personnel were dressing cables (EIIS/CBL) and inspecting cable connections in the nuclear instrumentation (NI) cabinet drawers (EIIS/CHA). The I&C personnel first dressed the cables one at a time starting with the Channel I source range and intermediate range. At power range NI Channel I (N-41) all 3

the cables were first disconnected, to permit untangling. A cabinet wiring diagram (92018-14/NIS Protection Channel I CAB NIS I) was marked showing the

! "as-found" configuration cf the cables. The cables for N-41 were reconnected after untangling to what the technician thought was the "as-found"

! configuration. During the dressing / inspection, it was decided by I&C

[ personnel that some enhancements to labeling'were desirable. Plant l information tags (not permanent labels) were applied.

After completing Channel I NIS, I&C continued on to Channel II. Upon completing the Channel II source range drawer cables, they proceeded to the

Channel II intermediate range drawer. After inspecting the intermediate range

drawer, the involved I&C supervisory personnel decided that the best method of l straightening out the disarrayed cables would be to first disconnect all the

, intermediate and power range drawer cables and dress the cables from the ,

! bottom drawer (power range) up. As the cables were disconnected, a cabinet j wiring diagram (2-92019-17/NIS Protection Channel II CAB NIS II) was marked up i

designating the "as-found" configuration of the cables.

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AEP:NRC:1009 Attachment Pagt 3 Information tags were filled out for each of the cables designating their function (e.g., Detector A, high voltage, spare),. based on the cabinet wiring diagram, and placed on the cables. All the old labeling was then removed. It was at this time that the I&C personnel found that the old labels for " Detector A signal" and "high voltage" cables did not match'the cabinet wiring diagram /new information tags for power range Channel II (N-42), and there was a discrepancy between the cabinet wiring diagram and the wiring diagram 2-97005 (Reactor Nuclear Instrumentation System). To verify the correct cable configuration, the cables were physically verified at the containment penetration and at the channel drawer. Upon determining that the cabinet wiring diagram was in error, the I&C personnel filled out lifted lead tags explaining the situation (i.e., that the cables were not connected as shown on the cabinet wiring diagram) and the lifted lead tags were hung on the cables. The information tags, which incorrectly identified the cables, were not removed.

k Based on findings concerning N-42, the I&C personnel decided to recheck N-41 against design drawings. They found that the cables, which they thought had been landed to the "as-found" configuration, were also at variance with

, the drawings. To document this, they placed lifted lead tags as had been done on N-42. No cables were moved at this time; I&C personnel believed the cables were connected as they had been prior to the outage. The inspection and redressing of the nuclear instrumentation cables was completed on May 31.

On July 6 at 1532 hours0.0177 days 0.426 hours 0.00253 weeks 5.82926e-4 months while ' Unit 2 was in Mode 3 (Hot Standby), N-42 was connected to the reactivity computer by I&C personnel to conduct low-power physics testing using **12 THP 6040. PER.355, Reactivity Computer Calibration and Setup. As required by procedure, the bistables (overpower Delta T and overtemperature Delta T reactor trips and runback) were tripped and the fuses (EIIS/FU) pulled, which placed N-42 in a tripped configuration. On July 7 at 1615 hours0.0187 days 0.449 hours 0.00267 weeks 6.145075e-4 months Unit 2 entered Mode 2. N-41 remained inoperable at this time due to the wiring error noted above. N-43 and N-44 (Channels III and IV, respectively) were operable. In this configuration the Technical Specification-required protection redundancy existed.

On July 10 at 0402 hours0.00465 days 0.112 hours 6.646825e-4 weeks 1.52961e-4 months , N-42 was disconnected from the reactivity j

computer using **12 THP 6040.PER.355. The I&C personnel restoring N-42 connected the " Detector A signal" and "high voltage" cables using the identification written on the information tags (incorrect) rather than the lifted lead tags (correct). The fuses for N-42 were replaced and the bistables restored to normal. N-42 was declared operable though in fact it was inoperable due to the " Detector A signal" and "high voltage" cables being incorrectly interchanged. The inoperability of both detectors was not noted at the time, since they were not providing an output signal due to the low reactor power level which existed at the time. Inoperability could only be determined at higher powers, when the differences between the inoperable and operable detectors could be noted.

I At 2311 hours0.0267 days 0.642 hours 0.00382 weeks 8.793355e-4 months on July 10 permission was granted to enter Mode 1.

i During the power increase to Mode 1, it was noted by Operations personnel that N-41 and N-42 indication was lagging N-43 (Channel III) and N-44 (Channel IV) on the 0-120 percent full power meter. Based on past experience, this difference at low power levels was not deemed cause for concern as it was not 1

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AEP:NRC:1009 Attachm:nt Page 4 uncommon for the power range channels to require adjustment after refueling.

The channel currents are predicted quantities and are usually adjusted at higher power levels. Mode 1 was reached at 0038 hours4.398148e-4 days 0.0106 hours 6.283069e-5 weeks 1.4459e-5 months on July 11.

Reactor power was increased to between 8 percent and 9 percent in preparation for turbine roll. At approximately 0110 hours0.00127 days 0.0306 hours 1.818783e-4 weeks 4.1855e-5 months it was clearly evident to the control room operators that a situation requiring investigation existed in that N-41 and N-42 were not following the power increase. N-41 and N-42 were indicating approximately half the power indicated on N-43 and N-44, and the Delta-flux indication was slightly positive on the two meters that received input from N-41 and N-42. It was not noted at that time that the lower Detector "B" current for both channels was reading zero. From approximately 0110 to 0200 hours0.00231 days 0.0556 hours 3.306878e-4 weeks 7.61e-5 months the problem was discussed between control room, Operations staff, plant management, I&C Section and Nuclear Section personnel. Neither N-41 nor N-42 were declared inoperable, since the cause for the indicated deviation was not known at this time.

At 0208 hours0.00241 days 0.0578 hours 3.439153e-4 weeks 7.9144e-5 months on July 11, I&C personnel began troubleshooting N-41 using

- 2 THP 6030 IMP.231, Power Range Nuclear Instrumentation Calibration.

Because Detector "B" current was indicating 0 amps (later determined to be a result of the interchanged cables for Detector A and high voltage), the I&C personnel checked and verified that the Detector "B" cables were properly connected for both N-41 and N-42. I&C contacted the Nuclear Section to determine if the channels were responding properly to the calculated / predicted quantities for the new core. The possibility of interchanged cables was discussed with Nuclear Section personnel; however, on checking the cable configuration on the N-41 drawer, the I6C personnel found the cables connected as identified on the lifted lead tags and believed the configuration was correct. At approximately 0350 hours0.00405 days 0.0972 hours 5.787037e-4 weeks 1.33175e-4 months , while troubleshooting N-41, the I&C personnel decided to check the cable connections on N-42. The I&C person was the rame individual who had placed the lifted lead tags on the cables in May.

He immediately recognized that the N-42 " Detector A signal" and the "high voltage" cables were interchanged (reconnected following use for the reactivity computer as identified on the information tags rather than the lifted lead tags).

At this time, the two I&C personnel who had restored N-42, after disconnecting the reactivity computer, wera in the control room. When asked why they had connected it in reverse of the lifted lead tags, they stated they had used the information tags thinking that the lifted lead tags were attached because N-42 had been connected to the reactivity computer. The I&C personnel then stopped troubleshooting procedures on N-41 per **2 THP 6030 IMP.231. At 0407 hours0.00471 days 0.113 hours 6.729497e-4 weeks 1.548635e-4 months , I6C personnel began troubleshooting N-42 (which were now suspected of having the " Detector A" and "high voltage" cables interchanged) per **2 THP 6030 IMP.231. N-42 was placed in a tripped configuration by pulling the instrument power fuses, and the cables were interchanged to the correct configuration. N-42 was restored to operable status at 0414 hours0.00479 days 0.115 hours 6.845238e-4 weeks 1.57527e-4 months , and it was verified that N-42 was now indicating the same as N-43 and N-44.

Since symptoms for N-41 and N-42 had been the same, the I&C personnel correctly surmised that the N-41 cables were also interchanged and that the lifted lead tags were, in fact, wrong. N-41 was then placed in a tripped condition by removal of the instrument power fuses, and the cables were

4 AEP:NRC:1009 Attach::nt Page 5 reconnected in the correct configuration. It was then verified that N-41 indication was consistent with the other three channels. N-41 was restored to operable status at 0422 on July 11.

Neither N-42 nor N-41 were declared inoperable by the I&C personnel when

/ the cables were found interchanged. Upon being questioned by the Shift Technical Advisor (STA) as to whether the condition had been reported to plant management, the I6C person said he had reported the NI cabinet wiring drawing error in May via a Condition Report and did not feel an additional report was necessary. However, during the investigation, no documentation of the report could be found.

On July 12 at approximately 0900 hours0.0104 days 0.25 hours 0.00149 weeks 3.4245e-4 months , the event was discussed with plant management and although no conclusion was reached on the operability /inoperability of the power range NIS, it was decided that a report to document the fact of the interchanged cables and initiate further investigation should be written. A report was written by an I&C technician at approximately 2200 hours0.0255 days 0.611 hours 0.00364 weeks 8.371e-4 months , which reported the circumstances of the interchanged cables but made no determination on the operability of the channels in question. The report was received by the STA on shift at approximately 2400 hours0.0278 days 0.667 hours 0.00397 weeks 9.132e-4 months . The STA reviewed the report during the midnight shift on July 13.

Since the NIS had not been declared inoperable, it was not realized that the 4-hour reporting requirement per 10 CFR 50.72 applied. However, a follow-up review involving plant management revealed that the detectors should have been declared inoperable and thus a report was necessary.

The NRC resident inspector was informed, and at 1505 hours0.0174 days 0.418 hours 0.00249 weeks 5.726525e-4 months on July 14, 1986 the Shift Supervisor made the required notification to NRC Operations Center via the Emergency Notification System phone.

Based on the above, it is our belief that the violation was the result of a personnel error by an I6C supervisor who failed to implement and follow procedures. This resulted in an impairment of administrative control systems designed to prevent occurrences of this nature, and the subsequent operation of the plant with two power range nuclear instrumentation channels inoperable.

Corrective Steps That Have Been Taken and the Results Achieved The incorrect wiring on the two power range NI channels was discovered on July 11, 1986. The wiring configuration was corrected and the two NI channels (N-41 and N-42) were declared operable on that same day. On July 14, 1986, following investigation of what had transpired, channel functional tests were performed on channels N 41 and N-42 to ensure that they were operating correctly.

On July 12, 1986, Condition Reports were written to document the wiring errors on NI-41 and NI-42 and the drawing error on NI-42.

Temporary Modification forms were initiated and approved for N-42 to document the configuration that did not conform to the approved drawings until the drawings were revised and issued. Information tags used to identify the NI cables were removed on July 21, 1986.

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AEP:NRC:1009 Attachaznt Pegs 6 Corrective Steos Taken to Avoid Further Violations

1. Operations Department power escalation procedures have been changed to alert operators in the control room to verify proper power range NI indication.

2. Information tags have been removed from the list of approved tags in the Plant Manager's Instruction.

3. A Plant Manager's Standing Order was written to control the temporary lifting and landing of leads and provide independent verification of proper system restoration.

4 Letters of Instruction were issued to the individuals directly involved in the incicent and to various sections and departments. The letters reviewed the circumstances of the event and reinforced the requirements for procedural adherence and individual responsibility.

In addition to the actions noted above, which were a direct result of the event, two other unrelated projects were finalized either during or shortly after the occurrence.

First, Revision 7 of PMI 2140 " Temporary Modifications" was issued and became effective on July 1,1986. This revision strengthens the control and review of Temporary Modifications, more clearly delineates what a Temporary Modification is and when it must be used, and clarifies the responsibilities of individuals in initiating a Temporary Modification.

Secondly, a concerted effort to review and oversee the work practices and overall performance of the I&C Section for improvement has resulted in the development of an I&C Production Control Group with responsibility for insuring that all work-related activities are properly pre-planned and technically reviewed. Also, as a result of a reorganization that took place on July 1,1986, we have taken steps to strengthen our on-site engineering support capability. This includes on-site participation by the American Electric Power Service Corporation I&C Section.

We feel that, although these two items were not a direct result of the occurrence, both provide additional positive controls to prevent a recurrence of this nature.

Date When Full Como11ance Will Be Achieved Full compliance was achieved on July 11, 1986, when the NI channels were declared operable.

NRC Violation No. II

" Unit 2 Technical Specification 6.8.1 requires written procedures be implemented covering applicable procedures recommended in Appendix A of Regulatory Guide No. 1.33, November 1972, which includes administrative procedures covering procedural adherence.

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AEP:NRC:1009 Attach: ant Page 7

- Administrative Proceiure PMI-2010, Plant Manager and Department Head Instructions, Procedures and Indexes, requires that instructions and procedures shall be adhered to by all plant personnel.

Administrative Procedure PMI-7030, Condition Reports and Plant Reporting, Paragraph 5.3, requires that the Shift Supervisor be immediately informed whenever any plant equipment is determined to be inoperable.

Contrary to the above, the Shift Supervisor was not notified on July 11, 1986 when power range nuclear instrument channels No. NI-41 and NI-42 were determined to be inoperable."

Resoonse to NRC Violation No. II Admission or Denial of the Alleged Violation Indiana & Michigan Electric Company admits to the violation.

Reasons for the Violation The violation was the result of the failure of personnel to recognize and

, declare the power range nuclear instrumentation channels inoperable when the symptoms and incorrect wiring were first discovered. (See response to Violation I.)

Once the inoperability of the channels was suspected, personnel failed to take prompt and aggressive action to make a final determination and initiate any reporting requirements.

Corrective Steps That Have Been Taken and the Results Achieved A report was written on July 12, 1986 documenting the fact that the NI cables had been interchanged. A follow-up review of the event by plant management on July 14, 1986 revealed that the NI detectors should have been declared inoperable. The NRC Resident Inspector was notified of the occurrence, and the Shift Supervisor notified the NRC Operations Center at 1505 hours0.0174 days 0.418 hours 0.00249 weeks 5.726525e-4 months on July 14, 1986.

Corrective Action Which Will Be Taken to Avoid Further Violations See Response to NRC Violation I.

Date When Full Compliance Was Achieved Full compliance was achieved on July 14, 1986, when the event was determined reportable per 10 CFR 50.72 and the Shift Supervisor notified the NRC Operations Center.

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ML20212A603

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Dear Mr. Taylor:

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